‘Rapid sequence spinal’ avoids general anesthesia in category-1 sections
MedWire News: Use of a "rapid sequence spinal" anesthesia protocol can minimize the need for general anesthesia in women requiring emergency cesarean sections, report UK researchers.
"We use the term 'rapid sequence spinal' to encapsulate the idea of performing a spinal anesthetic with the bare essentials while emphasizing the importance of limiting the number of attempts at insertion," say Stephen Kinsella and colleagues, from St Michael's Hospital in Bristol, in the journal Anaesthesia.
The protocol includes a "no touch" technique, using gloves only, with the glove packet employed as a sterile surface. An increased dose of hyperbaric bupivacaine can be used if no opioid is immediately available, local infiltration is not required, and just one attempt at spinal anesthesia is allowed, unless an obvious correction permits a second attempt.
Surgery can be started when the block height reaches at least T10 and is ascending, but conversion to general anesthesia must be considered in the event of any problems or delay.
The team used this protocol with 25 women requiring category-1 cesarean section, the most urgent emergency sections. Three women had umbilical cord prolapse, while 22 had severe fetal compromise.
Three cases had identified decision-to-delivery delays: one woman was not in hospital at first alert, one had a failed forceps delivery, and one was converted to general anesthesia.
Excluding these cases, the median total time for anesthesia was 8 minutes. The median time from starting the procedure to spinal injection was 2 minutes, and from injection to satisfactory block was 4 minutes.
The median block height considered "acceptable" for starting surgery was T4 (range T1 to T10).
Three women suffered discomfort or pain during surgery, but did not require treatment. In one case, surgery was paused briefly and then continued with no further pain reported.
"We attach provisos to the use of a rapid sequence spinal in our hospital," say Kinsella et al. "The possible risks attached to this technique have to be carefully weighed against those of rushed general anesthesia."
They note that a subgroup of category-1 cesarean section patients, such as those with placental abruption, fetal hemorrhage, and cord prolapse with preterm infant, will require decision-to-delivery times that can only be achieved with general anesthesia.
In an accompanying editorial, T. Girard and M. Schneider (University Hospital, Basel Switzerland) said: "Being aware that the risk of bad outcomes and catastrophic complications is omnipresent when providing general anesthesia to patients undergoing cesarean section, the rapid sequence spinal approach in this setting is not only promising but may prove to be the safer approach for the mother without unduly jeopardizing neonatal outcome."
They concluded: "It is quite obvious that the promising results collected in this small case series should be corroborated by further studies that include larger numbers of patients, allowing more conclusive conclusions."
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By Eleanor McDermid