General Anaesthesia For Caesarean Section Research Articles

Neuraxial and general anaesthesia for caesarean section.

Caesarean section (CS) is one of the most performed operations worldwide. In many parts of the world, there has been a reduction in anaesthetic associated obstetric mortality, and this has been attributed to the increased use of neuraxial anaesthesia and improved safety of general anaesthesia, alongside improved training and organisational changes. In resource-limited countries, anaesthesia contributes disproportionately to maternal mortality, with one in seven deaths being due to anaesthesia. A major contributory factor to this is the severe shortage of trained anaesthetic providers. Goals for anaesthesia for CS include the woman's comfort and foetal well-being, focusing on strategies to minimise morbidity and mortality for both. Anaesthetic options for CS include neuraxial techniques (spinal or combined-spinal epidural or epidural extension of labour analgesia) and general anaesthesia. There is increasing evidence of the benefit of neuraxial techniques over general anaesthesia in terms of maternal and foetal outcomes. For elective CS, spinal and combined-spinal anaesthesia predominate. General anaesthesia is mainly reserved for Category 1 CS where there is an immediate threat to the life of the mother or the baby. This review discusses the practical aspects of neuraxial and general anaesthesia for CS.

P.36 Retrospective cross sectional analysis of laryngoscope influence on intubation speed and attempts in general anaesthesia for caesarean section

P.36 Retrospective cross sectional analysis of laryngoscope influence on intubation speed and attempts in general anaesthesia for caesarean section

Comparison of neonatal outcomes of cesarean sections performed under primary or secondary general anesthesia: a retrospective study

BackgroundThe conversion of neuraxial anesthesia (NA) to general anesthesia (GA) during a cesarean section (CS) may be associated with a higher risk of neonatal morbidity by adding the undesirable effects of both these anesthesia techniques. We aimed to compare the neonatal morbidity of non-elective CS performed after conversion from NA to GA (secondary GA) vs. that after GA from the outset (primary GA). MethodsWe performed a monocentric retrospective study at the Angers University Hospital (France). All non-elective CSs performed under GA between January 2015 and December 2019 were included. The CSs were classified using a three-color coding system (green for non-urgent delivery, orange for urgent CS, and red for very urgent CS). The primary neonatal outcome was a composite of umbilical artery pH <7.10 or 5-min Apgar score <7. The crude and adjusted odds ratios (OR) for the risk of neonatal morbidity associated with secondary GA were estimated. ResultsWe included 247 patients, of whom 101 (41.3%) had a secondary GA and 146 (58.7%) had primary GA. In the secondary GA group, 86.1% (87/101) had epidural anesthesia and 13.9% (14/101) had spinal anesthesia. Multivariate analysis showed no difference in neonatal morbidity between the two groups (adjusted odds ratio 1.18, 95% CI 0.56 to 2.51). ConclusionsOur study found insufficient evidence to identify a difference in neonatal outcomes between secondary compared with primary GA for CS, regardless of the level of emergency. However, our study is underpowered and additional studies are needed to confirm these data.

General Anesthesia for Cesarean Section in a Pregnant Woman with Immune Thrombocytopenic Purpura (ITP): A Case Report and Review of the Literature

Background: Management of immune thrombocytopenia (ITP) during pre- gnancy can be challenging, particularly by identifying a threshold for safe administration of neuraxial/general anesthesia and minimizing postpartum hemorrhage. There is controversy over the safety of cesarean section (CS) in ITP patients. In this case report, we discuss general anesthesia management in a patient with ITP with severe thrombocytopenia. Case Presentation: A 28-year-old female with relapsed/refractory ITP and severe thrombocytopenia underwent general anesthesia and emergent cesarean section with successful outcomes and minimal bleeding. Platelet counts before CS were 5000 × 109 L, the patient received 1 unit of platelets before the procedure and 1 unit of platelet and tranexamic acid 500 mg was injected slowly during the procedure. No evidence of bleeding and no complications were observed in the patient or newborn. Conclusions: In an emergent circumstance, general anesthesia and cesarean section procedure were performed safely in a patient with severe thrombocytopenia, no hemorrhagic complications were seen for this patient or neonate. Objective of This Manuscript: To share our experience of a safe emergent CS procedure and general anesthesia in a patient with severe thrombocytopenia. Our experience may guide the management of ITP patients in emergent delivery circumstances.

CONVERSION RATE OF EPIDURAL ANALGESIA TO CAESAREAN SECTION REGIONAL OR GENERAL ANESTHESIA.

Epidural analgesia is acknowledged as the most common method of analgesia during labor. If emergent Caesarean section (CS) is indicated in parturient with existing labor epidural, the need for conversion from epidural analgesia to regional (RA) or general anesthesia (GA) increases accordingly. Recent guidelines suggest the rate of conversion to general anesthesia shows the quality of obstetric anesthesia care and should be under 5%. The aim of this study is to determine the conversion rate from epidural analgesia to Caesarean section anesthesia in "Sveti Duh" University Hospital Zagreb in order to enhance the quality of anesthetic care for obstetric patients. We retrospectively included in the study all parturients who received epidural labor analgesia but needed subsequent regional or general anesthesia for Caesarean section in our institution for the period of 1st January 2021 to 31st December 2021. After the data analysis on the conversion rate from epidural analgesia to Caesarean section anesthesia had been performed, we compared our data to current standards and relevant literature findings. Altogether 1202 epidural catheters were placed for labor analgesia in the study period, and in 199 of these cases, the emergent Caesarean section was indicated. Epidural analgesia was converted to epidural anesthesia (EA) in 153 (76,9%) parturients, to general anesthesia in 40 (20,1%), and to spinal anesthesia (SA) in six (3%) parturients. After comparison with recommended quality standards and with the results of similar studies by other authors, our findings show a significantly higher rate of conversion from epidural analgesia to general anesthesia than has been desirable since then. In order to reach the required quality standards regarding the conversion rate from epidural analgesia to Caesarean section anesthesia, it is necessary to improve the organization of the work of the obstetric anesthesiology team according to the principle of subspecialization. It is imperative to implement the best clinical practice protocols for obstetric anesthesiologists, but also to enhance the communication and coordination with the obstetric team.

ANAESTHETIC MANAGEMENT IN CAESAREAN SECTION IN A PARTURIENT WITH KYPHOSCOLIOSIS : A CASE REPORT

Alterations in maternal physiology and pathological changes in kyphoscoliosis results in anaesthetic complications for caesarean section with potential risk for both mother and fetus. Safe and skilled anaesthetic management to minimize risk to mother and fetus is required. We report a case of 25-year-old female, with G2P1L1, with 28 weeks of period of gestation, with history of previous caesarean section, with pre-eclampsia, with kyphoscoliosis in labour with contracted pelvis, managed by general anaesthesia for caesarean section.

Effect of intravenous dexmedetomidine and remifentanil on neonatal outcomes after caesarean section under general anaesthesia: A systematic review and meta-analysis.

Various strategies have been used to mitigate haemodynamic instability during general anaesthesia for caesarean section. However, the safety of these strategies for neonates remains controversial. To investigate the effects of intravenous dexmedetomidine and remifentanil on neonatal outcomes during caesarean section under general anaesthesia. Systematic review and meta-analysis of randomised controlled trials. Databases of PubMed, EMBASE and CENTRAL were searched until March 2020 and updated in February 2021. Randomised controlled trials were included if they compared dexmedetomidine and remifentanil infusion on neonatal outcomes after elective caesarean section under general anaesthesia. Primary outcomes were 1 and 5 min Apgar scores. Secondary outcomes were the incidence of neonatal mask ventilation or endotracheal intubation, and pH of the umbilical artery and vein. Studies that did not report primary outcomes were excluded. Five studies with 258 patients in total were included. The Apgar score at 1 min in the remifentanil group was lower than that in the dexmedetomidine group for both quantitative [weighted mean difference (WMD): 0.75; 95% CI, 0.44 to 1.07; τ2 = 0.00] and categorical outcomes (≥Apgar 7 vs. <Apgar 7) (risk ratio: 0.76; 95% CI, 0.59 to 0.99; τ2 = 0.01). When trial sequential analysis (TSA) for Apgar score at 1 min was performed, the cumulative Z curve crossed both the conventional test boundary and the trial sequential monitoring boundary for the quantitative outcome but did not cross the trial sequential monitoring boundary for the categorical outcome. For both conventional meta-analysis and TSA, there were neither differences in the Apgar score at 5 min for either quantitative or categorical outcomes nor were there differences in the incidence of mask ventilation or intubation, or pH values of the umbilical artery and vein. In our study, Apgar score at 1 min reported using both quantitative and categorical variables were lower in the remifentanil group than in the dexmedetomidine group but TSA showed that these differences were inconclusive for categorical variables. Data for other outcomes were scarce and did not allow any conclusions to be drawn. Thus, further studies with larger numbers of parturients and with neonatal outcomes as a primary endpoint are warranted to clarify the effects of intravenous dexmedetomidine and remifentanil. The protocol of this study has been registered in PROSPERO (CRD42019141102).

P.22 Reasons for providing general anaesthesia for elective caesarean section

Introduction: For elective (category 4) caesarean section, regional anaesthesia is generally considered the superior method and the Royal College of Anaesthetists suggest an audit standard of >95% of such deliveries being carried out under a regional technique. [1] Raising the Standards: RCoA Quality Improvement Compendium, https://rcoa.ac.uk/sites/default/files/documents/2020-08/21075% 20RCoA%20Audit%20Recipe%20Book_16%20Section% 20B.7_p241-268_AW.pdf Google Scholar Within our large tertiary obstetric unit, we aimed to characterise the reasons for undertaking planned elective general anaesthesia for caesarean section.

P.57 Retrospective review of conduct of general anaesthesia for caesarean section in a tertiary maternity unit

Introduction: With the increasing use of neuraxial techniques, general anaesthesia for caesarean section is now a relatively rare occurrence. However, there remain a small number of clinical scenarios where it is unavoidable. Obstetric patients have consistently been shown to be at higher risk of failed intubation,1 aspiration complications and awareness under anaesthesia.2 We conducted this study to review current practises within our institution in regards to conduct of general anaesthesia for caesarean section.

P.31 Trainee exposure to general anaesthesia for caesarean section

Introduction: It has long been questioned whether trainee anaesthesiologists are receiving adequate exposure to general anaesthesia for caesarean sections (GA CS).1 In 2020, the College of Anaesthesiologists of Ireland published their revised training curriculum which stipulated that trainees should be involved in the provision of anaesthesia for a minimum of 50 caesarean sections, of which at least 2 must be under GA.2 We sought to examine whether trainees were meeting this minimum number of GA CS during their 6-month rotation at our institution, and to compare the differences between 2009, 2019 and 2020 including the first wave of the Covid-19 pandemic.

P.47 Airway assessment on the labour ward

Introduction: The incidence of difficult intubation in the obstetric population is 1 in 250. [1] McDonnell NJ, Paech MJ, Clavsi OM, et al, the ANZCA Trails Group. Difficult and failed intubation in obstetric anaesthesia: an observational study of airway management and complications associated with general anaesthesia for caesarean section. Int J Obstet Aneth 2008;17:292-7. Google Scholar With the infrequent use of general anaesthesia, the anaesthetist must be prepared for potential difficulty. [2] Searle RD, Lyons G. Vanishing experience in training for obstetric general anaesthesia: an observational study. Int J Obstet Anesth 2008;17:233-7. Google Scholar This includes performing a detailed airway assessment prior to administering labour analgesia or anaesthesia. Previous departmental data found that 70% of patients undergo a comprehensive airway assessment. Recently the anaesthetic chart was modified to specifically indicate the presence or absence of a potentially difficult airway. We aimed to re-audit how comprehensive the initial airway assessment was, and whether potentially difficult airways were being highlighted.

General Anesthesia for Cesarean Section in a Pregnant Woman with Truncus Arteriosus Intraoperatively Monitored by Transesophageal Echocardiography

Truncus arteriosus (TA) is defined as a congenital cardiovascular malformation in which one great artery arises from the base of the heart and gives origin to the pulmonary and systemic arteries. TA patients who become pregnant have high morbidity and mortality rates because physiologic changes during pregnancy can worsen the cardiopulmonary balance causing cardiopulmonary decompensation. In this case report we report a successful general anesthesia in a truncus arteriosus patient with severe pulmonary hypertension (Eisenmenger syndrome) who underwent a full-term pregnancy delivery monitored by intraoperative transesophageal echocardiography, a new technique to assist physicians in dealing with patients with hemodynamic instability during both cardiac and noncardiac surgery.

Study of conversion of regional to general anaesthesia for caesarean section at a tertiary hospital

Study of conversion of regional to general anaesthesia for caesarean section at a tertiary hospital

The FloTrac/VigileoTM system for continuous cardiac output monitoring in a paraplegic woman undergoing general anesthesia for cesarean section

Abstract Rationale: Paraplegic women requiring cesarean section present plenty of challenges for anesthesiologists. One of the most serious challenges is cardiovascular instability induced by autonomic hyperreflexia. The FloTrac/Vigileo TM system is a pulse contour analysis device for continuous hemodynamic index monitoring. Here, we present a case report of a paraplegic woman who underwent general anesthesia for cesarean section under FloTrac/VigileoTM monitoring. Patient concerns: A 33-year-old paraplegic woman was scheduled for cesarean section at the 38th week of gestation. The woman was completely paralyzed below T4 after a surgical treatment for a spinal cord bulge at the neck-chest junction. Diagnoses: A paraplegic G1 P0 patient at 38 week gestation following in-vitro fertilization and embryo transfer requiring elective cesarean section. Interventions: We chose general anesthesia for the patient under FloTrac/VigileoTM system monitoring. In accordance with the FloTrac/VigileoTM system monitoring, vasoactive drugs and liquid infusion were adjusted in real time. Outcomes: Autonomic hyperreflexia emerged during the surgery and the patient was treated in a timely manner because of the FloTrac/VigileoTM system. There were no complications, and the patient delivered a healthy baby girl. Lessons: Paraplegic women can be treated with general anesthesia under FloTrac/VigileoTM system monitoring. The FloTrac/VigileoTM system monitoring can be used to help monitor and maintain a paraplegic patient's hemodynamic stability.

Evaluating anesthesia practice for caesarean section: A prospective cross-sectional study from a tertiary care institution of low- and middle-income country

Background and Objective: In low and middle-income countries (LMICs), general anesthesia for cesarean section has shown to increase the odds of maternal mortality. Use of regional anesthesia for cesarean section is an indicator for safe practice of anesthesia; therefore, this study aims to evaluate the current practice of use of regional anesthesia and its failure rate for cesarean section. The current practice is analyzed in the light of previously published data from the same institution of LMIC. Methods: After hospital ethics committee approval, this prospective cross-sectional study was performed from January 1 to June 30, 2019. Prospective data collected on predesigned form included technique of anesthesia employed for different category of cesarean section, failure of regional anesthesia, and other related data. The cesarean section rate and trends of technique of anesthesia over last 10 years were collected from hospital record system. Results: Compared to the published data from the year 2012 from the same institution, the results from this prospective data have shown an increase rate of cesarean section rate from 31% to 52% with an overall decline in the use of general anesthesia from 49% to 12.3%. In addition, rate of regional anesthesia for category 1–3 cesarean section has increased from 46.4% to 79.8% and for category 1 from 37.1% to 63.4%. Decline in failure rate of regional technique was observed from 6.7% to 2.4%. Conclusion: Assessing and analyzing practices helps in taking initiative to implement safe practices which are needed to achieve the target for best practice.

The efficacy of high flow nasal oxygenation for maintaining maternal oxygenation during rapid sequence induction in pregnancy: A prospective randomised clinical trial.

High-flow nasal oxygenation (HFNO) for pre-oxygenation in rapid sequence induction (RSI) has only been assessed in volunteer parturients without intubation. To evaluate the efficacy of HFNO in comparison with the conventional facemask for oxygenation during RSI for caesarean section under general anaesthesia. Operating room in a tertiary hospital. Prospective randomised, controlled study. Thirty-four healthy parturients undergoing general anaesthesia for caesarean section. Parturients were randomly assigned to HFNO or standard facemask (SFM) group. The primary outcome measure was the PaO2 immediately after intubation. Secondary outcomes included lowest saturation throughout the intubation procedure, end-tidal oxygen concentration (EtO2) on commencing ventilation, blood gas analysis (pH, PaCO2), fetal outcomes and intubation-related adverse events. PaO2 in the HFNO group was significantly higher than that in SFM group (441.41 ± 46.73 mmHg versus 328.71 ± 72.80 mmHg, P < 0.0001). The EtO2 concentration in the HFNO group was higher than that in the SFM group (86.71 ± 4.12% versus 76.94 ± 7.74%, P < 0.0001). Compared to baseline, PaCO2 immediately after intubation also increased significantly in both groups (HFNO group: 30.87 ± 2.50 mmHg versus 38.28 ± 3.18 mmHg; SFM group: 29.82 ± 2.57 mmHg versus 38.05 ± 5.76 mmHg, P < 0.0001), but there was no difference in PaCO2 between the two groups. There was no difference in lowest saturation, intubation times, duration of apnoea, pH value or fetal outcomes. Compared with SFM, HFNO provided a higher PaO2 and EtO2 immediately after intubation in parturients. HFNO is safe as a method of oxygenation during RSI in parturients undergoing general anaesthesia for caesarean section. Clinical trial ChiCTR1900023121.

Induction Opioids for Cesarean Section Under General Anesthesia: A Systematic Review and Meta-analysis of Randomized Controlled Trials

(Int J Obstet Anesth. 2019;40:4–13) Inducing general anesthesia (GA) for cesarean section (CS) can cause a significant sympathetic response that may then lead to serious adverse events, such as intracranial hemorrhage. Thus, administration of sympatholytic medications as part of the induction of GA would be desirable. While opioids are effective sympatholytic agents, older opioids may have adverse effects on the neonate. As a result their use has not been recommended during induction of GA for CS. Newer opioids are shorter-acting and it has been suggested they may have less adverse neonatal effects when used for GA induction for CS. However, more information is needed on their efficacy and potential adverse effects. This systematic review and meta-analysis was undertaken to evaluate the effects of shorter-acting induction opioids on Apgar scores, as well as other neonatal outcomes and their maternal sympatholytic efficacy.

Surgical Conditions With Rocuronium Versus Suxamethonium in Cesarean Section: A Randomized Trial

(Int J Obstet Anesth. 2020;41:14–21) Intubating conditions and onset time for rocuronium (ROC) versus suxamethonium (SUX) have been compared in several trials, but studies focusing on these drugs’ effect on surgery duration and ease of delivery of the fetus during cesarean section are lacking. This study, therefore, compared surgical conditions for delivery of the fetus in parturients receiving ROC versus SUX during general anesthesia for cesarean section.

Magnesium Sulfate and Clonidine; Effects on Hemodynamic Factors and Depth of General Anesthesia in Cesarean Section.

BackgroundMaking stable hemodynamic and also durable unawareness is a daily challenge in the setting of general anesthesia in women who undergo surgical delivery of neonate and have limitations to receive opioids derivatives.ObjectivesWe aimed to evaluate the effects of magnesium sulfate and clonidine on hemodynamic changes and depth of anesthesia and in mentioned mothers and also in neonatal APGAR index.MethodsCurrent randomized, double-blind controlled trial study was conducted among a total of 360 pregnant females (38 - 41 weeks of gestation) who underwent elective cesarean section. Participants were randomly divided into three drug-receiving groups (equal 120 members): magnesium sulfate (30 mg/kg), clonidine (3 µg/kg), and placebo (0.9% NaCl). Patients’ blood pressure, heart rate, cerebral state index (CSI) in specific time zones, and also late 24-hour recall were recorded. The CSI is an electroencephalographic monitoring method helping to assess the depth of anesthesia. Neonatal parameters, including APGAR score and umbilical venous blood sampling, were measured.ResultsMean patients’ age was 28 ± 4.5. A significant decreasing and stabilizing effect of magnesium sulfate and clonidine on hemodynamic parameters (blood pressure and heart rate) was revealed (P < 0.001). Evidence implied on deeper anesthesia (lower CSI) among drug receivers comparing to placebo (P < 0.001). None of the participants experienced a late 24-hour recall postoperatively. All neonates were healthy, and no decrease was reported in APGAR score at minutes 1 and 5. Umbilical blood gas analysis showed no signs of acidosis and/or hypoxemia.ConclusionsAdjuvant administration of either magnesium sulfate or clonidine is associated with hemodynamic stability and favorable unawareness in the setting of elective surgical delivery.

Scenario of General Anesthesia for Cesarean Section in Rural Tertiary Care Center in High Altitude Karnali Academy of Health Sciences

Background: General anesthesia for cesarean section is being less popular for cesarean section in present days but sometime general anesthesia is inevitable. The aim of the study is to assess the trends of general anesthesia, indications, clinical outcome in mother and fetus in high altitude setting of tertiary care center of Nepal.&#x0D; Methods: We conducted descriptive cross-sectional study all cases of cesarean section in Karnali Academy of health Sciences (KAHS) located at high altitude over three years period in our institute. Data were retrieved from the hospital records during three fiscal year (Jan 1st 2017 to Jan Dec 31st 2019). The record of all the patients who underwent cesarean section under general anesthesia was reviewed for demographic details, indication of general anesthesia, trends for general and spinal anesthesia and maternal and neonatal outcome.&#x0D; Results: Out of total deliveries 2175, 309 (14.2%) cases account for cesarean section. Among them, 52 (17%) required general anesthesia . Eclampsia 19(36%) remain the major indication for General Anesthesia in cesarean section followed by failure of spinal anesthesia number 14 (26%) , cord prolapse six (12%), antepartam haemorrhage five (10%), spinal site infection four (8%), Khiphoscoliosis two(4%), Patients request two (4%). Use for general anesthesia technique was consistent for three years with slow rise in use of spinal anesthesia . There was no any anesthesia related maternal mortality and nine intraoperative neonatal &#x0D; Conclusions: General anesthesia practices are consistently required in rural high-altitude setup. Eclampsia is the commonest indication followed by failure of spinal anesthesia and cord prolapse. Neonatal outcome is still not good.