Incidence and clinical impact of aspiration during cesarean delivery: A multi-center retrospective study

BACKGROUND

The risk of aspiration during general anesthesia for cesarean delivery has long been thought to be increased due to factors such as increased intra-abdominal pressures and delayed gastric emptying in pregnant patients. However, recent studies have reported normal gastric emptying in pregnant patients, suggesting that the risk of aspiration may not be as high as previously believed.

METHODS

We conducted a retrospective study of 48,609 cesarean deliveries, of which 22,690 (46.7%) were performed under general anesthesia at two large tertiary medical centers in Israel. The study aimed to examine the incidence of potentially severe aspiration during cesarean delivery, both under general and neuraxial anesthesia.

RESULTS

Among the patients included in the study, three were admitted to the intensive care unit due to suspected pulmonary aspiration. Two of these cases occurred during induction of general anesthesia for emergency cesarean delivery associated with difficult intubation and one under deep sedation during spinal anesthesia. The incidence of aspiration during cesarean delivery during general anesthesia in our study was 1 in 11,345 patients, and the incidence of aspiration during neuraxial anesthesia was 1 in 25,929 patients. No deaths due to aspiration were reported during the study period.

CONCLUSIONS

Our findings provide another contemporary analysis of aspiration rates in obstetric patients, highlighting increased risks during the management of difficult airways during general anesthesia and deep sedation associated with neuraxial anesthesia.

Anesthetic Approaches and Perioperative Complications of Total Hip Arthroplasty in Gaucher Disease: A Control-Matched Retrospective-Cohort Study

OBJECTIVES

Gaucher disease's (GD) pathophysiology generates anesthetic concerns in total hip joint arthroplasty (THA), and due to its rareness, data on perioperative risks are scarce. This 22-year study at a large reference center addresses anesthetic management and perioperative outcomes in GD.

METHODS

This retrospective-cohort study assessed anesthetic success and safety in 30 THA patients, comparing them with a control-matched group. Data on clinical characteristics, perioperative events, and outcomes were collected. The primary outcome was the success rate of anesthesia induction performance at first attempt. Secondary outcomes were difficult intraoperative course and hemodynamic management, and the development of postoperative complications. The age, sex, weight, body mass index, and primary-to-revision hip arthroplasty ratio were similar in both groups.

RESULTS

There was no significant difference at all-type anesthesia first initiation attempt success. No particular preference by staff anesthetists for general anesthesia or neuraxial procedures was observed. The GD group showed a significantly higher mean of intraoperative packed Red Blood Cell units administered ((0.73 vs. 0.18); (p = 0.038)), higher intraoperative and postoperative platelet transfusion incidence ((5/30 [16.7%] vs. 0/56 [0.00%]; p = 0.004) and (3/30 [10%] vs. 0/56 [0%]; p = 0.040)), and longer mean recovery room length of stay (426 ± 412 vs. 175 ± 140; p = 0.004). Postoperative complications were not significantly different.

Automating medical simulations

OBJECTIVE

This study aims to explore speech as an alternative modality for human activity recognition (HAR) in medical settings. While current HAR technologies rely on video and sensory modalities, they are often unsuitable for the medical environment due to interference from medical personnel, privacy concerns, and environmental limitations. Therefore, we propose an end-to-end, fully automatic objective checklist validation framework that utilizes medical personnel's uttered speech to recognize and document the executed actions in a checklist format.

METHODS

Our framework records, processes, and analyzes medical personnel's speech to extract valuable information about performed actions. This information is then used to fill the corresponding rubrics in the checklist automatically.

RESULTS

Our approach to activity recognition outperformed the online expert examiner, achieving an F1 score of 0.869 on verbal tasks and an ICC score of 0.822 with an offline examiner. Furthermore, the framework successfully identified communication failures and medical errors made by physicians and nurses.

CONCLUSION

Implementing a speech-based framework in medical settings, such as the emergency room and operation room, holds promise for improving care delivery and enabling the development of automated assistive technologies in various medical domains. By leveraging speech as a modality for HAR, we can overcome the limitations of existing technologies and enhance workflow efficiency and patient safety.

Obstetric anaesthesia manpower and service provision issues (introduction and European perspective)

Global health is an important and far-reaching concept in which health and access to surgical and anaesthetic care is crucial. Universal access to anaesthesia is a challenge in many countries. Manpower shortages are an important cause of difficulties and each European country has found different ways of facing a lack of healthcare professionals. In obstetric anaesthesia, the availability of competent anaesthesiologists has been related to the morbidity and mortality outcomes of patients. In this narrative review, authors from different European countries explain how manpower is managed in obstetric anaesthesia in delivery suites and obstetric operating rooms in different settings. To address manpower difficulties and issues, the goals are to achieve a minimum standard of care and at the same time, to promote clinical excellence through training, delegation to younger or less experienced colleagues, direct or at-a-distance supervision, or other means. The experience of sharing knowledge about the way in which manpower and service provision are organised in other healthcare settings is a significant opportunity to develop strategies for advancing tomorrow's obstetric anaesthesia in the world. While taking into account the level of socio-economic development in different countries, the aim is to standardise practice and workload organisation. Co-operative international projects in training and education in obstetric anaesthesia are ways in which better obstetric patient care can be achieved in the future.

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in the Multidisciplinary Management of Morbidly Adherent Placenta

BACKGROUND

Morbidly adherent placentation (MAP) increases the risk for obstetric hemorrhage. Cesarean hysterectomy is the prevalent perioperative approach. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive and relatively simple endovascular procedure to temporarily occlude the aorta and control below diaphragm bleeding in trauma. It has been effectively used to reduce obstetric hemorrhage.

OBJECTIVES

To evaluate whether REBOA during cesarean delivery (CD) in women with morbidly adherent placentation is a safe and effective treatment modality.

METHODS

We introduced REBOA for CD with antepartum diagnosis of MAP in 2019 and compared these patients (RG) to a standard approach group (SAG) treated in our center over the preceding year, as a control. All relevant data were collected from patient electronic files.

RESULTS

Estimated blood loss and transfusion rates were significantly higher in SAG; 54.5% of SAG patients received four RBC units or more vs. one administered in RG. No fresh frozen plasma, cryoprecipitate, or platelets were administered in RG vs. mean 3.63, 6, and 3.62 units, respectively in SAG. Ten SAG patients (90.9%) underwent hysterectomy vs. 3 RG patients (30%). Five SAG patients (45%) required post-surgical intensive care unit (ICU) admission vs. no RG patients. Bladder injury occurred in five SAG cases (45%) vs. 2 RG (20%). One RG patient had a thromboembolic event. Perioperative lactate levels were significantly higher in SAG patients.

CONCLUSIONS

Use of REBOA during CD in women with MAP is safe and effective in preventing massive bleeding, reducing the rate of hysterectomy, and improving patient outcome.

The anesthetic approach to a patient with placenta accreta spectrum

PURPOSE OF REVIEW

Placenta accreta poses significant risk of morbidity and mortality to a laboring patient. Here we review available treatment options, highlight trends in bleeding prevention and diagnosis that have been shown to improve patient outcome, and provide best practice suggestions. We also discuss the decision-making process for choice of anesthesia, as it is not based on a gold-standard paradigm.

RECENT FINDINGS

The use of resuscitative endovascular balloon occlusion of the aorta has been gaining popularity around the world. It has been shown to cause an equivocal reduction in perioperative bleeding in placenta accreta spectrum (PAS), reduce the rate of hysterectomies, and is a safe and relatively easy technique. There are other invasive radiology techniques that have also proven to be beneficial in bleeding prevention: balloon occlusion of hypogastric arteries intraoperatively, internal iliac artery embolization, and intraoperative ligation of the hypogastric or uterine arteries.

SUMMARY

Optimal management of PAS begins with early and definitive diagnosis. A multidisciplinary approach along with preparation of special equipment and the use of a check-list maximize the chance for success. Anesthesia could be done with all types of regional or under general, considering case-by-case factors but most importantly choosing according to the institution's best facility and skill.

Incidence of conversion to general anaesthesia and need for intravenous supplementation in parturients undergoing caesarean section under spinal anaesthesia: A retrospective observational study

BACKGROUND

Conversion from spinal anaesthesia to general anaesthesia (GA) was shown to be associated with more complications. It has been postulated that spinal injection of a low dose of local anaesthetic is a risk factor. We aimed to discover the rate of conversion from spinal anaesthesia to GA in women who received at least 10 mg heavy bupivacaine and opioids and assess its risk factors.

METHODS

All women that underwent spinal anaesthesia for caesarean section from 1 January 2017 to 31 December 2020 were included in this analysis. Spinal anaesthesia was performed according to department protocol using heavy bupivacaine 0.5% 10-13 mg, fentanyl 20 μg, and morphine 0.1 mg. We examined rate of conversion from spinal anaesthesia to GA and rate of need for analgesia/sedation.

RESULTS

There were 1.7% of women that required conversion to GA. Bupivacaine dose (OR 0.54 [95% CI 0.38 to 0.75], p < 0.001), surgery time (OR 1.03 [95% CI 1.02 to 1.04], p < 0.001), emergency caesarean section (OR 1.06 [95% CI 1.16 to 3.76], p = 0.015), and postpartum haemorrhage (OR 5.96 [95% CI 1.09 to 25.18], p = 0.025) were independent predictors of need for conversion to GA. Of the women who had CS under spinal anaesthesia, 4.1% of parturients required intraoperative analgesics/sedatives and 9.1% required anxiolysis.

CONCLUSIONS

A small proportion of women required conversion to GA. This conversion occurred especially with emergency caesarean section and when low spinal bupivacaine doses were used.

A multicenter interdisciplinary survey of practices and opinions regarding oral intake during labor

INTRODUCTION

Different society guidelines diverge regarding oral intake in labor. Our goal was to assess practices and opinions in Israeli labor and delivery units, comparing different disciplines.

METHODS

An anonymous Google Forms survey was sent to anesthesiologists, obstetricians and midwives in all Israeli labor and delivery units.

RESULTS

Responses were collected from all 27 labor and delivery units contacted, with a total of 501 respondents comprising 161 anesthesiologists, 102 obstetricians and 238 midwives. Forty-eight per cent stated there were no institutional guidelines for oral intake. The most common oral intake permitted was light food (60%). Midwives were significantly more likely than anesthesiologists and obstetricians to consider that women who are both low risk for cesarean delivery (P <0.00001) and high risk for cesarean delivery (P=0.001) should eat. Epidural analgesia did not impact recommendations regarding oral intake. The most common reasons for restricting oral intake were obstetric. Sixty-two per cent identified aspiration as the main risk associated with eating during labor, but 19% of midwives compared with 4% of anesthesiologists and obstetricians stated there were no risks (P <0.00001). The annual delivery volume of the unit did not impact staff practices.

CONCLUSIONS

There was a discrepancy between opinions and practices across all disciplines. Permissive practices identified in this survey should be addressed to find the safe middle ground between restrictive and permissive policies for low- and high-risk women.

Post-cesarean ileus: An assessment of incidence, risk factors and outcomes

OBJECTIVE

To estimate the frequency of post cesarean paralytic ileus and to identify associated risk factors and outcomes.

STUDY DESIGN

A retrospective cohort study of woman who underwent cesarean delivery between 2005 and 2019. All parturients who had cesarean delivery were stratified and compared according to whether or not they were diagnosed with a paralytic ileus. Women were excluded if they had an intestinal injury or repair during the cesarean or if they suffered from a post cesarean mechanical bowel obstruction diagnosed during re-laparotomy. Basic demographics, obstetric history, current delivery characteristics, re-suturing indications and outcomes were obtained and analyzed. Univariate analyses were followed by a multivariate analysis (adjusted Odds Ratio (aORs) ; [95% Confidence Interval]).

RESULTS

A total of 23,486 women met the inclusion and exclusion criteria of which 135 (0.6%) were diagnosed with paralytic ileus whilst 23,347 (99.4%) did not and served as the control group. Multivariate analysis revealed that an estimated intra-operative blood loss ≥ 1000 ml was the most significant risk factor for post cesarean paralytic ileus (aOR 2.27 (1.18-4.36)), followed by multifetal gestation (aOR 2.08 (1.24-3.51)), corporeal uterine incision (aOR 1.97 (1.07-3.63)), use of topical hemostatic agents (aOR 1.78 (1.19-2.66)) and increasing maternal age (aOR 1.78 (1.19-2.66)). Regarding maternal outcomes, post cesarean paralytic ileus was associated with higher rates of postpartum hemorrhage (44.4% vs. 13.4%, p < 0.01), transfusion of blood products (23.7% vs. 3.9%, p < 0.01), post-cesarean exploratory laparotomy (4.4% vs. 0.1%, p < 0.01) and prolonged hospital stay (32.6% vs. 5.2%, p < 0.01).

CONCLUSION

In our population, whilst post cesarean paralytic ileus is infrequent, when it occurs it is associated with increased short-term maternal morbidity.

Peripartum anesthetic management of patients with inflammatory bowel disease, a retrospective case-control study

OBJECTIVE

Inflammatory bowel diseases (IBD) are a group of pathologies associated with an increased rate of abortions, premature deliveries, cesarean sections and other morbidity during the peripartum period. The objective of this retrospective study was to investigate the anesthetic management for delivery of women with IBD.

MATERIAL AND METHODS

The records of patients with IBD, who delivered at our Center, were obtained for data which included anesthetic and obstetric management as well as neonatal outcome. Five subgroups were defined based on mode of delivery, presence or absence of epidural in normal vaginal delivery (NVD) and urgency of cesarean section, each of which was compared with control groups of healthy parturients in the same period. Additionally, the rate of cesarean sections and the use of epidural analgesia for NVD were compared with the general obstetric population of our center in the same period.

RESULTS

107 patients with IBD who delivered at our center were studied. The rates of cesarean sections and emergency cesarean sections were significantly higher compared to the general population. However, the rate of instrumental delivery and of epidural analgesia use for NVD were similar. Among those who underwent cesarean sections, no significant differences were found in anesthesia type, surgery duration, number of complications, type of monitoring or postoperative management compared to the control group.

CONCLUSION

Peripartum anesthetic management of patients with IBD does not differ significantly from that of parturients without it. Anesthesiologists can plan their anesthesia in a similar way as they do in healthy parturients.

Chronic pain in parturients with an accidental dural puncture: A case-controlled prospective observational study

BACKGROUND

We set out to examine incidence of chronic headache and back pain in women with PDPH after accidental dural puncture during labor.

METHODS

Chronic headache, backache, and disability were assessed 18-24 months postpartum. Women with PDPH treated with epidural blood patch (PDPH-EBP) were identified and matched with women who had a PDPH without epidural blood patch (PDPH-no EBP), with women with uncomplicated epidural analgesia and with women without epidural analgesia. Our primary outcome was incidence of chronic headache and backache. Secondary outcome was the effect of epidural blood patch on chronic pain development. We used Chi-square or Fisher's exact test to calculate odds ratios.

RESULTS

There was no statistically significant difference in demographic characteristics between groups. In the no epidural group, no women reported chronic headache and 2/116 (1.7%) reported chronic backache. In the uncomplicated epidural group, no women reported chronic headache and 7/116 (6.0%) reported chronic backache. In the PDPH-no EBP group, 9/56 (16.1%) women reported chronic headache and 10/56 (17.9%) reported chronic backache. In the PDPH-EBP group, 12/59 (20.3%) had chronic headache and 14/59 (23.7%) had chronic backache. No women in the no epidural or uncomplicated epidural group reported disability (chronic pain score of 3 or 4). High disability was reported by 8.9% of women in the PDPH-no EBP group and by 8.4% in the PDPH-EBP group.

CONCLUSION

Women with PDPH had a high incidence of chronic headache, back pain, and disability. We did not find a statistically significant difference in chronic pain development between conservatively treated and EBP-treated patients.

A Retrospective Investigation of Neuraxial Anesthesia Rates for Elective Cesarean Delivery Before and During the SARS-CoV-2 Pandemic

BACKGROUND

Our hospital used to perform cesarean delivery under general anesthesia rather than neuraxial anesthesia, mostly because of patient refusal of members of the conservative Bedouin society. According to recommendations implemented by the Israeli Obstetric Anesthesia Society, which were implemented due to the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic, we increased the rate of neuraxial anesthesia among deliveries.

OBJECTIVES

To compare the rates of neuraxial anesthesia in our cesarean population before and during SARS-CoV-2 pandemic.

METHODS

We included consecutive women undergoing an elective cesarean delivery from two time periods: pre-SARS-CoV-2 pandemic (15 February 2019 to 14 April 2019) and during the SARS-CoV-2 pandemic (15 February 2020 to 15 April 2020). We collected demographic data, details about cesarean delivery, and anesthesia complications.

RESULTS

We included 413 parturients undergoing consecutive elective cesarean delivery identified during the study periods: 205 before the SARS-CoV-2 pandemic and 208 during SARS-CoV-2 pandemic. We found a statistically significant difference in neuraxial anesthesia rates between the groups: before the pandemic (92/205, 44.8%) and during (165/208, 79.3%; P < 0.0001).

CONCLUSIONS

We demonstrated that patient and provider education about neuraxial anesthesia can increase its utilization. The addition of a trained obstetric anesthesiologist to the team may have facilitated this transition.

Peripartum anesthetic management of women with SARS-CoV-2 infection in eight medical centers across three European countries: prospective cohort observation study

OBJECTIVE

Several reports of obstetric anesthesia management have been published since the onset of the COVID-19 pandemic. We aimed to collect high-quality broad and detailed data from different university medical centers in several European Society of Anesthesiologist countries.

METHODS

This prospective observational survey was performed in eight medical centers in Spain, Israel and Portugal from 1^st April to 31^st July 2020. Institutional review board approval was received at each participating center. Inclusion criteria: all women with a positive test for COVID-19. Retrieved data included maternal, delivery, anesthetic, postpartum details, and neonatal outcomes. Descriptive data are presented, and outcomes were compared for women with versus without respiratory signs and symptoms.

RESULTS

Women with respiratory symptoms (20/12.1%) had significantly higher mean (standard deviation) temperature (37.2 °C (0.8) versus 36.8 °C (0.6)), were older (34.1 (6.7) years versus 30.5 (6.6)) and had higher body mass index kg m^-2 - (29.5 (7.5) versus 28.2 (5.1)). Women with respiratory symptoms delivered at a significantly earlier gestational age (50% < 37 weeks) with a 65% cesarean delivery rate (versus 22.1% in the group without respiratory symptoms) and 5-fold increased rate of emergency cesarean delivery, 30% performed under general anesthesia. A higher rate of intrauterine fetal death (3%) was observed than expected from the literature (0.2-0.3%) in developed countries. There was no evidence of viral vertical transmission.

CONCLUSION

Well-functioning neuraxial analgesia should be available to manage laboring women with respiratory symptoms, as there is a higher frequency of emergency cesarean delivery. We report a higher rate of undiagnosed parturient and intrauterine fetal death.

Epidural analgesia and vacuum-assisted delivery in primiparous women: maternal and neonatal outcomes

OBJECTIVE

We aimed to evaluate the effect of epidural analgesia (EA) on maternal and neonatal outcomes.

METHODS

We conducted a retrospective cohort database study on primiparous women who underwent a vacuum-assisted delivery (VAD) trial between 2005 and 2019 at a university-affiliated tertiary medical center. We compared women with and without the standard "one protocol" patient-controlled EA. The primary outcome was VAD failure. Secondary outcomes were maternal and neonatal morbidities. We performed univariate analysis, followed by multivariable logistic regression analysis to control for potential confounders. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were calculated.

RESULTS

Overall, 7042 primiparous women attempted VAD during the study period; 6238 (88.3%) and 804 (11.7%) women used and did not use EA, respectively. The VAD failure rate was significantly lower among women with than without EA use (2.5% vs. 4.2%, respectively, p < .01). On multivariable analysis, EA use was found to reduce the VAD failure rate (aOR, 0.05; 95% CI [0.01-0.49], p = .01). Notably, EA use was not associated with an increased rate of any maternal or neonatal adverse outcome (aOR, 1.01; 95% CI [0.8-1.27], p = .95 or aOR, 1.14 95% CI [0.89-1.45], p = .3, respectively).

CONCLUSIONS

EA use in primiparous women is associated with lower rates of VAD failure without an increase in adverse maternal or neonatal outcomes.

Long-term psychological and physical outcomes of women after postdural puncture headache: A retrospective, cohort study

BACKGROUND

Postdural puncture headache after accidental dural puncture during labour may lead to chronic sequalae.

OBJECTIVES

We aimed to measure the incidence of postpartum depression, posttraumatic stress disorder, chronic headache, backache and breastfeeding rates after a postdural puncture headache.

DESIGN

A retrospective, case-matched cohort study.

SETTING

A review of documented cases of dural puncture and matched case controls occurring at Rabin Medical Center and Shamir Medical Center from 01 January 2012 to 30 September 2018.

PATIENTS

The study cohort consisted of women with a documented postdural puncture headache and the controls were women with uneventful labour epidurals in the same 24-h period. Women were interviewed by telephone.

PRIMARY OUTCOMES MEASURE

The primary outcome measure was the incidence of postpartum depression after a postdural puncture headache.

RESULTS

Women with postdural puncture headache (n = 132) and controls (n = 276) had similar demographic data. The incidence of postpartum depression was 67/128 (52.3%) versus 31/276 (11.2%) for controls, P < 0.0001, 95% confidence intervals of the difference 31.5 to 50.2. Posttraumatic stress disorder was more frequent among women with postdural puncture headache, 17/132 (12.8%) versus controls 1/276 (0.4%), P < 0.0001, 95% confidence intervals of the difference 7.6 to 19.5. Women with postdural puncture headache breastfed less, 74/126 (54.5%) versus controls 212/276 (76.8%), P < 0.0001, 95% confidence intervals of the difference 33.1 to 55.2. Current headache and backache were significantly more frequent among women with postdural puncture headache [current headache 42/129 (32.6%) versus controls 42/276 (15.2%) P < 0.00001, 95% confidence intervals 0.085 to 0.266; current backache 58/129 (43.9%) versus controls 58/275 (21%) P < 0.0001, 95% confidence intervals 14.1 to 33.5].

CONCLUSION

We report an increased incidence of postpartum depression, posttraumatic stress disorder, chronic headache and backache and decreased breastfeeding following a postdural puncture headache. Our findings emphasise the need for postpartum follow-up for women with postdural puncture headache.

TRIAL REGISTRY NUMBER

Clinical trial registry number: NCT03550586.

Obstetric anesthesia services in Israel snapshot (OASIS) study: a 72 hour cross-sectional observational study of workforce supply and demand

Background

We planned an observational study to assess obstetric anesthesia services nationwide. We aimed to assess the effect of the anesthesia workload/workforce ratio on quality and safety outcomes of obstetric anesthesia care.

Methods

Observers prospectively collected data from labor units over 72 h (Wednesday, Thursday and Friday). Independent variables were workload (WL) and workforce (WF). WL was assessed by the Obstetric Anesthesia Activity Index (OAAI), which is the estimated time in a 24-h period spent on epidurals and all cesarean deliveries. Workforce (WF) was assessed by the number of anesthesiologists dedicated to the labor ward per week. Dependent variables were the time until anesthesiologist arrival for epidural (quality measure) and the occurrence of general anesthesia for urgent Cesarean section, CS, (safety measure). This census included vaginal deliveries and unscheduled (but not elective) CS.

Results

Data on 575 deliveries are from 12 maternity units only, primarily because a major hospital chain chose not to participate; eight other hospitals lacked institutional review board approval. The epidural response rate was 94.4%; 321 of 340 parturients who requested epidural analgesia (EA) received it. Of the 19 women who requested EA but gave birth without it, 14 (77%) were due to late arrival of the anesthesiologist. Median waiting times for anesthesiologist arrival ranged from 5 to 28 min. The OAAI varied from 4.6 to 25.1 and WF ranged from 0 to 2 per shift. Request rates for EA in hospitals serving predominantly orthodox Jewish communities and in peripheral hospitals were similar to those of the entire sample. More than a fifth (13/62; 21%) of the unscheduled CS received general anesthesia, and of these almost a quarter (3/13; 23%) were attributed to delayed anesthesiologist arrival.

Conclusions

Inadequate WF allocations may impair quality and safety outcomes in obstetric anesthesia services. OAAI is a better predictor of WL than delivery numbers alone, especially concerning WF shortage. To assess the quality and safety of anesthetic services to labor units nationally, observational data on workforce, workload, and clinical outcomes should be collected prospectively in all labor units in Israel.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13584-021-00460-2.

Epidural augmentation for urgent Cesarean Section : a nationwide Israeli survey

Background : Epidural augmentation to convert analgesia to emergency cesarean delivery anesthesia is a common practice. In this survey we examined the common augmentation practices in different hospitals in Israel. We investigated whether practices vary by hospital size and if written protocols for conversion correlate with intra-hospital homogeneity. Methods : A questionnaire containing 39 questions was sent to obstetric anesthesia unit heads and to four additional anesthesiologists (attending and residents) in 24 obstetric anesthesia units nationwide. Answers were received online anonymously using web-based survey site. Results : 99/120 participants responded to the survey. 80% of large hospitals have a detailed epidural augmentation protocol. The existence of a written protocol does not affect intrahospital management variability. Overall, 18 different drug mixtures for epidural augmentation were reported, and the most used drug combination is lidocaine, fentanyl and bicarbonate. In large hospitals, 72% add epinephrine and 96% initiate augmentation before operating room arrival. Most respondents reported a final administered total volume of 15-20 ml. In most hospitals there is no maternal or fetal monitoring during patient transfer from delivery room to the operating room, lasting 3.68 minutes on average, with a relative low risk of significant complication as a result of augmentation. Conclusion : We report variations in common practices, depending on hospital size. We recognized low rate of intra-hospital concordance between centers with or without a written protocol of augmentation. Regarding points for improvement, we would recommend adhering to the accepted institutional protocol.

Open versus endovascular REBOA control of blood loss during cesarean delivery in the placenta accreta spectrum: A single-center retrospective case control study

OBJECTIVE

The aim of this study was to compare two vascular control options for blood loss prevention and hysterectomy during cesarean delivery (CD2): endovascular balloon occlusion of the aorta (REBOA3) and open bilateral common iliac artery occlusion (CIAO4) in women with extensive placenta accreta spectrum (PAS5).

STUDY DESIGN

This was retrospective comparison of cases of PAS using either CIAO (October 2017 through October 2018) or REBOA (November 2018 through November 2019) to prevent pathologic hemorrhage during scheduled CD. Women with confirmed placenta increta/percreta underwent either CD then intraoperative post-delivery, pre-hysterectomy open vascular control of both CIA6 (CIAO group) or pre-operative, ultrasound-guided, fluoroscopy-free REBOA followed by standard CD and balloon inflation after fetal delivery (REBOA group). Intraoperative blood loss, transfusion volumes, surgical time, blood pressure, maternal and neonatal outcomes, hospitalization length and postoperative complications were compared.

RESULTS

The REBOA and CIAO groups included 12 and 16 women, respectively, with similar median age of 35 years and gestational age of 34-35 weeks. All REBOA catheters were successfully placed into aortic zone three under ultrasound guidance. The quantitated median intraoperative blood loss was significantly lower for the REBOA group, (541 [IQR 300-750] mL) compared to the CIAO group (3331 [IQR 1150-4750] mL (P = 0.001). As a result, the total volume of fluid and blood replacement therapy was significantly lower in the REBOA group (P < 0.05). Median surgical time in the REBOA group was less than half as long: 76 [IQR 64-89] minutes compared to 168 [IQR 90-222] minutes in the CIAO group (P = 0.001). None of the women with REBOA required hysterectomy, while 8/16 women in the CIAO group did (P = 0.008). Furthermore, the post-anesthesia recovery and hospital discharge times in the REBOA-group were shorter (P < 0.05). One thromboembolic complication occurred in each group. The only REBOA-associated complication was non-occlusive femoral artery thrombosis, with no surgical management required. No maternal or neonatal deaths occurred in either group.

CONCLUSION

Fluoroscopy-free REBOA for women with PAS is associated with improved vascular control, perioperative blood loss, the need for transfusion and hysterectomy and reduces surgical time when compared to bilateral CIAO.

Management practices for postdural puncture headache in obstetrics: a prospective, international, cohort study

BACKGROUND

Accidental dural puncture is an uncommon complication of epidural analgesia and can cause postdural puncture headache (PDPH). We aimed to describe management practices and outcomes after PDPH treated by epidural blood patch (EBP) or no EBP.

METHODS

Following ethics committee approval, patients who developed PDPH after accidental dural puncture were recruited from participating countries and divided into two groups, those receiving EBP or no EBP. Data registered included patient and procedure characteristics, headache symptoms and intensity, management practices, and complications. Follow-up was at 3 months.

RESULTS

A total of 1001 patients from 24 countries were included, of which 647 (64.6%) received an EBP and 354 (35.4%) did not receive an EBP (no-EBP). Higher initial headache intensity was associated with greater use of EBP, odds ratio 1.29 (95% confidence interval 1.19-1.41) per pain intensity unit increase. Headache intensity declined sharply at 4 h after EBP and 127 (19.3%) patients received a second EBP. On average, no or mild headache (numeric rating score≤3) was observed 7 days after diagnosis. Intracranial bleeding was diagnosed in three patients (0.46%), and backache, headache, and analgesic use were more common at 3 months in the EBP group.

CONCLUSIONS

Management practices vary between countries, but EBP was more often used in patients with greater initial headache intensity. EBP reduced headache intensity quickly, but about 20% of patients needed a second EBP. After 7 days, most patients had no or mild headache. Backache, headache, and analgesic use were more common at 3 months in patients receiving an EBP.

[ABDOMINAL WALL BLOCKS FOR POST CESAREAN DELIVERY ANALGESIA]

Intrathecal morphine administration at the time of neuraxial anesthesia performance is the gold standard for post-cesarean delivery (CD) analgesia. When intrathecal morphine administration is inappropriate or contraindicated, the use of systemic analgesic options increase side effects and risks to both the parturient and the breastfeeding neonate. Moreover, systemic analgesia is often inadequate. The increased clinical use of ultrasound has made way for regional analgesia techniques, mostly in the form of local anesthesia injected between muscular planes. The transversus abdominis plane (TAP) block is the most well-known and the most commonly used for Cesarean delivery. It has been shown to be effective in the absence of intrathecal morphine administration. It has however, not been shown to be beneficial when intrathecal morphine has been administered. Other, newer techniques are being increasingly used and investigated. Some may prove to be superior to the TAP block. These techniques include: ilioinguinal/ilio-hypogastric nerve blocks (II-IH), the quadratus lumborum (QL) blocks and the erector spinae plane (ESP) block. In this review, we will discuss and assess these techniques regarding analgesia following CD.

[PROSPECTIVE INVESTIGATION OF POSTOPERATIVE NAUSEA AND VOMITING FOLLOWING DUAL PROPHYLAXIS AND LOW DOSE NEURAXIAL MORPHINE FOR CESAREAN DELIVERY]

BACKGROUND

Spinal morphine provides the optimal treatment for post-cesarean analgesia, despite frequent nausea and vomiting. We investigated the incidence of nausea and vomiting 24 hours after cesarean delivery in women receiving intrathecal morphine 100 µcg and intravenous prophylactic dexamethasone and ondansetron.

METHODS

In a prospective, observational, Institutional Review Board (IRB) approved study of women undergoing cesarean delivery according to a standardized anesthetic protocol, the subjects were approached preoperatively and underwent standardized interviews regarding prior anesthesia experience and history of postoperative nausea and vomiting. In the post anesthesia care unit and 24 hours postoperatively, the women were interviewed regarding the incidence of nausea and vomiting, Women with and without nausea at 24 hours were compared for potential associated risk factors.

RESULTS

Among 201 women recruited, 29 (14.5%) had nausea and 7 (3.5%) vomited in the postoperative care unit. During the first 24 hours, 36 (17.9%) had experienced nausea and 19 (9.5%) had vomited when interviewed at the 24-hours postoperatively. Women who had nausea 24 hours postoperatively were more likely to have nausea in the post anesthesia care unit than women without nausea during 24 hours after cesarean delivery (41.7% versus 1.2%, p<0.001). We did not find preoperative risk factors for postoperative nausea and vomiting.

CONCLUSIONS

We report that almost 20% of the women managed with prophylactic dual therapy of ondansetron and dexamethasone had nausea during the 24 hours after administration of low dose intrathecal morphine. Our findings suggested that women who experience nausea or vomiting in the immediate postoperative period are at increased risk of nausea and vomiting in the 24-hour postoperative period.

Severe Maternal Morbidity Cases in Israel in a High-Volume High-Resource Referral Center: A Retrospective Cohort Study

BACKGROUND

Admission to an intensive care unit (ICU) is an objective marker of severe maternal morbidity (SMM).

OBJECTIVES

To determine the prevalence of obstetric ICU admissions in one medical center in Israel and to characterize this population.

METHODS

In this retrospective study the files of women coded for pregnancy, birth, or the perinatal period and admission to the ICU were pulled for data extraction (2005-2013).

RESULTS

During the study period, 111 women were admitted to the ICU among 120,279 women who delivered babies (0.09%). Their average age was 30 ± 6 years, most were multigravida, a few had undergone fertility treatments, and only 27% had complicated previous pregnancies. Most pregnancies (71.2%) were uneventful prior to admission. ICU admissions were divided equally between direct (usually hemorrhage) and indirect (usually cardiac disease) obstetric causes.

CONCLUSIONS

The indications for obstetrics ICU admission correlated with the proximate causes of maternal arrest observed worldwide. While obstetric hemorrhage is often unpredictable, deterioration of heart disease is foreseeable. Attention should be directed specifically toward improving the diagnosis and treatment of maternal heart disease during pregnancy in Israel.

[INTERVENTIONS TO IMPROVE THE QUALITY OF THE INTERNSHIP YEAR]

AIMS

To describe three interventions that have improved the quality of the internship.

BACKGROUND

All medical school graduates are required to take a one year internship, rotating through various hospital departments. By various objective and subjective measures, the quality, benefit and efficacy of the internship varies significantly between departments and hospitals and also depends on where the interns studied.

METHODS

The interventions were: First, all graduates of foreign medical schools (FMG) were required to interview and present a patient, demonstrating practical knowledge of spoken and written Hebrew and basic medical terminology prior to the start of the internship. Second, on the first day of their internship in internal medicine the new interns participate in an orientation day, addressing multiple clinical, administrative and other components. Third, upon the completion of their rotation in internal medicine, the interns participate in an interactive session to help them prepare for their future career.

RESULTS

First, during the first 3 years after introducing the Hebrew test, 101 FMGs took the test, 89 (88%) passed the first time, the remainder passed the 2nd or 3rd test after another 1-3 months of studying Hebrew. Of 31 women, 30 (97%) passed the first time, compared to 59/70 (84%) of the men (p=0.065); 27/28 (96%) of Jewish interns passed the first time compared to 62/73 (85%) non-Jewish interns (p=0.99). Physicians report on the significantly increased ability of FMGs to participate in all activities from the onset of their internship. Second, upon completion of the orientation, 137 interns provided feedback of its 12 components; satisfaction was marked on a Likert scale (ranging from 1 [low] to 5 [high]) and ranged from 4.2±0.1 to 4.7±0.6; high/very high satisfaction with the various components ranged from 79% to 96%. Third, feedback was provided by 96 interns after participating in the interactive session helping to prepare for the future; satisfaction with the 5 components of the session ranged from 3.8±0.8 (on the acquired insight into the possibilities, scope and limitations regarding their future career) to 4.5±0.7 (regarding the relevance of such sessions). Sub-analysis revealed several statistically significant differences between male and female interns (male interns indicated these sessions to be more important to them than females, p<0.01), and FMG (as compared to graduates from Israeli medical schools) indicated that they had acquired relevant information more often (p<0.001).

CONCLUSIONS

Various interventions positively impact the quality, benefit and efficacy of the internship as observed by physicians working with the residents, as well as perceived by the interns themselves.

The Effect of Labor Epidural Analgesia on Breastfeeding Outcomes: A Prospective Observational Cohort Study in a Mixed-Parity Cohort

BACKGROUND

The effect of labor epidural analgesia (LEA) on successful breastfeeding has been evaluated in several studies with divergent results. We hypothesized that LEA would not influence breastfeeding status 6 weeks postpartum in women who intended to breastfeed in an environment that encourages breastfeeding.

METHODS

In this prospective observational cohort study, a total of 1204 women intending to breastfeed, delivering vaginally with or without LEA, were included; breastfeeding was recorded at 3 days and 6 weeks postpartum. Primary outcome was breastfeeding at 6 weeks, and the χ test was used for comparisons between women delivering with and without LEA, according to parity status and previous breastfeeding experience. Total epidural fentanyl dose and oxytocin use (yes/no) were recorded. A multivariable logistic regression was performed to assess factors affecting breastfeeding at 6 weeks.

RESULTS

The overall breastfeeding rate at 6 weeks was 76.9%; it was significantly lower among women delivering with LEA (74.0%) compared with women delivering without LEA (83.4%; P < .001). Among 398 nulliparous women, 84.9% delivered with LEA, compared with 61.8% of multiparous women (P < .001). Multiparous women (N = 806) were more likely to breastfeed at 6 weeks (80.0% vs 70.6% nullipara; P < .001). Using multivariable logistic regression that accounted for 14 covariates including parity, and an interaction term between parity and LEA use, LEA was significantly associated with reduced breastfeeding at 6 weeks (odds ratio, 0.60; 95% confidence interval, 0.40-0.90; P = .015). In a modified multivariable logistic regression where parity was replaced with previous breastfeeding experience, both as a covariate and in the interaction term, only previous breastfeeding experience was associated with increased breastfeeding at 6 weeks (odds ratio, 3.17; 95% confidence interval, 1.72-5.80; P < .001).

CONCLUSIONS

In our mixed-parity cohort, delivering with LEA was associated with reduced likelihood of breastfeeding at 6 weeks. However, integrating women's previous breastfeeding experience, the breastfeeding rate was not different between women delivering with and without LEA among the subset of multiparous women with previous breastfeeding experience. Therefore, our findings suggest that offering lactation support to the subset of women with no previous breastfeeding experience may be a simple approach to improve breastfeeding success. This concept subscribes to the notion that women at risk for an undesired outcome be offered tailored interventions with a personalized approach.

The impact of epidural analgesia on the mode of delivery in nulliparous women that attain the second stage of labor

Objective: We aimed to evaluate the impact of epidural analgesia on the mode of delivery of nulliparous women with a term single fetus in vertex presentation (NTSV) that attained the second stage of labor.Study design: A single-center retrospective study provided a strict and constant department protocol for epidural analgesia practice and obstetric interventions, between 2005 and 2014. Epidural users were compared to nonusers. The primary outcome was the mode of delivery. Secondary outcomes were diagnosis of prolonged second stage of labor and maternal and neonatal morbidities. The outcomes were evaluated by adjusted multivariate analyses (Adjusted Odds Ratios (aOR), 95% CI).Results: During the study period, 25,643 NTSV attained the second stage of labor; 18 676 (73%) epidural users and 6967 (27%) nonusers. Epidural users had an increased risk of instrumental delivery 2.48, [2.22-2.76], along with a lower risk of cesarean delivery 0.38, [0.29-0.50]. Notably, the diagnosis of prolonged second stage of labor was comparable among the study groups 0.99, [0.89-1.12]. The epidural users had a significantly higher risk of early postpartum hemorrhage 1.15, [1.04-1.27]. The risk for neonatal morbidity was comparable among the study groups 1.21 [0.90-1.63].Conclusion: Epidural analgesia in a population of NTSV that attains the second stage of labor is associated with a higher risk of instrumental delivery, nonetheless with a reduced risk of cesarean delivery; independent of the length of the second stage of labor is and safe for the neonate.

Delaying laparoscopic surgery in pregnant patients with an equivocal acute appendicitis: a step-wise approach does not affect maternal or fetal safety

BACKGROUND

Accurate and timely diagnoses of acute appendicitis (AA) during pregnancy avoids maternal and fetal morbidity and mortality. We present our experience of using an initial transabdominal ultrasound (US) performed at presentation to diagnose AA in pregnant patients as well as the value of a delayed repeat study in those who remain equivocal. We explore the sensitivity and specificity of this algorithm as well as the maternal and fetal safety of this approach.

METHODS

Of the 225 patients identified within the study period who underwent laparoscopic appendectomy, 216 met the inclusion criteria and were retrospectively analyzed. If the US performed on presentation revealed AA, surgery was performed. Patients with a non-diagnostic US were admitted with surgery performed if there was clinical and/or biochemical deterioration. Patients who remained equivocal underwent a repeat delayed study. The results of the initial versus delayed studies were compared. Maternal and fetal complications were recorded and contrasted.

RESULTS

Of the 216 patients included, 164 (75.9%) had AA, 14 (6.5%) had complicated AA and 38 (17.6%) had a normal appendix. Initial US was diagnostic for 125/216 (57.9%) of patients and 19/34 (55.8%) of patients who underwent a delayed repeat study. The remaining patients underwent empirical surgery. The pooled sensitivity and specificity of US for the cohort was 79.2% and 92.1%, respectively. There was no difference in proxies of maternal or fetal safety between the groups.

CONCLUSION

US is a useful tool for diagnosing AA in pregnancy. In this cohort, performing a delayed repeat US during a period of observation in those patients who remained otherwise equivocal increased the diagnostic yield of the US. Delaying surgery in this specific group of patients does not affect maternal or fetal safety.

Anesthetic approach to postdural puncture headache in the peripartum period: An Israeli national survey

BACKGROUND

Accidental dural puncture frequency among pregnant women is about 1.5%, while approximately 60% of these women will suffer from post-dural puncture headache (PDPH) that may be debilitating.

METHODS

Following IRB approval, we conducted a national survey of the lead anesthesiologist in 23 labor and delivery rooms in Israel. Each survey inquired about medical center annual delivery volume, training program for residents, accidental dural puncture management, processing of information, and PDPH management strategies.

RESULTS

Data were collected from all 23 surveyed hospitals. As for methods for PDPH prevention, in most hospitals (87%) a prophylactic epidural blood patch (EBP) is not considered. Injection of epidural normal saline after delivery as a preventive measure is never considered in most (78.3%) hospitals, while four (17.4%) hospitals reported of constitutive use of this technique and one hospital only occasionally. Duration of conservative treatment was 24-48 hours in 95.7% of PDPH cases.

CONCLUSION

In this survey, different aspects of treatment and PDPH management were examined. EBP is considered the gold standard in treating PDPH, although prophylactic blood patch is ineffective. We observed a tendency of very low performance of both prophylactic EBP and epidural normal saline administration after delivery in most centers. Most hospitals perform EBP after 24-48 hours of conservative treatment, along with published recommendations that show increased EBP efficiency with this timeframe. In light of the survey information, we aim to reach a uniform literature-based management strategy across Israeli hospitals.

Retrospective study to investigate fresh frozen plasma and packed cell ratios when administered for women with postpartum hemorrhage, before and after introduction of a massive transfusion protocol

BACKGROUND

Administration of packed red blood cells (PRBC) and fresh frozen plasma (FFP) to women with postpartum hemorrhage (PPH) before and after introduction of a massive transfusion protocol.

METHODS

The retrospective PPH study cohort of two tertiary centers was identified using blood bank records, verified by patient electronic medical records. We identified women transfused with ≥3 units PRBC in a short time period within 24 hours of delivery. Since 2010, both centers have used a protocol using 1:1 FFP:PRBC ratios. Demographic, obstetric, and blood management data were retrieved from medical records. Outcome measures included estimated blood loss, blood product administration, and hematologic variables.

RESULTS

273 women were included, 112 (41.0%) prior to introduction of the protocol (2004-2009) and 161 (59.0%) afterwards (2010-2014). The frequency of women managed with 1:1 FFP:PRBC ratios was similar before 55/112 (49.1%) and after 83/161 (51.6%) introduction of the protocol (P=0.69). There was strong correlation between PRBC units transfused and the FFP:PRBC transfusion ratio (R-square 0.866, P <0.0001), demonstrating that as the number of transfused PRBC units increased, FFP:PRBC ratios became closer to 1:1. There were no outcome differences between women managed before and after introduction of the protocol.

CONCLUSIONS

Among women with PPH receiving ≥3 PRBC units within a short period of time, it appears that factors other than the existence of our massive transfusion protocol influence the number and ratio of PRBC and FFP units transfused. Blood products were not transfused according to exact ratios, even when guided by a protocol.

Five years' experience in an anesthesiology antenatal clinic for high-risk patients

INTRODUCTION

The aim, of this study is to describe our approach and outcomes in an outpatient anesthesia/analgesia antepartum clinic among ambulatory high-risk obstetric patients.

METHODS

This was a retrospective evaluation of the activity of the anesthesiology antenatal clinic from its inception in 2010 until 2016 (a 5-year period). The clinic works in collaboration with the Department of Obstetrics and Gynecology. The catchment area of the study University Affiliated Hospital attends a multiethnic population characterized by high parity.

RESULTS

There were 241 referrals over the 5 years, each of whom was discharged with a consult and a delivery management plan and 228 (95%) of which were performed as planned. Mean gestational age at consultation was 34.4 weeks (range: 20-37). There were no preconceptional consultation. No limitations regarding mode of anesthesia/analgesia was considered for 47% of the referrals. Nulliparous women accounted for 50% of the referrals and 17% were in their second pregnancy. The greatest number of referrals (30%) was for musculoskeletal conditions. No maternal death encountered. The mode of delivery was vaginal in 139 (65%) women; elective cesarean section in 44 (21%) women; and emergent cesarean section in 30 (14%) women. The neonatal outcomes were unremarkable; 210 (87%) in hospital births, 97.1% had an a 5' Apgar score of 9.

CONCLUSION

Our findings reveal the need for high-risk obstetric patients consult with a dedicated obstetric anesthesiologist to devise a management plan for labor and delivery that is tailored to their comorbidity and obstetric status, to ensure an optimum outcome for mother and child.

Epidural analgesia at trial of labor after cesarean (TOLAC): a significant adjunct to successful vaginal birth after cesarean (VBAC)

INTRODUCTION

Epidural analgesia has been considered a risk factor for labor dystocia at trial of labor after cesarean (TOLAC) and uterine rupture. We evaluated the association between exposure to epidural during TOLAC and mode of delivery and maternal-neonatal outcomes.

MATERIALS AND METHODS

A single center retrospective study of women that consented to TOLAC within a strict protocol between 2006 and 2013. Epidural "users" were compared to "non-users". Primary outcome was the mode of delivery: repeat in-labor cesarean or vaginal birth after cesarean (VBAC). Secondary outcomes were maternal/neonatal morbidities. Univariate/multivariate analyses for associations between epidural and mode of delivery were adjusted for significant covariates/mediators.

RESULTS

Of a total of 105,471 births registered, 9464 (9.0%) were eligible for TOLAC; 7149 (75.5%) women consented to TOLAC, among which 4081 (57.1%) had epidural analgesia. The in labor cesarean rate was significantly lower for the epidural "users" 8.7% vs. "non-users" 11.8%, P<0.0001, with a parallel increased rate of instrumental delivery. Uterine rupture rates were comparable: 0.4% and 0.29%, respectively (P=0.31). The adjusted multivariate model showed that epidural "users" were more likely to experience a VBAC, odds ratio (OR) 4.58 [3.67; 5.70]; P<0.0001 with a similar rate of adverse maternal-neonatal outcomes.

CONCLUSION

Epidural analgesia at TOLAC may emerge as a safe and significant adjunct for VBAC.

Concurrent medical conditions among pregnant women - ignore at their peril: report from an antenatal anesthesia clinic

Background

Care of pregnant women with concurrent medical conditions can be optimized by multidisciplinary antenatal management. In the current study we describe women with concurrent medical conditions who attended our antenatal anesthesia clinic over a 14-year period, 2002–2015 and, based on the findings, we suggest new policies, strategies and practices to improve antenatal care.

Methods

In 2002, an antenatal anesthesia clinic was established in Hadassah Medical Center. Each consultation focused on the concurrent medical condition. A written anesthesia strategy according to the medical condition and its anesthesia considerations was discussed and given to the patient. Data regarding clinic visits were recorded.

Results

A total of 451 clinic women attended the antenatal anesthesia clinic. Maternal age was 31.7 ± 6.0 years (mean ± SD), with gestational age of pregnancy 33.0 ± 5.4 weeks at the clinic visit. Musculoskeletal conditions (23% of all the women seen) were the most frequent concurrent conditions, followed by anesthesia related concerns 20%, neurologic conditions 19%, and cardiac conditions 15%. Women were provided plans that were deliberated carefully rather than being concocted during labor.

Conclusions

A wide range of concurrent medical conditions was seen in the antenatal anesthesia clinic, however fewer women attended the clinic than expected according to known population frequencies of concurrent medical conditions. Women with concurrent medical conditions should have labor and anesthesia plans considered during the nine months of pregnancy, prior to delivery, and hospitals should have a means of obtaining this information in a timely manner. Finally, there is a need to develop additional antenatal anesthesia clinics.

Anesthetic management of amniotic fluid embolism -- a multi-center, retrospective, cohort study

INTRODUCTION

Amniotic fluid embolism (AFE) is a rare and potentially lethal obstetric complication, commonly occurring during labor, delivery, or immediately postpartum. There is a paucity of data regarding incidence, risk factors, and clinical management. Our primary objective in this study was to evaluate clinical presentation of AFE and delineate anesthesia management of these cases.

METHODS

This 10 years retrospective multi-center cohort study was performed in five tertiary university-affiliated medical centers, between the years 2005 and 2015. All documented cases of AFE identified according to the ICD guidelines were reviewed manually to determine eligibility for AFE according to Clark's criteria. All cases confirming Clark's diagnosis were included in the cohort.

RESULTS

Throughout the study period, 20 cases of AFE were identified, with an incidence of 4.1 per 100,000 births. Average age at presentation was 35 ± 5 years. Seventy percent of cases presented during vaginal delivery, 20% occurred throughout a cesarean delivery, and 10% occurred during a dilation and evacuation procedure. The most common presenting symptom was sudden loss of consciousness in 12 parturients (66.7%), fetal bradycardia in 11 parturients (55%), and shortness of breath in 10 parturients (50%). Perimortem cesarean section was performed in 55% of cases, although only one case was performed in the delivery suite, while all others were performed in the operating room. Echocardiography was performed in 60% of the cases and all were pathological. Furthermore, 20% of cases were connected to an extracorporeal membrane oxygenation machine. There was a 15% mortality rate of 15%. A further 15% suffered major neurological disability, 25% suffered minor neurological morbidity, and 45% survived without severe complications.

CONCLUSION

AFE is associated with significant maternal morbidity. This study highlights the importance of providing advanced training for the delivery suite staff for cases of maternal cardiovascular collapse secondary to AFE and increasing awareness for this rare and devastating obstetric condition.

Timing of antibiotic prophylaxis in cesarean section: retrospective, difference-in-differences estimation of the effect on surgical-site-infection

BACKGROUND

Cesarean section (CS) is one of the most common surgical procedures performed worldwide. Surgical-site-infection (SSI) occurs in approximately 5-10% of CS. The benefit of prophylactic antibiotics for prevention of SSI has been demonstrated in the literature. The optimal timing of antibiotic prophylaxis (prior to surgical incision versus after cord clamping) was investigated in recent studies. In January 2014, the Israeli Ministry of Health introduced a national quality measure which monitors the administration of prophylactic antibiotics in CS. The custom clinical practice in our medical center was to administer prophylactic antibiotics immediately after cord clamping. Upon introduction of the national quality measurement program, the practice was changed to administration of antibiotics prior to surgical incision. Our objective was to examine the effect of timing of prophylactic antibiotics administration on the incidence of SSI following CS, in a single medical center that performs a large volume of deliveries, with a low rate of CS.

MATERIAL AND METHODS

Taking advantage of a discrete change in clinical practice, we used retrospective data and applied difference-in-differences design to estimate the effect of the timing of prophylactic antibiotics administration on SSI rates. The analysis included all CSs performed during 2012-2015 and all hysterectomies conducted during the study period.

RESULTS

The coverage rates of prophylactic antibiotics in CS before and after the policy change were 99.10% and 99.03%, respectively. The rates of SSI following CS, before and after the policy change, were 2.63% (n = 2499) and 2.32% (n = 3840), respectively. The rates of SSI following hysterectomy, before and after the policy, change were 6.82% (n = 396) and 7.09% (n = 437), respectively. Difference-in-differences (DID) estimates of the effect of policy change on the incidence of SSI in linear and logistic regression models were not significant (B = -0.6%, p = .64; odds ratio = 0.84, p = .58, respectively).

CONCLUSIONS

We found no effect of the timing of prophylactic antibiotic administration (prior to surgical incision versus after cord clamping) on SSI rates following CS.

Anesthesia management of complete versus incomplete placenta previa: a retrospective cohort study

PURPOSE

Placenta previa (PP) is a major cause of obstetric hemorrhage. Clinical diagnosis of complete versus incomplete PP has a significant impact on the peripartum outcome. Our study objective is to examine whether distinction between PP classifications effect anesthetic management.

METHODS AND MATERIALS

This multi-center, retrospective, cohort study was performed in two tertiary university-affiliated medical centers between the years 2005 and 2013. Electronic delivery databases were reviewed for demographic, anesthetic, obstetric hemorrhage, and postoperative outcomes for all cases.

RESULTS

Throughout the study period 452 cases of PP were documented. We found 134 women (29.6%) had a complete PP and 318 (70.4%) had incomplete PP. Our main findings were that women with complete PP intraoperatively had higher incidence of general anesthesia (p = .017), higher mean estimated blood loss (p < .001), increased blood components transfusions (p < .001), and significant increase in cesarean hysterectomy rate (p < .001) than women with incomplete PP. Additionally, complete PP was associated with more postoperative complications: higher incidence of admission to the intensive care unit (ICU) (p < .001), more mechanical ventilation (p = .02), a longer median postoperative care unit (PACU) (p = .02), ICU (p = .002), and overall length of stay in the hospital (p < .001).

CONCLUSIONS

Complete PP is associated with increased risk of hemorrhage compared with incomplete PP. Therefore distinction between classifications should be factored into anesthetic management protocols.

Neostigmine induced coronary artery spasm: A case report and literature review

Neostigmine is a cholinesterase inhibitor which does not cross the blood brain barrier and a commonly used for reversal of nondepolarizing muscle relaxants. In the following case report, we present a patient who developed coronary artery spasm, after the administration of repeated doses of neostigmine. Ours is the first case to demonstrate such a longstanding coronary artery vasospasm that lasted several hours in response to neostigmine, resulting in myocardial damage and left ventricular dysfunction. We would like to draw the attention of the anesthesiologists to this rare effect that may lead to perioperative cardiac complications.

Preoperative sleep quality predicts postoperative pain after planned caesarean delivery

BACKGROUND

Severe post-caesarean pain remains an important issue associated with persistent pain and postpartum depression. Women's sleep quality prior to caesarean delivery and its influence on postoperative pain and analgesic intake have not been evaluated yet.

METHODS

Women undergoing caesarean delivery with spinal anaesthesia (bupivacaine 12 mg, fentanyl 20 μg, morphine 100 μg) were evaluated preoperatively for sleep quality using the Pittsburgh Sleep Quality Index (PSQI) questionnaire (PSQI 0-5 indicating good sleep quality, PSQI 6-21 poor sleep quality). Peak and average postoperative pain scores at rest, movement and uterine cramping were evaluated during 24 h using a verbal numerical pain score (VNPS; 0 indicating no pain and 100 indicating worst pain imaginable), and analgesic intake was recorded. Primary outcome was peak pain upon movement during the first 24 h.

RESULTS

Seventy-eight of 245 women reported good sleep quality (31.2%; average PSQI 3.5 ± 1.2) and 167 poor sleep quality (68.2%; average PSQI 16.0 ± 3.4; p < 0.001). Women with poor sleep quality had significantly higher peak pain scores upon movement (46.7 ± 28.8 vs. 36.2 ± 25.6, respectively; p = 0.006). With multivariable logistic regression analysis, poor sleep quality significantly increased the risk for severe peak pain upon movement (VNPS ≥70; OR 2.64; 95% CI 1.2-6.0; p = 0.02).

DISCUSSION

A significant proportion of women scheduled for caesarean delivery were identified preoperatively as having poor sleep quality, which was associated with more severe pain and increased analgesic intake after delivery. The PSQI score may therefore be a useful tool to predict increased risk for acute post-caesarean pain and higher analgesic requirements, and help tailor anaesthetic management.

SIGNIFICANCE

Multiple studies have evaluated predictors for severe acute pain after caesarean delivery that may be performed in a clinical setting, however, sleep quality prior to delivery has not been included in predictive models for post-caesarean pain. The PSQI questionnaire, a simple test to administer preoperatively, identified that up to 70% of women report poor sleep quality before delivery, and poor sleep quality was associated with increased post-caesarean pain scores and analgesic intake, indicating that PSQI could help identify preoperatively women at risk for severe pain after caesarean delivery.

Use of Caudal Analgesia Supplemented with Low Dose of Morphine in Children Who Undergo Renal Surgery

INTRODUCTION

To test the efficacy and safety of caudal anesthesia (CA) supplemented by low dose morphine in children who undergo renal surgery.

MATERIALS AND METHODS

Forty patients aged 2 months-14 years were enrolled and randomly divided into two groups of 20 patients each: Group A (bupivacaine 0.2% with fentanyl); Group B (bupivacaine with morphine). The duration of surgery and hospitalization time were recorded. Postoperative pain score was measured by Face Legs Activity Cry Consolability scale and Wong-Baker Faces scale for those who are older. Overall use of rescue analgesics was calculated.

RESULTS

There was no statistical difference in the length of surgery, incidence of pruritus, postoperative nausea, vomiting and urinary retention between the two groups. However the postoperative opioid requirements were significantly higher in Group A 1.03 ± 0.9 mg/kg compared to Group B, in which only one patient required opioid therapy (p < 0.0001). Moreover the need for non-opioid rescue analgesic was higher in Group A, (36 ± 5.7 mg/kg of paracetamol) compared to morphine CA group there only 26 ± 3.6 mg/kg required during first 24 h of the postoperative period (p = 0.0312). The Face Legs Activity Cry Consolability pain score (1, 4, and 24 h after surgery) and Wong-Baker Faces scale were significantly higher in Group A. The hospitalization period was shorter in the CA morphine group, but the difference did not reach statistical significance. None developed hemodynamic instability or respiratory depression.

CONCLUSIONS

Our data show that CA supplemented with low dose morphine provides a longer duration of analgesia without significant side-effects in children undergoing renal surgery.

Thromboelastography as a Surrogate Marker of Perisurgical Hemostasis in Gaucher Disease

Thromboelastography (TEG) has long been available for routine monitoring of perisurgical and postpartum hemostasis, especially at point of care. The purpose of this study is to retrospectively compare TEG parameters to concomitant standard clotting test results in an unselected cohort of patients with Gaucher disease to ascertain whether TEG values are specific and sensitive enough to substitute for classic coagulation tests for decision making. This remains a cogent concern because of high incidence of thrombocytopenia in patients with Gaucher disease. Thromboelastography values were compared to concomitant platelet counts, partial thromboplastin time, international normalization ratio, and plasma fibrinogen. Demographic characteristics were collected from patients’ files. There were 22 patients with Gaucher disease (2 children; 12.5%) for whom there were 24 TEG results at the same time as classic coagulation test results and 30% performed platelet function tests. The current study shows linear and/or monotonic relationships between platelet counts and several TEG values that were significant over a range of platelet counts including severe thrombocytopenia. The fibrinogen component, correlating only with the rate of clot lysis, played a lesser role. Based on these preliminary results albeit in a small cohort with only 1 case of hemorrhage, there is putative support for the intention to treat patients with Gaucher disease based on TEG results using the same TEG protocol as for other patients undergoing comparable procedures in our institution.

Israeli survey of anesthesia practice related to placenta previa and accreta

BACKGROUND

Anesthesia practices for placenta previa (PP) and accreta (PA) impact hemorrhage management and other supportive strategies. We conducted a survey to assess reported management of PP and PA in all Israeli labor and delivery units.

METHODS

After Institutional Review Board waiver, we surveyed all 26 Israeli hospitals with a labor and delivery unit by directly contacting the representatives of obstetric anesthesiology services in every department (unit director or department chair). Each director surveyed provided information about the anesthetic and transfusion management in their labor and delivery units for three types of abnormal placentation based on antenatal placental imaging: PP, low suspicion for PA, and high suspicion for PA. The primary outcome was use of neuraxial or general anesthesia for PP and PA Cesarean delivery. Univariate statistics were used for survey responses using counts and percentages.

RESULTS

The response rate was 100%. Spinal anesthesia is the preferred anesthetic mode for PP cases, used in 17/26 (65.4%) of labor and delivery units. By comparison, most representatives reported that they perform general anesthesia for patients with PA: 18/26 (69.2%) for all low suspicion cases of PA and 25/26 (96.2%) for all high suspicion cases of PA. Although a massive transfusion protocol was available in the majority of hospitals (84.6%), the availability of thromboelastography and cell salvage was much lower (53.8% and 19.2% hospitals respectively).

CONCLUSIONS

In our survey, representatives of anesthesia labor and delivery services in Israel are almost exclusively using general anesthesia for women with high suspicion for PA; however, almost two-thirds use spinal anesthesia for PP without suspicion of PA. Among representatives, we found wide variations in anesthesia practice patterns with regard to anesthesia mode, multidisciplinary management, and hemorrhage anticipation strategies.