Sharpe, Emily E.

Dehydration in humans decreases orthostatic tolerance and alters sympathetic neural control of the circulation, but the mechanisms involved are unclear. Our goal was to evaluate the role of angiotensin II (AngII) in altering the sympathetic control mechanisms in dehydration. We hypothesized that dehydration would increase resting muscle sympathetic nerve activity (MSNA) and increase sensitivity of baroreflex control of MSNA and that these changes are mediated in part by AngII via AT1 receptors. We measured resting MSNA and baroreflex control of MSNA in healthy young adults under two conditions: euhydration and dehydration after 24 hr fluid restriction. We continuously measured heart rate (ECG), beat‐to‐beat blood pressure (Finometer), central venous pressure (peripherally inserted central catheter) and MSNA (peroneal microneurography) in both conditions. In each condition, measurements were taken before and after 50 mg losartan (AT1 antagonist). Dehydration was associated with a ~52 % increase in resting MSNA, but losartan did not consistently influence resting MSNA. Contrary to our hypothesis, baroreflex sensitivity increased ~39 % following losartan administration during dehydration. Our results confirm the sympathoexcitatory influence of dehydration, but the role of AngII in this process requires further evaluation. Supported by AHA 0750036Z and NIH CTSA UL1‐RR24150.

BACKGROUND: Early reports associating severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection with adverse pregnancy outcomes were biased by including only women with severe disease without controls. The Society for Obstetric Anesthesia and Perinatology (SOAP) coronavirus disease 2019 (COVID-19) registry was created to compare peripartum outcomes and anesthetic utilization in women with and without SARS-CoV-2 infection delivering at institutions with widespread testing. METHODS: Deliveries from 14 US medical centers, from March 19 to May 31, 2020, were included. Peripartum infection was defined as a positive SARS-CoV-2 polymerase chain reaction test within 14 days of delivery. Consecutive SARS-CoV-2–infected patients with randomly selected control patients were sampled (1:2 ratio) with controls delivering during the same day without a positive test. Outcomes were obstetric (eg, delivery mode, hypertensive disorders of pregnancy, and delivery <37 weeks), an adverse neonatal outcome composite measure (primary), and anesthetic utilization (eg, neuraxial labor analgesia and anesthesia). Outcomes were analyzed using generalized estimating equations to account for clustering within centers. Sensitivity analyses compared symptomatic and asymptomatic patients to controls. RESULTS: One thousand four hundred fifty four peripartum women were included: 490 with SARS-CoV-2 infection (176 [35.9%] symptomatic) and 964 were controls. SARS-CoV-2 patients were slightly younger, more likely nonnulliparous, nonwhite, and Hispanic than controls. They were more likely to have diabetes, obesity, or cardiac disease and less likely to have autoimmune disease. After adjustment for confounders, individuals experiencing SARS-CoV-2 infection exhibited an increased risk for delivery <37 weeks of gestation compared to controls, 73 (14.8%) vs 98 (10.2%) (adjusted odds ratio [aOR], 1.47; 95% confidence interval [CI], 1.03–2.09). Effect estimates for other obstetric outcomes and the neonatal composite outcome measure were not meaningfully different between SARS-CoV-2 patients versus controls. In sensitivity analyses, compared to controls, symptomatic SARS-CoV-2 patients exhibited increases in cesarean delivery (aOR, 1.57; 95% CI, 1.09–2.27), postpartum length of stay (aOR, 1.89; 95% CI, 1.18–2.60), and delivery <37 weeks of gestation (aOR, 2.08; 95% CI, 1.29–3.36). These adverse outcomes were not found in asymptomatic women versus controls. SARS-CoV-2 patients (asymptomatic and symptomatic) were less likely to receive neuraxial labor analgesia (aOR, 0.52; 95% CI, 0.35–0.75) and more likely to receive general anesthesia for cesarean delivery (aOR, 3.69; 95% CI, 1.40–9.74) due to maternal respiratory failure. CONCLUSIONS: In this large, multicenter US cohort study of women with and without peripartum SARS-CoV-2 infection, differences in obstetric and neonatal outcomes seem to be mostly driven by symptomatic patients. Lower utilization of neuraxial analgesia in laboring patients with asymptomatic or symptomatic infection compared to patients without infection requires further investigation.

Introduction: Mentorship is a key component to success in academic medicine. Women are under-represented in leadership positions within medicine. Women are less likely to identify mentors than men. Speed mentoring is an innovative strategy to facilitate mentorship in academic medicine. Materials and Methods: A speed mentoring event for women faculty members in an academic anesthesiology department was held, followed by a second event for trainees. Attendees completed surveys about mentorship experiences at baseline and in follow-up. Questions were rated on a 7-point Likert scale with 1 = strongly disagree and 7 = strongly agree with values reported as median (1st, 3rd quartile). Results: Baseline surveys indicated poor satisfaction with mentoring in the prior 6 months as 4.5 (3, 5.25). Twelve months later, mentees reported increased satisfaction with mentoring 6 (6, 6). Mentors and mentees felt their time was well spent during both events. There was an increase in the number of mentors identified after the events by both groups. Conclusions: Our results suggest speed mentoring is well received and impactful with minimal time and monetary investment. The attendees of the events identified an increased number of mentors after speed mentoring events, and this effect was maintained at 6–12 months. Speed mentoring may be one path to providing support for women to advance their careers in academic medicine. More research is warranted to better evaluate effectiveness of formats such as speed mentoring to facilitate improved mentorship for women in academic anesthesiology.

Abstract Hereditary angioedema (HAE) is a disease manifested by repeated episodes of localized submucosal or subcutaneous edematous episodes, potentially triggered by emotional stress, mechanical trauma, or intake of estrogens. We present our experience managing two parturients with HAE. Multidisciplinary care is essential for planning and executing the specialized care of these patients, and management included extensive planning among obstetric, anesthesiology, and allergy and immunology teams. Pregnancy has been shown to have a variable effect on triggering HAE episodes. First-line treatment includes C1 esterase inhibitor concentrate, which can also be used for prophylaxis in high-risk patients. Neuraxial analgesia is recommended to avoid general anesthesia and was established early in both individuals. Vaginal delivery was well tolerated without need for emergent treatment for angioedema symptoms.

BackgroundAdministering antibiotics is often difficult in patients with specific medication allergies. This investigation aimed to determine if a penicillin or cephalosporin allergy increased the risk for not receiving correct timing of prophylactic antibiotics at cesarean delivery. We hypothesized that patients with a penicillin or cephalosporin allergy would be less likely to receive antibiotics prior to incision for cesarean delivery.MethodsAll women undergoing cesarean delivery at Mayo Clinic Hospital, from 1 March 2008, to 28 February 2018 were retrospectively identified by electronic medical record query. Patients were grouped based on allergy status to penicillin/cephalosporins. Data recorded included the type and time of antibiotic given in relation to surgical incision. The primary outcome of this study was administration of antibiotics within 60 minutes prior to surgical incision. Characteristics potentially associated with the primary outcome were assessed using logistic regression.ResultsOf the 818 patients with a penicillin or cephalosporin allergy, 75 (9.2%) did not receive prophylactic antibiotic within 60 minutes prior to skin incision. Conversely, 326 (6.9%) of the 4744 patients without a penicillin or cephalosporin allergy did not receive their prophylactic antibiotic within 60 minutes prior to skin incision (P = .019). Patients undergoing an emergent cesarean delivery were also at an increased risk of not receiving their prophylactic antibiotic within 60 minutes prior to skin incision (P < .001).ConclusionPatients with a penicillin or cephalosporin allergy were less likely to receive prophylactic antibiotics within the recommended 60 minutes prior to surgical incision. Clear plans and communication are important for ensuring proper antibiotic administration at cesarean delivery to prevent surgical site infection.

Abstract Introduction Calcinosis cutis is a condition characterized by pathologic calcium deposition into superficial dermal skin layers. It is often associated with an autoimmune disease. However, it may also occur after minor localized trauma and infection. Description of Problem We report a case of lumbar epidural placement of labor analgesia in a parturient with severe dystrophic calcinosis cutis without apparent complications. Clinical Solution We recommend fastidious optimization of epidural placement conditions for all patients who may be at high risk for neuraxial anesthesia, including consideration of ultrasound use, use of an experienced anesthesia provider for neuraxial placement, and placement in early labor. Additionally, judicious discussion of risks, benefits, and alternatives when obtaining informed consent is critical, ideally with the patient identified for a comprehensive visit in a preoperative obstetric anesthesia clinic before delivery.

Abstract Background Intrathecal opioids are routinely administered during spinal anesthesia for postcesarean analgesia. The effectiveness of intrathecal morphine for postcesarean analgesia is well established, and the use of intrathecal hydromorphone is growing. No prospective studies have compared the effectiveness of equipotent doses of intrathecal morphine versus intrathecal hydromorphone as part of a multimodal analgesic regimen for postcesarean analgesia. The authors hypothesized that intrathecal morphine would result in superior analgesia compared with intrathecal hydromorphone 24 h after delivery. Methods In this single-center, double-blinded, randomized trial, 138 parturients undergoing scheduled cesarean delivery were randomized to receive 150 µg of intrathecal morphine or 75 µg of intrathecal hydromorphone as part of a primary spinal anesthetic and multimodal analgesic regimen; 134 parturients were included in the analysis. The primary outcome was the numerical rating scale score for pain with movement 24 h after delivery. Static and dynamic pain scores, nausea, pruritus, degree of sedation, and patient satisfaction were assessed every 6 h for 36 h postpartum. Total opioid consumption was recorded. Results There was no significant difference in pain scores with movement at 24 h (intrathecal hydromorphone median [25th, 75th] 4 [3, 5] and intrathecal morphine 3 [2, 4.5]) or at any time point (estimated difference, 0.5; 95% CI, 0 to 1; P = 0.139). Opioid received in the first 24 h did not differ between groups (median [25th, 75th] oral morphine milligram equivalents for intrathecal hydromorphone 30 [7.5, 45.06] vs. intrathecal morphine 22.5 [14.0, 37.5], P = 0.769). From Kaplan–Meier analysis, the median time to first opioid request was 5.4 h for hydromorphone and 12.1 h for morphine (log-rank test P = 0.200). Conclusions Although the hypothesis was that intrathecal morphine would provide superior analgesia to intrathecal hydromorphone, the results did not confirm this. At the doses studied, both intrathecal morphine and intrathecal hydromorphone provide effective postcesarean analgesia when combined with a multimodal analgesia regimen. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Background: Grand rounds and named lectureships are forums in academic medicine for sharing research, scholarly achievements, and clinical expertise. An invitation to speak at grand rounds is regarded as an honor and is part of the pathway to academic promotion. We describe gender representation relative to the national academic medical workforce among invited speakers at departmental grand rounds and annual named lectures at a large academic medical center. Materials and Methods: Lists of external speakers for grand rounds from 2015 through 2017 were obtained from 18 departments and for annual named lectures from 2007 to 2017 from 7 departments. Results: Of the 783 invited speakers to the 25 speaker series, there were 178 women (22.7%). The proportion of women speakers for departmental grand rounds ranged from 0% to 59.3%; representation of women speakers was lower than representation in their specialty in 14 of the 18 departments and significantly lower in 4 of the 18 departments. In four departments, there was a higher proportion of women than available in the specialty-specific academic medicine workforce. The proportion of women who spoke at annual named lectures was significantly lower in two of seven lecture series and ranged from 0% to 21.2%. Three departments had no women speakers. Conclusions: The underrepresentation of women as speakers is a potential target to improve gender representation and role modeling and provide equitable opportunity for academic advancement. Solutions may include formal diversity and inclusion training, intentional overrepresentation of invited female speakers, and inclusion of women on grand rounds planning committees.

Abstract Supraventricular tachycardia is a common arrhythmia in pregnancy. During labor and delivery, neuraxial analgesia is important to prevent arrhythmia recurrence. We present the case of a 27-year-old gravida 2 para 1 woman at 35 weeks’ gestation presenting with supraventricular tachycardia that converted to normal sinus rhythm with adenosine. To prevent recurrence of the arrhythmia, an early epidural was provided during labor to minimize catecholamine release.