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.

SNAP-II for prediction of mortality and morbidity in extremely preterm infants.

OBJECTIVE: To determine the specific Score of Neonatal Acute Physiology (SNAP-II) cut-off scores associated with outcomes in extremely preterm infants, and to examine its contribution to predictive models that include nonmodifiable birth predictors. STUDY DESIGN: Retrospective observational study of 9240 infants born at 22-28 weeks' gestation and admitted to the Canadian Neonatal Network from 2010 to 2015. Outcomes included early and hospital mortality, composite of mortality/morbidity and individual morbidities. The SNAP-II cut-off to predict each outcome was determined using the Youden index. Additional contributions were evaluated using a base model that adjusted for gestational age, birth weight z-score and sex and by comparing the area under the curve (AUC). RESULTS: The mortality/morbidity rate was 63% (5859/9240). Specific SNAP-II cut-offs ranged from 12 to 20 and were associated with each adverse outcome. Adding SNAP-II cut-offs to predictive models that included birth variables significantly improved (p < .05) the prediction of early mortality (AUC 0.84 versus 0.79), hospital mortality (AUC 0.80 versus 0.78), mortality/morbidity (AUC 0.76 versus 0.75), and severe neurological injury (AUC 0.69 versus 0.66) but had little or no effect on predictive models for retinopathy of prematurity, bronchopulmonary dysplasia, necrotizing enterocolitis, and nosocomial infection. CONCLUSIONS: SNAP-II cut-offs were independently associated with each adverse outcome and using the proposed SNAP-II cut-offs improved the performance of predictive models for certain short-term outcomes.

Maternal Vascular Malperfusion and Adverse Perinatal Outcomes in Low-Risk Nulliparous Women.

OBJECTIVE: To evaluate the disease burden of placental maternal vascular malperfusion pathology in a low-risk nulliparous population and test the hypothesis that a multiparameter model in the second trimester can predict maternal vascular malperfusion with high precision. METHODS: A single-center, prospective cohort study was conducted in healthy nulliparous women. Maternal vascular malperfusion disease burden was estimated by incidence, relative risk (RR), and population-attributable risk percent. Maternal risk factors, serum biomarkers, Doppler, and placental morphologic ultrasonography were examined in isolation and in combination for prediction of this placental pathology. RESULTS: The incidence of maternal vascular malperfusion pathology was 8.4% (72/856). Women with pathology had higher risk of preeclampsia (8.33% compared with 1.79%; RR 4.67, 95% CI 1.85-11.77%; population-attributable risk 23.6%, 95% CI 16.9-31.6%), small for gestational age (SGA) (47.22% compared with 9.45%; RR 5.00, 95% CI 3.6-6.93%; population-attributable risk 25.2%, 95% CI 22.1-28.5%), and the composite of adverse outcomes (defined as SGA or preeclampsia) (47.22% compared with 10.59%; RR 4.46, 95% CI 3.25-6.13; population-attributable risk 22.5%, 95% CI 19.8-25.5%). The combination of parameters was superior to individual modalities alone in predicting maternal vascular malperfusion, but achieved only moderate precision (area under the curve 0.77, 95% CI 0.71-0.84). CONCLUSION: One in 12 healthy nulliparous women develop maternal vascular malperfusion placental pathology, and these pregnancies had a 4.5 times higher risk of developing preeclampsia or delivering a SGA neonate compared with those without this pathology. A multiparameter model achieved modest precision to predict placental maternal vascular malperfusion. Importantly, in low-risk pregnancies, maternal vascular malperfusion accounts for one fourth of pregnancy outcomes with SGA or preeclampsia. The low population-attributable risk of this placental pathology for SGA and preeclampsia illustrates the importance of discovering novel associations to reduce the disease burden of these pregnancy complications.

Evaluation of the Family Integrated Care model of neonatal intensive care: a cluster randomized controlled trial in Canada and Australia.

BACKGROUND: Admission to the neonatal intensive care unit (NICU) may disrupt parent-infant interaction with adverse consequences for infants and their families. Several family-centered care programs promote parent-infant interaction in the NICU; however, all of these retain the premise that health-care professionals should provide most of the infant's care. Parents play a mainly supportive role in the NICU and continue to feel anxious and unprepared to care for their infant after discharge. In the Family Integrated Care (FICare) model, parents provide all except the most advanced medical care for their infants with support from the medical team. Our hypothesis is that infants whose families complete the FICare program will have greater weight gain and better clinical and parental outcomes compared with infants provided with standard NICU care. METHODS/DESIGN: FICare is being evaluated in a cluster randomized controlled trial among infants born at ≤ 33 weeks' gestation admitted to 19 Canadian, 6 Australian, and 1 New Zealand tertiary-level NICU. Trial enrollment began in April, 2013, with a target sample size of 675 infants in each arm, to be completed by August, 2015. Participating sites were stratified by country, and by NICU size within Canada, for randomization to either the FICare intervention or control arm. In intervention sites, parents are taught how to provide most of their infant's care and supported by nursing staff, veteran parents, a program coordinator, and education sessions. In control sites standard NICU care is provided. The primary outcome is infants' weight gain at 21 days after enrollment, which will be compared between the FICare and control groups using Student's t-test adjusted for site-level clustering, and multi-level hierarchical models accounting for both clustering and potential confounders. Similar analyses will examine secondary outcomes including breastfeeding, clinical outcomes, safety, parental stress and anxiety, and resource use. The trial was designed, is being conducted, and will be reported according to the CONSORT 2010 guidelines for cluster randomized controlled trials. DISCUSSION: By evaluating the impact of integrating parents into the care of their infant in the NICU, this trial may transform the delivery of neonatal care. TRIAL REGISTRATION: NCT01852695 , registered December 19, 2012.

Outcome comparison of very preterm infants cared for in the neonatal intensive care units in Australia and New Zealand and in Canada.

AIM: To compare risk-adjusted neonatal intensive care unit outcomes between regions of similar population demography and health-care systems in Australia-New Zealand and Canada to generate meaningful hypothesis for outcome improvements. METHODS: Retrospective study of data from preterm infants (<32 weeks gestational age) cared for in 29 ANZNN (Australian and New Zealand Neonatal Network) and 26 Canadian Neonatal Network (CNN) intensive care unit admitted between 2005 and 2007. Moribund infants or those with major congenital malformation were excluded. RESULTS: The 9995 ANZNN infants had a higher gestational age (29 vs. 28 weeks, P < 0.0001), lower rate of outborn status (13.2% vs. 19.1%, P < 0.0001) and Apgar score <7 at 5 min (14.8% vs. 21.6%, P < 0.0001) than their 7141 CNN counterparts. After adjustment, ANZNN and CNN infants had a similar likelihood of survival (adjusted odds ratio (AOR) 1.01 (0.88, 1.16)), but ANZNN infants were at lower risk of severe retinopathy (AOR 0.71 (0.61, 0.83)), severe ultrasound neurological injury (AOR 0.68 (0.59, 0.78)), necrotising enterocolitis (AOR 0.65 (0.56, 0.76)), chronic lung disease (AOR 0.67 (0.62, 0.73)) and late-onset sepsis (AOR 0.83 (0.76, 0.91)). ANZNN infants were at a higher risk of pulmonary air leak (AOR 1.20 (1.01, 1.42)), early-onset sepsis (AOR 1.33 (1.02, 1.74)). More ANZNN infants received any respiratory support (AOR 1.27 (1.14, 1.41)) and continuous positive airway pressure as sole respiratory support (AOR 2.50 (2.27, 2.70)). CONCLUSIONS: Despite similarities in settings, ANZNN infants fared better in most measures. Outcome disparities may be related to differences in tertiary service provision, referral and clinical practices.

Anesthesiologists' learning curves for bedside qualitative ultrasound assessment of gastric content: a cohort study.

PURPOSE: Focused assessment of the gastric antrum by ultrasound is a feasible tool to evaluate the quality of the stomach content. We aimed to determine the amount of training an anesthesiologist would need to achieve competence in the bedside ultrasound technique for qualitative assessment of gastric content. METHODS: Six anesthesiologists underwent a teaching intervention followed by a formative assessment; then learning curves were constructed. Participants received didactic teaching (reading material, picture library, and lecture) and an interactive hands-on workshop on live models directed by an expert sonographer. The participants were instructed on how to perform a systematic qualitative assessment to diagnose one of three distinct categories of gastric content (empty, clear fluid, solid) in healthy volunteers. Individual learning curves were constructed using the cumulative sum method, and competence was defined as a 90% success rate in a series of ultrasound examinations. A predictive model was further developed based on the entire cohort performance to determine the number of cases required to achieve a 95% success rate. RESULTS: Each anesthesiologist performed 30 ultrasound examinations (a total of 180 assessments), and three of the six participants achieved competence. The average number of cases required to achieve 90% and 95% success rates was estimated to be 24 and 33, respectively. CONCLUSION: With appropriate training and supervision, it is estimated that anesthesiologists will achieve a 95% success rate in bedside qualitative ultrasound assessment after performing approximately 33 examinations.

Symptom assessment of patients with advanced cancer and AIDS and their family caregivers: the results of a quality-of-life pilot study.

This longitudinal pilot study examined differences in demographic characteristics of 101 patients with advanced illness (cancer, AIDS) and 81 Family caregivers, evaluated the reliability of the Memorial Symptom Assessment Scale for these patients and their family caregivers; obtained preliminary data regarding similarities or differences in the symptom experience oF these patients and their family caregivers and changes in symptoms over time; and identified demographic variables that may be potential covariates related to the symptom experience. All demographic variables were significantly different for patients with advanced cancer and AIDS, and their symptom experience is similar only with regard to psychologic symptoms; however, based on the Memorial Symptom Assessment Scale, cancer and AIDS patients and their family caregivers have similar symptom experiences, indicating the need for palliative care for both patients and family. Further research is needed to establish the reliability of the Memorial Symptom Assessment Scale for use with family caregivers.