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Parker J, Hodson N, Young P, Shelton C. How should institutions help clinicians to practise greener anaesthesia: first-order and second-order responsibilities to practice sustainably. JOURNAL OF MEDICAL ETHICS 2023:jme-2023-109442. [PMID: 37734908 DOI: 10.1136/jme-2023-109442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 09/01/2023] [Indexed: 09/23/2023]
Abstract
There is a need for all industries, including healthcare, to reduce their greenhouse gas emissions. In anaesthetic practice, this not only requires a reduction in resource use and waste, but also a shift away from inhaled anaesthetic gases and towards alternatives with a lower carbon footprint. As inhalational anaesthesia produces greenhouse gas emissions at the point of use, achieving sustainable anaesthetic practice involves individual practitioner behaviour change. However, changing the practice of healthcare professionals raises potential ethical issues. The purpose of this paper is twofold. First, we discuss what moral duties anaesthetic practitioners have when it comes to practices that impact the environment. We argue that behaviour change among practitioners to align with certain moral responsibilities must be supplemented with an account of institutional duties to support this. In other words, we argue that institutions and those in power have second-order responsibilities to ensure that practitioners can fulfil their first-order responsibilities to practice more sustainably. The second goal of the paper is to consider not just the nature of second-order responsibilities but the content. We assess four different ways that second-order responsibilities might be fulfilled within healthcare systems: removing certain anaesthetic agents, seeking consensus, education and methods from behavioural economics. We argue that, while each of these are a necessary part of the picture, some interventions like nudges have considerable advantages.
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Affiliation(s)
- Joshua Parker
- Medical School, Lancaster University Faculty of Health and Medicine, Lancaster, UK
| | - Nathan Hodson
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Paul Young
- North West School of Anaesthesia, Health Education England North West, Manchester, UK
| | - Clifford Shelton
- Medical School, Lancaster University Faculty of Health and Medicine, Lancaster, UK
- Department of Anaesthesia, Wythenshawe Hospital, Manchester, UK
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Antończyk A, Kiełbowicz Z, Niżański W, Ochota M. Comparison of 2 anesthetic protocols and surgical timing during cesarean section on neonatal vitality and umbilical cord blood parameters. BMC Vet Res 2023; 19:48. [PMID: 36782240 PMCID: PMC9923906 DOI: 10.1186/s12917-023-03607-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 02/06/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND The objective of this study was to evaluate the relationship between the mode of anesthesia, the time form the induction to the extraction of a puppy and the immediate postnatal vitality and umbilical cord blood gases parameters in cesarean section derived-puppies. Two different anesthetic protocols were used: inhalation using isoflurane (ISO) and combined-inhalation and epidural (EPI) with propofol being the induction agent. RESULTS Significant differences were found in ISO group in pH values, pCO2 levels and Apgar scores between puppies at different extraction times (< 30 vs. ≥ 30 min). In ISO group puppies extracted later were more acidic (7.16 vs. 7.22), had higher levels of pCO2 (69 vs. 57 mmHg) and lower Apgar scores at birth (1.2 vs. 2.5). On the contrary, in EPI group no differences were observed between the delivery time, umbilical blood gas parameters and puppies' vitality. Furthermore, the dams from the EPI group required lower concentrations of isoflurane (MAC 1.11 ± 0.19 vs.1.37 ± 0.16, p < 0.001). CONCLUSIONS Multiple pregnancies frequent in dogs lead to significant differences in extraction times between the first and the last puppy during cesarean section. Obtained results showed that the mode of anesthesia and the surgical time would influence the neonatal outcome during cesarean section in dogs. The higher concentration of isoflurane with the longer time of exposure had a negative effect on the initial newborn vitality as well as the umbilical cord blood gas parameters. Therefore, when performing CS in giant dog breeds or expecting many puppies in the litter, it is worth considering epidural component that allow for lower concentrations of inhalant agents, which may contribute to a better clinical condition of newborns.
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Affiliation(s)
- Agnieszka Antończyk
- Faculty of Veterinary Medicine, Department and Clinic of Surgery, Wroclaw University of Environmental and Life Sciences, Pl. Grunwaldzki 51, 50-366, Wrocław, Poland.
| | - Zdzisław Kiełbowicz
- grid.411200.60000 0001 0694 6014Faculty of Veterinary Medicine, Department and Clinic of Surgery, Wroclaw University of Environmental and Life Sciences, Pl. Grunwaldzki 51, 50-366 Wrocław, Poland
| | - Wojciech Niżański
- grid.411200.60000 0001 0694 6014Faculty of Veterinary Medicine, Department of Reproduction and Clinic of Farm Animals, Wroclaw University of Environmental and Life Sciences, Pl. Grunwaldzki 49, 50-366 Wrocław, Poland
| | - Małgorzata Ochota
- grid.411200.60000 0001 0694 6014Faculty of Veterinary Medicine, Department of Reproduction and Clinic of Farm Animals, Wroclaw University of Environmental and Life Sciences, Pl. Grunwaldzki 49, 50-366 Wrocław, Poland
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Antończyk A, Ochota M. Is an epidural component during general anaesthesia for caesarean section beneficial for neonatal puppies' health and vitality? Theriogenology 2022; 187:1-8. [PMID: 35500422 DOI: 10.1016/j.theriogenology.2022.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 04/13/2022] [Accepted: 04/20/2022] [Indexed: 10/18/2022]
Abstract
Regional centro-axial block is a recommended technique for uncomplicated caesarean section in human medicine. Since the application of regional anaesthesia as the only technique in veterinary medicine is impractical, the objective of the study was to assess and compare the epidural component of caesarean section (CS) on maternal and fetal outcomes. Bitches (n = 36) undergoing elective CS were enrolled in this study. Females were randomly assigned into two groups: Gr I (Isoflurane, n = 20) and Gr IE (Isoflurane plus Epidural, n = 16). Anaesthesia was induced with propofol, and maintained with isoflurane in oxygen. In the IE group, epidural anaesthesia was also performed using lidocaine. The maternal intraoperative parameters were compared at three time points: T1 - just before the skin incision, T2 - after the last puppy removal, and T3 - at the end of surgery. At least 100 mcl of mixed umbilical cord blood was collected for gas analysis. The modified Apgar scoring system (AS) was used to objectively score newborn health and vitality immediately after birth (0 min), 5 and 20 min after birth. Systolic, diastolic, and mean blood pressure were lower in the IE group at T1, T2, and T3 compared to I group (p < 0.05). In the combined anaesthesia group blood pressure remained stable but low at all time points. Throughout surgery, the IE group required a lower concentration of isoflurane (p < 0.05). The median values of the umbilical blood gas results were found to be similar (p > 0.05) in both investigated groups. The initial results of the Apgar score were comparable in the I and IE groups (p > 0.05). However, subsequent AS measurements revealed significant differences between both groups. Puppies from the IE group received better AS scores at 5 and 20 min compared to the I group (median AS 8 and 9 vs. 5 and 8, respectively). The results obtained demonstrated that epidural anaesthesia administration reduced the requirement for isoflurane in dams undergoing caesarean section and despite episodes of maternal hypotension did not affect the results of neonatal umbilical blood gas. Furthermore, newborns from the epidural anaesthesia group improved more quickly postnatally, developing a satisfactory condition in a shorter time.
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Affiliation(s)
- Agnieszka Antończyk
- Wroclaw University of Environmental and Life Sciences, Faculty of Veterinary Medicine, Department and Clinic of Surgery, pl. Grunwaldzki 51, 50-366, Wrocław, Poland.
| | - Małgorzata Ochota
- Wroclaw University of Environmental and Life Sciences, Faculty of Veterinary Medicine, Department of Reproduction and Clinic of Farm Animals, pl. Grunwaldzki 49, 50-366, Wrocław, Poland.
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Andersen BR, Ammitzbøll I, Hinrich J, Lehmann S, Ringsted CV, Løkkegaard ECL, Tolsgaard MG. Using machine learning to identify quality-of-care predictors for emergency caesarean sections: a retrospective cohort study. BMJ Open 2022; 12:e049046. [PMID: 35256439 PMCID: PMC8905885 DOI: 10.1136/bmjopen-2021-049046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES Emergency caesarean sections (ECS) are time-sensitive procedures. Multiple factors may affect team efficiency but their relative importance remains unknown. This study aimed to identify the most important predictors contributing to quality of care during ECS in terms of the arrival-to-delivery interval. DESIGN A retrospective cohort study. ECS were classified by urgency using emergency categories one/two and three (delivery within 30 and 60 min). In total, 92 predictor variables were included in the analysis and grouped as follows: 'Maternal objective', 'Maternal psychological', 'Fetal factors', 'ECS Indication', 'Emergency category', 'Type of anaesthesia', 'Team member qualifications and experience' and 'Procedural'. Data was analysed with a linear regression model using elastic net regularisation and jackknife technique to improve generalisability. The relative influence of the predictors, percentage significant predictor weight (PSPW) was calculated for each predictor to visualise the main determinants of arrival-to-delivery interval. SETTING AND PARTICIPANTS Patient records for mothers undergoing ECS between 2010 and 2017, Nordsjællands Hospital, Capital Region of Denmark. PRIMARY OUTCOME MEASURES Arrival-to-delivery interval during ECS. RESULTS Data was obtained from 2409 patient records for women undergoing ECS. The group of predictors representing 'Team member qualifications and experience' was the most important predictor of arrival-to-delivery interval in all ECS emergency categories (PSPW 25.9% for ECS category one/two; PSPW 35.5% for ECS category three). In ECS category one/two the 'Indication for ECS' was the second most important predictor group (PSPW 24.9%). In ECS category three, the second most important predictor group was 'Maternal objective predictors' (PSPW 24.2%). CONCLUSION This study provides empirical evidence for the importance of team member qualifications and experience relative to other predictors of arrival-to-delivery during ECS. Machine learning provides a promising method for expanding our current knowledge about the relative importance of different factors in predicting outcomes of complex obstetric events.
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Affiliation(s)
- Betina Ristorp Andersen
- Department of Gynecology and Obstetrics, Nordsjællands Hospital & Department of Clinical Medicine, University of Copenhagen, Hillerod, Capital Region, Denmark
| | - Ida Ammitzbøll
- Department of Gynecology and Obstetrics, Nordsjællands Hospital & Department of Clinical Medicine, University of Copenhagen, Hillerod, Capital Region, Denmark
| | - Jesper Hinrich
- Cognitive Systems, Department of Applied Mathematics and Computer Science, Technical University of Denmark, Lyngby, Denmark
| | - Sune Lehmann
- Cognitive Systems, Department of Applied Mathematics and Computer Science, Technical University of Denmark, Lyngby, Denmark
| | | | - Ellen Christine Leth Løkkegaard
- Department of Gynecology and Obstetrics, Nordsjællands Hospital & Department of Clinical Medicine, University of Copenhagen, Hillerod, Capital Region, Denmark
| | - Martin G Tolsgaard
- Copenhagen Academy of Medical Education and Simulation, Rigshospitalet, Kobenhavn, Capital Region, Denmark
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Munsaka EF, Van Dyk D, Parker R. A retrospective audit of pain assessment and management post-caesarean section at New Somerset Hospital in Cape Town, South Africa. S Afr Fam Pract (2004) 2021; 63:e1-e6. [PMID: 34636591 PMCID: PMC8517764 DOI: 10.4102/safp.v63i1.5320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 07/20/2021] [Accepted: 07/21/2021] [Indexed: 12/03/2022] Open
Abstract
Background The most common major surgical procedure performed worldwide is the caesarean section (CS). Effective pain management is a priority for women undergoing this procedure, to reduce the incidence of persistent pain (a risk factor for postpartum depression), as well as optimise maternal-neonatal bonding and the successful establishment of breastfeeding. Multimodal analgesia is the gold standard for post-CS analgesia. At present, no perioperative pain management protocols could be identified for the management of patients presenting for CS at regional hospitals in South Africa. This audit aimed to review the folders of patients who underwent CS, with particular reference to perioperative pain management guidelines for CS. Methods A descriptive, retrospective, cross-sectional audit was conducted. Three hundred folders (10% of the annual number of caesarean procedures performed) from New Somerset Hospital, a regional hospital in Cape Town, South Africa were reviewed. Results The women were a mean age of 30 years (standard deviation [s.d.]: 6.2). Median gravidity was 3 (interquartile range [IQR]: 2–3) and parity was 1 (IQR: 1–2); 52% had previously undergone a CS. In 93.3% cases, spinal anaesthesia was employed for CS. Pain assessment was poor, with only 55 (18%) patients having their pain assessed on the day of the operation. Analgesia was prescribed in over 98% of the patients, however, medication was only administered as prescribed in 32.6%. Non-steroidal anti-inflammatory drugs (NSAIDs) were prescribed in < 5% of cases. None of the patients received a patient-controlled analgesia (PCA), transversus abdominis plane (TAP) block, or wound infusion catheter as supplementary strategies. Conclusion Pain management for post-CS patient at this hospital is lacking. There is the need for the implementation of a structured assessment tool to improve administration of analgesics in these patients. In addition, the reasons for the omission of NSAIDs from the analgesia regimen requires investigation. Hospital requires post-CS pain protocols to guide management especially in resource-limited settings.
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Affiliation(s)
- Effraim F Munsaka
- Department of Anaesthesia and Perioperative Medicine, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital, Cape Town.
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Kassa MW, Mkubwa JJ, Shifa JZ, Agizew TB. Type of anaesthesia for caesarean section and failure rate in Princess Marina Hospital, Botswana's largest referral hospital. Afr Health Sci 2020; 20:1229-1236. [PMID: 33402969 PMCID: PMC7751529 DOI: 10.4314/ahs.v20i3.26] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Caesarean Section (CS) is a mode of delivery to decrease maternal and perinatal morbidity and mortality. We aimed to determine the type of anaesthesia used for CS among live-birth deliveries; and the failure rate of spinal anaesthesia (SA) in Princess Marina Referral Hospital, Botswana. METHODS Women who underwent CS from May-December 2017 were enrolled in the study. Data were recorded from anaesthesia charts and abstracted using Excel spreadsheet. We established the type of anaesthesia used, comparing the rate of elective versus emergency indications, and failure rate of SA using STATA. Fisher's exact test used to compare results. RESULTS Among 2775 live-birth deliveries, 30.2% (837/2775) was by CS. Of those, 95.2% (797/837) had had SA and 4.8% (40/837) were GA. Under SA, 27.4% (218/797) were elective, and 72.6% (579/797) were emergency. Under GA 10% (4/40) were elective and 90.0% (36/40) were emergency. The overall failure rate of SA was 2% (16/813), that is 0.9% (2/220) for elective and 2.4% (14/593) among emergency indications; Fisher's exact test p = 0.2959. CONCLUSION Our study demonstrated that single shot SA is the most commonly preferred type of anaesthesia for both elective and emergency CS. The overall failure rate of SA was less common in our settings than previously reported.
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Affiliation(s)
- Mamo W Kassa
- Department of Anaesthesia and Critical Care, University of Botswana, Botswana
| | - Jack J Mkubwa
- Department of intensive care unit Princess Marina Hospital, Ministry of Health
| | - Jemal Z Shifa
- Department of Surgery, University of Botswana, Botswana
| | - Tefera B Agizew
- Department of Family Medicine and Public Health, University of Botswana
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ÇAKIR U, YİLDİZ D, KAHVECİOGLU D, OKULU E, ALAN S, ERDEVE O, ARSAN S, ATASAY B. Obstetrik anestezi yöntemlerinin preterm bebeklerde gastrointestinal sistem fonksiyonu üzerine etkisi var mı? CUKUROVA MEDICAL JOURNAL 2020. [DOI: 10.17826/cumj.627506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Enten G, Shenouda MA, Samuels D, Fowler N, Balouch M, Camporesi E. A Retrospective Analysis of the Safety and Efficacy of Opioid-free Anesthesia versus Opioid Anesthesia for General Cesarean Section. Cureus 2019; 11:e5725. [PMID: 31720193 PMCID: PMC6823078 DOI: 10.7759/cureus.5725] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction While uncommon for cesarean delivery, general anesthesia may be patient requested or necessary due to maternal contraindication. Traditionally, opioids are used as a part of the general anesthetic. Because of their associated complications, it is standard to limit opioid use and fetal narcotic exposure during cesarean delivery. We conducted a retrospective study to evaluate the feasibility of multi-modal opioid-free general anesthesia for cesarean delivery. Methods Electronic medical records were obtained for patients receiving general anesthesia for cesarean delivery of live pregnancies through 2017 at our tertiary care facility. Post-operative pain was estimated using a 10-cm visual analogue scale and by calculating postoperative narcotic requirements in milligram morphine equivalents (MME) over three-time periods: during post-anesthesia recovery in the post-anesthesia care unit (PACU), the first 24 hrs after PACU discharge, and 24-48 hrs after PACU discharge. Apgar scores were also obtained to quantify neonatal effects of the general anesthetic. Results Eight of 17 patients (47.06%) received opioid-free anesthesia (OFA), and nine of 17 patients (52.94%) received anesthesia with opioids (OA). No significant difference was found between groups in terms of postoperative mean Visual Analog Scale (VAS) pain score over each time period. Similarly, no significant difference was found between groups in terms of postoperative narcotics requirement at all study points. Apgar scores were not significantly different between the two groups. Conclusion The OFA group displayed equivalent analgesia to the OA group in terms of self-reported VAS pain scores and postoperative MME. A larger prospective study is recommended to fully evaluate OFA for cesarean delivery.
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Minimum effective volume of bupivacaine in spinal anesthesia for elective cesarean section. Does it differ with height? A non-randomized parallel study. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2016.10.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Ozturk Inal Z, Gorkem U, Inal HA. Effects of preoperative anxiety on postcesarean delivery pain and analgesic consumption: general versus spinal anesthesia. J Matern Fetal Neonatal Med 2018; 33:191-197. [PMID: 29886798 DOI: 10.1080/14767058.2018.1487948] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Objective: The aim of this study was to determine the effects of preoperative anxiety on the postoperative pain and analgesic consumption in patients undergoing cesarean deliveries (CDs).Materials and methods: This observational cohort study included 160 women, with ages ranging from 18 to 40 years old and a 37-week minimum gestation, received general (Group 1, n = 80) or spinal (Group 2, n = 80) anesthesia during an elective CD. The State Anxiety Inventory (SAI), Trait Anxiety Inventory (TAI), and Somatosensory Amplification Scale (SSAS) were used to measure the prenatal anxiety. The postoperative pain intensity was evaluated using the Visual Analogue Scale (VAS), and the pain and analgesic requirements were recorded at the 1st, 6th, 12th, 18th, and 24th postoperative hours.Results: No statistically significant differences were found between the groups in the demographics, clinical characteristics, or laboratory parameters. In addition, there were no differences with regard to the mean SAI, TAI, and SSAS scores and the diclofenac and pethidine consumptions (p > .05). The 1st hour [4.15 ± 1.84 versus 3.28 ± 2.41, odds ratio (OR) = 0.832, 95% confidence interval (CI) = 0.725-0.956, p = .009], 6th hour (3.85 ± 2.02 versus 3.13 ± 1.51, OR = 0.793, 95% CI = 0.668-0.942, p = .008), and 12th hour (3.64 ± 2.11 versus 2.94 ± 2.03, OR = 0.851, 95% CI = 0.737-0.983, p = .028) VAS scores were lower in Group 2 than in Group 1. No correlations were noted between the SAI, TAI, and SSAS scores and the VAS.Conclusions: While the patients with preoperative SAI scores >45 and who underwent cesarean deliveries (CDs) with general anesthesia had higher pain intensity scores in the first 12 hours than those underwent CDs with the spinal anesthesia, no difference was observed between the groups in terms of the postoperative analgesic requirements. Evaluating the patient's anxiety state and psychiatric evaluation may be useful for decreasing the postoperative pain intensity. Further studies are needed to corroborate our findings.
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Affiliation(s)
- Zeynep Ozturk Inal
- Department of Reproductive Endocrinology, Konya Education and Research Hospital, Konya, Turkey
| | - Umit Gorkem
- Department of Reproductive Endocrinology, Hitit University Medical Faculty, Çorum, Turkey
| | - Hasan Ali Inal
- Department of Reproductive Endocrinology, Konya Education and Research Hospital, Konya, Turkey
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Kor A, Yazdi K, Nasiri H, Mir Sadeghi M. Comparison of Effect of Two Treatment Methods: Oxygen Therapy with Face Mask and Nasal Catheter on Nausea and Vomiting and Comfort in Cesarean section under Spinal Anesthesia. JOURNAL OF RESEARCH DEVELOPMENT IN NURSING AND MIDWIFERY 2017. [DOI: 10.29252/jgbfnm.14.1.52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Charoenraj P, Charuluxananan S, Chatrkaw P, Tunprasit C, Wangdumrongwong P, Phupong V. Brief communication (Original). Anesthesia for cesarean section in parturients diagnosed with placenta previa in a Thai university hospital: a retrospective analysis of 562 consecutive cases. ASIAN BIOMED 2017. [DOI: 10.5372/1905-7415.0806.351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Abstract
Background: Anesthesia for cesarean delivery in parturients diagnosed with placenta previa remains controversial.
Objectives: To investigate factors correlated with choice of anesthesia in these parturients and their outcomes.
Methods: Retrospective analysis of patients with placenta previa and cesarean delivery at King Chulalongkorn Memorial Hospital. Peri operative anesthetic and complication data were collected using a structured collection form. Univariate analysis and multivariate logistic regression were used. P < 0.05 was considered significant.
Results: Among 50,237 deliveries from July 1, 2005 to June 30, 2011, there were 562 cesarean sections in diagnosed cases of placenta previa. Cesarean deliveries (479) were performed under spinal anesthesia (81%), epidural anesthesia (1.8%), and if the effects spinal anesthesia dissipated, general anesthesia (2.3%). Among 46 cases of cesarean hysterectomy, 27 patients (58.7%) received regional anesthesia. However, 6 of 10 patients with planned cesarean hysterectomy underwent general anesthesia, while 1 of 4 of a group with regional anesthesia needed conversion to general anesthesia. There was no serious anesthesia-related complication. Factors related to general anesthesia were: a higher American Society of Anesthesiologists (ASA) physical status OR 2.7 (95% CI 1.7-4.3) P < 0.001; presentation with bleeding OR 1.8(95% CI 1.0-3.1) P = 0.033; anterior site of placenta OR 1.8 (95% CI 1.1-3.2) P = 0.025; heart rate >125 bpm OR 5.6 (95% CI 1.5-214) P = 0.01; and pack red cell transfusion OR 3.4 (95% CI 2.0-5.7) P < 0.001.
Conclusions: Most parturients received regional anesthesia. Neuroaxial anesthesia and general anesthesia are safe.
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Affiliation(s)
- Pornarun Charoenraj
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Somrat Charuluxananan
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Phornlert Chatrkaw
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Chooksak Tunprasit
- Department of Anesthesiology, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand
| | - Parinya Wangdumrongwong
- Department of Anesthesiology, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand
| | - Vorapong Phupong
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
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Lamacraft G, Schmidt MJ, Diedericks BJS, Joubert G. An Audit of the Use of Regional Anaesthesia for Caesarean Section in the Free State: from 2002 to 2004. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2014. [DOI: 10.1080/22201173.2007.10872494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Guay J, Choi P, Suresh S, Albert N, Kopp S, Pace NL. Neuraxial blockade for the prevention of postoperative mortality and major morbidity: an overview of Cochrane systematic reviews. Cochrane Database Syst Rev 2014; 2014:CD010108. [PMID: 24464831 PMCID: PMC7087466 DOI: 10.1002/14651858.cd010108.pub2] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Various beneficial effects derived from neuraxial blocks have been reported. However, it is unclear whether these effects have an influence on perioperative mortality and major pulmonary/cardiovascular complications. OBJECTIVES Our primary objective was to summarize Cochrane systematic reviews that assess the effects of neuraxial blockade on perioperative rates of death, chest infection and myocardial infarction by integrating the evidence from all such reviews that have compared neuraxial blockade with or without general anaesthesia versus general anaesthesia alone for different types of surgery in various populations. Our secondary objective was to summarize the evidence on adverse effects (an adverse event for which a causal relation between the intervention and the event is at least a reasonable possibility) of neuraxial blockade. Within the reviews, studies were selected using the same criteria. METHODS A search was performed in the Cochrane Database of Systematic Reviews on July 13, 2012. We have (1) included all Cochrane systematic reviews that examined participants of any age undergoing any type of surgical (open or endoscopic) procedure, (2) compared neuraxial blockade versus general anaesthesia alone for surgical anaesthesia or neuraxial blockade plus general anaesthesia versus general anaesthesia alone for surgical anaesthesia and (3) included death, chest infection, myocardial infarction and/or serious adverse events as outcomes. Neuraxial blockade could consist of epidural, caudal, spinal or combined spinal-epidural techniques administered as a bolus or by continuous infusion. Studies included in these reviews were selected on the basis of the same criteria. Reviews and studies were selected independently by two review authors, who independently performed data extraction when data differed from one of the selected reviews. Data were analysed by using Review Manager Version 5.1 and Comprehensive Meta Analysis Version 2.2.044. MAIN RESULTS Nine Cochrane reviews were selected for this overview. Their scores on the Overview Quality Assessment Questionnaire varied from four to six of a maximal possible score of seven. Compared with general anaesthesia, neuraxial blockade reduced the zero to 30-day mortality (risk ratio [RR] 0.71, 95% confidence interval [CI] 0.53 to 0.94; I(2) = 0%) based on 20 studies that included 3006 participants. Neuraxial blockade also decreased the risk of pneumonia (RR 0.45, 95% CI 0.26 to 0.79; I(2) = 0%) based on five studies that included 400 participants. No difference was detected in the risk of myocardial infarction between the two techniques (RR 1.17, 95% CI 0.57 to 2.37; I(2) = 0%) based on six studies with 849 participants. Compared with general anaesthesia alone, the addition of a neuraxial block to general anaesthesia did not affect the zero to 30-day mortality (RR 1.07, 95% CI 0.76 to 1.51; I(2) = 0%) based on 18 studies with 3228 participants. No difference was detected in the risk of myocardial infarction between combined neuraxial blockade-general anaesthesia and general anaesthesia alone (RR 0.69, 95% CI 0.44 to 1.09; I(2) = 0%) based on eight studies that included 1580 participants. The addition of a neuraxial block to general anaesthesia reduced the risk of pneumonia (RR 0.69, 95% CI 0.49 to 0.98; I(2) = 9%) after adjustment for publication bias and based on nine studies that included 2433 participants. The quality of the evidence was judged as moderate for all six comparisons.No serious adverse events (seizure or cardiac arrest related to local anaesthetic toxicity, prolonged central or peripheral neurological injury lasting longer than one month or infection secondary to neuraxial blockade) were reported. The quality of the reporting score of complications related to neuraxial blocks was nine (four to 12 (median range)) of a possible maximum score of 14. AUTHORS' CONCLUSIONS Compared with general anaesthesia, a central neuraxial block may reduce the zero to 30-day mortality for patients undergoing surgery with intermediate to high cardiac risk (level of evidence, moderate). Further research is required.
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Affiliation(s)
- Joanne Guay
- University of SherbrookeDepartment of Anesthesiology, Faculty of MedicineSherbrookeQuebecCanada
| | - Peter Choi
- The University of British ColumbiaDepartment of Anesthesiology, Pharmacology & Therapeutics3300 ‐ 910 West 10th AvenueVancouverBCCanadaV5Z 4E3
| | - Santhanam Suresh
- Ann & Robert H. Lurie Children's Hospital of Chicago Research CenterDepartment of Pediatric Anesthesiology225 E. Chicago AveChicagoILUSA60611
- Northwestern University Feinberg School of MedicineDepartment of AnesthesiaChicagoILUSA
| | - Natalie Albert
- University of LavalDepartment of AnesthesiologyCHUQ‐CHUL 2705 West Laurier BlvdQuebecQCCanadaG1V 4G2
| | - Sandra Kopp
- Mayo Clinic College of MedicineDepartment of Anesthesiology200 1st St SWRochesterMNUSA55901
| | - Nathan Leon Pace
- University of UtahDepartment of Anesthesiology3C444 SOM30 North 1900 EastSalt Lake CityUTUSA84132‐2304
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Gürsoy C, Ok G, Aydın D, Eser E, Erbüyün K, Tekin İ, Baytur Y, Uyar Y. Effect of Anaesthesia Methods for Regaining Daily Life Activities in Cesarean Patients. Turk J Anaesthesiol Reanim 2014; 42:71-9. [PMID: 27366394 DOI: 10.5152/tjar.2014.96630] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 06/12/2013] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE Postpartum period is physically, socially and emotionally a difficult time for the parents and the baby to become a family. We tried to investigate how the anaesthesia method affects patients who underwent cesarean delivery, as a factor which also affects this period. METHODS Two hundred and six parturients, who underwent elective cesarean delivery in Celal Bayar University Hafsa Sultan Hospital were recruited for our study. After demographic data and anaesthesia methods were noted, an EQ-5D health survey and Katz ADL scale were evaluated face to face 24 hours postoperatively, and by telephone on the 5th postoperative day. RESULTS The percentage of patients who had general anaesthesia was 35.2% (n=71), while 19.8% (n=40) had epidural anaesthesia and 45% (n=91) had spinal anaesthesia. Among -these three methods, the EQ-5D health survey revealed that the outcome at postoperative 24 hours was best in epidural anaesthesia and that general anaesthesia outcome was the worst (p=0.007). The Katz ADL scale at postoperative 24. hours showed that epidural anaesthesia was better than the other methods for regaining daily life activities (p<0.05). CONCLUSION Our study showed that epidural anaesthesia had the most effective role among the methods in regaining daily life activities after elective cesarean delivery, which was demonstrated using the EQ-5D health survey and Katz ADL scale.
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Affiliation(s)
- Canan Gürsoy
- Department of Anaesthesiology and Reanimation, Celal Bayar University Faculty of Medicine, Manisa, Turkey
| | - Gülay Ok
- Department of Anaesthesiology and Reanimation, Celal Bayar University Faculty of Medicine, Manisa, Turkey
| | - Demet Aydın
- Department of Anaesthesiology and Reanimation, Celal Bayar University Faculty of Medicine, Manisa, Turkey
| | - Erhan Eser
- Department of Public Health, Celal Bayar University Faculty of Medicine, Manisa, Turkey
| | - Koray Erbüyün
- Department of Anaesthesiology and Reanimation, Celal Bayar University Faculty of Medicine, Manisa, Turkey
| | - İdil Tekin
- Department of Anaesthesiology and Reanimation, Celal Bayar University Faculty of Medicine, Manisa, Turkey
| | - Yeşim Baytur
- Department of Obstetrics and Gynaecology, Celal Bayar University Faculty of Medicine, Manisa, Turkey
| | - Yıldız Uyar
- Department of Obstetrics and Gynaecology, Celal Bayar University Faculty of Medicine, Manisa, Turkey
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Brookfield KF, Goodnough LT, Lyell DJ, Butwick AJ. Perioperative and transfusion outcomes in women undergoing cesarean hysterectomy for abnormal placentation. Transfusion 2013; 54:1530-6. [PMID: 24188691 DOI: 10.1111/trf.12483] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Revised: 09/13/2013] [Accepted: 09/21/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Women with placenta increta (PI) and placenta percreta (PP) are at high risk of obstetric hemorrhage; however, the severity of hemorrhage and perioperative morbidity may differ according to the degree of placental invasion. We sought to compare blood component usage and perioperative morbidity between women with PI versus PP undergoing cesarean hysterectomy (CH). STUDY DESIGN AND METHODS We identified 77 women who underwent CH for PI or PP from the NICHD MFMU Network Cesarean Registry, which sourced data from 19 centers from 1999 to 2002. We examined demographic, obstetric, and surgical data and rates of transfusion and perioperative morbidity. We performed statistical tests for between-group analyses; p values less than 0.05 were significant. RESULTS Rates of intraoperative or postoperative red blood cell (RBC) transfusion were similar between groups (PI 84% vs. PP 88%; p=0.7). We observed no between-group differences in rates of fresh-frozen plasma (FFP) transfusion (intraoperative FFP-PI 30% vs. PP 41%; p=0.3; postoperative FFP-PI 28% vs. PP 18%; p=0.4) or platelet (PLT) transfusion (intraoperative PLTs-PI 14% vs. PP 29%; p=0.2; postoperative PLTs-PI 9% vs. PP 9%; p=1.0). Among the morbidities, a higher proportion of PP women underwent cystotomy (PI 14% vs. PP 38%; p=0.02) and postoperative mechanical ventilation (PI 14% vs. PP 35%; p=0.03). CONCLUSION Rates of intraoperative RBC, FFP, and PLT transfusion are similar for PI and PP women, and perioperative outcomes are worse for PP women. We suggest the same mobilization transfusion medicine support for both groups, including blood ordering (type and cross-match for CH) and availability of emergency blood protocols including fibrinogen-containing preparations.
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Affiliation(s)
- Kathleen F Brookfield
- Department of Obstetrics & Gynecology, Stanford University School of Medicine, Stanford, California
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Horey D, Kealy M, Davey MA, Small R, Crowther CA. Interventions for supporting pregnant women's decision-making about mode of birth after a caesarean. Cochrane Database Syst Rev 2013:CD010041. [PMID: 23897547 DOI: 10.1002/14651858.cd010041.pub2] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Pregnant women who have previously had a caesarean birth and who have no contraindication for vaginal birth after caesarean (VBAC) may need to decide whether to choose between a repeat caesarean birth or to commence labour with the intention of achieving a VBAC. Women need information about their options and interventions designed to support decision-making may be helpful. Decision support interventions can be implemented independently, or shared with health professionals during clinical encounters or used in mediated social encounters with others, such as telephone decision coaching services. Decision support interventions can include decision aids, one-on-one counselling, group information or support sessions and decision protocols or algorithms. This review considers any decision support intervention for pregnant women making birth choices after a previous caesarean birth. OBJECTIVES To examine the effectiveness of interventions to support decision-making about vaginal birth after a caesarean birth.Secondary objectives are to identify issues related to the acceptability of any interventions to parents and the feasibility of their implementation. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2013), Current Controlled Trials (22 July 2013), the WHO International Clinical Trials Registry Platform Search Portal (ICTRP) (22 July 2013) and reference lists of retrieved articles. We also conducted citation searches of included studies to identify possible concurrent qualitative studies. SELECTION CRITERIA All published, unpublished, and ongoing randomised controlled trials (RCTs) and quasi-randomised trials with reported data of any intervention designed to support pregnant women who have previously had a caesarean birth make decisions about their options for birth. Studies using a cluster-randomised design were eligible for inclusion but none were identified. Studies using a cross-over design were not eligible for inclusion. Studies published in abstract form only would have been eligible for inclusion if data were able to be extracted. DATA COLLECTION AND ANALYSIS Two review authors independently applied the selection criteria and carried out data extraction and quality assessment of studies. Data were checked for accuracy. We contacted authors of included trials for additional information. All included interventions were classified as independent, shared or mediated decision supports. Consensus was obtained for classifications. Verification of the final list of included studies was undertaken by three review authors. MAIN RESULTS Three randomised controlled trials involving 2270 women from high-income countries were eligible for inclusion in the review. Outcomes were reported for 1280 infants in one study. The interventions assessed in the trials were designed to be used either independently by women or mediated through the involvement of independent support. No studies looked at shared decision supports, that is, interventions designed to facilitate shared decision-making with health professionals during clinical encounters.We found no difference in planned mode of birth: VBAC (risk ratio (RR) 1.03, 95% confidence interval (CI) 0.97 to 1.10; I² = 0%) or caesarean birth (RR 0.96, 95% CI 0.84 to 1.10; I² = 0%). The proportion of women unsure about preference did not change (RR 0.87, 95% CI 0.62 to 1.20; I² = 0%).There was no difference in adverse outcomes reported between intervention and control groups (one trial, 1275 women/1280 babies): permanent (RR 0.66, 95% CI 0.32 to 1.36); severe (RR 1.02, 95% CI 0.77 to 1.36); unclear (0.66, 95% CI 0.27, 1.61). Overall, 64.8% of those indicating preference for VBAC achieved it, while 97.1% of those planning caesarean birth achieved this mode of birth. We found no difference in the proportion of women achieving congruence between preferred and actual mode of birth (RR 1.02, 95% CI 0.96 to 1.07) (three trials, 1921 women).More women had caesarean births (57.3%), including 535 women where it was unplanned (42.6% all caesarean deliveries and 24.4% all births). We found no difference in actual mode of birth between groups, (average RR 0.97, 95% CI 0.89 to 1.06) (three trials, 2190 women).Decisional conflict about preferred mode of birth was lower (less uncertainty) for women with decisional support (standardised mean difference (SMD) -0.25, 95% CI -0.47 to -0.02; two trials, 787 women; I² = 48%). There was also a significant increase in knowledge among women with decision support compared with those in the control group (SMD 0.74, 95% CI 0.46 to 1.03; two trials, 787 women; I² = 65%). However, there was considerable heterogeneity between the two studies contributing to this outcome ( I² = 65%) and attrition was greater than 15 per cent and the evidence for this outcome is considered to be moderate quality only. There was no difference in satisfaction between women with decision support and those without it (SMD 0.06, 95% CI -0.09 to 0.20; two trials, 797 women; I² = 0%). No study assessed decisional regret or whether women's information needs were met.Qualitative data gathered in interviews with women and health professionals provided information about acceptability of the decision support and its feasibility of implementation. While women liked the decision support there was concern among health professionals about their impact on their time and workload. AUTHORS' CONCLUSIONS Evidence is limited to independent and mediated decision supports. Research is needed on shared decision support interventions for women considering mode of birth in a pregnancy after a caesarean birth to use with their care providers.
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Affiliation(s)
- Dell Horey
- Faculty of Health Sciences, La Trobe University, Bundoora, Australia.
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Abstract
BACKGROUND Lower-limb revascularization is a surgical procedure that is performed to restore an adequate blood supply to the limbs. Lower-limb revascularization surgery is used to reduce pain and sometimes to improve lower-limb function. Neuraxial anaesthesia is an anaesthetic technique that uses local anaesthetics next to the spinal cord to block nerve function. Neuraxial anaesthesia may lead to improved survival. This systematic review was originally published in 2010 and was first updated in 2011 and again in 2013. OBJECTIVES To determine the rates of death and major complications associated with spinal and epidural anaesthesia as compared with other types of anaesthesia for lower-limb revascularization in patients aged 18 years or older who are affected by obstruction of lower-limb vessels. SEARCH METHODS The original review was published in 2010 and was based on a search until June 2008. In 2011 we reran the search until February 2011 and updated the review. For this second updated version of the review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, LILACS, CINAHL and Web of Science from 2011 to April 2013. SELECTION CRITERIA We included randomized controlled trials comparing neuraxial anaesthesia (spinal or epidural anaesthesia) versus other types of anaesthesia in adults (18 years or older) with arterial vascular obstruction undergoing lower-limb revascularization surgery. DATA COLLECTION AND ANALYSIS Two review authors independently performed data extraction and assessed trial quality. We pooled the data on mortality, myocardial infarction, lower-limb amputation and pneumonia. We summarized dichotomous data as odds ratio (OR) with 95% confidence interval (CI) using a random-effects model. MAIN RESULTS In this updated version of the review, we found no new studies that met our inclusion criteria. We included in this review four studies that compared neuraxial anaesthesia with general anaesthesia. The total number of participants was 696, of whom 417 were allocated to neuraxial anaesthesia and 279 to general anaesthesia. Participants allocated to neuraxial anaesthesia had a mean age of 67 years, and 59% were men. Participants allocated to general anaesthesia had a mean age of 67 years, and 66% were men. Four studies had an unclear risk of bias. No difference was observed between participants allocated to neuraxial or general anaesthesia in mortality rate (OR 0.89, 95% CI 0.38 to 2.07; 696 participants; four trials), myocardial infarction (OR 1.23, 95% CI 0.56 to 2.70; 696 participants; four trials), and lower-limb amputation (OR 0.84, 95% CI 0.38 to 1.84; 465 participants; three trials). Pneumonia was less common after neuraxial anaesthesia than after general anaesthesia (OR 0.37, 95% CI 0.15 to 0.89; 201 participants; two trials). Evidence was insufficient for cerebral stroke, duration of hospital stay, postoperative cognitive dysfunction, complications in the anaesthetic recovery room and transfusion requirements. No data described nerve dysfunction, postoperative wound infection, patient satisfaction, postoperative pain score, claudication distance and pain at rest. AUTHORS' CONCLUSIONS Available evidence from included trials that compared neuraxial anaesthesia with general anaesthesia was insufficient to rule out clinically important differences for most clinical outcomes. Neuraxial anaesthesia may reduce pneumonia. No conclusions can be drawn with regard to mortality, myocardial infarction and rate of lower-limb amputation, or less common outcomes.
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Key Words
- aged
- female
- humans
- male
- amputation, surgical
- amputation, surgical/statistics & numerical data
- anesthesia, epidural
- anesthesia, epidural/adverse effects
- anesthesia, epidural/mortality
- anesthesia, general
- anesthesia, general/adverse effects
- anesthesia, general/mortality
- anesthesia, spinal
- anesthesia, spinal/adverse effects
- anesthesia, spinal/mortality
- lower extremity
- lower extremity/blood supply
- lower extremity/surgery
- myocardial infarction
- myocardial infarction/epidemiology
- pneumonia
- pneumonia/epidemiology
- randomized controlled trials as topic
- vascular surgical procedures
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Affiliation(s)
- Fabiano T Barbosa
- Department of Clinical Medicine, Armando Lages Emergency Hospital, Maceió, Brazil.
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WINTHER LP, MITCHELL AU, MØLLER AM. Inconsistencies in clinical guidelines for obstetric anaesthesia for Caesarean section: a comparison of the Danish, English, American, and German guidelines with regard to developmental quality and guideline content. Acta Anaesthesiol Scand 2013; 57:141-9. [PMID: 23136833 DOI: 10.1111/aas.12004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND Anaesthetists need evidence-based clinical guidelines, also in obstetric anaesthesia. We compared the Danish, English, American, and German national guidelines for anaesthesia for Caesarean section. We focused on assessing the quality of guideline development and evaluation of the guidelines' content. METHODS We compared the four countries' guideline developmental quality by using the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument, an international tool for development and assessment of guidelines. The clinically important content of these countries' guidelines was compared. RESULTS We found differences in the quality of guideline development in the four countries. The German guidelines scored very low in the AGREE analysis, and the Danish national guideline scored low in the AGREE analysis. The American and British guideline both achieved high scores in the AGREE analysis. We found differences in the content of the four countries' guidelines. The Danish, American, and British guidelines were comprehensive but with some variation in the content. CONCLUSION Development of national guidelines might benefit from following standardised regulations, such as those used in the AGREE tool. Content of guidelines is not standardised. Recommendations for the content of guidelines might contribute to standardising clinical guidelines.
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Affiliation(s)
| | - A. U. MITCHELL
- Research Unit; Department of Anaesthesiology; Herlev University Hospital; Herlev; Denmark
| | - A. M. MØLLER
- Research Unit; Department of Anaesthesiology; Herlev University Hospital; Herlev; Denmark
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Anaesthetic management in emergency cesarean section: Systematic literature review of anaesthetic techniques for emergency C-section. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2012. [DOI: 10.1016/j.rcae.2012.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Abstract
BACKGROUND Regional anaesthesia (RA) and general anaesthesia (GA) are commonly used for caesarean section (CS) and both have advantages and disadvantages. It is important to clarify what type of anaesthesia is more efficacious. OBJECTIVES To compare the effects of RA with those of GA on the outcomes of CS. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2011). We updated the search on 20 August 2012 and added the results to the awaiting classification section of the review. SELECTION CRITERIA Randomised and quasi-randomised controlled trials evaluating the use of RA and GA in women who had CS for any indication. Cluster-randomised trials and trials using a cross-over design are not included. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion, assessed risk of bias and extracted data. Data were checked for accuracy. MAIN RESULTS Twenty-two out of 29 included studies (1793 women) contributed data to this review.The included studies did not report some our primary outcomes: maternal death, incidence of maternal postoperative wound infection, maternal postoperative other infection such as endometritis and urinary tract infection, neonatal death.Compared to women who had GA, women who had either epidural anaesthesia or spinal anaesthesia were found to have a significantly lower difference between pre and postoperative haematocrit. For epidural, the mean difference (MD) was 1.70% and 95% confidence interval (CI) 0.47 to 2.93 (one trial, 231 women) and for spinal anaesthesia, the MD was 3.10% and 95% CI 1.73 to 4.47 (one trial, 209 women). Compared with GA, women having either an epidural anaesthesia or spinal anaesthesia had a lower estimated maternal blood loss (epidural versus GA: standardised mean difference (SMD) -0.32 mL; 95% CI -0.56 to -0.07; two trials, 256 women; spinal versus GA anaesthesia: SMD -0.59 mL; 95% CI -0.83 to 0.35; two trials, 279 women). There was evidence of a significant difference in terms of satisfaction with anaesthetic technique - compared with the epidural or spinal group, more women in the GA group stated they would use the same technique again if they needed CS for a subsequent pregnancy (epidural versus GA: risk ratio (RR) 0.80; 95% CI 0.65 to 0.98; one trial, 223 women; spinal versus GA anaesthesia: RR 0.80; 95% CI 0.65 to 0.99; one trial, 221 women).No significant difference was seen in terms of neonatal Apgar scores of six or less and of four or less at five minutes and the need for neonatal resuscitation with oxygen. AUTHORS' CONCLUSIONS There is no evidence from this review to show that RA is superior to GA in terms of major maternal or neonatal outcomes. Further research to evaluate neonatal morbidity and maternal outcomes, such as satisfaction with technique, will be useful.
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Affiliation(s)
- Bosede B Afolabi
- Department of Obstetrics and Gynaecology, University of Lagos, Lagos, Nigeria.
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Saracoglu KT, Saracoglu A, Cakar K, Fidan V, Ay B. Comparative study of intravenous opioid consumption in the postoperative period. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2012; 156:48-51. [PMID: 22580860 DOI: 10.5507/bp.2011.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Intravenous patient-controlled analgesia (IV PCA) using opiods is an accepted method for delivering postoperative analgesia. The aim of this study was to compare fentanyl and tramadol with IV PCA after spinal anesthesia (SA) and general anesthesia (GA) following cesarean section (C/S). METHODS Ninety women were randomly assigned to three groups (n=30). Group 1 was treated with IV fentanyl PCA after SA. Groups 2 and 3 were treated with IV fentanyl PCA and IV tramadol PCA after GA. Outcome measures were recorded for the first 24 h post-anesthesia. RESULTS PCA use was significantly lower after SA (P<0.05). Eighteen patients in the SA Group and 27 patients and 24 patients from the GA groups required additional opioid. Opioid consumption and patient satisfaction were similar for groups after GA (P>0.05). 638.4 ± 179.1 μg fentanyl was consumed by patients of Group 2, 356.3 ± 87.0 μg fentanyl and 559.5 ± 207.0 mg tramadol was consumed by Group 1 and Group 3 respectively. There was no significant difference in the overall severity and incidence of nausea, drowsiness or pruritus. CONCLUSION Our study shows that analgesic consumption and post-operative pain scores after SA in C/S decreased, without increase in adverse reactions.
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Affiliation(s)
- Kemal Tolga Saracoglu
- Department of Anesthesiology and Reanimation, Marmara University School of Medicine, Istanbul, Turkey.
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Barbosa FT, Castro AA, de Miranda CT. Neuraxial anesthesia compared to general anesthesia for procedures on the lower half of the body: systematic review of systematic reviews. Rev Bras Anestesiol 2012; 62:235-43. [PMID: 22440378 DOI: 10.1016/s0034-7094(12)70121-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2011] [Accepted: 06/19/2011] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Systematic reviews organize literature data by combining results from published studies in order to resolve conflicts in the area of medical knowledge describing the interventions. The inadequate reporting of systematic reviews can damage the credibility and interfere in the results' quality. The objective of this study was to determine the frequency of good quality systematic reviews comparing neuraxial anesthesia with general anesthesia for procedures on the lower half of the body. METHODS Systematic review of systematic reviews. Primary variable: The frequency of good quality systematic reviews. The information was analyzed from the following databases: LILACS (January 1982 to December 2010); PubMed (January 1950 to December 2010); The Cochrane Database of Systematic Review and Database of Abstracts of Reviews of Effects (volume 10, 2010); and SciELO (December 2010). The quality of systematic reviews was determined by the Overview Quality Assessment Questionnaire. The sample size calculation showed that it was necessary to analyze eight systematic reviews, taking into account that the frequency of good quality systematic reviews was 5%, an absolute precision of 15%, and a significance level of 5%. RESULTS Were identified 1,995 articles. The selection process eliminated 1,968 articles. Twenty-seven articles of systematic reviews were read in full, 9 were excluded due to incompatibility with the inclusion criteria, and 8 were duplicate publications. Ten systematic reviews were assessed for their quality. The frequency of good quality systematic reviews was 40% (4/10; 95% CI 9.6 to 70.4%). CONCLUSION The frequency of good quality systematic reviews was 40%.
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Affiliation(s)
- Fabiano Timbó Barbosa
- Basic Anesthetic and Surgical Technique, Universidade Federal de Alagoas, Av. Lourival Melo Mota S/N, Tabuleiro do Martins, Maceió, AL, Brazil.
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Horey D, Davey MA, Small R, Kealy M, Crowther CA. Interventions for supporting women with decisions about mode of birth in a pregnancy after caesarean birth. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2012. [DOI: 10.1002/14651858.cd010041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Ghaly RF, Candido KD, Chupatanakul L, Knezevic NN. Magnetic resonance imaging is essential prior to spinal subarachnoid blockade for parturients with a history of brain tumor resection undergoing cesarean section. Surg Neurol Int 2012; 3:75. [PMID: 22937476 PMCID: PMC3424678 DOI: 10.4103/2152-7806.98504] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Accepted: 06/15/2012] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Primary brain tumors are usually treated by surgical removal with the goal of complete resection within the constraints of preservation of neurological function. However, gross total resection may not mean complete tumor removal, and ongoing compression from a mass effect can lead to serious sequelae. Spinal subarachnoid blockade is contraindicated in patients with brain tumors or space occupying lesions. CASE DESCRIPTION A 32-year-old full term parturient presented to Labor and Delivery for semi-urgent repeat cesarean section. Three months ago, she underwent resection of a benign brain tumor and recovered with no new neurological deficits. The neurosurgeon was consulted by the anesthesia team and stated that the tumor was completely extirpated. Since there was no postoperative magnetic resonance imaging (MRI) and the patient still had some neurological deficits, the anesthesia team decided to proceed with a general anesthetic using a rapid sequence induction and intubation. Mild hyperventilation to maintain an end-tidal CO(2) of 30 mmHg was selected and conservative fluid management was maintained. Postcesarean MRI revealed residual tumor compressing the brain stem and a loculated cyst. If a spinal subarachnoid blockade technique had been selected, the risk of uncal herniation, based on the postoperative MRI findings, may have been realized. CONCLUSIONS The present case demonstrates the necessity of a comprehensive and thorough review prior to selecting the anesthetic approach to mange the patients with a history of brain tumor resection. Postoperative MR imaging should be performed to evaluate the extent of tumor resection and possible existence of residual tumor.
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Affiliation(s)
- Ramsis F Ghaly
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL 60504, USA
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Continuous spinal anesthesia for Cesarean hysterectomy and massive hemorrhage in a parturient with placenta increta. Can J Anaesth 2012; 59:473-7. [DOI: 10.1007/s12630-012-9681-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Accepted: 02/14/2012] [Indexed: 10/28/2022] Open
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Spinal versus general anesthesia in cesarean sections: the effects on postoperative pain perception. Arch Gynecol Obstet 2012; 286:75-9. [DOI: 10.1007/s00404-012-2265-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2011] [Accepted: 02/16/2012] [Indexed: 10/28/2022]
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Chen YH, Rau RH, Keller J, Lin HC. Possible effects of anaesthetic management on the 1 yr followed-up risk of herpes zoster after Caesarean deliveries. Br J Anaesth 2012; 108:278-82. [DOI: 10.1093/bja/aer386] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
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Hutchinson N. Sedation vs general anaesthesia for the ‘high-risk’ patient - what can TAVI teach us? Anaesthesia 2011; 66:965-8. [DOI: 10.1111/j.1365-2044.2011.06894.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Tendal B, Nüesch E, Higgins JPT, Jüni P, Gøtzsche PC. Multiplicity of data in trial reports and the reliability of meta-analyses: empirical study. BMJ 2011; 343:d4829. [PMID: 21878462 PMCID: PMC3171064 DOI: 10.1136/bmj.d4829] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVES To examine the extent of multiplicity of data in trial reports and to assess the impact of multiplicity on meta-analysis results. DESIGN Empirical study on a cohort of Cochrane systematic reviews. DATA SOURCES All Cochrane systematic reviews published from issue 3 in 2006 to issue 2 in 2007 that presented a result as a standardised mean difference (SMD). We retrieved trial reports contributing to the first SMD result in each review, and downloaded review protocols. We used these SMDs to identify a specific outcome for each meta-analysis from its protocol. Review methods Reviews were eligible if SMD results were based on two to ten randomised trials and if protocols described the outcome. We excluded reviews if they only presented results of subgroup analyses. Based on review protocols and index outcomes, two observers independently extracted the data necessary to calculate SMDs from the original trial reports for any intervention group, time point, or outcome measure compatible with the protocol. From the extracted data, we used Monte Carlo simulations to calculate all possible SMDs for every meta-analysis. RESULTS We identified 19 eligible meta-analyses (including 83 trials). Published review protocols often lacked information about which data to choose. Twenty-four (29%) trials reported data for multiple intervention groups, 30 (36%) reported data for multiple time points, and 29 (35%) reported the index outcome measured on multiple scales. In 18 meta-analyses, we found multiplicity of data in at least one trial report; the median difference between the smallest and largest SMD results within a meta-analysis was 0.40 standard deviation units (range 0.04 to 0.91). CONCLUSIONS Multiplicity of data can affect the findings of systematic reviews and meta-analyses. To reduce the risk of bias, reviews and meta-analyses should comply with prespecified protocols that clearly identify time points, intervention groups, and scales of interest.
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Affiliation(s)
- Britta Tendal
- Nordic Cochrane Centre, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen Ø, Denmark.
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Tsai PS, Hsu CS, Fan YC, Huang CJ. General anaesthesia is associated with increased risk of surgical site infection after Caesarean delivery compared with neuraxial anaesthesia: a population-based study. Br J Anaesth 2011; 107:757-61. [PMID: 21857016 DOI: 10.1093/bja/aer262] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND This study compared the odds ratio (OR) of surgical site infection (SSI) within 30 days after operation with general anaesthesia (GA) or neuraxial anaesthesia (NA) in Taiwanese women undergoing Caesarean delivery (CD). METHODS An epidemiologic design was used. The study population was based on the records of all deliveries in hospitals or obstetric clinics between January 2002 and December 2006 in Taiwan. Anonymized claim data from the Taiwan National Health Insurance Research Database (NHIRD) were analysed. Women who received CD were identified from the NHIRD by Diagnosis-Related Group codes. The mode of anaesthesia was defined by order codes. Multivariate logistic regression was used to estimate the OR and associated 95% confidence interval (CI) of post-CD SSIs for GA when compared with NA. The outcome was whether a woman had been diagnosed as having an SSI during the hospitalization or was re-hospitalized within 30 days after CD for the treatment of SSIs using five or 81 International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. RESULTS Among the 303 834 Taiwanese women who underwent CD during the 5 yr observation period, the 30 day post-CD SSI rate was 0.3% or 0.9% based on five or 81 ICD-9-CM codes. The multivariate-adjusted OR of having post-CD SSIs in the GA group was 3.73 (95% CI, 3.07-4.53) compared with the NA group (P<0.001) using five ICD-9-CM codes for the definition of SSI. CONCLUSIONS GA for CD was associated with a higher risk of SSI when compared with neuraxial anaesthesia.
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Affiliation(s)
- P-S Tsai
- Graduate Institute of Nursing, College of Nursing, Taipei Medical University, Taipei 110, Taiwan
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Dhawan R, Kacha A, Chaney MA, Fox AA, Wong CA. Case 2--2011: Acute myocardial infarction in a pregnant patient requiring coronary artery bypass graft surgery. J Cardiothorac Vasc Anesth 2011; 25:353-61. [PMID: 21295495 DOI: 10.1053/j.jvca.2010.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Indexed: 11/11/2022]
Affiliation(s)
- Richa Dhawan
- Department of Anesthesia and Critical Care, University of Chicago Medical Center, Chicago, IL, USA
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Breivik H, Norum HM. [Regional analgesia--risks and benefits]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2010; 130:392-7. [PMID: 20220867 DOI: 10.4045/tidsskr.08.0220] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Local anaesthetics may alleviate pain more effectively than any other anaesthetic method. In regional anaesthesia/analgesia, rare but serious complications make it necessary to always consider the risk-benefit ratio. The article discusses these issues and gives advice on effective and safe conduct. MATERIAL AND METHODS The article is based on non-systematic literature searches in the PubMed and Cochrane databases and our own experience from research and clinical work. RESULTS Regional anaesthesia is obtained by administering local anaesthetics near the spinal cord and nerve roots (spinal, epidural), spinal nerves (paravertebral), or close to peripheral nerves. Parts of the body will then become numb and paralysed. The same techniques are used for regional analgesia, but this is obtained by using more dilute solutions of local anaesthetics, and other analgesic drugs are often added. Pain impulses are inhibited, but sensation of touch and muscle functions are intact. Regional analgesia gives superior relief of pain provoked by movement. This facilitates early postoperative mobilization of patients, even after major surgery in weak patients. For these patients optimally performed regional analgesia may reduce postoperative morbidity and mortality better than general anaesthesia and opioid and non-opioid analgesics administered postoperatively. Infiltration of the wound with local anaesthetics followed by optimally dosed non-opioid and opioid analgesics is a good alternative for some types of surgery. The risk of spinal bleeding has increased due to increased patient age, routine thromboprophylaxis and frequent use of antihaemostatic drugs, including platelet inhibitors. Infections in the spinal cord are caused by insufficient hygiene. Selection of patients who are likely to benefit from regional anaesthesia/analgesia, strict hygienic precautions, optimal technique, close monitoring, and assistance from an acute pain team, as well as hospital protocols for handling rare but serious complications, have reduced the occurrence and consequences of serious complications. INTERPRETATION Optimal regional anaesthesia/analgesia may improve the postoperative result.
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Affiliation(s)
- Harald Breivik
- Institutt for sykehusmedisin, Universitetet i Oslo og Akuttklinikken, Anestesi Oslo universitetssykehus, Rikshospitalet 0027 Oslo, Norway.
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Yentur EA, Topcu I, Ekici Z, Ozturk T, Keles GT, Civi M. The effect of epidural and general anesthesia on newborn rectal temperature at elective cesarean section. Braz J Med Biol Res 2010; 42:863-7. [PMID: 19738991 DOI: 10.1590/s0100-879x2009000900014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2008] [Accepted: 07/08/2009] [Indexed: 11/21/2022] Open
Abstract
Both epidural and general anesthesia can impair thermoregulatory mechanisms during surgery. However, there is lack of information about the effects of different methods of anesthesia on newborn temperature. The purpose of this study was to determine whether there are differences in newborn rectal temperature related to type of anesthesia. Sixty-three pregnant women were randomly assigned to receive general or epidural anesthesia. Maternal core temperature was measured three times with a rectal probe just before anesthesia, at the beginning of surgery and at delivery. In addition, umbilical vein blood was sampled for pH. The rectal temperatures of the babies were recorded immediately after delivery, and Apgar scores were determined 1, 5, and 10 min after birth. The duration of anesthesia and the volume of intravenous fluid given during the procedure (833 +/- 144 vs 420 +/- 215 mL) were significantly higher in the epidural group than in the general anesthesia group (P < 0.0001). Maternal rectal temperatures were not different in both groups at all measurements. In contrast, newborn rectal temperatures were lower in the epidural anesthesia group than in the general anesthesia group (37.4 +/- 0.3 vs 37.6 +/- 0.3 degrees C; P < 0.05) immediately after birth. Furthermore, the umbilical vein pH value (7.31 +/- 0.05 vs 7.33 +/- 0.01; P < 0.05) and Apgar scores at the 1st-min measurement (8.0 +/- 0.9 vs 8.5 +/- 0.7; P < 0.05) were lower in the epidural anesthesia group than in the general anesthesia group. Since epidural anesthesia requires more iv fluid infusion and a longer time for cesarean section, it involves a risk of a mild temperature reduction for the baby which, however, did not reach the limits of hypothermia.
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Affiliation(s)
- E A Yentur
- Department of Anestheasiology, Celal Bayar University, Manisa, Turkey.
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Mathews A, Radhakrishnan L, Sharpe P. Spinal anaesthetic failure from an easily overlooked defect. Int J Obstet Anesth 2009; 18:421. [PMID: 19703764 DOI: 10.1016/j.ijoa.2009.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2008] [Revised: 03/25/2009] [Accepted: 03/27/2009] [Indexed: 11/18/2022]
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Tendal B, Higgins JPT, Jüni P, Hróbjartsson A, Trelle S, Nüesch E, Wandel S, Jørgensen AW, Gesser K, Ilsøe-Kristensen S, Gøtzsche PC. Disagreements in meta-analyses using outcomes measured on continuous or rating scales: observer agreement study. BMJ 2009; 339:b3128. [PMID: 19679616 PMCID: PMC2726927 DOI: 10.1136/bmj.b3128] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/11/2009] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To study the inter-observer variation related to extraction of continuous and numerical rating scale data from trial reports for use in meta-analyses. DESIGN Observer agreement study. DATA SOURCES A random sample of 10 Cochrane reviews that presented a result as a standardised mean difference (SMD), the protocols for the reviews and the trial reports (n=45) were retrieved. DATA EXTRACTION Five experienced methodologists and five PhD students independently extracted data from the trial reports for calculation of the first SMD result in each review. The observers did not have access to the reviews but to the protocols, where the relevant outcome was highlighted. The agreement was analysed at both trial and meta-analysis level, pairing the observers in all possible ways (45 pairs, yielding 2025 pairs of trials and 450 pairs of meta-analyses). Agreement was defined as SMDs that differed less than 0.1 in their point estimates or confidence intervals. RESULTS The agreement was 53% at trial level and 31% at meta-analysis level. Including all pairs, the median disagreement was SMD=0.22 (interquartile range 0.07-0.61). The experts agreed somewhat more than the PhD students at trial level (61% v 46%), but not at meta-analysis level. Important reasons for disagreement were differences in selection of time points, scales, control groups, and type of calculations; whether to include a trial in the meta-analysis; and data extraction errors made by the observers. In 14 out of the 100 SMDs calculated at the meta-analysis level, individual observers reached different conclusions than the originally published review. CONCLUSIONS Disagreements were common and often larger than the effect of commonly used treatments. Meta-analyses using SMDs are prone to observer variation and should be interpreted with caution. The reliability of meta-analyses might be improved by having more detailed review protocols, more than one observer, and statistical expertise.
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Affiliation(s)
- Britta Tendal
- Nordic Cochrane Centre, Rigshospitalet, Dept 3343, Blegdamsvej 9, DK-2100 Copenhagen, Denmark.
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Siassakos D, Hasafa Z, Sibanda T, Fox R, Donald F, Winter C, Draycott T. Retrospective cohort study of diagnosis-delivery interval with umbilical cord prolapse: the effect of team training. BJOG 2009; 116:1089-96. [PMID: 19438496 DOI: 10.1111/j.1471-0528.2009.02179.x] [Citation(s) in RCA: 163] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine whether the introduction of multi-professional simulation training was associated with improvements in the management of cord prolapse, in particular, the diagnosis-delivery interval (DDI). DESIGN Retrospective cohort study. SETTING Large tertiary maternity unit within a University Hospital in the United Kingdom. SAMPLE All cases of cord prolapse with informative case record: 34 pre-training, 28 post-training. METHODS Review of hospital notes and software system entries; comparison of quality of management for umbilical cord prolapse pre-training (1993-99) and post-training (2001-07). MAIN OUTCOME MEASURES Diagnosis-delivery interval; proportion of caesarean section (CS) in whom actions were taken to reduce cord compression; type of anaesthesia for CS births; rate of low (<7) 5-minute Apgar scores; rate of admission to neonatal intensive care unit (NICU) (if birthweight >2500 g). RESULTS After training, there was a statistically significant reduction in median DDI from 25 to 14.5 minutes (P < 0.001). Post-training, there was also a statistically significant increase in the proportion of CS where recommended actions had been performed (from 34.78 to 82.35%, P = 0.003). There was a nonsignificant increase in the use of spinal anaesthesia for CS, from 8.70 to 17.65%, and a nonsignificant reduction in the rate of low Apgar scores from 6.45 to 0% and in the rate of admission to NICU from 38.46 to 22.22%. CONCLUSIONS The introduction of annual training, in accordance with national recommendations, was associated with improved management of cord prolapse. Future studies could assess whether this improved management translates into better outcomes for babies and their mothers.
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Affiliation(s)
- D Siassakos
- Department of Obstetrics and Gynaecology, Southmead Hospital, Bristol, UK.
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Algert CS, Bowen JR, Giles WB, Knoblanche GE, Lain SJ, Roberts CL. Regional block versus general anaesthesia for caesarean section and neonatal outcomes: a population-based study. BMC Med 2009; 7:20. [PMID: 19402884 PMCID: PMC2683867 DOI: 10.1186/1741-7015-7-20] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2009] [Accepted: 04/29/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Anaesthesia guidelines recommend regional anaesthesia for most caesarean sections due to the risk of failed intubation and aspiration with general anaesthesia. However, general anaesthesia is considered to be safe for the foetus, based on limited evidence, and is still used for caesarean sections. METHODS Cohorts of caesarean sections by indication (that is, planned repeat caesarean section, failure to progress, foetal distress) were selected from the period 1998 to 2004 (N = 50,806). Deliveries performed under general anaesthesia were compared with those performed under spinal or epidural, for the outcomes of neonatal intubation and 5-minute Apgar (Apgar5) <7. RESULTS The risk of adverse outcomes was increased for caesarean sections under general anaesthesia for all three indications and across all levels of hospital. The relative risks were largest for low-risk planned repeat caesarean deliveries: resuscitation with intubation relative risk was 12.8 (95% confidence interval 7.6, 21.7), and Apgar5 <7 relative risk was 13.4 (95% confidence interval 9.2, 19.4). The largest absolute increase in risk was for unplanned caesareans due to foetal distress: there were five extra intubations per 100 deliveries and six extra Apgar5 <7 per 100 deliveries. CONCLUSION The infants most affected by general anaesthesia were those already compromised in utero, as evidenced by foetal distress. The increased rate of adverse neonatal outcomes should be weighed up when general anaesthesia is under consideration.
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Affiliation(s)
- Charles S Algert
- Kolling Institute of Medical Research, Clinical and Perinatal Population Health Research, University of Sydney, Australia.
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Laparoscopic ventral hernia repair during pregnancy. Hernia 2009; 13:559-63. [PMID: 19280274 DOI: 10.1007/s10029-009-0476-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2007] [Accepted: 01/09/2009] [Indexed: 10/21/2022]
Abstract
BACKGROUND Laparoscopic ventral hernia repair in comparison to open herniorrhaphy results in reduced length of stay, less post-operative pain, earlier return to work, and reduced complications for the repair of complex ventral hernias. The laparoscopic approach has been the standard of care for complex or large ventral hernias for non-pregnant patients over the past decade. Despite evidence that demonstrates that laparoscopy is safe during pregnancy, there is currently no consensus regarding the indications, contraindications, patient selection and post-operative care of pregnant patients evaluated for laparoscopic ventral herniorrhaphy. METHODS The medical records of our pregnant patient who underwent laparoscopic ventral herniorrhaphy were reviewed for demographics, operative indications, surgical technique, perioperative complications, recurrence, and outcome of the pregnancy. A Medline search using the terms: laparoscopy, surgery, and pregnancy was performed to review the literature from 1997 to 2007. RESULTS This case report represents the first published description of a safe and successful laparoscopic approach to the repair of a complex ventral hernia in a woman at 21 weeks gestation. The discussion reviews the current literature regarding the safety of laparoscopy in pregnant women and highlights techniques to reduce perioperative morbidity and risk to the fetus. CONCLUSIONS Laparoscopic ventral hernia repair can be safe during pregnancy with appropriate fetal monitoring and consideration of physiologic changes that occur during parturition. Elective procedures should be delayed until after delivery and all semi-elective surgeries until organogenesis is completed during the second trimester.
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Plaat F. Anaesthetic issues related to postpartum haemorrhage (excluding antishock garments). Best Pract Res Clin Obstet Gynaecol 2008; 22:1043-56. [PMID: 18849197 DOI: 10.1016/j.bpobgyn.2008.08.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The obstetric anaesthetist is a key member of the multidisciplinary team required to manage postpartum haemorrhage, having been trained in resuscitation and being experienced in managing haemorrhage and in monitoring and caring for the critically ill patient. The diagnosis of shock, initial resuscitation controversies surrounding fluid replacement, cell salvage in obstetrics and monitoring are discussed.
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Affiliation(s)
- Felicity Plaat
- Queen Charlotte's & Chelsea Hospital, Department of Anaesthesia, Hammersmith House, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK.
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Plaat F, Wray S. Role of the anaesthetist in obstetric critical care. Best Pract Res Clin Obstet Gynaecol 2008; 22:917-35. [DOI: 10.1016/j.bpobgyn.2008.06.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Management of the difficult and failed airway in obstetric anesthesia. J Anesth 2008; 22:38-48. [DOI: 10.1007/s00540-007-0577-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2006] [Accepted: 09/03/2007] [Indexed: 10/22/2022]
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