Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Mar 2017
ReviewThe role of ultrasonography in obstetric anesthesia.
Ultrasonography is increasingly being viewed as an everyday tool in obstetric anesthesia. For the administration of spinal or epidural anesthesia, it reduces needle redirection attempts in patients with difficult anatomy. ⋯ Accurate assessment of gastric volume status with ultrasound would be a useful everyday skill if it is adopted into mainstream practice. We provide a summary of current opinions on the role of ultrasound in practice and highlight the potential for its future use in obstetric anesthesia.
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Best Pract Res Clin Anaesthesiol · Mar 2017
ReviewDecision-to-delivery interval: Is 30 min the magic time? What is the evidence? Does it work?
Emergency caesarean section is required when delivery can reduce the risk to the life of the mother or foetus. When a caesarean section is indicated for foetal compromise, a decision-to-delivery interval of 30 min (or less) has been suggested as the ideal time frame within which an obstetric team should achieve delivery. In theory, a short decision-to-delivery interval may minimise intra-uterine hypoxia and improve neonatal outcome. ⋯ There are certain indications for caesarean section that necessitate a much shorter decision-to-delivery interval, but evidence suggests that the majority of neonates may be safely delivered within a longer interval of time. Current tools available for the diagnosis of foetal distress are imperfect, and the concept of foetal distress is poorly defined. Future research should focus on finding accurate means of diagnosing foetal distress in labouring women and establishing universally agreed evidence-based decision-to-delivery targets without compromising maternal or foetal safety.
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Effective pain management should be a key priority in women undergoing cesarean delivery. Suboptimal perioperative pain management is associated with chronic pain, greater opioid use, delayed functional recovery, impaired maternal-fetal bonding, and increased postpartum depression. ⋯ The use of neuraxial morphine and opioid-sparing adjuncts such as scheduled nonsteroidal anti-inflammatory medications and acetaminophen is recommended for all women undergoing cesarean delivery with neuraxial anesthesia unless contraindicated. Additional analgesic and opioid-sparing options such as wound instillation of local anesthetics, transversus abdominis plane blocks, dexamethasone, gabapentin, and ketamine may be used as appropriate in women at risk of severe postoperative pain or in women whose postoperative pain is not well controlled despite standard analgesic regimes.
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Best Pract Res Clin Anaesthesiol · Mar 2017
ReviewAny news on the postdural puncture headache front?
Unintentional dural puncture followed by postdural puncture headache is a well-known complication following neuraxial labor analgesia. Risk factors for the development of postdural puncture headache may be related to the patient's history and characteristics, the neuraxial technique, and obstetrical events. ⋯ Complications following postdural puncture headache may include transient or permanent hypoacusis, cranial nerve palsies, subdural hematoma, and chronic headache. Evidence is limited regarding the safety and effectiveness of different interventions aimed to prevent or treat postdural puncture headache.
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Best Pract Res Clin Anaesthesiol · Mar 2017
ReviewMaintenance of epidural labour analgesia: The old, the new and the future.
Neuraxial analgesia is considered the gold standard in labour analgesia, providing the most effective pain relief during childbirth. Improvements have enhanced the efficacy and safety of epidural analgesia through better drugs, techniques and delivery systems. ⋯ We also review the newer interactive techniques for drug delivery, such as computer-integrated patient-controlled epidural analgesia and variable frequency automated mandatory bolus. Finally, we discuss future clinical research developments, including the use of data analytics and long-term outcomes associated with childbirth pain management.