Obstetric Anesthesia Subcommiee Minutes
June 3, 2026
1:00–2:00 pm ET – Zoom
Chair: Brandon Togioka, MD (MPOG OB Subcommiee Chair)
Vice Chair: Sharon Reale, MD (MPOG OB Subcommiee Vice Chair)
MPOG Coordinang Center Facilitator: Kate Buehler, MS, RN (MPOG Clinical Program Manager)
Aendees:
David Arnolds, University of Michigan
Tiffany Malenfant, MPOG
Kate Buehler, MPOG
Michael McDonald, University of Pennsylvania
Mei Calabio, MPOG
Christine McKenzie, University of North Carolina
Brendan Carvalho, Stanford
Mary McKinney, Corewell Health
Ruth Cassidy, University of Michigan
Chris Milliken, University of Michigan
Megan Charette, MPOG
Melinda Mitchell, Henry Ford
Deb Claybaugh, MyMichigan Health
Allison Mootz, University of Texas Southwestern
Rob Coleman, MPOG
Katie O'Conor, Johns Hopkins
Carlos Delgado Upegui, University of Washington
Diana O'Dell, MPOG
Leanna Delhey, MPOG
Rebecca Pantis, MPOG
Heather Dobbs, Bronson Healthcare
Sharon Reale, Brigham & Women's
Holly Ende, Vanderbilt
Emily Sharpe, Mayo Clinic
Julie Foster, MyMichigan Health
Frances Guida Smiatacz, MPOG
Michael Furdyna, Brigham & Women's
Mason Smith, MyMichigan Health
Jackie Goatley, University of Michigan
Brian Taussig, NYU Langone
Ashraf Habib, Duke University
Brandon Togioka, OHSU
Melanie Herren, MPOG
Lawrence Tsen, Brigham & Women's
Wandana Joshi, Dartmouth Hitchcock
Pam Tyler, Corewell Health
Jeremy Juang, UCSF
Meridith Wade, MPOG
Rachel Kacmar, University of Colorado
Christine Warrick, University of Utah
Merajuddin Khan, Henry Ford
Blake Wilson, MyMichigan
John Kowalczyk, Brigham & Women's
Andrew Zittleman, MPOG
Heather LaLonde, Trinity Health
1) Announcements
SOAP Patient Safety Award
Dr. Daniel Berenson (Brigham & Women's Hospital) received the SOAP Patient Safety Award at the 2026
SOAP Annual Meeting in Montreal, Canada. This is a prestigious recognition within the field of obstetric
anesthesia.
His award-winning project was entitled Factors Associated with General Anesthesia After Neuraxial
Anesthesia for Cesarean Delivery, utilizing the MPOG dataset. Key findings include:
• Study population: ~500,000 patients across 68 sites, 2016–2025
• Primary outcome based on GA-02-OB (proportion of patients requiring conversion to GA after
neuraxial anesthesia)
• GA rates ranged from 1.2% to 30%; median approximately 4%
• Factors associated with GA conversion: non-SOAP Center of Excellence sites, Black race, higher
ASA classification, emergency status, epidural or CSE (vs. spinal), nighttime delivery, and
increased number of labor boluses
This project exemplifies how MPOG quality measures can serve as a foundation for impactful clinical
research that directly informs patient care.
Upcoming Meeting Dates (all via Zoom)
September 16, 2026 – 1:00 pm EST
2027 dates confirmed:
o February 3, 2027, 1-2pm EST
o June 2, 2027, 1-2pm EST
o September 15, 2027, 1-2 pm EST
GA Measure Update – IOU from September 2025 Vote
The September 2025 committee vote to modify the general anesthesia definition for obstetric cesarean
delivery patients (GA-01-OB, GA-02-OB, GA-03-OB) is in progress. The update is taking longer than
anticipated due to approximately 12 underlying phenotypes requiring revision.
• Previous Subcommittee Vote: Nitrous oxide given alone (without other inhaled agents,
neuromuscular blockers, or airway placement) for cesarean delivery will no longer be classified
as general anesthesia
• Additional fix: Artifact values for inhaled anesthetic agents without concurrent fresh gas flow
were being incorrectly captured as GA; this will be corrected
• The Pediatric Subcommittee simultaneously requested related changes for the induction period,
requiring coordinated revisions
• Target timeline: Dashboard update expected by July 2026
• Action: MPOG will post an update to the OB Subcommittee forum once complete. Sites will
continue to see inappropriately flagged nitrous-only cases until the update is live.
2) In the News (Research Highlights)
Three studies published as a cohort in the International Journal of Obstetric Anesthesia (IJOA) on the use
of dexmedetomidine in obstetric anesthesia were presented, with editorial authors Drs. Ende and
Sharpe joining as guest discussants.
• Study 1 (Community Hospital Setting): Conducted during an opioid shortage, intrathecal
dexmedetomidine was used in place of opioids. Post-operative pain scores were improved
compared to no adjunct.
• Study 2 (Multi-modal Review): Examined dexmedetomidine administered via all routes
(intrathecal, neuraxial, IV). Adverse events included bradycardia, hypotension, and heart rate
abnormalities.
• Editorial (Ende & Sharpe, IJOA): Titled appropriately “Clinical Enthusiasm, Limited Evidence,” the
editorial suggests that dexmedetomidine is likely safe and effective but emphasizes the lower
level of evidence from the retrospective studies and the need for higher-quality data.
Key Discussion Points
• Emily Sharpe (Mayo Clinic): The Takalo study used 10 mcg dexmedetomidine intrathecally, which is
higher than most clinical practice. Smaller doses are likely more appropriate. An upcoming
International Journal of Obstetric Anesthesia study on clonidine showed significant PACU
hypotension, reinforcing caution with alpha-2 agonists.
o Carlos Delgado Upegui (University of Washington) (via chat): Literature ranges are wide,
but 4–8 mcg (1–2 mL) epidural dexmedetomidine is what is used at UWMC.
o Allison Mootz (University of Texas Southwestern): 20–30 mcg epidural dexmedetomidine is
used for intrapartum cesarean deliveries with hot spots or difficulty achieving dense blocks.
o Wandana Joshi (Dartmouth Hitchcock) (via chat): 10 mcg dexmedetomidine given
epidurally with minimal hypotension or bradycardia.
o Michael Furdyna (Brigham & Women's) (via chat): Liu et al. (2023, Journal of Anesthesia)
suggests 0.5 mcg/kg (IBW) may be appropriate for visceral pain in cesarean delivery; above
that, more hypotension/bradycardia was noted.
• Holly Ende (Vanderbilt): MPOG represents an important opportunity to obtain large-scale
observational data on maternal adverse events, since large RCTs are difficult due to non-FDA-
cleared intrathecal use and IND requirements.
• Sharon Reale (Brigham & Women’s): Noted that the Ende & Sharpe editorial cites 4–5 mcg as
approximately the standard intrathecal dose referenced in the literature. One key MPOG challenge
is ensuring accurate documentation of administration routes (IV vs. intrathecal); current EHR
systems may not consistently support neuraxial charting of dexmedetomidine.
3) February Meeting Recap
The following updates from the February 2026 meeting were reviewed:
• NCR-01-OB (Neuraxial Catheter Replacement): Dashboard verbiage updated to clarify
passing vs. flagging; time between catheter placement and replacement now being added
for QI use
• UDP-01-OB (Unintended Dural Puncture): Committee recommended limiting inclusion
criteria to labor epidurals and cesarean deliveries; denominator simplified to per delivery
• 2026 Goals: Continue UDP measure development, develop an OB-specific IONV/PONV
prophylaxis measure, and incorporate brief research presentations into agendas
4) NCR-01-OB: Neuraxial Catheter Replacement – Measure Update
Status: Active/Released (Departmental Only)
Public spec: https://measures.mpog.org/Measures/Public/102
Dashboard Clarification
Sharon Reale (Brigham & Women’s): Following Dr. Habib's February feedback, the dashboard has been updated to
clarify that a passing case indicates the catheter was not replaced, and a flagged case indicates it was replaced.
Discussion: Spinal Placement After Epidural – Measure Design
• Sharon Reale (Brigham & Women’s): A key question was raised: should spinal placement after an epidural (in
the context of cesarean delivery) be added to NCR-01-OB or developed as a separate measure (NCR-02)?
o Arguments for combining: Simplifies interpretation; avoids proliferation of similar measures (similar
to GA-01, GA-02, GA-03 complexity)
o Arguments for separating: Allows specificity for research and QI; enables distinct thresholds for labor
replacement vs. cesarean conversion
o Ashraf Habib (Duke University): I think what would be valuable is if we can discriminate between a
block replaced for labor and a block replaced for a C-section. A block replaced for a C-section will
include a spinal or a CSE done for the C-section, as opposed to catheter replacement during labor. I
think this would be helpful.
Rachel Kacmar (University of Colorado) (via chat): Agree with separation of measures.
Brendan Carvalho (Stanford) (via chat): Agree with Ashraf.
• Lawrence Tsen (Brigham & Women's): Supported separate measures; noted that some practices routinely
remove labor epidurals and place a spinal for cesarean delivery. Separating replacement for analgesia versus
cesarean is clinically and operationally important.
• Ashraf Habib (Duke University): Proposed incorporating hyperbaric bupivacaine administration timing as a
data element to differentiate blocks placed for labor vs. cesarean delivery, as a proxy when encounter-level
documentation is limited.
• Kate Buehler (MPOG): Highlighted that OBAT (OB Anesthesia Type phenotype) can differentiate conversion
scenarios. However, data from many EPIC sites lacks circulator documentation, limiting the granularity of
procedure timing. Current data is “sparse” at some sites.
• Michael Furdyna (Brigham & Women's): Asked whether OBAT conversion categories would be sufficient to
flag relevant cases. Kate confirmed three enumerations would handle conversion scenarios.
o Christine McKenzie (University of North Carolina) (via chat): Are spinals for cesareans being included
in the denominator as well?
• Brandon Togioka (OHSU) confirmed spinals are included in the denominator and acknowledged this as a
known limitation.
o Michael Furdyna (Brigham & Women's) (via chat): Perhaps a poll to decide whether per patient or
per procedure for the denominator.
Decisions
• Consensus direction: Separate the NCR measure into labor epidural replacement vs. cesarean conversion; add
spinals after epidural within that framework
• Kate Buehler, Sharon Reale, and Brandon Togioka will explore feasibility of differentiating labor replacement
vs. cesarean conversion within existing MPOG logic
• Follow-up polls to be distributed via email for remaining denominator/design decisions
5) UDP-01-OB: Unintended Dural Puncture – Measure Update
Status: In Development – Request for Feedback
Measure Summary
• Description: Percentage of patients undergoing neuraxial epidural anesthesia for an obstetric procedure with
evidence of an unintended dural puncture (UDP)
• Threshold: ≤2%
• Measure time period: Neuraxial anesthesia start → 14 days after
• Attribution: Departmental only; no provider attribution (proposed)
Inclusion Criteria (Updated per February Vote)
Patients requiring neuraxial anesthesia for childbirth procedures:
• Labor epidurals and cesarean deliveries (primary)
• Cesarean hysterectomies
• External cephalic versions (ECV) – added given neuraxial use for this procedure
Note: PPTL, laceration repair, D&C, and other peripartum procedures were excluded per February 2026 committee
vote.
Carlos Delgado Upegui (University of Washington) (via chat): Sharon, are other peripartum procedures (PPTL, lac
repair, D&C) included in the numerator?
Sharon Reale (OB Subcommittee Vice Chair): These procedures were excluded following February
committee guidance; they can be reinstated if consensus changes.
Included Neuraxial Techniques
• CSE, epidural, caudal, and “multiple” (including spinal + epidural or unclear documentation)
• Excluded: No neuraxial technique, spinal-only, unknown neuraxial type
Numerator Logic – UDP Evidence
UDP is identified by any of the following within the 14-day window:
• Inadvertent dural puncture concept documented on the case (ID: 50291)
• Epidural blood patch concept documented on a subsequent case within 14 days (ID: 50507)
• Epidural blood patch CPT (62273) within 14 days of neuraxial procedure start
• ICD codes consistent with CSF leak / dural puncture / neuraxial headache (G96.0, G97.0, G97.41, O74.5, O89.4;
ICD-9 349.31)
Poll: Additional Medications as UDP Proxies
• Sharon Reale (Brigham & Women’s): The committee voted on whether to include three medications as
additional UDP identification proxies:
o Caffeine: Majority voted yes
o Fioricet (butalbital/caffeine/acetaminophen): Strong majority voted yes
o Sphenopalatine ganglion (SPG) block: Voted yes
o Michael Furdyna (Brigham & Women's) (via chat): If adding medications, should the case be
required to not have a spinal or CSE note to avoid false positives?
o Brian Taussig (NYU Langone) (via chat): OBs have been observed treating non-positional, non-PDPH
headaches with those medications, raising concern about false positives if overly sensitive criteria are
used.
• Lawrence Tsen (Brigham & Women's): ASRA guidelines speak against the use of SPG blocks for PDPH. The
committee should consider whether inclusion promotes a practice not endorsed by current guidelines.
• Brendan Carvalho (Stanford): Expressed concern about blending UDP (recognized wet tap) with blood patches
and PDPH – these are related but distinct concepts. Including them risks muddying the definition of what the
measure is capturing.
• Ashraf Habib (Duke University): Acknowledged the measure is capturing both UDP and PDPH. This should be
explicitly stated in the measure specification.
o Christine McKenzie (University of North Carolina) (via chat): What about cosyntropin?
o Michael Furdyna (Brigham & Women's) (via chat): Do any facilities still give cosyntropin?
• No consensus reached on cosyntropin; item tabled.
Denominator Discussion
Options reviewed at the last meeting in February: number of neuraxial procedures, number of obstetric
procedures, number of deliveries, or 14-day obstetric encounter.
• Brandon Togioka (OHSU): The delivery-based denominator was selected at the February meeting to avoid
double-counting when multiple neuraxial procedures occur in a short timeframe, and because UDP capture
(primarily via ICD-10 codes) is at the encounter level rather than the procedure level.
• Ashraf Habib (Duke University): Raised concern that every neuraxial procedure carries independent risk for
UDP; a per-procedure denominator more accurately reflects clinical risk. Acknowledged trade-offs after
further explanation.
o David Arnolds (University of Michigan) (via chat): Agree with Ashraf regarding the denominator.
• Brendan Carvalho (Stanford): Agreed denominator choice can affect incidence data, particularly at sites with
varying epidural rates. Noted the measure is capturing a blend of UDP and PDPH.
• Kate Buehler (MPOG): Concern raised about modifying denominator to neuraxial procedures given complexity
of identifying neuraxial placements – not precise; favored per-delivery for simplicity and consistency with NCR.
Acknowledged verbiage in the spec can be clarified to explicitly note PDPH is used as a surrogate.
o Christine McKenzie (University of North Carolina) (via chat): It's perfectly imperfect.
Brandon Togioka (OHSU) clarified that once the measure is developed, threshold discussion will occur; it may
initially be descriptive.
UDP-01-OB Preliminary Performance Data
Rates ranged from near 0% to approximately 4% across sites. Lower rates likely reflect incomplete data mapping
rather than true rates. Kate Buehler noted ongoing outreach to sites to improve discrete UDP variable mapping;
several sites are actively building discrete documentation fields.
• Michael Furdyna (Brigham & Women's) (via chat): High blue (numerator) is bad; low orange
(denominator) means a low number of cases.
UDP-01-OB Case Flagging and Attribution
• Proposed (pending follow-up email poll): Flag only the first neuraxial case per delivery episode. This was
discussed but not formally voted on at this meeting; consensus direction was discussed, and final
determination to be confirmed via follow-up polling.
• Maintain UDP as department-level reporting only – no provider attribution
6) 2026-2027 Priorities Discussion
Brandon Togioka (OHSU): The following workstreams were presented for prioritization. The committee voted
using ranked-choice polling.
Priority Options Presented
• Option A: Separate NCR-01-OB into two measures (labor epidural replacement vs. neuraxial block for cesarean
delivery), including spinals after epidurals
• Option B: Finalize pregnancy gestational age phenotype (using ICD-10 Z3A codes; approximately one-week
margin of error; high capture rate observed)
• Option C: Develop PONV-06-OB – a new OB-specific combined IONV/PONV prophylaxis measure for cesarean
delivery
Discussion:
• Christine McKenzie (University of North Carolina) (via chat): Is the goal for measuring spinal after neuraxial to
have a maximum threshold?
• Lawrence Tsen (Brigham & Women's) (via chat): With the second measure, how was pregnancy confirmed?
HCG? There can be failures of this.
• Michael Furdyna (Brigham & Women's) (via chat): It's ICD code-based, so we have to assume someone
confirmed pregnancy (HCG, US, wheat grass).
Kate Buehler (MPOG): A ranked-choice priority poll was administered.
Results:
• Highest priority: Develop a new measure to separate neuraxial replacement for labor vs. cesarean delivery
• Second priority: Finalize pregnancy gestational age phenotype
• Third priority: New cesarean-specific IONV/PONV prophylaxis measure
Action Items
1. NCR-01-OB
Revise NCR-01-OB to result labor epidural replacement only and create a separate measure (NCR-02-OB)
to assess epidural replacement or spinal administered for labor epidural converted to cesarean – MPOG
Coordinating Center Team
Update NCR-01-OB logic to consider hyperbaric bupivacaine administration timing as a proxy data
element to identify indication for neuraxial replacement - MPOG Coordinating Center Team
2. UDP-01-OB
Add caffeine, Fioricet, and SPG block to UDP numerator logic - MPOG Coordinating Center Team
Update measure specification verbiage to explicitly state PDPH serves as a surrogate for UDP - MPOG
Coordinating Center Team
3. Announce update to Obstetric GA measures once released; target release date: July 2026
4. Review current NCR-01-OB dashboard data locally and report any cases that are incorrectly flagged or passed
to Coordinating Center – OB Champions from participating MPOG sites
5. Dr. Togioka to present his ABX-01-OB 3-year measure review at the next meeting on September 16, 2026
(postponed due to time constraints)
6. Future meetings will continue to include brief MPOG research highlights
7. 2026-2027 OB Subcommittee Priorities:
(1) NCR measure separation
(2) Update UDP-01-OB measure and release to dashboards
(3) Gestational Age phenotype
(4) PONV-06-OB: IONV/PONV for Cesarean Delivery
Contact Information
• Kate Buehler, MS, RN – MPOG Clinical Program Manager (kjbucrek@med.umich.edu)
• Brandon Togioka, MD – Chair (togioka@ohsu.edu)
• Sharon Reale, MD – Vice Chair (screale@bwh.harvard.edu)
Meeting Adjourned: 14:05 ET
Next Meeting: Wednesday, September 16, 2026 – 1:00 pm ET / 10:00 am PT
Appendix A — Full Transcript
MPOG Obstetric Anesthesia Subcommittee Meeting
June 3, 2026
Announcements
Brandon Togioka [OHSU]: I think we'll get started, just in the interest of time. Thank you all so much for being
here. This is the MPOG Obstetric Anesthesia Subcommittee meeting. This is our second one of 2026. This is our
agenda for today. We have a very exciting announcement that we'll go through here briefly. Dr. Rial has an article.
It looks like we have a special guest here to discuss that article with you all. It's really great, very interesting
content. We'll briefly discuss our last meeting, which occurred in February, and then have a few measure updates
for neuraxial catheter replacement, which is currently active, and unintended dural puncture, which is likely our
next measure to be published. Following that, I'll do a brief review of ABX-01-OB. This is a measure to assess
appropriate administration and timing of prophylactic antibiotics before cesarean delivery. For those of you who
may not know, we review all active measures every 3 years, and so we're starting to hit that cadence again. This
will be the first one, and I will, towards the end of the meeting, try to solicit interest in leading future measures.
We'll end the meeting with a priorities discussion and a vote.
I'm not sure if Dr. Berenson's here, he may be. Anyways, I just wanted to briefly touch on this. It's very exciting. Dr.
Daniel Berenson won the Patient Safety Award this last year at SOAP, which occurred in Montreal, Canada. It's a
very prestigious award. If you look at the list of people that have been awarded it, there are many big names in OB
Anesthesia that have made a huge impact, so it's quite impressive to receive this award as a fellow. His project was
entitled Factors Associated with General Anesthesia After Neuraxial Anesthesia for Cesarean Delivery, and he did
utilize the MPOG data set. He looked at patient records from 2016 to 2025. His primary outcome was based on one
of our measures here, actually. It was GA-02-OB, which is a measure looking at the proportion of patients that
require conversion to general anesthesia after neuraxial anesthesia. Neuraxial in the MPOG data set is essentially
epidurals or CSEs. He used a mixed effects generalized linear model and looked at about 500,000 patients across
68 sites. The rates of general anesthesia vary quite a bit, probably somewhat due to lower sample size in certain
institutions, but the rates of GA range from about 1.2% to 30%. The median, I believe, was around 4%. The factors
that he found associated with GA are sites that are not SOAP Center of Excellence, Black race, higher ASA class,
emergency status, and the use of an epidural or CSE as opposed to a spinal, probably somewhat due to a
comparison of intrapartum versus scheduled cesarean delivery. Lastly, he did confirm previous studies showing
that nighttime delivery and an increased number of boluses during labor is associated with failure. We just wanted
to highlight this. It's a great example of the quality work that we're doing, parlaying into research, and then using
that to dovetail into improved patient care. Congratulations, Daniel.
These are upcoming meetings. The September one we previously did publish — these are all on Wednesdays,
same time, 10 a.m. Pacific and 1 p.m. Eastern Time. We just confirmed the three dates for 2027, listed here in
February, June, and September. These are aligned with our previous cadence for the committee. We always put
this in — if anyone's interested in joining, contact Kate, Dr. Alley, or myself, and you can join the committee.
There's one vote allowed per institution, but we welcome everyone to participate. Alright, and Kate, is this yours?
Kate Buehler [MPOG]: I think this one's me. This is an IOU. The general anesthesia definition was voted on last
September by this subcommittee to be modified specifically for obstetric cesarean delivery patients. We heard
you, and we are working on it, but I just wanted to give feedback that it has resulted in about 12 underlying
phenotypes needing to be revised in order for those measures to be updated — GA-01, GA-02, and GA-03. If you
may remember, the vote was to no longer consider, if nitrous oxide alone was given for a cesarean delivery with
no other inhaled anesthetic agents, no neuromuscular blockers, no airway placed, then we would consider that not
general anesthesia. We are working on making that update. In addition, we had a few cases sneaking through —
this was not for very many — that were inhaled anesthetic agents that did not have a fresh gas flow running at the
same time, basically artifact values, and those were being picked up as general anesthesia, and we want to get
those out. Those two changes, though they seem minor, have resulted in a number of underlying phenotypes
needing to be revised. At the same time, the pediatric subcommittee recommended some changes specific to
nitrous oxide use and the definition of general anesthesia as well, and they wanted to change that for the
induction period of anesthesia, and so we're trying to accommodate all of those requests at the same time, and it's
resulting in a bit of a delay. By July next month, I hope all of your GA measures can have this update seen on the
dashboard, but we'll keep everybody posted. I'll post to the OB Subcommittee forum. Wanted to give an update
that the GA measures have not been updated yet, so you will still see flagged cases that are inappropriately
flagged with nitrous only given. We know that. We're not ignoring you, we're working on it, and it should just take
a little bit longer. We don't want to break any other phenotypes in the process. Any questions about that? Sharon,
back to you.
In the News (Research Highlights)
Sharon Reale [Brigham & Women's]: All right, perfect. Just as part of this 'in the news' segment, we're going to be
bringing up a few research studies that are pertinent to OB anesthesia and potentially to this subcommittee. These
three studies were all published recently in IJOA, kind of as a cohort, and we're lucky enough to have two of the
editorial authors here — Holly and Emily, hopefully still here. The studies were both retrospective cohort studies
looking at the use of dexmedetomidine. The first one was at a community hospital where they had a shortage of
opioids, and they were actually using dexmedetomidine essentially in place of opioids, and they found that
postoperative pain scores were improved with the use of dexmedetomidine compared to nothing. The other study
was done looking at dexmedetomidine given through all modalities — intrathecal, neuraxial, and many IV — and
they looked at adverse events including things like heart rate abnormalities, hypotension, and bradycardia. Drs.
Ende and Sharp wrote a nice editorial that is something we should all be considering as OB anesthesiologists. What
is the role of dexmedetomidine in our practice? It seems to be helpful, doesn't seem to be terribly harmful, and is
something that's being used more and more. Things for us to all keep on our radar, potentially, whether it's QI
looking at adverse events that we know can occur, or also looking at it from the research perspective as well.
Anything you wanted to add, Drs. Ende or Sharp? If not, that's totally okay, but we're very happy to have you join
us.
Emily Sharpe [Mayo Clinic]: Thank you so much for the invitation. One of the things about that Takalo study that I
thought was interesting is that they used dexmedetomidine 10 micrograms intrathecal, which I think is a larger
dose than many of us use or other studies use. I think we should probably be using smaller doses than that. In
terms of MPOG, I definitely think being able to look at maternal adverse events on a larger scale would be
fantastic. I don't know if it's been published yet, but there's another study coming out of IJOA looking at clonidine,
and they showed significant hypotension in the PACU. I think there are a lot of benefits to these alpha-2
medications, but there are the side effects, specifically hypotension for both clonidine and dexmedetomidine. One
role it may have is with our high emphasis on intraoperative pain — could adding dexmedetomidine to our
regimen help with that, both intrathecal and epidural dexmedetomidine for intrapartum cesarean deliveries?
Those are my few thoughts.
Sharon Reale [Brigham & Women's]: Thank you for sharing. I think in the editorial you said that 4 to 5 micrograms
was probably the standard, and I agree this is something that would be great to look at. One of the challenges
specifically to MPOG is the appropriate documentation — people charting it correctly if it's IV or intrathecal. In our
institution, initially we weren't even able to chart it as neuraxial. I think Daniel has gotten that fixed, but.
Emily Sharpe [Mayo Clinic]: I have the same problem here. When I give intrathecal dexmedetomidine, I don't have
that option, so I have to do a quick note or a comment, and I have requested to have that fixed in our Epic, but it
hasn't gone through yet. It's a huge problem.
Holly Ende [Vanderbilt]: The only thing I'd add is the title of our editorial was something like 'Clinical Enthusiasm,
Limited Evidence,' or something like that. Earlier versions were a little bit more pro-dexmedetomidine, but based
on reviewer feedback, they really wanted us to emphasize that both of these articles are lower-level evidence and
that we should be pushing for higher-level evidence. It's really nice to see that you're potentially taking up this
topic, because MPOG — it's difficult to do large randomized trials, especially with medications that are not FDA
cleared for intrathecal use and the need for investigational new drugs, INDs from the FDA, and I know a lot of
people are not willing to do all of that work. MPOG would be a nice next step to get us some better data on this
topic, because people are very excited about it clinically, and these small retrospective studies really are just
whetting everyone's appetite for the type of data that we probably need.
Brandon Togioka [OHSU]: I see the question — I've never used dexmedetomidine epidurally. What's the
recommended dosage?
Holly Ende [Vanderbilt]: That's a good question. I've given 4 to 8 micrograms, just based on — we have one
attending here who uses it pretty regularly, and that's what he had told me, but I have never looked up the
literature myself to know the specific epidural dose. I also use 4 micrograms intrathecal. That I'm pretty
standardized on.
Emily Sharpe [Mayo Clinic]: I use 5 micrograms intrathecal. I haven't done an epidural either. To be honest, I love
dexmedetomidine, and people at my practice know that. I love IV dexmedetomidine, but I've always been wanting
a little bit more data before I started using it myself. I actually didn't really start using intrathecal
dexmedetomidine until I started writing this editorial. I felt like I should have a little bit of experience with it. What
I've started doing, because our surgeries take so long here — we do a lot of intrathecal epinephrine — I've started
swapping out when I use intrathecal epinephrine for dexmedetomidine, just to get a little bit more experience with
it.
Carlos Delgado Upegui (via chat) [University of Washington]: Ranges are super wide per the literature,
but 4–8 mcg (1–2 ml) is what we have used here at UWMC.
Allison Mootz [University of Texas Southwestern]: At UT Southwestern, which is where I'm at, Parkland Hospital,
we've started using Precedex epidural for intrapartum C-sections with hot spots or difficulty getting dense blocks,
and we use between 20 and 30 micrograms, one push. And that's it.
February Meeting Recap
Sharon Reale [Brigham & Women's]: Thank you, Allison. Well, thank you so much for that added insight. It's
always interesting to hear from the authors themselves. I liked the tidbit about how you were asked to soften your
title. We'll continue with the rest of the meeting. Thank you so much, Emily and Holly, for joining us and giving us
those pearls. We'll head to our February meeting recap. Basically, at the February meeting, the subcommittee
requested updates to the neuraxial catheter replacement metric in order to clarify what's passing and flagging, and
we're going to talk about that on the next slide. We also recommended that the unintended dural puncture
measure limit the inclusion criteria just to labor epidurals and cesarean deliveries, and we simplified the
denominator per delivery. Some goals for 2026 were that we continue developing the UDP measure, develop an
intraoperative and postoperative nausea and vomiting prophylaxis measure, and start incorporating some brief
research presentations into our agenda, going over OB anesthesia MPOG studies that are in the pipeline.
NCR-01-OB: Neuraxial Catheter Replacement - Measure Update
Sharon Reale [Brigham & Women's]: This is the updated dashboard for the neuraxial catheter replacement
measure, and thanks to Dr. Habib for catching this super quickly. We're just clarifying what's passing and not
passing. Passing is the catheter wasn't replaced, and we're flagging cases where it was replaced and excluding non-
OB procedures and cases without neuraxial. We're also going to start having time between catheter placement
and replacement, which will be helpful for QI measures and for research as well. A poll was posited as to whether
we could add to the neuraxial catheter replacement measure — specifically, adding spinal placement after
epidural in cesarean delivery. We talked about this at the February meeting, and the poll is going to ask whether it
should be an additional measure, like NCR02, or whether spinals after epidural placement should be added as part
of the existing NCR01 measure. Some benefits of including it in the same measure is that it simplifies
interpretation. Those of you familiar with the GA measure — there's GA01, GA02, GA03 — nobody really knows
what the difference between all of those is, and so it can get unwieldy with multiple subtypes. Keeping it separate,
the benefits would be that it can be nice to have that specificity for research or other purposes.
Wandana Joshi [Dartmouth Hitchcock]) (via chat): I have given 10 mcg dexmedetomidine epidurally with
minimal hypotension or bradycardia.
Michael Furdyna (via chat) [Brigham & Women’s]: Liu et al (2023, Journal of Anesthesia) suggests 0.5
mcg/kg (presumably IBW) may be a good dose for visceral pain in CS. Above that they found more
hypotension/bradycardia than desired.
Ashraf Habib [Duke University]: Sharon, can I ask a question?
Sharon Reale [Brigham & Women's]: Of course.
Ashraf Habib [Duke University]: Would the spinal placement incorporate both single-shot spinal and a combined
spinal epidural?
Sharon Reale [Brigham & Women's]: I think a lot of people would be doing combined spinal epidurals, and I think
to me that's kind of another reason to just keep it all in NCR01, because then are you going to have NCR02 for
spinals after epidurals, NCR03 for CSE after labor epidurals?
Kate Buehler [MPOG]: NCR-01 now, just to be totally transparent, includes CSEs. If we make this
modification to add single-shot spinals, that would be an addition, or a revision, to this measure.
Ashraf Habib [Duke University]: So NCR-01 includes a fresh CSE for a C-section?
Sharon Reale [Brigham & Women's]: Poorly functioning epidural.
Ashraf Habib [Duke University]: A fresh CSE for a C-section, not for labor.
Brandon Togioka [OHSU]: No, no, it would include both. Sorry.
Kate Buehler [MPOG]: Correct, yeah. the initial and the follow-up, yep. If it was a labor epidural
converted to C-section, you would have the CSE for the labor epidural included, and if they had to replace
it, that would also be flagged. It would also be flagged if you converted to C-section. Is that what you
mean?
Brandon Togioka [OHSU]: Yeah, right now it would count a CSE or epidural placed at any point after labor or
cesarean delivery, but it does not include spinal right now, and so this would just add additional spinal.
Ashraf Habib [Duke University]: I think what would be valuable is if we can discriminate between a block replaced
for labor and a block replaced for a C-section. A block replaced for a C-section will include a spinal or a CSE done
for the C-section, as opposed to catheter replacement during labor. I think this would be helpful.
Brendan Carvalho (via chat) [Stanford]: Agree with Ashraf.
Lawrence Tsen [Brigham & Women's]: I would vote for separate measures, in part because — to echo what Ashraf
was saying — I know of some practices where they uniformly and routinely just pull out the epidural when they go
for cesarean and do a spinal for the cesarean. I think it's not a recommended practice. I'm saddened by it, but I
know there are places where that is the routine procedure. I think separating them out for analgesia versus
cesarean is a good idea.
Brandon Togioka [OHSU]: I agree with you all. Separating it is ideal for sure. The challenge in terms of
programming is with the OBAT phenotype, which is kind of our base OB anesthesia phenotype. I totally agree with
you both — 100% is the way to go. But programming-wise, it is challenging because some of our — we kind of
have to take whatever data we have from people. Some people will have one encounter for labor and a new
encounter for cesarean delivery. For those, we could pretty easily differentiate labor replacement versus cesarean
delivery. But there are other sites that have it all in one encounter and do not reliably document the time of entry
into the operating room. Therefore, for those sites, it would be quite a challenge for us to be able to know when
that was placed in relation to the OR. We could potentially look at proxies like frequency of blood pressure
measurement. It's going to be somewhat imprecise. I totally agree with you both — that's the ideal way to do it,
but I think we need to talk about how much imprecision we're willing to take. Lawrence, and Ashraf, what are your
thoughts on that?
Rachel Kacmar (via chat): Agree with separation of measures.
Lawrence Tsen [Brigham & Women's]: That's a difficult situation. I'm curious if maybe we set an arbitrary
threshold that looks at epidurals or spinals after epidurals for cesarean. If you find that one institution rises over,
like, 10 or 15%, because it may be only a few practitioners that actually practice in that way, but it's enough of a
signal separation from the rest of us, that might indicate we need to treat that data slightly differently. I don't
know if we can set thresholds like that.
Ashraf Habib [Duke University]: I don't know how you're identifying a replacement block — I need to look at the
specs of it — but are you incorporating, for instance, the administration of hyperbaric bupivacaine and the timing
of it? Because giving hyperbaric bupivacaine around the time of the C-section would be something to indicate that
this block was replaced by spinal or CSE for the C-section.
Kate Buehler [MPOG]: We're not looking at that now.
Ashraf Habib [Duke University]: I think possibly there's something to consider. It might be helpful to delineate that
there was a new intrathecal medication given for the C-section after a labor epidural.
Kate Buehler [MPOG]: Has anybody looked at their results yet? This measure's been out for about 3 months now.
Has anybody had a chance to review their current NCR-01 data and found cases that are flagged that should not
be, or vice versa, cases that passed that should be flagged?
Brandon Togioka [OHSU]: I looked at our data, and it looks solid.
Ashraf Habib [Duke University]: I think I looked earlier on and sent you some things that were
highlighted, but I didn't look subsequently.
Kate Buehler [MPOG]: It may be helpful as we're preparing to potentially either revise this measure or create a
new measure. The logic we created for this is very unique — it's non-standard to any other measure that we have
written — and so I'm just wondering about the current version of the logic before I create another measure that
would more or less recycle some of that logic, or expand upon it, potentially looking at spinals. It may be worth
reviewing some cases locally at your site, and seeing, is the current logic even getting close to what we would want
before I replicate that, or expand it to include spinals, or create another measure that's looking at spinal placement
after labor epidural. If we're missing the mark, we may want to go back to the drawing board altogether, rather
than just revise this. That would be my plea. I think it's good, but I have limited insight because I don't actually
have access to your electronic health record. I'm viewing cases here in the central database when I'm validating.
Brandon Togioka [OHSU]: Michael Furdyna, I think you had your hand raised, sorry.
Michael Furdyna [Brigham & Women's]: I was just wondering — echoing what Dr. Habib said — I'm just
wondering how often the labor epidural as a separate encounter from the conversion actually happens. I feel like
most of the time it's usually labor epidurals combined. If you're trying to make the measure of whether or not the
spinal happened before the cesarean, would it just be enough to say that if it happens within the context of any of
the OBAT conversion categories, if that would be enough?
Kate Buehler [MPOG]: That was my plan — to do exactly that. We have a couple of enumerations that are specific
to conversion, either handling the conversion for the labor epidural portion, encounter one for cesarean,
encounter two, or the combined one, which would be a third enumeration. I would include those three
enumerations if we were looking at conversions. That should handle all conversion cases. That being said, OBAT is
only as good as the documentation that is in there, and after looking at several OB cases yesterday that had no
uterine incision and no newborn delivery, it is not the cleanest data set, because we don't get any of the circulator
documentation from most sites. The current standard extract out of MPOG for OB, for most Epic sites, does not
include any circulator documentation, and so we don't have a lot of those key data elements. For a lot of sites,
there are three notes: anesthesia start, anesthesia end. It can be pretty sparse.
Sharon Reale [Brigham & Women's]: Great discussion. The poll originally asked whether spinals should be added
or be separate. It sounds like we kind of agree they should be part of NCR01, but the priority is that we would like
to separate out replacements for cesarean delivery. Is that the consensus I heard? I'm wondering if we should skip
the poll and consider that, or we could vote on whether, instead of voting on spinals, we could vote on whether to
separate out replacements for labor versus conversion. Brandon, do you have any thoughts on that?
Brandon Togioka [OHSU]: I was just making for the meeting notes in the chat — I like Ashraf's idea a lot, of looking
at the dosages as a proxy. We could get a pretty good estimate of the indication for the new block. I think it is
doable. If that means separating them out, then we would create two measures — one for replacement in labor,
and one for replacement for a cesarean delivery. How would we do that, Kate?
Kate Buehler [MPOG]: It sounds like that's what is desired.
Sharon Reale [Brigham & Women's]: I think in the interim, Brandon, Kate, and I can look into whether that’s
feasible. I do agree it would be extremely useful if we could separate based on cesarean delivery versus labor
delivery, as opposed to neuraxial type itself.
UDP-01-OB: Unintended Dural Puncture – Measure Update
Sharon Reale [Brigham & Women's]: Switching to another measure — the UDP measure is the percentage of
patients undergoing neuraxial epidural anesthesia for some sort of OB procedure who have evidence of an
unintended dural puncture. The measure time period will be from neuraxial anesthesia start to 14 days after that,
to hopefully capture as many as possible without pulling in headaches for other reasons. The success will be no
unintended dural puncture. We set the threshold at less than 2% based on societal guidelines. The inclusion
criteria are patients having childbirth — labor epidurals, cesarean deliveries, cesarean hysterectomies. We also
decided to add external cephalic versions, since epidurals or combined spinal epidurals are often used for that, and
certainly could result in an unintended dural puncture as well. The procedures we're including are CSE, epidural,
and caudal, with the caveat that there are very few of those in the database. We're also including cases with
multiple procedures, such as replacements, or spinal plus epidural. We're not considering cases with no neuraxial
technique, spinal only, or an unknown neuraxial type. This is the logic for determining UDP, which I'll walk through
a little bit slowly, because it's imperfect but I think the best available option. One is inadvertent dural puncture
documented on the case — obviously the cleanest, however, not all sites are mapping this. Epidural blood patch —
we recognize that some cases of DPE or CSE could potentially lead to a PDPH requiring a blood patch; however, if
we didn't include blood patch, we would miss too many cases, given the documentation issues I just mentioned.
We also have ICD-9 and ICD-10 codes for unintended dural puncture. There's going to be a poll on whether you
think administration of any of these medications would improve identifying unintended dural puncture. There is a
trade-off here, because these things may be given to patients who have a PDPH potentially just from an intended
dural puncture with a spinal needle. However, it might pick up more cases and would improve our sensitivity. The
options are caffeine in the forms you see here, Fioricet, and a sphenopalatine ganglion block. The poll is asking:
should caffeine be considered as part of the measure, should Fioricet be considered as part of the measure, and
should SPG be considered as part of the measure?
Brandon Togioka (via chat) [OHSU]: For the meeting notes: Ashraf Habib recommended looking at
dosages to parse out indication for new neuraxial block: labor vs. surgery.
Brendan Carvalho [Stanford]: While the poll's running, if I can make a comment — we are struggling at the
moment differentiating what you're discussing, which is unrecognized accidental wet tap, from blood patches.
There are many postdural puncture headaches that are either unrecognized wet taps or are just part of a normal
procedure like a spinal. I worry that when you start to blend a lot of different concepts, it starts to muddy the
water a little bit, and what you really want is separate measures for all of these. My other comment is I have some
concern with including versions, because your numerator-denominator becomes problematic, because sometimes
you use neuraxial for them, sometimes you don't. And while you're only considering the ones that use neuraxial, if
you're trying to work out how many versions we have and how many do we use neuraxial, I would struggle to get
that information at the moment.
Sharon Reale [Brigham & Women's]: We'll discuss the numerator and denominator on the next page, but those
are very good points. Here's the poll, and then, Brendan, let's go back to that. Interesting. Caffeine, mostly yes.
Fioricet, even more yes. And SPG blocks, yes as well. I agree — including all those things can kind of muddy the
picture, like you said, Brendan, but they do improve the potential sensitivity. Any other thoughts on that?
Carlos M Delgado Upegui (via chat) [University of Washington]: Sharon, are other peripartum
procedures: PPTL, lac repair, D&C included in the numerator?
Michael Furdyna (via chat) [Brigham & Women’s]: If you’re adding medications, should you specify that
the case must not have a spinal or CSE note?
Christine Warrick (via chat) [University of Utah]: What about cosyntropin?
Michael Furdyna (via chat) [Brigham & Women's]: Do any facilities still give cosyntropin?
Lawrence Tsen [Brigham & Women's]: The last guidelines from ASRA spoke against the use of sphenopalatine
ganglion blocks — and that was something that we contributed to as SOAP. Are we trying to promote, are we
trying to question the practice, or are we trying to just assess things?
Sharon Reale [Brigham & Women's]: More just to pick up cases of potential UDP that were treated with an SPG
block. The numerator is obviously the number of UDPs. The denominator — we had a lengthy discussion at the last
meeting — it is the total number of deliveries, which is a hospital-based metric and is per patient rather than per
procedure. Again, pros and cons of this, but it's kind of the consensus we came to at the last meeting. The
important thing is that these are 14-day obstetric encounters, so for patients who are here for delivery, it would be
14 days from the neuraxial placement for delivery. If they had an ECV, it would be 14 days after the ECV, and then
it would reset for whenever they came back for their delivery, if that was the case. The next slide shows some
initial performance data. The blues are the numerators for each individual site contributing data on this specific
topic. The orange, on a different scale on the right, are the denominators — the numbers of deliveries. You can see
a range here, but all mostly within that threshold range.
Brian Taussig (via chat) [NYU Langone]: I've seen OBs treat non-positional, non-PDPH headaches with
those medications, so I fear in trying to be overly sensitive we will capture a lot of false positives.
Michael Furdyna (via chat) [Brigham & Women’s]: So high blue, low orange is bad?
Brandon Togioka (via chat) [OHSU]: High blue bad, low orange means a low number of cases.
Michael Furdyna (via chat) [Brigham & Women’s]: Thanks!
Sharon Reale [Brigham & Women's]: Anyone have any other thoughts, or Brandon, any other comments on this?
Ashraf Habib [Duke University]: Sharon, a question. What was the rationale of using number of deliveries rather
than the number of neuraxial procedures performed at the site?
Sharon Reale [Brigham & Women's]: Brandon, do you want to talk about that? We talked about it a lot at the last
meeting.
Brandon Togioka [OHSU]: If we make the denominator the number of blocks, there is no possible way — let's say
you're causing an unintended dural puncture on 100% of your blocks, but the way we're capturing it, based on 14-
day encounters, because we're looking for procedural proxies within that 14-day period — the more blocks you do,
the lower the possible maximum percentage you could get, if that makes sense. Given we're looking at things that
occur afterwards, and the maximum numerator you can have is 1, we thought it's better to make it per labor.
Maybe it's not clear.
Kate Buehler [MPOG]: We can't attribute the unintended dural puncture to a specific neuraxial procedure,
especially when we're using those ICD-10 codes, because the ICD-10 codes are just on the encounter, and so we
don't know which neuraxial placement potentially resulted in the UDP. To just keep it generic — we said there
could be 3 neuraxial procedures, potentially, in this 14-day period. That's not common, but we only have one UDP.
We tried to keep it at the patient level, like, what would the patient be experiencing at the health system level.
This is a departmental measure — we're not assigning provider attribution, we're just keeping it departmental. I
think that was the discussion — how we landed at per delivery at the last meeting. I can disseminate those notes
again too.
Sharon Reale [Brigham & Women's]: Ashraf is saying — what if every single patient at Brigham and Women's
Hospital needed two placements? Then our rate would be half what it actually is. Right?
Ashraf Habib [Duke University]: Yes, because every neuraxial procedure carries the risk of unintentional dural
puncture. If you report on the denominator being the number of procedures performed, that gives you the rate of
unintentional dural puncture — how many of your neuraxial procedures resulted in a PDPH, as opposed to the
number of patients. Some patients might not have a neuraxial procedure at all, and some might have more than
one.
Brendan Carvalho [Stanford]: I agree with Ashraf, and I think if you have low epidural rates, then obviously
delivery rates would dilute down the effect. If you have 100% epidural rate versus 50%, you'll already change your
incidence data. I also think you are mixing definitions, because unintended dural puncture is essentially a
recognized complication, so this is PDPH plus recognized wet tap, plus those who get blood patches. I don't know
what the measure is actually measuring.
David Arnolds (via chat): Agree with Ashraf regarding the denominator.
Ashraf Habib [Duke University]: So it looks like it's measuring unintentional dural puncture and/or PDPH.
Brendan Carvalho [Stanford]: Correct. Which is fine, but I think it's important to acknowledge that.
Ashraf Habib [Duke University]: Agree.
Brandon Togioka [OHSU]: We would only have an encounter created if these patients had anesthesia. For the
most part, they are getting neuraxial blocks. In MPOG, we don't get data on a patient that comes in and delivers
without an anesthetic encounter. If they deliver with just nurse-administered fentanyl, they're not in the data. It's
not quite as bad of a mismatch, although I agree, if you had a patient who comes in for general anesthesia for
cesarean delivery, yes, they would be included and they would have had no opportunity for an unintended dural
puncture. But since the regional instance is so high, it's not quite as bad. I think we're just struggling — the reality
is that with these procedure notes, the capture of people documenting unintended dural punctures is not great,
and so we're trying to increase our capture. I think the rate is a bit higher than what most places are citing, and I
know, Brendan, you've seen the SOAP Center of Excellence data, but a lot of sites are quoting really, really low
incidences, which is probably very unlikely. It's a balance of trying to figure out better capture while having a less
precise measure, and I don't know where we sit.
Ashraf Habib [Duke University]: Basically, the number of deliveries is derived from MPOG data on patients who
have MPOG records, so basically those are the patients who will mostly have neuraxial, but some of them might
have a general. If a facility has a 60% epidural rate, you're not capturing any of the other 40%.
Brandon Togioka [OHSU]: Exactly.
Kate Buehler [MPOG]: I am a little nervous to modify the denominator to number of neuraxial procedures, just
based on the experience we have with trying to identify replacement catheters and that complicated logic. I don't
know that it's going to be pure or accurate, either way. It's kind of messy data, and so we can do our best. I do
think there's an opportunity at least to modify the words and verbiage in a measure spec, so we could at least
make this more clear that this is not just reporting on unintended dural puncture, because we're using PDPH as a
surrogate for potential UDP. We could be more explicit in the specification to say that's what we're looking for in
the logic here. Or we could remove some of that, but then — to Brandon's point — these are going to drop
dramatically, because the majority of these are coming through ICD-10 codes, so this will drop, and most folks will
be way below 1%. That's okay if we want to be purists, if we want to keep this pure as UDP. We can do anything —
we just need to know what is preferred, and ideally don't love changing it every meeting. Each time we modify it,
we're happy to modify it, but if we keep changing, we will never publish anything. I like to gain consensus, roll it
out, and then get some feedback at some point from the broader sites as they validate cases — to say this is totally
wrong, or this logic needs to be modified — but continuing to modify inclusion-exclusion criteria is problematic. I
saw somebody wants potentially to modify — we had those procedures included, by the way. We removed DNCs
and others after the last meeting, as guided by the subcommittee in February. We can add them back in. We
definitely can — we have that logic built. We just need to know and gain some consensus so that we can move
forward.
Michael Furdyna [Brigham & Women's]: One question — if you are adding all of these neuraxial procedures, are
you filtering for the number of unique patients? If one person has 3 different procedures, 3 different shots for a
wet tap, would they then count as 3 in the denominator, or would they just count as 1 woman potentially
affected?
Kate Buehler [MPOG]: Currently, right now, one woman. I think what Dr. Habib is recommending is potentially
moving to where that would count as 3, to be more reflective of their opportunities to experience UDP. That would
be the most pure way to report this.
Christine Warrick (via chat) [University of Utah]: Are spinals for cesareans being included in the
denominator as well?
Brandon Togioka (via chat) [OHSU]: Yes.
Brandon Togioka (via chat) [OHSU]: I agree it’s a limitation.
Christine Warrick (via chat) [University of Utah]: 👍 Reacted to “I agree it’s a limitation”
ABX-01-OB – Measure Update
Sharon Reale [Brigham & Women's]: I think in the interest of time, Brandon has an antibiotic measure review to
go over, with a poll about your thoughts on that, and then we want to talk about new measure development
priorities. Do you think, Brandon, it's a reasonable time to pivot?
2026-2027 Priorities Discussion
Brandon Togioka [OHSU]: Sure. We have 8 minutes. I don't think we're going to get through it. In the interest of
time, should we just go to a discussion of our priorities briefly, since this has a lot to do with priorities, and I think it
will generate some conversation, and then we can hold on the review. Is that okay with you, Dr. Alley?
Sharon Reale [Brigham & Women's]: Yeah, of course.
Brandon Togioka [OHSU]: Okay. I appreciate it — we love feedback and interaction. It's wonderful to have so
many brilliant minds in this meeting, so thank you all so much.
Sharon Reale [Brigham & Women's]: I have to say, I always thought it should be per neuraxial, but I thought it was
Brendan, Brendan Carvalho, who was a proponent of the per delivery at the last meeting. Maybe I'm incorrectly
attributing that, but there were a lot of proponents of that.
Brendan Carvalho [Stanford]: Now that you've clarified that it's per delivery and there's a procedure note, so you
have a better handle on that for ECVs and others, I'm okay with that. I agree some people have multiple
procedures, but that is the rarity, and it just adds variance, but I can live with that now that it's been explained.
Michael Furdyna (via chat) [Brigham & Women’s]: Perhaps a poll to decide whether per patient or per
procedure, and go from there?
Ashraf Habib [Duke University]: I can live with it too, given the explanation about where the delivery is coming
from. Every measure has limitations, but I'm happy. I'm sorry to raise the point this time, but I'm happy to live with
it.
Kate Buehler [MPOG]: We can modify again. It's not out there yet — it's still up for revision. It's good. I just have to
know what to revise.
Brandon Togioka [OHSU]: Why don't we send some follow-up polls to the group by email, that Sharon, Kate, and I
can look at. I think it is amazing to have all of you here, and there are so many brilliant minds here — I really
appreciate your feedback. Okay, let's finish up with talking about our priorities.
Christine Warrick (via chat) [University of Utah]: It's perfectly imperfect.
Brandon Togioka [OHSU]: It's perfectly imperfect, yeah. Potential priorities — one is ironing out the unintended
dural puncture measure, which we should keep pushing ahead because we're pretty close. After that, we're going
to ask people to prioritize these three potential actions. One would be — Dr. Reale was talking about creating a
new measure or including spinal after neuraxial placement in NCR01, so basically just focusing on including capture
of spinals would be one. Another option — and we can really only focus on one more thing right now — a large
proportion of the MPOG staff is out on maternity leave, so it's limited in terms of getting things done right now.
Another option is finalizing our pregnancy phenotype, which I know there was a lot of interest in for research
reasons. We have identified ICD-10 codes that can capture delivery gestational age within a one-week margin of
error. When I was looking through it for one of my studies, it looks to be captured with a fairly high proportion of
deliveries, so I think it would be fairly reliable. The third would be something we talked about last time — creating
a new measure. It's really a new PONV measure specific to OB, but because we had a difficult time differentiating
intraoperative prophylaxis versus postoperative, we would combine them. We can wordsmith the name of it.
Those were the three options, and we were hoping for a vote here.
Sharon Reale [Brigham & Women's]: Sorry to interrupt, Brandon. Given the discussion we had about the neuraxial
catheter placement, do you want people, instead of voting on spinal placement, to vote for whether they want to
separate replacement for labor versus replacement for C-section, or just keep it the way it is for ease?
Brandon Togioka [OHSU]: Yeah, sure, if Kate can — you have the polls already created, right? I don't know if you
can do that easily.
Sharon Reale [Brigham & Women's]: Just — I'd say everyone, instead of voting for whether you want to separate
spinal placement, based on our discussion, vote for where it says spinal placement. Instead, think in your head —
labor epidural versus cesarean delivery — whether something was replaced for labor versus cesarean delivery.
Does that make sense?
Kate Buehler [MPOG]: I'm just modifying the poll fast, sorry.
Sharon Reale [Brigham & Women's]: Oh, thank you.
Kate Buehler [MPOG]: Okay. Let me just save this fast, and then we can launch it, hopefully.
Sharon Reale [Brigham & Women's]: Hopefully we'll get to all of these, but in the near future, this is the priority.
We may not be able to see a clearly comprehensible answer, just given the ranked choice voting kind of thing, but
Kate will be able to calculate it on her end after the meeting.
Kate Buehler [MPOG]: We'll post to the forum what we think the follow-up is, at least for priorities.
Sharon Reale [Brigham & Women's]: Unless it's super skewed, we'll know.
Kate Buehler [MPOG]: Okay — looks like 14 people are still voting. Okay! So, it looks like the highest priority is the
new measure for labor epidural versus C-section for neuraxial replacement. Second would be the pregnancy
phenotype, and then the lowest priority is a new cesarean-specific measure for IONV and/or PONV.
Sharon Reale [Brigham & Women's]: Yeah, I think it was clear.
Lawrence Tsen (via chat) [Brigham & Women’s]: With the second measure, how was pregnancy
confirmed? HCG? There can be failures of this.
Christine Warrick (via chat) [University of Utah]: Is the goal for measuring spinal after neuraxial to have a
max threshold?
Michael Furdyna (via chat) [Brigham & Women’s]: I think it’s ICD code-based so we just have to assume
that someone confirmed pregnancy (HCG, US, wheat grass).
Kate Buehler [MPOG]: Yeah, great.
Brandon Togioka [OHSU]: All right, well that's our time. Thank you all so much, it's wonderful to have you here.
I'm going to quickly hit on some of these questions in the chat. From Lawrence: with the second measure, how was
pregnancy confirmed? Everything's confirmed kind of looking back, so it's basically time of delivery, and then we —
I think this is referring to pregnancy phenotypes — we would know when they deliver, and then based on
gestational age, we can map back if they were pregnant if they had a non-obstetric procedure before. And then
Christine — goal of measuring spinal after neuraxial: to have a max threshold. Once we create the measures, we
can all discuss if there should be a threshold for success. Sometimes it's strictly descriptive, and we could just
discuss what that number should be if we create the measure. Awesome. Thank you all so much, great to see you.
Lawrence Tsen [Brigham & Women's]: Great seeing everyone.
Sharon Reale [Brigham & Women's]: Have a great day.
Kate Buehler [MPOG]: Bye!
