Best practice & research. Clinical anaesthesiology
-
Best Pract Res Clin Anaesthesiol · May 2022
ReviewSpinal hypotension in obstetrics: Context-sensitive prevention and management.
Spinal hypotension during caesarean section remains a common complication, with important attendant maternal and fetal adverse outcomes. Research elucidating the mechanisms of spinal hypotension has led to the development and refinement of effective management strategies, with a particular emphasis on prophylactic vasopressor administration. This has proved effective in well-resourced settings, with maternal comfort and the elimination of nausea now considered the primary aim of treatment. ⋯ Translational, context-sensitive research in resource-limited settings has shown promise in implementing pragmatic strategies based on research from resource-rich environments. We review the current best practice for the prevention and treatment of spinal hypotension, with a special emphasis on effective strategies in resource-limited settings. We further suggest a research agenda to address the knowledge gap in specific contexts.
-
In the developed world, cardiovascular disease has become the most frequent cause of death during pregnancy and postpartum, outnumbering by far obstetric causes of death such as bleeding or thromboembolism. Many factors contribute to this phenomenon, including an increasing age of pregnant women, co-morbidities, and an unhealthy lifestyle. ⋯ Profound knowledge of the cardiac pathophysiology is a prerequisite for the successful anaesthesiologic management of pregnant patients with cardiovascular disease. As there is no difference in general and regional anaesthesia regarding maternal outcomes, neuraxial anaesthesia using incremental techniques should be preferred for labour and (caesarean) delivery if not contraindicated by non-cardiac issues.
-
Best Pract Res Clin Anaesthesiol · May 2022
ReviewEnhancing recovery after cesarean delivery - A narrative review.
Enhanced recovery after cesarean delivery (ERAC) is increasingly being implemented worldwide with the aim to improve patient care for women undergoing this procedure. ERAC is associated with superior maternal outcomes including decreased length of hospital stay, opioid consumption, pain scores, times to mobilization and urinary catheter removal and hospitalization costs, without increasing hospital readmission rates. A number of preoperative, intraoperative, and postoperative interventions have been incorporated into ERAC protocols. ⋯ Protocols rarely assess patient-reported outcome measures, patient satisfaction, or patient experience. The best measures of ERAC success are yet to be fully elucidated. Further work is required to evaluate protocols, interventions, and how best to measure the effect of ERAC.
-
Best Pract Res Clin Anaesthesiol · May 2022
ReviewNeuraxial labor analgesia: Maintenance techniques.
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. ⋯ 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.
-
Best Pract Res Clin Anaesthesiol · May 2022
ReviewNeuraxial labor analgesia: Initiation techniques.
The ideal technique for labor analgesia would have a quick onset, predictable quality, and adjustable depth and duration. Moreover, it would be easy to perform and have minimal maternal and fetal side effects. A catheter-based neuraxial approach encompasses these desirable characteristics and includes the epidural, combined spinal epidural, dural puncture epidural, and intrathecal catheter techniques. ⋯ The selection of neuraxial analgesia techniques should consider the patient and team's goals and expectations, the clinical context, and the institutional culture. Labor analgesic techniques that initiate with an intentional dural puncture component have a faster onset, greater bilateral and sacral spread, and lower rates of epidural catheter failure. Further elucidation of the mechanisms, benefits, and risks of each neuraxial initiation technique will continue to benefit patients and care providers.