International journal of obstetric anesthesia最新文献

Background: The use of general anaesthesia (GA) for caesarean delivery (CD) introduces the risk of both difficult and failed intubation. Various strategies may be utilised to reduce this risk; however, not all are supported by evidence. We analysed the rate of difficult intubation following implementation of three recommendations specific to airway management in CD.

Methods: This was a retrospective single-center study of CD cases performed under GA at a tertiary care center between January 2013 and December 2022. Cases with GA induced after delivery or with incomplete airway management records were not included in the analysis. We compared outcomes for cases before (2013-2018) versus after (2019-2022) implementation of three specific recommendations: (1) video laryngoscopy (VL) for the first intubation attempt; (2) the presence of a second anesthetist; (3) use of endotracheal tube size 6.5 mm. The primary outcome was difficult intubation, defined as a composite variable (> 1 intubation attempt, use of a rescue device, SpO₂ < 90%). We conducted univariable and adjusted analyses of plausible variables associated with difficult intubation, including age, body mass index, predicted difficult airway, and each of three recommendations.

Results: We identified 1462 cases, 922 before and 540 after implementation. The frequency of difficult intubation was similar with 239 (25.9%) before versus 135 (25.0%) after implementation (p = 0.71; 95% CI -0.03 to 0.05). The recommendations were not associated with a decreased likelihood of difficult intubation in the univariable and adjusted models. Adoption of all three recommendations was significantly more frequent in the post-implementation period.

Conclusion: Implementation of standardised airway management recommendations had no significant impact on difficult intubation rate, though adoption of all three recommendations was not universal.

Postpartum hemorrhage (PPH) remains one of the leading causes of maternal mortality worldwide, with a significant impact on global health. Optimal management of PPH involves distinct steps executed simultaneously by a multidisciplinary approach, with anesthesiologists playing a key role in hemodynamic control and patient resuscitation. In this context, an aortic blood flow interruption through an internal balloon should be considered a rescue option among the various opportunities, to treat or prevent abdominal hemorrhages. Given this perspective, there is increasing interest in the role of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), originally used in trauma and military medicine, which has emerged as a novel strategy for managing PPH. Indeed, this technique has shown promise in managing severe cases of PPH, especially where traditional measures are insufficient. It also offers potential as a prophylactic measure in pregnancies with high risk for PPH, such as in the case of placenta accrete spectrum. This review aims to examine the efficacy, safety, and potential applications of REBOA in PPH management and prevention. At the same time, challenges such as the need for skilled operators, potential complications, costs, and the consideration of fetal safety were also discussed. REBOA presents as a promising tool against PPH, with efficacy in reducing blood loss, preserving fertility, and potentially decreasing maternal mortality and improving outcomes. However, its implementation requires careful consideration, training, and further research to establish clear guidelines for its use in obstetric care.

Background: Cosyntropin has been suggested to decrease the incidence of post-dural puncture headache (PDPH) by increasing the production of cerebrospinal fluid. This study examined the association of prophylactic cosyntropin administration with the incidence of PDPH and its management with an epidural blood patch after an unintentional dural puncture (UDP).

Methods: We conducted a retrospective cohort study of cases with UDP during placement of neuraxial labor analgesia. Per institutional practice and at the discretion of the anesthesiologist, intravenous cosyntropin 1 mg may be administered for PDPH prophylaxis. PDPH, time from UDP to cosyntropin administration, time to development of PDPH, and management with epidural blood patch(es) were recorded.

Results: Cosyntropin was administered in 164 of 234 (70%) cases with UDP. PDPH occurred 98/164 (60%) with cosyntropin and 45/70 (64%) without cosyntropin (p = 0.66). The PDPH adjusted incidence was 53% with cosyntropin and 62% without cosyntropin, difference 9% (95% CI -6% to 24%, p = 0.25). The adjusted epidural blood patch rate was 66% with cosyntropin and 78% without cosyntropin, difference of 12% (95% CI -5% to 28%, p = 0.17).

Conclusions: Prophylactic cosyntropin following UDP was not associated with a significant decrease in PDPH rate or use of epidural blood patch for management of PDPH. There was no significant difference in the rate of adverse hyperglycemic or hypertensive events amongst those who did or did not receive cosyntropin.