Inadequate neuraxial anaesthesia in patients undergoing elective caesarean section: a systematic review.

Neuraxial anaesthesia is widely utilised for elective caesarean section, but the prevalence of inadequate intra-operative anaesthesia is unclear. We aimed to determine the prevalence of inadequate neuraxial anaesthesia for elective caesarean section; prevalence of conversion from neuraxial anaesthesia to general anaesthesia following inadequate neuraxial anaesthesia; and the effect of mode of anaesthesia. We searched studies reporting inadequate neuraxial anaesthesia that used ≥ ED95 doses (effective dose in 95% of the population) of neuraxial local anaesthetic agents. Our primary outcome was the prevalence of inadequate neuraxial anaesthesia, defined as the need to convert to general anaesthesia; the need to repeat or abandon a planned primary neuraxial technique following incision; unplanned administration of intra-operative analgesia (excluding sedatives); or unplanned epidural drug supplementation. Fifty-four randomised controlled trials were included (3497 patients). The overall prevalence of requirement for supplemental analgesia or anaesthesia was 14.6% (95%CI 13.3-15.9%); 510 out of 3497 patients. The prevalence of general anaesthesia conversion was 2 out of 3497 patients (0.06% (95%CI 0.0-0.2%)). Spinal/combined spinal-epidural anaesthesia was associated with a lower overall prevalence of inadequate neuraxial anaesthesia than epidural anaesthesia (10.2% (95%CI 9.0-11.4%), 278 out of 2732 patients vs. 30.3% (95%CI 26.5-34.5%), 232 out of 765 patients). Further studies are needed to identify risk factors, optimise detection and management strategies and to determine long-term effects of inadequate neuraxial anaesthesia.

Enhanced recovery after caesarean delivery versus standard care studies: a systematic review of interventions and outcomes.

BACKGROUND: This systematic review aimed to determine whether enhanced recovery after caesarean delivery (ERAC) protocols should be adopted. METHODS: We searched four databases and abstracts from meetings for studies comparing ERAC to standard care. We report interventions, outcomes, qualitative impact of ERAC implementation and use GRADE scoring to determine quality of evidence and make recommendations regarding ERAC adoption, based on key outcomes (length of stay, financial savings, satisfaction, re-admission, opioid usage, breastfeeding success and maternal-neonatal bonding). RESULTS: Eleven published studies and 36 abstracts evaluating ERAC were included. Forty-two study interventions (40 in published studies) and 90 outcome measures (60 in published studies) were used. Most studies showed a reduction in hospital stay (6/7 studies) and reduced costs (2/2 studies) with ERAC compared with standard care. Satisfaction was inconsistently reported. Re-admission rates were similar between groups. Two studies showed a reduction and two showed no difference in opioid consumption with ERAC. One study showed improvement and another showed no change in outpatient breastfeeding rates with ERAC. One study showed better inpatient maternal-neonatal bonding. The GRADE level of evidence was low or very low for all outcomes. CONCLUSIONS: Studies evaluating ERAC used heterogeneous interventions and outcomes. Although there is currently low- or very low-level evidence supporting all outcomes evaluated, the majority of studies showed some benefits and none reported harm. On balance, we recommend the use of ERAC. Future studies are needed to strengthen ERAC recommendations by standardising interventions and reported outcomes.

Evaluation of patient-reported outcome measures of functional recovery following caesarean section: a systematic review using the consensus-based standards for the selection of health measurement instruments (COSMIN) checklist.

We performed a systematic review using 'consensus-based standards for the selection of health measurement instruments' (COSMIN) criteria to identify and evaluate the quality of patient-reported outcome measures (PROM) instruments that have been utilised to assess functional recovery following caesarean section, and determine the optimal instrument for use in this setting. A literature search was performed using five databases. Studies were included if a psychometrically validated instrument was used to assess functional recovery following caesarean section. The COSMIN appraisal checklist was utilised to: assess the quality of included studies reporting PROMs; determine psychometric quality of instruments; and identify the most promising instruments for use after caesarean section. We identified 13 PROMs used to assess the quality of recovery after caesarean section in 20 studies that included 9214 patients. All PROMs contained between two and seven domains. Five out of the 13 PROMs were specific to postpartum recovery. Only two of these PROM instruments were specifically designed for use after caesarean section (Obstetric Quality of Recovery-11 and Recovery from Caesarean Section Scale). We found very few adequate measures of functional recovery following caesarean section. Overall, the Obstetric Quality of Recovery-11 achieved the highest COSMIN standards for any PROM. Future development of PROMs for use after caesarean section should include multiple domains, and undergo validation as outlined by the COSMIN criteria.

Local anaesthetic techniques for post-caesarean delivery analgesia.

In this narrative review we summarise pertinent data from published studies investigating the use of local anaesthetic techniques as adjuncts for managing post-caesarean delivery pain. Based on currently available evidence, ultrasound-guided transversus abdominis plane (TAP), quadratus lumborum (QL) and ilio-inguinal and iliohypogastric (ILIH) blocks are preferable to landmark techniques. When intrathecal morphine is used for caesarean delivery analgesia, TAP blocks do not confer any additional benefit. In the absence of intrathecal morphine, TAP blocks have been shown to reduce pain scores and opioid consumption in the first 24 h postoperatively. In the absence of intrathecal morphine, single-dose local anaesthetic wound infiltration also results in a moderate reduction in opioid consumption postoperatively. If a wound catheter is to be incorporated into a multimodal analgesic regimen, a position below the fascia and a continuous infusion of low-concentration local anaesthetic solutions should be considered. Intraperitoneal local anaesthetic instillation may be of benefit in patients who undergo peritoneal closure but larger studies are still needed. Quadratus lumborum and ILIH blocks show promising results but the data are limited, so recommendations for routine use cannot be made. In summary, evidence supports the use of local anaesthetic techniques for post-caesarean delivery pain but additional research is required to determine the optimum dosing regimens, and the potential role of liposomal local anaesthetics. Further studies are required to compare techniques and determine their role in conjunction with low-dose long-acting neuraxial opioids.

Clinical evaluation of the intestinal microcirculation using sidestream dark field imaging--recommendations of a round table meeting.

INTRODUCTION: In clinical setting, Sidestream Dark Field (SDF) imaging has provided unprecedented insights into the gut microcirculation mainly by studying the intestinal mucosa of patients with ileostomies. Visualizing microvascular structure and function of ileal mucosa at the bedside brings unique opportunity for clinical research, particularly in critically ill patients. Several papers that were focused on intestinal microcirculation, used different methods of assessment because an accepted scoring systems does not exist so far and it is no surprise that it is rather difficult to compare the results from these studies. The present paper presents recommendations concerning specific aspects of image acquisition and proposes some parameters for the description of the intestinal microcirculation in human studies, as suggested by the participants of a round table meeting. METHODS: The round table meeting participants reviewed all relevant literature, discussed various aspects of image acquisition by SDF technology in patients with ileostomy and parameters for the description of intestinal mucosa microcirculation. Selected key conditions for high quality and reproducible image recordings were identified. To evaluate quality of intestinal microcirculation, selected parameters and scoring system were suggested and described. RESULTS: For image acquisition in ileostomies, five key points were proposed: optimal timing, optimal SDF device probe positioning, optimal stabilization, optimal number and length of acquired video recordings, and optimal avoidance of pressure artefacts. With regard to image analysis, simplified set of quantitative and qualitative parameters for the description of the intestinal mucosa microcirculation for the clinical studies has been proposed: vessels per villus, microvascular flow index, proportion of perfused villi, and borders of villi. The proposed parameters can be included in a semi-quantitative scoring system; however, this scoring system needs further validation. This simplified analysis does not require sophisticated software and can be performed manually on the video screen. CONCLUSION: We propose a simple methodology for image acquisition and suggest specific microvascular parameters to analyze SDF imaging studies of the intestinal mucosa microcirculation in patients with ileostomy. Proposed scoring system needs to be validated in further clinical studies.