A Case Report of Rotational Thromboelastometry-Assisted Decision Analysis for Two Pregnant Patients With Platelet Storage Pool Disorder.

Platelet storage pool disorders (PSPDs) constitute a diverse group of hematologic abnormalities, which share the common feature of a deficiency in the ability of platelets to aggregate. Parturients with PSPD can present management challenges to their care team when they present for childbirth, especially with regard to neuraxial anesthesia. We report a series of 2 deliveries from unrelated patients affected by PSPD. In particular, we highlight the utility of rotational thromboelastometry (ROTEM) and the need for a multidisciplinary approach to the care of patients with this hematologic abnormality.

The Most Influential Publications in Obstetric Anesthesiology, 1998-2017: Utilizing the Delphi Method for Expert Consensus.

BACKGROUND: There have been many advances in obstetric anesthesiology in the past 2 decades. We sought to create a list of highly influential publications in the field using the Delphi method among a group of obstetric anesthesiology experts to create an important educational, clinical, and research resource. METHODS: Experts in the field, defined as obstetric anesthesiologists selected to present the Gerard W. Ostheimer Lecture at the Society for Obstetric Anesthesia and Perinatology (SOAP) annual meeting within the past 20 years, were recruited to participate. The Delphi technique was used by administering 3 rounds of surveys. Participants were initially asked to identify the highly influential publications from the year they presented the Ostheimer lecture, in addition to the most influential publications from the time period overall. Highly influential publications were defined as those that changed traditional views, invoked meaningful practices, catalyzed additional research, and fostered ideas or practices that had durability over time. After each round of surveys, responses were collected and used as choices for subsequent surveys with the goal of obtaining group consensus. RESULTS: We determined expert consensus on 22 highly influential publications from 1998 to 2017. The focus of these publications ranged from disease entities, interventions, treatment methodologies, and complications. CONCLUSIONS: Key themes in the publications chosen included the reduction of maternal morbidity and mortality and refinements in the analgesic and anesthetic management of labor and delivery.

The effect of patient-selected or preselected music on anxiety during cesarean delivery: a randomized controlled trial.

Background: Women undergoing cesarean delivery may have significant anxiety prior to surgery. Nonpharmacological approaches to anxiety reduction are favored in this patient population.Objective: The aim of this study was to determine the effects of patient-selected or preselected music on anxiety in parturients undergoing scheduled cesarean delivery.Materials and methods: This is a prospective, randomized controlled trial (IRB protocol #2015P002043; ClinicalTrials.gov, NCT02732964), of 150 parturients undergoing elective cesarean delivery. Parturients were randomized to patient-selected music (Pandora®), preselected music (Mozart), or no music (control). The primary outcome was anxiety after music exposure (versus no music) in the preoperative holding room. Secondary outcomes included postoperative anxiety, postoperative pain, and patient satisfaction.Results: Baseline anxiety and anxiety following preoperative exposure did not differ in the Pandora versus control group (3.8 ± 2.4 versus 4.6 ± 2.6, mean difference -0.8 [95% CI -1.8 to 0.2], p = .12), but was lower in the Mozart group versus control group (3.5 ± 2.5 versus 4.6 ± 2.5, mean difference -1.1 [95% CI -2.2 to -0.1], p = .03). Postoperative anxiety did not differ in the Pandora versus control group (1.0 ± 1.4 versus 1.3 ± 2.0, mean difference -0.3 [95% CI -1.0 to 0.4], p = .43), or in the Mozart versus control group (0.8 ± 1.3 versus 1.3 ± 2.0, mean difference -0.5 [95% CI -1.2 to 0.2], p = .15). Postoperative pain was not different in the Pandora group versus control group (0.8 ± 1.5 versus 1.4 ± 1.9, mean difference -0.6 [95% CI -1.3 to 0.1], p = .10), but was lower in the Mozart versus control group (0.6 ± 1.3 versus 1.4 ± 1.9, mean difference -0.8 [95% CI -1.4 to -0.1], p = .03). Total patient satisfaction scores were not different among the control, Pandora, and Mozart groups.Conclusion: While preselected Mozart music results in lower anxiety prior to cesarean delivery, patient-selected Pandora music does not. Further investigation to determine how music affects patients, clinicians, and the operating room environment during cesarean delivery is warranted.Clinical trial registration: NCT02732964.

Does nitrous oxide labor analgesia influence the pattern of neuraxial analgesia usage? An impact study at an academic medical center.

STUDY OBJECTIVE: To compare the rate of epidural use before and after the implementation of nitrous oxide (N2O). DESIGN: Data were obtained from a nursing database of N2O usage and our obstetric anesthesia database. We compared 8 months before and 8 months after the introduction of N2O. It was available 24 h/d, 7 d/wk, consistent with neuraxial analgesia availability. Epidural utilization before and after introduction of N2O was compared using χ2 analysis. SETTING: Labor and delivery floor. MAIN RESULTS: Total number of births over the study period was 8539: 4315 pre-N2O and 4224 post-N2O. The rate of epidural usage was 77% pre-N2O and 74% after N2O (P= not significant, χ2). A total of 762 patients used N2O. Monthly analysis showed no change in pattern of neuraxial analgesia use in post-N2O period compared with the pre-N2O period. CONCLUSION: The introduction of N2O for labor analgesia was not associated with any change in our rate of labor epidural utilization. Under the conditions of our study, these results suggest that N2O does not discourage neuraxial use for labor pain relief.

Anesthetic management of a parturient with hyperekplexia.

Hyperekplexia is a hereditary disorder characterized by exaggerated startle reflex in response to unexpected acoustic, tactile, and other stimuli. Neonates with hyperekplexia may present with hypertonia, developmental delays, apnea, and sudden death. The diagnosis is based on published clinical criteria. In some cases, a mutation encoding the postsynaptic inhibitory glycine receptors (GLRA1, GLRB) or presynaptic glycine transporter (SLC6A5) resulting in abnormal glycinergic neurotransmission is present. We report the case of a 38-year-old gravida 6 para 1 (G6P1) parturient with hyperekplexia who underwent successful vaginal delivery managed by the anesthesiology and neonatology service teams from initial antenatal consultation to labor and delivery to hospital discharge.

Successful pregnancy and delivery in a patient with Carney complex: implications for anesthesiologists.

Carney complex is an autosomal dominant condition with widespread manifestations, including cardiac myxomas, nerve sheath tumors, and endocrinopathies. Although often associated with infertility, there are several reports of successful pregnancies in patients with Carney complex. However, none of the previous reports describe anesthetic considerations. Herein, we present a patient with Carney complex who successfully delivered vaginally with labor epidural analgesia.

Women's Experiences with Neuraxial Labor Analgesia in the Listening to Mothers II Survey: A Content Analysis of Open-Ended Responses.

BACKGROUND: Most women who give birth in United States hospitals receive neuraxial analgesia to manage pain during labor. In this analysis, we examined themes of the patient experience of neuraxial analgesia among a national sample of U.S. mothers. METHODS: Data are from the Listening to Mothers II survey, conducted among a national sample of women who delivered a singleton baby in a U.S. hospital in 2005 (N = 1,573). Our study population consisted of women who experienced labor, did not deliver by planned cesarean, and who reported neuraxial analgesia use (n = 914). We analyzed open-ended responses about the best and worst parts of women's birth experiences for themes related to neuraxial analgesia using qualitative content analysis. RESULTS: Thirty-three percent of women (n = 300) mentioned neuraxial analgesia in their open-ended responses. We found that effective pain relief was frequently spontaneously mentioned as a key positive theme in women's experiences with neuraxial analgesia. However, some women perceived timing-related challenges with neuraxial analgesia, including waiting in pain for neuraxial analgesia, receiving neuraxial analgesia too late in labor, or feeling that the pain relief from neuraxial analgesia wore off too soon, as negative aspects. Other themes in women's experiences with neuraxial analgesia were information and consent, adverse effects of neuraxial analgesia, and plans and expectations. CONCLUSIONS: The findings from this analysis underscored the fact that women appreciate the effective pain relief that neuraxial analgesia provides during childbirth. Although pain control was 1 important facet of women's experiences with neuraxial analgesia, their experiences were also influenced by other factors. Anesthesiologists can work with obstetric clinicians, nurses, childbirth educators, and pregnant and laboring patients to help mitigate some of the challenges with timing, communication, neuraxial analgesia administration, or expectations that may have contributed to negative aspects of women's birth experiences.

Cesarean delivery in the hybrid operating suite: a promising new location for high-risk obstetric procedures.

BACKGROUND: The increasing cesarean delivery rate and attendant placental implantation abnormalities, coupled with increasing general medical complexity in the obstetric population, has driven innovation to optimize the care of high-risk parturients during delivery. Novel and multidisciplinary approaches and locations may enhance the options available for care. METHODS: We reviewed the records of all 11 patients who underwent cesarean delivery in our hybrid operating suite between December 2007 and March 2013 and describe the high-risk cesarean deliveries. RESULTS: The most common indication for the use of the hybrid operating suite was an increased risk of hemorrhage, most commonly due to abnormal placental implantation. Other indications included cardiovascular disease and intracranial pathology. CONCLUSION: The hybrid operating suite may be an alternative location for obstetric delivery, and our experience suggests that this environment may prove advantageous for patients with a variety of comorbid conditions.

Controversies in obstetric anesthesia.

Obstetric anesthesia has become a widely evidence-based practice, with an increasing number of specialized anesthesiologists and a permanent research production. We believe that with the review of commonly discussed and controversial points the reader will be able to incorporate an evidence-based practice into their routine and offer to parturients and their babies a safe, reliable and consistent anesthesia care.

Neurologic issues and obstetric anesthesia.

The rising popularity of regional anesthesia in the last several decades has greatly changed the experience of labor. Although the use of regional anesthesia has aided in decreasing maternal morbidity and mortality, a new dimension of neurologic issues, particularly headache and peripheral neuropathy, is apparent. Obstetric anesthesiologists frequently encounter patients with preexisting neurologic disease. Although very few of these disorders contraindicate the use of neuraxial technique, there are limited published data on specific neurologic and neuromuscular disorders in pregnancy. Neurologists are often consulted by anesthesiologists and obstetricians to evaluate pregnant patients for the feasibility of labor analgesia and when postpartum neurologic complications arise. Early consultation with an obstetric anesthesiologist, discussion with a neurologist, and communication with the obstetrician allows for the education and discussion of the risks and benefits of both the mode of delivery and anesthetic options. This multidisciplinary approach is crucial in forming reasonable expectations for the patient. The aim of this discussion is to provide an obstetric anesthesiologist's perspective on regional anesthesia and its implications in obstetrics, and to enhance communication between our specialties.

Anesthesia in the pregnant patient with hematologic disorders.

The management of patients with hematologic disorders in pregnancy involves a multidisciplinary approach involving specialists from hematology, obstetrics, and anesthesiology. Whereas regional anesthesia has led to a decline in maternal morbidity and mortality, the presence of uncorrected coagulopathy or the use of anticoagulant or antithrombotic medications pose a special risk for the rare complication of an epidural hematoma after neuraxial anesthesia. This article briefly reviews the common principles of anesthesia for obstetric patients, provides an obstetric anesthesiologist's perspective on the implications of regional anesthesia in obstetrics, and enhances communication between the specialties.

Nocebo-induced hyperalgesia during local anesthetic injection.

Common practice during local anesthetic injection is to warn the patient using words such as: "You will feel a big bee sting; this is the worst part." Our hypothesis was that using gentler words for administration of the local anesthetic improves pain perception and patient comfort. One hundred forty healthy women at term gestation requesting neuraxial analgesia were randomized to either a "placebo" ("We are going to give you a local anesthetic that will numb the area and you will be comfortable during the procedure") or "nocebo" ("You are going to feel a big bee sting; this is the worst part of the procedure") group. Pain was assessed immediately after the local anesthetic skin injection using verbal analog scale scores of 0 to 10. Median verbal analog scale pain scores were lower when reassuring words were used compared with the harsher nocebo words (3 [2-4] vs 5 [3-6]; P < 0.001). Our data suggest that using gentler, more reassuring words improves the subjective experience during invasive procedures.

Anesthesia drugs in the obstetric and gynecologic practice.

The obstetrician-gynecologist is often solely responsible for analgesia/sedation and regional blocks during office-based and outpatient procedures. The American Society of Anesthesiologists guidelines for the provision of analgesia/sedation for nonanesthesiologists provide helpful recommendations to maximize patient safety during office-based and outpatient procedures. This article provides a review of the fundamentals of sedation/analgesia, monitored anesthesia care, and local anesthetics.