The Importance of Fetoplacental Doppler Velocimetry for Fetal Surveillance During General Anesthesia for Non-obstetric Surgery.

Fetal heart rate monitoring during general anesthesia for non-obstetric surgery at viable gestational ages is recommended to evaluate fetal well-being during the intervention. Alteration induced by anesthetic drugs could mimic fetal acute hypoxia, leading to pointless Cesarean sections. We report a case of a pregnant woman in the third trimester undergoing neurosurgical surgery. The continuous heart rate registration showed a non-reassuring pattern, potentially inducing the multidisciplinary team to expedite the delivery. The seriate fetoplacental Doppler evaluations were reassuring about normal fetal conditions, suggesting that ultrasound surveillance could be more reliable than intraoperative heart rate monitoring.

Ultrasound-Guided Bilateral Erector Spinae Plane Block vs. Ultrasound-Guided Bilateral Posterior Quadratus Lumborum Block for Postoperative Analgesia after Caesarean Section: An Observational Closed Mixed Cohort Study.

ESP block (ESPB) and posterior Quadratus Lumborum Block (pQLB) have been proposed as opioid-sparing techniques for the management of pain after abdominal surgery. Between December 2021 and October 2022, we conducted a retrospective comparative study at the delivery suite of Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy, to compare the efficacy of ESPB and pQLB in preventing postoperative pain after an elective caesarean section (CS). The primary outcome was total morphine consumption in the first 24 h. Secondary outcomes were time to first opioid request; Numerical Pain Rating Scale (NPRS) at 0, 2, 6, 12 and 24 h; vital signs; adverse events. Fifty-two women were included. The total cumulative dose of morphine was not significantly different between the two groups of patients (p = 0.897). Time to first dose of morphine, NPRS values and haemodynamic parameters were not statistically different between the two groups. NPRS values significantly increased (p < 0.001) at the different time intervals considered. The need for rescue doses of morphine was lower in the ESPB group compared to the pQLB group (hazard ratio of 0.51, 95% CI (0.27 to 0.95), p = 0.030). No adverse event was reported. ESPB seems to be as effective as pQLB in providing analgesia after CS.

Effect of a pre-emptive 2-hour session of high-flow nasal oxygen on postoperative oxygenation after major gynaecologic surgery: a randomised clinical trial.

BACKGROUND: We aimed at determining whether a 2-h session of high-flow nasal oxygen (HFNO) immediately after extubation improves oxygen exchange after major gynaecological surgery in the Trendelenburg position in adult female patients. METHODS: In this single-centre, open-label, randomised trial, patients who underwent major gynaecological surgery were randomised to HFNO or conventional oxygen treatment with a Venturi mask. The primary outcome was the Pao2/FiO2 ratio after 2 h of treatment. Secondary outcomes included lung ultrasound score, diaphragm thickening fraction, dyspnoea, ventilatory frequency, Paco2, the percentage of patients with impaired gas exchange (Pao2/FiO2 ≤40 kPa) after 2 h of treatment, and postoperative pulmonary complications at 30 days. RESULTS: A total of 83 patients were included (42 in the HFNO group and 41 in the conventional treatment group). After 2 h of treatment, median (inter-quartile range) Pao2/FiO2 was 52.9 (47.9-65.2) kPa in the HFNO group and 45.7 (36.4 -55.9) kPa in the conventional treatment group (mean difference 8.7 kPa [95% CI: 3.4 to 13.9], P=0.003). The lung ultrasound score was lower in the HFNO group than in the conventional treatment group (9 [6-10] vs 12 [10-14], P<0.001), mostly because of the difference of the score in dorsal areas (7 [6-8] vs 10 [9-10], P<0.001). The percentage of patients with impaired gas exchange was lower in the HFNO group than in the conventional treatment group (5% vs 37%, P<0.001). All other secondary outcomes were not different between groups. CONCLUSIONS: In patients who underwent major gynaecological surgery, a pre-emptive 2-h session of HFNO after extubation improved postoperative oxygen exchange and reduced atelectasis compared with a conventional oxygen treatment strategy. CLINICAL TRIAL REGISTRATION: NCT04566419.

Risk factors associated with severe perineal lacerations during vaginal delivery: a 10-year propensity score-matched observational study.

BACKGROUND: Severe perineal lacerations are rare obstetrical complications in high-income countries. However, the prevention of obstetric anal sphincter injuries is crucial because of their long-term consequences on a woman's digestive function, sexual-mental health, and well-being. The probability of obstetric anal sphincter injuries can be predicted by assessing antenatal and intrapartum risk factors. OBJECTIVE: This study aimed to assess the incidence of obstetric anal sphincter injuries at a single institution for 10 years and to identify women more at risk by evaluating the relationship between antenatal and intrapartum risk factors and severe perineal tears. The main outcome measured in this study was the occurrence of obstetric anal sphincter injuries during vaginal delivery. STUDY DESIGN: This was an observational retrospective cohort study conducted at a University Teaching Hospital in Italy. The study was conducted from 2009 to 2019 using a prospectively maintained database. The study cohort included all women with singleton pregnancy at term who delivered via vaginal delivery in cephalic presentation. Of note, data analysis was performed in 2 stages: a propensity score matching to balance possible differences between patients with obstetric anal sphincter injuries and those without and a stepwise univariate and multivariate logistic regression. A secondary analysis was performed to further evaluate the effect of parity, epidural anesthesia, and duration of the second stage of labor by adjusting for potential confounders. RESULTS: Of 41,440 patients screened for eligibility, 22,156 met the inclusion criteria, and 15,992 were balanced after propensity score matching. Obstetric anal sphincter injuries occurred in 81 cases (0.4%), 67 (0.3%) after spontaneous delivery and 14 (0.8%) after vacuum delivery(P=.002). There was an increased odds of severe lacerations of nearly 2-fold for nulliparous women delivering by vacuum delivery (adjusted odds ratio, 2.85; 95% confidence interval, 1.19-6.81; P=.019), with a reciprocal reduction in women with spontaneous vaginal delivery (adjusted odds ratio, 0.35; 95% confidence interval, 0.15-0.84; P=.019) and at least 1 previous delivery (adjusted odds ratio, 0.51; 95% confidence interval, 0.31-0.85; P=.005). Epidural anesthesia was associated with a lower incidence of obstetric anal sphincter injuries (adjusted odds ratio, 0.54; 95% confidence interval, 0.33-0.86; P=.011). The risk of severe lacerations was independent of the duration of the second stage of labor (adjusted odds ratio, 1.00; 95% confidence interval, 0.99-1.00; P=.3), whereas the risk was reduced when mediolateral episiotomy was performed (adjusted odds ratio, 0.20; 95% confidence interval, 0.11-0.36; P<.001). Neonatal risk factors include head circumference (odds ratio, 1.50; 95% confidence interval, 1.18-1.90; P=.001) and vertex malpresentation (adjusted odds ratio, 2.71; 95% confidence interval, 1.08-6.78; P=.033). Induction of labor (adjusted odds ratio, 1.13; 95% confidence interval, 0.72-1.92; P=.6), frequent obstetrical examinations (adjusted odds ratio, 1.17; 95% confidence interval, 0.72-1.90), and women's supine position at birth (adjusted odds ratio, 1.25; 95% confidence interval, 0.61-2.55; P=.5) were further evaluated. Among severe obstetrical complications, shoulder dystocia increased the risk of obstetric anal sphincter injuries by nearly 4 times (adjusted odds ratio, 3.92; 95% confidence interval, 0.50-30.74; P=.2), whereas postpartum hemorrhage occurred 3 times more often in cases of delivery complicated by severe lacerations (adjusted odds ratio, 3.35; 95% confidence interval, 1.76-6.40; P<.001). The relationship among obstetric anal sphincter injuries, parity, and the use of epidural anesthesia was further confirmed in a secondary analysis. We found that primiparas who delivered without epidural anesthesia had the highest risk of obstetric anal sphincter injuries (adjusted odds ratio, 2.53; 95% confidence interval, 1.46-4.39; P=.001). CONCLUSION: Severe perineal lacerations were found to be a rare complication of vaginal delivery. By using a robust statistical model, such as propensity score matching, we were able to investigate a broad range of antenatal and intrapartum risk factors, including use of epidural anesthesia, number of obstetrics examinations, and patient position at birth, which are usually underreported. Moreover, we found that women who delivered for the first time without epidural anesthesia had the highest risk of obstetric anal sphincter injuries.

Comparison of ropivacaine plasma concentration after posterior Quadratus Lumborum Block in Cesarean Section with ropivacaine with epinephrine vs. plane.

BACKGROUND: The posterior quadratus lumborum block (pQLB) has been used in postoperative pain management after cesarean section (CS). However, clinicians have no data about pQLB safety in pregnants, at increased risk of local anesthetic systemic toxicity (LAST). The purpose of the present study was to explore the efficacy and the safety of adding epinephrine to ropivacaine for bilateral pQLB vs. bilateral pQLB performed with ropivacaine alone in CS. METHODS: In this prospective trial 52 pregnants, ASA 2 physiological status, were consecutively allocated to one of two groups, e-pQLB and pQLB; e-pQLB group received 0.375% ropivacaine+100 mcg epinephrine, 20 mL each side; pQLB received 0.375% ropivacaine alone, 20 mL each side. The primary and secondary outcomes were to evaluate if the adjunct of epinephrine to ropivacaine increases efficacy and safety of pQLB, respectively. RESULTS: Authors found in e-pQLB group vs. p-QLB group: a total mean morphine consumption statistically lower during the first 24 postoperative hours (5.08±3.12, vs. 9.11±4.67 SD mg, P=0.0002); NRS values statistically lower at six hours from block, both at rest (1.73±1.88 SD vs. 2.88±2.53, P=0.03) and with movement (3.03±1.98 SD vs. 4.23±2.87, P=0.04); a longer time between block and the first opioid request (5.92±2.48 vs. 3.78±2.68 SD hrs, P<0.003); venous ropivacaine concentrations significantly lower at any time of samples but at 120 minutes. CONCLUSIONS: Adding epinephrine to ropivacaine increases efficacy and duration of pQLB. Moreover it increases block safety, reducing peak and mean venous ropivacaine concentration.

Lung ultrasound to monitor the development of pulmonary atelectasis in gynecologic oncologic surgery.

BACKGROUND: Atelectasis formation is considered the major cause of hypoxemia during general anesthesia (GA). Gynecologic oncologic surgery (GOS) often requires pneumoperitoneum and steep bed angulation that further reduce lung compliance by shifting bowels and diaphragm. The aim of our study was to assess the impact of intraoperative variables on lung aeration using lung ultrasound (LUS) score and their correlation with postoperative oxygenation in women undergoing GOS. METHODS: In this prospective observational study 80 patients scheduled for GOS were enrolled. After three minutes pre-oxygenation, propofol-sufentanil-sevoflurane GA and standard mechanical ventilation (MV) were administered (tidal volume of 8 mL/kg of predicted body weight, FiO2 40%, I:E ratio of 1:2 and PEEP 5 cm H2O). A 0-36 LUS score was calculated considering 12 pulmonary areas, and arterial blood gas analysis were performed before GA (T1) and in recovery room (T2). RESULTS: LUS score increased significantly between T1 (1.79±2.39) and T2 (11.08±4.40, ΔLUS=9.29±4.10, P<0.05), mostly in basal and posterior areas. Changes in LUS score correlated significantly with time of MV (r=0.246, P<0.05), cumulative time in TR position (r=0.321, P<0.05) and worsening in oxygenation (ΔPaO2/FiO2, r=-0.260, P<0.05). ΔLUS score significantly correlated with colloid infusion. The linear regression analysis showed that TR time can predict ΔLUS score (F1,78=8.97, P=0.004). No correlation was found with pneumoperitoneum, apnea time at induction and TR angle. CONCLUSIONS: Aeration loss after GOS detected using LUS correlates with TR time, MV time, colloid infusion and worsening in oxygenation.

Ultrasound-guided genitofemoral nerve block for inguinal hernia repair in the male adult: a randomized controlled pilot study.

BACKGROUND: Ultrasound-guided (USG) ilioinguinal/iliohypogastric nerve (II/IHN) block is a widely validated anesthetic technique for inguinal herniorrhaphy. As the spermatic cord, scrotum, and adjacent thigh receive sensory innervation from the genital branch of genitofemoral nerve (GFN), the addition of GFN block has been suggested to improve the quality of perioperative anesthesia and analgesia. The aim of this study is to compare GFN block plus II/IHN block with II/IHN block alone for intraoperative anesthesia and post-operative pain management. METHODS: We enrolled 80, ASA I-III, male adults scheduled for elective open herniorrhaphy. Patients were randomized to receive either USG II/IHN plus GFN block (Case Group) or USG II/IHN block alone (Control Group). The outcome measures were the assessment of postoperative VAS scores on coughing and the adequacy of anesthesia, measured with intraoperative requirement for extra local anesthetic (LA) infiltration and number of patients needing systemic sedation. RESULTS: The requirement of intraoperative additional doses of LA was significantly lower in the Case Group (median LA volume administered by the surgeon: 13.8±5.6 mL vs. 20.7±9.1 mL, P<0.05). Two patients in the Control Group needed systemic sedation. VAS scores at 15 minutes, 30 minutes, 1 hour, 2 hours, pre-discharge, and 24 hours were significantly lower in the Case Group (P<0.005). Four cases of femoral nerve block were reported, three in the Control Group, one in the Case Group (2.2% vs. 7.7%, P>0.05). CONCLUSIONS: The combination of GFN block and II/IHN block is associated with lower postoperative VAS scores and lower doses of intraoperative additional LA.

Acute lung injury complicating blood transfusion in post-partum hemorrhage: incidence and risk factors.

BACKGROUND: We retrospectively investigated the incidence and risk factors for transfusion-related acute lung injury (TRALI) among patients transfused for post-partum hemorrhage (PPH). METHODS: We identified a series of 71 consecutive patients with PPH requiring the urgent transfusion of three or more red blood cell (RBC) units, with or without transfusion of fresh frozen plasma (FFP) and/or platelets (PLT). Clinical records were then retrieved and examined for respiratory distress events. According to the 2004 consensus definition, cases of new-onset hypoxemia, within 6 hours after transfusion, with bilateral pulmonary changes, in the absence of cardiogenic pulmonary edema were identified as TRALI. If an alternative risk factor for acute lung injury was present, possible TRALI was diagnosed. RESULTS: Thirteen cases of TRALI and 1 case of possible TRALI were identified (overall incidence 19.7%). At univariate analysis, patients with TRALI received higher number of RBC, PLT and FFP units and had a longer postpartum hospitalization. Among the diseases occurring in pregnancy- and various pre-existing comorbidities, only gestational hypertension and pre-eclampsia, significantly increased the risk to develop TRALI (p = 0.006). At multivariate analysis including both transfusion- and patient-related risk factors, pregnancy-related, hypertensive disorders were confirmed to be the only predictors for TRALI, with an odds ratio of 27.7 ( 95% CI 1.27-604.3, p=0.034). CONCLUSIONS: Patients suffering from PPH represent a high-risk population for TRALI. The patients with gestational hypertension and pre-eclampsia, not receiving anti-hypertensive therapy, have the highest risk. Therefore, a careful monitoring of these patients after transfusions is recommended.

Latex sensitization: a special risk for the obstetric population?

BACKGROUND: Previous studies have reported a greater frequency of sensitization to latex in the female population and a higher incidence of anaphylactic reactions to latex during cesarean section. In this study, the authors investigated the prevalence of latex sensitization in obstetric patients compared with nonpregnant subjects. METHODS: Two hundred ninety-four healthy pregnant women who were at term with a singleton fetus and scheduled for caesarean section (group A) were compared with 294 healthy nulliparous women with childbirth potential undergoing gynecologic surgery (group B). Before surgery, patients completed a questionnaire, and venous blood samples were collected to measure specific immunoglobulin E serum concentrations with a fluorescent enzyme immunoassay test. Skin-prick tests were performed if adverse reactions occurred during surgery. Latex allergy was diagnosed on the basis of immunoglobulin E results and/or positive skin-prick tests. RESULTS: The prevalence of latex sensitization was higher in group A than in group B (15/294, 5.1% vs. 5/294, 1.7%; P < 0.05). A significant difference in specific immunoglobulin E serum concentration was noted between pregnant and nonpregnant patients who had a positive fluorescent enzyme immunoassay test (median serum concentration: 1.93 kilounits/l; interquartile range = 2.28 vs. 0.78 kilounits/l; interquartile range = 1.07; P less than 0.05). Two patients in group A experienced an anaphylactic reaction to latex. Statistical analysis disclosed no association between latex sensitization and accepted risk factor for latex allergy. CONCLUSIONS: The authors report a higher prevalence of latex sensitization in the obstetric population than in nonpregnant subjects undergoing gynecologic surgery.