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"apellidos" => "Gilsanz" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">3</span>" "identificador" => "fn0015" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Anestesia-Reanimación, Hospital Universitario La Paz, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Cirugía, Facultad de Medicina, Universidad Autónoma de Madrid, Honorary Member ESAIC, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Estándares de organización y práctica clínica en analgesia y anestesia obstétrica (EUROMISTOBAN). Un documento europeo" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Obstetric anaesthesia is an essential part of daily practice in almost every hospital in the world. Epidural analgesia has been routinely administered for labour pain in Spain and neighbouring countries for about 25 years, and for this reason anaesthesiologists now form part of most obstetric teams during child birth. In this capacity, we administer not only neuraxial nerve blocks, but also perioperative medicine in pregnant women as part of our daily practice.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Since the dawn of anaesthesia, patient-centred safety and quality of care have been among of the goals of our specialty. Contributions from the basic sciences and clinical practice, together with technological advances, have led to the emergence of a more scientific approach to anaesthesia, and over the past 20 years, safety and organizational factors have come under particular scrutiny.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> During this period, many things have changed in medical practice in general and in delivery rooms in particular, particularly in terms of patient safety. Numerous documents, protocols and guidelines have been published on clinical excellence in the difference situations encountered by obstetric patients.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–8</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">International context: why do we need European recommendations?</span><p id="par0015" class="elsevierStylePara elsevierViewall">The scientific societies of all industrialized, developed, and developing countries have gone to great lengths to develop guidelines. In Spain, official statements have been sponsored by SEDAR, SEGO and other scientific societies in partnership with the Ministry of Health,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> which have been useful in organizing obstetric care. Till now, however, we have not had a consensus statement that would ensure that all maternity centres Europe-wide, be they local, public, private, or teaching hospitals, meet the minimum standards of care required in Europe, and this is what we have tried to achieve with this recently published consensus statement: “European Minimum Standards in Obstetric Anaesthesia and Analgesia: EUROMISTOBAN”.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Although the World Federation of Societies of Anaesthesiologists has published a series of standards, they have a more global perspective and are not focused on obstetric patients or on Europe, and in certain aspects, therefore, are not applicable to our setting.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Various European<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–8</span></a> and American<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> scientific societies have published guidelines and protocols, including the first, second and upcoming third edition of SEDAR’s <span class="elsevierStyleItalic">Protocolos Asistenciales de la Sección de Anestesia Obstétrica</span> [Anaesthesia protocols in Obstetrics].<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">The origins of the EUROMISTOBAN project</span><p id="par0025" class="elsevierStylePara elsevierViewall">The idea for the EUROMISTOBAN<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> emerged from meetings held between the various committees of the European Society of Anaesthesia and Intensive Care and the heads of the Section of Anaesthesia and Intensive Care of the European Union of Medical Specialists (EBA/UEMS). The document was finalised under Spanish leadership in partnership with European decision-makers in obstetric anaesthesia and the organisation that oversees resident training in Europe (EBA/UEMS). When the statement was drafted, the first author held leadership positions in the European Society of Anaesthesia and Intensive Care and in the EBA/UEMS, a circumstance that gave both teams the opportunity to work towards a common goal. The EUROMISTOBAN is not a protocol, but instead attempts to embrace the differences in routine clinical practice and, focusing on what we have in common, reach a consensus on the equipment, resources and actions required to provide obstetric patients with quality care anywhere in Europe. Standardising obstetric anaesthesia in Europe follows in the footsteps of the EBA/UEMS European training requirements for anaesthesiology residents,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> which, like EUROMISTOBANT, focuses on what unites us in Europe and not on what separates us.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">The participants in the project</span><p id="par0030" class="elsevierStylePara elsevierViewall">Thirteen authors from 7 different European countries (Spain, France, Germany, Israel, Latvia, Italy and the United Kingdom) worked together to draft the EUROMISTOBAN. In this case, the experts prepared a document for use by the authorities, and not the other way around. As stated in an editorial of <span class="elsevierStyleItalic">Anesthesia & Analgesia,</span> specialty fields must evolve through the work of specialists.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The importance of this document in Spain and Europe will depend on our mutual capacity for transfer and involvement, and on the outlook of existing service managers and leaders in obstetric anaesthesia. At present, however, the framework on which the healthcare system is based depends on political and economic criteria, and is therefore beyond our remit.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Content of the recommendations</span><p id="par0035" class="elsevierStylePara elsevierViewall">This document deals with 10 core topics<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1)</span><p id="par0040" class="elsevierStylePara elsevierViewall">Human Resources.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2)</span><p id="par0045" class="elsevierStylePara elsevierViewall">Technical equipment and drugs.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3)</span><p id="par0050" class="elsevierStylePara elsevierViewall">Preoperative evaluation.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4)</span><p id="par0055" class="elsevierStylePara elsevierViewall">Initiation of labour analgesia.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5)</span><p id="par0060" class="elsevierStylePara elsevierViewall">Maintenance of labour analgesia.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6)</span><p id="par0065" class="elsevierStylePara elsevierViewall">Conversion of labour epidural analgesia into anaesthesia for caesarean delivery.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7)</span><p id="par0070" class="elsevierStylePara elsevierViewall">Standard management for caesarean delivery.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8)</span><p id="par0075" class="elsevierStylePara elsevierViewall">High-risk obstetric patient management.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">9)</span><p id="par0080" class="elsevierStylePara elsevierViewall">Postoperative care.</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">10)</span><p id="par0085" class="elsevierStylePara elsevierViewall">Maternal cardiac arrest.</p></li></ul></p><p id="par0090" class="elsevierStylePara elsevierViewall">1) The differences in obstetric anaesthesia practice among European countries became apparent when we conducted a survey to ascertain the availability of an anaesthesiologist to perform an "urgent" caesarean section, and the optimal response time. Practice, as shown in the consensus document, varies considerably: in some countries anaesthesiologists are on call, in others they are available in the labour suite, and in other cases there is no specific response time. This is an issue that warrants further investigation in Spain, as it has a direct bearing on the well-being of both the mother and the foetus. It would be highly beneficial to standardise the concept of urgency using standard classifications and definitions,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> and to obtain a clear understanding of the level of care available in units providing services to obstetric patients.</p><p id="par0095" class="elsevierStylePara elsevierViewall">2) Delivery rooms and operating rooms must have an adequate supply of medication and sufficient equipment to be able to deal with obstetric (bleeding, sustained foetal bradycardia, etc.) or anaesthesia (difficult airway, failed block, patients with comorbidities) emergencies and effectively resolve nerve block (high block, local anaesthesia toxicity, anaphylaxis, etc.) and other complications. There must also be clear protocols for transfer to referral hospitals in the case of high-risk patients or complications that cannot be resolved by the treating hospital. For these reasons, the afore-mentioned consensus statement published in the <span class="elsevierStyleItalic">European Journal of Anaesthesiology</span> includes detailed tables that describe these measures and/or essential drugs, and the ideal or recommended course of action. The core message the authors wish to transmit is that obstetric operating rooms should be equipped with the same technical, pharmacological, and human resources available in other operating rooms in the hospital.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">3, 4 and 5) Some recent articles recommend implementing protocols for administering high volume/low concentration neuraxial analgesia to achieve optimal pain relief with minimal motor blockade to minimise the effect of motor blockade on dilation and the type of delivery. Correct use of the techniques available allows clinicians to personalize analgesia as far as possible, and there is clear evidence that modern epidural analgesia does not affect outcomes in childbirth.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Given the fail rate of epidural analgesia, experts recommend developing local protocols. In this regard, an algorithm<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> and analgesia protocols that have been shown to reduce the failure rate, such as the use of programmed intermittent boluses, have been developed.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18,19</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Neuraxial analgesia is not a single technique, and either epidural or combined techniques can be used, depending on obstetric and pain-related factors. Various analgesia regimens based on combining local anaesthetics with opioids or other adjuvants can be used. Labour pain management is constantly evolving in an effort to find the best quality analgesia with the least effect on the mother and foetus. Smart perfusion pumps with feedback based on consumption and the progress of labour are possibly the most highly developed option at present, although further advances will continue to be made in this field.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> The indication for epidural or combined analgesia, the technique used, and the level of evidence for each approach have changed over time; for example, the indications for the state-of-the art epidural-dural puncture technique have yet to be definitively established.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Labour analgesia is a source of ongoing concern. A recent study associated epidural analgesia with an increased incidence of autism.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> This paper, however, that has been criticised by many scientific societies, such as SOAP and ACOG,<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> due to the numerous biases detected. Other studies have also raised concerns with regard to the effect of neuraxial analgesia on breastfeeding<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> and postpartum depression,<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> and the association between intrapartum hyperthermia and epidural analgesia, although some of these studies may also be biased.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> In short, neuraxial analgesia for labour pain is a dynamic, constantly evolving approach that is the focus of a considerable number of studies each year. Good neuraxial analgesia is not at odds with the current trend towards natural or minimal intervention birth, provided patient safety is guaranteed, and in this respect standards are also useful.</p><p id="par0110" class="elsevierStylePara elsevierViewall">6 and 7) It is important to bear in mind the high incidence of caesarean section in Europe, particularly in Spain. This is not the place to question or address this issue, but anaesthesiologist are under the obligation to provide adequate anaesthesia for this procedure. Regional techniques should be prioritised as much as possible. Local protocols should be developed on the administration of drugs to prevent and treat hypotension secondary to spinal anaesthesia, and on the minimum effective doses of oxytocin to avoid additional maternal hypotension.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> Prophylaxis against hypotension in caesarean section is now a burning topic in the specialized literature. The use of prophylactic phenylephrine infusion has surpassed that of ephedrine, and more evidence regarding the safe use of norepinephrine for this indication will probably emerge in the near future.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28–30</span></a> Some recommendations regarding general anaesthesia in caesarean section are currently the subject of debate; however, acid aspiration prophylaxis is still recommended. It is more important to develop local protocols to deal with difficult intubation. The implementation of enhanced recovery protocols after caesarean section will modify some of the recommendations in coming years.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> In caesarean section, anaesthesia management does not end once the procedure has finalised, but continues into the postoperative period, during which patients should receive the same level of monitoring as any other postoperative patient, depending on individual needs. Different levels of care can also be provided in postanaesthesia care units, bearing in mind the need for immediate skin-to-skin contact with the infant, provided the mother’s status is favourable.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> Neuraxial opioids (epidural or intrathecal) should be administered as part of a multimodal analgesia regimen in order to avoid as far as possible an increase in the incidence of opioid addiction, a true epidemic in the Western world.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">8 and 9) In Europe, and in Spain in particular, the number of high-risk patients requiring analgesia and anaesthesia management during childbirth and strict postpartum follow-up is increasing. This population includes elderly women, obese women, patients with hypertension or diabetes, and the growing number of women with congenital heart disease wishing to fulfil their dreams of motherhood. The immigrant population also presents a challenge in terms of high obstetric risk; their pregnancies are not as well controlled, and there is evidence of higher morbidity and mortality in this population. In this day and age, patients must be informed of all the risks and analgesic alternatives available, and be allowed to make their own choice. Mortality reports published in Europe<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">34,35</span></a> show that the highest mortality rates are found among the most deprived groups, obese patients, and those with emerging comorbidities - a situation that may change morbidity and mortality rates in coming years. A national registry of maternal mortality created by medical professionals would be of the utmost interest, as it would allow us to compare ourselves with other European countries and thus improve our standards and results globally.</p><p id="par0120" class="elsevierStylePara elsevierViewall">10) Some situations, such as maternal sepsis or cardiac arrest, require particular attention. Sepsis codes must be extended to the obstetric ward, and we believe it is of vital importance to introduce the modified obstetric early warning scoring systems‒MEOWS‒widely used in the United Kingdom, which allow clinicians to act quickly in case of maternal impairment.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">A commitment to maternal safety</span><p id="par0125" class="elsevierStylePara elsevierViewall">The Declaration of Helsinki on patient safety, published 11 years ago<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> recommends that all institutions should have local protocols and the necessary facilities for managing the following:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">1)</span><p id="par0130" class="elsevierStylePara elsevierViewall">Preoperative assessment and preparation.</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">2)</span><p id="par0135" class="elsevierStylePara elsevierViewall">Checking equipment and drugs.</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">3)</span><p id="par0140" class="elsevierStylePara elsevierViewall">Syringe labelling.</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">4)</span><p id="par0145" class="elsevierStylePara elsevierViewall">Difficult/failed intubation.</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">5)</span><p id="par0150" class="elsevierStylePara elsevierViewall">Malignant hyperpyrexia.</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">6)</span><p id="par0155" class="elsevierStylePara elsevierViewall">Anaphylaxis.</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">7)</span><p id="par0160" class="elsevierStylePara elsevierViewall">Local anaesthetic toxicity.</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">8)</span><p id="par0165" class="elsevierStylePara elsevierViewall">Massive haemorrhage.</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">9)</span><p id="par0170" class="elsevierStylePara elsevierViewall">Infection control.</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">10)</span><p id="par0175" class="elsevierStylePara elsevierViewall">Postoperative care including pain relief.</p></li></ul></p><p id="par0180" class="elsevierStylePara elsevierViewall">The crisis caused by the COVID 19 pandemic is an additional challenge to our healthcare system in particular and the welfare state in general. Future leadership roles have yet to be decided, and this might be the moment for China and emerging countries to come to the fore. Some professionals will not consider this to be important or relevant to EU obstetric standards, particularly considering that other obstetric standards published by the World Federation of Societies of Anesthesiologists, made up of powerful scientific societies such as the American Association of Anesthesia (ASA), Anesthesia Association of Australia and New Zealand (ANZCA), and the Institute of Clinical Excellence of the United Kingdom (NICE) may have little relevance to the situation in European. The European care model can only be maintained by joint protocols and position statements that send a clear message of scientific leadership, and respect for diversity and for the individual. Protocols, guidelines and recommendations complement each other, and the creation of minimum standards has proven to be useful in other specialty fields. We will update this consensus statement over the next 4 years, but meanwhile we believe it will be a useful tool for Spanish anaesthesiologists who perform obstetric anaesthesia as part of their clinical practice, and will help us standardise clinical practice across Europe in order to improve patient safety.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "International context: why do we need European recommendations?" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "The origins of the EUROMISTOBAN project" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "The participants in the project" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Content of the recommendations" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "A commitment to maternal safety" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:3 [ 0 => array:3 [ "etiqueta" => "1" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Honorary Secretary European Board of Anaesthesia (EBA-UEMS).</p>" "identificador" => "fn0005" ] 1 => array:3 [ "etiqueta" => "2" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">WFSA Obstetric Anaesthesia Committee Member, WFSA Council Member.</p>" "identificador" => "fn0010" ] 2 => array:3 [ "etiqueta" => "3" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Vicepresidente Sección Anestesia Obstétrica SEDAR.</p>" "identificador" => "fn0015" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:35 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The Helsinki Declaration on patient safety in anaesthesiology" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J. 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