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Sultan P. A narrative review of the literature relevant to obstetric anesthesiologists: the 2023 Gerard W. Ostheimer lecture. Int J Obstet Anesth 2024; 58:103973. [PMID: 38508963 DOI: 10.1016/j.ijoa.2023.103973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 11/28/2023] [Accepted: 12/27/2023] [Indexed: 03/22/2024]
Abstract
This narrative review of the 2023 Gerard W. Ostheimer lecture presented at the Society for Obstetric Anesthesia and Perinatology 2023 annual meeting summarizes 2022 literature relevant to obstetric anesthesiologists. ANTENATAL STUDIES Neonatal morbidity is reduced with antenatal maternal buprenorphine compared with methadone for treatment of opioid use disorder. Antenatal pregnancy allergy testing is safe and feasible. ANALGESIA AND ANESTHESIA STUDIES Intrathecal (IT) 3% chloroprocaine for cervical cerclage results in faster sensory block resolution and discharge readiness compared with bupivacaine. The ED90 of 3% chloroprocaine (with IT fentanyl 10 µg) is 49.5 mg. Dural puncture epidural technique does not improve the quality of labor analgesia in obese parturients compared with epidural analgesia. Low- (>0.08 to ≤0.1%) and ultra-low (<0.08%) concentrations of bupivacaine for epidural analgesia maintenance result in similar maternal and neonatal outcomes. Lower doses of first line uterotonic agents are non-inferior to higher doses (oxytocin 0.5 IU vs. 5 IU and carbetocin 20 vs. 100 µg) in patients at low risk for postpartum hemorrhage. Supplemental analgesia or conversion to general anesthesia is necessary in approximately 15% of elective cesarean deliveries. Intravenous dexamethasone improves analgesia outcomes, however optimal dosing and timing remain unclear; it may induce neonatal hypoglycemia in the setting of gestational diabetes. POSTPARTUM STUDIES A core outcome set may help evaluate enhanced recovery protocol implementation. History of migraine and accidental dural puncture (ADP) above the L3 level are associated with epidural blood patch (EBP) failure and ADP at or below L3 and >48 h interval between ADP and EBP are associated with success.
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Affiliation(s)
- P Sultan
- Stanford University School of Medicine, Stanford, CA, USA.
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O'Carroll JE, Zucco L, Warwick E, Radcliffe G, Moonesinghe SR, El-Boghdadly K, Guo N, Carvalho B, Sultan P. Ethnicity, socio-economic deprivation and postpartum outcomes following caesarean delivery: a multicentre cohort study. Anaesthesia 2024; 79:486-497. [PMID: 38359531 DOI: 10.1111/anae.16241] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2024] [Indexed: 02/17/2024]
Abstract
Disparities relating to postpartum recovery outcomes in different socio-economic and racial ethnic groups are underexplored. We conducted a planned analysis of a large prospective caesarean delivery cohort to explore the relationship between ethnicity, socio-economic status and postpartum recovery. Eligible patients were enrolled and baseline demographic, obstetric and medical history data were collected 18 h and 30 h following delivery. Patients completed postpartum quality of life and recovery measures in person on day 1 (EuroQoL EQ-5D-5L, including global health visual analogue scale; Obstetric Quality of Recovery-10 item score; and pain scores) and by telephone between day 28 and day 32 postpartum (EQ-5D-5L and pain scores). Socio-economic group was determined according to the Index of Multiple Deprivation quintile of each patient's usual place of residence. Data from 1000 patients who underwent caesarean delivery were included. There were more patients of Asian, Black and mixed ethnicity in the more deprived quintiles. Patients of White ethnicities had shorter postpartum duration of hospital stay compared with patients of Asian and Black ethnicities (35 (28-56 [18-513]) h vs. 44 (31-71 [19-465]) h vs. 49 (33-75 [23-189]) h, respectively. In adjusted models at day 30, patients of Asian ethnicity had a significantly greater risk of moderate to severe pain (numerical rating scale ≥ 4) at rest and on movement (odds ratio (95%CI) 2.42 (1.24-4.74) and 2.32 (1.40-3.87)), respectively). There were no differences in readmission rates or incidence of complications between groups. Patients from White ethnic backgrounds experience shorter postpartum duration of stay compared with patients from Asian and Black ethnic groups. Ethnic background impacts pain scores and recovery at day 1 postpartum and following hospital discharge, even after adjusting for socio-economic group. Further work is required to understand the underlying factors driving differences in pain and recovery and to develop strategies to reduce disparities in obstetric patients.
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Affiliation(s)
- J E O'Carroll
- Department of Anesthesiology, Peri-operative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Department for Targeted Intervention, Division of Surgery and Interventional Science, University College London
| | - L Zucco
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - E Warwick
- Anaesthesia and Perioperative Medicine, University College London Hospitals, London, UK
| | - G Radcliffe
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - S R Moonesinghe
- University College London Hospitals, London, UK
- Department for Targeted Intervention, Division of Surgery and Interventional Science, University College London
| | - K El-Boghdadly
- Guy's and St Thomas' NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - N Guo
- Department of Anesthesiology, Peri-operative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - B Carvalho
- Department of Anesthesiology, Peri-operative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - P Sultan
- Department of Anesthesiology, Peri-operative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
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O'Carroll JE, Sultan P. Quality of recovery following childbirth: a multidimensional concept. Anaesthesia 2024; 79:212-213. [PMID: 38093548 DOI: 10.1111/anae.16199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2023] [Indexed: 01/11/2024]
Affiliation(s)
| | - P Sultan
- Stanford University School of Medicine, Stanford, CA, USA
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Ciechanowicz S, Kim J, Mak K, Blake L, Carvalho B, Sultan P. Outcomes and outcome measures utilised in randomised controlled trials of postoperative caesarean delivery pain: a scoping review. Int J Obstet Anesth 2024; 57:103927. [PMID: 37852907 DOI: 10.1016/j.ijoa.2023.103927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 08/28/2023] [Accepted: 09/03/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Inadequately treated postoperative pain following caesarean delivery can delay recovery and the ability to care for a newborn. Effectiveness studies of interventions to treat postoperative caesarean delivery pain measure different outcomes, limiting data pooling for meta-analysis. We performed a comprehensive review of existing outcomes with the aim of recommending core outcomes for future research. METHODS A scoping review to identify all outcomes reported in randomised controlled trials (RCTs) and clinical trial registries of interventions to treat or prevent postoperative caesarean delivery pain, with postoperative pain as a primary outcome measure. We searched PubMed, Web of Science, CINAHL, LILACS, Embase, CDSR and CRCT for studies from May 2016 to 2021. Outcomes were extracted and frequencies tabulated. RESULTS Ninety RCTs and 11 trial registries were included. In total, 392 outcomes (375 inpatient and 17 outpatient) were identified and categorised. The most reported outcome domain was analgesia (n = 242/375, 64.5%), reported in 96% of inpatient studies, with analgesic consumption accounting for 108/375, 28.8% of analgesia outcomes. The second most common domain was pain intensity (n = 120/375, 32%), reported in 97% of inpatient studies, using the visual analogue scale (68/120, 59%) and the numerical reporting scale (37/120, 25%). Maternal and neonatal adverse effects accounted for 65/375 (17.3%) and 19/375 (5.1%) of inpatient outcomes, respectively. CONCLUSIONS Outcomes reported in RCTs for postoperative caesarean delivery pain vary widely. The results of this review suggest that standardisation is needed to promote research efficiency and aid future meta-analyses to identify optimal postoperative caesarean delivery pain management.
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Affiliation(s)
- S Ciechanowicz
- Department of Anaesthesia and Perioperative Medicine, University College London Hospital, London, UK.
| | - J Kim
- Department of Anaesthesia and Perioperative Medicine, University College London Hospital, London, UK
| | - K Mak
- Department of Anaesthesia and Perioperative Medicine, University College London Hospital, London, UK
| | - L Blake
- University of Arkansas for the Medical Sciences, UAMS Library, Little Rock, AR, USA
| | - B Carvalho
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University Medical School, CA, USA
| | - P Sultan
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University Medical School, CA, USA
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Sultan P, Guo N, Kawai M, Barwick FH, Carvalho B, Mackey S, Kallen MA, Gould CE, Butwick AJ. Prevalence and predictors for postpartum sleep disorders: a nationwide analysis. J Matern Fetal Neonatal Med 2023; 36:2170749. [PMID: 36710393 DOI: 10.1080/14767058.2023.2170749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To describe the prevalence and predictors of postpartum sleep disorders. DESIGN A retrospective cohort study. SETTING Postpartum. POPULATION Commercially insured women delivering in California (USA) between 2011 and 2014. METHODS Using the Optum Clinformatics Datamart Database. MAIN OUTCOME MEASURES Prevalence of a postpartum sleep disorder diagnosis with and without a depression diagnosis up to 12 months following hospital discharge for inpatient delivery. We also identified predictors of a postpartum sleep disorder diagnosis using multivariable logistic regression. RESULTS We identified 3535 (1.9%) women with a postpartum sleep disorder diagnosis. The prevalence of sleep disorder diagnoses was insomnia (1.3%), sleep apnea (0.25%), and other sleep disorder (0.25%). The odds of a postpartum sleep disorder were highest among women with a history of drug abuse (adjusted odds ratio (aOR): 2.70, 95% confidence interval (CI): 1.79-4.09); a stillbirth delivery (aOR: 2.15, 95% CI: 1.53-3.01); and chronic hypertension (aOR: 1.82; 95% CI: 1.57-2.11). A comorbid diagnosis of a postpartum sleep disorder and depression occurred in 1182 women (0.6%). These women accounted for 33.4% of all women with a postpartum sleep disorder. The strongest predictors of a comorbid diagnosis were a history of drug abuse (aOR: 4.13; 95% CI: 2.37-7.21) and a stillbirth delivery (aOR: 2.93; 95% CI: 1.74-4.92). CONCLUSIONS Postpartum sleep disorders are underdiagnosed conditions, with only 2% of postpartum women in this cohort receiving a sleep diagnosis using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes. Insomnia was the most common disorder and one-third of women diagnosed with a postpartum sleep disorder had a co-morbid diagnosis of depression. Future studies are needed to improve the screening and diagnostic accuracy of postpartum sleep disorders.
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Affiliation(s)
- P Sultan
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - N Guo
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - M Kawai
- Department of Psychiatry and Behavioral Sciences, Division of Sleep Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - F H Barwick
- Department of Psychiatry and Behavioral Sciences, Division of Sleep 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
| | - S Mackey
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - M A Kallen
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - C E Gould
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - A J Butwick
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
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O'Carroll JE, Zucco L, Warwick E, Arbane G, Moonesinghe SR, El-Boghdadly K, Guo N, Carvalho B, Sultan P. Quality of recovery following childbirth: a prospective, multicentre cohort study. Anaesthesia 2023. [PMID: 37226593 DOI: 10.1111/anae.16039] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2023] [Indexed: 05/26/2023]
Abstract
To better understand outcomes in postpartum patients who receive peripartum anaesthetic interventions, we aimed to assess quality of recovery metrics following childbirth in a UK-based multicentre cohort study. This study was performed during a 2-week period in October 2021 to assess in- and outpatient post-delivery recovery at 1 and 30 days postpartum. The following outcomes were reported: obstetric quality of recovery 10-item measure (ObsQoR-10); EuroQoL (EQ-5D-5L) survey; global health visual analogue scale; postpartum pain scores at rest and movement; length of hospital stay; readmission rates; and self-reported complications. In total, 1638 patients were recruited and responses analysed from 1631 (99.6%) and 1282 patients (80%) at one and 30 days postpartum, respectively. Median (IQR [range]) length of stay postpartum was 39.3 (28.5-61.0 [17.7-513.4]), 40.3 (28.5-59.1 [17.8-220.9]), and 35.9 (27.1-54.1 [17.9-188.4]) h following caesarean, instrumental and vaginal deliveries, respectively. Median (IQR [range]) ObsQoR-10 score was 75 ([62-86] 4-100) on day 1, with the lowest ObsQoR-10 scores (worst recovery) reported by patients undergoing caesarean delivery. Of the 1282 patients, complications within the first 30 days postpartum were reported by 252 (19.7%) of all patients. Readmission to hospital within 30 days of discharge occurred in 69 patients (5.4%), with 49 (3%) for maternal reasons. These data can be used to inform patients regarding expected recovery trajectories; facilitate optimal discharge planning; and identify populations that may benefit most from targeted interventions to improve postpartum recovery experience.
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Affiliation(s)
- J E O'Carroll
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - L Zucco
- Department of Anaesthesia and Perioperative Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - E Warwick
- Department of Anaesthesia and Perioperative Medicine, University College London Hospitals, NHS Foundation Trust, London, UK
| | - G Arbane
- Department of Anaesthesia and Perioperative Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - S R Moonesinghe
- Centre for Peri-operative Medicine, Research Department for Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK
| | - K El-Boghdadly
- Department of Anaesthesia and Perioperative Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - N Guo
- 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
| | - P Sultan
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Sultan P, Patel R. Intra-operative breakthrough pain during caesarean delivery: a path forward. Anaesthesia 2023; 78:534. [PMID: 36518015 DOI: 10.1111/anae.15949] [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: 12/01/2022] [Indexed: 12/23/2022]
Affiliation(s)
- P Sultan
- Stanford University School of Medicine, Stanford, CA, USA
| | - R Patel
- University College London, London, UK
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Ciechanowicz S, Pandal P, Carvalho B, Blake L, Van Damme S, Taylor J, Sultan P. Assessment of fatigue in postpartum women using patient-reported outcome measures: a systematic review utilising Consensus Based Standards for the Selection of Health Measurement Instruments (COSMIN) guidelines. Fatigue: Biomedicine, Health & Behavior 2022. [DOI: 10.1080/21641846.2022.2142030] [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] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- S. Ciechanowicz
- Department of Anaesthesia and Perioperative Medicine, University College London Hospital, London, UK
| | - P. Pandal
- Clinical Research Associate, Stanford University School of Medicine, Stanford, CA, USA
| | - B. Carvalho
- Stanford University School of Medicine, Stanford, CA, USA
| | - L. Blake
- UAMS Library, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - S. Van Damme
- Department of Experimental Clinical and Health Psychology, Ghent University, Ghent, Belgium
| | - J. Taylor
- Faculty of Health, University of Canberra, Canberra, Australia
| | - P. Sultan
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Mathias LAST, Carlos RV, Siaulys MM, Gabriades P, Guo N, Domingue B, O'Carroll J, Carvalho B, Sultan P. Development and validation of a Portuguese version of Obstetric Quality of Recovery-10 (ObsQoR-10-Portuguese). Anaesth Crit Care Pain Med 2022; 41:101085. [PMID: 35487408 DOI: 10.1016/j.accpm.2022.101085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 01/28/2022] [Accepted: 01/29/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND We aimed to develop and validate a Portuguese version of the Obstetric Quality of Recovery-10 (ObsQoR-10-Portuguese) patient-reported outcome measure and evaluate its psychometric properties. METHODS After ethical approval, we recruited term pregnant women undergoing uncomplicated elective cesarean delivery in a single Brazilian institution. Women were invited to complete the translated ObsQoR-10-Portuguese and EuroQoL (EQ-5D) questionnaires (including a global health visual analog scale [GHVAS]) at 24 h (±6 h) following delivery, and a subset of women an hour later. We assessed validity and reliability of ObsQoR-10-Portuguese. RESULTS One hundred thirteen enrolled women completed the surveys at 24 h and 29 women at 25 h (100% response rate). VALIDITY (i) convergent validity: ObsQoR-10-Portuguese correlated moderately with EuroQoL score (r = -0.587) and GHVAS score (r = 0.568) at 24 h. (ii) Discriminant validity: ObsQoR-10 discriminated well between good versus poor recovery (GHVAS score ≥ 70 versus < 70; difference in mean scores 14.2; p < 0.001). (iii) Hypothesis testing: 24-h ObsQoR-10-Portuguese scores correlated with gestational age (r = 0.191; p = 0.043). (iv) Cross-cultural validity: differential item functioning analysis suggested bias in 2 items. Reliability: (i) internal consistency was good (Cronbach's alpha = 0.82 and inter-item correlation = 0.31). (ii) Split-half reliability was very good (Spearman-Brown Prophesy Reliability Estimate = 0.80). (iii) Test re-test reliability was excellent (intra-class correlation coefficient = 0.87). (iv) Floor and ceiling effects: < 5% women scored either 0 or 100 (lowest and highest scores, respectively). CONCLUSION ObsQoR-10-Portuguese is valid and reliable, and should be considered for use in Portuguese-speaking women to assess their quality of inpatient recovery following cesarean delivery.
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Affiliation(s)
- L A S T Mathias
- Department of Anesthesiology, Pro Matre Paulista, Grupo Santa Joana, Sao Paulo, SP, Brazil
| | - R V Carlos
- Department of Anesthesiology, Pro Matre Paulista, Grupo Santa Joana, Sao Paulo, SP, Brazil; Department of Anesthesiology, Universidade de Sao Paulo, Hospital das Clínicas, Faculdade de Medicina, São Paulo, SP, Brazil
| | | | - P Gabriades
- Department of Anesthesiology, Pro Matre Paulista, Grupo Santa Joana, Sao Paulo, SP, Brazil
| | - N Guo
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - B Domingue
- Graduate School of Education, Stanford University, USA
| | - J O'Carroll
- 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
| | - P Sultan
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.
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O'Carroll J, Zucco L, Warwick E, Guo N, Carvalho B, Sultan P. O.3 Quality standards in obstetric anaesthesia - national adherence to key indicators for quality improvement in obstetric units. Int J Obstet Anesth 2022. [DOI: 10.1016/j.ijoa.2022.103289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Sarici K, Sultan P, Koro A, Aral H. T291 Total oxidant and antioxidant status in primary open angle glaucoma. Clin Chim Acta 2022. [DOI: 10.1016/j.cca.2022.04.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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O'Carroll J, Zucco L, Warwick E, Guo N, Carvalho B, Sultan P. P.63 A multicentre evaluation of quality of recovery following caesarean delivery. Int J Obstet Anesth 2022. [DOI: 10.1016/j.ijoa.2022.103359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Neall G, Bampoe S, Sultan P. Corrigendum to ‘Analgesia for Caesarean section’ [BJA Education 22 (2022) 197-203]. BJA Educ 2022; 22:448. [DOI: 10.1016/j.bjae.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Patel R, Kua J, Sharawi N, Bauer ME, Blake L, Moonesinghe SR, Sultan P. Inadequate neuraxial anaesthesia in patients undergoing elective caesarean section: a systematic review. Anaesthesia 2022; 77:598-604. [PMID: 35064923 DOI: 10.1111/anae.15657] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2021] [Indexed: 12/26/2022]
Abstract
Neuraxial anaesthesia is widely utilised for elective caesarean section, but the prevalence of inadequate intra-operative anaesthesia is unclear. We aimed to determine the prevalence of inadequate neuraxial anaesthesia for elective caesarean section; prevalence of conversion from neuraxial anaesthesia to general anaesthesia following inadequate neuraxial anaesthesia; and the effect of mode of anaesthesia. We searched studies reporting inadequate neuraxial anaesthesia that used ≥ ED95 doses (effective dose in 95% of the population) of neuraxial local anaesthetic agents. Our primary outcome was the prevalence of inadequate neuraxial anaesthesia, defined as the need to convert to general anaesthesia; the need to repeat or abandon a planned primary neuraxial technique following incision; unplanned administration of intra-operative analgesia (excluding sedatives); or unplanned epidural drug supplementation. Fifty-four randomised controlled trials were included (3497 patients). The overall prevalence of requirement for supplemental analgesia or anaesthesia was 14.6% (95%CI 13.3-15.9%); 510 out of 3497 patients. The prevalence of general anaesthesia conversion was 2 out of 3497 patients (0.06% (95%CI 0.0-0.2%)). Spinal/combined spinal-epidural anaesthesia was associated with a lower overall prevalence of inadequate neuraxial anaesthesia than epidural anaesthesia (10.2% (95%CI 9.0-11.4%), 278 out of 2732 patients vs. 30.3% (95%CI 26.5-34.5%), 232 out of 765 patients). Further studies are needed to identify risk factors, optimise detection and management strategies and to determine long-term effects of inadequate neuraxial anaesthesia.
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Affiliation(s)
- R Patel
- Surgical Outcomes Research Centre, Centre for Peri-Operative Medicine, University College London, UK
| | - J Kua
- Surgical Outcomes Research Centre, Centre for Peri-Operative Medicine, University College London, UK
| | - N Sharawi
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AK, USA
| | - M E Bauer
- Department of Anesthesiology, Duke University, Durham, NC, USA
| | - L Blake
- University of Arkansas for Medical Sciences, Little Rock, AK, USA
| | - S R Moonesinghe
- Surgical Outcomes Research Centre, Centre for Peri-Operative Medicine, University College London, London, UK
| | - P Sultan
- Department of Anesthesiology, Peri-Operative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Sultan P, Patel R, Sharawi N, Moonesinghe SR. Divinum sedare dolorem: it is divine to alleviate pain. Anaesthesia 2022; 77:942-943. [PMID: 35437745 DOI: 10.1111/anae.15743] [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] [Received: 04/04/2022] [Accepted: 04/08/2022] [Indexed: 11/29/2022]
Affiliation(s)
- P Sultan
- Stanford University School of Medicine, Stanford, CA, USA
| | - R Patel
- University College London, London, UK
| | - N Sharawi
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
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O’Carroll J, Carvalho B, Sultan P. Enhancing recovery after cesarean delivery – A narrative review. Best Pract Res Clin Anaesthesiol 2022; 36:89-105. [DOI: 10.1016/j.bpa.2022.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 01/17/2022] [Indexed: 11/25/2022]
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Singh NP, Monks D, Makkar JK, Palanisamy A, Sultan P, Singh PM. Efficacy of regional blocks or local anaesthetic infiltration for analgesia after caesarean delivery: a network meta-analysis of randomised controlled trials. Anaesthesia 2021; 77:463-474. [PMID: 34958680 DOI: 10.1111/anae.15645] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2021] [Indexed: 01/15/2023]
Abstract
Caesarean delivery is common and can cause severe postoperative pain but injection of local anaesthetic at various sites for regional blocks or local anaesthetic infiltration may reduce this. We aimed to compare and rank these sites. We searched PubMed, Google Scholar, EMBASE and CENTRAL to June 2021 for randomised controlled trials and performed a random-effects Bayesian model network meta-analysis. The primary outcome was dose of parenteral morphine equivalents in the first 24 postoperative hours. We used surface under cumulative ranking probabilities to order techniques. We analysed 114 trials (8730 participants). The ordered mean (95% credible interval) reduction in morphine equivalents, from 34 mg with placebo, were as follows: ilio-inguinal 15 (1-32) mg; ilio-inguinal-iliohypogastric 13 (6-19) mg; transversalis fascia 11 (4-26) mg; erector spinae 11 (10-32); transverse abdominis 9 (4-13) mg; wound catheter infusion 8 (2-15) mg; quadratus lumborum 8 (1-15) mg; wound infiltration 8 (2-13) mg; and no intervention -4 (-10 to 2) mg. Ordered efficacies for injection sites were different for other relevant outcomes, including pain (to 4-6 h and to 24 h) and time to rescue analgesia: there was no single preferred route of injection. The ordered mean (95% credible interval) reduction in dynamic pain scores (0-10 scale) at 24 h compared with placebo were as follows: wound infusion 1.2 (0.2-2.1); erector spinae 1.3 (-0.5 to 3.1); quadratus lumborum 1.0 (0.1-1.8); ilio-inguinal-iliohypogastric 0.6 (-0.5 to 1.8); transverse abdominis 0.6 (-0.1 to 1.2); wound infiltration 0.5 (-0.3 to 1.3); transversalis fascia -0.8 (-3.4 to 1.9); ilio-inguinal -0.9 (-3.6 to 1.7); and no intervention -0.8 (-1.8 to 0.2). We categorised our confidence in effect sizes as low or very low.
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Affiliation(s)
- N P Singh
- Department of Anaesthesia, Maharishi Markandeshwar Institute of Medical Sciences and Research, Maharishi Markandeshwar University, Mullana-Ambala, India
| | - D Monks
- Department of Anesthesia, Washington University, Saint Louis, MO, USA
| | - J K Makkar
- Department of Anaesthesia and Intensive care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - A Palanisamy
- Department of Anesthesia, Washington University, Saint Louis, MO, USA
| | - P Sultan
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA
| | - P M Singh
- Department of Anesthesia, Washington University, Saint Louis, MO, USA
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Sultan P, Jensen SE, Taylor J, El-Sayed Y, Carmichael S, Cella D, Angst MS, Gaudilliere B, Lyell DJ, Carvalho B. Proposed domains for assessing postpartum recovery: a concept elicitation study. BJOG 2021; 129:9-20. [PMID: 34536324 DOI: 10.1111/1471-0528.16937] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 07/07/2021] [Accepted: 07/20/2021] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To propose postpartum recovery domains. DESIGN Concept elicitation study. SETTING Semi-structured interviews. POPULATION Ten writing committee members and 50 stakeholder interviews (23 postpartum women, nine general obstetricians, five maternal and fetal medicine specialists, eight nurses and five obstetric anaesthetists). METHODS Alternating interviews and focus group meetings until concept saturation was achieved (no new themes discussed in three consecutive interviews). Interviews were digitally recorded and transcribed, and an iterative coding process was used to identify domains. MAIN OUTCOME MEASURES The primary outcome was to identify recovery domains. We also report key symptoms and concerns. Discussion frequency and importance scores (0-100; 0 = not important; 100 = vitally important to recovery) were used to rank domains. Discussion frequency was used to rank factors helping and hindering recovery, and to determine the greatest challenges experienced postpartum. RESULTS Thirty-four interviews and two focus group meetings were performed. The 13 postpartum recovery domains identified, (ranked highest to lowest) were: psychosocial distress, surgical/medical factors, infant feeding and breast health, psychosocial support, pain, physical function, sleep, motherhood experience, infant health, fatigue, appearance, sexual function and cognition. The most frequently discussed factors facilitating postpartum recovery were: family support, lactation/breastfeeding support and partner support. The most frequently discussed factor hindering recovery was inadequate social support. The most frequent challenges reported were: breastfeeding (week 1), breastfeeding (week 3) and sleep (week 6). CONCLUSIONS We propose 13 domains that comprehensively describe recovery in women delivering in a single centre within the USA. This provides a novel framework to study the postpartum recovery process. TWEETABLE ABSTRACT We propose 13 postpartum recovery domains that provide a framework to study the recovery process following childbirth.
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Affiliation(s)
- P Sultan
- Department of Anesthesia and Perioperative Pain, Stanford University School of Medicine, Stanford, CA, USA
| | - S E Jensen
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - J Taylor
- Department of Anesthesia and Perioperative Pain, Stanford University School of Medicine, Stanford, CA, USA
| | - Y El-Sayed
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - S Carmichael
- Pediatrics, Obstetrics and Gynecology and Health Research and Policy, Stanford University School of Medicine, Stanford, CA, USA
| | - D Cella
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - M S Angst
- Department of Anesthesia and Perioperative Pain, Stanford University School of Medicine, Stanford, CA, USA
| | - B Gaudilliere
- Department of Anesthesia and Perioperative Pain, Stanford University School of Medicine, Stanford, CA, USA
| | - D J Lyell
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - B Carvalho
- Department of Anesthesia and Perioperative Pain, Stanford University School of Medicine, Stanford, CA, USA
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Sultan P, Ando K, Sultan E, Hawkins J, Blake L, Barwick F, Kawai M, Carvalho B. A systematic review of patient-reported outcome measures used to assess sleep in postpartum women using Consensus Based Standards for the Selection of Health Measurement Instruments (COSMIN) guidelines. Sleep 2021; 44:6278483. [PMID: 34013345 DOI: 10.1093/sleep/zsab128] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/02/2021] [Indexed: 12/12/2022] Open
Abstract
STUDY OBJECTIVES We performed a systematic review to identify the best patient-reported outcome measure (PROM) of postpartum sleep in women. METHODS We searched 4 databases for validated PROMs used to assess postpartum sleep. Studies were considered if they evaluated at least 1 psychometric measurement property of a PROM. An overall rating was assigned for each psychometric measurement property of each PROM based upon COSMIN criteria. A modified GRADE approach was used to assess the level of evidence and recommendations were then made for each PROM. RESULTS We identified 15 validation studies of 8 PROMs, in 9,070 postpartum women. An adequate number of sleep domains was assessed by 5 PROMs: Bergen Insomnia Scale (BIS), Pittsburgh Sleep Quality Index (PSQI), General Sleep Disturbance Scale (GSDS), Athens Insomnia Scale (AIS) and the Sleep Symptom Checklist (SSC). BIS and GSDS were the only PROMs to demonstrate adequate content validity and at least a low level of evidence of sufficient internal consistency, resulting in Class A recommendations. The BIS was the only PROM, which is easily accessible and free to use for non-commercial research, that achieved a Class A recommendation. CONCLUSION The BIS is the best currently available PROM of postpartum sleep. However, this PROM fails to assess several important domains such as sleep duration (and efficiency), chronotype, sleep-disordered breathing and medication usage. Future studies should focus on evaluating the psychometric measurement properties of BIS in the North American setting and in different cultural groups, or to develop a more specific PROM of postpartum sleep.
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Affiliation(s)
- P Sultan
- Associate Professor. Department of Anesthesiology, Perioperative and Pain Medicine. Stanford University School of Medicine, Stanford, CA, USA
| | - K Ando
- Assistant Professor. Department of Anesthesiology, Perioperative and Pain Medicine. Stanford University School of Medicine, Stanford, CA, USA
| | - E Sultan
- Clinical Instructor. Department of Anesthesiology, Perioperative and Pain Medicine. Stanford University School of Medicine, Stanford, CA, USA
| | - J Hawkins
- Medical Student. Stanford University School of Medicine, Stanford, CA, USA
| | - L Blake
- Associate Professor. UAMS Medical Library, UAMS, Little Rock, AR, USA SCIENC ES
| | - F Barwick
- Clinical Associate Professor, Division of Sleep Medicine, Department of Psychiatry and Behavioral Sciences, Stanford University, School of Medicine
| | - M Kawai
- Clinical Associate Professor, Division of Sleep Medicine, Department of Psychiatry and Behavioral Sciences, Stanford University, School of Medicine
| | - B Carvalho
- Professor. Department of Anesthesiology, Perioperative and Pain Medicine. Stanford University School of Medicine, Stanford, CA, USA
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Sultan P, Carvalho B. Pain after vaginal delivery and during breastfeeding: underexplored and underappreciated. Int J Obstet Anesth 2021; 46:102969. [PMID: 33794439 DOI: 10.1016/j.ijoa.2021.102969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/09/2021] [Accepted: 02/16/2021] [Indexed: 10/21/2022]
Affiliation(s)
- P Sultan
- 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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Sultan P, Sultan E, Carvalho B. Regional anaesthesia for labour, operative vaginal delivery and caesarean delivery: a narrative review. Anaesthesia 2021; 76 Suppl 1:136-147. [PMID: 33426655 DOI: 10.1111/anae.15233] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2020] [Indexed: 02/06/2023]
Abstract
This narrative review discusses recent evidence surrounding the use of regional anaesthesia in the obstetric setting, including intrapartum techniques for labour and operative vaginal delivery, and caesarean delivery. Pudendal nerve blockade, ideally administered by an obstetrician, should be considered for operative vaginal delivery if neuraxial analgesia is contraindicated. Regional techniques are increasingly utilised in clinical practice for caesarean delivery to minimise opioid consumption, reduce pain, improve postpartum recovery and facilitate earlier discharge as part of enhanced recovery protocols. The evidence surrounding transversus abdominis plane and quadratus lumborum blockade supports their use when: long-acting neuraxial opioids cannot be administered due to contraindications; if emergency delivery necessitates general anaesthesia; or as a postoperative rescue technique. Current data suggest quadratus lumborum blockade is no more effective than transversus abdominis plane blockade after caesarean delivery. Transversus abdominis plane blockade, wound catheter insertion and single shot wound infiltration are all effective techniques for reducing postoperative opioid consumption, with transversus abdominis plane blockade favoured, followed by wound catheters and then wound infiltration. Ilio-inguinal and iliohypogastric, erector spinae plane and rectus sheath blockade all require further studies to determine their efficacy for caesarean delivery in the presence or absence of long-acting neuraxial opioids. Future studies are needed to: compare approaches for individual techniques; determine which combinations of techniques and dosing regimens result in optimal analgesic and recovery outcomes following delivery; and elucidate the populations that benefit most from regional anaesthesia in the obstetric setting.
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Affiliation(s)
- P Sultan
- Department of Anaesthesia, Stanford University School of Medicine, Stanford, CA, USA
| | - E Sultan
- Department of Anaesthesia, Stanford University School of Medicine, Stanford, CA, USA
| | - B Carvalho
- Department of Anaesthesia, Stanford University School of Medicine, Stanford, CA, USA
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Affiliation(s)
- B Carvalho
- Department of Anesthesiology, Peri-operative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - P Sultan
- Department of Anesthesiology, Peri-operative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Ali I, Sultan P, Aboelmaged M. A bibliometric analysis of academic misconduct research in higher education: Current status and future research opportunities. Account Res 2020; 28:372-393. [PMID: 33048578 DOI: 10.1080/08989621.2020.1836620] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The literature on academic misconduct has seen unprecedented growth over the past 20 years. As the research into this vital topic has grown, there have been a few reviews attempting to consolidate the literature. While the extant reviews have been insightful, a careful analysis reveals that these have somewhat different emphases, methods, and time intervals. Our study employs a bibliometric analysis approach on a large set of studies (779) published between 2000 and 2020. The analysis uncovers the key clusters, countries' co-authorship and evolution of research over the past two decades. It enriches contemporary knowledge on multifaceted issues of academic misconduct and offers resonant insights for academics, students, and policymakers. The paper concludes with several promising opportunities for future research.
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Affiliation(s)
- Imran Ali
- School of Business and Law, Central Queensland University, Rockhampton, Australia
| | - Parves Sultan
- School of Business and Law, Central Queensland University, Rockhampton, Australia
| | - Mohamed Aboelmaged
- College of Business Administration, University of Sharjah, Sharjah, United Arab Emirates
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Al-Sulttan S, Bampoe S, Howle R, Setty T, Columb M, Patel A, Fernando R, Husain T, Sultan P. A prospective, up-down sequential allocation study investigating the effectiveness of vital capacity breaths using high-flow nasal oxygenation versus a tight-fitting face mask to pre-oxygenate term pregnant women. Int J Obstet Anesth 2020; 45:28-33. [PMID: 33129656 DOI: 10.1016/j.ijoa.2020.08.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 08/03/2020] [Accepted: 08/16/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND The role of high flow nasal oxygenation (HFNO) for pre-oxygenation before obstetric general anaesthesia remains unclear. This study aimed to determine the number of vital capacity breaths using HFNO required to pre-oxygenate 90% of parturients to an end-tidal oxygen concentration fraction (FETO2) of ≥0.90 (termed EN90). METHODS Using up-down, sequential allocation trial design, volunteer term parturients undergoing caesarean delivery were investigated with HFNO with their mouth closed, followed by mouth open, and if FETO2 ≥0.90 was not achieved after a maximum of 20 vital capacity breaths, pre-oxygenation was attempted with a face mask. The primary outcome was the number of vital capacity breaths required using HFNO (mouth open and closed) to achieve EN90. Secondary outcomes included assessment of EN90 using mouth open versus mouth closed and face mask pre-oxygenation, maternal satisfaction and evaluation of fetal cardiotocography. RESULTS Twenty women at term were recruited. Successful pre-oxygenation occurred in 4 (20%), 3 (15%) and 14 (70%) women with HFNO mouth closed, HFNO mouth open, and via face mask respectively. At up to 20 vital capacity breaths, face mask pre-oxygenation was more successful at achieving EN90 compared with both HFNO with a closed (P=0.006) or open (P=0.001) mouth. Closed mouth HFNO did not outperform open mouth pre-oxygenation. CONCLUSION Face mask pre-oxygenation is more effective at achieving EN90 compared with to HFNO within a clinically acceptable number of vital capacity breaths. Further studies are needed to determine the role of HFNO in optimising the time before desaturation and for apnoeic oxygenation in term parturients.
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Affiliation(s)
- S Al-Sulttan
- Department of Anaesthesia, University College London NHS Trust, London, UK
| | - S Bampoe
- Department of Anaesthesia, University College London NHS Trust, London, UK; University College London, UK.
| | - R Howle
- Department of Anaesthesia, University College London NHS Trust, London, UK
| | - T Setty
- Anaesthesia, Queens Medical Centre, Nottingham, UK
| | - M Columb
- Anaesthesia & Intensive Care Medicine, University of Manchester Hospitals NHS Foundation Trust, Wythenshawe Hospital, UK
| | - A Patel
- University College London, UK
| | - R Fernando
- The Women's Wellness and Research Centre, Hamad Medical Corporation, Doha, Qatar
| | - T Husain
- Anaesthesia, Ashford & St Peters NHS Foundation Trust, UK
| | - P Sultan
- Stanford University School of Medicine, CA, USA
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Sultan P, Sharawi N, Blake L, Carvalho B. Enhanced recovery after caesarean delivery versus standard care studies: a systematic review of interventions and outcomes. Int J Obstet Anesth 2020; 43:72-86. [DOI: 10.1016/j.ijoa.2020.03.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 03/11/2020] [Accepted: 03/20/2020] [Indexed: 12/16/2022]
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Shalev S, Orbach-Zinger S, Sultan P, Guo N, Ronel I, Davis A, Weiniger CF. Obstetric quality of recovery scoring tool: assessment of validity, reliability and feasibility in an Israeli cesarean delivery population. Int J Obstet Anesth 2020; 44:51. [PMID: 32799064 DOI: 10.1016/j.ijoa.2020.07.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 07/20/2020] [Indexed: 12/26/2022]
Affiliation(s)
- S Shalev
- Division of Anesthesia, Critical Care and Pain, TelAviv Sourasky Medical Center, Israel
| | - S Orbach-Zinger
- Department of Anesthesia, Rabin Medical Centre and Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - P Sultan
- Division of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA
| | - N Guo
- Division of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA
| | - I Ronel
- Division of Anesthesia, Critical Care and Pain, Tel Aviv Sourasky Medical Center, Israel
| | - A Davis
- Department of Anesthesia, Rabin Medical Centre and Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - C F Weiniger
- Division of Anesthesia, Critical Care and Pain, Tel Aviv Sourasky Medical Center, Israel.
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Howle R, Sultan P, Shah R, Sceales P, Van de Putte P, Bampoe S. Gastric point-of-care ultrasound (PoCUS) during pregnancy and the postpartum period: a systematic review. Int J Obstet Anesth 2020; 44:24-32. [PMID: 32693329 DOI: 10.1016/j.ijoa.2020.05.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 05/12/2020] [Accepted: 05/19/2020] [Indexed: 11/18/2022]
Abstract
Personalised risk assessment of the likelihood of pulmonary aspiration is recommended for pregnant women undergoing general anaesthesia and gastric point-of-care ultrasound (PoCUS) may help to achieve this. Traditionally, risk assessment is based upon adherence to fasting times, but gastric emptying may vary during pregnancy and surgery often needs to be expedited. We systematically reviewed the evidence for gastric PoCUS up to August 2018 in pregnant and postpartum women to determine whether it can identify and quantify stomach contents, provide aspiration risk assessment via qualitative or quantitative means, and determine how gastric emptying is affected by pregnancy. Twenty-two articles comprising 1050 participants were included and studies were classified by qualitative or quantitative findings. The evidence suggests that gastric PoCUS is a reliable and feasible method of imaging the stomach in pregnancy in clinical practice. Qualitative assessment via the Perlas grading system can provide rapid assessment of gastric volume states. If fluid is visible, identification of patients at high risk of pulmonary aspiration requires measurement of antral cross-sectional area. Cut-off values of 608 mm2 and 960 mm2 are recommended in the semi-recumbent and right lateral semi-recumbent positions, respectively. Validated methods to quantify stomach volumes are available, however their usefulness is currently restricted to research. Gastric PoCUS also provides evidence that gastric emptying of ingested food is delayed by term pregnancy, labour and during the early postpartum period. However, the passage of fluids through the stomach appears unaffected throughout the peripartum period.
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Affiliation(s)
- R Howle
- University College Hospital, London, UK
| | - P Sultan
- Stanford University School of Medicine, CA, USA; University College London, London, UK
| | - R Shah
- Royal Free Hospital, London, UK
| | - P Sceales
- University College Hospital, London, UK; University College London, London, UK.
| | | | - S Bampoe
- University College Hospital, London, UK; University College London, London, UK
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El-Boghdadly K, Desai N, Halpern S, Blake L, Odor PM, Bampoe S, Carvalho B, Sultan P. Quadratus lumborum block vs. transversus abdominis plane block for caesarean delivery: a systematic review and network meta-analysis . Anaesthesia 2020; 76:393-403. [PMID: 32621529 DOI: 10.1111/anae.15160] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2020] [Indexed: 12/12/2022]
Abstract
Caesarean delivery is the most commonly performed inpatient surgical procedure globally. Pain after caesarean delivery is moderate to severe if not adequately treated, and is a primary anaesthetic concern for patients. Transversus abdominis plane and quadratus lumborum blocks are fascial plane blocks that have the potential to improve analgesia following caesarean delivery. Although proponents of the quadratus lumborum block suggest that this technique may provide better analgesia compared with transversus abdominis plane block, there are limited data directly comparing these two techniques. We, therefore, performed a systematic review and network meta-analysis to compare transversus abdominis plane and quadratus lumborum block approaches, seeking randomised controlled trials comparing both techniques to each other, or to control, with or without intrathecal morphine. In all, 31 trials with 2188 patients were included and our primary outcome, the cumulative intravenous morphine equivalent consumption at 24 h, was reported in 12 trials. In the absence of intrathecal morphine, transversus abdominis plane and quadratus lumborum blocks were equivalent, and both were superior to control (moderate-quality evidence). In the presence of intrathecal morphine, no differences were found between control, transversus abdominis plane and quadratus lumborum blocks (moderate-quality evidence). Similar results were found for resting and active pain scores at 4-6 h, 8-12 h, 24 h and 36 h, although quadratus lumborum block was associated with lower pain scores at 36 h when compared with transversus abdominis plane block (very low-quality evidence). However, transversus abdominis plane block was associated with a reduced incidence of postoperative nausea and vomiting (moderate-quality evidence) and sedation when compared with inactive control following intrathecal morphine administration (low-quality evidence). There are insufficient data to draw definitive conclusions, but transversus abdominis plane and quadratus lumborum block appear to be superior to control in the absence of intrathecal morphine, but provide limited additional benefit over inactive control when intrathecal morphine is also used.
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Affiliation(s)
- K El-Boghdadly
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK.,King's College London, UK
| | - N Desai
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK.,King's College London, UK
| | - S Halpern
- Department of Anesthesiology, and Pain Medicine, University of Toronto, ON, Canada
| | - L Blake
- University of Arkansas for Medical Sciences Library, Little Rock, AR, USA
| | - P M Odor
- Department of Anaesthesia, University College Hospital, London, UK
| | - S Bampoe
- Department of Anaesthesia, University College Hospital, London, UK
| | - B Carvalho
- Department of Anesthesiology, Stanford University, CA, USA
| | - P Sultan
- Department of Anesthesiology, Stanford University, CA, USA
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Sultan P, Tarafder T, Pearson D, Henryks J. Intention-behaviour gap and perceived behavioural control-behaviour gap in theory of planned behaviour: moderating roles of communication, satisfaction and trust in organic food consumption. Food Qual Prefer 2020. [DOI: 10.1016/j.foodqual.2019.103838] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Patel S, Sharawi N, Sultan P. Local anaesthetic techniques for post-caesarean delivery analgesia. Int J Obstet Anesth 2019; 40:62-77. [DOI: 10.1016/j.ijoa.2019.06.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 05/21/2019] [Accepted: 06/03/2019] [Indexed: 12/12/2022]
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Sharawi N, Klima L, Shah R, Blake L, Carvalho B, Sultan P. Evaluation of patient‐reported outcome measures of functional recovery following caesarean section: a systematic review using the consensus‐based standards for the selection of health measurement instruments (COSMIN) checklist. Anaesthesia 2019; 74:1439-1455. [DOI: 10.1111/anae.14807] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2019] [Indexed: 12/12/2022]
Affiliation(s)
- N. Sharawi
- Department of Anesthesiology University of Arkansas for Medical Sciences Little Rock AR USA
| | - L. Klima
- Department of Anesthesiology University of Arkansas for Medical Sciences Little Rock AR USA
| | - R. Shah
- Department of Anaesthesia University College London Hospital LondonUK
| | - L. Blake
- University of Arkansas for Medical Sciences Little Rock ARUSA
| | - B. Carvalho
- Stanford University School of Medicine Stanford CAUSA
| | - P. Sultan
- Stanford University School of Medicine Stanford CA USA
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Ciechanowicz S, Setty T, Robson E, Sathasivam C, Chazapis M, Dick J, Carvalho B, Sultan P. Development and evaluation of an obstetric quality-of-recovery score (ObsQoR-11) after elective Caesarean delivery. Br J Anaesth 2019; 122:69-78. [DOI: 10.1016/j.bja.2018.06.011] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 05/18/2018] [Accepted: 06/25/2018] [Indexed: 12/29/2022] Open
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del Arroyo A, Sanchez J, Patel S, Phillips S, Reyes A, Cubillos C, Fernando R, David A, Sultan P, Ackland G, Reeve A, Sodha S, Ciechanowicz S, Olearo E, Dick J, Stewart A. Role of leucocyte caspase-1 activity in epidural-related maternal fever: a single-centre, observational, mechanistic cohort study. Br J Anaesth 2019; 122:92-102. [DOI: 10.1016/j.bja.2018.09.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 09/03/2018] [Accepted: 09/24/2018] [Indexed: 01/19/2023] Open
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Sultan P, Carvalho B. Does the addition of active body warming to in-line intravenous fluid warming prevent maternal hypothermia during elective caesarean section? A randomised controlled trial. Int J Obstet Anesth 2018; 35:115-116. [DOI: 10.1016/j.ijoa.2017.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 09/28/2017] [Accepted: 11/29/2017] [Indexed: 11/30/2022]
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Howle R, Ciechanowicz S, Heppolette C, Nakhjavani B, Sultan P. Validation of an obstetric quality-of-recovery scoring tool (ObsQoR-11) after emergency Caesarean delivery. Br J Anaesth 2018. [DOI: 10.1016/j.bja.2018.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Pushpanathan E, Setty T, Carvalho B, Sultan P. A Systematic Review of Postoperative Pain Outcome Measurements Utilised in Regional Anesthesia Randomized Controlled Trials. Anesthesiol Res Pract 2018; 2018:9050239. [PMID: 30151005 PMCID: PMC6087609 DOI: 10.1155/2018/9050239] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 06/24/2018] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Regional anesthesia is a rapidly growing subspecialty. There are few published meta-analyses exploring pain outcome measures utilised in regional anesthesia randomized controlled trials (RCTs), which may be due to heterogeneity in outcomes assessed. This systematic review explores postoperative pain outcomes utilised in regional anesthesia RCTs. METHODS A literature search was performed using three databases (Medline, Embase, and CINAHL). Regional anesthesia RCTs with postoperative pain as a primary outcome were included if written in English and published in one of the top 20 impact factor journals between 2005 and 2017. Study quality was assessed using the Cochrane Collaboration's tool for assessing risk of bias. RESULTS From the 31 included articles, 15 different outcome measures in total were used to assess postoperative pain. The most commonly (16/31) used outcome measures were verbal numerical grading of pain out of 10, total opioid consumption, and visual analogue scale 10 cm (VAS). The need for analgesia was used as an outcome measure where studies did not use a pain rating score. Ten studies reported pain scores on activity and 27/31 studies utilised ≥2 pain outcomes. Time of measurement of pain score also varied with a total of 51 different time points used in total. CONCLUSION Analysis of the articles demonstrated heterogeneity and inconsistency in choice of pain outcome and time of measurement within regional anesthesia studies. Identification of these pain outcomes utilised can help to create a definitive list of core outcomes, which may guide future researchers when designing such studies.
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Affiliation(s)
- E. Pushpanathan
- Department of Anaesthesia, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - T. Setty
- Department of Anaesthesia, University College Hospitals London NHS Foundation Trust, London, UK
| | - B. Carvalho
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA
| | - P. Sultan
- Department of Anaesthesia, University College Hospitals London NHS Foundation Trust, University College London, London, UK
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Palmer E, Ciechanowicz S, Reeve A, Harris S, Wong DJN, Sultan P. Operating room-to-incision interval and neonatal outcome in emergency caesarean section: a retrospective 5-year cohort study. Anaesthesia 2018; 73:825-831. [DOI: 10.1111/anae.14296] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2018] [Indexed: 11/29/2022]
Affiliation(s)
- E. Palmer
- Department of Anaesthesia; University College London Hospital; London UK
- Division of Medicine; University College London; London UK
| | - S. Ciechanowicz
- Department of Anaesthesia; University College London Hospital; London UK
| | - A. Reeve
- Department of Anaesthesia; University College London Hospital; London UK
| | - S. Harris
- Department of Anaesthesia; University College London Hospital; London UK
- Division of Medicine; University College London; London UK
| | - D. J. N. Wong
- Surgical Outcomes Research Centre; University College London / University College London Hospital; London UK
| | - P. Sultan
- Department of Anaesthesia; University College London Hospital; London UK
- Division of Medicine; University College London; London UK
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Ng S, Habib A, Sodha S, Carvalho B, Sultan P. High-dose versus low-dose local anaesthetic for transversus abdominis plane block post-Caesarean delivery analgesia: a meta-analysis. Br J Anaesth 2018; 120:252-263. [DOI: 10.1016/j.bja.2017.11.084] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 08/29/2017] [Accepted: 08/29/2017] [Indexed: 10/18/2022] Open
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Affiliation(s)
- P Sultan
- Department of Anaesthesia, University College London Hospital, London, UK
| | - A S Habib
- Department of Anesthesia, Duke University School of Medicine, Durham, NC, USA
| | - B Carvalho
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA
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Rahman S, Walker D, Sultan P. Medical identification or alert jewellery: an opportunity to save lives or an unreliable hindrance? Anaesthesia 2017; 72:1139-1145. [DOI: 10.1111/anae.13958] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2017] [Indexed: 11/30/2022]
Affiliation(s)
- S. Rahman
- Department of Anaesthesia; Royal Free Hospital; Pond Street London UK
| | - D. Walker
- Department of Anaesthesia; University College London Hospitals; London UK
| | - P. Sultan
- Department of Anaesthesia; University College London Hospitals; London UK
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Phillips S, Subair S, Husain T, Sultan P. Apnoeic oxygenation during maternal cardiac arrest in a parturient with extreme obesity. Int J Obstet Anesth 2017; 29:88-90. [DOI: 10.1016/j.ijoa.2016.11.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 11/10/2016] [Indexed: 01/04/2023]
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Duffield A, Sultan P, Riley ET, Carvalho B. Optimal administration of cefazolin prophylaxis for cesarean delivery. J Perinatol 2017; 37:16-20. [PMID: 28050017 DOI: 10.1038/jp.2016.210] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 10/07/2016] [Accepted: 10/14/2016] [Indexed: 11/09/2022]
Affiliation(s)
- A Duffield
- Department of Anesthesiology, Sentara Martha Jefferson Hospital, Charlottesville, VA, USA
| | - P Sultan
- Department of Anaesthesia and Perioperative Medicine, University College London Hospital, London, UK
| | - E T Riley
- 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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Sultan P, Habib A, Carvalho B. Reply. Br J Anaesth 2016; 117:676-677. [DOI: 10.1093/bja/aew351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Sultan P, Habib AS, Cho Y, Carvalho B. The Effect of patient warming during Caesarean delivery on maternal and neonatal outcomes: a meta-analysis. Br J Anaesth 2015; 115:500-10. [PMID: 26385660 DOI: 10.1093/bja/aev325] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Perioperative warming is recommended for surgery under anaesthesia, however its role during Caesarean delivery remains unclear. This meta-analysis aimed to determine the efficacy of active warming on outcomes after elective Caesarean delivery. METHODS We searched databases for randomized controlled trials utilizing forced air warming or warmed fluid within 30 min of neuraxial anaesthesia placement. Primary outcome was maximum temperature change. Secondary outcomes included maternal (end of surgery temperature, shivering, thermal comfort, hypothermia) and neonatal (temperature, umbilical cord pH and Apgar scores) outcomes. Standardized mean difference/mean difference/risk ratio (SMD/MD/RR) and 95% confidence interval (CI) were calculated using random effects modelling (CMA, version 2, 2005). RESULTS 13 studies met our criteria and 789 patients (416 warmed and 373 controls) were analysed for the primary outcome. Warming reduced temperature change (SMD -1.27°C [-1.86, -0.69]; P=0.00002); resulted in higher end of surgery temperatures (MD 0.43 °C [0.27, 0.59]; P<0.00001); was associated with less shivering (RR 0.58 [0.43, 0.79]; P=0.0004); improved thermal comfort (SMD 0.90 [0.36, 1.45]; P=0.001), and decreased hypothermia (RR 0.66 [0.50, 0.87]; P=0.003). Umbilical artery pH was higher in the warmed group (MD 0.02 [0, 0.05]; P=0.04). Egger's test (P=0.001) and contour-enhanced funnel plot suggest a risk of publication bias for the primary outcome of temperature change. CONCLUSIONS Active warming for elective Caesarean delivery decreases perioperative temperature reduction and the incidence of hypothermia and shivering. These findings suggest that forced air warming or warmed fluid should be used for elective Caesarean delivery.
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Affiliation(s)
- P Sultan
- Department of Anaesthesia, University College London Hospital, London, UK
| | - A S Habib
- Department of Anesthesia, Duke University School of Medicine, Durham, NC, USA
| | - Y Cho
- Pacific Alliance Medical Center, Los Angeles, CA, USA
| | - B Carvalho
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA
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Elkomy MH, Sultan P, Carvalho B, Peltz G, Wu M, Clavijo C, Galinkin JL, Drover DR. Ondansetron pharmacokinetics in pregnant women and neonates: towards a new treatment for neonatal abstinence syndrome. Clin Pharmacol Ther 2014; 97:167-76. [PMID: 25670522 DOI: 10.1002/cpt.5] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 09/27/2014] [Indexed: 11/10/2022]
Abstract
Ondansetron is the drug of choice to prevent nausea in women undergoing cesarean surgery and can be used to prevent neonatal abstinence syndrome (NAS). The pharmacokinetics of ondansetron have not been characterized in pregnant women or in newborns. A nonlinear mixed-effects modeling approach was used to analyze plasma samples obtained from 20 nonpregnant and 40 pregnant women following a single administration of 4 or 8 mg ondansetron, from umbilical cord blood at delivery, and from neonates after birth. The analysis indicates that: ondansetron disposition is not affected by pregnancy (P > 0.05), but influenced by dose (P < 0.05), and is characterized by rapid transplacental transfer and longer elimination half-life in neonates compared to their mother. A dosing regimen for prevention of NAS was designed based on the model. The regimen involves IV administration of 4 mg to the mothers shortly before cord clamping, or oral administration of 0.07 mg/kg (or equivalently 0.04 mg/kg IV) to neonates.
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Affiliation(s)
- M H Elkomy
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California, USA; Department of Pharmaceutics and Industrial Pharmacy, Beni Suef University, Beni Suef, Egypt
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Soltanifar D, Jacobs M, Jones T, McGlennan A, Sultan P. Spinal anaesthesia for emergency caesarean delivery in a parturient with falciparum malaria. Int J Obstet Anesth 2014; 24:91. [PMID: 25433574 DOI: 10.1016/j.ijoa.2014.07.003] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 07/08/2014] [Accepted: 07/12/2014] [Indexed: 10/25/2022]
Affiliation(s)
- D Soltanifar
- Department of Anaesthetics, Royal Free Hospital, London, UK.
| | - M Jacobs
- Department of Anaesthetics, Royal Free Hospital, London, UK
| | - T Jones
- Department of Anaesthetics, Royal Free Hospital, London, UK
| | - A McGlennan
- Department of Anaesthetics, Royal Free Hospital, London, UK
| | - P Sultan
- Department of Anaesthetics, Royal Free Hospital, London, UK
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Soltanifar D, Afzal S, Harrison S, Sultan P. Caesarean delivery in a parturient with type III hereditary angioedema. Int J Obstet Anesth 2014; 23:398-9. [DOI: 10.1016/j.ijoa.2014.05.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 05/28/2014] [Accepted: 05/29/2014] [Indexed: 11/24/2022]
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Abstract
Purpose
– The purpose of this paper is to develop and test an integrated-process model/an index model by incorporating the antecedents and consequences of service quality in a higher education context.
Design/methodology/approach
– This research employed both qualitative and quantitative research methods. The data from three focus groups, conducted at an Australian University, generated key themes and their interrelationships. The theoretical model was then tested using the structural equation modelling (SEM) technique on a sample of 528 University students.
Findings
– The findings show that information (or marketing communications) and past experience are the antecedents of perceived service quality (PSQ). PSQ is a second order construct and has three dimensions: academic, administrative and facilities. The consequences of PSQ include trust, satisfaction, university-brand (UniBrand) performance and behavioural intentions. Overall, the results suggest a good validity of the model, and the nine path coefficients are found statistically significant.
Originality/value
– The model explains how service quality is formed, and how PSQ affects UniBrand and positive behavioural intentions overtime. This paper develops and validates three new constructs including information, past experience and UniBrand performance. In addition, it improves and validates other constructs including service quality, satisfaction, trust and behavioural intention. The paper also advances service quality literature and validates five hypothesised relationships between constructs that are relatively new in the service quality literature. Finally, this study validates a comprehensive three-tiered “integrated-process” model/an index model that includes antecedents, dimensions and consequences of service quality taking a University as a case. Universities aiming for a sustainable presence in a competitive global market and intending to enhance brand performance and attract and retain students are encouraged to consider this model and its implications.
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Sultan P, Arulkumaran N, Rhodes A. Provision of critical care services for the obstetric population. Best Pract Res Clin Obstet Gynaecol 2013; 27:803-9. [PMID: 23972289 DOI: 10.1016/j.bpobgyn.2013.07.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Revised: 07/07/2013] [Accepted: 07/22/2013] [Indexed: 10/26/2022]
Abstract
Management of the peripartum patient is a challenging aspect of critical care that requires consideration of both the physiological changes associated with pregnancy as well as the well-being of the foetus. In the UK, for every maternal death, approximately 118 near-miss events or severe acute maternal morbidities (SAMMs) occur. While a dedicated anaesthetic cover is usually provided on larger labour wards in the UK and US, a close communication with intensive care and other medical specialties must still be maintained. Medical outreach teams and early warning scores may help facilitate the early identification of clinical deterioration and prompt treatment. Ultimately level of care is allocated according to the clinical need, not the location, which may be a designated room, a normal labour room or a recovery area. Specialist obstetric units that provide high-dependency care facilities show lower rates of maternal transfer to critical care units and improved continuity of care before and after labour. The benefits of obstetric high-dependency units (HDUs) are likely to be determined by a number of logistic aspects of the hospital organisation, including hospital size and available resources. There remains a striking contrast in the burden of maternal mortality and morbidity and intensive care unit (ICU) resources between high- and low-income countries. The countries with the highest maternal mortality rates have the lowest number of ICU beds per capita. In under-resourced countries, patients admitted to ICUs tend to have higher illness severity scores, suggesting delayed admission to the ICU. The appropriate training of midwives is essential for successful HDUs located within labour wards.
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Affiliation(s)
- P Sultan
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK.
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Affiliation(s)
- M Ramadan
- University College Hospital, London NW1 2BU
| | | | - P Sultan
- University College Hospital, London
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