Faculty Bibliography

The obstetric anesthesiologist must consider the risk of spinal-epidural hematoma in patients with thrombocytopenia when choosing to provide neuraxial anesthesia. There are little data exploring this complication in the parturient. In this single-center retrospective study of 20,244 obstetric patients, the incidence of peripartum thrombocytopenia (platelet count <100,000/mm) was 1.8% (368 patients). Of these patients, 69% (256) received neuraxial anesthesia. No neuraxial hematoma occurred in any of our patients. The upper 95% confidence limit for spinal-epidural hematoma in patients who received neuraxial anesthesia with a platelet count of <100,000/mm was 1.2%.

OBJECTIVE:To compare chlorhexidine with alcohol, povidone-iodine with alcohol, and both applied sequentially to estimate their relative effectiveness in prevention of surgical site infections after cesarean delivery. METHODS:Women undergoing nonemergent cesarean birth at greater than 37 0/7 weeks of gestation were randomly allocated to one of three antiseptic skin preparations: povidone-iodine with alcohol, chlorhexidine with alcohol, or the sequential combination of both solutions. The primary outcome was surgical site infection reported within the first 30 days postpartum. Based on a surgical site infection rate of 12%, an anticipated 50% reduction for the combination group relative to either single skin preparation group, with a power of 0.90 and an α of 0.05, 430 women per group were needed to detect a difference. RESULTS:From January 2013 to July 2014, 1,404 women were randomly assigned to one of three groups: povidone-iodine with alcohol (n=463), chlorhexidine with alcohol (n=474), or both (n=467). The groups were similar with respect to demographics, medical disorders, indication for cesarean delivery, operative time, and blood loss. The overall rate of surgical site infection-4.3%-was lower than anticipated. The skin preparation groups had similar surgical site infection rates: povidone-iodine 4.6%, chlorhexidine with alcohol 4.5%, and sequential 3.9% (P=.85). CONCLUSION/CONCLUSIONS:The skin preparation techniques resulted in similar rates of surgical site infections. Our study provides no support for any particular method of skin preparation before cesarean delivery. CLINICAL TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov, www.clinicaltrials.gov, NCT01870583. LEVEL OF EVIDENCE/METHODS:I.

STUDY OBJECTIVE/OBJECTIVE:To confirm the relationship between bevel orientation, catheter direction, and radiopaque contrast spread in the lumbar region. DESIGN/METHODS:Pilot cadaver study. SETTING/METHODS:Anatomy laboratory of a university hospital. MEASUREMENTS/METHODS:Cadavers were randomized to two groups of 4 cadavers each. In Group 1, needle bevel direction at epidural entry was cephalad; in Group 2, it was caudad. After placement of each epidural catheter in L4-L5 interspace, 2 mL of radiopaque contrast was injected and a lumbar posterior-anterior radiograph was obtained. Catheter direction and direction of radiopaque contrast spread were collected. MAIN RESULTS/RESULTS:Due to the inability to access the epidural space secondary to surgical changes in the lumbar spine, one cadaver in the cephalad group was excluded. In 7 of 7 (100%) cadavers, the catheter tip direction according to the radiograph corresponded directly with bevel direction. CONCLUSIONS:A strong relationship exists between bevel orientation and catheter direction; however, catheter position does not reliably predict the direction in which the injected fluid spreads in all cadavers.