Neuraxial morphine after unintentional dural puncture is not associated with reduced postdural puncture headache in obstetric patients.

STUDY OBJECTIVE: To examine the relationship between neuraxial morphine exposure after unintentional dural puncture and the risk for postdural puncture headache in obstetric patients. DESIGN: Retrospective cohort study. SETTING: Obstetrical unit at a tertiary care referral center. PATIENTS: Parturients receiving labor epidural analgesia with recognized unintentional dural puncture. INTERVENTIONS: Cases in which neuraxial morphine was given for any reason were compared to cases in which it was not for the outcome of postdural puncture headache. MEASUREMENTS: Development of postdural puncture headache, headache severity, number of epidural blood patches, hospital length of stay. MAIN RESULTS: Of the 80 cases that were included, 38 women received neuraxial morphine and 42 did not. There was no significant difference in the incidence of headache between the two morphine groups (Headache present: Morphine: 27/56 [48.2%], No morphine: 29/56 [51.8%]; Headache free: Morphine: 11/24 [45.8%], No morphine: 13/24 [54.2%], P = 0.84). There was no difference in the need for epidural blood patch (Morphine: 24/42 [57.1%], No morphine: 18/38 [47.4%], P = 0.50) and headache severity (mean headache pain score: Morphine: 7.9 ±â€¯1.8 vs. No morphine: 7.3 ±â€¯2.4, P = 0.58). Hospital length of stay was higher in the morphine group (4.4 ±â€¯2.9 days vs. 3.0 ±â€¯1.5 days respectively, P = 0.008). Using logistic regression, morphine did not affect headache risk after controlling for covariates (morphine vs. no morphine: adjusted OR 1.24 [0.75]; P = 0.72; pre-eclampsia vs. no pre-eclampsia: adjusted OR 0.56 [0.41], P = 0.42; cesarean vs. normal spontaneous vaginal delivery: adjusted OR 0.97 [0.67]; P = 0.96). CONCLUSION: In cases of unintentional dural puncture, exposure to neuraxial morphine for any reason may not be protective against the risk of postdural puncture headache. Although an overall protective effect of neuraxial morphine was not observed in this study, its role in specific subsets of patients remains to be investigated.

Crisis Teams for Obstetric Patients.

An obstetric-specific crisis team allows institutions to optimize the care response for patients with emergent maternal or fetal needs. Characteristics of optimal obstetric rapid response teams are team member role designations; streamlined communication; prompt access to resources; ongoing education, rehearsal, and training; and continual team quality analysis. The outcomes must be incorporated into team responses and reinforced in training. Team response provides a key resource to reassure staff, physicians, and patients that prompt crisis care is only a single call away. Data show that team activation is common, improves the care process, and has promise to improve outcomes.

Cell salvage for postpartum haemorrhage during vaginal delivery: a case series.

BACKGROUND: The safety and effectiveness of cell salvage for vaginal delivery is unknown. This case series aimed to assess the utility and adverse events related to the use of cell salvage for maternal haemorrhage during vaginal delivery. MATERIALS AND METHODS: A cohort study design was chosen, focused on postpartum haemorrhages that occurred after vaginal delivery for which cell salvage equipment was requested to be set up in the labour and delivery room outside of a sterile operating room environment. Variables recorded included duration of stay in hospital, occurrence of wound infections, sepsis, thromboembolic events, and amniotic fluid embolism. RESULTS: Of 28 cases of postpartum haemorrhage during vaginal deliveries involving the setup or use of cell salvage equipment, ten were associated with successful re-infusion of salvaged shed blood. These ten cases were compared to the 18 cases in which cell salvage equipment was set up, but insufficient shed blood was salvaged for re-infusion. There were no instances of postpartum sepsis, wound infection, or thromboembolism associated with the use of cell salvage for vaginal delivery. Although one case of suspected amniotic fluid embolism occurred, severe symptoms began prior to the infusion of salvaged blood. DISCUSSION: Infusion of salvaged shed blood collected from a vaginal delivery field is feasible. The outcomes of these cases do not exclude an unacceptably high risk of infection or embolic events. Trials evaluating the safety and effectiveness associated with the use of cell salvage in vaginal deliveries are justified.

A Clinical Procedures Course for Medical Students.

INTRODUCTION: Doctors perform many clinical procedures throughout their careers. It is important for students to learn these procedures in a nonthreatening environment. This clinical procedures course introduces students to several basic diagnostic and therapeutic procedures, both invasive and noninvasive. These include managing pediatric and adult airways, starting intravenous lines, inserting arterial and central lines, inserting Foley catheters and nasogastric tubes, and performing lumbar punctures and paracentesis. METHODS: Small-group teaching is used to achieve these objectives; over the course of 4 weeks, the medical students meet once a week for 4 hours. Each meeting includes teaching and demonstrations of the procedures by faculty instructors and residents. This is followed by practice of the procedures on mannequin simulators and partial task trainers by the students. Feedback is then given to the students by the instructors. RESULTS: Based on conversations during the feedback sessions, the students feel that the materials used in the course are helpful in learning these clinical procedures. DISCUSSION: The medical students feel that the course familiarizes them with clinical procedures they may be asked to perform on patients during their clinical rotations and postgraduate training.

Transdermal scopolamine patch in addition to ondansetron for postoperative nausea and vomiting prophylaxis in patients undergoing ambulatory cosmetic surgery.

STUDY OBJECTIVE: To determine the efficacy of transdermal scopolamine in addition to ondansetron in decreasing the incidence of postoperative nausea and vomiting (PONV). DESIGN: Randomized controlled trial. SETTING: Academic hospital. PATIENTS: 126 ASA physical status I and II patients undergoing outpatient plastic surgery with three or more risk factors for PONV. INTERVENTIONS: Patients were randomly assigned to one of two groups to receive (Group 1) a transdermal scopolamine (TDS) patch or (Group 2), a placebo patch two hours before surgery. MEASUREMENTS: Occurrence of vomiting, severity of nausea using a visual analog scale (VAS), rescue medication, pain intensity and pain medications, and side effects were recorded every hour until discharge from hospital, then every 4 hours thereafter for a total of 24 hours. MAIN RESULTS: A statistically significant reduction in postoperative nausea between 8 and 24 hours in patients receiving TDS was noted. CONCLUSIONS: Transdermal scopolamine in addition to ondansetron benefits patients at high risk for PONV undergoing outpatient plastic surgery for up to 20 hours after surgery.

Eliminating postoperative nausea and vomiting in outpatient surgery with multimodal strategies including low doses of nonsedating, off-patent antiemetics: is "zero tolerance" achievable?

For ondansetron, dexamethasone, and droperidol (when used for prophylaxis), each is estimated to reduce risk of postoperative nausea and/or vomiting (PONV) by approximately 25%. Current consensus guidelines denote that patients with 0-1 risk factors still have a 10-20% risk of encountering PONV, but do not yet advocate routine prophylaxis for all patients with 10-20% risk. In ambulatory surgery, however, multimodal prophylaxis has gained favor, and our previously published experience with routine prophylaxis has yielded PONV rates below 10%. We now propose a "zero-tolerance" antiemetic algorithm for outpatients that involves routine prophylaxis by first avoiding volatile agents and opioids to the extent possible, using locoregional anesthesia, multimodal analgesia, and low doses of three nonsedating off-patent antiemetics. Routine oral administration (immediately on arrival to the ambulatory surgery suite) of perphenazine 8 mg (antidopaminergic) or cyclizine 50 mg (antihistamine), is followed by dexamethasone 4 mg i.v. after anesthesia induction (dexamethasone is avoided in diabetic patients). At the end of surgery, ondansetron (4 mg i.v., now off-patent) is added. Rescue therapy consists of avoiding unnecessary repeat doses of drugs acting by the same mechanism: haloperidol 2 mg i.v. (antidopaminergic) is prescribed for patients pretreated with cyclizine or promethazine 6.25 mg i.v. (antihistamine) for patients having been pretreated with perphenazine. If available, a consultation for therapeutic acupuncture procedure is ordered. Our approach toward "zero tolerance" of PONV emphasizes liberal identification of and prophylaxis against common risks.

Plasma and saliva substance P levels: the effects of acute pain in pregnant and non-pregnant women.

Substance P like immunoreactivity (SPLI) and total protein (TP) concentrations in plasma and saliva were measured in 80 healthy female patients divided into the following four groups: women in group 1 were not pregnant and they were awaiting tubal ligation; women in group 2 were not pregnant but they experienced acute postoperative pain following hysterectomy; women in group 3 were pregnant and were awaiting elective cesarean section; and women in group 4 were in active labor and experienced acute labor pain. Pain intensity was assessed using verbal Likert pain scores. The absolute measured concentration of SPLI (SPLIabs) was divided by the TP concentration to obtain corrected SPLI (SPLIcorr) concentration. Results were expressed mean +/- 1 SE and analyzed using analysis of variance with 95% confidence (P < 0.05). SPLIcorr concentrations were 1.8 +/- 0.1, 1.8 +/- 0.2, 1.1 +/- 0.1 1.1 +/- 0.1 pg/mg protein in groups 1, 2, 3 and 4, respectively. Patients in both pregnant groups had significantly lower plasma SPLIcorr concentrations compared to the non-pregnant groups. However, the presence of acute postoperative pain or labor pain did not significantly alter plasma SPLIcorr concentrations. Saliva SPLI concentrations were not significantly different among the four groups.