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Each baby counts: Themed report on anaesthetic care, including lessons identified from Each Baby Counts babies born 2015 to 2017

Royal College of Obstetricians & Gynaecologists| July 2018 | Recommendations made into anaesthetic care to reduce perinatal deaths and brain injuries during childbirth

The Royal College of Obstetricians & Gynaecologists has looked into stillbirths, neonatal deaths and brain injuries that occur during childbirth as part of its quality improvement programme. It has now released a new report into anaesthetic care: Recommendations made into anaesthetic care to reduce perinatal deaths and brain injuries during childbirth

This special report – supported by the Royal College of Anaesthetists and Obstetric Anaesthetists’ Association – will form part of a wider set of findings and recommendations from the Each Baby Counts programme, to be published in autumn 2018.

each baby counts
Image source: rcog.org.uk


Key findings of the report include:

  • Many of the lessons on ‘human factors’, identified in the Each Baby Counts 2015 full report, are echoed in this latest report.
  • Although there were no babies for whom anaesthetic problems were thought to be the sole contributor to their outcome, most of the anaesthetic issues noted in these reviews contributed to delays in delivery.
  • There is a clear need to optimise communication about the urgency of delivery to allow for informed choice of method of anaesthesia.
  • Key themes for improvement also included the care of women with partially effective regional anaesthesia and failed intubation.


  • There is a need for the development of a structured communication tool to include the three-fold elements of the delivery plan: mode of delivery, location of birth and category of urgency. This will form a key Each Baby Counts implementation output from this report, and the RCOG is committed to collaborating with the relevant organisations to produce this at the earliest opportunity.
  • All local reviews conducted into adverse neonatal outcomes should, where relevant, involve an obstetric anaesthetist and should include review of the detailed anaesthetic record.
  • Anaesthetists should always be informed of the degree of urgency of delivery. As an aid to communication, the classification of urgency of caesarean section should be used for all operative deliveries, vaginal as well as abdominal.
  • A decision about the purpose of transfer to theatre and urgency of any delivery should be made, together with the anaesthetist before transfer to theatre. The degree of urgency should be reviewed on entering theatre prior to the WHO check, and the obstetrician should confirm the degrees of urgency directly to the anaesthetist
  • Anaesthetists should use a structured and validated anaesthetic handover tool between shifts and, if possible, participate in the routine labour ward handover/review of the delivery suite board. This will help maintain situational awareness and enable early anticipation of anaesthetic difficulties.
  • All women who receive epidural analgesia should be reviewed to ensure the effectiveness of the epidural and to minimise delays should the need for operative delivery arise. The function of an in-labour epidural should be taken into consideration when deciding on the most appropriate and timely means of anaesthesia.
  • The safety of the mother must be the primary concern at all times. Women should not be put at risk of airway problems through inadequate preparation/positioning due to haste to achieve a rapid delivery. The required equipment for the management of difficult and failed tracheal intubation in obstetrics detailed in the OAA/DAS guidelines should always be available and all anaesthetists should undergo specific difficult airway training.

Source: Royal College of Obstetricians & Gynaecologists

The report Each baby counts can be downloaded here 

Multimodal Pain Management Strategies

Memtsoudis, S. et al. | Association of Multimodal Pain Management Strategies with Perioperative Outcomes and Resource Utilization: A Population-based Study | Anesthesiology | 2018 Vol. 128, 891-902


Background: Multimodal analgesia is increasingly considered routine practice in joint arthroplasties, but supportive large-scale data are scarce. The authors aimed to determine how the number and type of analgesic modes is associated with reduced opioid prescription, complications, and resource utilization.

Methods: Total hip/knee arthroplasties (N = 512,393 and N = 1,028,069, respectively) from the Premier Perspective database (2006 to 2016) were included. Analgesic modes considered were opioids, peripheral nerve blocks, acetaminophen, steroids, gabapentin/pregabalin, nonsteroidal antiinflammatory drugs, cyclooxygenase-2 inhibitors, or ketamine. Groups were categorized into “opioids only” and 1, 2, or more than 2 additional modes. Multilevel models measured associations between multimodal analgesia and opioid prescription, cost/length of hospitalization, and opioid-related adverse effects. Odds ratios or percent change and 95% CIs are reported.

Results: Overall, 85.6% (N = 1,318,165) of patients received multimodal analgesia. In multivariable models, additions of analgesic modes were associated with stepwise positive effects: total hip arthroplasty patients receiving more than 2 modes (compared to “opioids only”) experienced 19% fewer respiratory (odds ratio, 0.81; 95% CI, 0.70 to 0.94; unadjusted 1.0% [N = 1,513] vs. 2.0% [N = 1,546]), 26% fewer gastrointestinal (odds ratio, 0.74; 95% CI, 0.65 to 0.84; unadjusted 1.5% [N = 2,234] vs. 2.5% [N = 1,984]) complications, up to a –18.5% decrease in opioid prescription (95% CI, –19.7% to –17.2%; 205 vs. 300 overall median oral morphine equivalents), and a –12.1% decrease (95% CI, –12.8% to –11.5%; 2 vs. 3 median days) in length of stay (all P < 0.05). Total knee arthroplasty analyses showed similar patterns. Nonsteroidal antiinflammatory drugs and cyclooxygenase-2 inhibitors seemed to be the most effective modalities used.

Conclusions: While the optimal multimodal regimen is still not known, the authors’ findings encourage the combined use of multiple modalities in perioperative analgesic protocols.

Full document available here


Children exposed to general anaesthestic have poorer development, literacy and numeracy scores

Study finds that children exposed to general anesthesia before 4 years have poorer development at school entry and school performance | Pediatric Anesthesia | via Journal of Anaesthesia Practice


The new finding is based on a data-linkage study of over 210,000 children in New South Wales, Australia.

211,978 children included in the study were born in New South Wales at 37-plus weeks’ gestation without major congenital anomalies or neurodevelopmental disability. Of these, researchers had data on their school entry developmental assessment in 2009, 2012, or their Grade-3 school test results in 2008-2014.

The researchers compared the development and school results of children exposed to general anaesthesia during hospital procedures (37,880) up to 48 months of age to same-aged children with no exposure to general anaesthesia or hospitalisation (197,301).

Key findings

Compared to children unexposed to general anaesthesia, those exposed to general anaesthesia had a:

  • 17 per cent increased risk of poor child development
  • 34 per cent increased risk of lower numeracy scores on school tests
  • 23 per cent increased risk of lower reading scores on school tests

When the researchers restricted their analyses to children who’d had only one hospitalisation involving a procedure requiring general anaesthesia, they found no increased risk for poor development or reduced reading scores, however the risk of poor numeracy scores remained.

Full story at Journal of Anaesthesia Practice

Journal reference: Francisco J Schneuer, et al. The impact of general anesthesia on child development and school performance: a population-based study |  Pediatric Anesthesia |  2018; DOI: 10.1111/pan.13390

Local anaesthetics and regional anaesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children



Regional anaesthesia may reduce the rate of persistent postoperative pain (PPP), a frequent and debilitating condition. This review was originally published in 2012 and updated in 2017.


To compare local anaesthetics and regional anaesthesia versus conventional analgesia for the prevention of PPP beyond three months in adults and children undergoing elective surgery.

Search methods

We searched CENTRAL, MEDLINE, and Embase to December 2016 without any language restriction. We used a combination of free text search and controlled vocabulary search. We limited results to randomized controlled trials (RCTs). We updated this search in December 2017, but these results have not yet been incorporated in the review. We conducted a handsearch in reference lists of included studies, review articles and conference abstracts. We searched the PROSPERO systematic review registry for related systematic reviews.

Selection criteria

We included RCTs comparing local or regional anaesthesia versus conventional analgesia with a pain outcome beyond three months after elective, non-orthopaedic surgery.

Data collection and analysis

At least two review authors independently assessed trial quality and extracted data and adverse events. We contacted study authors for additional information. We presented outcomes as pooled odds ratios (OR) with 95% confidence intervals (95% CI), based on random-effects models (inverse variance method). We analysed studies separately by surgical intervention, but pooled outcomes reported at different follow-up intervals. We compared our results to Bayesian and classical (frequentist) models. We investigated heterogeneity. We assessed the quality of evidence with GRADE.

Main results

In this updated review, we identified 40 new RCTs and seven ongoing studies. In total, we included 63 RCTs in the review, but we were only able to synthesize data on regional anaesthesia for the prevention of PPP beyond three months after surgery from 41 studies, enrolling a total of 3143 participants in our inclusive analysis.

Evidence synthesis of seven RCTs favoured epidural anaesthesia for thoracotomy, suggesting the odds of having PPP three to 18 months following an epidural for thoracotomy were 0.52 compared to not having an epidural (OR 0.52 (95% CI 0.32 to 0.84, 499 participants, moderate-quality evidence). Simlarly, evidence synthesis of 18 RCTs favoured regional anaesthesia for the prevention of persistent pain three to 12 months after breast cancer surgery with an OR of 0.43 (95% CI 0.28 to 0.68, 1297 participants, low-quality evidence). Pooling data at three to 8 months after surgery from four RCTs favoured regional anaesthesia after caesarean section with an OR of 0.46, (95% CI 0.28 to 0.78; 551 participants, moderate-quality evidence). Evidence synthesis of three RCTs investigating continuous infusion with local anaesthetic for the prevention of PPP three to 55 months after iliac crest bone graft harvesting (ICBG) was inconclusive (OR 0.20, 95% CI 0.04 to 1.09; 123 participants, low-quality evidence). However, evidence synthesis of two RCTs also favoured the infusion of intravenous local anaesthetics for the prevention of PPP three to six months after breast cancer surgery with an OR of 0.24 (95% CI 0.08 to 0.69, 97 participants, moderate-quality evidence).

We did not synthesize evidence for the surgical subgroups of limb amputation, hernia repair, cardiac surgery and laparotomy. We could not pool evidence for adverse effects because the included studies did not examine them systematically, and reported them sparsely. Clinical heterogeneity, attrition and sparse outcome data hampered evidence synthesis. High risk of bias from missing data and lack of blinding across a number of included studies reduced our confidence in the findings. Thus results must be interpreted with caution.

Full reference:

Weinstein, E.J. et al.  |Local anaesthetics and regional anaesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children |Cochrane Database of Systematic Reviews 2018 |Issue 4 |Art. No.: CD007105. DOI:10.1002/14651858.CD007105.pub3.

The SR is available in full from the Cochrane Library

Perioperative Quality Improvement Programme (PQIP) publishes first annual report

Royal College of Anaesthetists |Perioperative Quality Improvement Programme | April 2018

The Perioperative Quality Improvement Programme (PQIP) has published its first Annual Report.  The study led by the National Institute of Academic Anaesthesia Health Services Research Centre, on behalf of the Royal College of Anaesthetists (RCoA) and a range of stakeholders, with the aim of improving patient outcomes from major surgery.

Since PQIP’s inception in 2017, over 6,500 patients have been recruited from 79 hospitals across England.  The report outlines PQIP’s five national improvement opportunities for 2018-19.  Among them are: a focus on individualised risk assessment, adherence to enhanced recovery principles,  implementation and adherence to enhanced recovery pathways,  and the optimisation of anaemia, diabetes, and postoperative pain.


Dr Liam Brennan, President of the RCoA, said:  “PQIP demonstrates that while there are pockets of excellence across the NHS, no hospital as yet offers a complete perioperative medicine package for every patient. All hospitals are encouraged to participate in this programme to enhance the delivery of perioperative care across the whole of the NHS .” (Royal College of Anesthetists)

The full press release from the Royal College of Anesthetists can be read here 

More details can be found at PQIP’s website 

The full report can be read here 

Cost-effectiveness research in Anesthesiology

Teja, B. et al. | Cost-Effectiveness Research in Anesthesiology | Anesthesia & Analgesia | published online ahead of print: March 21, 2018 


Perioperative interventions aimed at decreasing costs and improving outcomes have become increasingly popular in recent years. Anesthesiologists are often faced with a choice among different treatment strategies with little data available on the comparative cost-effectiveness.

We performed a systematic review of the English language literature between 1980 and 2014 to identify cost-effectiveness analyses of anesthesiology and perioperative medicine interventions. We excluded interventions related to critical care or pediatric anesthesiology, and articles on interventions not normally ordered or performed by anesthesiologists. Of the more than 5000 cost effectiveness analyses published to date, only 28 were applicable to anesthesiology and perioperative medicine and met inclusion criteria.

Multidisciplinary interventions were the most cost-effective overall; 8 of 8 interventions were “dominant” (improved outcomes, reduced cost) or cost-effective, including accelerated, standardized perioperative recovery pathways, and perioperative delirium prevention bundles.

Intraoperative measures were dominant in 3 of 5 cases, including spinal anesthesia for benign abdominal hysterectomy. With regard to prevention of perioperative infection, methicillin-resistant Staphylococcus aureus (MRSA) decolonization was dominant or cost-effective in 2 of 2 studies.

Three studies assessing various antibiotic prophylaxis regimens had mixed results. Autologous blood donation was not found to be cost-effective in 5 of 7 studies, and intraoperative cell salvage therapy was also not cost-effective in 2 of 2 reports.

Overall, there remains a paucity of cost-effectiveness literature in anesthesiology, particularly relating to intraoperative interventions and multidisciplinary perioperative interventions.

Based on the available studies, multidisciplinary perioperative optimization interventions such as accelerated, standardized perioperative recovery pathways, and perioperative delirium prevention bundles tended to be most cost-effective.

Our review demonstrates that there is a need for more rigorous cost-effective analyses in many areas of anesthesiology and that anesthesiologists should continue to lead collaborative, multidisciplinary efforts in perioperative medicine.

Full abstract available at Anesthesia & Analgesia

Welfare, morale and experiences of anaesthetists in training

A report on the welfare, morale and experiences of anaesthetists in training: the need to listen | The Royal College of Anaesthetists

Between December 2016 and January 2017, The Royal College of Anaesthetists (RCoA) conducted a survey of anaesthetists in training, to better understand their experiences of life on the frontline of UK hospital care. Well over half of all anaesthetists in training responded: 2,312 responses represent 58% of all anaesthetists in training across the UK.

Image source: http://www.rcoa.ac.uk

With over 1,000 free text comments, the survey provides a detailed picture of the issues faced by doctors training as anaesthe tists in today’s NHS.

Alongside these surveys and to better understand the results, throughout 2017 the RCoA held a series of Listening Events with anaesthetists in training across the UK. These events explored the emerging themes from the RCoA Survey. The feedback from over 200 anaesthetists in training who attended these events also informs the recommendations in this report.

Full publication: A report on the welfare, morale and experiences of anaesthetists in training: the need to listen