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Vadivelu N, Kodumudi G, Leffert LR, Pierson DC, Rein LK, Silverman MS, Cornett EM, Kaye AD. Evolving Therapeutic Roles of Nasogastric Tubes: Current Concepts in Clinical Practice. Adv Ther 2023; 40:828-843. [PMID: 36637690 PMCID: PMC9838367 DOI: 10.1007/s12325-022-02406-9] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 12/08/2022] [Indexed: 01/14/2023]
Abstract
Nasogastric tubes (NGT) have been in use for over 100 years and are still considered as essential and resuscitative tools in multiple medical specialties for acute and chronic care. They are vital for decompression of the stomach in the presence of bowel obstruction in the critically ill and useful as a conduit for the administration of medications and sometimes for short term parenteral nutrition. The placement of nasogastric tubes is relatively routine. However, they must be inserted and maintained safely and effectively to avoid serious and possibly even fatal associated complications. This review focuses on recent updates in research regarding nasogastric tubes. Cognizance of the recent advances in indications, contraindications, techniques of insertion, confirmation of correct positioning, securement, complications, management of complications, and state of the art research about the nasogastric tube is crucial for practitioners of all medical and surgical specialties.
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Affiliation(s)
- Nalini Vadivelu
- grid.47100.320000000419368710Department of Anesthesiology, Yale University School of Medicine, 333, Cedar Street, New Haven, CT 06520 USA
| | - Gopal Kodumudi
- grid.411417.60000 0004 0443 6864Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Hwy, Shreveport, LA 71103 USA
| | - Lisa R. Leffert
- grid.47100.320000000419368710Department of Anesthesiology, Yale University School of Medicine, 333, Cedar Street, New Haven, CT 06520 USA
| | - Doris C. Pierson
- grid.47100.320000000419368710Department of Anesthesiology, Yale University School of Medicine, 333, Cedar Street, New Haven, CT 06520 USA
| | - Laura K. Rein
- grid.47100.320000000419368710Department of Anesthesiology, Yale University School of Medicine, 333, Cedar Street, New Haven, CT 06520 USA
| | - Matthew S. Silverman
- grid.47100.320000000419368710Department of Anesthesiology, Yale University School of Medicine, 333, Cedar Street, New Haven, CT 06520 USA
| | - Elyse M. Cornett
- grid.411417.60000 0004 0443 6864Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Hwy, Shreveport, LA 71103 USA
| | - Alan D. Kaye
- grid.411417.60000 0004 0443 6864Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Hwy, Shreveport, LA 71103 USA
- grid.279863.10000 0000 8954 1233Department of Anesthesiology, Louisiana State University Health Sciences Center at New Orleans, 1542 Tulane Avenue Room 659, New Orleans, LA 70112 USA
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Pearson ACS, Leffert LR, Kain ZN. In Response. Anesth Analg 2022; 135:e3-e4. [PMID: 35709456 DOI: 10.1213/ane.0000000000006014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Amy C S Pearson
- Department of Anesthesia, University of Iowa, Iowa City, Iowa,
| | - Lisa R Leffert
- Department of Anesthesiology, Yale School of Medicine, Yale New Haven Hospital, New Haven, Connecticut, Department of Anesthesiology, Bridgeport Hospital, New Haven, Connecticut
| | - Zeev N Kain
- UCI Center on Stress and Health, Department of Anesthesiology and Perioperative Care, University of California, Irvine, California, Child Study Center, Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut, Department of Pediatrics, CHOC Children's Hospital, Orange, California
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Affiliation(s)
- Amy C S Pearson
- From the Department of Anesthesia, University of Iowa, Iowa City, Iowa
| | - Lisa R Leffert
- Department of Anesthesiology at Yale School of Medicine, Anesthesiology at Yale, New Haven Hospital and Bridgeport Hospital, New Haven, Connecticut
| | - Zeev N Kain
- UCI Center on Stress & Health and Department of Anesthesiology & Perioperative Care, University of California, Irvine, California.,Child Study Center, Yale University School of Medicine, New Haven, Connecticut.,Department of Pediatrics, Children's Hospital of Orange County, Orange, California
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Ende HB, Landau R, Cole NM, Burns SM, Bateman BT, Bauer ME, Booth JL, Flood P, Leffert LR, Houle TT, Tsen LC. Labor prior to cesarean delivery associated with higher post-discharge opioid consumption. PLoS One 2021; 16:e0253990. [PMID: 34242277 PMCID: PMC8270408 DOI: 10.1371/journal.pone.0253990] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 06/17/2021] [Indexed: 11/24/2022] Open
Abstract
Background Severe acute post-cesarean delivery (CD) pain has been associated with an increased risk for persistent pain and postpartum depression. Identification of women at increased risk for pain can be used to optimize post-cesarean analgesia. The impact of labor prior to CD (intrapartum CD) on acute post-operative pain and opioid use is unclear. We hypothesized that intrapartum CD, which has been associated with both increased inflammation and affective distress related to an unexpected surgical procedure, would result in higher postoperative pain scores and increased opioid intake. Methods This is a secondary analysis of a prospective cohort study examining opioid use up to 2 weeks following CD. Women undergoing CD at six academic medical centers in the United States 9/2014-3/2016 were contacted by phone two weeks following discharge. Participants completed a structured interview that included questions about postoperative pain scores and opioid utilization. They were asked to retrospectively estimate their maximal pain score on an 11-point numeric rating scale at multiple time points, including day of surgery, during hospitalization, immediately after discharge, 1st week, and 2nd week following discharge. Pain scores over time were assessed utilizing a generalized linear mixed-effects model with the patient identifier being a random effect, adjusting for an a priori defined set of confounders. A multivariate negative binomial model was utilized to assess the association between intrapartum CD and opioid utilization after discharge, also adjusting for the same confounders. In the context of non-random prescription distribution, this model was constructed with an offset for the number of tablets dispensed. Results A total of 720 women were enrolled, 392 with and 328 without labor prior to CD. Patients with intrapartum CD were younger, less likely to undergo repeat CD or additional surgical procedures, and more likely to experience a complication of CD. Women with intrapartum CD consumed more opioid tablets following discharge than women without labor (median 20, IQR 10–30 versus 17, IQR 6–30; p = 0.005). This association persisted after adjustment for confounders (incidence rate ratio 1.16, 95% CI 1.05–1.29; p = 0.004). Pain scores on the day of surgery were higher in women with intrapartum CD (difference 0.91, 95% CI 0.52–1.30; adj. p = <0.001) even after adjustment for confounders. Pain scores at other time points were not meaningfully different between the two groups. Conclusion Intrapartum CD is associated with worse pain on the day of surgery but not other time points. Opioid requirements following discharge were modestly increased following intrapartum CD.
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Affiliation(s)
- Holly B. Ende
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- * E-mail:
| | - Ruth Landau
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, New York, United States of America
| | - Naida M. Cole
- Department of Anesthesiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Sara M. Burns
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Brian T. Bateman
- Department of Anesthesiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Melissa E. Bauer
- Department of Anesthesiology, Division of Obstetric Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan, United States of America
| | - Jessica L. Booth
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States of America
| | - Pamela Flood
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California, United States of America
| | - Lisa R. Leffert
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Timothy T. Houle
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Lawrence C. Tsen
- Department of Anesthesiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
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Affiliation(s)
- Dana P Turner
- Department of Anesthesia, Critical Care & Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Lisa R Leffert
- Department of Anesthesia, Critical Care & Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Timothy T Houle
- Department of Anesthesia, Critical Care & Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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Abstract
OBJECTIVE Using experimental, yet realistic, headache calendars, this laboratory study evaluated the ability of individuals to identify the degree of association between triggers and headaches. BACKGROUND Individuals with headache often record daily diaries or calendars to identify their patterns of triggers. METHODS This cross-sectional, observational study included adults with migraine, tension-type, or cluster headache who had ever experienced more than 5 attacks. Participants (N = 300) were presented with headache calendars and asked to rate the strength of the relationship (how strongly one causes the other) between 3 experimental triggers (high stress, poor sleep, and cinnamon) and headache using a 0 ("no relationship") to 10 ("perfect relationship") scale for each calendar. RESULTS Calendars with a high positive correlation between trigger and headache had higher participant ratings than those with low correlations. The median [25th, 75th] of ratings for each correlation level was low correlation: 1 [0, 4], medium: 4 [2, 5], and high: 5 [4, 8], P < .0001. However, participants appeared to ignore negative associations (ie, trigger present with no headache) and rated calendars with more headache days as having higher associations, regardless of the true relationship. The ratings for 2, 6, and 26 headache days were 1 [0, 3], 4 [1, 6], and 8 [0, 10], respectively (P < .0001). Participants' previous beliefs about the triggers also affected their ratings (average correlation across triggers: r = 0.25, P < .0001). CONCLUSIONS This laboratory task supports the notion that individuals with headache are able to identify the association between headaches and triggers using headache calendars. However, these judgments can be biased by the individuals' previous beliefs about the trigger and by the degree of headache activity.
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Affiliation(s)
- Dana P Turner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Lisa R Leffert
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Timothy T Houle
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Efstathiou JA, Drumm MR, Paly JP, Lawton DM, O’Neill RM, Niemierko A, Leffert LR, Loeffler JS, Shih HA. Long-term impact of a faculty mentoring program in academic medicine. PLoS One 2018; 13:e0207634. [PMID: 30496199 PMCID: PMC6264475 DOI: 10.1371/journal.pone.0207634] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 11/02/2018] [Indexed: 11/18/2022] Open
Abstract
The authors conducted a prospective longitudinal study from 2009 to 2016 to assess the short and long-term impact of a formal mentorship program on junior faculty satisfaction and productivity. Junior faculty mentees enrolled in the program and junior faculty without formal mentorship were administered surveys before and after the program to assess satisfaction with their mentoring experiences. Long-term retention, promotion, and funding data were also collected. Twenty-three junior faculty mentees and 91 junior faculty controls were included in the study. Mentees came from the Departments of Radiation Oncology and Anesthesia, Critical Care, and Pain Management. After participating in the mentorship program, mentees demonstrated an increase in satisfaction from baseline in five of seven domains related to mentoring, while controls experienced no significant change in satisfaction in six of the seven domains. At long-term follow up, mentees were more likely than controls to hold senior faculty positions (percent senior faculty: 47% vs. 13%, p = 0.030) despite no difference in initial administrative rank. When comparing the subset of faculty who were Instructors at baseline, mentees were more likely to be funded and/or promoted than controls (p = 0.030). A majority of mentees reported that the program strengthened their long-term success, and many maintained their original mentoring relationships and formed new ones, highlighting the strong culture of mentorship that was instilled. Several short-term and long-term benefits were fostered from this formal mentorship program. These findings highlight the potential impact of mentorship programs in propagating a culture of mentorship and excellence.
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Affiliation(s)
- Jason A. Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
| | - Michael R. Drumm
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Jonathan P. Paly
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Donna M. Lawton
- Center for Faculty Development, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Regina M. O’Neill
- Sawyer Business School, Suffolk University, Boston, Massachusetts, United States of America
| | - Andrzej Niemierko
- Department of Radiation Oncology, Division of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Lisa R. Leffert
- Department of Anesthesia, Critical Care & Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Jay S. Loeffler
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Helen A. Shih
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
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Abstract
PURPOSE OF REVIEW This review summarizes the pathophysiology, peripartum treatment, and anesthetic management of parturients with cardiac disease. Valvular disease, coronary disease, and cardiomyopathy are specifically addressed in the context of the normal physiologic changes of pregnancy. We offer recommendations for anesthetic approaches, hemodynamic goals with an emphasis on interdisciplinary planning between anesthesiologists, cardiologists, cardiothoracic surgeons, obstetricians, maternal fetal medicine specialists, and neonatologists. RECENT FINDINGS Vaginal delivery with neuraxial analgesia can be well tolerated by many pregnant patients with cardiac disease when coordinated by an interdisciplinary team of experts. Cardiac disease in pregnancy can present a significant challenge for the interdisciplinary care team. A detailed understanding of each patient's cardiac pathology and the physiologic changes of pregnancy are critical to ensure a safe and successful labor and delivery. Optimized medical therapy in the peripartum period and neuraxial anesthesia with the judicious use of vasoactive agents can be of great benefit for these parturients. As is generally the case, cesarean delivery should be primarily reserved for obstetric indications and maternal wellbeing, with careful consideration of the fetus to guide best practices.
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Affiliation(s)
- Kate M Cohen
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Rebecca D Minehart
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Lisa R Leffert
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
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Abstract
OBJECTIVE To characterize risk and timing of postpartum stroke readmission after delivery hospitalization discharge. METHODS The Healthcare Cost and Utilization Project's Nationwide Readmissions Database for calendar years 2013 and 2014 was used to perform a retrospective cohort study evaluating risk of readmission for stroke within 60 days of discharge from a delivery hospitalization. Risk was characterized as odds ratios (ORs) with 95% CIs based on whether patients had hypertensive diseases of pregnancy (gestational hypertension or preeclampsia), or chronic hypertension, or neither disorder during the index hospitalization. Adjusted models for stroke readmission risk were created. RESULTS From January 1, 2013, to October 31, 2013, and January 1, 2014, to October 31, 2014, 6,272,136 delivery hospitalizations were included in the analysis. One thousand five hundred five cases of readmission for postpartum stroke were identified. Two hundred fourteen (14.2%) cases of stroke occurred among patients with hypertensive diseases of pregnancy, 66 (4.4%) with chronic hypertension, and 1,225 (81.4%) without hypertension. The majority of stroke readmissions occurred within 10 days of hospital discharge (58.4%), including 53.2% of patients with hypertensive diseases of pregnancy during the index hospitalization, 66.7% with chronic hypertension, and 58.9% with no hypertension. Hypertensive diseases of pregnancy and chronic hypertension were associated with increased risk of stroke readmission compared with no hypertension (OR 1.74, 95% CI 1.33-2.27 and OR 1.88, 95% CI 1.19-2.96, respectively). Median times to readmission were 8.9 days for hypertensive diseases of pregnancy, 7.8 days for chronic hypertension, and 8.3 days without either condition. CONCLUSION Although patients with chronic hypertension and hypertensive diseases of pregnancy are at higher risk of postpartum stroke, they account for a minority of such strokes. The majority of readmissions for postpartum stroke occur within 10 days of discharge; optimal blood pressure management may be particularly important during this period.
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Affiliation(s)
- Gloria Too
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Timothy Wen
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Amelia K. Boehme
- Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, NY,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York NY
| | - Eliza C. Miller
- Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Lisa R. Leffert
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston MA
| | - Frank J. Attenello
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles CA
| | - William J. Mack
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles CA
| | - Mary E. D’Alton
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Alexander M. Friedman
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY
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Leffert LR, Dubois HM, Butwick AJ, Carvalho B, Houle TT, Landau R. Neuraxial Anesthesia in Obstetric Patients Receiving Thromboprophylaxis With Unfractionated or Low-Molecular-Weight Heparin: A Systematic Review of Spinal Epidural Hematoma. Anesth Analg 2017. [DOI: 10.1213/ane.0000000000002173] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Sigakis MJG, Leffert LR, Mirzakhani H, Sharawi N, Rajala B, Callaghan WM, Kuklina EV, Creanga AA, Mhyre JM, Bateman BT. The Validity of Discharge Billing Codes Reflecting Severe Maternal Morbidity. Anesth Analg 2017; 123:731-8. [PMID: 27387839 DOI: 10.1213/ane.0000000000001436] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Discharge diagnoses are used to track national trends and patterns of maternal morbidity. There are few data regarding the validity of the International Classification of Diseases (ICD) codes used for this purpose. The goal of our study was to try to better understand the validity of administrative data being used to monitor and assess trends in morbidity. METHODS Hospital stay billing records were queried to identify all delivery admissions at the Massachusetts General Hospital for the time period 2001 to 2011 and the University of Michigan Health System for the time period 2005 to 2011. From this, we identified patients with ICD-9-Clinical Modification (CM) diagnosis and procedure codes indicative of severe maternal morbidity. Each patient was classified with 1 of 18 different medical/obstetric categories (conditions or procedures) based on the ICD-9-CM code that was recorded. Within each category, 20 patients from each institution were selected at random, and the corresponding medical charts were reviewed to determine whether the ICD-9-CM code was assigned correctly. The percentage of correct codes for each of 18 preselected clinical categories was calculated yielding a positive predictive value (PPV) and 99% confidence interval (CI). RESULTS The overall number of correctly assigned ICD-9-CM codes, or PPV, was 218 of 255 (86%; CI, 79%-90%) and 154 of 188 (82%; CI, 74%-88%) at Massachusetts General Hospital and University of Michigan Health System, respectively (combined PPV, 372/443 [84%; CI, 79-88%]). Codes within 4 categories (Hysterectomy, Pulmonary edema, Disorders of fluid, electrolyte and acid-base balance, and Sepsis) had a 99% lower confidence limit ≥75%. Codes within 8 additional categories demonstrated a 99% lower confidence limit between 74% and 50% (Acute respiratory distress, Ventilation, Other complications of obstetric surgery, Disorders of coagulation, Cardiomonitoring, Acute renal failure, Thromboembolism, and Shock). Codes within 6 clinical categories demonstrated a 99% lower confidence limit <50% (Puerperal cerebrovascular disorders, Conversion of cardiac rhythm, Acute heart failure [includes arrest and fibrillation], Eclampsia, Neurotrauma, and Severe anesthesia complications). CONCLUSIONS ICD-9-CM codes capturing severe maternal morbidity during delivery hospitalization demonstrate a range of PPVs. The PPV was high when objective supportive evidence, such as laboratory values or procedure documentation supported the ICD-9-CM code. The PPV was low when greater judgment, interpretation, and synthesis of the clinical data (signs and symptoms) was required to support a code, such as with the category Severe anesthesia complications. As a result, these codes should be used for administrative research with more caution compared with codes primarily defined by objective data.
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Affiliation(s)
- Matthew J G Sigakis
- From the *Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan; †Division of Obstetric Anesthesia, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts; ‡Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts; §Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia; ‖Epidemiology & Surveillance Branch, Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia; and ¶Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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Toledano RD, Leffert LR. Anesthetic and Obstetric Management of Placenta Accreta: Clinical Experience and Available Evidence. Curr Anesthesiol Rep 2017. [DOI: 10.1007/s40140-017-0200-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Leffert LR, Clancy CR, Bateman BT, Cox M, Schulte PJ, Smith EE, Fonarow GC, Schwamm LH, Kuklina EV, George MG. Patient Characteristics and Outcomes After Hemorrhagic Stroke in Pregnancy. Circ Cardiovasc Qual Outcomes 2016; 8:S170-8. [PMID: 26515206 DOI: 10.1161/circoutcomes.115.002242] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hospitalizations for pregnancy-related stroke are rare but increasing. Hemorrhagic stroke (HS), ie, subarachnoid hemorrhage and intracerebral hemorrhage, is more common than ischemic stroke in pregnant versus nonpregnant women, reflecting different phenotypes or risk factors. We compared stroke risk factors and outcomes in pregnant versus nonpregnant HS in the Get With The Guidelines-Stroke Registry. METHODS AND RESULTS Using medical history or International Classification of Diseases-Ninth Revision codes, we identified 330 pregnant and 10 562 nonpregnant female patients aged 18 to 44 years with HS in Get With The Guidelines-Stroke (2008-2014). Differences in patient and care characteristics were compared by χ(2) or Fisher exact test (categorical variables) or Wilcoxon rank-sum (continuous variables) tests. Conditional logistic regression assessed the association of pregnancy with outcomes conditional on categorical age and further adjusted for patient and hospital characteristics. Pregnant versus nonpregnant HS patients were younger with fewer pre-existing stroke risk factors and medications. Pregnant versus nonpregnant subarachnoid hemorrhage patients were less impaired at arrival, and less than half met blood pressure criteria for severe preeclampsia. In-hospital mortality was lower in pregnant versus nonpregnant HS patients: adjusted odds ratios (95% CI) for subarachnoid hemorrhage 0.17 (0.06-0.45) and intracerebral hemorrhage 0.57 (0.34-0.94). Pregnant subarachnoid hemorrhage patients also had a higher likelihood of home discharge (2.60 [1.67-4.06]) and independent ambulation at discharge (2.40 [1.56-3.70]). CONCLUSIONS Pregnant HS patients are younger and have fewer risk factors than their nonpregnant counterparts, and risk-adjusted in-hospital mortality is lower. Our findings suggest possible differences in underlying disease pathophysiology and challenges to identifying at-risk patients.
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Affiliation(s)
- Lisa R Leffert
- From the Department of Anesthesia, Critical Care and Pain Medicine (L.R.L., C.R.C., B.T.B.) and Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA; Clinical Trials Statistics Group (P.J.S.), Outcomes Research and Assessment Group (M.C.), Duke Clinical Research Institute, Durham, NC (M.C.)(M.C.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Medicine, Cardiomyopathy Center, Ronald Reagan, Ahmanson-University of California, Los Angeles Medical Center (G.C.F.); Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA (E.V.K.); and Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (M.G.G.).
| | - Caitlin R Clancy
- From the Department of Anesthesia, Critical Care and Pain Medicine (L.R.L., C.R.C., B.T.B.) and Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA; Clinical Trials Statistics Group (P.J.S.), Outcomes Research and Assessment Group (M.C.), Duke Clinical Research Institute, Durham, NC (M.C.)(M.C.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Medicine, Cardiomyopathy Center, Ronald Reagan, Ahmanson-University of California, Los Angeles Medical Center (G.C.F.); Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA (E.V.K.); and Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (M.G.G.)
| | - Brian T Bateman
- From the Department of Anesthesia, Critical Care and Pain Medicine (L.R.L., C.R.C., B.T.B.) and Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA; Clinical Trials Statistics Group (P.J.S.), Outcomes Research and Assessment Group (M.C.), Duke Clinical Research Institute, Durham, NC (M.C.)(M.C.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Medicine, Cardiomyopathy Center, Ronald Reagan, Ahmanson-University of California, Los Angeles Medical Center (G.C.F.); Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA (E.V.K.); and Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (M.G.G.)
| | - Margueritte Cox
- From the Department of Anesthesia, Critical Care and Pain Medicine (L.R.L., C.R.C., B.T.B.) and Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA; Clinical Trials Statistics Group (P.J.S.), Outcomes Research and Assessment Group (M.C.), Duke Clinical Research Institute, Durham, NC (M.C.)(M.C.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Medicine, Cardiomyopathy Center, Ronald Reagan, Ahmanson-University of California, Los Angeles Medical Center (G.C.F.); Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA (E.V.K.); and Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (M.G.G.)
| | - Phillip J Schulte
- From the Department of Anesthesia, Critical Care and Pain Medicine (L.R.L., C.R.C., B.T.B.) and Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA; Clinical Trials Statistics Group (P.J.S.), Outcomes Research and Assessment Group (M.C.), Duke Clinical Research Institute, Durham, NC (M.C.)(M.C.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Medicine, Cardiomyopathy Center, Ronald Reagan, Ahmanson-University of California, Los Angeles Medical Center (G.C.F.); Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA (E.V.K.); and Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (M.G.G.)
| | - Eric E Smith
- From the Department of Anesthesia, Critical Care and Pain Medicine (L.R.L., C.R.C., B.T.B.) and Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA; Clinical Trials Statistics Group (P.J.S.), Outcomes Research and Assessment Group (M.C.), Duke Clinical Research Institute, Durham, NC (M.C.)(M.C.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Medicine, Cardiomyopathy Center, Ronald Reagan, Ahmanson-University of California, Los Angeles Medical Center (G.C.F.); Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA (E.V.K.); and Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (M.G.G.)
| | - Gregg C Fonarow
- From the Department of Anesthesia, Critical Care and Pain Medicine (L.R.L., C.R.C., B.T.B.) and Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA; Clinical Trials Statistics Group (P.J.S.), Outcomes Research and Assessment Group (M.C.), Duke Clinical Research Institute, Durham, NC (M.C.)(M.C.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Medicine, Cardiomyopathy Center, Ronald Reagan, Ahmanson-University of California, Los Angeles Medical Center (G.C.F.); Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA (E.V.K.); and Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (M.G.G.)
| | - Lee H Schwamm
- From the Department of Anesthesia, Critical Care and Pain Medicine (L.R.L., C.R.C., B.T.B.) and Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA; Clinical Trials Statistics Group (P.J.S.), Outcomes Research and Assessment Group (M.C.), Duke Clinical Research Institute, Durham, NC (M.C.)(M.C.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Medicine, Cardiomyopathy Center, Ronald Reagan, Ahmanson-University of California, Los Angeles Medical Center (G.C.F.); Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA (E.V.K.); and Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (M.G.G.)
| | - Elena V Kuklina
- From the Department of Anesthesia, Critical Care and Pain Medicine (L.R.L., C.R.C., B.T.B.) and Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA; Clinical Trials Statistics Group (P.J.S.), Outcomes Research and Assessment Group (M.C.), Duke Clinical Research Institute, Durham, NC (M.C.)(M.C.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Medicine, Cardiomyopathy Center, Ronald Reagan, Ahmanson-University of California, Los Angeles Medical Center (G.C.F.); Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA (E.V.K.); and Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (M.G.G.)
| | - Mary G George
- From the Department of Anesthesia, Critical Care and Pain Medicine (L.R.L., C.R.C., B.T.B.) and Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA; Clinical Trials Statistics Group (P.J.S.), Outcomes Research and Assessment Group (M.C.), Duke Clinical Research Institute, Durham, NC (M.C.)(M.C.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Medicine, Cardiomyopathy Center, Ronald Reagan, Ahmanson-University of California, Los Angeles Medical Center (G.C.F.); Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA (E.V.K.); and Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (M.G.G.)
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Leffert LR, Clancy CR, Bateman BT, Cox M, Schulte PJ, Smith EE, Fonarow GC, Kuklina EV, George MG, Schwamm LH. Treatment patterns and short-term outcomes in ischemic stroke in pregnancy or postpartum period. Am J Obstet Gynecol 2016; 214:723.e1-723.e11. [PMID: 26709084 DOI: 10.1016/j.ajog.2015.12.016] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 12/02/2015] [Accepted: 12/13/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Stroke, which is a rare but devastating event during pregnancy, occurs in 34 of every 100,000 deliveries; obstetricians are often the first providers to be contacted by symptomatic patients. At least one-half of pregnancy-related strokes are likely to be of the ischemic stroke subtype. Most pregnant or newly postpartum women with ischemic stroke do not receive acute stroke reperfusion therapy, although this is the recommended treatment for adults. Little is known about these therapies in pregnant or postpartum women because pregnancy has been an exclusion criterion for all reperfusion trials. Until recently, pregnancy and obstetric delivery were specifically identified as warnings to intravenous alteplase tissue plasminogen activator in Federal Drug Administration labeling. OBJECTIVE The primary study objective was to compare the characteristics and outcomes of pregnant or postpartum vs nonpregnant women with ischemic stroke who received acute reperfusion therapy. STUDY DESIGN Pregnant or postpartum (<6 weeks; n = 338) and nonpregnant (n = 24,303) women 18-44 years old with ischemic stroke from 1991 hospitals that participated in the American Heart Association's Get With the Guidelines-Stroke Registry from 2008-2013 were identified by medical history or International Classification of Diseases, Ninth Revision, codes. Acute stroke reperfusion therapy was defined as intravenous tissue plasminogen activator, catheter-based thrombolysis, or thrombectomy or any combination thereof. A sensitivity analysis was done on patients who received intravenous tissue plasminogen activator monotherapy only. Chi-square tests were used for categoric variables, and Wilcoxon Rank-Sum was used for continuous variables. Conditional logistic regression was used to assess the association of pregnancy with short-term outcomes. RESULTS Baseline characteristics of the pregnant or postpartum vs nonpregnant women with ischemic stroke revealed a younger group who, despite greater stroke severity, were less likely to have a history of hypertension or to arrive via emergency medical services. There were similar rates of acute stroke reperfusion therapy in the pregnant or postpartum vs nonpregnant women (11.8% vs 10.5%; P = .42). Pregnant or postpartum women were less likely to receive intravenous tissue plasminogen activator monotherapy (4.4% vs 7.9%; P = .03), primarily because of pregnancy and recent surgery. There was a trend toward increased symptomatic intracranial hemorrhage in the pregnant or postpartum patients who were treated with tissue plasminogen activator, yet no cases of major systemic bleeding or in-hospital death occurred, and there were similar rates of discharge to home. Data on the timing of pregnancy, which were available in 145 of 338 cases, showed that 44.8% of pregnancy-related strokes were antepartum, that 2.8% occurred during delivery, and that 52.4% were during the postpartum period. CONCLUSIONS Using data from the Get With the Guidelines-Stroke Registry to assemble the largest cohort of pregnant or postpartum ischemic stroke patients who had been treated with reperfusion therapy, we observed that pregnant or postpartum women had similarly favorable short-term outcomes and equal rates of total reperfusion therapy to nonpregnant women, despite lower rates of intravenous tissue plasminogen activator use. Future studies should identify the characteristics of pregnant and postpartum ischemic stroke patients who are most likely to safely benefit from reperfusion therapy.
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Zaremba S, Mueller N, Heisig AM, Shin CH, Jung S, Leffert LR, Bateman BT, Pugsley LJ, Nagasaka Y, Duarte IM, Ecker JL, Eikermann M. Elevated upper body position improves pregnancy-related OSA without impairing sleep quality or sleep architecture early after delivery. Chest 2016; 148:936-944. [PMID: 25905714 DOI: 10.1378/chest.14-2973] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND During pregnancy, upper airway resistance is increased, predisposing vulnerable women to pregnancy-related OSA. Elevation of the upper body increases upper airway cross-sectional area (CSA) and improves severity of OSA in a subgroup of nonpregnant patients (positional-dependent sleep apnea). We tested the hypothesis that elevated position of the upper body improves OSA early after delivery. METHODS Following institutional review board approval, we conducted a randomized, crossover study on two postpartum units of Massachusetts General Hospital. Women during the first 48 h after delivery were included. Polysomnography was performed in nonelevated and 45° elevated upper body position. Upper airway CSA was measured by acoustic pharyngometry in nonelevated, 45° elevated, and sitting body position. RESULTS Fifty-five patients were enrolled, and measurements of airway CSA obtained. Thirty patients completed polysomnography in both body positions. Elevation of the upper body significantly reduced apnea-hypopnea index (AHI) from 7.7 ± 2.2/h in nonelevated to 4.5 ± 1.4/h in 45° elevated upper body position (P = .031) during sleep. Moderate to severe OSA (AHI > 15/h) was diagnosed in 20% of postpartum patients and successfully treated by elevated body position in one-half of them. Total sleep time and sleep architecture were not affected by upper body elevation. Change from nonelevated to sitting position increased inspiratory upper airway CSA from 1.35 ± 0.1 cm2 to 1.54 ± 0.1 cm2 during wakefulness. Position-dependent increase in CSA and decrease in AHI were correlated (r = 0.42, P = .022). CONCLUSIONS Among early postpartum women, 45° upper body elevation increased upper airway CSA and mitigated sleep apnea. Elevated body position might improve respiratory safety in women early after delivery. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT01719224; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Sebastian Zaremba
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Sleep Medicine, Department of Neurology, University Hospital Bonn, Rheinische Friedrich-Wilhelms-University, Bonn, Germany
| | - Noomi Mueller
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Anne M Heisig
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Christina H Shin
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Stefanie Jung
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Department of Pediatric Surgery, DRK-Kinderklinik Siegen, Teaching Hospital of Philipps University, Marburg, Germany; Department of Pediatric Urology, DRK-Kinderklinik Siegen, Teaching Hospital of Philipps University, Marburg, Germany
| | - Lisa R Leffert
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Brian T Bateman
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Lori J Pugsley
- Department of Obstetrics and Gynecology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Yasuko Nagasaka
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Ingrid Moreno Duarte
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Jeffrey L Ecker
- Department of Obstetrics and Gynecology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Matthias Eikermann
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Department of Anesthesia and Critical Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany.
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Leung Y, Fikry K, Shah B, Madapu M, Gaz RD, Leffert LR, Jiang Y. Continuous positive airway pressure with pressure support ventilation is effective in treating acute-onset bilateral recurrent laryngeal nerve palsy. ACTA ACUST UNITED AC 2015; 4:155-7. [PMID: 26035222 DOI: 10.1213/xaa.0000000000000150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Acute bilateral recurrent laryngeal nerve injury leading to acute vocal cord paralysis (VCP) is a serious complication of head and neck surgery, often requiring emergent surgical intervention. Although well documented, its presentation may be sudden and unexpected, occurring despite lack of obvious intraoperative nerve injury. There is limited literature on airway management strategies for patients with acute bilateral VCP before attaining a secure airway. We report a case of acute VCP that was successfully treated with continuous positive airway pressure via facemask ventilation. This effective temporizing strategy allowed clinicians to plan and prepare for tracheostomy, minimizing potential complications.
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Affiliation(s)
- Yiuka Leung
- From the *Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts; and †Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
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Liu Y, Pian-Smith MCM, Leffert LR, Minehart RD, Torri A, Coté C, Kacmarek RM, Jiang Y. Continuous measurement of cardiac output with the electrical velocimetry method in patients under spinal anesthesia for cesarean delivery. J Clin Monit Comput 2014; 29:627-34. [DOI: 10.1007/s10877-014-9645-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 11/24/2014] [Indexed: 12/31/2022]
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Abstract
OBJECTIVE To define the prevalence, indications, and temporal trends in obstetric-related ICU admissions. DESIGN Descriptive analysis of utilization patterns. SETTING All hospitals within the state of Maryland. PATIENTS All antepartum, delivery, and postpartum patients who were hospitalized between 1999 and 2008. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We identified 2,927 ICU admissions from 765,598 admissions for antepartum, delivery, or postpartum conditions using appropriate International Classification of Diseases, 9th Revision, Clinical Modification codes. The overall rate of ICU utilization was 419.1 per 100,000 deliveries, with rates of 162.5, 202.6, and 54.0 per 100,000 deliveries for the antepartum, delivery, and postpartum periods, respectively. The leading diagnoses associated with ICU admission were pregnancy-related hypertensive disease (present in 29.9% of admissions), hemorrhage (18.8%), cardiomyopathy or other cardiac disease (18.3%), genitourinary infection (11.5%), complications from ectopic pregnancies and abortions (10.3%), nongenitourinary infection (10.1%), sepsis (7.1%), cerebrovascular disease (5.8%), and pulmonary embolism (3.7%). We assessed for changes in the most common diagnoses in the ICU population over time and found rising rates of sepsis (10.1 per 100,000 deliveries to 16.6 per 100,000 deliveries, p = 0.003) and trauma (9.2 per 100,000 deliveries to 13.6 per 100,000 deliveries, p = 0.026) with decreasing rates of anesthetic complications (11.3 per 100,000 to 4.7 per 100,000, p = 0.006). The overall frequency of obstetric-related ICU admission and the rates for other indications remained relatively stable. CONCLUSIONS Between 1999 and 2008, 419.1 per 100,000 deliveries in Maryland were complicated by ICU admission. Hospitals providing obstetric services should plan for appropriate critical care management and/or transfer of women with severe morbidities during pregnancy.
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Abstract
Spinal anesthesia is widely regarded as a reasonable anesthetic option for cesarean delivery in severe preeclampsia, provided there is no indwelling epidural catheter or contraindication to neuraxial anesthesia. Compared with healthy parturients, those with severe preeclampsia experience less frequent, less severe spinal-induced hypotension. In severe preeclampsia, spinal anesthesia may cause a higher incidence of hypotension than epidural anesthesia; however, this hypotension is typically easily treated and short lived and has not been linked to clinically significant differences in outcomes. In this review, we describe the advantages and limitations of spinal anesthesia in the setting of severe preeclampsia and the evidence guiding intraoperative hemodynamic management.
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Affiliation(s)
- Vanessa G Henke
- UCLA Department of Anesthesiology, Ronald Reagan UCLA Medical Center, 757 Westwood Plaza, Suite 3325, Los Angeles, CA 90095-7403.
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Bryant A, Mhyre JM, Leffert LR, Hoban RA, Yakoob MY, Bateman BT. The Association of Maternal Race and Ethnicity and the Risk of Postpartum Hemorrhage. Anesth Analg 2012; 115:1127-36. [DOI: 10.1213/ane.0b013e3182691e62] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Tracy EE, Leffert LR, Clark VL, Ecker J. Regulatory and electronic alphabet soup: practice improvements and implications for providers. Technol Health Care 2011; 19:341-7. [PMID: 22027153 DOI: 10.3233/thc-2011-0640] [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] [Indexed: 11/15/2022]
Abstract
The growth of health information technology, the focus on patient safety and an increased degree of regulatory involvement in the practice of medicine have all transformed the way practitioners provide care. This paper reviews some of the recognized benefits of these advances, while outlining some of the challenges for providers at the bedside, utilizing a case study involving a hypothetical obstetric patient. The way external factors, such as information technology and regulatory requirements, influence the daily practice of medicine, should be carefully considered as the profession evolves.Integration and streamlining processes should remain a guiding principle to ensure patient safety and assist with workflow.
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Affiliation(s)
- Erin E Tracy
- Massachusetts General Hospital, Vincent Obstetrics and Gynecology, Boston, MA 02114, USA.
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Bateman BT, Berman MF, Riley LE, Leffert LR. The Epidemiology of Postpartum Hemorrhage in a Large, Nationwide Sample of Deliveries. Anesth Analg 2010; 110:1368-73. [DOI: 10.1213/ane.0b013e3181d74898] [Citation(s) in RCA: 416] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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