Anesthesiology
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Why is this important?
The numerous benefits of neuraxial anesthesia (spinal, epidural, combined spinal-epidural) versus general anesthesia for cesarean section are well established.
While maternal and emergent risks for general anesthesia are well known (ethnic groups; emergencies; maternal disease), Cobb et al. present the highest quality evidence to date showing obstetric anesthesia specialization is associated with a lower GA rate.
What did they do?
The researchers conducted a retrospective cohort study at a large metropolitan teaching hospital (Philadelphia, Pennsylvania) over a 4 year period, comparing general anesthesia versus neuraxial, and obstetric-specialized1 vs generalist anesthesiologists for 4,217 singleton CS deliveries.
And they found?
The total study GA rate was 9.0%. Two-thirds of CS anesthesia was provided by seven specialist obstetric anesthesiologists, versus one-third provided by 33 generalists.
Specialist obstetric anesthesiologists demonstrated a significantly lower GA rate, 7.3% vs 12.1% (OR-CI 0.45-0.79). This difference persisted for the urgent/emergent CS sub-group, though not for after-hours delivery.
Nonetheless several non-provider factors were more strongly associated with GA such as emergency CS (⇡ 7-fold), maternal medical indications for CS (⇡ 3-fold), and after-hours CS (⇡ OR 33%).
Thus care by a specialist obstetric anesthesiologist is associated with an almost-30% reduction in GA for CS .
"...consider selecting neuraxial techniques in preference to general anesthesia for most cesarean deliveries." - ASA obstetric anesthesia task force. 2
Between the lines...
The individual obstetric-specialized anesthesiologists in this study had an almost 10-fold greater cesarean case load than did the average generalist. Whether the outcome difference was due to technical expertise, decision making or a combination, one message here is that you get better at what you do when you intentionally do more of it.
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A specialized obstetric anesthesiologist was defined as having completed an obstetric anesthesia fellowship or specialist practice for at least 5 years with 33% full-time obstetric anesthesia case-load. ↩
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Randomized Controlled Trial Multicenter Study
Amisulpride for the Rescue Treatment of Postoperative Nausea or Vomiting in Patients Failing Prophylaxis: A Randomized, Placebo-controlled Phase III Trial.
Although antiemetics are commonly used to prevent postoperative nausea or vomiting, the failure rate is appreciable and there is currently no generally accepted standard for rescue treatment of postoperative nausea or vomiting after failed prophylaxis. This prospective, randomized, double-blind, parallel-group, placebo-controlled, multicenter study was designed to test the hypothesis that intravenous amisulpride, a dopamine D2/D3-antagonist, is superior to placebo at treating established postoperative nausea or vomiting after failed prophylaxis. ⋯ A single 10-mg dose of intravenous amisulpride was safe and more effective than placebo at treating established postoperative nausea or vomiting in patients failing postoperative nausea or vomiting prophylaxis.
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Review
Measuring Clinical Productivity of Anesthesiology Groups: Surgical Anesthesia at the Facility Level.
Benchmarking and comparing group productivity is an essential activity of data-driven management. For clinical anesthesiology, accomplishing this task is a daunting effort if meaningful conclusions are to be made. ⋯ Additional productivity components (total ASA units/h, h/case, h/operating room/d) allow for leaders to develop productivity dashboards. With the emergence of large groups that provide care in multiple facilities, these large groups can choose to invest more effort in collecting data and comparing facility productivity internally with group-defined measurements including total ASA units per full time equivalent.
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Multicenter Study Observational Study
Outcomes of Patients Presenting with Mild Acute Respiratory Distress Syndrome: Insights from the LUNG SAFE Study.
Patients with initial mild acute respiratory distress syndrome are often underrecognized and mistakenly considered to have low disease severity and favorable outcomes. They represent a relatively poorly characterized population that was only classified as having acute respiratory distress syndrome in the most recent definition. Our primary objective was to describe the natural course and the factors associated with worsening and mortality in this population. ⋯ Most patients with initial mild acute respiratory distress syndrome continue to fulfill acute respiratory distress syndrome criteria in the first week, and nearly half worsen in severity. Their mortality is high, particularly in patients with worsening acute respiratory distress syndrome, emphasizing the need for close attention to this patient population.