Reviewing past and present consent practices in unplanned obstetric interventions: an eye towards the future.

Many first-time mothers (primiparous) within UK National Health Service (NHS) settings require an obstetric intervention to deliver their babies safely. While the antepartum period allows time for conversations about consent for planned interventions, such as elective caesarean section, current practice is that, in emergencies, consent is addressed in the moments before the intervention takes place. This paper explores whether there are limitations on the validity of consent offered in time-pressured and emotionally charged circumstances, specifically concerning emergency obstetric interventions. Using the legal framework of the Mental Capacity Act, Montgomery v. Lanarkshire Health Board (2015) and McCulloch v Forth Valley Health Board (2023), we argue that while women have the capacity to consent during labour, their autonomy is best supported by providing more information about instrumental delivery (ID) during the antepartum period. This conclusion is supported by some national guidelines, including those developed by the Royal College of Obstetricians and Gynaecologists, but not all. Further, we examine the extent to which these principles are upheld in modern-day practice. Data suggest there is relatively little antepartum information provision regarding ID within NHS settings, and that primiparous women do not report a thorough understanding of ID before labour. Based on these results, and bearing in mind the pressures under which NHS obstetric services currently operate, we recommend further research into patient and clinician perceptions of the consent process for ID. Pending these results, we discuss possible modes of information delivery in future practice.

Should All Patients With Pulmonary Hypertension Undergoing Non-Cardiac Surgery Be Managed by Cardiothoracic Fellowship-Trained Anesthesiologists?

OBJECTIVES: To identify differences in practice patterns and outcomes related to the induction of general anesthesia for patients with pulmonary hypertension (PH) performed by anesthesiologists who have completed a cardiothoracic fellowship (CTA group) vs those who have not (non-CTA group). DESIGN: Retrospective study with propensity score matching. SETTING: Operating room. PARTICIPANTS: All adult patients with PH undergoing general anesthesia requiring intubation at a single academic center over 5 years. INTERVENTIONS: Patient baseline characteristics, peri-induction management variables, post-induction mean arterial pressure (MAP), and other outcomes were compared between CTA and non-CTA groups. METHODS AND MAIN RESULTS: Following propensity scoring matching, 402 patients were included in the final model, 100 in the CTA group and 302 in the non-CTA group. Also following matching, only cases of mild to moderate PH without right ventricular dysfunction remained in the analysis. Matched groups were overall statistically similar with respect to baseline characteristics; however, there was a greater incidence of higher ASA class (P = .025) and cardiology and thoracic procedures (P < .001) being managed by the CTA group. No statistical differences were identified in practice patterns or outcomes related to the induction of anesthesia between groups, except for longer hospital length of stay in the CTA group (P = .008). CONCLUSIONS: These results provide early evidence to suggest the induction of general anesthesia of patients with non-severe PH disease can be comparably managed by either anesthesiologists with or without a cardiothoracic fellowship. However, these findings should be confirmed in a prospective study.

Society of Cardiovascular Anesthesiologists Clinical Practice Update for Management of Acute Kidney Injury Associated With Cardiac Surgery.

Cardiac surgery-associated acute kidney injury (CS-AKI) is common and is associated with increased risk for postoperative morbidity and mortality. Our recent survey of the Society of Cardiovascular Anesthesiologists (SCA) membership showed 6 potentially renoprotective strategies for which clinicians would most value an evidence-based review (ie, intraoperative target blood pressure, choice of specific vasopressor agent, erythrocyte transfusion threshold, use of alpha-2 agonists, goal-directed oxygen delivery on cardiopulmonary bypass [CPB], and the "Kidney Disease Improving Global Outcomes [KDIGO] bundle of care"). Thus, the SCA's Continuing Practice Improvement Acute Kidney Injury Working Group aimed to provide a practice update for each of these strategies in cardiac surgical patients based on the evidence from randomized controlled trials (RCTs). PubMed, EMBASE, and Cochrane library databases were comprehensively searched for eligible studies from inception through February 2021, with search results updated in August 2021. A total of 15 RCTs investigating the effects of the above-mentioned strategies on CS-AKI were included for meta-analysis. For each strategy, the level of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. Across the 6 potentially renoprotective strategies evaluated, current evidence for their use was rated as "moderate," "low," or "very low." Based on eligible RCTs, our analysis suggested using goal-directed oxygen delivery on CPB and the "KDIGO bundle of care" in high-risk patients to prevent CS-AKI (moderate level of GRADE evidence). Our results suggested considering the use of vasopressin in vasoplegic shock patients to reduce CS-AKI (low level of GRADE evidence). The decision to use a restrictive versus liberal strategy for perioperative red cell transfusion should not be based on concerns for renal protection (a moderate level of GRADE evidence). In addition, targeting a higher mean arterial pressure during CPB, perioperative use of dopamine, and use of dexmedetomidine did not reduce CS-AKI (a low or very low level of GRADE evidence). This review will help clinicians provide evidence-based care, targeting improved renal outcomes in adult patients undergoing cardiac surgery.

Right Heart Failure Management: Focus on Mechanical Support Options.

Millions of American adults suffer from right heart failure (RHF), a condition associated with high rates of hospitalization, organ failure, and death. There is a multitude of etiologies and mechanisms that lead to RHF, often in a feedforward spiral of decline. The management of advanced cases of RHF can be particularly difficult. For patients who are refractory to the medical optimization of volume status, hemodynamic and pharmacologic support, and rhythm control, mechanical therapies may be warranted. Currently available mechanical assist devices for RHF include venoarterial extracorporeal oxygenation and right ventricular assist devices, both surgical and percutaneous. Each advanced therapy has its own potential advantages and limitations, and often is appropriate in different clinical contexts. In this review, the authors describe the pathophysiology and medical therapies for RHF and then focus on the different types of advanced therapies that currently exist to help inform medical decision-making for this complicated patient cohort.

Contemporary Comprehensive Monitoring of Veno-arterial Extracorporeal Membrane Oxygenation Patients.

The use of veno-arterial extracorporeal membrane oxygenation (VA ECMO) has increased substantially over the past few decades. Today's clinicians now have a powerful means with which to salvage a growing population of patients at risk for cardiopulmonary collapse. At the same time, patients supported with VA ECMO have become increasingly more complex. The successful use of VA ECMO depends not only on selecting the appropriate patients, but also on effectively navigating a potential torrent of device- and patient-related complications until ECMO is no longer needed. A multitude of monitoring tools are now available to help the treatment team determine the adequacy of care, to detect problems, and to anticipate recovery. Monitoring with devices such as the Swan-Ganz catheter, transthoracic and transesophageal echocardiography, chest radiography, and near-infrared spectroscopy can provide useful information to complement routine clinical care. Leveraging data derived from the ECMO circuit itself also can be instrumental in both evaluating the sufficiency of support and troubleshooting complications. Each of these tools, however, has its own unique sets of limitations and liabilities. A thorough understanding of these risks and benefits is critical to the contemporary care of the individual managed with VA ECMO. In addition, more research is needed to establish optimal evidence-based care pathways and best-practice principles for using these devices to improve patient outcomes.

Anesthesia for Resection and Reconstruction of the Trachea and Carina.

Airway surgery poses a host of unique challenges to both the surgical and anesthesiology teams. Accordingly, there are a variety of surgical, anesthetic, and airway management options to be strategically considered. Management can be challenging during multidisciplinary preoperative planning, during the surgical procedure itself, and during recovery. In this review, emphasis is placed on anesthesia challenges for patients undergoing major tracheal or carinal surgery with specific considerations related to perioperative management.

The outcomes of pregnancies with reduced fetal movements: A retrospective cohort study.

INTRODUCTION: The objective of this study was to examine the outcomes and interventions in pregnant women presenting with a perception of reduced fetal movements (RFM), and to determine if repeated episodes of RFM increase the risk of adverse outcomes. MATERIAL AND METHODS: This was a retrospective cohort study conducted in six NHS hospitals within the Thames Valley network region, UK and one neighboring hospital, an area with approximately 31 000 births annually. All women with a primary presentation of perceived RFM after 24 completed weeks of gestation during the month of October 2016 were included in the study. Prospective records in all units were examined and individual case-notes were reviewed. Pregnancy and neonatal outcomes and their relation with recurrent presentations with RFM were examined using relative risks with 95% CI. The main outcome measures are described. Neonatal outcomes measured were perinatal mortality, neonatal unit admission, abnormal cardiotocography at presentation, a composite severe morbidity outcome of Apgar <7 at 5 minutes or arterial pH <7.0 or encephalopathy, and birthweight. Pregnancy outcomes measured were induction of labor, cesarean section, admission and ultrasound usage rates. RESULTS: In all, 591 women presented with RFM during the month; using annual hospital birth figures, the incidence of RFM was estimated at 22.6% (range 14.9%-32.5%). More than 1 presentation of RFM occurred in 273 (46.2%). All 3 deaths (0.5%) were at the first presentation. More than 1 presentation was associated with higher induction rates (56.0% vs 31.9%), but no increase in any adverse outcomes including small-for-gestational-age. CONCLUSIONS: Reduced fetal movements, and recurrent episodes, are common, and lead to considerable resource usage and obstetric intervention. We found no evidence to suggest that recurrent episodes increase pregnancy risk.