… But Other Perioperative Complications Rise
There has been a 25% fall in anesthesia-related complications for women undergoing cesarean deliveries, with mortality rates falling as well, a comprehensive study of New York state hospital records has found. The bad news: Nonanesthetic perioperative complications jumped nearly 50%.
The study (Anesthesiology2015;123:1013-1023) examined 785,854 cesarean deliveries in hospitals across New York state from 2003 to 2012. The fall in anesthesia-related complications occurred in all settings, including large urban medical centers and small, rural hospitals.
The decline in complications from the use of epidural or spinal anesthesia is due at least in part to a drive by obstetric anesthesiologists over the past several years to improve the safety and quality of care, said Jean Guglielminotti, MD, PhD, lead study author and postdoctoral research fellow from the Anesthesiology Department at NewYork-Presbyterian Hospital/Columbia University Medical Center, in New York City.
“Our research shows anesthesia-related outcomes in cesarean deliveries have significantly improved,” Dr. Guglielminotti noted in a press release.
Not All Good News
The good news was tempered, however, by the lack of a decline in complication rates over the same 2003 to 2012 period for women given general anesthesia during cesarean deliveries.
Meanwhile, nonanesthetic perioperative complications rose by almost half, an increase that is likely related to the rise in pre-existing health issues and more advanced maternal age in women giving birth.
“Pregnant women nowadays are overall sicker and older,” said Ruth Landau, MD, one of the authors of the study and a professor of anesthesiology at Columbia University College of Physicians and Surgeons, in New York City. “We are providing safer care to a population of women who are substantially more at risk due to chronic health conditions.”
The study marks a major step forward in understanding the effect of years of efforts aimed at reducing anesthesia-related complications for women who undergo cesarean deliveries.
The study is the first to look at the results of these various initiatives on a broad scale, tracking hundreds of thousands of cases over a decade, Dr. Landau said.
All told, 5,715 cesarean deliveries had at least one complication. The rate for both major and minor anesthesia-related issues fell from 8.9 per 1,000 in 2003 to 6.6 per 1,000 in 2012, or a 25% reduction.
Mortality rates associated with cesarean deliveries also fell by 51% during the study period. The drop from 34 per 100,000 to 16 per 100,000 bucked national trends, although the numbers also may highlight the limitations of the state-specific data pool, the authors also noted.
Cesarean Deliveries Increase
The decrease has come even as the number of cesarean deliveries, which carry an increased risk for anesthesia-related adverse events, rose steadily over most of the study period, emphasizing the true decrease in anesthesia-related events during this decade. A total of 1.3 million cesarean deliveries were performed in 2010, making it the most common inpatient surgery in the United States.
Helping drive down anesthesia-related complications has been a concerted effort to provide and implement new guidelines and clinical recommendations along with quality improvement projects and reviews of closed malpractice claims; most of this work likely has resulted in better quality of care and communication, which have improved maternal safety.
“Anesthesia and analgesia for childbirth have become remarkably safe, and the magnitude of the observed reduction in anesthesia-related complications by Guglielminotti et al likely reflects gains in the safety of anesthetic management,“ noted an editorial in Anesthesiology, written by Jill M. Mhyre, MD, associate professor of anesthesiology at the University of Arkansas for Medical Sciences, in Little Rock, and Brian T. Bateman, MD, MSc, assistant professor of anesthesia at Harvard Medical School, in Boston.
However, there also is significant room for improvement in several areas, from the handling of minor anesthesia-related complications to the rising rate of “non-anesthetic perioperative complications,” the study found.
More progress was made in reducing major anesthesia-related adverse events, which fell 43%, than minor ones, which saw a 23% decline, the study found.
Postdural puncture headaches were found to be common, highlighting the need for better prevention, diagnosis and management of a condition that can have long-term effects, the authors wrote.
Another concern is the rate of complications related to general anesthesia, which has come even as the use of general anesthetic declined from 9.3% to 6.1% for unplanned cesarean deliveries, although not for operations that were planned.
One reason for the higher risk for complications with general anesthesia is that some physicians currently lack the skills and preparedness for its use in unplanned cesarean sections in emergency situations, the study found, citing research conducted in the United Kingdom (BJOG 2011;118:1-203).
Also a major concern is the big increase in nonanesthetic perioperative complications, which rose to 1,130 per 100,000 in 2012, from 770 per 100,000 in 2003, for a 47% jump.
“The observation that anesthesia-related complications are declining, while non-anesthetic perioperative complications are increasing suggests the need for physician anesthesiologists to look beyond the delivery of safe anesthesia and to embrace the role of the ‘peri-delivery’ physician,” the Anesthesiology editorial noted.
The study was praised by Lisa Leffert, MD, chief of obstetric anesthesia at Massachusetts General Hospital, in Boston.
“It is exactly what we should be doing right now, looking at how to make our practices and protocols for patients more and more safe,” Dr. Leffert said. “The study reminds us we have a lot more work to do in the field of obstetrics.”