Obstetric and anesthetic management in parturients with ventriculoperitoneal shunt: a case series.

Further study is needed to determine the safest mode of delivery and anesthetic management for parturients with ventriculoperitoneal shunts (VP). Prior recommendation for delivery in women with ventriculoperitoneal shunts was cesarean delivery. However, both vaginal delivery and neuraxial anesthesia have been shown to be safe in women with appropriately functioning VP shunts. We present a case series of parturients with VP shunt. Parturients with VP shunts were identified and VP shunt placement indications, neurologic symptoms during pregnancy, delivery mode, anesthetic type, and postpartum complications were reviewed. Forty patients were identified, and fifteen women with twenty deliveries were included. Two women experienced neurological symptoms during pregnancy and one required postpartum shunt revision for blurry vision and ataxia. There were ten cesarean deliveries and ten vaginal deliveries (eight normal spontaneous, one vacuum assisted, and one forceps assisted). Assisted vaginal deliveries were performed to decrease Valsalva including the patient with neurological symptoms related to shunt malfunction. Of the vaginal deliveries, six (60%) had epidural analgesia. Anesthesia for cesarean delivery included neuraxial anesthesia (n = 5) and general anesthesia (n = 5). In our cohort, women with VP shunt received neuraxial blockade without complication. Neuraxial techniques should be offered to women with appropriately functioning VP shunt.

Effect of an increased dose of intrathecal fentanyl on cesarean delivery anesthesia at a Texas level IV maternal care center.

Background: We hypothesized that increasing our intrathecal fentanyl dose for cesarean delivery from 10 µg to 15 µg would result in fewer patients receiving a rescue analgesia intervention. Methods: Patients who had a cesarean delivery from February 15, 2021 to February 14, 2023 and received a single injection spinal or combined spinal-epidural anesthetic for cesarean delivery were eligible for inclusion. We defined a rescue analgesia intervention as administration of local anesthetic through an epidural catheter, administration of systemic anesthetic adjuvant medication, or conversion to general anesthesia. Results: A total of 520 and 556 patients received 10 µg and 15 µg of intrathecal fentanyl for cesarean delivery, respectively, of which 154 (29.6%) and 122 (21.9%) patients required rescue analgesia interventions, respectively (P = 0.004). The odds ratio for receiving a rescue analgesia intervention was 0.668 (95% confidence interval 0.507 to 0.880; P = 0.004) for patients who received 15 µg of intrathecal fentanyl compared to 10 µg. Conclusion: Following implementation of an increased dose of intrathecal fentanyl, patients who received 15 µg of intrathecal fentanyl for cesarean delivery were approximately 33% less likely to require a rescue analgesia intervention during cesarean delivery compared to patients who received 10 µg.

Qualitative Assessment of Perioperative Lactation Patient Education: "I Think It's Something Women Navigate on Their Own".

Background: Patients who are lactating at the time of a procedure requiring anesthesia benefit from specific education and care coordination to support continued lactation and avoid complications. Before design and implementation of a comprehensive care pathway for this patient population at our institution, we sought to elicit the patient perspective. Methods: We conducted semistructured qualitative interviews with eight patients by phone regarding their experience as a lactating patient presenting for a procedure with anesthesia care at our institution. These were analyzed for predominant themes regarding their experiences. Results: The patients we interviewed reported receiving conflicting information and feeling a sense of uncertainty. Some patients experienced preventable health effects such as mastitis, and prior experience with breastfeeding was protective. The interviewed patients endorsed a desire for structured support and improved education resources. Discussion: This qualitative study of lactating patients undergoing anesthesia and surgery demonstrates a need for coordinated perioperative lactation care. A structured pathway for this patient population with access to updated care guidelines and patient education would be welcomed.

Mental Health Questions on State Medical License Applications and Evaluation of Updates.

This cross-sectional study evaluates the consistency of US medical license renewal applications with the Federation of State Medical Boards recommendations for questions regarding physician mental health.

A comparison of anesthetic outcomes between activation and removal of epidural catheters for patients who underwent unscheduled intrapartum cesarean delivery.

Background: We hypothesized that patients who underwent unscheduled intrapartum cesarean delivery and had removal of an indwelling epidural catheter followed by an attempt of a new regional anesthetic would be more likely to have regional anesthesia without conversion to general anesthesia or administration of additional anesthetic medication compared to patients who had activation of an epidural catheter. Methods: Patients who had an unscheduled intrapartum cesarean delivery from July 1, 2019, through June 30, 2021, who had an indwelling labor epidural catheter were included. Patients were propensity matched based on obstetric indication for cesarean delivery and number of physician-administered rescue analgesia boluses administered during labor. A multivariate proportional odds regression was performed. Results: After adjusting for parity, depression, last neuraxial labor analgesic technique, physician-administered rescue analgesia boluses, and duration from neuraxial placement to entering the operating room for cesarean delivery, patients who had removal of their epidural catheters were more likely to have regional anesthesia without conversion to general anesthesia or administration of additional anesthetic medication (odds ratio 4.298; 95% confidence interval 2.448, 7.548; P < 0.01). Conclusion: Removal of epidural catheters was associated with a greater chance of avoiding conversion to general anesthesia or administration of additional anesthetic medication.

Effect of an oxytocin protocol on secondary uterotonic use in patients undergoing Cesarean delivery.

PURPOSE: Protocol-driven oxytocin regimens can reduce oxytocin administration compared with a nonprotocol free-flow continuous infusion. Our aim was to compare secondary uterotonic use between a modified "rule of threes" oxytocin protocol and a free-flow continuous oxytocin infusion after Cesarean delivery. METHODS: We conducted a retrospective before-and-after study to compare patients who underwent Cesarean delivery between 1 January 2010 and 31 December 2013 (preprotocol) with patients who underwent Cesarean delivery between 1 January 2015 and 31 August 2017 (postprotocol). The preprotocol group received free-flow oxytocin administration and the postprotocol group received oxytocin according to a modified rule of threes algorithm. The primary outcome was secondary uterotonic use and the secondary outcomes included blood transfusion, hemoglobin value < 8 g·dL-1, and estimated blood loss. RESULTS: In total, 4,010 Cesarean deliveries were performed in 3,637 patients (2,262 preprotocol and 1,748 postprotocol). The odds of receiving secondary uterotonic drugs were increased in the postprotocol group (odds ratio [OR], 1.33; 95% confidence interval [CI], 1.04 to 1.70; P = 0.02). Patients in the postprotocol group were less likely to receive a blood transfusion. Nevertheless, the two groups were similar for the composite end point of transfusion or hemoglobin < 8 g·dL-1 (OR, 0.86; 95% CI, 0.66 to 1.11; P = 0.25). The odds of an estimated blood loss greater than 1,000 mL were reduced in the postprotocol group (OR, 0.64; 95% CI, 0.50 to 0.84; P = 0.001). CONCLUSIONS: Patients in the modified rule of threes oxytocin protocol group were more likely to receive a secondary uterotonic than those in the preprotocol group. Estimated blood loss and transfusion outcomes were similar.

RéSUMé: OBJECTIF: Les schémas thérapeutiques d'ocytocine basés sur un protocole peuvent réduire l'administration d'ocytocine par rapport à une perfusion continue en débit libre hors protocole. Notre objectif était de comparer l'utilisation secondaires d'agents utérotoniques entre un protocole modifié d'ocytocine en « règle de trois ¼ et une perfusion continue d'ocytocine à débit libre après un accouchement par césarienne. MéTHODE: Nous avons mené une étude rétrospective avant-après pour comparer les personnes ayant bénéficié d'une césarienne entre le 1er janvier 2010 et le 31 décembre 2013 (pré-protocole) avec les personnes ayant subi une césarienne entre le 1er janvier 2015 et le 31 août 2017 (post-protocole). Le groupe pré-protocole a reçu une administration d'ocytocine en débit libre et le groupe post-protocole a reçu de l'ocytocine selon un algorithme de règle de trois modifié. Le critère d'évaluation principal était l'utilisation secondaire d'agents utérotoniques et les critères d'évaluation secondaires incluaient la transfusion sanguine, un indice d'hémoglobine < 8 g·dL­1 et les pertes de sang estimées. RéSULTATS: Au total, 4010 accouchements par césarienne ont été réalisés chez 3637 patient·es (2262 pré-protocole et 1748 post-protocole). Les chances de recevoir des médicaments utérotoniques secondaires étaient plus élevées dans le groupe post-protocole (rapport de cotes [RC], 1,33; intervalle de confiance [IC] à 95 %, 1,04 à 1,70; P = 0,02). Les patient·es du groupe post-protocole étaient moins susceptibles de recevoir une transfusion sanguine. Néanmoins, les deux groupes étaient similaires en ce qui touchait au critère d'évaluation composite de transfusion ou d'hémoglobine < 8 g·dL­1 (RC, 0,86; IC 95, 0,66 à 1,11; P = 0,25). Les risques d'une perte de sang estimée supérieure à 1000 mL ont été réduits dans le groupe post-protocole (RC, 0,64; IC 95 %, 0,50 à 0,84; P = 0,001). CONCLUSION: Les patient·es du groupe du protocole d'ocytocine en règle de trois modifiée étaient plus susceptibles de recevoir un utérotonique secondaire que les personnes du groupe pré-protocole. Les pertes sanguines estimées et les résultats transfusionnels étaient similaires.

Peripartum anesthetic management in patients with Ebstein anomaly: a case series.

Ebstein anomaly is a rare congenital cardiac condition associated with displacement and incompetence of the tricuspid valve. Peripartum anesthetic management can be particularly challenging since these patients are at high risk of cardiac failure and tachyarrhythmias. Risk stratification is important since it helps to identify high-risk patients who should deliver at a tertiary care center where a multidisciplinary team (obstetrics, cardiology, anesthesiology, and neonatology) is immediately available. We describe the peripartum anesthetic management of 9 patients with Ebstein anomaly who underwent 12 deliveries at our institution. All patients tolerated neuraxial anesthesia and analgesia well. No maternal or fetal deaths occurred.

Postgraduate-Year-1 Residents' Perceptions of Social Media and Virtual Applicant Recruitment: Cross-sectional Survey Study.

BACKGROUND: The dissemination of information about residency programs is a vital step in residency recruitment. Traditional methods of distributing information have been printed brochures, websites, in-person interviews, and increasingly, social media. Away rotations and in-person interviews were cancelled, and interviews were virtual for the first time during the COVID-19 pandemic. OBJECTIVE: The purpose of our study was to describe postgraduate-year-1 (PGY1) residents' social media habits in regard to residency recruitment and their perceptions of the residency programs' social media accounts in light of the transition to virtual interviews. METHODS: A web-based 33-question survey was developed to evaluate personal social media use, perceptions of social media use by residency programs, and perceptions of the residency program content. Surveys were sent in 2021 to PGY1 residents at Mayo Clinic in Arizona, Florida, and Minnesota who participated in the 2020-2021 interview cycle. RESULTS: Of the 31 program directors contacted, 22 (71%) provided permission for their residents to complete the survey. Of 219 residents who received the survey, 67 (30%) completed the survey. Most respondents applied to a single specialty, and greater than 61% (41/67) of respondents applied to more than 30 programs. The social media platforms used most regularly by the respondents were Instagram (42/67, 63%), Facebook (36/67, 54%), and Twitter (22/67, 33%). Respondents used the program website (66/67, 99%), residents (47/67, 70%), and social media (43/67, 64%) as the most frequent resources to research programs. The most commonly used social media platforms to research programs were Instagram (38/66, 58%), Twitter (22/66, 33%), and Doximity (20/66, 30%). The type of social media post ranked as most interesting by the respondents was "resident life outside of the hospital." In addition, 68% (39/57) of the respondents agreed or strongly agreed that their perception of a program was positively influenced by the residency program's social media account. CONCLUSIONS: In this multispecialty survey of PGY1 residents participating in the 2020-2021 virtual interview season, respondents preferred Instagram to Twitter or Facebook for gathering information on prospective residency programs. In addition, the program website, current residents, and social media platforms were the top-ranked resources used by prospective applicants. Having an up-to-date website and robust social media presence, particularly on Instagram, may become increasingly important in the virtual interview environment.

Screening for peripartum cardiomyopathies using artificial intelligence in Nigeria (SPEC-AI Nigeria): Clinical trial rationale and design.

BACKGROUND: Artificial intelligence (AI), and more specifically deep learning, models have demonstrated the potential to augment physician diagnostic capabilities and improve cardiovascular health if incorporated into routine clinical practice. However, many of these tools are yet to be evaluated prospectively in the setting of a rigorous clinical trial-a critical step prior to implementing broadly in routine clinical practice. OBJECTIVES: To describe the rationale and design of a proposed clinical trial aimed at evaluating an AI-enabled electrocardiogram (AI-ECG) for cardiomyopathy detection in an obstetric population in Nigeria. DESIGN: The protocol will enroll 1,000 pregnant and postpartum women who reside in Nigeria in a prospective randomized clinical trial. Nigeria has the highest reported incidence of peripartum cardiomyopathy worldwide. Women aged 18 and older, seen for routine obstetric care at 6 sites (2 Northern and 4 Southern) in Nigeria will be included. Participants will be randomized to the study intervention or control arm in a 1:1 fashion. This study aims to enroll participants representative of the general obstetric population at each site. The primary outcome is a new diagnosis of cardiomyopathy, defined as left ventricular ejection fraction (LVEF) < 50% during pregnancy or within 12 months postpartum. Secondary outcomes will include the detection of impaired left ventricular function (at different LVEF cut-offs), and exploratory outcomes will include the effectiveness of AI-ECG tools for cardiomyopathy detection, new diagnosis of cardiovascular disease, and the development of composite adverse maternal cardiovascular outcomes. SUMMARY: This clinical trial focuses on the emerging field of cardio-obstetrics and will serve as foundational data for the use of AI-ECG tools in an obstetric population in Nigeria. This study will gather essential data regarding the utility of the AI-ECG for cardiomyopathy detection in a predominantly Black population of women and pave the way for clinical implementation of these models in routine practice. TRIAL REGISTRATION: Clinicaltrials.gov: NCT05438576.

Diabetes insipidus related to sedation in the intensive care unit: A review of the literature.

PURPOSE: To identify cases of diabetes insipidus (DI) related to sedation in the ICU to determine which medications pose the greatest risk and understand patterns of presentation. MATERIALS AND METHODS: We searched PubMed, Embase, Scopus, Google Scholar, and Web of Science. Search terms included "polyuria," "diabetes insipidus," "hypnotics and sedatives," "sedation," as well as individual medications. Case reports or series involving DI or polyuria related to sedation in the ICU were identified. RESULTS: We identified 21 cases of diabetes insipidus or polyuria in the ICU attributed to a sedative. Dexmedetomidine was implicated in 42.9% of cases, followed by sevoflurane (33.3%) and ketamine (23.8%). Sevoflurane was implicated in all 7 cases in which it was used (100%; 95% CI 59.0%, 100.0%), dexmedetomidine in 9 of 11 cases (81.8%; 95% CI 48.2, 97.7), and ketamine in 5 of 9 cases (55.6%; 95% CI 21.2%, 86.3%). CONCLUSIONS: Awareness of the potential for sedatives to cause DI may lead to greater identification with swifter medication discontinuation and subsequent resolution of DI.

Evaluating the cost-effectiveness of testing pregnant women for penicillin allergy.

INTRODUCTION: True penicillin allergy is rare and is commonly incorrectly reported. In fact, less than five percent of patients who report a penicillin allergy will have a currently active clinically-significant IgE- or T-cell-mediated hypersensitivity when appropriately tested. Penicillin is the agent of choice for intrapartum antibiotic prophylaxis to reduce the risk of group B streptococcus early-onset disease in the newborn. Inaccurate penicillin allergy status may lead to inappropriate antibiotic use, as most alternative drugs are more expensive and broader spectrum than penicillin. Penicillin allergy testing has been found to be safe in pregnancy and cost-effective in other patient populations. OBJECTIVE: To evaluate the cost-effectiveness of penicillin allergy testing and appropriate antibiotic treatment (test then treat strategy) compared to usual care among pregnant women. METHODS: We developed a decision tree to evaluate the cost of providing appropriate care via a test then treat strategy for pregnant women who report a penicillin allergy, compared to usual care. RESULTS: Using the test then treat strategy the additional cost to ensure appropriate care for all pregnant women who report a penicillin allergy, was $1122.38 per person. Adopting a test then treat strategy increased the number of appropriate antibiotic use from 7,843/10,000 to 10,000/10,000 simulations. CONCLUSION: Our results show that a test then treat strategy for pregnant women who report a penicillin allergy is a good-value intervention.

Dexmedetomidine-associated diabetes insipidus during skull base surgery in a pediatric patient.

Diabetes insipidus is characterized by polyuria due to an inability to auto-regulate water balance resulting in dangerous metabolic derangements. Intraoperative anesthetics have been increasingly identified as a cause of diabetes insipidus in adult patients; however, it is rare in pediatrics. We present a case of a 16-year-old male undergoing resection of a recurrent left juvenile nasopharyngeal angiofibroma who experienced intraoperative polyuria concerning diabetes insipidus. Urine output drastically decreased following discontinuation of dexmedetomidine with complete resolution within 24 h. We conclude that this case of transient diabetes insipidus was associated with dexmedetomidine administration.

Care for the Obstetric Patient with Complex Cardiac Disease.

The prevalence of cardiac disease-related maternal morbidity and mortality is on the rise in the United States. To ensure safe management of pregnancy in patients with cardiovascular disease, pre-delivery evaluation by a multidisciplinary Pregnancy Heart Team should occur. Appropriate anesthetic, cardiac, and obstetric care are essential. Risk stratification tools evaluate the etiology and severity of cardiovascular disease to determine the appropriate hospital type and location for delivery and anesthetic management. Intrapartum hemodynamic monitoring may need to be intensified, and neuraxial analgesia and anesthesia are generally appropriate. The anesthesiologist must be prepared for obstetric and cardiac emergencies.

Predictors of intraoperative pain during cesarean delivery under regional anesthesia.

It is unclear why some patients experience pain during cesarean delivery despite receiving appropriate regional anesthesia. Our primary aim was to determine what demographic and clinical variables predict intraoperative pain during cesarean delivery with neuraxial anesthesia. From July 2019 through March 2020, we administered a previously validated patient satisfaction survey to parturients who had a cesarean delivery under regional anesthesia for nonemergent obstetric indications. We performed a post hoc analysis restricted to subjects who had single injection spinal and combined spinal-epidural anesthesia. Parturients who did and did not report pain differed in height, intrathecal hyperbaric bupivacaine dose, and the time from incision to wound closure. We performed an ordinal logistic regression analysis on the 168 subjects with complete data using the aforementioned variables along with the time of day of cesarean delivery. Incision to wound closure time (P < 0.01) predicted intraoperative pain. The multivariate logistic regression model was statistically significant (P < 0.01) and had a receiver operator curve value of 0.74. The duration of time from incision to wound closure predicted intraoperative pain during cesarean delivery under regional anesthesia.

A Nationwide Cross-Sectional Survey of Anesthesiology Fellowship Program Directors: Attitudes on Parental Leave in Residency and Fellowship Training.

Introduction: Little is known about the impact of parental leave on anesthesiology fellowship directors' perception of their fellows. In addition, use of parental leave during residency can result in "off-cycle" residents applying for a fellowship. This study sought to clarify fellowship directors' attitudes and beliefs on effects of parental leave on fellows and off-cycle fellowship applicants. Methods: An online survey was sent to anesthesiology fellowship program directors through e-mail addresses obtained from websites of the Accreditation Council for Graduate Medical Education and specialty societies. Descriptive statistical analysis was used. Results: In total, 101 fellowship directors (31% response rate) completed the survey. Forty-one (41%) directors had a fellow who took maternity leave in the past 3 years. Among the programs, 49 (49%) have a written policy about maternity leave and 36 (36%) have a written paternity or partner leave policy. Overall, most fellowship directors believed that becoming a parent had no impact on fellow performance and professionalism; more respondents perceived a greater negative impact on scholarly activities, standardized test scores, and procedural volume for female trainees than male trainees. Some fellowship directors (10/94; 11%) reported they do not allow off-cycle residents in their program. Among programs that allow off-cycle residents, more directors perceived it a disadvantage rather than an advantage. Conclusions: Fellowship directors perceive that anesthesiology residents who finish training outside the typical graduation cycle are at a disadvantage for fellowship training.

Beyond the epidural: Alternatives to neuraxial labor analgesia.

Labor creates an intense pain experienced by women across the world. Although neuraxial analgesia is the most effective treatment of labor pain, in many cases, it may not be undesired, not available, or have contraindications. In addition, satisfaction with labor analgesia is not only determined by the efficacy of analgesia but a woman's sense of agency and involvement in the childbirth experience are also key contributors. Providing safe choices for labor analgesia and support is central to creating a tailored, safe, and effective analgesic treatment plan with high maternal satisfaction. Healthcare provider knowledge of various nonneuraxial analgesic options, including efficacy, contraindications, safe clinical implementation, and side effects of various techniques is needed for optimal patient care and satisfaction. Future rigorous scientific studies addressing all of these labor analgesia options are needed to improve our understanding. This review summarizes the current published literature for commonly available non-neuraxial labor analgesic options.

Association of an Obstetric Surgical Closing Protocol With Infection After Cesarean Delivery.

OBJECTIVE: To examine surgical site infection rates before and after the addition of a closing protocol to an existing surgical site infection risk-reduction bundle used during cesarean delivery. METHODS: We conducted a single-center retrospective cohort study to review the association of a closing protocol with rates of surgical site infection after cesarean delivery. The closing protocol included fresh surgical instruments and physician and scrub nurse glove change before fascia closure. Surgical site infections were defined using Centers for Disease Control and Prevention criteria. Eligible patients underwent cesarean delivery at our institution from July 1, 2013, through December 31, 2015 (n=1,708; preimplementation group), or from June 1, 2016, through April 30, 2018 (n=1,228; postimplementation group). RESULTS: The surgical site infection rate was 2.3% preimplementation and 2.7% postimplementation (difference 0.4%, 95% CI -1.6 to 0.7%]. The mean [SD] duration of the surgical procedure was longer postimplementation (59.6 [23.7] vs 55.6 [21.5] minutes; P<.001). CONCLUSION: Addition of a closing tray and glove change to our existing surgical site infection risk-reduction bundle was not associated with a reduction in the frequency of postcesarean surgical site infection but was associated with longer operating times.

Perioperative Diabetes Insipidus Caused by Anesthetic Medications: A Review of the Literature.

Diabetes insipidus (DI) is an uncommon perioperative complication that can occur secondary to medications or surgical manipulation and can cause significant hypovolemia and electrolyte abnormalities. We reviewed and evaluated the current literature and identified 29 cases of DI related to medications commonly used in anesthesia such as propofol, dexmedetomidine, sevoflurane, ketamine, and opioids. This review summarizes the case reports and frequency of DI with each medication and presents possible pathophysiology. Medication-induced DI should be included in the differential diagnosis when intraoperative polyuria is identified. Early identification, removal of the agent, and treatment of intraoperative DI are critical to minimize complications.

Analgesic considerations for induction of labor.

Induction of labor may be indicated to minimize maternal and fetal risks. The rate of induction is likely to increase as recent evidence supports elective induction at 39 weeks gestation. We review methods of induction and then analgesic options as they relate to indications and methods to induce labor. We specifically focus on parturients at high risk for anesthetic complications including those requiring anticoagulation, and those with cardiac disease, obesity, chorioamnionitis, prior spinal instrumentation, elevated intracranial pressure, known or anticipated difficult airway, thrombocytopenia, and preeclampsia. Guidelines regarding timing of anticoagulation dosing with neuraxial anesthetic techniques have been defined through consensus statements. Early epidural placement may be beneficial in patients with cardiac disease, obesity, anticipated difficult airway, and HELLP syndrome. Questions remain regarding how early is too early for epidural placement, what options are safest for patients with bacteremia, and what pain relief should be offered to those unable to tolerate cervical exams in early labor.