Eroin Kullanımı Olan Gebede Acil Sezaryen için Anestezi Yönetimi

Asiye Özkan Kaya; Resul Yılmaz

doi:10.37609/akya.3402

Yazarlar

Asiye Özkan Kaya

https://orcid.org/0000-0001-5419-8823

Resul Yılmaz

https://orcid.org/0000-0002-5527-2893

DOI: https://doi.org/10.37609/akya.3402.c11297

Özet

Otuz bir yaşındaki kadın hasta, preterm eylem ve fetal bradikardi nedeniyle acil sezaryen ile doğumuna karar verildi. Preoperatif değerlendirme sırasında, hastada bilinç bulanıklığı ve halüsinasyonlar gözlemlendi. Yakınlarından alınan bilgiye göre, hastanın günlük eroin kullanımı olduğu belirlendi. Fizik muayenesinde kaşeksi, kötü diş sağlığı ve miyotik pupiller dikkat çekiyordu. Monitörizasyon sonrasında elektrokardiyografi (EKG)’de supraventriküler taşikardi ve solunum sayısında azalma saptandı. Preoperatif rutin laboratuvar testlerinde hemoglobin, trombosit ve glukoz seviyeleri normal bulunurken, karaciğer enzimlerinde yükseklik tespit edildi. Genel anestezi altında sezaryen operasyonu gerçekleştirildi. Madde bağımlılığı olan gebelerin perioperatif yönetimi hem anestezi uzmanları hem de obstetrik ekipler için önemli bir zorluktur. Anestezik ajanlar ile madde etkileşimlerini önlemeye ve komplikasyonları azaltmaya odaklanılmalıdır. Bu süreçte klinik sorgulama, fizik muayene ve laboratuvar testleri önemlidir. İntraoperatif dönemde, temel monitörizasyonun yanı sıra hemodinamik stabilite sağlanmalı ve mümkünse rejyonel anestezi tercih edilmelidir. Opioid toleransı ve yoksunluk sendromu göz önünde bulundurularak uygun anestezik ajanlar seçilmelidir. Postoperatif dönemde ise analjezi yönetimi dikkatle yapılmalı ve opioid yoksunluğu riski göz önünde bulundurulmalıdır. Madde bağımlılığı olan gebelerin perioperatif yönetimi, multidisipliner bir yaklaşım gerektirir ve her hasta için bireysel olarak değerlendirilmelidir. Bu yaklaşım hem anne hem de bebek için en iyi sonuçları sağlamak için önemlidir. Bu bölümde, eroin bağımlısı, acil sezaryen ile doğum kararı alınması sonrası operasyona alınan bir gebede perioperatif yönetimde dikkat edilmesi gereken durumlara yer verilmiştir.

A 31-years-old woman patient was delivered by emergency cesarean section due to preterm labor and fetal bradycardia. During preoperative evaluation, confusion and hallucinations were observed in the patient. According to information received from his relatives, it was determined that the patient was a daily heroin user. Physical examination revealed cachexia, poor dental health, and miotic pupils. After monitoring, supraventricular tachycardia on electrocardiogram (EKG) and a decrease in respiratory rate were detected. Preoperative routine laboratory tests revealed normal hemoglobin, platelet and glucose levels, while elevated liver enzymes were detected. A cesarean section was performed under general anesthesia. Perioperative management of pregnant women with substance abuse is a significant challenge for both anesthesiologists and obstetric teams. It focuses on preventing substance interactions with anesthetic agents and reducing complications. Clinical questioning, physical examination and laboratory tests are important in this process. In the intraoperative period, in addition to basic monitoring, hemodynamic stability should be ensured and regional anesthesia should be preferred. Appropriate anesthetic agents should be selected taking into account opioid tolerance and withdrawal syndrome. In the postoperative period, analgesia management should be done carefully and the risk of opioid withdrawal should be taken into consideration. Perioperative management of pregnant women with substance abuse requires a multidisciplinary approach and should be evaluated individually for each patient. This approach is important to ensure the best outcomes for both mother and baby. In this section, the situations that need to be taken into consideration in the perioperative management of a pregnant woman who is addicted to heroin and who undergoes surgery after the decision to deliver by emergency cesarean section are included.

Referanslar

WHO Technical Report Series. WHO Expert Committee on Drug Dependence.Thirty-thirdreport Page:26. Available from: https://www.who.int/publications/i/item/9241209151 (Accessed 12 th May 2024)

Vucinovic M, Roje D, Vucinovic Z, et al. Maternal and neonatal effects of substance abuse during pregnancy: our ten year experience. Yonsei Medical Journal. 2008 Oct 31;49(5):705-713. doi:10.3349/ymj.2008.49.5.705

Cavaliere F, Iacobone E, Gorgoglione M, et al. Anesthesiologic preoperative evaluation of drug addicted patient. Minerva Anesthesiol 2005; 71:367-71. 5.

Genç, Simten, and Veli Mihmanlı. "Madde bağımlılığı ve gebelik." Okmeydanı Tıp Dergisi 30.2 (2014): 120-123. doi:10.5222/otd.supp2.2014.120

Rizk AH, Simonsen SE, Roberts L, et al. Maternity Care for Pregnant Women with Opioid Use Disorder: A Review. Journal of Midwifery Womens Health. 2019 Sep;64(5):532-544. doi:10.1111/jmwh.13019

Kuczkowski, Krzystof M. Anesthetic implications of drug abuse in pregnancy. Journal of Clinical Anesthesia. 2003 Aug;15(5):382-94. doi:10.1016/s0952-8180(03)00056-4

Koltenyuk V, Mrad I, Choe I, et al. Multimodal Acute Pain Management in the Parturient with Opioid Use Disorder: A Review. Journal of Pain Research. 2024 Feb 29;17:797-813 doi:10.2147/JPR.S434010

Karacalar Serap, Namigar Turgut, and Esra Akdaş Tekin. "Madde bağımlısı hastalarda anestezi uygulamaları ve yoğun bakımda karşılaşılan problemler." Okmeydanı Tıp Dergisi 30 (2014): 134-142. doi:10.5222/otd.supp2.2014.134

Gök F, Yosunkaya K. Yoğun Bakımda Hemodinamik Monitorizasyon. Turkiye Klinikleri J Anest Reanim-Special Topics 2012;5:1-13

Sangkum L., Thamjamrassri T., Arnuntasupakul, V., et al. (2021). The current consideration, approach, and management in postcesarean delivery pain control: a narrative review. Anesthesiology Research and Practice, 2021. doi:10.1155/2021/2156918

Roofthooft E., Joshi G.P., Rawal N., et al. on behalf of the 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: Update systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia. 2022;76:665–680. doi:10.1111/anae.15339

Tawfik MM, Mohamed YM, Elbadrawi RE, et al. Transversus Abdominis Plane Block Versus Wound Infiltration for Analgesia After Cesarean Delivery: A Randomized Controlled Trial. Anesthesia & Analgesia. 2017 Apr;124(4):1291-1297. doi:10.1213/ANE.0000000000001724

Singh NP, Makkar JK, Yadav N, et al. The analgesic efficacy of intravenous dexamethasone for post-caesarean pain: A systematic review with meta-analysis and trial sequential analysis. European Journalof Anaesthesiology 2022 Jun 1;39(6):498-510. doi:10.1097/EJA.0000000000001626

Gerbershagen MU, Baagil H. Caesarean Delivery: A Narrative Review on the Choice of Neuraxially Administered Opioid and Its Implications for the Multimodal Peripartum Pain Concept. Medicina (Kaunas). 2024 Feb 21;60(3):358. doi:10.3390/medicina60030358

Abebe M, Alemu B, Teku G, et al. Effectiveness of Single Intravenous Dexamethasone in Prolongation of Spinal Anesthesia for Postoperative Analgesia in Elective Cesarean Section: A Systematic Review of Randomized Controlled Trials. Journal of Pain Research. 2024 Apr 5;17:1361-1368. doi:10.2147/JPR.S451595

Zuarez-Easton S, Erez O, Zafran N,et al. Pharmacologic and nonpharmacologic options for pain relief during labor: an expert review. American Journal of Obstetrics and Gynecology 2023 May;228(5S):S1246-S1259. doi:10.1016/j.ajog.2023.03.003

Bradfield Z, Rose MS, Freeman N, et al. Women's perspectives of nitrous oxide for labour and procedural analgesia: A prospective clinical audit and cross-sectional study. "It's the best thing". Women and Birth. 2023 Nov;36(6):529-537. doi:10.1016/j.wombi.2023.06.007

Lucas DN, Siemaszko O, Yentis SM. Maternal hypoxaemia associated with the use of Entonox in labour. International Journal of Obstetric Anesthesia 2000 Oct;9(4):270-2. doi:10.1054/ijoa.1999.0383

Cheng DC. The drug addicted patient. Canadian journal of anaesthesia 1997 May;44(5 Pt 2): R101-11. English, French. doi:10.1007/BF03022269

Abushanab D, Al-Badriyeh D. Efficacy and Safety of Ibuprofen Plus Paracetamol in a Fixed-Dose Combination for Acute Postoperative Pain in Adults: Meta-Analysis and a Trial Sequential Analysis. CNS Drugs. 2021 Jan;35(1):105-120. doi:10.1007/s40263-020-00777-7

Ring LE, Landau R. Anesthetic management of the parturient with opioid addiction. International Anesthesiology Clinics. 2021 Jul 1;59(3):28-39. doi:10.1097/AIA.0000000000000323

Eidson LN, Murphy AZ. Inflammatory mediators of opioid tolerance: Implications for dependency and addiction. Peptides. 2019 May;115:51-58. doi:10.1016/j.peptides.2019.01.003

Jansson LM, Velez M, Harrow C. The opioid-ex- posed newborn: assessment and pharmacologic management. Journal of opioid management 2009; 5(1):47-55.

Anbalagan S, Falkowitz DM, Mendez MD. Neonatal Abstinence Syndrome. In: StatPearls. Treasure Island (FL): StatPearls Publishing; April 1, 2024.

Meyer M, Wagner K, Benvenuto A, et al. Intrapartum and postpartum analgesia for women maintained on methadone during pregnancy. Obstetrics & Gynecolgy 2007 Aug;110(2 Pt 1):261-6. doi:10.1097/01.AOG.0000275288.47258.e0

Kohan L, Potru S, Barreveld AM, et al. Buprenorphine management in the perioperative period: educational review and recommendations from a multisociety expert panel. Regional Anesth Pain Medicine. 2021 Oct;46(10):840-859. doi:10.1136/rapm-2021-103007

Ward EN, Quaye AN, Wilens TE. Opioid Use Disorders: Perioperative Management of a Special Population. Anesthesia & Analgesia. 2018 Aug;127(2):539-547. doi:10.1213/ANE.0000000000003477