Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · May 2022
ReviewPlacenta accreta. A review of current anesthetic considerations.
Placenta accreta spectrum (PAS) is a potentially life-threatening disorder with unique anesthetic challenges, and its incidence has increased over the past decades. We review current guidelines and best practice evidence for antenatal diagnosis and preoperative evaluation, management pathways, multidisciplinary staff coordination, and surgery location. We address specific considerations for choice of anesthesia modality, the role of interventional radiology, and various techniques for minimizing hemorrhage for both planned and unplanned cases, as well as postoperative care for the PAS patient.
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Best Pract Res Clin Anaesthesiol · May 2022
ReviewPost-dural puncture headache diagnosis and management.
Epidural analgesia, commonly used to alleviate labor pain, is not without complication. The most common complication associated with labor epidural analgesia (LEA) is Unintentional Dural Puncture (UDP), where many professionals go on to develop a Post Dural Puncture Headache (PDPH). ⋯ Other complications of dural puncture necessitating further treatment include hospital readmission, persistent headache, persistent backache, cerebral venous thrombosis, subdural hematoma, postpartum depression, post-traumatic stress disorder, and decreased maternal breastfeeding. In this article, we will define and discuss the definition and diagnosis for PDPH, the pathophysiology of PDPH, PDPH treatment options including conservative therapy, pharmacologic therapy, and invasive procedural measures including the therapeutic epidural blood patch, prophylactic epidural blood patch, intrathecal catheter placement after UDP, and potential new therapies.
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Best Pract Res Clin Anaesthesiol · May 2022
ReviewSpinal hypotension in obstetrics: Context-sensitive prevention and management.
Spinal hypotension during caesarean section remains a common complication, with important attendant maternal and fetal adverse outcomes. Research elucidating the mechanisms of spinal hypotension has led to the development and refinement of effective management strategies, with a particular emphasis on prophylactic vasopressor administration. This has proved effective in well-resourced settings, with maternal comfort and the elimination of nausea now considered the primary aim of treatment. ⋯ Translational, context-sensitive research in resource-limited settings has shown promise in implementing pragmatic strategies based on research from resource-rich environments. We review the current best practice for the prevention and treatment of spinal hypotension, with a special emphasis on effective strategies in resource-limited settings. We further suggest a research agenda to address the knowledge gap in specific contexts.
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Leading causes of intensive care unit (ICU) admission include hemorrhage, hypertensive disorders of pregnancy, and sepsis. Although the incidence of ICU admission in pregnancy may be low, this does not account for critical illness in labor and delivery or maternity unit suites, which is as high as 1-3%. ⋯ Recently, comorbidity-based screening tools, which quantify a patient's medical comorbidity burden, have been developed and validated in predicting ICU admission and death. Noninvasive ultrasonography such as point-of-care ultrasonography becomes essential in determining hemodynamic status, guides resuscitation, and manages cardiovascular dysfunction.
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Best Pract Res Clin Anaesthesiol · May 2022
ReviewLatest advances in postpartum hemorrhage management.
Hemorrhage is the leading cause of maternal mortality worldwide. A maternal health priority is improving how healthcare providers prevent and manage postpartum hemorrhage (PPH). Because anesthesiologists can help facilitate how hospitals develop approaches for PPH prevention and anticipatory planning, we review the potential utility of PPH risk-assessment tools, bundles, and protocols. ⋯ Point-of-care technologies for assessing changes in central hemodynamics (ultrasonography) and coagulation profiles (rotational thromboelastometry and thromboelastography) are also discussed. Anesthesiologists play a critical role in the medical and transfusion management of PPH. Therefore, we review blood ordering and massive transfusion protocols, fixed-ratio vs. goal-directed transfusion approaches, coagulation changes during PPH, and the potential clinical utility of the pharmacological adjuncts, tranexamic acid, and fibrinogen concentrate.