A Prospective Longitudinal Quality Initiative toward Improved Enhanced Recovery after Cesarean Pathways.

OBJECTIVE: This study aimed to evaluate whether enhanced recovery after cesarean (ERAC) pathways reduces inpatient and outpatient opioid use, pain scores and improves the indicators of postoperative recovery. STUDY DESIGN: This is a prospective, longitudinal, quality improvement study of all patients older than 18 undergoing an uncomplicated cesarean delivery (CD) at an academic medical center. We excluded complicated CD, patients with chronic pain disorders, chronic opioid use, acute postpartum depression, or mothers whose neonate demised before their discharge. Lastly, we excluded non-English- and non-Spanish-speaking patients. Our study compared patient outcomes before (pre-ERAC) and after (post-ERAC) implementation of ERAC pathways. Primary outcomes were inpatient morphine milligram equivalent (MME) use and the patient's delta pain scores. Secondary outcomes were outpatient MME prescriptions and indicators of postoperative recovery (time to feeding, ambulation, and hospital discharge). RESULTS: Of 308 patients undergoing CD from October 2019 to September 2020, 196 were enrolled in the pre-ERAC cohort and 112 in the post-ERAC cohort. Patients in the pre-ERAC cohort were more likely to require opioids in the postoperative period compared with the post-ERAC cohort (81.6 vs. 64.3%, p < 0.001). Likewise, there was a higher use of MME per stay in the pre-ERAC cohort (30 [20-49] vs. 16.8 MME [11.2-33.9], p < 0.001). There was also a higher number of patients who required prescribed opioids at the time of discharge (98 vs. 86.6%, p < 0.001) as well as in the amount of MMEs prescribed (150 [150-225] vs. 150 MME [112-150], p < 0.001; different shape of distribution). Furthermore, the patients in the pre-ERAC cohort had higher delta pain scores (3.3 [2.3-4.7] vs. 2.2 [1.3-3.7], p < 0.001). CONCLUSION: Our study has illustrated that our ERAC pathways were associated with reduced inpatient opioid use, outpatient opioid use, patient-reported pain scores, and improved indicators of postoperative recovery. KEY POINTS: · Implementation of ERAC pathways is associated with a higher percentage of no postpartum opioid use.. · Implementation of ERAC pathways is associated with lower delta (reported - expected) pain scores.. · The results of ERAC pathways implementation are increased by adopting a patient-centered approach..

General versus Regional Anesthesia and Neonatal Data: A Propensity-Score-Matched Study.

OBJECTIVE: This study aimed to evaluate whether there is a difference in neonatal outcomes with general anesthesia (GA) versus regional anesthesia (RA) when induction of anesthesia to delivery time (IADT) is prolonged (≥10 minutes). STUDY DESIGN: This is a retrospective case-control study that included cases from July 2014 until August 2020. We reviewed all singleton pregnancies delivered between 24 and 42 weeks of gestation with IADT ≥ 10 minutes. Urgent deliveries, those who received RA for labor pain management or started cesarean delivery under RA and converted to GA, as well as cases with fetal anomalies, were excluded. The propensity score (PS) matching method was performed using age, ethnicity/race, body mass index, gestational age at delivery, preexisting maternal comorbidities, and pregnancy complications. Analyses were performed with SAS software version 9.4. RESULTS: During the study period, we identified 258 cases meeting inclusion criteria. After the PS matching was applied, the study sample was reduced to 60 cases in each group. The median IADT and uterine incision to delivery time were similar between groups (41.5 [30.5, 52] vs. 46 minutes [38, 53.5], p = 0.2 and 1.5 [1, 3] vs. 2 minutes [1, 3], respectively). There was no significant difference between groups with respect to arterial or venous cord pH (7.24 [7.21, 7.26] vs. 7.23 [7.2, 7.27], p = 0.7 and 7.29 [7.26, 7.33] vs. 7.3 [7.26, 7.33], p = 0.4, respectively). Nor were there any associations between maternal characteristics and Apgar's score at 5 minutes, except for Apgar's score at 1 minute (p < 0.001). No significant difference was identified in the rate of admission to the neonatal intensive care unit (NICU; 11 [52.4%] vs. 10 [47.6%], p = 0.8) or NICU length of stay between GA and RA (4 [3, 14] vs. 4.5 [3, 11], p = 0.9). CONCLUSION: Our data indicate that even with prolonged IADT, favorable neonatal outcomes are seen with both GA and RA, in contrast with previous studies performed decades ago. KEY POINTS: · Improving cesarean delivery safety, including the safety of anesthesia, is of paramount importance.. · Reappraisal of historical outcomes is warranted as advances in the medical field unfold.. · Favorable neonatal outcomes are seen with both general and regional anesthesia..

Extracorporeal Membrane Oxygenation for Pregnant and Postpartum Patients.

Extracorporeal membrane oxygenation (ECMO) has seen increasing use for critically ill pregnant and postpartum patients over the past decade. Growing experience continues to demonstrate the feasibility of ECMO in obstetric patients and attest to its favorable outcomes. However, the interaction of pregnancy physiology with ECMO life support requires careful planning and adaptation for success. Additionally, the maintenance of fetal oxygenation and perfusion is essential for safely continuing pregnancy during ECMO support. This review summarizes the considerations for use of ECMO in obstetric patients and how to address these concerns.

Efficacy of sonorheometry point of the care device in determining low fibrinogen levels in pregnant blood: an invitro dilution and reconstitution study.

Quantra® Hemostasis Analyzer is a Point of the care device that uses ultrasound technology to assess clot formation. In this study, we establish how Quantra® system performs compared to conventional coagulation tests at low levels of fibrinogen in the blood obtained from pregnant women. 24 mL blood was obtained from each healthy parturient. Blood was analyzed for Quantra® variables (Q): Clot time (CT), Clot stiffness (CS), platelet contribution to CS (PCS), fibrinogen contribution to CS (FCS), and conventional coagulation (CL) tests: PT, aPTT, INR, Factor VIII and fibrinogen. 6 ml blood were centrifuged to obtain pregnant plasma. 30 mL of saline was added to 10 mL of blood to simulate crystalloid resuscitation (DB) and was evaluated for Q and CL. Fractions of pregnant plasma, or nonpregnant plasma (Blood Bank) was added to DB to obtain 15% and 30% clotting factor enriched samples. 4 ml of DB was added to 4 ml of original blood (1:1) to obtain the final sample (resus). Each of the samples were analyzed for Q and CL parameters. Regression analysis and Receiving Characteristics Curves were used to study the relationship between Quantra variables and CL tests. There were remarkably high linear correlations between Fibrinogen and CS (R = 0.93, P < 0.001), fibrinogen and FCS (R = 0.77, P < 0.001). An FCS value 2.45 (sensitivity of 79.2 and specificity of 97.3%), and CS value 10.85 hPa (sensitivity of 83% and specificity of 100%) predicted fibrinogen of 200 mg/dL. This study demonstrates a good correlation between Quantra® CS, FCS and serum fibrinogen.Clinical Trial Number: NCT04301193.

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.

Use of a novel non-invasive respiratory monitor to study changes in pulmonary ventilation during labor epidural analgesia.

Measuring continuous changes in maternal ventilation during labor neuraxial analgesia is technically difficult. Consequently, the magnitude of pulmonary minute ventilation (MV) alterations following labor analgesia remains unknown. We hypothesized that a novel, bio-impedance based non-invasive respiratory monitor would provide this information. Furthermore, we sought to determine if an association between changes in MV and maternal temperature existed. Following calibration with a Haloscale Standard Wright Respirometer, the ExSpiron respiratory volume monitor (RVM) measured MV, respiratory rate (RR), and tidal volume (TV) in 41 term parturients receiving epidural analgesia. Simultaneously, maternal oral temperatures were recorded at pre-specified hourly intervals after epidural analgesia initiation until delivery. Cumulative MV changes were calculated as the integral of MV change over time: MV [Formula: see text], where T represents the time between epidural placement and variable measurement. The association between changes in MV and cumulative MV versus maternal temperature was determined by comparing patients whose temperature did or did not increase by ≥ 0.5 °C. After initiation of epidural analgesia, MV decreased by 11.1 ± 27.6% [mean ± SD] at 30 min, p = 0.006, and 19.8 ± 26.1% at 2 h compared to baseline (12.6 ± 7.3 L/min at baseline vs. 15.3 ± 6.3 L/min at 2 h, p < 0.001), Minute ventilation remained decreased at 4 h by 14.3 ± 31.4% (p = 0.013). The cumulative MV also decreased by 437 ± 852 L [mean ± SD], p = 0.009) at 2 h and by 795 ± 1431 L, p < 0.001) at 4 h following epidural analgesia initiation, compared to baseline. The association between changes in cumulative MV and maternal temperature following epidural placement was weak (R < 0.3); however, a decrease in MV at 30 min (p = 0.002) and cumulative MV at 2 h (p = 0.012) was observed in women whose temperature increased by at least 0.5 °C during labor. Our findings suggest that RVM can be a useful noninvasive technology to investigate pulmonary physiology during labor. The association between maternal MV and temperature change during labor analgesia deserves further investigation.Trial Registrationwww.clinicaltrials.gov (NCT02339389).

Linshom thermodynamic sensor is a reliable alternative to capnography for monitoring respiratory rate.

Monitoring ventilation accurately is a technically challenging, yet indispensable aspect of patient care in the intra- and post-procedural settings. A new prototypical device known as the Linshom Respiratory Monitoring Device (LRMD) has been recently designed to non-invasively, inexpensively, and portably measure respiratory rate. The purpose of this study was to measure the accuracy and variability of LRMD measurements of respiratory rate relative to the measurement of capnography. In this prospective study, participants were enrolled and individually fitted with a face mask monitored by the LRMD and capnography. With a baseline oxygen flow rate and digital metronome to pace their respiratory rate, the participants were instructed to breathe at 10 breaths per minute (bpm) for 3 min, 20 bpm for 3 min, 30 bpm for 3 min, 0 bpm for 30 s, and resume regular breathing for 30 s. Both sensors were connected to a computer for continuous temperature and carbon dioxide waveform recordings. The data were then retrospectively analyzed. Twenty-six healthy volunteers, mean (range) age 27.8 (23-37) and mean (range) BMI 23.1 (18.8-29.2) kg/m2 were recruited. There were 15 males (57.7%) and 11 females (42.3%). After excluding 3 subjects for technical reasons, 13,800 s of breathing and 4,140 expiratory breaths were recorded. Throughout the protocol, the average standard deviation (SD) for the LRMD and capnography was 1.11 and 1.81 bpm, respectively. The overall mean bias (±2SD) between LRMD and capnography was -0.33 (±0.1.56) bpm. At the lowest and intermediate breathing rates reflective of hypoventilation and normal ventilation, the LRMD variance was 0.55 and 1.23 respectively, compared to capnography with 5.54 and 7.47, respectively. At higher breathing rates indicative of hyperventilation, the variance of the test device was 4.52, still less than that of capnography at 5.73. This study demonstrated a promising correlation between the LRMD and capnography for use as a respiratory rate monitor. The LRMD technology may be a significant addition to monitoring vital signs because it offers a minimally intrusive opportunity to detect respiratory rate and apnea, without expensive or complex anesthetic equipment, before the need for life-saving resuscitation arises.

A Randomized Controlled Trial of Music Use During Epidural Catheter Placement on Laboring Parturient Anxiety, Pain, and Satisfaction.

BACKGROUND: Although music is frequently used to promote a relaxing environment during labor and delivery, the effect of its use during the placement of neuraxial techniques is unknown. Our study sought to determine the effects of music use on laboring parturients during epidural catheter placement, with the hypothesis that music use would result in lower anxiety, lower pain, and greater patient satisfaction. METHODS: We conducted a prospective, randomized, controlled trial of laboring parturients undergoing epidural catheter placement with or without music. The music group listened to the patient's preferred music on a Pandora® station broadcast through an external amplified speaker; the control group listened to no music. All women received a standardized epidural technique and local anesthetic dose. The primary outcomes were 3 measures of anxiety. Secondary outcomes included pain, patient satisfaction, hemodynamic parameters, obstetric parameters, neonatal outcomes, and anesthesia provider anxiety. Intention-to-treat analysis with Bonferroni correction was used for the primary outcomes. For secondary outcomes, a P value of <.001 was considered statistically significant. RESULTS: A total of 100 parturients were randomly assigned, with 99 included in the intention-to-treat analysis. Patient characteristics were similar in both groups; in the music group, the duration of music use was 31.1 ± 7.7 minutes (mean ± SD). The music group experienced higher anxiety as measured by Numeric Rating Scale scores immediately after epidural catheter placement (2.9 ± 3.3 vs 1.4 ± 1.7, mean difference 1.5 [95% confidence interval {CI} 0.2-2.7], P = .02), and as measured by fewer parturients being "very much relaxed" 1 hour after epidural catheter placement (51% vs 78%, odds ratio {OR} 0.3 [95% CI 0.1-0.9], P = .02). No differences in mean pain scores immediately after placement or patient satisfaction with the overall epidural placement experience were observed; however, the desire for music use with future epidural catheter placements was higher in the music group (84% vs 45%, OR 6.4 [95% CI 2.5-16.5], P < .0001). No differences in the difficulty with the epidural catheter placement or in the rate of cesarean delivery were observed. CONCLUSIONS: Music use during epidural catheter placement in laboring parturients is associated with higher postprocedure anxiety and no improvement in pain or satisfaction; however, a stronger desire for music with future epidural catheter placements was observed. Further investigation is needed to determine the effect of music use in parturients requesting and using epidural labor analgesia.

Introduction of a new electronic medical record system has mixed effects on first surgical case efficiency metrics.

To evaluate the effect of deploying a new electronic medical record (EMR) system on first case starts in the operating room. Data on first case start times were collected after implementation of a new EMR (Epic) from June 2015 to May 2016, which replaced a legacy system of both paper and electronic records. These were compared to data from the same months in the three proceeding years. First patient in room (FPIR) on time was true if the patient was in operating room before 7:35 AM (or 9:35 AM on Wednesdays) and first case on time start (FCOTS) was true if completion of anesthetic induction was less than 20 min after the patient entered the operating room (or 35 min for cardiac and neurosurgery). Times beyond these cutoffs were quantified as FPIR and FCOTS delays in minutes. Average delays were compared by month with two-sample t tests and 95 % confidence intervals. There was a significant increase in FPIR delays in the first month (11.07 vs. 3.47 min, p < 0.0001), which abated by the fifth month. Post-implementation FCOTS delays improved by the third month (4.53 vs. 7.10 min, p < 0.0001). Both results persisted throughout the study. First month FPIR delays were not limited to any one specialty. EMRs have the potential to improve hospital workflows, but are not without learning curves. FPIR and FCOTS delays return to baseline after a few months, and in the case of FCOTS, can improve beyond baseline.

Effect of Anesthesia Staffing Ratio on First-Case Surgical Start Time.

On time start of the first case of the day is an important operating room (OR) efficiency metric, in which delays can have effects throughout the day. Although previous studies have identified various causes of first case start delays, none have attempted to evaluate the effect anesthesia staffing ratios have on first case start times. We performed a single-center retrospective analysis at an academic teaching hospital. Data was collected and analyzed over a period of 4 years and on more than 8,700 cases. We examined whether staffing ratios of attending only (solo staffing ratio), attending working with 1 resident/certified registered nurse anesthetist (CRNA) (1 to 1), or attending covering 2 residents/CRNAs (1 to 2) had a significant effect on first patient in room time (FPIR) and first case on time start (FCOTS). In addition, we examined whether staffing ratios had an effect on start times in various surgical subspecialties. We performed a univariate logistic regression analysis to determine if age, anesthesia base units, American Society of Anesthesiologists Physical Status (ASA PS) classification score, and staffing ratio was associated with FPIR and FCOTS being on time. Then, we performed a multivariate logistic regression analysis to determine if staffing ratio was associated with these outcomes, utilizing age, anesthesia base units, and ASA PS class as covariates. A decreased odds for FPIR being on time were seen in general and orthopedic surgeries when staffed 1 to 1, and cardiac surgery when staffed 1 to 2, when compared to solo staffing. FCOTS showed statistically significant differences when looking at all services with solo staffing having the highest odds for FCOTS being on time. This effect was seen also when analyzing only oncologic and orthopedic surgeries. Hospitals should consider using different staffing ratios in different surgical specialties to minimize delays and maximize OR efficiency.

Development and implementation of a dedicated postoperative evaluation service to improve compliance of postoperative visits.

BACKGROUND AND AIMS: Postoperative patient evaluation is an integral component of perioperative care. An audit of our anesthesia department's records demonstrated a compliance rate of <50%. We postulated that the development of clinical anesthesia service dedicated to performing such evaluations would improve compliance significantly. MATERIALS AND METHODS: This retrospective study examined postoperative follow-up completion rate at a large academic center. Data were collected from 58,000 anesthetics during three periods, between each of which an intervention was introduced. The first period examined completion rate when postoperative evaluations were left to the team performing the anesthetic. During the second period, this task was delegated to groups of anesthesiologists based on surgical subspecialty; these smaller groups utilized rotating residents. The third period examined completion rate after implementation of a postoperative evaluation service. All periods utilized the department's electronics database to identify operative patients. The number of adverse anesthesia events reported was also recorded. RESULTS: A significant difference in the proportions of compliance with postoperative evaluations among all three periods was detected. Compliance was 47% during period one and improved to 66% during period two. During period three, which employed a postoperative evaluation service, compliance was 83%. The number of adverse events reported per month increased significantly following the first study period from 95 reported monthly events to 215 and 201 in the second and third periods, respectively. CONCLUSION: By creating a dedicated postoperative evaluation service using available technology, we improved postoperative evaluation completion rate from 47% to 83%, and demonstrated a significant increase in the number of adverse events reported. Based on this, we support the deployment of a dedicated service as a quality improvement initiative.

Transfusion ratios for postpartum hemodilutional coagulopathy: an in vitro thromboelastographic model.

OBJECTIVE: A 1:1:1 ratio of packed red blood cells (PRBC), fresh frozen plasma (FFP), and platelets (PLT) has been advocated for trauma hemorrhage, but the effectiveness of this ratio for postpartum hemorrhage is unknown. We created an in vitro hemodilutional model to investigate this strategy. STUDY DESIGN: Blood from 20 parturients at term was diluted 50% with 0.9% normal saline. Diluted samples were reconstituted with 1:1 PRBC:FFP or 3:1 PRBC:FFP. In 10 samples, PLT were also added. Baseline, diluted, and reconstituted sample thromboelastographic values were compared. RESULTS: Maximum amplitude (MA) was lower compared to baseline values in both groups after 50% dilution with normal saline (P < .001) and remained lower than baseline despite reconstitution with 3:1:0 or 1:1:0 PRBC:FFP:PLT (P < .0001) or 3:1:1 PRBC:FFP:PLT (P < .01). MA approached baseline (P = not significant) in the samples with 1:1:1 PRBC:FFP:PLT. CONCLUSION: The addition of PLT to 1:1 PRBC:FFP optimized MA in this in vitro hemodilutional model of postpartum hemorrhage.

Successful strategies for the reduction of operating room turnover times in a tertiary care academic medical center.

BACKGROUND: Turnover time (TOT) is one of the classic measures of operating room (OR) efficiency. There have been numerous efforts to reduce TOTs, sometimes through the employment of a process improvement framework. However, most examples of process improvement in the TOT focus primarily on operational changes to workflows and statistical significance. These examples of process improvement do not detail the complex organizational challenges associated with implementing, expanding, and sustaining change. METHODS: TOT data for general and gastrointestinal surgery were collected retrospectively over a 26-mo period at a large multispecialty academic institution. We calculated mean and median TOTs. TOTs were excluded if the sequence of cases was changed or cases were canceled. Data were retrieved from the perioperative nursing data entry system. RESULTS: Using performance improvement strategies, we determined how various events and organizational factors created an environment that was receptive to change. This ultimately led to a sustained decrease in the OR TOT both in the general and gastrointestinal surgery ORs that were the focus of the study (44.8 min versus 48.6 min; P < 0.0001) and other subspecialties (49.3 min versus 53.0 min; P < 0.0001), demonstrating that the effect traveled outside the study area. CONCLUSIONS: There are obstacles, such as organizational culture and institutional inertia, that OR leaders, managers, and change agents commonly face. Awareness of the numerous variables that may support or impede a particular change effort can inform effective change implementation strategies that are "organizationally compatible."

The effects of 2-chloroprocaine on coagulation and fibrinolysis in the parturient: an in vitro study.

PURPOSE: Amide local anesthetics are known to inhibit coagulation. 2-chloroprocaine is the only ester agent used in obstetric anesthesia. It is used during obstetric emergencies, and also to supplement inadequate epidural block produced by amide local anesthetics. There is no study to date that has evaluated the effect of ester local anesthetics on blood coagulation and fibrinolysis in the parturient. METHODS: In this study, we obtained blood samples from healthy, term-parturients and mixed them with varying amounts of 2-chloroprocaine for final concentrations ranging from 0.26 to 7.8 mM. Thromboelastograph(®) was used to study the coagulation profile of these samples. RESULTS: Chloroprocaine impaired coagulation in a dose dependent manner, with increased R and K, and decreased MA and α. The difference, when compared to saline controls, reached statistical significance at a dose of 7.8 mM. An additional significant finding was that 2-chloroprocaine also enhanced fibrinolysis. CONCLUSIONS: Amide local anesthetics are known to impair coagulation, but 2-chloroprocaine produced significant fibrinolysis in addition to decreasing coagulation. This is the first study to date to demonstrate fibrinolytic properties of an ester local anesthetic. Further study evaluations are required to determine the cause of the variation in fibrinolysis. There is also a need to address the mechanism of increased fibrinolysis observed with 2-chroloprocaine.

Variability of subspecialty-specific anesthesia-controlled times at two academic institutions.

Realistic scheduling of operating room cases decreases costs, optimizes utilization and improves staff and patient satisfaction. Currently limited data exists to establish anesthesia-controlled time benchmarks based on specific subspecialty service. In this multicenter retrospective analysis of cases performed during a 53 month period at two large multispecialty academic institutions, data were retrieved from the perioperative information systems at each center. Both induction and emergence times were calculated. We then determined mean and median anesthesia controlled times based on each subspecialty service and compared them to previously published anesthesia-controlled time data. We obtained data on 104,184 cases at hospital A, and 122,560 cases at Hospital B. For all specialties at hospital A and hospital B, median induction time was 16.0 min and 17.0 min, emergence time was 14.0 and 8.0 min, and total anesthesia controlled time was 31.0 min and 27.0 min respectively. There was considerable variability among different surgical specialties deviating from the previously established 30 min benchmark. Subspecialties with lower total anesthesia controlled times in both centers were pain, general surgery, gynecology, plastic surgery and urology. Subspecialties with higher total anesthesia controlled times in both centers included cardiac surgery, neurosurgery, transplant and vascular. Cardiac surgery had the highest total time of 60 min and 50 min at Hospital A and B respectively. Individual specialty-specific anesthesia controlled times should be used for case scheduling and to benchmark anesthesia performance.

Relationship between maternal arterial and foetal cord carbon dioxide tension and neonatal outcome in critically ill pregnant women at delivery.

Background and Aims: No studies have evaluated the relationship between maternal arterial partial pressure of carbon dioxide (mPaCO2) and umbilical cord venous partial pressure of carbon dioxide (PCO2) in critically ill pregnant women at delivery. Based on the studies in healthy pregnant women, an mPaCO2 target of ≤50 mmHg is a suggested threshold during mechanical ventilation in critically ill parturients. We evaluated the relationship between mPaCO2 and neonatal cord gases in critically ill parturients at delivery as the primary objective. The relationship between mPaCO2 and APGAR scores at delivery was also analysed as a secondary objective. Methods: Maternal and neonatal cord gas data at delivery and APGAR scores were obtained by a retrospective chart review of 25 consecutive parturients with severe respiratory compromise who were delivered during mechanical ventilation. Linear regression was used to assess the relationship between mPaCO2 and umbilical artery and vein PCO2 and between mPaCO2 and APGAR scores at 1 and 5 min. Results: There was a positive correlation between mPaCO2 and neonatal cord venous PCO2 (P = 0.013). Foetal venous PCO2 exceeded predelivery mPaCO2 by 17.5 (7.5) mmHg. There was an inverse relationship between mPaCO2 and neonatal APGAR scores at 1 and 5 min (P = 0.006 and P = 0.007, respectively). Conclusion: Foetal cord venous PCO2 can be predicted if mPaCO2 values are known. Unlike in healthy pregnant women, there was an inverse relationship between rising mPaCO2 levels and neonatal APGAR scores in critically ill pregnant women who had several associated compounding factors.

A patient who received 191 spinal anesthetics over 5 years without evidence of neurologic complications by examination or magnetic resonance imaging.

We present the case of a 50-year-old man who suffered a crush injury to his right lower extremity in 2002 and received 191 spinal anesthetics to date with no identifiable neurologic complications by physical examination or imaging. He has undergone >300 operations at our institution related to recurrent infection and wound breakdown, including multiple amputations and debridements with 146 of these occurring in a span of 36 months. The patient has no focal neurologic deficits involving his right lower extremity and denies any associated pain or paresthesias. Magnetic resonance imaging of the patient's lumbar spine performed in September of 2009 revealed fibrotic changes, consistent with scar tissue formation, over the L2 and L3 spinous processes. There was no evidence of intrathecal scar tissue, adhesions, neuroma formation, or other changes that could be attributed to repeated lumbar puncture. Although uneventful in our single patient, safety with respect to the development of transient or permanent neurologic complications, infections, or subclinical pathology identified by imaging cannot be broadly extrapolated to repeat lumbar punctures.