Resident Competency and Proficiency in Combined Spinal-Epidural Catheter Placement Is Improved Using a Computer-Enhanced Visual Learning Program: A Randomized Controlled Trial.

BACKGROUND: Physician educators must balance the need for resident procedural education with clinical time pressures as well as patient safety and comfort. Alternative educational strategies, including e-learning tools, may be beneficial to orient novice learners to new procedures and speed proficiency. We created an e-learning tool (computer-enhanced visual learning [CEVL] neuraxial) to enhance trainee proficiency in combined spinal-epidural catheter placement in obstetric patients and performed a randomized controlled 2-center trial to test the hypothesis that use of the tool improved the initial procedure performed by the anesthesiology residents. METHODS: Anesthesiology residents completing their first obstetric anesthesiology rotation were randomized to receive online access to the neuraxial module (CEVL group) or no access (control) 2 weeks before the rotation. On the first day of the rotation, residents completed a neuraxial procedure self-confidence scale and an open-ended medical knowledge test. Blinded raters observed residents performing combined spinal-epidural catheter techniques in laboring parturients using a procedural checklist (0-49 pts); the time required to perform the procedure was recorded. The primary outcome was the duration of the procedure. RESULTS: The CEVL group had significantly shorter mean (±standard deviation) procedure time compared to the control group 22.5 ± 4.9 vs 39.5 ± 7.1 minutes (P < .001) and had higher scores on the overall performance checklist 36.4 ± 6.6 vs 28.8 ± 7.1 (P = .012). The intervention group also had higher scores on the open-ended medical knowledge test (27.83 ± 3.07 vs 22.25 ± 4.67; P = .002), but self-confidence scores were not different between groups (P = .64). CONCLUSIONS: CEVL neuraxial is a novel prerotation teaching tool that may enhance the traditional initial teaching of combined spinal-epidural procedures in obstetric anesthesiology. Future research should examine whether the use of web-based learning tools impacts long-term provider performance or patient outcomes.

Effect of Intrathecal Bupivacaine Dose on the Success of External Cephalic Version for Breech Presentation: A Prospective, Randomized, Blinded Clinical Trial.

BACKGROUND: Breech presentation is a leading cause of cesarean delivery. The use of neuraxial anesthesia increases the success rate of external cephalic version procedures for breech presentation and reduces cesarean delivery rates for fetal malpresentation. Meta-analysis suggests that higher-dose neuraxial techniques increase external cephalic version success to a greater extent than lower-dose techniques, but no randomized study has evaluated the dose-response effect. We hypothesized that increasing the intrathecal bupivacaine dose would be associated with increased external cephalic version success. METHODS: We conducted a randomized, double-blind trial to assess the effect of four intrathecal bupivacaine doses (2.5, 5.0, 7.5, 10.0 mg) combined with fentanyl 15 µg on the success rate of external cephalic version for breech presentation. Secondary outcomes included mode of delivery, indication for cesarean delivery, and length of stay. RESULTS: A total of 240 subjects were enrolled, and 239 received the intervention. External cephalic version was successful in 123 (51.5%) of 239 patients. Compared with bupivacaine 2.5 mg, the odds (99% CI) for a successful version were 1.0 (0.4 to 2.6), 1.0 (0.4 to 2.7), and 0.9 (0.4 to 2.4) for bupivacaine 5.0, 7.5, and 10.0 mg, respectively (P = 0.99). There were no differences in the cesarean delivery rate (P = 0.76) or indication for cesarean delivery (P = 0.82). Time to discharge was increased 60 min (16 to 116 min) with bupivacaine 7.5 mg or higher as compared with 2.5 mg (P = 0.004). CONCLUSIONS: A dose of intrathecal bupivacaine greater than 2.5 mg does not lead to an additional increase in external cephalic procedural success or a reduction in cesarean delivery.

Interscapular pain associated with neuraxial labour analgesia: a case series.

PURPOSE: Some labouring women with neuraxial labour analgesia experience severe upper back pain, typically between the scapulae. This pain may complicate management of neuraxial analgesia/anesthesia, and it may also have important implications for the mode of delivery. This case series describes the clinical course and management of three patients who developed interscapular pain associated with neuraxial labour analgesia. PRINCIPAL FINDINGS: Neuraxial labour analgesia was initiated in all patients with a combined spinal-epidural technique and maintained via patient-controlled epidural analgesia. Two patients were nulliparous. One patient experienced interscapular pain during initiation of epidural anesthesia for Cesarean delivery after 19 hr of maintenance of labour analgesia with local anesthetic/opioid solution. The other two patients experienced interscapular pain during routine maintenance of epidural labour analgesia. In two patients, the epidural space was identified using loss of resistance to air. Another patient recalled experiencing interscapular pain with her prior labour epidural. Management of these patients included decreasing the epidural infusion rate, increasing the concentration of local anesthetic in the epidural infusion solution, administration of epidural opioids, and replacement of the epidural catheter. All patients eventually experienced relief of their interscapular pain. CONCLUSIONS: While little is understood about the etiology of this unique anesthetic complication, it may have important clinical consequences, including inadequate analgesia, inability to provide timely epidural anesthesia, and an increased risk of Cesarean delivery. Future work should characterize at-risk patients, delineate effective treatment strategies, and identify any associated long-term consequences.

Platelet-derived growth factor-BB activates calcium/calmodulin-dependent and -independent mechanisms that mediate Akt phosphorylation in the neurofibromin-deficient human Schwann cell line ST88-14.

Neurofibromatosis type 1-derived Schwann cells isolated from malignant peripheral nerve sheath tumors (MPNSTs) overexpress PDGF receptor-ß and generate an aberrant intracellular calcium increase in response to PDGF-BB. Using the human MPNST Schwann cell line ST88-14, we demonstrate that, in addition to a transient phosphorylation of Akt, PDGF-BB stimulation produces an atypical sustained phosphorylation of Akt that is dependent on calcium and calmodulin (CaM). The sustained Akt phosphorylation did not occur in PDGF-BB-stimulated normal human Schwann cells or ST88-14 cells stimulated with stem cell factor, whose receptor is also overexpressed in ST88-14 cells. The sustained Akt phosphorylation induced by PDGF-BB was inhibited by pretreatment of the cells with either the intracellular calcium chelator 1,2-bis(2-aminophenoxy)ethane-N,N,N',N'-tetraacetic acid tetrakis(acetoxymethyl) ester (BAPTA-AM) or the CaM antagonist W7, whereas the transient portion was not inhibited. Akt also co-immunoprecipitated with CaM in a PDGF-BB-dependent manner, suggesting that direct interaction between Akt and CaM is involved in the sustained phosphorylation of Akt. Furthermore, we provide evidence that anti-apoptotic effects of PDGF-BB on serum-deprived ST88-14 cells can be inhibited by W7, implicating the PDGF-BB-induced activation of calcium/CaM in promoting cell survival, presumably through sustained Akt activation. We conclude that the activation of the calcium/CaM/Akt pathway resulting from stimulation of overexpressed PDGF receptor-ß may contribute to the survival and tumorigenicity of MPNST cells.

Clonidine as an Adjunct for the Successful Treatment of Labor Epidural Infusion-Associated Interscapular Pain.

Epidural infusion-associated interscapular pain for laboring parturients is a treatment dilemma for obstetric anesthesiologists. We report a case of a parturient who was successfully treated for labor epidural analgesia-associated interscapular pain. Our treatment plan included reducing the volume of local anesthetic administered by adding the adjunct of clonidine, increasing the epidural solution concentration of local anesthetic, and reducing the overall infusion rate. We conclude that epidural clonidine should be considered a safe adjunct when treating laboring parturients who report epidural infusion-associated interscapular pain.

Midazolam for the Successful Treatment of Refractory Spinal-Anesthesia-Associated Hypothermia After Cesarean Delivery.

Cesarean deliveries receiving spinal anesthesia with intrathecal morphine are associated with post-operative hypothermia. Lorazepam has been proposed as a reversal agent for treating intrathecal morphine-associated post-cesarean hypothermia. Midazolam is a benzodiazepine familiar to most anesthesia providers and is frequently administered in the perioperative period. We present a post-cesarean delivery spinal anesthesia-associated hypothermia patient successfully treated with intravenous midazolam.

Effects of Adding Intrathecal Epinephrine to Spinal Anesthesia on Anesthesia-Related Cesarean Delivery Outcomes: Should We Reconsider Its Use?

BACKGROUND:  Intrathecal epinephrine is used to increase the duration of spinal anesthesia for amenable surgical procedures anticipated to require additional time; however, in the ambulatory setting, it is associated with a prolonged time to post-anesthesia care unit (PACU) discharge. The current study's authors hypothesized that adding intrathecal epinephrine to spinal anesthesia for cesarean delivery would be associated with a dose-dependent prolonged post-anesthesia unit length of stay. METHODS: A single-center, retrospective study of patients undergoing repeat cesarean delivery under spinal anesthesia from 2011 to 2015 was conducted. Patients received spinal bupivacaine 12 mg, morphine 150 mcg, and fentanyl 15 mcg with no-epinephrine, 100 mcg, or 200 mcg of epinephrine. The primary outcome was recovery room length of stay. Secondary outcomes were surgical duration, intraoperative vasopressor use, perioperative opioids, and antiemetic use. RESULTS:  Data were analyzed for 1,362 patients. Median recovery room stay was 123 min (interquartile range, 100 to 150) and was not different among groups. More women receiving epinephrine 200 mcg had ≥2 prior cesarean deliveries compared with no-epinephrine or 100 mcg. No significant differences in surgical duration or intraoperative opioids were identified among the groups. Median intraoperative vasopressor use was increased by 225 mcg of phenylephrine equivalents (99% CI, 25 mcg to 430 mcg) in the 100 mcg group and 250 mcg of phenylephrine equivalents in the 200 mcg group (99% CI, 75 mcg to 500 mcg) compared to no-epinephrine (P<0.001). Recovery room antiemetic and opioid analgesic administration were not different among groups. CONCLUSIONS:  Based on the results of this study, the addition of intrathecal epinephrine for women undergoing cesarean delivery increases intraoperative vasopressor use but does not prolong PACU length of stay, reduce intraoperative opioids, or increase antiemetic requirements postoperatively. The current study also demonstrated that surgical duration times were not different among the no-epinephrine, 100 mcg, and 200 mcg epinephrine groups.

Spontaneous Resolution of Gravid Uterine Incarceration With Spinal Anesthesia: A Case Report.

Incarceration of the gravid uterus may pose significant risks to both maternal and fetal health. Anesthetic management for these patients is variable, and the ideal anesthetic technique is unknown. The patient presented to the labor and delivery unit with pelvic pain and urinary retention in the setting of a gravid incarcerated uterus. Previous attempts at manual reduction in the outpatient setting were unsuccessful. A combined spinal-epidural anesthetic was administered, followed by spontaneous resolution of the incarcerated uterus. In addition to providing analgesia, neuraxial blockade may occasionally be an adequate therapeutic technique for reduction of a gravid incarcerated uterus.