Accidental dural puncture during epidural blood patch: a narrative review.

Whilst performing an epidural blood patch (EBP) to treat post dural-puncture headache following accidental or intentional dural puncture, the risk of a subsequent accidental dural puncture (ADP) is commonly quoted as 1%. However, a recent review reported only three documented cases. It seems likely that this complication is more common than is acknowledged, yet there is a paucity of literature and an absence of any guidance as to how to proceed in practice. This review addresses three unanswered questions regarding ADP during EBP: what is the incidence; what are the immediate clinical consequences; and what is the optimal clinical management? The incidence may reasonably be estimated to be 0.5-1%. Even on large units, this complication will not be experienced by every consultant anaesthetist during their career. It is likely to occur 20-30 times per year in the United Kingdom, and in greater numbers in those countries with higher epidural rates. Immediately re-attempting an EBP at a different level may be a reasonable management approach which has high efficacy, and is without clear evidence of significant harm. However, the limited evidence means that the risks are poorly characterised, and more data may lead to alternative conclusions. There is uncertainty amongst obstetric anaesthetists about how to manage ADP during EBP. More data and pragmatic guidance, which evolves with further evidence, will ensure optimal care for patients suffering this compound iatrogenic complication.

Diagnostic terminology in Placenta Accreta Spectrum: a scoping review.

BACKGROUND: Anaesthetic management strategies for Placenta Accreta Spectrum (PAS) remain diverse, and literature interpretation is complicated by a range of terminology. The International Federation for Gynaecology and Obstetrics (FIGO) published guidance in 2018 to improve PAS diagnosis and management by standardising definitions. We mapped the range, clarity and consistency of terminology in literature pertaining to both PAS and anaesthesia, and determined whether this changed followed FIGO guidance. METHODS: A literature search of four medical databases was performed. Papers included had PAS (or any 'synonym') in the title, and mode of anaesthesia in the title or abstract. Narrative reviews, and papers not containing original data, were excluded. Diagnostic terms, and evidence supporting their use, were described. RESULTS: Among 680 abstracts identified, 62 papers were included. Thirty distinct terms were used to describe PAS and subtypes. Terminology was clearly defined 46% of the time and used consistently within a paper 47% of the time. Nine papers (15%) provided no diagnostic evidence to support the terminology used. In 14 (23%) papers published after FIGO guidelines, 14 terms were used to describe PAS. Two papers (14%) specified the diagnostic criteria used. Six (43%) confirmed diagnoses using pathology. Four (29%) were consistent in use of terminology throughout the paper. CONCLUSIONS: Despite international consensus criteria for reporting PAS, the language pertaining to PAS and anaesthesia remains heterogeneous, inconsistent and variably defined. Reporting of PAS should adhere to FIGO criteria to allow unambiguous interpretation of work, and generation of evidence that is transferrable into clinical practice.

Distractions during critical phases of anaesthesia for caesarean section: an observational study.

Aviation's 'sterile cockpit' rule holds that distractions on the flight deck should be kept at a minimum during critical phases of flight. To assess current practice at comparable points during obstetric regional anaesthesia, we measured ambient noise and distracting events during 30 caesarean sections in three phases: during establishment of regional anaesthesia; during testing of regional blockade; and after delivery of the fetal head. Mean (SD) noise levels were 62.5 (3.9) dB during establishment of blockade, 63.9 (4.1) dB during testing and 66.8 (5.0) dB after delivery (p < 0.001). The median rates of sudden, loud (> 70 dB) noises, non-clinical conversations and numbers of staff present in the operating theatre increased during each of the three phases. Conversely, entrances into, and exits from, theatre per minute were highest during establishment of regional anaesthesia and decreased over the subsequent two time periods (p < 0.001).

Critical phase distractions in anaesthesia and the sterile cockpit concept.

In aviation, the sterile cockpit rule prohibits non-essential activities during critical phases of flight, takeoff and landing, phases analogous to induction of, and emergence from, anaesthesia. We studied distraction during 30 anaesthetic inductions, maintenances and emergences. Mean (SD) noise during emergence (58.3 (6.2) dB) was higher than during induction (46.4 (4.3) dB) and maintenance (52 (4.5) dB; p<0.001). Sudden loud noises, greater than 70 dB, occurred more frequently at emergence (occurring 34 times) than at induction (occurring nine times) or maintenance (occurring 13 times). The median (IQR [range]) of staff entrances or exits were 0 (0-2 [0-7]), 6 (3-10 [1-18]) and 10 (5-12 [1-20]) for induction, maintenance and emergence, respectively (p<0.001). Conversations unrelated to the procedure occurred in 28/30 (93%) emergences. These data demonstrate increased distraction during emergence compared with other phases of anaesthesia. Recognising and minimising distraction should improve patient safety. Applying aviation's sterile cockpit rule may be a useful addition to our clinical practice.

An observational study of practice during transfer of patients from anaesthetic room to operating theatre.

We observed practice during transfer of 80 patients from anaesthetic room to operating theatre, to determine the duration of apnoea and the time without monitoring during the transfer process. Median (IQR [range]) time from disconnection of the breathing system in the anaesthetic room to the first breath in theatre was 54 (44-65 [27-196]) s, and from disconnection of the pulse oximetry probe to the first reading in theatre was 90 (74-103 [44-182]) s. In four patients (5%) arterial oxygen saturation fell to 94%, with the greatest desaturation observed 11%. The transfer process may represent a window of opportunity for the occurrence of harm or the first step in a chain of events leading to harm, and is difficult to justify on patient safety grounds.

Successful umbilical cord blood stem cell transplantation in a patient with Rothmund-Thomson syndrome and combined immunodeficiency.

The ATP-dependent DNA helicase Q4 (RECQL4) belongs to a family of conserved RECQ helicases that are felt to be important in maintaining chromosomal integrity (Kitao et al., 1998, Genomics: 54 (3): 443-452). Deletions in the RECQL4 gene located on chromosome 8 region q24.3 have been associated with Rothmund-Thomson syndrome (RTS, OMIM 268400), a condition characterized by poikiloderma, sparse hair, small stature, skeletal abnormalities, cataracts and an increased risk of malignancy. We present a patient with a molecularly confirmed diagnosis of RTS with two unique genetic alterations in RECQL4 (IVS16-2A>T and IVS2+27_51del25), who at the age of 7 months nearly succumbed to Pneumocystis carinii pneumonia. Evaluation of his immune system demonstrated a T- B+ NK- phenotype with agammaglobulinemia consistent with combined immunodeficiency (CID). Studies to evaluate for known genetic causes of CID were not revealing. The patient received an umbilical cord blood (UCB) transplant with complete immune reconstitution. This report represents the first description of a CID phenotype and UCB transplantation in a patient with RTS.