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Anestesia General para Césarea
Anestesia General para Césarea
URRENT
C
OPINION
Purpose of review
For most anaesthesiologists, the clinical experience with general anaesthesia for caesarean section is very
low. General anaesthesia is mostly performed for emergency grade 1 caesarean section and due to a lack
of time to apply a neuraxial anaesthesia technique. Unfortunately, the majority of anaesthesiologists rely on
historical and partly outdated approaches in this stressful situation. We propose an evidence-based
approach to general anaesthesia for caesarean section.
Recent findings
Rapid sequence induction using propofol and rocuronium should become the standard for general
anaesthesia in the obstetric patient. Short-acting opioids are still not given routinely but should never be
withheld in case of severe preeclampsia. Cricoid pressure can only be accurately performed by trained
caregivers and should be released if intubation appears to be difficult. Supra-glottic airway devices may
safely be used in fasted, nonobese elective caesarean section, but endotracheal intubation remains the
gold standard, especially in emergency caesarean section in labouring women. Both sevoflurane and
propofol are appropriate for the maintenance of general anaesthesia during caesarean section. Awareness
remains a major concern in obstetric anaesthesia.
Summary
We present a review of recent evidence on general anaesthesia for caesarean section.
Keywords
caesarean section, general anaesthesia, propofol, rapid sequence induction, rocuronium
INTRODUCTION
Due to its rapid and predictable onset, general anaesthesia for caesarean section (CS) is nowadays virtually exclusively used in emergency situations, or
when neuraxial anaesthesia techniques have failed
or are contraindicated.
With the widespread use of neuraxial anaesthesia, the frequency of caesarean section performed under general anaesthesia has decreased
so dramatically that the routine of the individual
anaesthesiologist with this procedure becomes
insufficient. The overall effect of this phenomenon is that increasingly less anaesthesiologists feel confident with this procedure and
that often historical and outdated approaches
are applied. This is a concerning situation, as
anaesthesia is in comparison to other surgical
conditions still overrepresented as a cause of
maternal death in pregnancy: 12% of maternal
deaths could be directly or indirectly attributed to
anaesthesia [1].
In this review, we overview recent evidence and
propose a modified technique of general anaesthesia
for caesarean section.
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PREPARATION: ASPIRATION
PROPHYLAXIS AND ANTIBIOTIC
ADMINISTRATION
The publication of Mendelson [2] in 1946, in which
all obstetric patients are considered at a high risk for
pulmonary aspiration when undergoing general
anaesthesia, is so ingrained in the anaesthetic literature that most anaesthesiologists ignore that evidence has changed dramatically since then. High
risk of aspiration injury of the lungs is reported in
the presence of a high intragastric volume and a low
intragastric pH (<2.5). However, in pregnant
women, risk of aspiration may probably not be as
high as previously thought.
a
Department of Anaesthesiology, University Hospitals of the KU Leuven
and bDepartment of Cardiovascular Sciences, KU Leuven, Leuven,
Belgium
KEY POINTS
Propofol is now a standard induction agent for general
anaesthesia in caesarean section in healthy,
noncompromised patients.
The combination of rocuronium and suggamadex
provides safer neuromuscular blockade than
succinylcholine.
Remifentanil should always be used in preeclamptic
and other high-risk patients for whom marked
haemodynamic fluctuations are dangerous.
RSI with cricoid pressure and endotracheal intubation
remains the gold standard management for general
anaesthesia in caesarean section.
Awareness remains a major concern in obstetric
anaesthesia.
(1)
(2)
(3)
(4)
(5)
(6)
(7)
Induction agents
Most textbooks still recommend a single dose of
thiopental 45 mg/kg as the induction agent of
choice for general anaesthesia in caesarean section,
arguing that this approach should result in an
acceptable depth of anaesthesia for the mother with
only limited neonatal depression. A recent survey
on the current practice in the UK showed that still
more than 90% of the responders are using thiopental for the induction of general anaesthesia in
caesarean section. In most cases, this choice was
based on historical reasons. Interestingly, 58% of
the responders would support the use of propofol for
induction [16].
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241
Muscle relaxants
Muscle relaxants are used to facilitate endotracheal
intubation and to provide optimal surgical conditions. Until recently, succinylcholine 1 mg/kg
was standardly used for RSI because of its rapid
onset. Succinylcholine is highly ionized and poorly
lipid soluble, and only small amounts undergo
trans-placental transfer. However, possibly lifethreatening and well known side-effects stimulated
the search for a muscle relaxant with a more benign
safety profile.
Rocuronium was introduced in 1994. Due to its
rapid onset in higher doses, it soon gained popularity
for the RSI in the obstetric patient. Abouleish et al.
[21] showed that rocuronium 0.6 mg/kg in combination with thiopental 6 mg/kg provided acceptable
intubating conditions in 90% of the obstetric
patients. Rocuronium did not adversely affect neonatal Apgar-scores, acidbase measurements, time to
sustained respiration or neurobehavioural scores
[21]. However, the onset time of rocuronium for
242
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Opioids
Historically, opioids were administered only after
umbilical cord clamping in an attempt to avoid
respiratory depression of the neonate. The other
major concern arising from the use of opioids is
maternal hypotension with a possible negative
effect on the utero-placental perfusion and the foetal well-being.
However, in the presence of preeclampsia [27],
maternal cardiac [28] or neurologic disease, a
judicious use of opioids can provide haemodynamic
stability during airway manipulation and surgery
and hence offers protection from complications
resulting from the abrupt increase in arterial pressure that is frequently observed during endotracheal
intubation [29]. Furthermore, omission of opioids is
a risk factor for intraoperative awareness [12].
Huang et al. [13] demonstrated that general
anaesthesia for caesarean section in women with
preeclampsia is associated with an increased risk of
stroke when compared with neuraxial anaesthesia.
They could not find an increased risk of stroke
associated with general anaesthesia in women without preeclampsia [13]. One possible mechanism
may be related to the neuroendocrine stress
response, resulting in elevated plasma concentrations of catecholamines in preeclamptic women
who received general anaesthesia in comparison
with those who received neuraxial anaesthesia. This
increase of maternal plasma catecholamines compromises not only the health of the mother but also
causes utero-placental vasoconstriction, adversely
affecting the foetus.
Due to its rapid onset and offset, the use remifentanil has gained increasing popularity for obstetric general anaesthesia in high-risk women. A recent
meta-analysis on the maternal and foetal effects of
remifentanil for general anaesthesia in parturients
undergoing caesarean section found that remifentanil attenuated the maternal circulatory response
to intubation and surgery [14]. Unfortunately, this
meta-analysis did not distinguish between preeclamptic and healthy patients. Less negative base
excess and higher pH in the remifentanil-group
suggested a beneficial neonatal effect. It was concluded that an adequately powered trial addressing
neonatal side-effects of remifentanil is warranted.
Remifentanil doses differed strongly among the
included studies and doseresponse effects should
be further defined in order to find the optimal dose
for both mother and infant [14]. Park et al. [29]
demonstrated that a single bolus of remifentanil
of 0.5 or 1 mg/kg for induction of anaesthesia in
severely preeclamptic patients attenuated maternal
heart rate and pressor responses, with only minimal
and transient neonatal respiratory depression. They
&
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&
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243
MAINTENANCE OF ANAESTHESIA
Notwithstanding limited evidence, sevoflurane has
become the maintenance agent of choice in general
anaesthesia for caesarean section. In the survey by
Murdoch et al. [16], sevoflurane was used in 52%,
followed by isoflurane (45%) and desflurane (1.6%).
Only 0.3% of the anaesthesiologists used propofol
for the maintenance of anaesthesia during caesarean
section.
Concentrations of volatile anaesthetics higher
than 1 minimum alveolar concentration (MAC)
should be avoided throughout the entire anaesthesia for caesarean section: before the delivery of the
baby because of the transplacental drug transfer and
consequent foetal depression; and after the delivery
of the baby due to the dose-dependent myometrialrelaxing properties of volatile anaesthetics [42].
Although anaesthetic requirements for volatile
anaesthetics are diminished by 2540% during pregnancy, maintenance of general anaesthesia for caesarean section with low concentrations of volatile
anaesthetics places parturients at an increased risk of
intraoperative awareness [11 ]. Nowadays, bispectral
index (BIS) monitoring is commonly used to monitor
depth of anaesthesia, whereas the isolated forearm
technique (IFT) is still the scientific gold standard for
detecting wakefulness during anaesthesia with neuromuscular blockade. After administration of thiopental 45 mg/kg and succinylcholine 12 mg/kg,
Zand et al. [43 ] found 41, 46 and 23% of the
parturients still obeying verbal commands at
&&
&
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&&
CONCLUSION
RSI with cricoid pressure and endotracheal intubation remains the gold standard for all labouring
women undergoing emergency caesarean section
and for the majority of women having elective caesarean section under general anaesthesia. Because of
the limited availability of thiopental and the noninferiority of propofol, the latter becomes increasingly popular for induction. The combination of
Volume 28 Number 3 June 2015
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