Article Notes
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A specialized obstetric anesthesiologist was defined as having completed an obstetric anesthesia fellowship or specialist practice for at least 5 years with 33% full-time obstetric anesthesia case-load. ↩
What did they do?
The researchers randomised 130 women to 10 mg intrathecal hyperbaric bupivacaine plus an ultrasound-guided TAP block, or to 10mg intrathecal hyperbaric bupivacaine with 100 mcg morphine, plus a sham TAP block.
And they found
There was no difference between either group for satisfaction, analgesia or adverse effects. They concluded that in the context of intrathecal morphine availability, there is no benefit from TAP block, although TAP block can produce comparable analgesia if IT morphine is not used.
What’s particularly interesting...
Unlike the majority of obstetric anaesthesia research, this study comes from the same environment that also manages the bulk of global deliveries: low and medium income countries.
It is also an important reminder that not only are techniques used in wealthier countries applicable and translatable to lower-resource settings, but so is high quality research – and as with all research, context is everything.
Daniel Jolley
Why is this important?
The numerous benefits of neuraxial anesthesia (spinal, epidural, combined spinal-epidural) versus general anesthesia for cesarean section are well established.
While maternal and emergent risks for general anesthesia are well known (ethnic groups; emergencies; maternal disease), Cobb et al. present the highest quality evidence to date showing obstetric anesthesia specialization is associated with a lower GA rate.
What did they do?
The researchers conducted a retrospective cohort study at a large metropolitan teaching hospital (Philadelphia, Pennsylvania) over a 4 year period, comparing general anesthesia versus neuraxial, and obstetric-specialized1 vs generalist anesthesiologists for 4,217 singleton CS deliveries.
And they found?
The total study GA rate was 9.0%. Two-thirds of CS anesthesia was provided by seven specialist obstetric anesthesiologists, versus one-third provided by 33 generalists.
Specialist obstetric anesthesiologists demonstrated a significantly lower GA rate, 7.3% vs 12.1% (OR-CI 0.45-0.79). This difference persisted for the urgent/emergent CS sub-group, though not for after-hours delivery.
Nonetheless several non-provider factors were more strongly associated with GA such as emergency CS (⇡ 7-fold), maternal medical indications for CS (⇡ 3-fold), and after-hours CS (⇡ OR 33%).
Thus care by a specialist obstetric anesthesiologist is associated with an almost-30% reduction in GA for CS .
"...consider selecting neuraxial techniques in preference to general anesthesia for most cesarean deliveries." - ASA obstetric anesthesia task force. 2
Between the lines...
The individual obstetric-specialized anesthesiologists in this study had an almost 10-fold greater cesarean case load than did the average generalist. Whether the outcome difference was due to technical expertise, decision making or a combination, one message here is that you get better at what you do when you intentionally do more of it.
Daniel Jolley
Why is this important?
Post-operative fatigue (POF) is common and has significant effects on post-operative recovery and quality of life.
Past studies have linked post-operative fatigue to the pro-inflammatory effects of surgery and anesthesia. Other studies have suggested anti-inflammatory benefits of steroids, tight glucose control and avoiding deep anesthesia.
What did they do?
Abdelmalak and team randomized 381 patients using a 3-factorial design for the three interventions. 306 patients were analysed for POF outcome.
Surgical interventions covered a wide range of major non-cardiac procedures, with mean surgical length just under 5 hours and 75% of patients being ASA 3 or 4.
And they found?
No difference for any of the interventions for either fatigue or quality of life.
Hang on...
While it may be that post-operative inflammation is not the causative factor for POF, more likely the study interventions had insufficient impact on inflammation to change fatigue outcomes.
For minor and moderate surgery of shorter duration in lower-acuity patients (ASA 1 & 2) who have experienced significant POF previously, these simple interventions may still be beneficial.
Daniel Jolley