Yale Anesthesiology

In this episode, Dr. Yavor Metodiev delves into the anesthetic considerations that should be taken when caring for a patient with oncological disease during pregnancy. Dr. Metodiev and colleagues concisely summarize the complexities of treating patients with oncological disease, emphasizing the crucial balance between maternal and fetal safety. With the increasing incidence of oncological disease in pregnant women (1 in 2000), anesthetists are expected to encounter more of these cases, and we play a pivotal role in managing these patients during the peripartum period. https://pubmed.ncbi.nlm.nih.gov/39775436/

In this episode, Dr. Blake Mergler, Dr. Reid Mergler, and Dr. Caoimhe Duffy examine the crucial role of anesthesiologists in recognizing and addressing trauma during labor. Their thorough narrative review highlights the importance of trauma-informed care, which shifts the focus from “what is wrong with the patient” to “what has happened to the patient.” The trio discusses how anesthesiologists can embrace this mindset, promoting empathy and understanding without judgment. https://pubmed.ncbi.nlm.nih.gov/39231043/ https://pubmed.ncbi.nlm.nih.gov/39897428/

In this episode, we explore the concept of a highly functional team, its characteristics, and the importance of fostering interdisciplinary teamwork among healthcare professionals such as anesthesiologists, obstetricians, nurses, and others. Dr. Girnius emphasizes that such collaboration enhances communication and efficiency and improves patient outcomes. Additionally, we discuss the process of identifying and implementing what needs to change while addressing the challenges associated with introducing change within our healthcare system. Improving Obstetric Anesthesia Care Through Teaming and Improvement Science https://pubmed.ncbi.nlm.nih.gov/39325012/ Preoperative Multidisciplinary Team Huddle Improves Communication and Safety for Unscheduled Cesarean Deliveries: A System Redesign Using Improvement Science https://pubmed.ncbi.nlm.nih.gov/39269911/

In this episode, we discuss the importance of following intravenous access recommendations for cesarean deliveries with Dr. Scott Seki at his institution. How do Dr. Seki and his colleagues define adequate intravenous access? Which patients are more or less likely to receive the recommended IV access? What are the patient implications if we fail to provide the recommended IV access? These are some of the questions we explored during this podcast. By the end of the episode, I began reevaluating the significance and sometimes implicit implications of not adhering to the recommended IV access standards.

In this episode, Dr. Landau, a renowned expert and researcher in the topic of pain, delves into the evolution of our understanding of this topic. We explore how the research and its definition have changed over the past few decades. Additionally, we discuss her study titled “Pain during cesarean delivery: a patient-related prospective observational study assessing the incidence and risk factors for intraoperative pain and intravenous medication administration.”

In this episode, Dr. Mark I. Zakowski delves into the pressing issue of pain during cesarean delivery. During our interview, we explore how our societies (ASA and SOAP) are collaborating to provide practitioners with valuable insights into managing this problem that affects approximately 15-20% of cesarean delivery patients. The ASA approved the “Statement on Pain during Cesarean Delivery” from the Committee on Obstetric Anesthesia, which advises all practitioners on the pervasive problem of failure to achieve pain-free cesarean delivery. This is a testament of how our societies are collaborating to improve patient care. Pain during Cesarean Delivery: We Can and Must Do Better https://pubmed.ncbi.nlm.nih.gov/38597801/ American Society of Anesthesiologists: Statement on pain during cesarean delivery. Edited by Committee on Obstetric Anesthesia. American Society of Anesthesiologists. 2023. Available at: https://www.asahq.org/standards-and-practice-parameters/state-ment-on-pain-during-cesarean-delivery

Dr. Allana Munro and Dr. Ronald George are two obstetric anesthesia experts whose research is focused on labor analgesia. Two years ago, they demonstrated that “achieving desired pain relief” is of utmost importance to our patients. The question remains: How can we safely achieve this while minimizing workload and side effects? In this episode, they discuss their study titled “An Innovative Approach to Determine Programmed Intermittent Epidural Bolus Pump Settings for Labor Analgesia: A Randomized Controlled Trial.” Using the response surface methodology, they identified optimal settings for the programmed intermittent epidural bolus pump (PIEB) that maximize maternal satisfaction, minimize clinician-administered boluses, and balance PCEA boluses delivered to those requested. An Innovative Approach to Determine Programmed Intermittent Epidural Bolus Pump Settings for Labor Analgesia: A Randomized Controlled Trial. https://pubmed.ncbi.nlm.nih.gov/38905148/ Patient Preferences for Outcomes Associated With Labor Epidural Analgesia. https://pubmed.ncbi.nlm.nih.gov/35355544/

In this episode, Dr. de Carvalho discusses his article, Efficacy and safety of ultrasound-guided versus landmark-guided neuraxial puncture: a systematic review, network meta-analysis and trial sequential analysis of randomized clinical trials. Dr. de Carvalho’s work reiterates that using ultrasound-guided neuraxial anesthesia results in a more efficient neuraxial placement. Ultrasound-guided neuraxial use results in fewer needle attempts and redirections and may improve patient satisfaction. Besides, his works demonstrate that ultrasound benefits both patients with normal and abnormal anatomy. Efficacy and safety of ultrasound-guided versus landmark-guided neuraxial puncture: a systematic review, network meta-analysis and trial sequential analysis of randomized clinical trials https://pubmed.ncbi.nlm.nih.gov/38876801/ Comparison of ultrasound-guided and traditional localisation in intraspinal anesthesia: a systematic review and network meta-analysis. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10626869/

In this episode, Dr. Lawrence Tsen discusses the findings of his paper on Labor Analgesia Initiation with Dural Puncture Epidural (DPE) Versus Conventional Epidural Techniques. The paper presents a randomized biased-coin sequential allocation trial to determine the effective dose for 90% of patients of Bupivacaine. We explore the benefits of using the DPE technique, if any, along with criticisms from some experts. Additionally, we delve into whether DPE techniques can improve analgesia and the mechanisms behind it. These are just a few of the topics covered in this podcast. Labor Analgesia Initiation With Dural Puncture Epidural Versus Conventional Epidural Techniques: A Randomized Biased-Coin Sequential Allocation Trial to Determine the Effective Dose for 90% of Patients of Bupivacaine https://pubmed.ncbi.nlm.nih.gov/37824436/ Effect of Dural-Puncture Epidural vs Standard Epidural for Epidural Extension on Onset Time of Surgical Anesthesia in Elective Cesarean Delivery: A Randomized Clinical Trial https://pubmed.ncbi.nlm.nih.gov/37526934/ Epidural catheter replacement rates with dural puncture epidural labor analgesia compared with epidural analgesia without dural puncture: a retrospective cohort study https://pubmed.ncbi.nlm.nih.gov/36030558/ Quality of Labor Analgesia with Dural Puncture Epidural versus Standard Epidural Technique in Obese Parturients: A Double-blind Randomized Controlled Study https://pubmed.ncbi.nlm.nih.gov/35157756/ Sacral sensory blockade from 27-gauge pencil-point dural puncture epidural analgesia or epidural analgesia in laboring nulliparous parturients: a randomized controlled trial https://pubmed.ncbi.nlm.nih.gov/39024984/ Determination of the Optimal Volume of Programmed Intermittent Epidural Bolus When Combined With the Dural Puncture Epidural Technique for Labor Analgesia: A Random-Allocation Graded Dose-Response Study https://pubmed.ncbi.nlm.nih.gov/37010955/ Dural Puncture Epidural for Labor Analgesia: Is It Really an Improvement over Conventional Labor Epidural Analgesia? https://pubmed.ncbi.nlm.nih.gov/35320341/

In this episode, Dr. Holly Ende discusses her article, Implementation of an Epidural Rounding Reminder in the Electronic Medical Record Improves Performance of Standardized Patient Assessments during Labor. Dr. Ende’s work underscores the necessity of regular assessments of the effectiveness of neuraxial labor analgesia. This proactive approach is crucial for the timely identification of malfunction, ensuring the best possible outcomes for patients. Implementation of an Epidural Rounding Reminder in the Electronic Medical Record Improves Performance of Standardized Patient Assessments during Labor https://pubmed.ncbi.nlm.nih.gov/36634697/ Centers of Excellence for Anesthesia Care of Obstetric Patients https://pubmed.ncbi.nlm.nih.gov/30994544/

In this episode, Dr. Rachel Kearns discussed the findings from her study -Epidural analgesia during labour and severe maternal morbidity: population-based study. This study solidifies that anesthesiologists bring more to the table than “just” labor pain management. Epidural analgesia during labour and severe maternal morbidity: population-based study. https://www.bmj.com/content/385/bmj-2023-077190 Unlocking maternal health: labour epidurals and severe morbidity https://www.bmj.com/content/385/bmj.q1053 Use of Labor Neuraxial Analgesia for Vaginal Delivery and Severe Maternal Morbidity https://pubmed.ncbi.nlm.nih.gov/35191971/

In this episode, Dr. Vishal Uppal and Allana Munro discussed with us the findings from their study -The Incidence and Predictors of Failed Spinal Anesthesia After Intrathecal Injection of Local Anesthetic for Cesarean Delivery: A Single-Center, 9-Year Retrospective Review. https://pubmed.ncbi.nlm.nih.gov/37014966/ Anesthesia-Related Maternal Mortality in the United States: 1979–2002 https://pubmed.ncbi.nlm.nih.gov/21173646/ Can epidurals as a quality marker Epidural analgesia during labour and severe maternal morbidity: population based study https://pubmed.ncbi.nlm.nih.gov/38777357/ Use of Labor Neuraxial Analgesia for Vaginal Delivery and Severe Maternal Morbidity https://pubmed.ncbi.nlm.nih.gov/35191971/ Raising the Standards: RCOA Quality Improvement Compendium. Accessed March 1, 2023. https://rcoa.ac.uk/sites/default/files/documents/2020-08/21075%20RCoA%20Audit%20Recipe%20Book_16%20Section%20B.7_p241-268_AW.pdf Mechanism and Management of Failed Spinal Anesthesia – NYSORA https://www.nysora.com/topics/complications/mechanisms-management-failed-spinal-anesthesia/

In this episode, Dr. Allison Mootz, an obstetric anesthesiology fellow at Brigham and Women, discusses her thought-provoking article titled- The Accuracy of ChatGPT-Generated Responses in Answering Commonly Asked Patient Questions About Labor Epidurals: A Survey-Based Study. https://pubmed.ncbi.nlm.nih.gov/38180897/ Comparing Physician and Artificial Intelligence Chatbot Responses to Patient Questions Posted to a Public Social Media Forum https://pubmed.ncbi.nlm.nih.gov/37115527/

In this episode, Dr. Ron George provides a tour de force of our past and present labor analgesia management. We discuss his recent publication, Modern Labor Epidural Analgesia: Implications for Labor Outcomes and Maternal-Fetal Health. https://pubmed.ncbi.nlm.nih.gov/37164496/ The Most Influential Publications in Obstetric Anesthesiology, 1998–2017: Utilizing the Delphi Method for Expert Consensus https://pubmed.ncbi.nlm.nih.gov/32282388/ Effect of low-dose mobile versus traditional epidural techniques on mode of delivery: a randomised controlled trial https://pubmed.ncbi.nlm.nih.gov/11454372/ A comparison of a basal infusion with automated mandatory boluses in parturient-controlled epidural analgesia during labor https://pubmed.ncbi.nlm.nih.gov/17312228/ The risk of cesarean delivery with neuraxial analgesia given early versus late in labor https://pubmed.ncbi.nlm.nih.gov/15716559/

In this episode, Dr. David Bishop, a Specialist Anesthesiologist and Head of the Clinical Unit of Anaesthesia at Edendale Hospital in Pietermaritzburg talks about a vital topic and his recent publication, Tranexamic acid at cesarean delivery: drug-error deaths. Tranexamic acid at cesarean delivery: drug-error deaths https://pubmed.ncbi.nlm.nih.gov/36300729/ Spinal tranexamic acid – a new killer in town https://pubmed.ncbi.nlm.nih.gov/30985919/ YouTube publication (Tranexamic acid during CS: Drug error warning (https://www.youtube.com/watch?v=jeFtFWeMwkw&t=184s) Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial https://pubmed.ncbi.nlm.nih.gov/28456509/

In this episode, Dr. Thomas Klumpner, whose research interests involve using technology to detect childbirth complications before they become life-threatening, discusses with us his research titled: Use of a Novel Electronic Maternal Surveillance System and the Maternal Early Warning Criteria to Detect Severe Postpartum Hemorrhage Use of a Novel Electronic Maternal Surveillance System and the Maternal Early Warning Criteria to Detect Severe Postpartum Hemorrhage https://pubmed.ncbi.nlm.nih.gov/32022745/ Singh et al., A validation study of the CEMACH recommended modified early obstetric warning system (MEOWS) https://pubmed.ncbi.nlm.nih.gov/22066604/ Klumpner, T, stal. User Perceptions of an Electronic Maternal Alerting System. A A Pract. 2020;14(11):e01308 – https://pubmed.ncbi.nlm.nih.gov/32935951/ Use of a novel electronic maternal surveillance system to generate automated alerts on the labor and delivery unit https://pubmed.ncbi.nlm.nih.gov/29945569/

In this episode, Dr. Vishal Uppal, whose primary research interests are improving the safety and efficacy of regional anesthesia techniques in high-risk patient populations, discussed his article Consensus Practice Guidelines on Postdural Puncture Headache From a Multisociety, International Working Group: A Summary Report. Consensus guidelines https://pubmed.ncbi.nlm.nih.gov/37581893/ Atypical headache following dural puncture in obstetric https://pubmed.ncbi.nlm.nih.gov/24934311/ A prospective controlled study of continuous spinal analgesia versus repeat epidural analgesia after accidental dural puncture in labour https://pubmed.ncbi.nlm.nih.gov/22153280/ One patch or more? Defining success in treatment of post-dural puncture headache https://pubmed.ncbi.nlm.nih.gov/28089183/ Sphenopalatine ganglion block for postdural puncture headache https://pubmed.ncbi.nlm.nih.gov/19413836/ Major Neurologic Complications Associated With Postdural Puncture Headache in Obstetrics: A Retrospective Cohort Study https://pubmed.ncbi.nlm.nih.gov/31335402/ The volume of blood for epidural blood patch in obstetrics: a randomized, blinded clinical trial https://pubmed.ncbi.nlm.nih.gov/21596867/

In this episode, Dr. Tracey Vogel, an obstetric anesthesiologist who is very well-versed in a topic we should all know about, discusses trauma-informed care. What is trauma-informed care, and how can we become a trauma-informed care unit? These and many more questions are addressed during this Podcast. “A service that is not trauma-informed is trauma denied.” Trauma-Informed Care on Labor and Delivery https://pubmed.ncbi.nlm.nih.gov/34776109/ Antepartum and intrapartum risk factors and the impact of PTSD on mother and child https://pubmed.ncbi.nlm.nih.gov/33456935/ Nocebo-induced hyperalgesia during local anesthetic injection https://pubmed.ncbi.nlm.nih.gov/20042440/ The relationship between women’s intention to request labor epidural analgesia, actually delivering with labor epidural analgesia, and Postpartum depression at six weeks https://pubmed.ncbi.nlm.nih.gov/28930940/ Impact of patient choice https://pubmed.ncbi.nlm.nih.gov/30867278/ Patient choice compared to no choice (“Deception study”) https://pubmed.ncbi.nlm.nih.gov/28486595/ Trauma-Informed Care During Pregnancy and Birth Pain during cesarean delivery: A patient-related prospective observational study assessing the incidence and risk factors for intraoperative pain and intravenous medication administration https://pubmed.ncbi.nlm.nih.gov/37865217/

In this episode, Dr. Mark Rollins and Dr. Chatterjee, two leading experts in anesthesia for maternal-fetal intervention, share their knowledge with us. Specifically, we discussed fetal benefits and preoperative, intraoperative, and postoperative management for this delicate procedure in which two patients are undergoing surgical intervention under our care. Should we provide analgesia directly or indirectly to the fetus? How can we achieve the tenet goal of excellent uterine relaxation without compromising placental perfusion? Is the use of Sugammadex warranted for midgestation fetal interventions? These and much more were discussed during this Podcast. Anesthesia for Maternal-Fetal Interventions: A Consensus Statement https://pubmed.ncbi.nlm.nih.gov/33048913/ Survey of Fetal Therapy Centers in the North American Fetal Therapy Network. https://pubmed.ncbi.nlm.nih.gov/33827094/ Sugammadex Administration in Pregnant Women and Women of Reproductive Potential: A Narrative Review https://pubmed.ncbi.nlm.nih.gov/31283616/ Society for Obstetric Anesthesia and Perinatology Statement on Sugammadex during pregnancy and lactation https://www.soap.org/assets/docs/SOAP_Statement_Sugammadex_During_Pregnancy_Lactation_APPROVED.pdf Sugammadex Use for Reversal in Nonobstetric Surgery During Pregnancy: A Reexamination of the Evidence https://pubmed.ncbi.nlm.nih.gov/37205805/ A Randomized Trial of Prenatal versus Postnatal Repair of Myelomeningocele (MOMs trial) https://pubmed.ncbi.nlm.nih.gov/21306277/

In this episode, Dr. B Amnon Berger shared the results of his study – Epidural catheter replacement rates with dural puncture epidural labor analgesia compared with epidural analgesia without dural puncture: a retrospective cohort study. Besides, we discussed the benefits of a dural puncture epidural technique and how it differs from the combined spinal-epidural technique. Dr. Ammon study https://pubmed.ncbi.nlm.nih.gov/36030558/ Importance of a working labor epidural https://pubmed.ncbi.nlm.nih.gov/34106837/ CSE first described https://pubmed.ncbi.nlm.nih.gov/7468971/ CSE/DPE techniques review https://pubmed.ncbi.nlm.nih.gov/10594432/ Epidural vs CSE https://pubmed.ncbi.nlm.nih.gov/9392696/ https://pubmed.ncbi.nlm.nih.gov/15321183/ https://pubmed.ncbi.nlm.nih.gov/15477051/ Epidural vs. DPE https://pubmed.ncbi.nlm.nih.gov/28622178/ https://pubmed.ncbi.nlm.nih.gov/28067707/ https://pubmed.ncbi.nlm.nih.gov/35157756/ https://pubmed.ncbi.nlm.nih.gov/37526934/ DPE + CEI vs PIEB https://pubmed.ncbi.nlm.nih.gov/32282386/