Annales françaises d'anesthèsie et de rèanimation
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Ann Fr Anesth Reanim · Jan 2006
[Pregnant woman anaesthetic management in gynaecologic laparoscopic surgery at the maternity hospital of Clermont-Ferrand].
To evaluate the anaesthetic management intended for pregnant women in the field of non obstetric and gynaecologic laparoscopic surgery. ⋯ Laparoscopic surgery during pregnancy requires double skilled management, both in anaesthesiology and obstetrics. On haemodynamics and breathing, pneumoperitoneum does not induce any additional effects when compared to operations without pregnancy. Except with delivery cases, anaesthetic support in laparoscopic surgery intended for pregnant women eventually does not generate any specific problems, but requires the same rigorous management as the one usually following surgery for pregnant patients.
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Many systemic techniques, so-called "alternatives" to labor epidural analgesia, have been described: they are all poorly effective and some are associated with significant maternal and neonatal side effects. Nonetheless, these techniques can provide good maternal satisfaction. Accordingly, they are indicated when epidural analgesia is contraindicated or unavailable. ⋯ It is not recommended to add it to systemic opioid (except under continuous supervision by the anaesthetic team), because of an increased incidence of maternal desaturation. The use of a subanaesthetic concentration of sevoflurane has been described recently; it is more effective than nitrous oxide. However, guidelines for safe implementation in labor ward remain to be determined.
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Recent data in animal experiments as in clinical trials have clearly reported that pain modulation is related to an equilibrium between antinociceptive and pronociceptive systems. Therefore, the apparent pain level could not only be a consequence of a nociceptive input increase but could also result from a pain sensitization process. Glutamate, via NMDA receptors, plays a major role in the development of such a neuronal plasticity in the central nervous system, leading to a pain hypersensitivity that could facilitate chronic pain development. ⋯ Many studies have reported that ketamine effects are elicited when this drug is administered the following manner: peroperative bolus (0.1 to 0.5 mg/kg), followed by a constant infusion rate (1 to 2 microg/kg per min) during the peroperative period and for 48 to 72 hours after anaesthesia. Those ketamine doses improved postoperative pain management by reducing hyperalgesia due to both surgical trauma and high peroperative opioid doses. This antihyperalgesic action of ketamine also limited the postoperative morphine tolerance leading to a decrease in analgesic consumption and an increase in the analgesia quality.