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Affiliation(s)
- A Butwick
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Abir G, Akdagli S, Butwick A, Carvalho B. Clinical and microbiological features of maternal sepsis: a retrospective study. Int J Obstet Anesth 2016; 29:26-33. [PMID: 27793427 DOI: 10.1016/j.ijoa.2016.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Revised: 08/26/2016] [Accepted: 09/04/2016] [Indexed: 01/11/2023]
Abstract
BACKGROUND Identifying pregnant women with sepsis is challenging because diagnostic clinical and laboratory criteria overlap with normal pregnant physiologic indices. Our primary study aim was to describe clinical and laboratory characteristics of women diagnosed with sepsis, severe sepsis and septic shock. Our secondary aim was to determine positive predictive values for International Classification of Disease (ICD)-9 billing codes for sepsis, severe sepsis, and septic shock. METHODS After gaining Institutional Review Board approval, we identified women with ICD-9 codes for sepsis, severe sepsis and septic shock who were admitted to a single tertiary obstetric center from 2007-2013. Diagnoses were confirmed using criteria from the International Sepsis Definitions Conference report. Demographic, obstetric, vital signs and laboratory data were abstracted by medical chart review. RESULTS We identified 190 women with sepsis-related ICD-9 codes: of these, 35 (18%) women met the criteria for a clinical diagnosis of sepsis, severe sepsis or septic shock. Twenty (57%) women had a sepsis-related diagnosis after cesarean delivery. Twenty-one (60%) women had one or more pre-existing medical conditions and 19 (54%) women had one or more obstetric-related conditions. The genital tract was the most common site of infection. We observed considerable heterogeneity in maternal vital signs and laboratory indices for women with ICD-9 codes for sepsis, severe sepsis, and septic shock. The positive predictive value for each sepsis-related ICD-9 code was low: 16% (95% CI 10 to 24%) for sepsis, 10% (95% CI 3 to 25%) for severe sepsis and 24% (95% CI 10 to 46%) for septic shock. CONCLUSION We identified marked heterogeneity in patient characteristics, clinical features, laboratory indices and microbiological findings among cohorts of women diagnosed with maternal sepsis, severe sepsis or septic shock. Based on our findings, the incidence of maternal sepsis using ICD-9 codes may be significantly overestimated.
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Affiliation(s)
- G Abir
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.
| | - S Akdagli
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - A Butwick
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - B Carvalho
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Hilton G, Daniels K, Goldhaber-Fiebert SN, Lipman S, Carvalho B, Butwick A. Checklists and multidisciplinary team performance during simulated obstetric hemorrhage. Int J Obstet Anesth 2016; 25:9-16. [PMID: 26421705 PMCID: PMC4727983 DOI: 10.1016/j.ijoa.2015.08.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 08/11/2015] [Accepted: 08/14/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Checklists can optimize team performance during medical crises. However, there has been limited examination of checklist use during obstetric crises. In this simulation study we exposed multidisciplinary teams to checklist training to evaluate checklist use and team performance during a severe postpartum hemorrhage. METHODS Fourteen multidisciplinary teams participated in a postpartum hemorrhage simulation occurring after vaginal delivery. Before participating, each team received checklist training. The primary study outcome was whether each team used the checklist during the simulation. Secondary outcomes were the times taken to activate our institution-specific massive transfusion protocol and commence red blood cell transfusion, and whether a designated checklist reader was used. RESULTS The majority of teams (12/14 (86%)) used the checklist. Red blood cell transfusion was administered by all teams. The median [IQR] times taken to activate the massive transfusion protocol and transfuse red blood cells were 5min 14s [3:23-6:43] and 14min 40s [12:56-17:28], respectively. A designated checklist reader was used by 7/12 (58%) teams that used the checklist. Among teams that used a checklist with versus without a designated reader, we observed no differences in the times to activate the massive transfusion protocol or to commence red blood cell transfusion (P>0.05). CONCLUSIONS Although checklist training was effective in promoting checklist use, multidisciplinary teams varied in their scope of checklist use during a postpartum hemorrhage simulation. Future studies are required to determine whether structured checklist training can result in more standardized checklist use during a postpartum hemorrhage.
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Affiliation(s)
- G Hilton
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.
| | - K Daniels
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - S N Goldhaber-Fiebert
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - S Lipman
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - B Carvalho
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - A Butwick
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Cho Y, Carvalho B, Butwick A, Blumenfeld Y, Riley E. Elective ceasarean section at 38 weeks versus 39 weeks: neonatal and maternal outcomes in a randomised controlled trial. BJOG 2014; 121:1748. [PMID: 25413764 DOI: 10.1111/1471-0528.13079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Y Cho
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA
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Butwick A, Hass C, Wong J, Lyell D, El-Sayed Y. Anticoagulant prescribing practices and anesthetic interventions among anticoagulated pregnant patients: a retrospective study. Int J Obstet Anesth 2014; 23:238-45. [PMID: 24910353 DOI: 10.1016/j.ijoa.2014.03.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Revised: 02/27/2014] [Accepted: 03/16/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND The peripartum management of anticoagulated patients poses important challenges for obstetric anesthesiologists, especially when deciding to perform neuraxial block. However, there is limited evidence evaluating anticoagulant prescribing practices and neuraxial block utilization in this setting. Our objective was to examine peripartum anticoagulant prescribing and anesthetic practices in a cohort of anticoagulated patients receiving subcutaneous enoxaparin, and subcutaneous or intravenous unfractionated heparin. METHODS We performed a retrospective study of anticoagulant prescribing patterns and anesthetic interventions among patients receiving enoxaparin and/or unfractionated heparin who delivered at a USA obstetric center over a seven-year period. RESULTS We identified 101 patients who received enoxaparin and/or unfractionated heparin before delivery. Thirty-nine (38.6%) patients received enoxaparin only, 41 (40.6%) patients received enoxaparin bridged to subcutaneous unfractionated heparin, 11 (10.9%) patients received enoxaparin and were converted to intravenous unfractionated heparin and 10 (9.9%) patients received only subcutaneous unfractionated heparin. The overall rate of neuraxial block utilization was 80.2%. The median [IQR] time-period between the last dose of enoxaparin and neuraxial block was significantly shorter for patients who received only enoxaparin vs. enoxaparin with subcutaneous unfractionated heparin (54h [12-192h] (n=26) vs. 216h [39-504h] (n=23), P=0.04). Among patients who received only subcutaneous unfractionated heparin, the time period between unfractionated heparin and neuraxial block was 24h [19-51h]. CONCLUSION In this study, the neuraxial block rate was high among patients receiving enoxaparin and/or subcutaneous unfractionated heparin with patients undergoing relatively long periods off anticoagulation. Careful multidisciplinary planning is recommended for the peripartum management of anticoagulated pregnant patients.
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Affiliation(s)
- A Butwick
- Department of Anesthesiology, Stanford University School of Medicine, Stanford, CA, USA.
| | - C Hass
- NYU School of Medicine, New York, NY, USA
| | - J Wong
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - D Lyell
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Y El-Sayed
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
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Butwick A. Methodological queries about point-of-care haemoglobin data. Anaesthesia 2013; 68:540-1. [PMID: 23573859 DOI: 10.1111/anae.12187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Butwick A, Hilton G, Carvalho B. Non-invasive haemoglobin measurement in patients undergoing elective Caesarean section. Br J Anaesth 2012; 108:271-7. [DOI: 10.1093/bja/aer373] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Butwick A, Dyer R. ST depression at caesarean section and the relation to oxytocin dose. A randomised controlled trial. BJOG 2010; 117:1165; author reply 1165-6. [DOI: 10.1111/j.1471-0528.2010.02625.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Carvalho B, Saxena A, Butwick A, Macario A. Vaginal twin delivery: a survey and review of location, anesthesia coverage and interventions. Int J Obstet Anesth 2008; 17:212-6. [PMID: 17881218 DOI: 10.1016/j.ijoa.2007.04.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2007] [Accepted: 04/01/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Twin pregnancies are associated with increased perinatal morbidity and mortality. No consensus exists whether vaginal twin delivery should take place in the labor room or operating room, or whether anesthesiologists should be present. We surveyed members of the California Society of Anesthesiologists (CSA) to review management of vaginal twin delivery, and examined anesthetic intervention retrospectively at our institution. METHODS 230 CSA members were asked to complete an online survey on location of vaginal twin delivery in their institution and whether they were required to be present throughout. We then retrospectively reviewed charts of vaginal twin deliveries at our institution over a 36-month period to analyze frequency and type of anesthetic intervention. RESULTS The online survey response rate was 58%; 64% of responders reported that vaginal twin deliveries were performed in the operating room and 55% that an anesthesiologist was present. There was a strong association between anesthesiologist's presence and delivery in the operating room (OR 7; 95% CI 3-20). We reviewed 81 charts of women who underwent vaginal twin delivery. The median (range) time that the anesthesiologist was present for each delivery was 60 (20-380) min. Of women undergoing vaginal twin delivery, 27% required anesthetic intervention during the second stage of labor with 6% having emergency cesarean delivery. CONCLUSION There is a lack of consensus regarding the appropriate location for vaginal twin delivery and the role of anesthesiologists. A significant percentage of women undergoing vaginal twin delivery in our institution received anesthetic intervention in the immediate delivery period.
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Affiliation(s)
- B Carvalho
- Department of Anesthesiology, Stanford University School of Medicine, Stanford, California, USA.
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Butwick A, Findley I, Wonke B. Management of pregnancy in a patient with beta thalassaemia major. Int J Obstet Anesth 2006; 14:351-4. [PMID: 16140004 DOI: 10.1016/j.ijoa.2005.02.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2004] [Revised: 02/01/2005] [Accepted: 02/01/2005] [Indexed: 11/15/2022]
Abstract
beta thalassaemia is one of the world's most wide-spread monogenetic disorders. Advances in the management of beta thalassaemia major by extensive blood transfusions and chelation therapy have improved survival of patients into adult life. Due to the prolonged life expectancy and improvements in quality of life, pregnancy has now become an important issue for patients and clinicians. We report a case of a pregnant patient with beta thalassaemia major who underwent a successful caesarean section under spinal anaesthesia. The multidisciplinary approach to management of beta thalassaemia major and pregnancy is discussed.
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Affiliation(s)
- A Butwick
- Department of Anaesthesia, St. George's Hospital, London, UK
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Volikas I, Butwick A, Wilkinson C, Pleming A, Nicholson G. Maternal and neonatal side-effects of remifentanil patient-controlled analgesia in labour. Br J Anaesth 2005; 95:504-9. [PMID: 16113038 DOI: 10.1093/bja/aei219] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Remifentanil has been suggested as an ideal opioid for patient-controlled analgesia (PCA) in labour, but the safety profile has not been established. The aims of this preliminary prospective observational study were to investigate the maternal side-effects and early neonatal effects, and to assess the placental transfer of remifentanil PCA during labour. METHODS Women with no known obstetric complications or contraindication to remifentanil were recruited (n=50). Remifentanil was administered at a bolus dose of 0.5 microg kg(-1) and a lockout period of 2 min. A visual analogue scale was used to assess pain, nausea and itching. Maternal observations were recorded hourly and fetal heart rate trace was assessed every 2 h. Umbilical cord gases, 1 and 5 min Apgar scores and neurological evaluation of the neonate were recorded. Maternal venous blood and umbilical artery and vein cord blood samples were collected for analysis of remifentanil concentration. RESULTS Fifty women enrolled in the study (24 multiparous, 26 primiparous). There was no evidence of cardiovascular instability or respiratory depression. Pain scores decreased significantly, but there was no significant change in nausea after initiating the PCA. A statistically significant increase in itching was found to be clinically mild and 22 women were slightly drowsy (95% confidence interval [CI], 30-58.7%) but alert to voice. Ten fetal heart rate traces demonstrated changes in the first 20 min, but did not require intervention (95% CI, 10-33.7%). The median 1 and 5 min Apgar scores were 9. The mean umbilical cord gases and neurological examination were within normal limits. Maternal vein and umbilical vein cord samples demonstrated placental transfer of remifentanil, and small amounts were detected in umbilical artery samples. CONCLUSIONS At the bolus dose used remifentanil PCA has an acceptable level of maternal side-effects and minimal effect on the neonate. Remifentanil crosses the placenta and appears to be either rapidly metabolized or redistributed in the neonate.
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Affiliation(s)
- I Volikas
- Department of Anaesthesia, St Helier Hospital, Surrey, UK.
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Butwick A, Garewal D. Ventilator-assisted nasotracheal intubation. Anaesthesia 2004; 59:197. [PMID: 14725535 DOI: 10.1111/j.1365-2044.2003.03645.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Butwick A, Carter P, Dolin SJ. A pilot study of the effect of the Queen's Square external bladder stimulator on urinary retention after knee replacement surgery. Anaesthesia 2003; 58:587-91. [PMID: 12846628 DOI: 10.1046/j.1365-2044.2003.03187.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Postoperative urinary retention remains an important problem after major orthopaedic surgery and can increase morbidity. External vibration applied to the suprapubic region has improved bladder emptying and urinary symptoms in patients with neurogenic bladders. Forty-three patients undergoing elective major knee surgery were randomly assigned to receive either a Queen's Square bladder stimulator or placebo device for 24 h postoperatively. No statistically significant differences in rates of urinary retention could be demonstrated in the bladder stimulator group compared to the placebo group (41% and 33%, respectively). There were no differences between the two groups when analysed for prostatic symptoms, type and effectiveness of analgesia and fluid balance. We conclude that, while the Queen's Square external bladder stimulator may be effective in treating chronic urinary retention associated with a neurogenic bladder, it does not appear to be effective in preventing postoperative urinary retention.
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Affiliation(s)
- A Butwick
- King Edward VII Hospital, Midhurst, West Sussex GU27 0BL, UK
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