Brendan Carvalho | Stanford University (original) (raw)

Papers by Brendan Carvalho

Research paper thumbnail of Labor & Delivery Operating Room Staffing and Operating Efficiency Using Queueing Theory

Research Square (Research Square), Feb 23, 2023

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Research paper thumbnail of Prevalence and predictors for postpartum sleep disorders: a nationwide analysis

The Journal of Maternal-Fetal & Neonatal Medicine

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Research paper thumbnail of A Systematic Scoping Review of Peridelivery Pain Management for Pregnant People With Opioid Use Disorder: From the Society for Obstetric Anesthesia and Perinatology and Society for Maternal Fetal Medicine

Anesthesia & Analgesia

The prevalence of pregnant people with opioid use disorder (OUD), including those receiving medic... more The prevalence of pregnant people with opioid use disorder (OUD), including those receiving medications for opioid use disorder (MOUD), is increasing. Challenges associated with pain management in people with OUD include tolerance, opioid-induced hyperalgesia, and risk for return to use. Yet, there are few evidence-based recommendations for pain management in the setting of pregnancy and the postpartum period, and many peripartum pain management studies exclude people with OUD. This scoping review summarized the available literature on peridelivery pain management in people with OUD, methodologies used, and identified specific areas of knowledge gaps. PubMed and Embase were comprehensively searched for publications in all languages on peripartum pain management among people with OUD, both treated with MOUD and untreated. Potential articles were screened by title, abstract, and full text. Data abstracted were descriptively analyzed to map available evidence and identify areas of limi...

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Research paper thumbnail of Obstetric services in the UK during the COVID-19 pandemic: A national survey

Anaesthesia Critical Care & Pain Medicine

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Research paper thumbnail of Comparing Postpartum Estimated and Quantified Blood Loss Among Racial Groups: An Observational Study

Cureus

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Research paper thumbnail of In-Hospital Opioid Consumption After the Previous Cesarean Delivery Weakly Predicts Opioid Consumption After Index Delivery: A Retrospective Cohort Study

Anesthesia & Analgesia

BACKGROUND: To predict opioid consumption and pain intensity after the index cesarean delivery, w... more BACKGROUND: To predict opioid consumption and pain intensity after the index cesarean delivery, we tested a hypothesis that opioid consumption after the previous cesarean delivery of the same patient can predict the opioid consumption after the index cesarean delivery. We further tested a secondary hypothesis that the pain scores after the previous cesarean delivery can predict the pain scores after the index cesarean delivery. METHODS: This is a retrospective cohort study of 470 women who underwent both previous and index cesarean deliveries at a single institution from January 2011 to June 2019. To predict the opioid consumption (primary outcome) and average pain scores (on 11-point numeric rating scale) after their index cesarean delivery, we used a linear regression model incorporating only the opioid consumption and average pain scores after the previous cesarean delivery, respectively (unadjusted models). Demographic and obstetric variables were then added as predictors (adjus...

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Research paper thumbnail of Storage of emergency airway equipment on labor and delivery units

Journal of Clinical Anesthesia

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Research paper thumbnail of Spinal prilocaine for caesarean section: walking a fine line

Anaesthesia, 2021

We thank Drs Carvalho and Sultan for their editorial [1] accompanying the article by Chapron et a... more We thank Drs Carvalho and Sultan for their editorial [1] accompanying the article by Chapron et al. [2] on retaining bupivacaine as the most frequently utilised intrathecal local anaesthetic for caesarean section. When discussing specific side effects of prilocaine, induction of methaemoglobinaemia by its major metabolite o-toluidine is consistently cited as the most important cause of drug intolerance. However, it should been understood that otoluidine is a genotoxic compound giving rise to DNA adducts in the human urinary bladder [3]. In 2010, otoluidine was classified as a human carcinogen by the International Agency of Research on Cancer [4], mainly based on human bladder cancer data after occupational exposure. After a single dose of 100 mg prilocaine in head and neck surgery patients, haemoglobin adducts of otoluidine, as a surrogate marker of its metabolic activation, are of the same order of magnitude as the adduct levels in workers with a high incidence of bladder cancer employed at a chemical plant in Niagara Falls, New York State [5]. This has been confirmed recently by Guntz et al. [6] following intrathecal administration of hyperbaric prilocaine in patients for lower limb surgery. As a threshold of effect cannot normally be determined for carcinogenic substances (i.e. there is no concentration at which the substance is entirely safe), the goal is to avoid exposure whenever possible. Therefore, prilocaine should not be used as a local anaesthetic if alternative local anaesthetics with improved clinical safety profiles are available. E.Weber E. Richter Ludwig-Maximilians-University, Munich, Germany Email: elmar.richter@lmu.de

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Research paper thumbnail of Superficial Cervical Plexus Block for Awake Large-Bore Central Line Placement in Parturients: A Case Series

A&A Practice, 2021

Pregnant patients with high-risk conditions including abnormal placentation or severe cardiovascu... more Pregnant patients with high-risk conditions including abnormal placentation or severe cardiovascular disease may require large-bore central venous access at the time of delivery. Central lines are generally inserted while obstetric patients are awake, either because neuraxial anesthesia is planned or to minimize fetal exposure to anesthetic medications. Despite local infiltration, the procedure can cause significant patient discomfort. This case series describes use of a superficial cervical plexus block (SCPB) to facilitate line placement in 4 pregnant women with high-risk conditions. SCPB is technically straightforward with low reported complication rates and should be considered for pregnant patients requiring large-bore central lines.

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Research paper thumbnail of A randomized trial to investigate needle redirections/re-insertions using a handheld ultrasound device versus traditional palpation for spinal anesthesia in obese women undergoing cesarean delivery

International Journal of Obstetric Anesthesia, 2021

BACKGROUND Ultrasound may be useful to identify the spinal anesthesia insertion point, particular... more BACKGROUND Ultrasound may be useful to identify the spinal anesthesia insertion point, particularly when landmarks are not palpable. We tested the hypothesis that the number of needle redirections/re-insertions is lower when using a handheld ultrasound device compared with palpation in obese women undergoing spinal anesthesia for cesarean delivery. METHODS Study recruits were obese (body mass index (BMI) >30 kg/m2) women with impalpable bony landmarks who were undergoing spinal anesthesia for elective cesarean delivery. Women were randomized to ultrasound or palpation. The primary study outcome was a composite between-group comparison of total number of needle redirections (any withdrawal and re-advancement of the needle and/or introducer within the intervertebral space) or re-insertions (any new skin puncture in the same or different intervertebral space) per patient. Secondary outcomes included insertion site identification time and patient verbal numerical pain score (0-10) for comfort during surgical skin incision. RESULTS Forty women completed the study. The mean BMI (standard deviation) for the ultrasound group was 39.8 (5.5) kg/m2 and for the palpation group 37.3 (5.2) kg/m2. There was no difference in the composite primary outcome (median (interquartile range) [range]) between the ultrasound group (4 (2-13) [2-22]) and the (6 (4-10) [1-17]) palpation group (P=0.22), with the 95% confidence interval of the difference 2 (-1.7 to 5.7). There were no differences in the secondary outcomes. CONCLUSIONS Handheld ultrasound did not demonstrate any advantages over traditional palpation techniques for spinal anesthesia in an obese population undergoing cesarean delivery, although the study was underpowered to show a difference.

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Research paper thumbnail of Point-of-Care Lung Ultrasound Pattern in Healthy Parturients: Prevalence of Pulmonary Interstitial Syndrome Following Vaginal Delivery, Elective and Unplanned Intrapartum Cesarean Delivery

Anesthesia & Analgesia, 2021

BACKGROUND: Pregnancy-related cardiovascular physiologic changes increase the likelihood of pulmo... more BACKGROUND: Pregnancy-related cardiovascular physiologic changes increase the likelihood of pulmonary edema, with the risk of fluid extravasating into the pulmonary interstitium being potentially at a maximum during the early postpartum period. Data on the impact of labor and peripartum hemodynamic strain on lung ultrasound (LUS) are limited, and the prevalence of subclinical pulmonary interstitial syndrome in peripartum women is poorly described. The primary aim of this exploratory study was to estimate the prevalence of pulmonary interstitial syndrome in healthy term parturients undergoing vaginal (VD), elective (eCD), and unplanned intrapartum cesarean deliveries (uCD). Secondary aims were to estimate the prevalence of positive lung regions (≥3 B-lines on LUS per region) and to assess the associations between positive lung regions and possible contributing factors. METHODS: In this prospective observational cohort study, healthy women at term undergoing VD, eCD, or uCD were enrol...

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Research paper thumbnail of Evaluation of inpatient postpartum recovery using the Obstetric Quality of Recovery-10 patient-reported outcome measure: a single-center observational study

American Journal of Obstetrics & Gynecology MFM, 2020

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Research paper thumbnail of Virtual reality successfully provides anxiolysis to laboring women undergoing epidural placement

Journal of Clinical Anesthesia, 2019

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Research paper thumbnail of Ocular sonography in pre-eclampsia: A simple technique to detect raised intracranial pressure?

International Journal of Obstetric Anesthesia, 2019

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Research paper thumbnail of 967: Impact of a post-cesarean analgesia order-set with split doses of oral opioids

American Journal of Obstetrics and Gynecology, 2019

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Research paper thumbnail of Supraglottic Airway Rescue After Failed Fiberoptic Intubation in a Patient With Osteogenesis Imperfecta: A Case Report

A&A Practice, 2019

We describe the management of a pregnant patient with osteogenesis imperfecta with a history of n... more We describe the management of a pregnant patient with osteogenesis imperfecta with a history of numerous fractures, severe scoliosis, and anticipated difficult airway. Her pregnancy was complicated by progressive shortness of breath and a fetal diagnosis of osteogenesis imperfecta. Spine anatomy precluded neuraxial anesthesia. Cesarean delivery was performed under general anesthesia at 34 weeks. Immediately after awake fiberoptic intubation and induction of general anesthesia, capnography waveform was lost with rapid profound oxygen desaturation. A supraglottic airway device was placed, oxygenation maintained with supraglottic airway and positive pressure ventilation throughout case, and the baby was delivered with Apgars of 8 and 9.

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Research paper thumbnail of Evaluation of Electronic Medical Records on Nurses' Time Allocation During Cesarean Delivery

Journal of patient safety, Jan 26, 2018

The impact of the electronic medical record (EMR) on nursing workload is not well understood. The... more The impact of the electronic medical record (EMR) on nursing workload is not well understood. The objective of this descriptive study was to measure the actual and perceived time that nurses spend on the EMR in the operating room during cesarean births. Twenty scheduled cesarean births were observed. An observer timed the circulating nurse's EMR use during each case. Immediately after each case, the nurse completed a questionnaire to estimate EMR time allocation during the case and their desired time allocation for a typical case. They were also asked about time allotted to various activities preoperatively, intraoperatively, and postoperatively for a typical cesarean birth. Mean observed nurse EMR time was 36 ± 12 minutes per case, 40% ± 10% of the duration of the cesarean delivery. Nurses tended to estimate greater time spent on the EMR; the perceived mean proportion of time spent on the EMR (55%) was greater than the actual timed value of 40% (P = 0.020). Nurse's desired ...

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Research paper thumbnail of The Accuracy of a Handheld Ultrasound Device for Neuraxial Depth and Landmark Assessment: A Prospective Cohort Trial

Anesthesia and analgesia, Jan 30, 2017

This study investigated the accuracy of a wireless handheld ultrasound with pattern recognition s... more This study investigated the accuracy of a wireless handheld ultrasound with pattern recognition software that recognizes lumbar spine bony landmarks and measures depth to epidural space (Accuro, Rivanna Medical, Charlottesville, VA) (AU). AU measurements to epidural space were compared to Tuohy needle depth to epidural space (depth to loss of resistance at epidural placement). Data from 47 women requesting labor epidural analgesia were analyzed. The mean difference between depth to epidural space measured by AU versus needle depth was -0.61 cm (95% confidence interval, -0.79 to -0.44), with a standard deviation of 0.58 (95% confidence interval, 0.48-0.73). Using the AU-identified insertion point resulted in successful epidural placement at first attempt in 87% of patients, 78% without redirects.

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Research paper thumbnail of Analysis of Physiological Respiratory Variable Alarm Alerts Among Laboring Women Receiving Remifentanil

Anesthesia & Analgesia, 2017

BACKGROUND: Remifentanil may be used by laboring women for analgesia, despite controversy because... more BACKGROUND: Remifentanil may be used by laboring women for analgesia, despite controversy because of potential apneas. We evaluated candidate variables as early warning alerts for apnea, based on prevalence, positive predictive rate, sensitivity for apnea event detection, and early warning alert time intervals (lead time) for apnea. METHODS: We performed a secondary analysis of respiratory physiological data that had been collected during a prospective IRB-approved study of laboring women receiving IV patient-controlled boluses of remifentanil 20 to 60 μg every 1 to 2 minutes. Analyzed data included the respiratory rate (RR), end-tidal CO2 (Etco 2), pulse oximetry (Spo 2), heart rate (HR), and the Integrated Pulmonary Index (IPI; Capnostream 20; Medtronic, Boulder, CO) that had been recorded continuously throughout labor. We defined immediate early warning alerts as any drop in a variable value below a prespecified threshold for 15 seconds: RR < 8 breaths per minute (bpm), Etco 2...

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Research paper thumbnail of Amniotic fluid embolism

Current Opinion in Anaesthesiology, 2016

This article reviews our current understanding of amniotic fluid embolism (AFE), specifically the... more This article reviews our current understanding of amniotic fluid embolism (AFE), specifically the pathogenesis, treatment strategies, potential diagnostic tests and future therapeutic interventions for AFE. The incidence and case mortality of AFE varies widely because of heterogeneous diagnostic criteria and varying reporting mechanisms across the world. Amniotic fluid embolism is thought to be caused by abnormal activation of immunologic mechanisms following entry of fetal antigens into maternal circulation. Mast cell degranulation and complement activation may play a role in this anaphylactoid or systemic inflammatory response syndrome. Development of serum biomarkers and immune-histochemical staining techniques to aid diagnosis and develop treatments are under development and evaluation. Treatment of AFE is supportive and directed at treating cardiovascular, pulmonary, and coagulation derangements. Treatment for coagulopathy (fresh frozen plasma, cryoprecipitate/fibrinogen concentrate, and antifibrinolytics) should be initiated promptly. Recombinant factor VIIa may lead to increased mortality and should not routinely be used. C1 esterase inhibitors may be a potential therapeutic option. AFE is a devastating obstetric complication that requires early and aggressive intervention with optimal cardiopulmonary resuscitation, as well as hemorrhage and coagulopathy management. Biomarkers offer promise to aid the diagnosis of AFE, and immunomodulation may provide future therapeutic interventions to treat this lethal condition.

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Research paper thumbnail of Labor &amp; Delivery Operating Room Staffing and Operating Efficiency Using Queueing Theory

Research Square (Research Square), Feb 23, 2023

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Research paper thumbnail of Prevalence and predictors for postpartum sleep disorders: a nationwide analysis

The Journal of Maternal-Fetal & Neonatal Medicine

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Research paper thumbnail of A Systematic Scoping Review of Peridelivery Pain Management for Pregnant People With Opioid Use Disorder: From the Society for Obstetric Anesthesia and Perinatology and Society for Maternal Fetal Medicine

Anesthesia & Analgesia

The prevalence of pregnant people with opioid use disorder (OUD), including those receiving medic... more The prevalence of pregnant people with opioid use disorder (OUD), including those receiving medications for opioid use disorder (MOUD), is increasing. Challenges associated with pain management in people with OUD include tolerance, opioid-induced hyperalgesia, and risk for return to use. Yet, there are few evidence-based recommendations for pain management in the setting of pregnancy and the postpartum period, and many peripartum pain management studies exclude people with OUD. This scoping review summarized the available literature on peridelivery pain management in people with OUD, methodologies used, and identified specific areas of knowledge gaps. PubMed and Embase were comprehensively searched for publications in all languages on peripartum pain management among people with OUD, both treated with MOUD and untreated. Potential articles were screened by title, abstract, and full text. Data abstracted were descriptively analyzed to map available evidence and identify areas of limi...

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Research paper thumbnail of Obstetric services in the UK during the COVID-19 pandemic: A national survey

Anaesthesia Critical Care & Pain Medicine

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Research paper thumbnail of Comparing Postpartum Estimated and Quantified Blood Loss Among Racial Groups: An Observational Study

Cureus

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Research paper thumbnail of In-Hospital Opioid Consumption After the Previous Cesarean Delivery Weakly Predicts Opioid Consumption After Index Delivery: A Retrospective Cohort Study

Anesthesia & Analgesia

BACKGROUND: To predict opioid consumption and pain intensity after the index cesarean delivery, w... more BACKGROUND: To predict opioid consumption and pain intensity after the index cesarean delivery, we tested a hypothesis that opioid consumption after the previous cesarean delivery of the same patient can predict the opioid consumption after the index cesarean delivery. We further tested a secondary hypothesis that the pain scores after the previous cesarean delivery can predict the pain scores after the index cesarean delivery. METHODS: This is a retrospective cohort study of 470 women who underwent both previous and index cesarean deliveries at a single institution from January 2011 to June 2019. To predict the opioid consumption (primary outcome) and average pain scores (on 11-point numeric rating scale) after their index cesarean delivery, we used a linear regression model incorporating only the opioid consumption and average pain scores after the previous cesarean delivery, respectively (unadjusted models). Demographic and obstetric variables were then added as predictors (adjus...

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Research paper thumbnail of Storage of emergency airway equipment on labor and delivery units

Journal of Clinical Anesthesia

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Research paper thumbnail of Spinal prilocaine for caesarean section: walking a fine line

Anaesthesia, 2021

We thank Drs Carvalho and Sultan for their editorial [1] accompanying the article by Chapron et a... more We thank Drs Carvalho and Sultan for their editorial [1] accompanying the article by Chapron et al. [2] on retaining bupivacaine as the most frequently utilised intrathecal local anaesthetic for caesarean section. When discussing specific side effects of prilocaine, induction of methaemoglobinaemia by its major metabolite o-toluidine is consistently cited as the most important cause of drug intolerance. However, it should been understood that otoluidine is a genotoxic compound giving rise to DNA adducts in the human urinary bladder [3]. In 2010, otoluidine was classified as a human carcinogen by the International Agency of Research on Cancer [4], mainly based on human bladder cancer data after occupational exposure. After a single dose of 100 mg prilocaine in head and neck surgery patients, haemoglobin adducts of otoluidine, as a surrogate marker of its metabolic activation, are of the same order of magnitude as the adduct levels in workers with a high incidence of bladder cancer employed at a chemical plant in Niagara Falls, New York State [5]. This has been confirmed recently by Guntz et al. [6] following intrathecal administration of hyperbaric prilocaine in patients for lower limb surgery. As a threshold of effect cannot normally be determined for carcinogenic substances (i.e. there is no concentration at which the substance is entirely safe), the goal is to avoid exposure whenever possible. Therefore, prilocaine should not be used as a local anaesthetic if alternative local anaesthetics with improved clinical safety profiles are available. E.Weber E. Richter Ludwig-Maximilians-University, Munich, Germany Email: elmar.richter@lmu.de

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Research paper thumbnail of Superficial Cervical Plexus Block for Awake Large-Bore Central Line Placement in Parturients: A Case Series

A&A Practice, 2021

Pregnant patients with high-risk conditions including abnormal placentation or severe cardiovascu... more Pregnant patients with high-risk conditions including abnormal placentation or severe cardiovascular disease may require large-bore central venous access at the time of delivery. Central lines are generally inserted while obstetric patients are awake, either because neuraxial anesthesia is planned or to minimize fetal exposure to anesthetic medications. Despite local infiltration, the procedure can cause significant patient discomfort. This case series describes use of a superficial cervical plexus block (SCPB) to facilitate line placement in 4 pregnant women with high-risk conditions. SCPB is technically straightforward with low reported complication rates and should be considered for pregnant patients requiring large-bore central lines.

Bookmarks Related papers MentionsView impact

Research paper thumbnail of A randomized trial to investigate needle redirections/re-insertions using a handheld ultrasound device versus traditional palpation for spinal anesthesia in obese women undergoing cesarean delivery

International Journal of Obstetric Anesthesia, 2021

BACKGROUND Ultrasound may be useful to identify the spinal anesthesia insertion point, particular... more BACKGROUND Ultrasound may be useful to identify the spinal anesthesia insertion point, particularly when landmarks are not palpable. We tested the hypothesis that the number of needle redirections/re-insertions is lower when using a handheld ultrasound device compared with palpation in obese women undergoing spinal anesthesia for cesarean delivery. METHODS Study recruits were obese (body mass index (BMI) >30 kg/m2) women with impalpable bony landmarks who were undergoing spinal anesthesia for elective cesarean delivery. Women were randomized to ultrasound or palpation. The primary study outcome was a composite between-group comparison of total number of needle redirections (any withdrawal and re-advancement of the needle and/or introducer within the intervertebral space) or re-insertions (any new skin puncture in the same or different intervertebral space) per patient. Secondary outcomes included insertion site identification time and patient verbal numerical pain score (0-10) for comfort during surgical skin incision. RESULTS Forty women completed the study. The mean BMI (standard deviation) for the ultrasound group was 39.8 (5.5) kg/m2 and for the palpation group 37.3 (5.2) kg/m2. There was no difference in the composite primary outcome (median (interquartile range) [range]) between the ultrasound group (4 (2-13) [2-22]) and the (6 (4-10) [1-17]) palpation group (P=0.22), with the 95% confidence interval of the difference 2 (-1.7 to 5.7). There were no differences in the secondary outcomes. CONCLUSIONS Handheld ultrasound did not demonstrate any advantages over traditional palpation techniques for spinal anesthesia in an obese population undergoing cesarean delivery, although the study was underpowered to show a difference.

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Research paper thumbnail of Point-of-Care Lung Ultrasound Pattern in Healthy Parturients: Prevalence of Pulmonary Interstitial Syndrome Following Vaginal Delivery, Elective and Unplanned Intrapartum Cesarean Delivery

Anesthesia & Analgesia, 2021

BACKGROUND: Pregnancy-related cardiovascular physiologic changes increase the likelihood of pulmo... more BACKGROUND: Pregnancy-related cardiovascular physiologic changes increase the likelihood of pulmonary edema, with the risk of fluid extravasating into the pulmonary interstitium being potentially at a maximum during the early postpartum period. Data on the impact of labor and peripartum hemodynamic strain on lung ultrasound (LUS) are limited, and the prevalence of subclinical pulmonary interstitial syndrome in peripartum women is poorly described. The primary aim of this exploratory study was to estimate the prevalence of pulmonary interstitial syndrome in healthy term parturients undergoing vaginal (VD), elective (eCD), and unplanned intrapartum cesarean deliveries (uCD). Secondary aims were to estimate the prevalence of positive lung regions (≥3 B-lines on LUS per region) and to assess the associations between positive lung regions and possible contributing factors. METHODS: In this prospective observational cohort study, healthy women at term undergoing VD, eCD, or uCD were enrol...

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Research paper thumbnail of Evaluation of inpatient postpartum recovery using the Obstetric Quality of Recovery-10 patient-reported outcome measure: a single-center observational study

American Journal of Obstetrics & Gynecology MFM, 2020

Bookmarks Related papers MentionsView impact

Research paper thumbnail of Virtual reality successfully provides anxiolysis to laboring women undergoing epidural placement

Journal of Clinical Anesthesia, 2019

Bookmarks Related papers MentionsView impact

Research paper thumbnail of Ocular sonography in pre-eclampsia: A simple technique to detect raised intracranial pressure?

International Journal of Obstetric Anesthesia, 2019

Bookmarks Related papers MentionsView impact

Research paper thumbnail of 967: Impact of a post-cesarean analgesia order-set with split doses of oral opioids

American Journal of Obstetrics and Gynecology, 2019

Bookmarks Related papers MentionsView impact

Research paper thumbnail of Supraglottic Airway Rescue After Failed Fiberoptic Intubation in a Patient With Osteogenesis Imperfecta: A Case Report

A&A Practice, 2019

We describe the management of a pregnant patient with osteogenesis imperfecta with a history of n... more We describe the management of a pregnant patient with osteogenesis imperfecta with a history of numerous fractures, severe scoliosis, and anticipated difficult airway. Her pregnancy was complicated by progressive shortness of breath and a fetal diagnosis of osteogenesis imperfecta. Spine anatomy precluded neuraxial anesthesia. Cesarean delivery was performed under general anesthesia at 34 weeks. Immediately after awake fiberoptic intubation and induction of general anesthesia, capnography waveform was lost with rapid profound oxygen desaturation. A supraglottic airway device was placed, oxygenation maintained with supraglottic airway and positive pressure ventilation throughout case, and the baby was delivered with Apgars of 8 and 9.

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Research paper thumbnail of Evaluation of Electronic Medical Records on Nurses' Time Allocation During Cesarean Delivery

Journal of patient safety, Jan 26, 2018

The impact of the electronic medical record (EMR) on nursing workload is not well understood. The... more The impact of the electronic medical record (EMR) on nursing workload is not well understood. The objective of this descriptive study was to measure the actual and perceived time that nurses spend on the EMR in the operating room during cesarean births. Twenty scheduled cesarean births were observed. An observer timed the circulating nurse's EMR use during each case. Immediately after each case, the nurse completed a questionnaire to estimate EMR time allocation during the case and their desired time allocation for a typical case. They were also asked about time allotted to various activities preoperatively, intraoperatively, and postoperatively for a typical cesarean birth. Mean observed nurse EMR time was 36 ± 12 minutes per case, 40% ± 10% of the duration of the cesarean delivery. Nurses tended to estimate greater time spent on the EMR; the perceived mean proportion of time spent on the EMR (55%) was greater than the actual timed value of 40% (P = 0.020). Nurse's desired ...

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Research paper thumbnail of The Accuracy of a Handheld Ultrasound Device for Neuraxial Depth and Landmark Assessment: A Prospective Cohort Trial

Anesthesia and analgesia, Jan 30, 2017

This study investigated the accuracy of a wireless handheld ultrasound with pattern recognition s... more This study investigated the accuracy of a wireless handheld ultrasound with pattern recognition software that recognizes lumbar spine bony landmarks and measures depth to epidural space (Accuro, Rivanna Medical, Charlottesville, VA) (AU). AU measurements to epidural space were compared to Tuohy needle depth to epidural space (depth to loss of resistance at epidural placement). Data from 47 women requesting labor epidural analgesia were analyzed. The mean difference between depth to epidural space measured by AU versus needle depth was -0.61 cm (95% confidence interval, -0.79 to -0.44), with a standard deviation of 0.58 (95% confidence interval, 0.48-0.73). Using the AU-identified insertion point resulted in successful epidural placement at first attempt in 87% of patients, 78% without redirects.

Bookmarks Related papers MentionsView impact

Research paper thumbnail of Analysis of Physiological Respiratory Variable Alarm Alerts Among Laboring Women Receiving Remifentanil

Anesthesia & Analgesia, 2017

BACKGROUND: Remifentanil may be used by laboring women for analgesia, despite controversy because... more BACKGROUND: Remifentanil may be used by laboring women for analgesia, despite controversy because of potential apneas. We evaluated candidate variables as early warning alerts for apnea, based on prevalence, positive predictive rate, sensitivity for apnea event detection, and early warning alert time intervals (lead time) for apnea. METHODS: We performed a secondary analysis of respiratory physiological data that had been collected during a prospective IRB-approved study of laboring women receiving IV patient-controlled boluses of remifentanil 20 to 60 μg every 1 to 2 minutes. Analyzed data included the respiratory rate (RR), end-tidal CO2 (Etco 2), pulse oximetry (Spo 2), heart rate (HR), and the Integrated Pulmonary Index (IPI; Capnostream 20; Medtronic, Boulder, CO) that had been recorded continuously throughout labor. We defined immediate early warning alerts as any drop in a variable value below a prespecified threshold for 15 seconds: RR < 8 breaths per minute (bpm), Etco 2...

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Research paper thumbnail of Amniotic fluid embolism

Current Opinion in Anaesthesiology, 2016

This article reviews our current understanding of amniotic fluid embolism (AFE), specifically the... more This article reviews our current understanding of amniotic fluid embolism (AFE), specifically the pathogenesis, treatment strategies, potential diagnostic tests and future therapeutic interventions for AFE. The incidence and case mortality of AFE varies widely because of heterogeneous diagnostic criteria and varying reporting mechanisms across the world. Amniotic fluid embolism is thought to be caused by abnormal activation of immunologic mechanisms following entry of fetal antigens into maternal circulation. Mast cell degranulation and complement activation may play a role in this anaphylactoid or systemic inflammatory response syndrome. Development of serum biomarkers and immune-histochemical staining techniques to aid diagnosis and develop treatments are under development and evaluation. Treatment of AFE is supportive and directed at treating cardiovascular, pulmonary, and coagulation derangements. Treatment for coagulopathy (fresh frozen plasma, cryoprecipitate/fibrinogen concentrate, and antifibrinolytics) should be initiated promptly. Recombinant factor VIIa may lead to increased mortality and should not routinely be used. C1 esterase inhibitors may be a potential therapeutic option. AFE is a devastating obstetric complication that requires early and aggressive intervention with optimal cardiopulmonary resuscitation, as well as hemorrhage and coagulopathy management. Biomarkers offer promise to aid the diagnosis of AFE, and immunomodulation may provide future therapeutic interventions to treat this lethal condition.

Bookmarks Related papers MentionsView impact