Clinical pearls part 3: anaesthetic management of abnormally invasive placentation.

PURPOSE OF REVIEW: Abnormal placentation is a clinical condition seen increasingly in the pregnant population. It is associated with significant morbidity and mortality, which may be mitigated through robust multidisciplinary care for these patients. The role of maternal critical care for these patients has largely been ignored in the literature. RECENT FINDINGS: Advances in pharmacological management of bleeding with recent publications of large multicentre trials in addition to new technologies in the management of massive obstetric haemorrhage (MOH) have revolutionized the management of abnormal placentation. These include the use of tranexamic acid, interventional radiology, cell saver technology, and point-of-care coagulation tests. The role of maternal critical care for the optimization of postoperative complications and physiological derangements has not been considered widely in the literature. This article summarizes the current evidence for interventions and suggests a protocol for the management of these high-risk patients. SUMMARY: A robust protocol outlining the key elements of the management of placenta accreta, including optimizing postoperative care, should be in place to promote desired outcomes.

The effects of bed height and time on the quality of chest compressions delivered during cardiopulmonary resuscitation: a randomised crossover simulation study.

INTRODUCTION: The 2010 International Liaison Committee on Resuscitation gave a detailed update on best practice for cardiopulmonary resuscitation (CPR) with a discussion on appropriate patient and CPR provider position, based largely on expert opinion. The objective of this study was to ascertain robust evidence on the effect of bed height and fatigue on chest compression effectiveness. METHODS: A modified Laerdal manikin was connected to a Dragor ventilator (to measure intrathoracic pressures generated). The manikin was placed on a hospital trolley and CPR was performed by candidates at three different bed heights in a randomised order: (1) mid-thigh, (2) anterior superior iliac spine and (3) xiphisternum. Chest compressions were continuous and asynchronous with ventilation, and were allowed to continue for 30 s before recordings were taken. At the anterior superior iliac spine level, chest compressions were continued for 2 min, when further measurements were taken. RESULTS: 101 subjects took part. The differences in intrathoracic pressures generated at different bed heights were compared using analysis of variance testing for multiple groups and were statistically significant for p<0.05. The authors also found that the effectiveness of CPR decreased 17% over a 2-minute period (p<0.05). CONCLUSIONS: The most effective bed height position, allowing CPR providers to achieve the highest intrathoracic pressures during CPR, was one where the patient's chest was in line with the CPR provider's mid-thigh. The provider performing CPR should change every 2 min.

Comparison of the Mapleson C system and adult and paediatric self-inflating bags for delivering guideline-consistent ventilation during simulated adult cardiopulmonary resuscitation.

There is a discrepancy between resuscitation teaching and witnessed clinical practice. Furthermore, deleterious outcomes are associated with hyperventilation. We therefore conducted a manikin-based study of a simulated cardiac arrest to evaluate the ability of three ventilating devices to provide guideline-consistent ventilation. Mean (SD) minute ventilation was reduced with the paediatric self-inflating bag (7.0 (3.2) l.min⁻¹) compared with the Mapleson C system (9.8 (3.5) l.min⁻¹) and adult self-inflating bag (9.7 (4.2) l.min⁻¹ ; p = 0.003). Tidal volume was also lower with the paediatric self-inflating bag (391 (52) ml) compared with the others (582 (87) ml and 625 (103) ml, respectively; p < 0.001), as was peak airway pressure (14.5 (5.2) cmH2O vs 20.7 (9.0) cmH2O and 30.3 (11.4) cmH2O, respectively; p < 0.001). Participants hyperventilated patients' lungs in simulated cardiac arrest with all three devices. The paediatric self-inflating bag delivered the most guideline-consistent ventilation. Its use in adult cardiopulmonary resuscitation may ensure delivery of more guideline-consistent ventilation in patients with tracheal intubation.