Inadequate neuraxial anaesthesia during caesarean delivery: a survey of practitioners

Failed spinal anesthesia for cesarean delivery: prevention, identification and management

PURPOSE OF REVIEW

There is an increasing awareness of the significance of intraoperative pain during cesarean delivery. Failure of spinal anesthesia for cesarean delivery can occur preoperatively or intraoperatively. Testing of the neuraxial block can identify preoperative failure. Recognition of the risk of high neuraxial block in repeat spinal in case of preoperative failure is important.

RECENT FINDING

Knowledge of risk factors for block failure facilitates prevention by selecting the most appropriate neuraxial procedure, adequate intrathecal doses and choice of technique. Intraoperative pain is not uncommon, and neither obstetricians nor anesthesiologists can adequately identify intraoperative pain. Early intraoperative pain should be treated differently from pain towards the end of surgery.

SUMMARY

Block testing is crucial to identify preoperative failure of spinal anesthesia. Repeat neuraxial is possible but care must be taken with dosing. In this situation, switching to a combined spinal epidural or an epidural technique can be useful. Intraoperative pain must be acknowledged and adequately treated, including offering general anesthesia. Preoperative informed consent should include block failure and its management.

Appraisal of clinical practice guidelines and consensus statements on obstetric anaesthesia: a systematic review using the AGREE II instrument

OBJECTIVES

Despite the publication of hundreds of trials on obstetric anaesthesia, the management of these conditions remains suboptimal. We aimed to assess the quality and consistency of guidance documents for obstetric anaesthesia.

DESIGN

This is a systematic review and quality assessment using the Appraisal of Guidelines for Research and Evaluation (AGREE) II methodology.

DATA SOURCES

Data sources include PubMed and Embase (8 June 2023), three Chinese academic databases, six guideline databases (7 June 2023) and Google and Google scholar (1 August 2023).

ELIGIBILITY CRITERIA

We included the latest version of international and national/regional clinical practice guidelines and consensus statements for the anaesthetic management of pregnant patients during labour, non-operative delivery, operative delivery and selected aspects of perioperative monitoring, postpartum care and analgesia, published in English or Chinese.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently screened the searched items and extracted data. Four reviewers independently scored documents using AGREE II. Recommendations from all documents were tabulated and visualised in a coloured grid.

RESULTS

Twenty-two guidance documents (14 clinical practice guidelines and 8 consensus statements) were included. Included documents performed well in the domains of scope and purpose (median 76.4%, IQR 69.4%-79.2%) and clarity of presentation (median 72.2%, IQR 61.1%-80.6%), but were unsatisfactory in applicability (median 21.9%, IQR 13.5%-27.1%) and editorial independence (median 47.9%, IQR 6.3%-73.2%). The majority of obstetric anaesthesia guidelines or consensus centred on different topics. Less than 30% of them specifically addressed the management of obstetric anaesthesia perioperatively. Recommendations were concordant on the perioperative preparation, and on some indications for the choice of anaesthesia method. Substantially different recommendations were provided for some items, especially for preoperative blood type and screen, and for the types and doses of neuraxial administration.

CONCLUSIONS

The methodological quality in guidance documents for obstetric anaesthesia necessitates enhancement. Despite numerous trials in this area, evidence gaps persist for specific clinical queries in this field. One potential approach to mitigate these challenges involves the endorsement of standardised guidance development methods and the synthesis of robust clinical evidence, aimed at diminishing difference in recommendations.

Incidence and clinical impact of aspiration during cesarean delivery: A multi-center retrospective study

BACKGROUND

The risk of aspiration during general anesthesia for cesarean delivery has long been thought to be increased due to factors such as increased intra-abdominal pressures and delayed gastric emptying in pregnant patients. However, recent studies have reported normal gastric emptying in pregnant patients, suggesting that the risk of aspiration may not be as high as previously believed.

METHODS

We conducted a retrospective study of 48,609 cesarean deliveries, of which 22,690 (46.7%) were performed under general anesthesia at two large tertiary medical centers in Israel. The study aimed to examine the incidence of potentially severe aspiration during cesarean delivery, both under general and neuraxial anesthesia.

RESULTS

Among the patients included in the study, three were admitted to the intensive care unit due to suspected pulmonary aspiration. Two of these cases occurred during induction of general anesthesia for emergency cesarean delivery associated with difficult intubation and one under deep sedation during spinal anesthesia. The incidence of aspiration during cesarean delivery during general anesthesia in our study was 1 in 11,345 patients, and the incidence of aspiration during neuraxial anesthesia was 1 in 25,929 patients. No deaths due to aspiration were reported during the study period.

CONCLUSIONS

Our findings provide another contemporary analysis of aspiration rates in obstetric patients, highlighting increased risks during the management of difficult airways during general anesthesia and deep sedation associated with neuraxial anesthesia.