Roderick E, Hoyle J and Yentis SM.
Aim of Study
To establish the level of neurological monitoring after neuraxial anaesthesia in maternity units across the UK, and whether units had protocols in place to manage an abnormally prolonged neuraxial block.
Design and Location
Online survey with open and closed questions sent to lead consultant obstetric anaesthetists in all UK maternity units. Two follow up reminders were sent to non-responders.
Open and closed questions. Some free text boxes. Questions focussed on level and method of neurological monitoring after neuraxial anaesthetisa and presence / absence plus content of any local policies or guidelines.
Method and level of routine post procedure neuraxial monitoring in obstetric patients.
Presence or absence of any local policy / guidelines surrounding
a) post proceudure neuraxial monitoring
b) management of complications (prolonged block).
Responses collated and analyzed with Microsoft Excel® spreadsheet, with 95%CI (Wald method) calculated using GraphPad® software .
59% response rate.
Formal policy for post neuraxial monitoring in place in only 56% of units.
Post procedure routine neurological monitoring carried out for sensory modality in 40% units and motor modality in 55% units.
Amongst the units routinely monitoring there exists a variable method of assessment and documentation:
* Sensory modality assessed – cold 60% , other 52%, touch 16%
* Motor modality assessed – mobilization 62%, bromage 27%, straight leg raise 24%, other 21%
* Frequency of monitoring – every 15 mins 9%, every 30 mins 20%, every 1h 29% every 4h 9%, other 38%
* Duration of monitoring – until discharge from recovery in majority of units (40 – 46%), next most common was until resolution of block (30 – 45%)
* Documentation – 30% in MEWS chart, 22% direct entry in notes, 13% separate chart, other 22%, none 2%
Management of prolonged block:
Protocol in place in only 34% units.
58% no protocol
5% of leads didn’t know if they had one or not!
Recommended action in event of prolonged block:
* Imaging before referral 67% (MRI 69% in hours, 59% OOH. CT 5% in hours, 20% OOH. Remainder did not specify ).
* 31% units recommend neurology referral in first instance. 15% units neurosurgical referral in first instance.
* 87% units reported a neurology referral was required before a request for imaging could be accepted….
Routine / formal monitoring of recovery after neuraxial blockade in obstetric patients in the UK is inconsistent and often absent.
Only a minority of UK departments have a protocol or policy in place to deal with suspected neurological complications after obstetric regional anaesthesia.
National Audit Project 3 (NAP3), the Obstetric Anaesthetists’ Association (OAA) and the Faculty of Pain Medicine (FPM) all clearly state that routine monitoring and policies should be in place, and that obstetric patients should receive the same standards of care post neuraxial anaesthetisa as non-obstetric population. The results of the survey suggest this is not the case.
In 19% of units the first routine formal monitoring of neurological recovery does not occur until next post-operative day. Given that if neurosurgical input is required, operative outcomes are best within 4h and anything >12hr is associated with very poor results the authors raised this as a serious cause for concern.
Some units only use non-objective verbal questions as the method of assessment, the authors highlighted the scope for misinterpretation and error relying solely on this method, particularly in those units with a high number of women with English as a second language.
112/189 units responded – only 59.3%
Survey only, not audit of practice – the reality may be different.
Informal snapshot of practice.
Copy of survey and open question / free text responses not included in the published article.
Manpower and logistical issues of various units not provided / discussed.
Complication rates of units responding not provided.
A number of points were discussed and not all reached consensus during the journal club meeting.
What was fairly unanimously agreed by the audience was that it would be sensible to have a written policy in place for the management of prolonged block – our obstetric anaesthetists are supportive of this in principle. We will compose a draft for review.
I also discussed the current absence of any formal monitoring of block resolution in obstetric recovery. Our midwives on labour ward usually ask women about heavy legs/ to mobilize pre-discharge, but this is not a part of routine formal monitoring and is not documented.
The JC audience agreed it would be sensible to institute a change in practice here. A formal record of mobilization for motor block resolution at discharge from recovery would probably be adequate. Formal documentation of neurological recovery by the anaesthetic team in particular was discussed – this should be in notes that follow the mother. We will need to clarify where this is to be documented.
As we usually use high spinal doses, perhaps review times need special consideration? Also, should we be documenting a trend in recovery rather than a single observation? Or is this necessary only in the presence of an identified abnormality?
There was significant discussion and no consensus regarding the need for any further more formal monitoring of sensory / motor recovery on top of that already provided by the follow up process (an audit proforma completed the next post-operative day). The practicalities and work load of such a change in practice were a key concern, particularly out of hours… especially as this is all in the context of few / rare complications.
Summary by Dr E Hyde. Presented at Journal Club Meeting 01 November 2018.