Intravenous vs Oral Acetaminophen for Analgesia After Cesarean Delivery: A Randomized Trial.

OBJECTIVE: Examination of postoperative analgesia with intravenous and oral acetaminophen. DESIGN: Prospective, three-arm, nonblinded, randomized clinical trial. SETTING: A single academic medical center. SUBJECTS: Parturients scheduled for elective cesarean delivery. METHODS: This trial randomized 141 parturients to receive intravenous acetaminophen (1 g every eight hours, three doses), oral acetaminophen (1 g every eight hours, three doses), or no acetaminophen. All patients received a standardized neuraxial anesthetic with intrathecal opioids and scheduled postoperative ketorolac. The primary outcome, 24-hour opioid consumption, was evaluated using the Kruskal-Wallace test and Tukey-Kramer adjustment for multiple comparisons. Secondary outcomes included 48-hour opioid consumption, first opioid rescue, pain scores, patient satisfaction, times to ambulation and discharge, and side effects. RESULTS: Over 18 months, 141 parturients with similar demographic variables completed the study. Median (interquartile range) opioid consumption in intravenous morphine milligram equivalents at 24 hours was 0 (5), 0 (7), and 5 (7) for the intravenous, oral, and no groups, respectively, and differed between groups (global P = 0.017). Opioid consumption and other secondary outcomes did not differ between the intravenous vs oral or oral vs no groups. Opioid consumption was reduced at 24 hours with intravenous vs no acetaminophen (P = 0.015). Patients receiving no acetaminophen had 5.8 times the odds of consuming opioids (P = 0.036), consumed 40% more opioids controlling for time (P = 0.041), and had higher pain scores with ambulation (P = 0.004) compared with the intravenous group. CONCLUSIONS: Intravenous acetaminophen did not reduce 24-hour opioid consumption or other outcomes compared with oral acetaminophen. Intravenous acetaminophen did decrease opioid consumption and pain scores compared with no acetaminophen.

Maternal Epidural Steroids to Prevent Neonatal Exposure to Hyperthermia and Inflammation.

BACKGROUND: Epidural analgesia is associated with a fourfold increased rate of intrapartum fever. The likely pathophysiology is a noninfectious maternal inflammatory activation. Safe interventions to reduce maternal and neonatal exposures to intrapartum fever and inflammation are needed. OBJECTIVE: The purpose of this study was to determine if prophylactic epidural steroids decrease fetal exposure to hyperthermia and inflammatory cytokines following epidural analgesia. STUDY DESIGN: This is a randomized, double-blinded, placebo controlled trial. Term nulliparous women requesting epidural analgesia received 80 mg methylprednisolone or preservative-free normal saline via the epidural catheter at placement. The primary outcome was maternal temperature >100.4°F. Secondary outcomes included fetal exposure to inflammation as assessed by cord blood interleukin-6 (IL-6) levels and rates of funisitis. Power analysis estimated a sample size requirement of 276, but new Food and Drug Administration (FDA) recommendations advising a black box warning on epidural steroids resulted in early study termination. RESULTS: A total of 116 subjects were enrolled: 58 treatments and 58 placebos. There was no difference in the rate of maternal intrapartum fever or cord blood IL-6 levels between treatment arms. No complications listed in the FDA warning occurred. CONCLUSION: Prophylactic epidural methylprednisolone was not effective in reducing intrapartum fever or neonatal inflammation following epidural analgesia. Alternate mechanisms and preventative strategies should be considered.

Labor Analgesia Onset With Dural Puncture Epidural Versus Traditional Epidural Using a 26-Gauge Whitacre Needle and 0.125% Bupivacaine Bolus: A Randomized Clinical Trial.

BACKGROUND: Lumbar epidurals (LEs) provide excellent analgesia. Combined spinal epidural and dural puncture epidural (DPE) are 2 techniques to expedite neuraxial analgesia onset. In DPE, dura is punctured but medication is not administered in the cerebrospinal fluid. Expedited analgesia onset has been demonstrated with DPE, using 0.25% bupivacaine; however, this concentration may impede an unassisted vaginal birth and is not currently used for induction and maintenance of labor analgesia. The primary goal of this study was to compare the percentage of patients who achieved adequate labor analgesia following DPE or LE with an epidural bolus of 0.125% bupivacaine. Adequate labor analgesia was defined as Visual Analog Scale (VAS) measurement ≤ 10 mm on a 100-mm scale during active contractions, measured 10 minutes after epidural bolus initiation. METHODS: Laboring patients were randomly assigned to receive LE or DPE. Immediately before epidural placement, subjects marked a VAS score during an active contraction and parturients with VAS < 50 mm were excluded. The epidural space was identified by a loss of resistance technique to saline (17G Tuohy needle [Arrow International, Inc, Redding, PA]). In the DPE group, dura was punctured with a 26G Whitacre needle (Arrow International, Inc). In all participants, a 19G epidural catheter (Arrow International, Inc) was inserted. An epidural bolus was then administered over 3 minutes (12 mL, 0.125% bupivacaine, 50 µg fentanyl) followed by infusion (0.1% bupivacaine, 2 µg/mL fentanyl). After initiation of epidural bolus (time zero), VAS measurements were collected at 2-minute intervals for up to 20 minutes. Median time to achieve adequate analgesia by treatment group was assessed by Kaplan-Meier analysis. Time to achieving adequate analgesia was evaluated using a Cox regression model. All analyses were conducted in SAS version 9.4. (SAS Institute, Cary, NC) RESULTS:: Data were analyzed from 80 participants (40 per group). Adequate analgesia at 10 minutes did not differ by neuraxial technique (DPE = 55.3% vs LE = 44.7%; P= .256). However, parturients receiving DPE had shorter median times to adequate analgesia (median [95% confidence interval], 8 minutes [6-10] vs 10 minutes [8-14]) and a 67% increase in the relative risk of achieving adequate analgesia compared to LE (relative risk = 1.67; 95% confidence interval, 1.02-2.64; P= .042). CONCLUSIONS: Although the percentage of parturients achieving adequate labor analgesia at 10 minutes after epidural bolus did not differ by technique, DPE was associated with faster time to VAS ≤ 10 mm compared with LE.

Utility of the Surgical Apgar Score in Kidney Transplantation: Is it Feasible to Predict ICU Admission, Hospital Readmission, Length of Stay, and Cost in This Patient Population?

BACKGROUND: This study analyzed the utility of the Surgical Apgar Scoring (SAS) system in predicting morbidity in kidney transplantation. Recipient comorbidities were evaluated for any effect on the SAS and then globally assessed for any relationship with intensive care unit (ICU) admission, need for dialysis, creatinine at discharge, length of stay, incremental, and total cost of transplantation. The hypothesis for this study is that a low SAS will be a statistically significant predictor of postoperative morbidity and associated costs. METHODS: This was an institutional review board (IRB)-approved retrospective longitudinal cohort study on 204 solitary kidney transplant recipients (2009-2011). Patients were divided into 2 groups: low to moderate = SAS ≤ 7 and high = SAS ≥ 8. These groups were then analyzed against a host of variables. RESULTS: Sixty-five percent of patients had an SAS of 7 or lower, while 35% had an SAS of 8 and higher. Recipients with a history of stroke were 88% more likely to be in the low-moderate SAS group (P = .017). Patients with lower SASs trended toward having less extended criteria donors (0.097) but were more likely to be admitted to the ICU (P = .043), leading to significantly higher transplant event hospitalization costs. Higher SASs were more likely to be readmitted to the hospital within 30 days of discharge (P = .027), leading to higher 30-day postdischarge costs (P = .014). Readmission rates, however, and 30-day follow-up costs were similar between SAS groups after controlling for donor characteristics, specifically donor marginality and recipient estimated glomerular filtration rate (eGFR). CONCLUSION: The findings of this study suggest that a history of stroke in the recipient may lend to a lower SAS and that a low SAS is associated with ICU admission following transplant, leading to higher hospital costs.

Neuraxial Anesthesia in Parturients with Thrombocytopenia: A Multisite Retrospective Cohort Study.

BACKGROUND: The primary aim of this study was to estimate the risk of neuraxial hematoma associated with neuraxial anesthetic procedures in thrombocytopenic parturients. METHODS: A multicenter retrospective cohort study design was used to estimate the risk for spinal-epidural hematoma in parturients with a platelet count of <100,000/mm receiving neuraxial anesthesia and the risk of complications in thrombocytopenic parturients who receive general anesthesia. RESULTS: No cases of spinal hematoma were observed in 102 thrombocytopenic parturients receiving epidural analgesia or 71 receiving spinal anesthesia. Including data from the previous published series (total n = 499), the exact binomial 95% confidence interval for the risk of spinal-epidural hematoma was 0% to 0.6%. Given the small number of patients at each specific platelet count, the theoretical risks at individual platelet count strata are presented. Overall aggregate serious morbidity rate in women who received general anesthesia secondary to thrombocytopenia was 6.5% (95% confidence interval, 2.1%-14.5%). CONCLUSIONS: Our work supports the relative maternal safety of neuraxial anesthesia in parturients with mild thrombocytopenia and estimates the maternal complication rate associated with the avoidance of neuraxial anesthesia. Remaining uncertainties at lower platelet counts make a national "low platelet" registry critical to a more accurate assessment of the risk of epidural hematoma and would aid in standardization of anesthesia practice.

A prospective observational study of ethnic and racial differences in neuraxial labor analgesia request and pain relief.

BACKGROUND: As ethnic and racial diversity increases, it is important that anesthesia providers understand the expectations and concerns of this changing population regarding labor analgesia. Our objective was to evaluate ethnic/racial differences in labor analgesia characteristics with regard to the timing of request for neuraxial analgesia. METHODS: Three hundred ninety-seven parturients were enrolled in this prospective observational cohort study. Term laboring parturients who planned vaginal delivery and requested neuraxial labor analgesia were eligible for inclusion. Data collected included cervical dilation at the time of neuraxial analgesia request, self-identified ethnicity/race, parity, education, insurance status, pain score before and after the initiation of neuraxial analgesia, and mode of delivery. The primary outcome was cervical dilation at the time of neuraxial analgesia request. Ethnicity/race classification was determined by asking the patient, "How would you define your ethnicity?" Patients were categorized into the ethnic/racial groups of non-Hispanic White, African American, Hispanic, or other. Univariate associations between cervical dilation and categorical variables were examined. Multivariate analysis was performed for the primary outcome of cervical dilation at the time of initiation of neuraxial analgesia. RESULTS: At the time of neuraxial analgesia placement, the mean difference in cervical dilation of Hispanic parturients was 0.8 cm compared to non-Hispanic Whites (95% confidence interval [CI], 0.1-1.4; P = 0.047). After controlling for education, reason for placement, labor augmentation, and mode of delivery in a multivariate model, Hispanic parturients had 0.5 cm greater cervical dilation compared to non-Hispanic Whites, which was not significant (95% confidence interval, -0.1 to 1.1; P = 0.089). CONCLUSIONS: Our data indicate that ethnicity/race plays a small role in acceptance and request for neuraxial labor analgesia.

Investigating Racial and Ethnic Disparities in Maternal Care at the System Level Using Patient Safety Incident Reports.

BACKGROUND: Maternal mortality in the United States is high, and women and birthing people of color experience higher rates of mortality and severe maternal morbidity (SMM). More than half of maternal deaths and cases of SMM are considered preventable. The research presented here investigated systems issues contributing to adverse outcomes and racial/ethnic disparities in maternal care using patient safety incident reports. METHODS: The authors reviewed incidents reported in the labor and delivery unit (L&D) and the antepartum and postpartum unit (A&P) of a large academic hospital in 2019 and 2020. Deliveries associated with a reported incident were described by race/ethnicity, age group, method of delivery, and several other process variables. Differences across racial/ethnic group were statistically evaluated. RESULTS: Almost two thirds (64.8%) of the 528 reports analyzed were reported in L&D, and 35.2% were reported in A&P. Non-Hispanic white (NHW) patients accounted for 43.9% of reported incidents, non-Hispanic Black (NHB) patients accounted for 43.2%, Hispanic patients accounted for 8.9%, and patients categorized as "other" accounted for 4.0%. NHB patients were disproportionally represented in the incident reports, as they accounted for only 36.5% of the underlying birthing population. The odds ratio (OR) demonstrated a higher risk of a reported adverse incident for NHB patients; however, adjustment for cesarean section attenuated the association (OR 1.25, 95% confidence interval 1.01-1.54). CONCLUSION: Greater integration of patient safety and health equity efforts in hospitals are needed to promptly identify and alleviate racial and ethnic disparities in maternal health outcomes. Although additional systems analysis is necessary, the authors offer recommendations to support safer, more equitable maternal care.

Racial and ethnic disparities in long-term contraception use among the birthing population at an academic hospital in the Southeastern United States.

Ensuring women and birthing people have access to the contraceptive of their choice is essential for patient-centered care, health equity, and reproductive justice. While trends in national data in the United States reveal racial disparities in long-term contraceptive use, health-system and hospital-level investigations are essential to understand disparities and encourage interventions. We used data from 5011 patients who delivered at a large academic hospital to determine the effect of race/ethnicity and social vulnerability index (SVI) on the odds of undergoing a long-term contraceptive procedure. Results indicate that SVI substantially affects the odds of long-term contraception for non-Hispanic White women and birthing people. In contrast, Hispanic and non-Hispanic Black women and birthing people have significantly higher odds of undergoing a long-term contraceptive procedure due to race/ethnicity. Contributions to these disparities may be based on factors including healthcare providers, organizational and external policies. Interventions at all levels of care are essential to address disparities in contraceptive care, outcomes, and patient experience.

Impact of Anesthesiologist Experience on Early Outcomes in Adult Orthotopic Liver Transplantation.

BACKGROUND: Liver transplantation is a complex surgical procedure. The experience of the anesthesiologist, and its potential relationship to patient morbidity and mortality, is yet to be determined. We sought to explore this possible association using our institutional training patterns as the subject of study. METHODS: This is a single center retrospective analysis investigating the association of an anesthesiologist's experience with liver transplantation and its potential effect on early patient outcomes in adult liver transplant recipients from January 2010 to September 2016. Training of team members consisted of a 6-month period of clinical shadowing with a senior anesthesiologist and co-staffing 8 liver transplant procedures before solo staffing a liver transplant. Specifically, patient outcomes for the first 5 transplants after this training were investigated. RESULTS: The only independent risk factor for early death or early graft loss was the amount of packed red blood cells administered during transplantation. With respect to secondary outcomes, the amount of packed red blood cells and hospitalization at the time of transplant were associated with the number of days on a ventilator, length of intensive care unit stay, and overall hospital length of stay. CONCLUSIONS: The results of this study conclude that the training model currently in place for our new team members has no negative impact on patient outcomes after liver transplantation.

Maternal and fetal oxidative stress and intrapartum term fever.

OBJECTIVE: The association between maternal chorioamnionitis and fetal oxidative stress has not been well established. STUDY DESIGN: A nested case control study was performed within a prospective cohort of term nulliparous women: 20 cases (intrapartum fever of >100.4 degrees F) and 20 afebrile controls. Oxidative stress was assessed using ThioGlo-1 (TG-1; Calbiochem, San Diego, CA) fluorescent sulfhydryl detection. Median levels (+/- interquartile range) of protein-thiol sulfhydryls were compared. RESULTS: In early labor, maternal oxidative stress (lower protein sulfhydryls) was significantly higher in those women who subsequently had intrapartum fever develop (79.87 +/- 22.88 vs 127.73 +/- 43.79 counts/second per microg protein; P < .001). In contrast, cord serum sulfhydryls were not different between groups (75.77 +/- 14.00 vs 75.04 +/- 17.83 counts/second per microg protein; P = .99) CONCLUSION: Our data suggest that the term human fetus is protected from maternal oxidative stress associated with intrapartum fever. However, maternal oxidative status in early labor is associated with subsequent intrapartum fever. Optimal fetal neuroprotection will require a more precise knowledge of pathogenic mechanisms.

Altered Thermoregulatory Responses Following Spinal Morphine for Caesarean Delivery: a Case Report.

OBJECTIVE: Spinal anaesthesia interferes with physiological thermoregulatory responses, potentially leading to peri-operative hypothermia. Spinal morphine can further compound this by a paradoxical clinical presentation leading to poor patient outcome. CASE REPORT: Following an uneventful caesarean delivery (CD) under spinal anaesthesia with intrathecal morphine for post-operative analgesia, a parturient presented in the recovery room with increasing somnolence, excessive sweating and a sensation of feeling hot. She was haemodynamically stable, but her temperature was 34.5°C. Active warming measures were implemented, and normothermia was achieved in 3 hours. CONCLUSION: Spinal morphine can alter the clinical presentation of hypothermia by manifesting as excessive sweating and subjective sensation of warmth. Teams involved in the perioperative care of parturients should be aware of (a) the possibility of spinal anaesthesia causing perioperative hypothermia, (b) intrathecal morphine masking the clinical presentation of hypothermia and (c) the importance of monitoring temperature of patients who have received spinal anaesthesia with added morphine.

Postural orthostatic tachycardia syndrome: anesthetic implications in the obstetric patient.

We report the anesthetic management of a parturient with postural orthostatic tachycardia syndrome. This syndrome is associated with hemodynamic instability, which can be worsened by the physiology of labor and delivery. We discuss anesthetic concerns with this disease in the parturient and suggest approaches for management of this disease.

Labor Epidural Analgesia and Postpartum Depression.

INTRODUCTION: Epidural labor analgesia may decrease the risk of postpartum depression (PPD). METHODS: In a secondary analysis of a prospective study, the association between epidural utilization and PPD was evaluated using a Fisher's exact test. PPD was defined as an Edinburgh Postnatal Depression score of ≥ 10 at 6-8 weeks postpartum. RESULTS: 20% (13/65) of women meet criteria for PDD. 24% (n=12/50) of women who received epidural labor analgesia developed PPD, compared to 6.7% (n=1/15) of women who did not receive epidural labor analgesia (P = 0.27). CONCLUSIONS: Labor epidural analgesia did not reduce the risk of postpartum depression.

The use of argatroban for carotid endarterectomy in heparin-induced thrombocytopenia.

Heparin-induced thrombocytopenia (HIT) is a major obstacle in cardiovascular surgeries. In this case report, we used argatroban, a direct thrombin inhibitor, to achieve and maintain anticoagulation for carotid endarterectomy. Unlike heparin, the direct thrombin inhibitors bind directly to thrombin, bypassing antithrombin III and the potential to precipitate HIT. A bolus of argatroban 150 microg/kg followed by an infusion of 5 microg . kg(-1) . min(-1) was used, and adequate anticoagulation was demonstrated with multiple laboratory tests (at 28 min, prothrombin time = 29.8 s, partial thromboplastin time = 69.1 s, international normalized ratio = 3.52 s, and activated clotting time = 220 s). The surgery was successful, and the patient was discharged the next day with no postoperative neurologic sequelae or other complications. We conclude that argatroban can be used safely and successfully for carotid endarterectomy in a patient with a history of HIT.