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The purpose of this article is to provide a summary of the Enhanced Recovery After Cesarean delivery (ERAC) protocol written by a Society for Obstetric Anesthesia and Perinatology (SOAP) committee and approved by the SOAP Board of Directors in May 2019. The goal of the consensus statement is to provide both practical and where available, evidence-based recommendations regarding ERAC. These recommendations focus on optimizing maternal recovery, maternal-infant bonding, and perioperative outcomes after cesarean delivery. They also incorporate management strategies for this patient cohort, including recommendations from existing guidelines issued by professional organizations such as the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists. This consensus statement focuses on anesthesia-related and perioperative components of an enhanced recovery pathway for cesarean delivery and provides the level of evidence for each recommendation.

Despite significant improvements in outcomes following non-obstetric surgery with implementation of enhanced recovery after surgery (ERAS) protocols, development of these protocols for cesarean delivery is lacking. We evaluated implementation of an ERAS protocol for patients undergoing elective cesarean delivery, specifically the effect on opioid consumption, pain scores and length of stay as well as complications and re-admissions.An ERAS protocol was developed and implemented for women undergoing elective cesarean delivery. The protocol construction included specific evidence-based items applicable to peripartum management and these were grouped into the three major phases of patient care: antepartum, intrapartum and postpartum. A before-and-after study design was used to compare maternal outcomes. To account for confounders between groups, a propensity matched scoring analysis was used. The primary outcome was postpartum opioid use in mg-morphine equivalents (MMEQ).We included 357 (n=196 before; n=161 after) women who underwent elective cesarean delivery. A significant difference in opioid consumption (28.4 ± 24.1 vs 46.1 ± 37.0 MMEQ, P 0.001) and in per-day postoperative opioid consumption (10.9 ± 8.7 vs 15.1 ± 10.3 MMEQ, P 0.001), lower peak pain scores (7 [5-9] vs 8 [7-9], P=0.007) and a shorter hospital length of stay (2.5 ± 0.5 vs 2.9 ± 1.2 days, P 0.001) were found after the introduction of the ERAS protocol.Implementation of ERAS protocols for elective cesarean delivery is associated with significant improvements in analgesic and recovery outcomes. These improvements in quality of care suggest ERAS protocols should be considered for elective cesarean delivery.

To evaluate the impact of initiation of an enhanced recovery after cesarean delivery (ERAC) protocol for elective cesarean delivery (CD) on neonatal outcomes.We performed a retrospective analysis of elective CD at ≥39 weeks gestational age between September 2014 and August 2018 at a single institution before and after ERAC protocol implementation. Our primary outcome was composite neonatal complication rate and secondary outcome was rate of breastfeeding. We performed univariate analyses to detect differences in outcomes between the pre-ERAC and post-ERAC groups.We included 362 neonates born via elective CD before (n = 135) and after (n = 227) ERAC implementation. The post-ERAC group experienced fewer composite neonatal complications (33.0% vs. 47.4%, p = 0.009) and greater breastfeeding rates (80.2% vs. 67.4%, p = 0.009) compared to the pre-ERAC group.ERAC protocol implementation does not negatively impact neonates and may benefit both mother and baby.

Enhanced recovery after cesarean delivery (ERAC) programs aim to decrease maternal morbidity and aid in maternal recovery and return to baseline. Multimodal analgesia is an important element of ERAC protocols, but no consensus exists on the timing of medication administration. We compared maternal pain outcomes following scheduled cesarean delivery with modification of the timing of administration of multimodal analgesia with non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen.Before-and-after study.Labor and delivery unit at a single academic institution.NSAIDs and acetaminophen were administered as a fixed-interval alternating regimen every 3 h for the initial ERAC group (ERAC 1) and fixed-interval combined regimen every 6 h for the modified ERAC group (ERAC 2). ERAC 1 and ERAC 2 groups were compared to historical controls (Pre-ERAC).520 women undergoing scheduled cesarean delivery (Pre-ERAC n = 179, ERAC 1 n = 179, and ERAC 2 n = 162).The primary outcomes were postoperative total and daily opioid utilization as measured in morphine milligram equivalents (MME). Secondary outcomes included postoperative length of stay, maximum pain scores, and racial disparities in care.The modified schedule of non-opioid analgesics involving combined administration (ERAC 2) versus alternating administration (ERAC 1) of multimodal analgesia resulted in decreased total postoperative opioid utilization (median = 26.3 vs 52.5 MME, Bonferroni corrected P = 0.002). Total postoperative opioid utilization among the ERAC 2 group was also significantly reduced compared to the Pre-ERAC group (median = 26.3 vs 105.0 MME, Bonferroni corrected P 0.0001).Multidisciplinary teams developing or modifying ERAC protocols for scheduled cesarean delivery should consider a combined administration at fixed intervals of NSAIDs and acetaminophen throughout the hospital stay to optimize postoperative pain management.

Background Enhanced Recovery (ER) is a change management framework in which a multidisciplinary team of stakeholders utilizes evidence-based medicine to protocolize all aspects of a surgical care to allow more rapid return of function. While service-specific reports of ER adoption are common, institutional-wide adoption is complex, and reports of institution-wide ER adoption are lacking in the United States. We hypothesized that ER principles were generalizable across an institution and could be implemented across a multitude of surgical disciplines with improvements in length of stay, opioid consumption, and cost of care. Methods Following the establishment of a formal institutional ER program, ER was adopted in 9 distinct surgical subspecialties over 5 years at an academic medical center. We compared length of stay, opioid consumption, and total cost of care in all surgical subspecialties as a function of time using a segmented regression/interrupted time series statistical model. Results There were 7774 patients among 9 distinct surgical populations including 2155 patients in the pre-ER cohort and 5619 patients in the post-ER cohort. The introduction of an ER protocol was associated with several significant changes: a reduction in length of stay in 5 of 9 specialties; reduction in opioid consumption in 8 specialties; no change or reduction in maximum patient-reported pain scores; and reduction or no change in hospital costs in all specialties. The ER program was associated with an aggregate increase in profit over the study period. Conclusions Institution-wide efforts to adopt ER can generate significant improvements in patient care, opioid consumption, hospital capacity, and profitability within a large academic medical center.

Enhanced recovery protocols (ERPs) are evidenced-based interventions designed to standardize perioperative care and expedite recovery to baseline functional status after surgery. There remains a paucity of data addressing the effect of ERPs on pelvic reconstructive surgery patients. An ERP was implemented at our institution including: patient counseling, carbohydrate loading, avoidance of opioids, goal-directed fluid resuscitation, immediate postoperative feeding and early ambulation. Patients undergoing elective pelvic reconstructive surgery before and after implementation of the ERP were identified in this cohort study. One hundred eighteen patients underwent pelvic reconstructive surgery within the ERP compared with 76 historic controls. Reductions were seen in length of hospital stay (29.9 vs. 27.9 h, p = 0.04), total morphine equivalents (37.4 vs. 19.4 mg, p

The purpose of this article is to provide a brief review of current literature examining the potential oncologic protective role local anesthetics may provide in the perioperative setting during cancer surgery. Paradoxically, curative surgery for cancer appears to favor the development of recurrences and distant metastasis. The accumulated knowledge about cancer biology and our understanding of the pathophysiological events occurring during the perioperative period have opened several theories on potential mechanisms for this century old observation. In such, cell-mediated immune response, the first line attack against cancer is suppressed during the perioperative period possibly providing circulating tumor cells with a fruitful environment allowing them to escape the immune system to form local recurrence and metastasis. In parallel, surgical stress, acute pain, and inflammatory cytokines released during surgery all directly or indirectly contribute to the immunosuppression state. Current data indicates that surgery itself cannot be regarded as the sole culprit for this paradox, and other factors during the perioperative period such as anesthetic drugs or anesthesia techniques are conceivably involved as well. As an example, volatile anesthetic seem to have negative effects while propofol appears to have protective effects. Opioids were also found to be immunosuppressive and therefore may not represent an ideal choice. Of the drugs used in anesthesia, local anesthetics seem to be the most attractive with regard to cancer surgery. Depending on their mode of administration, local anesthetics have been found in several reports to directly or indirectly blunt the systemic response to surgery, preserve immune function, alter cytokine release, and interfere with cancer cell signaling pathways. They are also analgesic and have anti-inflammatory properties. The former and the latter are sought effects in the perioperative period. However, their impact on recurrence, overall survival and metastasis remains controversial.

Objectives The aim of this study was to evaluate the imaging performance of a handheld ultrasound system and the accuracy of an automated lumbar spine computer-aided detection (CAD) algorithm in the spines of human subjects. Materials and methods This study was approved by the institutional review board of the University of Virginia. The authors designed a handheld ultrasound system with enhanced bone image quality and fully automated CAD of lumbar spine anatomy. The imaging performance was evaluated by imaging the lumbar spines of 68 volunteers with body mass index between 18.5 and 48 kg/m. The accuracy, sensitivity, and specificity of the lumbar spine CAD algorithm were assessed by comparing the algorithm's results to ground-truth segmentations of neuraxial anatomy provided by radiologists. Results The lumbar spine CAD algorithm detected the epidural space with a sensitivity of 94.2% (95% confidence interval [CI], 85.1%-98.1%) and a specificity of 85.5% (95% CI, 81.7%-88.6%) and measured its depth with an error of approximately ±0.5 cm compared with measurements obtained manually from the 2-dimensional ultrasound images. The spine midline was detected with a sensitivity of 93.9% (95% CI, 85.8%-97.7%) and specificity of 91.3% (95% CI, 83.6%-96.9%), and its lateral position within the ultrasound image was measured with an error of approximately ±0.3 cm. The bone enhancement imaging mode produced images with 5.1- to 10-fold enhanced bone contrast when compared with a comparable handheld ultrasound imaging system. Conclusions The results of this study demonstrate the feasibility of CAD for assisting with real-time interpretation of ultrasound images of the lumbar spine at the bedside.

Cardiovascular disease is the leading cause of peripartum death in the United States during pregnancy. The presence of concomitant diagnoses may complicate or conflict with the management of the primary cardiovascular diagnosis and further complicate pregnancy and delivery. We describe the management of a 29-year-old, gravida 5, para 1 woman with severe peripartum cardiomyopathy during this and a previous pregnancy complicated by multiple endocrine neoplasia type and factor V Leiden thrombophilia, limiting therapeutic options and contributing to considerable perioperative management challenges.

To examine implementing an enhanced recovery after surgery (ERAS) protocol for women undergoing major gynecologic surgery at an academic institution and compare surgical outcomes before and after implementation.Two ERAS protocols were developed: a full pathway using regional anesthesia for open procedures and a light pathway without regional anesthesia for vaginal and minimally invasive procedures. Enhanced recovery after surgery pathways included extensive preoperative counseling, carbohydrate loading and oral fluids before surgery, multimodal analgesia with avoidance of intravenous opioids, intraoperative goal-directed fluid resuscitation, and immediate postoperative feeding and ambulation. A before-and-after study design was used to compare clinical outcomes, costs, and patient satisfaction. Complications and risk-adjusted length of stay were drawn from the American College of Surgeons' National Surgical Quality Improvement Program database.On the ERAS full protocol, 136 patients were compared with 211 historical controls and the median length of stay was reduced (2.0 compared with 3.0 days; P=.007) despite an increase in National Surgical Quality Improvement Program-predicted length of stay (2.5 compared with 2.0 days; P=.009). Reductions were seen in median intraoperative morphine equivalents (0.3 compared with 12.7 mg; P.001), intraoperative (285 compared with 1,250 mL; P.001) and total intravenous fluids (-917.5 compared with 1,410 mL; P.001), immediate postoperative pain scores (3.7 compared with 5.0; P.001), and total complications (21.3% compared with 40.2%; P=.004). On the ERAS light protocol, 249 patients were compared with 324 historical controls and demonstrated decreased intraoperative and postoperative morphine equivalents (0.0 compared with 13.0 mg; P.001 and 15.0 compared with 23.6 mg; P.001) and decreased intraoperative and overall net intravenous fluids (P.001). Patient satisfaction scores showed a marked and significant improvement on focus questions regarding pain control, nurses keeping patients informed, and staff teamwork; 30-day total hospital costs were significantly decreased in both ERAS groups.Implementation of ERAS protocols in gynecologic surgery was associated with a substantial decrease in intravenous fluids and morphine administration coupled with reduction in length of stay for open procedures combined with improved patient satisfaction and decreased hospital costs.

BackgroundDisagreement among many underpowered studies has led to an equivocal understanding of the efficacy of the 5-HT3 antagonist ondansetron in preventing the consequences of sympathectomy after subarachnoid anesthesia. The authors assessed the efficacy of ondansetron with respect to the overall quality and statistical power of the meta-analyses.MethodsThe authors used a standard and a newer method of meta-analysis, trial sequential analysis (TSA), to estimate adjusted CIs based on how much information has been accrued. They also used random-effects meta-analyses techniques, small trial bias assessment, selection models, sensitivity analyses, and the Grading of Recommendations on Assessment, Development, and Evaluation system. These results from the aforementioned techniques were compared, and importance of consideration of these factors was discussed.ResultsFourteen randomized placebo-controlled trials (1,045 subjects) were identified and analyzed. By using conventional meta-analyses, the authors determined that ondansetron was associated with reduction in the incidence of hypotension (relative risk = 0.62 [95% CI, 0.46 to 0.83], P = 0.001; TSA-adjusted CI, 0.34 to 1.12; I2 = 60%, P = 0.002) and bradycardia (relative risk = 0.44 [95% CI, 0.26 to 0.73], P = 0.001; TSA-adjusted CI, 0.05 to 3.85; I2 = 0%, P = 0.84). However, the authors found indications of bias among these trials. TSAs demonstrated that the meta-analysis lacked adequate information size and did not achieve statistical significance when adjusted for sparse data and repetitive testing. The Grading of Recommendations on Assessment, Development, and Evaluation system showed that the results had low to very low quality of evidence.ConclusionsThe analyses fail to confirm evidence that ondansetron reduces the incidence of hypotension and bradycardia after subarachnoid anesthesia due to the risk of bias and information sizes less than the required. As results from meta-analysis are given significant weight, it is important to carefully evaluate the quality of the evidence that is input.

Background This study evaluated the efficacy of spinal anesthesia administration by resident physicians when using an ultrasound system with automated neuraxial landmark detection capabilities. Methods 150 patients were enrolled in this trial. Anesthesiology residents placed spinals in subjects undergoing scheduled cesarean delivery using one of three techniques to identify neuraxial landmarks: palpation, ultrasound, or combined palpation and ultrasound. Ultrasound was performed using a handheld system that automatically identified neuraxial landmarks (e.g. midline, intervertebral spaces). All residents watched a 10-minute video and received 20 minutes of hands-on training prior to participating in the study. First insertion success rate was the primary end point. Results Among all patients, use of ultrasound resulted in a 11% greater first-insertion success rate (RR: 1.11 [0.85-1.47], p=0.431), a 15% reduction in needle insertions (RR: 0.85, p=0.052), and a 26% decrease in needle passes (RR: 0.74, p=0.070). In obese patients of BMI ≥ 30 kg/m2, use of ultrasound resulted in 26% greater first-insertion success rates (RR: 1.26, p=0.187), a 21% decrease in needle insertions (RR: 0.79, p=0.025), a 38% decrease in needle passes (RR: 0.62, p=0.030), and a 75% decrease in patients reporting neutral or low patient satisfaction with anesthesia administration (RR: 0.25, p=0.004). Discussion Resident anesthesiologists competently utilized the ultrasound system after receiving minimal training. Technical endpoints and patient satisfaction trended towards improvement when ultrasound was used prior to spinal placement, with stronger trends observed in obese patients. Additional study is required to fully characterize the impact of the ultrasound system on clinical efficacy.

Parturients with Fontan physiology provide unique and complex challenges to anesthesiologists. Such challenges include the maintenance of a perfect balance between preload, pulmonary vascular resistance, afterload, and cardiac output in a setting of a single ventricle physiology. The physiological changes of pregnancy add additional burden to an already “fragile” physiology, making the anesthetic management for labor and/or cesarean delivery even more complex. Understanding the impact of these changes on the Fontan physiology and the effect of anesthetic choices on this dyad (pregnancy–Fontan) is an imperative prior to caring for these patients. In an effort to determine how these patients are best managed for labor and/or cesarean delivery, we have reviewed the literature examining the peripartum anesthetic management of parturients with Fontan circulation and have identified 27 case reports.

Palpation-based techniques are the most common approaches for facilitating lumbar spine bedside procedures such as lumbar puncture and spinal and/or epidural placement. However, the efficacy of these approaches is diminished in patients whose surface landmarks are difficult to palpate due to obesity or spinal deformities. In this work, we present the imaging results of a handheld ultrasound system that was developed to image the lumbar spine and facilitate lumbar punctures in patients whose landmarks are not easily palpable. The system features two novel technologies that permit improved imaging of the lumbar spine: 1) a bone-specific ultrasound imaging mode that enhances the contrast of bone surfaces relative to nearby soft-tissue structures and 2) a real-time computer-aided detection (CAD) algorithm that automatically identifies the spine midline, spinous processes, interlaminar spaces, and the depths to key landmarks. The imaging performance of these algorithms was assessed in 80 volunteers (BMI between 18.5 and 48 kg/m2) and was benchmarked against image interpretations provided by three radiologists. The CAD algorithm detected the interlaminar space with a sensitivity of 94.2% and a specificity of 85.5% and the spine midline with a sensitivity of 93.9% and a specificity of 91.3%. Overall, the results of this study demonstrate the feasibility of using a lumbar spine CAD algorithm and bone enhancement imaging technology to assist with image interpretation of ultrasound images of the lumbar spine.

ADVANCES IN SURGICAL TECHNIQUES have made survival to pregnancy possible in many patients with various types of congenitally abnormal hearts. Outcomes in these patients with adult congenital heart disease (ACHD) usually are favorable. However, when palliated or unrepaired, pregnancy represents a danger to the well-being of the expectant mother and her unborn child. This unusual case illustrates such an interaction. Additionally, the importance of making a correct diagnosis, the importance of early interdisciplinary team intervention, and maternal and fetal outcomes are highlighted.

Ultrasound data motion tracking is widely used to estimate relative tissue/transducer motion, for example in freehand 3-D imaging, in which successive 2-D ultrasound scan planes are registered in a 3-D volume. Speckle-tracking and decorrelation-based methods are used to estimate motion in the azimuthal and elevational planes. However, the performance of speckle-tracking is significantly degraded in sector-scan systems because of point-spread function rotation with lateral motion. In this paper, we develop a new method for joint azimuthal-elevational motion estimation based on the complex correlation of individual IQ-demodulated sector-scan A-lines arising from tissue motion in 3-D space. We show that our method has performance benefits over both speckle-tracking and decorrelation-based tracking for motion estimation in sector-scan systems, particularly when there is both elevational and azimuthal motion. Motion-tracking efficacy is further demonstrated by improved freehand imaging of a known target (anatomically accurate 3-D-printed lumbar spine model) in a tissue-mimicking phantom, with an rms surface distance error of 1.2 mm, compared with 2.43 mm for conventional methods. These data indicate that the new algorithm is capable of improved tracking performance for sector scan systems, enabling effective freehand 3-D scanning.

Background Multiple animal studies suggest that ondansetron ameliorates opioid-induced hyperalgesia and tolerance. In this study, we aimed to determine if the administration of ondansetron prior to spinal anesthesia would have an effect on intrathecal opioid-induced acute opioid tolerance, postoperative pain, and analgesic requirements in patients undergoing cesarean delivery with spinal anesthesia. Methods Eighty-six patients undergoing elective cesarean delivery were recruited and randomly allocated to receive either 8 mg intravenous ondansetron (n = 44) or placebo (n = 42) in a prospective, double-blind design. All patients received spinal anesthesia consisting of 15 mg bupivacaine, 20 μg of fentanyl, and 100 μg of preservative-free morphine. We used linear mixed-effects models to assess the difference in pain and opioid consumption in the first 24 hours after surgery between the 2 groups. Results No differences between the 2 groups were found in age, body mass index, American Society of Anesthesiologists physical status scores, duration of surgery, or sensory and motor block characteristics. There was no difference between the 2 groups in postoperative pain scores (P = 0.95) or opioid consumption (P = 0.68). Conclusions In patients undergoing cesarean delivery under spinal anesthesia with intrathecal opioids, the administration of ondansetron prior to spinal anesthesia did not significantly affect postoperative pain scores or opioid consumption. Thus, the administration of ondansetron did not have an effect on acute opioid tolerance in our study.

BACKGROUND Disagreement among many underpowered studies has led to an equivocal understanding of the efficacy of the 5-HT3 antagonist ondansetron in preventing the consequences of sympathectomy after subarachnoid anesthesia. The authors assessed the efficacy of ondansetron with respect to the overall quality and statistical power of the meta-analyses. METHODS The authors used a standard and a newer method of meta-analysis, trial sequential analysis (TSA), to estimate adjusted CIs based on how much information has been accrued. They also used random-effects meta-analyses techniques, small trial bias assessment, selection models, sensitivity analyses, and the Grading of Recommendations on Assessment, Development, and Evaluation system. These results from the aforementioned techniques were compared, and importance of consideration of these factors was discussed. RESULTS Fourteen randomized placebo-controlled trials (1,045 subjects) were identified and analyzed. By using conventional meta-analyses, the authors determined that ondansetron was associated with reduction in the incidence of hypotension (relative risk = 0.62 [95% CI, 0.46 to 0.83], P = 0.001; TSA-adjusted CI, 0.34 to 1.12; I = 60%, P = 0.002) and bradycardia (relative risk = 0.44 [95% CI, 0.26 to 0.73], P = 0.001; TSA-adjusted CI, 0.05 to 3.85; I = 0%, P = 0.84). However, the authors found indications of bias among these trials. TSAs demonstrated that the meta-analysis lacked adequate information size and did not achieve statistical significance when adjusted for sparse data and repetitive testing. The Grading of Recommendations on Assessment, Development, and Evaluation system showed that the results had low to very low quality of evidence. CONCLUSIONS The analyses fail to confirm evidence that ondansetron reduces the incidence of hypotension and bradycardia after subarachnoid anesthesia due to the risk of bias and information sizes less than the required. As results from meta-analysis are given significant weight, it is important to carefully evaluate the quality of the evidence that is input.

Study objectives Obstetric anesthesiologists commonly care for high-risk obstetric patients. However, it is unclear how obstetricians refer these patients for anesthetic evaluation and whether obstetric anesthesia clinics (OACs) are used. Our study aims were to determine the availability and characteristics of OACs at US academic obstetric centers and to evaluate how high-risk patients are referred for anesthetic evaluation. Design This is a survey study design. Setting University of Virginia Center for Survey Research. Intervention A survey questionnaire was constructed and electronically mailed to obstetric anesthesia directors based at hospitals with accredited anesthesia residency programs. Measurement One hundred thirteen obstetric anesthesia directors were contacted. We asked questions about the presence and operational characteristics of OACs. These characteristics were compared between hospitals with high, medium, and low annual delivery volumes. We also inquired about how high-risk patients are referred for anesthetic evaluation. Frequencies were compared using Fisher test, with P Main results The survey response rate was 58% (n = 65). Overall, only 25 (38%) respondents indicated that their hospital operated an OAC. The proportion of hospitals with an OAC and OAC operational hours did not significantly vary according to hospital delivery volume. Among hospitals with an OAC, 24% respondents indicated that obstetricians always refer high-risk patients to the OAC. Nearly half of respondents (44%) indicated that high-risk patients usually or sometimes receive their first anesthetic evaluation during the delivery hospitalization. Conclusion Our findings suggest that, among US academic centers, OACs are uncommon and the referral of high-risk patients for antenatal anesthetic evaluation is inconsistent. These findings suggest that more structured referral processes are needed to ensure that high-risk women receive anesthetic evaluation before labor or delivery.

Introduction Hypotension is the most common complication after subarachnoid anesthesia for cesarean delivery. Several therapeutic and preventive measures are used to attenuate this side effect. Serotonin receptor–blocking drugs have been suggested as one such approach. We sought to determine whether prophylactically administered intravenous ondansetron could attenuate hypotension in patients undergoing elective cesarean delivery performed under subarachnoid anesthesia. Methods Eighty-six patients undergoing elective cesarean delivery were recruited and randomly allocated to receive either 8 mg intravenous ondansetron (group O; n = 44) or placebo (group P; n = 42) in a prospective double-blind design. Systolic blood pressure (SBP), mean arterial pressure (MAP), diastolic blood pressure (DBP), and heart rate (HR) were measured at baseline and at 3-minute intervals from the time of initiation of subarachnoid anesthesia until delivery. Ondansetron effect on hemodynamics (SBP, DBP, MAP, and HR) was quantified and analyzed using a linear mixed effect model. Results We did not find differences in SBP (P = 0.78), MAP (P = 0.89), DBP (P = 0.82), or HR (P = 0.18) between the 2 groups during the study period. Phenylephrine requirements to treat hypotension were 350 μg (175–700 μg) in group O and 450 μg (300–700 μg) in group P (P = 0.30). The incidence of pruritus was 63% (n = 28 of 44) in group O and 56% (n = 23 of 42) in group P (difference, 0.08 [95% confidence interval, −0.23 to 0.41], P = 0.59). No difference in the incidence of nausea and vomiting or sensory level was found. Conclusions Ondansetron premedication does not attenuate hemodynamic changes after subarachnoid anesthesia nor does it reduce the amount of vasopressor use, pruritus, or nausea and vomiting.

Background One of the modalities of treatment for breast cancer surgery pain is opioids, and opioids are associated with adverse effects such as itching and postoperative nausea and vomiting (PONV). Intravenous (IV) lidocaine has been shown to reduce opioid consumption and to improve overall postoperative outcomes in abdominal surgery. In this study, we tested the effect of intraoperative IV lidocaine infusion on the quality of postoperative recovery after breast cancer surgery. Methods Seventy-one patients undergoing breast cancer surgery were randomly assigned to receive either placebo (group P; n = 34) or IV lidocaine (group L; n = 37, bolus 1.5 mg/kg at induction, then infusion at 2 mg/kg/h, stopped 2 hours after the end of surgery) in a prospective double-blind design. Intraoperative and postoperative morphine consumption was calculated. Postoperative pain scores, PONV, and fatigue were assessed at 2, 24, and 48 hours after surgery. Duration of postoperative hospital stay was recorded. Results Demographics were the same between the groups. There was no statistically significant difference in intraoperative or postoperative morphine consumption (P = 0.188 and P = 0.758) between groups. Overall pain scores either at rest or activity (P = 0.348 and P = 0.810, respectively), PONV (P = 0.350), fatigue (P = 0.758), or duration of postoperative hospital stay (P = 0.218) were not statistically different. Conclusions Our findings did not show a significant effect of IV lidocaine during breast cancer surgery on opioid consumption, pain score, PONV, or fatigue, indicating that the benefit of this approach does not generalize across all types of surgery.

Technical difficulties, poor image quality and reliance on pattern identifications represent some of the drawbacks of two-dimensional ultrasound imaging of spinal bone anatomy. To overcome these limitations, this study sought to develop real-time volumetric imaging of the spine using a portable handheld device. The device measured 19.2 cm × 9.2 cm × 9.0 cm and imaged at 5 MHz centre frequency. 2D imaging under conventional ultrasound and volumetric (3D) imaging in real time was achieved and verified by inspection using a custom spine phantom. Further device performance was assessed and revealed a 75-min battery life and an average frame rate of 17.7 Hz in volumetric imaging mode. The results suggest that real-time volumetric imaging of the spine is a feasible technique for more intuitive visualization of the spine. These results may have important ramifications for a large array of neuraxial procedures.

There is growing evidence suggesting that certain interventions during the perioperative period may have an impact on long-term outcomes of patients undergoing cancer surgery. It has been postulated that regional anesthetic techniques and other targeted interventions could decrease the risk of cancer recurrence, therefore increasing the disease-free interval and overall survival, of those patients undergoing cancer surgery. Conversely, however, it has also been theorized that volatile anesthetics, opioids and surgery itself are directly or indirectly linked to cancer recurrence. Among the opioids used during the perioperative period, morphine has raised most of the concerns regarding its putative effects on cancer. Indeed, morphine has been found to affect many cellular and cell signaling pathways involved in cancer genesis and possibly causing tumor growth. This chapter will focus on the role of the perioperative period on cancer progression, the recognized mechanisms of action of morphine on cancer and alternative pain management options for patients undergoing cancer surgery.

Ultrasound-based motion tracking is widely used to estimate both tissue motion, for diagnostic purposes, and to estimate bulk transducer motion relative to tissue in freehand 3D imaging, where successive 2D ultrasound scan planes are registered in a 3D volume. Speckle-tracking and decorrelation-based methods are used to estimate motion in the azimuthal and elevational planes. However, the performance of speckle-tracking is significantly degraded in sector-scan systems due to point spread function (PSF) rotation with lateral motion. In these systems, when there is both azimuthal and elevational motion, the accuracy of estimates in both planes are reduced. In this paper, we develop a new method for joint azimuthal-elevational motion estimation based on the complex correlation of individual IQ-demodulated sector-scan A-lines arising from tissue motion in 3D space. Using a new statistical model, we show that the phase of per-line decorrelation is linearly related to the dot product of the tissue motion vector and each A-line's direction unit vector. Motion-tracking efficacy is demonstrated by improved freehand imaging of a known target (anatomically accurate 3D-printed lumbar spine model) in a tissue-mimicking phantom, with a root mean squared (RMS) surface distance error of 1.2 mm, compared to 2.43 mm using a conventional approach. These data indicate that the new algorithm is capable of improved tracking performance for sector-scan systems, enabling effective freehand 3D scanning.

The portability, low cost, and non-ionizing radiation associated with medical ultrasound suggest that it has potential as a superior alternative to X-ray for bone imaging. However, when conventional ultrasound imaging systems are used for bone imaging, clinical acceptance is frequently limited by artifacts derived from reflections occurring away from the main axis of the acoustic beam. In this paper, the physical source of off-axis artifacts and the effect of transducer geometry on these artifacts are investigated in simulation and experimental studies. In agreement with diffraction theory, the sampled linear-array geometry possessed increased off-axis energy compared with single-element piston geometry, and therefore, exhibited greater levels of artifact signal. Simulation and experimental results demonstrated that the linear-array geometry exhibited increased artifact signal when the center frequency increased, when energy off-axis to the main acoustic beam (i.e., grating lobes) was perpendicularly incident upon off-axis surfaces, and when off-axis surfaces were specular rather than diffusive. The simulation model used to simulate specular reflections was validated experimentally and a correlation coefficient of 0.97 between experimental and simulated peak reflection contrast was observed. In ex vivo experiments, the piston geometry yielded 4 and 6.2 dB average contrast improvement compared with the linear array when imaging the spinous process and interlaminar space of an animal spine, respectively. This work indicates that off-axis reflections are a major source of ultrasound image artifacts, particularly in environments comprising specular reflecting (i.e., bone or bone-like) objects. Transducer geometries with reduced sensitivity to off-axis surface reflections, such as a piston transducer geometry, yield significant reductions in image artifact.

High spinal block is a potentially fatal complication of spinal anesthesia, with an incidence of 0.6 per 1000. Current prevention strategies include decreasing the dose of local anesthetic drug and altering patient positioning such that the location of hyperbaric anesthetic drugs in the neuraxis can be manipulated by gravity. Incorporation of a ferrofluid into a local anesthetic solution, combined with application of an external magnetic field in an in vitro spine model, allowed control of position of a solution of ferrofluid, dye, and local anesthetic against gravity, suggesting an additional mechanism by which anesthesia providers may prevent high spinal block.

A wealth of basic science data supports the hypothesis that the surgical stress response increases the likelihood of cancer dissemination and metastasis during and after cancer surgery. Anesthetic management of the cancer patient, therefore, could potentially influence long-term outcome. Preclinical data suggest that beneficial approaches might include selection of induction drugs such as propofol, minimizing the use of volatile anesthetics, and coadministration of cyclooxygenase antagonists with systemic opioids. Retrospective clinical trials suggest that the addition of regional anesthesia might decrease recurrence after cancer surgery. Other factors such as blood transfusion, temperature regulation, and statin administration may also affect long-term outcome.

The main objective of this study was to compare platelet serotonin (5-HT) uptake between early-onset alcoholics (EOA) and late-onset alcoholics (LOA). Subjects were 24 dependent male alcoholic in-patients and 21 healthy control subjects. 5-HT uptake was quantified by incubating platelets with [3H]5-HT at various concentrations (0.5 to 1000 nM). 5-HT uptake was higher in EOA, compared to both the LOA and control groups (P0.02) at the highest 5-HT concentration (1000 nM). No significant difference was found between LOA and controls or between EOA + LOA and controls. Previous studies have shown that 5-HT uptake was higher in platelets, lymphocytes, and brain of alcoholics vs controls, but our data suggest that higher platelet serotonin transporter function is limited to EOA, not LOA.