Strategies for intraoperative glucose management: a scoping review.

PURPOSE: Perioperative hyperglycemia is associated with adverse outcomes for patients with and without diabetes. Guidelines and published protocols for intraoperative glycemic management have substantial variation in their recommendations. We sought to characterize the current evidence-guiding intraoperative glycemic management in a scoping review. SOURCES: Our search strategy included MEDLINE (Ovid and EBSCO), PubMed, PubMed Central, EMBASE, CINAHL, Cochrane Library, SciVerse Scopus, and Web of Science and a gray literature search of Google, Google Scholar, hand searching of the reference lists of included articles, OAISter, institutional protocols, and ClinicalTrails.gov. PRINCIPAL FINDINGS: We identified 41 articles that met our inclusion criteria, 24 of which were original research studies. Outcomes and exposures were defined heterogeneously across studies, which limited comparison and synthesis. Investigators often created arbitrary and differing categories of glucose values rather than analyzing glucose as a continuous variable, which limited our ability to combine results from different studies. In addition, the study populations and surgery types also varied considerably, with few studies performed during day surgeries and specific surgical disciplines. Study populations often included more than one type of surgery, indication, and urgency that were expected to have varying physiologic and inflammatory responses. Combining low- and high-risk patients in the same study population may obscure the harms or benefits of intraoperative glycemic management for high-risk procedures or patients. CONCLUSION: Future studies examining intraoperative glycemic management should carefully consider the study population, surgical characteristics, and pre- and postoperative management of hyperglycemia.

RéSUMé: OBJECTIF: L'hyperglycémie périopératoire est associée à des effets indésirables chez les patients diabétiques et non diabétiques. Les lignes directrices et les protocoles publiés pour la prise en charge glycémique peropératoire présentent des variations substantielles dans leurs recommandations. Nous avons cherché à caractériser les données probantes actuelles guidant la prise en charge glycémique peropératoire dans une étude de portée. SOURCES: Notre stratégie de recherche a inclus les bases de données MEDLINE (Ovid et EBSCO), PubMed, PubMed Central, EMBASE, CINAHL, Cochrane Library, SciVerse Scopus et Web of Science, ainsi qu'une recherche documentaire grise sur Google, Google Scholar, la recherche manuelle des listes de référence des articles inclus, OAISter, les protocoles institutionnels et ClinicalTrials.gov. CONSTATATIONS PRINCIPALES: Nous avons identifié 41 articles qui répondaient à nos critères d'inclusion, dont 24 étaient des études de recherche originales. Les critères d'évaluation et les expositions étaient définis de manière hétérogène d'une étude à l'autre, ce qui a limité la comparaison et la synthèse. Les chercheurs ont souvent créé des catégories arbitraires et différentes de valeurs glycémiques plutôt que d'analyser la glycémie comme une variable continue, ce qui a limité notre capacité à combiner les résultats de différentes études. En outre, les populations étudiées et les types de chirurgie variaient également considérablement, avec peu d'études réalisées lors de chirurgies ambulatoires et dans certaines disciplines chirurgicales spécifiques. Les populations étudiées comprenaient souvent plus d'un type de chirurgie, d'indication et d'urgence, pour lesquelles des réponses physiologiques et inflammatoires variables étaient attendues. La combinaison de patients à faible et à haut risque dans la même population d'étude a pu masquer les inconvénients ou les avantages d'une prise en charge glycémique peropératoire pour les interventions ou les patients à haut risque. CONCLUSION: Les études futures portant sur la prise en charge glycémique peropératoire devraient examiner attentivement la population étudiée, les caractéristiques chirurgicales et la prise en charge pré- et postopératoire de l'hyperglycémie.

The effectiveness of a multifaceted, group-facilitated audit and feedback intervention to increase tranexamic acid use during total joint arthroplasty.

PURPOSE: Intraoperative tranexamic acid (TXA) is used to reduce blood loss and the need for transfusions following total hip arthroplasty (THA) and total knee arthroplasty (TKA). Despite evidence in literature and local practice protocols supporting TXA as a part of standard of care for joint arthroplasty, TXA administration is underutilized. We aimed to use group-facilitated audit and feedback as the foundation of a knowledge translation strategy to increase TXA use for THA and TKA procedures. METHODS: Anesthesiologists consented to receive two data reports summarizing their individual rates of TXA use and postoperative blood transfusions compared with site peers. Variables collected included patient demographics, TXA usage, and the frequency and volume of red blood cell transfusions administered in the 72-hr postoperative period. The facilitated feedback session discussed report findings and focused on factors contributing to local practice patterns and opportunities for change. RESULTS: Tranexamic acid use increased for THA procedures at the intervention site from 66.6 to 74.4% (absolute change, 7.9%; 95% confidence interval [CI], 2.4 to 13.3). Likewise, TXA use for TKA procedures increased from 62.4 to 82.3% (absolute change, 19.9%; 95% CI 15.0 to 25.0). CONCLUSIONS: Physicians and their teams were able to review their practice data on TXA utilization, reflect on differences compared with evidence-based guidelines, discuss findings with peers, and identify opportunities for improvement. The intervention increased the use of TXA for both TKA and THA and shifted the dosage to better align with evidence-based practice guidelines.

RéSUMé: OBJECTIF : L'acide tranexamique (ATX) peropératoire est utilisé pour réduire les pertes sanguines et les besoins transfusionnels après les arthroplasties totales de la hanche (ATH) et du genou (ATG). Malgré les données probantes et les protocoles de pratique locaux appuyant l'utilisation d'ATX dans le cadre de la norme de soins en cas d'arthroplastie, l'administration de cet agent est sous-utilisée. Notre objectif était d'utiliser l'audit et la rétroaction facilités par le groupe comme base d'une stratégie d'application des connaissances afin d'accroître l'utilisation de l'ATX lors des ATH et ATG. MéTHODE: Les anesthésiologistes ont consenti à recevoir deux rapports de données résumant leurs taux individuels d'utilisation d'ATX et de transfusions sanguines postopératoires par rapport à leurs pairs au sein du même établissement. Les variables recueillies comprenaient les données démographiques des patients, l'utilisation d'ATX et la fréquence et le volume des transfusions d'érythrocytes administrées au cours d'une période postopératoire de 72 heures. La séance de rétroaction facilitée a porté sur les conclusions du rapport et s'est concentrée sur les facteurs contribuant aux habitudes de pratique locales et aux possibilités de changement. RéSULTATS: L'utilisation d'acide tranexamique a augmenté pour les procédures d'ATH au site d'intervention, passant de 66,6 % à 74,4 % (variation absolue, 7,9 %; intervalle de confiance [IC] à 95 %, 2,4 à 13,3). De même, l'utilisation d'ATX pour les procédures d'ATG est passée de 62,4 % à 82,3 % (variation absolue, 19,9 %; IC 95 %, 15,0 à 25,0). CONCLUSION: Les médecins et leurs équipes ont pu passer en revue leurs données de pratique sur l'utilisation d'ATX, réfléchir aux différences par rapport aux lignes directrices fondées sur des données probantes, discuter des résultats avec leurs pairs et identifier les possibilités d'amélioration. L'intervention a augmenté l'utilisation d'ATX pour l'ATG et l'ATH et a modifié la posologie pour mieux s'aligner sur les lignes directrices de pratique fondées sur des données probantes.

Anesthesia-related adverse events in obstetric patients: a population-based study in Canada.

BACKGROUND: Anesthesia-related complications in obstetric patients could be catastrophic and impact the lives of both the parturient and the neonate. The objective of this study was to determine the frequency, temporal trend, and risk factors of anesthesia-related adverse events during hospitalization for delivery in Canada. METHODS: This retrospective population-based study utilized the hospitalization database of the Canadian Institute for Health Information for all parturients (gestation ≥ 20 weeks) in Canada (except Quebec) hospitalized for childbirth from April 2004 to March 2017. Complications were identified by the enhanced Canadian version of the tenth revision of the International Statistical Classification of Diseases and Related Health Problems codes. Data were summarized with descriptive statistics. Associations between hospitalizations with an anesthesia-related adverse event and patient characteristics, delivery method, and modality of anesthesia were assessed using multivariate logistic regression. RESULTS: Among 2,601,034 hospitalizations (3,194,875 interventions), 8,361 anesthesia-related adverse events occurred over a 13-year period (262 per 100,000 interventions; 95% confidence interval [CI], 256 to 267), with a significant decline over time (P < 0.001). These were two-fold and seven-fold higher per 100,000 interventions with general (488; 95% CI, 438 to 542) and general plus neuraxial (1,476; 95% CI, 1,284 to 1,689) anesthesia compared with neuraxial anesthesia alone (225; 95% CI, 219 to 230). Serious adverse events constituted 9% of all adverse events. The most common adverse event was spinal and epidural anesthesia-induced headache (6,908/8,361; 83%); the overall rate of failed or difficult intubations was low (201/8,361; 2%). Anesthesia-related events were more likely in those who had a Cesarean delivery compared with vaginal delivery (odds ratio [OR], 1.12; 95% CI, 1.06 to 1.18) and general anesthesia compared with neuraxial anesthesia (OR, 1.71; 95% CI, 1.53 to 1.93). Noteworthy associations were found between any anesthesia-related adverse events and cardiomyopathy (OR, 8.34; 95% CI, 2.59 to 26.83), eclampsia (OR, 3.11; 95% CI, 1.95 to 4.97), and obstructive sleep apnea (OR, 1.91; 95% CI, 1.66 to 2.19). CONCLUSION: The incidence of anesthesia-related adverse events in obstetric patients in Canada is low and declining. High vigilance is required in parturients undergoing Cesarean delivery, receiving general anesthesia, and those with pre-existing medical conditions.

RéSUMé: CONTEXTE: Les complications liées à l'anesthésie chez les patientes obstétricales pourraient être catastrophiques et avoir un impact tant sur la vie de la parturiente que sur celle du nouveau-né. L'objectif de cette étude était de déterminer la fréquence, la tendance temporelle et les facteurs de risque d'événements indésirables liés à l'anesthésie pendant l'hospitalisation pour accouchement au Canada. MéTHODE: Cette étude rétrospective basée sur la population a utilisé la base de données sur les hospitalisations de l'Institut canadien d'information sur la santé pour analyser les dossiers de toutes les parturientes (≥ 20 semaines de gestation) au Canada (à l'exception du Québec) hospitalisées pour accouchement entre les mois d'avril 2004 et mars 2017. Les complications ont été identifiées en suivant la version canadienne améliorée de la dixième révision des codes de la Classification statistique internationale des maladies et des problèmes de santé connexes. Les données ont été résumées à l'aide de statistiques descriptives. Les associations entre les hospitalisations comportant un événement indésirable lié à l'anesthésie et les caractéristiques de la patiente, la méthode d'accouchement et les modalités anesthésiques ont été évaluées à l'aide d'une régression logistique multivariée. RéSULTATS: Parmi les 2 601 034 hospitalisations (3 194 875 interventions), 8361 événements indésirables liés à l'anesthésie se sont produits sur une période de 13 ans (262 par 100 000 interventions; intervalle de confiance [IC] à 95 %, 256 à 267), avec une baisse significative au fil du temps (P < 0,001). Celles-ci étaient deux et sept fois plus élevées par 100 000 interventions avec une anesthésie générale (488; IC 95 %, 438 à 542) et avec une anesthésie générale plus neuraxiale (1476; IC 95 %, 1284 à 1689), respectivement, par rapport à une anesthésie neuraxiale seule (225; IC 95 %, 219 à 230). Les événements indésirables graves constituaient 9 % de tous les événements indésirables. L'événement indésirable le plus fréquent était les céphalées consécutives à l'anesthésie rachidienne et péridurale (6908/8361; 83 %); le taux global d'échecs d'intubation ou d'intubations difficiles était faible (201/8361; 2 %). Les événements liés à l'anesthésie étaient plus probables chez les parturientes ayant subi un accouchement par césarienne par rapport à un accouchement vaginal (rapport de cotes [RC], 1,12; IC 95 %, 1,06 à 1,18) et une anesthésie générale par rapport à une anesthésie neuraxiale (RC, 1,71; IC 95 %, 1,53 à 1,93). Des associations remarquables ont été notées entre tout événement indésirable lié à l'anesthésie et la cardiomyopathie (RC, 8,34; IC 95 %, 2,59 à 26,83), l'éclampsie (RC, 3,11; IC 95 %, 1,95 à 4,97) et l'apnée obstructive du sommeil (RC, 1,91; IC 95 %, 1,66 à 2,19). CONCLUSION: Au Canada, l'incidence d'événements indésirables liés à l'anesthésie chez les patientes obstétricales est faible et en baisse. Une vigilance élevée est de mise lors de la prise en charge de parturientes accouchant par césarienne, recevant une anesthésie générale et pour celles souffrant de conditions médicales préexistantes.

Incidence, morbidity, and associated factors for sepsis in women hospitalized for delivery: a nationwide retrospective observational population-based study in Canada.

PURPOSE: The objective of this research was to examine the epidemiology of maternal sepsis in Canada. METHODS: We conducted a population-based retrospective cohort study of women (≥ 20 weeks gestation) hospitalized for delivery in all Canadian hospitals (excluding Quebec) between 1 April 2004 and 31 March 2017. Data were obtained from the national Canadian Institute for Health Information database and sepsis cases were identified via International Classification of Diseases, Tenth Revision, Canada (ICD-10-CA) codes. Our primary outcome was the number of hospitalizations for delivery associated with maternal sepsis. We further explored associations between patient characteristics, obstetric procedures/conditions, medical conditions, and maternal sepsis. Associations were presented using odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: There were 4,183 cases of sepsis in 3,653,783 hospitalizations for delivery during the study period, with an incidence of 114 (95% CI, 111 to 118) per 100,000 hospitalizations and a mortality rate of 0.5%. Annual sepsis rates per 100,000 hospitalizations ranged from a high of 160 (95% CI, 146 to 177) in 2004 to 94 (95% CI, 83 to 106) in 2011. Highest regional rates were observed in the Territories (224 per 100,000). Severe sepsis was seen in 14% (n = 568) of all patients with sepsis, which was one or more of septic shock (15%; n = 85), organ failure (61%; n = 345), intensive care unit admission (78%; n = 443), or mortality (3%; n = 19). Multivariable models showed that postpartum hemorrhage (OR, 2.9; 95% CI, 2.7 to 3.2), Cesarean delivery (OR, 3.2; 95% CI, 3.0 to 3.5), anemia (OR, 3.9; 95% CI, 3.5 to 4.3), hysterectomy (OR, 4.9; 95% CI, 3.6 to 6.6), chorioamnionitis (OR, 7.6; 95% CI, 6.9 to 8.3), as well as cardiorespiratory, renal and liver conditions were associated with maternal sepsis. CONCLUSION: Maternal sepsis rates have been decreasing in Canada but remain higher than those in the UK and USA. Our study explored associations with maternal sepsis and shows that one in seven women with sepsis develop severe sepsis-related morbidity, which warrants risk stratification and health policy changes.

RéSUMé: OBJECTIF: L'objectif de cette étude était d'examiner l'épidémiologie du sepsis maternel au Canada. MéTHODE: Nous avons mené une étude de cohorte rétrospective basée sur la population de femmes (≥ 20 semaines de gestation) hospitalisées pour accouchement dans tous les hôpitaux canadiens excluant le Québec entre le 1er avril 2004 et le 31 mars 2017. Les données ont été obtenues à partir de la base de données nationale de l'Institut canadien d'information sur la santé et les cas de sepsis ont été identifiés au moyen des codes de la Classification internationale des maladies, dixième révision, Canada (CIM-10-CA). Notre critère d'évaluation principal était le nombre d'hospitalisations pour accouchement associées à un sepsis maternel. Nous avons également exploré les associations entre les caractéristiques des patientes, les interventions / conditions obstétricales, les conditions médicales et le sepsis maternel. Les associations ont été présentées à l'aide de rapports de cotes (RC) et d'intervalles de confiance (IC) à 95 %. RéSULTATS: Il y a eu 4183 cas de sepsis parmi les 3 653 783 hospitalisations pour accouchement au cours de la période à l'étude, avec une incidence de 114 (IC 95 %, 111 à 118) pour 100 000 hospitalisations et un taux de mortalité de 0,5 %. Les taux annuels de sepsis pour 100 000 hospitalisations variaient d'un pic de 160 (IC 95 %, 146 à 177) en 2004 à 94 (IC 95 %, 83 à 106) en 2011. Les taux régionaux les plus élevés ont été observés dans les Territoires (224 pour 100 000). Un sepsis sévère a été observé chez 14 % (n = 568) des patientes atteintes de sepsis. Cette complication s'est manifestée en choc septique (15 %; n = 85), défaillance d'organe (61 %; n = 345), admission aux soins intensifs (78 %; n = 443), ou mortalité (3 %; n = 19), ou en combinaison de ces complications. Des modèles multivariés ont montré que l'hémorragie du post-partum (RC, 2,9; IC 95 %, 2,7 à 3,2), l'accouchement par césarienne (RC, 3,2; IC 95 %, 3,0 à 3,5), l'anémie (RC, 3,9; IC 95 %, 3,5 à 4,3), l'hystérectomie (RC, 4,9; IC 95 %, 3,6 à 6,6), la chorioamnionite (RC, 7,6; IC 95 %, 6,9 à 8,3), ainsi que les affections cardiorespiratoires, rénales et hépatiques étaient associées au sepsis maternel. CONCLUSION: Les taux de sepsis maternel ont diminué au Canada, mais demeurent plus élevés qu'au Royaume-Uni et aux États-Unis. Notre étude a exploré les associations avec le sepsis maternel et montre qu'une femme sur sept atteinte de sepsis développe une morbidité sévère liée au sepsis, ce qui justifie une stratification des risques et des changements dans les politiques de santé.

Epidemiology of Cardiac Arrest During Hospitalization for Delivery in Canada: A Nationwide Study.

BACKGROUND: Cardiac arrest in pregnancy is a rare and devastating condition with high mortality and morbidity. The objective of this study was to generate information about maternal cardiac arrest in Canada by examining the frequency, temporal incidence, associated conditions, potential etiologies, and survival rates. METHODS: This retrospective population-based study used hospitalization data from the discharge abstract database of the Canadian Institute for Health Information relating to obstetric deliveries in Canada from April 1, 2002, to March 31, 2015. The data were accessed through the Public Health Agency of Canada's (PHAC) Canadian Perinatal Surveillance System. Cases of cardiac arrest were identified using the diagnostic and intervention codes from the International Statistical Classification of Diseases and the Canadian Classification of Health Interventions, respectively. Data on patient demographics, medical and obstetrical conditions, and potential etiologies of cardiac arrest were collected. Multivariable logistic regression analysis was used to identify conditions associated with cardiac arrest. RESULTS: There were 286 cases of maternal cardiac arrest among 3,568,597 hospitalizations for delivery during the 13-year period. A total of 204 (71.3%) women survived to hospital discharge (95% confidence interval, 65.7%-76.5%). There was no significant variation in the incidence of cardiac arrest or survival from arrest over time or across provinces. Among the pre-existing conditions, hypertensive disorders of pregnancy, gestational diabetes, malignancy, and diseases of the respiratory and nervous system were found to be significantly associated with cardiac arrest. Among the obstetrical conditions, placental abnormalities and polyhydramnios were associated with cardiac arrest. The common potential etiologies included postpartum hemorrhage, heart failure, amniotic fluid embolism, and complications of anesthesia. CONCLUSIONS: In this first Canadian study, the incidence of cardiac arrest during pregnancy was found to be 1:12,500 deliveries. The survival rate reported in our study is higher than reported previously in other countries. Our study findings contribute to better inform the development and implementation of policies and programs in an effort to prevent and manage this condition.

Remifentanil for labor analgesia: a comprehensive review.

Japan has seen significant developments in obstetric anesthesia in recent years, including the establishment of the Japanese Society of Obstetric Anesthesia and Perinatology. However, labor pain, which is one of the most important issues in obstetric practice, is still not treated aggressively. The rate of epidural administration for labor analgesia is very low in Japan as compared to other developed countries. Remifentanil has been used for labor analgesia, as part of general anesthesia for cesarean delivery, as well as for various fetal procedures around the world. Intravenous patient-controlled analgesia (IVPCA) with remifentanil is considered to be a reasonable option for labor pain relief. Several studies have demonstrated its efficacy with minimal maternal and neonatal adverse effects. On the other hand, reports of cases of maternal cardiac and respiratory arrest with remifentanil IVPCA within the past couple of years have redirected our attention to its safe use. Remifentanil IVPCA warrants one-to-one nursing monitoring, appropriate education of healthcare providers, continuous maternal oxygen saturation monitoring, end-tidal CO2 monitoring, and availability of both maternal and neonatal resuscitation equipment. This article provides an overview of knowledge and principles of using remifentanil IVPCA for labor analgesia and introduces its potential usage in Japan.

Does laryngoscopic view after intubation predict laryngoscopic view before intubation?

STUDY OBJECTIVE: To determine if an endotracheal (ET) tube will distort the laryngeal view obtained with direct laryngoscopy measuring with the modified Cormack-Lehane scale (MCL). DESIGN: Observational single-arm study. SETTING: The University of Calgary teaching hospitals. PATIENTS: Patients between 18 and 86 years of age undergoing elective surgical procedures. A total of 173 patients were enrolled and analyzed. INTERVENTIONS: Direct laryngoscopy view obtained before ET intubation and directly after intubation. MEASUREMENTS AND RESULTS: The MCL scales were described for each view obtained and compared to each other with each patient serving as their own control. The primary objective was a change in the best obtainable view by direct laryngoscopy from an acceptable view (MCLS 1 or 2a) to an unacceptable view (MCLS 2b, 3, or 4) or changing from an unacceptable view (MCLS 2b, 3, or 4) to an acceptable view (MCLS 1 or 2a). The main finding of this study was that the ET tube altered the MCL in 58 (33%) of 173 patients, "worsening" the grade in 30 patients (17.34%) and "improving" the grade in 28 patients (16.18%). CONCLUSIONS: We performed a prospective observational study to address the predictive value of postintubation laryngoscopy grade in adults. The presence of the ET tube both increased visualization of the glottis and worsened the view in different subjects. The important outcome was that the presence of the ET tube did in fact change the view obtained of the larynx during direct laryngoscopy. In conclusion, postintubation MCL grades may not be reliable to predict laryngeal grade and should be used with caution in the right clinical context.

Anesthesia for hip arthroscopy: a narrative review.

PURPOSE: Hip arthroscopy is a minimally invasive surgical procedure indicated for the treatment of specific hip disorders. In this narrative review, we aim to examine the key components in providing anesthesia for this procedure. SOURCE: MEDLINE(®), PubMed, and EMBASE™ databases were searched for peer-reviewed articles discussing the anesthetic management of patients undergoing hip arthroscopy. PRINCIPAL FINDINGS: The primary anesthetic regimen used for hip arthroscopy should balance patient factors, preferences of the surgeon, and the demands of the procedure itself. Both general and neuraxial anesthetic techniques are well suited for this mostly ambulatory surgical procedure. There is a lack of current literature specifically comparing the benefits and risks of the two techniques in this setting. Postoperative pain management consists mainly of intravenous and oral opioids; however, a variety of regional anesthesia techniques, such as lumbar plexus block and fascia iliaca block, can be performed pre- or postoperatively. Overall, hip arthroscopy is safe, although positioning-related difficulties, extravasation of irrigation fluid, hypothermia, infections, and thromboembolic events are potential perioperative complications that warrant specific monitoring and prompt treatment. CONCLUSIONS: Until now, the anesthetic technique for hip arthroscopy has not been well studied. Thus, increasing emphasis should be directed towards examining relevant clinical outcomes that can better inform evidence-based decision-making in the anesthetic management of hip arthroscopy patients. In the meantime, awareness of potential complications and vigilant monitoring are paramount in providing safe anesthetic care for patients undergoing hip arthroscopy.

Maternal cardiac arrest in a tertiary care centre during 1989-2011: a case series.

PURPOSE: To review and report maternal and neonatal outcomes after cardiac arrest during pregnancy in a large tertiary care centre and to consider steps to improve the outcomes. CLINICAL FEATURES: We performed a retrospective chart review of maternal cardiac arrest in the Mount Sinai Hospital, University of Toronto health records database for the period 1989-2011. Five cases were identified for an incidence of 1:24,883 deliveries (0.004%). Four of the five women were obese and older than 35 yr. Two women had pre-existing cardiac conditions, and one had placenta accrete. All three underwent perimortem Cesarean delivery (PMCD), but none of these procedures was done within the recommended time of the "four-minute rule." Two of the three women had repeated arrests and subsequently died. The other two women were in labour, received regional analgesia, and had assisted vaginal deliveries. Both of these patients survived, and all survivors (mothers and neonates) were neurologically intact. Four of five neonates survived. The etiology of the cardiac arrest was indeterminate in all five cases, although suspected amniotic fluid embolism was considered the most likely contributing factor in the majority of cases. Overall, the quality of the charting was inconsistent and incomplete. CONCLUSIONS: This series of five cases highlights the challenges to meeting the rule of initiating PMCD within four minutes of maternal cardiac arrest onset. We suggest focusing on the quality of ongoing resuscitation efforts and early delivery as our experience shows that mother and neonate can survive beyond five minutes after arrest. Improved documentation and creation of a national database for these rare events should be considered.

Regional anesthesia in Marfan syndrome, not all dural ectasias are the same: a report of two cases.

BACKGROUND: The anesthetic management of women with Marfan syndrome and dural ectasia undergoing Cesarean delivery remains controversial. We present two cases of patients with Marfan syndrome and dural ectasia where neuraxial anesthesia was used successfully. CASE 1: A 31-yr-old G1P0 female with Marfan syndrome presented for elective Cesarean delivery at 35(3/7) weeks' gestation. The magnetic resonance imaging of her spine revealed significant dural ectasia in the lumbosacral area with a mean lumbar dural sac area of 4.71 cm(2). Intrathecal administration of 0.75% hyperbaric bupivacaine 9 mg produced only limited perineal analgesia. The epidural catheter was titrated, and 0.5% bupivacaine 150 mg were required to achieve a T4 sensory level. CASE 2: A 34-yr-old G1P0 female with Marfan syndrome presented for elective Cesarean delivery at 37 weeks' gestation. The intrathecal administration of 0.75% hyperbaric bupivacaine 13.5 mg produced a T5 sensory level. Magnetic resonance imaging of her spine prior to discharge confirmed the diagnosis of moderate dural ectasia with a mean lumbar dural sac area of 3.61 cm(2). DISCUSSION: The two patients described in this report responded differently to spinal anesthesia, most likely based on the severity of their dural ectasia. Although preoperative magnetic resonance imaging may help to identify patients at risk for a failed spinal, we suggest considering a combined spinal-epidural technique in cases of dural ectasia.

Anesthetic management and outcome in patients during endovascular therapy for acute stroke.

BACKGROUND: Studies of endovascular treatment for acute ischemic stroke have identified general anesthesia as a predictor for poor outcome in comparison with local anesthesia/sedation. This retrospective study attempts to identify modifiable factors associated with poor outcome, while adjusting for baseline stroke severity, in patients receiving general anesthesia. METHODS: We reviewed charts of 129 patients treated between January 2003 and September 2009. The primary outcome was the modified Rankin Score of 0-2 for 3 months poststroke. Predictors of neurologic outcome included baseline National Institutes of Health Stroke Scale score, blood glucose concentration, and age. Additional risk factors evaluated were prolonged stroke onset-treatment interval and systolic blood pressure less than 140 mmHg. Choice of local anesthesia or general anesthesia was recorded. RESULTS: The study group was 96 out of 129 patients for whom modified Rankin Scale scores were available; 48 patients received general anesthesia and 48 local anesthesia. The proportion of patients with "good" outcomes were 15% and 60% in the general anesthesia group and local anesthesia group, respectively (P < 0.001). Lowest systolic blood pressure and general anesthesia were correlated (r = -0.7, P < 0.001). Independent predictors for good neurologic outcome were local anesthesia, systolic blood pressure greater than 140 mmHg, and low baseline stroke scores. CONCLUSIONS: Adjusted for stroke severity, patients who received general anesthesia for treatment are less likely to have a good outcome than those managed with local anesthesia. This may be due to preintervention risk not included in the stroke severity measures. Hypotension, more frequent in the general anesthesia patients, may also contribute.