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Intrapartum Care: Care of Healthy Women and Their Babies During Childbirth

The guideline is intended to cover the care of healthy women with uncomplicated pregnancies entering labour at low risk of developing intrapartum complications. In addition, recommendations are included that address the care of women who start labour as ‘low risk’ but who go on to develop complications. These include the care of women with prelabour rupture of membranes at term, care of the woman and baby when meconium is present, indications for continuous cardiotocography, interpretation of cardiotocography traces, and management of retained placenta and postpartum haemorrhage. Aspects of intrapartum care for women at risk of developing intrapartum complications are covered by a range of guidelines on specific conditions (see section 1.8) and a further guideline is planned on intrapartum care of women ‘at high risk’ of complications during pregnancy and the intrapartum period.

NICE Clinical Guidelines - National Collaborating Centre for Women's and Children's Health (UK).

Version: December 2014
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Incidence of epidural haematoma and neurological injury in cardiovascular patients with epidural analgesia/anaesthesia: systematic review and meta-analysis

This review reported no cases of epidural haematomas or persistent neurological injury, and few transient neurological injuries following epidural analgesia or anaesthesia. The authors estimated that the maximum risks for epidural haematoma were 1 in 1,700, 1 in 1,400 and 1 in 1,700 for epidural anaesthesia in cardiac, thoracic and vascular surgery, respectively. The review had some methodological weaknesses, but the authors’ conclusions appear appropriate and are likely to be reliable.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2006

Epidural analgesia for heart surgery

The use of thoracic epidural analgesia (TEA) in heart surgery is controversial. TEA produces a high level of pain relief and may reduce some of the adverse effects that are associated with heart surgery. Along with these potential benefits of TEA there is a widespread fear that TEA could cause bleeding into the epidural space (haematoma). We have conducted a review of medical trials to compare the effect of general anaesthesia (GA) alone with GA in combination with epidural analgesia on major complications in patients undergoing elective heart surgery. We identified 5035 titles of which 31 publications met all the inclusion criteria. These 31 publications reported on a total of 3047 patients, 1578 patients with GA and 1469 patients with TEA as well as GA. The risks of death, heart attack and stroke were not statistically significant, however our analysis showed statistically significant reductions in the risk of arrhythmias and pulmonary complications. Despite this, our findings must be viewed with caution. Epidural analgesia in heart surgery remains controversial in the absence of a sufficiently large and statistical significant effect on mortality, stroke, or myocardial infarction and while the risks are unclear.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2013

Epidural analgesia (a form of pain control) for the pain relief following hip and knee replacement

Epidural analgesia may give good pain relief after hip or knee replacement surgery, but this benefit must be weighed against the possibility of adverse effects and complications. Hip and knee replacements are common operations to improve mobility and quality of life. After surgery, good pain relief is essential to enable patients to start walking again. Epidurals (pain medicine injected into the spinal canal) are commonly used. However, this pain relief method may delay the start of blood thinners, which prevent life‐threatening blood clot formation (thrombosis) in veins, because there is also a risk of bleeding at the epidural injection site if blood thinners are used at the same time. This review found that an epidural comprising local anaesthetic with or without a strong opioid might give better pain relief than an epidural with only strong opioids; the benefit may be felt only in the first four to six hours after surgery. Aside from pain relief, there was insufficient information to draw conclusions on other benefits or harms arising from epidural analgesia.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2014

Epidural analgesia compared with systemic opioid‐based medicines for people undergoing open abdominal aortic surgery

Open surgery on the abdominal aorta (the main artery to the legs) requires aggressive postoperative pain management. The most commonly used pain management is epidural analgesia. This involves injecting pain‐relieving medicines through a catheter (narrow tube) that is placed in the epidural space (the outermost part of the spinal space). The alternative is systemic opioids (morphine‐like medicines injected into the bloodstream).

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2017

Postoperative spinal epidural hematoma: a systematic review

The authors concluded that the incidence of clinically relevant epidural haematoma after surgery was low, ranging from zero to 1%, and there were insufficient data to define the safety of anticoagulation prophylaxis. The authors acknowledged the limitations of the evidence and their cautious conclusions seem reliable.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2010

Major Trauma: Assessment and Initial Management

This guideline provides guidance on the assessment and management of major trauma, including resuscitation following major blood loss associated with trauma. For the purposes of this guideline, major trauma is defined as an injury or a combination of injuries that are life-threatening and could be life changing because it may result in long-term disability. This guideline covers both the pre-hospital and immediate hospital care of major trauma patients but does not include any management after definitive lifesaving intervention. It has been developed for health practitioners and professionals, patients and carers and commissioners of health services.

NICE Guideline - National Clinical Guideline Centre (UK).

Version: February 2016
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Pain Management Injection Therapies for Low Back Pain [Internet]

Low back pain is common and injections with corticosteroids are a frequently used treatment option. This report reviews the current evidence on effectiveness and harms of epidural, facet joint, and sacroiliac corticosteroid injections for low back pain conditions.

Technology Assessment Report - Agency for Healthcare Research and Quality (US).

Version: 2015
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Low Back Pain and Sciatica in Over 16s: Assessment and Management

This guideline covers the assessment and management of low back pain and sciatica in adults over the age of 16 years.

NICE Guideline - National Guideline Centre (UK).

Version: November 2016
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Venous Thromboembolism: Reducing the Risk of Venous Thromboembolism (Deep Vein Thrombosis and Pulmonary Embolism) in Patients Admitted to Hospital

Venous thromboembolism (VTE) is a term used to include the formation of a blood clot (a thrombus) in a vein which may dislodge from its site of origin to travel in the blood, a phenomenon called embolism. A thrombus most commonly occurs in the deep veins of the legs; this is called deep vein thrombosis. A dislodged thrombus that travels to the lungs is known as a pulmonary embolism.

NICE Clinical Guidelines - National Clinical Guideline Centre – Acute and Chronic Conditions (UK).

Version: 2010
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The Management of Hip Fracture in Adults [Internet]

Although hip fracture is predominantly a phenomenon of later life, it may occur at any age in people with osteoporosis or osteopenia, and this guidance is applicable to adults across the age spectrum. Skills in its management have, however been accrued, researched and reported especially by collaborative teams specialising in the care of older people (using the general designation ‘orthogeriatrics’). These skills are applicable in hip fracture irrespective of age, and the guidance includes recommendations that cover the needs of younger patients by drawing on such skills in an organised manner.

NICE Clinical Guidelines - National Clinical Guideline Centre (UK).

Version: 2011
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Comparison of different platelet transfusion thresholds prior to a lumbar puncture or epidural anaesthetic in people with a low platelet count

We evaluated the evidence about whether people with a low platelet count require a platelet transfusion prior to insertion of a lumbar puncture needle or epidural catheter, and if so what is the platelet count level at which a platelet transfusion is required.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2016

Air versus saline in the loss of resistance technique for identification of the epidural space

A survey of anaesthesiologists showed that 53% of those who replied used loss of resistance technique (LOR) with saline, 37% used LOR with air and 6% LOR with both air and saline; 3% used a different technique with or without one of the above LOR approaches. The methods used for identification of the epidural space are important for good quality of anaesthesia and for avoidance of complications such as epidural haematoma (i.e. accumulation of blood between the skull and the dura mater) and occasional low back pain.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2014

Heavy Menstrual Bleeding

Heavy menstrual bleeding (HMB) has an adverse effect on the quality of life of many women. It is not a problem associated with significant mortality. Many women seek help from their general practitioners and it is a common reason for referral into secondary care.

NICE Clinical Guidelines - National Collaborating Centre for Women's and Children's Health (UK).

Version: January 2007
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Oxytocin for reducing operative births in women with epidurals in labour

The rate of operative births (caesarean sections, forceps and vacuum extraction) continues to rise throughout the world. All three types of delivery are associated with significant complications for both the mother and her baby such as traumatic birth injuries, increased blood loss and placental complications in future pregnancies. One of the most common reasons for a woman to require an operative birth is because the labour does not progress adequately. Increasingly, epidurals are used to manage the pain during labour, however, epidurals may also slow the progression of labour. Oxytocin is a hormone that stimulates uterine contractions in labour and is given to women who are slow to progress in labour. By giving oxytocin to all women with epidurals during labour, the rate of operative deliveries, and the associated complications, could be reduced.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2013

The use of fibrin sealant during non-emergency surgery: a systematic review of evidence of benefits and harms

This study found that the effectiveness of fibrin sealants do not appear to vary according to surgical procedures with regard to reducing the risk of seroma or haematoma.

Health Technology Assessment - NIHR Journals Library.

Version: December 2016
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Hypertension in Pregnancy: The Management of Hypertensive Disorders During Pregnancy

This clinical guideline concerns the management of hypertensive disorders in pregnancy and their complications from preconception to the postnatal period. For the purpose of this guideline, ‘pregnancy’ includes the antenatal, intrapartum and postpartum (6 weeks after birth) periods. The guideline has been developed with the aim of providing guidance in the following areas: information and advice for women who have chronic hypertension and are pregnant or planning to become pregnant; information and advice for women who are pregnant and at increased risk of developing hypertensive disorders of pregnancy; management of pregnancy with chronic hypertension; management of pregnancy in women with gestational hypertension; management of pregnancy for women with pre-eclampsia before admission to critical care level 2 setting; management of pre-eclampsia and its complications in a critical care setting; information, advice and support for women and healthcare professionals after discharge to primary care following a pregnancy complicated by hypertension; care of the fetus during pregnancy complicated by a hypertensive disorder.

NICE Clinical Guidelines - National Collaborating Centre for Women's and Children's Health (UK).

Version: August 2010
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A meta-analysis of upright positions in the second stage to reduce instrumental deliveries in women with epidural analgesia

This review assessed whether maintaining an upright position during the second stage of labour reduced instrumental deliveries amongst women receiving epidural anaesthesia. The authors concluded that there were insufficient data to assess the effectiveness and safety of the upright position and that further research is needed. The authors' conclusions are appropriately cautious given the limited evidence available.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2005

Meta-analysis of thoracic epidural anesthesia versus general anesthesia for cardiac surgery

The review found that thoracic epidural analgesia with general anaesthesia in patients who underwent cardiac surgery reduced supraventricular arrhythmia and respiratory complications. The effects on mortality, myocardial infarction and stroke were uncertain. These conclusions appear reliable in most respects but the findings about supraventricular arrhythmia should be interpreted with caution due to heterogeneity between the studies and possible bias.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2011

Comparative Effectiveness of In-Hospital Use of Recombinant Factor VIIa for Off-Label Indications vs. Usual Care [Internet]

This report evaluates the level of evidence currently available to support the effectiveness and safety of using recombinant activated coagulation factor VII (rFVIIa) for clinical indications not approved by the U. S. Food and Drug Administration (FDA). rFVIIa is approved for a variety of uses in hemophilia patients who have developed antibody inhibitors that compromise the use of standard factor replacement. Use of this costly biologic product has expanded beyond these hemophilia-related indications to encompass a range of off-label uses, most of which are in-hospital uses. These uses differ substantially from the drug’s FDA approved label. The purpose of this report is two-fold: (1) To document the full range of clinical indications for which rFVIIa is being used and the types of studies available to evaluate these uses and (2) To provide a comparative effectiveness review of rFVIIa vs. usual care for several in-hospital clinical indications: intracranial hemorrhage, massive bleeding secondary to trauma, and the selected surgical procedures of cardiac surgery, liver transplantation, and prostatectomy.

Comparative Effectiveness Reviews - Agency for Healthcare Research and Quality (US).

Version: May 2010
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