Medication errors and mitigation strategies in obstetric anesthesia.

Purpose Of Review: Medication administration errors represent a significant yet preventable cause of patient harm in the peripartum period. Implementation of best practices contained in this manuscript can significantly reduce medication errors and associated patient harm.

Recent Findings: Cases of medication errors involving unintended intrathecal administration of tranexamic acid highlight the need to improve medication safety in peripartum patients and obstetric anesthesia.

Case Report of Hyponatremic Seizures in a Term Neonate Attributed to Excessive Maternal Coconut Water Ingestion During Labor.

We report the case of a term neonate who was somnolent at birth with ventilatory distress and experienced 2 seizures shortly after delivery. Laboratory tests revealed the neonate had a serum sodium of 113 mmol/L. The seizures stopped after treatment with midazolam, and the sodium was corrected slowly with 3% hypertonic saline without further sequelae.

Care Levels for Fetal Therapy Centers.

Fetal therapies undertaken to improve fetal outcome or to optimize transition to neonate life often entail some level of maternal, fetal, or neonatal risk. A fetal therapy center needs access to resources to carry out such therapies and to manage maternal, fetal, and neonatal complications that might arise, either related to the therapy per se or as part of the underlying fetal or maternal condition. Accordingly, a fetal therapy center requires a dedicated operational infrastructure and necessary resources to allow for appropriate oversight and monitoring of clinical performance and to facilitate multidisciplinary collaboration between the relevant specialties.

Beyond the epidural: Alternatives to neuraxial labor analgesia.

Labor creates an intense pain experienced by women across the world. Although neuraxial analgesia is the most effective treatment of labor pain, in many cases, it may not be undesired, not available, or have contraindications. In addition, satisfaction with labor analgesia is not only determined by the efficacy of analgesia but a woman's sense of agency and involvement in the childbirth experience are also key contributors.

Transfusion Preparedness in the Labor and Delivery Unit: An Initiative to Improve Safety and Cost.

Objective: To evaluate patient safety, resource utilization, and transfusion-related cost after a policy change from universal type and screen to selective type and screen on admission to labor and delivery.

Methods: Between October 2017 and September 2019, we performed a single-center implementation study focusing on risk-based type and screen instead of universal type and screen. Implementation of our policy was October 2018 and compared 1 year preimplementation with 1 year postimplementation.

Anesthesia for Maternal-Fetal Interventions: A Survey of Fetal Therapy Centers in the North American Fetal Therapy Network.

Introduction: A wide range of fetal interventions are performed across fetal therapy centers (FTCs). We hypothesized that there is significant variability in anesthesia staffing and anesthetic techniques.

Methods: We conducted an online survey of anesthesiology directors at every FTC within the North American Fetal Therapy Network (NAFTNet).

Error traps in anesthesia for fetal interventions.

A wide range of fetal interventions are being performed worldwide to save the fetus's life, prevent permanent fetal organ damage, and allow a successful transition to extrauterine life. However, these are invasive procedures and can be associated with serious complications. This article focuses on promoting a culture of safety by highlighting five common error traps while anesthetizing patients for fetal interventions.

Anesthesia for Maternal-Fetal Interventions: A Consensus Statement From the American Society of Anesthesiologists Committees on Obstetric and Pediatric Anesthesiology and the North American Fetal Therapy Network.

Maternal-fetal surgery is a rapidly evolving specialty, and significant progress has been made over the last 3 decades. A wide range of maternal-fetal interventions are being performed at different stages of pregnancy across multiple fetal therapy centers worldwide, and the anesthetic technique has evolved over the years. The American Society of Anesthesiologists (ASA) recognizes the important role of the anesthesiologist in the multidisciplinary approach to these maternal-fetal interventions and convened a collaborative workgroup with representatives from the ASA Committees of Obstetric and Pediatric Anesthesia and the Board of Directors of the North American Fetal Therapy Network.

Use of Remifentanil for Open in utero Fetal Myelomeningocele Repair Maintains Uterine Relaxation with Reduced Volatile Anesthetic Concentration.

Introduction: Open fetal repair of myelomeningocele (MMC) is an option for prenatally diagnosed spina bifida. Historically, high-dose volatile anesthetic was used for uterine relaxation but is associated with fetal cardiovascular depression. We examined the impact of administering a supplemental remifentanil infusion on the concentration of inhaled anesthetic required for intraoperative uterine relaxation.

New Method of Destroying Waste Anesthetic Gases Using Gas-Phase Photochemistry.

Background: The inhalation anesthetics are potent greenhouse gases. To reduce the global environmental impact of the health care sector, technologies are sought to limit the release of waste anesthetic gas into the atmosphere.

Methods: Using a photochemical exhaust gas destruction system, removal efficiencies for nitrous oxide, desflurane, and sevoflurane were measured at various inlet concentrations (25% and 50%; 1.

A Comparison of Spinal Anesthesia Versus Monitored Anesthesia Care With Local Anesthesia in Minimally Invasive Fetal Surgery.

Background: Minimally invasive fetal surgery is commonly performed to treat twin-to-twin transfusion syndrome with selective fetoscopic laser photocoagulation and twin-reversed arterial perfusion sequence using radiofrequency ablation. Although an increasing number of centers worldwide are performing these procedures, anesthetic management varies. Both neuraxial anesthesia and monitored anesthesia care with local anesthesia are used at different institutions.

Peripartum Anesthesia Considerations for Placenta Accreta.

Placenta accreta spectrum is becoming more common and is the most frequent indication for peripartum hysterectomy. Management of cesarean delivery in the setting of a morbidly adherent placenta has potential for massive hemorrhage, coagulopathies, and other morbidities. Anesthetic management of placenta accreta spectrum presents many challenges including optimizing surgical conditions, providing a safe and satisfying maternal delivery experience, preparing for massive hemorrhage and transfusion, preventing coagulopathies, and optimizing postoperative pain control.

Effects of Changes in Arterial Carbon Dioxide and Oxygen Partial Pressures on Cerebral Oximeter Performance.

Background: Cerebral oximetry (cerebral oxygen saturation; ScO2) is used to noninvasively monitor cerebral oxygenation. ScO2 readings are based on the fraction of reduced and oxidized hemoglobin as an indirect estimate of brain tissue oxygenation and assume a static ratio of arterial to venous intracranial blood. Conditions that alter cerebral blood flow, such as acute changes in PaCO2, may decrease accuracy.

Incidence and Management of Umbilical Artery Flow Abnormalities during Open Fetal Surgery.

Introduction: Umbilical artery (UA) Doppler ultrasound is used to assess uteroplacental insufficiency. Absent or reversed end diastolic flow (AREDF) in the UA is associated with increased perinatal mortality in fetuses with intrauterine growth restriction. We describe the incidence of UA Doppler abnormalities during open fetal surgery.

Non-Neuraxial Labor Analgesia: Options.

Although it is the most effective method to treat labor pain, neuraxial analgesia may be undesired, contraindicated, unsuccessful, or unavailable. Providing safe choices for labor pain relief is a central goal of health care providers alike. Consequently, knowledge of the efficacy, clinical implementation, and side effects of various non-neuraxial strategies is needed to provide appropriate options for laboring patients.

Direct Measurement of Tissue Oxygenation as a Method of Diagnosis of Acute Compartment Syndrome.

Objective: The aim of this study was to investigate the utility of direct measurement of tissue oxygenation during compartment syndrome (CS) and tourniquet-induced ischemia in a large animal model. We hypothesize that as compartment pressure (CP) rises, circulation within the compartment will decrease resulting in a decreased level of oxygen in the muscle.

Methods: This study used a dog model of both CS- and tourniquet-based ischemia.

Awake brain tumor resection during pregnancy: Decision making and technical nuances.

The co-occurrence of primary brain tumor and pregnancy poses unique challenges to the treating physician. If a rapidly growing lesion causes life-threatening mass effect, craniotomy for tumor debulking becomes urgent. The choice between awake craniotomy versus general anesthesia becomes complicated if the tumor is encroaching on eloquent brain because considerations pertinent to both patient safety and oncological outcome, in addition to fetal wellbeing, are involved.

Pupillary effects of high-dose opioid quantified with infrared pupillometry.

Background: The pupillary light reflex is a critical component of the neurologic examination, yet whether it is present, depressed, or absent is unknown in patients with significant opioid toxicity. Although opioids produce miosis by activating the pupillary sphincter muscle, these agents may induce significant hypercarbia and hypoxia, causing pupillary constriction to be overcome via sympathetic activation. The presence of either "pinpoint pupils" or sympathetically mediated pupillary dilation might prevent light reflex assessment.

Factors affecting the performance of 5 cerebral oximeters during hypoxia in healthy volunteers.

Background: Cerebral oximetry is a noninvasive optical technology that measures frontal cortex blood hemoglobin-oxygen saturation. Commercially available cerebral oximeters have not been evaluated independently. Unlike pulse oximeters, there are currently no Food and Drug Administration standards for performance or accuracy.

Effect of hemorrhage and hypotension on transcranial motor-evoked potentials in swine.

Background: Transcranial motor-evoked potentials (TcMEPs) monitor spinal cord motor tract integrity. Using a swine model, the authors studied the effects of vasodilatory hypotension, hemorrhage, and various resuscitation efforts on TcMEP responses.

Methods: Twelve pigs were anesthetized with constant infusions of propofol, ketamine, and fentanyl.

Anesthesia for in utero repair of myelomeningocele.

Recently published results suggest that prenatal repair of fetal myelomeningocele is a potentially preferable alternative when compared to postnatal repair. In this article, the pathology of myelomeningocele, unique physiologic considerations, perioperative anesthetic management, and ethical considerations of open fetal surgery for prenatal myelomeningocele repair are discussed. Open fetal surgeries have many unique anesthetic issues such as inducing profound uterine relaxation, vigilance for maternal or fetal blood loss, fetal monitoring, and possible fetal resuscitation.

Accuracy of carboxyhemoglobin detection by pulse CO-oximetry during hypoxemia.

Background: Carbon monoxide poisoning is a significant problem in most countries, and a reliable method of quick diagnosis would greatly improve patient care. Until the recent introduction of a multiwavelength "pulse CO-oximeter" (Masimo Rainbow SET(®) Radical-7), obtaining carboxyhemoglobin (COHb) levels in blood required blood sampling and laboratory analysis. In this study, we sought to determine whether hypoxemia, which can accompany carbon monoxide poisoning, interferes with the accurate detection of COHb.