Cesar Raudel Padilla

All Publications

• Critical Care in Placenta Accreta Spectrum Disorders-A Call to Action. American journal of perinatology Padilla, C. R., Shamshirsaz, A. A., Easter, S. R., Hess, P., Smith, C., El Sharawi, N., Sandlin, A. T. 2023; 40 (9): 988-995

  Abstract

  The rising in placenta accreta spectrum (PAS) incidence, highlights the need for critical care allotment for these patients. Due to risk for hemorrhage and possible hemorrhagic shock requiring blood product transfusion, hemodynamic instability and risk of end-organ damage, having an intensive care unit (ICU) with surgical expertise (surgical ICU or equivalent based on institutional resources) is highly recommended. Intensive care units physicians and nurses should be familiarized with intraoperative anesthetic and surgical techniques as well as obstetrics physiologic changes to provide postpartum management of PAS. Validated tools such of bedside point of care ultrasound and viscoelastic tests such as thromboelastogram/rotational thromboelastometry (TEG/ROTEM) are clinically useful in the assessment of hemodynamic status (shock diagnosis, assessment of both fluid responsiveness and tolerance) and transfusion guidance (in patients requiring massive transfusion as opposed to tranditional hemostatic resuscitation) respectively. The future of PAS management lies in the collaborative and multidisciplinary environment. We recommend that women with high suspicion or a confirmed PAS should have a preoperative plan in place and be managed in a tertiary center who is experienced in managing surgically complex cases. KEY POINTS: · The rising in placenta accreta spectrum incidence highlights the need for critical care expertise.. · Emerging tools such as point-of-care ultrasound and thromboelastography/rotational thromboelastometry represent new avenues for real time optimization of hemodynamic and hematological care of patients with PAS.. · Patients with PAS should be referred to a tertiary center having an intensive care unit (ICU) with surgical expertise (or equivalent based on institutional resources)..

  View details for DOI 10.1055/s-0043-1761638

  View details for PubMedID 37336216

• Causes of health inequities. Current opinion in anaesthesiology Lee, A., Padilla, C. 2022; 35 (3): 278-284

  Abstract

  PURPOSE OF REVIEW: A renewed focus on U.S. racial and ethnic maternal health disparities has arisen following high-profile incidents of police violence and antiracism protests which coincided with the coronavirus disease 2019 pandemic, which has exerted a disproportionate effect on minority communities. Understanding the causes of disparities is pivotal for developing solutions.RECENT FINDINGS: Social determinants of health must be addressed during clinical care; however, race must be used with caution in clinical decision-making. Medicaid expansion has been associated with a decrease in severe maternal morbidity and mortality, especially for racial and ethnic minority women. Indirect obstetric causes are the leading cause of maternal death.SUMMARY: Policy-level changes and investment in marginalized communities are required to improve access to quality maternity care at all stages, including preconception, interconception, prenatal, intrapartum and postpartum for 12 months after delivery. Improvements in hospital quality and implementation of evidence-based bundles of care are crucial. Clinicians should receive training regarding susceptibility to implicit bias. To support the research agenda, better collection of race and ethnicity data and anesthesia care indicators is a priority (see Video, Supplemental Digital Content 1 {Video abstract that provides an overview of the causes racial and ethnic disparities in maternal health outcomes.} http://links.lww.com/COAN/A85).

  View details for DOI 10.1097/ACO.0000000000001142

  View details for PubMedID 35671013

• Critical care in obstetrics. Best practice & research. Clinical anaesthesiology Padilla, C. R., Shamshirsaz, A. 2022; 36 (1): 209-225

  Abstract

  Leading causes of intensive care unit (ICU) admission include hemorrhage, hypertensive disorders of pregnancy, and sepsis. Although the incidence of ICU admission in pregnancy may be low, this does not account for critical illness in labor and delivery or maternity unit suites, which is as high as 1-3%. Most admissions, for example, to an ICU unit occur in the postpartum period, where studies have shown a range from 62 to 92% of admissions occurring during this period. A total of 60% of maternal deaths have been reported as preventable, with a delay in diagnosis and prompt medical treatment cited as primary factors, prompting for early recognition of high-risk obstetric patients. Recently, comorbidity-based screening tools, which quantify a patient's medical comorbidity burden, have been developed and validated in predicting ICU admission and death. Noninvasive ultrasonography such as point-of-care ultrasonography becomes essential in determining hemodynamic status, guides resuscitation, and manages cardiovascular dysfunction.

  View details for DOI 10.1016/j.bpa.2022.02.001

  View details for PubMedID 35659956

• Placenta Accreta Spectrum Disorders: Knowledge Gaps in Anesthesia Care. Anesthesia and analgesia Warrick, C. M., Markley, J. C., Farber, M. K., Balki, M., Katz, D., Hess, P. E., Padilla, C., Waters, J. H., Weiniger, C. F., Butwick, A. J. 1800

  Abstract

  Placenta accreta spectrum (PAS) disorder is a potentially life-threatening condition that can occur during pregnancy. PAS puts pregnant individuals at a very high risk of major blood loss, hysterectomy, and intensive care unit admission. These patients should receive care in a center with multidisciplinary experience and expertise in managing PAS disorder. Obstetric anesthesiologists play vital roles in the peripartum care of pregnant patients with suspected PAS. As well as providing high-quality anesthesia care, obstetric anesthesiologists coordinate peridelivery care, drive transfusion-related decision making, and oversee postpartum analgesia. However, there are a number of key knowledge gaps related to the anesthesia care of these patients. For example, limited data are available describing optimal anesthesia staffing models for scheduled and unscheduled delivery. Evidence and consensus are lacking on the ideal surgical location for delivery; primary mode of anesthesia for cesarean delivery; preoperative blood ordering; use of pharmacological adjuncts for hemorrhage management, such as tranexamic acid and fibrinogen concentrate; neuraxial blocks and abdominal wall blocks for postoperative analgesia; and the preferred location for postpartum care. It is also unclear how anesthesia-related decision making and interventions impact physical and mental health outcomes. High-quality international multicenter studies are needed to fill these knowledge gaps and advance the anesthesia care of patients with PAS.

  View details for DOI 10.1213/ANE.0000000000005862

  View details for PubMedID 35073282