Umfrage zur aktuellen Situation der Regionalanästhesie im deutschsprachigen Raum

The practice of regional anaesthesia in German speaking countries was investigated by a survey. The last part of the trilogy contains the presentation and evaluation of the data about the methods in obstetric anaesthesia. In 2002 questionnaires were mailed to 750 randomly selected departments of anaesthesia, 384 hospitals (51.2%) responded of which 278 had an obstetric unit. Caesarean section rate was 22.5+/-8.2% and for elective caesarean section spinal anaesthesia was mostly used. General anaesthesia was never used in 58.3% of Swiss, 10.2% of German, and 21.1% of Austrian hospitals. For non-elective caesarean section 42.1% of the hospitals often used a spinal anaesthesia, and 44.8% sometimes, in Switzerland these were 92.9% and 7.1%, respectively. Pain relief for labour was usually achieved with epidural anaesthesia or drugs. The trend from general to regional anaesthesia for caesarean section is continued, as is the trend from local infiltrative techniques to epidural anaesthesia for vaginal delivery. Switzerland was in the forefront for these developments.     

Analgesie und Anästhesie zur Geburtshilfe in der Schweiz 1999

QUESTION: This survey investigated the common practice of obstetric analgesia and anaesthesia in Swiss hospitals and evaluated the influence of the Swiss interest group for obstetric anaesthesia. METHODS: In March 1999 we submitted 145 questionnaires to all Swiss hospitals providing an obstetric service. RESULTS: The rate of epidural analgesia (EA) was higher in large hospitals (> 1,000 births/year) than in small services. EA was maintained by continuous infusion techniques in 53% of the responding hospitals. For elective caesarean section, spinal anaesthesia (SA) and EA were performed in 77% and 16% of the patients, respectively. General anaesthesia (5%) was only used in small hospitals (< 500 births/year). Emergency caesarean section was performed under SA in 75% of all hospitals and only in 25% was a general anaesthesia used. An already existing EA for labour analgesia was continued for anaesthesia for caesarean section in 63% of Swiss hospitals. CONCLUSIONS: Regional anaesthesia was most commonly used for obstetric anaesthesia in Swiss hospitals. Epidemiological studies, recommendations of the Swiss interest group for obstetric anaesthesia, as well as the expectations of pregnant women, increased the numbers of regional anaesthesia compared with the first survey in 1992.     

Obstetrical anaesthesia in Ontario

The purpose of this study was to determine the availability of regional anaesthesia for Caesarean section, of epidural opioids and patient-controlled analgesia after Caesarean section, and of epidural and other forms of analgesia in labour. A mail survey was sent to the “Head Nurse, Department of Obstetrics” at each of the 142 hospitals in Ontario with designated obstetric beds. Responses were obtained from 100% of hospitals. For Caesarean Section, general anaesthesia was used in all hospitals, and was the only option in seven. Epidural anaesthesia was used in 93% of hospitals, and spinal anaesthesia in 48%. Postoperatively, patient-controlled analgesia was used in 31% of hospitals and spinal opioids in 28%. In 66 hospitals, im or iv opioids were the only types of analgesia available. For analgesia in labour, im or iv opioids were used in 96% of hospitals, nitrous oxide was used in 75%, epidural analgesia in 75%, transcutaneous electrical nerve stimulation in 52% and patient-controlled analgesia in 10%. The overall epidural rate was 38%. Although the average rate in the 73 hospitals with fewer than 500 births per year was only 6% 14 large hospitals had an epidural rate of 60% or higher. It is concluded that regional techniques for peripartum analgesia have been widely accepted. Analgesia after Caesarean section could be improved. Epidural analgesia should be more widely available, especially in the many small hospitals in Ontario.     

Difficulty of epidural puncture for obstetric analgesia: risk factors

INTRODUCTION: Predicting technical difficulties in performing an epidural block can affect the anesthesiologist's choice of technique or decisions about who should carry it out. Our aim was to determine patient characteristics associated with difficulty in performing an epidural block for obstetric analgesia. MATERIAL AND METHODS: We designed a prospective observational study in 540 pregnant women who requested epidural analgesia for obstetric labor. Patient characteristics (age, weight, height), anatomical features (body constitution, visible and/or palpable spinal apophyses, structural anomalies), technical features (number of attempts, repositioning of the needle), anesthesiologist's experience (resident or staff), block success, time taken to accomplish the procedure, and obstetrical variables (parity, gestational age, cervical dilatation). RESULTS: The factor that best correlates with puncture difficulty in the obstetric patient is the presence of visible or palpable spinal apophyses and palpation prior to carrying out the block. Factors like weight, body constitution, or anesthesiologist's experience seem to influence the rate of success or failure of the epidural block for obstetric analgesia, although to a lesser degree. CONCLUSIONS: The most important factor for predicting success of an epidural block for obstetric analgesia in our practice is the presence of palpable spinal apophyses.     

Anesthetic management for obstetric hysterectomy: a multi-institutional study

A prospectively designed review of all obstetric hysterectomies performed in five university hospitals between November 1, 1984 and October 31, 1987 has been performed. There were 41,107 deliveries and 46 obstetric hysterectomies, an incidence of 0.11%. Twenty-five hysterectomies were elective and 21 were emergent. The indication for 11 of the 21 emergency hysterectomies was placenta previa and/or accreta. Women in the emergency group had greater intraoperative blood loss, were more likely to have intraoperative hypotension, and were more likely to receive donor blood than women in the elective group (P less than 0.05). Twelve patients (eight from the elective group and four from the emergency group) received continuous epidural anesthesia, and none required intraoperative induction of general anesthesia. There was no evidence that epidural anesthesia significantly affected blood loss, crystalloid replacement, or requirement for transfusion in the elective group. Abnormal placentation now represents a major indication for emergency obstetric hysterectomy. Furthermore, significant hemorrhage is more likely with emergency obstetric hysterectomy than with elective hysterectomy. Finally, elective cesarean hysterectomy is not a contraindication to performance of continuous epidural anesthesia.     

Practice of epidural analgesia for labour pain: a German survey.

Epidural analgesia is one of the preferred methods of analgesia for labour. The aim of the present survey was to evaluate current practice in obstetric analgesia in departments of anaesthesia and to make a comparison with former surveys from Germany and other countries. Questionnaires on the practice of pain relief, especially epidural analgesia, during labour and delivery were sent to 1178 anaesthetic departments in Germany in the second half of 1996. Five hundred and thirty-two completed replies were received, which represent 46.9% of all German obstetric units. The majority of the departments of anaesthesia practising epidural analgesia have an epidural rate of less than 10% and 10.2% of the departments do not offer this method to their parturients. In 86.8% of all units performing epidural analgesia, the epidural catheter is placed by an anaesthetist. Only 6.5% of the units provide a 24-h epidural service which is exclusively assigned to labour and delivery. In 77.8% of the units, this service is not exclusively assigned to obstetrics, but also to other duties. Of the obstetric units offering epidural analgesia, 14.7% have no epidural service at night. Plain local anaesthetics for epidural analgesia are used by 55.9% of the departments, a combination of local anaesthetics with epidural opioids by 28.7%. Epidural analgesia is predominantly (82.2%) maintained by intermittent bolus administration. Although the rate of epidural analgesia increased during recent decades, this method is not offered to all parturients. Further improvements in the use of epidural analgesia for labour seem to be necessary.     

Management of accidental dural puncture and post-dural puncture headache after labour: a Nordic survey

Background: A major risk with epidural analgesia is accidental dural puncture (ADP), which may result in post‐dural puncture headache (PDPH). This survey was conducted to explore the incidence of ADP, the policy for management of PDPH and the educational practices in epidural analgesia during labour in the Nordic countries. Methods: A postal questionnaire was sent to the anaesthesiologist responsible for Obstetric anaesthesia service in all maternity units (n=153) with questions relating to the year 2008. Results: The overall response rate was 93%. About 32% (22–47%) of parturients received epidural analgesia for labour. There were databases for registering obstetric epidural complications in 13% of Danish, 24% of Norwegian and Swedish, 43% of Finnish and 100% of hospitals in Iceland. The estimated incidence of ADP was 1% (n≈900). Epidural blood patch (EBP) was performed in 86% (n≈780) of the parturients. The most common time interval from diagnosis to performing EBP was 24–48 h. The success rate for EBP was >75% in 67% (62–79%) of hospitals. The use of diagnostic CT/MRI before the first or the second EBP was exceptional. No major complication was reported. Teaching of epidurals was commonest (86%) in the non‐obstetric population and 53% hospitals desired a formal training programme in obstetric analgesia. Conclusion: We found the incidence of ADP to be approximately 1%. EBP was the commonest method used for its management, and the success rate was high in most hospitals. Formal training in epidural analgesia was absent in most countries and trainees first performed it in the non‐obstetric population.     

A survey of labor patient-controlled epidural anesthesia practice in California hospitals

BACKGROUND: Patient-controlled epidural analgesia (PCEA) offers many advantages over continuous epidural infusions for labor analgesia including fewer physician interventions, improved analgesia and satisfaction, and reduced local anesthetic doses. However, anesthesiologists have been slow to adopt this technique, first described in 1988. No previous studies have evaluated specific labor patient-controlled epidural analgesia practices in the United States. The aim of this study was to determine labor epidural and patient-controlled epidural analgesia practices among California hospitals. METHODS: Following institutional review board exemption approval, an online survey was created using freeonlinesurveys.com. An anonymous survey was sent via e-mail to 230 California Society of Anesthesiologists' members chosen at random to represent their hospitals' labor analgesia practices. RESULTS: We received 133 replies from the 230 survey requests sent, a 58% response rate. The median labor epidural rate among the hospitals involved was 65% (range 0-95%). Overall, only 25% of California hospitals use patient-controlled epidural analgesia for analgesia in labor, with greater use among hospitals with dedicated obstetric anesthesia coverage and larger numbers of deliveries. Reasons given for not using patient-controlled epidural analgesia include cost, clinician preference, safety concerns and the inconvenience of change. CONCLUSIONS: Despite the potential advantages of patient-controlled epidural analgesia over continuous epidural infusions for labor analgesia, patient-controlled epidural analgesia has not been widely adopted in California hospitals. Education regarding this technique is needed to encourage its increased use.     

Obstetric anesthesia units in Israel: a national questionnaire-based survey

BackgroundThis survey was performed to assess the organization and practice of obstetric anesthesia units in Israel.MethodsA written questionnaire was mailed at the end of December 2005 to all Israeli anesthesia departments providing labor and delivery services in 2005 (n = 25).ResultsA response rate of 100% accounted for 125,340 deliveries. All labor and delivery suites had on-site anesthesia department services. Data are presented as mean (range) or frequency. Eleven hospitals performed 2500–4999 deliveries/year, 6 hospitals 5000–7499 deliveries/year, and 4 hospitals 7500–9999 deliveries/year. The overall cesarean delivery rate was 20% (0–27). Anesthesia for cesarean delivery (elective and emergency combined) was provided by: general anesthesia 15% (0.5–50), epidural 14.5% (0–99.5), spinal 68% (0–98), or combined spinal–epidural technique 0% (0–30). There was an operating room within or immediately adjacent to the labor ward in 16/25 units, including 10/11 units with >5000 deliveries/year. Labor analgesia was provided by epidural techniques in 50% (4–93) and nitrous oxide in 0.5% (0–90) of deliveries. A total of 11 units had 24 h dedicated anesthesiologist coverage, including all units >7500 deliveries but only 3/8 (38%) with 5000–7500 deliveries. Two of the 4 units with >7500 deliveries had no faculty member with formal training in obstetric anesthesia. Written protocols were available for labor analgesia (17/25), post-partum hemorrhage (12/25), aspiration prophylaxis (15/25) and maternal resuscitation (8/25).ConclusionIn this national appraisal of Israeli obstetric anesthesia services, a notable lack of written protocols, wide variations in staffing, and few specifically trained obstetric anesthesia personnel were observed.     

Aktuelle Praxis der Anästhesie zur Sectio caesarea an den deutschen Universitätsklinika Ergebnisse einer Erhebung im Jahr 1996

Obviously there is a world-wide trend towards regional anaesthesia for caesarean section (CS). Data on the current practice in Germany are lacking. Methods: In 1996 questionnaires on obstetric anaesthesia were mailed to all University departments of anaesthesia. Results: All 38 University Hospitals with obstetric units replied (100%). Mean annual delivery rate was 1156 with a mean CS-rate of 24%. For scheduled CS the University departments used general anaesthesia in most cases (60%), followed by epidural (31%) and spinal anaesthesia (9%). General anaesthesia was predominantly used for more urgent (87%) or emergency deliveries (99%). Spinal anaesthesia was offered to patients as an option of anaesthesia for CS in 16 of 38 departments, epidural anaesthesia in 36 of 38. The majority of university hospitals (22 of 38) performed more than 25% of their CS in epidural anaesthesia; 14 departments had a ratio of at least 50% of regional anaesthesia. 28 of 32 centres administered some kind of acid aspiration chemoprophylaxis as a routine management. Special devices for the management of a difficult airway were provided in 61% of the hospitals within the delivery unit. In 70% the anaesthesiologist was responsible for the postoperative pain management following CS. Conclusion: A significant trend towards regional anaesthesia for CS has taken place in German university hospitals: According to a former survey regional anaesthesia was used in less than 10% of CS in 1977, whereas in the current evaluation from 1996 this figure was significantly higher (40%). Nevertheless, compared to other countries the rate of general anaesthesia still is rather high.     

The impact of a teaching program on obstetric anesthesia practices in Croatia

BackgroundMany countries fail to use regional techniques for either labor analgesia or obstetric anesthesia. Kybele, an international outreach group, seeks to improve obstetric anesthesia practices worldwide. Its educational program in Croatia was evaluated by studying the change in use of regional anesthetic techniques in obstetrics after a Kybele visit.MethodsAn international Kybele team spent two weeks in an educational program in Croatia in September 2005. Croatian anesthesiologists evaluated its benefit via a questionnaire two months after the program. In addition, hospitals that hosted a Kybele member compiled data on rates of regional blockade for cesarean section and labor analgesia before and after the Kybele visit.ResultsAll Croatian anesthesiologists rated the overall experience as excellent or good. Eight out of nine hospitals contributed data to evaluate the program’s impact on obstetric anesthesia practice. The average rate of use of regional anesthesia for cesarean section increased across the eight hospitals (P < 0.001) after Kybele; some institutions used neuraxial blockade for the majority of cesarean sections following the Kybele educational program. The average rate of epidural analgesia for labor also increased among the eight hospitals after the Kybele visit (P < 0.02), although absolute rates were still modest (maximum rate  = 5%).ConclusionIn Croatia, a two-week educational program in obstetric anesthesia increased the use of regional anesthesia and analgesia for labor and delivery in the year that followed the program. Multiple factors limit availability of analgesia for childbirth in Croatia.     

Obstetric anesthesia practice in Canada

PURPOSE: To describe obstetric anesthesia in Canada as practiced in 1997: to identify practices at variance with the literature and the opinions of experts: and to identify questions for future research. METHODS: In 1997, a detailed postal questionnaire asking about the practice of obstetric anesthesia was mailed to all 1,539 specialist anesthesiologist members of the Canadian Anaesthetists' Society residing in Canada. Nonresponders were mailed a second questionnaire three months later RESULTS: There were 865 completed questionnaires returned for analysis (56.2%). Of these, 522 anesthesiologists practiced obstetric anesthesia (60.3%). The data were subdivided into those from anesthesiologists with a full or part-time university based practice (40.1%) and those from a community based practice (59.9%). University based and community-based anesthesiologists have very similar patterns of practice. Specific areas where anesthesia practice was different from current recommendations included: (1) information provided when obtaining consent for labour epidural analgesia, (2) use of opioids and local anesthetics for initiation of epidural analgesia, (3) use of coagulation testing in preeclampsia, (4) the common use of cutting spinal needles, (5) use of neuraxial morphine and nonsteroidal anti-inflammatory agents after Cesarean deliveries, (6) optimal treatment of neuraxial opioid side effects, (7) when to insert an endotracheal tube for general anesthesia after delivery, and (8) withdrawing epidural catheters through epidural needles. CONCLUSIONS: This survey presents reference data on the practice of obstetric anesthesia in Canada in 1997. Anesthesiologists with university affiliation have very similar practices to those without university affiliations.     

A survey of obstetric anaesthesia practice in British Columbia

Hospitals and anaesthetists in British Columbia were surveyed by means of questionnaires to assess patterns of obstetric anaesthesia practice, qualifications and numbers of obstetric anaesthesia personnel, hospital obstetric facilities and facilities and protocols for neonatal resuscitation. It was apparent that a large proportion of the obstetric anaesthesia service in this province was being provided by physicians who were not trained, nor certified, as anaesthesia specialists. Preanaesthetic assessment in the obstetric units differed in attitude and practice from the standards expected in the general operating rooms. There was also in community hospitals a significant incidence of failure to follow certain accepted safe practices (in obstetric patients), such as preinduction hydration and oxygenation, cricoid pressure during intubation and prevention of aortocaval compression. However, administration of general anaesthesia without endotracheal intubation, was rare in this survey. Post-anaesthetic recovery facilities in obstetric units were conspicuously deficient, even in the larger hospitals. The majority of community hospitals lacked written protocols for neonatal resuscitation; and the number of institutions reporting that the neonatal heart rates and temperatures were not routinely monitored is of concern. It is recommended that minimum standards for training in obstetric anaesthesia should be clearly defined; and provision should be made for revision and upgrading of knowledge and skills for physicians practicing anaesthesia in smaller community hospitals.     

Unexpectedly extensive conduction blocks in obstetric epidural analgesia

Life-threatening extensions of conduction block during obstetric epidural analgesia can be classified according to the risk to the mother. High blocks that occur in the presence of the anaesthetist should present a readily treatable problem. Reports of total spinal anaesthesia that occur with no anaesthetist in attendance call for a reappraisal of present practice. Changes in current anaesthetic practice, which might increase safety with epidural analgesia, are top-ups by midwives, but only when the anaesthetist is on the delivery suite; repeated assessment of the nature of the conduction block by an anaesthetist; and continuous infusions with anaesthetist-only top-ups.     

Obstetrical epidural anaesthesia in a rural Canadian hospital

Few rural hospitals offer obstetric epidural analgesia services and of those that do, there is a paucity of information about these anaesthetics. A retrospective review was conducted of all obstetrical epidurals from 1984–1988 in an 85-bed hospital in Saskatchewan to examine the indications, complications, and infant outcomes. During that period there were 1224 deliveries. From a total of 915 vaginal deliveries, 42 (4.6%) received an epidural. Caesarean sections numbered 309:183 (59.3%) were with epidural analgesia of which 69 were urgent and 114 elective. The overall complication rate was 23% with the most important being hypotension (12%), dural punctures (1.8%), in-adequate block requiring an intravenous supplement (4.0%) or a general anaesthetic (3.1%). Infant outcomes were favourable except for two unrelated intra-uterine deaths preceding labour.     

Aktuelle Praxis der Analgesie in der Geburtshilfe an den deutschen Universitätsklinika Ergebnisse einer Umfrage 1996. Teil 2

Obviously there is a world-wide trend towards regional analgesia for pain relief during delivery. Data on the current practice in Germany are lacking. Methods: In 1996 questionnaires on obstetric anaesthesia and analgesia were mailed to all university departments of anaesthesia. Results: All 38 university hospitals with obstetric units replied (100%). Mean annual delivery rate was 1156. Epidural analgesia (EA) (n=22), intramuscular injection of opioids (n=18), and non-opioids as a suppository (n=17) were often used for pain relief during labour. Intravenous injections (n=12) or pudendus anaesthesia (n=7) were practised as well. Entonox (N₂O/O₂), paracervical blocks or transcutaneous electrical stimulation (TENS) was rarely used. EA for relief of labour pain was offered in all university hospitals. Twelve of them had an epidural rate of less than 10%, in nine the rate was 10–19%, in eight hospitals 20–29% and 30% or more in nine. Indication for EA was a demand by the parturient (n=34), by the obstetrician (n=26) or the midwife (n=18), predominantly because of prolonged labour (n=32) or significant pain (n=21). Half of the university departments used an epidural combination of local anaesthetics (bupivacaine) and opioids (sufentanil (n=12) and/or fentanyl (n=9)). In all but one department the application of an epidural catheter was performed by anaesthesiologists exclusively. In some hospitals obstetricians (n=10) or midwives (n=4) were allowed to give epidural top-up injections. Of the 38 university departments 11 had an anaesthesiologists on duty 24 h a day responsible for the obstetric unit exclusively. Conclusion: In 1977, 14 of 18 university departments of anaesthesiology offered epidural analgesia for parturients. This option was available in all university departments in 1996. A mean rate of 10–20% epidurals for vaginal delivery is well within the limits reported from other countries, whereas the rate of regional anaesthesia for scheduled caesarean section (40%) still is rather low in Germany, as reported in part 1 of this survey (Anaesthesist 1998; 47:59–63).     

Labor epidural analgesia--how to set up the service: preface

The following featured articles are the proceedings of the panel discussion at the 19th Japanese Society of Regional Anesthesia, which was held on September 2nd, 2006 in Osaka. The president of the meeting, Professor Akira ASADA at Osaka City University Graduate School of Medicine, chose this topic among various aspects of regional anesthesia practice. Obstetric anesthesia practice relies heavily on regional anesthesia for both cesarean section and labor analgesia. Thus, obstetric anesthesiologists have played an important role in the basic as well as clinical research in the pharmacology of local anesthetic agents. Professor Morishima is one of those pioneers in obstetric anesthesia, and she kindly joined the panel discussion as the commentator. The distinguished panelists practice obstetric anesthesia at various settings from academic institution, regional perinatal center, to private practice. Some of them have started the labor epidural analgesia service by tackling obstacles. The others have strong interests in obstetric anesthesia, but yet are unable to provide labor analgesia. By sharing their success and difficulties, the readers of this discussion would be able to obtain some insights when they set up labor epidural analgesia service at their own practice settings.     

丁丙喏啡两种给药方式用于产科术后镇痛观察

目的：剖宫产患者术后需要尽早进行活动,常规的PCEA方法给患者和麻醉医生术后管理带来不便,本文观察丁丙喏啡硬膜外腔两种不同的给药方式在剖宫产术后镇痛中的效果,为临床应用提供参考。方法：采用一次性微量镇泵及单次硬膜外腔注入丁丙喏啡两种方法,观察术后镇痛效果。结果,两种方法对Bp、SpO2、HR的影响,各时点VAS评分,不良反应均无明显差异。结论：丁丙喏啡单次硬膜外腔给药用于剖宫产术后镇痛,安全有效,操作方便,不失为一种产科镇痛的方法。     

Epidural anesthesia: step by step to success

Besides pain management in obstetric patients epidural anaesthesia plays a major role in the perioperative setting. Especially the technique of thoracic epidural anaesthesia (TEA) provides better postoperative analgesia when compared with systemic pain therapy. TEA is associated with improved outcome in high-risk patients and patients undergoing extensive surgery. An acute pain management service is required to guarantee high effectiveness and a low complication rate. TEA is an important part of a multimodal perioperative concept, especially in fast-track surgery, which means advantages for patients outcome and hospitals economics.     

Unintentional dural puncture. A survey of recognition and management

A survey of the recognition and management of 21 unintentional dural punctures that occurred in a series of 3500 obstetric epidurals is presented. In seven cases, dural puncture was not recognised at the time of occurrence and two patients may have subsequently received mixed epidural and subarachnoid analgesia. In two patients with dural puncture in whom air had been used to locate the epidural space, cerebrospinal fluid did not drip from the hub of the needle. A test dose did not reveal incorrect catheter placement in seven patients. The provision of an epidural infusion of Hartmann's solution for 24 hours, together with bed rest, appeared to delay the onset of dural puncture headache rather than prevent it entirely. Blood patching was required only in five of the 21 patients but was entirely successful. The implications of these observations in relationship to obstetric epidural practice are discussed.