Husong Li, M.D., Ph.D. Assistant Professor Department of Anesthesiology University of Texas Medical Branch at Galveston, Texas
Introduction
Cesarean-section (CS) deliveries have accounted for nearly 1 million of approximately 4 million annual deliveries in US. Approximately 15% of CS was performed under general anesthesia in US (Anesthesiology Hawkins, JL 1997). Majority of CS were done under urgent or emergent situations. In 2000, CS rate is about 22% in US, and 31.8% in UTMB.
Fetal distress Significant coagulopathy Acute maternal hypovolemia and Homodynamic instability Sepsis or local skin infection failed regional anesthesia Maternal refusal of regional anesthesia
& Examination, LABs Airway evaluation Aspiration prophylaxis Basic machine and monitor preparation
Weight gain Oropharynx edema Enlarged breasts Obesity with short neck Full dentition Mallampati IV and mamdibular recession History of difficult airway
Airway evaluation
Anticipation of difficult endotracheal intubation (1 in 300 in OB and 1 in 2000 all patients) Thorough examination of neck, mandible, dentition, and Oropharynx Training and experience (Hawthorne L. Br J. Anesth 1996; 76: 680-684) Sniffing position
Airway evaluation
sniffing position
Moderate head elevation, extension of atlanto-occipital, and flexion of the lower portion of the cervical spine
2-3 different blades, ie MAC 3&4 Miller 2 6 to 7 mm ETT tubes with stylets LMAs sizes 3 and 4 Emergency airway cart ready in the OR Fiberoptic bronchoscope Possible surgical airway equipment
Aspiration prophylaxis
Pulmonary aspiration: 1 in 400-500 in OB versus 1 in 2000 in all surgical patients No agent or combination of agents can guarantee that a parturient will not aspirate or develop pneumonitis following failed intubations
Decrease in gastric and intestinal motility delayed gastric emptying by anxiety and pain Relaxation of lower esophageal sphincter tone Increase in abdominal pressure Increase gastric acid secretion Patients not fasting
PO 30 ml 0.3 M sodium citrate 15-30 minute prior to induction H2 blocker, ranitidine 50 mg IV Metoclopramide 10 mg IV, at least 5 minute prior to induction Omeprazole 40 mg the night before and the AM of surgery for high risk patients Ondansetron 4-8 mg IV
Prevention of Aspiration
Cricoid
pressure Adequate oxygenation of patient Treat hypotension promptly Efficient and timely intubation Orogastric or nasogastric tube Awake extubation
Monitors: esp. capnograph Suction tubing functional Airway equipments ready and functional LMAs: 2nd line of defense of difficult airway Others: ie. meds
Positioning Oxygenation Monitors Induction of general anesthesia Maintenance of general anesthesia Emergence from general anesthesia
Intraoperative ManagementPositioning
OR bed should be allowing trendelenburg and reversed positions Sniffing position Patients in supine position with a wedge under the right hip Head and back up position if preparing awake fiberoptic intubation
Intraoperative ManagementDenitrogenation
Denitrogenation
with O2 as soon as patient on OR bed Seal mask to achieve 100% O2 3-5 minutes or 4 VC breaths of 100% O2 O2 saturation drops faster during apnea (increase VO2 and decrease FRC)
Intraoperative ManagementMonitors
Pulse
oximeter probe Right size BP cuff Electrocardiographic electrodes capnograph Temperature monitor readily available Urinary output
Intraoperative Management
Communicate with surgeons and nursing staffs while pt is prepared and draped for surgery
Final check for your READINESS FOR INDUCTION of general anesthesia
sequence induction Cricoid pressure maintained until endotracheal tube cuff inflated and tube placement confirmed Agents:Thiopental/Ketamine/Propofol/ Etomidate/Succinylcholine
Induction Agents-Thiopental
Thiopental (STP) 2-5 mg/kg IV Fast and reliable Negative inotrope and vasodilator Cross placenta; STP concentration rarely exceed the threshold for fetal depression with dose less than 4 mg/kg No evidence of adverse effect of STP on fetus even the induction-to-delivery (ID) interval is prolonged; keep incision to delivery time less than 4-7 minutes
Induction Agents-Propofol
Propofol 1-2.5 mg/kg IV Rapid induction and rapid awakening Negative inotrope and vasodilator May inhibit oxytocin induced uterine contraction Can be rapidly cleared from neonatal circulation Dose greater than 2.8 mg/kg may result in lower apgar scores and lower neurobehavioral scores at 1 hour after delivery comparing with STP, but similar neurobehavioral scores by 4 hours after delivery (Celleno D. Br J Anesth 1989; 62:649-54)
Induction Agents-Ketamine
Ketamine 1-2.0 mg/kg IV Modest hemorrhage or parturient asthma Provide rapid analgesia, hypnosis, and amnesia May depress myocardium and reduce CO and BP in severe hypovolemic patients Avoid in hypertensive patients More than 2 mg/kg may associate with fetal depression Maternal psychotropic profiles: dreaming, dysphoria, hallucination during emergence (benzodiazepine reduce the side effects)
Induction Agents-Etomidate
Etomidate
0.2-0.3 mg/kg IV Cause little CV depression-for HD unstable parturient Neonatal adrenal suppression? pain at injection site Myoclonus
Induction Agents-Succinylcholine
Succinylcholine
mg/kg IV Spontaneous ventilation may resume in 2-3 minutes with low dose SUX (0.30.5 mg/kg), but peak time delayed by about 10-15 seconds 3rd line of defense of difficult airway Recovery from intubation dose of SUX is unchanged in the pregnant patients
PREDELIVEY 50% O2/50%N2O/0.5% Isoflurane 100% O2/1-1.5% Isoflurane POSTDELIVERY 50-70% N2O/30-50%O2/ 0.5% Isoflurane/Narcotics Minimize volatile agents to prevent postpartum hemorrhage; 0.5 MAC does not significantly increase maternal blood loss
bolus when needed Nondepolarizing agents accordingly ie. Nimbex, Vecuronium, Rocutonium. *Oxytocin 10-40 U IV infusion *Antibiotics of choice
Stomach emptied via an OG tube Upper airway suctioned Nondepolarizing agents reversed adequately Opioids for pain relief Extubation when patients regain protective reflexes; are able to maintain airway; respond appropriately to verbal commands; and are hemodynamically stable
Administration
or combine ketamine and thiopental for induction Minimize of induction to delivery interval 50%N2O/O2 with following AGENTS reduce awareness to less than 1 %
0.6% isoflurane 1% sevoflurane 3% desflurane
Decision to Incision or interval: 30 minutes? Uterine Incision to Delivery (UD) interval should be less than 3 minutes (Datta et al Obstet & Gynecol
1981; 58:331-335. Crawford JS. Et al. Br J. Anesth 1973; 45:726-732)
Neonates delivered after 3 minutes following uterine incision had lower apgar and acidotic blood gas Ultimate neonatal outcome? (Ong BY. Et al Anesth Analg 1998;
68:270-5)
incidence of low 1 minute apgar scores in elective under GA Increase incidence of low 1 and 5 minutes apgar scores in emergency under GA No different in ultimate neonatal outcome
incision Contraction of myometrial muscles Vasoconstrictors: prostaglandin released from fetus and placenta Maternal catecholamine release
to PACU with O2 Hypoxemia: airway obstruction and hypoventilation Hypotension Pain control Nausea and Vomiting