Anesthetic Management for Cesarean Delivery in a Patient With a Difficult Airway and Risks for Postpartum Hemorrhage: A Case Report.

Neuraxial anesthesia is the preferred anesthesia technique for cesarean delivery, however, conversion to general anesthesia may be required for a variety of clinical scenarios, including massive post-partum hemorrhage. Obstetric patients are known to have otherwise more difficult airways and emergent situations can increase the likelihood of failed intubation with potentially disastrous consequences. We describe a novel anesthesia technique for cesarean delivery using neuraxial anesthesia as the primary anesthetic technique and electively securing the airway for a patient with multiple risk factors for post-partum hemorrhage and features concerning difficult intubation.

Effects of State Law Limiting Postoperative Opioid Prescription in Patients After Cesarean Delivery.

BACKGROUND: The impact of the Florida State law House Bill 21 (HB 21) restricting the duration of opioid prescriptions for acute pain in patients after cesarean delivery is unknown. Our objective was to assess the association of the passage of Florida State law HB 21 with trends in discharge opioid prescription practices following cesarean delivery, necessity for additional opioid prescriptions, and emergency department visits at a large tertiary care center. METHODS: This was a retrospective cohort study conducted at a large, public hospital. The 2 cohorts represented the period before and after implementation of the law. Using a confounder-adjusted segmented regression analysis of an interrupted time series, we evaluated the association between HB 21 and trends in the proportions of patients receiving opioids on discharge, duration of opioid prescriptions, total opioid dose prescribed, and daily opioid dose prescribed. We also compared the need for additional opioid prescriptions within 30 days of discharge and the prevalence of emergency department visits within 7 days after discharge. RESULTS: Eight months after implementation of HB 21, the mean duration of opioid prescriptions decreased by 2.9 days (95% confidence interval [CI], 5.2-0.5) and the mean total opioid dose decreased by 20.1 morphine milligram equivalents (MME; 95% CI, 4-36.3). However, there was no change in the proportion of patients receiving discharge opioids (95% CI of difference, -0.1 to 0.16) or in the mean daily opioid dose (mean difference, 5.3 MME; 95% CI, -13 to 2.4). After implementation of the law, there were no changes in the proportion of patients who required additional opioid prescriptions (2.1% vs 2.3%; 95% CI of difference, -1.2 to 1.5) or in the prevalence of emergency department visits (2.4% vs 2.2%; 95% CI of difference, -1.6 to 1.1). CONCLUSIONS: Implementation of Florida Law HB 21 was associated with a lower total prescribed opioid dose and a shorter duration of therapy at the time of hospital discharge following cesarean delivery. These reductions were not associated with the need for additional opioid prescriptions or emergency department visits.

Transversus abdominis plane block compared with wound infiltration for postoperative analgesia following Cesarean delivery: a systematic review and network meta-analysis.

PURPOSE: This systematic review and network meta-analysis (NMA) compared postoperative analgesic efficacy of transversus abdominis plane (TAP) blocks with that of wound infiltration for Cesarean delivery (CD) without long-acting neuraxial opioid administration. METHODS: We sought randomized-controlled trials comparing TAP vs wound infiltration, and inactive control vs either TAP or wound infiltration. Wound infiltration included single-dose infiltration (WI), or continuous infusion via a catheter (WC). The primary outcome was 24 hr opioid consumption. Secondary outcomes included 12 and 24 hr pain scores (resting and movement), time to first analgesia request, incidence of postoperative nausea and vomiting (PONV), maternal sedation, and pruritus. We performed a NMA incorporating both direct and indirect comparisons and reported standardized mean differences and odds ratios with 95% confidence intervals for continuous and dichotomous outcomes. RESULTS: Forty-two studies were included, comprising 2,906 participants. Transversus abdominis plane blocks and WC were associated with significantly lower 24 hr opioid consumption than inactive controls, but there were no significant differences between WI and inactive controls. There was no statistically significant difference in 24 hr opioid consumption between TAP blocks and WC or WI techniques. The network ranking of treatments was TAP block, followed by WC or WI. No significant differences were shown between TAP, WC, and WI groups for 24 hr pain scores, time to first analgesia, PONV, sedation, and pruritus. Quality of evidence was moderate for most of the outcomes assessed. CONCLUSION: In the absence of long-acting neuraxial opioid after CD, single-dose TAP blocks and WC are effective opioid-sparing strategies.

RéSUMé: OBJECTIF: Cette revue systématique et méta-analyse en réseau (MAR) ont comparé l'efficacité analgésique postopératoire de blocs du plan du muscle transverse de l'abdomen (bloc TAP, Transversus Abdominis Plane) à celle d'infiltrations de l'incision chirurgicale après un accouchement par césarienne et en l'absence d'administration d'opioïdes neuraxiaux à action prolongée. MéTHODE: Nous avons examiné les études randomisées contrôlées comparant un bloc TAP à une infiltration de l'incision, et les comparateurs inactifs vs soit un bloc TAP ou une infiltration de l'incision. Les infiltrations de l'incision comprenaient des infiltrations à dose unique ou des perfusions continues via un cathéter. Le critère d'évaluation principal était la consommation d'opioïdes en 24 heures. Les critères d'évaluation secondaires comprenaient les scores de douleur à 12 et 24 h (au repos et avec mouvement), le délai jusqu'à la première demande d'analgésie, l'incidence de nausées et vomissements postopératoires (NVPO), la sédation maternelle et le prurit. Nous avons réalisé une MAR intégrant des comparaisons directes et indirectes et rapportons les différences moyennes standardisées et les rapports de cotes avec des intervalles de confiance de 95 % pour les critères d'évaluation continus et dichotomiques. RéSULTATS: Quarante-deux études ont été incluses, comprenant 2906 participantes. Les blocs TAP et les infiltrations par cathéter étaient associés à une consommation d'opioïdes en 24 heures significativement plus faible que les comparateurs inactifs, mais aucune différence significative n'a été observée entre infiltrations uniques et comparateurs inactifs. Aucune différence statistiquement significative dans la consommation d'opioïdes en 24 heures n'a été observée entre les blocs TAP et les techniques d'infiltration par perfusion continue ou unique. Le classement en réseau des traitements est : les blocs TAP, suivi par les infiltrations par perfusion continue ou unique. Aucune différence significative n'a été démontrée dans les scores de douleur à 24 h, le délai jusqu'à la première analgésie, les NVPO, la sédation et le prurit entre les groupes TAP, infiltration par perfusion continue et infiltration unique. La qualité des données probantes était modérée pour la plupart des critères évalués. CONCLUSION: En l'absence d'un opioïde neuraxial à action prolongée après un accouchement par césarienne, les blocs TAP en dose unique et les infiltrations par perfusion continue sont des stratégies efficaces pour réduire la consommation d'opioïdes.

The Effect of Glycopyrrolate on the Incidence of Hypotension and Vasopressor Requirement During Spinal Anesthesia for Cesarean Delivery: A Meta-analysis.

BACKGROUND: The objective of this meta-analysis was to determine the efficacy of glycopyrrolate at reducing spinal hypotension during cesarean delivery. METHODS: A literature search was performed to identify randomized controlled trials investigating the effect of glycopyrrolate on spinal-induced hypotension during cesarean delivery. Primary outcomes were intraoperative hypotension and vasopressor requirement (phenylephrine equivalents). Secondary outcomes included heart rate (HR), nausea and vomiting, dry mouth, and Apgar scores. Risk ratios (RRs), and mean differences (MDs) were calculated using random-effects modeling with 95% confidence intervals for primary outcomes and 99% confidence intervals for secondary outcomes. RESULTS: Five randomized controlled trials met our inclusion criteria. A total of 311 patients were included: 153 received glycopyrrolate and 158 placebo. The incidence of spinal-induced hypotension was no different with prophylactic glycopyrrolate compared to control (RR, 0.93 [0.71-1.21]; P = .59), but the total phenylephrine dose required was significantly reduced with glycopyrrolate (MD, -62.64 µg [-107.61 to -17.66 µg]; P = .006). The maximal HR achieved in the glycopyrrolate group was significantly higher compared to controls (MD, 15.85 bpm [5.40-26.31]; P < .0001); however, the incidence of bradycardia was not statistically different. The incidence of intraoperative nausea and vomiting was not different between groups; however, glycopyrrolate increased the risk of dry mouth (RR, 5.15 [1.82-14.57]; P < .0001). Apgar scores at 1 and 5 minutes did not differ between groups. CONCLUSIONS: Prophylactic glycopyrrolate does not reduce the incidence of spinal-induced hypotension but results in a modest reduction in vasopressor requirements while increasing maternal HR.