Sharpe, Emily E

BACKGROUND: Compared to standard labor epidurals, placement of a dural puncture epidural (DPE) has been shown to improve labor analgesia efficacy, speed onset of analgesia, and decrease failure rates. However, there is a concern of increased post-dural puncture headache (PDPH) risk. A 25-gauge or larger spinal needle is typically needed for a DPE to have improved efficacy over a standard epidural. A prior meta-analysis comparing combined spinal-epidurals (CSEs) with epidurals did not identify a difference in PDPH rates, but many of the included randomized controlled trials (RCTs) used smaller diameter (27–29 gauge) spinal needles. This systematic review and meta-analysis of RCTs evaluates headache frequency following CSE or DPE labor analgesia techniques with 24- or 25-gauge spinal needles. METHODS: Medline, EMBASE, Scopus, Database of Abstracts of Reviews of Effects, Web of Science Core Collection, and Cochrane databases were searched on May 7, 2024, for RCTs comparing either DPE or CSE techniques using 24- or 25-gauge spinal needles with epidural labor analgesia. The primary outcome was headache. The risk-of-bias 2 tool was used to assess bias. The odds ratio (OR) was the chosen effect size using binomial family Bayesian estimation. The reference category for estimation was the conventional epidural technique group. RESULTS: Encompassing 3278 patients, 1765 (53.8%) received labor epidurals, 971 (29.6%) received DPEs, and 542 (16.5%) received CSEs. The rate of headaches in both groups was low, with headache rates of CSE/DPE and epidural groups (0.59% vs 0.34%), respectively. Headache was a secondary outcome in all the RCTs. In 10 of the 16 RCTs (62.5%), no patients of 1428 (0%; 95% credible interval [CI], 0.00–0.25) reported a headache. A total of nine (0.6%) headaches were reported in the DPE/CSE patients (denominator 1513) and six (0.3%) headaches were reported in the traditional epidural patients (denominator 1765). The posterior distribution of the treatment effect ( θ ) showed that the log OR of 0.35 favored the control group as having fewer events, but the number of events was rare, and the 95% CI was wide (−0.49 to 1.22). CONCLUSIONS: Headache was a rare event in both groups. Although these results are reassuring that either technique is clinically safe, they should be interpreted cautiously. A large RCT examining PDPH as the primary outcome with long-term follow-up is needed to more precisely determine if placement of a DPE or CSE with a 24- or 25-gauge spinal needle increases the risk of PDPH.

Background: Breastfeeding has numerous health benefits for patients and their infants. There are inconsistencies in how anesthesia providers care for lactating patients undergoing anesthesia. Providers may be cautious and have patients “pump and dump” instead of following current evidence-based recommendations. Video-based education provides a novel reference for health care providers in their fast-paced work environments. This project evaluated the effectiveness of an online video module and resources accessed at the bedside for anesthesia providers caring for lactating patients. Materials and Methods: A preintervention survey was sent to anesthesia providers at a large academic institution to assess baseline knowledge of current recommendations for caring for lactating patients having anesthesia. A quick response code-linked video module and references were created and disseminated to all anesthesia providers. A postsurvey was sent to assess knowledge and satisfaction with the educational approach. Postsurvey data were compared with presurvey data. Results: All who watched the educational video found the education helpful to care for lactating patients undergoing surgery. In the posteducation group, 93% of providers selected the correct recommendation to continue breastfeeding or pumping after general anesthesia or sedation once the patient is awake and alert, compared with 48% in the pre-education group. After education, 92% would recommend preoperative feeding or pumping prior to transport to the operating room, compared with the 50% in the pre-education group. Conclusions: Video-based, just-in-time education is an effective way to deliver updated information to anesthesia providers. This format is conducive to just-in-time delivery, and there may be implications for other patient populations that present infrequently but require population-specific care.

AbstractDiabetes insipidus is characterized by polyuria due to an inability to auto‐regulate water balance resulting in dangerous metabolic derangements. Intraoperative anesthetics have been increasingly identified as a cause of diabetes insipidus in adult patients; however, it is rare in pediatrics. We present a case of a 16‐year‐old male undergoing resection of a recurrent left juvenile nasopharyngeal angiofibroma who experienced intraoperative polyuria concerning diabetes insipidus. Urine output drastically decreased following discontinuation of dexmedetomidine with complete resolution within 24 h. We conclude that this case of transient diabetes insipidus was associated with dexmedetomidine administration.