The World Health Organisation's Surgical Safety Checklist has been adopted and implemented by many hospitals throughout the world: from large tertiary teaching hospitals in wealthy countries, to small hospitals in low-resource settings.
The benefits to each hospital however are likely not the same. Does the WHO SSC implemented in a hospital that already has a 'Time Out' process bring the same benefit, if any, as to a hospital for which the checklist was completely new? Possibly not.
Several studies across a wide range of health systems have shown conflicting results in terms of reducing morbidity, mortality and length of stay.summary
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There is some evidence supporting the benefit of perioperative intravenous lignocaine/lidocaine infusion in both laparoscopic and open abdominal surgery.
The strongest evidence supports both improved analgesia and reduction in nausea, with weaker evidence suggesting faster improvement in GIT function and earlier discharge from hospital.
Safety data is reassuring but far from conclusive due to the small size of most studies.summary
Carbetocin is a long-acting synthetic oxytocin analog. Although a 100 mcg dose is currently recommended, there is still some question as to the ideal dose. Dosing as low as 20 mcg may possibly be equally effective.
Carbetocin is currently only recommended for use during elective cesarean delivery, obviating the need for a post-operative oxytocin infusion currently practiced in many countries. In some countries it is also used after vaginal delivery.
It is at least as efficacious as intravenous oxytocin, and may possibly be superior at reducing postpartum haemorrhage.
Due to it's comparatively high cost compared with oxytocin however, the economic benefit of avoiding post-operative oxytocin infusions has not been demonstrated.
In the scenario of emergency cesarean section after labor augmentation with oxytocin, a much larger dose is likely required and carbetocin cannot be recommended.
One study has suggested a post-operative analgesic benefit of carbetocin vs oxytocin, although the evidence base for this is far from conclusive.summary
A collection of landmark research articles relevant to obstetric anesthesia. Some, such as Hawkins' audits of U.S. maternal deaths, are significant because of their historical impact. Others hold direct clinical relevance for practice today.summary
Cardiac arrest is rare in pregnancy (1 in 30,000) and resuscitation is founded on the same approach used for the non-pregnant patient, focusing on:
- Calling for help
- A B C (D)
- Good for mother = good for baby
However, unique to maternal resuscitation:
- Airway difficulties are more likely.
- Aortocaval compression dramatically impedes resuscitation – employ left lateral tilt!
- Consider perimortem cesarean section
The rationale for Perimortem Cesarean Section is:
- The presence of baby and gravid uterus severely limits resuscitation of the mother.
- Emergency cesarean section at cardiac arrest is done for the mother’s benefit, not the baby.
- A decision to perform emergency CS must be made within 4 minutes of arrest, and the baby delivered within 5 minutes. (Although there is some evidence of benefit when performed up to 10 minutes after arrest.)
- The only equipment required is a scalpel and an appropriately skilled doctor.