Ashraf Habib - Academia.edu (original) (raw)

Papers by Ashraf Habib

Anesthesiology, 2022

Background The dural puncture epidural technique may improve analgesia quality by confirming midl... more Background The dural puncture epidural technique may improve analgesia quality by confirming midline placement and increasing intrathecal translocation of epidural medications. This would be advantageous in obese parturients with increased risk of block failure. This study hypothesizes that quality of labor analgesia will be improved with dural puncture epidural compared to standard epidural technique in obese parturients. Methods Term parturients with body mass index greater than or equal to 35 kg · m–2, cervical dilation of 2 to 7 cm, and pain score of greater than 4 (where 0 indicates no pain and 10 indicates the worst pain imaginable) were randomized to dural puncture epidural (using 25-gauge Whitacre needle) or standard epidural techniques. Analgesia was initiated with 15 ml of 0.1% ropivacaine with 2 µg · ml–1 fentanyl, followed by programed intermittent boluses (6 ml every 45 min), with patient-controlled epidural analgesia. Parturients were blinded to group allocation. The d...

Journal of Pain Research, 2021

Optimal pain relief requires a balance between adequate analgesia and risk of adverse effects. Op... more Optimal pain relief requires a balance between adequate analgesia and risk of adverse effects. Opioids remain the cornerstone for managing moderate to severe pain, but are associated with opioid-induced respiratory depression (OIRD) and gastrointestinal complications. Opioids exert their analgesic effects predominantly via G-protein signaling, however, adverse effects including OIRD are mediated by the β-arrestin pathway. Oliceridine is the first of a new class of biased opioid agonists that preferentially activate G-protein signaling over β-arrestin, which would theoretically improve analgesia and reduce the risk of adverse effects. Oliceridine is approved by the Food and Drug Administration (FDA) for the treatment of moderate to severe acute pain. The efficacy of Oliceridine was mainly established in two randomized controlled Phase III clinical trials of patients experiencing moderate to severe pain after bunionectomy (APOLLO-1) and abdominoplasty (APOLLO-2). The results of the APOLLO studies demonstrate that Oliceridine, when administered via patient-controlled analgesia (PCA) demand boluses of 0.35mg and 0.5mg, provides superior analgesia compared to placebo, and is equianalgesic to PCA morphine 1mg demand boluses, without significant difference in the incidence of respiratory complications. In a more pragmatic trial of surgical and non-surgical patients, the ATHENA observational cohort study reported rapid onset of analgesia with Oliceridine given with or without multimodal analgesia. However, these studies were designed to evaluate analgesic efficacy, and it is still uncertain if Oliceridine has a better safety profile than conventional opioids. Although several post hoc analyses of pooled data from the APOLLO and ATHENA trials reported that Oliceridine was associated with lower OIRD and gastrointestinal complications compared to morphine, prospective studies are needed to elucidate if biased agonists such as Oliceridine reduce the risk of adverse effects compared to conventional opioids.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature, 2018

Background-Postpartum anemia is associated with maternal and perinatal morbidity. Population-leve... more Background-Postpartum anemia is associated with maternal and perinatal morbidity. Population-level data may inform guideline development for postpartum anemia screening. Our objectives were to evaluate the associations between potential predictors (predelivery anemia and postpartum hemorrhage (PPH)) with severe postpartum anemia after cesarean section. Study Design and Methods-Data were collected from 70,939 hospitalizations for cesarean section performed at Kaiser Permanente Northern California facilities between 2005 and 2013. Severe postpartum anemia was defined as a hemoglobin < 8 g/dl before hospital discharge. Using multivariable logistic regression, we assessed the associations between predelivery anemia and PPH with severe postpartum anemia. Distributions of these characteristics among women with severe postpartum anemia were evaluated. Results-The overall rate of severe postpartum anemia was 7.3%; 95% confidence interval (CI) = 7.1-7.4. Severe postpartum anemia was strongly associated with a predelivery hemoglobin between 10 and 10.9 g/dl (adjusted odds ratio (aOR) 5.4; 95% CI = 4.89-5.91), predelivery hemoglobin <10 g/dl (aOR 30.6; 95% CI = 27.21-34.6, and PPH (aOR 8.45; 95% CI = 7.8-9.16). The proportions of women with severe postpartum anemia were highest for those experiencing PPH but no predelivery anemia (12.2%; 95% CI = 11.0-13.6), and those who did not incur PPH nor predelivery anemia (10.7%; 95% CI = 9.6-12.0). Conclusions-Our findings suggest that PPH and predelivery anemia are strong independent risk factors for severe postpartum anemia. Optimization of patients' hemoglobin prior to delivery may reduce the incidence of severe anemia after cesarean section.

Local and Regional Anesthesia, 2019

Obesity is a significant global health problem. It results in a higher incidence of complications... more Obesity is a significant global health problem. It results in a higher incidence of complications for pregnant women and their neonates. Cesarean deliveries are more common in obese parturients as well. The increased burden of comorbidities seen in this population, such as obstructive sleep apnea, necessitates antepartum anesthetic consultation. These patients pose unique challenges for the practicing anesthesiologist and may benefit from optimization prior to delivery. Complications from anesthesia and overall morbidity and mortality are higher in this population. Neuraxial anesthesia can be challenging to place in the obese parturient, but is the preferred anesthetic for cesarean delivery to avoid airway manipulation, minimize aspiration risk, prevent fetal exposure to volatile anesthetic, and decrease risk of post-partum hemorrhage from volatile anesthetic exposure. Monitoring and positioning of these patients for surgery may pose specific challenges. Functional labor epidural catheters can be topped up to provide conditions suitable for surgery. In the absence of a working epidural catheter, a combined spinal epidural anesthetic is often the technique of choice due to relative ease of placement versus a single shot spinal technique as well as the ability to extend the anesthetic through the epidural portion. For cesarean delivery with a vertical supraumbilical skin incision, a two-catheter technique may be beneficial. Concern for thromboembolism necessitates early mobilization and a multimodal analgesic regimen can help accomplish this. In addition, thromboprophylaxis is recommended in this population after delivery-especially cesarean delivery. These patients also need close monitoring in the post-partum period when they are at increased risk for several complications.

Anesthesia & Analgesia, 2019

Journal of the American Geriatrics Society, 2019

BACKGROUND/OBJECTIVES: Every year, up to 40% of the more than 16 million older Americans who unde... more BACKGROUND/OBJECTIVES: Every year, up to 40% of the more than 16 million older Americans who undergo anesthesia/surgery develop postoperative cognitive dysfunction (POCD) or delirium. Each of these distinct syndromes is associated with decreased quality of life, increased mortality, and a possible increased risk of Alzheimer's disease. One pathologic process hypothesized to underlie both delirium and POCD is neuroinflammation. The INTUIT study described here will determine the extent to which postoperative increases in cerebrospinal fluid (CSF) monocyte chemoattractant protein 1 (MCP-1) levels and monocyte numbers are associated with delirium and/or POCD and their underlying brain connectivity changes. DESIGN: Observational prospective cohort.

Canadian journal of anaesthesia = Journal canadien d'anesthesie, 2018

F1000Research, 2018

Enhanced recovery after surgery is a concept initially developed for patients undergoing colorect... more Enhanced recovery after surgery is a concept initially developed for patients undergoing colorectal surgery but has been adopted by other surgical specialties with similar positive outcomes. The adoption of enhanced recovery after surgery in the obstetric patient population is rapidly gaining popularity. This review highlights perioperative interventions that should be considered in an enhanced recovery after surgery protocol for women undergoing cesarean delivery.

Anesthesia and analgesia, 2018

Neuraxial anesthesia is currently the anesthetic technique of choice for cesarean delivery. A rec... more Neuraxial anesthesia is currently the anesthetic technique of choice for cesarean delivery. A recent report estimates that approximately 94% of all cesarean deliveries in the United States are performed using this technique. 1 Significant strides have been made in improving the safety of spinal anesthesia by raising awareness about adverse effects such as hypotension, inadequate intraoperative anesthesia and inadequate postoperative analgesia, and developing strategies for their prevention. However, there is still significant work to be done. Two publications in this month's Anesthesia & Analgesia have highlighted inadvertent perioperative hypothermia as one area where further work is needed. 2,3 Inadvertent perioperative hypothermia, the unintentional cooling of a patient's core temperature to less than 36°C, has long been a recognized complication of general anesthesia. However it is also common in women receiving spinal anesthesia for cesarean delivery, with the incidence reported as high as 91%. 4 In the general surgical population, inadvertent perioperative hypothermia is associated with adverse outcomes, which include increased blood loss, higher surgical site infection rates, higher rates of myocardial ischemia and prolonged hospitalization. 5-7 In the obstetric patient population, neonatal hypothermia, which may result from maternal hypothermia, is associated with an increase in respiratory distress syndrome, hypoglycemia and neonatal mortality, particularly in preterm and very low birth weight infants. 8 While the adverse surgical outcomes of hypothermia have not been adequately evaluated in the obstetric patient population, active warming techniques aimed at preventing inadvertent perioperative hypothermia have been associated with reduced maternal shivering, improved maternal thermal comfort, reduced neonatal hypothermia and improved neonatal acid base status. 9,10 The implementation of enhanced recovery after surgery protocols, which include perioperative active warming as a component, has shortened hospitalizations in women who deliver by scheduled cesarean with spinal anesthesia.

Survey of Anesthesiology, 2017

The purpose of this retrospective cohort study was to investigate factors associated with failed ... more The purpose of this retrospective cohort study was to investigate factors associated with failed and high spinal blocks in patients who received spinal anesthesia for Cesarean delivery following a labour epidural that was inadequate for surgical anesthesia. Methods We searched our perioperative database for women with a labour epidural who received spinal or combined spinal-epidural anesthesia for Cesarean delivery due to the inadequacy of the existing epidural. The primary outcome was the occurrence of failed spinal blocks, and the secondary outcome was the occurrence of high blocks following spinal administration. Results Of the 263 patients in the analysis, there were 29 (11%) failed spinals and nine (3%) high spinals. There was a significant difference between patients with failed spinals and those with successful spinals with regards to receipt of an epidural top-up dose for Cesarean delivery within 30 min of the spinal, type of neuraxial block, body mass index, age, and dose of hyperbaric bupivacaine. In a multivariable analysis, only receipt of an epidural top-up dose was associated with failure (OR, 6.0; 95% CI, 2.1 to 17.0; P \ 0.001). As for the risk of a high spinal, patient characteristics and block details were not different amongst patients, except for a younger age in those with a high block. Conclusions Administration of spinal anesthesia within 30 min of an epidural top-up dose is associated with increased

Current medical research and opinion, Aug 1, 2016

To assess whether maintenance of labor epidural analgesia using programmed intermittent epidural ... more To assess whether maintenance of labor epidural analgesia using programmed intermittent epidural bolus (PIEB) is associated with reduced local anesthetic (LA) consumption, patient-controlled epidural analgesia (PCEA) use, and rescue analgesia requirements compared to continuous epidural infusion (CEI). This is a retrospective study at an academic university medical center. Women receiving epidural labor analgesia from March to July of 2015 were identified and categorized into three groups: 1) CEI 5 mL/hr, 2) PIEB 5 mL/60 minutes, 3) PIEB 3 mL/30 minutes. The LA consisted of bupivacaine 0.125 mg/mL and fentanyl 2 μg/mL. All patients had similar PCEA settings. Data were collected on pattern of LA usage, obstetric outcomes and Bromage scores. The primary endpoint was total volume of LA consumed per hour. Secondary outcomes included need for clinician boluses, pattern of PCEA use, degree of motor blockade and delivery mode. We included 528 patients (262 had CEI, 162 had PIEB 5 mL/60 min...

British journal of anaesthesia, 2015

We performed this systematic review to assess the analgesic efficacy of perioperative pregabalin.... more We performed this systematic review to assess the analgesic efficacy of perioperative pregabalin. Subgroup analyses and meta-regression were performed to assess the impact of individual dose and frequency of pregabalin administration on analgesic efficacy. We included 55 studies. When all doses and administration regimens were combined, pregabalin was associated with a significant reduction in pain scores at rest and during movement and opioid consumption at 24 h compared with placebo {mean difference [95% confidence interval (CI)]=-0.38 (-0.57, -0.20), -0.47 (-0.76, -0.18), and -8.27 mg morphine equivalents (-10.08, -6.47), respectively}. Patients receiving pregabalin had less postoperative nausea and vomiting and pruritus compared with placebo [relative risk (RR) (95% CI)=0.62 (0.48, 0.80) and 0.49 (0.34, 0.70), respectively]. Sedation, dizziness, and visual disturbance were more common with pregabalin compared with placebo [RR (95% CI)=1.46 (1.08, 1.98), 1.33 (1.07, 1.64), and 3....

Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 2014

This study examines the peripartum anesthetic management and outcomes of women with dilated cardi... more This study examines the peripartum anesthetic management and outcomes of women with dilated cardiomyopathy in a large university medical centre over a seven-year period. Principal findings Twenty-five women were included in this series, 18 with a new diagnosis of cardiomyopathy and seven with a history of cardiomyopathy. Sixteen patients (64%) identified themselves as African American, seven (28%) were Caucasian, and two patients (8%) were Hispanic. The median (range) gestational age at the time of a new diagnosis of cardiomyopathy was 29 (7-38) weeks. Eight women (32%) had New York Heart Association class III/IV symptoms at the time of delivery or in the immediate postpartum period. A multidisciplinary team of obstetricians, anesthesiologists, cardiologists, and pediatricians were involved in the care of these women. The median (range) gestational age at the time of delivery was 33.5 (30-40) weeks. There were nine vaginal deliveries This article is accompanied by an editorial. Please see Can J Anesth 2015; 62: this issue.

Journal of Clinical Anesthesia, 2009

Study Objective: To compare anesthetic management and postoperative outcomes in patients undergoi... more Study Objective: To compare anesthetic management and postoperative outcomes in patients undergoing robot-assisted laparoscopic radical prostatectomy (RALP) and radical retropubic prostatectomy (RRP) with general anesthesia. Design: Retrospective database study of RALP and RRP patients at Duke University Medical Center from 6/2003 to 6/2006. Setting: University teaching hospital. Patients: 541 ASA physical status I, II, and III men, 280 of whom were RRP patients and 256 RALP patients. Measurements: Patient demographics, intraoperative fluids and blood products, hemodynamic parameters, pain scores in the Postanesthesia Care Unit (PACU), intraoperative and postoperative analgesic consumption, need for rescue antiemetics in the PACU, and intraoperative use of vasopressors and antihypertensives, were all recorded. Additional data included postoperative transfusion data; clinical status of the patient's cancer preoperatively and postoperatively; hematocrit, platelet count, and creatinine levels; and length of hospital stay.

Current Medical Research and Opinion, 2013

Objective: During the past two decades, professional associations, accrediting bodies, and payors... more Objective: During the past two decades, professional associations, accrediting bodies, and payors have made postsurgical pain treatment a high priority. In light of the disappointing findings in previous surveys, a survey was conducted to assess patient perceptions and characterize patient experiences/levels of satisfaction with post-surgical pain management. Research design and methods: Survey included a random sample of US adults who had undergone surgery within 5 years from the survey date. Participants were asked about their concerns before surgery, severity of perioperative pain, pain treatments, perceptions about post-surgical pain and pain medications, and satisfaction with treatments they received. Results: Of the 300 participants, 86% experienced pain after surgery; of these, 75% had moderate/extreme pain during the immediate post-surgical period, with 74% still experiencing these levels of pain after discharge. Post-surgical pain was the most prominent pre-surgical patient concern, and nearly half reported they had high/very high anxiety levels about pain before surgery. Approximately 88% received analgesic medications to manage pain; of these, 80% experienced adverse effects and 39% reported moderate/severe pain even after receiving their first dose. Study limitations: Key study limitations include the relatively small population size, potential for recall bias associated with the 14-month average time delay from surgery date to survey date, and the inability to account for influences of type of surgery and intraoperative anesthetic/analgesic use on survey results. Conclusions: Despite heightened awareness and clinical advancements in pain management, there has been little improvement in post-surgical analgesia as measured by this survey of post-surgical patients.

Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 2008

Purpose: Skin infiltration with lidocaine, although brief, can be very stressful, painful, and ma... more Purpose: Skin infiltration with lidocaine, although brief, can be very stressful, painful, and may perpetuate anxiety. Synera™, a local anesthetic patch, which contains an oxygen-activated heating component to enhance the delivery of a eutectic mixture of lidocaine (70 mg) and tetracaine (70 mg), has provided analgesia for minor, dermatological procedures. We hypothesized that the analgesic effect of Synera™, for pain in labouring parturients, would be superior to the traditional infiltration of lidocaine prior to epidural needle insertion. Methods: With Institutional Review Board approval, we recruited women, who consented to epidural labour analgesia and who met the following criteria: older than 18 yr; body mass index less than 45 kg•m-2 ; and with no history of hypersensitivity to any study medications. We randomized the labouring parturients into Synera (SS) or placebo (PL) groups. Group SS received the Synera™ patch and infiltration with saline prior to epidural needle insertion. Group PL received a placebo patch and infiltration with 2% lidocaine. Results: The groups were similar with respect to age, estimated gestational age, gravidity, parity, and body mass index. The subjects' pain, with epidural placement, was significantly greater in the SS group (P < 0.001). More SS subjects required additional, deep, local anesthetic infiltration compared to PL (P = 0.02). Conclusion: The Synera™ patch provided inferior analgesia, for performing epidural labour analgesia in labouring parturients, compared to traditional infiltration with 2% lidocaine.

Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 2007

Purpose: To report the use of regional anesthesia and iv nitroglycerin to provide anesthesia and ... more Purpose: To report the use of regional anesthesia and iv nitroglycerin to provide anesthesia and uterine relaxation for three Cesarean deliveries (CD) involving ex utero intrapartum treatment (EXIT) of potentially life-threatening airway obstruction in the newborn. Clinical features: Case 1-a 36-yr-old woman at 38 weeks' gestation was scheduled for an elective CD for fetal skeletal dysplasia and micrognathia. Case 2-a 34-yr-old woman at 35 weeks gestation had a fetal ultrasound revealing fixed neck flexion and micrognathia consistent with fetal arthrogryposis. Case 3-a 27-yr-old woman presented at 38 weeks gestation for CD for severe fetal micrognathia, with mandibular growth below the fifth percentile. For each case, a combined spinal epidural anesthetic was performed with 0.75% bupivacaine, fentanyl and morphine intrathecally followed by placement of a multiorifice epidural catheter. Prior to uterine incision patients received a loading dose followed by an iv infusion of nitroglycerin. Uterine relaxation was sufficient in all cases for delivery of the fetus, and allowed for evaluation by direct laryngoscopy and intubation while maintaining fetal-placental circulation. The surgical procedures were completed without incident. Conclusions: Anesthesia and uterine relaxation for CD and EXIT procedures can be safely provided with regional anesthesia and iv nitroglycerin.

British Journal of Anaesthesia, 2008

Idiopathic pulmonary haemosiderosis (IPH) is a rare condition associated with diffuse alveolar ha... more Idiopathic pulmonary haemosiderosis (IPH) is a rare condition associated with diffuse alveolar haemorrhage and pulmonary fibrosis. We describe the anaesthetic management of a parturient with a history of posterior spinal fusion presenting with an acute exacerbation of IPH necessitating vaginal delivery at 34 weeks gestation. We used a spinal catheter for labour analgesia and bilevel positive airway pressure (BIPAP) ventilation to improve oxygenation during labour. An arterial line sited to allow frequent arterial blood gas sampling also facilitated continuous cardiac output monitoring. The use of a carefully titrated neuraxial block for analgesia, in conjunction with BIPAP, was associated with minimal haemodynamic and respiratory compromise during labour in this patient.

Anesthesia & Analgesia, 2012

The authors concluded that a single dose of intravenous dexamethasone 5mg to 10mg was an effectiv... more The authors concluded that a single dose of intravenous dexamethasone 5mg to 10mg was an effective antiemetic in women receiving neuraxial morphine for caesarean delivery or abdominal hysterectomy. Possible publication bias suggested the findings should be interpreted with caution. The evidence base was generally small and the authors' recommendation to interpret the findings with caution seems appropriate. Authors' objectives To assess the prophylactic efficacy of an antiemetic (dexamethasone) in patients receiving neuraxial anaesthesia with neuraxial morphine. Searching MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL) and Web of Science were searched up to February 2011 without language restrictions. The search strategy was reported. Reference lists of retrieved articles were searched manually.