An audit of the efficacy of a structured handover tool in obstetric anaesthesia

IntroductionThe SAFE handover tool was developed to reduce critical omissions during handovers in obstetric anaesthesia. It comprises a simple proforma onto which the outgoing team documents patients who fall into one of four anaesthetically relevant categories: Sick patients; At-risk patients (of emergency caesarean section, major haemorrhage or anaesthetic problems); Follow-ups; and Epidurals. We hypothesised that its use would reduce the number of critical omissions at handover.MethodsThe efficacy of the SAFE handover tool was assessed through several audit cycles in a single maternity unit. The four SAFE categories were considered the gold standard, since they encompassed the consensus opinion of senior obstetric anaesthetists with respect to parturients they most wanted to know about at handover. Against these criteria it was possible to compare the number of cases that should have been handed-over against the number that were actually handed-over.ResultsAfter implementation of the handover tool, patients were four times more likely to be handed-over than without the use of the tool: an increase from 49% to 79% of relevant cases (P < 0.0001, OR 4.1, 95% CI 2.19–7.6). The handover tool was particularly effective at increasing the handover rates of Sick and At-risk parturients, which increased from 21% to 67% (P < 0.0001, OR 7.7, 95% CI 2.7–21.7) and 25% to 78% (P < 0.01, OR 9.9, 95% CI 1.6–61.6), respectively.ConclusionThe SAFE handover tool significantly increased handover rates of anaesthetically relevant parturients. It is easy to remember and consistent with UK National Health Service Litigation Authority’s guidance on risk management in maternity units.     

Enhanced recovery from obstetric surgery: a UK survey of practice

BackgroundIn the UK earlier discharge of patients following elective caesarean section would require that more patients are discharged the day after surgery. The introduction of enhanced recovery in other specialties has resulted in shorter postoperative stay. We surveyed current UK practice to find whether this was consistent with enhanced recovery and what changes units would need to introduce to establish such a programme.MethodsWe conducted an Obstetric Anaesthetists’ Association approved electronic survey of all the UK lead obstetric anaesthetists between March and May 2013.ResultsA response rate of 81% was achieved with 96% of those who responded supporting the concept of enhanced recovery. Only 4% of units routinely discharged their patients on day one. There were a number of practices consistent with enhanced recovery. Postoperative pain was controlled by regular paracetamol (97%) and non-steroidal anti-inflammatory drugs (100% when not contraindicated), with oral opioids (68%) being used for breakthrough pain. Over 70% of units allowed minimal interruption of perioperative oral intake and 72% of units mobilised their patients within 12 h of surgery or when the neuraxial block had worn off. In contrast, a minority of units monitored patient temperature in theatre (27%) or used active warming (18%), and 28% routinely removed the urinary catheter within 12 h of surgery or when the neuraxial block had worn off. Regarding neonatal recovery, only 23% reported using delayed cord clamping and 53% used skin-to-skin contact in theatre.ConclusionMost obstetric units support the concept of enhanced recovery following caesarean section and many could introduce a programme for elective surgery with relatively small changes in patient care.     

Effect of an infection control educational programme on anaesthetists’ attitude and anaesthetic field bacterial contamination

ObjectivesTo evaluate the impact of an infection control educational programme in anaesthetic practice on the clinical performance of the personnel working in anaesthetic field and anaesthetic work place bacterial contamination.MethodsThis study was conducting on 35 personnel involved in 500 operations over two and half months. Their compliance towards handling of anaesthetic equipments, wearing of protective tools and hand hygiene was evaluated using a 13 items check list pre and post delivering of an educational infection control programme (intervention). Of 500 operations 300 were randomly selected for evaluation of bacterial contamination. Two swabs were taken from anaesthetic place before induction of general anaesthesia (T0) and 30 min intraoperative (T1) pre and post intervention. Another swab was taking from anaesthetists’ hands 15 min after induction of anaesthesia (T2).ResultsThe intervention programme influenced positively the attitude of junior anaesthetists and nurses regarding the proper use of protective tools, anaesthetic equipments and hand hygiene. Senior anaesthestists’ compliance with hand hygiene, frequency use of gloves and anaesthetic filter did not change after intervention. But their attitude towards handling of laryngoscope, anaesthetic face mask and catheter for suction improved after intervention. The adherence of housekeepers to hand hygiene, frequency of gloves use and anaesthetic equipments’ disinfection improved significantly after intervention. Ninety-two (63%) swabs were positive for bacteria at T0 before intervention. They reduced to 9 (6.3%) positive swabs after intervention. The number of positive swabs at T1 was 121 (82.9%) before intervention, reduced to 68 (47.2%) after intervention. One hundred and eight (74%) swabs from hands of anaesthetists were positive for bacteria before intervention. They lowered significantly to 55 (38.2%) after intervention. Bacterial cross infection between anaesthetic machine and anaesthetists’ hands existed pre and post intervention. In conclusion, infection control programme enhanced personnel clinical compliance and reduced bacterial contamination in anaesthetic place.     

The delivery of obstetric anaesthetic care in UK maternity units: a survey of practice in 2021

BackgroundAnaesthetists are crucial members of the maternity unit team, providing peri-operative analgesia and anaesthesia, and supporting the delivery of medical care to high-risk women. The effective contribution from obstetric anaesthetists to safety in maternity units depends on how anaesthesia services are organised and resourced. There is a lack of information on how obstetric anaesthetic care is resourced in the UK.MethodsThe Obstetric Anaesthetists’ Association surveyed UK clinical leads for their hospital’s obstetric anaesthetic service and examined compliance with national recommendations.ResultsThere were 153 responses by lead obstetric anaesthetists from 184 maternity units in the UK (83%). The number of consultants per 1000 deliveries was 2.2 [1.6–2.7] (median [IQR]). In 20% of units, there was a dedicated on-call rota (on-call only for obstetric anaesthesia), whilst the remainder had a ‘combined’ on-call rota (on-call for other clinical areas in addition to obstetrics). Multidisciplinary ward rounds were held in 83% of units. Twenty-five (16%) units reported having no regular multidisciplinary ward rounds, of which nine (6%) did not have any multidisciplinary ward rounds. Planned operating lists for elective caesarean sections were provided in 77% of units.ConclusionsIn the largest survey of obstetric anaesthesia workload to be reported for any health system, we found significant disparities between obstetric anaesthesia service provision and current national recommendations for areas including consultant staffing, support for elective caesarean section lists, antenatal anaesthetic clinics, and consultant support for service development. Wide national variation in service provision was identified.     

Immediate birth – an analysis of women and their babies undergoing time critical birth in a tertiary referral obstetric hospital

BackgroundAt our institution, the emergency obstetric ‘code green’ activates the system for immediate birth, usually by caesarean section. This study aimed to determine the incidence of immediate birth, indications, modes of anaesthesia, and short-term neonatal and maternal outcomes.MethodA review was performed for all women at the Royal Women’s Hospital, Parkville, Australia who underwent immediate birth over a two-year period: January 1, 2013 to December 31, 2014.ResultsWithin the study period 14,115 women gave birth, of which 387 women underwent an immediate birth, the majority (83%) by caesarean section. The commonest indication for immediate birth was prolonged fetal bradycardia (53%), however cord prolapse (4%) produced the most rapid decision-to-delivery interval, with a median [IQR] time of 14 [13–16] min versus 18 [14–23] min for all immediate births (P < 0.01). Epidural top-up was the most common anaesthesia method. Conversion to general anaesthesia following inadequate neuraxial anaesthesia occurred in 6.2% of women. Among 103 general anaesthetics, there was one failed intubation (successful ventilation) and one dental injury. Nine women (2.3%) were admitted to the high dependency or intensive care units, and there were no maternal deaths. Babies born by caesarean section with a decision-to-delivery interval of less than 30 min were more likely to have longer times to establish respiration (22.6% vs 16.7%, P < 0.001).ConclusionRequest for immediate delivery is a common obstetric emergency. Epidural top-up has become the most common anaesthetic technique. Rapid delivery times can be achieved with an integrated emergency response system.     

Optimisation de la prise en charge anesthésique en chirurgie abdominale urgente chez le sujet âgé

ObjectivesPeroperative haemodynamic profile comparison of two anaesthetic protocols for emergency abdominal surgery of old patients.Patients and methodsNon-randomized monocentric study. Patients in the Optimization group were prospectively studied. Anaesthesia was induced by etomidate–succinylcholine and maintained with effect site and end-tidal target controlled administration of remifentanil and desflurane respectively to keep the BIS values between 45 and 55. These patients were matched with retrospectively studied patients constituting the Control group. The latter's were anaesthetized with etomidate–succinylcholine and anaesthesia was maintained by manually controlled administration of sufentanil and desflurane to keep systolic arterial pressure (SAP) within a range of more or less 30% of preoperative baseline SAP.ResultsTwelve patients (86 ± 5 yrs) were included in the Optimization group, 11 (86 ± 4 yrs) in the Control group. The time spent at a SAP within more or less 30% of baseline values was 92 ± 7% and 71 ± 29% of total anesthesia time in the Optimization and Control groups respectively (p < 0.05). That spent at a SAP less than 15 and 30% of baseline values was 23 ± 11% et 3 ± 5% of total anaesthesia time in the Optimization group, whereas in the MAN group it was 65 ± 21% and 27 ± 30% respectively (p < 0.05). Desflurane and ephedrine consumption was less in the Optimization group as well as crystalloid or colloid volume loading.ConclusionAnaesthetic agents target controlled administration and/or neurophysiologic depth of anaesthesia monitoring improve the time course of the haemodynamic effects in elderly patients undergoing abdominal surgery in emergency.     

A United Kingdom national obstetric intubation equipment survey

BackgroundFailed intubation is relatively common in the obstetric patient. Overall, there has been a decline in experience of general anaesthesia in obstetrics. The level of anaesthetic preparedness in the event of a difficult obstetric intubation is unknown.MethodsWith approval from the Obstetric Anaesthetists’ Association, a national postal survey of obstetric units in the United Kingdom was conducted. The survey addressed airway equipment availability and existence of difficult airway algorithms and formal difficult airway drills. The number of deliveries, general anaesthetic cases and failed intubations in each unit was also ascertained.ResultsOne hundred and eighty-seven units completed the national obstetric intubation equipment survey questionnaire (78% response rate). All obstetric units possessed a laryngoscope with a normal handle and adult Macintosh blade, a bougie and a laryngeal mask airway. A 7.0 internal diameter endotracheal tube was most often used for securing the airway, and 90% of units stored all airway equipment on a designated difficult airway trolley. A fiberoptic bronchoscope was not readily available and on average it would take >10 min to obtain. A failed intubation incidence of 1:309 was reported. Only one third of units promoted difficult airway training.ConclusionEssential airway equipment was readily available in the event of a difficult obstetric intubation, with the exception of a fiberoptic bronchoscope. Few units conduct difficult airway training.     

Provision of fascia iliaca compartment block in the acute management of proximal femoral fractures: A national observational study of UK hospitals

AimsFascia iliaca compartment block (FICB) is a simple regional anaesthetic block that has been shown to be superior to other regional anaesthetic blocks with regards to success rate and analgesic efficacy in the acute management of proximal femoral fractures. The objective was to quantitatively assess the provision of FICB for patients with proximal femoral fractures in the UK.MethodsA national observational study of all acute medical trusts in the UK (n = 187) was conducted. Each trust was contacted and asked to complete a freedom of information request relating to the use of regional nerve blocks in patients with a proximal femoral fracture between 2/11/2014 and 2/11/2015. The STROBE checklist was used to help design and conduct the study.Results144/187(77.0%) of medical trusts across the UK responded. Overall, 61.8% of trusts routinely performed FICB for patients with a neck of femur (NOF) fracture. The number of trusts with a specific standardised proforma for NOF fracture patients was 127/144 (88.2%), while 83/144 (57.6%) included a section relating to FICB. 50/144 (34.7%) of trusts had no hospital related guideline for FICBs in NOF fracture patients. The use of analgesia in NOF fracture patients was audited in 95/144 (66.0%) of trusts. Where FICB was administered, the procedure was typically conducted by specialists in emergency medicine (50.6%), anaesthetics (34.6%) and orthopaedics (14.8%). Common reasons for lack of FICB provision include: lack of trained staff, resumption of adequate analgesia via other methods and a perception that there is insufficient evidence for routine use of peripheral nerve blocks improving survival and outcomes.ConclusionsAdministration of regional nerve blocks for patients with proximal femoral fractures is increasing but variable between trusts. Further work should examine how barriers to the delivery of FICBs might be addressed.     

Retrospective analysis of transfusion outcomes in pregnant patients at a tertiary obstetric center

BackgroundThe decision to use red blood cell transfusion and/or blood products (fresh frozen plasma, platelets, cryoprecipitate) to manage obstetric hemorrhage or treat postpartum anemia is often made empirically by physicians. We performed a retrospective study to review transfusion outcomes in pregnant and postpartum patients at a large obstetric center.MethodsA retrospective, observational study was performed of obstetric in-patients who received red blood cell transfusion and/or blood products over a one-year period. Data abstracted included transfusion data, pre-transfusion hemoglobin (Hb) and lowest recorded (nadir) Hb, and maternal and neonatal outcomes.ResultsDuring the study period, 74 patients received transfusion therapy (1.4%). Pre-transfusion and nadir Hb values were 7.6 g/dL and 7.0 g/dL respectively. Median [IQR] total red blood cells transfused were 2 units [2-3], with 41 (55%) patients receiving 1-2 units. Based on chart review, no specific indications for transfusion were identified in 25 patients (34%), and 13 patients (18%) had undetected postpartum anemia (Hb values <8.2 g/dL) at least 24 h after delivery.ConclusionMore formal assessment and documentation of the etiologic factors associated with transfusion management in pregnant patients is advised. In addition, the identification and management of undetected postpartum anemia is underappreciated.     

Use of anaesthetic rooms in obstetric anaesthesia; a postal survey of obstetric anaesthetists and departments in the United Kingdom

BACKGROUND: Use of anaesthetic rooms has been much discussed in the UK in recent years, but attitudes and practices of obstetric anaesthetists regarding their use for caesarean section have never been sought. METHOD: A postal survey was conducted to discover the extent of use of anaesthetic rooms versus operating theatre for induction of anaesthesia and reasons for using or not using them. Questionnaires regarding individual practices were sent to 400 randomly selected members of the Obstetric Anaesthetists' Association ( approximately 25% of UK membership). Questionnaires regarding departmental policies were sent to 100 "clinicians responsible for surveys" (approximately 38% of departments providing obstetric anaesthesia in the UK). RESULTS: For elective caesarean section, 70% of individual clinicians never used an anaesthetic room, 9% rarely, 5% usually, 9% for all regional anaesthetics and 6% always. For emergency caesarean section the corresponding figures were 83%, 5%, 5%, 3% and 2% respectively. Use of the anaesthetic room was independent of the seniority of anaesthetists. In 68% of departments it was standard practice or policy to induce all anaesthetics for caesarean section in the operating room. Conversely, only 1% of departments had a policy to induce all anaesthetics in the anaesthetic room. Patient safety was the usual reason given for anaesthetising in the operating room. CONCLUSION: The majority of obstetric anaesthetists have abandoned the use of anaesthetic induction rooms, the main reason being patient safety. For the same reason, two-thirds of departments providing obstetric anaesthesia consider induction of anaesthesia in the operating room their standard practice.     

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.     

Analgesia epidural en obstetricia: ¿cómo afecta al desarrollo y finalización del parto?

Background and objectiveEpidural analgesia is routinely used in obstetrics but has been blamed for possible effects on labor that lead to greater use of instruments or conversion to cesarean delivery. We aimed to assess this possibility in a cohort of obstetric patients receiving or not receiving epidural analgesia.Patients and methodsProspectively enrolled full-term obstetric patients were distributed in 2 groups according to whether they received epidural analgesia or not. We compared maternal and fetal characteristics, obstetric variables, and type of delivery between groups to record the likely causes of difficult labor and delivery and detect a possible influence of epidural analgesia.ResultsOf a total of 602 patients, 462 received epidural analgesia and 140 did not. Epidural analgesia was related to a higher rate of use of instruments but not cesareans (P < .01) and more frequent need for oxytocin (30.7% of the epidural analgesia group vs 0% of the group receiving no epidural analgesia, P < .001). The women receiving analgesia also had a longer mean (SD) duration of the dilatation phase of labor (6.4 [4.2] hours in the epidural group vs 4.7 [3.5] hours in the no-epidural group, P < .01) and of the expulsion phase (1.0 [0.6] hours vs 0.7 [0.6] hours, respectively; P < .01). We observed no effects on the incidence of tearing, rate of episiotomy, or other variables. Predictors of instrumentation or conversion to cesarean delivery were longer duration of the first phase (odds ratio [OR] 1.2; 95% confidence interval [CI], 1.1–1.3), longer duration of the second phase (OR 2.3; 95% CI, 1.3–3.9), and maternal obesity (OR, 1.1; 95% CI, 0.9–1.2). Previous deliveries and initiation of epidural analgesia after the fetus has reached Hodge’s first plane decreased risk 2.7-fold and 3.03-fold, respectively.ConclusionsAlthough epidural analgesia has traditionally been associated with a higher incidence of difficult labor and delivery, this association was not unequivocally evident in this cohort of patients. The apparent increase seems to be attributable to such obstetric factors as longer duration of stages of labor, higher body mass index, and first delivery.     

Drug errors in obstetric anaesthesia: a national survey

We conducted a postal survey of lead obstetric anaesthetists in all consultant-led maternity units in the UK about drug errors and the measures taken to reduce or prevent them. Of the 179 out of 240 (75%) who responded, 70 (39%) knew of at least one drug error in their unit during the last year, with 28 of them (40%) experiencing more than one. Of the most recent errors, giving the wrong drug (most commonly thiopental instead of antibiotics or vice versa [14 cases], or suxamethonium instead of [Formula: see text] [8 cases] or other drugs [4 cases]) was the most common error, occurring in 27 units (15%). Errors involving epidural/spinal analgesia/anaesthesia (including drugs intended for these routes but given via other routes) occurred in 20 cases. Only 36 respondents (20%) described protocols for checking anaesthetic drugs. Methods described for reducing drug errors were use of coloured labels (20%) or pre-filled labelled syringes (6%), limiting the range of drugs available (6%) and keeping drugs in separate trays once drawn up (6%).     

Anaesthesia for caesarean section — a German survey

Background: Anaesthetic practice for caesarean section has changed during the last decades. There is a world-wide shift in obstetric anaesthetic practice in favour of regional anaesthesia. Current data concerning anaesthetic practice in patients under-going caesarean section from Germany are not available. A comparison with figures from the UK, USA, Norway and other European countries might be of general interest.
Methods: Questionnaires on the practice of anaesthesia for caesarean section and anaesthetic coverage of the obstetric units were sent to 1178 university, tertiary care, district, community and private hospitals in Germany.
Results: The 532 completed replies of this survey represent 46.9% of the German obstetric units. Most hospitals (42.3%) have delivery rates between 500 and 1000 per year. General anaesthesia is the most common anaesthetic technique for elective (61%), urgent (83%) and emergency caesarean section (98%). Epidural anaesthesia is performed in 23% of scheduled and 5% of non-scheduled caesarean sections, and spinal anaesthesia in 14% and 10%, respectively. Acid aspiration prophylaxis before elective caesarean section is used in 68.7% of the departments. The majority of the departments provide a 24-hour anaesthetic coverage; however, in only 6.2% of the units, this service is assigned to obstetric anaesthesia, exclusively.
Conclusion: Compared to data from 1978, anaesthetic practice for caesarean section has changed with an increase in regional anaesthesia. However, German anaesthetists prefer general anaesthesia for caesarean section. In contrast, anaesthetists in other countries predominantly use regional techniques, and the difference to German practice is striking. International consensus discussion and recommendations as well as comparable European instruments of quality control in obstetric anaesthesia are desirable.     

A national survey of acute hospitals in England on their current practice in the use of femoral nerve blocks when splinting femoral fractures

IntroductionMissed compartment syndrome can have devastating long-term impact on a patient's function. Femoral fracture has been reported in 52–58% of acute thigh compartment syndromes in the existing literature. Time to diagnosis of compartment syndrome is cited as a key determinant of outcome. Use of femoral nerve blocks in splinting of femoral fractures may mask signs of early compartment syndrome. We present the attitudes of emergency department and orthopaedic staff in NHS trusts in England with regard to this issue.Methods and materialsSurvey of all 171 acute hospitals in the United Kingdom accepting trauma admissions. On-call middle grade doctors in emergency and orthopaedic department completed a telephone survey into departmental protocol and their experience of femoral nerve blocks for lower limb fractures.ResultsMiddle grades from all 171 trusts completed the survey (100% response rate). 54 emergency departments (30.8%) had a protocol for the use of femoral nerve blocks. Middle grades in the ED reported using a nerve block routinely in 95 hospitals (54%) with 63 using a long-acting and 32 a short-acting agent. Of those that did not 70% (n = 53) felt they were unnecessary, 21% (n = 16) were not confident in the technique and 9% (n = 7) had worries over compartment syndrome. 68% would be worried about compartment syndrome in high-energy injuries. Orthopaedic departmental protocols for nerve block use were reported in 16 trusts (9%). 45 orthopaedic middle grades (26%) indicated that they would use them routinely with 17 using long-acting and 28 using short-acting agents. 59.5% (n = 75) of orthopaedic middle grades felt nerve blocks were unnecessary, whilst 22% (n = 28) had worries about compartment syndrome and 18% (n = 23) were not confident with the technique. 77% orthopaedic middle grades would be more worried about compartment syndrome in high energy injuries.ConclusionFemoral nerve block is an under-utilised, effective mode of analgesia following femoral fractures. There is a low risk of associated compartment syndrome, but clinicians should be especially vigilant in high-energy injuries. We recommend that all acute trusts receiving trauma should have a protocol for the use of femoral nerve blocks agreed by the emergency and orthopaedic departments.     

UK national survey of venous thromboembolism prophylaxis in ankle fracture patients treated with plaster casts

BackgroundAnkle fractures are one of the commonest orthopaedic injuries. A substantial proportion of these are treated non-operatively at outpatient clinics with cast immobilization. We conducted this survey to assess the current practice in UK regarding thromboembolism prophylaxis in these patients.MethodsA telephonic survey was carried out on junior doctors within orthopaedic departments of 56 hospitals across the UK. A questionnaire was completed regarding venous thromboembolism risk assessment, prophylaxis, hospital guidelines, etc.Results84% (n = 47) hospitals did not routinely use any prophylaxis for these patients, while 7% (n = 4) hospitals used chemo-prophylaxis. Only 5.3% (n = 3) hospitals had DVT prophylaxis guidelines regarding these patients while other 9% (n = 5) hospitals were in process of developing such guidelines. In 64% (n = 36) hospitals, no formal DVT risk assessment was carried out.ConclusionA large variation exists across NHS hospitals and a poor risk assessment is being carried out in these patients. Development of local guidelines and extension of national guidelines to include high risk outpatients may improve the situation.     

Attitudes and practices of New Zealand anaesthetists with regard to emergency drugs

A postal survey of anaesthetists practising in New Zealand assessed practices with regard to the preparation of pre-drawn syringes of emergency drugs in theatre, and attitudes towards the drawing up of drugs by non-medically qualified assistants. Opinion and practice varied widely; a quarter of respondents routinely draw up such drugs and a third either never or very infrequently do so. The drugs most commonly drawn up in this way were suxamethonium, atropine, syntocinon, ephedrine and metaraminol. Providing anaesthesia single-handed, anaesthesia involving paediatric, obstetric or vascular cases, the use of major regional techniques and laryngeal mask anaesthesia were reported as factors which prompted a number of respondents to draw up one or more of these drugs. The majority (68.5%) had received no teaching on the issue and nearly all (83.5%) reported that there was no institutional policy in their workplace(s). "Syringe swap" or "wrong drug" errors related to such pre-drawn drugs were reported by 26.5%, while delay in drawing up a drug in an emergency was reported by 37%. Nearly all (98%) respondents believed that it was acceptable for an anaesthetic technician (or similar assistant) to draw up drugs in an emergency but only 14% approved of assistants drawing up drugs routinely. We conclude that there is no uniformity of opinion amongst New Zealand anaesthetists about which if any drugs should be pre-drawn for possible emergency use, and that few would endorse the drawing up of drugs by non-medically qualified assistants, except in emergency, or under other clearly delineated circumstances.     

Postpartum hemorrhage treated with a massive transfusion protocol at a tertiary obstetric center: a retrospective study

BackgroundA massive transfusion protocol may offer major advantages for management of postpartum hemorrhage. The etiology of postpartum hemorrhage, transfusion outcomes and laboratory indices in obstetric cases requiring the massive transfusion protocol were retrospectively evaluated in a tertiary obstetric center.MethodsWe reviewed medical records of obstetric patients requiring the massive transfusion protocol over a 31-month period. Demographic, obstetric, transfusion, laboratory data and adverse maternal outcomes were abstracted.ResultsMassive transfusion protocol activation occurred in 31 patients (0.26% of deliveries): 19 patients (61%) had cesarean delivery, 10 patients (32%) had vaginal delivery, and 2 patients (7%) had dilation and evacuation. Twenty-six patients (84%) were transfused with blood products from the massive transfusion protocol. The protocol was activated within 2 h of delivery for 17 patients (58%). Median [IQR] total estimated blood loss value was 2842 [800–8000] mL. Median [IQR] number of units of red blood cells, plasma and platelets from the massive transfusion protocol were: 3 [1.75–7], 3 [1.5–5.5], and 1 [0–2.5] units, respectively. Mean (SD) post-resuscitation hematologic indices were: hemoglobin 10.3 (2.4) g/dL, platelet count 126 (44) × 10⁹/L, and fibrinogen 325 (125) mg/dL. The incidence of intensive care admission and peripartum hysterectomy was 61% and 19%, respectively.ConclusionsOur massive transfusion protocol provides early access to red blood cells, plasma and platelets for patients experiencing unanticipated or severe postpartum hemorrhage. Favorable hematologic indices were observed post resuscitation. Future outcomes-based studies are needed to compare massive transfusion protocol and non-protocol based transfusion strategies for the management of hemorrhage.     

The economic benefits of cell salvage in obstetric haemorrhage

BackgroundCell salvage is increasingly used in the management of major obstetric haemorrhage. Its financial considerations were evaluated over a 5-year period.MethodCell salvage was introduced in the Liverpool Women’s NHS Foundation Trust in 2006. Data were collected from all cases in which it was set-up and included the volume of blood processed and returned and whether surgery was elective or emergency.ResultsBetween 1st January 2006 and 30th June 2011, cell salvage for collection was set-up 587 times and blood was returned in 137 patients. Total volume of blood returned was 47 143 mL, equivalent to 189 units of packed red cells. The return rate was higher for emergency than elective cases (P = 0.03). As the use of cell salvage has extended over time to include a greater proportion of patients, return rates have decreased (P < 0.0001). The volume of blood returned from cell salvage was significantly related to the estimated blood loss (P < 0.00001), with a best fit line described by estimated blood loss = 3.45x + 454, where x was the volume of blood returned. In 2011 total costs of cell salvage were £9245 for the equivalent of 83 units of blood. At the current price of £125 per unit of allogeneic blood this would have cost £10 375: a saving of £1130. No intraoperative or postoperative complications associated with cell salvage were seen.ConclusionThe routine use of cell salvage was associated with more salvaged blood being returned to patients, which offset the cost of collection sets when compared to the cost of using allogeneic blood. Cell salvage is an appropriate expenditure to reduce the use of allogeneic blood.