Norman Bolden

Anesthesia complications during scheduled cesarean delivery for morbidly obese women

OBJECTIVE We sought to estimate the morbidity associated with regional anesthesia in morbidly obese women undergoing scheduled cesarean delivery. STUDY DESIGN This was a retrospective cohort study of women undergoing elective scheduled cesarean delivery from September 2004 through December 2008. RESULTS A total of 142 morbidly obese, 251 overweight and obese, and 185 normal-weight women met inclusion criteria. Differences between groups were identified regarding: complicated placement (5.6%, 2.8%, and 0%, respectively; P = .007), failure to establish (2%, 0%, and 0%, respectively; P = .047), and insufficient duration (4%, 0%, and 0%, respectively; P = .02) of regional anesthesia. The groups differed in the frequency of general anesthesia (6%, 0%, and 0%, respectively; P = .003), intraoperative hypotension (3%, 0%, and 0%, respectively; P = .01), and overall anesthetic complications (8.4%, 0%, and 0%, respectively; P < .0001). Prepregnancy body mass index > or = 40 kg/m(2) (receiver operating characteristic area under the curve, 0.856; positive likelihood ratio, 4.0) and delivery body mass index > or = 45 kg/m(2) (receiver operating characteristic area under the curve, 0.877; positive likelihood ratio, 4.1) were predictive of anesthetic complications. CONCLUSION Morbidly obese women have significant risk for anesthesia complications during cesarean delivery.

Perioperative Complications in Obstructive Sleep Apnea Patients Undergoing Surgery: A Review of the Legal Literature.

BACKGROUND:Obstructive sleep apnea (OSA) is common in patients undergoing surgery. OSA, known or suspected, has been associated with significant perioperative adverse events, including severe neurologic injury and death. This study was undertaken to assess the legal consequences associated with poor outcomes related to OSA in the perioperative setting. METHODS:A retrospective review of the legal literature was performed by searching 3 primary legal databases between the years 1991 and 2010 for cases involving adults with known or suspected OSA who underwent a surgical procedure associated with an adverse perioperative outcome. OSA had to be directly implicated in the outcome, and surgical mishaps (i.e., uncontrolled bleeding) were excluded. The adverse perioperative outcome had to result in a lawsuit that was then adjudicated in a court of law with a final decision rendered. Data were abstracted from each case regarding patient demographics, type of surgery, type and location of adverse event, associated anesthetic and opioid use, and legal outcome. RESULTS:Twenty-four cases met the inclusion criteria. The majority (83%) occurred in or after 2007. Patients were young (average age, 41.7 years), male (63%), and had a known diagnosis of OSA (96%). Ninety-two percent of cases were elective with 33.3% considered general procedures, 37.5% were ears, nose and throat procedures for the treatment of OSA, and 29.1% were considered miscellaneous interventions. Complications occurred intraoperatively (21%), in the postanesthesia care unit (33%), and on the surgical floors (46%). The most common complications were respiratory arrest in an unmonitored setting and difficulty in airway management. Immediate adverse outcomes included death (45.6%), anoxic brain injury (45.6%), and upper airway complications (8%). Overall, 71% of the patients died, with 6 of the 11 who suffered anoxic brain injury dying at an average of 113 days later. The use of opioids and general anesthetics was believed to play a role in 38% and 58% of cases, respectively. Verdicts favored the plaintiffs in 58% of cases and the defendants in 42%. In cases favoring the plaintiff, the average financial penalty was

Avoiding adverse outcomes in patients with obstructive sleep apnea (OSA): development and implementation of a perioperative OSA protocol

2.5 million (±

Impact of morbid obesity on epidural anesthesia complications in labor.

2.3 million; range,

Management of obstructive sleep apnea in pregnant women.

650,000––

Preoperative screening and perioperative care of the patient with sleep-disordered breathing.

7.7 million). CONCLUSIONS:Perioperative complications related to OSA are increasingly being reported as the central contention of malpractice suits. These cases can be associated with severe financial penalties. These data likely underestimate the actual medicolegal burden, given that most such cases are settled out of court and are not accounted for in the legal literature.

Accidental Dural Puncture Management: 10-Year Experience at an Academic Tertiary Care Center.

Obstructive sleep apnea (OSA) is associated with postoperative airway obstruction, hypoxemia, cardiac arrhythmias, cardiorespiratory arrest, hypoxic encephalopathy, and death. Three cases highlighting important issues in patients with OSA are presented that occurred prior to and after implementation of an OSA protocol.

Making the case for obstetric “response teams” and simulation in labor and delivery: management of catastrophic amniotic fluid embolism during labor

OBJECTIVE We sought to determine whether morbid obesity is associated with increased maternal hypotension or fetal heart rate (FHR) abnormalities after epidural anesthesia placement during labor. STUDY DESIGN This was a retrospective cohort study of women undergoing epidural anesthesia during labor at term from April 2008 through July 2010. RESULTS A total of 125 morbidly obese patients were matched for age and race with 125 normal-weight patients. Morbidly obese patients had more frequent persistent systolic (16% vs 4%, P = .003) and diastolic (49% vs 29%, P = .002) hypotension and more prolonged (16% vs 5%, P = .006) and late (26% vs 14%, P = .03) FHR decelerations. Increasing body mass index was associated with persistent systolic (odds ratio, 1.06; 95% confidence interval, 1.02-1.10) and diastolic (odds ratio, 1.04; 95% confidence interval, 1.01-1.06) hypotension after controlling for epidural bolus dose and hypertensive disorders. CONCLUSION Morbidly obese women have more hypotension and prolonged FHR decelerations following epidural anesthesia during labor at term.

Society of anesthesia and sleep medicine: proceedings of 2012 annual meeting

A 32-year-old woman, gravida 6 para 5004, at 37 0/7 weeks of gestation presented for a repeat cesarean delivery. The patient’s pregnancy was complicated by morbid obesity (body mass index [calculated as weight (kg)/[height (m)]2] 53.1), chronic hypertension, and obstructive sleep apnea (OSA) but not pregestational or gestational diabetes. Her antenatal course was uneventful. Her OSA was diagnosed 2 years before this pregnancy but she failed to initiate therapy. A repeat polysomnogram performed at 20 weeks confirmed her OSA with an apnea–hypopnea index of nine events per hour, indicating mild sleep apnea. Her lowest oxygen saturation on the overnight polysomnogram was 76% and she spent 3.9% of her total sleep time with an SpO2 level less than 90%. After multiple visits for evaluation and continuous positive airway pressure (CPAP) adjustment, she initiated CPAP treatment at 12 cm H2O at 26 weeks of gestation. She reported nightly compliance thereafter. The patient underwent an uncomplicated repeat cesarean delivery and a tubal ligation under combined spinal– epidural (12 mg bupivacaine, 20 g fentanyl, 0.2 mg morphine). The neonate weighed 3,148 grams and Apgar scores at 1 and 5 minutes were 9 and 9, respectively. Secondary to our departmental postoperative sleep apnea protocol (Fig. 1), she was monitored on labor and delivery for 24 hours after her cesarean delivery. The patient declined CPAP. Within the first 4 hours postoperatively, the patient was noted to have intermittent hypoxemia with a pulse oximetry nadir of 83%. At that time, her lungs were clear, there was no tachycardia, and she denied chest pain. Therefore, venous thromboembolism or pulmonary edema was deemed unlikely. Subsequently, her pulse oximetry ranged between 93% and 94%. Given her sleep apnea, she was kept on continuous pulse oximetry monitoring for the remainder of her admission. No narcotics beyond the spinal narcotics administered by anesthesia intraoperatively could be administered for the first 24 hours without permission from the anesthesia service (per our neuraxial opioid standing orders). There were no standing orders for opioid medications (intravenous or oral) in the postoperative period beyond 24 hours. Rather, physician assessment of vital signs was required before narcotic administration and ketorolac was used for analgesia. The hypoxemia was most profound in the first 24 hours. On postoperative day 2, her oxygen saturation was consistently approximately 96% with a nadir of 93%. By postoperative day 3, the patient’s pulse oximetry returned back to her preoperative baseline of 98% with no desaturations (on room air). Given her long-standing history of sleep apnea, an echocardiogram was performed to evaluate for the presence of pulmonary hypertension and was noted to be normal. The remainder of the patient’s course was uneventful and she was discharged home on postoperative day 4.

Perioperative complications during use of an obstructive sleep apnea protocol following surgery and anesthesia.

Purpose of review Emerging data are raising concerns that patients with known or suspected obstructive sleep apnea (OSA) are at increased risk for a myriad of perioperative complications. Strategies to identify patients preoperatively with OSA, or at risk for OSA, are being advocated. In addition, approaches to identify patients most at risk for OSA-related postoperative complications have been described. While lacking solid evidence, a number of perioperative management strategies have been proposed for the care of these patients. Recent findings Recent studies utilizing different methodologies have provided additional evidence regarding the impact that OSA can have on postoperative outcomes, including increased risk of difficult intubations, adverse pulmonary outcomes, and delirium. Tools, such as the STOP-Bang questionnaire and limited channel monitoring, have been investigated with regards to their utility to identify not only patients at risk for OSA but also those at risk for more severe OSA. Consensus-based guidelines for the perioperative care of OSA patients have recently been published. Summary OSA is quite common in patients presenting for elective surgery and has been linked to increased perioperative complications. Attempts to identify these patients preoperatively appear prudent. Protocols on how best to manage these patients are available, although validation of their effectiveness is needed.