GA caesarean section & post-partum depression

This large study (Guglielminotti 2020) of 428,204 New York caesarean section records (2006-2013), including 34,356 general anaesthetics (8%), investigated the association between mode of anaesthesia and post-partum depression (PPD). Other studies have shown an association between caesarean section (emergency > elective) and PPD. (Sun 2021, Xu 2017, and others), though this is the first to look specifically at general anaesthesia as a PPD risk factor.

Guglielminotti and Li found that general anaesthesia increased the odds of severe PPD by 54% (aOR 1.54, 1.21-1.95), and suicidal ideation by a massive 91% (aOR 1.91, 1.12-3.25), though not a significant increase in anxiety or PTSD.

The researchers discuss many potential causative factors, particularly known associations between GA CS & poor pain control, and subsequent pain & PPD – while also acknowledging the obvious potential for confounders. Of note patients receiving GA were older, more often non-Caucasian, had more co-morbidities, neonatal complexity, and lower socio-economic levels – also all independently associated with PPD risk.

In order to quantify the potential confounding contribution of emergency vs elective status, the researchers employed the novel E value:

To assess the impact of emergent cesarean delivery on our results, we calculated the E value associated with the aOR for the risk of PPD and suicidality. This relatively new metric takes into consideration 2 associations: (1) that between the confounder (emergent cesarean delivery) and the outcome (PPD); and (2) the association between the confounder (emergent cesarean delivery) and the exposure (general anesthesia).

An E value of 1.7 for the unmeasured confounder emergent cesarean delivery indicates that to explain away the association between general anesthesia and depression, either: (1) emergent cesarean delivery increases the risk of depression by at least 70%; or (2) emergent cesarean delivery is at least 70% more prevalent among general anesthesia than among neuraxial anesthesia. Either association is clinically plausible.

Keep it in perspective...

We already know that general anaesthesia for CS is suboptimal: it compromises both maternal experience and safety, but it should (hopefully) only ever be a chosen mode of anaesthesia when there is a true contraindication to regional anaesthesia – even at the modestly-high 8% GA rate among this New York cohort.

Looking at it from the other end, bear in mind that the modestly-faster time-to-incision for GA over regional is also of questionable neonatal benefit.

The take-home:

Just another reason to avoid GA CS when possible – but you already knew that, right?

"...general anesthesia is a potentially modifiable risk factor for PPD. This finding provides further supporting evidence favoring neuraxial over general anesthesia in cesarean delivery whenever possible."

Supraglottic airway training and manikins

Interesting prospective simulation & equipment study by way of the University of Freiburg. Schmutz et al. investigated how effective five different second generation supraglottic airway devices (SADs) performed in two common airway manikins: the TruCorp AirSim® and the crowd favourite, Laerdal's Resusci Anne® Airway Trainer™.

While ventilation was achieved in all SAD-manikin combinations, the Resusci Anne® Airway Trainer™ was associated with better and more consistent performance for SAD position, participant subjective assessment and ease of gastric tube insertion for most of the SADs. The TruCorp AirSim® did however achieve better leak pressures across most of the SADs (LMA® Supreme™, Ambu® AuraGain™, i-gel®, KOO™-SGA & LTS-D™).

But then, what are the implications for airway simulation training? The researchers correctly note that:

The most important quality of a manikin is the ability to simulate the real-world conditions and thus to give the trainee an authentic feedback.

The bottom line for SAD manikins?

While considering how manikin choice and SAD availability match with your aims for simulation training, the bigger picture is that the primary goal of any manikin-SAD coupling is real-life fidelity – and for that reason, participant subjective assessment is king. And so in this study at least, the Resusci Anne® Airway Trainer™ wins.

Head-rotation to improve LMA leak pressure?

Another interesting little airway study, this time out of Sapporo, Japan (Chaki 2021). A neat little randomised but-not-blinded  study of the effect of head rotation on the oropharyngeal leak pressure of both the i-gel and LMA Supreme 2nd generation supraglottic airways.

The researchers investigated the leak pressure (OPLP) of the i-gel and LMA Supreme in paralysed patients with the head: 1. neutral, 2. rotated 30°, and 3. rotated 60°. They found that rotation of the head through 30° and  60° progressively increased OPLP by a clinically-significantly amount (0° vs 60°  5.5 cmH2O (3.3-7.8) & 6.5 cmH2O (5.1-8.0) respectively).

Before you get too excited...

The result however may not be reliably applicable to all populations, notably the study subjects were overwhelmingly small (x̄ ~160cm & 60kg) Japanese women (71%), receiving a TIVA muscle-relaxant anaesthetic (propofol, remifentanil, rocuronium). How well this improvement-with-rotation holds up among, for example, spontaneously ventilating large Caucasian males, is unclear.


When using an i-gel or LMA Supreme 2nd generation supraglottic airway, careful head rotation to 60° may increased oropharyngeal leak pressure and so assist with ventilation troubleshooting. However head and neck rotation of anaesthetised, paralysed patients should be performed gently and cautiously – you are after all, not a chiropractor!

COVID mRNA vaccines and immune persistence

A great Good News study just published in Nature by researchers from Wash U Med investigated persisting COVID immunity following the Pfizer mRNA vaccination (BNT162b2). Turner et al. looked at the presence of not only circulating antibody-secreting B cells, but also germinal centre B cells found in the axillary lymph nodes of 14 study volunteers.

While the persistence of mRNA-vaccine induced immunity to SARS-CoV-2 has already been demonstrated to last at least 6 months, and likely 12 months, we do not yet know if or when vaccine boosters will be required beyond that.

Turner's study is particularly exciting because they found spike-protein binding B cells in the germinal centre of draining lymph nodes in all 14 post-immunisation participants for the full 15 weeks of the study. The germinal centre response was so vigorous and persistent that the researchers believe this could represent COVID-protection lasting for years.

"Ellebedy said the immune response observed in his team’s study appears so robust and persistent that he thinks that it could last for years. The researcher based his assessment on the fact that germinal centre reactions that persist for several months or longer usually indicate an extremely vigorous immune response that culminates in the production of large numbers of long-lasting immune cells, called memory B cells. Some memory B cells can survive for years or even decades..." – Dr Francis Collins, NIH Directors Blog

This study builds on the same team's earlier work (Turner 2021 May) looking at bone marrow plasma cells in those who have recovered from mild COVID infection, also showing a long-lived immune response.

COVID persistent immunity takeaway:

Although COVID-19 and developed vaccines have been circulating for only 12-18 months, these immune-response studies give some hope that the miracle of mRNA vaccines may not only be in their efficacy, but also in the longevity of protection.

Mentioned studies:

  1. Guglielminotti J Li G. Exposure to General Anesthesia for Cesarean Delivery and Odds of Severe Postpartum Depression Requiring Hospitalization. Anesth. Analg. 2020 Nov 1; 131 (5): 1421-1429.
  2. Schmutz A, Bohn E, Spaeth J et al. Comprehensive evaluation of manikin-based airway training with second generation supraglottic airway devices. Ther Clin Risk Manag. 2019 Jan 1; 15: 367-376.
  3. Chaki T, Tachibana S, Kumita S et al. Head Rotation Reduces Oropharyngeal Leak Pressure of the i-gel and LMA® Supreme™ in Paralyzed, Anesthetized Patients: A Randomized Trial. Anesth. Analg. 2021 Mar 1; 132 (3): 818-826.
  4. Turner JS, O'Halloran JA, Kalaidina E et al. SARS-CoV-2 mRNA vaccines induce persistent human germinal centre responses. Nature. 2021 Jun 28.