Michaela K. Farber

Cesarean delivery in the hybrid operating suite: a promising new location for high-risk obstetric procedures.

BACKGROUND: The increasing cesarean delivery rate and attendant placental implantation abnormalities, coupled with increasing general medical complexity in the obstetric population, has driven innovation to optimize the care of high-risk parturients during delivery. Novel and multidisciplinary approaches and locations may enhance the options available for care. METHODS: We reviewed the records of all 11 patients who underwent cesarean delivery in our hybrid operating suite between December 2007 and March 2013 and describe the high-risk cesarean deliveries. RESULTS: The most common indication for the use of the hybrid operating suite was an increased risk of hemorrhage, most commonly due to abnormal placental implantation. Other indications included cardiovascular disease and intracranial pathology. CONCLUSION: The hybrid operating suite may be an alternative location for obstetric delivery, and our experience suggests that this environment may prove advantageous for patients with a variety of comorbid conditions. 

The influence of a night-float call system on the incidence of unintentional dural puncture: A retrospective impact study

BACKGROUND:Resident night-float systems have been associated with adverse outcomes. We hypothesized that an obstetric anesthesia night float would increase the incidence of unintentional dural punctures. METHODS:The July to December incidence of unintentional dural puncture before (control group) and with night float (night-float group) was compared retrospectively. The incidence of unintentional dural puncture by day of week and trainee level was evaluated. RESULTS:The unintentional dural puncture rate of control group was 0.73% (20 of 2758) vs 1.49% (39 of 2612) in the night-float group (P = 0.008; relative risk = 2.06; 95% confidence interval = 1.23–3.74). The proportion of unintentional dural punctures attributed to clinical anesthesia-1 residents in the night-float and control groups was 28.2% (11 of 39) and 5.0% (1 of 20), respectively (relative risk = 5.64; 95% confidence interval = 1.07–152; P = 0.044). CONCLUSIONS:Implementation of night float increased the incidence of unintentional dural puncture.

Anesthetic management of a parturient with neuromyelitis optica

Women with neuromyelitis optica, an acute inflammatory demyelinating condition of the central nervous system, have an unpredictable clinical course in pregnancy. Providing neuraxial anesthesia for these patients is controversial, although relapses may occur after exposure to either general or neuraxial anesthesia and are common. We report the successful obstetric anesthesia management of a parturient with neuromyelitis optica, review the medical literature, and discuss specific considerations for obstetric anesthesia in patients with underlying demyelinating disease.

Does nitrous oxide labor analgesia influence the pattern of neuraxial analgesia usage? An impact study at an academic medical center

STUDY OBJECTIVE To compare the rate of epidural use before and after the implementation of nitrous oxide (N2O). DESIGN Data were obtained from a nursing database of N2O usage and our obstetric anesthesia database. We compared 8 months before and 8 months after the introduction of N2O. It was available 24 h/d, 7 d/wk, consistent with neuraxial analgesia availability. Epidural utilization before and after introduction of N2O was compared using χ2 analysis. SETTING Labor and delivery floor. MAIN RESULTS Total number of births over the study period was 8539: 4315 pre-N2O and 4224 post-N2O. The rate of epidural usage was 77% pre-N2O and 74% after N2O (P= not significant, χ2). A total of 762 patients used N2O. Monthly analysis showed no change in pattern of neuraxial analgesia use in post-N2O period compared with the pre-N2O period. CONCLUSION The introduction of N2O for labor analgesia was not associated with any change in our rate of labor epidural utilization. Under the conditions of our study, these results suggest that N2O does not discourage neuraxial use for labor pain relief.

The effect of co-administration of intravenous calcium chloride and oxytocin on maternal hemodynamics and uterine tone following cesarean delivery: a double-blinded, randomized, placebo-controlled trial.

BACKGROUND Oxytocin administration to prevent uterine atony following cesarean delivery is associated with adverse effects including hypotension, tachycardia, and nausea. Calcium chloride increases mean arterial pressure, systemic vascular resistance, and uterine smooth muscle contractility. This study evaluated whether the co-administration of calcium chloride with oxytocin following cesarean delivery could alter maternal hemodynamics. Secondary outcomes included uterine tone and blood loss. METHODS Sixty healthy parturients with singleton, term, vertex pregnancies undergoing elective cesarean delivery under spinal anesthesia were randomized to one of three study solutions given intravenously immediately after umbilical cord clamping: (1) placebo, oxytocin 5U alone; (2) CA-200, oxytocin 5U+calcium chloride 200mg; or (3) CA-400, oxytocin 5U+calcium chloride 400mg. Blood pressure, heart rate, uterine tone, vasopressor or alternate uterotonic use and the incidence of nausea or vomiting were recorded. Baseline and intraoperative plasma concentration of ionized calcium and hematocrit were measured. RESULTS Plasma concentration of ionized calcium was elevated in both study groups compared with placebo (P=0.001). Blood pressure decreased and heart rate increased in all groups (P <0.0001), with no differences between groups. No differences were observed between groups in uterine tone, vasopressor use, hematocrit change, estimated blood loss, incision-to-delivery interval, delivery-to-skin closure interval, total intravenous fluid administered or incidence of nausea. CONCLUSIONS The decrease in blood pressure associated with oxytocin administration following cesarean delivery was not attenuated with co-administration of calcium chloride at the doses evaluated. Vasopressor use, uterine tone, and blood loss were also unaffected.

Parturients with hypertrophic cardiomyopathy: case series and review of pregnancy outcomes and anesthetic management of labor and delivery

BACKGROUND Advances in understanding the pathogenesis, diagnosis and management of hypertrophic cardiomyopathy have resulted in increased longevity and a better quality of life of affected patients considering pregnancy. Several case series which focused predominantly on obstetric details have reported generally good outcomes. However, there remains a paucity of data on the specifics of obstetric anesthesia in women with hypertrophic cardiomyopathy. METHODS After Institutional Review Board approval, we reviewed antepartum transthoracic echocardiograms, cardiology, obstetric, anesthetic, and nursing labor records with a focus on anesthesia for labor and delivery and early postpartum complications in patients with hypertrophic cardiomyopathy who delivered between January 1993 and December 2013. RESULTS There were 23 completed pregnancies in 14 patients: 12 parturients (52%) delivered vaginally, of whom seven (30%) required assistance (forceps, vacuum), and 11 (48%) had a cesarean delivery. In 17 cases (74%) delivery was uneventful, but six patients (26%) had complications including congestive heart failure (n=3) and postpartum hemorrhage (n=3). All patients had neuraxial labor anesthesia/analgesia, and none received general anesthesia. No hemodynamic instability or fetal distress directly related to anesthesia was documented. CONCLUSION The database search of approximately 160000 deliveries over 20 years revealed only a small number of hypertrophic cardiomyopathy patients with completed pregnancies. No maternal or neonatal deaths were documented. Overall morbidity rate was 26% with a 13% incidence of peripartum congestive heart failure. In patients with mild to moderate disease, neuraxial anesthesia was safe, effective and well tolerated with no hemodynamic instability related to administration of local anesthetics.

Anesthetic Management of a Patient with an Allergy to Propylene Glycol and Parabens

Multiple pharmaceutical products contain excipients, or additive chemicals, to improve stability, bioavailability, antimicrobial activity, or palatability. Two of the most common excipients are propylene glycol and parabens. We report the successful anesthetic management of a patient with idiosyncratic reactions to prescribed and over-the-counter medications containing propylene glycol and parabens.

Phenylephrine InfusionDriving a Wedge in Our Practice of Left Uterine Displacement

◆ EDITORIAL VIEWS Can We Really Suggest that Anesthesia Might Cause Attention-deficit/Hyperactivity Disorder? 209 D. Efron, L. Vutskits, and A. J. Davidson Phenylephrine Infusion: Driving a Wedge in Our Practice of Left Uterine Displacement? 212 M. K. Farber and B. T. Bateman Measuring Perioperative Mortality: The Key to Improvement 215 I. A. Walker and I. H. Wilson Decision to Extubate Brain-injured Patients: Limiting Uncertainty in Neurocritical Care 217 T. Godet, R. Chabanne, and J.-M. Constantin

Differences between anticipated and perceived difficulty and insertion duration of labor epidural techniques among anesthesiologists, nurses and patients.

BACKGROUND Difficulty with the labor epidural technique has been described using a variety of criteria, but remains inadequately defined. We sought to determine the reasons cited for difficulty with the insertion of labor epidural techniques among anesthesiologists, nurses, and patients. We hypothesized that the perception of procedural difficulty would correlate among participants and with the elapsed duration of the insertion attempt. METHODS A total of 140 participant sets (i.e. anesthesiologist, nurse and patient) were asked to complete a questionnaire on procedural difficulty, immediately before (i.e. anticipated) and after (i.e. perceived) a standardized epidural technique. Procedural duration, using specified start and end times, was recorded in seconds by an independent co-investigator. Demographic data for all groups were recorded. RESULTS Perceived difficulty with the epidural technique was similar among all groups (range 10-14%; P=0.29) and correlated with anticipated difficulty (anesthesiologist P=0.0004; nurse P=0.00001; patients P=0.006) and procedural duration (all groups P <0.001). The most common reasons cited for perceived difficulty were procedural duration (anesthesiologist P=0.58), number of attempts (nurse P=0.02), and pain experienced (patient P=0.035). CONCLUSIONS Difficulty with the epidural technique is associated with anticipated difficulty and procedural duration. The reasons for perceived difficulty differ among anesthesiologists, nurses and obstetric patients, with patients most commonly citing pain experienced.

The incidence and management of inability to advance Arrow FlexTip Plus epidural catheters in obstetric patients

BACKGROUND Difficulty advancing epidural catheters is troublesome to obstetric anesthesiologists. Flexible epidural catheters have been shown to reduce paresthesiae and intravascular catheter placement in parturients, but the cause of inability to advance these catheters past the epidural needle tip remains undefined. Specifically, its incidence and effective management strategies have not been described. METHODS All labor epidural catheters were recorded for a 22-week period. Difficulty advancing the epidural catheter was defined as an inability to advance the catheter beyond the needle tip after obtaining loss of resistance. Anesthesiologists completed a survey when difficulty advancing a catheter occurred. RESULTS A total of 2148 epidural catheter placements were performed. There were 97 cases of an inability to advance the epidural catheter (4.5%, 95% CI 3.7 to 5.5%). This occurred in 4.2% of combined spinal-epidural and 4.6% of epidural placements (OR 0.92, 95% CI 0.53 to 1.62). On a 0 to 10scale, the median [IQR] provider confidence in loss of resistance was 9 [8, 10]. A total of 230 corrective maneuvers were performed, using nine distinct approaches. The incidence of accidental dural puncture was 3.1% if an inability to advance occurred (n=97) compared to 1.2% for other placements (n=2051, P=0.12). DISCUSSION Inability to advance Arrow FlexTip Plus® epidural catheters was relatively common (4.5%) and occurred despite confidence in obtaining loss of resistance. Injecting saline may be corrective and appears to have little disadvantage. However, removing the needle and performing a new placement was the most successful corrective maneuver.