Sugammadex versus neostigmine for routine reversal of neuromuscular blockade and the effect on perioperative efficiency.

Sugammadex produces recovery from neuromuscular blockade more rapidly and reliably than neostigmine. We sought to determine if sugammadex is associated with improved perioperative efficiency when compared to traditional neuromuscular blockade reversal with neostigmine, potentially offsetting the higher medication cost. This retrospective analysis involved patients receiving either neostigmine or sugammadex for reversal of neuromuscular blockade at a single academic tertiary care hospital. The final propensity-matched groups consisted of 4060 in each group (neostigmine or sugammadex). The primary outcome measured was total time in the operating room. Secondary outcomes included specific measures of perioperative efficiency as well as postoperative pulmonary failure. The average operating room time for patients was 169.59 [1.27] minutes for neostigmine and 157.06 [1.33] minutes for sugammadex (P < 0.001). The difference was primarily accounted for by shorter surgical times (121.45 [1.18] vs 109.62 [1.22] minutes, P < 0.011). Sugammadex was also associated with a shorter post-anesthesia care unit length of stay (102.47 [1.04] vs 98.67 [1.02] minutes, P < 0.001). For 8120 patients, sugammadex use was associated with shorter operating room and surgical durations as well as shorter post-anesthesia care unit stay. The favorable pharmacodynamic profile of sugammadex may improve surgical and perioperative efficiency and offset higher medication cost.

Extracellular Vesicles From Women With Severe Preeclampsia Impair Vascular Endothelial Function.

BACKGROUND: Preeclampsia (PE) manifesting as hypertension and organ injury is mediated by vascular dysfunction. In biological fluids, extracellular vesicles (EVs) containing microRNA (miRNA), protein, and other cargo released from the placenta may serve as carriers to propagate injury, altering the functional phenotype of endothelial cells. PE has been consistently correlated with increased levels of placenta-derived EVs (pEVs) in maternal circulation. However, whether pEVs impaired endothelial cell function remains to be determined. In this study, we hypothesize that pEVs from pregnant women with severe PE (sPE) impair endothelial function through altered cell signaling. METHODS: We obtained plasma samples from women with sPE (n = 14) and normotensive pregnant women (n = 15) for the isolation of EVs. The total number of EV and pEV contribution was determined by quantifying immunoreactive EV-cluster of designation 63 (CD63) and placental alkaline phosphatase (PLAP) as placenta-specific markers, respectively. Vascular endothelial functional assays were determined by cell migration, electric cell-substrate impedance sensing in human aortic endothelial cells (HAECs), and wire myography in isolated blood vessels, preincubated with EVs from normotensive and sPE women. RESULTS: Plasma EV and pEV levels were increased in sPE when compared to normotensive without a significant size distribution difference in sPE (108.8 ± 30.2 nm) and normotensive-EVs (101.3 ± 20.3 nm). Impaired endothelial repair and proliferation, reduced endothelial barrier function, reduced endothelial-dependent vasorelaxation, and decreased nitrite level indicate that sPE-EVs induced vascular endothelial dysfunction. Moreover, sPE-EVs significantly downregulated endothelial nitric oxide synthase (eNOS and p-eNOS) when compared to normotensive-EV. CONCLUSIONS: EVs from sPE women impair endothelial-dependent vascular functions in vitro.

Utilization of epidural volume extension technique for external cephalic version.

External cephalic version (ECV) has been successfully utilized to reduce breech presentations at term and offers an alternative to elective cesarean delivery. Unfortunately, there is not a consensus on which type of regional anesthesia conveys the highest chances for a successful ECV. This case report describes the use of the epidural volume extension technique to provide surgical anesthesia for ECV with a reduced dose of local anesthetic, with the goals of minimizing motor block and hypotension in the setting of an outpatient procedure.

Role of exosomal microRNA signatures: An emerging factor in preeclampsia-mediated cardiovascular disease.

Preeclampsia (PE) and vascular dysfunction are major causes of maternal and neonatal morbidity and mortality. Although extensively studied, the complete understanding of the pathophysiology behind PE remains unclear. Current reports indicate that exosomes are essential mediators in PE-related cardiovascular disease (CVDs). Exosomes are synthesized from multivesicular bodies (MVB) and contain functionally active microRNAs miRNAs). These miRNAs have been shown to mediate physiological and pathological functions through autocrine, paracrine, and endocrine signaling mechanisms. The role of miRNAs in pregnant women with PE has been studied extensively. However, little is known about the effect of exosomal miRNAs (exomiR) in PE. This paper will review and discuss the existing evidence for exomiR function in PE and highlight the need for future studies to explore the role that exomiR signatures have in cardiovascular dysfunction associated with PE.

Unilateral Facial Nerve Palsy After Inadvertent Dural Puncture Initially Diagnosed as Bell's Palsy, Improved With Epidural Blood Patch: A Case Report.

Cranial nerve (CN) VII palsy is a rare complication of neuraxial blockade. The likely etiology of the palsy is intracranial hypotension from cerebrospinal fluid loss leading to traction on CN VII. The presentation of symptoms of CN VII palsy from intracranial hypotension closely resembles a more common cause of CN VII injury, Bell's palsy, and the 2 can be difficult to differentiate. We present a patient who had a dural puncture with development of a headache and CN VII palsy, which improved with epidural blood patch (EBP). EBP should be considered for patients with suspected CN palsy from intracranial hypotension.

Comparing Bupivacaine, Lidocaine, and a Combination of Bupivacaine and Lidocaine for Labor Epidural Activation: A Prospective, Randomized, Double-Blind Study

Objective: Epidural anesthesia for the parturient is often provided in a clinical context where rapid onset of segmental analgesia is important; however, little is published on the ideal local anesthetic to safely achieve this onset. To fi ll this gap in knowledge, we studied bupivacaine and lidocaine, two local anesthetics (LA) commonly used for labor epidural activation, either as a single drug or in combination to determine the onset of epidural analgesia. Methods: In this double-blinded study, seventy-five patients were randomized into three groups (n = 25 each) for labor epidural activation: 10 mL of 0.25% bupivacaine, 10 mL of 1% lidocaine, or 5 mL of 0.25% bupivacaine plus 5 mL of 1% lidocaine. Patients were assessed for the fi rst 20 min after drug administration at 5-min intervals. Data collected included sensory level to pinprick, maternal blood pressure, vasopressor administration, and peak motor blockade. Results: Data were analyzed on 71 of 75 patients. Time to loss of sensation to pinprick at the T10 dermatome in the bupivacaine group was signifi cantly longer than the lidocaine group (p = 0.006), but the time to loss of sensation to pinprick at the T10 dermatome did not signifi cantly differ in the bupivacaine plus lidocaine group when compared to both the bupivacaine (p = 0.114) as well as the lidocaine (p = 0.203) groups. Phenylephrine usage did not signifi cantly differ amongst the three groups (p = 0.062). Conclusion: Lidocaine provides statistically signifi cant faster onset of epidural analgesia when compared to bupivacaine only. Combining the two LA did not signifi cantly affect onset.

Utility of ultrasonography in identification of midline and epidural placement in severely obese parturients.

BACKGROUND: Due to body habitus, lumbar epidural placement can be challenging in severely obese parturients. Several studies have been published assessing the usefulness of ultrasonography in the placement of neuraxial blocks. One patient population that is under-represented in these studies is the severely obese parturient. We sought to determine if performing an abbreviated ultrasound exam of the lumbar spine to determine midline by locating spinous process could facilitate lumbar epidural placement in severely obese parturients. METHODS: One hundred fifty patients with a Body Mass Index (BMI) of ≥35 kg/m2 were randomized into two groups. The palpation (P) group had midline identified by the traditional palpation technique. The ultrasonography (U) group had midline identified by ultrasound visualization of the spinous process in the transverse plane. Midline identification and epidural placement were done by both junior and senior anesthesiology residents at our teaching institution. RESULTS: Data were analyzed on all 150 patients. BMI was similar in the U and P groups (43.3 vs. 44.4 kg/m2, P=0.359). Time for epidural placement (6.2 vs. 9.0 minutes, P<0.01) and total procedure time (6.9 vs. 9.5 minutes, P<0.01) were significantly less in the U group. The number of needle passes (2.1 vs. 2.8, P=0.02) was also less in the U group. There was no significant difference in the failure rates of the U and P groups (4.0% vs. 9.3%, P=0.19). CONCLUSIONS: The use of an abbreviated ultrasound exam to identify midline in severely obese parturients can reduce the time required for lumbar epidural placement.

Comparing low-dose bupivacaine with epidural volume extension to standard bupivacaine dosing for short obstetric procedures: a prospective, randomized study.

BACKGROUND: Intrathecal bupivacaine's long duration of action can unnecessarily increase the time to meet Postanesthesia Care Unit (PACU) discharge criteria for patients undergoing short obstetric procedures. We sought to use a technique known as epidural volume extension (EVE) to determine if we could provide an adequate surgical block while significantly decreasing the time required to meet PACU discharge criteria for patients undergoing short obstetric procedures. METHODS: Fifty participants were randomized into two groups. The control group received a 10 mg of 0.5% isobaric bupivacaine plus 15 µg of fentanyl injection in the intrathecal space via a combined spinal-epidural technique. The EVE group received a 5 mg of 0.5% isobaric bupivacaine plus 15 µg of fentanyl injection in the intrathecal space followed immediately by a 10 mL injection of sterile saline through the epidural needle for the EVE. RESULTS: Data were analyzed on 45 of the 50 patients. Time to meet PACU discharge criteria was significantly reduced in the EVE group when compared to the control group (50 vs. 135 minutes, P<0.001). The EVE group had a faster time to complete motor recovery when compared to the control group (66 vs. 181 minutes, P<0.001). Peak block height was similar in both groups at the time of surgery start (T5 vs. T5, P=0.44). CONCLUSIONS: The use of low-dose isobaric bupivacaine in combination with 10 mL of saline EVE allows for faster motor recovery and time to meet PACU discharge criteria in patients undergoing short obstetric procedures.

Obesity and Neonatal Cord Blood Gas Results at Cesarean: Effect of Intraoperative Blood Pressure.

Objective Our aims were to evaluate whether there is an inverse association between body mass index (BMI) and umbilical artery pH and to investigate the contribution of intraoperative hypotension on the umbilical artery pH. Study Design We conducted a retrospective cohort study of all women with a nonanomalous singleton at 37 to 41 weeks who underwent a scheduled cesarean delivery under spinal anesthesia at our facility from January 2006 to March 2012. The primary outcome was the proportion of patients in each BMI category with arterial cord pH < 7.10. Intraoperative blood pressure data were compared across BMI categories. Results In total, 717 mother-infant pairs met enrollment criteria. Mean arterial pH was significantly lower in women with elevated BMI (p = 0.014), notably with BMI ≥ 40 kg/m2. Baseline blood pressure increased linearly with increasing BMI (p < 0.001), however, so did the maximum drop in all blood pressure parameters (p < 0.001). After adjusting for potential confounders, including blood pressure, there was no longer an association between cord pH and BMI (p = 0.72). Conclusion For women undergoing a scheduled cesarean delivery under spinal anesthesia, umbilical artery pH is lower in women with BMI ≥40 kg/m2. Relative hypotension after spinal anesthesia is more pronounced with increasing BMI and may explain this effect.

Cost comparison of intrathecal morphine to intravenous patient-controlled analgesia for the first 24 h post cesarean delivery: a retrospective cohort study.

PURPOSE: Intrathecal morphine provides superior pain control for patients undergoing cesarean delivery when compared to intravenous opioid patient-controlled analgesia. However, no study has assessed the overall cost associated with each modality as a primary outcome. The aim of this study is to determine the overall cost of each modality for the first 24 h post cesarean delivery. METHODS: Charts of patients undergoing cesarean delivery at our institution from January 1, 2014 to December 31, 2014 were reviewed. Patients receiving intrathecal morphine were compared to patients undergoing general anesthesia and receiving intravenous opioid patient-controlled analgesia for post-procedure analgesia. The primary outcome measured was total cost of each modality for the first 24 h after delivery. Secondary outcomes included post-procedure pain scores, time to removal of the Foley catheter, need for rescue medications, and adverse events. RESULTS: There was a significant difference in total cost of intrathecal morphine when compared to intravenous opioid patient-controlled analgesia ($51.14 vs. $80.16, p < 0.001). Average pain scores between 0-1 h (0 vs. 5, p < 0.001) and 1-6 h (2.5 vs. 3.25, p < 0.001) were less in the intrathecal morphine group. The intrathecal morphine group received more ketorolac (p < 0.001) and required more rescue opioids (p = 0.042). There were no significant differences in documented adverse events. CONCLUSIONS: The use of intrathecal morphine for post-cesarean pain control leads to a significant cost savings for the first 24 h when compared to intravenous opioid patient-controlled analgesia. Patients also experienced less pain and were not at increased risk for adverse events.

Risk factors for failed reactivation of a labor epidural for postpartum tubal ligation: a prospective, observational study.

STUDY OBJECTIVE: To determine specific risk factors that increase the failure rate of labor epidurals reactivated for use as a surgical block for postpartum tubal ligation. DESIGN: Prospective, observational study. SETTING: Labor and delivery suite and operating rooms at the Women and Infants Center. PATIENTS: One hundred patients undergoing postpartum tubal ligation with an existing labor epidural that is documented to be within 2 cm of initial placement. MEASUREMENTS: Body mass index, patient satisfaction with her epidural during labor and delivery, time from delivery to reactivation for tubal ligation, depth to loss of resistance, and the need for top-ups during labor were recorded preoperatively. Failure to reactivate was recorded and defined as any patient that (1) did not achieve a T6 level to pinprick, (2) had perceived pain (pain score >3) that required administration of an intravenous opioid or local anesthetic infiltration, or (3) required conversion to general anesthesia. MAIN RESULTS: The overall success rate of reactivation was 78%. Significant risk factors for failure to reactivate were (1) poor patient satisfaction (P = .016), (2) increased time from delivery to reactivation (P = .044), and (3) the need for top-ups during labor and delivery (P = .032). CONCLUSION: Poor satisfaction score of the epidural during labor and delivery, increasing time from delivery to epidural reactivation for tubal ligation, and the need for top-ups during labor and delivery increase the incidence of reactivation failure. No correlation was found with body mass index or loss of resistance and failure to reactivate.