Improving obstetric anesthesia training in developing countries

Obstetric anesthesia refers to peripartum anesthesia and analgesia care provided during antenatal period, labor, vaginal delivery, cesarean sections, removal of retained placenta, morbidly adherent placenta, antepartum and postpartum hemorrhage and postpartum tubal ligation. In wide perspective, obstetric anesthesia also includes neonatal resuscitation, caring of the parturient with systemic disease, and obstetrical intensive care management. Specialized training is mandatory to reduce maternal and neonatal mortality and morbidity, especially we need to have structured emergency obstetric care training in developing countries. Local associations and societies need to join hands with national and international associations to launch specific training in this neglected field

Hazards and limitation of perioperative transfusion: need to adopt blood transfusion guidelines

Blood transfusion is an important component of perioperative management of patients and in many instances can be lifesaving. Anesthesiologists are an important member of the multidisciplinary team involved regularly in requesting and administering blood components to the patients. Therefore, it is essential that anesthesiologists are familiar with indications and appropriate use of blood components and also with limitation and adverse effects associated with its use. Numbers of international guidelines regarding transfusion are available; however, these guidelines require local translation into policies, protocols and practice in order to deliver care to the patient. Institutions need to identify their local barriers and resources available and consult from the evidence based international guidelines to develop their own guidelines on blood transfusion. However, it must be remembered that it is a multidisciplinary engagement involving blood bank, laboratory, operating room and clinical staff; therefore, it is a challenging task which demands coordinated team work to translate guidelines into safe patient care

Placenta accreta: anesthetic management and resuscitation strategies

Placenta accreta [PA] is the term used to describe the clinical condition of abnormal adherence of the entire or a part of the placenta to the uterine wall. Management of PA begins with the identification of high-risk patients with adequate screening. These patients need to be referred to the specialized centre, where a multidisciplinary team is formed and management plan is formulated. This involves patient's counselling with the possibility of hysterectomy, blood transfusion, ICU admission, postoperative ventilation and maternal and foetal risk of mortality. Arrangement of blood products, technique of anesthesia and the use of central venous line depends on the severity of the case. The presence of blood products in the operating room, pre-induction institution of A- line and two large bore cannulas and the use of rapid infusion set are recommended. In cases of massive haemorrhage in patients with PA, it is advisable to limit the use of crystalloids and colloids, and institute the damage control resuscitation by transfusing one unit of RBC along with one unit each of FFP and platelets

Medical errors related to look-alike and sound-alike drugs

Despite recent developments in the inventory management, introduction of electronic drug trolleys and cabinets, color coding of the filled syringes and many more interventions, medication errors could not be eliminated. The most common of these are syringe swap and human errors regarding wrong drug administration due to look-alike drug containers or sound-alike names of the drugs belonging to diverse groups. Many of the fatalities, that occur in third world countries due to these causes, go unnoticed and unregistered. This special article complements two special editorials on the same topic by Professor Joseph D. Tobias et al and Professor Robert Stoelting, a case report, a patient's perspective and a 'Cliniquiz' being published in the current issue of the journal. It discusses salient features of this issue as well as preventive measures and recommendations

What is new in postoperative analgesia after caesarean sections?

The rate of Caesarean sections is on an increase and with it an increased awareness among the mothers to remain pain free during and after the surgery. This has put anesthesiologists to explore possibilities and options other than the routine methods of surgical analgesia. The cons and pros of using opioids, NSAID's, nerve blocks and regional techniques, all have been scrutinized and the associated disadvantages and side effects discussed

General Anaesthesia for emergency caesarian section in a patient with Eisenmenger's Syndrome and Pre-eclampsia

Pregnancy is poorly tolerated in patients with Eisenmenger syndrome [ES] with maternal mortality of 30-50%. Physiological changes of pregnancy decreases systemic vascular resistance that further aggravates the bi-directional or right to left shunt associated with ES. When it occurs with eclampsia, the morbidity and mortality are even higher. We report a case of 30 weeks pregnant woman with ES, who underwent emergency caesarian section because of pre-eclampsia. The intra-operative course was uneventful but she died on the second post-operative day. Post-operatively she was managed by the cardiologist in the coronary care unit. The probable cause being that she was over transfused, as the fluid status was not assessed by any invasive monitoring [like CVP]. It was concluded that patients should be monitored closely in the post-operative period in the intensive care unit with complete invasive monitoring for up to a week to prevent factors resulting in worsening of the shunt [such as fluid balance] and thromboembolic phenomenon