Obstetric Anaesthesia presentation^J National Weekly MPDSR meeting_presentation 6th June 2024.pdf

Newer modalities in labour analgesia and anaesthesia for caesarean section including regional anaesthesia techniques and airway management are emerging constantly. Techniques such as point of care ultrasound, especially of the lungs and stomach and point of care tests of coagulation based on viscoelastometry are about to revolutionise perioperative obstetric care. This has improved the quality of care thereby ensuring good perioperative outcomes in the parturient with comorbidities. Critical care for obstetrics is an emerging field that requires a multidisciplinary approach with obstetricians, maternal-foetal medicine experts, intensivists, neonatologists, and anaesthesiologists working together with enhanced preparedness and uniform protocols. Newer techniques and concepts of understanding have thus been established in the traditional speciality of obstetric anaesthesia over the last decade. These have improved maternal safety and neonatal outcomes. This article touches upon some recent advances that have made a significant impact in the field of obstetric anaesthesia and critical care.

Key words: Critical care, general anaesthesia, obstetrics, ultrasonography
INTRODUCTION
Obstetric anaesthesia is a steadily progressing speciality. It has evolved from the traditional practices such as ‘chloroform’ for labour analgesia, to protocolised safe procedures. The modern obstetric anaesthesiologist plays the role of a ‘peripartum physician’ who ensures quality in care. Obstetric anaesthesiologists of today with compelling evidence, a sound knowledge of maternal anatomy and physiology, and a strong backup of advanced technology including monitoring devices, airway equipment, and ultrasound (US) bear only a small resemblance to their traditional counterparts. Obstetric critical care with its fast-evolving modalities of care is also developing to match the advances and novel concepts in obstetric perioperative care. Keeping this in mind, we did a thorough literature search related to obstetric anaesthesia and critical care in various databases and the information thus obtained is presented in this article.

LABOUR ANALGESIA
Multiple options are currently available for labour analgesia, although lumbar epidural still remains the best option in terms of analgesia. Randomised control.


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Indian J Anaesth. 2023 Jan; 67(1): 19–26. Published online 2023 Jan 21. doi: 10.4103/ija.ija_1032_22
PMCID: PMC10034925PMID: 36970483
Recent advances in obstetric anaesthesia and critical care
Madhuri S. Kurdi, Vennila Rajagopal,1 Kalyani SDL Sangineni,2 Murugan Thalaiappan,3 Anju Grewal,4 and Sunanda Gupta5
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ABSTRACT
Newer modalities in labour a

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SAFE OBSTETRIC ANAESTHESIA
at a PERIPHERAL HC IV
PRESENTER: RUGUMAYO RICHARD

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•ANAESTHESIA PREPARATION.
1)Pre-operative patient assessment.
2)Airway assessment.
3)Basic Investigations. (CBC, LFTs, RFTs, Urinalysis).
4)Machine assessment.
5)Operating table assessment.
6)PAC preparation.
7)PrepareforAnaesthesiaadministration.(LA,LocalregionalandGA).
•PATIENTMONITORINGDURINGANAESTHESIA.
•PATIENTRECOVERYFROMANAESTHESIA.
•PATIENTFOLLOWUPpostoperatively.
Presentation Outline

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Anaesthesia preparations
Pre-operativepatientassessment.
•Createrapportwiththepatient.
•Clerkthepatient.Takehistoriesfocusonpastmedical,surgical,anaesthesia,
allergies,socialhistory(smokingandalcohol,drugabuse.
•Currentconditionofthepatient,gestationperiod,indicationforC/S(PE).
•Counselthepatientandrelatives(respectivematernitycare)fortheoperation
ifconscious.
•Checkconsent.
•Informthepatientaboutthepossibleanaesthesiaoptions(G/A,S/A,Dual
TechniqueandLA)expressbothadvantageanddisadvantage.

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Air way assessment
•Methods(tests)carryouttopredictAirwaymanagement.
Canbeeasyordifficultintubation.
IfatrainedAnaesthetistsusingconventionallaryngoscopetakesmorethan
3attemptsormorethan10minutetocompletetrachealintubation.Difficult
intubation.

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Predict difficult air way in the following
Pathology of the mouth
Big breasts
Short neck
Receding jaw
Contractures
Obesity
Protudingteeth
Factures of the jaw
Big gaps or toothless

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METHODS USED IN ASSESSING THE AIRWAY
L ookexternally.
E valuate the 3-3-2 rule.
M allampati.
O bstruction?
N eckmobility.

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LOOK EXTERNALLY
•Beardsorfacialhair.
•Short,fatneck.
•Morbidlyobesepatients.
•Facialornecktrauma.
•Brokenteeth(canlacerateballoons).
•Dentures(shouldberemoved).
•Largeteeth.
•Protrudingtongue.
•Anarroworabnormallyshapedface
•Buckteeth..

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E:Evaluate the 3-3-2 rule
✓3fingersfitinmouth-Interincisordistance
✓3fingersfitfrommentum
tohyoidcartilage.
✓2fingersfitfromthefloor
ofthemouthtothetopof
thethyroidcartilage

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M:Mallampati classification
I ma g e result for la ry ng oscopy cla ssifica tion ima g es

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O: Obstruction?
◼Blood.
◼Vomitus.
◼Teeth.
◼Epiglottis.
◼Dentures.
◼Tumors.
◼Impacted Objects

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•N: Neck mobility -Measurement of
Atlanto-Occipital Angle.
•Ashortthyromentaldistance=
ananteriorlarynx.>7cm
isusually=easyintubation
<6cm=difficultairway.
Thyro-MentalDistance.
NB.Verycoonisthehairstyleofhavingpuff.

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Basic investigations:
1.CBC.LookatHB.
1.LowHB-determinethechoiceof
technique.
2.Shouldabove9gdl.,platelets–
above100,
3.below50-90notsafefor
anesthesiainperipheralunits.
4.Refer.
2.RFTSifpossible.serumcreatinine
>1.1mg/dLordouble
3.LFTsifpossible.
4.Urinalysis.Mainlyproteins,
ketones,glucose.
5.Ifpossible,Bloodgasanalysis
(ABG-PCO2,PO2,HCT,Lactose).
NB.DonotdelayAnaesthesia
iftheabovearehardtoatyourdo
unit.

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Machine check
✓Powersource.(electricityorsolar.
✓Drivinggas–oxygensource.
(cylinder,piped,tank).
✓Accessoryoxygen-cylinderor
concentrator.
✓Thebreathingcircuit.Testforthe
leak.
✓Thevaporizers–levelofinhalation
agent,workability.
✓Checktheflowmeters-foroxygen,
medicalairorsurgicalairifany.
✓Checktheventifworking.
✓Checktheoxygenbag-rightsize
forthepatient,leakage…
✓LookattheAPLvalve-working,
adjusting.
✓Checktheflashbutton.
✓Lookatthecapnography,oxygen
sensor.
✓Lookatthescavengingsystemor
sodalinecolourchange.
✓Calibratethemachineaccordingly.
✓Thenenternewpatient.

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Check the operating table
•Abilitytotilt.
•Changepositionupanddown,sideways.
•Abilitytoholdlegsupport,armrests,anaesthestic
screen,headplate,footsupport,bodysupport,
footplate….
•Lubrication.
•Pillows.
•Shouldersupport.
•Afaultybedcanleadtohighortotalspinal,failed
intubation.

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Prepare for anaesthesia(technique
to use)
Thechoicedepends.
•Onthehealthofthemother,
(pre-eclampticoreclamptic,
consciousorunconscious.)
•Healthofthefetus(liveordead)
and
•Thetechnicalabilityofthe
anesthetist.(abilitytointubate,
givespinal.)
•G/Amayavoidthehypotension
duetoS/Aandsaferin
thrombocytopenia.
•PEpatientsmaybeverydifficult
tointubate-severeairwayedema.
•NB.Mustassesstheairwaywith
extremecareandbepreparedfor
adifficultorimpossibleintubation.
•PEpatienthaveexaggerated
cardiovascularresponsesof
hypertensionandtachycardiato
Ketamine,intubationandextubation.

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Spinal anesthesia
1)Pre-eclampticoreclampticpatients
rarelyhavecoagulationabnormalities.
•Theplateletcountshouldideallybe
above100,000.
•Plateletcount-notavailable-
estimateofclottingability-Observe
puncturesites- notbleed
excessively.
•S/Apuncture-inPtswithclotting
abnormalitiesmaycausea
hematoma-inepiduralspace
resultinginpermanentparalysis.
2)TheSAshouldnotcauseasevere
hypotensionifthepatient'sblood
pressureiscontrolled,andtheyhavehad
adequatefluidresuscitation.
3)Postdeliverycareineclampsia.
•Thepatientremainsatriskfrompre-
eclampsiaforupto48hoursafter
delivery.
•Morethan50%ofconvulsionsand
pulmonarycomplicationsoccurinthe
postpartumperiod.

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Know what equipment is available
•Anassistantwithexperiencein
maintainingcricoidpressureshould
beavailableifageneralanesthetic
isrequired.
•Sourceofoxygen.
•Suctionapparatusisfunctional
(manualasabackup).
•Arollorwedgeshouldbeavailable
(oftenarolled-uptowelwillsuffice).
•Intubationequipment(masks,
laryngoscopeblades,endotracheal
tubes(preferablysize6.0,65,7.0),
stylets,introducerandoralairways.
•AlternativeairwayslikeLMAor
combitubecanbelifesavingin
difficultorfailedintubation.
•ABMVshouldbeavailableincase
theanesthesiacircuitfails.
•Resuscitationequipment and
medicationsshouldbeready.
•Monitoringequipmentshouldbe
availableandfunctional.
•SPINALPACK,SterileLASolutions.
•Anestheticmedications.forthe
inductionofgeneralanesthesia.

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•Onceapatientisintheaterdoaquickpatient
assessment.
•Maternalhealthhistory.
•checkAnesthesiarelatedhistory.
•checkVitalsignassessment.
•checkLaboratoryvaluesifavailable(CBC;
Bleedingandclottingtime,platelets).
•Examinationofthebackforregional
anesthesia.
•Documentationoforalintakebutallpregnant
mothersarefullstomach.
•Consentforanesthesia.
•FunctionalIV.

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•Preoperativemedicationsshouldfocusonminimizingtheriskof
aspiration.
•Antiacidslike
•Ranitidine50mgIVPorfamotidine20mgIVPdecreasesacidity.
•sodiumcitrate,ivomeprazole.
•AntiemeticIVMetoclopramide,IVDexa,30minutespriortothe
inductionofanesthesia.
•Ondansetron4-8mg
•Maygiveglycopyrrolate(0.1-0.2mgIVP)oratropine(0.4mgIVP)to
reduceoralsecretions.
•Avoidsedativestheydepressthebaby.
•Pre-loadingofthepatientwithnon-glucosecrystalloidsolutionsshouldbe
givenbeforeS/A.

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Patient monitoring during Anaesthesia
•Fetalheartratemonitoringshouldbe
monitoredupuntilregionalanesthesiais
initiated(ifavailable).
•ForS/AMonitorvitalsigns
frequently.
•Checkthepatient’sbloodpressure
every1-2minutesinSAuntilthebabyis
delivered.
•Ifstableafterthedelivery,theblood
pressurefrequencycanbedecreasedto
5minutes.
•Rememberthatspinalanesthesiamay
takeupto15minutestosetup,epidural
anesthesiamaytakelonger.
•Assesstheblock.
•ForcesareanblockatlevelofT4-T6
shouldbeadequate.

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Monitor complications of
S/A
•Hypotension.IncreasetheIVinfusion
andtreatthepatientwithephedrine(5-10
mgIVP)orphenylephrine(50-100mcg
IVP).
•Nauseashouldbeconsideredtobe
relatedtohypotensionuntil.checkthe
patient’sbloodpressure.
•Monitorheartratecontinuously.
•AblockaboveT4causesbradycardia.
•Treatmentwithvasopressors:ephedrine
(5-10mgIVP)oratropine(0.5mgIVP).
•Epinephrine(5-10mcgIVP)maybe
usedandtitratedtoeffectif
unresponsivetoephedrineor
atropine.
Monitorshortnessofbreath.
•Thepregnantpatienthasdecreased
lungcapacityandincreasedoxygen
consumption.Administeroxygento
allpregnantpatients.
•SAaffectdiaphragmandintercostal
muscles.Decreasingthelung
capacities.
•Monitorpulseoximetryandreassure
thepatient.

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Monitorthepatientforahigh
spinal
•Assessfornumbnessandtinglingofthe
chest,fingers,arms,andneck.
•Problemsspeaking-blockistoohigh.
•Monitorrespiratorydistressandlossof
consciousness.
•Elevatetheheadandneck.Administer100%
oxygen,treatbloodpressure,andpreparefor
intubation.AndsupportonMV.
•Supporttheheartandrespiratoryfunction.
•Monitorvitalsignsandprepareforcardiac
arrest.
•Generally,thepatientwillrecoverquicklyfrom
ahighspinal.
•Monitor for SS and SS of LA toxicity.
•Remember bupivacaine is cardo toxic
and irreversible and lignocaine is cardo
friendly.
•Act immediately and treat each sign.
•Symptoms range from ringing in the
ears, numbness of the mouth or
tongue, dizziness, confusion,
decreased level of consciousness,
convulsions, and cardiac arrest.

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•Monitor fluid intake.
•Give iv fluids with caution in PE but they
need fluids.
•Replace blood loss with crystalloid
intravenous solutions (3 ml of crystalloid
for 1 ml of blood loss).
•Alternatively, colloid solutions may be
used (1 ml of colloid for 1 ml of blood
loss).
•Use plasma expanders (Rheosobilacte).
•Use or replace lost blood with
blood or blood products.
•Avoid 5 % dextrose use 50%
dextrose.
•Monitor blood loss.
•Field of operation.
•Uterine contraction.
•Blood pressure.
•Monitor urine out put.
•Look at volume, colour….

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•For General Anesthesia
•Pre-oxygenatethepatientfor5
minutes100%O2.
•ConsiderRSI.Usepropofol2
mg/kgIVPandthiopental4mg/kg.
Avoidketamine.
•Applycricoidpressureasthe
patientlosesconsciousness.
•Administersuccinylcholineina
doseof1.5mg/kg(unless
contraindicated).
•Nondepolarizingmusclerelaxants
maybeusedifsuccinylcholineis
contraindicated;onsetwillbe
slower.
•Avoidmaskventilatingthepatient
unlesshypoxiaoccurs.Fullstomach
toavoidaspiration.
•Intubatewhenitisapparentthatthe
patientisparalyzed.
•Surgerymaystartoncethepatientis
intubated,ventilated,andtheairway
issecure.
•Inhaledanestheticsshouldbeuse.
Youmayavoidhalothane.
•Monitordepthofanaesthesia.
•Levelofoxygenandgases.

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•Duringallanaestheticsmonitorthe
patient’s
•Oxygenation
•Ventilation
•Circulationand
•Temperature
•Someofthephysiologicdisturbances
thatoccurintheperioperativeperiod
include:
•apnea
•respiratorydepression
•airwayobstruction
•cardiacdepression
•Hypertension
•hypotension,hypervolemia,hypovolemia.
•Arrhythmias.
•bloodloss,fluidshifts
•weakness
•bradycardia,tachycardia
•hyperthermiaandhypothermia
•Monitorthetubefor-Knick,leakage,extubation,
anddisconnection.
•Suctionofsecretions.
•Signsofrecovery.
•Extubationwhenfullyawakeandundercough
extubation.
•Continuewithoxygenadministrationuntilthe
patientisabletobreathspontaneously.
•ThendischargethroughPACU.

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Preparation for PACU
•Pt should be monitored by
assessing circulation involves.
•ECG, blood pressure every 5
minutes,peripheral circulation,
patient's temperature.
•Pulse oximetry or capnography.
•Administer 100% O2.
•Suction the patient.
•Position in recovery position (left
lateral.)
•Levelofconsciousness.
•Postoperativepainmanagement(
canbeablock,iv).
•Monitorforbloodloss,signsof
shockandmanageimmediately.
•Monitorurineoutputandassess
AKI.
•Assessforthesignsofpulmonary
edemaandgivefluidwithcaution.
•Sendthepatienttowardwhenfully
awake.
•ForS/Awaitfor30-60minutes
fromthetimeofSAadministration.

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Patient follow up post operatively
•To assess the full recovery from anesthesia.
•To cont. monitoring with post op team.
•To assess and manage postoperative pain which is usually
neglected.
•To assess the functionality of vital organs. Renal, hepatic….
•To assess for the complications of anaesthesia and fix them.
•NB. Pt should be followed up to 48 hrsby anaesthesia team.

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Thank you!
Questions are welcome