Current opinion in anaesthesiology
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The use of simulation in medicine has grown significantly over the past 2 decades. Simulation in obstetric anesthesia can be divided into four broad uses: technical skills, nontechnical or teamwork skills, individual clinical competence, and the safety of the clinical environment. This review will describe recent trends in the use of simulation in several of these categories. ⋯ As the use of simulation continues to grow, research should concentrate on whether anesthesia or teamwork skills learned in the simulated environment change behavior and improve outcomes in the clinical setting. More instructional publications would also facilitate the growth into more clinical environments.
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To guide the optimal fluid management during cesarean delivery. The article focuses on fluid management to prevent hypotension during cesarean delivery performed under spinal anesthesia and excludes obstetric hemorrhage. ⋯ Current evidence suggests that combining a prophylactic vasopressor regimen with HES preloading, HES coloading or crystalloid coloading is the best method of preventing maternal hypotension after the initiation of spinal anesthesia. Crystalloid preloading is clinically ineffective and thus should no longer be used.
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This review assesses the maternal and fetal effects of vasopressor administration during spinal anaesthesia for caesarean delivery, with emphasis on recent findings. ⋯ Phenylephrine is the current vasopressor of choice for the prevention of maternal hypotension and nausea. Phenylephrine regimens need to be developed that can reliably and safely be used with noninvasive blood pressure cycle times less frequent than every minute. Further vasopressor should be used with caution when vagolytic therapy is, quite rightly, used to treat bradycardia associated with hypotension.
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Clinical studies and new guidelines are frequently being published in the area of preoperative fasting. A growing population of patients with obstructive sleep apnea is being referred for outpatient procedures including adenotonsillectomy. ⋯ A more liberal preoperative intake is encouraged with fasting for 2 h for clear liquids, 4 h for breast milk, 6 h for formula and light meals, and 8 h for heavy meals is widely accepted. Interpersonal variation in residual gastric volume exists. Children with obstructive sleep apnea under 3 years of age and those with severe obstructive sleep apnea and comorbidities are not candidates for ambulatory surgery. Polysomnography has specific preoperative indications. Dexmedetomidine can decrease emergence agitation and has an opioid-sparing effect. Intravenous acetaminophen is presented as an opioid-sparing analgesic. Dexamethasone is effective in preventing postoperative nausea without increased risk of bleeding. Surgical techniques may affect postoperative pain.
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This review summarizes recent developments in maternal mortality surveillance, and draws from recent confidential mortality reports to suggest ways the anesthesiologist can contribute to safer systems of care. ⋯ A growing number of countries and organizations have established systems for comprehensive maternal death surveillance and confidential review to ensure that each death counts and that the lessons learned are widely disseminated to improve future maternal safety.