A randomized controlled trial of spinal morphine with an enhanced recovery pathway and its effect on duration of analgesia after cesarean delivery.

BACKGROUND: Intrathecal morphine is frequently administered after cesarean delivery to provide pain relief lasting up to 24 h. An enhanced recovery after cesarean pathways reduces the amount of postoperative opioids needed. The ideal dose of intrathecal morphine when combined with a pathway has not been determined. METHODS: This was a non-inferiority trial in 72 healthy women undergoing a scheduled cesarean delivery. Women were randomized to receive either 50 mcg, 150 mcg, or 250 mcg of intrathecal morphine during spinal anesthesia, with a standardized postoperative enhanced recovery pathway. The time to request supplemental opioids was the primary outcome. Secondary outcomes included pain scores, side effects, and quality of recovery at 24 h. RESULTS: The duration of analgesia with 50 mcg of morphine (median 24.5 h [IQR: 3.5-34.4]) was inferior to 150 mcg (29.4 h [24.5-72]), and both doses were inferior to 250 mcg (32 h [30.5-72]). Women who received 50 mcg morphine had higher pain scores than the other doses, received more supplemental opioids, and had lower quality recovery scores. The secondary outcomes between 150 mcg and 250 mcg were similar. Side effects were similar among all groups. 63% of women who received 250 mcg remained opioid-free at 72 h, compared to 150 mcg (52%) and 50 mcg (30%). CONCLUSIONS: The duration of analgesia using intrathecal morphine with an enhanced recovery pathway was longer with 250 mcg than with lower doses, and side effects were similar. 50 mcg provided inferior pain relief over 24 h. More than half of our patients avoided additional opioids for up to 72 h with either 150 mcg or 250 mcg doses. REGISTRATION: Clinical trial number NCT05069012.

Anesthesia Considerations for Placenta Accreta Spectrum.

Anesthesiologists are critical members of the multidisciplinary team managing patients with suspected placenta accreta spectrum (PAS). Preoperatively, anesthesiologists provide predelivery consultation for patients with suspected PAS where anesthetic modality and invasive monitor placement is discussed. Additionally, anesthesiologists carefully assess patient and surgical risk factors to choose an anesthetic plan and to prepare for massive intraoperative hemorrhage. Postoperatively, the obstetric anesthesiologist hold unique skills to assist with postoperative pain management for cesarean hysterectomy. We review the unique aspects of peripartum care for patients with PAS who undergo cesarean hysterectomy and explain why these responsibilities are critical for achieving successful outcomes for patients with PAS. KEY POINTS: · Anesthesiologists are critical members of the multidisciplinary team planning for patients with suspected placenta accreta spectrum.. · Intraoperative preparation for massive hemorrhage is a key component of anesthetic care for patients with PAS.. · Obstetric anesthesiologists have a unique skill set to manage postpartum pain and postoperative disposition for patients with PAS who undergo cesarean hysterectomy..

Interpol Review Paper of Marks and Impression Evidence 2019-2022.

This section contains an overview of publications relevant to advances in scientific methods and general discussions concerning shoe and toolmark examiners, which were published between January 2019 and May of 2022 and is the sequel to the review for the 19th Interpol International Forensic Science Managers Symposium in 2019 by Martin Baiker-Sorensen. A literature search was conducted covering relevant articles published in the main forensic journals.

Placenta Accreta Spectrum Disorders: Knowledge Gaps in Anesthesia Care.

Placenta accreta spectrum (PAS) disorder is a potentially life-threatening condition that can occur during pregnancy. PAS puts pregnant individuals at a very high risk of major blood loss, hysterectomy, and intensive care unit admission. These patients should receive care in a center with multidisciplinary experience and expertise in managing PAS disorder. Obstetric anesthesiologists play vital roles in the peripartum care of pregnant patients with suspected PAS. As well as providing high-quality anesthesia care, obstetric anesthesiologists coordinate peridelivery care, drive transfusion-related decision making, and oversee postpartum analgesia. However, there are a number of key knowledge gaps related to the anesthesia care of these patients. For example, limited data are available describing optimal anesthesia staffing models for scheduled and unscheduled delivery. Evidence and consensus are lacking on the ideal surgical location for delivery; primary mode of anesthesia for cesarean delivery; preoperative blood ordering; use of pharmacological adjuncts for hemorrhage management, such as tranexamic acid and fibrinogen concentrate; neuraxial blocks and abdominal wall blocks for postoperative analgesia; and the preferred location for postpartum care. It is also unclear how anesthesia-related decision making and interventions impact physical and mental health outcomes. High-quality international multicenter studies are needed to fill these knowledge gaps and advance the anesthesia care of patients with PAS.

Geographic variation in management of patients with placenta accreta spectrum: An international survey of experts (GPASS).

OBJECTIVE: To describe global geographic variations in the diagnosis and management of placenta accreta spectrum (PAS). METHODS: An international cross-sectional study was conducted among PAS experts practicing at medical institutions in member states of the United Nations. Survey questions focused on diagnostic evaluation and management strategies for PAS. RESULTS: A total of 134 centers participated. Participating centers represented each of the United Nations' designated regions. Of those, 118 (88%) reported practicing in a medium-volume or high-volume center. First-trimester PAS screen was reported in 35 (26.1%) centers. Respondents consistently implement guideline-supported care practices, including utilization of ultrasound as the primary diagnostic modality (134, 100%) and implementation of multidisciplinary care teams (115, 85.8%). Less than 10% of respondents reported routinely managing PAS without hysterectomy; these centers were predominantly located in Europe and Africa. Antepartum management and availability of mental health support for PAS patients varied widely. CONCLUSION: Worldwide, there is a strong adherence to PAS care guidelines; however, regional variations do exist. Comparing variations in care to outcomes will provide insight into the clinically significant practice variability.

Rapid Cycle Implementation and Retrospective Evaluation of a SARS-CoV-2 Checklist in Labor and Delivery.

BACKGROUND: Preparedness efforts for a COVID-19 outbreak required redesign and implementation of a perioperative workflow for the management of obstetric patients. In this report we describe factors which influenced rapid cycle implementation of a novel comprehensive checklist for the perioperative care of the COVID-19 parturient. METHODS: Within our labour and delivery unit, implementation of a novel checklist for the COVID-19 parturient requiring perioperative care was accomplished through rapid cycling, debriefing and on-site walkthroughs. Post-implementation, consistent use of the checklist was reported for all obstetric COVID-19 perioperative cases (100% workflow checklist utilization). Retrospective analysis of the factors influencing implementation was performed using a group deliberation approach, mapped against the Consolidated Framework for Implementation Research (CFIR). RESULTS: Analysis of factors influencing implementation using CFIR revealed domains of process implementation and innovation characteristics as overwhelming facilitators for success. Constructs within the outer setting, inner setting, and characteristic of individuals (external pressures, baseline culture, and personal attributes) were perceived to act as early barriers. Constructs such as communication culture and learning climate, shifted in influence over time. CONCLUSION: We describe the influential factors of implementing a novel comprehensive obstetric workflow for care of the COVID-19 perioperative parturient during the first surge of the pandemic using the CFIR framework. Early workflow adoption was facilitated primarily by two domains, namely thoughtful innovation design and careful implementation planning in the setting of a long-standing culture of improvement. Factors initially assessed as barriers such as communication, culture and learning climate, transitioned into facilitators once a perceived benefit was experienced by healthcare teams. These results provide important information for the implementation of rapid change during a time of crisis.

Adaptation of an Obstetric Anesthesia Service for the Severe Acute Respiratory Syndrome Coronavirus-2 Pandemic: Description of Checklists, Workflows, and Development Tools.

BACKGROUND: Care of the pregnant patient during the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic presents many challenges, including creating parallel workflows for infected and noninfected patients, minimizing waste of materials, and ensuring that clinicians can seamlessly transition between types of anesthesia. The exponential community spread of disease limited the time for development and training. METHODS: The goals of our workflow and process development were to maximize safety for staff and patients, minimize the risk of contamination, and reduce the waste of unused supplies and materials. We used a cyclical improvement system and the plus/delta debriefing method to rapidly develop workflows consisting of sequential checklists and procedure-specific packs. RESULTS: We designed independent workflows for labor analgesia, neuraxial anesthesia for cesarean delivery, conversion of labor analgesia to cesarean anesthesia, and general anesthesia. In addition, we created procedure-specific material packs to optimize supplies and prevent wastage. Finally, we generated sequential checklists to allow staff to perform standard operating procedures without extensive training. CONCLUSIONS: Collectively, these workflows and tools allowed our staff to urgently care for patients in high-risk situations without prior experience. Over time, we refined the workflows using a cyclical improvement system. We present our checklists and workflows as well as the system we used for their development, so that others may use them to their benefit.

Outcomes of Surgical Coronary Revascularization Performed Before Solid Abdominal Organ Transplants.

BACKGROUND: Cardiac risk stratification and coronary angiography are routinely performed as part of kidney and liver transplant candidacy evaluation. There are limited data on the outcomes of surgical coronary revascularization in this patient population. This study investigated outcomes in patients with end- stage renal or hepatic disease who were undergoing coronary artery bypass grafting (CABG) to attain kidney or liver transplant candidacy. METHODS: This study was a retrospective analysis of all patients who underwent isolated CABG at our institution, Indiana University School of Medicine (Indianapolis, IN), between 2010 and 2016. Patients were divided into 2 cohorts: pretransplant (those undergoing surgery to attain renal or hepatic transplant candidacy) and nontransplant (all others). Baseline characteristics and postoperative outcomes were compared between the groups. RESULTS: A total of 1801 patients were included: 28 in the pretransplant group (n = 22, kidney; n = 7, liver) and 1773 in the nontransplant group. Major adverse postoperative outcomes were significantly greater in the pretransplant group compared with the nontransplant group: 30-day mortality (14.3% vs 2.8%; P = .009), neurologic events (17.9% vs 4.8%; P = .011), reintubation (21.4% vs 5.8%; P = .005), and total postoperative ventilation (5.2 hours vs 5.0 hours; P = .0124). The 1- and 5-year mortality in the pretransplant group was 17.9% and 53.6%, respectively. Of the pretransplant cohort, 3 patients (10.7%) underwent organ transplantation (all kidney) at a mean 436 days after CABG. No patients underwent liver transplantation. CONCLUSIONS: Outcomes after CABG in pre-kidney transplant and pre-liver transplant patients are poor. Despite surgical revascularization, most patients do not ultimately undergo organ transplantation. Revascularization strategies and optimal management in this high-risk population warrant further study.

Outcomes of Florida Sleeve Procedure in Patients with Bicuspid Versus Tricuspid Aortic Valve.

OBJECTIVE: Outcomes of the Florida Sleeve (FS) procedure in patients with bicuspid aortic valve (BAV) have not been reported before. We compared outcomes of the FS procedure between patients with BAV and those with tricuspid aortic valve (TAV). METHODS: From May 1, 2002 to January 1, 2016, 177 patients including 18 BAV and 159 TAV underwent the FS procedure. Baseline characteristics, perioperative outcomes, and echocardiographic measurements were compared between the 2 groups. Kaplan-Meier and life-table analyses were used to evaluate survival and freedom from reintervention rates. RESULTS: Mean ± standard deviation age and aortic root diameter were comparable in BAV and TAV groups, 47.83 ± 11.19 versus 49.59 ± 15.79 years (P = 0.55) and 56.57 ± 6.18 versus 55.17 ± 8.84 mm (P = 0.46), respectively. The 30-day mortality and stroke rates were zero in the BAV group and 1.88% (n = 3) in the TAV group (P = 1.00). One patient (5.55%) in the BAV group and 8 (5.03%) patients in the TAV group needed permanent pacemaker implantation (P = 0.62). Freedom from reoperation was 93% in the BAV group and 99% in the TAV group at 8 years (P = 0.041). Patient survival rate was 100% in the BAV group and 91% in the TAV group at 8 years (P = 0.42). Freedom from aortic insufficiency greater than mild was 93% in the BAV group and 96.5% in the TAV group at 5 years (P = 0.61). CONCLUSIONS: This is the first study reporting outcomes of the FS procedure in patients with BAV. This technique is feasible, and the results appear to be durable when compared to patients with TAV.

Impact of troponin I level on coronary artery bypass grafting outcomes.

PURPOSE: The effect of preoperative cardiac troponin level on outcomes after coronary artery bypass grafting (CABG) is unclear. We investigated the impact of preoperative cardiac troponin I (cTnI) level as well as the time interval between maximum cTnI and surgery on CABG outcomes. METHODS: All patients who underwent isolated CABG at our institution between 2009 and 2016 and had preoperative cTnI level available were identified using our Society of Thoracic Surgeons registry. Receiver operating characteristic (ROC) analysis was performed to identify a cTnI threshold level. Subjects were divided into groups based on this value and outcomes compared. RESULTS: A total of 608 patients were included. ROC analysis identified 5.74 µg/dL as the threshold value associated with worse postoperative outcomes. Patients with peak cTnI >5.74 µg/dL underwent CABG approximately 1 day later, had twice the risk of adverse postoperative events, and had 2.8 day longer postoperative length of stay than those with peak cTnI ≤5.74 µg/dL. cTnI level was not associated with mortality or 30-day readmission. Time interval between peak cTnI and surgery did not affect outcomes. CONCLUSION: Elevated preoperative cTnI level beyond a certain threshold value is associated with adverse postoperative outcomes but is not a marker for increased mortality. Time from peak cTnI does not affect postoperative outcomes or mortality and may not need to be considered when deciding timing of CABG.

Use of Erector Spinae Plane Block in Thoracic Surgery Leads to Rapid Recovery From Anesthesia.

BACKGROUND: Ultrasound guidance has resulted in a continuous evolution in techniques for pain control for video-assisted thoracoscopic surgery (VATS). The objective of this study was to compare erector spinae plane block with intercostal block as multimodal analgesia to elucidate quality of postoperative pain control and preservation of pulmonary function after VATS. METHODS: A consecutive cohort of patients undergoing elective VATS was enrolled in the study and divided into erector spinae plane block and intercostal block groups. Spirometry and visual analog scale pain score exams were performed to measure forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), FEV1/FVC ratio, and forced expiratory flow in intervals of 25% to 75%. Chronic pain was assessed by reviewing surgical follow-up notes. RESULTS: Seventy-eight patients were included. Comparing the erector spinae plane block group with the intercostal block group found significant improvement in visual analog scale pain score (3.2 vs 6.4, P < .001), postanesthesia care unit length of stay (127.3 vs 189.5 minutes, P = .045), preservation in lung volume parameters at 2 hours (FVC: 40.5% vs 51.4%, P < .001; FEV1: 40.9% vs 53.8%, P < .001; and forced expiratory flow in intervals of 25%-75%: 39.7% vs 53.7%, P = .019) and at 24 hours (FVC: 37.8% vs 50.5%, P < .001; FEV1: 34.3% vs 51.9%, P < .001; forced expiratory flow in intervals of 25%-75%: 27.1% vs 56.3%, P < .001), respectively. CONCLUSIONS: Erector spinae plane block improves acute and chronic pain control and preserves lung function. Thus, it has the potential for enhanced recovery from VATS as part of a multimodal analgesia regimen.

Transthoracic echocardiographic assessment of the right ventricle before and after caesarean delivery: A preliminary investigation.

Transthoracic echocardiographic evaluation of the right ventricle is more difficult than the left ventricle and has not been well characterised in the parturient during delivery. As a preliminary investigation, our goal was to use bedside transthoracic echocardiography to evaluate right ventricular myocardial function before and after caesarean delivery. Term parturients undergoing caesarean delivery under spinal anaesthesia were enrolled. Echocardiography was performed pre- and postoperatively. Assessment of myocardial function included longitudinal myocardial strain using 2D-speckle tracking for both ventricles, and fractional area change for the right ventricle. Troponin-T, creatine kinase-muscle/brain and brain natriuretic peptide were measured pre- and postoperatively. One hundred patients were enrolled; 98 completed the study. Adequate images from both timepoints (pre- and postoperatively) were obtained in 85 patients for left ventricle assessment, and 66 for the right ventricle. Right ventricular fractional area change (mean (standard deviation)) (24.9% (8.9%) to 24.9% (9.2%); P = 0.99) and strain (-19.7% (6.8%) to -18.1% (6.5%); P = 0.08) measurements suggested mild baseline dysfunction and did not change after delivery. Left ventricular strain values were normal and unchanged after delivery (-23.8% (7.4%) to -24.3% (6.7%); P = 0.51). One patient had elevated troponin-T and demonstrated worse biventricular function. Elevation of brain natriuretic peptide (n=7) was associated with mildly decreased left ventricular strain, but creatine kinase-muscle/brain (n=4) was not associated with consistent changes in cardiac function. Further investigations into peripartum right ventricular function are required to validate the findings in this preliminary study. Findings of baseline mild right ventricular dysfunction and functional changes associated with troponin-T and brain natriuretic peptide warrant rigorous investigation.

The presence of a dedicated cardiac surgical intensive care service impacts clinical outcomes in adult cardiac surgery patients.

BACKGROUND: Postoperative critical care management is an integral part of cardiac surgery that contributes directly to clinical outcomes. In the United States there remains considerable variability in the critical care infrastructure for cardiac surgical programs. There is little published data investigating the impact of a dedicated cardiac surgical intensive care service. METHODS: A retrospective study examining postoperative outcomes in cardiac surgical patients before and after the implementation of a dedicated cardiac surgical intensive care service at a single academic institution. An institutional Society of Thoracic Surgeons database was queried for study variables. Primary endpoints were the postoperative length of stay, intensive care unit length of stay, and mechanical ventilation time. Secondary endpoints included mortality, readmission rates, and postoperative complications. The effect on outcomes based on procedure type was also analyzed. RESULTS: A total of 1703 patients were included in this study-914 in the control group (before dedicated intensive care service) and 789 in the study group (after dedicated intensive care service). Baseline demographics were similar between groups. Length of stay, mechanical ventilation hours, and renal failure rate were significantly reduced in the study group. Coronary artery bypass grafting patients observed the greatest improvement in outcomes. CONCLUSIONS: Implementation of a dedicated cardiac surgical intensive care service leads to significant improvements in clinical outcomes. The greatest benefit is seen in patients undergoing coronary artery bypass, the most common cardiac surgical operation in the United States. Thus, developing a cardiac surgical intensive care service may be a worthwhile initiative for any cardiac surgical program.

Post Dural Puncture Headache, Managed with Epidural Blood Patch, Is Associated with Subsequent Chronic Low Back Pain in Patients: a Pilot Study.

PURPOSE OF REVIEW: Post dural puncture headache (PDPH) is a relatively common complication which may occur in the setting of inadvertent dural puncture (DP) during labor epidural analgesia and during intentional DP during spinal anesthetic placement or diagnostic lumbar puncture. Few publications have established the long-term safety of an epidural blood patch (EBP) for the treatment of a PDPH. RECENT FINDINGS: The aim of this pilot study was to examine the association of chronic low back pain (LBP) in patients who experienced a PDPH following labor analgesia and were treated with an EBP. A total of 146 patients were contacted and completed a survey questionnaire via telephone. The EBP group was found to be more likely to have chronic LBP (percentage difference 20% [95% CI 6-33%], RR 2.6 [95% CI 1.3-5.2]) and also LBP < 6 (percentage difference 24% [95% CI 9- 37%], RR 2.3 [95% CI 1.3-4.1]). There were no significant differences in the severity and descriptive qualities of pain between the EBP and non-EBP groups. Our findings suggest that PDPH treated with an EBP is associated with an increased prevalence of subsequent low back pain in parturients. The findings of this pilot study should spur further prospective research into identifying potential associations between DP, EBP, and chronic low back pain.

Epidural Blood Patch does not Contribute to the Development of Chronic Low Back Pain in Patients who Undergo Lumbar Punctures: A Pilot Study.

Purpose of Review: Post dural puncture headache (PDPH) is a known and relatively common complication which may occur in the setting of patients undergoing lumbar punctures (LP) for diagnostic or therapeutic purposes, and is commonly treated with an epidural blood patch (EBP). There have been few publications regarding the long-term safety of EBP for the treatment of PDPH. Recent Findings: The aim of this pilot study was to examine any association of chronic low back pain (LBP) in patients who experienced a PDPH following a LP, and were treated with an EBP. A total of 49 patients were contacted and completed a survey questionnaire via telephone. There was no increased risk of chronic LBP in the dural puncture group receiving EBP (percentage difference 1% [95% CI -25% - 26%], RR: 0.98 [95% CI 0.49 - 1.99]) compared to the dural puncture group not receiving EBP. There were no significant differences in the severity and descriptive qualities of pain between the EBP and non-EBP groups. Both groups had higher prevalence of back pain compared to baseline. Summary: Our findings suggest that dural puncture patients undergoing EBP do not experience low back pain with increased frequency compared to dural puncture patients not undergoing EBP. Higher prevalence of LBP compared to baseline and compared to general population was seen in both groups. However, this pilot study is limited by a small sample size and no definitive conclusion can be drawn from this observation. The findings of this study should spur further prospective research into identifying potential associations between LP, EBP and chronic low back pain.

The Florida Sleeve Procedure Is Durable and Improves Aortic Valve Function.

BACKGROUND: The Florida (FL) Sleeve procedure was introduced as a simplified approach for valve-sparing correction of functional Type I aortic insufficiency (AI) associated with aortic root aneurysms. In this study, short- and long-term outcomes after the FL Sleeve procedure were investigated. METHODS: From May 2002 to January 2016, 177 patients underwent the FL Sleeve procedure. Left ventricular end-diastolic diameter (LVEDD), left ventricular end-systolic diameter, left ventricular ejection fraction, and degree of AI (none = 0, minimal = 1, mild = 2, moderate = 3, severe = 4) were evaluated by echocardiography. RESULTS: Mean ± standard deviation of age was 49.41 ± 15.37 years. Survival rate was 98% at 1 year, 97% at 5 years, and 93% at 8 years. Freedom from reoperation was 99% at 1 year and 98% at 2 to 8 years. Three patients (1.69%) died during hospitalization. Three patients (1.69%) developed periprocedural stroke. Postoperative follow-up echocardiography was available in 140 patients at 30 days, and 31 patients at 5 years. AI grade significantly improved from baseline at 30 days (2.18 ± 1.26 vs. 1.1 ± 0.93, p < 0.001) and at 5 years (2.0 ± 1.23 vs. 1.45 ± 0.88, p = 0.04). Preoperative mean LVEDD significantly decreased from 52.20 ± 6.73 to 46.87 ± 8.40 (p < 0.001) at 30 days, and from 53.22 ± 7.07 to 46.61 ± 10.51 (p = 0.01) at 5 years. CONCLUSIONS: The FL Sleeve procedure is a safe, effective, and durable treatment of aortic root aneurysm and Type I AI. Long-term survival and freedom from reoperation rates are encouraging.