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

Results

During the study period, 864,058 cesarean delivery discharges were identified; of them, 60,502 (7.00%) were completed with general anesthesia (Figure 1). After excluding 398,044 cases with accepted indications for general anesthesia, the final study sample consisted of 466,014 cesarean deliveries, including 26,431 cases (5.67%) completed with general anesthesia without a recorded clinical indication.

Figure 1.

Flowchart of the study. aThe hospital annual proportion of women who received neuraxial techniques during labor and vaginal deliveries and the temporal trends in the utilization of neuraxial techniques during labor and vaginal deliveries were calculated in these discharges. bDoes not round up.

Comparing the excluded cases (those with a clinical indication for general anesthesia) with cases without a recorded clinical indication, the rate of general anesthesia was higher in discharges with a clinical indication for general anesthesia (8.56% vs. 5.67%; P < 0.001). The rates of adverse events in discharges with a clinical indication for general anesthesia were also significantly higher than in discharges without a clinical indication for general anesthesia (Table 2). General anesthesia cases without an indication accounted for 43.69% of all general anesthesia cases (with and without and indication).

Risk of Serious Adverse Events Associated With General Anesthesia

The risk of serious adverse events associated with general anesthesia without a recorded clinical indication before and after adjustment is presented in Table 3. After adjustment, general anesthesia was associated with a significant increase in the risk of anesthesia-related complications (overall and severe), surgical site infection, and venous thromboembolic events. It was not associated with an increased risk of the composite outcome of death or cardiac arrest. Results were unchanged in the two sensitivity analyses examining various cutoffs values for the comorbidity index for obstetric patients and the Charlson comorbidity index (Supplemental Digital Content Table 7, http://links.lww.com/ALN/B862).

Temporal Trends in the use of General Anesthesia

The rate of general anesthesia for cesarean delivery without a recorded clinical indication decreased from 5.6% in 2003 to 2004 to 4.8% in 2013 to 2014 (14% decrease; 95% CI, 10 to 18; P < 0.001). A statistically significant decrease was observed in all subgroup analyses according to patient and hospital characteristics except for high-delivery-volume hospitals and minority patients (Supplemental Digital Content Table 8, http://links.lww.com/ALN/B862). In hospitals with more than 2,500 annual deliveries, no change in the utilization of general anesthesia without a recorded clinical indication was observed. In minority women, the utilization of general anesthesia increased from 5.4% in 2003 to 2004 to 6.0% in 2013 to 2014 (11% increase; 95% CI, 4 to 18; P < 0.001).

During the study period, the utilization of neuraxial technique during labor and vaginal deliveries increased significantly across racial groups and hospitals (Supplemental Digital Content Table 9, http://links.lww.com/ALN/B862).

Risk Factors for General Anesthesia use

The univariable comparisons of cesarean deliveries with general or neuraxial anesthesia are presented in Table 4. In the final multilevel model (Table 5), the following patient-level factors were associated with a significantly increased likelihood of potentially avoidable general anesthesia: age less than 19 yr, racial or ethnic minority, Medicaid or Medicare beneficiaries, preexisting or pregnancy-associated conditions, nonelective admission, and admission during weekend. Hospital-level factors associated with a significantly increased odds of general anesthesia were the following: teaching hospital, neonatal level-of-care designation 1 or 3, lower use of neuraxial techniques during labor and vaginal deliveries, higher annual volume of deliveries, and higher proportion of women with a comorbidity index greater than 2. Relative to hospitals with labor neuraxial analgesia rate greater than or equal to 75%, the adjusted odds ratios of potentially avoidable general anesthesia increased to 1.35, 1.60, and 3.24 as the labor neuraxial analgesia rate decreased to 50 to 74.9%, 25 to 49.9%, and less than 25%, respectively.

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