Current opinion in anaesthesiology
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For most anaesthesiologists, the clinical experience with general anaesthesia for caesarean section is very low. General anaesthesia is mostly performed for emergency grade 1 caesarean section and due to a lack of time to apply a neuraxial anaesthesia technique. Unfortunately, the majority of anaesthesiologists rely on historical and partly outdated approaches in this stressful situation. We propose an evidence-based approach to general anaesthesia for caesarean section. ⋯ We present a review of recent evidence on general anaesthesia for caesarean section.
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Curr Opin Anaesthesiol · Jun 2015
ReviewThe role of cardiac output monitoring in obstetric anesthesia.
Haemodynamic monitoring in obstetric patients has evolved during the last decade, with the development of minimally invasive and noninvasive continuous cardiac output (CO) monitors. This review focuses on recent articles that improve our understanding of physiology and haemodynamic changes during spinal anaesthesia in healthy pregnant women, and pathophysiology in women with preeclampsia and other cardiovascular disease. ⋯ In healthy women, left lateral tilt remains an important clinical intervention during caesarean delivery, and phenylephrine is an essential early adjunct to fluid therapy. Noradrenaline may have a clinical benefit in selected patients. Carbetocin has similar haemodynamic effects to oxytocin. Haemodynamic changes associated with delivery per se may be minor compared with those due to oxytocin. Uncomplicated severe preeclampsia is usually associated with a normal to raised CO. Early-onset preeclampsia may be associated with more vasoconstriction and lower CO than late-onset disease. Passive leg raising may be useful to judge fluid responsiveness, and lung ultrasound may predict pulmonary oedema in preeclampsia. Further research is warranted to study the area of circulatory changes during delivery and the postpartum period, in healthy and preeclamptic women.
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Curr Opin Anaesthesiol · Jun 2015
ReviewPostcaesarean section analgesia: are opioids still required?
The use of opioids for postoperative pain relief after caesarean section is widely spread. Because of unwanted well known side-effects, alternative drugs and methods of pain relief have been introduced, either in addition to or instead of opioids. Can postcaesarean analgesia be achieved these days without opioids? ⋯ The dependency on opioids for postcaesarean analgesia is diminishing, but in order to develop effective, well tolerated alternatives, more research is needed.In the meantime, opioids are here to stay.
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Spinal anesthesia has long been described as a well-tolerated and effective means of providing anesthesia for infants undergoing lower abdominal surgery. Now, spinal anesthetics are being used for an increasing variety of surgeries previously believed to require a general anesthetic. This, along with increasing concerns over the neurocognitive effects of general anesthetics on developing brains, suggests that further exploration into this technique and its effects is essential. ⋯ Early findings of spinal anesthesia exposure in infancy have shown it to have no independent effect on neurocognitive delay as well as to provide sound cardiorespiratory stability. With safer means of administering a spinal anesthetic, such as with ultrasound guidance, it is a readily available and desirable tool for those providing anesthesia to infants.
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Curr Opin Anaesthesiol · Jun 2015
ReviewTo use or not to use hydroxyethyl starch in intraoperative care: are we ready to answer the 'Gretchen question'?
The decision of the European Medicines Agency (EMA) against the use of hydroxyethyl starch (HES)-based volume replacement solutions in critically ill patients has led to a general uncertainty when dealing with HES-based solutions, even though HES-containing solutions can still be used for the treatment of hypovolaemia caused by acute (sudden) blood loss. This review discusses current evidence of the intraoperative use of HES-based solutions. ⋯ The use of 6% HES 130/0.4 in elective surgery patients is associated with reduced fluid accumulation and no clinically relevant difference in bleeding or the rate of acute kidney injury as compared with crystalloid use alone. Current data do not allow a conclusion on mortality. As they provide no benefit, older starch preparations should not be used.