Flinn, S, Herbert, K, Graham, K, and Siegler, JC. Differential effect of metabolic alkalosis and hypoxia on high-intensity cycling performance. J Strength Cond Res 28(10): 2852-2858, 2014-The purpose of this study was to investigate the effects of sodium bicarbonate (NaHCO 3 ) ingestion and acute hypoxic exposure on repeated bouts of high-intensity cycling to task failure. Twelve subjects completed 4 separate intermittent cycling bouts cycling bouts to task failure (120% peak power output for 30-second interspersed with 30-second active recovery) under the following conditions: normoxia (F I O 2 % at 20.93%) alkalosis (NA), normoxia placebo (NP), hypoxia (F I O 2 % at 14.7%) alkalosis (HA), and hypoxia placebo (HP). For the NA and HA trials, the buffer solution (0.3 g$kg 21 of NaHCO 3 ) was dispensed into gelatin capsules and consumed over 90 minutes with 1 L of water. Whole-blood acidbase findings demonstrated metabolic alkalosis in both NA and HA before exercise (HCO 3 2 : 32.8 6 1.8 mmol$L 21 ). Time to task failure was significantly impaired in the hypoxic conditions (NA: 199.1 6 62.3 seconds, NP: 183.8 6 45.0 seconds, HA: 127.8 6 27.9 seconds, HP: 133.3 6 28.7 seconds; p , 0.001; h 2 = 0.7). There was no difference between the HA and HP conditions (p = 0.41); however the 2 normoxic conditions approached significance with the NA condition on average resulting in approximately 15-second improvement in time to task failure (p = 0.09). These findings suggest that an acute decline in F I O 2 % consistent with hypoxic exposure is more inhibiting than metabolic acidosis during intermittent highintensity cycling to task failure. In application, the use of hypoxia and NaHCO 3 concurrently to improve performance under these conditions does not seem warranted. Figure 2. Time to task failure (s) for the 4 trial conditions (NA, NP, HA, and HP). Data are presented as mean 6 SD. *Significantly different from hypoxic conditions (p , 0.001). NA = normoxia alkalosis; NP = normoxia placebo; HA = hypoxia alkalosis; HP = hypoxia placebo.Figure 3. Individual performance data represented as responders, nonresponders, and negative responders. Journal of Strength and Conditioning Research the TM | www.nsca.com

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Objective This study compares the number of units of red blood cells (RBCs) transfused in patients with placenta accreta spectrum (PAS) treated with or without a multidisciplinary algorithm that includes placental uterine arterial embolization (P-UAE) and selective use of either immediate or delayed hysterectomy. Study design This is a retrospective study of deliveries conducted at a tertiary care hospital from 2001 to 2018 with pathology-confirmed PAS. Those with previable pregnancies or microinvasive histology were excluded. To improve the equity of comparison, analyses were made separately among scheduled and unscheduled cases, therefore patients were assigned to one of four cohorts as follows: (1) scheduled/per-algorithm, (2) scheduled/off-algorithm, (3) unscheduled/per-algorithm, or (4) unscheduled/off-algorithm. Primary outcomes included RBCs transfused and estimated blood loss (EBL). Secondary outcomes included perioperative complications and disposition. Results Overall, 95 patients were identified, with 87 patients meeting inclusion criteria: 36 treated per-algorithm (30 scheduled and 6 unscheduled) and 51 off-algorithm patients (24 scheduled and 27 unscheduled). Among scheduled deliveries, 9 (30.0%) patients treated per-algorithm received RBCs compared with 20 (83.3%) patients treated off-algorithm (p < 0.01), with a median (interquartile range [IQR]) of 3.0 (2.0, 4.0) and 6.0 (2.5, 7.5) units transfused (p = 0.13), respectively. Among unscheduled deliveries, 5 (83.3%) per-algorithm patients were transfused RBCs compared with 25 (92.6%) off-algorithm patients (p = 0.47) with a median (IQR) of 4.0 (2.0, 6.0) and 8.0 (3.0, 10.0) units transfused (p = 0.47), respectively. Perioperative complications were similar between cohorts. Conclusion A multidisciplinary algorithm including P-UAE and selective use of delayed hysterectomy is associated with a lower rate of blood transfusion in scheduled but not unscheduled cases. Key Points

Because technology for valvular replacement continues to evolve, we expect it to be further reaching in the applications for intermediate- to high-risk surgical candidates. Although the patient population for transcatheter aortic valve replacement has widened, it is still extremely rare in the pregnant patient. We report a case of a transcatheter valve-in-valve implantation in the second trimester of pregnancy. The patient experienced an excellent outcome after comprehensive coordination across multiple services. We discuss anesthetic considerations in the care of the pregnant patient for transcatheter aortic valve implantation.