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Impact of consultant presence on regional anesthesia to general anesthesia conversion for category 1 cesarean sections
Abstract Number: F-07
Abstract Type: Original Research
Introduction: In the UK a 4 grade classification system categorises the urgency of cesarean section (CS), category 1 denotes the most urgent, with a decision to delivery interval <30 minutes. The highest incidence of regional anesthesia (RA) failure, resulting in conversion to general anesthesia (GA), occurs in category 1 CS. The Royal College of Anaesthetists (RCOA) have suggested an auditable standard for the RA to GA conversion rate for category 1 CS, stating it should be <15%. They also highlighted that all cases where a regional analgesic technique was started for labor, are considered as having RA for CS, whether that regional block was extended for CS or not.1
Method: We collected data for all category 1 CS carried out between January 2011 and December 2015. Mode of anesthesia, time and day of the week, RA to GA conversion and consultant presence were documented. Consultant anesthesiologist presence on the labor ward was assumed between 0800-1700 Monday–Friday. Consultant obstetrician presence was assumed between 0800-2200 Monday-Friday, and 0800-2000 Saturday-Sunday. Results were analysed using proportions and differences in proportions with 95% confidence intervals, and exact 2-sided p values, with p<0.05 as significant.
Results: A total of 861 category 1 CS were performed, of which, 268 received a primary GA (no prior regional technique), and 593 received RA. 65 were converted from RA to GA, giving a RA to GA conversion rate of 11% (95% CI 8.6-13.8). Presence of both consultant anesthesiologist and consultant obstetrician on the labor ward were found to have a significant effect.
Discussion: The RA to GA conversion rate for category 1 CS was 11%, which was within the standard of <15%. Consultant anesthesiologist presence was found to be a significant factor, with absence of a consultant anesthesiologist more than doubling the RA to GA conversion rate. Absence of a consultant obstetrician had an even greater effect, resulting in a RA to GA conversion rate of 16%, exceeding the standard set by the RCOA. Our findings suggest, that junior staff, in the absence of direct consultant support, are more likely to convert a RA technique to GA. This could possibly be due to a lack of experience, or a perceived lack of time.
Conclusion: Consultant presence on the labor ward reduces the RA to GA conversion rate for category 1 CS.
1. Royal College of Anaesthetists. Raising the Standard: a compendium of audit recipes. 3rd Edition 2012.