How I manage major hemorrhage.

Acute hemorrhage can be a life-threatening emergency that is complex in its management and affects many patient populations. The last 15 years has seen the introduction of comprehensive massive hemorrhage protocols, wider use of viscoelastic testing, new coagulation factor products, and the publication of robust randomized controlled trials in diverse bleeding patient populations. Although gaps continue to exist in the evidence-base for several aspects of patient care, there is now sufficient evidence to allow for an individualized hemostatic response based on the type of bleeding and specific hemostatic defects. We present three clinical cases that highlight some of the challenges in acute hemorrhage management, focusing on the importance of inter-professional communication, rapid provision of hemostatic resuscitation, repeated measures of coagulation, immediate administration of tranexamic acid, and prioritization of surgical or radiologic control of hemorrhage. This article provides a framework for the clear and collaborative conversation between the bedside clinical team and the consulting hematologist to achieve prompt and targeted hemostatic resuscitation. In addition to providing consultations on the hemostatic management of individual patients, the hematology service must be involved in setting hospital policies for the prevention and management of patients with major hemorrhage.

Lived experiences of transgender and nonbinary people in the perioperative context: a qualitative study.

BACKGROUND: Transgender and nonbinary (TNB) people experience obstacles that create barriers to accessing health care, including stigmatization and health inequities. Our intention was to describe the lived experiences of TNB patients and identify potential gaps in the education of health care professionals. METHODS: We conducted a qualitative descriptive study influenced by phenomenology by interviewing with TNB adults who underwent surgery in Canada within the previous 5 years. We recruited participants using purposeful and snowball sampling via online social networking sites. Audio recordings were transcribed. Two authors coded the transcripts and derived the themes. RESULTS: We interviewed 21 participants, with a median interview duration of 49 minutes. Participants described positive and negative health care encounters that led to stress, confusion, and feelings of vulnerability. Major themes included having to justify their need for health care in the face of structural discrimination; fear and previous traumatic experiences; community as a source of support and information; and the impact of interactions with health care professionals. INTERPRETATION: Participants detailed barriers to accessing care, struggled to participate in shared decision-making, and desired trauma-informed care principles; they described strength in community and positive interactions with health care professionals, although barriers to accessing gender-affirming care often overshadowed other aspects of the perioperative experience. Additional research, increased education for health care professionals, and policy changes are necessary to improve access to competent care for TNB people.

An Innovative Approach to Determine Programmed Intermittent Epidural Bolus Pump Settings for Labor Analgesia: A Randomized Controlled Trial.

BACKGROUND: Three settings are required on a programmed intermittent epidural bolus (PIEB) pump for labor analgesia: the PIEB next bolus (PIEBnb), PIEB interval (PIEBi), and PIEB volume (PIEBv). The ideal settings for these parameters are still unknown. We hypothesized a mathematical modeling tool, response surface methodology (RSM), could estimate 3 PIEB pump parameters while balancing 3 clinically important patient outcomes simultaneously. The study objective was to use RSM to estimate PIEB settings (PIEBnb, PIEBi, and PIEBv) while maximizing maternal satisfaction, minimizing the need for clinician-administered boluses, and optimizing the ratio of delivered/requested patient-controlled epidural analgesia (PCEA) boluses simultaneously. METHODS: With institutional ethics approval, a double-blind randomized trial was completed in a tertiary care labor and delivery center. Nulliparous, English-speaking American Society of Anesthesiologists (ASA) physical status II patients aged 18 to 45 years at full term, single gestation in vertex presentation, in spontaneous labor and ≤7 cm cervical dilation were included. Patients with comorbidities, contraindications to neuraxial analgesia, using chronic analgesics, <152 cm, or body mass index (BMI) >45 kg/m2 were excluded. After informed consent, labor analgesia was initiated using 10 mL ropivacaine 0.2% with 10 µg/mL fentanyl solution and PCEA (volume 6 mL every 10 minutes). Patients were randomized to predetermined PIEB settings. RSM identified 3 pump settings that represented a stationary point that best maximized or minimized 3 outcomes simultaneously: PCEA ratio (a ratio closest to 1), clinician bolus (optimal is 0), and maternal satisfaction (visual analog scale, 0-100, ideal response is ≥90). RESULTS: Of 287 potential participants, 192 did not meet inclusion criteria or declined to participate, and 26 were withdrawn, leaving 69 patients for study inclusion. Using RSM, the suggested PIEB settings for all the primary study outcomes were as follows: PIEBnb = 29.4 minutes, PIEBi = 59.8 minutes, and PIEBv = 6.2 mL. These PIEB settings corresponded to the following clinical outcomes: maternal satisfaction at 93.9%, PCEA ratio at 0.77, and need for clinician bolus at 0.29. The dermatome sensory score was between T10 and T5 in 89% of the patients. The median lowest Bromage score was 4. CONCLUSIONS: This novel study used a mathematical model to estimate PIEB pump settings while simultaneously maximizing 3 clinical outcomes. Equally weighted clinical outcomes prevent maximal outcome optimization and may not reflect patient priorities. Future studies or quality improvement endeavors could use RSM methodology to estimate PIEB pump settings targeting optimal values for a single clinical outcome of determined importance to parturients.

Modern labor epidural analgesia: implications for labor outcomes and maternal-fetal health.

Epidural analgesia is an important means of pain control during labor throughout the world. Over its historic development, it has been implicated in several undesirable outcomes, including prolongation of labor and increased need for operative delivery. These effects have emerged in some retrospective and observational studies, but such methods of investigation are highly prone to bias and are particularly ill-suited for the study of labor analgesia. In high-quality studies, including Cochrane reviews and meta-analyses, epidural analgesia has been suggested to extend the first stage of labor by 30 minutes and the second stage by 15 minutes, when compared with alternative forms of analgesia. Although this may be a reproducible effect, it may be argued that it is clinically negligible. With respect to mode of delivery, similar high-quality studies have consistently shown no increased risk of cesarean delivery associated with epidural analgesia. Some forms of epidural analgesia were associated with higher risk of assisted vaginal delivery, but the use of newer modalities has been shown to abolish this effect. Specific advancements have centered on reducing total anesthetic consumption, given that local anesthetic-induced motor block is theorized to interfere with maternal expulsive efforts in the second stage of labor. These measures include the use of low-concentration local anesthetic solutions equivalent to ≤0.1% bupivacaine, shown in meta-analyses to lead to no higher risk of assisted vaginal delivery relative to nonepidural analgesia. Additional advancements in the maintenance of analgesia include programmed intermittent epidural bolus and patient-controlled epidural analgesia, the combination of which has been shown to reduce the risk of assisted vaginal delivery, also likely mediated by reduction in local anesthetic dose. These techniques have gained popularity in the past two decades, such that studies published since 2005 show no higher risk of assisted vaginal delivery with epidural than with opioid analgesia (as reported in a Cochrane review). Labor epidural analgesia has implications for maternal and fetal health perinatally. It is known to result in transient maternal hypotension (particularly with initiation), which may progress to the level of necessitating fluid or vasopressor therapy. This is not clearly associated with any adverse outcomes. There is also a consistently higher incidence of fever in parturients receiving neuraxial anesthesia, likely of noninfectious origin, which has similarly not been associated with adverse neonatal outcomes. Finally, neonates of parturients who receive epidural analgesia have been shown to have no worse Apgar scores and more favorable acid-base status than their counterparts. These observations should serve to reassure providers that modern labor analgesia, as currently understood, is not consistently associated with any significant adverse outcomes for the parturient or fetus. In this review, we describe variations of modern labor epidural analgesia, conduct an in-depth review of current literature on its use, and explore the most up-to-date evidence on its implications for the progression and outcomes of labor, including the pertinent maternal and fetal side effects.

The association between labour epidural analgesia and postpartum depression in primiparous patients: a historical cohort study.

PURPOSE: Peripartum pain has been associated with postpartum depression (PPD), and labour epidural analgesia (LEA) may be able to modify this risk. The objective of this historical cohort study was to examine the association between LEA and PPD among primiparous patients. METHODS: With institutional research ethics board approval, a provincial perinatal database was searched for primiparous patients who delivered a liveborn singleton infant between 2004 and 2018. Those patients who experienced PPD following their first delivery were identified by a history of PPD in the perinatal records of their second pregnancy. We used logistic regression to compute odds ratios (ORs) for the association between LEA and PPD and performed an adjusted analysis to control for confounding variables. RESULTS: A total of 35,437 primiparous patients were identified, 67% (n = 23,599) of whom received LEA. In the cohort, 3.7% (n = 1,296) of patients developed PPD. Patients who received LEA had increased odds of developing PPD compared with patients who did not receive LEA (adjusted OR, 1.29; 95% confidence interval [CI], 1.12 to 1.48). In a multivariable regression model, LEA remained a significant predictor for PPD, as did body mass index, pre-existing anxiety, and maternal antidepressant use. CONCLUSION: This historical cohort study found an association between LEA and PPD among primiparous patients who subsequently had a second pregnancy in the same province. The findings call into question the hypothesis that LEA decreases the risk for PPD and further illustrates the complexities of PPD.

RéSUMé: OBJECTIF: La douleur péripartum a été associée à la dépression post-partum (DPP), et l'analgésie péridurale obstétricale (APO) pourrait modifier ce risque. L'objectif de cette étude de cohorte historique était d'examiner l'association entre l'APO et la DPP chez les primipares. MéTHODE: Après avoir obtenu l'approbation du comité d'éthique de la recherche de l'établissement, une base de données périnatale provinciale a été consultée pour trouver des personnes primipares qui ont accouché d'un seul enfant vivant né entre 2004 et 2018. Les primipares qui ont présenté une DPP après leur premier accouchement ont été identifiées par la présence d'antécédents de DPP dans les dossiers périnataux de leur deuxième grossesse. Nous avons utilisé la régression logistique pour calculer les rapports de cotes (RC) pour l'association entre l'APO et la DPP et réalisé une analyse ajustée pour tenir compte des variables de confusion. RéSULTATS: Au total, nous avons identifié 35 437 personnes primipares, dont 67 % (n = 23 599) ont bénéficié d'une APO. Dans la cohorte, 3,7 % (n = 1296) ont manifesté une DPP. Les personnes ayant reçu une APO présentaient un risque accru de développer une DPP par rapport aux primipares qui n'avaient pas reçu d'APO (RC ajusté, 1,29; intervalle de confiance [IC] à 95 %, 1,12 à 1,48). Dans un modèle de régression multivariée, l'APO est restée un prédicteur significatif de DPP, tout comme l'indice de masse corporelle, une anxiété préexistante et l'utilisation maternelle d'antidépresseurs. CONCLUSION: Cette étude de cohorte historique a révélé une association entre l'APO et la DPP chez les personnes primipares qui ont par la suite eu une deuxième grossesse dans la même province. Les résultats remettent en question l'hypothèse selon laquelle l'APO diminue le risque de DPP et illustre davantage les complexités de la DPP.

Racial and ethnic disparities in obstetric anesthesia: a scoping review.

PURPOSE: Health disparities continue to affect racial and ethnic marginalized obstetric patients disproportionally with increased risk of Cesarean delivery and pregnancy-related death. Yet, the literature on what influences such disparities in obstetric anesthesia service and its clinical outcomes is less well known. We set out to describe racial and ethnic disparities in obstetric anesthesia during the peripartum period in the USA via a scoping review of the recent literature. SOURCE: Using the Institute of Medicine's definition of disparities, we searched the National Library of Medicine's PubMed/Medline, Embase, Web of Science, APA PsycINFO, and Google Scholar for articles published between 1 January 2000 and 30 June 2022 to identify literature on racial and ethnic disparities in obstetric anesthesia. PRINCIPAL FINDINGS: Out of 8,432 articles reviewed, 15 met our inclusion criteria. All but one study was observational. Seven studies were single-institutional while the remaining used multicentre data/databases. All studies compared two or more race and ethnicity classifications. Studies in this review described disparities in the use of labour epidural analgesia, labour epidural request timing, anesthesia for Cesarean deliveries, postpartum pain management, and epidural blood patch for postdural puncture headaches. Several studies reported disparities observed in the unadjusted models becoming no longer significant when adjusted for other covariates. CONCLUSION: Based on the findings of the present scoping review on racial and ethnic disparities in obstetric anesthesia, we present an evidence map identifying knowledge gaps and propose a future research agenda.

RéSUMé: OBJECTIF: Les disparités en matière de santé continuent d'affecter de manière disproportionnée les patient·es en obstétrique marginalisé·es sur le plan racial et ethnique, avec un risque accru d'accouchement par césarienne et de décès lié à la grossesse. Pourtant, la littérature sur ce qui influence de telles disparités dans les services d'anesthésie obstétricale et leurs issues cliniques est moins bien connue. Notre objectif était de décrire les disparités raciales et ethniques en matière d'anesthésie obstétricale au cours de la période péripartum aux États-Unis via une étude de portée de la littérature récente. SOURCES: En utilisant la définition des disparités de l'Institute of Medicine, nous avons effectué des recherches dans les bases de données PubMed/Medline de la National Library of Medicine, Embase, Web of Science, APA PsycINFO et Google Scholar pour trouver des articles publiés entre le 1er janvier 2000 et le 30 juin 2022, afin d'identifier la littérature sur les disparités raciales et ethniques en anesthésie obstétricale. CONSTATATIONS PRINCIPALES: Sur 8432 articles examinés, 15 répondaient à nos critères d'inclusion. Toutes les études sauf une étaient observationnelles. Sept études étaient monocentriques tandis que les autres utilisaient des données/bases de données multicentriques. Toutes les études comparaient deux classifications de race et d'origine ethnique ou plus. Les études de cette revue décrivaient des disparités dans l'utilisation de l'analgésie péridurale obstétricale, le moment de la demande pour une péridurale obstétricale, l'anesthésie pour les accouchements par césarienne, la prise en charge de la douleur post-partum et les injections de sang autologue en péridural pour les céphalées post-ponction durale. Plusieurs études ont fait état de disparités observées dans les modèles non ajustés qui n'étaient plus significatives lors de l'ajustement pour tenir compte d'autres covariables. CONCLUSION: Sur la base des résultats de cette étude de portée sur les disparités raciales et ethniques en anesthésie obstétricale, nous présentons une carte des données probantes identifiant les lacunes dans les connaissances et proposons un futur programme de recherche.

Development of obstetric anesthesia core competencies for USA residency programs through a Delphi process.

PURPOSE: The standard for anesthesia residency training in the USA mainly relies on the Accreditation Council for Graduate Medical Education (ACGME) Outcome Project, a framework that lacks specific directives for subspecialties including obstetric anesthesia. We aimed to identify core competencies in obstetric anesthesiology that can be adapted to different residency training programs to help improve the quality of training and accountability of the institutions within the USA. METHODS: We identified a preliminary list of competencies from review of existing competency-based obstetric anesthesia training curricula and practice guidelines. We used a modified Delphi methodology to achieve expert consensus among members of the Society for Obstetric Anesthesia and Perinatology education committee. The panellists were asked to evaluate the importance of each competency using a five-point Likert scale, with consensus after two rounds defined at 80% agreement. The responders were also asked at which level of training each competency should be attained. RESULTS: The Delphi rounds had 75% response rate and derived 94 competencies that were categorized under the six ACGME domains: patient care (38), medical knowledge (45), system-based practice (two), practice-based learning and improvement (five), interpersonal communication skills (two), and professionalism (two). CONCLUSION: We generated a residency training competency list for obstetric anesthesiology through expert consensus. This list can be used by residency training programs to develop a structured competency-based curriculum with tangible milestones, thereby reducing heterogeneity in the standard of training.

RéSUMé: OBJECTIF: La norme pour la formation en résidence en anesthésie aux États-Unis repose principalement sur le Projet de résultats (Outcome Project) de l'Accreditation Council for Graduate Medical Education (ACGME), un cadre qui ne dispose pas de directives spécifiques pour les surspécialités, notamment pour l'anesthésie obstétricale. Notre objectif était d'identifier les compétences de base en anesthésiologie obstétricale qui pourraient être adaptées aux différents programmes de formation en résidence afin d'améliorer la qualité de la formation et la responsabilisation des établissements aux États-Unis. MéTHODE: Nous avons dressé une liste préliminaire de compétences en passant en revue les programmes de formation axés sur les compétences et les lignes directrices de pratique existants en anesthésie obstétricale. Nous avons utilisé une méthodologie Delphi modifiée pour parvenir à un consensus d'expert·es parmi les membres du comité d'éducation de la Society for Obstetric Anesthesia and Perinatology. Les panélistes ont été invité·es à évaluer l'importance de chaque compétence à l'aide d'une échelle de Likert à cinq points, le consensus étant défini à 80 % d'accord après deux tours. On a également demandé aux répondant·es à quel niveau de formation chaque compétence devrait être atteinte. RéSULTATS: Les étapes du processus Delphi ont eu un taux de réponse de 75 % et ont permis de déterminer 94 compétences qui ont été classées dans les six domaines ACGME : soins aux patient·es (38), connaissances médicales (45), pratique systémique (deux), apprentissage et amélioration basés sur la pratique (cinq), compétences en communication interpersonnelle (deux) et professionnalisme (deux). CONCLUSION: Nous avons généré une liste de compétences pour la formation de résidence en anesthésiologie obstétricale grâce à un consensus d'expert·es. Cette liste peut être utilisée par les programmes de formation en résidence pour élaborer un programme structuré axé sur les compétences avec des jalons tangibles, réduisant ainsi l'hétérogénéité dans la norme de formation.

A Systematic Scoping Review of Peridelivery Pain Management for Pregnant People With Opioid Use Disorder: From the Society for Obstetric Anesthesia and Perinatology and Society for Maternal Fetal Medicine.

The prevalence of pregnant people with opioid use disorder (OUD), including those receiving medications for opioid use disorder (MOUD), is increasing. Challenges associated with pain management in people with OUD include tolerance, opioid-induced hyperalgesia, and risk for return to use. Yet, there are few evidence-based recommendations for pain management in the setting of pregnancy and the postpartum period, and many peripartum pain management studies exclude people with OUD. This scoping review summarized the available literature on peridelivery pain management in people with OUD, methodologies used, and identified specific areas of knowledge gaps. PubMed and Embase were comprehensively searched for publications in all languages on peripartum pain management among people with OUD, both treated with MOUD and untreated. Potential articles were screened by title, abstract, and full text. Data abstracted were descriptively analyzed to map available evidence and identify areas of limited or no evidence. A total of 994 publications were imported for screening on title, abstracts, and full text, yielding 84 publications identified for full review: 32 (38.1%) review articles, 14 (16.7%) retrospective studies, and 8 (9.5%) case reports. There were 5 randomized controlled trials. Most studies (64%) were published in perinatology (32; 38.1%) journals or anesthesiology (22; 26.2%) journals. Specific areas lacking trial or systematic review evidence include: (1) methods to optimize psychological and psychosocial comorbidities relevant to acute pain management around delivery; (2) alternative nonopioid and nonpharmacologic analgesia methods; (3) whether or not to use opioids for severe breakthrough pain and how best to prescribe and monitor its use after discharge; (4) monitoring for respiratory depression and sedation with coadministration of other analgesics; (5) optimal neuraxial analgesia dosing and adjuncts; and (6) benefits of abdominal wall blocks after cesarean delivery. No publications discussed naloxone coprescribing in the labor and delivery setting. We observed an increasing number of publications on peripartum pain management in pregnant people with OUD. However, existing published works are low on the pyramid of evidence (reviews, opinions, and retrospective studies), with a paucity of original research articles (<6%). Opinions are conflicting on the utility and disutility of various analgesic interventions. Studies generating high-quality evidence on this topic are needed to inform care for pregnant people with OUD. Specific research areas are identified, including utility and disutility of short-term opioid use for postpartum pain management, role of continuous wound infiltration and truncal nerve blocks, nonpharmacologic analgesia options, and the best methods to support psychosocial aspects of pain management.

A survey of labour epidural practices at obstetric anesthesia fellowship programs in the United States.

PURPOSE: Labour epidural analgesia (LEA) is an evolving field. Various neuraxial techniques and dosing regimens are available to the modern obstetric anesthesia provider, allowing for significant practice variability. To begin a search for consensus on optimal care, we sought to query fellowship training practices for LEA. METHODS: We conducted an electronic survey of institutions with American Council for Graduate Medical Education-accredited obstetric anesthesiology fellowship programs. We studied the frequency of epidural initiation techniques, including combined spinal epidural (CSE), dural puncture epidural, and epidural bolus. For maintenance techniques, we appraised the use of continuous epidural infusion, programmed intermittent bolus (PIEB), and patient-controlled epidural analgesia (PCEA). RESULTS: Of 40 institutions surveyed, we received 32 responses (80% response rate). Twenty-eight of 40 (70%) were included in the analysis. A plurality of institutions (12/28; 43%) preferred CSE, and among those who used CSE, 23/27 (85%) included intrathecal opioids. A majority of institutions used protocols with PIEB (55%), while almost all (92%) used PCEA. Most participants (88%) reported using dilute concentration maintenance infusions of 0.1% bupivacaine/ropivacaine or less. CONCLUSION: Despite significant variability in LEA practice, some clear patterns emerged in our survey, including preference for opioid-containing CSE and maintenance with PIEB, PCEA, and dilute epidural solutions.

RéSUMé: OBJECTIF: L'analgésie péridurale obstétricale (APO) est un domaine en évolution. Diverses techniques neuraxiales et posologies sont disponibles pour le praticien en anesthésie obstétricale moderne, ce qui permet une variabilité significative de la pratique. Pour démarrer une recherche de consensus sur les soins optimaux, nous avons cherché à déterminer les pratiques d'APO dans le cadre de formation des fellows. MéTHODE: Nous avons réalisé une enquête électronique auprès d'établissements possédant des programmes de fellowship en anesthésiologie obstétricale accrédités par l'American Council for Graduate Medical Education. Nous avons étudié la fréquence des techniques de péridurale, notamment de rachi-péridurale combinée (RPC), de péridurale avec ponction durale et de bolus péridural. Pour les techniques de maintien, nous avons évalué l'utilisation de l'analgésie péridurale par perfusion continue, l'administration programmée de bolus périduraux (PIEB; programmed intermittent epidural bolus) et l'analgésie péridurale contrôlée par la patiente (APCP). RéSULTATS: Sur les 40 établissements sondés, nous avons reçu 32 réponses (taux de réponse de 80 %). Vingt-huit des 40 (70 %) établissements ont été inclus dans l'analyse. Plusieurs institutions (12/28; 43 %) ont répondu qu'elles préféraient la RPC, et parmi celles qui utilisaient la RPC, 23/27 (85 %) incluaient des opioïdes intrathécaux. La majorité des établissements utilisaient des protocoles avec le PIEB (55 %), tandis que presque tous (92 %) utilisaient l'APCP. La plupart des établissements participants (88 %) ont rapporté utiliser des perfusions de maintien à des concentrations diluées de bupivacaïne/ropivacaïne de 0,1 % ou moins. CONCLUSION: Malgré une variabilité significative dans la pratique de l'APO, certaines tendances claires ont émergé dans notre sondage, notamment une préférence pour les RPC contenant des opioïdes et le maintien avec un PIEB, une APCP et des solutions péridurales diluées.

Postoperative mortality risk prediction that incorporates intraoperative vital signs: development and internal validation in a historical cohort.

PURPOSE: Accurate risk reassessment after surgery is crucial for postoperative planning for monitoring and disposition. Existing postoperative mortality risk prediction models using preoperative features do not incorporate intraoperative hemodynamic derangements that may alter risk stratification. Intraoperative vital signs may provide an objective and readily available prognostic resource. Our primary objective was to derive and internally validate a logistic regression (LR) model by adding intraoperative features to established preoperative predictors to predict 30-day postoperative mortality. METHODS: Following Research Ethics Board approval, we analyzed a historical cohort that included patients aged ≥ 45 undergoing noncardiac surgery with an overnight stay at two tertiary hospitals (2013 to 2017). Features included intraoperative vital signs (blood pressure, heart rate, end-tidal carbon dioxide partial pressure, oxygen saturation, and temperature) by threshold and duration of exposure, as well as patient, surgical, and anesthetic factors. The cohort was divided temporally 75:25 into derivation and validation sets. We constructed a multivariable LR model with 30-day all-cause mortality as the outcome and evaluated performance metrics. RESULTS: There were 30,619 patients in the cohort (mean [standard deviation] age, 66 [11] yr; 50.2% female; 2.0% mortality). In the validation set, the primary LR model showed a c-statistic of 0.893 (99% confidence interval [CI], 0.853 to 0.927), a Nagelkerke R-squared of 0.269, a scaled Brier score of 0.082, and an area under precision-recall curve of 0.158 (baseline 0.017 for an uninformative model). The addition of intraoperative vital signs to preoperative factors minimally improved discrimination and calibration. CONCLUSION: We derived and internally validated a model that incorporated vital signs to improve risk stratification after surgery. Preoperative factors were strongly predictive of mortality risk, and intraoperative predictors only minimally improved discrimination. External and prospective validations are needed. STUDY REGISTRATION: www. CLINICALTRIALS: gov (NCT04014010); registered on 10 July 2019.

RéSUMé: OBJECTIF: Une réévaluation précise des risques après la chirurgie est cruciale pour la planification postopératoire du monitorage et du congé. Les modèles existants de prédiction du risque de mortalité postopératoire utilisant des caractéristiques préopératoires n'intègrent pas les perturbations hémodynamiques peropératoires, lesquelles pourraient modifier la stratification du risque. Les signes vitaux peropératoires peuvent fournir une ressource pronostique objective et facilement disponible. Notre objectif principal était de dériver et de valider en interne un modèle de régression logistique (RL) en ajoutant des caractéristiques peropératoires aux prédicteurs préopératoires établis pour prédire la mortalité postopératoire à 30 jours. MéTHODE: À la suite de l'approbation du Comité d'éthique de la recherche, nous avons analysé une cohorte historique qui comprenait des patients âgés de ≥ 45 ans bénéficiant d'une chirurgie non cardiaque avec un séjour d'une nuit dans deux hôpitaux tertiaires (2013 à 2017). Les caractéristiques comprenaient les signes vitaux peropératoires (tension artérielle, fréquence cardiaque, pression télé-expiratoire en CO2, saturation en oxygène et température) par seuil et durée d'exposition, ainsi que des facteurs propres au patient, chirurgicaux et anesthésiques. La cohorte a été divisée temporellement 75:25 en ensembles de dérivation et de validation. Nous avons élaboré un modèle de RL multivariée avec la mortalité toutes causes confondues à 30 jours comme critère, et évalué les mesures de performance. RéSULTATS: Il y avait 30 619 patients dans la cohorte (âge moyen [écart type], 66 [11] ans; 50,2 % de femmes; 2,0 % de mortalité). Dans l'ensemble de validation, le modèle de RL primaire a montré une statistique c de 0,893 (intervalle de confiance [IC] à 99 %, 0,853 à 0,927), un R carré de Nagelkerke de 0,269, un score de Brier mis à l'échelle de 0,082 et une aire sous la courbe de rappel et précision de 0,158 (ligne de base 0,017 pour un modèle non informatif). L'ajout de signes vitaux peropératoires aux facteurs préopératoires a amélioré de façon minimale la discrimination et l'étalonnage. CONCLUSION: Nous avons dérivé et validé en interne un modèle qui incorporait des signes vitaux pour améliorer la stratification des risques après la chirurgie. Les facteurs préopératoires étaient fortement prédictifs du risque de mortalité, et les prédicteurs peropératoires n'ont que que très peu amélioré la discrimination. Une validation externe et prospective est nécessaire. ENREGISTREMENT DE L'éTUDE: www.ClinicalTrials.gov (NCT04014010); enregistrée le 10 juillet 2019.

The Society for Obstetric Anesthesia and Perinatology Coronavirus Disease 2019 Registry: An Analysis of Outcomes Among Pregnant Women Delivering During the Initial Severe Acute Respiratory Syndrome Coronavirus-2 Outbreak in the United States.

BACKGROUND: Early reports associating severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection with adverse pregnancy outcomes were biased by including only women with severe disease without controls. The Society for Obstetric Anesthesia and Perinatology (SOAP) coronavirus disease 2019 (COVID-19) registry was created to compare peripartum outcomes and anesthetic utilization in women with and without SARS-CoV-2 infection delivering at institutions with widespread testing. METHODS: Deliveries from 14 US medical centers, from March 19 to May 31, 2020, were included. Peripartum infection was defined as a positive SARS-CoV-2 polymerase chain reaction test within 14 days of delivery. Consecutive SARS-CoV-2-infected patients with randomly selected control patients were sampled (1:2 ratio) with controls delivering during the same day without a positive test. Outcomes were obstetric (eg, delivery mode, hypertensive disorders of pregnancy, and delivery <37 weeks), an adverse neonatal outcome composite measure (primary), and anesthetic utilization (eg, neuraxial labor analgesia and anesthesia). Outcomes were analyzed using generalized estimating equations to account for clustering within centers. Sensitivity analyses compared symptomatic and asymptomatic patients to controls. RESULTS: One thousand four hundred fifty four peripartum women were included: 490 with SARS-CoV-2 infection (176 [35.9%] symptomatic) and 964 were controls. SARS-CoV-2 patients were slightly younger, more likely nonnulliparous, nonwhite, and Hispanic than controls. They were more likely to have diabetes, obesity, or cardiac disease and less likely to have autoimmune disease. After adjustment for confounders, individuals experiencing SARS-CoV-2 infection exhibited an increased risk for delivery <37 weeks of gestation compared to controls, 73 (14.8%) vs 98 (10.2%) (adjusted odds ratio [aOR], 1.47; 95% confidence interval [CI], 1.03-2.09). Effect estimates for other obstetric outcomes and the neonatal composite outcome measure were not meaningfully different between SARS-CoV-2 patients versus controls. In sensitivity analyses, compared to controls, symptomatic SARS-CoV-2 patients exhibited increases in cesarean delivery (aOR, 1.57; 95% CI, 1.09-2.27), postpartum length of stay (aOR, 1.89; 95% CI, 1.18-2.60), and delivery <37 weeks of gestation (aOR, 2.08; 95% CI, 1.29-3.36). These adverse outcomes were not found in asymptomatic women versus controls. SARS-CoV-2 patients (asymptomatic and symptomatic) were less likely to receive neuraxial labor analgesia (aOR, 0.52; 95% CI, 0.35-0.75) and more likely to receive general anesthesia for cesarean delivery (aOR, 3.69; 95% CI, 1.40-9.74) due to maternal respiratory failure. CONCLUSIONS: In this large, multicenter US cohort study of women with and without peripartum SARS-CoV-2 infection, differences in obstetric and neonatal outcomes seem to be mostly driven by symptomatic patients. Lower utilization of neuraxial analgesia in laboring patients with asymptomatic or symptomatic infection compared to patients without infection requires further investigation.

The association between labour epidural analgesia and postpartum depressive symptoms: a longitudinal cohort study.

BACKGROUND: Pain is a risk factor for postpartum depression (PPD) and labour epidural analgesia (LEA) may lower the incidence of PPD. We evaluated depressive symptoms risk at three, six, and 12 months postpartum in women with LEA compared with women without LEA. METHODS: With ethics approval, hypotheses were tested using data from a longitudinal prospective observational cohort study between January 2015 and January 2019 in nulliparous women aged ≥ 18 yr with uncomplicated, singleton pregnancies. Email surveys were completed at baseline (18-20 weeks' gestation) and at three-, six- and 12 months postpartum, including the Edinburgh Postpartum Depression Scale (EPDS). Maternal, infant, and anesthesia characteristics were abstracted from electronic databases. The EPDS scores at three, six, and 12 months postpartum were analyzed using generalized estimating equations with and without covariates. RESULTS: Of the 909 women who consented to participate, 709 women were included in the study. Antenatal EPDS scores, not LEA, predicted postpartum depressive symptom risk (P < 0.001). The adjusted 95% confidence intervals suggest mean EPDS scores differ from 1.0 point lower in the LEA group at 12 months to 1.5 points higher in the no LEA group at three months on its 0-30 scale. All the confidence intervals included zero at three, six, and 12 months, so were considered non-significant (P > 0.05). CONCLUSION: This study did not identify an association between LEA and risk of depressive symptoms postpartum, although small mean differences between groups cannot be ruled out. Future studies should focus on other modifiable variables that influence the development of PPD.

RéSUMé: CONTEXTE: La douleur constitue un facteur de risque de dépression post-partum (DPP) et l'analgésie péridurale obstétricale (APO) pourrait réduire l'incidence de DPP. Nous avons évalué le risque de symptômes de dépression à trois, six, et 12 mois post-partum chez les femmes ayant reçu une APO comparativement aux femmes sans APO. MéTHODE: Après avoir obtenu l'approbation du comité d'éthique, l'hypothèse a été testée en se fondant sur les données d'une étude de cohorte observationnelle prospective longitudinale réalisée entre janvier 2015 et janvier 2019 auprès des femmes nullipares âgées de ≥ 18 ans avec des grossesses simples et sans complication. Des sondages électroniques ont été complétés au début de l'étude (données de base, 18 à 20 semaines de grossesse), puis à trois, six et douze mois post-partum, et incluaient l'Échelle de dépression postnatale d'Édimbourg (EPDS). Les caractéristiques maternelles, infantiles et anesthésiques ont été extraites des bases de données électroniques. Les scores sur l'EPDS à trois, six, et 12 mois post-partum ont été analysés utilisant des équations d'estimation généralisées avec et sans covariables. RéSULTATS: Parmi les 909 femmes qui ont consenti à participer, 709 femmes ont été incluses dans l'étude. Les scores prénataux sur l'EPDS, et non l'APO, ont prédit le risque de symptômes de dépression post-partum (P < 0,001). Les intervalles de confiance ajustés de 95 % suggèrent que les scores moyens sur l'EPDS différaient de 1,0 point de moins dans le groupe APO à 12 mois à 1,5 point de plus dans le groupe sans APO à trois mois sur l'échelle de 0 à 30. Tous les intervalles de confiance englobaient le zéro à trois, six et 12 mois, et ont donc été considérés comme non significatifs (P > 0,05). CONCLUSION: Cette étude n'a pas identifié d'association entre l'APO et le risque de symptômes dépressifs post-partum, bien que de petites différences moyennes entre les groupes ne puissent être exclues. Les études futures devraient se concentrer sur d'autres variables modifiables qui influencent l'apparition de la DPP.

Perioperative mobile application for mothers undergoing Cesarean delivery: a prospective cohort study on patient engagement.

PURPOSE: Giving birth is the most common reason for hospital admission, with Cesarean delivery being the most frequently performed inpatient surgery. Through a needs assessment and iterative design process involving patients and obstetric anesthesiologists, we previously developed a mobile application, C-Care, for patients undergoing Cesarean delivery. The focus of C-Care is perioperative education and self-monitoring of potential anesthetic complications. This study aimed to obtain feedback on patient engagement with C-Care. METHOD: We conducted a prospective cohort study of patients ≥ 18 yr (n = 36) undergoing elective Cesarean delivery. Anonymous usage data were recorded for 30 days. On postoperative days 1-5, participants received daily self-monitoring questionnaires within C-Care. Fourteen days after surgery, participants received an online survey regarding satisfaction and use of C-Care. RESULTS: Thirty-five out of 36 participants visited the application after orientation, with a median [interquartile range (IQR)] age of 32 [31-36] yr. Each participant visited the application a median of 15 [9-31] times over 30 days and completed a median of 3 [2-4] out of five self-monitoring questionnaires. Each participant viewed a median of 4 [2-7] out of eight education topics, with the most viewed patient education topics being "Controlling Pain" and "The First Few Days". Visits to the application were highest in the first week postpartum. Of the 18 respondents who completed the day 14 survey, 83% (n = 15) participants would recommend C-Care to other women, and the median participant satisfaction score was 7.5 out of 10 (range, 2-10). CONCLUSION: Most participants used this mobile application for patient education and self-monitoring after elective Cesarean delivery. Insights into patient engagement with C-Care after Cesarean delivery could help design more effective perioperative mobile telehealth programs. TRIAL REGISTRATION: www.ClinicalTrials.gov (NCT03746678); registered 5 November 2018.

RéSUMé: OBJECTIF: L'accouchement est la raison la plus courante d'admission à l'hôpital, et l'accouchement par césarienne constitue la chirurgie hospitalière la plus fréquemment pratiquée. Grâce à une évaluation des besoins et un processus de conception itérative impliquant des patientes et des anesthésiologistes obstétricaux, nous avions mis au point une application mobile baptisée C-Care destinée aux patientes subissant un accouchement par césarienne. L'application C-Care a pour but d'être un outil d'éducation périopératoire et d'autosurveillance des complications anesthésiques potentielles. Cette étude visait à obtenir des commentaires de rétroaction sur l'intérêt des patientes pour l'application C-Care. MéTHODE: Nous avons mené une étude de cohorte prospective auprès de patientes ≥ 18 ans (n = 36) subissant un accouchement par césarienne programmée. Des données d'utilisation anonymes ont été enregistrées pendant 30 jours. Les jours postopératoires 1-5, les participantes ont reçu des questionnaires quotidiens d'autosurveillance dans l'application C-Care. Quatorze jours après la chirurgie, les participantes ont reçu un sondage en ligne sur leur satisfaction et leur utilisation de C-Care. RéSULTATS: Trente-cinq des 36 participantes, d'un âge médian [écart interquartile (ÉIQ)] de 32 ans [31-36], ont consulté l'application après leur formation initiale. Chaque participante a consulté l'application 15 [9-31] fois en moyenne sur 30 jours et a rempli en moyenne 3 [2-4] questionnaires d'autosurveillance sur cinq. Chaque participante a consulté en moyenne 4 [2-7] des huit sujets de formation, les sujets les plus consultés étant « Le contrôle de la douleur ¼ et « Les premiers jours ¼. Les consultations de l'application ont été les plus élevées au cours de la première semaine post-partum. Parmi les 18 répondantes qui ont complété le sondage du jour 14, 83 % (n = 15) des participantes recommanderaient C-Care à d'autres femmes, et le score médian de satisfaction des participantes était de 7,5 sur 10 (fourchette, 2-10). CONCLUSION: La plupart des participantes ont utilisé cette application mobile destinée à l'éducation des patientes et à l'autosurveillance après un accouchement par césarienne programmée. Une compréhension de l'intérêt des patientes pour C-Care après un accouchement par césarienne pourrait permettre la conception d'applications mobiles périopératoires plus efficaces. ENREGISTREMENT DE L'éTUDE: www.clinicaltrials.gov (NCT03746678); enregistrée le 5 novembre 2018.

Tranexamic acid: current use in obstetrics, major orthopedic, and trauma surgery.

PURPOSE: In this Continuing Professional Development module, we review the practical pharmacology of tranexamic acid and its clinical use in trauma, obstetrics, and major orthopedic surgery. PRINCIPAL FINDINGS: Tranexamic acid is a synthetic drug that inhibits fibrinolysis. Multiple clinical trials in various clinical settings have shown that it can reduce blood loss, transfusion rates, and bleeding-associated mortality. In trauma and obstetrical bleeding, early tranexamic acid administration (< three hours) may have greater clinical benefits. Overall, tranexamic acid use appears safe with no significant increase of thromboembolic or seizure events. Nevertheless, current evidence has limitations related to wide heterogeneity in dose, route, and timing of drug administration, as well as generalizability of the large-scale trial findings to higher income nations. CONCLUSIONS: Tranexamic acid is an efficacious and safe pharmacological-based blood conservation technique in the management of clinically significant hemorrhage. All anesthesiologists should have a good understanding of the pharmacotherapeutic properties and perioperative role of tranexamic acid therapy both inside and outside of the operating room. The use of tranexamic acid is likely to continue to rise with endorsement by various clinical guidelines and healthcare organizations. Further quantitative research is needed to evaluate optimal dosing and drug efficacy in these clinical scenarios.

RéSUMé: OBJECTIF: Dans ce module de Développement professionnel continu, nous passons en revue la pharmacologie pratique de l'acide tranexamique et son utilisation clinique dans le trauma, l'obstétrique, et les chirurgies orthopédiques majeures. CONSTATATIONS PRINCIPALES: L'acide tranexamique est un médicament synthétique inhibant la fibrinolyse. Plusieurs essais cliniques dans divers contextes cliniques ont montré qu'il peut réduire les pertes de sang, les taux de transfusion et la mortalité associée aux saignements. Dans les cas de saignement traumatologique et obstétrical, l'administration précoce d'acide tranexamique (< trois heures) pourrait avoir de plus grands bienfaits cliniques. Globalement, l'utilisation d'acide tranexamique semble sécuritaire et n'entraîne pas d'augmentation significative des complications thromboemboliques ou de convulsions. Néanmoins, les données probantes actuelles comportent des limites liées à une grande hétérogénéité dans la posologie, la voie et le moment d'administration du médicament, ainsi qu'à l'aspect généralisable des résultats des études à grande échelle pour les pays à revenu élevé. CONCLUSION: L'acide tranexamique est une technique pharmacologique de conservation du sang efficace et sécuritaire pour la prise en charge de l'hémorragie cliniquement significative. Les anesthésiologistes devraient tous posséder une bonne compréhension des propriétés pharmacothérapeutiques et du rôle périopératoire de la thérapie par acide tranexamique, tant à l'intérieur qu'à l'extérieur de la salle d'opération. L'utilisation de l'acide tranexamique continuera vraisemblablement à augmenter au fur et à mesure de l'obtention de son approbation par diverses lignes directrices cliniques et organismes de soins de santé. D'autres recherches quantitatives sont nécessaires pour évaluer le dosage optimal et l'efficacité du médicament dans ces scénarios cliniques.

Sexual and gender minorities educational content within obstetric anesthesia fellowship programs: a survey.

PURPOSE: Improved patient-provider relationships can positively influence patient outcomes. Sexual and gender minorities (SGM) represent a wide variety of marginalized populations. There is an absence of studies examining the inclusion of SGM-related health education within postgraduate training in anesthesia. This study's objective was to perform an environmental scan of the educational content of North American obstetric anesthesia fellowship programs. METHODS: An online survey was developed based on a review of the existing literature assessing the presence of SGM content within other healthcare-provider curricula. The survey instrument was distributed electronically to 50 program directors of North American obstetric anesthesia fellowship programs. Survey responses were summarized using descriptive statistics. RESULTS: Survey responses were received from 30 of the 50 program directors (60%). Of these, 54% (14/26) felt their curriculum adequately prepares fellows to care for SGM patients, yet only 19% (5/26) of participants stated that SGM content was part of their curriculum and 31% (8/26) would like to see more incorporated in the future. Perceived lack of need was chosen as the biggest barrier to curricular inclusion of SGM education (46%; 12/26), followed by lack of available/interested faculty (19%; 5/26) and time (19%; 5/26). CONCLUSIONS: Our results suggest that, although curriculum leaders appreciate that SGM patients are encountered within the practice of obstetric anesthesia, most fellowship programs do not explicitly include SGM curricular content. Nevertheless, there appears to be interest in developing SGM curricular content for obstetric anesthesia fellowship training. Future steps should include perspectives of trainees and patients to inform curricular content.

RéSUMé: OBJECTIF: L'amélioration des relations patient-fournisseur peut avoir une influence positive sur les devenirs des patients. Les minorités sexuelles et de genre (MSG) représentent une vaste diversité de populations marginalisées. Aucune étude n'a examiné l'inclusion d'éducation médicale liée aux MSG dans le cadre de la formation surspécialisée en anesthésie. L'objectif de cette étude était de mener une enquête générale sur le contenu éducatif des programmes de fellowship nord-américains en anesthésie obstétricale. MéTHODE: Un sondage électronique a été mis au point en se fondant sur la littérature existante afin d'évaluer l'offre de contenu traitant des MSG dans le cadre d'autres programmes de cours destinés aux fournisseurs de soins de santé. Le sondage a été distribué électroniquement à 50 directeurs de programmes de fellowship en anesthésie obstétricale en Amérique du Nord. Les réponses au sondage ont été résumées à l'aide de statistiques descriptives. RéSULTATS: Des réponses au sondage de 30 des 50 directeurs de programme ont été reçues (60 %). Parmi ces réponses, 54 % (14/26) étaient d'avis que leur programme de cours était adapté pour préparer les fellows à s'occuper de patients issus des MSG, mais seuls 19 % (5/26) des participants déclaraient que du contenu spécifique portant sur les MSG était intégré dans leur programme, et 31 % (8/26) aimeraient voir davantage de contenu pertinent intégré à l'avenir. L'absence perçue de besoin a été retenue comme l'obstacle le plus important à l'inclusion de formation concernant les MSG dans le programme de cours (46 %; 12/26), suivie par le manque de personnel disponible / intéressé (19 %; 5/26) et de temps (19 %; 5/26). CONCLUSION: Nos résultats suggèrent que bien que les directeurs de programmes soient conscients que des patients issus des MSG soient suivis dans la pratique de l'anesthésie obstétricale, la plupart des programmes de fellowship n'incluent pas explicitement de contenu éducatif lié aux MSG. Toutefois, il semble y avoir un intérêt pour la mise au point de contenu éducatif pertinent aux MSG dans le cadre des programmes de fellowship en anesthésie obstétricale. L'étape suivante serait d'inclure les opinions des fellows et des patients afin de guider le contenu des programmes.

Pharmacologic labour analgesia and its relationship to postpartum psychiatric disorders: a scoping review.

PURPOSE: This scoping review aimed to summarize the current literature on postpartum psychiatric disorders (e.g., postpartum depression, postpartum anxiety, postpartum post-traumatic stress disorder) and the possible relationship of these disorders to the use of pharmacologic labour analgesia (e.g., epidural analgesia, nitrous oxide, parenteral opioids) to identify knowledge gaps that may aid in the planning of future research. SOURCES: PubMed, PsycINFO, CINAHL, and EMBASE were searched from inception to November 9, 2018 for studies that included both labour analgesia and the postpartum psychiatric disorders specified above. PRINCIPAL FINDINGS: Two reviewers assessed the studies and extracted the data. Of the 990 identified citations, 17 studies were included for analysis. Existing studies have small sample sizes and are observational cohorts in design. Patient psychiatric risk factors, method of delivery, and type of labour analgesia received were inconsistent among studies. Most studies relied on screening tests for diagnosing postpartum psychiatric illness and did not assess the impact of labour analgesia on postpartum psychiatric illness as the primary study objective. CONCLUSIONS: Future studies should correlate screen-positive findings with clinical diagnosis; consider adjusting the timing of screening to include the antepartum period, early postpartum, and late postpartum periods; and consider the degree of labour pain relief and the specific pharmacologic labour analgesia used when evaluating postpartum psychiatric disorders.

RéSUMé: OBJECTIF: Cette étude exploratoire avait pour objectif de résumer la littérature actuelle portant sur les troubles psychiatriques postpartum (par ex., dépression postpartum, anxiété postpartum, état de stress post-traumatique postpartum) et la relation possible de ces troubles avec l'utilisation d'une analgésie pharmacologique pour le travail obstétrical (par ex., analgésie péridurale, protoxyde d'azote, opioïdes parentéraux) afin d'identifier les lacunes dans nos connaissances qui pourraient aiguiller la planification de futures recherches. SOURCES: Des recherches ont été effectuées dans les bases de données PubMed, PsycINFO, CINAHL et EMBASE de leur création jusqu'au 9 novembre 2018 afin d'en extraire les études incluant des informations concernant l'analgésie du travail et les troubles psychiatriques postpartum spécifiés ci-dessus. CONSTATATIONS PRINCIPALES: Deux évaluateurs ont passé en revue les études et extrait les données. Parmi les 990 citations identifiées, 17 études ont été incluses pour analyse. Les études existantes ont de petites tailles d'échantillon et sont conçues comme des cohortes observationnelles. Les facteurs de risque psychiatrique des patientes, le mode d'accouchement et le type d'analgésie reçue pour le travail n'étaient pas uniformes d'une étude à l'autre. La plupart des études s'appuyaient sur des tests de dépistage pour poser un diagnostic de maladie psychiatrique postpartum et n'évaluaient pas l'impact de l'analgésie du travail sur la maladie psychiatrique postpartum comme critère d'évaluation principal. CONCLUSION: Les études futures devraient corréler les résultats positifs au dépistage à un diagnostic clinique; envisager d'ajuster le moment de dépistage afin d'inclure la période antepartum ainsi que les périodes du postpartum initial et tardif; et tenir compte du degré de soulagement de la douleur du travail ainsi que de l'analgésie pharmacologique spécifique utilisée pour le travail lors de l'évaluation des troubles psychiatriques postpartum.

An interpretive phenomenological analysis of formative feedback in anesthesia training: the residents' perspective.

BACKGROUND: Consistent formative feedback is cornerstone to competency-by-design programs and evidence-based approaches to teaching and learning processes. There has been no published research investigating feedback from residents' perspectives. We explored the value residents place on feedback in routine operating room settings, their experiences, and understanding of the role of feedback in their training and developing professional identity. METHODS: Interpretive phenomenological analysis of residents' experiences with feedback received in clinical settings involved two focus groups with 14 anesthesia residents at two time points. Analysis was completed in the context of a teaching hospital adapting to new practices to align with nationally mandated clinical competencies. Focus group conversations were transcribed and interpreted through the lens of a social constructivist approach to learning as a dynamic inter- and intra-personal process, and evidence-based assessment standards set by the International Test Commission (ITC). RESULTS: Residents described high quality feedback as consistent, effortful, understanding of residents' thought processes, and containing actionable advice for improvement. These qualities of effective evaluation were equally imperative for informal and formal evaluations. Residents commented that highest quality feedback was received informally, and formal evaluations often lacked what they needed for their professional development. CONCLUSION: Residents have a deep sense of what promotes their learning. Structured feedback tools were seen positively, although the most important determinants of their impact were faculty feedback- and broader evaluation-skills and motivations for both formal and informal feedback loops.

Society for Obstetric Anesthesia and Perinatology Consensus Statement: Monitoring Recommendations for Prevention and Detection of Respiratory Depression Associated With Administration of Neuraxial Morphine for Cesarean Delivery Analgesia.

The majority of women undergoing cesarean delivery in the United States receive neuraxial morphine, the most effective form of postoperative analgesia for this surgery. Current American Society of Anesthesiologists (ASA) and American Society of Regional Anesthesia and Pain Medicine (ASRA) recommend respiratory monitoring standards following neuraxial morphine administration in the general surgical population that may be too frequent and intensive when applied to the healthy obstetric population receiving a single dose of neuraxial morphine at the time of surgery. There is limited evidence to support or guide the optimal modality, frequency, and duration of respiratory monitoring in the postoperative cesarean delivery patient receiving a single dose of neuraxial morphine. Consistent with the mission of the Society for Obstetric Anesthesia and Perinatology (SOAP) to improve outcomes in pregnancy for women and neonates, the purpose of this consensus statement is to encourage the use of this highly effective analgesic technique while promoting safe practice and patient-centered care. The document aims to reduce unnecessary interruptions from respiratory monitoring in healthy mothers while focusing vigilance on monitoring in those women at highest risk for respiratory depression following neuraxial morphine administration. This consensus statement promotes the use of low-dose neuraxial morphine and multimodal analgesia after cesarean delivery, gives perspective on the safety of this analgesic technique in healthy women, and promotes patient risk stratification and perioperative risk assessment to determine and adjust the intensity, frequency, and duration of respiratory monitoring.

Supplemental perioperative intravenous crystalloids for postoperative nausea and vomiting.

BACKGROUND: Postoperative nausea and vomiting (PONV) is a common complication following general anaesthesia. It may be associated with patient dissatisfaction, increased costs of treatment, and unintended admission to hospital.Supplemental intravenous crystalloid administration in the perioperative period may be a simple intervention to prevent PONV. OBJECTIVES: To assess whether supplemental intravenous crystalloid administration prevents PONV in patients undergoing surgical procedures under general anaesthesia. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 7), MEDLINE (1946 to August 2018), Embase (1947 to August 2018), and the Cumulative Index of Nursing and Allied Health Literature (CINAHL; 1971 to August 2018). We searched clinical trials registers for ongoing or unpublished completed studies (August 2018), handsearched three major journals (British Journal of Anaesthesia, European Journal of Anaesthesiology, and Anesthesiology; August 2018), and conducted backward and forward citation searching of relevant articles. SELECTION CRITERIA: We included randomized controlled trials of participants older than six months undergoing surgical procedures under general anaesthesia and given supplemental perioperative intravenous crystalloids, defined as a volume larger than that received by a comparator group, to prevent PONV. DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures described by Cochrane. MAIN RESULTS: We included 41 studies (4224 participants). Participants underwent ambulatory or short length of stay surgical procedures, and were predominantly American Society of Anesthesiology (ASA) class I or II. There is one study awaiting classification and three ongoing studies. All studies took place in surgical centres, and were conducted in geographically diverse settings. Risk of bias was generally unclear across all domains.Supplemental intravenous crystalloid administration probably reduces the cumulative risk of postoperative nausea (PON) (risk ratio (RR) 0.62, 95% confidence interval (CI) 0.51 to 0.75; 18 studies; 1766 participants; moderate-certainty evidence). When the postoperative period was divided into early (first six hours postoperatively) and late (at the time point closest to or including 24 hours postoperatively) time points, the intervention reduced the risk of early PON (RR 0.67, 95% CI 0.58 to 0.78; 20 studies; 2310 participants; moderate-certainty evidence) and late PON (RR 0.47, 95% CI 0.32 to 0.69; 17 studies; 1682 participants; moderate-certainty evidence).Supplemental intravenous crystalloid administration probably reduces the risk of postoperative vomiting (POV) (RR 0.50, 95% CI 0.40 to 0.63; 20 studies; 1970 participants; moderate-certainty evidence). The intervention specifically reduced both early POV (RR 0.56, 95% CI 0.41 to 0.76; 19 studies; 1998 participants; moderate-certainty evidence) and late POV (RR 0.48, 95% CI 0.29 to 0.79; 15 studies; 1403 participants; moderate-certainty evidence).Supplemental intravenous crystalloid administration probably reduces the need for pharmacologic treatment of PONV (RR 0.62, 95% CI 0.51 to 0.76; 23 studies; 2416 participants; moderate-certainty evidence).The effect of supplemental intravenous crystalloid administration on the risk of unplanned postoperative admission to hospital is unclear (RR 1.05, 95% CI 0.77 to 1.43; 3 studies; 235 participants; low-certainty evidence).No studies reported serious adverse events that may occur following supplemental perioperative intravenous crystalloid administration (i.e. admission to high-dependency unit, postoperative cardiac or respiratory complication, or death). AUTHORS' CONCLUSIONS: There is moderate-certainty evidence that supplemental perioperative intravenous crystalloid administration reduces PON and POV, in ASA class I to II patients receiving general anaesthesia for ambulatory or short length of stay surgical procedures. The intervention probably also reduces the risk of pharmacologic treatment for PONV. The effect of the intervention on the risk of unintended postoperative admission to hospital is unclear. The risk of serious adverse events resulting from supplemental perioperative intravenous crystalloid administration is unknown as no studies reported this outcome. The one study awaiting classification may alter the conclusions of the review once assessed.