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Cesarean section-Perioperative nausea and vomiting under spinal anesthesia

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Impending maternal death Anesthesia for cesarean section General anesthesia Regional anesthesia Spinal anesthesia Epidural anesthesia Combined spinal and epidural ... – PowerPoint PPT presentation

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Title: Cesarean section-Perioperative nausea and vomiting under spinal anesthesia


1
Cesarean section-Perioperative nausea and
vomiting under spinal anesthesia
  • Present by R1???/V.S.???
  • 2007.10.09

2
Cesarean section
  • Cesarean section?????????????????????????????
    Cesarean?????????,?Section?????????,Cesarean
    ?????????????(Julius Caesar)???????,????,?
    ???????,???????Cesarean section????????????
    ???Cadere??,??????????????????Caesones
    ,?????????????????????LexRogis????? ???Lex
    Cesare??,????,???????,???? ??????,??????????

3
Major indication for cesarean section
  • Labor unsafe for mother and fetus
  • 1. Increased risk of uterine rupture
  • --previous classic cesarean section
  • --previous extensive myomectomy or
    uterine reconstruction
  • 2. Increased risk of maternal hemorrhage
  • --central or partial placenta previa
  • --abruptio placentae
  • --previous vaginal reconstruction

Clinical anesthesiology 4th edit. 2006
4
Major indication for cesarean section
  • Dystocia
  • 1. Abnormal fetopelvic relations
  • --fetopelvic dispropotion
  • --abnoemal fetal presentation transverse
  • or oblique line, breech presentation
  • --dysfunctional uterine activity


Clinical anesthesiology 4th edit. 2006
5
Major indication for cesarean section
  • Immediate or emergent delivery necessary
  • 1. Fetal distress
  • 2. Umbilical cord prolapse
  • 3. Maternal hemorrhage
  • 4. Amnionitis
  • 5. Genital herpes with rupture membrane
  • 6. Impending maternal death

Clinical anesthesiology 4th edit. 2006
6
Anesthesia for cesarean section
  • General anesthesia
  • Regional anesthesia
  • Spinal anesthesia
  • Epidural anesthesia
  • Combined spinal and epidural anesthesia

Clinical anesthesiology 4th edit. 2006
7
Spinal anesthesia in cesarean section
  • Hyperbaric bupivacaine
  • Concentration 0.5, 0.75, and 1 not involve
    extent, but effect the density of block
  • 0.75 is equal to 1, less headache
  • Duration 1.5 to 2 hours
  • Does ??, gt15mg increase complication

Miller 6th edit
8
Figure 58-10  Relationship between patient
weight and height and block height during spinal
anesthesia with 12 mg hyperbaric bupivacaine in
50 term parturients undergoing cesarean section.
Circles represent one patient squares, two
patients triangles, three patients and
diamonds, four patients.  (From Shnider SM, Moya
F Effects of meperidine on the newborn infant.
Am J Obstet Gynecol 8910091015, 1964.)
Miller 6th edit
9
Spinal anesthesia in cesarean section
  • Adequate block T6T4
  • Should receive 10001500mL bolus L/R
  • Doesnt help hypotension but useful in some
    patient
  • Supine, left uterine displacement, O2, NBP
    12/min, ephedrine keeps SBPgt100mmHg
    (prophylactic administration is not recommended),
    slight Trendelenburg position

clinical anesthesiology 4th edit. 2006 Miller 6th
edit
10
Cesarean section
  • Perioperative nausea and vomiting

11
Background
  • Incidence 66
  • Etiology
  • 1. Surgical procedure surgical stimuli, such
    as peritoneal traction and exteriorization of the
    uterus, vagal hyperactivity, hypotension
  • 2. Drugs systemic opioid, uterotonic drug
  • Accompany visceral pain, despite of adequate
    dermatome sensory block.
  • The Prophylactic Granisetron Does Not Prevent
    Postdelivery Nausea and Vomiting During Elective
    Cesarean Delivery Under Spinal Anesthesia Anesth
    Analg 2007104679 83
  • Intrathecal fentanyl is superior to intravenous
    ondansetron for the prevention of perioperative
    nausea during cesarean delivery with spinal
    anesthesia International anesthesia Research
    Society Volume 90(5), May 2000, pp1162-1166

12
In the Miller..
  • Despite achieving an adequate (T4) block, some
    women under spinal anesthesia will experience
    some degree of visceral discomfort during
    cesarean section, particularly in situations in
    which the obstetrician exteriorizes the uterus.
    The quality of the spinal anesthesia has been
    reported to be improved by the addition of
    epinephrine, morphine, fentanyl, or sufentanil.

Miller 6th edit
13
Thinking
  • Position? Manual?
  • Prophylactic drug
  • Perioperative drug gas, intrathecal and IV drug
  • Fetus safe?

14
Thinking
  • Hypotension is well correlated to intraoperative
    nausea and vomiting
  • Maintain BP is another thinking process
  • Pain management

The Prophylactic Granisetron Does Not Prevent
Postdelivery Nausea and Vomiting During Elective
Cesarean Delivery Under Spinal Anesthesia Anesth
Analg 2007104679 83
15
Position associates with BP
16
Manual displacement of the uterus during
Caesarean section
  • Anaesthesia, 2007, 62, pages 460465

17
Method
  • 90 ASA 1 and 2 pregnant women with term singleton
    pregnancies and no maternal and fetal
    complications, scheduled for elective or
    emergency Caesarean section, were randomly
    allocated to group LT (15 left lateral table
    tilt, n 45) and group MD (leftward manual
    displacement, n 45)
  • Median block sensory level of T6

18
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23
Volatile agent
24
Nitrous oxide anxiolysis for elective cesarean
section
  • Journal of Clinical Anesthesia (2005) 17, 543548

25
Method
  1. Prospective, randomized, double-blinded study.
  2. 60 ASA status I and II patients scheduled for
    elective cesarean section under spinal anesthesia
  3. Randomized to 2 groups to receive either 100 O2
    via facemask or 40 N2O in O2 via facemask.
  4. After entering the operating room and before the
    administration of the spinal, the patient was
    given 30 mL PO sodium bicitrate, and a facemask
    supplying the study medication was strapped to
    the patients face. Nitrous oxide has a rapid
    onset of clinical effects (less than 2 minutes)

26
no difference!
27
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28
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29
Discussion
  • N2O not slow delivery, not interfere uterine tone
  • Side effect shows up when gt70
  • Supplemental oxygen did not increase fetal
    oxygenation in patients undergoing elective
    cesarean section under spinal anesthesia
    (Recently, Khaw et al )

30
Prophylactic drug usage?
  • Primperan
  • Droperidol
  • 5-HT3 antagonist
  • Opioid
  • Propofol
  • Other intrathecal injection

31
The Prophylactic Granisetron Does Not
Prevent Postdelivery Nausea and Vomiting During
Elective Cesarean Delivery Under Spinal
Anesthesia
  • Anesth Analg 2007104679 83

32
Method
  • Randomized, double-blind, placebocontrolled trial
    in 176 parturients.
  • Fluid10 mL/kg of lactated Ringers solution,
  • Spinal anesthesia 0.75 hyperbaric bupivacaine
    15 mg, fentanyl 10 g, and morphine 100 g
  • SBP maintained at 100 of baseline with aliquots
    of phenylephrine.
  • Oxytocin 0.5 IU was administered IV upon delivery
    followed by a maintenance infusion.
  • Either granisetron 1 mg or normal saline IV
    immediately after cord clamping.

33
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34
Discussion
  • no difference between the granisetron group
    (20.4) and the control group (17)
  • Various study 2255 ?
  • In this study, INOV in control group may be
    under-estimated

35
Prophylactic drug usage?
  • Primperan
  • Droperidol
  • 5-HT3 antagonist
  • Opioid
  • Propofol
  • Other intrathecal injection

36
A single dose of fentanyl and midazolam prior to
Cesarean section have no adverse neontal effects
  • CAN J ANESTH 2006 / 53 1 / pp 7985

37
Method
  • Double-blinded,randomized,placebo-controlled
    trial
  • 60 healthy women received either a combination of
    1 µgkg1 fentanyl and 0.02 mgkg1 midazolam
    intravenously or an equal volume of iv saline at
    the time of their skin preparation for a
    bupivacaine spinal anesthetic.
  • Non-parametric power analysis

38
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40
Discussion
  • Maternal more pleasant
  • No obvious effect on neonatal

41
Prophylactic drug usage?
  • Primperan
  • Droperidol
  • 5-HT3 antagonist
  • Opioid
  • Propofol
  • Other intrathecal injection

42
Dose-Range Effects of Propofol for Reducing
Emetic Symptoms During Cesarean Delivery
  • Obstet Gynecol 200299759.

43
Method
  • Randomized, double-masked trial
  • 80 patients
  • Received lidocaine I.V. 0.1 mg/kg (for injection
    pain relief) followed by either placebo or
    propofol at three different doses (0.5
    mg/kg/hour, 1.0 mg/kg/hour, 2.0 mg/kg/hour) (n
    20 in each group) immediately after clamping of
    the umbilical cord

44
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45
Discussion
  • Reduced the incidence of intraoperative,
    postdelivery nausea, and vomiting
  • Mechanism unclear

46
Prophylactic drug usage?
  • Primperan
  • Droperidol
  • 5-HT3 antagonist
  • Opioid
  • Propofol
  • Other intrathecal injection

47
Influence of injection rate of hyperbaric
bupivacaine on spinal block in parturients a
randomized trial
  • CAN J ANESTH 2007 / 54 4 / pp 290295

48
Method
  • Prospective, randomized, double-blind clinical
    trial
  • 90 ASA I and II term parturients
  • Randomized to receive either fast injection (over
    4 seconds, Group F) or slow injection (over 40
    sec, Group S) of 0.75 hyperbaric bupivacaine 12
    mg morphine 200 µg.

49
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50
Other drug combined
  • Morphine
  • Epinephrine
  • Sufentanyl or fentanyl

51
Combined with morphine
Combined Intrathecal Morphine and Bupivacaine for
Cesarean Section ANESTH ANALG 198867374
52
Combined with sufentanyl
Intrathecal sufentanil (1.5mg) added to
hyperbaric bupivacaine (0.5) for elective
cesarean section provides adequate analgesia
without need for pruritus therapy J Anesth
(2006) 20274278
53
Combined with epinephrine
Epinephrine Improves the Quality of Spinal
Hyperbaric Bupivacaine for Cesarean Section
ANESTH ANAL.C 39s 198766095-400
54
Intrathecal fentanyl is superior to intravenous
ondansetron for the prevention of perioperative
nausea during cesarean delivery with spinal
anesthesia
  • International anesthesia Research Society Volume
    90(5), May 2000, pp1162-1166

55
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56
Conclusion-what we can do?
  • Manual displacement?BP-stable induces less
    perioperative nausea and vomiting?
  • N2O?for anxiety
  • Prophylatic 5HT3?expensive and controversial
  • Fentanyl and Midazolam?further study
  • Propofol?1mg/kg/hr after birth
  • Intrathecal injection with opioid

57
Reference
  • clinical anesthesiology 4th edit. 2006
  • Miller 6th edit
  • Manual displacement of the uterus during
    Caesarean sectionAnaesthesia, 2007, 62, pages
    460465
  • The Prophylactic Granisetron Does Not Prevent
    Postdelivery Nausea and Vomiting During Elective
    Cesarean Delivery Under Spinal Anesthesia Anesth
    Analg 2007104679 83
  • Nitrous oxide anxiolysis for elective cesarean
    section Journal of Clinical Anesthesia (2005)
    17, 543548
  • A single dose of fentanyl and midazolam prior to
    Cesarean section have no adverse neontal effects
    CAN J ANESTH 2006 / 53 1 / pp 7985
  • Dose-Range Effects of Propofol for Reducing
    Emetic Symptoms During Cesarean Delivery Obstet
    Gynecol 200299759.
  • Intrathecal fentanyl is superior to intravenous
    ondansetron for the prevention of perioperative
    nausea during cesarean delivery with spinal
    anesthesia International anesthesia Research
    Society Volume 90(5), May 2000, pp1162-1166
  • Epinephrine Improves the Quality of Spinal
    Hyperbaric Bupivacaine for Cesarean Section
    ANESTH ANAL.C 39s 198766095-400
  • Influence of injection rate of hyperbaric
    bupivacaine on spinal block in parturients a
    randomized trial CAN J ANESTH 2007 / 54 4 / pp
    290295
  • Combined Intrathecal Morphine and Bupivacaine for
    Cesarean Section ANESTH ANALG 198867374
  • Intrathecal sufentanil (1.5mg) added to
    hyperbaric bupivacaine (0.5) for elective
    cesarean section provides adequate analgesia
    without need for pruritus therapy J Anesth
    (2006) 20274278
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