BACKGROUND: The prevention of maternal hypotension by traditional crystalloid preloading prior to spinal anesthesia in obstetric patients undergoing spinal anesthesia has recently been questioned by many. A review of published data with unbiased comparison comparing preloading and no preloading prior to spinal anesthesia was attempted to assess the relative benefits and side-effects in terms of incidence of maternal hypotension, dose of vasopressors given and APGAR scores at one and 5 minutes. METHODS: A medline search of published randomized controlled trials (RCT) from 1966-1997 comparing crystalloid and no crystalloid preloading prior to spinal anesthesia in patients for cesarean section was done. Search for available meta-analysis on preloading, only three met the criteria for analysis. The outcome measures were limited to three due to lack of available data for comparison. RESULTS: Using the Peto Odds Ratio, analysis of the three studies showed no significant difference in the incidence of hypotension between those who were preloaded and those who were not. But a trend towards a lower incidence of hypotension among those who were preloaded was seen. Using the weighted means difference (WMD) to analyze the dose of vasopressors given, there was no significant difference between preloading and no preloading but a trend towards a greater total dose of vasopressors was seen in those not preloaded. There was no significant difference in APGAR scores in the three studies. CONCLUSION: There is no sufficient evidence to support a change in practice to no preloading prior to spinal anesthesia for elective cesarean section based on the results of this meta-analysis. Further studies must be done to increase the validity and precision of results comparing preloading and no preloading.
Human ; Female ; ANESTHESIA, SPINAL ; CESAREAN SECTION ; OBSTETRICS ; HYPOTENSIONS

BACKGROUND: A myriad of foreign studies have shown the advantage of a pencil-point spinal needle (Whitacre) in reducing the incidence of post-ducal puncture headache (PDPH), especially in the population most at risk for PDPH - the obstetric patients. In the Philippines, there has been no data comparing the incidence of PDPH between the standard spinal needle (Quincke) and the newer Whitacre needle. This study aims to compare the incidence of spinal headache between the Quincke and the Whitacre spinal needle in Filipino obstetric patients. METHODS: A randomized double-blind study was conducted on 200 obstetric patients for elective cesarean sections under subarachnoid anesthesia using either a Quincke or a Whitacre spinal needle of the same gauge (G25). The incidence and quality of post-ducal puncture headache was compared between the two groups. Both groups were also compared in terms of ease of lumbar puncture, quality of motor block, and the incidence of postoperative complications RESULTS: The incidence of PDPH was significantly higher in the Quincke group (8 percent) as compared to the Whitacre group (1 percent). The case of insertion of the spinal needle was considered effortless (1 attempt) in 67 percent of the Quincke group and in 61 percent of the Whitacre group. Degree of motor blockade was noted to be more solid in the Whitacre group (93 percent) as compared to 83 percent in the Quincke group. There were 2 failed spinal attempts in the Quincke group and 3 in the Whitacre group for which general anesthesia was resorted to. Other postoperative complications of non-spinal headache (Quincke- 4 percent vs. Whitacre- 3 percent) and backache or back soreness as specified by the patients (Quincke 12 percent vs Whitacre 15 percent) did not differ significantly. CONCLUSION: Results imply that the G25 Whitacre needle with a conical, non-cutting bevel is an improved alternative to the G25 Quincke needle in terms of reducing the incidence and quality of postdural puncture headache in Filipino obstetric patients. The design of the spinal needle tip influences the occurrence of PDPH. (Author)
Human ; Middle Aged ; Adult ; Young Adult ; Adolescent ; OBSTETRICS ; POST-DURAL PUNCTURE HEADACHE

Background: While the standard lumbar epidural analgesia technique has often been described as the gold standard for pain relief during labor, its disadvantages of delayed onset and the presence of motor blockade to a certain degree pose several constraints to pain burdened mother who also may not want to be confined in the supine position during the entire labor process. An alternative which may address these issues is the combined spinal epidural or walking epidural technique. We embarked on this study to compare both techniques in terms of onset and degree of analgesia and the outcome of labor. Methods: Eighty (80) nulligravid ASA 1-2 term patients were randomly assigned to receive labor pain relief either using the standard continuous lumbar epidural analgesia (CLEA) using .125 percent bupivacaine with fentanyl or the combined spinal epidural analgesia (CSE) technique using intrathecal fentanyl and bupivacaine followed by bupivacaine boluses with fentanyl as needed. Outcome measures studied were Visual Analogue Pain Scores, onset degree and duration of pain relief and the progress and outcome of labor including neonatal outcome. Side effects were also noted. Results: Very significant was the rapid onset of action, denser, and longer duration of pain relief in the CSE group. Likewise a faster rate of cervical dilation resulting in a shorter first stage of labor was noted. Second stage duration and mode of delivery in both groups however did not differ significantly. Maternal satisfaction during the first stage was greater in the CSE group, although overall maternal satisfaction was comparable in both groups. Pruritus, although a significant occurrence in the CSE group did not need any intervention for treatment. No adverse effects on both the neonate and mother were noted. Conclusion: Based on the results of our study, the CSE or walking epidural is a encouraging alternative to laboring mothers, especially those in severe pain requiring rapid and profound relief. Our results show that compared the standard epidural technique, it hastens the rate of first stage labor - but whether ambulation plays a significant role in this aspect needs to be further investigations
Human ; LABOR PAIN ; OBSTETRIC LABOR ; ANALGESIA, EPIDURAL ; PAIN

Background: In an effort to prevent and address perioperative hypoxemia, it has become customary to provide supplemental oxygen to all surgical patients. Recently, the value of such a practice has been questioned. This study was designed to determine the incidence as well as the potential risk factors associated with perioperative hypoxemia. Methods: During a 9 - week period, 84 ASA I-II patients who underwent ambulatory surgical procedures under spinal anesthesia were observed. Arterial oxygen saturation (SpO2) was monitored using a pulse oximeter prior to induction of anesthesia, during operation and until the patient was discharged from the recovery room. Patients breathed room air during the entire perioperative course unless dyspnea and/or desaturation occurred. Descriptive statistics was used to examine differences in oxygen saturations before, during, and after surgery. The association between each of the potential risk factors and the number of patients requiring supplemental oxygen was analyzed using Fisher's exact test (for attribute data e.g. level of sensory block) and the Wilcoxon's rank sum test for continuous data (e.g. age, smoking in pack years) to calculate the probability that the proportions did not differ. A/>< 0.05 was considered statistically significant. Results: The incidence of preoperative, intra-operative and postoperative hypoxemia was 0 percent, 0 percent and 1.14 percent respectively while the need for supplemental oxygen was 2.27 percent intra-operatively and 2.27 percent postoperatively. Statistical analysis revealed that the level of block and body mass index were significant factors (P < 0.05) influencing the need for oxygen support. The need for supplemental oxygen was not associated with age, smoking history, surgical position, sedation level and Visual Analog Scale score. Conclusion: Results suggest that seemingly healthy patients who undergo lower abdominal, urologic, gynecologic or lower extremity surgical procedures under spinal anesthesia are at a low risk for hypoxemia. Pulse oximetry as part of routine monitoring may obviate the need for supplemental oxygen in this patient population. (Author)
Human ; ANESTHESIA ; ANOXEMIA ; OXIMETRY ; ANESTHESIA, SPINAL ; AMBULATORY SURGICAL PROCEDURES

Ruptured Sinus of Valsalva (RSOV) is a rarely encountered cardiac anomaly that can potentially lead to adverse clinical outcomes. RSOV increases the risk of morbidity during pregnancy due to the physiological changes associated with gestation, that can exacerbate the underlying cardiac pathology. We present the case of a 29-year-old female with an uncorrected RSOV who required an emergency cesarean section for abruptio placenta. The patient underwent the procedure under spinal anesthesia, with careful titration of norepinephrine infusion and close monitoring of hemodynamic parameters using an invasive intra-arterial line. Given the absence of established anesthetic protocols for parturients with RSOV undergoing cesarean delivery, a comprehensive understanding of the complex interaction between the hemodynamic effects of RSOV, pregnancy, and anesthesia is essential. This understanding enables the safe use of spinal anesthesia in urgent situations, leading to favorable patient outcomes.
Sinus of Valsalva ; Aortic Rupture ; Cesarean Section ; Anesthesia, Spinal

The Philippine Council for Health Research and Development-Department of Science and Technology (PCHRD-DOST), and the Philippine College of Surgeons (PCS) signed a Memorandum of Agreement on 1 June 1999, whereby both agreed to support the formation of Evidence-Based Clinical Practice Guidelines (EBCPGs) on specific areas of surgical care in the Philippines. The areas were to be specified by the PCS, and those areas should have a reasonably large potential of improving the quality of patient care throughout the country, and can be implemented nationwide in both government and private health facilities The first clinical area selected was on when to refer for preoperative cardiac evaluation for elective noncardiac surgery, and when would the intraoperative presence of a cardiologist be beneficial. A Technical Working Group (TWG) was appointed, which: 1) searched and appraised the evidence; 2) prepared a first draft EBCPG; 3) presented the evidence to a Panel of Experts; 4) supervised the panel using the nominal group technique (6 November 1999 - PCS Building); and 5) prepared the second draft EBCPG based on the consensus recommendations of the panel. All processes strictly conformed to the methods of evidence-based guidelines formation specified by evidence-baesd medicine texts The second draft EBCPG was presented on 11 December 1999 during the 55th Clinical Congress of the PCS, and the final draft approved by the PCS Board of Regents on 29 January 2000 Literature search was conducted through the MEDLINE, COCHRANE Library an the HERDIN Database. A total of 2,156 titles, 427 abstracts and 77 full text articles were appraised. Data from 23 prospective cohort studies were encoded into the software COCHRANE Review Manager (RevMan), Version 3.0 for Windows (updated October 7, 1996). Tables were generated which contained authors, outcome rates, relative risks and the 95% confidence intervals of the relative risks. Three perioperative outcomes were identified-cardiac morbidity, cardiac death, and overall cardiac events

Human ; Risk ; Cardiologists ; Surgeons ; Research ; Publications ; Patient Care ; Health Facilities

Purpose: This study aims to evaluate surgical outcomes (i.e. length of stay [LOS], 30-day morbidity, mortality, reoperation, and readmission rates) with the use of the Enhanced Recovery After Surgery (ERAS) pathway, and determine its association with the rate of compliance to the different ERAS components. Methods: This was a prospective cohort of patients, who underwent the following elective procedures: stoma reversal (SR), colon resection (CR), and rectal resection (RR). The primary endpoint was to determine the association of compliance to an ERAS pathway and surgical outcomes. These were then retrospectively compared to outcomes prior to the implementation of ERAS. Results: A total of 267 patients were included in the study. The overall compliance to the ERAS component was 92.0% (SR, 91.8%; CR, 93.1%; RR, 90.7%). There was an associated decrease in morbidity rates across all types of surgery, as compliance to ERAS increased. The average total LOS decreased in all groups but was only found to have statistical significance in SR (12.1±6.7 days vs. 10.0±5.4 days, P=0.002) and RR (19.9±11.4 days vs. 16.9±10.5 days, P=0.04) groups. Decreased postoperative LOS was noted in all groups. Morbidity rates were significantly higher after ERAS implementation, but reoperation and mortality rates were found to be similar. Conclusion Increased compliance to ERAS protocol is associated with a decrease in morbidity across all surgery types. The implementation of an ERAS protocol significantly decreased mean hospital LOS, without any increase in major surgical complications. Having your own hospital ERAS pathway improves documentation and accuracy of reporting surgical complications.

Initial Planning: Statement 1: A Community-oriented Health Care Plan that contains tasks and activities related to the community organization, environment, health care and social processes in order to mitigate the effect of the COVID-19 epidemic on the community should be developed. Statement 2: The plan should also include adjustments needed to continue the delivery of other health services i.e. maternal and child health, immunization, treatment of other communicable and non-communicable disease but with strict COVID-19 transmission precautions. Adjustment in the Community Organization and Environment: Statement 3: A local task force should be organized to develop and implement the community health plan. The task force should be recognized and supported by the whole community. Statement 4: A facility in the barangay that can be used for isolation in case that a member will be diagnosed to have mild COVID-19. A hospital facility for referral of high-risk cases should also be identified and an emergency referral and transport plan should be established. Statement 5: All community health workers should wear appropriate personal protective equipment in the process of performing their community health work. Statement 6: Households in the community who have members at high-risk i.e. more than 60 years old, with existing chronic illness or other life-threatening condition should be identified and advised to take extra precautions i.e. personal hygiene, wearing mask and physical distancing. Statement 7: During the declared community quarantine period by the community or higher-level authority, all community members and household should be advised to stay at home, limit celebrations and community gatherings Performance of Routine Tasks and Activities: Statement 8: A community-directed information, education and communication (IEC) plan should be developed and implemented for the following: a) Informing every household in the community on the basic and accurate information about COVID-19 and the community plan. b) Encouraging everyone to practice personal hygiene that includes regular and appropriate hand washing, daily bath, coughing and sneezing etiquette, wearing of mask, minimizing hand contact with eyes, nose and mouth and strict personal use of eating utensils, bath towels, etc. c) Encouraging everyone to clean everyday frequently touched surface like doorknobs, light and appliance control switch, gadgets, armchairs and tabletops. Cleaning agents can be ordinary detergents and water or 70% alcohol. d) Encouraging everyone to report and seek help to the community health worker if a household member is exposed and developed mild symptoms of COVID-19 What to Do When a Member or Household is Exposed or Diagnosed COVID-19: Statement 9: If there is a household whose member is exposed to a COVID-19, the person should be encouraged to stay home preferably in a room or area adequate for isolation, wear mask and maintain at least 2 meters physical distance from other family members. Statement 10: Other household members should be advised to watch out and monitor for the appearance of symptoms like fever, colds and cough. If the person is low risk but there is difficulty of breathing or worsening of symptoms or if the person is high risk i.e. elderly or with existing chronic disease and symptoms appear, they encouraged to inform the community health worker and facilitate the necessary referral and transport arrangement to the hospital. Call first before going. Statement 11: If the symptoms are mild, continue home isolation or in the isolation facility identified by the community, take over-thecounter medications like paracetamol for fever, increase water intake and ensure adequate nutrition, sleep and rest. Family members and community health workers are encouraged to provide psychological and social support to isolated patients. Discontinuation of isolation can be done if symptoms resolve within 14-21 days Epidemiology and Surveillance Statement 12: The municipal or city health office should be provided daily with a situation report of the implementation of communityoriented health care for COVID-19. Situation report should include: a) The number of exposed, number of diagnosed cases, number of mild cases, number of cases referred to the hospital and number of cases recovered or died in the community. b) Brief description of best practices
COVID-19 ; Noncommunicable Diseases ; Quarantine