During the perioperative and postoperative care of pregnant women it is prudent to pay close attention to the changed physiology of these patients. The main principles of care are the preservation of maternal and fetal homeostasis as well as avoidance of any substances with toxic effects on the fetus. In order to provide pregnant patients with good quality care, all relevant disciplines should be involved as early as possible. Modern anesthetic drugs can be used as they seem to be without teratogenic effects. Adequate perioperative surveillance and assessment of the fetus is also important.The mainstay of pain management during pregnancy is the World Health Organization (WHO) pain ladder. It is of the utmost importance to use only substances without teratogenic or fetotoxic properties. Considering non-opioid drugs, the use of paracetamol is a viable option, whereas non-steroidal anti-inflammatory drugs (NSAID) should only be used with rigorous restrictions. Tramadol is a first-line drug when using opioids with low potency, whereas morphine can be used as an opioid with a higher potency after careful consideration of the risk-benefit ratio. If possible anticonvulsives should not be used as an adjunct in pain management during pregnancy. The use of thoroughly investigated antidepressants seems to be a better alternative. Apart from drug therapy it is important to use all available conservative pain treatment options.
ZusammenfassungArterielle Hypertonie, Herzinsuffizienz und koronare Herzerkrankung kann man in Deutschland als Volkskrankheiten betrachten. Somit ist der Anästhesist täglich mit Patienten konfrontiert, die kardial wirksame Medikamente einnehmen. Welche soll man perioperativ weiter verabreichen und welche besser pausieren? Dieser Beitrag stellt hierzu internistische Behandlungskonzepte und den perioperativen Umgang mit kardialen Medikamenten vor.
Purpose of review
This review summarizes the current indications and principles of ECT. Contemporary anesthetic considerations are described with a focus on the optimal use of hypnotic agents and providing ECT in pregnant patients.
Recent findings
ECT is useful in treatment-resistant major depression, bipolar disorders, and treatment-resistant schizophrenia. It is a well tolerated treatment in pregnant patients with treatment-resistant depression. Cognitive side effects may be attenuated by using unilateral placement of scalp electrodes, fewer treatment sessions, and the use of ultrabrief pulse width of the electrical charge. All modern hypnotics can be used for induction of anesthesia for ECT but should be titrated to effect. Etomidate is superior to Propofol in regarding seizure quality. The use of Ketamine shows good seizure quality and may alleviate cognitive impairment. Providing ECT for pregnant patients may prove challenging because of logistic difficulties and the physiologic changes during pregnancy. Although representing an effective treatment option in severely ill patients, ECT is underutilized because of stigmatization and ethnic and financial disparities.
Summary
ECT is effective in treating treatment-resistant psychiatric illnesses. Symptoms of cognitive impairment are the most common side effects but can be treated by modifying the technique of ECT. All modern hypnotics can be used for the induction of general anesthesia. Etomidate and Ketamine may be of special interest in patients with insufficient seizure duration. Treating pregnant patients with ECT requires a multidisciplinary approach, in order to provide a safe therapy for mother and unborn child. Stigmatization and social disparities are hindering the widespread use of ECT as an effective treatment for severely ill psychiatric patients.
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