Gillian Abir

All Publications

• Virtual simulation training for postpartum hemorrhage in low-to-moderate-volume hospitals in the US AJOG Global Reports Minor, K., Bianco, K., Mayo, J., Abir, G., Judy, A., Lee, H., Leonard, S., Ayotte, S., Hedli, L., Schaffler, K., Sie, L., Daniels, K. 2024
• Obstetric anesthesiology education and training in the modern era. International journal of obstetric anesthesia Abir, G. 2023; 55: 103898

  View details for DOI 10.1016/j.ijoa.2023.103898

  View details for PubMedID 37285723

• Cesarean delivery under neuraxial anesthesia in a patient with a liver transplant SRPSKI ARHIV ZA CELOKUPNO LEKARSTVO Krusic, S., Pejcic, N., Stojanovic-Tasic, M., Damnjanovic, D., Abir, G. 2023; 151 (5-6): 367-370

  View details for DOI 10.2298/SARH221108056K

  View details for Web of Science ID 001045268200017

• Automated Alert System of Second-Line Uterotonic Drug Administration. A&A practice Abir, G., Riley, E. T., Oakeson, A. M., Judy, A., Wang, E., Carvalho, B. 2023; 17 (5): e01687

  Abstract

  Multidisciplinary team management of postpartum hemorrhage (PPH) is needed to optimize care and improve outcomes. Lucile Packard Children's Hospital, Stanford, is a tertiary referral center with 4600 deliveries/y (>70% high-risk deliveries), and there have been times when the obstetric anesthesia team was alerted late or not at all for PPHs. Introduction of an automated alert process to the obstetric anesthesia team when a second-line uterotonic drug was administered has ensured prompt evaluation. Utilization of this automated drug alert system has improved communication and reduced failure to inform the obstetric anesthesiology team of PPH after vaginal and cesarean deliveries.

  View details for DOI 10.1213/XAA.0000000000001687

  View details for PubMedID 37222414

• Virtual Compared to In-Person Obstetric Anesthesiology Trainee Education During the COVID-19 Pandemic: A Short Report. Cureus Fedoruk, K., Abir, G., Carvalho, B. 2022; 14 (6): e26423

  Abstract

  BACKGROUND: The COVID-19 pandemic brought many changes to medical training, including in-person education platforms being disbanded and replaced with virtual education. At our institution, dedicated obstetric anesthesiology teaching for residents and fellows occurs daily and is highly valued and rated. In March 2020 due to the COVID-19 pandemic, we changed the teaching platform from in-person to virtual teaching (via video communication). We subsequently surveyed residents, fellows, and attendings to determine the impact of virtual compared with in-person teaching.METHODS: To assess the impact of this change, an electronic survey was sent to 10 anesthesiology residents on their 2nd obstetric anesthesiology rotation, and 10 residents on their 1st rotation, respectively. The electronic survey was also sent to three fellows and eight obstetric anesthesiology attendings. Answers were based on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree).RESULTS: The results for 1st rotation residents were higher in all domains compared with 2nd rotation residents and fellows, where "quality" achieved statistical significance (p=0.009) between 1st and 2nd rotation residents. "Engagement" was overall the most impacted domain for trainees. Attendings did not feel that virtual teaching impacted their ability to provide adequate education, however, learner engagement was again the lowest rated domain, and teachers strongly favored resuming in-person teaching.CONCLUSIONS: Virtual teaching is an appropriate alternative when in-person teaching is not possible. Future initiatives are needed to improve engagement and better facilitate virtual teaching.

  View details for DOI 10.7759/cureus.26423

  View details for PubMedID 35915679

• Storage of emergency airway equipment on labor and delivery units. Journal of clinical anesthesia Riley, E. T., Carvalho, B., Abir, G. 2022; 80: 110886

  View details for DOI 10.1016/j.jclinane.2022.110886

  View details for PubMedID 35623264

• Accuracy of visual estimation of blood loss in obstetrics using clinical reconstructions: an observational simulation cohort study. International journal of obstetric anesthesia Athar, M. W., Abir, G., Seay, R. C., Guo, N., Butwick, A., Carvalho, B. 2022; 50: 103539

  Abstract

  INTRODUCTION: Postpartum hemorrhage is the leading cause of maternal mortality worldwide, and optimal management requires accurate blood loss estimations. The aim of this study was to assess whether differences exist between visually estimated blood loss versus actual blood loss based on delivery mode, blood volume or distribution/location and knowledge of patient's current cardiovascular status.METHODS: For this observational cohort study, photographs were taken of 18 blood loss scenarios for vaginal delivery and cesarean delivery, and six photographs were duplicated and annotated with maternal vital signs. Scenarios were categorized into 50% (500 mL), 100% (1000 mL) and 200% (2000 mL) of the defined blood loss volume for postpartum hemorrhage and the photographs were shown to participants to visually estimate blood loss volumes.RESULTS: The mean ± standard deviation estimates of actual 500 mL, 1000 mL and 2000 mL blood loss volumes were 1208 ± 438 mL, 1676 ± 630 mL and 2637 ± 1123 mL, respectively (P <0.001 among groups). The difference was significantly greater in vaginal delivery than cesarean delivery scenarios (1064 ± 849 mL vs. 284 ± 456 mL; P <0.001). Estimated blood loss volume was not influenced by blood loss distribution/location, or by provider group or experience. The cardiovascular status of the patient impacted estimations only if tachycardia and hypotension were present.CONCLUSIONS: Most providers significantly overestimated blood loss volumes (by nearly 700 mL). Provider and scenario factors that impact inaccuracies in visual estimated blood loss identified in this study can be used to guide education and training.

  View details for DOI 10.1016/j.ijoa.2022.103539

  View details for PubMedID 35397264

• Chapter 73: Anesthetic Management of Pregnant Patients with Novel Coronavirus Quick Hits in Obstetric Anaesthesia Sheikh, M., Abir, G., Sultan, P. Springer. 2022; 1st
• Emergency Resources in Obstetrics. Anesthesiology clinics Seligman, K. M., Abir, G. 2021; 39 (4): 631-647

  Abstract

  Utilization of emergency resources in obstetrics can help to optimize health care providers' care to pregnant and postpartum patients. There is a vast array of resources with various accessibility modalities that can be used before, during, and/or after an obstetric emergency. These resources can also be included as teaching material to increase knowledge and awareness with the aim to reduce maternal morbidity and mortality and improve patient outcomes.

  View details for DOI 10.1016/j.anclin.2021.08.004

  View details for PubMedID 34776101

• Maternal sepsis update. Current opinion in anaesthesiology Abir, G., Bauer, M. E. 2021; 34 (3): 254-259

  Abstract

  Maternal sepsis is the second leading cause of maternal death in the United States. A significant number of these deaths are preventable and the purpose of this review is to highlight causes such as delays in recognition and early treatment.Maternal sepsis can be difficult to diagnose due to significant overlap of symptoms and signs of normal physiological changes of pregnancy, and current screening tools perform poorly to identify sepsis in pregnant women. Surveillance should not only include during pregnancy, but also throughout the postpartum period, up to 42 days postpartum. Education and awareness to highlight this importance are not only vital for obstetric healthcare provides, but also for nonobstetric healthcare providers, patients, and support persons.Through education and continual review and analysis of evidence-based practice, a reduction in maternal morbidity and mortality secondary to maternal sepsis should be attainable with dedication from all disciplines that care for obstetric and postpartum patients. Education and vigilance also extend to patients and support persons who should be empowered to escalate care when needed.

  View details for DOI 10.1097/ACO.0000000000000997

  View details for PubMedID 33927129

• An observational pilot study of a novel loss of resistance syringe for locating the epidural space. International journal of obstetric anesthesia Athar, M. W., Guo, N., Ortner, C., Carvalho, B., Abir, G., Riley, E. T. 2021: 102984

  Abstract

  BACKGROUND: The EpiFaith syringe is a novel loss-of-resistance syringe that utilizes a spring-loaded plunger that automatically moves forward within the syringe when there is a loss of resistance. We evaluated the syringe in a clinical setting, among a cohort of pregnant women receiving neuraxial labor analgesia.METHODS: In a non-randomized, observational study, four anesthesiologists used the EpiFaith syringe 10 times each while placing epidural catheters for labor analgesia. The anesthesiologists scored each placement on an 11-point Likert scale (-5 = absolutely worse, 0 = the same, and 5 = absolutely better than using their regular loss-of-resistance syringe technique).RESULTS: All 40 neuraxial placements correctly located the epidural space. Air was used in the syringe in 35 of the 40 cases. In 50%, 27.5% and 22.5% of cases the anesthesiologists reported that using the EpiFaith syringe was better than, the same as, or worse than using their regular syringe, respectively. There were no inadvertent dural punctures.CONCLUSIONS: This feasibility study found that three of the four anesthesiologists scored the EpiFaith syringe as better or the same as using their regular loss-of-resistance syringe. More extensive studies are required to determine if the EpiFaith syringe reduces adverse outcomes such as unintentional dural punctures.

  View details for DOI 10.1016/j.ijoa.2021.102984

  View details for PubMedID 33994273

• A strategy for disaster preparedness in obstetrics. American journal of disaster medicine Daniels, K., Monga, M., Gupta, S., Abir, G., Chanisse, M., Newton, C. 2021; 16 (3): 207-213

  Abstract

  Many hospital units, including obstetric (OB) units, were unprepared when the novel coronavirus began sweeping through communities. National and international bodies, including the World Health Organization, Centers for Disease Control Prevention, and the American College of Obstetricians and Gynecologists, directed enormous efforts to present the latest evidence-based practices to healthcare institutions and communities. The first hospitals that were affected in China and the United States (US) did heroic work in assisting their colleagues with best practices they had acquired. Despite these resources, many US hospitals struggled with how to best incorporate and implement this new information into disaster plans, and many protocol changes had to be established de novo. In general, disaster planning for OB units lagged behind other disaster planning performed by specialties such as emergency medicine, trauma, and pediatrics.Fortunately, two pre-existing collaborative disaster groups, the OB Disaster Planning Workgroup and the Western Regional Alliance for Pediatric Emergency Management, were able to rapidly deploy during the pandemic due to their pre-established networks and shared goals.These groups were able to share best practices, identify and address knowledge gaps, and disseminate information on a broad scale. The case will be made that the OB community needs to establish more such regional and national disaster committees that meet year-round. This will ensure that in times of urgency, these groups can increase the cadence of their meetings, and thus rapidly disperse time-sensitive policies and procedures for OB units nationwide.Given the unique patient population, it is imperative that OB units establish regional coalitions to facilitate a coordinated response to local and national disasters.

  View details for DOI 10.5055/ajdm.2021.0403

  View details for PubMedID 34904705

• Chapter 37: Maternal Critical Care in a Disaster. Principles and Practice of Maternal Critical Care Abir, G., Daniels, K. Springer. 2020; 1st
• Chapter 114: Emergency Aids for Obstetric Crises in Anesthesiology Manual of Clinical Anesthesiology Abir, G., Seligman, K., Chu, L. F. Wolters Kluwer. 2020; 2nd
• Cognitive Aids in Obstetric Units: Design, Implementation, and Use. Anesthesia and analgesia Abir, G. n., Austin, N. n., Seligman, K. M., Burian, B. K., Goldhaber-Fiebert, S. N. 2019

  Abstract

  Obstetrics has unique considerations for high stakes and dynamic clinical care of ≥2 patients. Obstetric crisis situations require efficient and coordinated responses from the entire multidisciplinary team. Actions that teams perform, or omit, can strongly impact peripartum and perinatal outcomes. Cognitive aids are tools that aim to improve patient safety, efficiency in health care management, and patient outcomes. However, they are intended to be combined with clinician judgment and training, not as absolute or exhaustive standards of care for patient management. There is simulation-based evidence showing efficacy of cognitive aids for enhancing appropriate team management during crises, especially with a reader role, with growing literature supporting use in obstetric and nonobstetric clinical settings when combined with local customization and implementation efforts. The purpose of this article is to summarize current understanding and available resources for cognitive aid design, implementation, and use in obstetrics and to highlight existing gaps that can stimulate further enhancement in this field.

  View details for DOI 10.1213/ANE.0000000000004354

  View details for PubMedID 31425259

• Obstetric Anesthesia Emergency Manual Abir, G., Seligman, K., Chu, L. Stanford Anesthesia Informatics and Media (AIM) Lab. 2019
• Anesthesia for non-delivery obstetric procedures Abir, G., Carvalho, B. UpToDate. 2019
• Preoperative anterior thigh temperature does not correlate with perioperative temporal hypothermia during cesarean delivery with spinal anesthesia: Secondary analysis of a randomized control trial. International journal of obstetric anesthesia Cobb, B. n., Abir, G. n., Carvalho, B. n. 2018; 33: 40–45

  Abstract

  Core-to-peripheral redistribution of heat, secondary to sympathetic-mediated vasodilation, is the major mechanism leading to early perioperative hypothermia after neuraxial anesthesia. The study aim was to determine if preoperative anterior thigh (peripheral lower extremity) temperature predicted perioperative temporal (core) temperature decrease during cesarean delivery with spinal anesthesia.Secondary analysis of data derived from a prospective, randomized study of 46 healthy women undergoing scheduled cesarean delivery with spinal anesthesia was performed. Anterior thigh temperature was measured preoperatively prior to spinal anesthesia. The primary outcome was maximum perioperative temporal temperature decrease. Secondary outcomes included incidence of temporal hypothermia (temperature <36°C), shivering, and thermal comfort scores. This study ran concurrently with a previously published trial comparing no active intraoperative warming with active warming.There was no correlation between preoperative anterior thigh temperature and maximum perioperative temporal temperature decrease (r=-0.049, P=0.751). The mean±standard deviation preoperative anterior thigh temperature of women who developed temporal hypothermia compared to those who did not was 32.4±0.8°C versus 32.4±0.70°C respectively (P=0.995). Preoperative anterior thigh temperature did not correlate with the incidence of shivering (r=0.267, P=0.080) or thermal comfort scores (r=0.233, P=0.129).Preoperative anterior thigh temperature does not correlate with the degree of perioperative temporal temperature decrease, likelihood of developing hypothermia, shivering, or thermal comfort during cesarean delivery with spinal anesthesia. Although core-to-peripheral redistribution of heat after neuraxial anesthesia is a major mechanism of perioperative heat loss, a lower extremity temperature prediction hypothesis was not confirmed in this population.

  View details for PubMedID 29017742

• Chapter 4: Simulation-based Training AWHONN’s High-Risk and Critical Care Obstetrics Arafeh, J., Abir, G. Wolters Kluwer. 2018; 4th
• Chapter 25: Cardiopulmonary Resuscitation in Pregnancy AWHONN’S High-Risk and Critical Care Obstetrics Arafeh, J., Abir, G. Wolters Kluwer. 2018; 4th
• Maternal mortality and the role of the obstetric anesthesiologist. Best practice & research. Clinical anaesthesiology Abir, G., Mhyre, J. 2017; 31 (1): 91-105

  Abstract

  Maternal mortality is increasing in the United States and remains unacceptably high in many parts of the world. Pre-existing conditions and social determinants of health frequently contribute to maternal death. General solutions to enhance maternal safety focus on systems to identify women at high risk and to tailor the management before, during, and after pregnancy. This review highlights condition-specific solutions for the leading etiologies of maternal death, including cardiac disease, sepsis, hemorrhage, venous thromboembolism, hypertensive disorders of pregnancy, and amniotic fluid embolism. Although anesthesia is an exceedingly rare cause of maternal death, specific hazards remain, including airway management, high neuraxial block, and unintentional dural puncture. The review concludes with an overview of strategies to create an institutional culture of both safety and equity, including multidisciplinary team training, simulation, shared decision-making, family-centered care, and serious morbidity review.

  View details for DOI 10.1016/j.bpa.2017.01.005

  View details for PubMedID 28625309

• Clinical and microbiological features of maternal sepsis: a retrospective study INTERNATIONAL JOURNAL OF OBSTETRIC ANESTHESIA Abir, G., Akdagli, S., Butwick, A., Carvalho, B. 2017; 29: 26-33

  Abstract

  Identifying pregnant women with sepsis is challenging because diagnostic clinical and laboratory criteria overlap with normal pregnant physiologic indices. Our primary study aim was to describe clinical and laboratory characteristics of women diagnosed with sepsis, severe sepsis and septic shock. Our secondary aim was to determine positive predictive values for International Classification of Disease (ICD)-9 billing codes for sepsis, severe sepsis, and septic shock.After gaining Institutional Review Board approval, we identified women with ICD-9 codes for sepsis, severe sepsis and septic shock who were admitted to a single tertiary obstetric center from 2007-2013. Diagnoses were confirmed using criteria from the International Sepsis Definitions Conference report. Demographic, obstetric, vital signs and laboratory data were abstracted by medical chart review.We identified 190 women with sepsis-related ICD-9 codes: of these, 35 (18%) women met the criteria for a clinical diagnosis of sepsis, severe sepsis or septic shock. Twenty (57%) women had a sepsis-related diagnosis after cesarean delivery. Twenty-one (60%) women had one or more pre-existing medical conditions and 19 (54%) women had one or more obstetric-related conditions. The genital tract was the most common site of infection. We observed considerable heterogeneity in maternal vital signs and laboratory indices for women with ICD-9 codes for sepsis, severe sepsis, and septic shock. The positive predictive value for each sepsis-related ICD-9 code was low: 16% (95% CI 10 to 24%) for sepsis, 10% (95% CI 3 to 25%) for severe sepsis and 24% (95% CI 10 to 46%) for septic shock.We identified marked heterogeneity in patient characteristics, clinical features, laboratory indices and microbiological findings among cohorts of women diagnosed with maternal sepsis, severe sepsis or septic shock. Based on our findings, the incidence of maternal sepsis using ICD-9 codes may be significantly overestimated.

  View details for DOI 10.1016/j.ijoa.2016.09.003

  View details for Web of Science ID 000394917700006

• Postpartum tubal ligation: A retrospective review of anesthetic management at a single institution and a practice survey of academic institutions. Journal of clinical anesthesia McKenzie, C. n., Akdagli, S. n., Abir, G. n., Carvalho, B. n. 2017; 43: 39–46

  Abstract

  The primary aim was to evaluate institutional anesthetic techniques utilized for postpartum tubal ligation (PPTL). Secondarily, academic institutions were surveyed on their clinical practice for PPTL.An institutional-specific retrospective review of patients with ICD-9 procedure codes for PPTL over a 2-year period was conducted. Obstetric anesthesia fellowship directors were surveyed on anesthetic management of PPTL.Labor and delivery unit. Internet survey.202 PPTL procedures were reviewed. 47 institutions were surveyed; 26 responses were received.Timing of PPTL, anesthetic management, postoperative pain and length of stay.There was an epidural catheter reactivation failure rate of 26% (18/69 epidural catheter reactivation attempts). Time from epidural catheter insertion to PPTL was a significant factor associated with failure: median [IQR; range] time for successful versus failed epidural catheter reactivation was 17h [10-25; 3-55] and 28h [14-33; 5-42], respectively (P=0.028). Epidural catheter reactivation failure led to significantly longer times to provide surgical anesthesia than successful epidural catheter reactivation or primary spinal technique: median [IQR] 41min [33-54] versus 15min [12-21] and 19min [15-24], respectively (P<0.0001). Fifty-eight percent (15/26) of respondents routinely leave the labor epidural catheter in-situ if PPTL is planned. Sixty-five percent (17/26) and 7% (2/26) would not attempt to reactivate the epidural catheter for PPTL if >8h and >24h post-delivery, respectively.Epidural catheter reactivation failure increases with longer intervals between catheter placement and PPTL. Failed epidural catheter reactivation increases anesthetic and operating room times. Our results and the significant variability in practice from our survey suggest recommendations on the timing and anesthetic management are needed to reduce unfulfilled PPTL procedures.

  View details for PubMedID 28985581

• Active Warming Utilizing Combined IV Fluid and Forced-Air Warming Decreases Hypothermia and Improves Maternal Comfort During Cesarean Delivery: A Randomized Control Trial ANESTHESIA AND ANALGESIA Cobb, B., Cho, Y., Hilton, G., Ting, V., Carvalho, B. 2016; 122 (5): 1490-1497

  Abstract

  The aim of this study was to apply both IV fluid and forced-air warming to decrease perioperative hypothermia in women undergoing cesarean delivery with spinal anesthesia. The authors hypothesize that combined-modality active warming (AW) would increase maternal temperature on arrival at the postanesthesia care unit (PACU) and decrease the incidence of maternal perioperative hypothermia (<36°C) compared with no AW.Forty-six healthy women (n = 23 per group) undergoing scheduled cesarean delivery with spinal anesthesia (10-12 mg bupivacaine + 10 μg fentanyl) were enrolled in this double-blinded, randomized controlled trial. Women were randomly assigned to receive either AW (warmed IV fluid and lower body forced-air warmer) or no warming (NW; blankets only). SpotOn Monitoring System was used to measure core temperature intraoperatively and for 1 hour postoperatively. The primary outcome measure was maternal temperature on arrival at the PACU. Secondary outcome measures included incidence of maternal perioperative hypothermia (<36°C), incidence of shivering, thermal comfort scores (0-100 scale), Apgar scores, and umbilical cord blood gas analysis.Demographic, obstetric, and surgical data were similar between study groups. The AW group (35.9°C ± 0.5°C) had a significantly higher temperature on arrival at the PACU compared with the NW group (35.5°C ± 0.5°C, P = 0.006; 95% confidence interval of mean difference, 0.1°C-0.7°C). Fourteen (64%) women in the AW group and 20 (91%) in the NW group were hypothermic during the study period (P = 0.031). Median (interquartile range) thermal comfort scores were 100 (95-100) in the AW group and 90 (70-100) in the NW group (P = 0.008). There were no significant differences in the incidence of intraoperative shivering (22% in the AW and 45% in the NW groups; P = 0.11), Apgar scores, or umbilical vein blood gas values between the study groups.Fluid combined with forced-air warming is effective in decreasing the incidence of perioperative hypothermia and improving maternal thermal comfort. However, despite multimodal AW, the majority of women became hypothermic, and shivering was not prevented. The findings suggest that combined AW for cesarean delivery with spinal anesthesia is difficult, and only modest benefit should be expected.

  View details for DOI 10.1213/ANE.0000000000001181

  View details for Web of Science ID 000374664400040

  View details for PubMedID 26895002

• Checklists and multidisciplinary team performance during simulated obstetric hemorrhage. International journal of obstetric anesthesia Hilton, G., Daniels, K., Goldhaber-Fiebert, S. N., Lipman, S., Carvalho, B., Butwick, A. 2016; 25: 9-16

  Abstract

  Checklists can optimize team performance during medical crises. However, there has been limited examination of checklist use during obstetric crises. In this simulation study we exposed multidisciplinary teams to checklist training to evaluate checklist use and team performance during a severe postpartum hemorrhage.Fourteen multidisciplinary teams participated in a postpartum hemorrhage simulation occurring after vaginal delivery. Before participating, each team received checklist training. The primary study outcome was whether each team used the checklist during the simulation. Secondary outcomes were the times taken to activate our institution-specific massive transfusion protocol and commence red blood cell transfusion, and whether a designated checklist reader was used.The majority of teams (12/14 (86%)) used the checklist. Red blood cell transfusion was administered by all teams. The median [IQR] times taken to activate the massive transfusion protocol and transfuse red blood cells were 5min 14s [3:23-6:43] and 14min 40s [12:56-17:28], respectively. A designated checklist reader was used by 7/12 (58%) teams that used the checklist. Among teams that used a checklist with versus without a designated reader, we observed no differences in the times to activate the massive transfusion protocol or to commence red blood cell transfusion (P>0.05).Although checklist training was effective in promoting checklist use, multidisciplinary teams varied in their scope of checklist use during a postpartum hemorrhage simulation. Future studies are required to determine whether structured checklist training can result in more standardized checklist use during a postpartum hemorrhage.

  View details for DOI 10.1016/j.ijoa.2015.08.011

  View details for PubMedID 26421705

• Simulation Study Assessing Healthcare Provider's Knowledge of Pre-Eclampsia and Eclampsia in a Tertiary Referral Center. Simulation in healthcare Hilton, G., Daniels, K., Carvalho, B. 2016; 11 (1): 25-31

  Abstract

  The aim of the study was to assess knowledge of labor and delivery healthcare providers at a tertiary referral center in the management of pre-eclampsia and eclampsia.Thirteen multidisciplinary teams participated in this institutional review board-exempt study. Each group encountered the same scenario that involved a pre-eclamptic parturient who progressed to eclampsia. The participants were unaware of the scenario topic before the drill and that key interventions would be recorded and timed. Seven of 13 groups were randomized to have a cognitive aid available.Twelve of 13 groups attempted to lower the blood pressure; however, only 7 of 12 groups used the correct first-line antihypertensive medication as per the American College of Obstetricians and Gynecologists' guidelines. All groups requested and administered the correct bolus dose of magnesium (4-6 g intravenously). Only 2 of 13 groups took appropriate action to lower the blood pressure to a "safe range" before induction of general anesthesia, and 4 of the 13 anesthesiologists made drug modifications for induction of anesthesia. None of the 7 groups randomized to have a cognitive aid used it.Our results show widespread magnesium sulfate utilization; however, the use of antihypertensive medication is not universally administered in compliance with current guidelines. The importance of blood pressure management to reduce maternal morbidity and mortality in the setting of pre-eclampsia needs to be emphasized. Interestingly, availability of a cognitive aid did not ensure its utilization in this scenario. Findings suggest that for cognitive aids to be effectively used, it is essential that staff has been trained and become familiar with them before an emergent event.

  View details for DOI 10.1097/SIH.0000000000000125

  View details for PubMedID 26836465

• The impact of advanced maternal age on peripartum thromboelastographic coagulation profiles: a prospective observational exploratory study. Canadian journal of anaesthesia = Journal canadien d'anesthe´sie Butwick, A., Gutierrez, M. C., Hilton, G. 2015; 62 (5): 504-512

  Abstract

  Advanced maternal age (AMA) is a known risk factor for pregnancy-related venous thromboembolism. However, it is unclear if underlying differences exist in the maternal coagulation profiles of AMA vs non-AMA women. The aim of this prospective observational study was to compare peripartum thromboelastography parameters of AMA and non-AMA women undergoing elective Cesarean delivery (CD).We compared the peripartum thromboelastographic profiles of healthy AMA women (age > 35 yr) and non-AMA women (age ≤ 35 yr) undergoing elective CD under neuraxial anesthesia. Blood samples were drawn prior to CD and at 24 hr and 72 hr post-CD. At each time point, we assessed thromboelastographic and other standard laboratory coagulation indices. We used a linear mixed-effects regression model (SAS(®) PROC MIXED) to assess between-group differences for individual thromboelastographic and laboratory coagulation parameters.The median [interquartile range] ages of women were 38 [37-41] yr and 29 [25-34] yr in the AMA and non-AMA groups, respectively (P < 0.001). We observed no statistically significant effect of study group on any thromboelastographic or laboratory coagulation parameters. No statistically significant correlations were found between any thromboelastographic parameter and maternal age. Peripartum thromboelastography and coagulation profiles of healthy AMA and healthy non-AMA women up to 72 hr post-CD were also similar.These data suggest that maternal thromboelastographic profiles of healthy AMA and non-AMA women undergoing elective CD are similar. The study was registered at ClinicalTrials.gov (identifier: NCT01416454).

  View details for DOI 10.1007/s12630-014-0300-0

  View details for PubMedID 25549988

• The impact of breastfeeding on postpartum pain after vaginal and cesarean delivery. Journal of clinical anesthesia Wen, L., Hilton, G., Carvalho, B. 2015; 27 (1): 33-38

  Abstract

  Oxytocin may play a role in pain modulation. The analgesic effects of breastfeeding with its associated endogenous oxytocin release have not been well investigated. To determine the impact of breastfeeding on incisional, perineal, and cramping pain after cesarean and vaginal delivery.Institutional review board-approved prospective observational study.Labor and delivery and maternity wards.Healthy (American Society of Anesthesiology physical statuses 1 and 2) multiparous women who had cesarean (n = 40) and vaginal (n = 43) deliveries of singleton term infants and who were breastfeeding were enrolled.Women completed diaries to record incisional, perineal, or cramping pain scores 5 minutes before, during, and 5 minutes after breastfeeding.Demographic, obstetric, and neonatal variables, as well as analgesic use, were recorded.There was no difference in incisional pain before, during, and after breastfeeding in women post-cesarean delivery. Cramping pain was significantly increased during, as compared with before or after breastfeeding in both the vaginal (P < .001) and cesarean (P < .001) delivery cohorts.There was no analgesic effect on incisional pain during breastfeeding, indicating that endogenous oxytocin associated with breastfeeding may not play a significant role in postpartum cesarean wound pain modulation. Breastfeeding increased cramping pain after vaginal and cesarean delivery. The increase in cramping pain is most likely due to the breastfeeding-associated oxytocin surge increasing uterine tone.

  View details for DOI 10.1016/j.jclinane.2014.06.010

  View details for PubMedID 25468582

• Prospective longitudinal cohort questionnaire assessment of labouring women's preference both pre- and post-delivery for either reduced pain intensity for a longer duration or greater pain intensity for a shorter duration. British journal of anaesthesia Carvalho, B., Hilton, G., Wen, L., Weiniger, C. F. 2014; 113 (3): 468-473

  Abstract

  Assessments of labour pain focus on pain intensity, not on duration. We aimed to assess the importance labouring women apply to pain intensity and duration before labour and post-delivery.Forty healthy women scheduled for labour induction were enrolled in this institutional review board-approved, prospective cohort study. Participants completed a pain preference questionnaire before active labour and within 24-h of delivery. The questionnaire consisted of seven stem questions that evaluated preference for pain intensity or duration. The pain preference ratio was determined by dividing the percentage of women who preferred reduced pain intensity for longer duration by that of those who preferred greater pain intensity for shorter duration (estimate of the odds). The overall hypothetical pain burden was determined by multiplying intensity by time. All questions presented the same overall hypothetical pain burden.Pain preference questionnaire scores demonstrated preference for low intensity pain for a longer duration rather than higher intensity for a shorter duration, both pre-labour (P<0.001) and post-delivery (P<0.001): the null median imputed as 3 of 6 (i.e. no preference for pain intensity over pain duration). This preference for pain duration over intensity was greater post-delivery compared with before labour (P=0.03). There was a significant correlation (r=0.83; P=0.04) between the pain preference ratio vs overall hypothetical pain burden before labour but not after delivery (r=0.28; P=0.59).In this preliminary labour assessment, women preferred lower pain intensity at the cost of longer pain duration. This suggests that pain intensity is the primary driver of hypothetical pain burden-a preference reinforced post-delivery.

  View details for DOI 10.1093/bja/aeu149

  View details for PubMedID 24907280

• Steps Toward a National Disaster Plan for Obstetrics OBSTETRICS AND GYNECOLOGY Daniels, K., Oakeson, A. M., Hilton, G. 2014; 124 (1): 154-158

  Abstract

  Hospitals play a central role in disasters by receiving an influx of casualties and coordinating medical efforts to manage resources. However, plans have not been fully developed in the event the hospital itself is severely damaged, either from natural disasters like earthquakes or tornados or manmade events such as a massive electrical failure or terrorist attacks. Of particular concern is the limited awareness of the obstetric units' specialized needs in the world of disaster planning. Within the same footprint of any obstetric unit, there exists a large variety of patient acuity and needs including laboring women, postoperative patients, and healthy postpartum patients with their newborns. An obstetric-specific triage method is paramount to accurately assess and rapidly triage patients during a disaster. An example is presented here called OB TRAIN (Obstetric Triage by Resource Allocation for Inpatient). To accomplish a comprehensive obstetric disaster plan, there must be 1) national adoption of a common triage and evacuation language including an effective patient tracking system to avoid maternal-neonatal separation; 2) a stratification of maternity hospital levels of care; and 3) a collaborative network of obstetric hospitals, both regionally and nationally. However, obstetric disaster planning goes beyond evacuation and must include plans for shelter-in-place and surge capacity, all uniquely designed for the obstetric patient. Disasters, manmade or natural, are neither predictable nor preventable, but we can and should prepare for them.

  View details for DOI 10.1097/AOG.0000000000000326

  View details for Web of Science ID 000337734000022

  View details for PubMedID 24901273

• On-time scheduled cesarean delivery start time process-improvement initiative. Obstetrics and gynecology Blumenfeld, Y. J., Riley, E., Hilton, G., Lee, H. C., El-Sayed, Y. Y., Druzin, M. L. 2014; 123: 138S-9S

  Abstract

  Cesarean deliveries comprise approximately 30% of all births, many of which are scheduled. Given the labile nature of labor and delivery units, scheduled cesarean deliveries are often delayed. Our aim was to improve on-time scheduled cesarean delivery start times.A multidisciplinary team (obstetrician-gynecologist, nursing, anesthesia, and hospital administration) met to review scheduled cesarean delivery data, identify logistic barriers to on-time starts, and develop a plan to improve cesarean delivery start times. After identifying possible barriers to on-time starts, the following process was instituted: planned preoperative visit 1-2 days before scheduled cesarean delivery, mandatory submission of History & Physical and consent forms by the time of the preoperative visit, and initial preparation of the first scheduled patient for cesaren delivery by nighttime nursing before morning change of shift. The process launched on March 1, 2013. Data from scheduled cesarean deliveries 6 months before and 3 months after the initiative were reviewed and analyzed.Of 1,298 total cesarean deliveries, 423 were scheduled, defined as cesarean delivery scheduled at least 24 hours in advance (300 before and 123 after the initiative). Sixty-four of 300 scheduled cesarean deliveries (21.3%) were on time before compared with 67 of 123 (54.5%) after the initiative began (P<.001). Among delayed cases, there was no difference in the average delay time between those before and after the initiative (55.7 compared with 54.4 minutes P=.93); however, 50.7% of cases were either on time or delayed by 15 minutes or less before the initiative compared with 69.9% of cases after (P<.001).A multidisciplinary initiative significantly increased scheduled cesarean delivery on-time start times.

  View details for DOI 10.1097/01.AOG.0000447113.07157.f3

  View details for PubMedID 24770007

• Chapter 12: Obstetric Events Crisis Management in Anesthesiology Hilton, G. Elsevier. 2014; 2nd
• Anesthetic management of a parturient with VACTERL association undergoing Cesarean delivery CANADIAN JOURNAL OF ANESTHESIA-JOURNAL CANADIEN D ANESTHESIE Hilton, G., Mihm, F., Butwick, A. 2013; 60 (6): 570-576

  Abstract

  PURPOSE: We present the anesthetic management of a parturient with VACTERL association undergoing combined regional and general anesthesia for Cesarean delivery. Defined as a syndrome, VACTERL association comprises at least three of the following abnormalities: vertebral, anal atresia, cardiac, tracheoesophageal, renal, and limb. CLINICAL FEATURES: The patient's anatomic abnormalities and comorbidities comprised severe cervicothoracic scoliosis, kyphoscoliosis, congenitally fused ribs, and severe restrictive lung disease. She had a Mallampati class 3 airway, a right laterally flexed neck, and reduced mandibular protrusion. We performed a lumbar spine ultrasound for epidural placement which was used to provide peri- and postoperative analgesia. Due to the anticipated difficult tracheal intubation, the patient underwent an awake fibreoptic intubation and subsequently received general anesthesia. The patient's trachea was extubated on the first postoperative day, and she received adequate post-Cesarean epidural analgesia. CONCLUSION: This case highlights the challenges that anesthesiologists face when managing parturients at extremely high risk for perioperative anesthetic morbidity due to the presence of severe pre-existing disease, anticipated difficult airway, and major spinal abnormalities complicating neuraxial anesthesia. We used a combined general and epidural anesthetic approach to control ventilation, provide effective postoperative analgesia, and reduce the risk of anesthetic-related perioperative morbidity. An individualized approach should be considered for the anesthetic management of high-risk pregnant patients with complex and multiple medical and surgical morbidities undergoing labour and delivery.

  View details for DOI 10.1007/s12630-013-9919-5

  View details for Web of Science ID 000319416000009

• Continuous spinal anesthesia for Cesarean hysterectomy and massive hemorrhage in a parturient with placenta increta CANADIAN JOURNAL OF ANESTHESIA-JOURNAL CANADIEN D ANESTHESIE Sultan, P., Hilton, G., Butwick, A., Carvalho, B. 2012; 59 (5): 473-477

  Abstract

  We present anesthetic management using a continuous spinal anesthesia (CSA) technique in a patient with placenta increta who underwent elective Cesarean hysterectomy with massive postpartum hemorrhage.A 34-yr-old parturient (G3P2) was scheduled for Cesarean delivery and possible hysterectomy at 35(+3) weeks due to suspected placenta accreta. Her body mass index was 21 kg·m(-2) and she had a reassuring airway. Inadvertent dural puncture occurred during combined spinal-epidural (CSE) placement, and a decision was made to thread the epidural catheter and utilize a CSA technique. Following delivery of a healthy infant, morbid adherence of the placenta to the myometrium was confirmed, and a supracervical hysterectomy was performed. Eight litres of blood loss occurred postpartum requiring resuscitation with crystalloid 3,800 mL, colloid 1,500 mL, red blood cells 16 units, fresh frozen plasma 16 units, platelets 4 units, and cryoprecipitate 1 unit. The patient developed pulmonary edema requiring conversion to general anesthesia. The patient's cardiovascular status was stable throughout surgery, and her lungs were mechanically ventilated for 18 hr postoperatively in the intensive care unit. The intrathecal catheter was removed 24 hr after placement. She developed no adverse neurological sequelae and reported no postdural puncture headache. The pathology report confirmed placenta increta.A CSA technique may be a viable option in the event of inadvertent dural puncture during planned CSE or epidural placement in patients with a reassuring airway undergoing Cesarean delivery. Although a catheter-based neuraxial technique is appropriate for Cesarean hysterectomy for abnormal placentation, conversion to general anesthesia may be required in the event of massive perioperative hemorrhage and fluid resuscitation.

  View details for DOI 10.1007/s12630-012-9681-0

  View details for PubMedID 22395824

• Non-invasive haemoglobin measurement in patients undergoing elective Caesarean section BRITISH JOURNAL OF ANAESTHESIA Butwick, A., Hilton, G., Carvalho, B. 2012; 108 (2): 271-277

  Abstract

  The ability to measure haemoglobin (Hb) real-time and non-invasively offers important clinical value in the assessment of acute changes in maternal Hb during the peripartum period. This study evaluates the Masimo Rainbow SET(®) Radical-7 Pulse CO-Oximeter in a pregnant population undergoing Caesarean section (CS).Fifty patients undergoing elective CS were enrolled in this prospective, controlled study and followed for 48 h after surgery. Non-invasive Masimo Hb (SpHb) values were compared with laboratory Hb values from venous blood samples drawn at baseline, immediately post-CS, and 24 h post-CS using the Bland-Altman plots. Longitudinal analysis of SpHb changes over time was performed using mixed-effects regression modelling.For the comparison between SpHb and laboratory Hb, SpHb displayed a significant positive bias at baseline {1.22 g dl(-1) [95% confidence interval (CI): 0.89-1.54]} and at 24 h post-CS [1.36 g dl(-1) (95% CI: 1.04-1.68)]. The bias immediately post-CS was 0.14 g dl(-1) (95% CI: -0.18 to 0.46). The limits of agreement at baseline, immediately post-CS, and at 24 h post-CS were: -0.9 and 3.33, -2.35 and 2.56, and -0.55 and 3.27 g dl(-1), respectively. The mean decrease in SpHb from baseline to 48 h post-CS was ∼1 g dl(-1).The variability in bias and limits of agreements of the Rainbow SET(®) Radical-7 Pulse CO-Oximeter SpHb may limit its clinical utility for assessing Hb concentration in patients undergoing elective CS. Modifications are needed in the calibration of the device to improve accuracy and precision in an obstetric setting. The study was registered at clinicaltrials.gov (NCT01108471) before participant enrolment: URL=http://clinicaltrials.gov/ct2/show/NCT01108471?term=butwick&rank=1.

  View details for DOI 10.1093/bja/aer373

  View details for Web of Science ID 000299414800015

  View details for PubMedID 22116296

• Non-invasive measurement of hemoglobin during cesarean hysterectomy: a case series INTERNATIONAL JOURNAL OF OBSTETRIC ANESTHESIA Butwick, A. J., Hilton, G., Riley, E. T., Carvalho, B. 2011; 20 (3): 240-245

  Abstract

  Obstetric patients diagnosed with abnormal placentation (placenta accreta, increta or percreta) are at increased risk of major postpartum hemorrhage and cesarean hysterectomy. Obstetric anesthesiologists are primarily involved in intraoperative transfusion management in these cases. Hemoglobin assessment is invaluable for assisting transfusion decision-making during the acute period of obstetric hemorrhage. However, laboratory and point-of-care tests of hemoglobin concentration are time-dependent and intermittent, and do not provide a real-time assessment of change during the acute phase of blood loss. A new non-invasive hemoglobin monitor has been introduced recently, which provides real-time measurement of hemoglobin values (SpHb) using multi-wavelength pulse co-oximetry. We present a review of five patients with suspected abnormal placentation who received SpHb monitoring during cesarean hysterectomy at our institution. We discuss the potential clinical utility of non-invasive hemoglobin monitoring for pregnant patients at high risk of obstetric hemorrhage, and the potential role of SpHb in guiding transfusion therapy.

  View details for DOI 10.1016/j.ijoa.2011.03.009

  View details for Web of Science ID 000293042800009

  View details for PubMedID 21640577

• What were the perceptions of primary care teams on learning from a single multidisciplinary simulation-based training intervention? Education for primary care : an official publication of the Association of Course Organisers, National Association of GP Tutors, World Organisation of Family Doctors Strachan, A. N., Graham, A. C., Hormis, A. P., Hilton, G. 2011; 22 (4): 229-234

  Abstract

  Medical emergencies in general practice are uncommon and their management requires good teamwork, communication and effective use of the available resources by the whole primary care team. To address this need the Montagu Clinical Simulation Centre developed and delivered a half-day simulation-based medical emergencies course for primary care teams (GPs, practice nurses and administrative staff). Each half-day course comprises two simulated medical emergencies, which are video-taped and then debriefed. The course was evaluated using a multi-level approach by seeking the staff's reactions to the course, their learning, the behaviour changes produced and the results for the organisation. We gained this information through self-reporting using end-of-course and follow-up questionnaires. The immediate feedback was very positive, showing they had learnt the objectives set. We then surveyed all those who had attended training between 2003 and 2007. A follow-up questionnaire was developed and sent to the practice managers who then co-ordinated their completion and return using a pre-paid return envelope. The survey was carried out in two cohorts. The first set of follow-up questionnaires was sent out in September 2004 to all those that had attended up to the end of May 2004 and the second set sent out in May 2008 to those who had attended between June 2004 and May 2007. Of the 338 available to complete the follow-up questionnaire, 208 responded, giving a response rate of 62%. Eighty percent of practices had made changes to equipment, emergency protocols or training and 20% of the participants had been involved in managing a medical emergency since attending the course. Of those, 86% indicated that their management and confidence had improved, that they were better able to take a lead role, give instruction and delegate tasks as required. Based on the self-reported perceptions of learning, we believe that the lessons learnt have been translated into positive changes at a personal and practice level for all members of the primary care team. The participants valued the chance to train as a complete unit. We plan to evaluate simulation-based training in the workplace to see if this has a greater impact.

  View details for PubMedID 21781389

• Failure to Ventilate with the Drager Apollo (R) Anesthesia Workstation ANESTHESIOLOGY Hilton, G., Moll, V., Zumaran, A. A., Jaffe, R. A., Brock-Utne, J. G. 2011; 114 (5): 1238-1240

  View details for Web of Science ID 000289980200029

  View details for PubMedID 21430517

• Kinked Perifix® FX Springwound epidural catheters Canadian Journal of Anesthesia Hilton, G., Jette, C. G., Ouyang, Y., Riley, E. T. 2011; 58 (4): 413-14
• Prolonged propofol infusions in pregnant neurosurgical patients JOURNAL OF NEUROSURGICAL ANESTHESIOLOGY Hilton, G., Andrzejowski, J. C. 2007; 19 (1): 67-68

  View details for Web of Science ID 000243186800012

  View details for PubMedID 17198107