Analgesia For Delivery Research Articles

Programmed intermittent epidural bolus for post-cesarean delivery analgesia: a randomized controlled double-blind trial.

The aim of this study was to assess the efficacy of programmed intermittent epidural boluses (PIEB) in postoperative pain management compared with continuous epidural infusion (CEI) after cesarean delivery. A total of 58 participants were randomly allocated to receive PIEB (3mL bolus every 60min) or CEI (3mL/h) for postoperative analgesia after undergoing elective cesarean section under combined spinal-epidural anesthesia. Both groups had the same epidural solution containing ropivacaine 0.2% plus fentanyl 2µg/mL. The primary outcome was postoperative pain score at rest and mobilization at 6, 12, 24, and 48h. The secondary outcomes were the total amount of ropivacaine used in the 48h study period and the time to the first PCEA bolus. Data from 58 women were analyzed. There was a reduction in pain verbal numerical rating scores at 12h in patients receiving PIEB compared with CEI at rest [2 (1.75-3) vs. 3 (2-4), p = 0.011]; and on movement [4 (3-5) vs. 5 (4-6), p = 0.038]. No differences were found in pain scores at any other time-point up to 48h. Total ropivacaine consumption at 48h was less in the PIEB group compared with the CEI group [316mg (304-321) vs. 336mg (319-344), p = 0.001]. Postoperative epidural analgesia for patients who underwent cesarean delivery with PIEB compared with CEI resulted in less ropivacaine usage while providing comparable analgesia.

An injectable mesoporous silica-based analgesic delivery system prolongs the duration of sciatic nerve block in mice with minimal toxicity

The major limitation of traditional local anesthetics is the finite duration of a single injection. The present study developed two kinds of novel injectable anesthetic nanocomposites based on mesoporous silica, and evaluated their long-lasting analgesic effect and biosafety. The nanoparticulate carriers, mesoporous silica nanoparticles (MSNs) and mesoporous silica-coated gold nanorods (GNR@MSN), were firstly constructed using the oil-water biphase reaction approach and then ropivacaine (RPC), a local anesthetic, was loaded into the mesoporous carriers by vacuum suction. Transmission electron microscopic images showed the well-ordered mesoporous structure for drug loading. RPC-loaded MSNs and RPC-loaded GNR@MSN exhibited a sustained-release pattern in vitro, and the latter also showed a controlled-release manner triggered by near-infrared (NIR) irradiation. RPC-loaded MSNs and RPC-loaded GNR@MSN caused an initial sensory blockade in mice that lasted for 6 h, almost 2.5 folds of that from free RPC solution. Furthermore, upon NIR irradiation, the latter induced three additional periods of the blockade. Neither of them showed motor nerve block, which may be due to the sustained release manner. The low myotoxicity and low neurotoxicity of the two nanocomposites were presented both in vitro and in vivo. These results demonstrate the potential of the mesoporous silica-based analgesic nanocomposites in effectively controlling postoperative pain, maybe RPC-loaded MSNs for moderate pain and RPC-loaded GNR@MSN for severe pain. Statement of significanceAdequate postoperative analgesia helps early functional exercise after surgery and accelerates rapid recovery, while uncontrolled postoperative pain probably develops chronic post-surgical pain that impacts the life quality of patients for a long time. However, postoperative pain management is still a challenge. The current treatment drugs are always accompanied by some side effects due to their systemic effect. Opioids have risks of addiction and respiratory depression, and nonsteroidal anti-inflammatory drugs can lead to gastrointestinal reaction. Therefore, the long-lasting local anesthetic formulation with good biocompatibility is the most promising solution to manage post-surgical pain. The present study developed novel injectable anesthetic nanocomposites based on mesoporous silica, providing long-lasting pain relief in mice with minimal toxicity.

A Quality Initiative to Decrease Time Until Analgesic for Fracture-associated Pain in the Pediatric Emergency Department.

Introduction:Long bone fractures are a common cause of pain in the pediatric emergency department (PED), and ensuring timely delivery of analgesic medications is essential for these children. We aimed to decrease the median time to the first dose of analgesic for long bone fracture–associated pain in our PED to 36 minutes or less by July 1, 2015.Methods:A series of 4 initiatives were implemented in successive “plan, do, study, act” rapid cycles. Initiatives consisted of educational interventions for staff regarding Emergency Severity Index procedures for triaging pain, transition to in-room triage, enhanced communication about quality goals using a “quality board,” and ongoing staff educational sessions on outlier cases as well as biases and barriers to quality.Results:We implemented the initiatives from April through July of 2015. The monthly median time to analgesic delivery for long bone fracture–associated pain in the PED decreased from 72 minutes in April to 33.5 minutes in July of 2015. For 12 months following the first intervention, the average monthly median time to the first analgesic dose was 48.5 versus 66.3 minutes for the prior 12 months.Conclusions:A series of 4 interventions led to a decrease in the median time to the first dose of analgesic for long bone fracture–associated pain in the PED.

Safety and effectiveness of parent- or nurse-controlled analgesia in neonates: a systematic review.

The aim of this systematic review was to determine the safety and effectiveness of parent- or nurse-controlled analgesia on neonatal patient outcomes. More specifically, the objective was to determine the effect of parent- or nurse-controlled analgesia on neonatal pain scores, analgesic use, and incidence of iatrogenic withdrawal syndrome, as well as any opioid-associated adverse events. Despite recent innovations in neonatology leading to significant improvements in short- and long-term outcomes for newborns requiring intensive care, optimal management of pain and distress remains a challenge for the multidisciplinary treatment team. The inability of neonates to communicate pain easily, inconsistent practice among health professionals, insufficient analgesic prescriptions, and delays in medical reviews all impact effective pain management. Exploring the effect of parent- or nurse-controlled analgesia may identify a modality that negates these concerns and improves the pharmacological management of pain in newborns. This review considered experimental and observational studies evaluating the safety and effectiveness of parent- or nurse-controlled analgesia that included babies born at 23 weeks' gestation to four weeks post-term. The interventions considered for inclusion were any type of analgesia delivered by an infusion pump that allowed bolus dosing or a continuous analgesic infusion with bolus dosing as required. Studies using algorithms and protocols to guide timing and dosage were eligible for inclusion. Comparators included the standard management of pain for neonates in the newborn intensive care unit. A modification to the a priori protocol was made to include all neonates nursed outside of a neonatal intensive care unit to ensure all studies that examined the use of parent- or nurse-controlled analgesia in the neonatal population were included in the review. An extensive search of six major databases was conducted (CINAHL, Cochrane Library, Embase, PubMed, PsycINFO, and Web of Science). Studies published from 1997 to 2020 in English were considered for inclusion in this review. Databases searched for unpublished studies included MedNar and ProQuest Dissertations and Theses. Fourteen studies were included in this review: two randomized controlled trials, six quasi-experimental studies, one case-control study, and five case series. There was considerable heterogeneity in the interventions and study outcome measures within the studies, resulting in an inability to statistically pool results. The small sample sizes and inability to distinguish data specific to neonates in six of the studies resulted in low quality of evidence for the safety and effectiveness of parent- or nurse-controlled analgesia in neonates. However, studies reporting neonatal data demonstrated low pain scores and a trend in reduced opioid consumption when parent- or nurse-controlled analgesia was used. The use of parent- or nurse-controlled analgesia in the neonatal population has shown some effect in reducing the amount of opioid analgesia required without compromising pain relief or increasing the risk of adverse events. Due to the paucity of evidence available, certainty of the results is compromised; therefore, larger trials exploring the use of parent- or nurse-controlled analgesia in neonates and the development of nurse-led models for analgesia delivery are needed. PROSPERO CRD42018114382.

Association between epidural analgesia and indications for intrapartum caesarean delivery in group 1 of the 10-group classification system at a tertiary maternity hospital, Shanghai, China: a retrospective cohort study

BackgroundIn this study, we aimed to determine whether epidural analgesia affects the indications for intrapartum caesarean delivery, such as foetal distress, dystocia, or maternal request, in nulliparous term women with spontaneous labour (Group 1 in the 10-Group Classification System).MethodsWe conducted a retrospective cohort study and collected data from the electronic medical records of deliveries performed in our institution between 1 January 2017 and 30 June 2017. Women conforming to the criterion of Group 1 according to the 10-Group Classification System were enrolled. We compared labour outcomes between women with and without epidural analgesia and analysed the association between epidural analgesia and indications for caesarean by using multivariate logistic regression analysis.ResultsA total of 3212 women met the inclusion criteria, and 2876 were enrolled in the final analyses. Women who received epidural analgesia had a significantly lower intrapartum caesarean delivery rate (16.0% vs. 26.7%, P < 0.001), higher rates of amniotomy (53.4% vs. 42.3%, P < 0.001) and oxytocin augmentation (79.5% vs. 67.0%, P < 0.001), and a higher incidence of intrapartum fever (≥38 °C) (23.3% vs. 8.5%, P < 0.001) than those who did not receive epidural analgesia. There were no significant differences between the groups for most indications, except a lower probability of maternal request for caesarean delivery (3.9% vs. 10.5%, P < 0.001) observed in women who received epidural analgesia than in those who did not. Epidural analgesia was revealed to be associated with a decreased risk of maternal request for caesarean delivery (adjusted odds ratio [aOR], 0.30; 95% confidence interval [CI], 0.22–0.42; P < 0.001); however, oxytocin augmentation was related to an increased risk of maternal request (aOR, 2.34; 95%CI, 1.47–3.75; P < 0.001). Regarding the reasons for the maternal request for caesarean delivery, significantly fewer women complained of pain (0.5% vs. 4.6%, P < 0.001) or had no labour progress (1.3% vs. 3.6%, P < 0.001) among those who received analgesia.ConclusionsAmong the women in Group 1, epidural analgesia was associated with a lower intrapartum caesarean delivery rate, which may be explained by a reduction in the risk of maternal request for an intrapartum caesarean delivery.

Comparison of the analgesic effects of two quadratus lumborum blocks (QLBs), QLB type II vs QLB type III, in caesarean delivery: A randomised study.

Quadratus lumborum blocks (QLBs) are relatively novel regional anaesthesia techniques, and the efficacy of all three types of QLB for postoperative analgesia in caesarean delivery (CD) has been demonstrated in separate studies. The aim of the present study is to compare the analgesic efficacy of the QLB-II and QLB-III blocks performed at the end of surgery in patients undergoing spinal anaesthesia for CD. We conducted a comparative, blinded, prospective, randomised and efficiency study. A total of 80 patients scheduled for elective CD under spinal anaesthesia were randomly allocated to receive either bilateral ultrasound-guided QLB-II or QLB-III block in a 1:1 ratio. The primary outcome was opioid consumption administered by a patient-controlled analgesia in the first 24hours postoperatively. The secondary outcome of the study was pain intensity. Also, the time of first opioid requirement and the presence of nausea and vomiting were recorded. Morphine consumption was statistically significantly lower in the QLB-III group when compared with the QLB-II group at the 3rd, 6th, 12th and 24thhours (P<.001, P<.001, P=.004, and P=.015, respectively). The QLB-III group showed significantly lower pain scores at rest at the 1st, 3rd, 6th, 9th and 24thhours after surgery (P<.001, P<.001, P<.001, P=.007 and P<.001, respectively). The QLB-III group also showed significantly lower pain score on movement at all measurement times (P<.001). The analgesic efficacy of QLB-III was superior to QLB-II in patients who had undergone CD under spinal anaesthesia without use of intrathecal opioids and nonsteroidal anti-inflammatory drugs.

On anesthesia and race

Racial tensions continue to ignite social unrest in the United States. Structural racism is increasingly recognized as a public health issue. It is therefore necessary to continue addressing the interaction of race and medicine, including anesthesiology. While many may overlook the impact that racial discrimination has had on the development of anesthesiology, understanding pain through a racialized lens has always been entwined with this medical specialty since its origins. Considering the first public demonstration of ether anesthesia in 1846 occurred 15 years before the American Civil War (1861-1865), it is naïve to pretend that anesthesia has been insulated from racial prejudice.We increasingly recognize the effects of variables, such as housing and education, which are important as social determinants of health. Across ethnic and racial lines, statistically significant differences persist in pain assessment and analgesia delivery. To understand these irregularities without relying on unsupported theories, we must challenge our current understanding of race in medicine. By reviewing the history of anesthesia through a racialized lens, we may better explore our biases and develop strategies towards racially equitable care. This article focuses on anesthesia's roots on the plantation in the American South, the medical perpetuation of racial disparities, and the challenges we face in healthcare today.

Antenatal follow-up, anesthesia management and perinatal outcomes in pregnancy with renal transplant

Objective:Due to the recent increase in the successful pregnancies after renal transplant, the number of renal transplant recipients having vaginal or cesarean delivery possibly associated with high maternal, fetal and/or neonatal risk requiring team approach increased. We aimed to evaluate antenatal follow-up, perinatal outcomes, and anesthesia management in pregnancies with renal transplantation and to compare them with the current literature.Materials and Methods:After ethics committee approval, renal transplant recipients who gave birth in our hospital between January 2010 and December 2019 were documented in this retrospective study. Demographic characteristics, comorbidities, antenatal follow-up, anesthesia management, and maternal, fetal, and neonatal outcomes were presented.Results:A total of 20 pregnant women who underwent renal transplant were identified. The mean age of the parturients was 31±5 years. The median interval from transplantation to conception was 8.15±4.8 years. Antenatal mean serum creatinine level and proteinuria were 1.48±1.39 mg/dL and 1.397±1.316 mg/dL, respectively. No allograft rejection was recorded. Comorbidities including hypertension (n=12), preeclampsia (n=6), and preterm delivery (n=10) were noted. The median gestational age was 35±3 weeks and the median newborn weight was 2.520±832 gram. There was one abortion, two pregnancy terminations, and 17 deliveries (3 vaginal and 14 cesareans). Cesarean sections (11/14; 78.6%) were mostly performed under spinal block and general anesthesia was performed in three (21.4%) women. Epidural analgesia for vaginal delivery was recorded in one parturient.Conclusion:Despite the presence of preterm delivery and comorbidities, antenatal/peripartum follow-up and analgesia/anesthesia management of renal transplant recipients revealed good perinatal outcomes.

P.42 Quality of recovery following intrathecal morphine versus diamorphine for elective caesarean delivery at a tertiary centre

Introduction: The effectiveness of intrathecal (IT) morphine for post caesarean delivery (CD) analgesia is well established internationally as part of a multimodal analgesic regimen. [1] Sutton CD, Carvalho B. Optimal pain management after cesarean delivery. Anesthesiol Clin 2017;35:107–24. Google Scholar UK obstetric anaesthetic practice has favoured IT diamorphine. Our institution adopted IT morphine and fentanyl (morphine+fentanyl) as an adjuvant to hyperbaric bupivacaine for CD from 2019 due to supply issues. Given differences in lipid solubility of the two drugs, IT morphine could have prolonged effects, resulting in superior analgesia at 24 h post CD, but at the risk of worse side effects (nausea, pruritus). Given the multidimensional nature of post-CD recovery, IT morphine could result in poorer overall quality of recovery.

P.69 Evaluating the introduction of intrathecal morphine for caesarean section

Introduction: Due to ongoing supply issues with diamorphine,and, given the demonstrated safety profile of using central neuraxial morphine in obstetric patients, [1] Crowgey TR, Dominguez JE, Peterson-Layne C, et al. A retrospective assessment of the incidence of respiratory depression after neuraxial morphine administration for postcesarean delivery analgesia. Anesth Analg. 2013; 117:1368-70. Google Scholar it was decided to replace diamorphine with preservative free morphine for procedures in labour theatre. We evaluated whether this change had impacted on patients undergoing caesarean section, particularly with respect to analgesia requirements and occurrence of side effects.

Emulgel-Novel Trend in Topical Drug Delivery System - Review Article

Aim: The main aim of this present article on emulgels is to compile the recent literatures with special focus on topical delivery of novel emulgels. Back ground: Topical drug delivery system is defined as a direct effect of drug containing medication to the skin to get the effect of drug or to cure disorders. Major disadvantage of conventional gel is that the delivery of hydrophobic drug. This can be overcome by emulgel. Emulgel systems are now a day’s mostly depends on the pharmaceutical scientists due to their substantial potential and act as drug delivery vehicle by adding a broad range of drug molecules. Results: Emulgels are mostly used for the delivery of analgesics, anti-inflammatory, anti-fungal, anti-acne drugs and various cosmetic formulations. So to know the potential of emulgel as delivery vehicles, this review gives summary of the ideal properties, formulation and characterization of emulgel.

Labour epidurals in Gauteng Province, South Africa

Background. Inadequately controlled labour pain is associated with numerous deleterious physiological and psychological effects. Epidural labour analgesia is accepted as the gold standard. Objectives. To establish the frequency of labour epidural analgesia for vaginal and caesarean section delivery in Gauteng Province (GP) private and public hospitals. Methods. GP maternity hospitals belonging to the three largest private hospital groups, and public academic, tertiary, regional and district maternity hospitals, were approached for inclusion in the study. A total of 24/47 private hospitals and 21/26 public hospitals agreed to participate in the present study and data from these hospitals were included in the data analysis. This was a retrospective study, and the delivery statistics and registers for 2015 were examined from all participating hospitals. Consecutive convenience sampling was applied. Results. A total of 3 560 labour epidurals were placed in the 45 participating hospitals in GP in 2015. About two-thirds (62%; n =2 208) of these labour epidurals were placed in the private sector. The median (interquartile range (IQR)) annual epidural frequency for all participating private hospitals was 6% (1.37 - 8.42). Only two public hospitals in GP were able to offer labour epidural services in 2015 and the annual proportion of deliveries with epidural placement was 4.1%. Both hospitals were academic hospitals affiliated with a single university. Conclusion. Similar to other developing countries, the labour epidural rates in GP hospitals were well below international labour epidural rates in 2015. This lack of service provision may be compromising patient care as well as the training of healthcare professionals.

Sustained release ketamine-loaded porous silicon-PLGA microparticles prepared by an optimized supercritical CO2 process.

Ketamine in sub-anaesthetic doses has analgesic properties and an opioid-sparing effect. Intrathecal (i.t.) delivery of analgesics bypasses systemic metabolism and delivers the analgesic agent adjacent to the target receptors in the spinal cord and so small doses are required to achieve effective pain relief. In order to relieve intractable cancer-related pain, sustained-release ketamine formulations are required in combination with a strong opioid because frequent i.t. injection is not practical. In this study, ketamine or ketamine-loaded porous silicon (pSi) were encapsulated into poly(lactic-co-glycolic acid) (PLGA) microparticles by a novel supercritical carbon dioxide (scCO2) method, thereby avoiding the use of organic solvent. Multiple parameters including theoretical drug loading (DL), presence of pSi, size of scCO2 vessel, PLGA type, and use of co-solvent were investigated with a view to obtaining high DL and a sustained-release for an extended period. The most important finding was that the use of a large scCO2 vessel (60mL) resulted in a much higher encapsulation efficiency (EE) compared with a small vessel (12mL). In addition, pre-loading ketamine into pSi slightly improved the level of drug incorporation (i.e. EE and DL). Although the in vitro release was mainly affected by the drug payload, the use of the large scCO2 vessel reduced the burst release and extended the release period for PLGA microparticles with 10% or 20% ketamine loading. Together, our findings provide valuable information for optimization of drug delivery systems prepared with the aid of scCO2.

Evaluation of the PRADO home discharge support programme for orthopaedic surgery in 2018

BackgroundBetween 2015 and 2017, nearly 80,000 hospital stays in orthopaedic surgery were entered into a home discharge support programme (PRADO) offered by the statutory health insurance system. The objective of this study was to assess the impact of the PRADO programme on enrolled stays in orthopaedic surgery over the last three years. HypothesisThe home discharge support programme used in orthopaedic surgery shortens hospital stays and decreases the rate of readmission within 30days. Material and methodsThe home discharge support programme PRADO was evaluated both quantitatively and qualitatively. The quantitative study used a multicentre retrospective cohort design with matching to controls identified in the national healthcare database. All hospital stays entered into the home discharge support programme between January 2015 and December 2017 were enrolled in the study. Follow-up was 6months after discharge. The main outcome measure was the rate of readmission within 30days after discharge. The secondary outcome measures were emergency department visits, admission to rehabilitation, mean stay duration, visits to recommended healthcare professionals, medication consumption, and total healthcare expenditure at 6months. The statistical analysis used the per protocol approach. The qualitative study involved semi-structured individual and group interviews designed to investigate adhesion of the professionals and their perceptions of programme implementation, funding, and costs. ResultsOf 82,202 stays in the programme, 71,761 (87%) were matched and included in the analysis. Characteristics were comparable between the programme stays and the control stays. The programme stays had a significant reduction in the number of all-cause ambulatory and non-ambulatory readmissions (4.5% vs. 4.9%, p<0.0001 and 3.9% vs. 4.2%, p=0.0009, respectively). Emergency department visits and rehabilitation admissions within 30days were significantly less common in the programme group than in the control group (mean values, 2.1% vs. 2.3%, p=0.01 and 3.4% vs. 8.4%, p≤0.0001, respectively). Mean stay length was not significantly different between the two groups. Visits to recommended healthcare professionals occurred significantly more often and earlier in the programme group. The delivery of analgesics and heparin was significantly higher in the programme group, whereas no difference occurred in the delivery of antibiotics. Mean total health expenditures at 6months were lower in the programme group (2248 € vs. 2485 €). The success of the PRADO programme was dependent on leadership from the medical staff within the institution and on assistance provided by the hospital throughout its implementation. The criteria for patient eligibility to the programme were not routinely shared by or clear to the healthcare staff. DiscussionThe PRADO programme effectively improves the care of orthopaedic surgery patients and raises the issue of whether some admissions to rehabilitation may be unnecessary. Level of evidenceIII; comparative retrospective study.

Regional Anesthesia Abdominal Blocks and Local Infiltration After Cesarean Delivery: Review of Current Evidence.

In this review, we discuss surgical infiltration and various abdominal wall blocks, including transversus abdominis plane (TAP) block and quadratus lumborum blocks, and review the literature on the evidence behind these approaches and analgesia for cesarean delivery (CD). Adequate pain management in the parturient following CD is important to facilitate early ambulation and neonatal care while also improving patient satisfaction and decreasing hospital length of stay. Neuraxial opioids have been a mainstay for postoperative analgesia; however, this option may not be available for patients undergoing emergency CD and have contraindications to neuraxial approaches, refusing an epidural or spinal, or with technical difficulties for neuraxial placement. In such cases, alternative options include a fascial plane block or surgical wound infiltration. The use of regional blocks or surgical wound infiltration is especially recommended in the parturient who does not receive neuraxial opioids for CD. Adequate postoperative analgesia following CD is an important component of the overall care of the parturient as it helps facilitate earlymobilization and improve patient satisfaction. In conclusion, the use of abdominal fascial plane blocks or surgical wound infiltration is recommended in theparturient who does not receive neuraxial opioids for CD.

Patient-Controlled Analgesia

Patient-controlled analgesia (PCA) is a method for controlling pain in which a patient is able to self-administer pain medications via activation of a mechanical distribution system. The key element of PCA is that the patient is in control of the analgesia. Respiratory depression is preceded by sedation, and a sedated patient is unable or unlikely to push the PCA button. The pump can also be programmed to have a continuous infusion rate, which is administered to the patient regardless of whether the patient activates a dose. Basal rates bypass the safety mechanism of patient control and can place the patient at higher risk for respiratory depression and sedation. Initiation of a PCA is often most appropriate in patients requiring frequent as-needed dosing of medications or when such dosing is anticipated. Patients’ acceptance of the technique is high, related in part to a sense of control over their own pain relief, a reduction in the delay for the receipt of pain medications, not receiving injections, and not having to interrupt or to bother nurses. This review contains 2 tables and 20 references. Key words: analgesic delivery systems, morphine metabolism, multimodal pain management, opioid pharmacology, opioid side effects, patient-controlled analgesia, patient safety, respiratory depression

Patient-Controlled Analgesia

Patient-controlled analgesia (PCA) is a method for controlling pain in which a patient is able to self-administer pain medications via activation of a mechanical distribution system. The key element of PCA is that the patient is in control of the analgesia. Respiratory depression is preceded by sedation, and a sedated patient is unable or unlikely to push the PCA button. The pump can also be programmed to have a continuous infusion rate, which is administered to the patient regardless of whether the patient activates a dose. Basal rates bypass the safety mechanism of patient control and can place the patient at higher risk for respiratory depression and sedation. Initiation of a PCA is often most appropriate in patients requiring frequent as-needed dosing of medications or when such dosing is anticipated. Patients’ acceptance of the technique is high, related in part to a sense of control over their own pain relief, a reduction in the delay for the receipt of pain medications, not receiving injections, and not having to interrupt or to bother nurses. This review contains 2 tables and 20 references. Key words: analgesic delivery systems, morphine metabolism, multimodal pain management, opioid pharmacology, opioid side effects, patient-controlled analgesia, patient safety, respiratory depression

Postdural Puncture Headache Related to Procedure: Incidence and Risk Factors After Neuraxial Anesthesia and Spinal Procedures.

Postdural puncture headache (PDPH) is a potential complication of certain neuraxial anesthesia and spinal procedures, and some risk factors for PDPH have been identified. However, there have been no detailed analyses of rates and risk factors of PDPH after various spinal and neuraxial anesthesia procedures. Patient data from January 1, 2015, to December 31, 2017, were retrospectively analyzed. The patients underwent dural puncture procedures (spinal anesthesia, lumbar puncture [spinal tap], lumbar cerebrospinal fluid [CSF] drainage) or nondural puncture procedures (transforaminal epidural injection, interlaminar epidural injection, epidural catheterization with patient-controlled analgesia for delivery). PDPH incidence and risk factors were evaluated. For dural puncture procedures, PDPH incidence was 2.96%, and risk factors were younger age, female sex, and lumbar puncture. Larger needle gauge was a risk factor according to Student t-test but not during logistic regression analysis. PDPH incidence was higher after lumbar puncture using a 22 G Tuohy needle (4.63%) than after lumbar CSF drainage using an 18 G Tuohy needle (3.05%). For nondural puncture procedures, PDPH incidence was 0.53% and did not differ between procedure types; no risk factors were identified. PDPH incidence and risk factors depended on the type of neuraxial anesthesia and spinal procedures. PDPH incidence after lumbar puncture using a 22 G Tuohy needle was higher than that after lumbar CSF drainage using an 18 G Tuohy needle, suggesting that catheter insertion may reduce PDPH risk. In non-dural puncture procedures, PDPH risk did not differ according to type of procedure, and no risk factors were found.

Prophylactic anticoagulation for preterm premature rupture of membranes: a decision analysis

The current standard of care in the setting of preterm premature rupture of membranes involves antenatal hospitalization until delivery. The reduced physical activity during this time compounds the heightened risk for venous thromboembolism in pregnancy. Prophylactic anticoagulation can decrease this risk of venous thromboembolism; however, this benefit must be balanced against the risks of precluding neuraxial analgesia or increasing the risk of postpartum hemorrhage. The objective of this study was to determine the optimal modality for venous thromboembolism prophylaxis during hospitalization for preterm premature rupture of membranes using a decision analysis model. A decision-analytical Markov model was constructed using the TreeAge software comparing the use of unfractionated heparin, low-molecular-weight heparin or no anticoagulation in women with a singleton pregnancy who were hospitalized for preterm premature rupture of membranes after 24 weeks and remained hospitalized until delivery. Maternal outcomes examined included attainment of neuraxial analgesia (vs no analgesia for vaginal delivery or general anesthesia for cesarean delivery), venous thromboembolism, postpartum hemorrhage, and maternal death. Probabilities and utilities were derived from existing literature. Sensitivity analyses were performed to interrogate model assumptions, and a Monte Carlo probabilistic sensitivity analysis was performed to examine the robustness of the model. In this decision-analytical model, no prophylactic anticoagulation maximized maternal utilities. Clinical outcomes among a theoretical cohort of 100,000 women are shown in the Table. The 1- and 2-way sensitivity analyses supported this conclusion. Monte Carlo probabilistic sensitivity analysis indicated that no prophylaxis was the preferred choice in 56% of simulations, unfractionated heparin in 34% of simulations, and low-molecular-weight heparin in 10% of simulations. Our results do not support the routine use of prophylactic anticoagulation in women admitted to the hospital for preterm premature rupture of membranes. These findings can be used to inform clinical decisions when admitting low-risk singleton pregnancies to the hospital in the setting of preterm premature rupture of membranes.

Pruritus after continuous administration of epidural morphine for post-cesarean delivery analgesia: a case control study

BackgroundPruritus is one of the most common side effects of epidural morphine administered for post-surgery analgesia, and pregnant women tend to be highly susceptible. The relative contributions of morphine concentration, local anesthetics, and level of pain to pruritus after epidural morphine for post-cesarean delivery analgesia remain unclear. Accordingly, the present study aimed to identify risk factors for pruritus after continuous administration of epidural morphine for post-cesarean delivery analgesia.MethodsThis case control study was based on routinely collected clinical data. Participants included women who had undergone cesarean section and adopted a patient-controlled analgesia pump for postoperative analgesia. A series of logistic regression analyses were performed. Interaction terms were added to explore the moderation effects of combined local anesthetics and pain level on associations between morphine concentration and pruritus. Robustness of the results was checked through sensitivity analysis using propensity scores matching approach.ResultsHigher morphine concentration, assisted reproductive treatment, and multipara and cesarean section history were significantly more prevalent in the pruritus group than in the control group. The probabilities of pruritus at morphine concentrations of 10, 15, 20, 25, 30 and 40 μg/mL increased sequentially from 0.05, 0.1, 0.2, 0.35, 0.54 to 0.84, respectively. The trend remained steep in the ropivacaine stratum and became flatter when combined with levobupivacaine. At mild pain combined with levobupivacaine, the incidence of pruritus increased from 0.33 (95% confidence interval [CI] 0.1–0.68) in the 10 μg/mL morphine group to 0.48 (95% CI 0.1–0.88) in the 40 μg/mL morphine group. In the stratum of moderate pain combined with levobupivacaine, the incidence increased from 0.4 (95% CI 0.04–0.92) to 0.56 (95% CI 0.03–0.98). The results in the sensitivity analysis were in consistent with above findings.ConclusionsHigher concentrations of morphine, multipara, and assisted reproductive treatment were factors associated with a higher probability of pruritus. Pain level or combined local anesthetics could moderate the association between morphine concentration and pruritus.