International Journal of Obstetric Anesthesia S7 S8 International Journal of Obstetric Anesthesia

56 Pages·2014·1.31 MB·English

International Journal of Obstetric Anesthesia S7
O1 Accuracy and precision of the ultrasound cardiac output O2 Cardiac function and structure using transthoracic
monitor (USCOM 1A) in pregnancy: comparison with 3- echocardiography in term HIV positive women
dimensional transthoracic echocardiography AT Dennis,  RA Dyer*,  M Gibbs*,  L Nel*,  A Myburgh*,  JM
HM McNamara,  V Sharma*,  PM Barclay   Castro†,  JL Swanevelder*  
Tom Bryson Department of Anaesthesia, Liverpool Women's Anaesthesia, The Royal Womens Hospital, Melbourne,
Hospital, Liverpool, UK, *Department of Cardiology, Royal Australia, *Anaesthesia, Groote Schuur Hospital &
Liverpool University Hospital, Liverpool, UK University of Cape Town, Cape Town, South Africa,
Introduction: Women who become critically unwell during †Cardiology, St Vincent's Hospital, Melbourne, Australia 
pregnancy present specific challenges for haemodynamic Introduction: In South Africa up to 30% of pregnant women
monitoring. Invasive devices are undesirable, as such women are human immunodeficiency virus (HIV) positive (+). These
are usually breathing spontaneously, not sedated and may be women may have cardiovascular problems including systolic
labouring or coagulopathic.1 The ultrasound cardiac output dysfunction and may progress to dilated cardiomyopathy. The
monitor (USCOM 1A, USCOM Ltd, Sydney, NSW, Australia) effects of pregnancy and HIV on haemodynamics have not
is entirely non-invasive, measuring cardiac output via a been extensively researched1 and in term women are unknown.
Doppler probe placed on the suprasternal notch. Previous This study compared haemodynamics in term HIV+ women
studies of this device in pregnancy include small numbers with those of term healthy pregnant (HP) women, using
measuring changes in cardiac output,2 but none have transthoracic echocardiography (TTE).
assessed its accuracy in this patient population. Maternal Methods:After ethics approval, 30 term HIV+ women with CD4
haemodynamic changes such as increased aortic blood flow, counts >200 cells/mm3 and on either highly active anti-
displacement of the heart and increased left ventricular retroviral therapy or single drug management and 40 term HP
outflow tract diameter have potential to affect measurement. women, underwent TTE scanning.
The aim was therefore to measure agreement between the
Results: Assessment was possible in all 70 women. HP &
USCOM and a reference method, in pregnant women.
HIV+ women were similar age and body mass index. Mean
Methods: Ethical approval was obtained and written informed (SD) CD4 count andduration of therapy were 452±187.8
consent was given by all participants. Ninety-two healthy cells/mm3 and 15.9±22.4 months, respectively. Inter-observer
women with a singleton pregnancy of 25 weeks of gestation variability for left ventricular (LV) outflow tract diameter and
onwards were recruited from antenatal clinics. In the left lateral LV velocity time integral was within 10 and 11 % of the mean
position at rest, cardiac output was measured with the values, respectively.
U S C O M a n d t h r e e -dimensional transthoracic
Variable Healthy HIV+
echocardiography (3D-TTE). A single operator performed all
Mean arterial pressure (mmHg) 84±15.2 82±13.1
USCOM measurements, with a different operator performing all
SVR(dyne.s/cm5) 1237 ±321 1323 ±344
echocardiography. Both were blinded to results from the other
Cardiac index (L/min/m2) 3.1±0.70 2.8±0.64*
device. Each USCOM trace was analysed using two modes:
LV mass (g) 170±40.4 140 ±38.8*
Flowtrace (FT) and Touchpoint (TP). A second, blinded
Fractional shortening (%) 40±8.8 42 ±6.3
USCOM reading was taken to assess reproducibility.
LV end diastolic area (cm2) 15.1 ±2.7 17.2 ±3.1*
Results: USCOM readings were obtained in all 92, and 3D-
Heart rate (BPM) 88±13.1 83±15.7
TTE images in 85 participants. Mean cardiac output was 5.7.
Septal IV relaxation (ms) 64±17.3 63±12.9
7.7 and 6.2 L min-1, measured by 3D-TTE, USCOM FT and
Septal s´ velocity (cm/s) 9.3±1.7 8.5±1.5*
USCOM TP respectively. Bland-Altman analysis of agreement
Septal e´ velocity (cm/s) 12.4 ±2.5 11.5 ±2.4
between 3D-TTE and USCOM for measurement of CO is
Mitral valve E/A 1.6±0.50 1.7±0.65
shown in the table below.
Mitral valve E/septal e´ 7.7±2.13 7.7±2.0
Bland-Altman analysis USCOM FT USCOM TP RV IV relaxation (ms) 37.5 ±12.8 44.1 ±10.4*
Bias (L min-1) +2.0 +0.4 RV s´ velocity (cm/s) 17.0 ±2.9 14.7 ±3.1*
Limits of agreement (L min-1) -0.2 to + 4.2 -1.4 to +2.3 RV e´ velocity (cm/s) 18.7 ±3.4 16.3 ±4.1*
Mean percentage difference (%) 32.6 31.4 Pericardial effusion 21 (53) 25 (83)*
Size of effusion (cm) 0.3±0.28 0.5±0.20*
Mean percentage difference for measurement of stroke volume
was 27% (FT) and 27.5% (TP). Intraclass correlation for Data are mean ± SD, number (%). SVR: systemic vascular
repeated USCOM measurements was 0.9 (FT) and 0.86 (TP). resistance: IV: isovolumetric; RV: right ventricle. Data
Discussion: The USCOM has acceptable agreement with 3D- compared using unpaired two-tailed t-tests with Welsh’s
TTE for measurement of cardiac output in pregnancy. The correction. and Fisher’s exact test. *P<0.05
large positive bias, particularly in FT mode, may be due to the Discussion: Compared with HP, HIV+ women had reduced
hyperdynamic cardiovascular state of pregnancy. The clinician cardiac index, LV and RV systolic myocardial velocities and
should be aware of this when using the device, and we increased LV ED areas in the presence of reduced LV mass.
recommend the use of TP mode in this patient population. These findings suggest subclinical impairment of systolic
References function and limited diastolic impairment, reflecting reduced
adaptation to the increased haemodynamic demands of
1. Armstrong S, Fernando R, Columb M. Minimally-and non-invasive
assessment of maternal cardiac output: go with the flow! Int J pregnancy. Changes may be due to HIV or drug therapy.
Obstet Anesth 2011; 20: 330–40
Reference
2. Lee SW, Khaw KS, Ngan Kee WD, Leung TY, Critchley LAH.
Haemodynamic effects from aortocaval compression at different 1. Longenecker C, Mondo C, Le V, Jensen T, Foster E. HIV infection
is not associated with echocardiographic signs of cardiomyopathy or
angles of lateral tilt in non-labouring term pregnant women. Br J
pulmonary hypertension among pregnant Ugandan women. Int J
Anaesth 2012; 109: 950-6
Cardiol 2011;147: 300–2.
S8 International Journal of Obstetric Anesthesia
O3 Choice of drugs for neuraxial labour analgesia: An OAA O4 Haemodynamics using transthoracic echocardiography
approved survey of current practice in women with untreated preeclampsia in South Africa
Reference
Reference
0.20*
Lee SW, Khaw KS, Ngan Kee WD, Leung TY, Critchley LAH.
Haemodynamic effects from aortocaval compression at different 1. Longenecker C, Mondo C, Le V, Jensen T, Foster E. HIV infection
is not associated with echocardiographic signs of cardiomyopathy or
angles of lateral tilt in non-labouring term pregnant women. Br J
pulmonary hypertension among pregnant Ugandan women. Int J
Anaesth 2012; 109: 950-6
Cardiol 2011;147: 300–2.
S8 International Journal of Obstetric Anesthesia
O3 Choice of drugs for neuraxial labour analgesia: An OAA O4 Haemodynamics using transthoracic echocardiography
approved survey of current practice in women with untreated preeclampsia in South Africa
V Nalawade,  U Misra   AT Dennis,  RA Dyer*,  M Gibbs*,  L Nel*,  JM Castro†,  JL
Anaesthetics, Sunderland Royal hospital, Sunderland, UK Swanevelder*  
Anaesthesia, The Royal Womens Hospital , Melbourne,
Introduction: Bupivacaine has been used to provide labour
Australia, *Anaesthesia, Groote Schuur Hospital &
analgesia for many years. It is, however, extremely cardiotoxic
University of Cape Town, Cape Town, South Africa,
if accidental overdose were to occur. This led to the search
†Cardiology, St Vincent's Hospital, Melbourne, Australia 
for newer agents and ropivacaine was introduced followed by
L-bupivacaine. Although less potent, in high doses Introduction: Preeclampsia (PE) is a life-threatening
ropivacaine and L-bupivacaine are less cardiotoxic than hypertensive disease of pregnancy. From an aetiological and
bupivacaine. Some serious adverse incidents involving clinical perspective it is important to understand
accidental intravenous bolus administration of dilute haemodynamics and quantify cardiac output (CO) in women
bupivacaine solution led to the release of the NPSA-21 safety with untreated (UT) disease. Continuing previous work in
alert in the UK.1 It recommended the use of licensed premixed Australia,1the aim of this study was to quantify
bags of local anaesthetic (LA) and adjuvants for use on haemodynamics in women with UTPE in South Africa (SA)
labour wards. The aim of our survey was to investigate using transthoracic echocardiography (TTE), as these women
whether there is uniformity in the choice of LA and adjuvants may represent a different phenotype and disease severity.
used for maintenance of labour analgesia in the U.K. and Methods: After ethics approval 15 HIV negative women with
whether most units have changed to using licensed bags of UTPE were recruited and compared with 40 healthy term
premixed LA and opioid. pregnant (HP) women+. All underwent standardised TTE
Methods: An OAA approved on-line survey no.140 was examination.
distributed to lead obstetric anaesthetists in the UK. Results: Fourteen women (93%) had severe PE. Women were
Results: Questionnaires were sent to 197 units and the similar in body mass index, parity and age.
response rate was 80.2% Variable Healthy Untreated PE
Gestation (weeks) 40±1.8 36 ±5.6*
Haemoglobin (g/dL) 10.7 ±1.42 10.3 ±1.9
Mean arterial pressure (mmHg) 84±15.2 120 ±11.9*
Cardiac index (L/min/m2) 3.1±0.70 3.6±0.94
SVR (dyne.s/cm5) 1237 ±321 1592 ±531*
Cardiac output (L/min) 5.7±1.3 6.6±2.1
SV (mL) 66±14 79±15.8*
CWI (mmHg.L/m2) 266±77.7 425 ±109.7*
LV ED diameter (cm) 4.6±0.44 4.5±0.49
LV mass (g) 170±40.4 216 ±32.2*
Fractional shortening (%) 40±8.8 40 ±7.1
Heart rate (beats/min) 88±13.1 83±14.2
Septal s´ velocity (cm/s) 9.3±1.7 8.4±1.6
57% of units use low-dose bupivacaine for labour analgesia: Biphasic septal s´ wave 6 (15) 7 (47)*
0.1% is the commonest concentration in which bupivacaine Mitral valve E/Septal e´ 7.7±2.13 10.5 ±3.3*
(83.6%) and L-bupivacaine (85.0%) are used. Fentanyl is the TAPSE 2.6±0.39 2.6±0.36
most frequently used additive (98.1%) and the favourable Pericardial effusion 21 (53) 10 (67)
concentration used is 2 µg/mL (94.8%). Labour epidural Size of effusion (cm) 0.3±0.28 0.5±0.24*
analgesia is maintained using patient-controlled epidural Longitudinal Strain (%) - -18.1 ±3.7
analgesia (PCEA) by 29.8% (46/154) units while PCEA plus Data are mean ± SD, number (%), SVR=systemic vascular
background infusion, continuous infusion and intermittent
resistance, SV=stroke volume, CWI=cardiac work index,
top-ups are used by 20.1% (31/154), 26.6% (41/154) and 21.4%
LV=left ventricle, ED=end-diastolic, HR=heart rate,
(33/154) units, respectively. Only one unit reported using a
TAPSE=tricuspid annular plane systolic excursion *P<0.05
computer integrated PCEA. 64.5% (102/158) of units use compared using unpaired two-tailed t-tests with Welsh’s
licensed premixed bags from a manufacturer while 10.1%
correction. +These SA women were also a control group for a
(16/158) were prepared by hospital pharmacy. Some units use
study investigating haemodynamics in HIV positive women.
syringes rather than bags which are prepared in a pharmacy
Discussion: Anaemia was common. Compared with term HP
(17.7%) or on labour ward (1.9%).
women, women with UTPE had increased SVR and SV and
Discussion: Despite concerns regarding its toxicity,
preserved systolic function with no change in HR or LVED
bupivacaine is still the favoured local anaesthetic in the UK.
diameter. Women with UTPE had reduced diastolic function,
In spite of the NPSA safety alert LA syringes with additives
abnormal interventricular septum movement, increased LV
are still prepared on the labour ward. It may be useful to have
mass and larger pericardial effusions than HP women. There is
revised recommendations for providing safe maintenance of
variability in haemodynamics between women; however TTE
labour epidural analgesia.
can assess cardiac function in individual women with PE.
Reference
Reference
1..Safer practice with epidural injections and infusions. NPSA, Patient
1. Dennis AT, Castro JM, Simmons SW, Permezel M, Royse CF.
Safety Alert 21, 2007.
Haemodynamics in women with untreated pre-eclampsia.
Anaesthesia 2012;67:1105-18.
International Journal of Obstetric Anesthesia S9
O5 Measurement of epidural insertion pressures in O6 Pharmacokinetics of ondansetron in non-pregnant and
labouring women of varying body mass indices pregnant women
References
Reference
1..Safer practice with epidural injections and infusions. NPSA, Patient
1. Dennis AT, Castro JM, Simmons SW, Permezel M, Royse CF.
Safety Alert 21, 2007.
Haemodynamics in women with untreated pre-eclampsia.
Anaesthesia 2012;67:1105-18.
International Journal of Obstetric Anesthesia S9
O5 Measurement of epidural insertion pressures in O6 Pharmacokinetics of ondansetron in non-pregnant and
labouring women of varying body mass indices pregnant women
MYK Wee,  R Isaacs,  B Parker,  N Vaughan*,  V Dubey*   P Sultan,  M Elkomy*,  G Peltz*,  C Clavijo*,  M Wu*,  JL
Dept. of Anaesthesia, Poole Hospital NHS Foundation Trust, Galinkin*,  D Drover*,  B Carvalho*  
Poole, UK, *School of Design, Engineering and Computing, Anaesthetics, Royal Free Hospital, London, UK,
Bournemouth University, Bournemouth, UK *Anesthesiology, Stanford University School of Medicine,
Introduction:To create high-fidelity epidural simulators it is California, USA
important to incorporate in vivo epidural pressure Introduction:Ondansetron is a potent and selective 5-hydroxy
measurements.1 This study presents the results of insertion tryptamine receptor antagonist that is widely used to treat
pressures as a Tuohy needle is advanced through to the nausea and vomiting in women undergoing caesarean surgery.
epidural space in a porcine cadaver followed by a clinical trial 1 Ondansetron may also be effective in preventing maternal or
of labouring women of varying body mass index (BMI). The neonatal narcotic drug withdrawal symptoms.2 However, there
ultimate aim is to use these measured epidural pressures is no information about ondansetron pharmacokinetics in
together with ultrasound and MRI images for the development pregnant women or neonates. The aim of this study was to
of a novel epidural simulator to aid training. characterise ondansetron pharmacokinetics in non-pregnant,
Methods:Ethics approval was granted. A porcine saddle cut pregnant women and neonates, and determine the drug’s
was obtained within 24 h of slaughter. Epidural pressure trans-placental passage.
measurements were made using a 16-G Tuohy needle (Smiths Methods: Healthy women undergoing elective caesarean
Medical) utilising a 3-way tap, pressure transducer (Kimal) and delivery at Stanford University, California were randomly
a custom designed wireless transmitter and receiver allowing assigned to receive 4 or 8 mg intravenous ondansetron for this
remote recording of pressures. Following informed consent, prospective, open-label, Institutional Review Board-approved
epidural pressures were measured in four groups of labouring study. A population pharmacokinetic approach was used to
women (5/group) with BMIs between <25 to >45 (see Table 1). analyse the measured ondansetron concentrations in 372
Ultrasound images of the lumbar region were done before the blood samples obtained from 20 non-pregnant and 40 pregnant
procedure and MRIs were taken within 72 h of delivery. women after treatment with either 4 or 8 mg of ondansetron.
Results: The maximum porcine epidural pressure ranged from Maternal blood samples were taken again 7, 15, and 40 min,
470-500 mmHg equivalent to a peak force of 11.1-11.8 N. The and 8 h after the drug was administered. Ondansteron levels
maximum maternal epidural pressure ranged from 450-530 were also measured from venous umbilical cord blood at
mmHg eqivalent to a peak force of 10.6-12.3 N. Mean epidural delivery, and from neonates 30 min to 24 h after birth.
pressures decrease with increasing BMI (Table). Epidural
Results: The analysis demonstrated that: ondansetron
pressure recordings by different operators demonstrate
disposition is not affected by pregnancy; the ondansetron
individual characteristic properties.
dose was the most important covariate affecting its
Table:Measured epidural pressures in labouring women pharmacokinetics; ondansetron readily crossed the placenta;
BMI Highest mean Lowest mean and ondansetron displayed a significantly longer half-life in
(kg/m2) pressure pressure Mean SD neonates. The mean population parameter estimates were
(mmHg) (mmHg) (mmHg) central distribution volume of 28 L; clearances of 22 L/h and 15
L/h for the 4- and 8-mg doses respectively; steady-state
18.5-
530 363 461 46.94 volumes of 167 L and 124 L for the 4- and 8-mg doses
24.9
respectively; and inter-compartmental clearance of 329 L/h.
25-34.9 520 320 430 79.68
35-44.9 510 285 415 101.19 Discussion: Ondansetron exhibits pregnancy-independent
>45 450 280 376 71.33 kinetics suggesting that the ondansetron dose does not need
Discussion: The clinical trial in labouring women of various to be altered during pregnancy. The study also shows that
BMI demonstrated that the mean epidural pressures decrease ondansetron readily crosses the placenta, however drug
with increasing BMI. The reason for this is being investigated. elimination in the neonate during the first day of life is delayed
The measured pressures with ultrasound and MRI lumbar compared to their mother. These findings will help facilitate
images will be incorporated into a novel epidural simulator accurate maternal, trans-placental and neonatal dosing of
currently under development. Individual pressure recordings ondansetron.
can be used to refine the individual's epidural technique References
improving efficacy and safety. 1. Hsu ES. A review of granisetron, 5-hydroxytryptamine3 receptor
antagonists, and other antiemetics. Am J Ther 2010;17:476-86
Acknowledgements:We are grateful to the OAA for funding.
2. Chu LF, Liang DV, Li X, et al. From mouse to man: the 5-HT3
Reference receptor modulates physical dependence on opioid narcotics.
Pharmacogenet Genomics 2009;19:193-205
1. Vaughan N, Dubey VN, Wee MYK, Isaacs R. A review of epidural
simulators: where are we today? Med Eng Phys 2013;35:1235-50.
S10 International Journal of Obstetric Anesthesia
O7 Randomized evaluative study of phenylephrine or O8 Evaluation of non-Luer epidural equipment
norepinephrine for maintenance of blood pressure
during spinal anaesthesia for caesarean delivery: The
RESPOND study
Reference
References
S10 International Journal of Obstetric Anesthesia
O7 Randomized evaluative study of phenylephrine or O8 Evaluation of non-Luer epidural equipment
norepinephrine for maintenance of blood pressure AG Ling,  R Vedantham,  P Sharpe  
during spinal anaesthesia for caesarean delivery: The Anaesthesia, University Hospitals of Leicester, Leicester, UK
RESPOND study
Introduction: Data on non-Luer neuraxial connectors has
WD Ngan Kee,  SWY Lee,  FF Ng,  PE Tan,  KS Khaw   focused mainly on spinal needles.1,2 We evaluated opinions
Department of Anaesthesia & Intensive Care, The Chinese on four Surety compliant epidural systems (Sarstedt, Pajunk,
University of Hong Kong, Shatin, Hong Kong Vygon and BBraun) in comparison with our current Portex
Introduction: When phenylephrine (PHE), a pure alpha- (Luer) equipment using a high-fidelity epidural training
agonist, is used to maintain blood pressure (BP) during spinal mannequin.
anaesthesia (SA) for caesarean delivery (CD), heart rate (HR) Methods: Ethical approval was deemed unnecessary for this
often decreases, which may also decrease cardiac output (CO). project. Twenty post-fellowship anaesthetists were asked to
1 Norepinephrine (NOR) is a potent vasoconstrictor but also a assess and compare five epidural kits in a random order on a
weak beta-agonist. In this double-blind study we training mannequin. They evaluated on a 10-point scale: the
hypothesized that NOR would be effective for maintaining BP needle, feel of loss of resistance, connection stability of the
with less tendency to decrease HR and CO vs PHE. syringe, ease of feeding the catheter, assembly of the adaptor
Methods: With ethics approval and written consent, we and filter, stability of the connection between catheter and
randomized 104 healthy women having elective CD under SA adaptor, feel of aspiration/flushing, overall satisfaction and
to have BP maintained using PHE 100 µg/mL or NOR 5 µg/mL, whether they would be prepared to use the equipment on a
relative doses based on previous animal studies. Vasopressors patient. Data were analysed using independent samples
were infused by computer control to maintain systolic BP near Kruskal-Wallis tests.
baseline, with crystalloid coload. BP and HR were measured Results: The Portex (Luer) package scored better in most
Q1min and CO was measured by suprasternal Doppler Q5min. assessment criteria. Of the four Surety compliant systems
We compared area under the curve for serial haemodynamic there was no difference between needles. During loss of
values normalized to % of baseline vs. time for 15 min, BP resistance testing, all four Surety compliant systems scored
control with performance error calculations, Apgar scores, and similarly but below the Portex system. Catheters by Sarstedt
cord blood gases and O2 content. and Pajunk scored significantly worse than other systems. No
Results: 101 patients completed the study. The incidences of single non-Luer package was recommended for patient
hypotension, hypertension and nausea/vomiting were low and evaluation or being as good as our original, Portex (Fig. 1).
similar between groups. Serial haemodynamics analysis
showed that for NOR, HR and CO were greater over time but
SBP and SVR were lower (Table). BP control analysis showed
higher bias for PHE (2.3±3.5%) vs NOR (0.7±3.1%,P=0.01) but
no other differences. Mean vasopressor infusion rate was
greater in the NOR group (0.48±0.13 ml/min) vs. the PHE group
(0.41±0.12ml/min, P=0.007). Umbilical venous pH and O
2
content were higher in the NOR group (P<0.05).
Table: Analysis of area under the curve for serial
haemodynamic changes (units are value*time).
  PHE NOR P
Systolic blood pressure 1532±67 1494±67 0.005
Heart rate 1343±130 1443±185 0.002
Cardiac output 1497±176 1639±189 <0.001
Stroke volume 1638±188 1648±156 0.8 Discussion: Of the current non-Luer kits available, no single
Systemic vascular resistance 1552±244 1374±158 <0.001 brand had an ideal kit that rivalled the Portex (Luer) equipment.
Most concerns were around catheters and connectors. The
Discussion:NOR was associated with greater HR and CO; the
Sarstedt catheter was too flexible and the markings difficult to
greater umbilical venous pH and O content with NOR could
2 read and the Pajunk reinforced catheter was too soft to thread
be explained by greater uteroplacental blood flow. Because of
having to be replaced multiple times during testing due to
its intrinsic beta-agonist activity, NOR may be a better
kinking or other damage. There were also concerns with some
obstetric vasopressor than PHE. However, our results may
of the adaptor to filter combinations, many anaesthetists
also be partly explained by use of a less potent dose in the
feeling that the design may lead to easy disconnection of the
NOR group. NOR has potential to be an ideal vasopressor for
catheters from the adaptor and filter. The components in these
maintaining BP during SA for CD. Further work is suggested
new epidural kits are constantly evolving. Our assessment
to confirm our findings and to compare NOR with PHE at
suggests that at present no one single non-Luer product is as
different potency ratios.
good as the original system it is aimed to replace.
Reference
References
1. Stewart A, Fernando R, McDonald S, et al. The dose-dependent
effects of phenylephrine for elective cesarean delivery under spinal 1. Sharpe P, Scott S, Gross JM. An evaluation of non-Luer safety
anesthesia. Anesth Analg 2010;111:1230-7. connectors for neuraxial procedures. Anaesthesia 2013; 68:562-70
2. Kinsella SM, Goswami A, Laxton C, et al. A clinical evaluation of
four non-Luer spinal needle and syringe systems. Anaesthesia 2012;
67:1217-24
International Journal of Obstetric Anesthesia S11
O9 Epidural asepsis: a pilot study on potential contamination O10 Feasibility testing of a model for assessing flow
using two techniques when drawing up normal saline characteristics of epidural boluses
References
References
1. Sharpe P, Scott S, Gross JM. An evaluation of non-Luer safety
connectors for neuraxial procedures. Anaesthesia 2013; 68:562-70
2. Kinsella SM, Goswami A, Laxton C, et al. A clinical evaluation of
four non-Luer spinal needle and syringe systems. Anaesthesia 2012;
67:1217-24
International Journal of Obstetric Anesthesia S11
O9 Epidural asepsis: a pilot study on potential contamination O10 Feasibility testing of a model for assessing flow
using two techniques when drawing up normal saline characteristics of epidural boluses
MYK Wee,  M Onofrei,  B Parker,  M Stewart,  S Hill   T Husain,  I Nikiforos*,  R Fernando,  T Girard†  
Dept. of Anaesthesia, Poole Hospital NHS Foundation Trust, Anaesthesia, University College London Hospitals, London,
Poole, UK UK, *Medical Physics, University College London Hospitals,
Introduction:Infectious complications associated with central London, UK, †Anesthesiology, University Hospital of Basel, 
neuraxial blockade (CNB) have potentially devastating Basel, Switzerland
consequencesincluding meningitis, paralysis and even death.1 Introduction: Compared to continuous infusion, the use of
The reported incidence of epidural abscess after CNB varies intermittent techniques, such as patient-controlled epidural
from 1:1000 to 1:1 000 000.2 A UK national survey of aseptic analgesia, are associated with less anaesthetic interventions
technique in obstetric CNB in 2009 showed 99% use of gown, and motor block.1 Studies of in vitro epidural bolus flow have
gloves and sterile drape, 87% use of a surgical cap and 91% shown that intermittent boluses result in greater bolus
use of a face mask.3 However, there is no consensus in the distribution, compared to continuous infusions, suggesting a
most aseptic technique used for drawing up saline to be used greater pressure was generated within the catheter.2 In multi-
for the epidural procedure. The aim of this study was to orifice epidural catheters, lower pressures have been shown to
ascertain if there is a difference in drawing up saline with a result in preferential flow through more proximal orifices.3 We
sterile needle directly from the ampoule or saline from a sterile aimed to produce a bench top model in order to assess flow
tray after being expressed by an assistant. distribution characteristics of epidural boluses generated at
Methods: Ethics approval was sought but not required. various flow rates by commonly used epidural pumps.
Women in labour consented to the study in their labour Methods: Local research & ethics committee approval was
rooms. An initial laboratory study indicated that 0/5 and 3/5 waived. Funding to manufacture the model was received from
grew commensals from epidural saline samples taken via the Smiths Medical (St Paul, USA). A clear perspex container of
needle technique (NT) and tray technique (TT), respectively. know dimensions, was superimposed with a standardised 10
This informed a sample size calculation where we assumed cm x 10 cm grid. Epidural catheters (19G & 20G) were
contamination of 5% using NT and 50% using the TT. To introduced into the container, with the distal portion of the
detect this difference at the 5% significance level with 90% catheter submerged in a standardised gelatin-saline solution.
power required 23 samples per group (46 in total). The Boluses of 5 mL of ink-stained saline were delivered at high
technique used was randomised using computer generated (500 mL/h), medium (250 mL/h) and low (180mL/h) flow rates
randomisation. The anaesthetist used the standard aseptic by epidural pumps, and by manual bolus. The flow patterns of
technique (surgical hat, mask, gown and sterile gloves) after boluses were recorded, and the area of spread was calculated
hand washing with chlorhexidine or iodine scrubs. 20 mL using image analyser software (Digimiser©, Mariakerke,
saline was drawn up either via a sterile needle (NT) or from a Belgium).
sterile tray (TT). 10mL saline was inoculated into each of the Results: Bolus distribution areas (frontal and transverse) are
aerobic and anaerobic culture bottles. shown for three flow rates below. Although there was no
Results: One culture from the NT and 4 cultures from the TT significant difference in area of distribution between the flow
arm grew staphylococci, streptococci and other commensals. rates, flow was noted to be more uniformly through all catheter
Using a 2-sided Fisher's exact test P = 0.35 which was not orifices at higher flow rates.
significant. Table: Epidural bolus distribution for three epidural flow rates
Discussion: Although the results were not statistically
significant, there is a tendency for more contamination using
the expression of saline into the epidural tray. The clinical
implications of this are unknown. The non-significant result
could be due to our error in overestimating the potential
Data are mean ±SD. 
contamination using the tray technique. A larger sample study
is planned based on the results of this pilot study. Discussion: Our novel bench top model to assess epidural
bolus epidural flow distribution has allowed us to quantify the
References
affect of bolus flow rate on bolus distribution. Surprisingly, at
1. Hebl J. The importance and implications of aseptic techniques
the rates that currently available epidural pumps deliver
during regional anesthesia. Reg Anesth Pain Med 2006;31:311-23.
boluses, there is no difference in the area of distribution.
2. Grewal S, Hocking G, Wildsmith JAW. Epidural Abscesses. Br J
Anaesth 2006;96:292-302. Further work will validate the model in the use of manually
3. McKenzie A, Darragh K. A national survey of prevention of delivered boluses, so that the optimal flow rate for epidural
infection in obstetric central neuraxial blockade in the UK. bolus delivery can be found.
Anaesthesia 2011;66:497-502.
References
1. van der Vyver M, Halpern S, Joseph G. Br J Anaesth 2002;89:459–
65.
2. Gray M, Dinesh S. In-vitro spread of epidural infusion regimes:
infusion vs. PCEA bolus vs. manual injection. Int J Obstet Anesth.
2009; 18: S26.
3. Power I, Thorburn J. Differential flow from multihole epidural
catheters. Anaesthesia. 1988; 43: 876–8.
S12 International Journal of Obstetric Anesthesia
O11 Identification of the midline in late pregnancy: normal O12 The severity of preeclampsia score: an e-Delphi study
vs raised body mass index
References
Reference
S12 International Journal of Obstetric Anesthesia
O11 Identification of the midline in late pregnancy: normal O12 The severity of preeclampsia score: an e-Delphi study
vs raised body mass index W Pollock ,  M Flood ,  AT Dennis*,  S Lapinsky†,  K
M Butcher,  R George,  J Ip,  J Campbell,  SM Yentis   Konig,  N Harley §,  S McDonald  
Obstetric Anaesthesia, Chelsea & Westminster hospital, Midwifery, Anaesthesia, Obstetrics & Intensive Care, La
London, UK Trobe University & Mercy Hospital for Women, Heidelberg,
Introduction: Identifying the midline in parturients, especially Australia, *Royal Womens Hospital, Parkville, Australia,
obese ones, during central neuraxial blockade can be difficult, †University of Toronto & Mt Sinai Hospital, Toronto, 
even using ultrasound.1 We previously found that non-obese Canada, §Royal Melbourne Hospital, Parkville, Australia 
parturients can accurately identify their midline when asked to Introduction: Preeclampsia is a life-threatening hypertensive
place a finger along Tuffier’s line, though their pinprick multi-system disorder of pregnancy with no agreed definition
discrimination was less precise.2 The aim of this study was to of severity. It is a major reason for admission to an intensive
repeat our investigation in obese parturients in late pregnancy. care (IC) unit yet severity of illness scores have not been
Methods: After research ethics committee approval and written adapted for this condition. Basing our work on the established
consent, we asked 25 mothers of ≥36 weeks of gestation and Acute Physiology And Chronic Health Evaluation version II
body mass index ≥30 kg/m²to point to the middle of their back (APACHE II)1 framework widely used in IC medicine, we aim to
along Tuffier’s line using the index finger of their dominant develop a severity of preeclampsia score applicable to all
hand. This point was marked. The true midline at the L3-4 women presenting with preeclampsia to aid immediate clinical
interspace was located using ultrasound and also marked. The recognition of severity, management, staffing and resource
distance between these points was measured. A 20-cm allocation, and numerical classification for research purposes.
horizontal line was drawn level with the L3-4 interspace, As the first step we obtained international expert consensus
centred on the true midline, and pinpricks delivered at 0.5-cm on key variables to include in the adapted framework.
intervals along this line using a Neuropen® (Owen Mumford Methods: Following ethics approval, a 3-round on-line
Ltd, Oxford, UK) with neurological examination pin attached, electronic Delphi (e-Delphi) study was conducted sampling
starting first from the left and then the right. The woman was international multi-disciplinary professionals with expertise in
asked to describe whether each pinprick was felt in the middle, preeclampsia. Participants ranked variables as to usefulness in
left or right of her back. The distance between those pinpricks describing severity of preeclampsia, using a 7-point Likert
described as being in the middle and the true midline was scale, and added any new variables. New suggestions and
measured, starting from both the left and the right, and variables with disagreement were considered in Round 2. All
averaged to give a final ‘discrimination range’. Data were variables with median ≥4 score were retained for Round 3.
analysed with the Mann-Whitney U-test or unpaired t-test, P Results: Round 1 comprised 113 survey invitations with 54
<0.05 indicating statistical significance. (48%) responses. 48 considered themselves expert in
Results: Obese women were less able to discriminate the preeclampsia and were included in Rounds 2 and 3. They were
midline and deviations from it than non-obese parturients from 9 countries, with 54% from Australia. Most were
(Table). However, if a participant stated that the stimulus was obstetricians and/or maternal-fetal specialists (59%), whilst
to the left or the right, she was correct 99% of the time in both 10% were anaesthetists. 94% acknowledged the score’s
groups. research utility and 81% agreed there was clinical utility.
Table: Comparison of non-obese (data from Ip et al.2) and Usefulness was defined as variables with median score ≥6 and
least useful defined as variables with median score ≤3. 
obese parturients in late pregnancy.
Non-Obese Obese P value Median (IQR)
BMI (kg/m²) 22.0 (1.8) 39.6 (7.7) <0.0001 Useful variables
Gestation (weeks) 38.4 (1.0) 37.6 (1.4) 0.04 Pulmonary oedema 7.0 (6.0-7.0)
F-M dist (mm) 2 (0-5 [0-12]) 5 (5-10 [0-10]) 0.007 Neurological symptoms 6.5 (6.0-7.0)
DR (mm) 18 (13-25 [8-40]) 33 (25-45 [3-85]) <0.0001 Haemolysis or red blood cell fragmentation 6.0 (5.0-7.0)
Platelet count 6.0 (5.0-7.0)
Data are median (IQR [range]). F-M dist: finger-midline
Placental abruption 6.0 (5.0-6.8)
distance; DR: discrimination range.
Least useful variables
Discussion: We found that whilst obese and non-obese
Maternal uterine artery (UA) Doppler 3.0 (2.0-5.0)
parturients were similarly accurate at identifying left/right,
Serum bilirubin 3.0 (2.0-4.0)
obese women were less accurate at identifying and
sFLT-1/PIGF ratio 3.0 (2.0-4.0)
discriminating their midline than non-obese women. This may
Plasma fibronectin 2.0 (1.0-3.0)
add to the difficulty in siting a neuraxial block in obese women,
Serum alpha-fetoprotein 2.0 (1.0-3.0)
in whom palpation of bony landmarks may already be more
sFT1=FMS-like tyrosine kinase, PIGF=placental growth factor
difficult and the depth of insertion greater.
References Discussion: Clinical signs and haematological variables were
most useful with maternal UA Doppler and biomarkers least
1. Bauer M, George III J, Seif J, Farag E. Recent advances in epidural
analgesia. Anesthesiol Res Pract 2012; 2012: 309219 useful. Addition of useful descriptors to an adapted APACHE
2. Ip J, Campbell J, Yentis SM. Sensory thresholds and mothers’ self- II framework, including vital signs of systolic and diastolic
identification of the midline in late pregnancy. Int J Obstet Anesth blood pressure, temperature, respiratory and heart rate, may
2012; 21: S9
aid in the creation of a severity of preeclampsia score.
Reference
1. Knaus W, Draper E, Wagner D, et al. J APACHE II:A severity of
disease classification system.Crit Care Med 1985;3:818-29
International Journal of Obstetric Anesthesia S13
P1 Transthoracic echocardiography in patients with P2 Point-of-view HD Video Assessment: Video Direct
preeclampsia and pulmonary oedema Observed Procedural Skills (VDOPS)
References
Reference
Maternal uterine artery (UA) Doppler 3.0 (2.0-5.0)
Serum bilirubin 3.0 (2.0-4.0)
sFLT-1/PIGF ratio 3.0 (2.0-4.0)
Plasma fibronectin 2.0 (1.0-3.0)
Serum alpha-fetoprotein 2.0 (1.0-3.0)
1. Knaus W, Draper E, Wagner D, et al. J APACHE II:A severity of
disease classification system.Crit Care Med 1985;3:818-29
International Journal of Obstetric Anesthesia S13
P1 Transthoracic echocardiography in patients with P2 Point-of-view HD Video Assessment: Video Direct
preeclampsia and pulmonary oedema Observed Procedural Skills (VDOPS)
AT Dennis,  RA Dyer*,  M Gibbs*,  L Nel*,  JM Castro†,  JL D Leslie,  M Oliver,  MR Stacey  
Swanevelder*   Department of Anaesthesia, University Hospital of Wales ,
Anaesthesia, Royal Womens Hospital, Melbourne, Australia, Cardiff, UK
*Anaesthesia, Groote Schuur Hospital & University of Cape Introduction: Junior doctor training in the UK has undergone
Town, Cape Town, South Africa, †Cardiology, St Vincent's  significant changes, with reduced working hours. This
Hospital, Melbourne, Australia necessitates novel assessment tools to provide more training
Introduction: Pulmonary oedema (PO) is a life-threatening opportunities. Workplace-based assessments, in their current
complication of preeclampsia (PE).1 In hypertensive PO form, are time consuming to arrange, and not treated uniformly
assumptions are often made regarding cardiac function (CF) by assessors. Video assessment is well established in general
without appropriate investigations such as transthoracic practice and sport,1 and we believe it could complement
echocardiography (TTE). TTE is recommended in PO but current anaesthetic training. We used high definition video
rarely used in the obstetric setting. We present three cases in sport glasses to record the anaesthetists point of view whilst
which TTE performed at the time of PO confirmed diagnosis, performing central neuraxial blockade for elective caesarean
assessed CF and assisted with management. section.
Case reports: TTE employed the Rapid Obstetric Screening Methods:The glasses have the sensor mounted above the
Echocardiography (ROSE) scan method, focusing on nose piece. Modifications included rotating the sensor 90º
parasternal and apical views, using M-mode, pulse wave and (portrait wide-angle) and removing the lenses making them
Tissue Doppler Imaging. At the time of PO Case 1 was less intrusive. After patient and operator consent, tray
hypertensive, 38.4 weeks pregnant receiving magnesium preparation (opening pack till application of drape) and
sulphate. Case 2 was hypertensive nine days after CS with a procedure attempts (application of drape till injection
wound infection and acute 19% weight gain. Case 3 was complete) were recorded by glasses worn by both the
hypertensive two days after CS for acute rise in blood anaesthetist and by an observer giving two viewpoints. The
pressure (BP) 175/105 mmHg with abruption, postpartum videos were downloaded, synchronised and stored securely
haemorrhage (PPH) and transfusion. No patient had mitral on an encrypted hard disk. A debrief and feedback session
stenosis. with the consultant followed after completion of the case.
Video analysis using StudioCode software allowed labelling of
  Case 1 Case 2 Case 3
events during procedures.
Age (years) 23 30 41
Results: 16 anaesthetists of various grades volunteered to
Booking weight (kg) 60 54 52
take part, with only one trainee declining participation. The
Booking Systolic BP (mmHg) 120 90 138
glasses reliably gave excellent views of operators hands,
Booking Diastolic BP (mmHg) 90 60 88
needle, tray and patient position. The non-intrusive recording
Haemoglobin (g/dL) 7.1 8.9 9.3
enabled trainees to perform as they usually would. The ability
Systolic BP (mmHg) 190 150 150
to discuss performance whilst reviewing the procedure was
Diastolic BP (mmHg) 145 100 100
very positively received by all operators. StudioCode allowed
Fractional shortening (%) 19 25 28
simple data collection such as time taken for procedure, as well
Ejection fraction (EF) (%) 15 45 45
as more complex data such as glitches and ergonomics.
LV end diastolic diameter (cm) 4.7 5.3 5.5
Heart rate (beats/min) 126 70 80 Table: Time taken for tray preparation and procedure attempt
Mitral valve E/ septal e´ 9.7 8.7 12.2
Event Recorded Number Time taken (Min/Median/Max)
Treatment after TTE Hydralazine Frusemide Frusemide
Tray Preparation 16 2:19 / 3:13 / 5:25
LV: left ventricle Procedure Attempt 23 1:12 / 2:33 / 3:41
Discussion: Precipitating factors and CF were different in each
Discussion:The quality of an assessment tool is dictated by
case. PO was either associated with a marked increase in
its reliability, validity, educational benefit,and cost.2 Our
afterload or fluid imbalance in the setting of normal responses
experience so far suggests it is relatively simple to implement,
to surgery, sepsis, or PPH. EF was preserved in Cases 2 and 3
and well received by both patients and anaesthetists alike. The
(fluid imbalance), but reduced in Case 1 (increased afterload).
video produced by these glasses represents excellent value,
In Case 1 afterload reduction rapidly improved LV function
with negligible running costs. Regular use could allow trainees
and in all cases LV function improved quickly over a short time
to develop a portfolio of procedures; demonstrate consistent
course. None of the three women had a dilated ventricle.
levels of performance, and therefore competence. We believe
Elevated HR in hypertensive PO may indicate systolic
that video analysis of practical procedures using recordable
dysfunction and a need to reduce blood pressure by
video sports glasses will be a valid, reliable,non-intrusive and
vasodilatation. Hypertensive PO in the absence of tachycardia
educationally beneficial way of improving assessment, and
may indicate diastolic dysfunction and a need to reduce
therefore training.
preload by diuresis. Redistribution of fluid from the lungs with
References
ventilation strategies and frusemide is necessary in all cases.
TTE defined mechanisms of CF in PO and guided therapy, 1. Ram P, Grol R, Rethans JJ, et al.. Assessment of general
practitioners by video observation of communicative and medical
including anaesthetic technique. Anaemia, acute weight gain,
performance in daily practice: issues of validity, reliability and
and poor fluid and BP control may be risk factors for PO. feasibility. Med Educ 1999;33:447-54.
Reference 2. Kathirgamanathan A, Woods L. Educational tools in the assessment
of trainees in anaesthesia. Contin Educ Anaesth Crit Care Pain
1. Dennis AT, Solnordal CB. Acute pulmonary oedema in pregnant 2011;11:138-42.
women. Anaesthesia 2012;67:646-59.
S14 International Journal of Obstetric Anesthesia
P3 An analysis of the workflow impact of P4 Chronic pain after caesarean section
References
References
P1 Transthoracic echocardiography in patients with
preeclampsia and pulmonary oedema
9.7 8.7 12.2
Treatment after TTE Hydralazine Frusemide Frusemide
1. Ram P, Grol R, Rethans JJ, et al.. Assessment of general
practitioners by video observation of communicative and medical
performance in daily practice: issues of validity, reliability and
feasibility. Med Educ 1999;33:447-54.
Reference 2. Kathirgamanathan A, Woods L. Educational tools in the assessment
of trainees in anaesthesia. Contin Educ Anaesth Crit Care Pain
1. Dennis AT, Solnordal CB. Acute pulmonary oedema in pregnant 2011;11:138-42.
women. Anaesthesia 2012;67:646-59.
S14 International Journal of Obstetric Anesthesia
P3 An analysis of the workflow impact of P4 Chronic pain after caesarean section
changing scheduled elective cesarean deliveries from 37  CE Warnaby,  NJ Beale,  R Russell,  O Kciuk,  L Buck,  A
to 39 weeks Koelewyn,  J Quinlan  
B Carvalho,  Y Cho,  A Butwick,  Y Blumenfeld ,  E Riley   Nuffield Division of Anaesthesia, University of Oxford, John
Anesthesiology, Stanford University, Stanford, USA Radlciffe Hospital, Oxford, UK
Introduction: Delivery of infants before 39 weeks of gestation Introduction: Chronic pain lasting >3 months after caesarean
increases the risk of adverse neonatal outcomes, including section occurs in up to 18% of women.1 The mechanism by
increased mechanical ventilation and admission to NICU.1 which acute postoperative pain converts to chronic post-
However, scheduling caesarean delivery (CD) at ≥39 weeks surgical pain (CPSP) is incompletely understood. Various
(compared to ≥37 weeks) may increase unscheduled and after- factors including pain perception, surgical and anaesthetic
hours CDs, requiring delivery before their scheduled CD.2 The technique, acute postoperative pain management and caring
aim of this study was to determine the impact of waiting until for the baby may affect the rate of conversion.2 The aim of this
39 weeks gestation on the timing of CD. on-going observational study is to determine the incidence of
Methods: After ethical approval, we conducted a CPSP and identify predictive factors for its development.
retrospective, single center study of all women who underwent Methods: Following ethics committee approval and informed
CD between January 2010 and September 2013. On April 1, consent, 650 women have currently been recruited into the
2011, an institutional policy was implemented to eliminate non- study investigating pain after caesarean section. Verbal and
medically indicated deliveries before 39 weeks gestation. The numerical pain scores at rest and movement were recorded at 6
timing of CD before (01/01/2010 to 03/30/2011) and after hours and 2, 7, and 30 days and 4 and 12 months after surgery.
(06/01/2011 to 09/30/2013) the policy change was determined; Results: Of the 650 women consented, 85% had elective
April and May 2011 were omitted to account for an adjustment caesarean sections. Of these, data collection rates were 84% at
period. Data were extracted from an institutional database. 6 hours, 86% at 2 days, 78% at 7 days, 66% at 30 days, 70% at
Extracted data included date and time of admission and type of 4months and 65% at 12 months. When asked if they "suffer
delivery. Shifts were divided into daytime shifts (7am-5pm) and pain relating to their caesarean section", the incidence of pain
nighttime shifts (5pm-7am) in accordance with our institution’s reduced from 22.8% at 4 months to 12.8% at 12 months.
current anesthesia shift times. Furthermore, the incidence of pain reported on movement
Results: On average 4214 deliveries per year occurred at our reduced from 27.6% to 15.2% over the same time period but the
hospital during the study period. The overall CD rate changed incidence of pain at rest was consistent at 8%.
slightly between the two study periods (41.5% pre vs. 39.4%;
post change, P=0.012).The Figure shows the average
percentage of CDs that occurred each hour before and after
the policy change. There was a very slight increase in the
percentage of CDs performed in the daytime shifts (55.4% pre
vs. 58.7% post change, P = 0.014). There was also a small
increase in the CD percentage occurring during the weekend
shifts (17.6% pre vs. 21.6% post change, P=0.002).
Discussion: In the largest UK study to date, the rate of
conversion to CPSP after caesarean section based on the
patients who report "suffering from pain" is 23% at 4 months
and 13% at 12 months. This incidence of CPSP after caesarean
section is higher at 4 months when compared to previous
Figure:Percentage of caesarean deliveries by each hour of the retrospective studies. However, there does appear to be
day resolution of pain over time as only half of these patients
Discussion: Our analysis suggests that scheduling CD at ≥39 suffer from pain at 12 months post-surgery. This incidence of
weeks compared to ≥37 weeks does not impact the temporal CPSP is largely driven by the pain reported on movement
pattern of CDs. The most significant change was an increase rather than that at rest, which we found to be consistent at 8%
in CDs during weekend shifts. This change amounted to one at both time periods. It is therefore important not simply to
extra CD during the weekend shift on average, which does not assess pain at one time point but study its features and
impact the workflow enough to warrant a change in staffing progression. Further assessment of predictive factors for the
patterns. development of CPSP will be performed to identify those
women at increased risk.
References
References
1. Tita AT, Landon MB, Spong CY, et al. Timing of elective repeat
cesarean delivery at term and neonatal outcomes. N Engl J Med 1. Kainu JP, Sarvela J, Tippana, et al. Persistent pain after caesarean
2009; 360:111-20 section and vaginal birth. Int J Obstet Anesth 2010;19:4-9.
2. Suzuki S. The effect of time of day on unscheduled cesarean delivery 2. Landau R, Bollag L, Ortner C. Chronic pain after childbirth. Int J
and perinatal outcome. Int J Gynaecol Obstet 2012;116:177-8 Obstet Anesth 2013;22:133-45.
International Journal of Obstetric Anesthesia S15
P5 Hypnotic agents for induction of general anaesthesia in P6 Too fast? Ketonuria as a marker of prolonged fasting in
caesarean section patients: systemic review and meta- elective caesarean section
analysis of randomized trials
References
References
1. Tita AT, Landon MB, Spong CY, et al. Timing of elective repeat
cesarean delivery at term and neonatal outcomes. N Engl J Med 1. Kainu JP, Sarvela J, Tippana, et al. Persistent pain after caesarean
2009; 360:111-20 section and vaginal birth. Int J Obstet Anesth 2010;19:4-9.
2. Suzuki S. The effect of time of day on unscheduled cesarean delivery 2. Landau R, Bollag L, Ortner C. Chronic pain after childbirth. Int J
and perinatal outcome. Int J Gynaecol Obstet 2012;116:177-8 Obstet Anesth 2013;22:133-45.
International Journal of Obstetric Anesthesia S15
P5 Hypnotic agents for induction of general anaesthesia in P6 Too fast? Ketonuria as a marker of prolonged fasting in
caesarean section patients: systemic review and meta- elective caesarean section
analysis of randomized trials A Clark,  R Agaram  
K Houthoff Khemlani,  J Jokinen*,  P Kranke*,  J U Schreiber   Anaesthetic Department, Princess Royal Maternity Hospital,
Anaesthesiology, Maastricht University Medical Center, Glasgow, UK
Maastricht, Netherlands, *Anaesthesiology, Würzburg  Introduction:Fasting from midnight before elective caesarean
University Hospital, Würzburg, Germany  section is a common preoperative instruction to ensure
Introduction: The ideal induction drug for caesarean section adequate gastric emptying. We hypothesised that this can
under general anesthesia should have a quick onset inducing lead to prolonged periods of fasting, well beyond the
maternal unconsciousness rapidly with a minimum of recommended minimum of 6 h, the result of which could result
unwanted side effects such as awareness, haemodynamic in a potentially detrimental catabolic state before surgery.
compromise and neonatal depression. Currently, thiopental is Methods:Ethics approval was waived by the chair of the local
frequently used to this aim1 but it is not clear if there would be ethics committee. Over a calendar month, on arrival in theatre,
a best evidence choice of a dedicated hypnotic agent to use parturients were asked when they last ate food and drank clear
for caesarean section. fluids. Following catheterisation, the presence of ketonuria
Methods: Systematic review and meta-analysis of randomized was tested for using a urine dipstick (ketostix, Bayer). All
controlled trials according to PRISMA recommendations. diabetic patients were excluded.
Trials were considered for quantitative analysis if they Results: Fifty-three women, were recruited in November 2013.
reported at least one of the following variables: maternal or The mean fasting time from food was 15 h (range 10-21 h), and
neonatal arterial and or umbilical vein blood samples (pH, mean time from clear fluids 10.5 h (range 2-22 h). Twenty-seven
pCO2, pO2), maternal systolic blood pressure (SBP) or Apgar patients (51%) had ketonuria. Of the 29 who had fasted up to
score. Methodological quality of the included studies was 15 h, six (20%) were ketotic compared to 21 (84%) of the 25
assessed using the Oxford quality score.2 patients who had fasted for longer than 15 h. The mean fasting
Results: Data from 16 trials matched the criteria and were time in the ketotic group was 16.4 h (range 12-21 h) compared
suitable for quantitative analysis (664 participants). to 13.5 h (range 10-18 h) in the non-ketotic group. The
Thiopental, ketamine or propofol were used for induction. The incidence of ketonuria over the course of the day is illustrated
average score of the methodological quality was 2. Induction in the Figure.
with propofol resulted in a significantly higher umbilical
arterial pO2 and less increase in SBP post intubation (mean
difference 12 mmHg) when compared to thiopental.
Significantly more neonates in the propofol group had an
Apgar <7 at 1 minute but not at 5 minutes after delivery. In
comparison to ketamine, fewer neonates in the thiopental
group suffered from an Apgar <7 at 1 and 5 minutes after
delivery.
Discussion: Based on the sparse data and limited evidence
with short-term outcomes only, propofol and thiopental seem
to be equally suited whereas the use of ketamine as induction
agent resulted in lower Apgar scores at 1 and 5 minutes post
delivery. However, better data would be needed to make a firm
recommendation.
References Figure: Incidence of ketonuria over the duration of the
1. Marcus HE, Behrend A, Schier R, et al. Anesthesiological operative day.
management of Caesarean sections: nationwide survey in Germany. Discussion: We have demonstrated that parturients are
Anaesthesist 2011; 60: 916-28.
fasting for prolonged periods before elective caesarean
2. Jadad AR, Moore RA, Carroll D, et al. Assessing the quality of
section. Moreover, greater than half were ketotic at the start of
reports of randomized clinical trials: is blinding necessary? Control
Clin Trials 1996; 17: 1-12 surgery. Enhanced recovery in obstetric surgery is now
emerging1 and we believe these data support the need to
improve preoperative fasting management to limit unnecessary
catabolic stress. Potentially, this could include the
introduction of a timely enhanced recovery style carbohydrate
drink2 taken on the day of surgery.
References
1. Lucas DN, Gough KL. Enhanced recovery in obstetrics--a new
frontier? Int J Obstet Anesth 2013; 22: 92-5.
2. Noblett SE, Watson DS, Huong H, et al. Pre-operative oral
carbohydrate loading in colorectal surgery: a randomized controlled
trial. Colorectal Disease 2006; 8: 563–9.
S16 International Journal of Obstetric Anesthesia
P7 Evaluation of FIBTEM A5 guided fibrinogen concentrate P8 Recovering post-operative obstetric patients: Are we 
administration in massive obstetric haemorrhage
References
References
S16 International Journal of Obstetric Anesthesia
P7 Evaluation of FIBTEM A5 guided fibrinogen concentrate P8 Recovering post-operative obstetric patients: Are we 
administration in massive obstetric haemorrhage meeting standards?
I D Harrod,  A Bhalla,  C Chevannes,  P Barclay,  S Mallaiah   RA Asghar,  A Quinn  
Anaesthesia, Liverpool Women's Hospital, Liverpool, UK Anaesthesia, Leeds General Infirmary, Leeds, UK
Introduction:Coagulopathy associated with major obstetric Introduction:In 2013 the Association of Anaesthetists of
haemorrhage (MOH) can be rapidly diagnosed using ROTEM. Great Britain and Ireland (AAGBI) and the Obstetric
1 A FIBTEM value of <12 mm at 5 min (A5) corresponds to a Anaesthetists' Association (OAA) released safety guidelines
fibrinogen concentration of approximately 2 g/L and indicates for post-anaesthesia recovery,1 core competencies for
significant defibrination. In 2011 our MOH algorithm recovery staff2 and obstetric anaesthetic services.3These
advocated the use of shock packs, giving FFP and guidelines set recommended standards for post anaesthesia
cryoprecipitate. These frozen products require defrosting and care units (PACU’s) and PACU staff which may not be met by
cross-matching time, involving a delay of approximately 60 all UK obstetric units thus exposing patients to increased risk.
min. Fibrinogen concentrate (Riastap, CSL Behring) is a Methods: We conducted an OAA approved electronic
pasteurised, freeze-dried product available without these national survey which was sent to 197 UK lead obstetric
disadvantages and unlikely to transmit pathogens. In July anaesthetists. This survey was designed to elicit if obstetric
2012, we amended our algorithm to incorporate fibrinogen 3 g units are currently meeting the AAGBI/ OAA recovery
for patients with haemorrhage associated guidelines.
hypofibrinogenaemia, repeated as necessary. The primary aim
Results: 146 responses were received (74.1% response rate).
of this study was to evaluate whether this change produced a
85.9% of respondents report that postoperative obstetric
reduction in the number of transfused blood products.
patients are recovered separately from non-obstetric patients
Methods: Data were collected for 12 months from MOH and remotely from the main PACU. Approximately 80% of
patients with FIBTEM A5<12 using the shock pack algorithm. obstetric PACU's are equipped with emergency drugs and an
This was compared with data collected for 12 months emergency alarm, 58.2% of units have difficult airway
following the introduction of fibrinogen concentrate. equipment immediately available and 37.7% have end-tidal
Results: The two groups were comparable for age, estimated carbon dioxide monitoring. 100% of units are recording non
blood loss, obstetric diagnosis and surgical management. invasive blood pressure, 98.7% are consistently using pulse
oximetry and >90% record temperature and respiratory rate.
Fibrinogen
Shock Pack However, only 56.2 % are monitoring the ECG and only 46.9%
Concentrate Group Pvalue
n=42 of hospitals are currently providing trained and registered
n=52
PACU staff to recover obstetric patients. The remainder are
No. of blood products
8 [3-14.5] 3 [2-4.75] 0.0004 recovered by midwives, 19% of whom were deemed
transfused (units)
appropriately trained in recovery. 36% of respondents felt that
Fibrinogen mass* (g) 3.9 [0-9.2] 0 [0-3] 0.0003
recovery staff are not appropriately trained in recognition and
FFP (units) 4.0 [0-4.5] 0 [0-0] <0.0001
management of local anaesthetic toxicity. Qualitative
Cryoprecipitate (units) 0 [0-2.0] 0 [0-0] <0.0001
comments revealed some recurrent themes. Some units
Platelets (units) 0 [0-1] 0 [0-0] 0.0061
differentiate between general (GA) and regional anaesthesia
Red blood cells (units) 4 [2-6.25] 3 [2-4] ns
(RA); GA patients being recovered by PACU staff and RA
% requiring > 6 units 24% 8% 0.0443
patients being recovered by midwives, with some RA patients
% TACO 9% 0% 0.0367
being recovered in individual delivery rooms. Interestingly
% ICU admission 9% 2% ns
some anaesthetists report that PACU staff are available for
Data are median [IQR] or %. P values are from Mann Whitney obstetric recovery during the day but midwives adopt this role
U test or Fisher's exact test. *Fibrinogen mass calculation is out of hours. Some comment that they are gradually adopting
based on an average fibrinogen content of 2.15 g per pooled the new guidelines, others have expressed concern regarding
bag of cryoprecipitate2and 0.95 g per unit of FFP (mid-point of funding for trained PACU staff
95% CI 0.554 to 1.395).3
Discussion: This survey indicates that some units are
Discussion: Our new algorithm allows the rapid correction of
providing superior care for GA patients or those operated on
hypofibrinogenaemia with a significant reduction in the total
during the day. It would be interesting to compare the result of
number of allogenic blood products required, the total mass of
this survey to post-operative care in non obstetric surgical
fibrinogen and the number of patients receiving >6 units of red
patients, the majority of whom will be recovered in a purpose
blood cells. Avoiding large volumes of FFP may have also
built, fully equipped PACU by recovery trained personnel.
reduced the risk of transfusion associated cardiac overload
Implementing the 2013 post anaesthesia recovery guidelines
(TACO) and need for intensive care admission.
will be a slow process, in the meantime anaesthetists should
References provide ample support to all staff involved in recovering
1. C Chevannes, A Bhalla, I Harrod, et al. Fast rotational patients, particularly complex obstetric patients.
thromboelastometry evaluation in major obstetric haemorrhage. Br
J Anaesth 2012; 109:473P-484P References
2. NHSBT, 1. Association of Anaesthetists of Great Britain and Ireland.Immediate
http://hospital.blood.co.uk/library/pdf/components/SPN223_5_4.pdf Post-anaesthesia Recovery 2013. Anaesthesia 2013; 68: 288-97.
3. Handbook of Transfusion Medicine. Fourth Edition. January 2007 2. Association of Anaesthetists of Great Britain & Ireland. UK
National Core Competencies for Post-anaesthesia Care 2013.
London, 2013.
3. Association of Anaesthetists of Great Britain and Ireland and
Obstetric Anaesthetists' Association. Guidelines for Obstetric
Anaesthetic Services 2013. London, 2013.
International Journal of Obstetric Anesthesia S17
P9 Maternal satisfaction with analgesia following hospital P10 The availability and use of ultrasound in obstetric
discharge after caesarean section: a Trust approved anaesthesia in the UK
telephone survey
Reference