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Transcript
pciety or Obstetric Anesthesia and Perinatology Hilton Head I à The Society for Obstetric Anesthesia and Perinatology is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Annual Meeting Program Committee Valerie A. Arkoosh, MD Joy L Hawkins, MD Alex F. Pue, MD MCP Ilahnemann University Philadelphia, PA Program Chair Mary Birch Hospital for Women University of Colorado health Science Center San Diego, CA Robert D'Angelo, MD Denver, CO Gary M.S. Vasdev, MD Wake Forest University School of Medicine Winston-Salem, NC Craig M. Palmer, MD Program Vice Chair Mayo Clinic Andrew P. Harris, MD, MHS University of Arizona health Science Center Tucson, AZ Johns hopkins hospitals Linda S. Polley, MD Richard N. Wissler, MD, PhD Baltimore, MD University of Michigan Medical School Ann Arbor, MI University of Rochester Medical Center Rochester, MN Rochester, NY Accreditation & Designation The Society for Obstetric Anesthesia and Perinatology is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Society for Obstetric Anesthesia and Perinatology designates this educational activity for a maximum of 25 hours incategory i credit towards the AMA Physician's Recognition Award. Each physician should claim only those hours of credit that he/she actually spent in the educational activity Mission of SOAP The purpose of this Society is to provide a forum for discussion of medical problems unique to the peripartun-i period and to promote excellence in medical care, research, education in anesthesia, obstetrics, and neonatology. Mission of SOAP Program Committee The mission of the Society's Program Committee is to provide anesthesiologists, obstetricians, and other physicians and members of related allied health specialties with the knowledge and skills that will reinforce past learning as well as disseminatenew concepts and practices involving anesthesia and analgesia for the pregnant woman. Goals of the SOAP 2002 Program To provide ongoing CME activities designed to teach our audience how to best provide analgesia for labor and anesthesia for cesarian section and other procedures during pregnancy and postpartum period; To provide an Annual Scientific Meeting to the members as a forum for discussion that includes the opportunity for expression of new clinical insights, research results, applications and courses that will enhance the practice of obstetrical anesthesiology; To provide a forum for discussions dealing with specific issues that will enhance the effectiveness and cost efficiency of obstetrical anesthesia and analgesia; To provide information and a forum for discussion on subjects which have been requested by members of the previous annual meeting and via needs assessment requests. Educational Format CME activities may include the following formats: Plenary sessions, debates, lectures, poster discussions, problem-based learning, and refresher courses. Participants in the SOAP 2002 Program Attendance shall be open to all health practitioners, provided that they have registered for the meeting. CME credit will only be offered to MDs or DOs or equivalent. A Verification of Participation form (found on page 3) must be turned in to SOAP at the conclusion of the meeting. Table of Contents Distinguished Service Award 2 Verification of Participation 3 Abtract Presentor Disclosures 5 Faculty Disclosures 7 Faculty 8 General Information 10 Meeting at a Glan 11 Poster Exhibits 14 Wednesday / Thursday at a Glance Neonatal Resuscitation 17 Gertie Marx Symposium 18 Oral Presentations #1 19 Debate No. 1: Anesthesiologis'ts May Leave the Hospital Wen a Patient Has an Indwelling Epidural Catheter 20 Poster Review #1 21 Hands-on Airway Workshop 24 Refresher Course Lectures 38 Paternal Medicationsfor Labor & Delivery Reimbursement Options in Obstetric Anesthesia Friday at a Glance Zuspan Papers 53 What's New in Neonatology: Vignettes in Neonatal Resuscitation 54 What's New in Obstetrics? 60 Poster Review #2 65 Saturday at a Glance Multidisciplinary Obstetric Simulated Emergency Scenarios (MOSES) 69 Research Works in Progress 72 Clinical Forum: Scripted Cases ofParturients with Cardiovascular Disorders 73 ASA Presidential Address 85 Debate No.2: FailedEpiduralfor Urgent C/S: Sp rinal is Preferable to Gen eralAnesthesia 86 Poster Review #3 87 Gerard W. Ostheimer: What New in Obstetric Anesthesia Lecture 89 Sunday at a Glance Breakfast with the Experts 145 Fred Hehre Lecture 147 Oral Presentations #2 159 Oral Presentations - Best Paper of the Meeting Award 160 Exhibitors - Product Description 161 i (JÓflP2OO2 2002 Distinguished Service Award Founders of the Society for Obstetric Anesthesia & Perinatology Robert O. Bauer, MD * Richard B. Clark, MD James O. Elam, MD* James A. Evans, MD* Robert E Hustead, MD Bradley E. Smith, MD * deceased I I I I I I I I I I I I State: I I I Country: IFirstÌair1e: Daytime Phone #( I I I ) Date I I I I I I I I I I Credits Ext: Zip/Postal Code: I I I I I I "Certificates for AMA PRA category i credit should only be given to physicians. Certificates should be provided after physicians complete the educational activity so they can document participation. Certificates should only be given for the actual credit claimed and earned by the physician." From the Physician's Recognition Award Infonnation Booklet for CME Providers Signature of Attendee I wish to claim the following number of credits for the above-captioned SOAP meeting: I certify that I am claiming the number of hours I actually spent in the educational activity. Email address: City: Mailing Address: c, I...astl'arrie: PLEASE PRINT CLEARLY AND COMPLETE ALL SECTIONS SOAP designates this educational activity for up to 25 hours in category i credit toward the AMA Physician's Recognition Award. Each physician should claim only those hours of credit that he/she actually spent in the educational activity. The Society for Obstetric Anesthesia & Perinatology (SOAP) maintains records of learner participation for six years. To enable SOAP to maintain accurate records of your participation and TO RECEIVE YOUR CME CERTIFICATE, you must complete, sign and return this form to the SOAP's headquarters office. Your certificate of participation will be mailed to you within 4-6 weeks. Return to: SOAP, PO Box 11086, Richmond, VA 23230.1086 or fax to (804) 282-0090. Forms MUST be returned no later than July 5, 2002 to receive a CME certificate for this educational offering. May 1-5, 2002 Hilton Head Island, South Carolina 34th Annual Meeting VERIFICATION OF PARTICIPATION 4 Abstract Presentor Disclosures No relationship w/commercial supporters Research Support Speaker's Bureau Consultant.. Shareholder (Directly Purchased) Other Financial Support Large Gift(s) Did not receive disclosure information prior to printing. Disclosure will occur prior to presentation. Unless otherwise indicated all faculty will comply with Trade/Unlabeled Use of products policy in their presentation Rishimani Adsumelli - I Gilbert Aldape - I James Alexander I Burak Alptekin Astra Zeneca -3 Pamela Angle - I Martin Angst- i Evelyn Ansa - I Valerie Arkoosh - I Paul Audu - I Gubby Ayida - I Ulku Aypar Dupont Pharma - Paul Bach Product (bentastarch 10%) Michelle Chochinov - i Christopher Ciliberto - I Fli7abeth Coates - I Mark Esler SCohen. I Steven Eubanks - I Tammy Euliano - i Shaul Cohen Astra Zeneca -3 Sheila Cohen - I Malachy Columb PritiDalal -I Danette Daniels - 1 Alaedin Darwich -I Colin Davis-i Robin Davisson - i Jonathan Benumof - I Samina Bharmal - I David Bimbach - I Freeha Bokhari Astra Zeneca -3 Terrance Breen - I Nicole Brockhurst - I Michael Brown - i Simon Brown - I Ingrid Browne - I Alexandra Bullough - I Elizabeth Burley Astra Zeneca -3 Genelle Buti - i Jodle Buxbaum -1 Valerie Bythell - 1 Arthur Calimaran - 1 William Camann - I D Cariaso - i B Carvalho -1 Carmencita Castro - I Renee Caswell - I Donald Caton - i Dmitri Chamchad. I Theodore Cheek - i Tahir Farooq Astra Zeneca-3 Roshan Fernando - I Helene Finegold - 1 Pamela Flood - I J Forster - I Regina Fragneto - I Marilyn Fredericksen - I Lanniece Freeman AstraZeneca-3 Jennifer Friedman - I Michael Froeich I Amiram Gafni - I Sophie Gagnon - I Robert Griser - i Philippe Gautier - i Karen Gertenbach - I James Costello - I James Coyne - I Pushkar Dadarkar - I Ashi Daftary -I Ati]io Barbeito - I Sylviana Barsoum AsfraZeneca-3 Scott Falk-I Study Group UK COMET N Bailur - I James Bates - i Dupont Pharma - Paul Bach Product (pentastarcb 10%) Sebastian de la Fuente - I Cheryl De Simone - i Peter DeBaili - I Howard Denenberg Astra Zeneca -3 Cheryl DeSimone - i Connie Dimarco - I Lauren DiMaria - I Yanahang Dong - I Joanne Douglas K Giarrusso-I - JGinosar-i Steven Ginsberg Astra Zeneca -3 Raphael Giraud - i Raymond Glassenberg - i Samuel Glassenberg - I Evan Goodman - I Stephanie Goodman - I Caroline Grange - 1 Mark Greenberg - I Rebecca Greene - I Dupont Pharma - Paul Bach Ívduct (pentastarcb 10%) John Downing - I D Drover - I Scott Drysdale - I Clive Duke - I Susan Dumas - I Peter Dwane - i Anne Gregg-I Vladimir Grodecki - i Victor Grosu AstraZeneca-3 Vit Gunka Duke Eason - i Robert Eberle - I Jeffrey Ecker - I James Eisenach - I Dupont Pharma - Paul Bach Product (pentastarcb 10%) Andrew Elimian -1 Habib El-Moalem - I Brett Gutsche - i Ashraf Habib - I 5 Stephen Hallworth - I Steven Hallworth Stephen Halpern - I MaryHannah-I Denisa Haret - I Helen Harker - I Miriam Harnett - 1 Scott Helsley - 1 David Hepner - i Philip Hess-I James Hill-i Ellen Hodnett - i Darren Hoffmann - 1. David Hood - I Jay Horrow-1 McCallum Hoyt-I Karen Hsu-1 Jane Huffnagle - i Su.zane Huffnagle - I Osamu Ishihara - I Andra James - I Robert James - I Ben Johnson - I E Johnson - I Raymond Johnson - I Geena Joseph - i Ninos Joseph - i Allaudin Kamani Dupont Pbarma - Paul Bach Product (pentastarch 10%) Bupesh Kaul - i C Kenaan -1 Beklen Kerimoglu - i Christian Kern-i Khadija Khan - i Katsuynki Kinoshita - i Paul Kliffer-i Paul Kligfield - I Bhavani-Shankar KOda1i - i Antigoni Koutoulas - i A Koutrouveis - i Piotr Krasuski - i J.Yasha Kresh - I Jean Kronberg - I Krzysztof Kuczkowski - I Hector Lacassie - I Madeline Lai - I Sims Portex -3 Ruth Landau - I Bee Lee - I Aviva Lee-Parritz Lisa Leffert - I Craig Leicht - I Barbara Leighton - I Dymtro Leschinskiy - I Kenneth Leveno - I Yunpmg Li-1 Michael Lilly - I Yin Lim-I E Lockhart-i Timothy Long -I Stephen Longmire - I Nancy Lowe -I Alison Macarthur - I A. Makhdumi -1 Sabah Malek - I Sonia Maihotra - I Mark Norris - I Jon Obray - i David O'Gorman - I Arne Ohlsson - I Adeyemi Olufolabi - I Geraldine O'Suffivan - I Medge Owen - I VinnieSodhi-I Tede Spahn - I Laura Spears AstraZeneca Corporation -3 Joan Spiegai - I Margaret Srebrnjak - I J.Philip-I Sajith Philip - 1 Barbara Philips-Bute - I May Pian-Smith - I Jose Pinheiro - I Joy Steadman Sims Portex-3 John Plummer - i Linda Polley - I Deborah Stein - I Bonnie Stevens - I T Strauss-Hoder - I Robyn Stremler - i Max Su - i John Sullivan - i Kishwar Sultana -1 Maya Suresh - i John Szalai - 1 L Tabaczewska - I Satoru Takeda - i D Portnoy-I Ramiah Ramasubramanjan - I Kirk Ramm -i Patrick Ramsey - i. Jaynatbie Ranasinghe Julio Marenco - I Robert McCarthy -I Donald Mclntire - I Mahfouz Megally - I Jorge Melgen Sims Portex-3 Pamela Mergens - I David Merrill -I Simon Millar - 1 Beth Minzter- I Edward Mirikatani -1 Jenny Mitchell - I Sudharma Ranasinghe - I Emily Ramer - I Mira Razzaque - I Felicity Reynolds - I James Reynolds - i Anne Riddell - I Amy Riegel - i May Mok-1 Dwight Rouse - I Phyllis Money - i R Russell - i Noor Sabzposh - i Syed Wasil Sabzposh - I Kathleen Morgan - 1 Mary Mowbray :1 Meraj Siddiqui Sims Portex-3 F Siswawala - I E. Slaymaker - i Richard Smiley - I Caroline Snowman - I Moeen Panni - I Ray Paschall - I Nisa Patel - I A Peaceman - I B. Perez - i Amy Phelps - i Gordon Mandel - I Susan Mann-I Julia Morch-Siddafl - I Anwar Morgan -1 G Shih - i Neeta Shukla - i P Panni-i Angela Maflozzi - I CMoore-I SSherwani-I Quisqueya Palacios - I Susan Palmer - I Stephen Pratt - I Sivam Ramanathan - i RMarcus-I John Schultz - I Scott Segal - I Sanjeev Sethi - I Kelly Shannon - I Shiv Sharma - i Honorarium Sims Portex KennyTam-I Sam Tang-I Junko Taya - i Ian Taylor - I Katsuo Terni - i Umamaheswary Tharmaratnam L i Dorothy Thompson - I Jenny Thompson - 1 Donna Thornley - 1 Martha Tingle -1 Chuanyao Tong - i Takeko Toyama Edward Riley - i Jose Rivers - 1 Ryan Romeo -1 Sims Portex -3 Chris Sadler - 1 Connie Tran - I Holly Muir -i Urna Munnur -I S Myers-I Sukran Sahin - I M. Ramez Salem - I Andreas Sandner-Kiesling - i Alan Santos - I Kavita Sarang - i Terry Myhr - I Rama Sashidharan -1 Lev Nakhamchik-I Norah Naughton - I R Satya-Krishna - I Manuel Vallejo - I Barbara Scavone - I Claire Van Harnel - i Warwick Ngan Kee - I Gunther Schlager - Medha Vanarase - I Lawrence Tsen - I Lori Tungpalan - i Luminita Tureanu - I Nesimi Uckunkaya - I Rakesh Vadhera - I 6 Gurinder Vasdev - I Anasuya Vasudevau - I Ivan Veickovic - I Tracey Vogel - i Deborah Wagner - I Ashutosh Wali - I MaryWalsh-I Vivien Walsh - I Jason Wang - i CWass-i Malcolm Watters - i C. Weidner - I Robert Weiss - I Julie Weston - I Davida White-Pettaway - I Megan Whittaker - I J. Wiley - I Andrew Willan - 1 Matthew Wilson - I RoryWindrim-I Daniele Winkler - I Dawn Wison - I Richard Wissler - I April Wong - I Cynthia Wong - i Maddy Woods - I E Yaghmour -1 Yasin Zada AstraZeneca Pbar,naceuticals- 3 Hui Zhu - I Tracy Zinner - I Faculty Disclosures i. No relationship w/commercial supporters Research Support Speaker's Bureau 4 Consultant Shareholde«Directly Purchased) Other Financial Support Large Gift(s) Did not receive disclosure information prior to printing. Disclosure will occur prior to presentation. Unless otherwise indicated all faculty will comply with Trade/Unlabeled Use of products policy in their presentation Valerie A. Arkoosh, MDi G.M. Bassell, MDi Yaakov Beilin, MD 1 Anthony Bissette, MD 8 Kristi S. Borowski, MD 8 Thomas Kastner, MD 8 MarkT. Keegan,MD-1 Mathew M. Kumar, MD,JD - i Brenda A. Bucklin, MD - KennethP.Scott,MDi B.ScottSegal,MDI Richard M. Smiley, MD, PhD 1 CraigH Leicht,MDi AnilKSoni,MD-8 Barbara L. Leighton, MD - I AlisonJ. MacArthur, MD 1 Juraj Sprung, MD - i Maya S.Suresh,MD-1 Gerald A. Burger, MD 8 W Mark Burtinel, MD 8 Christopher Burkie, MD - i Ronald A. MacKenzie, DO - i Andrew M. Malinow, MD 1 Gary M.S. Vasdev, MD - i Ashu Wall, MD, FRARCS - I GertieF.Marx,MDi William R. Camann, MD - Anne May, MBBS, FRCA - i Mary Ellen Warner, MD - I Carole Warnes, MD - i Richard N. Wissler, MD, PhD 8 i I David C. Campbell, MD, MSc, FRCPC 1 Robert Chantigian, MD - i Theodore G. Cheek, MD - i David H. Chestnut, MD 8 Lauri P. Cox, RN, BSN, IBLLL I Patricia A. Dailey, MD - i James P. McMichael, MD - i Edward R Molina-Lamas, MD, FACA - i Holly Muir, MD Skye Pharm Inc. 2 MariaMurry,CNM-8 Robert D'Angelo, MDi Geraldine O'Sullivan, MBBS, FRCA 8 Medge D. Owen, MD - i Marie L DeRuyter, MD 8 Martin DeRuyter, MD 8 Michael J. Paech, FANZCA AbbottAustralasia P74 Ltd-2, 4 David M. Dewan, MD - Craig M. Palmer, MD Preferred Medical-2 i M. Joanne Douglas, MD, FRCP _i Roshan Fernando, MBBS, FRCA Neurocom 2 PortexLtd.-2 William Franz, MD 8 RobertRGaiser,MD_i Sumedha Panchal, MDI Donald H. Penning, MD, MSc, FRCPC 1 - David R Gambling, MBBS - Alex F.Pue,MDI i Batty Glazer, MDi Debbie Ward Gordon, RN, MSN - I Michael Greene, MD - i Deanna Griebenow, CNM 8 -i Barry A. Harrison, MD - i Andrew P. Harris, MD Joy L. Hawkins, MD 1 Christopher james, MD i Keith L. Johansen, MD 1 Gerard S. Kamath, MD 8 Kimberly-Clark-2 Susan K. Palmer, MD - i Bhargavi,Gall,MD_1 Stephen H. Halpern, MD 8 Ballard-2 Sivam Ramanathan, MD 8 KirkRamin MDI Mira Ra.zzaque, MD - I Edwin H. Rho, MD 1 Edward T. Riley, MD 8 AlainSabri,MD-8 Christopher Sadler, PhD, MBBS, FRCA - i Sukran Sahin, MD 8 Alan C. Santos, MD, MPH AstraZeneca 2 Chiroscience-2 Purdue-4 Mukesh C. Sarna, MD, FRCA 8 7 DavidJ.ody,MD-8 Cynthia A. Wong, MD - i Frederick P. Zuspan, MD Matrea Healtbcare (Board) 4 Kathryn J. Zuspan, MD - i Faculty Laurie Cox, RN, BSN, IBLLL Deanna Griebenow, CNM MOE Hahnemann University Mayo Clinic Philadelphia, PA Wake Forest University Medical Center Winston-Salem, NC G.M. Bassell, MD Patricia A. Dailey, MD Stephen H. Halpern, MD Wesley Medical Center Wichita, KS Mills-Peninsula health System Hilisborough, CA University of Toronto Yaakov Beim, MD Robert D'Angelo, MD Andrew P. Harris, MD, MHS Mt. Sinai School of Medicine New York NY Wake Forest University School of Medicine Winston-Salem, NC Johns Hopkins hospital David J. Birnbach, MD Marie L DeRuyter, MD* Barry Harrison, MD* St. Luke's Roosevelt Medical Center New York, NY Mayo Clinic Mayo Clinic Jacksonville, FL Rochester, MN Anthony Bissette, MD* Martin DeRuyter, MD* Joy L Hawkins, MD Mayo Clinic Mayo Clinic University of Colorado hospital Rochestei MN Rochester, MN Denver, CO Kristi S. Borowski, MD David M. Dewan, MD ChristopherJames, MD Mayo Clinic Rochester, MN Wake Forest University School of Medicine Winston-Salem, NC Jacksonville, FL Brenda A. Bucklin, MD M.Joanne Douglas, MD, FRCP KeithJohansen, MD University of Nebraska Medical Center Omaha, NE British Columbia Women's Ilospital Vancouver, British Columbia, Canada Mayo Clinic Gerald A. Burger, MD Roshan Fernando, MBBS, FRCA Gerard S. Kamath, MD* Wyoming Medical Center Mayo Clinic Casper, WY Royal Free hospital London, United Kingdom W. Mark Burtinel, MD* William Franz, MD Thomas Kastner, MD Mayo Clinic Mayo Clinic Mayo Clinic Rochester, MN Rochester, MN Rochester, MN Christopher Burkie, MD* Robert R. Gaiser, MD Mark T. Keegan, MD* Mayo Clinic University of Pennsylvania Mayo Clinic Rochester, MN Philadelphia, PA Rochester, MN William R. Camann, MD Bhargavi Gall, MD* MathewM. Kuniar, MD,JD Brigham & Women's Hospital Boston, MA Mayo Clinic Mayo Clinic Rochester, MN Rochester, MN David C. Campbell, MD, MSc, FRCPC David R. Gambling, MBBS Craig H. Leicht, MD, MPH Royal University hospital Mary Birch hospital for Women Western Pennsylvania h hospital University of Saskatchewan San Diego, CA Pittsburgh, PA Saskatoon, Saskatchewan, Canada Barry Glazer, MD Barbara L. Leighton, MD Robert Chantigian, MD St. Francis Hospital Mayo Clinic Indianapolis, IN Cornell University New York, NY t4 [-PJiiUî Valerie A. Arkoosh, MD Rochester, MN Toronto, ON, Canada Baltimore, MD Mayo Clinic.Jacksonville Rochester, MN Rochester, MN Deborah Ward Gordon, RN, MSN Andrew M. Malinow, MD Wake Forest University Medical Center Philadelphia, PA Winston-Salem, NC University of Maryland School of Medicine Baltimore, MD University of Pennsylvania Michael Greene, MD Gertie F. Marx, MD David H. Chestnut, MD Massachusetts General llospital Boston, MA Albert Einstein College of Medicine University of Alabama - Birmingham Birmingham, AL New York, NY * Denotes Airway Workshop Faculty 8 O Rochester, MN Theodore G. Cheek, MD AlisonJ. MacArthur, MD Mira Razzaque, MD Carole Warnes, MD Mount Sinai Hospital Toronto, ON, Canada Royal London Hospital London, UK Mayo Clinic Ronald A. MacKenzie, DO* Edwin H. Rho, MD* Richard N. Wissler, MD, PhD Mayo Clinic Rochestei MN Mayo Clinic Rochester, MN University of Rochester Medical Center Rochester, NY Anne May, MBBS, FRCA Edward T. Riley, MD David J. Wiody, MD Leicester Royal Infirmary Leicester, United Kingdom Stanford University State Univrsity of New York Stanford, CA New York, NY James P. McMichael, MD AlainSabri,MD* Cynthia A. Wong, MD Capital Anesthesiology Association Austin, Dt Mayo Clinic Rochester, MN Northwestern University Medical School Chicago, IL Edward R. Molina-Lamas, MD, FACA Christopher Sadler, PhD, MBBS, FRCA Frederick R Zuspan, MD The Women's Hospital of Texas houston, TX Royal London hospital London, United Kingdom Ohio Stale University Rochester, MN - Columbus, OH Holly Muir, MD, FRCPC Sukran Sahin, MD Kathryn J. Zuspan, MD Duke University Medical Center Durham, NC Uludag University Medical University Bursa, Turkey Hennepin County Medical Center Edina, MN Maria Murry, CNM Alan C. Santos, MD, MPH Mayo Clinic Rochester, MN St. Luke's/Roosevelt Hospital Center NewYork, NY Geraldine O'Sullivan, MBBS, FRCA Mukesh C. Sarna, MD, FRCA St. Thomas hospital London, United Kingdom Beth Israel Deaconess Medical Center Boston, MA Medge Owen, MD Kenneth R Scott, MD* Wake Forest University Medical Center Winston-Salem, NC Mayo Clinic Rochester, MN MichaelJ. Paech, FANZCA B. Scott Segal, MD King Edward Memorial Hospital for Women Perth, Australia Brigham & Women's Hospital Boston, MA Craig M. Palmer, MD Richard M. Smiley, MD, PhD University of Arizona Health Science Center Tucson, AZ Columbia University New York, NY Susan K. Palmer, MD* Anil K. Soni, MD University of Colorado - Aurora Aurora, CO Beth Israel Deaconess Medical Center Boston, MA Sumedha Panchal, MD Jurai Sprung, MD* Weffi Medical College Edgewater, NJ Mayo Clinic Rochester, MN Donald H. Penning, MD, MSc, FRCPC Maya S. Suresh, MD Johns Hopkins University Baltimore, Ml) Baylor College of Medicine Houston, TX Alex F. Pue, MD Gary M.S. Vasdev, MD* Mary Birch Hospital for Women San Diego, CA Mayo Clinic Kirk Ramm, MD Ashu Wall, MD, FFARC* Mayo Clinic Baylor College of Medicine Rochester, MN houston, TX Sivam Ramanathan, MD Mary Ellen Warner, MD* MaGee Women's Hospital Mayo Clinic Pittsbrugh, PA Rochester, MN Rochester, MN * Denotes Airway Workshop Faculty General Information Hotel Information The Hilton Head Island Marriott Beach and Golf Resort, a natural splendor of Hilton Head Island, South Carolina, is located in Palmetto Dunes, a premier oceanfront destination. The resort is 10 minutes from the Hilton Head Island Airport and 45 minutes from the Savannah International Airport. SOAP will be one of the first groups to stay in this multi-million dollar renovated premier resort. Beautiful ocean and island views are available from private terraces outside each guest room. You'll discover uncounted ways to enjoy the sun, basking beside the oceanfront Olympic size pool, stroking along nine miles of golden sand, or enjoy tee for two on one of the six world class 18-hole championship golf courses When the business day is done, you can enjoy an invigorating match at a world-class tennis facility or visit the Spa, a fully equipped health club, complete with indoor heated pool, whirlpools, sauna and massage therapist. You can sightsee in near-by Shelter Cove or Harbour Town before dining in one of four elegant restaurants. Discover the perfect blend of experienced service and resort ambiance as only Marriott can deliver! SOAP Dine-Around (Thursday, 6:00 pm) Menus, sign-up sheets along with transportation options will be available on site. Fun Run/VcTalk - Sea Pines Forest Preserve (Friday, 1:30 pm) Transportation will be provided from the Marriott to the natural preserve in Sea Pines Plantation for a 5K Fun Run. The 605-acre Sea Pines Forest Preserve has approximately 8 miles of trails that follow antebellum rice dikes from the I 840s and old logging trails from the 1 950s. Supported by a grant from B. Braun. SOAP Tennis Tournament (Friday, 1:45-5:15 pm) SOAP will host a tennis tournament Friday afternoon at the Palmetto Dunes Tennis center. The format will be a mixed doubles round robin. SOAP Golf Tournament - Golden Bear Golf Club (Friday, 1:00-6:00 pm) Created by the Jack Nicklaus' design team, the Golden Bear Golf Club is an excellent example of Hilton Head Island golf. Created on a fairly flat terrain, with little natural mounding, the Nicklaus Architectural group relied primarily on ponds, marsh and the forest to carve a challenging, yet fair test of golf. Golden Bear is highly-regarded by, and a local favorite of the golf community on Hilton Head Island. The course reaches just over 7,000 yards at the tips, but most visitors will have plenty of challenges at either 6,643 or 6,184 yards. SOAP Banquet/Beach Music Party (Friday, 6:30) Our annual banquet theme is "Beach Music Party", which will be held at the Hilton Head Island Marriott Beach & Golf Resort. Highlights of the Party will include a live band, "Sterlin Colvin and the Improv" who, along with a couple instructors will have everyone "shagging" a popular dance indigenous to the Carolinas and Virginia. So get out your casual beach wear and enjoy a night of Hilton Head Island hospitality, casual dinner, dancing and merriment. Advance registration necessary. Sunset Sailing (Saturday, 5:30 pm) Enjoy sunset sailing on America's Cup Race; "Stars and Stripes" and "Pau Hana" Catamaran. Cocktails and hors d'oeuvres, will be served. Seating is extremely limited (US Coast Guard Regulations). Sign-up will be at the Baxter booth on Thursday morning on a first-come, first-serve basis. If you are interested, please email <shane_montgomerybaxter.com>, however, sign-up will only be on-site. Please wear non-marking soft shoes and bring a light jacket. Those on Stars and Stripes should be prepared to get a little wet. For liability/safety issues, sorry no children are allowed. Supported by Baxter. Tours, Shopping, Sea Kayaking, Bike Rentals, etc. Deep sea fishing, parasailing, sunset sails and dolphin cruises are favorites, in addition to plenty of outlet and boutique shopping. Please contact the hotel concierge directly at 843-842-8000 for assistance in planning your extra-curricular activities. lo Scientific Program Wednesday, May 1, 2002 8:00 am - 2:00 pnr 2:00 - 6:00 pm 2:00 .. 6:00 pm 2:00 - 6:00 pm 3:00 - 6:00 pm Executive Committee / Board of Directors Meeting Committee Meetings Registration Poster Mounting (Both Sessions) Neonatal Resuscitation Course (Limited Registration - By Ticket Only) Coordinator: Medge Owen, MD; 6:00 - 8:00 pm uri P. Cox, RN, BSN, IB; Debbie Ward Gordon, RN, MSN Wine/Cheesé Reception - (Hilton Head Island Marriott) Thursday, May 2, 2002 7:00 am 7:00 - 7:45 am 7:45 - 8:00 am Registration Breakfast with Exhibitors & Posters Opening Remarks & Welcome Joy L. Hawkins, MD; Gary M.S. Vasdev, MD 8:00 - 9:30 am Gertie Marx Symposium - Joy L. Hawkins, MD (Moderator) Judges: Germi E Marx, MD; GM Bassell, MD; Geraldine O'Sullivan, FRCA; Robert D'Angelo, MD; Donald H. Penning, MD, MSc, FRCPC; David H. Chestnut, MD; Joy L Hawkins, MD 9:30 - 9:45 am Distinguished Service Award Presentation Valerie A. Arkoosh, MD 9:45 - 10:15 am 10:15 am - 11:15 n Break with Exhibitors & Posters Oral Presentations #1 Moderator: ChristopherJames,MD 11:15 - 12:15 pm Debate No. I Anesthesiologists May Leave the Hospital When a Patient Has an Indwelling Epidural Catheter Moderator: Kathryn J. Zuspan, MD CON: Theodore G. Cheek, MD PRO: Gerald A. Burger, MD 12:15 - 1:15 pm 1:15 - 2:15 pm Lunch with Exhibitors and Posters Poster Review #1 Introduction: Valerie A. Arkoosh, MD Moderator: Yaakov Beim, MD 2:15 - 2:30 pm Break with Exhibitors and Posters "Hands on" Airway Workshop (Limited Registration - By Ticket Only) 2:30 - 4:00 pm 4:15 - 5:45 pm Group 1 Group 2 Refresher Course Lectures - 2:30 - 3:30 pm Paren teral Medications for Labor & Delivery Coordinators: Barry Harrison, MD; Gerard S. Kamath, MD David C. Campbell, MD, MSc, FRCPC 4:00 - 5:00 pm - Covering Labor & Delivery in a Community Hospital Patricia A. Dailey, MD 6:00 pm SOAP Dine Around (sign-up on site) Scientific Program Friday, May 3 2002 6:30 am 7:00 - 8:00 am 8:00 - 9:00 am Registration Breakfast with Exhibitors & Posters The Zuspan Award by Perinatal Resources Inc Moderator/Judge: David J. Birnbach, MD Judges: David H. Chestnut, MD; Michael Greene, MD; Anne May, MBBS, FRCA; Alan C. Santbs, MD; Stephen H. Halpern, MD; Susan K. Palmer, MD 9:00 - 10:00 am What's New in Neonatology: Vignettes in Neonatal Resuscitation Introduction: Gary M.S. Vasdev, MD; Presentor: Robert Chantigian, MD 10:00 - 10:10 am Presentation of the Zuspan Award by Perinatal Resources, Inc Frederick P. Zuspan, MD; 10:10 - 10:30 am Break with Exhibitors & Posters 10:30 - 11:30 am What's New in Obstetrics? Introduction:Joy L Hawkins, MD; Presentor Michael Greene, MD 11:30 am - 12:30 pm Poster Review #2 Moderator: Robert R. Gaiser, MD 1:30 pm Fun Run/Walk, Tennis Tournament, and Golf Tournament (12:45 pm) 6:30 pm Banquet - Beach Music Party (Hilton Head Island Marriott) Saturday, May 4, 2002 6:30 am 7:00 - 8:00 am 7:00 - 8:00 am Registration Breakfast with Exhibitors & Posters Multidisciplinary Obstetric Simulated Emergency Scenarios (MOSES) 7:00 - 8:00 am Research Works in Progress Robert D'Angelo, MD; (Limited Registration - By Ticket Only) Richard M. Smiley, MD, PhD Christopher Sadler, PhD, MBBS, FRCA; Mira Razzaque, MD 8:00 - 9:30 am Clinical Forum: Scripted Cases of Parturients with Cardiovascular Disorders Moderators: Carole Warnes, MD; Kirk Ramm, MD; William R. Camann, MD 9:30 - 10:00 am 10:00 - 11:00 am Break with Exhibitors & Posters ASA Presidential Address Barry Glazer, MD 11:00 am - 12:00 n Debate No. 2 Failed Epidural for Urgent C/S: Spinal is Preferable to General Anesthesia Moderator: Andrew M. Malinow, MD PRO: David R. Gambling, MBBS 12:00 - 1:00 pm 1:00 - 2:00 pm CON: M. Joanne Douglas, MD, FRCPC Lunch Poster Review #3 Introduction: Alan C. Santos, MD; Moderator: Holly Muir, MD, FRCPC 2:00 - 3:00 pm Gerard W. Ostheimer Anesthesia Lecture: What's New in Obstetric Anesthesia? Introduction: Alan C. Santos, MD; Presentor: David H. Wiody, MD 3:00 - 3:30 pm 3:30 - 5:00 pm 5:30 pm Break with Exhibitors & Posters Business Meeting Sunset Sailing (Limited Space, Ticket Only) 12 Scientific Program Sunday, Miy 5, 2002 6:30 am 7:00 - 8:00 am Registration Breakfast with the Experts (Limited Registration - By Ticket Only) 1. Post-partum Analgesia - AlisonJ. MacArther, MD 2., Continuous Spinal Analgesia - Craig M. Palmer, MD Labor Analgesia with Limited Staffing Resources - Richard N. Wissler, MD International OB Anesthesia Education Opportunites - Medge Owen, MD; Sukran Sahin, MD Fine Tuning Your CSE - Craig Leicht, MD, MPH Answering Big Questions in Obstetric Anesthesia Research - B. Scott Segal, MD; Richard M. Smiley, MD, PhD Ambulation after Labor Regional Anesthesia - Roshan Fernando, MBBS, FRCA Fetal Distress and Unable to Intubate. What Next? - Maya Suresh, MD The Morbidly Obese Preeclamptic Parturient - Sumedha Panchal, MD Post Partum Tubal Ligation - Brenda A. Bucidin, MD Billing-James P. McMichael, MD Billing - Edward R. Molinas-Lamas, I'4D, FACA Obstetrics and Family Medicine Issues in Labor and Delivery - Keith Johansen, MD; Thomas Kastner, DM; Walter Franz, MD Is OB Anesthesia More Liable for Litigation than Other Subspecialties - Mathew Kumar, MD,JD Post Dural Puncture Headache - Anil Soni, MD; Mukesh Sarna, MD Legislative Issues - Andrew P. Harris, MD, MHS PCEA Should Always Be Used in Preference to Continuous Epidural Infusion Analgesia in LaborMichael J. Paech, FANZCA Anesthesia for Placenta Accerta - Alex E Pue, MD 8:15 - 9:15 am Fred Hehre Lecture David M. Dewan, MD 9:15 - 10:15 am Oral Presentations #2 Moderator: Cynthia A. Wong, MD 10:15 - 10:45 am Coffee Break 10:45 - 11:45 am Oral Presentations - Best Paper of the Meeting Award Moderator/Judge: MichaelJ. Paech, FANZCA Judges: Sivam Ramanathan, MD; Edward T. Riley, MD; Scott Segal, MD 11:45 am - 12:00 n I Adjournment Best Paper of the Meeting Award Moderators: Joy L. Hawkins, MD; Gary M.S. Vasdev, MD 2002 Annual Meeting Elections During the annual business meeting in Hilton Head, South Carolina, members will elect a Second Vice President, Secretary; Director at Large, 2006 Meeting Host and an Alternate Representative for the ASA House of Delegates. 13 Poster Exhibits P-16 P-17 P-18 P-19 P-20 P-21 P-22 P-23 P-24 P-25 P-26 P-27 P-28 P-29 P-30 LEG TOURNIQUETS TO SEQUESTER BLOOD DURING C/S IN AJEHOVAH's WIThESS WITH TWINS AND PLACENTA PREVIA Eason, D; Palmer, S.K. ANESTHETIC MANAGEMENT OF TH EXIT (EX UThRO INTRAPARTEJM TREATMEN1) PROCEDURE UTIUZINGSEVOFLURANE Palk. S.A ; Hoyt, M. PREGNANCY COMPUCATED BY HEPATOCELLULAR CARCINOMA $hih, G; Forster,J.; Myers, S. ORALJEWELRY IN THE PARTURIENT: A NEW CONCERN FOR THE ANESTHESIOLOGIST JKuczkowsld. K.M; Benumof J.L ONCE A POST-DURAL PUNCTURE HEADACHE PATIENT, ALWAYS POST-DURAL PUNCTURE HEADACHE PATIENT Kuczkowski, K.M; Benumof, J.L ANOTHER REBOUND PHENOMENON: HYPERJ'ZALEMIA AFIER CESSATION OF TOCOLYTIC THERAPY Kuczkowski. KM. Benumof, J.L COMBINED SPINAL EPIDURAL ANESTHESIA: A NEW ANESTHETIC OPTION FOR REPEAT CESAREAN SECTION IN A MORBIDLY OBESE PARTURIENT Kuczkowski, KM; Benumof, J.L AMPHETAMINE ABUSE IN PREGNANCY: ANESTHETIC IMPLICATIONS Kuczkowski. K M.; Benumof, J.L ANESTHETIC CONSIDERATIONS FOR INTRA-ABDOMINAL PREGNANCY Coyne. J.T; Mitchell, J.Z. CONTINUOUS SPINAL ANESTHESIA FOR CESAREAN SECTION IN A MORBIDLY OBESE PATIENT WITH MULTIPLE SCLEROSIS Wison D.C; Goodman, S.R.; Ciliberto, C.F.; Smiley, R.M. INTRA-OPERATIVE MYOCARDIAL INFARCTION IN A PARTIJPJENT: ANESTHETIC IMPLICATIONS Costello,J.\V; Greenberg, M.; Kuczkowski, KM. ANESThETIC CONSIDERATIONS IN A PARTURIENT WITH MITRAL VALVE ATRESIA AND SINGLE VENTRICLE PHYSIOLOGY Haret, D.M.; Fragneto, R. BRADYCARDIA/ASYSTOLE AFIER LOW DOSE CSE LABOR ANALGESIA - IS IT BEZOLD-JARISCH REFLEX? A CASE DISCUSSION OF ETIOLOGY & MANAGEMENT Pan, P.H; Moore, C.H. AMNIOTIC FLUID EMBOUSM IN A PARTURIENT WITH AN UNDIAGNOSED PHEOCHROMOCYTOMA Arisa, E.M; DeSimone, C.A.; Ebene, R.L ATYPICAL SENSORY NEUROLOGIC CHANGE ASSOCIATED WITH POSTDURAL PUNCTURE HEADACHE IN A PARTURIENT: A UNIQUE CASE OF LHERMI nE'S SIGN Obray. J.J3,; Long, T.R.; Brown, M.J.; Wass, C.T. P-31 CASE REPORT - SOLE COMBINED SPINAL EPIDURAL FOR CESAREAN SECTION AND HEMICOLECTOMY Dadarkar, R; Vasdev, G.M. P-32 P-33 P-34 ANESTHETIC MANAGEMENT OF A VENTILATOR-DEPENDENT PARTURIENT WITH THE KINGDENBOROUGH SYNDROME Habib, A.S.; Millar, S.; Muir, H.A. ANESTHESIA FOR CESAREAN SECTION IN A PATIENT WITH SPINAL MUSCULAR ATROPHY Habib, A.S; Helsley, S.; Millar, S.; Muir, H.A. ANESTHETIC MANAGEMENT FOR DELI VERY FOR A PARTURIENT WITH MAY-HEGGUN ANOMALY: A CASE REPORT Calimaran. A.L; Wong, C.A. 14 NOTES CID o z Scientific Program WednesdayMay 1, 2002 8:00 am - 2:00 pm 2:00 - 6:00 pm 2:00 - 6:00 pm 2:00 - 6:00 pm 3:00 - 6:00 pm 6:00 - 8:00 pm Executive Committee / Board of Directors Meeting Committee Meetings Registration Poster Mounting (Both Sessions) Neonatal Resuscitation Course (Limited Registration - By Ticket Only) Coordinator: Medge Owen, MD; Lauri P. Cox, RN, BSN; Debbie Ward Gordon, RN, MSN Wine/Cheese Reception - (Hilton Head Island Marriott) Thursday, May 2, 2002 7:00 am 7:00 - 7:45 am 7:45 - 8:00 am Registration Breakfast with Exhibitors & Posters Opening Remarks & Welcome Joy L. Hawkins, MD; Gary M.S. Vasdev, MD 8:00 - 9:30 am Gertie Marx Symposium - Joy L. Hawkins, MD (Moderator) Judges: Gertie E Marx, MD; GM Bassell, MD; Geraldine O'Sullivan, FRCA; Robert D'Angelo, MD; Donald H. Penning, MD, MSc, FRCPC; David H. Chestnut, MD; Joy L. Hawkins, MD 9:30 - 9:45 am Distinguished Service Award Presentation Valerie A. Arkoosh, MD 9:45 - 10:15 am 10:15 am - 11:15 n Break with Exhibitors & Posters Oral Presentations #1 Moderator: Christopher James, MID 11:15 - 12:15 pm Debate No. i Anesthesiologists May Leave the Hospital When a Patient Has an Indwelling Epidural Catheter Moderator: Kathryn J. Zuspan, MD PRO: Gerald A. Burger, MD 12:15 - 1:15 pm 1:15 - 2:15 pm CON: Theodore G. Cheek, MD Lunch with Exhibitors and Posters Poster Review #1 Introduction: Valerie A. Arkoosh, MD Moderator: Yaakov Beim, MD 2:15 - 2:30 pm Break with Exhibitors and Posters "Hands on" Airway Workshop Refresher Course Lectures (Limited Registration - By Ticket Only) 2:30 - 4:00 pm 4:15 - 5:45 pm Group I Group 2 Coordinators: Barry Harrison, IID; 2:30 - 3:30 pm Parenteral Medications for Labor & Delivery David C. Campbell, MD, MSc, FRCPC Gerard S. Kamath, MD 4:00 - 500 pm Covering Labor & Delivery in a Community Hospital Patricia A. Dailey, MD Neonatal Resuscitation Cócdiñator: Medge Owen, MD; Lauri P. Cox, RN, BSN; Debbie Ward Gordon, RN, MSN 3:OO-6:OOpm Course material will be distributed at the beginning of the session. In this course, the participant will be trained in neonatal resuscitation. Following examination, the participant will be certified by the American Academy of Pediatrics. 17 Gertie Marx Symposium Judges: Gertie F. Marx, MD; GM Bassell, MD; Geraldine O'Suffivan, FRCA; Robert D'Angelo, MD; Donald H. Penning, MD, MSc, FRCPC; David H. Chestnut, MD; Joy L. Hawkins, MD 8:00 - 9:30 am GM-i THE EFFECT OF OVARIAN HORMONES ON ISOFLURANE HYPERALGESIA Flood, P.; Daniels, D. GM-2 PEAK POINT CORRELATION DIMENSION: A NOVEL PREDICTOR OF ADVERSE HEMODYNAMIC RESPONSE TO SPINAL ANESTHESIA. Chamchad, D; Arkoosh, V.; Buxbaum, J.; Horrow, J.; Nakhamchik, L.; Kresh, J. GM3 EFFECT OF EPIDURAL TEST DOSE ON AMBULATION AFTER A COMBINED SPINAL EPIDURAL TECHNIQUE FOR LABOR ANALGESIA Calimaran, A.L.; Strauss-Hoder, T.P.; McCarthy, R.J.; Wong, C.A. GM-4 PLATELET COUNT & PLATELET FUNCTION: AN IN VITRO MODEL FOR PRODUCING WHOLE BLOOD WITH LOW PLATELET COUNTS Patel. N.; Fernando, R.; Riddell, A.; Brown, S. GM-5 EARLY LABOR IS MORE PAINFUL IN PARTURIENTS WHO EVENTUALLY DELIVER BY CESAREAN SECTION FOR DYSTOCIA Panni. M.K.; Spiegel, J.; Segal, S. GM-6 THE IMPORTANCE OF METHODOLOGICAL VARIABLES IN THE STUDY OF HYPOTENSION AFTER SPINAL ANESTHESIA FOR CESAREAN SECTION: PENTASTARCH VS. NORMAL SALINE Bach, P.S.; Kamani, A.A.; Douglas, J.M.; Gunka, V.; Esler, M. All Abstracts listed on this page are in the Anesthesiology Supplement 18 Oral Presentations #1 Moderator: Christopher James, MD 1O:15- 11:15 am BP-4 SPECTRAL ECG ANALYSIS PREDICTS LABOR OUTCOME IÑNULLIPAROUS INDUCEDLABOR PATIENTS Leighton, B.L.; DiMaria, L.J.; Whittaker, M.S.; Maihotra, S.; Kligfield, P.D. 01-2 HERPES SIMPLEX LABIAUS REACTIVATION WITH INTRATHECAL MORPHINE IN SEROPOSITIVE PARTURIENTS Shannon. K.T.; Ramanathan, S. 01-3 LEVOBUPIVACAINE IS UNREUABLE FOR USE AS A SPINAL TEST DOSE. Owen, M.D.; Hood, D.D. 01-4 INTRATHECAL FENTANYL AS AN ADJUNCT TO BUPIVACAINE/MORPHINE SPINAL ANESTHESIA FOR CESAREAN SECTION Velickoviç T A, Leicht, C H All Abstracts listed on this page are in the Anesthesiology Supplement. 19 Debate No i Anesthesiologists Mqy Leave the Hospital When a Patient Has an Indwelling Epidural Catheter Moderator: Katheryn J. Zuspan, MD PRO: Gerald A. Burger, MD CON: Theodore G. Cheek, MD 1:00 - 2:00 pm Supporting manuscripts will be, available online after the meeting. Following this debate, the participants will be able to outline the medical, medicolegal and administrative issûes involved in the decision to leave the hospital when a parturient has an indwelling epidural catheter for labor analgesia. 20 Poster Review #1 Moderator: Yaakov Beilin, MD 1:15-2:150 pm p-35 P-36 RELATIVE MOTOR BLOCKING POTENCIES OF BUPWACAINE MD LEVO-BUPWACAINE IN LABOUR Lacassie. H.J; Columb, M.O. DO DIFFICULT EPIDURAL PLACEMENTS OR INEXPERIENCED STAFF CAUSE MORE LOW BACK PAIN ON DAY ONE POSTPARTUM? Goodman, F.J.; Dumas, S.D.; Lilly, M.H. PATIENT CONTROLLED ANALGESIA USING FENTANYL FOR SECOND TRIMESTER LABOR ANALGESIA. VARYIÑG BOLUS DOSE AND LOCKOUT INTERVAL , . P-37 P-38 Castto. C; Tharmaratnam, U; Tam, K.; Brockhurst, N.; Tureanu, L.; Windrim, R.; Mwbray, M. THE EFFECTS OF LOW-DOSE EPIDURAL TECHNIQUE FOR LOR ANALGESIA ON FETAL HEART RATh (FHR) P-39 P-40 P-41 P-42 P-43 e-44 , JJiII,J.; Alexander,J.M.; Sharma, S.K.; Mclntirc, D.D.; Leveno, K.J. EPIDURAL ROPIVACAINE VS BUPWACAINE FOR LABOR: A META-ANALYSIS Halpern. S.; Walsh, V.; Joseph, G. EPIDURAL ANALGESIA LENGTHENS THE FRIEDMAN ACTIVE PHASE OF LABOR Alexander,J.M.; Sharma, S.K.; Mclntire, D.D.; Leveno, KJ. Influence of Heignt, Weight and Patient Postiion on Sensory Level After Intrathecal Lanor Analgesia with a Hypobaric Solution \Vong. C.A; Johnson, E.;Strauss-Hoder, T.P.; Cariaso, D.F.; McCarthy, R.J. ASSESSING THE OUTCOME OF A TEST DOSE Dalai, P, Gertenbach K Harker H , O Sullivan, G, Re) nolds F FETAL HEART RATE AND UTERINE CONTRACTION PAll ERN ABNORMALITIES AFIJiR COMBINED SPINAL/EPIDURALVS.SYSTEMICLABORANALGESIA Scavone, B.M.; Sullivan,J.T.; Peaceman, A.M.; McCarthy, R.K; Strauss-Hodr, T.P.; Wong, C.A. THE INFLUENCE OF CONTINUOUS LABOR SUPPORT ON THE CHOICE OF ANALGESIA, AMBULATION AND OBSTETEIC OUTCOME Muir H A Hodnett, E D Hannah, M E, Lowe, N K \Villan, A R Stevens, B Weston, JA Ohisson, A, Gafni A, r Myhr P-45 DOES PLACENTAL LOCATION AND/OR FETAL POSITION LEAD TO PROLONGED FETAL DECELERATIONS FOLLOWING LABOR ANALGESLV Ansa F M Ebene, RL De Simone C A Norris M C ,White Pettaway D, Koutoulas A Mallozzi, A P-48 UNIPORT VS MULTIPORT EPIDURAL CATHETERS FOR LABOUR:A META-ANALYSIS Srehrnjak, M.; Halpern, S. HOW LOW IS LOW-RISK WHICH PARTURIENTS MAY NOT NEED AN W Hess, EF; Mann, S.; Pratt, S.D. DOES IYPE OF LABOR ANALGESIA ALTER THE PAÏIERN OF OXYTOCIN USE? Sullivan, J.T.; Scavone, B.M.; McCarthy, R.J;; Wong, C.A. P-49 P-so IS FETAL BRADYCARDIA FOLLOWING COMBINED SPINAL-EPIDURAL ANALGESIA DUE TO TETANIC UTERINE CONTIIACTIONS WITH DECREASED UTEROPLACENTAL PERFUSION? Marenco, J.E.; Birnbach, D.J.; O'Gorman, D.A.; Browne, I.M.; Stein, D.J.; Santos, A.C. MINI-DOSE INTRATHECAL MORPHINE REDUCES ANALGESIC REQUIREMENTS WITHOUT INCREASING SIDE EFFECTS Vasudevan, A.; Wang, J.; Pratt, S.; Snowman, C.; Hess, P.E. AllAbstracts listed on this page are in the Anesthesiology Supplement 21 Poster Review #1 P-51 POOLED ANALYSIS OF RANDOMIZED TEIALS OF EPIDURAL VS. OPIOID ANALGESIA ON THE RISK OF CESAREAN SECTION Sega!, S.; Su, M. P-52 EFFECT OF LOW DOSE MOBILE VERSUS HIGH DOSE EPIDURAL TECHNIQUES ON THE PROGRESS OF LABORAMETA-ANALYSIS Angle, P.; Halpern, S.; Morgan, A. P-53 P-54 P-55 P-56 P-57 P-58 P-59 P-60 INITIATION OF LABOR ANALGESIA WITH EPIDURAL BUPIVACAINE: EFFECT OF PARITY [3reen, T.W,; Muir, H.A.; Dwane, P.; Olufolabi, A.; Schultz,J.; Habib, A.; Millar, S.; Drysdale, S.; Spahn, T. COMPARISON OF THE MINIMUM LOCAL ANALGESIC CONCENTRATIONS OF BUPIVACAINE FOR NULLIPAROUS AND MULTIPAROUS WOMEN IN LABOR Policy, LS.; Columb, M.O.; Naughton, N.N.; Wagner, D.S. PREGNANCY WEIGHT GAIN AND LABOR OUTCOME Romeo, R.C.; Ramanathan, S. EPIDURAL-PCA FOR LABOR PAIN: DO MULTIPARAE REQUIRE LESS EPIDURAL MEDICATIONS THAN PRIMIPARAE? Cohen, S.; Denenberg. H.; Bokhari, E; Farooq, T.; Burley, E.; Grosu, V.; Spears, L.; Freeman, L.; Barsoum, S. HISTORICAL PERSPECTIVE OF RECTAL ANALGESIA FOR LABOR AND DELIVERY Tungpalan, L.A.; Mergens, P.A.; Caswell, RE.; Vasdev, G.M. TEMPERATURE OF SUFENTANIL INTRATHECAL INJECTATE AFFECTS SPINAL LABOR ANALGESIA Zhu. H; Grodecki, V.; Huffnagle, S.; Huffnagle,J.; Audu, P. ANESTHESIOLOGIST INTERVENTION RATE AND EFFICACY OF PARTURIENT-CONTROT I PD EPIDURAL ANALGESIA (PCEA) - EFFECT OF INCREASING CONCENTRATION OF BOLUS SOLUTION USING 0.0625% BUPIVACAINE + 0.0002% FENTANYL BACKGROUND INFUSION Js1er, M.D,; Kliffer, P.; Money, P.; Douglas,J.; HOWMOBILE DO MOBILE EPIDURALS NEED TO BE? Dharmai, S P-61 A PROSPECTIVE RANDOMIZED DOUBLE-BUND COMPARISON OF OBSTETRIC OUTCOME AFrER LABOR EPIDURAL ANALGESIA USING LOW CONCENTRATION ROPIVACAINE OR BUPIVACAINE INFUSIONS WITH FENTANYL Lee. B.B, Ngan Kee, W.D. P-62 EPIDURAL FENTANYL INFUSIONS IN THE PRESENCE OF LOCAL ANESTHETICS EXERT SEGMENTAL ANALGESIA: AN MLAC INFUSION STUDY IN NUWPAROUS LABOR Ginosar, Y; Columb, M.; Cohen, S.E.; Mirikatani, E.; Tingle, M.S.; Ratner, E.E; Riley, ET. All Abstracts listed on this page are in the Anesthesiology Supplement 22 Poster Revièw. #1 P-95 j PERIODONTITIS ASSOCIATED WITH PRETERM LABOR, PRETERM LOW BIRTH WEIGHT, AND PREEC- P-96 LAMPSIA? .. Vallejos M.C.; Daftary,A. Riegel, A.R.; Phelps, A.L.; Kaul, B.; Mandell, G.L.; Ramanathan, S. ASA PHYSICAL STATUS CLASSIFICATION - A PREGNANT PAUSE l3arbeito, A.; Schultz,J.; Muir, H.; Dwane, P.; Olufolabi, A.; Breen, T.; Habib, A.; Millar, S.; Drysdale, S.; Spahn, T. ECV FACIUTATION BY ANESTHESIA FOR BREECH PRESENTATION * A QUANTITATIVE SYSTEMATIC REVIEW Gagnon S.; Tureanu, L.M.; Macarthur, A.J. META ANALYSTS CHALLENGE THE PUERPERAL PREDICTIONS OF MALLAMPATI ADVOCATES P-98 Glassenherg. R.; Fredericksen, M. P-100 P-loi P-102 . EXPECTANT MANAGEMENT, POSTDURAL PUNCTURE HEADACHE AND LENGTH OF HOSPITAL STAY Angle, R; Tang, S.; Thompson, D.; Szalai, J.P. INCIDENCE OF POST-DURAL PUNCTURE HEADACHE AND EPIDURAL BLOOD PATCH FOLLOWIÑG DURAL PUNCTURE WITH EPIDURAL NEEDLE IN 15,411 OBSTETRIC PATIENTS IN A LARGE, TERTIARY CARE TEACHING HOSPITAL Toyama. T.M.; Ranasinghe, J.S.; Siddiqui, M.N.; Steadman, J.L.; Lai, M.. A COMPARISON OF THE USE OF ATRAUMATIC SPINAL NEEDLES BETWEEN ANESTHESIOLOGY AND EMERGENCY MEDICINE TRAINING PROGRAMS Kerimoglu, R; Birnbach, D.J.; Marenco,J.E.; Stein, D.J. EXPANDED ANTIGEN-MATCHING FOR ERYTHROCYTE TRANSFUSION OF WOMEN WITH SICKLE CELL DISEASE DURING PREGNANCY REDUCES TRANSFUSION-RELATED ALLOIMMUNIZATION Ramsey, P.S.; Winkler, D.D.; Rouse, D.J. P-103 P-104 P-105 P-106 P-107 SUPINE POSITION DURATION FOLLOWING AN EPIDURAL BLOOD PATCH Hepner, DJ ; Kodali, B.; Camann , W.; Harnett, M.; Sega!, S.; Tsen, L.C. ANESTHESIA FOR EGG RETRIEVAL IN JAPAN: THE FIRaT NATIONWIDE SURVEY Terui, K.; Taya,J.; Ishihara, O.; Takeda, S.; Kinoshita, K. DECREASE IN THE INCIDENCE OF POST DURAL PUNCTURE HEADACHE: LONG TERM PLUGGING OF THE DURAL HOLE WITH THE EPIDURAL CATHETER Kuczkowski, KM; Benumof, J.L. DOES THE TIJ"IE OF THE DAYAFFECT OBSTETRIC ANESTHESIA WORKLOAD? Vogel, T.M; Ramanathan, S. COSYNTROPIN FOR THE TREATMENT OF POSIDURAL PUNCTURE HEADACHE I-lelsley. S.; Muir, H.; Breen, T.; DeBalli, P.; Dwane, P.; Drysdale, S.; Habib, A.; Millar, S.; Schultz,J.; Olufolabi, A. P-108 AMBULATORY GYNECOLOGICAL PROCEDURES OF CERVIX AND UTERUS CAN BE DONE SAFELY WITH MINIDOSELIDOCAINEANDFENTANYL Steadman, J.L; Siddiqui, M.N.; Ranasinghe, J.S.; Toyama, T.; Melgen, J.; Lai, M. All Abstracts listed on this page are in the Anesthesiology Supplement 23 "Hands on" Airway Workshop Session 1: 2:30 - 4:00 pm Session 2: 4:15 - 5:45 pm Coordinators: Barry Harrison, MD; Gerard S. Kamath, MD Following this course, the participant ill be familiar with the use of equipment for difficult airways. Participants will utilize mannequins and simulated surgical airways with these devices. 24 - Management of the Difficult Airway in Obstetrics: Brief Overview of Workshop Aims and Objectivés BA Harrison, MD; GS Kamath, MD; Mayo Medical Center, Rochester, MN Regional Anesthesia has largely supplanted general anesthesia in the management of the obstetric patient requiring surgical intervention. However, general endotracheal anesthesia is required in a variety of situations. Acute fetal distress. Maternal bleeding emergencies with hemodynamic instability. Failure of regional anesthesia. Refusal of regional anesthesia Other contraindications to regional anesthetic Endotracheal intubation may also be required emergently in the eclamptic mother or following high spinal anesthesia or local anesthetic toxicity Epidemiology of the obstetric difficult airway. Incidence of difficult, failed, and cannot intubate, cannot ventilate Intubation Measurement Obstetric Incidence General Incidence Study 1:2000 Cormack and Lehane Difficult: Mallampati grade III 1:46 (2.1%) Difficult: 1:50 (2.0%) Yeo and Thomas Laryngoscopy grade Gynecologic 1:56 (1.8%) 1:294 (0.34%) Lyons and MacDonald Failed 1:283 (0.35%) 1:2330 Sampsoon and Young Failed 1:750 Rocke, Murray, Rout et Failed (0.13%) Prospective al Cannot ventilate cannot intubate 0.00-1% to 0.02% Benumof = Several studies have suggested that difficulties in airway management are more frequent in obstetric anesthesia than in the general surgical population due to a combination of anatomical and physiological changes. In addition, the risk of aspiration exists with every parturient because of higher gastric volumes, increased gastric acidity, and altered upper and lower esophageal sphincter competencies. Several factors make management of the difficult airway altogether more challenging in obstetrics than in other surgical situations Fetal priorities may preclude attention to complete airway assessment of the mother Frequently, this makes the option of waking the mother one that may severely compromise fetal outcome Injudicious and frequent attempts at intubation increase incrementally the nsk of aspiration and airway trauma The resultant edema and bleeding may make previously possible mask intubation difficult and even impossible. , The parturient has a lower oxygen reserve (L FRC) and a rate of 02 utilization that can be up to twice that of the non pregnant individual The consequences of failure to maintain ventilation and oxygenation, therefore, result in more disastrous outcomes more readily. Airway management in obstetrics is also more challenging for a variety of factors other thai those already enumerated. The Obstetric Suite and OR's are frequently physically removed from the general OR's This makes rapid access to skilled help and technical assistance more challenging As these are frequently emergencies, they occur at least as often 'after hours" when additional assistance is unavailable The full time obstetric anesthesiologist has fewer opportunities at routine endotracheal intubation than his 'non obstetric" colleagues. 25 The aim of this airway workshop is to familiarize the anesthesia practitioner with current techniques and equipment for the management of the difficult and failed intubation. It is hoped that the course participants will familiarize themselves with these techniques and have the equipment required readily available for their use in their practice. It is beyond the scope of this outline to detail essentials like airway assessment. These are well-covered in standard resources. However, it is important to note that despite rigorous detail to airway assessment, some will prove unexpectedly difficult and some assessed difficult will prove to be easily managed. The reasons that the predictive tests fail are: The problem has a low prevalence. The predictive tests are subject to observer variation. They require patient cooperation. They utilize absolute measurements across a varying patient population. They measure "difficulty" which is hard to define. A prediction of failure is more appropriate, sincè difficulty can be managed by definition! The following table indicates the sensitivity, specificity and positive predictive value of a variety of airway assessment tests and the definition of difficulty utilized in these studies. Table II. Reported sensitivities, specificities and positive predictive values (PPVs) of various tests for predicting difficult tracheal intubation. Derivation Sample to which the derived Sensitivity Specificity PPV Definition of "defficulty" studies* scoring system was applied Reference Original sample 96% 82% 31% C & L 3-4 2 Original sample 75% 75% C & L 34/4 <20% 3 Original sample 4 5 New sample New sample 10% 99% 70% 87% 96% 31%oo <92% <94% <74% <96% <15% 62% 7-17% 65-91% 42-56% 45-60% 68% 65-81% 81% 25% 99% 16% 15-39% 8-15% 37% Validation Studies* 6 Thyromental distance 7 7, 8 6,9 2 Mallampati test (original) 10 Mallampati test (modified) 7,8 7 9,10 Thyromental distance plus Mallampati test Wilson score Sternomental distance Mouth opening Neck movement Jaw protrusion 8 1-82% 8 1-84% 87-89% 53% 66-82% 98% 42-55% 82% 26-47% 10-17% 17-26% 29% 69% 86-92% 4-21% 5-21% 2% 8-9% 64% Combination of view and no. of intubation attempts C & L 3-4 Intubation aid, e.g. bougie or different blade required C&L 3-4 C&L3-4/4 C&L 3-4 or bougie required C&L 3-4 C&L 3-4/4 C&L 3-4 C&L 3-4 or bougie required C&L 3-4 pr bougie required 6-9% Epiglottis only visible/C&L 3-4 27% C&L 3-4 or bougie required 2 94-95% 7-25% C&L 3-4/4 2 98% 8-30% C&L 3-4/4 2 95-96% 5-21% C&L 3-4 or bougie required 8 85% 9% 10 Indirect laryngoscopy 98% 31% C&L 3-4 *flerivtjnn tiir1c - Ç,t,,,.,,,, ___--------_j J 'ucasureu ano usea ro oerive a test such as a scoring system; validation studies = predefined test(s) applied to a group of surgical patients in order to assess its (their) performance ±Original sample = the one from which the scoring system was derived T C&L = Cormack & Lehane scoring system for laryngoscopy (16); grades 3 or 4 defined in the original reference as no part of the glottis visible. ooAssuming an incidence of "difficulty" of 2%. 8 - 89% 26 cS18O _P!I ÌT 70 W 60 o ..'. uF -i_ ... 1 iii. 90 lip -LL -- III VAI _Il ¡II L:i!iII ii_ !!ii loo 'ivi Illustration i indicates the rate of desaturation in various individuals without adequate ventilation. As, indicated earlierihe parturient mother has a lower reserve and higher oxygen utilization. Fatal desaturation may thus occur before an intubating dose of succinylcholine wears off sufficiently to allow adequate spontaneous respiration to resume. 4 5 6 6.87 lime of VE = Ointninues Airway Techniques A. Visualization Decreases This workshop will emphasize techniques that allow direct ventilation of the airway and passage of the tube through the cords. Flexible fiberoptic bronchoscopes Rigid fiberoptic devices B. Rescue Ventilation 1. Devices that allow "rescue" ventilation when two persons bag mask ventilation with oral and/or nasopharyngeal airways has failed. 2 LMA Combitube 3 Emphasize the role of the LMA "family" of devices (ILMA, LMA, Poro-Seal) as both ventilation devices and conduits that enable subsequent ET tube placement. C. Surgical techniques, when the above fail: i Cricothyroidotomy 2. Jet ventilation 3. Tracheostomy For the purpose of completeness, other devices on the ASA algorithm will be demonstrated. (Retrograde intubation/light wand, etc) 27 Pathology and the difficult obstetric airway The main disorder quoted extensively is difficult airway associated with pregnancy-induced hypertension. Several papers report case reports of pregnancy-induced hypertension and eclampsia with significant facial and laryngeal edema contributing to difficult endotracheal intubation. Although difficult, it was still possible to intubate using a small sized Erl'. The suggestion is to have small sized endotracheal tubes available at the time of intubation. However, in their prospective study, Rooke et al. found that neither facial edema nor swollen tongue predicted difficult intubation. Other pregnancy related diagnosis related to hemorrhage and respiratory distress may indirectly contribute to the obstetric difficult airway. With improved medical care, many patients with congenital abnormalities are now able to conceive and deliver babies. However, these congenital abnormalities may contribute to airway problems. It is also important to evaluate acquired medical diagnosis with respect to airway problems. Obesity and obstructive sleep apnea both contribute to the difficult obstetric airway. Intubation In Obstetrics: There is no easy airway in obstetrics! -, Indications: Apart from endotracheal intubation for elective cesarean section all intubations are emergencies. During emergency endotracheal intubation, corners may be cut, a full airway assessment may not be performed, inductions drugs, monitors and equipment may not have been checked and these items may not be readily available. Pre-existing and pregnancy related diagnoses, maternal hypovolemia, or coagulopathy may not be fully appreciated. Skilled help may also not be readily available. All these factors contribute to the emergency airway posing higher risk than the elective airway. Common indications for endotracheal intubation are general anesthesia for cesarean section. However, a failed regional technique, high spinal or high epidural block, local anesthesia toxicity, cardiac arrest, respiratory and neurological emergencies may all result in the need for endotracheal intubation. Although much debate exists, fetal distress requiring cesarean section is probably the most common indication for endotracheal intubation and general anesthesia. The purported advantages include faster onset and less hemodynamic disturbance. However, studies comparing onset of anesthesia and fetal outcome judged by Apgar scores at 1 minute, neonatal blood gas analysis have demonstrated no difference between general anesthesia and regional anesthesia for fetal distress. Obstetric Airway Assessment: An airway assessment is essential prior to all anesthesia and analgesia procedures on the labor floor. A complete assessment can be performed in approximately 1-2 minutes. ,Table 3 outlines an airway assessment. Some advocate that all patients on the labor floor should undergo an airway assessment examination on admission. A committee report of American College of Obstetrician and Gynecologists state that the obstetric care team should "be alert' for the general anesthesia risk factors, specialist consultation obtained and consideration given for the planned placement of an epidural catheter in early labor. I 2 3 4 5 6 7 Table 3. Essentials of airway assessment Facial edema Obesity and short neck Neck flexion and extension - atlanto-occipital extension Mandibular space - thyromental distance Mouth opening Dentition - Protruding maxillary incisors, missing teeth Oropharyngeal structures Mallampati Classification Unfortunately, only a few obstetric studies have evaluated airway assessment prospectively. Rocke et al. performed an airway assessment in 1500 parturient undergoing emergency and elective cesarean section under general anesthesia. Their group discovered a significant correlation (p<O.Ol) between oropharyngeal structures and the laryngoscopy view and difficulty at intubation. Multivariate analysis demonstrated visualization of oropharyngeal structures, short neck (obesity), receding mandible and protruding maxillary incisors all to be significant. It is important to note that one of the end points in this study was difficult intubation, as judged by a scoring system developed by the authors. In there study, there were actually only two cases of failed intubation, giving an incidenée of 1:750 or 0.13%. Yeo, Chung and Thomas demonstrated a significant (pczO.OS) prediction between Mallampati score and difficult intubation. Their end point was the laryngeal view. In this study, there were also difficult 28 intubations noted even though the Mallampati was Grade 2. In this study, the race was predominantly Asian while in the Rocke paper the race was not stated; but as the paper was from South African maternity hospital, a proportion of the patients may have been African. An English paper demonstrated that racial origins influenced the difficulty of intubation. Therefore, in airway assessment the racial origin may be an important clue of difficulty. Preparation for Intubation: Routinely, 30 mls 0.3 M sodium citrate is administered to neutralize the stomach's acidity. To prevent further production of acid, a H2 blocker can also be administered. Metoclopramide will facilitate gastric emptying, provided that it is administered before systemic opioids are administered. Although the use of these medications is routine, it is difficult to prove that these medications have decreased the incidence or outcome of aspiration pneumonitis. - The presence of personnel in the delivery suite trained in airway management is essential. Because the delivery suite is usually isolated from the main operating room and personnel not always available, it is advisable to have midwives trained in airway management, importantly cricoid pressure. In papers detailing the difficult and failed airway assessment in obstetrics, it is usually defined as the most senior anesthesia care personnel attempting, assessing and failing. Standardization and quantification of skills is difficult. All essential monitoring, drug and equipment must be checked and ready prior to any regional or general anesthetic procedure in the obstetric operating room. Emergency airway adjuncts such as oral and nasal airways, COPA airway, endotracheal tube stylets, a gum elastic bougie and a light wand should be readily available. An emergency airway cart should be readily available. Endotracheal Induction and Intubation: Because of the anatomical and physiological changes of pregnancy and labor, the techniques of endotracheal intubation need to be adapted. The patient needs to be correctly positioned. The neck needs to be flexed at the cervico thoracic junction and extended at the atlanto occipital joint. Properly positioned pillows help to exaggerate the position, optimizing it and improving success. Measuring end tidal nitrogen, and watching the level reach a plateau, infers complete denitrogenation and optimal pre oxygenation. Anesthesia is usually induced intravenously with thiopentone, propofol or ketamine. Cricoid pressure is in position at the onset of induction and fully applied as the patient is induced. There may be difficulty inserting the scope due to poor positioning of the patient, the increased size of the chest wall and improperly positioned cricoid pressure. Surprisingly, there has been no study suggesting which blade is optimal. At present the blade the operator is most familiar with should be used. Following endotracheal intubation, confinnation is necessary by quantitative or qualitative measurement of end-tidal CO2. Dfflcult Airway Algorithms and Failed Intubation Drills ASA difficult airway ajgorìthm: The ASA Difficult Airway Algorithm has standardized the approach to the difficult airway. Standards or guidelines aim to minimize the mortality and morbidity assoçiated with the difficult airway and also aids education and research. However, the ASA difficult airway algorithm needs to be adapted to obstetrics. Significant differences between the obstetric and ASA algorithm are: Most cases are emergency and not elective. Maternal, uterine and fetal physiology. Both mother and fetal needs to be assessed. 4 Spontaneous breathing is preferred Assessment and decisions: Similar to the ASA Difficult Airway Algorithm, initial assessments and then decisions must be made. The initial assessments include: i Maternal status Fetal status Airway status The decisions that need to be made following these assessments are: 1. Expected versus unexpected difficult airway 2 Expected difficult airway - Regional technique versus Awake technique - Awake: Surgical technique versus non-surgical technique - 29 Cardiac arrest: Difficult or failed intubation may lead to a cardiac arrest. Therefore, the potential for maternal cardiac arrest must be assessed. Aspiration and lung injury will exacerbate the hypoxia of the difficult and failed airway also increasing the potential for cardiac arrest. Protocols for cardiopulmonary resuscitation in pregnancy advocate perimortem cesarean delivery within 5 minutes of cardiac arrest. In the difficult or failed intubation, earlier cesarean section may aid resuscitation. Obstetric difficult and failed airway algorithm: Many difficult and failed obstetric airway algorithms exist. Most are complicated aiming to cover all contingencies related to the expected and unexpected difficult obstetric airway. For these algorithms, the quality of evidence for the algorithm is neither stated or they are mainly a compilation of case reports. Importantly, there is no evidence of efficacy. Simplifying the algorithm has the potential to make it easier to use and also to assess its efficacy. Usually, this approach is related to failed intubation, and is referred to as drills. A 17-year review of a failed intubation drill illustrated some of the benefits of this approach. Out of 5802 cesarean sections between 1978 and 1994, there were 23 (0.4%) failures to intubate the trachea. The algorithm used was simple and specific for unexpected failed intubation. Most of the failures were for emergency situations. Eighteen patients were allowed to waken and regional techniques utilized. Manual ventilation was difficult in seven and impossible in two. Four patients had an LMA inserted. Using the LMA in this situation, the lungs were difficult to ventilate in two episodes and impossible to oxygenate on one occasion. No anesthesia or anesthesia obstetric association or society has developed evidence based guidelines for the obstetric difficult airway or failed obstetric intubation. As stated to be complete such guidelines are extremely complicated and lack evidence making their value questionable. An approach to the expected and the unexpected difficult airway algorithm are outlined in Figures 3 and 4, respectively. The main aim of these guidelines is intended for discussion of the airway management techniques. Expected Difficult Intubation Once the assessment and decision has determined that it is an expected difficult airway then the decision is between regional and awake intubation. If awake intubation is decided, then the decision is between surgical versus nonsurgical technique. Though an awake surgical airway technique is included for completeness, for the obstetric difficult airway it is most likely to be of benefit during upper airway trauma affecting the parturient or when an obvious pre-existing airway problem exists. There have been two case reports in the literature where the tracheotomy was inserted prior to delivery. In one case, the patient subsequently underwent cesarean section under regional anesthesia with the tracheotomy used as a backup. Regional Technique / Expected Difficult Intubation Awake Intubation Technique Non Surgical Technique / Non fiberoptic Spinal anesthesia Epidural anesthesia Combined spinal-epidural Local anesthetic agent Laryngoscope Light wand V' Fiberoptic Bronchoscope Bullard blade Upsher blade Wu scope Surgical Technique Tracheostomy Figure 3: The "expected" difficult airway algorithm. Regional anesthesia and the difficult obstetric airway: Regional is the usual selection in the expected difficult airway. In non-emergency obstetric situations the choice of regional technique is dependent on the anesthesiologist. 30 Emergency situations with severe time limitations are no contraindications to a regional technique. Although the literature supports equal outcome comparing regional to general anesthesia in emergency situations, there is no literature to support the optimal regional technique. Usually, the regional technique is between a spinal anesthetic or loading a functioning epidural or loading an epidural from a continuous spinal epidural. In severely pre-eclamptic patients undergoing cesarean section, spinal versus epidural, the hemodynamic and fetal outcome showed no significant difference. When comparing combined spinal epidural anesthesia (CSEA) and epidural anesthesia for cesarean section, CSEA had greater efficacy and fewer side effects. Although conventional wisdom endorses a regional technique in the expected difficult airway, complications or failure of the regional technique may make it necessary to intubate the trachea. Thus, a backup plan is necessary with the appropriate equipment being available. A case report described a patient with a failed combined spinal epidural, who failed an endotracheal intubation, was then woken and underwent an awake, fiberoptic intubation. This is one of many case reports illustrating potential difficulties of regional anesthesia. The absolute contraindications to regional anesthesia in obstetric anesthesia are patient refusal and a coagulopathy When deciding on the regional technique, it is importantto select the technique that minimizes airway, cardiac, and respiratory emergencies for the individual parturient. Local anesthesia and the upper airway: Either the use of selected nerve blocks or direct application of local anesthetic agents will provide adequate anesthesia of the upper airway The hormonal changes in pregnancy increase the sensitivity of peripheral nerves to local anesthetic agents With pregnancy the upper airway membranes have increased vascularity, increasing the uptake of the local anesthetic, decreasing the duration of action of the local anesthetic Thus these two factors may balance out, however, it is important to be vigilant for local anesthetic toxicity The local anesthetic agent pnlocaine may induce a dose related methemoglobinemia The fetus may be more susceptible due to the inability to metabolize the compound due to metabolics and the administration of other drugs. Awake Non-fiberoptic Techniques: Following adequate anesthesia to the upper airway, non-fiberoptic techniques can be utilized for endotracheal intubation Different sized MacIntosh and Miller blades as well as specialized laryngoscopes with fiberoptic light sources or different shapes can be used. Airway adjuncts, such as stylets, intubating bougies, and external manipulation of the larynx may all play a role in aiding intubation. The lighted stylet can also aid intubation in the awake non-fiberoptic intubation. Although blind nasal intubation can be used in awake non-fiberoptic techniques, bleeding from the vascular membranes may further complicate the already difficult intubation. The use of the LMA, ILM or the ProSeal can be utilized in the awake endotracheal intubation. The ILM is probably a preferred choice as a definitive cuffed airway can be introduced. However, a literature survey found no case reports of the ILM in cesarean sections. There are two case series of the LMA being used for cesarean section. Positive pressure ventilation with peak airway pressure up to 20 cm H20 was used with no reports of aspiration. However, both of these were reported in abstract form, and review of the English literature failed to show that they have been published in a peer review journal. There are no reports of the Proseal LMA and the obstetric airway. Awake Fiberoptic Techniques: Fiberoptic techniques are popular for the expected difficult airway, especially in the parturient. Fiberoptic techniques use expensive equipment, have steep training curves and usually are not easily portable. The fiberoptic devices should allow the delivery of supplemental oxygen, as hypoxia is a common complication during these procedures. There are multiple case reports of the success of the fiberoptic bronchoscope in the expected and also the unexpected difficult obstetric airway. However, there has been no case series, the failure rate is unknown as well as the complication rate. Potential complications include failure, hypoxia, and risk of bleeding from the vascular membranes, especially if the nasal route is chosen. Difficulty passing the ETT may be seen in preeclampsia where patients may have laryngeal edema. One case report exists concerning the use of the Bullard and the difficult obstetric airway. Although there have been no published case reports concerning the Wu scope in the obstetric airway, the inventor, Dr Wu, has used the scope for parturients with difficult obstetric airways undergoing cesarean section. (Personal communication, Dr Wu) 31 Retrograde Technique: Retrograde intubation techniques can be utilized in the expected or unexpected difficult obstetric airway. In the expected difficult obstetric airway, it can utilize when an awake fiberoptic technique has failed. Many times when the initial technique has failed, bleeding and edema results increasing the difficulty of subsequent attempts. Once the guide wire has been passed through the cricothyroid membrane and exits the mouth or nose, it can be threaded up the suction channel of the fiberoptic scope. The fiberoptic scope is then advanced along the guide wire under direct vision through to the trachea. Unexpected Difficult Intubation: - ???? Ventilation Manual ventilation: With non-obstetric unexpected difficult airway the ability to demonstrate that mask ventilation is possible is done before the administration of neuromuscular blockers and an attempt at intubation. In obstetric anesthesia, due to the aspiration risk, a rapid sequence induction is usually performed. Thus, it is unknown if mask ventilation is successful before intubations attempts. Thus, when intubation is difficult, as demonstrated by the laryngeal view or there is failure to intubate, then mask ventilation must be attempted to insure oxygenation and ventilation. Because of the increased weight and edema in pregnancy, mask ventilation can be difficult. Oral airways are introduced to improve the efficiency of mask ventilation. Nasal airways can also be utilized; however, the increased vascularity of the nasal mucosa increase the potential for bleeding and further make the already difficult airway more difficult. Manipulation of the airway with the aim of improving the seal of the mask airway is important. Many algorithms and authors suggest that two people may be necessary, one to maintain a seal of mask and airway while the other needs to ventilate the patient. While this is occurring, it is advocated to maintain cricoid pressure. If mask ventilation is inadequate with cricoid pressure, then it should be relieved to see if improved ventilation occurs. In the British literature, it is advocated to place the patient in the Trendelenburg position. In this position, if vomiting or regurgitation does occur, they advocate that it is less likely to enter the trachea and lungs. Throughout the mask ventilation, left lateral tilt is maintained. The first step in the difficult or failed obstetric airway is to maintain oxygenation and ventilation through bag mask ventilation. Once this first essential step has been undertaken then the assessment of the maternal fetal status is undertaken. The obstetric team present needs input at this stage and a decision made with respect to the immediacy of delivering the baby. Unexpected Difficult Intubation Bag Mask Ventilation LMA Combitùbe ??Successful? Wake patient Continue: LMA Combitube Surgical airway Needle jet ventilation Cricothyrotomy Tracheostomy Maintain bag mask ventilation Volatile anesthesia Trendelenburg Spontaneous Ventilation Figure 4. The "unexpected" difficult airway algorithm Unexpected dfficult intubation - Can ventilate Non-urgent delivery: The suggested course of action is to awake the mother and then to use either a regional or an awake intubation technique. Case series have demonstrated that this approach works. Immediate delivery: A suggested course of action is to continue to mask ventilate, with or without cricoid, induce anesthesia with a volatile anesthetic, allow for resumption of spontaneous ventilation and maintain left lateral tilt and Trendelenburg position. Again, case series suggests that this is practical. U'4A: The LMA has been used with success in the can ventilate non-urgent and immediate delivery. These are published usually as "one off' case reports. With all case reports, there is a selection bias. If complications or negative outcomes are present, they are least likely to be published. Unexpected Difficult Intubation - Cannot ventilate Non-urgent delivery: The implicit aim is to waken the patient and then use a regional or awake intubation technique. However, it is still essential to maintain oxygenation of the patient. Apneic oxygenation may be able to maintain adequate oxygen saturation during this period. Although adequate ventilation may be impossible, partial incomplete bag mask ventilation may suffice in the interim allowing oxygenation and ventilation while the patient wakens. Evidence, even case reports, is difficult to discover to provide documentation for this step. Additionally, the use of non-surgical techniques (as described below) to maintain oxygenation and ventilation has also been described while waiting for the patient to waken. Urgent delivery: With urgent delivery, the decision must be made to go to an urgent non-surgical, surgical rescue ventilatory mode. Cesarean delivery with local infiltration anesthesia may be considered. The technical or comfort factor of the anesthesia care provider determines which technique to go to first in this situation. It is important to note that the anatomical and physiological changes with pregnancy may make oxygenation and ventilation difficult with a LMA, Combitube or needle jet ventilator technique. High airway pressures will need to be generated by these devices due to the decreased lung compliance associated with pregnancy and also any lung injury. Therefore, the high pressures may lead to barotrauma and inadequate oxygenation and ventilation. It is important to determine the efficacy of each intervention at this stage in the cesarean delivery. Non-surgical - urgent delivery LMA: Case reports have described the successful use of the LMA in the cannot intubate cannot ventilate, failed obstetric intubation. In a survey of obstetric anesthesia consultants in the United Kingdom, 71% of the respondents stated that they would use the LMA in the cannot intubate, cannot ventilate obstetric airway with 91% of the obstetric units stating that the LMA was available. Twenty-four of the consultant anesthetists had personal experience with the use of the LMA. Although complete details of the use was not stated, eight stated that it was life saving, two stated that attempts to pass a gum elastic bougie through the LMA failed and three had used the LMA; but without success, removed it and established mask ventilation. Twenty-two consultant anesthetists were against the use of the LMA-risk of aspiration being the principle reason given. The ProSeal has the potential to offer advantage of being able to ventilate and decrease the risk of aspiration, but it is still only FDA approved to 30 cm H20. The FasTrach LMA or intubating LMA has potential advantages as will allow the introduction of a definite airway. However, the lack of expertise and time may limit this technique. To date there are no case reports describing either the Proseal or the intubating LMA in the cannot intubate, cannot ventilate failed obstetric airway. Combitube: There are no case reports in the literature describing the use of the Combitube in the difficult or failed obstetric intubation. The Combitube has been used with success in the cannot intubate, cannot ventilate non-obstetric difficult airway. It has also been used with success in anesthetic cases in the operating room. Aspiration is the main potential complication with this device. There is a case report suggesting an esophageal perforation; however, multiple airway devices were used. The perforation also occurred distal to the site in the esophagus that the Combitube had been inserted. In a can not intubate, can not ventilate failed obstetric an esophageal gastric tube airway was inserted. Following insertion into the esophagus, the EGTA was attached to the anesthesia machine. Anesthesia was then administered, the baby delivered and the mother had an uneventful recovery. Surgical - urgent delivery Transtracheal jet ventilation: There are no casè reports of the use of transtracheal jet ventilation in the difficult or failed obstetric airway. High airway pressure may be required to overcome the decreased lung compliance seen in pregnancy. Acute lung injury secondary to pulmonary aspiration will decrease lung compliance even further making it difficult to maintain oxygenation and ventilation with jet ventilation. Also, without a definitive secured airway, pulmonary aspiration may result. Cricothyrotomy: There is not an abundance of case reports of cricothyrotomy, either surgical or using the Seldinger techniques in the difficult or failed obstetric airway. These techniques are used infrequently by anesthesiologists in the difficult airway. Emergency room physicians and surgeons tend to use this technique, if the airway has proven difficult. When using either the Seldinger or surgical cricothyrotomy on Cadavers by naïve medical personnel, both techniques were equally poorly performed. Essential equipment is a surgical blade size, dissectors/introducer and tracheotomy tube. Tracheotomy: In the obstetric setting, it is difficult to find a case report detailing an emergency tracheotomy in the difficult or failed airway. Obstetricians usually do not have as much familiarity with the technique of tracheotomy compared with general surgeons. This may, in part, describe why it has not been used in the labor and delivery room. Without anecdotal case reports to guide, no definitive conclusion is possible. The advice is to use whatever technique the anesthesia provider is the most comfortable. Thus, becoming familiar and practicing with difficult airway equipment is crucial. In the emergency room, cricothyrotomy has become the default airway to use in the difficult or failed airway. 34 Difficult airway equipment in obstetrics - not if, but when! With the difficult and failed obstetric airway, it is more a question of "when" than "if." Therefore, it is essential to have difficult airway equipment available. There are different approaches. One is to have every anesthesia machine equipped with one or two pieces of emergency airway equipment. This may consist of a gum elastic bougie to be used as an intubating guide and or a disposable LMA. These two pieces of equipment, or their equivalents, will be of benefit in most airway emergencies. Although each piece of equipment is inexpensive, fitting out each anesthesia location will add to the expense. Many anesthetic departments have developed "difficult airway carts". The aim is to have all difficult airway equipment available in one cart. It is usually portable, being able to be wheeled to where needed. There is continued upkeep needed to insure the equipment is in working order. The equipment on the airway cart can vary; the selection is dependent on the preference and experience of the anesthesia care team. The carts can go from either basic to very sophisticated. Price of the equipment and the numbers required will also influence the decision on the cart's equipment: Table 4 lists the specialized intubation equipment of one such airway cart used at the Mayo Clinic. Table 4 List of Difficult Airway Cart Major Equipment I Intubating flexible fiberoptic bronchoscope 2 Bullard portable laryngoscope Proseal LMA 3 4 Fastrach LMA Combitube 5 6 Jet ventilation apparatus Cricothyrotomy kit 7 Trachlight 8 - To be able to use the equipment in an emergency it is important to gain previous exposure to devel6p the necessary skills. Practice with equipment can be obtained on models. An additional approach is to use the equipment with every day patient use. This can be safe and "real life" with small modifications. Increasingly, airway simulators both aid the skill level with the difficult airway equipment and also, importantly, the relevance of the use of the difficult airway equipment in the airway algorithm. Conclusions The difficult and failed obstetric airway is a problem for all involved in the care of the pregnant patient in the labor and delivery room. All must be trained in the assessment and care of the obstetric airway--this means the non-difficult as well as the difficult airway. The anesthesia care provider must provide leadership in this endeavor, both at the local and national levels. Locally, they must be responsible for the education and training of all obstetric staff. They must measure outcomes through continuous quality assurance. Although poor outcomes have been decreased substantially, other outcomes, example number of maternal intubations and morbidity are necessary. A difficult and failed airway algorithm needs to be developed for each labor and delivery room. Although there is an increase in the specialized obstetric anesthesiologist, it is necessary to insure that all anesthesia care practitioners are aware and skilled in carrying out the protocol. Situational awareness and optimal progression from one step of the algorithm to the next is key to prevent morbidity. At the national level, general and specialized societies caring for the obstetric patient must Cooperate and act mutually to optimize airway management in obstetrics especially for the difficult and failed airway. 35 References Nath G, Sekar M. Predicting difficult intubation-a comprehensive scoring system. Anaes and mt Care. 1997; 25:482-6. EI-Ganzouri AR, McCarthy RJ, Turnan KJ, Tanck EN, Ivankovich AD. 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Failed intubation. Six years experience in a teaching maternity unit. Anaesthesia 1985; 40(8) 759762. Samsoon CLT, Young JRB. Difficult tracheal intubation: A retrospective study. Anesthesia 1987; 42(5):487-490. Rocke DA, Murray WB, Rout CC, et al: Relative risk analysis of factors associated with difficult intubation in obstetric anesthesia. Anesthesiology 1992; 77(1):67-73. Benumof JL. Management of the difficult airway. With special emphasis on awake tracheal intubation. Anesthesiology 1991; 75: 1087-1110 Mallampati SR, Gatt SP, Gugino LD et al. A clinical sign to predict difficult tracheal intubation: a prospective study. Canadian Anaesthetists Society Journal 1985; 32: 429- 434 Crapo RO. Normal cardiopulmonary physiology during pregnancy. Clinical Obstetrics and Gynecology. 1996;39:3-16. Brock-Utne JG, Downing JW, Seedat F. Laryngeal oedema associated with pre-eclamptic toxaemia. Anaesthesia 1977; 32:556-8. Brimacombe J. Acute Pharyngolarlyngeal Oedema and Pre-Eclamptic Toxaemia. Case Report. Anaesthesia and Intensive Care 1991; 20(1):97-8. 36 3 1 . Marx GF, Luykx WM, Cohen S. Fetal-neonatal status following caesarean section for fetal distress. British Journal of Anaesthesia. 1984;57(9): 1009-13. D'Alession JG, Ramanathan J. Effects of maternal anesthesia in the neonate. [Review]. Seminars in Perinatology 1998; 22(5):350-62. Morgan BM, Magni V, Goroszenuik T. Anaesthesia for emergency caesarean section. British Journal of Obstetrics & Gynecology 1990; 97(5):420-4. The American College of Ostetricians and Gynecologists. Anesthesia for emergency deliveries. ACOG Committee opinion #104. Washington DC: American College of Obstetricians and Gynecologists, 1992. Johnson MD, Luppi CJ, Over D. Cardiopulmonary resuscitation in pregnancy. In Gambling DR, MJ Ed. Obstetric Anesthesia and Uncommon Disorders. 1997. Suresh MS, Wali A. Failed Intubation in Obstetrics Airway Management Strategies in the High Risk Obstetric Patient Anesthesiology Clinics of North America. 1998; 477-498. Ezri T, Szmuk P, Evron S, Geva D, Hagay Z, Katz J. Difficult Airway Obstetric Anesthesia. A review. Obstetrical and Gynecological Survey 2001; 56, 10:631-641. Davies JM, Weeks S, Crone LA, Pavlin E. Difficult Intubation in the Parturient. Can J. Anaesth. 1989; 36:668-674. Hawthorne L, Wilson R, Lyons G, Dresner M. Failed Intubation Revisited: 17-year experience in a teaching maternity unit. British Journal of Anaesthesia 1996; 76:680-684. Fuhrman TM, Farina RA. Elective tracheostomy for a patient with a history of difficult intubation. J. Clin Anesthes 1995;7:250-2. : Callander CC, Thomas JS. The ethics of difficult tracheal intubation (letter). Anaesthesia l988;43:703-4. Hood D, Curry R. Spinal versus Epidural Anesthesia for Cesarean Section in Sevrely Pre-eclamptic Patients: A Retrospective Study. Anesthesiology 1999; 90:1276-1282. Choi DH, Kim JA, Chung IS. Comparison of Combined Spinal Epidural Anesthesia and Epidural Anesthesia forCesarean Section. Acta Anaesthesiologica Scandinavica. 2000; 44:214-19. Hawksworth CRE, Purdie J. Failed combined spinal epidural the failed intubation at an elective caesarean section. Hospital Medicine.59;1998: 173 Popitz-Bergez F, Leeson S, Talhamirier J, et al. Intraneural Lidocaine Uptake Compared to Analgesia Differences Between Pregnant and Non-pregnant Rats. Reg Anesth. 1997;22:363. Taddio A, Stevens B, Craig K et al. Efficacy and Safety of Lidocaine-prilocaine Cream for Pain during Circumcision. N EngI J Med. 1997;336:1 197. Yang H, Suh B: Laryngeal mask airway in cesarean section. 1 1th World Congress of Anesthesiology, Sydney, 14-20 April 1996, Abstract Handbook p.439. 11th World Liew E, Chan-Liao M. Experience of using laryngeal mask anesthèsia for caesarean section. Congress of Anesthesiology, Sydney. 14-20 April 1996, Abstract Handbook p.439. Edwards RM. Fibreoptic Intubation: A Solution to Failed Intubation in a Parturient? Anaestehsia and Intensive Care 1994; 22(6):718-19. Cohn Aaron I. MD, Hart Robert T MD, McGraw Scott R MD, Blass Norman H MD. The Bullard Laryngoscope for Emergency Airway Management in a Morbidly Obese Parturient. Anesthesia & Analgesia. 1995; 81(4):872-873. Chadwick IS, Vohra A. Anaesthesia for emergency caesarean section using the Brain Laryngeal Airway (Letter). Anaesthesia 1989; 44:261-2. McLune S, Regan M, Moore J. Laryngeal mask airway for cesarean section. Aneaesthesia 1990; 45 :227-8. Gataure PS, Hughes JA. The laryngeal mask airway in obstetrical anesthesia. Can J Anaesth 1995;42:130-3. Baraka A, Salem R. The Combitube oesophageal-tracheal double lumen airway for difficult intubation. Canadian Journal of Anaesthesia. 1993 ;40( 12): 1222-3. Klein H FRCA, Williamson M, Sue-Ling HM MD FRCS, Vucevic M FRCA, Quin AC FFARCSI. Esophageal Rupture Associated with the Use of the Combitube. Anesthesia & Analgesia. 1997; 85(4):937939. Tunstall ME, Geddes C. Failed Intubation In Obstetric Anesthesia, An indication for use of the "Esophageal Gastric Tube Airway". Br. J Anaesth 659-66 1, 1984 1 37 Refresher Course Lectures Parental Medications for Labor & Deliver)' David C. Campbell, MD, MSc, FRCPC 2:30 - 3:30 pm Following this lecture, the participants will be able to choose appropriate parenteral medications and methods of administration for providing analgesia during labor. Covering Labor and Delivery in a Communiy Hospital Patricia A. Dailey, MD 4:00 - 5:00 pm Following this lecture, the participants will be able to describe and compare several different options for billing for obstetric anesthetics, newer coding procedures in obstetric anesthesia, VBAC standby issues, staffing issues, J CAHO compliance issues, and realities of community practice. 38 Parenteral Medications for Labor and Delivery David C. Campbell, MD, MSc, FRCPC Associate Professor Chairman (acting) Director of Obstetric Anesthesiology Department of Anesthesia College of Medicine University of Saskátchewan E-mail: [email protected] Refresher Course Outline: Review Indications for Epidural Labor Analgesia Review "State-of-the-Art" Initiation of Epidural Labor Analgesia Review "State-of-the-Art" Maintenance of Epidural Labor Analgesia Review Absolute Contraindications to Epidural Labor Analgesia Review Parenteral Analgesic Options when Epidural Labor Analgesia Contraindicated Review Patient Controlled Intravenous Analgesia (PCIA) Options Review the University of Saskatchewan Experience References: Campbell DC. Low dose epidural labour analgesia. Techniques Reg Anesth and Pain Management 5:3-8, 2001 Campbell DC. The Evolution and Revolution of Epidural Analgesia in Labour. The Canadian Journal of Continuing Medical Education Special Women's Issue 12 233-42, 2000 3 Halpern SH, Breen TW, Campbell DC, Muir HA Intravenous PCA Fentanyl vs Epidural PCA Fentanyl/Bupivacaine: Neonatal Effects. Anesthesiology 90:A19, SOAP Suppi. April 1999 4. Muir HA, Breen TW, Campbell DC, Halpern SH. Is Intravenous PCA Fentanyl an Effective Method for Providing Labor Analgesia? Anesthesiology 90:A28, SOAP Suppi. April 1999 39 Covering Labor and Delivery in a Community Hospital Staffmg and Reimbursement Issues Patricia A. Dailey, M.D. I. What is required if your hospital provides labor and delivery services? A. Guidelines for Perinatal Care. 4th Edition': Basic Care Facility Capability to begin an emergency CS within 30 min of the decision to do só Detection and care of unanticipated maternal-fetal problems Availability of anesthesia on 24-hour basis Specialty Care Facility Above+ Care of high-risk mothers and fetuses Care of preterm infants with a birth weight of 1500 g or more; stable or moderately ill newborns who have problems expected to resolve rapidly Director of obstetric anesthesia services should be board certified in anesthesia and should have training and experience in obstetric anesthesia Subspecialty Care Facility Above+ Personnel qualified to manage obstetric or neonatal emergencies should be in-house 24 hours/day in house availability of anesthesia Board-certified anesthesiologist with special training or experience in maternal-fetal anesthesia should be in charge of obstetric anesthesia services B. Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Standard TX.2.1 Apresedation orpreanesthesia assessment is performedfor each patient before beginning moderate or deep sedation and before anesthesia induction. Intent of TX.2.1 (per JCAHO)The following is buried in the intent of TX.2.1: "Hospitals providing obstetric or emergency operative services can pròvide anesthesia services within approximately 30 minutes after anesthesia is deemed necessary. In organizations providing labor services for patients seeking vaginal delivery after previous cesarean delivery, appropriate facilities and personnel, including obstetric anesthesia and nursing personnel, are immediately available to perform emergency cesarean delivery when conducting a trial of labor for women with a prior uterine scar." 40 California Health and Safety Code 1256.2 (effective 1/1/1999)' "It is unprofessional conduct for a physician to deny or to threaten to withhold pain management services, from a woman in active labor, based upon that patient's source of payment, or ability to pay for medical services." Signs must be posted inLabor and Delivery Units that attest to the hospital's compliance with this policy. Comment: 1256.2 does not explicitly state that wemust provide regional analgesia. Ifthe hospital doés not have the resources to provide labor epidurals to anyone, 1256.2 does not require regional analgesia availability. Rather, we cannot discriminate. In other words, we cannot provide epidurals to our friends or the wives or daughters of our colleagues unless we offer epidurals to all women delivering at the institution. Small hospitals don't have to have a labor epidural service, but if the occasional VIP receives an epidural, then the same service should be provided for all. I urge you to read Dr. Sheila Cohen's editorial writteñ for the California Society of Anesthesiologists Jan-Feb 1999 Bulletin and reprinted in IJOA2. EMTALA (Emergency Medical Treatment and Labor Act The general principle of EMTALA is "Access to care and non-discriminatory treatment". Patients may not be coerced into being transferred or seeking care elsewhere, even if their insurance will not pay for their visit or is required by their insurance. For a pregnant woman who is having contractions, an emergency medical condition exists if there is inadequate time for a safe transfer or transfer may pose a health risk to the woman or baby Vaginal Birth after Cesarean Delivery (VBAC) The ACOG Practice Bulletin of July 1999 on VBAC3 has generated much controversy among obstetricians and anesthesiologists. This bulletin recommends that: Because uterine rupture may be catastrophic, VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available tó provide emergency care. A physician be immediately available throughout active labor capable of monitoring labor and performing an emergency cesarean delivery Anesthesia and personnel for emergency cesarean delivery be available The previous Practice Bulletin of October 1998 said readily available vs. the current immediately available. Dictionary definitions of "immediately" include "without delay", "as soon as", and "without interval of time". Definitions for "readily" include "in a prompt, timely manner" and "without hesitating". In our hospital, we have asked the obstetricians to notify the oncall anesthesiologist when a VBAC patient is in active labor so that we can be immediately available. This was recently inserted into the rules and regulations of the Department of OB/Gyn In addition, the "30 minute rule" between decision to delivery may not be valid with VBAC. A federal court decision, in a case in which the time elapsed from the onset of FHR deceleration to delivery was 27 minutes, concluded that the 30 minute rule represented the maximum period of 41 elapse and did not represent a minimum standard of care.4 A retrospective study of uterine rupture after previous CS deteniiined that significant neonatal morbidity occurred when> 18 minutes elapsed between the onset of prolonged deceleration and delivery.'4 A recent ASA newsletter includes the statement: "In contrast to other obstetric emergencies such as prolapsed cord or placenta accreta, VBAC is a completely elective procedure that allows for reasonable precautions in assuming this small but significant risk."5 Nurse Midwives Nurse midwives are increasingly managing the labor and delivery ofpatients. Is it necessary for an obstetrician to become involved in the care of a patient once we are asked to provide neuraxial analgesia? Our current ASA Guidelines say "yes". The ASA "Guidelines for Regional Anesthesia in Obstetrics"6 state: "Regional anesthesia should not be administered until 1) the patient has been examined by a qualified individual; and 2) a physician with obstetrical privileges to perform operative vaginal or cesarean delivery, who has knowledge of the maternal and fetal status and progress of and who approves the initiation of labor anesthesia, is readily available to supervise the labor and manage any obstetric complications that may arise." The clinical and legal implications of anesthesiologists providing regional analgesia/anesthesia to nurse midwife patients are discussed in an article in the ASA Newsletter7 and many letters to the editor in response. In some states, certified nurse midwives only need to collaborate with a physician, in California they must be supervised. There are many issues involved. A major issue is "the ability to rescue" in the case of either maternal or fetal distress. AWHONN (Association of Women's Health, Obstetric and Neonatal Nurses) AWHONN has published a new position statement'5 on the role of RN's in the care of women receiving regional analgesia. Since publication of this statement, labor and delivery nurses at some institutions are refusing to decrease the epidural infusion rate or restart an infusion that has been stopped. The AWHONN statement is noteworthy in what it states a non-anesthetist registered nurse should not perform. These include: "Rebolus an epidural either by injecting medication into the catheter or increasing the rate of a continuous infusion Increase/decrease the rate of a continuous infusion Re-initiate an infusion once it has been stopped Manipulate PCEA doses or dosage intervals Be responsible for obtaining informed consent for analgesia/anesthesia procedures; however, the nurse may witness the patient signature for informed consent prior to analgesia/anesthesia administration." 42 It is the view of the California Society of Anesthesiologists Board of Directors that a RN should be allowed to adjust an infusion rate, on a patient-specific order from the physician, provided that the RN has adequate education and training involving complications of labor regional anesthesia and programming of the pumps. Of course, a physician with appropriate privileges must be readily available during the regional anesthetic to manage anésthetic complications. The AWHONN restrictions can be challenged provided we educate and train the riurses. The' AHWONN position statement says: "The requisite education and clinical skill 'acquisition necessary to provide safe management ofregional analgesia/anesthesia for the pregnantwoman are not included in basic education programs for entry intoj,ractice as a registered nurse; therefore such analgesia/anesthesia management should be reserved exclusively for licensed, credentialed anesthesia care providers." We should take the lead and organize educational in-services on ànesthesià and analgesia for the registered nurses in Labor and Delivery. As we all know, a new RN is not allowed to manage an OB patient without additional training. This knowledge is acquired.' But oncè acquired, the L & D RN manages the laboring patient by examining the patient, interpreting the fetal heart rate' strip, adjusting oxytocin infusions, and administering potentially-toxic medications suéh as IV magnesium; often with no obstetrician or nurse midwife present in the facility." II. How can we afford to provide an OB anesthesia service? ' A. Size of Service When is it possible to provide continuous obstetric anesthesia coverage? In the mid-1990's, Íbre the current penetration of HMOs and discounted fee for service, Ostheimer8 suggested that 2000 deliveries/year is the borderline for full-time coverage of an obstetric service by a designated anesthesiologist: C/S rate of 20% (2000 x 20% = 400 cesarean deliveries) 50% of vaginal deliveries would require epidurallspinal anesthesia (=800) 400 + 800 = 1200 deliveries/365 days =3 -4 deliveries/day Dr. Ostheimer suggested that 3-4 deliveries/day requiring anesthesia services provides enough work assuming at least 50% of the patients will completely pay their bill (at UCR rates). ' ' V What about the reimbursement for the 3-4 deliveries/day in the "real world" of HMO's, capitation, and discounted fee-for-service? Depending on the patient demographics, these patients could all be Medicaid/indigent or in the increasingly rare situation, all fee-for-service. In my practice (25OØ deliveries/yr; 55-65% epidural rate), it is a blend of Medicaid, HMO, and fee-for-service. Over the past few years, the Medicaid population has increased as financial incentives have been provided to the obstetricians. Unfortunately pediatricians and anesthesiologists have not seen the same incentives. Our reimbursement does not cover our flj,aflpower cost to provide 24/7/3 65 dedicated OB anesthesia coverage even with 2500 jjyçrjes/year. An excellent paper by Elizabeth Bell and coworkers looks at manpower cost and reimbursement for an obstetric analgesia service at Duke University." The authors examined only the direct attending physician costs ($206,405 average attending anesthesiologist compensation), without 43 including dependent providers, supplies, or equipment. They found that around-the clock, dedicated obstetric staffing cannot operate profitably under any reasonable circumstances at their institution; they had 2351 obstetric anesthesia cases in fiscal year 1998. The cost per patient during the study period was $325 if the obstetric anesthesia service was staffed on an intermittent basis (2.5 FTEs); dedicated staffing (4.4 FTEs) cost $728/patient. Medicaid in North Carolina paid $204/patient; indemity paid $300-430/1,atient. I suggest that you read this article" and the accompanying editorial by David Chestnut. 2 The above article uses figures from North Carolina in 1998. You need to determine how many FTEs you need to cover an obstetric anesthesia service. Are they on an intermittent basis or dedicated staffing? What does an FTE cost in your geographic area? Will you be an all MD practice or use the anesthesia care team model? In many areas there has been regionalization ofperinatal care. However, with the emergence of HMOs/hospital alliances, many requiring their own Labor and Delivery Suite, there has been a return to smaller units. This is happening all over the country and is being reported on in newspapers and gaining the attention of legislators. If the HMO/hospital sees 24 hour/day; obstetric anesthesia coverage as a selling point for their hospital and the number of deliveries do not justify full-time coverage, then anesthesiologists need to negotiate with HMOs/hospital to supplement the income of the anesthesiologists on a "break even" basis. This issue was addressed in a newspaper article'3 about a hospital 15 minutes outside of Sacramento: "A Right to Relief? In some small hospitals, women in labor are being refused what they have come to consider their childbirth right: the pain-blocking epidural." The following is my letter to the editor.'4 "A Right to Relief' (January 26) discusses the availability of labor epidurals for childbirth in small hospitals. Anesthesiologists are committed to minimizing the pain and discomfort of childbirth. However, we should not lose focus of our foremost commitment; safety of the mother and baby. Unfortunately, emergencies may occur during childbirth When selecting a hospital, expectant parents should consider the capabilities of the hospital and whether physicians skilled in managing obstetric and anesthetic complications are available. Optimally, an anesthesiologist should be available to provide the mother with access to all options for pain relief. However, hospitals must decide if optimal patient care justifies obstetrical anesthesia services, particularly if there are not enough deliveries to support a dedicated anesthesiologist around the clock. Hospitals must recognize that, to meet 2002 standards of care, there are costs to provide such services. The trend is for small obstetric services to merge so they may offer the safest care possible." 44 B. How to provide an OB anesthesia service Know your practice (see sample calculation) Number of patients - Regional analgesia rate Cesarean section rate Insurance mix How is this changing? Percentage of Medi-Ca! OB vs non-Medi-Cal OB Is this increasing? OB style of practice Timing of epidurals, induction rates, CS rate, patient expectations Get hospital to provide stipend Learn what hospitals in the area or hospital system are providing as : -stipends. Review state laws re physician on call services. Negotiate with your hospital to obtain financial support to facilitate provision of 24-hour obstetric analgesia coverage. Have your anesthesia group provide stipend We have recently gone to income pooling and pay a stipend for OB coverage; any services provided while on OB go into the pooled units. r Maximize time on OB while being immediately available-do interruptible tasks Cover acute pain management service Attend hospital admimstrative meetings Help cover preoperative evaluation climc Continuing education Computer with on-line capability in call roóm Improve collection rates; audit billing and payments 6 Attract insurersfHMOs/obstetncians with better payment/payer records Increase the size of the service/merge services: increase patients, increase epidural rate Negotiate with insurers; write better contracts 45 III. Billing for your services A. New ASA RVG Base Codeseffeòt ive 1/1/2002 01960 01961 01962 01963 Anesthesia, vaginal delivery Anesthesia, cesarean section Anesthesia, emergency hysterectomy Anesthesia, cesarean hysterectomy 1967 Neuraxial labor analgesia/anesthesia for planned vaginal delivery (this includes any repeat subarachnoid needle placement and drug injection and/or any necessary replacement of an epidural catheter during labor 1968 Anesthesia, cesarean delivery following neuraxial labor analgesia/anesthesia (list separately in addition to code for primary procedure) (Use in conjunction with 01967) 1969 B Anesthesia, cesarean hysterectomy following Neuraxial labor analgesia/anesthesia (list separately in addition to code for primary procedure) (Use in conjunction with 01967) 3 5 Neuraxial analgesiatime documentation The ASA Committee on Economics has worked for the many years to develop guidelines for a charge system to standardize time documentation for regional analgesia for labor. The ASA "Relative Value Guide" (RVG) for 2002 suggests four options for anesthesiologists to consider when billing for neuraxial labor analgesia. The guide states that professional charges and reimbursement policies should reasonably reflect the intensity and time involved in performing and monitoring any neuraxial labor analgesic. Methods to determine professional charges consistent with these principles include: Basic units plus patient contact time (insertion, management óf adverse events, delivery, removal) plus one unit hourly. Basic units plus time units (insertion through delivery), subject to a reasonable cap. Single fee Incremental fees (e.g., 0<2 hrs, 2-6 hrs, >6hrs). Most practitioners decide on a standard accounting method and use it for all their cases. However, you need to know how the different insurance carriers, HMO's, and state agencies handle the time charges. For example, you may be billing based on method #1 but the carrier may assume you are billing according to method #2 and they may pay based on the time units billed/4. Some state agencies may not pay except for direct patient contact time, i.e. they may not pay one unit/hour for the continuous infusion. 46 C.. Medicaid Billing In many states, Medicaid uses the "base umts plus patient contact time" for OB Anesthesia For example, in California, MediCal states "If billing for regiiialanesthesia ... only the time actually spent with the patient is reimbursable. For example, if the patient is under anesthesia for 9 hours and 15 but the application of anesthesia and subsequent check-back periods total only 3 hours and 15 minutes, then the claim should read Epidural anesthesia start time 0500 Stop time 14 15 Time actually spent with the patient: 195 minutes."9 "The modifier - ZB (adds one unit) may be used to bill for anesthesia services during an emergency procedure on an otherwise healthy or medically stable and uncompromised patient Examples are a patient who requires a non-elective cesarean section 9 As Larry Sullivan, MD (past President California Society of Anesthesiologists) writes'0: "The ability to document physician-patient direct contact time accurately in an obstetrical setting is nearly impossible and ignores the point of the anesthesiologist's overall responsibility, even when not at the bedside." It is his opinion that the CSA should pursue a FLAT or GLOBAL fee arrangement for obstetrical anesthesia under the Medi-Cal program ONLY, rather than depend on time-based methodology. Several states pay a flat fee for obstetrical anesthesia for Medicaid patients. For example, North Carolina Medi-Caid in 1999 paid a flat fee of $204 for continuous epidural analgesia during labor and delivery, whether vaginal or CS.12 (This is equal to 12 units x $17/unit.) D. Billing for VBAC Standby: good and BAD news In light of the new ACOG guidelines for VBAC, many anesthesiologists are questioning how they can bill for being immediately available. The following is one possibility: The CPT book has a code for Physician Standby Services: 99360 Physician standby service, requiring prolonged physician attendance, each 30 minutes (e.g. operativé standby, standby for frozen section, for cesarean/high risk delivery, for monitoring EEG). The CPT book even provides an example: A 24 y.o. patient is admitted to OB unit attempting VBAC. Fetal monitoring shows increasing fetal distress. Patient's blood pressure is rising and labor is progressing slowly. A primary care physician is requested by the OB/GYN to standby in the unit for possible cesarean delivery and neonatal resuscitation. The code is used to bill for physician standby services, requested by another physician, that involve prolonged physician attendance without direct (face-to-face) patient contact. The physician may not be providing care or services to other patients during this period. It is also not used if the period of standby ends with the performance of a procedure subject to a "surgical package" by the physician who was on standby. Code 99360 is used to report the total duration of time spent by a physician on a given date on standby. It is billed at a flat fee in 30-minute increments. A full 30 minutes of standby must be provided for each unit of service reported. The code is used to report the total amount of time spent by a physician on a given day on standby. Here's the BAD news The code has a value of"0" under the Medicare's RBRVSthis makes it likely that many private payers would also fail to recognize the service Alternative coding would be to use an E & M code provided the anesthesiologist evaluates the patieñt, interviews her, and discusses the anesthetic options. If the anesthesiologist provides a service, the service would be billed and not the E & M code. 48 Example of a practice analysis Assumptions: 1000 deliveries / year 20% cesarean section rate: 10% no labor epidural 1 hr anesthesia time = 7 unit base + 5 time units: 10% labor epidural to CS: 1 hr anesthesia time 3 unit base +4 time units: 50% epidural rate 30 minutes to place +5 hours infusion = 5 unit base + 2 units to place +5 units: Insurance breakdown: $60/unit 10% indemnity @ $40/unit 60% HMO @ $17/unit 30% MediCal @ .1000 x 10% c/s = 100 Cs! year x 12 units/cs = 1200 units/year Indemnity (10%) 120 x $60/unit = 720 x $40/unit = HMO (60%) : 360 x $17/unit MediCal (30%) Total expected reimb for C/S (no labor) 1000 xlO% c/s = .100 Cs! year x 7 units/cs Indemnity (10%) HMO (60%) MediCal (30%) 700 units/year 70 x $60/unit = 420 x $40/unit = 210 x $17/unit = Total expected reimb for C/S (had labor) $ total 12 units total 7units total 12 units 7,200 $ 28,800 $ 6,120 $ 42,120 $ 4,200 $ 16,800 $ 3.570 $ 24,570 1000 x 50% epidural = 500 epid/year x 12 units = 6000 units/year $ 36,000 600 x $60/unit = hidemnity (10%) 3600 x $40/unit = $144,000 HMO (60%) $ 30,600 1800 x $17/unit = MediCal (30%) . Total expected reimb for epidural Grand total expected reimbursement for L & D for 1 year = Reimbursement for 24 hours = $210,600 $277,290 760 $ Less cost of billing Less uncollectable Cost of 4-5 FTE /year = cost of providing dedicated OB Anesthesiologist 49 References Guidelines for Perinatal Care, 4th Edition, American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, 1997. Cohen, Sheila: mt J ObstetAnesth 8:223-225, 2000 ACOG Practice Bulletin Vaginal Birth after Previous cesarean Delivery. Number 5, July 1999. Contact ACOG telephone 202-863-2518 or e-mail <[email protected]> for more information Phelan IP: VBAC: Time to reconsider. OBG Management November 1996 pp62-68 ACOG calls for "Immediately Available" VBAC Services. American Society of Anesthesiologists NEWSLETTER November 1999 vol. 63 No 11, pg. 21. Guidelines for Regional Anesthesia in Obstetrics. American Society of Anesthesiologists amended October 18, 2000. Hawkins, JL: Certified nurse midwives, obstetric anesthesia, and you. ASA Newsletter August 1999. Ostheimer GW: The Labor and Delivery Suite, pp 443-451 in Manual of Obstetric Anesthesia. Ostheimer GW, editor. New York, Churchill Livingstone, 1996. Medi-Cal Medical Service Provider Manual. California Department of Health Services. September 1999. Sullivan RL: President's Page. CSA bulletin November-December 1999, pg 5. Bell, ED, et al: How much labor is in a labor epidural? Anesthesiology 92:851-858, 2000. Chestnut DH: How do we measure (the cost of) pain relief? Anesthesiology 92:643 -645, 2000. http://www.sacbee.comlcontentlriews/story/1 529336p-l6O5 807c.html http://www.sacbee.com/content/opinion/letters/stOry/l 61296lp-l689l 22c.html Leung AS, et al: Uterine rupture after previous cesarean delivery: Maternal and fetal consequences. Am J Obstet Gynecol 169:945-950, 1993. "Role of the Registered Nurse (RN) in the Care of the Pregnant Woman Receiving Analgesia/Anesthesia by Catheter Techniques (Epidural, Intrathecal, Spinal, PCEA Catheters)". http://www.awhonn.org/sitemap/ebg/Cardiovascular_Health_BackroufllPositioflstatements/ Epidural/epidural.html California Health and Safety Code. http://www.leginfo.ca.gov/cgibin/displaycode?sectionhsc&groupø 1001 -02000&flle=1 250-1263 NOTES NOTES Scientific Program Friday, May 3, 2002 6:30 am Registration 7:00 - 8:00 am Breakfast with Exhibitors & Posters 8:00 - 9:00 am The Zuspan Award by Perinatal Resources Inc Moderator/Judge: David J. Birnbach, MD Judges: David H. Chestnut, MD; Michael Greene, MD; Anne May, MBBS, FRCA; Alan C. Santos, MD; Stephen H. Halpern, MD; Susan K. Palmer, MD 9:00 - 10:00 am What's New in Neonatology: Vignettes in Neonatal Resuscitation Introduction: Gary M.S. Vasdev, MD; Presentor: Robert Chantigian, MD 10:00 - 10:10 am Presentation of the Zuspan Award by Perinatal Resources, Inc Frederick P. Zuspan, MD; 10:10 - 10:30 am Break with Exhibitors & Posters 10:30 - 11:30 am What's New in Obstetrics? Introduction: Joy L. Hawkins, MD; Presentor: Michael Greene, MD 11:30 am - 12:30 pm Poster Review #2 Moderator: Robert R. Gaiser, MD 1:30 pm Fun Run/Walk, Tennis Tournament, and Golf Tournament (12:45 pm) 6:30 pm Banquet - Beach Music Party (Hilton Head Island Marriott) Zuspan Awàrd by Perinatal Resources, Inc. Moderator/Judge: David J. Blrnbach, MD Judges: David H. Chestnut, MD; Michael Greene, MD; Anne May, MBBS, FRCA; Alan C. Santos, MD; Stephen H. Halpern, MD; Susan K. Palmer, MD 8:00 -. 9:00 am Z-i PULSE PRESSURE AS AN EARLY PREDICTOR ÓF PREECLAMPSIA Msumefli, R.S.; Elimian, A. Z-2 A RANDOMISED CONTROLLED TRIAL COMPARING TRADITIONAL WITH TWO "MOBILE" EPIDURAL TECHNIQUES: EFFECT ON URINARY CATHETEIUSATION IN LABOR Comet, S.; Wilson, M.J. Z-3 ENDOTHELIAL DYSFUNCTION IN PREECLAMPSIA: A PILOT STUDY WITH NON-INVASWE BLOOD PRESSURE WAVEFORM ANALYSIS Pian-Smith, M.C; Ecke; J.; Hsu, K.; Leffert, L.; Louglirey, J, Z-4 A DOUBLE-BUND PLACEBO-CONTROLLED TRIAL OF PROPHYLACTIC ACETAMINOPHEN TO PREVENT EPIDURAL-FEVER: PILOT STUDY DATA Goetzl, L.; Evans, T.; Rivers, J.; Lieberman, E. All Abstracts listed on this page are in the Anesthesiology Supplement. JVhatc New in Neoñatology: V:gnettes in Neonatal Resuscitation? Robert Chantigian, MD 9:30 - 10:00 am Following this lecture, the participant will be familiarized with clinical aspects of neonatal care as illustrated by study cases. Vignettes In Newborn Resuscitation Robert C. Chantigian, M.D. - I. Introduction The basic approach to resuscitating a newborn is similar to that of resuscitating an adult: "ABC's": Airway, Breathing, Circulation, Drying and Drugs, Evaluation, and Finish. Mother - 21-year-old G1PO, term pregnancy, few early decelerations, CSE for labor and NSVD. Newborn - Newborn appears term, active, crying, but blue. What do you do now? Mother 22 year old G1PO, term pregnancy. CSE for labor and a NSVD Newbòrn - Apgar 9/9, looked normal at birth but 15 minutes after birth is cyanotic. What do you do now? Mother 23 year old G1PO, 33 weeks SPROM. No analgesia for labor, but had a pudendal for her forceps delivery. Newborn Apgar scores 8/8, baby weighs 2000 grams. 20 minutes after birth the, baby had a "respiratory arrest" for 30 seconds. What do you do now? Mother - 24-year-àld G2P1, term pregnancy, good FHR tracing, epidural for labor and for a difficult vaginal breech delivery. Newborn - Newborn is depressed, few respirations, little movement, and is very blue. What do you do now? Mother 25 year old G1PO, term pregnancy, epidural for labor and NSVD. Newborn - Apgar 8/9. Normal at birth but very cyanotic when crying. What do you do now? Mother - 26 year old G1PO, term pregnancy, narcotics for analgesia. Variable decelerations with little variability noted, vaginal delivery soon was performed and the nuchal cord was cut for delivery. Newborn - At delivery respirations were poor and you quickly intubate the newborn. After a few breaths the newborn looks OK and is extubated. Apgar scores are 5/7 but something is not right. Baby has nasal flaring, tachypnea, grunting, and is getting worse. What do you do now? Mother 27 year old G4P3 with blood type O negative. Her previous child died at birth from hydrops fetalis, which she attributes to medical care. Now she is about 38 weeks by history with no prenatal care. Her baby is about to be delivered. Newborn - A severely swollen newborn is delivered. Respirations are absent so you attempt to intubate the trachea despite the obvious whole body edema. You get the tube in but cannot get the chest to move. What do you do now? 55 - 2 Mother - 28-year-old G4P3 woman, 43-weeks pregnant has variable decelerations noted on the fetal monitor. Meconium staining is apparent when the membrane ruptures. A forceps vaginal delivery is performed, and you are asked to take care of the newborn. Newborn - The newborn has obvious meconium staining. What do you do for the newborn this year? - Mother - 29-year-old G1PO, 42-weeks EGA, labor induced, two doses of narcotic and epidural anesthetic for pain. Non-reassuring FHR tracing is noted and forceps vaginal delivery quickly performed. Newborn - Initially active, Apgar 8; then develops obvious depression (little respiratory effort, floppy, blue, heart rate 60-80 beats/minute). Initial treatment is unsuccessful, now what? The UV cord gas from the time of delivery comes back p02 - 30, pCO2 - 35, pH - 7.29. What does this mean? S Mother - 30-year-old G1PO has SPROM at 32-weeks EGA. Received an epidural for labor and has a normal vaginal delivery. Newborn - A small baby is delivered. What do you do now? Mother - 31 year old G i PO, term pregnancy, good FHR tracing, epidural for labor and NSVD. Newborn - healthy active newborn with a birth defect, the left hand is missing. What do you do now? Mother - 32-year-old G5P3 woman, 41-weeks pregnant has a sudden onset of vaginal bleeding. The fetal heart rate is rapidly decreasing, and a STAT cesarean section is performed with general anesthesia. Newborn - The newborn is very pale, and your initial Apgar score is zero. What do you do now? The 5-minute Apgar score is zero. Now what do you do? The 10minute Apgar score is zero. Now what do you do? II. Basic Approach (suction mouth and nose, intubate as needed) Airway Breathing (watch chest for expansion, listen for crying or auscultate for breath sounds, assist breathing as needed) Newborns are obligate nasal breathers. The nasal passages are narrow, prone to obstruction, and should be suctioned in all newborns. 5Extrauterine breathing usually begins by 30 seconds (average time 9 seconds) after delivery. The tidal volume is similar to adults; 6 to 7 ml/kg. After a few minutes, the resting respiratory rate becomes about 30 to 40 breaths per minute. Slight nasal flaring, raies, and mild retractions are not uncommon at birth and usually clear spontaneously in less than an hour. S 56 The cricoid cartilage is the narrowest part of the upper airway. If an endotracheal tube is needed, I use a 2.5 I.D. E'l'T for preterm and a 3.0 I.D. ET'!' for term or postterm newborns. If a large air leak exists, the next larger size tube can then be placed. When intubating newborns, keep in mind that the normal tracheal length is about 4 cm; therefore, put the tip of the oral endotracheal tube i to 2 cm past the vocal cords. For a typical 27-weék EGA newborn, thè lip to mid-trachea distance is about 7 cm; for a 40-week EGA newborn, the lip to mid-trachea distance is about 10 cm. If respirations are weak after stimulation or the heart rate is less than 100, start positive pressure ventilation with 100% oxygen and watch the chest rise. P°2 pCO2 pH NORMAL BLOOD GASES AT BIRTH ARTERIAL (minutes after delivery) UMBILICAL 30 min 60 min Artery 10 min Vein 70 20 68 60 s' 30 50 35 40 35 40 7.36 7.24 7.33 7.25 7.32 Circulation (check heart rate and, if needed, blood pressure and oxygen saturation) . The newborn cardiovascular system undergoes significant changes at the time of delivery (fetal to transitional to adult circulatory patterns). The heart rate for the first 30 minutes is quite labile with ratesof 100 to 200 beats per minute. After 30 minutes, the heart rate is about 120 bèats per minute and varies with the newborn's activity. Heart rate can easily be checked by palpating the base of the umbilical cord or by auscultating the chest for heart tones. Bradycardia is poorly tolerated in newborns. Start CPR (3:1 ratio = 3 compressions I 1 ventilation or 90 compressions and 30 respirations per minute) when the heart rate is less than 60 beats per minute after 30 seconds of positive pressure ventilation. Compress the lower third of the sternum to a depth of approximately one third of the anterior-posterior diâmeter of the chest. Blood pressure in the term newborn is about 70/45. A systolic blood pressure less than 50 torr in a term newborn requires treatment, usually with volume expansion. The blood volume in the term newborn is 80 to 100 ml/kg. The hemoglobin level is 15 to 20 gm per 100 ml (Hct 45 to 60). 57 Drying (drying helps stimulate breathing änd often increases the heart rate as well as preventing heat loss) Drugs Oxygen Indication - hypoxia, bradycardia Concentration - loo % or with a blender 21 to 100 % Dose - Start with 100 % (although some are now suggesting room air); rapidly decrease the concentration as tolerated to keep the oxygen saturation between 85 to 95% Epinephrine (needed in about 0.2% of all deliveries) Indication - Heart rate <60 after 30 seconds of PPV and chest compressions Concentration - 1:10,000 (0.1 mg/mi) Dose - Start with 0.1 to 0.3 ml/kg (0.01 to 0.03 mg/kg) then q 3-5 minutes pm Naloxone Indication - respiratory depression due to acute use of narcotics (avoid in the drug-addicted newborn) Concentration - 0.4 mg/mi or 1.0 mg/ml Dose -0.1 mg/kg Volume Expansion Indication - hypovolemia Crystalloid (Saline, Lactated Ringer's Solution) Blood (O negative) Dose - 10 ml/kg and repeat pm (usually more than 20 ml/kg are needed) Sodium Bicarbonate Indication - suspected or documented metabolic acidosis Concentration - 0.5 mEq/ml or 4.2 percent solution Dose -2 mEq/kg (or 4 mI/kg) given over at least 2 minutes (after adequate ventilation has been established). Further doses are based on blood gas results. Surfactant Indication - Respiratory Distress Syndrome (RDS) Drugs - Beractant (Survanta), Colfosceril (Exosurfl, Calfactant (Infasurf), Poractant alfa (Curosurl) A neonatologist, should be involved as soon as possible. Administer down the ETT with positive pressure ventilation. Prostaglandin E1 Indication - Maintain patency of the ductus arteriosus in children with certain complex cardiac defects Dose - 0.05 to 1.0 ugfkg/min A neonatologist, pediatric cardiologist, or pediatric intensivist should be involved as soon as possible. Evaluate (assign Apgar Scores, look for birth defects, and diagnose and treat newborn problems) 5 Finish (clamp umbilical cord, if the newborn is doing well, and find help if -needed) III. Gestational age, birth weight and ETT size and distance inserted Gestational Age (weeks) 22 IV. Mean Weight (grams) ET Tube Size ET Tube Distance (mm I.D.) (Lips to Mid-trachea cm) 500 27 1000 2.5 7 33 2000 2.5-3.0 8 38 3000 9 40 3300 3.0-3.5? 3.5-4.0? 10 References Desmond MM, Franklin RR, Valibona C, et al. The clinical behavior of the newly born. I. The term baby. J Pediatrics 62: 307-324, 1963. 't Chantigian RC. Differential diagnosis of the neonate in distress. In Ostheimer GW (ed). Manual of Obstetric Anesthesia - 2nd edition. Churchill-Livingstone. 1992. Heyman HJ. Neonatal resuscitation and anesthesiologist liability. Anesthesiology 81:783, 1994. Chantigian RC. Resuscitation and Critical Care. Dewan DM, Hood DD (ed). Practical Obstetric Anesthesia. Saunders. 1997. Liu WF, Harrington T. The need for delivery room intubation of thin meconium in the low-risk newborn - a clinical trial. Am J Perinatology 15:675-682, 1998. Cleary GM, Wiswell, TE. Meconium-stained amniotic fluid and the meconium aspiration syndrome - an update. Pediatr Clinics of North America 45:511-529, 1998. Lam BCC, Yeung CY. Surfactant lavage for meconium aspiration syndrome - a pilot study. Pediatr 103:1014-1018, 1999. International Guidelines for Neonatal Resuscitation: An Excerpt From the Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: International Consensus on Science. Pediatrics 2000; 106. American Heart Association, American Academy of Pediatrics. Neonatal Resuscitation 4th edition (NRP program textbook) 2000. Textbook KlausMH, Fanaroff AA. Care of the High-Risk Neonate 59 5th Ed. Saunders 2001. What's New in Obstet,*s? Michael Greene, MD 1030-11 30a1m Following this lecture, the participant will understand some of the current concerns in obstetrics and their possible ramification in obstetric care. 60 What' s New with Vaginal Birth After Cesarean? Michael F. Greene M.D. Every medical student is taught early in his or her career the basic principle that no tissue heals to produce a scar that is as strong as the native tissue was before it was disrupted. This is true despite our best efforts at surgical repair and pertains to skin, fascia, bone and uterine muscle. Thus, as cesarean sections became more commonplace, it came as no surprise when hysterotomy scars from cesarean deliveries ruptured under the stress of subsequent pregnancies and labors. Douglas recognized this 40 years ago in a series that he published from the New York Lying-In Hospital.' At that time, the overall cesarean delivery rate was 4% with half of those done for the indication of a prior cesarean section. Among more than 2,000 women with prior cesarean section scars, uterine rupture during labor occurred in just over 1%, and more than a third of those involved fetuses died. Douglas concluded that, "Probably the most vehement objections to the policy of vaginal delivery after cesarean section allude to the occurrence of catastrophic ruptures of the uterine scar." That kind of experience and reason coupled with the dogmatic proclamation of "once a cesarean section, always a cesarean section", cast the practice of vaginal birth after cesarean (VBAC) into widespread disrepute for decades. Subsequently, cesarean sections went from commonplace to epidemic with the U.S. national rate peaking in the late 1980s at nearly 23%. This attracted the attention of medical academicians, health care policy analysts, public health officials and those who paid the nation's escalating health care bills, because cesarean sections generally result in greater short term and long term maternal morbidity, mortality, and expense than vaginal deliveries. A third of the cesarean sections were elective repeat procedures with absolute numbers rising as the primary cesarean section rate rose. An obvious opportunity to curb the overall cesarean section ratewas to revive the practice of vaginal birth after cesarean. Enthusiastic reports of success2'3 and optimistic assessments of meta-analyses4 propelled the VBAC juggernaut. Insurers assembled programs to promote VBAC and educate doctors and patients regarding their benefits. Some insurers even felt justified in refusing tó pay for repeat cesarean seètions that were not preceded by attempts at VBAC. Individual physicians, and to some extent their professional organizations, were cajoled or coerced into supporting these programs, lest they be dropped from the provider roster or portrayed as uncooperative and non-progressive. As experience again accumulated howevèr, so too did reports of maternal and perinatal morbidity and mortality associated with VBAC, most of which was attributable to uterine rupture.5'6'7 Efforts to improve the safety of VBAC have focused on attempts to identify risk factors for uterine rupture. Zelop et al.8 found that 1,021 women with a history of a sùccessful vaginal delivery were at significantly lower risk of uterine rupturè (0.2%) than 2,762 women without a vaginal delivery (L1%). Ironically, the two women who ruptured their uteri in the prior vaginal delivery group, each had two prior successful VBACs. Thus, even a history of a successful VBAC is not a guarantee that a patient will not rupture her uterus in a subsequent VBAC attempt. Not surprisingly, women with two prior cesarean sections are at significantly greater risk of uterine rupture during VBAC 61 II i attempt thán women with only one prior scar (3.7% vs. O.8%). Neither length of labor, nor use of epidural anesthesia, were associated with an increased risk for uterine rupture during VBAC attempt.9 Investigations into the effects of labor induction and oxytocic agents used to induce labor have yielded inconsistent results. Compared to spontaneous labor, Ravasia et aL'9 found a significantly higher incidence of uterine rupture associated with labor induced with PGE2 gel (2.9% vs. 0.5%) but not with oxytocin (0.7%). In contrast, Zelop et al." found induction of labor with oxytocin to be associated with a statistically significant increase in risk for uterine rupture (2.0% vs. 0.7%) compared to spontaneous labor. Although their data suggested an increased risk for uterine rupture with PGE2 induction of labor, the number of events was small, their confidence interval for this risk estimate was wide and included unity. Rageth et al.'2 observed a modest but statistically significant increase in risk for uterine rupture with induction of labor but they do not specify the oxytocic agent(s) used. Reports of two small uncontrolled case series'3"4 suggested a 5-10% risk of uterine rupture associated with use of the very potent oxytocic synthetic prostaglandin E, analog, misoprostol. The most recent study to heat up the controversy appeared in the New England Journal of Medicine in July 2001. In that study, Lydon-Rochelle et al)5 used a large state-wide database of 20,000 women in Washington state to examine the risk of uterine rupture associated with induction of labor. All of the women were delivering their first singleton babies after one prior cesarean section. The overall risk of uterine rupture was 4.5 per I ,000, which is very consistent with many other studies. The risks of rupture associated with spontaneous labor and non-prostaglandin induction of labor were 5.2 and 7.7 per 1,000 respectively. These were both significantly greater than the 1.6 per 1,000 rate seen with repeat cesarean section without labor but not different from one another. Most striking was the 24.5 per 1,000 rate of uterine rupture observed with prostaglandin induction of labor. Their database did not contain information regarding the type of prostaglandin used. To examine the possibility that all ormost of the observed increase in risk associated with prostaglandin induction might be due to misoprostol, the authors stratified their analysis by time prior to 1996 and during 1996. Misoprostol has been used for this purpose only relatively recently and there was no suggestion of a recent increase in incidence in rupture with prostaglandin induction. This suggests that the risk is not associated with misoprostol alone but extends to other prostaglandin preparations. Purists will object that prostaglandins are not approved, indicated or intended for use to induce labor at term but only to prepare the unfavorable cervix. Extensive clinical experience with these agents suggests that they frequently do induce labor regardless of the intent and that this is a semantic difference. The authors demonstrate that their 91 patients with diagnoses oL uterine ruptures had substantially greater incidences of a variety of postpartum complications, suggesting that these were truly clinically important ruptures and not merely asymptomatic dehiscences. Finally, there was an eleven-fold difference in infant death (0.5% vs 5.5%) between the 20,000 women who did not rupture their uteri and the 91 who did. It is important to emphasize that this study, like all others to date, was an observational study of the results of clinical practice and not a randomized trial. The relative risk of 3.3 for uterine rupture with a trial of spontaneous labor as compared to elective repeat cesarean section is consistent with the odds ratio of 2.1 for a similar comparison calculated by Mozurkewich and Hutton in theirmeta-analysis of 11 studies with 39,000 subjects.'6 Mozurkewich and Hutton also calculated statistically significant increases in risk for fetal death (odds ratio i .7) and Apgar score less than 7 at 5 minutes (odds ratio 2.2) associated with a trial of labor as compared to elective repeat cesarean delivery. These risks reflect broad experience with large numbers of subjects over many years in a wide range of clinical practice settings. There is no evidence or reason to believe that they can be substantially reduced by improvements in clinical care. What benefits might offset these risks? Women who successfully complete trials of labor generally have less post partum discomfort and shorter lengths of hospital stay than women who undergo repeat cesarean section. There is evidence that a trial of labor is associated with a lower risk for febrile morbidity than elective repeat cesarean sectjon.16 The findings of reduced risks for transfusion and hysterectomy with trial of labor are likely due to patient selection because they are not driven by uterine ruptures, which are more common with trial of labor. 16 Slovic recognized that "experts" (e.g. health care policy wonks, public health officials and insurance company executives) perceive "risk" differently from lay people (patients).'7 Experts judge risk according to technical estimates of actual numbers of" fatalities, which for perinatal mortality is 5.8 per 1,000 with trial of labor after cesarean section compared to 3.4 per 1,000 with elective repeat cesarean section. The absolute difference between the two is 2.4 per 1,000 (1/4 17), a relatively small number. Lay people judge "risk" more according to their degree of "dread" for the unwanted outcome. "Dread" in turn is determined by the degree to which the outcome is irreversible, potentially lethal, and uncontrollable. By these criteria, perinatal mortality during a trial of labor would seem to be associated with a high degree of dread. The process of obtaining informed consent for medical care requires that physicians provide patients with the information that a "reasonable person" would want to know under the circumstances. Most reasonable persons would want to know that attempt at VBAC is associated with a higher risk of perinatal mortality than elective repeat cesarean section. People have different abilities to tolerate or accept risk. Some people would see the 5.8 per 1,000 risk of perinatal mortality associated with VBAC as very small and acceptable. Others would ask if there is a way to further reduce that risk and, if there is, to take that alternative course. 63 Douglas RG, Birnbaum SJ, MacDonald FA. 1. Pregnancy and labor following cesarean section. Am J Obstet Gynecol 1963;86:961-971. Martin JN, Harris BA, Huddleston JF, et al. Vaginal delivery following previous cesarean birth. Am J Obstet Gynecol 1983;146:255-262. Phelan JP, Clark SL, Diaz F, Paul RH. Vaginal birth after cesarean section. Am J Obstet Gynecol 1987;157:1510-1515. - 2 . r . . Rosen MG, Dickinson JC, Westhoff CL. Vaginal birth after cesarean: A metaanalysis of morbidity and mortality. Obstet Gynecol i 99 1 ;77:465-470; Scott JR. Mandatory trial of labor after cesarean delivery: An alternative viewpoint; Obstet Gynecol 1991;77:811-814. Farmer RM, Kirschbaum T, Potter D, et al. Uterine rupture during trial of labor alter previous cesarean section. Am J Obstet Gynecol 1991;165:996-1001. McMahon MJ, Luther ER, Bowes WA, Olshan AF. Comparison of a trial of labor with an elective second cesarean section. N Eng! J Med 1996;335:689-695. Zelop CM, Shipp TD, Repke JT, et al. Effect of previous vaginal delivery on the risk of uterine rupture during a subsequent trial of labor. Am J Obstet Gynecol 2000;183:l 184-1 186. Caughey AB, Shipp TD, Repke JT, et al. Rate of uterine rupture during a trial of labor in women with one or two prior cesarean deliveries. Am J Obstet Gynecol 1999; 181:872-876. Ravasia DJ, Wood SL, Pollard JK. Uterine rupture during induced trial of labor among women with previous cesarean delivery. Am J Obstet Gynecol 200183:1176-1179. Zelop CM, Shipp TD, Repke JT, et al. Uterine rupture during induced or augmented labor in gravid women with one prior cesarean delivery. Am J Obstet Gynecol 1999; 181:882-886. Rageth JC, Juzi C, Grossenbacher H. Delivery after previous cesarean: A risk evaluation. Obstet Gynecol i 999;93 :332-337. Wing DA, Lovett K, Paul RH. Disruption of prior uterine incision following misoprostol for labor induction in women with previous cesarean delivery. Obstet Gynecol 1998;91:828-830. Plaut MM, Schwartz ML, Lubarsky S. Uterine rupture associated with the use of misoprostol in the gravid patient with a previous cesarean section. Am J Obstet Gynecol 1999;180:1535-1542. Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP. Risk of uterine rupture during labor in women with prior cesarean delivery. N Engl J Med 2001 ;345:3-8. Mozurkewich EL, Hutton EK. Elective repeat cesarean delivery versus trial of labor: A meta-analysis of the literature from 1989-1999. Am J Obstet Gynecol 2000;183:1 187-1197. Slovic P. Perception of Risk. Science 1987;236:280-285. Poster Review #2 Moderator: Robert R. Gaiser, MD 11:30 am- 12:30pm. BEATING THE ODDS OF À FAILED INTUBATION: NUMBER NEEDED TO TREAT ORTHE TRICK OF TURNING TO BINOMIALTABLES Glassenberg It; Fredericksen, M. SUPPLEMENTARY OXYGEN IMPROVES UMBIUCAL CORD BLOOD GASES IN OBESE MOTHERS UNDERGOING ELECTIVECAESAREANSECTION Bullough, A.; Taylor, I.; Van Hamel, C.; Watters, M. THE URGENCY OF CAESAREAN CLASSIFICATION AND FETAL OUTCOME . Sashidharan R..; Duke, C.; Leschinskiy, D.; Philip, S.; Hallworth, S. . - FIBEROPTIC ENDOTRACHEAL INTUBATION OF THE ENDOMORPH: METAMORPHOSIS IN AIRWAY MANAGEMENT Glas senberg. R; Fredericksen, M. THROMBOPROPHYLAXIS IN EMERGENCY LSCS: AN AUDIT CYCLE COMPLETED Sashidharan. R..; Leschinskiy, D. SPINAL ANESTHESIA FOR CESAREAN SECTION FOLLOWING SUBOPTIMAL LABOR EPIDURAL ANALGESIA Dadarkar, P,; Philip,J.; Perez, B.; Makhdumi, A.; Slaymaker, E.; Weidner, C.; Tabaczewska, L; Wiley,J.; Sharma, S. DOES DENSITY INFLUENCE THE SPREAD OF INTRATHECAL BUPIVACAINE IN THE PROLONGED SITIING POSITION BEFORE ELECTIVE CESAREAN SECTION? Sodhi.. V,; Fernando, R; Hallworth, S.; Sarang, K.; Patel, N. LOW-DOSE ROPIVACAINE VS. BUPIVACAINE FOR SPINAL ANESTHESIA FOR CESAREAN SECTION Velickovic T &; Leicht, C.H. SHORT STATURE IS ASSOCIATED WITH A HIGHER CESAREAN SECTION AND EPIDURAL RATE Dimarca C.S,; Ramm, K.D.; Ramsey, P.S.; Vasdev, G.M. EPIDURAL MORPHINE FOR POST-CESAREAN ANALGESIA - DOES ADDING FENTANYL MAKE A DIFFERENCE? Ranasinghe. S,; Steadman,J.; Siddiqui, M.; Lai, M.; Kenaan, C.; Toyama, T.; Bailur, N.; Melgan,J. MORPHINE-INDUCED HYPOTHERMIA AFIER CESAREAN DELIVERY AND ITS REVERSAL WITH LORAZEPAM Wang. J.; Snowman, C.; Pratt, S.; Hess, P.E. FACTORS PREDICTING FAILURE OF LABOR EPIDURAL CATHETERS DURING CESAREAN SECTION Hihib, A S.; Drysdale, S.; Olufolabi, A.J.; Philips-Bute, B.G.; Muir, H.A. PERIPARTUM HYSTERECTOMIES ANESTHETIC AND OBSTETRIC OUTCOMES Zinner, T.R; Khan, K; Lee-Parritz, A.; Camann, Wit FETAL ACIDEMIA AND ANESTHESIA Froc! ich, M.A,; Caton, D. FETAL EFFECTS OF MATERNAL ANALGOSEDATION Froc! ich, M.A,; Euliano, T.Y.; Caton, D. FIBEROPTIC INTUBATION IN PARTURIENTS UNDERGOING CESAREAN SECTION FZrasuski, P; Shukia, N.; Wali, A.; Um, Y.; Vadhera, R.; Longmire, S.; Munnur, U; Rivers, J.; Tran, C.; Palacios, Q.; Suresh, M.S. DOES THE TYPE OF PRENATAL CAREGIVER INFLUENCE THE RATE OF EPIDURAL USAGE AMONG PARTURIENTS? Friedman,J.D.; Ramm, K.D.; Vasdev, G.M.; Ramsey, P.S. All Abstracts are in the Anesthesiology Supplement. 65 Poster Review #2 P-81 ANALGESIA AFIER CESAREAN SECTION: DOES THE PRE-EMPTIVE EFFECT OF EPIDURAL DIAMORPHP AFFECT OUTCOME? Mok, M.U.; Thompson, J.; Vanarase, M.; Grangr. C P-82 EXAMINING THE INFORMATION REQUIREMENTS OF WOMEN HAVING ELECTWE CESAREAN SECTIQ DR JULIA MöRCH-SIDDALL DR VALERIE BYTHELL DEPARTMENT OF ANESTHESIA, ROYAL VICTOP INFIRMARY, NEWCASTLE UPON TYNE UK Morch-Siddall. J; Bythell, V. P-83 P-84 P-85 P-86 P-87 P-88 DOES INCREASED INTRAVENOUS HYDRATION DECREASE THE INCIDENCF Al T'ZT' A /VcMrrT FOLLOWING CESAREAN SECTION? Gaiser. RR; Dong, Y; Cheek, T.G.; Gutsche, B.B. GENERAL ANESTHESIA FOR CESAREAN SECTION: CURRENT PRACTICE PAIIERNS Satya-Krishna, R.; Grange, C; Russell, R. PRURITIS ASSOCIATED WITH INTRATHECAL MORPHINE FOR CESAREAN SECTION: A COMPARISO BETWEEN 100 AND 200 MCG Habib. A.S; Drysdale, S.; Phillips-But; B.G.; Muir, H.A. ARE ROUTINE TYPE & SCREEN ORDERS NECESSARY FOR CESAREAN SECTION? DeBalli, R; Spahn, T.; Muir, HA. THE EFFECT OF THE ADDITION OF EPINEPHRINE ON EARLY SYSTEMIC ABSORPTION OF EPIDU ROPIVACAINE IN HUMANS Lee. B.B; Ngan Kee, W.D.; Plummer,J.L.; Wong, A.S. IS 6% HETASTARCH PREFERRED OVER PROPHYLACTIC W EPHEDRINE FOR PREVENTION OF HYPOTENSIO' FROM INThATHECAL ROPIVACAINE FORC/S? Cohen, S.; Penenherg. H; Aiptekin, B.; Ginsberg, S.; Bokhari, F.; Burley, E.; Zada, Y; Freeman, L. All Abstracts are in the Anesthesiology Supplement. NOTES NOTES Scientific Program Saturday, May 4, 2002 6:30 am 7:00 - 8:00 am Registration Breakfast with Exhibitors & Posters 7:00 Multidisciplinary Obstetric Simulated Emergency Scenarios (MOSES) - 8:00 am (Limited Registration - By Ticket Only) Christopher Sadler, PhD, MBBS, FRCA; Research Works in Progress Robert D'Angelo, MD; Richard M. Smiley,'MD, PhD Mira Razzaque, MD 8:00 - 9:30 am Clinical Forum: Scripted Cases of Parturients with Cardiovascular Disorders Moderators: Carole Warnes, MD; Kirk Ramm, MD; William R. Camann, MD 9:30 - 10:00 am 10:00 11:00 am Break with Exhibitors & Posters ASA Presidential Address Barry Glazer, MD 11:00 am - 12:00 n Debate No. 2 Failed Epidural for Urgent C/S: Spinal is Preferable to General Anesthesia Moderator: Andrew M. Malinow, MD PRO: David R. Gambling, MBBS 12:00 1:00 pm 1:00 - 2:00 pm CON: M. Joanne Douglas, MD, FRCPC Lunch Poster Review #3 Introduction: Alan C. Santos, MD; Moderator: Holly Muir, MD, FRCPC 2:00 - 3:00 pm Gerard W. Ostheimer Anesthesia Lecture: What's New in Obstetric Anesthesia? Introduction: Alan C. Santos, MD; Presentor: David H. Wiody, MD 3:0e - 3:30 pm 3:30 5:00 pm 5:30 pm Break with Exhibitors & Posters Business Meeting Sunset Sailing (Limited Space, Ticket Only) Multidiscplinarj' Obstetric Simulated Emergencjì Scenarios (MOSES) Christopher Sadler, PhD, MIBBS, FRCA; Mira Razzaque, MD 700-800 am During this presentation, the participant will learn about the multidisciplinary management of emergency situations in obstetrics. 69 Multidisciplinary Obstetric Simulated Emergency Scenarios (MOSES) workshop Sadler C, FRCA, Razzaque M, FRCA & Davis C, MRCOG Barts and The London Medical Simulation Centre, St Bartholomew's Hospital West Smithfield, London EC1A 7BE. The NHS litigation bill in the UK stands at £400 million; half of this is from the field of Obstetrics and Gynaecology'. Substandard care was identified in over 60 % of direct deaths in the latest confidential enquiry into maternal deaths (CEMD)2. Healthcare providers in Obstetrics and Gynaecology have been charged with achieving a 25 % reduction in the instances of harm resulting in litigation by 2005'. What risk reduction strategies might make an impact on these figures? Failure of communication and team working between professionals is the main cause of major substandard care (42%) in direct and indirect deaths reported in the CEMD2. In an attempt to improve team efficiency, previous enquiries have recommended that obstetric units run regular fire drills to ensure that all members of staff know exactly what to do in an emergency3. Simulation centres have been identified as possible tools to help in risk reduction strategies by allowing healthcare professionals to practice emergency drills without any risk to real patients'. Human factors courses, which examine how behaviour can influence development and resolution of crisis situations, are available in Anaesthesia4. However, we are unaware of any courses that look at behaviour and team working in a multidisciplinary setting. Consequently, we have devised the MOSES course for obstetricians, anaesthetists and midwives with the goals of (1) teaching effective multidisciplinary team working (2) demonstrating the role human behaviour can play in crisis prevention and resolution and (3) practicing obstetric emergency drills. The MOSES course is run in a High Fidelity Medical Simulation Centre using a computerized manikin (Laerdal SimMan) as the pregnant mother. The simulation centre includes a clinical area housing the manikin that can be arranged as labour ward or the obstetric operating theatre. The manikin is controlled by a laptop behind a one-way mirrored window looking onto the clinical area. The clinical area is fully equipped and staffed. The manikin breathes spontaneously, has breath sounds and heart sounds, peripheral pulses, talks and can be anaesthetised and ventilated. Modifications have been made to the manikin to allow assessment of cervical dilation and delivery of a simulated fetus by Lower Segment Caesarean Section. A simulated auditory and visual cardiotochograph adds to the realism. Course participants manage real time multidisciplinary scenarios lasting about 30 minutes. Participants are required to make diagnoses and treat as they see appropriate using real drugs and simulated blood products when required. Several cameras record 70 different views of the scenarios onto videotape. After the scenario participants are debriefed using video playback to demonstrate teaching points. Trained facilitators from anaesthesia, obstetrics and midwifery direct the discussion to concentrate on team working and behavioural issues that can impact on crisis development and resolution. This workshop will: Introduce-the MOSES course. Involve the audience in a team working exercise to identify good/bad team working behaviours. Ask the audience to analyse some video footage of an obstetric emergency for good/bad team working behaviours. Demonstrate how Laerdal SimMan can be used for Obstetric 'fire drill' training. References: Building a Safer NHS for Patients. Department of Health 2001. Report on the Confidential Enquiries into Maternal Deaths in the United Kingdom 2000. Report on the Confidential Enquiries into Maternal Deaths in the United Kingdom 1997. Gaba DM, Howard SK, Fish Kl. Crisis Management in Anesthesiology. New York: Churchill-Livingstone, 1994. 71 Research Works. in Progress Moderators Robert D'Angelo, MD, Richard M Smiley, MD, PhD 7:00 - 8:00 am Notes: Clinical Fo rum. Scrzbted Cases of Parturients with Cardiovascùla r Disorders Moderator: Carole Warnes, MD; Kirk Ramm, MD; William R. Camann, MD 8:00 - 9:30 am Participant will learn about multidisciplinary management of obstetric patients with life-threatening cardiovascular disease. These will be illustrated using study cases. Clinical Forum: Scripted Cases of Parturients with Cardiovascular Disorders Carote Warnes, M.D. Professor of Cardiology Department of Cardiology Mayo Clinic Rochester, MN Kirk Ramm, M.D. Chair, Division of MFM Department of OB/GYN Mayo Clinic Rochester, MN William Camann, M.D. Director, Obstetric Anesthesia Harvard Medical School Brigham and Women's Hospital Boston, MA Case I MEDICAL PRESENTATION: (Dr. Warnes) 30-year-old woman transported by helicopter emergently and she is 30 weeks pregnant. Her past medical history reveals 2-weeks of dyspnea and cough treated with antibiotics, now in extremis with orthopnea. On admission: BP 85/60, profoundly dyspneic, sitting upright, coughing. Lowvolume pulses with a sinus tachycardia at 120 BPM. A Harsh systolic murmur was heard in the aortic area and a third heart sound. Investigations: Chest x-ray: Severe pulmonary edema with cardiac enlargement. Echocardiogram: Severe aortic stenosis with calcified valve (probably bicuspid valves) area approximately 0.7 cm2, mean gradient 50 mm Hg, peak 95 mm Hg. Aortic regurgitation grade 1-2/4. Left ventricular ejection fraction 36% OBSTETRIC MANAGEMENT: (Dr. Ramm) General Principles - All Obstetric Patients Physiologic changes of pregnancy A. 50% increase in intravascular volume B. Decreased systemic vascular resistance (SVE) I. Potential right-to-left shunts 2. Preeclampsia has opposite effect C. Hypercoagulable state of pregnancy All clotting factors increase except factors XI and XIII Marked fibrinogen increase Free protein S falls by second trimester D. Marked fluctuations in cardiac output during labor and delivery 74 Specific General A. Aortic stenosis 1. Significant stenosis uncommon among women of childbearing age 2. Majority secondary to congenitally stenotic aortic valves a. Bicuspid Unicuspid Supra/subvalvular stenosis - B. Mortality 1. Maternal 17% 2. Perinatal 32% 3. Greatest risk gradient >100 mmHg 4. Risk of sudden death out of proportion to degree of clinical symptoms C. Management Varies with degree of disease Fixed cardiac outflow 3. Tachycardia - avoid Reduced preload Shortened ejection period Increased myocardial oxygen consumption Coronary perfusion Increased ventricular diastolic pressure Reduced systemic afterload 4. Prenatal a. Reduce physical activity b; Bedrest c. Maintenance of venous return 5. Labor and delivery Factors Increased cardiac effort Systemic peripheral dilation Blood loss with delivery Supine hypotension Valsalva Pulmonary artery catheter b. (1) Optimize preload to avoid decreased output or a. pulmonary edema c. Avoid Valsalva in second stage Forceps Vacuum d. Aggressive management of third stage Avoid postpartum hemorrhage Critical disease D. Valvuloplasty E. Valvotomy - 75 ANESTHESIA MANAGEMENT: (Dr. Camann) Vaginal: Invasive monitoring with arterial line and CVPIPA. Maintain CVPIPAWP at high-normal levels. Maintenance of sinus rhythm is important to preserve ventricular filling. Oxygen administration throughout labor should be used. Careful attention to adequate uterine displacement is vital. Regional analgesia/anesthesia, previously thought to be contraindicated in patients with AS, has been used. Caution is essential, and a slow onset of block should be sought. Intrathecal opioids (without local anesthetics) may be used for early labor, with gradual instillation of a low-dose epidural local anesthetic infusion as labor progresses. No epinephrine should be added, as unintentional IV injection could cause life-threatening tachycardia. A dense anesthetic level of Tl0-T8 should be slowly obtained as the patient approaches delivery, with consideration for an assisted second stage and minimal maternal expulsive efforts. II. Cesarean: General anesthesia would be advocated by most anesthesiologists. Thiopental or propofol may result in unwanted myocardial depression, while ketamine may result in undesirable tachycardia. A combination of etomidate and opioid represents a good choice for induction. Arterial and central monitoring are warranted. Regional anesthesia has been used for cesarean delivery in the presence of severe AS. Single-shot spinal should be avoided. An epidural with slow titration of anesthetic level can be used. Oxygen, adequate uterine displacement and judicious sedation are all important. REFERENCES: Ramsey PS, Ramm KD, Ramm SM. Cardiac disease in pregnancy. Am J Perinatol 2001, 18:245-66. Baker PN, Cunningham FG. Platelet and coagulation abnormalities. In: Lindhemier ML, Roberts JM, Cunningham FG, eds. Chesley's hypertensive diseases in pregnancy, 2nd ed. Stamford, CT Appleton & Lange, 1999 349, 1999 Bremme K, Ostlund E, Almqvist I, Heinonen K, Blomback M. Enhanced thrombin generation and fibrinolytic activity in normal pregnancy and the puerperium. Obstet Gynecol 1992, 80:132. Faught W, Garner P, Jones G, Ivey B. Changes in protein C and protein S levels in normal pregnancy. Am J Obstet Gyncol 1995, 172;147. Gatti L, Tenconi PM, Guarnen D, Bertulessi C, Qssola MW, Bosco P, Gianotti GA. Hemostatic parameters and platelet activation by flow-cytometry in normal pregnancy: a longitudinal study. mt J Clin Lab Res 1994, 24:2 17. Cunningham FG, Gant NF, Leveno KJ, Gilstrap LC ifi, Hauth JC. Cardiovascular diseases. In: Seils A, Nougaim SR, Davis K, eds. Williams obstetrics, 21st ed. McGraw-Hill, 2001:1181-207. Gei AF, Hankins GDV. Cardiac disease and pregnancy. Obstet Gynecol Clin North Am 2001, 28:465-5 12. American College of Obstetricians and Gynecologists. Cardiac disease in pregnancy. Technical Bulletin 168, June 1992 Clark SL. Cardiac disease. In: Clark SL, Cotton DD, Hankins GDV, Phelan JF, eds. Critical care obstetrics, 3rd edition. Maiden, Massachusetts: Blackwell Science, 1997:290313. American College of Obstetricians and Gynecologists. Cardiac disease in pregnancy. ACOG Technical Bulletin 1992:168:1-8. r Ramm SM, Maberry MC, Gilstrap LC. Congènital heart disease. Clin Obstet Gynecol 1989, 32:41-7. Easterling TR, Chadwick HS, Otto CM, Benedetti TJ. Aortic stenosis in pregnancy. Obstet Gynecol 1988, 72:113-8. Arias F, Pinedo J. Acrtic stenosis and pregnancy. J Reprod Med 1978, 20:229-32. Case II MEDICAL PRESENTATION: (Dr. Warnes) 23-year-old with complex cyanotic congenital heart disease and severe pulmonary vascular disease referred urgently with a 16 weeks gravid uterus. Patieñt was known to have complex pulmonary atresia with hypoplastic pulmonary arteries. Husband considers urgent referral unnecessary, and states that doctors are "completely mad". Her medical history: Patient cyanotic at an early age treated with a Right Blalock-Taussig shunt at aged 10 and a Left Blalock-Taussig shunt at aged 11. She underwent cardiac catheterization at aged 15, which demonstrated the left Blalock-Taussig shunt was not working. One-year previously (1996) she had an ascending aortato-left pulmonary artery shunt. The pulmonary arteries severely hypoplastic with systemic pressures in the pulmonary arteries; i.e., Eisenmenger physiology, patient functional class II. Patient had never been given any counseling regarding pregnancy or contraception. The patient presented at 16 weeks pregnant feeling slightly more short of breath but has no ankle swelling or palpitations, or on any medications Her examination revealed: moderate cyanosis, bounding pulse 80 BPM and sinus rhythm, BP 110/70, jugular venoùs pressure elevated 2 cm, left and right ventricular lifts, continuous murmur over the sternum, an additional continuous murmur over the right side, and no peripheral edema. Hemoglobin: 14.3 g/dL Patient would not consider termination of pregnancy. At 20 weeks gestation: Getting a little more tired, resting saturation 84%, on prenatal vitamin supplements and baby aspirin. At 28 weeks: Patient more cyanotic, on modified bedrest and limited activity in the house, jugular venous pressure elevated 3 cm, pulse 85 BPM and sinus rhythm, BP 100/70. Auscultation of the chest was clear. No hepatomegaly or peripheral edema. 77 OBSTETRIC MANAGEMENT: (Dr. Ramm) Counseling Risks with cyanotic heart disease A. Fetal Increased risk for fetal conotruncal abnormality 6-10% Increased risk for spontaneous abortion Increased risk intrauterine growth restriction, stillbirth, and prematurity Increased cesarean delivery rates B. Maternal Increased risk of DVT, pulmonary infarction, stroke Increased risk of arrhythmia Increased risk of death (up to 50%) Risk of aortic rupture given baseline dilation C. General II. Termination option Delivery in tertiary care center Management A. Fetal imaging 1. Early fetal ultrasound Establish dates as delivery will be premature Document intrauterine pregnancy as ectopic rupture and hemorrhage would be hazardous 2. 18-week anatomy scan Document normal anatomic relationships Multiple anomalies that would be incompatible with life important considerations given maternal risks 3. Fetal echocardiogram a. 20-22 weeks' gestation 4. Ultrasound every 4-6 weeks throughout gestation for fetal growth and fluid assessment 5. Fetal testing; biophysical profile (BPP) or nonstress testing (NST) weekly beginning at 28 weeks until delivery B. Maternal imaging Cardiac echocardiogram early in pregnancy if not performed in past year Repeat echocardiogram late second trimester to early third trimester to assess change in function C. General prenatal care 1. Diet and weight gain Nutrition consult Keep weight gain at 20-25 pounds Limit exercise 78 2. Rest periods Adjust per symptoms Admission rest late second or early third trimester 3. Baby aspirin/anticoagulation D. Labor and delivery 1. Hemodyn amie changes Autotransfusion Hemorrhage e. Regional/general analgesia Maternal positioning Hemodynamic monitoring 2. Route of delivery Vaginal Cesarean 3. Timing of delivery Prematurity risks Maternal risks 4. MedicationS Oxytocin Prostaglandins e. Steroids (lung maturity) AnticoagulatiOn Vasodilators 5. Postpartum issues Two-week admission Sterilization ANESTHESIA MAÑAGEMENT: (Dr. Camann) General Principles: Chronic hypoxemia may result in Pulmonary hypertension is poorly tolerated in pregnancy. allow for normal adaptation restricted fetal growth. Fixed pulmonary vascular resistance may not exacerbate right-to-left shunting. to pregnancy. pregnancy-associated decrease in SVR may relatively contraindicated, Arterial monitoring should be used, but central/PA would be Oxygen should be continuously hazardous and unlikely to offer useful information. nitric oxide or prostacyclin may be administered. If responsive to pulmonary vasodilation, those discussed in the previous administered. Concerns for regional vs. general are similar to would likely be used, and this may case (aortic stenosis). Thromboembolic prophylaxis embolism is the leading cause of complicate regional techniques. Pulmonary or systemic syndrome. Life-threatening maternal mortality in pregnancy patients with Eisenmenger's is often a terminal event. pulmonary hemorrhage from excessive pulmonary tree pressures 79 REFERENCES Ramsey PS, Ramm KD, Ramm SM. Cardiac disease in pregnancy. Am J Perinatol 2001, 18 245-66 Ramm KD, Ramm SM, Gilstrap LC ifi. Assessment of fetal well-being. In: Gall SA, ed. Multiple pregnancy and delivery. Chicago, IL: Mosby-YearBook Inc., 1996:170-81. Ramm SM, Ramm KD, Gilstrap LC. Anticoagulants and thrombolytics during pregnancy. Semin Perinatol 1997, 21:149-53. Manning FA, Morrison I, Harman CR, Lange IR, Menticoglou S. Fetal assessment based on fetal biophysical profile scoring: experience in 19,221 referred high-risk pregnancies, 2. An analysis of false-negative fetal deaths. Am J Obstet Gynecol 1987, 157:880. . Manning FA, Platt LD, Sipos L. Antepartum fetal evaluation: development of a fetal biophysical profile. Am J Obstet Gynecol 1980, 136:787. . Cunningham FG, Gant NF, Leveno ¡U, Gilstrap LC ifi, Hauth JC. Cardiovascular 21st ed. McGrawdiseases. In: Seils A, Nougaim SR, Davis K, eds. Williams obstetriès, Hill,2001:l181-207. Whittemore R, Hobbins JC, Engle MA. Pregnancy and its outcome in women with and Gei AF, Hankins GDV. Cardiac disease and pregnancy. Obstet Gynecol Clin North Am 2001, 28 465-5 12 Clark SL. Cardiac disease. In: Clark SL, Cotton DD, Hankins GDV, Phelan JF, eds. Critical care obstetrics, 3' edition. Malden, Massachusetts: Blackwell Science, 1997:290313. Kerr MG. Cardiovascular dynamics in pregnancy and labor. Br Med Bull 1968, 24:19-24. Robson SC, Dunlop W, Boys RI, Hunter S. Cardiac output during labor. Br Med J 1987, 295:1169-72. Kjeldsen J. Hemodynamic investigations during labor and delivery. Acta Obstet Gynecol Scand 1979, 89:10-252. Whittemore R, Hobbins JC, Eagle MA. Pregnancy and its oùtcome in women with and without surgical treatment of congenital heart disease. Am J Cardiol 1982, 50:641-51. Mortenson JD, Ellsworth HS. Pregnancy before and after surgical correction of left-toright cardiovascular shunts. Obstet Gynecol 1967, 29:241. Ducey JP, Ellsworth SM. The hemodynamic effects of severe mitral stenosis and pulmonary hypertension during labor and delivery. Intensive Care Med 1989, 15:192-5. Fuster V, Steele PM, Edwards WD, Gersh BJ, McGoon MD, Frye RL. Primary pulmonary hypertension: natural history and the importance of thrombosis. Circulation 1984, 70:5807. Smedstad KG, Cramb R, Morison DH. Pulmonary hypertension and pregnancy: a series of eight cases. Can J Anaesth 1994,41:502-12. Tahir H. Pulmonary hypertension, cardiac disease and pregnancy. mt J Gynecol Obstet 1995, 5 1:109-13. 80 Sinnenberg RI. Pulmonary hypertension in pregnancy. South Med J 1980, 73:1529. Midwall J, Jaffin H, Herman MV, Kupersmith J. Shunt flow and pulmonary hemodynamics during labor and delivery in the Eisenmenger's syndrome. Am J Cardiol 1978, 42:299-303. McCaffrey RM, Dunn LI. Primary pulmonary hypertension in'pregnancy Obstet Gynecol Surv 1964, 19:567-91. Hoeper MM, Schwarze M, Ehierding S, Adler-Schuermeyer A, Spiekerkoetter E, Niedermeyer J, Hamm M, Fabel H. Long-term treatment of primary, pulmonary hypertnsion with aerosolized iloprost, a prostacyclin analogue. N Engi J Med 2000, 342:1866-70. Easterling TR, Ralph DD, Schmucker BC. Pulmonary hypertensión in pregnancy: treatment with pulmonary vasodilators. Obstet Gynecol 1999, 93:494-8. Lust KM, Boots RJ, Dooris M, Wilson J. Management of labor in Eisenmenger syndrome with inhaled nitric oxide. Am J Obstet Gynecol 1999, 18 1:419-23. Goodwin TM, Gherman RB, Hameed A, Elkayam U. Favorable response of Eisenmenger syndrome to inhaled nitric oxide during pregnancy. Am J Obstet Gynecol 1999, 180:64-7. Gleicher N, Midwell J, Hochberger D, Jaffin H. Eisenmenger's syndrome, and pregnancy. ' Obstet Gynecol Surv 1979, 34:721-41. '1 Lieber S, Dewilde PH, Huyghens L, Traey E, Gepts E. Eisenmenger's syndrome and pregnancy. Acta Cardiol 1986, 40:421-4. Yentis SM, Steer PJ, Plaat F. Eiseñmenger's syndrome in pregnancy: maternal and fetal mortality in the 1990's. Br J Obstet Gynaecol 1988, 105:921-2. ' 81 Case III MEDICAL PRESENTATION: (Dr. Warnes) A 24-year-old woman referred at 12 weeks of pregnancy. She had a known history of Holt-Oram syndrome, secundum ASD closed at 7 years of age. She was found to be in atrial flutter while pregnant, duration unknown. On examination: Overweight, functional class 2, JVP. normal, pulse 75 BPM, apical systolic murmur of mitral regurgitation. Echocardiogram: Enlarged LV, EF=50%, moderate tricuspid and mild-to-moderate mitral regurgitation. Next steps in her medical management. Options: Leave in atrial flutter Anticoagulation DC cardioversion Pharmacological Cardioversion Optimization of Cardiac function OBSTETRIC MANAGEMENT (Dr Ramm) Genetic Counseling A. Holt-Oram Syndrome 1. "Atriodigital dysplasia," "cardiac-limb," "hand-heart" Congenital heart defect (secundum ASD) Upper extremity defects Polydactyly (1) Syndactyly Radial defects (including thumb) 2. Autosomal dominant a. High degree penetrance H. 3. Antiepileptic medications Arrhythmia A. Cardioversion Electrocardioversion a. Little risk to fetus Pharmacologic - antiarrhythmics Risk drug dependent Interferes directly with depolarization Lidocaine - may cause uterine artery spasm Procainamide - chronic use lupus-like syndrome Encainide - no human studies Flecainide - no human studies Tocainide - no human studies Disopyramide - embryotoxic lab animals/uterine contractions 82 Mexiletine - no human studies Quinidine - probably safe; no well-controlled trials c Antisympathetic effects (1) Propranolol - intrauterine growth-retardation, bradycardia, apnea, and respiratory depression, hypoglycemia Markedly prolonged duration of action potential d Bretylium - no human studies Amiodarone - no human studies/possible fetal cretinism Blockade of slow inward (calcium-sodium channel) depolarization current (1) Verapamil - may affect uterine blood flow Cardiac glycosides - many years of use, no reported adverse fetal effects or teratogenicity B. Anticoagulation Coumadin a. Crosses placenta b. Warfarin syndrome Heparin a. Fetal safety b. Osteoporosis c. Thrombocytopenia Pregnancy management A. Fetal surveillance B. Labor and delivery Regional analgesia Anticoagulation Forceps delivery - - - - - - III. -- - - - - ANESTHESIA MANAGEMENT: (Dr. Camann) - - Anesthetic management for cardioversion: Sedation using propofol until loss of eyelid reflex, usually not more than 75-100 mg. Oral antacid prophylaxis, but not metoclopramide, as this may exacerbate tachycardia. No opioids, as post-procedure emesis may be induced. My preference is to avoid airway instrumentation, even in later stages of pregnancy, as induction of GA and endotracheal intubation is likely to be associated with more problems than a brief sedative with GI prophylaxis in an appropriately fasted patient. 83 REFERENCES: Ramsey PS, Ramm KD, Ramm SM. Cardiac disease in pregnancy. Am J Perinatol 2001, 18:245-66. Magalini SI, Magalini SC, de Francisci G. Holt-Oram. In: Dictionary of medical syndromes, Yd edition. Philadelphia, PA: J. B. Lippincott Company, 1990:420. cunningham FG, Gant NF, Leveno KJ, Gilstrap LC ifi, Hauth JC. Cardiovascular 215t ed. McGrawdiseases. In: Seils A, Nougaim SR, Davis K, eds. Williams obstetrics, Hill, 2001:1181-207. Gilstrap LC ifi, Little BB. Cardiovascular'drugs during pregnancy. In: Drugs and pregnancy. New York, NY: Elsevier Science Publishing Co, Inc., 1992:69-91. Gei AF, Hankins GDV. Cardiac disease and pregnancy. Obstet Gynecol Clin North Am 2001,28:465-512. Clark SL. Cardiac disease. In: Clark SL, Cotton DD, Hankins GDV, Phelan JF, eds. 3rd edition. Maiden, Massachusetts: Blackwell Science, 1997:290Critical care obstetrics, 313. Brown CEL, Wendel GD. Cardiac arrhythmias during pregnancy. Çlin Obstet Gynecol 1989, 32:89-102. Schroeder JS, Harrison DC. Repeated cardioversion during pregnancy. Treatment of refractory paroxysmal atrial tachycardia during three successive pregnancies. Am J Cardiol 1971, 27:445. Rotmensch HH, Rotmensch S, Eikayam U. Management of cardiac dysrhythmia during pregnancy: Current concepts. Drugs 1987, 33:623-33. Jaffe R, Gruber A, Fejgin M, et al. Pregnancy with an artificial pacemaker. Obstet Gynecol Surv 1987,42:137-9. ASA Presidential Address Barry Glazer, MD 1O:OO-11:OOam NOTES: 85 Debate No. 2 Failed Epiduralfor Urgent C/S.' Spinal is Preferable to GeneralAnesthesia Moderator: Andrew M. Malinow MD Pro: David R. Gambling, MIBBS Con: M. Joanne Douglas, MD, FRCPC ll:OOam - 12:00 n Supporting manuscripts will be available online after the meeting. Following this debate, the participants will be able to compare and contrast the risks and benefits of spinal versus general anesthesia when an epidural catheter has failed for an urgent cesarean delivery. 86 Poster Review #3 Moderator: Holly Muir, MD, FRCPC 11:30 am-12:3Opm LOWER LIMB NEUROLOGICAL SEQUELAE AI1ER LABOR EPIDURAL ANALGESIA p Kaul, B.; Darwich, A.A.; Vallejo, M.C.; Ramanathan, S.; Mandel, G.L -2 SPINAL ANESTHESIA FOR CESAREAN SECTION AFIER FAILED LABOR EPIDURAL ANALGESIA: RETROSPECTIVE ANALYSIS OF TWO DOSING REGIMENS Vadher., R.B; Siswawala, EJ.; Portnoy, D.; Koutrouveis, A.P. RESEARCH: AN INNOVATIVE TOOL FOR INITIATING AN OBSTETRiC ANESTHESIA SERVICE Owen, M.D; Sahin, S.; Uckunkaya, N. DEVELOPING OUTCOMEMEASURES FOROBSTETRICANESTHESIA EDUCATION Owen, M.D; Sabin, S.; Aypar, U.; James, R. NATIONAL IN-TRAINING EXAM TRENDS: BACK TO THE FUTURE OR FORWARD TO THE PAST p3 p Glas senherg. R.. COMBINED SPINAL-EPIDURAL WITH PATIENT-CONTROL EPIDURAL ANALGESIA FOR LABOR. QUALflY ASSURANCE SURVEY FROM A UNIVERSITY HOSPITAL IN SWITZERLAND T 'andau; Giraud; Kern P7 ESTABLISHING A HIGH RISK REGISTRY TO IMPROVE PATIENT CARE AND RESIDENT EDUCATION Finegold, H. Ramanathan, S. HOW DO WE EDUCATE OUR PATIENTS ABOUT OBSTETRIC ANESTHESIA? (ANIMATED WEBSITE:- O 2 çW.PAINFREEBIRTHING.COM) Kodali. B MEDICAL STUDENT EDUCATION IN OB ANESTHESIOLOGY: CONNECTING BASIC AND CLINICAL SCIENCES IN A NEW MEDICAL SCHOOL CURRICULUM Wissler,R. INITIAL FEEDBACK ON MOSES (MULTIDISCIPLINARY OBSTETRIC SIMULATED EMERGENCY SCENARIOS): A COURSE ON TEAM TRAINING, HUMAN BEHAVIOUR AND 'FIRE DRILLS' Davis, C; Gregg, A.; Thornley, D.; Razzaque, M.; Woods, M.; Ayida, G.; Sadler, C. COMBINED OBSTETRIC AND ANESTHESIAJOURNAL CLUB SERIES: A FORUM FOR COLLABORATION. SHANKAR B KODAU, CAMANN WR, DEPARTMENT OF ANESTHESIA BRIGHAM AND WOMEN'S HOSPITAL, HARVARD MEDICAL SCHOOL BOSTON, MA 02115 Camanri, W; KodaJi, B. IS THERE A RELATIONSHIP BETWEEN RESPONSE TIME FOR LABOR EPIDURAL AND PATIENT SATISFAC- TION? -i4 Megally, M.; Joseph, N.J.; Salem, M. NITROGLYCERIN FORMANUAL REMOVAL OF PLACENTA Sahzposh, S.A; Sabzposh, N.A.; Sultana, K. REGIONAL ANESTHESIA USE IN PARTURIENTS WITH FACTOR V LEIDEN MUTATION Walsh, MJ; Harnett, M.J.; Tsen, LC. All Abstracts are. in the Anesthesiology Supplement. 87 Poster Review #3 P-89 P-90 P-91 P-92 P-93 P-94 IN VITRO IN VESTIGATION:DURAL TRAUMA PA'i .LERNS,CSF LEAK AND EPIDURAL NEEDLE PUNCTURE Angle, P,; Kronberg, J.; Thompson, D. SODIUM NITROPRUSSIDE (SNP) INHIBITh HYPDXIC FETO-PLACENTAL VASOCONSTRICTION (HFPV) IN DUAL PERFUSED, SINGLE ISOLATED HUMAN PLACENTAL COTYLEDON Ramasubramanian, it; Minzter, B.H.; Paschall, RL.; E, L.; Johnson, B.; Johnson, R. Downing. SPINAL PROSTAGLANDINS MODULATE PAIN FROM UTERINE CERVICAL DISTENSION Tong. C,; Eisenach, J.C. USE OF NIRS TO MONITOR PLACENTA TISSUE OXYGENATION Olufolahi, A.; James, A.; Coates, E.; El-Moalem, H.; Reynolds,J. EXTRACELLULAR REGULATED KINASE-MEDIATED PHOSPHORYLATION OF MYOMETRIAL CALDESMO DURING PREGNANCYAND LABOR Ji. Y,; Malek, S.; Morgan, KG. EPIDURAL BOLUS ADMINISTRATION AND CONTINUOUS EPIDURAL INFUSION F FENTANYL DIFFER 1 THEIRMECHANISMOFACTION Ginosar. 1; Riley, E.T.; Angst , M.S. All Abstracts are in the Anesthesiology Supplement. 88 Gerard W': Ostheimer: What's New in Obstetric Anesthesia Lecture 'i David H. Wiody, MD 2:00 - 3:00 pm Following this lecture, the participant will know the current obstetric anesthesia literature and its impact on anesthetic management of the pregnant woman. 'I 89 Society for Obstetric Anesthesia and Perinatology The Gerard W. Ostheimer Anesthesia Lecture: What's New in Obstetric Anesthesia? David Wiody, M.D. Clinical Associate Professor of Anesthesia Vice Chair for Clinical Affairs State University of New York Downstate Medical Center 90 Methods A hand search of the table of contents of the following anesthesia, OB-GYN, midwifery, and general medicine journals was performed: Acta Anaesthesiologica Belgica Acta Anaesthesiologica Scandinavica Acta Obstetricia et Gynecologica Scandinavica AANA Journal American Journal of Hypertension American Journal of Obstetrics and Gynecology Anaesthesia Anaesthesia and Intensive Care Der Anaesthesist Anesthesia and Analgesia Anesthesiology Annales Francaises d'Anesthesie et de de Reanimation Birth British Journal of Anaesthesia British Journal of Obstetrics and Gynaecology British Medical Journal Canadian Journal of Anaesthesia Chest Circulation European Journal of Anaesthesiology European Journal of Obstetrics & Gynecology and Reproductive Biology International Journal of Obstetric Anesthesia Journal of the American Medical Association Journal of Clinical Anesthesia Journal of Human Lactation Journal of Nurse Midwifery and Women's Health Journal of Pediatrics The Lancet Middle East Journal of Anaesthesiology New England Journal of Medicine Obstetrics and Gynecology Pediatrics Regional Anesthesia and Pain Medicine In addition, PUBMED (http://www.pubmed.gov) and NLM Gateway (http://gateway.nlm.flih.gOV) searches were performed for a number of topics that were felt to be pertinent to the practice of obstetric anesthesia, including coexisting diseases, medicolegal and economic issues in obstetric anesthesia, and the effect of maternal analgesia on the progress of labor and newborn behavior. A LEXIS-NEXIS search was also performed to identify articles published in the popular press, in both the US and the UK, which might affect the public's view' of obstetric anesthesia, for both good and ill. This review defines "What's New in Obstetric Anesthesia" quite broadly. I have attempted to identify all those papers published in 200 ithat deal specifically with the anesthetic management of the pregnant patient. I have also chosen papers dealing with local anesthetic pharmacology, spinal and epidural anesthesia, and postoperative pain management, which, the field. while not specifically dealing with obstetric anesthesia, are certainly applicable to induction, A broad range of articles dealing with obstetric management issues (VBAC, labor of papers that preterm labor, obstetric complications) was selected. I have chosen a number and the deal with the prevention of RDS, the mechanisms of newborn neurologic injury, pathophysiology of meconium aspiration syndrome, even when they do not address about preanesthetic management issùes. Finally, I have undoubtedly cited more articles disorder as eclampsia than is absolutely necessary, but I am sure that many of you find this fascinating as I do. 91 Outline Alternative medicine Cesarean section Coagulation Coexisting disease Cardiac Endocrine Hematologic Hepatic HIV Neoplasm Neurologic Orthopedic Psychiatric/substance abuse Renal Respiratory Complications-anesthetic Airway Allergy Cardiac arrest Equipment High spinal Hypotension Infection Local anesthetic neurotoxicity Neurologic Spinal headache Complications-obstetric Abdominal pregnancy Amniotic fluid embolism Hemorrhage Hyperemesis gravidarum Incontinence Maternal mortality Multiple gestation Preterm labor-antenatal steroids Preterm labor-Surveillance/tocolysis Retained placenta Shivering Debates Economics and staffing Fetal monitoring Labor analgesia Alternative techniques Epidural techniques-ambulation Epidural techniques-anatomy Epidural techniques-CSEA Epidural techniques-equipment Epidural techniques-fetal effects Epidural techniques-maternal satisfaction Epidural techniques-PCEA Epidural techniques-pharmacology Epidural techniques-physiology Epidural techniques-test dose Intrathecal techniques Local anesthetic pharmacology Mass media Maternal fever and neonatal sepsis workup Medicolegal issues/medical ethics Newborn Behavior Brachial plexus injury Cerebral palsy Chorioamnionitis Meconium aspiration Respiratory distress Resuscitation/evaluation Nonobstetric surgery Obstetric management issues Breech Induction of labor Instrumental delivery Intrapartum care VBAC Pharmacologic/physiologic alterations of pregnancy Postoperative pain management Adjuvant drugs Complications Epidural Intrathecal Preeclampsia Anesthetic management Blood pressure management HELLP Outcome Pathophysiology Prediction/Prevention Progress of labor Epidural anesthesia Risk factors for cesarean section - - 92 Alternative medicine . . Eàkert K, Turnbull D, MacLennan A. Immersion in water in the first stage of labor: a. randomized controlled trial. Birth 28:84-93, 2001. Women who bathed during the first stage of labor used analgesics as frequently as controls; their infants were more likely to require resuscitation. . Factor-Litvak P, Cushman LF et al. Use of complementary and alternative medicine among women in NYC. J Altern Complement Med 6:659-66, 2001. More than half of the women surveyed have used an alternative therapy. Hodnett ED. Caregiver support for women during childbirth (Cochrane Review). In: The Cochrane Library, 1, 2002. Reduces need for analgesic interventions.. Kanakura Y, Kometani K et al. Moxibustion treatment of breech presentation. Am J Chin .. Med 29:37-45, 2001. In women with breech presentation noted at 28 weeks EGA, 92% who underwent moxibustion therapy converted to vertex compared to 74% of controls. .. . . . Kavanaugh J, Kelly AJ, Thomas J. Sexual intercourse for cervical ripening and induction of labor. (Cochrane Review). In: The Cochrane Library, 1, 2002. The investigators concluded that there was insufficient published evidence to support the efficacy of sexual intercourse for induction of labor. They surmise that it may prove dfficult to standardize sexual intercourse for future studies. Kavanaugh J, Kelly Ai, Thomas J. Breast stimulation for cervical ripening and induction of labor (Cochrane Review). In: The Cochrane Library, 1, 2002. Breast stimulation reduced the number of patients not in labor at 72 hours compared with women receiving no intervention; There were no signcant differences compared to an oxytocin group. Knight B, Mudge C et al. Effect of acupuncture on nausea of pregnancy: a randomized controlled trial. Obstet Gynecol 97:184-8, 2001. Acupuncture and sham acupuncture were equally as effective in reducing nausea in the first trimester. Ohlsson G, Buchhave P et al. Warm tub bathing during labor: maternal and neonatal effects. Acta Obstet Gynecol Scand 80:311-314, 2001. No djfference in the use of epidural analgesia; unlike #1, no evidence of deleterious effect on the newborn. . 93 Rayburn WF, Gonzalez CL et al. Effect of prenatally administered hypericum (St. John's wort) on growth and physical maturation of mouse offspring. Am J Obstet Gynecol 184:19 15,2001. Rayburn WF, Gonzalez CL et al. Impact of hypericum (St. John's wort) given prenatally on cognition of mice offspring. Neurotoxicol Teratol 23:629-37, 2001. Neither of these studies demonstrated any adverse effect on growth or development. Simpson M, Parsons M et al. Raspberry leaf in pregnancy: its safety and efficacy in labor. J Midwifery Womens Health 46:51-9, 2001. While no adverse effects could be identified, neither did raspberry leaf have any signcanr effect on the duration of the first sta ge of labor. Slotnick RN. Safe, successful nausea suppression in early pregnancy with P-6 acustimulation. J Reprod Med 46:811-4, 2001. Smith CA, Crowther CA. Acupuncture for induction of labor (Cochrane Review). In: The Cochrane Library, 1, 2002. None of the published trials of acupuncture met the inclusion requirements for this review. Smith CA. Homeopathy for induction of labor (Cochrane Review). In: The Cochrane Library, 1, 2002. 15.Stamp G, Kruzins G, Crowther C. Perineal massage in labor and prevention of perineal trauma: randomized controlled trial. BMJ 322:1277-80,2001. There were no dWerences in the incidence of 1 and 2nd degree tears or episiotomies between the massage and control groups. Steele NM, French J et al. Effect of acupressure by Sea-Bands on nausea and vomiting of pregnancy. J Obstet Gynecol Neonatal Nurs 30:61-70, 2001. Tsui B, Dennehy CE, Tsourounis C. A survey of dietary supplement use during pregnancy at an academic medical center. Am J Obstet Gynecol 185:433-7, 2001. Vutyavanich T, Kraisarin T, Ruangsri R. Ginger for nausea and vomiting in pregnancy. Obstet Gynecol 97:577-82, 2001. 28/32 patients receiving ¡ gm ginger daily had improvement in nausea scores compared to 10/35 controls. Werntoft E, Dykes AK. Effect of acupressure on nausea and vomiting during pregnancy. J Reprod Med 46:835-9, 2001. 94 Cesarean section , Anderson L, Walker J. Rate of injection through Whitacre needles affects distribution of spinal anaesthesia. Br J Anaesth 86:245-8, 2001 . In patients undergoing GU surgery, injection ofbupivacaine 15 mg over ¡Os led to a more rapid onset (20 minutes vs 30 minutes) and more rapid recovery (180 minutes vs 270 minutes) compared to injection over three minutes. . : Bagratee JS, Moodley J et al. A randomized controlled trial of antibiotic prophylaxis in elective caesarean delivery. Br J Obstet Gynaecol 108:143-8, 2001. Cefoxitin prophylaxis had no effect on infectious morbidity. . Chelmow D, Ruehli MS, Huang E. Prophylactic use of antibiotics for nonlaboring patients undergoing cesarean delivery with intact membranes: a meta-analysis. Am J Obstet Gynecol 184:656-61, 2001. Unlike #21, this meta-analysis showed signcant decreases in maternal fever and, endometritis, and a trend toward reduction in wound infections. Chung C-J, Choi S-R et al. Hyperbaric spinal ropivacaine for cesarean delivery: a comparison to hyperbaric bupivacaine. Anesth Analg 93:157-61,2001. 18 mg 0.5% hyperbaric ropivacaine compared to 12 mg 0.5% hyperbaric bupivacaine; time to complete recovery ofmotorfunction 159 minutes vs. 114 minutes. Connolly C, Mci_cod GA, Wildsmith JAW. Spinal anaesthesia for caesarean section with bupivacaine 5 mg ml in glucose 8 or 80 mg ml'. Anaesthesia 86:85-7, 2001. No djfference in onset time, dose of ephedrine required, or patient satisfaction. Median block was higher (2 dermatomes) in 8 mg mt' group for first 120 minutes. Cotzias CS, Paterson-Brown S, Fisk NM. Obstetricians say yes to maternal request for elective caesarean section: a survey of current opinion. Eur J Obstet Gynecol Reprod Biol 97:15-6, 2001. 69% of obstetricians in the UK would peiform a cesarean section upon maternal request. 26.Han T-H, Brimacombe J et al. The LMA is effective (and probably safe) in selected healthy parturients for elective cesarean section: a prospective study of 1067 cases. Can J Anesth 48:1117-21, 2001. Effective, yes. Safe?-the jury is out. Would any of you electively use an LMAfor Cesarean section in the absence of a failed intubation? Kapur D, Grimseh K. A comparison of CSF pressure and block height after spinal anesthesia in the right and left lateral position. Eur J Anaesthesiol 18:668-672, 2001. No dWerence. Khaw KS, Ngan Kee WD et al. Spinal ropivacaine for cesarean section. Anesthesiology 95:1346-50, 2001. ED50=16.7 mg, estimated ED95-26.8 mg 95 Lam DTC, Ngan Kee WD, Khaw KS. Extension of epidural blockade in labour for emergency caesarean section using 2% lidocaine with epinephrine and fentanyl, with or without alkalinization. Anaesthesia 56:790-4, 2001. Alkalinization decreased time to surgical anesthesia from 9.7 to 5.2 minutes. Liu SS, McDonald SB. Current issues in spinal anesthesia. Anesthesiology 94:888-906, 2001. Discusses ambulatory anesthesia, CSEA, TNS, spinal headache, anticoagulation. McGurgan P, Coulter-Smith S, O'Donovan PJ. A national confidential survey of obstetrician's personal preferences regarding mode of delivery. Eur J Obstet Gynecol Reprod Biol 97:17-19, 2001. Moodley J, Jjuuko G, Rout C. Epidural compared with general anesthesia for cesarean delivery in conscious women with eclampsia. Br J Obstet Gynaecol 108:378-82, 2001. Epidural anesthesia was as safe as general anesthesia in "stable" patients. Moran C, Ni Bhuinneain M et al. Myocardial ischaemia in normal patients undergoing elective cesarean section. Anaesthesia 56:1051-1058, 2001. Patolia DS, Hilliard RLM et al. Early feeding after cesarean: randomized trial. Obstet Gynecol 98:113-6,2001. Early feeding (regular diet <8 hrs postop) led to shorter hospital stays. When surgery exceeded 40 minutes, ileus was more likely to develop. Reid VC, Hartmann KE et al. Vaginal preparation with povidone iodine and postcesarean infectious morbidity. Obstet Gynecol 97: 147-52, 2001. No effect on wound infection, fever, endometritis. Russell 1F. Editorial: Assessing the block for cesarean section. mt J Obstet Anesth 10:83-5,2001. Suggests that loss of touch sensation is more reliable than loss of pinprick or cold for identifying adequate block. Wright JB, Wright AL et al. A survey of trainee obstetricians' preferences for childbirth. Eur J Obstet Gynecol Reprod Biol 97:23-5, 2001. 15% of trainees preferred elective cesarean delivery for themselves. Coagulation Burrows RF, Gan ET et al. A randomized double-blind placebo controlled trial of LMWH as prophylaxis in preventing venous thrombotic events after cesarean section: a pilot study. Br J Obstet Gynaecol 108:835-9, 2001. Douglas MJ. Platelets, the parturient and regional anesthesia. Tnt J Obstet Anesth 10:113120, 2001. 96 Harnett MJP, Datta S, Bhavani-Shankar K. The effect of magnesium on coagulation in parturients with preeclampsia Anesth Analg 92 1257-60, 2001 No significant effect on overall coagulation function as measure by TEG McDonagh RJ, Ray JG et al. Platelet count may predict abnormal bleeding time among pregnant women with hypertension and preeclampsia; Can J Anesth 48:563-9, 2001. A platelet count <75,000 predicted prolonged bleeding time. But does it predict abnormal bleeding ' Miller JM, Nolan TE. Case-control study of antenatal cocaine use and platelet levels. Am J Obstet Gynecol 184:434-7, 2001. Cocaine use identified by toxicology screen was not associated with thrombocytopenia Obstetric Medicine Group of Australasia. Anticoagulation in pregnancy and the puerperium. MJA 175:258-263, 200L Vincelot A, Nathan N et al. Platelet function during pregnancy: an evaluation using the PFA-100 analyzer. Br J Anaesth 87:890-3, 2001. Platelet function may be preserved with levels as low as 60,000. Wu CL. Regional anesthesia and anticoagulation. J Clin Anesth 13:49-58, 2001. A nice review, including detailed discùssion of timing of catheter removal. Coexisting disease CARDIAC 46 Ayhan A, Yucel A et al Feto-maternal morbidity and mortality after cardiac valve replacement. Acta Obstet Gynecol Scand 80:713-8, 2001. Anticoagulation with either heparin or coumadin was well-tolerated by mother and fetus. 47 Brar HBK Anaesthetic management of a caesarean section in a patient with Marfan's syndrome and aortic dissection Anaesth Intensive Care 29 67-70, 2001 Cole PJ, Cross MH, Dresner M. Incremental spinal anaesthesia for caesarean section in a patient with Eisenmenger'S syndrome. Br J Anaes 86:723-6, 2001. Hemodynamics monitored with CVP and transthoracic bioimpedance cardiography Easterling TR, Carr DB et al. Treatment of hypertension in pregnancy: effect of atenolol on maternal disease, preterm delivery, and fetal growth. Obstet Gynecol 98:427-33, 2001. Maternal blood pressure was well-controlled, fetal growth was better maintained when maternal hemodynamics were optimized. 97 Elkayam U, Tummala P. Maternal and fetal outcomes of subsequent pregnancies in women with peripartum cardiomyopathy. N Engi J Med 344:1567-71, 2001. See also Reimold SC, Rutherford JD. Editorial: Peripartum cardiomyopathy. N Engi J Med 344:1629-30,2001. During subsequent pregnancies, heart failure developed in 44% of those with persistent LV dysfunction after a previous episode of peripartum cardiomyopathy and, surprisingly, in 21% of women with normalization of LVfunction by echo. Stress echocardiography may be a more sensitive method of evaluating women who have apparently recovered from peripartum cardiomyopathy. Ellison J, Thomson AJ et al. Use of enoxaparin in a pregnant woman with a mechanical heart valve prosthesis. Br J Obstet Gynaecol 108:757-9, 2001. Gei AF, Hankins GDV. Cardiac disease in pregnancy. Obstet Gynecol Clin North Am 28(3):465-505, 2001. An extensive review. Lam GK, Stafford RE. Inhaled nitric oxide for primary pulmonary hypertension in pregnancy. Obstet Gynecol 98:895-8, 2001. Lasinka-Kowara M, Dudziak M. Two cases of postpartum cardiomyopathy initially misdiagnosed for pulmonary embolism. Can J Anesth 48:773-7,2001. Echocardiography established correct diagnosis. Lee M-J, Huang A et al. Labor and vaginal delivery with maternal aortic aneurysm. Obstet Gynecol 98:935-8, 2001. Good outcome in a patient with a 4.5 cm aortic aneurysm unassociated with Marfan 's syndrome. LEA was used, 2nd stage was shortened with low forceps delivery. Lind J, Wallenberg HCS. The Marfan syndrome and pregnancy: a retrospective study in a Dutch population. Eur J Obstet Gynecol Reprod Biol 98:28-35, 2001. Risk factors for poor outcomes included aortic diameter> 40 mm, progressive dilatation, and decreased cardiac function. McCarroll CP, Paxton LD et al. Use of remifentanil in a patient with peripartum cardiomyopathy requiring caesarean section. Br J Anesth 86:135-8, 2001 McKechnie RS, Patel D et al. Spontaneous coronary artery dissection in a pregnant woman. Obstet Gynecol 98:899-902, 2001. Successfully treated with ECMO and angioplasly followed by stent placement. Monnery L, Nanson J, Charlton G. Primary pulmonary hypertension in pregnancy: a role for novel vasodilators. Br J Anaesth 87:295-8, 2001. Nanson J, Elcock D et al. Do physiological changes in pregnancy change defibrillation energy requirements? Br J Anaesth 87:237-9, 2001. No signcant change in transthoracic impedance at term. = Olofsson Ch, Bremme K et al. Cesarean section under epidural ropivacaine 0.75% in a parturient with severe pulmonary hypertension. Acta Anaesthesiol Scand 45:258-60, 2001. Penning S, Robinson KD et al. A comparison of echocardiography and PA catheterization for evaluation of PA pressures in pregnant patients with suspected pulmonary hypertension. Am J Obstet Gynecol 184:1568-70, 2001. 32% of patients estimated to have pulmonary hypertension by echocardiography had normal PA pressures when catheterized. Penning S, Thomas N et al. Cardiopulmonary bypass support for emergency cesarean delivery in a patient with severe pulmonary hypertension. Am J Obstet Gynecol 184:225-6, 2001. Ramsey PS, Ramm KD, Ramm SM. Cardiac disease in pregnancy. Am J Perinatol 18:245-65, 2001. Roberts N, Ross D et al. Thromboembolism in pregnant women with mechanical prosthetic heart valves anticoagulated with low molecular weight heparin. Br J Obstet Gynaecol 108:327-9, 2001. LMWH may not be a suitable substitute for coumadin Schabe! JE, Jasiewicz RC. Anesthetic management of a pregnant patient with congenitally corrected transposition of the great arteries for labor and vaginal delivery. J Clin Anesth 13:517-20, 2001. Shnaider R, Ezri T et al. CSEA for cesarean section in a patient with peripartum dilated cardiomyopathy. Can J Anesth 48:681-3, 2001. Siu SC, Sermer M et al. Prospective multicenter study of pregnancy outcomes in women with heart disease. Circulation 104:525-52 1, 2001. Survey of 562 women with a wide variety of cardiac disorders. 13% of pregnancies were complicated by significant morbidity or mortality. Stewart R, Tuazon D et al. Pregnancy and primary pulmonary hypertension: successful outcome with epoprostenol therapy. Chest 119:973-5, 2001. Suntharalingam G, Dob D, Yentis SM. Obstetric epidural analgesia in aortic stenosis: a low dose technique for labour and instrumental delivery. lin J Obstet Anesth 10:129-34, 2001. Good outcomes in five patients. Invasive monitoring was not used. 99 ENDOCRINE ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists: thyroid disease in pregnancy. Obstet Gynecol 98:879-88, 2001. Lucas MJ. Diabetes complicating pregnancy. Obstet Gynecol Clin North Am 28(3):51336, 200L Mandel SJ, Cooper DS. The use of antithyroid drugs in pregnancy and lactation. J Clin Endocrinol Metab 86:2354-9, 2001. Maresh M. Diabetes in pregnancy. Curr Opin Obstet Gynecol 13:103-7, 2001. HEMATOLOGIC Euliano TY. Cesarean section combined with splenectomy in a parturient with ITP. J Clin Anesth 13:313-318, 2001. Schmitt HJ, Becke K, Neihardt B. Epidural anesthesia for cesarean delivery in a patient with polycythemia rubra vera and preeclampsia. Anesth Analg 92:1535-7, 2001. Stoche RM, Garcia LV, Klamt JG. Labor analgesia in a patient with paroxysmal nocturnal hemoglobinuria with thrombocytopenia. Reg Anesth Pain Med 26:79-82, 2001. HEPATIC Goh S-K, Gull SE, Alexander GJM. Pregnancy in primary biliary cirrhosis complicated by portal hypertension: report of a case and review of the literature. Br J Obstet Gynaecol 108:760-2, 2001. Holzman RS, Riley LE et al. Perioperative care of a patient with acute fatty liver of pregnancy. Anesth Analg 92:1268-70, 2001. Patient required aggressive treatment of coagulopathy; article discusses overlap with HELLP syndrome. HIV 80 Ahdieh L Pregnancy and infection with human immunodeficiency virus Clin Obstet Gynecol 44:154-66, 2001. Ahmad H, Mehta NJ et al. Pneumocystis carinii pneumonia in pregnancy. Chest 120:666-671, 2001. Clinical course is more aggressive during pregnancy. PCPprophylaxis should not be withheld from HI V-infected pregnant women in whom it is indicated. i Chen KT, Sell RL, Tuomala RE. Cost-effectiveness of elective cesarean delivery in HIV-infected women. Obstet Gynecol 97:161-8, 2001. Elective cesarean section will not be cost-effecive jfantiretroviral therapy decreases perinatal transmission by 50% Rodriquez EJ, Spann C et al. Postoperative morbidity associated with cesarean delivery among HIV-seropositive women. Am J Obstet Gynecol 184:1108-11, 2001. No increase in major postoperative complications compared to age-matched controls. Scarrow SE. Obstetrical delivery of the HIV-positive woman: legal and ethical considerations. Obstet Gynecol Surv 56:178-83, 2001. Asserts need to respect a woman 's wishes f she declines antiretrovirals or elective C/S. NEOPLASM Bullough AS, Karadia S, Watters M. Phaeochromocytoma: an unusual cause of hypertension in pregnancy. Anaesthesia 56:43-6, 2001. Severe hypertension developed after C/S. A rare etiology that must always be ruled out. Crosby E. Clinical case discussion: anesthesia for cesarean section in a parturient with a large intrathoracic tumour. Can J Anesth 48:575-83, 2001. Chan YK. Anesthetic management of a parturient with superior vena cava obstruction' for cesarean section. Anesthesiology 94:167-9, 2001. A successful epidural anesthetic was administered; a cardiac surgeon was prepared to initiate fern-fern bypass should cardiopulmonary collapse occur. NEUROLOGIC Beni-Adani L, Pomeranz S et al. Huge acoustic neurinomas presenting in the late stage of pregnancy. Acta Obstet Gynecol Scand 80:179-84, 2001. In this slowly-growing tumor, surgery was delayed until one week post-cesarean section. VP shunting made this delay acceptable. Boker A, Ong BY. Anesthesia for cesarean section and posterior fossa craniotomy in a patieñt with von Hippel-Lindau disease. Can J Anesth 48:387-90, 2001. General anesthesia was indicated due to symptomatic intracranial hypertension and significant local mass effects in the posterior fossa. Brown MD, Levi ADO. Surgery for lumbar disc herniation during pregnancy. Spine 26 440-3, 2001 Three cases with severe preop neurologic deficits, successfully treated surgically, two peiformed under LEA. Daskalakis GJ Katsetos CN et al. Syringomyelia and pregnancy-case report. Eur J Obstet Gynecol Reprod Bio! 97:98-100, 2001. Cesarean section was elected to avoid straining in the second stage; general anesthesia was administered to avoid changes in CSF dynamics. Demiraran Y, Ozgön M et al. Epidural anaesthesia for cesarean section in a patient with von Hippel-Lindau disease. Eur J Anaesthesiol 18:330-332, 2001. Engrand N, Van de Pene P et al. Intratheca! baclofen for severe tetanus in a pregnant woman. Eur J Anaesthesiol 18:26 1-3, 2001. Gençosmanoglu BE, Hand M et al. Case report: spinal cord injury caused by gunshot wound during pregnancy. J Spinal Cord Med 24:123-6, 2001. Epidural analgesia during labor prevented autonomic hyperrefixia. Holmes LB, Harvey EA et al. The teratogenicity of anticonvulsant drugs. N Eng! J Med 344:1132-8, 2001. Birth defects were secondary to drug treatment, not epilepsy itself Murayama K, Mamiya K et al. Cesarean section in a patient with syringomyelia. Can J Anesth 48:474-7, 2001 Penney DJ, Smailman JMB. Arnold-Chiari malformation and pregnancy. mt J Obstet Anesth 10:139-41, 2001. Durai puncture may lead to neurologic deterioration. Piotin M, de Sousa Fiiho CBA et al. Endovascular treatment of acutely ruptured intracranial aneurysms in pregnancy. Am J Obstet Gynecol 185:1261-2, 2001. In selected patients in experienced centers, a viable alternative to surgery.. Roberts LI, Goucke CR. Retro-orbital tumour: an uncommon cause of headache in pregnancy. Anaesth Intensive Care 29:276-80, 2001. This patient required large doses of morphine (150 mg t.i.d.) for pain control due to her. desire to avoid surgery or radiotherapy during pregnancy. Schabel JE. Subarachnoid block for a patient with progressive chronic inflammatory demyelinating polyneuropathy. Anesth Anaig 93:1304-6, 2001. First reported case of regional anesthesia. Van Calenbergh SGK, Poppe WAJ, Van Calenbergh F. An intracranial tumour: an uncommon cause of hyperemesis in pregnancy. Eur J Obstet Gynecol Reprod Bio! 95:182-3, 2001. Vassiliev DV, Nystrom EUM et al. Combined spinal and epidural anesthesia for labor. and cesarean delivery in a patient with Guillain-Barre syndrome. Reg Anesth Pain Med. 26:174-6, 2001. This patient with resolving Guillain-Barre syndrome underwent cesarean section under epidural anesthesia. There was no evidence of unusual drug sensitivity. 102 ORTHOPEDIC Meger GR, Majewski WT, Lyle WG. Free tissue transfer in pregnancy: guidelines for perioperative managemenL Microsurgery 21:202-207, 2001. Michel TC, Rosenberg AL, Poiley LS. Obstetric anesthetic management of a parturient with Larsen syndrome and short stature. Anesth Anaig 92: 1266-7, 2001. Cesarean section peifonned under epidural anesthesia in a 130 cm pczrturient. T3 level was obtained with 15 ml 2% lidocaine. PSYCHIATRIC/SUBSTANCE ABUSE Birnbach DJ, Browne 1M et al. Identification of polysubstance abuse in the parturient. Br J Anaesth 87:488-90, 2001. Confirmation of reliability of the TesTcup system. 52% of unregistered parturients tested positive for cocaine. Franko DL, Biais MA et al. Pregnancy complications and neonatal outcomes in women with eating disorders. Am J Psychiatry 158:1461-6, 2001. Women with symptomatic eating disorders during pregnancy were more likely to deliver by cesarean section and suffer postpartum depression. Lester BM, El Sohly M et al. The maternal lifestyle study: drug use by meconium toxicology and maternal self-report. Pediatrics 107:309-3 17, 2001. Rabheru K. The use of electroconvulsive therapy in special patient populations. Can J Psychiatry 46:710-9, 2001. Suggests that ECT should be considered as afirst-line therapy for depression during pregnancy due to the potential teratogenic effects of psychotropic drugs. RENAL Davison iM. Renal disorders in pregnancy. Cuff Opin Obstet Gynecol 13:109-1 14, 2001. An extensive review, including normal renal physiology, pregnancy in chronic renal disease and in dialysis patients, and in patients with a renal allo graft. Lindheimer MD, Davison JM, Katz AI. The kidney and hypertension in pregnancy: twenty exciting years. Semin Nephrol 21:173-89, 2001. An extensive discussion of chronic renal disease and the renal effects of preeclampsia. Sanders CL, Lucas MJ. Renal disease in pregnancy. Obstet Gynecol Clin North Am 28(3):593-600, 2001. 103 RESPIRATORY Catanzarite V, Wilims D et al. Acute respiratory distress syndrome in pregnancy and the puerperium: causes, courses, and outcomes. Obstet Gynecol 97:760-4, 2001. Leading causes: infection, preeclampsia, aspiration. Maternal mortality was 39%. One third of cases were felt to be preventable. O Dietrich CL, Smith CE. Anesthesia for cesarean delivery in a patient with an undiagnosed traumatic diaphragmatic hernia. Anesthesiology 95:1028-3 1, 2001. Gershon AS, Faughnan ME. Transcatheter embolotherapy of maternal pulmonary; arteriovenous malformations during pregnancy. Chest 119:470-7, 2001. Seven patients with worsening symptomatic pulmonary AVMs underwent successful embolotherapy Liu S, Wen SW et al. Maternal asthma and pregnancy outcomes: a retrospective cohort study. Am J Obstet Gynecol 184:90-6, 2001. Maternal asthma was significantly assòciated with preterm birth, SGA infants, preterm labo r, preeclampsia, and cesarean section. MandaI NG, White N, Wee MYK. Carbon monoxide poisoning in a parturient and the use of hyperbaric oxygen for treatment. mt J Obstet Anesth 10:71-4, 2001. Maternal symptoms and non-reassuring fetal heart rate resolved with hyperbaric oxygen therapy. Ratner EF, Cohen SE et al. Mask induction with sevoflurane in a parturient with severe tracheal stenosis. Anesthesiology 95:553-5, 2001. Wendel PJ. Asthma in pregnancy. Obstet Gynecol Clin North Am 28(3):537-51, 2001. Complications-anesthetic AIRWAY Ezri T, Szmuk et al. Difficult airway in obstetric anesthesia: a review. Obstet Gynecol Surv 56:631-41, 2001. A comprehensive review written for obstetricians, but a valuable resource for anesthesiologists as well. O Ng A, Smith G. Gastroesophageal reflux and aspiration of gastric contents in anesthetic practice. Anesth Anaig 93:494-5 13, 2001. An extensive review of the anatomy and physiology of the LES, npo status, and the risks of aspiration with some of the newer airway devices. 104 ALLERGY Browne IM, Birnbach DJ. A pregnant woman with previous anaphylactic reaction to local anesthetics: a case report. Am J Obstet Gynecol 185:1253-4, 2001. Local anesthetic allergies are best evaluated prior to pregnancy; this patient underwent uncomplicated skin testing at 29 weeks EGA. Eckhout GV, Ayad S. Anaphylaxis due to airborne exposure to latex in a primigravida. Anesthesiology 95:1034-5, 2001. Stannard L, Bellis A. Maternal anaphylactic reaction to a general anaesthetic at emergency caesarean section for fetal bradycardia. Br J Obstet Gynaecol 108:539-40, 2001. Patient was later found to be allergic to atracurium and succinylcholine. Prompt resuscitation was lifesaving. CARDIAC ARREST Kinsella SM, Tuckey JP. Perioperative bradycardia and asystole: relationship to vasovagal syncope and the Bezold-Jarisch reflex. Br J Anaesth 86:859-68, 2001. Once again, reinforces the necessity of aggressive treatment, including early use of epinephrine. Krismer AC, Hogan QH et al. The efficacy of epinephrine or vasopressin for resuscitation during epidural anesthesia. Anesth Analg 93:734-42, 2001. Response to a single dose of vasopressin was more prolonged and acidosis after multiple doses was less than after epinephrine. Pollard JB. Cardiac arrest during spinal anesthesia: common mechanisms and strategies for prevention. Anesth Analg 92:252-6, 2001. Discounts the role of a respiratory etiology, in these cases. Physiologic changes of pregnäncy may protect against cardiac arrest.. EQUIPMENT Asai T, Yamamoto K et al. Breakage of epidural catheters: a comparison of an Arrow reinforced catheter and other nonreinforced catheters. Anesth Analg 92:246-8, 2001. breakage. In vitro study suggesting that reinforced catheters may be more prone to comparative Burns SM, Cowan CM et al. Intrapartum epidural catheter migration: a study of three dressing applications. Br J Anaes 86:565-7, 2001. catheter during its Nishio I, Sekiguchi M et al. Decreased tensile strength of an epidural removal by grasping with a hemostat. Anesth Analg 93:210-2, 2001. . Vallejo MC, Adler U et al.. Periosteal entrapment of an epidural catheter in the intrathecal space. 'Anesth Analg 92:1532-4, 2001. , 105 , . HIGH SPINAL 131.Kar GS, Jenkins JG. High spinal anesthesia: two cases encountered in a survey of 81,322 obstetric epidurals. mt j Obstet Anesth 10:189-91, 2001. See also Yentis SM, Dob DP. Editorial: High regional block-the failed intubation of the new millennium? mt j Obstet Anesth 10:159-61, 2001. Although the incidence of high regional block is lower than failed intubation, the absolute number of such high blocks is likely to increase as the administration of regional anesthesia becomes more frequent. The editorial provides a detailed protocolfor the management of high block. Shaw IC, Birks RJS. A case of extensive block with the combined spinal-epidural technique during labor. Anaesthesia 56:346-9,2001. Etiology was unclear: subarachnoid or subdural. HYPOTENSION Ayorinde BT Buczkowski Pet al. Evaluation of pre-emptive intramuscular phenylephrine and ephedrine for reduction of spinal anaesthesia-induced hypotension during caesarean section. Br J Anaesth 86:372-6, 2001. Phenylephrine 4 mg and ephedrine 45 mg significantly reduced incidence of hypotension (33% and 48 % incidence, respectively) compared to controls (70%). Burns SM, Cowan CM, Wilkes RG. Prevention and management of hypotension during spinal anaesthesia for elective caesarean section: a survey of practice. Anaesthesia 56:794-8, 2001. Survey of UK practice. Emmett RS, Cyna AM et al. Techniques for preventing hypotension during spinal anaesthesia for caesarean (Cochrane Review). In: The Cochrane Library, 1, 2002. No intervention was found to eliminate the need to treat hypotension during SAB. Effective methods of reducing hypotension were crystalloid 20 mI/kg, colloid vs crystalloid, prophylactic ephedrine, and lower limb compression. Ewaldsson C-A, Hahn RG. Volume kinetics of Ringer's solution during induction of spinal and general anaesthesia. Br J Anaes 87:406-14, 2001. In a non-obstetric population, volume kinetic analysis suggested 350 ml crystalloid administered over 2 minutes immediately prior to anesthetic induction could prevent hypotension. Frölich MA. Role of the atrial natriuretic factor in obstetric spinal hypotension. Anesthesiology 95:37 1-6, 2001. Mercier FJ, Riley ET et al. Phenylephrine added to prophylactic ephedrine infusion during spinal anesthesia for elective cesarean section. Anesthesiology 95:668-74, 2001. Addition of phenylephrine decreased the incidence of hypotension by 50%. UA pH values were signcantly higher. 106 Morgan PJ, Halpern SH, Tarshis J. The effects of an increase of central blood volume before spinal anesthesia for cesarean delivery: a qualitative systematic review. Anesth Anaig 92:997-1005,2001. Ngan Kee WD, Khaw KS et al. Metaraminol infusion for maintenance of arterial blood pressure during spinal anesthesia for cesarean delivery: the effect of a crystalloid bolus. Anesth Anaig 93:703-8, 2001. Crystalloid preload had no additional benefit in patients receiving a metaraminol infusion to maintain BP. Ngan Kee WD, Khaw KS et al. Randomized controlled study of colloid preload before spinal anesthesia for caesarean section. Br J Anesth 87:772-4, 2001. Ngan Kee WD, Lau TK et ai. Comparison of metaraminol and ephedrine infusions for maintaining arterial pressure during spinal anesthesia for elective cesarean section. Anesthesiology 95:307-13, 2001. Metaraminol improved pH values and more closely maintained BP in target range. 142a.Picker O, Schindler AW, Scheeren TWL. Endogenous endothelin and vasopressin support blood pressure during epidural anesthesia in conscious dogs. Anesth Analg 93:15806, 2001. Simon L, Provenchère S et ai. Dose of prophylactic intravenous ephedrine during spinal anesthesia for cesarean section. J Clin Anesth 13:366-9, 2001. INFECTION Dawson S. Epidural catheter infections. J Hosp Infect 47:3-8, 2001. Kinirons B, Mimoz O et aL Chlorhexidine versus povidone iodine in preventing colonization of continuous epidural catheters in children. Anesthesiology 94:239-44, 2001. Chlorhexidine more effectively reduced catheter colonization. Mann TJ, Ori ikowski CE et al. The effect of the biopatch, a chiorhexidine impregnated dressing, on bacterial colonization of epidural catheter exit sites. Anaesth Intensive care 29:600-3, 2001. Bacterial colonization at exit site: 40% controls, 3.4% biopatch. Tsen LC. Letter to the editor: the mask avenger. Anesth Anaig 92:279,2001. See also 92:279-80, 2001 and Browne IM, Birnbach DJ. Letter to the editor: unmasked mischief. Dolinski SY. Reply. 92:280-1, 2001. Are masks necessary during neuraxial anesthetic placement? 107 LOCAL ANESTHETIC NEUROTOXICITY Aouad MT, Siddik SS et al. Does pregnancy protect against intrathecal lidocaineinduced transient neurologic symptoms? Anesth Analg 92:401-4, 2001. The incidence of TNS was zero percent in 200 women undergoing C/S. Authors conclude that the true frequency of TNS does not exceed 3% in parturients. Hashimoto K, Hampl KF et al. Epinephrine increases the neurotoxic potential of intrathecally administered lidocaine in the rat. Anesthesiology 94:876-8 1, 2001. Oka S, Matsumoto M et al. The addition of epinephrine to tetracaine injected intrathecally sustains an increase in glutamate concentrations in the CSF and worsens neuronal injury. Anesth Analg 93:1050-7, 2001. These two studies support the hypothesis that epinephrine increases the toxicity of intrathecal local anesthetics. Is there any rationale for using this technique? Philip J, Sharma SK. Transient neurologic symptoms after spinal anesthesia with lidocaine in obstetric patients. Anesth Anaig 92:405-9, 2001. 3% incidence in 58 patients undergoing PPBTL. Saito S, Radwan Jet al. Direct neurotoxicity of tetracaine on growth cones and neuntes of growing neurons in vitro. Anesthesiology 95:726-33, 2001. Salazar F, Bogdanovich A et al. Transient neurologic symptoms after spinal anaesthesia using isobaric 2% mepivacaine and isobaric 2% lidocaine. Acta Anaesthesiol Scand 45:2405, 2001. Schneider MC, Birnbach DJ. Editorial: Lidocaine neurotoxicity in the obstetric patient: is the water safe? Anesth Analg 92:287-90, 2001. "We believe that, for the present, there is still insufficient safety evidence to suggest that spinal hyperbaric 5% lidocaine be routinely used in obstetrics" Truong HHL, Girard M et al. Spinal anesthesia: a comparison of procaine and lidocaine. Can J Anesth 48:470-3, 2001. See also Boucher C, Girard M. Intrathecal fentanyl does not modify the duration of spinal procaine block. Can J Anesth 48:466-9, 2001. Procaine has been suggested to replace lidocaine for brief procedures. The incidence of failed blocks, however, is higher with procaine. Addition offentanyl does not appear to have any benefit. Winnie AP, Nader AM. Santayana's prophecy fulfilled. Reg Anesth Pain Med 26:55864, 2001. A critique of the completely short sighted decision to manufacture a generic preparation of chioroprocaine with a low pH and containing metabisulfite. NEUROLOGIC Crofts TR, Monagle J et al. Bilateral frontal haemorrhages associated with continuous spinal analgesiá. Anaesth Intensive Care 29:51-3, 2001. Eggert SM, Eggers KA. Subarachnoid haemorrhage following spinal anaesthesia in an obstetric.patient. Br J Anesth 86:442-4,2001. Farrar D, Raoof N. Bell's palsy, childbirth and epidural analgesia; mt J Obstet Anesth 10:68-70, 2001. Seventh nerve palsy is more common in pregnancy. The authors postulate a possible role for otherwise uncomplicated epidural analgesia in precipitating this disorder. Joseph D, AñwariJS. CSF cutaneous fistula after labor epidural analgesia. Middle East J Anesthesiol 16:223-230, 2001. Litz Rl, Hübler M et al. Spinal-epidural hematoma following epidural anesthesia in the presence of antiplatelet and heparin therapy. Anesthesiology 95:1031-3, 2001. The combination of a borderline platelet count, LMWH, and ibuprofen undoubtedly predisposed this 63 year old to the development of a neuraxial hematoma. Reynolds F. Damage to the conus medullaris following spinal anaesthesia. Anaesthesia 56:235-47,2001. Seven patients with conus medullaris damage, all of whom underwent durai puncture at what was thought to be the L2.3 interspace. Because of the difficulty of identifying spinal interspaces accurately utilizing Tuffer's line, the author recommends avoiding puncture above the L3 vertebra. Rorarius MK, Suominen P et al. Neurologic sequelae after caesarean section. Acta Anaesthesiol Scand 45:34-41, 2001. Most neurologic symptoms resolved within 1-2 days. Wang LP, Hauerberg J, Schmitt JF. Long-term outcome after neurosurgically treated spinal epidural abscess following epidural analgesia. Acta Anaesthesiol Scand 45:233-9, 2001. Only 20%of patients with paresis secondary to epidural abscess had made a successful recovery by discharge. 44% of survivors had persistent bowel or bladder dysfunction on long term follow up. 109 SPINAL HEADACHE Banks S, Paech M, Gurrin L. An audit of epidural blood patch after accidental durai puncture with a Tuohy needle in obstetric patients. mt i Obstet Anesth 10: 172-6, 2001. 81% of patients with an accidental durai puncture developed headache. In patients who received a blood patch, 31% had recurrence of headache, and 28% required more than one patch. Volume of blood used did not affect the success rate. Boezaart AP. Effects of CSF loss and epidural blood patch on cerebral blood flow in swine. Reg Anesth Pain Med 26:401-6, 2001. CSF loss increased CBF; epidural blood patch restored it to normal. Charsley MM, Abram SE. The injection of intrathecal normal saline reduces the severity of postdural puncture headache. Reg Anesth Pain Med 26:30 1-5, 2001. See also Benzon HT, Wong CA. Editorial: Postdural puncture headache: mechanisms, treatment, and prevention. Reg Anesth Pain Med 26:293-295, 2001. Injection of 10 ml normal saline either through the Tuohy needle or an intrathecal catheter decreased the headache rate from 62% to 32%. Chisholm ME, Campbell DC. Postpartum postural headache due to superior sagittal sinus thrombosis mistaken for spontaneous intracranial hypotension. Can J Anesth 48:302-4, 2001. Not all headaches are spinal. Davies iM, Murphy A et al. Subdural haematoma after durai puncture headache treated by epidural blood patch. Br J Anaesth 86:720-3, 2001. Elbiaadi-Aziz N, Benzon HT et al. CSF leak treated by aspiration and epidural blood patch under CT guidance. Reg Anesth Pain Med 26:363-7, 2001. Jeskins GD, Moore PAS et al. Long-term morbidity following durai puncture in an obstetric population. mt J Obstet Anesth 10:17-24,2001. See also Schneider MC. Editorial: Pleading not guilty for long-term maternal morbidity following durai puncture. mt J Obstet Anesth 10:1-3, 2001; This retrospective patient survey suggests a disturbingly high incidence of chronic headache and backache after accidental durai puncture. The accompanying editorial presents a more sanguine view, commenting on the methodological shortcomings of the survey. Landau R, Ciliberto CF et al. Complications with 25g and 27g Whitacre needles during combined spinal-epidural analgesia in labor. Tnt J Obstet Anesth 10:168-71, 2001. In patients undergoing CSEfor labor, the incidence of PDPH was 4% in the 25g group and 0.7% in the 27g group. Levine DN, Rapalino O. The pathophysiology of lumbar puncture headache. J Neurol Sci 192:1-8, 2001. Postulates that altered lumbar epidural space compliance is the primary mechanism for PDPH after lumbar puncture. 110 Paech M, Banks S, Gurrin L. An audit of accidentai durai puncture during epidural insertion of a Tuohy needle in obstetric patients. mt j Obstet Anesth 10:162-7, 2001. Intraspinal opioid administration decreased headache; intrathecal catheterization did not decrease headache but decreased EBP. - Safa-Tisseront V, Thormann F et al. Effectiveness of epidural blood patch in the management of post-dural puncture headache. Anesthesiology 95:334-9,2001. Contrary to common belief EBP produced complete relief in only 75% of patients. Success rate was related to the size of the durai puncture. Thoennissen J, Herker H et al. Does bed rest after cervical or lumbar puncture prevent headache? a systematic review and meta-analysis. CMAJ 165:1311-6, 2001. Van de Veide M, Teunkens A et al. PDPH following spinal epidural or epidural anaesthesia in obstetric patients. Anaesth Intensive Care 29:595-9, 2001. Complications-obstetric ABDOMINAL PREGNANCY Carpenter T, Evans P, Wheeler T. An unusual mode of delivery. Br J Obstet Gynaecol 108:436-7, 2001. Hughes S, Goodyear P, Sansome A. The anaesthetic management of a woman with a 31-week abdominal pregnancy. mt J Obstet Anesth 10:321-4,2001. Preparation for massive hemorrhage is essential; leaving the placenta in situ minimizes blood loss. AMNIOTIC FLUID EMBOLISM Awad iT, Shorten GD. Amniotic fluid embolism and isolated coagulopathy: atypical presentation of amniotic fluid embolism. Eur J Anaesthesiol 18:410-3, 2001. Hypoxemia and hypotension were absent; was it AFE? Benson MD, Kobayashi H et al. Immunologic studies in presumed amniotic fluid embolism. Obstet Gynecol 97:510-4, 2001. Complement activation, not anaphylaxis, appears to be the mechanism. Davies S. Amniotic fluid embolus: a review of the literature. Can J Anesth 48:88-98, 2001. Farrar SC, Gherman RB. Tryptase analysis in a woman with amniotic fluid embolism: a case report. J Reprod Med 46:926-8, 2001. Unlike #181, elevated tryptase levels suggest an anaphylactoid mechanism. 111 Kaneko Y, Ogihara et al. Continuous hemodiafiltration for DIC and shock due to amniotic fluid embolism. Intern Med 40:945-7,2001. Pang ALY, Watts RW. AFE during caesarean section under spinal anaesthesia: is sympathetic blockade a risk factor? Aust NZ J Obstet Gynaecol 4 1:342-3, 2001. Speculates that maternal vasodilatation predisposes to entry of amniotic fluid into the circulation. - - HEMORRHAGE Abdi S, Cameron IC et al. Spontaneous hepatic rupture and maternal death following an uncomplicated pregnancy and delivery. Br J Obstet Gynaecol 108:431-3, 2001.: Alexander J, Thomas P, Sanghera J. Treatments for secondary postpartum haemorrhage (Cochran Review). In: The Cochrane Library, 1, 2002 There were no suitable studies dealing with hemorrhage between 24 hours and 12 weeks postpartum. Bouvier-Colle M-H, El Joud DO et al. Evaluation of the quality of care for severe obstetrical haemorrhage in three French regions. Br J Obstet Gynaecol 108:898-903, 2001. Risks for substandard care: <500 deliveries/year, no 24 hour on-site anesthetist. den Hertog CEC, de Groot ANJA, van Dongen PWJ. History and use of oxytocics. Eur J Obstet Gynecol Reprod Biol 94:8-12, 2001. Elbourne Dr, Prendiville WJ et al. Prophylactic use of oxytocin in the third stage of labor (Cochrane Review). In: The Cochrane Library, 1, 2002 Less blood loss, more manual removals of placentas compared to controls. Guid Oei S, Kho SN, ten Broeke EDM. Arterial balloon occlusion of the hypogastric arteries: a life-saving procedure for severe obstetric hemorrhage. Am J Obstet Gynecol 185:1255-6, 2001. Moon PF, Bliss SP et al. Fetal oxygen content is restored after maternal hemorrhage and fluid replacement with polymerized bovine hemoglobin, but not with hetastarch, in pregnant sheep. Anesth Analg 93: 142-50, 2001. Munn MB, Owen J et al. Comparison of two oxytocin regimens to prevent uterine atony at cesarean delivery. Obstet Gynecol 98:386-90, 2001. 80 U/500 ml infused over 30 minutes sign zfi cantly reduces the need for additional uterotdnic agents compared to JOU/500 ml. Pandian Z, Wagaarachchi PT, Danelian PJ. An unusual cause of hypovolemic shock in the postpartum period. Acta Obstet Gynecol Scand 80:871-2, 2001. Ruptured splenic artery aneurysm. Ramsey PS, Meyer LM et al. Delayed postpartum hemorrhage: a rare presentation of carbon monoxide poisoning. Am J Obstet Gynecol 184:243-4, 2001. 112 Singla AK,' Lapinski RH et al. Are women who are Jehovah's Witnesses at risk of,' maternal death? Am J Obstet Gynecol 185:893-5, 2001.,... 44 times more likely to die from hemorrhage despite optimum presurgical preparation. '' Early hysterectomy may be lifesaving." . . , Tamzian O, Arulkumaran S. The surgical management of postpartum hemorrhage. ' .. Curr Opin Obstet Gynecol 13:127-3 1, 2001. ' Yap OW, Kim ES, Laros RK. Maternal and neonatal outcomes after,uterine rupture in,. labor. Am J Obstet Gynecol 184:1576-81, 2001. "In an institution that has in-house obstetric, anesthesia and surgical staff uterine rupture does not result in major maternal morbidity or mortality or neonatal mortality." . . HYPEREMESIS GRAVIDARUM . .' . . . Jewel! D, Young G. Interventions for nausea and vomiting in early pregnancy (Cochrane Review). In: The Cochrane Library, 1, 2002.' . , Kölble N, Hummel T et al. Gustatory and olfactory function in the first trimester of, pregnancy. Eur J Obstet Gynecol Reprod Biol 99:179-83, 2001. Olfaction was unchanged; gustatory function was diminished. The authors hypothesize that this encourages nutrient intake.. . . . ' INCONTINENCE' Farrell SA, Allen VA, Baskett TF. Parturition and urinary incontinence in primiparas. Obstet Gynecol 97:350-6, 2001. Cesarean protects against development of incontinence.: 'Forceps delivery increased risk of '' : incontinence by 1.5 compared with NSVD. MacArthur C, Glazener CMA et al. Obstetric practice and faeca! incontinence three, months after delivery. Br J Obstet Gynaecol 108:678-83, 2001. Vacuum extraction unassociated with increased likelihood offecal incontinence;forceps delivery increased risk offecal incontinence by a factor of two. MATERNAL MORTALITY Horon IL, Çheng D. Enhanced surveillance for pregnancy-associated mortality: Maryland, 1993-1998. JAMA 285:1455-9,2001. In Maryland, a pregnant or recently pregnant woman is more likely to be the victim of a «« ' ,' homicide than to die of àny other cause. . . . ' ' ' , . . . . Lydon-Rochelle M, Holt VL et al. Cesarean delivery and postpartum mortality among primiparas in Washington state, 1987-96. Obstet Gynecol 97:169-74, 2001. Cesarean delivery is a marker for preexisting conditions that increase maternal mortality, rather than being an independent riskfactorfor maternal death. admission for Panchal S, Arria A, Labhsetwar SA. Maternal mortality during hospital Anesth Analg 93:134delivery: a retrospective analysis using a state-maintained database. 113 41, 2001. See also Hawkins JL, Birnbach DJ. Editorial: Maternal mortality in the United States: where are we going and how will we, get there? Anesth Analg 93:1-3, 200L Detailed analysis from a single state. The editorialists comment on the shortcomings of maternal mortality data in the US compared with the Confidential Enquiries in the UK. MULTIPLE GESTATION' Johansson BGA, Helgadottir EA. A case of locked twins successfully treated with nitroglycerin sublingually before manual reposition and vaginal delivery. Acta Obstet Gynecol Scand 80:275-6, 2001. Breech/vertex twins became locked at delivery. NTG saved the day, but common OB practice in the US is to electively section breech/vertex twins. ' Marino TM, Goudas L et al. The anesthetic management of triplet cesarean delivery: a retrospective case series of maternal outcomes. Anesth Analg 93:991-5, 2001. PRETERM LAB OR-ANTENATAL STEROIDS ' Bloom SL, Sheffield JS et al. Antenatal dexamethasone and decreased birth weight. Obstet Gynecol 97:485-90, 2001. Dexamethasone appears to impair fetal growth. Canterino JC, Verma U et al. Antenatal steroids and neonatal periventricular. leukomalacia. Obstet Gynecol 97:135-9, 2001. Antenatal steroids significantly reduced the incidence of periventricular leukomalacia with and without intraventricular hemorrhage. ' Goldenberg RL, Wright LL. Clinical commentary: repeated courses of antenatal steroids. Obstet Gynecol 97:316-7,2001. Guinn DA, Atkinson MW. Single vs. weekly courses of antenatal corticosteroids for women at risk of preterm delivery. JAMA 286:1581-7, 2001. NIH consensus development panel. Antenatal corticosteroids revisited: repeated courses. Obstet Gynecol 98:144-50. Vermillion ST, Soper DE. Is betamethasone effective longer than 7 days after treatment? Obstet Gynecol 97:49 1-3, 2001. Walfisch A, Hallak M, Mazor M. Multiple courses of antenatal steroids: risks and benefits. Obstet Gynecol 98:491-7, 2001. #210-214 all suggest that there is insufficient evidence to support the routine administration of repeated doses of antenatal corticosteroids outside the setting of a randomized controlled trial. 114 PRETERM LABOR-SURVEILLANCE AND TOCOLYSIS The European atosiban study group. The oxytocin antagonist atosiban versus the beta agonist terbutaline in the treatment of preterm labor. Acta Obstet Gynecol Scand 80:413-22, 2001. Atosiban is as effective, and has a better safety profile than terbutaline. Kotani N, Kushikata T et al. Rebound perioperative hyperkalemia in six patients alter cessation of ritodrine for premature labor. Anesth Anaig 93:709-11, 2001. Peak potassium levels ranged form 6.8-7.9 mmol/L. Locatelli A, Vergani P et al. Can a cyclo-oxygenase type-2 selective tocolytic agent avoid the fetal side effects of indomethacin? Br J Obstet Gynaecol 108:325-6, 2001. The selective COX-2 inhibitor nimesulide has similar side effects as indomethacin. Macones GA, Marder SJ et al. The controversy surrounding indomethacin for tocolysis. Am J Obstet Gynecol 184:264-72, 2001. Owen J, Yost N et al. Mid-trimester endovaginal sonography in women at high risk for spontaneous preterm birth. JAMA 286:1340-8, 2001. Papatsonis DNM, Lok CAR et al. Calcium channel blockers in the management of preterm labor and hypertension in pregnancy. Eur J Obstet Gynecol Reprod Biol 97:122-40, 2001. Compared with ß-adrenergic agents, nfedipine is associated with a more frequent successful prolongation of pregnancy. Rosen Ii, Zucker D et al. The great tocolytic debate: some pitfalls in the study of safety. Am J Obstet Gynecol 184:1-7, 2001. Documents the methodological problems with many studies evaluating the safety of tocolytic agents. Sorenson HT, Czeizel AE et al. The risk of limb deficiencies and other congenital abnormalities in children exposed in utero to calcium channel blockers. Acta Obstet Gynecol Scand 80 397-401, 2001 No evidence of increased birth defects. The worldwide atosiban versus beta-agonists study group. Effectiveness and safety of the oxytocin antagonist atosiban versus beta-agonists in the treatment of preterm labor. Br J Obstet Gynaecol 108:133-42, 2001. 115 RETAINED PLACENTA Caponas G. Glycerol trinitrate and acute uterine relaxation: á literature review. Anaésth Intense Care 29:163-77, 2001. D espite numerous case reports, there is scant evidence demonstrating the efficacy of. nitroglycerine to provide acute uterine relaxation. Caroli G, Berger E. Umbilical vein injection for management of retained placenta (Cochrane Review). In: The Cochrane Library, 1, 2002. Safe and effective. SHIVERING Ravid D, Gideon Y et al. Postpartum chills phenomenon: Is it a feto-maternal transfusion reaction? Acta Obstet Gynecol Scand 80:149-5 1, 2001. Maternal-fetal blood group incompatibility is signflcantly more common among shivering than non-shivering parturients. . ; Schwartzkopf KRG, Hoff H et al. A comparison between meperidine, clonidine, and urapidil in the treatment of postanesthetic shivering. Anesth Analg 92:257-60, 2001 Tsai Y-C, Chu K-S. A comparison of tramadol, amitryptiline, and meperidine for postepidural anesthetic shivering in parturients. Anesth Analg 93:1288-92, 2001. Tramadol is as effective as meperidine and produces less somnolence. Debates The use of CSEA for elective caesarean section is a waste of time and money. Pro: KD Thomson. Con: M Paech. mt J Obstet Anesth 10:30-5, 2001. Should nurses manage epidural or intrathecal analgesia/anesthesia by rebolusing or adjusting dosages of continuous infusions during labor and birth? Pro: JP McMichael. Con: KR Simpson. MCN Am J Matern Child Nurs 26:234-5, 2001. Research on women in labour is ethically unsound. Pro: EL Horsman. Con: A Holdcroft. Tnt J Obstet Anesth 10:297-30 1, 2001. Economics and staffing Dexter F, Macario A. Optimal number of beds and occupancy to minimize staffing costs in an obstetrical unit? Can J Anesth 48:295-301, 2001. See also Halpern S, WatsonMacDonell J. Editorial: Optimizing obstetrical suite staffing: it's more than mathematics. Can J Anesth 48:219-221, 2001. Provides a mathematical model for staffing based on the assumption that patient census follows a Poisson distribution. The editorial points out that this represents afirst approximation that will of necessity be modified by local conditions. 116 Leighton BL. Letter: To increase obstetric reimbursement rates, we need to improve the product. Anesthesiology 94:178, 2001. See also Reply: Bell E. Anesthesiology 94:179, 2001. An exchange on the problem of diminishing thi rd party reimbursement for labor analgesia. Does LEA increase the cost of medical care through increased section rates, prolonged labor, and neonatal sepsis workup? Obst TE, Nauenberg E, Buck GM. Maternal health insurance coverage as a determinant of obstetrical anesthesia care. J Health Care Poor Underserved 12:177-91, 2001. Women in northern New York State were less likely to receive epidural analgesia if they were insured by Medicaid; Are anesthesiologists refusing to provide LEA to these patients, are they admitted to hospitals that do not offer an epidural service, or are they less likely to request LEA because of other factors? Fetal monitoring . Albers LL. Monitoring the fetus in labor: evidence to support the methods. J Midwifery Womens Health 46:366-73, 2001. Provides a rationale for the use of intermittent auscultation in selected low risk pregnancies. Amer-Wahlin I, Hellsten C et al. Cardiotocography only versus cardiotocography plis ST analysis of fetal electrocardiogram for intrapartum fetal monitoring. Lancet 358:534-8, 2001. The addition of ST segment analysis significantly decreased the incidence offetal academia and cesarean section for fetal distress. Roberts D, Kumar B et al. Computerised antenatal fetal heart rate recordings between 24 and 28 weeks of gestation. Br J Obstet Gynaecol 108:858-62, 2001. Sheiner E, Hadar A et al. Clinical significance of fetal heart rate tracings during the second stage of labor. Obstet Gynecol 97:747-52, 2001. Late decelerations and FHR<70 in the second stage were associated with fetal acidemia. Astrakhan BK, Sahota DS et al. Computerised analysis of the fetal heart rate and relation to acidaemia at delivery. Br J Obstet Gynaecol 108:848-52, 2001. Tan KH, Sabapathy A. Fetal manipulation for facilitating tests of fetal well being. (Cochrane Review). In: The Cochrane Library, 1, 2002. Published studies do not demonstrate that fetal manipulation reduces the incidence of nonreactive tracings. . Thacker SB, Stroup D, Chang M. Continuous electronic heart rate monitoring for fetal assessment during labor (Cochrane Review). In: The Cochrane Library, 1, 2002. The only significant benefit of continuous EFM was a reduction in the incidence of neonatal seizures. 117 Tincello D, White S, Walkinshaw S. Computerised analysis of fetal heart rate recordings in maternal type I diabetes. Br JObstet Gynaecol 108:853-7, 2001. Fetuses of diabetic mothers had a more immature form of FHR than was expected. Westgate JA, Bennet L et al. Fetal heart rate overshoot during repeated umbilical cord occlusion in sheep. Obstet Gynecol 97:454-9, 2001. Labor analgesia ALTERNATIVE TECHNIQUES Alehagen S, Wijma K, Wijma B. Fear during labor. Acta Obstet Gynecol Scand 80:315-20, 2001. Primiparous women reported higher levels offear. Fear during the first stage was correlated with the total amount of pain relief received. Blair JM, Hill DA, Fee JPH. Patient-controlled analgesia for labour using remifentanil. Br J Anaesth 87:415-20, 2001. Bolus doses of 0.25-0.5 mcg/kg with a 2 minute lockout and no background infusion provided adequate analgesia. Nadir V, Henry R. Bilateral paravertebral block: a satisfactory technique for labour analgesia. Can J Anesth 48: 179-84, 2001. An alternative to the more technically difficult lumbar sympathetic block in patients who could not receive epidural analgesia. Righard L. Making childbirth a normal process. Birth 28:1-4, 2001. Roelants F, De Franceschi et al. Patient-controlled intravenous analgesia using remifentanil in the parturient. Can J Anesth 48:175-8, 2001. 0.05 mcg/kg/min basal infusion, 25 mcg bolus, 5 minute lockout provided adequate analgesia with minimal sedation and no reported newborn depression. Tsen LC, Thomas J et al. Transcutaneous electrical nerve stimulation does not augment epidural labor analgesia. J Clin Anesth 13:57 1-5, 2001. Young D. Editorial: The nature and management of labor pain: what is the evidence? Birth 28;149-51, 2001. Report on "The nature and management of labor pain: an evidence based symposium" sponsored by the Maternity Center Association and the New York Academy of Medicine. Needless to say, the emphasis of this editorial is colored by its provenance. 118 EPIDURAL TECHNIQUES-AMBULATION Connelly NR, Parker RK et al. The influence of a bupivacaine and fentanyl epidural infusion after epidural fentanyl in patients allowed to ambulate in early labor. Anesth Arìalg 93:1001-5, 2001. Vallejo MC, Firestone LL et al. Effect of epidural analgesia with ambulation on labor duration. Anesthesiology 95:857-61, 2001. Ambulation did not shorten labor in women receiving epidural ropivacaine. EPIDURAL TECHNIQUES-ANATOMY Grau T, Leipold RW et al. The lumbar epidural space in pregnancy: visualization by ultrasonography. Br J Anaesth 86:798-804, 2001. Ultrasound demonstrated anatomic changes in pregnant women that predisposed to more dfflcult epidural placement, changes which regressed by 9 months postpartum. Grau T, Leipold RW. Colour Doppler imaging of the interspinous and epidural space. Eur J Anaesthesiol 18:706-12, 2001. EPIDURAL TECHNIQUES-CSEA Comparative Obstetric Mobile Epidural Trial (COMET) Study Group UK. Effect of low-dose mobile versus traditional epidural techniques on mode of delivery: a randomized controlled trial. Lancet 358:19-23, 2001. See also Thornton JG, Capogna G. Editorial: Reducing likelihood of instrumental delivery with epidural anesthesia. Lancet 358:2, 2001 and Letters to the editor: Lancet 358:1725-6, 2001. In this study of 1054 nulliparas, the NSVD rate was 43% in a low-dose CSE group and 43% in a low dose infusion group, compared with 35%in a traditional epidural group. Hess PB, Pratt SD et al. Predictors of breakthrough pain during labor epidural analgesia. Anesth Analg 93:414-8, 2001. Patients receiving CSEA were less likely to have breakthrough pain than conventional epidurals. Risks for breakthrough pain: nulliparity, heavier fetal weight, epidural placement at an earlier cervical dilation. Norris MC, Fogel ST, Conway-Long C. Combined spinal-epidural versus epidural labor analgesia. Anesthesiology 95:913-20, 2001. Labor outcome and progress were similar in both groups. Incidence of accidental durai puncture, headache, and blood patch were similar. Deleted 119 EPIDURAL TECHNIQUES-EQUIPMENT Frölich MA, Caton D. Pioneers in epidural needle design. Anesth Anaig 93:215-20, 2001. EPIDURAL TECHNIQUES-FETAL EFFECTS Capogna G. Effect of epidural analgesia on the fetal heart rate. Eur J Obstet Gynecol Reprod Biol 98:160-4, 2001. Suggests that bradycardia may be secondary to changes in uterine contraction patterns. Reaffirms that these changes need not lead to maternal or fetal morbidity. Paternoster DM, Micaglio M et al. The effects of epidural analgesia and uterine contractions on fetal oxygen saturation during the first stage of labor. Tnt J Obstet Anesth 10:103-7, 2001. Oxygen saturation measured by fetal pulse oximetly was unchanged by epidural analgesia. Saturation increased during contractions, but then fell signcantly below baseline levels. Stuart KAC, Krakauer H et al. Labor epidurals improve outcomes for babies of mothers at high risk for unscheduled cesarean section. J Perinatol 21:1768-85, 2001. In a high risk population, epidural analgesia was cost neutral and led to better neonatal, outcomes. Van de Velde M, Vercauteren M, Vandermeersch E. Fetal heart rate abnormalities alter regional analgesia for labor pain: the effect of intrathecal opioids. Reg Anesth Pain Med 26:257-62, 2001. ITsufentanil 7.5 mg was more likely to lead to fetal bradycardia than conventional epidural. or IT bupivacaine 2.5 mg/sufentanil 1.5 mcg. This did not result in more cesarean deliveries or adverse fetal outcome. EPIDURAL TECHNIQUES-MATERNAL SATISFACTION Kannan S, Jamison RN, Datta S. Maternal satisfaction and pain control in women electing natural childbirth. Reg Anesth Pain Med 26:468-72, 2001. D espite lower pain scores, women who planned an unmedicated birth but received epidural analgesia reported less satisfaction with their birthing experience than women who delivered without analgesia. Wu CL, Naqibuddin M et al. Measurement of patient satisfaction as an outcome of regional anesthesia and analgesia: a systematic review. Reg Anesth Pain Med 26:196-208, 2001. EPIDURAL TECHNIQUES-PCEA Smedvig JP, Soreide E, Gjessing L. Ropivacaine 1 mg/mi, plus fentanyl 2 mcg/ml for epidural analgesia during labor: is mode of administration important? Acta Anaesthesioi Scand 45:595-9, 2001. 120 EPIDURAL TECHNIQUES-PHARMACOLOGY Bernard J-M, Le Roux D et al. The dose-range effects of sufentanil added to 0.125% bupivacaine on the quality of patient-controlled epidural analgesia during labor. Anesth Anaig 92:184-8, 2001. Capogna G, Parpaglioni R et al. Minimum analgesic dose of epidural sufentanil for first-stage labor analgesia: a comparison between spontaneous and prostaglandin-induced labors in nulliparous women. Anesthesiology 94:740-4,2001. Minimum analgesic dose was 22.2 mcg in spontaneous labor and 27.3 mcg in prostaglandin induced labor. Cherng C-H, Wong C-S. Epidural fentanyl speeds the onset of sensory block during epidural lidocaine anesthesia. Reg Anesth Pain Med 26:523-26, 2001. Onset time: 8.3 minutes vs 14.2 minutes in patients undergoing knee arthroscopy. Chua NP, Sia AT, Ocampo CE. Parturient-controlled epidural analgesia during labour: bupivacaine vs. ropivacaine. Anaesthesia 56:1169-73, 2001. Equal amounts of 0.25% bupivacaine and 0.25% ropivacaine were consumed. Kopacz DJ, Bernards CM. Effect of clonidine on lidocaine onlidocaine clearance in '1 vivo. Anesthesiology 95:1371-6, 2001. Decreased blood flow prolonged the duration of lidocaine at the superficial peroneal nerve. Debon R, Allaouchiche B et al. The analgesic effect of sufentanil combined with ropivacaine 0.2% for labor analgesia: a comparison of three sufentanil doses. Anesth Analg 92:180-3, 2001. Addition of 5, 10, and 15 mcg of sufentanil to 12 ml 0.2% ropivacaine prolonged analgesia to a similar degree. Fernandez-Guisasola J, Serrano ML. A comparison of 0.0625% bupivacaine with fentanyl and 0.1% ropivacaine with fentanyl for continuous epidural labor analgesia. Anesth Analg 92:1261-5, 2001. Analgesia was equivalent, suggesting that bupivacaine is more potent than ropivacaine. Lee BB, Ngan Kee WD et al. Dose-response study of epidural ropivacaine for labor analgesia. Anesthesiology 94:767-72, 2001. ED50=18.4mg. Le Guen H, Roy D et al. Comparison of fentanyl and sufentanil in combination with bupivacaine for patient-controlled epidural analgesia during labor. J Clin Anesth 13:98-102, 2001. s Litwin AA. Mode of delivery following labor epidural analgesia: influence of ropivacaine and bupivacaine. AANA Journal 69:259-60, 2001. 121 Palm S, Gertzen W et al. Minimum local analgesic dose of plain ropivacaine vs. ropivacaine combined with sufentanil during epidural analgesia for labor. Anaesthesia 56:526-9,200L MLAC=0.13% plain, 0.09% when sufentanil 0.75 mcg/ml was added: Porter JM, Kelleher N et al. Epidural ropivacaine hydrochloride during labour: protein binding, placental transfer and neonatal outcome. Anaesthesia 56:418-23, 2001. Robinson AP, Lyons GR et al. Levobupivacaine for epidural analgesia in labor: the sparing effect of epidural fentanyl. Anesth Analg 92:410-4, 2001. MLAC=0.091% in controls, 0.047% with fentanyl 2 mcg/ml, and 0.050% with fentanyl 3 mcg/ml; i.e., the effect offentanyl was not dose dependent. Rodriquez J, Rodriquez V et al. Epidural washout with high volumes of saline to accelerate recovery from epidural anaesthesia. Acta Anaesthesiol Scand 45:893-8, 2001. No clinically useful effect; signs of intracranial hypertension developed in one patient who received 4 times the volume of the initial LA dose. Sitzman BT, DiFazio CA et al. Reversal of lidocaine with epinephrine epidural anesthesia using epidural saline washout. Reg Anesth Pain Med 26:246-5 1, 2001. Two 15 ml boluses of normal saline administered 15 minutes apart at the end of surgery reduced time offull recovery from a T4 level block from 153 to 108 minutes. Vercauteren MP, Meert TP et al. Drug iñteractions in the epidural space. Acta Anaesthesiol BeIg 52:437-43, 2001. A review of the drugs that can be added to local anesthetics to improve the quality of block: opioids, ketamine, a-adrenergic agents. Wang C, Sholas MG et al. Evidence that spinal segmental nitric oxide mediates tachyphylaxis to peripheral local anesthetic nerve block. Acta Anaesthesiol Scand 45:94553, 2001. The NO synthase inhibitor L-NAME prevents the development of tachyphylaxis to sciatic nerve blockade. It is much more effective when administered intrathecally rather than systemically, suggesting that tachyphylaxis has a spinal site of action. EPIDURAL TECHNIQUES-PHYSIOLOGY Hawthorne L, Slaymaker A et al. Effect of fluid preload on maternal haemodynamics for low-dose epidural analgesia in labor. mt J Obstet Anesth 10:312-5, 2001. No preload vs. 7 ml/kg bolus: no difference in cardiac index or mean BP after 20 ml bupivacaine + 2 mcg/mlfentanyl. Leather HA, Wouters PF. Oesophageal Doppler monitoring overestimates cardiac output during lumbar epidural anaesthesia. Br J Anaesth 86:794-7, 2001. Redistribution of blood flow renders esophageal Doppler measurement of CO unreliable. Rajek A, Greif R, Sessler DI. Effects of epidural anesthesia on thermal sensation. Reg Anesth Pain Med 26:527-31, 2001. 122 EPIDURAL TECHNIQUES-TEST DOSE/IV INJECTION Bahar M, Chanimov M et al. Lateral recumbent head-down posture for epidural catheter insertion reduces intravascular injection. CanJ Anesth 48:48-53, 2001. Gogarten W, Striimper D et al. Testing an epidural catheter in obstetrics: epinephrine or isoproterenol) Tnt J Obstet Anesth 10 40-5,2001 Discusses limitations of standard epinephrine test dose and possible advantage of isoproterenol, once neurotoxicily concerns are allayed. Ngan Kee WD, Khaw KS et al. The limitations of ropivacaine with epinephrine as an epidural test dose in parturients. Anesth Anaig 92:1529-31, 2001. Tanaka M, Nishikawa T. T-wave amplitude as an indicator for detecting intravascular injection of epinephrine test dose in awake and anesthetized elderly patients. Anesth Anaig 93:1332-7, 2001. Tanaka M, Sato M et al. The efficacy of simulated intravascular test dose in sedated patients. Anesth Analg 93:1612-7, 2001. r An increase in systolic BP and a decrease in T-wave amplitude are more reliable than tachycardia for detecting IV injection of an epinephrine-containing test dose in sedated patients. INTRATHECAL TECHNIQUES D'Angelo R, Dean LS et al. Neostigmine combined with bupivacaine, clonidine, and sufentanil for spinal labor analgesia. Anesth Analg 93:1560-4, 2001. Addition of spinal neostigmine produces severe nausea in parturients (53%) with no useful prolongation of analgesia. Hughes D, Hill D, Fee JPH. Intrathecal ropivacaine or bupivacaine with fentanyl for labor. Br J Anaesth 87:733-7, 2001. IT ropivacaine 2.5 mg with fentanyl 25 mcg provided equivalent analgesia and less motor block than bupivacaine 2.5 mg with fentanyl. If the local anesthetic dose was decreased would the dWerence in motor block persist? Muiroy MF, Larkin KL, Siddiqui A. Intrathecal fentanyl-induced pruritus is more severe in combination with procaine than with lidocaine or bupivacaine. Reg Anesth Pain Med 26:252-6, 2001. Addition offentanyl to procaine appears to be of little benefit. Palmer CM. Continuous intrathecal sufentanil for postoperative analgesia. Anesth Analg 92:244-5, 2001. Pavy TJG. Patient-controlled spinal analgesia for labour and cesarean delivery. Anaesth Intensive Care 29:58-61, 2001. 123 Soni AK, Miller CG et al. Low dose intrathecal ropivacaine with or without sufentanil provides effective analgesia and does not impair motor strength during labour Can J Anesth 48:677-80, 2001. Ropivacaine 3 mg provides effective analgesia; addition of sufentanil 10 mcg prolongs effective analgesia (time to first request for additional analgesia) from 41 to 95 minutes. This duration appears similar to duration of sufentanil alone; therefore, is there any benefit to adding ropivacaine? Stocche RM, Klamt JG et al. Effects of intrathecal sufentanil on plasma oxytocin and cortisol concentrations in women during the first stage of labor. Reg Anesth Pain Med 26:545-50, 2001. IT sufentanil decreases both oxytocin and cortisol concentrations. Can this have any effect on the progressof labor? Stocks GM, Hallworth SP et al. Minimum local analgesic dose of intrathecal bupivacaine in labor and the effect of intrathecal fentanyl. Anesthesiology 94:593-8, 2001. Addition of either 5, 15, or 25 mcgfentanyl to IT bupivacaine produces similar decreases in minimum local analgesic dose (from 1 99 mg to 069, 0 71, and 085, respectively) Swenson JD, Owen J et al. The effect of distance from injection site to the brainstem using spinal sufentanil. Reg Anesth Pain Med 26:306-9, 2001. See also Eisenach JC. Editorial: Lipid soluble opioids do move in cerebrospinal fluid. Reg Anesth Pain Med 26 296-7, 2001 Despite its high lipid solubility, sufentanil migrates large distances in the suba rachnoid space; distance from the injection site to the brainstem will influence the likelihood of respiratory depression. Vaughan DJA, Ahmad N et al. Choice of opioid for initiation of combined spinal epidural analgesia in labour: fentanyl or diamorphine. Br J Anaesth 86:567-9, 2001. ITDiamorphine 250 mcg has a similar side effect profile and a longer duration (101 minutes vs. 73 minutes) compared tofentanyl 25 mcg. Vercauteren MP, Hans G et al. Levobupivacaine combined with sufentanil and epinephrine for intrathecal labor analgesia: a comparison with racemic bupivacaine. Anesth Anaig 93:996-1000, 2001. Clinically similar, except for motor block. Incidence of Bromage i block: bupivacaine 34%, levobupivacaine 0%. Vercauteren MP, Jacobs S et al. Intrathecal labor analgesia with bupivacaine and sufentanil: the effect of adding 2.25 mcg epinephrine. Reg Anesth Pain Med 26:473-7, 2001. Duration of analgesia increased from 79 to 93 minutes with the addition of epinephrine. Yeh H-M, Chen L-K et al. The addition of morphine prolongs fentanyl-búpivacaine spinal analgesia for the relief of labor pain. Anesth Analg 92:665-8, 2001. Addition of morphine 0.15 mg prolonged analgesia form 148 to 252 minutes. 124 Local anesthetic pharmacology Aydin ON, Eyigor M, Aydin N. Antimicrobial activity of ropivacaine and other local anesthetics. Eur J Anaesthesiol 18:687-94, 2001. Ropivacaine has no antimicrobial activity; lidocaine was somewhat more active. The clinical significance is unclear. Groban L, Deal DD et al. Cardiac resuscitation after incremental overdosage with lidocaine, bupivacaine, levobupivacaine, and ropivacaine in anesthetized dogs. Anesth Analg 92:37-43, 2001. Lefrant J-Y, de La Coussaye JE et al. The comparative electrophysiologic and hemodynamic effects of a large dose of ropivacaine and bupivacaine inanesthetized and ventilated piglets. Anesth Analg 93:1598-1605, 2001. 4 mg/kg bupivacaine and 6 mg/kg ropivacaine had similar hemodynamic effects; bupivacaine had a greater effect on ventricular conduction. Liu B-G, Zhuang X-L et al. Effects of bupivacaine and ropivacaine on high-voltageactivated calcium currents of the dorsal horn neurons in newborn rats. Anesthesiology 95:139-43, 2001. Lo B, Hönemann CW et al. Local anesthetic actions on thromboxane-induced platelet aggregation. Anesth Analg 93: 1240-5, 2001. Local anesthetics have only a limited ability to inhibit thromboxane-induced platelet aggregation; this mechanism is unlikely to account for the antithrombotic effects of local anesthetics. Lyons G, Reynolds F. Editorial: Toxicity and safety of epidural local anesthetics. mt J Obstet Anesth 10:259-62, 2001. A nice discussion of the issues in toxicity studies and the problems of assessing potency of local anesthetics. McLeod GA, Burke D. Levobupivacaine. Anaesthesia 56:331-41, 2001. Considers the relative toxicities of bupivacaine and levobupivacaine, and essentially concludes that the older compound should be .uperseded by the single isomer preparation. 312.Ohmura S, Kawada M et al. Systemic toxicity and resuscitation in bupivacaine-, levobupivacaine-, or ropivacaine-infused rats. Anesth Analg 93 :743-8, 2001. Toxicity of levobupivacaine was intermediate between the other agents; less epinephrine was required to resuscitate from ropivacaine-induced asystole. 313. Porter JM, Crowe B et al. The effects of ropivacaine hydrochloride on platelet function: an assessment using the platelet function analyzer (PFA-100). Anaesthesia 56:15-18, 2001. Santos AC, DeArmas PI. Systemic toxicity of levobupivacaine, bupivacaine and ropivacaine during continuous intravenous infusion to pregnant and non-pregnant ewes. 95:1256-64, 2001. For all three agents, the doses required to produce convulsions were lower in pregnant than in non-pregnant sheep. Cardiovascular collapse occurred at similar doses for both pregnant and non-pregnant animals. Zapata-Sudo G, Traciez MM et al. Is comparative cardiotoxicity of S(-) and R(+) bupivacaine related to enantiomer-selective inhibition of L-type Ca2 channels? Anesth Analg 92:496-501, 2001. Mass media Good Morning America, February 6, 2001. New techniques used during pregnancy and birth. The Mail on Sunday, February 11, 2001. Jab blunder kills another patient. "The latest victim of a hospital injection blunder died yesterday as an inquiry began into the tragedy. The unnamed patient had spent three days in intensive care after an 'experienced consultant' injected a local anesthetic into a vein instead of the spine." The Times, March 29, 2001. Maternal bonding "affected by painkillers" "Women who take painkillers during childbirth may have trouble breastfeeding and bonding with their babies, Swedish scientists have reported. Infants whose mothers were given an epidural anesthetic during labor were less likely to breastfeed normally in the first few hours after childbirth." Sunday Express, April 15, 2001. We must have the truth about birth pain injections "The potential risks of epidurals remain one of the Health Service's most closely guarded secrets. This cover-up cannot be allowed to continue." Sunday Express, April 22, 2001. World health expert backs our warning over the danger of using pain-killing drugs for childbirth. "Dr. Marsden Wagner, former director of women and children's health at WHO and adviser to UNICEF, said injections into the spine to relieve labor pains were fraught with peril." 126 Maternal fever and neonatal sepsis workup Goetzl L, Cohen A et al. Maternal epidural use and neonatal sepsis evaluation in afebrile mothers. Pediatrics 108:1099-1102, 2001. Criteria for sepsis workup in afebrile women included ROM>24 hours, FHR>160 (major criteria), and temperature 99.6-100.4°, ROM 12-24 hours, WBC>15,000 on admission, and Apgar <7 at five minutes (minor criteria). Increases in the frequency of several of these criteria in women receiving epidural analgesia led to increased sepsis workups, although, once again, the incidence of sepsis was unchanged. Impey L, Greenwood C et al. Fever in labour and neonatal encephalopathy: a prospective cohort study. Br J Obstet Gynaecol 108:594-7, 2001. Maternalfever is more predictive of encephalopathy than even an abnòrmal FH. The authors somewhat off-handedly suggest that this relationship may have implications for the provision of epidural analgesia; they go on to say, however, that a large increase in epidural use has not been associated with an increase in neonatal encephalopathy. Kaul B, Vallejo M et al. Epidural labor analgesia and neonatal sepsis evaluation rate: a quality improvement study. Anesth Analg 93:986-90, 2001. In one institution, refined criteria for neonatal sepsis evaluations seems to eliminate an increased risk of sepsis workup in infants whose mothers received LEA. Negishi C, Lenhardt R et al. Opioids inhibit febrile responses in humans, whereas epidural analgesia does not. Anesthesiology 94:218-22, 2001. Implies that the incidence offever in mothers receiving LEA must be compared with true controls, i.e. women receiving no analgesics. Petrova A, Demissie K et al. Association of maternal fever during labor with neonatal and infant morbidity and mortality. Obstet Gynecol 98:20-7, 2001. Intrapartum fever is associated with increased neonatal morbidity; it is unclear to me if this is in reality an association between infection and neonatal morbidity. Sciscione AC, Zainia et al. A new device for measuring intrauterine temperature. Am J Obstet Gynecol 184: 1431-5, 2001. Intrauterine temperatures displayed a linear relationship with oral and lympanic temperatures. All were increased in women receiving epidural analgesia. Vallejo MC, Kaul B et al. Chorioamnionitis, not epidural analgesia, is associated with maternal fever during labour. Can J Anesth 48:1122-6, 2001. When women with chorioamnionitis are excluded, LEA is unassociated with fever. Yancey MK, Zhang J et al. Labor epidural analgesia and intrapartum maternal hyperthermia. Obstet Gynecol 98:763-70, 2001. The same natural experiment that demonstrates a neutral effect of epidural analgesia on C/S rates can also implicate the technique for less desirable results. Incidence offever. of >100.4°rose from 0.6% before introduction of an epidural service to 11% afterwards. Neonatal sepsis workups increased, but the proportion of infants receiving antibiotics after workup was unchanged. 127 Medicolegal issues/medical ethics Coates J. Medicolegal diary: obtaining consent for epidural analgesia for women in labour. NZMedJ114:72-3,2001. Yentis SM. Ethical guidance for research in obstetric anaesthesia. Tnt J Obstet Anesth 10:289-9 1. Guidelines of the OAA, must reading for clinical researchers. Newborn BEHAVIOR 331 Halpern SH, Littleford JA et al The neurologie and adaptive capacity score is not a reliable method of newborn evaluation Anesthesiology 94 958-62, 2001 The NACS is the most widely-used tool in the anesthetic literature for assessing newborn behavior. However, its reliability had never been evaluated until this study. The further usefulness of the NAGS is drawn into serious question by this paper. Ransjö-Arvidson A-B, Matthiesen A-S et al. Maternal analgesia during labor disturbs newborn behavior: effects on breastfeeding, temperature, and crying. Birth 28:5-12, 2001. This study, widely reported in the popular press, studied 28 newborns, two (i) of which received epidural analgesia alone and no other analgesics. The difficulties in drawing conclusions from a such a small study are apparent: BRAcHIAL PLEXUS INJURY Bar J, Dvir A et al. Brachial plexus injury and obstetrical risk factors. Tnt J Gynecol Obstet 73:21-25, 2001. Greater maternal age, diabetes, and higher birth weight were associated with a higher risk of Erb 's palsy. 2/62 affected infants were born by elective cesarean section. CEREBRAL PALSY Croen LA, Grether JK et al. Congenital abnormalities among children with cerebral palsy: more evidence for prenatal antecedents. J Pediatr 138:804-10, 2001. Congenital malformations were found in 19% of infants with GP and 4% of controls Farkouh LI, Thorp JA et al. Antenatal magnesium exposure and neonatal demise. AmJ Obstet Gynecol 185:869-72, 2001. Enthusiasm for studies suggesting that maternal magnesium sulfate therapy reduces the incidence of cerebral palsy are tempered by other studies suggesting an increase in perinatal mortality. This study of 12,876 cases failed to show any relationship between magnesium administration and neonatal death. Lemons JA, Bauer CR et al. VLBW outcomes of the National Institute of Child Health and Human Development Neonatal Research Network, January 1995 through December 1996. Pediatrics 107:1-8, 2001. 128 Sameshima H, Ikenoue T. Long-term magnesium sulfate treatment as protection against hypoxic-ischemic brain injury in seven-day-old rats. Am J Obstet Gynecol 184:185-90, 2001. Post-insult administration of magnesium protected against neuronal loss. Thorp JA, James PG et al. Perinatal factors associated with severe intracranial hemorrhage. Am J Obstet Gynecol 185:859-62, 2001; CH0RI0AMNI0NITIs Hitti J, Tarczy-Hornoch P et al. Amniotic fluid infection, cytokines, and adverse outcome among infants at 34 weeks' gestation or less. Obstet Gynecol 98:1080-8, 2001. Schmidt B, Cao L et al. Chorioamnionitis and inflammation of the fetal lung. Am J Obstet Gynecol 184:173-7, 2001. MECONIUM ASPIRATION Blackwell SC, Moldenhauer J et al. Meconium aspiration syndrome in term neonates with normal acid-base status at delivery: is it different? Am J Obstet Gynecol 184:1422-6, 2001. Normal acid-base status was seen in many cases of severe meconium aspiration syndrome; this implies a preexisting injury or a non-hypoxic mechanism. Ghidini A, Spong CY. Severe meconium aspiration syndrome is not caused by aspiration of meconium. Am J Obstet Gynecol 185:931-8, 2001. RESPIRATORY DISTRESS Alano MA, Ngougmna E et al. Analysis of NSAIDs in meconium and its relation to persistent pulmonary hypertension of the newborn. Pediatrics 107:519-23, 2001. Maternal exposure to NSA IDs was greatly underreported and strongly associated with persistent pulmonary hypertension. Clark RH, Gerstmann DR et al. Lung injury in neonates: causes, strategies for prevention, and long-term consequences. J Pediatr 139:478-86, 2001. Discusses ventilator strategies to decrease lung injury. Levine EM, Ghai V et al. Mode of delivery and risk of respiratory diseases in newborns. Obstet Gynecol 97:439-42, 2001.. Even in elective cesareans, the incidence of persistent pulmonary hypertension was almost five-fold higher than in vaginal deliveries. RESUSCITATION/EVALUATION Casey BM, Mclntire DD, Leveno KJ. The continuing value of the Apgar score for the assessment of newborn infants. N Engi J Med 344:467-47 1, 2001. A study of 152,000 live births that validates the Ap gar score 's predictive value. Gaiser R, Lewin SB et al. Anesthesiologist's interest in neonatal resuscitation certification. J Clin Anesth 13:374-6, 2001. 129 Moster D, Lie RT et al. The association of Apgar score with subsequent death and cerebral palsy: a population-based study in term infants. J Pediatr 138:798-803, 2001. Infants with a 5 minute Apgar score of 0-3 had a 386-fold increased risk of neonatal death compared to infants with scores of 7-10. Pate! D, Piotrowski ZH et al. Effect of a statewide neonatal resuscitation training program on Apgar scores among high-risk neonates in flhinois. Pediatrics 107:648-55, 2001. After widespread training in newborn resuscitation was implemented, high-risk newborns with low 1 minute Ap gars were more likely to increase their 5 minute score. Vento M, Asensi M et al. Resuscitation with room air instead of 100% oxygen prevents oxidative stress in moderately asphyxiated term neonates. Pediatrics 107:642-7, 2001. Room air resuscitated infants recover more quickly than those resuscitated with 100% oxygen. Biochemical markers of oxidative stress are present up to 4 weeks after resuscitation with 100% oxygen. Nonobstetric surgery Castro MA, Shipp TD et al. The use of helical computed tomography in pregnancy for the diagnosis of acute appendicitis. Am J Obstet Gynecol 184:954-7, 2001. Both sensitive and specific. Fisk NM, Gitau R et al. Effect of direct fetal opioid analgesia on fetal hormonal and hemodynamic stress response to intrauterine needling. Anesthesiology 95:828-35, 2001. Intravenous fentanyl administered to fetuses prior to intrahepatic vein transfusion forjetai hydrops attenuated the fetal stress response. Schwartz DA, Moriarty KP et al. Anesthetic management of the EXIT (Ex utero intrapartum treatment) procedure. J Clin Anesth 13:387-91, 2001. Steinbrook RA, Bhavani-Shankar K. Hemodynamics during laparoscopic surgery in pregnancy. Anesth Analg 93:1570-1, 2001. Hemodynamic changes were similar to those seen in non-pregnant patients. Tsen LC, Schultz R et al. Intrathecal low-dose bupivacaine versus lidocaine for in vitro fertilization procedures. Reg Anesth Pain Med 26:52-6, 2001. Bupivacaine delayed discharge but was otherwise a suitable substitute for lidocaine. Wiesner G, Hoerauf K et al. High-level, but not low-level, occupational exposure to inhaled anesthetics is associated with genotoxicity in the micronucleus assay. Anesth Anaig 92:118-22, 2001. 130. Obstetric management issues BREECH ACOG Committee on Obstetric Practice. Committee opinion #265: mode of term singleton breech delivery. Obstet Gynecol 98:1189-90, 2001. "Planned vaginal delivery of a term singleton breech may no longer be appropriate." Birnbach DJ, Matut J et al. The effect of intratheòal analgesia on the success of external cephalic version. Anesth Analg 93:410-3, 2001. Success rate: 80% spinal, 33% controls. Hofmeyr GJ. External cephalic version facilitation for breech presentation at term (Cochrane Review). In: The Cochrane Library, 1, 2002. Not enough evidence at present to evaluate the use of regional anesthesia. Tocolysis enhances success rates. Hofmeyr GJ, Hannah ME. Planned caesarean section for term breech delivery (Cochrane Review). In: The Cochrane Library,1, 2002. Provides support for A COG Opinion (ref#357) INDUCTION OF LABOR Alfirevic Z. Oral misoprostol for induction of labor (Cochrane Review). In: The Cochrane Library, 1, 2002. Effective, but data on optimal regimens and safety are lacking. Boulvain M, Stan C, Irion O. Membrane sweeping for induction of labor (Cochrane Review). In: The Cochrane Library, 1,2002. Routine use of membrane sweeping has no apparent clinical benefit. French L. Oral prostaglandin E2 for induction of labor (Cochrane Review). In: The Cochrane Library, 1, 2002. Oral prostaglandin E2 was sign jJï cantly associated with GI disturbances; there were no clear advantages to its use compared with other induction techniques. Hofmeyr GJ, Gulmezoglu AM. Vaginal misoprostol for cervical ripening and induction of labor (Cochrane Review). In: The Cochrane Library, 1, 2002. Effective, but uterine hyperstimulaiton is a concern; reviewers could not exclude the possibility of uterine rupture. Howarth GR, Botha DJ. Amniotomy plus intravenous oxytocin for induction of labor (Cochrane Review). In: The Cochrane Library, 1, 2002. The reviewers concluded that data on the effectiveness of this combination are lacking. No clinical recommendations were made. 131 Goldberg AB, Greenberg MB, Darney PD. Misoprostol and pregnancy. New Eng! J Med 344:38-47, 2001. See also Hale RW, Zinberg S. Editorial: Use of misoprostol in pregnancy. N Engi J Med 344:59-60. 2001 and Friedman MA. Letter: Manufacturer's warning regarding unapproved uses of misoprostol. N Engi J Med 344:61, 2001. Goldberg provides an extensive review of the uses of misoprostol during pregnancy, including pregnancy termination, cervical ripening, and treatment of PPH. The editorial discusses the efforts of the manufacturer, G.D. Searle, to dissuade physicians from utilizing the drug for those off-label uses. Kelly AJ, Kavanaugh J, Thomas J. Vaginal prostaglandin (PGE2 and PGF2) for induction of labor at term (Cochrane Review). In: The Cochrane Library, 1, 2002. Yawn BP, Wollan P et al. Temporal changes in rates and reasons for medical induction of term labor, 1980-1996. Am J Obstet Gynecol 184:611-9,2001. Rate of induction increased from 13% to 26%; The most common indications are elective induction and postdates pregnancy (40-41 weeks). INSTRUMENTAL DELIVERY Gardella C, Taylor M et al. The effects of sequential use of vacuum and forceps for assisted vaginal delivery on neonatal and maternal outcomes. Am J Obstet Gynecol 185:896902, 2001. Sequential use of vacuum and forceps increases the risk of both maternal and fetal injury. INTRAPARTUM CARE Chalmers B, Mangiaterra V, Porter R. WHO principles of perinatal care: the essential antenatal, perinatal, and postpartum care course. Birth 28:202-7, 2001. "Do not restrict fluids during labor, and allow women with normally progressing labors to eat light meals if needed". Chien L-Y, Whyte R et al. Improved outcome of preterm infants when delivered in tertiary care centers. Obstet Gynecol 98:247-52, 2001. Enkin M, Keirse MJNC et al. Effective care in pregnancy and childbirth: a synopsis. Birth 28:41-51, 2001. "Forms of care with a trade-off between beneficial and adverse effects" include epidural analgesia and fluid preload prior to epidural. "Forms of care unlikely to be beneficial" include withholding food and drink from women in labor. Hofmeyr GJ. Amnioinfusion for meconium-stained liquor in labour (Cochrane Review). In: The Cochrane Library, 1, 2002. Hofmeyr GJ, Gulmezoglu AM. Maternal hydration for increasing amniotic fluid volume in oligohydramnios and normal amniotic fluid volume (Cochrane Review). In: The Cochrane Library, 1, 2002. Two liters of oralfluid signcantly increased amniotic fluid volume and may be useful in cases of oligohydramnios. 132 Lauzon L, Hodnett E. Labour assessment programs to delay admission to labour wards (Cochrane Review). In: The Cochrane Library, 1,2002. Nager CW, Helliwell JP. Episiotomy increases perineal laceration length in primiparous women. Am J Obstet Gynecol 185:444-50, 2001. Why are routine episiotomies still performed? Rouse DJ, Owen J et al. Active phase labor arrest: revisiting the 2-hour minimum. Obstet dynecol 98:550-4, 2001. Women with such an arrest can often achieve successful vaginal delivery. Sherard GB, Newton ER. Is routine hemoglobin and hematocrit testing on admission to labor and delivery needed? Obstet Gynecol 98:1038-40, 2001. If Hgb obtained at 26-28 weeks is acceptable, there is no advantage to obtaining a repeat determination upon admission. VBAC Bujold E, Gauthier RJ. Should we allow a trial of labor after a previous cesarean for dystocia in the second stage of labor? Obstet Gynecol 98:652-5, 2001. VBAC after a previous cesarean section performed for second stage dystocia has a 75% success rate. Goetzl L, Shipp TD et al. Oxytocin dose and the risk of uterine rupture in trial of labor after cesarean. Obstet Gynecol 97:38 1-4, 2001. Hibbard JU, Ismail MA et al. Failed vaginal birth after a cesarean section: how risk)) is it? I. Maternal morbidity. Am J Obstet Gynecol 184:1365-73, 2001. Lydon-Rochelle M, Holt V et al. Risk of uterine rupture during labor among women with a prior cesarean delivery. N Engl J Med 345:3-8, 2001. See also Greene MF. Editorial: Vaginal delivery after cesarean section: is the risk acceptable? N Engi J Med 345:54-5, 2001 and Flamm BL. Editorial: VBAC and the New England Journal of Medicine: a strange controversy. Birth 28:276-9, 2001. Induction, particularly induction with prostaglandins, was associated with a higher risk of uterine rupture during VBAC than when labor commenced spontaneously. Even in the spontaneous group, however, uterine rupture occurred in 5.2/1000 deliveries. Shipp TD, Zelop CM et al. Interdelivery interval and risk of symptomatic uterine rupture. Obstet Gynecol 175-7, 2001. Interdelivery intervals of up to 18 months were associated with a higher risk of symptomatic uterine rupture duringVBAC compared to longer intervals. Pharmacologic and physiologic alterations of pregnancy Bernstein 1M, Ziegler W, Badger GJ. Plasma volume expansion in early pregnancy. Obstet Gynecol 97:669-72, 2001. Plasma volume expansion cannot be identified before the sixth week of gestation. By the end of the first trimester, plasma volume increases by 14%. Greenwood JP. Sympathetic neural mechanisms in normal and hypertensive pregnancy in humans. Circulation 104:2200-2204, 2001. Central sympathetic outflow is increased during normal pregnancy. It is further augmented in women with pregnancy-induced hypertension. He Y-L, Seno H et al. The effects of uterine and umbilical blood flows on the transfer of propofol across the human placenta during in vitro perfusion. Anesth Analg 93:15 1-6, 2001. Higuchi H, Adachi Y et al. Early pregnancy does not reduce the C50 of propofol for loss of consciousness. Anesth Analg 93:1565-9, 2001. Hsu M-M, Chou Y-Y et al. An analysis of excitatory amino acids, nitric oxide, and prostaglandin E2 in the CSF of pregnant women: the effect on labor pain. Anesth Anaig 93:1293-6, 2001. Labor pain increases CSF concentrations of the excitatory amino acids glutamate and aspartate but not prostaglandin E2 or NO. McAuliffe F, Kametas et al. Blood gases in pregnancy at sea level and at high altitude. BrJ Obstet Gynaecol 108:980-5, 2001. Pan PH, Moore C. Comparison of cisatracurium induced neuromuscular blockade between immediate postpartum and nonpregnant patients. J Clin Anesth 13:112-7, 2001. Mean onset time and clinical duration of cisatracurium are considerably shorter immediately postpartum than in nonpregnant controls. Rodriquez I, Kilborn MJ et al. Drug-induced QT prolongation in women during the menstrual cycle. JAMA 285:1322-6, 2001. Can this be related to the cardiotoxicizy of local anesthetics in pregnancy? Tsen LC, Natale et al. Can estrogen influence the response to noxious stimuli? J Clin Anesth 13:118-21, 2001. Tsujiguchi N, Yamakage M et al. Mechanisms of direct inhibitory action of propofol on uterine smooth muscle contraction in pregnant rats. Anesthesiology 95:1245-55, 2001. Veille J-C, Kitzman DW et al. LV diastolic filling response to stationary bicycle exercise during pregnancy and the postpartum period. Am J Obstet Gynecol 185:822-7, 2001. LV chamber stzfJhess increases during maximal exercise in pregnancy. 134 Yoo KY, Lee J et al. The effects of opioids on isolated human pregnant uterine muscles. Anesth Analg 92:1006-9, 2001. Fentanyl and meperidine appear to directly inhibit uterine contractility, but at levels 1000 times greater than those seen clinically. Postoperative pain management ADJUVANT DRUGS American Academy of Pediatrics Committee on Drugs. The transfer of drugs and other chemicals into human milk. Pediatrics 108:776-89, 2001. States that the use of ketorolac is acceptable in breasifeeding women. Unfortunately, this is not supported by the manufacturer's package insert. Charuluxananan S, Kyokong O et al. Nalbuphine vs. propofol for treatment of lT morphine-induced pruritus after cesarean delivery. Anesth Anaig 93:162-5, 2001. Ko S-H, Lim H-R et al. Magnesium sulfate does not reduce postoperative analgesic requirements. Anesthesiology 95:640-6, 2001. Lim NLSH, Lo WK et al. Single dose diclofenac suppository reduces post-Cesarean PCEA requirements. Can J Anesth 48:383-6, 2001. Diclofenac group used 52 ml of local anesthetic mixture, controls used 74 ml. Pavy TJG, Paech MJ, Evans SF. The effect of intravenous ketorolac on ópioid requirement and pain after cesarean delivery. Anesth Analg 92:1010-4, 2001. Reduced epidural meperidine usage by 30%, but did not improve quality of pain relief or reduce opioid side-effects. Siddik SM, Aouad MT et al. Diclofenac and/or propacetamol for postoperative pain management after cesarean delivery in patients receiving PCA morphine. Reg Anesth Pain Med 26:310-5, 2001. See also Halpern SH, Walsh VL. Editorial: Multimodal therapy for post-cesarean delivery pain. Reg Anesth Pain Med 26:298-300, 2001. Yanagidate F, Hamaya Y, Dohi S. Clonidine premedication reduces maternal requirement for intravenous morphine after cesarean delivery without affecting newborn's outcome. Reg Anesth Pain med 26:461-7, 2001. COMPLICATIONS . Cherian VT, Smith I. Prophylactic ondansetron does not improve patient satisfaction in women using PCA after caesarean section. Br J Anaesth 87:502-4, 2001. Ho S-T, Wang J-J et al. Dexamethasone for preventing nausea and vomiting associated with epidural morphine: a dose-ranging study. Anesth Analg 92:745-8, 2001. 5 mg dexamethasone reduced incidence of nausea and vomiting from 50% to 18%. Kjellberg F, Tramèr MR. Pharmacological control of opioid-induced pruritus: a quantitative systematic review of randomized trials. Eur J Anaesth 18:346-57, 2001. 135 Murphy DB, El Behiery H et al. Pharmacokinetic profile of epidurally administered methylnaltrexone, a novel peripheral opioid antagonist in a rabbit model. Br J Anaesth 86:120-2, 2001. Pan PH, Moore CH. Comparing the efficacy of prophylactic metoclopramide, ondansetron, and placebo in cesarean section patients given epidural anesthesia. J Clin Anesth 13:430-5, 2001. Pellegrini JE, Bailey SL et al. The impact of nalmefene on side effects due to intrathecal morphine at cesarean section. AANA Journal 69:199-201, 2001. Wang J-J, Ho S-t et al. Dexamethasone prophylaxis of nausea and vomiting after epidural morphine for post-Cesarean analgesia. Can J Anesth 48:185-90, 2001. EPIDURAL Hodgson PS, Liu SS. A comparison of ropivacaine with fentanyl to bupivacaine with fentanyl for postoperative PCEA. Anesth Analg 92:1024-8, 2001. No signflcant differences between drugs; recommends the use of 0.05% solutions to minimize motor block Jastrzab G, Fairbrother G, Khor. Management of postoperative epidural analgesia: a survey of Australian practice. Anaesth Intensive Care 29:266-72, 2001. Lee J, Shim JY et al. Epidural naloxone reduces intestinal hypomotility but not analgesia of epidural morphine. Can J Anesth 48 :54-58, 2001. Menigaux C, Guignard B et al. More epidural than intravenous sufentanil is required to provide comparable postoperative pain relief. Anesth Analg 93:472-6, 2001. Suggests that epidural sufentanil has a primarily systemic effect. Subramaniam B, Subramaniam K et al. Preoperative epidural ketamine in combination with morphine does not have a clinically relevant intra- and postoperative opioid-sparing effect. Anesth Analg 93:1321-6, 2001. INTRATHECAL Campbell DC, Riben CM et al. Intrathecal morphine for postpartum tubal ligation postoperative analgesia. Anesth Analg 93; 1006-11, 2001. 100 mcg provided effective relief Maternal pain was surprisingly high in the control group; they required 40 mg PCA morphine over the first 24 hours. Kim MH, Lee YM. Intrathecal midazolam increases the analgesic effects of spinal blockade with bupivacaine in patients undergoing hemorrhoidectomy 86:77-9, 2001. Lamina 2 is densely packed with benzodiazepine receptors Standl TG, Horn E-p et al. Subarachnoid sufentanil for early postoperative pain management in orthopedic patients. Anesthesiology 94:230-8, 2001. 136 Pre eclampsia ANESTHETIC MANAGEMENT Ramanathan J, Vaddadi AK, Arheart KL. CSEA with low doses of intrathecal bupivacaine in women with severe preeclampsia. Reg Anesth Pain Med 26:46-5 1, 2001. Effective, with minimum blood pressure changes and good newborn outcomes. \Veè L, Sinha P, Lewis M. The management of eclampsia by obstetric anaesthetists in UK: a postal survey. mt J Obstet Anes 10:108-112, 2001. Survey of experience with use of magnesium and other anticonvulsants in treatment of eclamptic seizures. Mg:69%, diazepam:29%. BLOOD PRESSURE MANAGEMENT Blumenfeld JD, Laragh JH.. Management of hypertensive crises: the scientific basis for treatment decisions. Am J Hypertens 14:1154-67, 2001. HELLP SYNDROME Isler CM, Barrilleaux et al. A prospective, randomized trial comparing the efficacy of dexamethasone and betamethasone for the treatment of antepartum HELLP. Am J Obstet Gynecol, 184:1332-9, 2001. Dexamethasone increases, urine output, decreases AST, and decreases blood pressure to a greater extent than betamethasone. Both increase platelet count. Vigil-De Gracia P. Acute fatty liver and HELLP syndrome: two distinct pregnancy disorders. mt J Gynecol Obstet 73:215-220,2001. More common in AFLP: hyperbilirubinemia, hypoglycemia, hypofibrinogenemia.. Encephalopathy is more common in AFLP, as is renal insufficiency. These differences reflect the dWerent pathologic alterations (HELLP: endothelial dysfunction, AFLP: mitochondrial dysfunction.) OUTCOME Mackay AP, Berg CJ, Atrash HK. Pregnancy-related mortality from preeclampsia and eclampsia. Obstet Gynecol 97:533-8, 2001. Preeclampsia accounts for 1.5 deaths/100,000 live births in the US. Mortality increases with age. Black women are three times more likely to die from preeclampsia-eclampsia than white women. PATHOPHYSIOLOGY Belfort MA, Tooke-Miller C et al. Pregnant women with chronic hypertension and superimposed pre-eclampsia have high cerebral perfusion pressure. Br J Obstet Gynaecol 108:1141-7, 2001. Suggests a mechanism for the increased incidence of eclampsia in women with superimposed preeclampsia. Blanco MV, Grosso O et al. Dimensions of the left ventricle, atrium, and aortic root in pregnancy-induced hypertension. Am J Hypertension 14:390-2, 2001. 137 Chambers JC, Fusi L. Association of maternal endothelial dysfunction with preeclampsia. JAMA 285:1607-12, 2001. Endothelial dysfunction persists postpartum in previously preeclamptic women. Diedrich F, Renner A et al. Lipid hydroperoxides and free radical scavenging enzyme activities in preeclampsia and HELLP syndrome: no evidence for circulating primary product of lipid peroxidation. Am J Obstet Gynecol 185:166-72, 2001. Esplin MS, Fausett MB et al. Paternal and maternal components of the predisposition to preeclampsia. N Engi J Med 344:867-72, 2001. See also Pipkin FB. Editorial: Risk factors for preeclampsia. N Engi J Med 344:925-6, 2001. Granger JP, Alexander BT et al. Pathophysiology of pregnancy-induced hypertension. Am J Hypertens 14:178S-185S, 2001. Granger JP, Alexander BT et al. Pathophysiology of hypertension during preèclampsia linking placental ischemia with endothelial dysfunction. Hypertension 38 (part 2):7 18-22, 2001. Magnus P, Eskild A. Seasonal variation in the occurrence of pre-eclampsia. Br J Obstet Gynaecol 108:1116-9, 2001. Mothers of children born in August had the lowest risk of preeclampsia, and mothers of those born in December had the highest risk (adjusted odds ratio 1.26). Mortenson JT, Thultrup AM et al. Smoking, sex of the offspring, ànd risk of placental abruption, placenta previa, and preeclampsia: a population-based cohort study. Acta Obstet Gynaecol Scand 80:894-8, 2001. Smoking is again shown to protect against preeclampsia. Female fetuses were more susceptible to the effects of smoking on the incidence of placenta previa. Regan CL, Levine RJ et al. No evidence for lipid peroxidation in severe preeciampsia. Am J Obstet Gynecol 185:572-8, 2001. Roberts JM, Cooper. Pathogenesis and genetics of pre-eclampsia. Lancet 357:53-6, 2001. Sharkey LC, McCune SA et al. Spontaneous pregnancy-induced hypertension and intrauterine growth restriction in rats. Am J Hypertension 14:1058-66, 2001. A possibly useful animal model for preeclampsia. Trogstad LIS, Eskild A et al. Is preeclampsia an infectious disease? Acta Obstet Gynecol Scand 80:1036-8, 2001. The risk of developing preeclampsia was greater in women who were seronegative for antibodies to HSV-2, CMV, and EBV. The authors suggest that seronegative women are more likely to acquire these infections during pregnancy, and postulate that infection during pregnancy might lead to preeclampsia. PREDICTION/PREVENTION Atallah AN, Hofmeyr GJ, Duley L. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems (Cochrane review). In: The Cochrane Library, 1,2002. Calcium supplementation appears to be benefi cia! for women at high risk of developing preeclampsia. The optimal dosage is unclear at this time. Coomarasamy A, Papaioannou S et al. Aspirin for the prevention of preeclampsia in women with abnormal uterine artery Doppler: a meta-analysis. Obstet Gynecol 98:861-6, 2001. Meta -analysis offive trials demonstrates that abnormal uterine artery Doppler studies identify women who would benefit from ASA therapy. Dekker G, Sibai B. Primary, secondary, and tertiary prevention of pre-eclampsia. Lancet 357:209-15, 2001. Duley L, Henderson-Smart D et al. Antiplatelet drugs for prevention of preeclampsia and its consequences: systematic review. BMJ 322:329-33, 2001. A meta-analysis of 39 trials consisting of 30,000 women demonstrated a 15% decrease in the incidence of preeclampsia, an 8% decrease in preterm birth, and a 14% decrease in fetal or neonatal death. Goffinet F, Aboulker D et al. Screening with a uterine Doppler in low risk pregnant women followed by low dose aspirin in women with abnormal results: a multicenter randomized controlled trial. Br J Obstet Gynaecol 108:510-8, 2001. There were no differences between screened and non-screened women in the incidence of IUGR, preeclampsia, or any other markers of Perinatal morbidity. Roberts JM. Preeclampsia: Is there value in assessing before clinically evident disease? Obstet Gynecol 98:596-9, 2001. Thadhani R, Ecker JL et al. Pulse pressure and risk of preeclampsia: a prospective study. Obstet Gynecol 97:515-20, 2001. Elevated pulse pressure at 7-15 weeks identifies women at high risk of developing preeclampsia. Wallenberg HCS. Prevention of pre-eclampsia: status and perspectives 2000. Eur J Obstet Gynecol Reprod Biol 94:13-22, 2001. Progress of labor EPIDURAL ANESThESIA Howell CJ, Kidd C et al. A randomized controlled trial of epidural compared with nonepidural analgesia in labour. Br J Obstet Gynaecol 108:27-33. See also Kinsella SM. Commentary: Epidural analgesia for labor and instrumental vaginal delivery: an anaesthetic problem with an obstetric solution. Br J Obstet Gynaecol 108:1-2; No difference in the incidence of chronic backache; instrumental delivery rates were increased in the epidural group (30% vs 19%). Lindeberg SN, Thorén T, Hanson U. A high rate of epidural analgesia with bupivacaine-sufentanil is consistent with a low rate of caesarean section and instrumental deliveries. EurJ Obstet Gynecol Reprod Biol 98:193-8, 2001. An alteration in technique increased the use of LEA from 38% to 63%. The cesarean section rate was unchanged (approximately 10%), as was the instrumental delivery rate. Lucas MJ, Sharma SK. A randomized trial of labor analgesia in women with pregnancy-induced hypertension. Am J Obstet Gynecol 185:970-5, 2001. The authors stated that the duration of labor was increased "significantly" in the epidural group, although analysis of their data showed no dWerence in the length ofthefirst stage (epidural 271 minutes, IV 266 minutes) and only a slight increase in the length of the second sta ge (53 minutes vs. 40 minutes). The C/S rate was the same in both groups. The authors state in their abstract that the incidence of chorioamnionitis was increased in the epidural group; in reality, this was based on an increased incidence of maternalfever in the epidural group, and not on any objective measure of maternal infection. Finally, the authors were concerned about the 11% incidence of hypotension requiring treatmént in the epidural group. This seems to be a fairly low incidence of what is usually a minor side-effect, and should be contrasted with the 12-fold increase in the need for neonatal naloxone administration in the IV group. Yancey MK, Zhang J et al. Epidural analgesia and fetal head malposition at vaginal delivery. Obstet Gynecol 97:608-12, 2001. Another natural experiment from Tripler Army Medical Center (See also #328). An increase in epidural utilization from 1% to 83% had no effect on the rate offetal head malposition. Zhang J Yancey MK et al. Does epidural analgesia prolong labor and increase risk of cesarean delivery? A natural experiment. Am J Obstet Gynecol 185:128-34, 2001. No change in rate of cesarean section, cesarean section for dystocia, instrumental delivery, or length offirst sta ge; second stage was prolonged (by 25 minutes). RISK FACTORS FOR CESAREAN SECTION Alexander JM, Sharma SK. Intensity of labor pain and cesarean delivery. Anesth Analg 92:1524-8, 2001. Women who required >50 mg/hr meperidine via PCA were 10 times more likely to require cesarean section for obstructed labor. 140 Sheiner E, Shoham-Vardi I et al. Infertility treatment is an independent risk factor for cesarean section among nulliparous women aged 40 and above. 185:888-92, 2001. The investigators analyzed the deliveries of 115 nulliparas aged >40 years with singleton gestations. There were 80 spontaneous pregnancies, and 35 were the result of infertility treatment. There were no djfferences in obstetric risk factors or labor characteristics between the two groups. Interestingly, the use of epidural analgesia was not mentioned in the study. Cesarean section was more likely in the infertility group (71.4%) than in the spontaneous pregnancy group (41.3%). ADDITIONAL ARTICLES Some of the articles that were identified via PUBMED were published in journals that were either unavailable to me or written in languages other than English. Their abstracts seemed interesting enough, however, that I have listed them for those of you with a greater access to journals or a more well rounded education than I possess... Besmer I, Schupfer G et al. Postpartum neurologic complications following delivery with peridural analgesia: case report with literature review. Anaesthesist 50:852-5. Ferrari L, De Sevin F et al. Intracranial subdural hematoma after obstetric durai puncture. Ann Fr Anesth Reanim 20:563-6, 2001. Frigo MG, Camorcia M et al. Prehydration and anaesthesia in obstetrics: state of the art. Minerva Anestesiol 67:161-8, 2001. Hagberg C, Ezri T, Abouleish E. Etiology and incidence of endotracheal intubation following spinal anesthesia for cesarean section. Isr Med Assoc J 9:653-6, 2001. Ishikawa T, Kawahara S et al. Anesthesia for electroconvulsive therapy during pregnancy: a case report. Masui 50:991-7, 2001. . Iwama H, Furuta S et al. Extra-strong compression stocking reduces use of vasopressor agents during spinal anesthesia for cesarean section. Arch Gynecol Obstet 265:60-3, 2001. Use of ephedrine was decreased from 85% to 49%. Kulka PJ, Scheu C et al. Myocardial infarction during pregnancy. Anaesthesist 50:2804, 2001. Lahme T, Jung WK et al. Patient surgical masks during regional anesthesia: hygienic necessity or dispensable ritual? Anaesthesist 50:846-5 1, 2001. Use of a patient mask did not reduce the airborne concentration of bacteria over the operative field. Leykin Y, Luccca M. Complications related to the epidural catheter in caesarean delivery. Minerva Anestesiol 67:175-80, 2001. 141 Sheiner E, Shoham-Vardi I et al. Infertility treatment is an independent risk factor for cesarean section among nulliparous women aged 40 and above. 185:888-92, 2001. The investigators analyzed the deliveries of 115 nulliparas aged >40 years with singleton gestations. There were 80 spontaneous pregnancies, and 35 were the result of infertility treatment. There were no differences in obstetric risk factors or labor characteristics between the two groups. Interestingly, the use of epidural analgesia was not mentioned in the study. Cesarean section was more likely in the infertility group (71.4%) than in the spontaneous pregnancy group (41.3%). ADDITIONAL ARTICLES Some of the articles that were identified via PUBMED were published in journals that were either unavailable to me or written in languages other than English. Their abstracts seemed interesting enough, however, that I have listed them for those of you with a greater access to journals or a more well rounded education than I possess. Besmer I, Schupfer G et al. Postpartum neurologic complications following delivery with peridural analgesia: case report with literature review. Anaesthesist 50:852-5. 460. Ferrari L, De Sevin F et al. Intracranial subdural hematoma after obstetric durai puncture. Ann Fr Anesth Reanim 20:563-6, 2001. Frigo MG, Camorcia M et al. Prehydration and anaesthesia in obstetrics: state of the art. Minerva Anestesiol 67:161-8, 2001. Hagberg C, Ezri T, Abouleish E. Etiology and incidence of endotracheal intubation following spinal anesthesia for cesarean section. Isr Med Assoc J 9:653-6, 2001. Ishikawa T, Kawahara S et al. Anesthesia for electroconvulsive therapy during pregnancy: a case report. Masui 50:991-7, 2001. Iwama H, Furuta S et al. Extra-strong compression stocking reduces use of vasopressor agents during spinal anesthesia for cesarean section. Arch Gynecol Obstet 265:60-3, 2001. Use of ephedrine was decreased from 85% to 49%. Kulka PJ, Scheu C et al. Myocardial infarction during pregnancy. Anaesthesist 50:280- 4,2001. Lahme T, Jung WK et al. Patient surgical masks during regional anesthesia: hygienic necessity or dispensable ritual? Anaesthesist 50:846-5 1, 2001.' Use of a patient mask did not reduce the airborne concentration of bacteria over the operative field. Leykin Y, Luccca M. Complications related to the epidural catheter in caesarean delivery. Minerva Anestesiol 67:175-80, 2001. 142 Newman MG, Lindsay MK Graves W. The effect of epidural analgesia on rates of episiotomy use and episiotomy extension in an inner city hospital. J Matern Fetal Med 10:97-101, 2001. Epidural anesthesia increased the use of episiotomy but decreased the likelihood of episiotomy extension. Rezig K, Diar N et al. Goiter in pregnancy: a predictable cause of difficult intubation. Ann Fr Anesth Reanim 20:639-42, 2001. Rout CC. Anaesthesia and analgesia for the critically ill parturient. Best Pract Res Clin Obstet Gynaecol 15:507-22, 2001. Sanchez-Conde P, Nicolas J et al. Comparison of ropivacaine and bupivacaine for epidural analgesia during labor. Rev Esp Anestesiol Reanim 48:199-203, 2001. ACKNOWLEDGEMENTS Many thanks to Dr. James Cottreil and the SUNY-Downstate Medical Center Department of Anesthesiology for providing the time necessary for me to prepare this review. I would also like to acknowledge the invaluable assistance of the staff of the Morgan Library at Long Island College Hospital, and the Library of the New York Academy of Medicine. This review would be incomplete if I failed to recognize the many contributions of Dr. Ostheimer to this Society and to obstetric anesthesiology. Finally, special thanks to Dr. Patrick Gibson, himself a student of Dr. Ostheimer, and the person most responsible for my decision to devote my energies to obstetric anesthesia. 143 Scientific Program Sunday, May 5, 2002 6:30 am 7:00 - 8:00 am Registration Breakfast with the Experts (Limited Registration - By Ticket Only) Post-partum Analgesia - Alison J. MacArther, MD Continuous Spinal Analgesia - Craig M. Palmer, MD Labor Analgesia with Limited Staffing Resources - Richard N. Wissler, MD International OB Anesthesia Education Opportunites - Medge Owen, MD; Sukran Sahin, MD Fine Tuning Your CSE - Craig Leicht, MD, MPH Answering Big Questions in Obstetric Anesthesia Research - B. Scott Segal, MD; Richard M. Smiley, MD, PhD Ambulation after Labor Regional Anesthesia - Roshan Fernando, MBBS, FRCA Fetal Distress and Unable to Intubate. What Next? - Maya Suresh, MD The Morbidly Obese Preeclamptic Parturient - Sumedha Panchal, MD Post Partum Tubal Ligation - Brenda A. Bucklin, MD Billing - James P. McMichael, MD Billing - Edward R. Molinas-Lamas, MD, FACA Obstetrics and Family Medicine Issues in Labor and Delivery - Keith Johatsen, MD; Thomas Kastner, DM; Walter Franz, MD Is OB Anesthesia More Liable for Litigation than Other Subspecialties Mathew Kumar, MD, JD Post Durai Puncture Headache - Anil Soni, MD; Mukesh Sarna, MD Legislative Issues - Andrew P. Harris, Ml), MHS PCEA Should Always Be Used in Preference to Continuous Epidural Infusion Analgesia in Labor- MichaeFJ. Paech, FANZCA Anesthesia for Placenta Accerta - Alex E Pue, MD 8:15 - 9:15 am Fred Hehre Lecture David M. Dewan, MD 9:15 - 10:15 am Oral Presentations #2 Moderator: Cynthia A. Wong, MD 10:15 - 10:45 am Coffee Break 10:45 - 11:45 am Oral Presentations - Best Pa.er of the Meetin' Award Moderator/Judge: Michael J. Paech, FANZCA Judges: Sivam Ramanathan, MD; Edward T. Riley, MD; Scott Segal, MD 11.45 am - 12:00 n Best Paper of the Meeting Award / Adjournment Moderators: Joy L. Hawkins, MD; Gary M.S. Vasdev, MD Breakfast with the Experts (Limited Registration - By Ticket Ónly) 7:00 - 8:00 àm Post-p artum Analgesia - Alison J. MacArther, MD Continuous Spinal Analgesia - Craig M. Palmer, MD Labor Analgesia with Limited Staffing Resources - Richard N. Wissler, MD International OB Anesthesia Education Opportunites - Medge Owen, MD; Sukran Sahin, MD Fine Tuning Your CSE - Craig Leicht, MD, MPH Answering Big Questions in Obstetric Anesthesia Research - B. Scott Sega!, MD; Richard M. Smiley, MD, PhD Ambulation after Labor Regional Anesthesia - Roshan Fernando, MBBS, FRCA Fetal Distress and Unable to Intubate. What Next? - Maya Suresh, MD The Morbidly Obese Preeclamptic Parturient - Sumedha Panchal, MD Post Partum Tubal Ligation - Brenda A. Bucklin, MD Billing - James P. McMichael, MD Billing - Edward R. Molinas-Lamas, MD, FACA Obstetrics and Family Medicine Issues in Labor and Delivery - Keith Johansen, MD; Thomas Kastner, DM; Walter Franz, MD Is OB Anesthesia More Liable for Litigation than Other Subspecialties Mathew Kumar, MD, JD Post Durai Puncture Headache - Anil Soni, MD; Mukesh Sarna, MD Legislative Issues - Andrew P. Harris, MD, MHS PCEA Should Always Be Used in Preference to Continuous Epidural Infusion Analgesia in Labor- Michael J. Paech, FANZCA Anesthesia for Placenta Accerta - Alex F Pue, MD 145 The Morbidly Obese Preeclamptiò Patient Breakfast With The Experts 38 year old G! P0000 presents at 38 2/7 weeks presents for induction of labor. She is 5'5" and weighs 340 lbs. Her medical history is significant for morbid obesity, gestational diabetes, and mild preeclampsia (BP 150/92, 2 proteinuria). Laboratory studies include: Hgb 10.1; platelet count 142,000. She has a class IV airway. Medications include magnesium sulfate and oxytocin. What is your plan for labor analgesia? What is your plan for anesthesia if the patient requires a cesarean delivery? 146 Fred Hehre Lecture David M. Dewan, MD 8:15 -9:15 am Participant will learn about the changes in obstetric anesthesia practice over the last 25 years and how these changes have impacted the specialty. 147 Obstetric Anesthesia 1977 - 2002 A personal perspective - From Consilience to Victory OBJECTIVE: This lecture will provide an overview of the changes in obstetric anesthesia during the last 24 years Following this lecture the audience will gain an understanding of how these changes have impacted the specialty of obstetric anesthesia, academic anesthesia training, the patients and themselves. The period from 1977 to 2002 has been a remarkable era for obstetric anesthesia, both at my institution and nationally. We have made tremendous progress in the delivery of health care to the pregnant patient, making it more accessible, and of higher quality. We, as a specialty, have gained credibility. It has been two and a half decades of victory. A victory we won by, doing three things: 1) being there, 2) doing the right thing, and 3) being memorable. These three actions lead us to victory whether it is in our personal or professional lives or with patient care, resident education, or research. This is the path we must choose if we are to continue to move forward, for we have many challenges lying before us. When you compare the progress made at our institution during the last 25 years and the progress we have made nationally, the similarities are remarkable. I believe the tools we utilized at our institutiàn to achieve victory parallel those used by you to achieve national success. The tools we used are set forth in the book entitled Consilience: The Unity of Knowledge.' Consilience is the concept that for a given situation the best solution is one which is compatible with social science, ethics, biology, and environmental science. In other words, the best solution is best for all parties. Something that is good for science, but detrimental to society, is not a good solution. The outcome does not meet the consilience test. By doing three things, being there, doing the right thing, and being memorable, we have victory and we have a test for consilience, a victory within itself. Doing the right thing is a good solution and a victory. Let's look at being memorable. To do that means we have to understand what memory is. Good solutions create good memories for you, the obstetrician, and the patient. In the same, highly difficult to read, but incredibly insightful book, the author delves into what distinguishes recall and memory. In the authors perspective, recall is simply the recollection of facts. In contradistinction, memory has associated emotions. For example, reading about the World Trade Center 100 years from now will have a significantly different impact on the reader than for those who witnessed the event when it occurred. The history reader will recall facts, we will have memories which will be felt. 148 Let's transfer this to our specialty. In the practice of anesthesia, reading about a durai puncture clearly has a different impact than the memory of performing an unintentional durai puncture with its astounding intensity of emotion. As one of my colleagues once said, "The room sure gets hot." According to the Consilience concept, and documented by my own personal experience, attached emotions which accompany memory may allow the brain to prioritize previously experienced scenarios. For example, as a second-year anesthesia resident I was dispatched to the labor and delivery suite to assist a medical student in providing a generai anesthetic for cesarean section in an obese patient. My attending was four floors away. We proceeded with a rapid sequence induction; the medical student attempted laryngoscopy and informed me, "I don't see anything." My response was "try again"; he did - same result. I asked him to step aside, and I unsuccessfully attempted mask ventilation. As my heart rate increased I attempted laryngoscopy only to substantiate the medical students findings. Nothing recognizable was visible. Once more I attempted mask ventilation and heard the horrible sound behind me of a slowing heart rate. This patient was about to die! I inserted an oral airway to no avail and followed that with a nasal trumpet. Fortunately I was able to marginally ventilate the patient with this latter maneuver as she recovered from her succinylcholine. As she regained adequate respirations, my attending entered the room. The patient returned the subsequent day for cesarean section utilizing epidural analgesia. It is little wonder that when my brain replays scenarios regarding the management of obese patients, general anesthesia does not top my list. I do not recall this patient, I remember this patient. The emotions attached to this memory warn me about the hazards of general anesthesia in the obese pregnant patient. Memories, both positive and negative, help determine future behavior. Memories create victories and reinforce consilience. In the next hour I will discuss the achievements we made locally and you made nationally and share with you our experience at Wake Forest and I hope to provide a template for futuré actions. The template is one of being visible, doing the right thing, and creating memories, resulting in victòry. Let's go back to 1977, how our victory got started. In 1977 there were 3,326,632 live births in the United States.2 The cesarean section rate had increased dramatically in the preceding 10 years and was now l5.2%. Maternal mortality was at 14.3/100,000 deliveries,3 with anesthesia accounting for 4-6% of all maternai deaths.4'5 Obstetric anesthesia was a lonely stepchild as far as most anesthesia departments were concerned, with job advertisements promoting a benefit of employment as "no OB." The president of the Florida Society of Anesthesiologists once said, "Obstetric anesthesia, if it would just go away, we would all be happy.ó In 1969 an anesthesiologist was present at only, 12% of déliveries and CRNAs were present at only 25%. The remainder of coverage was provided by obstetricians and "others." As late as 1981 full-time anesthesia was present at only 21% of hospitals.8 Regional anesthesia was utilized for 50% of cesarean sections and epidural analgesia was utilized in only 16% of labors. We were not present! As a resident at Wake Forest, I witnessed first-hand the negative aspects of this level of care. While covering the ICU, we received a transfer from a nearby hospital of a woman who received a mask anesthetic, by a CRNA, for cesarean section that resulted in massive aspiration. It was a lethal event. I vividly recall a baby, a husband, and a dying mother. There was no consilience, no being there, no doing the right thing, no positive memory. . 149 It was in this environment that I entered, with Dr. Frank James, my Section Head and mentor, the world of obstetric anesthesia. In 1977, Winston-Salem, North Carolina, was a community of approximately 120,000 with three hospitals delivering infants. None of the hospitals were happy. The medical school had a marginal number of deliveries to provide adequate resident training. The community hospital, in part because it was new, received an inordinate (from their perspective) number of indigent patients, and the third hospital delivered insufficient numbers of patients to remain viable. In order to solve this problem, through the wisdom of Dr. Frank James, Section Head, and Dr. Frank Greis,; Chairman of the department of OB/GYN at Wake Forest (both Fred Hehre lecturers), the community leaders made the decision to consolidate obstetric services in the community hospital. The medical school would provide anesthesia coverage, a high-risk perinatal . service, and neonatology coverage. At that time, the physical plant we would use seemed large. We were allocated 13,831 square feet for the acute services which included 2 ORs, 2 cesarean section rooms, 3 delivery rooms, and 10 labor beds, of which half were double patient rooms. We were to provide coverage with five anesthesiologists, five CRNA's, three residents (one of whom was an obstetric resident), and one fellow. Our workload for the first year was 2,141 gynecology cases and 4,028 deliveries. The cesarean section rate during the first year was 18.1%. Considering the disrespect obstetric anesthesia had nationally at the time and the fact that the medical school was "invading" the community hospital, to say that our reception was "not warm" would be an understatement. The barriers we confronted were numerous: 1) fear of regional anesthesia (and its perceived impact on the progress of labor) by obstetricians, 2) perceived loss of control by the obstetricians and labor nurses, 3) the poorlyreceived concept of residents working on private patients, 4) a community hospital with an administration that didn't trust the "school" to the degree that they demanded the right to oversee department finances, 5) a visible and vocal lamaze community that was vigorously anti-epidural. I remember well walking in my first day, hardly finding my way to where I was supposed to be, knowing only a few people, and knowing full well that some of the others, "as yet unidentified," clearly opposed my presence. s. Fortunately, Dr. James had clearly outlined our mission, which was to provide excellent patient care, resident teaching, and research. However our more immediate goals were 1) to establish regional analgesia for labor, 2) reduce the use of general anesthesia for cesarean section, 3) provide safe regional anesthesia for cesarean section (remembering that left uterine displacement and volume preloading were new and not universally accepted advances even among anesthesia practitioners at that time), and 4) establish a working relationship with hospital administration. We would do all this by providing a 24-hour a day, in-house coverage, the first commitment by any anesthesia team in the community in that era to take in-house call. We would be visible - we would be present. One of the first steps to victory - being there. Our first year of experience was neither good nor bad but laid the foundation for the future. Thirty-two percent of vaginal deliveries utilized epidural analgesia, 36% received inhalation analgesia, and 32% received monitored anesthesia care (we attended vaginal deliveries). For cesarean section 5% received spinal anesthesia, 42% epidural anesthesia, and, in retrospect, an astounding 53% had general endotracheal anesthesia for the cesarean section. It is fair to emphasize endotracheal anesthesia considering the time. , 150 How would we accomplish our mission outlined by Dr. James in this environment? By being there, doing the right thing and being memorable, establishing consilience, establishing victory, one patient at a time. As it turns out the mode of delivery of anesthesia care was perfect for the mission. It would make us visible and present. It was up to us to do the right thing and be memorable. Let me take you back to a typical delivery. 4J.i patients were interviewed as soon as they arrived. This preanesthesia consultation was uniformly applied. If a patient opted for epidural analgesia, following catheter placement, blocks were initiated with 2% chioroprocaine and maintained with incremental injections of 0.25% bupivacaine. Every patient received a "sitting dose." Perineal analgesia was nearly always established in the labor room prior to transfer to the traditional delivery room. Patients not utilizing epidural analgesia were also transferred to the delivery room where they either received monitored anesthesia care or inhalation analgesia. Finally, following delivery patients were transferred to the PACU prior to discharge to the ward. This was an incredibly time-consuming venture for anesthesia, but had the unanticipated benefit of forced interaction with obstetricians, nurses, and most importantly the patients. So many times we were told by the patients that they knew us better than their obstetrician because by the time delivery occurred, we had spent more time with them than their obstetrician had. Memories were being created. We had to make them memorable and we had to do the right thing. For example if a patient has a unilateral block which you correct resulting in a comfortable patient, the memory and emotion created for you and the patient is one of satisfaction, trust and, for you, personal victory. However ignoring or missing a patchy block meant you might have the "opportunity" to be present for the exquisite pain of a mid-forceps delivery. Neither the patient, the obstetrician, nor the nurses are left with a feeling of trust regarding your services. Fortunately, the time-consuming venture of hourly redoses and forced patient interactions made us confront our failures rather than ignore them. Anesthesiologists, despite intellectually knowing that there is a minimum failure rate associated with epidural analgesia, find it difficult to revisit patients ¡n whom analgesia is poor, thus avoiding stress. How many times in this setting when called for a redose have you said, " Oh no, not her again!" It is, however, this patient who deserves attention. Confronting and dealing with our failures and observing the outcome allows us to prioritize memories. Prioritizing memories enables us to choose a course of action in the next similar scenario which may improve the outcome. Seen from this perspective, each of our encounters with family, administrators, colleagues, and patients is not only an opportunity for us to learn but, more importantly, an opportunity for us to create a positive memory for all concerned. It is the memories we create by our individual, ethical, interactions that predict future experiences and lead us to victory. Let's see how being there, doing the right thing, and creating memories applies to my personal and professional life experience. Each of us has personal, professional, patient care, and, for some of us, research triumphs. In each of these doing the right thing and being ethical will create victorious memories. I was asked the question, "What is your greatest personal triumph?" and after surprisingly little reflection I answered "Raising my daughter." I have had the opportunity to raise a daughter from age 12 to 24 as the sole parent, a task which was unexpected and intimidating. I remember vividly while traveling by car with her at age . 151 13 to New York State to see her grandfather for Christmas, when she suddenly made the following statement; "Dad, I don't have any memories." At that time I resolved to take personal responsibility for providing positive, ethical, and enriching memories. Certainly these included memorable vacations, but in retrospect memories were more about being there and doing the right thing. For example, when she was ill, thanks to my incredibly understanding colleagues, I was uniformly able to arrange to be with her. As part of her "treatment" I prepared mashed potatoes. For me this was parenting, for her it was creating an environment of warmth, trust, and safety. My mashed potatoes were attached to a memory. My daughter is now 24 and, to this day, mashed potatoes are still the best things that I can cook. Doing the right thing creates good memories and creates victories, sometimes in unanticipated ways. Arriving at Forsyth as ajunior faculty I had proven clinical skills. During my residency and two years in the Navy, however, administration was a blank area. When Dr. James left to become the Chairman of the Department of Anesthesiology and I assumed the position of Section Head, I was inexperienced and somewhat : administratively unprepared. Remember, this was a hostile environment. In fact when I assumed the Section Head position and asked to meet with the chief hospital administrator, he refused because he said he only met with chairmen. Within my first four months I had my first catastrophe. At that time the department of anesthesia had a separate professional contract and a billing contract, both with a 90-day lock in. Unless renegotiation was requested within 90 days of the expiration date, the contract was automatically renewed. I met with an administrator in advance of the deadline regarding the professional contract and made the fatal assumption that I was discussing both contracts. When the executive asked to delay discussions for a week, I made the second faulty assumption that this was done in good faith. After the week passed, the administration invoked automatic renewal of the contract because negotiations had not begun regarding Jth contracts. I had experienced my first journey into the area of administration and the memories created for me were distasteful. I now had a scenario and a memory with attached emotions, which if not replaced by better emotions, boded ill for the future. I needed a victory. Urgently I met with the administrator, and while trying to keep my composure, stated that his actions were not consistent with the character and values I expected from an honorable person and were not compatible with developing a long-term working relationship. To his credit he came to me, sincerely apologized, and in the next few years supported our Sections position in various arenas. I subsequently returned his good faith by opting for one year not to increase rates. It was the appropriate ethical decision at that time because it was good for us (at that time our cash flow was excellent), it was good for the hospital which was worried about its public image, and it was good for the patients. It was a memory that he did not forget and is a victory about doing the right thing. He subsequently became the leader of the entire Piedmont Novant Health system of which Forsyth hospital is only a part. We have become friends, respectful of each other, and because of the mutual trust our memories have evoked, over the lastlO years have operated on a handshake contract. With his approval I recently completely a two-year tenure as Chairman of the Surgical Services Counsel which oversees the workings of all surgical services in three community hospitals. Twenty-five years previously I was one of the enemies. Who would have thought this could happen? Doing the right thing does matter. I ask each of you now to think about what is your - . - 152 relationship with your hospital. What is your relationship with your administrators? Do you have one? Are you visible and present? Are you interacting? Are you taking each encounter as an opportunity to do the right and ethical thing and creating positive memories - establishing victories for both of you. Doing the right thing does matter. Sometimes you won't even remember the event, but they will. Patient care is simplistically no more than repetitive encounters with the public; encounters filled with memories and recall. As with your personal and professional life it can be filled with victories and defeats; Some victories will occur because of happenstance. As you recall, in our opening unit, many of the labor rooms were double patient rooms. This had unintended positive consequences for us. For exämple, I vividly remember interviewing a primiparous patient regarding her anesthetic options and being informed by her that she would not need anesthesia and did not need to speak with me. This felt like an immediate discounting of the need or use for my service. From the curtain behind me came the voice of the other patient, "I have already had a baby and I will listen to anything you have to say." Immediately there was a sense of validation of our work and value. I assure you, the patient who discounted our service also heard. If we had not been visible by interviewing jj patients, only those who requested our service, this would not have happened. There would be no memory of our section, of our role, and our importance. I felt victorious. In another circumstance I placed an epidural in a patient and, after removing her pain, walked over to the other patient and asked her what analgesia she wanted. She pointed to the patient I just anesthetized and said, 1 don't know what it is, but I want what she has." A "When Harry met Sally" moment. Visible and memorable. Happenstance created memories. We did not sell epidural analgesia to the public; being there and creating memories "sold" them. At other times being involved created the opportunity for victory. While attending a monitored anesthesia care delivery, a previously healthy gravida one experienced a pulmonary embolism. Because we were there and the equipment was there, the patient was intubated, ventilated, and ultimately had a good outcome. The nurses, obstetricians, patient, and husband all had a memory of that event. No longer were we viewed as an intrusion at delivery. At other times creating positive memories involves doing the right, albeit uncomfortable, thing. When obstetric anesthesia arrived at Forsyth, one of the private obstetricians, who was particularly anti-anesthesia, hated left uterine displacement perceiving that it interfered with surgery. One morning, at three A.M., the surgeon was preparing to do a cesarean section. He requested that left uterine displacement be removed. We refused and the obstetrician became irate and refused to operate. The obstetrician lost his composure and proceeded to call the Dean at home in an attempt to have left uterine displacement removed. He failed. Was the memory good for all parties? Ultimately, yes. The patient received the best anesthetic, we did the right thing, and the obstetrician learned that we had principles regarding patient care. The same obstetrician became one of our strongest advocates. Being present, accepting responsibility for outcomes, both good and bad, builds a history of trust (not blame) which creates the future. What I learned over 25 years was that doing the right thing, being present, creates learning experiences and memories. Are you visible on labor and delivery? Do your patients remember you? Is your relationship with your obstetricians a relationship of trust or blame? Are you celebrating your victories one by one? 153 One final vignette from my own personal experience. I was informed one day that a patient was requesting me to perform her anesthetic for cesarean section. I did not recognize the patient's name nor did she give a reason for requesting my service. I walked by the door to the interview room to see if I could recognize her and could not. I could not ever recall seeing this woman in my life. I entered the room and introduced myself and confirmed the fact that she was requesting me to perform her anesthetic. She said yes. I apologized for not remembering her and asked her why she was requesting me. She informed me that I had performed her last anesthetic. I said, "I assume all went well?" A frown crossed her face as she reflected upon her previous experience, obviously reliving it, and said, "It was horrible!" "The epidural did not work." "You attempted to repair it, and when they started the surgery I had great pain and you had to put me to sleep." I asked, feeling perplexed, why, considering this, she wanted me to be her attending again. Her answer was, "Because no matter how bad it got, I trusted you." A memory I hold now from seven years ago. These are the relationships we build one patient at a time: being there, being present and committed, and doing the right thing and being memorable - developing consilience with a unity of knowledge. Are you establishing relationships with your patients? Do your patients remember you helping them achieve their victory? Victory is also about resident education. Resident education involves a continuum from data acquisition to wisdom. Wisdom is the ability to transfer skills and expertise learned in one area to other areas. Progression through the learning process offers potential ethical conflicts between resident teaching and patient care. One of our obligations to residents is to create memories for them that will enable them in later years to subsequently prioritize scenarios when confronted with dilemmas, that is, to transfer knowledge and have wisdom. Residents, especially in early training, tend to focus on data acquisition, and, not infrequently, the data acquired conflict with a diagnosis. For example dermatomes identified utilizing a pin should not discount the patient's complaint, "I am more numb on one side." At our facility the attending anesthesiologist makes postoperative visits for Li deliveries. One realization,I have had over the years is that it is a rare patient who complains when a poor block is replaced by an effective one. In contrast, the number of patients who complained because a block is not repeated is remarkable. Not infrequently the patient will state, "I was numb on one side" while the chart documents symmetry. Distinguishing between an adequate and an inadequate block is a surprisingly difficult venture. It is hard for residents, like all of us, to accept a perceived failure. Accepting the fact that 5% of epidurals fail, despite perfect technique, is gaining expertise. Learning when to replace blocks is wisdom. How do we create memories for residents to teach wisdom without creating ethical conflict? If we see a patient with a marginal block during labor who is proceeding to cesarean section, our action or inaction will dictate outcome. Not infrequently, a resident will maintain the blockade is adequate and that the patient is simply experiencing "pressure." In this case we could proceed with the marginal block, allow the resident to experience first-hand the quality of the block he or she has just utilized and probably have the opportunity to do a general anesthetic. Alternatively, we may insist they repair the quality of block and an uneventful regional anesthetic will follow. In the second scenario the only emotion likely attached to this scenario is the irritation the resident has for the attending's forcing upon them the extra work of replacing' an "adequate block." In 154 the first scenario the patient experiences pain and suffers the risk of general anesthesia. At our institution, ethics are always for the patient, and we have to use alternative strategies to create memories for the residents. Some solutions may not be as effective as we anticipate. The department has a patient simulator which we hoped would offer an alternative strategy for acquiring skills. While this may be true, a recent paper by our. plTysicians revealed that simple skills, taught in the anesthesia simulator lab, were forgotten relatively quickly.9 It is my contention that the lack of emotions, thus the lack of sustained memory, attached with the simulator accounts for the short-term retention rate. We have to find the intermediate ground. I was recently informed about a patient who was having a cesarean section for failure to progress utilizing a preexisting epidural. The resident and I visited the patient where I was unimpressed by the quality of blockade, but the resident contended that it would workjust fine. Since this was a non-emergent circumstance, I offered the resident the chance to attempt to achieve anesthesia for cesarean section. Hoping to guide him to the correct decision, I obtained an Allis clamp and asked the house-staff to use it and check for anesthesia by pinching the abdomen prior to transport to the operating room. At transfer the resident called me, I asked him about the quality of blockade, and he informed me that the patient had passed the "Allis test." Following prep and drape the obstetrician clamped the abdomen which was accompanied by a groan of pain by the patient. I asked the resident did you use the Allis? He answered, "Yes, but not that hard." We repaired the epidural in the operating room by manipulating the catheter and the outcome was good. Other than inconvenience for the obstetrician all parties experienced benefit, the patient remained awake, the resident learned, and the surgeon was content with regional anesthesia. Three months later the resident returned bringing his own Allis clamp with him. As the years have proceeded and technology has replaced incremental injections and the time we spend with each patient has declined, the opportunities to create memories are lost for residents, patients, and ourselves We need to explore other ways to achieve victory Some of our victories have occurred in the area of research Successful research outcomes provide value for the anesthesiologist, patient, and the obstetrician, according to the theory of cons ilience. In our early years one of our anesthesiologist wanted to compare end tidal CO2 vs. arterial PCO2 at cesarean section. Capnògraphy was not as yet on the horizon for the anesthesia specialty. We obtained a laboratory device which measured end tidal CO2 and proceeded with the investigation Dunng one of the studies, we diagnosed esophageal intubation The endotracheal tube was replaced and the patient did well Suffice it to say we never removed the device from the cesarean section room and later capnography became a national standard of care A victory and a memory of doing the right thing and being there Our institution was one of the first institutions to investigate PCEA and publish results speculating about its benefits It appears all are winners, all are victorious Patients like PCEA because they retain some control, obstetricians like PCEA because, with proper coaching, less dense analgesia is present at delivery, and it is good for us because it dramatically decreases our workload, freeing us to provide analgesia to others who might otherwise not have received our service Similarly CSE because of its rapid onset has enabled us to reach even more patients The number of required physician encounters per patient by the anesthesia team has decreased dramatically over the years since the introduction of CSE and PCEA. I did some . 155 calculations regarding our current anesthesia delivery practice compared with 1977. It turns out that comparing these two practices resulted in 28 1 days saved in workload by not redosing when you compare CSEIPCEA vs the older technique of incremental redosing Research is good for patient care and an opportunity for victory So what has happened in our hospital after 25 years') We are currently redesigning and building a new LDR suite which will open in 2005 It will include 43,200 square feet for acute care services including 2 cesarean section rooms, 5 operating rooms, and 24 LDR's In 2001, the last year of available statistics we have had a significant growth in service. We had 6,539 deliveries which included 5,124 vaginal deliveries and i 4 1 5 cesarean sections for a cesarean section rate of 2 1 . i 6%- this, in addition to, our 3,000 gynecologic cases. For cesarean section 1 . i % received CSE, 56.3% spinal anesthesia, 35.5% epidural anesthesia, and 7. 1 % general anesthesia. For vaginal delivery, 50 5% received epidural analgesia and 29 4% received a combined spinal epidural analgesic A remarkable shift in the utilization of anesthetic techniques Regional anesthesia is the preferred anesthetic Contrast the following scenario regarding cesareañ section anesthesia with our early experience An obstetrician, at two a m was to perform an emergent cesarean section for a laboring patient with a breech presentation The patient was ASA I with a Class I airway, NPO, with no contraindications to general anesthesia The patient refused regional anesthesia When the obstetrician heard this he said, "This decision is not acceptable " He walked into the patient room and again the patient refused regional anesthesia The obstetrician said, "That is fine, and I will see if I can find you a new obstetrician " The patient relented, had a spinal anesthetic, loved it and all parties were happy We were victorious We are now uniformly accepted by administration, patients, and obstetricians Research is accepted as an important aspect of our care Nationally in 2000 there were 4,064,948 births IO The cesarean section rate was 22 9% in 2000,b0 and the maternal mortality rate was approximately 7 5/100,000 deliveries Anesthesia mortality has declined from 4 3/million births in 1 979- 1 98 1 to i 7/million in 1988-1990 12 By 1992 eighty-four percent of cesarean sections utilized regional anesthesia, and 37% of labor patients received epidural analgesia 13 Regional anesthesia is more prevalent and safer than ever before. We have succeeded and have had a quarter of a century of resounding victory What's left for us to do') General anesthesia mortality is 17 fold the rate for regional anesthesia.i2 As when I entered the specialty 25 years ago, aspiration añd airway problems remain We must not rest on our laurels but bring new skills from the operating room to labor and delivery for managing difficult airways The LMA, fiberoptic intubator, and the Fastrach LMA may be life saving Interestingly, when asked what our faculty thought were the greatest advances in the previous 25 years were, technology advances led the list Technology enabled us to make regional anesthesia available to more patients, and that has been one of our foci Now we must make sure that we are not distancing ourselves from the patients with this victory Technology can impose impediments for reliably assessing the adequacy of analgesia We aren't there Today when a patient requires additional analgesia she pushes a button. In many ways we have replaced ourselves with a round, fingertip operated device Despite the fact that the number of redoses predicts the failure rate of epidural anaigesia,i4 I have seen lockout creep The number of cc's allocated per hour either by continuous infusion or PCEA 156 bolus increases in an effort to save time by not having to personally db a redose. We are not confronting our failures as quickly or reliably as we did because we aren't there. Up to 10% of labor epidurals may not be used for cesarean section. How many of these are inadequate? What is the conversion rate to general anesthesia rate at your institution? According to the ASA Closed Claims Survey, aspects which differentiate obstetric anesthesia suits from non-obstetric suits are the greater number of claims for minor complaints and pain during anesthesia.'6 Is this an accident? Is it because we aren't there? Will one of these inadequate blocks lead to a catastrophe? Twenty-five years ago anesthesia personnel used the argument against placing endotracheal tubes for cesarean sections because aspiration had never happened to "them." Today I am concerned that the same attitude is developing regarding failed intubation subsequent to failed regional blockade associated with poor labor analgesia. The frequency of failed intubation and ventilation is low. Is it likely that a failed intubation and failed ventilation will occur in your career during a conversion from regional to general anesthesia? Probably not. Yet there were over four million deliveries in the United States in 2000 SO it is likely that this event did occur. Are we in danger of becoming Firestone? The individual utilizing Firestone tires was probably safe but the nation had a problem. Attention to detail is vital. Each of us should assess how often a labor analgesic is insufficient at our institution. We must do this by being visible and present. We have been victorious in the last 25 years personally and professionally. As you look around the room remember that this audience was started by a handful of people at a time when most anesthesia provider's viewed obstetric anesthesia as best if you didn't have to do it. What a great victory. It is now you, the audience, who are going to write the next 25 year history. I challenge you to be ethical by doing the right thing, being visible, and present, and creating for yourself and others, positive memories, one encounter at a time. You may not remember the encounter but certainly in the case of patients, they will remember you. Practice consilience, do what's best for all, and you will gain wisdom. Even better, you will be victorious. : 157 References i. Book :. Website Journal Journal ' . Journal Newsletter Journal Journal Presentation Journal ' Wilson EO, Consilience: The Unity of Knowledge. New York: Alfred A. Knopflnc., 1999. www.cdc.gov/faststarts/births.htm CDC, NVSR vol; 29, April 2001 Petitti DB, Cefalo RC, Shapiro S, Whalley P. In-hospital maternal mortality in the United States: Time trends and relation to method ofdelivery. Obstet Gynecol 1982, 59(1) 6-12. Kaunitz AM, Hughes JM, Grimes DA, et al. Causes of maternal mortality in the United States. Obstet Gynecol, May 1985, 65:(5) 605-612. McLean R, Mattison E, Cochrane N. Symposium/Maternal mortality study. Annual Report, 1970-1976. New York State Journal of Medicine, January 1979. Garrett LP. Florida Society of Anesthesiologists' Newsletter, February 1984. James FM. Availability of anesthesia personlie for obstetrics. Southern Medical Journal, August 1971, 64(8): 992-995. Gibbs CP, Krischer J, Peckham BM, et al. Obstetric Anesthesia: A national survey. Anesthesiology 1986, 65:298-306. Ford RPA, Saunders 1CM, Whelan R, Olympio MA. Wake Forest University Baptist Medical Center. Changes in technical management of esophageal intubation following simulation training. Given at the International Meeting on Medical Simulation. January 2002. Martin JA, Hamilton BE, Ventura MA. Births: Preliminary Data for 2000. Division of Vital Statistics. National Vital Statistics Reports, July 24, 2001,49(5)1-6. Publication Journal Journal Maternal Mortality - United States, 1982-1996. Hawkins JL, Koonin LM, Palmer SK, Gibbs CP. Anesthesiarelated deaths during obstetric delivery in the United States, 19791990. Anesthesiology 1997; 96:277-84. Hawkins JL, Gibbs CP, Orleans M, et al. Obstetric anesthesia work force survey, 1981 versus 1992. Anesthesiology 1 997;87: 135-43. Journal Journal Journal Coq CL, Ducot B, Benhamou D. Reports of Investigation. Risk factors of inadequate pain releif during epidural analgesia for labour and delivery. Can J Anaesth 1998; 45(8) 7 19-723. Garry M, Davies S. Failure of regional blockade for caesarean section. International Journal of Obstetric Anesthesia (2002) Il, 9-12. Chadwick HS, Posner K, Caplan RA, et al. A comparison of obstetric and nonobstetric anesthesia malpractice claims. Anesthesiology 1991, 74:242-249. 158 Oral Presentations #2 Moderator: Cynthia A. Wong, MD - 9:15-1O:l5am 02-1 CAN ROPIVACAINE AND LEVONUPIVACAINE BE USED AS AN INTRAVENOUS TEST DOSE FOR REGIONAL ANESTHESIA? Gautier, P.; OEven. M.D.; Hood, D.D. 02-2 THE VIRTUAL LARYNX: TEACHING INTUBATION SKILLS WITH FEWER PATIENTS Glassenberg, R. Glassenberg, S. 02-3 MATERNAL SURGERY DURING PREGNANCY: A POSTNATAL OUTCOME STUDY USING GUINEA PIGS de la Fuente, S.G.; Pibeiro, J.C.; Greene, R.R.; Eubanks, S.W.; Reynolds1, J.D. P-9 THE USE OF VIDEO TAPES OF SPECIFIC ERRORS AS AN ADJUNCT TO TEACH EPIDURAL TECHNIQUE J3irnbach, D.J.; Marenco, J.E.; Kerimoglu, B.; Stein, D.J.; Santos, A.C. All Abstracts listed on this page are in the Anesthesiology Supplement. 159 Oral Presentatioñs. I Best Paper of the Meeting Award Moderator/Judge: Michael J. Paech, FANZCA Judges: Sivam Ramanathan, MD; Edward T. Riley, MD; Scott Segal, MD 10:45 - 11:45 am 02-4 ALPHA-1 AGONISTS VS EPHEDRINE FOR C/S HYPOTENSION: A SYSTEMATIC REVIEW Halpern, S.; Chochinow, M, BP-2 IN VITRO INVESTIGATION: EPIDURAL CATHETER PENETRATION OF HUMAN DURA Angle, EJ.; Kronberg, J.; Thompson, D. BP-3 MORPHINE'S SITE OF ACTION FOR ANALGESIA TO UTERINE CERVICAL DISTENSION IS CENTRAL AND ANTAGONIZED BY ESTROGEN Risenach, J.C.; Sandner-Kiesling, A. 01-1 RANDOMIZED TRIAL OF NEURAXIALVS. SYSTEMIC ANALGESIA FOR LATENT PHASE LABOR: EFFECT ON INCIDENCE OF CESAREAN DELIVERY - \Vong, C.A.; Scavone, B.M.; Sullivan, J.T.; Marcus, R.L.; Sherwani, S.S.; Strauss-Hoder, 'r.P.; Yaghmour, E.A.; McCarthy, R.J. All Abstracts on this page are located in the Anesthesiology Supplement. 160 SOAP 2002 Annual Meeting Exhibit Hall Hours Thursday, May 2, 2002 Exhibitors 7:00 am - 2:30 pm The Sociqy for Obstetric Änesthesià & Perinatology lye/comes and thanks all representatives of industrj for their support of this meeting, and for providing education through their exhibits. 7:00-7:45 ara Breakfast w! Exhibitors 9:45-10:15 am Coffee Break w/Exhibitors 12:15-1:15 pm Lunch w! Exhibitors 2:15-2:3Opm BreakwlExhibitors Friday, May 3, 2002 7:00 - 10:30 am 7:00-8:00 am Breakfast w/Exhibitors 10:10-10:30 am Coffee Break w/Exhibitors Saturday, May 4, 2002 7:00 - 10:30 am A list of 2002 exhibItors follows 7:00-8:00 am Breakfast w!Exhibitors 9:30-10:00 am Coffee Breakw!Exhibitors 3:00-3:30 pm BreakwfExhibitors BOOTH # COMJANy NAME 21 Arrow International Arrow International develops, manufactures, and markets a broad range of clinically advanced disposable catheters and related products. e product offering includes central venous catheters, hemodialysis catheters, P1CC catheters, wire-reinforced "Super Arrow-Flex" introducers, as well as Arrow's unique AltROWgard® infection protection surface treatment technology. AstraZeneca AstraZeneca produces a wide range of products that make significant contributions to treatment options and patient care. The company has one of the world's leading portfolios to treat cancer and gastrointestinal disorders, in addition to the areas of anesthesia, pain Iflanagement, cardiovascular disease, respiratory and central nervous system disorders. You are invited to visit our exhibit to speak with a representative about our products. 13. Braun Medical Inc. B. Braun Medical offers a full range of regional anesthesia products featuring the Perifix SoftTip and the Perifix® FX springwound epidural catheters, Pencan® pencil point spinal needles, Espocan® combined spinal/epidural sets with Docking System, Stirnuplex® insulated nerve block needles, Contiplex® insulated Tuohy needle and the new Stimuplex® HNSI I peripheral nerve stimulator. 13D Medical Systems Pull line of spinal, epidural, combined spinal epidural and nerve block procedure trays and accessories. GlaxoSmjthKline GlaxoSmithKline is one of the world's leading research-based pharmaceutical companies with a powerful combination of skills to visit our exhibit to learn more about our products and programs. We are dedicated to discover and deliver innovative medicines. Please improving patient care and access to medicines. 10 25 26 Imgyn Medical Technologies arterial Itnagyn Medical Technologies is developing a unique reflectance pulse oximeter technology [PRO (subscript 2)] that measures wider saturation range with less sensitivity to hair, mounted sensor. The system performs over a Oxygen saturation via a surface of the Pigmentation and other factors than other oximetry systems currently on the market. The reflectance approach overcomes many Imagyn has successby measuring reflected light rather than transmitted light. ositionaI limitations of current transmission systems fully demonstrated its PRO2 performance 30 in the most difficult of applications by measuring fetal oxygen saturation intrapartum through the intact amniotic membrane and fetal hair. PRO2 is currently an investigational device. 161 SOAP 2002 Annual Meeting Corporate Supporters ii B. Braun Fun Run Baxter Sunset Sailing Lippincott, Williams & Wilkins Lippincott Williams & Wilkins is a global publisher of medical, nursing and allied health information resources in books, journals, 15 newsletters, and electronic media formats. Please stop by booth # 15 to review one of the many titles that we have available for display. PNA Medical Systems PNA Medical Systems is presenting advanced Regional Anesthesia and Plexus Anesthesia systems, the Sprotte Spinal Needle, Insulated Sprotte and Short Bevel Unipolar needles. "MultiStim Plex" for percutaneous nerve identification and "MultiStim VARIO" for percutaneous nerve identification as well as measuring depth of neuro-muscular blocks. Also being displayed, a full spectrum of innovative Continuous Plexus Anesthesia kits. Portex, Inc. Portex Inc. presents a full line of pain management products featuring continuous epidural, single shot epidural, CSE and spinal products. With the recent Portex aquisition of the Abbott pain management line of kits and trays, Portex now offers an even wider selection of pain management options in both standard and custom configurations. Purdue Pharma, LP I Stamford Forum i6 22, 29 Stanford, CT 06901 (203) 588-5000 Rusch, Inc. 12 Rusch is a worldwide leader in the manufacture of disposable and airway management devices. Since 1885, our high standards of quality and continuous innovation have provided anesthesiologists with Endotracheal and Endobronchial tubes, Laryngoscopes, Oral and Nasal airways and specialty devices in a complete range of sizes. Sorenson Medical, Inc. Microject® Pumps represent a low cost alternative to other ambulatory pumps. They are electronically programmable, accurate, and simple to operate. Microject Pumps are about the size and weight of a TV remote control and require only two AA batteries. For more information, contact Sorenson Medical at 877-352-1888. W.B. Saunders/Mosby/Churchifi 19 WB. SAUNDERS, MOSBY, and CHURCHILL LIVINGSTONE, a combined premier worldwide medical and health science publishing company, under the umbrella of ELSEVIER SCIENCE, HEALTH SCIENCE DIVISION, presentsour latest titles in ANESTHESIA. Come visit our booth and browse through our complete selection of publications induding books, periodicals, and software. 162 NOTES 163 NOTES 164 NOTES 165 NOTES NOTES NOTES 168 I / f N N Prepared by: BLUE CHIP EXPO, INC (843) 681-4545 11111111111 r MARRIOTT BEACH & GOLF RESORT HILTON HEAD ISLAND, Sc I I I I I I I I I I I I I Registration 20 11 10 '\/ \/ 30 19 12 5 21 22 29 16 15 25 26 6 Food & Beverage 11111 I i I 15 - 8' Deep by 10' wide booths 46 -4' X 8' Double-Sided Poster Boards 17 -4' X 8' Single-Sided Poster Boards 1II I Society for Obstetric Anesthesia and Perinatology Future Meetings 35th May 14-17, 2003 Annual Meeting Point Hilton at Squaw Peak Phoenix, AZ 36th May 12-16, 2004 Annual Meeting Sanibel Harbor Resort and Spa Ft. Myers, FL Society for Obstetric Anesthesia and Perinatology P.O. Box 11086 / 2209 Dickens Road Richmond, VA 23230-1086 Phone (804) 282-5051 / Fax (804) 282-0090 Email: [email protected] wwwsoap.org Name:
