Neurovascular Complications of Iatrogenic Fusarium solani Meningitis.

A multinational outbreak of nosocomial fusarium meningitis occurred among immunocompetent patients who had undergone surgery with epidural anesthesia in Mexico. The pathogen involved had a high predilection for the brain stem and vertebrobasilar arterial system and was associated with high mortality from vessel injury. Effective treatment options remain limited; in vitro susceptibility testing of the organism suggested that it is resistant to all currently approved antifungal medications in the United States. To highlight the severe complications associated with fusarium infection acquired in this manner, we report data, clinical courses, and outcomes from 13 patients in the outbreak who presented with symptoms after a median delay of 39 days.

The application of DPE, CSEA, and EA in labor analgesia for nulliparous women and their impact on maternal and infant safety.

This work compared the effects of dural puncture epidural (DPE), combined spinal epidural analgesia (CSEA) and epidural analgesia (EA) on labor analgesia for primiparae and their impacts on maternal and infant safety. A total of 204 primiparae in need of labor analgesia for vaginal delivery were allocated to DPE, CSEA and EA groups. At 10 min, 30 min and 1 h after analgesia, the DPE and CSEA groups showed lower VAS scores and quicker onset of action than EA group. There was no significant difference in the duration of analgesia and labor and fetal decelerations among the 3 groups. At 1 min and 5 min after childbirth, the neonatal Apgar scores showed no significant difference between the 3 groups. The Bromage scores of DPE and EA groups were lower than those of CSEA group. The incidence of pruritus, hypotension, and postpartum headache in DPE and EA groups were lower than those in CSEA group. To sum up, the efficacy of DPE in labor analgesia for primiparae is similar to that of CSEA, with no obvious effect on labor stage and neonatal Apgar score, no additional complications and less LLMB, pruritus, hypotension and postpartum headache.

Epidural analgesia in labour: separating fact from fiction for autism and neurodevelopment.

Having epidural analgesia in labour has been associated with a later diagnosis of autism spectrum disorder in the offspring, resulting in concerns about childhood wellbeing. Neurodevelopmental changes are inconsistently reported in the literature, creating challenges in the interpretation of these findings. Here we explore the limitations of the current evidence base, and why findings differ between studies, concluding that the current body of evidence does not support a causal association between use of epidural analgesia in labour and autism spectrum disorder.

Behavioural and neuropsychological outcomes in children exposed in utero to maternal labour epidural analgesia.

BACKGROUND: Recent studies report conflicting results regarding the relationship between labour epidural analgesia (LEA) in mothers and neurodevelopmental disorders in their offspring. We evaluated behavioural and neuropsychological test scores in children of mothers who used LEA. METHODS: Children enrolled in the Raine Study from Western Australia and delivered vaginally from a singleton pregnancy between 1989 and 1992 were evaluated. Children exposed to LEA were compared with unexposed children. The primary outcome was the parent-reported Child Behaviour Checklist (CBCL) reporting total, internalising, and externalising behavioural problem scores at age 10 yr. Score differences, an increased risk of clinical deficit, and a dose-response based on the duration of LEA exposure were assessed. Secondary outcomes included language, motor function, cognition, and autistic traits. RESULTS: Of 2180 children, 850 (39.0%) were exposed to LEA. After adjustment for covariates, exposed children had minimally increased CBCL total scores (+1.41 points; 95% confidence interval [CI] 0.09 to 2.73; P=0.037), but not internalising (+1.13 points; 95% CI -0.08 to 2.34; P=0.066) or externalising (+1.08 points; 95% CI -0.08 to 2.24; P=0.068) subscale subscores. Increased risk of clinical deficit was not observed for any CBCL score. For secondary outcomes, score differences were inconsistently observed in motor function and cognition. Increased exposure duration was not associated with worse scores in any outcomes. CONCLUSIONS: Although LEA exposure was associated with slightly higher total behavioural scores, there was no difference in subscores, increased risk of clinical deficits, or dose-response relationship. These results argue against LEA exposure being associated with consistent, clinically significant neurodevelopmental deficits in children.

Using part of the initial analgesic dose as the epidural test dose did not delay the onset of labor analgesia: a randomized controlled clinical trial.

BACKGROUND: Epidural test dose for labor analgesia is controversial and varies widely in clinical practice. It is currently unclear whether using a portion of the initial dose for analgesia as the test dose delays the onset time of analgesia, compared to the traditional test dose. METHODS: One hundred and twenty-six parturients who chose epidural analgesia during labor were randomly assigned to two groups. The first dose in group L was 3 ml 1.5% lidocaine, and in the RF group was 10 ml 0.1% ropivacaine combined with 2 µg/ml fentanyl. After 3 min of observation, both groups received 8 ml 0.1% ropivacaine combined with 2 µg/ml fentanyl. The onset time of analgesia, motor and sensory blockade level, numerical pain rating scale, patient satisfaction score, and side effects were recorded. RESULTS: The onset time of analgesia in group RF was similar to that in group L (group RF vs group L, 7.0 [5.0-9.0] minutes vs 8.0 [5.0-11.0] minutes, p = 0.197). The incidence of foot numbness (group RF vs group L, 34.9% vs 57.1%, p = 0.020) and foot warming (group RF vs group L, 15.9% vs 47.6%, p < 0.001) in group RF was significantly lower than that in group L. There was no difference between the two groups on other outcomes. CONCLUSIONS: Compared with 1.5% lidocaine 3 ml, 0.1% ropivacaine 10 ml combined with 2 µg/ml fentanyl as an epidural test dose did not delay the onset of labor analgesia, and the side effects were slightly reduced. CLINICAL TRIAL REGISTRATION: http://www.chictr.org.cn (ChiCTR2100043071).

Parturients feel capable of giving informed consent for epidural analgesia: A qualitative and quantitative analysis.

INTRODUCTION: The patient's right to autonomy confirmed by informed consent is a cornerstone in modern medicine. Epidural analgesia is increasingly popular in obstetric analgesia, but physicians disagree whether labour pain impairs parturient decision-making. We investigated the fraction of parturients feeling capable of giving informed consent including their knowledge of risks. METHODS: Bedside survey postpartum women at the Herlev Hospital, Denmark. The inclusion criteria were recipient of epidural analgesia during labour. A power calculation based on the recognition of genuine and false side effects required the inclusion of 50 participants. RESULTS: Forty out of fifty (80%) of the participants felt they could make a judicious consent during labour and 46 out of 50 (92%) felt they knew enough about epidural analgesia to give consent to the procedure again if necessary. Participants spontaneously reported a median of two risks associated with epidural analgesia. Additionally, when prompted with a cued list of true and false risks from epidural analgesia, the participants reported on average 5.1 genuine risks compared with 0.4 made-up risks. The difference (4.7) suggests the included women could discern genuine risks from made-up risks. DISCUSSION: The majority of participants reported the capacity to give informed consent. Our quantitative results show the participants could clearly distinguish genuine risks of epidural labour analgesia from made-up risks. Our qualitative data likewise suggest that participants understood the information and consequently their informed consent was genuine. Accordingly, parturients are able to give informed consent. This is supported by parturients' ability to identify risks from epidural labour analgesia.

Race-Based Variation in the Utilization of Epidural Analgesia in Addition to General Anesthesia for Open Abdominal Aortic Aneurysm Repair in the United States.

BACKGROUND: Epidural analgesia (EA) is recommended along with general anesthesia (GA) for patients undergoing open abdominal aortic aneurysm repair (AAA) and is known to be associated with improved postoperative outcomes. This study evaluates inequities in using this superior analgesic approach and further assesses the disparities at patient and hospital levels. METHODS: A retrospective analysis was performed using the Vascular Quality Initiative database of adult patients undergoing elective open AAA repair between 2003 and 2022. Patients were grouped and analyzed based on anesthesia utilization, that is, EA + GA (Group I) and GA only (Group II). Study groups were further stratified by race, and outcomes were studied. Univariate and multivariate analyses were performed to study the impact of race on the utilization of EA with GA. A subgroup analysis was also carried out to learn the EA analgesia utilization in hospitals performing open AAA with the least to most non-White patients. RESULTS: A total of 8,940 patients were included in the study, of which EA + GA (Group I) comprised n = 4,247 (47.5%) patients, and GA (Group II) had n = 4,693 (52.5%) patients. Based on multivariate regression analysis, the odds ratio of non-White patients receiving both EA and GA for open AAA repair compared to White patients was 0.76 (95% confidence interval: 0.53-0.72, P < 0.001). Of the patients who received both EA + GA, non-White race was associated with increased length of intensive care unit stay and a longer total length of hospital stay compared to White patients. Hospitals with the lowest quintile of minorities had the highest utilization of EA + GA for all patients compared to the highest quintile. CONCLUSIONS: Non-White patients are less likely to receive the EA + GA than White patients while undergoing elective open AAA repair, demonstrating a potential disparity. Also, this disparity persists at the hospital level, with hospitals with most non-White patients having the least EA utilization, pointing toward system-wide disparities.

The association between epidural labour analgesia and postpartum depression: a randomised controlled trial.

There is conflicting evidence regarding the association between epidural labour analgesia and risk of postpartum depression. Most previous studies were observational trials with limited ability to account for confounders. We aimed to determine if epidural analgesia was associated with a significant change in the incidence of postpartum depression in this randomised controlled trial. We enrolled women aged 21-50 years old with a singleton fetus ≥ 36 weeks gestation. Patients were advised regarding available labour analgesic modalities during enrolment (epidural block; intramuscular pethidine; nitrous oxide; or intravenous remifentanil). On request for analgesia, patients were offered the modality that they had been allocated randomly to first. Blinded investigators recorded patient and obstetric characteristics within 24 h of delivery and assessed for postpartum depression at 6-10 weeks following delivery using the Edinburgh Postnatal Depression Scale (score ≥ 13 considered positive for postpartum depression). The modified intention-to-treat population consisted of all patients who received any form of labour analgesia, while per-protocol consisted of patients who received their randomised modality as their first form of labour analgesia. Of 881 parturients allocated randomly (epidural n = 441, non-epidural n = 440), we analysed 773 (epidural n = 389, non-epidural n = 384); 62 (15.9%) of women allocated to epidural group developed postpartum depression compared with 65 (16.9%) women allocate to the non-epidural group. There were no significant differences in the incidence of postpartum depression between the two groups (adjusted risk difference (95%CI) 1.6 (-3.0-6.3%), p = 0.49). Similar results were obtained with per-protocol analysis (adjusted risk difference (95%CI) -1.0 (-8.3-6.3%), p = 0.79). We found no significant difference in the risk of postpartum depression between patients who received epidural labour analgesia and those who utilised non-epidural analgesic modalities.

Socio-economic disadvantage and utilisation of labour epidural analgesia in Scotland: a population-based study†.

Socio-economic deprivation is associated with adverse maternal and childhood outcomes. Epidural analgesia, the gold standard for labour analgesia, may improve maternal well-being. We assessed the association of socio-economic status with utilisation of epidural analgesia and whether this differed when epidural analgesia was advisable for maternal safety. This was a population-based study of NHS data for all women in labour in Scotland between 1 January 2007 and 23 October 2020, excluding elective caesarean sections. Socio-economic status deciles were defined using the Scottish Index of Multiple Deprivation. Medical conditions for which epidural analgesia is advisable for maternal safety (medical indications) and contraindications were defined according to national guidelines. Of 593,230 patients in labour, 131,521 (22.2%) received epidural analgesia. Those from the most deprived areas were 16% less likely to receive epidural analgesia than the most affluent (relative risk 0.84 [95%CI 0.82-0.85]), with the inter-decile mean change in receiving epidural analgesia estimated at -2% ([95%CI -2.2% to -1.7%]). Among the 21,219 deliveries with a documented medical indication for epidural analgesia, the socio-economic gradient persisted (relative risk 0.79 [95%CI 0.75-0.84], inter-decile mean change in receiving epidural analgesia -2.5% [95%CI -3.1% to -2.0%]). Women in the most deprived areas with a medical indication for epidural analgesia were still less likely (absolute risk 0.23 [95%CI 0.22-0.24]) to receive epidural analgesia than women from the most advantaged decile without a medical indication (absolute risk 0.25 [95%CI 0.24-0.25]). Socio-economic deprivation is associated with lower utilisation of epidural analgesia, even when epidural analgesia is advisable for maternal safety. Ensuring equitable access to an intervention that alleviates pain and potentially reduces adverse outcomes is crucial.

Influence of Regional Analgesia on Self-Reported Quality of Sleep After Gynecological Abdominal Surgery: A Secondary Analysis of a Randomized Trial.

OBJECTIVES: To determine whether intrathecal morphine (ITM) analgesia in abdominal surgery for presumed gynecological malignancy was associated with better self-reported sleep quality postoperatively compared with epidural analgesia (EDA), and to evaluate risk factors for bad sleep quality. METHODS: A secondary analysis of a randomized open controlled trial, comparing ITM and EDA as postoperative analgesia in 80 women undergoing laparotomy under general anaesthesia in an enhanced recovery after surgery framework. A total of 38 women allocated to ITM and 39 to EDA completed the study. The Swedish Postoperative Symptoms Questionnaire assessed symptoms and sleep quality during the first postoperative week. Multiple logistic regression models evaluated risk factors. The results are presented as adjusted odds ratios with 95% CIs. RESULTS: The sleep quality night-by-night did not differ significantly between the women who had ITM or EDA. Risk factors for bad sleep quality for night 1 were age (0.91; 0.84-0.99), operation time (1.02; 1.00-1.03), and opioid consumption (0.96; 0.91-0.99). For night 2, regular use of hypnotics preoperatively (15.81; 1.52-164.27) and opioid consumption (1.07; 1.00-1.14) were independent risk factors for bad sleep. After the second night, no risk factors were disclosed. CONCLUSIONS: ITM and EDA did not appear to affect the sleep quality postoperatively differently in women undergoing laparotomy for presumed gynecological malignancy. Risk factors for self-reported bad sleep quality varied during the first 3 days after surgery. Younger age, longer operation time, and preoperative use of hypnotics were associated with bad sleep quality, whereas the effect of opioid consumption on sleep quality varied depending on the time since surgery. These findings merit further studies.

Sphenopalatine ganglion blocks for post-dural puncture headache: A case report in a 3-year-old child.

Post-dural puncture headache is a distressing complication that may occur after lumbar puncture or unintentional dural puncture. Risk factors in the pediatric population have not been well elicited, and the true incidence is unknown. Conservative management includes conservative physical measures and medical therapies. Epidural blood patch remains the gold standard for managing severe refractory headache, but greater occipital nerve blocks and sphenopalatine ganglion blocks have been used with success. Sphenopalatine ganglion blocks are easy to perform, minimally invasive and, in the postoperative setting where epidural analgesia is utilized, provide an alternative that should be considered.

Prolonged second stage of labor in delivery using epidural analgesia is a risk factor for postpartum urinary retention.

AIM: To determine the postpartum urinary retention rate and risk factors after delivery using epidural analgesia. METHODS: This single-center retrospective study targeted 341 women who gave birth after at least 37 weeks of gestation from April to August 2021; from this cohort, 208 patients were examined. The postpartum urinary retention rate was compared between the no epidural analgesia group (n = 107) and epidural analgesia group (n = 101). Subsequently, risk factors for postpartum urinary retention were investigated in the epidural analgesia group. RESULTS: After adjustment by propensity score matching for age, body mass index, being primiparous, and labor induction as covariates, the analysis of the incidence of postpartum urinary retention revealed that the epidural analgesia group exhibited a significantly higher postpartum urinary retention rate than the no epidural analgesia group (30% vs. 11%, p = 0.02). The investigation results regarding risk factors for postpartum urinary retention in the epidural analgesia group obtained through a univariate analysis showed that being primiparous and having a prolonged second stage of labor were significantly correlated with postpartum urinary retention. Multivariate analysis indicated that a prolonged second stage of labor was an independent risk factor for postpartum urinary retention (p = 0.03; odds ratio: 3.18; 95% confidence interval: 1.08-9.77). All patients recovered from postpartum urinary retention by day 4. CONCLUSIONS: The postpartum urinary retention rate after delivery using epidural analgesia was 25.7%. In the case of epidural analgesia deliveries, a prolonged second stage of labor was an independent risk factor for postpartum urinary retention.

Examining the relationship between autism spectrum disorder in children whose mother had labour epidural analgesia for their birth: A retrospective cohort study.

BACKGROUND: Controversy exists regarding the association between autism spectrum disorder (ASD) in children whose mother had labour epidural analgesia for their birth, as the few existing investigations have reported mixed findings. OBJECTIVE: This study aims to evaluate the possibility of an association in our heterogeneous population. DESIGN: A retrospective population-based cohort study. SETTING: Vaginal deliveries that took place between the years 2005 and 2017 at Soroka University Medical Center, a tertiary referral hospital in Israel, and a follow-up on the incidence of ASD in the children. PATIENTS: A hundred and thirty-nine thousand, nine hundred and eighty-one labouring patients and their offspring. MAIN OUTCOME MEASURES: The incidence of children diagnosed with ASD (both hospital and community-based diagnoses) was compared based on whether their mothers had received labour epidural analgesia during their labour. A Kaplan-Meier survival curve compared cumulative incidence of ASD. A Cox proportional hazards model was used to control for relevant confounders. RESULTS: Labour epidural analgesia was administered to 33 315 women. Epidural analgesia was more common among high-risk pregnancy groups (including pregnancies complicated with diabetes mellitus, hypertensive disorders, intrauterine growth restriction, and oligohydramnios; P  < 0.001). In a Cox proportional hazards model, the association between epidural analgesia during labour and ASD in the children lost statistical significance following adjustment for confounders such as maternal age, gestational age, hypertensive disorders, diabetes mellitus, and ethnicity [adjusted hazard ratio = 1.13, 95% confidence interval (CI), 0.96 to 1.34, P  = 0.152]. CONCLUSION: In our population, after adjusting for confounders, epidural analgesia is not independently associated with autism spectrum disorder in the children. These findings enhance our knowledge regarding the safety of epidural analgesia and enable patients to make informed decisions about their pain relief techniques during labour.

Maternal intrapartum fever during epidural labour analgesia: Incidence and influencing factors.

BACKGROUND: The management and nursing care of women's temperature during delivery is an important part of clinical obstetrics. We aimed to evaluate maternal intrapartum fever during epidural labour analgesia to provide evidence for the management and care of women in labour. METHODS: This study was conducted and reported according to the STROBE statement. Women in labour undergoing epidural labour analgesia in our hospital from 1 January 2021 to 31 August 2022 were retrospectively selected. The characteristics of women in labour with and without intrapartum fever were compared. Pearson correlation and logistic regression analysis were used to analyse the influencing factors of postpartum fever. RESULTS: A total of 196 women in labour were included, the incidence of maternal intrapartum fever in women in labour undergoing epidural analgesia was 27.5%. Pearson correlation analyses showed that BMI, oxytocin use, labour duration, number of vaginal examinations, time from rupture of the foetal membranes to the end of labour and duration of epidural analgesia were all correlated with the occurrence of intrapartum fever (all P < 0.05). Logistic regression analyses indicated that body mass index ≥28 kg/m2 (OR = 1.825), oxytocin use (OR = 2.082), labour duration ≥9.2 h (OR = 2.613), number of vaginal examinations ≥8 (OR = 2.044-3.115), the time from rupture of the foetal membranes to the end of labour ≥250 min (OR = 2.766) and duration of epidural analgesia ≥300 min (OR = 3.106) were risk factors for intrapartum fever in women in labour undergoing epidural analgesia (all P < 0.05). CONCLUSIONS: Maternal intrapartum fever in women in labour undergoing epidural analgesia is common and influenced by many factors. Nurses should take early preventive care measures according to these factors during epidural analgesia in labour.

Long-term effects of neuraxial analgesia.

PURPOSE OF REVIEW: This review article explores the potential longer-term implications of neuraxial analgesia in labour for both the mother and her child. RECENT FINDINGS: Neuraxial techniques for labour analgesia are well tolerated and effective, and long-term adverse sequelae are rare. Labour epidural analgesia is not independently associated with long-term headache, backache, postnatal depression or anal sphincter injury, and evidence supports that epidurals may offer protection against severe maternal morbidity, particularly in women at a higher risk of complications. However, there is an increasing awareness that postdural puncture headache may be associated with chronic headache, back pain and postnatal depression, emphasizing the need for adequate follow-up until symptoms resolve.For the neonate, a growing body of evidence refutes any association between epidural analgesia in labour and the later development of autism spectrum disorder. The clinical significance of epidural related maternal fever remains uncertain and is a research priority. SUMMARY: Women should continue to access the significant benefits of neuraxial analgesia in labour without undue concern about adverse sequelae for themselves or their offspring. Measures to prevent, appropriately manage and adequately follow-up women who have suffered complications of neuraxial analgesia, such as postdural puncture headache, are good practice and can mitigate the development of long-term sequelae.

Epidural-related maternal fever: incidence, pathophysiology, outcomes, and management.

Epidural-related maternal fever affects 15% to 25% of patients who receive a labor epidural. Two meta-analyses demonstrated that epidural-related maternal fever is a clinical phenomenon, which is unlikely to be caused by selection bias. All commonly used neuraxial techniques, local anesthetics with or without opioids, and maintenance regimens are associated with epidural-related maternal fever, however, the impact of each component is unknown. Two major theories surrounding epidural-related maternal fever development have been proposed. First, labor epidural analgesia may lead to the development of hyperthermia through a sterile (noninfectious) inflammatory process. This process may involve reduced activation of caspase-1 (a protease involved in cell apoptosis and activation of proinflammatory pathways) secondary to bupivacaine, which impairs the release of the antipyrogenic cytokine, interleukin-1-receptor antagonist, from circulating leucocytes. Detailed mechanistic processes of epidural-related maternal fever remain to be determined. Second, thermoregulatory mechanisms secondary to neuraxial blockade have been proposed, which may also contribute to epidural-related maternal fever development. Currently, there is no prophylactic strategy that can safely prevent epidural-related maternal fever from occurring nor can it easily be distinguished clinically from other causes of intrapartum fever, such as chorioamnionitis. Because intrapartum fever (of any etiology) is associated with adverse outcomes for both the mother and baby, it is important that all parturients who develop intrapartum fever are investigated and treated appropriately, irrespective of labor epidural utilization. Institution of treatment with appropriate antimicrobial therapy is recommended if an infectious cause of fever is suspected. There is currently insufficient evidence to warrant a change in recommendations regarding provision of labor epidural analgesia and the benefits of good quality labor analgesia must continue to be reiterated to expectant mothers.

Characterization of Epidural Analgesia Interruption and Associated Outcomes After Esophagectomy.

INTRODUCTION: Interruption of thoracic epidural analgesia may impact the postoperative course following esophagectomy. This study investigates the incidence and causes of epidural interruption in esophagectomy patients along with associated postoperative outcomes. METHODS: This single-institution retrospective analysis examined patients undergoing esophagectomy who received a thoracic epidural catheter from 2016 to 2020. Patients were stratified according to whether epidural catheter infusion was interrupted or not postoperatively. Outcomes were compared between the two groups, and predictors of epidural interruption and postoperative complications were estimated using multivariable logistic regression. RESULTS: Of the 168 patients who received a thoracic epidural before esophagectomy, 60 (35.7%) required epidural interruption and 108 (64.3%) did not. Interruption commonly occurred on postoperative day 1 and was due to hypotension 80% of the time. Heart failure (10.0% versus 0.9%, P = 0.009), atrial fibrillation (20.0% versus 3.7%, P = 0.002), preoperative opioid use (30.0% versus 16.7%, P = 0.043), and higher American Society of Anesthesiology classification (88.4% versus 70.4%, P = 0.008) were more prevalent in the epidural interruption cohort. The female gender was associated with epidural interruption on multivariable logistic regression (adjusted odds ratio [AOR] 2.45, P = 0.039). Patients in the epidural interruption cohort had a higher incidence of delirium (30.5% versus 13.9%, P = 0.010), sepsis (13.6% versus 3.7%, P = 0.028), and severe anastomotic leak (18.3% versus 7.4%, P = 0.032). On adjusted analysis, heart disease (AOR 4.26, P = 0.027), BMI <18.5 (AOR 9.83, P = 0.031), and epidural interruption due to hypotension (AOR 3.51, P = 0.037) were associated with severe anastomotic leak. CONCLUSIONS: Early epidural interruption secondary to hypotension in esophagectomy patients may be a harbinger of postoperative complications such as sepsis and severe anastomotic leak. Patients requiring epidural interruption due to hypotension should have a low threshold for additional workup and early intervention.

Thoracic epidural analgesia in intensive care unit patients with acute pancreatitis: the EPIPAN multicenter randomized controlled trial.

BACKGROUND: Findings from preclinical studies and one pilot clinical trial suggest potential benefits of epidural analgesia in acute pancreatitis. We aimed to assess the efficacy of thoracic epidural analgesia, in addition to usual care, in improving clinical outcomes of intensive care unit patients with acute pancreatitis. METHODS: A multicenter, open-label, randomized, controlled trial including adult patients with a clinical diagnosis of acute pancreatitis upon admission to the intensive care unit. Participants were randomly assigned (1:1) to a strategy combining thoracic epidural analgesia and usual care (intervention group) or a strategy of usual care alone (control group). The primary outcome was the number of ventilator-free days from randomization until day 30. RESULTS: Between June 2014 and January 2019, 148 patients were enrolled, and 135 patients were included in the intention-to-treat analysis, with 65 patients randomly assigned to the intervention group and 70 to the control group. The number of ventilator-free days did not differ significantly between the intervention and control groups (median [interquartile range], 30 days [15-30] and 30 days [18-30], respectively; median absolute difference of - 0.0 days, 95% CI - 3.3 to 3.3; p = 0.59). Epidural analgesia was significantly associated with longer duration of invasive ventilation (median [interquartile range], 14 days [5-28] versus 6 days [2-13], p = 0.02). CONCLUSIONS: In a population of intensive care unit adults with acute pancreatitis and low requirement for intubation, this first multicenter randomized trial did not show the hypothesized benefit of epidural analgesia in addition to usual care. Safety of epidural analgesia in this setting requires further investigation. TRIAL REGISTRATION: ClinicalTrials.gov registration number NCT02126332 , April 30, 2014.

Epidural analgesia and emergency delivery for presumed fetal compromise: post-hoc analysis of RAVEL multicenter randomized controlled trial.

OBJECTIVE: To investigate the association between epidural analgesia (EDA) vs patient-controlled remifentanil analgesia (PCRA) and emergency delivery for presumed fetal compromise, in relation to birth-weight quintile. METHODS: This was a post-hoc per-protocol analysis of the RAVEL multicenter equivalence randomized controlled trial. Non-anomalous singleton pregnancies between 36 + 0 and 42 + 6 weeks' gestation were randomized at the time of requesting pain relief to receive EDA or PCRA. The primary outcome was emergency delivery for presumed fetal compromise. Secondary outcomes included mode of delivery and neonatal outcomes. Analysis was performed according to birth-weight quintile and was corrected for relevant confounding variables. RESULTS: Of 619 pregnant women, 336 received PCRA and 283 received EDA. Among women receiving EDA, 14.8% had an emergency delivery for presumed fetal compromise, compared with 8.3% of women who received PCRA. After adjusting for parity, women receiving EDA had higher odds of presumed fetal compromise compared to those receiving PCRA (odds ratio, 1.69 (95% CI, 1.01-2.83)). A statistically significant linear-by-linear association was observed between presumed fetal compromise and birth-weight quintile (P = 0.003). The incidence of emergency delivery for presumed fetal compromise was highest in women receiving EDA and delivering a neonate with a birth weight in the lowest quintile. CONCLUSIONS: Intrapartum EDA is associated with a higher rate of emergency delivery for presumed fetal compromise compared to treatment with PCRA. Birth-weight quintile is a strong predictor of this outcome, independent of pain management method. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Effect of intrapartum epidural analgesia on rate of emergency delivery for presumed fetal compromise: nationwide registry-based cohort study.

OBJECTIVES: To determine the rate of emergency delivery for presumed fetal compromise after epidural analgesia (EDA) compared with that after alternative analgesia or no analgesia, and to assess whether this rate is increased in pregnancies with reduced placental reserve. METHODS: This was a nationwide registry-based cohort study of 629 951 singleton pregnancies delivered at 36 + 0 to 42 + 0 weeks of gestation that were recorded in the Dutch national birth registry between 2014 and 2018, including 120 426 cases that received EDA, 86 957 that received alternative analgesia and 422 568 that received no analgesia during labor. Pregnancies with congenital anomaly, chromosomal abnormality, fetal demise, planned Cesarean delivery, non-cephalic presentation at delivery and use of multiple forms of analgesia were excluded. The primary outcome was emergency delivery for presumed fetal compromise. Secondary outcomes included delivery characteristics and neonatal outcome. Negative binomial regression analysis was stratified by parity and results are presented according to birth-weight centile, after adjusting for confounding. RESULTS: Among women who received EDA, 13.2% underwent emergency delivery for presumed fetal compromise, compared with 4.1% of women who had no analgesia (relative risk (RR), 3.23 (95% CI, 3.16-3.31)) and 7.0% of women who received alternative analgesia (RR, 1.72 (95% CI, 1.67-1.77)). Independent of birth weight, the RR of presumed fetal compromise after EDA vs no analgesia was higher in parous women (adjusted RR (aRR), 2.15 (95% CI, 2.04-2.27)) compared with nulliparous women (RR, 1.88 (95% CI, 1.84-1.94)). Stratified for parity, the effect of EDA was modified significantly by birth-weight centile (interaction P-value, < 0.001 for nulliparous and 0.004 for parous women). The emergency delivery rate following EDA was highest in those with a birth weight < 5th centile (25.2% of nulliparous and 16.6% of parous women), falling with each increasing birth-weight centile category up to the 91st -95th centile (11.8% of nulliparous and 7.2% of parous women). CONCLUSIONS: Intrapartum EDA is associated with a higher risk of emergency delivery for presumed fetal compromise compared with no analgesia and alternative analgesia, after adjusting for relevant confounding. The highest rate of emergency delivery for presumed fetal compromise was observed at the lowest birth-weight centiles. RRs of emergency delivery for presumed fetal compromise after EDA were modestly but consistently modified by birth-weight centile, supporting the hypothesis that the adverse effects of EDA are exacerbated by reduced placental function. While EDA provides effective pain relief during labor, alternative strategies for pain management may be preferable in pregnancies with a high background risk of fetal compromise. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.