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The prevalence of pregnant people with opioid use disorder (OUD), including those receiving medications for opioid use disorder (MOUD), is increasing. Challenges associated with pain management in people with OUD include tolerance, opioid-induced hyperalgesia, and risk for return to use. Yet, there are few evidence-based recommendations for pain management in the setting of pregnancy and the postpartum period, and many peripartum pain management studies exclude people with OUD. This scoping review summarized the available literature on peridelivery pain management in people with OUD, methodologies used, and identified specific areas of knowledge gaps. PubMed and Embase were comprehensively searched for publications in all languages on peripartum pain management among people with OUD, both treated with MOUD and untreated. Potential articles were screened by title, abstract, and full text. Data abstracted were descriptively analyzed to map available evidence and identify areas of limited or no evidence. A total of 994 publications were imported for screening on title, abstracts, and full text, yielding 84 publications identified for full review: 32 (38.1%) review articles, 14 (16.7%) retrospective studies, and 8 (9.5%) case reports. There were 5 randomized controlled trials. Most studies (64%) were published in perinatology (32; 38.1%) journals or anesthesiology (22; 26.2%) journals. Specific areas lacking trial or systematic review evidence include: (1) methods to optimize psychological and psychosocial comorbidities relevant to acute pain management around delivery; (2) alternative nonopioid and nonpharmacologic analgesia methods; (3) whether or not to use opioids for severe breakthrough pain and how best to prescribe and monitor its use after discharge; (4) monitoring for respiratory depression and sedation with coadministration of other analgesics; (5) optimal neuraxial analgesia dosing and adjuncts; and (6) benefits of abdominal wall blocks after cesarean delivery. No publications discussed naloxone coprescribing in the labor and delivery setting. We observed an increasing number of publications on peripartum pain management in pregnant people with OUD. However, existing published works are low on the pyramid of evidence (reviews, opinions, and retrospective studies), with a paucity of original research articles (6%). Opinions are conflicting on the utility and disutility of various analgesic interventions. Studies generating high-quality evidence on this topic are needed to inform care for pregnant people with OUD. Specific research areas are identified, including utility and disutility of short-term opioid use for postpartum pain management, role of continuous wound infiltration and truncal nerve blocks, nonpharmacologic analgesia options, and the best methods to support psychosocial aspects of pain management.

Since the advent of neuraxial analgesia for labor, approaches to maintaining intrapartum pain relief have seen significant advancement. Through pharmacologic innovations and improved drug delivery mechanisms, current neuraxial labor analgesia maintenance techniques have been shaped by efforts to maximize patient comfort during the birthing process, while minimizing undesirable side effects and promoting the unimpeded progress of labor. To these ends, a modern anesthesiologist may avail themselves of several techniques, including programmed intermittent epidural bolus (PIEB), patient controlled epidural analgesia (PCEA) and dilute concentration local anesthetic + opioid epidural solutions. We explore the historical development and the evidential underpinnings of these techniques, in addition to several contemporary neuraxial labor analgesia practices. We also summarize current understanding of the effects these interventions have on maternal/fetal health and the labor course, as well as several important aspects of analgesic safety and monitoring.

The goal of this systematic review is to assess the incidence, prevalence, and timing of common postpartum (up to 1 year after delivery) medical, surgical/procedural, and psychosocial complications and mortality.Childbirth is the most common cause for hospitalization, and cesarean delivery is the most commonly performed inpatient surgery. After delivery, mothers are at risk of short- and long-term complications that can impact their well-being. The results of this review will inform evidence-based recommendations for patient education, monitoring, and follow-up.We will include studies performed in Canada and/or the United States that report the incidence or prevalence of medical, procedural/surgical, and psychosocial complications within 1 year postpartum. Observational studies (analytical cross-sectional studies, retrospective and prospective cohorts), randomized or non-randomized controlled trials with a control or standard of care group, systematic reviews, and meta-analyses will be included. Studies with fewer than 100 patients, participants younger than 18 years, no reporting of duration, or focus on patients with a specific condition rather than a general postpartum population will be excluded.The search strategy was codeveloped with a medical librarian and included full-text English-language articles published within the past 10 years (2011-2021) in PubMed, CINHAL, Web of Science, and Cochrane Database of Systematic Reviews. Screening, critical appraisal, and data extraction will be performed by two independent reviewers using Covidence, standardized JBI tools, and a standardized form, respectively. For each complication, the incidence or prevalence, timing of the frequency measurement, and duration of follow-up from individual studies will be determined. Meta-analysis will be performed if feasible.PROSPERO CRD42022303047.

In this Continuing Professional Development module, we review the practical pharmacology of tranexamic acid and its clinical use in trauma, obstetrics, and major orthopedic surgery. Tranexamic acid is a synthetic drug that inhibits fibrinolysis. Multiple clinical trials in various clinical settings have shown that it can reduce blood loss, transfusion rates, and bleeding-associated mortality. In trauma and obstetrical bleeding, early tranexamic acid administration (< three hours) may have greater clinical benefits. Overall, tranexamic acid use appears safe with no significant increase of thromboembolic or seizure events. Nevertheless, current evidence has limitations related to wide heterogeneity in dose, route, and timing of drug administration, as well as generalizability of the large-scale trial findings to higher income nations. Tranexamic acid is an efficacious and safe pharmacological-based blood conservation technique in the management of clinically significant hemorrhage. All anesthesiologists should have a good understanding of the pharmacotherapeutic properties and perioperative role of tranexamic acid therapy both inside and outside of the operating room. The use of tranexamic acid is likely to continue to rise with endorsement by various clinical guidelines and healthcare organizations. Further quantitative research is needed to evaluate optimal dosing and drug efficacy in these clinical scenarios.

Labour epidural analgesia (LEA) is an evolving field. Various neuraxial techniques and dosing regimens are available to the modern obstetric anesthesia provider, allowing for significant practice variability. To begin a search for consensus on optimal care, we sought to query fellowship training practices for LEA.We conducted an electronic survey of institutions with American Council for Graduate Medical Education-accredited obstetric anesthesiology fellowship programs. We studied the frequency of epidural initiation techniques, including combined spinal epidural (CSE), dural puncture epidural, and epidural bolus. For maintenance techniques, we appraised the use of continuous epidural infusion, programmed intermittent bolus (PIEB), and patient-controlled epidural analgesia (PCEA).Of 40 institutions surveyed, we received 32 responses (80% response rate). Twenty-eight of 40 (70%) were included in the analysis. A plurality of institutions (12/28; 43%) preferred CSE, and among those who used CSE, 23/27 (85%) included intrathecal opioids. A majority of institutions used protocols with PIEB (55%), while almost all (92%) used PCEA. Most participants (88%) reported using dilute concentration maintenance infusions of 0.1% bupivacaine/ropivacaine or less.Despite significant variability in LEA practice, some clear patterns emerged in our survey, including preference for opioid-containing CSE and maintenance with PIEB, PCEA, and dilute epidural solutions.RéSUMé: OBJECTIF: L’analgésie péridurale obstétricale (APO) est un domaine en évolution. Diverses techniques neuraxiales et posologies sont disponibles pour le praticien en anesthésie obstétricale moderne, ce qui permet une variabilité significative de la pratique. Pour démarrer une recherche de consensus sur les soins optimaux, nous avons cherché à déterminer les pratiques d’APO dans le cadre de formation des fellows. MéTHODE: Nous avons réalisé une enquête électronique auprès d’établissements possédant des programmes de fellowship en anesthésiologie obstétricale accrédités par l’American Council for Graduate Medical Education. Nous avons étudié la fréquence des techniques de péridurale, notamment de rachi-péridurale combinée (RPC), de péridurale avec ponction durale et de bolus péridural. Pour les techniques de maintien, nous avons évalué l’utilisation de l’analgésie péridurale par perfusion continue, l’administration programmée de bolus périduraux (PIEB; programmed intermittent epidural bolus) et l’analgésie péridurale contrôlée par la patiente (APCP). RéSULTATS: Sur les 40 établissements sondés, nous avons reçu 32 réponses (taux de réponse de 80 %). Vingt-huit des 40 (70 %) établissements ont été inclus dans l’analyse. Plusieurs institutions (12/28; 43 %) ont répondu qu’elles préféraient la RPC, et parmi celles qui utilisaient la RPC, 23/27 (85 %) incluaient des opioïdes intrathécaux. La majorité des établissements utilisaient des protocoles avec le PIEB (55 %), tandis que presque tous (92 %) utilisaient l’APCP. La plupart des établissements participants (88 %) ont rapporté utiliser des perfusions de maintien à des concentrations diluées de bupivacaïne/ropivacaïne de 0,1 % ou moins. CONCLUSION: Malgré une variabilité significative dans la pratique de l’APO, certaines tendances claires ont émergé dans notre sondage, notamment une préférence pour les RPC contenant des opioïdes et le maintien avec un PIEB, une APCP et des solutions péridurales diluées.

Pain is a risk factor for postpartum depression (PPD) and labour epidural analgesia (LEA) may lower the incidence of PPD. We evaluated depressive symptoms risk at three, six, and 12 months postpartum in women with LEA compared with women without LEA. With ethics approval, hypotheses were tested using data from a longitudinal prospective observational cohort study between January 2015 and January 2019 in nulliparous women aged ≥ 18 yr with uncomplicated, singleton pregnancies. Email surveys were completed at baseline (18–20 weeks’ gestation) and at three-, six- and 12 months postpartum, including the Edinburgh Postpartum Depression Scale (EPDS). Maternal, infant, and anesthesia characteristics were abstracted from electronic databases. The EPDS scores at three, six, and 12 months postpartum were analyzed using generalized estimating equations with and without covariates. Of the 909 women who consented to participate, 709 women were included in the study. Antenatal EPDS scores, not LEA, predicted postpartum depressive symptom risk (P 0.05). This study did not identify an association between LEA and risk of depressive symptoms postpartum, although small mean differences between groups cannot be ruled out. Future studies should focus on other modifiable variables that influence the development of PPD.

Background Postoperative nausea and/or vomiting affects up to 80% of parturients undergoing cesarean delivery, but there is a lack of obstetric-specific risk-prediction models. We performed this study to identify postoperative nausea/vomiting risk factors in parturients undergoing cesarean delivery, formulate an obstetric-specific prediction model (Duke score), and compare its performance against the Apfel score. Methods A post-hoc analysis of data from two randomized controlled trials studying nausea/vomiting in women undergoing cesarean delivery with intrathecal morphine. Potential risk factors for postoperative nausea/vomiting within 24 h of surgery with univariate associations with P ≤0.20 were considered for inclusion in the multivariable analysis. After identifying the final multivariable model, we derived our Duke score by assigning points to the selected factors. We then tested the association of the Duke and Apfel scores with postoperative nausea and vomiting, and compared the area-under-the-receiver operating characteristic curve. Results Analysis included 260 parturients, of whom 146 (56.2%) experienced postoperative nausea/vomiting. Non-smoking during pregnancy (OR 2.29 [95% CI 1.12 to 4.67], P=0.023), and history of postoperative nausea/vomiting after cesarean delivery and/or morning sickness (2.09 [1.12 to 3.91], P=0.021) were independent predictors of postoperative nausea/vomiting and included in the Duke score. Both Duke and Apfel scores trended linearly with postoperative nausea/vomiting risk (Duke P=0.001; Apfel P=0.049) and had comparable areas-under-the-receiver operating characteristic curve (Duke 0.63 [0.57 to 0.70]; Apfel 0.59 [0.52 to 0.65], P=0.155). Conclusions Both Duke and Apfel scores exhibited similar but poor predictive performance. Until better tools are developed, routine prophylactic anti-emetics appears to be a reasonable approach in this patient population.

Purpose Patient preferences for labor epidural analgesia (LEA) have been incompletely evaluated. This study aimed to determine the importance of various LEA outcomes to both antenatal and postpartum patients. Methods This was a cross-sectional study approved by the institutional ethics board. Questionnaires were distributed to two separate and distinct cohorts screened for eligibility: pregnant patients at an antenatal visit and postpartum patients during childbirth admission. A list of common LEA outcomes was compiled using research published in leading anesthesia journals. Participants ranked the outcomes according to perceived importance. They assigned each a number from 1 to 10 (priority ranking; 1 indicated the highest priority outcome and 10 the least). They were also asked to 'spend' $100 towards the outcomes (relative value scale), allocating more money to outcomes more important to them. Results Two hundred twentyquestionnaires were completed (105 antenatal, 115 postpartum). 'Achieving desired pain relief' was the most important outcome for both cohorts. It was valued more by the postpartum cohort (Median $50 (25 - 60) vs $30 (18 - 50)). 'Overall satisfaction with the pain management,''experiencing a short time to achieve pain relief,'and 'experiencing a short duration of labor' received more money than avoiding various LEA-related side effects. The postpartum cohort ranked 'experiencing a short time to achieve pain relief' as more important than the antenatal cohort (Median 5 (3 - 7) vs 3 (2 - 5)). Conclusions Achieving the desired pain relief was the highest LEA outcome preference for both antenatal and postpartum patients. Avoiding side effects was less important relative to pain-related outcomes.

This scoping review aimed to summarize the current literature on postpartum psychiatric disorders (e.g., postpartum depression, postpartum anxiety, postpartum post-traumatic stress disorder) and the possible relationship of these disorders to the use of pharmacologic labour analgesia (e.g., epidural analgesia, nitrous oxide, parenteral opioids) to identify knowledge gaps that may aid in the planning of future research. PubMed, PsycINFO, CINAHL, and EMBASE were searched from inception to November 9, 2018 for studies that included both labour analgesia and the postpartum psychiatric disorders specified above. Two reviewers assessed the studies and extracted the data. Of the 990 identified citations, 17 studies were included for analysis. Existing studies have small sample sizes and are observational cohorts in design. Patient psychiatric risk factors, method of delivery, and type of labour analgesia received were inconsistent among studies. Most studies relied on screening tests for diagnosing postpartum psychiatric illness and did not assess the impact of labour analgesia on postpartum psychiatric illness as the primary study objective. Future studies should correlate screen-positive findings with clinical diagnosis; consider adjusting the timing of screening to include the antepartum period, early postpartum, and late postpartum periods; and consider the degree of labour pain relief and the specific pharmacologic labour analgesia used when evaluating postpartum psychiatric disorders.

Improved patient-provider relationships can positively influence patient outcomes. Sexual and gender minorities (SGM) represent a wide variety of marginalized populations. There is an absence of studies examining the inclusion of SGM-related health education within postgraduate training in anesthesia. This study’s objective was to perform an environmental scan of the educational content of North American obstetric anesthesia fellowship programs. An online survey was developed based on a review of the existing literature assessing the presence of SGM content within other healthcare-provider curricula. The survey instrument was distributed electronically to 50 program directors of North American obstetric anesthesia fellowship programs. Survey responses were summarized using descriptive statistics. Survey responses were received from 30 of the 50 program directors (60%). Of these, 54% (14/26) felt their curriculum adequately prepares fellows to care for SGM patients, yet only 19% (5/26) of participants stated that SGM content was part of their curriculum and 31% (8/26) would like to see more incorporated in the future. Perceived lack of need was chosen as the biggest barrier to curricular inclusion of SGM education (46%; 12/26), followed by lack of available/interested faculty (19%; 5/26) and time (19%; 5/26). Our results suggest that, although curriculum leaders appreciate that SGM patients are encountered within the practice of obstetric anesthesia, most fellowship programs do not explicitly include SGM curricular content. Nevertheless, there appears to be interest in developing SGM curricular content for obstetric anesthesia fellowship training. Future steps should include perspectives of trainees and patients to inform curricular content.

BackgroundEarly reports associating severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection with adverse pregnancy outcomes were biased by including only women with severe disease without controls. The Society for Obstetric Anesthesia and Perinatology (SOAP) coronavirus disease 2019 (COVID-19) registry was created to compare peripartum outcomes and anesthetic utilization in women with and without SARS-CoV-2 infection delivering at institutions with widespread testing.MethodsDeliveries from 14 US medical centers, from March 19 to May 31, 2020, were included. Peripartum infection was defined as a positive SARS-CoV-2 polymerase chain reaction test within 14 days of delivery. Consecutive SARS-CoV-2-infected patients with randomly selected control patients were sampled (1:2 ratio) with controls delivering during the same day without a positive test. Outcomes were obstetric (eg, delivery mode, hypertensive disorders of pregnancy, and delivery

We conducted a Cochrane systematic review on the effectiveness of supplemental intravenous crystalloid administration in preventing postoperative nausea and vomiting. We included randomised controlled trials of patients undergoing surgery under general anaesthesia and given supplemental peri-operative intravenous crystalloid. Our primary outcomes were the risk of postoperative nausea and the risk of postoperative vomiting. We assessed the risk of bias for each included study and applied the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework for the certainty of evidence. We included 41 studies. We found that the intervention probably reduces the overall risk of postoperative nausea, the risk ratio (95%CI) being 0.62 (0.51-0.75) (I2 =57%, p&nbsp

The majority of women undergoing cesarean delivery in the United States receive neuraxial morphine, the most effective form of postoperative analgesia for this surgery. Current American Society of Anesthesiologists (ASA) and American Society of Regional Anesthesia and Pain Medicine (ASRA) recommend respiratory monitoring standards following neuraxial morphine administration in the general surgical population that may be too frequent and intensive when applied to the healthy obstetric population receiving a single dose of neuraxial morphine at the time of surgery. There is limited evidence to support or guide the optimal modality, frequency, and duration of respiratory monitoring in the postoperative cesarean delivery patient receiving a single dose of neuraxial morphine. Consistent with the mission of the Society for Obstetric Anesthesia and Perinatology (SOAP) to improve outcomes in pregnancy for women and neonates, the purpose of this consensus statement is to encourage the use of this highly effective analgesic technique while promoting safe practice and patient-centered care. The document aims to reduce unnecessary interruptions from respiratory monitoring in healthy mothers while focusing vigilance on monitoring in those women at highest risk for respiratory depression following neuraxial morphine administration. This consensus statement promotes the use of low-dose neuraxial morphine and multimodal analgesia after cesarean delivery, gives perspective on the safety of this analgesic technique in healthy women, and promotes patient risk stratification and perioperative risk assessment to determine and adjust the intensity, frequency, and duration of respiratory monitoring.

Background: This study was a proof of concept of a novel means to evaluate microcirculatory changes during spinal anesthesia for cesarean delivery. It sought to examine the distributive circulatory effects of spinal anesthesia and evaluate the impact of phenylephrine administration on the microcirculation of these women. Methods: After Research Ethics Board approval, healthy, non-laboring pregnant women with singleton, term pregnancies scheduled for elective cesarean delivery were recruited. Participants were randomly assigned to receive either phenylephrine infusion or phenylephrine bolus. Spinal anesthesia was standardized. A sidestream dark-field (SDF) MicroScan ® video microscope was applied to the sublingual mucosa to obtain microcirculation videos in five different visual fields. Videos were made before and after spinal anesthesia. The resultant videos were analyzed randomly and blindly. The mean microvascular flow index (MFI) values were compared before and after spinal anesthesia. The difference in MFI following spinal anesthesia was compared between phenylephrine infusion and bolus groups. Results: Thirty-two patients were recruited for the study; 22 patients had complete video sets for analysis. Baseline characteristics were similar between the two groups, including preoperative hemodynamics. There were no significant differences between pre- and post-spinal MFI. The post-spinal MFI within the infusion group (mean ± standard deviation: 2.74 ± 0.21) was not significantly different from the bolus group (2.56 ± 0.42, P = 0.22). Conclusion: Despite theoretical physiological implications of spinal anesthesia and phenylephrine on the microcirculation, significant alteration of the MFI was not observed between pre- and post-spinal anesthesia (within group). Additionally, despite an eight-fold larger phenylephrine dose for continuous infusion prophylaxis used in this group of women, this did not result in a significant alteration of the microcirculation compared to those who received phenylephrine treatment for hypotension (between groups). J Clin Med Res. 2019;11(8):543-549 doi: https://doi.org/10.14740/jocmr3778

Cesarean delivery (CD) is the most commonly performed inpatient surgery in Canada, with 103,425 performed in 2016–2017. Mobile technology can contribute to patient-centred perioperative care. Our aim was to involve patients and anesthesiologists in designing a mobile application to enhance the perioperative care of CD patients. We completed an exploratory qualitative study involving three iterative design cycles. Individual structured phone or in-person interviews with CD patients (n = 15) and anesthesiologists (n = 9) were conducted. Thematic analysis was used to 1) assess gaps and opportunities in the anesthesiology care after CD, 2) identify roles and limitations of mobile application technology in bridging perioperative care, and 3) to solicit feedback on a prototype mobile application for the anesthesiology postoperative care of elective CD patients. Patients and anesthesiologists were in favour of adding mobile applications to the interdisciplinary perioperative management of patients undergoing CD, particularly for providing reliable information, identifying and following patients with complications, and research in perioperative outcomes. Medical–legal issues, privacy, workflow, and payment policy frameworks are barriers for mobile technology linking patients and anesthesiologists. Our final prototype was refined to focus on timely, concise education and self-monitoring. The participant-driven changes in direction of the prototype showed the importance of involving key stakeholders early. This study provides guidance on further iterative development and implementation of an interdisciplinary mobile platform for patient-centred perioperative care and outcomes research.

ImportanceMaternal depression is frequently reported in the postpartum period, with an estimated prevalence of approximately 15% during the first postpartum year. Despite the high prevalence of postpartum depression, there is no consensus regarding which patient-reported outcome measure (PROM) should be used to screen for this complex, multidimensional construct.ObjectiveTo evaluate psychometric measurement properties of existing PROMs of maternal postpartum depression using the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) guideline and identify the best available patient-reported screening measure.Evidence ReviewThis systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. PubMed, CINAHL, Embase, and Web of Science were searched on July 1, 2019, for validated PROMs of postpartum depression, and an additional search including a hand search of references from eligible studies was conducted in June 2021. Included studies evaluated 1 or more psychometric measurement properties of the identified PROMs. A risk-of-bias assessment was performed to evaluate methods of each included study. Psychometric measurement properties of each PROM were rated according to COSMIN criteria. A modified Grading of Recommendations Assessment, Development, and Evaluation approach was used to assess the level of evidence supporting each rating, and a recommendation class (A, recommended for use; B, further research required; or C, not recommended) was given based on the overall quality of each included PROM.FindingsAmong 10 264 postpartum recovery studies, 27 PROMs were identified. Ten PROMs (37.0%) met the inclusion criteria and were used in 43 studies (0.4%) involving 22 095 postpartum women. At least 1 psychometric measurement property was assessed for each of the 10 validated PROMs identified. Content validity was sufficient in all PROMs. The Edinburgh Postnatal Depression Scale (EPDS) demonstrated adequate content validity and a moderate level of evidence for sufficient internal consistency (with sufficient structural validity), resulting in a recommendation of class A. The other 9 PROMs evaluated received a recommendation of class B.Conclusions and RelevanceThe findings of this systematic review suggest that the EPDS is the best available patient-reported screening measure of maternal postpartum depression. Future studies should focus on evaluating the cross-cultural validity, reliability, and measurement error of the EPDS to improve understanding of its psychometric properties and utility.

Giving birth is the most common reason for hospital admission, with Cesarean delivery being the most frequently performed inpatient surgery. Through a needs assessment and iterative design process involving patients and obstetric anesthesiologists, we previously developed a mobile application, C-Care, for patients undergoing Cesarean delivery. The focus of C-Care is perioperative education and self-monitoring of potential anesthetic complications. This study aimed to obtain feedback on patient engagement with C-Care.We conducted a prospective cohort study of patients ≥ 18 yr (n = 36) undergoing elective Cesarean delivery. Anonymous usage data were recorded for 30 days. On postoperative days 1-5, participants received daily self-monitoring questionnaires within C-Care. Fourteen days after surgery, participants received an online survey regarding satisfaction and use of C-Care.Thirty-five out of 36 participants visited the application after orientation, with a median [interquartile range (IQR)] age of 32 [31-36] yr. Each participant visited the application a median of 15 [9-31] times over 30 days and completed a median of 3 [2-4] out of five self-monitoring questionnaires. Each participant viewed a median of 4 [2-7] out of eight education topics, with the most viewed patient education topics being "Controlling Pain" and "The First Few Days". Visits to the application were highest in the first week postpartum. Of the 18 respondents who completed the day 14 survey, 83% (n = 15) participants would recommend C-Care to other women, and the median participant satisfaction score was 7.5 out of 10 (range, 2-10).Most participants used this mobile application for patient education and self-monitoring after elective Cesarean delivery. Insights into patient engagement with C-Care after Cesarean delivery could help design more effective perioperative mobile telehealth programs.www.ClinicalTrials.gov (NCT03746678); registered 5 November 2018.RéSUMé: OBJECTIF: L’accouchement est la raison la plus courante d’admission à l’hôpital, et l’accouchement par césarienne constitue la chirurgie hospitalière la plus fréquemment pratiquée. Grâce à une évaluation des besoins et un processus de conception itérative impliquant des patientes et des anesthésiologistes obstétricaux, nous avions mis au point une application mobile baptisée C-Care destinée aux patientes subissant un accouchement par césarienne. L’application C-Care a pour but d’être un outil d’éducation périopératoire et d’autosurveillance des complications anesthésiques potentielles. Cette étude visait à obtenir des commentaires de rétroaction sur l’intérêt des patientes pour l’application C-Care. MéTHODE: Nous avons mené une étude de cohorte prospective auprès de patientes ≥ 18 ans (n = 36) subissant un accouchement par césarienne programmée. Des données d’utilisation anonymes ont été enregistrées pendant 30 jours. Les jours postopératoires 1-5, les participantes ont reçu des questionnaires quotidiens d’autosurveillance dans l’application C-Care. Quatorze jours après la chirurgie, les participantes ont reçu un sondage en ligne sur leur satisfaction et leur utilisation de C-Care. RéSULTATS: Trente-cinq des 36 participantes, d’un âge médian [écart interquartile (ÉIQ)] de 32 ans [31-36], ont consulté l’application après leur formation initiale. Chaque participante a consulté l’application 15 [9-31] fois en moyenne sur 30 jours et a rempli en moyenne 3 [2-4] questionnaires d’autosurveillance sur cinq. Chaque participante a consulté en moyenne 4 [2-7] des huit sujets de formation, les sujets les plus consultés étant « Le contrôle de la douleur » et « Les premiers jours ». Les consultations de l’application ont été les plus élevées au cours de la première semaine post-partum. Parmi les 18 répondantes qui ont complété le sondage du jour 14, 83 % (n = 15) des participantes recommanderaient C-Care à d’autres femmes, et le score médian de satisfaction des participantes était de 7,5 sur 10 (fourchette, 2-10). CONCLUSION: La plupart des participantes ont utilisé cette application mobile destinée à l’éducation des patientes et à l’autosurveillance après un accouchement par césarienne programmée. Une compréhension de l’intérêt des patientes pour C-Care après un accouchement par césarienne pourrait permettre la conception d’applications mobiles périopératoires plus efficaces. ENREGISTREMENT DE L’éTUDE: www.clinicaltrials.gov (NCT03746678); enregistrée le 5 novembre 2018.

Pain is a risk factor for postpartum depression (PPD) and labour epidural analgesia (LEA) may lower the incidence of PPD. We evaluated depressive symptoms risk at three, six, and 12 months postpartum in women with LEA compared with women without LEA.With ethics approval, hypotheses were tested using data from a longitudinal prospective observational cohort study between January 2015 and January 2019 in nulliparous women aged ≥ 18 yr with uncomplicated, singleton pregnancies. Email surveys were completed at baseline (18-20 weeks' gestation) and at three-, six- and 12 months postpartum, including the Edinburgh Postpartum Depression Scale (EPDS). Maternal, infant, and anesthesia characteristics were abstracted from electronic databases. The EPDS scores at three, six, and 12 months postpartum were analyzed using generalized estimating equations with and without covariates.Of the 909 women who consented to participate, 709 women were included in the study. Antenatal EPDS scores, not LEA, predicted postpartum depressive symptom risk (P0.001). The adjusted 95% confidence intervals suggest mean EPDS scores differ from 1.0 point lower in the LEA group at 12 months to 1.5 points higher in the no LEA group at three months on its 0-30 scale. All the confidence intervals included zero at three, six, and 12 months, so were considered non-significant (P0.05).This study did not identify an association between LEA and risk of depressive symptoms postpartum, although small mean differences between groups cannot be ruled out. Future studies should focus on other modifiable variables that influence the development of PPD.RéSUMé: CONTEXTE: La douleur constitue un facteur de risque de dépression post-partum (DPP) et l’analgésie péridurale obstétricale (APO) pourrait réduire l’incidence de DPP. Nous avons évalué le risque de symptômes de dépression à trois, six, et 12 mois post-partum chez les femmes ayant reçu une APO comparativement aux femmes sans APO. MéTHODE: Après avoir obtenu l’approbation du comité d’éthique, l’hypothèse a été testée en se fondant sur les données d’une étude de cohorte observationnelle prospective longitudinale réalisée entre janvier 2015 et janvier 2019 auprès des femmes nullipares âgées de ≥ 18 ans avec des grossesses simples et sans complication. Des sondages électroniques ont été complétés au début de l’étude (données de base, 18 à 20 semaines de grossesse), puis à trois, six et douze mois post-partum, et incluaient l’Échelle de dépression postnatale d’Édimbourg (EPDS). Les caractéristiques maternelles, infantiles et anesthésiques ont été extraites des bases de données électroniques. Les scores sur l’EPDS à trois, six, et 12 mois post-partum ont été analysés utilisant des équations d’estimation généralisées avec et sans covariables. RéSULTATS: Parmi les 909 femmes qui ont consenti à participer, 709 femmes ont été incluses dans l’étude. Les scores prénataux sur l’EPDS, et non l’APO, ont prédit le risque de symptômes de dépression post-partum (P0,001). Les intervalles de confiance ajustés de 95 % suggèrent que les scores moyens sur l’EPDS différaient de 1,0 point de moins dans le groupe APO à 12 mois à 1,5 point de plus dans le groupe sans APO à trois mois sur l’échelle de 0 à 30. Tous les intervalles de confiance englobaient le zéro à trois, six et 12 mois, et ont donc été considérés comme non significatifs (P0,05). CONCLUSION: Cette étude n’a pas identifié d’association entre l’APO et le risque de symptômes dépressifs post-partum, bien que de petites différences moyennes entre les groupes ne puissent être exclues. Les études futures devraient se concentrer sur d’autres variables modifiables qui influencent l’apparition de la DPP.

Background: Data suggest that pregnant women are not at elevated risk of acquiring severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection or developing severe disease compared with nonpregnant patients. However, management of pregnant patients who are critically ill with coronavirus disease 2019 (COVID-19) infection is complicated by physiologic changes and other pregnancy considerations and requires balancing maternal and fetal well-being. Case: We report the case of a patient at 28 weeks of gestation with acute respiratory distress syndrome (ARDS) from COVID-19 infection, whose deteriorating respiratory condition prompted delivery. Our patient's oxygenation and respiratory mechanics improved within hours of delivery, though she required prolonged mechanical ventilation until postpartum day 10. Neonatal swabs for SARS-CoV-2 and COVID-19 immunoglobulin (Ig) G and IgM were negative. Conclusion: We describe our multidisciplinary management of a preterm pregnant patient with ARDS from COVID-19 infection and her neonate.

PurposeImproved patient-provider relationships can positively influence patient outcomes. Sexual and gender minorities (SGM) represent a wide variety of marginalized populations. There is an absence of studies examining the inclusion of SGM-related health education within postgraduate training in anesthesia. This study's objective was to perform an environmental scan of the educational content of North American obstetric anesthesia fellowship programs.MethodsAn online survey was developed based on a review of the existing literature assessing the presence of SGM content within other healthcare-provider curricula. The survey instrument was distributed electronically to 50 program directors of North American obstetric anesthesia fellowship programs. Survey responses were summarized using descriptive statistics.ResultsSurvey responses were received from 30 of the 50 program directors (60%). Of these, 54% (14/26) felt their curriculum adequately prepares fellows to care for SGM patients, yet only 19% (5/26) of participants stated that SGM content was part of their curriculum and 31% (8/26) would like to see more incorporated in the future. Perceived lack of need was chosen as the biggest barrier to curricular inclusion of SGM education (46%; 12/26), followed by lack of available/interested faculty (19%; 5/26) and time (19%; 5/26).ConclusionsOur results suggest that, although curriculum leaders appreciate that SGM patients are encountered within the practice of obstetric anesthesia, most fellowship programs do not explicitly include SGM curricular content. Nevertheless, there appears to be interest in developing SGM curricular content for obstetric anesthesia fellowship training. Future steps should include perspectives of trainees and patients to inform curricular content.

In this Continuing Professional Development module, we review the practical pharmacology of tranexamic acid and its clinical use in trauma, obstetrics, and major orthopedic surgery.Tranexamic acid is a synthetic drug that inhibits fibrinolysis. Multiple clinical trials in various clinical settings have shown that it can reduce blood loss, transfusion rates, and bleeding-associated mortality. In trauma and obstetrical bleeding, early tranexamic acid administration (three hours) may have greater clinical benefits. Overall, tranexamic acid use appears safe with no significant increase of thromboembolic or seizure events. Nevertheless, current evidence has limitations related to wide heterogeneity in dose, route, and timing of drug administration, as well as generalizability of the large-scale trial findings to higher income nations.Tranexamic acid is an efficacious and safe pharmacological-based blood conservation technique in the management of clinically significant hemorrhage. All anesthesiologists should have a good understanding of the pharmacotherapeutic properties and perioperative role of tranexamic acid therapy both inside and outside of the operating room. The use of tranexamic acid is likely to continue to rise with endorsement by various clinical guidelines and healthcare organizations. Further quantitative research is needed to evaluate optimal dosing and drug efficacy in these clinical scenarios.RéSUMé: OBJECTIF: Dans ce module de Développement professionnel continu, nous passons en revue la pharmacologie pratique de l’acide tranexamique et son utilisation clinique dans le trauma, l’obstétrique, et les chirurgies orthopédiques majeures. CONSTATATIONS PRINCIPALES: L’acide tranexamique est un médicament synthétique inhibant la fibrinolyse. Plusieurs essais cliniques dans divers contextes cliniques ont montré qu’il peut réduire les pertes de sang, les taux de transfusion et la mortalité associée aux saignements. Dans les cas de saignement traumatologique et obstétrical, l’administration précoce d’acide tranexamique (trois heures) pourrait avoir de plus grands bienfaits cliniques. Globalement, l’utilisation d’acide tranexamique semble sécuritaire et n’entraîne pas d’augmentation significative des complications thromboemboliques ou de convulsions. Néanmoins, les données probantes actuelles comportent des limites liées à une grande hétérogénéité dans la posologie, la voie et le moment d’administration du médicament, ainsi qu’à l’aspect généralisable des résultats des études à grande échelle pour les pays à revenu élevé. CONCLUSION: L’acide tranexamique est une technique pharmacologique de conservation du sang efficace et sécuritaire pour la prise en charge de l’hémorragie cliniquement significative. Les anesthésiologistes devraient tous posséder une bonne compréhension des propriétés pharmacothérapeutiques et du rôle périopératoire de la thérapie par acide tranexamique, tant à l’intérieur qu’à l’extérieur de la salle d’opération. L’utilisation de l’acide tranexamique continuera vraisemblablement à augmenter au fur et à mesure de l’obtention de son approbation par diverses lignes directrices cliniques et organismes de soins de santé. D’autres recherches quantitatives sont nécessaires pour évaluer le dosage optimal et l’efficacité du médicament dans ces scénarios cliniques.

Purpose Postoperative cognitive dysfunction is difficult to predict and diagnose, and can have severe consequences in the long term. The purpose of this study was to examine the feasibility of using a computerised test battery, the Dalhousie Computerized Assessment Battery in the perioperative clinic to detect cognitive changes after surgery. Methods Fifty patients were recruited for this study. Patients completed the Dalhousie Computerized Assessment Battery and tests of general cognition, mood and pain at baseline and at three months postoperatively. Results This pilot study had a screening rate (85.4%) and low attrition rate (12%). At baseline, patients exhibited no significant cognitive differences compared to a normative dataset. Postoperative cognitive dysfunction incidence was 2.7% on Montreal Cognitive Assessment, 13.6% with Dalhousie Computerized Assessment Battery and 36.3% based on subjective reports. Conclusion Computerised cognitive testing in the perioperative setting proved feasible. Deficits in spatial working memory and dual tasks may be most compromised by surgically related variables.

Purpose of review High-quality analgesia has been linked to improved patient satisfaction as well as improved short-term and long-term postoperative outcomes. Acute surgical pain is a modifiable risk factor for development of chronic postoperative pain, which is reported by up to 26% of gynecologic surgical patients. In other surgical populations, multimodal analgesia has shown improved pain control and decreased reliance on opioids. This review examines recent evidence for various analgesic modalities applied specifically to the gynecologic surgical population. Recent findings Nonopioid agents like acetaminophen, nonsteroidal anti-inflammatories, and gamma-aminobutyric acid analogs resulted in reduction in postoperative pain and opioid consumption. Application of regional anesthetic techniques had a favorable effect that persisted beyond the immediate recovery period. Preemptive analgesia remains unproven. The best evidence for effective combinations comes from ERAS studies that incorporated multimodal analgesia into a systemic approach geared towards early discharge. Summary Multimodal analgesia had demonstrated advantages for all types of gynecological surgeries in terms of improving postoperative pain control and minimizing opioid-related adverse effects. Multimodal analgesia includes acetaminophen, NSAIDS, and gamma-aminobutyric acid analogs combined with intraoperative nonopioid analgesics such as ketamine, regional anesthesia or intrathecal morphine. Further research should focus on determining most effective combinations and doses of multimodal analgesia.

Background: Development of predictive models of preeclampsia has only yielded modest results. We hypothesized that impaired indices of microcirculatory function could be detected using sidestream dark field imaging. The objective of this study was to examine microvascular function in women at high risk for preeclampsia at mid-gestation. Methods: Women between 16 and 22 weeks of gestation were screened for eligibility. Patients were recruited if they met eligibility criteria indicating high risk for preeclampsia. Investigators performed non-invasive sidestream dark field imaging of the sublingual microcirculation. Images were analyzed to determine microcirculatory parameters (microvascular flow index, perfused vessel density, total vessel density, and proportion of perfused vessels). After delivery, charts were reviewed to determine if they developed gestational hypertension, preeclampsia or severe preeclampsia. Results: Twelve of 66 participants (18.2%) developed preeclampsia or severe preeclampsia during the course of their pregnancy. Microvascular flow index was not significantly different between participants with normal pregnancies and participants with preeclampsia or severe preeclampsia (2.75 ± 0.38 vs. 2.80 ± 0.34, respectively; P = 0.459). Similarly, there were no significant differences between groups in the remaining microcirculatory parameters. Conclusions: Sidestream dark field imaging of the sublingual microcirculation may remain an appropriate tool to identify women at risk for preeclampsia, albeit later in pregnancy. J Clin Med Res. 2018;10(5):391-395 doi: https://doi.org/10.14740/jocmr3368w

INTRODUCTION The outcome of patients in septic shock has been shown to be related to changes within the microcirculation. Modern imaging technologies are available to generate high resolution video recordings of the microcirculation in humans. However, evaluation of the microcirculation is not yet implemented in the routine clinical monitoring of critically ill patients. This is mainly due to large amount of time and user interaction required by the current video analysis software. The aim of this study was to validate a newly developed automated method (CCTools®) for microcirculatory analysis of sublingual capillary perfusion in septic patients in comparison to standard semi-automated software (AVA3®). METHODS 204 videos from 47 patients were recorded using incident dark field (IDF) imaging. Total vessel density (TVD), proportion of perfused vessels (PPV), perfused vessel density (PVD), microvascular flow index (MFI) and heterogeneity index (HI) were measured using AVA3® and CCTools®. RESULTS Significant differences between the numeric results obtained by the two different software packages were observed. The values for TVD, PVD and MFI were statistically related though. CONCLUSION The automated software technique successes to show septic shock induced microcirculation alterations in near real time. However, we found wide degrees of agreement between AVA3® and CCTools® values due to several technical factors that should be considered in the future studies.

Cesarean delivery (CD) is the most commonly performed inpatient surgery in Canada, with 103,425 performed in 2016–2017. Mobile technology can contribute to patient-centred perioperative care. Our aim was to involve patients and anesthesiologists in designing a mobile application to enhance the perioperative care of CD patients. We completed an exploratory qualitative study involving three iterative design cycles. Individual structured phone or in-person interviews with CD patients (n = 15) and anesthesiologists (n = 9) were conducted. Thematic analysis was used to 1) assess gaps and opportunities in the anesthesiology care after CD, 2) identify roles and limitations of mobile application technology in bridging perioperative care, and 3) to solicit feedback on a prototype mobile application for the anesthesiology postoperative care of elective CD patients. Patients and anesthesiologists were in favour of adding mobile applications to the interdisciplinary perioperative management of patients undergoing CD, particularly for providing reliable information, identifying and following patients with complications, and research in perioperative outcomes. Medical–legal issues, privacy, workflow, and payment policy frameworks are barriers for mobile technology linking patients and anesthesiologists. Our final prototype was refined to focus on timely, concise education and self-monitoring. The participant-driven changes in direction of the prototype showed the importance of involving key stakeholders early. This study provides guidance on further iterative development and implementation of an interdisciplinary mobile platform for patient-centred perioperative care and outcomes research.

A clinically relevant number of patients report pain 1 year after vaginal delivery or Caesarean delivery. Study objectives were to identify the incidence of peripartum pain; determine whether pre-existing pain, pregnancy pain, or pain 2 weeks postpartum predicts pain at 3 months; and to identify whether delivery mode, epidural analgesia use, or delivery complications predict non-genito-pelvic pain postpartum.Primiparous women at 30 to 36 weeks GA with an uncomplicated singleton pregnancy were recruited from a large perinatal clinic. Participants completed questionnaires on sociodemographics and non-genito-pelvic pain. Questionnaires were completed in the perinatal clinic and then electronically 2 weeks and 3 months postpartum.Of the 133 women included, 50 patients (38%) had a chronic pain condition or pain prior to pregnancy, whereas 73 patients (55%) reported pain in pregnancy. Pain was present 2 weeks postpartum in 57 patients (43%) and 3 months postpartum in 33 patients (25%). Patients with pre-existing pain were more likely to experience pain 2 weeks postpartum (P = 0.006), and patients with pain 2 weeks postpartum were more likely to have pain 3 months postpartum (P = 0.005). Women who had a Caesarean delivery (P 0.001) were more likely to have non-genito-pelvic pain at 2 weeks but not 3 months postpartum.Women with pain 2 weeks postpartum were significantly more likely to have pain at 3 months. Further investigation is required to determine whether pre-existing pain, pain in pregnancy, or pain at 2 weeks postpartum can adequately predict the likelihood of chronic pain.

This scoping review aimed to summarize the current literature on postpartum psychiatric disorders (e.g., postpartum depression, postpartum anxiety, postpartum post-traumatic stress disorder) and the possible relationship of these disorders to the use of pharmacologic labour analgesia (e.g., epidural analgesia, nitrous oxide, parenteral opioids) to identify knowledge gaps that may aid in the planning of future research.PubMed, PsycINFO, CINAHL, and EMBASE were searched from inception to November 9, 2018 for studies that included both labour analgesia and the postpartum psychiatric disorders specified above.Two reviewers assessed the studies and extracted the data. Of the 990 identified citations, 17 studies were included for analysis. Existing studies have small sample sizes and are observational cohorts in design. Patient psychiatric risk factors, method of delivery, and type of labour analgesia received were inconsistent among studies. Most studies relied on screening tests for diagnosing postpartum psychiatric illness and did not assess the impact of labour analgesia on postpartum psychiatric illness as the primary study objective.Future studies should correlate screen-positive findings with clinical diagnosis; consider adjusting the timing of screening to include the antepartum period, early postpartum, and late postpartum periods; and consider the degree of labour pain relief and the specific pharmacologic labour analgesia used when evaluating postpartum psychiatric disorders.RéSUMé: OBJECTIF: Cette étude exploratoire avait pour objectif de résumer la littérature actuelle portant sur les troubles psychiatriques postpartum (par ex., dépression postpartum, anxiété postpartum, état de stress post-traumatique postpartum) et la relation possible de ces troubles avec l’utilisation d’une analgésie pharmacologique pour le travail obstétrical (par ex., analgésie péridurale, protoxyde d’azote, opioïdes parentéraux) afin d’identifier les lacunes dans nos connaissances qui pourraient aiguiller la planification de futures recherches.Des recherches ont été effectuées dans les bases de données PubMed, PsycINFO, CINAHL et EMBASE de leur création jusqu’au 9 novembre 2018 afin d’en extraire les études incluant des informations concernant l’analgésie du travail et les troubles psychiatriques postpartum spécifiés ci-dessus.Deux évaluateurs ont passé en revue les études et extrait les données. Parmi les 990 citations identifiées, 17 études ont été incluses pour analyse. Les études existantes ont de petites tailles d’échantillon et sont conçues comme des cohortes observationnelles. Les facteurs de risque psychiatrique des patientes, le mode d’accouchement et le type d’analgésie reçue pour le travail n’étaient pas uniformes d’une étude à l’autre. La plupart des études s’appuyaient sur des tests de dépistage pour poser un diagnostic de maladie psychiatrique postpartum et n’évaluaient pas l’impact de l’analgésie du travail sur la maladie psychiatrique postpartum comme critère d’évaluation principal.Les études futures devraient corréler les résultats positifs au dépistage à un diagnostic clinique; envisager d’ajuster le moment de dépistage afin d’inclure la période antepartum ainsi que les périodes du postpartum initial et tardif; et tenir compte du degré de soulagement de la douleur du travail ainsi que de l’analgésie pharmacologique spécifique utilisée pour le travail lors de l’évaluation des troubles psychiatriques postpartum.

Improved patient-provider relationships can positively influence patient outcomes. Sexual and gender minorities (SGM) represent a wide variety of marginalized populations. There is an absence of studies examining the inclusion of SGM-related health education within postgraduate training in anesthesia. This study's objective was to perform an environmental scan of the educational content of North American obstetric anesthesia fellowship programs.An online survey was developed based on a review of the existing literature assessing the presence of SGM content within other healthcare-provider curricula. The survey instrument was distributed electronically to 50 program directors of North American obstetric anesthesia fellowship programs. Survey responses were summarized using descriptive statistics.Survey responses were received from 30 of the 50 program directors (60%). Of these, 54% (14/26) felt their curriculum adequately prepares fellows to care for SGM patients, yet only 19% (5/26) of participants stated that SGM content was part of their curriculum and 31% (8/26) would like to see more incorporated in the future. Perceived lack of need was chosen as the biggest barrier to curricular inclusion of SGM education (46%; 12/26), followed by lack of available/interested faculty (19%; 5/26) and time (19%; 5/26).Our results suggest that, although curriculum leaders appreciate that SGM patients are encountered within the practice of obstetric anesthesia, most fellowship programs do not explicitly include SGM curricular content. Nevertheless, there appears to be interest in developing SGM curricular content for obstetric anesthesia fellowship training. Future steps should include perspectives of trainees and patients to inform curricular content.RéSUMé: OBJECTIF: L’amélioration des relations patient-fournisseur peut avoir une influence positive sur les devenirs des patients. Les minorités sexuelles et de genre (MSG) représentent une vaste diversité de populations marginalisées. Aucune étude n’a examiné l’inclusion d’éducation médicale liée aux MSG dans le cadre de la formation surspécialisée en anesthésie. L’objectif de cette étude était de mener une enquête générale sur le contenu éducatif des programmes de fellowship nord-américains en anesthésie obstétricale. MéTHODE: Un sondage électronique a été mis au point en se fondant sur la littérature existante afin d’évaluer l’offre de contenu traitant des MSG dans le cadre d’autres programmes de cours destinés aux fournisseurs de soins de santé. Le sondage a été distribué électroniquement à 50 directeurs de programmes de fellowship en anesthésie obstétricale en Amérique du Nord. Les réponses au sondage ont été résumées à l’aide de statistiques descriptives. RéSULTATS: Des réponses au sondage de 30 des 50 directeurs de programme ont été reçues (60 %). Parmi ces réponses, 54 % (14/26) étaient d’avis que leur programme de cours était adapté pour préparer les fellows à s’occuper de patients issus des MSG, mais seuls 19 % (5/26) des participants déclaraient que du contenu spécifique portant sur les MSG était intégré dans leur programme, et 31 % (8/26) aimeraient voir davantage de contenu pertinent intégré à l’avenir. L’absence perçue de besoin a été retenue comme l’obstacle le plus important à l’inclusion de formation concernant les MSG dans le programme de cours (46 %; 12/26), suivie par le manque de personnel disponible / intéressé (19 %; 5/26) et de temps (19 %; 5/26). CONCLUSION: Nos résultats suggèrent que bien que les directeurs de programmes soient conscients que des patients issus des MSG soient suivis dans la pratique de l’anesthésie obstétricale, la plupart des programmes de fellowship n’incluent pas explicitement de contenu éducatif lié aux MSG. Toutefois, il semble y avoir un intérêt pour la mise au point de contenu éducatif pertinent aux MSG dans le cadre des programmes de fellowship en anesthésie obstétricale. L’étape suivante serait d’inclure les opinions des fellows et des patients afin de guider le contenu des programmes.

BACKGROUND: Postoperative nausea and vomiting (PONV) is a common complication following general anaesthesia. It may be associated with patient dissatisfaction, increased costs of treatment, and unintended admission to hospital. Supplemental intravenous crystalloid administration in the perioperative period may be a simple intervention to prevent PONV. OBJECTIVES: To assess whether supplemental intravenous crystalloid administration prevents PONV in patients undergoing surgical procedures under general anaesthesia. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 7), MEDLINE (1946 to August 2018), Embase (1947 to August 2018), and the Cumulative Index of Nursing and Allied Health Literature (CINAHL; 1971 to August 2018). We searched clinical trials registers for ongoing or unpublished completed studies (August 2018), handsearched conference proceedings of anaesthesiology societies, as published in three major journals (British Journal of Anaesthesia, European Journal of Anaesthesiology, and Anesthesiology; August 2018), and conducted backward and forward citation searching of relevant articles. SELECTION CRITERIA: We included randomized controlled trials of participants older than six months undergoing surgical procedures under general anaesthesia and given supplemental perioperative intravenous crystalloids, defined as a volume larger than that received by a comparator group, to prevent PONV. DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures described by Cochrane. MAIN RESULTS: We included 41 studies (4224 participants). Participants underwent ambulatory or short length of stay surgical procedures, and were predominantly American Society of Anesthesiology (ASA) class I or II. There is one study awaiting classification and three ongoing studies. All studies took place in surgical centres, and were conducted in geographically diverse settings. Risk of bias was generally unclear across all domains. Supplemental intravenous crystalloid administration probably reduces the cumulative risk of postoperative nausea (PON) (risk ratio (RR) 0.62, 95% confidence interval (CI) 0.51 to 0.75; 18 studies; 1766 participants; moderate‐certainty evidence). When the postoperative period was divided into early (first six hours postoperatively) and late (at the time point closest to or including 24 hours postoperatively) time points, the intervention reduced the risk of early PON (RR 0.67, 95% CI 0.58 to 0.78; 20 studies; 2310 participants; moderate‐certainty evidence) and late PON (RR 0.47, 95% CI 0.32 to 0.69; 17 studies; 1682 participants; moderate‐certainty evidence). Supplemental intravenous crystalloid administration probably reduces the risk of postoperative vomiting (POV) (RR 0.50, 95% CI 0.40 to 0.63; 20 studies; 1970 participants; moderate‐certainty evidence). The intervention specifically reduced both early POV (RR 0.56, 95% CI 0.41 to 0.76; 19 studies; 1998 participants; moderate‐certainty evidence) and late POV (RR 0.48, 95% CI 0.29 to 0.79; 15 studies; 1403 participants; moderate‐certainty evidence). Supplemental intravenous crystalloid administration probably reduces the need for pharmacologic treatment of PONV (RR 0.62, 95% CI 0.51 to 0.76; 23 studies; 2416 participants; moderate‐certainty evidence). The effect of supplemental intravenous crystalloid administration on the risk of unplanned postoperative admission to hospital is unclear (RR 1.05, 95% CI 0.77 to 1.43; 3 studies; 235 participants; low‐certainty evidence). No studies reported serious adverse events that may occur following supplemental perioperative intravenous crystalloid administration (i.e. admission to high‐dependency unit, postoperative cardiac or respiratory complication, or death). AUTHORS' CONCLUSIONS: There is moderate‐certainty evidence that supplemental perioperative intravenous crystalloid administration reduces PON and POV, in ASA class I to II patients receiving general anaesthesia for ambulatory or short length of stay surgical procedures. The intervention probably also reduces the risk of pharmacologic treatment for PONV. The effect of the intervention on the risk of unintended postoperative admission to hospital is unclear. The risk of serious adverse events resulting from supplemental perioperative intravenous crystalloid administration is unknown as no studies reported this outcome. The one study awaiting classification may alter the conclusions of the review once assessed.

BACKGROUND Health researchers are increasingly using social media in a professional capacity, and the applications of social media for health researchers are vast. However, there is currently no published evidence synthesis of the ways in which health researchers use social media professionally, and uncertainty remains as to how best to harness its potential. OBJECTIVE This scoping review aimed to explore how social media is used by health researchers professionally, as reported in the literature. METHODS The scoping review methodology guided by Arksey and O’Malley and Levac et al was used. Comprehensive searches based on the concepts of health research and social media were conducted in MEDLINE, EMBASE, CINAHL, PsycINFO, ERIC, and Web of Science databases, with no limitations applied. Articles were screened at the title and abstract level and at full text by two reviewers. One reviewer extracted data that were analyzed descriptively to map the available evidence. RESULTS A total of 8359 articles were screened at the title and abstract level, of which 719 were also assessed at full text for eligibility. The 414 articles identified for inclusion were published in 278 different journals. Studies originated from 31 different countries, with the most prevalent being the United States (52.7% [218/414]). The health discipline of the first authors varied, with medicine (33.3% [138/414]) being the most common. A third of the articles covered health generally, with 61 health-specific topics. Papers used a range of social media platforms (mean 1.33 [SD 0.7]). A quarter of the articles screened reported on social media use for participant recruitment (25.1% [104/414]), followed by practical ways to use social media (15.5% [64/414]), and use of social media for content analysis research (13.3% [55/414]). Articles were categorized as celebratory (ie, opportunities for engagement, 72.2% [299/414]), contingent (ie, opportunities and possible limitations, 22.7% [94/414]) and concerned (ie, potentially harmful, 5.1% [21/414]). CONCLUSIONS Health researchers are increasingly publishing on their use of social media for a range of professional purposes. Although most of the sentiment around the use of social media in health research was celebratory, the uses of social media varied widely. Future research is needed to support health researchers to optimize their social media use.

Poor reporting quality may contribute to irreproducibility of results and failed 'bench-to-bedside' translation. Consequently, guidelines have been developed to improve the complete and transparent reporting of in vivo preclinical studies. To examine the impact of such guidelines on core methodological and analytical reporting items in the preclinical anesthesiology literature, we sampled a cohort of studies. Preclinical in vivo studies published in Anesthesiology, Anesthesia & Analgesia, Anaesthesia, and the British Journal of Anaesthesia (2008-2009, 2014-2016) were identified. Data was extracted independently and in duplicate. Reporting completeness was assessed using the National Institutes of Health Principles and Guidelines for Reporting Preclinical Research. Risk ratios were used for comparative analyses. Of 7615 screened articles, 604 met our inclusion criteria and included experiments reporting on 52 490 animals. The most common topic of investigation was pain and analgesia (30%), rodents were most frequently used (77%), and studies were most commonly conducted in the United States (36%). Use of preclinical reporting guidelines was listed in 10% of applicable articles. A minority of studies fully reported on replicates (0.3%), randomization (10%), blinding (12%), sample-size estimation (3%), and inclusion/exclusion criteria (5%). Statistics were well reported (81%). Comparative analysis demonstrated few differences in reporting rigor between journals, including those that endorsed reporting guidelines. Principal items of study design were infrequently reported, with few differences between journals. Methods to improve implementation and adherence to community-based reporting guidelines may be necessary to increase transparent and consistent reporting in the preclinical anesthesiology literature.

Cesarean delivery (CD) is the most commonly performed inpatient surgery in Canada, with 103,425 performed in 2016-2017. Mobile technology can contribute to patient-centred perioperative care. Our aim was to involve patients and anesthesiologists in designing a mobile application to enhance the perioperative care of CD patients.We completed an exploratory qualitative study involving three iterative design cycles. Individual structured phone or in-person interviews with CD patients (n = 15) and anesthesiologists (n = 9) were conducted. Thematic analysis was used to 1) assess gaps and opportunities in the anesthesiology care after CD, 2) identify roles and limitations of mobile application technology in bridging perioperative care, and 3) to solicit feedback on a prototype mobile application for the anesthesiology postoperative care of elective CD patients.Patients and anesthesiologists were in favour of adding mobile applications to the interdisciplinary perioperative management of patients undergoing CD, particularly for providing reliable information, identifying and following patients with complications, and research in perioperative outcomes. Medical-legal issues, privacy, workflow, and payment policy frameworks are barriers for mobile technology linking patients and anesthesiologists. Our final prototype was refined to focus on timely, concise education and self-monitoring.The participant-driven changes in direction of the prototype showed the importance of involving key stakeholders early. This study provides guidance on further iterative development and implementation of an interdisciplinary mobile platform for patient-centred perioperative care and outcomes research.RéSUMé: OBJECTIF: L’accouchement par césarienne est la chirurgie avec hospitalisation la plus fréquemment réalisée au Canada, atteignant 103 425 cas en 2016–2017. La technologie mobile pourrait contribuer aux soins périopératoires centrés sur la patiente. Notre objectif était d’impliquer les patientes et les anesthésiologistes pour mettre au point une application mobile afin d’améliorer les soins périopératoires des femmes accouchant par césarienne. MéTHODE: Nous avons réalisé une étude qualitative exploratoire comprenant trois cycles itératifs de conception. Des entretiens individuels structurés par téléphone ou en personne avec des patientes subissant une césarienne (n = 15) et des anesthésiologistes (n = 9) ont été menés. Une analyse thématique a été utilisée pour 1) évaluer les écueils et les opportunités dans les soins anesthésiques après une césarienne, 2) identifier les rôles et les limites de la technologie d’application mobile pour combler les besoins des soins périopératoires, et 3) demander une rétroaction concernant un prototype d’application mobile pour les soins anesthésiques postopératoires des patientes subissant une césarienne planifiée. RéSULTATS: Les patientes et les anesthésiologistes étaient en faveur de l’ajout d’applications mobiles à la prise en charge périopératoire des patientes subissant une césarienne, particulièrement pour offrir des informations fiables, identifier et faire le suivi des patientes souffrant de complications, et effectuer de la recherche sur les pronostics périopératoires. Les questions médicolégales, le respect de la vie privée, la charge de travail et les cadres de politiques de paiement constituent des obstacles à la connexion des patientes et des anesthésiologistes via la technologie mobile. Notre prototype final a été amélioré afin de se concentrer sur des outils de formation concis et opportuns et sur l’auto-monitorage. CONCLUSION: Les changements proposés au prototype par les participants ont démontré l’importance d’impliquer les principaux intéressés tôt dans le processus. Cette étude offre des pistes quant à la mise au point et la mise en œuvre progressives d’une plateforme mobile interdisciplinaire pour des soins périopératoires centrées sur les patients et la recherche sur les pronostics périopératoires.

BACKGROUND Combined spinal-epidural (CSE) analgesia is widely used for delivering labor analgesia. Epidural volume extension (EVE) involves the injection of fluid into the epidural space compressing the dural sac, causing cephalad shift of the cerebral spinal fluid. Our hypothesis was that EVE with 10 mL normal saline during CSE would increase the sensory block height at 15 minutes after intrathecal injection. We expected EVE to decrease pain scores, decrease analgesia onset time, and decrease motor block compared with performing CSE without EVE (NEVE). METHODS We randomly assigned 60 healthy term laboring nulliparous parturients with cervical dilation

In this continuing professional development module, we review recent Society of Obstetricians and Gynaecologists of Canada (SOGC) guidelines for the classification and diagnosis of hypertensive disorders of pregnancy (HDP) as well as review the clinical features, laboratory investigations, and outcomes of HDP. We explore the evidence for anesthetic management and prevention of end-organ damage in women with HDP and describe the role and contribution of anesthesiologists as part of a multidisciplinary care team. Hypertensive disorders of pregnancy can have variable presentations with clinical signs and symptoms that often do not correlate with the underlying severity and progression of the disease. Failure of timely diagnosis and treatment contributes significantly to adverse maternal (neurologic complications, pulmonary edema, and postpartum hemorrhage) and neonatal (respiratory and neurologic complications and stillbirth) outcomes. In the Canadian context, improvements in medical care have led to better maternal and neonatal outcomes. Timing of delivery is crucial in balancing maternal risks and fetal benefits of ongoing pregnancy. Evidence-based SOGC guidelines regarding diagnosis and management of HDP address many aspects of clinical care relevant to anesthesiologists, who have an important role in the multidisciplinary care team. Hypertensive disorders of pregnancy are on the rise worldwide, and this trend is expected to continue. The major contributors to maternal mortality are failure to recognize HDP promptly or to treat the condition adequately. It is essential that anesthesiologists understand the disease process and acquire knowledge of the guidelines governing current obstetrical care in order to provide evidence-based multidisciplinary quality care to these patients. Anesthetic management helps prevent potentially deleterious maternal and fetal outcomes.

Excessive time for analysis may impede microcirculatory studies with large amounts of video data. Engaging more personnel in the analyses seems to be a rational approach in that scenario and could shorten the time-interval between capturing images and obtaining results. Our hypothesis was that novice users would be able to determine standard microcirculatory parameters using a semi-automated software with an acceptable degree of variability after participating in a standardized interactive training session. 14 volunteers were included in the study. All volunteers analyzed separately the same sample video after the training. The kappa statistic was calculated for the primary outcome parameter microvascular flow index (MFI) within small and large vessels and indicated a fair level of agreement in the results of the novice users. A standardized interactive tutorial can be useful to teach microcirculatory analysis in previously untrained subjects.

We describe the management of a parturient woman with hypertrophic cardiomyopathy who developed a symptomatic accelerated idioventricular rhythm who required an urgent cesarean delivery at 32 weeks. Transthoracic echocardiography helped guide anesthetic management, including epidural dosing, fluid management, and phenylephrine infusion rates. This case demonstrates the application of transthoracic echocardiography to guide anesthetic management in a parturient woman at risk for cardiovascular compromise.