AMBULATORY ANESTHESIA AND OBSTETRIC ANESTHESIA

1. AMBULATORY ANESTHESIA AND OBSTETRIC ANESTHESIA Berrin Günaydın, MD, PhD Gazi University Faculty of Medicine Department of Anesthesiology Obstetric Anesthesia Ankara - Turkey

2. GAZI UNIVERSITY FACULTY OF MEDICINE

3. Definition of ambulatory anesthesia Preoperative Evaluation History taking Physical examination Fasting & medications Laboratory screening Premedication Monitorization Anesthesia choices Postoperative Care for obstetric procedures done on ambulatory basis Objectives

4. Ambulatory (outpatient) surgery Basic advantages Economic savings Earlier ambulation Lessened risk of nosocomial infections Anesthesia for ambulatory surgery Patients return home within 24 hours of an operative procedure Definition

5. Procedures done on ambulatory basis • Evacuation of incomplete miscarriage • Surgical treatment of tubal ectopic pregnancy • Cervical cerclage • External cephalic version • Hysterosalpingography (HSG) - Hysteroscopy • Assisted reproductive technologies - procedures • Transvaginal ultrasound guided oocyte retrieval (TUGOR)

6. Questionnaires forscreening & detecting common medical problems Maternal death & anesthetic history Relevant obstetric history Preoperative EvaluationHistory taking

7. Measurement of vital signs (pulse, blood pressure, respiratory rate, temperature) Airway, heart & lung examination Back examination(when neuraxial anesthesia is planned) Preoperative EvaluationPhysical examination

8. Clear fluids Modest amount is allowed up to2 h prior to induction of anesthesia Solids should be avoided 6-8 h depending on the type of ingestion (e.g.fat) Patients should bring their own medications Antihypertensives should be taken Oral hypoglycaemics should be omitted Preoperative EvaluationFasting & Chronic medications White P. Ambulatory anesthesia advances into the new ilennium. Anesth Analg 2000 Hawkins. ASA Practice Guidelines for Obstetric Anesthesia IJOA 2007

9. Preoperative EvaluationLaboratory screening • Platelet count • Maternal history • Physical examination • Clinical signs • Blood type & cross-match • Maternal history • Anticipated hemorrhage • Institutional policies White & Freire. Ambulatory (outpatient) Anesthesia. Anesthesia 2005 ASA Task Force on Obstetric Anesthesia Practice Guidelines Anesthesiology 2007

10. Benzodiazepinesif indicated Small dose of midazolam IV(1-3 mg) Alpha-2 agonists Clonidine (0.1-0.3 PO) Dexmedetomidine (50-70 µg IM or 50 µg IV) Aspiration prophylaxis (for diabetics & morbid obeses) H2-receptor antagonists (ranitidine) Nonparticulate antacids (sodium citrate) Gastrokinetic agents (metoclopramide) Premedication White P. Ambulatory Anesthesia. Anesthesia 2005 Hawkins JL. ASA Practice Guidelines for Obstetric Anesthesia. IJOA 2007

11. Monitorization • Heart rate (maternal & fetal) and ECG • Blood pressure (noninvasive) • Pulse oximetry (SpO2) • Capnometry (ETCO2) • BIS White P. Ambulatory anesthesia advances into the new ilennium. Anesth Analg 2000 ASA Task Force on Obstetric Anesthesia Prcatice Guidelines Anesthesiology 2007

12. General Anesthesia Regional anesthesia Monitored Anesthesia Care (MAC) Anesthesia Techniques Borkowski. Cleveland Clin J Med 2006

13. Propofol(1.5-2.5 mg/kg)is used widely (easy +quick recovery, clear head, lacks PONV) Sevoflurane(8% in 50% N2O-O2) non-irritant to airway, rapid induction, minimal side-effects, but more PONV General AnesthesiaInduction agents • Thiopentone (3-6 mg/kg) • Midazolam (0.2-0.4 mg/kg) • Etomidate(0.2-0.3 mg/kg) • Ketamine (0.75-1.5 mg/kg) Russell R. Summer Update on Obstetric Anesthesia, 2006 Levy D. Three day course on obstetric anesthesia, 2007 Borkowski. Cleveland Clin J Med 2006 White. Anesth Analg 2000

14. General AnesthesiaMaintenance • TIVA (propofol &remifentanil or alfentanil)-TCI (BIS < 60) Russell R. Summer Update on Obstetric Anesthesia, 2006 Levy D. Three day course on obstetric anesthesia, 2007 Borkowski. Cleveland Clin J Med 2006 White. Anesth Analg 2000

16. General AnesthesiaMaintenance • Isoflurane • Sevoflurane • Desflurane • ? N2O

17. Musclerelaxants (short and intermediate acting drugs) Mivacurium Rocuronium Cisatracurium Airway Face mask LMA Endotracheal intubation General Anesthesia Russell R. Summer Update on Obstetric Anesthesia, 2006 Levy D. Three day course on obstetric anesthesia, 2007 Borkowski. Cleveland Clin J Med 2006 White. Anesth Analg 2000

18. General Anesthesia Reversal agents • Benzodiazepin antagonist (flumazenil) • Antichoinesterase drugs • Sugammadex (rocuronium antagonist) • Opioid antagonists (naloxone)

19. Spinal anesthesia • Advantages • Simple-quick procedure • Short turnover time • Patients are alert • Less nausea-vomiting • Disadvantages • Incidence of headache and radiating back pain • Slow return of motor power • Difficultyin micturition might delay discharge • Rare but significant advers events (neurologic injury, infection) Chakravorty et al. Spinal anesthesia in the ambulatory setting. Ind J Anaesth 2003 Mordecai & Brull Curr Opin Anaesthesiol 2005, Korhonen. Curr Opin Anaesthesiol 2006

20. Spinal anesthesia • Prevention against disadvantages • 27 G Whitacre spinal needle is associated with lower incidence of PDPH • Older (chloroprocaine) & newer (ropivacaine & levobupivacaine) local anesthetics in conjuction with adjuvant intrathecal medications (opioids, vasopressors) help fast resolution of motor function and ability to micturate Mordecai & Brull Curr Opin Anaesthesiol 2005 Korhonen. Curr Opin Anaesthesiol 2006

21. Neuraxial anesthetics Ideal neuraxial anesthetic • Adaequate analgesia and duration • Short recovery • Minimal side effects • 7.5 mg of spinal hyperbaric bupivacaine is with low incidence of TNS • Epidural with 2-chloroprocaine is preferable to spinal anesthesia

22. Conscious (MAC) vs Unconscious Sedation

23. Drugs used for MAC

24. Multimodal approach NSAID and/or nonopioid analgesics(local anesthetics, acetaminophen, proparacetamol) COX2 inhibitors (celecoxib) LA wound infiltration at the time of surgery patient controlled elastomeric pump Neuraxial opioids Postoperative CarePain Carvalho B. Summer Update on Obstetric Anesthesia, 2006 White P. Anesth Analg 2000

25. Postoperative CarePONV • Prophylactic antiemetics • Multimodal treatment regimen • Butyrophenones • Phenotiazines • Gastrokinetic drugs • Anticholinergics • Antihistamines • Serotonin antagonists (4-8 mg IV) • NK-1 antagonists • Dexametazone (4-8 mg IV) • Acupuncture (P6 and others) White P. Anesth Analg 2000 White & Freire. Anesthesia 2005

26. Aldrete Activity Respiration Circulation Conscious level Color of the skin Postanesthesia Discharge Scoring System (PDSS) Vital signs Activity level Nausea &vomiting Pain Surgical bleeding Discharge Criteria Chakravorty et al. Spinal anesthesia in the ambulatory setting.Ind J Anaesth 2003

27. Surgical treatment of miscarriage(vacuum aspiration or D&C) Anesthetic options • Target-controlled intravenous sedation-analgesia with propofol & remifentanil • Paracervical block (PCB) • Sedation + PCB (MAC) • Short acting iv induction or inhalation agent (sevoflurane) with short acting opioid/N2O mask ventilation or LMA Nanda K et al. Cochrane Data Base Syst Rev 2006 Fassoulaki et al. No change in plasma endorphine and melatonine levels after sevoflurane anesthesia. JCA 2007

28. Hysterosalpingography (HSG) • Any analgesics (oral or topical) vs placebo or no treatment • Topical analgesics vs placebo or no treatment • Opioid vs non-opioid analgesics • Topical analgesics vs oral analgesics • Intaruterine local anesthetic vs PCB Ahmad G et al. Cochrane Data Base Syst Rev 2007

29. Hysteroscopy • Local • MAC • General • Regional Spinal anesthesia to T7 level was achieved using 3 mL of 2% isobaric lidocaine (60 mg) with 100 µ epinephrine *TNS was associated with single shot spinal anesthesia Lotfallah et al. J Reprod Med. 2005 Farid et al. JCA 2001

30. Tubal ectopic pregnancy • Treatment options requiring anesthesia are salpingectomy or salpingostomy either laparoscopically or open surgery • General anesthesia • Induction with short acting iv agent (usually propofol) • Maintenance with TIVA or sevo/desflurane in N2O/opioid Hajenius PJ et al. Cochrane Data Base Syst Rev 2007

31. Cervical Cerclage • Prevents miscarriage or premature delivery due to cervical incompetence in 85-90% of cases and requires anesthesia • Regional • usually spinal anesthesia • epidural • General anesthesia

32. Cervical Cerclage Neuraxial anesthesia (spinal or epidural) • Use of low-dose epidural 0.125% bupivacaine with epinephrine & fentanyl • Spinal anesthesia lidocaine 30 mg or bupivacaine 5.25 mg both with fentanyl 20 µg have been used successfully for cervical cerclage Tsen. What’s new and novel in obstetric anesthesia?IJOA 2005 Schumann & Rafique. Low dose epidural anesthesia for cervical cerclage. CJA 2003; 50:424

33. External Cephalic Version • Spinal analgesia with 7.5 mg bupivacaine (n=36) vs with no analgesia (n=34) • Success rate • Spinal (66.7%) vs no analgesia (32.4%) (p=0.0004) • Spinal analgesia significantly increases success rate of external cephalic version among parturients at term which allows possible normal vaginal delivery Weiniger et al.External cephalic version for breech presentation with or without spinal analgesia in nulliparous women at term: a randomized controlled trial.Obstet Gynecol. 2007;110:1343-50

34. TUGOR • General • Inhalational anesthesia • TIVA • Regional blocks • Spinal • Epidural • PCB • Conscious sedation (MAC) PCB + IV remifentanil Tsen. Int Anaesthesiol Clin 2007 Gunaydin et al.J Opioid Manag 2007

36. Gunaydin et al.J Opioid Manag 2007

37. CONCLUSIONS • Ambulatory surgery aims the best patient care possible at the reasonable cost, ambulatory anesthesia must meet these requirements • Issues that prolong stay in PACU primarily • Pain & PONV after general anesthesia or MAC • Unresolved blocks & urinary retention after neuraxial blocks should be managed by choosing appropriate pharmacologic agents (mainly short acting agents with less side effects)

38. Terimah Kasih