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The current practice of aspiration prophylaxis in obstetric anesthesia: a survey among non-physician anesthetic providers working in hospitals in Ethiopia

BMC Anesthesiology volume 21, Article number: 256 (2021) Cite this article

Abstract

Background

Pulmonary aspiration is one of the most important complications of obstetric anesthesia. Prevention of pulmonary aspiration is commonly performed by the application of different anesthetic maneuvers and administration of drugs. This study aimed to assess the non-physician anesthetic providers current practice of aspiration prophylaxis during anesthesia for cesarean section in Ethiopia.

Methods

This survey study was conducted from October 01 to November 05, 2020, on a total of 490 anesthetic providers working in hospitals in Ethiopia. A structured checklist was used to collect data from non-physician anesthetic providers.

Results

Four hundred and ninety (490) anesthetic providers participated in our study. The majority of the respondents (84%) were working in the public sector. Most of the cesarean delivery was done under regional anesthesia and more than half of anesthetic providers in Ethiopia administered aspiration prophylaxis routinely. Metoclopramide was the most frequently given as a prophylaxis for pulmonary aspiration.

Conclusions

More than half of the anesthetic providers administered aspiration prophylaxis routinely. Metoclopramide was the commonest administered aspiration prophylaxis for parturients who underwent cesarean delivery to prevent aspiration.

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Introduction

Cesarean section (CS) was introduced in clinical practice as a life-saving procedure both for the mother and the baby [1]. Currently, most CS is done under regional anesthesia techniques [2, 3]. It has not without a public health concern as it is associated with morbidity and mortality [4].

In Ethiopia, the prevalence of C/S is higher than [5, 6] the World Health Organization recommended rate which is up to 15% [7]. Studies conducted in Ethiopia revealed that about 30% of cesarean deliveries were developed complications after anesthesia [8] and others studies indicated that over half of cesarean deliveries were performed under general anesthesia [9, 10].

According to the American College of Obstetricians and Gynecologists (ACOG) report, cesarean delivery significantly increased woman’s risk of pregnancy-related morbidity and mortality which accounts (35.9 deaths per 100,000 live deliveries) as compared to a woman having vaginal delivery (9.2 deaths per 100,000 live births) [11].

Even though the mortality rate of pulmonary aspiration of gastric contents has declined, it is one of the most important complications of general anesthesia in obstetric patients [1, 12, 13]. Increased risk of aspiration is due to prolonged gastric emptying time in labor, increased intra-abdominal pressure due to the gravid uterus, and relaxation of the lower esophageal sphincter due to hormonal changes [14,15,16].

To reduce this risk numerous measures and maneuvers are used to prevent aspiration of acid gastric contents during general anesthesia (GA) [17,18,19,20]. The morbidity and mortality of this complication can be significantly reduced by decreasing the acidity of the inhaled contents. These include preoperative fasting, non-particulate antacids, H2 receptor blockers, gastro kinetic drugs like metoclopramide, rapid sequence induction with cricoid pressure, and awake extubation during emergence from general anesthesia [21,22,23].

Pulmonary aspiration could lead to poor patient outcomes once it occurs. Prevention is paramount important in medicine. Its role is more pronounced in a resource-limited setting; when the cost of medical care is highly lacking. This study might be baseline information for further researchers and might be supportive information for the scientific world. This study aimed to assess the anesthetic providers current practice of aspiration prophylaxis during anesthesia for cesarean section in Ethiopia.

Methods

Study setting, design, period, and population

There are ten geographical regions and two city administrations in Ethiopia. A total of 490 anesthesia professionals working in hospitals of Ethiopia were included in this survey from October 01 to November 05, 2020. Anesthetic providers in Ethiopia can be physician or non-physician anesthetic providers. Non-physician anesthetic providers include Master of Science in anesthesia who are trained for 2 years after graduating with a Bachelor of Science degree in anesthesia, Bachelor of Science degree in anesthesia who are trained 4 years of university training or 3 years of additional training after accomplishing nursing diploma, and Level V anesthetic providers who trained a diploma nurse, and additional one-year anesthesia training. In Ethiopia, almost all anesthesia service is covered by non-physician anesthetic providers. This study was conducted only in non-physician anesthetic providers.

Sampling technique

All available non-physician anesthetic providers working in Hospitals of Ethiopia were surveyed.

Data collection technique

A structured checklist regarding the current practice of anesthesia on aspiration prophylaxis for CS was used to collect data. This tool for data collection was adopted from ASA and Perinatology guidelines [21]. The data collection tool has two subsections; section one socio-demographic variables (Age, Sex, region, etc.), and anesthetic providers practice of aspiration prophylaxis for Obstetric anesthesia (anesthetic maneuvers, drugs for aspiration prophylaxis, etc.).

A questionnaire was constructed using a google form and the link (https://forms.gle/nCQtvSnqYjcm49us5) was sent to all non-physician anesthetic providers working in Ethiopian hospitals through the common telegram group and individual email address to get a better response rate. The Telegram Messenger (Telegram Inc. Dubai UAE; www.telegram.org) group has 730 anesthetic providers.

Data analysis

Data were checked manually for completeness and then coded by using the SPSS (Statistical Package for Social Sciences/Statistical Product and Service Solution (IBM Corp. Armonk NY USA) version 23 computer program for analysis. Descriptive statistics were employed to summarize the results.

Data quality control

The investigators, cross-checked for the completeness, and consistency of the data before data analysis.

Results

Socio-demographic characteristics of the respondents

Four hundred and ninety non-physician anesthetic providers have participated with a response rate of 67%. The majority of the respondents (84%) were working in the public sector (Table 1).

Table 1 Socio-demographic characteristics of the Respondents
Full size table

The practice of anesthetic providers for aspiration prophylaxis

More than half of the anesthetic providers were administered aspiration prophylaxis routinely. Metoclopramide was the most commonly administered as a prophylaxis for pulmonary aspiration (Table 2, Figs. 1 and 2).

Table 2 The practice of anesthetic providers for aspiration prophylaxis
Full size table
Fig. 1
figure 1

Frequency of aspiration prophylaxis use among anesthetic providers who are working in hospitals of Ethiopia

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Fig. 2
figure 2

Commonly drugs used for aspiration prophylaxis use among anesthetic providers who are working in hospitals of Ethiopia

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Discussion

In Ethiopia, about 30% of mothers who underwent cesarean deliveries were developed complications after anesthesia [8]. Studies conducted in others settings of Ethiopia indicated that over half of cesarean deliveries were performed under general anesthesia [9, 10] that might increase aspiration-related maternal morbidity and mortality. While Aspiration is a commonly reported complication during Cesarian delivery globally; we do not have any specific data on its prevalence in Ethiopia. This risk might be minimized by the use of aspiration prophylaxis [12, 24, 25]. Actions taken to prevent aspiration of gastric contents may depend on the assessment of the level of risk of aspiration; administration of drugs; and application of different anesthetic maneuvers (e.g., RSI) are common strategies of prevention [19, 20, 26].

Administering preoperative gastrointestinal stimulants, gastric acid secretion blockers, and antacids might be used for patients at increased risk of pulmonary aspiration. Routine administration of preoperative gastrointestinal stimulants, gastric acid secretion blockers, and antacids to reduce the risk of pulmonary aspiration in patients with no apparent increased risk for pulmonary aspiration is not recommended (Table 3) [24, 27,28,29,30,31,32,33].

Table 3 A review of currently used drugs for aspiration prophylaxis
Full size table

Our study showed that the majority of the respondents (94%) perform spinal anesthesia for cesarean delivery which is in line with a study done in Israel as 95% of the cases are done under regional anesthesia [34]. This finding is dissimilar with research done in Turk by Mehmet Aksoy et al. on anesthesia techniques for cesarean sections as the proportion of general anesthesia was about 45% which is too high as compared to our finding and this discrepancy could be justified by their study is a retrospective analysis of last decade data [35].

The finding of this study indicated that more than half of anesthetic providers (54%) administered aspiration prophylaxis routinely. While a survey study of UK obstetric unit on acid aspiration prophylaxis in labor found that an increase in the use of acid aspiration prophylaxis for at risk parturients to 61% [36]. This discrepancy might be due to clinical setup differences as the UK is the most developed country and they might have clinical evidence-based clinical practice guidelines.

The current study showed 93% of anesthetists used cricoid pressure with rapid sequence induction, and about 96% of patients were extubated fully awake. Similarly, a study done in England by Desai N et al. on a survey of the practice of rapid sequence induction for cesarean section found that cricoid pressure is applied for 98% of the cases [37] and Shaikh et al. showed that 84% of anesthetic providers used rapid sequence induction with cricoid pressure during general anesthesia, while about 50% of anesthetic providers performed extubation when patients were fully awake. In contrast to our findings, antacids were used by 90% of the anesthetic providers [23]. This difference may be due to the limited availability of antacids.

Our study showed that most of the anesthetic providers working in hospitals of Ethiopia give metoclopramide (63%) followed by Cimetidine (17%), ranitidine (13%), and sodium citrate (6%) for parturients who underwent CS delivery to prevent aspiration. In contrast to our finding, a study conducted in New Zealand by Kluger et al. showed that 47% of anesthetic providers administered metoclopramide, 72% of anesthetic providers give H2 antagonists, and 95% of anesthetic providers administered sodium citrate as prophylaxis for pulmonary aspiration [38]. Another study done in England by Desai N et al. on a survey of the practice of rapid sequence induction for cesarean section found that metoclopramide, ranitidine, and sodium citrate were used for 43, 86, and 88% of the case to prevent aspiration [37]. A difference in a clinical setting could be a probable justification for this discrepancy.

Conclusions

More than half of the anesthetic providers administered aspiration prophylaxis routinely. Metoclopramide was the commonest administered aspiration prophylaxis for parturients who underwent CS delivery to prevent pulmonary aspiration. Prevention is paramount important in medicine. Its role is more pronounced in resource-limited settings; when the cost of medical care is highly lacking.

Limitation

The limitation of this study might be we only surveyed non-physicians anesthetic providers, no data on pulmonary aspiration risk or prevalence in our settings, lack of national protocols for prevention of pulmonary aspiration.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

ACOG :

American College of Obstetricians and Gynecologists

CS :

Cesarean Section

GA :

General Anesthesia

RA :

Regional anesthesia

RSI :

Rapid sequence induction

WHO :

World Health Organization

References

  1. Uharček P, Mlynček M, Uharčeková P, Pretiová L. Anaesthesia for caesarean section and acid aspiration prophylaxis: a survey of Slovak obstetric departments. Eur J Anaesthesiol. 2007;24(8):724–6.

    Article  Google Scholar 

  2. Stourac P, Blaha J, Klozova R, Noskova P, Seidlova D, Brozova L, et al. Anesthesia for cesarean delivery in the Czech Republic: a 2011 national survey. Anesth Analg. 2015;120(6):1303–8.

    Article  CAS  Google Scholar 

  3. Stourac P, Kosinova M, Blaha J, Grochova M, Klozova R, Noskova P, et al. Changes in caesarean section anaesthesia between 2011 and 2015: Czech and Slovak national surveys. Eur J Anaesthesiology| EJA. 2019;36(10):801–3.

    Article  Google Scholar 

  4. Feng XL, Wang Y, An L, Ronsmans C. Cesarean section in the People’s republic of China: current perspectives. Int J Women's Health. 2014;6:59.

    Article  Google Scholar 

  5. Gedefaw G, Demis A, Alemnew B, Wondmieneh A, Getie A, Waltengus F. Prevalence, indications, and outcomes of caesarean section deliveries in Ethiopia: a systematic review and meta-analysis. Patient Saf Surg. 2020;14:11.

    Article  Google Scholar 

  6. Taye MG, Nega F, Belay MH, Kibret S, Fentie Y, Addis WD, et al. Prevalence and factors associated with caesarean section in a comprehensive specialized hospital of Ethiopia: a cross-sectional study; 2020. Ann Med Surg (2012). 2021;67:102520.

    Article  Google Scholar 

  7. Betran AP, Torloni MR, Zhang JJ, Gülmezoglu AM. WHO statement on caesarean section rates. BJOG. 2016;123(5):667–70.

    Article  CAS  Google Scholar 

  8. Tesfaye T, Hailu D, Mekonnen N, et al. Magnitude of maternal complication and associated factors among mothers undergone cesarean section at Yirgalem general hospital, SNNPR. Ethiopia Int J Health Sci Res. 2017;7(5):264–72.

    Google Scholar 

  9. Abebe FE, Gebeyehu AW, Kidane AN, Eyassu GA. Factors leading to cesarean section delivery at Felegehiwot referral hospital, Northwest Ethiopia: a retrospective record review. Reprod Health. 2015;13(1):1–7.

    Article  Google Scholar 

  10. Abdissa Z, Awoke T, Belayneh T, Tefera Y. Birth outcome after caesarean section among mothers who delivered by caesarean section under general and spinal anesthesia at Gondar University teaching hospital north-West Ethiopia. J Anesth Clin Res. 2013;4(7):4–8.

    Article  Google Scholar 

  11. Rayburn WF, Strunk AL. Profiles about practice settings of American College of Obstetricians and Gynecologists fellows. Obstet Gynecol. 2013;122(6):1295–8.

    Article  Google Scholar 

  12. Stuart J, Kan A, Rowbottom S, Yau G, Gin T. Acid aspiration prophylaxis for emergency caesarean section. Anaesthesia. 1996;51(5):415–21.

    Article  CAS  Google Scholar 

  13. Lim G, Facco FL, Nathan N, Waters JH, Wong CA, Eltzschig HK. A review of the impact of obstetric anesthesia on maternal and neonatal outcomes. Anesthesiology. 2018;129(1):192–215.

    Article  Google Scholar 

  14. Avidan MS, Groves P, Blott M, Welch J, Leung T, Pozniak A, et al. Low complication rate associated with cesarean section under spinal anesthesia for HIV-1–infected women on antiretroviral therapy. J Am Soc Anesthesiologists. 2002;97(2):320–4.

    Google Scholar 

  15. Machado LS. Cesarean section in morbidly obese parturients: practical implications and complications. N Am J Med Sci. 2012;4(1):13.

    Article  Google Scholar 

  16. Simonson DC, Ahern MM, Hendryx MS. Anesthesia staffing and anesthetic complications during cesarean delivery: a retrospective analysis. Nurs Res. 2007;56(1):9–17.

    Article  Google Scholar 

  17. de Souza DG, Doar LH, Mehta SH, Tiouririne M. Aspiration prophylaxis and rapid sequence induction for elective cesarean delivery: time to reassess old dogma? Anesth Analg. 2010;110(5):1503–5.

    Article  Google Scholar 

  18. Salem MR, Khorasani A, Zeidan A, Crystal GJ. Cricoid pressure controversies: narrative review. Anesthesiology. 2017;126(4):738–52.

    Article  Google Scholar 

  19. Zdravkovic M, Rice MJ, Brull SJ. The clinical use of cricoid pressure: first, do no harm. Anesth Analg. 2020;132(1):261–7.

    Article  Google Scholar 

  20. Klucka J, Kosinova M, Zacharowski K, De Hert S, Kratochvil M, Toukalkova M, et al. Rapid sequence induction: An international survey. Eur J Anaesthesiol. 2020;37(6):435.

    PubMed  PubMed Central  Google Scholar 

  21. Anesthesia PGfO. 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.

    Article  Google Scholar 

  22. Newson A. The effectiveness and duration of preoperative antacid therapy. Anaesth Intensive Care. 1977;5(3):214–7.

    Article  CAS  Google Scholar 

  23. Shaikh JM, Sabbar S, Aziz N, Shaikh NB, Akhund T. Acid aspiration prophylaxis during anaesthesia for caesarean section: a survey among anaesthetists at Hyderabad. J Ayub Med College Abbottabad. 2009;21(4):87–9.

    Google Scholar 

  24. Dongare PA, Bhaskar SB, Harsoor S, Garg R, Kannan S, Goneppanavar U, et al. Perioperative fasting and feeding in adults, obstetric, paediatric and bariatric population: practice guidelines from the Indian Society of Anaesthesiologists. Indian J Anaesth. 2020;64(7):556.

    Article  Google Scholar 

  25. Maronge L, Bogod D. Complications in obstetric anaesthesia. Anaesthesia. 2018;73:61–6.

    Article  Google Scholar 

  26. Engelhardt T, Webster N. Pulmonary aspiration of gastric contents in anesthesia. Surv Anesthesiol. 2000;44(2):74.

    Article  Google Scholar 

  27. Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. Application to healthy patients undergoing elective procedures: An updated report by the American Society of Anesthesiologists Task Force on preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration. Anesthesiology. 2017;126(3):376–93.

    Article  Google Scholar 

  28. Dattatraya G, Ullhas M. A comparative efficacy of conventional H 2 receptor blocker ranitidine and newer proton pump inhibitors omeprazole, pantoprazole and esomeprazole for improvement of gastric fluid property in adults undergoing elective surgery. IOSR-JDMS. 2015;14:45–8.

    Google Scholar 

  29. Manchikanti L, Grow JB, Colliver JA, Hadley CH, Hohlbein LJ. Bicitra®(sodium citrate) and metoclopramide in outpatient anesthesia for prophylaxis against aspiration pneumonitis. J Am Soc Anesthesiologists. 1985;63(4):378–84.

    CAS  Google Scholar 

  30. Memis D, Turan A, Karamanlioglu B, Saral P, Türe M, Pamukçu Z. The effect of intravenous pantoprazole and ranitidine for improving preoperative gastric fluid properties in adults undergoing elective surgery. Anesth Analg. 2003;97(5):1360–3.

    CAS  PubMed  Google Scholar 

  31. Pandit S, Kothary S, Pandit UA, Mirakhur R. Premedication with cimetidine and metoclopramide: effect on the risk factors of acid aspiration. Anaesthesia. 1986;41(5):486–92.

    Article  CAS  Google Scholar 

  32. Radwan KG, Omar SH, Youssef MA, Farouk H, Kamal NM, Sabra ANA. Pre-operative intravenous co-Administration of Ranitidine and Metoclopramide: effect on gastric content in laparoscopic cholecystectomy. Med J Cairo Univ. 2010;78(2):125–30.

    Google Scholar 

  33. Solanki DR, Suresh M, Ethridge HC. The effects of intravenous cimetidine and metoclopramide on gastric volume and pH. Anesth Analg. 1984;63(6):599–602.

    Article  CAS  Google Scholar 

  34. Shatalin D, Weiniger C, Buchman I, Ginosar Y, Orbach-Zinger S, Ioscovich A. A 10-year update: national survey questionnaire of obstetric anesthesia units in Israel. Int J Obstet Anesth. 2019;38:83–92.

    Article  CAS  Google Scholar 

  35. Aksoy M, Aksoy AN, Dostbil A, Çelik MG, Ahıskalıoğlu A. Anaesthesia techniques for caesarean operations: retrospective analysis of last decade. Turkish J Anaesthesiol Reanim. 2014;42(3):128–32.

    Article  Google Scholar 

  36. Calthorpe N, Lewis M. Acid aspiration prophylaxis in labour: a survey of UK obstetric units. Int J Obstet Anesth. 2005;14(4):300–4.

    Article  CAS  Google Scholar 

  37. Desai N, Wicker J, Sajayan A, Mendonca C. A survey of practice of rapid sequence induction for caesarean section in England. Int J Obstet Anesth. 2018;36:3–10.

    Article  CAS  Google Scholar 

  38. Kluger M, Willemsen G. Anti-aspiration prophylaxis in New Zealand: a national survey. Anaesth Intensive Care. 1998;26(1):70–7.

    Article  CAS  Google Scholar 

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Acknowledgments

Debre Tabor University for providing internet service.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Authors and Affiliations

  1. Department of Anesthesia, School of Medicine, College of Health Sciences, Debre Tabor University, PO. Box: 272, Debre Tabor, Ethiopia

    Metages Hunie, Efrem Fenta, Simegnew Kibret & Diriba Teshome

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  1. Metages Hunie
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Contributions

All authors provide a significant contribution to this work. MH and EF participated in conception, study design, data acquisition, analysis and interpretation of data. SK and DT also participated in data acquisition, data analysis and interpretation, and in reviewing the manuscript. All authors have read and approved to be submitted.

Corresponding author

Correspondence to Metages Hunie.

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Ethics approval and consent to participate

This work have been performed according to the Declaration of Helsinki, and ethical clearance was obtained from Debre Tabor University College of health sciences Ethical Review Committee. Written informed consent was secured from each study participant. Confidentiality was assured throughout the research.

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Not applicable.

Competing interests

The authors of this study declared that as there were no competing interests.

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Hunie, M., Fenta, E., Kibret, S. et al. The current practice of aspiration prophylaxis in obstetric anesthesia: a survey among non-physician anesthetic providers working in hospitals in Ethiopia. BMC Anesthesiol 21, 256 (2021). https://doi.org/10.1186/s12871-021-01478-4

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BMC Anesthesiology

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