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

Abstract

Neuraxial anaesthesia is widely utilised for elective caesarean section, but the prevalence of inadequate intraoperative 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.

Prevention and management of intra‐operative pain during caesarean section under neuraxial anaesthesia: a technical and interpersonal approach

“…There is currently no standardised approach to testing a neuraxial block before caesarean section, nor is there an algorithm for managing a neuraxial block that is inadequate for surgery. A recent systematic review of inadequate neuraxial anaesthesia in patients undergoing elective caesarean section has highlighted the absence of national guidance in this area [5].…”

SP22 For emergency CS, a labour epidural should be removed and a spinal anaesthetic used instead

“…The Obstetric Anaesthetists' Association (OAA) in the United Kingdom estimates that only 5% of labour epidurals will not work well enough for a Caesarean section 7 , should it be required. In an Irish study, the rate of labour epidurals converted to spinal or general anaesthesia for Caesarean section was 9% 8 , the conversion rate from an Indian study was approximately 4% 9 , a Maltese study identified a rate of epidural conversion to spinal or general anaesthesia for Caesarean section as 0.85% and 1.5% respectively 10 , a Chinese publication showed a conversion rate to general anaesthesia of 3% 11 , while a systematic review in 2022 by authors from the United Kingdom and the United States of America including over 3000 patients showed an overall prevalence of inadequate epidural anaesthesia of around 30% 12 . It is however worth noting that this systematic review relates to elective caesarean section, and not emergencies, with the possibility that epidural analgesia was not established for a significant period of time prior to the procedure.…”

What is ‘genuine’ failure of neuraxial anaesthesia?

“…Patel et al. undertook a systematic review with 54 studies (3497 patients) which were widely distributed internationally [1]. With 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 benzodiazepines) or unplanned epidural drug supplementation, the overall prevalence was found to be 14.6%.…”

“…Twitter: @SusannaStanford What is 'genuine' failure of neuraxial anaesthesia? In their systematic review, Patel et al want to give an answer to this question, but they risk gravely underestimating the issue [1].…”