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pearl
1
Although epidural analgesia results in a small improvement in acute post-abdominal surgery pain compared to transversus abdominis plane block, the magnitude is small and associated with post-op hypotension.
Desai N, El-Boghdadly K, Albrecht E. Epidural vs. transversus abdominis plane block for abdominal surgery - a systematic review, meta-analysis and trial sequential analysis. Anaesthesia. 2021 Jan 1; 76 (1): 101-117.
  Daniel Jolley
summary
1
Take-away message
• Analgesia post-caesarean section (CS) is of global importance, as both the most frequently performed surgical procedure, and one that is commonly associated with significant pain, impacting maternal experience.
• Fascial blocks, such as the transversus abdominis plane (TAP) and quadratus lumborum block (QLB), have been advocated for use in reducing post-CS pain. This network meta-analysis confirms the equivalent benefit of either block in improving post-operative pain in the absence of using intrathecal morphine.
• Although the QLB is advocated for its potential to reduce both somatic and visceral pain, unlike the TAP block, comparing studies investigating either block did not reveal any significant benefit of TAP over QLB.
• No analgesic benefit was found for either when intrathecal morphine is used (although TAP block may be associated with lower incidence of nausea, vomiting & sedation, in the presence of IT morphine).
• As is common to many meta-analyses, these conclusions are somewhat undermined by the moderate-to-low levels of evidence in the included studies.
El-Boghdadly K, Desai N, Halpern S et al. Quadratus lumborum block vs. transversus abdominis plane block for caesarean delivery: a systematic review and network meta-analysis. Anaesthesia. 2021 Mar 1; 76 (3): 393-403.
  Daniel Jolley
pearl
1
Transversus abdominis plane & quadratus lumborum block both offer equivalent analgesia benefit following caesarean section in the absence of intrathecal morphine, although little or know benefit if intrathecal morphine is used.
El-Boghdadly K, Desai N, Halpern S et al. Quadratus lumborum block vs. transversus abdominis plane block for caesarean delivery: a systematic review and network meta-analysis. Anaesthesia. 2021 Mar 1; 76 (3): 393-403.
  Daniel Jolley
pearl
1
Quadratus lumborum block modestly reduces post-operative pain after caesarean section when intrathecal morphine is not used.
Hussain N, Brull R, Weaver T et al. Postoperative Analgesic Effectiveness of Quadratus Lumborum Block for Cesarean Delivery under Spinal Anesthesia. Anesthesiology. 2021 Jan 1; 134 (1): 72-87.
  Daniel Jolley
pearl
1
Intraoperative anaesthesia handovers increase the risk of adverse outcomes by 40%.
Boet S, Djokhdem H, Leir SA et al. Association of intraoperative anaesthesia handovers with patient morbidity and mortality: a systematic review and meta-analysis. Br J Anaesth. 2020 Oct 1; 125 (4): 605-613.
  Daniel Jolley
pearl
1
Deep neuromuscular block does not improve surgical conditions for laparoscopic renal surgery.
GHM Honing, Martini CH, Olofsen E et al. Deep neuromuscular block does not improve surgical conditions in patients receiving sevoflurane anaesthesia for laparoscopic renal surgery. Br J Anaesth. 2021 Feb 1; 126 (2): 377-385.
  Daniel Jolley
pearl
1
A small QTc prolongation seen with carbetocin is unlikely to be clinically significant.
Clunies-Ross N, Roston TM, Taylor J et al. The Effect of Carbetocin Dose on Transmural Dispersion of Myocardial Repolarization in Healthy Parturients Scheduled for Elective Cesarean Delivery Under Spinal Anesthesia: A Prospective, Randomized Clinical Trial. Anesth. Analg. 2021 Feb 1; 132 (2): 485492485-492.
  Daniel Jolley
summary
1
This large study of 428,204 New York caesarean section records (2006-2013), including 34,356 general anaesthetics (8%), investigated the association between mode of anaesthesia and post-partum depression (PPD). Other studies have shown an association between caesarean section (emergency > elective) and PPD. (Sun 2021, Xu 2017, and others), though this is the first to look specifically at general anaesthesia as a PPD risk factor.
Guglielminotti and Li found that general anaesthesia increased the odds of severe PPD by 54% (aOR 1.54, 1.21-1.95), and suicidal ideation by a massive 91% (aOR 1.91, 1.12-3.25), though not a significant increase in anxiety or PTSD.
The researchers discuss many potential causative factors, particularly known associations between GA CS & poor pain control, and subsequent pain & PPD – while also acknowledging the obvious potential for confounders. Of note patients receiving GA were older, more often non-Caucasian, had more co-morbidities, neonatal complexity, and lower socio-economic levels – also all independently associated with PPD risk.
In order to quantify the potential confounding contribution of emergency vs elective status, the researchers employed the novel E value:
To assess the impact of emergent cesarean delivery on our results, we calculated the E value associated with the aOR for the risk of PPD and suicidality. This relatively new metric takes into consideration 2 associations: (1) that between the confounder (emergent cesarean delivery) and the outcome (PPD); and (2) the association between the confounder (emergent cesarean delivery) and the exposure (general anesthesia).
An E value of 1.7 for the unmeasured confounder emergent cesarean delivery indicates that to explain away the association between general anesthesia and depression, either: (1) emergent cesarean delivery increases the risk of depression by at least 70%; or (2) emergent cesarean delivery is at least 70% more prevalent among general anesthesia than among neuraxial anesthesia. Either association is clinically plausible.
Keep it in perspective...
We already know that general anaesthesia for CS is suboptimal: it compromises both maternal experience and safety, but it should (hopefully) only ever be a chosen mode of anaesthesia when there is a true contraindication to regional anaesthesia – even at the modestly-high 8% GA rate among this New York cohort.
Looking at it from the other end, bear in mind that the modestly-faster time-to-incision for GA over regional is also of questionable neonatal benefit.
The take-home:
Just another reason to avoid GA CS when possible – but you already knew that, right?
"...general anesthesia is a potentially modifiable risk factor for PPD. This finding provides further supporting evidence favoring neuraxial over general anesthesia in cesarean delivery whenever possible."
Guglielminotti J Li G. Exposure to General Anesthesia for Cesarean Delivery and Odds of Severe Postpartum Depression Requiring Hospitalization. Anesth. Analg. 2020 Nov 1; 131 (5): 142114291421-1429.
  Daniel Jolley
pearl
1
General anaesthesia for emergency caesarean section is associated with the shortest time-to-incision but also lower 5-min Apgar scores. Longer time-to-incision is not associated with worse neonatal outcomes.
Palmer E, Ciechanowicz S, Reeve A et al. Operating room-to-incision interval and neonatal outcome in emergency caesarean section: a retrospective 5-year cohort study. Anaesthesia. 2018 Jul 1; 73 (7): 825-831.
  Daniel Jolley
comment
0
Unfortunate wording in the conclusion here, implying causation where in fact there is no evidence of such. Delivery mode does not have a significant effect – it is rather significantly associated with PPD.
The mode of delivery has a significant effect on the occurrence of mild postpartum depression.
It's unfortunate that the authors and editors were not more careful with their wording in a very emotionally-charged and controversial area.
Sun L, Wang S, Li XQ. Association between mode of delivery and postpartum depression: A systematic review and network meta-analysis. Aust N Z J Psychiatry. 2021 Jun 1; 55 (6): 588-601.
  Daniel Jolley