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Excess in Moderation: General Anesthesia for Cesarean Delivery

Hawkins, Joy L. MD

doi: 10.1213/ANE.0000000000000651
Editorials: Editorial
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From the Department of Anesthesiology, University of Colorado School of Medicine, Aurora, Colorado.

Accepted for publication January 11, 2015.

Funding: None.

The author declares no conflicts of interest.

Reprints will not be available from the author.

Address correspondence to Joy L. Hawkins, MD, Department of Anesthesiology, University of Colorado School of Medicine, 12631 East 17th Ave., Mail Stop 8203, Aurora, CO 80045. Address e-mail to Joy.Hawkins@ucdenver.edu.

The ultimate goal for anesthesiologists is to provide the safest and most effective care for their patients. Parturients on the labor and delivery unit represent a group with perhaps the highest stakes for achieving excellent patient satisfaction and a safe outcome for mother and newborn. In this issue of Anesethsia & Analgesia, Stourac et al.1 report a fascinating national survey of current anesthesia practices for cesarean delivery in the Czech Republic and identify areas for improvement. The survey contains a wealth of useful and interesting information and begs the question: how should the authors and readers proceed from here? As the authors point out, the definition of normal obstetric anesthesia practice varies widely from country to country, so how do we identify the optimal way to care for parturients during cesarean delivery?

A prominent finding in the survey was that general anesthesia was used in 44.4% of cesarean deliveries. The authors’ conclusions imply that the high rate may be a negative quality indicator. This is certainly a significantly higher rate of general anesthesia than is seen in the United States or in many Western European countries, but how much is too much general anesthesia? What should the rate of general anesthesia for cesarean delivery be, and what evidence can we use to determine that threshold? If 44.4% is too much, is 25% a reasonable goal? Does 15% indicate even better quality care? Is 5%, the often-quoted rate in the United States, too low? Is the rate of general anesthesia for cesarean delivery even a valid quality indicator? There is no evidence-based method to determine the appropriate rate of general anesthesia for cesarean delivery or even data to provide an acceptable range.

The strong preference of anesthesiologists for neuraxial anesthesia for the obstetric patient is unique. In no other patient group do anesthesiologists strive to avoid general anesthesia for major abdominal surgery. There certainly are both real and theoretical reasons to prefer neuraxial anesthesia over general anesthesia for cesarean delivery, such as maternal bonding with the newborn, the potential for skin-to-skin contact immediately after delivery, less blood loss, better postoperative pain management with fewer opioid side effects, and possibly a lower risk of thrombotic complications. However, in some emergency situations, or in the presence of specific maternal comorbidities, general anesthesia may be preferable to a neuraxial technique for cesarean delivery. These situations might include umbilical cord prolapse, significant placental abruption, prolonged fetal bradycardia in the absence of labor neuraxial analgesia, and maternal cardiac disease, such as critical aortic stenosis or significant pulmonary hypertension. Thus, the appropriate choice of anesthetic should be decided on a case-by-case basis depending on maternal and fetal conditions.

The main reason anesthesiologists avoid general anesthesia in favor of neuraxial is because of the concern for difficult airway management. In the 1970s and 1980s, this was a valid concern when much higher mortality rates were reported during general than neuraxial anesthesia.2 However, more recent evidence from the Centers for Disease Control and Prevention,3 the Serious Complication Registry (SCORE) from the Society for Obstetric Anesthesia and Perinatology,4 the American Society of Anesthesiologists (ASA) Closed Claims Project,5 and The Doctor’s Company, a medical malpractice insurance company,6 have not found difficult airway management or pulmonary aspiration to be major sources of obstetric anesthesia complications. Much has changed in obstetric anesthetic practice since the 1970s and 1980s that make general anesthesia safer, at least in the United States and other high-income countries. We have better equipment to manage the unexpected difficult airway, including supraglottic airway devices, video laryngoscopes, promulgation of difficult airway algorithms, and multidisciplinary simulations and team training to improve performance when a crisis occurs. For the subset of patients for whom general anesthesia really might be riskier because of a suspected difficult airway or significant obesity, or who might be at increased risk for emergency cesarean delivery, an epidural catheter can be placed early in labor for use in the event of intrapartum cesarean delivery. Documentation of a preanesthetic airway examination might be a more relevant quality indicator than the rate of general anesthesia.

The SCORE project described anesthetic practice and outcomes by reviewing 307,000 deliveries from 30 centers in the United States between 2004 and 2009.4 There were no cases of pulmonary aspiration, and although the rate of failed intubation was 1 in 533, there were no hypoxic cardiac arrests secondary to a lost airway although these low rates could be explained by selection bias. Instead, the most common serious complications in the SCORE project were related to neuraxial anesthetics. High neuraxial block attributable to unrecognized spinal catheters or spinal anesthesia induced after a failed epidural block occurred with an incidence of 1 in 4336.

In the most recent ASA Closed Claims database report on obstetric anesthesia claims, maternal injuries related to neuraxial anesthesia, such as nerve injury, headache, pain during surgery, and emotional distress, make up the majority of cases.5 Many of the claims for pain and emotional distress were related to inadequate neuraxial blocks that were used for surgical procedures, perhaps because the anesthesia provider was reluctant to convert to general anesthesia. When a neuraxial anesthetic does not provide an adequate surgical block, failure to induce general anesthesia will lead to physical pain and emotional distress for the mother, and may increase the risk of aspiration if deep sedation is used with an unsecured airway. There is potential morbidity for the mother and liability for the anesthesiologist. In these circumstances, failure to convert to general anesthesia can be considered poor quality care. Other claims against the anesthesiologist for adverse neonatal outcomes were often related to delay of delivery when excessive time was taken to initiate neuraxial anesthesia rather than proceeding with induction of general anesthesia.5 Anesthesiologists should move beyond the single issue of airway management as the entire basis for our anesthetic choices for cesarean delivery. General anesthesia should not be perceived as poor quality care. In some circumstances, it might be the best choice and may be just as safe as neuraxial anesthesia in modern practice.3

Even though there are appropriate indications for general anesthesia, and I do not believe the general anesthesia rate should be used as a quality indicator, I agree with the authors of the Czech survey that a general anesthesia rate of 44% is high, if only because these women are not benefiting from the real advantages of neuraxial compared with general anesthesia. How might anesthesiologists in the Czech Republic lower the rate of general anesthesia? In the survey, the indication for general anesthesia differed depending on whether the cesarean delivery was urgent or elective. In emergency cases, urgency was the indication in 67%, patient refusal in 15%, and failure of neuraxial anesthesia in 4%. In elective cases, patient refusal occurred in 64%, and failure of neuraxial anesthesia was the indication in another 9%. Emergency and some urgent situations may be indications for general anesthesia for cesarean delivery. Expeditious initiation of neuraxial anesthesia may also be appropriate even when there is compromise to the mother or fetus, but excessive delay if the procedure is technically difficult or prolonged may harm the mother or newborn. However, the most common reasons for general anesthesia in elective cases were patient refusal and failure of neuraxial anesthesia. Why were patients refusing neuraxial anesthesia for elective cesarean delivery?

The high rate of patient refusal of neuraxial anesthesia and the relatively high failure rate of epidural anesthesia may be more concerning than the common use of general anesthesia. Anesthesiologists and obstetricians perceive many benefits to neuraxial anesthesia for cesarean delivery, and it is up to physicians to communicate these benefits to their patients. However, neuraxial anesthesia does have a quantifiable failure rate, whereas general anesthesia is virtually 100% reliable. This survey found an 8% failure rate for epidural anesthetics. A failed block and intraoperative conversion to general anesthesia is discouraging for the patient, the obstetrician, and the anesthesiologist, especially if preceded by the patient experiencing pain. Neuraxial anesthetic techniques require extensive training, can be technically challenging, and once chosen for cesarean delivery, require a great deal of interpersonal interaction with the patient and her support person in the operating room. This can be mentally taxing compared with the general operating room, where there is only 1 person requiring attention, and an unconscious patient at that. One might say that general anesthesia is easier for the anesthesiologist, especially if there is little opportunity to maintain neuraxial anesthesia skills in one’s practice.

To increase the use of neuraxial anesthesia in any practice, and to take advantage of all its benefits, a number of obstacles can be reduced or removed.

  1. Antepartum patient education efforts should begin in the obstetrician’s office. Anesthesiologists can develop a simple 1-page explanation of neuraxial procedures, their benefits, and their rare complications.
  2. Ongoing education must be pursued so that anesthesiologists stay current with neuraxial techniques, medications, and troubleshooting when neuraxial blockade is less than perfect. Task trainers and simulation allow providers to practice their techniques in a safe, non–patient-care environment.
  3. Repetition increases comfort with any procedure. In this survey, only 40.5% of deliveries included anesthesia services, mainly for cesarean delivery rather than labor analgesia. As neuraxial labor analgesia becomes more common, anesthesiologists will be more comfortable with block initiation and management and more likely to consider using epidural anesthesia for cesarean delivery when the epidural catheter is already in place and working well.
  4. Access to adjuvants that improve the quality of neuraxial blocks can be increased. Anesthesiologists should recognize that neuraxial fentanyl and sufentanil have been widely used for decades despite lack of official approval by national agencies such as the Food and Drug Administration in the United States. National anesthesiology organizations should explore the reason for the high cost of preservative-free morphine. Despite higher costs, its superior postoperative pain control may offset its initial cost by reducing the use of parenteral opioids, decreasing the need for nursing interventions, and improving patient mobilization.
  5. Although epidural bupivacaine and ropivacaine can be effective surgical anesthetics, their long onset time and duration are rarely optimal for cesarean delivery, and their systemic toxicity is more serious than other local anesthetics. Using 2% lidocaine for elective or urgent surgeries (and if it can be made available, 3% 2-chloroprocaine for truly emergent cases) should improve throughput and efficiency in the obstetric operating rooms.

With an understanding of current practice in the Czech Republic, the authors are in an excellent position to lead development of evidence-based guidelines for obstetric anesthesia practice, ideally produced jointly with their national organization of obstetricians. Practices such as preoperative airway evaluation and documented Mallampati score (documented in only 37.5% of cases), timely administration of antibiotic prophylaxis (used in only 86% of cesarean deliveries) before skin incision (done in only 11%), reversal of nondepolarizing muscle relaxants (55% did not reverse), and use of pencil-point needles for spinal anesthesia (used in only 60%) would quickly lead to improved patient outcomes.

The authors are to be commended for their dedication to improving anesthetic care for parturients in the Czech Republic. Although attention will likely be focused on the high use of general anesthesia for cesarean delivery, there are other more important goals for obstetric anesthesiologists to strive for than just increased use of neuraxial anesthesia. The perioperative surgical home is a popular concept being developed in the United States; perhaps anesthesiologists can work toward developing the peripartum obstetric home.7 Coexisting medical conditions are the most common cause of maternal mortality in the United States,8 and anesthesiologists are adept at optimizing medical comorbidities in the perioperative period. Techniques are just techniques; anesthesiologists practice medicine and have the ability to impact the entire continuum of care.

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DISCLOSURES

Name: Joy L. Hawkins, MD.

Contribution: This author helped write the manuscript.

Attestation: Joy L. Hawkins approved the final manuscript.

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

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REFERENCES

1. Stourac P, Blaha J, Klozova R, Noskova P, Seidlova D, Brozova L, Jarkovsky J. Anesthesia for cesarean delivery in the Czech Republic: a 2011 national survey. Anesth Analg. 2015;120:1303–8
2. Hawkins JL, Koonin LM, Palmer SK, Gibbs CP. Anesthesia-related deaths during obstetric delivery in the United States, 1979–1990. Anesthesiology. 1997;86:277–84
3. Hawkins JL, Chang J, Palmer SK, Gibbs CP, Callaghan WM. Anesthesia-related maternal mortality in the United States: 1979–2002. Obstet Gynecol. 2011;117:69–74
4. D’Angelo R, Smiley RM, Riley ET, Segal S. Serious complications related to obstetric anesthesia: the serious complication repository project of the Society for Obstetric Anesthesia and Perinatology. Anesthesiology. 2014;120:1505–12
5. Davies JM, Posner KL, Lee LA, Cheney FW, Domino KB. Liability associated with obstetric anesthesia: a closed claims analysis. Anesthesiology. 2009;110:131–9
6. Lofsky AS. Doctors company reviews maternal arrest cases. Anesthesia Patient Safety Foundation Newsletter, Summer. 2007;22:28–30
7. Kain ZN, Vakharia S, Garson L, Engwall S, Schwarzkopf R, Gupta R, Cannesson M. The perioperative surgical home as a future perioperative practice model. Anesth Analg. 2014;118:1126–30
8. Creanga AA, Berg CJ, Syverson C, Seed K, Bruce FC, Callaghan WM. Pregnancy-related mortality in the United States, 2006–2010. Obstet Gynecol. 2015;125:5–12
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