Abstract

Anesthetic management of patients with mitochondrial disease requires an in-depth knowledge and understanding of its pathophysiology to ensure the safe conduct of anesthesia. Our case report illustrates the importance of careful anesthetic planning and execution for a four-year-old undergoing full mouth rehabilitation. It is essential to avoid factors that increase metabolic stress, such as prolonged fasting, hypoglycemia, postoperative nausea, hypothermia, acidosis, hypovolemia, and ischemic or hypoxic events. Balanced general anesthesia was achieved by using incremental doses of anesthetics, narcotics, and muscle relaxants, all selected to minimize any potential impact on mitochondrial function. The perioperative period was uneventful.

Introduction

Children with mitochondrial disease exhibit unique anesthetic challenges during the perioperative period, necessitating careful monitoring with judicious selection and use of anesthetics. Mitochondrial dysfunction impairs its ability to support oxidative phosphorylation and adenosine triphosphate (ATP) synthesis [1]. Organs with high metabolic demands are principally reliant on mitochondrial function and can exhibit symptoms of dysfunction under stressful conditions [1]. Consequently, the central nervous, cardiovascular, metabolic, and neuromuscular systems are affected [2]. We report a successful anesthetic management of a child with oxidative phosphorylation deficiency type 3 who underwent full mouth rehabilitation.

Case Presentation

A four-year-old child, weighing 11.8 kg, with a history of delayed developmental milestones since early infancy, bilateral sensorineural deafness, hypotonia, and frailness of limbs, was scheduled for full mouth rehabilitation under general anesthesia (GA). At three months of age, the evaluation revealed elevated serum levels of alanine, glutamine, lactate, and ketones. The genetic and metabolic tests confirmed combined oxidative phosphorylation type 3. The child had no history of seizures, lethargy, vomiting, or recurrent respiratory tract infections. There was also a history of sibling death at 75 days of age following fever and seizures. The child underwent bilateral cochlear implantation at one and two years of age under GA, which was uneventful. Additionally, the child had a history of recent (eight months prior) cardiac failure with an ejection fraction (EF) of 28% following respiratory infection, which warranted intensive care unit (ICU) admission and medical management.

During the current admission, routine preoperative blood investigations were normal (Table 1).

An echocardiogram showed left ventricular hypertrophy, grade III diastolic dysfunction, good biventricular function, and an EF of 76%. The patient was on T. Carvedilol 3.125 mg, T. Pyridoxine 50 mg, T. Co-enzyme Q 25 mg, and Syp Levocarnitine 2.5 mg, all of which were continued on the day of surgery.

On examination, the child was alert, with a heart rate of 107 beats per minute, blood pressure of 90/60 mmHg, oxygen saturation (SpO2) of 99%, and a respiratory rate of 18 breaths per minute. The motor power was 4/5 in upper limbs and 3/5 in lower limbs, with good head control and no signs of cardiac failure. The patient was accepted under the American Society of Anesthesiologists – Physical Status (ASA – PS) III under GA. The established fasting guidelines for solid foods were followed precisely, and the child was allowed to take small sips of water up until one hour before the surgical procedure.

Pre-induction monitors included ECG, non-invasive blood pressure (NIBP), SpO2, and temperature. The intravenous line was secured following induction of anesthesia with sevoflurane in oxygen at 6 L/minute. The airway was secured via the nasal route using a flexometallic tube size 4 after intravenous Fentanyl 10 mcgs, Propofol 5 mg, and Atracurium 3 mg. The maintenance of anesthesia was done with air, oxygen, and Sevoflurane at a minimum alveolar concentration (MAC) of 1 and FiO2 (fraction of inspired oxygen) of 0.4. Dextrose 5% at 30 mL/hour was infused with periodic monitoring of blood sugar values. Saline-soaked throat pack was kept in situ before the start of surgery. In addition to standard ASA monitoring, intra-arterial blood pressure monitoring was instituted given the history of cardiac failure and for monitoring metabolic parameters with arterial blood gas analysis (Table 2). Multimodal analgesia was provided with intravenous Fentanyl and Paracetamol. The surgical procedure lasted for 2 hours 40 minutes with minimal blood loss.

At the end of the procedure, neuromuscular blockade was reversed with intravenous neostigmine 0.6 mg and glycopyrrolate 0.2 mg, and after adequate ventilatory efforts and wakefulness, the child was extubated. Oral intake was restarted two hours post-surgery, and the child was subsequently discharged from the Post-Anesthesia Care Unit (PACU).

Discussion

Mitochondrial disorders have an incidence of 1 in 4 to 5,000 live births and present as multisystem disorders, affecting the central nervous, cardiovascular, muscular, and gastrointestinal systems with varying magnitudes of dysfunction [1,3]. Patients with this condition often require anesthesia for diagnostic purposes and surgical correction of skeletal and neurological deformities. These patients are unable to adapt to stressful conditions demanding high energy requirements resulting in respiratory failure, cardiac depression, conduction abnormalities, seizures, and metabolic encephalopathy [4,5]. Although our child had uneventful general anesthesia for cochlear implant surgery twice, there was a history of cardiac failure secondary to respiratory infection in the recent past, highlighting the unpredictable response to stressful situations.

Our main goal during the perioperative period was to minimize energy demands on the mitochondrial chain, which was achieved by administrating titrated doses of anesthetic agents. Additionally, to mitigate risks associated with prolonged fasting a liberal intake of fluids was permitted until one hour before induction of anesthesia. Excessive crying due to hunger, hypoglycemia, hypovolemia-related sympathetic stimulation, and anxiety leads to high energy requirements paving the way for alternate substrates (fatty acids) for ATP production. However, in patients on ketogenic diets for seizure management, it is imperative to avoid glucose-containing intravenous fluids. Such patients often have difficulty with processing large quantities of glucose and may develop hyperglycemia, if glucose administration exceeds normal maintenance levels [1,6]. Since our child was not on a ketogenic diet, we administered a dextrose-containing solution for intraoperative maintenance therapy with frequent blood glucose monitoring.

Metabolic encephalopathy develops secondary to hypothermia, shivering, hyperthermia, and hypoglycemia. So, we ensured normothermia by monitoring temperature throughout surgery along with convective warmers. All volatile anesthetics suppress oxidative phosphorylation, particularly at complex I and coenzyme Q, animal studies have shown mitochondrial toxicity of volatile anesthetics follows the order: halothane > isoflurane > sevoflurane [7]. In contrast to intravenous anesthetics, which rely on energy-dependent metabolic processes for elimination, volatile anesthetics are predominantly exhaled, which is advantageous. So, we opted for sevoflurane for both induction and maintenance of anesthesia which also has the least metabolism in vivo compared to other agents with cardio stability [1,8].

Propofol inhibits mitochondrial function at multiple levels by affecting complex I, and complex IV, the transport of long-chain acylcarnitine esters and fatty acid transport [1,9]. This can make patients with mitochondrial defects particularly susceptible to developing lactic acidosis, rhabdomyolysis, and lipidemia, leading to cardiovascular collapse and death [1,10]. Continuous propofol infusion specifically inhibits the transport of long-chain acylcarnitine esters, resulting in these life-threatening complications rather than a single bolus dose. Hence, we used a lower dose of propofol along with sevoflurane before intubation. We selected atracurium to avoid the risk of residual neuromuscular blockade that could exacerbate respiratory acidosis in a child with preexisting motor weakness and hypotonia, because of its organ-independent metabolism.

Narcotics have minimal impact on mitochondrial function, but morphine should be used with caution given its profound respiratory depressant effects in patients with preexisting myopathy and compromised respiratory function [1,11]. The effect of anesthetics in mitochondrial disorders is not entirely due to the direct toxic effects on the respiratory chain. It is a summative effect related to the intensity of multisystem dysfunction, duration, and type of surgery evoking stress response. The uneventful perioperative course in our child can be attributed to meticulous planning, judicious of anesthetic agents, and minor surgical procedures all of which avoided metabolic decompensation.

Conclusions

From an anesthesiologist’s perspective, the primary focus is to maintain the metabolic physiology without major stress on the mitochondrial chain. This is achieved by careful perioperative planning and the use of anesthetics tailored to the individual patient and surgery-centric priorities. Vigilant monitoring of both physiological and metabolic parameters coupled with appropriate choice and dosing of anesthetic agents will aid in safe perioperative management.

References

1. Niezgoda J, Morgan PG: Anesthetic considerations in patients with mitochondrial defects. Paediatr Anaesth. 2013, 23:785-93. 10.1111/pan.12158
2. Footitt EJ, Sinha MD, Raiman JA, Dhawan A, Moganasundram S, Champion MP: Mitochondrial disorders and general anaesthesia: a case series and review. Br J Anaesth. 2008, 100:436-41. 10.1093/bja/aen014
3. Schaefer AM, Taylor RW, Turnbull DM, Chinnery PF: The epidemiology of mitochondrial disorders–past, present and future. Biochim Biophys Acta. 2004, 1659:115-20. 10.1016/j.bbabio.2004.09.005
4. Miró O, Barrientos A, Alonso JR, Casademont J, Jarreta D, Urbano-Márquez A, Cardellach F: Effects of general anaesthetic procedures on mitochondrial function of human skeletal muscle. Eur J Clin Pharmacol. 1999, 55:35-41. 10.1007/s002280050589
5. Hsieh VC, Krane EJ, Morgan PG: Mitochondrial disease and anesthesia. J Inborn Errors Metab Screen. 2017, 5:232640981770777. 10.1177/2326409817707770
6. Parikh S, Saneto R, Falk MJ, Anselm I, Cohen BH, Haas R, Medicine Society TM: A modern approach to the treatment of mitochondrial disease. Curr Treat Options Neurol. 2009, 11:414-30. 10.1007/s11940-009-0046-0
7. Fedorov A, Lehto A, Klein J: Inhibition of mitochondrial respiration by general anesthetic drugs. Naunyn Schmiedebergs Arch Pharmacol. 2023, 396:375-81. 10.1007/s00210-022-02338-9
8. Morgan PG, Hoppel CL, Sedensky MM: Mitochondrial defects and anesthetic sensitivity. Anesthesiology. 2002, 96:1268-70. 10.1097/00000542-200205000-00036
9. Withington DE, Decell MK, Al Ayed T: A case of propofol toxicity: further evidence for a causal mechanism. Paediatr Anaesth. 2004, 14:505-8. 10.1111/j.1460-9592.2004.01299.x
10. Wolf A, Weir P, Segar P, Stone J, Shield J: Impaired fatty acid oxidation in propofol infusion syndrome. Lancet. 2001, 357:606-7. 10.1016/S0140-6736(00)04064-2
11. Muravchick S, Levy RJ: Clinical implications of mitochondrial dysfunction. Anesthesiology. 2006, 105:819-37. 10.1097/00000542-200610000-00029

Abstract

One-lung ventilation presents unique challenges for the anesthesiologist. We present a case where the patient underwent robotic bronchoscopy to mark the lesion locations before bilateral wedge resections and a unilateral lobectomy. An 8.5 mm endotracheal tube was used to facilitate the robotic bronchoscopy. Subsequently, an EZ-Blocker double-sided bronchial blocker was placed to selectively isolate each lung during different phases of the procedure. This clinical situation required specific equipment, rather than a traditional double-lumen tube or a one-sided bronchial blocker, to efficiently manage the patient.

Introduction

One-lung ventilation can pose unique challenges for the anesthesiologist. Successful one-lung ventilation techniques often require careful planning and a thorough understanding of the different uses of airway equipment. The decision to use a double-lumen tube versus a bronchial blocker is usually based on the preference of the surgeon or anesthesiologist; however, certain clinical situations may favor one over the other. When reliable separation of ventilation is needed, a double-lumen tube is often preferred [1]; however, as discussed in this case, a bronchial blocker may be the superior choice.

An important consideration when using bronchial blockers involves ensuring the proper positioning relative to the right upper lobe bronchus. The distance between the start of the right main bronchus and the right upper lobe bronchus may be very short, potentially leading to a slow or incomplete collapse of the right upper lobe. This anatomical relationship increases the likelihood of bronchial blockers becoming dislodged [2]. On the other hand, double-lumen tubes have their own inherent drawbacks, such as difficulty in placement, as well as the risk of laryngeal injury and sore throat [3].

A significant advantage of using bronchial blockers is that the patient may remain intubated after surgery, whereas a double-lumen tube often needs to be exchanged for a traditional endotracheal tube [4]. While double-lumen tubes are more commonly used, understanding the clinical use of bronchial blockers is essential, as they may offer advantages in certain unique clinical situations.

Written informed consent was obtained from the patient for the publication of this report. This report adheres to the case report (CARE) guidelines.

Case Presentation

The patient was a 72-year-old female who presented for an elective robotic bronchoscopy with tumor localization, followed by potential bilateral pulmonary wedge resections. Her medical history included a right upper lobe mass and ground-glass nodules in the left and right lower lobes, identified on chest X-ray (Figure 1). She had never smoked and had no known allergies. Her vital signs were normal, with an oxygen saturation of 95% on room air, a temperature of 97.9 °F, a respiratory rate of 16 breaths per minute, blood pressure of 123/59 mmHg, and a pulse of 77 beats per minute. Over a 24-hour period, her intake was 1000 mL, and her output, including chest tube drainage and urine, totaled 1560 mL. The patient data are shown in Table 1.

Figure 1: Right upper lobe mass identified on chest X-ray

The arrow shows the right upper lobe mass. Ground glass nodules in the left and right lower lobes are better visualized on CT, which is unavailable

CT: computed tomography

The physical examination revealed that the patient was alert and oriented. Her head and eyes were atraumatic, indicating no complications that could affect anesthesia or the surgical procedure. Her ears, nose, and throat (ENT) examination showed moist mucosal membranes, and she exhibited no respiratory distress, with symmetric chest expansion. Her extremities had a full range of motion, her neurological status was intact, and her psychiatric affect was normal. She denied experiencing fever, chills, or sweats, and her breathing was stable.

Pathological examination confirmed adenocarcinoma in situ in both the left lower lobe and right lower lobe, and invasive acinar adenocarcinoma in the right upper lobe. The right upper lobe tumor measured 4.8 x 2.7 x 2.6 cm and was well-differentiated. There was evidence of visceral pleural invasion, and the bronchial margin was positive for adenocarcinoma. Metastatic carcinoma was found in one out of three regional lymph nodes.

Preoperative laboratory results and pulmonary function tests were within normal limits. Upon entry into the operating room, the patient’s identity was confirmed. Standard monitors were applied, and general anesthesia was induced with fentanyl, lidocaine, propofol, and rocuronium. An 8.5 endotracheal tube was used per the pulmonologist’s request to facilitate the robotic bronchoscopy. After induction, a left radial arterial line and a 16-gauge IV were placed for intraoperative monitoring.

With the patient supine, the pulmonologist performed a robotic bronchoscopy, using dye to mark the locations of the nodules in the left lower lobe and the right lower lobe (Figure 2). Following the bronchoscopy, an EZ-Blocker double-sided bronchial blocker (Figure 3) was placed to isolate each lung, with proper placement confirmed via bronchoscopy. She was positioned in the right lateral decubitus position for the left lung procedure. The left lung was first isolated by inflating the left balloon of the bronchial blocker, which the surgeon confirmed. A wedge resection of the left lower lobe was performed and sent for frozen and gross pathological evaluation. After analyzing the frozen sample, the decision was made to proceed with the right lung. The left lung was re-inflated, and the patient was returned to the supine position before isolating the right lung. She was then placed in the left lateral decubitus position, the bronchial blocker was repositioned, and the right balloon was inflated. A right lower lobe wedge resection and a right upper lobectomy were performed. At the end of the procedure, normal ventilation was resumed, and an arterial blood gas analysis showed unremarkable results before extubation.

Figure 2: Robotic bronchoscopy to mark the locations of the nodules in the left lower lobe and the right lower lobe

Figure 3: EZ-Blocker Endobronchial Blocker*

*[5]

Following the surgery, the patient was admitted to the hospital, where she developed an air leak from her chest tube, likely related to the surgical procedure. Small air leaks are common after lung surgery and typically resolve over time, as was the case here. The patient was treated accordingly and discharged on postoperative day 12 following the removal of her chest tubes.

Discussion

This case was selected for our report because it was the first case of a combined robotic bronchoscopy with bilateral thoracotomy performed in Nevada, highlighting the rarity of bilateral lung resections during the same anesthetic procedure. Over the past decade, numerous case reports and retrospective studies have shown the viability of single-stage bilateral lung resections. One study showed that single-stage bilateral pulmonary resection is a safe procedure, particularly when limited to wedge resection on at least one side [6]. Although patients who underwent single-stage bilateral pulmonary resection experienced longer mean operative time and duration of chest tube drainage, this study of 19 patients revealed no postoperative complications and no difference in postoperative hospital stay compared to those undergoing unilateral procedures. However, another study found that single-stage bilateral video-assisted thoracoscopic surgery (VATS) led to a higher postoperative leukocyte count and required longer postoperative ICU and hospital stays than the two-stage bilateral VATS approach [7]. Nonetheless, similar rates of postoperative complications, mechanical ventilation, and chest tube duration were observed between the two groups. Despite conflicting reports, there is a consensus that single-stage bilateral pulmonary resection is safe and effective provided patients undergo rigorous preoperative assessment [6-8].

Understanding the patient’s readiness for undergoing bilateral lung resection based on pulmonary function tests is crucial. Current guidelines use the predicted postoperative forced expiratory volume in one second (PPO FEV1) and the predicted postoperative diffusing capacity for carbon monoxide (PPO Dlco) to determine the appropriateness for surgery [7]. If both values exceed 60%, no additional tests are required. However, if either test result falls between 30 and 60%, an exercise test should be performed. If this test is negative, or if either value is less than 30%, a cardiopulmonary exercise test should be performed. If the cardiopulmonary exercise test shows a peak oxygen consumption of less than 35%, the patient is likely at high risk for mortality during the procedure. Given that this patient underwent resection of multiple lobes, it was important to calculate the patient’s PPO FEV1 and PPO Dlco from their preoperative pulmonary function tests to ensure that the procedure could be completed safely.

Besides evaluating the patient’s pulmonary function tests, the indications for performing a single-stage bilateral pulmonary resection over the traditional two-stage approach must be considered. Firstly, if there are concerns about the patient’s ability to tolerate multiple procedures, a single-stage approach would be favored. In the two-stage approach, the second operation is generally scheduled one to three months after the initial operation, but complications during this period may disrupt the postoperative course and delay further treatment. Second, for a single-stage approach to be feasible, suspicious nodules should be located peripherally on at least one side, enabling wedge or sublobar resections that preserve adequate pulmonary function [8]. Third, it is ideal that the patient is free of comorbidities that increase the risk of peri- or postoperative complications, such as diabetes mellitus, end-stage renal disease on dialysis, interstitial lung disease, or severe chronic obstructive pulmonary disease (COPD) [8].

Furthermore, Matsubara et al. proposed the following criteria for selecting patients to undergo a single-stage bilateral pulmonary resection for bilateral metastatic lung tumors: (1) the patient must be at low risk for pulmonary resection; (2) the primary lesion must be controlled, (3) no other metastatic disease (if present, it can be managed by surgery or other treatments, and modalities); and (4) all pulmonary lesions are resectable by wedge resection on at least one side [9].

Our patient fulfilled multiple criteria favoring single-stage bilateral pulmonary resection. The patient was a healthy 72-year-old female with no significant comorbidities such as diabetes mellitus, end-stage renal disease, or lung disease, aside from the bilateral lesions, which could increase the risk of peri- or postoperative complications. Preoperative laboratory results and pulmonary function tests were within normal limits, indicating the patient’s ability to tolerate bilateral pulmonary resection. According to Wang et al., this patient would be considered “low-risk” due to her health status and normal preoperative hemoglobin levels [10]. CT imaging and robotic bronchoscopy confirmed that the pulmonary lesions were located peripherally, allowing for wedge resection on one side. With no evidence of metastatic disease and the intention of curative treatment, the patient was a strong candidate for single-stage bilateral pulmonary resection.

Important anesthetic considerations included careful selection of appropriate airway equipment in consultation with the pulmonologist and surgeon. The airway equipment needed to facilitate bronchoscopy at the beginning of the case and allow for the isolation of either lung, depending on the stage of the thoracoscopic surgery. While double-lumen tubes are commonly used for thoracoscopic procedures and allow for lung isolation, they were not feasible in this case because robotic bronchoscopy would have been difficult through a double-lumen tube [11]. Additionally, the use of a double-sided bronchial blocker over traditional bronchial blockers made lung isolation more convenient. Unlike traditional bronchial blockers, which require repositioning to isolate the opposite lung, the double-sided bronchial blocker has a separate balloon for each bronchus, allowing for an easy transition between lungs during the procedure.

Conclusions

In this case, a bronchial blocker proved superior to a double-lumen tube for a procedure involving robotic bronchoscopy and bilateral thoracotomy. The precise lung isolation provided by the bronchial blocker enabled a safe and efficient pulmonary resection. Comprehensive pulmonary function tests and CT imaging confirmed the patient’s suitability for a single-stage procedure, helping to avoid complications associated with the two-stage approach.

This case underscores the importance of selecting optimal airway management techniques in complex thoracic surgeries to enhance patient outcomes. We emphasize the usefulness of a double-sided bronchial blocker in single-stage procedures, allowing for bronchoscopy at the beginning of the operation and subsequent independent lung isolation without the need to re-instrument the airway by placing a double-lumen tube. This approach reinforces the viability and safety of single-stage bilateral pulmonary resections, particularly in well-selected patients. Despite some conflicting evidence in the literature, the utility of single-stage procedures in such patients remains advantageous. The combination of robotic bronchoscopy with a double-sided bronchial blocker highlights advancements in airway management during thoracic surgery, offering valuable insights into optimizing procedures for complex pulmonary resections.

References

1. Cohen E: Current practice issues in thoracic anesthesia. Anesth Analg. 2021, 133:1520-31. 10.1213/ANE.0000000000005707
2. Liu Z, Zhao L, Zhu Y, Bao L, Jia QQ, Yang XC, Liang SJ: The efficacy and adverse effects of the Uniblocker and left-side double-lumen tube for one-lung ventilation under the guidance of chest CT. Exp Ther Med. 2020, 19:2751-6. 10.3892/etm.2020.8492
3. Szegedi LL, Licker M: Lung isolation versus lung separation: double-lumen tubes. Anesthesia in Thoracic Surgery, Changes of Paradigms. Granell Gil M, Şentürk M (ed): Springer, Cham, Switzerland; 2020. 4:51-63. 10.1007/978-3-030-28528-9_4
4. Neustein SM: The use of bronchial blockers for providing one-lung ventilation. J Cardiothorac Vasc Anesth. 2009, 23:860-8. 10.1053/j.jvca.2009.05.014
5. Teleflex: EZ-Blocker Endobronchial Blocker. (2024). Accessed: October 3, 2024: https://www.teleflex.com/usa/en/product-areas/anesthesia/airway-management/endobronchial-blockers/index.html.
6. Iida T, Kohno T, Fujimori S, Ikeda T, Suzuki S: Single-stage video-assisted thoracoscopic surgery: Right upper lobectomy and left lower lobectomy for synchronous bilateral lung cancers. Int J Surg Case Rep. 2017, 33:55-7. 10.1016/j.ijscr.2017.02.035
7. Lan L, Qiu Y, Zhang C, Ma T, Cen Y: Comparison of single-stage and two-stage bilateral video-assisted thoracic surgery. J Int Med Res. 2020, 48:300060520967558. 10.1177/0300060520967558
8. Brunelli A, Kim AW, Berger KI, Addrizzo-Harris DJ: Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013, 143:e166S-90S. 10.1378/chest.12-2395
9. Matsubara T, Toyokawa G, Kinoshita F, et al.: Safety of simultaneous bilateral pulmonary resection for metastatic lung tumors. Anticancer Res. 2018, 38:1715-9. 10.21873/anticanres.12406
10. Wang Z, Zhang X, Sun X, Liu J: One-stage VATS surgery for synchronous bilateral lung lesion: a safe and feasible procedure. J Cardiothorac Surg. 2023, 18:126. 10.1186/s13019-023-02215-3
11. Reisenauer J, Simoff MJ, Pritchett MA, et al.: Ion: technology and techniques for shape-sensing robotic-assisted bronchoscopy. Ann Thorac Surg. 2022, 113:308-15. 10.1016/j.athoracsur.2021.06.086

Background

Variability in obstetric anaesthetia practice and care delivered within the UK is under-explored. The ObsQoR study explored structures, processes, and outcomes of obstetric anaesthesia in 107 hospitals within the UK’s National Health Service, and the results of the hospital-level survey are reported here.

Methods

Hospitals were surveyed to assess obstetric anaesthesia provision, practice, and care delivery. Questions explored staffing, service provision and training, facilities present, clinical practices, outcome measurement, and key indicators of quality in obstetric anaesthesia.

Results

We received responses from 106 participating hospitals, representing 69% of all UK obstetric units. One hundred (94%) hospitals had a dedicated consultant obstetric anaesthetist within working hours, with 27 (25%) of hospitals’ duty anaesthetists having additional clinical responsibilities outside the care of obstetric patients outside of working hours. Around 102 hospitals (98%) offer multidisciplinary team training, of which 95 (93%) use a simulation-based method. Dedicated high-risk antenatal clinics were present in 50 (47%) hospitals. The majority of hospitals provide written patient information in multiple languages for discussing obstetric anaesthesia options (77, 82%). Seventy-three hospitals (69%) use point-of-care testing to estimate haemoglobin concentration. Labour epidural analgesia is most commonly delivered via patient-controlled epidural analgesia in 80 (76%) hospitals, and the incidence of post-dural puncture headaches was recorded by 80 (76%) hospitals.

Conclusions

These results demonstrate variation in the provision of staffing, facilities, clinical practices, and outcome measurements across the UK. To deliver safe and equitable care across the UK, there needs to be standardisation of anaesthetic peripartum care based on national recommendations and the benchmarking and measurement of appropriate markers of quality.