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Padilla CR, Shamshirsaz AA, Easter SR, Hess P, Smith C, El Sharawi N, Sandlin AT. Critical Care in Placenta Accreta Spectrum Disorders-A Call to Action. Am J Perinatol 2023; 40:988-995. [PMID: 37336216 DOI: 10.1055/s-0043-1761638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
The rising in placenta accreta spectrum (PAS) incidence, highlights the need for critical care allotment for these patients. Due to risk for hemorrhage and possible hemorrhagic shock requiring blood product transfusion, hemodynamic instability and risk of end-organ damage, having an intensive care unit (ICU) with surgical expertise (surgical ICU or equivalent based on institutional resources) is highly recommended. Intensive care units physicians and nurses should be familiarized with intraoperative anesthetic and surgical techniques as well as obstetrics physiologic changes to provide postpartum management of PAS. Validated tools such of bedside point of care ultrasound and viscoelastic tests such as thromboelastogram/rotational thromboelastometry (TEG/ROTEM) are clinically useful in the assessment of hemodynamic status (shock diagnosis, assessment of both fluid responsiveness and tolerance) and transfusion guidance (in patients requiring massive transfusion as opposed to tranditional hemostatic resuscitation) respectively. The future of PAS management lies in the collaborative and multidisciplinary environment. We recommend that women with high suspicion or a confirmed PAS should have a preoperative plan in place and be managed in a tertiary center who is experienced in managing surgically complex cases. KEY POINTS: · The rising in placenta accreta spectrum incidence highlights the need for critical care expertise.. · Emerging tools such as point-of-care ultrasound and thromboelastography/rotational thromboelastometry represent new avenues for real time optimization of hemodynamic and hematological care of patients with PAS.. · Patients with PAS should be referred to a tertiary center having an intensive care unit (ICU) with surgical expertise (or equivalent based on institutional resources)..
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Affiliation(s)
- Cesar R Padilla
- Division of Obstetric Anesthesiology, Stanford University School of Medicine, Stanford, California
| | - Amir A Shamshirsaz
- Department of Obstetrics and Gynecology/Surgical Critical Care Texas Children's Hospital, Baylor College of Medicine, Texas
| | - Sarah R Easter
- Department of Obstetrics and Gynecology/Anesthesiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Phillip Hess
- Department of Anesthesiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Carly Smith
- Department of Anesthesiology and Pain Management, Anesthesiology Institute, Cleveland Clinic, Ohio
| | - Nadir El Sharawi
- Division of Obstetrical Anesthesia, University of Arkansas for Medical Sciences, Fayetteville, Arkansas
| | - Adam T Sandlin
- Division of Maternal-Fetal Medicine, University of Arkansas for Medical Sciences, Fayetteville, Arkansas
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Abstract
The purpose of this review is to describe updates following initial recommendations on best anesthesia practices for obstetric patients with coronavirus disease 2019. The first surge in the United States prompted anesthesiologists to adapt workflows and reconsider obstetric anesthesia care, with emphasis on avoidance of general anesthesia, the benefit of early neuraxial labor analgesia, and prevention of emergent cesarean delivery whenever possible. While workflows have changed to allow sustained safety for obstetric patients and health care workers, it is notable that obstetric anesthesia protocols for labor and delivery have not significantly evolved since the first coronavirus disease 2019 wave.
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Warrick CM, Markley JC, Farber MK, Balki M, Katz D, Hess PE, Padilla C, Waters JH, Weiniger CF, Butwick AJ. Placenta Accreta Spectrum Disorders: Knowledge Gaps in Anesthesia Care. Anesth Analg 2022; 135:191-197. [DOI: 10.1213/ane.0000000000005862] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Kjaer K. Quality Assurance and Quality Improvement in the Labor and Delivery Setting. Anesthesiol Clin 2021; 39:613-630. [PMID: 34776100 DOI: 10.1016/j.anclin.2021.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Quality assurance (QA) is the maintenance of a desired level of quality, whereas quality improvement (QI) is the continuous process of creating systems to make things better. Implementation science promotes the systematic uptake of best practices. Bundles are a structured list of best practices whereas toolkits provide the necessary details, rationale, and implementation materials, such as sample policies and protocols. Metrics that can guide care on the labor and delivery (L&D) floor may be related to team structure (obstetric, multidisciplinary, anesthetic), processes (patient monitoring, team effects), and outcomes (postpartum hemorrhage, venous thromboembolism). Multiple anesthetic quality metrics have been proposed, including the mode of anesthesia for cesarean delivery.
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Affiliation(s)
- Klaus Kjaer
- Weill Cornell Medical College, 525 East 68th Street, New York, NY 10065, USA.
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Bernstein K, Landau R. Management of maternal COVID-19: considerations for anesthesiologists. Curr Opin Anaesthesiol 2021; 34:246-253. [PMID: 33867458 DOI: 10.1097/aco.0000000000001001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To describe updates to pragmatic recommendations that were published during the first coronavirus disease 2019 (COVID-19) surge, including the current thinking about whether pregnancy worsens the severity of COVID-19. RECENT FINDINGS Although a majority of pregnant women infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) remain asymptomatic or paucisymptomatic, pregnancy puts women at higher risk of severe COVID-19 and adverse birth outcomes. Pregnant and recently pregnant women are more likely to be admitted to intensive care units and receive mechanical ventilation than nonpregnant patients with COVID-19, although preexisting maternal comorbidities are significant risk factors.Early provision of neuraxial labor analgesia with a functional indwelling epidural catheter has been universally promoted, with the goal to reduce avoidable general anesthesia for cesarean delivery and mitigate risks for healthcare workers during airway manipulation. This recommendation, along with updated workflow models of anesthesia coverage, may contribute to a reduction in general anesthesia rates. SUMMARY Initial recommendations to provide early neuraxial labor analgesia and avoid general anesthesia for cesarean delivery have not changed over time. Although workflows have significantly changed to allow continued patient and healthcare workers' safety, clinical anesthesia protocols for labor and delivery are essentially the same.
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Affiliation(s)
- Kyra Bernstein
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, New York, USA
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A survey of USA anesthesiology residents regarding their perceptions of, and barriers to, fellowship training in obstetric anesthesia. Int J Obstet Anesth 2021; 46:103159. [PMID: 33893007 DOI: 10.1016/j.ijoa.2021.103159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/02/2021] [Accepted: 03/19/2021] [Indexed: 11/20/2022]
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Ring L, Landau R, Delgado C. The Current Role of General Anesthesia for Cesarean Delivery. CURRENT ANESTHESIOLOGY REPORTS 2021; 11:18-27. [PMID: 33642943 PMCID: PMC7902754 DOI: 10.1007/s40140-021-00437-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2021] [Indexed: 12/20/2022]
Abstract
Purpose of the Review The use of general anesthesia for cesarean delivery has declined in the last decades due to the widespread utilization of neuraxial techniques and the understanding that neuraxial anesthesia can be provided even in urgent circumstances. In fact, the role of general anesthesia for cesarean delivery has been revisited, because despite recent devices facilitating endotracheal intubation and clinical algorithms, guiding anesthesiologists facing challenging scenarios, risks, and complications of general anesthesia at the time of delivery for both mother and neonate(s) remain significant. In this review, we will discuss clinical scenarios and risk factors associated with general anesthesia for cesarean delivery and address reasons why anesthesiologists should apply strategies to minimize its use. Recent Findings Unnecessary general anesthesia for cesarean delivery is associated with maternal complications, including serious anesthesia-related complications, surgical site infection, and venous thromboembolic events. Racial and socioeconomic disparities and low-resource settings are major contributing factors in the use of general anesthesia for cesarean delivery, with both maternal and perinatal mortality increasing when general anesthesia is provided. In addition, more significant maternal pain and higher rates of postpartum depression requiring hospitalization are associated with general anesthesia for cesarean delivery. Summary Rates of general anesthesia for cesarean delivery have overall decreased, and while general anesthesia no longer is a contributing factor to anesthesia-related maternal deaths, further opportunities to reduce its use should be emphasized. Raising awareness in identifying situations and patients at risk to help avoid unnecessary general anesthesia remains crucial.
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Affiliation(s)
- Laurence Ring
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY USA
| | - Ruth Landau
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY USA
| | - Carlos Delgado
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA USA
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Minehart RD, Jackson J, Daly J. Racial Differences in Pregnancy-Related Morbidity and Mortality. Anesthesiol Clin 2021; 38:279-296. [PMID: 32336384 DOI: 10.1016/j.anclin.2020.01.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Racism in the United States has deep roots that affect maternal health, particularly through pervasive inequalities among black women compared with white. Anesthesiologists are optimally positioned to maintain vigilance for these disparities in maternal care, and to intervene with their unique acute critical care skills and knowledge. As leaders in patient safety, anesthesiologists should drive hospitals and practices to develop and implement national bundles for patient safety, as well as using team-based training practices designed to improve hospitals that care for racially diverse mothers.
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Affiliation(s)
- Rebecca D Minehart
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, GRJ 440, Boston, MA 02114, USA.
| | - Jaleesa Jackson
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, GRJ 440, Boston, MA 02114, USA
| | - Jaime Daly
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, GRJ 440, Boston, MA 02114, USA
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Drzymalski DM, Gao W, Moss DR, Liao BT, Shore-Lesserson L, Podovei M. Factors associated with neonatal resuscitation knowledge and comfort across academic anesthesia institutions. J Matern Fetal Neonatal Med 2020; 35:3891-3897. [PMID: 33167742 DOI: 10.1080/14767058.2020.1843018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Neonatal resuscitation training is a requirement for all obstetric anesthesia fellows. However, while the majority of anesthesiologists who work on labor and delivery report having been involved in the resuscitation of a newborn, most do not have NRP training. OBJECTIVE By studying a national cohort of anesthesiologists, our objective was to identify factors associated with knowledge and comfort with neonatal resuscitation and to inform decisions about neonatal resuscitation in obstetric anesthesia fellowship training. MATERIALS AND METHODS After receiving exempt status, a survey assessing knowledge and comfort with neonatal resuscitation was sent to US academic institutions. Univariable and multiple variable regression analyses were performed to assess factors associated with knowledge and comfort. All statistical analyses were performed using R software (R version 3.4.3 [2017-11-30]; R Foundation for Statistical Computing, Vienna, Austria). RESULTS Responses were received from 32 (84%) of 38 academic institutions that participated. A total of 245 surveys were collected from 20 December 2018 to 27 September 2019. The mean (standard deviation (SD)) percentage of correct knowledge answers in the cohort was 43.3% (22.6%). Knowledge scores were associated with obstetric anesthesia fellowship training, regularly working with infants, and current neonatal resuscitation program (NRP) training. The mean (SD) sum of comfort ratings from the individual questions was 49.9 (17.9). Comfort ratings were associated with pediatric anesthesia fellowship training, regularly working with infants, current NRP training, and having at least one year of general pediatrics residency training. CONCLUSIONS Obstetric anesthesiologists have the knowledge but appear to lack the comfort to perform neonatal resuscitation. As obstetric anesthesiologists are sometimes involved in neonatal resuscitation, maintenance of certification is important in maintaining comfort with neonatal resuscitation if not regularly working with infants.
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Affiliation(s)
- Dan M Drzymalski
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA, USA
| | - Wenxi Gao
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA, USA
| | - David R Moss
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA, USA
| | - Benita T Liao
- Department of Anesthesiology, Cohen Children's Medical Center - Long Island Jewish Medical Center, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
| | - Linda Shore-Lesserson
- Department of Anesthesiology, Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
| | - Mihaela Podovei
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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10
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Lee A, Leffert L. Gloving up for the fight against racial and ethnic disparities in obstetric anesthesia care. J Clin Anesth 2020; 67:109988. [PMID: 32711352 DOI: 10.1016/j.jclinane.2020.109988] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 07/11/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Allison Lee
- Department of Anesthesiology, Columbia University, 622 West 168th St, PH-5, New York, NY 10032, USA.
| | - Lisa Leffert
- Department of Anesthesia, Critical Care & Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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11
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Bjornestad EE, Haney MF. An obstetric anaesthetist-A key to successful conversion of epidural analgesia to surgical anaesthesia for caesarean delivery? Acta Anaesthesiol Scand 2020; 64:142-144. [PMID: 31628671 DOI: 10.1111/aas.13493] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 09/05/2019] [Accepted: 09/15/2019] [Indexed: 11/28/2022]
Affiliation(s)
| | - Michael F. Haney
- Anesthesia and Intensive Care Medicine University Hospital of Umeå Umeå University Umea Sweden
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