A Survey of Intravenous Remifentanil Use for Labor Analgesia at Academic Medical Centers in the United States

Obstetric analgesia and anaesthesia in SARS-CoV-2-positive parturients across 10 maternity units in the north-west of England: a retrospective cohort study

Since the start of the COVID‐19 pandemic, few studies have reported anaesthetic outcomes in parturients with SARS‐CoV‐2 infection. We reviewed the labour analgesic and anaesthetic interventions utilised in symptomatic and asymptomatic parturients who had a confirmed positive test for SARS‐CoV‐2 across 10 hospitals in the north‐west of England between 1 April 2020 and 31 May 2021. Primary outcomes analysed included the analgesic/anaesthetic technique utilised for labour and caesarean birth. Secondary outcomes included a comparison of maternal characteristics, caesarean birth rate, maternal critical care admission rate along with adverse composite neonatal outcomes. A positive SARS‐CoV‐2 test was recorded in 836 parturients with 263 (31.4%) reported to have symptoms of COVID‐19. Neuraxial labour analgesia was utilised in 104 (20.4%) of the 509 parturients who went on to have a vaginal birth. No differences in epidural analgesia rates were observed between symptomatic and asymptomatic parturients (OR 1.03, 95%CI 0.64–1.67; p = 0.90). The neuraxial anaesthesia rate in 310 parturients who underwent caesarean delivery was 94.2% (95%CI 90.6–96.0%). The rates of general anaesthesia were similar in symptomatic and asymptomatic parturients (6% vs. 5.7%; p = 0.52). Symptomatic parturients were more likely to be multiparous (OR 1.64, 95%CI 1.19–2.22; p = 0.002); of Asian ethnicity (OR 1.54, 1.04–2.28; p = 0.03); to deliver prematurely (OR 2.16, 95%CI 1.47–3.19; p = 0.001); have a higher caesarean birth rate (44.5% vs. 33.7%; OR 1.57, 95%CI 1.16–2.12; p = 0.008); and a higher critical care utilisation rate both pre‐ (8% vs. 0%, p = 0.001) and post‐delivery (11% vs. 3.5%; OR 3.43, 95%CI 1.83–6.52; p = 0.001). Eight neonates tested positive for SARS‐CoV‐2 while no differences in adverse composite neonatal outcomes were observed between those born to symptomatic and asymptomatic mothers (25.8% vs. 23.8%; OR 1.11, 95%CI 0.78–1.57; p = 0.55). In women with COVID‐19, non‐neuraxial analgesic regimens were commonly utilised for labour while neuraxial anaesthesia was employed for the majority of caesarean births. Symptomatic women with COVID‐19 are at increased risk of significant maternal morbidity including preterm birth, caesarean birth and peripartum critical care admission.

Update on Non-neuraxial Labor Analgesia

Purpose of Review

This review will present recent updates for the use of non-neuraxial analgesia for laboring women.

Recent Findings

Non-neuraxial labor analgesia by nitrous oxide and intravenous opioids are described, and safety concerns with regard to remifentanil administration have been a major focus of recent studies. Fentanyl and nitrous oxide offer some efficacy, albeit less than remifentanil, however with a greater safety margin.

Summary

Women may request or require alternatives to neuraxial labor analgesia, in some cases due to concurrent comorbidities. Remifentanil offers the most efficacious alternative analgesia option; however, safety concerns may preclude widespread use.

Case Report of Remifentanil Labor Analgesia for a Pregnant Patient With Congenital Methemoglobinemia Type 1

Congenital methemoglobinemia is a rare disease characterized by cyanosis and a left shifting of the oxyhemoglobin dissociation curve. The disease necessitates avoidance of certain medications commonly used in obstetrics, making labor analgesia and anesthesia challenging. We present a case report of peripartum anesthetic management of a pregnant patient with congenital methemoglobinemia type 1 who received remifentanil labor analgesia and continuous methemoglobin monitoring. Continuous real-time monitoring of methemoglobin concentrations may prove to be a useful monitor in future care settings. A review of literature encompassing various perioperative and obstetric anesthesia and analgesia management considerations is presented.

What obstetricians should know about obstetric anesthesia during the COVID-19 pandemic

The COVID-19 pandemic has prompted obstetric anesthesiologists to reconsider the ways in which basic anesthesia care is provided on the Labor and Delivery Unit. Suggested modifications include an added emphasis on avoiding general anesthesia, a strong encouragement to infected individuals to opt for early neuraxial analgesia, and the prevention of emergent cesarean delivery, whenever possible. Through team efforts, adopting these measures can have real effects on reducing the transmission of the viral illness and maintaining patient and caregiver safety in the labor room.

Obstetric Anesthesia: Leading the Way in Patient Safety

The subspecialty of obstetric anesthesiology has embraced patient safety research, which has led to a reduction in obstetric anesthesia-related morbidity and mortality. Although there are innumerable individual improvements, this article highlights the following innovations: safer and more effective labor analgesia, safer treatments for hypotension associated with neuraxial blockade, advances in spinal and epidural techniques for operative deliveries, lower incidence of postdural puncture headache through improved technology, safer parental agents for labor analgesia, improved safety of general anesthesia in obstetrics, improved education and the use of simulation including team training, and reductions in operating room-related infections.

Application of remifentanil combined with propofol in the diagnosis of colon cancer with awakening painless digestive endoscopy

Anesthetic effect of remifentanil combined with propofol in awakening painless endoscopy was analyzed. Retrospective analysis of 120 cases of colon cancer were treated in Dongying People's Hospital from June 2015 to December 2017. All of them were treated by awakening painless digestive endoscopy, divided into 60 cases in observation group (combined with remifentanil and propofol anesthesia), and 60 cases in control group (combined intravenous anesthesia of finanib and propofol). The data were respectively recorded at time-points of oxygen inhalation, intubation for 10 min, awakening time, waking time, and the time-points for each represented as the time-points of T1, T2, T3, T4, T5 and recorded the diastolic blood pressure (DBP), respiratory rate (RR) and heart rate (HR), and compared the awakening effect and the occurrence of adverse reaction. There was no significant difference in the DBP index between the two groups at time-point T1 (P>0.05). The time-points of T2, T3, T4 and T5 were significantly different from the observation group (P<0.05). There was no significant difference in RR index between the two groups and between the same groups (P>0.05). Compared with the control group, the awakening time and consciousness recovering of the observation group is lower (P<0.05). The incidence of adverse reactions after awakening operation between the two groups was statistically significant (P<0.05). The local pain rate in the observation group after the awakening operation was lower than the control group. The combined use of trace remifentanil and small dose propofol in the awakening painless digestive endoscopy can make the patients with colon cancer more stable when they are in the awakening state, so as to improve the safety of awakening painless digestive endoscopy. It is worth promoting in clinical practice.

A Review of the Impact of Obstetric Anesthesia on Maternal and Neonatal Outcomes

Obstetric anesthesia has evolved over the course of its history to encompass comprehensive aspects of maternal care, ranging from cesarean delivery anesthesia and labor analgesia to maternal resuscitation and patient safety. Anesthesiologists are concerned with maternal and neonatal outcomes, and with preventing and managing complications that may present during childbirth. The current review will focus on recent advances in obstetric anesthesia, including labor anesthesia and analgesia, cesarean delivery anesthesia and analgesia, the effects of maternal anesthesia on breastfeeding and fever, and maternal safety. The impact of these advances on maternal and neonatal outcomes is discussed. Past and future progress in this field will continue to have significant implications on the health of women and children.

ABM Clinical Protocol #28, Peripartum Analgesia and Anesthesia for the Breastfeeding Mother

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols, free from commercial interest or influence, for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Drug Dosing in Pregnant Women: Challenges and Opportunities in Using Physiologically Based Pharmacokinetic Modeling and Simulations

The unmet medical need of providing evidence‐based pharmacotherapy for pregnant women is recognized by the regulatory bodies. Physiologically based pharmacokinetic (PBPK) modeling offers an attractive platform to quantify anticipated changes in the pharmacokinetics (PKs) of drugs during pregnancy. Recent publications applying a pregnancy PBPK module to the prediction of maternal and fetal exposure of drugs are summarized. Future opportunities to use PBPK models to predict breast milk exposure and assess human fetotoxicity risks are presented.

Modern Neuraxial Anesthesia for Labor and Delivery

The availability of safe, effective analgesia during labor has become an expectation for women in most of the developed world over the past two or three decades. More than 60% of women in the United States now receive some kind of neuraxial procedure during labor. This article is a brief review of the advantages and techniques of neuraxial labor analgesia along with the recent advances and controversies in the field of labor analgesia. For the most part, we have aimed the discussion at the non-anesthesiologist to give other practitioners a sense of the state of the art and science of labor analgesia in the second decade of the 21st century.