The association between labour epidural analgesia and postpartum depression in primiparous patients: a historical cohort study

PURPOSE

Peripartum pain has been associated with postpartum depression (PPD), and labour epidural analgesia (LEA) may be able to modify this risk. The objective of this historical cohort study was to examine the association between LEA and PPD among primiparous patients.

METHODS

With institutional research ethics board approval, a provincial perinatal database was searched for primiparous patients who delivered a liveborn singleton infant between 2004 and 2018. Those patients who experienced PPD following their first delivery were identified by a history of PPD in the perinatal records of their second pregnancy. We used logistic regression to compute odds ratios (ORs) for the association between LEA and PPD and performed an adjusted analysis to control for confounding variables.

RESULTS

A total of 35,437 primiparous patients were identified, 67% (n = 23,599) of whom received LEA. In the cohort, 3.7% (n = 1,296) of patients developed PPD. Patients who received LEA had increased odds of developing PPD compared with patients who did not receive LEA (adjusted OR, 1.29; 95% confidence interval [CI], 1.12 to 1.48). In a multivariable regression model, LEA remained a significant predictor for PPD, as did body mass index, pre-existing anxiety, and maternal antidepressant use.

CONCLUSION

This historical cohort study found an association between LEA and PPD among primiparous patients who subsequently had a second pregnancy in the same province. The findings call into question the hypothesis that LEA decreases the risk for PPD and further illustrates the complexities of PPD.

Analysis of Twitter conversations in obstetric anesthesiology using the hashtag #OBAnes during the onset of the COVID-19 pandemic

BACKGROUND

#OBAnes is the most used hashtag in obstetric anesthesiology. The primary objective of the study was to characterize #OBAnes tweets at the onset of the COVID-19 pandemic.

METHODS

Observational study of all tweets using #OBAnes between June 30, 2019 and October 19, 2020. A list of 19 topics was compiled to categorize each tweet. All Twitter users were manually assigned into one of 19 Symplur Healthcare Stakeholder categories.

RESULTS

There were 12 431 tweets with #OBAnes during the study period, posted by 1704 unique users. The top user category was Doctor (n = 1211, 71%) with 9665 (78%) tweets. The top three topics identified within Twitter conversations were neuraxial anesthesia, COVID-19, and general anesthesia.

CONCLUSIONS

Twitter facilitated thousands of obstetric anesthesia-related discussions during the onset of the COVID-19 pandemic, with most conversations centering on anesthesia type (neuraxial or general anesthesia).

Development of obstetric anesthesia core competencies for USA residency programs through a Delphi process

PURPOSE

The standard for anesthesia residency training in the USA mainly relies on the Accreditation Council for Graduate Medical Education (ACGME) Outcome Project, a framework that lacks specific directives for subspecialties including obstetric anesthesia. We aimed to identify core competencies in obstetric anesthesiology that can be adapted to different residency training programs to help improve the quality of training and accountability of the institutions within the USA.

METHODS

We identified a preliminary list of competencies from review of existing competency-based obstetric anesthesia training curricula and practice guidelines. We used a modified Delphi methodology to achieve expert consensus among members of the Society for Obstetric Anesthesia and Perinatology education committee. The panellists were asked to evaluate the importance of each competency using a five-point Likert scale, with consensus after two rounds defined at 80% agreement. The responders were also asked at which level of training each competency should be attained.

RESULTS

The Delphi rounds had 75% response rate and derived 94 competencies that were categorized under the six ACGME domains: patient care (38), medical knowledge (45), system-based practice (two), practice-based learning and improvement (five), interpersonal communication skills (two), and professionalism (two).

CONCLUSION

We generated a residency training competency list for obstetric anesthesiology through expert consensus. This list can be used by residency training programs to develop a structured competency-based curriculum with tangible milestones, thereby reducing heterogeneity in the standard of training.

Scale up of anaesthesia services in underserved rural Tanzania

BACKGROUND

Because of critical shortage of physician anaesthesiologists, the government of Tanzania adopted a task shifting strategy for provision of anaesthesia services. This paper describes the results of an operational study designed to increase the number of anaesthesia providers for emergency obstetric surgeries in order to reduce maternal and perinatal mortality in underserved rural Tanzania.

METHODS

In 2016 a before-after cohort study was conducted in seven health centres in rural Tanzania. Five health centres received an intervention and two were selected to track secular trends (control group). Ten associate clinicians, i.e. assistant medical officers, clinical officers, and nurse midwives, from five health centres were trained in anaesthesia skills for emergency obstetric surgeries for three months followed by quarterly supportive supervision, mentoring and teleconsultation to reinforce skills. Primary and secondary outcome measures included Caesarean delivery (CD) rate, quality and safety of anaesthesia, and uptake of the educational program for anaesthesia.

RESULTS

Out of the 2,179 CDs performed in the intervention facilities from 2016 to 2019, two women died from complications of anaesthesia. The risk of death from anaesthetic complications was 0.9 per 1000 CD (95% CI 0.1-3.3. The risk of death was not established in the control group because of inadequate documentation and records keeping. The proportion of CD performed under spinal anaesthesia in intervention facilities doubled from 28% (60/214 with 95% CI 22-35) at baseline (July 2014 - June 2016) to 57% (558/971 with 95% CI of 54-61) in year three (July 2018 - June 2019), while in the control group increased by only 40% from 19% (92/475 with 95% CI of 16-23) at baseline and 27% (68/251 with 95% CI of 22-33) in year three. In 2020I, this educational training program was then adopted by the government with minor content changes and increasing duration of training to six months.

CONCLUSIONS

This three month educational training program for associate clinicians in anaesthesia, complemented by supportive supervision, can increase the CD rate to one that fills the "unmet need" and the proportion of operations performed under spinal anaesthesia, the gold standard technique for CD. The program can be used to meet the urgent demand for anaesthesia services in other underserved areas in Africa.

Racial and ethnic disparities in obstetric anesthesia: a scoping review

PURPOSE

Health disparities continue to affect racial and ethnic marginalized obstetric patients disproportionally with increased risk of Cesarean delivery and pregnancy-related death. Yet, the literature on what influences such disparities in obstetric anesthesia service and its clinical outcomes is less well known. We set out to describe racial and ethnic disparities in obstetric anesthesia during the peripartum period in the USA via a scoping review of the recent literature.

SOURCE

Using the Institute of Medicine's definition of disparities, we searched the National Library of Medicine's PubMed/Medline, Embase, Web of Science, APA PsycINFO, and Google Scholar for articles published between 1 January 2000 and 30 June 2022 to identify literature on racial and ethnic disparities in obstetric anesthesia.

PRINCIPAL FINDINGS

Out of 8,432 articles reviewed, 15 met our inclusion criteria. All but one study was observational. Seven studies were single-institutional while the remaining used multicentre data/databases. All studies compared two or more race and ethnicity classifications. Studies in this review described disparities in the use of labour epidural analgesia, labour epidural request timing, anesthesia for Cesarean deliveries, postpartum pain management, and epidural blood patch for postdural puncture headaches. Several studies reported disparities observed in the unadjusted models becoming no longer significant when adjusted for other covariates.

CONCLUSION

Based on the findings of the present scoping review on racial and ethnic disparities in obstetric anesthesia, we present an evidence map identifying knowledge gaps and propose a future research agenda.

Modern labor epidural analgesia: implications for labor outcomes and maternal-fetal health

Epidural analgesia is an important means of pain control during labor throughout the world. Over its historic development, it has been implicated in several undesirable outcomes, including prolongation of labor and increased need for operative delivery. These effects have emerged in some retrospective and observational studies, but such methods of investigation are highly prone to bias and are particularly ill-suited for the study of labor analgesia. In high-quality studies, including Cochrane reviews and meta-analyses, epidural analgesia has been suggested to extend the first stage of labor by 30 minutes and the second stage by 15 minutes, when compared with alternative forms of analgesia. Although this may be a reproducible effect, it may be argued that it is clinically negligible. With respect to mode of delivery, similar high-quality studies have consistently shown no increased risk of cesarean delivery associated with epidural analgesia. Some forms of epidural analgesia were associated with higher risk of assisted vaginal delivery, but the use of newer modalities has been shown to abolish this effect. Specific advancements have centered on reducing total anesthetic consumption, given that local anesthetic-induced motor block is theorized to interfere with maternal expulsive efforts in the second stage of labor. These measures include the use of low-concentration local anesthetic solutions equivalent to ≤0.1% bupivacaine, shown in meta-analyses to lead to no higher risk of assisted vaginal delivery relative to nonepidural analgesia. Additional advancements in the maintenance of analgesia include programmed intermittent epidural bolus and patient-controlled epidural analgesia, the combination of which has been shown to reduce the risk of assisted vaginal delivery, also likely mediated by reduction in local anesthetic dose. These techniques have gained popularity in the past two decades, such that studies published since 2005 show no higher risk of assisted vaginal delivery with epidural than with opioid analgesia (as reported in a Cochrane review). Labor epidural analgesia has implications for maternal and fetal health perinatally. It is known to result in transient maternal hypotension (particularly with initiation), which may progress to the level of necessitating fluid or vasopressor therapy. This is not clearly associated with any adverse outcomes. There is also a consistently higher incidence of fever in parturients receiving neuraxial anesthesia, likely of noninfectious origin, which has similarly not been associated with adverse neonatal outcomes. Finally, neonates of parturients who receive epidural analgesia have been shown to have no worse Apgar scores and more favorable acid-base status than their counterparts. These observations should serve to reassure providers that modern labor analgesia, as currently understood, is not consistently associated with any significant adverse outcomes for the parturient or fetus. In this review, we describe variations of modern labor epidural analgesia, conduct an in-depth review of current literature on its use, and explore the most up-to-date evidence on its implications for the progression and outcomes of labor, including the pertinent maternal and fetal side effects.

Global issues in obstetric anaesthesia: perspectives from South Africa, Japan, China, Latin America and North America

South Africa is classified as a low- and middle-income country, with a complex mixture of resource-rich and resource-limited settings. In the major referral hospitals, the necessary skill level exists for the management of complex challenges. However, this contrasts with the frequently-inadequate skill levels of anaesthesia practitioners in resource-limited environments. In Japan, obstetricians administer anaesthesia for 40% of caesarean deliveries and 80% of labour analgesia. Centralisation of delivery facilities is now occurring and it is expected that obstetric anaesthesiologists will be available 24 h a day in centralised facilities in the future. In China, improvements in women's reproductive, maternal, neonatal, child, and adolescent health are critical government policies. Obstetric anaesthesia, especially labour analgesia, has received unprecedented attention. Chinese obstetric anaesthesiologists are passionate about clinical research, focusing on efficacy, safety, and topical issues. The Latin-American region has different landscapes, people, languages, and cultures, and is one of the world's regions with the most inequality. There are large gaps in research, knowledge, and health services, and the World Federation of Societies of Anaesthesiologists is committed to working with governmental and non-governmental organisations to improve patient care and access to safe anaesthesia. Anaesthesia workforce challenges, exacerbated by coronavirus disease 2019, beset North American healthcare. Pre-existing struggles by governments and decision-makers to improve health care access remain, partly due to unfamiliarity with the role of the anaesthesiologist. In addition to weaknesses in work environments and dated standards of work culture, the work-life balance demanded by new generations of anaesthesiologists must be acknowledged.

A Systematic Scoping Review of Peridelivery Pain Management for Pregnant People With Opioid Use Disorder: From the Society for Obstetric Anesthesia and Perinatology and Society for Maternal Fetal Medicine

The prevalence of pregnant people with opioid use disorder (OUD), including those receiving medications for opioid use disorder (MOUD), is increasing. Challenges associated with pain management in people with OUD include tolerance, opioid-induced hyperalgesia, and risk for return to use. Yet, there are few evidence-based recommendations for pain management in the setting of pregnancy and the postpartum period, and many peripartum pain management studies exclude people with OUD. This scoping review summarized the available literature on peridelivery pain management in people with OUD, methodologies used, and identified specific areas of knowledge gaps. PubMed and Embase were comprehensively searched for publications in all languages on peripartum pain management among people with OUD, both treated with MOUD and untreated. Potential articles were screened by title, abstract, and full text. Data abstracted were descriptively analyzed to map available evidence and identify areas of limited or no evidence. A total of 994 publications were imported for screening on title, abstracts, and full text, yielding 84 publications identified for full review: 32 (38.1%) review articles, 14 (16.7%) retrospective studies, and 8 (9.5%) case reports. There were 5 randomized controlled trials. Most studies (64%) were published in perinatology (32; 38.1%) journals or anesthesiology (22; 26.2%) journals. Specific areas lacking trial or systematic review evidence include: (1) methods to optimize psychological and psychosocial comorbidities relevant to acute pain management around delivery; (2) alternative nonopioid and nonpharmacologic analgesia methods; (3) whether or not to use opioids for severe breakthrough pain and how best to prescribe and monitor its use after discharge; (4) monitoring for respiratory depression and sedation with coadministration of other analgesics; (5) optimal neuraxial analgesia dosing and adjuncts; and (6) benefits of abdominal wall blocks after cesarean delivery. No publications discussed naloxone coprescribing in the labor and delivery setting. We observed an increasing number of publications on peripartum pain management in pregnant people with OUD. However, existing published works are low on the pyramid of evidence (reviews, opinions, and retrospective studies), with a paucity of original research articles (<6%). Opinions are conflicting on the utility and disutility of various analgesic interventions. Studies generating high-quality evidence on this topic are needed to inform care for pregnant people with OUD. Specific research areas are identified, including utility and disutility of short-term opioid use for postpartum pain management, role of continuous wound infiltration and truncal nerve blocks, nonpharmacologic analgesia options, and the best methods to support psychosocial aspects of pain management.

Postoperative mortality risk prediction that incorporates intraoperative vital signs: development and internal validation in a historical cohort

PURPOSE

Accurate risk reassessment after surgery is crucial for postoperative planning for monitoring and disposition. Existing postoperative mortality risk prediction models using preoperative features do not incorporate intraoperative hemodynamic derangements that may alter risk stratification. Intraoperative vital signs may provide an objective and readily available prognostic resource. Our primary objective was to derive and internally validate a logistic regression (LR) model by adding intraoperative features to established preoperative predictors to predict 30-day postoperative mortality.

METHODS

Following Research Ethics Board approval, we analyzed a historical cohort that included patients aged ≥ 45 undergoing noncardiac surgery with an overnight stay at two tertiary hospitals (2013 to 2017). Features included intraoperative vital signs (blood pressure, heart rate, end-tidal carbon dioxide partial pressure, oxygen saturation, and temperature) by threshold and duration of exposure, as well as patient, surgical, and anesthetic factors. The cohort was divided temporally 75:25 into derivation and validation sets. We constructed a multivariable LR model with 30-day all-cause mortality as the outcome and evaluated performance metrics.

RESULTS

There were 30,619 patients in the cohort (mean [standard deviation] age, 66 [11] yr; 50.2% female; 2.0% mortality). In the validation set, the primary LR model showed a c-statistic of 0.893 (99% confidence interval [CI], 0.853 to 0.927), a Nagelkerke R-squared of 0.269, a scaled Brier score of 0.082, and an area under precision-recall curve of 0.158 (baseline 0.017 for an uninformative model). The addition of intraoperative vital signs to preoperative factors minimally improved discrimination and calibration.

CONCLUSION

We derived and internally validated a model that incorporated vital signs to improve risk stratification after surgery. Preoperative factors were strongly predictive of mortality risk, and intraoperative predictors only minimally improved discrimination. External and prospective validations are needed.

STUDY REGISTRATION

www.

CLINICALTRIALS

gov (NCT04014010); registered on 10 July 2019.

Assessment of Patient-Reported Outcome Measures for Maternal Postpartum Depression Using the Consensus-Based Standards for the Selection of Health Measurement Instruments Guideline: A Systematic Review

IMPORTANCE

Maternal depression is frequently reported in the postpartum period, with an estimated prevalence of approximately 15% during the first postpartum year. Despite the high prevalence of postpartum depression, there is no consensus regarding which patient-reported outcome measure (PROM) should be used to screen for this complex, multidimensional construct.

OBJECTIVE

To evaluate psychometric measurement properties of existing PROMs of maternal postpartum depression using the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) guideline and identify the best available patient-reported screening measure.

EVIDENCE REVIEW

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. PubMed, CINAHL, Embase, and Web of Science were searched on July 1, 2019, for validated PROMs of postpartum depression, and an additional search including a hand search of references from eligible studies was conducted in June 2021. Included studies evaluated 1 or more psychometric measurement properties of the identified PROMs. A risk-of-bias assessment was performed to evaluate methods of each included study. Psychometric measurement properties of each PROM were rated according to COSMIN criteria. A modified Grading of Recommendations Assessment, Development, and Evaluation approach was used to assess the level of evidence supporting each rating, and a recommendation class (A, recommended for use; B, further research required; or C, not recommended) was given based on the overall quality of each included PROM.

FINDINGS

Among 10 264 postpartum recovery studies, 27 PROMs were identified. Ten PROMs (37.0%) met the inclusion criteria and were used in 43 studies (0.4%) involving 22 095 postpartum women. At least 1 psychometric measurement property was assessed for each of the 10 validated PROMs identified. Content validity was sufficient in all PROMs. The Edinburgh Postnatal Depression Scale (EPDS) demonstrated adequate content validity and a moderate level of evidence for sufficient internal consistency (with sufficient structural validity), resulting in a recommendation of class A. The other 9 PROMs evaluated received a recommendation of class B.

CONCLUSIONS AND RELEVANCE

The findings of this systematic review suggest that the EPDS is the best available patient-reported screening measure of maternal postpartum depression. Future studies should focus on evaluating the cross-cultural validity, reliability, and measurement error of the EPDS to improve understanding of its psychometric properties and utility.

A survey of labour epidural practices at obstetric anesthesia fellowship programs in the United States

Purpose

Labour epidural analgesia (LEA) is an evolving field. Various neuraxial techniques and dosing regimens are available to the modern obstetric anesthesia provider, allowing for significant practice variability. To begin a search for consensus on optimal care, we sought to query fellowship training practices for LEA.

Methods

We conducted an electronic survey of institutions with American Council for Graduate Medical Education-accredited obstetric anesthesiology fellowship programs. We studied the frequency of epidural initiation techniques, including combined spinal epidural (CSE), dural puncture epidural, and epidural bolus. For maintenance techniques, we appraised the use of continuous epidural infusion, programmed intermittent bolus (PIEB), and patient-controlled epidural analgesia (PCEA).

Results

Of 40 institutions surveyed, we received 32 responses (80% response rate). Twenty-eight of 40 (70%) were included in the analysis. A plurality of institutions (12/28; 43%) preferred CSE, and among those who used CSE, 23/27 (85%) included intrathecal opioids. A majority of institutions used protocols with PIEB (55%), while almost all (92%) used PCEA. Most participants (88%) reported using dilute concentration maintenance infusions of 0.1% bupivacaine/ropivacaine or less.

Conclusion

Despite significant variability in LEA practice, some clear patterns emerged in our survey, including preference for opioid-containing CSE and maintenance with PIEB, PCEA, and dilute epidural solutions.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12630-022-02192-6.

Neuraxial labor analgesia: Maintenance techniques

Since the advent of neuraxial analgesia for labor, approaches to maintaining intrapartum pain relief have seen significant advancement. Through pharmacologic innovations and improved drug delivery mechanisms, current neuraxial labor analgesia maintenance techniques have been shaped by efforts to maximize patient comfort during the birthing process, while minimizing undesirable side effects and promoting the unimpeded progress of labor. To these ends, a modern anesthesiologist may avail themselves of several techniques, including programmed intermittent epidural bolus (PIEB), patient controlled epidural analgesia (PCEA) and dilute concentration local anesthetic + opioid epidural solutions. We explore the historical development and the evidential underpinnings of these techniques, in addition to several contemporary neuraxial labor analgesia practices. We also summarize current understanding of the effects these interventions have on maternal/fetal health and the labor course, as well as several important aspects of analgesic safety and monitoring.

Patient Preferences for Outcomes Associated With Labor Epidural Analgesia

Purpose

Patient preferences for labor epidural analgesia (LEA) have been incompletely evaluated. This study aimed to determine the importance of various LEA outcomes to both antenatal and postpartum patients.

Methods

This was a cross-sectional study approved by the institutional ethics board. Questionnaires were distributed to two separate and distinct cohorts screened for eligibility: pregnant patients at an antenatal visit and postpartum patients during childbirth admission. A list of common LEA outcomes was compiled using research published in leading anesthesia journals. Participants ranked the outcomes according to perceived importance. They assigned each a number from 1 to 10 (priority ranking; 1 indicated the highest priority outcome and 10 the least). They were also asked to ‘spend’ $100 towards the outcomes (relative value scale), allocating more money to outcomes more important to them.

Results

Two hundred twenty questionnaires were completed (105 antenatal, 115 postpartum). ‘Achieving desired pain relief’ was the most important outcome for both cohorts. It was valued more by the postpartum cohort (Median $50 (25 - 60) vs $30 (18 - 50)). ‘Overall satisfaction with the pain management,’ ‘experiencing a short time to achieve pain relief,’ and ‘experiencing a short duration of labor’ received more money than avoiding various LEA-related side effects. The postpartum cohort ranked ‘experiencing a short time to achieve pain relief’ as more important than the antenatal cohort (Median 5 (3 - 7) vs 3 (2 - 5)).

Conclusions

Achieving the desired pain relief was the highest LEA outcome preference for both antenatal and postpartum patients. Avoiding side effects was less important relative to pain-related outcomes.

Tranexamic acid: current use in obstetrics, major orthopedic, and trauma surgery

PURPOSE

In this Continuing Professional Development module, we review the practical pharmacology of tranexamic acid and its clinical use in trauma, obstetrics, and major orthopedic surgery.

PRINCIPAL FINDINGS

Tranexamic acid is a synthetic drug that inhibits fibrinolysis. Multiple clinical trials in various clinical settings have shown that it can reduce blood loss, transfusion rates, and bleeding-associated mortality. In trauma and obstetrical bleeding, early tranexamic acid administration (< three hours) may have greater clinical benefits. Overall, tranexamic acid use appears safe with no significant increase of thromboembolic or seizure events. Nevertheless, current evidence has limitations related to wide heterogeneity in dose, route, and timing of drug administration, as well as generalizability of the large-scale trial findings to higher income nations.

CONCLUSIONS

Tranexamic acid is an efficacious and safe pharmacological-based blood conservation technique in the management of clinically significant hemorrhage. All anesthesiologists should have a good understanding of the pharmacotherapeutic properties and perioperative role of tranexamic acid therapy both inside and outside of the operating room. The use of tranexamic acid is likely to continue to rise with endorsement by various clinical guidelines and healthcare organizations. Further quantitative research is needed to evaluate optimal dosing and drug efficacy in these clinical scenarios.

The association between labour epidural analgesia and postpartum depressive symptoms: a longitudinal cohort study

BACKGROUND

Pain is a risk factor for postpartum depression (PPD) and labour epidural analgesia (LEA) may lower the incidence of PPD. We evaluated depressive symptoms risk at three, six, and 12 months postpartum in women with LEA compared with women without LEA.

METHODS

With ethics approval, hypotheses were tested using data from a longitudinal prospective observational cohort study between January 2015 and January 2019 in nulliparous women aged ≥ 18 yr with uncomplicated, singleton pregnancies. Email surveys were completed at baseline (18-20 weeks' gestation) and at three-, six- and 12 months postpartum, including the Edinburgh Postpartum Depression Scale (EPDS). Maternal, infant, and anesthesia characteristics were abstracted from electronic databases. The EPDS scores at three, six, and 12 months postpartum were analyzed using generalized estimating equations with and without covariates.

RESULTS

Of the 909 women who consented to participate, 709 women were included in the study. Antenatal EPDS scores, not LEA, predicted postpartum depressive symptom risk (P < 0.001). The adjusted 95% confidence intervals suggest mean EPDS scores differ from 1.0 point lower in the LEA group at 12 months to 1.5 points higher in the no LEA group at three months on its 0-30 scale. All the confidence intervals included zero at three, six, and 12 months, so were considered non-significant (P > 0.05).

CONCLUSION

This study did not identify an association between LEA and risk of depressive symptoms postpartum, although small mean differences between groups cannot be ruled out. Future studies should focus on other modifiable variables that influence the development of PPD.

Perioperative mobile application for mothers undergoing Cesarean delivery: a prospective cohort study on patient engagement

Purpose

Giving birth is the most common reason for hospital admission, with Cesarean delivery being the most frequently performed inpatient surgery. Through a needs assessment and iterative design process involving patients and obstetric anesthesiologists, we previously developed a mobile application, C-Care, for patients undergoing Cesarean delivery. The focus of C-Care is perioperative education and self-monitoring of potential anesthetic complications. This study aimed to obtain feedback on patient engagement with C-Care.

Method

We conducted a prospective cohort study of patients ≥ 18 yr (n = 36) undergoing elective Cesarean delivery. Anonymous usage data were recorded for 30 days. On postoperative days 1–5, participants received daily self-monitoring questionnaires within C-Care. Fourteen days after surgery, participants received an online survey regarding satisfaction and use of C-Care.

Results

Thirty-five out of 36 participants visited the application after orientation, with a median [interquartile range (IQR)] age of 32 [31–36] yr. Each participant visited the application a median of 15 [9–31] times over 30 days and completed a median of 3 [2–4] out of five self-monitoring questionnaires. Each participant viewed a median of 4 [2–7] out of eight education topics, with the most viewed patient education topics being “Controlling Pain” and “The First Few Days”. Visits to the application were highest in the first week postpartum. Of the 18 respondents who completed the day 14 survey, 83% (n = 15) participants would recommend C-Care to other women, and the median participant satisfaction score was 7.5 out of 10 (range, 2–10).

Conclusion

Most participants used this mobile application for patient education and self-monitoring after elective Cesarean delivery. Insights into patient engagement with C-Care after Cesarean delivery could help design more effective perioperative mobile telehealth programs.

Trial registration

www.ClinicalTrials.gov (NCT03746678); registered 5 November 2018.

Supplementary Information

The online version of this article (10.1007/s12630-020-01907-x) contains supplementary material, which is available to authorized users.

An interpretive phenomenological analysis of formative feedback in anesthesia training: the residents' perspective

BACKGROUND

Consistent formative feedback is cornerstone to competency-by-design programs and evidence-based approaches to teaching and learning processes. There has been no published research investigating feedback from residents' perspectives. We explored the value residents place on feedback in routine operating room settings, their experiences, and understanding of the role of feedback in their training and developing professional identity.

METHODS

Interpretive phenomenological analysis of residents' experiences with feedback received in clinical settings involved two focus groups with 14 anesthesia residents at two time points. Analysis was completed in the context of a teaching hospital adapting to new practices to align with nationally mandated clinical competencies. Focus group conversations were transcribed and interpreted through the lens of a social constructivist approach to learning as a dynamic inter- and intra-personal process, and evidence-based assessment standards set by the International Test Commission (ITC).

RESULTS

Residents described high quality feedback as consistent, effortful, understanding of residents' thought processes, and containing actionable advice for improvement. These qualities of effective evaluation were equally imperative for informal and formal evaluations. Residents commented that highest quality feedback was received informally, and formal evaluations often lacked what they needed for their professional development.

CONCLUSION

Residents have a deep sense of what promotes their learning. Structured feedback tools were seen positively, although the most important determinants of their impact were faculty feedback- and broader evaluation-skills and motivations for both formal and informal feedback loops.

Acute Respiratory Distress Syndrome in a Preterm Pregnant Patient With Coronavirus Disease 2019 (COVID-19)

BACKGROUND

Data suggest that pregnant women are not at elevated risk of acquiring severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection or developing severe disease compared with nonpregnant patients. However, management of pregnant patients who are critically ill with coronavirus disease 2019 (COVID-19) infection is complicated by physiologic changes and other pregnancy considerations and requires balancing maternal and fetal well-being.

CASE

We report the case of a patient at 28 weeks of gestation with acute respiratory distress syndrome (ARDS) from COVID-19 infection, whose deteriorating respiratory condition prompted delivery. Our patient's oxygenation and respiratory mechanics improved within hours of delivery, though she required prolonged mechanical ventilation until postpartum day 10. Neonatal swabs for SARS-CoV-2 and COVID-19 immunoglobulin (Ig) G and IgM were negative.

CONCLUSION

We describe our multidisciplinary management of a preterm pregnant patient with ARDS from COVID-19 infection and her neonate.

Sexual and gender minorities educational content within obstetric anesthesia fellowship programs: a survey

PURPOSE

Improved patient-provider relationships can positively influence patient outcomes. Sexual and gender minorities (SGM) represent a wide variety of marginalized populations. There is an absence of studies examining the inclusion of SGM-related health education within postgraduate training in anesthesia. This study's objective was to perform an environmental scan of the educational content of North American obstetric anesthesia fellowship programs.

METHODS

An online survey was developed based on a review of the existing literature assessing the presence of SGM content within other healthcare-provider curricula. The survey instrument was distributed electronically to 50 program directors of North American obstetric anesthesia fellowship programs. Survey responses were summarized using descriptive statistics.

RESULTS

Survey responses were received from 30 of the 50 program directors (60%). Of these, 54% (14/26) felt their curriculum adequately prepares fellows to care for SGM patients, yet only 19% (5/26) of participants stated that SGM content was part of their curriculum and 31% (8/26) would like to see more incorporated in the future. Perceived lack of need was chosen as the biggest barrier to curricular inclusion of SGM education (46%; 12/26), followed by lack of available/interested faculty (19%; 5/26) and time (19%; 5/26).

CONCLUSIONS

Our results suggest that, although curriculum leaders appreciate that SGM patients are encountered within the practice of obstetric anesthesia, most fellowship programs do not explicitly include SGM curricular content. Nevertheless, there appears to be interest in developing SGM curricular content for obstetric anesthesia fellowship training. Future steps should include perspectives of trainees and patients to inform curricular content.

Health Researchers' Use of Social Media: Scoping Review

Background

Health researchers are increasingly using social media in a professional capacity, and the applications of social media for health researchers are vast. However, there is currently no published evidence synthesis of the ways in which health researchers use social media professionally, and uncertainty remains as to how best to harness its potential.

Objective

This scoping review aimed to explore how social media is used by health researchers professionally, as reported in the literature.

Methods

The scoping review methodology guided by Arksey and O’Malley and Levac et al was used. Comprehensive searches based on the concepts of health research and social media were conducted in MEDLINE, EMBASE, CINAHL, PsycINFO, ERIC, and Web of Science databases, with no limitations applied. Articles were screened at the title and abstract level and at full text by two reviewers. One reviewer extracted data that were analyzed descriptively to map the available evidence.

Results

A total of 8359 articles were screened at the title and abstract level, of which 719 were also assessed at full text for eligibility. The 414 articles identified for inclusion were published in 278 different journals. Studies originated from 31 different countries, with the most prevalent being the United States (52.7% [218/414]). The health discipline of the first authors varied, with medicine (33.3% [138/414]) being the most common. A third of the articles covered health generally, with 61 health-specific topics. Papers used a range of social media platforms (mean 1.33 [SD 0.7]). A quarter of the articles screened reported on social media use for participant recruitment (25.1% [104/414]), followed by practical ways to use social media (15.5% [64/414]), and use of social media for content analysis research (13.3% [55/414]). Articles were categorized as celebratory (ie, opportunities for engagement, 72.2% [299/414]), contingent (ie, opportunities and possible limitations, 22.7% [94/414]) and concerned (ie, potentially harmful, 5.1% [21/414]).

Conclusions

Health researchers are increasingly publishing on their use of social media for a range of professional purposes. Although most of the sentiment around the use of social media in health research was celebratory, the uses of social media varied widely. Future research is needed to support health researchers to optimize their social media use.

Possible Impact of Spinal Anesthesia and Phenylephrine on Sublingual Microcirculation of Cesarean Delivery Patients

Background

This study was a proof of concept of a novel means to evaluate microcirculatory changes during spinal anesthesia for cesarean delivery. It sought to examine the distributive circulatory effects of spinal anesthesia and evaluate the impact of phenylephrine administration on the microcirculation of these women.

Methods

After Research Ethics Board approval, healthy, non-laboring pregnant women with singleton, term pregnancies scheduled for elective cesarean delivery were recruited. Participants were randomly assigned to receive either phenylephrine infusion or phenylephrine bolus. Spinal anesthesia was standardized. A sidestream dark-field (SDF) MicroScan^® video microscope was applied to the sublingual mucosa to obtain microcirculation videos in five different visual fields. Videos were made before and after spinal anesthesia. The resultant videos were analyzed randomly and blindly. The mean microvascular flow index (MFI) values were compared before and after spinal anesthesia. The difference in MFI following spinal anesthesia was compared between phenylephrine infusion and bolus groups.

Results

Thirty-two patients were recruited for the study; 22 patients had complete video sets for analysis. Baseline characteristics were similar between the two groups, including preoperative hemodynamics. There were no significant differences between pre- and post-spinal MFI. The post-spinal MFI within the infusion group (mean ± standard deviation: 2.74 ± 0.21) was not significantly different from the bolus group (2.56 ± 0.42, P = 0.22).

Conclusion

Despite theoretical physiological implications of spinal anesthesia and phenylephrine on the microcirculation, significant alteration of the MFI was not observed between pre- and post-spinal anesthesia (within group). Additionally, despite an eight-fold larger phenylephrine dose for continuous infusion prophylaxis used in this group of women, this did not result in a significant alteration of the microcirculation compared to those who received phenylephrine treatment for hypotension (between groups).

Reporting preclinical anesthesia study (REPEAT): Evaluating the quality of reporting in the preclinical anesthesiology literature

Poor reporting quality may contribute to irreproducibility of results and failed 'bench-to-bedside' translation. Consequently, guidelines have been developed to improve the complete and transparent reporting of in vivo preclinical studies. To examine the impact of such guidelines on core methodological and analytical reporting items in the preclinical anesthesiology literature, we sampled a cohort of studies. Preclinical in vivo studies published in Anesthesiology, Anesthesia & Analgesia, Anaesthesia, and the British Journal of Anaesthesia (2008-2009, 2014-2016) were identified. Data was extracted independently and in duplicate. Reporting completeness was assessed using the National Institutes of Health Principles and Guidelines for Reporting Preclinical Research. Risk ratios were used for comparative analyses. Of 7615 screened articles, 604 met our inclusion criteria and included experiments reporting on 52 490 animals. The most common topic of investigation was pain and analgesia (30%), rodents were most frequently used (77%), and studies were most commonly conducted in the United States (36%). Use of preclinical reporting guidelines was listed in 10% of applicable articles. A minority of studies fully reported on replicates (0.3%), randomization (10%), blinding (12%), sample-size estimation (3%), and inclusion/exclusion criteria (5%). Statistics were well reported (81%). Comparative analysis demonstrated few differences in reporting rigor between journals, including those that endorsed reporting guidelines. Principal items of study design were infrequently reported, with few differences between journals. Methods to improve implementation and adherence to community-based reporting guidelines may be necessary to increase transparent and consistent reporting in the preclinical anesthesiology literature.

Patient-centred perioperative mobile application in Cesarean delivery: needs assessment and development

PURPOSE

Cesarean delivery (CD) is the most commonly performed inpatient surgery in Canada, with 103,425 performed in 2016-2017. Mobile technology can contribute to patient-centred perioperative care. Our aim was to involve patients and anesthesiologists in designing a mobile application to enhance the perioperative care of CD patients.

METHOD

We completed an exploratory qualitative study involving three iterative design cycles. Individual structured phone or in-person interviews with CD patients (n = 15) and anesthesiologists (n = 9) were conducted. Thematic analysis was used to 1) assess gaps and opportunities in the anesthesiology care after CD, 2) identify roles and limitations of mobile application technology in bridging perioperative care, and 3) to solicit feedback on a prototype mobile application for the anesthesiology postoperative care of elective CD patients.

RESULTS

Patients and anesthesiologists were in favour of adding mobile applications to the interdisciplinary perioperative management of patients undergoing CD, particularly for providing reliable information, identifying and following patients with complications, and research in perioperative outcomes. Medical-legal issues, privacy, workflow, and payment policy frameworks are barriers for mobile technology linking patients and anesthesiologists. Our final prototype was refined to focus on timely, concise education and self-monitoring.

CONCLUSION

The participant-driven changes in direction of the prototype showed the importance of involving key stakeholders early. This study provides guidance on further iterative development and implementation of an interdisciplinary mobile platform for patient-centred perioperative care and outcomes research.

Supplemental perioperative intravenous crystalloids for postoperative nausea and vomiting

BACKGROUND

Postoperative nausea and vomiting (PONV) is a common complication following general anaesthesia. It may be associated with patient dissatisfaction, increased costs of treatment, and unintended admission to hospital.Supplemental intravenous crystalloid administration in the perioperative period may be a simple intervention to prevent PONV.

OBJECTIVES

To assess whether supplemental intravenous crystalloid administration prevents PONV in patients undergoing surgical procedures under general anaesthesia.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 7), MEDLINE (1946 to August 2018), Embase (1947 to August 2018), and the Cumulative Index of Nursing and Allied Health Literature (CINAHL; 1971 to August 2018). We searched clinical trials registers for ongoing or unpublished completed studies (August 2018), handsearched three major journals (British Journal of Anaesthesia, European Journal of Anaesthesiology, and Anesthesiology; August 2018), and conducted backward and forward citation searching of relevant articles.

SELECTION CRITERIA

We included randomized controlled trials of participants older than six months undergoing surgical procedures under general anaesthesia and given supplemental perioperative intravenous crystalloids, defined as a volume larger than that received by a comparator group, to prevent PONV.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures described by Cochrane.

MAIN RESULTS

We included 41 studies (4224 participants). Participants underwent ambulatory or short length of stay surgical procedures, and were predominantly American Society of Anesthesiology (ASA) class I or II. There is one study awaiting classification and three ongoing studies. All studies took place in surgical centres, and were conducted in geographically diverse settings. Risk of bias was generally unclear across all domains.Supplemental intravenous crystalloid administration probably reduces the cumulative risk of postoperative nausea (PON) (risk ratio (RR) 0.62, 95% confidence interval (CI) 0.51 to 0.75; 18 studies; 1766 participants; moderate-certainty evidence). When the postoperative period was divided into early (first six hours postoperatively) and late (at the time point closest to or including 24 hours postoperatively) time points, the intervention reduced the risk of early PON (RR 0.67, 95% CI 0.58 to 0.78; 20 studies; 2310 participants; moderate-certainty evidence) and late PON (RR 0.47, 95% CI 0.32 to 0.69; 17 studies; 1682 participants; moderate-certainty evidence).Supplemental intravenous crystalloid administration probably reduces the risk of postoperative vomiting (POV) (RR 0.50, 95% CI 0.40 to 0.63; 20 studies; 1970 participants; moderate-certainty evidence). The intervention specifically reduced both early POV (RR 0.56, 95% CI 0.41 to 0.76; 19 studies; 1998 participants; moderate-certainty evidence) and late POV (RR 0.48, 95% CI 0.29 to 0.79; 15 studies; 1403 participants; moderate-certainty evidence).Supplemental intravenous crystalloid administration probably reduces the need for pharmacologic treatment of PONV (RR 0.62, 95% CI 0.51 to 0.76; 23 studies; 2416 participants; moderate-certainty evidence).The effect of supplemental intravenous crystalloid administration on the risk of unplanned postoperative admission to hospital is unclear (RR 1.05, 95% CI 0.77 to 1.43; 3 studies; 235 participants; low-certainty evidence).No studies reported serious adverse events that may occur following supplemental perioperative intravenous crystalloid administration (i.e. admission to high-dependency unit, postoperative cardiac or respiratory complication, or death).

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that supplemental perioperative intravenous crystalloid administration reduces PON and POV, in ASA class I to II patients receiving general anaesthesia for ambulatory or short length of stay surgical procedures. The intervention probably also reduces the risk of pharmacologic treatment for PONV. The effect of the intervention on the risk of unintended postoperative admission to hospital is unclear. The risk of serious adverse events resulting from supplemental perioperative intravenous crystalloid administration is unknown as no studies reported this outcome. The one study awaiting classification may alter the conclusions of the review once assessed.

Assessing the feasibility of using the Dalhousie Computerized Attention Battery to measure postoperative cognitive dysfunction in older patients

Purpose

Postoperative cognitive dysfunction is difficult to predict and diagnose, and can have severe consequences in the long term. The purpose of this study was to examine the feasibility of using a computerised test battery, the Dalhousie Computerized Assessment Battery in the perioperative clinic to detect cognitive changes after surgery.

Methods

Fifty patients were recruited for this study. Patients completed the Dalhousie Computerized Assessment Battery and tests of general cognition, mood and pain at baseline and at three months postoperatively.

Results

This pilot study had a screening rate (85.4%) and low attrition rate (12%). At baseline, patients exhibited no significant cognitive differences compared to a normative dataset. Postoperative cognitive dysfunction incidence was 2.7% on Montreal Cognitive Assessment, 13.6% with Dalhousie Computerized Assessment Battery and 36.3% based on subjective reports.

Conclusion

Computerised cognitive testing in the perioperative setting proved feasible. Deficits in spatial working memory and dual tasks may be most compromised by surgically related variables.

The impact of analgesic intervention during the second stage of labour: a retrospective cohort study

PURPOSE

The incidence of epidural top-ups received in the second stage of labour in nulliparous women and the obstetrical and neonatal implications associated with these boluses are explored in this retrospective observational study. We hypothesized that an epidural top-up in the second stage of labour reduces operative deliveries by resolving inadequate analgesia.

METHODS

A population-based cohort analysis was performed using perinatal data from 1 January 2013 through 31 December 2014. An anesthesia database provided information to determine the top-up incidence. Women with or without a top-up for second-stage duration were compared for method of delivery and neonatal characteristics using descriptive statistics. Logistic regression identified predictive factors for method of delivery.

RESULTS

Of the 1,462 women with a second stage of labour > one hour who received epidural analgesia, 105 (7%) required a top-up during the second stage of labour. Women who received a top-up were more likely to have had induction of labour and/or augmentation (89% vs 76%; odds ratio [OR], 2.43; 95% confidence interval [CI], 1.32 to 4.49; P = 0.003), a longer second stage (303 min vs 171 min; mean difference, 132 min; 95% CI, 113 to 151; P < 0.001), and more assisted vaginal (41% vs 17%; OR, 3.35; 95% CI, 2.21 to 5.1; P < 0.001) or Cesarean deliveries (26% vs 11%; OR, 3.04; 95% CI, 1.91 to 4.8; P < 0.001) than women without a top-up.

CONCLUSION

Most women who received a top-up had a vaginal (spontaneous or assisted) delivery. Compared with women without a top-up, women requiring a top-up had more predictors of difficult labour and higher rates of assisted vaginal delivery and Cesarean delivery.

Preliminary clinical evaluation of automated analysis of the sublingual microcirculation in the assessment of patients with septic shock: Comparison of automated versus semi-automated software

INTRODUCTION

The outcome of patients in septic shock has been shown to be related to changes within the microcirculation. Modern imaging technologies are available to generate high resolution video recordings of the microcirculation in humans. However, evaluation of the microcirculation is not yet implemented in the routine clinical monitoring of critically ill patients. This is mainly due to large amount of time and user interaction required by the current video analysis software. The aim of this study was to validate a newly developed automated method (CCTools®) for microcirculatory analysis of sublingual capillary perfusion in septic patients in comparison to standard semi-automated software (AVA3®).

METHODS

204 videos from 47 patients were recorded using incident dark field (IDF) imaging. Total vessel density (TVD), proportion of perfused vessels (PPV), perfused vessel density (PVD), microvascular flow index (MFI) and heterogeneity index (HI) were measured using AVA3® and CCTools®.

RESULTS

Significant differences between the numeric results obtained by the two different software packages were observed. The values for TVD, PVD and MFI were statistically related though.

CONCLUSION

The automated software technique successes to show septic shock induced microcirculation alterations in near real time. However, we found wide degrees of agreement between AVA3® and CCTools® values due to several technical factors that should be considered in the future studies.

Sidestream Dark Field Imaging of the Microcirculation to Assess Preeclampsia Microvascular Dysfunction

Background

Development of predictive models of preeclampsia has only yielded modest results. We hypothesized that impaired indices of microcirculatory function could be detected using sidestream dark field imaging. The objective of this study was to examine microvascular function in women at high risk for preeclampsia at mid-gestation.

Methods

Women between 16 and 22 weeks of gestation were screened for eligibility. Patients were recruited if they met eligibility criteria indicating high risk for preeclampsia. Investigators performed non-invasive sidestream dark field imaging of the sublingual microcirculation. Images were analyzed to determine microcirculatory parameters (microvascular flow index, perfused vessel density, total vessel density, and proportion of perfused vessels). After delivery, charts were reviewed to determine if they developed gestational hypertension, preeclampsia or severe preeclampsia.

Results

Twelve of 66 participants (18.2%) developed preeclampsia or severe preeclampsia during the course of their pregnancy. Microvascular flow index was not significantly different between participants with normal pregnancies and participants with preeclampsia or severe preeclampsia (2.75 ± 0.38 vs. 2.80 ± 0.34, respectively; P = 0.459). Similarly, there were no significant differences between groups in the remaining microcirculatory parameters.

Conclusions

Sidestream dark field imaging of the sublingual microcirculation may remain an appropriate tool to identify women at risk for preeclampsia, albeit later in pregnancy.

A randomized trial of phenylephrine infusion versus bolus dosing for nausea and vomiting during Cesarean delivery in obese women

PURPOSE

Hypotension is common after spinal anesthesia for Cesarean delivery. It is associated with nausea, vomiting, and fetal acidosis. Previous research on phenylephrine excluded obese subjects. We compared the incidence of intraoperative nausea and vomiting (IONV) in obese patients who received a prophylactic phenylephrine infusion vs those who received bolus dosing for the treatment of spinal-induced hypotension.

METHODS

In this multicentre, double-blinded randomized controlled trial, 160 obese women undergoing elective Cesarean delivery under spinal anesthesia were randomized to receive a prophylactic phenylephrine infusion initiated at 50 μg·min^-1 (and titrated according to a predefined algorithm) or 100 μg phenylephrine boluses to treat hypotension. Maternal systolic blood pressure was maintained within 20% of baseline. The primary study outcome was the incidence of IONV.

RESULTS

Intraoperative nausea and vomiting were significantly reduced in the infusion group compared to the bolus group (46% vs 75%, respectively; relative risk [RR], 0.61; 95% confidence interval [CI], 0.47 to 0.80; P < 0.001). This was associated with significantly reduced need for intraoperative rescue antiemetics (26% vs 42%, respectively; RR, 0.62; 95% CI, 0.40 to 0.97; P = 0.04), but no difference in the incidence of vomiting. Postoperative vomiting at two hours was reduced in the infusion group (11% vs 25%; RR, 0.44; 95% CI, 0.21 to 0.90; P = 0.02);however, there were no differences in the incidence or severity of postoperative nausea, need for rescue antiemetics at two hours and 24 hr, or the incidence of postoperative vomiting at 24 hr.

CONCLUSION

In obese women undergoing Cesarean delivery with spinal anesthesia, prophylactic phenylephrine infusion was associated with less intraoperative nausea, less need for rescue antiemetics, and reduced early postoperative vomiting.

TRIAL REGISTRATION

www.clinicaltrials.gov (NCT01481740). Registered 22 July 2011.

Implementation of Programmed Intermittent Epidural Bolus for the Maintenance of Labor Analgesia

Programmed intermittent epidural bolus (PIEB) is an exciting new technology that has the potential to improve the maintenance of epidural labor analgesia. PIEB compared with a continuous epidural infusion (CEI) has the potential advantage of greater spread within the epidural space and therefore better sensory blockade. Studies have demonstrated a local anesthetic-sparing effect, fewer instrumental vaginal deliveries, less motor blockade, and improvements in maternal satisfaction with PIEB compared with CEI. However, the optimal PIEB regimen and pump settings remain unknown, and there are a number of logistical issues and practical considerations that should be considered when implementing PIEB. The PIEB bolus size and interval, PIEB start time delay period, and patient-controlled epidural analgesia bolus size and lockout time can influence the efficacy of PIEB used for epidural labor analgesia. Educating all members of the health care team is critical to the success of the technique. This review summarizes the role of PIEB for the maintenance of labor analgesia, outlines implementation strategies, suggests optimal settings, and presents potential limitations of the technique.

Maternal microcirculation and sidestream dark field imaging: a prospective assessment of the association between labour pain and analgesia on the microcirculation of pregnant women

BACKGROUND

Pregnancy places significant demands on the cardiovascular system leading to measurable changes in the macrocirculation and potentially the microcirculation. During labour, both uterine contractions and labour pain can further impact cardiovascular status. The objective of this observational study was to compare sublingual microcirculation in labouring parturients before and after epidural analgesia.

METHODS

Healthy pregnant, labouring women requesting epidural analgesia were approached to participate. Participants with cardiovascular disease, diabetes, obesity, smoking or caffeine intake were excluded. The sidestream dark field device was applied to the sublingual mucosa obtaining images of at least 20 seconds in 5 visual fields before and after epidural analgesia. Video clips were analyzed randomly and blindly. The primary outcome was mean microvascular flow index (MFI).

RESULTS

Twelve participants completed this study. The results demonstrate no statistically significant difference in the MFI during labour pain (2.9±0.1) compared to after epidural analgesia (3.0±0.04, p = 0.31). Furthermore, there were no statistically significant differences in any secondary outcomes.

CONCLUSION

Our findings indicate that epidural analgesia may not impact sublingual microcirculation in labouring women. This agrees with literature supporting epidural analgesia as a safe, appropriate method of pain relief during labour with limited impact on peripheral macro or microcirculation.

Analysis of microcirculation measurements by novice users trained by a standardized interactive tutorial: An inter-observer variability study

Excessive time for analysis may impede microcirculatory studies with large amounts of video data. Engaging more personnel in the analyses seems to be a rational approach in that scenario and could shorten the time-interval between capturing images and obtaining results. Our hypothesis was that novice users would be able to determine standard microcirculatory parameters using a semi-automated software with an acceptable degree of variability after participating in a standardized interactive training session. 14 volunteers were included in the study. All volunteers analyzed separately the same sample video after the training. The kappa statistic was calculated for the primary outcome parameter microvascular flow index (MFI) within small and large vessels and indicated a fair level of agreement in the results of the novice users. A standardized interactive tutorial can be useful to teach microcirculatory analysis in previously untrained subjects.

Anesthetic Management Guided by Transthoracic Echocardiography During Cesarean Delivery Complicated by Hypertrophic Cardiomyopathy

We describe the management of a parturient woman with hypertrophic cardiomyopathy who developed a symptomatic accelerated idioventricular rhythm who required an urgent cesarean delivery at 32 weeks. Transthoracic echocardiography helped guide anesthetic management, including epidural dosing, fluid management, and phenylephrine infusion rates. This case demonstrates the application of transthoracic echocardiography to guide anesthetic management in a parturient woman at risk for cardiovascular compromise.

Persistent paralysis after spinal anesthesia for cesarean delivery

Anterior spinal artery syndrome has rarely been reported as a cause of permanent neurologic complications after neuraxial anesthesia in obstetric patients. A parturient developed anterior spinal artery syndrome after spinal anesthesia for cesarean delivery. A healthy 32-year-old parturient presented at 41(2/7) weeks for primary elective caesarean delivery for breech presentation. Spinal anesthesia was easily performed with clear cerebrospinal fluid, and block height was T4 at 5 minutes. Intraoperative course was uneventful except for symptomatic bradycardia (37-40 beats per minute) and hypotension (88/44 mm Hg) 4 minutes postspinal anesthesia, treated with ephedrine and atropine. Dense motor block persisted 9 hours after spinal anesthesia, and magnetic resonance imaging of the lumbosacral region was normal, finding no spinal cord compression or lesion. Physical examination revealed deficits consistent with a spinal cord lesion at T6, impacting the anterior spinal cord while sparing the posterior tracts.