DOI: 10.1097/01.aoa.0000337938.41276.02
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Issn Print: 0275-665X
Publication Date: 2008/12/01
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Excerpt
A postal questionnaire was developed based on previously published guidelines and sent to the lead obstetric anesthetists at each of the maternity units in the UK. Information on how working epidurals for labor were topped up was obtained by asking which local anesthetics were used and where administered, whether consultants advocate the same practice to their trainees, how long it takes to move a patient from the labor area to the operating room, what basic monitoring and resuscitation facilities are available, availability of written guidelines, and occurrence of complications.
Of 254 surveys sent, 209 replies were received of which 200 were used for the final analysis. A full dose of local anesthetic was given in the delivery room in 136 sites (68%), test dose only in the delivery room in 25 (12.5%), test dose and full dose in operating room in 30 (15%), and no answer in 9 (4.5%). Sixty-eight (34%) anesthetists reported that their sites gave a test dose before the full dose; 123 (61.5%) gave the full dose, either as a bolus or in divided doses, without a test dose. Bupivacaine 0.5% was used as the sole agent by 83 (41.5%) of respondents and in combination with other local anesthetics with and without epinephrine and bicarbonate by another 49 (24%). Lidocaine 2% was used alone by 11 (5.5%) respondents and in combination with other agents by 60 (34.5%). Levobupivacaine and ropivacaine were used as the only local anesthetics by 25 (12.5%) and 7 (3.5%) respondents, respectively. Sixty (30%) respondents added epinephrine to the mixture of local anesthetics and another 24 (12.0%) added sodium bicarbonate. Transfer times from the delivery room to the operating room ranged from 1 to 20 minutes, the mode being 1 minute, and with 93% of sites having times of ≤5 minutes. In 170 units, the senior anesthetist recommended that trainees follow the same practice as themselves. Guidelines for epidural block extension for emergency CS were available in 128 (64%) of the units. Of the 161 units that extend or initiate the extension of epidural block in the delivery room, 140 have ephedrine immediately available in the room. Monitoring with 1 or more monitors (noninvasive blood pressure, electrocardiogram, pulse oximetry) during transfer to the delivery room was used by 41 (25%) of respondents; 114 units (71%) used no monitor. Adverse incidents [reported by 33 respondents (16.5%)] included inadequate block in 8 patients, high block requiring intubation or not in 12 and 14, respectively, intravascular injection in 6 with subsequent seizures in 2, and cardiac arrest in 1.
The results of this survey provide insights into how epidural analgesia is converted to surgical anesthesia for emergency CS and accurately represent practice in the UK as an excellent response rate of 82% was achieved. The incidence of seizures and cardiac arrest, although rare, indicate that the administration of a test dose should be considered before the full dose of local anesthetic, and that the full dose should be given in the operating room where full monitoring and treatment equipment are readily available.
