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Eley V, Llewellyn S, Pelecanos A, Callaway L, Smith M, van Zundert A, Stowasser M. Finger cuff versus invasive and noninvasive arterial pressure measurement in pregnant patients with obesity. Acta Anaesthesiol Scand 2024; 68:645-654. [PMID: 38442731 DOI: 10.1111/aas.14399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/21/2023] [Accepted: 02/15/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND Pregnant patients with obesity may have compromised noninvasive blood pressure (NIBP) measurement. We assessed the accuracy and trending ability of the ClearSight™ finger cuff (FC) with invasive arterial monitoring (INV) and arm NIBP, in obese patients having cesarean delivery. METHODS Participants were aged ≥18 years, ≥34 weeks gestation, and body mass index (BMI) ≥ 40 kg m-2. FC, INV, and NIBP measurements were obtained across 5-min intervals. The primary outcome was agreement of FC measurements with those of the reference standard INV, using modified Bland-Altman plots. Secondary outcomes included comparisons between FC and NIBP and NIBP versus INV, with four-quadrant plots performed to report discordance rates and evaluate trending ability. RESULTS Twenty-three participants had a median (IQR) BMI of 45 kg m-2 (44-48). When comparing FC and INV the mean bias (SD, 95% limits of agreement) for systolic blood pressure (SBP) was 16 mmHg (17, -17.3 to 49.3 mmHg), for diastolic blood pressure (DBP) -0.2 mmHg (10.5, -20.7 to 20.3), and for mean arterial pressure (MAP) 5.2 mmHg (11.1, -16.6 to 27.0 mmHg). Discordance occurred in 54 (26%) pairs for SBP, 41 (23%) for DBP, and 41 (21.7%) for MAP. Error grid analysis showed 92.1% of SBP readings in Zone A (no-risk zone). When comparing NIBP and INV, the mean bias (95% limits of agreement) for SBP was 13.0 mmHg (16.7, -19.7 to 29.3), for DBP 5.9 mmHg (11.9, -17.4 to 42.0), and for MAP 8.2 mmHg (11.9, -15.2 to 31.6). Discordance occurred in SBP (84 of 209, 40.2%), DBP (74 of 187, 39.6%), and MAP (63 of 191, 33.0%). CONCLUSIONS The FC and NIBP techniques were not adequately in agreement with INV. Trending capability was better for FC than NIBP. Clinically important differences may occur in the setting of the perfusion-dependent fetus.
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Affiliation(s)
- Victoria Eley
- Department of Anaesthesia and Perioperative Medicine, The Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- Medical School, Faculty of Medicine, The University of Queensland, St Lucia, Queensland, Australia
| | - Stacey Llewellyn
- Statistics Unit, QIMR Berghofer Medical Research Institute, Herston, Brisbane, Queensland, Australia
| | - Anita Pelecanos
- Statistics Unit, QIMR Berghofer Medical Research Institute, Herston, Brisbane, Queensland, Australia
| | - Leonie Callaway
- Medical School, Faculty of Medicine, The University of Queensland, St Lucia, Queensland, Australia
- Obstetric Medicine, Women's and Newborns Services, The Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Matthew Smith
- Obstetrics and Gynaecology, Women's and Newborns Services, The Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Andre van Zundert
- Department of Anaesthesia and Perioperative Medicine, The Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- Medical School, Faculty of Medicine, The University of Queensland, St Lucia, Queensland, Australia
| | - Michael Stowasser
- Medical School, Faculty of Medicine, The University of Queensland, St Lucia, Queensland, Australia
- Endocrine Hypertension Research Centre, University of Queensland Frazer Institute, Princess Alexandra Hospital, Woolloongabba, Brisbane, Queensland, Australia
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Roets M, Sturgess D, Tran T, Obeysekera M, Perros A, Tung JP, Flower R, van Zundert A, Dean M. Intraoperative cell salvage: The impact on immune cell numbers. PLoS One 2023; 18:e0289177. [PMID: 37527263 PMCID: PMC10393166 DOI: 10.1371/journal.pone.0289177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 07/13/2023] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND Patient outcomes are influenced by many confounding factors peri-operatively, including the type of surgery, anaesthesia, transfusion, and immune competence. We have previously demonstrated (in-vitro) that compared to allogeneic blood transfusion (ABT), intraoperative cell salvage (ICS) improves immune competence. The peri-operative immune response is complex. Altered or impaired immune responses may predispose patients to develop adverse outcomes (i.e., post-operative wound infection, pneumonia, urinary tract infection etc.) Surgical patients may develop infection, even without the confirmed presence of a definite microbiological pathogen. With all these factors in mind it is important to consider changes in immune cell numbers (and sub-populations) and functional capacity during peri-operative transfusion. METHODS In this TRIMICS-Cell (Transfusion Related Immune Modulation and Intraoperative Cell Salvage-Cell numbers) study (n = 17, October 2018-November 2019) we prioritized and analysed peri-operative changes in the number and proportions of immune cell populations and sub-populations (B cells (CD20+), NK (natural killer) cells (CD56+), monocytes (CD14+), T cells (total CD3+ and sub-populations: T helper cells (CD4+), cytotoxic T cells (CD8+), effector T cells (CD4+ CD127+), activated effector T cells (CD4+ CD25+ CD127+) and regulatory T cells (CD4+ CD25+ CD127-)), plasmacytoid dendritic cells (pDC; Lineage-, HLA-DR+, CD11c-, CD123+), classical dendritic cell (cDC) (Lineage-, HLA-DR+, CD11c+), and cDC activation (Lineage-, HLA-DR+, CD11c+), co-stimulatory/adhesion molecules and pDC (CD9+, CD38+, CD80+, CD83+, CD86+, CD123+). Firstly we analysed the whole cohort of study patients and secondly according to the relevant transfusion modality (i.e., three study groups: those who received no transfusion, received ICS only (ICS), or both ICS and allogeneic packed red blood cells (pRBC) (ICS&RBC)), during major orthopaedic surgery. RESULTS For the whole study cohort (all patients), changes in immune cell populations were significant: leucocytes and specifically neutrophils increased post-operatively, returning towards pre-operative numbers by 48h post-operatively (48h), and lymphocytes reduced post-operatively returning to pre-operative numbers by 48h. When considering transfusion modalities, there were no significant peri-operative changes in the no transfusion group for all immune cell populations studied (cell numbers and proportions (%)). Significant changes in cell population numbers (i.e., leucocytes, neutrophils and lymphocytes) were identified in both transfused groups (ICS and ICS&RBC). Considering all patients, changes in immune cell sub-populations (NK cells, monocytes, B cells, T cells and DCs) and functional characteristics (e.g., co-stimulation markers, adhesion, activation, and regulation) were significant peri-operatively and when considering transfusion modalities. Interestingly DC numbers and functional capacity were specifically altered following ICS compared to ICS&RBC and pDCs were relatively preserved post-operatively following ICS. CONCLUSION A transient peri-operative alteration with recovery towards pre-operative numbers by 48h post-surgery was demonstrated for many immune cell populations and sub-populations throughout. Immune cell sub-populations and functional characteristics were similar peri-operatively in those who received no transfusion but changed significantly following ICS and ICS&RBC. Interesting changes that require future study are a post-operative monocyte increase in the ICS&RBC group, changes in cDC considering transfusion modalities, and possibly preserved pDC numbers post-operatively following ICS. Future studies to assess changes in immune cell sub-populations, especially during peri-operative transfusion, while considering post-operative adverse outcomes, is recommended.
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Affiliation(s)
- Michelle Roets
- Department of Anaesthesia, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - David Sturgess
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Department of Anaesthesia, Surgical Treatment and Rehabilitation Service, Brisbane, Queensland, Australia
| | - Thu Tran
- Australian Red Cross Lifeblood, Kelvin Grove, Queensland, Australia
| | | | - Alexis Perros
- Australian Red Cross Lifeblood, Kelvin Grove, Queensland, Australia
| | - John-Paul Tung
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Australian Red Cross Lifeblood, Kelvin Grove, Queensland, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Robert Flower
- Australian Red Cross Lifeblood, Kelvin Grove, Queensland, Australia
| | - Andre van Zundert
- Department of Anaesthesia, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Melinda Dean
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Australian Red Cross Lifeblood, Kelvin Grove, Queensland, Australia
- School of Health, University of the Sunshine Coast, Sunshine Coast, Queensland, Australia
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Everts PA, Lana JF, Onishi K, Buford D, Peng J, Mahmood A, Fonseca LF, van Zundert A, Podesta L. Angiogenesis and Tissue Repair Depend on Platelet Dosing and Bioformulation Strategies Following Orthobiological Platelet-Rich Plasma Procedures: A Narrative Review. Biomedicines 2023; 11:1922. [PMID: 37509560 PMCID: PMC10377284 DOI: 10.3390/biomedicines11071922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/03/2023] [Accepted: 07/05/2023] [Indexed: 07/30/2023] Open
Abstract
Angiogenesis is the formation of new blood vessel from existing vessels and is a critical first step in tissue repair following chronic disturbances in healing and degenerative tissues. Chronic pathoanatomic tissues are characterized by a high number of inflammatory cells; an overexpression of inflammatory mediators; such as tumor necrosis factor-α (TNF-α) and interleukin-1 (IL-1); the presence of mast cells, T cells, reactive oxygen species, and matrix metalloproteinases; and a decreased angiogenic capacity. Multiple studies have demonstrated that autologous orthobiological cellular preparations (e.g., platelet-rich plasma (PRP)) improve tissue repair and regenerate tissues. There are many PRP devices on the market. Unfortunately, they differ greatly in platelet numbers, cellular composition, and bioformulation. PRP is a platelet concentrate consisting of a high concentration of platelets, with or without certain leukocytes, platelet-derived growth factors (PGFs), cytokines, molecules, and signaling cells. Several PRP products have immunomodulatory capacities that can influence resident cells in a diseased microenvironment, inducing tissue repair or regeneration. Generally, PRP is a blood-derived product, regardless of its platelet number and bioformulation, and the literature indicates both positive and negative patient treatment outcomes. Strangely, the literature does not designate specific PRP preparation qualifications that can potentially contribute to tissue repair. Moreover, the literature scarcely addresses the impact of platelets and leukocytes in PRP on (neo)angiogenesis, other than a general one-size-fits-all statement that "PRP has angiogenic capabilities". Here, we review the cellular composition of all PRP constituents, including leukocytes, and describe the importance of platelet dosing and bioformulation strategies in orthobiological applications to initiate angiogenic pathways that re-establish microvasculature networks, facilitating the supply of oxygen and nutrients to impaired tissues.
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Affiliation(s)
- Peter A Everts
- Research & Education Division, Gulf Coast Biologics, Fort Myers, FL 33916, USA
- OrthoRegen Group, Max-Planck University, Indaiatuba, São Paulo 13334-170, Brazil
| | - José Fábio Lana
- OrthoRegen Group, Max-Planck University, Indaiatuba, São Paulo 13334-170, Brazil
- Department of Orthopaedics, The Bone and Cartilage Institute, Indaiatuba, São Paulo 13334-170, Brazil
| | - Kentaro Onishi
- Department of PM&R and Orthopedic Surgery, University of Pittsburg Medical Center, Pittsburgh, PA 15213, USA
| | - Don Buford
- Texas Orthobiologics, Dallas, TX 75204, USA
| | - Jeffrey Peng
- Stanford Health Care-O'Connor Hospital Sports Medicine, Stanford University School of Medicine, San Jose, CA 95128, USA
| | - Ansar Mahmood
- Department of Trauma and Orthopaedic Surgery, University Hospitals, Birmingham B15 2GW, UK
| | - Lucas F Fonseca
- Department of Orthopaedics, The Federal University of São Paulo, São Paulo 04024-002, Brazil
| | - Andre van Zundert
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane and the University of Queensland, Brisbane 4072, Australia
| | - Luga Podesta
- Bluetail Medical Group & Podesta Orthopedic Sports Medicine, Naples, FL 34109, USA
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Eley V, Christensen R, Guy L, Wyssusek K, Pelecanos A, Dodd B, Stowasser M, van Zundert A. Correction: ClearSight™ finger cuff versus invasive arterial pressure measurement in patients with body mass index above 45 kg/m 2. BMC Anesthesiol 2023; 23:75. [PMID: 36927335 PMCID: PMC10018951 DOI: 10.1186/s12871-023-02034-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
Affiliation(s)
- Victoria Eley
- Department of Anaesthesia and Perioperative Medicine, The Royal Brisbane and Women's Hospital, Butterfield St, Herston, Queensland, 4006, Australia. .,Faculty of Medicine, The University of Queensland, St Lucia, Queensland, 4067, Australia.
| | - Rebecca Christensen
- Department of Anaesthesia and Perioperative Medicine, The Royal Brisbane and Women's Hospital, Butterfield St, Herston, Queensland, 4006, Australia.,Faculty of Medicine, The University of Queensland, St Lucia, Queensland, 4067, Australia
| | - Louis Guy
- Department of Anaesthesia and Perioperative Medicine, The Royal Brisbane and Women's Hospital, Butterfield St, Herston, Queensland, 4006, Australia.,Faculty of Medicine, The University of Queensland, St Lucia, Queensland, 4067, Australia
| | - Kerstin Wyssusek
- Department of Anaesthesia and Perioperative Medicine, The Royal Brisbane and Women's Hospital, Butterfield St, Herston, Queensland, 4006, Australia.,Faculty of Medicine, The University of Queensland, St Lucia, Queensland, 4067, Australia
| | - Anita Pelecanos
- Statistics Unit, Queensland Institute of Medical Research Berghofer, Herston, Brisbane, 4006, Australia
| | - Benjamin Dodd
- Faculty of Medicine, The University of Queensland, St Lucia, Queensland, 4067, Australia.,Department of Surgery, The Royal Brisbane and Women's Hospital, Butterfield St, Herston, Queensland, 4006, Australia
| | - Michael Stowasser
- Faculty of Medicine, The University of Queensland, St Lucia, Queensland, 4067, Australia.,Hypertension Unit, Princess Alexandra Hospital, Woolloongabba, Brisbane, 4102, Australia
| | - Andre van Zundert
- Department of Anaesthesia and Perioperative Medicine, The Royal Brisbane and Women's Hospital, Butterfield St, Herston, Queensland, 4006, Australia.,Faculty of Medicine, The University of Queensland, St Lucia, Queensland, 4067, Australia
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Roets M, Sturgess DJ, Obeysekera MP, Tran TV, Wyssusek KH, Punnasseril JEJ, da Silva D, van Zundert A, Perros AJ, Tung JP, Flower RLP, Dean MM. Intraoperative Cell Salvage as an Alternative to Allogeneic (Donated) Blood Transfusion: A Prospective Observational Evaluation of the Immune Response Profile. Cell Transplant 2021; 29:963689720966265. [PMID: 33076681 PMCID: PMC7784599 DOI: 10.1177/0963689720966265] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Allogeneic blood transfusion (ABT) is associated with transfusion-related immune modulation (TRIM) and subsequent poorer patient outcomes including perioperative infection, multiple organ failure, and mortality. The precise mechanism(s) underlying TRIM remain largely unknown. During intraoperative cell salvage (ICS) a patient's own (autologous) blood is collected, anticoagulated, processed, and reinfused. One impediment to understanding the influence of the immune system on transfusion-related adverse outcomes has been the inability to characterize immune profile changes induced by blood transfusion, including ICS. Dendritic cells and monocytes play a central role in regulation of immune responses, and dysfunction may contribute to adverse outcomes. During a prospective observational study (n = 19), an in vitro model was used to assess dendritic cell and monocyte immune responses and the overall immune response following ABT or ICS exposure. Exposure to both ABT and ICS suppressed dendritic cell and monocyte function. This suppression was, however, significantly less marked following ICS. ICS presented an improved immune competence. This assessment of immune competence through the study of intracellular cytokine production, co-stimulatory and adhesion molecules expressed on dendritic cells and monocytes, and modulation of the overall leukocyte response may predict a reduction of adverse outcomes ( i.e., infection) following ICS.
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Affiliation(s)
- Michelle Roets
- Department of Anaesthesia, the Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.,Faculty of Medicine, the University of Queensland, Queensland, Australia
| | - David John Sturgess
- Faculty of Medicine, the University of Queensland, Queensland, Australia.,Department of Anaesthesia, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | | | - Thu Vinh Tran
- Australian Red Cross Lifeblood, Kelvin Grove, Queensland, Australia
| | - Kerstin Hildegard Wyssusek
- Department of Anaesthesia, the Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.,Faculty of Medicine, the University of Queensland, Queensland, Australia
| | | | - Diana da Silva
- Department of Anaesthesia, the Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.,Faculty of Medicine, the University of Queensland, Queensland, Australia
| | - Andre van Zundert
- Department of Anaesthesia, the Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.,Faculty of Medicine, the University of Queensland, Queensland, Australia
| | | | - John Paul Tung
- Australian Red Cross Lifeblood, Kelvin Grove, Queensland, Australia
| | | | - Melinda Margaret Dean
- Australian Red Cross Lifeblood, Kelvin Grove, Queensland, Australia.,School of Health and Sport Sciences, University of the Sunshine Coast, Petrie, Queensland, Australia
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Eley V, Christensen R, Guy L, Wyssusek K, Pelecanos A, Dodd B, Stowasser M, van Zundert A. ClearSight™ finger cuff versus invasive arterial pressure measurement in patients with body mass index above 45 kg/m 2. BMC Anesthesiol 2021; 21:152. [PMID: 34006231 PMCID: PMC8130355 DOI: 10.1186/s12871-021-01374-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 05/07/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Measuring blood pressure in patients with obesity is challenging. The ClearSight™ finger cuff (FC) uses the vascular unloading technique to provide continuous non-invasive blood pressure measurements. We aimed to test the agreement of the FC with invasive radial arterial monitoring (INV) in patients with obesity. METHODS Participants had a body mass index (BMI) ≥45 kg/m2 and underwent laparoscopic bariatric surgery. FC and INV measurements were obtained simultaneously every 5 min on each patient, following induction of anesthesia. Agreement over time was assessed using modified Bland-Altman plots and error grid analysis permitted clinical interpretation of the results. Four-quadrant plots allowed assessment of concordance in blood pressure changes. RESULTS The 30 participants had a median (IQR) BMI of 50.2 kg/m2 (IQR 48.3-55.3). The observed bias (SD, 95% limits of agreement) for systolic blood pressure (SBP) was 14.3 mmHg (14.1, -13.4 - 42.0), 5.2 mmHg (10.9, -16.0 - 26.5) for mean arterial pressure (MAP) and 2.6 mmHg (10.8, -18.6 - 23.8) for diastolic blood pressure (DBP). Error grid analysis showed that the proportion of readings in risk zones A-E were 90.8, 6.5, 2.7, 0 and 0% for SBP and 91.4, 4.3, 4.3, 0 and 0% for MAP, respectively. Discordance occurred in ≤8% of pairs for consecutive change in SBP, MAP and DBP. CONCLUSIONS The vascular unloading technique was not adequately in agreement with radial arterial monitoring. Evaluation in a larger sample is required before recommending this technique for intraoperative monitoring of patients with BMI ≥45 kg/m2.
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Affiliation(s)
- Victoria Eley
- Department of Anaesthesia and Perioperative Medicine, The Royal Brisbane and Women's Hospital, Butterfield St, Herston, Queensland, 4006, Australia. .,Faculty of Medicine, The University of Queensland, St Lucia, Queensland, 4067, Australia.
| | - Rebecca Christensen
- Department of Anaesthesia and Perioperative Medicine, The Royal Brisbane and Women's Hospital, Butterfield St, Herston, Queensland, 4006, Australia.,Faculty of Medicine, The University of Queensland, St Lucia, Queensland, 4067, Australia
| | - Louis Guy
- Department of Anaesthesia and Perioperative Medicine, The Royal Brisbane and Women's Hospital, Butterfield St, Herston, Queensland, 4006, Australia.,Faculty of Medicine, The University of Queensland, St Lucia, Queensland, 4067, Australia
| | - Kerstin Wyssusek
- Department of Anaesthesia and Perioperative Medicine, The Royal Brisbane and Women's Hospital, Butterfield St, Herston, Queensland, 4006, Australia.,Faculty of Medicine, The University of Queensland, St Lucia, Queensland, 4067, Australia
| | - Anita Pelecanos
- Statistics Unit, Queensland Institute of Medical Research Berghofer, Herston, Brisbane, 4006, Australia
| | - Benjamin Dodd
- Faculty of Medicine, The University of Queensland, St Lucia, Queensland, 4067, Australia.,Department of Surgery, The Royal Brisbane and Women's Hospital, Butterfield St, Herston, Queensland, 4006, Australia
| | - Michael Stowasser
- Faculty of Medicine, The University of Queensland, St Lucia, Queensland, 4067, Australia.,Hypertension Unit, Princess Alexandra Hospital, Woolloongabba, Brisbane, 4102, Australia
| | - Andre van Zundert
- Department of Anaesthesia and Perioperative Medicine, The Royal Brisbane and Women's Hospital, Butterfield St, Herston, Queensland, 4006, Australia.,Faculty of Medicine, The University of Queensland, St Lucia, Queensland, 4067, Australia
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Eley VA, van Zundert A, Callaway L. What is the failure rate in extending labour analgesia in patients with a body mass index ≥ 40 kg/m(2)compared with patients with a body mass index < 30 kg/m(2)? a retrospective pilot study. BMC Anesthesiol 2015; 15:115. [PMID: 26231175 PMCID: PMC4522121 DOI: 10.1186/s12871-015-0095-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 07/20/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Early utilisation of neuraxial anaesthesia has been recommended to reduce the need for general anaesthesia in obese parturients. The insertion and management of labour epidurals in obese women is not straight-forward. The aim of this pilot study was to compare the failure rate of extension of epidural analgesia for emergency caesarean section, in pregnant women with a body mass index (BMI) ≥ 40 kg/m(2), to those with a BMI < 30 kg/m(2). The results will be used to calculate the sample size of a planned prospective study. METHODS In this retrospective, (1:1) case-control pilot study, obese subjects and control subjects were selected from the obstetric database, if they delivered between January 2007 and December 2011. All subjects used epidural analgesia during labour and subsequently required anaesthesia for Category 1 or 2 Caesarean Section. Data was extracted from the patient medical record. Failure to extend was analysed using liberal and restrictive definitions. Chi-square or Fisher's exact tests were used to detect differences between groups. Multiple logistic regression was used to examine variables predictive of extension failure. RESULTS There were 63 subjects in each group. The mean BMI of the obese group was 45.4 (5.8) kg/m(2) and 23.9 (3.0) kg/m(2) in the control group. The odds ratio for failure to extend the existing epidural blockade (liberal definition) was 2.48 (95 % CI:1.02 - 6.03) for the obese group compared with the control group (adjusted for age, parity and gestation). Using the restrictive definition, the odds ratio for failure in the obese group was 6.78 (95 % CI:1.43 - 32.2). The combination of respiratory co-morbidity and gestational diabetes significantly predicted extension failure. Surgical time and epidural complications on labour ward were significantly greater in the obese group. CONCLUSIONS In this small retrospective cohort, patients with a BMI ≥ 40 kg/m(2) were significantly more likely to fail epidural extension for caesarean section. The presence of respiratory co-morbidity and gestational diabetes were significant predictors of extension failure; their clinical relevance requires further evaluation.
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Affiliation(s)
- Victoria A Eley
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Butterfield St, Herston, 4006, Queensland, Australia.
- School of Medicine, The University of Queensland, Herston Rd, Herston, 4006, Queensland, Australia.
| | - Andre van Zundert
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Butterfield St, Herston, 4006, Queensland, Australia.
- School of Medicine, The University of Queensland, Herston Rd, Herston, 4006, Queensland, Australia.
| | - Leonie Callaway
- School of Medicine, The University of Queensland, Herston Rd, Herston, 4006, Queensland, Australia.
- Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Butterfield St, Herston, 4006, Queensland, Australia.
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