Antisepsis for neuraxial procedures in Irish obstetric units and its possible impact on patient safety. A survey of national practice and associated complications.

INTRODUCTION: The Association of Anaesthetists' guidelines recommend 0.5% chlorhexidine gluconate for skin antisepsis before obstetric neuraxial procedures. In this national survey, we identified the practice of all 19 obstetric units in Ireland. A secondary aim was to investigate complications in units not following guidelines. METHODS: A consultant obstetric anaesthetist in each unit was asked seven questions relating to the antiseptic solution used, its application, their awareness of relevant guidelines, the unit epidural and caesarean section rates, and cases of either chemical arachnoiditis or central nervous system (CNS) infection in the previous year. RESULTS: All units responded (n=6 incomplete data) and consented verbally to anonymous data use. Thirteen (68%) used 0.5% chlorhexidine and three used 2% chlorhexidine swab-sticks (ChloraPrep™) exclusively; a fourth used mostly 2% chlorhexidine while two units used povidone iodine exclusively (11%). There were no cases of chemical arachnoiditis. One of three reported infective complications was attributed in part to the antiseptic used (povidone iodine) and practice was subsequently changed. CONCLUSION: Twenty-one percent of obstetric anaesthesia units in Ireland, catering for one-third of the total deliveries, use the ChloraPrep™ swab-stick and consider it the safest form of application. Chlorhexidine gluconate has been implicated in devastating neurological injury, however there is no evidence that a less concentrated solution such as 0.5% is safer. We suggest a meticulous application technique should be considered more important for patient safety than the concentration of solution.

Dexmedetomidine, high-flow nasal oxygen and sugammadex-reversal of rocuronium: overcoming anaesthetic challenges in a parturient with congenital muscular dystrophy presenting for caesarean section.

Congenital muscular dystrophies are characterised by progressive skeletal muscle weakness from birth or early infancy. Maternal respiratory compromise, joint contractures and presence of spinal instrumentation or fusion are some of the anaesthetic challenges that may be encountered in the obstetric setting. The choice of anaesthetic technique for surgical delivery needs to be considered on an individual basis. Multidisciplinary involvement is paramount to optimise peripartum care and outcomes. In this case report, we present the use of dexmedetomidine, humidified high-flow nasal oxygen, rocuronium and sugammadex in the anaesthetic management of a wheelchair-bound, non-invasive bilevel positive airway pressure ventilation-dependent parturient with congenital muscular dystrophy, who was presenting for caesarean section.

Ultrasound to identify the lumbar space in women with impalpable bony landmarks presenting for elective caesarean delivery under spinal anaesthesia: a randomised trial.

BACKGROUND: Ultrasound can facilitate neuraxial blockade in patients with poorly defined anatomical surface landmarks, but there are no studies comparing an ultrasound-guided technique with landmark palpation for spinal anaesthesia. The objective of this study was to compare pre-procedural lumbar ultrasonography with landmark palpation to locate the needle insertion point in women with impalpable lumbar spinous processes presenting for caesarean delivery. METHODS: After institutional ethics committee approval, 20 women with impalpable lumbar spinous processes presenting for elective caesarean delivery were recruited. Patients were randomised to palpation or ultrasound. The primary outcome of the study was the number of needle passes to achieve lumbar puncture. Secondary outcomes were the overall procedural time and patient satisfaction score. RESULTS: There was no difference in mean (±SD) body mass index of both groups (ultrasound 39.1 ± 5.02kg/m2 vs. palpation 38.3±3.77kg/m2). There were significantly fewer needle passes in the ultrasound group (median 3 [IQR 1.8-3.2]) compared to the palpation group (median 5.5 [IQR 3.2-7.2] (P=0.03)). More time was required to locate the needle insertion point in the ultrasound group (ultrasound 91.8±30.8s vs. palpation 32.6±11.4s, P<0.001). There was no difference in the total procedural time between groups (ultrasound 191.8±49.4s vs. palpation 192±110.9s, P=0.99). CONCLUSION: The use of ultrasonography to locate the needle insertion point reduced the number of needle passes in women with impalpable lumbar spinous processes undergoing elective caesarean delivery under spinal anaesthesia. Its use did not prolong overall procedural time.