Best practice in obstetric general anaesthesia: an umbrella review of pharmacological strategies for induction of general anaesthesia

INTRODUCTION: General anaesthesia for caesarean delivery carries specific maternal and neonatal risks. Drug choice, dose and timing during induction of general anaesthesia may influence maternal and neonatal physiology and outcomes. The objective of this umbrella review was to systematically identify, summarise and appraise evidence for pharmacological techniques for induction of general anaesthesia for caesarean delivery. METHODS: Databases were searched for eligible studies, including meta-analyses, systematic reviews, randomised controlled trials not previously synthesised and relevant observational studies. Data extraction, methodological quality assessment and evaluation of evidence certainty were conducted. Interventions were grouped into four categories: induction opioids; induction hypnotics; drugs to obtund the pressor response to laryngoscopy; and neuromuscular blocking drugs. RESULTS: provided comparable tracheal intubation conditions to suxamethonium without affecting neonatal outcomes, based on moderate quality evidence. DISCUSSION: Current evidence supports the safety of short-acting opioids, propofol as the preferred induction drug and rocuronium as a suitable alternative to suxamethonium during induction of anaesthesia for caesarean delivery. Overall, the evidence base is constrained by exclusion of high-risk pregnancies and emergency cases, thus limiting generalisability.