Impact of intra-operative dexamethasone after scheduled cesarean delivery: a retrospective study

BackgroundDexamethasone is an effective analgesic and anti-emetic in patients undergoing many surgical procedures but its effects on pain after cesarean delivery are poorly studied. The aim of this study was to evaluate if routine intra-operative administration of dexamethasone improved analgesia and decreased postoperative nausea and vomiting after scheduled cesarean delivery.MethodsElectronic medical record data for scheduled cesarean deliveries performed under neuraxial anesthesia, before and after a practice change that introduced the routine use of intravenous dexamethasone 4 mg, were obtained. Patients were analyzed based on whether they received routine care (n=182) or also received dexamethasone (n=187). The primary outcome was time to first opioid use. Secondary outcomes included postoperative opioid consumption, pain scores, incidence and treatment of postoperative nausea and vomiting, satisfaction and length of stay.ResultsThere was no significant difference between groups in median time to first postoperative opioid administration (15.8 [3.4–48.0] h routine care vs 14.7 [3.2–38.8] h routine care plus dexamethasone, P=0.08). There were no significant differences in any secondary outcomes.ConclusionsThis impact study involving more than 360 patients suggests that routine administration of intra-operative intravenous dexamethasone 4 mg does not provide additional analgesic benefit after scheduled cesarean delivery, in the context of a multimodal postoperative analgesic regimen. Studies are required to determine if a larger dose or repeated administration influence postoperative analgesia or side effects, or whether certain subsets of patients may benefit.     

Maternal and neonatal outcomes with the addition of intrathecal midazolam as an adjuvant to spinal anesthesia in cesarean delivery: A systematic review and meta-analysis of randomized controlled trials

Study objectiveTo determine the efficacy and safety, in terms of maternal and neonatal outcomes, of adding intrathecal midazolam to spinal anesthesia for cesarean delivery in healthy pregnant women.DesignA meta-analysis of randomized controlled trials was conducted. PubMed, Cochrane Library, Embase, and Web of Science were searched manually, and citation screening was completed on May 20, 2021.SettingMost of the included data were collected in the operating room and postoperative recovery area.PatientsA total of 1382 healthy parturients undergoing cesarean delivery with single-shot spinal anesthesia were recruited in 19 eligible randomized controlled trials.InterventionsSingle intrathecal midazolam adjuvant was compared to a control, with the local anesthetic dose in spinal anesthesia identical between the intervention and control groups.MeasurementsThe primary outcomes were time to first analgesic use, maternal adverse effects, and neonatal Apgar scores at 1 and 5 min. The secondary outcomes were the onset and duration of the sensory and motor blocks.Main resultsAdjuvant intrathecal midazolam prolonged the time to the first analgesic (mean difference [MD]: 59.96 min, 95% confidence interval [CI]: [23.12, 96.79]) and decreased perioperative maternal nausea and/or vomiting (odds ratio [OR], 0.28; 95% CI: [0.17, 0.45]). However, more sedation events were observed with midazolam (OR, 3.93; 95% CI: [1.12, 13.78]). There was no significant difference in the neonatal Apgar scores at 1 or 5 min (MD: -0.29, 95% CI: [−0.61, 0.03]; MD: -0.00, 95% CI: [−0.11, 0.1], respectively). Intrathecal midazolam also shortened sensory and motor block onset by less than 1 min and prolonged sensory block duration but had no significant effect on motor block duration.ConclusionsCurrent evidence indicates that intrathecal midazolam, as an adjuvant to spinal anesthesia, provides modest analgesic and significant antiemetic effects at the cost of more sedation events in cesarean delivery patients. The neonatal Apgar score was not affected by intrathecal midazolam administration. However, more objective, sensitive, and long-term measurements of neonatal safety and maternal neurological effects should be performed in the future.     

Acute postcesarean pain is associated with in-hospital exclusive breastfeeding,length of stay and post-partum depression

Study objectiveThe primary aim of the proposed study was to determine the association between postoperative pain and breastfeeding after cesarean delivery during hospital stay.DesignRetrospective cohort study.SettingPostoperative recovery area and operating room.PatientsData was obtained on singleton pregnancies undergoing scheduled cesarean deliveries under spinal anesthesia between 2013 and 2016.InterventionsDetermine the association between postoperative pain and breastfeeding after cesarean delivery.MeasurementsPostoperative pain score, breastfeeding, LATCH score post-partum depression and length of stay values collected.Main resultsThe dataset consisted of electronic medical records from 5350 patients. We found that the pain score is negatively associated with the LATCH score; higher pain was associated with lower LATCH scores, −0.01 [−0.01,-0.00], p < .0402. Every one-point increase in average pain score was associated with a 21% reduction in the odds of in-hospital exclusive breast-feeding relative to exclusive formula-feeding, OR = 0.79 [0.70–0.90], p < .0002. We observed that the post-partum depression status was associated with the average postoperative pain score, F (1, 5347) = 41.51, p < .0001. We also found a significant positive association between the average pain score and the duration of hospital stay (p < .0001); every one-point increase in the average pain-score was associated with a 7.98 [6.28, 9.68] hour increase in length of stay.ConclusionsOur results demonstrate significant association between the increase in post-cesarean pain scores and deterioration of breastfeeding initiation while also exposing slight reductions in the quality of breastfeeding. Additionally, we found that increases in post-cesarean pain scores also positively associate with postpartum depression and duration of stay, with each increase in pain score resulted in an almost one-day increase in the length of stay.     

Ephedrine versus ondansetron in the prevention of hypotension during cesarean delivery: a randomized,double-blind,placebo-controlled trial

BackgroundMaternal hypotension is common after spinal anesthesia for cesarean delivery. We compared the effects of prophylactic ephedrine with ondansetron on post-spinal blood pressure.MethodsOne hundred and sixty-eight term, singleton parturients were enrolled in this prospective, double-blind, placebo-controlled trial. Patients were randomized to receive either prophylactic intravenous ephedrine 10 mg (Group E), ondansetron 8 mg (Group O) or normal saline (Group P) immediately after spinal anesthesia. The primary outcome was maternal blood pressure between spinal block and delivery; secondary outcomes were nausea and vomiting scores, Apgar scores, numbers requiring intraoperative vasoconstrictors and the dose of vasoconstrictors required.ResultsFifty-six patients were recruited to each group, but two in Group P were excluded from the analysis owing to protocol violations. There were no significant differences between the groups in maternal systolic, diastolic or mean arterial pressures, or the proportion of patients experiencing hypotension. The proportion of patients in Group E requiring intraoperative ephedrine or any vasoconstrictor (ephedrine and/or norepinephrine) was significantly lower than that in Group P (P=0.023 and 0.034, respectively). The proportion of patients in Group O requiring intraoperative norepinephrine was significantly lower than that in Group P (P=0.02). There was no difference in the proportions of patients in Groups E and O requiring any vasoconstrictors (P=0.34).ConclusionsThere was no significant difference in maternal blood pressure in women administered prophylactic ephedrine or ondansetron after spinal anesthesia for cesarean delivery compared with placebo. Ephedrine reduced the proportion of patients requiring a rescue vasoconstrictor before delivery.     

Effect of preoperative pregabalin on post-caesarean delivery analgesia: a dose-response study

IntroductionWe hypothesised that preoperative administration of a single-dose of pregabalin would be associated with lower morphine consumption after uncomplicated caesarean delivery.MethodsAfter Institutional Ethics Committee approval, 135 parturients scheduled for elective caesarean delivery under spinal anaesthesia were randomly allocated to receive either placebo, or oral pregabalin 150 mg or 300 mg, one hour before induction of anaesthesia. Maternal cumulative morphine requirement at 24 h, pain scores, sedation scores, nausea and vomiting, pruritus, pregabalin-related adverse effects, Apgar scores, Neurologic and Adaptive Capacity scores and umbilical cord acid-base status were recorded.ResultsCompared with placebo or pregabalin 150 mg, the use of a preoperative dose of pregabalin 300 mg resulted in significantly lower cumulative morphine consumption at 24 h (mean dose: placebo 12.9 mg [95% CI 11.6 to 14.2]; pregabalin 150 mg 11.9 mg; [95% CI 10.7 to 13.1]; pregabalin 300 mg 6 mg [95% CI 5.4 to 7.3]; P<0.001). Pregabalin 300 mg resulted in lower pain scores at 4 h and 6 h after delivery (P<0.001), and fewer instances of nausea, vomiting and pruritus (P<0.009). Dizziness and abnormal vision were observed most frequently in the pregabalin 300 mg group (P<0.05 and P<0.009, respectively). The three groups were similar in terms of maternal sedation, Apgar scores, Neurologic and Adaptive Capacity scores and umbilical cord acid-base status. Three babies in the pregabalin 300 mg group (6.7%) experienced short-term poor latching-on for breastfeeding.ConclusionIn our study, preoperative administration of pregabalin 300 mg reduced postoperative morphine consumption and early postoperative pain in parturients undergoing elective caesarean delivery, although maternal side effects were more common.     

Factors influencing cesarean delivery operative times: a prospective observational cohort study

BackgroundThis study aimed to determine the distribution of operative delivery times for uncomplicated parturients undergoing elective cesarean delivery with neuraxial anesthesia. A secondary aim was to explore patient and surgical factors associated with longer cesarean delivery times.MethodsA prospective observational study of 331 parturients undergoing elective cesarean delivery with neuraxial anesthesia was conducted. Factors examined included age, body mass index, ethnicity, number of previous cesarean deliveries, stretch mark and scar severity and surgical experience.ResultsOperative times ranged from 13 to 108 min with a mean (SD) of 43.4 (±15.7) min. Only 6 (1.8%) parturients had operative times >90 min and none were converted to general anesthesia. As the number of previous cesarean deliveries increased, the mean operative time increased linearly from 39.5 (±13.0) min in subjects with no previous cesarean deliveries to 52.8 (±18.1) min in subjects with 3 or 4 previous cesarean deliveries (P < 0.0005). For parturients with previous cesarean deliveries, operative times were longer for those with scar scores ?5 than for those with scores <5 (P < 0.01). Stretch mark scores were not associated with operative times. Tubal ligation prolonged the total operative time by a mean of 7 min (P < 0.0005), and attending staff required a mean of 6 more min than residents or fellows (P < 0.01). There was no correlation between operative times, age and body mass index and little variation with ethnicity.ConclusionsThese findings identify previous cesarean deliveries, increased scar intensity, tubal ligation and surgical experience as factors that increase operative times for cesarean delivery. The data also suggest that neuraxial anesthesia lasting 90 min should provide adequate analgesia for most uncomplicated parturients undergoing elective cesarean delivery.     

Intravenous Dexamethasone Injection Reduces Pain From 12 to 21 Hours After Total Knee Arthroplasty: A Double-Blind,Randomized, Placebo-Controlled Trial

BackgroundPain after total knee arthroplasty (TKA) affects postoperative recovery and patient satisfaction. The analgesic benefits of corticosteroids have not been well studied. We, therefore, investigated the analgesic effects of intravenous (IV) dexamethasone (DEX) in patients undergoing a TKA.MethodsThis was a randomized, double-blind, placebo-controlled trial of 0.15 mg/kg of IV DEX vs saline placebo in unilateral TKA. Fifty patients/arm were recruited. Primary outcomes were pain level, determined by a visual analog scale, and the amount of morphine consumption (mg) ≤48 hours post-TKA. Secondary outcomes were rates of nausea and vomiting, C-reactive protein concentrations, and functional outcomes.ResultsThe DEX group had a significantly lower mean visual analog scale score both at rest and during motion at 12, 15, 18, and 21 hours (P < .05). At 21 hours, the mean difference (Δ) in pain at rest was −11 points (95% confidence interval [CI], −21 to −2 points; P = .02) while the mean difference in pain during motion was −15 points (95% CI, −25 to −5 points; P = .004). The DEX group also had lower rates of nausea and vomiting: 29/50 (58%) vs 42/50 (84%) (P = .008) and lower mean C-reactive protein level: 89 vs 167, Δ = −78 mg/L (95% CI, −100 to −58 mg/L, P < .0001). There were no significant differences in mean morphine consumption by 48 hours, modified Western Ontario and McMaster University Osteoarthritis Index scores, and range of motion of the knee at 3-month follow-up (P > .05).ConclusionIV DEX relieves postoperative pain between 12 to 21 hours after TKA and may be a useful adjunct for controlling pain in patients undergoing TKA.     

Assessment of endothelial glycocalyx disruption in term parturients receiving a fluid bolus before spinal anesthesia: a prospective observational study

BackgroundFluid bolus administration is a standard treatment for hypotension. However, the effectiveness of the traditional prophylactic bolus in parturients undergoing spinal anesthesia for cesarean delivery has been questioned. One potential mechanism for the failure of a prophylactic fluid bolus to prevent hypotension is hypervolemia-induced destruction of the endothelial glycocalyx, a structure that plays a vital role in regulating intravascular fluid shifts.MethodsThirty healthy parturients undergoing elective cesarean delivery under spinal anesthesia were recruited. Known endothelial glycocalyx biomarkers, heparan sulfate and syndecan-1 along with atrial natriuretic peptide, were measured before and after a 750-mL crystalloid fluid bolus. Cardiac performance parameters, cardiac index and systemic vascular resistance, were monitored during the fluid bolus using thoracic-impedance cardiography.ResultsA significant increase in both heparan sulfate 96 ng/mg (P=0.0098) and syndecan-1 2.4 ng/mg (P=0.045) were observed after the fluid bolus. There was a non-significant increase in atrial natriuretic peptide 0.6 pg/mg (P=0.293). Cardiac parameters showed a small but significant change; over an average of 15 min, cardiac index increased by 0.1 L/min/m² (P=0.0005) and systemic vascular resistance decreased by 30.7 dyn.s/cm⁵ (P=0.0025).ConclusionsA prophylactic fluid bolus in parturients undergoing spinal anesthesia for cesarean delivery disrupts the endothelial glycocalyx, as noted by a statistically significant increase in post-bolus heparan sulfate and syndecan-1 levels. Although studied in the past, atrial natriuretic peptide could not explain this disruption. Our fluid bolus did not have a clinically relevant effect on cardiac performance.     

Pre-emptive multimodal analgesic bundle with transversus abdominis plane block enhances early recovery after laparoscopic cholecystectomy

BackgroundAs postoperative pain after laparoscopic cholecystectomy may delay recovery and discharge, a multimodal and pre-emptive analgesic approach is necessary. This study demonstrated that a multimodal analgesic bundle improves postoperative recovery, using the Quality of Recovery-40K (QoR-40K) questionnaire during the first 24 h after laparoscopic cholecystectomy.MethodsIn this prospective non-randomized study with two parallel groups, 80 patients undergoing laparoscopic cholecystectomy were allocated into either the multimodal analgesia group or the conventional analgesia group. The multimodal analgesia group received a pre-emptive analgesic bundle (preoperative intravenous administration of paracetamol, ketorolac, and dexamethasone, and a posterior approach to the transversus abdominis plane block), while the conventional analgesia group did not. The primary outcome was the QoR-40K score during the first 24 h after surgery. Secondary outcomes were the peak visual analog scale pain score at rest and the incidence rates of rescue analgesic use and nausea/vomiting during the first 24 h after surgery.ResultsThe QoR-40K score was higher in the multimodal analgesia group than in the conventional analgesia group (196 [190–199] vs. 182 [172–187], p < 0.001). The peak visual analog scale pain score was significantly lower in the multimodal analgesia group than in the conventional analgesia group. Multimodal analgesia also reduced the incidence rates of rescue analgesic use and postoperative nausea/vomiting (22.5% [95% CI, 9.6–35.4%] vs. 55.0% [39.6–70.4%], p = 0.003), compared to conventional analgesia.ConclusionsMultimodal analgesia significantly improves the quality of early postoperative recovery after laparoscopic cholecystectomy, as shown by the QoR-40K score.     

Low-dose intravenous dexmedetomidine reduces shivering following cesarean delivery: a randomized controlled trial

BackgroundIntravenous dexmedetomidine 30 µg reduces shivering after cesarean delivery but can result in sedation and dry mouth. We hypothesized that prophylactic administration of 10 µg of IV dexmedetomidine would reduce the patient-reported severity of shivering after cesarean delivery, without an increased incidence of side effects.MethodsAfter institutional review board approval and informed written consent, women undergoing scheduled cesarean delivery with spinal or combined spinal-epidural anesthesia were randomized to receive either intravenous normal saline or dexmedetomidine 10 µg immediately after delivery. The primary outcome was a patient-rated subjective shivering score using a 10-cm visual analog scale at 30 and 60 min after arrival in the Post-Anesthesia Care Unit. Secondary outcomes included subjective scores for pain, nausea, itching, dry mouth, and sedation, as well as 24-h medication administration and investigator-rated observations of shivering, vomiting, pruritus, and sedation. Repeated measures ANOVA with Tukey-Kramer multiple-comparison test was applied for primary outcomes.ResultsOne hundred patients were enrolled, and 85 completed the study and were included in analysis. The mean ± SD shivering score in the dexmedetomidine group was significantly lower by repeated measures analysis than among controls across the first 60 min (P=0.0002), and individually at both 30 and 60 min (placebo 1.8 ± 2.6 vs. dexmedetomidine 0.6 ± 1.4 at 30 min; 1.2 ± 2.1 vs. 0.3 ± 0.6 at 60 min; both P <0.01). Patient-rated and observer-rated side effects did not significantly differ between groups.ConclusionsProphylactic administration of intravenous dexmedetomidine 10 µg after delivery reduces shivering without notable side effects.     

Evaluation of the impact of enhanced recovery after surgery protocol implementation on maternal outcomes following elective cesarean delivery

BackgroundDespite significant improvements in outcomes following non-obstetric surgery with implementation of enhanced recovery after surgery (ERAS) protocols, development of these protocols for cesarean delivery is lacking. We evaluated implementation of an ERAS protocol for patients undergoing elective cesarean delivery, specifically the effect on opioid consumption, pain scores and length of stay as well as complications and re-admissions.MethodsAn ERAS protocol was developed and implemented for women undergoing elective cesarean delivery. The protocol construction included specific evidence-based items applicable to peripartum management and these were grouped into the three major phases of patient care: antepartum, intrapartum and postpartum. A before-and-after study design was used to compare maternal outcomes. To account for confounders between groups, a propensity matched scoring analysis was used. The primary outcome was postpartum opioid use in mg-morphine equivalents (MMEQ).ResultsWe included 357 (n=196 before; n=161 after) women who underwent elective cesarean delivery. A significant difference in opioid consumption (28.4 ± 24.1 vs 46.1 ± 37.0 MMEQ, P <0.001) and in per-day postoperative opioid consumption (10.9 ± 8.7 vs 15.1 ± 10.3 MMEQ, P <0.001), lower peak pain scores (7 [5–9] vs 8 [7–9], P=0.007) and a shorter hospital length of stay (2.5 ± 0.5 vs 2.9 ± 1.2 days, P <0.001) were found after the introduction of the ERAS protocol.ConclusionsImplementation of ERAS protocols for elective cesarean delivery is associated with significant improvements in analgesic and recovery outcomes. These improvements in quality of care suggest ERAS protocols should be considered for elective cesarean delivery.     

Analgesic efficacy of erector spinae plane block in lumbar spine surgery: A systematic review and meta-analysis

Study objectiveErector spinae plane block (ESPB) has gained popularity for perioperative analgesia in various surgeries. However, its efficacy in lumbar surgery remains unclear. This review aimed to determine whether ESPB could improve analgesic efficacy in lumbar spine surgery.DesignA meta-analysis of randomized controlled trials.SettingPerioperative setting.PatientsPatients undergoing lumbar spine surgery under general anesthesia.InterventionsWe searched the databases including PubMed, Cochrane Library, EMBASE, Web of Science etc. for published eligible controlled trials comparing ESPB with control (no block/sham block) in lumbar spine surgery.MeasurementsThe primary outcome was opioid consumption in the first 24 h after surgery.Main resultsTwelve studies comprising 665 participants were included. Compared to the control, ESPB reduced the opioid (morphine milligram equivalents) consumption significantly 24 h after surgery [mean difference (MD) = −14.55; 95% confidence interval (CI), −21.03 to −8.07; P < 0.0001] and lowered the pain scores at various time points (at rest or during movement) for 48 h after surgery. ESPB increased the patient satisfaction score (0−10) (MD = 2.38; 95% CI, 2.10 to 2.66; P < 0.0001), decreased the postoperative nausea and vomiting [risk ratio (RR) = 0.36; 95% CI, 0.20 to 0.67; P = 0.001], and minimized the length of hospital stay (MD = −1.24 days; 95% CI, −2.31 to −0.18; P = 0.02). Furthermore, subgroup analysis revealed additional reduction in opioid consumption by the block approach at the vertebral level of incision/operation than that at the fixed thoracic/lumbar level. However, considerable heterogeneity and low-grade quality of evidence were observed.ConclusionsESPB provided effective postoperative analgesia resulting in better patient satisfaction and recovery with decreased postoperative nausea and vomiting in patients undergoing lumbar surgery compared to the control. However, the low-grade quality of evidence compromised the findings, therefore further high-quality of evidence is required.PROSPERO registration number: CRD42021233362.     

Impact of cesarean versus vaginal delivery on the risk of postpartum acute kidney injury: A retrospective database controlled study in 116,876 parturients

Study objectiveThe rate of cesarean delivery is increasing globally but the risk of perioperative organ injury associated with cesarean delivery is not well defined. The objective of this study was to determine the risk of postpartum acute kidney injury, a peripartum complication defined by an acute decrease in kidney function, associated with cesarean delivery compared to vaginal delivery.SettingPopulation-based discharge database.PatientsThe Optum Clinformatics® Data Mart was queried for parturients that underwent cesarean or vaginal delivery between January 2016 to January 2018. Using a propensity score model based on 27 antepartum characteristics, we generated a final matched cohort of 116,876 parturients.Intervention/ExposureCesarean delivery as the mode of delivery.MeasurementsThe risk of acute kidney injury associated with each delivery mode and the effect of acute kidney injury on the length of hospital stay for parturients.Main resultsThe matched cohort consisted of 116,876 deliveries, with 58,438 cases in each group. In the cesarean delivery group, the incidence of postpartum acute kidney injury was 24.5 vs. 7.9 per 10,000 deliveries in the vaginal delivery group (adjusted odds ratio = 3; 95% CI, 2.13–4.22; P < .001). The median of the length of hospital stay [interquartile range] was longer by 50% in parturients who developed postpartum acute kidney injury after vaginal delivery (3 [2–4] days vs. those who did not, 2 [2, 3] days; P < .001) and by 67% after cesarean delivery (5 [4–7] days vs. 3 [3, 4] days; P < .001).ConclusionsCesarean delivery is associated with a significantly increased risk of postpartum acute kidney injury as compared to vaginal delivery. The development of postpartum acute kidney injury is associated with prolonged length of hospital stay.     

Analgesic requirements and postoperative recovery after scheduled compared to unplanned cesarean delivery: a retrospective chart review

BackgroundStudies examining the effects of various analgesics and anesthetics on postoperative pain following cesarean delivery conventionally use the scheduled cesarean population. This study compares postoperative analgesic requirements and recovery profiles in women undergoing scheduled cesarean compared to unplanned cesarean delivery following labor. We postulated that unplanned cesarean deliveries may increase postoperative analgesic requirements.MethodsWe conducted a retrospective chart review of 200 cesarean deliveries at Lucile Packard Children’s Hospital, California. We examined the records of 100 patients who underwent scheduled cesarean delivery under spinal anesthesia (hyperbaric bupivacaine 12 mg with intrathecal fentanyl 10 μg and morphine 200 μg) and 100 patients that following a trail of labor required unplanned cesarean under epidural anesthesia (10–25 mL 2% lidocaine top-up with epidural morphine 4 mg after clamping of the umbilical cord). We recorded pain scores, analgesic consumption, time to first analgesic request, side effects, and length of hospital stay.ResultsWe found no differences in postoperative pain scores and analgesic consumption between scheduled and unplanned cesarean deliveries for up to five days postoperatively. There were no differences in treatment of side effects such as nausea, vomiting, or pruritus (P > 0.05).ConclusionThe results indicate that women experience similar pain and analgesic requirements after scheduled compared to unplanned cesarean delivery. This suggests that the non-scheduled cesarean population may be a suitable pain model to study pain management strategies; and that alterations in pain management are not necessary for the unplanned cesarean delivery population.     

Post-cesarean gabapentin is not associated with lower opioid consumption or pain scores in women on chronic buprenorphine therapy: A 10-year retrospective cohort study

Study objectiveTo determine if postoperative gabapentin administration is associated with decreased opioid consumption or pain scores following cesarean delivery in women on chronic buprenorphine.DesignRetrospective cohort study.SettingPostoperative recovery area and postpartum inpatient unit.Patients214 women undergoing cesarean delivery while on chronic buprenorphine at a single institution between 2007 and 2017.InterventionsGabapentin treatment for post-cesarean analgesia.MeasurementsThe primary outcome was opioid consumption in morphine milligram equivalents, comparing patients who received ≥1 dose of gabapentin within 24 h of cesarean delivery to those who did not. Secondary outcomes included opioid consumption 24–48 and 48–72 h post-cesarean and postoperative numerical rating scale pain scores.Main resultsOf 214 included patients, 64 (30%) received gabapentin while 150 (70%) did not. Gabapentin patients were more likely than controls to have received neuraxial fentanyl (30% vs. 14%, p = 0.01) and transversus abdominis plane block (6% vs. 1%, p = 0.05) and overall received higher doses of ketorolac and acetaminophen. Control patients were more likely to have received neuraxial morphine (78% vs. 90%, p = 0.04) and received higher doses of ibuprofen. In unadjusted analysis, there was no significant difference in morphine milligram equivalent consumption 0–24 h postoperatively between gabapentin (55 mg [IQR 26,84]) and control (53 mg [IQR 28,75]) groups (p = 0.38). After controlling for potential confounders, there remained no significant effect of gabapentin administration (overall effect p = 0.99). Opioid consumption and pain scores were also not significantly different at any other time points.ConclusionsIn parturients receiving chronic buprenorphine, inclusion of gabapentin in a multimodal analgesic regimen was not associated with lower opioid consumption or pain scores during the first 72 h after cesarean delivery. Prospective randomized studies are needed to confirm these findings.     

The incidence of postoperative nausea and vomiting after caesarean section in patients with hyperemesis gravidarum: a retrospective cohort study

BackgroundPostoperative nausea and vomiting is one of the most common anaesthetic complications of caesarean section. This study examined the association between hyperemesis gravidarum during pregnancy and nausea and vomiting after caesarean section.MethodsA single-centre, retrospective cohort study, using electronic databases of patients with and without hyperemesis gravidarum, undergoing caesarean section from 2015 to 2019. The incidence and severity of postoperative nausea and vomiting were established by a review of the documentation of administration of postoperative anti-emetics within the 24-h period after surgery, and examined using univariable, multivariable binary and ordered logistic regression models.ResultsData were compared for 76 patients with hyperemesis gravidarum and 315 patients without the condition. The incidence of postoperative nausea and vomiting in the hyperemesis group versus the non-hyperemesis group was 43.4% vs 29.6%, respectively. The odds of experiencing postoperative nausea and vomiting was 1.95 times higher in women with hyperemesis gravidarum than in those without (aOR 1.95, 95% CI 1.13 to 3.36, P=0.016). The odds of having more severe postoperative nausea and vomiting were greater in the hyperemesis gravidarum group (aOR 1.91, 95% CI 1.14 to 3.20, P=0.014).ConclusionPatients with hyperemesis gravidarum are more likely to develop nausea and vomiting after caesarean section, and this is likely to be of greater severity than in those without the condition. This finding should assist the effective provision of intra-operative and postoperative anti-emetics for patients with hyperemesis gravidarum undergoing caesarean section.     

Optimizing Rapid Recovery After Anterior Hip Arthroplasty Surgery: A Comparative Study of Fascia Iliaca Compartment Block and Local Infiltration Analgesia

BackgroundMultimodal pain therapy combining analgesics, local infiltration analgesia (LIA) and peripheral nerve blocks, such as fascia iliaca compartment block (FICB), can improve postoperative pain, nausea and vomiting (PONV) and ambulation in patients undergoing total hip arthroplasty (THA). We hypothesized that addition of FICB would decrease opioid requirements and length of stay (LOS) but could create a motor block.MethodsThis is a single center, prospective, blinded randomized controlled study of 152 patients undergoing elective THA via direct anterior approach from October 2019 till August 2021. Three patient groups were defined: patients receiving only spinal anesthesia (control group, n = 53); spinal anesthesia with LIA perioperatively (n = 50); and spinal anesthesia with FICB on the recovery unit (n = 49). Outcome measures consisted of postoperative pain scores, PONV, length of hospital stay, opioid requirements and mobility.ResultsOverall pain scores were low for all patient groups, with a lower pain score for LIA in comparison to the control group until 4 hours postoperatively (P < .05). Length of hospital stay, postoperative pain, nausea and vomiting (PONV) scores and quadriceps muscle strength did not differ significantly between groups. The control group showed higher scores at 12 hours postoperatively in comparison to FICB regarding rehabilitation potential, use of walking aids and activities of daily living (P < .05), but all groups reached the same endpoint 48 hours postoperatively. The LIA and FICB groups required less opioids until 24 hours postoperatively.ConclusionLIA is a beneficial adjuvant therapy to spinal anesthesia in THA patients as it may decrease pain scores and the need for opioid consumption. Adjuvant FICB only provided lower opioid requirements.     

Adaptación cultural y validación al español de la Escala de intensidad de náuseas y vómitos postoperatorios

IntroductionPostoperative nausea and vomiting (PONV) is a common problem in patients undergoing surgical procedures, generating patient dissatisfaction and increasing hospital costs. The Postoperative Nausea and Vomiting Intensity Scale identifies clinically significant cases; however, it has not been validated in Spanish.ObjectiveTo carry out a cross-cultural adaptation of the PONV Intensity Scale into Spanish and validate it for use in the postoperative period of patients undergoing elective non-cardiac and non-intracranial surgery.Materials and methodsCross-sectional validation study of a diagnostic test. The NVPO Intensity Scale was culturally adapted to Spanish and administered to 393 adult hospitalized patients at 6 postoperative hours. The data were compared with the Apfel Scale and nausea measured on a visual analogue scale (VAS). Internal consistency and inter-observer concordance were calculated.Results59.8% of patients presented NVPO, of which 14.5% were clinically significant. An acceptable internal consistency was obtained for the NVPO Intensity Scale (Cronbach's alpha 0.7) and a high inter-observer correlation (Kappa 0.9, 95% CI 0.86-0.92), statistically significant, for the overall scale. The correlation with VAS was high (Rho Spearman 0.9). The mean VAS and Apfel scale score was significantly higher in patients with clinically significant PONV.ConclusionsThe PONV Intensity Scale adapted to Spanish is a valid and reliable instrument for monitoring and evaluating postoperative nausea and vomiting.     

A systematic review of the effects of adding neostigmine to local anesthetics for neuraxial administration in obstetric anesthesia and analgesia

BackgroundDrugs used in obstetric patients must accomplish two goals: efficacy and safety for both mother and fetus. Neostigmine has been co-administered epidurally and intrathecally with local anesthetics and other adjuncts in the obstetric setting. The aim of this meta-analysis was to assess the efficacy and incidence of adverse events related to the use of neostigmine in obstetric anesthesia.MethodsA meta-analysis of randomized-controlled human trials was conducted using the data sources Google Scholar and PubMed (updated 1 November 2014). Inclusion criteria were: random allocation to treatment; comparison of neostigmine or neostigmine with local anesthetics and/or other adjuvants versus placebo or placebo with local anesthetics and/or other adjuvants; and approval by an ethics committee.ResultsThe use of neostigmine as an adjuvant in neuraxial anesthesia is associated with a reduction in the dose of local anesthetic during labor analgesia and postoperative analgesia following cesarean section: mean reduction of local anesthetic (ropivacaine or bupivacaine) vs. control −4.08 (95% CI −6.7 to −1.5) mg/h (P=0.002). The risk of nausea was increased vs. control with intrathecal neostigmine (OR 8.99 [95% CI 4.74 to 17.05], P <0.001) but not with epidural neostigmine (OR 0.97 [95% CI 0.46 to 2.05], P=0.94). Use of neuraxial neostigmine was associated with a decrease in the risk of pruritus but there was no increase in the incidence of hypotension, dizziness or sedation and no effect on the incidence of abnormal fetal heart rate patterns or Apgar scores.ConclusionsNeuraxial administration of neostigmine significantly reduces local anesthetic consumption without serious adverse side effects to the mother or fetus. However, neostigmine is only recommended for epidural administration as intrathecal use significantly increases the incidence of maternal nausea and vomiting.     

The effect of co-administration of intravenous calcium chloride and oxytocin on maternal hemodynamics and uterine tone following cesarean delivery: a double-blinded,randomized, placebo-controlled trial

BackgroundOxytocin administration to prevent uterine atony following cesarean delivery is associated with adverse effects including hypotension, tachycardia, and nausea. Calcium chloride increases mean arterial pressure, systemic vascular resistance, and uterine smooth muscle contractility. This study evaluated whether the co-administration of calcium chloride with oxytocin following cesarean delivery could alter maternal hemodynamics. Secondary outcomes included uterine tone and blood loss.MethodsSixty healthy parturients with singleton, term, vertex pregnancies undergoing elective cesarean delivery under spinal anesthesia were randomized to one of three study solutions given intravenously immediately after umbilical cord clamping: (1) placebo, oxytocin 5 U alone; (2) CA-200, oxytocin 5 U + calcium chloride 200 mg; or (3) CA-400, oxytocin 5 U + calcium chloride 400 mg. Blood pressure, heart rate, uterine tone, vasopressor or alternate uterotonic use and the incidence of nausea or vomiting were recorded. Baseline and intraoperative plasma concentration of ionized calcium and hematocrit were measured.ResultsPlasma concentration of ionized calcium was elevated in both study groups compared with placebo (P=0.001). Blood pressure decreased and heart rate increased in all groups (P <0.0001), with no differences between groups. No differences were observed between groups in uterine tone, vasopressor use, hematocrit change, estimated blood loss, incision-to-delivery interval, delivery-to-skin closure interval, total intravenous fluid administered or incidence of nausea.ConclusionsThe decrease in blood pressure associated with oxytocin administration following cesarean delivery was not attenuated with co-administration of calcium chloride at the doses evaluated. Vasopressor use, uterine tone, and blood loss were also unaffected.