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McCallum R. Hoyt, M.D., M.B.A.Brigham and Women’s HospitalHarvard Medical SchoolBoston, Massachusetts

I was commenting to someone the other day how my concept of summer has changed over my life. Once it was the enjoyment

of slow, lazy days doing pretty much whatever I wanted and bordering on boredom, to now being anything but slow and lazy doing very little of what I want. This summer is shaping up to be more of what I’ve become accustomed to, not only in my personal life but also as SOAP President. My term began at the Annual Meeting, about which I’ll write a quick summary and respond to some frequently made requests. I’ll also apprise you of some

legislation that recently passed in two states and can potentially impact our practice.Six hundred and thirty-three attended the Annual Meeting in Monterey, which was another

successful event. The theme of the meeting, “Obstetric Anesthesia in an Evidence-Based Environment,” was emphasized in the Gertie Marx/FAER Education lecture given by the “father of evidence-based medicine,” Gordon Guyatt, M.D., B.Ch., F.R.C.P.C., M Sc. The debate, breakfast session, clinical forum and Hehre Lecture all contributed toward that theme. Several new elements were introduced to the meeting format. On the Wednesday beforehand, alongside the two workshops, a new pre-meeting session was offered called “Clinical Concepts.” This seminar is envisioned as an afternoon of talks focused on furthering knowledge on one particular issue. For the introductory session, the topic was “Coagulopathies.” Early reports are that this was well received and likely to continue in the future albeit with a bit more structure, such as with handouts. The business meeting was moved from the end of the first day to being held during lunch of that day. Comments about this move were positive, and the election results from this year’s business meeting are: Manny Vallejo, Jr., M.D.,

Continued on page 2

Contents:44th Annual Meeting

Summary page 3

EDITOR’S CORNER page 5

TREASURER’S REPORT page 6

COMMITTEE REPORTS

Disbursement page 8

economics and Government Affairs

page 9

International outreach Committee

page 10

Nitrous Oxide for Labor Analgesia

page 11

Drug Shortage Crisis: Patient Safety Concerns for Obstetric Anesthesiologists

page 14

PIONEERS’ CORNER page 15

www.soap.org summer 2012

PresIDent’s UPDAteThe Busy Days of Summer

2

PresIDent’s UPDAte

D.M.D. as Second Vice President and Kenneth Nelson, M.D. for a second term as Secretary. Also, the Broadmoor in Colorado was picked for the meeting site in 2015. Brenda Bucklin, M.D. will be the meeting host. Another well-received shift was to move the awards presentation from the banquet to the last day’s general session.

We heard your complaints about electronic access to the abstracts and lecture notes. For the lectures presented on Friday and Saturday, Anesthesia Illustrated recorded them and you can see them again (or for the first time if you missed them in Monterey) by clicking on the “AI” link on SOAP’s home page. Also, all abstracts will be available on the website; they are being posted there for the meeting just completed. Going forward, the accepted ones will be made available for download shortly before the meeting.

The social events also had a healthy turnout, and although the venue suffered a bit, the weather stayed sunny, albeit brisk. Over 400 attended the Welcome Reception, and the Annual Banquet at the Monterey Aquarium was a huge hit. Catered by Top Chef Master Cindy Pawlcyn and designed as a walk-around buffet, 256 attended and gave it rave reviews.

The old adage “All politics is local” is very true in the case of the legislation we have just seen passed in Massachusetts and New York, where nurse midwives have successfully removed the

required collaboration with a physician with obstetric privileges. As a result, they are much closer to independent practice and will no longer be under the respective states’ board of medicine oversight. This change places obstetric anesthesia providers in direct conflict with our “Optimal Goals” statement (please see the Economic and Governmental Affairs Committee report on page 9 in this issue). This change in midwifery scope of practice was not contested by the American Congress of Obstetricians and Gynecologists (ACOG) or the states’ obstetric component societies. Under my request, the Economic and Governmental Affairs Committee formulated a statement that can be accessed on the SOAP website. Essentially, it reaffirms our commitment to our joint ASA and ACOG policy. It also reminds us that how changes in scope of practice are interpreted is a matter for each individual institution. Thus, it remains in your best interest to stay active in your medical staff committee at your institution. I am pressing for a joint SOAP and ASA statement and will inform you of it should I be successful.

As an ongoing project for my year as your President, I will be working with our Executive Director, Karen Hurley, to strengthen the management functions, better document how SOAP operates and refresh our website, membership offerings and strategic plans. We on the Board are always interested in hearing from you, so please do not hesitate to contact us.

Enjoy your lazy days of summer!

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Michaela Farber, M.D.Brigham and Women’s HospitalHarvard Medical SchoolBoston, Massachusetts

The 44th Annual Meeting of the Society for Obstetric

Anesthesia and Perinatology (SOAP), themed “Obstetric Anesthesia in an Evidenced-Based Environment,” was held from May 2 to May 5, 2012 at the Hyatt Regency Monterey Resort and Spa in Monterey,

California. Attendance was exemplary with 633 participants from 17 countries. Three well-attended pre-meeting activities held on May 2 included the “Use of Ultrasound in Obstetric Anesthesia” workshop directed by Jose Carvalho, MBBCh, FRCA, MDCH (Mt. Sinai Hospital, Toronto) and a “High Risk Obstetric Crisis Simu-lation” workshop coordinated by Gillian Hilton, MBChB, FRCA (Stanford University). A new session for this meeting called Clini-cal Concepts was a tremendous success; the inaugural topic was “Coagulopathy: Nuts and Bolts to Cutting Edge” moderated by Phillip Hess, M.D. (Beth Israel Deaconess Hospital, Boston). The pre-meeting day culminated in a lovely evening wine tasting and appetizer reception as a warm welcome to all attendees.

The meeting officially commenced on Thursday morning with opening statements by SOAP President Maya Suresh, M.D. (Baylor College, Houston), President-Elect McCallum (Cally) Hoyt, M.D., M.B.A. (Brigham and Women’s Hospital, Boston) and Meeting Host, Dennis Shay, M.D. (San Diego, California). Joy Hawkins, M.D. (University of Colorado) provided an update on Foundation for Anesthesia Education and Research (FAER) grants. The meeting started on a high note with the Gertie Marx Research Competition moderated by Alan Santos, M.D., M.P.H. (St. Luke’s Roosevelt Hospital, New York City); the top six peer-reviewed obstetric anesthesia research abstracts were presented by residents and fellows. The first place winner of the competition was Naida Cole, M.D., who presented work on the in vitro effects of carbetocin vs. oxytocin on human myometrial contractions after oxytocin pre-treatment (Table 1). The second place winner of the competition was Joel Shapiro, M.D., who presented work on the non-invasive placental and fetal organ hemodynamic monitoring using BOLD fMRI in pregnant mice: comparing the effects of maternal ephedrine and phenylephrine administration (Table 1). The third place winner of the competition was Pervez Sultan, M.D., who presented work on the endogenous pain inhibition does not appear to be the mechanism responsible for pregnancy-induced analgesia (Table 1).

David Birnbach, M.D., M.P.H., (University of Miami) presented Gerry Bassell, M.D. (University of Kansas) with the SOAP Distinguished Service Award for his contributions to the field of obstetric anesthesiology. Dr. Birnbach’s well-received presentation was as humorous as it was reverent. Pertinent to

the evidence-based theme of this year’s meeting was Gordon Guyatt’s, M.D., B. Sc., FRCPC, B. Sc. (McMaster University, Ontario) Gertie Marx/FAER Education lecture entitled “Why Bother with Evidence-Based Obstetrical Anesthesia?” Dr. Guyatt, an internist, first coined the term “evidence-based medicine” in 1990. The morning session ended with the first Poster Session skillfully moderated by Brenda Bucklin, M.D. (University of Colorado) and Katherine Arendt, M.D. (Mayo Clinic).

Vilma Ortiz, M.D. (Massachusetts General Hospital, Boston) started the afternoon session by moderating six compelling oral presentations. An inaugural Special Poster Session Walk-Around with Richard Smiley, M.D., Ph. D. (Columbia University) was a great success; six posters were discussed with a crowd so large that Dr. Smiley needed a microphone. This event was followed by the Obstetric Anesthesiology Research Session “What’s the Future?” moderated by Cynthia Wong, M.D. (Northwestern University). Four thought-provoking presentations were given by Pamela Flood, M.D. (University of California San Francisco), Ruth Landau, M.D. (University of Washington), Roshan Fernando, FRCA (University College, London), and Stephen Pratt, M.D. (Beth Israel Deaconess Hospital, Boston). Topics included labor pain mechanisms, chronic pain after childbirth, spinal anesthesia-induced hypotension, and simulation.

Opportunities for career development and networking for up-and-coming obstetric anesthesiologists were abundand at the meeting, including a Fellows Reception, as well as a Resident Dinner and Breakout Session at the end of the first day. The Resident Breakout Session, orchestrated by Paloma Toledo, M.D., M.P.H. (Northwestern University), began with program speaker Arvind Palanisamy, M.D., FRCA (Brigham and Women’s Hospital, Boston) addressing the topic of “Planning a Research Career.” Dinner was provided and breakout sessions enabled medical student and resident investigators to present and discuss their research in small group settings.

On Friday morning, a breakfast session directed by Pam Angle, M.D., FRCPC, M. Sc. (Sunnybrook Health Sciences Centre, Toronto) demonstrated the use of evidence-based medicine in clinical obstetric scenarios. The full session began with a robust debate between two well-matched speakers: Scott Segal, M.D., MHCM (Tufts University) took the pro side and Robin Russell, M.D., FRCA (John Radcliffe Hospital, Oxford, United Kingdom) the con on the topic, “Patient Outcomes are Better with Protocol-Driven Care.” Dr. Raymond Powrie (Brown University) discussed useful pearls and pitfalls learned from his experience with near-miss maternal morbidity and mortality in the “What’s New in Obstetric Medicine?” lecture. Kenneth Nelson, M.D. (Wake Forest University) moderated six “Best Paper” presentations. Gordon Lyons, M.D. , newly retired from St. James’ University Hospital (Leeds, UK), delivered the Fred Hehre Lecture. His topic “A Critical Examination of Regional Technique” emphasized aseptic technique and the risk of spinal cord trauma from inadvertently high needle placement. After the educational sessions for the

44th Annual Meeting Summary

Continued on page 4

4

day, the 44th Annual SOAP Banquet was held in the superb setting of the Monterey Bay Aquarium where guests were able to dine and connect with colleagues while discovering the marine life of Monterey’s world-famous coastline. The event was catered by Top Chef Master, Ms. Cynthia Pawlsyn.

Early risers on Saturday took part in an invigorating Hatha Yoga session. The educational sessions began with a multidisciplinary clinical forum, “Postpartum Hemorrhage Management – Perspectives from Three Disciplines” including Lawrence (Tim) Goodnough, M.D. (Stanford University), Maurice Druzin, M.D. (Stanford University), and Andrea Fuller, M.D. (University of Colorado) with Brendan Carvalho, MBBCh, FRCA, MDCH (Stanford University) as moderator. Ashley Tonidandel, M.D., M.S. (Wake Forest University) and Pamela Flood, M.D. (University of California San Francisco) provided insightful moderation of the second poster session. These and other award winners are highlighted in Table 1. Alexander Butwick, MBBS, FRCA, M.S.

(Stanford University) delivered this year’s Gerard W. Ostheimer Lecture, in which he skillfully conveyed highlights from his comprehensive syllabus of the top 150 articles published in 2011 relevant to obstetric anesthesiologists. This lecture was followed by another “What’s New in Obstetrics?” lecture, “Evolving Consensus on Standardization of Fetal Heart Rate Pattern Management” given by Julian (Bill) Parer, M.D., Ph.D. (University of California San Francisco).

The final afternoon session began with a second set of oral presentations moderated by Dennis Shay, M.D. from San Diego. The educational session ended with “Best Case Reports: What Can We Learn From This?” moderated by Bhavani Kodali, M.D. and Michaela Farber, M.D. (Brigham and Women’s Hospital). Cally Hoyt, M.D., M.B.A. concluded the meeting with farewell remarks and the meeting ended with a wonderful outdoor courtyard reception. Next year’s 45th annual SOAP meeting from April 24-28, 2013 at the Caribe Hilton San Juan, Puerto Rico, is bound to be amazing! Please visit www.soap.org for more details.

table 1. soAP 2012 Award recipientsAwARD RECIPIENT INSTITUTION AbSTRACT TITLE

Gertie Marx research Competition 1st place

naida Cole, M.D.Mount sinai Hospital toronto, on, Canada

Carbetocin vs. oxytocin: In-vitro human myometrial contractions after oxytocin pre-treatment

Gertie Marx research Competition 2nd place

Joel shapiro, M.D.Hadassah Hebrew University

Jerusalem, Israel

non-invasive placental and fetal organ hemodynamic monitoring using BoLD fMrI in pregnant mice: comparing the effects of maternal ephedrine and phenylephrine administration

Gertie Marx research Competition 3rd place

Pervez sultan, M.B., B.s.University College

London Hospital, UK

endogenous pain inhibition does not appear to be the mechanism responsible ror pregnancy-induced analgesia

Patient safety Award Allan s. Klapper, M.D.West Penn Allegheny Health systems

Pittsburgh, PAteam based strategy to improve compliance with national safety and practice guidelines

Distinguished service Award Gerard Bassell, M.D. Wesley Medical Center, Wichita, Ks

Media Award Melinda Wenner Moyer slate Magazine: the truth about epidurals

Zuspan Award suresh Anandakrishnan, M.D.Mount sinai Hospital toronto, on, Canada

Carbetocin at elective cesarean delivery: A dose finding study

soAP/Kybele International outreach Grant

David “Matt” Hatch, M.D., M.B.A.Wake Forest University

Winston-salem, nC

An analysis of obstetric anesthesia techniques for cesarean section at ridge regional Hospital in Ghana

soAP obstetric History Award Carmen Dargis, M.D. Mayo Clinic, rochester, Mn ethylene oxygen: the history of a Midwestern anesthetic technique

Best Paper AwardBrendan Carvalho, MBBCh, FrCA,

M.D.CHstanford University Medical Center

stanford, CA

Postoperative subcutaneous instillation of ketorolac but not hydromorphone reduces pain, analgesic use and wound exudate concentrations of IL-6 and IL-10 following cesarean delivery

Best Case report with onyi onuoha, M.D., MPH, BsnUniversity of Pennsylvania

Philadelphia, PAHemodynamic changes in a parturient severe left ventricular outflow obstruction

teacher of the Year Award < 10 years

Brendan Carvalho, MBBCh, FrCA, M.D.CH

stanford University Medical Center stanford, CA

teacher of the Year Award> 10 years

May Pian-smith, M.D., M.s.Massachusetts General Hospital

Boston, MA

resident/Medical student Best Case report

elizabeth Lange, M.D. University of Illinois, Chicago, ILA case of neuraxial analgesia in a patient with antithrombin III deficiency receiving antithrombin III supplementation during labor

resident/Medical student Best original research

Allana Munro, M.D.Dalhousie University

Halifax, nova scotia, Canadasublingual microcirculation of pregnant and non-pregnant women

Continued from page 3

Meeting Summary

5

Michael A. Frölich, M.D., M.S.University of Alabama at Birmingham

Dear SOAP and ASA Mem-bers:

The summer edition of the SOAP newsletter traditionally features the summary of our annual meeting and several important committee meeting reports. In addition to these updates on the society business and programs, every

newsletter includes articles that discuss timely issues. One of the topics discussed in this edition is the drug shortage in medicine, a problem that has affected our ability to deliver the best patient care. Drs. Craigo, Mhyre and Nixon highlight these safety concerns as a result of the drug shortage.

More traditional features of the SOAP newsletter are articles that explore timeless and historical topics related to anesthesia practice. In this edition, Dr. Baysinger discusses the use of nitrous oxide for labor analgesia and Drs. Dargis and Vasdev explore the use of ethylene oxygen as anesthetic technique. Both articles are very interesting and informative.

As Media Committee Chair, I would like to give you a brief update on the activities within this very important component of our society. At the board of directors meeting in Monterey, Dr. William Camann was appointed as chair of the Website Task Force, and Dr. Richard Month was appointed as chair of the Subcommittee for Social Media. Both of these components are rapidly expanding in their activity and importance to the society, and this growth is being reflected in an expanded committee structure.

We are continuously working to maintain our website to effectively function as an information hub for our members. We are also working to expand access to historical information. This allows our members to view meeting content such as scientific abstracts going back to the inception of SOAP. We are also expanding our media archives that will house pictures of past meetings and events.

Within the social media arena, we are continuing our presence on Facebook and will explore other venues such as Twitter and Youtube. Other activities include the use of a quick response (QR) code on our website and brochures for use with mobile devices. Dr. D’Angelo is exploring the use of recorded lectures and webinars to disseminate information to our members within the scope of our budget – yet another means to use social media to educate our colleagues.

With this short report, I am sending you my best wishes.

eDItor’s CornerGrowing Committee Structure Underscores SOAP’s Progress

the sol shnider, M.D. obstetric Anesthesia Meeting

March 14 - 17, 2013 Grand Hyatt Hotel

San Francisco, California

Visit SOAP.org for more information

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John T. Sullivan, M.D., M.B.A.Northwestern Feinberg School of MedicineChicago, Illinois

Despite an unstable busi-ness economy in the first

part of 2012, SOAP continues to experience financial growth in both operational and in-vestment performance. Sum-mer is not the optimal time to report growth trends in our assets as we are still paying

expenses for our annual meeting, but I thought I would provide a brief report of our financial health following the spring meetings as well as an elaboration of our financial structure and some new strategic directions.

2012 Meeting PerformanceAs of this report, both of our meetings appear to have been

modestly profitable and membership numbers appear on track to cover our administrative expenses. SOAP is now in its third year managing the Sol Shnider meeting. Our focus has been to sustain the educational excellence and tradition of this meeting, which had been carefully nurtured by the University of California, San Francisco faculty for many years. Attendance at both the Sol Shnider and SOAP Annual Meeting in Monterey, California, was very good and coupled with careful management has led to modest profits that will support other SOAP programs.

Financial structureSOAP’s financial structure is somewhat more complicated

than the average subspecialty society due to variable spending restrictions on some of our assets donated from Gertie Marx. Because of this, our assets are held in five separate accounts, including 1) an operating cash account, 2) a reserve cash account, 3) a general endowment fund known as OAPEF (there is current discussion about its future name), 4) the Gertie Marx Education Fellowship Fund and 5) the Gertie Marx Trust (SOAP and the Foundation for Anesthesia Education and Research each received one quarter of her trust upon her death). Independence Advisors, led by Chas Boinske, has managed SOAP’s investment accounts (numbers 2-5 above) for much of the last decade. Most of our funds in these accounts are held in diversified portfolios that have posted competitive returns through a wide range of market conditions. For example, growth in these accounts has been robust in the first quarter of 2012 with our non-fixed income accounts earning 7 percent. Independence Advisors’ management fees are a reasonable at approximately 1 percent of assets annually. Examples of the portfolio composition of two of these accounts are provided below:

soAP-Gertie Marx education Fellowship FundCurrent Portfolio Allocation on March 31, 2012Total Portfolio Value = $ 391,437.40

Cash and Equivalents $2,346.77

Fixed Income $146,672.43

Alternative Investments $16,767.79

Real Estate $19,399.14

Equities $206,251.27

soAP-obstetric Anesthesia and Perinatology endowment Fund (oAPeF)Current Portfolio Allocation on March 31, 2012Total Portfolio Value = $ 694,516.32

Cash and Equivalents $2,341.69

Fixed Income $260,488.23

Alternative Investments $32,498.96

Real Estate $35,105.45

Equities $363,951.99

We have a goal of maintaining a cash reserve of approximately $200,000, which is split between our operating account at Citibank and a fixed investment portfolio with Independence Advisors. We plan to transfer excess cash beyond that reserve each fall into our endowment accounts to support programs and optimize returns. We also plan to further encourage donations to our society by clarifying how funds are used and making it easier to pledge directly through the website.

Administrative ManagementOne area of financial uncertainty for SOAP has been the future

costs of our management. ASA has provided administrative management of SOAP now for several years and has recently established a per-member managerial fee (with a volume discount for societies with membership above 1,000 and modest project fee increases over the next few years). As part of our responsible stewardship of the organization, we intermittently reexamine our society management relative to our changing needs and the market for medical specialty society management.

Program supportRegarding the use of SOAP funds, in the last newsletter I

elaborated on several SOAP programs, including the initiation of research grants, the development of a multi-institutional

treAsUrer’s rePort2012 Growth and New Strategies for a Stronger Society

Continued on page 7

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treAsUrer’s rePort

research network, the financing of a new workforce survey and support for global health initiatives. I wanted to elaborate in this article on some of the investment we’ve made in our educational endeavors. At both of our meetings this year, we piloted a program of videotaping key lectures for the purpose of broader dissemination on the Internet. Many believe this will represent a much more important part of medical education in the future; however, there are some concerns currently, including its high cost. On the upside, it could result in dissemination of important maternal health education to a wider audience globally who may not be able to attend our meetings. We are cautiously exploring this opportunity.

new strategiesSOAP will also be employing an exciting new strategy to

attempt to broaden our global reach specifically at our meetings beginning with next year’s annual meeting in Puerto Rico. The strategy comprises adopting the tiered registration pricing formula of the World Congress of Anaesthesiologists (based on country of origin), live translation of key portions of the meeting into Spanish and conducting a pre-meeting symposium in Spanish language translation. We believe these initiatives will make attending our annual meeting much more attractive to a large number of anesthesiologists whose primary language is not English.

As always, it has been an honor to be entrusted with the management of SOAP finances. I would like to encourage those able and willing society members to run for SOAP Treasurer in the spring to help ensure a healthy financial legacy. I look forward to passing the torch and working to ensure a smooth transition of office.

Continued from page 6

1st Latin American Symposium

La Sociedad de Anestesiología Obstétrica y Perinatología, “SOAP” por sus siglas en inglés, anuncia su Primer Simposio Latinoamericano de Anestesiología Obstétrica a llevarse a cabo el miércoles 24 de abril del 2013 en el Hotel Caribe Hilton en San Juan, Puerto Rico. Luego del simposio, tomará lugar el congreso anual de SOAP desde el jueves 25 al domingo 28 de abril, 2013.

¡Esperamos verles en San Juan!*Todas las presentanciones del Simposio Latinoamericano se

ofrecerán en español. Detalles adicionales del programa se ofrecerán oportunamente.

The Society of Obstetric Anesthesia and Perinatology (SOAP) announces its 1st Latin American Symposium on Obstetric Anesthesia to be held on Wednesday April 24, 2013 at the Caribe Hilton Hotel in San Juan, Puerto Rico. The annual SOAP meeting will follow from Thursday the 25th to Sunday the 28th of April, 2013.

Please join us in San Juan!*All presentations of the Latin American Symposium will be

conducted in Spanish. Program details to follow.

Vilma E. Ortiz, M.D., and Barbara Scavone, M.D.

www.soap.org

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Valerie Arkoosh, M.D., M.P.H.University of PennsylvaniaPhiladelphia, Pennsylvania

The Disbursement Commit-tee was formed to consider

and make recommendations to the SOAP Board of Direc-tors as to the disbursement of funds from the Obstetric Anesthesia and Perinatology Education Fund (OAPEF), the Gertie Marx Education Fund and other requests that may

come to the board. The committee is composed of four past SOAP Presidents (Valerie Arkoosh, M.D., M.P.H., Chair, Gerald Bassell, M.D., Joy Hawkins, M.D., Alan Santos, M.D., M.P.H.), the SOAP Treasurer (John Sullivan, M.D., M.B.A.), the Chair of the SOAP Ed-ucation Committee (Manuel Vallejo, M.D., D.M.D.) and the Chair of the SOAP Research Committee (Richard Smiley, M.D., Ph.D.).

During 2011, the committee was pleased to award the 2012 SOAP/Gertie Marx Education and Research Grant to Dr. Terrence K. Allen, Assistant Professor of Anesthesiology, Division of

Women’s Anesthesiology, Duke University Medical Center, for his project titled “Mechanisms of Progesterone Mediated Effects on Cyotkine-Induced Metalloproteinase Activity in Human Trophoblast Cells.” The funds for this $50,000 (over two years) grant are available thanks to an extremely generous bequest to SOAP from the estate of Dr. Marx. The committee would like to thank all of the submitters and grant reviewers who graded the submissions using an approach similar to the one used by the NIH. The grading process was rigorous and went smoothly. The grant will be offered again in 2013 with applications due October 1, 2012. Initial funds will be disbursed in January 2013. Go here for the application details www.soap.org/gertie-marx-award.php.

The committee would also like to alert the membership to OAPEF. First, we encourage all members to consider donating to this tax-deductible fund. Donations are solicited with annual dues and at the time of meeting registration. Second, OAPEF funds may be requested to fund small projects (<$15,000) that would not be eligible for the SOAP/Gertie Marx Education and Research Grant. Members interested in soliciting these funds should contact committee Chair Valerie Arkoosh, M.D., M.P.H.

The committee is honored to serve the membership and board and encourages and welcomes feedback on any of the items discussed above.

Disbursement Committee: Funding Tomorrow’s LeadersCoMMIttee rePorts

SOAP 45th Annual MeetingApril 24-28, 2013 Caribe Hilton San Juan, Puerto Rico

Visit SOAP.org for more information

9

Curtis L. Baysinger, M.D,Vanderbilt University Medical CenterNashville, Tennessee

“Distant water won’t help to put out a fire close at hand.”

– Chinese Proverb

Massachusetts and New York enacted legislation

recently extending the scope of nurse midwife practice by removing the requirement

that certified nurse midwives practice under the supervision of a physician. This provision would potentially allow practice pat-terns at odds with the ASA and the American College of Ob-stetricians and Gynecology joint statement, “Optimal Goals for Anesthesia Care in Obstetrics,” which states that 1) a qualified physician who can perform an operative delivery be readily avail-able during anesthetic administration and 2) that a physician with obstetric privileges should be responsible for midwifery backup if complications should occur.1 Both the ASA Committee on Obstetrical Anesthesia and this committee drafted responses reaffirming this policy. This committee further stated that the col-laboration should occur before the initiation of anesthetic care in most practice situations. Approximately one and a half years ago, the Centers for Medicare & Medicaid Services revised its Anes-thesia Services Interpretive Guidelines requiring that all sedation, analgesia and anesthesia services in an institution be organized under one department of anesthesiology. This department would have the responsibility of setting the policies for anesthesia and analgesia and for the credentialing of personnel authorized to provide those services. Recent changes in state law do not pre-clude facilities from adhering to these guidelines when adopting policies for anesthesia care for obstetrical patients. SOAP and this committee urges all members to become directly involved in their facilities’ committees charged with directing anesthesia care. As suggested by the proverb cited above, local action will increasingly be required of members at their own institutions to best ensure high-quality and safe anesthesia care in obstetrics

Many SOAP members may be aware of a joint 2010 report from the Robert Wood Johnson Foundation and the Institute of Medicine recommending that non-physician health care providers become full partners with physicians in redesigning health care in the United States. These two organizations, along with AARP, have created an advocacy effort to promote increased leadership roles and removal of barriers to practice for these advanced practice non-physician providers, with efforts primarily focused on state and local governmental and regulatory

agencies. This committee urges SOAP members to become involved in highlighting the patient safety implications resulting from this advocacy campaign to state governments. To reiterate the above, local action will be increasingly required by members to best ensure high-quality and safe anesthesia care.

Drug shortagesDrug shortages have interfered with patient care with

anesthesia providers in general, and obstetric anesthesia providers in particular have been adversely affected as well. The SOAP Patient Safety Committee has prepared a statement suggesting actions to help deal with shortages and resolve the ongoing problem. While the recent executive order by the Obama Administration mandating that the FDA be informed by a generic drug manufacturer of their decision to terminate production of a vital drug no later than six months before exiting the marketplace will provide time for health organizations to find alternative sources, this action will not end generic anesthetic drug shortages. The SOAP Economic and Government Affairs Committee urges the membership to contact SOAP, the FDA, ASA and their congressional leadership with examples of potential patient harm resulting from a drug shortage.

Finally, the United States Supreme Court ruled in favor of the constitutionality of the insurance mandate, which was determined to be constitutional and may impact several of the provisions contained within the Affordable Care Act. Some of the key provisions that provide strong incentives for the establishment of accountable care organizations (ACOs) may be altered, making specific recommendations on how to best react to the changes these organizations will create difficult. Economic forces will increasingly demand that obstetric anesthesia providers show the value of their services regardless of changes to federal legislation. Proving our value by coordinating women’s operative care may be the best way to ensure that high-quality obstetric anesthesia care will be maintained in the future health care environment.

reference:1. American College of Obstetricians and Gynecologists and American

Society of Anesthesiologists. Optimal goals for anesthesia care in obstetrics. Obstet Gynecol 2009; 113:1197-9.

Economics and Government Affairs Committee:Local Action Is Needed Now

CoMMIttee rePorts

10

Ashraf Habib, M.D.Duke UniversityDurham, North Carolina

The International Outreach Committee is preparing to

receive applications for the SOAP/ Kybele International Outreach Grant. This grant provides funding needed to get involved with international outreach projects in collabo-ration with Kybele. The grant recipient is expected to com-

plete a project with the goal of enhancing the practice of obstetric anesthesia in one of the countries with an ongoing outreach pro-gram. Deadline for application is October 1, 2012. Further information is available from Dr. Ashraf Habib habib001@mc.duke.edu, Dr. Medge Owen mowen@wfubmc.edu or the SOAP website www.soap.org/int-outreach-grant-announce-ment.pdf. This is an exciting opportunity to get involved with international outreach and have an impact on the practice of obstetric anesthesia in an international location.

Currently, committee members are busy with several ongoing outreach projects. In 2007, Kybele and the Ghana Health Service partnered to reduce maternal and neonatal mortality at Ridge Hospital in Accra. Dr. Yemi Olufolabi olufo001@mc.duke.edu and Medge Owen, M.D. mowen@wfubmc.edu led two to three yearly trips of multidisciplinary teams. Significant accomplishments were achieved, including a 36 percent reduction in still birth rates and a decrease in maternal mortality ratio from 496 to 328/100,000 live births. Case fatality rates for preeclampsia and hemorrhage decreased from 3.1 10 1.1 percent and 14.8 10 1.9 percent, respectively. A nurse anesthesia school was started, with

the first class graduating recently. A second program began in another Ghanian site, Suniyani, led by Dr. Ron George rbgeorge@dal.ca. The last visit in January 2011 focused on improved neonatal resuscitation, maternal postpartum analgesia and organized management of obstetric emergencies. Through the team educational initiatives, an organized neonatal resuscitation continuing education program has been established chaired by a local nurse.

Dr. Ling Hu lingqunh@gmail.com led two trips to China in 2008 and 2010 to promote safe and effective labor analgesia. In the second visit in June 2010, there was a marked improvement, with an epidural rate of up to 70 percent in two hospitals. Several local obstetric anesthesia meetings were held during the team visits. Practice guidelines for obstetric anesthesia have also been established. The team helped with research protocols and publications. The book by William Camann, M.D., Easy Labor, was

translated to Chinese to help improve patient education.

The program in Egypt led by Dr. Sabri Barsoum BARSOUs@ccf.org and Dr. Habib habib001@mc.duke.edu was effective in increasing the rate of regional anesthesia for cesarean section and encouraging the use of pencil

point needles. However, a trip in February 2011 was cancelled due to instability in the country and will be rescheduled when conditions allow. In a recent trip to Romania in May 2011, a team led by Dr. Virgil Manica vmanica@comcast.net continued education in two maternity units in Lasi and conducted a symposium on obstetric anesthesia for the high-risk parturient.

A lot is going on with significant impacts on the practice of obstetric anesthesia worldwide! If you are interested in any of the above projects, please contact the trip leaders.

International Outreach Committee:Thinking Globally to Improve Obstetric Anesthesia Care

CoMMIttee rePorts

“Significant accomplishments were achieved, including a 36 percent reduction in still birth rates

and a decrease in maternal mortality ratio from 496 to 328/100,000 live births.”

11

Curtis Baysinger, M.D.Vanderbilt University Medical CenterNashville, Tennessee

Inhaled nitrous oxide was in-troduced to provide pain re-

lief during labor in 1881, and its routine use for labor an-algesia began after introduc-tion of an apparatus for self-administration in 1934.1,2 The technique is used by 60 per-cent of laboring women in the

United Kingdom,2 50 percent of laboring women in Australia,3 and almost 50 percent of women who deliver in Finland and Can-ada.4 In contrast, one recent survey reported that only 1 percent of women reported the use of nitrous oxide for labor analgesia in the United States5 and there appear to be only two centers in the United States where it is routinely available. Other inhalational agents alone, or in combination with nitrous oxide, have been studied for labor analgesia, but these reports are largely from the United Kingdom. Furthermore, only nitrous oxide has been used for inhalational analgesia to any great extent elsewhere.1,6

Efficacy:Studies that evaluate the efficacy of techniques used for labor

analgesia are difficult to design. Severe pain is experienced by most women at some point in labor, but its intensity is highly variable and depends upon maternal factors, the size and presentation of the fetus, whether labor is spontaneous or augmented, the rate of cervical dilation during the first stage and parity.7 The experience of pain for women during labor and vaginal delivery depends on numerous psychosocial factors as well.8 Labor pain typically increases as labor progresses; however, most studies that use women as their own control assume that the pain of labor remains constant. Only recently have mathematical techniques been described to adjust for changes in labor pain as labor progresses.9 In addition, studies that ask for patients’ assessment of labor pain two to three days after delivery show a marked difference from pain assessed during labor,1 and thus the validity of post-delivery survey studies suffer from recall bias. Randomized controlled trials that assign patients to a group that offers no analgesia in order to assess the efficacy of a particular technique are not ethical. The known superior pain relief offered by epidural analgesia (associated with reductions in visual analog pain scores from 8 out of 10 to 3 out of 10)10 and higher maternal satisfaction scores in comparison to other forms of labor analgesia may make recruitment of suitable study subjects difficult.11

Efficacy and Maternal Satisfaction:The efficacy and safety of nitrous oxide for labor analgesia

has not been recently evaluated. The most recent review,1 in 2002, summarized the results of 11 randomized controlled trials, of which only one was published after 1996. This review concluded that current published work does not provide clear quantitative objective evidence of the analgesic efficacy of nitrous oxide.1 While one study in that review reported moderate decreases in visual analog pain scores (from 8/10 to 6/10) when the concentration of inspired nitrous oxide was increased from 0 percent to 70 percent,12 another study by Carstinou et al. showed no difference in visual analog pain scores when inhaled 50 percent nitrous oxide in oxygen was compared to air administration during labor.13 However, many of the women in that study wished to continue the inhaled therapy after the study period. In addition, many women in other studies have reported significant “benefit” to its use and the majority who used it during labor stated that they would choose it as a form of pain relief for subsequent labors.1,2 These data suggest that further study to define the nature of maternal pain relief during labor with inhaled nitrous oxide administration is warranted and that there are other as yet undefined factors that seem to promote patient satisfaction with its use.1,2,4,14

The peak analgesic effect of nitrous oxide lags the start of its administration by 50 seconds; however, uterine contractions typically peak 30 seconds after they start and stop 30 seconds later, out of phase with the analgesic effects of nitrous oxide administered beginning at the start of a contraction.1 Studies designed to determine the best techniques for its intermittent administration to attain the highest concentrations at the time of peak pain during a contraction are indicated.1

Comparison of Efficacy With Other Methods of Labor Analgesia:

Nearly all efficacy studies of inhaled nitrous oxide have compared its use to placebo (inhaled air administration), the analgesic benefit of increasing the inhaled concentration or the effects of adding other volatile agents to the inhaled mixture.1 Most studies have shown that other volatile inhaled agents provide analgesia equal to or better than nitrous oxide when administered alone, or when added to nitrous oxide, but at the expense of increased maternal sedation.1 Only one study has directly compared the efficacy of nitrous oxide to intravenous opioid administration. Volmanen et al.15 compared intermittent patient-controlled administration of intravenous remifentanil to self-administered nitrous oxide and noted that remifentanil decreased visual analog pain scores (mean reduction in pain score of 1.5 points on a 0-10 scale) compared to nitrous oxide (mean reduction in pain score of 0.5 points on a 0-10 scale), but with increased maternal sedation scores (sedation score 2 with

Nitrous Oxide for Labor Analgesia

Continued on page 12

12

remifentanil and 0.5 with nitrous oxide, both on a 0-3 scale).15 Such small reductions in pain scores with either technique are probably not clinically significant and are much smaller than the reductions of 5 points (on a 0-10 scale) typically seen with epidural analgesia. These reductions in pain score are associated with the very high rates of maternal satisfaction seen with epidural analgesia when compared to other methods of pain relief.10,11 Reductions in pain scores with inhaled nitrous oxide use seem similar to that of systemic opioids,16 which some authors suggest have little effect on labor pain.14

A few studies of non-pharmacologic methods of pain relief suggest that the analgesia is similar to that associated with ni-trous oxide use with similar levels of patient satisfaction.1,17,18 One nonrandomized study comparing nitrous oxide to transcutaneous electrical nerve stimulation, intramuscular meperidine and pro-mazine administration, and epidural analgesia demonstrated the superior pain relief associated with epidural analgesia; however, 90% of women also reported partial relief with nerve stimula-tion or nitrous oxide and only 54% reported some pain relief with meperidine/promazine.1,19 There are no studies compar-ing nitrous oxide to pudendal block for the relief of pain during the second stage of labor. Randomized controlled studies that compare nitrous oxide to paracervical block-ade would be difficult to con-duct. Paracervical block is not widely used for labor analgesia because of the relatively high incidence of fetal heart rate abnormalities that accompany the block, despite recent improvements in technique designed to improve its safety.6

Adverse effects:Inhaled nitrous oxide analgesia for labor has been used

for several decades in the United Kingdom with good safety outcomes for both mother and child. Its use does not seem to appreciably affect the rates of maternal nausea or vomiting during labor.1,14 The direct respiratory depressant effect of nitrous oxide in combination with the maternal hypocapnia that accompanies labor may increase the rate of maternal oxygen desaturation in between labor contractions,1,14,20 although one small well conducted study failed to show a significant effect.13 The addition of systemic opioid administration may be expected to increase the likelihood of maternal hypoxemia.20,21 One small study reported that the rate of maternal desaturation was higher with nitrous oxide administration when compared to epidural analgesia.22 The significance of mild maternal hypoxemia upon the fetus is unknown.14 Most studies have failed to show significant adverse neonatal effects measured by Apgar score1,23

or umbilical artery and vein blood gases.24 This is in contrast to studies of systemic opioid administration for labor analgesia in which significantly higher rates of neonatal depression have been reported, especially in comparison studies with epidural analgesia for labor.25

Maternal drowsiness is reported to occur in 0-24 percent of laboring women1 and rates of maternal unconsciousness appear to increase in a dose dependent fashion from approximately 1 percent when 50 percent nitrous oxide are used to 5 percent when 80 percent nitrous oxide is used.14,26 These rates would be expected to be higher during the continuous administration of nitrous oxide.14

Recent work has demonstrated the neurotoxic effects of anesthetic agents on the developing rodent27 and primate brain.28 Nitrous oxide administration may have more risk for creating these changes than other agents.29,30 The effects on human fetuses exposed to nitrous oxide or other anesthetic agents in utero is unknown.27

Environmental pollution occurs frequently during inhaled administration and health care workers are often exposed to levels of nitrous oxide in excess of occupational exposure limits.29,30

Although the long term effects on the health of workers are unclear30,31 there may be an increased risk of adverse reproductive outcomes in health care workers due to such occupational exposure.32 Nitrous oxide administration does not affect uterine activity and thus would not

be expected to affect the course of the first and second stages of labor and rates of cesarean delivery. By way of comparison, epidural analgesia does not affect the incidence of cesarean section, or length of the first stage of labor, although slight prolongation of the second stage of labor can be expected.33

Management of Inhaled nitrous oxide Analgesia:Procedures for the administration of inhaled nitrous oxide

for labor have to comply with the sedation policies developed within each institution’s department of anesthesiology. These policies should be in accordance with recent Centers for Medicare & Medicaid Services guidelines for anesthesia care34; its administration should be performed in health care facilities with written protocols for its use and where pulse oximetry and gas scavenging systems are available.1 Although nitrous oxide has a long history of safe use, several case series documenting maternal hypoxemia indicate this occurrence may put an “at risk” fetus in jeopardy.14 Environmental pollution is frequent if adequate methods of scavenging of un-breathed and exhaled gas are not employed. This may pose health risks to exposed

Nitrous Oxide for Labor Analgesia

Continued on page 13

“A few studies of non-pharmacologic methods of pain relief suggest that the analgesia is similar to that associated with nitrous oxide use with similar

levels of patient satisfaction.”

Continued from page 11

13

health care workers and other participants in the mother’s care, and may contribute significantly to global warming (nitrous oxide is a “greenhouse gas”).14 Appropriate patient consent should be obtained and in particular reflect the possibility of long term adverse effects on child neurologic development.27 Nursing and obstetric providers should receive instruction on its safe use with periodic assessment of competence and perhaps certification. Because the efficacy of inhaled nitrous oxide in relieving pain during labor has not been well established, alternative means of pain relief should be available and considered (such as pudendal nerve block during the second stage of labor, and systemic opioids if neuraxial analgesia techniques are not available). Systemic opioids would be expected to increase the risk of respiratory depression associated with nitrous oxide use,1,14,20 and pulse oximetry monitoring of the mother would be indicated in this situation. Rosen1 has suggested areas for continued research to include: techniques to improve the timing of administration to better coincide with the pain of uterine contraction; safety of administration by non-anesthesia personnel; the efficacy of additional co-administered methods to improve analgesia; and the development of methods to better measure the degree of maternal pain relief when nitrous oxide is used during labor.

references:1. Rosen MA. Nitrous oxide for relief of labor pain: A systematic review. Am J

Obstet gynecol 2002; 186: S110-126.2. Clyburn P. The use of Exntonox for labour pain should be abandoned.

Opposer. Int J Obstet Anesth 2001; 10: 25-39.3. Australian Institute of Health and Welfare. Australian mother and babies

2007: Perinatal status report. www.preru.unsw.edu.ev.4. Rooks JP. Nitrous oxide for pain in labor-why not in the United States?

Birth 2007; 34: 3-5.5. Hawkins J, Gibbs C, Orleans M, et al. Obstetric anesthesia ; a national

survey. Anesthesiology 1986; 65: 298-306.6. Paech M. Newer techniques of labor analgesia. Anesthesiology Clin N Am

2003; 21; 1-17.7. Caton D, Corry MP, Frigoletto FD, Hopkins DP, Lieberman E, Mayberry

L, Rooks JP, Rosenfield A, Sakala C, Simkin P, Young D. The nature and management of labor pain; Executive summary. Am J Obstet Gynecol 2002; 186: s1-15.

8. Lowe NK. The nature of labor pain. Am J Obstet Gynecol 2002; 186: S16-24.9. Debiec J, Conell-Price J, Evansmith J, Shafer SL, Flood P. Mathematical

modeling of the pain and progress of the first stage of nulliparous labor. Anesthesiology 2009; 111: 1093-110.

10. Halpern SH, Muir H, Breen TW, Campbell DC, Barrett J, Liston R, Balnchard JW. A multicenter randomized controlled trial comparing patient-controlled epidural with intravenous analgesia for pain relief in labor. Anesth Analg 2004; 99: 1532-8.

11. Wong CA. Epidural and spinal analgesia/anesthesia for labor and vaginal delivery. In, Chestnut DH, Polley LS, Tsen LC, Wong CA, editors. Chestnut’s Obstetric Anesthesia: Principles and Practice. Philadelphia, PA, Mosby Elsevier 2009: 429-492.

12. Westling F, Milsom I, Zetterstrom H, Ekstorom-Jodal B. Effects of nitrous oxide oxygen inhalation on the maternal circulation during vaginal delivery. Acta Anaesthesiol Scand 1992; 36; 175-181.

13. Carstoniu J, Levytam S, Norman P, Daley D, Katz J, Sandler AN. Nitrous oxide in early labor-safety and analgesic efficacy assessed by a double-blind, placebo-controlled study. Anesthesiology 1994; 80: 30-35.

14. Yentis SM. The use of Entonox for labour pain should be abandoned. Proposer. Int J Obstet Anesth 2001; 10; 25-29.

15. Volmanen P, Akural E, Raudaskoski T, Ohtonen P, Alahutta S. Comparison of remifentanil and nitrous oxide in labour analgesia. Acta Anaestheiol Scand 2005; 49: 453-458.

16. Olofsson C, Ekblom A, Ekman-Orderberg G, Hjelm A, Irestedt L. Lack of analgesic effect of systemically administered morphine or pethidine on labour pain. Br J Obstet Gyencol 1996; 103: 968-972.

17. Minnich ME. Childbirth preparation and nonpharmacologic analgesia. In Chestnut DH, Polley LS, Tsen LC, Wong CA, editors. Chestnut’s Obstetric Aneshtesia: Principles and Practice. Philadelphia, PA, Mosby Elsevier 2009: 405-414.

18. Ranta P, Jouppila P, Spalding M, Kangas-Saarela T, Hollmen A, Jouppila R. Parturients’ assessment of water blocks, pethidine, nitrous oxide, paracervical and epidural blocks in labour. Int J Obstet Anesth 1994; 4: 193-8.

19. Harrison RF, Shore M, Woods T, Mathews G, Gardiner J, Unwin A. . A comparative study of transcutaneous electrical nerve stimulation(TENS) entonox, pethidine+promazine, and lumbar epidural for pain relief in labor. Acta Obstet Gyncol Scand 1987; 66: 9-14.

20. Lucas DN, Siemaszko O, Yentis SM. Maternal hypoxaemia associated with the use of Entoonx in labour. Int J Obstet Anesth 2000; 9: 270-2.

21. Deckardt R, Fembacher PM, Schneider KT, Graef H. Maternal arterial oxygen saturation during labor and delivery: Pain-dependent alterations and effects on the newborn. Obset Gynecol 1987; 70: 21-5.

22. Arfeen A, Armstrong PJ, Whitfield A. The effects of Entonox and epidural analgesia on arterial oxygen saturation of women in labour. Anaesthesia `1994; 49: 32-4.

23. Stefani S, Hughes S, Shnider S, Levinson G, Abboud TK, Henriksen EGH, Williams V, Johnson J. Neonatal neurobehavioral effects of inhalation analgesia for vaginal delivery. Anesthesiology 1982; 56: 351-5.

24. Griffin RP, Reynolds F. Maternal hyopxaemia during labour and delivery: the influence of analgesia and effect on neonatal outcome.

25. Halpern SH, Muir H, Breen TW, Campbell DC, Barrett J, Liston R, Blanchard JW. A multicenter randomized controlled trial comparing patient-controlled epidural with intravenous analgesia for pain relief in labor. Anesth Analg 2004; 99: 1532-8.

26. McAneny T, Doughty AG. Self-administration of nitrous oxide/oxygen in obstetrics. Anaesthesia 1963; 18: 488-97.

27. Creely CE, Olney JW. The young: Neuroapoptosis induced by anesthetics and what to do about it. Anesth Analg 2010; 110: 442-8.

28. Bambrink AM, Evers AS, Avidan MS, Farber NB, Smith DJ, Zhang X, Dissen GA, Creely CE, Olney JW. Isoflurane-induced neurapoptosis in the neonatal rhesus macaque brain. Anesthesiology 2010; 112: 834-41.

29. Sanders RD, Weimann J, Maze M. Biologic effects of nitrous oxide. Anesthesiology 2008; 109: 707-22.

30. Mills GG, Singh D, Longan M, O’Sullivan J, Caunt JA. Nitrous oxide exposure on the labour ward. Int J Obstet Anesth 1996; 5: 160-4.

31. Fernando R, jones T. Systemic analgesia: parenteral and inhalational agents. In, Chestnut DH, Polley LS, Tsen LC, Wong CA, editors. Chestnut’s Obstetric Aeeshtesia: Principles and Practice. Philadelp;hia, PA, Mosby Elsevier 2009: 415-427.

32. Rowland AS, Baird DD, Weinberg CR, Shore DL, Shy CM, Wilcox AJ. Reduced fertility among women employed as dental assistants exposed to high levels of nitrous oxide. N Engl J Med 1992;327:993-7.

33. Leighton BL, Halpern SH. The effects of epidural analgesia on labor, maternal, and neonatal outcomes: A systematic review. Am J Obstet Gyencol 2002; 186: S69-77.

34. Revised Hospital Anesthesia Services Interpretive Guidelines-State Operations Manual(SOM) Appendix A. Centers for Medicare and Medicaid Services, December 11, 2009.

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14

The production and distribution of pharmaceuticals is an intricate process and each step is laden with its own pitfalls

and potential for failure.1-2 Despite an executive order from President Obama in October 2011 and legislation recently approved by the House Energy and Commerce Committee (H.R. 5651) to reduce prescription drug shortages, the number of medications currently “on shortage” is on the rise.3

Drug shortages are a significant patient safety concern. In a national survey administered by the Institute of Safe Medication Practices (ISMP) in 2010, one in three physicians reported an adverse patient outcome due to drug shortages.4 Decreased availability of necessary medications may result in delayed or inadequate treatment, use of suboptimal therapies or even - when no alternative is available - no treatment at all. Hospitals in desperation turn to “gray market” drug suppliers only to receive products of inconsistent quality and unreliable efficacy. These medications may have uncertain production origins and be subject to questionable storage and handling practices.5

In addition to delaying and compromising treatment, drug shortages increase the risk of medication errors via several mechanisms. First, in order to obtain an adequate supply of necessary medications, hospital pharmacies may purchase drugs from multiple suppliers, each using different packaging. Replacement drugs may appear identical to other medications already in use at the institution, increasing the risk of “look-alike” errors by the end user. Second, these new suppliers may provide different concentrations of the drug on shortage. This can lead to drastic under- or over-dosing if the change in concentration is not recognized. Erratic supply and frequent changes in dispensed concentrations further increase the risk of error. This is a particular concern for trainees who may already be at increased risk for medication errors.6 Third, medication errors may result when physicians are forced by a shortage to use unfamiliar medications or adapt familiar medications to alternative uses.

For the obstetric anesthesia provider there may be additional unrecognized risks for harm. Neuraxial techniques are more common in the obstetric setting. While intravenous drug errors may result in harm, the epidural and intrathecal spaces are much less forgiving, and errors can be catastrophic. The Food and Drug Administration website currently lists several neuraxial medications on shortage. In response, hospital purchasers may substitute medications containing preservatives toxic to the epidural or intrathecal space. This can occur with adjuncts as well as local anesthetics containing EDTA or sodium metabisulfites. A scarcity of these drugs may also affect neuraxial kit production and supply. When this happens, anesthesiologists must resort to alternate kits, further disrupting daily practice. Finally, providers facing shortages may be tempted to reduce medication waste by splitting single-dose vials into multiple doses. Such practices are not condoned by the CDC and may increase the risk of infection.7,8

Obstetric anesthesia providers create a cushion of safety for women and babies in a dynamic, high-stakes environment peppered with latent errors. The drug shortage crisis adds even more potential for patient harm to our practice environments while compromising and complicating our efforts to ensure safety. To assist you in mitigating the effects of the drug shortage crisis, a Statement on Drug Shortages has been created by the SOAP Patient Safety Committee, providing quick access to suggested best practices. A brief summary is included in this newsletter, and the full statement may be accessed on the SOAP website.

For more information concerning ongoing drug shortages, please see the FDA website at www.fda.gov/drugs/drugsafety/drugshortages/ucm050792.htm.

references:1. Fox ER, et al. ASHP Guidelines on Managing Drug Product Shortages in Hospitals and

Health Systems. Am J Health Syst Pharm. 2009. 66(15):1399-406.2. De Oliveira GS, Jr., Theilken LS, McCarthy R.J. Shortage of perioperative drugs: implications

for anesthesia practice and patient safety. Anesth Analg. 2011; 113(6)1429-35.3. Kaakeh R, et al. Impact of drug shortages on U.S. health systems. Am J Health Syst

Pharm. 2011; 68(19):1811-9.4. Institute for Safe Medical Practices. Drug shortages: National survey reveals high level of

frustration, low level of safety. ISMP Medication Safety Alert, 2010. 15(19):1-6.5. Institute for Safe Medical Practices. Gray market, black heart: pharmaceutical gray

market finds a disturbing niche during the drug shortage crisis. ISMP Medication Safety Alert, 2011. 16(17):1-4.

6. Cooper L, et al. Influences observed on incidence and reporting of medication errors in anesthesia. Can J Anaesth. 2012; 59(6):562-570.

7. Bennett SN, et al. Postoperative infections traced to contamination of an intravenous anesthetic, propofol. N Engl J Med. 1995; 333(3):147-54.

8. Centers for Disease Control website, Questions about single dose /single use vials. Accessed on May 14, 2012. 2012 http://www.cdc.gov/injectionsafety/providers/provider_faqs_singlevials.html.

Drug Shortage Crisis: Patient Safety Concerns for Obstetric Anesthesiologists

Jill Mhyre, M.D.University of MichiganAnn Arbor, Michigan

Heather Nixon, M.D.University of Illinois at ChicagoChicago, Illinois

15

The following is the subject of the winning SOAP Obstetric History Prize from the 2012 SOAP Annual Meeting. Congratulations to Dr. Dargis on her award.

In the early 1900s, scientists discovered that the toxic effect of illuminating gas on carnations was due to ethylene gas This

discovery prompted research into the potentially toxic effects of ethylene on animals. Initial experiments in frogs failed to demonstrate toxicity. The animals actually became anesthetized, exhibiting no response to noxious stimuli, with prompt recovery upon cessation of the exposure. No residual side effects were observed. This led to further study into the potential use of ethylene for anesthesia and analgesia in humans.

Ethylene was introduced into practice as an anesthetic agent in 1923 in Chicago by Drs. Luckhardt and Carter.1 They noted a rapid, pleasant induction and emergence. Ethylene alone generally provided adequate surgical relaxation2 while maintaining cardiopulmonary stability. It was not considered a respiratory irritant. The side effect profile was mild, including transient postoperative nausea and vomiting. Ethylene was quickly introduced as an option for obstetric anesthesia.

Obstetric anesthesia at this time was a field in constant development. Ether was delivered in 1847 by James Young Simpson to relieve labor pain, followed by the use of chloroform and nitrous oxide. James Taylor Gwathmey developed a method of administering rectal ether for labor analgesia.

Intravenous barbiturates and narcotics were used but led to significant respiratory depression in the newborns, often requiring resuscitation. Regional anesthesia was still somewhat controversial for the use of labor analgesia. The first epidural for this purpose was reported in 1931 and would not become a standard of practice until several decades later.3 Thus the search continued for ideal inhalational agents.

Ethylene was well suited for use in obstetric analgesia and anesthesia, due to its rapid, pleasant induction and emergence, cardiopulmonary stability and surgical relaxation for both routine and operative deliveries.4 Analgesia preceded anesthesia, allowing practitioners to provide analgesia during contractions without excessive sedation of laboring mothers. Reports of blood loss with ethylene were somewhat mixed, but were generally lower than that seen with ether or chloroform.5 Ethylene did not alter fetal heart tones nor did it prolong the second stage of labor, maintaining both the frequency and intensity of uterine contractions.6 Neonates born to mothers receiving ethylene were immediately pink without evidence of cyanosis or need for resuscitation.

Though ethylene filled an important role in the history of obstetric anesthesia, it was not without disadvantages. It was inherently explosive, necessitating trained personnel and

specialized equipment for safe delivery, including continuous metal connections from the patient’s mask to the anesthesia machine and grounding of the machine itself. Ethylene was therefore unsuitable for use in home births, a popular practice at the time, or in operating rooms

using open flame or cautery. Obstetric anesthesia also continued to evolve. New inhalational agents with improved safety profiles were introduced in the 1930s. Following the first labor epidural in 1931, rapid advancements were made in the field of regional anesthesia for obstetrics, ultimately leading to the techniques of spinal, epidural and combined spinal-epidural anesthesia that we routinely use today.

references:1. Luckhardt AB, Carter JB. Anesth Analg. 1923; 2(6): 221-32. 2. Heaney NS. JAMA. 1924; 83(26): 2061-2062.3. Bacon DR. Anesthesiology Clin. 2008; 26:67-74.4. Blevins WJ. California and Western Medicine. 1929; 30:106-8.5. Plass ED, Swanson CN. JAMA. 1926; 87(21):1716-9.6. Rucker MP. Anesth Analg. 1926; 5:235-46.

Ethylene Oxygen: The History of a Midwestern Obstetric Anesthetic Technique

PIoneers’ Corner

Carmen R. Dargis, M.D. Mayo ClinicRochester, Minnesota

Gurinder M. Vasdev, M.D.Mayo ClinicRochester, Minnesota

“Ethylene was introduced into practice as an anesthetic agent in 1923 in Chicago by Drs. Luckhardt and Carter.1 They noted a rapid, pleasant induction and emergence.”

16

520 n. northwest HighwayPark ridge, IL 60068-2573

2012-2013 soAP Board of DirectorsPresident

McCallum R. Hoyt, M.D. M.B.A.Boston, MA

President-elect Barbara M. Scavone, M.D.

Chicago, IL

1st Vice PresidentRobert R. Gaiser, M.D.

Philadelphia, PA

2nd Vice PresidentManual C. Vallejo Jr., M.D. D.M.D.

Pittsburgh, PA

treasurerJohn T. Sullivan, M.D., M.B.A.

Chicago, IL

secretaryKenneth E. Nelson, M.D.

Winston-Salem, NC

Immediate Past PresidentMaya S. Suresh, M.D.

Houston, TX

AsA House of DelegatesRichard N. Wissler, M.D., Ph.D.

Rochester, NY

AsA Alternate House of DelegatesPaloma Toledo, M.D., M.P.H.

Chicago, IL

Director at LargeBrendan Carvalho, M.D., B.Ch., FRCA

Stanford, CA

Chair, AsA Committee on oB Anesthesia

Craig M. Palmer, M.D. Tucson, AZ

2012 HostDennis C. Shay, M.D.

San Diego, CA

2013 HostVilma E. Ortiz, M.D.

Boston, MA

2014 HostJose Carvalho, M.D., Ph.D., FANZCA

Toronto, Ontario, Canada

Journal LiaisonWilliam R. Camann, M.D.

Waban, MA

newsletter editorMichael A. Froelich, M.D.

Birmingham, AL

Chair, educational track subcommittee on oB Anesthesia of the AsA

Lawrence C. Tsen, M.D.Boston, MA