Department ofAnaesthesia

& Pain Medicine

Sunshine Hospital Handbook

Updated February 2015

Table of contents

ForewordThese guidelines have been produced by the Western Hospital Department of Anaesthesia and Pain Medicine to assist junior trainees who may not have had exposure to obstetric and paediatric anaesthesia. They also assist rotating trainees to be aware of local practices. Junior trainees are expected to conform to the guidelines closely and liaise with consultant anaesthetists regularly. These guidelines do not replace clinical judgment; the patient’s best interest is always the first priority.

Obstetric Guidelines• Introduction to Sunshine Hospital• Epidural analgesia on labour ward

o Competency for administration neuraxial analgesia in labouro Safe performance of procedureo Setting up Patient Controlled Epidural Anaesthesia (PCEA)o Management of immediate and delayed complications

• Severe pre-eclampsia• Major obstetric haemorrhage• Caesarean Section

o Spinal for Caesarean sectiono Emergency and Alert Caesarean sectiono GA for Caesarean sectiono Western Health APMS Guidelines for Post CS Analgesia

• Other obstetric anaesthesia issues

Paediatric Guidelines• Patients requiring post-operative care in the special care nursery• Pre-operative resuscitation of patients with pyloric stenosis• Fasting guidelines• Premedication guidelines• Paediatric analgesia guidelines• Management of paediatric post-operative nausea and vomiting• Parental presence at induction of anaesthesia in the paediatric patient

Other useful resources• Oxford Specialist Handbooks in Anaesthesia: Obstetric Anaesthesia

o Clyburn et al., Oxford University Press, 2008• Chestnut’s Obstetric Anesthesia: Principles and Practice, 4th Edition

o Chestnut et al., Mosby, 2009• Shnider and Levinson’s Anesthesia for Obstetrics

o Hughes, Levinson, Rozsen, Lippincott Williams and Wilkins, 2002• Oxford Specialist Handbooks in Anaesthesia: Paediatric Anaesthesia

o Doyle, Oxford University Press, 2007• A Practical Approach to Pediatric Anesthesia

o Jolzman, Mancuso, Polaner (eds)., Lippincott Williams and Wilkins, 2008

• Paediatric Anaesthesia (Problems in Anaesthesia)o Stoddart, Lauder (eds)., Informa Healthcare, 2004

Obstetric Guidelines

Introduction to Obstetrics at Sunshine Hospital

Sunshine hospital is the third busiest obstetric hospital in the Victoria with over 5500 deliveries per annum. There is at least one elective Caesarean section (CS) theatre list daily and in addition to emergencies deliveries. The acute pain medicine service is actively involved in the administration of labour analgesia and in following up all patients who receiving neuraxial blockade.

While many patients require referral to a tertiary centre for obstetric or neonatal reasons, there are significant numbers of complex patients that are managed at Sunshine Hospital. Many of these are expected, but some are recognised only at the time of delivery. In addition, parturients are increasingly presenting with medical problems with advancing age of primagravida women. Together with the expansion of the special care nursery and the expected reopening of the intensive care unit both the number and the acuity of parturients at Sunshine will continue to rise.

The following is a list of obstetric conditions where a consultant anaesthetist should be informed; their level of involvement will vary depending on the condition of the patient and the experience of the trainee on duty. There is some overlap with the list further on regarding consultant anaesthetist involvement for patients requiring epidural analgesia. Trainees recently commencing practice in obstetric anaesthesia and analgesia should discuss with a consultant anaesthetist all epidural requests.

Obstetric conditions• Alert Caesarean (immediate CS)• CS under general anaesthesia• Anticipated difficult CS (3 or more CS, known fibroids, past difficult)• Pregnancy induced hypertension requiring IV antihypertensives• Pre-eclampsia• Placenta praevia (or accreta, increta, percreta)• Antepartum haemorrhage • History of postpartum haemorrhage• Multiple pregnancy

Maternal conditions• Obesity (BMI > 35) +/- difficult airway• Pre-existing coagulopathy• Significant cardiovascular or respiratory disease• Anything other concerns expressed by anaesthetic or obstetric staff

Epidural analgesia in labour

Assessment of competency to administer neuraxial analgesia in labour

This is a structured process for competency in epidural analgesia in labour for trainees with no experience. The volume of practice requirements are discussed in detail further, these are indicative only. The Sunshine Hospital Handbook forms the basis of the reading material required for the epidural knowledge, however trainees are encouraged to undertake further reading with the references provided.

All trainees are encouraged to study the materials provided and familiarise themselves with local practices. Trainees not having obstetric epidural experience will be required to complete the competency in full.

The obstetric anaesthesia and analgesia SSU supervisor will contact all trainees at the start of the term to ascertain their level of obstetric experience. For trainees who have not completed an obstetric epidural competency program, the following will need to be complete

For trainees not having obstetric epidural experience• Introductory session for Obstetric Epidural Insertion and Management

including LOR simulatoro Assess satisfactory LOR technique

• Labour ward epiduralso 5 supervised epidurals, logged, satisfactory performance using DOPS

Please log your procedures in the training portfolio system (TPS). However, trainees are encouraged to log additional details if desired. For assessment of procedures, please complete a DOPS in the training portfolio system. A guide to assessment of epidural procedural performance as well as the competency check list can be found in the appendix of this handbook. Dr Sheridan will sign off on the competency after reviewing theTPS; the trainee should keep one themselves.

Introduction to Epidural Analgesia in Labour

Epidural analgesia is the most effective form of analgesia available to labouring women. About two thirds of normal, healthy pregnant women suffer severe or intolerable pain during labour, and only about 2% describe little or no discomfort. The most common indication for epidural analgesia in labour is maternal request. However parturients should be encouraged to have an epidural for the following indications;

Medical indications• Diabetes Mellitus• Obesity• Difficult airway• Significant cardiovascular or respiratory disease

Obstetric indications• Pre-eclampsia and other hypertensive disorders of pregnancy• Twin pregnancy for vaginal delivery• Breech presentation for vaginal delivery• Premature or prolonged labour• Anticipated instrumental delivery

ContraindicationsPatient refusal is an absolute contraindication. However, there may be occasions when an epidural is considered desirable or necessary despite the presence of one or more of the following conditions. Discussion with a consultant anaesthetist must take place prior to any epidural attempts.

• Patient refusal• Local sepsis at epidural site• Uncorrected hypovolaemia or conditions of fixed reduced cardiac output• Coagulopathy

o Platelet count < 75 000, or < 100 000 but rapidly fallingo APTT > 8 seconds prolongedo PT/INR > 1.3 x controlo In severe pre-eclampsia the pathology must be less than 6 hrs old

• Thromboprophylaxis / Treatmento Heparin 5000 s/c within last 2/24o Prophylactic dose low molecular weight heparin within 12/24o Therapeutic dose low molecular weight heparin within 24/24o Times may need to be longer in the setting of impaired renal function

(including in pre-eclampsia)• Temperature > 38.5 in presence of infection• Foetal distress. This may require management first

The following conditions should be discussed with a consultant anaesthetist• Risk of significant haemorrhage i.e. placenta praevia, accreta, increta or

percreta, intrauterine fibroids• Technical difficulties anticipated i.e. previous back surgery, kyphoscoliosis,

and morbid obesity.• Attempted placement has failed after attempting for 20 minutes• Neurological disorders• Severe anaemia

Epidural space anatomy

• The spinal cord terminates at approximately L1 in adults and L3 in infants• The line joining the iliac crests (intercristine or Tuffier's line) is approximately

at the L3/4 level• The subarachnoid space ends at approximately S2 in adults.• The subarachnoid space extends laterally along the nerve roots to the dorsal

root ganglia• There is a potential space between the dura and the arachnoid mater (the

subdural space)• The epidural (extradural) space lies between the walls of the vertebral canal

and the spinal dura mater. It is a potential low-pressure space, occupied by areolar tissue, loose fat, and the internal vertebral venous plexus

• The ligamentum flavum is thin in the cervical region, reaching maximal thickness in the lumbar region (2–5mm)

• From superficial to deep the layers which much be traversed are skin, subcutaneous tissue, supraspinous ligament, interspinous ligament, ligamentum flavum, epidural space

• The average depth to the epidural space in adults is 4-5cm. However this is variable depending on body habitus

• One aims to identify these layers as the Tuohy needle is advanced to ascertain when loss of resistance should be expected

Preparation prior to procedure (including assessment and consent)

Communication skills throughout• Maintain professional manner with obstetric & midwifery staff• Introduce self and establish rapport• Display empathy with patient’s pain and experience of labour• Maintain dialogue throughout procedure• Interact with and manage partner or other support persons as required

Patient assessment (from patient and staff)• Anaesthetic history, particularly previous epidural experience and education• Past obstetric history (including mode of delivery)• History of current pregnancy (including gestation, parity, abnormal lie or

placentation, diabetes and/or hypertensive disorders)• Progress of labour• Indication for epidural and any contraindication (check drug chart for

antithrombotics)• Relevant examination including airway• Note BP and volume status, especially in patients with pre-eclampsia.

Establishment of epidural blockade in the presence of intravascular depletion can cause profound hypotension, and foetal distress.

Explanation and consent• Develop analgesia plan• Explain procedure• Discuss risks and benefits. Many women will have limited recall of the

discussion, thus it is preferable if a support person is present. Written patient information may be useful. Discussion of the mechanism of complications (e.g. causes of neurological damage or the mechanisms of PDPH) is not necessary unless specifically requested.

• Answer questions and obtain consent

Risks and Complications

Minor• Headache related to posture, may require epidural blood patch. Risk 1/100• Back pain. Tenderness at site for 24/24. Prolonged back pain lasting 3-6

months occurs in about 20% of all pregnant women. It is probably unrelated to epidural placement.

• Neuropraxia up to1/1000. Only about 5% of these are related to epidural placement. Risk factors include prolonged 2nd stage, instrumental delivery, macrosomia.

• Shivering• Pruritus• Need for urinary catheter• Inadequate analgesia. Risk 1/10, most are salvageable.• Block failure and need to repeat procedure.

Major• Permanent neurological damage. Risk varies; 1/13000 – 1/166667• Epidural abscess 1/50000• Epidural haematoma 1/170000• Need for urgent general anaesthetic and CS. (seizure due to LA toxicity, high

block or total spinal, severe foetal distress) 1/5000

Alternatives• Nitrous oxide. This can be effective if started 1 minute before the onset of

painful contractions. This is best achieved by getting the partner or midwife to feel for tightenings. Approximately 50% of women will have some benefit, but 30% of women may find it completely ineffective.

• IM Opioid. Women in labour are commonly prescribed Pethidine 1 to 1.5 mg/kg IM 4 hrly prn. This alone is effective in about 60% of patients, with the commonly known side effects. The dose is usually timed to be at least three hours before delivery to avoid foetal respiratory depression. Pethidine may be administered with nitrous oxide; however there is a risk of hypoxia between contractions, due to a combination of respiratory depression and diffusion hypoxia. Morphine is equally effective.

• PCA fentanyl. Made up to a concentration of 10µg/ml (1000µg in 100mL normal saline) with no background, a bolus of 20 µg and a lockout of 5 minutes. The bolus dose may be increased if necessary.

• CSE (combined spinal epidural). Has slightly faster onset than epidural alone, but associated with more pruritus. Consider this technique in late multiparous women, repeat procedures for failed epidurals, anticipated operative or instrumental delivery and CS where an epidural is indicated for post-operative pain management. Suitable doses include 0.2% Ropivacaine 2mL with 25 microg fentanyl or 0.5% Bupivacaine 0.5mL with 25microg fentanyl made up to 3mL with saline. There should be discussion with a consultant anaesthetist if this is felt to be necessary.

Performing the procedure

Be aware that the ratio of midwives to women in labour is not 1:1. This impacts on the assistance available in the labour ward; the APMS nurse can assist in hours. Ensure APMS audit sheet is completed and placed in the box in PACU.

Preparation• Assess patient and obtain consent as discussed earlier in this document• Ensure safe environment and assistance • Check location and availability of resuscitation equipment • Obtain epidural drug trolley in the cupboard, drugs required for epidural

(local anaesthetics in drug room behind the desk, schedule 8 drugs in the DD safe inside the drug room)

• Ensure baseline monitoring appropriate• Ensure adequate IV access (at least 18G) and running line. Fluid loading may

occur prior to or whilst insertion of epidural taking place (average 500mL crystalloid, but depends on patient condition and any other co-morbidities such as pre-eclampsia), but is not essential in euvolaemic women. Should be considered in patients at risk of non reassuring FHR, as should careful positioning avoiding aortocaval compression post procedure.

• Position appropriately as per anaesthetist and patient preferenceo Sitting: middle of bed, pelvis square and level, supportedo Lateral: edge of bed, back perpendicularo Height of bed appropriateo Back curled and patient supported

• Full aseptic techniqueo Aseptic hand wash or alcoholic hand-rubo Mask, gloves, gown

• Prepare sterile field and lay out equipment• Skin prep

o Chlorhexidine and alcohol swab stick by assistant, allow to dry

Identify Epidural Space• Drape while maintaining asepsis• Confirm appropriate patient positioning• Identify land marks• Maintain dialogue with patient and explain upcoming procedure• Infiltrate with local anaesthetic and use 23G / 25G needle to assist in

identifying space and anatomy. Resistance to injection suggests placement in a ligament

• Insert epidural needle and advance into ligament• Attach saline filled syringe• Advance needle and syringe in controlled fashion into ligamentum flavum with

pressure (constant or intermittent) on plunger. Aim to advance into the epidural space when the woman is not having a contraction.

• Identify loss of resistance and release pressure on the plunger and needle• Detach syringe and assess that Tuohy not intrathecal• Consider injecting 5 mL of saline into epidural space, this reduces the risk of

vascular cannulation (Mhyre JM et al, Anesth Analg 2009; 108: 1232-42)

Place Catheter• Note depth to epidural space• Warn patient of possible paraesthesia• Thread catheter to 5 cm past depth of Tuohy (leave a minimum of 3cm in,

more in obese patients)• Remove needle while maintaining catheter position• Ascertain catheter position (raise above patient’s head, watch for meniscus

drop-may not drop during contraction, ask patient to cough to see meniscus bounce. Then drop catheter to below insertion point, wait for blood / CSF)

• Aspirate catheter before injection of a bolus dose for CSF and blood• Affix filter• Inject safe, initial incremental dose (e.g. 0.2% Ropivacaine 5mL +/- fentanyl).

Exclude intrathecal / intravascular placement by questioning and examining the patient. The patient should not be pain free at this stage. Specifically question for the following symptoms;

o Heavy legso Hot feeling in bottomA metallic taste in the moutho Higher blocko Tingling of the lips, buzzing ears, light headed

• Aspiration of the catheter is not in itself a 100% reliable test for CSF or blood• High block or total spinal may be delayed for up to 20 minutes• The presence or absence of tachycardia when using adrenaline containing

solutions is also not a reliable test of intravascular injection in labour• Fix catheter securely with LockIt PlusTM dressing and sterile tegaderm on top

Confirm establishment of block• Re confirm no symptoms or signs of intrathecal or intravascular block• Dose with safe increments (5mL of 0.2% Ropivacaine, 5 minutes apart. Aim to

give a total of 15 - 20mL of 0.2% Ropivacaine with 50-100 microg fentanyl)• Commence PCEA as discussed below• Confirm monitoring of CTG and maternal BP. Blood pressure should be

measured every 5 minutes for 20 minutes and the anaesthetist must remain in the labour ward for that time. BP should be kept within 10-20% of baseline as placental circulation is not autoregulated.

• Confirm adequacy of analgesia - test with ice for height and evenness after 10-20 minutes

• Document procedure including APMS audit sheet• Ensure any follow up as appropriate

Setting up Patient Controlled Epidural Analgesia (PCEA)

PCEA +/- Intermittent mandatory blousing (IMB) +/- background infusion is used in the labour wards for maintenance of epidural analgesia. PCEA without background infusion reduces local anaesthetic use and is associated with less motor block and the need for anaesthetic intervention when compared with continuous infusion. (IMB) may be programmed into the pump. Once the block has been established, common settings for the “Rem bodyguard” pump are:

• 100mL pre-mix bag of 0.2% Ropivacaine with 2 mcg/mL fentanyl• Bolus dose of 5mL• Lockout of 15 minutes• 4 hour dose limit of 60mL

This dose should be sufficient for most women. Assess the block and check that the catheter hasn't moved from the depth it was left at if called to give a top up because the woman has reached the 4 hour dose limit.

Observations for nursing staff after placement of epidural

Initial observations after loading dose and after anaesthetic epidural boluses• 5 minutely BP for 20 minutes, continuous CTG• Verbal assessment of conscious state and ease of respiration

Ongoing Assessment• ½ hourly BP, HR, sedation score & continuous CTG• Ensure patients are not lying flat on their back facing the ceiling and not at risk

of aorto-caval compression. • Check upper sensory level and motor block ½ hourly• Sensory assessment using ice should be assessed and documented 20

minutes following commencement.• If patient complains of numbness or tingling in upper limbs.• Respiratory Distress.• Hypotension and/or maternal bradycardia

Reportable observations• BP < 100 systolic• HR < 60• Respiratory difficulty• Excessive sedation

• Sensory level above T7 (Costal margin), if above T4 stop PCEA and notify APMS immediately

• Inadequate analgesia• Inability to move legs

Epidural Catheter Manipulation and Removal

For non-Caesarean deliveries, the catheter is typically removed soon after delivery unless there is concern about coagulopathy (e.g. thrombocytopaenia in severe pre-eclampsia). Ensure this is handed over to the midwives if may be a concern.For CS, the catheter is removed at the end of the case unless there is concern about coagulopathy.

The platelet count and coagulation status required for safe catheter removal is the same as for catheter insertion;

• Platelet count > 75 000• APTT < 8 seconds prolonged• PT/INR < 1.5 x control• 12 hours after the last dose of prophylactic LMWH• 24 hours after the last dose of therapeutic LMWH• 6 hours after the last dose of UFH prophylaxis• UFH / LMWH may be restarted 2 hours after catheter removal

Management of Immediate Complications

HypotensionBP should be maintained more aggressively than in general surgical patients. Maternal BP has a direct effect on placental circulation and foetal wellbeing. The BP should remain within 20% of base line and ideally 10%. Patients with severe pre-eclampsia often need a slightly higher BP than normal to maintain placental perfusion and BP should be maintained at 140/90. Anaesthetists must remain available after epidural placement to treat this.

Causes• Sympathetic block• Aorto-caval compression• Dehydration• Blood loss (may be concealed ie abruption)• Vasodilatation i.e. MgSO4• Rare; embolus, anaphylaxis

Management• O2 via mask

• IV fluids: no more than 2L crystalloid due to risk of APO (unless bleeding)• Left lateral position• Metaraminol 0.5mg (preferable) or Ephedrine 6 mg every 2 min to 30 mg • Check block height and other causes• Monitor foetus• Call for assistance if not resolving

Can’t find the epidural space• Sit the patient up, if not already. Recheck and optimise position • If the space is too deep, long needles are available• Consider using ultrasound (and calling for help) if landmarks not palpable• Identify the spinous process above and below with a 23G needle• Insert the epidural needle just below the spinous process above, or try the

interspace above or below• If bone is encountered, ask the patient whether they feel it more on the left or

on the right and then re-orientate the Tuohy• If this fails use a paramedian approach, 1 cm lateral to the midline opposite

the spinous process, advance along the spinous process until laminar is encountered. Then walk the needle up in a cephalad and slightly medial direction until it passes into the interlamellar space.

• If you cannot find the epidural space after attempting for 20 minutes or the patient is distressed, call the consultant anaesthetist.

Bloody tap• If blood comes down the Tuohy resite at a difference interspace.• If blood in catheter, flush catheter with saline and aspirate as catheter is

withdrawn until no blood can be aspirated. If 3 cm of catheter is still in the space then proceed cautiously with a test dose. Any less will require re-siting.

• Try a 5 mL bolus of normal saline or 0.2% Ropivacaine down the needle before insertion of the catheter. This will decrease the risk of cannulation of epidural veins.

High Block & Total SpinalThe ideal height of an epidural in labour 10-20 min after initial bolus is about T8-10 bilaterally. The cause of an unexpectedly high block may be:

• Inadvertent subarachnoid or subdural placement of catheter• Patient factors e.g. short stature, obesity, multiple pregnancy, spinal deformity• Wrong drug e.g. 0.5% rather than 0.25% bupivacaine• Pump programming error

A subdural catheter can be difficult to diagnose. One should suspect a subdural catheter if the block is unexpectedly high for the amount of local anaesthetic given,

with relative sparing of motor and sympathetic nerves. Onset can be slow (15 – 30 minutes) and it is often patchy. Discuss with a consultant anaesthetist.

Management of High Block• Cease infusion, sit patient upright if tolerated • Check ABC and treat as required

o Atropine for bradycardiao Vasopressors for hypotension

• Reassure the patient and explain what has happened• Administer O2 via Hudson mask if symptomatic• The block may continue to rise so ensure resuscitation equipment is

available• Monitor foetus• Aspirate catheter to check for subarachnoid placement.• Remain with the patient until block is decreasing, call the consultant

anaesthetist• Subsequent infusions should be ceased until the block has dropped below

T8 and then any subsequent infusion or bolus given cautiously. Consider a 3mL dose to 2% lignocaine to ascertain location of catheter (avoid if suspect intrathecal).

Other clinical manifestations of a total spinal:CVS- hypotension, bradycardia, apnoea, reduced oxygen saturationsneurological- nausea/anxiety, arm/hand dysaesthesia or paralysis, loss of consciousness

• In the event of total spinal, decreased GCS or respiratory distresso Call for assistanceo O2

o RSI and intubationo Fluids +/- vasopressors to maintain BPo Lateral tilto Foetal monitoringo Amnestic i.e. midazolamo The patient will usually require ventilation for about 2 hours. CS is

usually not required unless foetal distress occurs.

Unilateral or patchy blocksIncidence is about 10%. Assess the block. Check the catheter to see if it has moved.

For unilateral blocks• Pull the catheter back leaving a minimum of 3cm in the epidural space.• Bolus the catheter. Ensure the maximum dose over 4 hours is ropivacaine 3

mg/kg. Start with 5-10 mL of the premix bag. Occasionally a more concentrated local anaesthetic may be used; remember this will not compensate for a poorly working epidural.

• Consider bolusing the catheter with the unblocked side down; this can be difficult if the woman has severe pain or is distressed.

For patchy blocks or perineal pain• This can be difficult to treat• Additional opioid, i.e. 50-100 µg fentanyl made to 5 mL with saline. Cumulative

opioid dose limit is 1 µg/kg fentanyl per hour• Bolus sitting up with 10mL of the premix bag• If the above does not result in satisfactory analgesia, resite catheter• Consider CSE• Supplement analgesia as described in alternatives. If PCA fentanyl is used,

fentanyl should be removed from the epidural solution.

Failed epidural analgesiaIf no block after apparently satisfactory attempt or inadequate analgesia despite manipulation

• Test with 5mL of 2% lignocaine with 1:200000 adrenaline• Assess the presence of motor block• If no block, resite epidural and consider CSE at this time

Local Anaesthetic ToxicityManagement depends on whether the patient has mild or severe symptoms and signs of local anaesthetic toxicity. Mild local anaesthetic toxicity may present with;

• A metallic taste in the mouth• Tingling of the lips• Buzzing in the ears• Light-headed feeling

Patients presenting with mild local anaesthetic toxicity should have their vital signs and the foetus monitored. Usually this is due to intravascular local anaesthetic injection but occasionally is due to total dose given. The total doses of local anaesthetic administered as well as the location of the catheter should be ascertained. No further local anaesthetic should be given until symptoms resolve. Inform the consultant anaesthetist and consider re-siting the epidural catheter.

Severe local anaesthetic toxicity may present with seizures or cardiovascular collapse. This is an emergency; call for assistance, manage the woman as per ALS guidelines and expedite delivery of the foetus. See ANZCA endorsed guideline re management of LA toxicity and intralipid therapy http://www.aagbi.org/sites/default/files/la_toxicity_2010_0.pdf Dural Puncture

• Leave the needle in place and replace the trochar to prevent loss of CSF• Establish analgesia with 2.5mL 0.2% Ropivacaine and 25 µg fentanyl.

Bupivacaine as described in CSE section can also be used.• In general, Intrathecal catheters are not recommended. Attempt at a

different interspace.o However, if epidural placement was particularly difficult, consider an

intrathecal catheter. The following precautions must be taken;o Inform the consultant anaesthetist, all other anaesthetic registrars and

midwives of the intrathecal cathetero A sticker is placed on the filter and a sign placed above the patient’s

bed indicating an intrathecal catheter is in place.o Document clearly in the patient’s notes.o Bolus doses are given when the patient complains of paino The catheter can be used for CS. The block to T4 is established with

increment of 1 ml 0.5% heavy bupivacaine.• For a repeat attempt after recognised dural puncture, always use LOR to

saline as air will lead to painful pneumocephalus.• CSF may be in the epidural space and track down the Tuohy• The epidural catheter should only be used once the patient is complaining of

pain and a cautious test dose used as epidural LA may leak into CSF through the dural puncture

• Routine instrumental delivery is not required.• The patient needs to be warned of the increased risk of headache and

followed up daily. Hand over directly to APMS if possible.

Management of Delayed Complications

Post Dural Puncture Headache (PDPH)Differential diagnosis

• Migraine• HT• Brain tumour• Meningitis• Subdural haemorrhage• Subarachnoid haemorrhage• Cortical vein thrombosis• Sinusitis• Pneumocephalus• Caffeine withdrawal

Signs & symptoms• Postural• Fronto-occipital in location but can be quite variable• May involve cranial nerve palsy. CN VI most common, IV, III, VIII can also be

involved. This is an indication for an early blood patch.Clinical assessment

• Past Hx headache, type• Hx of epidural• Blood pressure, proteinuria• Temperature• Tenderness over sinuses, photophobia, neck stiffness• Full neurological assessment

Management of PDPH• Be empathetic and document. There are medico-legal implications• Consider an early blood patch (but not <24/24) if;

o Patient requesto Tuohy needle as cause (as PDPH cause by small spinal needles are

more likely to resolve)o Severe symptoms suggest large tear. Delay in blood patch with large

tears may have a risk of seizures of about 1%.o Cranial nerve involvement

o If symptoms warrant after 24/24 then the patient should be considered for blood patch. Prophylactic EBP or EBP <24 hours have been shown to be lacking in efficacy

• Conservative management include;o Simple analgesicso Bed resto Hydrationo Caffeine

• Studies demonstrate that most forms of conservative management are lacking in efficacy. They probably enable patients to tolerate symptoms better so they can consider treatment options as well as to await improvement for PDPH which would have resolved anyway (mainly those with pencil point spinal needles).

Epidural blood patch (EBP)Risks and Complications

• The usual complications associated with epidurals• Failure. 70-80% will be effective initially, but 10-20% will redevelop symptoms

requiring a repeat EBP• Severe prolonged lumbosacral pain• Radicular pain (NSAID may be helpful – most are mild and self-limiting)• Neck ache• Fever or infection

Contraindications• Patient refusal• Sepsis• Coagulopathy

The Procedure• Informed consent• Done in PACU or in an anaesthetic room or OR• 2 operators. A consultant anaesthetist must be present• Use the same space or one below • 2nd operator takes blood under strict aseptic conditions once LORS identified• Blood is injected slowly until limited by back or neck pain • The optimal volume of blood is unclear, but a one should attempt to

administer up to 20mL of blood unless the patient complains of back pain. (Paech et al Anesth Analg Volume 113(1), July 2011, 126)

• Patient should lie flat for 1 hour• Follow up a few hours and 24/24 after, and the results documented• Failed patches may be repeated• If repeated patches fail - review diagnosis, consider neurology review

Reasons for failure• Wrong diagnosis

• Wrong space• Inadequate volume

Neurological deficit post epidural

Causes• Obstetric / surgical• Epidural related• Unrelated (eg. Degenerative conditions, undiagnosed medical conditions)

Clinical presentations of nerve lesionsMost lesions are unilateral sensory in nature, with motor and bilateral lesions being much less common. Some of the common presentations include:

• Unilateral area of paraesthesia in buttock or lower limb• Unilateral foot drop• L2/3 sensory lesion (“paraesthesia meralgica”)• Femoral and obturator neuropathies• Radicular pain• Cauda equina syndrome

History• Previous neurological problems including MS• Back disease including disc prolapse• Neurological deficit during pregnancy• Significant features of delivery, forceps, stirrups• Significant features of any surgery• Features of epidural insertion, paraesthesia, multiple attempts, level• Extent of neurological disability, incontinence, sensation to bladder and bowel

Examination• Inspect epidural site for bleeding, erythema, swelling• Palpate epidural site for tenderness• Check for fever• Full neurological examination of lower limbs

Assessment• Pattern of deficit• Check blood results, WCC and other inflammatory markers

Management• Document thoroughly and discuss with a consultant anaesthetist• Inform the anaesthetist who initially performed the block• Epidural haematoma presents classically of radicular back pain and lower limb

sensory loss, followed by leg weakness, bladder and bowel dysfunction, and progressing to paraplegia.

• Fever, back pain, and focal neurological deficits is diagnostic of an epidural abscess, however not all may be present. Sensory and bladder problems may be the only presentation.

• A diagnosis of epidural abscess or haematoma requires immediate neurosurgical assessment, with MRI available at Sunshine and Footscray. A consultant referral is required and urgent liaison with the MRI radiologist is required. A CT is not a suitable substitute for an MRI

• Focal neurology that is identifiable to a peripheral nerve is more reassuring as this is typically due to an obstetric cause

• Patients with obstetric or surgical causes should be referred back to the parent unit

• Patients with significant sensory deficit or if medico-legal issues are suspected, should be referred to the Neurologist at Footscray for nerve conduction studies etc

• Patients with mild or resolving sensory deficit should be followed up by the APMS

Management of Severe Pre-eclampsia

Pre-eclampsia is a multisystem disease present only in pregnancy and in the immediate post-partum period. Historically it was diagnosed when hypertension and proteinuria was present beyond 20 weeks gestation; however it is now recognised pre-eclampsia affects virtually every organ system. Deaths are usually due to intracranial haemorrhage and cerebral infarction, acute pulmonary oedema, respiratory failure and hepatic failure or rupture.

The following criteria define severe pre-eclampsia and these guidelines apply. HELLP (haemolysis, elevated liver enzymes, low platelets) is considered a variant of severe pre-eclampsia. A consultant anaesthetist must be involved in the management of any parturient with severe pre-eclampsia.

• Systolic BP >160mmHg and/or• Diastolic BP > 110mmHg

• Proteinuria >5g/day or > +++ on dipstick or• Protein/creatinine ratio >0.5g/mmol• Decreased GFR. Serum creatinine >0.09 mmol/l• Oliguria <500mL/24 hours (20mL/hour)

• Neurological symptoms i.e. severe headache, visual disturbance, papilloedema, hyper-reflexia and clonus

• Eclampsia (seizures)

• Liver enzyme elevation (AST/ALT >70iu/L)• Epigastric pain, liver tenderness, nausea and vomiting

• Coagulopathy (Thrombocytopaenia <100x106 and or DIC)• Haemolysis (blood film, elevated LDH or total bilirubin, falling Hb)

• Pulmonary oedema

Principles of Management• Consultation and multidisciplinary team approach• High dependency nursing• Eclampsia prophylaxis• Blood pressure control• Cautions volume expansion• Epidural analgesia• Regular investigations, maternal monitoring and foetal monitoring• Delivery

ConsultationManagement of severe pre-eclampsia requires early multidisciplinary input. Good communication between obstetricians, midwives and anaesthetists is essential. Anaesthetic expertise includes resuscitation, fluid management, insertion of invasive monitoring if required and analgesia/anaesthesia for labour and delivery. Anaesthetic registrars need to be proactive in ensuring they are aware of any potential complicated patients on labour ward.

High Dependency NursingPatients with severe pre-eclampsia are nursed in the labour ward. They may be brought to recovery for stabilisation prior to delivery if clinical conditions dictate (eg requiring arterial line). The ICU liaison nurse should be involved is this instance. Patients potentially requiring transfer should be discussed with the ICU at Footscray.

Indications for transfer include• Need for respiratory support including APO• Complex coagulopathy and massive blood loss• Inotropic support• Neurological impairment• Renal impairment potentially requiring renal replacement therapy

Eclampsia ProphylaxisPatients should be adequately hydrated before initiating Magnesium therapy; the resultant hypotension due to vasodilatation may induce foetal distress. Magnesium sulphate 50% (undiluted) is drawn up to 50ml; administered via a syringe pump through a peripheral IV. A 4 gram bolus (8mL) is given over 15 min (32 mL/hr) and continued at 1g/hr (2 mL/hr) until at least 24/24 postpartum. The patient is warned that she may feel transient hot flushing on commencement. The Western Health protocol for magnesium administration is at http://info.wh.org.au/PPManual/fwdlink.asp?ID=853

Magnesium therapy should be monitored every 6/24. Knee jerks should be checked and levels sent. The patient should have normal reflexes and serum levels of 1.7-3.5 mmol/l. Toxicity may occur in the event of accidental overdosage or with decreased renal function as magnesium is renally excreted unchanged. Toxicity is indicated by;

• Abolished reflexes• Drowsiness• Respiratory rate less than 10

In the event of toxicity, the management is supportive. Stop the infusion for a limited time and start at a lower rate. In rare instances of severe overdose Calcium gluconate (5ml of 10%) may be given as an antidote. This may reverse all the effects of magnesium and eclampsia may occur. Magnesium levels may sometimes be slightly above 3.5 and but the patient remains hyper-reflexic with no signs of toxicity; clinical assessment should take precedence over investigations.

Magnesium is a tocolytic and increased doses of oxytocin may be required to counter this effect. Intra-partum CTG tracings may show reduced variability so scalp pH may be required to differentiate this effect from hypoxia. Beware of using MgSO4 in the presence of hyperkalaemia as it may exacerbate arrhythmias.

Volume expansionOn diagnosis the average patient with severe pre-eclampsia will be about 10-15% dehydrated. Give an initial bolus of about 1000-1500ml of Hartmanns solution will be required. This is especially important before starting Magnesium sulphate or establishing an epidural because of the vasodilatory effect.

A urinary catheter should be placed in all patients and hourly urine output measured. Maintenance fluids of Hartmanns solution should be commenced and a urine output of 0.5ml/kg/hr maintained. Assess fluid status with JVP and chest auscultation.

Persistent oliguria after 2L of crystalloid should be treated with 500mL of colloid. A CVC should be inserted if oliguria persists after colloid bolus. CVP should be maintained between 2-4mmHg. Treat with diuretics if CVP is elevated to minimise the significant risk of fluid overload and pulmonary or cerebral oedema. Failure to respond at this point may require transfer for renal replacement therapy.

Diastolic dysfunction may be present in severe pre-eclampsia; invasive monitoring placed early and fluid boluses may need to be more conservative.

Sudden fluid shifts and rises in CVP often occur after delivery due initially to the autotransfusion of the contracted uterus and then the movement of interstitial fluid into the central compartment over the next few days. Patients remain at risk of APO in the early postpartum period.

Renal failure requiring dialysis is very rare in pre-eclampsia and pulmonary oedema occurs relatively frequently. Renal impairment can occur despite adequate filling due to endothelial dysfunction. Apart from adequate filling, perfusion pressure across the kidney, O2 and Hb, secondary measures are of unproven benefit in renal preservation. Dopamine may be harmful. Frusemide may theoretically be of benefit but is unproven.

Epidural AnalgesiaEpidural analgesia is strongly recommended in severe pre-eclampsia for the following reasons;

• Decreased sympathetic activity and improved blood pressure control• Improved renal and placental blood flow

• Increased need for instrumental delivery and CS in this group.It is preferable that epidurals are placed early before the onset of coagulopathy. General anaesthesia is best avoided due to;

• Pressor response to intubation leading to cerebral haemorrhage• Increased risk of failed intubation due to oedema• Increased risk to compromised foetus

In general patients with mild pre-eclampsia do not require coagulation studies for epidural placement. A patient with severe pre-eclampsia should at least have a platelet count done in the previous 6 hours, and more frequently if falling rapidly. If this is greater than 150,000 then the likelihood of any other coagulation disorder is rare. If platelet counts are borderline then an APTT and PT should also be checked. The use of low dose aspirin is not a contra-indication to the insertion of an epidural.

Blood Pressure ControlLarge drops in blood pressure and perfusion pressure are not be well tolerated by the mother or foetus. Target blood pressure should be 140-150/90-100. Aim to lower BP 10-20mmHg every 10-20 minutes. Treatment is often initiated with oral nifedipine, methyldopa or labetalol; the addition of magnesium infusion and epidural analgesia is often adequate.

Hydralazine can be used to treat resistant hypertension. Bolus doses of 5mg every 5 minutes can be given up to 20mg. If necessary, an infusion should be administered via a syringe pump as per Western Health protocol. Maternal tachycardia is usually a sign of relative intravascular depletion and should initially be treated with a bolus of fluid.

Other medications that can be used to treat resistant hypertension include GTN or sodium nitroprusside. IV labetalol is very effective and may have a more favourable side effect profile than hydralazine; it is not currently available on the Western Health formulary. ACE inhibitors should not be used.

Maternal monitoringClinical

• Symptoms i.e. conscious state, headache, visual disturbance, abdominal pain• Signs i.e. jitteriness, tendon reflexes• BP 5 min for 20 min after any intervention and then hourly.• Hourly urine output.•

Invasive monitoringIndications for insertion of a CVC

• Difficulty controlling blood pressure; and• Renal impairment or persistent oliguria; or • Pulmonary oedema

A CVC is very rarely required. If this is being considered liaise with the obstetric team as to timing of delivery as CVC insertion should occur in PACU or OR; this may be the

most appropriate location for further stabilisation. Position should be checked with X-ray.

Intra-arterial pressure monitoring should be considered in patients who require immediate delivery but remain hypertensive (>160/110) or are sufficiently unstable to require stabilisation in PACU with the direct involvement of anaesthetic staff.

Baseline investigationsSerum electrolytes, including Ca++ and Mg++

Renal function (urea, uric acid, creatinine, protein/creatinine ration), LDHFBE and clottingLiver function tests, total protein and albuminCatheter urine for microscopy and culture

Ongoing investigationsMg++ should be checked at least 6/24 while on therapy and more frequently if there is renal dysfunction. Other tests (platelet count & coagulation profile) should be repeated at the same time to allow safe neuraxial blockade.

Foetal monitoringSometimes the request for urgent caesarean section is made because of foetal distress where the patient has severe pre-eclampsia and is inadequately resuscitated. Preferably stabilisation should occur pre CS and often this may resolve the foetal distress. Circumstances may dictate immediate delivery despite an unstable parturient.

Other therapySteroids may be of use in severe pre-eclampsia complicated by liver dysfunction and coagulopathy. Platelet count may rise after steroids but it is unclear whether using dexamethasone to generate a number at which one could safely undertake regional anaesthesia is beneficial or harmful.

Platelet transfusion (1 pool) are indicated if the platelet count is < 50,000, FFP is required if APTT or INR are 1.5.control. Cryoprecipitate is required if fibrinogen is <1.5g/dl (and there is bleeding or CS is planned). There may be delays at Sunshine Hospital; plan ahead with investigations and blood product requests. Haematology involvement is advisable.

DeliveryThis should be achieved as rapidly as is appropriate after the patient’s condition is stabilised and by the route that the obstetrician deems most appropriate.

If CS is required, patients generally do not become hypotensive after spinal anaesthesia as endothelial dysfunction persists despite sympathetic blockade. If GA in indicated, the pressor response must be blunted. Alfentanil 2mg, Remifentanil or Esmolol are suitable. Inform the neonatal team if opioids have been given. In both

instances, reduced doses of vasopressors should be used initially as responses may be exaggerated.

Major Post-Partum Haemorrhage - Overview

This is not intended to be a comprehensive guide to the management of major obstetric haemorrhage. A brief overview of the topic is offered to aid further reading. Trainees need be aware of what resources are available at Sunshine Hospital and how to mobilise these should an unexpected obstetric haemorrhage occur after hours.

DefinitionThe current ICD-10-AM definition defines a PPH as blood loss of between 500-750mL. However this is well tolerated by most women, and accordingly a more clinically relevant definition of massive PPH being the replacement of 50% of the patient’s estimated blood volume in less than 3 hours or a blood loss of >150mL per minute.

AetiologyThe four “T”s of PPH are Tone, Tissue, Trauma and Thrombin. An empty, contracted, intact uterus will not bleed unless there is a coagulopathy.

Tone (uterine atony). Risk factors include;• Maternal obesity and/or diabetes• Multiple pregnancy or macrosomia• Grand multiparity• Prolonged / augmented labour• Intra-amniotic infection• Abnormal uterine anatomy including fibroid uterus

Tissue (retained products of conception)• Retained placenta or clots• Placenta praevia, accreta, increta or percreta

Trauma (genital tract trauma). Risk factors include;• Precipitous or operative delivery

Thrombin (coagulopathy)• Inherited states (e.g. von Willebrand’s disease, haemophilia)• Acquired states (e.g. ITP, pre-eclampsia, FDIU, infection, abruption, amniotic

fluid embolus, dilutional coagulopathy)• Iatrogenic (thromboprophylaxis or treatment)

PresentationAs the list of aetiology suggests, many major cases of obstetric haemorrhage can be predicted. However, where it is unexpected, recognition may happen late as pregnant women compensate very well for hypovolaemia until very late. Hypotension does not occur until late, at 1500mL blood loss or more. Obstetric haemorrhage is often concealed, and can occur extremely rapidly. Treatment should begin as soon as haemorrhage is obvious, assumed, or predicted.

ManagementThe management priorities are

• Call for help (both anaesthetic, obstetric, haematology and nursing. Ensure the consultant anaesthetist is present or coming in ASAP)

• Activate the massive transfusion protocol if needed • Resuscitate the patient and set up additional equipment• Assess source of bleeding and obtain haemostasis

Call for helpThis is the most important step. Ensure communication is effective between all personnel involved. Delegate a person to have sole responsibility for liaising telephone results, recording fluid administration and requesting further assistance.

Activate the massive transfusion protocolThis recruits blood bank services and enable them to continue release products to the patient without further paperwork. Additional blood products will need time to come to Sunshine Hospital as there is limited supply of some products.

Resuscitation• Give oxygen in high concentration• Obtain large bore IV access (minimum 2 x 16G, 14G or RIC better)• Maintain patient temperature – warmed fluids, forced air warmers• Give blood early. Cross-matched if possible, O-ve if necessary• Attempt to prevent or treat coagulopathy with early use of products• Set up level 1 infuser and cell saver if needed• Invasive monitoring (arterial line, CVC) are useful but must not cause delay• If bleeding is torrential, tran-abdominal aortic compression may be life saving

Assess and control bleedingThe cause of the bleeding must be identified and treated. Bloods must be sent to the lab as frequently as necessary dictated by the clinical situation.

Management of Uterine Atony• Uterine massage• Oxytocin (5 unit bolus followed by infusion, 40 units in 1000mL Hartmann’s

over 4 hours)• Ergometrine (250microg IV and 250microg IM)• Prostaglandin F2 alpha. 5mg ampoule, made to 10mL with normal saline.

Injected intra-myometrially, 1mg at a time. Use caution in patients with a history of asthma or other reactive airways disease.

Ongoing bleeding despite maximal uterotonic therapy would likely require surgical management. Treatment options may include

• Internal uterine tamponade (e.g. a Bakri balloon catheter, inserted pv)• External uterine tampondae performed at laparotomy (B-Lynch suture)• Hysterectomy

Major Post-Partum HaemorrhageConsiderations for Sunshine Hospital

To emphasise again, the management priorities are;• Call for help (both anaesthetic, obstetric, haematology and nursing)• Activate the massive transfusion protocol (see below)• Resuscitate the patient and set up additional equipment• Assess source of bleeding and obtain haemostasis

Massive transfusion protocolhttp://info.wh.org.au/library/scripts/objectifyMedia.aspx?file=pdf/459/60.pdf&siteID=2&str_title=WH%20MASSIVE%20TRANSFUSION%20PROTOCOL.pdf

Copies of this protocol are available on the wall in the Sunshine theatres. Call blood bank at Sunshine on 51480 and “activate MTP”. The afterhours haematologist on call is available on 9244 0450 to assist. (Contents of blood fridge deleted)

Additional equipmentThere is an emergency trolley in the corridor, which should be wheeled into theatre. This has pump sets, large bore IV’s, blood tubes and kits for CVC and art lines. A Level 1 rapid infuser is also available.

A cellsaver is also available. The technicians are responsible for setting up the collection disposables, the nurse in charge organises an outside perfusionist to process the collected blood. Anaesthetists need to be able to assist in set up.

The following is the procedure for setting up the blood collection reservoir.

Collect the following equipment• Cell saver machine• One bag of normal saline, add 30000 units of heparin• One Aspiration and Anticoagulation Line• One Blood Collection Reservoir• One Regulated Suction Source (Located on the cell saver machine)

Set up as follows• Hang bag of saline with 30000 units heparin on Cell Saver IV pole.• Using aseptic technique, open and pass to the sterile field the Aspiration and

Anticoagulation line. • Remove the Blood Collection Reservoir from the container.• Completely clamp ends with the straight adapter and affix to bottom of the

Reservoir. Place Reservoir in the holding ring on the cell saver machine.• Attach regular suction tubing from the regulated vacuum source (set not to

exceed 150MM / HG) to the yellow-capped port located on the top of the reservoir.

• Receive double lumen end of Aspiration and Anticoagulation Line from the sterile field. Remove a blue cap from any one of the horizontal ports on the Reservoir top and attach the Aspiration line to this port (see illustration on emergency setup sheet located on the cell saver machine). Spike the bag of heparin saline solution with the other lumen and prime Reservoir with approximately 100ml of anticoagulant. After priming, adjust drip rate to approximately one drop per second. 

3 blue caps

6 7 (yellow port)2

2a

4 2b

5 1

8

Aspiration and Anticoagulation Assembly1. Suction line connector2. Cross section of A&A tubing

a. large lumen for anticoagulated shed bloodb. small lumen for solution administration

3. Saline and heparin solution bag

4. Drip chamber5. Roller clamp6. Collection reservoir7. Line to vacuum source8. Reservoir drain

Caesarean Section

Antacid Prophylaxis in ObstetricsElective CS

• Ranitidine 150mg, 1.5hrs preop• Sodium Citrate 0.3 molar 30mL on arrival in theatre.

Emergency CS• Ranitidine (Effervescent) 150mg in 30 mL as soon as possible pre-op (or

50mg I/V) +/- Metoclopramide 10mg Oral or IV.• Sodium Citrate 0.3 molar 30mL on arrival in theatre

Spinal Anaesthesia for CS• Use a 25 or 27G pencil point spinal needle with a 20G introducer. For obese

patients longer needles are available. Consider also the long spinal needle through an epidural needle or a CSE kit.

• Co-load with 1L hartmanns (insert IV, start fluid then perform aseptic handwash)

• 0.5% heavy Bupivacaine 2.2 mL + Fentanyl 15 g• Consider a CSE in CS for premature foetuses (<30/40), anticipated difficult CS

or triplets or higher order pregnancy.• The practice of barbotage seems of little advantage, however most

anaesthetists check aspirate CSF at the beginning and end of the injection. (can be difficult through a 27G)

• If the block is below T4, the patient should be placed head down to extend the block. This is no longer possible after 15 minutes as the LA fixes

• Place wedge under the right hip• Have metaraminol drawn up and available as hypotension is common with

spinal anaesthesia for CS• Studies now suggest that BP management should be proactive. Some

anaesthetists give a dose of vasopressor as soon as the block has been placed or run a vasopressor infusion during the case. This may also reduce the incidence of vomiting

• Some women have a profoundly vagal response to spinal anaesthetic. Give atropine in 0.6 + 0.6mg increments if HR <80 and symptomatic. Consider giving prophylactically if bradycardia occurs

• Check the block height to cold and pain. It should be bilaterally to T4• Give 1g cephazolin (2g if patient >80kg) pre incision• Immediately after delivery give oxytocin 5 units (a further 5 can be given after

5 min if required) and set up an infusion of oxytocin (40 units in 1L of Hartmann’s over 4 hours)

• Post-operatively, patients should remain in recovery for 30 min while the usual BP, pulse and block height is checked. It is the anaesthetist’s responsibility to write up fluids for the next 24 hours, analgesia and anti-emetics. Refer to the section on the Sunshine Hospital guidelines for analgesia post CS

Emergency Caesarean Section An emergency Caesarean section should be performed under neuraxial anaesthesia wherever possible. If an epidural is already in place and working well for analgesia during labour then it should be topped up for CS. Discuss with a consultant anaesthetist if spinal anaesthesia is being considered where the epidural is thought not to be reliable.

The addition of fresh adrenaline and NaHCO3 significantly speeds the onset of surgical anaesthesia.

The solution usually used is made up as follows:• 20mL 2% Lignocaine• 0.1mL of 1:1000 Adrenaline or 1mL 1:10000 (100 microg)• 2mL Sodium Bicarbonate 8.4%• Fentanyl 100µg (may be given separately if preferred)

Give 15mL irrespective of the block height to ice unless a concentrated local anaesthetic has been given as a bolus in the last 1/2 hour.

Alert CaesareanThe “alert Caesarean” is a system activated when a woman requires immediate Caesarean section. During the day it is overhead paged, but overnight the responders are paged directly.

The labour ward staff will bring the patient directly. The neonatal team will also be paged to theatre directly. On activation of the alert the anaesthetic team go directly to the allocated OR (usually 6) and make preparations (including drawing up drugs for GA, and making an epidural top-up solution if one is in situ).

It is faster and safer top a working epidural (compared to GA) so this should occur at the same time as making a brief but directed assessment when the woman first arrives in the OR. Obtain the most important information first;

• Indication for Alert CS• ?Working epidural• Any past history or family history of significant GA problems• Any other major medical problems• Allergies• Airway assessment

As for the indication for the alert, these can include;• Cord prolapse• Antepartum haemorrhage / abruption• Prolonged foetal bradycardia• Elevated lactate

Cord prolapse and significant APH are generally indications for a general anaesthetic. Much of the bleeding in placental abruption can be concealed.

For prolonged foetal bradycardia, the FHR should always be checked on arrival in OR, as it often recovers thus allowing time for a regional technique. An alert CS due to an isolated elevated lactate can usually be managed with a regional technique. Ascertain from the obstetricians if they had any preference of anaesthetic technique particularly with regards to the foetal status; but ultimately the decision is up to the anaesthetist.

If in this situation it is felt unsafe to administer a general anaesthetic without consultant anaesthetist presence (for instance, difficult airway or morbidly obese) inform the obstetricians of this, proceed with a regional technique, and have the charge nurse call the consultant anaesthetist and inform them of the situation and that their presence is urgently required. Keep the consultant anaesthetist updated. The woman’s safety is the always the first priority; do not proceed with GA if it is felt the consultant anaesthetist should be present for this.

General Anaesthesia for Caesarean Section

The supervising consultant anaesthetist should always be called when a general anaesthetic is anticipated. In the event of an after hours emergency, have the nurse in charge call if the anaesthetic registrar preoccupied with managing the patient.

Caesarean Section is a major operation. Patients should be fully assessed whenever possible at a preoperative visit. Consent should include an explanation of RSI, and FBE and G&H taken.

Arrival and Induction• Confirm that antacid prophylaxis has been given (see below)• Establish a free running IV. 16G if possible, 18G is acceptable• Position the mother supine on the table, with a wedge under the right hip

(15°-30° tilt)• Prepare for a difficult intubation. Have an LMA and gum elastic bougie /

Frova intubating catheter at hand• Pre-oxygenate the patient with a tight fitting mask using 100% oxygen.

Pre-oxygenate for 3 minutes aiming for an EtO2 of greater than 80%. The anaesthetic nurse attaches standard monitors and BIS at this time. Ensure capnography is working.

• Position the woman’s head. Use the Oxford pillow for obese patients.• When the patient is prepped and draped, instruct the anaesthetic nurse to

position her fingers over the cricoid cartilage. Check this is correctly placed.

• Administer a rapid bolus of approximately 5 mg/kg (lean body weight) Thiopentone, followed by 1.5 mg/kg of Suxamethonium (max 150mg) once the eyelids start to droop. Apply cricoid pressure

• Propofol is an acceptable alternative. It is not licensed for use in pregnant women but much more familiar than Thiopentone to most anaesthetists. 2.5 – 3mg/kg is appropriate

• Do not intubate until fasciculation ceases. Confirm ETT placement with auscultation and ETCO2. Remove cricoid once confirmed

• Inform the obstetricians they can proceed• Ensure blood pressure does not fall below 10% of baseline using fluid and

vasopressors• For maintenance of anaesthesia, initially use 100% O2 with 3% Sevoflurane

prior to delivery. Use high flows to start with. • Further muscle relaxation is usually not required. Give NDMR (approx.

20mg of atracurium or rocuronium) if requested• Immediately after delivery give oxytocin 5 units (a further 5 can be given

after 5 min if required) and set up an infusion of oxytocin (40 units in 1L of Hartmanns over 4 hours.)

• Further uterotonic may be required, give ergometrine 125microg boluses up to 250microg IV if requested. Ask the obstetricians if 250microg IM should be administered.

• After the baby has been delivered and the cord has been clamped, give IV opioid. Morphine up to 30mg may be required, usually start with 20mg and titrate to a respiratory rate of 8-10. Add N2O, aiming for 50:50 N2O and O2. Reduce ET sevoflurane to around 1%, titrating to BIS of 40-60.

• Give prophylactic antiemetics. Ergometrine is particularly emetogenic • Consider the use of IV parecoxib. See the CS analgesia guidelines for

further analgesia• These patients should be extubated awake• Consider TAP blocks and prescribe a PCA

Western Health APMS Guidelines for Analgesia Post CS

Prescriber must enter administration timesFor all patients (except PPH / coagulopathic; discuss with consultant anaesthetist and obstetrician) prescribe enoxaparin 40mg daily sc, 1st dose 6 hours post CS

Epidural or Spinal CS

Intraoperative Analgesia·• Rectal analgesia at conclusion of surgery, If not contra-Indicated.• Paracetamol 1.5-2.0g PR • Diclofenac 100mg PR

o Parecoxib 40mg may be substituted• Oxycodone (Proladone) 30mg PR (Not If Intrathecal (IT) morphine

administered)o IM Morphine10mg may be substituted

• TAP Blocks as desired

Recovery Room• No parenteral opioid (proladone takes 2-3 hrs to reach full effect)• Inform if IT morphine administered so that appropriate ward observations

are done (however, IT morphine is generally not recommended)

Ward: Oral analgesia• Paracetamol 1g QID• Strict NSAID (choose one only)

o Diclofenac 50mg TDS (BD If <50kg) X 2 dayso lbuprofen 400mg TDS X 2 days

• Targin (oxycodone/naloxone) 20mg/10mg BD X 5 doses (Not If IT morphine administered, oxycontin 20mg also acceptable)

• Oxynorm 5-20mg 3 hourly PRN (Not If IT morphine administered)• Laxatives PRN• Anti-emetics X 2 PRN

General Anaesthetic CS

Intra-operative analgesia• Opioid as per anaesthetist choice• Parecoxib 40mg lV (delay subsequent NSAID >12 hrs)• No rectal medication• TAP Blocks as required

Recovery Room• Opioid “As Per Protocol”

o Morphine: 1-4 mg, IV, 5/60 PRN to max of 20mgo Fentanyl: 10-40microg, 5/60 PRN to max of 200microg

Ward• PCA

o Morphine :2mg bolus, 5min lockout, no background, no maximum limito Fentanyl: 30-40microg bolus, 5min lock out, no background, no

maximum limit• Paracetamol 1g QlD• Strict NSAID (choose one only)

o Diclofenac: 50mg TDS (BD If <50kg) X 2 dayso lbuprofen: 400mg TDS X 2 days

• Laxatives PRN• Antiemetics X 2 PRN

Opioid Tolerant Patients and CS

• As for GA, need higher opioid doses• Methadone: usual dose at usual time on day of delivery in addition to PCA• Buprenorphine/Suboxone: Withhold on day of delivery If possible

Other Obstetric Anaesthesia Issues

Retained Placenta Surgical anaesthesia is not given in the labour ward, thus manual removal of placental (MROP) is a procedure that occurs in the OR.

Careful assessment of the volume status and what resuscitation has occurred prior to the patient’s arrival is vital. The volume of blood lost is often greatly underestimated in labour ward. General anaesthetic is recommended if blood loss is uncertain.

A woman with a working epidural should have a top up with the mix described earlier in “Emergency Caesarean Section”. 15-20mL may be required to produce a block to T6. Alternatively a spinal anaesthetic using 2.2mL 0.5% heavy Bupivacaine + 15 microg fentanyl can be used.

If bleeding is ongoing, expected to be problematic or the patient is not able to adequately resuscitated, GA is indicated. Ensure large bore IV access and the availability of blood products. It is not unreasonable to offer a woman a GA if she so desires and there are no indicators of difficult airway. A woman should be considered to have a full stomach until at least 24 hours post-delivery.

Repair of Third / Fourth Degree Perineal TearsRepair of third- and fourth- degree tears occurs in the OR to enable optimal visualisation and repair. A working epidural can be topped up with 10mL of the mix used for CS. Alternatively spinal anaesthesia with 1.5mL of 0.5% heavy bupivacaine, allowing the woman to sit for a few minutes after block placement will produce a dense saddle block.

Again, the volume status of the woman should be assessed prior to anaesthesia and on an ongoing basis. Blood loss is hard to estimate but it can be significant until the suturing is nearly completed. Ongoing communication with the obstetric team is essential. Occasionally the surgeons or the woman may request a GA, especially for complex fourth degree tears.

Spinal anaesthesia on the labour ward for forceps deliveryAnaesthesia is not administered outside of the operating complex or other suitable areas; analgesia is administered on labour wards. If analgesia is required for instrumental delivery on the ward, a CSE (with 0.2% Ropivacaine 2mL and 25microg fentanyl) can be performed as described earlier. Feed the catheter but this will usually be not required.

Trial of forcepsTrial of instrumental delivery often progresses to CS. If the parturient has a working epidural, top up with 10mL of the solution described in “Emergency Caesarean Section” and aim for a block up to T10. Further doses can be given if the case proceeds to CS. For spinal anaesthesia give the usual CS dose.

Paediatrics Guidelines

Patients requiring post-operative care in the special care nursery

IntroductionNeonates are at increased risk in the early post-operative period due to their physiological immaturity and the added risks of

• Potential fluid loss and deficit• Residual anaesthetic agents• Use of narcotics• Hypothermia• Fasting

Leading to the problems of• Apnoea• Hypoglycaemia• Cardiovascular collapse• Incorrect drug dosing

Neonates are a challenge to care for in the post-operative period and experience is best concentrated in one area, especially in a peripheral hospital such as Sunshine. Having “a set age criteria” must take into account the prematurity, birth weight and other significant history of the patient. As a base line we would use a post conceptual age of less than 44 weeks as a criteria for admission but in the end this is a complex medical decision. Anaesthetists must always check that beds are actually available with the nurse in charge with as much warning as possible.

Pre- operative resuscitation of patients with pyloric stenosis

The resuscitation of these patients is under the direct control of the surgeon involved. Patients will not be anaesthetised until they have been adequately resuscitated. Our criteria are as follows

• Adequate hydration on clinical grounds• Serum chloride > 95 mmol/l• pH <7.45 or Bicarbonate < 30 mmol/l

Investigations must be performed several hours before the scheduled time of surgery to avoid unnecessary delay

Fasting Guidelines

Appropriate preoperative fasting reduces gastric volume and gastric acidity. This reduces the risk of gastro-oesophageal reflux and aspiration during anaesthesia. Although extremely rare in paediatrics, this may result in serious morbidity.

Minimum fasting times before elective surgery are as follows:

For paediatric patients older than 6 months of age,Solids, including all types of milk – 6 hoursClear fluids – 2 hours

For paediatric patients younger than 6 months of age,Solids, excluding milk – 6 hoursNon-human milk – 4 hoursBreast milk – 4 hoursClear fluids – 2 hours

Clear fluids (e.g. Apple juice, cordial, water) are non-particulate.A good rule of thumb is that newsprint can be read through clear fluids.Orange juice is not a clear fluid.

For emergency cases, the appropriate anaesthetist will advise regarding fasting on an individual case basis

Pre-medication Guidelines

Hospitalisation and surgery can be very unsettling for our paediatric patients. At Western Health, our aim is to make the process as stress-free and calm as possible, to enable our patients to return to their life outside hospital with minimal negative effects.Children who are anxious during induction of anaesthesia may have greater risk of negative psychological and behavioural effects that persist for some time after surgery1. The use of preoperative sedation may reduce anxiety in selected paediatric patients2.

Oral midazolam is efficacious as a preoperative sedative. It is most useful for patients aged between about two and four years old.The usual dose is 0.5mg per kg to a maximum of 15mg.Midazolam should be given 20 –30 minutes prior to induction of anaesthesia.Midazolam tastes bitter so should be given in combination with paracetamol syrup if ordered, or 10 –20ml apple juice or neat cordial.Oral midazolam, as ordered on preoperative medication chart, may be administered by nursing staff on the paediatric unit, day procedure unit, and operating theatre.

Extreme care must be taken when prescribing sedative medication for children with history of apnoea or active respiratory disease as hypoventilation and desaturation may occur.

Children who are sedated with midazolam may have poor balance, so should remain in bed or on parent’s lap. This should be explained to the parents.Children who are sedated should remain in easy view of nursing staff.

Some children may refuse oral premedication. In this case, the prescribing doctor should be notified..Some adolescents may display particularly anxious behaviour. This group may also benefit from preoperative sedation, eg Temazepam 10-20mg orally at least 30min preoperatively.

Local anaesthetic cream (Angel = Amethocaine) may be used to minimise pain associated with cannulation for intravenous induction of anaesthesia. The anaesthetist may order this on the drug chart, or verbally via telephone if unable to attend the patient on the ward preoperatively. Apply the cream over a vein, about the size of a 10cent piece, under a transparent occlusive dressing. The veins on the dorsum of the hand and antecubital fossa are the most common sites used. Two separate sites should be so prepared. These creams need to be applied for at least 45 minutes to have their anaesthetic effect.

Paediatric Analgesia Guidelines

Our aim is to keep our patients as comfortable as possible throughout the perioperative period. We employ multimodal analgesia to minimise side effects of any one modality.

Simple Analgesia

ParacetamolLoading dose: 30mg/kg oral paracetamol as per preop paediatric protocol will be given by paediatric nursing staffSubsequent dosing: Oral 15m/kg every 4 – 6 hours with a maximum daily dose of 90mg/kg for 2 days, and 60mg/kg thereafter. IV paracetamol is available for use in children who remain nil orally for more than a few hoursFor neonates, maximum daily dose should not exceed 60mg/kg/day

Hepatotoxicity may occur with paracetamol overdosage. Restriction of daily dosage to 60mg/kg (or less) is necessary in children who are unwell, obese, malnourished, or fasting for prolonged periods.Rectal paracetamol has highly variable absorption and should not be used.

IbuprofenUsual dose is 5 to 10 mg/kg (adult up to 400mg) every 4 to 6 hours.Usual NSAID side effects including bleeding so avoid post-tonsillectomy. Check with orthopaedic surgeon - ? effect on bone/callus formation.

ParecoxibLittle or no antiplatelet effects but still other NSAID side effects.Usual dose is 1mg/kg (maximum of 40mg). Not widely used in small children.P.I. : “Not investigated in paediatric patients under 18yrs of age”

Opioid Analgesia

Refer to Western Health Procedure: Patient Controlled Analgesia & Continuous Opioid Infusion for Adults (including paediatric patients over 50kgs) CC5.1.9

The following minor modifications apply to paediatric patients.All requests from outside theatre for PCA or opioid infusions for paediatric patients shall go through the anaesthetic registrar on call for Sunshine Hospital.Pumps are programmed in mL not mg after the appropriate dilution based on weight.

Reportable respiratory rates

Age years Breaths per minute

< 2 years Report less than 20

2 – 8 years Report less than 15

>8 years Report less than 10

Pain assessment scales in children include:FLACC score (see appendix)Faces Pain Scale - Revised (see appendix)Numeric rating scale (0 = no pain, 10 = most severe pain)

Beware of opioid induced respiratory depression in young infants and children with sleep apnoea in addition to the usual side effects of sedation and constipation.

Techniques to minimise opioid requirements whilst maintaining good analgesia should be used in these children. This may include regional blockade with concurrent simple analgesia +/- tramadol.

However, circumstances may arise where opioid administration is necessary. Such children should be monitored continuously with pulse oximetry. These children should be nursed in a location highly visible to staff at all times.

CodeineNo longer commonly used in children as metabolism to the active metabolite morphine is highly variable via CYP2D6 resulting in highly variable clinical efficacy.

OxycodoneThe most frequently used oral opioid. The dose is 0.1-0.2mg/kg 3 hourly PRN

TramadolAlthough Tramadol is a weak opioid agonist, its main analgesic effects are due to effects on serotonin and noradrenaline in descending spinal pathways. Advantages include less sedation, respiratory depression and constipation compared to other opioid agonists. Tramadol is useful for the relief of moderate pain or as a morphine-sparing agent in the management of severe pain.

Usual dose is 3mg/kg intra-operative load,then 1 – 2mg/kg every 6 hours (max. 400mg/day).Can cause nausea and vomiting, so give IV doses over 10 minand oral doses with food.Tramadol is not widely used in infants.

Intravenous opioids in theatre and recoveryFor painful procedures not amenable to effective regional blockade, intravenous opioids are useful.

Typical intraoperative doses are as follows (based on lean body weight)Fentanyl 0.5 to 1.0 microgram/kg for minor procedures

Morphine 50 to 100 microgram/kgSubsequent intraoperative bolus doses may be given if deemed necessary, but it may be prudent to wait until spontaneous respiration has returned.

Children have a propensity for postoperative nausea and vomiting, once opioids have been administered. Prophylactic anti-emetics should be considered.Typical PRN intravenous opioids in paediatric recovery are

Morphine0.1mg Morphine/kg diluted to 10ml with Normal Saline: 2ml bolus 5minutely prn x 5This equates to a morphine bolus of 20 microgram/kg.

Fentanyl1 microgram Fentanyl/kg diluted to 10ml with Normal Saline:2ml bolus, 5 minutely prn x 5This equates to a fentanyl bolus of 0.2 microgram/kg

Further analgesic requirements in PACU should be assessed by the anaesthetist.

Intravenous opioid infusionsThe following standard prescription should be used on AD 347 for all patients with body weight between 10kg and 50kg. Patients weighing greater than 50kg can be treated as an adult. Patients <10kg should be referred directly to a consultant Anaesthetist.

Morphine: 1mg/kg made up to a total of 100mL Normal Saline (10 microg/kg/mL)• program pump in mL (not mg)• intravenous infusion rate: 0 – 4mL/hr (0 – 40microg/kg/hr)• Nurse initiated bolus: 2mL (20microg/kg)• Lock out: 5 minute• 1 Hour Maximum: 8mL (80 microg/kg)

Preparation of the infusion and programming of the pump (in mL not mg) must be checked by a Consultant Anaesthetist, Anaesthetic Registrar or the Acute Pain Nurse.

Nurse initiated boluses are to be given through the GEMSTAR pump as a “loading dose”.

Such boluses can be given at 5 minute intervals providing the following criteria are met.

• The patient has not received 4 boluses in the previous 60 minuteso (If more than 4 nurse initiated bolus doses are required in an

hour, the Pain Service must be contacted)• The nurse has fulfilled competency requirements regarding intravenous opioid

administration• The patient is in pain (score recorded)• The respiratory rate is greater than: (rate to be recorded)

o 20/min for patients younger than 2years

o 15/min for patients aged 2 to 8yearso 10/min for patients older than 8 years

• The patient is awake or easily roused by voice (sedation score 0 or 1).

Prior to administration of a opioid bolus dose, the patient’s pain is be assessed and observations are to be documented. Such documentation enables all members of the treating team to determine effectiveness of analgesia given, and accurately reflects the history of the patient’s condition.Patient Controlled Opioid Analgesia

Patient controlled analgesia (PCA) may be suitable for children with cognitive ability of early primary school level. Ideally, this should be assessed, and the technique discussed, at the pre-anaesthetic visit.

The following standard prescription should be used on AD 347 for appropriate patients with body weight less than 50kg. Patients >50kg can be treated as an adult.

Morphine1mg/kg Morphine made up to a total of 100mL Normal Saline (10 microg/kg/mL)

• program pump in mL (not mg)• PCA bolus dose of 2mL (20microg/kg)• lock-out interval 5 minutes• 1 hour maximum 10mL; i.e. maximum of 5 bolus doses per hour

Fentanyl10microg/kg Fentanyl made up to a total of 100mL Normal Saline (0.1microg/kg/mL)

• program pump in mL (not mg)• PCA bolus dose 2 mL (0.2microg/kg)• lock-out interval 5 minutes• 1 hour maximum 10mL; i.e. maximum of 5 boluses per hour

PLEASE NOTE: Preparation of the infusion and programming of the pump for paediatric analgesic infusions must be checked by a Consultant Anaesthetist, Anaesthetic Registrar or the Acute Pain Nurse.

Paediatric Regional AnalgesiaTechniques using local anaesthesia +/- adjuvants can provide high quality analgesia and minimise dose-related side-effects of other analgesic modalities. Care must be taken to limit dosage per kg body weight to avoid local anaesthetic toxicity (central nervous and cardiovascular systems). Ropivacaine is preferred over Bupivacaine due to better outcomes from treatment of cardiotoxicity.

Local infiltrationEnsure communication with surgical colleagues regarding safe dosage limits if administered intraoperatively.Bupivacaine (0.25% & 0.5%, up to 2.5mg/kg) andRopivacaine (0.2% & 0.75% up to 3mg/kg)are preferred to lignocaine as they last longer.

Adrenaline (up to 10microgram/ml) may be added to provide vasoconstriction to decrease bleeding, but must not be used on digits or appendages.

CaudalProvides dose related neuraxial blockade for surgery involving perineum, lower limbs, and lower abdomen.Infection in the epidural space is an extremely rare but undesirable risk.To minimise this risk the following precautions should be employed:Use sterile equipment and sterile glovesPrep with alcoholic solutionBupivacaine 0.25% up to 2.5mg/kg or Ropivacaine 0.2% up to 3mg/kg

AdjuvantsAdrenaline test dose for detection of intravascular injection:Adrenaline 1:200,000 solution is made by freshly adding 0.1mL of Adrenaline 1:1,000 to 20ml of local anaesthetic solution (5 mcg/ml of Adrenaline).Following a test dose caudal injection of 0.1ml/kg of this freshly prepared solution, a heart rate rise of more than 10 beats/min within 15 to 30 seconds of injection is a sensitive and specific indicator for intravascular injection3.

Clonidine 1 – 2 microgram/kg increases the duration of sensory blockade.Beware of side effects of bradycardia, hypotension, and sedation.These are all dose related, and particularly undesirable in small babies

Ilio-inguinal blockSafe easy block for covering the groin. Can be unilateral or bilateral.St. Vincent’s needle is blunt and gives good feel for the “pop” as the 2 muscle layers are passed through..Ropivacaine 0.75% up to 2mg/kgBupivacaine 0.25%: ¼ ml/kg for each layer

Penile blockUseful for operations on distal penis when caudal is contra-indicated.St Vincent’s needle for feeling “pop” through Buck’s fascia.Ropivacaine 0.5%: for each side 1ml + 0.1ml/kg

Ultrasound-guided Transversus Abdominus Plane blockTAP blocks may be performed in children for surgeries on the lower abdominal wall. Care must be taken to keep local anaesthetic dosage within safe limits to avoid toxicity.

Management of Paediatric PONV

• Postoperative vomiting in children is twice as frequent as in adults.• Nausea is difficult to assess in the young child.

Patient risk factors• previous history• no sex difference until puberty• risk is low for children < 2 years of age but increases with age.

Procedural risk factors• type of surgery: squint repair, adenotonsillectomy• Anaesthetic drugs: opioids, nitrous oxide, volatile agent

Prophylaxis of PONVPresence of risk factors should prompt consideration of prophylactic measures against PONV:

• adequate hydration• Multimodal analgesia to minimise opioid requirement• Avoidance of nitrous oxide• Oxygen supplementation (up to 80%)• Consider total intravenous anaesthesia (consultant anaesthetist)

Prophylactic anti-emetic: (Low risk patients should not require this.)

Moderate or high risk patients should receive antiemetics from 2 to 3 different classes

• Dexamethasone 0.15mg/kg max. 8mg at beginning of case• Ondansetron 0.1mg/kg IV max 4mg• Metoclopramide 0.2mg/kg IV load max. 20mg (dubious efficacy)

Treatment of PONV

• Ondansetron 0.1mg/kg IV, max 4mg, 8hrly• Metoclopramide 0.2mg/kg IV, max 20mg, over 10min, 6hrly

Consider:• Droperidol 10microgram/kg IV, max of 625microgram, 8hrly• Promethazine 0.5mg/kg IV, max of 25mg, 8hrly

Exclude inciting or mechanical factor eg. Opioid infusion, bowel obstruction. IV hydration until tolerating oral fluids.

Parental Presence in Theatre

Induction of anaesthesia can be an anxious time for both children and their parents. It is generally agreed that children suffer separation anxiety from around 9 months of age and older. So for those children older than 9 - 12 months, parental presence at induction may help to alleviate anxiety in the child (and also with the parent). But parental presence in the anaesthetic room or operating theatre remains at the discretion of the anaesthetist. In some situations, such as where a parent is extremely upset himself or herself, it would not be helpful to the child.

The nursing staff in the holding area will help the parent cover street clothes with gown, overshoes and hat. The parent must agree to leave the child once the child is anaesthetised, or when asked to leave by staff. The anaesthetist needs to predetermine that the parent will comply with these requests.

Due to limited physical space, usually only one parent may accompany the child. An interpreter may be required if the parent does not speak English. Anxiety in the child varies proportionally with the number of people in the room. This should be kept in mind during induction of anaesthesia. A staff member separate from the anaesthetic nurse and anaesthetist must be available to show the parent from the theatre once the child is anaesthetised.

Appendix 1

Guide to assessment of labour neuraxial analgesia

Pre procedure

1 Assesses the patient

2 Chooses the anaesthetic technique appropriately

3 Explains the procedure and obtains informed consent

4 Ensures adequate assistance, monitoring, equipment and IV access

Procedure

5 Demonstrates satisfactory aseptic technique including safety with prep

6 Positions the patient correctly for the block

7 Identifies landmarks

8 Inserts epidural catheter satisfactorily using appropriate technique

9 Performs aspiration test and responds appropriately to the result

10 Administers appropriate test dose

Post Procedure

11 Performs safe incremental dosing

12 Assesses analgesia and ensures further care of patient as appropriate

13 Demonstrates good record keeping

14 Demonstrates good behaviour, communication skills and attitudes

Overall ability to perform procedure

NC - Not yet competent

CS - Able to perform procedure competently with supervision

C - Able to perform procedure independently

Appendix 2

Logbook for competency to administer neuraxial analgesia in labour

Trainee Name: ________________________________

Number DOPS

Elective CS, spinal, TPS reviewed

Elective CS, CSE, TPS reviewed

Labour Epidural, TPS reviewed

Completed

Epidural Simulator Session (complete at any time)

Epidural Knowledge Test (complete at any time)

Other comments:

Competent to administer neuraxial analgesia in labour

______________________________ ______________________________Signature of supervisor Date

Once assessed as competent, ensure a copy is kept by the Department of Anaesthesia and Pain Medicine. The trainee should keep a copy for their own records.

Appendix 3AAGBI Safety GuidelineManagement of Severe Local Anaesthetic Toxicity

1Recognition

Signs of severe toxicity:• Sudden alteration in mental status, severe agitation or loss of consciousness, with

or without tonic-clonic convulsions• Cardiovascular collapse: sinus bradycardia, conduction blocks, asystole and

ventricular tachyarrhythmias may all occur

2Immediatemanagement

• Stop injecting the LA• Call for help• Maintain the airway and, if necessary, secure it with a tracheal tube• Give 100% oxygen and ensure adequate lung ventilation (hyperventilation may help by

increasing plasma pH in the presence of metabolic acidosis)• Confirm or establish intravenous access• Control seizures: give a benzodiazepine, thiopental or propofol in small

incremental doses• Assess cardiovascular status throughout• Consider drawing blood for analysis, but do not delay definitive treatment to do this

3Treatment

In circulatory arrest• Start cardiopulmonary resuscitation

(CPR) using standard protocols• Manage arrhythmias using the same

protocols, recognising that arrhythmias may be very refractory to treatment

• Consider the use of cardiopulmonary bypass if available

Give intravenouslipid emulsion(following the regimen overleaf)

• Continue CPR throughout treatment with lipid emulsion

• Recovery from LA-induced cardiac arrest may take >1 h

• Propofol is not a suitable substitute for lipid emulsion

• Lignocaine should not be used as an anti-arrhythmic therapy

Without circulatory arrestUse conventional therapies to treat:• hypotension,• bradycardia,• tachyarrhythmia

Consider intravenouslipid emulsion(following the regimen overleaf)

• Propofol is not a suitable substitute for lipid emulsion

• Lignocaine should not be used as an anti-arrhythmic therapy

4Follow-up

• Arrange safe transfer to a clinical area with appropriate equipment and suitable staff until sustained recovery is achieved

• Exclude pancreatitis by regular clinical review, including daily amylase or lipase assays for two days

• Report cases as follows:in the United Kingdom to the National Patient Safety Agency(via www.npsa.nhs.uk)in the Republic of Ireland to the Irish Medicines Board (via www.imb.ie)

If Lipid has been given, please also report its use to the international registry at

Your nearest bag of lipid emulsion is kept

This guideline is not a standard of medical care. The ultimate judgment with regard to a particular clinical procedure or treatment plan must be made by the clinician in the light of the clinical data presented and the diagnostic and treatment options available.

IMMEDIATELY

Give an initial intravenous bolus injection of 20% lipid emulsion

1.5 mL/kg over 1 min and Start an intravenous infusion of 20%lipid emulsion at 15 mL/kg/hr

AFTER 5 MIN

Give a maximum of two repeat boluses (same dose) if:

• cardiovascular stability has not been restored or

• an adequate circulation deteriorates

Leave 5 min between bolusesA maximum of three boluses can be given (including the initial bolus)

and

Continue infusion at same rate, but:Double the rate to 30 ml/kg/hr

at

any time after 5 min, if:

• cardiovascular stability has not been restored or

• an adequate circulation deteriorates

Continue infusion until stable and adequate circulation restored or maximum dose of lipid emulsion given

An approximate dose regimen for a 70kg patient would be as follows:

IMMEDIATELY

AFTER 5 MIN

Give an initial intravenous bolusinjection of 20% lipid emulsion

100mL over 1 min Start an intravenous infusion of 20%lipid emulsion at 1000mL/hr

Give a maximum of two repeatboluses of 100mL

Continue infusion at same rateBut double rate to 2000mL/hr if

indicated at any time

Do not exceed a maximum cumulative dose of 840mL

Do not exceed a maximum cumulative dose of 12mL/kg

This AAGBI Safety Guideline was produced by a Working Party that comprised:Grant Cave, Will Harrop-Griffiths (Chair), Martyn Harvey, Tim Meek, John Picard, Tim Short and Guy Weinberg.

This Safety Guideline is endorsed by the Australian and New Zealand College of Anaesthetists (ANZCA)

AND

AND

AND

AND

Appendix 4 Face Pain Scale – Revised (FPS-R)

In the following instructions, say "hurt" or "pain," whichever seems right for a particular child.

"These faces show how much something can hurt. This face [point to left-most face] shows no pain. The faces show more and more pain [point to each from left to right] up to this one [point to right-most face] - it shows very much pain. Point to the face that shows how much you hurt [right now]."

Score the chosen face 0, 2, 4, 6, 8, or 10, counting left to right, so '0' = 'no pain' and '10' = 'very much pain.'Do not use words like 'happy' and 'sad'. This scale is intended to measure how children feel inside, not how their face looks.

Appendix 5

FLACC Score

CATEGORY SCORE DESCRIPTION

Face 0 No particular expression or smile1 Occasional grimace/frown, withdrawn or disinterested2 Frequent quivering chin, clenched jaw

Legs 0 Normal position or relaxed1 Uneasy, restless, tense2 Kicking or legs drawn up

Activity 0 lying quietly, normal position, moves easily1 Squirming, shifting back and forth, tense2 Arched, rigid or jerking

Cry 0 No cry1 Moans or whimpers, occasional complaint2 Crying steadily, screams, or sobs, frequent complaints

Consolability 0 Content and relaxed1 Reassured by occasional touching, hugging or talking, distractible2 Difficult to console or comfort