Ashutosh Wali

Intrapartum epidural analgesia and maternal temperature regulation.

OBJECTIVE: To examine maternal temperature changes after epidural analgesia. METHODS: A prospective cohort of nulliparas at term was monitored with hourly maternal tympanic temperatures after epidural analgesia (n=99). Temperature response after epidural analgesia was examined in the group as a whole. Subsequently, mean maternal temperature curves were compared between women who remained afebrile throughout labor (n=77) and women who developed intrapartum fever with body temperature greater than 100.4ºF (n=22). Baseline maternal characteristics were assessed. RESULTS: Women who later developed intrapartum fever had a higher mean temperature within 1 hour after epidural analgesia. In contrast, women who remained afebrile had no increase in core temperature. During the first 4 hours after epidural analgesia initiation, women who later develop intrapartum fever have an increase in mean tympanic temperature of 0.33ºF per hour. CONCLUSION: Epidural analgesia is not associated with increased temperature in the majority of women. Hyperthermia is an abnormal response confined to a minority subset, which occurs immediately after exposure. Our findings do not support a universal perturbation of maternal thermoregulation after epidural analgesia. LEVEL OF EVIDENCE: II

Normovolemic hemodilution before cesarean hysterectomy for placenta percreta.

Background Placenta percreta can create life-threatening hemorrhage at the time of delivery. The additional challenge of patient refusal of blood transfusion for religious reasons requires the use of comprehensive blood-conserving strategies. Case A Jehovahs Witness with two previous cesarean deliveries and a placenta previa was diagnosed antenatally as having placenta percreta. Acute normovolemic hemodilution was performed in conjuction with cearean husterecomy with no maternal or fetal side effects. Conclusion Acute normovolemic hemodilution can be used safely in the pregnant woman at high risk for excessive intraoperative blood loss and should be considered in obstetric patients who strictly adhere to religious convictions prohibiting the acceptance of blood products.

Maternal Morbidity, Mortality, and Risk Assessment

Maternal deaths in developed countries continue to decline and are rare. Maternal mortality statistics are essentially similar in the United States and United Kingdom. However, the situation is completely different in developing countries, where maternal mortality exceeds 0.5 million every year. This article not only assesses morbidity risks in some of the leading causes of maternal death but also highlights strategies to minimize the risks and to prevent maternal morbidity and mortality.

Epiduroscopy: Review of technique and results

AbstractBack pain is a common medical problem with significant impact on society. It is estimated that 80% of adults in USA have back pain at some point in their life. It leads to over

An unexpected case of a difficult airway secured using an aintree intubating catheter for intermittent oxygenation and exchange of a laryngeal mask airway for an endotracheal tube

24 billion per year in direct medical costs. In 95% cases, the symptoms subside without treatment within 3 months. The rest (5%) require extensive, expensive diagnostic work-up and treatment. Surgical treatment, often repeated, although able to release stenotic changes, tends to create new scar tissue. Unfortunately, from 40% to 80% of these patients experience persistent pain — referred to as postlaminectomy syndrome (Manning and Rowlingson, 1998; North et al., 1991). Introduction of epiduroscopy into clinical practice has revolutionized the visualization of the epidural space and offered new options in the treatment of postlaminectomy syndrome. The authors describe the technique and demonstrate the image obtained during the procedure. The outcome of epidural steroid injections under epiduroscopic guidance, in 22 patient...

The Role of the Lightwand

Abstract Failed endotracheal intubation will always be a major concern for anesthesiologists because of the devastating outcomes associated with it. Any methods used to safely secure a difficult airway ultimately improves patient

FAILED INTUBATION IN OBSTETRICS: Airway Management Strategies

The lightwand has been used in airway management for more than five decades and was first described to assist direct laryngoscopic orotracheal intubation in 1957 [1]. Soon after, in 1959, a study reported the successful use of the lightwand, based on the principle of transillumination of the throat, to facilitate nasotracheal intubation in 29 of 30 patients with severe trismus [2]. The authors noted three concerns that are still valid today: the need for a dark room to appreciate transillumination in the neck, the difficulty in transilluminating patients with thick necks, and the risk of thermal injury [2]. The lightwand was first used as a commercial stylet, later that year [3]. However, the initial interest in the device soon waned, probably because of the difficulty in transillumination of the light through red rubber tracheal tubes that were being used at that time. The lightwand regained popularity with the advent of clear, plastic tracheal tubes in 1985. It was reported to be useful in accurately determining the position of tracheal tubes, with 96 % accuracy, in less than 5 s [4] and was used to facilitate difficult tracheal intubation in adults [5]. Currently, many lightwand devices (e.g., Flexilum™, Concept Corporation, Clearwater FL; Surch Lite™, Aaron Medical, Clearwater FL and Tubestat™, Xomed, Jackonville FL) are available from different manufacturers (Fig. 10.1). The Trachlight™ (Laerdal, Wappingers Falls, NY) was the most widely used and studied of these devices (Fig. 10.2); however, the manufacturer discontinued this product in 2009 due to declining sales.