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Accidental dural puncture during labor analgesia can lead to post-dural puncture headache (PDPH) and other complications. The gold standard treatment for PDPH is an epidural blood patch (EBP), but it is not always successful. A recent study investigated the use of prophylactic intravenous cosyntropin to prevent PDPH and reduce the need for EBP. However, the study found that cosyntropin did not mitigate PDPH or eliminate the need for EBP. Another study showed that inserting an intrathecal catheter and injecting intrathecal saline decreased the severity of PDPH and the need for EBP. The addition of prophylactic cosyntropin did not reduce the occurrence of PDPH but may decrease the need for EBP. Further research is needed to confirm these findings. [Extracted from the article]

Summary: If an accidental dural puncture occurs, one option is to insert a catheter and use it as an intrathecal catheter. This avoids the need for a further injection and can rapidly provide labour analgesia and anaesthesia for caesarean section. However, there are no recommendations for managing intrathecal catheters and, therefore, significant variation in clinical practice exists. Mismanagement of the intrathecal catheter can lead to increased motor block, high spinal anaesthesia, drug error, hypotension and fetal bradycardia. Care must be taken with an intrathecal catheter to adhere to strict aseptic technique, meticulous labelling, cautious administration of medications and good communication with the patient and other staff. Every institution considering the use of intrathecal catheters should establish a protocol. For labour analgesia, we recommend the use of dilute local anaesthetic agents and opioids. For caesarean section anaesthesia, gradual titration to the level of the fourth thoracic dermatome, with full monitoring, in a facility equipped to manage complications, should be performed using local anaesthetics combined with lipophilic opioids and morphine or diamorphine. Although evidence of the presence and duration of intrathecal catheters on the development of post‐dural puncture headache and need for epidural blood patch is limited, we suggest considering leaving the intrathecal catheter in for 24 hours to reduce the chance of developing a post‐dural puncture headache while maintaining precautions to avoid drug error and cerebrospinal fluid leakage. Injection of sterile normal saline into the intrathecal catheter may reduce post‐dural puncture headache. The level of evidence for these recommendations was low. [ABSTRACT FROM AUTHOR]

The articles discusses the blood pressure, cardiac output and hemodynamics of pregnant women who have cesarean section deliveries (CDs), offering a comparison of women with both twin and single pregnancies. The administration of prophylactic phenylephrine infusion (PPI) and spinal anesthesia to parturients, or pregnant women, is discussed.

As the number and success of renal transplantation has grown, there has been an increase in the number of renal transplant patients giving birth. To date, there has been no data on obstetric anesthesia management of these patients. The purpose of this study was to build an Israeli national database on parturients after renal transplant. A sixteen-year (calendar years 1996-2011) retrospective study was conducted at three major tertiary centers with a combined current birth rate of approximately 25 000 deliveries annually. We found 83 labors in 64 women. Forty-two percent of this population suffered from hypertension while 12.5% had diabetes. Forty-seven percent of women had a vaginal delivery while 53% of women had a cesarean section. The rate of epidural analgesia for labor was 59%, and rate of regional anesthesia during cesarean section was 75%. There were no anesthetic complications in any cases. Standard ASA monitoring was used in all cases except for one woman with severe hypertension who required an arterial line during her cesarean section. Forty-seven percent of newborn were under 37 weeks with average gestational week 36 ± 3 days and birth weight 2.5 ± 0.7 kg. Average Apgar was 8.4 ± 1.3 at one minute and 9.3 ± 0.7 at five minutes. There was one neonatal death in the CS group due to placental abruption. Patients after renal transplant can safely undergo birth and obstetric analgesia. [ABSTRACT FROM AUTHOR]

Background We designed a prospective observational study to assess the effect of preoperative anxiety on hypotension after spinal anaesthesia. Methods After IRB approval and signed informed consent, 100 healthy term parturients undergoing elective Caesarean delivery under spinal anaesthesia were enrolled. Direct psychological assessments of preoperative anxiety were verbal analogue scale (VAS) (0–10) anxiety score and State-Trait Anxiety Inventory questionnaire (STAI-s); salivary amylase was measured as an indirect physical assessment of anxiety. Direct and indirect anxiety data were transformed into ordinal groups for low, medium, and high anxiety (VAS: low 0–3, medium 4–6, high 7–10; STAI-s: low <40, medium 40–55, high >55; log10 salivary amylase: low <3, medium 3–4, high >4). Spinal anaesthesia was performed using hyperbaric bupivacaine 10 mg and fentanyl 20 μg. All patients received i.v. crystalloid 500 ml prehydration and 500 ml cohydration. Hypotension was treated by standardized protocol (fluid bolus and ephedrine or phenylephrine depending on maternal heart rate). Systolic arterial pressure (SAP) was measured at baseline and every minute after spinal anaesthesia. The effect of low, medium, and high anxiety groups on the maximum percentage change in SAP (%ΔSAP) was assessed (one-way analysis of variance, Tukey's honestly significant difference). Results Ninety-three patients were included in analysis. There was a significant effect of direct psychological measures of anxiety on %ΔSAP (VAS P=0.004; STAI-s P=0.048). There was a significant difference between low and high anxiety groups (VAS P=0.003; STAI-s P=0.038), but not between other anxiety groups. Salivary amylase did not correlate with %ΔSAP. Conclusions Preoperative anxiety assessed by VAS had a significant effect on hypotension after spinal anaesthesia. [ABSTRACT FROM PUBLISHER]

Objective: To identify parturients at risk of inability to extend labor epidural analgesia in whom alternative methods of anesthesia should be considered for Cesarean section (CS). Methods: For 6 months, we prospectively studied women undergoing a CS with a functioning epidural catheter in place from the delivery ward. All parturients received the same epidural protocol: bolus of bupivacaine 0.1% and fentanyl, then bupivacaine 0.1% and fentanyl (2 μg/ml) 10–15 ml/h and an additional 5 ml of bupivacaine 0.125% top-ups according to patient request. Sixteen millilitres of lidocaine 2%, 1 ml of bicarbonate, and 100 μg of fentanyl were given for CS. Failed epidural analgesia was defined as the need to convert to general anesthesia. Results: Of the 101 parturients studied, 20 (19.8%) required conversion to general anesthesia. In univariate analysis, the likelihood of failed epidural anesthesia was inversely correlated with parturient’s age ( P = 0.014) and directly correlated with pre-pregnancy weight ( P = 0.019), weight at the end of pregnancy ( P = 0.003), body mass index (BMI) at the end of pregnancy ( P = 0.0004), gestational week ( P = 0.008), number of top-ups ( P = 0.0004) and visual analog scale (VAS) 2 h before CS ( P = 0.03). In multivariate analysis, the number of top-ups in the delivery ward was the best predictor of epidural anesthesia failure (odds ratio 4.39, P = 0.005). Conclusion: Younger, more obese parturients at a higher gestational week, requiring more top-ups during labor, having a higher VAS in the 2 h before CS are at risk of inability to extend labor epidural analgesia to epidural anesthesia for CS. [ABSTRACT FROM AUTHOR]

Aim:: To identify parturients at risk of inability to extend labor epidural analgesia in whom alternative methods of anesthesia should be considered for Cesarean section (CS). Methods:: For 6 months, we prospectively studied women undergoing CS with a functioning epidural catheter in place from the delivery ward. All parturients received the same epidural protocol: bolus of bupivacaine 0.1% and fentanyl, followed by bupivacaine 0.1% and fentanyl (2 μg/ml) 10–15 ml/h and an additional 5 ml of bupivacaine 0.125% as top-up according to patient request. Sixteen milliliters of lidocaine 2%, 1 ml of bicarbonate and 100 μg of fentanyl were given for CS. Failed epidural analgesia was defined as the need to convert to general anesthesia. Results:: Of the 101 parturients studied, 20 (19.8%) required conversion to general anesthesia. In univariate analysis, the likelihood of failed epidural anesthesia was inversely correlated with parturient age ( P = 0.014) and directly correlated with pre-pregnancy weight ( P = 0.019), weight at the end of pregnancy ( P = 0.003), body mass index at the end of pregnancy ( P = 0.0004), gestational week ( P = 0.008), number of top-ups ( P = 0.0004) and visual analog scale (VAS) score 2 h before CS ( P = 0.03). In multivariate analysis, the number of top-ups in the delivery ward was the best predictor of epidural anesthesia failure (odds ratio, 4.39; P = 0.005). Conclusion: Younger, more obese parturients at a higher gestational week, requiring more top-ups during labor and having a higher VAS score in the 2 h before CS are at risk for inability to extend labor epidural analgesia to epidural anesthesia for CS. [ABSTRACT FROM AUTHOR]

Chemotherapy with bleomycin may cause a syndrome of pulmonary sensitivity to supranormal inspired oxygen concentrations that persists for an unknown period of time after exposure. We present a mentally retarded adolescent patient in whom supranormal inspired oxygen was temporarily necessary to manage her difficult airway. Subsequently her pulmonary function deteriorated acutely and, after intermittent stabilization, irreversibly. In this case, bleomycin exposure may have played a pivotal role in modulating minor insults to trigger fatal acute respiratory distress syndrome (ARDS). [ABSTRACT FROM AUTHOR]

It is routine to give a uterotonic drug following delivery of the neonate during caesarean section. However, there is much heterogeneity in the relevant research, which has largely been performed in low-risk elective cases or women with uncomplicated labour. This is reflected in considerable variation in clinical practice. There are significant differences between dose requirements during elective and intrapartum caesarean section. Standard recommended doses are higher than required, with the potential for acute cardiovascular adverse effects. We recommend a small initial bolus dose of oxytocin, followed by a titrated infusion. The recommended doses of oxytocin may have to be increased in women with risk factors for uterine atony. Carbetocin at equipotent doses to oxytocin has similar actions, while avoiding the requirement for a continuous infusion after the initial dose and reducing the need for additional uterotonics. As with oxytocin, carbetocin dose requirements are higher for intrapartum caesarean sections. A second-line agent should be considered early if oxytocin/carbetocin fails to produce good uterine tone. Women with cardiac disease may be very sensitive to the adverse effects of oxytocin and other uterotonics, and their management needs to be individualised. [ABSTRACT FROM AUTHOR]

Summary: Accidental dural puncture during an attempt to establish labour epidural analgesia can result in postdural puncture headache and long‐term debilitating conditions. Epidural blood patch, the gold standard treatment for this headache, is invasive and not always successful. Inserting an intrathecal catheter after accidental dural puncture may prevent postdural puncture headache. We evaluated the effect of intrathecal catheter insertion on the incidence of postdural puncture headache and the need for epidural blood patch and whether duration of intrathecal catheterisation or injection of intrathecal saline affected outcome. Our retrospective study was conducted at two tertiary, university‐affiliated medical centres between 2017 and 2022 and included 92,651 epidurals and 550 cases of accidental dural puncture (0.59%); 219 parturients (39.8%) received an intrathecal catheter and 331 (60.2%) a resited epidural. Use of an intrathecal catheter versus resiting the epidural did not decrease the odds of postdural puncture headache, adjusted odds ratio (aOR) (95%CI) 0.91 (0.81–1.01), but was associated with a lower need for epidural blood patch (aOR (95%CI) 0.82 (0.73–0.91), p < 0.001). We found no benefit in leaving in the intrathecal catheter for 24 h postpartum (postdural puncture headache, aOR (95%CI) 1.01 (1.00–1.02), p = 0.015; epidural blood patch, aOR (95%CI) 1.00 (0.99–1.01), p = 0.40). We found an added benefit of injecting intrathecal saline as it decreased the incidence of postdural puncture headache (aOR (95%CI) 0.85 (0.73–0.99), p = 0.04) and the need for epidural blood patch (aOR (95%CI) 0.75 (0.64–0.87), p < 0.001). Our study confirms the benefits of intrathecal catheterisation and provides guidance on how to best manage an intrathecal catheter. [ABSTRACT FROM AUTHOR]

Background: Anesthesia practices for placenta previa (PP) and accreta (PA) impact hemorrhage management and other supportive strategies. We conducted a survey to assess reported management of PP and PA in all Israeli labor and delivery units.Methods: After Institutional Review Board waiver, we surveyed all 26 Israeli hospitals with a labor and delivery unit by directly contacting the representatives of obstetric anesthesiology services in every department (unit director or department chair). Each director surveyed provided information about the anesthetic and transfusion management in their labor and delivery units for three types of abnormal placentation based on antenatal placental imaging: PP, low suspicion for PA, and high suspicion for PA. The primary outcome was use of neuraxial or general anesthesia for PP and PA Cesarean delivery. Univariate statistics were used for survey responses using counts and percentages.Results: The response rate was 100%. Spinal anesthesia is the preferred anesthetic mode for PP cases, used in 17/26 (65.4%) of labor and delivery units. By comparison, most representatives reported that they perform general anesthesia for patients with PA: 18/26 (69.2%) for all low suspicion cases of PA and 25/26 (96.2%) for all high suspicion cases of PA. Although a massive transfusion protocol was available in the majority of hospitals (84.6%), the availability of thromboelastography and cell salvage was much lower (53.8% and 19.2% hospitals respectively).Conclusions: In our survey, representatives of anesthesia labor and delivery services in Israel are almost exclusively using general anesthesia for women with high suspicion for PA; however, almost two-thirds use spinal anesthesia for PP without suspicion of PA. Among representatives, we found wide variations in anesthesia practice patterns with regard to anesthesia mode, multidisciplinary management, and hemorrhage anticipation strategies. [ABSTRACT FROM AUTHOR]