Anaesthesia for caesarean section in a patient with Eisenmenger syndrome

<h3></h3> Planning, Preparation and Pre-emption are three key concepts in the practice of anaesthesia. In obstetric anaesthesia specifically, these three 'P's are particularly relevant as parturients are commonly present the...

<h3>Introduction</h3> Intrapartum caesarean delivery (CD) is a common obstetric intervention. Published cohorts report up to 31,2% of intrapartum CD among parturients admitted to delivery room.¹ It also represents 60 to...

Regional anaesthesia (spinal or epidural anaesthesia) for caesarean section is the preferred option when balancing risks and benefits to the mother and her fetus. Spinal anaesthesia for caesarean section is thought to be advantageous due to simplicity of technique, rapid administration and onset of anaesthesia, reduced risk of systemic toxicity and increased density of spinal anaesthetic block. To assess the relative efficacy and side-effects of spinal versus epidural anaesthesia in women having caesarean section. The Cochrane Pregnancy and Childbirth Group Trials Register (February 2003) and the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2003). Types of studies considered for review include all published randomised controlled trials involving a comparison of spinal with epidural anaesthesia for caesarean section. Two reviewers independently assessed trials for inclusion. Review Manager software was used for calculation of the treatment effect represented by relative risk (RR) and weighted mean difference (WMD) using a random effects model with 95% confidence intervals (CI). Ten trials (751 women) met our inclusion criteria. No difference was found between spinal and epidural techniques with regards to failure rate (RR 0.98, 95% CI 0.23 to 4.24; four studies), need for additional intraoperative analgesia (RR 0.88, 95% CI 0.59 to 1.32; five studies), need for conversion to general anaesthesia intraoperatively, maternal satisfaction, need for postoperative pain relief and neonatal intervention. Women receiving spinal anaesthesia for caesarean section showed reduced time from start of the anaesthetic to start of the operation (WMD 7.91 minutes less (95% CI -11.59 to -4.23; four studies), but increased need for treatment of hypotension RR 1.23 (95% CI 1.00 to 1.51; six studies). Both spinal and epidural techniques are shown to provide effective anaesthesia for caesarean section. Both techniques are associated with moderate degrees of maternal satisfaction. Spinal anaesthesia has a shorter onset time, but treatment for hypotension is more likely if spinal anaesthesia is used. No conclusions can be drawn about intraoperative side-effects and postoperative complications because they were of low incidence and/or not reported.

Intraoperative awareness (IA) is diagnosed when patients can recall their surroundings or an event related to the surgery that occurred while they were under general anaesthesia. The female gender and Caesarean section are considered to be contributing factors. The aim of the present study was to analyse the frequency of IA in patients undergoing general anaesthesia either for Caesarean section or gynaecological procedures. ASA I and II women were included into the study. Patients were randomly allocated to 4 groups: A, B and C included patients qualified for elective gynaecological surgery, and group D comprised Caesarean section patients. Premedication was not given. Group A received total intravenous anaesthesia with TCI, and groups B, C and D received balanced anaesthesia. The depth of anaesthesia was monitored with an AEP monitor. Blinded structured interviews were conducted 2 hours after anaesthesia and on postoperative days 7 and 30. 337 patients were enrolled into the study. 45 patients reported diverse sensations connected to the anaesthesia (Group A - 7 patients, B - 9 patients, C - 2 patients, D - 28 patients). There were mainly dream sensations, but IA was present in 3 cases. In all of the cases, IA was recognised during the first interview. One episode of awareness appeared in group B, and the other two appeared in group D. One Caesarean section was complicated by intraoperative haemorrhage. The patient from group B had similar sensations during previous anaesthesia. Two women enrolled in the study reported awareness in the past, which did not occur this time. Awareness during general anaesthesia occurs occasionally. The frequency of occurrence in a group of patients undergoing general anaesthesia for uncomplicated Caesarean section is not higher than for other procedures. The anaesthesia for Caesarean section, as well as for other procedures, may be accompanied by pleasant dreams.

The vasovagal response is characterized by an inappropriate combination of bradycardia and paradoxical vasodilation. During a general or neuraxial anesthesia-induced sympathectomy, a sudden vagal activation and/or an acute reduction in sympathetic tone can cause serious vasovagal responses. Neuraxial anesthesia for Cesarean section may trigger vasovagal response, due to multiple risk factors; high neuraxial block, sudden hemorrhage, aortocarval compression, peritoneal manipulation, and emotional stress. A 39-year-old pregnant woman, at 38 weeks of gestation with episodes of non-sustained ventricular arrhythmia and newly developed vasovagal syncope during pregnancy, was scheduled to undergo a spinal anesthesia for an elective Cesarean section. Immediately after the placental expulsion, a sudden severe bradycardia, followed by a cardiac arrest occurred. The patient fully recovered after prompt cardiopulmonary resuscitation with chest compression, manual ventilation with oxygen, rapid injection of epinephrine and hydration. This case illustrates a serious potential risk of vasovagal response superimposed on neuraxial anesthesia, during a Cesarean section, especially during placental expulsion.

Background: Hypotension is the most common adverse effect in parturients after spinal anaesthesia for Caesarean section. Despite various pharmacological and non-pharmacological methods used in its prevention and treatment, vasopressors have become very important in the management of this form of hypotension. Objective: This study was aimed at comparing the efficacy and safety of prophylactic intravenous infusions of phenylephrine and ephedrine at preventing maternal hypotension during Combined Spinal Epidural anaesthesia (CSE) for Caesarean section. Methods: Sixty ASA I and II patients scheduled for elective Caesarean section, were randomly allocated into two groups. Patients in Group I received Phenylephrine 80 μg/min while patients in Group II received Ephedrine 1 mg/min immediately after the subarachnoid 10 mg plain bupivacaine injection while the epidural catheter was being inserted and secured. All the patients received a crystalloid preload of 1 litre of 0.9% normal saline prior to the induction of CSE. Results: The overall incidence of hypotension was 8.5% (6.7% in the phenylephrine group and 10.3% in the ephedrine groups). The lowest systolic (105.8 ± 9.2 mmHg) and diastolic arterial pressures (60.9 ± 8.9 mmHg) occurred in the ephedrine group while the lowest heart rates occurred in the phenylephrine group. The mean umbilical artery pH was 7.3 while Apgar scores at 1st and 5th min were essentially the same in the two groups. Conclusion: Prophylactic intravenous infusions of phenylephrine and ephedrine are safe and effective at reducing the incidence and severity of hypotension during combined spinal epidural anaesthesia for elective Caesarean section with no associated neonatal acidosis.

Bupivacaine is an amide local anaesthetic used in hyperbaric and isobaric forms. These are administered intrathecally into the spine to provide regional anaesthesia for caesarean section. Several trials have compared hyperbaric and isobaric bupivacaine but none have conclusively shown benefit of either. This systematic review aimed to summarize the effectiveness and safety of hyperbaric versus isobaric bupivacaine in providing anaesthesia for caesarean section. We considered the adequacy of anaesthesia for completion of caesarean section and the need for interventions to treat complications. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 4), MEDLINE (January 1966 to May 2011) and EMBASE (January 1980 to May 2011). We handsearched journals. We imposed no language restriction. We reran our search in the above databases from January 2011 to January 2013; the studies are awaiting assessment and will be dealt with when we update the review. We included all randomized controlled trials involving parturients undergoing spinal anaesthesia for elective caesarean section that compared the use of hyperbaric with isobaric bupivacaine. Two authors independently extracted the data. The data that were extracted included the number of events and the sample sizes in both the intervention and control groups. For continuous outcomes, we extracted mean and standard deviation.We reported odds ratios and risk ratios (RR) for binary outcomes and mean differences (MD) for continuous outcomes. We included six studies with a total of 394 patients in this review. Anaesthesia performed with hyperbaric bupivacaine appeared to be less likely to need conversion to general anaesthesia (two studies, 158 patients included in meta-analysis; RR 0.17, 95% confidence interval (CI) 0.03 to 0.94). There was no difference in the need for supplemental analgesics. The time till sensory block to the T4 level was also shorter with hyperbaric bupivacaine (two studies, 126 patients; MD -1.06 minutes, 95% CI -1.80 to -0.31). There were no other significant differences between the two anaesthetics. The criteria for conversion to general anaesthesia should be clearly defined in future research. This review found that intrathecal hyperbaric bupivacaine had a more rapid onset of sensory blockade at the T4 level than isobaric bupivacaine. It may also result in less need for conversion to general anaesthesia and supplemental analgesia. However, due to the rarity of this outcome, variability in the dose, use of adjuvant drugs and differences in the technique used for regional anaesthesia the evidence is weak. Any apparent advantage of hyperbaric bupivacaine needs to be confirmed in larger randomized trials. There were no differences in the adverse effects studied.

We describe the use of continuous spinal anesthesia (CSA) for an elective cesarean section in a 29-year-old parturient with Eisenmenger's syndrome at 30 weeks of gestation. It is essential in patients with Eisenmenger's syndrome to prevent significant increases in right-to-left shunt following the reduction in systemic vascular resistance. In this case, the patient hoped to be awake during the operation because of her fear of death. We therefore applied CSA to this patient because single-shot spinal anesthesia and epidural anesthesia might cause sudden cardiovascular depression. In fact, sudden cardiovascular changes were avoided by the titration of local anesthetics and the operation was uneventful, although prompt treatment of hypotension was essential and adjustment of the anesthetic levels was difficult. Postoperative patient-controlled spinal analgesia provided satisfactory pain relief with hemodynamic stability and no significant side effects. However, thorough experience with the requisite techniques is critical in CSA because of the technical difficulty of the procedure, and anesthesiologists must gain such experience in less-demanding cases before attempting to administer it in patients presenting extreme challenges as described in this case report.

Background and Aims: Spinal anesthesia is the preferred technique over general anesthesia in caesarean section. General anesthesia is still used for category-1 emergency caesarean section because of time constraints. We usually follow rapid sequence general anesthesia in obstetrics to avoid aspiration. However, this technique poses several problems. An approach of spinal anesthesia termed as rapid sequence spinal anesthesia has been described. The present study was designed to compare the time intervals (time for anesthesia, time to surgical readiness, incision to delivery time, emergence time) and Apgar score between rapid sequence spinal anesthesia and rapid sequence general anesthesia during category-1 caesarean section and to evaluate whether rapid sequence spinal anesthesia is a better option in category-1 caesarean section. Materials and Methods: In this prospective randomized study, 60 patients of American Society of Anesthesiologists physical status (ASA-PS) I posted for category-1 emergency caesarean section were randomly allocated into two equal groups and received either of the two techniques. Demographic data, respective time intervals, and Apgar scores were noted and compared. Results: The time for anesthesia, surgical readiness, and emergence were significantly longer (P < 0.001) in rapid sequence general anesthesia group as compared to rapid sequence spinal anesthesia group (144.80 ± 3.42 vs 131.20 ± 3.40 s, 178.76 ± 4.09 vs 169.93 ± 3.08 s, 512.13 ± 34.33 vs 222.10 ± 12.80 s). No significant difference was found in incision to delivery time and Apgar scores between the two groups. Conclusion: Because anesthesia to delivery time is shorter in rapid sequence spinal anesthesia, this technique may be equivalent to rapid sequence general anesthesia in category-1 emergency caesarean section.

Data are presented for anaesthesia for Caesarean section (CS) in the South-west Thames region of the UK. The CS rate rose from 12.7% in 1987 to 24.2% in 2002. The rate of increase shows no sign of slowing. The rate of regional anaesthesia (RA) for elective CS rose from 69.4% in 1992 to 94.9% in 2002, when spinal anaesthesia was used for 86.6% of cases. This may limit the opportunities to teach other anaesthetic techniques. The rate of RA for emergency CS rose from 49.3% in 1992 to 86.7% in 2002. There is an unacceptable rate of failure of RA for both elective and emergency CS, 1.3% of RAs for elective CS and 4.9% of RAs for emergency CS were converted to general anaesthesia.

Aim: Guidelines recommend opioid-free (OF) anesthesia in elective cesarean sections (CS).However, opioids are commonly administered after a baby's delivery for postoperative pain in daily practice.Our aim was to compare OF and opioid-based (OB) general anesthesia in elective surgery (CS). Methods:The study was a cross-sectional study including patients who had undergone elective CS with OF (Group OF) and OB (Group OB) general anesthesia between June 1, 2022, and November 30, 2022.Intraoperatively administered analgesics for postoperative pain mainly included acetaminophen and non-steroidal anti-inflammatory drugs (NSAID) in Group OF and fentanyl, acetaminophen, and tramadol in Group OB.Non-steroidal anti-inflammatory drugs were administered as analgesics at the maternity ward.Results: Of 368 patients, 278 were excluded due to regional anesthesia.In 90 patients, 45 were in Group OF and 45 were in Group OB.Group OF received less intraoperative fluid compared with Group OB.Two groups required a similar number of NSAIDs on postoperative day zero.Group OF had more NSAID consumption on postoperative days one and two. Conclusion:Opioid-free general anesthesia did not change the required number of NSAIDs 24 hours after surgery and necessitated less intraoperative crystalloid fluid.Our study supports Enhanced recovery after surgery protocols, which recommend multimodal analgesics and sparing opioids in CS, and adds to the accumulating evidence that suggests the use of OF general anesthesia in CS.

ANAESTHESIA FOR CAESAREAN SECTION: Analysis of blood concentrations of halothane using 0.2% or 0.65% halothane with 50% nitrous oxide in oxygen

BackgroundCesarean section is a common surgical procedure, usually performed under neuraxial anesthesia and, more rarely, under general anesthesia. The choice of anesthesia in cesarean sections can significantly influence neonatal outcomes, especially in urgent and emergency cases. Previous studies have shown mixed results, often confounded by the inclusion of both elective and emergency cesarean section cases, varying statistical methods, and a focus solely on resuscitation immediate-term neonatal outcomes.ObjectiveThis study aims to use robust statistical methods to evaluate the impact of anesthesia type on immediate and longer-term neonatal outcomes in urgent and emergency cesarean section cases, where additional detrimental factors might influence this relationship.MethodsWe analyzed 395 women who underwent non-elective cesarean sections between 2021 and 2023. Inverse probability of treatment weighting (IPTW) served to focus on the role of anesthesia type eliminating confounding variables effect, in simulated randomized controlled trial conditions.ResultsGeneral anesthesia increases odds of neonatal resuscitation (OR 6.1, p < 0.001), NICU admission (OR 1.8, p: 0.04), and a 15% lower Apgar score at 1 min (p: 0.02). General anesthesia also increased NICU admission rate for respiratory insufficiency (OR 7.6, p < 0.001), the need for oxygen (OR 4.8, p: 0.003) and CPAP (OR 3.6, p < 0.001) in NICU. Negative controls and consistent sensitivity analyses further validated the robustness of our findings.ConclusionGeneral anesthesia in non-elective cesarean sections is associated with worse neonatal outcomes, extending beyond the resuscitation phase to sustained NICU morbidity. Our study provides novel insights into the specific neonatal resuscitation maneuvers required when general anesthesia is used, enhancing clinicians preparedness for managing high-risk deliveries. These findings underscore the critical importance of anesthesia choice, advocate for the preference of neuraxial techniques, and highlight the need for further research into long-term neonatal outcomes.

Background: Postoperative shivering is an important common complication after general anesthesia. This may lead to dissatisfaction and a sense of discomfort, especially in parturients undergoing cesarean section. In addition to warming, many drugs have been investigated for prevention of shivering. The aim of this study was to evaluate the efficacy of intravenous paracetamol for prevention of shivering after general anesthesia in cesarean section. Materials and Methods: In this prospective randomized double-blind controlled clinical trial, 110 pregnant women, physical Status I or II, based on the classification of American Society of Anesthesiologists (ASA), aged 18–40 years, who were scheduled for elective cesarean section under general anesthesia were included in the study. They were randomly divided into two groups of 55 each. One group received 100 ml normal saline, and another group received 1 g of paracetamol in 100 ml normal saline intravenously, 15 min after the delivery of the baby. The anesthesia technique was similar in both the groups. Tympanic membrane temperature was measured before and after the induction of anesthesia and every 15 min till the end of recovery from anesthesia. Postanesthetic shivering was graded on a scale of 0 to 4; if the score was more than 2, it was treated with 25 mg pethedine. Vital signs and side effects were recorded during the surgery and recovery period. Results: There were no significant differences between the two groups regarding age, weight, height, and duration of surgery (P > 0.05). Shivering was seen in 5 parturients (9.1%) in paracetamol group (group A) and 28 parturients (50.9%) in the saline group (group N). On a scale of 0 to 4, shivering was of lower intensity in paracetamol group compared to the saline group (P 0.05). There was no difference in the incidence of hypotension, nausea, and vomiting among the two groups (P > 0.05). Conclusion: The prophylactic use of intravenous paracetamol during surgery is effective for the prevention of postoperative shivering.

Anaesthesia for Caesarean section in a patient with Parkinson’s disease