Newsletter July 2023: ACCESS Study: Register Your Centre to Join This European Caesarean Delivery Study of Anaesthesia Practice

Carolyn Weiniger

Variations exist in the management of anaesthesia for caesarean deliveries among European centres. While the ideal rate of general anaesthesia for planned caesarean deliveries should be below 5%, the actual rate is unknown across European countries. General anaesthesia carries risks of failed intubation, gastric aspiration, and reported awareness in 1 out of 212 cases. (1-3) Unfortunately, neuraxial anaesthesia, the common mode of anaesthesia, may not always provide sufficient anaesthesia for surgery. Augmented labour epidural analgesia may be insufficient, and women may experience intraoperative pain during caesarean deliveries under neuraxial anaesthesia. The most common reason for anaesthesiologists to face legal action during caesarean deliveries is intraoperative pain resulting from failed neuraxial anaesthesia. (4-7) Currently, there are no standard strategies to assess the efficacy of neuraxial anaesthesia for caesarean deliveries or to manage failed neuraxial anaesthesia.

Due to the lack of real-time data in European centres, there is a clear need to report and assess anaesthesia practices using standardized criteria and real-time data to quantify variations in caesarean delivery practices. This information can help optimize anaesthesia practices for caesarean deliveries, including prevention, detection, and management of failures.

To address this, the Obstetric Anaesthesiology Subforum of the European Society of Anaesthesiology and Intensive Care, along with colleagues from around Europe, is planning a multinational, multicentre study.

The goal is to gather data from over 16,000 caesarean deliveries during the 12-month study period, gathering data from each centre during a 2-week snapshot study window. Currently, National Coordinators from 30 European countries and over 370 centres within these countries have been identified. To expand the study, additional countries and centres are being openly recruited. Each country requires a National Coordinator, and if your country does not yet have one, you can apply by completing the pre-study poll (Pre-Study Poll Link CLICK HERE). In each country, applications for a Lead Investigator from each centre, who can oversee the project locally, are being accepted in collaboration with the National Coordinator.

To apply as a National Coordinator, express your interest by completing the pre-study poll. The following countries already have a National Coordinator: Andorra, Austria, Belgium, Denmark, England, Estonia, Finland, Germany, Greece, Iceland, N. Ireland, Ireland, Italy, Israel, Malta, Latvia, The Netherlands, Norway, Poland, Portugal, Romania, Serbia, Scotland, Slovakia, Slovenia, Spain, Sweden, Switzerland, Turkey, Wales.

To register your centre, complete the pre-study poll. Provide your centre’s details and relevant information.

If there is no National Coordinator for your country and your centre meets the minimum criteria for the number of caesarean deliveries, please complete the pre-study poll and include your comments. If your centre anticipates more than 10 caesarean deliveries in a 2-week period, you are eligible to join the study.

The team will contact you directly for further discussion.

Once you complete the pre-study poll, you will receive comprehensive details, including the study protocol and requirements for ethical approvals. In summary, each participating centre will select a 2-week study window within the 12-month study period starting from September 2023. During this period, data will be collected in the electronic case report for 24 predefined questions for all caesarean deliveries. The study aims to describe the variation in anaesthesia management for caesarean deliveries through a prospective observational investigation of all cases. The primary objective is to report the rate of general anaesthesia among all caesarean deliveries during the study period.

The study will measure various outcomes, including the urgency and indication for the caesarean, decision-to-delivery interval for non-planned caesareans, patient characteristics, time of day, details of neuraxial anaesthesia and any block testing, details of general anaesthesia if performed, and any conversions from neuraxial to general anaesthesia. It will also capture information on any intravenous supplements administered for neuraxial anaesthesia.

The study is scheduled to start in September 2023, and you will pre-declare your 2-week study period, which can be any time until September 2024.

National Coordinators and Lead Investigators will be eligible for study authorship commensurate with their efforts.

If your centre has fewer than 10 caesarean deliveries during the study period, your data will still be included, as the total number of caesarean deliveries in your country is expected to be sufficient.

This study has the potential to bring significant improvements to our practice. Caesarean delivery is the most common surgical intervention. Concerns about potential risks or the need to justify the decision for general anaesthesia may make anaesthesiologists reluctant to provide general anaesthesia. However, neuraxial anaesthesia may be inadequate, leading to pain during caesarean delivery, and can be a cause of litigation claims related to intraoperative pain. Current guidelines for managing failed neuraxial anaesthesia and intraoperative pain during caesarean deliveries are lacking. This study aims to provide guidance, enhance patient safety, raise awareness of current practices, and generate suitable recommendations and practice guidelines through a real-time examination of caesarean delivery anaesthesia practices.

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References 

1. Odor PM, Bampoe S, Lucas DN, Moonesinghe SR, Andrade J, Pandit JJ, Pan-London Peri-operative Research Network: Incidence of accidental awareness during general anaesthesia in obstetrics: a multicentre, prospective cohort study. Anaesthesia 2021; 76: 759-776
2. Sobhy S, Zamora J, Dharmarajah K, Arroyo-Manzano D, Wilson M, Navaratnarajah R, Coomarasamy A, Khan KS, Thangaratinam S: Anaesthesia-related maternal mortality in low-income and middle-income countries: a systematic review and meta-analysis. Lancet Glob Health 2016; 4: e320-7
3. Lucas N: Section B.7 – Obstetric practice, RCoA Audit Recipe Book 16. Edited by Johnston C, 2020, pp 241-268
4. Thangamuthu A, Russell IF, Purva M: Epidural failure rate using a standardised definition. Int J Obstet Anesth 2013; 22: 310-5
5. McCombe K, Bogod DG: Learning from the Law. A review of 21 years of litigation for pain during caesarean section. Anaesthesia 2018; 73: 223-230
6. Stanford SE, Bogod DG: Failure of communication: a patient’s story. Int J Obstet Anesth 2016; 28: 70-75
7. Keltz A, Heesen P, Katz D, Neuman I, Morgenshtein A, Azem K, Binyamin Y, Hadar E, Eidelman LA, Orbach-Zinger S: Intraoperative pain during caesarean delivery: Incidence, risk factors and physician perception. Eur J Pain 2022; 26: 219-226

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