Anesthesia and analgesia
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Anesthesia and analgesia · Oct 2018
Epidural Analgesia and Subcutaneous Heparin 3 Times Daily in Cancer Patients With Acute Postoperative Pain.
The use of epidural analgesia in conjunction with subcutaneous administration of unfractionated heparin 3 times per day could increase the risk of spinal epidural hematoma, but insufficient patient experience data exist to determine this. We retrospectively reviewed the incidence of spinal epidural hematoma in 3705 cases at our institution over a 7-year period of patients receiving acute postoperative epidural analgesia and heparin 3 times per day. No cases of spinal epidural hematoma were reported (95% CI, 0-0.0009952).
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Anesthesia and analgesia · Oct 2018
Neuraxial Anesthesia During Cesarean Delivery for Placenta Previa With Suspected Morbidly Adherent Placenta: A Retrospective Analysis.
What did they do?
Markley et al. conducted a single-center retrospective cohort study of 23 years of data from a tertiary North American academic hospital. The investigators identified 129 patients meeting criteria, requiring elective Cesarean delivery (CD/CS) for suspected morbidly adherent placenta (MAP): placenta accreta, increta or percreta.
Why the fuss?
Historically there has been concern that neuraxial anaesthesia may add additional complexity when managing a major haemorrhage associated with MAP CS, by:
- Complicating large volume resuscitation in an awake patient.
- Accentuating hypotension due to sympathectic block.
- Having an unsecured airway in the event of intraoperative crisis.
- Creating neuraxial uncertainty when coagulopathy occurs.
And they found...
The majority of patients with morbidly adherent placentas can be safely managed with neuraxial anesthesia alone. GA conversion was also safe for those requiring it.
Of the 129 patients, 5% were electively given a GA. Of the 122 (95%) who received neuraxial anesthesia (NA), only 15 (12%) were converted to GA after delivery.1 There were three difficult intubations (AFOI, VL and bougie each) among the 22 GAs. NA was predominately combined-spinal epidural or epidural.
Of the 72 patients requiring hysterectomy, 21% (15) needed NA-GA conversion.
The only independent predictors for GA conversion were history of ≥3 previous CS and long surgical duration.
The big question
Although retrospective, this data again reassures that neuraxial anesthesia can be a safe and appropriate choice for cesarean delivery with placenta accreta, increta or percreta. The big question will be whether you are happy managing an emergent NA-GA conversion and intubation in the 1-in-8 requiring it (or 1-in-5 with hysterectomy) or plan for an elective GA pre-surgery.
summary
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Notably, a further 5 (4%) required GA conversion before delivery due to inadequate block. ↩