EDITORIAL

Year : 2022  |  Volume : 12  |  Issue : 2  |  Page : 82-84

Patient safety in obstetric anesthesia

Vimi Rewari, Sana Y Hussain
Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India

Correspondence Address:
Dr. Sana Y Hussain
5^th Floor, Anaesthesia office, Academic Block, Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/JOACC.JOACC_47_22

Figure 1: Swiss cheese model of patient safety in anesthesia Click here to view

1. Following general safety measures – The Joint Commission endorses universal methods of safety and updates it regularly. It has three basic components – pre-procedure verification, site marking, and time out. The surgical safety checklist addresses these basic tenets of safety including correct patient, correct site, and correct procedure.^[8] The anesthesiologist, obstetrician, and nurse discuss specific patient concerns and decide for plan of management.
2. Increasing safety during general anesthesia – Difficult airway and aspiration pneumonia have been implicated as major causes of anesthesia-related maternal deaths.^[9] Despite the development of various advanced airway equipment and better techniques, incidence of failed obstetric intubation remains higher than in the non-obstetric population. A recent review stated an incidence of failed tracheal intubation of 2.6 per 1000 obstetric general anesthetics and associated maternal mortality of 2.3 per 100,000 general anesthesia.^[10]
   
   It is important to have a protocolized and stepwise approach to difficult airway management, focusing more on ways to maintain oxygenation in case of difficult intubation. Difficult airway cart should always be present inside the maternity OT including supraglottic airways, videolaryngoscope, etc. Availability of expert help, simulation training, aspiration prophylaxis, continuous oxygen saturation, and capnography monitoring is of paramount importance to reduce maternal complications related to difficult airway. Safe extubation and provision of postoperative care should be planned.
3. Improving safety in neuraxial anesthesia – Spinal anesthesia is the most common technique used for caesarean sections. Although the incidence of complications like spinal hematoma, high spinal is less, they do occur leading to significant morbidity and mortality.^[7] Low local anesthetic volume with adjuvants, careful epidural drug administration, complying by regional anesthesia guidelines in the presence of coagulopathy or for patients on anticoagulants is important. Hypotension not only affects the mother, but can be deleterious to the fetus as well. Hence, it should be prevented and managed by placing a wedge under the right buttock to prevent supine hypotension, fluid administration, and use of vasopressors like phenylephrine. Post-dural puncture headache is one of the most common complications of spinal block. Use of pencil point needles should be encouraged, patients should be followed postoperatively and if the condition does not respond to conservative methods, treatment options should move to epidural blood patch taking care of strict asepsis. Different alternatives like greater occipital nerve block or transnasal sphenopalatine block may also be tried.^[11],[12]
4. Safety in labor analgesia – Painless labor is every woman's right. Patient safety should be a priority when planning pain relief during labor. Utmost vigilance is required to confirm epidural catheter placement and to rule out intrathecal migration of catheter. Care should be taken to avoid inadvertent dural puncture. Dilute concentrations of local anesthetics should be used and presence of an accompanying person should be ensured during ambulatory epidurals to avoid patient fall. Labor analgesia suite should be well equipped with all resuscitation equipment, monitors, and trained personnel.
5. Avoiding drug errors – Multiple drugs are used during anesthetic care of obstetric patients and errors can occur during drug prescription, preparation, or administration. These include errors like wrong drug administration, inaccurate dosages, and incorrect routes. A review by Kaur et al.^[13] in this issue highlights the literature on drug errors and their consequences in obstetric anesthesia practice. Wrong drug administration in spinal route has been reported leading to significant patient harm. Oxytocin and magnesium sulphate are commonly used drugs in obstetric practice which need close monitoring of vitals and drug dosages. Simple methods like clear prescription, use of color coded labels and double checking by a second person before administration should be followed. Continuous vigilance in all steps of drug handling is necessary to minimize complications due to drug errors.
6. Managing high-risk patients – Proper screening and evaluation of high-risk patients should be done. Recognizing the early warning signs of changing physiological parameters before the occurrence of critical or fatal event is important. To address this, use of Modified Early Obstetric Warning System has been recommended.^[14] High-risk cases include, but are not limited to patients with hypertensive disorders of pregnancy, cardiac diseases, severe systemic illness, placenta accreta, postpartum hemorrhage.
   
   Establishing antenatal anesthesia clinics can help in timely predelivery optimization, patient counselling, education, and formulation of plan in case of operative delivery.
   
   Quick but complete anesthetic evaluation and examination should also be done prior to emergency surgeries. Protocols for managing high-risk patients should be in place, facility for swift arrangement of blood and blood products and a postoperative unit with critical monitoring should be present. Lack of obstetric ICUs leads to inadequate management of high-risk parturients. Efforts should be directed to establish maternal critical care units. In places with inadequate setup, a smooth and sound referral system to higher centres and safe patient transfer should be ensured.
7. Safe hospital system – Hospitals should develop and propagate systems with patient safety at its core. A dedicated maternity OT with well-equipped labor analgesia suite and trained staff is a must. Triage and early management of obstetric emergencies and safe transfer of patients should be arranged. Poorly organized patient transfer can lead to significant morbidity. Hence, the logistics of patient transfer including equipment and personnel for both in-hospital and interhospital transfers should be preplanned. The most important goal during patient shifting is to ensure continuity of care. Policies should be formulated around medication safety, medication orders, avoiding unapproved abbreviations, proper documentation, informed consents, infection control, blood transfusion, and implementation of surgical safety checklist. Regular audits should be done to ensure strict compliance to patient safety policies, increase accountability and to find gaps in safe healthcare delivery with plans and actions to bridge them. Effective ways of adverse event reporting should be done. Based on feedbacks, formulation and dissemination of continuous quality improvement programs should be done. A close interaction between individuals and system provides better patient outcome [Figure 2].
8. Training, teamwork, and communication – Obstetric anesthesia has its own challenges and requires expertize and balanced decision-making. Anesthesiologists should lay focus on obstetric anesthesia and obstetric critical care training for better maternal care. Simulated training should be encouraged for different conditions like difficult airway during general anesthesia for caesarean sections, maternal cardiac arrest, etc.

Figure 2: Interaction between individual and system factors for safer maternal outcomes Click here to view

References

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