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Sanchez J, Prabhu R, Guglielminotti J, Landau R. Racial and Ethnic Concordance Between the Patient and Anesthesia Team and Patients' Satisfaction With Pain Management During Cesarean Delivery. Anesth Analg 2024:00000539-990000000-00821. [PMID: 38768069 DOI: 10.1213/ane.0000000000006764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND Racial and ethnic concordance between patients and health care providers increases patient satisfaction but has not been examined in obstetric anesthesia care. This study evaluated the association between racial and ethnic concordance and satisfaction with management of pain during cesarean delivery (PDCD). METHODS This was a secondary analysis on a cohort of patients undergoing cesarean deliveries under neuraxial anesthesia that examined PDCD. The outcome was satisfaction, recorded within 48 hours after delivery using the survey question, "Overall, how satisfied are you with the anesthesia care during the C-section as it relates to pain management?" Using a 5-point Likert scale, satisfaction was defined with the answer "very satisfied." Participants were also asked, "If you have another C-section, would you want the same anesthesia team?" The exposure was racial and ethnic concordance between the patient and anesthesia team members (attending with a resident, nurse anesthetist, or fellow) categorized into full concordance, partial concordance, discordance, and missing. Risk factors for satisfaction were identified using a multivariable analysis. RESULTS Among 403 participants, 305 (78.2%; 95% confidence interval [CI], 73.8-82.1) were "very satisfied," and 358 of 399 (89.7%; 95% CI, 86.3-92.5) "would want the same anesthesia team." Full concordance occurred in 18 (4.5%) cases, partial concordance in 117 (29.0%), discordance in 175 (43.4%), and missing in 93 (23.1%). Satisfaction rate was 88.9% for full concordance, 71.8% for partial concordance, 81.1% for discordance, and 78.5% for missing (P value = .202). In the multivariable analysis, there was insufficient evidence for an association of concordance with satisfaction. Compared to full concordance, partial concordance was associated with a nonsignificant 57% (95% CI, -113 to 91) decrease in the odds of being satisfied, discordance with a 29% (95% CI, -251 to 85) decrease, and missing with a 39% (95% CI, -210 to 88) decrease. Risk factors for not being "very satisfied" were PDCD, anxiety disorders, pregnancy resulting from in vitro fertilization, intravenous medication administration, intrapartum cesarean with extension of labor epidural, having 3 anesthesia team members (instead of 2), and a higher intraoperative blood loss. CONCLUSIONS Our inability to identify an association between concordance and satisfaction is likely due to the high satisfaction rate in our cohort (78.2%), combined with low proportion of full concordance (4.5%). Addressing elements such as PDCD, anxiety, intravenous medication administration, and use of epidural anesthesia for cesarean delivery, and a better understanding of the interplay between concordance and satisfaction are warranted.
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Affiliation(s)
- Jose Sanchez
- From the Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
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2
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Sanchez J, Prabhu R, Guglielminotti J, Landau R. Pain during cesarean delivery: A patient-related prospective observational study assessing the incidence and risk factors for intraoperative pain and intravenous medication administration. Anaesth Crit Care Pain Med 2024; 43:101310. [PMID: 37865217 DOI: 10.1016/j.accpm.2023.101310] [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: 05/17/2023] [Revised: 10/12/2023] [Accepted: 10/12/2023] [Indexed: 10/23/2023]
Abstract
INTRODUCTION The incidence of pain during cesarean delivery (PDCD) remains unclear. Most studies evaluated PDCD using interventions suggesting inadequate analgesia: neuraxial replacement, unplanned intravenous medication (IVM), or conversion to general anesthesia. Few assess self-reported pain. This study evaluates the incidence of and risk factors for self-reported PDCD and IVM administration. METHODS Between May and September 2022, English-speaking women undergoing cesarean delivery under neuraxial anesthesia were approached within the first 48 h. Participants answered a 16-question survey about intraoperative anesthesia care. Clinical characteristics were extracted from electronic medical records. The primary outcome was PDCD. Secondary outcomes were analgesic IVM (opioids alone or in combination with ketamine, midazolam, or dexmedetomidine) and conversion to general anesthesia. Risk factors for PDCD and analgesic IVM were identified using multivariable logistic regression models. RESULTS Pain was reported by 46/399 (11.5%; 95% CI: 8.6, 15.1) participants. Analgesic IVM was administered to 16 (34.8%) women with PDCD and 45 (12.6%) without. Conversion to general anesthesia occurred in 3 (6.5%) women with and 4 (1.1%) without PDCD. Risk factors associated with PDCD were substance use disorder and intrapartum epidural extension. Risk factors associated with analgesic IVM were PDCD, intrapartum epidural extension when ≥2 epidural top-ups were given for labor analgesia, and longer surgical duration. DISCUSSION In our cohort of scheduled and unplanned cesarean deliveries, the incidence of PDCD was 11.5%. A significant proportion of women (15.1%) received analgesic IVM, of which some but not all reported pain, which requires further evaluation to identify triggers for IVM administration and strategies optimizing shared decision-making.
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Affiliation(s)
- Jose Sanchez
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, 622 West 168th Street, PH5-505, New York, NY 10032, USA
| | - Rohan Prabhu
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, 622 West 168th Street, PH5-505, New York, NY 10032, USA
| | - Jean Guglielminotti
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, 622 West 168th Street, PH5-505, New York, NY 10032, USA
| | - Ruth Landau
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, 622 West 168th Street, PH5-505, New York, NY 10032, USA.
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3
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Thomas CL, Lange EMS, Banayan JM, Zhu Y, Liao C, Peralta FM, Grobman WA, Scavone BM, Toledo P. Racial and Ethnic Disparities in Receipt of General Anesthesia for Cesarean Delivery. JAMA Netw Open 2024; 7:e2350825. [PMID: 38194235 PMCID: PMC10777252 DOI: 10.1001/jamanetworkopen.2023.50825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/19/2023] [Indexed: 01/10/2024] Open
Abstract
Importance General anesthesia for cesarean delivery is associated with increased maternal morbidity, and Black and Hispanic pregnant patients have higher rates of general anesthesia use compared with their non-Hispanic White counterparts. It is unknown whether risk factors and indications for general anesthesia differ among patients of differing race and ethnicity. Objective To evaluate differences in general anesthesia use for cesarean delivery and the indication for the general anesthetic by race and ethnicity. Design, Setting, and Participants In this retrospective, cross-sectional, single-center study, electronic medical records for all 35 117 patients who underwent cesarean delivery at Northwestern Medicine's Prentice Women's Hospital from January 1, 2007, to March 2, 2018, were queried for maternal demographics, clinical characteristics, obstetric and anesthetic data, the indication for cesarean delivery, and the indication for general anesthesia when used. Data analysis occurred in August 2023. Exposure Cesarean delivery. Main Outcomes and Measures The rate of general anesthesia for cesarean delivery by race and ethnicity. Results Of the 35 117 patients (median age, 33 years [IQR, 30-36 years]) who underwent cesarean delivery, 1147 (3.3%) received general anesthesia; the rates of general anesthesia were 2.5% for Asian patients (61 of 2422), 5.0% for Black patients (194 of 3895), 3.7% for Hispanic patients (197 of 5305), 2.8% for non-Hispanic White patients (542 of 19 479), and 3.8% (153 of 4016) for all other groups (including those who declined to provide race and ethnicity information) (P < .001). A total of 19 933 pregnant patients (56.8%) were in labor at the time of their cesarean delivery. Of those, 16 363 (82.1%) had neuraxial labor analgesia in situ. Among those who had an epidural catheter in situ, there were no racial or ethnic differences in the rates of general anesthesia use vs neuraxial analgesia use (Asian patients, 34 of 503 [6.8%] vs 1289 of 15 860 [8.1%]; Black patients, 78 of 503 [15.5%] vs 1925 of 15 860 [12.1%]; Hispanic patients, 80 of 503 [15.9%] vs 2415 of 15 860 [15.2%]; non-Hispanic White patients, 255 of 503 [50.7%] vs 8285 of 15 860 [52.2%]; and patients of other race or ethnicity, 56 of 503 [11.1%] vs 1946 of 15 860 [12.3%]; P = .16). Indications for cesarean delivery and for general anesthesia were not different when stratified by race and ethnicity. Conclusions and Relevance Racial disparities in rates of general anesthesia continue to exist; however, this study suggests that, for laboring patients who had labor epidural catheters in situ, no disparity by race or ethnicity existed. Future studies should address whether disparities in care that occur prior to neuraxial catheter placement are associated with higher rates of general anesthesia among patients from ethnic and racial minority groups.
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Affiliation(s)
- Caroline Leigh Thomas
- Department of Anesthesiology and Critical Care, University of Chicago Medical Center, Chicago, Illinois
| | | | | | - Yinhua Zhu
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Chuanhong Liao
- Department of Public Health Services, University of Chicago, Chicago, Illinois
| | - Feyce M. Peralta
- Department of Anesthesiology, Northwestern University, Chicago, Illinois
| | - William A. Grobman
- Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus
| | - Barbara M. Scavone
- Department of Anesthesia and Critical Care, University of Chicago Medical Center, Chicago, Illinois
- Department Obstetrics & Gynecology, University of Chicago Medical Center, Chicago, Illinois
| | - Paloma Toledo
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Miami, Florida
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Fedoruk K, Xie J, Wang E, Fowler C, Riley E, Carvalho B. Effect of an electronic medical record nudge to improve quality improvement program tracking of neuraxial catheter replacements in obstetric patients. BMJ Open Qual 2023; 12:e002240. [PMID: 37903567 PMCID: PMC10619052 DOI: 10.1136/bmjoq-2022-002240] [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: 12/24/2022] [Accepted: 09/09/2023] [Indexed: 11/01/2023] Open
Abstract
BACKGROUND Monitoring complications associated with medical procedures requires reliable and accurate record keeping. Nudge reminders executed by way of electronic medical record (EMR) alerts influence clinician behaviour. We hypothesised that the introduction of an EMR nudge would improve documentation of replaced neuraxial blocks by obstetric anaesthesiologists at our institution. METHODS We developed an EMR nudge that would alert the physician to a replaced neuraxial block if two or more neuraxial procedure notes in a single patient encounter were detected. The nudge encouraged physicians to document neuraxial block replacements in our institution's quality improvement database. We assessed the rate of physician adherence to replaced neuraxial block charting prior to the introduction of the nudge (January 2019-September 2019) and after the implementation (October 2019-December 2020). RESULTS 494 encounters during the chart review period, January 2019-December 2020, required a neuraxial block replacement, representing an actual neuraxial replacement rate of 6.3% prior to the introduction of the nudge in October 2019. This rate was largely unchanged (6.2%) after the introduction of the nudge (0.1% difference, 95% CI: -0.0119 to 0.0099). Prior to the introduction of the nudge, the proportion of correctly charted failed/replaced blocks in our quality improvement database was 80.0%, and after nudge introduction, the rate was 96.2% (p value <0.00001, OR=6.32, 95% CI: 3.15 to 12.66). A p-chart of the monthly adherence rate demonstrated sustained improvement over time. CONCLUSIONS EMR nudge technology significantly improved adherence with quality metric monitoring of neuraxial catheter replacement in obstetric patients. The results imply that data collection for quality metric databases of neuraxial block failures and replacements that rely on clinician memory without a nudge are likely under-reporting neuraxial block failures and replacements. This study supports widespread implementation of nudges in EMRs to improve quality metric reporting.
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Affiliation(s)
- Kelly Fedoruk
- Anesthesiology, Stanford University School of Medicine, Stanford, California, USA
| | - James Xie
- Anesthesiology, Stanford University School of Medicine, Stanford, California, USA
| | - Ellen Wang
- Anesthesiology, Stanford University School of Medicine, Stanford, California, USA
| | - Cedar Fowler
- Anesthesiology, Stanford University School of Medicine, Stanford, California, USA
| | - Edward Riley
- Anesthesiology, Stanford University School of Medicine, Stanford, California, USA
| | - Brendan Carvalho
- Anesthesiology, Stanford University School of Medicine, Stanford, California, USA
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5
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Matthews L, Lim G. Analgesia in Pregnancy. Obstet Gynecol Clin North Am 2023; 50:151-161. [PMID: 36822700 DOI: 10.1016/j.ogc.2022.10.016] [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] [Indexed: 02/25/2023]
Abstract
Pain management during labor and delivery is complex and must balance efficacy and toxicity to both the pregnant person and the fetus. There are numerous ways to achieve safe and effective analgesia and anesthesia during labor and delivery, including neuraxial and nonneuraxial techniques. This review describes important anesthetic considerations that should be made when formulating a pain management plan and an overview of common anesthesia-related complications encountered in the obstetric population.
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Affiliation(s)
- Leslie Matthews
- Department of Anesthesiology & Perioperative Medicine, Division of Obstetric & Women's Anesthesiology, University of Pittsburgh School of Medicine, 300 Halket Street Suite 3510, Pittsburgh, PA 15215, USA.
| | - Grace Lim
- Department of Anesthesiology & Perioperative Medicine, Division of Obstetric & Women's Anesthesiology, University of Pittsburgh School of Medicine, 300 Halket Street Suite 3510, Pittsburgh, PA 15215, USA; Department of Obstetrics Gynecology and Reproductive Sciences University of Pittsburgh School of Medicine, 300 Halket Street Suite 3510, Pittsburgh, PA 15215, USA
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Ende HB, French B, Shi Y, Damron J, Bauchat JR, Dumas S, Wanderer JP. Implementation of an Epidural Rounding Reminder in the Electronic Medical Record Improves Performance of Standardized Patient Assessments during Labor. Appl Clin Inform 2023; 14:238-244. [PMID: 36634697 PMCID: PMC10033221 DOI: 10.1055/a-2011-8259] [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: 10/03/2022] [Accepted: 01/09/2023] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Poorly functioning labor epidural catheters lead to pain and dissatisfaction. Regular catheter assessment ensures timely identification of malfunction and may improve safety by facilitating rapid and successful conversion to general anesthesia for emergency cesarean. Informatics-based systems encourage standardization of care to identify epidural malfunctions earlier. OBJECTIVES This article demonstrates that visual epidural rounding reminder display on an electronic patient board would alert clinicians to elapsed time and decrease mean time between assessments. METHODS As a quality initiative, we implemented an epidural rounding reminder on our obstetric patient board. The reminder indicated the number of elapsed minutes since placement or last patient assessment. We retrospectively reviewed labor epidural charts 3 months prior to and 5 months following reminder implementation, with a 4-week washout period. The primary outcome was mean time between documented epidural assessments, with secondary outcomes including maximum time between assessments, total number of assessments during labor, catheter replacement rates, and patient satisfaction. Unadjusted comparisons between pre- and postimplementation groups were conducted using Wilcoxon's rank-sum and Pearson's chi-square tests, as appropriate. A test for equal variances was conducted for time between assessment outcomes. RESULTS Following implementation, mean time between assessments decreased from a median of 173 (interquartile range [IQR]: 53, 314) to 100 (IQR: 74, 125) minutes (p <0.001), and maximum time between assessments decreased from median 330 (IQR: 60, 542) to 162 (IQR: 125, 212) minutes (p < 0.001). Total number of evaluations during labor increased from 3 (IQR: 2, 4) to 5 (IQR: 3, 7; p < 0.001). Decreased variance in mean and maximum time between assessments was noted following reminder implementation (p < 0.001). Epidural replacement rates decreased from 14 to 5% postimplementation (p < 0.001). Patient satisfaction was unchanged. CONCLUSION Implementation of an informatics-based solution can promote standardization of care. A simple epidural rounding reminder prompted clinicians to perform more frequent labor epidural assessments. In the future, these process improvements must be linked to improvements in patient experiences and outcomes.
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Affiliation(s)
- Holly B Ende
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Benjamin French
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Yaping Shi
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - James Damron
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Jeanette R Bauchat
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Susan Dumas
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Jonathan P Wanderer
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
- Department of Bioinformatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States
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7
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Im M, Riley ET, Hoang D, Lim G, Zakowski M, Carvalho B. Obstetric Anesthesia Procedure-Based Workload and Facility Utilization of Society of Obstetric Anesthesia and Perinatology Centers of Excellence Designated Institutions. Anesth Analg 2022; 135:1142-1150. [PMID: 35759390 DOI: 10.1213/ane.0000000000006112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Optimal workload and staffing for obstetric anesthesia services have yet to be determined. We surveyed Society of Obstetric Anesthesia and Perinatology (SOAP) Centers of Excellence (COE) for Obstetric Anesthesia Care institutions to evaluate procedure-based obstetric anesthesia workload and facility use. METHODS After institutional review board (IRB) exemption, an online survey instrument (REDCap) was sent by email (1 initial and 2 reminders) to all SOAP COEs. Survey data included the number of deliveries, cesarean delivery rate, neuraxial labor analgesia rate, the number of labor and operating rooms, and the number of in-house and backup obstetric anesthesia providers. Obstetric anesthesia activity was estimated using a time-based workload ratio per provider (Stanford Work Index, 1.0 = clinically working every minute of every hour on duty) during weekday, weeknight, and weekend shifts. We compared workload between academic and nonacademic centers and correlated operating and labor rooms with cesarean and vaginal delivery volume. RESULTS Fifty-one of 53 surveys were returned (96% response rate). Data from 33 academic and 14 nonacademic US institutions were analyzed. For academic centers, median Stanford Work Index for all staff (included trainees and Certified Registered Nurse Anesthetists) was 0.20 (weekday) and 0.19 (weeknight and weekends); nonacademic centers were 0.33 (weekday, P < .001 versus academic), 0.23 (weeknight, P = .009 versus academic), and 0.23 (weekends, P = .03 versus academic practices). Attending-only Stanford Work Indices were similar between academic and nonacademic centers. Total number of rooms on the obstetric suite (operating, labor, or triage room) was strongly correlated with delivery volume ( R2 = 0.55). CONCLUSIONS The results outline staffing procedure-based workload ratios and facility utilization at SOAP COEs in the United States. These data can be used by other institutions that provide obstetric anesthesia services to guide their obstetric anesthesia staffing. The importance of considering the workload associated with different shifts and between academic and nonacademic centers is also highlighted. The results show that approximately one-third of an obstetric anesthesiologist's workload is spent on performing procedures. We did not, however, measure the other tasks anesthesiologists practice as peripartum physicians (eg, managing critically ill parturients, doing pre- and postprocedural evaluations, or performing emergent and unexpected procedures), and future studies are required to determine the time required to perform these tasks. Studies to determine the optimal staffing models to handle workload fluctuations and improve outcomes are also required.
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Affiliation(s)
- Mary Im
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford School of Medicine, Palo Alto, California
| | - Edward T Riley
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford School of Medicine, Palo Alto, California
| | - Dan Hoang
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford School of Medicine, Palo Alto, California
| | - Grace Lim
- Department of Anesthesiology & Perioperative Medicine, University of Pittsburgh School of Medicine, UPMC Magee, Pittsburgh, Pennsylvania
| | - Mark Zakowski
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Brendan Carvalho
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford School of Medicine, Palo Alto, California
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8
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Cesarean delivery using an ERAS-CD process for nonopioid anesthesia and analgesia drug/medication management. Best Pract Res Clin Obstet Gynaecol 2022; 85:35-52. [PMID: 35995654 DOI: 10.1016/j.bpobgyn.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 07/13/2022] [Indexed: 12/14/2022]
Abstract
Cesarean delivery (CD) is a surgical delivery of a neonate with surgical access through the maternal abdominal and uterine structures. The Enhanced Recovery After Surgery (ERAS) protocol is a standardized perioperative care program and surgery quality improvement process that has had global spread across numerous surgical disciplines. The medical and surgical use of opioids for pain management and the nonmedical opioid use, over the last three decades, have significantly increased the prevalence of abuse and addiction to opioids. This review summarizes pain, pregnancy substance use, and ERAS-directed analgesia and anesthesia for opioid use reduction or elimination in the operative and postoperative periods. Enhanced recovery (quality and safety) in the surgical CD context requires collaboration, consensus, and appropriate clinical prioritization to allow for the identification of 'the right patient, in the right clinical situation, with the right informed consent, and the right clinical care team and health system'.
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9
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White RS, Lui B, Bryant-Huppert J, Chaturvedi R, Hoyler M, Aaronson J. Economic burden of maternal mortality in the USA, 2018-2020. J Comp Eff Res 2022; 11:927-933. [PMID: 35833509 DOI: 10.2217/cer-2022-0056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To evaluate the economic burden of age- and race/ethnicity-based US maternal mortality disparities. Economic burden is estimated by years of potential life lost (YPLL) and value of statistical life (VSL). Methods: Maternal mortality counts (2018-2020) were obtained from the CDC Wide-ranging Online Data for Epidemiologic Research database. Life-expectancy data were obtained from the Social Security actuarial tables. YPLL and VSL were calculated and stratified by age (classified as under 25, 25-39, and 40 and over) and race/ethnicity (classified as Hispanic, non-Hispanic White, non-Hispanic Black). Results: Economic measures associated with maternal mortality increased by an estimated 30%, from a YPLL of 32,824 and VSL of US$7.9 billion in 2018 to a YPLL of 43,131 and VSL of US$10.4 billion in 2020. Conclusion: Our findings suggest that age, race and ethnicity are major drivers of the US maternal mortality economic burden.
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Affiliation(s)
- Robert S White
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY 10065, USA
| | - Briana Lui
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY 10065, USA
| | - Joe Bryant-Huppert
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY 10065, USA
| | - Rahul Chaturvedi
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY 10065, USA
| | - Marguerite Hoyler
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Jaime Aaronson
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY 10065, USA
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10
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Krawczyk P, Jaśkiewicz R, Huras H, Kołak M. Obstetric Anesthesia Practice in the Tertiary Care Center: A 7-Year Retrospective Study and the Impact of the COVID-19 Pandemic on Obstetric Anesthesia Practice. J Clin Med 2022; 11:jcm11113183. [PMID: 35683567 PMCID: PMC9181341 DOI: 10.3390/jcm11113183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/22/2022] [Accepted: 05/27/2022] [Indexed: 02/01/2023] Open
Abstract
There are many benefits of neuraxial anesthesia (NA) in the obstetric population. We performed a retrospective analysis of anesthesia provided to obstetric patients in the tertiary care center between 1 January 2014 and 31 December 2020 and the influence of the COVID-19 pandemic on anesthetic practice. A total of 15,930 anesthesia procedures were performed. A total of 2182 (17.52%) cesarean sections (CS) required general anesthesia (GA), including 383 (3.07%) of emergency conversion from NA. NA for CS consisted of 9971 (80.04%) spinal anesthesia (SA) and 304 (2.44%) epidural anesthesia (EPI). We found a decrease in the GA rate for CS in 2020 (11.87% vs. 14.81%; p < 0.001). The conversion rate from NA to GA for CS was 2.39% for SA and 31.38% for EPI. The conversion rate from labor EPI to SA for CS increased in 2020 (3.10% vs. 1.24%; p < 0.001), as well as the SA rate for other obstetric procedures (61.32%; p < 0.001). We report 2670 NA for vaginal delivery, representing 31.13% of all vaginal deliveries. NA constituted the vast majority of obstetric anesthesia. However, we report a relatively high incidence of GA. There was a decrease in GA use in the obstetric population during the pandemic. Further reduction in GA use is possible, including an avoidable conversion from NA to GA.
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Affiliation(s)
- Paweł Krawczyk
- Department of Anesthesiology and Intensive Care Medicine, Jagiellonian University Medical College, Kopernika 17, 31-501 Cracow, Poland
- Correspondence:
| | - Remigiusz Jaśkiewicz
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, Jakubowskiego 2, 30-688 Cracow, Poland;
| | - Hubert Huras
- Department of Obstetrics and Gynecology, Jagiellonian University Medical College, Kopernika 23, 31-501 Cracow, Poland; (H.H.); (M.K.)
| | - Magdalena Kołak
- Department of Obstetrics and Gynecology, Jagiellonian University Medical College, Kopernika 23, 31-501 Cracow, Poland; (H.H.); (M.K.)
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11
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McGlennan CM, Christmas TR. "You test because you cannot afford to make assumptions". Anaesthesia 2022; 77:861-864. [PMID: 35587999 DOI: 10.1111/anae.15759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2022] [Indexed: 11/30/2022]
Affiliation(s)
- C M McGlennan
- Department of Anaesthesia, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - T R Christmas
- Department of Anaesthesia, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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12
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Tyler Smith C, Petty K, Derenzo J, Romeo R, Lim G. Quality Assurance Methods to Reduce General Anesthesia Rates in Cesarean Delivery. Int J Obstet Anesth 2022; 51:103564. [DOI: 10.1016/j.ijoa.2022.103564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 04/11/2022] [Accepted: 05/11/2022] [Indexed: 10/18/2022]
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13
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Intravenous Dexmedetomidine as an Adjunct to Neuraxial Anesthesia in Cesarean Delivery: A Retrospective Chart Review. Anesthesiol Res Pract 2022; 2021:9887825. [PMID: 34987573 PMCID: PMC8723858 DOI: 10.1155/2021/9887825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 12/15/2021] [Indexed: 11/18/2022] Open
Abstract
Background Dexmedetomidine is a selective α-2 agonist commonly used for sedation that has been used in obstetric anesthesia for multimodal labor analgesia, postcesarean delivery analgesia, and perioperative shivering. This study evaluated the role of intravenous dexmedetomidine to provide rescue analgesia and/or sedation during cesarean delivery under neuraxial anesthesia. Methods We conducted a single-center, retrospective cohort study of all parturients undergoing cesarean delivery under neuraxial anesthesia between December 1, 2018, and November 30, 2019, who required supplemental analgesia during the procedure. Patients were divided into two groups: patients who received intravenous dexmedetomidine (Dexmed group) and patients who received adjunct medications such as fentanyl, midazolam, ketamine, and nitrous oxide (Standard group). Primary outcome was incidence of conversion to general anesthesia. Results During the study period, 107 patients received adjunct medications. There was no difference in conversion to general anesthesia between the Dexmed group and the Standard group (6% (4/62) vs. 9% (4/45); p=0.718). In the Dexmed group, the mean dexmedetomidine dose received was 37 μg (range 10 to 140 μg). While the use of inotropic/vasopressor medications was common and similar in both groups, there was an increase in the incidence of bradycardia (Dexmed 15% vs. Standard 2%; p=0.042) but not hypotension (Dexmed 24% vs. Standard 24%; p=1.00) in the Dexmed group. Conclusion In patients who required supplemental analgesia for cesarean delivery, those who received dexmedetomidine versus other medications had a similar rate of conversion to general anesthesia, a statistically significant increase in bradycardia, but no difference in the incidence of hypotension.
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The continued evolution of peripartum anesthesiologists. Can J Anaesth 2021; 69:283-288. [PMID: 34939140 PMCID: PMC8694547 DOI: 10.1007/s12630-021-02159-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 11/15/2021] [Accepted: 11/15/2021] [Indexed: 11/15/2022] Open
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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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Landau R, Janvier AS. Are we finally tackling the issue of pain during cesarean section? Anaesth Crit Care Pain Med 2021; 40:100938. [PMID: 34391983 DOI: 10.1016/j.accpm.2021.100938] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 06/02/2021] [Indexed: 12/20/2022]
Affiliation(s)
- Ruth Landau
- Department of Anesthesiology, Columbia University, 622 West 168th St, PH-5, New York, NY 10032, USA.
| | - Anne-Sophie Janvier
- Department of Anesthesiology, Columbia University, 622 West 168th St, PH-5, New York, NY 10032, USA
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Gitterman A, Klaus J, Williams K, Murphy J. Peripartum optimization and coordination of collaborative care practice: a critical role for the obstetric anesthesiologist in combating maternal morbidity and mortality. Curr Opin Anaesthesiol 2021; 34:205-211. [PMID: 33935167 DOI: 10.1097/aco.0000000000000984] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Antenatal anesthesia clinics remain uncommon despite the rising incidence of maternal morbidity and mortality in the United States. The purpose of the present review is to outline the major considerations and challenges surrounding antenatal anesthetic evaluation. RECENT FINDINGS Data from the general surgical population would suggest a mortality benefit associated with preoperative anesthesia evaluation, although no such data exists in the obstetric population.Robust systems for case ascertainment and referral are needed. Recent publications on obstetric comorbidity indices may provide useful tools to ascertain high-risk parturients for a referral to antenatal obstetric anesthesiology clinics and higher levels of maternal care. Major obstetric organizations have identified and laid out criteria for maternal level of care. Anesthesiology resources also play a role in these designations and can help triage patients to facilities with appropriate resources. SUMMARY Obstetric anesthesiologists have a critical role not only in preoperative patient optimization but also in coordinating multidisciplinary care for optimal patient outcomes.
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Affiliation(s)
- Anna Gitterman
- Johns Hopkins Hospital, Department of Anesthesiology and Critical Care Medicine, Baltimore, Maryland, USA
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Abstract
PURPOSE OF REVIEW Perinatal depression is a common and debilitating complication of pregnancy and childbirth. Recent studies have elucidated relationships between acute birth events on depression risk, and novel treatments for postpartum depression have been discovered and approved. This article reviews current understandings about birth events on depression, new screening standards, and novel treatments for postpartum depression. RECENT FINDINGS Pain, analgesia, and depression are complex traits that are inter-related during and after pregnancy. Certain individuals may benefit more than others from addressing pain and suffering around childbirth. Exposures to general anesthesia or postdural puncture headache are associated with postpartum depression symptoms, although a causal relationship is unlikely. Brexanolone, ketamine and its related compounds, and nonpharmacologic options offer new or alternative therapies for depression, although safety information for some of these treatments in pregnancy and lactation are needed. Maternal health bundles call for close attention to perinatal mental health screening with validated instruments, and for timely treatment referrals in the 'fourth trimester'. SUMMARY Clinical monitoring and timely treatment of depression in the perinatal and postpartum periods is critical for maternal postpartum health and recovery. Perinatal specialists and researchers should continue to focus on tailored treatments specific to this special population.
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Affiliation(s)
- Grace Lim
- University of Pittsburgh Department of Anesthesiology & Perioperative Medicine
- University of Pittsburgh Department of Obstetrics & Gynecology, UPMC Magee-Women’s Hospital
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19
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Legislation, Market Size, and Access to Gender-affirming Genital Surgery in the United States. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3422. [PMID: 33680670 PMCID: PMC7929723 DOI: 10.1097/gox.0000000000003422] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 12/16/2020] [Indexed: 02/07/2023]
Abstract
The value of gender-affirming genital surgery (GAGS) has been established for certain transgender or gender non-conforming patients. This study aimed to determine the availability of GAGS by state and region in the United States, and to query possible associations of access to care with healthcare legislation and local market size.
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Maternal safety: recent advances and implications for the obstetric anesthesiologist. Curr Opin Anaesthesiol 2020; 33:793-799. [PMID: 33002958 DOI: 10.1097/aco.0000000000000925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Recognition of the increasing maternal mortality rate in the United States has been accompanied by intense efforts to improve maternal safety. This article reviews recent advances in maternal safety, highlighting those of particular relevance to anesthesiologists. RECENT FINDINGS Cardiovascular and other chronic medical conditions contribute to an increasing number of maternal deaths. Anesthetic complications associated with general anesthesia are decreasing, but complications associated with neuraxial techniques persist. Obstetric early warning systems are evolving and hold promise in identifying women at risk for adverse intrapartum events. Postpartum hemorrhage rates are rising, and rigorous evaluation of existing protocols may reveal unrecognized deficiencies. Development of regionalized centers for high-risk maternity care is a promising strategy to match women at risk for adverse events with appropriate resources. Opioids are a growing threat to maternal safety. There is growing evidence for racial inequities and health disparities in maternal morbidity and mortality. SUMMARY Anesthesiologists play an essential role in ensuring maternal safety. While continued intrapartum vigilance is appropriate, addressing the full spectrum of contributors to maternal mortality, including those with larger roles beyond the immediate peripartum time period, will be essential to ongoing efforts to improve maternal safety.
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Kacmar RM, Mhyre JM. The Continued Crisis of Maternal Mortality: Is Consolidation of Care the Answer? Anesth Analg 2019; 130:49-51. [PMID: 31842171 DOI: 10.1213/ane.0000000000004364] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Rachel M Kacmar
- From the Department of Anesthesiology, University of Colorado School of Medicine, Aurora, Colorado
| | - Jill M Mhyre
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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Carvalho B, Kinsella SM. Obstetric Anaesthetists' Association/National Perinatal Epidemiology Unit collaborative project to develop key indicators for quality of care in obstetric anaesthesia: first steps in the right direction. Anaesthesia 2019; 75:573-575. [PMID: 31797362 DOI: 10.1111/anae.14935] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2019] [Indexed: 11/28/2022]
Affiliation(s)
- B Carvalho
- Stanford University School of Medicine, Stanford, CA, USA
| | - S M Kinsella
- Department of Anaesthesia, St Michael's Hospital, University Hospitals Bristol Foundation Trust, Bristol, UK
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