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BackgroundUltrasound is commonly used to facilitate epidural catheter placement. However, data are lacking regarding its potential to confirm its position in the epidural space. Our aim was to visualize flow in the epidural space of patients receiving epidural analgesia for labor using color flow Doppler ultrasound.MethodsWe conducted a prospective observational cohort study that included patients who had delivered vaginally under epidural analgesia. We used a 5–2 mHz curvilinear probe in a left and right paramedian longitudinal oblique view to visualize the anterior and posterior complex at the interspace of epidural catheter insertion, one and two interspaces above and below. At each window, the color flow Doppler function was used to visualize flow within the epidural space on injection of normal saline (1 mL). If no flow was visualized at any interspace, one assessment at the level of insertion was repeated with a 1 mL air/saline mixture. We studied a convenience sample size of 40 patients.ResultsWe visualized flow in the epidural space in all 40 patients. Flow was visualized on injection of 1 mL of saline in 37/40 patients (93%). In the remaining 3/40 patients (7%), flow was visualized with an air/saline mixture. Flow on injection of saline was visualized only at the interspace of insertion in 26/37 patients (70%), at the interspace of insertion and one interspace above in 10/37 (27%), or only at one interspace above in 1/37 (3%). Flow was visualized only on the left or on the right paramedian view in 19/37 patients (51%), despite a symmetrical sensory block in all patients.ConclusionColor flow Doppler ultrasound is a feasible and fast way to determine flow in the epidural space in the obstetric population. Its potential clinical uses are confirmation of the epidural catheter position after placement, as well as troubleshooting of unsatisfactory epidural analgesia. Interestingly, our results suggest that epidural catheters predominantly remain at the interspace of insertion.Trial registration numberNCT05126745.

Intraoperative handovers are common in anesthesia practice and are associated with increased patient morbidity and mortality. Checklists may improve transfer of information during handovers. This before-and-after study sought to examine the effect of a checklist on intraoperative handover. We hypothesized that introducing a handover checklist would improve our primary outcome of completeness of data transfer.From February to August 2016, anesthesia providers (residents, fellows, and consultants) at a single tertiary academic center participated in a handover study. Baseline handovers between anesthesia care providers were videotaped, analyzed, and compared with anesthetic records. An intraoperative handover checklist was then introduced, and handovers completed with it were videotaped. The completeness of handovers was compared between the baseline routine and checklist groups. The primary outcome was completeness of information transfer.Sixty-seven anesthesia providers participated in the study. Use of the intraoperative handover checklist improved completeness of handover by 6% (95% confidence interval [CI], 2 to 10; P0.01). There was no relationship observed between the provider (consultants/fellows vs resident) of the handovers and the degree of completeness (95% CI, 3 to 8; P = 0.33). Complexity had a significant impact on the handover completeness with low or high complexity cases more completely handed over than those of medium complexity both before and after the intervention-a 6% increase for low complexity (95% CI, 1 to 11; P = 0.02) and a 9% increase for high complexity (95% CI, 3 to 14; P0.01).Use of a checklist during intraoperative handovers improved completeness of data transfer. Handover checklists should be considered to improve handover completeness.RéSUMé: OBJECTIF: Les transferts peropératoires sont fréquents dans la pratique de l’anesthésie et sont associés à une augmentation de la morbidité et de la mortalité des patients. Les listes de vérification pourraient améliorer le transfert d’informations pendant les transitions. Cette étude avant-après a cherché à examiner l’effet d’une liste de vérification sur les transferts peropératoires. Nous avons émis l’hypothèse que l’introduction d’une liste de vérification de transfert améliorerait notre critère d’évaluation principal, nommément la complétude du transfert des informations. MéTHODE: De février à août 2016, des prestataires d’anesthésie (résidents, fellows et consultants) d’un seul centre universitaire tertiaire ont participé à une étude sur les transferts. Les transferts de base entre les fournisseurs de soins d’anesthésie ont été filmés, analysés et comparés aux dossiers d’anesthésie. Une liste de contrôle de transfert peropératoire a ensuite été introduite, et les transferts réalisés avec celle-ci ont été filmés. La complétude des transferts a été comparée entre les groupes faisant un transfert normal de base et ceux utilisant la liste de vérification. Le critère d’évaluation principal était la complétude du transfert d’informations. RéSULTATS: Soixante-sept fournisseurs d’anesthésie ont participé à l’étude. L’utilisation de la liste de vérification de transfert peropératoire a amélioré la complétude du transfert de 6 % (intervalle de confiance [IC] à 95 %, 2 à 10; P0,01). Aucune relation n’a été observée entre le fournisseur (consultants/fellows) vs résidents) responsable des transferts et le degré de complétude du transfert (IC 95 %, 3 à 8; P = 0,33). La complexité a eu un impact significatif sur la complétude du transfert, les cas de basse ou haute complexité étant transférés de manière plus complète que les cas de complexité moyenne, tant avant qu’après l’intervention – avec une augmentation de 6 % pour les cas de faible complexité (IC 95 %, 1 à 11; P = 0,02) et une augmentation de 9 % pour les cas de complexité élevée (IC 95 %, 3 à 14; P0,01). CONCLUSION: L’utilisation d’une liste de vérification lors des transferts peropératoires a amélioré la complétude du transfert des informations. Les listes de vérification de transfert devraient être envisagées pour améliorer la complétude des transferts.

Programmed intermittent epidural bolus (PIEB) provides better analgesia for labour pain than continuous epidural infusion does. Nevertheless, commonly used PIEB regimens are associated with high sensory block. We hypothesized that a PIEB technique with slower bolus delivery speed would produce lower sensory levels. We recruited term nulliparous women with singleton pregnancies during the first stage of labour. All participants had an American Society of Anesthesiologists Physical Status score of II-III, had epidural catheters placed at L3/4, and had epidural analgesia maintained with PIEB 10 mL every 40 min using 0.0625% bupivacaine with fentanyl 2 µg·mL-1. Women were randomized to receive PIEB delivered at 250 mL·hr-1 (G250) or 125 mL·hr-1 (G125). The study was completed six hours after the loading dose or at full cervical dilatation, whichever occurred first. The primary outcome was the presence of sensory block to ice ≥ T6 in at least one assessment during the study period (maximum six hours). We analyzed data from 90 women. The proportion of women presenting sensory block ≥ T6 at any time was not different between G125 and G250 groups (60.0% vs 64.4%; difference, -4.4%; 95% confidence interval [CI], -24.5 to 15.6; P = 0.66). The median [interquartile range] highest sensory block level was also not different between G125 and G250 groups (T6 [T7-T5] vs T5 [T7-T5], P = 0.39). Women in the G125 group had a lower incidence of hypotension than women in the G250 group did (11.1% vs 33.3%; difference, -22.2%; 95% CI, -38.8 to -5.67; P = 0.01). Quality of analgesia and patient satisfaction were not different between groups. The maintenance of epidural analgesia with a PIEB delivery speed of 125 mL·hr-1 did not produce lower sensory block levels when compared with 250 mL·hr-1. The slower injection speed regimen was associated with lower incidence of hypotension, but this secondary finding warrants confirmation in a future trial. www.ClinicalTrials.gov (NCT03236298); registered 1 August 2017.

Approximately one in five women will experience severe postoperative pain after Cesarean delivery (CD). Previously, a bedside three-item questionnaire (3-IQ) has shown to predict women experiencing higher evoked pain intensity after CD, with an area under the receiver operator characteristics (ROC) curve of 0.72. We hypothesized that the addition of psychophysical pain tests to the existing 3-IQ would improve the ability to predict severe pain in women undergoing elective CD under spinal anesthesia This was a prospective cohort study on women undergoing elective CD under spinal anesthesia. Women were assessed preoperatively using the 3-IQ, pressure algometry (PA) and mechanical temporal summation (TS) response. All women received standard perioperative care, including a multimodal analgesia regimen that included intrathecal fentanyl and morphine. A 0–100 mm visual analogue scale (VAS) was used to assess the severity of pain at rest (VASr) and on movement (VASm) at 24 and 48 hr after surgery. Patient satisfaction and opioid consumption were also recorded. We performed ROC curve analyses to assess whether we could improve the ability to predict our primary outcome of severe pain on movement at 24 hr (VASm24 ≥ 70). We studied 195 women. Median [interquartile range] VASm24 was 53 [32–72] and 28% of patients experienced a VASm24 ≥ 70. The ability to predict a VASm24 ≥ 70 assessed by the area under the ROC curve was 0.64 using the 3-IQ and 0.67 using the 3-IQ combined with TS and PA. The addition of PA and TS to the 3-IQ model resulted in a predictive model that performed similarly to the 3-IQ model alone. Further research is warranted in this area to better predict women at risk of severe pain post CD.

We studied the programmed intermittent epidural bolus (PIEB) time interval between boluses of 2.5 mL of bupivacaine 0.25% with fentanyl 8 µg·mL−1 to produce effective analgesia in 90% of women (EI90) during the first stage of labour. In a double-blind sequential allocation trial using a biased coin up-and-down design to determine the EI90, the PIEB boluses of 2.5 mL of 0.25% bupivacaine plus fentanyl 8 µg·mL−1 were delivered at varying intervals—60, 50, 40, and 30 min. The primary outcome was the adequate response of the patient to the PIEB regimen, defined as no use of supplemental analgesia for six hours or until the first stage of labour was completed, whichever came first. The secondary outcomes were the upper sensory block level to ice, motor block and hypotension. The isotonic regression with extrapolation approach was used to estimate the EI90. In the 20 women studied, the estimated EI90 was 20 (95% CI, 5.9 to 28.8) min. For the secondary outcomes, we classified women into those assigned to 30 min (16 women) and those assigned to more than 30 min (four women). The median upper sensory block for women in the 30-min group and more than 30 min were T6 (or T5) and T7, respectively. No participants experienced motor block. Hypotension occurred in one patient in the 30-min group. The estimated EI90 for boluses of 2.5 mL of bupivacaine 0.25% with fentanyl 8 µg·mL−1 was 20 (95% CI, 5.9 to 28.8) min. These results suggest that there is no advantage in using this regimen compared with those reported in the literature using the same dose of bupivacaine in concentrations of 0.0625% and 0.125%. www.clinicaltrials.gov (NCT03735771); registered 7 November 2018.

Point-of-care ultrasound (POCUS) uses ultrasound at the bedside to aid decision-making in acute clinical scenarios. The increased use of ultrasound for regional anesthesia and vascular cannulation, together with more anesthesiologists trained in transesophageal echocardiography have contributed to the widespread use of POCUS in perioperative care. Despite the support of international experts, the practice of POCUS in perioperative care is variable as Canadian guidelines for anesthesiologists do not currently exist. Using a Delphi process of online surveys and a face-to-face national Canadian meeting, we developed a consensus statement for basic POCUS (bPOCUS) performance and training with a group of national experts from all Canadian universities. The group of experts consisted of 55 anesthesiologists from 12 Canadian universities considered local leaders in the field. An initial exploratory online survey of 47 statements was conducted. These statements were derived from previous generic guidelines or consensus conferences, or were based on current literature. Fourteen statements reached full consensus, 19 had 90-100% agreement, and 14 had less than 90% agreement. Eight new statements were proposed during the national meeting, and all statements without full agreement were discussed. A second online survey included 42 modified or new statements. From this second survey, 16 statements obtained full consensus, 39 had very good agreement, and one had good agreement. The final document includes 56 statements that define the scope of practice and necessary training for perioperative bPOCUS. The statements include five bPOCUS domains: cardiac, lung, airway, gastric, and abdomen. The use of bPOCUS is evolving and will play a significant role in perioperative medicine. This consensus statement aims to define a Canadian national standard on which curricula may be based. It also provides a framework to allow further development of bPOCUS in the perioperative setting.RéSUMé: L’échographie ciblée (POCUS) utilise l’échographie au chevet des patients pour faciliter la prise de décisions dans les situations cliniques urgentes. L’utilisation accrue de l’échographie pour l’anesthésie régionale et la cannulation vasculaire, ainsi que l’augmentation du nombre d’anesthésologistes formés à l’échocardiographie transesophagienne, ont contribué à l’utilisation généralisée de l’échographie ciblée dans les soins périopératoires. Malgré son endossement par des experts internationaux, la pratique de l’échographie ciblée en soins périopératoires est variable, car il n’existe pas, à l’heure actuelle, de lignes directrices canadiennes destinées aux anesthésiologistes. À l’aide d’un processus Delphi de sondages en ligne et d’une réunion nationale canadienne en personne, un groupe d’experts nationaux provenant de toutes les universités canadiennes a élaboré une déclaration consensuelle pour la formation de base en et l’exécution de l’échographie ciblée (bPOCUS). Le groupe d’experts était composé de 55 anesthésiologistes issus de 12 universités canadiennes considérés comme des chefs de file locaux dans le domaine. Un premier sondage exploratoire en ligne comportant 47 énoncés a été réalisé. Ces énoncés étaient dérivés de lignes directrices antérieures ou de conférences consensuelles, ou étaient fondés sur la littérature actuelle. Quatorze énoncés ont obtenu un consensus complet, 19 ont atteint un taux de 90 à 100 %, et 14 ont obtenu moins de 90 % d’accord. Huit nouveaux énoncés ont été proposés au cours de la réunion nationale, et tous les énoncés n’ayant pas obtenu d’accord complet ont été discutés. Un deuxième sondage en ligne comprenait 42 énoncés modifiés ou nouveaux. Dans ce deuxième sondage, 16 énoncés ont obtenu un consensus total, 39 un très bon accord et un énoncé un bon accord. Le document final comporte 56 énoncés qui définissent le champ de pratique et la formation nécessaire pour l’échographie ciblée périopératoire de base. Les énoncés portent sur cinq domaines de l’échographie ciblée de base : échographie cardiaque, pulmonaire, des voies respiratoires, gastrique et abdominale. L’utilisation de l’échographie ciblée de base évolue et jouera un rôle important en médecine périopératoire. Cette déclaration consensuelle vise à définir une norme nationale canadienne sur laquelle les programmes d’études pourront s’appuyer. Elle fournit également un cadre pour encourager le développement ultérieur de l’échographie ciblée de base dans un contexte périopératoire.

BACKGROUND: Pulmonary aspiration is a potentially lethal perioperative complication related to gastric size and contents. Several perioperative factors are believed to increase gastric size, while others are less studied. Therefore, this study aimed to investigate the effect of anxiety, hormone-induced ovarian stimulation, and prolonged face mask ventilation (FMV) on gastric size via measuring antral cross-sectional area (CSA) using ultrasound.METHODS: This prospective observational study was conducted in Rabin Medical Center, Israel. We recruited 49 female patients undergoing hormone-induced ovarian stimulation and oocyte retrieval for in-vitro fertilization. Preoperatively, they ranked anxiety level on a visual numeric anxiety score (VNS). In the operation room, pre-and postoperative gastric ultrasound examinations were performed. Anesthesia was induced intravenously, followed by FMV with a peak inspiratory pressure of 15 cm H2O.RESULTS: There was no substantial correlation between pre-operative VNS anxiety and antral CSA (p=0.697). Moreover, the number of follicles, blood estradiol, and progesterone levels did not correlate with antral CSA (p=0.590, p=0.104, and p=0.511, respectively). The median duration of FMV was 13 minutes [IQR 18 to 8.5] and did not correlate with the antral CSA delta (p=0.312).CONCLUSIONS: Neither preoperative anxiety nor extensive ovarian stimulation affects gastric size. Moreover, prolonged FMV with a peak inspiratory pressure of 15 cm H2O did not increase the gastric size by insufflation. These findings add to a growing body of literature on this topic. Furthermore, it provides new evidence that FMV is still safe even in a relatively short procedure.TRIAL REGISTRATION: ClinicalTrials.gov (Registration number, NCT04833530; Registration date, 06/04/2021).

Preoperative fasting is routinely performed to prevent anaesthesia-related pulmonary aspiration. To capture patients' experiences with preoperative fasting, a 13-item questionnaire was developed and validated using Rasch analysis and shortened to 6 items. This extension study aims to assess this questionnaire's ability to discriminate between participants with a short versus long duration of fasting and early versus late day surgery.Single-centred cross-sectional study.Subjects were recruited via consecutive sampling of cataract patients on surgery day at Kensington Eye Institute in Toronto from February to December 2019.A validated preoperative fasting questionnaire was administered. Discriminative ability was assessed by comparing responses in patients scheduled for surgery in the morning (8:00 am-12:00 pm) versus afternoon (12:00 pm-3:30 pm) and fasting for short (≤8 hours) versus long (8 hours) duration. Diagnostic ability of the 6-item questionnaire relative to the 13-item questionnaire was assessed with receiver operating characteristics curve analysis.A total of 164 patients (mean age 70.8 ± 10.0 years; 57% female) were included. Total scores of patients having surgery in the morning were greater (i.e., less fasting-related burden) than in the afternoon (p = 0.04). There was no significant difference in scores between patients fasting for a short versus long duration (p0.05). Receiver operating characteristics curve analysis showed excellent diagnostic ability of the 6-item questionnaire relative to the 13-item version (area under the curve = 0.964).The 6-item questionnaire for fasting-related burden has excellent discriminative ability between early versus late surgery patients. The time fasting while awake may be a more relevant predictor of fasting-related burden relative to the total duration of fasting.

The optimal epidural mixtures and settings for programmed intermittent epidural bolus (PIEB) labour analgesia have yet to be determined. A previous study by our group demonstrated that 10 mL boluses of bupivacaine 0.0625% with fentanyl 2 µg·mL−1 administered every 40 min provided effective analgesia during the first stage of labour for 90% of women, without breakthrough pain. We wanted to determine the effective PIEB time interval of 5 mL boluses of bupivacaine 0.125% with fentanyl 2 µg·mL−1 under the same study circumstances, aiming at a future comparative study. This double-blind dose-finding study used the biased coin up-and-down sequential allocation method to determine the effective PIEB interval 90% (EI90) needed to provide effective analgesia without breakthrough pain during the first stage of labour. We used fixed 5 mL boluses of bupivacaine 0.125% with fentanyl 2 µg.mL−1 and studied time intervals of 60, 50, 40, and 30 min. The first patient was assigned an interval of 60 min and the remaining intervals were assigned as per the biased coin up-and-down method. The estimated EI90 was 36.5 min (95% confidence interval [CI], 34.0 to 39.0) by the truncated Dixon and Mood method and 34.2 min (95% CI, 30.8 to 41.5) by the isotonic regression method. We found that 20/40 women had an upper sensory block to ice above T6, 34/40 women had no motor block, and no woman required treatment for hypotension. The EI90 between 5 mL boluses of bupivacaine 0.125% with fentanyl 2 µg·mL−1 during the first stage of labour is approximately 35 min. www.clinicaltrials.gov (NCT #02758405); registered 2 May, 2016.

BACKGROUND Ultrasound assistance improves success rates and reduces adverse outcomes of lumbar punctures (LPs) among adult patients in the emergency room and the operating room, but has not been evaluated in pediatric patients with cancer. Our objectives were (1) to determine whether pediatric oncologists could perform ultrasound-assisted LPs following a structured teaching curriculum, and (2) to determine the feasibility of recruiting pediatric cancer patients to a clinical trial of this procedure. METHODS Three pediatric oncologists completed a curriculum composed of didactic teaching followed by hands-on workshops. Each learner was evaluated during 20 attempts at three ultrasound tasks using the cumulative sum method. The three pediatric oncologists then performed ultrasound assessments prior to routinely scheduled LPs. Feasibility was defined as ability to perform at least 30 ultrasound-assisted LPs within 6 months. Secondary outcomes were the proportion of successful, bloody, or traumatic LPs, time required, and perceived helpfulness of ultrasound. RESULTS All three pediatric oncologists achieved competence in the three tasks of ultrasound scanning within 20 evaluated attempts. We recruited 62 patients within 1 month, and 58 underwent an ultrasound-assisted LP. All LPs were successful. Two LPs (4%) had ≥500 red blood cells (RBCs)/μl, and nine (16%) had ≥10 RBCs/μl. Median time to conduct the scan was 1.9 minutes (range 0.8-4.0 minutes). In 37 (64%) of the LPs, ultrasound assistance was considered helpful or very helpful. CONCLUSIONS Pediatric oncologists readily achieved competence in ultrasound-assisted LPs, and ultrasound was commonly perceived as helpful. It is feasible to proceed to a randomized trial of this procedure in pediatric cancer.

Programmed intermittent epidural bolus (PIEB) provides better analgesia for labour pain than continuous epidural infusion does. Nevertheless, commonly used PIEB regimens are associated with high sensory block. We hypothesized that a PIEB technique with slower bolus delivery speed would produce lower sensory levels.We recruited term nulliparous women with singleton pregnancies during the first stage of labour. All participants had an American Society of Anesthesiologists Physical Status score of II-III, had epidural catheters placed at L3/4, and had epidural analgesia maintained with PIEB 10 mL every 40 min using 0.0625% bupivacaine with fentanyl 2 µg·mLWe analyzed data from 90 women. The proportion of women presenting sensory block ≥ T6 at any time was not different between G125 and G250 groups (60.0% vs 64.4%; difference, -4.4%; 95% confidence interval [CI], -24.5 to 15.6; P = 0.66). The median [interquartile range] highest sensory block level was also not different between G125 and G250 groups (T6 [T7-T5] vs T5 [T7-T5], P = 0.39). Women in the G125 group had a lower incidence of hypotension than women in the G250 group did (11.1% vs 33.3%; difference, -22.2%; 95% CI, -38.8 to -5.67; P = 0.01). Quality of analgesia and patient satisfaction were not different between groups.The maintenance of epidural analgesia with a PIEB delivery speed of 125 mL·hrwww.ClinicalTrials.gov (NCT03236298); registered 1 August 2017.RéSUMé: OBJECTIF: L’administration programmée intermittente de bolus périduraux (PIEB, pour programmed intermittent epidural bolus) fournit une meilleure analgésie pour la douleur du travail que l’analgésie péridurale par perfusion continue. Néanmoins, les régimes de PIEB couramment utilisés sont associés à un bloc sensoriel élevé. Nous avons émis l’hypothèse qu’une technique de PIEB avec une vitesse d’administration plus lente du bolus produirait des niveaux sensoriels inférieurs. MéTHODE: Nous avons recruté des femmes nullipares à terme ayant des grossesses uniques au cours de la première étape du travail obstétrical. Toutes les participantes avaient un score de statut physique II-III de l’American Society of Anesthesiologists, des cathéters périduraux placés au niveau L3/4 et une analgésie péridurale maintenue avec des PIEB de 10 mL de bupivacaïne 0,0625 % et de 2 μg·mL

Background The provision of care to pregnant persons and neonates must continue through pandemics. To maintain quality of care, while minimizing physical contact during the Severe Acute Respiratory Syndrome-related Coronavirus-2 (SARS-CoV2) pandemic, hospitals and international organizations issued recommendations on maternity and neonatal care delivery and restructuring of clinical and academic services. Early in the pandemic, recommendations relied on expert opinion, and offered a one-size-fits-all set of guidelines. Our aim was to examine these recommendations and provide the rationale and context to guide clinicians, administrators, educators, and researchers, on how to adapt maternity and neonatal services during the pandemic, regardless of jurisdiction. Method Our initial database search used Medical subject headings and free-text search terms related to coronavirus infections, pregnancy and neonatology, and summarized relevant recommendations from international society guidelines. Subsequent targeted searches to December 30, 2020, included relevant publications in general medical and obstetric journals, and updated society recommendations. Results We identified 846 titles and abstracts, of which 105 English-language publications fulfilled eligibility criteria and were included in our study. A multidisciplinary team representing clinicians from various disciplines, academics, administrators and training program directors critically appraised the literature to collate recommendations by multiple jurisdictions, including a quaternary care Canadian hospital, to provide context and rationale for viable options. Interpretation There are different schools of thought regarding effective practices in obstetric and neonatal services. Our critical review presents the rationale to effectively modify services, based on the phase of the pandemic, the prevalence of infection in the population, and resource availability.

In this review, we summarize evidence regarding the use of routine and investigational pharmacologic interventions for pregnant and lactating patients with coronavirus disease 2019 (COVID-19). Antenatal corticosteroids may be used routinely for fetal lung maturation between 24 and 34 weeks' gestation, but decisions in those with critical illness and those 24 or 34 weeks' gestation should be made on a case-by-case basis. Magnesium sulfate may be used for seizure prophylaxis and fetal neuroprotection, albeit cautiously in those with hypoxia and renal compromise. There are no contraindications to using low-dose aspirin to prevent placenta-mediated pregnancy complications when indicated. An algorithm for thromboprophylaxis in pregnant patients with COVID-19 is presented, which considers disease severity, timing of delivery in relation to disease onset, inpatient vs outpatient status, underlying comorbidities and contraindications to the use of anticoagulation. Nitrous oxide may be administered for labor analgesia while using appropriate personal protective equipment. Intravenous remifentanil patient-controlled analgesia should be used with caution in patients with respiratory depression. Liberal use of neuraxial labor analgesia may reduce the need for emergency general anesthesia which results in aerosolization. Short courses of non-steroidal anti-inflammatory drugs can be administered for postpartum analgesia, but opioids should be used with caution due to the risk of respiratory depression. For mechanically ventilated pregnant patients, neuromuscular blockade should be used for the shortest duration possible and reversal agents should be available on hand if delivery is imminent. To date, dexamethasone is the only proven and recommended experimental treatment for pregnant patients with COVID-19 who are mechanically ventilated or who require supplemental oxygen. Although hydroxycholoroquine, lopinavir/ritonavir and remdesivir may be used during pregnancy and lactation within the context of clinical trials, data from non-pregnant populations have not shown benefit. The role of monoclonal antibodies (tocilizumab), immunomodulators (tacrolimus), interferon, inhaled nitric oxide and convalescent plasma in pregnancy and lactation needs further evaluation. © 2020 The Authors. Ultrasound in ObstetricsGynecology published by John WileySons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Approximately one in five women will experience severe postoperative pain after Cesarean delivery (CD). Previously, a bedside three-item questionnaire (3-IQ) has shown to predict women experiencing higher evoked pain intensity after CD, with an area under the receiver operator characteristics (ROC) curve of 0.72. We hypothesized that the addition of psychophysical pain tests to the existing 3-IQ would improve the ability to predict severe pain in women undergoing elective CD under spinal anesthesia METHODS: This was a prospective cohort study on women undergoing elective CD under spinal anesthesia. Women were assessed preoperatively using the 3-IQ, pressure algometry (PA) and mechanical temporal summation (TS) response. All women received standard perioperative care, including a multimodal analgesia regimen that included intrathecal fentanyl and morphine. A 0-100 mm visual analogue scale (VAS) was used to assess the severity of pain at rest (VASr) and on movement (VASm) at 24 and 48 hr after surgery. Patient satisfaction and opioid consumption were also recorded. We performed ROC curve analyses to assess whether we could improve the ability to predict our primary outcome of severe pain on movement at 24 hr (VASm24 ≥ 70).We studied 195 women. Median [interquartile range] VASm24 was 53 [32-72] and 28% of patients experienced a VASm24 ≥ 70. The ability to predict a VASm24 ≥ 70 assessed by the area under the ROC curve was 0.64 using the 3-IQ and 0.67 using the 3-IQ combined with TS and PA.The addition of PA and TS to the 3-IQ model resulted in a predictive model that performed similarly to the 3-IQ model alone. Further research is warranted in this area to better predict women at risk of severe pain post CD.RéSUMé: OBJECTIF: Environ une femme sur cinq souffrira de douleur postopératoire sévère après un accouchement par césarienne. Un questionnaire à trois critères (Q3C) administré au chevet de la patiente a déjà été utilisé pour prédire quelles femmes éprouveraient une intensité de douleur évoquée plus élevée après une césarienne, avec une aire sous la courbe ROC de 0,72. Nous avons émis l’hypothèse que l’ajout de tests psychophysiques de douleur au Q3C existant améliorerait notre capacité à prédire la douleur sévère chez les femmes bénéficiant d’une césarienne élective sous rachianesthésie. MéTHODE: Il s’agissait d’une étude de cohorte prospective auprès de femmes bénéficiant d’une césarienne élective sous rachianesthésie. Les femmes ont été évaluées en préopératoire à l’aide du Q3C, de l’algométrie par pression (AP) et de la réponse à une sommation temporale (ST) mécanique. Toutes les femmes ont bénéficié des soins périopératoires standard, ainsi que d’un régime d’analgésie multimodal incluant fentanyl et morphine intrathécaux. Une échelle visuelle analogique (EVA) de 0 à 100 mm a été utilisée pour évaluer la sévérité de la douleur au repos (EVAr) et en mouvement (EVAm) à 24 et 48 heures après la chirurgie. La satisfaction des patientes et la consommation d’opioïdes ont également été enregistrées. Nous avons effectué des analyses de la courbe ROC pour déterminer s’il nous était possible d’améliorer notre capacité à prédire notre critère d’évaluation principal, soit la douleur sévère à la mobilisation à 24 heures (EVAm24 ≥ 70). RéSULTATS: Nous avons étudié 195 femmes. L’EVAm 24 médiane [écart interquartile] était de 53 [32-72] et 28 % des patientes ont noté un score sur l’EVAm24 ≥ 70. La capacité à prédire un score sur l’EVAm24 ≥ 70 tel qu’évalué par la surface sous la courbe ROC était de 0,64 en utilisant le Q3C et de 0,67 en utilisant le Q3C combiné à la ST et l’AP. CONCLUSION: L’ajout de l’AP et de la ST au modèle de Q3C a résulté en un modèle prédictif présentant une performance similaire au modèle de Q3C seul. D’autres recherches sont nécessaires dans ce domaine pour mieux prédire les femmes à risque de douleur sévères après une césarienne.

We studied the programmed intermittent epidural bolus (PIEB) time interval between boluses of 2.5 mL of bupivacaine 0.25% with fentanyl 8 µg·mLIn a double-blind sequential allocation trial using a biased coin up-and-down design to determine the EI90, the PIEB boluses of 2.5 mL of 0.25% bupivacaine plus fentanyl 8 µg·mLIn the 20 women studied, the estimated EI90 was 20 (95% CI, 5.9 to 28.8) min. For the secondary outcomes, we classified women into those assigned to 30 min (16 women) and those assigned to more than 30 min (four women). The median upper sensory block for women in the 30-min group and more than 30 min were T6 (or T5) and T7, respectively. No participants experienced motor block. Hypotension occurred in one patient in the 30-min group.The estimated EI90 for boluses of 2.5 mL of bupivacaine 0.25% with fentanyl 8 µg·mLwww.clinicaltrials.gov (NCT03735771); registered 7 November 2018.RéSUMé: OBJECTIF: Nous avons étudié l’intervalle de temps d’administration programmée de bolus périduraux (PIEB) entre des bolus de 2,5 mL de bupivacaïne 0,25 % avec 8 μg·mL

The optimum time interval for 10 ml boluses of bupivacaine 0.0625% + fentanyl 2 μg.ml-1 as part of a programmed intermittent epidural bolus regimen has been found to be 40 min. This regimen was shown to be effective without the use of supplementary patient-controlled epidural analgesia boluses in 90% of women during the first stage of labour, although with a rate of sensory block to ice above T6 in 34% of women. We aimed to determine the optimum programmed intermittent epidural bolus volume at a 40 min interval to provide effective analgesia in 90% of women (EV90 ) during the first stage of labour, without the use of patient-controlled epidural analgesia. We performed a prospective double-blind dose-finding study using the biased coin up-and-down sequential allocation method in 40 women. The estimated EV90 was 11.0 (95%CI 10.0-11.7) ml with the isotonic regression method and 10.7 (95%CI 10.3-11.0) ml with the truncated Dixon and Mood method. Overall, 18 women had a sensory block above T6, and 37 women exhibited no motor block. No women required treatment for hypotension. In conclusion, it is not possible to reduce the programmed intermittent epidural bolus volume from 10 ml, used in our current regimen, without compromising the quality of analgesia. Using this regimen, a high proportion of women will develop a sensory block above T6.

Most studies that have compared programmed intermittent epidural bolus (PIEB) with continuous epidural infusion regimens have included patient-controlled epidural analgesia and/or manual bolus as rescue analgesia for breakthrough pain. Consequently, the optimal time interval between PIEB is yet to be determined. We designed a study to establish the optimal time interval between PIEB of 10 mL of bupivacaine 0.0625% with fentanyl 2 μg/mL to produce effective analgesia in 90% of women during first stage of labor without breakthrough pain.We conducted a double-blind sequential allocation trial with a biased-coin up-down design to obtain the effective interval 90% for the PIEB regimen. We included American Society of Anesthesiologists physical status 2-3 nulliparous women at term undergoing spontaneous or induced labor requesting epidural analgesia. An ultrasound-assisted epidural catheter placement was performed at L2/3 or L3/4. A test dose of 3 mL of bupivacaine 0.125% plus fentanyl 3.3 μg/mL was followed by a loading dose of 12 mL of the same solution. PIEB was then started in women whose pain scores achieved Verbal Numerical Rating Score ≤1/10 within 20 minutes after the end of the loading dose. In all subjects, the programmed bolus dose was fixed at 10 mL of bupivacaine 0.0625% with fentanyl 2 μg/mL. The first bolus was delivered 1 hour after the loading dose. The PIEB interval was set at 60 minutes for the first patient and at varying time intervals (60, 50, 40, and 30 minutes; groups 60, 50, 40 and 30, respectively) for the subsequent patients, according to a biased-coin design. The primary outcome was effective analgesia, defined as no requirement for a patient-controlled epidural analgesia or a manual bolus for 6 hours after the initiation of the epidural analgesia or until the patient presented with full cervical dilatation, whichever event occurred first. Pain scores, sensory block levels to ice, degree of motor block, and blood pressure were assessed hourly.We studied 40 women. The estimated effective interval 90% was 42.6 minutes (95% confidence interval 38.9-46.4) using the truncated Dixon and Mood method and 36.8 minutes (95% confidence interval 31.0-49.0) using the Isotonic Regression analysis. Almost 70% of the patients in group 30 presented with sensory block above T6, compared with 44%, 22%, and 11% in groups 40, 50, and 60, respectively. Only patients in group 30 presented with motor blockade. The incidence of hypotension was low in all groups with no treatment required.The optimal time interval between PIEB of 10 mL of bupivacaine 0.0625% with fentanyl 2 μg/mL is approximately 40 minutes. Further studies to determine the efficacy of this regimen throughout the entire duration of labor are warranted.

BACKGROUND The transcatheter electric stimulation test (Tsui test) can be performed at the bedside to confirm the correct placement of a wire-reinforced epidural catheter within the epidural space. The most commonly observed motor response with a uniport epidural catheter placed in the lumbar area is the unilateral contraction of the lower limbs. Wire-reinforced multiport catheters have recently been introduced into clinical practice; however, the characteristics of the Tsui test with such catheters are unknown. We designed a randomized controlled trial to test the hypothesis that the incidence of a bilateral response to the Tsui test would be higher with a multiport catheter, with all other characteristics of the test remaining unchanged. METHODS We recruited laboring women requesting epidural analgesia. The epidural catheter placement was performed in a standard fashion, assisted by ultrasound, aiming at the L3-L4 interspace. Patients were randomly allocated for the placement of either a 19-G uniport or a 19-G multiport wire-reinforced catheter. The Tsui test (frequency 2 Hz; pulse width 0.2 millisecond) was performed immediately after securing the catheter (baseline) and at 5 minutes after a test dose with 3 mL lidocaine 2%. The current output was increased from zero until motor activity was detected up to a maximum of 20 mA. Subsequently, an initial loading dose of 10 mL bupivacaine 0.125% and 50 μg fentanyl was administered. The sensory block level to ice was assessed bilaterally at 20 minutes after injection of the loading dose. The primary outcome was the motor response pattern to the electric stimulation of the epidural catheter, either unilateral or bilateral; secondary outcomes included minimal current intensity needed to elicit a motor response at baseline and 5 minutes after the test dose, sensory block level and incidence of symmetrical sensory block at 20 minutes after injection of the loading dose, pain scores before the test dose and at 20 minutes after the loading dose, and need for catheter replacement within 2 hours of completion of the loading dose. RESULTS Sixty-three women were assessed for eligibility and 46 were randomly allocated equally to each group. Three patients were excluded, resulting in 21 subjects in the multiport group and 22 subjects in the uniport group. Patient characteristics in both groups were similar. The incidence of unilateral motor response to the Tsui test was 95.2% (20/21) and 95.5% (21/22) in the multiport and uniport groups, respectively (rate difference 0.22%; 95% confidence interval, for the difference -29.2 to 29.2%; P = 0.99). The minimal current intensity (mean ± SD) required to produce a motor response at baseline was 5.4 ± 3.5 mA and 5.4 ± 4.1 mA in the multiport and uniport groups, respectively (P = 0.98). The sensory block levels to ice on the left and right, as well as pain scores at 20 minutes, were similar in both groups. No epidural catheters were resited. CONCLUSIONS The Tsui test produced a high percentage of unilateral motor response in women with both uniport and multiport wire-embedded catheters. A larger study is necessary to confirm that there is no clinically significant difference in the motor response patterns between the 2 catheter types.

Purpose Following discharge, patients requiring high opioid doses may be at risk for both under- and overdosing, posing a major challenge to community physicians. The aim of this study was to examine the effectiveness and degree of satisfaction with a personalized taper schedule and physician letter through interviews of patients and physicians. Methods This was a 1-year prospective study. Following ethics approval and informed written consent, patients admitted for elective surgery, 18 to 60 years of age, receiving opioid analgesics, were recruited. Prior to discharge, the acute pain service team provided patients with a taper schedule explained in detail. Individualized physician letters were faxed to treating family physicians. Patients were contacted by phone 2, 4, and 6 weeks after discharge. Physicians were contacted once, a month after discharge. Patients and physicians were asked to grade the taper schedule on a 1- to 5-point Likert scale. Questions pertained to clarity, usefulness, ability to follow the instructions, and general satisfaction. Results Twenty-six patients and 21 physicians completed the study. Physicians were generally satisfied with both the taper schedule and letter and rated all aspects between 3.76 and 4.38 of 5. Similarly, patients were satisfied with the taper schedule and rated all aspects between 4.08 and 4.5. Conclusions Both physicians and patients generally found the taper schedule and letter helpful in assisting them to taper off their opioid use. This is one way of bridging the gap in continuity of care between the acute and primary care providers while reducing the risk to patients during the transition period.

The optimal epidural mixtures and settings for programmed intermittent epidural bolus (PIEB) labour analgesia have yet to be determined. A previous study by our group demonstrated that 10 mL boluses of bupivacaine 0.0625% with fentanyl 2 µg·mLThis double-blind dose-finding study used the biased coin up-and-down sequential allocation method to determine the effective PIEB interval 90% (EI90) needed to provide effective analgesia without breakthrough pain during the first stage of labour. We used fixed 5 mL boluses of bupivacaine 0.125% with fentanyl 2 µg.mLThe estimated EI90 was 36.5 min (95% confidence interval [CI], 34.0 to 39.0) by the truncated Dixon and Mood method and 34.2 min (95% CI, 30.8 to 41.5) by the isotonic regression method. We found that 20/40 women had an upper sensory block to ice above T6, 34/40 women had no motor block, and no woman required treatment for hypotension.The EI90 between 5 mL boluses of bupivacaine 0.125% with fentanyl 2 µg·mLwww.clinicaltrials.gov (NCT #02758405); registered 2 May, 2016.

Multidisciplinary care teams exist throughout healthcare systems. In the operating room (OR), effective communication between teams is essential, especially during crisis situations where patient safety can be in acute danger. An often-neglected skillset in educational curriculums is challenging authority. This narrative synthesis aims to explore the literature on challenging authority in the OR environment. A systematic search of Medline, EBM reviews and PsycINFO was conducted using terms related to challenging authority, speaking up, communication, patient safety, gradients and hierarchy. The initial search identified 4822 publications, out of which 31 studies were included. The data synthesis of the included studies was grouped into three distinct categories following a meta-aggregative approach: discussion and review articles, observational or qualitative studies, and studies identifying the role of specific barriers or investigating the effect of educational interventions. Themes emerging from expert beliefs, what reality tells us and what we test are consistent. Hierarchy, organisational culture and education are the most frequently observed and tested themes. Simulation research has been successful in eliciting and confirming the role of specific barriers to speaking up. Barriers and enablers are largely modifiable within institutions however, education regarding the importance of speaking up will need to accompany these modifications for any significant changes to occur.

Ultrasonography can accurately identify the cricothyroid membrane; however, its impact on the subsequent accuracy of external palpation is not known. In this study, we tested the ability of anesthesia participants to identify the midpoint of the cricothyroid membrane using external palpation with and without ultrasound (US)-guided practice.Following institutional ethics approval and informed consent, anesthesia participants consisting of anesthesia residents, fellows, and practicing anesthesia assistants underwent didactic teaching on neck landmarks. The participants were then randomized to practice palpation of neck landmarks with US guidance (US group) or without ultrasonography (non-US [NUS] group). After the practice session, each participant identified the cricothyroid membrane using external palpation on the neck of 10 volunteers and marked the anticipated entry point for device insertion (palpation point [PT]). The midpoint of the cricothyroid membrane of each volunteer had been premarked with invisible ink using ultrasonography (US point) by a separate member of the research team. The primary outcome was the accuracy rate defined as the percentage of the attempts with the distance ≤5 mm measured from the PT to US point for the participant. The primary outcome was compared between NUS and US groups using Wilcoxon rank sum test. A mixed-effect logistic regression or mixed-effect linear model was also conducted for outcomes accounting for the clustering and adjusting for potential confounders.Fifteen anesthesia participants were randomized to US (n = 8) and NUS (n = 7) groups. A total of 80 and 61 attempts were performed by the US and NUS groups, respectively. The median accuracy rate in the US group was higher than the NUS group (65% vs 30%; P = .025), and the median PT-US distance in the US group was shorter than in the NUS group (4.0 vs 8.0 mm; P = .04). The adjusted mean PT-US distance in the US group was shorter compared to the NUS group (adjusted mean [95% CI], 3.6 [2.9-4.6] vs 6.8 [5.2-8.9] mm; P.001).Anesthesia participants exposed to practice with US-guided palpation of the cricothyroid membrane location were better able to identify the cricothyroid membrane using only blind palpation than participants without US-guided practice. Practice with US-guided palpation of neck landmarks improves subsequent blind localization of the cricothyroid membrane using palpation alone.

Background Misidentification of the cricothyroid membrane in a “cannot intubate-cannot oxygenate” situation can lead to failures and serious complications. The authors hypothesized that preprocedure ultrasound-guided identification of the cricothyroid membrane would reduce complications associated with cricothyrotomy. Methods A group of 47 trainees were randomized to digital palpation (n = 23) and ultrasound (n = 24) groups. Cricothyrotomy was performed on human cadavers by using the Portex® device (Smiths Medical, USA). Anatomical landmarks of cadavers were graded as follows: grade 1—easy = visual landmarks; 2—moderate = requires light palpation of landmarks; 3—difficult = requires deep palpation of landmarks; and 4—impossible = landmarks not palpable. Primary outcome was the complication rate as measured by the severity of injuries. Secondary outcomes were correct device placement, failure to cannulate, and insertion time. Results Ultrasound guidance significantly decreased the incidence of injuries to the larynx and trachea (digital palpation: 17 of 23 = 74% vs. ultrasound: 6 of 24 = 25%; relative risk, 2.88; 95% CI, 1.39 to 5.94; P = 0.001) and increased the probability of correct insertion by 5.6 times (P = 0.043) in cadavers with difficult and impossible landmark palpation (digital palpation 8.3% vs. ultrasound 46.7%). Injuries were found in 100% of the grades 3 to 4 (difficult–impossible landmark palpation) cadavers by digital palpation compared with only 33% by ultrasound (P < 0.001). The mean (SD) insertion time was significantly longer with ultrasound than with digital palpation (196.1 s [60.6 s] vs. 110.5 s [46.9 s]; P < 0.001). Conclusion Preprocedure ultrasound guidance in cadavers with poorly defined neck anatomy significantly reduces complications and improves correct insertion of the airway device in the cricothyroid membrane.

Bedside gastric ultrasound can reliably assess gastric contents in the perioperative period. We aimed to describe the qualitative and quantitative ultrasound assessment of the gastric antrum in fasted pregnant women at term.Pregnant women were examined after a minimum period of overnight fasting (solid food, 6 hours; clear liquids, 2 hours) before their scheduled cesarean delivery. A standardized ultrasound examination of the gastric antrum was performed. Based on the qualitative assessment in the supine and right lateral decubitus positions, women were classified using a 3-point grading system (grade 0, no fluid; grade 1, fluid seen in right lateral decubitus position only; and grade 2, fluid seen in the both supine and right lateral decubitus positions). A quantitative assessment of the antral cross-sectional area (CSA) was performed using still images in the right lateral decubitus position.One hundred three women were included in the study; 53 of 103 exhibited grade 0 and 49 of 103 exhibited grade 1 antrum. One woman presented a grade 2 antrum (1/103 = 0.97%; 95% confidence interval [CI], 0.05%-6.06%). Overall, 95% of fasting subjects presented with an antral CSA ≤9.6 cm (95% CI, 8.6-10.3 cm) in the right lateral decubitus position (median [interquartile range] = 4.5 [3.2] cm), corresponding to an estimated gastric volume of ≤117 mL (95% CI, 108-127 mL) or ≤1.5 mL/kg (95% CI, 1.3-1.7 mL/kg).All women but one presented with antral CSA compatible with residual gastric fluid. The qualitative 3-point grading system may be used to assess individual risk of perioperative gastric content aspiration. Our results suggest that an antral CSA of 10.3 cm in the right lateral decubitus position more accurately describes the upper limit of normal findings in the fasted pregnant patient at term.

Simulation is an important alternative to evaluate cricothyrotomy, a rare life-saving procedure. This crossover study aimed to determine whether contextualization of a crisis scenario would impact the performance of a cricothyrotomy procedural task. Sixty-five anesthesia assistants and emergency medicine and anesthesia residents underwent a teaching session in surgical cricothyrotomy using one of two sets of cricothyrotomy kits: the Portex 6.0 and Melker 3.5 (n = 32) or the Portex 6.0 and Melker 5.0 (n = 33). Within six weeks following the session, the participants performed cricothyrotomies on a full-body patient mannequin simulator coupled with a porcine larynx (tissue-mannequin simulator) using the assigned two kits in a “cannot intubate, cannot ventilate” (CICV) contextualized scenario (CS) and in a CICV verbalized non-contextualized scenario (NCS). Each participant performed a total of four cricothyrotomies using the two kits in the two scenarios. The primary outcome measure was insertion time, and secondary outcome measures were severity of injuries and failure rate. Outcome measures were compared between scenarios for each kit. Mean (SD) insertion time for a successful cricothyrotomy was not significantly different between NCS and CS for the Melker 3.5 [83.0 (45.0) sec vs 63.3 (36.1) sec, respectively; P = 0.96; mean difference (MD), 19.7 sec; 95% confidence interval (CI), −1.9 to 41.3], the Melker 5.0 [86.5 (36.8) sec vs 107.1 (55.6) sec, respectively; P = 0.11; MD, −20.6 sec; 95% CI, −44.9 to 3.7], and the Portex 6.0 [59.5 (35.5) sec vs 59.0 (35.0) sec, respectively; P = 0.95; MD, 0.5 sec; 95% CI, −13.2 to 14.2]. Failure rate and severity of injuries, measured as mean average injury score for each kit, were also similar between scenarios. Contextualization of a crisis scenario did not affect the performance of a cricothyrotomy procedural task on a tissue-mannequin simulator. These findings may have implications when considering the feasibility and cost-effectiveness for assessing the performance of cricothyrotomy procedural tasks.

Ultrasound imaging of the spine is thought to reduce failed and traumatic neuraxial procedures. Most of the evidence supporting this assumption has been produced in the context of an expert sonographer performing the ultrasound assessment, and it remains unknown whether this technique is useful when used by multiple individual operators.To invesstigate the impact of preprocedural spinal ultrasound on the ease of insertion of labour epidurals by a group of trainees. We hypothesised that the ultrasound-assisted technique would improve the ease of insertion when compared with the conventional palpation technique.A randomised controlled trial.Academic hospital in Toronto, Canada.A group of 17 second-year anaesthesia residents and five anaesthesia fellows underwent a training programme in ultrasound assessment of the spine. Parturients with easily palpable lumbar spines were randomised to either ultrasound or palpation group. Residents and fellows performed both the assessment (ultrasound or palpation) and the epidural procedure.ease of insertion of epidural catheter composed of the time taken to insert the epidural catheter, number of interspace levels attempted and number of needle passes.total procedural time (assessment and insertion); first pass success rate; number of attempts required to thread the epidural catheter; failure of epidural analgesia; and patient satisfaction.We analysed 128 epidural catheter insertions (residents 84, fellows 44). There was no difference in median (interquartile range, IQR) epidural insertion time between the ultrasound and palpation groups [174 (120 to 241) versus 180 (130 to 322.5) s, respectively; P = 0.14]. The number of interspace levels attempted and needle passes were also similar in both groups. The total procedural time was longer in the ultrasound group.The use of preprocedural spinal ultrasound by a cohort of anaesthesia trainees did not improve the ease of insertion of labour epidural catheters in patients with easily palpable lumbar spines, as compared with the traditional palpation technique based on anatomical landmarks.ClinicalTrials.gov identifier: NCT00996905.

Bedside gastric ultrasonography can be performed reliably by anaesthetists to assess gastric content in the peri-operative period. We aimed to study the relationship between gastric cross-sectional area, assessed by ultrasound, and volumes of clear fluids ingested by pregnant women. We recruited 60 non-labouring third-trimester pregnant women in a randomised controlled and assessor-blinded study. A standardised scanning protocol of the gastric antrum was performed in the 45° semirecumbent and 45° semirecumbent-right lateral positions. Subjects were randomly allocated to drink one out of six predetermined volumes of apple juice (0 ml, 50 ml, 100 ml, 200 ml, 300 ml, 400 ml). Qualitative and quantitative assessments at a baseline period after an 8-h fast, and immediately after the drink, were used to establish the correlation between antral cross-sectional area and volume ingested. A predictive model to estimate gastric volume was developed. Antral cross-sectional area in the semirecumbent right lateral position significantly correlated with the ingested volume (Spearman rank correlation = 0.7; p < 0.0001). A cut-off value of 9.6 cm2 discriminated ingested volumes ≥ 1.5 ml.kg-1 with a sensitivity of 80%, a specificity of 66.7%, and an area under the curve of 0.82. A linear predictive model was developed for gastric volume based only on antral cross-sectional area (Volume (ml) = -327.1 + 215.2 × log (cross-sectional area) (cm2 )). We conclude that in pregnant women in the third trimester of gestation, the antral cross-sectional area correlates well with volumes ingested, and this cut-off value in the semirecumbent right lateral position discriminates high gastric volumes.

This narrative review summarizes the current knowledge on point-of-care ultrasound (POCUS) of gastric contents in order to inform an assessment of aspiration risk and guide anesthetic management at the bedside. An I-AIM framework (Indication, Acquisition, Interpretation, and Medical decision-making) is used to summarize and organize the content areas. This narrative review spans the breadth of the literature on pediatric and adult subjects as well as on special patient populations such as obstetric and severely obese individuals. Areas that need further investigation include the diagnostic accuracy of gastric POCUS from a Bayesian perspective and the impact of POCUS on patient outcomes, healthcare economics, and educational curricula.

Background Pulmonary aspiration of gastric contents in pregnant women undergoing general anaesthesia is one of the most feared complications in obstetric anaesthesia. Bedside gastric ultrasonography is a feasible imaging tool to assess the gastric content. The purpose of this study was to investigate the reliability of qualitative bedside assessment of the gastric content performed by anaesthesiologists on third trimester pregnant women. Methods Pregnant women (≥32 weeks gestational age) were randomized to undergo ultrasound (US) assessments of their stomach in a fasting state (>8 h), or after ingestion of clear fluids only, or solid food. Three anaesthesiologists trained in gastric ultrasonography performed the assessments using a low-frequency curved-array US transducer (5–2 MHz). Primary outcome of the study was the consistency of raters in diagnosing the correct status of the gastric content, which was used to determine the interrater reliability among the three anaesthesiologists. Secondary outcomes were overall proportion of correct and incorrect diagnoses and the specific proportions of correct diagnosis across the three gastric content groups. Results We analysed 32 pregnant women. The interrater reliability displayed a kappa statistic of 0.74 (bias corrected 95% CI: 0.68–0.84). The overall proportion of correct diagnosis was 87.5% (84 of 96). The odds of correct diagnosis for ‘solid contents' were 16.7 times the odds for ‘empty', and 14.3 times for ‘clear fluid'. Conclusions Our results show the consistency of the qualitative US assessment of gastric contents of pregnant women in the third trimester by anaesthesiologists. A kappa of 0.74 suggests substantial agreement in terms of interrater reliability for this diagnostic measurement. Clinical trial registration ClinicalTrials.gov identifier: NCT01564030.

Spinal ultrasonography provides guidance for epidural insertion in obstetric patients. The primary objective of the study was to develop a training program in spinal ultrasound for anaesthetists and to determine its effect on the skill acquisition of anaesthetists with no prior spinal ultrasound experience. Eighteen anaesthetists underwent two structured workshops (one week apart), each followed by a practice session and videorecorded assessments. Participants were randomised to a protocol-driven or non-protocol driven spinal ultrasound teaching program. Two experts rated each individual's performance using a global rating scale (GRS), checklist and image quality scale. The primary outcome was the mean difference in GRS score between the two workshops, analysed using linear mixed models. Intraclass correlation coefficients were calculated to assess agreement between assessors' ratings. A total of 108 ultrasound scans were performed on five pregnant volunteers during the assessment periods. After adjusting for confounders, GRS scores increased on all three rating scales at the second workshop, this increase being 6.01 points (95% confidence interval 4.56 to 7.46, P

Study Objective To evaluate predictors of desaturation and to identify practice for patient transport following general anesthesia. Design Observational quality assurance study. Setting Postanesthesia Care Unit (PACU) of a university-affiliated, tertiary-care hospital. Patients All adult postsurgical patients who received general anesthesia and who were admitted to the PACU. Measurements Patients were observed over a three-month study period during transfer to the PACU with or without oxygen supplementation. Sixteen variables related to patient, surgery, and anesthesia were recorded. Results The study recorded a total of 502 PACU admissions. The practice pattern showed that 57% of patients were transferred without oxygen and 19% of the entire sample had an initial oxygen desaturation of less than 90% on arrival to the PACU. Only 0.8% of patients experienced oxygen desaturation when they were transferred with oxygen supplementation. After logistic regression analysis, the most significant predictor of desaturation was transport without oxygen. Conclusions The majority of anesthesiologists did not use supplemental oxygen for patient transfer. As a result, a higher incidence of postoperative desaturation was noted in their patients. Significant predictors of desaturation after general anesthesia included patients' sedation score, low respiratory rate, and transport without oxygen. The use of oxygen almost completely prevented desaturation during transport.

Focused assessment of the gastric antrum by ultrasound is a feasible tool to evaluate the quality of the stomach content. We aimed to determine the amount of training an anesthesiologist would need to achieve competence in the bedside ultrasound technique for qualitative assessment of gastric content. Six anesthesiologists underwent a teaching intervention followed by a formative assessment; then learning curves were constructed. Participants received didactic teaching (reading material, picture library, and lecture) and an interactive hands-on workshop on live models directed by an expert sonographer. The participants were instructed on how to perform a systematic qualitative assessment to diagnose one of three distinct categories of gastric content (empty, clear fluid, solid) in healthy volunteers. Individual learning curves were constructed using the cumulative sum method, and competence was defined as a 90% success rate in a series of ultrasound examinations. A predictive model was further developed based on the entire cohort performance to determine the number of cases required to achieve a 95% success rate. Each anesthesiologist performed 30 ultrasound examinations (a total of 180 assessments), and three of the six participants achieved competence. The average number of cases required to achieve 90% and 95% success rates was estimated to be 24 and 33, respectively. With appropriate training and supervision, it is estimated that anesthesiologists will achieve a 95% success rate in bedside qualitative ultrasound assessment after performing approximately 33 examinations.

Background Effective operating theatre (OT) communication is important for team function and patient safety. Status asymmetry between team members may contribute to communication breakdown and threaten patient safety. We investigated how hierarchy in the OT team influences an anaesthesia trainee's ability to challenge an unethical decision by a consultant anaesthetist in a simulated crisis scenario. Methods We prospectively randomized 49 postgraduate year (PGY) 2–5 anaesthesia trainees at two academic hospitals to participate in a videotaped simulated crisis scenario with a simulated OT team practicing either a hierarchical team structure (Group H) or a non-hierarchical team structure (Group NH). The scenario allowed trainees several opportunities to challenge their consultant anaesthetist when administering blood to a Jehovah's Witness. Three independent, blinded raters scored the performances using a modified advocacy–inquiry score (AIS). The primary outcome was the comparison of the best-response AIS between Groups H vs NH. Secondary outcomes included the comparison of best AIS by PGY and the percentage in each group that checked and administered blood. Results The AIS did not differ between the groups (P=0.832) but significantly improved from PGY2 to PGY5 (P=0.026). The rates of checking blood (92% vs 76%, P=0.082) and administering blood (62% vs 57%, P=0.721) were high in both groups but not significantly different between the groups. Conclusions This study did not show a significant effect of OT team hierarchical structure on trainee's ability to challenge authority; however, the results are concerning. The challenges were suboptimal in quality and there was an alarming high rate of blood checking and administration in both groups. This may reflect lack of training in appropriately and effectively challenging authority within the formal curriculum with implications for patient safety.

This article provides an overview of the use of ultrasonography in obstetric anesthesia. It discusses the indications, benefits, and techniques of using ultrasonography to optimize the delivery of anesthesia and provide safe and efficacious clinical care. More specifically, it discusses the use of ultrasonography to facilitate neuraxial anesthesia, abdominal field blocks, central and peripheral vascular access, as well as the assessment of the lung fields and gastric contents, and identification of the cricothyroid membrane.

Background and Objectives Ultrasonography of the spine improves technical performance of spinal anesthesia, but what is unclear is whether it can predict difficulty. We tested the hypothesis that a good ultrasound view at a given intervertebral level is associated with absence of technical difficulty. Methods We performed preprocedural ultrasound of the L1-S1 intervertebral spaces in 100 patients undergoing orthopedic surgery. Visibility of the ligamentum flavum–dura mater and the posterior longitudinal ligament was evaluated using paramedian sagittal oblique and transverse midline (TM) views. Views were classified as good if both of these structures were visible on ultrasound. An operator, blinded to the ultrasound scan, performed surface landmark–guided spinal anesthesia using a midline approach. Absence of technical difficulty was defined as successful dural puncture within 2 skin punctures or 10 needle passes. Results A good TM view had the best diagnostic accuracy; if this view was obtained, absence of technical difficulty with dural puncture at that level was highly likely (positive predictive value, 85%). Dural puncture could still be feasible despite the absence of a good TM view, as reflected by a negative predictive value of 30%. This was attributed to the limitations of ultrasound imaging in this patient population, as well as the low overall prevalence of difficult dural puncture. Parasagittal oblique views did not have significant diagnostic utility for a midline needle approach. Conclusions Ultrasound can be useful in predicting the absence of technical difficulty in performing dural puncture and thus in selecting the optimal intervertebral level for spinal anesthesia.

Background: Ultrasound (US) imaging of the spine has been shown to be a reliable tool to facilitate lumbar epidural needle placement; however, its feasibility in thoracic epidural placement is still unknown. The objective of this study was to assess the accuracy and reliability of prepuncture US imaging in the paramedian sagittal oblique plane to estimate the depth to the epidural space and optimum insertion point for guiding epidural needle placement at the mid-low thoracic level. Methods: This prospective study included 35 healthy adult patients who requested thoracic epidural analgesia before their upper abdominal surgeries. Ultrasound imaging was done in the paramedian sagittal oblique plane at the desired thoracic level to identify the intervertebral space, the distance from the skin to the epidural space (US depth [UD]) and the needle insertion point. Subsequently, a staff anesthesiologist located the epidural space through the predetermined insertion point and marked the actual distance from the skin to the epidural space (needle depth [ND]) on the needle with a sterile marker. The agreement between the UD and the ND was calculated using the Pearson and concordance correlation coefficients and Bland-Altman analysis with 95% limits of agreement. Results: The average patient age was 56 (SD, 14) years, and body mass index was 28 (SD, 6) kg/m2. The precision of the agreement between UD and ND estimated by Pearson correlation coefficient was 0.75, and the accuracy was 0.80, whereas the concordance correlation coefficient was 0.60 (confidence interval, 0.43-0.78). The mean UD and ND were 4.3 (SD, 0.96) and 5.0 (SD, 1.2) cm, respectively. The Bland-Altman analysis showed a mean difference of −0.71 cm (95% limits of agreement, 0.8 to −2.2 cm). There was a significant direct correlation of the ND with the body mass index (r2 = 0.27, P = 0.008). The mean number of attempts was 1 (p25-p75 = 1-2), and the epidural space was identified with 2 or less redirections in 88% of the cases. Conclusions: We found a good correlation between the US-estimated distance to the epidural space and the actual measured needle distance in our patients. We suggest that our proposed prepuncture US method, using the paramedian sagittal oblique approach, can be a useful guide to facilitate the placement of epidural needles at mid-low thoracic levels. A randomized controlled trial is necessary to confirm the utility of prepuncture US in thoracic epidural placement.

Summary Spinal anaesthesia is the preferred anaesthetic technique for elective Caesarean deliveries. Hypotension is the most common side-effect and has both maternal and neonatal consequences. Different strategies have been attempted to prevent spinal-induced hypotension, including the use of low-dose bupivacaine. We conducted a systematic search for randomized controlled trials comparing the efficacy of spinal bupivacaine in low dose (LD ≤8 mg) with conventional dose (CD >8 mg) for elective Caesarean delivery. Thirty-five trials were identified for eligibility assessment, 15 were selected for data extraction, and 12 were finally included in the meta-analysis. We investigated sources of heterogeneity, subgroup analysis, and meta-regression for confounding variables (baricity, intrathecal opioids, lateral vs sitting position, uterine exteriorization, and study population). Sensitivity analysis was performed to test the robustness of the results. In the LD group, the need for analgesic supplementation during surgery was significantly higher [risk ratio (RR)=3.76, 95% confidence interval (95% CI)=2.38–5.92] and the number needed to treat for an additional harmful outcome (NNTH) was 4 (95% CI=2–7). Furthermore, the LD group exhibited a lower risk of hypotension (RR=0.78, 95% CI=0.65–0.93) and nausea/vomiting (RR=0.71, 95% CI=0.55–0.93). Conversion to general anaesthesia occurred only in the LD group (two events). Neonatal outcomes (Apgar score, acid–base status) and clinical quality variables (patient satisfaction, surgical conditions) showed non-significant differences between LD and CD. This meta-analysis demonstrates that low-dose bupivacaine in spinal anaesthesia compromises anaesthetic efficacy (risk of analgesic supplementation: high grade of evidence), despite the benefit of lower maternal side-effects (hypotension, nausea/vomiting: moderate grade of evidence).

Background and Objectives Unintentional dural puncture is one of the most frequent complications of the epidural technique. One previous study suggested that atypical sonoanatomy of the ligamentum flavum/dura mater unit may be a risk factor for this complication. In this study, we describe the anatomy of the lumbar spine, assessed by magnetic resonance imaging (MRI) and ultrasound, in women sustaining unintentional dural puncture during epidural catheter placement for labor analgesia. Methods We approached women who sustained a recognized unintentional dural puncture. Following consent, technical aspects of the epidural catheter placement were documented. Postpartum MRI of the lumbar spine and bedside spinal ultrasound were performed. Ultrasound images of the ligamentum flavum/dura mater unit in the transverse view were classified as typical, atypical, or inconclusive. Magnetic resonance imaging images were reviewed by a neuroradiologist, who was blinded to the level of the puncture. Results We included 10 women with unintentional dural punctures in the study. In 5 of the 10 women, these dural punctures occurred despite epidural catheter insertion by experienced practitioners. These women had a mean body mass index of 28.5 kg/m2 (range, 24–38 kg/m2). Two women suffered dural punctures twice. Ultrasound imaging in the paramedian view produced typical images in all patients. In the transverse view, 7 of 10 women showed atypical or inconclusive images, with atypical images seen at either L4/5 or L5/S1. Magnetic resonance imaging results revealed no anatomical abnormalities, with the exception of 1 woman who showed a ligamentum flavum gap away from the puncture site. Conclusions Our results suggest that unintentional dural punctures occur in likely anatomically normal women. Furthermore, the transverse ultrasound views may fail to demonstrate typical ligamentum flavum/dura mater unit at the lower lumbar levels despite its confirmed presence by MRI.

The radiological intercristal line (Tuffier's line) usually intersects the spine at the L4-L5 interspace. The intercristal line determined by palpation may be used erroneously as a surrogate for the true radiological Tuffier's line. We studied term pregnant women to establish the level at which a transverse line connecting the superior aspects of the iliac crests, as determined by palpation, intersects the lumbar spine, as assessed by ultrasound.Term pregnant women were recruited, with the exception of those with scoliosis or previous spinal surgery. With the subjects in the sitting position, the attending anesthesiologist palpated and marked the superior aspects of the iliac crests bilaterally. One of the investigators, blinded to the markings, performed a lumbar spine ultrasound scan to identify the lumbar interspaces. Each interspace was marked on the patient's back. The bilateral markings were then revealed, and a line connecting them was drawn on the patient's back. This line and the markings of the interspace levels were plotted on a transparent sheet.Forty-five women were studied. The palpated intercristal line was located above the L4-L5 interspace in all of the women. The median level of intersection was immediately below the L2-L3 interspace, with a range from immediately above L1-L2 to immediately above L4-L5. There was a low positive correlation between the level of intersection and the body mass index (r = 0.32; P = 0.03).In pregnant women at term, the intercristal line determined by palpation does not correspond to the Tuffier's line determined radiologically, and it may intersect the spine at up to three interspaces higher.

Ultrasound assessment of the lumbar spine to facilitate neuraxial anesthesia has recently received much attention. The transfer of knowledge pertaining to this skill has never been studied. The purpose of this study was to determine the amount of teaching needed to achieve competence in spinal ultrasound.Participants were given reading material and a link to a video presentation on spinal ultrasound. As well, they attended a 45-min lecture followed by a 30-min hands-on workshop. They were then assessed individually 1-2 weeks later. The assessment was performed on a live model using a low frequency curved ultrasound probe (2-5 mHz). Participants were asked to determine, at random lumbar spinal levels, the optimal insertion point and the depth to the ligamentum flavum-dura mater unit (up to 20 trials, 2 min per trial). Feedback was provided by an expert for each incorrect task. The learning curves were constructed, using the cumulative sum method, by comparing the participants' results with those of a benchmark established by experts. Statistical analysis was performed using STATA 9.2 for Macintosh (College Station, TX, USA).A total of 308 anesthesiologists were approached and 18 anesthesiologists participated in the study. Only five of the 18 participants (27%) achieved competence in determining the interspace, with a median number of 11 attempts (range 8-18). None of the participants achieved competence in determining either the insertion point or the depth to the ligamentum flavum-dura mater unit.Under the study conditions, 20 supervised trials plus teaching sessions were not enough for the participants to achieve competence in different aspects of ultrasound assessment of the lumbar spine. These results may well be considered when planning teaching sessions and workshops in the future.