Quality of Recovery After Unplanned and Planned Cesarean Deliveries: A Prospective Observational Study Using the Obstetric Quality of Recovery-10 Tool.

BACKGROUND: There is a paucity of literature examining the differences between patient-reported outcome measures after planned and unplanned cesarean delivery using a validated quality of recovery tool. The Obstetric Quality of Recovery-10 (ObsQoR-10) scoring tool has been validated to quantify functional recovery after cesarean delivery. We aimed to use the ObsQoR-10 to compare the postoperative recovery characteristics of patients undergoing planned and unplanned cesarean deliveries. METHODS: We conducted a prospective single-center observational study. Patients undergoing planned and unplanned cesarean deliveries under neuraxial anesthesia were asked to complete the ObsQoR-10 questionnaire 24 hours, 48 hours, and 1 week postpartum. We collected information on total in-hospital postoperative opioid consumption and patients´ perception of readiness for discharge at 24 and 48 hours postpartum. Additionally, patient characteristics were collected to assess their correlation with our findings. RESULTS: We included 112 patients (56 in each group). No statistical differences in ObsQoR-10 scores at 24 hours, 48 hours, and 1 week postpartum were observed between the planned and unplanned cesarean deliveries. Additionally, there was no difference between the groups in patients' perception of readiness for hospital discharge at 24 and 48 hours and opioid consumption in the first 2 days after surgery. Most patients in both groups did not think they would be ready for discharge at 24 hours postpartum. Analysis of the individual components of ObsQoR-10 at 24 hours showed a difference in the responses assessing the severity of shivering (higher in unplanned cesarean deliveries) and the ability to look after personal hygiene (lower in unplanned cesarean deliveries). CONCLUSIONS: As assessed by the ObsQoR-10, no significant difference in the quality of recovery was observed between patients undergoing planned and unplanned cesarean delivery.

Differential sensory block during labour epidural analgesia: a prospective observational study to investigate the relationship of lower and upper sensory block levels to cold, pinprick, and light touch.

PURPOSE: A zone of differential block to cold has been recently documented during labour epidural analgesia, with an upper sensory block level (USBL) and a lower sensory block level (LSBL). We aimed to determine the correlation between USBL and LSBL to cold and pinprick and sensory block level to light touch during labour epidural analgesia. METHODS: We conducted a prospective observational study in patients requesting labour epidural analgesia. We placed an epidural catheter at L2/L3 or L3/L4, followed by a programmed intermittent epidural bolus plus patient-controlled epidural analgesia regimen. We assessed the sensory block levels 140 min after administering the loading dose. The primary outcomes were the USBL and LSBL to cold and pinprick and the sensory block level to light touch. RESULTS: We studied 30 patients. The median [interquartile range (IQR)] USBL and LSBL to ice were T7 [T7-T6] and T9 [T10-T8], respectively. The median [IQR] USBL and LSBL to pinprick were T8 [T10-T6] and T10 [T12-T10], respectively. There was a strong correlation between USBL to ice and pinprick (Spearman correlation coefficient, 0.57) and between LSBL to ice and pinprick (Spearman correlation coefficient, 0.52). There was no significant correlation between sensory block level to light touch and either USBL or LSBL to ice or pinprick. CONCLUSION: We observed two sensory block levels to ice and pinprick. Further studies are required to understand if one modality-cold or pinprick-is superior to the other in assessing sensory block levels in this context. Light touch is unreliable as a modality of sensory block assessment during labour epidural analgesia. TRIAL REGISTRATION: ClinicalTrials.gov (NCT05187962); registered 12 January 2022.

RéSUMé: OBJECTIF: Une zone de bloc différentiel de réaction au froid a récemment été documentée pendant l'analgésie péridurale obstétricale, avec un niveau de bloc sensoriel supérieur (USBL, pour upper sensory block level) et un niveau de bloc sensoriel inférieur (LSBL, pour lower sensory block level). Notre objectif était de déterminer la corrélation entre l'USBL et le LSBL au contact du froid et de la piqûre et le niveau de bloc sensoriel au toucher léger pendant l'analgésie péridurale obstétricale. MéTHODE: Nous avons mené une étude observationnelle prospective chez des patient·es demandant une analgésie péridurale obstétricale. Nous avons placé un cathéter péridural au niveau L2/L3 ou L3/L4, suivi d'une administration programmée de bolus périduraux plus un régime d'analgésie péridurale contrôlée par le/la patient·e. Nous avons évalué les niveaux de bloc sensoriel 140 min après l'administration de la dose de charge. Les critères d'évaluation principaux étaient l'USBL et le LSBL en réaction au froid et à la piqûre d'épingle et le niveau de bloc sensoriel en réaction au toucher léger. RéSULTATS: Nous avons étudié 30 patient·es. Les USBL et LSBL médians [écart interquartile (ÉIQ)] à la glace étaient situés au niveau T7 [T7-T6] et T9 [T10-T8], respectivement. Les USBL et LSBL médians [écart interquartile (ÉIQ)] à la piqûre étaient localisés au niveau T8 [T10­T6] et T10 [T12­T10], respectivement. Il y avait une forte corrélation entre l'USBL à la glace et à la piqûre (coefficient de corrélation de Spearman, 0,57) et entre le LSBL à la glace et à la piqûre (coefficient de corrélation de Spearman, 0,52). Il n'y avait pas de corrélation significative entre le niveau de bloc sensoriel en réaction au toucher léger et l'USBL ou le LSBL en réaction à la glace ou à la piqûre. CONCLUSION: Nous avons observé deux niveaux de bloc sensoriel à la glace et à la piqûre. D'autres études sont nécessaires pour comprendre si une modalité ­ le froid ou la piqûre ­ est supérieure à l'autre pour évaluer les niveaux de bloc sensoriel dans ce contexte. Le toucher léger n'est pas fiable en tant que modalité d'évaluation du bloc sensoriel pendant l'analgésie péridurale obstétricale. ENREGISTREMENT DE L'éTUDE: ClinicalTrials.gov (NCT05187962); enregistré le 12 janvier 2022.

Anesthetic management of patients with class 3 obesity undergoing elective Cesarean delivery: a single-centre historical cohort study.

PURPOSE: The preferred neuraxial anesthetic technique for patients with class 3 obesity undergoing elective Cesarean delivery is still under debate. We aimed to describe the anesthetic technique used in our tertiary institution across body mass index (BMI) groups and different surgical incisions. METHOD: In this historical cohort study, we reviewed medical records of patients with a BMI ≥ 40 kg·m-2 undergoing elective Cesarean delivery between July 2014 and December 2020. We collected data on patient characteristics, anesthetic and surgical technique, and procedural times. For data analysis, we stratified patients by BMI into three different groups: 40.0-49.9 kg·m-2, 50.0-59.9 kg·m-2, and ≥ 60.0 kg·m-2. RESULTS: We included 396 deliveries, distributed as follows: 258 with a BMI 40.0-49.9 kg·m-2, 112 with a BMI 50.0-59.9 kg·m-2, and 26 with a BMI ≥ 60.0 kg·m-2. For patients with a BMI 40.0-49.9 kg·m-2, the anesthetic technique of first choice was predominantly spinal anesthesia (71%), whereas for those with a BMI ≥ 60.0 kg·m-2, spinal anesthesia was never used as the anesthetic of first choice. With regard to the surgical incision, spinal anesthesia was almost exclusively used for patients undergoing Pfannenstiel incision and was rarely used for a higher supra- or infraumbilical transverse or midline incision. The overall incidence of general anesthesia was low (7/396, 1.8%). Anesthetic time, surgical time, and operating room time increased almost twofold in patients with a BMI ≥ 60.0 kg·m-2 compared with those with a BMI of 40.0-49.9 kg·m-2. CONCLUSION: Neuraxial anesthesia was successfully used in approximately 98% of patients with class 3 obesity undergoing elective Cesarean delivery. The choice of regional anesthesia technique varied with increasing BMI and with the planned surgical incision. Procedural times increased with increasing BMI. This information should prove useful for comparing anesthetic choices and outcomes in this challenging population.

RéSUMé: OBJECTIF: La technique d'anesthésie neuraxiale préférée pour les patientes atteintes d'obésité de classe 3 bénéficiant d'un accouchement par césarienne programmée n'a pas encore été déterminée. Nous avons cherché à décrire la technique d'anesthésie utilisée dans notre établissement d'enseignement supérieur à travers les groupes d'indice de masse corporelle (IMC) et les différentes incisions chirurgicales. MéTHODE: Dans cette étude de cohorte historique, nous avons examiné les dossiers médicaux de patientes ayant un IMC ≥ 40 kg·m­2 ayant bénéficié d'un accouchement par césarienne programmée entre juillet 2014 et décembre 2020. Nous avons recueilli des données sur les caractéristiques des patientes, la technique anesthésique et chirurgicale et les délais de procédure. Pour l'analyse des données, nous avons stratifié les patientes par IMC en trois groupes différents, soit : 40,0­49,9 kg·m­2, 50,0­59,9 kg·m­2, et ≥ 60,0 kg·m­2. RéSULTATS: Nous avons inclus 396 accouchements, répartis comme suit : 258 pour un IMC de 40,0 à 49,9 kg·m­2, 112 pour un IMC de 50,0 à 59,9 kg·m­2, et 26 pour un IMC ≥ 60,0 kg·m­2. Pour les patientes ayant un IMC de 40,0 à 49,9 kg·m­2, la technique anesthésique de premier choix était principalement la rachianesthésie (71 %), alors que pour celles dont l'IMC ≥ de 60,0 kg·m­2, la rachianesthésie n'a jamais été utilisée comme modalité anesthésique de premier choix. En ce qui concerne l'incision chirurgicale, la rachianesthésie était presque exclusivement utilisée pour les patientes bénéficiant d'une incision de Pfannenstiel et était rarement utilisée pour une incision transversale ou médiane supra- ou infra-ombilicale supérieure. L'incidence globale d'anesthésie générale était faible (7/396, 1,8 %). Le temps d'anesthésie, le temps chirurgical et le temps passé en salle d'opération ont presque doublé chez les patientes ayant un IMC ≥ 60,0 kg·m­2 par rapport à celles ayant un IMC de 40,0 à 49,9 kg·m­2. CONCLUSION: L'anesthésie neuraxiale a été utilisée avec succès chez environ 98 % des patientes atteintes d'obésité de classe 3 bénéficiant d'un accouchement par césarienne programmée. Le choix de la technique d'anesthésie régionale variait en fonction de l'augmentation de l'IMC et de l'incision chirurgicale prévue. Les temps procéduraux augmentaient avec l'augmentation de l'IMC. Ces informations devraient s'avérer utiles pour comparer les choix et les issues en matière d'anesthésie dans cette population difficile.

Oxytocin at Elective Cesarean Delivery: A Dose-Finding Study in Pregnant People With Twin Pregnancy.

BACKGROUND: Multiple pregnancy is associated with higher risk of uterine atony, postpartum hemorrhage (PPH), blood transfusion, hysterectomy, and death. The optimal dose of oxytocin at cesarean delivery in people with twin pregnancy is unknown. We sought to determine the effective bolus dose of oxytocin required to initiate adequate uterine tone in 90% of people (ED90) with twin pregnancy undergoing elective cesarean delivery. Our hypothesis was that the dose of oxytocin would be higher than 0.5 international units (IU) but lower than 5 IU. METHODS: A double-blind dose-finding study using the biased coin up-down method was undertaken in people with twin pregnancy ≥36 weeks gestational age undergoing elective cesarean delivery under neuraxial anesthesia. Those with additional risk factors for PPH, apart from twin pregnancy, were excluded. Oxytocin was administered as an intravenous bolus over 1 minute on delivery of the second fetus. The first patient received 0.5 IU, and subsequent oxytocin doses were administered according to a sequential allocation scheme. The actual doses administered were 0.5, 1, 2, 3, 4, and 5 IU of oxytocin. The primary outcome was the response defined as the satisfactory uterine tone at 2 minutes after completion of administration of the oxytocin bolus, as assessed by the operating obstetrician. Secondary outcomes included need for rescue uterotonic drugs, adverse effects, and estimated blood loss. The ED90 was estimated using the Dixon-Mood and the isotonic regression methods. RESULTS: Thirty patients were included in study. The estimated ED90 of oxytocin was 4.38 IU (95% confidence interval [CI], 3.68-4.86 IU) and 3.41 IU (95% CI, 2.83-3.98 IU) by the isotonic regression and Dixon-Mood methods, respectively. Seven patients had inadequate tone at the 2-minute evaluation point and required rescue uterotonic drugs. The median (interquartile range [IQR]) estimated blood loss was 1031 mL (732-1462 mL) calculated by the change in 24-hour hematocrit. Incidence of hypotension after oxytocin administration was 27%, nausea 30%, and vomiting 17%. CONCLUSIONS: Our results demonstrated that people with twin pregnancy require a much higher dose of oxytocin than those with singleton pregnancies. We recommended people with twin pregnancies should receive an initial 5 IU bolus over at least 1 minute when undergoing elective cesarean delivery under neuraxial anesthesia.

Programmed intermittent epidural bolus for labour analgesia: a randomized controlled trial comparing bolus delivery speeds of 125 mL·hr-1 versus 250 mL·hr-1.

PURPOSE: Programmed intermittent epidural bolus (PIEB) provides better analgesia for labour pain than continuous epidural infusion does. Nevertheless, commonly used PIEB regimens are associated with high sensory block. We hypothesized that a PIEB technique with slower bolus delivery speed would produce lower sensory levels. METHODS: We recruited term nulliparous women with singleton pregnancies during the first stage of labour. All participants had an American Society of Anesthesiologists Physical Status score of II-III, had epidural catheters placed at L3/4, and had epidural analgesia maintained with PIEB 10 mL every 40 min using 0.0625% bupivacaine with fentanyl 2 µg·mL-1. Women were randomized to receive PIEB delivered at 250 mL·hr-1 (G250) or 125 mL·hr-1 (G125). The study was completed six hours after the loading dose or at full cervical dilatation, whichever occurred first. The primary outcome was the presence of sensory block to ice ≥ T6 in at least one assessment during the study period (maximum six hours). RESULTS: We analyzed data from 90 women. The proportion of women presenting sensory block ≥ T6 at any time was not different between G125 and G250 groups (60.0% vs 64.4%; difference, -4.4%; 95% confidence interval [CI], -24.5 to 15.6; P = 0.66). The median [interquartile range] highest sensory block level was also not different between G125 and G250 groups (T6 [T7-T5] vs T5 [T7-T5], P = 0.39). Women in the G125 group had a lower incidence of hypotension than women in the G250 group did (11.1% vs 33.3%; difference, -22.2%; 95% CI, -38.8 to -5.67; P = 0.01). Quality of analgesia and patient satisfaction were not different between groups. CONCLUSION: The maintenance of epidural analgesia with a PIEB delivery speed of 125 mL·hr-1 did not produce lower sensory block levels when compared with 250 mL·hr-1. The slower injection speed regimen was associated with lower incidence of hypotension, but this secondary finding warrants confirmation in a future trial. TRIAL REGISTRATION: www.ClinicalTrials.gov (NCT03236298); registered 1 August 2017.

RéSUMé: OBJECTIF: L'administration programmée intermittente de bolus périduraux (PIEB, pour programmed intermittent epidural bolus) fournit une meilleure analgésie pour la douleur du travail que l'analgésie péridurale par perfusion continue. Néanmoins, les régimes de PIEB couramment utilisés sont associés à un bloc sensoriel élevé. Nous avons émis l'hypothèse qu'une technique de PIEB avec une vitesse d'administration plus lente du bolus produirait des niveaux sensoriels inférieurs. MéTHODE: Nous avons recruté des femmes nullipares à terme ayant des grossesses uniques au cours de la première étape du travail obstétrical. Toutes les participantes avaient un score de statut physique II-III de l'American Society of Anesthesiologists, des cathéters périduraux placés au niveau L3/4 et une analgésie péridurale maintenue avec des PIEB de 10 mL de bupivacaïne 0,0625 % et de 2 µg·mL-1 de fentanyl, administrés toutes les 40 minutes. Les femmes ont été randomisées à recevoir des PIEB administrés à une vitesse de 250 mL·h-1 (G250) ou 125 mL·h-1 (G125). L'étude se terminait six heures après la dose de charge ou lors de la dilatation cervicale complète, selon la première éventualité. Le critère d'évaluation principal était la présence d'un bloc sensoriel à la glace ≥ T6 lors d'au moins une évaluation au cours de la période à l'étude (pour un maximum de six heures). RéSULTATS: Nous avons analysé les données de 90 femmes. La proportion de femmes présentant un bloc sensoriel ≥ T6 à tout moment n'était pas différente entre les groupes G125 et G250 (60,0 % vs 64,4 %; différence, -4,4 %; intervalle de confiance [IC] à 95 %, -24,5 à 15,6; P = 0,66). Le niveau médian [écart interquartile] le plus élevé de bloc sensoriel n'était pas non plus différent entre les groupes G125 et G250 (T6 [T7-T5] vs T5 [T7-T5], P = 0,39). Les femmes du groupe G125 avaient une incidence d'hypotension plus faible que les femmes du groupe G250 (11,1 % vs 33,3 %; différence, -22,2 %; IC 95 %, -38,8 à -5,67; P = 0,01). La qualité de l'analgésie et la satisfaction des patientes n'étaient pas différentes d'un groupe à l'autre. CONCLUSION: Le maintien de l'analgésie péridurale avec une vitesse d'administration des PIEB de 125 mL·h-1 n'a pas entraîné de taux de blocs sensoriels inférieurs par rapport à une vitesse de 250 mL·h-1. Le régime de vitesse d'injection plus lente a été associé à une incidence plus faible d'hypotension, mais cette constatation secondaire mérite d'être confirmée dans une étude future. ENREGISTREMENT DE L'éTUDE: www.ClinicalTrials.gov (NCT03236298); enregistrée le 1er août 2017.

Changes in sensory block level during a programmed intermittent epidural bolus regimen for labour analgesia: a prospective observational cohort study.

PURPOSE: In the context of a programmed intermittent epidural bolus (PIEB) regimen for labour analgesia, one can identify an upper sensory block level (USBL), defined as the highest dermatome with any altered sensation to cold, and a lower sensory block level (LSBL), defined as the highest dermatome with complete sensory block to cold. This study investigated whether and how these sensory block levels vary within PIEB cycles. METHODS: We enrolled patients requesting epidural analgesia. An epidural catheter was placed at L2/L3 or L3/L4. A test dose of 3 mL of bupivacaine 0.125% with fentanyl 3.3 µg·mL-1 was administered, followed by 12 mL of the same solution as the loading dose. A PIEB plus patient-controlled epidural analgesia (PCEA) regimen was initiated 40 min after the loading dose, with bupivacaine 0.0625% with fentanyl 2 µg·mL-1: PIEB 10 mL, PIEB interval 40 min, PCEA 5 mL, lockout interval 10 min, maximum hourly 30 mL. As per institutional protocol, sensory block levels to ice were assessed 20 min after the loading dose and then hourly. Patients included in the study underwent eight extra assessments: immediately before the second and fourth PIEB and 10, 20, and 30 min after the second and third PIEB. RESULTS: We studied 30 patients. The USBL and LSBL achieved their peak value 100 min after the loading dose. The median [interquartile range] USBL was T8 [T9-T7] and T6 [T7-T4] 20 and 100 min after the loading dose, respectively; LSBL was T10 [T11-T6] and T8 [T9-T6], respectively. There was no significant variation in USBL or LSBL within the PIEB cycle between the second and the third or the third and the fourth PIEB. CONCLUSION: Once peak sensory block levels are established, there is no significant variation in the USBL and LSBL within the PIEB cycles. STUDY REGISTRATION: www. CLINICALTRIALS: gov (NCT04716660); registered 21 January 2021.

RéSUMé: OBJECTIF: Dans le contexte du schéma de bolus périduraux intermittents programmés (PIEB) pour l'analgésie du travail, on peut identifier un niveau de bloc sensoriel haut (USBL) défini comme étant le dermatome le plus haut ayant une quelconque modification de la sensation au froid et un niveau de bloc sensoriel bas (LSBL) défini comme étant le dermatome le plus haut ayant un bloc sensoriel complet au froid. Cette étude a cherché à savoir si et comment ces niveaux de blocs sensoriels varient au cours des cycles de PIEB. MéTHODES: Nous avons recruté des patientes demandant une analgésie péridurale. Un cathéter péridural a été placé au niveau L2/L3 ou au niveau L3/L4. Une dose test de 3 mL de bupivacaïne 0,125% avec fentanyl 3,3 µg·ml−1 était administrée, suivie de 12 mL de la même solution représentant la dose de base. Un protocole de PIEB plus analgésie péridurale contrôlée par la patiente (PCEA) a débuté 40 min après l'administration de la dose de base, comportant de la bupivacaïne 0,0625% et du fentanyl 2 µg·ml−1: PIEB 10 mL; intervalle de PIEB 40 min.; PCEA 5 ml; intervalle de verrouillage 10 min.; maximum par heure 30 mL. Conformément au protocole de l'établissement, les niveaux de bloc sensoriel à la glace ont été évalués 20 min après l'administration de la dose de base, puis toutes les heures. Les patientes incluses dans l'étude ont eu huit évaluations supplémentaires: immédiatement avant le deuxième et le quatrième PIEB et 10, 20 et 30 min après les deuxième et troisième PIEB. RéSULTATS: Nous avons étudié 30 patientes. L'USBL et le LSBL ont atteint leur valeur pic 100 min après l'administration de la dose de base. L'USBL médian [plage interquartile] était T8 [T9­T7] et T6 [T7­T4], respectivement 20 et 100 min après la dose de base; Le LSBL était, respectivement, T10 [T11­T6] et T8 [T9­T6]. Il n'y avait pas de variation significative de l'USBL ou du LSBL dans le cycle de PIEB entre le deuxième et le troisième ou le troisième et le quatrième PIEB. CONCLUSION: Une fois les niveaux maximums de blocs sensoriels établis, il n'y a pas de variation significative dans l'USBL et le LSBL dans les cycles de PIEB. ENREGISTREMENT DE L'éTUDE: www.clinicaltrials.gov (NCT04716660); enregistrée le 21 janvier 2021.

Assessment of sensory block during labour epidural analgesia: a prospective cohort study to determine the influence of the direction of testing.

PURPOSE: Assessment of sensory block level during labour epidural analgesia is an essential component of clinical practice and patient safety. Nevertheless, the methods and direction of testing are not standardized. In our hospital, sensory block testing to ice is routinely used, but while some anesthesiologists test the block from a nonanesthetized to an anesthetized area, some do it in the opposite direction. It is unknown how these two different practices affect identification of the sensory block level. The objective of this study was to determine the agreement between these two practices. METHODS: We enrolled 31 patients admitted to the labour and delivery unit in a prospective cohort study. At their request, labour epidural analgesia was performed as per institutional routine. Sensory block level to ice was assessed using opposite directions by two randomly assigned independent investigators, one and two hours after the loading dose was administered. RESULTS: Sensory block levels to ice assessed from an anesthetized area to a nonanesthetized area were lower than those when assessed with the stimulus applied in the opposite direction, typically one segment lower. DISCUSSION: Given the small difference detected with both methods, it may be acceptable to use either in clinical practice. Nevertheless, the lack of standardization may have a significant impact when comparing studies involving assessment of sensory block to ice. STUDY REGISTRATION: www. CLINICALTRIALS: gov (NCT03572439); registered 28 June 2018.

RéSUMé: OBJECTIF: L'évaluation du niveau de bloc sensoriel pendant l'analgésie péridurale obstétricale est une composante essentielle de la pratique clinique et de la sécurité des patientes. Néanmoins, les méthodes et l'orientation des tests ne sont pas standardisées. Dans notre hôpital, les tests à la glace des blocs sensoriels sont couramment utilisés, mais alors que certains anesthésiologistes testent le bloc d'une zone non anesthésiée à une zone anesthésiée, certains le font dans la direction opposée. Nous ne savons pas dans quelle mesure ces deux pratiques différentes affectent l'identification du niveau du bloc sensoriel. L'objectif de cette étude était de déterminer la concordance entre ces deux pratiques. MéTHODE: Nous avons recruté 31 patientes admises à l'unité obstétricale dans une étude de cohorte prospective. À leur demande, l'analgésie péridurale obstétricale a été réalisée conformément à la routine institutionnelle. Le niveau du bloc sensoriel tel que mesuré par un test à la glace a été évalué dans les deux directions par deux chercheurs indépendants assignés au hasard, une et deux heures après l'administration de la dose de charge. RéSULTATS: Les niveaux de blocs sensoriels tels que mesurés par un test à la glace évalués d'une zone anesthésiée à une zone non anesthésiée étaient inférieurs à ceux évalués lorsque le stimulus était appliqué dans la direction opposée, habituellement un segment plus bas. DISCUSSION: Compte tenu de la petite différence détectée entre les deux méthodes, il peut être acceptable d'utiliser l'une ou l'autre dans la pratique clinique. Néanmoins, le manque de standardisation peut avoir un impact significatif lors de la comparaison d'études impliquant l'évaluation du bloc sensoriel à l'aide d'un test à la glace. ENREGISTREMENT DE L'éTUDE: www.ClinicalTrials.gov (NCT03572439); enregistrée le 28 juin 2018.

Carbetocin versus oxytocin following vaginal and Cesarean delivery: a before-after study.

PURPOSE: A nationwide shortage of oxytocin in Canada resulted in a temporary switch from oxytocin to carbetocin for all postpartum women at our institution. This change offered a unique opportunity to conduct a pragmatic comparative assessment of the efficacy of carbetocin and oxytocin. METHODS: In a retrospective before-after study, we reviewed the medical records from 641 women in the carbetocin group and 752 women in the oxytocin group . The standard carbetocin dosing was 100 µg iv following vaginal and intrapartum Cesarean delivery, while for elective Cesarean delivery it was 50 µg, with an additional 50 µg if required. The standard oxytocin dosing was 5 IU iv followed by 2.4 IU·hr-1 for four to six hours after vaginal delivery, while for Cesarean delivery it was 1-3 IU iv, three minutes apart, up to 10 IU if required, followed by the same maintenance. In both modalities of delivery, if uterine tone was suboptimal, the maintenance dose of oxytocin could be increased to 4.8 IU·hr-1. In both groups, additional uterotonics were used as required. The primary outcome was the need for additional uterotonics. Secondary outcomes included estimated and calculated blood loss, the occurrence of postpartum hemorrhage, and the need for blood transfusion. RESULTS: The incidence of additional uterotonic use was not different between the carbetocin and oxytocin groups (12.0% vs 8.8%; P = 0.05; odds ratio, 1.39; 95% confidence interval, 0.97 to 2.00). The incidence of postpartum hemorrhage was higher in the carbetocin group than in the oxytocin group (10.3% vs 6.6%; P = 0.01). Blood transfusion was more common in the carbetocin group (1.4% vs 0.3%; P = 0.02). CONCLUSION: There was no difference in the use of additional uterotonics when carbetocin or oxytocin were used in a cohort of women undergoing vaginal deliveries and both elective and emergency Cesarean deliveries.

RéSUMé: OBJECTIF: Une pénurie nationale d'ocytocine au Canada a entraîné l'utilisation temporaire de la carbétocine en remplacement de l'ocytocine pour toutes les femmes en post-partum dans notre établissement. Grâce à cette substitution, nous avons bénéficié d'une occasion unique de mener une évaluation comparative pragmatique de l'efficacité de la carbétocine et de l'ocytocine. MéTHODE: Dans une étude rétrospective avant-après, nous avons examiné les dossiers médicaux de 641 femmes dans le groupe carbétocine et de 752 femmes dans le groupe ocytocine. Le dosage standard de carbécotine était de 100 µg iv après un accouchement vaginal et pendant un accouchement par césarienne intrapartum, tandis que pour un accouchement par césarienne élective, le dosage était de 50 µg, avec 50 µg supplémentaires au besoin. Le dosage standard d'ocytocine était de 5 UI iv suivi de 2,4 UI·h-1 pendant quatre à six heures après un accouchement vaginal, tandis que pour un accouchement par césarienne, il était de 1 à 3 UI iv, à trois minutes d'intervalle, jusqu'à 10 UI au besoin, suivi du même dosage d'entretien. Dans les deux types d'accouchement, si le tonus utérin était sous-optimal, la dose d'entretien d'ocytocine pouvait être augmentée à 4,8 UI·h-1. Dans les deux groupes, des utérotoniques supplémentaires ont été utilisés au besoin. Le critère d'évaluation principal était le besoin d'utérotoniques supplémentaires. Les critères d'évaluation secondaires comprenaient la perte de sang estimée et calculée, la survenue d'une hémorragie du post-partum et la nécessité d'une transfusion sanguine. RéSULTATS: L'incidence d'utilisation d'utérotoniques supplémentaires n'était pas différente entre les groupes carbétocine et ocytocine (12,0 % vs 8,8 %; P = 0,05; rapport de cotes,1,39; intervalle de confiance à 95 %, 0,97 à 2,00). L'incidence d'hémorragie du post-partum était plus élevée dans le groupe carbétocine que dans le groupe ocytocine (10,3 % vs 6,6 %; P = 0,01). Les transfusions sanguines étaient plus fréquentes dans le groupe carbétocine (1,4 % vs 0,3 %; P = 0,02). CONCLUSION: Aucune différence dans l'utilisation d'utérotoniques supplémentaires n'a été observée lors de l'utilisation de carbétocine ou d'ocytocine dans une cohorte de femmes accouchant par voie vaginale ou par césarienne élective ou en urgence.

Obstetric Emergencies Requiring Rapid Response Team Activation: A Retrospective Cohort Study in a High-Risk Tertiary Care Centre.

OBJECTIVE: The purpose of this study was to better understand obstetric codes requiring rapid response team activation by examining their incidence, indications, team response, and patient outcomes. METHODS: This was a retrospective study in peripartum women who required activation of the following codes during hospitalization between January 2014 and May 2018: "Code 77 (C77)" (obstetric emergency), "Code Blue (CB)" (cardiopulmonary compromise) or "Code Omega (CO)" (massive transfusion). Hospital database and health records were searched to identify and review cases. Data on code characteristics, resuscitative measures, and maternal and neonatal outcomes were collected. RESULTS: A total of 147 codes were identified during the study period (C77, 110; CO, 25; CB 12), with an overall incidence of 1 per 203 deliveries (C77, 1:271 deliveries, CO, 1:1194 deliveries; CB, 1:2488 deliveries). Common indications for C77 were cord prolapse (33%) and fetal bradycardia (32%), and for CO and CB, postpartum hemorrhage (84%) and cardiac arrest (42%), respectively. Most codes (67%) occurred after hours. The median decision-to-delivery interval was 8 (interquartile range 5-15) minutes after C77. Emergency cesarean delivery was performed for 57% of obstetric emergencies, and general anesthesia was administered in 63% of cesarean deliveries. Maternal and neonatal mortality rates were 0.68% and 7%, respectively. Major maternal morbidity was seen in 33% of cases. Debrief was documented for 4% of codes. CONCLUSION: Rapid response team activation was required more commonly in C77 than in CO or CB. Their response time and decision-to-delivery intervals were rapid. Mortality was low; however, one-third of parturients had major morbidities. We suggest closer patient monitoring, immediate availability of resources, and appropriate documentation and debriefing.

Programmed intermittent epidural bolus for labour analgesia during first stage of labour: a sequential allocation trial to determine the effective interval time between boluses of a fixed volume of 2.5 mL of bupivacaine 0.25% plus fentanyl 8 µg·mL-1.

PURPOSE: We studied the programmed intermittent epidural bolus (PIEB) time interval between boluses of 2.5 mL of bupivacaine 0.25% with fentanyl 8 µg·mL-1 to produce effective analgesia in 90% of women (EI90) during the first stage of labour. METHODS: In a double-blind sequential allocation trial using a biased coin up-and-down design to determine the EI90, the PIEB boluses of 2.5 mL of 0.25% bupivacaine plus fentanyl 8 µg·mL-1 were delivered at varying intervals-60, 50, 40, and 30 min. The primary outcome was the adequate response of the patient to the PIEB regimen, defined as no use of supplemental analgesia for six hours or until the first stage of labour was completed, whichever came first. The secondary outcomes were the upper sensory block level to ice, motor block and hypotension. The isotonic regression with extrapolation approach was used to estimate the EI90. RESULTS: In the 20 women studied, the estimated EI90 was 20 (95% CI, 5.9 to 28.8) min. For the secondary outcomes, we classified women into those assigned to 30 min (16 women) and those assigned to more than 30 min (four women). The median upper sensory block for women in the 30-min group and more than 30 min were T6 (or T5) and T7, respectively. No participants experienced motor block. Hypotension occurred in one patient in the 30-min group. CONCLUSION: The estimated EI90 for boluses of 2.5 mL of bupivacaine 0.25% with fentanyl 8 µg·mL-1 was 20 (95% CI, 5.9 to 28.8) min. These results suggest that there is no advantage in using this regimen compared with those reported in the literature using the same dose of bupivacaine in concentrations of 0.0625% and 0.125%. TRIAL REGISTRATION: www.clinicaltrials.gov (NCT03735771); registered 7 November 2018.

RéSUMé: OBJECTIF: Nous avons étudié l'intervalle de temps d'administration programmée de bolus périduraux (PIEB) entre des bolus de 2,5 mL de bupivacaïne 0,25 % avec 8 µg·mL−1 de fentanyl nécessaire pour procurer une analgésie efficace chez 90 % des femmes (IE90) au cours du premier stade du travail obstétrical. MéTHODE: Dans une étude de répartition séquentielle à double insu utilisant une méthodologie de tirage au sort biaisé de haut en bas pour déterminer l'IE90, des bolus PIEB de 2,5 mL de bupivacaïne 0,25 % plus 8 µg·mL−1 fentanyl ont été administrés à des intervalles variables ­ 60, 50, 40 et 30 min. Le critère d'évaluation principal était une réponse adéquate de la patiente au régime de PIEB, définie comme aucun recours à une analgésie supplémentaire pendant six heures ou jusqu'à la fin du premier stade du travail, à la première condition obtenue. Les critères d'évaluation secondaires comportaient le niveau du bloc sensitif supérieur tel qu'établi par un test de glace, ainsi que la présence d'un bloc moteur et d'hypotension. Nous avons utilisé une méthode de régression isotonique avec une approche d'extrapolation pour estimer l'IE90. RéSULTATS: Chez les 20 femmes étudiées, l'IE90 estimé était de 20 (IC 95 %, 5,9 à 28,8) min. En ce qui touche aux critères d'évaluation secondaires, nous avons catégorisé les femmes selon qu'elles étaient assignées à recevoir un bolus aux 30 min (16 femmes) ou à des intervalles de plus de 30 min (quatre femmes). Le niveau du bloc sensitif supérieur médian pour les femmes dans le groupe 30 min et plus de 30 min se situait à T6 (ou T5) et T7, respectivement. Aucune participante n'a subi de bloc moteur. Une patiente dans le groupe à 30 min a subi un épisode d'hypotension. CONCLUSION: L'IE90 estimé pour les bolus de 2,5 mL de bupivacaïne 0,25 % avec 8 µg·mL−1 de fentanyl était de 20 (IC 95 %, 5,9 à 28,8) min. Ces résultats suggèrent qu'il n'y a aucun avantage à utiliser ce régime posologique plutôt que ceux rapportés dans la littérature utilisant une même dose de bupivacaïne à des concentrations de 0,0625 % et 0,125 %. ENREGISTREMENT DE L'éTUDE: www.clinicaltrials.gov (NCT03735771); enregistrée le 7 novembre 2018.

Predicting pain after Cesarean delivery: pressure algometry, temporal summation, three-item questionnaire.

PURPOSE: Approximately one in five women will experience severe postoperative pain after Cesarean delivery (CD). Previously, a bedside three-item questionnaire (3-IQ) has shown to predict women experiencing higher evoked pain intensity after CD, with an area under the receiver operator characteristics (ROC) curve of 0.72. We hypothesized that the addition of psychophysical pain tests to the existing 3-IQ would improve the ability to predict severe pain in women undergoing elective CD under spinal anesthesia METHODS: This was a prospective cohort study on women undergoing elective CD under spinal anesthesia. Women were assessed preoperatively using the 3-IQ, pressure algometry (PA) and mechanical temporal summation (TS) response. All women received standard perioperative care, including a multimodal analgesia regimen that included intrathecal fentanyl and morphine. A 0-100 mm visual analogue scale (VAS) was used to assess the severity of pain at rest (VASr) and on movement (VASm) at 24 and 48 hr after surgery. Patient satisfaction and opioid consumption were also recorded. We performed ROC curve analyses to assess whether we could improve the ability to predict our primary outcome of severe pain on movement at 24 hr (VASm24 ≥ 70). RESULTS: We studied 195 women. Median [interquartile range] VASm24 was 53 [32-72] and 28% of patients experienced a VASm24 ≥ 70. The ability to predict a VASm24 ≥ 70 assessed by the area under the ROC curve was 0.64 using the 3-IQ and 0.67 using the 3-IQ combined with TS and PA. CONCLUSION: The addition of PA and TS to the 3-IQ model resulted in a predictive model that performed similarly to the 3-IQ model alone. Further research is warranted in this area to better predict women at risk of severe pain post CD.

RéSUMé: OBJECTIF: Environ une femme sur cinq souffrira de douleur postopératoire sévère après un accouchement par césarienne. Un questionnaire à trois critères (Q3C) administré au chevet de la patiente a déjà été utilisé pour prédire quelles femmes éprouveraient une intensité de douleur évoquée plus élevée après une césarienne, avec une aire sous la courbe ROC de 0,72. Nous avons émis l'hypothèse que l'ajout de tests psychophysiques de douleur au Q3C existant améliorerait notre capacité à prédire la douleur sévère chez les femmes bénéficiant d'une césarienne élective sous rachianesthésie. MéTHODE: Il s'agissait d'une étude de cohorte prospective auprès de femmes bénéficiant d'une césarienne élective sous rachianesthésie. Les femmes ont été évaluées en préopératoire à l'aide du Q3C, de l'algométrie par pression (AP) et de la réponse à une sommation temporale (ST) mécanique. Toutes les femmes ont bénéficié des soins périopératoires standard, ainsi que d'un régime d'analgésie multimodal incluant fentanyl et morphine intrathécaux. Une échelle visuelle analogique (EVA) de 0 à 100 mm a été utilisée pour évaluer la sévérité de la douleur au repos (EVAr) et en mouvement (EVAm) à 24 et 48 heures après la chirurgie. La satisfaction des patientes et la consommation d'opioïdes ont également été enregistrées. Nous avons effectué des analyses de la courbe ROC pour déterminer s'il nous était possible d'améliorer notre capacité à prédire notre critère d'évaluation principal, soit la douleur sévère à la mobilisation à 24 heures (EVAm24 ≥ 70). RéSULTATS: Nous avons étudié 195 femmes. L'EVAm 24 médiane [écart interquartile] était de 53 [32-72] et 28 % des patientes ont noté un score sur l'EVAm24 ≥ 70. La capacité à prédire un score sur l'EVAm24 ≥ 70 tel qu'évalué par la surface sous la courbe ROC était de 0,64 en utilisant le Q3C et de 0,67 en utilisant le Q3C combiné à la ST et l'AP. CONCLUSION: L'ajout de l'AP et de la ST au modèle de Q3C a résulté en un modèle prédictif présentant une performance similaire au modèle de Q3C seul. D'autres recherches sont nécessaires dans ce domaine pour mieux prédire les femmes à risque de douleur sévères après une césarienne.

Comparison of Intermittent Intravenous Boluses of Phenylephrine and Norepinephrine to Prevent and Treat Spinal-Induced Hypotension in Cesarean Deliveries: Randomized Controlled Trial.

BACKGROUND: Phenylephrine (PE) is currently the vasopressor of choice to prevent and treat spinal-induced hypotension at cesarean delivery (CD). However, its use is often associated with reflex bradycardia. Norepinephrine (NE) has been put forward as an alternative vasopressor during CD due to its ability to treat hypotension while maintaining heart rate (HR). Recent studies have focused on the role of NE used as an infusion with favorable results compared to PE. No studies have compared equipotent bolus doses of PE and NE at CD. We hypothesized that when used in equipotent doses as an intermittent bolus regimen to prevent and treat spinal-induced hypotension, NE would result in a reduction in the incidence of bradycardia compared to PE. METHODS: This was a double-blind, randomized clinical trial of women undergoing elective CD under spinal anesthesia. Women were randomized to receive either PE 100 µg or NE 6 µg when the systolic blood pressure (SBP) was below baseline. In addition to the randomized treatment, ephedrine was given intravenously to both groups if the SBP was below baseline and the HR <60 bpm or if the SBP was <80% of baseline for 2 consecutive readings. The primary outcome was bradycardia (HR <50 bpm) in the predelivery period. Secondary outcomes included hypotension (SBP <80% of baseline), hypertension (SBP >120% of baseline), tachycardia (HR >120% of baseline), ≥2 episodes of bradycardia, nausea, vomiting, umbilical artery and vein blood gases, and Apgar scores. RESULTS: One hundred twelve patients were randomized. The incidence of bradycardia was lower in the NE group compared to the PE group (10.7% vs 37.5%; P < .001; difference [95% confidence interval {CI}], -26.8% [-41.8% to -11.7%]), implying an estimated 71% relative reduction (95% CI, 35%-88%). The distribution of the number of bradycardia episodes was also different between the 2 groups (P = .007). Further testing showed that the patients in the PE group had a higher risk of multiple bradycardia episodes (≥2 episodes) compared to the NE group (19.6% for PE versus 3.6% for NE; P = .008). The proportion of patients requiring rescue boluses of ephedrine was lower in the NE group compared to the PE group (7.2% for NE versus 21.4% for PE; P < .03; difference [95% CI], -14.3% [-27.0% to -1.6%]). No differences were observed between the 2 groups in the incidence of other secondary outcomes. CONCLUSIONS: When used as an intermittent bolus regimen to prevent and treat spinal-induced hypotension during CD, NE resulted in a significant reduction in the incidence of bradycardia as compared to an equipotent bolus regimen of PE. We conclude that the hemodynamic profile offered by NE during CD is superior to that of PE due to less fluctuations in HR and possibly cardiac output.

A biased coin up-and-down sequential allocation trial to determine the optimum programmed intermittent epidural bolus time interval between 5 mL boluses of bupivacaine 0.125% with fentanyl 2 µg·mL-1.

PURPOSE: The optimal epidural mixtures and settings for programmed intermittent epidural bolus (PIEB) labour analgesia have yet to be determined. A previous study by our group demonstrated that 10 mL boluses of bupivacaine 0.0625% with fentanyl 2 µg·mL-1 administered every 40 min provided effective analgesia during the first stage of labour for 90% of women, without breakthrough pain. We wanted to determine the effective PIEB time interval of 5 mL boluses of bupivacaine 0.125% with fentanyl 2 µg·mL-1 under the same study circumstances, aiming at a future comparative study. METHODS: This double-blind dose-finding study used the biased coin up-and-down sequential allocation method to determine the effective PIEB interval 90% (EI90) needed to provide effective analgesia without breakthrough pain during the first stage of labour. We used fixed 5 mL boluses of bupivacaine 0.125% with fentanyl 2 µg.mL-1 and studied time intervals of 60, 50, 40, and 30 min. The first patient was assigned an interval of 60 min and the remaining intervals were assigned as per the biased coin up-and-down method. RESULTS: The estimated EI90 was 36.5 min (95% confidence interval [CI], 34.0 to 39.0) by the truncated Dixon and Mood method and 34.2 min (95% CI, 30.8 to 41.5) by the isotonic regression method. We found that 20/40 women had an upper sensory block to ice above T6, 34/40 women had no motor block, and no woman required treatment for hypotension. CONCLUSION: The EI90 between 5 mL boluses of bupivacaine 0.125% with fentanyl 2 µg·mL-1 during the first stage of labour is approximately 35 min. TRIAL REGISTRATION: www.clinicaltrials.gov (NCT #02758405); registered 2 May, 2016.

Intraperitoneal Instillation of Lidocaine Improves Postoperative Analgesia at Cesarean Delivery: A Randomized, Double-Blind, Placebo-Controlled Trial.

BACKGROUND: Cesarean delivery is a commonly performed procedure worldwide. Despite improvements in balanced multimodal analgesia, there remains a proportion of women for whom postoperative pain relief and patient satisfaction are still inadequate. Intraperitoneal instillation of local anesthetic has been shown to be effective in reducing postoperative pain after abdominal surgery. We sought to investigate the effect of intraperitoneal instillation of lidocaine on postcesarean delivery pain as part of a multimodal analgesia regimen. METHODS: We studied women scheduled for elective cesarean delivery under spinal anesthesia. Spinal anesthesia was performed with 0.75% hyperbaric bupivacaine, fentanyl, and morphine. At the end of the cesarean delivery, immediately before parietal peritoneum or fascia closure, patients were randomized to receive either lidocaine (20 mL 2% lidocaine with epinephrine) or placebo (20 mL normal saline) instilled into the peritoneal cavity. The primary outcome was pain score on movement at 24 hours. Secondary outcomes were pain score at rest and on movement at 2, 24, and 48 hours; maternal satisfaction score; analgesic consumption; incidence of nausea, vomiting, and itching; and return of bowel function. RESULTS: Two hundred four women were recruited. Baseline characteristics were similar between the lidocaine and placebo groups. Pain scores at 24 hours postcesarean delivery on movement (parameter estimate 0.02 [95% confidence interval {CI} -0.14 to 0.18]; P = .823) and at rest (parameter estimate 0.00 [95% CI -0.32 to 0.33]; P = .986) were similar in both groups. Pain scores at 2 hours postcesarean delivery on movement (parameter estimate -0.58 [95% CI -0.90 to -0.26]; P = .001) and at rest (parameter estimate -1.00 [95% CI -1.57 to -0.43]; P = .001) were lower in the lidocaine group. Subgroup analysis of patients with peritoneum closure revealed significantly lower pain scores at 24 hours on movement (parameter estimate -0.33 [95% CI -0.64 to -0.03]; P = .032) in the lidocaine group. The number of women requesting postoperative opioids for breakthrough pain was significantly lower in the lidocaine group compared with that of the placebo (40 [40%] vs 61 [65%], respectively, relative risk 0.59 [95% CI 0.43-0.81]; P = 0.001). CONCLUSIONS: The use of intraperitoneal instillation of lidocaine improves early postoperative pain management after cesarean delivery. Furthermore, it reduces the number of women requesting systemic opioids in the immediate postpartum period. Women undergoing peritoneal closure may particularly benefit from this intervention.

Norepinephrine Intermittent Intravenous Boluses to Prevent Hypotension During Spinal Anesthesia for Cesarean Delivery: A Sequential Allocation Dose-Finding Study.

BACKGROUND: The use of phenylephrine as the first-line agent for prevention and treatment of maternal hypotension during cesarean delivery (CD) may reduce cardiac output, posing a theoretical risk to mother and fetus. Norepinephrine has been suggested as a potential alternative, because its ß-adrenergic effects might result in greater heart rate and cardiac output than phenylephrine. The use of norepinephrine to prevent and treat hypotension during CD is new, and its use as a bolus has not been fully determined in this context. The purpose of this study was to determine the effective norepinephrine dose, when given as intermittent intravenous (IV) boluses, to prevent postspinal hypotension in 90% of women undergoing elective CD (ED90). METHODS: This was a prospective, double-blind sequential allocation dose-finding study, using the biased coin up-and-down design. Forty-term pregnant women undergoing elective CD under spinal anesthesia received a set intermittent norepinephrine bolus of either 3, 4, 5, 6, 7, or 8 µg every time their systolic blood pressure (SBP) fell to below 100% of baseline. The primary outcome was the success of the norepinephrine regimen to maintain SBP at or above 80% of baseline, from induction of spinal anesthesia to delivery of the fetus. Secondary outcomes included nausea, vomiting, hypertension (SBP > 120% of baseline), bradycardia (<50 bpm), upper sensory level of anesthesia to ice cold and umbilical artery and vein blood gases. The ED90 and 95% confidence intervals (CIs) were estimated using both truncated Dixon and Mood and isotonic regression methods. RESULTS: The estimated ED90 of norepinephrine was 5.49 µg (95% CI, 5.15-5.83) using the truncated Dixon and Mood method and 5.80 µg (95% CI, 5.01-6.59) using the isotonic regression method. CONCLUSIONS: The use of intermittent IV norepinephrine boluses to prevent spinal-induced hypotension in elective CD seems feasible and was not observed to be associated with adverse outcomes. Practically, we suggest an ED90 dose of 6 µg. Further work is warranted to elucidate the comparative effects of intermittent IV bolus doses of phenylephrine and norepinephrine, in terms of efficacy and safety.

Programmed Intermittent Epidural Bolus for Labor Analgesia During First Stage of Labor: A Biased-Coin Up-and-Down Sequential Allocation Trial to Determine the Optimum Interval Time Between Boluses of a Fixed Volume of 10 mL of Bupivacaine 0.0625% With Fentanyl 2 µg/mL.

BACKGROUND: Most studies that have compared programmed intermittent epidural bolus (PIEB) with continuous epidural infusion regimens have included patient-controlled epidural analgesia and/or manual bolus as rescue analgesia for breakthrough pain. Consequently, the optimal time interval between PIEB is yet to be determined. We designed a study to establish the optimal time interval between PIEB of 10 mL of bupivacaine 0.0625% with fentanyl 2 µg/mL to produce effective analgesia in 90% of women during first stage of labor without breakthrough pain. METHODS: We conducted a double-blind sequential allocation trial with a biased-coin up-down design to obtain the effective interval 90% for the PIEB regimen. We included American Society of Anesthesiologists physical status 2-3 nulliparous women at term undergoing spontaneous or induced labor requesting epidural analgesia. An ultrasound-assisted epidural catheter placement was performed at L2/3 or L3/4. A test dose of 3 mL of bupivacaine 0.125% plus fentanyl 3.3 µg/mL was followed by a loading dose of 12 mL of the same solution. PIEB was then started in women whose pain scores achieved Verbal Numerical Rating Score ≤1/10 within 20 minutes after the end of the loading dose. In all subjects, the programmed bolus dose was fixed at 10 mL of bupivacaine 0.0625% with fentanyl 2 µg/mL. The first bolus was delivered 1 hour after the loading dose. The PIEB interval was set at 60 minutes for the first patient and at varying time intervals (60, 50, 40, and 30 minutes; groups 60, 50, 40 and 30, respectively) for the subsequent patients, according to a biased-coin design. The primary outcome was effective analgesia, defined as no requirement for a patient-controlled epidural analgesia or a manual bolus for 6 hours after the initiation of the epidural analgesia or until the patient presented with full cervical dilatation, whichever event occurred first. Pain scores, sensory block levels to ice, degree of motor block, and blood pressure were assessed hourly. RESULTS: We studied 40 women. The estimated effective interval 90% was 42.6 minutes (95% confidence interval 38.9-46.4) using the truncated Dixon and Mood method and 36.8 minutes (95% confidence interval 31.0-49.0) using the Isotonic Regression analysis. Almost 70% of the patients in group 30 presented with sensory block above T6, compared with 44%, 22%, and 11% in groups 40, 50, and 60, respectively. Only patients in group 30 presented with motor blockade. The incidence of hypotension was low in all groups with no treatment required. DISCUSSION: The optimal time interval between PIEB of 10 mL of bupivacaine 0.0625% with fentanyl 2 µg/mL is approximately 40 minutes. Further studies to determine the efficacy of this regimen throughout the entire duration of labor are warranted.

Barriers to collaborative anesthetic care between anesthesiologists and nurses on the labour and delivery unit: a study using a modified Delphi technique.

INTRODUCTION: The practice of obstetrical anesthesia relies on collaborative effort between anesthesiologists and nurses, but teamwork remains a challenge. We sought to identify a consensus on the perceived barriers to collaborative care between anesthesiologists and perinatal nurses in a Canadian tertiary labour and delivery (L&D) unit. METHODS: A cross-sectional consensus-building study was conducted using a modified Delphi technique. We aimed to reach consensus on the barriers to collaborative care as well as to identify the reasons behind the issues and possible interventions. This technique involved conducting four parallel sequential rounds of questionnaires: Round 1 - posing open-ended questions to nurses and anesthesiologists; Round 2 - establishing an initial within-group consensus; Round 3 - conducting a cross-over round to determine the interprofessional consensus and the remaining anesthesia and nursing consensuses; Round 4 - ranking to identify the top three barriers identified by the three consensuses. RESULTS: Twenty-one anesthesiologists and 15 nurses were recruited. Themes of barriers to collaboration included issues on professionalism, availability, dissonance, team coordination, communication, organizational structure, educational gaps, and role clarity. The top two barriers from the interprofessional consensus were communication issues. DISCUSSION: Anesthesiologists and nurses at our tertiary L&D unit identified communication as a major barrier to collaborative care. This study also shows the feasibly of using the modified Delphi technique in L&D units seeking to improve collaborative care.

The effect of an increased pulse width on the pattern of motor response (unilateral versus bilateral) during the Tsui test in labouring parturients: a randomized crossover trial.

BACKGROUND AND OBJECTIVES: The typical response to the Tsui test performed via an epidural catheter placed in the lumbar area is the unilateral motor response of the lower limbs. Studies show that longer pulse widths can stimulate peripheral nerves at a lower threshold current from a farther distance. Therefore, we designed a study to test the hypothesis that epidural catheter stimulation with a 1.0-msec pulse width would increase the incidence of bilateral motor response in parturients when compared with stimulation with a 0.1-msec pulse width. METHODS: Parturients requesting epidural analgesia were recruited into this randomized crossover study. The Tsui test was performed at both pulse widths before and five minutes after an epidural test dose of 2% lidocaine 3 mL. The primary outcome was the motor response pattern (either unilateral or bilateral) to the epidural catheter stimulation at baseline. RESULTS: Twenty women were recruited for the study, which was stopped early due to futility. The rates of unilateral motor response in the 0.1-msec (18/20) and the 1-msec (18/20) group were both 90% (rate difference, 0%; 95% confidence interval [CI], -0.3 to 0.3; P = 1.0). The mean (SD) current required to elicit a motor response at baseline was 4.2 (2.6) mA in the 0.1-msec group and 1.7 (1.1) mA in the 1-msec group (mean difference, 2.5; 95% CI, 1.2 to 2.3; P < 0.001). CONCLUSIONS: The motor response pattern following the stimulation of a lumbar epidural catheter with pulse widths of 0.1 msec or 1 msec is similar and typically unilateral. The threshold current is lower with the 1-msec pulse width stimulus. TRIAL REGISTRATION: www.clinicaltrials.gov, NCT02762149. Registered 2 May 2016.