Bupivacaine Dosing for Cesarean Delivery in Parturients of Short Stature: A Retrospective Case-Control Study.

The ED50 and ED95 of spinal bupivacaine for cesarean delivery has been well described in the literature; however, parturients with extremes of stature have been excluded. Parturients of short stature are a height of ≤ 148 cm. This retrospective, case-control study evaluated anesthetic outcomes for parturients of short stature and controls who underwent cesarean delivery over a 10-year period. Women were matched for anesthetic type and body mass index. Data extracted included patient demographics and obstetric and anesthetic information. The primary outcome was dose of intrathecal bupivacaine. Categorical data were compared using a chi-squared test, continuous data were compared using a t-test or Mann-Whitney U test. Data for 26 women of short stature and 52 controls were evaluated. The mean dose of bupivacaine used for spinal anesthesia in parturients of short stature was 9.8 ± 1.0 mg (P <.0001). The mean intrathecal bupivacaine dose used in combined spinal epidural anesthesia was 10.5 mg (interquartile range, 9-10.9) in parturients of short stature (P = .002). All but one patient of short stature achieved an adequate surgical level; there were no instances of high spinal blockade. Adequate surgical anesthesia was achieved with reduced dosing of spinal bupivacaine in parturients of short stature without an increase in adverse outcomes.

Resident Competency and Proficiency in Combined Spinal-Epidural Catheter Placement Is Improved Using a Computer-Enhanced Visual Learning Program: A Randomized Controlled Trial.

BACKGROUND: Physician educators must balance the need for resident procedural education with clinical time pressures as well as patient safety and comfort. Alternative educational strategies, including e-learning tools, may be beneficial to orient novice learners to new procedures and speed proficiency. We created an e-learning tool (computer-enhanced visual learning [CEVL] neuraxial) to enhance trainee proficiency in combined spinal-epidural catheter placement in obstetric patients and performed a randomized controlled 2-center trial to test the hypothesis that use of the tool improved the initial procedure performed by the anesthesiology residents. METHODS: Anesthesiology residents completing their first obstetric anesthesiology rotation were randomized to receive online access to the neuraxial module (CEVL group) or no access (control) 2 weeks before the rotation. On the first day of the rotation, residents completed a neuraxial procedure self-confidence scale and an open-ended medical knowledge test. Blinded raters observed residents performing combined spinal-epidural catheter techniques in laboring parturients using a procedural checklist (0-49 pts); the time required to perform the procedure was recorded. The primary outcome was the duration of the procedure. RESULTS: The CEVL group had significantly shorter mean (±standard deviation) procedure time compared to the control group 22.5 ± 4.9 vs 39.5 ± 7.1 minutes (P < .001) and had higher scores on the overall performance checklist 36.4 ± 6.6 vs 28.8 ± 7.1 (P = .012). The intervention group also had higher scores on the open-ended medical knowledge test (27.83 ± 3.07 vs 22.25 ± 4.67; P = .002), but self-confidence scores were not different between groups (P = .64). CONCLUSIONS: CEVL neuraxial is a novel prerotation teaching tool that may enhance the traditional initial teaching of combined spinal-epidural procedures in obstetric anesthesiology. Future research should examine whether the use of web-based learning tools impacts long-term provider performance or patient outcomes.

Anesthetic management for Cesarean delivery in parturients with a diagnosis of dwarfism.

PURPOSE: The literature on the anesthetic management of parturients with dwarfism is sparse and limited to isolated case reports. Pregnancy complications associated with dwarfism include an increased risk of respiratory compromise, an increased risk of Cesarean delivery, and an unpredictable degree of anesthesia with neuraxial techniques. Therefore, we conducted this retrospective review to evaluate the anesthetic management of parturients with a diagnosis of dwarfism. METHODS: We used a query of billing data to identify short statured women who underwent a Cesarean delivery during May 1, 2008 to May 1, 2013. We then hand searched the electronic medical record for qualifying patients with heights < 148 cm and a diagnosis of dwarfism. The extracted data included patient demographics and obstetric and anesthetic information. RESULTS: We identified 13 women with dwarfism who had 15 Cesarean deliveries in total. Twelve of the women had disproportionate dwarfism, and ten of the 15 Cesarean deliveries were due to cephalopelvic disproportion. Neuraxial anesthesia was attempted in 93% of deliveries. The dose chosen for initiation of neuraxial anesthesia was lower than the typical doses used in parturients of normal stature. Neuraxial anesthetic complications included difficult neuraxial placement (64%), high spinal (7%), inadequate surgical level (13%), and unrecognized intrathecal catheter (7%). CONCLUSIONS: The data collected suggest that females with a diagnosis of dwarfism may have difficult neuraxial placement and potentially require lower dosages of local anesthetic for both spinal and epidural anesthesia to achieve adequate surgical blockade.