(Anesthesiology. 2017;127(2):220–226) Clinical practice guidelines are developed using current literature and/or expert opinion in a specific field for the purpose of enhancing quality, safety and patient satisfaction. Guidelines in high-income countries may differ from those of low-to-middle income countries as there may be differences in provider training and availability, infrastructure and resources. In low-to-middle income countries, guidelines are best developed by local practitioners. This report was based on the process of developing national obstetric anesthesia practice guidelines in the Republic of Armenia as the result of a global partnership.

Background: Disparity exists in anesthesia practices between high-and low-to-middle income countries, and awareness has been raised within the global health community to improve the standards of anesthesia care and patient safety. The establishment of international collaborations and appropriate practice guidelines may help address clinical care deficiencies. This report's aim was to assess the impact of a multiyear collaboration on obstetric anesthesia practices in the Republic of Armenia.Methods: An invited multinational team of physicians conducted six visits to Armenia between 2006 and 2015 to observe current practice and establish standards of obstetric anesthesia care. The Armenian Society of Anaesthesiologists and Intensive Care specialists collected data on the numbers of vaginal delivery, cesarean delivery, and neuraxial anesthesia use in maternity units during the period. Data were analyzed with the Fisher exact or chi-square test, as appropriate.Results: Neuraxial anesthesia use for cesarean delivery increased significantly (P < 0.0001) in all 10 maternity hospitals within the capital city of Yerevan. For epidural labor analgesia, there was sustained or increased use in only two hospitals. For hospitals located outside the capital city, there was a similar increase in the use of neuraxial anesthesia for cesarean delivery that was greater in hospitals that were visited by an external team (P < 0.0001); however, use of epidural labor analgesia was not increased significantly. Over the course of the collaboration, guidelines for obstetric anesthesia were drafted and approved by the Armenian Ministry of Health.Conclusions: Collaboration between Armenian anesthesiologists and dedicated visiting physicians to update and standardize obstetric anesthesia practices led to national practice guidelines and sustained improvements in clinical care in the Republic of Armenia.

One dead every minute. The stark reality is that somewhere between 382,910 and 437,860 women worldwide died from a direct or indirect childbirth-related cause in 1990. This is an astonishing figure that eclipses the number of deaths from natural disasters such as the 2004 Asian tsunami and the 2010 Haitian earthquake. It is made worse when we realize that many of these deaths are avoidable and that there is an enormous variation in mortality rates across the planet. In 2010, Save the Children quoted the lifetime risk in Afghanistan as 1 in 6, compared to 1 in 47,600 in Ireland. Such discrepancies between the developed and developing countries are alarming and have been cited as ‘the largest discrepancy of all public-health statistics’, substantially greater than that for child or neonatal mortality. This chapter considers the size of the problem, the global initiatives aiming to tackle it, Millennium Development Goal 5, the role that obstetric anaesthesia can play, and how those who practise in the developed world can help their neighbours in developing countries.

In our department, currently there is variation in the number of xrays that patients receive following ORIF of distal radius fractures. This audit investigated the use of xrays following ORIF of distal radius fractures. Patients were identified from daily trauma lists. Patients who had a primary ORIF or ORIF following failed conservative management were included in the study. PACS was used to identify the number of post-operative xrays performed. These were correlated with clinic letters to see if there was any change in management following xray review. Between July and November 2013, 102 patients were admitted with distal radius fracture. Of these, 35 (mean age:51 years) had an ORIF. Four were not followed-up in Scotland. Of the remaining 31 patients, eleven had one post-operative xray, seventeen had two and three had three xrays. Of the patients who had one xray, seven had the xray in the first three weeks, the rest at six weeks. Patients who had two xrays had an xray at two and 6 weeks. Of the three patients who had three xrays, two had comminuted fractures that required further CT investigation, one for a suspicion of an intra-articular screw, the other for possibility of non-union. The third patient had no apparent reason for requiring three xrays. Thus of the 31 patients in the study, 29 did not require any further investigations. The results show a variation in the frequency of post-operative xrays after fixation of distal radius fractures. In most cases the management plan was unchanged after plain xrays were undertaken. This suggests that a protocol driven approach to follow-up after fixation of distal radius fractures could reduce the burden on fracture clinic and radiology departments. We propose that unless indicated by intra-operative findings or post-operative concerns, patients should have xrays at the two week review appointment.

We report two cases of Caesarean section in patients with Marfan's syndrome where continuous subarachnoid anaesthesia failed to provide an adequate surgical block. This was possibly because of dural ectasia, which was confirmed by a computed tomography scan in both cases.

PURPOSE:Gestational diabetes insipidus (GDI) is a rare endocrinopathy complicating about 4:100,000 deliveries. We present the case of a preterm parturient with GDI and severe hypernatremia (serum sodium concentration = 174 mmol.L(-1)) presenting for an urgent Cesarean section.CLINICAL FEATURES:Fluid resuscitation and desmopressin supplementation partially corrected the patient's homeostasis, allowing us to carefully titrate epidural anesthesia for an urgent Cesarean section. After delivery, the patient was transferred to the intensive care unit. The serum sodium concentration of the mother and the neonate was normalized over 48 hr and three days respectively.CONCLUSION:The careful perioperative management of GDI led to a favourable outcome of the mother and fetus.

We describe the anesthetic management for cesarean section and tubal ligation of a 23-year-old primipara with type II spinal muscular atrophy (benign Werdnig Hoffmann). She was wheelchair-bound, had severe restrictive lung disease, and severe kyphoscoliosis, with Harrington rods extending from the thoracic to the sacral spines. A general anesthetic was given. We used propofol and alfentanil for rapid-sequence induction of anesthesia. We did not use any muscle relaxants intraoperatively. Postoperative care was provided in the intensive care unit. The patient made a good recovery.

The King-Denborough syndrome (KDS) is a rare disorder that is associated with myopathy, susceptibility to malignant hyperthermia (MH) as well as congenital skeletal and facial anomalies. We report the anesthetic management of a parturient with KDS.

Previous experiments have demonstrated that aggressive behaviour of male rats in a territorial setting is facilitated by corticosterone. Moreover, the inhibition of the endogenous corticosterone response prevents agonistic behaviour. The aim of the present paper was to investigate the effect of mineralocorticoid receptor (MR) blockade on the expression of aggressive behaviour at the beginning of the dark phase, when MRs are mostly occupied due to the diurnal peak of corticosterone secretion. High levels of aggressive behaviour were induced in male Wistar rats cohabiting with females by exposing them 3 times to an intruder male rat of smaller size. Intruder males were introduced at the beginning of the active period on every second day for 20 minutes, while the female was temporarily removed. A gradual increase in the number of biting attacks was noticed, the rats performing 6.7 +/- 2.0 attacks per 20 min on the last day (n=8). One hour before the fourth encounter rats were injected with the MR blocker spironolactone (10 mg/kg). Attacking behaviour was almost totally abolished (0.87 +/- .35 attacks per 20 min; n=8). Vehicle injections were ineffective (9.3 +/- 2.1 attacks per 20 min; n=8). Offensive threats underwent similar changes while other behaviours showed non-significant variation, with the exception of resting which increased towards the end of the observation period. The time course of these effects showed that the primary action was on offensive aggressive behaviour. This report is the first to show that the almost total MR occupancy at the beginning of the dark (active) period of the day is a prerequisite for the expression of aggressiveness in response to a social challenge.