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Anaesthetists working regularly on labour ward are likely to encounter obstetric patients with Chiari malformation with or without syringomyelia. The management of such patients has been variable in different institutions and advice on the safety of neuraxial procedures inconsistent. The most likely reason for management variations stems in the lack of any robust evidence in the literature and guidance based on individual perception of acceptable risk. The Obstetric Anaesthetists' Association (OAA) set up a multidisciplinary expert group of clinicians routinely involved in the management of obstetric patients with Chiari malformation and syringomyelia. The aim of the expert group was to conduct a literature review and critically evaluate the published evidence with the goal to reach a consensus on the appropriate management of obstetric patients with Chiari 1 malformation with or without syringomyelia receiving obstetric anaesthesia care. Recommendations and statements were graded as per the US Preventive Services Task Force methodology. A total of 1187 articles were identified in the initial literature search of which 49 were screened as relevant and used in the consensus statement document. A structured narrative review was undertaken which included antenatal care, mode of delivery, labour analgesia, anaesthesia for caesarean delivery and management of complications related to neuraxial techniques. The expert group agreed on eight recommendations and 10 statements which were assigned low or moderate level of certainty. We found almost no published evidence on the peripartum anaesthetic management of obstetric patients who experience significant or rare symptoms of Chiari malformation. Consequently, the expert group made recommendations and statements only considering patients who are on the less severe spectrum of symptoms of Chiari malformation and syringomyelia. With careful assessment and follow up most patients with stable or no symptoms can be managed within routine obstetric anaesthetic protocols.
Neuraxial anesthesia is preferred for cesarean deliveries, yet general anesthesia use remains notably high in certain locations. We aimed to quantify general anesthesia use for cesarean delivery and explore obstetric unit provider perspectives on contributing factors. We conducted a single-center explanatory sequential mixed-methods study at a quaternary referral academic center. Cesarean deliveries from July 1, 2023, to June 30, 2024, were identified from the institutional Multicenter Perioperative Outcomes Group (MPOG) database. Primary outcome was rate of general anesthesia, grouped by case-timing and emergency-status. Semi-structured interviews were conducted with anesthesiologists, obstetricians, and labor nurses (n = 23). The interviews were analyzed using the Knowledge-Attitudes-Practices framework. Among 1894 cesarean deliveries, 223 (11.8%) were performed under general anesthesia, which was more frequent after-hours (13.8% [142/1033] vs. 9.4% [81/861]) and in emergencies (13.9% [130/938] vs. 9.7% [93/956]). Providers preferred neuraxial anesthesia when feasible and viewed general anesthesia as rapid and reliable but associated with maternal airway risk, adverse patient experience, and neonatal risk. Reported drivers of general anesthesia included emergency workflow compression, after-hours resource limitations, inefficient team communication, absent or failed labor epidural analgesia, and pain during cesarean delivery. A functioning labor epidural catheter was considered protective. Efficient communication at both the system- and provider levels was the most frequently suggested improvement. General anesthesia was more frequent after-hours and in emergency cases. Mixed methods integrated analysis suggests that improving provider and system-level communication and clarifying decision-making roles may improve neuraxial feasibility under time-pressure and reduce avoidable general anesthesia.
Labor epidural analgesia may be inadequate during labor or for cesarean delivery anesthesia. No prediction model identifies cases of labor epidural analgesia with increased risk for epidural catheter replacement or conversion to spinal or general anesthesia. We conducted a retrospective cohort study of patients receiving labor epidural analgesia initiated with standard epidural or dural puncture epidural technique in a large, multihospital healthcare system between 2017 and 2024. Demographic, comorbidity, vital-sign, and procedural data were extracted from the electronic health record. The composite outcome was epidural catheter replacement, subsequent spinal anesthesia, or advanced airway placement indicating general anesthesia for cesarean delivery within the same anesthesia encounter. Statistical and machine-learning models were developed; one hospital was held out for external validation. The cohort included 82,823 cases of epidural catheter placement among 65,419 unique patients; 5010 cases (6.0%) met the composite outcome. Logistic regression and XGBoost performed similarly on external validation (area under the receiver operating characteristic curve, 0.67). Important predictors included prior replacement or conversion during the same encounter, end-of-pregnancy body mass index, pre-placement pain score, prior cesarean delivery, parity, and delivery hospital. Decision-curve analysis and Monte Carlo simulation suggested possible utility for screening and triage when anesthesia staffing is limited. We developed and externally validated Risk Estimation for Anesthesia Catheter Technique replacement or conversion in Obstetrics (REACT-OB) to estimate the risk of this outcome. Prospective validation is required before clinical use.
Practice variability in obstetric anesthesia remains common despite evidence-based recommendations, and standardizing care may be challenging in clinical practice settings. We hypothesized that a peer-led implementation process grounded in Society for Obstetric Anesthesia and Perinatology (SOAP) Centers of Excellence benchmarks recommendations, combining structured weekly meetings and a co-authored digital reference tool, could achieve clinically meaningful reductions in self-reported practice variability within a newly established obstetric anesthesia team. This prospective quality improvement project was conducted in a tertiary-care private hospital in Brazil between February and December 2025, with 21 anesthesiologists providing obstetric anesthesia care. This implementation project comprised five steps, including weekly peer-led meetings to build consensus on institutional practice and address components identified as having the highest pre-intervention variability. These were identified to be the spinal needle used for cesarean delivery, neuraxial labor analgesia technique and solutions, intrathecal adjuvants for cesarean delivery, and vasopressor strategy for spinal-induced hypotension. After selecting these four practices for the intervention, a digital pocket guide was developed. A 20-question survey collecting self-reported practice changes was distributed post-intervention, and the primary outcome was self-reported adoption of team-agreed clinical practices. The response rate to the survey was 76.2%. Complete adoption was reported for spinal needle selection, labor analgesia solution, and intrathecal adjuvants for cesarean delivery. Programmed intermittent epidural bolus analgesia use increased from 6.25% to 93.75%, and prophylactic norepinephrine infusion was adopted by 93.75%. Residual barriers included technical confidence, interprofessional resistance, and logistical difficulty. This quality improvement initiative achieved near-complete self-reported practice standardization within 10 months at minimal cost, offering a reproducible template for translating SOAP recommendations into institutional practice.
The development of a national plan for surgery, obstetrics, and anaesthesia remains a priority for Mali. Our objective was to assess the availability, accessibility, quality, and financing of surgical, obstetric, and anaesthesia care, to provide the scientific basis for developing a national plan. This was a cross-sectional, prospective study conducted from January to June 2023. All regions of Mali, including the district of Bamako, were included. In each region, at least one health district was randomly selected. We selected 25 centres, representing 38% of public facilities. The survey involved district hospitals, health workers and patients. The data were analysed using R software version 4.5.1. Each hospital of the district covered a health area with a population ranging from 7,913 to 818,436. The time to reach the nearest public facility offering safe surgical care was 2 hours for 50% of the population. The total capacity of the facilities was 1,343 beds, or an average of 34 beds per 100,000 inhabitants. All 25 referral health centres had at least one operating room. The basic trio (general surgeon, obstetrician-gynaecologist, anesthesiologist-resuscitator) was available in 14 centres (56%). The average number of annual surgical procedures was 135 per 100,000 inhabitants. Caesarean section, hernia repair, appendectomy, and laparotomy were performed in all centres. Open bone injuries were treated in six centres. Costs for the same procedures varied from one centre to another, and health insurance coverage rates ranged from 1% to 25%. In Mali, surgery is inaccessible to the majority of the population. Limitations include geographic distance, the availability of well-equipped operating rooms and specialists, and low health insurance coverage rates. L'élaboration d'un plan national de chirurgie, d'obstétrique et d'anesthésie reste une priorité pour le Mali. Notre objectif était d'évaluer la disponibilité, l'accessibilité, la qualité et le financement des soins chirurgicaux, obstétricaux et anesthésiques, afin de fournir les bases scientifiques pour l'élaboration d'un plan national. C'était une étude transversale, prospective faite de janvier à juin 2023. Toutes les régions du Mali et Bamako ont été incluses. Dans chaque région au moins un district sanitaire a été tiré au sort. Nous avons retenu 25 centres soit 38% des structures publiques. L'enquête a concerné les agents de santé et les patients. Les données ont été analysées sur le logiciel R version 4.5.1. Chaque centre de santé de référence (CSRef) couvrait une aire de santé dont la population variait entre 7913 habitants et 818436 habitants. La durée pour atteindre la structure publique la plus proche offrant les soins chirurgicaux sûrs était de 2 heures pour 50% de la population. La capacité d'accueil totale des structures était de 1343 lits, soit une moyenne de 34 lits pour 100 000 habitants. Tous les 25 centres de santé de référence disposaient d'au moins un bloc opératoire. Le trio de base (chirurgien généraliste, gynécologue-obstétricien, anesthésiste-réanimateur) était disponible dans 14 centres (56%). Le nombre moyen d'actes chirurgicaux annuels était de 135 pour 100 000 habitants. La césarienne, la cure de la hernie, l'appendicectomie et la laparotomie étaient réalisées dans tous les centres. Les fractures ouvertes étaient traitées dans six centres. Les coûts des mêmes actes étaient variables d'un centre à un autre et le taux de couverture d'assurance maladie était de 1 à 25%. Au Mali la chirurgie n'est pas accessible pour la majorité des populations. Les limites sont la distance géographique, la disponibilité de blocs opératoires bien équipés, de spécialistes et le faible taux de couverture d'assurance maladie.
The Gerard W. Ostheimer lecture is presented each year at the Society for Obstetric Anesthesia and Perinatology annual meeting and highlights new research relevant to the practice of obstetric anesthesiology. This focused review of the lecture summarizes 13 selected studies published in 2024, and discussed in the 2025 Ostheimer lecture, that are most likely to influence obstetric anesthesia practice. Key topics include cardiac arrest in pregnancy; pain during cesarean delivery; dural puncture epidural technique for labor analgesia; postdural puncture headache management; guidelines for continuous intrathecal labor analgesia following an unintentional dural puncture; intravenous calcium chloride, optimizing oxytocin dosing strategies, second-line uterotonic selection, and intravenous tranexamic acid for postpartum hemorrhage; video laryngoscopy for neonatal intubation; and reconsideration of anesthetic approaches for postpartum tubal ligation. The results of these studies offer practical findings that may help anesthesiologists deliver safer and more effective, patient-centered care.
Women with a history of surgical correction for adolescent idiopathic scoliosis are often denied neuraxial anesthesia during labor and delivery due to concerns of technical difficulties, anesthetic failures, inadvertent dural punctures, and hardware infections. We report four successful neuraxial procedures by four different anesthesiologists in three patients with previous posterior spinal instrumentation and fusion who delivered at our institution. The procedures include spinal anesthesia for cerclage, epidural analgesia for labor followed by successful conversion to epidural anesthesia for intrapartum cesarean delivery, spinal anesthesia for cesarean delivery, and epidural analgesia for vaginal delivery. Modern surgical techniques improve success rates of neuraxial anesthesia. Antenatal anesthesia consultation, knowledge of the lowest instrumented vertebra, familiarity with neuraxial ultrasound and multidisciplinary collaboration between orthopedic, obstetric, and anesthesiology teams are key. Anesthesiologists should offer and attempt neuraxial anesthesia if desired by these patients. Neuraxial anesthesia should not be withheld from them because they have spine instrumentation.
Currently, no universally accepted standard of care exists for anesthesia management during uterine evacuation procedures, and the comprehensive risk of aspiration under deep sedation without intubation remains unclear. The main concern regarding deep sedation without intubation is the risk of pulmonary aspiration due to inadequate airway protection, especially given the physiological changes associated with pregnancy. Although intubation can mitigate this risk, it introduces its own complications such as airway injury and hypoxemia. We conducted a systematic review following the PRISMA guidelines. Databases were searched from January 1, 2000 to April 13, 2026 to find eligible studies that evaluated patients undergoing uterine evacuation procedures under deep sedation without intubation and reported pulmonary aspiration risks. Six retrospective, cohort studies fit the inclusion criteria. Across these studies, a total of 81,120 patients underwent a uterine evacuation procedure under deep sedation without intubation. There were a total of two cases of pulmonary aspiration reported, only one of which was aspiration of gastric contents. The most common secondary anesthesia-related adverse event was conversion to intubation which occurred in five individuals. Risk of bias across studies was determined to be fair using the National Institute of Health Quality Evaluation Tool, and the certainty of evidence was rated very low using the GRADE tool. Deep sedation without intubation appears to be a safe approach for uterine evacuation procedures with pulmonary aspiration and other anesthesia-related adverse events reported rarely. Future prospective studies are required to identify patient-specific factors that serve as risk modifiers.
Mother-infant bonding is central to early infant development and maternal well-being. The mode of anesthesia for cesarean delivery may influence maternal recovery, early contact with the newborn, and the postpartum psychological experience. This study aimed to assess the association between mode of anesthesia for cesarean delivery and mother-infant bonding, and its relationship with risk of postpartum depression and early anxiety symptoms. In this cross-sectional study, women were recruited 1 to 3 days after cesarean delivery at Soroka University Medical Center. Eligible participants had delivered a live-born singleton term infant. During hospitalization, participants completed validated questionnaires assessing mother-infant bonding, risk for postpartum depression, and early postpartum anxiety symptoms. Outcomes were compared between women who underwent cesarean delivery under general anesthesia and those who received neuraxial anesthesia. Multivariable logistic regression was used to examine whether anesthesia mode was independently associated with impaired bonding. A total of 366 women were included, of whom 96 underwent cesarean delivery under general anesthesia and 270 under neuraxial anesthesia. No significant between-group differences were found in mother-infant bonding outcomes. The impaired-bonding difference was borderline but not statistically significant. Risk for postpartum depression and early postpartum anxiety symptoms was low and comparable between groups. After adjustment for potential confounders, anesthesia mode was not independently associated with impaired mother-infant bonding. In this cohort, anesthesia mode for cesarean delivery was not independently associated with impaired early mother-infant bonding. Risk for postpartum depression and early anxiety symptoms did not differ significantly between groups.
Maternal hypothermia frequently occurs after cesarean delivery under spinal anesthesia. We assessed whether active fluid warming would decrease the incidence of postoperative hypothermia as compared with no active warming in this context. In this randomized double-blind controlled trial, patients undergoing scheduled cesarean delivery with spinal anesthesia and intrathecal morphine were randomized to active intravenous fluid warming (intervention group, n = 35) or no active warming (control group, n = 35). Maternal temperature was continuously monitored with a zero-heat-flux sensor. Primary endpoint was the proportion of maternal hypothermia (temperature < 36 °C) upon post-anesthesia care unit arrival. Postoperative hypothermia occurred in 58.8% of the patients in the intervention group vs. 80.0% in the control group (RR = 0.74, 95% CI 0.53 to 1.02; P = 0.056). Mean maternal temperature upon post-anesthesia care unit arrival was significantly higher in the intervention group (35.8 °C ± 0.6 vs. 35.4 °C ± 0.6, respectively; P = 0.005). No significant differences were observed regarding shivering, thermal discomfort, or neonatal outcomes. Active fluid warming reduces the incidence of hypothermia after cesarean delivery, although the study was underpowered to detect a significant difference.
Game-based learning shows promise in health professions training, but guidance for large-group education is limited. We describe the design, implementation, and evaluation of a multi-station game-based workshop delivered during anesthesiology grand rounds. Four game-based stations were designed using constructive alignment. Seventy-two participants, including anesthesia residents and faculty, rotated through all four 15-min stations focusing on anesthesia in pregnancy, point-of-care ultrasound, thromboelastography, and crisis resource management. Each station included structured debriefing. A post-workshop survey assessed perceived engagement, knowledge reinforcement, and participant experience. Fifty-five participants completed the survey (76.4%). Median item scores ranged from 4 to 5, with agreement rates above 80% across items. Free-text comments emphasized enjoyment, and perceived knowledge reinforcement, while a minority noted concerns about learning depth. A game-based workshop was well-received for obstetric anesthesia education, with findings highlighting the importance of aligning game mechanics with learning objectives and protecting time for structured debriefing.
Postpartum tubal ligation procedures have high anesthetic failure rates. The objective of this study was to compare our institution's failure rates to previous studies. This retrospective single-center study analyzed patients undergoing tubal ligation after vaginal delivery from 2013 to 2023, comparing successful and failed neuraxial anesthetics. The primary outcome was the failed neuraxial anesthesia rate, defined as performance of a second neuraxial procedure, administration of moderate-to-deep sedation, or conversion to general anesthesia. Of 363 patients, there were 294 (81.0%) successful neuraxial anesthetics and 69 (19%) failures. Amongst successes, 39 (10.7%) were de novo spinal anesthetics, and 255 (70.3%) were labor epidural catheter reactivations. There were no statistical differences in failure rates between modes of anesthesia (18.3% with reactivation of in situ labor epidural catheter vs. 23.5% with de novo spinal anesthesia; P = 0.44). The most common clinical scenario for a neuraxial anesthetic to have qualified as a failure was administration of moderate-to-deep sedation in 41 of 69 cases of failure (59.4%), followed by neuraxial replacement in 20 cases (29.0%) The overall conversion rate to general anesthesia in this cohort was 2.8% (10/363). Neuraxial anesthesia failure rates were similar to previously described rates of failure, with no difference between spinal anesthetics and labor epidural catheter reactivations. Sedation administration was the most common reason for defining a failed neuraxial anesthetic in this cohort, with few conversions to general anesthesia overall. Standardized definitions of neuraxial anesthesia failure and intended vs. unintended sedation administration for postpartum tubal ligation are warranted to further report failure rates and characterize why failures occur.
While obstetric anesthesia for humans and domesticated species is well-described, "exotic" species present unique physiological and logistical challenges. Zoological veterinarians are faced with a lack of species-specific information, necessitating extrapolation of anesthetic knowledge and expertise from related species. The North Sulawesi babirusa (Babyrousa babyrussa celebensis) is a vulnerable tusked pig with limited existing literature regarding its anesthetic or surgical management. Here we describe the successful cesarean delivery of two babirusa piglets after signs of challenging labor. General anesthesia was induced via remote intramuscular injection (i.e. dart) and maintained with isoflurane via an endotracheal tube. Airway management is notably different and a challenge distinct from other animals, even other exotic animals like the giraffe. We compare the similarities and "peculiarities" of human vs. zoological obstetric anesthesia care, including the reliance on general anesthesia over neuraxial techniques. Despite the many anatomical differences between humans, babirusas, and other animals, the fundamental goals of maternal safety and smooth neonatal transition remain universal. While human anesthesiologists may appreciate the luxury of a cooperative patient and a controlled environment, the successful management of our friends across the animal kingdom is important and offers valuable insights into the range of obstetric anesthesia.
Inadvertent intrathecal administration of tranexamic acid can result in severe mortality and morbidity. Less is known about the consequences of inadvertent epidural administration of tranexamic acid in awake patients. Our patient inadvertendly received 810 mg (9 mL) of tranexamic acid instead of 1% lidocaine to lumbar epidural space, to provide analgesia for postpartum repair of perineal tears. No symptoms were experienced from the tranexamic acid dose, and anesthesia for the repair was provided with local administration of local anesthetics. The patient was monitored for four hours in the labor room without detectable neurologic symptoms, or changes in subjective well-being. She subsequently recovered from the delivery normally and experienced no symptoms within a four-week follow-up. Several system level risks contributed to medication error. Prevention of this type of medication error would require use of non-Luer connectors for neuraxial analgesia and use of pre-filled tranexamic acid syringes with Luer connectors.
This case report describes target-controlled propofol anesthesia using the Eleveld pharmacokinetic-pharmacodynamic model in a third-trimester pregnant woman with significant comorbidity undergoing elective non-obstetric surgery. A 31-year-old woman, 35 weeks pregnant with portal hypertension secondary to portal vein thrombosis after gastric bypass, underwent endoscopic esophageal variceal ligation under total intravenous anesthesia with remifentanil and propofol, guided by Bispectral Index monitoring. Propofol was administered via effect-site target-controlled infusion using the Eleveld model, with an initial stepwise increase in target concentration followed by adjustments guided by the Bispectral Index. All infusion and monitor data were recorded and compared with model-predicted values using a simulator. During induction, the observed Bispectral Index decreased more rapidly and profoundly than predicted, whereas during maintenance there was good agreement between observed and predicted values, with fluctuations of approximately 20%. The divergence observed during induction likely reflects the complex hemodynamic interaction between pregnancy and portal hypertension and remifentanil administration, where increased cardiac output and expanded blood volume alter the initial drug distribution, with a net effect of these competing physiological changes difficult to quantify. Clinically, anesthesia and recovery were uneventful, with timely emergence and tracheal extubation. This case suggests that the Eleveld model is feasible in this setting despite the presence of physiological confounders; nonetheless, continuous electroencephalogram-based titration is necessary to ensure safe anesthesia care.
Off-label intrathecal adjuvants such as α2-agonists and lipophilic opioids are often used to intensify and prolong neuraxial anesthesia during cesarean delivery. We aimed to assess its side effects, efficacy, and safety in cesarean delivery. This single-center retrospective cohort study was conducted at a university hospital in the Netherlands. Data from cesarean deliveries with spinal anesthesia, performed between July 1, 2011, and January 1, 2023, were extracted from electronic records. Cases were categorized according to spinal solution: hyperbaric bupivacaine without adjuvants, hyperbaric bupivacaine with lipophilic opioids, and hyperbaric bupivacaine with clonidine. The two primary outcomes were intraoperative and postoperative hypotension. Logistic regression and sensitivity analyses were performed to assess robustness. Secondary outcomes included conversion to general anesthesia, intravenous supplementation, neonatal Apgar scores, and maternal neurology consultation. There were 6,103 cesarean deliveries included in the analysis: 57.3% with bupivacaine only, 11.2% with bupivacaine and opioids, and 31.4% with bupivacaine with clonidine. Intraoperative hypotension was significantly more frequent with bupivacaine and clonidine compared with bupivacaine only (aOR 1.34 95% CI 1.15-1.57) and bupivacaine with opioids (aOR 0.93, 95% CI 0.74-1.18). Hypotension in the recovery room was most frequent with bupivacaine with clonidine (aOR 3.44 95% CI 2.89-4.10). Intravenous supplementation and conversion to general anesthesia were less frequent with addition of opioids or clonidine. There were no relevant differences in other secondary outcomes. Intrathecal clonidine increases the risk of intraoperative and postoperative hypotension despite the use of prophylactic vasopressors. It improves neuraxial block efficacy when added to hyperbaric bupivacaine alone, as reflected by lower rates of intravenous supplementation and conversion to general anesthesia, similar to lipophilic opioids. Its use should be limited to selected cases at risk of severe pain and where postoperative hypotension can be monitored and treated appropriately.
Recent Irish and European reports have highlighted variation in obstetric critical care, but patient-level data spanning a longer timeframe from tertiary centres remain limited. In particular, few data describe how admission incidence, case mix, organ support requirements, and temporal trends vary within an integrated tertiary maternity and critical care model. We aimed to describe obstetric critical care admissions over 11-years at an Irish tertiary referral centre. We performed a retrospective cohort study of all pregnant and postpartum women admitted to the critical care unit at the Galway University Hospital from 2013 to 2023. Eligible cases were identified from critical care admission records and reviewed using the Metavision clinical information system, supplemented by paper chart review where necessary. Extracted data included patient and obstetric characteristics, indication for admission, level of care, organ support, acute kidney injury, critical care length of stay, and maternal mortality. Admission incidence was calculated per 1000 maternal deliveries. Temporal trends were assessed using logistic or linear regression, as appropriate. There were 207 admissions, representing 6.7 per 1000 maternal deliveries. Sepsis (37.2%) and haemorrhage (28.0%) were the leading indications. A majority of women received level 2 care (76.5%), with respiratory support 55.0% of cases, vasopressor or inotropic support in 21.7% of cases, and renal replacement therapy 1.4% of cases. Mean length of stay in the critical care unit was 1.9 days. Vasopressor or inotropic use increased significantly over time (P = 0.025). Obstetric critical care admission was uncommon and usually involved short-duration level 2 care. Sepsis predominated over haemorrhage, contrasting with recent Irish transfer data. These findings support interpreting admission rates alongside local service configuration, escalation pathways, and organ support practice.
Chronic pain after cesarean delivery affects 17% of patients which can impact quality of life. Interventions to prevent acute to chronic pain transition are limited. The primary aim of this study was to assess feasibility of Empowered Relief, a 2-hour pain skills session delivered by an instructor in the outpatient setting. Patients were screened and approached at the 6-week postpartum clinic visit for pain severity and interference using qualitative questions and a 0-10 numeric rating scale. Those with moderate to severe pain (numeric rating scale ≥ 4/10) were consented and randomized to intervention (Empowered Relief) or standard follow up care. The primary outcome was feasibility of the intervention. Secondary outcomes were changes in pain interference, severity, and catastrophizing at 12 weeks postpartum. Data is presented as median values with interquartile ranges. Of the 48 patients that were assessed for pain severity between July and November 2025, 4 (8%) reported ≥ 4/10 pain and were eligible; 44 (92%) were ineligible. Of 4 eligible cases for the intervention, 3 declined participation due to time commitment; one consented however, did not attend the intervention session. The trial was terminated due to low eligibility rate and inability to conduct the intervention. Pain interference > 0/10 was reported by 59% of patients (24/41). Median pain severity was 0 [0,3] and pain interference was 1 [0,1.25]. In 88% of cases, reported pain scores to the research team were higher than those reported to the clinical team. Using pain severity (with a threshold of ≥ 4/10 on the numeric rating scale) in the 6-week postpartum follow-up clinic setting resulted in insufficient sample of eligible patients to evaluate the Empowered Relief intervention. Future studies should consider inclusion criteria based on any pain interference or severity.
There is a high risk of inadequate block with spinal anesthesia for postpartum tubal ligation that could be related to inadequate intrathecal dosing. This study aimed to investigate the association between intrathecal bupivacaine dose and inadequate blocks and to assess factors associated with inadequate blocks. Patients undergoing a postpartum tubal ligation between 2003 and 2025 with spinal anesthesia with hyperbaric bupivacaine were included in this retrospective cohort study. Cases were grouped according to bupivacaine dose as low (7.5-9.75 mg), middle (10.5-12 mg), and high (≥13.5 mg). The primary outcome was the occurrence of an inadequate block, defined as supplementation with intravenous analgesics, or failed block with repeat neuraxial anesthesia or conversion to general anesthesia. Data were analyzed using Kruskal-Wallis and Fisher's exact tests and multivariable logistic regression. An inadequate block occurred in 132/594 (22.2%) patients: 3/14 (21.4%, low dose), 95/336 (28.3%, middle dose), and 34/244 (13.9%, high dose). Inadequate blocks were less likely with ≥13.5 mg bupivacaine vs. 10.5-12 mg [OR 0.48, 95% CI (0.26 to 0.86); P = 0.015], and with more recent years since start of the study [0.95 (0.9 to 1); P = 0.029]. Longer surgical duration [(1.03 (1.01 to 1.04); P < 0.001] and higher intrathecal fentanyl dose [1.03 (1 to 1.05); P = 0.043] were associated with increased odds of inadequate block. Intrathecal hyperbaric bupivacaine at a dose ≥13.5 mg was associated with lower odds of inadequate anesthesia for postpartum tubal ligation compared with 10.5-12 mg in the context of an evolving institutional practice.