Automated Alert System of Second-Line Uterotonic Drug Administration.

Multidisciplinary team management of postpartum hemorrhage (PPH) is needed to optimize care and improve outcomes. Lucile Packard Children's Hospital, Stanford, is a tertiary referral center with 4600 deliveries/y (>70% high-risk deliveries), and there have been times when the obstetric anesthesia team was alerted late or not at all for PPHs. Introduction of an automated alert process to the obstetric anesthesia team when a second-line uterotonic drug was administered has ensured prompt evaluation. Utilization of this automated drug alert system has improved communication and reduced failure to inform the obstetric anesthesiology team of PPH after vaginal and cesarean deliveries.

Obstetric Anesthesia Procedure-Based Workload and Facility Utilization of Society of Obstetric Anesthesia and Perinatology Centers of Excellence Designated Institutions.

BACKGROUND: Optimal workload and staffing for obstetric anesthesia services have yet to be determined. We surveyed Society of Obstetric Anesthesia and Perinatology (SOAP) Centers of Excellence (COE) for Obstetric Anesthesia Care institutions to evaluate procedure-based obstetric anesthesia workload and facility use. METHODS: After institutional review board (IRB) exemption, an online survey instrument (REDCap) was sent by email (1 initial and 2 reminders) to all SOAP COEs. Survey data included the number of deliveries, cesarean delivery rate, neuraxial labor analgesia rate, the number of labor and operating rooms, and the number of in-house and backup obstetric anesthesia providers. Obstetric anesthesia activity was estimated using a time-based workload ratio per provider (Stanford Work Index, 1.0 = clinically working every minute of every hour on duty) during weekday, weeknight, and weekend shifts. We compared workload between academic and nonacademic centers and correlated operating and labor rooms with cesarean and vaginal delivery volume. RESULTS: Fifty-one of 53 surveys were returned (96% response rate). Data from 33 academic and 14 nonacademic US institutions were analyzed. For academic centers, median Stanford Work Index for all staff (included trainees and Certified Registered Nurse Anesthetists) was 0.20 (weekday) and 0.19 (weeknight and weekends); nonacademic centers were 0.33 (weekday, P < .001 versus academic), 0.23 (weeknight, P = .009 versus academic), and 0.23 (weekends, P = .03 versus academic practices). Attending-only Stanford Work Indices were similar between academic and nonacademic centers. Total number of rooms on the obstetric suite (operating, labor, or triage room) was strongly correlated with delivery volume ( R2 = 0.55). CONCLUSIONS: The results outline staffing procedure-based workload ratios and facility utilization at SOAP COEs in the United States. These data can be used by other institutions that provide obstetric anesthesia services to guide their obstetric anesthesia staffing. The importance of considering the workload associated with different shifts and between academic and nonacademic centers is also highlighted. The results show that approximately one-third of an obstetric anesthesiologist's workload is spent on performing procedures. We did not, however, measure the other tasks anesthesiologists practice as peripartum physicians (eg, managing critically ill parturients, doing pre- and postprocedural evaluations, or performing emergent and unexpected procedures), and future studies are required to determine the time required to perform these tasks. Studies to determine the optimal staffing models to handle workload fluctuations and improve outcomes are also required.

Intra-aortic Balloon Pump for Cesarean Hysterectomy and Massive Hemorrhage in a Parturient with Placenta Accreta and Pulmonary Embolus.

During cesarean hysterectomy for a placenta accreta, a 36-year-old parturient underwent a massive resuscitation for profound bleeding and also suffered a pulmonary embolus leading to cardiac arrest. Chest compressions and epinephrine were required for resucitation. When surgery was complete, she was taken to the intensive care unit on an epinephrine infusion and inhaled nitric oxide but was brought back to the operating room after 3 h for surgical exploration. Echocardiography revealed a poorly contracting left ventricle, and an intra-aortic balloon pump was inserted. She gradually recovered full function and was discharged home after 35 days.

The Crystalloid Co-Load: Clinically as Effective as Colloid Preload for Preventing Hypotension from Spinal Anaesthesia for Caesarean Delivery.

OBJECTIVE: Colloid preloading diminishes post-spinal hypotension. However, whether colloid preloading is superior to crystalloid co-loading is uncertain. In this retrospective study, we compared the effects of a colloid preload versus a crystalloid co-load on vasopressor requirements and maternal haemodynamics among women undergoing elective caesarean delivery (CD) with spinal anaesthesia. METHODS: We extracted data from the medical records of 160 healthy women who underwent elective CD with spinal anaesthesia at an academic obstetric centre before and after an institutional fluid-loading protocol change. Patients received a 500 mL 6% hydroxyethyl starch preload or a 1000 mL crystalloid co-load. The primary outcome was the total phenylephrine dose administered from spinal block placement to delivery. RESULTS: Our cohort comprised 79 women in the colloid group and 77 women in the crystalloid group. The mean phenylephrine use was significantly lower in the colloid group than in the crystalloid group (489±403 µg vs. 647±464 µg, respectively, p=0.02). The maximal drop in systolic blood pressure was greater in the colloid group than in the crystalloid group (36±20 mmHg vs. 29±16 mmHg, respectively, p=0.02). There were no clinically significant differences between the groups in heart rate, blood loss, temperature and Apgar scores. CONCLUSION: Vasopressor use was lower in colloid preloading than in crystalloid co-loading. However, differences in all outcome measures were minimal and likely clinically insignificant, suggesting that both fluid-loading techniques are appropriate to use for the prevention of spinal hypotension in women undergoing CD.

Evaluation of Opioid Use With Split Doses of Oral Opioids in a Postcesarean Delivery Analgesia Order Set.

OBJECTIVE: To evaluate whether an order set change that halved the initial dose of oxycodone and allowed the remainder to be given 1 hour later, if requested, was associated with reduced opioid use and side effects after cesarean delivery. METHODS: This retrospective, clinical practice study reviewed electronic medical records after implementation of a new order set for cesarean delivery. Oxycodone orders changed from 5 mg (for verbal pain score of 4/10 or lower) and 10 mg (for 5-10/10) to 2.5 mg (for verbal pain score 1-4/10) or 5 mg (for 5-10/10), and the patient requesting pain relief, with a nurse check within 1 hour to administer another 2.5 or 5 mg, respectively, if needed. The primary outcome was opioid use (in intravenous morphine equivalents) in the first 48 hours. Secondary outcomes included incidence and treatment of nausea or vomiting and pruritis, average and peak verbal pain scores within 48 hours, and satisfaction. RESULTS: The records of 1,050 women were examined (542 before and 508 after the change). Opioid use in the first 48 hours was lower after the practice change (median [interquartile range] 10.0 [1.3-25.0] mg before vs 4.4 [0-12.5] mg after; P<.001). A small increase in average verbal pain score occurred (mean [SD] 1.8 [1.0] before vs 2.0 [1.3] after; difference -0.2; 95% CI -0.3 to -0.04). Peak verbal pain score (5.9 [2.0] before vs 6.0 [2.1] after; difference -0.1; 95% CI -0.4 to 0.1) and mean (SD) satisfaction score (97.7 [7.2] before vs 97.1 [7.5] after; difference 0.6, 95% CI -0.5 to 1.6) did not change. Fewer patients reported postoperative nausea or vomiting (30.9% before vs 19.3% after; odds ratio 0.5; 95% CI 0.4 to 0.7). CONCLUSION: Split doses of oxycodone were associated with 56% reduction in 48 hours opioid use after cesarean delivery.

Transesophageal Echocardiographic Observation of Caval Thrombus Followed by Intraoperative Placement of Inferior Vena Cava Filter for Presumed Pulmonary Embolism During Cesarean Hysterectomy for Placenta Percreta: A Case Report.

During a cesarean hysterectomy for placenta percreta, transesophageal echocardiography was used to monitor volume status and guide resuscitation. After delivery of the neonate but before massive surgical hemorrhage, a thrombus appeared in the inferior vena cava. Roughly 3 hours later, the patient had hemodynamic changes consistent with an intraoperative pulmonary embolism. Boluses of epinephrine stabilized the patient. An inferior vena cava filter was placed via an in situ internal jugular central venous cannula to prevent further embolic events. We believe transesophageal echocardiography is a useful monitor during surgery for placenta percreta.

Cost-benefit Analysis of Maintaining a Fully Stocked Malignant Hyperthermia Cart versus an Initial Dantrolene Treatment Dose for Maternity Units.

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: The Malignant Hyperthermia Association of the United States recommends that dantrolene be available for administration within 10 min. One approach to dantrolene availability is a malignant hyperthermia cart, stocked with dantrolene, other drugs, and supplies. However, this may not be of cost benefit for maternity units, where triggering agents are rarely used. METHODS: The authors performed a cost-benefit analysis of maintaining a malignant hyperthermia cart versus a malignant hyperthermia cart readily available within the hospital versus an initial dantrolene dose of 250 mg, on every maternity unit in the United States. A decision-tree model was used to estimate the expected number of lives saved, and this benefit was compared against the expected costs of the policy. RESULTS: We found that maintaining a malignant hyperthermia cart in every maternity unit in the United States would reduce morbidity and mortality costs by $3,304,641 per year nationally but would cost $5,927,040 annually. Sensitivity analyses showed that our results were largely driven by the extremely low incidence of general anesthesia. If cesarean delivery rates in the United States remained at 32% of all births, the general anesthetic rate would have to be greater than 11% to achieve cost benefit. The only cost-effective strategy is to keep a 250-mg dose of dantrolene on the unit for starting therapy. CONCLUSIONS: It is not of cost benefit to maintain a fully stocked malignant hyperthermia cart with a full supply of dantrolene within 10 min of maternity units. We recommend that hospitals institute alternative strategies (e.g., maintain a small supply of dantrolene on the maternity unit for starting treatment).

Intrathecal Migration of an Epidural Catheter While Using a Programmed Intermittent Epidural Bolus Technique for Labor Analgesia Maintenance: A Case Report.

We describe a case of intrathecal migration of a wire-reinforced epidural catheter in a parturient who received epidural labor analgesia. Epidural analgesia was initiated with a combined-spinal epidural technique and maintained by programmed intermittent epidural boluses. Epidural catheter aspiration after insertion was negative for cerebrospinal fluid. The patient's response to the first four doses of local anesthetic was consistent with epidural drug delivery. After the fifth dose, she developed a complete lower extremity motor block, hypotension, and high sensory blockade. Catheter aspiration was then positive for cerebrospinal fluid. After symptom resolution, labor pain was successfully managed with this inadvertent intrathecal catheter.

Nitrous oxide for labor analgesia: Utilization and predictors of conversion to neuraxial analgesia.

STUDY OBJECTIVE: We examined the characteristics of women who choose nitrous oxide for labor analgesia and identified factors that predict conversion from nitrous oxide to labor neuraxial analgesia. DESIGN: Retrospective descriptive study. SETTING: Labor and Delivery Ward. PATIENTS: 146 pregnant women who used nitrous oxide for analgesia during labor and delivery between September 2014 and September 2015. INTERVENTIONS: Chart review only. MEASUREMENTS: Demographic, obstetric, and intrapartum characteristics of women using nitrous oxide were examined. Multivariable logistic regression was performed to identify factors associated with conversion from nitrous oxide to neuraxial analgesia. Data are presented as n (%), median [IQR], adjusted relative risk (aRR), and 95% confidence intervals (CI) as appropriate. RESULTS: During the study period, 146 women used nitrous oxide for labor analgesia (accounting for 3% of the total deliveries). The majority (71.9%) of women who used nitrous oxide were nulliparous, and over half (51.9%) had expressed an initial preference for "nonmedical birth." The conversion rate to neuraxial blockade was 63.2%, compared to a concurrent institutional rate of 85.1% in women who did not use nitrous oxide. Factors associated with conversion from nitrous oxide to neuraxial blockade were labor induction (aRR=2.0, CI 1.2-3.3) and labor augmentation (aRR=1.7, CI 1.0-2.9). CONCLUSION: Only a small number of women opted to use nitrous oxide during labor, analgesia was minimal, and most converted to neuraxial analgesia. Women with induced and augmented labors should be counseled about the increased likelihood that they will convert to neuraxial analgesia.

Risk Factors for Severe Postpartum Hemorrhage After Cesarean Delivery: Case-Control Studies.

BACKGROUND: Women who undergo intrapartum caesarean delivery (CD) are at increased risk of postpartum hemorrhage (PPH) compared with those undergoing prelabor CD. To determine whether the presence and strength of the associations between individual risk factors and severe PPH vary among women undergoing prelabor CD or intrapartum CD, stratified analyses are needed according to CD subtype. METHODS: To identify risk factors for severe PPH within 2 distinct CD populations, prelabor CD and intrapartum CD, we performed 2 case-control studies. Women in each study cohort delivered at a tertiary obstetric center in the United States between 2002 and 2012. For each study, cases were women who had a blood loss ≥1500 mL or who received an intraoperative or postoperative transfusion up to 48 hours after delivery. Risk factors for severe PPH among women undergoing prelabor CD or intrapartum CD were examined in separate logistic regression models. RESULTS: For prelabor CD, we identified 269 cases and 550 controls. Clinical factors with the highest adjusted odds for severe PPH during prelabor CD were general anesthesia (adjusted odds ratio [aOR] = 22.3; 95% confidence interval [CI], 4.9-99.9; reference group = spinal anesthesia), multiple pregnancies (aOR = 8.0; 95% CI, 4.2-15.0; reference group = singleton pregnancy), and placenta previa (aOR = 6.3; 95% CI, 3.4-11.8). For intrapartum CD, we identified 278 cases and 572 controls. Clinical factors with the highest adjusted odds for severe PPH during intrapartum CD were general anesthesia (aOR = 5.4; 95% CI, 1.7-17.1), multiple pregnancies (aOR = 3.2; 95% CI, 1.7-6.3), and a predelivery hemoglobin ≤ 9.9 g/dL (aOR = 3.0; 95% CI, 1.3-6.9; reference group = predelivery hemoglobin ≥ 11 g/dL). CONCLUSIONS: Women who undergo prelabor CD and intrapartum CD have several shared risk factors for severe PPH (general anesthesia and multiple pregnancies). However, the risk factor profiles for severe PPH differed between these CD cohorts. Recognizing these differences may be important when planning resources and interventions for high-risk patients undergoing either prelabor or intrapartum CD.

Effect of a High-Rate Versus a Low-Rate Oxytocin Infusion for Maintaining Uterine Contractility During Elective Cesarean Delivery: A Prospective Randomized Clinical Trial.

BACKGROUND: Oxytocin is routinely used as prophylaxis against uterine atony. During elective cesarean delivery (CD), an oxytocin bolus is used to initiate adequate uterine tone, followed by an oxytocin infusion to maintain uterine contractility. However, it is unclear whether oxytocin maintenance infusion rate influences total estimated blood loss (EBL). METHODS: We performed a prospective, randomized, double-blind trial in 51 women undergoing elective CD. Women were randomly assigned to receive an oxytocin maintenance infusion of 2.5 or 15 U/h. All women received an oxytocin 1 U bolus to initiate adequate uterine tone. The primary outcome was EBL. EBL values between groups were compared using a Mann-Whitney U test; P < .05 as statistically significant. The median EBL difference with 95% confidence intervals was also calculated. Secondary outcomes included adequacy of uterine tone, use of additional uterotonics, and oxytocin-related side effects, including hypotension. RESULTS: Of 51 women, 24 received a low-rate infusion and 27 received a high-rate infusion. Median (interquartile range) EBL values in the low-rate and high-rate groups were 634 (340-886) mL versus 512 (405-740) mL, respectively (P = .7). The median difference in EBL between groups was 22 mL; 95% confidence interval = -158 to 236 mL. The rate of postpartum hemorrhage did not differ between groups (low-rate group: 4/24 [16.7%] versus high-rate group: 4/26 [15.4%]). There were no between-group differences over time (first 20 minutes after commencing infusion) in the incidence of adequate uterine tone (P = .72) or hypotension (P = .32). CONCLUSIONS: Among women undergoing elective CD receiving an oxytocin maintenance infusion, EBL and uterine tone did not differ between women receiving 2.5 U/h oxytocin and those receiving 15 U/h oxytocin. Our findings suggest that efficacy can be obtained with a low oxytocin maintenance infusion rate; however, dose-finding studies are needed to determine the infusion rate that optimizes drug efficacy while minimizing side effects.