Background
Fast recovery after cesarean section is vital since the mother not only has to take care of herself but also the newborn. Recovery scores are useful tools to measure and compare recovery; ...however, standardized questionnaires may miss in‐depth patient experiences. What is important to women in the postoperative period after cesarean section can vary in different populations, making it crucial to understand the specific needs of one's own population. This study aims to explore what matters most to Danish mothers during the early phase of recovery following elective cesarean section.
Methods
Qualitative design: Adult, Danish‐speaking women undergoing elective cesarean section under spinal anesthesia were included in three Danish hospitals. Semi‐structured interviews focusing on women's experiences of recovery, pain, and mobilization both in hospital and after discharge were conducted for 4–7 days following their cesarean section. Baseline characteristics and maternal outcomes were collected from patient files. The interviews were recorded, transcribed verbatim, and analyzed using manifest content analysis.
Results
In total, 25 women were interviewed a median of 6 days post cesarean section (IQR 5–8). Three themes emerged: “Experience of being a cesarean section patient,” “I'm doing good – and better than expected,” and “Challenges when going home.” The cesarean section itself was described as a disturbing experience. The initial days post‐cesarean section were described as very painful, but hereafter, many patients expressed surprise at their rapid recovery. None used opioids after discharge. Post‐discharge, having a partner's support, especially with other children to care for, was helpful, and moving from lying to sitting position and getting out of bed were noted as particularly painful. Many women requested more information and specific rehabilitation programs.
Conclusions
In this qualitative study of Danish women 4–7 days after elective cesarean sections, the women described the initial days as very painful but felt that they recovered rather quickly thereafter. The study indicated a need for enhanced communication, especially regarding the experience of surgery, pain after cesarean section, and physical rehabilitation plans.
Editorial Comment
In this qualitative, explorative study, participants were interviewed by telephone 4–7 days following their elective cesarean section. The focus was the women's experience of recovery, pain, and mobilization, both in hospital and when going home. The findings identified a need for more information about the perioperative course, as most participants were surprised and unprepared both for the pain from other areas than the scar and for the surgery experience being unpleasant, and many requested physical rehabilitation plans.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Background
Acetylcholinesterase inhibitors, such as neostigmine, have traditionally been used for reversal of non‐depolarizing neuromuscular blocking agents. However, these drugs have significant ...limitations, such as indirect mechanisms of reversal, limited and unpredictable efficacy, and undesirable autonomic responses. Sugammadex is a selective relaxant‐binding agent specifically developed for rapid reversal of non‐depolarizing neuromuscular blockade induced by rocuronium. Its potential clinical benefits include fast and predictable reversal of any degree of block, increased patient safety, reduced incidence of residual block on recovery, and more efficient use of healthcare resources.
Objectives
The main objective of this review was to compare the efficacy and safety of sugammadex versus neostigmine in reversing neuromuscular blockade caused by non‐depolarizing neuromuscular agents in adults.
Search methods
We searched the following databases on 2 May 2016: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE (WebSPIRS Ovid SP), Embase (WebSPIRS Ovid SP), and the clinical trials registries www.controlled‐trials.com, clinicaltrials.gov, and www.centerwatch.com. We re‐ran the search on 10 May 2017.
Selection criteria
We included randomized controlled trials (RCTs) irrespective of publication status, date of publication, blinding status, outcomes published, or language. We included adults, classified as American Society of Anesthesiologists (ASA) I to IV, who received non‐depolarizing neuromuscular blocking agents for an elective in‐patient or day‐case surgical procedure. We included all trials comparing sugammadex versus neostigmine that reported recovery times or adverse events. We included any dose of sugammadex and neostigmine and any time point of study drug administration.
Data collection and analysis
Two review authors independently screened titles and s to identify trials for eligibility, examined articles for eligibility, ed data, assessed the articles, and excluded obviously irrelevant reports. We resolved disagreements by discussion between review authors and further disagreements through consultation with the last review author. We assessed risk of bias in 10 methodological domains using the Cochrane risk of bias tool and examined risk of random error through trial sequential analysis. We used the principles of the GRADE approach to prepare an overall assessment of the quality of evidence. For our primary outcomes (recovery times to train‐of‐four ratio (TOFR) > 0.9), we presented data as mean differences (MDs) with 95 % confidence intervals (CIs), and for our secondary outcomes (risk of adverse events and risk of serious adverse events), we calculated risk ratios (RRs) with CIs.
Main results
We included 41 studies (4206 participants) in this updated review, 38 of which were new studies. Twelve trials were eligible for meta‐analysis of primary outcomes (n = 949), 28 trials were eligible for meta‐analysis of secondary outcomes (n = 2298), and 10 trials (n = 1647) were ineligible for meta‐analysis.
We compared sugammadex 2 mg/kg and neostigmine 0.05 mg/kg for reversal of rocuronium‐induced moderate neuromuscular blockade (NMB). Sugammadex 2 mg/kg was 10.22 minutes (6.6 times) faster then neostigmine 0.05 mg/kg (1.96 vs 12.87 minutes) in reversing NMB from the second twitch (T2) to TOFR > 0.9 (MD 10.22 minutes, 95% CI 8.48 to 11.96; I2 = 84%; 10 studies, n = 835; GRADE: moderate quality).
We compared sugammadex 4 mg/kg and neostigmine 0.07 mg/kg for reversal of rocuronium‐induced deep NMB. Sugammadex 4 mg/kg was 45.78 minutes (16.8 times) faster then neostigmine 0.07 mg/kg (2.9 vs 48.8 minutes) in reversing NMB from post‐tetanic count (PTC) 1 to 5 to TOFR > 0.9 (MD 45.78 minutes, 95% CI 39.41 to 52.15; I2 = 0%; two studies, n = 114; GRADE: low quality).
For our secondary outcomes, we compared sugammadex, any dose, and neostigmine, any dose, looking at risk of adverse and serious adverse events. We found significantly fewer composite adverse events in the sugammadex group compared with the neostigmine group (RR 0.60, 95% CI 0.49 to 0.74; I2 = 40%; 28 studies, n = 2298; GRADE: moderate quality). Risk of adverse events was 28% in the neostigmine group and 16% in the sugammadex group, resulting in a number needed to treat for an additional beneficial outcome (NNTB) of 8. When looking at specific adverse events, we noted significantly less risk of bradycardia (RR 0.16, 95% CI 0.07 to 0.34; I2= 0%; 11 studies, n = 1218; NNTB 14; GRADE: moderate quality), postoperative nausea and vomiting (PONV) (RR 0.52, 95% CI 0.28 to 0.97; I2 = 0%; six studies, n = 389; NNTB 16; GRADE: low quality) and overall signs of postoperative residual paralysis (RR 0.40, 95% CI 0.28 to 0.57; I2 = 0%; 15 studies, n = 1474; NNTB 13; GRADE: moderate quality) in the sugammadex group when compared with the neostigmine group. Finally, we found no significant differences between sugammadex and neostigmine regarding risk of serious adverse events (RR 0.54, 95% CI 0.13 to 2.25; I2= 0%; 10 studies, n = 959; GRADE: low quality).
Application of trial sequential analysis (TSA) indicates superiority of sugammadex for outcomes such as recovery time from T2 to TOFR > 0.9, adverse events, and overall signs of postoperative residual paralysis.
Authors' conclusions
Review results suggest that in comparison with neostigmine, sugammadex can more rapidly reverse rocuronium‐induced neuromuscular block regardless of the depth of the block. Sugammadex 2 mg/kg is 10.22 minutes (˜ 6.6 times) faster in reversing moderate neuromuscular blockade (T2) than neostigmine 0.05 mg/kg (GRADE: moderate quality), and sugammadex 4 mg/kg is 45.78 minutes (˜ 16.8 times) faster in reversing deep neuromuscular blockade (PTC 1 to 5) than neostigmine 0.07 mg/kg (GRADE: low quality). With an NNTB of 8 to avoid an adverse event, sugammadex appears to have a better safety profile than neostigmine. Patients receiving sugammadex had 40% fewer adverse events compared with those given neostigmine. Specifically, risks of bradycardia (RR 0.16, NNTB 14; GRADE: moderate quality), PONV (RR 0.52, NNTB 16; GRADE: low quality), and overall signs of postoperative residual paralysis (RR 0.40, NNTB 13; GRADE: moderate quality) were reduced. Both sugammadex and neostigmine were associated with serious adverse events in less than 1% of patients, and data showed no differences in risk of serious adverse events between groups (RR 0.54; GRADE: low quality).
Background
Inadequate pain relief with moderate to severe pain remains a challenge after cesarean section and may significantly impair postoperative recovery. However, detailed assessment on the ...timing of severe pain, opioid consumption, influence on activities such as mobilization, breastfeeding, and caring for the infant are difficult to conduct, especially after discharge. Short message services (SMS)‐based questionnaires may offer a low‐cost way of providing such data but with the risk of insufficient response rates. We assessed the feasibility of collecting detailed, prospective data on postoperative pain and recovery during the initial hours and days following cesarean section using SMS‐based questionnaires.
Methods
Prospective Danish single‐center cohort study involving elective cesarean sections under spinal anesthesia with fentanyl and bupivacaine. The postoperative pain regimen consisted of paracetamol, NSAID and oral morphine by request. Patients received an SMS‐based questionnaire at 6, 12, 18, 24, and 48 h postoperatively, as well as on days 7 and 30. Primary outcome: Response rate and time from receiving the SMS to completion of the questionnaires. Secondary outcomes: Opioid consumption and Patient Reported Outcomes Measures on pain and recovery.
Results
From December 2022 to June 2023; 100 patients were included. The response rate was 78% at 6 h postoperatively, decreasing to 63% at 24 h. The median response time from receiving to answering the SMS‐based questionnaire at 6 h after cesarean section was 23 min (IQR 2–72), decreasing to 20 min (IQR 2–78) after 24 h. Severe pain, corresponding to a Numeric Rating Scale (NRS) score >6, was reported by 57% (95% CI 65–84) at 6 h, decreasing to 28% (95% CI 34–58) at 24 h. Median opioid consumption within the first 24 h was 30 mg (IQR 20–50).
Conclusion
SMS‐based questionnaires on Patient Reported Outcome Measures are a feasible and cost‐effective way of prospectively collecting frequent data with acceptable response rates, even shortly after cesarean section. Secondarily 66% of patients reported severe pain during the first 24 h following cesarean section, with the highest pain scores within the initial 12 h. Future studies should focus on optimizing pain‐management within this timeframe.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
5.
Acute respiratory distress in Maniitsoq, Greenland Duch, Patricia; Ebbehøj, Niels E; Lynggaard, Folmer
Scandinavian journal of trauma, resuscitation and emergency medicine,
04/2012, Volume:
20, Issue:
Suppl 2
Journal Article
Current treatment of postdural puncture headache includes epidural blood patch (EBP), which is invasive and may result in rare but severe complications. Sphenopalatine ganglion block is suggested as ...a simple, minimally invasive treatment for postdural puncture headache. We aimed to investigate the analgesic effect of a transnasal sphenopalatine ganglion block with local anaesthetic vs saline.
We conducted a blinded, randomised clinical trial including adults fulfilling the criteria for EBP. Participants received a sphenopalatine ganglion block bilaterally with 1 ml of either local anaesthetic (lidocaine 4% and ropivacaine 0.5%) or placebo (saline). Primary outcome was pain in upright position 30 min post-block, measured on a 0–100 mm VAS.
We randomised 40 patients with an upright median pain intensity of 74 and 84 mm in the local anaesthetic and placebo groups at baseline, respectively. At 30 min after sphenopalatine ganglion block, the median pain intensity in upright position was 26 mm in the local anaesthetic group vs 37 mm in the placebo group (estimated median difference: 5 mm; 95% confidence interval: –14 to 21; P=0.53). In the local anaesthetic group, 50% required an EBP compared with 45% in the placebo group (P=0.76).
Administration of a sphenopalatine ganglion block with local anaesthetic had no statistically significant effect on pain intensity after 30 min compared with placebo. However, pain was reduced and EBP was avoided in half the patients of both groups, which suggests a major effect not necessarily attributable to local anaesthetics.
NCT03652714.
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FIS, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Background
E‐learning is increasingly used in postgraduate medical education. Its numerous benefits include an enhanced learning experience through learning style individualisation, interactive ...elements, and assessment through tests and quizzes. Current meta‐analyses conclude that the overall effectiveness of e‐learning is comparable to traditional teaching modalities. However, studies demonstrating its benefits are heterogeneous and of varying quality. This randomised controlled trial aims to investigate whether contemporary e‐learning completed prior to a course in obstetric anaesthesia prepares the course participants better than self‐study of written course material.
Methods
A randomised controlled trial allocated second‐year resident anaesthetists to receive either e‐learning in postpartum haemorrhage and written course material in preeclampsia or e‐learning in preeclampsia and written course material in postpartum haemorrhage, prior to a compulsory course in obstetric anaesthesia. The primary outcome was knowledge after completion of e‐learning before the course, assessed by type X multiple‐choice questions with a score ranging from zero to 35.
The secondary outcomes were anxiety level before course simulations, performance during course simulations, and knowledge four and 12 weeks after the course.
Results
The per protocol analysis of the primary outcome included 45 participants and demonstrated a mean difference of 1.8 (95% CI 0.7–2.9; p = .002) in knowledge after completion of e‐learning before the course, in favour of e‐learning compared to written course material. There were no statistically significant differences in the secondary outcomes.
Conclusion
This blinded parallel group randomised controlled trial found a numerically small but statistically significant difference in knowledge favouring e‐learning over written course material.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
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