Jinekolojik ve Obstetrik Cerrahide Anestezi ve Analjezi
Özet
Jinekolojik ve obstetrik cerrahide anestezi ve analjezi yönetimi; hastanın klinik durumu, cerrahi yöntemin niteliği ve Amerikan Anestezi Derneği (ASA) risk skorlaması doğrultusunda belirlenmektedir. Laparotomik, laparoskopik ve histeroskopik jinekolojik girişimlerde hastanın pozisyonuna bağlı hemodinamik ve solunumsal fizyolojik değişiklikler ile dilüsyonel hiponatremi ve emboli gibi ciddi komplikasyon riskleri yakından izlenmelidir. Obstetrik cerrahi ve ağrısız doğum uygulamalarında ise maternal mortaliteyi azaltmak adına, kontrendikasyon bulunmadığı sürece rejyonel anestezi (spinal, epidural veya kombine) ilk tercih olarak önerilmektedir. Tok gebelerde genel anestezi uygulanması gerektiğinde zor havayolu ve aspirasyon pnömonisi risklerine karşı hızlı seri indüksiyon ve preoperatif antiasit tedavisi hayati önem taşır. Transversus abdominis ve quadratus lumborum gibi gövde blokları postoperatif opioid tüketimini azaltırken, rejyonel anestezide lokal anesteziklere eklenen düşük doz lipofilik opioidler güçlü analjezi sağlar. Anestezik ajanların çoğunun anne sütüne geçişi minimal düzeydedir. Sonuç olarak, perioperatif dönemde hasta onamının alınması, yakın monitörizasyon ve multidisipliner iletişim, komplikasyonları en aza indirerek hasta konforunu ve anne-bebek bağını optimize etmektedir.
Anesthesia and analgesia management in gynecological and obstetric surgeries is determined based on the patient's clinical status, the characteristics of the surgical method, and the American Society of Anesthesiologists (ASA) risk scoring. Hemodynamic and respiratory physiological changes depending on the patient's positioning, as well as serious complication risks such as dilutional hyponatremia and embolism, must be closely monitored during laparotomies, laparoscopic, and hysteroscopic gynecological interventions. In obstetric surgery and labor analgesia, regional anesthesia (spinal, epidural, or combined) is recommended as the primary choice unless contraindicated to reduce maternal mortality. When general anesthesia is required in full-stomach pregnant patients, rapid sequence induction and preoperative antacid treatment are vital against the risks of difficult airway and aspiration pneumonitis. While plane blocks such as transversus abdominis and quadratus lumborum reduce postoperative opioid consumption, low-dose lipophilic opioids added to local anesthetics in regional anesthesia provide potent analgesia. The transition of most anesthetic agents into breast milk is minimal. Consequently, obtaining patient consent, close monitoring, and multidisciplinary communication during the perioperative period minimize complications, thereby optimizing patient comfort and the mother-infant bond.
Referanslar
Günaydın B. ASA Fiziksel Durum Sınıflandırma Sistemi: ASA Physical Status Classification System. Turk J Anaesthesiol Reanim. 2021;49(2):192-193.
American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Practice advisory for preanesthesia evaluation Anesthesiology. 2002;96(2):485-96.
Schneck H, Scheller M. Acid aspiration prophylaxis and caesarean section. Curr Opin Anaesthesiol. 2000 Jun;13(3):261-5. doi: 10.1097/00001503-200006000-00004. PMID: 17016311.
Paranjothy S, Griffiths JD, Broughton HK, Gyte GML, Brown HC, Thomas J. Interventions at caesarean section for reducing the risk of aspiration pneumonitis. International Journal of Obstetric Anesthesia. 2011;20:142–8.).
Johns N, O'Neill S, Ventham NT, Barron F, Brady RR, Daniel T. Clinical effectiveness of transversus abdominis plane (TAP) block in abdominal surgery: a systematic review and meta-analysis. Colorectal Dis. 2012 Oct;14(10):e635-42. doi: 10.1111/j.1463-1318.2012.03104.x. PMID: 22632762.).
Elsharkawy H, El-Boghdadly K, Barrington M. Quadratus Lumborum Block: Anatomical Concepts, Mechanisms, and Techniques. Anesthesiology. 2019 Feb;130(2):322-335. doi: 10.1097/ALN.0000000000002524. PMID: 30688787.
Zhou H, Ma X, Pan J, Shuai H, Liu S, Luo X, Li R. Effects of transversus abdominis plane blocks after hysterectomy: a meta-analysis of randomized controlled trials. J Pain Res. 2018 Oct 18;11:2477-2489. doi: 10.2147/JPR.S172828. PMID: 30425560; PMCID: PMC6204870.
Tran DQ, Bravo D, Leurcharusmee P, Neal JM. Transversus Abdominis Plane Block: A Narrative Review. Anesthesiology. 2019 Nov;131(5):1166-1190. doi: 10.1097/ALN.0000000000002842. PMID: 31283738.
Paranjothy S, Griffiths JD, Broughton HK, Gyte GML, Brown HC, Thomas J. Interventions at caesarean section for reducing the risk of aspiration pneumonitis. International Journal of Obstetric Anesthesia. 2011;20:142–8.)
Butterworth J, Mackey D, Wasnick J, editors. Spinal, epidural and caudal blocks. Morgan & Mikhail’s ClinicalAnesthesiology. 5th ed. 2013. p. 937-74.
Balki M, Carvalho JCA. Intraoperative nausea and vomiting during cesarean section under regional anesthesia. Int JObstet Anesth 2005;14: 230–41.
Tsen LC. Anesthesia for cesarean delivery. In: Chestnut DH, Wong CA, Tsen LC, Ngan Kee W, Beilin Y, Mhyre J, editors.Chestnut’s Obstetric Anesthesia Principles and Practice. 5th edition. Phidelphia: Elseiver Saunders; 2014. p. 545–603
George RB, Allen TK, Habib AS. Serotonin receptor antagonists for the prevention and treatment of pruritus, nausea, and vomiting in women undergoing cesarean delivery with intrathecal morphine: A systematic review and meta-analysis. AnesthAnalg 2009;109:174–82.
Gerges FJ, Kanazi GE, Jabbour-Khoury SI. Anesthesia for laparoscopy: a review. J Clin Anesth. 2006 Feb;18(1):67-78. doi: 10.1016/j.jclinane.2005.01.013. PMID: 16517337.
Schoeffler P, Bazin JE, Fourgeaud L. Anästhesie für die laparoskopische Chirurgie [Anesthesia for laparoscopic surgery]. Ther Umsch. 1993 Aug;50(8):559-63. German. PMID: 8211856.
Hirvonen EA, Nuutinen LS, Kauko M. Hemodynamic changes due to Trendelenburg positioning and pneumoperitoneum during laparoscopic hysterectomy. Acta Anaesthesiol Scand. 1995 Oct;39(7):949-55. doi: 10.1111/j.1399-6576.1995.tb04203.x. PMID: 8848897.
Gutt CN, Oniu T, Mehrabi A, Schemmer P, Kashfi A, Kraus T, Büchler MW. Circulatory and respiratory complications of carbon dioxide insufflation. Dig Surg. 2004;21(2):95-105. doi: 10.1159/000077038. Epub 2004 Feb 27. PMID: 15010588.
Günaydın B, Polat GG. Traş B (Çeviri editörü) Nezhat’ın Operatif Jinekolojik Laparoskopi ve Histeroskopisi. Ankara, Güneş Tıp Kitapevi, 2011:35-39
Schoeffler P, Bazin JE, Fourgeaud L. Anästhesie für die laparoskopische Chirurgie [Anesthesia for laparoscopic surgery]. Ther Umsch. 1993 Aug;50(8):559-63. German. PMID: 8211856.
Kahokehr A, Sammour T, Soop M, Hill AG. Intraperitoneal use of local anesthetic in laparoscopic cholecystectomy: systematic review and metaanalysis of randomized controlled trials. J Hepatobiliary Pancreat Sci. 2010 Sep;17(5):637-56. doi: 10.1007/s00534-010-0271-7. PMID: 20393755.
Gerges FJ, Kanazi GE, Jabbour-Khoury SI. Anesthesia for laparoscopy: a review. J Clin Anesth. 2006 Feb;18(1):67-78. doi: 10.1016/j.jclinane.2005.01.013. PMID: 16517337..)
Cholkeri-Singh A, Sasaki KJ. Hysteroscopy safety. Curr Opin Obstet Gynecol. 2016 Aug;28(4):250-4. doi: 10.1097/GCO.0000000000000289. PMID: 27258237.
Bradley LD. Complications in hysteroscopy: prevention, treatment and legal risk. Curr Opin Obstet Gynecol. 2002 Aug;14(4):409-15. doi: 10.1097/00001703-200208000-00008. PMID: 12151831.
Roofthooft E, Joshi GP, Rawal N, Van de Velde M; PROSPECT Working Group* of the European Society of Regional Anaesthesia and Pain Therapy and supported by the Obstetric Anaesthetists’ Association. PROSPECT guideline for elective caesarean section: updated systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia. 2021 May;76(5):665-680. doi: 10.1111/anae.15339. Epub 2020 Dec 28. PMID: 33370462; PMCID: PMC8048441.
American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Practice guidelines for obstetric anesthesia: an updated report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Anesthesiology. 2007 Apr;106(4):843-63. doi: 10.1097/ALN.0000000000000935. PMID: 26580836.
Mushambi MC, Athanassoglou V, Kinsella SM. Anticipated difficult airway during obstetric general anaesthesia: narrative literature review and management recommendations. Anaesthesia. 2020 Jul;75(7):945-961. doi: 10.1111/anae.15007. Epub 2020 Mar 6. PMID: 32144770.
Practice Guidelines for Obstetric Anesthesia: An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia and the Society for Obstetric Anesthesia and Perinatology. Anesthesiology. 2016 Feb;124(2):270-300. doi: 10.1097/ALN.0000000000000935. PMID: 26580836.
Trikha A, Singh PM. Management of major obstetric haemorrhage. Indian J Anaesth. 2018 Sep;62(9):698-703. doi: 10.4103/ija.IJA_448_18. PMID: 30237595; PMCID: PMC6144554.
Mitchell KD, Smith CT, Mechling C, Wessel CB, Orebaugh S, Lim G. A review of peripheral nerve blocks for cesarean delivery analgesia. Reg Anesth Pain Med. 2019 Oct 25:rapm-2019-100752. doi: 10.1136/rapm-2019-100752. Epub ahead of print. PMID: 31653797; PMCID: PMC7182469.
Mitchell J, Jones W, Winkley E, Kinsella SM. Guideline on anaesthesia and sedation in breastfeeding women 2020: Guideline from the Association of Anaesthetists. Anaesthesia. 2020 Nov;75(11):1482-1493. doi: 10.1111/anae.15179. Epub 2020 Aug 1. PMID: 32737881.)
Wong CA. Epidural and Spinal Analgesi/Anesthesia for Labor and Delivery. In:Chesnut DH, Polly LS, Tsen LC, Wong CA(eds). Chesnut’s Obstetric Anesthesia Principals and Practice. 4th edition. Philadelphia: Elsevier Mosby 2009; 429-92.
Ngan Kee WD, Khaw KS, Tan PE, Ng FF, Karmakar MK. Placental transfer and fetal metabolic effects of phenylephrine and ephedrine during spinal anesthesia for cesarean delivery. Anesthesiology. 2009 Sep;111(3):506-12. doi: 10.1097/ALN.0b013e3181b160a3. PMID: 19672175.
Loo CC, Dahlgren G, Irestedt L. Neurological complications in obstetric regional anaesthesia. Int J Obstet Anesth. 2000 Apr;9(2):99-124. doi: 10.1054/ijoa.1999.0347. PMID: 15321097.
Orbach-Zinger S, Jadon A, Lucas DN, Sia AT, Tsen LC, Van de Velde M, Heesen M. Intrathecal catheter use after accidental dural puncture in obstetric patients: literature review and clinical management recommendations. Anaesthesia. 2021 Aug;76(8):1111-1121. doi: 10.1111/anae.15390. Epub 2021 Jan 21. PMID: 33476424.
Van de Velde M. Low-dose spinal anesthesia for cesarean section to prevent spinal-induced hypotension. Curr Opin Anaesthesiol. 2019 Jun;32(3):268-270. doi: 10.1097/ACO.0000000000000712. PMID: 30747727.
