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General Anesthesia for General Anesthesia for Cesarean SectionCesarean Section
Dr. Imam Ghozali., SpAn.,MKes
IntroductionIntroduction
Cesarean-section (CS) deliveries have accounted for nearly 1 million of approximately 4 million annual deliveries in US.
Approximately 15% of CS was performed under general anesthesia in US (Anesthesiology Hawkins, JL 1997). Majority of CS were done under urgent or emergent situations.
Indications for General Anesthesia Indications for General Anesthesia
Fetal distressSignificant coagulopathyAcute maternal hypovolemia and
Homodynamic instability Sepsis or local skin infection failed regional anesthesiaMaternal refusal of regional anesthesia
Preoperative Preparation for Preoperative Preparation for General Anesthesia General Anesthesia
History & Examination, LABsAirway evaluationAspiration prophylaxisBasic machine and monitor preparation
Factors may complicate Factors may complicate endotracheal intubationsendotracheal intubations
Weight gain Oropharynx edema Enlarged breasts Obesity with short neck Full dentitionMallampati IV and mamdibular recessionHistory of difficult airway
Airway evaluationAirway evaluation
Anticipation of difficult endotracheal intubation (1 in 300 in OB and 1 in 2000 all patients)
Thorough examination of neck, mandible, dentition, and Oropharynx
Training and experience (Hawthorne L. Br J. Anesth 1996; 76: 680-684)
Sniffing position
Airway evaluationAirway evaluation
Moderate head elevation, extension of atlanto-occipital, and flexion of the lower portion of the cervical spine
sniffing position
Preparation and PreventionPreparation and Prevention
2-3 different blades, ie MAC 3&4 Miller 2 6 to 7 mm ETT tubes with styletsLMAs sizes 3 and 4Emergency airway cart ready in the OR Fiberoptic bronchoscope Possible surgical airway equipment
Aspiration prophylaxis Aspiration prophylaxis
Pulmonary aspiration: 1 in 400-500 in OB versus 1 in 2000 in all surgical patients
No agent or combination of agents can guarantee that a parturient will not aspirate or develop pneumonitis following failed intubations
Factors increase the risk of aspiration
Decrease in gastric and intestinal motilitydelayed gastric emptying by anxiety and
painRelaxation of lower esophageal sphincter
toneIncrease in abdominal pressure Increase gastric acid secretionPatients not fasting
Prevention of Aspiration-Prevention of Aspiration-Pharmacological agentsPharmacological agents
PO 30 ml 0.3 M sodium citrate 15-30 minute prior to induction
H2 blocker, ranitidine 50 mg IVMetoclopramide 10 mg IV, at least 5
minute prior to inductionOmeprazole 40 mg the night before and the
AM of surgery for high risk patientsOndansetron 4-8 mg IV
Prevention of AspirationPrevention of Aspiration
Cricoid pressure Adequate oxygenation of patientTreat hypotension promptlyEfficient and timely intubationOrogastric or nasogastric tube Awake extubation
Basic Machine and Monitor Basic Machine and Monitor PreparationPreparation
Monitors: esp. capnographSuction tubing functional Airway equipments ready and functionalLMAs: 2nd line of defense of difficult
airwayOthers: ie. meds
IntraoperativeIntraoperative Management of Management of Parturient Parturient
PositioningOxygenationMonitorsInduction of general anesthesiaMaintenance of general anesthesia Emergence from general anesthesia
IntraoperativeIntraoperative Management-Management-PositioningPositioning
OR bed should be allowing trendelenburg and reversed positions
Sniffing positionPatients in supine position with a wedge
under the right hipHead and back up position if preparing
awake fiberoptic intubation
IntraoperativeIntraoperative Management-Management-DenitrogenationDenitrogenation
Denitrogenation with O2 as soon as patient on OR bed
Seal mask to achieve 100% O23-5 minutes or 4 VC breaths of 100%
O2 O2 saturation drops faster during apnea
(increase VO2 and decrease FRC)
IntraoperativeIntraoperative Management-Management-MonitorsMonitors
Pulse oximeter probeRight size BP cuffElectrocardiographic electrodescapnographTemperature monitor readily available Urinary output
IntraoperativeIntraoperative ManagementManagement
Communicate with surgeons and nursing staffs while pt is prepared and draped for surgery
Final check for your READINESS FOR INDUCTION of general anesthesia
Induction of general anesthesia Induction of general anesthesia
Rapid sequence inductionCricoid pressure maintained until
endotracheal tube cuff inflated and tube placement confirmed
Agents:Thiopental/Ketamine/Propofol/Etomidate/Succinylcholine
Induction Agents-ThiopentalInduction Agents-ThiopentalThiopental (STP) 2-5 mg/kg IVFast and reliableNegative inotrope and vasodilatorCross placenta; STP concentration rarely
exceed the threshold for fetal depression with dose less than 4 mg/kg
No evidence of adverse effect of STP on fetus even the induction-to-delivery (ID) interval is prolonged; keep incision to delivery time less than 4-7 minutes
Induction Agents-PropofolInduction Agents-Propofol Propofol 1-2.5 mg/kg IV Rapid induction and rapid awakening Negative inotrope and vasodilator May inhibit oxytocin induced uterine contraction Can be rapidly cleared from neonatal circulation Dose greater than 2.8 mg/kg may result in lower
apgar scores and lower neurobehavioral scores at 1 hour after delivery comparing with STP, but similar neurobehavioral scores by 4 hours after delivery (Celleno D. Br J Anesth 1989; 62:649-54)
Induction Agents-KetamineInduction Agents-Ketamine Ketamine 1-2.0 mg/kg IV Modest hemorrhage or parturient asthma Provide rapid analgesia, hypnosis, and amnesia May depress myocardium and reduce CO and BP
in severe hypovolemic patients Avoid in hypertensive patients More than 2 mg/kg may associate with fetal
depression Maternal psychotropic profiles: dreaming,
dysphoria, hallucination during emergence (benzodiazepine reduce the side effects)
Induction Agents-EtomidateInduction Agents-Etomidate
Etomidate 0.2-0.3 mg/kg IVCause little CV depression-for HD
unstable parturientNeonatal adrenal suppression?pain at injection siteMyoclonus
Induction Agents-Succinylcholine Induction Agents-Succinylcholine
Succinylcholine (SUX) 0.3 to 1.5 mg/kg IV
Spontaneous ventilation may resume in 2-3 minutes with low dose SUX (0.3-0.5 mg/kg), but peak time delayed by about 10-15 seconds
3rd line of defense of difficult airwayRecovery from intubation dose of SUX is
unchanged in the pregnant patients
Maintenance of General Maintenance of General Anesthesia Anesthesia
PREDELIVEY50% O2/50%N2O/0.5% Isoflurane100% O2/1-1.5% Isoflurane
POSTDELIVERY50-70% N2O/30-50%O2/0.5% Isoflurane/NarcoticsMinimize volatile agents to prevent
postpartum hemorrhage; 0.5 MAC does not significantly increase maternal blood loss
Maintenance of General Maintenance of General AnesthesiaAnesthesia
Succinylcholine bolus when neededNondepolarizing agents accordingly ie.
Nimbex, Vecuronium, Rocutonium.*Oxytocin 10-40 U IV infusion*Antibiotics of choice
Emergence from General Emergence from General AnesthesiaAnesthesia
Stomach emptied via an OG tubeUpper airway suctionedNondepolarizing agents reversed adequatelyOpioids for pain reliefExtubation when patients regain protective
reflexes; are able to maintain airway; respond appropriately to verbal commands; and are hemodynamically stable
Awareness during General Awareness during General Anesthesia Anesthesia
High incidence between induction of anesthesia and delivery of the fetus
Administration of only 50% N2O in oxygen without other agents results in maternal awareness in 12-26% of cases (Warren TM Anesth Analg 1983; 62:516-20; Crawford JS Br J anesth 1971; 43:179-82 Abboud
TK et al Acta Anesthesiol Scand 1985; 29: 663-8)
Awareness during General Awareness during General AnesthesiaAnesthesia
Ketamine or combine ketamine and thiopental for induction
Minimize of induction to delivery interval
50%N2O/O2 with following AGENTS reduce awareness to less than 1 %
0.6% isoflurane1% sevoflurane3% desflurane
Fetus Consideration during Fetus Consideration during Emergency Cesarean SectionEmergency Cesarean Section
Decision to Incision or interval: 30 minutes?Uterine Incision to Delivery (UD) interval
should be less than 3 minutes (Datta et al Obstet & Gynecol
1981; 58:331-335. Crawford JS. Et al. Br J. Anesth 1973; 45:726-732)
Neonates delivered after 3 minutes following uterine incision had lower apgar and acidotic blood gas
Ultimate neonatal outcome? (Ong BY. Et al Anesth Analg 1998;
68:270-5)
Factors Cause Uterine Artery Factors Cause Uterine Artery Spasm Spasm
Uterine incisionContraction of myometrial
musclesVasoconstrictors: prostaglandin
released from fetus and placentaMaternal catecholamine release
Post Anesthesia CarePost Anesthesia Care
Transport to PACU with O2Hypoxemia: airway obstruction and
hypoventilationHypotensionPain controlNausea and VomitingShivering and hypothermia
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