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CEMACH 2007 - Recommendations on use of ultrasound device in case with abnormal anatomy
- GIRISH SADHU (24 January 2008)
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response to Dr Melarkode
- Griselda M Cooper, John McClure (24 January 2008)
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Saving Mother's Lives
- Krishnan Melarkode (22 January 2008)
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GIRISH SADHU, Specialist Registrar in Anaesthetics St Mary's Hospital, Manchester
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The cemach recommendations have always been invaluable for anaesthetists to learn and change their practise to avoid or manage anaesthetic complications .It is unfortunate that we have to learn from failures after a serious event has occurred. The cemach 2007 recommendations for the 6 direct anaesthetic deaths have been clear and precise for all but one case. In the case of Anatomical compromise, a woman with pectus excavatum had a failed right internal jugular cannulation and then had a subclavian vein cannulated at the second attempt. Shortly after, she had a cardiac arrest due to haemothorax secondary to trauma of the proximal part of the intrathoracic internal jugular. The discussion suggests that it is unlikely that ultrasound guidance would have avoided this complication. It is unclear if ultrasound was used for cannulating the internal jugular vein in the first place. If it was not then there is a strong argument in favour of using ultrasound device as it may have resulted in a successful cannulation of internal jugular vein .This would have avoided the subsequent suclavian vein cannulation and its complications where ultrasound has minimal benefits [1]. The benefit of using ultrasound especially in cases with abnormal anatomy is well known. We believe that the NICE guidelines of 2002[2] on use of ultrasound in central venous cannulations should be adopted to the obstetric group of patients and units should have a dedicated ultrasound device for this purpose. [1] Daniel Hind et al. Ultrasonic locating devices for central venous cannulation: meta-analysis. BMJ 2003;327:361 [2] National Institute for Clinical Excellence. Guidance on the use of ultrasound locating devices for placing central venous catheters. NICE Technical report number 49; September 2002. Conflict of Interest:None declared |
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Griselda M Cooper , John McClure
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We thank Dr Melarkode for his interest in the recent chapter from Saving Mothers’ Lives that was reprinted in the British Journal of Anaesthesia. We are largely in agreement with his comments, but to take them individually. 1. The management of obese women is challenging and is likely to become even more so as the prevalence continues to increase. One of our aims was to increase awareness of the problems before arriving on the labour ward to allow forward planning. The suggestion of the anaesthetist attending the midwifery handover is a positive one and would improve team working and communication. Nevertheless, there is always the possibility that the anaesthetist is in theatre and unable to attend and the anaesthetists must communicate with each other. 2. The benefit of good communication about high risk cases is self evident. It takes long persistence to make it happen consistently and has continually reinforced at a local level until it becomes routine. 3. The use of pre-mixed local anaesthetic with fentanyl is preferable to it being made up by the anaesthetist because of the issues of errors and sterility. However, we commented that it was not clear why 500 ml bags of such a solution were being used when the potential for confusion with intravenous fluids is obvious. In our units 100 ml bags are used. Colour coding is one useful suggestion but misapplication would still be possible. Although the improvements in anaesthetic safety have been huge during the history of the Confidential enquiries into maternal deaths in the UK, achieving a zero occurrence has so far been eluded. Every life lost has wide reaching consequences for the families left behind. We hope that widespread communication of the findings will make for a safer future. Griselda Cooper and John McClure Conflict of Interest:None declared |
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Krishnan Melarkode, Specialist Registrar Addenbrooke's Hospital, Cambridge
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Editor – I wish to respond to the special article by Drs. Cooper and McClure (1) on the Confidential Enquiries into Maternal and Child Health (CEMACH) triennium report 2003-05. I would like to add further regarding obese pregnant patients, use of premixed 500 ml bags of 0.1% bupivacaine and 2 mcg/ml fentanyl for epidural analgesia and practical problems that occur out of hours. I fully agree to the comments by the authors on the anaesthetic management of obese pregnant patients. There is definitely a need for a protocol driven approach for their management. Besides this, it is important to change our practice of handovers in the obstetric unit. Individual handovers amongst anaesthetists, obstetricians and midwives should no longer be continued. Instead, a common handover between doctors and midwives would be ideal. This will enable all of us to highlight problems at the handover stage itself and issues such as ease of venous cannulation, epidural analgesia, airway problems, review of blood investigations, obstetric and anaesthetic plan can be discussed since problems usually seem to occur out of hours and during emergency periods unlike during routine hours when a dedicated consultant anaesthetist is present in the obstetric unit. The midwives also need to contribute actively in the management of high risk cases. Many a times, anaesthetists are involved in the management of high risk cases at the last minute when there is chaos in the labour ward. When such patients are admitted to the labour ward, on most occasions the midwives do not alert the trainee anaesthetists on call in the unit and anaesthetic related issues go unnoticed. On most occasions, the midwives also do not seem to realise the importance of pre- anaesthetic assessments. Patients might be heading towards an operative intervention, but the anaesthetists are alerted only when the obstetric registrar is consenting the patient. I fail to understand why should there be a delay till such a stage. Instead, it would be better in the interest of the patient that the anaesthetist on call is informed earlier. This would help in identifying anaesthetic related problems much earlier and if required, the consultant anaesthetist on call could be alerted and appropriate advice taken. This might prevent catastrophic events when the patient is eventually taken to theatre. Also, I feel it is unsafe to continue the practice of using pre mixed 500 ml bags of bupivacaine and fentanyl for labour analgesia. These bags look similar to other intravenous fluids and it is only on close examination that the words “for epidural use only” can be seen. It is very easy for anyone to miss this warning in an emergency scenario. There is no need for 500 ml bags as most of the solution is thrown away. It would be sensible that manufacturers prepare bags of less volume. Also, it would be ideal for these bags to be colour coded so that they can be distinguished from other intravenous fluids or an entirely different type of giving set produced which cannot be compatible with normal intravenous fluid bags. I would like a feedback on what do the authors feel regarding these issues to ensure a safe anaesthetic practice especially with regards to obstetric anaesthesia. Reference: 1. Cooper GM, McClure JH. Anaesthesia chapter from Saving Mothers’ Lives; reviewing maternal deaths to make pregnancy safer. Br J Anaesth 2008; 100 (1): 17-22. Conflict of Interest:None declared |
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