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Update

Update on Anaesthesia

for c-sectionDr Kerry LitchfieldConsultant Anaesthetist

Princess Royal Maternity

Glasgow, Scotland

• Caesarean section is the most common

surgical procedure in the world

• 1 in 5 women worldwide

• Increasing according to all health stats

http://ic.nhs.uk

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• Deliveries NHS England and Wales decreasing

[646,904 in 2013-14]

• Increasing CS rate

• 26.2% [166,081]

The category 4

• Previous caesarean section

• Malpositions (Breech)

• Placenta praevia or morbidly adherent placenta

• Multiple pregnancy

• Maternal choice

https://www.nice.org.uk/guidance/cg132

• Planned delivery 39

weeks gestation

• Maternal choice

• Expectations

• The gentle c-section

• Enhanced recovery

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2011 - Guideline 132 - Caesarean Section

“Woman who are recovering well… following caesarean section should

be offered early discharge (after 24 hours) from hospital”

14 elements

14 elements

Perioperative

Care Bundle

Caesarean delivery

Preparation class

Updated information

Leaflet

Patient discharge

criteria checklist

Early oral nutrition

IV fluids down

Early mobilisation

Catheter out ASAP

Preoperative

Education

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ERAS bundle compliance and length of stay LOS by Scottish hospitals

Anaesthesia for CS

• SSS, CSE, epidural and general anaesthetic

• LA and long acting neuraxial opiates

https://www.nice.org.uk/guidance/cg132

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Regional anaesthesia

• Safe and preferred

• Widely used indeveloped

world

• Cat 4 RA >95%

• Pain requiring treatment <5%

• RA to GA conversion rate <1%

• Cochrane review RA vs GA no

added benefit for neonate

• CSE vs single shot spinal

• Risk vs benefits

• Institutional preference

• NAP complications for CSE

• Standard LA vs short acting

• IT opiate dosing

• Other adjuncts

• Additional techniques for post op analgesia

LA

• Common practice hyperbaric bupivacaine

• 10-15mg ED95 11.2mg with opiates

• Duration of 90 mins surgical time

• Looking for shorter acting...no u-catheter and

earlier mobilisation

• 2-Chloroprocaine

• Hyperbaric Prilocaine

LA and long acting opiate

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Additives

• Opiates... Very familiar

• Reduced doses to prevent SE

• Respiratory depression

• Combinations...

• New drugs...

• Dexmetomidine

• Clonidine

IT opioids Current UK practice

• TAP survey

• Other surveys?

• ERAS stuff

• Rollins

• Ferns: survey

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• Pruritus 40-90%

• N&V 20-30%

• Respiratory depression 1: 2-5000*

• [L Tsen]

ITM 13% mild 4% severe

• Depodur

DepDur 10mg vs Epi Morphine 4mg

• Limited use• Epidural or CSE only• Resp depression• Side effects • Cost• Familiarity• LA interaction

IT Adjuncts

• Ketamine: small doses, opiate sparing, no

increased SE

• Dexmedetomidine: opiate sparing, sedation

without respiratory depression, prolongs

motor block

• Clonidine

Heesen M et all. Acta Anaesthesiol Scand 2015; 59 (4);: 414-26Nair AS et al. J Obstet Anaesth Crit Care

IT Clonidine• Prolongs sensory and

motor block

• Sedation

• No hypotension

• APGARS unchanged

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Patient preference for outcomes

associated with CS Treatment of hypotension

• Maintain SAP > 90% of baseline

• Alpha agonists are best

• Prophylactic phenylephrine infusion

• Lateral tilt and co-loading

• Use heart rate as surrogate for CO

• Less hypotension preeclampsia and EMCS

• Individualised treatment in cardiac

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• Position matters?

Nausea and vomiting

• Cochrane review 2012

• Prophylaxis advised

• Risk factors

• Ondansetron*,

droperidol, cyclizine

• Corticosteroids

• Risk stratify and use

local hospital policy

• Different to

treatment....

Surgical antibiotic

prophylaxis

• Broad spectrum

• Pre-incision

• Larger doses >100kgs

• Repeat dosing: PPH*

and longer surgery*

• Easy to miss*

Hold the oxytocin...for a minute

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• Natural or gentle c section

• Mother and baby centred

• Improves STS, feeding, bonding

• Simple but requires active change by whole

team

• Planning monitoring, IV access, no oxygen

• Fetal and maternal well being still paramount

• 1gr TXA reduces bleeding

• Give it early and repeat

• NO 1:1:1 transfusion ratios

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https://www.nice.org.uk/guidance/ipg144

https://www.nice.org.uk/guidance/ipg144

Mean pain scores 1st 24hrs post CS

and SVD

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Impact on daily activities

• Reduces chronic persistent CS pain

• Post partum depression

Sng BL, et al. Anaesth Intens Care 2009Kainu JP et al. Int J Obstet Anesth 2010

Post CS analgesia options

• Local experience

• Resources

• Nursing support

• Familiarity with techniques

• Original anaesthetic technique used

• Multimodal

• Oral

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‘we do not know the safest and most effective analgesic regimen to use after obstetric procedures such as caesarean section’

Opioids post CS

• Codeine,

Dihydrocodeine,

Oxycodone

• Oral morphine

preparations

• Sustained release

• Delayed release

• And the others

Oral best

• RCT PCA morphine vs oral timed oral paracetamol/ oxycodone

• Oral opioids traditionally ‘step-down’

• Less pain, less N&V, less sedation

• Is oral best? YES

www.healtham/gyeco/more/oral_painkillers_best_after c_section.

Davis K. Am J Obs Gynecol 2006

Sustained release opioids

• Morphine sustained release [MST],

• Oxycontin

• Less yo-yo

• ?beneficial for breast feeding

• Increase satisfaction

• Reduce workload?

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Other opioids

• Morphine sparing....

• Minimal respiratory depression

• Sedation, confusion, interaction 5HT3

Peripheral Nerve Blocks

• Blocking peripheral nerves with LA reduces

opioid consumption

• Transversus abdominus plane (TAP) blocks

• Ilioinguinal/ illiohypogastric NB’s

• LA infiltration

• Wound catheters

• Newer quadratus lumborum

Kelly S, Malhotra R. Comparative Effectiveness Research 2011

TAP Evidence

• Opioid sparing

• Better than placebo

• IT morphine superior

• Limited duration unless catheter inserted

• Routine vs. selected use

Kelly S, Malhotra R. Comparative Effectiveness Research 2011

Kanazi GE et al. Anesth Analg. 2010

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LA in the wound

• Wound catheters opioid sparing, reduced pain scores

• Longer theatre time

• Cost offset by less use post op analgesia

• Long acting LA?

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• RSI with Cricoid since 1961

• All change….

• Awareness and the difficult airway

From: The future of general anaesthesia in obstetricsBJA Educ. 2016;17(3):79-83. doi:10.1093/bjaed/mkw046BJA Educ | © The Author 2016. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com

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Roc rocks,

I’ll miss you sux

THRIVE: a solution to the difficult

intubation on labour ward?

• Transnasal humidified rapid-insufflation ventilatory exchange

• A solution for maintaining oxygenation during intubation?

• Optiflow system supplies flow

rates of 70 litres per minute of

humidified oxygen.

• Prolongs apnoea time on average

by 17 minutes.

http://www.oaa-anaes.ac.uk/ui/content/content.aspx?ID=3515

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Questions