Intravenous fluid regimens

La Société canadienne de pédiatrie vous autorise à imprimer une copie unique de ce document tiré de notre site Web. Pour obtenir l'autorisation d'en réimprimer ou d'en reproduire des copies multiples, lisez notre politique sur les droits d'auteur, à l'adresse www. Jeremy N Friedman; Société canadienne de pédiatrie. Le présent point de pratique expose les connaissances actuelles du problème et contient un résumé des recherches récentes sur le sujet.

En raison du ratio plus élevé entre leur cerveau et leur volume intracrânien, les enfants risquent davantage de présenter ces séquelles que les adultes. Ces recommandations découlaient de la dépense calorique des enfants en santé, tandis que la composition électrolytique était dérivée de celle du lait humain et du lait de vache.

Les premières études prospectives comparant la tonicité des solutés IV portaient principalement sur les populations ayant subi une intervention chirurgicale ou hospitalisés en soins intensifs, certaines études plus petites incluant des enfants admis dans des unités hospitalières [ 17 ] - [ 25 ].

La méthodologie de la deuxième étude, menée au Canada, était semblable à celle effectuée en Australie [ 32 ]. Les présentes recommandations ne visent pas les nourrissons et les enfants qui ne font pas partie du groupe des enfants âgés de un mois à 18 ans. Le comité de la pédiatrie communautaire de la Société canadienne de pédiatrie a révisé le présent point de pratique.

Therefore, they assumed that co-loading could fill the central compartment as volume would shift towards the periphery, and that this regimen would be more effective than preloading to prevent maternal hypotension. Two studies in parturients compared directly crystalloid preload with co-load.

The effect panty minceur intersport a colloid co-load was compared with colloid preload in four separate studies.

In one study, Teoh et al. The investigators noted a transient increase in cardiac output at five and ten minutes following spinal anesthesia in patients receiving crystalloids and colloids, respectively. To summarize, compared with all other intravascular loading strategies, the regimen consisting in the administration of a crystalloid solution as preload regimen I is the least advantageous for the prevention of maternal hypotension and maintenance of cardiac output.

At present, there is not enough evidence to favour any intravascular loading regimen over the others. Colloids are likely to offer more flexibility as their administration, as preload or co-load, provides the same benefits. On the other hand, hydroxyethyl starches are more expensive than crystalloid solutions and can be associated with pruritus, alterations in hemostasis, and renal failure. They also carry the risk of anaphylaxis, with an incidence of 0. In Canada, ephedrine and phenylephrine are the two most commonly used vasopressors to treat hypotension induced by spinal anaesthesia during Cesarean delivery.

Traditionally, phenylephrine was used only as a second line agent, as there were concerns about its predominant vasoconstrictive action that could result in a reduction of local utero-placental perfusion and compromise fetal well-being.

However, many studies showed in elective Cesarean deliveries that giving ephedrine resulted in more fetal acidosis than phenylephrine. There is general agreement among experts to recommend the use of phenylephrine as first line therapy for the treatment of arterial hypotension induced by spinal anesthesia.

Over the last few years, prophylactic administration of phenylephrine infusions has gained in popularity. This pharmacological approach to prevent maternal hypotension has a number of advantages, including a clinically significant reduction of hypotensive episodes, as well as a lower incidence of nausea and vomiting, compared with the administration of phenylephrine prn. Episodes of bradycardia associated with hypertension are easily treated by reducing the phenylephrine infusion rate.

However, some patients will have bradycardia associated with hypotension ; in this case, ephedrine remains the drug of choice and is recommended. An alternative is to give an anticholinergic agent, e. Like Ngan Kee et al. However, ephedrine remains a vasopressor of choice in cases of maternal hypotension associated with bradycardia and should still be part of the easily and immediately available therapeutic armamentarium.

Virtually all studies comparing ephedrine with phenylephrine with respect to maternal and fetal outcomes were performed in healthy subjects with normal pregnancies who presented with no co-morbidities or indicators of fetal distress.

Extrapolating the results of these studies to patients showing signs of utero-placental hypoperfusion must be done with great caution.

Indeed, a study conducted on an animal model of placental hypoperfusion suggests that phenylephrine is associated with reduced utero-placental flow and increased vascular resistance, and increased fetal lactate levels. No study has evaluated the effects of a phenylephrine infusion on fetal variables in human subjects. Recent literature shows that phenylephrine infusion may cause i reduced maternal cardiac output and an increased peripheral vascular resistance; ii decreased PaO 2 in the umbilical cord venous and arterial blood, suggesting increased fetal oxygen extraction to compensate for a possible reduction of the utero-placental flow.

Therefore, we cannot recommend the use of a phenylephrine infusion as first line treatment for maternal hypotension in the setting of an emergency Cesarean delivery under spinal anesthesia, when there are signs of utero-placental insufficiency.

Further studies are required to establish the safety of such practice. A detailed discussion regarding the pathophysiological concepts and anesthetic considerations relevant to pre-eclampsia is beyond the scope of this Continuing Professional Development module. We will therefore direct the reader to the excellent review written on this topic by Gogarten.

Moreover, sympathetic blockade causes only a modest decrease in peripheral vascular resistance in pre-eclamptic women, and this may explain the lower incidence of hypotension in these patients.

There is no study that compares phenylephrine and ephedrine in these patients. Considering a potential increased sensitivity to vasopressors in these patients, low to moderate doses of vasopressors e.

It is apparent that further studies evaluating use of of vasopressor medications in pre-eclamptic patients are warranted. Recent studies suggest that pre-eclamptic patients can tolerate the volume loading of crystalloids in excess of 1 L without inducing pulmonary edema.

The practice of obstetrical anesthesia is in constant evolution, and the changing management of arterial hypotension induced by spinal anesthesia for Cesarean delivery is a clear illustration of the progress in clinical care we observe. The introduction of colloids, co-loading strategies, and phenylephrine infusions in daily practice greatly improves the management of hypotension and increases maternal comfort during elective caesarean deliveries under spinal anesthesia.

The safety of both approaches to fluid management and phenylephrine administration appears to be well established. It remains to be seen whether one or the other of the different maigrir hanche gym and vasopressor prophylactic regimens provides an advantage in healthy parturients in terms of long-term complications such as wound infections and sepsis, wound healing, postoperative bleeding, and hospital length of stay.

These questions will be the subject of forthcoming clinical studies. A yr-old healthy pregnant woman is transferred to the operating room for an elective Cesarean delivery. The patient refuses an attempt of vaginal delivery, having had a previous Cesarean delivery in the past. The current pregnancy has been unremarkable, and the related obstetrical history, review of systems, physical examination, and fetal heart rate are all reassuring.

Not anticipating any special issues of concerns, you proceed with spinal anesthesia for the surgery. Your plan is to administer 0. Her past medical history is negative. She has no other signs reflecting the severity of the disease, such as pulmonary edema, disorders of hemostasis, headaches or liver pain.

You offer the patient a spinal anesthetic.

Intravenous fluid regimens

Read the current article and the references indicated in bold. Par ailleurs, Tamilselvan et coll. Tout au plus, Teoh et coll. Les investigateurs ont remarqué une augmentation transitoire du débit cardiaque dans les cinq et dix premières minutes suivant la rachianesthésie chez les sujets recevant des cristalloïdes et des colloïdes, respectivement. Les colloïdes offrent probablement plus de flexibilité puisque leur administration en préremplissage ou en coremplissage procure les mêmes avantages.

Pendant longtemps, la phényléphrine a été utilisée en seconde intention car on craignait que son effect vasoconstricteur prédominant puisse réduire la perfusion régionale utéroplacentaire et compromettre le bien-être foetal. La discussion détaillée des concepts physiopathologiques et des considérations anesthésiques reliés à la pré-éclampsie dépasse les objectifs de ce module de développement professionnel continu.

Ainsi, nous réferrons le lecteur à une excellente synthèse écrite sur le sujet par Gogarten.

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La sécurité des deux types de liquide et de la phényléphrine semble maintenant bien acceptée par la communauté scientifique. Une femme enceinte de 28 ans en bonne santé se présente au bloc opératoire pour subir une césarienne programmée. Vous lui proposez une anesthésie rachidienne. Lisez cet article et les références en gras. Skip to main content Skip to sections. Advertisement Hide. Download PDF. Fluid and vasopressor management for Cesarean delivery under spinal anesthesia: Continuing Professional Development.

Purpose The purpose of this Continuing Professional Development module is to review the physiology of maternal hypotension induced by spinal anesthesia in pregnant women, and the effects of fluids and vasopressors. Principal findings Maternal hypotension induced by spinal anesthesia is caused mainly by peripheral vasodilatation and is not usually associated with a decrease in cardiac output.

Conclusion A volume loading regimen other than crystalloid preload should be adopted. This process is experimental and the keywords may be updated as the learning algorithm improves. La prise en charge des liquides et des vasopresseurs pour la césarienne effectuée sous rachianesthésie.

Conclusion Une stratégie de remplissage vasculaire autre que le préremplissage avec des cristalloïdes devrait être employée. Plan the fluid and vasopressor therapy in the case of an urgent Cesarean delivery. For adequate surgical anesthesia during a Cesarean delivery, the sensory blockade level should be as high as the T5 dermatome. Moreover, Tamilselvan et al. Even aggressive intravascular volume loading, especially with crystalloids i.

Studies showed that intravascular volume loading given prior to the administration of the spinal anesthestic increases cardiac output. However, maintenance of cardiac output during onset of sympathetic blockade depends, in part, on both the type of fluid given crystalloids or colloids and the timing of its administration.

Open image in new window. Emergency Cesarean deliveries Virtually all studies comparing ephedrine with phenylephrine with respect to maternal and fetal outcomes were performed in healthy subjects with normal pregnancies who presented with no co-morbidities or indicators of fetal distress. Pre-eclampsia A detailed discussion regarding the pathophysiological concepts and anesthetic considerations relevant to pre-eclampsia is beyond the scope of this Continuing Professional Development module.

Instructions for completing the continuing professional development CPD module: 1. Answer the multiple choice questions regarding the case scenario.

Après avoir lu ce module, le lecteur devrait être en mesure de: 1- décrire les principaux changements hémodynamiques induits par la rachianesthésie chez la femme enceinte subissant une césarienne programmée. De plus, Tamilselvan et coll. Pré-éclampsie La discussion détaillée des concepts physiopathologiques et des considérations anesthésiques reliés à la pré-éclampsie dépasse les objectifs de ce module de développement professionnel continu.

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Directives pour compléter le module de développement professionnel continu DPC 1. Répondez aux questions à choix de réponses concernant les cas cliniques. Russell IF. Levels of anaesthesia and intraoperative pain at caesarean section under regional block. Int J Obstet Anesth ; 4: Spinal anaesthesia for caesarean section: fluid loading, vasopressors and hypotension French.

Ann Fr Anesth Reanim ; Definitions of hypotension after spinal anaesthesia for caesarean section: literature search and application to parturients. Acta Anaesthesiol Scand ; Management of hypotension following spinal anesthesia for cesarean section. Anesth Analg ; Maternal and fetal haemodynamic effects of spinal and extradural anaesthesia for elective caesarean section. Br J Anaesth ; The effects of varying volumes of crystalloid administration before cesarean delivery on maternal hemodynamics and colloid osmotic pressure.

PubMed Google Scholar. The effects of an increase of central blood volume before spinal anesthesia for cesarean delivery: a qualitative systematic review. Continuous invasive blood pressure and cardiac output monitoring during cesarean delivery: a randomized, double-blind comparison of low-dose versus high-dose spinal anesthesia with intravenous phenylephrine or placebo infusion.

Anesthesiology ; Suprasternal Doppler estimation of cardiac output: standard versus sequential combined spinal epidural anesthesia for cesarean delivery. Incremental spinal anaesthesia for elective caesarean section: maternal and fetal haemodynamic effects.

The effects of crystalloid and colloid preload on cardiac output in the parturient undergoing planned cesarean delivery under spinal anesthesia: a randomized trial. Randomized trial of bolus phenylephrine or ephedrine for maintenance of arterial pressure during spinal anaesthesia for caesarean section. Hemodynamic effects of ephedrine, phenylephrine, and the coadministration of phenylephrine with oxytocin during spinal anesthesia for elective cesarean delivery.