Additive value of superficial parasternal intercostal plane block and serratus anterior plane block in lung transplantation surgery: a retrospective exploratory study.

BACKGROUND: Adequate pain control following lung transplantation (LTx) surgery is paramount. Thoracic epidural analgesia (TEA) is the gold standard; however, the potential use of extracorporeal membrane oxygenation (ECMO) and consequent anticoagulation therapy raises safety concerns, prompting clinicians to seek safer alternatives. The utility of thoracic wall blocks in general thoracic surgery is well established; however, their role in the context of LTx has been poorly investigated. METHODS: In this retrospective exploratory study, we assessed the effect of adding a superficial parasternal intercostal plane (sPIP) block and serratus anterior plane (SAP) block to standard anesthetic and analgesic care on tracheal extubation rates, pain scores and opioid consumption until 72 hours postoperatively in LTx. RESULTS: Sixty patients were included in the analysis; 35 received the standard anesthetic and analgesic care (control group), and 25 received sPIP and SAP blocks in addition to the standard anesthetic and analgesic care (intervention group). We observed higher tracheal extubation rates in the intervention group at 8 hours postoperatively (16.0% vs 0.0%, p=0.03). This was also shown after adjusting for known prognostic factors (OR 1.18; 95% CI 1.04 to 1.33, p=0.02). Furthermore, we noted a lower opioid consumption measured by morphine milligram equivalents at 24 hours in the intervention group (median 405 (IQR 300-490) vs 266 (IQR 168-366), p=0.02). This was also found after adjusting for known prognostic factors (ß -118; 95% CI -221 to 14, p=0.03). CONCLUSION: sPIP and SAP blocks are safe regional analgesic techniques in LTx involving ECMO and clamshell incision. They are associated with faster tracheal extubation and lower opioid consumption. These techniques should be considered when TEA is not appropriate. Further high-quality studies are warranted to confirm these findings.

The association between fetal head station at the first diagnosis of the second stage of labor and delivery outcomes.

BACKGROUND: Controversy surrounds the impact of the fetal head station on labor duration and mode of delivery. Although an extensive body of evidence has been published evaluating fetal head station in early labor, there is a paucity of data on the impact of fetal head descent during the second stage. OBJECTIVE: This study aimed to explore the association between fetal head station at the diagnosis of the second stage of labor and the second stage duration and the risk of operative delivery. STUDY DESIGN: This is a retrospective cohort study of all singleton vertex deliveries in a single tertiary center (2011-2016). Women were grouped according to fetal head station upon the diagnosis of the second stage of labor as follows: above (S<0), at the level (S=0), and below (S>0) the level of the ischial spine. The duration of the second stage and the risk of operative delivery were compared between the groups and stratified by parity. RESULTS: Overall, 34,334 women met the inclusion criteria. Of these, 18,743 (54.6%) were nulliparous and 15,591 (45.4%) were multiparous. Of the nulliparous women, 8.1%, 35.8%, and 56.1% were diagnosed as having fetal head above, at the level, and below the ischial spine upon second stage diagnosis. Of the multiparous women, 19.7%, 35.6%, and 44.7% were diagnosed as having fetal head above, at the level, and below the ischial spine. Fetal head station upon second stage diagnosis was independently and significantly associated with second stage duration (P<.001); however, its contribution was 4.5-fold among nulliparous women compared with multiparous women. In multivariable analysis, after controlling for maternal age, gestational age at delivery, prepregnancy body mass index, epidural anesthesia, and birthweight, the risk of operative delivery was substantially increased in a dose-dependent pattern for both nulliparous and multiparous women. CONCLUSION: The fetal head station at the first diagnosis of the second stage is significantly and independently associated with the duration of the second stage and correlated with the risk of operative delivery in both nulliparous and multiparous women (P<.001).

Long-term psychological and physical outcomes of women after postdural puncture headache: A retrospective, cohort study.

BACKGROUND: Postdural puncture headache after accidental dural puncture during labour may lead to chronic sequalae. OBJECTIVES: We aimed to measure the incidence of postpartum depression, posttraumatic stress disorder, chronic headache, backache and breastfeeding rates after a postdural puncture headache. DESIGN: A retrospective, case-matched cohort study. SETTING: A review of documented cases of dural puncture and matched case controls occurring at Rabin Medical Center and Shamir Medical Center from 01 January 2012 to 30 September 2018. PATIENTS: The study cohort consisted of women with a documented postdural puncture headache and the controls were women with uneventful labour epidurals in the same 24-h period. Women were interviewed by telephone. PRIMARY OUTCOMES MEASURE: The primary outcome measure was the incidence of postpartum depression after a postdural puncture headache. RESULTS: Women with postdural puncture headache (n = 132) and controls (n = 276) had similar demographic data. The incidence of postpartum depression was 67/128 (52.3%) versus 31/276 (11.2%) for controls, P < 0.0001, 95% confidence intervals of the difference 31.5 to 50.2. Posttraumatic stress disorder was more frequent among women with postdural puncture headache, 17/132 (12.8%) versus controls 1/276 (0.4%), P < 0.0001, 95% confidence intervals of the difference 7.6 to 19.5. Women with postdural puncture headache breastfed less, 74/126 (54.5%) versus controls 212/276 (76.8%), P < 0.0001, 95% confidence intervals of the difference 33.1 to 55.2. Current headache and backache were significantly more frequent among women with postdural puncture headache [current headache 42/129 (32.6%) versus controls 42/276 (15.2%) P < 0.00001, 95% confidence intervals 0.085 to 0.266; current backache 58/129 (43.9%) versus controls 58/275 (21%) P < 0.0001, 95% confidence intervals 14.1 to 33.5]. CONCLUSION: We report an increased incidence of postpartum depression, posttraumatic stress disorder, chronic headache and backache and decreased breastfeeding following a postdural puncture headache. Our findings emphasise the need for postpartum follow-up for women with postdural puncture headache. TRIAL REGISTRY NUMBER: Clinical trial registry number: NCT03550586.

[MALIGNANT HYPERTHERMIA].

INTRODUCTION: In this article we describe the treatment of a patient who developed suspicious symptoms of malignant hyperthermia syndrome during anesthesia for elective cerebral catheterization. We also described an up-to-date review of malignant hyperthermia, diagnosis and treatment. Details regarding the case: this is a case of a 57 year old male patient who was admitted for an elective catheterization under general anesthesia. Four hours following anesthesia induction, the patient presented with the following symptoms: a gradual increase in end tidal carbon dioxide measurements, an elevated core temperature, tachycardia, decreased oxygen saturation and excessive sweating. Arterial blood gases indicated respiratory acidosis. With a clinical diagnosis of malignant hyperthermia, the catheterization procedure was stopped. The patient was disconnected from the anesthesia machine and was ventilated with a clean ventilator with 100% oxygen. Additionally, active patient cooling was initiated along with supportive pharmacologic treatment. The patient was then moved, anesthetized and ventilated into the post anaesthesia care unit. Following a clinical and laboratory improvement the patient was extubated.

Contemporary patterns of labor in nulliparous and multiparous women.

BACKGROUND: Controversy surrounds the definition of "normal" and "abnormal" labor. OBJECTIVE: In this study, we used contemporary labor charts to explore labor patterns in large obstetric population (2011-2016). STUDY DESIGN: Detailed information from electronic medical records of live singleton deliveries at term (≥37 weeks of gestation) was extracted. Cases of elective cesarean deliveries, nonvertex presentation, and cesarean deliveries during the first stage of labor were excluded. RESULTS: Overall, 35,146 deliveries were included, of whom 15,948 deliveries (45.3%) were of nulliparous women. Median cervical dilation at admission was not significantly different between nulliparous (median, 4 cm; interquartile range, 3-5 cm) and multiparous women (median, 4 cm; interquartile range, 3-6 cm). In all, 99.3% of the women delivered vaginally. For nulliparous women, the median duration of the first stage of labor was 274 minutes (interquartile range, 145-441 minutes; 95th percentile, 747.5 minutes). Likewise, for multiparous women, the corresponding duration was 133 minutes (interquartile range, 56-244 minutes; 95th percentile, 494 minutes). During the latent phase (cervical dilation at admission, ≤4 cm), the time elapsed to the second stage of labor was 120-140 minutes longer in nulliparous women, whereas the gap between the groups decreased dramatically with advanced cervical dilation on admission. Nulliparous and multiparous women appeared to progress at a similar pace during the latent phase; however, after 5 cm, labor accelerated faster in multiparous women. Epidural anesthesia lengthens duration first and second stages of labor in all parities. Partograms according to cervical dilation at presentation are proposed. CONCLUSION: Cervical dilation rate is relatively constant between nulliparous and multiparous pregnant women during the latent phase. Time interval of the first stage was far slower than previously described, which allowed labor to continue for a longer period during this stage. These findings may reduce the rate of intrapartum iatrogenic interventions.

No longer rare diseases and obstetric anesthesia.

PURPOSE OF REVIEW: With new medical technologies and changing life styles, maternal demographics has changes and consequently older and sicker women are becoming pregnant.In this review, we present these different high-risk parturient populations, which were once considered rare for the practicing obstetric anesthesiologist. RECENT FINDINGS: With lifestyle and medical advances, older and sicker women are getting pregnant. Older women are more prone to pregnancy complications. Cancer survivors are becoming pregnant and more pregnant women are being diagnosed with cancer. Previous neurological and cardiac conditions considered not compatible with pregnancy are now seen more frequently. As the rate of obesity increases so does the rate of obstructive sleep apnea, which is known to be associated with many adverse maternal and neonatal sequalae. Finally, increased use of both opioids and marijuana has led to increased number of pregnant women using these illicit substances. SUMMARY: Future research and implementation of international guidelines for management of these high-risk parturient population is necessary in order to reduce maternal and neonatal morbidity.