Effect of Dural-Puncture Epidural vs Standard Epidural for Epidural Extension on Onset Time of Surgical Anesthesia in Elective Cesarean Delivery: A Randomized Clinical Trial.

Importance: Dural-puncture epidural (DPE) and standard epidural are common modes of neuraxial labor analgesia. Little is known about conversion of DPE-initiated labor analgesia to surgical anesthesia for cesarean delivery. Objective: To determine whether DPE provides a faster onset and better-quality block compared with the standard epidural technique for cesarean delivery. Design, Setting, and Participants: This double-blind, randomized clinical trial was conducted between April 2019 and October 2022 at a tertiary care university hospital (University of Arkansas for Medical Sciences). Participants included women aged 18 years and older undergoing scheduled cesarean delivery with a singleton pregnancy. Interventions: Participants were randomized to receive DPE or standard epidural in the labor and delivery room. A T10 sensory block was achieved and maintained using a low concentration of bupivacaine with fentanyl through the epidural catheter until the time of surgery. Epidural extension anesthesia was initiated in the operating room. Main Outcomes and Measures: The primary outcome was the time taken from chloroprocaine administration to surgical anesthesia (T6 sensory block). The secondary outcome was the quality of epidural anesthesia, as defined by a composite of the following factors: (1) failure to achieve a T10 bilateral block preoperatively in the delivery room, (2) failure to achieve a surgical block at T6 within 15 minutes of chloroprocaine administration, (3) requirement for intraoperative analgesia, (4) repeat neuraxial procedure, and (5) conversion to general anesthesia. Results: Among 140 women (mean [SD] age, 30.1 [5.2] years), 70 were randomized to the DPE group, and 70 were randomized to the standard epidural group. The DPE group had a faster onset time to surgical anesthesia compared with the standard epidural group (median [IQR], 422 [290-546] seconds vs 655 [437-926] seconds; median [IQR] difference, 233 [104-369] seconds). The composite rates of lower quality anesthesia were 15.7% (11 of 70 women) in the DPE group and 36.3% (24 of 66 women) in the standard epidural group (odds ratio, 0.33; 95% CI, 0.14-0.74; P = .007). Conclusions and Relevance: Anesthesia initiated following a DPE technique resulted in faster onset and improved block quality during epidural extension compared with initiation with a standard epidural technique. Further studies are needed to confirm these findings in the setting of intrapartum cesarean delivery. Trial Registration: ClinicalTrials.gov Identifier: NCT03915574.

Optimizing systems to manage postpartum hemorrhage.

Systems to optimize the management of postpartum hemorrhage must ensure timely diagnosis, rapid hemodynamic and hemostatic resuscitation, and prompt interventions to control the source of bleeding. None of these objectives can be effectively completed by a single clinician, and the management of postpartum hemorrhage requires a carefully coordinated interprofessional team. This article reviews systems designed to standardize hemorrhage diagnosis and response.

Workforce solutions to address health disparities.

PURPOSE OF REVIEW: This review focuses on physician workforce racial & ethnic diversity as a solution to improve perioperative and peripartum health equity. RECENT FINDINGS: Black, Indigenous, and Hispanic physicians remain underrepresented in medicine (URiM) and anesthesiology, and efforts to expand this workforce have had limited impact. Psychological forces, including implicit bias, aversive racism, outgroup bias, racial attention bias, stereotype threat, and imposter syndrome all act to reinforce structural racism and decrease opportunity for advancement. Evidence based solutions are emerging, but require institutional commitment and widespread engagement of the entire medical community. SUMMARY: Academic medicine has recognized the need to diversify the physician workforce for more than 50 years, and yet Black, Indigenous, and Hispanic physicians remain URiM. Foundational assumptions and power structures in medicine limit entry, advancement, and retention of URiM physicians. Solutions require leadership and institutional commitment to change the policies, procedures, priorities, and culture of academic medicine.

ED 90 of Intrathecal Chloroprocaine With Fentanyl for Prophylactic Cervical Cerclage: A Sequential Allocation Biased-Coin Design.

BACKGROUND: Chloroprocaine is a short-acting local anesthetic that has been used for spinal anesthesia in outpatient surgery. There is limited experience with spinal chloroprocaine for prophylactic cervical cerclage placement. We sought to determine the effective dose of intrathecal chloroprocaine for 90% of patients (ED90) undergoing prophylactic cervical cerclage placement. We hypothesized that the ED90 of intrathecal chloroprocaine when combined with 10-ug fentanyl would be between 33 and 54 mg. METHODS: In this prospective 2-center double-blinded study, we enrolled women undergoing prophylactic cervical cerclage placement under combined spinal-epidural anesthesia. A predetermined dose of intrathecal 3% chloroprocaine with fentanyl 10 ug was administered. The initial dose was 45-mg intrathecal chloroprocaine. Subsequent dose adjustments were determined based on the response of the previous subject using an up-down sequential allocation with a biased-coin design. A dose was considered effective if at least a T12 block was achieved, and there was no requirement for epidural activation or intraoperative analgesic supplementation during the procedure. The primary outcome was the ED90 of intrathecal chloroprocaine with fentanyl 10 ug. Secondary outcomes included duration of surgery, anesthetic side effects, time to resolution of motor and sensory block, time to achieve recovery room discharge criteria, and patient satisfaction with anesthetic care. Isotonic regression was used to estimate the ED90. RESULTS: Forty-seven patients were enrolled into the study. Two patients were excluded (1 protocol violation and 1 failed block). In total, 45 patients completed the study. The estimated ED90 (95% confidence interval) for intrathecal chloroprocaine combined with fentanyl 10 ug was 49.5 mg (45.0-50.1 mg). The median (interquartile range [IQR]) duration of surgery was 15 (10-24) minutes. Resolution of the motor (Bromage 0) and sensory block took a median time of 60 (45-90) minutes and 90 (75-105) minutes, respectively. The median time to achieve recovery room discharge criteria was 150 (139-186) minutes. Satisfaction with anesthetic management was high in all patients. There were no reports of postdural puncture headache or transient neurological symptoms postoperatively. CONCLUSIONS: The ED90 of intrathecal chloroprocaine combined with fentanyl 10 ug was 49.5 mg. Intrathecal chloroprocaine was associated with rapid block recovery and high patient satisfaction, which makes it well suited for outpatient obstetric procedures.

Factors associated with non-survival from in-hospital maternal cardiac arrest: An analysis of Get With The Guidelines® (GWTG) data.

INTRODUCTION: Maternal mortality has risen in the United States during the 21st century. Factors influencing outcome of maternal cardiac arrest (MCA) remain largely unexplored. OBJECTIVE: We sought to further elucidate the factors affecting maternal death from in-hospital (IH) MCA. METHODS: Our query of the American Heart Association's GWTG®-Resuscitation voluntary registry from 2000-2017 revealed 561 index cases of IH MCA with complete outcome data. Logistic regression was performed using hospital death as the primary outcome and included variables with a p value = 0.1 or less based upon univariate analysis. Age, race, year of arrest, pre-existing conditions, first documented pulseless rhythm and location of arrest were used in the model. Sensitivity analyses and assessment of variable interaction were also performed to test model stability. Institutional review deemed this research exempt from ethical approval. RESULTS: Among 561 cases of MCA, 57.2% (321/561) did not survive to hospital discharge. IH death was not associated with maternal age, race and year of event. In the final model, IH death was significantly associated with pre-arrest hypotension/hypoperfusion (OR = 1.80 (95% CI, 1.16-2.79); p = 0.009). The occurrence of MCA outside of the delivery suite (referent group) or operating room was associated with a significantly higher risk of death: ICU/Post-Anesthesia Care Unit (PACU) (OR = 3.32 (95% CI, 2.00-5.52); p < 0.001) and ER/other (OR = 1.89 (95% CI, 1.15-3.11); p = 0.012). While MCA cases with a shockable vs. non-shockable first documented pulseless rhythm had similar outcomes, those with an indeterminate rhythm were less likely to die, (OR = 0.41(95% CI, 0.20-0.84); p = 0.014). In a sensitivity analysis, removal of the indeterminate group did not alter outcomes regarding first documented pulseless rhythm or arrest location. Area under the curve for the final model was 0.715 (95% CI 0.673-0.757). CONCLUSIONS: Our study identified several novel factors associated with IH death of our MCA cohort. More research is required to further understand the pathophysiologic dynamics affecting outcomes of IH MCA in this unique population.

Difficulty in Advancing Flexible Epidural Catheters When Establishing Labor Analgesia: An Observational Open-Label Randomized Trial.

BACKGROUND: While flexible epidural catheters reduce the risk of paresthesia and intravascular cannulation, they may be more challenging to advance beyond the tip of a Tuohy needle. This may increase placement time, number of attempts, and possibly complications when establishing labor analgesia. This study investigated the ability to advance flexible epidural catheters through different epidural needles from 2 commonly used, commercially available, epidural kits. METHODS: We hypothesized that the multiorifice wire-reinforced polyamide nylon blend epidural catheters will have a higher rate of successful first attempt insertion than the single-end hole wire-reinforced polyurethane catheters for the establishment of labor analgesia. The primary outcome was a difference in proportions of failure to advance the epidural catheter between the 2 epidural kits and was tested by a χ2 test. Two-hundred forty epidural kits were collected (n = 120/group) for 240 laboring patients requesting epidural analgesia in this open-label clinical trial from November 2018 to September 2019. Two-week time intervals were randomized for the exclusive use of 1 of the 2 kits in this study, where all patients received labor analgesia through either the flexible epidural catheter "A" or the flexible epidural catheter "B." Engineering properties of the equipment used were then determined. RESULTS: Flexible epidural catheter "A," the single-end hole wire-reinforced polyurethane catheter, did not advance at the first attempt in 15% (n = 18 of 120) of the parturients compared to 0.8% (n = 1 of 120) of the catheter "B," the multiorifice wire-reinforced polyamide nylon blend epidural catheter (P < .0001). Twenty-five additional epidural needle manipulations were recorded in the laboring patients who received catheter "A," while 1 epidural needle manipulation was recorded in the parturients who received catheter "B" (P < .0001). Bending stiffness of the epidural catheters used from kit "B" was twice the bending stiffness of the catheters used from kit "A" (bending stiffness catheters "A" 0.64 ± 0.04 N·mm2 versus bending stiffness catheters "B" 1.28 ± 0.20 N·mm2, P = .0038), and the angle formed by the needle and the epidural catheter from kit "A" was less acute than the angle formed from kit "B" (kit "A" 14.17 ± 1.72° versus kit "B" 21.83 ± 1.33°, P = .0036), with a mean difference of 7.66° between the 2 kits' angles. CONCLUSIONS: The incidence of an inability to advance single-end hole wire-reinforced polyurethane catheter was higher compared to the use of multiorifice wire-reinforced polyamide nylon blend epidural catheter. Variation of morphological features of epidural needles and catheters may play a critical role in determining the successful establishment of labor epidural analgesia.

Comparison of Chloroprocaine Versus Lidocaine With Epinephrine, Sodium Bicarbonate, and Fentanyl for Epidural Extension Anesthesia in Elective Cesarean Delivery: A Randomized, Triple-Blind, Noninferiority Study.

BACKGROUND: For emergent intrapartum cesarean delivery (CD), the literature does not support the use of any particular local anesthetic solution to extend epidural analgesia to cesarean anesthesia. We hypothesized that 3% chloroprocaine (CP) would be noninferior to a mixture of 2% lidocaine, 150 µg of epinephrine, 2 mL of 8.4% bicarbonate, and 100 µg of fentanyl (LEBF) in terms of onset time to surgical anesthesia. METHODS: In this single-center randomized noninferiority trial, adult healthy women undergoing CD were randomly assigned to epidural anesthesia with either CP or LEBF. Sensory blockade (pinprick) to T10 was established before operating room (OR) entry for elective CD. On arrival to the OR, participants received the epidural study medications in a standardized manner to simulate the conversion of "epidural labor analgesia to surgical anesthesia." The primary outcome was the time to loss of touch sensation at the T7 level. A noninferiority margin was set at 3 minutes. The secondary outcome was the need for intraoperative analgesia supplementation. RESULTS: In total, 70 women were enrolled in the study. The mean onset time to achieve a bilateral sensory block to touch at the T7 dermatome level was 655 (standard deviation [SD] = 258) seconds for group CP and 558 (269) seconds for group LEBF, a difference in means of 97 seconds (90% confidence interval [CI], SD = -10.6 to 204; P = .10 for noninferiority). The upper limit of the 90% CI for the mean difference exceeded the prespecified 3-minute noninferiority margin. There was no meaningful difference in the requirement for intraoperative analgesia between the 2 groups. CONCLUSION: Both anesthetic solutions have a rapid onset of anesthesia when used to extend low-dose epidural sensory block to surgical anesthesia. Data from the current study provide insufficient evidence to confirm that CP is noninferior to LEBF for rapid epidural extension anesthesia for CD, and further research is required to determine noninferiority.

Obstetric Anesthesia During the COVID-19 Pandemic.

With increasing numbers of coronavirus disease 2019 (COVID-19) cases due to efficient human-to-human transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the United States, preparation for the unpredictable setting of labor and delivery is paramount. The priorities are 2-fold in the management of obstetric patients with COVID-19 infection or persons under investigation (PUI): (1) caring for the range of asymptomatic to critically ill pregnant and postpartum women; (2) protecting health care workers and beyond from exposure during the delivery hospitalization (health care providers, personnel, family members). The goal of this review is to provide evidence-based recommendations or, when evidence is limited, expert opinion for anesthesiologists caring for pregnant women during the COVID-19 pandemic with a focus on preparedness and best clinical obstetric anesthesia practice.

Racial and Ethnic Disparities in the Incidence of Severe Maternal Morbidity in the United States, 2012-2015.

OBJECTIVE: To describe racial and ethnic disparities in the incidence of severe maternal morbidity during delivery hospitalizations in the United States. METHODS: We conducted a pooled, cross-sectional analysis of 2012-2015 data from the National Inpatient Sample to define the prevalence of chronic conditions and incidence of severe maternal morbidity among deliveries to non-Hispanic white, non-Hispanic black, Hispanic, Asian or Pacific Islander, and Native American or Alaska Native women. We used weighted multivariable logistic regression and predictive margins to generate prevalence and incidence estimates. Adjusted rate ratios and differences were calculated to quantify disparities across racial and ethnic categories. Subgroup analyses were performed to examine the incidence of severe maternal morbidity among deliveries to women with comorbid physical health conditions, behavioral health conditions, and multiple chronic conditions within each racial and ethnic category. RESULTS: The incidence of severe maternal morbidity was significantly higher among deliveries to women in every racial and ethnic minority category compared with deliveries among non-Hispanic white women. Severe maternal morbidity occurred in 231.1 (95% CI 223.6-238.5) and 139.2 (95% CI 136.4-142.0) per 10,000 delivery hospitalizations among non-Hispanic black and non-Hispanic white women, respectively (P<.001). When excluding cases in which blood transfusion was the only indicator of severe maternal morbidity, only deliveries to non-Hispanic black women had a higher incidence of severe maternal morbidity compared with deliveries among non-Hispanic white women: 50.2 (95% CI 47.6-52.9) and 40.9 (95% CI 39.6-42.3) per 10,000 delivery hospitalizations, respectively (risk ratio 1.2 [95% CI 1.2-1.3], risk difference 9.3 [95% CI 6.5-12.2] per 10,000 delivery hospitalizations; P<.001 for each comparison). Among deliveries to women with comorbid physical and behavioral health conditions, significant differences in severe maternal morbidity were identified among racial and ethnic minority compared with non-Hispanic white women and the largest disparities were identified among women with multiple chronic conditions. CONCLUSION: Programs for reducing racial and ethnic disparities in severe maternal morbidity may have the greatest effect focusing on women at highest risk for blood transfusion and maternity care management for women with comorbid chronic conditions, particularly multiple chronic conditions.

Characteristics and outcomes of maternal cardiac arrest: A descriptive analysis of Get with the guidelines data.

BACKGROUND: Maternal mortality has risen in the United States in the twenty-first century, yet large cohort data of maternal cardiac arrest (MCA) are limited. OBJECTIVE: We sought to describe contemporary characteristics and outcomes of in-hospital MCA. METHODS: We queried the American Heart Association's Get with the Guidelines Resuscitation voluntary registry from 2000 to 2016 to identify cases of maternal cardiac arrest. All index cardiac arrests occurring in women aged 18-50 with a patient illness category designated as obstetric or location of arrest occurring in a delivery suite were included. Institutional review deemed that this research was exempt from ethical approval. RESULTS: A total of 462 index events met criteria for MCA, with a mean age of 31 ± 7 years and a racial distribution of: 49.4% White, 35.3% Black and 15.3% Other/Unknown. While 32% had no pre-existing conditions or physiologic disorders, respiratory insufficiency (36.1%) and hypotension/hypoperfusion (33.3%) were the most common antecedent conditions. In most cases, the first documented pulseless rhythm was non-shockable; pulseless electrical activity (50.8%) or asystole (25.6%). Only 11.7% presented with a shockable rhythm; ventricular fibrillation (6.5%) or pulseless ventricular tachycardia (5.2%) while the initial pulseless rhythm was unknown in 11.9% of cases. Return of spontaneous circulation occurred in 73.6% but 68 (14.7%) had more than one arrest. The rate of survival to discharge was 40.7% overall; 37.3% with non-shockable rhythms, 33% with shockable rhythms and 64.3% with unknown presenting rhythms. CONCLUSIONS: Maternal survival at hospital discharge in this cohort was less than 50%, lower than rates reported in other epidemiological datasets. More research is required in maternal resuscitation science and translational medicine to continue to improve outcomes and understand maternal mortality.

A Systematic Review Evaluating Neuraxial Morphine and Diamorphine-Associated Respiratory Depression After Cesarean Delivery.

The prevalence of neuraxial opioid-induced clinically significant respiratory depression (CSRD) after cesarean delivery is unknown. We sought to review reported cases of author-reported respiratory depression (ARD) to calculate CSRD prevalence. A 6-database literature search was performed to identify ARD secondary to neuraxial morphine or diamorphine, in parturients undergoing cesarean delivery. "Highest" (definite and probable/possible) and "lowest" (definite) prevalences of CSRD were calculated. Secondary outcomes included: (1) prevalence of CSRD associated with contemporary doses of neuraxial opioid, (2) prevalence of ARD as defined by each study's own criteria, (3) case reports of ARD, and (4) reports of ARD reported by the Anesthesia Closed Claims Project database between 1990 and 2016. We identified 78 articles with 18,455 parturients receiving neuraxial morphine or diamorphine for cesarean delivery. The highest and lowest prevalences of CSRD with all doses of neuraxial opioids were 8.67 per 10,000 (95% CI, 4.20-15.16) and 5.96 per 10,000 (95% CI, 2.23-11.28), respectively. The highest and lowest prevalences of CSRD with the use of clinically relevant doses of neuraxial morphine ranged between 1.63 per 10,000 (95% CI, 0.62-8.77) and 1.08 per 10,000 (95% CI, 0.24-7.22), respectively. The prevalence of ARD as defined by each individual paper was 61 per 10,000 (95% CI, 51-74). One published case report of ARD met our inclusion criteria, and there were no cases of ARD from the Closed Claims database analysis. These results indicate that the prevalence of CSRD due to neuraxial morphine or diamorphine in the obstetric population is low.

Reduction of Peripartum Racial and Ethnic Disparities: A Conceptual Framework and Maternal Safety Consensus Bundle.

Racial and ethnic disparities exist in both perinatal outcomes and health care quality. For example, black women are three to four times more likely to die from pregnancy-related causes and have more than a twofold greater risk of severe maternal morbidity than white women. In an effort to achieve health equity in maternal morbidity and mortality, a multidisciplinary workgroup of the National Partnership for Maternal Safety, within the Council on Patient Safety in Women's Health Care, developed a concept article for the bundle on reduction of peripartum disparities. We aimed to provide health care providers and health systems with insight into racial and ethnic disparities in maternal outcomes, the etiologies that are modifiable within a health care system, and resources that can be used to address these etiologies and achieve the desired end of safe and equitable health care for all childbearing women.