culture, family firm, institutionalism, transformational leadership, values,

No abstract

This prospective, blinded, randomized study compares the incidence of postdural puncture headache (PDPH) and the epidural blood patch (EBP) rate for five spinal needles when used in obstetric patients. One thousand two women undergoing elective cesarean delivery under spinal anesthesia were recruited. We used two cutting needles: 26-gauge Atraucan and 25-gauge Quincke, and three pencil-point needles: 24-gauge Gertie Marx (GM), 24-gauge Sprotte, and 25-gauge Whitacre. The needle for each weekday was chosen randomly. Cutting needles were inserted parallel to the dural fibers. The incidences of PDPH were, respectively, 5%, 8.7%, 4%, 2.8%, and 3.1% for Atraucan, Quincke, GM, Sprotte, and Whitacre needles (P = 0.04, chi(2) analysis), and the corresponding EBP rates in those with PDPH were 55%, 66%, 12.5%, 0%, and 0% (P = 0.000). The Quincke needle had a more frequent PDPH rate than the Sprotte or the Whitacre needle (P = 0.02) and a more frequent EBP rate than the GM, Sprotte, or the Whitacre needle (P = 0.01). The Atraucan needle had a more frequent EBP rate than the Sprotte or Whitacre needle (P = 0.05). Neither the PDPH rate nor the EBP rates differed among the pencil-point needles. The cost of EBP must be taken into consideration when choosing a spinal needle. We conclude that pencil-point spinal needles should be used for subarachnoid anesthesia in obstetric patients.

Although commitment is one of the attributes of family firms of continuing interest to researchers, they almost always study it from the perspective of the owning family. In the current work, we analyze the commitment of the non-family employees. We propose a model of commitment, with the aim of studying the implications that this variable may have for family businesses. We study both the aspects on the basis of the approaches of Meyer and Allen's three-component model of organizational commitment and stewardship theory. Results show that the identification level of nonfamily employees positively and significantly influences the profitability and the survival or continuity of familyowned businesses. At the same time that their involvement level positively and significantly influences the survival or continuity of family-owned businesses.

A lthough epidural analgesia is used widely for pain relief during labor, the failure rate ranges from 1.5% to 20%. This prospective, randomized, nonblinded study investigated whether ultrasound measurement of the depth from the skin to the epidural space before epidural placement decreases the failure rate of labor analgesia. The second objective of the study was to correlate the ultrasoundmeasured depth to the epidural space with the actual depth of the needle when the epidural space is reached.A total of 370 laboring parturients were randomized to undergo epidural placement by first-year anesthesia residents with or without prior ultrasound measurement of the depth to the epidural space. Patients in the ultrasound group underwent ultrasound visualization of the epidural space in the longitudinal median and transverse planes while in the sitting position. The ultrasound measurements were used to estimate the distance from the skin to the ligamentum flavum before the epidural catheter was inserted. The epidural was performed in both groups using the midline approach at the L3-4 or L4-5 vertebral interspace using a loss of resistance to saline technique. All patients received a 10 mL bolus of ropivacaine 0.1% + 100 mcg fentanyl and were then placed on a continuous maintenance epidural infusion of ropivacaine 0.1% and fentanyl 2 mcg/ mL. Outcomes measured included the incidence of epidural catheter replacement for failed analgesia, the number of epidural attempts, and the number of accidental dural punctures.The 189 patients in the ultrasound group and 181 in the control group did not differ significantly in age, height, weight, body mass index, gestation, or parity. The groups did not differ in cervical dilation, station at epidural placement, and initial visual analog score for pain. The use of ultrasound, undertaken by an investigator skilled in ultrasound epidural placement (not the learner), added 60 ± 15 seconds to the mean preparation time. The epidural block failed in 3 and 10 patients in the ultrasound and control groups, respectively, with one in the ultrasound and 6 in the control group considered early failures (within the first 90 min after placement), P = NS. Patients in the control group had more initial placement attempts (2 vs. 1), but the need for staff intervention was not significantly different. The ultrasoundestimated mean epidural depth was 4.6 ± 0.9 cm when measured in the longitudinal plane and 4.7 ± 1.0 cm as measured in the transverse plane showed a strong correlation with the actual clinical depth of the epidural space. No significant differences in staff interventions, need for additional top-ups, or delivery outcomes were determined.In conclusion, the investigators determined that the use of ultrasound to measure the depth of the epidural space before an epidural catheter is inserted for labor analgesia is an excellent teaching tool for neophyte learners of the clinical skill set necessary to locate the epidural space.

High-definition ultrasonography offers potential advantages in the administration of peripheral nerve blockade. The significant difference in major central nervous system local anesthetic toxicity observed in this study supports the use of ultrasound guidance in conjunction with peripheral nerve stimulation to provide brachial plexus peripheral nerve blockade in an academic, ambulatory anesthesia practice.

BACKGROUND: In women undergoing cesarean delivery under spinal anesthesia with intrathecal morphine, transversus abdominis plane (TAP) block with bupivacaine hydrochloride (HCl) may not improve postsurgical analgesia. This lack of benefit could be related to the short duration of action of bupivacaine HCl. A retrospective study reported that TAP block with long-acting liposomal bupivacaine (LB) reduced opioid consumption and improved analgesia following cesarean delivery. Therefore, we performed a prospective multicenter, randomized, double-blind trial examining efficacy and safety of TAP block with LB plus bupivacaine HCl versus bupivacaine HCl alone. METHODS: Women (n = 186) with term pregnancies undergoing elective cesarean delivery under spinal anesthesia were randomized (1:1) to TAP block with LB 266 mg plus bupivacaine HCl 50 mg or bupivacaine HCl 50 mg alone. Efficacy was evaluated in a protocol-compliant analysis (PCA) set that was defined a priori. The primary end point was total postsurgical opioid consumption (oral morphine equivalent dosing [MED]) through 72 hours. Pain intensity was measured using a visual analog scale. Adverse events (AEs) after treatment were recorded through day 14. RESULTS: Total opioid consumption through 72 hours was reduced with LB plus bupivacaine HCl versus bupivacaine HCl alone (least squares mean [LSM] [standard error (SE)] MED, 15.5 mg [6.67 mg] vs 32.0 mg [6.25 mg]). This corresponded to an LSM treatment difference of −16.5 mg (95% confidence interval [CI], −30.8 to −2.2 mg; P = .012). The area under the curve of imputed pain intensity scores through 72 hours supported noninferiority of LB plus bupivacaine HCl versus bupivacaine HCl alone (LSM [SE], 147.9 [21.13] vs 178.5 [19.78]; LSM treatment difference, −30.6; 95% CI, −75.9 to 14.7), with a prespecified noninferiority margin of 36 ( P = .002). In an analysis of all treated patients, including those not meeting criteria for inclusion in the PCA, there was no difference in postsurgical opioid consumption between groups. In the LB plus bupivacaine HCl group, 63.6% of patients experienced an AE after treatment versus 56.2% in the bupivacaine HCl–alone group. Serious AEs after treatment were rare (≈3% in both groups). CONCLUSIONS: TAP block using LB plus bupivacaine HCl as part of a multimodal analgesia protocol incorporating intrathecal morphine resulted in reduced opioid consumption after cesarean delivery in the PCA set. Results suggest that with correct TAP block placement and adherence to a multimodal postsurgical analgesic regimen, there is an opioid-reducing benefit of adding LB to bupivacaine TAP blocks after cesarean delivery ( ClinicalTrials.gov identifier: NCT03176459).

Early preoperative assessment, epidural insertion, and replacement for failed regional anesthesia/analgesia along with preparation for general anesthesia and difficult airway intubation is advocated to decrease potential complications in the morbidly obese parturient.