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ANAESTHESIA FOR CAESAREAN SECTION ROLE OF INTRAUTERINE RESUSCITATION

ANAESTHESIA FOR CAESAREAN SECTION ROLE OF INTRAUTERINE RESUSCITATION. Presenter: Dr Neha Gupta Moderator: Dr Geetanjali. University College of Medical Sciences & GTB Hospital, Delhi. www.anaesthesia.co.in. email: anaesthesia.co.in@gmail.com. James Young Simpson (1811-1870). HISTORY.

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ANAESTHESIA FOR CAESAREAN SECTION ROLE OF INTRAUTERINE RESUSCITATION

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  1. ANAESTHESIA FOR CAESAREAN SECTION ROLE OF INTRAUTERINE RESUSCITATION Presenter: Dr Neha Gupta Moderator: Dr Geetanjali University College of Medical Sciences & GTB Hospital, Delhi www.anaesthesia.co.in email: anaesthesia.co.in@gmail.com

  2. James Young Simpson (1811-1870)

  3. 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

  4. 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)

  5. CAESAREAN SECTION It is defined as the birth of an infant through incision in the abdomen(laparotomy) and uterus(hysterotomy). (derived from the latin wordcaedere which imply to cut)

  6. Relative Maternal Relative CPD Maternal preference Fetal: Twins with first in non cephalic presentation Pregnancy Related Lesser degrees APH Previous Caesarean INDICATIONS FOR CAESAREAN SECTION Absolute Maternal • Cephalo-pelvic Disproportion • Non progression of labour Fetal: • Fetal Distress • Non-cephalic presentations • Multiple gestations Pregnancy Related • Abruptio Placenta • Grade 3 or 4 Placenta Previa • Cervical obstructive lesions • Large vulvarcondylomata

  7. 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,placentaaccreta, uterine rupture

  8. 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

  9. ANAESTHESIA FOR CASEAREAN SECTION Techniques of Anaesthesia: 1. Regional Anaesthesia • Subarachnoid Block • Epidural Anaesthesia • Combined Spinal-Epidural Anaesthesia 2. General anaesthesia 3. Local anaesthesia

  10. Anaesthesia for Caesarean Section Depends on: • Indication for CS • Urgency of the procedure • Maternal and fetal health • Maternal desires • If time not a factor RA preferred • Epidural for Labour Analgesia in-situ Extension of Block • RA contraindicated, or Emergency procedure GA

  11. Classification of caesarean section according to urgency Category 1- requiring IMMEDIATE delivery -a threat to maternal or fetal life Category 2- requiring URGENT delivery -maternal or fetal compromise that is not immediately life threatening Category 3- requiring EARLY delivery -no maternal or fetal compromise Category 4-ELECTIVE delivery -at time suited to the woman and maternity staff

  12. Category 1 sections should be delivered within 15 minutes Examples of category 1 include- 1.Major haemorrhage 2.Profound and persistent fetal bradycardia 3.Prolapsed cord 4.Shoulder dystocia 5.Uterine rupture

  13. 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

  14. SPINAL ANAESTHESIA SAB most common and preferred technique for CS. Advantages of SABDisadvantages • Simplicity of technique Limited Duration • Reliability • Rapid onset Hypotension • Dense neural block • Less shivering Prolonged Motor block • Minimal fetal exposure to drugs Nausea & Vomiting

  15. 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 EPIDURAL ANAESTHESIA

  16. COMBINED SPINAL EPIDURAL ANAESTHESIA • Rapid and predictable onset of SAB • Ability to augment anaesthesia CSE TECHNIQUES • Use of conventional doses of hyperbaric drugs • Sequential CSE technique • Extradural volume extension (EVE) technique

  17. COMBINED SPINAL EPIDURAL ANAESTHESIA Benefits: • Lower intrathecal dose of LA • Increased success rates for correct epidural placement • More intense block, less intra operative pain compared to epidural Disadvantages: • Untested epidural catheter • Hypotension

  18. 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

  19. 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, Hypotension, Accidental intravascular injection or dural tap under Epidural anaesthesia, PDPH, LA toxicity

  20. PRELOADING /CO-LOADING • Preloading- rapid adminisration of crystalloids (1-1.5l) prior to initiation of intrathecal injection. • Co-loading- rapid administration of crystalloids(20 ml/kg) initiated at the time of intrathecal injection. • Crystalloids/ colloids Implication – Initiation of anaesthesia should not be delayed in order to administer a fixed volume of fluid.

  21. Anti aspiration prophylaxis Increased risk of Gastric Aspiration in pregnancy • ↓ gastric motility • ↓ LES tone • ↑ gastric emptying time. • ↑ Intragastric pressure

  22. 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.

  23. POSITIONING IN RA • Minimum left lateral tilt of 25º • left lateral displacement to be maintained with a wedge under the right buttock . 1o cm 34 cm 2.5 cm

  24. 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.

  25. CHOICE OF LOCAL ANAESTHETIC FOR SAB chestnut’s obstetric anaesthesia (4th edition)

  26. Local anaesthetics for epidural anaesthesia chestnut’s obstetric anaesthesia (4th edition)

  27. DECREASE IN LOCAL ANAESTHETIC REQUIREMENT DURING PREGNANCY 1.↑ Neural susceptibility to LA 2. Epidural plexus engorgement 3. CSF changes a)↓CSF protein (↑unbound drug) b)↑ CSF pH (↑ unionised drug) 4. Apex of thoracic kyphosis higher 5.Pelvic widening & resultant head down tilt in lateral position

  28. Pelvic widening & resultant head down tilt

  29. Adjuvant agents ADVANTAGES • Improves the quality of intraoperative anaesthesia • Prolongs the postoperative analgesia • Reduce the dose of LA and thus the side effects

  30. ADJUVANTS

  31. Side effects OF OPIOID ADJUVANTS • Pruritis • Delayed respiratory depression • Nausea and vomiting • Urinary retention • Reactivation of varicella zoster

  32. Spinal Needles Quincke type Spinal Needles Whitacre type Spinal Needles

  33. 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 effect • maternal tachycardia

  34. Phenylephrine: (first line agent) • alpha-receptor agonist • Equally effective as ephedrine • better umbilical cord pH • better preserves uterine blood flow Dose : 50- 100 µg S/E - maternal bradycardia

  35. 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.

  36. EPIDURAL TEST DOSE • Role – To check the intrathecal and intravascular placement of epidural catheter • 3 ml LA + 15µg Epinephrin (1:200,000) • Response - ↑HR- 30 bpm,↑SBP – 20 mmHg in 45 sec. • Test dose is less specific in labouring patients • Points against routine use – • Aspiration of multiorifice catheter is 98% sensitive • Low concentration of LA • Recommended 2 stage safety check is ASPIRATE and OBSERVE FOR 5 MIN.

  37. 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 15µg (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.

  38. 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

  39. Regional Anaesthesia – Complications NAUSEA AND VOMITING CAUSES – 1.Hypotension hypotension Gut ischemia brain stem hypoperfusion Release of emetogenic Stimulation of vomiting Substance Centre Vomiting

  40. 2. Increased vagal activity 3. Surgical stimuli- exteriorisation of uterus 4. Bleeding 5. Drugs : ureterotonic agents Treatment • Prevention of hypotension • Metoclopramide • Ondansetron

  41. 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 Stiffness • Ocular or Auditory symptoms • Onset within 48 hours

  42. Regional Anaesthesia – Complications Pathophysiology Treatment: Early: Psychological support prevent dehydration Drugs: NSAIDs, Caffeine, Sumatriptan Epidural Saline Patch Epidural Blood Patch-15-20 mL autologous blood used. Leakage of CSF Traction on pain sensitive structures

  43. Regional Anaesthesia – Complications High Spinal Anaesthesia: • Rostral spread of intrathecal dose, or Inadvertent intrathecal administration of epidural dose • Clinical Features: • Complete motor and sensory palsy, • Hypotension, Bradycardia, • Unconsciousness, • Loss of protective airway reflexes, • respiratory arrest • Treatment: Prompt tracheal intubation and ventilation with 100% oxygen, maintenance of maternal circulation

  44. Regional anaesthesia – Complications ACCIDENTAL DURAL PUNCTURE • Incidence-3% (in obstetric patients) Steps to be followed in case of accidental dural puncture* 1.Injection of CSF from the epidural syringe back into the SAS through epidural needle 2.Insertion of epidural catheter into the SAS 3.Injection of NS through intrathecal catheter before removal 4.Administration of continousintrathecal labour analgesia 5.Leaving the intrathecal catheter in situ for a total of 12-20 hours *Kuczkowski K M et.al. ActaAnaesthesiolscand :2003

  45. Regional Anaesthesia – Complications LA toxicity: • IV injection of LA. Bupivacaine most cardiotoxic, Toxicity enhanced in pregnancy. • Clinical Features: Convulsions, Arrhythmias Cardiovascular collapse Treatment – for CNS Symptoms-symptomatic oxygen supplementation ,tracheal intubation Prevention – Epidural test dose with adrenalin 15µg.

  46. 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

  47. 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 cephalopelvicdispropotion in labour.

  48. Single shot spinal anaesthesia PATIENT PREPARATION • Preanaesthetic evaluation –history -clinical examination • Fasting was 8 hours. • Informed consent taken • Inj Ranitidine (50 mg i.v.), Inj metoclopramide(10 mg i.v.) 30 min prior to surgery • Monitoring i.e.ECG, NIBP ,Pulse oximetry. • Coloading : 1.5 l ringer lactate • Positioning : Left lateral Displacement maintained with a Wedge under right buttock.

  49. 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

  50. ANAESTHESIA FOR CAESAREAN SECTION ROLE OF INTRAUTERINE RESUSCITATION MODERATOR: DR GEETANJALI

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