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BackgroundThe past two decades have seen an increase in cannabis use due to both regulatory changes and an interest in potential therapeutic effects of the substance, yet many aspects of the substance and their health implications remain controversial or unclear.MethodsIn November 2020, the American Society of Regional Anesthesia and Pain Medicine charged the Cannabis Working Group to develop guidelines for the perioperative use of cannabis. The Perioperative Use of Cannabis and Cannabinoids Guidelines Committee was charged with drafting responses to the nine key questions using a modified Delphi method with the overall goal of producing a document focused on the safe management of surgical patients using cannabinoids. A consensus recommendation required ≥75% agreement.ResultsNine questions were selected, with 100% consensus achieved on third-round voting. Topics addressed included perioperative screening, postponement of elective surgery, concomitant use of opioid and cannabis perioperatively, implications for parturients, adjustment in anesthetic and analgesics intraoperatively, postoperative monitoring, cannabis use disorder, and postoperative concerns. Surgical patients using cannabinoids are at potential increased risk for negative perioperative outcomes.ConclusionsSpecific clinical recommendations for perioperative management of cannabis and cannabinoids were successfully created.

Background Heterogeneity among reported outcomes from enhanced recovery after cesarean delivery impact studies is high. This study aimed to develop a standardized enhanced recovery core outcome set for use in future enhanced recovery after cesarean delivery studies. Methods An international consensus study involving physicians, patients, and a director of midwifery and nursing services was conducted using a three-round modified Delphi approach (two rounds of electronic questionnaires and a third-round e-discussion) to produce the core outcome set. An initial list of outcomes was based on a previously published systematic review. Consensus was obtained for the final core outcome set, including definitions for key terms and preferred units of measurement. Strong consensus was defined as 70% or greater agreement and weak consensus as 50 to 69% agreement. Of the 64 stakeholders who were approached, 32 agreed to participate. All 32, 31, and 26 stakeholders completed Rounds 1, 2 and 3, respectively. Results The number of outcomes in the final core outcome set was reduced from 98 to 15. Strong consensus (70% or greater stakeholder agreement) was achieved for 15 outcomes. The core outcome set included length of hospital stay; compliance with enhanced recovery protocol; maternal morbidity (hospital re-admissions or unplanned consultations); provision of optimal analgesia (maternal satisfaction, compliance with analgesia, opioid consumption or requirement and incidence of nausea or vomiting); fasting times; breastfeeding success; and times to mobilization and urinary catheter removal. The Obstetric Quality of Recovery-10 item composite measure was also included in the final core outcome set. Areas identified as requiring further research included readiness for discharge and analysis of cost savings. Conclusions Results from an international consensus to develop a core outcome set for enhanced recovery after cesarean delivery are presented. These are outcomes that could be considered when designing future enhanced recovery studies. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Introduction: Strategies to achieve efficiency in non-operating room locations have been described, but emergencies and competing priorities in a birth unit can make setting optimal staffing and operation benchmarks challenging. This study used Queuing Theory Analysis (QTA) to identify optimal birth center operating room (OR) and staffing resources using real-world data. Methods: Data from a Level 4 Maternity Center (9,626 births/year, cesarean delivery (CD) rate 32%) were abstracted for all labor and delivery operating room activity from July 2019 - June 2020. QTA has two variables: Mean Arrival Rate, λ and Mean Service Rate µ. QTA formulas computed probabilities: P0 = 1-(λ/ µ) and Pn = P0 (λ/µ)n where n = number of patients. P0…n is the probability there are zero patients in the queue at a given time. Multiphase multichannel analysis was used to gain insights on optimal staff and space utilization assuming a priori safety parameters (i.e., 30 min decision to incision in unscheduled CD; ≤5 min for emergent CD; no greater than 8 hours for nil per os time). To achieve these safety targets, a Results: There were 4,017 total activities in the operating room and 3,092 CD in the study period. Arrival rate λ was 0.45 (patients per hour) at peak hours 07:00–19:00 while λ was 0.34 over all 24 hours. The service rate per OR team (µ) was 0.87 (patients per hour) regardless of peak or overall hours. The number of server teams (s) dedicated to OR activity was varied between two and five. Over 24 hours, the probability of no patients in the system was P0 = 0.61, while the probability of 1 patient in the system was P1 = 0.23, and the probability of 2 or more patients in the system was P≥ 2 = 0.05 (P3 = 0.006). However, between peak hours 07:00–19:00, λ = 0.45, µ = 0.87, s = 3, P0 = 0.48; P1 = 0.25; and P≥ 2 = 0.07 (P3 = 0.01, P4 = 0.002, P5 = 0.0003). Conclusion: QTA is a useful tool to inform birth center OR efficiency while upholding assumed safety standards and factoring peaks and troughs of daily activity. Our findings suggest QTA is feasible to guide staffing for maternity centers of all volumes through varying model parameters. QTA can inform individual hospital-level decisions in setting staffing and space requirements to achieve safe and efficient maternity perioperative care.

Optimal workload and staffing for obstetric anesthesia services have yet to be determined. We surveyed Society of Obstetric Anesthesia and Perinatology (SOAP) Centers of Excellence (COE) for Obstetric Anesthesia Care institutions to evaluate procedure-based obstetric anesthesia workload and facility use.After institutional review board (IRB) exemption, an online survey instrument (REDCap) was sent by email (1 initial and 2 reminders) to all SOAP COEs. Survey data included the number of deliveries, cesarean delivery rate, neuraxial labor analgesia rate, the number of labor and operating rooms, and the number of in-house and backup obstetric anesthesia providers. Obstetric anesthesia activity was estimated using a time-based workload ratio per provider (Stanford Work Index, 1.0 = clinically working every minute of every hour on duty) during weekday, weeknight, and weekend shifts. We compared workload between academic and nonacademic centers and correlated operating and labor rooms with cesarean and vaginal delivery volume.Fifty-one of 53 surveys were returned (96% response rate). Data from 33 academic and 14 nonacademic US institutions were analyzed. For academic centers, median Stanford Work Index for all staff (included trainees and Certified Registered Nurse Anesthetists) was 0.20 (weekday) and 0.19 (weeknight and weekends); nonacademic centers were 0.33 (weekday, P.001 versus academic), 0.23 (weeknight, P = .009 versus academic), and 0.23 (weekends, P = .03 versus academic practices). Attending-only Stanford Work Indices were similar between academic and nonacademic centers. Total number of rooms on the obstetric suite (operating, labor, or triage room) was strongly correlated with delivery volume ( R2 = 0.55).The results outline staffing procedure-based workload ratios and facility utilization at SOAP COEs in the United States. These data can be used by other institutions that provide obstetric anesthesia services to guide their obstetric anesthesia staffing. The importance of considering the workload associated with different shifts and between academic and nonacademic centers is also highlighted. The results show that approximately one-third of an obstetric anesthesiologist's workload is spent on performing procedures. We did not, however, measure the other tasks anesthesiologists practice as peripartum physicians (eg, managing critically ill parturients, doing pre- and postprocedural evaluations, or performing emergent and unexpected procedures), and future studies are required to determine the time required to perform these tasks. Studies to determine the optimal staffing models to handle workload fluctuations and improve outcomes are also required.

Opioid abuse and dependence continues to rise in both the general population and pregnancy, with opioid overdose deaths having quadrupled in the last 15 years. Illicit drug use in last 30 days of pregnancy was over 4% with almost 0.6% documented maternal opiate use at time of birth. The management of the opioid-tolerant, buprenorphine-dependent or methadone-dependent patient in the peripartum period is reviewed. Options for treatment of opioid dependence, acute pain management, and perioperative multimodal analgesia are discussed. The effects of maternal management on neonatal abstinence syndrome are also reviewed.