Paloma Toledo

A randomized comparison of programmed intermittent epidural bolus with continuous epidural infusion for labor analgesia.

Bolus injection through an epidural catheter may result in better distribution of anesthetic solution in the epidural space compared with continuous infusion of the same anesthetic solution. In this randomized, double-blind study we compared total bupivacaine consumption, need for supplemental epidural analgesia, quality of analgesia, and patient satisfaction in women who received programmed intermittent epidural boluses (PIEB) compared with continuous epidural infusion (CEI) for maintenance of labor analgesia. The primary outcome variable was bupivacaine consumption per hour of analgesia. Combined spinal epidural analgesia was initiated in multiparas scheduled for induction of labor with cervical dilation between 2 and 5 cm. Subjects were randomized to PIEB (6-mL bolus every 30 min beginning 45 min after the intrathecal injection) or CEI (12-mL/h infusion beginning 15 min the after the intrathecal injection). The epidural analgesia solution was bupivacaine 0.625 mg/mL and fentanyl 2 &mgr;g/mL. Breakthrough pain in both groups was treated initially with patient-controlled epidural analgesia (PCEA) followed by manual bolus rescue analgesia using bupivacaine 0.125%. The median total bupivacaine dose per hour of analgesia was less in the PIEB (n = 63) (10.5 mg/h; 95% confidence interval, 9.5–11.8 mg/h) compared with the CEI group (n = 63) (12.3 mg/h; 95% confidence interval, 10.5–14.0 mg/h) (P < 0.01), fewer manual rescue boluses were required (rate difference 22%, 95% confidence interval of difference 5% to 38%), and satisfaction scores were higher. Labor pain, PCEA requests, and delivered PCEA doses did not differ. PIEB combined with PCEA provided similar analgesia, but with a smaller bupivacaine dose and better patient satisfaction compared with CEI with PCEA for maintenance of epidural labor analgesia.

The accuracy of blood loss estimation after simulated vaginal delivery.

BACKGROUND:Visual blood loss estimation often underestimates blood loss. In this study we sought to determine the effect of calibrated drape markings on blood loss estimation in a simulated vaginal delivery. METHODS:Subjects were randomized to estimate simulated blood loss (300, 500, 1000, and 2000 mL) in calibrated or noncalibrated vaginal delivery drapes and then crossover. RESULTS:Visual blood loss estimation with noncalibrated drapes underestimated blood loss, with worsening accuracy at larger volumes (16% error at 300 mL to 41% at 2000 mL). The calibrated drape error was <15% at all volumes. CONCLUSIONS:Calibrated vaginal delivery drapes improve blood loss estimation.

A randomized controlled trial of the impact of simulation-based training on resident performance during a simulated obstetric anesthesia emergency.

Introduction: The percentage of patients having cesarean delivery (CD) under general anesthesia has decreased, which may have implications for residency training in anesthesiology. We undertook this study to assess the effect of focused simulation-based training on resident performance during a simulated general anesthetic for emergency CD. Methods: Thirty-two second-year anesthesiology resident volunteers were randomly assigned to one of the two groups: a group trained on the patient simulator performing general anesthesia for emergency CD (CD group) and a control group trained on the simulator using a different general anesthetic scenario unrelated to obstetric anesthesia (SHAM group). Between 6 and 9 weeks, all the residents performed the emergency CD scenario on the simulator and were videotaped. Two blinded observers scored the videotaped performances using a valid and reliable scoring system separately and were blinded to each others score. The time interval from the start of the scenario until the simulated surgical incision was noted. Total scores and component scores in six subcategories were compared between resident groups, as was the start to incision time interval. Results: Residents in the CD group had higher total scores and higher scores in the preoperative assessment, equipment availability check, and intraoperative management before delivery subcategories than residents in the SHAM group. The start to incision time interval did not differ between the groups. Conclusions: Anesthesiology residents who underwent focused training on a simulator that included performance of a general anesthetic for emergency CD exhibited improved performance during a subsequent simulated anesthetic scenario compared with trainees who did not undergo such instruction.

The effect of live and web-based education on the accuracy of blood-loss estimation in simulated obstetric scenarios

OBJECTIVE Visual estimation of blood loss has been shown to be inaccurate. The objective of this study was to evaluate the impact of a didactic training program on the accuracy of the estimation of blood loss and to compare the effectiveness of training provided by a web-based vs live session. STUDY DESIGN Multidisciplinary labor and delivery unit personnel participated in live or web-based training. Both sessions comprised a 5-station pretest and posttest. The primary outcome was the accuracy of estimated blood loss in the pretest compared with the posttest with the use of the Mann-Whitney U test. RESULTS Among 372 providers, the median improvement between pre- and posttest results was 34% (95% confidence interval, 10-57%; P < .001). This improvement did not differ significantly between the live sessions and web-based sessions (4%; 95% confidence interval, -10% to 12%). CONCLUSION Our study supports the use of live or web-based training to improve blood loss estimation accuracy.

The Use of Postpartum Hemorrhage Protocols in United States Academic Obstetric Anesthesia Units

BACKGROUND:Postpartum hemorrhage (PPH) is the leading cause of severe maternal morbidity, cardiac arrest, and death during the hospitalization for childbirth. Protocol-driven care has been associated with improved outcomes in many settings; the National Partnership for Maternal Safety now recommends that PPH protocols be implemented in every labor and delivery unit in the United States. In this study, we sought to identify the level of PPH protocol availability in academic United States obstetric units. We hypothesized that the majority (>80%) of academic obstetric anesthesia units would have a PPH protocol in place. METHODS:A survey was developed by an expert panel. Domains included hospital characteristics, availability of PPH protocol or plans to develop such a protocol, and protocol components included in the upcoming National Partnership for Maternal Safety obstetric hemorrhage safety bundle initiative. The electronic survey was emailed to the 104 directors of United States academic obstetric anesthesia units. Responses were stratified by PPH protocol availability as appropriate. Univariate statistics were used to characterize survey responses and the probability distribution for PPH protocol availability was estimated using the binomial distribution. RESULTS:The survey response rate was 58%. The percentage of responding units with a PPH protocol was lower than hypothesized (P = 0.03); there was a PPH protocol in 67% of responding units (N = 40, 95% confidence interval [CI]: 53%–78%). The median annual delivery volume for responding units with PPH protocol was 3900 vs 2300 for units without PPH protocol (P = 0.002), with no difference in cesarean delivery rate (P = 0.73) or observed PPH rate (P = 0.69). There was no difference in annual delivery volume between responding and nonresponding hospitals (P = 0.06), suggesting that academic centers with delivery volume >3200 births per year are more likely than smaller volume hospitals to have a PPH protocol in place (odds ratio 3.16 (95% CI: 1.01–9.90). Adjusting for delivery volume among nonresponding hospitals, we estimate that 67% (95% CI: 55%–77%) of all academic obstetric anesthesia units had a PPH protocol in place at the time of this survey. Institutional processes for escalation do not correlate with the presence of a PPH protocol. There was a massive transfusion protocol in 95% of units with a PPH protocol and in 90% of units without (95% CI of difference: −7% to 7%). A PPH code team or rapid response team was available in 57% of responding institutions, with no difference between units with or without a PPH protocol [mean difference 4%, 95% CI (−24% to 32%)]. CONCLUSIONS:Despite increasing emphasis on national quality improvement in patient safety, there are no PPH protocols in at least 20% of U.S. academic obstetric anesthesia units. Delivery volume is the most important variable predicting the presence of a PPH protocol. National efforts to ensure universal presence of a PPH protocol in all academic centers will achieve the greatest impact by focusing on small-volume facilities. Future work is needed to evaluate and facilitate PPH implementation in nonacademic obstetric units.

Racial and ethnic disparities in neuraxial labor analgesia.

BACKGROUND Racial and ethnic disparities in the treatment of pain have been well documented, and there is evidence of such disparities in neuraxial analgesia use. Our objectives of this study were to analyze racial/ethnic disparities in neuraxial analgesia use, as well as anticipated use, among laboring Hispanic, African-American, and Caucasian women, and to evaluate sociodemographic, clinical, and decision-making predictors of actual and anticipated neuraxial analgesia use among these women. METHODS Laboring women, in a large urban academic hospital, were interviewed using a face-to-face survey to determine individual factors that may influence choice of labor analgesia. After delivery, the type of labor analgesia used was recorded. The primary outcome was use of neuraxial analgesia. Multivariable logistic regression models were estimated to test the likelihood that race and ethnicity were significantly associated with neuraxial analgesia use, anticipated neuraxial analgesia use, and the intrapartum decision to use neuraxial analgesia. RESULTS There was a univariate association between race/ethnicity and anticipated as well as actual use of neuraxial analgesia. However, there was no association between race/ethnicity and the intrapartum decision to use neuraxial analgesia. After controlling for confounders, the association between race/ethnicity and actual use of neuraxial analgesia no longer remained significant (adjusted odds ratio: Hispanic versus Caucasian women 0.66, 95% confidence interval [CI]: 0.24 to 1.80; African-American versus Caucasian women 0.93, 95% CI: 0.31 to 2.77). In contrast, Hispanic women were less likely than Caucasian women to anticipate using neuraxial analgesia even after controlling for confounders (adjusted odds ratio 0.40, 95% CI: 0.20 to 0.82). CONCLUSIONS After controlling for confounding variables, Hispanic women anticipated using neuraxial analgesia at a lower rate than other racial/ethnic groups; however, actual use was similar among groups.

Decay in blood loss estimation skills after web-based didactic training

Introduction Accuracy in blood loss estimation has been shown to improve immediately after didactic training. The objective of this study was to evaluate retention of blood loss estimation skills 9 months after a didactic web-based training. Methods Forty-four participants were recruited from a cohort that had undergone web-based training and testing in blood loss estimation. The web-based posttraining test, consisting of pictures of simulated blood loss, was repeated 9 months after the initial training and testing. The primary outcome was the difference in accuracy of estimated blood loss (percent error) at 9 months compared with immediately posttraining. Results At the 9-month follow-up, the median error in estimation worsened to −34.6%. Although better than the pretraining error of −47.8% (P = 0.003), the 9-month error was significantly less accurate than the immediate posttraining error of −13.5% (P = 0.01). Conclusion Decay in blood loss estimation skills occurs by 9 months after didactic training.

Low-dose ketamine with multimodal postcesarean delivery analgesia: a randomized controlled trial.

BACKGROUND Ketamine at subanesthetic doses has analgesic properties that have been shown to reduce postoperative pain and morphine consumption. We hypothesized that intravenous ketamine 10mg administered during spinal anesthesia for cesarean delivery, in addition to intrathecal morphine and intravenous ketorolac, would decrease the incidence of breakthrough pain and need for supplemental postoperative analgesia. METHODS Using a randomized double-blind placebo-controlled design, healthy women scheduled for cesarean delivery receiving hyperbaric spinal bupivacaine, fentanyl and morphine were randomized to intravenous ketamine 10mg or saline following delivery. Postoperative analgesia included scheduled ketorolac and acetaminophen/hydrocodone tablets as needed for breakthrough pain. The primary outcome was the incidence of breakthrough pain in the first 24h. Secondary outcomes included the number of acetaminophen/hydrocodone tablets administered and numeric rating scale for pain (0-10). RESULTS Group characteristics did not differ. There was no difference in the incidence of breakthrough pain (ketamine 75% VS. saline 74%, P=0.86). There was no difference in 24-h or 72-h use of supplemental acetaminophen/hydrocodone tablets between groups. Pain scores in the first 24h were similar, but lower in the ketamine compared to the saline group 2weeks postpartum (difference -0.6, 95% CI -1.1 to -0.9). CONCLUSIONS We found no additional postoperative analgesic benefit of low-dose ketamine during cesarean delivery in patients who received intrathecal morphine and intravenous ketorolac. Subjects who received ketamine reported lower pain scores 2weeks postpartum.

Cell Salvage in Obstetrics.

Intraoperative cell salvage is a strategy to decrease the need for allogeneic blood transfusion. Traditionally, cell salvage has been avoided in the obstetric population because of the perceived risk of amniotic fluid embolism or induction of maternal alloimmunization. With advances in cell salvage technology, the risks of cell salvage in the obstetric population parallel those in the general population. Levels of fetal squamous cells in salvaged blood are comparable to those in maternal venous blood at the time of placental separation. No definite cases of amniotic fluid embolism have been reported and appear unlikely with modern equipment. Cell salvage is cost-effective in patients with predictably high rates of transfusion, such as parturients with abnormal placentation.

Readability, content, and quality assessment of web-based patient education materials addressing neuraxial labor analgesia

BACKGROUND:Studies in a variety of disciplines have shown that the readability of Web-based patient education materials is above that of the sixth grade reading level recommended by the U.S. Department of Health and Human Services. The aim of this study was to evaluate the readability, content, and quality of English- and Spanish-language patient education materials addressing neuraxial labor analgesia. METHODS:The websites of 122 U.S. academic medical centers with obstetric anesthesia divisions were searched for English- and Spanish-language patient education materials. Readability of English-language patient education materials was assessed with 3 validated indices: Flesch-Kincaid Grade Level, Simple Measure of Gobbledygook, and Gunning Frequency of Gobbledygook. Readability of Spanish-language patient education materials was assessed using the Spanish Lexile Measure. A 1-sample t test was used to evaluate the mean readability level against the recommended sixth grade reading level. A scoring matrix was developed to evaluate the content of patient education materials. Website quality was assessed using the Patient Education Materials Assessment Tool for Print. RESULTS:We identified 72 English-language and 29 Spanish-language patient education materials. The mean readability levels of all patient education materials were higher than the recommended sixth grade reading level using all indices (Flesch-Kincaid Grade Level: 9.1 ± 1.9, Simple Measure of Gobbledygook: 8.6 ± 1.4, Gunning Frequency of Gobbledygook: 11.8 ± 2.1; P < 0.001 for all). All patient education materials discussed the benefits of neuraxial analgesia. However, only 14% (upper 95% confidence interval: 24%) discussed contraindications to neuraxial anesthesia. Postdural puncture headache and hypotension were the most commonly addressed complications (92%). All other complications were addressed by less than half of patient education materials. Patient Education Materials Assessment Tool for Print scores were consistent with poor website understandability (median score, 64%; interquartile range, 64–73). CONCLUSIONS:The mean readability of Web-based patient education materials addressing neuraxial labor analgesia was above the recommended sixth grade reading level. Although most patient education materials explained the benefits of neuraxial analgesia, possible contraindications and complications were not consistently presented. The content, readability, and quality of patient education materials are poor and should be improved to help patients make more informed decisions about analgesic options during labor and delivery.