I read with great interest the paper by Kinsella et al on rapid sequence spinal anaesthesia [1]. I have three issues I would like to raise. Firstly, I am concerned about the potential compromise of aseptic precautions in this technique. As indicated in the article, the majority of UK anaesthetists routinely wear gown, gloves, mask and hat when performing a spinal [2], and while logic suggests that for a no-touch technique a gown is probably unnecessary, (unlike for epidural insertion, where there is a catheter that may become contaminated), the AAGBI’s 2008 publication “Infection Control in Anaesthesia” [3] specifically states: “The Working Party is aware that many anaesthetists do not employ this level of asepsis for ‘one-shot’ spinals or epidurals but believes that when central neural spaces are penetrated, full aseptic precautions are required.”

There is also the issue of preparation of the skin. I am not convinced that a single wipe of 0.5% chlorhexidine over the intended insertion site allows satisfactory decontamination of the skin, especially given that chlorhexidine is colourless. Therefore, the extent of the prepared area may not be obvious. Traditionally, two applications of alcoholic chlorhexidine have been recommended [4], although recent work has suggested that one spray of alcoholic 0.5% chlorhexidine is sufficient to completely decontaminate the skin in 100% of subjects [5]. A spray will cover a larger area than a wipe, and may be performed by another member of the theatre team. It is important to remember that the chlorhexidine-containing fluid must be allowed time to dry, both to be fully effective, and because of a possible risk of chronic adhesive arachnoiditis. I am concerned that the atmosphere of urgency that is present within the operating theatre, when a Category 1 caesarean section is announced, may result in anaesthetists performing or being pressurised to perform spinal anaesthesia, before the cleaning solution is completely dry. This may increase the risk of such rare complications. It may therefore be better to recommend that the patient’s back is given a single spray with alcoholic 0.5% chlorhexidine, which is allowed to dry while the anaesthetist prepares his equipment.

Finally, I am concerned that adoption of such techniques will furthe rdecrease the exposure of junior anaesthetists to general anaesthesia for caesarean section. Whilst it is well-recognised that regional techniques have advantages over general anaesthesia for obstetric surgery, the incidence of general anaesthesia will never be zero in this population. Indeed, Kinsella et al recommend that general anaesthesia should be the fall-back technique when spinal anaesthesia is not immediately successful. However, the widespread adoption of regional anaesthesia, coupled with a fall in the number of hours worked by junior doctors in recent years, means that the number of general anaesthetics performed for obstetric surgery may be as low asone per junior doctor per year [6]. Performing a general anaesthetic aftera failed rapid sequence spinal will not only cost time, it will also add to the stress and pressure of an already difficult situation. It strikes me that patients such as these slim women (mean approximate weight of 66kg), assuming that they present during daylight hours in a consultant-led unit, present avaluable opportunity for juniors to gain supervised experience in providing general anaesthesia for caesarean section. This opportunity should not be sacrificed for a potentially suboptimal spinal technique, simply to avoid general anaesthesia at all costs.

Roy M Williamson

Liverpool Women’s Hospital

Liverpool

References

1. Kinsella SM, Girgirah K, Scrutton MJL. Rapid sequence spina lanaesthesia for category-1 urgency caesarean section: a case series. Anaesthesia 2010; 65: 664–669.

[2] Naik M, Mannakkara C, Aravindham N. National postal survey of methods used to ensure aseptic whilst performing regional analgesia and anaesthesia in obstetrics. International Journal of Obstetric Anesthesia 2008; 17:S27.

[3] Association of Anaesthetists of Great Britain and Ireland. Infection Control in Anaesthesia. Anaesthesia

2008; 63: 1027-1036.

[4] Reynolds F. Infection as a complication of neuraxial blockade. . International Journal of Obstetric Anesthesia 2005; 14: 183-188.

[5] Malhotra S, Dharmadasa A, Phillip S, Jepson A, Siegmueller C, Yentis SM. One versus two applications of chlorhexidine/ethanol for skin disinfection before regional anaesthesia. International Journalof Obstetric Anesthesia 2010; 19: S10.

[6] Searle RD, Lyons G. Vanishing experience in training for obstetric general anaesthesia: an observational study. International Journal of Obstetric Anesthesia 2008; 17:233–237.

We would like to thank Dr Williamson for his interest in our article. We describe a pragmatic approach to an emergency situation and, as mentioned in our article, fully accept that some may criticise the aseptic technique we describe - despite the fact that it is routine practice in other countries. It could be argued that several aspects of our ‘rapid sequence spinal' may not conform to nationally recommended guidelines - length of consent and preoperative anaesthetic assessment for example. However, all recognise that such ‘shortcuts' may be acceptable practice in any emergency situation whether carried out under regional or general anaesthesia. It is notable that any technique of instituting regional anaesthesia rapidly attracts more scrutiny from the anaesthetic profession as a whole, than rushing to a ‘quick GA' - despite the evidence that the latter results in greater morbidity and mortality in obstetrics.

The issue of chlorhexidine and arachnoiditis relates to liquid-to-liquid contamination of spinal equipment on the tray [1], and therefore one must make sure that the solution is kept away from the equipment. Spraying chlorhexidine would be a straightforward adjustment to the technique if this was routine practice in an institution. The product license of chlorhexidine in applicator sticks (Chloraprep® with Tint 2%) has been changed to say "Direct contact with neural tissue must be avoided" and we will be changing to this product to reduce the chance of contamination. We remain dubious about any risk of wet skin preparation solution causing arachnoiditis. In spite of this, we suggest that if necessary the skin is wiped dry before performing the spinal injection, acknowledging that skin bacterial decontamination will be less effective.

We do not avoid general anaesthesia at all costs, and explained in our paper the difficult decision making based on risks and benefits in the individual case. On the other hand we would not subscribe to the view that we should be maintaining or increasing the number of general anaesthetics performed for caesarean section in order to train our trainees. Women having an elective caesarean section overwhelmingly choose regional anaesthesia. Using a rapid sequence spinal approach, along with multidisciplinary co-operation, allows more women having category 1 caesarean section the same choice. There are women having less urgent caesarean sections, who wish to have general anaesthesia, and the training opportunities lie here in more appropriate circumstances.

SM Kinsella

MJL Scrutton

K Girgirah

1.      Bogod D. The truth, the whole truth? Anaesthesia News 2010;Issue 271:7-8.