Intravenous Dexmedetomidine as an Adjunct to Neuraxial Anesthesia in Cesarean Delivery: A Retrospective Chart Review

Background. Dexmedetomidine is a selective α-2 agonist commonly used for sedation that has been used in obstetric anesthesia for multimodal labor analgesia, postcesarean delivery analgesia, and perioperative shivering. This study evaluated the role of intravenous dexmedetomidine to provide rescue analgesia and/or sedation during cesarean delivery under neuraxial anesthesia. Methods. We conducted a single-center, retrospective cohort study of all parturients undergoing cesarean delivery under neuraxial anesthesia between December 1, 2018, and November 30, 2019, who required supplemental analgesia during the procedure. Patients were divided into two groups: patients who received intravenous dexmedetomidine (Dexmed group) and patients who received adjunct medications such as fentanyl, midazolam, ketamine, and nitrous oxide (Standard group). Primary outcome was incidence of conversion to general anesthesia. Results. During the study period, 107 patients received adjunct medications. There was no difference in conversion to general anesthesia between the Dexmed group and the Standard group (6% (4/62) vs. 9% (4/45); p = 0.718 ). In the Dexmed group, the mean dexmedetomidine dose received was 37 μg (range 10 to 140 μg). While the use of inotropic/vasopressor medications was common and similar in both groups, there was an increase in the incidence of bradycardia (Dexmed 15% vs. Standard 2%; p = 0.042 ) but not hypotension (Dexmed 24% vs. Standard 24%; p = 1.00 ) in the Dexmed group. Conclusion. In patients who required supplemental analgesia for cesarean delivery, those who received dexmedetomidine versus other medications had a similar rate of conversion to general anesthesia, a statistically significant increase in bradycardia, but no difference in the incidence of hypotension.

Safe obstetric anesthesia practice-COVID-19

COVID-19 or Corona virus disease 2019 was declared a pandemic by the WHO on 11th March 2020. Cesarean delivery is a commonly performed major surgery around the world. Important considerations while performing a cesarean section on a confirmed or suspected case of COVID19 are safety of the woman and the fetus; and prevention of transmission of SARS-CoV2 infection to the fetus as well as the healthcare providers. Woman and her birthing partner should be screened for the symptoms of COVID-19 before scheduled admission. Cesarean section in a woman suffering from COVID-19 should be managed by a multidisciplinary team consisting of anesthetists, obstetricians, labor and delivery nurses, neonatologist, critical care experts and infectious disease specialists, all members working in tandem with each other. General changes in workflow, reorganization of obstetric anesthesia services and proper use of personal protective equipment (PPE) are required for safe delivery of obstetric anesthesia during the COVID pandemic. Regional anesthesia is the preferred method of anesthesia for cesarean delivery. Using regional anesthesia reduces the need of aerosol generating procedures and avoids the use of mechanical ventilation. It also decreases the possibility of exacerbating the respiratory complications due to intubation. General anesthesia is recommended when a COVID-19 parturient presents with desaturation (oxygen saturation≤ 93%) for emergency cesarean delivery. Use of mechanical barriers around patient’s head during intubation and extubation might reduce exposure. The patient should be allowed to remain in the operating room itself till sufficiently recovered to be shifted directly to the isolation room.

Impact of COVID-19 on obstetric anesthesia: a systematic review

With an increase in Coronavirus Disease 2019 (Covid-19) incidents around the world, it has become more important than ever to be prepared for the uncertain context of labor and delivery in obstetrics. As medical staff did not encounter such a situation previously, no prior knowledge and guidelines were present to assist them. During the care of obstetric women infected with COVID-19 as well as those who are suspected of COVID-19 infection, there are two objectives, the care of asymptomatic to severely sick pregnant and postpartum women and preventing exposure of medical professionals and others during childbirth hospitalization. The focus of this review is to provide anesthesiologists who are dealing with infected pregnant mothers with some facts or, as data is insufficient, expert opinion, with an emphasis on awareness and optimal medical obstetric anesthesia training. This review will provide possible recommendations for the obstetric anesthesiologists when treating infected obstetric women and these recommendations also help anesthesia providers to prepare themselves for future pandemics.

The current practice of aspiration prophylaxis in obstetric anesthesia: a survey among non-physician anesthetic providers working in hospitals in Ethiopia

Background Pulmonary aspiration is one of the most important complications of obstetric anesthesia. Prevention of pulmonary aspiration is commonly performed by the application of different anesthetic maneuvers and administration of drugs. This study aimed to assess the non-physician anesthetic providers current practice of aspiration prophylaxis during anesthesia for cesarean section in Ethiopia. Methods This survey study was conducted from October 01 to November 05, 2020, on a total of 490 anesthetic providers working in hospitals in Ethiopia. A structured checklist was used to collect data from non-physician anesthetic providers. Results Four hundred and ninety (490) anesthetic providers participated in our study. The majority of the respondents (84%) were working in the public sector. Most of the cesarean delivery was done under regional anesthesia and more than half of anesthetic providers in Ethiopia administered aspiration prophylaxis routinely. Metoclopramide was the most frequently given as a prophylaxis for pulmonary aspiration. Conclusions More than half of the anesthetic providers administered aspiration prophylaxis routinely. Metoclopramide was the commonest administered aspiration prophylaxis for parturients who underwent cesarean delivery to prevent aspiration.

The Anesthetic Modality but Not the Mode of Delivery Seem to Modulate the Methylation Status of Cyclooxygenase-2 Promoter of the Newborns

Objective Cesarean section (CS) rates are high. Epidemiological data supports increased risk of inflammatory conditions in the offspring born by CS. Epigenetic alterations occurring during the perinatal period may account for this risk. Cyclooxygenase-2 (COX2) has strong implications for inflammatory diseases. The methylation of COX2 of newborn infants was compared with respect to their mode of delivery. Study Design Ninety healthy term infants born by vaginal delivery (VD), planned cesarean section (PCS), or emergency CS (ECS) were recruited (30 infants in each group). For obstetric anesthesia, local (LA), regional (RA), or general (GA) anesthesia were used. Carefully selected exclusion criteria were implemented to eliminate any confounders with potential epigenetic effects. Umbilical artery blood samples were collected. Demographic and clinical characteristics, folate and CRP levels, and mean methylation levels of the COX2 gene promoter were determined. Results Except the birth weight and maternal age parameters, VD, PCS, and ECS were similar. The methylation percentage of COX2 was higher in ECS (16.9 ± 5.1) than VD (14.5 ± 4.1) and PCS (14.8 ± 2.9), albeit p was 0.064. Because of the dual anesthetic modality populations (RA and GA) in PCS and ECS and the recent literature on anesthetics and epigenetics, the anesthetic modality groups were also analyzed. The methylation percentage of COX2 was significantly different between LA, RA, and GA groups (14.5 ± 4.1, 13.9 ± 2.8, and 17.0 ± 4.6, respectively, p = 0.012). Conclusion When the mode of delivery is the question of debate, the anesthetic modality should be remembered as an important epigenetic modulator. Key Points

Ultrasound Assisted Neuraxial Blockade in Obstetric Anesthesia

Central Neuraxial Blocks (CNBs) relevant to the practice of obstetric anesthesia and analgesia are spinal, epidural and combined spinal-epidural injections. These techniques are routinely used for cesarean deliveries and labor pain relief. Traditionally, CNBs are performed using surface anatomical landmarks. In the first instance the highest point of each iliac crest is identifies. The imaginary line connecting these points allegedly passes through the L4 vertebral body in non-pregnant women, and L3 vertebral body in pregnant women [1]. Based on this, the operator palpates and counts the spinous processes and decides on the needle entry point. Although this technique is widely accepted as relatively reliable, the correlation is inconsistent even in non-complicated cases. Obesity, tissue edema, pelvic rotation, limited ability to bend forward, hyperlordosis, labor pain, underlying spinal deformity or previous back surgery and instrumentation pose additional difficulty for anesthesiologists to correctly locate the intervertebral levels.