RESUMEN
BACKGROUND: Severe upper back/interscapular, neck and shoulder pain during labor epidural analgesia (PLEA) is not uncommon. The objective of this quality initiative was to evaluate the incidence, demographic associations and management of PLEA. METHODS: An eight-month, single-center quality improvement initiative was performed for the detection and management of PLEA. After survey-based consensus among obstetric anaesthetist attendings and fellows, a three-step PLEA treatment protocol with interventions and numeric rating scale (NRS, 0 - 10 scale) pain assessments was introduced. Demographic data and outcomes were compared among parturients with and without PLEA. RESULTS: Among 2888 women who received labor epidural analgesia from October 2022 through May 2023, 36 (1.2% [95% CI 0.9% to 1.7%]) reported PLEA. Women with PLEA were younger, more likely to be nulliparous, and had a higher body mass index (BMI) than women without PLEA (pâ¯<â¯0.05 for all). A total of 72.2% (26/36) of women with PLEA received at least one protocol treatment. Twenty-three women received first-line therapy, with pain relief in 91.3% (21/23). The median NRS score decreased from 9 [IQR 8-10] to 3 [1-4]. Women with PLEA had a higher incidence of cesarean delivery (CD) and a longer interval between epidural placement and delivery; 52.8 vs. 17.5% (pâ¯<â¯0.001) and 16.5 vs. 6.9â¯hours (pâ¯<â¯0.001), respectively. CONCLUSIONS: The incidence of PLEA was higher than previously reported. Patients with PLEA were younger, more commonly nulliparous, had higher BMI, longer epidural infusion times and higher CD rates. A three-step treatment protocol was successful in managing PLEA.
RESUMEN
BACKGROUND: Sporadic intracranial vascular malformations can pose significant risk to parturients, and additional reports of management may inform patient care. Here we describe the peripartum management of parturients with intracranial vascular malformations. METHODS: After Institutional Review Board approval, we performed a retrospective analysis of parturients with a known sporadic intracranial vascular malformation including cavernous malformation, developmental venous anomaly, or arteriovenous malformation who delivered at our institution between 2007 and 2020. RESULTS: We identified 10 parturients (five cavernous malformations, three developmental venous anomalies, and two arteriovenous malformations) with 16 deliveries. Among all deliveries, 13 (81.3%) were cesarean deliveries without trial of labor; 11 of these (84.6%) received a single-shot spinal and two (15.4%) received an epidural for surgical anesthesia. Two deliveries (12.5%) began with attempted trial of labor but ultimately required cesarean delivery for failure to progress; one of these cases received epidural anesthesia and the other received combined spinal-epidural anesthesia. One delivery was via spontaneous vaginal delivery with epidural analgesia. Overall, our study's cesarean delivery rate was 93.8% and spontaneous vaginal delivery rate was 6.2%. Three of 16 pregnancies were complicated by seizure, obstructive hydrocephalus, or intracranial hemorrhage. There were no intensive care unit admissions or maternal deaths. CONCLUSIONS: In our case series of 16 deliveries, there were no complications directly resulting from neuraxial procedures. It remains unclear whether intracranial developmental venous anomalies or unruptured arteriovenous malformations impart increased risk during pregnancy. Antepartum planning with a multidisciplinary team approach enables risk stratification and optimal management.
Asunto(s)
Anestesia Obstétrica , Cesárea , Humanos , Femenino , Embarazo , Estudios Retrospectivos , Adulto , Anestesia Obstétrica/métodos , Anestesia Epidural/métodos , Anestesia Raquidea/métodos , Malformaciones Arteriovenosas Intracraneales/terapia , Malformaciones Arteriovenosas Intracraneales/complicaciones , Parto Obstétrico/métodos , Adulto JovenRESUMEN
INTRODUCTION: Subspecialty training in obstetric anesthesiology is associated with improved patient outcomes and reduced anesthesia-related morbidity and mortality. Despite this, the demand for fellowship-trained obstetric anesthesiologists far exceeds the supply. This survey study aimed to evaluate the perceived value of obstetric anesthesiology subspecialty training on career trajectory, job satisfaction, quality of life, and job autonomy. METHODS: After Institutional Review Board approval, we conducted a cross-sectional study of fellowship-trained obstetric anesthesiologists in the United States of America. In March and April 2022, program directors of obstetric anesthesiology fellowships distributed an electronic survey link containing 29 multiple-choice questions to their program alumni. Survey content included respondent demographic characteristics, practice models, career information, and perceived value of an obstetric anesthesiology fellowship. RESULTS: We surveyed 217/502 (43%) fellowship-trained obstetric anesthesiologists with a response rate of 158/217 (73%). Most worked in urban, academic, and level IV perinatal health centers. The majority believed an obstetric anesthesiology fellowship was "extremely beneficial" (77%), enhanced quality of life (84%), improved the quality of patient care (99%), and was influential in helping obtain their first post-training job (86%). The perceived value of the fellowship included an enhanced career trajectory, a sense of purpose, improved job satisfaction, a sense of work community, lower burnout, involvement in maternal health initiatives, increased mentorship, and departmental leadership. CONCLUSION: In this survey study, fellowship-trained obstetric anesthesiologists perceived a positive impact of fellowship training on career trajectory, job protection and autonomy, quality of life, and job satisfaction. This information may be meaningful to trainees considering pursuing a fellowship and a career in obstetric anesthesiology.
Asunto(s)
Anestesiología , Internado y Residencia , Femenino , Embarazo , Humanos , Estados Unidos , Anestesiología/educación , Anestesiólogos , Becas , Estudios Transversales , Calidad de Vida , Encuestas y CuestionariosAsunto(s)
Trabajo de Parto , Hemorragia Posparto , Embarazo , Femenino , Humanos , Hemorragia Posparto/terapia , Anestesiólogos , Parto Obstétrico , MassachusettsAsunto(s)
Hemorragia Posparto , Embarazo , Femenino , Humanos , Hemorragia Posparto/terapia , Proyectos Piloto , Estudios Prospectivos , Parto Obstétrico , RegistrosRESUMEN
BACKGROUND: Peripartum quantitative blood loss (QBL) measurement is recommended over visual estimation. However, QBL measurement after vaginal delivery has been inadequately evaluated. The primary aim of this study was to determine the characteristics of QBL measurements from a large, multicenter cohort of patients having vaginal deliveries. We also determined the incidence of postpartum hemorrhage (PPH) and the relationship between gravimetric QBL from weighed sponges vs. volumetric QBL from liquid drape or suction cannister contents. METHODS: Data were collected from 41 institutions in the United States of America that use an automated QBL device after vaginal delivery as part of routine care. The QBL device tracks cumulative blood loss based on gravimetry and volumetric V-drape assessment, automatically subtracting the dry weights of all blood-containing sponges, towels, pads and other supplies as well as the amniotic fluid volume. RESULTS: Between January 2017 and April 2020, 104â¯079 QBL values were obtained from patients having vaginal deliveries. Total median [IQR] QBL was 171 [61-362] mL. The PPH incidence, stratified by QBL, was 15.2% (>500â¯mL), 3.4% (>1000â¯mL), and 1.0% (>1500â¯mL). The contribution of QBL from V-drapes was 60.6±26.3% of total QBL. CONCLUSION: Results from this large set of QBL measurements and the PPH incidence provide normative "real-world" clinical care values that can be expected as hospitals transition from estimated blood loss to QBL to assess the blood loss at vaginal delivery.
Asunto(s)
Parto Obstétrico , Hemorragia Posparto , Parto Obstétrico/métodos , Femenino , Humanos , Incidencia , Hemorragia Posparto/epidemiología , Embarazo , Estudios RetrospectivosRESUMEN
BACKGROUND: Maternal and fetal concerns have prompted a significant reduction in general anesthesia (GA) use for cesarean delivery (CD). The obstetric comorbidity index (OB-CMI) is a validated, dynamic composite score of comorbidities encountered in an obstetric patient. We sought to estimate the association between OB-CMI and odds of GA vs. neuraxial anesthesia (NA) use for CD. METHODS: In this single-center, retrospective cohort study conducted at a large academic hospital in the United States of America, OB-CMI was calculated on admission and every 12â¯h for women undergoing CD at ≥23â¯weeks' gestation (n=928). The CD urgency, anesthesia type, and most recent OB-CMI were extracted from the medical record. The association between OB-CMI and GA use was estimated by logistic regression, with and without adjustment for CD urgency, parity and race. RESULTS: Each one-point increase in OB-CMI was associated with a 32% (95% confidence interval [CI] 17% to 48%) increase in the odds of GA use (Model 1, area under the receiver operating characteristic curve [AUC] 0.708, 95% CI 0.610 to 0.805). The AUC improved to 0.876 (95% CI 0.815 to 0.937) with the addition of emergent CD (Model 2, Pâ¯<0.001 vs. Model 1), but not parity and race (Model 3, AUC 0.880, 95% CI 0.824 to 0.935; P=0.616 vs. Model 2). CONCLUSIONS: The OB-CMI is associated with increased odds of GA vs. NA use for CD, particularly when emergent. Collected in real time, the OB-CMI may enable prophylaxis (e.g. comorbidity modification, earlier epidural catheter placement, elective CD) or preparation for GA use.
Asunto(s)
Anestesia Epidural , Cesárea , Anestesia General , Parto Obstétrico , Femenino , Edad Gestacional , Humanos , Embarazo , Estudios Retrospectivos , Estados UnidosRESUMEN
Quantitation of blood loss after vaginal and cesarean delivery has been advocated for the timely detection of postpartum hemorrhage and activation of protocols for resuscitation. Morbidity and mortality from postpartum hemorrhage is considered to be largely preventable and is attributed to delayed recognition with under-resuscitation or inappropriate resuscitation. Optimizing detection of postpartum hemorrhage through refining how blood loss is measured is therefore clinically relevant. In this review on quantitative blood loss for postpartum hemorrhage, recent advances in the methods used to quantitate blood loss will be reviewed, with a comparison of utility and precision for blood loss measurement after vaginal and cesarean delivery. Considerations for the implementation of a quantitative blood loss system on the labor and delivery unit, including its benefits and challenges, will be discussed. The existing evidence for impact of blood loss quantitation in obstetrics on hemorrhage-related morbidity will be delineated, along with knowledge gaps and future research priorities.
Asunto(s)
Trabajo de Parto , Hemorragia Posparto , Cesárea , Parto Obstétrico , Femenino , Humanos , Morbilidad , Hemorragia Posparto/prevención & control , EmbarazoRESUMEN
BACKGROUND: Increasingly, evidence supports the use of educational paradigms that focus on teacher-learner interaction and learner engagement. We redesigned our monthly obstetric anesthesia resident didactics from a lecture-based curriculum to an interactive format including problem-based learning, case discussion, question/answer sessions, and simulation. We hypothesized that the new curriculum would improve resident satisfaction with the educational experience, satisfaction with the rotation, and knowledge retention. METHODS: Fifty-three anesthesiology residents were prospectively recruited and quasi-randomized through an alternating-month pattern to attend either interactive sessions or traditional lectures. Residents completed a daily satisfaction survey about quality of teaching sessions and a comprehensive satisfaction survey at the conclusion of the rotation. Knowledge retention was assessed with a knowledge test completed on the final day. The primary outcome was daily satisfaction with the curriculum, and secondary outcomes included overall satisfaction with the curriculum, overall rotation satisfaction, and within-resident difference between pre- and post-knowledge test scores. RESULTS: No differences were observed in daily resident satisfaction after interactive sessions vs traditional lectures. Furthermore, no differences were observed between the interactive sessions and traditional lecture groups in overall satisfaction with the curriculum, overall satisfaction with the entire rotation or within-resident difference between pre- and post-knowledge test scores. CONCLUSIONS: Our study failed to demonstrate improvement in resident satisfaction or knowledge retention following implementation of an interactive curriculum on a month-long obstetric anesthesia rotation. Reasons may include misalignment of the intervention with measured study outcomes, lack of sensitivity of the survey tools, and inadequate training of faculty presenters.
Asunto(s)
Anestesiología , Internado y Residencia , Anestesiología/educación , Curriculum , Humanos , Satisfacción Personal , Encuestas y CuestionariosAsunto(s)
Sistemas de Atención de Punto , Tromboelastografía , Australia , Cesárea , Femenino , Humanos , Embarazo , Estudios Prospectivos , Nanomedicina TeranósticaRESUMEN
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.
Asunto(s)
Anestesia Obstétrica/métodos , Cardiomiopatía Hipertrófica/complicaciones , Parto Obstétrico/métodos , Trabajo de Parto , Complicaciones Cardiovasculares del Embarazo , Adulto , Femenino , Humanos , Embarazo , Resultado del EmbarazoRESUMEN
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.
Asunto(s)
Cloruro de Calcio/administración & dosificación , Hemodinámica/efectos de los fármacos , Oxitocina/administración & dosificación , Útero/efectos de los fármacos , Adulto , Cloruro de Calcio/sangre , Cesárea , Método Doble Ciego , Femenino , Humanos , Oxitocina/sangre , Embarazo , Útero/fisiologíaRESUMEN
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.
Asunto(s)
Analgesia Epidural/estadística & datos numéricos , Analgesia Obstétrica/estadística & datos numéricos , Anestesiología/estadística & datos numéricos , Trabajo de Parto , Personal de Enfermería en Hospital/estadística & datos numéricos , Satisfacción del Paciente/estadística & datos numéricos , Adulto , Análisis de Varianza , Femenino , Humanos , Dolor , Dimensión del Dolor , Embarazo , Encuestas y Cuestionarios , Factores de Tiempo , Resultado del TratamientoRESUMEN
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.
Asunto(s)
Anestesia Epidural/efectos adversos , Anestesia Obstétrica/efectos adversos , Catéteres/efectos adversos , Adulto , Anestesia Epidural/instrumentación , Anestesia Obstétrica/instrumentación , Cateterismo/efectos adversos , Cateterismo/instrumentación , Competencia Clínica , Duramadre/lesiones , Espacio Epidural , Falla de Equipo/estadística & datos numéricos , Femenino , Humanos , Incidencia , Internado y Residencia , EmbarazoRESUMEN
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.