Dr David M Levy Consultant Obstetric Anaesthetist Pain and distress during Caesarean section under regional anaesthesia Dr David M Levy Consultant Obstetric Anaesthetist 16 May 2013
Pain and distress during Caesarean section under regional anaesthesia Testing block height New UK audit standards Spinals after epidurals Adjuncts to regional block Legal cases
Failed spinals Fettes, Jansson, Wildsmith BJA 2009; 102: 739
Failed spinals Fettes, Jansson, Wildsmith BJA 2009; 102: 739
Oxford Head Elevating Laryngoscopy Pillow
RCoA standard (target for best practice) Cat 4 Cat 1-3 Cat 1 CS under RA >95% >85% >50% Pain during CS <5% <15% <20% RA to GA conversion <1%
RCoA standard (target for best practice) Cat 4 Cat 1-3 Cat 1 CS under RA >95% >85% >50% Pain during CS <5% <15% <20% RA to GA conversion <1%
RCoA standard (target for best practice) Cat 4 Cat 1-3 Cat 1 CS under RA >95% >85% >50% Pain during CS <5% <15% <20% RA to GA conversion <1%
RCoA standard (target for best practice) Cat 4 Cat 1-3 Cat 1 CS under RA >95% >85% >50% Pain during CS <5% <15% <20% RA to GA conversion <1% Previously <1% Previously <3%
Block height at start of CS T5 to light touch T10 and rising
S5 - T5 Where’s T5? Congreve K et al Anaesthesia 2006; 61: 453
Yentis: diagram A: some cold B: icy cold C: ‘true’ height IJOA 2006; 15: 2
Ousley et al Anaesthesia 2012; 67: 1356
Epidural failure rate 20 000 deliveries, 3 yrs Neuraxial labor analgesia rate 83% 7.1% of pre-existing epidurals failed at CS
Epidural failure rate 20 000 deliveries, 3 yrs Neuraxial labor analgesia rate 83% 7.1% of pre-existing epidurals failed at CS (n = 122) 1.3% epidural replaced 1.5% spinal 4.3% GA
Epidural failure rate 20 000 deliveries, 3 yrs Neuraxial labor analgesia rate 83% 7.1% of pre-existing epidurals failed at CS (n = 122) 1.3% epidural replaced 1.5% spinal 4.3% GA 6 high blocks required intubation 2 spinals after initial spinal 1 spinal after epidural 2 epidural top-ups
Spinals after epidurals? Breda, Netherlands Labour epidural infusions C Section: straight to spinal: – no top-ups Total spinal in 1/128
Leeds: regional blocks requiring ventilatory support LGI, 1997 – 2003 5/342 (1.46%) of spinals after epidurals No predictors (previous epidural doses/spinal doses) practice of spinals after epidurals after five cases of litigation for pain after topped-up epidurals
Leeds: regional blocks requiring ventilatory support LGI, 1997 – 2003 5/342 (1.46%) of spinals after epidurals No predictors (previous epidural doses/spinal doses) practice of spinals after epidurals after five cases of litigation for pain after topped-up epidurals
Adjuncts to regional block
Alfentanil
3 mcg/kg then 1.5 mcg/kg; 2 min lockout
Ketamine
Vapour/nitrous oxide
Litigation in the UK 2011-12: annual NHS spending £104 billion NHSLA paid out over £1 billion on clinical claims Major proportion: claimant legal fees
Take-home message Low threshold for offering GA If GA offered Relay conversation to partner Document offer and response Note time
Questions... dmlevy@nhs.net