International journal of obstetric anesthesia
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Int J Obstet Anesth · Aug 2019
ReviewPost-cesarean delivery pain. Management of the opioid-dependent patient before, during and after cesarean delivery.
The opioid crisis has reached an unprecedented magnitude in the United States and worldwide, and data on opioid use and misuse in the obstetric population are extremely concerning. Despite an abundant number of studies evaluating strategies to prevent neonatal opioid withdrawal syndrome in babies born to mothers who are chronic opioid users, in babies born to mothers using chronic opioids, numerous questions remain unanswered, including (1) how to optimally manage postpartum pain in opioid-dependent patients (2) how to reconcile buprenorphine and methadone use with intrapartum and post-partum analgesia, so as to avoid opioid withdrawal during and after delivery (3) how to safely and effectively provide a stepwise multimodal approach that incorporates systemic opioid-sparing approaches, such as neuraxial opioids, clonidine, ketamine, gabapentin, and regional anesthetic blocks, to ensure adequate pain relief while avoiding opioid withdrawal (4) how to optimally manage post-partum recovery and (5) how to avoid excessive opioid prescription and possibly leftover opioids that may promote persistent use, misuse and diversion. With the recognition that an increasing number of pregnant women are taking chronic opioids, the goals of this review article are to summarize the existing literature on post-cesarean pain management in the obstetric patient with an opioid-use disorder; and to provide clinicians with a stepwise approach for management before, as well as during and after, cesarean delivery of women who have been chronically using opioids during their pregnancy.
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Int J Obstet Anesth · Aug 2019
Comparative StudyThe comparative accuracy of a handheld and console ultrasound device for neuraxial depth and landmark assessment.
The study aimed to compare the accuracy of epidural depth estimation of a handheld ultrasound device, with an integrated algorithm that estimates epidural depth (AU; Accuro, Rivanna Medical), to that of a console ultrasound machine (GU; GE LOGICTM S8). ⋯ The AU and GU provided comparable epidural depth estimates. The AU device may be a reasonable alternative to more sophisticated ultrasound devices in determining the epidural space and depth in a non-obese obstetric population.
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Int J Obstet Anesth · Aug 2019
Case ReportsHepatic adenoma during pregnancy and anesthetic management.
We report the case of a 24-year-old woman with a large hepatic adenoma diagnosed in the third trimester of pregnancy. The adenoma was at risk of rupture. She underwent scheduled preterm cesarean delivery under combined spinal-epidural anesthesia, followed by transarterial embolization on post-partum day six. Definitive resection of the adenoma took place two months postpartum.
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Int J Obstet Anesth · Aug 2019
Design errors in vital sign charts used in consultant-led maternity units in the United Kingdom.
Paper-based charts remain the principal means of documenting the vital signs of hospitalised pregnant and postnatal women. However, poor chart design may contribute to both incorrect charting of data and clinical responses. We decided to identify design faults that might have an adverse clinical impact. ⋯ We recommend the urgent development of an evidence-based, standardised obstetric observation chart, which integrates 'human factors' and user experience. It should have a clear layout and style, appropriate colour scheme, correct language and labelling, and the ability for vital signs to be documented accurately and quickly. It should incorporate a suitable early warning score to guide clinical management.