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///2010 Abstract Details
2010 Abstract Details2019-08-03T15:49:10-05:00

Topping up of labor epidurals for emergency cesarean section - a survey of registrar (resident) practice in London, UK

Abstract Number: 111
Abstract Type: Original Research

Nadir Sharawi MB ChB1 ; Suyogi Jigajinni MBChB, BSc, FRCA2; Pervez Sultan MBChB, FRCA3; Dharshini Radhakrishnan MBBS, FRCA4

Introduction: Labor epidurals (LE) are common in UK units, used in roughly 35% of women (Ruppen et al, 2006), many of whom present for emergency cesarean section (ECS). Extending 'topping up' an LE for ECS is a core skill in obstetric anesthesia, and a 2003 UK survey showed practice in this area varied widely between consultants (Regan & OSullivan, 2008). It is the case however, especially out of hours, that often it is the anesthetic registrar (AR) who manages many of these cases, not the consultant. We therefore looked purely at AR practice when topping up an LE for ECS, thus reviewing a previously unaddressed area.

Methods: The online survey was distributed to all 285 ARs providing obstetric cover in two London anesthesia training schools. Questions covered: top up preparation, agents, test dose, where the top up started, reasons for using top up mixture, confidence with top up mixture and knowledge of unit protocol.

Results: 167/285 ARs responded (59%), from 34 different units. 11% of ARs pre-prepared their top up mixture. 32% used 0.5% Bupivicaine, 25% used 0.5% L-Bupivicaine, 20% used 0.5% Bupivicaine/2% Lidocaine mixture, 10% used 0.5% L-Bupivicaine/2% Lidocaine mixture, 9% used 2% Lidocaine, 4% used 0.75% Ropivicaine. 7% added epinephrine, 2% added NaHCO3, 8% combined both. 34% gave a test dose. 53% started topping up in the operating room (OR) and 47% in the labor room. 40% used their current mixture as they had tried others and felt it was best, 41% as it was the only one they had used, and 19% as the unit they currently worked in specified it (representing 8/34 units - 3 of which used pre-filled syringes). 15% were not confident about the mixture they currently used. 67% knew the unit protocol for LE top up for ECS.

Discussion: This is the first survey to look specifically at AR practice in this area. Most did not pre-prepare top up mixtures. Time can be lost and errors made by preparing mixtures in an emergency. 66% did not use a test dose, the risk of rapid intrathecal/intravascular injection cannot be overlooked. 47% started the top up in the labor room, as recommended in the Confidential Enquiry into Stillbirths and Deaths in Infancy, and 53% started in the OR. The risks of complications during transfer if topped up in the room must be balanced with risks of delay in reaching the OR. The most common agent used was 0.5% Bupivicaine (34%), and 17% used additives. Encouragingly, 40% had tried many mixtures before deciding theirs was best, but 60% had either only experienced one mixture or were on a unit where mixture use was specified. This is of note as 15% felt unconfident about the mixture they currently used. While having a protocol specifying a top up mixture has many benefits, ARs must be happy using it, and be trained to use others. 67% of ARs knew the unit protocol for LE top up for ECS. All 34 units may have had a protocol in place, but we highlight the importance not just of having one, but ensuring ARs know it.

SOAP 2010