Local anaesthetic adjuncts for peripheral regional anaesthesia: a narrative review

Moderate-to-severe postoperative pain persists for longer than the duration of single-shot peripheral nerve blocks and hence continues to be a problem even with the routine use of regional anaesthesia techniques. The administration of local anaesthetic adjuncts, defined as the concomitant intravenous or perineural injection of one or more pharmacological agents, is an attractive and technically simple strategy to potentially extend the benefits of peripheral nerve blockade beyond the conventional maximum of 8–14 hours. Historical local anaesthetic adjuncts include perineural adrenaline that has been demonstrated to increase the mean duration of analgesia by as little as just over 1 hour. Of the novel local anaesthetic adjuncts, dexmedetomidine and dexamethasone have best demonstrated the capacity to considerably improve the duration of blocks. Perineural dexmedetomidine and dexamethasone increase the mean duration of analgesia by up to 6 hour and 8 hour, respectively, when combined with long-acting local anaesthetics. The evidence for the safety of these local anaesthetic adjuncts continues to accumulate, although the findings of a neurotoxic effect with perineural dexmedetomidine during in-vitro studies are conflicting. Neither perineural dexmedetomidine nor dexamethasone fulfils all the criteria of the ideal local anaesthetic adjunct. Dexmedetomidine is limited by side-effects such as bradycardia, hypotension and sedation, and dexamethasone slightly increases glycaemia. In view of the concerns related to localised nerve and muscle injury and the lack of consistent evidence for the superiority of the perineural vs. systemic route of administration, we recommend the off-label use of systemic dexamethasone as a local anaesthetic adjunct in a dose of 0.1–0.2 mg.kg⁻¹ for all patients undergoing surgery associated with significant postoperative pain.     

Carbetocin vs. oxytocin at elective caesarean delivery: a double-blind,randomised, controlled,non-inferiority trial of low- and high-dose regimens

Carbetocin or oxytocin are given routinely as first-line uterotonic drugs following delivery of the neonate during caesarean delivery to prevent postpartum haemorrhage. Low doses may be as effective as high doses with a potential reduction in adverse effects. In this double-blind, randomised, controlled, non-inferiority trial, we assigned low-risk patients undergoing elective caesarean delivery under spinal anaesthesia to one of four groups: carbetocin 20 μg; carbetocin 100 μg; oxytocin 0.5 IU bolus + infusion; and oxytocin 5 IU bolus + infusion. The study drug was given intravenously after delivery of the neonate. Uterine tone was assessed by the obstetrician 2, 5 and 10 minutes after study drug administration according to an 11-point verbal numerical rating scale (0 = atonic, 10 = excellent tone). The primary outcome measure was uterine tone 2 min after study drug administration. The pre-specified non-inferiority margin was 1.2 points on the 11-point scale. Secondary outcomes included uterine tone after 5 and 10 minutes, use of additional uterotonics, blood loss and adverse effects. Data were available for 277 patients. Carbetocin 20 μg resulting in uterine tone of (median (IQR [range])) 8 (7–8 [1–10]) was non-inferior to carbetocin 100 μg with tone 8 (7–9 [3–10]), median (95%CI) difference 0 (−0.44–0.44). Similarly, oxytocin 0.5 IU with tone 7 (6–8 [3–10]) was non-inferior to oxytocin 5 IU with tone 8 (6–8 [2–10]), median (95%CI) difference 1 (0.11–1.89). Carbetocin 20 μg was also non-inferior to oxytocin 5 IU, and oxytocin 0.5 IU was non-inferior to carbetocin 100 μg. Uterine tone after 5 and 10 minutes, use of additional uterotonics, blood loss and adverse effects were similar in all groups.     

PROSPECT guideline for elective caesarean section: updated systematic review and procedure-specific postoperative pain management recommendations

Caesarean section is associated with moderate-to-severe postoperative pain, which can influence postoperative recovery and patient satisfaction as well as breastfeeding success and mother-child bonding. The aim of this systematic review was to update the available literature and develop recommendations for optimal pain management after elective caesarean section under neuraxial anaesthesia. A systematic review utilising procedure-specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials published in the English language between 1 May 2014 and 22 October 2020 evaluating the effects of analgesic, anaesthetic and surgical interventions were retrieved from MEDLINE, Embase and Cochrane databases. Studies evaluating pain management for emergency or unplanned operative deliveries or caesarean section performed under general anaesthesia were excluded. A total of 145 studies met the inclusion criteria. For patients undergoing elective caesarean section performed under neuraxial anaesthesia, recommendations include intrathecal morphine 50–100 µg or diamorphine 300 µg administered pre-operatively; paracetamol; non-steroidal anti-inflammatory drugs; and intravenous dexamethasone administered after delivery. If intrathecal opioid was not administered, single-injection local anaesthetic wound infiltration; continuous wound local anaesthetic infusion; and/or fascial plane blocks such as transversus abdominis plane or quadratus lumborum blocks are recommended. The postoperative regimen should include regular paracetamol and non-steroidal anti-inflammatory drugs with opioids used for rescue. The surgical technique should include a Joel-Cohen incision; non-closure of the peritoneum; and abdominal binders. Transcutaneous electrical nerve stimulation could be used as analgesic adjunct. Some of the interventions, although effective, carry risks, and consequentially were omitted from the recommendations. Some interventions were not recommended due to insufficient, inconsistent or lack of evidence. Of note, these recommendations may not be applicable to unplanned deliveries or caesarean section performed under general anaesthesia.     

Efficacy of regional blocks or local anaesthetic infiltration for analgesia after caesarean delivery: a network meta-analysis of randomised controlled trials

Caesarean delivery is common and can cause severe postoperative pain but injection of local anaesthetic at various sites for regional blocks or local anaesthetic infiltration may reduce this. We aimed to compare and rank these sites. We searched PubMed, Google Scholar, EMBASE and CENTRAL to June 2021 for randomised controlled trials and performed a random-effects Bayesian model network meta-analysis. The primary outcome was dose of parenteral morphine equivalents in the first 24 postoperative hours. We used surface under cumulative ranking probabilities to order techniques. We analysed 114 trials (8730 participants). The ordered mean (95% credible interval) reduction in morphine equivalents, from 34 mg with placebo, were as follows: ilio-inguinal 15 (1–32) mg; ilio-inguinal–iliohypogastric 13 (6–19) mg; transversalis fascia 11 (4–26) mg; erector spinae 11 (10–32); transverse abdominis 9 (4–13) mg; wound catheter infusion 8 (2–15) mg; quadratus lumborum 8 (1–15) mg; wound infiltration 8 (2–13) mg; and no intervention −4 (−10 to 2) mg. Ordered efficacies for injection sites were different for other relevant outcomes, including pain (to 4–6 h and to 24 h) and time to rescue analgesia: there was no single preferred route of injection. The ordered mean (95% credible interval) reduction in dynamic pain scores (0–10 scale) at 24 h compared with placebo were as follows: wound infusion 1.2 (0.2–2.1); erector spinae 1.3 (−0.5 to 3.1); quadratus lumborum 1.0 (0.1–1.8); ilio-inguinal–iliohypogastric 0.6 (−0.5 to 1.8); transverse abdominis 0.6 (−0.1 to 1.2); wound infiltration 0.5 (−0.3 to 1.3); transversalis fascia −0.8 (−3.4 to 1.9); ilio-inguinal −0.9 (−3.6 to 1.7); and no intervention −0.8 (−1.8 to 0.2). We categorised our confidence in effect sizes as low or very low.     

Oxytocin at elective caesarean delivery: a dose-finding study in women with obesity

Prophylactic oxytocin administration at the third stage of labour reduces blood loss and the need for additional uterotonic drugs. Obesity is known to be associated with an increased risk of uterine atony and postpartum haemorrhage. It is unknown whether women with obesity require higher doses of oxytocin in order to achieve adequate uterine tone after delivery. The purpose of this study was to establish the bolus dose of oxytocin required to initiate effective uterine contraction in 90% of women with obesity (the ED₉₀) at elective caesarean delivery. We conducted a double-blind dose-finding study using the biased coin up-down design method. Term pregnant women with a BMI ≥ 40 kg.m⁻² undergoing elective caesarean delivery under regional anaesthesia were included. Those with conditions predisposing to postpartum haemorrhage were not included. Oxytocin was administered as an intravenous bolus over 1 minute upon delivery of the fetus. With the first woman receiving 0.5 IU, oxytocin doses were administered according to a sequential allocation scheme. The primary outcome measure was satisfactory uterine tone, as assessed by the operating obstetrician 2 minutes after administration of the oxytocin bolus. Secondary outcomes included the need for rescue uterotonic drugs, adverse effects and estimated blood loss. We studied 30 women with a mean (SD) BMI of 52.3 (7.6) kg.m^-2. The ED₉₀ for oxytocin was 0.75 IU (95%CI 0.5–0.93 IU) by isotonic regression and 0.78 IU (95%CI 0.68–0.88 IU) by the Dixon and Mood method. Our results suggest that women with a BMI ≥ 40 kg.m^-2 require approximately twice as much oxytocin as those with a BMI < 40 kg.m^-2, in whom an ED₉₀ of 0.35 IU (95%CI 0.15–0.52 IU) has previously been demonstrated.     

Advances in regional anaesthesia and acute pain management: a narrative review

Regional anaesthesia has undergone several exciting advances in the past few decades. Ultrasound-guided techniques of peripheral nerve blockade have become the gold standard thanks to the associated improvements in efficacy, ease of performance and safety. This has increased the accessibility and utilisation of regional anaesthesia in the anaesthesia community at large and is timely given the mounting evidence for its potential benefits on various patient-centred outcomes, including major morbidity, cancer recurrence and persistent postoperative pain. Ultrasound guidance has also paved the way for refinement of the technical performance of existing blocks concerning simplicity and safety, as well as the development of new regional anaesthesia techniques. In particular, the emergence of fascial plane blocks has further broadened the application of regional anaesthesia in the management of painful conditions of the thorax and abdomen. The preliminary results of investigations into these fascial plane blocks are promising but require further research to establish their true value and role in clinical care. One of the challenges that remains is how best to prolong regional anaesthesia to maximise its benefits while avoiding undue harm. There is ongoing research into optimising continuous catheter techniques and their management, intravenous and perineural pharmacological adjuncts, and sustained-release local anaesthetic molecules. Finally, there is a growing appreciation for the critical role that regional anaesthesia can play in an overall multimodal anaesthetic strategy. This is especially pertinent given the current focus on eliminating unnecessary peri-operative opioid administration.     

Quadratus lumborum block vs. transversus abdominis plane block for caesarean delivery: a systematic review and network meta-analysis*

Caesarean delivery is the most commonly performed inpatient surgical procedure globally. Pain after caesarean delivery is moderate to severe if not adequately treated, and is a primary anaesthetic concern for patients. Transversus abdominis plane and quadratus lumborum blocks are fascial plane blocks that have the potential to improve analgesia following caesarean delivery. Although proponents of the quadratus lumborum block suggest that this technique may provide better analgesia compared with transversus abdominis plane block, there are limited data directly comparing these two techniques. We, therefore, performed a systematic review and network meta-analysis to compare transversus abdominis plane and quadratus lumborum block approaches, seeking randomised controlled trials comparing both techniques to each other, or to control, with or without intrathecal morphine. In all, 31 trials with 2188 patients were included and our primary outcome, the cumulative intravenous morphine equivalent consumption at 24 h, was reported in 12 trials. In the absence of intrathecal morphine, transversus abdominis plane and quadratus lumborum blocks were equivalent, and both were superior to control (moderate-quality evidence). In the presence of intrathecal morphine, no differences were found between control, transversus abdominis plane and quadratus lumborum blocks (moderate-quality evidence). Similar results were found for resting and active pain scores at 4–6 h, 8–12 h, 24 h and 36 h, although quadratus lumborum block was associated with lower pain scores at 36 h when compared with transversus abdominis plane block (very low-quality evidence). However, transversus abdominis plane block was associated with a reduced incidence of postoperative nausea and vomiting (moderate-quality evidence) and sedation when compared with inactive control following intrathecal morphine administration (low-quality evidence). There are insufficient data to draw definitive conclusions, but transversus abdominis plane and quadratus lumborum block appear to be superior to control in the absence of intrathecal morphine, but provide limited additional benefit over inactive control when intrathecal morphine is also used.     

Local anaesthetic delivery regimens for peripheral nerve catheters: a systematic review and network meta-analysis

There are numerous possible techniques for delivering local anaesthetic through peripheral nerve catheters. These include continuous infusions, patient-controlled boluses and programmed intermittent boluses. The optimal delivery regimen of local anaesthetic is yet to be conclusively established. In this review, we identified prospective trials of delivery regimens through peripheral nerve catheters. Our primary outcome was visual analogue scale scores for pain at 48 h. Secondary outcomes were: visual analogue scores at 24 h; patient satisfaction scores; rescue opioid use; local anaesthetic consumption; and nausea and vomiting. Network meta-analysis was used to compare these outcomes. Predefined sub-group analyses were performed. Thirty-three studies enrolling 1934 participants were included. In comparison with continuous infusion, programmed intermittent boluses improved visual analogue pain scores at both 48 and 24 h, the weighted mean difference (95%CI) being −0.63 (−1.12 to −0.14), p = 0.012 and −0.48 (−0.92 to −0.03), p = 0.034, respectively. Programmed intermittent boluses also improved satisfaction scores, the weighted mean difference (95%CI) being 0.70 (0.10–1.31), p = 0.023, and reduced rescue opioid use, the weighted mean difference (95%CI) in oral morphine equivalent at 24 h being −23.84 mg (−43.90 mg to −3.77 mg), p = 0.020. Sub-group analysis revealed that these findings were mostly confined to lower limb and truncal catheter studies; there were few studies of programmed intermittent boluses for upper limb catheters. Programmed intermittent boluses may provide optimal delivery of a local anaesthetic through peripheral nerve catheters. Further research is warranted, particularly to delineate the differences between upper and lower limb catheter locations, which will help clarify the clinical relevance of these findings.     

Systemic adjunct analgesics for cesarean delivery: a narrative review

It is critical to adequately treat postoperative cesarean delivery pain. The use of parenteral or neuraxial opioids has been a mainstay, but opioids have side effects that can be troubling and the opioid crisis in the United States has highlighted the necessity to utilize analgesics other than opioids. Other analgesic options include neuraxial analgesics, nerve blocks such as the transversus abdominis plane block, and non-opioid parenteral and oral medications. The goal of this article is to review non-opioid systemic analgesic adjuncts following cesarean delivery, focusing on their efficacy and side effects as well as their impact on reduction of opioid requirements after surgery.     

Choice of local anaesthetic for epidural caesarean section: a Bayesian network meta-analysis

Rapid-onset epidural local anaesthesia can avoid general anaesthesia for caesarean delivery. We performed a Bayesian network meta-analysis of direct and indirect comparisons to rank speed of onset of the six local anaesthetics most often used epidurally for surgical anaesthesia for caesarean delivery. We searched Google Scholar, PubMed, EMBASE, Ovid, CINAHL and CENTRAL to June 2019. We analysed 24 randomised controlled trials with 1280 women. The mean (95%CrI) onset after bupivacaine 0.5% was 19.8 (17.3–22.4) min, compared with which the mean (95%CrI) speed of onset after lidocaine 2% with bicarbonate, 2-chloroprocaine 3% and lidocaine 2% was 6.4 (3.3–9.6) min faster, 5.7 (3.0–8.3) min faster and 3.9 (1.8–6.0) min faster, respectively. Speed of onset was similar to bupivacaine 0.5% after ropivacaine 0.75% and l-bupivacaine 0.5%: 1.6 (−1.4 to 4.8) min faster and 0.4 (−2.2 to 3.0) min faster, respectively. The rate (95%CrI) of intra-operative hypotension was least after l-bupivacaine 0.5%, 315 (236–407) per 1000, and highest after 2-chloroprocaine 3%, 516 (438–594) per 1000. The rate (CrI) of intra-operative supplementation of analgesia was least after ropivacaine 0.75% 48 (19–118) per 1000 and highest after 2-chloroprocaine 3%, 250 (112–569) per 1000.     

Regional anaesthesia for orthopaedic procedures

Regional anaesthesia is apposite for orthopaedic surgery for anatomical reasons and to reduce complications from general anaesthesia. A reduction in pain scores, drowsiness and nausea can improve postoperative mobility and facilitate earlier hospital discharge. Disadvantages include block failure, nerve injury, possible loss of motor function and proprioception and local anaesthetic toxicity. Complications are rare but may be reduced by the use of ultrasound and nerve stimulation, performing the block on a conscious patient and stopping injection if there is pain or high resistance. Patients should be assessed preoperatively to rule out contraindications such as local infection or coagulopathy, and clear explanations of the procedure and any possible complications should be given. Patients should also be assessed postoperatively and any suspicious findings investigated promptly and followed up until there is complete resolution.     

Regional anaesthesia for orthopaedic procedures

Regional anaesthetic techniques are fundamental in the anaesthetic care of orthopaedic patients. They may be used as the primary anaesthetic technique or to provide postoperative pain relief. Compared to general anaesthesia alone, regional techniques can provide superior perioperative analgesia, fewer systemic drug adverse effects such as nausea, vomiting and confusion, and earlier mobilization which can reduce nosocomial complications and facilitate expedited hospital discharge. Disadvantages include block failure, nerve injury, unrecognised injury to the anaesthetised limb, prolonged motor blockade and local anaesthetic toxicity. Preoperative assessment should identify contraindications, document pre-existing neurological deficits, and clarify surgical and perioperative aims. Informed consent should be obtained after a clear explanation of the procedure, its risks, and potential complications. Serious and long-term neurological complications are rare and may be reduced by an awake regional technique, sonographic guidance, regular aspiration and by ensuring low pressure injections. Postoperative follow-up is essential and suspicious neurological findings should be detected, investigated, and managed in an early and timely manner.     

Regional anaesthesia for caesarean birth and what to do if it fails

Regional anaesthetic techniques are the most frequently used type of anaesthetic for caesarean births. They have a better safety pro?le than general anaesthesia in the pregnant woman. The choice of whether to use a spinal, epidural or combined spinal–epidural technique will depend on patient and surgical factors. Particular care is required in those receiving therapeutic anticoagulation or with clotting abnormalities. Women should be provided with information regarding the risks and intended bene?ts of the different techniques to make an informed choice regarding mode of anaesthesia. All women having caesarean births must have vital sign monitoring, antacid prophylaxis and intraoperative venous thromboembolic prophylaxis. A left lateral tilt must be maintained until delivery of the baby to reduce the effects of aortocaval compression. Adequate anaesthesia must be con?rmed prior to commencing surgery and strategies for managing failed spinal anaesthesia should be defined in local guidelines. Breakthrough pain during caesarean birth is a distressing complication and must be addressed. General anaesthesia should be offered and, if declined, the woman's pain must be adequately managed with alternative analgesic methods. These include nitrous oxide, opioids and local anaesthetic in?ltration.     

Regional anaesthesia for caesarean section and what to do if it fails

Regional anaesthetic techniques are the most frequently used type of anaesthetic used for caesarean deliveries. They have a better safety profile than general anaesthesia in the pregnant woman. The choice of whether to use a spinal, epidural or combined spinal–epidural technique will depend on patient and surgical factors. Particular care is required in those receiving therapeutic anticoagulation or with clotting abnormalities. Women should be provided with information regarding the risks and intended benefits of the different techniques to make an informed choice regarding mode of anaesthesia. All women having caesarean deliveries must have vital sign monitoring, antacid prophylaxis and intraoperative venous thromboembolic prophylaxis. A left lateral tilt must be maintained until delivery of the baby to reduce the effects of aortocaval compression. Adequate anaesthesia must be confirmed prior to commencing surgery and strategies for managing failed spinal anaesthesia should be considered. Breakthrough pain during caesarean delivery is a distressing complication and must be addressed. General anaesthesia should be offered and, if declined, the woman's pain must be adequately managed with alternative analgesic methods. These include nitrous oxide, opioids and local anaesthetic infiltration.     

Regional anaesthesia and propofol sedation for carotid endarterectomy

BACKGROUND: Many surgeons now perform carotid endarterectomy under regional anaesthesia. The aim of the present study was to review a sedation technique using a computer-controlled infusion of propofol. METHODS: A consecutive series of 84 carotid endarterectomies done by a single surgeon and commenced under regional anaesthesia with sedation was studied. There were 54 men and 27 women (three bilateral procedures), with a median age of 71 years (range 48-87 years). All patients had carotid stenosis > 70% 80 procedures were done for symptomatic disease and three asymptomatic patients were treated before cardiac surgery (one bilateral). RESULTS: Seventy-seven procedures were completed under regional anaesthesia and sedation alone; seven required conversion to general anaesthetic, usually for intolerance of the operation. An intraoperative shunt was required on only four occasions (5%). Postoperatively eight patients required critical care monitoring, usually for blood pressure control. The remainder were nursed on the vascular ward, and 68% were discharged home on the day after surgery. No patient died, but there were two neurological complications. One patient had a cerebellar stroke 10 days after surgery, but recovered fully after 4 months. A second developed cerebral oedema due to severe intraoperative hypertension and required intensive care for 15 days. He too recovered fully. Five patients had a further episode of transient cerebral ischaemia within 1 month of operation, but in all cases duplex imaging showed a widely patent carotid and there were no sequelae. CONCLUSION: Target controlled propofol infusion is an effective method of sedation in patients undergoing carotid endarterectomy.     

Regional nerve blockade for early analgesic management of elderly patients with hip fracture – a narrative review

Elderly patients with hip fracture experience high morbidity and mortality, and are often undertreated for pain. Acute pain management in the elderly is challenging, with physiological frailty, medical comorbidities and cognitive impairment commonly compounding pain assessment and treatment. Guidelines outlining current best practice for acute pain management in the elderly now exist, but evidence suggests that practice remains variable and there continues to be scope for improvement. We conducted a narrative review of the literature to examine the challenges of acute pain management in the elderly, and to evaluate evidence for the role of regional nerve blocks for acute pain associated with hip fracture in the elderly. There is consistent evidence that regional nerve blocks can effectively reduce pain associated with hip fracture, providing rapid‐onset, site‐specific analgesia that is more effective than standard systemic analgesia alone. There is also moderate evidence that nerve blocks may contribute to reduced rates of delirium, and some suggestion of reduced length of inpatient stay, morbidity and mortality, although limited evidence is available. Fascia iliaca blocks are emerging as a block of choice, with evidence they can be safely and rapidly administered under ultrasound guidance in the acute setting, by both trained medical and nursing staff, with good effect. Ideally, comprehensive pain protocols for elderly hip fracture patients are required, that integrate evidence‐based fascia iliaca block use, timely and repeated pain assessment, and multidisciplinary orthogeriatric patient care.     

A randomised controlled trial of intravenous dexmedetomidine added to dexamethasone for arthroscopic rotator cuff repair and duration of interscalene block

Prolongation of peripheral nerve blockade by intravenous dexamethasone may be extended by intravenous dexmedetomidine. We randomly allocated 122 participants who had intravenous dexamethasone 0.15 mg.kg⁻¹ before interscalene brachial plexus block for day-case arthroscopic rotator cuff repair to intravenous saline (62 participants) or intravenous dexmedetomidine 1 μg.kg⁻¹ (60 participants). The primary outcome was time from block to first oral morphine intake during the first 48 postoperative hours. Fifty-nine participants reported taking oral morphine, 25/62 after placebo and 34/60 after dexmedetomidine, p = 0.10. The time to morphine intake was shorter after dexmedetomidine, hazard ratio (95%CI) 1.68 (1.00–2.82), p = 0.049. Median (IQR [range]) morphine doses were 0 (0–12.5 [0–50]) mg after control vs. 10 (0–30 [0–50]) after dexmedetomidine, a difference (95%CI) of 7 (0–10) mg, p = 0.056. There was no effect of dexmedetomidine on pain at rest or on movement. Intra-operative hypotension was recorded for 27/62 and 50/60 participants after placebo vs. dexmedetomidine, respectively, p < 0.001. Other outcomes were similar, including durations of sensory and motor block. In conclusion, dexmedetomidine shortened the time to oral morphine consumption after interscalene block combined with dexamethasone and caused intra-operative hypotension.     

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

Neuraxial anaesthesia is widely utilised for elective caesarean section, but the prevalence of inadequate intra-operative 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

A woman who experiences pain during caesarean section under neuraxial anaesthesia is at risk of adverse psychological sequelae. Litigation arising from pain during caesarean section under neuraxial anaesthesia has replaced accidental awareness under general anaesthesia as the most common successful medicolegal claim against obstetric anaesthetists. Generic guidelines on caesarean section exist, but they do not provide specific recommendations for this area of anaesthetic practice. This guidance aims to offer pragmatic advice to support anaesthetists in caring for women during caesarean section. It emphasises the importance of non-technical skills, offers advice on best practice and aims to encourage standardisation. The guidance results from a collaborative effort by anaesthetists, psychologists and patients and has been developed to support clinicians and promote standardisation of practice in this area.