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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

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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/

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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/

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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/

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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/

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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/

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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/

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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/

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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/

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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/