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Babazade R, Lin YL, Valles GH, Capogna G, Micaglio M, Vadhera RB, Gebhard RE. Cost-minimization analysis of the continuous real-time pressure sensing technology in parturients requesting labor epidural analgesia. Braz J Anesthesiol 2023; 73:358-360. [PMID: 35798209 DOI: 10.1016/j.bjane.2022.06.004] [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] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 06/06/2022] [Accepted: 06/15/2022] [Indexed: 05/28/2023]
Affiliation(s)
- Rovnat Babazade
- The University of Texas Medical Branch at Galveston, Department of Anesthesiology, Galveston, Texas, USA; Cleveland Clinic, Texas and Outcomes Research Consortium, Cleveland, Ohio, USA.
| | - Yu-Li Lin
- University of Texas Medical Branch at Galveston, The Office of Biostatistics, Department of Preventive Medicine and Community Health, Texas, USA
| | - Guillermo Hidalgo Valles
- Universidad de Chile, Clínica Alemana de Santiago, Universidad del Desarrollo, Department of Anesthesiology, Santiago, Chile
| | - Giorgio Capogna
- Citta`di Roma Hospital, Department of Anesthesiology, Rome, Italy
| | | | - Rakesh B Vadhera
- The University of Texas Medical Branch at Galveston, Department of Anesthesiology, Galveston, Texas, USA
| | - Ralf E Gebhard
- University of Miami, Miller School of Medicine, Department Anesthesiology, Miami, Florida, USA
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Wilkes D, Martinello C, Medeiros FA, Babazade R, Hurwitz E, Khanjee N, Iyer PS, Leary P, Vadhera RB. Ultrasound-determined landmarks decrease pressure pain at epidural insertion site in immediate post-partum period. Minerva Anestesiol 2017; 83:1034-1041. [PMID: 28402092 DOI: 10.23736/s0375-9393.17.11782-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Women have blamed epidurals for their post-partum back pain for decades. Survey-based studies have shown similar incidence of chronic back pain between women who delivered with epidurals compared to those who did not. However, epidural insertion site pain has yet to be evaluated by a quantitative measure: pressure pain threshold (PPT). Algometer measured PPT has been shown to be accurate and reproducible in acute, chronic, and postoperative pain studies. This study determines the effect of ultrasound-based landmarks on the PPT at the epidural insertion site in the post-partum period. METHODS Participants were randomized into either the ultrasound or sham groups. In addition, a non-randomized control group (no epidural) participated. Ultrasound of the lumbar region was used to mark mid intervertebral levels in the US group but not in the sham group. Epidural were placed using the marks in the US group or palpated bony landmarks in the sham group. PPT at each intervertebral space measured before and after the use of epidural. RESULTS Epidural placement did significantly decreased PPT in US (68%) and US sham (79%) groups and less in the control group (21%). US group showed decreased PPT only at insertion site whereas US sham group also showed decreased PPT at insertion site and adjacent levels. CONCLUSIONS We showed that epidural placed with ultrasound-determined landmarks not only improves the success of epidural placement but also minimizes the number of intervertebral levels with decreased PPT.
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Affiliation(s)
- Denise Wilkes
- Department of Anesthesiology, The University of Texas Medical Branch, Galveston, TX, USA -
| | - Caroline Martinello
- Department of Anesthesiology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Felipe A Medeiros
- Department of Anesthesiology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Rovnat Babazade
- Department of Anesthesiology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Erin Hurwitz
- Department of Anesthesiology and Pain Management, UT Southwestern Medical Center, Dallas, TX, USA
| | - Naveed Khanjee
- Department of Anesthesiology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Prashanth S Iyer
- Department of Anesthesiology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Paul Leary
- Department of Anesthesiology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Rakesh B Vadhera
- Department of Anesthesiology, The University of Texas Medical Branch, Galveston, TX, USA
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Clark SL, Romero R, Dildy GA, Callaghan WM, Smiley RM, Bracey AW, Hankins GD, D'Alton ME, Foley M, Pacheco LD, Vadhera RB, Herlihy JP, Berkowitz RL, Belfort MA. Proposed diagnostic criteria for the case definition of amniotic fluid embolism in research studies. Am J Obstet Gynecol 2016; 215:408-12. [PMID: 27372270 PMCID: PMC5072279 DOI: 10.1016/j.ajog.2016.06.037] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Revised: 06/16/2016] [Accepted: 06/21/2016] [Indexed: 11/24/2022]
Abstract
Amniotic fluid embolism is a leading cause of maternal mortality in developed countries. Our understanding of risk factors, diagnosis, treatment, and prognosis is hampered by a lack of uniform clinical case definition; neither histologic nor laboratory findings have been identified unique to this condition. Amniotic fluid embolism is often overdiagnosed in critically ill peripartum women, particularly when an element of coagulopathy is involved. Previously proposed case definitions for amniotic fluid embolism are nonspecific, and when viewed through the eyes of individuals with experience in critical care obstetrics, would include women with a number of medical conditions much more common than amniotic fluid embolism. We convened a working group under the auspices of a committee of the Society for Maternal-Fetal Medicine and the Amniotic Fluid Embolism Foundation whose task was to develop uniform diagnostic criteria for the research reporting of amniotic fluid embolism. These criteria rely on the presence of the classic triad of hemodynamic and respiratory compromise accompanied by strictly defined disseminated intravascular coagulopathy. It is anticipated that limiting research reports involving amniotic fluid embolism to women who meet these criteria will enhance the validity of published data and assist in the identification of risk factors, effective treatments, and possibly useful biomarkers for this condition. A registry has been established in conjunction with the Perinatal Research Branch of the Eunice Kennedy Shriver National Institute of Child Health and Human Development to collect both clinical information and laboratory specimens of women with suspected amniotic fluid embolism in the hopes of identifying unique biomarkers of this condition.
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Affiliation(s)
- Steven L Clark
- Baylor College of Medicine, Houston, TX; Perinatology Research Branch of the Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Detroit, MI, and Bethesda, MD; Columbia University, New York, NY; Centers for Disease Control and Prevention, Atlanta, GA; Banner Health, Phoenix, AZ; University of Texas Medical Branch, Galveston, TX.
| | - Roberto Romero
- Baylor College of Medicine, Houston, TX; Perinatology Research Branch of the Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Detroit, MI, and Bethesda, MD; Columbia University, New York, NY; Centers for Disease Control and Prevention, Atlanta, GA; Banner Health, Phoenix, AZ; University of Texas Medical Branch, Galveston, TX
| | - Gary A Dildy
- Baylor College of Medicine, Houston, TX; Perinatology Research Branch of the Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Detroit, MI, and Bethesda, MD; Columbia University, New York, NY; Centers for Disease Control and Prevention, Atlanta, GA; Banner Health, Phoenix, AZ; University of Texas Medical Branch, Galveston, TX
| | - William M Callaghan
- Baylor College of Medicine, Houston, TX; Perinatology Research Branch of the Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Detroit, MI, and Bethesda, MD; Columbia University, New York, NY; Centers for Disease Control and Prevention, Atlanta, GA; Banner Health, Phoenix, AZ; University of Texas Medical Branch, Galveston, TX
| | - Richard M Smiley
- Baylor College of Medicine, Houston, TX; Perinatology Research Branch of the Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Detroit, MI, and Bethesda, MD; Columbia University, New York, NY; Centers for Disease Control and Prevention, Atlanta, GA; Banner Health, Phoenix, AZ; University of Texas Medical Branch, Galveston, TX
| | - Arthur W Bracey
- Baylor College of Medicine, Houston, TX; Perinatology Research Branch of the Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Detroit, MI, and Bethesda, MD; Columbia University, New York, NY; Centers for Disease Control and Prevention, Atlanta, GA; Banner Health, Phoenix, AZ; University of Texas Medical Branch, Galveston, TX
| | - Gary D Hankins
- Baylor College of Medicine, Houston, TX; Perinatology Research Branch of the Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Detroit, MI, and Bethesda, MD; Columbia University, New York, NY; Centers for Disease Control and Prevention, Atlanta, GA; Banner Health, Phoenix, AZ; University of Texas Medical Branch, Galveston, TX
| | - Mary E D'Alton
- Baylor College of Medicine, Houston, TX; Perinatology Research Branch of the Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Detroit, MI, and Bethesda, MD; Columbia University, New York, NY; Centers for Disease Control and Prevention, Atlanta, GA; Banner Health, Phoenix, AZ; University of Texas Medical Branch, Galveston, TX
| | - Mike Foley
- Baylor College of Medicine, Houston, TX; Perinatology Research Branch of the Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Detroit, MI, and Bethesda, MD; Columbia University, New York, NY; Centers for Disease Control and Prevention, Atlanta, GA; Banner Health, Phoenix, AZ; University of Texas Medical Branch, Galveston, TX
| | - Luis D Pacheco
- Baylor College of Medicine, Houston, TX; Perinatology Research Branch of the Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Detroit, MI, and Bethesda, MD; Columbia University, New York, NY; Centers for Disease Control and Prevention, Atlanta, GA; Banner Health, Phoenix, AZ; University of Texas Medical Branch, Galveston, TX
| | - Rakesh B Vadhera
- Baylor College of Medicine, Houston, TX; Perinatology Research Branch of the Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Detroit, MI, and Bethesda, MD; Columbia University, New York, NY; Centers for Disease Control and Prevention, Atlanta, GA; Banner Health, Phoenix, AZ; University of Texas Medical Branch, Galveston, TX
| | - J Patrick Herlihy
- Baylor College of Medicine, Houston, TX; Perinatology Research Branch of the Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Detroit, MI, and Bethesda, MD; Columbia University, New York, NY; Centers for Disease Control and Prevention, Atlanta, GA; Banner Health, Phoenix, AZ; University of Texas Medical Branch, Galveston, TX
| | - Richard L Berkowitz
- Baylor College of Medicine, Houston, TX; Perinatology Research Branch of the Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Detroit, MI, and Bethesda, MD; Columbia University, New York, NY; Centers for Disease Control and Prevention, Atlanta, GA; Banner Health, Phoenix, AZ; University of Texas Medical Branch, Galveston, TX
| | - Michael A Belfort
- Baylor College of Medicine, Houston, TX; Perinatology Research Branch of the Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Detroit, MI, and Bethesda, MD; Columbia University, New York, NY; Centers for Disease Control and Prevention, Atlanta, GA; Banner Health, Phoenix, AZ; University of Texas Medical Branch, Galveston, TX
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Abstract
OBJECTIVE To determine if passive leg raising (PLR) significantly increases cardiac output in a cohort of healthy pregnant women during the third trimester. STUDY DESIGN Using a noninvasive monitor, baseline hemodynamic measurements for arterial blood pressure, systolic and diastolic blood pressure, heart rate, cardiac output, cardiac index, stroke volume, and systemic vascular resistances were obtained with patients in the semirecumbent position. Measurements were repeated after a 3-minute PLR maneuver in supine, right lateral decubitus, and left lateral decubitus positions. RESULTS After 10 minutes of bed rest, the cohort's mean baseline heart rate was 80 ± 12 beats/minute. Baseline stroke volume was 98 ± 14 mL, mean cardiac output was 7.8 ± 1.2 L/min, and mean cardiac index was 4.32 ± 0.63 L/min. The baseline systemic vascular resistance value was 893 ± 160 dynes/sec/cm(5). Baseline mean arterial blood pressure was 84 ± 11 mm Hg. Following a PLR maneuver in the supine position, heart rate decreased significantly. No difference was noted in other measurements. Findings were similar with PLR in the left lateral decubitus. PLR in the right lateral decubitus resulted in significantly decreased heart rate, cardiac output, and cardiac index. CONCLUSIONS PLR did not result in cardiac output recruitment in a cohort of healthy pregnant women during the third trimester.
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Affiliation(s)
| | - Caroline Martinello
- Department of Anesthesiology, The University of Texas Medical Branch, Galveston, Texas
| | - George C Kramer
- Department of Anesthesiology, The University of Texas Medical Branch, Galveston, Texas
| | - Maged M Costantine
- Department of Obstetrics and Gynecology, The University of Texas Medical Branch, Galveston, Texas
| | - Rakesh B Vadhera
- Department of Anesthesiology, The University of Texas Medical Branch, Galveston, Texas
| | - George R Saade
- Department of Obstetrics and Gynecology, The University of Texas Medical Branch, Galveston, Texas
| | - Gary D Hankins
- Department of Obstetrics and Gynecology, The University of Texas Medical Branch, Galveston, Texas
| | - Luis D Pacheco
- Department of Anesthesiology, The University of Texas Medical Branch, Galveston, Texas
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Abstract
Epidural blockade is an important option for anesthesia in parturients undergoing abdominal delivery. Despite the multiple benefits of this method, there is at least one significant downside--a relatively high occurrence of unsatisfactory anesthesia that requires intervention. Depending on the presumed mechanism of epidural block failure and other clinically relevant factors (e.g., timing of diagnosis, urgency of the procedure, and so forth), certain effective measures are recommended to successfully manage this demanding situation. In general, it is important to make every effort to make the pre-existing epidural effective or replace it with another regional technique, because overall, regional anesthesia is associated with significantly lower maternal mortality. It is important to identify a dysfunctional epidural block preoperatively before a maximum volume of local anesthetic has been administered. If catheter manipulation does not produce substantial improvement, and there is no time constraint, it is safe and reasonable to replace the epidural catheter. However, risks associated with excessive volume of local anesthetic should be kept in mind. Additional epidural injections or a second catheter placement might be considered under special circumstances. Single-shot spinal anesthesia after a failed epidural may provide fast onset and reliable surgical anesthesia. Available data, although limited and contradictory, suggest the possibility of unpredictably high or total spinal anesthesia. Many authors, however, believe that appropriate precautions and modifications in technique make this a safe alternative. These modifications include limiting the amount of epidural local anesthetic administered when diagnosing a nonfunctioning epidural and decreasing the dose of intrathecal local anesthetic by 20% to 30%. If there is no documented block when the spinal is inserted, and more than 30 minutes have passed from the last epidural dose, it is probably safe to use a normal dose of local anesthetic. Continuous spinal anesthesia with a macro catheter might be a dependable alternative, particularly if large amounts of local anesthetic have already been used or the patient's airway is a cause for concern. Although there are no reports of combined spinal epidural anesthesia being used in this context, it would appear to be an attractive alternative. It allows the anesthesiologist to give smaller doses intrathecally, while still offering the flexibility of augmenting the block if needed. When inadequate epidural block becomes apparent during surgery there are limited alternatives. Depending on the origin and the pattern of inadequate anesthesia, options may include psychological support, supplementation with a variety of inhalational and intravenous agents, and local anesthetic infiltration. Induction of general anesthesia is typically left as a backup option, but must be strongly considered if the patient continues to have pain/discomfort.
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Affiliation(s)
- Dmitry Portnoy
- Department of Anesthesiology, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555-0591, USA.
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