Anesthesia for Cesarean Delivery in the Czech Republic: A 2011 National Survey : Anesthesia & Analgesia

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Obstetric Anesthesiology: Research Report

Anesthesia for Cesarean Delivery in the Czech Republic

A 2011 National Survey

Stourac, Petr MD, PhD*; Blaha, Jan MD, PhD; Klozova, Radka MD; Noskova, Pavlina MD; Seidlova, Dagmar MD, PhD§; Brozova, Lucie Bc; Jarkovsky, Jiri MSc, PhD

Author Information
doi: 10.1213/ANE.0000000000000572

Until 2010, when leading obstetric anesthesiologists at 4 major Czech university hospitals formed the Expert Committee of Labor Anesthesia and Analgesia (ESPAA), there was no regular monitoring of obstetric anesthesia and analgesia care. Some data were available from Dr. Antonin Parizek, an obstetrician who had been trying, at irregular intervals, to retrospectively collect data on the availability of epidural analgesia in maternity units and anesthetic techniques for cesarean delivery since 1993. Thanks to these observations, we can create a realistic picture of the trends in obstetric anesthesia in the Czech Republic during the last 2 decades.1

Because the main goal of the ESPAA was to improve obstetric anesthesia care in the Czech Republic, the nationwide project “Obstetric Anesthesia and Analgesia Month Attributes in the Czech Republic (OBAAMA-CZ)” was created in 2011. The main objective of the project was to describe in detail the current practices and techniques in obstetric anesthesia care. The current article summarizes the findings on anesthesia practices for cesarean delivery only. Other data will be summarized at a later date.

METHODS

The project was approved by the ethics committee for multicenter studies of the University Hospital Brno; informed patient consent was not required. The outcome of the cross-sectional nationwide survey was to describe current practices in obstetric anesthesia in the Czech Republic, mainly for cesarean delivery. All 97 departments of anesthesia that provide obstetric anesthesia were contacted (10 university, 8 regional, and 79 local hospitals), first by mail and then personally by telephone, with a request to participate in the 1-month project that monitored anesthetic practices in the peripartum period (OBAAMA-CZ). The centers participated in the project via an electronic application form on the study website (obaama.registry.cz). The project had the endorsement of the Czech Society of Anesthesia and Intensive Care Medicine and was conducted in November 2011.

The OBAAMA-CZ database was based on a structured questionnaire created by the OBAAMA-CZ Steering Committee. The online database was created by the Institute of Biostatistics and Analyses, Masaryk University, through standardized software TrialDB (Yale University, New Haven, CT). A test operation of the database was launched in 4 university hospitals for 1 week in September 2011. The structure of the Electronic Case Report Form consisted of 2 parts. The first part included demographic and summary data for each participating obstetric facility for 2010. These entries were compared with the data from the reference month, November 2011, to check the representativeness of the data. The prospective part of the study followed consecutive cases of obstetric anesthesia and analgesia at all participating sites in November 2011; each case at each participating institution was entered into the study database. Each record was related to an individual parturient and contained the following sections: demographic data, medical history, information on mode of delivery (including cesarean delivery indication, time of surgery, type of anesthesia, and detailed information on its performance). Consecutive cesarean deliveries performed in participating centers are reported in this study.

Statistical Analysis

The data were summarized using absolute and relative frequencies for categorical variables (95% confidence intervals [CIs]) and median (range) for continuous variables. Because of the differences in distribution of anesthesia techniques among the type of participating hospitals, the weighted estimate was adopted for the computation of estimated overall prevalence of anesthesia techniques. The records from the different types of participating centers (university, regional, and local) were weighted based on population data, so their proportion (weight) in the computation of anesthesia type proportions (simple percentages based on weighted dataset) reflected the population structure of types of centers; the total sum of weighted records influencing the width of the provided asymptotic CIs remained the same as before weighting (N = 1166). The population data were obtained from the database of the Institute of Health Information and Statistics of the Czech Republic (http://uzis.cz/en; data provided on request: [email protected]). Previously published data, by Parizek et al.,1 of neuraxial anesthesia population estimates were compared with the CIs of our current estimate to identify statistically significant differences; the comparison with 95% CI is equivalent to 1-sample binomial test with α = 0.05.

The analyses were computed using Statistica 10 (StatSoft, Prague, Czech Republic) and SPSS 22 software (IBM Corporation, Armonk, NY).

RESULTS

Forty-nine obstetric facilities of 97 obstetric centers or departments responded to the survey (51%) (Fig. 1). Eight centers were university (16%; 80% of 10 university hospital obstetric departments), 8 were regional (16%; 100% of 8 regional obstetric departments), and 33 were local (68%; 41.8% of 79 local obstetric departments). Stratification of centers by deliveries per year is shown in Table 1. During the study period, there were 4787 births registered in the OBAAMA-CZ database in participating centers, which was 60% of all deliveries in the Czech Republic during November 2011.2

T1-20
Table 1:
Participating Centers Stratified by Deliveries per Year
F1-20
Figure 1:
Participating centers. University (circle), regional (triangle), and local (dot).

Anesthesia services were used in 1943 (40.5%) deliveries. The most common reason was cesarean delivery (1166; 60.0%). The overall cesarean delivery rate was 24.4%; 56.8% of these were intrapartum cesarean deliveries and 43.2% were elective. Forty-one (83.7%) centers reported availability of continuous anesthetic service (24 hours/7 days) for the delivery room. Teams dedicated solely to delivery room requirements were available in 22 departments (44.9%).

The demographic characteristics of the parturients are shown in Supplemental Digital Content Table 1 (https://links.lww.com/AA/B49). The average age of mothers at the time of delivery was 30.8 ± 5.2 years, and 1087 cases (93.2%) were ASA physical status I or II.

Anesthesia for Cesarean Delivery

A general overview of the types of anesthesia administered for cesarean delivery is shown in Table 2. Table 3 shows the type of anesthesia according to type of center. Administration of epidural analgesia for labor, before the decision for cesarean delivery, was recorded in 100 cases, but only in 44 cases the epidural analgesia was extended to anesthesia for cesarean delivery. Combined spinal-epidural (CSE) anesthesia was not administered for any cesarean delivery. Detailed characteristics of general and neuraxial anesthesia for cesarean delivery are shown in Supplemental Digital Content Tables 2–4 (https://links.lww.com/AA/B50; https://links.lww.com/AA/B51; https://links.lww.com/AA/B52). Details on preoperative management, Mallampati scores, indications for cesarean delivery, and neonatal outcome characteristics are shown in Supplemental Digital Content Tables 5–8 (https://links.lww.com/AA/B53; https://links.lww.com/AA/B54; https://links.lww.com/AA/B55; https://links.lww.com/AA/B56). The main characteristics of perioperative and postoperative care are shown in Table 4.

T2-20
Table 2:
Choice of Anesthesia for Cesarean Delivery
T3-20
Table 3:
Anesthesia Technique for Cesarean Delivery by Type of Center
T4-20
Table 4:
Perioperative Management and Postoperative Care

Compared with previously published national data during the 1990s by Parizek et al.1 shown in Figure 2 (1993, 6.7%; 1994, 8.7%; 1996, 13.9%; and 1998, 31.6%), there is an upward trend in the use of neuraxial anesthesia for cesarean delivery during 21st century (2000, 40.5%; 2002, 50.6%; and 2011, 55.6%).1

F2-20
Figure 2:
Neuraxial anesthesia for cesarean delivery in Czech Republic between years 1993 and 2011. Data are presented as percentage of all anesthetics for cesarean delivery (adapted from Parizek et al., 2012).1 Gray area represents 95% confidence interval for the Obstetric Anesthesia and Analgesia Month Attributes in the Czech Republic (OBAAMA-CZ 2011) study (values outside this interval are statistically significantly different from OBAAMA-CZ; this is equivalent to 1-sample binomial test with α = 0.05).

DISCUSSION

The purpose of this national survey was to identify current obstetric anesthesia practices in the Czech Republic. More than 50% of obstetric centers and departments participated in the month-long study, and we collected data on 60% of all deliveries in the country. The response rate was comparable with that in other published studies for the Czech Republic and other countries (Poland, Germany, and Great Britain).3–6 The response rate for regional centers (100% response rate) and for university centers (80% response rate) was high, but the response rate of local centers was poor (<45%).

The traditional and recommended approach for obstetric general anesthesia for cesarean delivery is to use thiopental and succinylcholine for rapid sequence induction of anesthesia, nitrous oxide, and a volatile drug for anesthesia maintenance until delivery and opioid administration after umbilical cord clamping. This technique has a robust safety record and has changed very little during the last 4 decades.6–8 This traditional approach also was confirmed in our observation with predominant use of thiopental and succinylcholine for rapid sequence induction. The majority of anesthesiologists chose general anesthesia mainly because of urgency or when neuraxial blockade was rejected by the patient. These results are similar to those of McGlennan and Mustafa9 and British (2011) and Polish (2009) national surveys.4,6 Compared with other countries, however, the high rate of general anesthesia for cesarean delivery in the Czech Republic (44.4%) is quite surprising. This figure is high compared with data from other Western countries and cannot be explained by the urgency of cesarean delivery and lack of time for administration of neuraxial anesthesia. If we extract only elective cesarean delivery from the overall data, the ratio between neuraxial and general anesthesia in the Czech Republic is an alarming 66:34! For example, in the United States, the use of general anesthesia for elective cesarean delivery was reported at the level of 5% of cases,10–12 in Great Britain <15%, Belgium 4%, France 1%, Spain <30%, Italy 34%, and Germany <10%.3,5,13 Of interest, the cesarean delivery rate has almost tripled in the last 2 decades (Fig. 3).

F3-20
Figure 3:
Cesarean delivery rate in Czech Republic between years 1993 and 2011. Data are presented as percentage of all deliveries. Adapted from Parizek et al., 2012.1

A surprising finding in our survey was that the use of neuraxial anesthesia was more frequent in small local hospitals than in large academic medical centers. Widely considered the “state-of-the-art” technique for cesarean delivery anesthesia, one would think that the widespread use of neuraxial anesthesia would begin first at the central teaching hospitals and be disseminated slowly to smaller regional and local hospitals as more and more providers are trained using the technique. We can only hypothesize as to the reasons for this finding. In local hospitals, only a small team of anesthesiologists is available, and operationally the team may be under greater time pressure than in larger hospitals. Thus, they have to choose the most practical, easy, and safe approach. Moreover, it may be easier to enforce practice changes in smaller teams of both anesthesiologists and obstetricians than in large centers. Another reason may be the high percentage of maternal refusal of neuraxial anesthesia. Parturients generally are well informed about the care provided in “their” hospital, including the possibilities and the quality of obstetric anesthesia services. It can therefore be assumed that in hospitals where the use of neuraxial anesthesia is not routine, parturients have a tendency to refuse it.

An interesting finding was an extremely low incidence of Mallampati class IV airway examinations (0.20%, weighted estimate 0.43% [95% CI, 0.04%–1.06%]). This rate was surprisingly low compared with other studies14; a possible reason for this difference may be insufficient attention to this examination. Of concern, only 37.5% (437) of parturients were evaluated for Mallampati score.

Similar to other settings worldwide, spinal anesthesia was much more common than epidural for cesarean delivery in the Czech Republic.4,10 This is likely because of its safety, efficacy, and simplicity of administration, which in our study did not differ substantially from the techniques and anesthetics used in the rest of the world. An exception is the infrequent use of opioids as an additive to plain bupivacaine (used <15% of the time). A possible reason is that fentanyl and sufentanil are not approved for intrathecal use in the Czech Republic, and anesthesiologists may be hesitant to use them without regulatory approval. Preservative-free morphine is the only opioid available for intrathecal injection. Commercially produced morphine for intrathecal administration is quite expensive in the Czech Republic; hence, morphine for spinal blockade is available only in a few centers where the hospital pharmacy is able to prepare it as a magistral preparation. This is another area for possible future improvement.

Epidural anesthesia during the study period was performed in 5 centers only. Of 146 epidural anesthetics, 85 (59%) were administered in 1 large university center. This center was the only one using lidocaine 2%; because of the large number of epidural anesthetics performed in this center, this was the most commonly used local anesthetic for epidural anesthesia. Bupivacaine, however, despite potentially greater cardiotoxicity15 and longer latency, remains the local anesthetic drug of choice for epidural anesthesia in most centers (similar to that used in Poland4 and Germany5), primarily because of its economic advantages compared with levobupivacaine. Because of corporate decisions, since 2010 ropivacaine is no longer available in the Czech Republic. Chloroprocaine is also not available in the Czech Republic. It is astonishing that only 1 participating center was using lidocaine 2% (a local anesthetic with substantially faster onset time and less cardiotoxicity than bupivacaine) for epidural blockade for cesarean delivery, and this was the only center that converted epidural labor analgesia to epidural anesthesia by “topping up” for cesarean delivery anesthesia. A possible reason for this practice pattern is the lack of locally published obstetric anesthesia guidelines written in Czech. Publication of “local” experiences has been recognized by ESPAA as one of the most important aims for the near future.16

Neuraxial blockade failure (defined as need for conversion to general anesthesia) was recorded in 1% of spinal and 8% of epidural anesthetics. We recorded a high incidence, however, of supplementary sedation during neuraxial anesthesia (19% for epidural and 22% for spinal anesthesia). Because the degree of sedation was not investigated in detail, the reasons for the sedation can only be surmised. Given that the question of the neuraxial blockade failure was investigated separately within the study, it is likely that the reason for intraoperative sedation was most commonly anxiety or mild discomfort.

It is interesting that the CSE blockade was not used in any case. The most likely explanation is the cost of a CSE kit, especially compared with a spinal needle. Although practice outside the Czech Republic differs regarding the use of CSE anesthesia for elective cesarean deliveries, the technique is useful for patients with anticipated long procedures or other comorbidities such as morbid obesity or heart disease.17

The study has some limitations. The main limitation is the uneven representation of large (university and regional) and small (local) obstetric departments. Although the study involved most university and regional departments, <45% of small hospitals participated in the study. However, smaller centers made up 68% of the hospitals participating in the study, and thus the study should represent a fair sample. Another weakness was insufficiently detailed monitoring of some important variables (e.g., supplemental sedation during neuraxial anesthesia). We also noted unnecessarily detailed monitoring of other variables, such as some personal data, which will help inform future survey design. It would also be useful to have a better understanding of the obstacles faced in the use of different anesthetic techniques in individual departments. These and other issues will be addressed in the next national survey OBAAMA-CZ 2, which is planned by ESPAA for autumn 2015.

In conclusion, in this prospective national survey, we obtained important data on current anesthesia practices for cesarean delivery in the Czech Republic. Compared with previously published national data obtained during the 1990s, there is a confirmed upward trend in the use of neuraxial anesthesia for cesarean delivery during 21st century.1 Compared with other Western countries, the high rate of general anesthesia (44%) is unfavorable.

DISCLOSURES

Name: Petr Stourac, MD, PhD.

Contribution: This author was responsible for designing the study, conducting it, analyzing the data, and writing the manuscript.

Attestation: Petr Stourac has seen the original study data, reviewed the analysis, approved the final manuscript, and is the author responsible for archiving the study files.

Name: Jan Blaha, MD, PhD.

Contribution: This author designed the study, conducted it, analyzed the data, wrote the manuscript, and created the figures.

Attestation: Jan Blaha has seen the original study data, reviewed the data analysis, and approved the final manuscript.

Name: Radka Klozova, MD.

Contribution: This author helped design the study, conduct it, analyze the data, and review the manuscript.

Attestation: Radka Klozova has seen the original study data, reviewed the data analysis, and approved the final manuscript

Name: Pavlina Noskova, MD.

Contribution: This author helped design the study, conduct it, analyze the data, and review the manuscript.

Attestation: Pavlina Noskova has seen the original study data, reviewed the data analysis, and approved the final manuscript.

Name: Dagmar Seidlova, MD, PhD.

Contribution: This author helped design the study, conduct it, analyze the data, and review the manuscript.

Attestation: Dagmar Seidlova has seen the original study data, reviewed the analysis, and approved the final manuscript.

Name: Lucie Brozova, Bc.

Contribution: This author helped design the study and analyze the data.

Attestation: Lucie Brozova has seen the original study data, reviewed the data analysis, and approved the final manuscript.

Name: Jiri Jarkovsky, MSc, PhD.

Contribution: This author helped design the study and analyze the data.

Attestation: Jiri Jarkovsky has seen the original study data, reviewed the data analysis, and approved the final manuscript.

This manuscript was handled by: Cynthia A. Wong, MD.

ACKNOWLEDGMENTS

The authors thank all the members of OBAAMA-CZ study group and all other investigators from participating centers for their extraordinary work on this national survey. The members of OBAAMA-CZ study group are listed in Appendix 1 (Supplemental Digital Content, https://links.lww.com/AA/B57). In addition to the authors, Daniel Schwarz, MSc, PhD, and Hana Zelinkova, MSc, Institute of Biostatistics and Analyses, Masaryk University, Brno, Czech Republic, contributed to the preparation of the OBAAMA-CZ database and statistical processing of the results.

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