Oksitosine Karşı Anafilaksi Öyküsü Olan Bir Gebenin Sezaryenle Doğumunda İlk Seçenek Olarak Metilergonovin Kullanımı

SP13 Pro-con debate: for emergency CS, a labour epidural should be removed, and a spinal anaesthetic used instead- pro

Hypotension after spinal anesthesia for cesarean delivery remains a major clinical problem. Fluid preloading regimens together with vasopressors have been used to reduce its incidence. Previous studies have used noninvasive arterial blood pressure measurement and vasopressor requirements to evaluate the effect of preload. We used a suprasternal Doppler flow technique to measure maternal cardiac output (CO) and corrected flow time (FTc, a measure of intravascular volume) before and after spinal anesthesia after 3 fluid preload regimens. We hypothesized that colloid solutions, compared with crystalloid, would produce the largest increase in CO and have the lowest incidence of hypotension. Sixty healthy term women scheduled for planned cesarean delivery under spinal anesthesia were recruited for this randomized, double-blind study. Baseline heart rate, systolic blood pressure (SBP), CO, and FTc were recorded in the left lateral tilt position. Patients were randomized to receive 1 of 3 fluid preload regimens given over 15 min: 1.5 L crystalloid (Hartman's solution), 0.5 L of 6% w/v hydroxyethyl starch (HES) solution (HES 0.5), or 1 L of 6% w/v HES solution (HES 1.0). Further measurements were made after fluid loading every 5 min for 30 min. After 30 min, spinal anesthesia was induced with hyperbaric bupivacaine 12.5 mg with fentanyl 15 microg and recordings were continued every 5 min for 20 min or until surgery started. The primary outcome, CO, was compared among groups. The incidence of hypotension (defined as a 20% reduction in SBP from the baseline), ephedrine use, and umbilical cord blood gases were also compared. Patient characteristics, heart rate, SBP, and cord gases were similar among groups. Although CO and FTc increased after preload in all groups (P < 0.005), this was only maintained with HES 1.0 after spinal anesthesia (P < 0.005). There were no differences among groups in the incidence of hypotension (70% vs 35% vs 65% for Hartman's solution, HES 0.5, and HES 1.0, respectively; P = 0.069) or mean ephedrine dose (10.4 vs 5.7 vs 9.7 mg; P = 0.26). Despite CO and FTc increases after fluid preload, particularly with HES 1.0 L, hypotension still occurred. The data suggest that CO increases after these preload regimens cannot compensate for reductions in arterial blood pressure after spinal anesthesia.

Enhanced recovery after cesarean (ERAC) delivery is an evidence-based, multi-disciplinary approach throughout pre-, intra-, post-operative period. The ultimate goal of ERAC is to enhance recovery and improve the maternal and neonatal outcomes. This review highlights the role of anesthesiologist in ERAC protocols. This review provided a general introduction of ERAC including the purposes and the essential elements of ERAC protocols. The tool used for evaluating the quality of ERAC (ObsQoR-11) was discussed. The role of anesthesiologist in ERAC should cover the areas including management of peri-operative hypotension, prevention and treatment of intra- and post-operative nausea and vomiting, prevention of hypothermia and multi-modal peri-operative pain management, and active pre-operative management of unplanned conversion of labor analgesia to cesarean delivery anesthesia. Although some concerns still remain, ERAC implementation should not be delayed. Regular assessment and process improvement should be imbedded into the protocol. Further high-quality studies are warranted to demonstrate the effectiveness and efficacy of the ERAC protocol.

IntroductionThe proportion of women electing for cesarean delivery has increased in both developed and developing countries. Cesarean delivery on maternal request (CDMR) refers to a primary cesarean delivery performed because the mother requests this method of delivery in the absence of standard medical/obstetrical indications.Several studies compared anesthesia modalities in cesarean section regarding clinical outcomes such as maternal mortality, post-operative pain and bleeding, but only a few compared health-related quality of life (HRQoL) of women undergoing general anesthesia versus spinal anesthesia. The aim of this study was to determine whether pregnant women who undergo general anesthesia (GA) for cesarean delivery compared with spinal anesthesia (SA) differ regarding their perceived HRQoL.MethodologyWe enrolled 160 pregnant women with American Society of Anesthesiologists (ASA) class II, scheduled for CDMR with GA or SA. Anesthesia modality was based on patient’s preference. Participants assessed their state of health with the EuroQoL-5 Dimensions-3 Levels (EQ-5D-3L) self-administered questionnaire at four time points: six hours before cesarean delivery, 24 hours after cesarean delivery, one week and one month after cesarean delivery. Patients also rated their health on the EQ visual analog scale (EQ-VAS) from 100 mm “best imaginable health state” to 0 mm “worst imaginable health state”.ResultsMore women who underwent spinal anesthesia reported “no problem” with regards to “mobility’ (64% vs. 30%, p = 0.00), “usual activities” (90% vs. 38%, p = 0.00), and “pain/discomfort” (20% vs. 5%, p = 0.007). Repeated measurement analysis showed that the two groups started off with the same EQ-VAS score, however, both decreased over time with different slope resulting in different scores at 24 hours after CS. Then the scores increased in both groups over time and ended up being rather close at one month after CS.DiscussionUnless there is a contraindication, neuraxial anesthesia is the anesthetic technique of choice for cesarean delivery in all parturient in general. This concept is based on more mortality and morbidity that have been seen with general anesthesia in this particular population. Our study demonstrated significant advantages of spinal anesthesia compared to general anesthesia in cesarean section regarding postoperatively perceived HRQoL. We showed that more pregnant women who chose spinal anesthesia as their anesthesia modality reported “no problem” with respect to “mobility” and “Self-care” 24 hours after cesarean section. On the top of that, more women in this group had “no problem” in their “usual activities” at one week and one month after cesarean delivery time points. Moreover, EQ-5D general health score was higher 24 hours after cesarean delivery with regional anesthesia comparing to general anesthesia.ConclusionWe determined that compared to general anesthesia, spinal anesthesia is the technique of choice for cesarean section because not only it avoids a general anesthetic and the risk of failed intubation, but also because it provides effective pain control, mobility and fast return back to daily activities for new mothers and increase their quality of life.

SP22 For emergency CS, a labour epidural should be removed and a spinal anaesthetic used instead

Spinal anesthesia for the cesarean delivery of triplets is associated with an increased incidence of maternal hypotension and placental hypoperfusion. We performed a retrospective case series analysis between January 1992 and June 2000 to evaluate the effects of regional anesthetic techniques for cesarean delivery in triplet pregnancies on maternal and neonatal outcome. Spinal and epidural anesthesia were compared with respect to intraoperative hemodynamics and neonatal outcomes. Ninety-six triplet pregnancies were delivered by cesarean section, of which 91 received regional anesthesia. A statistically significant decrease in systolic blood pressure was demonstrated immediately after the induction of spinal as compared with epidural anesthesia. The total volume of IV crystalloid used was significantly larger in the Spinal Anesthesia group. The number of patients receiving more than 15 mg of ephedrine and the cumulative dose of ephedrine was significantly larger in the Spinal group compared with the Epidural group. There were no differences in the rate of perioperative complications between the Spinal and Epidural Anesthesia groups. Neonatal Apgar scores were similar in both groups. The data suggest that both epidural and spinal anesthesia for triplet cesarean delivery are safe techniques, but the latter is associated with a larger initial decrease in systolic blood pressure. This decreasing of systolic blood pressure, however, remained within the physiological range and did not seem to be clinically significant. The need for more crystalloid fluids and ephedrine should be anticipated when spinal anesthesia is used for these cases. A large retrospective case series of the effects of spinal and epidural anesthesia on maternal hemodynamic profile during cesarean delivery for triplet gestation was performed. Our findings suggest that spinal anesthesia results in outcomes comparable to epidural anesthesia for both mother and newborns.

Obstetric Anesthesia Workforce Survey

Prophylactic administration of oxytocin as a part of active management of the third stage of labor reduces the risk of postpartum hemorrhage. Prophylactic oxytocin is often administered as an infusion rather than a bolus. The aim of the current up-down sequential allocation dose-response study was to test the hypothesis that parturients who receive intrapartum exogenous oxytocin therapy, and who subsequently undergo cesarean delivery for labor dystocia, will have a higher estimated effective dose in 90% of paturients (ED90) for oxytocin infusion in the third stage of labor compared with nonlaboring parturients. The study design was a single-blinded, dual-arm, dose-response study using a 9:1 biased-coin sequential allocation method to estimate the ED90 of an infusion of prophylactic oxytocin in women undergoing cesarean delivery with neuraxial anesthesia. The experimental (laboring) group included women scheduled for intrapartum cesarean delivery after prior exposure to exogenous oxytocin, and the control (nonlaboring) group included women scheduled for elective cesarean delivery. The starting infusion rate was 18 IU/h, with an incremental dose of 2 IU/h. The outcome was satisfactory uterine tone 4 minutes after delivery as judged by the obstetrician. Secondary outcomes included requirement for additional uterotonic agents and maternal side effects (e.g., nausea and vomiting, ST-segment depression). Dose-response data for each group were evaluated by a log-logistic function and ED90 estimates derived from the fitted equations using the delta method. Thirty-eight and 32 subjects participated in the nonlaboring and laboring groups, respectively. The oxytocin ED90 was significantly greater for the laboring group (44.2 IU/h [95% confidence interval (CI), 33.8-55.6]) compared with that for the nonlaboring group (16.2 IU/h [95% CI, 13.1-19.3]; difference in dose 28 IU/h [95% CI of difference, 26-29, P < 0.001]). Significantly more women in the laboring group (34%) than in the nonlaboring group (8%) required supplemental uterotonic agents (difference 26% [95% CI of the difference, 7%-44%, P = 0.008]). The overall incidence of side effects was greater in the laboring group (69%) than in the nonlaboring group (34%; difference 25% [95% CI of the difference, 10%-59%, P = 0.004]). Women with prior exposure to exogenous oxytocin require a higher initial infusion rate of oxytocin to prevent uterine atony after cesarean delivery than women without prior exposure.

Background: Spinal anaesthesia is the commonest performed technique for caesarean deliveries except in the emergency setting where general anaesthesia is preferred due to its rapid onset and predictability. There are several modifications to performing general anaesthesia for COVID-19 patients in Australia. We hypothesised that the performance time of these techniques amongst specialist anaesthetists would be similar for COVID-19 parturients undergoing emergency caesarean delivery. Methods: We designed a simulation cross-over study. The primary outcome was the time taken to perform general anaesthesia or spinal anaesthesia in this setting. We also examined the decision-making process time, the decision to incision time and the level of stress associated with both scenarios. Results: Nine specialist anaesthetists participated in the research. There was no difference in the time taken to perform spinal or general anaesthesia (mean difference (GA–SA scenario) –1.2 (–5.3–2.8) minutes, p = 0.5). Irrespective of group allocation the mean time to complete the spinal anaesthesia scenario was 27.4 (standard deviation = 7.8) minutes, while for the general anaesthesia scenario was 24.0 (7.2) minutes. There was no difference between these times (mean difference (GA–SA scenario) = –3.5 minutes, 95th percent confidence interval –9.7–2.8 minutes, p = 0.24). There was no evidence of a carryover effect for the two scenarios based on the group allocation (p = 0.69) and no significant difference between stress levels (p = 0.44). Conclusions: The time to perform spinal anaesthesia was similar to the time to perform general anaesthesia for a confirmed COVID-19 parturient in a simulation environment.

Background: Preeclampsia is a multisystem disorder characterized by new onset of hypertension systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg and proteinuria &gt;300 mg/24 h arising after 20 weeks of gestation in a previously normotensive woman and associated with significant maternal and neonatal morbidity and mortality worldwide. Women with preeclampsia have an increased rate of cesarean section consequent upon the high incidence of intrauterine growth restriction, fetal distress, and prematurity. The aim of this study was to determine and compare maternal &amp; neonatal outcome among pre-eclamptic women following caesarian delivery under general and spinal anesthesia. Material &amp; Methods: This was a comparative observational study and was conducted in the Department of Anesthesiology of Holy Family red crescent Medical College Hospital, Dhaka, Bangladesh during the period from February,2020 to February,2023. In this study we included 250 preeclamptic women undergoing cesarean delivery. The patients were randomly divided into two groups – GA group (Patients who were given general anesthesia) &amp; SA group (Patients who were given spinal anesthesia). Results: In total 250 patients from both the groups completed the study. In our study we found majority (44.8%) of our patients were aged 28-32 years. The mean age was 27.13 ± 3.76 years. Majority (62.8% ) of our patients were cases of emergency caesarean delivery &amp; 37.2% were elective caesarean delivery classes. Most of the students (41.2%) used magnesium sulfate. Intraoperative systolic BP, diastolic BP was significantly lower in SA group than GA group. We found headache, vomiting, fever and wound gaping, postpartum hemorrhage &amp; lower respiratory tract infection was significantly higher in GA group. On contrary, hypotension &amp; pulmonary edema was higher in SA group. Apgar score at 1st, 5th &amp; 10th minutes was significantly higher in GA group than SA group. In GA group, neonatal mortality at 48 h was 10.4% whereas it was 4.8% in SA group. Conclusion: In our study, we found intra-operative blood pressure and pulse rate was observed significantly higher in GA group than SA. Severe preeclamptic mothers receiving general anesthesia and their babies required more critical care support. Maternal as well as neonatal mortality was significantly higher with general anesthesia. Therefore, spinal anesthesia is a safer alternative to general anesthesia among women with severe preeclampsia following caesarean delivery with less postoperative morbidity and mortality.

Patients with spinal canal pathology, including spinal stenosis and lumbar disk disease, are often not considered candidates for neuraxial blockade because of the risk of exacerbating preexisting neurologic deficits or developing new neurologic dysfunction. In contrast, a history of spine surgery is thought to increase the likelihood of difficult or unsuccessful block. In this retrospective study we investigated the risk of neurologic complications and block efficacy in patients with preexisting spinal canal pathology, with or without a history of spine surgery, after neuraxial anesthesia. During the 15-year study period, all patients with a history of spinal stenosis or lumbar radiculopathy undergoing a neuraxial technique were studied. Patient demographics, preoperative neurologic diagnoses and neurologic findings at the time of surgery/neuraxial block, details of the neuraxial block including technique (spinal vs. epidural, single injection vs. continuous), injectate, technical complications (paresthesia elicitation, bloody needle/catheter placement, inability to advance catheter, accidental dural puncture), and block success were noted. New or progressive neurologic deficits were identified. All patients were followed until resolution or last date of evaluation. There were 937 patients included, 207 (22%) of whom had undergone spinal surgery. A history of spinal stenosis was present in 187 (20%), lumbar radiculopathy in 570 (61%), and peripheral neuropathy in 210 (22%) patients; 180 patients (19%) had multiple neurologic diagnoses. A majority of patients had active but stable neurologic symptoms at the time of surgery. Overall block success was 97.2%. A history of spine surgery did not affect the success rate or frequency of technical complications. Ten (1.1%; 95% confidence interval [CI] 0.5%-2.0%) patients experienced new deficits or worsening of existing symptoms. Three (1.4%) complications occurred in patients with a history of spinal surgery, and the remaining 7 (1.0%) in patients without prior surgical decompression or stabilization (P = NS). Although an orthopedic procedure was not a risk factor, in 5 of the 6 patients in which the surgery was a unilateral lower extremity procedure, the postoperative deficit involved the operative side. Likewise, in both patients undergoing bilateral orthopedic procedures who developed bilateral deficits, the outcome was worse on the previously affected side. A surgical cause was presumed to be the primary etiology in 4 (40%) of 10 patients. The primary etiology of the remaining 6 (60%) complications was judged to be nonsurgical (including anesthetic-related factors). The presence of a preoperative diagnosis of compressive radiculopathy (P = 0.0495) or multiple neurologic diagnoses (P = 0.005) increased the risk of neurologic complications postoperatively. We conclude that patients with preexisting spinal canal pathology have a higher incidence of neurologic complications after neuraxial blockade (1.1%; 95% CI 0.5%-2.0%) than that previously reported for patients without such underlying pathology. However, in the absence of a control group of surgical patients with similar anatomic pathology undergoing general anesthesia, we cannot determine whether the higher incidence of neurologic injury is secondary to the surgical procedure, the anesthetic technique, the natural history of spinal pathology, or a combination of factors and the relative contributions of each.

A randomized trial of crystalloid versus colloid solution for prevention of hypotension during spinal or low-dose combined spinal-epidural anesthesia for elective cesarean delivery

The purpose of this study is to determine if spectral analysis of beat-to-beat heart rate variability will provide important data on autonomic nervous system function during either spinal or epidural anesthesia that is not apparent from the monitoring of mean heart rate and blood pressure. Twelve ASA I patients presenting for elective cesarean delivery (7 epidural and 5 spinal anesthetics) were prospectively selected for study. Control and postblock 10-minute segments of instantaneous heart rates were analyzed for each patient. The total spectral power (Ps, 0.02-0.5 Hz), low frequency spectral power (PLF, 0.02-0.12 Hz), and high frequency spectral power (PHF, 0.12-0.5 Hz) were calculated for each data segment. The complexity of the heart rate time series was estimated by calculating the approximate entropy. Neither spinal or epidural anesthesia had any effect on heart rate or blood pressure. Both spinal and epidural anesthesia did produce a significant decrease in PS, PLF, and PHF. Although there were significant decreases in both the PLF and PHF, there was no change in the PLF/PHF ratio. There was a significant reduction in approximate entropy with spinal and epidural anesthesia, indicating a decrease in complexity of the heart rate dynamics. These data suggest that autonomic tone decreased with spinal and epidural anesthesia but the sympathetic-parasympathetic balance (expressed as PLF/PHF) did not change. Spectral measures, as well as approximate entropy, provide an independent evaluation of the integrity of the autonomic nervous system and cardiovascular control mechanisms that cannot be discerned from mean heart rate and blood pressure.

Use of indwelling urinary catheter at cesarean delivery

Minimum effective bolus dose of oxytocin during elective Caesarean delivery