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Purpose A zone of differential block to cold has been recently documented during labour epidural analgesia, with an upper sensory block level (USBL) and a lower sensory block level (LSBL). We aimed to determine the correlation between USBL and LSBL to cold and pinprick and sensory block level to light touch during labour epidural analgesia. Methods We conducted a prospective observational study in patients requesting labour epidural analgesia. We placed an epidural catheter at L2/L3 or L3/L4, followed by a programmed intermittent epidural bolus plus patient-controlled epidural analgesia regimen. We assessed the sensory block levels 140 min after administering the loading dose. The primary outcomes were the USBL and LSBL to cold and pinprick and the sensory block level to light touch. Results We studied 30 patients. The median [interquartile range (IQR)] USBL and LSBL to ice were T7 [T7–T6] and T9 [T10–T8], respectively. The median [IQR] USBL and LSBL to pinprick were T8 [T10–T6] and T10 [T12–T10], respectively. There was a strong correlation between USBL to ice and pinprick (Spearman correlation coefficient, 0.57) and between LSBL to ice and pinprick (Spearman correlation coefficient, 0.52). There was no significant correlation between sensory block level to light touch and either USBL or LSBL to ice or pinprick. Conclusion We observed two sensory block levels to ice and pinprick. Further studies are required to understand if one modality—cold or pinprick—is superior to the other in assessing sensory block levels in this context. Light touch is unreliable as a modality of sensory block assessment during labour epidural analgesia. Trial registration ClinicalTrials.gov (NCT05187962); registered 12 January 2022.

Background and AimsPregnant people with obesity class 3 are thought to be at higher risk of adverse respiratory-events. There is little information in the literature on the incidence and severity of obesity-related postpartum respiratory depression. Our institution’s current standard of practice is to consider maintaining patients with BMI>50 who have received long-acting neuraxial opioids following cesarean delivery(CD) in the Labour and Delivery Unit for respiratory monitoring. This represents a significant workload for the system. This study aimed to determine the incidence of respiratory complications in this subset of patients.MethodsWe reviewed medical records of patients with BMI>40 who underwent CD and received long-acting neuraxial opioids between January 2015- December 2022. Patients were divided into three groups according to their BMI: 40-49, 50-59, and >60. Clinically significant respiratory-events (see the definition in table 1) within the first 24 hours post-CD were compared.ResultsDemographics, patient characteristics, comorbidities, and respiratory events are presented in table 1. No severe respiratory events were observed in any of the groups from 497 patients (figure 1). Three moderate respiratory-events were observed, one in each group. Thirteen, 9 and 5 mild respiratory-events were observed in BMI 40-49, 50-59, and >60groups, respectively.Abstract EP197 Table 1Patient characteristics and incidence of postoperative respiratory eventsAbstract EP197 Figure 1Comparison of the respiratory events (%) per study groups[Figure omitted. See PDF]ConclusionsOur results suggest that there is no association between BMI and severe respiratory-events after CD under neuraxial anesthesia and the use of long- acting neuraxial opioids. Extended admission to a high-acuity setting may not be necessary for the majority of these patients. In addition to BMI, the presence of patient comorbidities and physician assessment may prove valuable in determining the necessity for admission.Initial Ethics Commity Approval Letter 22-0202-C

Purpose The purpose of our study was to determine the minimum effective dose of oxytocin maintenance infusion required to maintain adequate uterine tone in 90% of patients (ED 90 ) after administration of the initial bolus at elective Cesarean delivery (CD) under spinal anesthesia. Methods We conducted a prospective, double-blind dose-finding study with biased coin up-down design. Immediately after delivery, a 1-IU oxytocin bolus was administered, followed by a maintenance infusion. The obstetrician assessed the uterine tone by palpation as satisfactory or unsatisfactory. In case of unsatisfactory response, the dose for the next patient was increased by 2 IU·hr −1 . For satisfactory response, the dose for the next patient was either decreased by 2 IU·hr −1 with a probability of 1/9, or remained unchanged. The primary outcome was a satisfactory uterine tone from five minutes after delivery until discharge from postanesthesia care unit. The secondary outcomes were blood loss, need for additional uterotonics, and side effects. Results We analyzed data for 40 patients. The ED 90 of oxytocin maintenance infusion was 4.5 IU·hr −1 (95% confidence interval, 3.3 to 5.5) based on the isotonic regression estimator. The median [interquartile range] blood loss was 861 [553–1,181] mL; 18% received additional uterotonics, and 38% developed hypotension post delivery. Conclusion Based on the results of this dose-finding study, we recommend a maintenance infusion rate of 4.5 IU·hr −1 following an oxytocin bolus of 1 IU for adequate uterine tone in pregnant patients undergoing elective CDs. This infusion rate is four-fold lower than that required without an initial bolus. Study registration ClinicalTrials.gov ( NCT04946006 ); first submitted 25 June 2021.

IntroductionEpidural analgesia is the preferred method to manage pain during labor and delivery. The insertion of the epidural catheter can be complicated by unintentional dural puncture that may result in postdural puncture headache. There is limited evidence on the long-term implications of this complication. We sought to investigate if women who sustained a dural puncture have a higher risk of developing chronic headache, low back pain and visual or auditory impairment.MethodsWe conducted a 1:1 case–control study with women who delivered at our institution from January 2015 to December 2019. Cases were women who received epidural analgesia and sustained an unintentional dural puncture, and controls were women who received epidural analgesia but did not sustain such complication. We matched cases and controls for date of delivery, age, and body mass index. All women completed an online survey with validated questionnaires for diagnosis of chronic headache and chronic back pain. We used dichotomic (yes/no) questions to look for the presence of chronic visual and auditory impairment.ResultsSixty-three case–control pairs were studied. Women who sustained a dural puncture during their epidural catheter insertion had a higher risk of developing chronic headache (14.3%, vs 4.8%, p=0.057, adjusted OR (AOR): 3.67 (95% CI 1.05 to 12.82)) and chronic back pain (39.7% vs 19.1%, p=0.009, AOR: 2.67 (95% CI 1.25 to 5.72)) than women who did not sustain a dural puncture. The incidence of chronic auditory impairment was also higher in the dural puncture group (14.3% vs 1.6%, p=0.01, AOR: 9.98 (95% CI 1.21 to 82.62)).ConclusionsAn unintentional dural puncture during epidural catheter insertion in parturients is associated with increased risk of chronic headache, back pain and auditory impairment.

A zone of differential block to cold has been recently documented during labour epidural analgesia, with an upper sensory block level (USBL) and a lower sensory block level (LSBL). We aimed to determine the correlation between USBL and LSBL to cold and pinprick and sensory block level to light touch during labour epidural analgesia. We conducted a prospective observational study in patients requesting labour epidural analgesia. We placed an epidural catheter at L2/L3 or L3/L4, followed by a programmed intermittent epidural bolus plus patient-controlled epidural analgesia regimen. We assessed the sensory block levels 140 min after administering the loading dose. The primary outcomes were the USBL and LSBL to cold and pinprick and the sensory block level to light touch. We studied 30 patients. The median [interquartile range (IQR)] USBL and LSBL to ice were T7 [T7-T6] and T9 [T10-T8], respectively. The median [IQR] USBL and LSBL to pinprick were T8 [T10-T6] and T10 [T12-T10], respectively. There was a strong correlation between USBL to ice and pinprick (Spearman correlation coefficient, 0.57) and between LSBL to ice and pinprick (Spearman correlation coefficient, 0.52). There was no significant correlation between sensory block level to light touch and either USBL or LSBL to ice or pinprick. We observed two sensory block levels to ice and pinprick. Further studies are required to understand if one modality-cold or pinprick-is superior to the other in assessing sensory block levels in this context. Light touch is unreliable as a modality of sensory block assessment during labour epidural analgesia. ClinicalTrials.gov (NCT05187962); registered 12 January 2022.

The purpose of our study was to determine the minimum effective dose of oxytocin maintenance infusion required to maintain adequate uterine tone in 90% of patients (ED ) after administration of the initial bolus at elective Cesarean delivery (CD) under spinal anesthesia. We conducted a prospective, double-blind dose-finding study with biased coin up-down design. Immediately after delivery, a 1-IU oxytocin bolus was administered, followed by a maintenance infusion. The obstetrician assessed the uterine tone by palpation as satisfactory or unsatisfactory. In case of unsatisfactory response, the dose for the next patient was increased by 2 IU·hr . For satisfactory response, the dose for the next patient was either decreased by 2 IU·hr with a probability of 1/9, or remained unchanged. The primary outcome was a satisfactory uterine tone from five minutes after delivery until discharge from postanesthesia care unit. The secondary outcomes were blood loss, need for additional uterotonics, and side effects. We analyzed data for 40 patients. The ED of oxytocin maintenance infusion was 4.5 IU·hr (95% confidence interval, 3.3 to 5.5) based on the isotonic regression estimator. The median [interquartile range] blood loss was 861 [553-1,181] mL; 18% received additional uterotonics, and 38% developed hypotension post delivery. Based on the results of this dose-finding study, we recommend a maintenance infusion rate of 4.5 IU·hr following an oxytocin bolus of 1 IU for adequate uterine tone in pregnant patients undergoing elective CDs. This infusion rate is four-fold lower than that required without an initial bolus. ClinicalTrials.gov ( NCT04946006 ); first submitted 25 June 2021.

PurposeProgrammed intermittent epidural bolus (PIEB) provides better analgesia for labour pain than continuous epidural infusion does. Nevertheless, commonly used PIEB regimens are associated with high sensory block. We hypothesized that a PIEB technique with slower bolus delivery speed would produce lower sensory levels.MethodsWe recruited term nulliparous women with singleton pregnancies during the first stage of labour. All participants had an American Society of Anesthesiologists Physical Status score of II-III, had epidural catheters placed at L3/4, and had epidural analgesia maintained with PIEB 10 mL every 40 min using 0.0625% bupivacaine with fentanyl 2 µg·mL-1. Women were randomized to receive PIEB delivered at 250 mL·hr-1 (G250) or 125 mL·hr-1 (G125). The study was completed six hours after the loading dose or at full cervical dilatation, whichever occurred first. The primary outcome was the presence of sensory block to ice ≥ T6 in at least one assessment during the study period (maximum six hours).ResultsWe analyzed data from 90 women. The proportion of women presenting sensory block ≥ T6 at any time was not different between G125 and G250 groups (60.0% vs 64.4%; difference, -4.4%; 95% confidence interval [CI], -24.5 to 15.6; P = 0.66). The median [interquartile range] highest sensory block level was also not different between G125 and G250 groups (T6 [T7-T5] vs T5 [T7-T5], P = 0.39). Women in the G125 group had a lower incidence of hypotension than women in the G250 group did (11.1% vs 33.3%; difference, -22.2%; 95% CI, -38.8 to -5.67; P = 0.01). Quality of analgesia and patient satisfaction were not different between groups.ConclusionThe maintenance of epidural analgesia with a PIEB delivery speed of 125 mL·hr-1 did not produce lower sensory block levels when compared with 250 mL·hr-1. The slower injection speed regimen was associated with lower incidence of hypotension, but this secondary finding warrants confirmation in a future trial.Trial registrationwww.ClinicalTrials.gov (NCT03236298); registered 1 August 2017.

PurposeApproximately one in five women will experience severe postoperative pain after Cesarean delivery (CD). Previously, a bedside three-item questionnaire (3-IQ) has shown to predict women experiencing higher evoked pain intensity after CD, with an area under the receiver operator characteristics (ROC) curve of 0.72. We hypothesized that the addition of psychophysical pain tests to the existing 3-IQ would improve the ability to predict severe pain in women undergoing elective CD under spinal anesthesiaMethodsThis was a prospective cohort study on women undergoing elective CD under spinal anesthesia. Women were assessed preoperatively using the 3-IQ, pressure algometry (PA) and mechanical temporal summation (TS) response. All women received standard perioperative care, including a multimodal analgesia regimen that included intrathecal fentanyl and morphine. A 0–100 mm visual analogue scale (VAS) was used to assess the severity of pain at rest (VASr) and on movement (VASm) at 24 and 48 hr after surgery. Patient satisfaction and opioid consumption were also recorded. We performed ROC curve analyses to assess whether we could improve the ability to predict our primary outcome of severe pain on movement at 24 hr (VASm24 ≥ 70).ResultsWe studied 195 women. Median [interquartile range] VASm24 was 53 [32–72] and 28% of patients experienced a VASm24 ≥ 70. The ability to predict a VASm24 ≥ 70 assessed by the area under the ROC curve was 0.64 using the 3-IQ and 0.67 using the 3-IQ combined with TS and PA.ConclusionThe addition of PA and TS to the 3-IQ model resulted in a predictive model that performed similarly to the 3-IQ model alone. Further research is warranted in this area to better predict women at risk of severe pain post CD.