Anesthesiologist Specialization and Use of General Anesthesia for Cesarean Delivery.

BACKGROUND: Guidelines for obstetric anesthesia recommend neuraxial anesthesia (i.e., spinal or epidural block) for cesarean delivery in most patients. Little is known about the association of anesthesiologist specialization in obstetric anesthesia with a patient's likelihood of receiving general anesthesia. The authors conducted a retrospective cohort study to compare utilization of general anesthesia for cesarean delivery among patients treated by generalist versus obstetric-specialized anesthesiologists. METHODS: The authors studied patients undergoing cesarean delivery for live singleton pregnancies from 2013 through 2017 at one academic medical center. Data were extracted from the electronic medical record. The authors estimated the association of anesthesiologist specialization in obstetric anesthesia with the odds of receiving general anesthesia for cesarean delivery. RESULTS: Of the cesarean deliveries in our sample, 2,649 of 4,052 (65.4%) were performed by obstetric-specialized anesthesiologists, and 1,403 of 4,052 (34.6%) by generalists. Use of general anesthesia differed for patients treated by specialists and generalists (7.3% vs. 12.1%; P < 0.001). After adjustment, the odds of receiving general anesthesia were lower among patients treated by obstetric-specialized anesthesiologists among all patients (adjusted odds ratio, 0.71; 95% CI, 0.55 to 0.92; P = 0.011), and in a subgroup analysis restricted to urgent or emergent cesarean deliveries (adjusted odds ratio, 0.75; 95% CI, 0.56 to 0.99; P = 0.049). There was no association between provider specialization and the odds of receiving general anesthesia in a subgroup analysis restricted to evening or weekend deliveries (adjusted odds ratio, 0.76; 95% CI, 0.56 to 1.03; P = 0.085). CONCLUSIONS: Treatment by an obstetric anesthesiologist was associated with lower odds of receiving general anesthesia for cesarean delivery; however, this finding did not persist in a subgroup analysis restricted to evening and weekend deliveries.

Implementation Science in Perioperative Care.

There is a 17-year gap between the initial publication of scientific evidence and its uptake into widespread practice in health care. The field of implementation science (IS) emerged in the 1990s as an answer to this "evidence-to-practice gap." In this article, we present an overview of implementation science, focusing on the application of IS principles to perioperative care. We describe opportunities for additional training and discuss strategies for funding and publishing IS work. The objective is to demonstrate how IS can improve perioperative patient care, while highlighting perioperative IS studies and identifying areas in need of additional investigation.

Enhanced versus automated urinalysis for screening of urinary tract infections in children in the emergency department.

BACKGROUND: Urinary tract infections (UTI) are the most common serious bacterial infection in febrile infants. Urinalysis (UA) is a screening test for preliminary diagnosis of UTI. UA can be performed manually or using automated techniques. We sought to compare manual versus automated UA for urine specimens obtained via catheterization in the pediatric emergency department. METHODS: In this prospective study, we processed catheterized urine samples from infants with suspected UTI by both the manual method (enhanced UA) and the automated method. We defined a positive enhanced UA as ≥ 10 white blood cells per cubic millimeter and presence of any bacteria per 10 oil immersion fields on a Gram-stained smear. We defined a positive automated UA as ≥ 2 white blood cells per high-powered field and presence of any bacteria using the IRIS iQ200 ELITE. We defined a positive urine culture as growth of ≥ 50,000 colony-forming units per milliliter of a single uropathogen. We analyzed data using SPSS software. RESULTS: A total of 703 specimens were analyzed. Prevalence of UTI was 7%. For pyuria, the sensitivity and positive predictive value (PPV) of the enhanced UA in predicting positive urine culture were 83.6% and 52.5%, respectively; corresponding values for the automated UA were 79.5% and 37.5%, respectively. For bacteriuria, the sensitivity and PPV of a Gram-stained smear (enhanced UA) were 83.6% and 59.4%, respectively; corresponding values for the automated UA were 73.4%, and 26.2%, respectively. Using criteria of both pyuria and bacteriuria for the enhanced UA resulted in a sensitivity of 77.5% and a PPV of 84.4%; corresponding values for the automated UA were 63.2% and 51.6%, respectively. Combining automated pyuria (≥ 2 white blood cells/high-powered microscopic field) with a Gram-stained smear resulted in a sensitivity of 75.5% and a PPV of 84%. CONCLUSIONS: Automated UA is comparable with manual UA for detection of pyuria in young children with suspected UTI. Bacteriuria detected by automated UA is less sensitive and specific for UTI when compared with a Gram-stained smear. We recommend using either manual or automated measurement of pyuria in combination with Gram-stained smear as the preferred technique for UA of catheterized specimens obtained from children in an acute care setting.

Maternal outcomes in women supplemented with a high-protein drink in labour.

BACKGROUND: Because of the potential aspiration risk, oral intake is restricted during labour. AIMS: To determine whether high-protein drink supplementation in labour decreases nausea and emesis and promotes patient satisfaction. MATERIALS AND METHODS: The study was registered with www.clinicaltrials.gov (NCT01414478). Labouring women were randomised into two groups: Group P received a high-protein drink (325 mL) with ice chips/water PRN; and Group C served as control and received only ice chips/water PRN (Study 1). Incidences of nausea and emesis were measured hourly until delivery and at 1 h postdelivery. Patient satisfaction was measured the following day. A secondary aim was to evaluate the rate of gastric emptying (t½ ) in women who ingested either 325 mL of a high-protein drink or ice chips/water (Study 2) using ultrasound. RESULTS: In Study 1, 150 women were recruited (Group P = 75; Group C = 75). There were no differences in the overall incidences of nausea (P = 0.14), emesis (P = 0.15) or in the incidences at the measured time periods (MANOVA, P > 0.05). Median patient satisfaction scores were higher in Group P than in Group C (P = 0.007). In Study 2, 18 additional patients (Group PG = 9; Group CG = 9) were analysed to determine US gastric emptying t½ rates (PG : 25.56 ± 15.90 min [95% CI: 15.17 - 35.94] compared with CG : 20.00 ± 8.70 min [95% CI: 14.34 - 25.66], P = 0.19). CONCLUSION: In labour, patient satisfaction is improved with high-protein drink supplementation compared with ice chips/water with comparable gastric emptying rates.

Efficacy of the bilateral ilioinguinal-iliohypogastric block with intrathecal morphine for postoperative cesarean delivery analgesia.

The ilioinguinal-iliohypogastric (IIIH) block is frequently used as multimodal analgesia for lower abdominal surgeries. The aim of this study is to compare the efficacy of IIIH block using ultrasound visualization for reducing postoperative pain after caesarean delivery (CD) in patients receiving intrathecal morphine (ITM) under spinal anesthesia. Participants were randomly assigned to 1 of 3 treatment groups for the bilateral IIIH block: Group A = 10 mL of 0.5% bupivacaine, Group B = 10 mL of 0.5% bupivacaine on one side and 10 mL of a normal saline (NSS) placebo block on the opposite side, and Group C = 10 mL of NSS placebo per side. Pain and nausea scores, treatment for pain and nausea, and patient satisfaction were recorded for 48 hours after CD. No differences were noted with respect to pain scores or treatment for pain over the 48 hours. There were no differences to the presence of nausea (P = 0.64), treatment for nausea (P = 0.21), pruritus (P = 0.39), emesis (P = 0.35), or patient satisfaction (P = 0.29). There were no differences in pain and nausea scores over the measured time periods (MANOVA, P > 0.05). In parturients receiving ITM for elective CD, IIIH block offers no additional postoperative benefit for up to 48 hours.