general anaesthesia for caesarean section: delivering best practice · 2020. 3. 10. · general...
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General Anaesthesia forCaesarean Section:
Delivering Best Practice
Robin RussellNuffield Department of Anaesthetics
John Radcliffe HospitalOxford
Editor in Chief International Journal of Obstetric Anesthesia
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Hamer Hodges et al. Br J Anaesth 1959
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0
20
40
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100
1980 1985 1990 1995 2000 2005 2010
UK trends in caesarean section
Caesarean section rate
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0
20
40
60
80
100
1980 1985 1990 1995 2000 2005 2010
UK trends in caesarean section
Caesarean section rate
General anaesthesia rate
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Drivers for change• Maternal mortality• Airway problems• Aspiration of stomach contents• Awareness• Uterine relaxation• Effects on the baby• Maternal preference
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GA non-GA
Deaths associated with anaesthesia
CEMD / CEMACH / CMACE / MBRRACE
0
5
10
15
20
25
30
35
40
45
50
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General vs. neuraxial anaesthesia
Hawkins et al. Obstet Gynecol 2011
Case Fatality Rates*
Year of death GA Neuraxial Rate Ratios
1979-1984 20.0 8.6 2.3 (95% CI 1.9-2.9)
1985-1990 32.3 1.9 16.7 (95% CI 12.9-21.8)
1991-1996 16.8 2.5 6.7 (95% CI 3.0-14.9)
1997-2002 6.5 3.8 1.7 (95% CI 0.6-4.6)
*Deaths per million GA or neuraxial anaesthetics
Case fatality rates and rate ratios of anaesthesia-relateddeaths during caesarean delivery in USA
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Indications for general anaesthesia
• Urgency
• Refusal
• Contraindication
• Inadequate neuraxial block
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Current controversies
• Intubation
• Awareness
• Induction agents
• TIVA
• Neonatal effects
• Oxygen
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Accidental awareness in obstetric anaesthesia
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Patient• Female• Younger age• Obese• Difficult airway• Maternal anxiety• ↑ Cardiac output
Organisational• Trainee• Out-of-hours• Emergency• Induction – incision• Follow-up
Factors related to accidental awareness
Anaesthetic• Induction agent• Fixed doses• Rapid sequence• Neuromuscular block• Effect on baby• Uterine tone
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“Mind The Gap”
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Recommendations1. Risk & consent2. Dose of induction agents3. Additional doses if airway problem4. Adequate end tidal volatile levels5. Use of nitrous oxide6. Use of opioids7. Use of uterotonic agents8. Drug errors
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Thiopental Propofol Other
• 2011 OAA survey• 56% response rate• 93% thiopental• Historic• Awareness• Neonate• 58% would use propofol
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Author Journal n Thiopental Propofol Assessment Outcome
Celleno J Clin Anesth1993
60 5 mg/kg 2.4 mg/kg EEG “Light anaesthesia” in 50% of propofol group
Lee Korean J Anesth2007
45 4 mg/kg 2 mg/kg BIS BIS significantly lower from 0-9 min in propofol group
Mercan M E J Anesth2012
82 5 mg/kg 2.5 mg.kg BIS BIS significantly lower at uterine incision & delivery in propofol group
Cakirtekin Turk J Anaesth Reanim2015
70 5 mg/kg 2 mg/kg BIS BIS significantly lower from 0-8 min in propofol group
Thiopental vs. Propofol: Awareness
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Punjasawadwong et al. 2014
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Author Journal n Thiopental Propofol Assessment Outcome
Celleno Br J Anaesth1989
40 5 mg/kg 2.8 mg/kg ApgarENNS
↓ 1 & 5 min Apgar scores and ENNS with propofol
Gregory Can J Anaesth1990
30 4 mg/kg 2 mg/kg+ infusion
ApgarNACS
pH
Apgar scores & pH similar; NACS poorer with propofol
Capogna Int J Obstet Anesth1991
56 4.8 mg/kg 2.3 mg/kg ApgarNACS
pH
↓ 1 min Apgar score with propofol; other outcomes similar
Celleno J Clin Anesth1993
40 5 mg/kg 2.8 mg.kg ApgarNACS
pH
↓ 1 min Apgar score & ↓ 1 & 4 h NACS with propofol; other outcomes similar
Tumukunde BMC Anaesthesia2015
150 4 mg/kg 2 mg/kg ApgarNICU
Apgar score similar↑ NICU admissions with propofol
Thiopental vs. Propofol: Neonate
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• Maternal haemodynamics• Airway reflexes• Drug errors• Storage• Cost• Familiarity• Availability
Thiopental vs. Propofol: Other Outcomes
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Hessen et al. Acta Anesthesiol Scand 2013
Remifentanil & pressor response
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Hessen et al. Acta Anesthesiol Scand 2013
Remifentanil & pressor response
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• 10 patients non-emergency CS• Remifentanil bolus 0.5 µg/kg
infusion 0.2 µg/kg/min• Propofol TCI 5 µg/mL
2.5 µg/mL post intubation• Suxamethonium 1.5 mg/kg• End tidal CO2 3.7-4.0 kPa• FiO2 0.5• Hypotension 20%• Awareness Not reported• Haemorrhage Not reported• 1 min Apgar <5 60%• 5 min Apgar <5 Nil• UA pH > 7.20 100%• Mask ventilation 60%• NICU admission Not reported
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Reynolds & Seed Anaesthesia 2005
Umbilical artery pH & base deficit: spinal vs GA
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• Cohort study• 5320 deliveries 1976 – 1982• CS = 497• GA = 193 vs RA = 304• Hazard ratio ↓ RA (P=0.017)• Limitations: unrandomised
low CS ratedrug usagemissing data
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• 20 women• Elective caesarean section• Supine• 5 L/min• 10 L/min• 15 L/min• Circle breathing system• ≥10 L/min optimal• Air entrainment in 22%
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Hignett et al. Anesth Analg 2011
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Non-pregnant Control Group Caesarean section Group
Supine(n=10)
Head-up(n=10)
Supine(n=10)
Head-up(n=10)
Age (years) 31.2 ± 2.9 32.7 ± 5.9 29.5 ± 4.5 28.6 ± 6.2
Weight (kg) 65.2 ± 9.1 61.9 ± 11.6 70.9 ± 12.8* 72.4 ± 7.0*
Pre-op SpO2 (%) 98.1 ± 1.5 98.5 ± 0.94 97.5 ± 1.3 97.9 ± 0.77
Time to SpO2 95% (s) 243 ± 7.4 331 ± 7.2* 173 ± 4.8* 156 ± 2.8*
Baraka et al. Anesth Analg 1992
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“The anaesthetist should consider attaching nasal cannulae with 5 l.min-1 oxygen flow before starting pre-oxygenation to maintain bulk flow of oxygen during intubation attempts.”
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Umbilical vein Umbilical artery
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GA for caesarean section
• Awareness
• Induction agents
• TIVA
• Neonatal effects
• Oxygen