Yale Anesthesiology

In this episode, Dr. Yavor Metodiev delves into the anesthetic considerations that should be taken when caring for a patient with oncological disease during pregnancy. Dr. Metodiev and colleagues concisely summarize the complexities of treating patients with oncological disease, emphasizing the crucial balance between maternal and fetal safety. With the increasing incidence of oncological disease in pregnant women (1 in 2000), anesthetists are expected to encounter more of these cases, and we play a pivotal role in managing these patients during the peripartum period. https://pubmed.ncbi.nlm.nih.gov/39775436/

In this episode, we explore the concept of a highly functional team, its characteristics, and the importance of fostering interdisciplinary teamwork among healthcare professionals such as anesthesiologists, obstetricians, nurses, and others. Dr. Girnius emphasizes that such collaboration enhances communication and efficiency and improves patient outcomes. Additionally, we discuss the process of identifying and implementing what needs to change while addressing the challenges associated with introducing change within our healthcare system. Improving Obstetric Anesthesia Care Through Teaming and Improvement Science https://pubmed.ncbi.nlm.nih.gov/39325012/ Preoperative Multidisciplinary Team Huddle Improves Communication and Safety for Unscheduled Cesarean Deliveries: A System Redesign Using Improvement Science https://pubmed.ncbi.nlm.nih.gov/39269911/

In this episode, Dr. Landau, a renowned expert and researcher in the topic of pain, delves into the evolution of our understanding of this topic. We explore how the research and its definition have changed over the past few decades. Additionally, we discuss her study titled “Pain during cesarean delivery: a patient-related prospective observational study assessing the incidence and risk factors for intraoperative pain and intravenous medication administration.”

Dr. Allana Munro and Dr. Ronald George are two obstetric anesthesia experts whose research is focused on labor analgesia. Two years ago, they demonstrated that “achieving desired pain relief” is of utmost importance to our patients. The question remains: How can we safely achieve this while minimizing workload and side effects? In this episode, they discuss their study titled “An Innovative Approach to Determine Programmed Intermittent Epidural Bolus Pump Settings for Labor Analgesia: A Randomized Controlled Trial.” Using the response surface methodology, they identified optimal settings for the programmed intermittent epidural bolus pump (PIEB) that maximize maternal satisfaction, minimize clinician-administered boluses, and balance PCEA boluses delivered to those requested. An Innovative Approach to Determine Programmed Intermittent Epidural Bolus Pump Settings for Labor Analgesia: A Randomized Controlled Trial. https://pubmed.ncbi.nlm.nih.gov/38905148/ Patient Preferences for Outcomes Associated With Labor Epidural Analgesia. https://pubmed.ncbi.nlm.nih.gov/35355544/

In this episode, Dr. Lawrence Tsen discusses the findings of his paper on Labor Analgesia Initiation with Dural Puncture Epidural (DPE) Versus Conventional Epidural Techniques. The paper presents a randomized biased-coin sequential allocation trial to determine the effective dose for 90% of patients of Bupivacaine. We explore the benefits of using the DPE technique, if any, along with criticisms from some experts. Additionally, we delve into whether DPE techniques can improve analgesia and the mechanisms behind it. These are just a few of the topics covered in this podcast. Labor Analgesia Initiation With Dural Puncture Epidural Versus Conventional Epidural Techniques: A Randomized Biased-Coin Sequential Allocation Trial to Determine the Effective Dose for 90% of Patients of Bupivacaine https://pubmed.ncbi.nlm.nih.gov/37824436/ Effect of Dural-Puncture Epidural vs Standard Epidural for Epidural Extension on Onset Time of Surgical Anesthesia in Elective Cesarean Delivery: A Randomized Clinical Trial https://pubmed.ncbi.nlm.nih.gov/37526934/ Epidural catheter replacement rates with dural puncture epidural labor analgesia compared with epidural analgesia without dural puncture: a retrospective cohort study https://pubmed.ncbi.nlm.nih.gov/36030558/ Quality of Labor Analgesia with Dural Puncture Epidural versus Standard Epidural Technique in Obese Parturients: A Double-blind Randomized Controlled Study https://pubmed.ncbi.nlm.nih.gov/35157756/ Sacral sensory blockade from 27-gauge pencil-point dural puncture epidural analgesia or epidural analgesia in laboring nulliparous parturients: a randomized controlled trial https://pubmed.ncbi.nlm.nih.gov/39024984/ Determination of the Optimal Volume of Programmed Intermittent Epidural Bolus When Combined With the Dural Puncture Epidural Technique for Labor Analgesia: A Random-Allocation Graded Dose-Response Study https://pubmed.ncbi.nlm.nih.gov/37010955/ Dural Puncture Epidural for Labor Analgesia: Is It Really an Improvement over Conventional Labor Epidural Analgesia? https://pubmed.ncbi.nlm.nih.gov/35320341/

In this episode, Dr. Rachel Kearns discussed the findings from her study -Epidural analgesia during labour and severe maternal morbidity: population-based study. This study solidifies that anesthesiologists bring more to the table than “just” labor pain management. Epidural analgesia during labour and severe maternal morbidity: population-based study. https://www.bmj.com/content/385/bmj-2023-077190 Unlocking maternal health: labour epidurals and severe morbidity https://www.bmj.com/content/385/bmj.q1053 Use of Labor Neuraxial Analgesia for Vaginal Delivery and Severe Maternal Morbidity https://pubmed.ncbi.nlm.nih.gov/35191971/

In this episode, Dr. Allison Mootz, an obstetric anesthesiology fellow at Brigham and Women, discusses her thought-provoking article titled- The Accuracy of ChatGPT-Generated Responses in Answering Commonly Asked Patient Questions About Labor Epidurals: A Survey-Based Study. https://pubmed.ncbi.nlm.nih.gov/38180897/ Comparing Physician and Artificial Intelligence Chatbot Responses to Patient Questions Posted to a Public Social Media Forum https://pubmed.ncbi.nlm.nih.gov/37115527/

In this episode, Dr. David Bishop, a Specialist Anesthesiologist and Head of the Clinical Unit of Anaesthesia at Edendale Hospital in Pietermaritzburg talks about a vital topic and his recent publication, Tranexamic acid at cesarean delivery: drug-error deaths. Tranexamic acid at cesarean delivery: drug-error deaths https://pubmed.ncbi.nlm.nih.gov/36300729/ Spinal tranexamic acid – a new killer in town https://pubmed.ncbi.nlm.nih.gov/30985919/ YouTube publication (Tranexamic acid during CS: Drug error warning (https://www.youtube.com/watch?v=jeFtFWeMwkw&t=184s) Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial https://pubmed.ncbi.nlm.nih.gov/28456509/

In this episode, Dr. Vishal Uppal, whose primary research interests are improving the safety and efficacy of regional anesthesia techniques in high-risk patient populations, discussed his article Consensus Practice Guidelines on Postdural Puncture Headache From a Multisociety, International Working Group: A Summary Report. Consensus guidelines https://pubmed.ncbi.nlm.nih.gov/37581893/ Atypical headache following dural puncture in obstetric https://pubmed.ncbi.nlm.nih.gov/24934311/ A prospective controlled study of continuous spinal analgesia versus repeat epidural analgesia after accidental dural puncture in labour https://pubmed.ncbi.nlm.nih.gov/22153280/ One patch or more? Defining success in treatment of post-dural puncture headache https://pubmed.ncbi.nlm.nih.gov/28089183/ Sphenopalatine ganglion block for postdural puncture headache https://pubmed.ncbi.nlm.nih.gov/19413836/ Major Neurologic Complications Associated With Postdural Puncture Headache in Obstetrics: A Retrospective Cohort Study https://pubmed.ncbi.nlm.nih.gov/31335402/ The volume of blood for epidural blood patch in obstetrics: a randomized, blinded clinical trial https://pubmed.ncbi.nlm.nih.gov/21596867/

In this episode, Dr. Mark Rollins and Dr. Chatterjee, two leading experts in anesthesia for maternal-fetal intervention, share their knowledge with us. Specifically, we discussed fetal benefits and preoperative, intraoperative, and postoperative management for this delicate procedure in which two patients are undergoing surgical intervention under our care. Should we provide analgesia directly or indirectly to the fetus? How can we achieve the tenet goal of excellent uterine relaxation without compromising placental perfusion? Is the use of Sugammadex warranted for midgestation fetal interventions? These and much more were discussed during this Podcast. Anesthesia for Maternal-Fetal Interventions: A Consensus Statement https://pubmed.ncbi.nlm.nih.gov/33048913/ Survey of Fetal Therapy Centers in the North American Fetal Therapy Network. https://pubmed.ncbi.nlm.nih.gov/33827094/ Sugammadex Administration in Pregnant Women and Women of Reproductive Potential: A Narrative Review https://pubmed.ncbi.nlm.nih.gov/31283616/ Society for Obstetric Anesthesia and Perinatology Statement on Sugammadex during pregnancy and lactation https://www.soap.org/assets/docs/SOAP_Statement_Sugammadex_During_Pregnancy_Lactation_APPROVED.pdf Sugammadex Use for Reversal in Nonobstetric Surgery During Pregnancy: A Reexamination of the Evidence https://pubmed.ncbi.nlm.nih.gov/37205805/ A Randomized Trial of Prenatal versus Postnatal Repair of Myelomeningocele (MOMs trial) https://pubmed.ncbi.nlm.nih.gov/21306277/

In this episode, Dr. Grace Lim, Associate professor and the Chief of the Obstetric Anesthesia division at the University of Pittsburgh, whose research is aimed at eliminating pain and suffering in special populations, optimizing perioperative medication use, and personalizing patient care, discussed with us two of her articles related to pain management of patients with and without opioid use disorder. Unfortunately, there is a big gap in knowledge and consensus when caring for patients with a history of opioid use disorder. In this episode, we discussed some of them. References CDC – About Opioid Use During Pregnancy https://www.cdc.gov/pregnancy/opioids/basics.html Associations between postpartum pain type, pain intensity and opioid use in patients with and without opioid use disorder: a cross-sectional study https://pubmed.ncbi.nlm.nih.gov/36371258/ A Systematic Scoping Review of Peridelivery Pain Management for Pregnant People With Opioid Use Disorder: From the Society for Obstetric Anesthesia and Perinatology and Society for Maternal-Fetal Medicine https://pubmed.ncbi.nlm.nih.gov/36135926/ Labor Pain, Analgesia, and Postpartum Depression: Are We Asking the Right Questions? https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7080613/ Other resources related to OUD Buprenorphine versus Methadone for Opioid Use Disorder in Pregnancy https://pubmed.ncbi.nlm.nih.gov/36449419/ Post-cesarean delivery pain. Management of the opioid-dependent patient before, during and after cesarean delivery https://pubmed.ncbi.nlm.nih.gov/36449419/

In this episode, Dr. Sharon Reale shares with us the results of her study titled Frequency and Risk Factors for Difficult Intubation in Women Undergoing General Anesthesia for Cesarean Delivery: A Multicenter Retrospective Cohort Analysis. As Dr. Reale pointed out during this Podcast, most of the available literature regarding the obstetric airway comes from data outside of the United States. Dr. Reale’s study strength resides in the use of a centralized extensive database, the Multicenter Perioperative Outcomes Group (MPOG). Here are the links to the studies mentioned during our Podcast: Frequency and Risk Factors for Difficult Intubation in Women Undergoing General Anesthesia for Cesarean Delivery: A Multicenter Retrospective Cohort Analysis- https://pubmed.ncbi.nlm.nih.gov/35188971/ Serious Complications Related to Obstetric Anesthesia- https://pubmed.ncbi.nlm.nih.gov/24845921/ Airway changes during labor and delivery – https://pubmed.ncbi.nlm.nih.gov/18292672/ Failed intubation in obstetrics: a self-fulfilling prophecy? –https://pubmed.ncbi.nlm.nih.gov/17126002/ Anesthesia-related maternal mortality in the United States: 1979-2002. – https://pubmed.ncbi.nlm.nih.gov/21173646/ Pregnancy-Related Mortality in the United States, 2011–2013- https://pubmed.ncbi.nlm.nih.gov/28697109/

In this episode, Dr. Pervez Sultan, a leading expert in creating obstetric Patient Reported Outcome Measurements (PROMs), including the validated Obstetric quality of recovery (OBsQoR-10), discusses their future in our field. And let me tell you, their future is PROMising, from using it as a benchmark score to compare amongst institutions to analyzing results between obstetricians and anesthesiologists alike to explore which technique(s) (e.g., uterus exteriorization vs. no exteriorization; intrathecal morphine doses) provide the best functional recovery for our patients. Here are the links to the papers discussed during our Podcast: Scoping review of postpartum recovery measures – https://pubmed.ncbi.nlm.nih.gov/32442292/ Proposed domains of postpartum recovery https://pubmed.ncbi.nlm.nih.gov/34536324/ Best measures of postpartum: Global recovery – https://pubmed.ncbi.nlm.nih.gov/34042993/ Pain https://pubmed.ncbi.nlm.nih.gov/34016441/ Sleep – https://pubmed.ncbi.nlm.nih.gov/34013345/ Depression https://pubmed.ncbi.nlm.nih.gov/35749118/ Anxiety https://pubmed.ncbi.nlm.nih.gov/37402438/ ERAC – Beyond the pain scores https://pubmed.ncbi.nlm.nih.gov/32585468/ Obstetric Quality of Recovery-10 item measure ​UK multicenter cohort study https://pubmed.ncbi.nlm.nih.gov/37226593/ US https://pubmed.ncbi.nlm.nih.gov/33345919/ ​Portuguese https://pubmed.ncbi.nlm.nih.gov/35487408/ ​Turkish https://pubmed.ncbi.nlm.nih.gov/36301286/ Hebrew https://pubmed.ncbi.nlm.nih.gov/37717463/ Japanese https://pubmed.ncbi.nlm.nih.gov/37334251/ Core outcome set for ERAC https://pubmed.ncbi.nlm.nih.gov/35511169/