Conflicts of Interest Anesthesia Practice: Relationships with Industry, Responsibility to the Health Care System, and Research Integrity.

Conflicts of interest (COIs) between clinical obligations and other roles and responsibilities occur throughout health care, including anesthetic practice. In some circumstances, these conflicts are unavoidable. This article describes some of the potential conflicts and explores approaches to managing them in 3 key areas: relationships with industry, responsibility to the health care system, and obligations in research. Although working with industry has many benefits, COIs may arise from financial arrangements, potential biases that may go unrecognized, prioritization of commercial interests and even guideline development.

Obstetric anaesthetic practice in the UK: a descriptive analysis of the National Obstetric Anaesthetic Database 2009-14.

BACKGROUND: Data on UK obstetric anaesthetic practice between 2009 and 2014 were collected by the Obstetric Anaesthetists' Association's National Obstetric Anaesthetic Database. This database provides information on workload, variation in practice, and complication rates. METHODS: During 2009-14, data were submitted by 190 UK hospitals. The number of hospitals that submitted data each year ranged between 114 and 145. During this 6 yr period, between 27 and 35 data items were requested, although not all hospitals submitted information on all data items. The dataset was assessed for quality and only those data items with acceptable quality were analysed. RESULTS: The dataset contains information on 3 030 493 deliveries, 770 545 Caesarean sections, 623 050 women with labour neuraxial analgesia, and 61 121 general anaesthetics for Caesarean section. There was increased use of patient-controlled regimens for labour neuraxial analgesia over the 6 yr period. The mean rate of general anaesthesia used for Caesarean section was 8.75% (95% confidence interval, 8.26-9.24%). The rate of failed intubation for general anaesthesia for Caesarean section was one in 379. Inadvertent dural puncture rates varied between hospitals with a mean of 1.2% (95% confidence interval, 1.02-1.37%). The rate of a high neuraxial block causing unconsciousness was one in 6667 for all blocks. CONCLUSIONS: This unique large dataset provides a valuable insight of obstetric anaesthetic activity in the UK. Although missing data may place limitations on interpretation, it provides comparative estimates for the rates of rare complications and highlights variations in practice in time and place.

Antenatal anaesthesia clinics - the way forward?

Specialist antenatal clinics are increasingly being used to enable anaesthetists to evaluate pregnant women with co-morbidities and those at high risk of obstetric complications. In this journal a team from Israel describe the process of setting up and running such a clinic over a 14 year period. One of the challenges they identify was the limited referral of high risk women. Based on UK and US literature, the use of structured referral tools, clear criteria for referral and regular antenatal multidisciplinary meetings may help to address this.

Critical care in pregnancy.

Childbirth is a major event in the lives of mothers and their families. Critical illness in pregnancy is uncommon but may arise from conditions unique to pregnancy, conditions exacerbated by pregnancy and coincidental conditions. According to the latest Confidential Enquiry into Maternal Deaths in the UK, haemorrhage remains a leading direct cause of mortality; however, there has been an increase in mortality due to indirect causes. The obstetric population has changed over the past decade and we are caring for much older mothers with pre-existing disorders and advanced chronic medical conditions. It is therefore essential to adopt an early multidisciplinary approach for the care of these women. With birth rates increasing, complex caseloads and changes in training of both medical and midwifery staff, the challenge of caring for critically ill obstetric patients requires urgent attention.

Operative delivery rates following induction of labour for obstetric cholestasis.

The aim of this study was to determine whether women induced for obstetric cholestasis (OC) have increased rates of operative delivery compared with women without OC who are induced. This retrospective case-control study included 64 women with OC (singleton pregnancies), who had labour induced compared with two control groups (matched for parity and gestational week at delivery). The majority of women were induced at 37 weeks. We found no significant increase in the rate of operative or assisted delivery in OC cases compared with either control group. Women with OC who are induced between 36 and 40 weeks gestation do not have increased rates of assisted or operative delivery compared with induced controls.

Anaesthetic issues related to postpartum haemorrhage (excluding antishock garments).

The obstetric anaesthetist is a key member of the multidisciplinary team required to manage postpartum haemorrhage, having been trained in resuscitation and being experienced in managing haemorrhage and in monitoring and caring for the critically ill patient. The diagnosis of shock, initial resuscitation controversies surrounding fluid replacement, cell salvage in obstetrics and monitoring are discussed.

Role of the anaesthetist in obstetric critical care.

The anaesthetist plays a key role in the management of high-risk pregnancies, and must be a member of the multidisciplinary team that is required to care for the critically ill obstetric patient. Anaesthetists are trained in advanced life support and resuscitation. They are experienced in the management of the critically ill, and provide anaesthesia, sedation and pain management. The obstetric anaesthetist should undertake education of medical and midwifery staff in the early recognition, monitoring and treatment of the sick mother, resuscitation training, running 'skills drills' for emergency simulations, risk management and audit of maternal morbidity on the labour ward. To date, there is little evidence to inform the anaesthetic management of the critically ill obstetric patient; most recommendations and guidelines are based on the management of non-obstetric, critically ill patients. Management must be adapted to encompass the physiological changes of pregnancy. Evidence-based guidelines on management of the critically ill woman with specific obstetric conditions are also lacking.