General anaesthetic and airway management practice for obstetric surgery in England: a prospective, multicentre observational study*

Abstract

Summary There are no current descriptions of general anaesthesia characteristics for obstetric surgery, despite recent changes to patient baseline characteristics and airway management guidelines. This analysis of data from the direct reporting of awareness in maternity patients’ (DREAMY) study of accidental awareness during obstetric anaesthesia aimed to describe practice for obstetric general anaesthesia in England and compare with earlier surveys and best‐practice recommendations. Consenting patients who received general anaesthesia for obstetric surgery in 72 hospitals from May 2017 to August 2018 were included. Baseline characteristics, airway management, anaesthetic techniques and major complications were collected. Descriptive analysis, binary logistic regression modelling and comparisons with earlier data were conducted. Data were collected from 3117 procedures, including 2554 (81.9%) caesarean deliveries. Thiopental was the induction drug in 1649 (52.9%) patients, compared with propofol in 1419 (45.5%). Suxamethonium was the neuromuscular blocking drug for tracheal intubation in 2631 (86.1%), compared with rocuronium in 367 (11.8%). Difficult tracheal intubation was reported in 1 in 19 (95%CI 1 in 16–22) and failed intubation in 1 in 312 (95%CI 1 in 169–667). Obese patients were over‐represented compared with national baselines and associated with difficult, but not failed intubation. There was more evidence of change in practice for induction drugs (increased use of propofol) than neuromuscular blocking drugs (suxamethonium remains the most popular). There was evidence of improvement in practice, with increased monitoring and reversal of neuromuscular blockade (although this remains suboptimal). Despite a high risk of difficult intubation in this population, videolaryngoscopy was rarely used (1.9%).

Incidence of accidental awareness during general anaesthesia in obstetrics: a multicentre, prospective cohort study

“…Any symptom rated as 'moderately' or higher was considered positive. Patients were considered to have screened positive for PTSD if responses from a single follow-up interval included at least: one 'positive' B item (intrusion symptoms, questions 1-5); one C item (avoidance symptoms, questions 6-7); two D items (negative alterations of cognitions and mood, questions [8][9][10][11][12][13][14]; two E items (alterations in arousal and reactivity, questions [15][16][17][18][19][20].…”

Comparison of videolaryngoscopy and direct laryngoscopy for tracheal intubation in obstetrics: a mixed-methods systematic review and meta-analysis

“…In the UK, however, just over half of obstetric units in 2015 reported the presence of an available videolaryngoscope, 72 and in a more recent prospective and multicentre observational study, videolaryngoscopy was used for only 1.9% of parturients who required general anesthesia. 73 We suggest that the lack of difference shown between direct laryngoscopy and videolaryngoscopy in our metaanalysis for patients not predicted to have a difficult airway and scheduled for elective surgery should encourage an overall increased adoption of videolaryngoscopy in obstetrics. In doing so, we would obviate the need for a risk stratification to determine which laryngoscope is chosen as first-line, particularly as the positive predictive value and the sensitivity of airway examination is low, 74 and have the potential to decrease the incidence of rescue intubations in what is otherwise a stressful and time-critical scenario.…”

Making the grade: has Cormack and Lehane grading stood the test of time?

“…However, in a recent large, prospective observational study of obstetric surgery patients, Odor et al. found Cormack‐Lehane grades 1 and 2a to be associated with 38% of all difficult tracheal intubations [13]. Other data suggest that the incidence of failed tracheal intubation is 1:224, regardless of the grade of view [14].…”