Anaesthetists of all grades who work on a labour ward are likely to be involved in the insertion or management of an intrathecal catheter after inadvertent dural puncture at some point in their careers. Although the use of intrathecal catheters after inadvertent dural puncture in labour has increased in popularity over recent decades, robust evidence on best practice has been lacking.
The Obstetric Anaesthetists' Association set up an expert working party to review the literature. A modified Delphi approach was used to produce statements and recommendations on insertion and management of intrathecal catheters for labour and operative delivery following inadvertent dural puncture during attempted labour epidural insertion. Statements and recommendations were graded according to the US Preventive Services Task Force grading methodology.
A total of 296 articles were identified in the initial literature search. Further screening identified 111 full text papers of relevance. A structured narrative review was produced which covered insertion of an intrathecal catheter; initial dosing; maintenance of labour analgesia; topping-up for operative delivery; safety features; complications; and recommended follow-up. The working party agreed on 17 statements and 26 recommendations. These were generally assigned a low or moderate level of certainty. The safety of mother and baby were a key priority in producing these guidelines.
With careful management, intrathecal catheters can provide excellent labour analgesia and may also be topped-up to provide anaesthesia for caesarean or operative vaginal delivery. The use of intrathecal catheters, however, also carries the risk of significant drug errors which may result in high- or total-spinal anaesthesia, or even cardiorespiratory arrest. It is vital that all labour wards have clear guidelines on the use of these catheters, and that staff are educated as to their potential complications.
Critical care beds are a limited resource, yet research indicates that recommendations for postoperative critical care admission based on patient-level risk stratification are not followed. It is unclear how prioritisation decisions are made in real-world settings and the effect of this prioritisation on outcomes.
This was a prespecified analysis of an observational cohort study of adult patients undergoing inpatient surgery, conducted in 274 hospitals across the UK and Australasia during 2017. The primary outcome was postoperative morbidity at day 7. Logistic regression models were used to evaluate the relationship between critical care admission and patient and health system factors. The causal effect of critical care admission on outcome was estimated using variation in critical care occupancy as a natural experiment in an instrumental variable analysis.
A total of 19,491 patients from 248 hospitals were eligible for analysis, of whom 2107 were directly admitted to critical care postoperatively. Postoperative morbidity occurred in 2829/19,491 (15%) patients. Increasing surgical risk was associated with critical care admission, as was increased availability of critical care beds (odds ratio (95%CI) 1.04 (1.01–1.06), p = 0.002) per available bed; however, the probability of admission varied significantly between hospitals (median odds ratio 3.05). There was no evidence of a difference in postoperative morbidity with critical care admission (odds ratio (95%CI) 0.91 (0.57–1.45), p = 0.710).
Postoperative critical care admission is variable and related to bed availability. Statistical methods that adjust for unobserved confounding lowered the estimates of harm previously reported to have been associated with postoperative critical care admission. Our findings provide a rationale for a clinical trial which would evaluate any potential benefits for postoperative critical care admission for patients in whom there is no absolute indication for admission.
Nearly half of adult patients undergoing surgery experience moderate or severe postoperative pain. Inadequate pain management hampers postoperative recovery and function and may be associated with adverse outcomes. This multidisciplinary consensus statement provides principles that might aid postoperative recovery, and which should be applied throughout the entire peri-operative pathway by healthcare professionals, institutions and patients.
We conducted a directed literature review followed by a four-round modified Delphi process to formulate recommendations for organisations and individuals.
We make recommendations for the entire peri-operative period, covering pre-admission; admission; intra-operative; post-anaesthetic care unit; ward; intensive care unit; preparation for discharge; and post-discharge phases of care. We also provide generic principles of peri-operative pain management that clinicians should consider throughout the peri-operative pathway, including: assessing pain to facilitate function; use of multimodal analgesia, including regional anaesthesia; non-pharmacological strategies; safe use of opioids; and use of protocols and training for staff in caring for patients with postoperative pain.
We hope that with attention to these principles and their implementation, outcomes for adult patients having surgery might be improved.
We read with great interest the article by Grape et al. [1]. The authors conducted a meta-analysis that included meta-regression and trial sequential analysis, providing a comprehensive synthesis of 12 prospective, randomised controlled trials comparing intrathecal diamorphine with controls across various surgical procedures [1]. We identified a concern that may compromise the quality of this meta-analysis. The authors stated that the methodological quality of the included trials was assessed using the Cochrane Collaboration's Risk of Bias tool 2 (RoB2) [1]. The risk of bias assessment they describe encompassed seven domains: random sequence generation; allocation concealment; blinding of participants and personnel; blinding of outcome assessment; incomplete outcome data; selective reporting; and other biases. The approach employed, along with the reference cited, was actually consistent with the Cochrane Collaboration's Risk of Bias tool 1 (RoB1) [1, 2]. It is important to note that RoB2 resembles but differs from RoB1. Specifically, RoB2 evaluates six domains: the randomisation process; deviations from intended interventions; missing outcome data; measurement of the outcome; selection of the reported results; and overall bias [3]. The article by Sterne et al. discusses this in detail [3]. Additionally, two common figures depicting the risk of bias for the included studies can be generated using the RoB2 assessment spreadsheet (ROB2_IRPG_beta_v9) [3], or through the use of a web application called robvis® [4]. We suggest that the authors review their risk of bias assessment approach to align with the latest standards and improve the rigour of their meta-analysis.
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