High neuraxial block in obstetrics: patient experience is paramount

The editorial by Lee et al. [1] reminds us of the distressing consequences of a high neuraxial block in obstetric practice. This is relevant especially to the scenario of epidural catheter top-up, either for analgesia or to create a surgical block. The latter is very common, with epidurals reportedly ‘topped up’ with local anaesthetic for approximately 20% of caesarean deliveries [2] despite an associated failure rate of approximately 20% [3]. Epidurals that prove to be inadequate for local anaesthetic top-up are also likely to have been inadequate for labour analgesia. These patients should already be known to obstetric anaesthetists, with a low threshold for re-siting a new epidural catheter. Topping-up an epidural that has required more than two additional boluses of local anaesthetic in labour should, in our view, be avoided. Intrathecal anaesthesia following failed epidural top-up for caesarean delivery is accepted practice despite the risk of high neuraxial block requiring respiratory support [2]. Lee et al. describe how the dose of local anaesthetic delivered intrathecally should be reduced by up to 50–60%. However, neuraxial anaesthesia has been found to be inadequate in > 14% of caesarean deliveries [4] and achieving ideal conditions for surgery can therefore be difficult to judge in these circumstances. It is possible to mitigate the risks of high neuraxial block with minimal intrathecal dose reduction through patient positioning. This would depend on many factors such as when the epidural bolus was delivered, the drug used and the current condition of the patient. A constant dialogue with the patient can evaluate the evolution of the block, whilst regularly reinforcing the key message that general anaesthesia always remains an option. Unfortunately, we do not know how an epidural top-up or intrathecal anaesthesia after an epidural top-up will behave. We also do not know how a patient might respond to a high neuraxial block, physiologically and psychologically. However, we do know that patient experience of caesarean delivery is one of the most important outcomes to patients that anaesthetists can influence. The key to navigating this complex and uncertain period lies in our compassion, communication, listening and constant vigilance. These are the real factors that can have a substantial impact on psychological outcomes and they deserve prospective exploration in future research.