Adverse Events and Factors Associated With Potentially Avoidable Use of General Anesthesia in Cesarean Deliveries

Jean Guglielminotti, M.D., Ph.D.; Ruth Landau, M.D.; Guohua Li, M.D., Dr.PH.

Disclosures

Anesthesiology. 2019;130(6):912-922. 

In This Article

Abstract and Introduction

Abstract

Background: Compared with neuraxial anesthesia, general anesthesia for cesarean delivery is associated with increased risk of maternal adverse events. Reducing avoidable general anesthetics for cesarean delivery may improve safety of obstetric anesthesia care. This study examined adverse events, trends, and factors associated with potentially avoidable general anesthetics for cesarean delivery.

Methods: This retrospective study analyzed cesarean delivery cases without a recorded indication for general anesthesia or contraindication to neuraxial anesthesia in New York State hospitals, 2003 to 2014. Adverse events included anesthesia complications (systemic, neuraxial-related, and drug-related), surgical site infection, venous thromboembolism, and the composite of death or cardiac arrest. Anesthesia complications were defined as severe if associated with death, organ failure, or prolonged hospital stay.

Results: During the study period, 466,014 cesarean deliveries without a recorded indication for general anesthesia or contraindication to neuraxial anesthesia were analyzed; 26,431 were completed with general anesthesia (5.7%). The proportion of avoidable general anesthetics decreased from 5.6% in 2003 to 2004 to 4.8% in 2013 to 2014 (14% reduction; P < 0.001). Avoidable general anesthetics were associated with significantly increased risk of anesthesia complications (adjusted odds ratio, 1.6; 95% CI, 1.4 to 1.9), severe complications (adjusted odds ratio, 2.9; 95% CI, 1.6 to 5.2), surgical site infection (adjusted odds ratio, 1.7; 95% CI, 1.5 to 2.1), and venous thromboembolism (adjusted odds ratio, 1.9; 95% CI, 1.3 to 3.0), but not of death or cardiac arrest. Labor neuraxial analgesia rate was one of the most actionable hospital-level factors associated with avoidable general anesthetics. Relative to hospitals with a rate greater than or equal to 75%, the adjusted odds ratio of avoidable general anesthetics increased to 1.3 (95% CI, 1.2 to 1.4), 1.6 (95% CI, 1.5 to 1.7), and 3.2 (95% CI, 3.0 to 3.5) as the rate decreased to 50 to 74.9%, 25 to 49.9%, and less than 25%, respectively.

Conclusions: Compared with neuraxial anesthesia, avoidable general anesthetics are associated with increased risk of adverse maternal outcomes.

Introduction

Compared with neuraxial anesthesia, general anesthesia for cesarean delivery is associated with significantly increased risks of maternal adverse events. These include death, cardiac arrest, anesthesia-related complications, or surgical site infection.[1–4] Increased risk of deep venous thrombosis and pulmonary embolism is also suggested.[5] These higher risks of maternal adverse events were taken into consideration in the 2007 and 2016 American Society of Anesthesiologists Practice Guidelines for Obstetric Anesthesia, hence the statements "neuraxial techniques are preferred to general anesthesia for most cesarean deliveries" and "consider selecting neuraxial techniques in preference to general anesthesia for most cesarean deliveries."[6,7]

Use of general anesthesia for cesarean delivery has consequently markedly decreased during the last decade.[8] This decrease was associated with a parallel decrease in anesthesia-related morbidity.[1,8] The current general anesthesia rate for cesarean delivery is estimated around 5.5%.[9,10] Further reduction in this rate could be a potential area for clinical interventions to improve the safety and quality of obstetric anesthesia care and reduce anesthesia-related morbidity. However, use of general anesthesia for cesarean delivery may be clinically indicated in women with specific preexisting or pregnancy-associated conditions (e.g., severe heart valve stenosis), in high-risk obstetrical situations (e.g., morbidly adherent placenta), or in women with contraindications to neuraxial techniques (e.g., coagulation factor deficit). In these situations, the risk–benefit balance may favor general anesthesia, and the additional risk associated with general anesthesia compared with neuraxial anesthesia can be deemed acceptable. On the contrary, additional risks associated with general anesthesia without a clinical condition precluding use of neuraxial anesthesia could be deemed as unnecessary because exposure to general anesthesia-associated risks is avoidable. To date, most of the research on general anesthesia for cesarean delivery has examined general anesthesia as a whole without individualizing situations in which general anesthesia was not clinically indicated.[8,9,11] Characterizing patient- and hospital-level factors associated with general anesthesia without a recorded clinical indication or characterizing groups of patients and hospitals with potentially avoidable use of general anesthesia use could help identify targets for quality assurance programs.

This study examined risks of maternal adverse events, temporal trends, and patient- and hospital-level risk factors for potentially avoidable general anesthesia in cesarean deliveries.

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