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Anaesthesia for Obstetric Surgical Procedures

Anaesthesia for Obstetric Surgical Procedures. September 2010. Retained placenta. Sensory block to T10 required Spinal/existing epidural Patient potentially hypovolaemic. Repair of perineal tear. Spinal/existing epidural Good quality saddle block required Potentially hypovolaemic patient.

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Anaesthesia for Obstetric Surgical Procedures

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  1. Anaesthesia for Obstetric Surgical Procedures September 2010

  2. Retained placenta • Sensory block to T10 required • Spinal/existing epidural • Patient potentially hypovolaemic

  3. Repair of perineal tear • Spinal/existing epidural • Good quality saddle block required • Potentially hypovolaemic patient

  4. Anaesthesia for Cervical Suture • 1st/2nd trimester • Spinal/GA • If GA • Avoid prolonged exposure to nitrous oxide • Potentially teratogenic in first trimester • Avoid hypotension/hypercarbia – fetal acidosis

  5. Introduction • NHS maternity statistics 2008-09: UK c/section rate = 24.6% • RJMH c/section rate = 36.2% • NOAD 2007: anaesthesia for c/section • Spinal – 59.6% • Epidural top-up – 22.1% • GA – 10.1% • CSE – 7.2% • De novo epidural – 0.8%

  6. RCOA Audit Standards • Elective c/section > 95% RA • Emergency c/section> 85% RA • Elective c/section <1% RA to GA • Emergency c/section < 3% RA to GA

  7. Elective c/section • Common indications: • Maternal request! • Breech presentation • Previous c/section • Placenta praevia • Significant medical conditions

  8. Choice of Anaesthetic • Patients preference • Patients physical profile, health considerations, pregnancy factors • Anticipated surgical difficulties • Experience and speed of surgeon

  9. Preparation for Anaesthesia • Preop assessment • Informed consent • Antacid prophylaxis • Fully prepared anaesthetic room/theatre • Checked anaesthetic machine • Monitoring equipment • Tilting operating table • Resuscitation equipment • Trained anaesthetic assistant • Large bore I.V. access

  10. Spinal Anaesthesia • Used >90% elective LSCS • Incidence of PDPH approx 1:400 due to small gauge PP needles • Technically simple • Consistent, dense quality of block • Failure rate approx 1%

  11. Spinal Anaesthesia • Standard technique • PP needle, no larger than 25G to minimise PDPH risk • Injection at, or below L3/L4 interspace to avoid damage to conus • Diamorphine 300mcg • Injection performed in sitting position, then moved immediately to L tilted supine position on completion • Phenylephrine ivi to prevent hypotension

  12. Spinal Anaesthesia • Hyperbaric Bupivicaine 0.5% - most used LA in UK • Recommended doses vary • Surgery requires sensory blockade to T4 • Patient factors influencing dose • Height • Abdominal size

  13. Intrathecal Opiates • Fentanyl • Highly lipid soluble • Reduced intraop discomfort • Provides no post op analgesia • Morphine • Long duration of action • Little intraop effect due to poor lipophillicity • Diamorphine • Rapid onset • Long duration of action • Side Effects: • PONV approx 30% • Pruritus

  14. Spinal induced hypotension • Can cause fetal distress • Symptoms: dizziness, N&V • Should be treated aggressively • Approp positioning • Fluid preloading • Use of Phenylephrine ivi • Titrated to maternal BP • Higher fetal pH than Ephedrine

  15. Spinal after epidural • Technique most likely to lead to high/total spinal anaesthesia. ? Dural sac compression by epidural fluid • No formula for reducing spinal dose. NB inadequate block • Precautions • Warn patient of risk of conversion to GA • Assess airway • Perform spinal in approp environment • Reduction of spinal dose • Consider leaving epidural catheter in situ

  16. Epidural ‘top-up’ • Category 2 LSCS with epidural in situ • Slow onset anaesthesia • Inferior anaesthesia to spinal during surgery • L-Bupivicaine 0.5%; Ropivicaine 0.75%; supplemental Diamorphine.

  17. CSE • 3 approaches • ‘Full’ dose spinal with epidural back up if inadequate block height/duration • Reduced dose spinal with supplemental epidural top-ups • Epidural volume extension-low dose spinal extended by dural sac compression using epidural saline • ‘Needle through needle’ • Separate needle, separate interspace

  18. CSE • Used to reduce incidence of spinal failure • Tall patients • IUGR • Prolonged surgery • Reduces haemodynamic changes by more gradual onset anaesthesia; reduced risk of excessive block height • Cardiac patients • Short patients • Short duration of blockade esp motor blockade

  19. Continuous Spinal • Niche role • ‘Difficult’ equipment • PDPH • Careful titration of dose • Haemodynamic stability • Cardiac disease • Extremely small stature • Severe skeletal deformity • Extended period of anaesthesia

  20. Pain during LSCS • Leading cause of litigation • Closed claims analysis 1995-2007 • Pain during surgery - 31% (57) • Informed consent • Give adequate doses of drugs including opioid • Produce and document adequate sensory and motor block • Management • Alfentanil 250mcg iv • Entonox • Conversion to GA • NB. Clear documentation of management esp if patient refuses GA

  21. GA • Indications • Refusal of RA • Contraindications eg. Coagulopathy • Insufficient time to establish RA • Serious haemorrhage anticipated • Failed RA

  22. GA • Reliable and safe if • Aspiration prophylaxis • Trained anaesthetic assistance • Meticulous pre-oxygenation • Well rehearsed failed intubation drill • Approp drug regimen to reduce incidence of awareness • Awake extubation

  23. Drugs used for GA • RSI with cricoid pressure • Thiopentone/Propofol? • Propofol • Poorer neonatal profile • Shorter duration of amnesia • Longer time to recovery of spontaneous ventilation • Suxamethonium/Rocuronium? • Inadequate doses assoc with difficult intubations • NB 1.5mg/kg; Increased Vd • Prolonged action of Rocuronium • NB. Sugammadex

  24. Perioperative Drugs • Opiates at induction and post op analgesia • On delivery of neonate • Syntocinon 5IU and IVI • Prophylactic antibiotics • Thromboprophylaxis

  25. Complications • Failed intubation (1 in 300) • Increased fatty tissue • Complete dentition • Increased pharnygeal and laryngeal oedema • Incorrect drug dosages • Large tongue • Large breasts • Increasing obesity • Aspiration (1 in 400-600) • Awareness • Increased intaop blood loss • PONV

  26. Post op pain relief • Introp: • Diclofenac 100mg PR • Intrathecal Diamorphine • IV Morphine and TAP blocks • Post op: • Diclofenac 50mg PO TID • Paracetamol 1g PO QID • Codeine 30-60mg PO QID

  27. Emergency LSCS • Grades of urgency – category 1 to 4 • Nationally accepted classification • ‘Continuum of risk’ • Facilitates audit • Improves multidisciplinary communication • Individual, ‘case by case’ approach to decision to delivery interval

  28. Emergency LSCS • Category 1 & 2 • In utero fetal resuscitation • Syntocinon off • Position full L lateral • Oxygen • I.V fluids • Low BP – vasopressors • Tocolysis: GTN 400mcg/B2 agonist • Choice of anaesthesia • Post op analgesia • Post op care

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