BACKGROUND:Placenta accreta spectrum (PAS) with resuscitative endovascular balloon occlusion of the aorta (REBOA) presents unique anaesthetic challenges, yet optimal management strategies remain undefined. OBJECTIVE:To provide a real-world description of anaesthetic practices, REBOA management, and surgical outcomes in patients undergoing caesarean delivery with REBOA for PAS across four international centres. DESIGN:International multicentre retrospective cohort study. SETTING:Four tertiary care centres across Israel and Spain between January 2019 and December 2023. PATIENTS:A total of 47 patients diagnosed with PAS who underwent caesarean delivery with REBOA placement. INTERVENTION:None. MAIN OUTCOME MEASURES:The primary outcome was to evaluate the anaesthetic management and outcomes of PAS patients undergoing caesarean delivery with REBOA. Secondary outcomes included assessment of REBOA utilisation patterns, blood loss management strategies and maternal and neonatal outcomes. RESULTS:Initial anaesthesia was predominantly neuraxial (85.1%), with combined spinal-epidural being the most common (46.8%). Conversion to general anaesthesia occurred in 52.5% of neuraxial cases, primarily due to pain (52.4%) and surgeon requests (42.9%). REBOA was placed in all cases but inflated in only 76.6%, mainly under ultrasound guidance (57.4%), with significantly shorter anaesthesia-to-delivery intervals than fluoroscopy (60.0 vs. 111.0 min, P  = 0.003). Median estimated blood loss was 1.5 l [0.9 to 2.5]. Hysterectomy was performed in 57.4% of cases. REBOA-related complications were minimal (4.3%), and maternal outcomes were generally favourable, with 31.9% requiring intensive care admission. Neonatal outcomes were good, with median Apgar scores of 9.0 at both one and five minutes. CONCLUSIONS:Although REBOA shows promise in PAS management, the high neuraxial-to-general anaesthesia conversion rate suggests the need for refined anaesthetic protocols. Combined spinal-epidural with readiness to convert to general anaesthesia may offer the optimal approach. Ultrasound-guided REBOA placement appears to significantly reduce procedural time. Success depends on thorough preparation, clear communication and adaptability to rapidly changing clinical situations.

This study aimed to determine whether the use of capnography reduces the incidence of respiratory and cardiovascular adverse events during procedural sedation and analgesia (PSA) for gastrointestinal endoscopic procedures (GEP) provided by experienced anaesthesiologists. A prospective cohort study was conducted, including patients undergoing GEP under PSA. Patients were divided in two groups: Group A (pulse oximetry) and Group B (capnography with Capnostream™ monitor plus pulse oximetry). Interventions undertaken to resolve hypoxaemia, airway obstruction, or apnoea were recorded. Age, comorbidities, ASA Classification, sedative drugs, respiratory and cardiovascular adverse events, recovery Aldrete Scale value, and patient satisfaction were also recorded. Both parametric and non-parametric tests were applied. A total of 1,146 patients were included: Group A, n = 538, and Group B, n = 608. Diagnostic colonoscopy was the most frecuent procedure (49.7

BACKGROUNDPlacenta accreta spectrum (PAS) with resuscitative endovascular balloon occlusion of the aorta (REBOA) presents unique anaesthetic challenges, yet optimal management strategies remain undefined.OBJECTIVETo provide a real-world description of anaesthetic practices, REBOA management, and surgical outcomes in patients undergoing caesarean delivery with REBOA for PAS across four international centres.DESIGNInternational multicentre retrospective cohort study.SETTINGFour tertiary care centres across Israel and Spain between January 2019 and December 2023.PATIENTSA total of 47 patients diagnosed with PAS who underwent caesarean delivery with REBOA placement.INTERVENTIONNone.MAIN OUTCOME MEASURESThe primary outcome was to evaluate the anaesthetic management and outcomes of PAS patients undergoing caesarean delivery with REBOA. Secondary outcomes included assessment of REBOA utilisation patterns, blood loss management strategies and maternal and neonatal outcomes.RESULTSInitial anaesthesia was predominantly neuraxial (85.1%), with combined spinal-epidural being the most common (46.8%). Conversion to general anaesthesia occurred in 52.5% of neuraxial cases, primarily due to pain (52.4%) and surgeon requests (42.9%). REBOA was placed in all cases but inflated in only 76.6%, mainly under ultrasound guidance (57.4%), with significantly shorter anaesthesia-to-delivery intervals than fluoroscopy (60.0 vs. 111.0 min, P = 0.003). Median estimated blood loss was 1.5 l [0.9 to 2.5]. Hysterectomy was performed in 57.4% of cases. REBOA-related complications were minimal (4.3%), and maternal outcomes were generally favourable, with 31.9% requiring intensive care admission. Neonatal outcomes were good, with median Apgar scores of 9.0 at both one and five minutes.CONCLUSIONSAlthough REBOA shows promise in PAS management, the high neuraxial-to-general anaesthesia conversion rate suggests the need for refined anaesthetic protocols. Combined spinal-epidural with readiness to convert to general anaesthesia may offer the optimal approach. Ultrasound-guided REBOA placement appears to significantly reduce procedural time. Success depends on thorough preparation, clear communication and adaptability to rapidly changing clinical situations.

BACKGROUND Labour epidural analgesia reportedly fails in up to 10 to 25% of cases. A joint taskforce of European Society of Anaesthesiology and Intensive Care (ESAIC) experts was created to develop this focused guideline on the management of failing epidural analgesia in a previously well functioning epidural catheter. DESIGN Six clinical questions were defined using a PICO (Population/Intervention/Comparison/Outcome) strategy to conduct a systematic literature search. The questions pertained to clinical management of failing epidural (PICOs 1, 2 and 3), human resource and team training (PICOs 4 and 5) and clinical management of a failing epidural for intrapartum caesarean delivery (PICO 6). The taskforce produced recommendations and clinical practice statements (CPS) and validated them through a Delphi process. The final version of the guideline was submitted to all ESAIC members for critical review and approved by the Guidelines Committee and the ESAIC Board of Directors. RESULTS In the initial search, 3737 titles were identified, 93 were retained for complete article analysis and 56 were finally allocated to the PICOs. The full-text analysis of the selected articles precluded extraction of significant data for all PICOs except for PICO 6, for which six articles were identified. Based on the experience, knowledge and opinion of the experts, the task force proposed and validated two recommendations and 11 CPSs. CONCLUSION This guideline complemented other recently published expert opinion papers. We hope that this new guidance will serve clinicians to increase parturient safety and quality of care during labour and delivery, while at the same time provide inspiration for further research to fill the current knowledge gaps.

Introduction A national survey was conducted among maternity hospitals nationwide to understand the variability in clinical practice for obstetric analgesia and to reach a consensus on optimal care in the future in Spain. Materials and methods Spanish experts in obstetric anesthesiology designed a survey on the practice of obstetric analgesia during childbirth, following a Delphi process. The survey was sent to 195 Spanish maternity hospitals between April and September 2022 using Google Forms. A descriptive study of the results was performed. Results Responses were obtained from 108 centers (55.4%), of which 88 (83.8%) were public hospitals. The most commonly used technique was epidural analgesia in 97 (92.4%) centers. Nine (8.6%) centers used the combined spinal-epidural (CSE) technique, 5 (4.8%) used spinal analgesia, and 3 (2.9%) used dural puncture epidural (DPE) analgesia. The most commonly used local anesthetic was levobupivacaine 0.1-0.25% in 82 (78.1%) centers. Fentanyl or sufentanil were added to the local anesthetic in 96 (91.4%) centers. Epidural maintenance was performed with continuous epidural infusion (CEI) + patient-controlled epidural analgesia (PCEA) or programmed intermittent epidural bolus (PIEB) + PCEA in 64 (60.9%) and 33 (30.5%) centers, respectively. Fifteen (14.3%) centers lacked alternative techniques to epidural analgesia and 25 (23.8%) did not follow obstetric analgesia protocols. Conclusion Despite the variability in clinical practice for obstetric analgesia in Spain, the vast majority of centers follow recommendations in this field. There is room for improvement, which should be considered a fundamental strategy for progressing towards excellence.

Introducción Se llevó a cabo una encuesta nacional entre las maternidades del territorio español para conocer la variabilidad de la práctica clínica en analgesia obstétrica y consensuar un óptimo cuidado futuro en España. Material y métodos Expertos españoles en anestesiología obstétrica, diseñaron una encuesta sobre la práctica de la analgesia obstétrica durante el parto, siguiendo un proceso Delphi. La encuesta fue enviada a 195 maternidades españolas entre abril y septiembre de 2022 utilizando Google Forms. Se realizó un estudio descriptivo de los resultados. Resultados Se obtuvieron respuestas de 108 centros (55,4%), de los que 88 (83,8%) fueron hospitales públicos. La técnica más utilizada fue la analgesia epidural en 97 (92,4%) centros. Nueve (8,6%) centros usaban la técnica espinal-epidural combinada (CSE), cinco (4,8%) la analgesia espinal y tres (2,9%) la analgesia epidural con punción dural (DPE).El anestésico local más empleado fue la levobupivacaína 0,1-0,25% en 82 (78,1%) centros. El fentanilo o el sulfentanilo eran añadidos al anestésico local en 96 (91,4%) centros. Se realizaba el mantenimiento epidural con infusión epidural continua (CEI) + bolos epidurales controlados por la paciente (PCEA) o bolos epidurales intermitentes programados (PIEB) + PCEA en 64 (60,9%) y 33 (30,5%) centros, respectivamente. Quince (14,3%) centros carecían de técnicas alternativas a la analgesia epidural y 25 (23,8%) no seguían protocolos de analgesia obstétrica. Conclusión A pesar de la variabilidad en la práctica clínica en la analgesia obstétrica en España, la gran mayoría de los centros siguen recomendaciones en este campo. El margen de mejora es posible y debería considerarse como estrategia fundamental para una evolución hacia la excelencia.

BACKGROUND:Specific guidelines to manage caesarean delivery anaesthesia are lacking. A European multicentre study, ACCESS investigates caesarean delivery anaesthesia management in European centres. In order to identify ACCESS participating centres, a registration survey was created. OBJECTIVE:The aim of the current report is to describe the characteristics of ACCESS study participating centres, the rationale for the ACCESS study and the study methodology. DESIGN AND SETTING:The ACCESS study is a European multicentre cross-sectional study to describe anaesthesia management for caesarean delivery (CD) using a snapshot (2-week) design. The ACCESS registration survey gathered: contact details for National Coordinators (NC); Lead Investigators (LI) per centre; centre annual CD volume; expected no. of CD during 2-week snapshot window; centre practice information; data collection language. The ACCESS registration survey was launched July 2022 (Google Forms, Google Inc., Mountain View, CA, USA) and distributed through personal connections, national and international societies, social media networks, during Euroanaesthesia 2023, through the European Society of Anaesthesiology and Intensive Care newsletter. RESULTS:The ACCESS registration survey identified Lead Investigators for 418 centres, in 32 countries, representing an anticipated number of 15,073 CD cases over the planned 12-month study period. A median (range) of 20 (2 to 400) CD cases are anticipated per centre during the 2-week snapshot window. Most 366/418 (87.6%) centres are small, ≤2000 annual CD cases, 42 are medium 2000-5000 cases and 10 are large, ≥5000 annual CD cases. Registered centres reported in 134 (32.0%) centres that anaesthesia for caesarean delivery is performed mostly by a specialist obstetric anaesthesiologist. CONCLUSION:The ACCESS registration survey revealed variability in volume and CD practice as well as training-levels and staffing among European countries. The ACCESS study (https://www.access-study.org/) aims to generate practice data to guide CD anaesthetic management strategies.