Incidence Of Anesthesia Research Articles

Spinal Anaesthesia Induced Hypotension and Related Adverse Effects in Caesarean Section Delivery and Neonatal Outcome: A Comparison of Using Crystalloid Pre-Loading and Co- Loading in Caesarean Patients

Background: Volume loading by rapid infusion of crystalloid solution before/during induction of spinal anaesthesia may effectively reduce the incidence of anaesthesia induced hypotension.Objective:To compare the efficacy of crystalloid pre-loading and co-loading to preventhypotension and related adverse effects as well aspoor neonatal outcome in caesarean section delivery under spinal anaesthesia.Methods:This single blinded randomized controlled clinical trial was conducted in the Department of Anaesthesia, Analgesia & Intensive Care, Dhaka Medical College Hospital, Dhaka, between January 2013 and December 2014. A total of 90 patients were selected –45patients of group I received co-loading with Ringer’s lactatesolution, while another 45 patients of group II received a pre-loading of the same fluid.Blood pressure and heart rate were recorded. Ephedrine and adrenaline were administered as needed to treat hypotension.APGAR scores of the newborn were recorded at 1st minute and 5th minute after delivery. Adverse effects like nausea, vomiting, light headedness and shivering was observed all through during operation and post-operative phase in all patients, if any, and recorded.Results:The incidence of hypotension was 17 (37.8%) in group I (co-loading) and 27 (60%) in group II (pre-loading), which was significantly higher in group II (p<0.05).Adverse effects – nausea, vomiting, light headedness and shivering was observed more in group II patients; however, the difference was not statistically significant. In neonates, APGAR score at 1 minute was found ≤7 in 18 (40.0%) from group I, while 28 (62.2%) from group II; the difference was statistically significant (p<0.05). No significant difference was observed in APGAR score at 5 minutes, as found ≤7 in 6 (13.3%) and 3 (6.7%) in group I andgroup II respectively.Conclusion:Severity of hypotension, increased ephedrine requirement and poor APGAR score wereevident in patients who received crystalloid pre-loading group(group II), which meanscrystalloid co-loading group(group I) procedurewas more effective in preventing spinal anaesthesia induced hypotension and secured better neonatal outcome.International Journal of Human and Health Sciences Vol. 05 No. 01 January’21 Page: 90-95

The incidence and causes of failed spinal anesthesia in a tertiary care Hospital: A retrospective observational study

Introduction: Spinal anesthesia (SA) is one of the most frequently applied anesthesia procedures today. However, SA failure rate varies between 1 and 17%. The age of the patient, the position at which the procedure is performed, or the characteristics of the technical operation can affect success. In this study, we aimed to compare the most frequent SA failures according to the types of surgery and causes of failure. The results of SA procedures performed in a Hospital were comparing to those published in the current literature. Material and Method: This study was conducted in Department of Anesthesia, MGMMC and M Y Hospital, Indore, Madhya Pradesh, India. It was a one year retrospective study from January 2019 to December 2019. All the parturient undergoing surgery section was included in the study. Results: Of all anesthesia procedures, SA was applied at a rate of 25.97%. Our SA failure rate was calculated as 17.14%. Considering a single surgical procedure, obstetric anesthesia was the most common surgery with failed SA (27.77%). The most common cause of failure was insufficient analgesia (31.25%) and Unsuccessful lumbar puncture (27.07%) Conclusion: the incidence of failed spinal anesthesia was found to be higher compared to previous studies with the implication that we should give attention for this disgusting event. Since the study tried to identify risk factors for failure, we should act accordingly to minimize the failure rate.

Learning From Others: A Case Report from the Anesthesia Incident Reporting System

Learning From Others: A Case Report from the Anesthesia Incident Reporting System

High Incidence of Burst Suppression during Propofol Sedation for Outpatient Colonoscopy: Lessons Learned from Neuromonitoring.

Background Although anesthesia providers may plan for moderate sedation, the depth of sedation is rarely quantified. Using processed electroencephalography (EEG) to assess the depth of sedation, this study investigates the incidence of general anesthesia with variable burst suppression in patients receiving propofol for outpatient colonoscopy. The lessons learned from neuromonitoring can then be used to guide institutional best sedation practice. Methods This was a prospective observational study of 119 outpatients undergoing colonoscopy at Thomas Jefferson University Hospital (TJUH). Propofol was administered by CRNAs under anesthesiologists' supervision. The Patient State Index (PSi™) generated by the Masimo SedLine® Brain Root Function monitor (Masimo Corp., Irvine, CA) was used to assess the depth of sedation. PSi data correlating to general anesthesia with variable burst suppression were confirmed by neuroelectrophysiologists' interpretation of unprocessed EEG. Results PSi values of <50 consistent with general anesthesia were attained in 118/119 (99.1%) patients. Of these patients, 33 (27.7%) attained PSi values <25 consistent with variable burst suppression. The 118 patients that reached PSi <50 spent a significantly greater percentage (53.1% vs. 42%) of their case at PSi levels <50 compared to PSi levels >50 (p=0.001). Mean total propofol dose was significantly correlated to patient PSi during periods of PSi <25 (R=0.406, p=0.021). Conclusion Although providers planned for moderate to deep sedation, processed EEG showed patients were under general anesthesia, often with burst suppression. Anesthesiologists and endoscopists may utilize processed EEG to recognize their institutional practice patterns of procedural sedation with propofol and improve upon it.

A Clinical Study to Compare 25 G Whitacre and Quincke Spinal Needles for Incidence of Post Dural Puncture Headache (PDPH) and Failed Spinal Anaesthesia

Post dural puncture headache (PDPH) is the most distressful complication of spinal anaesthesia. The modifiable risk factors include spinal needle type and size. Thus the present study was attempted with a primary aim to compare 25G Whitacre and 25G Quincke spinal needles with respect to the incidence, onset and severity of PDPH, incidence of failed spinal anaesthesia (FSA) and the quality of block achieved (sensory and motor). The study was conducted from December 2017 to August 2019. 120 patients posted for lower abdominal and lower limb surgeries were allocated in two groups of 60 each. Patients received sub arachnoid block (SAB) with 15 mg of 0.5% bupivacaine using 25 G Whitacre needle in Group A and using 25G Quincke’s needle in Group B. All the patients were evaluated for incidence, onset and severity of PDPH at 24hr, 48hrs and 72hrs after SAB, rate of FSA and quality of block using modified bromage scale and pinprick method. Demographic data was comparable in both the groups. Incidence of PDPH was 1.6% in Whitacre group as compared to 15% in Quincke’s group . However the result was statistically insignificant for rate of FSA and quality of block achieved. It is concluded that pencil point 25 G Whitacre needles are associated with a lower incidence of PDPH as compared to cutting 25G Quincke spinal needle and thus should be used in a population that is at high risk of developing PDPH.

The incidence and factors associated with failed spinal anesthesia among parturients underwent cesarean section, 2019: A prospective observational study

BackgroundSpinal anesthesia is the method of choice for cesarean section as it is associated with low occurrence of intra-operative and post-operative morbidities. Despite this significant move towards spinal anesthesia, it has a risk of failure reported in the range of 1–17%. Failed spinal is a disgusting event for the mother and the anesthetist that may lead to decreased maternal satisfaction and may potentially impact fetal and maternal outcomes. ObjectiveThe study was designed to determine the incidence and factors associated with failed spinal anesthesia during cesarean section. MethodsA prospective institution based observational study was conducted on 275 parturients from October 1st to December 31st, 2019. After collection, the data was data entered and analyzed by SPSS version 21. The main outcome measure was the incidence of failed spinal anesthesia and the chi-square test was used to compare failure rates and multivariable regression analysis was performed to investigate potential factors. ResultsThe study involved 275 parturients and the overall incidence of failed spinal was 19.5%. Co-morbidity (OR = 9.615; CI = 1.255–7.368), emergency procedure (AOR = 2.191; CI = 1.087–4.417), needle size (2.3; CI = 0.92–0.615), anesthetist's experience (AOR = 4.23; CI = 2.14–8.34), surgeon's experience (AOR = 2.530; CI = 1.319–4.853), bloody CSF flow (AOR = 2.440; CI = 0.103–0.582), and volume of local anesthetics (AOR = 2.781; CI = 1.432–5.398) were significantly associated with failed spinal anesthesia. Conclusions and recommendationsThe incidence of failed spinal anesthesia was found to be high compared to previous studies. Since the study tried to identify risk factors for failure, we should act accordingly to minimize the failure rate.

Efficacy of Pulpal Anesthesia Using a Needle-less Syringe.

The purpose of this study was to investigate the manufacturer's claims regarding a novel needleless intraligamentary local anesthesia injection device (Numbee, BioDent) to provide effective single tooth anesthesia. Investigators compared the Numbee with a traditional inferior alveolar nerve block (IANB) during a restorative procedure on mandibular teeth. A randomized, split-mouth design was conducted with 15 adult subjects receiving an IANB on one side and a Numbee injection on the same tooth type on the contralateral side. Subjects recorded injection pain using the Visual Analog Scale (VAS) and their preferred injection technique. Anesthesia was considered profound with 2 consecutive electric pulp tester readings of 80. If subjects became symptomatic during the restorative procedure, rescue anesthesia was administered. The difference in VAS scores for injection pain between the Numbee and the IANB was not significant (p = .078). For the IANB, the incidence of profound anesthesia was 46%, and required rescue anesthesia was 20%. For the Numbee, the incidence of profound anesthesia was 0%, and required rescue anesthesia was 60%. Subject preference was evenly split (50/50%) between the 2 techniques. The IANB outperformed the Numbee device for achieving profound anesthesia and requiring less rescue anesthesia.

The Use of Patient Digital Facial Images to Confirm Patient Identity in a Children's Hospital's Anesthesia Information Management System

Patient identification errors, albeit rare, continue to occur despite the implementation of the Universal Protocol. Researchers at a tertiary care children's hospital hypothesized that introduction of a digital photograph to the preanesthesia checklist would reduce wrong-patient charting and near-miss events around the induction of anesthesia. In late 2014 a digital facial image obtained either on arrival to the preoperative preparation area or for inpatients, on admission to the hospital, was added to the initial verification screen (anesthesia sign-in) of the anesthesia information management system (AIMS). This verification process includes visual inspection of the patient's facial image and checking the patient's hospital ID bracelet for the patient's name, birthdate, and hospital number against the AIMS verification page. Wrong-patient charting and near-miss events were reviewed weekly by the electronic health record (EHR) perioperative team through analysis of AIMS records and through provider self-report to the institution's Anesthesia Incident Reporting System. Between January 1, 2015, and July 1, 2018, 95,146 patients (42,255 females; 52,891 males) were anesthetized in the hospital with only one instance of charting on the wrong patient in the AIMS. A Wilson score interval would give a percentage of 0.001% (95% confidence interval: 0.0002%-0.006%). Therefore, we are 95% certain that the true rate of charting on the wrong patient is below 1 in 16,794 patients. At the induction of anesthesia, the addition of a current digital facial image to the Universal Protocol may be useful in preventing misidentification and mischarting on the anesthetic record.

Ameliyathane Dışı Anestezi Deneyimlerimiz

Aim: In this study, we aimed to discuss our experience and results of non-operating room anesthesia. Materials and Methods: Anesthesia records of patients older than 18 years who underwent sedo-analgesia outside the operating room for diagnosis and treatment between May 2017 and December 2017 were retrospectively screened. The records were examined in terms of demographic data, applied procedure, duration of the procedure, sedation grade, medications used, developing minor and major complications, chronic obstructive pulmonary disease story and intensive care need. Relationships between complications with demographic data and categorical variables were analyzed. Results: Totally 2562 patients underwent sedo-analgesia. 1428 (55.7%) of these cases were female and 1134 (44.3%) of them were male. The average age of patients was 53.08±16.55. 268 (10.5%) of the cases were ASA I, 1683 (65.7%) were ASA II, 598 (23.3%) were ASA III and 13 (0.5%) were ASA IV. 519 (20.3%) patients were minimally sedated, 1541 (60.1%) were moderate sedated and 502 (19.6%) deep sedated. The longest procedure time in endoscopic retrograde cholangiopancreatography was 28.7 ± 16.3 min, and the shortest procedure time in endoscopy was 10.3 ± 3.1 min. The most commonly performed procedure was colonoscopy with 31%. The most commonly used drug combination was midazolam + propofol + fentanyl applied to 1231 patients (48%). 148 (5.76%) patients had minor complication, and 10 (0.37%) patients had major complication. A total of 15 (0.58%) patients underwent intensive care after the procedure. Desaturation was statistically significantly higher in patients with ASA III and above, in procedures take longer than 15 minutes, in patients older than 65 years, and in the presence of chronic obstructive pulmonary disease. The intensive care need after the procedure was also significantly higher in these patient groups. Conclusion: The incidence of non-operating room anesthesia is increasing steadily. The risks associated with these practices are similar to the anesthesia in the operating room. In order to increase patient safety and reduce complications, it is important to carry out a thorough evaluation before the procedure, to provide proper monitored anesthesia care in appropriate physical conditions, and to establish healthy communication between the teams.

Benefits of ultra-fast-track anesthesia for children with congenital heart disease undergoing cardiac surgery

BackgroundTo compare the outcomes of ultra-fast-track anesthesia (UFTA) and conventional anesthesia in cardiac surgery for children with congenital heart disease (CHD) and low birth weight.MethodsOne hundred and ninety-four CHD children, aged 6 months to 2 years, weighting 5 to 10 kg, were selected for this study. The 94 boys and 100 girls with the American Society of Anesthesiologists (ASA) physical status III and IV were randomly divided into two groups each consisting of 97 patients, and were subjected to ultra-fast-track and conventional anesthesia for cardiac surgery. For children in UFTA group, sevoflurane was stopped when cardiopulmonary bypass (CPB) started and cis-atracurium was stopped at the beginning of rewarming, and remifentanil (0.3 μg/kg/mim) was then infused. Propofol and remifentanil were discontinued at skin closure. 10 min after surgery, extubation was performed in operating room. For children in conventional anesthesia group, anesthesia was given routinely and they were directly sent to ICU with a tracheal tube. Extubation time, ICU stay and hospital stay after operation were recorded. Sedation-agitation scores (SAS) were assessed and adverse reactions as well as other anesthesia –related events were recorded.ResultsThe extubation time, ICU stay and hospital stay were significantly shorter in UFTA group (P < 0.05) and SAS at extubation was lower in UFTA group than in conventional anesthesia group, but similar in other time points. For both groups, no airway obstruction and other serious complications occurred, and incidence of other anesthesia –related events were low.ConclusionsUFTA shortens extubation time, ICU stay and hospital stay for children with CHD and does not increase SAS and incidence of adverse reactions.

Patterns in medication incidents: A 10-yr experience of a cross-national anaesthesia incident reporting system

BackgroundMedication-related adverse events (MRE) in anaesthesia care are frequent and require a deeper understanding if we are to prevent medication harm. MethodsWe searched for reported MRE from the Spanish Anaesthesia Incident Reporting System (SENSAR) database over a 10-yr period. SENSAR is a cross-national, multicentre system focused on perioperative and critical care. A descriptive analysis of independent variables, phase of medication process, type of MRE, and medication group involved, and their relationships with morbidity was conducted. ResultsA total of 1970 MRE were identified from 7072 reported incidents. Patient harm was reported in 31% of the MRE. The administration phase was more frequent (42%) and showed the highest harm rate (44%) compared with other medication process phases. The most frequent types of MRE were wrong treatment regimen and wrong medication (55% of cases). The medication groups most commonly reported were those that alter haemostasis (18%), vasoconstrictor agents (13%), and opioids (10%). Vasoconstrictor agents, benzodiazepines, and neuromuscular blocking agents were the medication groups involved in patient harm four-fold more, and opioids three-fold more, than medications that alter haemostasis. The 1970 incidents were investigated and led to implementation of 4223 local corrective patient safety and quality improvement measures. ConclusionsPatient harm in the perioperative setting from medications remains a major issue for patients, hospital leaders, and clinicians. We found patterns and specific causes that can be mitigated through proven systems solutions, and should be taken into consideration in designing sustainable solutions for safe perioperative care. Clinical trial registrationNCT03615898.

Anesthetists’ Heart Rate Variability as an Indicator of Performance During Induction of General Anesthesia and Simulated Critical Incidents

Abstract. In the environment of anesthesia, good performance describes the absence of threat for the patient as well as a quick reaction to challenging and possibly life-threatening circumstances. Elsewhere, performance and cognitive function have been linked to indicators of vagally-mediated heart rate variability (HRV). This exploratory study examines the correlation between anesthetists’ HRV and their performance during uneventful induction of general anesthesia and during a simulated critical incident. For this study electrocardiograms (ECG) were obtained from two different groups of anesthetists providing general anesthesia in uneventful real cases in the operation room (OR, n = 38) and during the management of a hypotension scenario in a high-fidelity human patient simulator environment (SIM, n = 23). Frequency, time domain, and nonlinear HRV metrics were calculated from 5-min ECG recordings. To separate high performing (HP) and low performing (LP) individuals, the time needed for induction (in the OR setting) and the length and depth of hypotension (in the SIM setting) were used as performance correlates. The Mann-Whitney- U-test was used to assess differences in HRV within the groups. In both settings (OR and SIM), linear and nonlinear HRV metrics did not differ significantly between the HP and LP group. Also, the anesthetists’ work experience and sex were not related to performance. While providing general anesthesia and during a simulated critical incident, high and low performing individuals do not differ with respect to HRV metrics, sex, and work experience. Further research including the HRV under resting conditions is necessary.

Randomized comparison between perineural dexamethasone and dexmedetomidine for ultrasound-guided infraclavicular block

BackgroundThis randomized trial compared perineural dexamethasone (5 mg) and dexmedetomidine (100 µg) for ultrasound-guided infraclavicular brachial plexus block. We hypothesized that both adjuvants would result in similar durations of motor...

"Status Thymolymphaticus" - a Risk of Anaesthesia?

The administration of narcotics such as ether and chloroform to combat pain during surgery was overshadowed from the beginning by serious, often fatal incidents. Even the use of local anaesthetics, which were praised as being less dangerous, was not as uncomplicated as had initially been hoped for and was often fatal. Investigations into the various causes of anaesthetic incidents were carried out at an early stage, but usually did not lead to clear results. In these cases, the physicians involved in the administration of narcotics adopted the explanation attempts of the Austrian physicians Arnold Paltauf and Rudolf Ritter von Kundrat, who at the end of the 1880s also explained inexplicable narcosis incidents in apparently healthy individuals with the presence of a constitutional anomaly: the so-called "status thymicus, lymphaticus or thymolymphaticus". If, in case of a fatal anaesthetic incident, the event was attributed to the presence of this anomaly, one also spoke of "thymus death" and usually refrained from further legal investigations. Corresponding statements therefore acquired a great forensic significance, since now also in cases of a "mors subita" in infants or small children in the domestic sphere unjustly accused persons in the presence of a verifiable thymus hyperplasia did not have to be prosecuted further under criminal law. In operative medicine, the "status thymolymphaticus" has become a topic for decades, especially among the persons performing the anaesthesia, so that a historical review of the feared alleged syndrome appears justified.

Aspiration during anaesthesia in the first 4000 incidents reported to webAIRS.

The first 4000 reports to the webAIRS anaesthesia incident reporting database were used to evaluate pulmonary aspiration in patients undergoing procedures under general anaesthesia or sedation. Demographic data, predisposing factors, outcome and potential preventative measures were evaluated. In these reports, 121 cases of aspiration were identified. Aspirated substances included gastric contents, bile type fluids, blood and solids; 60 (49.6%) patients were admitted to the intensive care unit/high dependency unit, and 43 (35.5%) required mechanical ventilation. Aspiration was associated with significant harm in &gt;50% of reports, and eight (6.6%) patients died. Factors associated with a risk ratio of aspiration &gt;1.5 and outside the 95% confidence interval for no event included: age &gt;80 years, emergency procedure, procedure undertaken in freestanding day unit or gastroenterology department, procedure undertaken between 1800 and 2200 hours and endoscopy procedures. Only 11 (9%) cases appeared to be inadequately fasted, and 77 (64%) were definitely fasted. In the remaining 33 (27%), fasting was not mentioned. In 18 (14.9%) cases, aspiration occurred in the presence of cricoid pressure. Potential measures to prevent aspiration included using a cuffed endotracheal tube rather than a laryngeal mask airway in cases at high risk of aspiration and being made more aware of potential risk factors by improvements in team communication. Aspiration continues to be an important complication of anaesthesia, and one that can be difficult to predict and to prevent.

A Comparative Study of Two Different Doses of Intravenous Ondansetron for Prevention of Post-spinal Anesthesia Shivering in Inguinal Hernia Repair Surgery

Background: Shivering is one of the most commonly encountered problems after both general and regional anesthesia and its incidence about 40% to 50% of the patients whom undergoing surgical operation under spinal anesthesia. The aim of this work was to compare two different clinically relevant doses of ondansetron (4mg vs 8mg) in prevention of postspinal anesthesia in inguinal herniorrhaphy. Patients and Methods: A comprehensive sample included elective unilateral inguinal hernia in Zagazig University hospitals during period of six months from November 2018 to April 2019 (10-11 cases / month) sample will be 63 cases randomly allocated into 3 groups; group A (ondansetron 4mg IV), group B (ondansetron 8mg IV) and group C (control group). Results: Each dose of ondansetron 4 mg or 8 mg have the ability to decrease the incidence of postspinal anesthesia with no significant differences between the two doses. There were no significant difference regarding side effects of the two doses of ondansetron in prevention of post spinal shivering. Conclusion: we concluded that both doses of intravenous ondansetron 4mg and 8mg are efficient and safe in reducing the incidence and severity of shivering during spinal anesthesia.

Congenital heart defects in children with cleft lips and/or palates at an academic hospital in central South Africa

Background: Globally, cleft deformities are the most common craniofacial anomalies and show an association with congenital heart defects. Little research on cleft lips and/or palates (CL/P) and congenital heart defects has been reported from Africa, and none from South Africa. In 2001, it was proposed that CL/P be listed as one of six priority conditions for monitoring and notification to South African health authorities. This goal of creating a national registry has not been achieved. A near-fatal anaesthetic incident following a missed cardiac lesion in a child with a cleft lip and palate prompted this study. Objectives: To describe the prevalence of congenital heart defects diagnosed in children with CL/P presenting for corrective surgery during the Smile Week over three consecutive years (2013–2015) at an academic hospital in South Africa. Methods: A retrospective, descriptive file review of 62 patients with CL/P was performed. Since 2013, echocardiography has been performed on all patients with CL/P. Results: Twenty-three, 21 and 18 patients were operated in 2013, 2014 and 2015, respectively. Of these patients, 85.5% (n = 53) had no clinical evidence of a cardiac defect, of which eight did have clinically significant cardiac defects on echocardiography. Sixteen patients (25.8%) in total (n = 16/62) with a cleft deformity had a clinically significant congenital heart lesion. Of the 16 patients with a cardiac defect on transthoracic echocardiography, only four had clinical evidence of cardiac defect. Therefore, sensitivity of clinical examination was 25%, whereas the specificity was 89.1%. Three of the four patients with a syndrome had a clinically significant echocardiographic finding. Conclusion: A national guideline for the preoperative care of patients with CL/P, including routine echocardiography, is needed. Furthermore, a national registry is required for patients with CL/P with associated congenital anomalies.

Pulpal Anesthesia of Adjacent Teeth Following Infiltration of 2% Lidocaine With 1:100,000 Epinephrine in the Maxillary Lateral Incisor and First Molar.

The purpose of this study was to determine anesthetic success in adjacent teeth following a primary infiltration of the maxillary lateral incisor and first molar using 1.8 mL of 2% lidocaine with 1:100,000 epinephrine. Three hundred eight asymptomatic subjects received an infiltration of a cartridge of 2% lidocaine with 1:100,000 epinephrine over the maxillary lateral incisor (163 subjects) or first molar (145 subjects). Pulpal anesthesia of the injected tooth and adjacent mesial and distal teeth was monitored with the electric pulp tester in 2-minute cycles for a total of 60 minutes. No response from the subject at the maximum output (80 reading) of the pulp tester was used as the criterion for pulpal anesthesia. Comparisons of the odds of pulpal anesthesia (defined as an 80/80 response to electric pulp testing over 60 minutes) between the experimentally injected tooth and adjacent teeth were analyzed using mixed-models, repeated-measures logistic regression. When compared with the lateral incisor infiltration, the adjacent mesial tooth (central incisor) and distal tooth (canine) achieved statistically lower anesthetic success. When compared with the first molar, the mesial tooth (second premolar) did not differ statistically. However, significant differences were shown between the first molar and the second molar, with the distal tooth (second molar) achieving a statistically higher rate of pulpal anesthesia, which was related to a better duration of anesthesia. For asymptomatic patients, local anesthesia of the adjacent mesial (central incisor) and distal (canine) teeth to the infiltrated lateral incisor had lower pulpal anesthetic success. Because standard infiltration anesthesia of the lateral incisor is of short duration, repeating the infiltration at 30 minutes will result in a high incidence of pulpal anesthesia for 60 minutes. Local anesthesia of the adjacent distal tooth to the first molar (second molar) had a statistically higher rate of total pulpal anesthesia than the infiltrated first molar due to the longer duration of pulpal anesthesia. However, if pulpal anesthesia is required for 60 minutes in the first and second molars, the clinician may need to add an additional infiltration to ensure anesthesia.

175: Perinatal outcomes after implementing a hemorrhage risk assessment at admission

To evaluate the impact of a novel assessment of hemorrhage risk at admission on subsequent perinatal outcomes. This retrospective cohort analysis of a multicenter database included women admitted to labor and delivery from January 2015 to June 2018. A novel nursing assessment developed by Association of Women's Health, Obstetric and Neonatal Nurses was used to categorize patients as low, medium or high risk for hemorrhage. This was implemented 6/1/2016 across the centers. Perinatal outcomes related to blood transfusion, estimated blood loss (EBL) ≥ 1000cc, ICU admission, chorioamnionitis, general anesthesia, oxytocin use and cesarean delivery were evaluated before and after implementation. There were a total of 109,719 women included, with 38,751 women included prior to implementation of the hemorrhage risk assessment and 70,968 women after implementation. Rates of any blood transfusion (0.5 to 0.4%, p=0.02) and EBL ≥ 1000cc (6.3 to 6.0%, p=0.02) were significantly lower after implementation. Incidence of ICU admission, chorioamnionitis and general anesthesia did not change overall in the time period studied. There were higher rates of oxytocin use (83.4 to 85.2%, p<0.0001) and spontaneous vaginal delivery (58.8 to 59.9%, p=0.01). Details on perinatal outcomes are included (Table). After implementation of a hemorrhage risk assessment at admission, we found a 20% reduction in rates of blood transfusion and EBL ≥ 1000cc. Significantly increased oxytocin use was also observed. Further analysis must be done to assess if any other changes could account for these trends.

Epidemiology of general anesthesia prior to age 3 in a population-based birth cohort.

Utilization of general anesthesia in children has important policy, economic, and healthcare delivery implications, yet there is little information regarding the epidemiology of these procedures in the United States. The primary objective of this study was to describe in a geographically defined population the incidence of procedures requiring general anesthesia up to the child's third birthday, and the patient characteristics associated with receiving these procedures. A secondary objective was to determine the proportion of children in the population who meet the risk criteria promulgated by the Food and Drug Administration (FDA). A retrospective cohort of children born from 1994 to 2007 in Olmsted County, MN was established. Birth certificate information and receipt of general anesthesia before age 3 were collected. Proportional hazard regressions were performed to evaluate the association between characteristics of children and incidence of general anesthesia. Among the 20 922 children in the cohort, 3120 (14.9%) underwent at least 1 general anesthesia before age 3. In multivariate regression, factors independently associated with receiving at least 1 procedure included prematurity, male sex, lower birth weight, cesarean delivery, a non-Hispanic mother, and a White mother, controlling for multiple gestation, number of children previously born, age, education, and marital status of the mother. Seven hundred and twenty-three children (3.5%) had at least 1 subsequent procedure. Estimated gestational age <32 weeks and low birth weight were independently associated with receiving repeated anesthesia. Eight hundred and twenty children (3.9%) had a single prolonged exposure above 3 hours, multiple exposures prior to age 3, or both. Approximately 1 in 7 children were exposed to at least 1 episode of general anesthesia before age 3, and approximately 1 in 4 children who received general anesthesia fall within the high-risk category as defined by the recent FDA warning. The apparent disparities in surgical utilization related to race and ethnicity in this study population deserve further exploration.