Prevalence and factors associated with high-risk gastric contents in women admitted to the maternity unit for childbirth: a prospective multicentre cohort study.

BACKGROUND: This multicentre prospective observational study sought to determine the prevalence and the factors associated with high-risk gastric contents in women admitted to the maternity unit for childbirth, and to identify the clinical situations in which ultrasound assessment of gastric contents would be most helpful (i.e. when the prevalence of high-risk gastric contents is close to 50%). METHODS: Ultrasound assessments of gastric contents were performed within the first hour after admission to the maternity unit. The prevalence of high-risk gastric contents was calculated and variables associated with high-risk gastric contents were identified using logistic regression analyses. RESULTS: A total of 1003 parturients were analysed. The prevalence of high-risk gastric contents was 70% (379/544; 95% confidence interval: 66-74%) in women admitted in spontaneous labour and 65% (646/1003; 95% confidence interval: 61-67%) in the whole cohort. Lower gestational age, increased fasting duration for solids, and elective Caesarean delivery were independently associated with reduced likelihood of high-risk gastric contents. In women admitted in spontaneous labour and in the whole cohort, the prevalence of high-risk gastric contents ranged from 85% to 86% for fasting duration for solids <6 h, 63%-68% for fasting 6-8 h, 54%-55% for fasting 8-12 h, and 47%-51% for fasting ≥12 h. CONCLUSIONS: Around two-thirds of parturients had high-risk gastric contents within the first hour after admission to the maternity unit. Our results suggest that gastric emptying for solids continues in labouring women, and that gastric ultrasound would be most helpful when fasting duration is ≥8 h.

Continuous wound infusion combined with intrathecal morphine for analgesia after Cesarean delivery compared with intrathecal morphine or continuous wound infusion alone.

STUDY REGISTRATION: www. CLINICALTRIALS: gov (NCT02279628); registered 31 October 2014.

Effects of pupillary reflex dilation-guided opioid administration on remifentanil and morphine consumption during laparoscopic surgery: A randomised controlled trial.

BACKGROUND: Analysis of pupillary reflex dilation (PRD) assesses the balance of nociception--antinociception. Laparoscopic surgery induces haemodynamic variations that are misleading. During laparoscopy, PRD guidance helps differentiate haemodynamic changes because of excess nociception from secondary changes related to the reflex release of endocrine factors. OBJECTIVE: The present study evaluated the effect of PRD-guided antinociception on the administration of intra-operative remifentanil and immediate postoperative morphine consumption in patients undergoing elective laparoscopic surgery. DESIGN: The study was a single-blind, randomised controlled trial. SETTING: The study took place at two sites at the University Hospital of Nancy from March 2014 to November 2017. PATIENTS: A total of 100 patients who underwent scheduled laparoscopic surgery were included. INTERVENTIONS: Patients were randomly given remifentanil guided by PRD (PRD-guided) or standard anaesthesia care (control). MAIN OUTCOME MEASURES: The primary outcome was intra-operative remifentanil consumption. Secondary outcomes included morphine consumption in the immediate postoperative period and the number of intra-operative haemodynamic events. RESULTS: Data from 95 patients were analysed. Intraoperative remifentanil consumption was lower in the PRD-guided group than in the control group: median [IQR], 0.09 [0.07 to 0.11] vs. 0.14 [0.12 to 0.16] µg kg-1 min-1, with a mean difference (95% confidence Interval, CI) of 0.048 (0.035 to 0.060) µg kg-1 min-1; P < 0.0001. Morphine consumption was 0.13 [0.1 to 0.5] vs. 0.15 [0.11 to 0.4] mg kg-1 (P  = 0.52) in the PRD-guided and control groups, respectively. The number of hypertensive and tachycardia events was greater in the PRD-guided group than in the control group: Hypertensive events 60.4% vs. 32.6%, relative risk 1.85 (95% CI, 1.24 to 2.84), P = 0.004; tachycardia events 31.6% vs. 4.3%, relative risk 2.09 (95% CI, 1.45 to 2.84), P < 0.001. CONCLUSIONS: When PRD is used to differentiate between haemodynamic events arising from noxious stimuli and those events because of other nonsurgical stimuli, then intra-operative remifentanil administration is reduced intra-operatively during laparoscopic surgery but there was no change in postoperative morphine consumption. TRIAL REGISTRATION: Clinicaltrials.gov NCT02116868.

[Evaluating the learning curve for the transversus abdominal plane block: a prospective observational study]. / Évaluation de la courbe d'apprentissage du bloc du plan transverse abdominal: étude prospective observationnelle.

PURPOSE: Anesthesia is a medical specialty where a large number of technical skills need to be mastered with the learning curve for these skills depending on both the technique and the individual involved. The transversus abdominis plane (TAP) block has demonstrated its effectiveness especially in postoperative analgesia following midline laparotomy. It is usually described as a simple technique even though little is known about the learning curve for this block. The purpose of this study was to determine the learning curve for ultrasound-guided TAP block in anesthesiologists who had no prior experience performing the block. METHODS: This was a prospective observational study performed in gynecological and general surgery patients at the University Hospital Center of Nancy (France) between November 2011 and June 2012. After a short theoretical training, sixresidents were asked to perform, 20 TAP blocks under the supervision of a senior staff physician. The success of the procedure involved the visualization and identification of the different muscle planes, the peritoneum, the tip of the needle, an evaluation of the effectiveness of the block (sensory block), the absence of intervention from the supervisor, the absence of complications, less than three attempts, and a satisfaction score by the supervisor > 7 on a 0-10 rating scale. A learning curve/cummulative summation (LC-CUSUM) was generated. RESULTS: The six residents performed all 20 TAP blocks. All residents had already performed ultrasound-guided procedures. The procedure was considered mastered after performing 16 blocks on average for a 90% success rate. The average time (SD) to complete the block decreased from 6.8 (4.1 min) at the beginning to 2.8 (1.3) min at the end of the study. There was a decrease in the number of repositionings of the needle and in the number of interventions by the supervisor throughout the study. The LC-CUSUM analysis revealed that all residents had acquired the TAP block technique within 20 procedures. CONCLUSION: This study demonstrates that the TAP block can be rapidly mastered even if the learning curve varies due to inter-individual differences in dexterity and in the ease of obtaining the ultrasound images.

Cerebral oximetry assessed by near-infrared spectrometry during preeclampsia: an observational study: impact of magnesium sulfate administration.

OBJECTIVES: To determine the regional cerebral oxygen saturation of hemoglobin (rcSO2) in severe preeclamptic parturients exhibiting neurologic symptoms compared with healthy pregnant women (control) and to describe the effects of MgSO4 infusion on rcSO2 and cerebral and systemic hemodynamic variables. DESIGN: Prospective, observational study. SETTING: Obstetric critical care unit in a university-affiliated hospital. PATIENTS: Twenty severe preeclamptic parturients presenting with neurologic signs before any administration of MgSO4, and 20 control parturients. INTERVENTION: Infusion of MgSO4 in severe preeclamptic patients. MEASUREMENTS AND MAIN RESULTS: We measured rcSO2 using near-infrared spectroscopy, blood flow velocities of the middle cerebral artery, and cardiac output at baseline, 5 minutes, 1 hour, and 6 hours after the MgSO4 bolus (4 g), followed by continuous MgSO4 infusion (1 g/h). These measurements were also obtained in 20 control parturients at baseline and 6 hours. Baseline rcSO2 was significantly lower in the severe preeclamptic group: 61% (56-69) vs 66% (63-71) (p = 0.037). At inclusion, blood pressures were significantly higher in the severe preeclamptic group compared with the control group, whereas cardiac output and transcranial Doppler readings were similar. Five minutes after the MgSO4 bolus infusion, a median increase of 8.6% (3.2-18.1) in rcSO2 was observed (p = 0.007), reaching values of the control group that were maintained up to 6 hours. Blood pressures and systolic velocities of the middle cerebral artery significantly decreased (p < 0.01) after the MgSO4 bolus, whereas cardiac output did not change. The percentage increase in rcSO2 was negatively correlated to the mean blood pressure (r = 0.60, p < 0.0001). CONCLUSION: Cerebral oxygenation impairment can be detected by near-infrared spectroscopy monitoring in severe preeclamptic parturients. These results suggested the presence of disorders in cerebral microcirculation and/or changes in cerebral oxygenation. MgSO4 infusion in patients with severe preeclampsia restored rcSO2 to control levels with no systemic side effects. Further studies are needed to confirm the usefulness of near-infrared spectroscopy monitoring in patients with preeclampsia and to assess the action of other antihypertensive therapies on rcSO2.

Ultrasound assessment of gastric contents prior to placental delivery: A prospective multicentre cohort study.

BACKGROUND: There is ongoing debate regarding the optimal general anaesthetic technique for manual removal of the placenta after vaginal delivery. Using ultrasound examination of the gastric antrum, this study aimed to assess the change in gastric contents during vaginal delivery and to determine the prevalence of stomach at risk for pulmonary aspiration in the immediate postpartum period before placental delivery. METHODS: In this prospective multicentre cohort study, antral ultrasonography was performed at full cervical dilatation within the thirty minutes preceding the beginning of expulsive efforts and after vaginal birth, before placental delivery. High-risk gastric content was defined as the visualisation of any solid content in the antrum or antral cross-sectional area in the semi-recumbent position (SR-CSA) > 608 mm². RESULTS: Twenty-six women were included and analysed. There was a significant decrease in both the proportion of patients with solid gastric content and the SR-CSA between the two-ultrasound examinations. Twenty-one patients (80.8%) exhibited a decrease in the SR-CSA during vaginal delivery. The prevalence of stomach at risk for pulmonary aspiration was significantly lower after vaginal delivery than before vaginal delivery (23.1% vs. 57.7%, P = 0.0004). CONCLUSION: Our results suggest that gastric emptying is at least partially preserved during vaginal birth. Nevertheless, almost a quarter of women did have high-risk gastric content in the immediate postpartum period. Point-of-care antral ultrasonography may be of interest for the fast assessment of the gastric content status when a general anaesthesia is required for manual removal of retained placenta.

Guidelines for the management of women with severe pre-eclampsia.

OBJECTIVE: To provide national guidelines for the management of women with severe pre-eclampsia. DESIGN: A consensus committee of 26 experts was formed. A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. METHODS: The last SFAR and CNGOF guidelines on the management of women with severe pre-eclampsia were published in 2009. The literature is now sufficient for an update. The aim of this expert panel guidelines is to evaluate the impact of different aspects of the management of women with severe preeclampsia on maternal and neonatal morbidities separately. The experts studied questions within 7 domains. Each question was formulated according to the PICO (Patients Intervention Comparison Outcome) model and the evidence profiles were produced. An extensive literature review and recommendations were carried out and analysed according to the GRADE® methodology. RESULTS: The SFAR/CNGOF experts panel provided 25 recommendations: 8 have a high level of evidence (GRADE 1+/-), 9 have a moderate level of evidence (GRADE 2+/-), and for 7 recommendations, the GRADE method could not be applied, resulting in expert opinions. No recommendation was provided for 3 questions. After one scoring round, strong agreement was reached between the experts for all the recommendations. CONCLUSIONS: There was strong agreement among experts who made 25 recommendations to improve practices for the management of women with severe pre-eclampsia.

Sulprostone for postpartum hemorrhage in a parturient with a history of Tako-tsubo cardiomyopathy.

A 32 year old parturient with a history of Tako-tsubo cardiomyopathy, who suffered from postpartum hemorrhage for which sulprostone was administered without any adverse events, is reported. Anesthetic considerations related to the management of patient with a history of Tako-tsubo cardiomyopathy, especially triggers that may cause a recurrence, are described. The potential deleterious effects of sulprostone in a patient with a history of Tako-tsubo cardiomyopathy are discussed.

An evaluation of the cutaneous distribution after obturator nerve block.

UNLABELLED: In 1973, Winnie et al. introduced the inguinal paravascular three-in-one block, which allegedly provides anesthesia of three nerves--the femoral, lateral cutaneous femoral, and obturator nerves--with a single injection. This concept was undisputed until the success of the obturator nerve block was reassessed by using evidence of adductor weakness rather than cutaneous sensory blockade, the latter being variable in its distribution and often absent. We performed this study, therefore, to evaluate the area of sensory loss produced by direct injection of local anesthetic around the obturator nerve. A selective obturator nerve block with 7 mL of 0.75% ropivacaine was performed in 30 patients scheduled for knee surgery. Sensory deficit and adductor strength were evaluated for 30 min by using sensory tests (cold and light-touch perception) and the pressure generated by the patient's squeezing a blood pressure cuff placed between the knees. Subsequently, a three-in-one block was performed, and the sensory deficit was reassessed. The obturator nerve block was successful in 100% of cases. The strength of adductors decreased by 77% +/- 17% (mean +/- SD). In 17 patients (57%), there was no cutaneous contribution of the obturator nerve. The remaining 7 patients (23%) had an area of hypoesthesia (cold sensation was blunt but still present) on the superior part of the popliteal fossa, and the other 6 (20%) had sensory deficit located at the medial aspect of the thigh. The three-in-one block resulted in blockade of the lateral aspect of the thigh in 87% of cases, whereas the anteromedial aspect was always anesthetized. By use of magnetic resonance imaging in eight volunteers, we demonstrated that the obturator nerve has already divided into its two branches at the site of local anesthetic injection. However, the injection of blue dye after having simulated the technique in five cadavers showed that the fluid regularly spread to both branches. We conclude that after three-in-one block, a femoral nerve block may have been assessed as an obturator nerve block in 100% of cases when testing the cutaneous distribution of the obturator nerve on the medial aspect of the thigh. IMPLICATIONS: Previous studies reporting an incidence of obturator nerve block after three-in-one block may have mistaken a femoral nerve block for an obturator nerve block in 100% of cases when the cutaneous distribution of the obturator nerve was assessed on the medial aspect of the thigh. The only way to effectively evaluate obturator nerve function is to assess adductor strength.