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.

Diagnostic nerve blocks in the management of low back pain secondary to facet joint syndrome

Low back pain is currently one of the main public health problems. Among the multiple causes, pain in the zygapophysial joints, also called facets or posterior vertebral joints, are an important cause, usually secondary to osteoarthritis. The source of low back pain is often difficult to find, making the therapeutic approach to the patient sub-optimal. Diagnostic blocks are a very important tool in establishing an adequate treatment for patients with low back pain, as long as they are performed accurately, with an adequate local anaesthetic volume, with a suitable image and fluoroscopic projection and its result are precisely interpreted. In this article a review is presented on the importance of diagnostic blocks, as well as how they should be performed in order to obtain the maximum information and the greatest therapeutic benefit.

Prognosis and predictors of mortality in critically ill elderly patients

OBJECTIVES

to evaluate mortality of patients≥80 years admitted to the Surgical Intensive Care Unit (SICU), global hospital mortality and factors related to it.

MATERIAL AND METHODS

observational retrospective study of patients≥80 years admitted to SICU between June 2012 and June 2015.

RESULTS

a total of 299 patients were included, 54 of them died in the SICU (18.1%) and 80 patients (26.8%) died during their hospital stay. SICU mortality was independently related to age (OR=1.125; 95%CI: 1.042-1.215; P=.003), SAPS II (OR=1.026; 95% CI: 1.008-1.044; P=.004), need for renal replacement therapy (RRT) (OR=1.960; 95%CI: 1.046-3.671; P=.036) and need for mechanical ventilation for more than 24hours (OR=2.834; 95%CI: 1.244-6.456; P=.013). Factors independently related to hospital mortality were age (OR=1.125; 95%CI: 1.054-1.192; P<.001), SOFA score (OR=1.154; 95% CI: 1.079-1.235; P<.001), need for RRT (OR=1.924; 95%CI: 1.121-3.302; p=0.018) and need for mechanical ventilation for more than 24hours (OR=3.144; 95% CI: 1.771-5.584; P<.001).

CONCLUSIONS

In critically ill patients over 80 years hospital mortality was independently related to age, SOFA score, RRT need and need for mechanical ventilation for more than 24hours. Our results raise important issues about end-of-life care and life-sustaining interventions in elderly, critically ill patients.

Update on management of invasive candidiasis

Given the growing incidence of invasive candidiasis in critically ill and haemato-oncological patients and its poor outcomes, an early diagnosis and treatment are need for get a better prognosis. This document reviews the current ap-proaches that help in diagnosis of invasive candidiasis based on culture-independent microbiological tests. The combination of clinical prediction scores with fungal serological markers could facilitate the approach in antifungal therapy, optimiz-ing it. This article also reviews the epidemiology and primary risk factors for invasive candidiasis in these patients, updating the therapeutic approach algorithms in both clinical contexts based on the main evidence and international guidelines.

Antimicrobial management in nosocomial peritonitis: microbiota, drug and time

Complicated intra-abdominal infection requires surgical treatment and broad-spectrum empiric antibiotic treatment used early. The rapid spread of multidrug-resistant bacteria has become a serious threat, especially in critical care units. The excessive use of carbapenems has led to carbapenemase-producing Enterobacteriaceae, leaving tigecycline and colistin as therapeutical options. The new antimicrobials, ceftazidime-avibactam and ceftolozane-tazobactam open new horizons in the treatment of multi-drug resistant Enterobacteriaceae. Candida peritonitis causes a high mortality in the critical patient. Diagnosis and early treatment are associated with a better prognosis, the administration of an echinocandin being of choice in these patients.

Use of the cumulative sum method (CUSUM) to assess the learning curves of ultrasound-guided continuous femoral nerve block

BACKGROUND

Although ultrasound is a basic competence for anaesthesia residents (AR) there is few data available on the learning process. This prospective observational study aims to assess the learning process of ultrasound-guided continuous femoral nerve block and to determine the number of procedures that a resident would need to perform in order to reach proficiency using the cumulative sum (CUSUM) method.

METHODS

We recruited 19 AR without previous experience. Learning curves were constructed using the CUSUM method for ultrasound-guided continuous femoral nerve block considering 2 success criteria: a decrease of pain score>2 in a [0-10] scale after 15minutes, and time required to perform it.

RESULTS

We analyse data from 17 AR for a total of 237 ultrasound-guided continuous femoral nerve blocks. 8/17 AR became proficient for pain relief, however all the AR who did more than 12 blocks (8/8) became proficient. As for time of performance 5/17 of AR achieved the objective of 12minutes, however all the AR who did more than 20 blocks (4/4) achieved it.

CONCLUSIONS

The number of procedures needed to achieve proficiency seems to be 12, however it takes more procedures to reduce performance time. The CUSUM methodology could be useful in training programs to allow early interventions in case of repeated failures, and develop competence-based curriculum.

[Diagnostic and therapeutic approach of intraabdominal candidiasis]

Invasive fungal disease is associated to a high mortality rate on critical ill patients. In the last decades an important epidemiological shift has been described. Early diagnosis and treatment are related with a better prognosis. The key factors lie in a set of predictive scores that allow to identify patients that will benefit of early treatment, as well as using diagnosis techniques that are culture independent. New diagnosis approximations are being developed with promising results: in situ hybridisation using PNA-FISH probes, MALDI-TOF MS and rapid nucleic acids detection assays. The use of echinocandin is recommended as antifungal therapy on critical ill patients with candida peritonitis.

[Resistant gram-negative bacteria. Therapeutic approach and risk factors]

The rapid spread of multidrug-resistant bacteria has become a serious threat, especially in critical care units, thereby prolonging the hospital stay. Enterobacteriaceae have a high capacity to adapt to any environment. Plasmids are the reason behind their expansion. The choice of empiric therapy for intra-abdominal or urinary infections requires knowledge of the intrinsic microbiological variability of each hospital or critical care unit, as well as the source of infection, safety or antibiotic toxicity, interaction with other drugs, the dosage regimen and the presence of risk factors. Carbapenems are the drug of choice in the case of suspected infection by ESBL-producing Enterobacteriaceae. The new ceftazidime/avibactam and ceftolozane/tazobactam drugs are opening up promising new horizons in the treatment of multidrug-resistant Enterobacteriaceae.

Location of the sciatic nerve at the popliteal fossa in the adult population: Relationship with gender and anthropometric data studied. Implications for daily practice

OBJECTIVE

To determine whether the location of the sciatic nerve (SN) at the popliteal fossa is related to anthropometric variables in the adult population, and to identify possible anatomical variations and their possible implications for clinical practice.

MATERIALS AND METHOD

Prospective observational study in elective ambulatory surgery patients. Patients were examined using ultrasound, looking at depth, laterality and distance at which the SN bifurcates at the level of the popliteal fossa. These measurements were linked to gender and the anthropometric data of the patients.

RESULTS

A total of 62 patients were included, with 124 measurements. A statistically significant association was found between SN depth and the diameter of the thigh measured at 10 cm from the popliteal crease (P<.001). Mean depth: 3.32 ± 0.8 cm, mean laterality: 1.43 ± 0.9 cm, mean SN bifurcation distance: 61.78 ± 12 mm and mean SN diameter: 7.45 ± 1.17 mm. There were no statistical differences when comparing the measured variables with the age and gender. Similar results were obtained between measurements when comparing both lower limbs in the same patient. There was no statistical difference between height and distance at which the SN bifurcates.

CONCLUSIONS

The depth and laterality of SN are independent of gender, weight and height. The depth at which the SN is located at the level of the popliteal fossa is related to the diameter of the thigh. The bifurcation of SN in popliteal fossa is not related to height.

Perioperative temperature control: Survey on current practices

INTRODUCTION

Prevention of perioperative hypothermia decreases morbidity and mortality, as well as hospital costs. This study was conducted to evaluate the level of implementation of protocols in 3 tertiary Spanish University Hospitals.

MATERIAL AND METHODS

A survey among anaesthesiologists assessed estimated importance and clinical practice in terms of prevention of perioperative hypothermia. Results were compared depending on their experience. P<.05 was considered significant.

RESULTS

A total of 116 anaesthesiologists answered the survey, of whom 48 (41.3%) were residents, 32 (27.6%) were staff with less than 10 years of experience, and 36 (31.1%) staff with 10 years or more of experience, In a 0-10 importance scale, prevention of hypothermia was scored 7.49±1,79, with no difference between groups (P=.58). Younger staff were more concerned of the end surgery temperature than other colleagues (P=.02). The most usual practice was a combination warming the intravenous fluids and an electric blanket (55%). Only 20% of the anaesthesiologists monitored temperature intra-operatively, even though 75% considered it an important parameter. No unit had a written protocol for prevention of perioperative hypothermia.

DISCUSSION AND CONCLUSION

Despite the absence of prevention protocols, the anaesthesiologists were aware of the importance maintaining a normal peri-operative temperature, but this awareness is still not enough to influence their perioperative management to diagnose and prevent hypothermia. A harmonisation of practice at local, regional and national level could improve this practice in the future.

Proteomic analysis reveals heat shock protein 70 has a key role in polycythemia Vera

JAK-STAT signaling through the JAK2^V617F mutation is central to the pathogenesis of myeloproliferative neoplasms (MPN). However, other events could precede the JAK2 mutation. The aim of this study is to analyze the phenotypic divergence between polycytemia vera (PV) and essential thrombocytemia (ET) to find novel therapeutics targets by a proteomic and functional approach to identify alternative routes to JAK2 activation. Through 2D-DIGE and mass spectrometry of granulocyte protein from 20 MPN samples, showed differential expression of HSP70 in PV and ET besides other 60 proteins. Immunohistochemistry of 46 MPN bone marrow samples confirmed HSP70 expression. The median of positive granulocytes was 80% in PV (SD 35%) vs. 23% in ET (SD 34.25%). In an ex vivo model KNK437 was used as an inhibition model assay of HSP70, showed dose-dependent inhibition of cell growth and burst formation unit erythroid (BFU-E) in PV and ET, increased apoptosis in the erythroid lineage, and decreased pJAK2 signaling, as well as a specific siRNA for HSP70. These data suggest a key role for HSP70 in proliferation and survival of the erythroid lineage in PV, and may represent a potential therapeutic target in MPN, especially in PV.

[Septic shock due to a community acquired Clostridium difficile infection. A case study and a review of the literature]

The epidemiology of Clostridium difficile infection has changed in the past decade. The incidence rate of community acquired cases has increased in patients with no typical risk factors. We present a patient who was diagnosed with community-acquired Clostridium difficile infection who presented with acute abdominal pain, and subsequently developed acute renal failure and septic shock. We describe the diagnosis, treatment and outcome and brief review of the literature.

Inhibition of related JAK/STAT pathways with molecular targeted drugs shows strong synergy with ruxolitinib in chronic myeloproliferative neoplasm

This study aimed to assess the antitumour effects, molecular mechanisms of action, and potential synergy of ruxolitinib with sorafenib, KNK437, dasatinib, and perifosine, in Philadelphia-negative chronic myeloproliferative neoplasms (MPN). Cytotoxic and cytostatic effects of the different compounds were determined in the JAK2 V617F-positive cell lines, HEL and Ba/F3 (JAK2V617F EPOR) , and in primary mononuclear and bone marrow CD34-positive cells from 19 MPN patients. Ruxolitinib [50% inhibitory concentration (IC50 )(PV)  = 15 nmol/l], as well as sorafenib (IC50 PV=8μmol/l), KNK437 (IC50 PV=100μmol/l ), and perifosine (IC50 PV=15μmol/l ), were able to inhibit proliferation in cell line models and in primary cells from MPN patients. Dasatinib, KNK437, and sorafenib showed a strong synergistic effect in combination with ruxolitinib [combination index (CI)(PV)  < 0·3]. Western blot confirmed that ruxolitinib blocked ERK, and consequently STAT5 activation, sorafenib inhibited ERK, P38 and STAT5, dasatinib blocked SRC and STAT5, and KNK437 decreased the stability of the JAK2 protein, reducing its expression. Inhibiting JAK2-related proliferative pathways has the potential to inhibit cell proliferation in MPNs. Furthermore, the combination of ruxolitinib with inhibitors that target these pathways has a strong synergistic effect, which may be due to decreased activation of the common effector, STAT5.

[Iliac artery occlusion balloons for suspected placenta accreta during cesarean section]

Massive obstetric hemorrhage still remains a major cause of maternal mortality and morbidity. The risk factors associated with this pathology must be identified in order to schedule the appropriate delivery with the necessary resources. A case is presented of an iliac artery occlusion with intravascular balloons for suspected placenta accreta during cesarean section. The perioperative treatment, as well as an analysis of the treatment options is described, along with their advantages and disadvantages, from the use of postpartum hemorrhage protocols, blood transfusion and procoagulant factors, and other maneuvers to control bleeding, until the hysterectomy.

[Failed back surgery, spinal cord stimulation and pregnancy: presentation of a case]

Spinal cord stimulation is increasingly used to manage chronic pain syndromes, such as complex regional pain syndrome, chronic back pain, refractory angina pectoris or peripheral vascular diseases, which are unresponsive to other common less aggressive treatment methods. The early use of this technique in the aforementioned diseases makes it suitable in young women of childbearing age and who wish to become pregnant. We report the case of a 33-year-old woman who became pregnant 4 months after having undergone posterior cord stimulation, and we review the approach to this situation and the perioperative management during the perinatal period.

[General anaesthesia and obstetric bleeding in caesarean section. One year's experience in a university hospital]

INTRODUCTION

Obstetric haemorrhage is an important worldwide cause of morbidity and mortality. General anaesthesia for caesarean section is rarely used. Our goal is to analyse the incidence, causes and risk factors associated with general anaesthesia for caesarean section, and the prevalence of obstetric haemorrhage (HO), its risk factors and predictors of post-caesarean HO together with the use of blood in our hospital population.

METHODS

A retrospective study was conducted on all caesarean section discharge reports from PACU in 2008.

RESULTS

General anaesthesia was required in 12.4% of the patients. Epidural catheter failure as a cause of general anaesthesia was infrequent (2.8%) and within the recommended standards.

CONCLUSIONS

The most frequent indications for caesarean section under general anaesthesia included mainly life-threatening emergencies, and the most important risk factors for general anaesthesia, including coagulation disorders, bleeding in the third trimester, foetal distress and severe pre-eclampsia. General anaesthesia is a risk factor for transfusion, as is abruptio placentae, placenta previa and pre-eclampsia.

[Massive obstetric haemorrhage in a patient with placenta percreta]

We present a case of a 38 year-old patient with prenatal diagnosis of placenta praevia. When the elective caesarean began it was found a placenta accreta. In spite of an emergency hysterectomy, embolisation using interventional radiography was needed after a massive obstetric haemorrhage. The post-operative period progressed without incidents.

Acute myeloid leukemia and transcription factors: role of erythroid Krüppel-like factor (EKLF)

We have investigated the role of erythroid transcription factors mRNA expression in patients with acute myeloid leukemia (AML) in the context of cytogenetic and other prognostic molecular markers, such as FMS-like Tyrosine Kinase 3 (FLT3), Nucleophosmin 1 (NPM1), and CCAAT/enhance-binding protein α (CEBPA) mutations. Further validation of Erythroid Krüppel-like Factor (EKLF) mRNA expression as a prognostic factor was assessed.We evaluated GATA binding protein 1 (GATA1), GATA binding protein 2 (GATA2), EKLF and Myeloproliferative Leukemia virus oncogen homology (cMPL) gene mRNA expression in the bone marrow of 65 AML patients at diagnosis, and assessed any correlation with NPM1, FLT3 and CEBPA mutations. EKLF-positive AML was associated with lower WBC in peripheral blood (P = 0.049), a higher percentage of erythroblasts in bone marrow (p = 0.057), and secondary AMLs (P = 0.036). High expression levels of EKLF showed a trend to association with T-cell antigen expression, such as CD7 (P = 0.057). Patients expressing EKLF had longer Overall Survival (OS) and Event Free Survival (EFS) than those patients not expressing EKLF (median OS was 35.61 months and 19.31 months, respectively, P = 0.0241; median EFS was 19.80 months and 8.03 months, respectively, P = 0.0140). No correlation of GATA1, GATA2, EKLF and cMPL levels was observed with FLT-3 or NPM1 mutation status. Four of four CEBPA mutated AMLs were EKLF positive versus 10 of 29 CEBPA wild-type AMLs; three of the CEBPA mutated, EKLF-positive AMLs were also GATA2 positive. There were no cases of CEBPA mutations in the EKLF-negative AML group. In conclusion, we have validated EKLF mRNA expression as an independent predictor of outcome in AML, and its expression is not associated with FLT3-ITD and NPM1 mutations. EKLF mRNA expression in AML patients may correlate with dysregulated CEBPA.

[Spanish Society of Anaesthesia (SEDAR) guidelines for pre-anaesthesia checking procedures]

We present this document as a guide to preparing a specific institutional pre-anaesthesia checklist, as recommended in the Helsinki declaration on patient safety in anaesthesiology. Also, the recently recommended WHO "safe surgery check-list" includes a check-list for anaesthesia. A working group was established in accordance with the charter of the Spanish Society of Anaesthesiology and Resuscitation (Sociedad Española de Anestesiología y Reanimación [SEDAR]). The new patient safety culture introduced into medicine, and the recommendations of European anaesthesia societies has led us to design and update protocols in order to improve results in this important part of our speciality. We have prepared these recommendations or guidelines using, as examples, updates of pre-anaesthesia check-lists by other American (ASA), British, or Canadian societies of anaesthesia. With that aim, we enlisted the help of anaesthesia ventilator experts and the participation and advice of experienced anaesthesiologists from all parts of Spain. After various corrections and modifications, the document was available at www.sedar.es, so that any anaesthesiologist could propose any correction, or give their opinion. Finally, these guidelines have been approved by the SEDAR Board of Directors, before it was sent for publication in this journal. The aims of this document are to provide: a guideline applicable to all anaesthesia machines, a descriptive pre-anaesthesia check-list that include everything necessary for the anaesthesia procedure, and a resumed check-list to be available in all the anaesthesia machines or other equivalent, but prepared for each institution, which should include anaesthetic equipment and drugs. So, in order to ensure the aims and requirements of the European Board of Anaesthesiology, the European Society of Anaesthesiology, and the WHO are met, each institution should have a protocol for checking equipment and drugs. These guidelines are applicable to any anaesthesia equipment, enabling every institution to develop their own checking protocols, adapted to their anaesthesia machines and their procedures. With the consent of the SEDAR, this group will collaborate with anaesthesia machines providers in order to develop specific checklists for each of their models that will be available at www.sedar.es.

A randomized control trial of patient-controlled epidural analgesia (PCEA) with and without a background infusion using levobupivacaine and fentanyl

BACKGROUND

Continuous infusion associated with patient-controlled epidural analgesia (PCEA) is used in many maternal units. This randomized controlled study evaluated the effect of a 10 mL/h background infusion associated with a 10 mL-20 minutes lockout time demand-only PCEA protocol using L-bupivacaine plus fentanyl in terms of local anaesthetic consumption, pain management and maternal satisfaction.

METHODS

Forty consenting parturients were randomly assigned to receive a 0.125% levobupivacaine plus 1.5 mcg/mL fentanyl PCEA (10 mL bolus with a 20 min lock time) with or without a 10 mL/h background infusion. The total volume of local anesthetic, the number of PCEA demand boluses, pain levels, delivery outcome and maternal satisfaction were evaluated.

RESULTS

The total volume of local anaesthetic was 35[20-120] mL in demand-only PCEA group versus 63.8[22.5-123] mL in PCEA plus background infusion group (P<0.001). This decrease in total volume was associated with an increase of self-administrated boluses in demand-only group (3.5[2-12] boluses, versus 1[0-3] bolus in PCEA plus background infusion group) (P<0.001). Pain scores were comparable between groups at any time of the study (P>0.05). Maternal satisfaction did not differ between groups (10[8-10] vs. 10[7-10]; P=0.11).

CONCLUSION

When a levobupivacaine plus fentanyl PCEA protocol with high volume boluses and long lockout interval is used for labour analgesia, the background infusion increased the total local anesthetic dose with no change in pain management and maternal satisfaction.

Epigenomic profiling in polycythaemia vera and essential thrombocythaemia shows low levels of aberrant DNA methylation

AIMS

The purpose of this study was to compare the DNA-methylation signature in classic chronic Philadelphia negative myeloproliferative neoplasms (MPN), polycythaemia vera (PV) and essential thrombocythaemia (ET), in order to obtain a global insight into DNA-methylation changes associated with these malignancies.

METHODS

Thirty-five MPN samples from 11 ET JAK2 V617F, 12 ET JAK2 wild type (WT) and 12 PV JAK2 V617F patients as well as 12 from healthy donors were analysed. DNA samples extracted from whole peripheral blood were hybridised to the 'HumanMethylation27 DNA Analysis BeadChip.'

RESULTS

All groups showed a very homogeneous methylation pattern. Only the ZNF577 gene showed a differential methylation profile between PV JAK2 V617F positive and controls. This aberrant methylation was correlated with a differential gene expression of ZNF577. No aberrant hypermethylation was found in the SOCS-1 and SOCS-3 genes.

CONCLUSIONS

According to our results, an aberrant methylation pattern does not seem to play a crucial role in MPN pathogenesis; nor does it justify phenotypical differences between PV and ET.

4.1R-deficient human red blood cells have altered phosphatidylserine exposure pathways and are deficient in CD44 and CD47 glycoproteins

BACKGROUND

Protein 4.1R is an important component of the red cell membrane skeleton. It imparts structural integrity and has transmembrane signaling roles by direct interactions with transmembrane proteins and other membrane skeletal components, notably p55 and calmodulin.

DESIGN AND METHODS

Spontaneous and ligation-induced phosphatidylserine exposure on erythrocytes from two patients with 4.1R deficiency were studied, using CD47 glycoprotein and glycophorin C as ligands. We also looked for protein abnormalities in the 4.1R-based multiprotein complex.

RESULTS

Phosphatidylserine exposure was significantly increased in 4.1R-deficient erythrocytes obtained from the two different individuals when ligands to CD47 glycoprotein were bound. Spontaneous phosphatidylserine exposure was normal. 4.1R, glycophorin C and p55 were missing or sharply reduced. Furthermore there was an alteration or deficiency of CD47 glycoprotein and a lack of CD44 glycoprotein. Based on a recent study in 4.1R-deficient mice, we found that there are clear functional differences between interactions of human red cell 4.1R and its murine counterpart.

CONCLUSIONS

Glycophorin C is known to bind 4.1R, and we have defined previously that it also binds CD47. From our evidence, we suggest that 4.1R plays a role in the phosphatidylserine exposure signaling pathway that is of fundamental importance in red cell turnover. The linkage of CD44 to 4.1R may be relevant to this process.

[Estimating the angle of left lateral decubitus position during cesarean section: observational study of anesthesiologists' estimates and of midwives and nurses' level of understanding]

OBJECTIVES

To determine the difference between the estimated and measured values of the left lateral decubitus (LLD) angle in the positioning of patients for scheduled cesarean section; to determine whether the accuracy of estimates differs between staff anesthesiologists and residents; and to assess the angle estimates of midwives and surgical nurses as well as their level of knowledge with respect to the utility of the LLD position.

METHODS

This was a prospective, observational, double-blind study comparing staff anesthesiologists working in obstetrics to residents in their second, third, or fourth-year of training. We also presented a task and questions to midwives and surgical nurses who assisted during categories 3 and 4 cesarean sections (elective and scheduled procedures) according to the classification system of he National Institute of Clinical Excellence. The anesthesiologist was asked to place the patient in LLD position after onset of anesthesia and to estimate the LLD angle. A second anesthesiologist measured the angle. The midwives and nurses were asked to place a vacant surgical table at approximately 15 degrees; the angle was then measured. Patient variables (weight, height, anesthetic technique) and staff variables (position, understanding of the purpose of the maneuver, estimated DLL angle, and measured angle) were recorded.

RESULTS

Of 55 women who underwent cesarean sections (98.18% under regional anesthesia), 25 were assessed by staff anesthesiologists and 30 by residents. A total of 14 midwives and 10 surgical nurses participated in the surgical table positioning task and answered questions. The mean (SD) DLL angle estimate of the anesthesiologists was 12.4 degrees (3.4 degrees); the mean measured angle was 7.8 degrees (3.1 degrees). The estimates of staff anesthesiologists were significantly more accurate (P < .001). All the midwives understood the reason for using the DLL position in cesarean section, while only 1 nurse (10%) did (P < .05).

CONCLUSION

The DLL position angle is overestimated by resident anesthesiologists and midwives. It seems that the use and understanding of DLL positioning could be improved.

Frequency of congenital dyserythropoietic anemias in Europe

Congenital dyserythropoietic anemias (CDAs) are rare hereditary disorders characterized by ineffective erythropoiesis and striking abnormalities of erythroblast morphology. The mutated genes are known for the most frequent types, CDA I and II, but data about their frequency do not exist. The objective of this retrospective study was to estimate the frequency of CDA I and II, based on all cases reported in the last 42 yr in publications and identified registries or surveys. Reports were collected of 124 and 377 confirmed cases of CDA I and CDA II cases, respectively. The cumulated incidence of both types combined varied widely between European regions, with minimal values of 0.08 cases/million in Scandinavia and 2.60 cases/million in Italy. CDA II is more frequent than CDA I, with an overall ratio of approximately 3.2, but the ratio also varied between different regions. The most likely explanations for the differences are both differences in the availability of advanced diagnostic procedures and different levels of the awareness for the diagnosis of the CDAs. The estimations reported here are most probably below the true incidence rates, because of failure to make the correct diagnosis and to underreporting. Limited data do not suggest differing levels of risk in identified ethnic groups.

[Maternal hypotension with low doses of spinal bupivacaine or levobupivacaine and epidural volume expansion with saline for cesarean section]

BACKGROUND AND OBJECTIVE

Epidural volume extension (EVE) with saline solution can contribute to greater cephalad spread of drugs injected into the subarachnoid space during cesarean section. We studied the incidence of material hypotension with spinal bupivacaine or levobupivacaine (L-bupivacaine) and the spread after epidural saline injection.

MATERIAL AND METHODS

After ethics committee approval, we randomized women scheduled for cesarean section to 4 groups to receive 5 mg of 0.25% bupivacaine with (n=51) or without (n=6) saline EVE; 5 mg of 025% L-bupivacaine (n=50); or 6 mg of 03% L-bupivacaine (n=50). All patients also received 25 microg of fentanyl per 2 mL of local hyperbaric spinal anesthetic. In all except the non-EVE group, 10 mL of saline was infused through an epidural catheter 5 minutes after anesthetic infusion. We recorded patient demographic data, procedural and anesthetic times, incision-clamping times, occurrence of hypotension, ephedrine dose required, motor and sensory blockade, requirement for rescue analgesics, and neonatal outcome.

RESULTS

After 6 patients had been randomized to the non-EVE group, no further patients were assigned because all the women required rescue analgesics. Demographic data, duration of procedure, time between. incision and delivery, and Apgar scores were similar in all the groups. The incidence of hypotension was lower in the group receiving 5 mg of L-bupivacaine (26% vs. 52.9% in the bupivacaine 5-mg group, and 56% in the 6-mg L-bupivacaine group, P = .04). More women given 5 mg of L-bupivacaine required rescue analgesia (46%) than did those receiving 5 mg of bupivacaine (235%) or 6 mg of L-bupivacaine (28%) (P = .039). Hypotension was associated with a lower umbilical cord pH (P = .001). Ephedrine doses over 20 mg were also associated with a lower umbilical cord pH (P = .031).

CONCLUSIONS

The incidence of hypotension was lowest in the group anesthetized with 5 mg of L-bupivacaine, but the need for rescue analgesia was greater in this group. Doses of 5 mg and 6 mg may be sufficient for cesarean section, as they provide a good level of sensory blockade.

Anesthetic management of an adult patient with Cornelia de Lange Syndrome

Cornelia de Lange Syndrome is a well-known congenital disease characterized by multiple malformations that make anesthetic management a challenge. Since few individuals survive the earliest stage of life, papers describing the details of anesthetic management are mainly reported in the pediatric population. These individuals who move into adulthood develop physical changes that should be taken into consideration. This article reports the case of a 34-year-old patient undergoing an orthopedic procedure. The operation was performed under general anesthesia because the patient showed severe scoliosis and joint contractures, so extraordinary difficulty in neuroaxial and peripheral techniques was expected. The aggressive behavior of the patient impeded the proper assessment of a preoperative airway. Fiber optic intubation was performed under slight sedation after three unsuccessful attempts. Dental crowding, prominent upper central incisors that were more pronounced than in most children, a short and stiff neck, and poor patient cooperation due to mental retardation and occasional autistic behavior made airway management difficult. This case should alert anesthesiologists to the greater difficulties of managing patients with Cornelia de Lange Syndrome when they become adults.

[Treating severe acute anemia due to vaginal bleeding in the Jehovah's Witness: a report of 2 cases]

For reasons of religious belief, Jehova's Witnesses do not accept blood transfusions or the infusion of blood products. In situations in which severe, life-threatening anemia develops, patient refusal to receive a transfusion can create serious ethical and legal problems. The principle of patient autonomy, which implies the freedom to accept or reject treatment, comes into conflict with the physician's obligation to safeguard the patient's life using all means possible. We report 2 cases of severe anemia in Jehova's Witnesses. One was due to menorrhagia and the other to postpartum bleeding. The physician should be aware of alternatives to infusion of blood products and know how to cope with an unexpected critical event in these patients. The measures we took were effective in our patients. In the case of menorrhagia, hormone treatment is effective when the woman wishes to preserve the ability to conceive and avoid surgery (endometrial ablation and hysterectomy). In postpartum bleeding refractory to conservative treatment, selective embolization of bleeding vessels may make it unnecessary to resort to more aggressive treatment, such as obstetric hysterectomy.

[Monitoring skill acquisition in obstetric epidural puncture at a university hospital using the cumulative sum method]

BACKGROUND AND OBJECTIVE

Skill acquisition in anesthesiology is subject to a great deal of interindividual variability. Our aim was to develop and test an individualized tool for monitoring acquisition of technical skills based on the cumulative sum (CUSUM) approach. This system objectively assesses whether an individual has acquired a minimum skill level and identifies the moment when the skill has been learned.

MATERIAL AND METHODS

Nine third-year residents in anesthesiology and postoperative recovery care participated. The residents anonymously recorded their first 100 obstetric epidural analgesia procedures in a database. The data were then analyzed with the CUSUM method. We considered acceptable skill acquisition to be reflected by a first-attempt success rate of 80% and a rate of success with help of 20%.

RESULTS

A total of 765 epidural blocks were analyzed, giving a mean (SD) of 84.7 (2.8) procedures per resident (range, 47-100 procedures per resident). Seven residents became competent with the skill after 23 procedures and 2 residents were not successful in learning the skill. At the end of the study, 3 residents had required help with more than 20% of the procedures. Data collection from the trainees seemed to vary, leading to possible under- or overestimation of failures and/or need for help. Accidental dural puncture occurred 6 times (0.78%) and blood vessel puncture 40 times (5.2%).

CONCLUSIONS

Although some third-year residents reach the targeted rate of success quickly, we believe that close supervision is useful to control progress along the learning curve for individuals who need more help.

[Failure of extension of epidural analgesia to anesthesia for emergency cesarean section]

Epidural analgesia provides effective control of labor pain and allows emergency cesarean section to be performed without recourse to general anesthesia. This technique is subject to failure, however. We sought to determine the incidence of failure of extension of epidural analgesia for labor to epidural anesthesia for emergency cesarean section. We also analyzed possible risk factors for failure. A 2-month observational study was carried out in a tertiary-care university hospital in patients who had an epidural catheter inserted for labor analgesia and who later underwent emergency cesarean section. Epidural catheter failure was defined if additional analgesia was required during surgery or if general anesthesia was required. Data were gathered on possible risk factors, such as obesity, difficult epidural puncture, leakage of blood on insertion, history of cesarean delivery, need for rescue analgesia, and level of satisfaction with analgesia during dilation. In total, 134 emergency cesareans were performed in women carrying an epidural catheter. The catheter failed to administer the anesthetic in 18 patients (13.4%). General anesthesia was required in 9 cases (6.7%). Difficult insertion (more than 2 attempts) was associated with a higher failure rate (P=.064). The relative risk of epidural catheter failure was 2.86-fold higher when rescue analgesia was needed during delivery than in cases when no supplement was required (P=.021). Receiving adequate analgesia during labor seems to be a protective factor (80%) against anesthetic catheter failure during cesarean section (P=.01). We conclude that high demand for rescue analgesia and signs of inadequate analgesia during labor should warn of epidural catheter failure if extension to anesthesia becomes necessary for a cesarean delivery.

Long-term follow-up of donor chimerism and tolerance after human liver transplantation

We aimed to quantify peripheral donor chimerism (DC) and to analyze its association with graft and recipient outcome. Forty-two liver transplant recipients and their respective donors were studied, providing a total of 148 posttransplantation serum samples. DC was assessed with real-time quantitative polymerase chain reaction (qPCR) to detect polymorphic markers. DC did not decrease with time post-transplantation and was higher in child recipients versus adults and in recipients of deceased donor liver transplants versus recipients of live donor liver transplants. Higher levels of DC were detected in Rh-positive blood group donors, in O blood group recipients versus A blood group recipients, and in recipients with hepatitis C virus versus recipients with alcoholic cirrhosis. High DC was associated with patients with organ damage due to recurrent disease and rejection. Stable, high levels of DC, in the absence of other major clinical events, may thus be a marker of transplantation tolerance, and this knowledge may help to tailor immunosuppressive treatment. In conclusion, qPCR is a useful technique for DC follow-up in liver transplantation, although the evolution of DC levels should be analyzed in accordance with the clinical outcome of the patient.

High resolution melting analysis for JAK2 Exon 14 and Exon 12 mutations: a diagnostic tool for myeloproliferative neoplasms

JAK2 mutations are important criteria for the diagnosis of Philadelphia chromosome-negative myeloproliferative neoplasms. We aimed to assess JAK2 exon 14 and exon 12 mutations by high-resolution melting (HRM) analysis, which allows variation screening. The exon 14 analysis included 163 patients with polycythemia vera, secondary erythrocytoses, essential thrombocythemia, or secondary thrombocytoses, and 126 healthy subjects. The study of exon 12 included 40 JAK2 V617F-negative patients (nine of which had polycythemia vera, and 31 with splanchnic vein thrombosis) and 30 healthy subjects. HRM analyses of JAK2 exons 14 and 12 gave analytical sensitivities near 1% and both intra- and interday coefficients of variation of less than 1%. For HRM analysis of JAK2 exon 14 in polycythemia vera and essential thrombocythemia, clinical sensitivities were 93.5% and 67.9%, clinical specificities were 98.8% and 97.0%, positive predictive values were 93.5% and 79.2%, and negative predictive values were 98.8% and 94.6, respectively. Correlations were observed between the results from HRM and three commonly used analytical methods. The JAK2 exon 12 HRM results agreed completely with those from sequencing analysis, and the three mutations in exon 12 were detected by both methods. Hence, HRM analysis of exons 14 and 12 in JAK2 shows better diagnostic values than three other routinely used methods against which it was compared. In addition, HRM analysis has the advantage of detecting unknown mutations.