1. 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

3. 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

4. Failed spinals
Fettes, Jansson, Wildsmith BJA 2009; 102: 739

5. Failed spinals
Fettes, Jansson, Wildsmith BJA 2009; 102: 739

6. Oxford Head Elevating Laryngoscopy Pillow

9. 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%

10. 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%

11. 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%

12. 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%

13. Block height at start of CS
T5 to light touch
T10 and rising

14. S5 - T5
Where’s T5?
Congreve K et al Anaesthesia 2006; 61: 453

15. Yentis: diagram A: some cold B: icy cold C: ‘true’ height
IJOA 2006; 15: 2

16. Ousley et al Anaesthesia 2012; 67: 1356

18. Epidural failure rate 20 000 deliveries, 3 yrs
Neuraxial labor analgesia rate 83%
7.1% of pre-existing epidurals failed at CS

19. 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

20. 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

21. Spinals after epidurals?
Breda, Netherlands
Labour epidural infusions
C Section: straight to spinal: – no top-ups
Total spinal in 1/128

22. 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

23. 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

24. Adjuncts to regional block

25. Alfentanil

26. 3 mcg/kg then 1.5 mcg/kg; 2 min lockout

27. Ketamine

29. Vapour/nitrous oxide

30. 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

31. Take-home message Low threshold for offering GA If GA offered
Relay conversation to partner
Document offer and response
Note time

32. Questions...