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Intraoperative hypotension (IOH) is associated with increased morbidity and mortality. Hypotension Prediction Index (HPI) is a machine learning derived algorithm that predicts IOH shortly before it occurs. We tested the hypothesis that the application of the HPI in combination with a pre-defined Goal Directed Therapy (GDT) hemodynamic protocol reduces IOH during major gynaecologic oncologic surgery. We enrolled women scheduled for major gynaecologic oncologic surgery under general anesthesia with invasive arterial pressure monitoring. Patients were randomized to a GDT protocol aimed at optimizing stroke volume index (SVI) or hemodynamic management based on HPI guidance in addition to GDT. The primary outcome was the amount of IOH, defined as the timeweighted average (TWA) mean arterial pressure (MAP) < 65 mmHg. Secondary outcome was the TWA-MAP < 65 mmHg during the first 20 min after induction of GA. After exclusion of 10 patients the final analysis included 60 patients (30 in each group). The median (25-75th IQR) TWA-MAP < 65 mmHg was 0.14 (0.04-0.66) mmHg in HPI group versus 0.77 (0.36-1.30) mmHg in Control group, P < 0.001. During the first 20 min after induction of GA, the median TWA-MAP < 65 mmHg was 0.53 (0.06-1.8) mmHg in the HPI group and 2.15 (0.65-4.2) mmHg in the Control group, P = 0.001. Compared to a GDT protocol aimed to SVI optimization, a machine learning-derived algorithm for prediction of IOH combined with a GDT hemodynamic protocol, reduced IOH and hypotension after induction of general anesthesia in patients undergoing major gynaecologic oncologic surgery.Trial registration number: NCT04547491. Date of registration: 10/09/2020.

Intraoperative hypotension (IOH) is common during major surgery and is associated with a poor postoperative outcome. Hypotension Prediction Index (HPI) is an algorithm derived from machine learning that uses the arterial waveform to predict IOH. The aim of this study was to assess the diagnostic ability of HPI working with non-invasive ClearSight system in predicting impending hypotension in patients undergoing major gynaecologic oncologic surgery (GOS). In this retrospective analysis hemodynamic data were downloaded from an Edwards Lifesciences HemoSphere platform and analysed. Receiver operating characteristic curves were constructed to evaluate the performance of HPI working on the ClearSight pressure waveform in predicting hypotensive events, defined as mean arterial pressure < 65 mmHg for > 1 min. Sensitivity, specificity, positive predictive value and negative predictive value were computed at a cutpoint (the value which minimizes the difference between sensitivity and specificity). Thirty-one patients undergoing GOS were included in the analysis, 28 of which had complete data set. The HPI predicted hypotensive events with a sensitivity of 0.85 [95% confidence interval (CI) 0.73–0.94] and specificity of 0.85 (95% CI 0.74–0.95) 15 min before the event [area under the curve (AUC) 0.95 (95% CI 0.89–0.99)]; with a sensitivity of 0.82 (95% CI 0.71–0.92) and specificity of 0.83 (95% CI 0.71–0.93) 10 min before the event [AUC 0.9 (95% CI 0.83–0.97)]; and with a sensitivity of 0.86 (95% CI 0.78–0.93) and specificity 0.86 (95% CI 0.77–0.94) 5 min before the event [AUC 0.93 (95% CI 0.89–0.97)]. HPI provides accurate and continuous prediction of impending IOH before its occurrence in patients undergoing GOS in general anesthesia.

Introduction/Aims Intrathecal nusinersen administration can be challenging in certain adult spinal muscular atrophy (SMA) patients with difficult spinal anatomy who require imaging techniques (fluoroscopy or computed tomography scans) or invasive approaches (catheter placement, laminotomy) to identify the intrathecal space. We used ultrasound (US) assistance to access the lumbar intrathecal space in patients with SMA who experienced previous difficulties or failures with intrathecal dosing. Methods Eighteen adult patients with difficult spines were enrolled. We used US assistance, and we recorded the successful administrations, number of attempts, procedure times, and "patient satisfaction." Results There were 57 consecutive successful nusinersen spinal administrations in all patients enrolled. In 50% of patients, two or fewer attempts were needed to obtain a successful administration, with four or fewer attempts in 83.3%; only three patients reported more than four attempts because of both severe scoliosis and severe spine rotation (two patients) and obesity (one patient). The mean procedure time was 11.8 min (range, 1.7-28.9). Patient satisfaction was 4.97/5 (range, 4-5; median, 5) on Likert scale at 5 min and at 72 h. No major adverse events were reported, and two post dural puncture headaches were managed with medical therapy and with complete resolution within 72 h. Discussion US assistance seems to be a valid option among treatment choices for intrathecal nusinersen administration in patients with difficult spine. The absence of radiation exposure and the lack of need for intravenous sedation or general anesthesia are additional potential advantages to US assisted administration.

BACKGROUND: We retrospectively investigated the incidence and risk factors for transfusion-related acute lung injury (TRALI) among patients transfused for post-partum hemorrhage (PPH). METHODS: We identified a series of 71 consecutive patients with PPH requiring the urgent transfusion of three or more red blood cell (RBC) units, with or without transfusion of fresh frozen plasma (FFP) and/or platelets (PLT). Clinical records were then retrieved and examined for respiratory distress events. According to the 2004 consensus definition, cases of new-onset hypoxemia, within 6 hours after transfusion, with bilateral pulmonary changes, in the absence of cardiogenic pulmonary edema were identified as TRALI. If an alternative risk factor for acute lung injury was present, possible TRALI was diagnosed. RESULTS: Thirteen cases of TRALI and 1 case of possible TRALI were identified (overall incidence 19.7%). At univariate analysis, patients with TRALI received higher number of RBC, PLT and FFP units and had a longer postpartum hospitalization. Among the diseases occurring in pregnancy- and various pre-existing comorbidities, only gestational hypertension and pre-eclampsia, significantly increased the risk to develop TRALI (p = 0.006). At multivariate analysis including both transfusion- and patient-related risk factors, pregnancy-related, hypertensive disorders were confirmed to be the only predictors for TRALI, with an odds ratio of 27.7 ( 95% CI 1.27-604.3, p=0.034). CONCLUSIONS: Patients suffering from PPH represent a high-risk population for TRALI. The patients with gestational hypertension and pre-eclampsia, not receiving anti-hypertensive therapy, have the highest risk. Therefore, a careful monitoring of these patients after transfusions is recommended

BACKGROUND: To investigate changes in heat pain threshold and modifications in heat pain processing during pregnancy and labour, seventy-six nulliparous pregnant women were enrolled in two studies. METHODS: In the first study (psychophysical), 60 pregnant women underwent a quantitative sensory testing (QST) investigating heat perception in two body areas (right forearm and T10 dermatome) according to these groups: 32-33 gestational weeks (GW), 39-40 GW, early stage of active labour and 24 h after the delivery. In the other study (neurophysiological), contact heat-evoked potentials (CHEPs) were recorded in other 16 women at the 32nd GW and in 11 of these also at the 40th GW. RESULTS: The psychophysical study showed that heat pain threshold was significantly increased at the forearm at 32-33 GW (median ± IQR: 39.6 ± 0.7 °C), at 39-40 GW (40.6 ± 1.1 °C) and at early stage of active labour (40.8 ± 1.5 °C) as compared to 20 non-pregnant controls (p < 0.001). Heat pain threshold tested at T10 level was significantly increased at 32-33 GW (41.0 ± 1.6 °C), at 39-40 GW (42.1 ± 1.8 °C), and at early stage of active labour (42.3 ± 1.3 °C) as compared to the non-pregnant women (p < 0.001). The N2-P2 CHEP amplitude (main negative N2 and positive P2 components of the vertex biphasic potential) recorded from the pregnant women was significantly lower at the 40th than at the 32nd GW, after stimulation of both the forearm (p < 0.001) and the abdomen (p < 0.001). CONCLUSIONS: In pregnant women, there is a progressive increase of heat pain threshold and a reduction of the CHEP amplitude, suggesting that a general inhibitory mechanism may be involved.

Acute myocardial infarction rarely occurs in women during childbearing age (1:20,000), but maternal mortality rate is high (11%). Management of pregnant woman affected by myocardial infarction could be a challenge for obstetricians, cardiologists and anesthetists. In this report, we present the management of a 36 years-old nulliparous woman affected from hypertension and dyslipidemia, who experienced acute myocardial infarction at 25th gestational week and was scheduled for caesarean delivery at 35th week. General anesthesia for cesarean section was conducted using sevoflurane and remifentanil target controlled infusion (TCI); the patient was monitored with ECG, pulse oximetry, invasive blood pressure, haemodynamic measurement by lithium dilution cardiac output (LiDCO plus) and bispectral index. The titrated use of remifentanil and the close control of hemodynamic parameters by LiDCO plus monitoring may contribute to improve maternal outcome and newborn well-being in the management of general anesthesia for caesarean section.

BACKGROUND: This study evaluates the effects of spinal anesthesia with hyperbaric bupivacaine plus sufentanil on bladder function in women undergoing cesarean section. SUBJECTS AND METHODS: Thirty caucasian healthy pregnants scheduled for elective Cesarean section under spinal anesthesia performed with hyperbaric bupivacaine plus sufentanil were enrolled. Filling cystometry, proprioceptive bladder sensation during cystometry, rate of spontaneous voiding, post void residual volume, anocutaneous and bulbocavernosus reflex were analyzed at 4, 6 and 8 hours after spinal anesthesia. RESULTS: The proportion of women experiencing first sensation, first desire and strong desire at 4 hours was significantly different from that reported at 6 and 8 hours (p < 0.05 for first sensation and p < 0.01 for first and strong desire). Significant differences were also observed between volumes at which first sensation arose at first measurement (4 hours) and at second and third measurements (p < 0.01). There was a significant difference in rate of spontaneous micturition, with 80% of patients at 8 hours able to spontaneously void versus 40% at 6 hours, (p < 0.01). Moreover, a lower percentage of women had absent and/or light reflexes at 4 hour than at 6 and 8 hours (p < 0.01). CONCLUSIONS: Spinal anesthesia with bupivacaine plus sufentanil causes a clinically significant disturbance on bladder function in women undergoing cesarean section. Even thought recovery of proprioceptive bladder sensation is fast, a full recovery of spontaneous voiding requires a much longer time. A close monitoring of urinary function and of bladder distension is, therefore, advisable.

Latex sensitization: a special risk for the obstetric population

Remove Latex from the Labor and Delivery Suite Reply

Sensitization to latex seems to occur more frequently in women than in men. Obstetric and gynecological surgical procedures have recently been shown to be a common setting for latex anaphylaxis. We analyzed all the cases of anaphylactic reactions during 1240 cesarean sections in 2004; the patients were questioned for risk factors and underwent allergy testing for drugs and latex. Four patients had anaphylaxis under spinal anesthesia and in all cases it was due to latex allergy. Reported symptoms included facial edema, profuse sweating, itching, generalized erythematous rash and hypotension. Only one patient manifested a severe reaction which included bronchospasm, dyspnea, tachypnea and anaphylactic shock, requiring orotracheal intubation and epinephrine. Our data showed a high incidence (1:310) of intraoperative latex anaphylactic reactions in the one-year study period. This may be related to the very specific population (all women) in a very specific setting (obstetrics). To prevent anaphylactic reactions during obstetric surgery it is important to identify potential risk factors to include, for example atopy, adverse reactions to foods and latex items. If latex allergy is confirmed or strongly suspected, patients should be managed in a latex-safe environment. Premedication with antihistamines and steroids might be useful to further reduce the risk. After the delivery, specific desensitization may represent a good therapeutic option.