BACKGROUND:Intraoperative pain during cesarean delivery with or without conversion to general anesthesia has been shown to negatively impact maternal and perinatal morbidity. Efforts to reduce these adverse events are a recent focus of obstetric anesthesia care. We aimed to assess rates of and risk factors for conversion to general anesthesia and intraoperative pain during intrapartum cesarean delivery with an indwelling epidural catheter in our academic center. METHODS:In this retrospective cohort study, all women undergoing cesarean delivery with an indwelling epidural catheter between January 2017 and June 2022 were included. Labor epidural analgesia was provided according to a standardized protocol, and conversion to epidural anesthesia was achieved in the operating room before surgery. We determined the conversion rate to general anesthesia and associated risk factors. Second, we examined the rate of administration of analgesics/sedatives and related risk factors in cesarean cases that were not converted to general anesthesia. RESULTS:Among the 1192 women undergoing intrapartum cesarean delivery with epidural anesthesia, there were 97 cases with conversion to general anesthesia (8.1%), of which 87 (89.7%) were due to a failed epidural. Higher age, higher weight, and higher gestational age were associated with decreased odds of conversion to general anesthesia. Higher gravidity and longer surgical time were associated with increased odds. An emergent indication was not associated with conversion to general anesthesia. Intravenous analgesic/sedative supplementation occurred in 141 cases (12.9%). Higher age was associated with decreased odds of supplementation, and longer surgical time was associated with increased odds. CONCLUSION:In our tertiary academic center, the rate of intraoperative conversion to general anesthesia and administration of analgesic/sedative medication among women undergoing intrapartum cesarean delivery with epidural anesthesia was relatively high. Emergency cesarean delivery was not associated with either of the above endpoints.

(Anaesthesia. 2023;78:1256–1261) Previous studies have come to different conclusions about whether insertion of an intrathecal (IT) catheter after accidental dural puncture (ADP) during epidural anesthesia reduces complications. The most common complication is postdural puncture headache (PDPH), which can have short-term and long-term effects, including decreased breastfeeding and increased risk for postpartum depression, chronic headache, and backache. The usual treatment for PDPH is an epidural blood patch (EBP), which itself can have serious complications. Accidental dural puncture occurs in ∼0.5% to 1.0% of all epidurals. The authors of this study investigated whether IT catheter insertion was associated with a decreased risk of PDPH and a decreased need for EBP.

BACKGROUND Cardiac surgery involving cardiopulmonary bypass induces a significant systemic inflammatory response, contributing to various postoperative complications, including pulmonary dysfunction, myocardial and kidney injuries. OBJECTIVE To investigate the effect of Nitric Oxide delivery via the cardiopulmonary bypass circuit on various postoperative outcomes. DESIGN A prospective, single-centre, double-blinded, randomised controlled trial. SETTING Rabin Medical Centre, Beilinson Hospital, Israel. PATIENTS Adult patients scheduled for elective cardiac surgery were randomly allocated to one of the study groups. INTERVENTIONS For the treatment group, 40 ppm of nitric oxide was delivered via the cardiopulmonary bypass circuit. For the control group, nitric oxide was not delivered. OUTCOME MEASURES The primary outcome was the incidence of hypoxaemia, defined as a p a O 2 /FiO 2 ratio less than 300 within 24 h postoperatively. The secondary outcomes were the incidences of low cardiac output syndrome and acute kidney injury within 72 h postoperatively. RESULTS Ninety-eight patients were included in the final analysis, with 47 patients allocated to the control group and 51 to the Nitric Oxide group. The Nitric Oxide group exhibited significantly lower hypoxaemia rates at admission to the cardiothoracic intensive care unit (47.1 vs. 68.1%), P = 0.043. This effect, however, varied in patients with or without baseline hypoxaemia. Patients with baseline hypoxaemia who received nitric oxide exhibited significantly lower hypoxaemia rates (61.1 vs. 93.8%), P = 0.042, and higher p a O 2 /FiO 2 ratios at all time points, F (1,30) = 6.08, P = 0.019. Conversely, this benefit was not observed in patients without baseline hypoxaemia. No significant differences were observed in the incidence of low cardiac output syndrome or acute kidney injury. No substantial safety concerns were noted, and toxic methaemoglobin levels were not observed. CONCLUSIONS Patients with baseline hypoxaemia undergoing cardiac surgery and receiving nitric oxide exhibited lower hypoxaemia rates and higher p a O 2 /FiO 2 ratios. No significant differences were found regarding postoperative pulmonary complications and overall outcomes. TRIAL REGISTRATION NCT04807413.

Background: Pulmonary aspiration is a potentially lethal perioperative complication that can be precipitated by gastric insufflation. Face mask ventilation (FMV), a ubiquitous anesthetic procedure, can cause gastric insufflation. FMV with an inspiratory pressure of 15 cm H(2)0 provides the best balance between adequate pulmonary ventilation anda low probability of gastric insufflation. There is no data about the effects of FMV > 120 seconds. Objectives: To investigate the effect of prolonged FMV on gastric insufflation. Methods: We conducted a prospective observational study at a tertiary medical center with female patients who underwent oocyte retrieval surgery under general anesthesia FMV. Pre- and postoperative gastric ultrasound examinations measured the gastric antral cross-sectional area to detect gastric insufflation. Pressure-controlled FMV with an inspiratory pressure of 15 cm H(2)0 was continued from the anesthesia induction until the end of the surgery. Results: The study comprised 49 patients. Baseline preoperative gastric ultrasound demonstrated optimal and good image quality. All supine measurements were feasible. The median duration of FMV was 13 minutes (interquartile range 9-18). In the postoperative period, gastric insufflation was detected in only 2 of 49 patients (4.1%). There was no association between the duration of FMV and delta gastric antral cross-sectional area (-0.01; 95% confidence interval -0.04 to 0.01, P= 0.31). Conclusions: Pressure-controlled FMV with an inspiratory pressure of 15 cm H(2)0 carries a low incidence of gastric insufflations, not only as a bridge to a definitive airway but as an alternative ventilation method for relatively short procedures in selective populations.

(Acta Anaesthesiol Scand. 2022;66:563–568) Within obstetric anesthesia, accidental dural puncture is the most prevalent complication, contributing to a postdural puncture headache (PDPH) in 60% to 70% of patients. Currently, epidural blood patch (EBP) is a standard treatment for PDPH, yet questions regarding optimal blood volume, effectivity, and others remain. EBP can be done through conventional EBP (C-EBP) or through fluoroscopy-guided EBP (F-EBP) methods. The aim of this study is to determine headache intensity at hospital discharge, compare blood volumes used in C-EBPs versus F-EBPs, and analyze the outcomes of both treatment methods.

(Reg Anesth Pain Med. 2022;47:249–250. doi: 10.1136/rapm-2021-103285) Accidental dural puncture (ADP) is a persistent concern among anesthesiologists as a serious obstetric anesthesia complication yet there remains a need to investigate modifiable risk factors. The aim of this study was to survey anesthesiologists who performed an ADP and describe their perspectives on the patient, proceduralist, task, and organization-related risk factors that may contribute to ADP.

Pulmonary aspiration is a potentially lethal perioperative complication related to gastric size and contents. Several perioperative factors are believed to increase gastric size, while others are less studied. This prospective observational study aimed to investigate the effect of preoperative anxiety and hormone-induced ovarian stimulation on gastric size examined by gastric ultrasound. We recruited 49 female patients undergoing hormone-induced ovarian stimulation and oocyte retrieval for in vitro fertilization at Rabin Medical Centre, Petah Tikva, Israel. Preoperatively, women ranked their anxiety level using a verbal numeric anxiety score (VNS). In addition, we recorded the extent of ovarian stimulation and measured the antral cross-sectional area (CSA) using gastric ultrasound. There was no substantial correlation between preoperative VNS anxiety and antral CSA (p = .697). Moreover, the number of follicles, blood estradiol, and progesterone levels did not correlate with antral CSA (p = .590, p = .104, and p = .511, respectively). In conclusion, neither preoperative anxiety nor extensive ovarian stimulation affects gastric size in fasting healthy patients. However, further studies are warranted in this area to define these findings better. Trial registration: Clinicaltrials.gov, identifier: NCT04833530

Summary Accidental dural puncture during an attempt to establish labour epidural analgesia can result in postdural puncture headache and long‐term debilitating conditions. Epidural blood patch, the gold standard treatment for this headache, is invasive and not always successful. Inserting an intrathecal catheter after accidental dural puncture may prevent postdural puncture headache. We evaluated the effect of intrathecal catheter insertion on the incidence of postdural puncture headache and the need for epidural blood patch and whether duration of intrathecal catheterisation or injection of intrathecal saline affected outcome. Our retrospective study was conducted at two tertiary, university‐affiliated medical centres between 2017 and 2022 and included 92,651 epidurals and 550 cases of accidental dural puncture (0.59%); 219 parturients (39.8%) received an intrathecal catheter and 331 (60.2%) a resited epidural. Use of an intrathecal catheter versus resiting the epidural did not decrease the odds of postdural puncture headache, adjusted odds ratio (aOR) (95%CI) 0.91 (0.81–1.01), but was associated with a lower need for epidural blood patch (aOR (95%CI) 0.82 (0.73–0.91), p < 0.001). We found no benefit in leaving in the intrathecal catheter for 24 h postpartum (postdural puncture headache, aOR (95%CI) 1.01 (1.00–1.02), p = 0.015; epidural blood patch, aOR (95%CI) 1.00 (0.99–1.01), p = 0.40). We found an added benefit of injecting intrathecal saline as it decreased the incidence of postdural puncture headache (aOR (95%CI) 0.85 (0.73–0.99), p = 0.04) and the need for epidural blood patch (aOR (95%CI) 0.75 (0.64–0.87), p < 0.001). Our study confirms the benefits of intrathecal catheterisation and provides guidance on how to best manage an intrathecal catheter.

INTRODUCTION:This case involved a 67-year-old female who was admitted for general anesthesia for a mitral clip procedure. Following anesthesia induction, the patient underwent an uneventful orotracheal intubation. Shortly afterwards she developed an ongoing respiratory failure, accompanied by neck and chest subcutaneous emphysema. Upon workup, she was found to have a 6 cm long tracheal laceration on the posterior side. Emergency repair surgery was performed using an extracorporeal membrane oxygenator (ECMO). The patient passed away 11 days later from sepsis. The aim of this case report is to increase awareness of this rare intubation complication, and explore the best approach to prevent, diagnose and treat tracheal injuries during endotracheal intubation.

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.

BACKGROUND:Epidural blood patch is a common effective treatment for postdural puncture headache after accidental dural puncture during labor and may be done in conventional or fluoroscopy-guided methods. The aim of this study was to compare intensity of headache at the time of discharge from the hospital and to compare blood volumes injected in conventional epidural blood patches versus fluoroscopic-guided blood patches and evaluate the side effects of both method of treatment.METHODS:Between the years 2010 and 2020, 84 patients who were diagnosed with postdural puncture headache received either a conventional epidural blood patch or a fluoroscopic-guided blood patch. Blood volumes were compared and evaluation of side effects was made based on data collected during and after the procedure.RESULTS:Eighty-four patients were included in this study. Fifty-two women in the conventional epidural blood patch group and 32 in the fluoroscopic-guided blood patch group. Women in the conventional epidural blood patch group received statistically significantly higher doses of blood than women in the fluoroscopic-guided blood patch group: conventional method 29 ml IQR [23-36] versus fluoroscopic method 16 ml, IQR [12-18], p < .001 with no difference in headache pain intensity at hospital release. There was no difference between groups in hospital length of stay, or persistent PDPH. There was also no difference chronic headache or backache between the two groups.CONCLUSIONS:Women who received fluoroscopic epidural blood patch required a much lower volume of blood injected while there was no difference between groups in headache pain intensity at discharge.

Abstract BACKGROUND: Pulmonary aspiration is a potentially lethal perioperative complication related to gastric size and contents. Several perioperative factors are believed to increase gastric size, while others are less studied. Therefore, this study aimed to investigate the effect of anxiety, hormone-induced ovarian stimulation, and prolonged face mask ventilation (FMV) on gastric size via measuring antral cross-sectional area (CSA) using ultrasound.METHODS: This prospective observational study was conducted in Rabin Medical Center, Israel. We recruited 49 female patients undergoing hormone-induced ovarian stimulation and oocyte retrieval for in-vitro fertilization. Preoperatively, they ranked anxiety level on a visual numeric anxiety score (VNS). In the operation room, pre-and postoperative gastric ultrasound examinations were performed. Anesthesia was induced intravenously, followed by FMV with a peak inspiratory pressure of 15 cm H2O.RESULTS: There was no substantial correlation between pre-operative VNS anxiety and antral CSA (p=0.697). Moreover, the number of follicles, blood estradiol, and progesterone levels did not correlate with antral CSA (p=0.590, p=0.104, and p=0.511, respectively). The median duration of FMV was 13 minutes [IQR 18 to 8.5] and did not correlate with the antral CSA delta (p=0.312).CONCLUSIONS: Neither preoperative anxiety nor extensive ovarian stimulation affects gastric size. Moreover, prolonged FMV with a peak inspiratory pressure of 15 cm H2O did not increase the gastric size by insufflation. These findings add to a growing body of literature on this topic. Furthermore, it provides new evidence that FMV is still safe even in a relatively short procedure.TRIAL REGISTRATION: ClinicalTrials.gov (Registration number, NCT04833530; Registration date, 06/04/2021).

Intraoperative pain is a possible complication of neuraxial anaesthesia for caesarean delivery. There is little information available about its incidence, risk factors and physician perception.

Introduction: There have been numerous reports studying the effect of neuraxial analgesia on breastfeeding success, but the results are inconsistent. Methods: We performed a literature search in various databases for studies comparing neuraxial analgesia to non-neuraxial or no analgesia. Outcomes were the percentage of women breastfeeding fully or mixed with formula. Where possible, nulliparous parturients were analyzed separately. We conducted an analysis excluding studies of serious and critical risk of bias. Odds ratios and 95% confidence intervals were calculated. Results: We included 15 studies (13 observational studies, 1 secondary analysis of a randomized controlled trial, 1 case-control study) with 16,112 participants. Overall, there were 6 studies that found no difference between groups, 6 studies that showed a significantly lower incidence of breastfeeding in the neuraxial group and 3 studies finding mixed results (at some time-points statistically significant and at some time-point statistically non-significant results). In nulliparous only studies, 2 found no difference between study groups, 1 found a lower breastfeeding rate in the neuraxial group and 3 studies showed mixed results. Excluding studies with a serious and critical risk of bias, 1 study found no difference between study groups, 3 studies found a decrease of breastfeeding rates in the neuraxial group, and 1 study showed mixed results. Discussion: In our review we found a high disparity in results. One reason is probably the high potential of confounding (immediate skin to skin placement, maternity leave etc.). Education programs and breastfeeding support are likely more important in determining long term breastfeeding success.

We would like to report our experience from the Israel National Obstetric Anesthesia WhatsApp group. Obstetric anesthesia is a high-pressure field that requires quick decisions for emergency cases. To provide rapid information sharing, we established a WhatsApp group that comprises 38 attending anesthesiologists from 19/21 (90%) of hospitals in Israel. We investigated our WhatsApp group messages and compared the discussions before and after the COVID-19 pandemic became a concern in Israel. Likewise, we sent a questionnaire before and during the COVID-19 pandemic to ask members about the benefits of the WhatsApp group. Two independent authors screened the chat history of the WhatsApp group from its inception on March 24, 2017 until March 28, 2020. According to the Institutional Review Board of Shaare Zedek Medical Center, ethical approval was not required for this study. Data were collected about the subject of the discussion, the number of participants, the number of responses, the time it took between raising a topic and receiving the first reply, and the type of media sent. The topics discussed were divided into the following categories: patient case, clinical discussion, obstetric unit organization, conference-related, articles, lectures, and questionnaires. We considered two specific time periods: before the COVID-19 pandemic (from March 24, 2017 to March 3, 2020) and during the COVID-19 pandemic (from March 5, 2020 to March 28, 2020). Before the pandemic there were 2651 messages sent and during the COVID-19 period there were a total of 121 messages sent (Table 1). We found a higher number of messages sent per month during the COVID-19 pandemic than before the pandemic and fewer responders during the COVID-19 pandemic than before it. The response rates were 34/38 (89.4%) and 25/38 (65.7%) to the first and second questionnaires, respectively. During both periods participants agreed they benefited greatly from using the group (5-point Likert scale: 5 = "benefited greatly" and 1 = "did not learn anything").Table 1WhatsApp message characteristics before and during the COVID-19 pandemicBefore COVID-19During COVID-19P-valueaChi-square or Fisher's exact test (when the expected number of events were below 5) were performed for categorical variables. Student's t-test or Mann-Whitney U test (for non-parametric values) were performed for continuous variables(95% CI of difference)OverallMessages per month (mean)7612177Number of responses7 (2.0, 13.0)7 (3.0, 16.0)0.006(2.0 to 8.5)7 (1.8; 13)Number of responders5 (2.0, 8.0)4 (2.0, 13.0)0.013(2.5 to 6)4 (2.0; 8.0)Time to first response (min)5 (1.3, 10.0)4 (1.0, 8.0)0.374.5 (1.0; 9.8)Satisfaction ratebSurvey responses on a 5-point Likert scale where 5 = "benefited greatly" and 1 = "did not learn anything" and on yes/no level.5 (5.0, 5.0)5 (5.0, 5.0)0.089Satisfaction ratecSurvey responses on a 5-point Likert scale where 5 = "benefited greatly" and 1 = "did not learn anything" and on yes/no level.4 (3.0, 5.0)5 (5.0, 5.0)0.001(−2.0 to −1.0)All values, except mean messages per month, are presented as median (1st quartile; 3rd quartile).CI: confidence interval.Questions asked before COVID-19:1. How much did you learn from the group professionally on a scale from 1 to 5?2. How much did you learn about equipment and protocols on a scale from 1 to 5?3. Have you implemented any recommendations that you received in the group (yes/no)?4. Did you gain knowledge about specific cases (yes/no)?Questions asked during COVID-19:1. How much have you learned about SARS-CoV-2 from this WhatsApp group on a scale from 1 to 5?2. How much did this WhatsApp group help you prepare to treat a SARS-CoV-2 parturient on a scale from 1 to 5?a Chi-square or Fisher's exact test (when the expected number of events were below 5) were performed for categorical variables. Student's t-test or Mann-Whitney U test (for non-parametric values) were performed for continuous variablesb,c Survey responses on a 5-point Likert scale where 5 = "benefited greatly" and 1 = "did not learn anything" and on yes/no level. Open table in a new tab All values, except mean messages per month, are presented as median (1st quartile; 3rd quartile). CI: confidence interval. Questions asked before COVID-19: 1. How much did you learn from the group professionally on a scale from 1 to 5? 2. How much did you learn about equipment and protocols on a scale from 1 to 5? 3. Have you implemented any recommendations that you received in the group (yes/no)? 4. Did you gain knowledge about specific cases (yes/no)? Questions asked during COVID-19: 1. How much have you learned about SARS-CoV-2 from this WhatsApp group on a scale from 1 to 5? 2. How much did this WhatsApp group help you prepare to treat a SARS-CoV-2 parturient on a scale from 1 to 5? A WhatsApp group for peers in the field of obstetric anesthesiology can add substantial value to the group members. This opinion was confirmed by the questionnaires. Unlike other published studies that focus on the use of a WhatsApp group for educational needs, we focused our WhatsApp group on clinical matters.1Bakshi S.G. Doctor J.R. Trivedi B. Chatterjee A.S. Thota R.S. Jain P.N. WhatsApp-based teaching module for acute pain management: a prospective educational project.Can J Anesth. 2019; 66: 736-737Crossref PubMed Scopus (4) Google Scholar This group not only allowed senior obstetric anesthesiologists to exchange ideas about managing obstetric anesthesiology units, but also to expand their clinical knowledge about anesthetic guidelines and how to deal with complicated cases. We found that most of the discussions held were about obstetric unit organization and about anonymous patient cases. Participation was very high for these two topics, with the members of the group being proactive in sharing their thoughts and recommendations. Anesthesiologists may require rapid advice regarding a new clinical situation. Because the median response time (including all hours of the day or night) in our WhatsApp group was 4.5 min (only 4 min during the COVID-19 pandemic compared with 5 min before COVID-19), we believe that this requirement was met. A study published by a group of gynecologists describing their use of a WhatsApp group reported the mean time to first response was 52 min.2Carmona S. Alayed N. Al-Ibrahim A. D'Souza R. Realizing the potential of real-time clinical collaboration in maternal–fetal and obstetric medicine through WhatsApp.Obstet Med. 2018; 11: 83-89Crossref PubMed Scopus (22) Google Scholar The benefit of using WhatsApp as a tool of communication has been discussed in previous studies, in which researchers distributed and followed up on questionnaires via WhatsApp. Alias et al. described the use of WhatsApp to call for help during an anesthesia emergency.3Alias N. Suhahimi N. Rahim S. Ghani M. Mohamed A.H. 'Whatsapp' call for help in medical emergencies? A case report.IIUM Med J Malaysia. 2018; 17: 1Crossref Google Scholar Help arrived immediately, demonstrating the benefit of using WhatsApp in clinical settings. Bamber et al. reported use of a WhatsApp questionnaire during crisis management of COVID-19.4Bamber J.H. Lucas D.N. COVID‐19 and access to labour epidural analgesia in UK hospitals.Anaesthesia. 2020; 75: 1119-1120Crossref PubMed Scopus (9) Google Scholar Raitt et al. described the introduction of key performance indicators (KPI) for pre-hospital emergency anesthesia and used WhatsApp to invite clinicians to participate in a web-based survey about the KPI review and reporting process.5Raitt J. Hudgell J. Knott H. Masud S. Key performance indicators for pre hospital emergency Anaesthesia - a suggested approach for implementation.Scand J Trauma Resusc Emerg Med. 2019; 27: 42Crossref PubMed Scopus (6) Google Scholar Obtaining regular feedback from staff is important and in these two studies it was shown that WhatsApp can be used in order to efficiently and easily send out a survey or questionnaire.4Bamber J.H. Lucas D.N. COVID‐19 and access to labour epidural analgesia in UK hospitals.Anaesthesia. 2020; 75: 1119-1120Crossref PubMed Scopus (9) Google Scholar, 5Raitt J. Hudgell J. Knott H. Masud S. Key performance indicators for pre hospital emergency Anaesthesia - a suggested approach for implementation.Scand J Trauma Resusc Emerg Med. 2019; 27: 42Crossref PubMed Scopus (6) Google Scholar In conclusion, we report that group members found the use of a professional WhatsApp group provides rapid and useful clinical information, particularly in a crisis period such as the COVID-19 pandemic. We suggest that other communities consider use of such a group to bring rapid advice to specialists in other countries and other fields of medicine. None. None.

(Eur J Anaesthesiol. 2021;38:130–137) Accidental dural puncture (ADP) occurs in 0.4% to 6% of patients who receive neuraxial analgesia, and a significant number of ADP patients develop postdural puncture headache (PDPH). PDPH is associated with impaired maternal-neonatal bonding, longer hospital stay, limited ambulation and maternal morbidity. While previous studies have investigated long-term physical outcomes associated with PDPH, limited data exists on the associations between PDPH and long-term psychological outcomes, like postpartum depression (PPD) and postpartum posttraumatic stress disorder (PTSD). This study compared the frequency of these outcomes in women with PDPH with a control group of women without PDPH.

BACKGROUND:We performed an open controlled one-arm clinical trial to assess whether preoperative anxiety influences phenylephrine dosage required to maintain normotension during cesarean section under spinal anesthesia.METHODS:Ninety-four parturients undergoing elective cesarean delivery under spinal anesthesia were included. Anxiety levels were measured using a verbal numerical scale anxiety score (0-10). Phenylephrine infusion to prevent hypotension was adjusted by a standard algorithm. The primary outcome was total phenylephrine dose. Linear uni- and multivariate regressions were performed to assess the relationship between preoperative anxiety and the outcome. P < .05 was considered statistically significant.RESULTS:We found no association between preoperative anxiety and phenylephrine dosage (R2  = 0.05). Taking the number of attempts for spinal anesthesia and surgical time into account did not lead to a significant improvement of the regression model.CONCLUSION:In conclusion, we did not find a large independent effect of preoperative anxiety on phenylephrine dose required to maintain normotension in our cohort. We believe that spinal hypotension and phenylephrine dose requirement are multifactorial and anxiety is only one of the factors in this complex interaction.

BACKGROUND:Transcatheter aortic valve implantation (TAVI) is used in patients with severe aortic stenosis (AS) who are at high surgical risk. Pre- and post-operative management is challenging as these patients are older, have significant comorbidities and a very high expected mortality rate in conventional surgery. There is no consensus in the literature about the preferred form of anesthesia, however, currently most centers perform the procedure using local anesthesia with sedation (LA-S).OBJECTIVES:To compare general anesthesia (GA) and LA-S in patients undergoing TAVI.METHODS:A retrospective review of the first 100 patients who underwent TAVI (11/2008-6/2011) at the Rabin Medical Center, due to severe and symptomatic AS and a counter-indication for conventional valve replacement surgery.RESULTS:A total of 46 patients underwent the procedure with GA and 54 with LA-S. In 63 patients, the transfemoral approach was used, transapical in 23, and transaxillary in 11. There were no significant differences in short- and long-term mortality, but average hospitalization was longer in the GA group. A larger proportion of patients needed norepinephrine and blood transfusions during the procedure in the GA group. In the LA-S group, more conduction, vascular complications and postoperative fever were observed. In comparisons between anesthesia methods with the transfemoral approach, most of the differences lost their significance. Therefore, these differences are most likely attributed to the surgical approach and not to the anesthesia method.CONCLUSIONS:There is no clear preference for GA in TAVI. LA-S appears to be an effective and safe option for eligible patients.

BACKGROUND:There are cases where epidural analgesia is initially effective but subsequently fails and needs to be resited. We evaluated the rate of normal vaginal delivery and operative delivery among parturients who had resited epidurals compared to parturients with epidurals that were not resited.METHODS:A retrospective electronic medical review of parturients with a singleton gestation attempting normal vaginal delivery under epidural analgesia between the years 2012-2016 was conducted. Resited epidurals were defined as epidurals that were considered effective but subsequently removed and reinserted. For each resited epidural, two previous and two consecutive deliveries of parturients with normally functioning epidural catheter inserted by the same anesthesiologist were matched controls (non-resited epidurals).RESULTS:There were 35,984 attempted vaginal deliveries with 118 resited epidurals and 472 non-resited epidurals. When adjusted for nulliparity, oxytocin administration, sex and weight of the baby, and maternal BMI, labor epidural catheter replacement was not associated with need for instrumental or caesarean delivery, (OR 1.5, 95% CI 0.91-2.49, P = .11).CONCLUSIONS:Need for labor epidural catheter replacement does not appear to be associated with need for operative delivery based on this single-centre cohort analysis.

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.