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Stella CL, Jodicke CD, How HY, Harkness UF, Sibai BM. Postpartum headache: is your work-up complete? Am J Obstet Gynecol 2007; 196:318.e1-7. [PMID: 17403403 DOI: 10.1016/j.ajog.2007.01.034] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2006] [Revised: 01/08/2007] [Accepted: 01/24/2007] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Headache is a common finding in the postpartum period, and there are limited data describing the cause and treatment of women with postpartum headache. Our objective was to describe our experience with women who were hospitalized for postpartum headache and to develop a management algorithm for these women. STUDY DESIGN Data for 95 women with headache >24 hours after delivery from 2000-2005 were reviewed retrospectively. Maternal assessment included an evaluation for benign and serious causes of headache that included preeclampsia, dural puncture, and neurologic lesions. Neurologic imaging were performed on the basis of initial neurologic findings and clinical course. Outcomes that were studied included cause, a need for cerebral imaging, neurologic findings, maternal complications, and long-term follow-up evaluations. RESULTS The mean onset of headache was 3.4 days (range, 2-32 days) after delivery. Tension-type/migraine headache was the most common cause (47%). Preeclampsia/eclampsia and spinal headache comprised 24% and 16% of cases, respectively. Anesthesia evaluation was required in 15 patients because of suspected spinal headache; blood patch was required in 12 of these patients. Cerebral imaging was performed in 22 patients because of focal neurologic deficits and/or failure to respond to initial therapy; 15 of these women (68%) had abnormal findings. Ten patients had serious cerebral pathologic findings, such as hemorrhage, thrombosis, or vasculopathy. There were no deaths; 2 women had minor residual neurologic damage on follow-up evaluation. CONCLUSION The evaluation of persistent headaches that develop >24 hours after delivery must be performed in a stepwise fashion and requires a multidisciplinary approach. Preeclampsia should be considered initially in women with hypertension and proteinuria. Normotensive women should be evaluated initially for tension-type/migraine headache or spinal headache. Patients with headache that is refractory to usual therapy and patients with neurologic deficit require cerebral imaging to detect the presence of life-threatening causes.
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Affiliation(s)
- Caroline L Stella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, OH 45267-0526, USA
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202
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Kallio H, Snäll EVT, Luode T, Rosenberg PH. Hyperbaric articaine for day-case spinal anaesthesia. Br J Anaesth 2006; 97:704-9. [PMID: 16891634 DOI: 10.1093/bja/ael222] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Articaine and lidocaine are clinically very similar suggesting that articaine could be suitable for day-case spinal anaesthesia. A dose-response study with articaine in ambulatory spinal anaesthesia was therefore performed. METHODS In this randomized double-blind study, 90 day-case surgery patients received spinal anaesthesia with 60 mg (A60), 84 mg (A84) or 108 mg (A108) of hyperbaric articaine hydrochloride. Sensory block was tested with pinprick and motor block on a modified Bromage scale. A structured interview was performed on the first and seventh postoperative days. RESULTS Sensory block reached the T10 dermatome in a median (range) of 5 (5-10) and was maintained at this level for 70 (35-145), 70 (15-115) and 85 (20-115) min in the A60, A84 and A108 groups, respectively. Six patients in the A108 group, two in the A84 group and one in the A60 group had maximum spread of analgesia to T(1) or higher (NS). Patients in the A108 group needed more medication for hypotension (P=0.018), had more often nausea and vomiting (P=0.027), took oral fluids later (P=0.031) and both sensory block recovery [median (range)] [2.5 (2-4.5) h] (P=0.017) and motor block recovery [2 (1.3-4) h] (P=0.009) were delayed. No patients in the A108 group needed opioid intraoperatively while fentanyl was needed in 5 (17%) and 2 (7%) patients in the A60 and A84 groups, respectively. Discharge criteria were attained in approximately 4.5 h after articaine injection (NS) and no drug-related sequelae were observed. CONCLUSIONS Hyperbaric articaine 60 and 84 mg resulted in spinal anaesthesia allowing surgery of the lower extremities for about 1 h. Recovery was rapid. Use of 108 mg of articaine is not recommended because of frequent extensive cephalad spread of the block, accompanied by arterial hypotension and nausea.
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Affiliation(s)
- H Kallio
- Department of Anaesthesiology and Intensive Care Medicine, Helsinki University Central Hospital Helsinki, Finland.
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203
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Sleth JC, Saizy C, Servais R, Pluskwa F, Lafforgue E. [Intrathecal catheter after wet tap in labour: headache prevention?]. ACTA ACUST UNITED AC 2006; 25:1083-4. [PMID: 17005360 DOI: 10.1016/j.annfar.2006.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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204
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Abstract
Since the discovery of spinal anesthesia in 1885 by J Leonard Corning, spinal needles have been modified to simplify their use and minimize complications. Needle design variables, such as diameter, tip design and orifice location, have been altered to enable rapid flow of cerebral spinal fluid (CSF) and injected medications, yet simultaneously limit dural trauma and loss of CSF. CSF loss can result in a severe postdural puncture headache (PDPH). Blunt pencil-point tip needles have been observed to cause a lower incidence of PDPH than similar sized sharp, cutting tip needles. Smaller diameter needles are also associated with a lower incidence of PDPH. A recent alteration in spinal needles is not to the needle per se, but rather the microcatheters placed through them; currently used in Europe, such catheters are again being evaluated in the USA. Further advancements in spinal needles will most likely involve some of the design elements previously altered, as well as new features not yet recognized as important at this time.
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Affiliation(s)
- Lawrence C Tsen
- Harvard Medical School, Department of Anesthesiology, Perioperative and Pain Medicine, Boston, MA 02115, USA.
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205
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Ranta PO, Ala-Kokko TI, Kukkonen JE, Ohtonen PP, Raudaskoski TH, Reponen PK, Rawal N. Incisional and epidural analgesia after caesarean delivery: a prospective, placebo-controlled, randomised clinical study. Int J Obstet Anesth 2006; 15:189-94. [PMID: 16798442 DOI: 10.1016/j.ijoa.2006.02.003] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2005] [Accepted: 02/24/2006] [Indexed: 11/23/2022]
Abstract
BACKGROUND This study evaluated efficacy, safety and patient satisfaction with incisional analgesia with a subfascial catheter compared to epidural analgesia for pain relief following caesarean section. METHODS Forty patients were randomised after elective caesarean section to receive either intermittent 10-mL boluses of 0.125% levobupivacaine into the epidural space and physiologic saline into the surgical wound or intermittent 10-mL boluses of 0.25% levobupivacaine into the wound and epidural saline with a repeated 10-dose regimen. Analgesic efficacy was evaluated by numerical pain scores (0-10, 0=no pain, 10=worst pain) and based on the consumption of supplemental opioid. Side effects, patient satisfaction and plasma concentrations of levobupivacaine were recorded. RESULTS In the epidural group average pain scores were lower (1.8 vs. 3, P=0.006) and the consumption of local anaesthetic (29 mL vs. 38 mL, P=0.01) was smaller during the first four postoperative hours, after which both groups had pain scores of 3 or less at rest. All parturients were able to walk after the 24-h study period. The total consumption of rescue opioid oxycodone (32 vs. 37 mg, P=0.6) during the whole 72-h study period was low in both study groups. Side effects were mild and rare. Satisfaction scores were equally high in the two groups. Peak plasma concentrations of levobupivacaine were below the toxic range. CONCLUSION Incisional local analgesia via a subfascial catheter provided satisfactory pain relief with patient satisfaction comparable to that seen with epidural analgesia. This technique may be a good alternative to the more invasive epidural technique following caesarean section as a component of multimodal pain management.
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MESH Headings
- Adult
- Analgesia, Epidural/adverse effects
- Analgesia, Epidural/methods
- Analgesia, Obstetrical/adverse effects
- Analgesia, Obstetrical/methods
- Analgesia, Patient-Controlled/adverse effects
- Anesthesia, Local/adverse effects
- Anesthesia, Local/methods
- Anesthetics, Local/administration & dosage
- Bupivacaine/administration & dosage
- Bupivacaine/analogs & derivatives
- Cesarean Section
- Combined Modality Therapy
- Double-Blind Method
- Female
- Humans
- Levobupivacaine
- Pain Measurement
- Pain, Postoperative/drug therapy
- Pain, Postoperative/prevention & control
- Pregnancy
- Prospective Studies
- Time Factors
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Affiliation(s)
- P O Ranta
- Department of Anaesthesiology and Intensive Care, Oulu University, Finland.
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206
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Gulur P, Nishimori M, Ballantyne JC. Regional anaesthesia versus general anaesthesia, morbidity and mortality. Best Pract Res Clin Anaesthesiol 2006; 20:249-63. [PMID: 16850776 DOI: 10.1016/j.bpa.2005.10.002] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The regional versus general anaesthesia debate is an age-old debate that has brought about few clear answers. Most concur that multiple factors including the patient, the surgery, the method of regional and general anaesthesia, and the quality of perioperative care, all influence surgical outcome. In this age of evidence-based medicine, the heterogenous data available need to be reconciled with the advances in perioperative care and the significant decline in complications associated with the surgical process as a whole. This review considers general issues such as the type of available evidence, and its limitations, particularly with regard to the relatively broad question of neuraxial versus general anaesthesia. It then assesses current evidence on regional versus general anaesthesia for specific scenarios such as hip fracture surgery, carotid endarterectomy, Caesarean section, ambulatory orthopaedic surgery, and postoperative cognitive dysfunction in elderly patients after non-cardiac surgery.
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Affiliation(s)
- Padma Gulur
- Massachusetts General Hospital Pain Center, Harvard Medical School, Massachusetts General Hospital Pain Center, 15 Parkman Street, WACC 333, Boston, MA 02114, USA.
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207
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Morley-Forster PK, Singh S, Angle P, Littleford J, Currin M, Halpern SH. The effect of epidural needle type on postdural puncture headache: a randomized trial. Can J Anaesth 2006; 53:572-8. [PMID: 16738291 DOI: 10.1007/bf03021847] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE A prospective, randomized trial in labouring parturients was undertaken to assess whether the 18G Special Sprotte epidural needle is associated with a lower incidence of accidental dural puncture (ADP) in comparison with the 17G Tuohy needle. A secondary purpose was to determine if the incidence of postdural puncture headache (PDPH ) differed between groups when ADP occurred. METHODS Following Institutional Review Board approval 1,077 parturients requesting epidural analgesia at three tertiary obstetrical units were randomized to epidural catheter insertion with a 17G Tuohy or 18G Special Sprotte needle. Patients were followed for seven days by a blinded assessor to determine the occurrence of PDPH using standardized criteria. If postural headache or neck ache presented, an ADP was diagnosed even if cerebrospinal fluid (CSF) was not observed at insertion. This subgroup was followed daily to assess headache characteristics and response to blood patch. RESULTS Six Tuohy group patients, and two patients in the Sprotte group were excluded. One of the six excluded in the Tuohy group had an ADP. Twenty-eight ADPs occurred, nine unrecognized by CSF visualization (1.8% Tuohy, 3.4% Sprotte, P = 0.12). The incidence of unrecognized ADPs was higher in the Sprotte group (40% Sprotte vs 20% Tuohy, P < 0.05). If ADP occurred, the incidence of PDPH was lower in the Sprotte group (100% Tuohy vs 55% Sprotte, P = 0.025). The ease of use, and user satisfaction were higher in the Tuohy group (84 +/- 17.3% Tuohy vs 68.2 +/- 25.3% Sprotte, P < 0.001). CONCLUSION The incidence of ADP was not reduced with the Special Sprotte epidural needle in comparison with the Tuohy needle, but PDPH after ADP occurred less frequently in the Sprotte group.
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Affiliation(s)
- Patricia K Morley-Forster
- Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine, University of Western Ontario, London, Ontario, Canada.
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208
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Raffin L, Batiste C, Noël D, Serbouh A. Blood patch, il n'est jamais trop tard. ACTA ACUST UNITED AC 2006; 25:201-5. [PMID: 16310337 DOI: 10.1016/j.annfar.2005.08.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2005] [Accepted: 08/07/2005] [Indexed: 10/25/2022]
Abstract
Long lasting postural puncture headache secondary to an unintentional dural puncture (UDP) during epidural anaesthesia (EA) or following deliberate dural puncture for spinal anaesthesia, and neurological or neuroradiological examination, is becoming unusual. Placing the bevel of Tuohy needle parallel to the longitudinal axis of the dural cylinder when searching for epidural space, and in the later cases, widespread use of small diameter, atraumatic needles, have decreased both its incidence and severity. Furthermore, in the absence of any contraindication, patients suffering from such troubles are now quite systematically offered a curative epidural blood patch (EBP) whose effectiveness is documented. Authors report an original case of a fainthearted patient who underwent caesarean section under EA when she was 31-year-old, and whose disabling painful symptoms related to a UDP were successfully relieved by one EBP that she ended to accept more than seven years later. On the occasion of a short literature review, physiopathology and management are debated.
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Affiliation(s)
- L Raffin
- Clinique Les Martinets, 97, avenue Albert-1(er), 92500 Rueil-Malmaison, France.
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209
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Goldszmidt E, Kern R, Chaput A, Macarthur A. The incidence and etiology of postpartum headaches: a prospective cohort study. Can J Anaesth 2005; 52:971-7. [PMID: 16251565 DOI: 10.1007/bf03022061] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE We sought to determine the incidence, etiology, characteristics and risk factors for all headaches in the first week postpartum. METHODS This was a prospective cohort study of 985 women delivering over a three-month period in a single tertiary-care institution. These women underwent a structured interview and follow-up to collect demographic data and to assess for the presence and characteristics of postpartum headache (PPHa) or neck/shoulder pain. All headaches were diagnosed using an algorithm based on the diagnostic criteria of the International Headache Society. Multivariate analysis was used to examine possible risk factors. RESULTS Three hundred eighty-one of the 985 study participants (39%) reported headaches or neck/shoulder pain during the study period. The median time to onset of the PPHa was two days (0, 6; 1st and 3rd quartiles) and duration was four hours (2, 24; 1st and 3rd quartiles). Primary headaches accounted for > 75% of PPHa. Only a small number of headaches (4%) were incapacitating. Postdural puncture headache accounted for 4.7% of all PPHa. Significant risk factors for the development of PPHa were: known inadvertent dural puncture [odds ratio (OR)adj = 6.36; 95% confidence interval (CI) 1.29, 31.24]; previous headache history (1-12/yr-OR(adj) = 1.57; 95% CI 1.01, 2.44; > 12/yr-OR(adj) = 2.25; 95% CI 1.63, 3.11); multiparity (OR(adj) = 1.37; 95% CI 1.03, 1.82) and increasing age (OR(adj) = 1.03/yr; 95% CI 1.00, 1.06). CONCLUSIONS Postpartum headaches are common, often first noted after discharge from hospital. The majority are related to primary headache disorders. Increased awareness of this epidemiological relationship and improved diagnosis of primary headache conditions may lead to improved headache-specific therapy and avoidance of unnecessary investigations or read-mission to hospital.
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Affiliation(s)
- Eric Goldszmidt
- Department of Anesthesia, Mount Sinai Hospital, Toronto, Ontario, Canada.
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210
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Affiliation(s)
- Jonathan P Gladstone
- Department of Neurology, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ 85259, USA
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211
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Baraz R, Collis RE. The management of accidental dural puncture during labour epidural analgesia: a survey of UK practice. Anaesthesia 2005; 60:673-9. [PMID: 15960718 DOI: 10.1111/j.1365-2044.2005.04222.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The management of accidental dural puncture and postdural puncture headache in obstetric practice continues to be of great interest. This survey aims to explore the current management of this complication in the United Kingdom and compares the findings to a similar survey undertaken in 1993. A postal questionnaire was sent to all maternity units (n = 248). The return rate was 71%. Of these, 144 units (85%) now have written guidelines for the management of accidental dural puncture compared to 58% in 1993. In 47 units (28%), the epidural catheter is now routinely placed intrathecally following accidental dural puncture; in 69 units (41%) the catheter is re-sited and in the remaining 53 units (31%) either option is allowed. This is in contrast to the previous survey, which found that catheters were re-sited in 99% of units. Only 31 units (18%) now limit the second stage of labour and 19 (11%) avoid pushing and deliver by ventouse or forceps, whilst 116 units (69%) allow labour to take place without any intervention. Only 44 units (26%) now treat postdural puncture headache with an epidural blood patch as soon as it is diagnosed, whereas in 120 units (71%) the blood patch is performed only after failure of conservative measures. Due to the large increase in the use of the intrathecal catheter following this complication, a follow-up questionnaire was posted 5 months later to those units (n = 99) that reported this practice in the initial survey, with a 94% response rate. The two most commonly cited reasons for intrathecal catheterisation were to avoid further dural puncture (76%) and to allow immediate analgesia for labour (75%).
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Affiliation(s)
- R Baraz
- Anaesthetic Specialist Registrar, Department of Anaesthesia, University Hospital of Wales, Cardiff and Vale NHS Trust, Cardiff CF14 4XW, Wales, UK.
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212
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Gosch UW, Hueppe M, Hallschmid M, Born J, Schmucker P, Meier T. Post-dural puncture headache in young adults: comparison of two small-gauge spinal catheters with different needle design. Br J Anaesth 2005; 94:657-61. [PMID: 15722381 DOI: 10.1093/bja/aei100] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND To reduce the risk of post-dural puncture headache (PDPH) in continuous spinal anaesthesia, small-gauge spinal catheter systems with different techniques of dural perforation have been developed. METHODS Two systems, the catheter through-needle technique (MicroCatheter, Portex, UK) and the catheter over-needle technique (22G Spinocath, B. Braun, Germany), were used in 18 young healthy volunteers (age 18-30 yr), who were enrolled in a neuroendocrinological investigation for analysis of neuropeptides in cerebrospinal fluid (CSF). After intermittent sampling of CSF (17 x 0.5 ml over 4 h), the catheter was removed and the development of PDPH and pain intensity were documented prospectively by the subjects in a standardized headache assessment (11-point numerical rating scale [NRS]). RESULTS The study revealed a high overall incidence of PDPH (78%) with no significant differences between groups (P=0.26). However, the over-needle group showed a significantly shorter duration of PDPH (2.4 [SD 2.3] vs 5.1 [3.1] days, P=0.050) and lower maximum pain intensity (3.1 [2.9] vs 7.3 [3.4] NRS, P=0.014) than the through-needle group. CONCLUSIONS The results demonstrate a potential benefit of the catheter over-needle technique for the reduction of the duration and intensity of PDPH.
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Affiliation(s)
- U W Gosch
- Department of Anaesthesiology, University of Lübeck, Ratzeburger Allee 160, D-23538 Lübeck, Germany.
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213
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Tsen LC. What’s new and novel in obstetric anesthesia? Contributions from the 2003 scientific literature. Int J Obstet Anesth 2005; 14:126-46. [PMID: 15795148 DOI: 10.1016/j.ijoa.2004.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2004] [Accepted: 12/24/2004] [Indexed: 10/25/2022]
Abstract
THE PREGNANT PATIENT: Age; maternal disease; prophylactic antibiotics; gastroesophageal reflux; obesity; starvation; genotyping; coagulopathy; infection; substance abuse; altered drug responses in pregnancy; physiological changes of pregnancy. THE FETUS: Fetal monitoring; intrauterine surgery. THE NEWBORN: Breastfeeding; maternal infection, fever, and neonatal sepsis evaluation. OBSTETRIC COMPLICATIONS: Embolic phenomena; hemorrhage; preeclampsia; preterm delivery. OBSTETRIC MANAGEMENT: External cephalic version and cervical cerclage; elective cesarean delivery; fetal malpresentation; vaginal birth after cesarean delivery; termination of pregnancy. OBSTETRIC ANESTHESIA: Analgesia for labor and delivery; anesthesia for cesarean delivery; anesthesia for short obstetric operations; complications of anesthesia. MISCELLANEOUS: Consent; ethics; history; labor support; websites/books/leaflets/journal announcements.
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Affiliation(s)
- L C Tsen
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston MA 02115, USA.
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214
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Buettner A, Popham P, Morgan D. Incidence of epidural blood patch following obstetric regional analgesia in private Australian anaesthetic practice. Int J Obstet Anesth 2005; 14:5-8. [PMID: 15627531 DOI: 10.1016/j.ijoa.2004.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/01/2004] [Indexed: 11/19/2022]
Abstract
BACKGROUND Collection of audit data about epidural blood patches has traditionally relied on voluntary reporting, which is notoriously incomplete. The records of Medicare-funded Australian private obstetric practice, which represents 30% of all deliveries, allow a novel method of central data collection and retrieval. METHOD Data relating to all deliveries, epidurals and blood patches in private practice in Australia over a two-year period were retrieved from the Health Insurance Commission. RESULTS The overall rate of epidural analgesia in labour was estimated at 30% and the proportion of epidurals that progressed to blood patching was 0.35%. The rate of epidural blood patching varied between states from 0.18% to 0.56%. CONCLUSION Despite certain limitations of our data interpretation, we regard this technique as a useful audit tool capable of generating accurate and robust audit data that might otherwise be unobtainable.
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Affiliation(s)
- A Buettner
- Department of Anaesthesia, Royal Women's Hospital, Carlton 3053, Australia.
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215
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Wong AYC. Is PDPH from a 25-gauge Whitacre needle always short-lasting and self-resolving? Can J Anaesth 2004; 51:637; author reply 637-8. [PMID: 15197130 DOI: 10.1007/bf03018409] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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216
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Choi PTL. Reply. Can J Anaesth 2004. [DOI: 10.1007/bf03018410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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