Obstetric anesthesia services in Israel snapshot (OASIS) study: A 72 hour cross-sectional observational study of workforce supply and demand

BACKGROUND: We planned an observational study to assess obstetric anesthesia services nationwide. We aimed to assess the effect of the anesthesia workload/workforce ratio on quality and safety outcomes of obstetric anesthesia care. METHODS: Observers prospectively collected data from labor units over 72 h (Wednesday, Thursday and Friday). Independent variables were workload (WL) and workforce (WF). WL was assessed by the Obstetric Anesthesia Activity Index (OAAI), which is the estimated time in a 24-h period spent on epidurals and all cesarean deliveries. Workforce (WF) was assessed by the number of anesthesiologists dedicated to the labor ward per week. Dependent variables were the time until anesthesiologist arrival for epidural (quality measure) and the occurrence of general anesthesia for urgent Cesarean section, CS, (safety measure). This census included vaginal deliveries and unscheduled (but not elective) CS. RESULTS: Data on 575 deliveries are from 12 maternity units only, primarily because a major hospital chain chose not to participate; eight other hospitals lacked institutional review board approval. The epidural response rate was 94.4%; 321 of 340 parturients who requested epidural analgesia (EA) received it. Of the 19 women who requested EA but gave birth without it, 14 (77%) were due to late arrival of the anesthesiologist. Median waiting times for anesthesiologist arrival ranged from 5 to 28 min. The OAAI varied from 4.6 to 25.1 and WF ranged from 0 to 2 per shift. Request rates for EA in hospitals serving predominantly orthodox Jewish communities and in peripheral hospitals were similar to those of the entire sample. More than a fifth (13/62; 21%) of the unscheduled CS received general anesthesia, and of these almost a quarter (3/13; 23%) were attributed to delayed anesthesiologist arrival. CONCLUSIONS: Inadequate WF allocations may impair quality and safety outcomes in obstetric anesthesia services. OAAI is a better predictor of WL than delivery numbers alone, especially concerning WF shortage. To assess the quality and safety of anesthetic services to labor units nationally, observational data on workforce, workload, and clinical outcomes should be collected prospectively in all labor units in Israel

Периоперационный менеджмент абдоминальной гистерэктомии: новые подходы и обзор литературы

Абдоминальная гистерэктомия (АГ) является однй из наиболее распространенных операций, выполняемых при злокачественных, а также доброкачественных опухолях органов женской репродуктивной системы. Эффективный периоперационный менеджмент зависит от сотрудничества между хирургами, анестезиологами, гемостазиологами и службами управления болью лечебного учреждения и представляет собой сочетание упреждающей аналгезии, общей и региональной анестезии, изучения и регулирования функционального состояния системы гемостаза.Abdominal hysterectomy (AH) is one of the most common surgeries performed for malignant as well as benign indications. Effective perioperative managementdepends on the cooperation between the surgeons, anesthetists, hemostasiologists and the hospital’s pain management service, and is a combination of preemptive analgesia, general and regional anesthesia, studying and regulation of the functional state of the hemostasis system. The objective of this work is to present the currently available therapeutic strategies for the treatment of posthysterectomy pain and trombotic complications in the light of our experience and the literature review

Состояние новорожденных после конверсии эпидуральной анальгезии в анестезию при кесаревом сечении: проспективное рандомизированное исследование

АКТУАЛЬНОСТЬ: При проведении эпидуральной анальгезии (ЭА) в родах в случае необходимости оперативного родоразрешения встает вопрос о выборе дальнейшей тактики регионарной анестезии. В статье рассмотрены особенности влияния местных анестетиков на состояние новорожденного при проведении конверсии ЭА в анестезию при необходимости выполнения операции кесарева сечения в зависимости от используемого местного анестетика. ЦЕЛЬ ИССЛЕДОВАНИЯ: Оценить состояние новорожденного при проведении конверсии ЭА в родах через естественные родовые пути в анестезию при кесаревом сечении в зависимости от применяемого местного анестетика. МАТЕРИАЛЫ И МЕТОДЫ: Проведено проспективное рандомизированное исследование 143 детей, рожденных от матерей, которым проводили конверсию ЭА в анестезию для оперативного родоразрешения методом кесарева сечения. В зависимости от используемого местного анестетика пациенток распределили на три группы, в 1-й группе в эпидуральное пространство вводили 20,0 мл 2 % раствора лидокаина в комбинации с 0,1 мг эпинефрина, во 2-й группе — 20,0 мл 0,5 % раствора бупивакаина, в 3-й — 20,0 мл 0,75 % раствора ропивакаина. Оценку состояния новорожденных проводили по шкале Апгар на 1-й и 5-й минутах жизни и по шкале NACS в первые 15 мин, через 2, 24 и 72 ч после рождения. РЕЗУЛЬТАТЫ: Оценка новорожденных по шкале Апгар независимо от применяемого местного анестетика при эпидуральной анестезии на 1-й и 5-й минутах соответствовала 7 баллам и более (р > 0,05). Психоневрологическое состояние новорожденных при оценке по шкале NACS статистически значимо не различалось во всех группах и на всех этапах исследования. Внутри каждой группы между этапами исследования средние значения оценок по NACS статистически значимо увеличивались по сравнению с предыдущим. ВЫВОДЫ: Конверсия ЭА в родах через естественные родовые пути в анестезию при кесаревом сечении безопасна для плода и новорожденного при использовании 20,0 мл 2 % раствора лидокаина в комбинации с 0,1 мг эпинефрина или 20,0 мл 0,5 % раствора бупивакаина либо 0,75 % раствора ропивакаина в объеме 20,0 мл

Amniotic fluid embolism: A rare complication of second-trimester amniocentesis

Amniotic fluid embolism occurring following diagnostic amniocentesis is extremely rare. Only 2 cases have been reported in the English literature over the past 55 years, the most recent one approximately 3 decades ago. We present a case of amniocentesis at 24 weeks' gestation that was performed as part of an evaluation of abnormal fetal ultrasound findings. Immediately following amniotic fluid aspiration, maternal hemodynamic collapse occurred, initially diagnosed and treated as anaphylactic shock. Shortly after initial therapy, coagulopathy was noted and amniotic fluid syndrome suspected. Rapid response restored maternal hemodynamic stability; however, the fetus had suffered fatal damage

Amniotic fluid embolism: A rare complication of second-trimester amniocentesis

Amniotic fluid embolism occurring following diagnostic amniocentesis is extremely rare. Only 2 cases have been reported in the English literature over the past 55 years, the most recent one approximately 3 decades ago. We present a case of amniocentesis at 24 weeks' gestation that was performed as part of an evaluation of abnormal fetal ultrasound findings. Immediately following amniotic fluid aspiration, maternal hemodynamic collapse occurred, initially diagnosed and treated as anaphylactic shock. Shortly after initial therapy, coagulopathy was noted and amniotic fluid syndrome suspected. Rapid response restored maternal hemodynamic stability; however, the fetus had suffered fatal damage

Epidural analgesia at trial of labor after cesarean (TOLAC): a significant adjunct to successful vaginal birth after cesarean (VBAC)

Epidural analgesia has been considered a risk factor for labor dystocia at trial of labor after cesarean (TOLAC) and uterine rupture. We evaluated the association between exposure to epidural during TOLAC and mode of delivery and maternal-neonatal outcomes.A single center retrospective study of women that consented to TOLAC within a strict protocol between 2006 and 2013. Epidural "users" were compared to "non-users". Primary outcome was the mode of delivery: repeat in-labor cesarean or vaginal birth after cesarean (VBAC). Secondary outcomes were maternal/neonatal morbidities. Univariate/multivariate analyses for associations between epidural and mode of delivery were adjusted for significant covariates/mediators.Of a total of 105,471 births registered, 9464 (9.0%) were eligible for TOLAC; 7149 (75.5%) women consented to TOLAC, among which 4081 (57.1%) had epidural analgesia. The in labor cesarean rate was significantly lower for the epidural "users" 8.7% vs. "non-users" 11.8%, P<0.0001, with a parallel increased rate of instrumental delivery. Uterine rupture rates were comparable: 0.4% and 0.29%, respectively (P=0.31). The adjusted multivariate model showed that epidural "users" were more likely to experience a VBAC, odds ratio (OR) 4.58 [3.67; 5.70]; P<0.0001 with a similar rate of adverse maternal-neonatal outcomes.Epidural analgesia at TOLAC may emerge as a safe and significant adjunct for VBAC

Epidural analgesia at trial of labor after cesarean (TOLAC): a significant adjunct to successful vaginal birth after cesarean (VBAC)

Epidural analgesia has been considered a risk factor for labor dystocia at trial of labor after cesarean (TOLAC) and uterine rupture. We evaluated the association between exposure to epidural during TOLAC and mode of delivery and maternal-neonatal outcomes.A single center retrospective study of women that consented to TOLAC within a strict protocol between 2006 and 2013. Epidural "users" were compared to "non-users". Primary outcome was the mode of delivery: repeat in-labor cesarean or vaginal birth after cesarean (VBAC). Secondary outcomes were maternal/neonatal morbidities. Univariate/multivariate analyses for associations between epidural and mode of delivery were adjusted for significant covariates/mediators.Of a total of 105,471 births registered, 9464 (9.0%) were eligible for TOLAC; 7149 (75.5%) women consented to TOLAC, among which 4081 (57.1%) had epidural analgesia. The in labor cesarean rate was significantly lower for the epidural "users" 8.7% vs. "non-users" 11.8%, P<0.0001, with a parallel increased rate of instrumental delivery. Uterine rupture rates were comparable: 0.4% and 0.29%, respectively (P=0.31). The adjusted multivariate model showed that epidural "users" were more likely to experience a VBAC, odds ratio (OR) 4.58 [3.67; 5.70]; P<0.0001 with a similar rate of adverse maternal-neonatal outcomes.Epidural analgesia at TOLAC may emerge as a safe and significant adjunct for VBAC

EMERGENCY CESAREAN SECTION WITH REDO MITRAL VALVE REPLACEMENT FOR ACUTE PROSTHETIC VALVE DYSFUNCTION: A CASE REPORT

Objective: Cardiovascular diseases emerge as one of the leading causes of maternal morbidity and mortality in developed countries. These risks are even higher in women with prosthetic cardiac valves. The core of the care for these women and the fetus during the hypercoagulable state of the pregnancy and postpartum period is the achievement of coagulation control using adjusted anticoagulation therapy protocols. A multidisciplinary team that includes obstetricians, cardiologists, hematologists, and anesthesiologists in a referral center is essential for an optimal maternal-fetal outcome. In particular, these measures are directed at preventing one of the most serious complications associated with mechanical valve dysfunction. The dysfunctional valve in the mitral position increases maternal and fetal mortality by 30%, especially in the presence of heart failure symptoms. Here we present a case of a 32-week pregnant woman diagnosed with dysfunction of the mechanical mitral valve (MV) and an emergency multidisciplinary approach to her treatment