Education in obstetric anesthesiology: an international approach.

Competency-based training and active teaching methods are increasingly becoming accepted and utilized in medical schools and hospitals, and obstetric anesthesiology training is expected to follow this process. This article summarizes current modalities of obstetric anesthesiology training in five countries from various parts of the world. Analysis of these curricula shows that implementation of new educational methods is variable, incomplete, and lacking in data related to patient outcomes. Research in assessments and practical applications are required to avoid wide ranges of educational strategies.

Prevention of postdural puncture headache after accidental dural puncture: a quantitative systematic review.

No clear consensus exists on how to best prevent severe headache from occurring after accidental dural puncture. We conducted a quantitative systematic review to identify all available evidence for the prevention of postdural puncture headache (PDPH) and included 17 studies with 1264 patients investigating prophylactic epidural blood patch (PEBP), epidural morphine, intrathecal catheters, and epidural or intrathecal saline. The relative risk (RR) for headache after PEBP was 0.48 [95% confidence interval (CI): 0.23-0.99] in five non-randomized controlled trials (non-RCTs) and 0.32 (0.10-1.03) in four randomized controlled trials (RCTs). The RR for epidural morphine (based on a single RCT) was 0.25 (0.08-0.78). All other interventions were based on non-RCTs and failed statistical significance, including long-term intrathecal catheters with an RR of 0.21 (0.02-2.65). There are a number of promising options to prevent PDPH, yet heterogeneity between the studies and publication bias towards small non-RCTs with positive results limits the available evidence. Thus, a large multicentre RCT is needed to determine the best preventative practices.

Predicting prolonged fetal heart rate deceleration following intrathecal fentanyl/bupivacaine.

BACKGROUND: Intrathecal opioids for labor analgesia are occasionally associated with fetal heart rate abnormalities. We wanted to identify risk factors for this occurrence. METHODS: The fetal tracings of 151 consecutive patients were reviewed for the period including 30 min before and 60 min after combined spinal-epidural analgesia using intrathecal bupivacaine with fentanyl. Their progress of labor at injection was also recorded. RESULTS: Lack of fetal head engagement (odds ratio 5.5, 95% CI 2.1-14.2) and the presence of variable fetal heart rate decelerations (odds ratio 3.6, 95% CI 1.6-8.4) were associated with prolonged fetal heart rate deceleration after combined spinal-epidural analgesia. CONCLUSION: This case-control study suggests that if the fetal head is not engaged or if the fetus is experiencing variable decelerations, there is an increased risk of prolonged fetal heart rate deceleration following intrathecal fentanyl/bupivacaine. This finding must now be confirmed in a cohort study.

Glass recycling in the labour suite is environmentally sound and economical.

BACKGROUND: Glass bottles are used for the storage of local anaesthetics in the US and are recyclable. Recycling would result in hospital solid waste reduction. METHODS: The members of the Department of Anaesthesia were surveyed to determine where these local anaesthetic bottles were disposed of. From November 2002 to April 2003, glass bottles used on the labour and delivery suite were saved for recycling. The number of bottles and the weight recycled were recorded. The number of procedures involving anaesthesia were also recorded during this time period. RESULTS: Residents dispose of the local anaesthetic bottle in the sharps container while consultants dispose of them in the trash (P<0.05). Both means of disposal are not recycled in the US. The average amount of glass recycled per month was 19.37 (3.15) kg. Our hospital pays $0.46/kg (0.26 UK pound/kg) for sharps disposal. By not disposing of the glass in the sharps container, the average savings per month was $8.95 (1.45) (5.15 UK pounds (0.84)). CONCLUSION: The recycling of glass is good for the environment through waste reduction and results in small savings to the hospital.

[Airway challenge testing - accuracy of the interrupter technique]. / Die Bestimmung der bronchialen Sensitivität - ist die Widerstandsmessung mittels Unterbrechermethode ein zuverlässiges Verfahren?

According to national and international recommendations the bronchial sensitivity should be determined based on the decrease of the FEV1 by 20 % (FEV1 - 20) or the increase of the airway resistance by means of body plethysmography by 100 % (Raw + 100). Measurement of airway resistance by interrupter technique (Rint) is a simple method and needs no active cooperation of the patient, but is not recommended in airway challenge testing. We investigated the role of the increase of Rint by 100 % (Rint + 100) compared to Raw + 100 and FEV1 - 20 during carbachol airway challenge testing by means of dosimetry. We examined 123 patients with following symptoms: 85 x coughing, 31 x coughing and dyspnea, 7 x medical opinion. Significant correlations between Rint and Raw were found before and after the challenge tests (Rint before/after 0,3 +/- 0,13/0,36 +/- 0,25 kPa*s/l; Raw before/after 0,24 +/- 0,09/0,50 +/- 0,41 kPa*s/l; r = 0,504/0,672; p < 0,001 [Pearson]). The median values of Rint and Raw were significantly different (p < 0,001 [Wilcoxon]). Moreover Rint systematically overestimated airway resistance in the normal range and underestimated the increase of airway resistance during challenge testing (r = 0,783; p < 0,001 [Pearson]). In 58 patients an increased airway responsiveness was found. In 21 oft these patients there was no increase of Rint above the initial value. Sensitivity/specificity/positive predictive value/negative predictive value in % to the detection of airway hyperresponsiveness were in Rint + 100 9/95/63/54, in FEV1 - 20 61/100/100/66 and in Raw + 100 98/100/100/98. In conclusion we found significant correlations between Rint and Raw, but the median values were systematically and significantly different. Rint + 100 had a low sensitivity to detect airway hyperresponsiveness and is not comparable with FEV1 - 20 or Raw + 100.

Anesthesiologists' interest in neonatal resuscitation certification.

STUDY OBJECTIVE: To survey graduates from our residency program to determine their involvement and their interest in becoming certified in neonatal resuscitation. DESIGN: Survey questionnaire. SETTING: Graduates from the University of Pennsylvania Anesthesia Program between 1989 and 1999. SUBJECTS: 212 individuals completed the residency; addresses were available for 189 and the response rate for these individuals was 156. RESULTS: Of the respondents with obstetric anesthesia responsibilities, 65% have been involved in resuscitation of the newborn. Sixteen percent were certified, but 81% were interested in certification. If the hospital had less than 1000 deliveries per year, the probability of the anesthesiologist having to perform neonatal resuscitation was 11.0 times greater than if the hospital had more than 1000 deliveries per year (confidence interval, 1.4--86). CONCLUSIONS: Despite guidelines recommending the contrary, anesthesiologists are involved in the resuscitation of the newborn. The majority of these individuals are not certified but are interested in becoming certified. The ASA should establish programs to offer the opportunity to learn and to reinforce these skills.

Should intrathecal lidocaine be used in the 21st century?

Hyperbaric 5% lidocaine has been available for intrathecal use since 1954. The initial studies concluded that it was a safe drug for short procedures. Recently, the use of this drug for spinal anesthesia has been questioned. There were cases of cauda equina syndrome following its use for continuous spinal anesthesia. Following these occurrences, it was felt that lidocaine should not be used for continuous spinal anesthesia, rather for single-shot spinal anesthesia only. Intense follow-up of patients receiving intrathecal lidocaine for single-shot spinal anesthesia revealed a higher incidence of back pain radiating to the thighs and legs as compared to other drugs or general anesthesia. Although these symptoms have been linked to the drug, there were other factors affecting the incidence. Lithotomy position was a more significant predictor for developing these symptoms. Furthermore, there are seven cases of cauda equina syndrome following single-shot hyperbaric lidocaine. Cauda equina syndrome is a permanent disability. It occurred in patients of varying ages and with doses ranging from 60 mg to 120 mg. There are safe alternatives to lidocaine for outpatient spinal anesthesia, such as bupivacaine, prilocaine, or mepivacaine. These drugs have a lower incidence of transient neurologic symptoms and do not delay discharge. Given the possibility of permanent neurologic injury and given that safe alternatives exist, one has to question whether intrathecal lidocaine should still be used in the 21st century.

Anesthesia for fetoscopic fetal surgery: twin reverse arterial perfusion sequence and twin-twin transfusions syndrome.

IMPLICATIONS: Twin reversed arterial perfusion sequence and twin-twin transfusion syndrome can be managed by fetoscopic fetal surgery. It is important to consider the fetal, uteroplacental, and maternal issues when choosing an anesthetic technique. We report on three patients with differing anesthetic issues using fetoscopic surgery for umbilical cord coagulation.

Teaching airway management skills. How and what to learn and teach.

It is important to instruct all individuals involved in patient care in airway management. The degree of skills actually taught depends on the student. Currently, there are many options for teaching. Mannequin training is the one best suited to instruct a large number of students in a variety of skills. Training of surgical and obstetric residents improves relations, may improve patient safety, and educates these individuals regarding the risks of failed intubation. Actual clinical decisions regarding patient management are based on the airway examination. There is room for improvement in instruction, even in anesthesiology programs. Various techniques must be taught and practiced. As more anesthesiologists become trained and then train other physicians, the number of cases in the Closed Claims Study involving the airway will continue to decrease.

Effects of immediately initiating an epidural infusion in the combined spinal and epidural technique in nulliparous parturients.

BACKGROUND AND OBJECTIVES: Intrathecal fentanyl with bupivacaine provides rapid labor analgesia of limited duration. We investigated the effect of initiating an epidural infusion of 0.1% ropivacaine with fentanyl 2 microg/mL and epinephrine 1:400,000 (REF) on the duration of analgesia and incidence of side effects after intrathecal injection in the combined spinal and epidural technique. METHODS: Thirty-four nulliparous parturients with a cervical dilation of 3 to 5 cm were randomized to receive epidural saline or REF at 10 mL following the intrathecal injection of fentanyl 25 microg and bupivacaine 2.5 mg. Degree of analgesia, severity of pruritus, motor block, blood pressure, and sensory level to coolness were assessed until the patient requested additional analgesia. RESULTS: Analgesia was significantly longer in the REF group, 158.4 +/- 59.6 minutes versus 103.8 +/- 26.2 minutes. The decrease in blood pressure compared with the blood pressure at intrathecal injection was greater for the REF group at all times, but achieved statistical significance at 60 minutes. There was no difference in ephedrine use, pruritus, or motor block between groups. There was no difference in sensory level to coolness at 90 minutes after intrathecal injection between groups. CONCLUSIONS: Initiating an infusion of REF prolongs the duration of analgesia, but also results in a greater decrease in blood pressure. Despite this effect on blood pressure, there was no difference in ephedrine use.

Comparison of combined spinal-epidural and low dose epidural for labour analgesia.

PURPOSE: To compare the combined spinal-epidural (CSE) technique with the epidural technique with regard to time to initiate and manage, motor block, onset of analgesia and satisfaction during labour. METHODS: Upon requesting analgesia, 50 healthy term parturients were randomized in a prospective, double-blind fashion to receive either CSE analgesia or lumbar epidural analgesia in the labour floor of a university hospital at an academic medical centre. The epidural group (n = 24) received bupivacaine 0.0625%-fentanyl 0.0002% with 0.05 ml in 10 ml local anesthetic sodium bicarbonate 8.4% and epinephrine 1:200,000. The CSE group (n = 26) received intrathecal 25 microg fentanyl and 2.5 mg bupivacaine. Additional analgesia was provided upon maternal request. RESULTS: There were no differences (P>0.05) in time to perform either technique, motor blockade, or parturient satisfaction or in the number of times that the anesthesiologist was called to perform any intervention. Although the first sign of analgesia was not different between the two groups, the onset of complete analgesia was more rapid with the CSE technique (Visual Analogue Pain Score (VAPS) at five minutes < three: 26/26 vs. 17/24, P+/-0.001). CONCLUSION: Although epidural analgesia with a low concentration of local anesthetic and opioid mixture takes longer to produce complete analgesia, it is a satisfactory alternative to CSE.

Obstetricians' ability to assess the airway.

OBJECTIVES: To assess the ability of obstetricians to recognize parturients at risk for difficult intubation and to examine the effect of education in airway examination on that ability. METHODS: The airways of 160 parturients were examined by four physicians: one attending and one resident obstetrician, and one attending and one resident anesthesiologist. After each airway examination, the physicians completed questionnaires about possible difficult intubation, use of antepartum consultation, and choice of analgesia early in labor. RESULTS: Instruction in airway examination did not affect obstetricians' ability to assess airways. Compared with the attending anesthesiologist's opinion, the sensitivity and specificity of the attending obstetrician before instruction were 0.59 and 0.82, respectively, and for the obstetric resident, 0.41 and 0.89, respectively. After instruction, the sensitivity and specificity for the obstetric attending physician were 0.60 and 0.83, respectively and for the obstetric resident, 0.50 and 0.87, respectively. In airways judged possible difficult intubations by the obstetricians, instruction did not affect the use of antepartum consultation or early epidural analgesia by the residents. In the obstetric attending physicians there was a significant increase in use of early epidural analgesia. CONCLUSION: Although instruction in airway examination did not affect obstetricians' ability to predict difficult airways, it did affect treatment of labor analgesia.

Anesthetic considerations for fetal surgery.

This article outlines the perioperative management of the parturient who presents for fetal surgery. Anesthetic considerations include the physiological changes of pregnancy, preterm labor, the consequences of tocolytic drugs, maternal and fetal anesthesia, and postoperative analgesia.

Comparative evaluation of four different infusion rates of ropivacaine (2 mg/mL) for epidural labor analgesia.

BACKGROUND AND OBJECTIVES: Previous studies have reported comparable efficacy for ropivacaine and bupivacaine when used for labor analgesia at concentrations of 2.5 mg/mL. In this multicenter study, we assessed ropivacaine at the commercially available concentration of 2 mg/mL (0.2%) for labor pain management. METHODS: After Institutional Review Board approval and informed consent, 128 women at term were randomly assigned to receive ropivacaine at one of the four infusion rates via a lumbar epidural catheter. Analgesia was initiated with a 5-mL test dose, followed by injections of 5-15 mL of 2 mg/mL ropivacaine. The continuous infusion was then started at 4, 6, 8, or 10 rmL/hour. Rescue analgesia was provided with 5-mL "top-up" injections as necessary to provide maternal comfort. Pain relief was assessed by using a visual analog pain scale (VAPS) and motor block was assessed by using a modified Bromage scale. RESULTS: All infusion regimens effectively decreased VAPS, and most patients in all groups had minimal or no motor block at the end of the first stage of labor. Mean total number of the top-up injections required per patient were 3, 2, 1.5, and 1.4, respectively, in the 4, 6, 8, and 10-mL/hour groups (P < .05, 4 mL/hour vs. all other groups). Despite receiving more total bolus dosages, the 4-mL/hour group had less motor block in the lower extremities (P < .05). Apgar scores and neurological adaptive capacity scores were similar for all groups. CONCLUSIONS: The 2 mg/mL of ropivacaine produces satisfactory labor analgesia at epidural infusion rates of 4, 6, 8, and 10 mL/hour, provided supplemental bolus dosages are available. Clinically, a rate of 6 mL/hour may be the lowest effective rate that provides the best combination of pain relief, motor block, and rebolusing, although rates of 8 and 10 mL/hour produced similar results.

Comparison of three different doses of intrathecal fentanyl and sufentanil for labor analgesia.

STUDY OBJECTIVE: To compare the duration of analgesia and incidence of side effects of three doses of intrathecal fentanyl (25 micrograms, 37.5 micrograms, 50 micrograms) with three doses of intrathecal sufentanil (5 micrograms, 10 micrograms, 15 micrograms). DESIGN: Randomized, double-blind study. SETTING: Labor suite of the Hospital of the University of Pennsylvania. PATIENTS: 60 ASA physical status I and II parturients in active labor who requested analgesia. INTERVENTIONS: Patients received one of the six doses of opioid diluted with normal saline to achieve a volume of 1.5 ml intrathecally. MEASUREMENTS AND MAIN RESULTS: Duration of analgesia, contraction pain, degree of pruritus, maternal blood pressure, maternal heart rate, fetal heart rate, Apgar scores, and neurologic and adaptive capacity scores were measured. There was no statistical difference among the doses of fentanyl in duration of analgesia. In addition, there was no statistical difference among the doses of sufentanil. The durations of analgesia for all doses of sufentanil were statistically longer than that for all doses of fentanyl. There was no difference among all the groups for maximal pruritus score. The duration of pruritus did not differ among doses of fentanyl or sufentanil; the duration of pruritus was significantly longer for sufentanil. All groups had a decrease in blood pressure. There was no difference among the groups in regard to the effect on the systolic or diastolic blood pressure. CONCLUSIONS: Intrathecal sufentanil produced analgesia of longer duration than fentanyl for all doses studied. The duration of pruritus with sufentanil was also longer.

Epidural lidocaine for cesarean delivery of the distressed fetus.

Lidocaine with epinephrine and sodium bicarbonate has a rapid onset of action. We therefore wished to compare its use with that of chloroprocaine for urgent cesarean delivery. Thirty parturients for cesarean section under epidural anesthesia were divided into three groups. Group 1 required elective cesarean section and served as the control group for neonatal lidocaine levels. Groups 2 and 3 had been receiving epidural infusions of 0.125% bupivacaine with epinephrine 1:400,000 and required urgent cesarean section. They were randomized to receive either 1.5% lidocaine with epinephrine or 3% chloroprocaine, both with sodium bicarbonate 2 ml in a total volume of 25 ml. All patients had adequate anesthesia and none required supplementation. The time from completion of injection to the achievement of a T4 sensory level was significantly shorter in the chloroprocaine group (3.1 vs. 4.4 min). There were no differences in Apgar scores or Neurologic and Adaptive Capacity Scores between the lidocaine and chloroprocaine groups. Lidocaine was detectable in maternal serum from four of the urgent cases and all of the elective cases. It was detectable in five neonates from the elective group but none from the emergency group. In parturients with preexisting epidural catheters and a baseline epidural infusion to maintain a T10 sensory level, chloroprocaine is faster in onset than lidocaine, but the difference in this study was only 1.3 min, and both agents provided excellent anesthesia.