Prise en charge anesthésique de patientes obèses de classe 3 bénéficiant d’un accouchement par césarienne programmée: une étude de cohorte historique monocentrique

Purpose: The preferred neuraxial anesthetic technique for patients with class 3 obesity undergoing elective Cesarean delivery is still under debate. We aimed to describe the anesthetic technique used in our tertiary institution across body mass index (BMI) groups and different surgical incisions. Method: In this historical cohort study, we reviewed medical records of patients with a BMI ≥ 40 kg·m–2 undergoing elective Cesarean delivery between July 2014 and December 2020. We collected data on patient characteristics, anesthetic and surgical technique, and procedural times. For data analysis, we stratified patients by BMI into three different groups: 40.0–49.9 kg·m–2, 50.0–59.9 kg·m–2, and ≥ 60.0 kg·m–2. Results: We included 396 deliveries, distributed as follows: 258 with a BMI 40.0–49.9 kg·m–2, 112 with a BMI 50.0–59.9 kg·m–2, and 26 with a BMI ≥ 60.0 kg·m–2. For patients with a BMI 40.0–49.9 kg·m–2, the anesthetic technique of first choice was predominantly spinal anesthesia (71%), whereas for those with a BMI ≥ 60.0 kg·m–2, spinal anesthesia was never used as the anesthetic of first choice. With regard to the surgical incision, spinal anesthesia was almost exclusively used for patients undergoing Pfannenstiel incision and was rarely used for a higher supra- or infraumbilical transverse or midline incision. The overall incidence of general anesthesia was low (7/396, 1.8%). Anesthetic time, surgical time, and operating room time increased almost twofold in patients with a BMI ≥ 60.0 kg·m–2 compared with those with a BMI of 40.0–49.9 kg·m–2. Conclusion: Neuraxial anesthesia was successfully used in approximately 98% of patients with class 3 obesity undergoing elective Cesarean delivery. The choice of regional anesthesia technique varied with increasing BMI and with the planned surgical incision. Procedural times increased with increasing BMI. This information should prove useful for comparing anesthetic choices and outcomes in this challenging population

Color flow Doppler in spinal ultrasound: A novel technique for assessment of catheter position in labor epidurals

Background: Ultrasound is commonly used to facilitate epidural catheter placement. However, data are lacking regarding its potential to confirm its position in the epidural space. Our aim was to visualize flow in the epidural space of patients receiving epidural analgesia for labor using color flow Doppler ultrasound. Methods: We conducted a prospective observational cohort study that included patients who had delivered vaginally under epidural analgesia. We used a 5-2 mHz curvilinear probe in a left and right paramedian longitudinal oblique view to visualize the anterior and posterior complex at the interspace of epidural catheter insertion, one and two interspaces above and below. At each window, the color flow Doppler function was used to visualize flow within the epidural space on injection of normal saline (1 mL). If no flow was visualized at any interspace, one assessment at the level of insertion was repeated with a 1 mL air/saline mixture. We studied a convenience sample size of 40 patients. Results: We visualized flow in the epidural space in all 40 patients. Flow was visualized on injection of 1 mL of saline in 37/40 patients (93%). In the remaining 3/40 patients (7%), flow was visualized with an air/saline mixture. Flow on injection of saline was visualized only at the interspace of insertion in 26/37 patients (70%), at the interspace of insertion and one interspace above in 10/37 (27%), or only at one interspace above in 1/37 (3%). Flow was visualized only on the left or on the right paramedian view in 19/37 patients (51%), despite a symmetrical sensory block in all patients. Conclusion: Color flow Doppler ultrasound is a feasible and fast way to determine flow in the epidural space in the obstetric population. Its potential clinical uses are confirmation of the epidural catheter position after placement, as well as troubleshooting of unsatisfactory epidural analgesia. Interestingly, our results suggest that epidural catheters predominantly remain at the interspace of insertion. Trial registration number: NCT05126745