Joanne Douglas

Coagulation in pregnancy

The coagulation system undergoes significant change during pregnancy. The clinician caring for the parturient must understand these changes, particularly when the parturient has a pre-existing haematological condition. Because many haematological conditions are rare, there often is limited information to guide the obstetric and anaesthetic management of these parturients.

Double-blind comparison of epidural ropivacaine 0.25% and bupivacaine 0.25%, for the relief of childbirth pain.

PurposeTo evaluate the efficacy of ropivacaine 0.25% when administered epidurally for relief of labour pain and to compare it with bupivacaine 0.25%.MethodsIn a multicentre investigation, 60 ASA I and II labouring women were randomized in a double-blind fashion to receive either bupivacaine 0.25% or ropivacaine 0.25% administered epidurally by intermittent top-up for labour analgesia. Using a standardized technique, epidural analgesia was initiated after the woman received 10–15 ml · kg−1 crystalloid solution. Maternal blood pressure, heart rate, analgesia sensory level, degree of motor block and visual analogue pain scores were measured by the research nurse prior to, and at regular intervals, following the administration of analgesia. Total dose of local anaesthetic administered, duration of labour, mode of delivery, and maternal and fetal/neonatal side effects were noted. The fetus/neonate was assessed by the research nurse using the fetal heart rate tracing. Apgar scores at delivery and neonatal neurobehavioural assessments at 2 and 24 hr postnatally. Maternal and investigators’ satisfaction with the analgesia achieved was assessed after delivery.ResultsNo differences were found between the two agents in any of the variables studied.ConclusionRopivacaine 0.25%, when administered epidurally by intermittent top-ups for labour analgesia, was equally efficacious as bupivacaine 0.25%.ObjectifÉvaluer l’efficacité de la ropivacaïne épidurale 0,25% administrée pour soulager la douleur du travail et la comparer avec la bupivacaïne 0,25%.MéthodesAu cours d’une investigation multicentrique, 60 parturientes ASA I et II en travail ont été réparties aléatoirement pour recevoir en double aveugle soit de la bupivacaïne 0,25% soit de la ropivacaine 0.25% administrées en doses intermittentes épidurales pour le soulagement de la douleur du travail. Avec une technique standardisée, l’analgésie épidurale a été induite après l’administration de 10–15 ml· kg−1 d’une solution de cnstalloïde. La pression artérielle et la fréquence cardiaque maternelles, le niveau du bloc sensitif et moteur et le score de la douleur sur une échelle visuelle analogique ont été enregistrés par une infirmière de recherche avant et à intervalles réguliers après l’administration de l’anesthésie. La dose totale administrée d’anesthésique local, la durée du travail, le mode d’accouchement et les effets maternels et foetaux ont aussi été enregistrés. Le foetus et. par la suite, le nouveau-né a été évalué par l’infirmière de recherche avec le tracé du coeur foetal. le score d’Apgar à la naissance et des évaluations neurocomportementales à deux et 24 heures après la naissance. Le degré de satisfaction de la mère et des investigateurs relativement à l’analgésie a été évalué après l’accouchement.RésultatsAucune différence entre les deux agents n’a été notée en ce qui concerne les vanables étudiées.ConclusionLa ropivacaïne 0,25% en administration épidurale à doses intermittentes pour l’analgésie du travail a été aussi efficace que la bupivacaine 0,25%.

Vasopressors in obstetrics.

Hypotension is a common, treatable side effect of neuraxial anesthesia, which has significant side effects for the mother and demonstrable biochemical effects in the fetus. It is clear that a shift in management of hypotension in the obstetric population is in order, but we can only speculate on the benefits for the compromised fetus due to the lack of available information in that patient population.

Spinal anesthesia for Cesarean section in a parturient with long QT syndrome.

PurposeTo report the first use of spinal anesthesia for Cesarean section (CS) in a parturient with a long QT syndrome (LQTS) and an automatic implantable cardiac defibrillator (AICD). Although both general and epidural anesthesia have been described for CS in patients with LQTS, there are no previous case reports on the use of spinal anesthesia. The clinical features, diagnosis, treatment and anesthetic management of LQTS are discussed.Clinical featuresA 31-yr-old woman, gravida 2 para 1 known to have LQTS and an AICD, presented in labour at 35 weeks gestation, three weeks before her scheduled CS. Her previous delivery by CS under spinal anesthesia at our institution was uneventful. On this occasion, we elected to administer spinal anesthesia because she was asymptomatic (no arrhythmia or cardiac arrest) for the last few years, was hemodynamically stable, and had received uneventful spinal anesthesia before.ConclusionSpinal anesthesia was used safely for CS in this parturient with LQTS.RésuméObjectifPrésenter le premier usage de rachianesthésie pour une césarienne chez une parturiente atteinte du syndrome du QT long (SQTL) et porteuse d’un défibrillateur cardiaque automatique implantable (DCAI). On a déjà décrit l’usage d’anesthésie générale et péridurale pour la césarienne de patientes atteintes du SQTL, mais non celui de la rachianesthésie dans ce cas. Les caractéristiques cliniques, le diagnostic, le traitement et la prise en charge anesthésique du SQTL sont discutés.Éléments cliniquesUne femme de 31 ans, secondigeste et primipare, connue pour avoir le SQTL et porteuse d’un DCAI, s’est présentée en travail à 35 semaines de grossesse, trois semaines avant la césarienne prévue. Son accouchement précédent par césarienne sous rachianesthésie s’était bien déroulé. Nous avions alors choisi d’administrer une rachianesthésie parce que la patiente était asymptomatique (pas d’arythmie ou d’arrêt cardiaque) depuis quelques années, présentait une hémodynamique stable et avait déjà reçu une rachianesthêsie sans incident.ConclusionLa rachianesthêsie a été utilisée de façon sécuritaire pour la césarienne chez une patiente atteinte du SQTL.

Brief review: Anesthetic implications of long QT syndrome in pregnancy

PurposeTo review the effects of the long QT syndrome (LQTS) in the parturient and the current anesthetic management of patients with LQTS.SourceRelevant articles were obtained from a MEDLINE search spanning the years 1980–2006 and a PubMed search spanning the years 1949–2006. Bibliographies of retrieved articles were searched for additional articles.Principal findingsThe prevalence of LQTS in the developed world is one per 1,100 to 3,000 of the population. Clinically, LQTS is characterized by syncope, cardiac arrest and occasionally, by a history of seizures. The QT interval can also be prolonged by drugs, electrolyte imbalances, toxins and certain medical conditions. Long QT syndrome patients are at risk of torsades de pointes and ventricular fibrillation. Medical management aims to reduce dysrhythmia frequency. The LQTS is subdivided into different groups (LQT1-6) depending on the cardiac ion channel abnormality. Torsades can be precipitated by adrenergic stimuli such as stress or pain (LQT1 and 2), sudden noises (LQT2) or whilst sleeping (LQT3). Patients with LQTS require careful anesthetic management as they are at high risk of torsades perioperatively despite minimal data on the effects of anesthetic agents on the QT interval. While information on effects of LQTS in pregnancy is limited, the incidence of dysrhythmia increases postpartum. Isolated case reports of patients with LQTS women highlight several peripartum dysrhythmias.ConclusionAn understanding of LQTS and the associated risk factors contributing to dysrhythmias is important for anesthesthesiologists caring for parturients with LQTS.ObjectifPasser en revue les effets du syndrome du QT long (LQTS) chez les parturientes ainsi que la prise en charge actuelle des patientes souffrant du LQTS.SourceLes articles pertinents ont été obtenus d’une recherche sur MEDLINE allant de 1980 à 2006 et d’une recherche sur PubMed couvrant la période allant de 1949 à 2006. Les bibliographies des articles trouvés ont été analysées afin de trouver des articles supplémentaires sur le sujet.Constatations principalesDans les pays développés, la prévalence du LQTS est de un cas sur 1100 à 3000 personnes. Le LQTS est cliniquement caractérisé par des syncopes, un arrêt cardiaque et, occasionnellement, par des antécédents de convulsions. L’intervalle QT peut également être prolongé par des médicaments, des déséquilibres électrolytiques, des toxines et certains états de santé. Les patients souffrant du LQTS sont à risque de torsades de pointes et de fibrillation ventriculaire. La prise en charge médicale vise à réduire la fréquence des dysrythmies. Le LQTS se divise en plusieurs sous-groupes (LQT1-6) selon l’anormalité du canal ionique cardiaque. Les torsades peuvent être précipitées par des stimuli adrénergiques tels que le stress ou la douleur (LQT1 ou 2), les bruits soudains (LQT2) ou pendant le sommeil (LQT3). Les patients souffrant du LQTS nécessitent une prise en charge anesthésique prudente, étant donné qu’ils présentent un risque élevé de torsades avant, pendant et après la chirurgie et ce, malgré le peu de données disponibles concernant les effets des agents anesthésiques sur l’intervalle QT. Bien que les informations au sujet des effets du LQTS sur la grossesse soient limitées, il a été observé que l’incidence de la dysrythmie augmente en post-partum. Des rapports de cas isolés de patientes souffrant du LQTS soulignent de nombreuses dysrythmies périnatales.ConclusionUne meilleure compréhension du LQTS et des facteurs de risques associés contribuant aux dysrythmies est importante pour les anesthésiologistes traitant les parturientes souffrant du LQTS.

Effect of preoperative skin infiltration with 0.5% bupivacaine on postoperative pain following cesarean section under spinal anesthesia

Recent work suggests that preoperative skin infiltration with local anesthetic may lead to reduced postoperative pain. We have studied this in a randomised, prospective, double-blind trial of 40 women having cesarean section under spinal anesthesia. After establishment of the spinal block, the incision line was infiltrated in 20 women with 30 ml 0.5% bupivacaine and in 20 with 30 ml normal saline. There was no difference in pain scores between the 2 groups on any of the 3 postoperative days, perhaps due to the high quality analgesia provided by supplemental subarachnoid morphine.

Preoperative dextrose does not affect spinal- induced hypotension in elective Cesarean section

PurposeTo determine if preoperative intravenous dextrose affects the incidence and ease of treatment of spinalinduced hypotension in parturients having elective Cesarean section under spinal anesthesia.MethodsIn this prospective, double-blind study, following informed consent, 119 ASA I, II parturients for elective Cesarean section were randomized to receive intravenously either dextrose 5% in normal saline (Group D) or normal saline (Group NS) at 125 ml·hr−1 for two hours prior to delivery. Following a bolus of 15 ml·kg−1 normal salineiv, spinal anesthesia was induced with hyperbaric bupivacaine 0.75%, fentanyl and morphine. Hypotension (systolic blood pressure < 100 mm Hg or > 20% decrease) was treated with fluids and/or vasopressor. Data collected: demographics, blood glucose concentrations (fasting, time of spinal, delivery), blood pressure (baseline, one minute intervals from spinal to delivery), neonatal Apgar scores, umbilical blood gas analyses, glucose and lactate concentrations.ResultsThere was no difference between the two groups in the rate of hypotension (P=0.272). All parturients who experienced hypotension received fluids, and there was also no difference between the groups in vasopressor requirement [mean dose of ephedrine: Group D = 21.6 mg (95% Cl 15.1–28.2), Group NS = 16 mg (95% Cl 12.0–20.5)].ConclusionThe routine administration of dextrose 5% at a rate of 5.22 g·hr−1 preoperatively does not affect the hypotension rate, or make it easier to treat.RésuméObjectif:Déterminer si l’administration intraveineuse préopératoire de dextrose modifie l’incidence d’hypotension à induction rachidienne et la facilité de son traitement chez des parturientes qui subissent une césarienne élective sous rachianesthésie.MéthodeAyant accordé leur consentement éclairé, 119 parturientes ASA I et II ont participé à une étude prospective à double insu. Réparties au hasard, elles ont reçu pendant deux heures avant la césarienne prévue une perfusion intraveineuse de dextrose 5 % dans une solution salée (Groupe D), ou d’une solution salée (Groupe S), de 125 ml·hr−1. Après l’administration iv d’un bolus de 15 ml·kg−1 de solution salée, la rachianesthésie a été induite avec de la bupivacaïne hyperbare à 0,75 %, du fentanyl et de la morphine. On a traité l’hypotension (la tension artérielle systolique < 100 mmHg ou une baisse > 20 %) avec des liquides et/ou un vasopresseur. On a noté: des renseignements personnels, les concentrations de glucose sanguin (à jeun, au moment de la rachianesthésie, lors de l’accouchement), la tension artérielle (une mesure de base, des mesures à intervalles d’une minute de la rachianesthésie à l’accouchement), l’indice d’Apgar, la gazométrie ombilicale, les concentrations de glucose et de lactate.RésultatsIl n’y a pas eu de différence intergroupe quant à la fréquence d’hypotension (P = 0,272). Toutes les parturientes qui ont souffert d’hypotension ont reçu des liquides. Il n’y a pas eu de différence intergroupe pour la demande de vasopresseur [dose moyenne d’éphédrine: Groupe D = 21,6 mg (IC 95 %; 15, 1–28,2); Groupe NS= 16 mg(IC 95%; 12,0–20,5)].ConclusionL’administration préopératoire de routine de dextrose à 5 % selon un débit de 5,22 g·hr−1 n’a pas d’effet sur la fréquence d’hypotension et ne facilite pas son traitement.

Provision of obstetric anesthesia: throwing down the gauntlet!

When we consider the challenges of obstetric anesthesia, most of us focus on the risks to a (relatively) young, (relatively) healthy mother and her fetus, on the often emergency nature of the care we provide, and on the unexpected need for our services. In this issue of the Journal, we present our readers with yet another challenge that we often fail to consider—what happens if no anesthesia providers are available to cope with these challenges? In 1999, Donen et al. drew attention to the potential crisis of Canada not having a sufficient number of anesthesiologists to meet its demands. In 1996, they conducted a survey of 2,206 specialist anesthesiologists and 487 general practitioner anesthesiologists (GPAs) who were identified as providing anesthetic services. Within the Canadian health care framework, GPAs provide a vital and important service to smaller, more rural communities and to a number of medium-sized communities. However, according to a 1999 report, there was a decrease in the number of GPAs from the 523 identified in a 1986 survey. Any further decline in the number of anesthetic practitioners could mean a loss of anesthetic services to those communities, including the provision of obstetrical anesthetic services. And yet, as identified by the Society for Obstetricians and Gynaecologists of Canada (SOGC) and others, pregnant women expect delivery in their local communities, and they also expect to have the safe obstetrical care that is available in larger hospitals. In this issue of the Journal, Dr. Angle et al. point out that small obstetric units/hospitals are closing in Ontario, possibly due to lack of anesthetic services. This problem is not limited to one province; it is widespread across Canada and across other parts of the world. In Canada, the majority of anesthetic care in small hospitals is provided by GPAs who face problems relating to burn-out (constantly ‘‘on-call’’), lack of access to continuing professional development (CPD) opportunities, an inability to ‘‘get away’’ from their practice due to a shortage of locums, and a decrease in the number of physicians wanting to work in rural areas. Not only will these issues lead to a further closure of small obstetrical units, but they will also lead to a reluctance by new family physicians to practice in remote areas. And yet, geographic (and meterological) realities suggest that all women should have emergency maternity services readily available at a reasonable distance. In Canada, weather frequently impedes access from smaller, more remote communities to larger facilities. The question then is—how do we provide and maintain emergency obstetric facilities? Anesthetic services are essential to any obstetrical unit, as even births predicted to be normal can suddenly present an urgent need for operative delivery. At least 26% of parturients require anesthesia services for delivery (based on the 2005–2006 average Cesarean delivery rate in Canada). However the percentage is much higher if other aspects of anesthetic practice are included, for example, anesthetic consultation, labour analgesia, and maternal/ neonatal resuscitation services. Failure to have a skilled anesthesia practitioner could mean that the ability to provide emergency obstetrical care is limited, if not impossible, even if there is a physician who can perform a Cesarean delivery. J. Douglas, MD R. Preston, MD Department of Anesthesia, British Columbia’s Women’s Hospital and Health Centre, University of British Columbia, Vancouver, BC V6H 3N1, Canada

General anesthesia for obstetrics: a deadly or a winning combination

ConclusionFor the foreseeable future, there will still be a need and a place for general anesthesia in obstetrics. To prevent the associated risks more research is needed. For example, does cricoid pressure decrease the risk of pulmonary aspiration or does it add one more hazard to intubation? Is the decrease in pulmonary aspiration due to cricoid pressure or is it due to other measures such as avoidance of solids during labour and antacid prophylaxis? Answers to these questions may increase the safety of general anesthesia. Although there will always be a concern when general anesthesia is administered to the obstetric patient, appropriate patient selection and attention to detail should result in general anesthesia being a winning combination for the mother and her fetus/neonate.

A prospective observational study comparing the ease of use and safety of two neuraxial anesthesia kits on an epidural-spinal training model

To the Editor, Quality and safety are major initiatives of the anesthesia community. Periodic evaluation of procedural skills could potentially decrease the risk of common and potentially dangerous errors while promoting self-awareness. Although infectious complications following neuraxial anesthesia are rare, they remain a significant cause of morbidity/mortality and subsequent litigation. We queried whether introducing the new Wiley Spinal neuraxial kit (Epimed, NY, USA) for continuous spinal anesthesia (CSA) would affect sterile technique when compared with B. Braun’s custom kit (B. Braun, PA, USA) for combined spinal-epidural anesthesia (CSE) used in our hospital. After anesthesiologists and fellows (subjects) received training in the new CSA kit, we compared the number of breaches in sterile technique that occurred when the subjects used the two kits in a simulation session. Following approval by the University of British Columbia Research Ethics Board (March 2012) and informed consent, each subject (n = 12) was trained using a lumbar model, GENESIS Simulator (Epimed International, Farmers Branch, TX, USA), to perform CSA with the new kit. Interventions and observations were completed during March-July 2012. Within five weeks following their training, the subjects randomly used the CSE and CSA kits in a videotaped simulation session. To ensure that the videotape assessors were blinded to the subjects’ identity, all subjects wore masks, gowns, and gloves to conceal their hands and forearms, and no panoramic views or sounds were captured. Comments were elicited about the kits and lumbar model, and satisfaction was scored on a five-point Likert scale (5 = very satisfied). Two blinded assessors compared the performances randomly using a pre-established checklist to evaluate possible contamination of the operating field. A point was deducted if a breach occurred. Sterile skin preparation and opening the kit were not evaluated in order to focus on draping and handling of needles/catheter for breaches in aseptic technique. The videotapes were scored using the checklist. The areas assessed for breaches in aseptic technique were: placement of the drape on the model, placement of items on the tray and table, awareness of hand location, and handling the needles and catheter. A priori, maintenance of sterility during insertion was the surrogate for assessing risk of infection (safety). The number of breaches was similar between the two kits (Wilcoxon signed-rank test: W = 42; P = 0.14). The median (range) number of breaches in the CSA vs CSE group was 3 (1-4) vs 2 (0-5), respectively. The median (range) difference in the number of breaches (CSA-CSE) was 1 (-3 to 3). The total number of breaches was calculated for each subject for each technique and compared with the number S. Benavides, MD (&) Department of Anesthesia, BC Women’s Hospital, University of British Columbia, Vancouver, BC, Canada e-mail: sandritabds@gmail.com