We read with interest the case series by Kinsella et al regarding rapid sequence spinal in the setting of a category 1 caesarean section, originally described by the same authors in 2003 [1]. Some may consider this to be a common modification of routine neuraxial practice when faced with a 30 minute decision-to-delivery interval. This article does highlight several important points when performing this method, namely adopting a no touch technique, wearing of sterile gloves, limiting the number of attempts, and finally converting to general anaesthesia if delays or problems are encountered. However, this study once again raises the ongoing debate of compulsory wearing of a surgical facemask in the setting of dural puncture [2,3], as noted by its absence in this paper. Arguments against wearing facemasks are based on the lack of epidemiological studies. Research on the standard of care practiced by obstetric anaesthetists demonstrates these divided opinions. In one survey only 50.6% wore facemasks for central neuraxial anaesthesia [4], while in another study only 71% felt that wearing a facemask was essential [5]. Nonetheless, there is evidence supporting operator oropharyngeal commensals (viridians streptococci) as the source of pathogenesis, particularly in the form of case reports [6] and clusterings [7]. Philips et al [8] observed that the presence of a surgical mask effectively eliminated the spray of oral flora from the mouth of talking volunteer anaesthetists as demonstrated by an absence of growth on agar plates distanced 30 cm from their mouths, with maximum efficacy at 15 minutes. This is particularly applicable to the rapid spinal anaesthesia setting where time is limited and practitioners will often explain the procedure when performing same. Surely such a simple, cheap barrier that takes minimal time to place, that could reduce the risk of dispersion of oropharyngeal organisms, and has maximal efficacy in the time scale required should be brought into standard practice of care [8]. Iatrogenic meningitis is a rare, but a potentially devastating complication. Is it worth the risk?
C Murphy
S Crowe
Department of Anaesthesia
Adelaide and Meath Hospital Dublin Incorporating the National Children's Hospital
Dublin
References
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