Neuraxial Morphine Anesthesia Given During Cesarean Delivery and Risk of Urinary Retention: A Retrospective Study.

BACKGROUND: Cesarean deliveries (CD) are commonly performed using neuraxial anesthesia. The use of neuraxial morphine has proven beneficial in terms of postoperative pain management; however, its effect on postoperative urine retention remains unclear. OBJECTIVES: To determine whether morphine injection into the neuraxis during CD influences postoperative urinary retention rate. METHODS: We conducted a retrospective case-control observational study of patients undergoing CD. We compared patients using morphine injected into the intrathecal or epidural spaces (November 2020 to October 2021) to a historical cohort of patients undergoing CD without morphine (November 2019 to October 2020). The primary outcome was the rate of postoperative overt urinary retention necessitating bladder catheterization. RESULTS: The study group comprised 283 patients, and 313 patients in the control group were eligible for analysis. No differences were found with respect to the baseline demographic and indication for CD. The number of postpartum urinary bladder catheterizations due to urine retention was higher in the study group (5% vs. 1%, P-value = 0.003). No cases of 30-day readmission were recorded. Moreover, patients treated with neuraxial morphine required fewer repeat doses of postoperative anesthesia (oral analgesia 7.4 vs. 10.1, intravenous analgesia 0.29 vs. 0.31, oral opioids 0.06 vs. 3.70, intravenous opioids 0.01 vs. 0.45, P-value < 0.001 for all). CONCLUSIONS: While neuraxial morphine used during CD appears to be safe and effective, the risk of postoperative urinary retention seems to be increased due to its use. Cases of overt urinary retention treated by bladder catheterization does not lead to short-term complications.

[TEAM SKILLS IN DELIVERY ROOM'S EMERGENCIES - PROMPT (PRACTICAL OBSTETRICS MULTI PROFESSIONAL TRAINING)].

INTRODUCTION: Poor obstetric consequences of unexpected events in the delivery room, such as a shoulder dystocia and umbilical cord prolapse at birth or severe maternal infection cause harm to the mother, the newborn, the extended family and the staff. A vigorous attempt has been made to anticipate or prevent those events and try to deal with them skillfully and quickly in order to reduce the rate of complications. One of the methods to bring about successful treatment of these events is by integrated staff training in the delivery room, that is, joint training of obstetricians, midwives in the field of nursing, and anesthesiologists. The PROMPT (Practical Obstetrics Multi Professional Training) method has proven effective in improving medical outcomes in cases of shoulder dystocia at birth, significantly improving the response rate in birth management with changes in fetal monitoring and reducing the rate of neonates with a low Apgar score at birth. The training method was brought from England and was recently taught by joint teams from two Clalit hospitals. The system trained local "coaches" from the medical staff, whose task would be to bring the training at all stages into the hospitals selected for the task. The training stages, which take place inside the delivery rooms and not in training centers as is customary today, include practicing selected cases with players, using practice dolls, dedicated flow charts and customized action boxes, as well as creating a sharing atmosphere and improving communication among staff members. In the advanced stage, training programs will be prepared for additional delivery rooms and we will be able to monitor and document a change for the better in managing such events in the future.

Enhanced Recovery after Surgery is Feasible and Beneficial and Should Be the Standard in Major Gynecological Surgeries.

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols are evidence-based protocols designed to standardize medical care, improve outcomes, and lower healthcare costs. OBJECTIVES: To evaluate the implementation of the ERAS protocol and the effect on recovery during the hospitalization period after gynecological laparotomy surgeries. METHODS: We compared demographic and clinical data of consecutive patients at a single institute who underwent open gynecological surgeries before (August 2017 to December 2018) and after (January 2019 to March 2020) the implementation of the ERAS protocol. Eighty women were included in each group. RESULTS: The clinical and demographic characteristics were similar among the women operated before and after implementation of the ERAS protocol. Following implementation of the protocol, decreases were observed in post-surgical hospitalization (from 4.89 ± 2.56 to 4.09 ± 1.65 days, P = 0.01), in patients reporting nausea symptoms (from 18 (22.5%) to 7 (8.8%), P = 0.017), and in the use of postoperative opioids (from 77 (96.3%) to 47 (58.8%), P < 0.001). No significant changes were identified between the two periods regarding vomiting, 30-day re-hospitalization, and postoperative minor and major complications. CONCLUSIONS: Implementation of the ERAS protocol is feasible and was found to result in less postoperative opioid use, a faster return to normal feeding, and a shorter postoperative hospital stay. Implementation of the protocol implementation was not associated with an increased rate of complications or with re-admissions.

Remifentanil versus fentanyl for esophagogastroduodenoscopy in children.

OBJECTIVES: We compared sedation by propofol combined with either fentanyl or remifentanil in pediatric outpatients undergoing diagnostic esophagogastroduodenoscopy. PATIENTS AND METHODS: Forty-two children scheduled for esophagogastroduodenoscopy in our institution were randomly assigned to receive 2 mg/kg propofol plus either 1 µg/kg bolus of fentanyl (group F; n = 20) or 0.5 µg/kg bolus of remifentanil (group R; n = 22). Cardiorespiratory parameters, sedation level, adverse effects related to the drugs and/or to the procedure, ease of performance for the endoscopist, and time to awakening were analyzed. RESULTS: There were no clinically significant changes in hemodynamics. Apnea periods >20 seconds and decreases in SaO2 <90% occurred more frequently in group R (31.8% vs 0%, P < 0.01, and 27.3% vs 5.0%, P > 0.05, respectively). Children in group R had significantly shorter average time to awakening: 9.5 ± 5.6 vs 16.5 ± 10.5 minutes (P = 0.01), and received a significantly lower total dose of propofol (P = 0.034). Adverse effects within the first 24 hours postprocedure occurred less frequently in group R (P = 0.03). CONCLUSIONS: Remifentanil in combination with propofol provides good analgesic and sedative effects, which were shorter lasting compared with fentanyl-based sedation, and caused fewer delayed adverse effects. The use of remifentanil was associated with respiratory depression, emphasizing the need for experienced anesthesiologists.