Prevalence of difficult intubation and failed intubation in a diverse obstetric community-based population.

OBJECTIVE: To describe the incidence of difficult and failed intubations in obstetric patients during a 6 year period monitored by a quality assurance program together with American Society of Anesthesiologists Physical Status (ASA PS) scores, and obesity (body mass index >30 kg/m2). METHODS: Following Institutional Review Board approval, data about obstetric patients who experienced unanticipated difficult or failed intubations from 2010 to 2015 was obtained from the quality assurance database of a large, community-based anesthesiology group practice. The database employs standardized definitions for difficult intubation (>3 laryngoscopic attempts by experienced providers) and failed intubation (inability to intubate leading to surgical airway or waking up the patient). ASA PS scores and comorbidities were also identified for obstetric general anesthetics using an internally developed quality assurance program, Quantum Clinical Navigation System. RESULTS: There were 2802 obstetric general anesthetics in the database of which 1085 (38.7%) were deemed as emergencies. There were no cases of failed intubation and seven cases of unanticipated difficult intubations (1:400 cases, 0.25% of all obstetric general anesthetics, 95% confidence interval 0.1-0.5%), six of which occurred during emergency surgery. There was an increase in obesity (p = .003) and ASA PS (p = .02) over the period of the study. The incidence of difficult intubation was not found to be significantly changed (p = .68). CONCLUSIONS: Despite an increase in ASA PS score and obesity, there was no increase in the incidence of difficult intubation in obstetric patients. Limitations of the study include its retrospective design, and the small number of difficult intubation cases identified.

Advancing obstetric anesthesia practices in Georgia through clinical education and quality improvement methodologies.

OBJECTIVE: To determine whether an integrated program of clinical education and improvement methods regarding the safe use of regional anesthesia for obstetrics would result in improved and sustained practice change in Georgia. METHODS: Between 2006 and 2009, intervention teams undertook several visits to 5 Georgian hospitals. Rates of regional anesthesia for labor and cesarean delivery prior to and following the intervention were collected from participating and non-participating hospitals. There were multifaceted educational activities and quality improvement activities at intervention sites, including protocol development, social marketing, and supply chain logistics. Host hospitals evaluated the program via a questionnaire. RESULTS: The use of general anesthesia for cesarean delivery decreased significantly (P<0.001) and the use of epidural analgesia for labor increased significantly (P<0.001); there was no change in non-participating hospitals. Over the course of the program, medication and supply availability improved. Program evaluations were uniformly positive. CONCLUSION: A structured program of education and quality improvement led to an increase in the use of regional anesthesia for vaginal and cesarean deliveries. Achievements were sustained during periods of economic and political turmoil.

Neostigmine decreases bupivacaine use by patient-controlled epidural analgesia during labor: a randomized controlled study.

BACKGROUND: Intrathecal neostigmine not only produces analgesia but also severe nausea. In contrast, epidural neostigmine enhances opioid and local anesthetic analgesia without causing nausea. Previous studies examined only single epidural neostigmine bolus administration and did not assess the efficacy of continuous epidural infusion or several aspects of maternal and fetal safety. We therefore tested the hypothesis that epidural neostigmine in combination with bupivacaine by continuous infusion during labor would reduce the amount of bupivacaine required. METHODS: Twelve healthy women scheduled for elective cesarean delivery were assigned to receive epidural neostigmine, 40 microg (first six subjects) or 80 microg (second six subjects) as a single bolus, with fetal heart rate (FHR) and uterine contractions monitored for 20 min. In a subsequent experiment, 40 healthy laboring women were randomized to receive bupivacaine 1.25 mg/mL alone or with neostigmine 4 microg/mL by patient-controlled epidural analgesia. The primary outcome measure was hourly bupivacaine use. RESULTS: Epidural neostigmine bolus did not alter baseline FHR, induce contractions, or produce nausea. Epidural neostigmine infusion reduced bupivacaine requirement by 19% in all patients and 25% in those with >4 h of treatment (P < 0.05 for both) but might have contributed to the incidence of mild sedation. Mode of delivery, incidence of maternal nausea, and FHR abnormality were similar between groups. CONCLUSIONS: These data show that adding epidural neostigmine 4 microg/mL reduces the hourly bupivacaine requirement by 19%-25% with patient-controlled epidural analgesia during labor. Administered as a bolus and by continuous infusion at the studied doses, epidural neostigmine does not cause nausea and does not induce uterine contractions or FHR abnormalities, but mild sedation can occur.

Uterine cervical afferents in thoracolumbar dorsal root ganglia express transient receptor potential vanilloid type 1 channel and calcitonin gene-related peptide, but not P2X3 receptor and somatostatin.

BACKGROUND: Little is known regarding the phenotype of afferents that innervate the uterine cervix. Chronic estrogen sensitizes uterine cervical afferents to mechanical distension, but whether this reflects changes in afferent neurotransmitter or excitatory ion channel expression is unknown. The authors used immunocytochemistry to characterize uterine cervical afferents and the effects of estrogen on them. METHODS: Fluorogold was injected into the uterine cervix of intact rats (n = 7) and those with ovariectomy alone (n = 9) or with estrogen supplementation (n = 8). Bilateral dorsal root ganglia at T12-L2 were removed and immunostained for transient receptor potential vanilloid type 1 (TRPV1), P2X3 receptor, calcitonin gene-related peptide, and somatostatin. The proportion of fluorogold-traced dorsal root ganglion neurons expressing each of these markers was compared with untraced neurons. RESULTS: Most fluorogold-traced cells were found at L1 (> 55%) and were of small diameter (24 microm). TRPV1 expression was similar between traced and untraced cells, except the estrogen treatment increased TRPV1 expression in traced cells. Calcitonin gene-related peptide expression was greater in traced than in untraced cells, with no effect of experimental treatment. No traced cells expressed the P2X3 receptor or somatostatin, although each of these was present in untraced cells. CONCLUSION: Uterine cervical afferents in the hypogastric nerve express TRPV1, an important nociceptive channel, which may play a role in estrogen-induced sensitization of cervical afferents. High expression of calcitonin gene-related peptide suggests a sensory and efferent role for this peptide. In contrast to other viscera, these afferents do not express somatostatin or P2X3 receptor, indicating a unique phenotype of these C fibers.