Paul G. Preston

Intravenous Remifentanil Placental Transfer, Maternal and Neonatal Effects

Background Remifentanil has not been studied in obstetric patients. This study evaluates the placental transfer of remifentanil and the neonatal effects when administered as an intravenous infusion. Methods Nineteen parturients underwent nonemergent cesarean section with epidural anesthesia and received 0.1 [micro sign]g [middle dot] kg‐1 [middle dot] min‐1 remifentanil intravenously, which was continued until skin closure. Maternal arterial (MA), umbilical arterial (UA), and umbilical venous (UV) blood samples were obtained at delivery for analysis of drug concentrations of remifentanil, its metabolite, and blood gases. Maternal vital signs were monitored continuously, and pain and sedation levels were assessed intermittently. Apgar scores were obtained at 1, 5, 10, and 20 min, and Neonatal and Adaptive Capacity Scores were noted 30 and 60 min after delivery. Parturients and newborns were observed for at least 24 h after surgery for side effects. Results The means and SDs of UV:MA and UA:UV ratios for remifentanil were 0.88 +/‐ 0.78 and 0.29 +/‐ 0.07, respectively. Mean clearance was 93 ml [middle dot] min‐1 [middle dot] kg‐1. The mean UV:MA and UA:MV ratios for remifentanil acid were 0.56 +/‐ 0.29 and 1.23 +/‐ 0.89, respectively. The mean MA (remifentanil acid):MA (remifentanil) ratio was 2.92 +/‐ 3.65. There were no adverse effects on the neonates, but there was a sedative effect and respiratory depressant effect on the mothers. Conclusions Remifentanil crosses the placenta but appears to be rapidly metabolized, redistributed, or both. Maternal sedation and respiratory changes occur, but without adverse neonatal or maternal effects.

How to Integrate Findings from Simulation Exercises to Improve Obstetrics Care in the Institution

The opening of a new facility often brings teams from different backgrounds who have previously never worked together. Organizational goals of safety and high reliability from the first day of operations would be impossible to attain without testing. Simulation is now being used to test new services, departments, and entire facilities before opening. This has been accomplished by establishing a well-developed program of in situ simulation with strong physician and nursing educator co-leads and simulation teams. This article describes a process for testing through simulation and the systemic findings from testing existing and new facilities and services.