(Anesthesiology 2017;127:625–632)
Increased rate of cesarean delivery without measurable improvements in maternal or neonatal outcomes is a major public health problem. Breech presentation is a major contributor to the incidence of cesarean delivery and can be prevented by external cephalic version (ECV). Neuraxial blockade for ECV improves maternal satisfaction and procedural success and decreases maternal pain. Meta-analysis of randomized controlled trials suggests that administering higher doses of local anesthetic (LA) for neuraxial block leads to increased ECV success, although the protocol for providing neuraxial blockade for this procedure has not yet been standardized.
Background: Malignant peripheral nerve sheath tumor (MPNST) cells overexpress PDGF receptor-, which increases intracellular calcium when activated. Results: Calcium/calmodulin (CaM) is involved in sustained phosphorylation of Akt and promotion of cell survival in an MPNST cell line. Conclusion: MPNST cells evade normal cell death through CaM-dependent sustained activation of Akt. Significance: Activation of CaM by abnormally expressed growth factor receptors may contribute to NF1 tumor formation.
Background
Breech presentation is a leading cause of cesarean delivery. The use of neuraxial anesthesia increases the success rate of external cephalic version procedures for breech presentation and reduces cesarean delivery rates for fetal malpresentation. Meta-analysis suggests that higher-dose neuraxial techniques increase external cephalic version success to a greater extent than lower-dose techniques, but no randomized study has evaluated the dose–response effect. We hypothesized that increasing the intrathecal bupivacaine dose would be associated with increased external cephalic version success.
Methods
We conducted a randomized, double-blind trial to assess the effect of four intrathecal bupivacaine doses (2.5, 5.0, 7.5, 10.0 mg) combined with fentanyl 15 μg on the success rate of external cephalic version for breech presentation. Secondary outcomes included mode of delivery, indication for cesarean delivery, and length of stay.
Results
A total of 240 subjects were enrolled, and 239 received the intervention. External cephalic version was successful in 123 (51.5%) of 239 patients. Compared with bupivacaine 2.5 mg, the odds (99% CI) for a successful version were 1.0 (0.4 to 2.6), 1.0 (0.4 to 2.7), and 0.9 (0.4 to 2.4) for bupivacaine 5.0, 7.5, and 10.0 mg, respectively (P = 0.99). There were no differences in the cesarean delivery rate (P = 0.76) or indication for cesarean delivery (P = 0.82). Time to discharge was increased 60 min (16 to 116 min) with bupivacaine 7.5 mg or higher as compared with 2.5 mg (P = 0.004).
Conclusions
A dose of intrathecal bupivacaine greater than 2.5 mg does not lead to an additional increase in external cephalic procedural success or a reduction in cesarean delivery.
(Anesth Analg. 2019;128:999–1004)
The apprenticeship model is still the most common method for residents to learn the technical skill of placing a spinal-epidural catheter. However, this method has its drawbacks, as on average it takes 45 to 60 attempts for a student to achieve a 90% success rate. While other methods have also been explored to teach this skill, such as watching videos of the procedure before attempting it, this study proposed that E-learning is a valid method to enhance anesthesiology education.
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