Is Communication Improved With the Implementation of an Obstetrical Version of the World Health Organization Safe Surgery Checklist?
OBJECTIVE:Communication failures are consistently seen as a root cause of preventable adverse outcomes in obstetrics. We assessed whether use of an Obstetric Safe Surgery Checklist for cesarean deliveries (CDs), based on the WHO Safe Surgery Checklist, can improve communication; reduce team member confusion about urgency of the case; and decrease documentation discrepancies among nursing, obstetric, anesthesia, and pediatric staff. METHODS:Retrospective review of 600 CDs on our 2 labor and delivery suites before and after the introduction of 2 consecutive versions of our obstetric safe surgery checklist (100 cases in each cohort) was undertaken. The first version was released in 2010, and after modifications based on initial findings, our current version was released in 2014. One hundred consecutive CDs were identified from each of the 3 periods at each hospital, and charts for those patients and newborns were abstracted. Notes by obstetricians, nurses, anesthesiologists, and pediatricians were reviewed. We compared the rates of agreement in the documentation of the indication for the CD between the different members of the team. Chi-square analyses were performed. RESULTS:Complete agreement among the 4 specialties in the documented indication for CD before introduction of our initial safe surgery checklist was noted in 59% (n = 118) of cases. After initial checklist introduction, agreement decreased to 43% (n = 86; P = 0.002). We then modified our checklist to include indication for CD and level of urgency and changed our policy to include pediatric staff participation in the timeout. Agreement in a subsequent chart review increased to 80% (n = 160), significantly better than in our initial analysis (P < 0.001) and our interim review (P < 0.001). The greatest improvement in agreement was observed between obstetricians and pediatricians. CONCLUSIONS:Implementation of a safe surgery checklist can improve communication at CDs, but care should be taken when implementing checklists because they can have unanticipated consequences. Ongoing review and modification are critical to ensure safer medical care.
Enhanced Recovery after Surgery (ERAS) at Cesarean to Reduce Postoperative Length of Stay: A Randomized Controlled Trial
OBJECTIVE:Our objective was to determine whether an enhanced recovery after surgery (ERAS) pathway at the time of cesarean birth would permit a reduction in postoperative length of stay and improve postoperative patient satisfaction compared to standard perioperative care (SC). STUDY DESIGN/METHODS:Patients undergoing nonemergent cesarean delivery at â‰¥ 37 weeks of gestation were randomized to ERAS or SC. ERAS involved multiple evidence-based interventions bundled into one protocol. The primary outcome was discharge on postoperative day 2 (POD#2). Secondary outcome variables included pain medication requirements, breastfeeding rates and various measures of patient satisfaction. RESULTS:From September 27, 2017 to May 2, 2018, 58 women were randomized to ERAS and 60 to SC. The groups were similar in medical comorbidities, demographic and perioperative characteristics. ERAS was not associated with a significantly increased rate of POD#2 discharges when compared with SC, 8.6% vs. 3.3%, respectively (OR: 2.74, 95% CI 0.51-14.70), but it was associated with a significantly reduced postoperative length of stay (LOS) when compared with standard care, with median LOS of 73.5 [(IQR): 71.08-76.62)] v. 75.5 [(IQR: 72.86-76.84)] hours from surgery, difference in median LOS: (-1.92, 95% CI -3.80 - -0.29). ERAS was not associated with a reduction in postoperative narcotic use, 117.16 Â± 54.17 vs. 119.38 Â± 47.98 morphine milligram equivalents (Mean difference: -2.22, 95% CI -20.86-16.42). More subjects randomized to the ERAS protocol reported breastfeeding at discharge, 67.2% vs. 48.3% (p=0.046). When patients were surveyed 6 weeks postpartum, those in the ERAS group were more likely to feel that their expectations were met, they achieved their postoperative milestones earlier and to report continued breastfeeding. CONCLUSION/CONCLUSIONS:ERAS after cesarean was not associated with an increase in the number of women discharged on POD#2, but that may have been related to factors other than patients' medical readiness for discharge. Evidence that ERAS after cesarean may have the potential to improve outcomes such as day of discharge are suggested by the observed reduction in overall postoperative LOS, improved patient satisfaction and an increase in breastfeeding rates. Even better results may accrue with more provider and patient experience with ERAS.
Hepatic adenoma during pregnancy and anesthetic management
We report the case of a 24-year-old woman with a large hepatic adenoma diagnosed in the third trimester of pregnancy. The adenoma was at risk of rupture. She underwent scheduled preterm cesarean delivery under combined spinal-epidural anesthesia, followed by transarterial embolization on post-partum day six. Definitive resection of the adenoma took place two months postpartum.
Enhanced recovery after surgery at cesarean to reduce postoperative length of stay: A randomized controlled trial [Meeting Abstract]
A Retrospective Case Series of a Novel Spinal Cord Stimulator Trial Technique with Less Displacement and Migration of the Trial Leads
Background:Spinal cord stimulation is an established treatment option for certain chronic pain conditions which have been previously unresponsive to conservative therapies or potentially for a subset of patients who have not improved following spine surgery. Prior to permanent lead implantation, stimulator lead trials are performed to ensure adequate patient benefit. During these trials, one of the most common complications and reasons for failure is the displacement and migration of the trial leads, resulting in lost therapeutic coverage. Other complications include infection and dislodged bulky dressings. There is a paucity of literature describing an adequate procedural method to prevent these common complications. Objective:This study utilizes a series of 19 patients to evaluate a new technique for securing percutaneous spinal cord simulator trial leads, which may minimize dislodgement and migration complications and improve the rate of trial success. Study Design:Retrospective case series. Setting:New Jersey Medical School, Department of Anesthesiology, Pain Management Division. Methods:A retrospective chart review was conducted on 19 consecutive patients undergoing placement of the percutaneous thoracic spinal cord stimulator trial leads for pain associated with lumbar spine pathology over a two-year period (2010-2012). Results:Of the 19 patients in our cohort, there was one trial lead displacement, no lead migrations, and no site infections. Thirteen patients went on to permanent lead implantation. This improved trial lead placement technique had a high success rate with a low number of complications. Limitations:Small sample size, retrospective case series, and no control group for comparison. Conclusion:This case series was able to demonstrate that our described novel spinal cord stimulator trial lead placement and dressing technique can decrease the incidence of lead displacement and migration, thus improving trial success.
Thrombosis and compartment syndrome requiring fasciotomy: Complications of internal iliac artery balloon catheters for morbidly adherent placenta [Letter]
Comparison of Subcuticular Suture Type for Skin Closure After Cesarean Delivery: A Randomized Controlled Trial
OBJECTIVE:To compare the rate of wound complications among women who underwent cesarean delivery through a Pfannenstiel skin incision followed by subcuticular closure with either poliglecaprone 25 suture or polyglactin 910 suture. METHODS:Patients undergoing nonemergent cesarean delivery at or beyond 37 weeks of gestation were randomized to undergo subcuticular skin closure with either poliglecaprone 25 or polyglactin 910. The primary outcome was a wound composite outcome of one or more of the following: surgical site infection, wound separation, hematoma, or seroma within the first 30 days postpartum. To detect a reduction in the primary outcome rate from 12% to 4%, with a power of 0.90 and a two-tailed Î± of 0.05, 237 women per study group were required. Analysis was performed according to the intent-to-treat principle. RESULTS:From May 28, 2015, to August 5, 2016, 275 women were randomized to poliglecaprone 25 and 275 to polyglactin 910, of whom 520 (95%) were included in the final analysis: 263 in the poliglecaprone 25 group [of whom 231 (88%) actually underwent poliglecaprone 25 closure) and 257 in the polyglactin 910 group [of whom 209 (81%) actually underwent polyglactin 910 closure]. The groups were similar in demographic characteristics, medical comorbidities, and perioperative characteristics. Poliglecaprone 25 was associated with a significantly decreased rate of overall wound complications when compared with polyglactin 910, 8.8% compared with 14.4% (relative risk 0.61, 95% CI 0.37-0.99; P=.04). CONCLUSION:Closure of the skin after cesarean delivery with poliglecaprone 25 suture decreases the rate of wound complications compared with polyglactin 910 suture. CLINICAL TRIAL REGISTRATION:ClinicalTrials.gov, NCT02459093.
Risk of Epidural Hematoma after Neuraxial Techniques in Thrombocytopenic Parturients: A Report from the Multicenter Perioperative Outcomes Group
BACKGROUND: Thrombocytopenia has been considered a relative or even absolute contraindication to neuraxial techniques due to the risk of epidural hematoma. There is limited literature to estimate the risk of epidural hematoma in thrombocytopenic parturients. The authors reviewed a large perioperative database and performed a systematic review to further define the risk of epidural hematoma requiring surgical decompression in this population. METHODS: The authors performed a retrospective cohort study using the Multicenter Perioperative Outcomes Group database to identify thrombocytopenic parturients who received a neuraxial technique and to estimate the risk of epidural hematoma. Patients were stratified by platelet count, and those requiring surgical decompression were identified. A systematic review was performed, and risk estimates were combined with those from the existing literature. RESULTS: A total of 573 parturients with a platelet count less than 100,000 mm who received a neuraxial technique across 14 institutions were identified in the Multicenter Perioperative Outcomes Group database, and a total of 1,524 parturients were identified after combining the data from the systematic review. No cases of epidural hematoma requiring surgical decompression were observed. The upper bound of the 95% CI for the risk of epidural hematoma for a platelet count of 0 to 49,000 mm is 11%, for 50,000 to 69,000 mm is 3%, and for 70,000 to 100,000 mm is 0.2%. CONCLUSIONS: The number of thrombocytopenic parturients in the literature who received neuraxial techniques without complication has been significantly increased. The risk of epidural hematoma associated with neuraxial techniques in parturients at a platelet count less than 70,000 mm remains poorly defined due to limited observations.
In Response [Comment]
Comparison of subcuticular suture type in post-cesarean wound complications: a randomized controlled trial [Meeting Abstract]