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Dr David M Levy Consultant Obstetric Anaesthetist

Pain and distress during Caesarean section under regional anaesthesia. Dr David M Levy Consultant Obstetric Anaesthetist. 16 May 2013. Pain and distress during Caesarean section under regional anaesthesia. Testing block height New UK audit standards Spinals after epidurals

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Dr David M Levy Consultant Obstetric Anaesthetist

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  1. Pain and distressduring Caesarean section under regional anaesthesia Dr David M Levy Consultant Obstetric Anaesthetist 16 May 2013

  2. Pain and distressduring Caesarean section under regional anaesthesia • Testing block height • New UK audit standards • Spinals after epidurals • Adjuncts to regional block • Legal cases

  3. Failed spinals Fettes, Jansson, Wildsmith BJA 2009; 102: 739

  4. Failed spinals Fettes, Jansson, Wildsmith BJA 2009; 102: 739

  5. Oxford Head Elevating Laryngoscopy Pillow

  6. RCoA standard (target for best practice)

  7. RCoA standard (target for best practice)

  8. RCoA standard (target for best practice)

  9. RCoA standard (target for best practice)

  10. T5 to light touch T10 and rising Block height at start of CS

  11. S5 - T5 Where’s T5? Congreve K et al Anaesthesia 2006; 61: 453

  12. Yentis: diagram • A: some cold • B: icy cold • C: ‘true’ height IJOA2006;15: 2

  13. Ousley et alAnaesthesia 2012;67: 1356

  14. Epidural failure rate • 20 000 deliveries, 3 yrs • Neuraxial labor analgesia rate 83% • 7.1% of pre-existing epidurals failed at CS

  15. Epidural failure rate • 20 000 deliveries, 3 yrs • Neuraxial labor analgesia rate 83% • 7.1% of pre-existing epidurals failed at CS (n= 122) 1.3% epidural replaced 1.5% spinal 4.3% GA

  16. Epidural failure rate • 20 000 deliveries, 3 yrs • Neuraxial labor analgesia rate 83% • 7.1% of pre-existing epidurals failed at CS (n= 122) 1.3% epidural replaced 1.5% spinal 4.3% GA • 6 high blocks required intubation • 2 spinals after initial spinal • 1 spinal after epidural • 2 epidural top-ups

  17. Spinals after epidurals? • Breda, Netherlands • Labour epidural infusions • C Section: straight to spinal: – no top-ups • Total spinal in 1/128

  18. Leeds: regional blocks requiring ventilatory support • LGI, 1997 – 2003 • 5/342 (1.46%) of spinals after epidurals • No predictors (previous epidural doses/spinal doses) • practice of spinals after epidurals after five cases of litigation for pain after topped-up epidurals

  19. Leeds: regional blocks requiring ventilatory support • LGI, 1997 – 2003 • 5/342 (1.46%) of spinals after epidurals • No predictors (previous epidural doses/spinal doses) • practice of spinals after epidurals after five cases of litigation for pain after topped-up epidurals

  20. Adjuncts to regional block

  21. Alfentanil

  22. 3 mcg/kg then 1.5 mcg/kg; 2 min lockout

  23. Ketamine

  24. Vapour/nitrous oxide

  25. Litigation in the UK • 2011-12: annual NHS spending £104 billion • NHSLA paid out over £1 billion on clinical claims • Major proportion: claimant legal fees

  26. Take-home message • Low threshold for offering GA • If GA offered • Relay conversation to partner • Document offer and response • Note time

  27. Questions... dmlevy@nhs.net

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