Quoi de neuf en anesthsie obsttricale en 2014

Quoi de neuf en anesthésie obstétricale en 2014 -2015 ? Jean Guglielminotti Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, NY, USA Département d’Anesthésie-Réanimation, CHU Bichat-Claude Bernard, Paris, France IAME, UMR 1137, INSERM “Infection-Antimicrobials-Modeling-Evolution”, Paris, France

• Pas de conflit d’interet • Pas d’activité clinique depuis 18 mois……. .

• Analgésie du travail • Césarienne • Mortalité et morbidité maternelles • Perioperative /peridelivery medicine/physicians • Mortalité et morbidité maternelles associées a l’anesthésie • Profiling / Ranking

Analgésie du travail • Attentes maternelles et « mother-expressed outcomes » • Compétences • Casaques

Trends in perinatal health in France from 1995 to 2010. Results from the French National Perinatal Surveys. 1995 1996 2003 2010 Epidural/spinal 53. 8% 66. 5% 74. 9% 81. 4% General 5. 4% 2. 6% 1. 7% 1. 2% Other 2. 4% 1. 4% 0. 9% 1. 6% None 38. 4% 29. 5% 22. 5% 15. 7% Blondel B et al. J Gynecol Obs Biol Reprod 2012; 41: e 1 -e 15

“Trop” de péridurales ? ? Confidential Enquiries into Maternal Deaths and Morbidity 1 anesthesia-related death per 1, 000 maternities

“Trop” de péridurales ? Serious complications related to obstetric anesthesia: the serious complication repository project of the Society for Obstetric Anesthesia and Perinatology. - 30 academic centres 2004 -2009 - 256, 795 anesthetics in 307, 495 deliveries (83%) - Neuraxial techniques for vaginal deliveries 76. 0% - General anesthesia for cesarean deliveries 5. 6% D’Angelo R Anesthesiology 2014; 120: 1505 -12

Taux de péridurale ↓↓↓ Attentes maternelles « Mother-centered outcomes »

Women's experiences with neuraxial labor analgesia in the Listening to Mothers II Survey Attanasio L et al Anesth Analg In press

Defining competence in obstetric epidural anaesthesia for inexperienced trainees. Failure - Pain - Other form of analgesia/anesthesia - Complication - Work alone = 10 - 65% success rate = 50 - 80% success rate =75 Drake EJ et al Br J Anaesth 2015; 114: 951 -957

The effect of gowning on labor epidural catheter colonization rate Siddiqui NT Reg Anesth Pain Med 2014; 39: 520 -4

Césarienne • Ocytociques • Prédiction de l’hypotension

The ED 90 of prophylactic oxytocin infusion after delivery of the placenta during cesarean delivery in laboring compared with nonlaboring women - Nonlaboring 16 IU/h (95% CI: 13 -19) - Laboring 44 IU/h (95% CI: 34 -56) - Difference 28 IU/h (95% CI: 26 -29) Lavoie A et al. Anesth Analg. 2015; 121: 159 -64

Medecine personnalisee/stratifiee

A randomized, double-blinded trial of a “Rule of Threes” algorithm versus continuous infusion of oxytocin during elective cesarean delivery Kovacheva VP Anesthesiology In Press

Kovacheva VP Anesthesiology In Press

Hypotension et césarienne Quelle prophylaxie ? ↓↓↓ Quelles patientes ?

The predictive ability of non-invasive haemodynamic parameters for hypotension during caesarean section - Bupi HB 10 mg and 10 microg fentanyl - Postloading with 500 ml HES - Ephedrine when SBP below 80 mm Hg Limits: - Not current practice: Treatment on request with no prophylactic infusion of vasoactive drugs - Hypotension or no hypotension - Severity of hypotension and doses of vasoactive drugs required ? Yokose M et al. Anaesthesia 2015; 70: 555 -562

- Bupi HB 11 mg, 2. 5 microg sufentanyl and 200 microg morphine - Prophylactic IV infusion of ephedrine and phenylephrine for maternal SBP 80 -120% baseline - Rescue bolus of ephedrine or phenylephrine according to HR when SBP < 80% baseline R 2 = 26% Acute Preoperative Stress and Hypotension After Spinal Anesthesia. PHRC NI 09032

Mortalité et morbidité et maternelles • MBRACE-UK 2009 -2011 • Morbidité maternelle et poids des maladies chroniques • Hémorragie du postpartum • Pré eclampsie

Confidential Enquiries into Maternal Deaths and Morbidity Direct maternal mortality rate per 100, 000 maternities; UK: 1985– 2011 Indirect maternal mortality rates per 100, 000 maternities; UK: 1985– 2011 https: //www. npeu. ox. ac. uk/downloads/files/mbrrace-uk/reports/Saving%20 Lives%20 Improving%20 Mothers%20 Care%20 report%202014%20 Full. pdf The UK is the UK… Maternal mortality is increasing in the Netherlands and in the US !!!

Confidential Enquiries into Maternal Deaths and Morbidity 2009 -2012

Mortalité maternelle ↓↓↓ Morbidité maternelle sévère « Near-miss maternal morbidity»

Severe maternal morbidity in the United States 1998 -2011 http: //www. cdc. gov/reproductivehealth/Maternal. Infant. Health/Severe. Maternal. Morbidity. html

Temporal trends in anesthesia-related adverse events in cesarean deliveries, New York State, 2003– 2012 Guglielminotti J et al. Anesthesiology In Press

Maladies chroniques et morbidité maternelle Complications in cesarean deliveries SID • Acute myocardial infarction or ischemia, • Acute heart failure • Acute respiratory failure • Blood-clot pulmonary embolism or deep venous thrombosis • Disseminated intravascular coagulation • Acute renal failure • Sepsis or septic shock, • Stroke Guglielminotti J Personal data SID NY State

Comorbidités et grossesse 1995 1998 2003 2010 Age ≥ 40 ans 2. 3% 2. 7% 3. 5% IMC ≥ 30 kg/m² -- 6. 0% 7. 4% 9. 9% Blondel B et al. J Gynecol Obstet Biol Reprod 2012; 41: e 1 -e 15

Comorbidités et grossesse Chronic hypertension (NIS data) Pulmonary hypertension (NIS data) Bateman BT et al. Am J Obstet Gynecol 2012; 206: 134. e 1 -8. Guglielminotti et al. Personnal data

Anesthesiology In Press

Levels of maternal care ACOG 2015

Hémorragie du postpartum • Toujours d’actualité • Nouvelles RPC !!!! • Traitements pharmacologiques ? ?

Incidence, risk factors, and temporal trends in severe postpartum hemorrhage Severe: - Transfusion - Hysterectomy - Surgical repair of the uterus Kramer MS et al. Am J Obstet Gynecol. 2013; 209: 449. e 1 -7

http: //www. cngof. asso. fr/data/RCP/CNGOF_2014_HPP. pdf

Protocoles de service ( « Appropriation » ) Despite increasing emphasis on national quality improvement in patient safety, there are no PPH protocols in at least 20% of U. S. academic obstetric anesthesia units. Kacmar RM et al. Anesth Analg 2014; 119: 906 -10

Tranexamic acid for the prevention and treatment of postpartum haemorrhage • Nevertheless, the current level of evidence supporting its efficacy is insufficient, as are the data about its benefit: harm ratio. • Large, adequately powered multicentre RCTs are required before its widespread use for preventing and treating PPH can be recommended. Sentilhes L et al. Br J Anaesth 2015; 114: 576 -587

Pre-emptive treatment with fibrinogen concentrate for postpartum haemorrhage Inclusion: Severe PPH Treatment: Fibrinogen 2 gr single dose Outcome: RBC transfusion up to 6 weeks postpartum At inclusion : Blood loss 1459 ml and fibrinogen 4. 5 g/l Wikkelso AJ et al. Br J Anaesth 2015; 114: 623 -633

Pre-emptive treatment with fibrinogen concentrate for postpartum haemorrhage Wikkelso AJ et al. Br J Anaesth 2015; 114: 623 -633

Pré éclampsie • Critères diagnostiques ACOG 2013 • Ne pas attendre pour traiter et rester simple. . !!

Leffert LR Int J Obst Anesth 2015; 24: 264 -274 ACOG Task Force on Hypertension in Pregnancy Obstet Gynecol 2013; 122: 1122 -1131

Oral nifedipine or intravenous labetalol for hypertensive emergency in pregnancy Severe hypertension: SBP > 160 mm Hg or DBP > 110 mm Hg Titration: - Nifedipine 1 cp 10 mg per os toutes les 20 min (max 5 cp) - OR Labetalol IV 20, 40, 80, 80 mg toutes les 20 minutes (max 5 doses) Shekhar S et al. Obstet Gynecol 2013; 5: 1057 -1063

Mortalité et morbidité maternelles associées à l’anesthésie • MBRACE-UK • SCORE project • NIS • Profiling

Obstetric Anesthesia Safety/Quality/Performance Serious Death complications (1/1, 000) (1/3, 000) Complications (1/200) “Which cannot be measured, cannot be improved” Deming 44

Confidential Enquiries into Maternal Deaths and Morbidity 1 anesthesia-related death per 1, 000 maternities The UK is the UK…

Anesthesia-related deaths • 4 deaths directly related to anesthesia • 2 deaths resulting form prolonged hypoventilation associated with general anesthesia • One during anesthesia (possible bronchospasm) • One after anesthesia (delayed reintubation) • 2 late deaths related to postdural puncture • Cerebral vein thrombosis • Subdural hematoma • 2 deaths not directly related to anesthesia and asoicated with local anesthetic toxicity • One after an epidural top up • One after a wound infiltration at the end of a cesarean section

Serious complications related to obstetric anesthesia: the serious complication repository project of the Society for Obstetric Anesthesia and Perinatology. - 30 academic centres 2004 -2009 - 256, 795 anesthetics in 307, 495 deliveries (83%) - Neuraxial techniques for vaginal deliveries 76. 0% - General anesthesia for cesarean deliveries 5. 6% D’Angelo R Anesthesiology 2014; 120: 1505 -12

Serious complications related to obstetric anesthesia: the serious complication repository project of the Society for Obstetric Anesthesia and Perinatology. Serious complication : 157 or 5. 1 per 10, 000 deliveries Serious complications related to anesthesia : 85 or 3. 3 per 10, 000 deliveries

Monitoring obstetric anesthesia safety across hospitals through multilevel modeling La mortalité et la morbidité sévère ne sont plus des indicateurs adaptés pour décrire la qualité de l’anesthésie obstétricale Source Période Incidence NNT Mortalité MBRACE-UK 2009 -2012 1 pour 1 000 000 Complications sévères SCORE 2004 -2009 3. 3 pour 10 000 1 pour 3 000 Complications Administrative 2010 -2011 data NY State 4. 7 pour 1 000 1 pour 200 Guglielminotti J, Li G. Anesthesiology 2015; 122: 1268 -79

Obstetric Anesthesia Safety/Quality/Performance Serious Death complications (1/1, 000) (1/3, 000) Complications (1/200) “Which cannot be measured, cannot be improved” Deming 50

Administrative Data = Hospital Discharge Record Data • Cheap • Available • Hospital, State, or Nation Level Iezzoni LI Ann Intern Med 1997; 127: 666 -74

Temporal trends in anesthesia-related adverse events in cesarean deliveries, New York State, 2003– 2012 Minor ARAEs: - 23% Major ARAEs: - 43% ARAEs during general anesthesia: NS Guglielminotti J et al. Anesthesiology In Press

Données au niveau de chaque hôpital/médecin si on veut poursuivre l’amélioration de la qualité des soins en anesthésie Profiling/ranking

Between hospitals variation in outcomes HOSPITAL RANKING/PROFILING Dimick JB. Health Serv Res 2010; 45: 1614 -29

Complications de l’anesthésie Profiling et modèles multiniveaux Guglielminotti J, Li G. Anesthesiology 2015; 122: 1268 -79

“And those who look only to the past or the present are certain to miss the future” US President John F. Kennedy, Frankfurt, June 25, 1963

Patient controlled analgesia with remifentanil versus epidural analgesia in labour Freeman LM et al. BMJ 2015; 350: h 846

Freeman LM et al. BMJ 2015; 350: h 846

The epidemiology of postpartum hemorrhage in a large, nationwide sample of deliveries Bateman BT et al. Anesth Analg 2010; 110: 1368 -1373

Prevalence, trends, and outcomes of chronic hypertension: a nationwide sample of delivery admissions Chronic hypertension with comorbidities Bateman BT et al. Am J Obstet Gynecol 2012; 206: 134. e 1 -8.

MEDECINE PERIOPERATOIRE ( « PERIPARTUM » )

“And those who look only to the past or the present are certain to miss the future” JFK