Rocuronium 0.3 or 0.9 mg/kg comparing onset time, duration of action, and intubating conditions in patients 80 years and older: A randomized study.

BACKGROUND: Limited data exist about the optimal dose of rocuronium for intubation in elderly patients. We hypothesized that rocuronium 0.9 mg/kg would lead to a shorter onset time than 0.3 mg/kg in patients above 80 years. METHODS: Thirty-four patients were randomized to either rocuronium 0.3 or 0.9 mg/kg. The primary outcome was onset time defined as time to train-of-four (TOF) count of 0. Other outcomes included duration of action (time to TOF ratio >0.9), proportion of excellent intubating conditions using the Fuchs-Buder scale and tracheal intubating conditions using the Intubating Difficulty Scale (IDS). RESULTS: Rocuronium 0.9 mg/kg resulted in shorter onset time compared to rocuronium 0.3 mg/kg; 108 s (SD 40) vs. 228 s (SD 140) (difference: 119 s [95% CI: 41-196], p = .005), respectively. However, in 66% of the patients receiving rocuronium 0.3 mg/kg a TOF count of 0 was not obtained. Duration of action was longer after rocuronium 0.9 mg/kg: 118 min (SD 43) vs. 46 min (SD 13) (difference: 72 min [95% CI: 49-95] p < .0001), and a greater proportion of excellent intubating conditions (Fuchs-Buder) was obtained; 11/16 (69%) vs 4/18 (22%) (p = .006). No difference was found regarding IDS score. CONCLUSION: Rocuronium 0.9 mg/kg resulted in a shorter onset time compared to rocuronium 0.3 mg/kg in patients above 80 years of age. In 66% of the patients receiving rocuronium 0.3 mg/kg a TOF count of 0 was not obtained.

The role of central serotonergic markers and estradiol changes in perinatal mental health.

OBJECTIVE: Women have an increased risk for mental distress and depressive symptoms in relation to pregnancy and birth. The serotonin transporter (SERT) may be involved in the emergence of depressive symptoms postpartum and during other sex-hormone transitions. It may be associated with cerebrospinal fluid (CSF) levels of the main serotonin metabolite 5-hydroxyindolacetic acid (5-HIAA). In 100 healthy pregnant women, who were scheduled to deliver by cesarean section (C-section), we evaluated 5-HIAA and estradiol contributions to mental distress 5 weeks postpartum. METHODS: Eighty-two women completed the study. CSF collected at C-section was analyzed for 5-HIAA, with high performance liquid chromatography. Serum estradiol concentrations were quantified by liquid chromatography tandem mass spectrometry before C-section and postpartum. Postpartum mental distress was evaluated with the Edinburgh Postnatal Depression Scale (EPDS). Associations between EPDS, 5-HIAA, and Δestradiol were evaluated in linear regression models adjusted for age, parity and SERT genotype. RESULTS: Higher levels of postpartum mental distress symptoms were negatively associated with a large decrease in estradiol concentrations (ßΔE2  = 0.73, p = 0.007) and, on a trend level, positively associated with high antepartum 5-HIAA levels (ß5-HIAA  = 0.002, p = 0.06). CONCLUSION: In a cohort of healthy pregnant women, postpartum mental distress was higher in women with high antepartum 5-HIAA (trend) and lower in women with a large perinatal estradiol decrease. We speculate that high antepartum 5-HIAA is a proxy of SERT levels, that carry over to the postpartum period and convey susceptibility to mental distress. In healthy women, the postpartum return to lower estradiol concentrations may promote mental well-being.

[Delivery and analgesia of labouring women with congenital spine abnormalities].

Congenital spine abnormalities are common. These anomalies can be associated with other anomalies and different degrees of symptom severity. In pregnant women multidisciplinary planning and considerations of special needs may be necessary as summarised in this review. Recommendation for caesarean section should, for most parts, be made on obstetric indication only. Neuroaxial analgesia during birth and anaesthesia for caesarean section is seldom contraindicated in women with back abnormalities. However, in tethered cord, it is important to avoid iatrogenic damage to the conus when placing spinal anaesthesia.

Onset time and duration of action of rocuronium 0.6 mg/kg in patients above 80 years of age: A comparison with young adults.

BACKGROUND: The number of elderly is increasing, and a large proportion of these people will require surgery and anaesthesia. However, little data exist regarding rocuronium in patients above 80 years of age. The aim of this study was to determine the onset time and duration of action for rocuronium 0.6 mg/kg in patients above 80 years compared with young adults. METHODS: This prospective observational study included 16 young (18-40 years) and 16 elderly (>80 years) patients scheduled for total intravenous anaesthesia. Neuromuscular block following rocuronium 0.6 mg/kg was monitored with acceleromyography using train-of-four (TOF) stimulation. The primary outcome was onset time (from administration of rocuronium until TOF count = 0). Secondary outcomes were duration of action (from administration to TOF ratio >0.9) and intubating conditions according to Intubation Difficulty Score. RESULTS: Elderly patients, median age of 84 years, had significantly prolonged onset time compared to younger patients; median 135 seconds (135-158) vs 90 seconds (90-105), respectively, a mean difference of 82 seconds (40-124) and Wilcoxon Mann-Whitney odds (WMW) of 19.48 (7.48-X). Duration of action in elderly patients was significantly longer, with a median time of 81 minute (71-97) vs 53 minute (42-73), respectively, a mean difference of 31 minute (14-48), and WMW odds of 6.35 (2.59-X). There was no significant difference in intubating conditions. CONCLUSIONS: Patients above 80 years had significantly prolonged onset time and duration of action after rocuronium 0.6 mg/kg compared with patients aged 18-40 years.

ERS/TSANZ Task Force Statement on the management of reproduction and pregnancy in women with airways diseases.

This European Respiratory Society/Thoracic Society of Australia and New Zealand statement outlines a review of the literature and expert opinion concerning the management of reproduction and pregnancy in women with airways diseases: asthma, cystic fibrosis (CF) and non-CF bronchiectasis. Many women with these diseases are now living into reproductive age, with some developing moderate-to-severe impairment of lung function in early adulthood. The statement covers aspects of fertility, management during pregnancy, effects of drugs, issues during delivery and the post-partum period, and patients' views about family planning, pregnancy and parenthood. The statement summarises current knowledge and proposes topics for future research, but does not make specific clinical recommendations.

[Advanced labour pain relief].

Delivery and labour pain is normally the most painful event in a woman's lifetime. Physical and psychological factors may influence the severity of labour pain, and labour pain relief is an important issue for the obstetric anaesthetist. We describe the current most effective pharmacological techniques used for labour analgesia: systemically with remifentanil and regionally with epidural analgesia.

[Sectio and Brugada syndrome].

Brugada syndrome (BS) is an inherited cardiac disease with increased risk of ventricular tachyarrythmias, cardiac arrest and sudden death. BS is diagnosed on various criteria including specific electrocardiographic abnormalities in a structurally normal heart. Many drugs have been reported to induce fatal arrhythmias in patients with BS and in particular sodium channel blockers i.e. local anaesthetics such as bupivacaine. We report the anaesthetic management of two women with BS during caesarean section and provide a general discussion on the use of bupivacain for neuraxial blockade for patients with BS.

Hemostatic resuscitation in postpartum hemorrhage - a supplement to surgery.

BACKGROUND: Postpartum hemorrhage is a potentially life-threatening albeit preventable condition that persists as a leading cause of maternal death. Identification of safe and cost-effective hemostatic treatment options remains crucial as a supplement to surgery and uterotonic agents. OBJECTIVE: This review summarizes the background, current evidence and recommendations with regard to the role of fibrinogen, tranexamic acid, prothrombin complex concentrate, desmopressin, and recombinant factor VIIa in the treatment of patients with postpartum hemorrhage. The benefits and evidence behind traditional standard laboratory tests and viscoelastic hemostatic assays, i.e. thromboelastography TEG(®) and thromboelastometry ROTEM(®) , are discussed. In addition we assess and elaborate on the current paradigm and evidence for transfusion of these patients. DATA SOURCES: Publications between 1994 and 2014 were identified from PubMed, EMBASE, Cochrane Library databases, and ClinicalTrial.gov. RESULTS: Viscoelastic hemostatic assays were found to provide a real-time continuum of coagulation and fibrinolysis when introduced as a supplement in transfusion management of postpartum hemorrhage. Fibrinogen should be considered when hypofibrinogenemia is identified. Early administration of 1-2 g tranexamic acid is recommended, followed by an additional dose in cases of ongoing bleeding. Uncontrolled hemorrhage requires early balanced transfusion. CONCLUSION: Despite the lack of conclusive evidence for optimal hemostatic resuscitation in postpartum hemorrhage, the use of viscoelastic hemostatic assays, fibrinogen, tranexamic acid and balanced transfusion therapy may prove to be potentially pivotal in the treatment of postpartum hemorrhage.

'In situ simulation' versus 'off site simulation' in obstetric emergencies and their effect on knowledge, safety attitudes, team performance, stress, and motivation: study protocol for a randomized controlled trial.

BACKGROUND: Unexpected obstetric emergencies threaten the safety of pregnant women. As emergencies are rare, they are difficult to learn. Therefore, simulation-based medical education (SBME) seems relevant. In non-systematic reviews on SBME, medical simulation has been suggested to be associated with improved learner outcomes. However, many questions on how SBME can be optimized remain unanswered. One unresolved issue is how 'in situ simulation' (ISS) versus 'off site simulation' (OSS) impact learning. ISS means simulation-based training in the actual patient care unit (in other words, the labor room and operating room). OSS means training in facilities away from the actual patient care unit, either at a simulation centre or in hospital rooms that have been set up for this purpose. METHODS AND DESIGN: The objective of this randomized trial is to study the effect of ISS versus OSS on individual learning outcome, safety attitude, motivation, stress, and team performance amongst multi-professional obstetric-anesthesia teams.The trial is a single-centre randomized superiority trial including 100 participants. The inclusion criteria were health-care professionals employed at the department of obstetrics or anesthesia at Rigshospitalet, Copenhagen, who were working on shifts and gave written informed consent. Exclusion criteria were managers with staff responsibilities, and staff who were actively taking part in preparation of the trial. The same obstetric multi-professional training was conducted in the two simulation settings. The experimental group was exposed to training in the ISS setting, and the control group in the OSS setting. The primary outcome is the individual score on a knowledge test. Exploratory outcomes are individual scores on a safety attitudes questionnaire, a stress inventory, salivary cortisol levels, an intrinsic motivation inventory, results from a questionnaire evaluating perceptions of the simulation and suggested changes needed in the organization, a team-based score on video-assessed team performance and on selected clinical performance. DISCUSSION: The perspective is to provide new knowledge on contextual effects of different simulation settings. TRIAL REGISTRATION: ClincialTrials.gov NCT01792674.

Balloon occlusion of the internal iliac arteries in the multidisciplinary management of placenta percreta.

OBJECTIVE: To evaluate our experience with prophylactic balloon occlusion of the internal iliac arteries as a part of a multidisciplinary algorithm for the management of placenta percreta. DESIGN: Consecutive case series. Setting. Rigshospitalet, Copenhagen University Hospital, Denmark. Sample. Seventeen women with placenta percreta. METHODS: Demographic characteristics, intraoperative data and outcomes are summarized and discussed. MAIN OUTCOME MEASURES: Feasibility of local resection, intraoperative blood loss and transfusion requirements. RESULTS: The multidisciplinary management allowed for local resections in nine of the 11 women who requested preservation of fertility. The mean intraoperative blood loss was 4050 mL (range 450-16 000 mL, median 2500 mL). Adhesions to the bladder or the parietal peritoneum were associated with an intraoperative blood loss >6000 mL. CONCLUSIONS: Prophylactic balloon occlusion of the internal iliac arteries as part of a multidisciplinary algorithm allowed for a safe management of all cases in our consecutive series of 17 women with placenta percreta. However, intraoperative blood loss and transfusion requirements were significant. We have therefore decided to modify our multidisciplinary algorithm to include balloon occlusion of the common iliac arteries rather than the internal iliac arteries.

The FIB-PPH trial: fibrinogen concentrate as initial treatment for postpartum haemorrhage: study protocol for a randomised controlled trial.

BACKGROUND: Postpartum haemorrhage (PPH) remains a leading cause of maternal mortality worldwide. In Denmark 2% of parturients receive blood transfusion. During the course of bleeding fibrinogen (coagulation factor I) may be depleted and fall to critically low levels, impairing haemostasis and thus worsening the ongoing bleeding. A plasma level of fibrinogen below 2 g/L in the early phase of postpartum haemorrhage is associated with subsequent development of severe haemorrhage. Use of fibrinogen concentrate allows high-dose substitution without the need for blood type crossmatch. So far no publications of randomised controlled trials involving acutely bleeding patients in the obstetrical setting have been published. This trial aims to investigate if early treatment with fibrinogen concentrate reduces the need for blood transfusion in women suffering severe PPH. METHODS/DESIGN: In this randomised placebo-controlled double-blind multicentre trial, parturients with primary PPH are eligible following vaginal delivery in case of: manual removal of placenta (blood loss ≥ 500 ml) or manual exploration of the uterus after the birth of placenta (blood loss ≥ 1000 ml). Caesarean sections are also eligible in case of perioperative blood loss ≥ 1000 ml. The exclusion criteria are known inherited haemostatic deficiencies, prepartum treatment with antithrombotics, pre-pregnancy weight <45 kg or refusal to receive blood transfusion. Following informed consent, patients are randomly allocated to either early treatment with 2 g fibrinogen concentrate or 100 ml isotonic saline (placebo). Haemostatic monitoring with standard laboratory coagulation tests and thromboelastography (TEG, functional fibrinogen and Rapid TEG) is performed during the initial 24 hours.Primary outcome is the need for blood transfusion. To investigate a 33% reduction in the need for blood transfusion, a total of 245 patients will be included. Four university-affiliated public tertiary care hospitals will include patients during a two-year period. Adverse events including thrombosis are assessed in accordance with International Conference on Harmonisation (ICH) good clinical practice (GCP). DISCUSSION: A widespread belief in the benefits of early fibrinogen substitution in cases of PPH has led to increased off-label use. The FIB-PPH trial is investigator-initiated and aims to provide an evidence-based platform for the recommendations of the early use of fibrinogen concentrate in PPH. TRIAL REGISTRATION: ClincialTrials.gov NCT01359878.

[Most anaesthetics can be used without damaging effects of the breastfed child]. / De fleste anæstesimidler kan bruges uden skadelig påvirkning af barnet ved amning.

Breastfeeding women who undergo general anaesthesia often receive conflicting recommendations regarding the need to discard their milk before resumption of breastfeeding. This narrative review describes the sparse evidence to support the current practice of discarding milk as advocated by many physicians. However, individual drugs such as diazepam, morphine, codeine and pethidine should be avoided when possible and otherwise only be administered as single doses with observation of the child. There is an urgent need for high-quality research before sufficient light can be shed on this topic.

[Treatment of placenta percreta requires a multidisciplinary approach]. / Behandling af placenta percreta kræver involvering af flere specialer.

Placenta percreta is a rare life-threatening obstetrical condition, often resulting in severe haemorrhage and hysterectomy. The incidence seems to be increasing, probably secondary to the increase in caesarean section rates. We present a protocol for an elective multidisciplinary approach with proactive management to reduce haemorrhage and allow appropriate surgery, which imply a low maternal and fetal morbidity as well as maintained fertility.