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SECTION
ROLE OF INTRAUTERINE
RESUSCITATION
Presenter: Dr Neha Gupta
Moderator: Dr Geetanjali
email: anaesthesia.co.in@gmail.com
HISTORY
1847 : Introduction of inhalational agents
James Young Simpson on Jan 19, 1847 first used chloroform
to anaesthetize a woman with a deformed pelvis for
delivery.
Early 20th century: Expanded use of opioids
Twilight sleep was a technique developed by Von
steinbuchel. It combined opioids with scopolamine to
make women amnesic during labor .
Mid 20th century (1900-1930): Refinement of regional
anaesthesia
INTRODUCTION
Until 19th Century: Performed only for the most desperate
situations, with very high mortality rates.
Early 20th Century: Mortality rates 10%, but still performed
only for the most severe cases of contracted pelvis
In India the caesarean rates have increased from 21.8%
in 1988-89 to 25.4% in 1993-94 *
(* Bhasin SK, Rajoura OP, Sharma AK,et al. A high prevalence of caesarean
section rate in East Delhi. Indian J Community Med 2007;32:222-4)
CAESAREAN SECTION
Pregnancy Related
Abruptio Placenta
Grade 3 or 4 Placenta Previa
Cervical obstructive lesions
Large vulvar condylomata
Relative
Maternal
Relative CPD
Maternal preference
Fetal:
Twins with first in non
cephalic presentation
Pregnancy Related
Lesser degrees APH
Previous Caesarean
COMPLICATIONS OF CS
Hemorrhage
Uterine atony
Uterine laceration
Broad ligament hematoma
Infection
Endometritis
Wound infection
Post op complications
Cardiovascular: venous thromboembolism
Gastrointestinal: ileus, adhesions, injury
Genitourinary: bladder or ureter injury
Respiratory: atelectasis , aspiration
Chronic pain
Future risk
Placenta previa,placenta accreta, uterine rupture
PAIN PATHWAYS
During Caesarean Section:
Pain due to Incision Pfannensteil / Midline
Pain due to stretching to the skin and
subcutaneous tissues
Intraperitoneal dissection and manipulation
Additional somatic pain due to diaphragmatic
stimulation
Involves dermatomes up to T8 and visceral pain
pathways up to T4 levels
Implications: Aim is to achieve T4 dermatomal
level
Techniques of Anaesthesia:
1. Regional Anaesthesia
Subarachnoid Block
Epidural Anaesthesia
Combined Spinal-Epidural Anaesthesia
2. General anaesthesia
3. Local anaesthesia
Indication for CS
Maternal desires
If time not a factor
RA preferred
Epidural for Labour Analgesia in-situ
Extension of Block
RA contraindicated, or Emergency procedure
GA
REGIONAL ANAESTHESIA
Definitive benefits over GA, including
No risk of aspiration
No risk of failed intubation or ventilation
Less blood loss
Less fetal exposure to drugs
Better neurobehavioral score of fetus at birth
Analgesia can be extended to postoperative
period
SPINAL ANAESTHESIA
SAB most common and preferred technique for CS.
Advantages of SAB
Disadvantages
Simplicity of technique
Limited Duration
Reliability
Rapid onset
Hypotension
Dense neural block
Less shivering Prolonged Motor block
Minimal fetal exposure to drugs Nausea &
Vomiting
EPIDURAL ANAESTHESIA
Advantages
Level Titrable
Slower onset of
sympathetic block
Block height and
Duration Extendable
Less intense motor
block
Post operative
analgesia
Less Chances of DVT
Disadvantages
Slow onset of
anaesthesia
Increased failure rates
Accidental IV injection
Catheter migration
Increased chances of
total / high spinal
Technically difficult
CSE TECHNIQUES
1.Use of conventional doses of hyperbaric drugs
2.Sequential CSE technique
3.Extradural volume extension (EVE) technique
placement
More intense block, less intra operative pain
compared to epidural
Disadvantages:
Untested epidural catheter
Hypotension
GENERAL ANAESTHESIA
Indications:
Maternal refusal
Local site infection
Raised intracranial
tension
Severe Fetal Distress
Acute maternal
hypovolemia
Significant
coagulopathy
Inadequate RA/failed RA
Relative
Contraindications:
Anticipated difficult
airway
Malignant
hyperthermia
Severe asthma
CONSIDERATIONS IN REGIONAL
ANAESTHESIA
Preloading/ co-loading
Anti aspiration prophylaxis
Positioning in RA
Choice of LA
Choice of vasopressors
Epidural test dose
Complications of RA i.e. Nausea and vomiting,
PRELOADING /CO-LOADING
Preloading- rapid adminisration of crystalloids (1-
time.
- Intragastric
pressure
Antiaspiration Prophylaxis:
Planned CS:
Ranitidine 150 mg and Metoclopramide 10 mg
PO night before and 60-90 minutes before
surgery
Emergency CS :
0.3M Sodium Citrate, 30mL PO 30 Min before
Surgery.
Ranitidine 50 mg IV + Metoclopramide, 10
mg IV prior to surgery.
POSITIONING IN RA
Minimum left lateral tilt of 25
left lateral displacement to be maintained
1o
cm
2.5
cm
34
cm
POSITIONS FOR RA
Lateral position
better
uteroplacental blood
flow
more comfortable
minimises patient
movement during
needle insertion
Sitting position
Distance from skin
to epidural space is
shorter
Interspinous spaces
difficult to appreciate
Restricted use : i.e.
umbilical cord
prolapse, footling
presentation.
Dosage (mg)
Range (ml)
Duration
(min)
Bupivacaine(H)
(0.5%)
7.5-15
1.5-3
60-120
Ropivacaine
15-25
Lidocaine(H)
(5% )
60-80
60-120
1.2-1.5
45-75
chestnuts obstetric
anaesthesia (4th edition)
Dose range
Duration(min)
Bupivacaine 0.5%
75-125 mg
120-180
Ropivacaine 0.5%
75-125 mg
120-180
75-100
Adjuvant agents
ADVANTAGES
Improves the quality of intraoperative
anaesthesia
Prolongs the postoperative analgesia
Reduce the dose of LA and thus the side
efects
ADJUVANTS
DRUG
DOSAGE
Range(ml)
Duration(min)
Fentanyl
(5o g/ml)
10-25 g
0.2-0.5
180-240
morphine
0.1-0.25 mg
720-1440
Sufentanyl
2.5-5g
180-240
Midazolam
1-2 mg
Spinal Needles
Quincke type Spinal Needles
CHOICE OF VASOPRESSORS
Ephedrine:
mixed alpha and beta adrenergic receptor agonist
Increase blood pressure without a decrease in uterine
blood flow
DOSE 10 mg prophylaxis
5- 10 mg therapeutic
S/E
Tachyphylaxis
Can lower umbilical cord pH by
1.Readily cross placenta cause fetal tachycardia
2. Stimulate fetal metabolism by direct b-adrenergic efect
maternal tachycardia
alpha-receptor agonist
Why phenylephrine?
Does not have beta adrenergic agonist action
thus
No beta adrenergic action in fetus and thus
better maintain fetal metabolism
Least chances of fetal acidosis or hypoxia, as
reflected by better maintained umbilical cord
pH.
RECOMMENDED SAFETY
PROCEDURE BEFORE INJECTION OF
TEST DOSE
Perform aspiration test
In labour- 2 ml of 1.5- 2% LA with out ADR
For C.S 3 ml of 1.5- 2% LA with 15g (1: 200,000)
ADR
In PIH, IUGR, DM or Fetal distress Bupivacaine in 5
ml increments
Test dose failure or Total spinal block Treat promptly
Prince G et al: Obstetric epidural test dose. A reappraisal.
Anaesthesia 1986.
Regional Anaesthesia
Complications
HYPOTENSION :
Def: in SBP of more than 20%-30% from baseline
OR a SBP lower than 100 mm hg.
Prevention :
Left uterine displacement
Prehydration
Prophylaxis with vasopressor
Leg elevation or wrapping
Treatment : i.v fluids
vasopressors
Regional Anaesthesia
Complications
NAUSEA AND VOMITING
CAUSES
1.Hypotension
hypotension
Gut ischemia
hypoperfusion
brain stem
Release of emetogenic
Stimulation of vomiting
Substance
Centre
Vomiting
2.
3.
4.
5.
Treatment
Prevention of hypotension
Metoclopramide
Ondansetron
Regional Anaesthesia
Complications
Post Dural Puncture Headache
Risk factors:
Age<40
Women
Pregnancy
Use of wider guage and dura cutting spinl needle.
Symptoms:
Frontal / Occipital headache
Positional
Varying severity
Neck Stifness
Ocular or Auditory symptoms
Onset within 48 hours
Regional Anaesthesia
Complications
Pathophysiology
Leakage of CSF
Treatment:
Early: Psychological support
prevent dehydration
Drugs: NSAIDs, Cafeine, Sumatriptan
Epidural Saline Patch
Epidural Blood Patch-15-20 mL autologous blood
used.
Regional Anaesthesia
Complications
High Spinal Anaesthesia:
Rostral spread of intrathecal dose, or Inadvertent
Regional anaesthesia
Complications
ACCIDENTAL DURAL PUNCTURE
Incidence-3% (in obstetric patients)
Regional Anaesthesia
Complications
LA toxicity:
IV injection of LA.
ROLE OF INTRALIPID
Role - local anesthetic-induced cardiac arrest that is unresponsive
to standard therapy, in addition to standard cardio-pulmonary
resuscitation
Mechanism: . may serve as a lipid sink, providing a large lipid
phase in the plasma, enabling capture of the local anaesthetic
molecules and making them unavailable to tissues .Dose regime:
Intralipid 20% ,1.5 mL/kg i.v over 1 minute ,followed by 0.25
mL/kg/min,
Repeat bolus every 3-5 minutes up to 3 mL/kg total dose until
circulation is restored
Maximum dose - 8 mL/kg
Case 1
24 yr old, primigravidae, ASA grade I, with
complaints of
Amenorrhea for 9 months
Leaking per vaginum for 2 hours
Pain abdomen for 2 hours
Obstetric history- WNL
GPE WNL
Plan - Emergency LSCS in view of cephalopelvic
dispropotion in labour.
PATIENT PREPARATION
Preanaesthetic evaluation history
-clinical examination
Fasting was 8 hours.
Informed consent taken
Inj Ranitidine (50 mg i.v.), Inj metoclopramide(10
Sitting position
25 G quincke needle; in L3-L-4 space ;
10 mg(2 ml) of 0.5%bupivcaine H
T4 level achieved .
Oxygen by face mask to provide an Fio2 0.5 -0.6
No hypotension reported.
Pfannensteil Incision made, baby delivered within 15
min.
Injection oxytocin (5U i.v. f/b 15 U slow i.v. in 500 ml RL)
I/O - No complications.
Post op : level T6
MODERATOR: DR GEETANJALI
GENERAL ANAESTHESIA
GA associated mortality
Pulmonary aspiration- 1: 400-500 versus 1:
2000
Failed tracheal intubation 1: 300 versus 1:
2000
CONSIDERATIONS IN GA
Airway assesment
Positioning
Anti-aspiration prophylaxis
Preoxygenation
RSI
Skin incision uterine incision time, Uterine incision
AIRWAY ASSESSMENT
1.Mallampatti classification
2.Atlanto occipital joint extension
3.Thyromental distance
4. Mandibular protrusion test
Benumofs 11 point sytem for evaluation of
airway
AIRWAY ASSESSMENT
1.Mallampatti classification
2.Atlanto occipital joint extension
3.Thyromental distance
4. Mandibular protrusion test
Benumofs 11 point sytem for evaluation of
airway
CONSIDERATIONS IN GA
Airway assesment
Positioning
Anti-aspiration prophylaxis
Preoxygenation
RSI
Skin incision uterine incision time, Uterine incision
POSITIONING
RAMP POSITION in
morbidly obese
patients
-ideal position leads to
horizontal alignment
between the external
auditary meatus and
sternal notch
-achieved by use of
blankets or
commercially
available devices
CONSIDERATIONS IN GA
Airway assessment
Positioning
Anti-aspiration prophylaxis
Preoxygenation
RSI
Skin incision uterine incision time, Uterine incision
Anaesthesia
ProblemDifficult laryngoscopy and failed
intubation in group of patients who are
already at risk of rapidly developing
hypoxemia
INTRAVENOUS AGENTS
AGENT
F:M
THIOPENTONE
0.4 to 1.1
PROPOFOL
KETAMINE
CLINICAL
IMPLICATIONS
REMARKS
Freely difusible.
Prompt and reliable
induction.
Fetal brain levels <
levels enough to
cause depression
Popular agent of
choice
No analgesic and
amnesic efects.
0.65 to
0.85(bolus
2 to 2.5
mg/kg)
0.50 to
0.54 (inf @
6-9
mg/kg/hr)
Sedative efect on
neonate
Lower 1 and 5 min
apgar scores (2.8
mg/kg)
1.26( in 1.5
0.5
min)
Used in
in hemodynamic
hypotension
Used
and asthma
instability
Rapidly crosses
placenta
agent
Post-delivery:
O2:N2O :: 30:70
Reduction of Inhalation agent(0.5-0.75 MAC)
Morphine 0.1 mg/kg or Fentanyl 1-2 g/kg.
Extubation done when neuromuscular blockade
fully reversed and patient is awake and responds
to command.
UTEROTONIC AGENTS
1.Oxytocin infusion
Route : i.v.
Side efects :hypotension ,tachycardia, water
intoxication
Bolus injection Maternal tachycardia &
Hypotension
Dose : 200 Mu/min
2.Methylergometrin
Route :i.m /i.v.
Side efect: Severe Hypertension, bradycardia
Dose : 0.2 mg
EXTERIORISATION OF UTERUS
Increase the incidence of nausea and
vomiting
Cause a tugging sensation
Require a higher level of dermatomal block
episodes
How to avoid:
Lyons and Macdonald* recommend Larger induction dose of barbiturate(thiopental 5-7
mg/kg)
Isoflurane 1% prior to delivery
After delivery: administration of opioid and decrease conc
.of isoflurane
For RA:
Midazolam 0.075 mg/kg provide 30-60 min of anterograde
amnesia in RA
Complications of general
anaesthesia
ASPIRATION PNEUMONITIS
First Described by Mendelson in 1946.
Chemical injury to tracheobronchial tree and alveoli
caused by inhalation of sterile acidic gastric
contents.
RISK FACTORS:
Gastric Volume > 25mL
Gastric pH < 2.5
Predisposing Factors:
Impaired LES tone
Impaired laryngeal reflexes
Altered gastric motility
Absence of pre-operative fasting
Aspiration Pneumonitis
Pathophysiology:
Aspiration of Acidic Contents
Epithelial Degeneration
Interstitial & Alveolar Oedema
Haemorrhage into alveoli
Destruction of
Pneumocytes
Decreased
Surfactant
Hyaline membrane
Formation
V/Q mismatch
Destruction of
Microvasculature
Increased Pulmonary
Vascular Resistance
Increased Vd/Vt
Aspiration Pneumonitis
Diagnosis
Time of presentation variable First 24 Hours
History of predisposing factors
Wheeze & laboured breathing
Progresses to ARDS and Pulmonary Oedema
CXR Changes with Hypoxemia: Suspect Silent
Aspiration
CXR: B/L flufy interstitial shadows
Aspiration Pneumonitis
Treatment:
Mild Nebulisation, Oxygen Inhalation
Severe Prompt intubation &Tracheal Suctioning
before Positive pressure ventilation
PEEP, CPAP To maintain oxygenation
Mech. Ventilation Low tidal volume (6mL/kg)
and Plateau Pressure <30 cm H20
Fluids : CVP guided
Antibiotics- not efficaceous, can lead to infection
by resistant organisms.
Steroids- not recommended
patients
- In elective surgery fasting should be
6-8 hours
depending on the fat content
Complications of general
anaesthesia
HYPOTENSION most important cause Induction agents-intravenous
-inhalational
Use of oxytocin
Major Blood loss /PPH
Treatment
using the induction agent in appropriate doses
use of vasopressors as previously discussed
active management of PPH
Complications of general
anaesthesia
UTERINE ATONY
Causes:
High parity
Overdistended uterus
Prolonged labour
Abnormal placentation hypotension
Treatment :
Oxytocin(200mU/ min)
Methylergometrine(0.2 mg i.m.)
Prostaglandin F2 (250 g i.m.)
Complications of general
anaesthesia
POST OP NAUSEA AND VOMITING
Risk factors
Female gender
History of motion sickness
Use of perioperative steroids
Non smoking status
Dose
Time
Metoclopramide
10 mg i.v.
Prior to surgery or
after cord
clamping
Ondansetron
4 mg i.v.
After cord
clamping
Granisetron
40mcg/kg i.v.
After cord
clamping
CASE 2
-MPG 2
-Neck movements-normal
-TMD - WNL
Management of Failed
Intubation in Pregnant
Patients
Failed
Intubation
Adequate
Assess Fetus
Fetal Distress
Mask with
cricoid
pressure
No Fetal Distress
Surgical Airway
Awaken Patient
Regional
Intubate
Fail
Succeed
Extubate over
Jet Stylet
Fail
Succeed
Management of Failed
Intubation in Pregnant
Patients
Failed Intubation
Call for help
Ventilate with 100% Oxygen
(1) Facemask with cricoid pressure OR
(2) LMA and cricoid pressure
Assess Ventilation and Oxygenation
Inadequate
CVCI
Consider Non surgical Airway
(1) LMA with Cricoid Pressure OR
(2) Combitube OR
(3) TTJV
Surgical Airway:
(1) Cricothyrotomy OR
(2) Tracheostomy
Deliver Baby
Disadvantages :
1.Placement can induce vomiting, laryngospasm
2.Aspiration of gastric contents is not prevented.
3.Improper positioning can lead to gastric
insufflation
4.Use of PPV may be limited.
5.Multiple insertion attempts may lead to airway
trauma.
However, use of PLMA avoid these disadvantages
to an extent
KEY POINTS
During pregnancy LES tone is , gastric motility
REFERENCES
Obstetric Anaesthesia, Principles and Practice,
Anaesthesia, 7th Ed
www.anaesthesia.co.in
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email: anaesthesia.co.in@gmail.com
www.anaesthesia.co.in
email: anaesthesia.co.in@gmail.com
anticipated difficult
airway
Accept airway
manipulation
avoid airway
manipulation
labour
v
v
CSE
LEA
CSA
Caesarean delivery
elective
emergenc
y
airway preparation
Awake laryngoscopy
Awake fob intubation
SPINAL
LEA
CSE
CSA
SPINAL
CSE
CSA
Awake tracheostomy
Propofol:
Controversial
Rapid smooth induction, rapid awakening.
Dose: 2-2.5mg/kg
F:M ratio at Delivery: 0.7
Neonatal Apgar scores and neurobehavioral scores
Ketamine:
Rapid onset. Has sympathomimetic action.
Better in Asthma and hypovolemia
Provides analgesia, amnesia and hypnosis
Dose 1mg/kg.
100% oxygen can be administered
Disadvantages
Muscle Relaxants:
Succinyl Choline:
Dose-1-1.5mg/Kg
Optimal intubation time of 45 Sec
Minimal placental transfer
Rocuronium:
Dose: 0.6mg/kg (Intubation time 98 sec)
Vecuronium:
Dose:0.1 mg/kg(onset time -144 sec)
Used when scholine is contraindicated