What Should an Anesthesiologist and Surgeon Do When They Disagree About Terms of Perioperative DNR Suspension?

This case examines perioperative suspension of a do-not-resuscitate (DNR) order during surgery. The commentary considers the appropriateness of DNR orders; types of DNR order suspension in the context of alternative anesthesia techniques; and what is required from a surgeon, anesthesiologist, and patient or surrogate to reach a decision expressing the patient's best interest. It concludes by offering communication recommendations based on joint discussion and decision sharing.

The effect of second-stage pushing and body mass index on postdural puncture headache.

STUDY OBJECTIVE: To explore how pushing during labor and body mass index affect the development of postdural puncture headache in parturients who experienced dural puncture with Tuohy needles. DESIGN: Retrospective cohort. SETTING: Obstetric ward and operating rooms at a university-affiliated hospital. PATIENTS: One hundred ninety parturients who had witnessed dural puncture with 17 or 18 gauge Tuohy needles from 1999-2014. INTERVENTIONS: Patients were categorized by pushing status and body mass index (kg/m2): nonobese <30, obese 30-39.99, morbidly obese 40-49.99, and super obese ≥50. MEASUREMENTS: Headache, number of days of headache, maximum headache score, and epidural blood patch placement. MAIN RESULTS: Compared with women who did not push, women who pushed during labor had increased risk of postdural puncture headache (odds ratio [OR], 2.1 [1.1-4.0]; P=.02), more days of headache (P=.02), and increased epidural blood patch placement (P=.02). Super obese patients were less likely to develop headache compared with nonobese (OR, 0.33 [0.13-0.85]; P=.02), obese (OR, 0.37 [0.14-0.98]; P=.045], and morbidly obese patients (OR, 0.20 [0.05-0.68]; P<.01). In a multivariate logistic regression model, lack of pushing (OR, 0.57 [0.29-1.10]; P=.096) and super obesity (OR, 0.41 [0.16-1.02]; P=.056] were no longer significantly associated with reduced risk of postdural puncture headache. CONCLUSIONS: Parturients who did not push before delivery and parturients with body mass index ≥50kg/m2 were less likely to develop postdural puncture headache in a univariate analysis. Similar trends were demonstrated in a multivariate model, but were no longer statistically significant.

Failure rate and complications associated with the use of spinal catheters for the management of inadvertent dural puncture in the parturient: a retrospective comparison with re-sited epidural catheters.

Objective To report on the failure rate of spinal catheters placed following inadvertent dural puncture (IDP) compared with re-sited epidural catheters in the obstetric population. Research design and methods Patients who experienced IDP during epidural or combined spinal epidural placement with 17 or 18 gauge Tuohy needles for labor analgesia between 2003 and 2014 were identified using our post-dural puncture headache (PDPH) database. Patients were categorized into two groups: those who had spinal catheters inserted and those who had epidural catheters re-sited. Main outcome measure Failure rate associated with spinal or re-sited epidural catheters (defined as need for repeat block or alternative analgesic modality). Secondary outcomes were incidence of PDPH, need for epidural blood patch (EBP), and adverse events. Results A total of 109 patients were included in the final analysis; 79 ultimately had spinal catheters and 30 ultimately had re-sited epidural catheters. There were no differences between spinal catheters and re-sited epidural catheters in failure rate (22% vs. 13%, P = 0.33), incidence of PDPH (73% vs. 60%, P = 0.24), need for EBP (42% vs. 30%, P = 0.28), number of headache days, or maximum headache scores. There was also no difference in the rate of adverse events including high block levels, hypotension, and fetal bradycardia (9% vs. 7%, P = 1.0) between the two groups. Conclusions There were no differences in failure rates, PDPH outcomes, or adverse events between spinal catheters and re-sited epidural catheters following IDP in parturients receiving labor analgesia. Limitations of the study include its single-center retrospective non-randomized design, and the uneven number of patients in the two groups with a relatively small number in the re-sited epidural catheter group.