Development of the obstetric unanticipated difficult video-laryngoscopy algorithm through a quality improvement randomized open-label in situ simulation study.

BACKGROUND: Video-laryngoscopy is increasingly used during general anesthesia for emergency cesarean deliveries. Given the heightened risk of difficult tracheal intubation in obstetrics, addressing challenges in airway management is crucial. In this simulation study, we hypothesized that using a flexible bronchoscope would lead to securing the airway faster than the Eschmann introducer when either device is used in addition to video-laryngoscopy. METHODS: Twenty-eight anesthesia trainees (n=14/group) were randomized to use either one of the rescue devices and video-recorded in a simulated scenario of emergency cesarean delivery. The primary outcome was the time difference in establishing intubation; secondary outcomes were the differences in incidence of hypoxemia, need for bag and mask ventilation, and failed intubation between the two rescue devices. RESULTS: Mean (±SD) time to intubation using flexible bronchoscopy was shorter compared to using an Eschmann introducer (24 ±â€¯10 vs 86 ±â€¯35 s; P<0.0001; difference in mean 62 seconds, 95% CI 42 to 82 seconds). In the fiberoptic bronchoscopy group, there were no episodes of hypoxemia or need for bag and mask ventilation; in contrast both such events occurred frequently in the Eschmann introducer group (71%, 10/14); P=0.0002). All flexible bronchoscopy-aided intubations were established on the first attempt. The incidence of failed intubation was similar in both groups. CONCLUSIONS: Our data from simulated emergency tracheal intubation suggest that flexible bronchoscopy combined with video-laryngoscopy results in faster intubation time than using an Eschmann introducer combined with video-laryngoscopy.

Dexamethasone for postoperative nausea and vomiting prophylaxis in cesarean delivery and a delayed diagnosis of neonatal congenital adrenal hyperplasia.

The case of a false-negative newborn screen for congenital adrenal hyperplasia in a 37 weeks' gestation 46,XX neonate, thought to be due to maternal administration of dexamethasone intra-operatively prior to umbilical cord clamping, for postoperative nausea and vomiting prophylaxis after neuraxial anesthesia, is described.

Relationship between postpartum mood disorder and birth experience: a prospective observational study.

BACKGROUND: This study aims to investigate the relationship between the birth experience and the risk of developing postpartum depression or post-traumatic stress disorder. METHODS: In this prospective, longitudinal, observational study, women were assessed at different time points for depression and post-traumatic stress disorder. The risk of depression or post-traumatic stress disorder based on patient characteristics and specific birth events was assessed within three months postpartum. RESULTS: We enrolled 600 women; 426 were eligible for postpartum assessment. At six weeks and three months postpartum, 15.9% and 12.7% screened positive for depression respectively. Positive post-traumatic stress disorder screenings at six weeks and three months postpartum were 6.2% and 5.1% respectively. Twenty-seven women (8.3%) with a negative screening at six weeks converted to a positive depression or post-traumatic stress disorder screening at three months. A pre-existing history of anxiety or depression was associated with an increased risk of developing depression (aOR 2.12, 95% CI 1.30 to 3.47) and post-traumatic stress (aOR 3.15, 95% CI 1.42 to 7.02) within three months postpartum. The risk of developing post-traumatic stress disorder within three months postpartum was also increased among patients experiencing their first delivery (aOR 2.55, 95% CI 1.10 to 5.88) or operative management of postpartum hemorrhage (aOR 4.44, 95% CI 1.16 to 17.02). CONCLUSION: Depression and post-traumatic stress symptoms either persisted or had new onset at three months postpartum. Mental health screening and postpartum follow-up after six weeks should be considered in high-risk patients who have a history of psychopathology, nulliparity, or undergo operative management of postpartum hemorrhage.

Risk factors for failed conversion of labor epidural analgesia to cesarean delivery anesthesia: a systematic review and meta-analysis of observational trials.

BACKGROUND: This systematic review and meta-analysis evaluates evidence for seven risk factors associated with failed conversion of labor epidural analgesia to cesarean delivery anesthesia. METHODS: Online scientific literature databases were searched using a strategy which identified observational trials, published between January 1979 and May 2011, which evaluated risk factors for failed conversion of epidural analgesia to anesthesia or documented a failure rate resulting in general anesthesia. RESULTS: 1450 trials were screened, and 13 trials were included for review (n=8628). Three factors increase the risk for failed conversion: an increasing number of clinician-administered boluses during labor (OR=3.2, 95% CI 1.8-5.5), greater urgency for cesarean delivery (OR=40.4, 95% CI 8.8-186), and a non-obstetric anesthesiologist providing care (OR=4.6, 95% CI 1.8-11.5). Insufficient evidence is available to support combined spinal-epidural versus standard epidural techniques, duration of epidural analgesia, cervical dilation at the time of epidural placement, and body mass index or weight as risk factors for failed epidural conversion. CONCLUSION: The risk of failed conversion of labor epidural analgesia to anesthesia is increased with an increasing number of boluses administered during labor, an enhanced urgency for cesarean delivery, and care being provided by a non-obstetric anesthesiologist. Further high-quality studies are needed to evaluate the many potential risk factors associated with failed conversion of labor epidural analgesia to anesthesia for cesarean delivery.