Chronic hypertension and acute hypertensive crisis
Hung N. Winn, Frank A. Chervenak, Roberto Romero in Clinical Maternal-Fetal Medicine Online, 2021
Although intrapartum analgesia with narcotics may be used, attempting to manage or prevent eclampsia with profound maternal sedation is dangerous and ineffective. Epidural anesthesia is permissible when an experienced anesthesiologist is available and no coagulopathies are present. Hazards include the possibility of extensive sympatholysis with resultant decreased cardiac output, maternal hypotension, and impairment of an already compromised uteroplacental perfusion (1). The advantage, of course, is that epidural anesthesia blunts the sympathetic response to pain, which may be exaggerated in women with preexisting hypertension. Women with chronic hypertension complicated by significant cardiovascular or renal disease require special attention to intake and urine output, because they may be susceptible to fluid overload with resultant pulmonary edema.
Current recommendations for the prevention of deep venous thrombosis
Peter Gloviczki, Michael C. Dalsing, Bo Eklöf, Fedor Lurie, Thomas W. Wakefield, Monika L. Gloviczki in Handbook of Venous and Lymphatic Disorders, 2017
Surgery represents a major risk for VTE, and varies by the type, duration, and indication for surgery, type of anesthesia, associated risk factors, and patient-specific variables, including age.2,3,8–10 In general, patients requiring anesthesia have a 22-fold increased risk of VTE. From a surgical perspective, the highest risk is associated with orthopedic procedures, especially hip or knee replacement, hip fracture surgery, and trauma surgery, including patients with spinal cord injury. Patient-specific variables include cancer, congenital thrombophilia, prior history of VTE, obesity, and increasing age (>60 years).9 In general, spinal/epidural anesthesia carries a lower risk than general anesthesia.11 Outpatient surgery has a lower associated risk than inpatient surgery.9 Patients undergoing vascular surgery may have less risk than other surgeries, possibly because of the intra-operative use of heparin therapy. Aortic surgery carries a higher risk than distal bypass surgery.12,13
Second Stage Of Labor
Vincenzo Berghella in Obstetric Evidence Based Guidelines, 2022
The second stage can be further divided into passive and active second stage. According to the Agency for Healthcare Research and Quality (AHRQ), passive second stage is defined as full dilation of the cervix without voluntary or involuntary pushing [14]. Active second stage is defined as when the fetus is visible or once pushing has started with or without contractions [14]. These guidelines suggest that the passive phase in a nulliparous woman can be allowed for up to 2 hours regardless of anesthesia. In a multiparous woman, passive phase is suggested to be allowed for 1 hour without an epidural and 2 hours with an epidural. The active phase of the second stage of labor is suggested in nulliparous women to have a time limit of 1 hour without an epidural and 2 hours with an epidural. In a multiparous woman, active phase is suggested as 1 hour regardless of anesthesia [14]. Epidural anesthesia is shown to increase the length of the second stage by 13.66 minutes regardless of parity in a large meta-analysis [50, 51]. The suggestions regarding length of the active second stage are not supported by level 1 data, and longer second stages are allowed if maternal and fetal conditions permit (see Table 9.2).
Effect of encouraging a combined spinal epidural technique for cesarean delivery anesthesia
Published in Baylor University Medical Center Proceedings, 2022
Alexa Borja, Jessica Ehrig, Kristen Vanderhoef, Kendall Hammonds, Michael P. Hofkamp
The Baylor Scott & White Research Institute institutional research board waived informed consent for this study. We searched our electronic medical record (Epic, Verona, Wisconsin) for subjects who had cesarean deliveries from May 15, 2019, through April 15, 2021, which corresponded to when we encouraged a combined spinal anesthetic technique for cesarean delivery. Subjects who received a spinal anesthetic without subsequent placement of a labor epidural were defined as having single-shot spinal anesthesia. Subjects who received a spinal anesthetic followed by placement of an epidural catheter were defined as having combined spinal epidural anesthesia. We excluded subjects for receiving neuraxial labor analgesia, puncture of the dura by a Touhy epidural needle, hysterectomy at the time of cesarean delivery, conversion to general anesthesia for reasons other than failure of the neuraxial anesthetic, and use of a lower dose of intrathecal hyperbaric bupivacaine due to maternal comorbidities. A study investigator entered data from the electronic medical record into Research Electronic Data Capture (REDCap) housed at the Baylor Scott & White Research Institute. At our institution, regional anesthesia for cesarean deliveries is performed exclusively by anesthesiology residents and attending anesthesiologists. Data were analyzed using SAS version 9.4 (SAS, Cary, NC).
Safety and efficacy of retrograde intrarenal surgery for the treatment of renal stone in solitary kidney patients
Published in Renal Failure, 2018
Dehui Lai, Meiling Chen, Yongzhong He, Xun Li, Shawpong Wan
Continuous epidural anesthesia was used in all the patients. The procedures were performed in the lithotomy position. After retrieval of the DJ and retrograde pyelography, a 0.035-inch guidewire was placed into the upper tract. A 14 F ureteral access sheath (UAS) of appropriate length was inserted over the guidewire. A flexible ureteroscope was next advanced over the same guidewire, reaching to the renal pelvis. A complete inspection of the pelvicalyceal system was performed and small stones were removed using a nitinol basket. Stones located in the pelvis and the upper pole were fragmented using a 365-μm laser fiber with an energy setting of 1–1.5 J and a rate of 8–12 Hz. Stones located in middle or lower pole were fragmented using 200-μm laser fiber at an energy setting of 0.8–1 J and a rate of 10–15 Hz. After adequate stone fragmentation, the larger fragments were removed with a stone basket; the smaller fragments were either irrigated out or left in situ for the patient to pass. At the end of the procedure, a fluoroscope was used to check for large residual fragments. The UAS was removed along with the ureteroscope. Ureteral injuries were visually assessed. A DJ was left in all the patients at the end of the procedure.
Enoxaparin administration within 24 hours of caesarean section: a 6-year single-centre experience and patient outcomes
Published in Journal of Obstetrics and Gynaecology, 2019
Kaori Moriuchi, Yoshitsugu Chigusa, Eiji Kondoh, Ryusuke Murakami, Yusuke Ueda, Haruta Mogami, Masaki Mandai
To the best of our knowledge, this is the largest study that collected cases receiving enoxaparin within 24 hours of CS. There are three previous studies in the literature regarding early enoxaparin usage. Watanabe et al. first demonstrated that compared with unfractionated heparin (n = 140), a thromboprophylaxis with enoxaparin (n = 131) soon after CS did not increase the incidence of haemorrhagic complications (two cases in unfractionated heparin; 2/140 = 1.4% vs. one case in enoxaparin; 1/131 = 0.76%) (Watanabe et al. 2011). The usage of an epidural anaesthesia is unclear in this study. The second study was a retrospective study which enrolled 243 patients who received enoxaparin 2.85 hours (mean) after their operation. An epidural anaesthesia was not performed in all cases, and the authors reported 15 cases (6.2%) of haemorrhagic complications, although these patients did not require a further treatment (Shiga et al. 2016). The third study was a prospective cohort study that compared the safety of enoxaparin with unfractionated heparin. Among 98 participants who received enoxaparin 6 hours after operation, an epidural anaesthesia was performed in 95 cases, and serious bleeding complications were not detected (Mukai et al. 2016). The outcomes in our study are consistent with those previous studies.
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