Advertisement

Obstetric comorbidity index and the odds of general vs. neuraxial anesthesia in women undergoing cesarean delivery: a retrospective cohort study

  • Author Footnotes
    † Present address: Department of Anesthesiology, University of Michigan Medical School, 1500 E Medical Center Drive, Ann Arbor, MI, USA.
    S. Singh
    Footnotes
    † Present address: Department of Anesthesiology, University of Michigan Medical School, 1500 E Medical Center Drive, Ann Arbor, MI, USA.
    Affiliations
    Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, USA
    Search for articles by this author
  • M.K. Farber
    Affiliations
    Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, USA
    Search for articles by this author
  • B.T. Bateman
    Affiliations
    Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, USA
    Search for articles by this author
  • M.I. Lumbreras-Marquez
    Affiliations
    Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, USA
    Search for articles by this author
  • C.J. Richey
    Affiliations
    Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, USA
    Search for articles by this author
  • S.R. Easter
    Affiliations
    Division of Maternal-Fetal Medicine and Division of Critical Care Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
    Search for articles by this author
  • K.G. Fields
    Affiliations
    Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, USA
    Search for articles by this author
  • L.C. Tsen
    Correspondence
    Correspondence to: L.C. Tsen, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA, USA.
    Affiliations
    Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, USA
    Search for articles by this author
  • Author Footnotes
    † Present address: Department of Anesthesiology, University of Michigan Medical School, 1500 E Medical Center Drive, Ann Arbor, MI, USA.
Published:March 30, 2022DOI:https://doi.org/10.1016/j.ijoa.2022.103546

      Highlights

      • The obstetric comorbidity index (OB-CMI) is a composite measure of comorbidities.
      • OB-CMI predicts maternal morbidity, mortality, and intensive care unit admission.
      • There is a move to decrease general anesthesia (GA) for cesarean delivery.
      • This study found an association between OB-CMI and GA for cesarean delivery.

      Abstract

      Background

      Maternal and fetal concerns have prompted a significant reduction in general anesthesia (GA) use for cesarean delivery (CD). The obstetric comorbidity index (OB-CMI) is a validated, dynamic composite score of comorbidities encountered in an obstetric patient. We sought to estimate the association between OB-CMI and odds of GA vs. neuraxial anesthesia (NA) use for CD.

      Methods

      In this single-center, retrospective cohort study conducted at a large academic hospital in the United States of America, OB-CMI was calculated on admission and every 12 h for women undergoing CD at ≥23 weeks’ gestation (n=928). The CD urgency, anesthesia type, and most recent OB-CMI were extracted from the medical record. The association between OB-CMI and GA use was estimated by logistic regression, with and without adjustment for CD urgency, parity and race.

      Results

      Each one-point increase in OB-CMI was associated with a 32% (95% confidence interval [CI] 17% to 48%) increase in the odds of GA use (Model 1, area under the receiver operating characteristic curve [AUC] 0.708, 95% CI 0.610 to 0.805). The AUC improved to 0.876 (95% CI 0.815 to 0.937) with the addition of emergent CD (Model 2, P <0.001 vs. Model 1), but not parity and race (Model 3, AUC 0.880, 95% CI 0.824 to 0.935; P=0.616 vs. Model 2).

      Conclusions

      The OB-CMI is associated with increased odds of GA vs. NA use for CD, particularly when emergent. Collected in real time, the OB-CMI may enable prophylaxis (e.g. comorbidity modification, earlier epidural catheter placement, elective CD) or preparation for GA use.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to International Journal of Obstetric Anesthesia
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

      1. FastStats. https://www.cdc.gov/nchs/fastats/delivery.htm. Accessed March 23, 2020.

        • Kovacheva V.P.
        • Brovman E.Y.
        • Greenberg P.
        • et al.
        A contemporary analysis of medicolegal issues in obstetric anesthesia between 2005 and 2015.
        Anesth Analg. 2019; 128: 1199-1207https://doi.org/10.1213/ANE.0000000000003395
        • Guglielminotti J.
        • Landau R.
        • Li G.
        Adverse events and factors associated with potentially avoidable use of general anesthesia in cesarean deliveries.
        Anesthesiology. 2019; 130: 912-922https://doi.org/10.1097/ALN.0000000000002629
        • Guglielminotti J.
        • Li G.
        Exposure to general anesthesia for cesarean delivery and odds of severe postpartum depression requiring hospitalization.
        Anesth Analg. 2020; 131: 1421-1429https://doi.org/10.1213/ANE.0000000000004663
        • Tsen L.C.
        • Pitner R.
        • Camann W.R.
        General anesthesia for cesarean section at a tertiary care hospital 1990–1995: indications and implications.
        Int J Obstet Anesth. 1998; 7: 147-152https://doi.org/10.1016/s0959-289x(98)80001-0
        • Palanisamy A.
        • Mitani A.A.
        • Tsen L.C.
        General anesthesia for cesarean delivery at a tertiary care hospital from 2000 to 2005: a retrospective analysis and 10-year update.
        Int J Obstet Anesth. 2011; 20: 10-16https://doi.org/10.1016/j.ijoa.2010.07.002
        • Bauer M.E.
        • Kountanis J.A.
        • Tsen L.C.
        • Greenfield M.L.
        • Mhyre J.M.
        Risk factors for failed conversion of labor epidural analgesia to cesarean delivery anesthesia: a systematic review and meta-analysis of observational trials.
        Int J Obstet Anesth. 2012; 21: 294-309https://doi.org/10.1016/j.ijoa.2012.05.007
        • Cobb B.T.
        • Lane-Fall M.B.
        • Month R.C.
        • et al.
        Anesthesiologist specialization and use of general anesthesia for cesarean delivery.
        Anesthesiology. 2019; 130: 237-246https://doi.org/10.1097/ALN.0000000000002534
        • Wikner M.
        • Bamber J.
        Quality improvement in obstetric anaesthesia.
        Int J Obstet Anesth. 2018; 35: 1-3https://doi.org/10.1016/j.ijoa.2018.03.009
        • Pritchard N.
        • Lo Q.
        • Wikner M.
        • Bamber J.
        Collecting data for quality improvement in obstetric anaesthesia.
        Int J Obstet Anesth. 2019; 39: 142-143https://doi.org/10.1016/j.ijoa.2019.02.008
        • McGlennan A.
        • Mustafa A.
        General anaesthesia for caesarean section.
        Contin Educ Anaesth Crit Care Pain. 2009; 9: 148-151https://doi.org/10.1093/bjaceaccp/mkp025
        • Sumikura H.
        When was the last time you induced general anesthesia for cesarean section?.
        J Anesth. 2015; 29: 819-820https://doi.org/10.1007/s00540-015-1985-0
        • Juang J.
        • Gabriel R.A.
        • Dutton R.P.
        • Palanisamy A.
        • Urman R.D.
        Choice of anesthesia for cesarean delivery: an analysis of the National Anesthesia Clinical Outcomes Registry.
        Anesth Analg. 2017; 124: 1914-1917https://doi.org/10.1213/ANE.0000000000001677
        • Bateman B.T.
        • Mhyre J.M.
        • Hernandez-Diaz S.
        • et al.
        Development of a comorbidity index for use in obstetric patients.
        Obstet Gynecol. 2013; 122: 957-965https://doi.org/10.1097/AOG.0b013e3182a603bb
        • Metcalfe A.
        • Lix L.M.
        • Johnson J.-A.
        • et al.
        Validation of an obstetric comorbidity index in an external population.
        BJOG. 2015; 122: 1748-1755https://doi.org/10.1111/1471-0528.13254
        • Easter S.R.
        • Bateman B.T.
        • Sweeney V.H.
        • et al.
        A comorbidity-based screening tool to predict severe maternal morbidity at the time of delivery.
        Am J Obstet Gynecol. 2019; 221: 271.e1-271.e10https://doi.org/10.1016/j.ajog.2019.06.025
        • Bliddal M.
        • Möller S.
        • Vinter C.A.
        • et al.
        Validation of a comorbidity index for use in obstetric patients: a nationwide cohort study.
        Acta Obstet Gynecol Scand. 2020; 99: 399-405https://doi.org/10.1111/aogs.13749
      2. Classification of Urgency of Caesarean Section – a Continuum of Risk (Good Practice No. 11). Royal College of Obstetricians & Gynaecologists. https://www.rcog.org.uk/en/guidelines-research-services/guidelines/good-practice-11/. Accessed January 25, 2020.

        • Lucas D.N.
        • Yentis S.M.
        • Kinsella S.M.
        • et al.
        Urgency of caesarean section: a new classification.
        J R Soc Med. 2000; 93: 346-350https://doi.org/10.1177/014107680009300703
        • Kinsella S.M.
        • Scrutton M.J.L.
        Assessment of a modified four-category classification of urgency of caesarean section.
        J Obstet Gynaecol. 2009; 29: 110-113https://doi.org/10.1080/01443610802585546
      3. Yang D, Dalton J.E. A unified approach to measuring the effect size between two groups using SAS. SAS Global Forum, 2012. Available at: http://support.sas.com/resources/papers/proceedings12/335-2012.pdf.

        • Austin P.C.
        Using the standardized difference to compare the prevalence of a binary variable between two groups in observational research.
        Commun Stat Simul Comput. 2009; 38: 1228-1234
        • Yang S.
        • Berdine G.
        The receiver operating characteristic (ROC) curve.
        Southwest Respir Crit Care Chron. 2017; 5: 34-36https://doi.org/10.12746/swrccc.v5i19.391
        • Carvalho B.
        • Kinsella S.M.
        Obstetric Anaesthetists’ Association/National Perinatal Epidemiology Unit collaborative project to develop key indicators for quality of care in obstetric anaesthesia: first steps in the right direction.
        Anaesthesia. 2020; 75: 573-575https://doi.org/10.1111/anae.14935
        • Chau A.
        • Vijjeswarapu M.A.
        • Hickey M.
        • et al.
        Cross-disciplinary perceptions of structured interprofessional rounds in promoting teamwork within an academic tertiary care obstetric unit.
        Anesth Analg. 2017; 124: 1968-1977https://doi.org/10.1213/ANE.0000000000001890
        • Lawrence S.
        • Malacova E.
        • Reutens D.
        • Sturgess D.J.
        Increased maternal body mass index is associated with prolonged anaesthetic and surgical times for caesarean delivery but is partially offset by clinician seniority and established epidural analgesia.
        Aust N Z J Obstet Gynaecol. 2021; 61: 394-402https://doi.org/10.1111/ajo.13277
        • Saravanakumar K.
        • Rao S.G.
        • Cooper G.M.
        Obesity and obstetric anaesthesia.
        Anaesthesia. 2006; 61: 36-48https://doi.org/10.1111/j.1365-2044.2005.04433.x
      4. Practice Guidelines for Obstetric Anesthesia: an updated report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia and the Society for Obstetric Anesthesia and Perinatology. Anesthesiology 2016;124:270–300. doi: 10.1097/ALN.0000000000000935.

        • Mendis N.
        • Hamilton G.M.
        • McIsaac D.I.
        • et al.
        A systematic review of the impact of surgical special care units on patient outcomes and healthcCare resource utilization.
        Anesth Analg. 2019; 128: 533-542https://doi.org/10.1213/ANE.0000000000003942
        • Bamber J.H.
        • Lucas D.N.
        • Plaat F.
        • et al.
        The identification of key indicators to drive quality improvement in obstetric anaesthesia: results of the Obstetric Anaesthetists’ Association/National Perinatal Epidemiology Unit collaborative Delphi project.
        Anaesthesia. 2020; 75: 617-625https://doi.org/10.1111/anae.14861
        • Butwick A.J.
        • Blumenfeld Y.J.
        • Brookfield K.F.
        • Nelson L.M.
        • Weiniger C.F.
        Racial and ethnic disparities in mode of anesthesia for cesarean delivery.
        Anesth Analg. 2016; 122: 472-479https://doi.org/10.1213/ANE.0000000000000679