Pregnancy and Labor Epidural Effects on Gastric Emptying: A Prospective Comparative Study.

BACKGROUND: The lack of reliable data on gastric emptying of solid food during labor has led to some discrepancies between current guidelines regarding fasting for solid food in the parturient. This prospective comparative study aimed to test the hypothesis that the gastric emptying fraction of a light meal would be reduced in parturients receiving epidural analgesia and with no labor analgesia compared with nonpregnant and pregnant women. METHODS: Ten subjects were enrolled and tested in each group: nonpregnant women, term pregnant women, parturients with no labor analgesia, and parturients with epidural labor analgesia. After a first ultrasound examination was performed to ensure an empty stomach, each subject ingested a light meal (125 g yogurt; 120 kcal) within 5 min. Then ultrasound measurements of the antral area were performed at 15, 60, 90, and 120 min. The fraction of gastric emptying at 90 min was calculated as [(antral area90 min / antral area15 min) - 1] × 100, and half-time to gastric emptying was also determined. For the Parturient-Epidural group, the test meal was ingested within the first hour after the induction of epidural analgesia. RESULTS: The median (interquartile range) fraction of gastric emptying at 90 min was 52% (46 to 61), 45% (31 to 56), 7% (5 to 10), and 31% (17 to 39) for nonpregnant women, pregnant women, parturients without labor analgesia, and parturients with labor epidural analgesia, respectively (P < 0.0001). The fraction of gastric emptying at 90 min was statistically significant and lower in the Parturient-Epidural group than in the Nonpregnant and Pregnant Control groups. In addition, the fraction of gastric emptying at 90 min was statistically significant and lower in the Parturient-No-Epidural group than in the Parturient-Epidural group. CONCLUSIONS: Gastric emptying in parturients after a light meal was delayed, and labor epidural analgesia seems not to worsen but facilitates gastric emptying. This should be taken into consideration when allowing women in labor to consume a light meal.

Women's view on fasting during labor in a tertiary care obstetric unit. A prospective cohort study.

OBJECTIVE: Maternal satisfaction and comfort may in part depend on fasting instruction given during labor. This study aimed to assess the satisfaction and the wishes of parturients with regards to fasting during labor. STUDY DESIGN: This prospective cohort study was conducted among parturients assessing the fasting instructions they were given. We assessed whether women did have any oral intake during labor and focused on women's view of fasting during labor. Maternal discomfort related to thirst and hunger was assessed using 0-10 scales. RESULTS: A total of 193 women were included, among whom 71 (37 %) received spontaneously given instructions and 60 (31 %) received instruction upon request. One hundred sixteen (60 %) women were allowed to drink clear fluids, in a limited way for 106 women (91 % of those concerned); 119 women did drink clear fluids during labor. One hundred thirty-two (68 %) women had a thirst-related discomfort score ≥ 4 without any statistical difference whether they had or had not drunk clear fluids. Colder water, unrestricted volume of water and sweet drink were desired by 74 (64 %), 38 (33 %) and 28 (24 %) women who had been allowed to drink, respectively. CONCLUSION: These results emphasize that thirst contributes to maternal discomfort during labor. Permitting limited intake of water does not ensure high maternal satisfaction. Fresh clear fluids, unrestricted amounts of fluids and sweet fluids could contribute to improve maternal comfort.

Assessment of Coagulation by Thromboelastography During Ongoing Postpartum Hemorrhage: A Retrospective Cohort Analysis.

BACKGROUND: Rapid assessment of hemostasis during postpartum hemorrhage (PPH) is essential to allow characterization of coagulopathy, to estimate bleeding severity, and to improve outcome. Point of care (POC) coagulation monitors could be of great interest for early diagnosis and treatment of coagulation disorders in PPH. METHODS: Women with ongoing PPH >500 mL who clinically required an assessment of coagulation with thromboelastography (TEG) were included. The primary aim of this retrospective observational cohort study was to assess the predictive accuracy of TEG parameters for the diagnosis of coagulation disorders (hypofibrinogenemia ≤2 g/L, thrombocytopenia ≤80,000/mm, prothrombin ratio ≤50%, or activated partial thromboplastin time ratio ≥1.5) during PPH. The analyzed TEG parameters were Kaolin-maximum amplitude (K-MA), Kaolin-maximum rate of thrombus generation using G (K-MRTGG), functional fibrinogen-maximum amplitude (FF-MA), and functional fibrinogen-maximum rate of thrombus generation using G (FF-MRTGG). Secondary aims of this study were (1) comparison of the time delay between classical parameters and velocity curve-derived parameters (K-MA versus K-MRTGG and FF-MA versus FF-MRTGG) and (2) evaluation of the accuracy of TEG parameters to predict severe hemorrhage estimated by calculated blood losses. RESULTS: Ninety-eight patients were included with 98 simultaneous TEG analyses and laboratory assays. All parameters had an excellent predictive performance. For the Kaolin assay, no significant difference was evidenced between K-MA and K-MRTGG for the predictive performance for hypofibrinogenemia ≤2 g/L and/or thrombocytopenia ≤80,000/mm (respective area under the curve [AUC], 0.970 vs 0.981). For the functional fibrinogen assay, no significant difference was evidenced between FF-MA and FF-MRTGG for the predictive performance for hypofibrinogenemia ≤2 g/L (respective AUC, 0.988 vs 0.974). For both assays, the time to obtain results was shorter for the velocity parameters (K-MRTGG: 7.7 minutes [2.4 minutes] versus K-MA: 24.7 minutes [4.2 minutes], P < .001; FF-MRTGG: 2.7 minutes [2.7 minutes] versus FF-MA: 14.0 minutes [4.3 minutes], P < .001). All TEG parameters derived from the Kaolin and functional fibrinogen assays and Clauss fibrinogen were significantly predictive of severe PPH >2500 mL. CONCLUSIONS: During PPH, when coagulation assessment is indicated, TEG provides a rapid and reliable detection of hypofibrinogenemia ≤2 g/L and/or thrombocytopenia ≤80,000/mm. No difference in performance was evidenced between the velocity-derived parameters (K-MRTGG and FF-MRTGG) and the classical parameters (K-MA and FF-MA). However, velocity-derived parameters offer the advantage of a shorter time to obtain results: FF-MRTGG parameter is available within ≤5 minutes. POC assessment of hemostasis during PPH management may help physicians to diagnose clotting disorders and to provide appropriate hemostatic support.

Pain monitoring in anesthetized children: first assessment of skin conductance and analgesia-nociception index at different infusion rates of remifentanil.

BACKGROUND: Analgesia and nociception can not be specifically monitored during general anesthesia. Movement of the patient or hemodynamic variations are usually considered as symptoms of insufficient analgesia. The measure of skin conductance (SC) allows an assessment of peripheral sympathetic activity. The analgesia-nociception index (ANI) provides an evaluation of the parasympathetic activity based on heart rate variability. These two non-invasive monitors might allow a better assessment of perioperative nociception. OBJECTIVES: Describe the profiles of SC and ANI after a standardized nociceptive stimulation, in anesthetized children, at different infusion rates of remifentanil. MATERIALS/METHODS: For this pilot study, 12 children (8.4 ± 5 years) scheduled for middle-ear surgery were anesthetized with desflurane to maintain a bispectral index at 50. Remifentanil was used for analgesia, at an initial infusion rate of 0.2 µg·kg(-1) ·min(-1) . Remifentanil infusion rate was then decreased: Five steady-state periods of 10 min were obtained at 0.2, 0.16, 0.12, 0.08, and 0.04 µg·kg(-1) ·min(-1) . At the end of each period, a standardized tetanic stimulation was applied to the patient. Variations in heart rate, blood pressure, SC, and ANI were recorded before and after each stimulation. RESULTS: After the stimulation, ANI was significantly decreased compared with prestimulation values for all remifentanil infusion rates. This decrease was greater at 0.04 µg·kg(-1) ·min(-1) than at the other infusion rates. SC, heart rate, and blood pressure were not modified by the stimulations, whatever the dose of remifentanil. CONCLUSION: ANI might provide a more sensitive assessment of nociception in anesthetized children than hemodynamic parameters or skin conductance.

Clinical validation of Xpert MTB/RIF for the diagnosis of extrapulmonary tuberculosis.

Extrapulmonary tuberculosis (EPTB) accounts for more than 20% of tuberculosis (TB) cases. Xpert MTB/RIF (Xpert) (Cepheid, Sunnyvale, CA, USA) is a fully automated amplification system, for which excellent results in the diagnosis of pulmonary TB in highly endemic countries have been recently reported. We aimed to assess the performance of the Xpert system in diagnosing EPTB in a low incidence setting. We investigated with Xpert a large number of consecutive extrapulmonary clinical specimens (1,476, corresponding to 1,068 patients) including both paediatric (494) and adult samples. We found, in comparison with a reference standard consisting of combination of culture and clinical diagnosis of TB, an overall sensitivity and specificity of 81.3% and 99.8% for Xpert, while the sensitivity of microscopy was 48%. For biopsies, urines, pus and cerebrospinal fluids the sensitivity exceeded 85%, while it was slightly under 80% for gastric aspirates. It was, in contrast, lower than 50% for cavitary fluids. High sensitivity and specificity (86.9% and 99.7%, respectively) were also obtained for paediatric specimens. Although the role of culture remains central in the microbiological diagnosis of EPTB, the sensitivity of Xpert in rapidly diagnosing the disease makes it a much better choice compared to smear microscopy. The ability to rule out the disease still remains suboptimal.

Neonatal fluid management.

Perioperative fluid management in paediatrics has been the subject of many controversies in recent years, but fluid management in the neonatal period has not been considered in most reviews and guidelines. The literature regarding neonatal fluid management mainly appears in the paediatric textbooks and few recent data are available, except for resuscitation and fluid loading during shock and major surgery. In the context of anaesthesia, many neonates requiring surgery within the first month of life have organ malformation and/or dysfunction. This article aims at reviewing basic physiological considerations important for neonatal fluid management and mainly focusses on fluid maintenance and replacement during surgery.

A new formula of age-related anatomical landmarks for blockade of the sciatic nerve in the popliteal fossa in children using the posterior approach.

BACKGROUND: Anatomical landmarks for sciatic nerve blockade are poorly described in children. In adults, the site of puncture of the high approach is located at least 10 cm above the popliteal skin crease. METHODS: We hypothesized that correcting the adult landmarks (10 cm) by the ratio of the calculated child femoral shaft length over the adult femoral shaft length would provide adequate landmarks for needle introduction for popliteal nerve block in children. RESULTS: The theoretical landmarks were calculated and tested in 21 infants and children. In all cases, the sciatic nerve was easily located using the nerve stimulator when the needle was inserted at the calculated place and 29 catheters were successfully placed in these 21 children. CONCLUSION: These simple landmarks adapted to children age are expected to help the clinicians to perform safely sciatic blocks at the popliteal fossa in young patients.

Evaluation of the GenoCard as a tool for transport and storage of samples for tuberculosis molecular drug susceptibility testing.

Early identification and monitoring of the spread of resistant M. tuberculosis strains is essential to control tuberculosis. The paper-based transport device GenoCard enables the safe shipment of inactivated biological material and strains to be used for molecular detection of drug resistance.

Comparison of a commercial and an in-house T cell-based assay for the diagnosis of Mycobacterium tuberculosis infection.

Identification of individuals with a tuberculosis infection is a very important element for the control of tuberculosis. The currently used tuberculin skin test has poor sensitivity and specificity. Recently, an important advance in tuberculosis diagnosis occurred with the development of in vitro T cell-based IFN-gamma release assays. The aim of this study was to compare a RD1-based in-house ELISPOT-IFN-gamma assay with a commercial (T-SPOT.TB) assay for the diagnosis of tuberculosis infection. The results showed an almost complete concordance between the two assays, confirming that our restricted but highly selected pool of peptides is sufficient to detect tuberculosis infection.

Use of T-SPOT.TB in latent tuberculosis infection diagnosis in general and immunosuppressed populations.

Immunosuppressed patients have a nine-fold greater risk of developing active tuberculosis (TB) disease given the latent TB infection than the general population. Few data are available on the predictivity of T-SPOT.TB in immunosuppressed patients. We had a T-SPOT.TB determination and a TST from 197 immunosuppressed haematological patients and 324 community contacts of infectious TB cases. In the general population, TST was positive in 275 (84.9%), T-SPOT.TB in 167 (51.5%) (p < 0.0001). In immunosuppressed patients, TST was positive in 34 (17.3%), T-SPOT.TB in 70 (35.5%). T-SPOT.TB is not influenced by immunosuppression and even an indeterminate result may yield useful information on patient's anergy.

Use of genotype MTBDR assay for molecular detection of rifampin and isoniazid resistance in Mycobacterium tuberculosis clinical strains isolated in Italy.

Mycobacterium tuberculosis is one of the leading causes of death worldwide, and multidrug-resistant tuberculosis (MDR-TB) is associated with a high case fatality rate. Rapid identification of resistant strains is crucial for the early administration of appropriate therapy, for prevention of development of further resistance, and to curtail the spread of MDR strains. The Genotype MTBDR (Hain Lifescience, Nehren, Germany) is a reverse hybridization line probe assay designed for the rapid detection of rpoB and katG gene mutations in clinical isolates. The ability of this technique to correctly identify resistant and MDR-TB strains was tested on 206 isolates from the Italian drug resistance surveillance system. This panel included the majority of MDR strains isolated in Italy in the past 3 years. The results of the test were compared to conventional drug susceptibility test performed on isolated strains and verified by sequencing the regions of interest of the bacterial genome. The rate of concordance between the results of the MTBDR and those obtained with "in vitro" sensitivity was 91.5% (130 of 142) for rifampin and 67.1% (116 of 173) for isoniazid. We also applied this test directly to a panel of 36 clinical specimens collected from patients with active TB. The MTBDR correctly identified the two cases of MDR-TB included in the panel. These results show that the MTBDR test is useful in the detection and management of tuberculosis when MDR disease is suspected.

Comparison of an in-house and a commercial RD1-based ELISPOT-IFN-gamma assay for the diagnosis of Mycobacterium tuberculosis infection.

OBJECTIVE: To compare a RD1-based in-house ELISPOT-interferon-gamma (IFN-gamma) assay with a commercial (T-SPOT.TB) assay for the diagnosis of Mycobacterium tuberculosis (TB) infection and the efficacy of the tuberculin skin test (TST) and ELISPOT assay in detecting latent TB infection (LTBI). DESIGN: Eighty-six subjects (65 household contacts of contagious TB-infected patients, 13 subjects with active or previous TB infection, and 8 with suspected TB infection) were consecutively recruited in the context of a surveillance program. METHODS: Enrolled subjects underwent the Mantoux TST and two different ELISPOT-IFN-gamma assays: an in-house assay using a pool of selected M. tuberculosis peptides (MTP) and the commercial T-SPOT.TB assay. RESULTS: The in-house and commercial ELISPOT-IFN-gamma assays showed almost complete concordance (99%) in diagnosing acute or LTBI. When comparing the efficacy of the TST with the in-house ELISPOT assay in detecting TB infection, a small agreement was observed (k=0.344, P<0.0001): 36% of the subjects with a positive TST were ELISPOT-MTP negative and 12% with a negative TST were ELISPOT-MTP positive. Furthermore, 78% of the ELISPOT-MTP negative individuals were ELISPOT- Bacillus Calmette-Guérin (BCG) positive, most of whom had received BCG vaccination. CONCLUSION: Our in-house ELISPOT assay based on a restricted pool of highly selected peptides is equivalent to the commercial T-SPOT.TB assay, is cheaper and is probably not confounded, unlike the TST, by BCG vaccination in our setting.

Evaluation of chromogenic medium (ORSAB) for routine identification of methicillin resistant Staphylococcus aureus (MRSA).

Performance of chromogenic medium (ORSAB) for routine detection of methicillin resistant S. aureus (MRSA) was evaluated on 510 specimens collected from patients suspected of MRSA infection or colonization. Addition of ORSAB plates to the routine protocol allowed MRSA identification in 24 hours from samples plating. In 18 samples MRSA colonies were identified only on ORSAB plates, those cases would have been missed by routine protocol alone.