03 warwick ngan kee
Transcript of 03 warwick ngan kee
Regional Anaesthesia for Caesarean SectionWarwick D. Ngan KeeDept of Anaesthesia & Intensive CareThe Chinese University of Hong Kong
• Spinal Drugs Fluids Blood Pressure
• CSE Dose
• Epidural Topup
OUTLINE:
• Spinal Drugs Fluids Blood Pressure
• CSE Dose
• Epidural Topup
OUTLINE:
Local Anaesthetic
Bupivacaine
Bupivacaine is the local anaesthetic of choice
Hyperbaric vs Plain:• Faster onset
• Less conversion to GA
Hyperbaric vs Plain:• Faster onset
• Less conversion to GA
• Less variability of block
Hyperbaric local anaesthetic more reliable
Local Anaesthetic
Bupivacaine
Additives+
• Opioids • Adrenaline• Clonidine• Neostigmine• Ketamine
Possible advantages:
1. Decrease side effects
2. Increase efficacy
Adding adjunct agents
Possible disadvantages: 1. Drug error
2. Breach of sterility
3. Incompatibility
4. Cost
5. Safety (often “off-label”)
Adding adjunct agents
• Opioids • Adrenaline• Clonidine• Neostigmine• Ketamine
Only add an opioid
Local Anaesthetic
Bupivacaine Fentanyl
Lipophilic Opioid+
Bupivacaine Spinal
Added Fentanyl 0 - 50 µg
0 2.5 5 6.25 12.5 25 37 50
Fentanyl Dose (µg)
IntraopOpioid(%)
67%
50%
25%
0% 0% 0% 0% 0%
Intraoperative Opioid Supplementation
Hunt et al. Anesthesiology 1989;71:535-40.
Nausea and Vomiting?
Elective Spinal Caesarean (n=30)
Hyperbaric Bupivacaine 12 mg
• FENTANYL: Less intraoperative pain • FENTANYL: Less intraoperative nausea
Manullang et al. Anesth Analg 2000;90:1162-6.
IV Ondansetron 4 mg
IT Fentanyl15 µg
Adding an opioid improves patient comfort
Morphine• 100 - 200 µg
• Preservative-free
• Postop analgesia
Morpheus
• Spinal Drugs Fluids Blood Pressure
• CSE Dose
• Epidural Topup
OUTLINE:
Intravenous fluidsMany Uncertainties
Colloidvs
Crystalloid?
Prehydration vs
Cohydration?
Prehydration
Rapid IV fluid infusion started before spinal injection
(Preload)
Cohydration(Coload)
Rapid IV fluid infusion started after spinal injection
Crystalloid
Prehydration Cohydration
Colloid
IV Fluid: Type and Timing
Crystalloid
Prehydration Cohydration
Colloid
- +
+ +
IV Fluid: Type and Timing
Colloid Prehydration:
• Cost.• Effects on coagulation.• Fluid overload. • Haemodilution.• Allergic reactions.
D I S A D V A N T A G E S
Recommendation:• Crystalloid: cohydration• Colloid: prehydration or cohydration• Don't rely on IV fluids • Don't delay for IV fluids
• Spinal Drugs Fluids Blood Pressure
• CSE Dose
• Epidural Topup
OUTLINE:
Phenylephrine
A L P H A A G O N I S T SA L P H A A G O N I S T S
Phenylephrine
A L P H A A G O N I S T SA L P H A A G O N I S T S
• Phenylephrine is more effective
Why use phenylephrine?
PhenylephrineEphedrine
carbon
hydrogen
oxygen
nitrogen
Phenylephrine
A L P H A A G O N I S T SA L P H A A G O N I S T S
• Phenylephrine is more effective
Why use phenylephrine?
• Ephedrine causes fetal acidosis
Lee A, Ngan Kee WD, Gin T. Anesth Analg 2002;94 920-6.
Figure 1. Meta-analysis of trials - effect on umbilical arterial pH
Weighted mean difference (umbilical cord arterial blood pH)
-0.10 -0.05 0.00 0.05 0.10
Alahuhta
Hall
LaPorta
Moran
Pierce
Thomas
Overall effect
Favours ephedrine Favours phenylephrine
Ephedrine depresses fetal pH and BE
00.20.40.60.81.01.21.41.61.82.0
Ephedrine Phenylephrine
1.13
0.17 *
* P < 0.0001
Umbilical Venous : Maternal Arterial (Median values)
Ngan Kee WD Anesthesiology 2009; 111:506-12
Ephedrine crosses the placenta more
Phenylephrine
• Preparation
How to use phenylephrine?
• Timing
• Method of Giving
10 mg / 1ml 100 ml
+ = 100 µg/ml
Dilute carefully…..
Preparation....
Prevention versus Treatment
Timing....
Most effective management: •Start administration immediately after intrathecal injection
• Both effective• Intermittent bolus simple• Infusion convenient
Infusion versus Boluses
Method of Giving....
Recommendation:
• Bolus dose: 50-100 µg (0.5-1ml)• Begin immediately after IT injection• Measure BP Q1min• Further boluses when BP start to decrease
Bolus technique:
Recommendation:Infusion technique:
• Syringe pump• Start 50 µg/min immediately after induction• Measure BP Q1min• Increase rate if BP falls• Decrease/stop if BP increases
Recommendation:What about bradycardia?
• Associated with cardiac output • Tolerate to 50-60 bpm
• BP low: IVF, ephedrine, atropine/glycopyrrolate*
• BP high/normal: stop and wait!
* Beware hypertension with anticholinergics!
• Preeclampsia• Fetal compromise
• Few studies • Less vasopressor needed
Recommendation:What about high risk cases?
• Use less aggressive dosing
• Spinal Drugs Fluids Blood Pressure
• CSE Dose
• Epidural Topup
OUTLINE:
Dose required for adequate spinal block
Single shot spinal
Single shot spinal
Dose required for adequate spinal block
CSE
Dose required for adequate spinal block
0
20
40
60
80
100
StandardLow Dose
Hypotension(%)
73%
14%
P < 0.001
Incidence of Hypotension
Teoh et al. Int J Obstet Anesth 2006;15:273-8
**
• Spinal Drugs Fluids Blood Pressure
• CSE Dose
• Epidural Topup
OUTLINE:
Hillyard et al. Br J Anaesth 2011;107:668-78
2008-2009• 93,000 Emerg C-sections• 22% Epidural Anaesthesia
Labour Epidural Topups
Assessment of Urgency
Assessment of Epidural Function
Type of Anaesthetic?
GA Regional
(With informed consent)
Epidural Topup
OK
De Novo Spinal(or CSE)
Not OK
Assessment of Epidural Function
• How is pain control?
• How much local anaesthetic?
• What is block height?
• How frequent interventions?
Epidural Topup….
….or De Novo Spinal?
Assessing Epidural:
Epidural Topup….
….What Drug?
BupivacaineLevobupivacaineRopivacaine
Lidocaine(+ epinephrine)
Emergency TOPUPS
• Speed of onset
• Safety
• Often given under time pressure
• Large dose, given rapidly
CONSIDERATIONS
• If the quality of epidural block is paramount, then 0.75% ropivacaine is suggested.
• If the speed of onset is important, then a lidocaine and epinephrine solution, with or without fentanyl, appears optimal
Complications of Extension of Epidural Block
Complications of Extension of Epidural Block
Regan KL, O'Sullivan G. Anaesthesia 2008;63:136-42
8
14
6
2
1
12
F A I L E D B L O C K
F A I L E D B L O C KAssessment & Discussion
GA Regional
(With informed consent)
De Novo Spinal(or CSE)
0.16%
11.1%
Furst SR, Reisner LS. J Clin Anesthesia 1995;7:71-4
Spinal After Epidural: Risk of High Block
F A I L E D B L O C KAssessment & Discussion
GA Regional
De Novo Spinal(or CSE)
Reduce Dose
K E Y P O I N T S
Regional Anaesthesia for Caesarean Section
K E Y P O I N T S
Spinal Anaesthesia• Hyperbaric local anaesthetic
• + Fentanyl / Sufentanil
• ± Morphine
Regional Anaesthesia for Caesarean Section
Intravenous Fluids• Crystalloid cohydration
• Colloid prehydration or cohydration
• No need to delay for fluids
K E Y P O I N T S
Regional Anaesthesia for Caesarean Section
Vasopressors• Avoid large doses of ephedrine before delivery
• Phenylephrine preferred
• Bolus or infusion
• Bradycardia: stop and wait.
K E Y P O I N T S
Regional Anaesthesia for Caesarean Section
Combined Spinal Epidural (CSE)• Good for reducing dose
• Better haemodynamic stability
• Useful for prolonged surgery
K E Y P O I N T S
Regional Anaesthesia for Caesarean Section
Epidural Topup for C-Section• 2% Lidocaine + Adrenaline ± Bicarbonate
• 0.75% Ropivacaine
• Spinal after epidural: reduce dose
K E Y P O I N T S
Regional Anaesthesia for Caesarean Section
Regional Anaesthesia for Caesarean SectionWarwick D. Ngan KeeDept of Anaesthesia & Intensive CareThe Chinese University of Hong Kong