Benchmarking care for very low birthweight infants in Ireland and Northern Ireland.

BACKGROUND: Benchmarking is that process through which best practice is identified and continuous quality improvement pursued through comparison and sharing. The Vermont Oxford Neonatal Network (VON) is the largest international external reference centre for very low birth weight (VLBW) infants. This report from 2004-7 compares survival and morbidity throughout Ireland and benchmarks these results against VON. METHODS: A standardised VON database for VLBW infants was created in 14 participating centres across Ireland and Northern Ireland. RESULTS: Data on 716 babies were submitted in 2004, increasing to 796 babies in 2007, with centres caring for from 10 to 120 VLBW infants per year. In 2007, mortality rates in VLBW infants varied from 4% to 19%. Standardised mortality ratios indicate that the number of deaths observed was not significantly different from the number expected, based on the characteristics of infants treated. There was no difference in the incidence of severe intraventricular haemorrhage between all-Ireland and VON groups (5% vs 6%, respectively). All-Ireland rates for chronic lung disease (CLD; 15-21%) remained lower than rates seen in the VON group (24-28%). The rates of late onset nosocomial infection in the all-Ireland group (25-26%) remained double those in the VON group (12-13%). DISCUSSION: This is the first all-Ireland international benchmarking report in any medical specialty. Survival, severe intraventricular haemorrhage and CLD compare favourably with international standards, but rates of nosocomial infection in neonatal units are concerning. Benchmarking clinical outcomes is critical for quality improvement and informing decisions concerning neonatal intensive care service provision.

Interventions to prevent hypothermia at birth in preterm and/or low birthweight infants.

BACKGROUND: Hypothermia incurred during routine postnatal resuscitation is a world-wide issue (across all climates), associated with morbidity and mortality. Keeping vulnerable preterm infants warm is problematic even when recommended routine thermal care guidelines are followed in the delivery suite. OBJECTIVES: To assess efficacy and safety of interventions designed for prevention of hypothermia in preterm and/or low birthweight infants applied within ten minutes after birth in the delivery suite compared with routine thermal care. SEARCH STRATEGY: The standard search strategy of The Cochrane Collaboration was followed. Electronic databases were searched: MEDLINE (1966 to July Week 4 2007 ), CINAHL (1982 to July Week 4 2007), EMBASE (1974 to 01/08/2007), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2007), Database of Abstracts of Reviews of Effects (DARE 1994 to July 2007), conference/symposia proceedings using ZETOC (1993 to 17/08/2007), ISI proceedings (1990 to 17/08/2007) and OCLC WorldCat (July 2007). Identified articles were cross-referenced. No language restrictions were imposed. SELECTION CRITERIA: All trials using randomised or quasi-randomised allocations to test a specific intervention designed to prevent hypothermia, (apart from 'routine' thermal care) applied within 10 minutes after birth in the delivery suite to infants of < 37 weeks' gestational age or birthweight

Ventricular bigeminy during phenylephrine infusion used to maintain normotension during caesarean section under spinal anaesthesia.

A 31-year-old primiparous, healthy woman presented for emergency caesarean section. Following the siting of a spinal anaesthetic, seconds after starting a phenylephrine infusion, she developed ventricular bigeminy. She reverted to sinus rhythm spontaneously when the phenylephrine infusion was stopped at delivery. The possible proarrhythmic and antiarrhythmic effects of phenylephrine are discussed. We suggest that this was most probably a stretch-induced ventricular arrhythmia due to increased ventricular afterload.

Interventions to prevent hypothermia at birth in preterm and/or low birthweight babies.

BACKGROUND: Hypothermia incurred during routine postnatal resuscitation is a world-wide issue (across all climates), with associated morbidity and mortality. Keeping vulnerable preterm infants warm is problematic even when recommended routine thermal care guidelines are followed in the delivery suite. OBJECTIVES: To assess efficacy and safety of interventions, designed for prevention of hypothermia in preterm and/or low birthweight infants, applied within 10 minutes after birth in the delivery suite compared with routine thermal care. SEARCH STRATEGY: The standard search strategy of The Cochrane Collaboration was followed. Electronic databases were searched: MEDLINE (1966 to May Week 4 2004 ), CINAHL (1982 to May Week 4 2004), EMBASE (1974 to 09/07/04), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2004), Database of Abstracts of Reviews of Effects (DARE 1994 to July 2004), conference/symposia proceedings using ZETOC (1993 to July 2004), ISI proceedings (1990 to 09/07/2004) and OCLC WorldCat (July 2004). Identified articles were cross-referenced. No language restrictions were imposed. SELECTION CRITERIA: All trials using randomised or quasi-randomised allocations to test a specific intervention designed to prevent hypothermia, (apart from 'routine' thermal care) applied within 10 minutes after birth in the delivery suite to infants of < 37 weeks' gestational age or birthweight

Failed tracheal intubation in obstetrics: no more frequent but still managed badly.

In the South-West Thames region of the United Kingdom, during a 5-year period from 1999 to 2003, there were 20 failed tracheal intubations occurring in 4768 obstetric general anaesthetics (incidence 1 : 238). In half of the 16 cases for which the patient's notes could be examined there was a failure to follow an accepted protocol for failed tracheal intubation.

Some immediate serious complications of obstetric epidural analgesia and anaesthesia: a prospective study of 145,550 epidurals.

BACKGROUND: Inadvertent intravascular, intrathecal or subdural injection in obstetric regional analgesia are potentially life-threatening, so following a catastrophic complication it was decided to collect data regionally. METHOD: Obstetric anaesthetists from 14, later 12 maternity units in the South West Thames Region collected and pooled data on obstetric anaesthetic interventions and complications from 1987 to 2003. RESULTS: During the 17-year period, 145,550 epidurals (26.3%) were administered to 553,905 mothers. The incidence of intravascular injection was 1 in 5,000 epidurals (0.02% [95%CI 0.014-0.029%]), of intrathecal injection 1 in 2,900 epidurals (0.035% [95%CI 0.027-0.046%]), of subdural injection 1 in 4,200 epidurals (0.024% [95%CI 0.017-0.033%]) and of high or total spinal block 1 in 16,200 epidurals (0.006% [95%CI 0.003-0.012%]). The incidence of serious complications did not change during the course of the study, nor was there any difference in the incidence of serious complications in obstetric units of different sizes or in obstetric units with different rates of epidural analgesia. CONCLUSION: The incidence of intravascular, intrathecal and subdural injection and of high or total spinal block was similar to that found in previous prospective studies in obstetric and non-obstetric patients. The incidence of these complications has not changed and is not related to the number of deliveries or the epidural rate in obstetric units.

Anaesthesia for Caesarean section: a survey in a UK region from 1992 to 2002.

Data are presented for anaesthesia for Caesarean section (CS) in the South-west Thames region of the UK. The CS rate rose from 12.7% in 1987 to 24.2% in 2002. The rate of increase shows no sign of slowing. The rate of regional anaesthesia (RA) for elective CS rose from 69.4% in 1992 to 94.9% in 2002, when spinal anaesthesia was used for 86.6% of cases. This may limit the opportunities to teach other anaesthetic techniques. The rate of RA for emergency CS rose from 49.3% in 1992 to 86.7% in 2002. There is an unacceptable rate of failure of RA for both elective and emergency CS, 1.3% of RAs for elective CS and 4.9% of RAs for emergency CS were converted to general anaesthesia.

Failed tracheal intubation in obstetrics: a 6-year review in a UK region.

In the South Thames (West) region of the United Kingdom, during a 6-year period from 1993 to 1998, there was a significant increase in the Caesarean section rate accompanied by a significant decrease in the use of general anaesthesia for operative delivery. During this time, there were 36 failed tracheal intubations occurring in 8970 obstetric general anaesthetics (incidence 1/249). There was no significant difference in the incidence of failed tracheal intubation in each of the six years. In 24 of the 26 cases for which the patients' notes could be examined, there was either no recording of preoperative assessment, a failure to follow an accepted protocol for failed tracheal intubation, or no follow-up.

Masseter muscle rigidity after vecuronium.

Masseter muscle rigidity after suxamethonium, usually occurring in children induced with halothane, is associated with malignant hyperthermia. A case is reported in which masseter muscle rigidity occurred in an adult following vecuronium. From the limited data available, this and two similar reported cases, it appears that non-depolarizing muscle relaxants can, very rarely, cause masseter muscle rigidity in adults. This masseter muscle rigidity may complicate airway management, but is unlikely to progress to generalized rigidity and malignant hyperthermia.

Efficacy of epidural blood patch in the obstetric population.

A retrospective audit of obstetric epidurals was performed at Royal Surrey County Hospital. The aim was to determine the efficacy of epidural blood patch in the management of post-dural puncture headache following inadvertent dural puncture in the obstetric population, over a 5-year period between March 1993 and February 1998. During that time, there were 55 recognized dural punctures (overall incidence 0.96%). A total of 62 epidural blood patches were performed in 48 patients. Following treatment with one epidural blood patch, 33% of patients obtained complete and permanent relief, 50% partial relief and 12% no relief. Twenty-nine percent of patients required a second epidural blood patch of which 50% were completely successful, 36% were partially successful and 14% gave no relief.