General anaesthesia for obstetric surgery has distinct characteristics that may contribute towards a higher risk of accidental awareness during general anaesthesia. The primary aim of this study was to investigate the incidence, experience and psychological implications of unintended conscious awareness during general anaesthesia in obstetric patients. From May 2017 to August 2018, 3115 consenting patients receiving general anaesthesia for obstetric surgery in 72 hospitals in England were recruited to the study. Patients received three repetitions of standardised questioning over 30 days, with responses indicating memories during general anaesthesia that were verified using interviews and record interrogation. A total of 12 patients had certain/ probable or possible awareness, an incidence of 1 in 256 (95%CI 149-500) for all obstetric surgery. The incidence was 1 in 212 (95%CI 122-417) for caesarean section surgery. Distressing experiences were reported by seven (58.3%) patients, paralysis by five (41.7%) and paralysis with pain by two (16.7%). Accidental awareness occurred during induction and emergence in nine (75%) of the patients who reported awareness. Factors associated with accidental awareness during general anaesthesia were: high BMI (25-30 kg.m -2 ); low BMI (<18.5 kg.m -2 ); out-of-hours surgery; and use of ketamine or thiopental for induction. Standardised psychological impact scores at 30 days were significantly higher in awareness patients (median (IQR [range]) 15 (2.7-52.0 [2-56]) than in patients without awareness 3 (1-9 [0-64]), p = 0.010. Four patients had a provisional diagnosis of post-traumatic stress disorder. We conclude that direct postoperative questioning reveals high rates of accidental awareness during general anaesthesia for obstetric surgery, which has implications for anaesthetic practice, consent and follow-up.

Acute bacterial meningitis (ABM) carries a 20–50% mortality rate with significant morbidity in survivors. Appropriate investigations and expeditious treatment (particularly antibiotics and often steroids) significantly improve outcomes. The National Institute for Clinical and Health Excellence (NICE) has not published guidance directing management in adults despite robust evidence informing treatment. We aimed to evaluate the investigation and initial management of suspected ABM against a European guideline1 in five East Anglian hospitals. We subsequently explored whether the results reflected insufficient knowledge by inviting all doctors in these emergency and acute medical departments to complete a survey. Audit Clinical coding searches over 12 months at 5 hospitals for any type of meningitis identified 32 patients with proven ABM (bacteria in cerebrospinal fluid or typical composition) or those treated as ABM if lumbar puncture (LP) was omitted. 28 patients (88%) survived to discharge. Blood culture collection preceded antibiotics in 28 patients (88%). LP was attempted in 26 patients (81%), all undergoing prior head imaging; 19 patients (73%) merited this scan suggesting that LP (and subsequent antibiotics) were unnecessarily delayed in 7 patients (27%). LP was performed within the recommended 4 hours in 17 patients (65%); the median time to LP was 218 minutes (range: 5–1235). Median time to antibiotic administration from first documented suspicion of ABM was 72 minutes (range: 0–4740); 9 patients (28%) were treated within the recommended 30 minutes. 29 patients (94%) were treated according to local antibiotic policy (or had valid reasoning for deviation). High dose corticosteroids, recommended for non–meningococcal ABM before or with the first antibiotic dose, were given to 11 patients (34%); the remainder had no documented contraindication although 2 patients (6%) later cultured meningococcus. Median time to steroid administration was 17 hours, 16 hours after antibiotics. 25 patients (78%) had seizures or reduced conscious level at presentation; 12 of these (48%) received acyclovir. Survey: 101 doctors (22 consultants, 41 registrars and 38 junior doctors; response rate 62%) completed an online questionnaire addressing ABM management in adults against European guidance.1 18 doctors (18%) correctly identified the indications for head imaging before LP; 1% identified all contraindications to LP. 32% selected the correct indications and 1% the correct contraindications to high–dose corticosteroids. 62% referred to (non–existent) NICE guidelines; none were aware of the European guidelines.1 The majority felt their undergraduate and postgraduate training in managing ABM sufficient and reported a median confidence of 7/10 (where 10=fully confident) in it's management. Conclusions Unjustified variance from European guidelines occurred in one or more aspect of every patient's management. Significant deficits in knowledge, particularly regarding expeditious antibiotic and steroid therapy, appear to be contributory ...