ASPIRE Obstetric Anesthesia Subcommittee Meeting

December 7, 2022

Agenda

Announcements

July 2022 Meeting recap

TEMP 01: Fluid warmers acceptable active warming device?

Preliminary GA-03-OB Data Review

Oxytocin Dosing for Cesarean Delivery

Duke Research Study: Placenta Accrete

Announcements

OB Subcommittee Meetings:

– February 15, 2023 1pm EST

– May 24, 2023 1pm EST

– November 15, 2023 1pm EST

July Meeting Recap

• Presented data capture rates for cesarean delivery cases in MPOG

– ~70% of cases have medications documented within 0-1 hour before

scheduled cesarean delivery

– ~40% of cases have medications documented within 1 hour before

conversion cases (L&D data is not always included in the MPOG data

submission)

• Subcommittee voted to move forward with GA-03-OB:

– % of cesarean delivery cases converted to GA from an epidural

– Measure spec drafted and posted to Basecamp for feedback

TEMP 01: Active Warming

Background

• TEMP 01-published in January 2020

• Every 3 years, each ASPIRE measure is reviewed by the Quality Committee

• Last reviewed at the July Quality Committee meeting and decision was made to defer

to the OB subcommittee: Should TEMP 01 continue to accept fluid warming as active

warming for this patient population?

• Additional discussion from QC: Place temp sensing foley to get accurate core temp in

cesarean patients (instead of skin temperature)

TEMP 01 Considerations for Cesarean Delivery Cases

Description:

Percentage of cases in which an active warming device was applied intraoperatively, or the patient

maintained a temperature above 36.0°C without active warming.

Active warming defined as:

- Convective warming

- Conductive warming

- Endovascular warming

- Radiant heaters

- For cesarean delivery cases only: Fluid warmers

Exclusions:

‒ Labor epidurals & cases less than 60 minutes case duration

Warming Literature

Obstetric Active Warming Literature: Forced Air Warming vs. No Warming

• N=30 elective cesarean patients

• No significant difference between

study groups (FAW vs. no active

warming)

Fluid warming in Cesarean cases

• Meta-analysis using randomized control trials utilizing forced air warming or

warmed fluid within 30 min of neuraxial placement

• N= 13 studies:

– 416 patients warmed with FAW or warm fluids

– 373 patients in control group (no warming)

• Suggests FAW or warmed fluids should be used for elective cesareans.

Obstetric Active Warming Literature: Forced Air vs. Passive

• 30 patients randomly assigned forced air warming or passive insulation

• Core temperatures after 2 h of anesthesia were greater in the actively warmed

(37.1°C ± 0.4°C) compared to unwarmed (36.0°C ± 0.5°C;P < 0.01) patients.

• Shivering was observed in 2 of 15 warmed vs. 9 of 15 unwarmed mothers (P < 0.05).

Obstetric Active Warming Literature: Fluid Warming + Forced Air Warming

100 patients scheduled for elective c-section:

 50 patients warmed with IV fluid infusion + forced air warmer

 50 patients warmed with only forced air warmer

Core body temp and shivering incidence recorded:

Every 10min from prespinal -> end of surgery & 0, 15, and 30 minutes after arrival in PACU

Fluid warming + forced air warming maintained slightly warmer near core body temperatures postoperatively &

reduced shivering compared to those warming with forced air alone.

Obstetric Active Warming Literature: Fluid Warming + Forced Air

• RCT including 46 women undergoing scheduled cesarean delivery with spinal

• 23 in control and 23 intervention

• Intervention = warmed IV fluid + lower body forced-air warmer

• Control = No warming, blankets only

• Intervention group warmer in PACU & improved comfort; no other significant findings

related to intraop shivering, Apgar scores, umbilical vein blood gas values

TEMP 01 Discussion

 Literature is limited to small studies & focused primarily on forced air warming +/-

fluid warming

 Continue to include cesarean deliveries?

 Continue to include fluid warmers as active warming?

 Other considerations?

 Poll:

• Include c-sections in TEMP 01 (yes/no)

• If yes, include fluid warmers as active warming?

GA-03-OB Specification: DRAFT

Description:

Percentage of cesarean delivery cases converted to general anesthesia after epidural

• GA-03b-OB: Percentage of cesarean delivery cases converted to general anesthesia after

combined spinal epidural

Inclusion:

Cesarean delivery cases with epidural anesthesia administered

• GA-03b-OB: Cesarean delivery cases with combined spinal epidural

Exclusion:

• Cesarean Hysterectomies as determined by the “Obstetric Anesthesia Type” Phenotype.

• Non-cesarean delivery cases, including labor epidural only cases

• Cesarean delivery cases without epidural placement (or CSE for GA-03b)

GA-03 Considerations

• Added exclusion for cases that were converted to GA >=75 minutes after

neonate delivery (attempting to exclude cases that were clearly converted for

medical reasons, not failed epidurals)

• Cases converted to GA before neonate delivery and after epidural placement

will be included, regardless of reason for conversion

• Unfortunately, documentation is not standardized enough to weed out a

medical reason vs. failed epidural

Review of Existing General Anesthesia Measures for Cesarean Delivery

 GA-01-OB: Percentage of cesarean delivery cases where GA was used

 GA-02-OB: Percentage of cesarean delivery cases where GA was administered

after neuraxial anesthesia

 GA-03-OB: Percentage of cesarean delivery cases converted to general anesthesia

after epidural

 GA-03b-OB: Percentage of cesarean delivery cases converted to general

anesthesia after combined spinal epidural

500

1000

1500

2000

2500

3000

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

GA-01 Performance

December 2021 - September 2022

GA 01 Score (%) Total C-section Cases

GA-03-OB Next Steps

• Neuraxial and Obstetric Anesthesia Type phenotypes need some revisions before we

make this measure public on dashboards

• Any other considerations?

• Does the group want to move forward with this measure?

Oxytocin Dosing

Basecamp Discussion – July 2022

• Post regarding oxytocin dosing at other sites for

cesarean delivery

• Practices reported on forum:

– No bolus; first infusion: 30U over 1 hour + second infusion

30U over 4 hours

– No bolus; first infusion: 80U over 1 hour + second infusion

30U over 4 hours

– Bolus dose of 1.2U with infusion 15U/hr x ~2 hours

– Bolus dose of 3U with infusion of remaining 27U at a rate of

45U/hour

– No bolus; first infusion: 18U over 1 hour + ? Second infusion

at discretion of obstetrician

Oxytocin for Cesarean Delivery: Literature Review

International Consensus Statement

Also includes recommendations for second-line medications (beyond the oxytocin

recommendations):

• Prospective, randomized, double-blind

trial including 51 women:

• All women received bolus of 1U after

delivery of neonate +

– 24 women received infusion 2.5 U/hr

– 27 women received infusion 15 U/hr

• EBL (634mL vs. 512mL; p-value=0.7)

• PPH rates & uterine tone did not differ

between low and high infusion groups

either

Literature review: Dose effectiveness

MPOG Coordinating Center Review

• Reviewed 238 Cesarean cases across 49 sites for dosing and bolus amount as well as

timing of first dose.

• For sites that bolus off pump, MPOG unable to determine dose amounts (not

consistently documented)

• This preliminary review showed:

– No standard bolus amount (1-6 units).

– No standard infusion rate was found among sites.

• Discussion…and poll

Anesthetic Management of Cesarean

Hysterectomy for Placenta Accreta

Spectrum

Nicole Zanolli & Dr. Ashraf Habib

Gaps

• Current literature lacks large multicenter

studies that address optimal anesthetic

management of cesarean hysterectomy for

PAS

Background

https://radiology.ucsf.edu/blog/ucsf-radiologys-role-

multidisciplinary-approach-placenta-service-maps-ucsf

• Placenta accreta spectrum (PAS) can complicate

delivery leading to massive hemorrhage

• Patients with suspected cases of PAS are often

scheduled for cesarean hysterectomy

Primary objective

• Provide a descriptive analysis of anesthetic management of cesarean

hysterectomy for PAS

Secondary objective

• Compare the anesthetic management and outcomes between cases

performed under general, neuraxial or combined neuraxial/general

anesthesia

• Primary comparison: transfusion requirements

• Inclusion Criteria

• January 1, 2015- December 31, 2021

• “Cesarean Hysterectomy” in OBAT phenotype

• MPOG case reviewer to insure will manually reviewed

• Exclusion Criteria

• Patients <13 years of age

• Length of procedure <15 minutes

• Procedures occurring after cesarean hysterectomy

Study design: retrospective cohort study

Progress

• Completed single center review of PAS cases at Duke

• High quality data for fluid and blood administration, intraoperative drug

administration, pre and post op CBC’s

• Received PCRC approval

• Optimized identification of cesarean hysterectomies performed for PAS

• Planning for individual case review

• Address limitations

• Post op destination: ICU vs floor

• Type of PAS

• Planned vs unplanned procedure

THANK YOU!

Nicole Barrios MHA, BSN-RN

Obstetric Anesthesia Subcommittee Lead

nicbarri@med.umich.edu

Monica Servin, MD

MPOG Obstetric Anesthesia

Subcommittee Chair

monicar@med.umich.edu