RATIONALE:Postoperative pain is an important outcome for individuals undergoing breast cancer surgery. Regional analgesia techniques are considered integral to postoperative pain management, but are not without risks. OBJECTIVES:To assess the analgesic benefits and harms of different regional analgesia techniques in women undergoing breast cancer surgery. SEARCH METHODS:We searched CENTRAL, MEDLINE, Embase, CINAHL, Scopus, and Web of Science from inception to 6 June 2023 without restrictions on language, publication year, or publication status. ELIGIBILITY CRITERIA:We included randomised controlled trials (RCTs) comparing two or three of the following regional analgesia techniques in women undergoing breast cancer surgery: paravertebral block (PVB), erector spinae plane block (ESPB), pectoral nerve block (PEC), and serratus anterior plane block (SAPB). OUTCOMES:Our critical outcomes were postoperative pain (rated on a visual analogue scale (VAS) or numeric rating scale (NRS) of 0-10) and rates of regional analgesia-related complications. Our important outcomes were quality of recovery, time to first analgesic request, postoperative opioid and nonsteroidal anti-inflammatory drug (NSAID) use, and postoperative nausea and vomiting (PONV). RISK OF BIAS:We used the Cochrane risk of bias tool (RoB 2) to assess risk of bias. SYNTHESIS METHODS:We conducted network meta-analyses (NMAs) using multivariate frequentist random-effects models to calculate mean differences (MDs), standardised mean differences (SMDs), or risk ratios (RRs), each with its 95% confidence interval (CI). We used CINeMA to rate the certainty of evidence. We only included studies with an overall low risk of bias in the primary analysis. For postoperative pain, we considered one point difference as the minimal clinically important difference (MCID). INCLUDED STUDIES:We included 39 RCTs with a total of 2348 participants. The studies were conducted between 2013 and 2023 in Egypt, India, Turkey, China, Japan, USA, and Thailand. Most used single-shot long-acting anaesthetics administered with ultrasound guidance. In 35 studies, the surgery was modified radical mastectomy. All studies performed surgery under general anaesthesia in the hospital. Our primary analysis for postoperative pain included 16 studies. SYNTHESIS OF RESULTS:Critical outcomes Postoperative pain at rest at two hours This NMA included seven studies (384 participants). PEC is slightly more effective than PVB in reducing postoperative pain at rest at two hours (MD -0.47, 95% CI -0.73 to -0.22; P < 0.001, I2 = 0%; high-certainty evidence), but this difference is smaller than the MCID. Compared with PVB, ESPB is similarly effective (MD -0.12, 95% CI -0.31 to 0.07; P = 0.21, I2 = 0%; high-certainty evidence), and SAPB probably has similar effectiveness (MD -0.50, 95% CI -1.09 to 0.09; P = 0.094, I2 = 0%; moderate-certainty evidence). Postoperative pain during movement at two hours This NMA included four studies (246 participants). PEC may be more effective than PVB in reducing postoperative pain during movement at two hours (MD -1.06, 95% CI -1.98 to -0.14; P = 0.024, I2 = 79.6%; low-certainty evidence). ESPB compared with PVB may be similarly effective (MD -0.46, 95% CI -1.24 to 0.33; P = 0.25, I2 = 79.6%; low-certainty evidence). Postoperative pain at rest at 24 hours This NMA included 13 studies (793 participants). PEC is slightly more effective than PVB in reducing postoperative pain at rest at 24 hours (MD -0.32, 95% CI -0.61 to -0.03; P = 0.029, I2 = 38.7%; high-certainty evidence), but the difference is smaller than the MCID. Compared with PVB, ESPB is similarly effective (MD -0.15, 95% CI -0.35 to 0.05; P = 0.14, I2 = 38.7%; high-certainty evidence), and SAPB is similarly effective (MD -0.16, 95% CI -0.42 to 0.10; P = 0.23, I2 = 38.7%; high-certainty evidence). Postoperative pain during movement at 24 hours This NMA included eight studies (545 participants). Compared with PVB, ESPB probably has similar effectiveness for reducing postoperative pain during movement at 24 hours (MD -0.09, 95% CI -0.48 to 0.31; P = 0.67, I2 = 74.1%; moderate-certainty evidence), PEC may be similarly effective (MD 0.08, 95% CI -0.48 to 0.64; P = 0.78, I2 = 74.1%; low-certainty evidence), and SAPB may be similarly effective (MD 0.16, 95% CI -0.38 to 0.69; P = 0.57, I2 = 74.1%; very low-certainty evidence), although the evidence from the last analysis is very uncertain. Postoperative pain at rest at 48 hours One study (44 participants) reported postoperative pain at rest at 48 hours and found little or no difference in effectiveness between PVB and ESPB, though the evidence is very uncertain (MD 0.18, 95% CI -0.31 to 0.67; P = 0.47; very low-certainty evidence). Postoperative pain during movement at 48 hours This NMA included two studies (104 participants). Compared with PVB, ESPB may be similarly effective for reducing postoperative pain during movement at 48 hours (MD 0.13, 95% CI -0.55 to 0.81; P = 0.71, I2 = 0%; very low-certainty evidence) and PEC may be similarly effective (MD -0.07, 95% CI -0.43 to 0.29; P = 0.71, I2 = 0%; very low-certainty evidence), although the evidence from both analyses is very uncertain. Complications Three studies (170 participants) recorded complications, but there were no reported events of block failure, local anaesthetic systemic toxicity, hypotension, nerve damage, intraneural injection, accidental vascular puncture, bleeding at puncture site, infection, or pneumothorax. Certainty of evidence We frequently downgraded the certainty of the evidence for imprecision due to small sample sizes and wide CIs, particularly for complications and analgesic use. Heterogeneity also affected certain pain outcomes. Limited data availability further reduced certainty, with outcomes based on one or two studies rated as very low. AUTHORS' CONCLUSIONS:Overall, the regional analgesia techniques included in our NMAs seem comparable in reducing postoperative pain and rates of complications. FUNDING:This Cochrane review had no dedicated funding. REGISTRATION:Protocol (2022): doi.org/10.1002/14651858.CD014818.

Objective: Each repeat cesarean section (CS) potentially adds surgical complexity. The determination of appropriate anesthesia strategy to meet the surgical challenge is of crucial importance for the maternal and neonatal outcome. Study design: This prospective cohort study was conducted from 1 -Jan -2021 to 31 -Dec -2021 at a single large obstetric centre of all repeat CS. We compared the characteristics and the appropriateness of the anesthesia techniques for low -order repeat CS (LOR-CS) (1 or 2 previous CS) and high order repat CS (HOR-CS) group (3 or more repeat CS). Results: During the study period, 1057 parturients met the study entry criteria, with 821 parturients in the LORCS group and 236 parturients in the HOR-CS group. The use of spinal anesthesia was more common for HOR-CS 84.3%. Overall surgical time varied between LOR-CS (38 min, 29 -49) and HOR-CS (42 min, 31 -57) (p = 0.004). The rate of moderate and severe adhesions was relatively high in HOR-CS and the duration of overall surgical time for cases with mild adhesions was 38 min (29 -48), for moderate adhesions was 44 min (34.8 -56.5), and for severe adhesions was 56 min (44.8 -74.3). There was no significant difference in the Estimated Blood Loss (EBL) between LOR-CS and HOR-CS, with values of 653 +/- 292 ml vs. 660 +/- 285 ml, respectively. Conclusion: Our data indicate that spinal anesthesia, standard monitoring and regular anesthetic setup are safe and suitable for the majority of HOR-CS, except in cases with high suspicion of placental accreta spectrum.

Many inherited conditions result from disorders of intermediary metabolism. Many more are discovered annually using advanced gene sequencing and other tools. These diseases cause symptoms because of the accumulation of precursors, absence of the final product, excessive toxic intermediaries, or a combination of all three mechanisms. Many are fatal in childhood, but some are compatible with adult life and pregnancy. A better understanding of the enzymatic deficiencies and new technologies have made recombinant enzyme replacement therapy possible. Along with early diet manipulation, current management allows many patients to live relatively normal lives. Because fertility may not be affected, some of these conditions will be encountered by the anesthesiologist. This chapter describes diseases caused by certain enzyme deficiencies and the by-products that cause symptoms. Some are exacerbated by pregnancy and the stress of labor and delivery. The anesthesiologist plays an essential role in reducing physiologic stress and avoiding triggering agents and routines that cause severe metabolic derangements or cardiopulmonary decompensation. The final portion of the chapter describes the most recent advances in the prevention and treatment of malignant hyperthermia in pregnancy, discussing the impact on mother and baby.

Background: It remains controversial whether general anaesthetic drugs contribute to perioperative neurocognitive disorders in adult patients. Preclinical studies have generated conflicting results, likely because of differing animal models, study protocols, and measured outcomes. This scoping review of preclinical studies addressed the question: 'Do general anaesthetic drugs cause cognitive deficits in adult animals that persist after the drugs have been eliminated from the brain?' Methods: Reports of preclinical studies in the MEDLINE database published from 1953 to 2021 were examined. A structured review process was used to assess original studies of cognitive behaviours, which were measured after treatment (>= 24 h) with commonly used general anaesthetic drugs in adult animals.Results: The initial search yielded 380 articles, of which 106 were fully analysed. The most frequently studied animal model was male (81%; n=86/106) rodents (n=106/106) between 2-3 months or 18-20 months of age. Volatile anaesthetic drugs were more frequently studied than injected drugs, and common outcomes were memory behaviours assessed using the Morris water maze and fear conditioning assays. Cognitive deficits were detected in 77% of studies (n=82/106) and were more frequent in studies of older animals (89%), after inhaled anaesthetics, and longer drug treatments. Limitations of the studies included a lack of physiological monitoring, mortality data, and risk of bias attributable to the absence of randomisation and blinding. Conclusions: Most studies reported cognitive deficits after general anaesthesia, with age, use of volatile anaesthetic drugs, and duration of anaesthesia as risk factors. Recommendations to improve study design and guide future research are presented.

Objectives This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess whether the analgesic efficacy and safety differ according to the regional analgesia technique used in women undergoing breast cancer surgery.

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.

( Int J Obstet Anesth . 2021;45:142–149) Postpartum depression (PPD) has a reported prevalence of 6.5% to 12.9% and is associated with negative effects on maternal and neonatal physical and psychological health. Many factors contribute to the risk of PPD, including marital satisfaction, history of depression, genetic factors, hormonal factors, and labor pain. Previous meta-analyses found no evidence that neuraxial analgesia is associated with low rates of PPD, but new information has been reported since these studies were published. This systematic review aimed to investigate whether the use of neuraxial labor analgesia has any effect on the incidence of PPD.

(Anaesthesia. 2020;75:109–121) The potential for maternal hypotension is one key risk of spinal anesthesia for elective cesarean delivery (CD). A variety of methods to prevent postspinal hypotension during CD are recommended in the literature. While an international consensus statement published in 2018 recommended prophylactic vasopressors for all CDs it did not take into account the risks associated with these agents. Also, a recent meta-analysis comparing different methods to prevent hypotension was inadequate to determine treatment efficacy. The aim of this study was to determine the relative efficacy of interventions, including vasopressors, to prevent hypotension associated with spinal anesthesia during elective CD.

Caesarean delivery is the most commonly performed inpatient surgical procedure globally. Pain after caesarean delivery is moderate to severe if not adequately treated, and is a primary anaesthetic concern for patients. Transversus abdominis plane and quadratus lumborum blocks are fascial plane blocks that have the potential to improve analgesia following caesarean delivery. Although proponents of the quadratus lumborum block suggest that this technique may provide better analgesia compared with transversus abdominis plane block, there are limited data directly comparing these two techniques. We, therefore, performed a systematic review and network meta-analysis to compare transversus abdominis plane and quadratus lumborum block approaches, seeking randomised controlled trials comparing both techniques to each other, or to control, with or without intrathecal morphine. In all, 31 trials with 2188 patients were included and our primary outcome, the cumulative intravenous morphine equivalent consumption at 24 h, was reported in 12 trials. In the absence of intrathecal morphine, transversus abdominis plane and quadratus lumborum blocks were equivalent, and both were superior to control (moderate-quality evidence). In the presence of intrathecal morphine, no differences were found between control, transversus abdominis plane and quadratus lumborum blocks (moderate-quality evidence). Similar results were found for resting and active pain scores at 4-6 h, 8-12 h, 24 h and 36 h, although quadratus lumborum block was associated with lower pain scores at 36 h when compared with transversus abdominis plane block (very low-quality evidence). However, transversus abdominis plane block was associated with a reduced incidence of postoperative nausea and vomiting (moderate-quality evidence) and sedation when compared with inactive control following intrathecal morphine administration (low-quality evidence). There are insufficient data to draw definitive conclusions, but transversus abdominis plane and quadratus lumborum block appear to be superior to control in the absence of intrathecal morphine, but provide limited additional benefit over inactive control when intrathecal morphine is also used.

The original article was updated to amend number “0.09” in Table 2a (instead “-0.09”).

Postpartum depression (PPD) is a significant complication of childbirth, some documenting it as the most common [1,2]. It develops in 6.5% to 12.9% of all parturients [1–6]. PPD causes many long-term sequalae in mother, child, and partner both physically and psychologically [7]. The most tragic of outcomes is suicide. Unfortunately it has been reported as being the second-leading cause of death among mothers during the postpartum period, approaching 20% of deaths during the first postpartum year [8–10].

(Am J Obstet Gynecol. 2019;19.e2–29.e2) Postpartum anemia is associated with fatigue, depression, and impaired cognition. Postpartum anemia affects up to 50% of women in well-resourced countries and up to 80% of women in developing countries, which can affect maternal-child bonding. However, adverse gastrointestinal reactions to oral iron treatments (ie, nausea, vomiting, and constipation) occur in up to 40% of patients, resulting in poor compliance and persistent anemia. Intravenous (IV) iron may be ideal for these patients, as it mitigates the absorption challenges and produces a more rapid increase in hemoglobin (Hb) concentration and iron stores. The disadvantages of IV iron include increased cost and the need for treatment at a hospital or outpatient facility. This study was an updated systematic review of all randomized trials comparing oral versus IV iron therapy to treat postpartum anemia. The primary outcome measure was postpartum Hb.

Spinal anaesthesia for caesarean section commonly causes maternal hypotension. This systematic review and network meta-analysis compared methods to prevent hypotension in women receiving spinal anaesthesia for caesarean section. We selected randomised controlled trials that compared an intervention to prevent hypotension with another intervention or inactive control by searching MEDLINE and Embase, Web of Science to December 2018. There was no language restriction. Two reviewers extracted data on trial characteristics, methods and outcomes. We assessed risk of bias for individual trials (Cochrane tool) and quality of evidence (GRADE checklist). We assessed 109 trials (8561 women) and 12 different methods that resulted in 30 direct comparisons. Methods ranked by OR (95%CI) from most effective to least effective were: metaraminol 0.11 (0.04-0.26); norepinephrine 0.13 (0.06-0.28); phenylephrine 0.18 (0.11-0.29); leg compression 0.25 (0.14-0.43); ephedrine 0.28 (0.18-0.43); colloid given before induction of anaesthesia 0.38 (0.24-0.61); angiotensin 2, 0.12 (0.02-0.75); colloid given after induction of anaesthesia 0.52 (0.30-0.90); mephentermine 0.09 (0.01-1.30); crystalloid given after induction of anaesthesia 0.78 (0.46-1.31); and crystalloid given before induction of anaesthesia 1.16 (0.76-1.79). Phenylephrine caused maternal bradycardia compared with control, OR (95%CI) 0.23 (0.07-0.79). Ephedrine lowered umbilical artery pH more than phenylephrine, standardised mean difference (95%CI) 0.78 (0.47-1.49). We conclude that vasopressors should be given to healthy women to prevent hypotension during caesarean section with spinal anaesthesia.

Background: Transesophageal echocardiography has important applications for the management of the critically ill patient. There is a need to develop effective training programs for the critical care community in acquiring skill at critical care transesophageal echocardiography. Objective: We studied the effectiveness of a 1-day simulation-based course that focused on the acquisition of skill in the performance of critical care transesophageal echocardiography. Methods: Learners received training in image acquisition with a transesophageal simulator and training in image interpretation in small group sessions. Skill at image acquisition and image interpretation was assessed at the beginning and at the completion of the course. Results: There were 27 learners who attended the course. Pre and post knowledge scores were 55 (19; mean [SD]) and 88 (9; P < .0005), respectively. Pre and post image acquisition scores were 3.6 (3.7) and 9.9 (0.3; P < .0001), respectively. Conclusions: A 1-day course in critical care transesophageal echocardiography that combined case-based image interpretation with image acquisition training using a simulator improved technical skills and knowledge base.

Background: A structured approach to hemorrhagic emergencies in obstetrics has gained popularity with the implementation of massive hemorrhage protocols. The trauma literature suggests that routine quality reviews should be in place to improve patient outcomes. The aim of this study was to develop quality indicators and assess compliance by the clinical team. Methods: A multidisciplinary team set the institutional quality indicators for the massive hemorrhage protocol review. A retrospective review of all obstetrical massive hemorrhage protocol activation events from September 2010 to January 2015 was performed. All protocol events occurred before the creation of the quality indicators. Data were retrieved from patient records. Results: There were 17 (0.09%) protocol activations for 19 790 deliveries during the study period. All 17 (100%) patients received at least one unit of red blood cells. Overactivation, defined as the transfusion of <2 units of red blood cells, occurred in two cases (12%). Common causes of non-compliance were: 24% (4/17) temperature monitoring, 18% (3/17) lactate measurement, 41% (7/17) arterial blood gas sampling, and 18% (3/17) hemoglobin maintenance within the target range of 55-95 g/L. Admission to intensive care and peripartum hysterectomy occurred in 12 and 5 cases (71% and 29%), respectively. Conclusions: Suboptimal compliance was found in multiple areas, which may be attributable to the low frequency of activation of our massive haemorrhage protocol in obstetrics. The quality targets identified in this report can act as a basis for other institutions developing quality indicators to evaluate performance. (C) 2018 Published by Elsevier Ltd.