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General Anesthesia for Cesarean Delivery as Metric for Quality
Abstract Number: T2B-5
Abstract Type: Original Research
Intro.General anesthesia (GA) rates for cesarean delivery are a proposed quality metric in obstetric anesthesia (1). Advised rates of conversion from regional to GA in cesarean delivery are <1% in non-emergent settings and <5% in unscheduled or emergent settings (1). However, these rates may need institutional adjustment given patient, system/cultural, and practitioner factors. To explore the utility of this quality metric, we aimed to identify intervenable factors to reduce the rate of general anesthesia for emergent and non-emergent cesarean deliveries.
Methods. A retrospective analysis of all cesarean deliveries at a high-volume academic center from 1/1/2016 to 1/31/2017 was chosen. A “non-emergent” case was defined as performed at a time suitable to maternity services (1). An “emergent” case was defined as cesarean delivery with maternal or fetal compromise or any need for unscheduled cesarean delivery (1). Reasons for GA in emergent and non-emergent cases were abstracted and coded from the record. GA reasons between emergent and non-emergent cases were compared by Fisher’s exact test. A P < 0.05 was considered statistically significant.
Results. 2923 cases were identified. 1133 (38.8%) were emergent; 1790 (61.2%) were non-emergent. GA occurred in 133 (4.6%, 133/2923) of all cesarean deliveries. Conversion from planned regional to GA occurred in 17 (0.9%, 17/1790) of non-emergencies and 106 (9.4%, 106/1133) of emergencies. Reasons for conversion to GA in emergencies included no time for regional or block set-up (n=71), failed regional (n=33), high spinal (n=1), inadequate surgical conditions despite adequate block (n=1). Of GA cases, 109 (3.73%, 109/2923) were emergent and 24 (0.82%, 24/2923) were non-emergent. Most frequent reasons for GA in emergencies were no time for regional (64.2%, 70/109) and failed regional (29.4%, 32/109). Most frequent reason for GA in non-emergencies was failed regional (62.5%, 15/24). Failed regional occurred proportionally more in non-emergent GA (non-emergent: 62.5% (15/24) vs. emergent: 29.4% (32/109), P = 0.002). Patient refusal of regional occurred more often in non-emergent GA cases (non-emergent: 12.5% (3/24) vs. emergent: 2.8% (3/109), P = 0.04).
Conclusions. Conversion from regional to GA in emergencies may exceed advised rates for acceptable reasons. Nevertheless, improvement opportunities are identified. Patient refusal of neuraxial anesthesia occurs more often in non-emergent cesarean delivery by GA, indicating a need for effective patient education strategies. Factors linked to failed regional in both emergent and non-emergent cases must be addressed. An ideal quality metric measures a process amenable to change in favor of desirable outcomes for clinicians and patients alike. Given that patient refusal of neuraxial often drives rates of GA, the merits of GA rates in cesarean delivery as a goal for quality requires additional study.
1. Quality Imprvmnt in Anaesth. London,2012,220-1