Anaesthesia
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McCombe and Bogod report on their analysis of 55 medicolegal claims relating to obstetric neuraxial anaesthesia and analgesia.
Why is this important?
Not only is neurological injury the second most common reason for obstetric anaesthetic claims (behind inadequate regional anaesthesia resulting in pain during Caesarean section), the average claim cost is greater.
McCombe and Bogod provide a factful exploration of many of the causes of neurological complications.
Which themes emerged from their analysis?
- Consent, particularly around providing inadequate pre-procedure information of the risk of neurological injury1 and the challenges, medical and legal, to achieving informed consent.
- Nerve injury and it's mechanisms: non-anaesthetic causes2, direct trauma, chemical, and compression (abscess, haematoma).
- Complication recognition & management means timely follow-up and assessment, and maintaining a high index of suspicion for abnormalities. Remember the 4 hour rule: blocks should be regressing 4 hours after the last dose.
Important reminders
The level of spinal cord termination varies a lot among individuals, as does the level of Tuffier's line3. Considering the inaccuracy of spinal level identification by anaesthetists, there is a lot of potential to place a needle higher than expected.
Bottom-line: the intrathecal space should be accessed at the lowest possible level, and "the L2/3 interspace should not be an option."
And never allow chlorhexidine to contaminate gloves, the sterile workspace or neuraxial equipment.
summary
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Noting from NAP3 the risk of nerve injury ranges from, temporary injury 1:1,000, prolonged (>6 months) 1:13,000, to severe (including paralysis) 1:250,000. ↩
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'Obstetric palsy' (pelvic nerve compression) estimated by Bromage as occurring in 1:3000 deliveries; arterial obstruction & ischaemia 1:15,000; AV malformations 1:20,000. A prospective French study found postpartum neuropathy in 0.3%, 84% were femoral, and 69% resolved at 6 weeks. ↩
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Although generally accepted as being at the L4/5 interspace, in up to 50% of people the intercristal line might be at or above L2/3! ↩
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The cost effectiveness of reusable vs. single-use flexible bronchoscopy in the peri-operative setting has yet to be determined. We therefore aimed to determine this and hypothesised that single-use flexible bronchoscopes are cost effective compared with reusable flexible bronchoscopes. We conducted a systematic review of the literature, seeking all reports of cross-contamination or infection following reusable bronchoscope use in any clinical setting. ⋯ The cost per use of a single-use flexible bronchoscope was £220 sterling. The cost effectiveness analysis demonstrated that reusable flexible bronchoscopes have a cost per patient use of £511 sterling due to the costs of treatment of infection. The findings from this study suggest benefits from the use of single-use flexible bronchoscopes in terms of cost effectiveness, cross-contamination and resource utilisation.
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The cost effectiveness of reusable vs. single-use flexible bronchoscopy in the peri-operative setting has yet to be determined. We therefore aimed to determine this and hypothesised that single-use flexible bronchoscopes are cost effective compared with reusable flexible bronchoscopes. We conducted a systematic review of the literature, seeking all reports of cross-contamination or infection following reusable bronchoscope use in any clinical setting. ⋯ The cost per use of a single-use flexible bronchoscope was £220 sterling. The cost effectiveness analysis demonstrated that reusable flexible bronchoscopes have a cost per patient use of £511 sterling due to the costs of treatment of infection. The findings from this study suggest benefits from the use of single-use flexible bronchoscopes in terms of cost effectiveness, cross-contamination and resource utilisation.