Obs and dlt-1

Prof. A. K.
Sethi’s EORCAPS-2015
Prof. A. K. Sethi’s EORCAPS-2015 Prof. A. K. Sethi’s EORCAPS-2015
Equipment for Lung Isolation
and Intercostal Chest Drains
Dr Prakash Sharma
Two Lumens, two cuffs, two pilot balloons, two
inflating lumens, made of PVC
Double Lumen Tube

Double lumen tube M K
Opening in the bronchial cuff in right sided tube
Disposable, PVC, size 35 Fr, Left Sided
Robertshaw type double lumen tube
EORCAPS‐2015 EORCAPS‐2015

MK Double lumen tube
Two color coded pilot balloons
Two D shaped lumens
Two curves distal & proximal ‐ tracheal & bronchial
Two color coded high volume low
pressure cuffs ‐ bronchial (blue) &
tracheal (white)
Portex,32 Fr, Right, for single use only,
depth markings from distal end of tube
1
Prof. A. K. Sethi’s EORCAPS-2015

Double lumen tube Double lumen tube
Suction
DLT Connectors
catheters
Radio opaque marker present at ends of both
lumens or runs in entire length of the tube
Double lumen tube Double lumen tube
Sheridan‐ two bronchial
cuffs in series
Mallinckrodt‐
Portex Rusch
pear shaped Rusch ‐
Mallinckrodt‐ Portex
donut shaped cylindrical
Shape of endobronchial cuff in right sided DLT
Shape of endobronchial cuff in left sided DLT

MK
Two lumens, two cuffs, two pilot balloons, red rubber
Reusable, Red rubber left sided, size small
tube without carinal hook
Robertshaw Double lumen tube
Robertshaw Double lumen tube
2

Robertshaw DLT Left Sided Robertshaw DLT Right Sided
MK MK
• Ovoid shaped lumen
• Bronchial cuff has longer slot in
• Distal tip has angle of 20° its lateral aspect
• low compliant cuff • Distal tip has an angle of 20°
• length of bronchial segment • Cuff inflates above upper edge of
is 23‐25 mm slot for effective seal
slot for effective seal
• Sizes ‐ small, medium, large

Robertshaw DLT
Advantages: Questions
• Large lumen, which facilitates suctioning & decreases Indications of DLT
airway resistance How to insert the DLT?
Advantages & disadvantages of Robertshaw DLT
Disadvantages: Sizes available, complications of DLT
• low volume high pressure bronchial cuff
low volume high pressure bronchial cuff OLV h
OLV, changes with lateral decubitus position
ith l t l d bit iti
• Small internal lumen
• More mucosal damage
• Difficult insertion

MK
Two lumens, two cuffs, two pilot balloons, red rubber Reusable, red rubber, size 35 FG, Left sided double
tube with carinal hook without slit in the bronchial cuff lumen tube with carinal hook called as Carlens DLT
Carlens Double Lumen Tube
3

Carlens DLT Carlens DLT
MK
Advantages
• Carinal hook aids in proper placement & minimizes
• D shaped cross section with tube advancement after placement
endobronchial lumen as round
tube
Disadvantages
• Tip has angle of 45° in relation
to shaft
to shaft • Increased difficulty & trauma during intubation
• Available sizes: 35,37,39, 41 FG • Amputation of hook
• Side :Left side • Malpositioning of tube due to hook
• Physical interference during pneumonectomy
• Difficulty in passing suction catheter due to D
shaped lumen
• Low compliant cuff

White DLT
MK
Two lumens, two cuffs, two pilot balloons, red rubber
tube with carinal hook with opening in the bronchial cuff Reusable, red rubber, size 37 FG, Right sided double
lumen tube with carinal hook called as Whites DLT
Whites Double Lumen Tube

White DLT
MK
Questions
• Role of carinal hook, its advantages ,disadvantages
• D shaped tracheal lumen & complications
• Tip has angle of 45° in relation to • Method of insertion & role of silk thread at time of
shaft of tube insertion
• Sizes 37, 39 FG • Available sizes for White & Carlens
Available sizes for White & Carlens
• Available only in Right side
4

MK
Double lumen tube made of silicone with wire reinforced Disposable, silicone, 37 FG, Left sided, Double Lumen tube
endobronchial portion with wire reinforced endobronchial portion called as
Silbroncho Double Lumen Tube
Silbroncho Double Lumen Tube

Silbroncho DLT Silbroncho DLT
MK MK
Soft, flexible, wire reinforced endobronchial tip
D‐ shaped lumen and tip has an angle of Smaller, flexible, silicone bronchial cuff near the
45°with the shaft of the tube end of tube

Silbroncho DLT
Sizes: 33, 35, 37,39 Fr ; Side: both left & right side
Advantages
• Soft, flexible tip reduces trauma during intubation
• Silicone cuffs are less subject to tearing
• Cuff design & location allow increased depth of
placement & less dislodgement with change of
position
• Allows movement of tube within patient without
kinking or dislodging cuff
Single lumen tube, two cuffs, two pilot balloons, red rubber
• Especially useful for acutely angled left stem bronchi
tube with carinal hook with opening in the bronchial cuff
Gordon Green Endobronchial Tube
EORCAPS‐2015
EORCAPS‐2015
5
Gordon Green
IMK Gordon Green
IMK
• Has proximal angulation of 15°
• Sizes : 8.0,9.0 mm ID
• Available only in right side
Available only in right side
Reusable, Red rubber, size 8mm ID, Right sided, single
lumen tube called as Gordon Green Endobronchial Tube
EORCAPS‐2015
EORCAPS‐2015

MK
Longer single lumen tube, very narrow cuff & short
distal lumen past the cuff Cuffed, silicone tube, shape of conventional single lumen
tube with an enclosed bronchial blocker on its concave
Disposable, cuffed, PVC, 7mm ID, Endobronchial tube side with two pilot balloons
Univent tube

MK Univent tube
MK
Endobronchial blocker on the concave side Suction port
Pilot balloons
Locking clamp
p
Tip of the blocker
Disposable, cuffed, silicone, size 6mm ID single lumen
tube with an enclosed bronchial blocker called as
Univent tube
6

Univent tube Univent tube
Distal end of blocker MK
Advantages
• Difficult airway
Blue, high pressure low volume cuff • Selective lobar ventilation
Slight bend in above the cuff
• Easy conversion to regular ETT
Radio opaque tip
Has external depth markings • Absence of need to reintubate for postoperative
ventilation
• Patients with tracheostomy requiring OLV
• Patients with hemoptysis or bleeding diathesis

Univent tube
Questions
• Indications, advantages, complications
• Available sizes ‐3.5, 4.5, 6, 6.5, 7, 7.5, 8, 8.5,
9mm ID
• Method of insertion
• Tubes ≥ to 5mm ID used for CPAP, suctioning, or
oxygen insufflation
Double‐lumen balloon‐tipped catheter with nylon
wire jetting out as a loop
Wire guided endobronchial blocker (WEB)
Arndt's blocker
Prof. A. K. Sethi’s EORCAPS-2015 Prof. A.Arndt’s Blocker

K. Sethi’s EORCAPS-2015
IMK
IMK
flexible, nylon wire, passing from proximal
to distal end & exits as a small loop
Disposable, double‐lumen, balloon‐tipped catheter,
size 9 Fr, 65 cm in length called as inflation lumen
guide wire lumen
Wire guided endobronchial (WEB) or Arndt's blocker
7

Arndt’s Blocker IMK
IMK
Three way Multiport adaptor
Port A: Bronchial blocker
Port B: FOB
Port C: Anaesthesia breathing
Port C: Anaesthesia breathing
system
Port D : Tracheal tube
D
High volume, low pressure, blue cuff with spherical or
elliptical shape

Arndt’s blocker Arndt’s blocker
Advantages Disadvantages
• Patients who need rapid sequence induction &OLV • Difficult navigation with FOB in smaller tubes
• Known and unknown difficult airway • More frequent malposition
• Patients who require OLV and nasotracheal intubation • More prone to dislodgment with change of
• Selective lobar ventilation in patients with previous position
pneumonectomy • Shearing of balloon while removing it
g g
• Hemoptysis • Difficult suctioning as channel is just 1.4 mm
• Trauma • Once withdrawn ,reinsertion of wire loop is not
• Eliminates tube exchange for ventilation possible
• Allow CPAP delivery • Small diameter of suction channel increases
time required for lung to collapse.

IMK
Disposable, Double lumen, balloon tipped catheter,
Size 9Fr, 65 cm in length with proximal control wheel
Double lumen, balloon tipped catheter with proximal called as Cohen Tip deflecting Bronchial blocker
control wheel
Cohen Tip deflecting Bronchial blocker
8

Cohen Tip deflecting Bronchial blocker
IMK
High pressure low
volume, blue cuff
Inflation Lumen
Indicator arrow
Central lumen
Depth markings
Double lumen balloon tipped catheter with swivel
Control wheel
connector
Uniblocker
GTK
Uniblocker
GTK
Central lumen
Inflating
Swivel connector lumen
Soft, silicon, high
volume gas barrier cuff
soft, open lumen tip
Disposable, polyurethane, double lumen, balloon
Shaft
tipped catheter, size 5Fr, 40 cm length, high torque
control blocker called as Uniblocker

Uniblocker
Advantages
• Easy to direct & malleable for smooth manipulation
• Soft tip allows repositioning without trauma
• Easy removal without disconnecting swivel
connector
• Metallic, radio opaque mesh allows smoother
manipulation.
• Gas Barrier cuff
• Open lumen tip enables smooth deflation
• Easy torque control allows smooth placement Single lumen, balloon tipped catheter with a wire stylet
Fogarty embolectomy catheter
9

MK Fogarty embolectomy catheter
MK
High‐pressure, low‐
Wire stylet
volume spherical cuff
Stylet to be curved at the distal end
Markings from the tip every 5 cm
Disposable, latex, single lumen, balloon tipped catheter,
size 5Fr,Length 80 cm called as

Fogarty embolectomy catheter Fogarty embolectomy catheter
MK
5 Fogarty Arterial embolectomy catheter 1.5 cc capacity
120805F
5 refers to size of catheter
1.5 cc is maximum balloon inflation capacity with
liquid
120805F is the lot No
Fogarty comes in a white stick like cover on which is
mentioned the size & length

Fogarty embolectomy catheter Fogarty embolectomy catheter
Disadvantages
Cover of Fogarty catheter mentions
Size 5 FG, length 80 cm, sterile by EO, single use, name of • Does not allow suctioning, CPAP or oxygen insufflation
the company: Bio sensors International, model no, lot no,
manufacturing and expiry date, inflation capacity, • Spherical cuff ‐ more prone to dislodgement
• Takes longer for lung deflation
• Cannot be used in patients with latex allergy
Cannot be used in patients with latex allergy
• Vascular device & not designed as blocker
• Stylet cannot be coupled with a FOB
• Air leak from breathing circuit when placed inside tube
Also, warning that it contains natural rubber latex which may
cause allergic reactions in some, disposable
10
Advantages
• Provide segmental or lobar lung isolation
• Used in any size patient
• Can be passed through or alongside SLT in an already
intubated patient
• Used in patients who cannot be orally intubated but
nasotracheal intubation is feasible
• Used in tracheostomized patient Four lumen, bifurcated Y shaped distal end, two color
coded cuffs and pilot balloons
EZ Blocker

GTK EZ Blocker
GTK
Color coded pilot balloons
Four Lumen two cuffs blocker
Two central lumens
Two cuff inflation lumens Radiopaque shaft with markings
Disposable, four lumen, balloon tipped catheter, size 7Fr,
75 cm length with bifurcated distal end called as
EZ Blocker

EZ Blocker
GTK
Y shaped distal end,4cm long,
fully symmetrical, differently
colored ‐blue & yellow
y
Two polyurethane, spherically
shaped, low‐volume cuffs
CPAP Circuit
11

CPAP Circuit
MK
Questions
Indications for use of various bronchial blockers,
their advantages & disadvantages, sizes
available
How to achieve one lung ventilation in children
Management of OLV
Management of hypoxemia ….
Intercostal Chest Drain
Red rubber, catheter, Flower at distal tip
Reusable red rubber Mallecot Catheter size 9F
Hollow tube with trocar
Disposable, PVC, size 9F, Chest drainage tube with trocar
12
Disposable, PVC, size 9F, Chest drainage tube
without trocar Chest drainage tube with chest drainage bag
Rubber connector with tapering ends showing
direction of flow
Chest drainage tube with dilators
Disposable, rubber, Heimlich chest drain valve
Both ends have tapering diameters Proximal
Distal end Patient end
Single, transparent chamber with rubber

sleeve inside showing direction of flow
One bottle collection system
13
Two bottle collection system
Three bottle collection system
EORCAPS‐2015
14
Viva Voce –How To Describe

O2 THERAPY
EQUIPMENTS Identify
Classify according to flow
(Low/ High)
Classify according to performance
(Variable/Fixed)
Dr. Akhil Taneja Classify according to capacity‐for low flow devices
(No/Small/High/Very high)
Brief description of device
Low flow system High flow system
• Total gas flow is less than patient’s inspiratory flow rate • Total gas flow is more than patient’s inspiratory flow rate
• Variable performance (any exceptions?) • Usually fixed performance
• Factors that determine Fio2? • Fixed Fio2 delievered
EQUIPMENT FACTORS
PATIENT FACTORS
Size of the jet orifice
Respiratory rate
Oxygen flow rate
Tidal volume
Fio2 Size of the entrainment ports
Mask volume
Peak inspiratory flow rate (PIFR)
Volume of reservior
Anatomical reservior
Fio2 is independent of flow meter setting
Nasopharyngeal Oxygen Catheter
1
Nasopharyngeal Oxygen Catheter Nasopharyngeal Oxygen Catheter
• Low flow Proximal conical connecter
• Variable perfomance
• No capacity system
Atraumatic polyester foam
• Creates a anatomic reservoir of oxygen to the
oropharyngeal space Distal holes
Nasopharyngeal Oxygen Catheter

• Insertion technique
• Common contra‐indications & complications
• Correct
Correct placement
placement
– Distance from ala nasi to tragus
– Just behind soft palate
– Slightly above the uvula
• Should be changed every 8 hours alternated between nares
Nasal cannulae,Binasal cannula,Nasal prongs
• Low flow
Nasal cannulae, Binasal cannula, • No capacity

Nasal prongs
• Creates a anatomic reservoir of oxygen to the
nasopharyngeal space
• Ideal choice for home based oxygen therapy
2
Nasal cannulae,Binasal cannula,Nasal prongs Nasal cannulae,Binasal cannula,Nasal prongs
Adjustable strap
• Factors that determine Fio2?
2 ? beyond 0.4(40%)

• Maximum FioNot
• Contraindications ?
Prongs
• Complications ?
Nasal cannulae,Binasal cannula,Nasal prongs
Oxygen flow rates(L/min.) Fio2
1 0.24
2 0.28
3 0.32
4 0.36
5 0.40
6 0.44
Fio2 increases by 4% for every 1 litre increase in flow rate

Higher flow rates do not result in much higher Fio2
rather drying and irritating effect on nasal mucosa and
increased patient discomfort
Face Mask - Shell type
• Low flow
• Small capacity ( Paed.‐ 70‐100 ml/ Adult‐100‐250 ml)
Face Mask - Shell Type • Volume of mask act as reservoir of oxygen
• Aka Hudson mask
3
Side holes Face Mask - Shell type
• Plastic reservoirs designed to fit over nose and
mouth
• Holes on each side of mask
– Air entrainment during inspiration
– Passage of exhaled gases during expiration
Plastic resevior • Elastic strap
Strap
• Small bore tube for delivery of oxygen
Oxygen gets collected in the apparatus dead space at the end
of expiration and is inhaled at the beginning of next breath
Face Mask - Shell type Face Mask - Shell type
• Factors that determine Fio2?
• Maximum FioNot
2 ? beyond 0.6(60%) 5‐6 0.35
6‐7 0.40
• Small holes on each side of mask ?
7‐8 0.50
Minimum flow rate of 5 L/Min. required to replace
• Minimum flow rate required to prevent
exhaled gases and prevent Co2 rebreathing 8‐10 0.60
rebreathing?
Face Mask - variants Face Mask - variants
• Low flow
Large Holes • Variable performance
• Large bore tubing
• Large holes
g Diffuser
Direct the flow towards the patient's nose
Nebulization • Nebulization chamber and mouth
chamber
• Noisy
Aerosoloxygen
Humidified (Nebulizer)
can be mask
delivered
Oxy mask
4
Face Mask – variants- Oxy mask Face Mask – variants- Oxy mask
• Low/High flow
1 0.24‐0.27
2 0.27‐0.32
3 0.30‐0.60 • Variable perfomance
4 0.33‐0.65
5 0.36‐0.69
• Open oxygen mask
7 0.48‐0.80
10 0.53‐0.85
12 0.57‐0.89
• No intrinsic PEEP /No CO2 rebreathing
≥15 0.60‐0.90
• Allows communication with patients
ONE MASK
DELIVERS 24% TO 90% OXYGEN
Venturi mask
Venturi mask Venturi mask

Exhalation port
Adjustable strap
• High flow
Venturi barrel
• Fixed perfomance
• Aka HAFOE (HIGH AIRFLOW WITH OXYGEN ENRICHMENT)
system
• Deliver precise FiO2 Air entrainment port
Creates a constant proportion of air –oxygen mixture in
Jet port 100% O2
excess of patient inspiratory flow rate
5
Venturi mask – single control for venturi Venturi mask -venturi valves
Venturi mask……….. Venturi effect Factors Affecting Air Entrainment
• Based on Bernoulli principle The amount of air that is entrained is dependent on two
factors:
• Can be applied to both liquids and gases – Size of the jet orifice
– Size of the entrainment ports
Relationship between velocity and pressure of a moving liquid
Fig 38
38-13
13
Size of the jet orifice
When a fluid flows through a constriction, the velocity is Page 882
increased Fio2 Size of the entrainment ports
The increase in kinetic energy (velocity) must be compensated
by decrease in potential energy (pressure)
Source Gas
(Oxygen)
This drop in pressure causes room air to be entrained
Fio2 is independent of flow meter setting
Venturi mask What will happen to FIO2 when…

• Venturi (jet mixing principle) ?
• I decrease the size of the jet? ____________
Air/O2 ratio for 40% setting @10 lit./ min
• How to calculate Air‐Oxygen(A:O) RATIO for a given Fio2?
100-40 60 3 • I increase the size of the jets? ____________
----------- = --------- = ---- = 3:1
40 -A 100‐
20 20 Fio2 1
O Fio2‐ 20 • I decrease the size of the ports? __________
For every 1 lit. of oxygen 3 lit. of air will be entrained
If Fio2 is less then .36 (36%) use 21 instead of 20
• I increase the size of the ports? ___________
TOTAL FLOW = FLOW METER SETTING (A+O)
• How to calculate total flow delivered to patient for a given
flow meter setting and Fio
= 102x ? (3+1)= 40 lit/min • I decrease the oxygen flow? _____________
TFR (A+O) X O2 flow (L/Min.)
Delivered to patient • I increase the oxygen flow? ______________
6
Oxygen mask with reservoir bag
MK
• High Fio2
• Low flow
• Variable perfomance No valve Inpiratory valve Expiratory valve X 2

Only exhalation port
• Partial rebreathing mask ( 40%‐70%) @ flow rate 6‐10 lit/min
• Non rebreathing mask (70%‐90%) @ flow rate 12‐15 lit/min Partial rebreathing Non rebreathing
• Working principle ?
• Why does partial reabreathing mask requires less flow as

Reservoir of partial rebreathing mask receives FGF +
compared to non rebrething mask?
exhaled gases.
The oxygen concentration of exhaled gases combined
with fresh oxygen supply allows for lower flow rates
with fresh oxygen supply allows for lower flow rates
• Which one of these conserve oxygen?
and conserve oxygen use
• What is the minimum flow rate required ?
Atleast 10 lit/min to keep the bag inflated
• What is the capacity of attached reservoir bag
7
Oxygen Face Tent
• Alternative to an aerosol mask
• Convenient for delivering both humidification and oxygen
• Fits under the patient’s chin and loosely covers the mouth and
nose
• Fio2 of 28% to 40% with flow rates from 8 to 12 L/min.
Oxygen Face Tent
CAPNO2 mask Capnoxygen mask

Main stream Side stream
OXYGEN MASK WITH CO2 MONITORING
•Conventional medium concentration oxygen mask
•Sampling port that permits sampling of exhaled carbon dioxide
•Use during consious sedation
Gas inlet Oxygen Hood
• Clear, plastic cylinders that encompass the infant's head
• Fio2 ‐ .80 to .90
• Flow rates of 10 to 15 L/min
• Oxygen enters the hood through a gas inlet
Oxygen Hood
• Exhaled gas exits through the opening at the neck
8
Volumetric deep breathing exerciser
MK
Volumetric deep breathing exerciser Encourages slow, deep breaths
Aka Keeps alveoli open
Volumetric incentive spirometer Reduces respiratory complications
Tri balls Incentive spirometer Coach 2 Volume Incentive Spirometers

one‐way valve ensures patients inhale, rather than exhale into the unit
02 connection for supplemental oxygen
Few more
• How to get Venturi effect with nasal cannula?
Medication
Reservior • Cause of fogging in face mask?
• Medical air/ oxygen storage and uses?
• Non medical applications of venturi principle?
Duet vibratory PEP therapy system • Oxygen toxicity?
And a lot more to be read….

Vibratory PEP therapy and nebulization in one device
9
WHY IS OBSTETRIC PATIENT DIFFERENT

FROM OTHER PATIENTS
| Two lives rather than

one.
NORMAL PREGNANCY… | Altered maternal

SPECIAL CONSIDERATIONS physiology with effects
on mother and fetus.
IN ANEMIA
| Uteroplacental
circulation with drug
transfer
Dr Sonia Wadhawan
CHANGES IN THE CARDIOVASCULAR SYSTEM

| Cardiac output: +40%
| Stroke volume: +30%
| Heart rate: +15%
PHYSIOLOGICALCHANGES IN | Ejection fraction: Increased
| PCWP No change
PREGNANCY AND ITS | Central venous ppressure: No change
g
IMPLICATIONS | Systemic vascular resistance: -20%
| Uterine blood flow increases from 50ml/min to
700 to 900ml/min.
| 35% Ï in blood volume with 45% Ï in plasma

volume & 20% Ï in red blood cell volume
(dilutional anemia)
HEMODYNAMIC CHANGES DURING PLASMA PROTEINS AND COAGULATION

LABOR AND THE PUERPERIUM PROFILE
Cardiac Output in Labor: Plasma proteins Coagulation Profile

Ï 10% in early first stage
| Plasma Albumin | Platelet count < 1 to 1.5
Ï 25% in the late first stage
concentration Ð from lac/cc
Ï 40% in the second stage. 4.5 gm% to 3.3 gm% | Unchanged Factor II, V
Ï 75% in immediate postpartum period. | Plasma Globulin Ï by | Ï Factors I,VII,VIII, IX,
10% at term X, XII
pregnancy. | Ð Factors XI, XIII
CO returns to prelabor values in 24 hrs.
| A:G ratio changes | BT, PT, PTT: unchanged
from 1.4 to 0.9. | Thromboelastography:
CO returns to prepregnancy levels between 12 to | Maternal colloid Hypercoagulable
24 weeks. osmotic pressure Ð | FDP: Ï
1
IMPLICATIONS OF CVS & AORTOCAVAL COMPRESSION

HEMATOLOGICAL CHANGES
In supine position:
| Ð blood viscosity from lower hematocrit creates Mid pregnancy onwards enlarged
uterus compresses IVC & lower
lower resistance to blood flow. AortaÎÐ cardiac output
| Ï circulating volume protects mother from effects of

hemorrhage at delivery. In supine position aortal
compression causes diminished
blood flow to kidneys,
| Hypercoagulable state: protective adaptation to uteroplacental unit & lower
decrease bleeding. (risk of thromboembolism). extremities.
| Maternal colloid osmotic pressure Ð leads to tissue

edema. Engorgement of veins in the
epidural space due to caval
compressionÎ reduction in
| Gestational thrombocytopenia. volume of epidural & sub
arachnoid space
AORTOCAVAL COMPRESSION & RESPIRATORY SYSTEM

SUPINE HYPOTENSION SYNDROME
| Minute ventilation +45%
| Supine hypotension syndrome is | Alveolar ventilation +45%
characterised by pallor, bradycardia,
sweating, nausea, hypotension, | Functional residual capacity -20%
dizziness & occurs when a pregnant | Vital capacity No change
patient lies supine & resolves when she
turns to one side | Inspiratory capacity +15%
| Tidal volume +45%
| Maternal hypotension causes uterine | I
Inspiratory
i reserve volume
l +5%
5%
hypoperfusion
| Expiratory reserve volume -20%
| Residual volume -20%
| Transfer patient in the left lateral
position | Respiratory Rate +10%
| Oxygen consumption +20%
| Uterine displacement upto 15° after 20 | Airway resistance -35%
weeks of gestation; 30° in twins,
polyhydramnios. | PaCO2(mmHg) 30
| PaO2(mmHg) 100-110
| Oxygen supplementation.

IMPLICATIONS OF RESPIRATORY SYSTEM
AIRWAY
AND AIRWAY CHANGES
| ÏWater retention | Greater risk of hypoxemia( Functional residual capacity
ÏO2 consumption & ÐFRC) (FRC) is our “air tank” for
apnea.
| ÐColloid osmotic pressure | Respiratory alkalosisÎ
Ðserum HCO3 ÎÐbuffering
capacity
| Leaky capillaries leads to engorgement of the
larynx nasal and oropharyngeal edema
larynx,
| Avoid nasopharygeal
instrumentation& repeated
| Friable mucosa attempts at intubation
| Smaller size ETT

| Enlarged breasts and redundant soft tissue in
the neck and chest.
| Difficult airway cart
| Thus pregnancy makes airway difficult
2
GASTROINTESTINAL SYSTEM: Ï RISK ASPIRATION PROPHYLAXIS

OF ASPIRATION Elective LSCS Emergency LSCS
| ÐLower esophageal sphincter tone (progesterone) | Omeprazole 20 mg or | Oral antacid: 30ml of

Ranitidine 150mg HS 0.3mol/l Na citrate, PO,
and morning before 30-45min before surgery.
| Progesterone Î smooth muscle relaxation Î | IV: Metoclopramide 0.15-
surgery
delayed gastric emptying 0.25mg/Kg, 5-10 min
| Metoclopramide:
b f
before S
Sx
10mg PO
| Distortion of LES and pylorus. Ranitidine 50mg 15 min
| Oral antacid: 30ml of before Sx
0.3mol/l Na citrate, | IM: Metoclopramide 0.15-
| Increased intragastric pressure by gravid uterus PO, 30-45 min before 0.25mg/Kg, 30-45 min
surgery. before Sx.
| Placental Gastrin Î Ï acid secretion and Ranitidine 50mg 30-45
acidity. min before Sx
HEPATORENAL ENDOCRINOLOGICAL CHANGES
| Decrease in plasma cholinesterase | Thyromegaly & ÏTBG:total T3, T4 Ï & TSH Ð

but no change in free T3 T4.
| Ï S.Bil, ALT, AST, LDH
| Insulin resistance
| Altered albumin & clotting factors.
| Accelerated starvation due to Ï metabolic
| Ï Renal blood flow & GFR function
| ÏCorticosteroid-binding globulin andÏ plasma

| Physiological glycosuria (Ðtubular reabsorption).
cortisol both bound & free
THE NERVOUS SYSTEM: CHANGES IN THE UTEROPLACENTAL CIRCULATION

SPINE
| UBF= UPP(UAP-UVP)/UVR
| Exaggerated lumbar lordosisÎ Ï technical
| ÐUPP: Decreased Uterine arterial
difficulty & Ïcephalad spread. pressure(UAP)
| Ð epidural space and CSF volume(engorged - supine position
epidural veins)ÎÏ cephalad spread - hypovolemia
| Ï sensitivity of nerves to LA.(progesterone
LA (progesterone & -hypotension
h i : drug
d induced/symp
i d d/ bl k
block
endorphins) Increased uterine venous pressure(UVP)
| Ï LA diffusion across membrane d/t increase - venacaval compression
CSF pH. - uterine contractions/hypertonicity
| Soft ligaments: Ïchances of dural puncture
| Increased UVR:
catecholamines/vasopressin/epinephrine/
methoxamine
3
CASE PRESENTATION OF NORMAL HISTORY: IST TRIMESTER

PREGNANCY
| Booked/unbooked
| Diagnosis of pregnancy : Urine Pregnancy Test, USG
for confirmation
A 25 yr old multipara with previous | H/O morning sickness +, excessive vomiting,
two LSCS with 38 weeks medications for it
pregnancy comes to the hospital.
| H/O heart burn,
burn regurgitation of food
| H/O↑ frequency of micturition
| H/O bleeding per vaginum,, abnormal uterine
enlargement, excessive weight gain
| H/O medications
| All routine investigations performed
(haemogram, blood group, RBS, TSH, urine R/M,
HIV, VDRL, HBsAg)
HISTORY: 2ND TRIMESTER & 3RD Prof. A. K. Sethi’s EORCAPS-2015 Prof. A. K. Sethi’s EORCAPS-2015
TRIMESTER HISTORY: CONTD

| H/O aortocaval compression
| Obstetric history
| H/O abnormal uterine enlargement,
excessive weight gain | Menstrual history
| H/O
O headache,, blurring
g of vision,, swelling
g | Past history : h/o DM, HTN, TB, thyroid disease or
any other chronic ailment, past surgical history
of feet, Ð urine output
| Family history : h/o DM, HTN, TB, blood dyscrasias,
| H/O fatigue, breathlessness, awareness of twinning
heart beat, loss of appetite
| Personal history : Veg/Non-veg , h/o smoking, alcohol
| H/O tetanus immunization and any other consumption, h/o blood transfusion, drug allergy, anti
D immunoglobulin requirement.
drug intake (Fe, folate)

EXAMINATION
ANAESTHETIC DRUGS FOR LSCS
- Height, Weight, Nutrition
INDUCTION AGENTS: THIOPENTONE SODIUM
- Vitals :PR : rate, rhythm,volume and character ; BP; temp
- GPE : Pallor, icterus, clubbing, cyanosis, lymphadenopathy, edema
y Most popular & safe. Prompt & reliable
- Airway examination
induction
- CVS: Apex beat - 4th ICS, 2cms outside midclavicular line, flow murmurs
y Highly lipid soluble, weakly acidic.
- Respiratory system : Breath sounds, Crepts/rhonchi/wheeze
y No airway irritability.
- CNS examination
i ti : Hi
Higher
h mental
t l ffunctions,
ti motor/sensory
t /
y Dose: 3-5mg/kg
examination
y Crosses placenta, F/M ratio of 0.4-1.1
- Spine:Lumbar Lordosis+, Kyphosis/Scoliosis, tenderness, sacral edema Fetal brain levels < levels enough to cause
- Abdominal examination :Inspection : Skin – Linea nigra seen, Purple depression
striae present, ovoid y Disadvantage: No analgesic effect.
- Palpation : Symphysio-fundal Height, Presentation – cephalic
- Auscultation : FHS
4
PROPOFOL (USE CONTROVERSIAL)

KETAMINE
y Rapid smooth induction, rapid awakening & y Provides analgesia, amnesia and hypnosis
attenuates the response to laryngoscopy &
y Rapid onset. Has sympathomimetic action.
intubation.
y Better in Asthma and hypovolemia
y Dose 1-2mg/kg.
y Dose: 2-2.5mg/kg
y 100% oxygen can be administered
y Disadvantages
y F:M ratio at Delivery: 0.6 – 0.8
Increases laryngoscopy and intubation response,
myocardial depression
y Neonatal Apgar scores lower in propofol group
ÏUterine tone & ÐUBF at high dose
compared to Thiopentone
y Ï incidence of maternal hypotension
MUSCLE RELAXANTS
OTHERS | Succinylcholine (1-2 mg/Kg)
- minimal drug transfer
| Etomidate:
- action in 45sec
- no change in dose : ÏVd is counterbalanced by Ð
- rarely used
choline esterase levels.
- ?causes cortisol production suppression in neonate - decreased myalgia: gestational hormone
- myoclonus in the parturient.
|Nondepolarising muscle relaxants: Quaternary
| Opioids: ammonium compounds fully ionised & poorly lipid
All cross the placenta. They are weak bases, bound to α1- soluble. Do not cross the placenta.
glycoprotein. - Rocuronium used when succinylcholine is
Fentanyl(FM 0.6, highly lipid soluble & albumin bound), contraindicated (caution in difficult airway)
Pethidine(active metabolite) - Rocuronium: 0.9-1.2mg/Kg, intubation time< 1min
Morphine(FM 0.9,poorly lipid soluble & low protein binding) - NDMR primarily used for maintenance of muscle
Sufentanil crosses the placental barrier relaxation during GA
MISCELLANEOUS DRUGS
INHALATIONAL AGENTS | Local Anaesthetics:
Lignocaine: short duration of action, good motor block,
more placental transfer, F/M ratio 0.4-0.6,
| MAC decreased by 25-40% ÎÏsensitivity to tachyphylaxis, ion trapping
inhalational agents(progesterone, β endorphin) Bupivacaine longer duration of action, less toxicity,
less tachyphylaxis, low F/M ratio 0.3-0.4, has high
protein binding(96%)
Levobupivacaine: S enantiomer, less cardiotoxic
| R id Induction
Rapid I d i andd emergence ffrom R i
Ropivacaine:Ð
i Ð cardiac
di toxicity,
i i less
l motor block,
bl k less
l
anaesthesia potency
| Anticholinergics: Atropine passes through the

placental barrier unlike glycopyrrolate
| With MAC > 1, atonic PPH( effects oxytocin)
| Benzodiazepines: Diazepam crosses the placenta
easily(highly lipid soluble), F/M ratio is 1, as
compared to midazolam with F/M ratio 0.76.
5
KEEP DIFFICULT AIRWAY CART READY IN ALL CASES ROLE OF ANAESTHESIOLOGIST IN

At least one alternative blade(e.g. straight, McCoy, OBSTETRIC PRACTICE
polio blade,, short handle)
Intubating LMA (Size 3,4,5 with dedicated tubes
and pushers)
Supraglottic device(Proseal LMA / Supreme LMA)
| Labour analgesia
Flexible fibreoptic laryngoscope (with
portable/battery light source)
Stylet,
y , Bougieg
| Anaesthesia for operative delivery
Cricothyroid cannulae with High pressure jet
ventilation system (Manujet)
| Anaesthesia for incidental surgeries in
Surgical Cricothyroidotomy kit
parturient.
| Critical care in Obstetric patient(resuscitaion)
ANAESTHESIA FOR OPERATIVE DELIVERY

RA GA SPINAL VS EPIDURAL BLOCK
Spinal Epidural
| Most elective or semi urgent | Urgent LSCS
LSCS. | Where RA is contraindicated.
| Advantages: | Advantages:
| Difficult airway -Coagulopathy
- Simple technique -Slower fall in BP
| Co-morbid conditions -Sepsis/ local site infection -Post operative analgesia
Awake mother to experience - Reliable
| -Intracranial mass with Ï ÏICP -Titrate extent of block
childbirth - Faster
F t bl block
k
-Severe psychiatric disorder
| Minimum exposure of fetus to - Dense block | Disadvantages:
| Surgical emergencies like
drugs, better fetal outcome. - Smaller dose of LA - Difficult technique
Bleeding placenta previa,
Epidural catheter for labor - Slower onset of action
| eclampsia
analgesia can be extended. - Increased failure rate
| Maternal refusal | Disadvantages:
| Can take care of postoperative - Larger dose:maternal
| Failed NAB - Rapid fall in BP toxicity possible/fetal
analgesia. exposure
| Disadv: Risk of - PDPH
| No risk of aspiration - Risk of dural puncture
aspiration/CVCI/fetal exposure /intravascular injection
to multiple drugs.
CASE SCENARIO 1
COMBINED SPINAL EPIDURAL
| Combines rapidity of spinal block with the ability

to augment block through epidural catheter.
| Epidural needle is an introducer for the longer
spinal needle, esp in obese patients. A 25 yr old multipara with previous two LSCS
| Titrate height of block/ supplement an with 38 weeks pregnancy presented in early labor
incomplete block. for caesarian section.
| Combined adv of dense block with provision of
postop analgesia.
| Untested epidural catheter/ delayed test dose. Central neuraxial block
6
DRUGS USED IN CNAB

CENTRAL NEURAXIAL BLOCK FOR LSCS
Spinal anaesthesia Epidural anaesthesia
| Aspiration prophylaxis
| Preloading/coloading: balanced salt solution | Bupivacaine: 7.5 | Bupivacaine 0.5%: 75-
| Maintain uterine displacement
to15mg 125mg
| Lignocaine: 60-80mg | Lignocaine2% with epi
| Sitting or lateral position
| Ropivacaine
R i i 0.75%,
0 75% 5μg/ml
| Desired height of block T4
0.5%: 15-25mg | Ropivacaine 0.5%: 75-
| Bupivacaine - agent of choice
| Adjuvants: 125mg
| Additives: opioids like fentanyl, sufentanil.
-Fentanyl: 10-25μg | Adjuvants:
| 30-33%Ð in dose requirement of LA
-Sufentanil: 2.5 to 5μg -Fentanyl: 50-100μg
| Maintain normotension by appropriate position,
-Sufentanil: 10-20μg
fluids and drugs, monitor vitals
| Oxygen supplementation
WHAT HAS HAPPENED?

CASE SCENARIO 2
A 25 yr old multipara with previous two LSCS | Maternal hypotension leading to hypoxia
with 38 weeks pregnancy presented in early leading to restlessness and nausea.
labor.
| Unopposed parasympathetic activity with uterine

p
She received spinal anaesthesia with 2.2ml of
0.5% heavy bupivacaine. and peritoneal stretch
Perop patient started becoming restless and | Stimulation of under surface of diaphragm(C3-
feeling nauseated. C5)
| What has happened?

| How will you manage?
RX OF HYPOTENSION
CASE SCENARIO 3
| Maintain uterine displacement
| Lower limb elevation
| Rapid fluid infusion
| Oxygen supplementation A 25 yr old multipara with previous two LSCS

| Vasopressors
with 38 weeks pregnancy presented in early labor
-Ephedrine:(α & β adrenergic activity) improves both with cord prolapse for immediate LSCS.
preload and afterload. Traditionally was the preferred
vasopressor of choice. Disadv: Ï FHR & variability.
-Phenylephrine: Alternative to ephedrine, more α GENERAL ANAESTHESIA
action, has improved fetal outcome.
-Mephentermine, methoxamine
Miller 7th & 8th edition. Phenylephrine better than ephedrine
7

| Shift to OT in left lateral position with oxygen
supplementation
Ð
GENERAL ANAESTHESIA FOR LSCS | Aspiration prophylaxis
Ð
| Prevention of aspiration | Uterine tilt
Ð
| IV infusion of balanced salt solution using a large bore IV
| Prevention of supine hypotension Cannula
Ð
| P
Preoxygenation
ti &RSI with ith sellick’s
lli k’ manuever
| Have a plan of action for failed intubation.
Ðdifficult airway cart
| Induction with thiopentone & NM block with
suxamethonium/ rocuronium
| Maintenance of normal maternal ventilation and
Ð
oxygenation | Intubate with ETT, inflate cuff, check ventilation &
confirm EtCO2
Ð
| Minimizing the duration of exposure of fetus to | Maintenance with Iso/Sevo with 50:50::N2O:O2
general anaesthetics. Ð
CASE SCENARIO 4
| After delivery of fetus:give opioids, oxytocin, flow change
A 25 yr old multipara with previous two LSCS
Ð Prevent hypoxia, hypotension with 38 weeks pregnancy presented in early labor
with cord prolapse for immediate LSCS.
| R
Reversal:
l AAwake
k extubation
b i
Laryngoscopy performed
Ð
Ð
| Post operative care: vitals, analgesia & oxygen Cormack Lehane Grade IV
supplementation Ð
What will you do?
DIFFICULT AIRWAY
Failed intubation
| Plan A: Initial tracheal intubation plan Ð
(Optimal position and preoxygenation of all Plan B: Oxygenate & ventilate
patients) 2-hand mask ventilation/guedel’s airway/cricoid
| Difficult laryngoscopy, OR
Max 2 attempts Call for help Plan C: SGA
Oxygenation & ventilateÎ succeedÎ proceed
| Alternate Laryngoscope/videolaryngoscopy ÐCVCI
| BURP/reduce or release cricoid pressure/bougie Plan D
Cannula cricothyroidotomy/surgical cricothyroidotomy
| Failed intubation Successful intubation
8

When laryngoscopy was performed on the patient
there was some fluid in the oropharynx?
FREQUENTLY ASKED QUESTIONS
What should one do?
| Induction delivery time: >5 and <15 min

What is Mendelson syndrome?
Aspiration Pneumonitis
Chemical injury to tracheobronchial tree and | Uterine incision delivery time: < 90 sec
alveoli caused by inhalation of sterile acidic
gastric contents.
| Normal blood loss:
RISK FACTORS: LSCS: 500-1000ml
Gastric Volume > 25mL Vaginal delivery: 200-500 ml
Gastric pH < 2.5
CRITERIA FOR ANEMIA IN PREGNANCY

WHAT IS ANEMIA?
| WHO:
Hb < 11gm/dl, Hematocrit < 33% in 1st & 3rd
trimester
Quantitative or qualitative reduction of Hb or
g RBC’s or both resulting
circulating g in reduced
oxygen carrying capacity of the blood to the Hb < 10.5gm/dl,
/dl Hematocrit
H i < 32% in
i 2ndd
tissues and organs trimester
| In developing countries (India) it is 10gm/dl
| India incidence: 54% in Rural Indian women and

46% in Urban.
ICMR CLASSIFICATION OF SEVERITY OF ANEMIA

COMPENSATORY MECHANISM IN AN
ANEMIC PREGNANT PATIENT
| Increase in cardiac output.
| Mild: 10-10.9 gm%

| Rightward shift of ODC
| Moderate: 7 - 10gm%
| Decrease in blood viscosity
| Severe: <7gm%
| Increase in 2,3 DPG in red blood cells
| V.Severe/decompensated:<4gm%
| Release of renal erythropoietin leading to
stimulation of erythroid precursors in bone
marrow
9
EFFECTS OF ANEMIA IN PREGNANCY

CLASSIFICATION OF ANEMIA
Maternal Effects Effect on Fetus Morphological Causative
During Pregnancy: poor

|
weight gain, pre eclampsia,
| Preterm LBW and poor APGAR | Microcytic hypochromic | Physiological
score
intercurrent infection, heart
failure (at 30-32wks), preterm | Nutritional eg. Iron
labour | Fetal distress | Normocytic deficiency anemia, folate
| During labour: uterine
normochromic | Infections like malaria,
inertia, PPH, cardiac failure, | IUD due to severe maternal hookworm
shock anoxemia.
| Macrocytic | Hemorrhagic:
| During peurperium: | Failure to thrive acute/chronic
puerperal sepsis,
Subinvolution, failing lactation, | Aplastic
puerperal venous thrombosis, Poor intellectual developmental
pulmonary embolism
|
| Hemoglobinopathies
milestones
| Chronic systemic disease.
| CVS morbidities
PHYSIOLOGICAL ANEMIA PREANAESTHETIC EVALUATION

| History:
Why? Blood Picture:
Tiredness, easy fatigability, breathlessness,
palpitations, nausea, loss of appetite, Cause of
| Plasma volume - Ï40% | RBC 3.2million/cumm anemia, co-morbid condition, H/O drug intake
(Iron, FA)
protects mother from
hypotension due to | Hemoglobin< 10gm%
hemorrhage | Examination:
| RBC - Ï 20% | RBC morphology on GPE: Pallor, icterus, cyanosis edema, JVP Ï,
peripheral smear is glossitis, stomatitis, Koilonychia, mouth
ÏO2 demand soreness.
normocytic,
| ÏPlasma vol > ÏRBC normochromic
volÎ Ðviscosity and
resistance to flow | PVC 30% Airway & Spine examination
PAC: SYSTEMIC EVALUATION

INVESTIGATIONS
| CVS - Tachycardia, Wide pulse pressure. | CBC, Peripheral smear (Cell morphology: Cell
- Functional cardiac murmur (Ejection murmur). size/ Hb content /Anisocytosis, Poikilocytosis,
- Evidence of cardiomegaly, CHF. Polychromasia)
| Reticulocyte count
| RS
S – Tachypnea,
ac yp ea, hyperventilation,
ype ve a o , B/L basal
asa ccrepts
ep s | S.Iron,
S Iron TIBC,
TIBC S.Ferritin
S Ferritin
| S.Folic acid, Vit B12, proteins
| Abd. – Gravid uterus, hepatosplenomegaly
| LFT
| CNS - altered sensorium/ Mental disturbances (B12 def). | Urine : routine microscopy
| Stool for occult blood, worm infestation.
| ECG
| Bone marrow studies, sickle test
10
TREATMENT OF IRON DEFICIENCY MINISTRY OF H&F, GOVT OF INDIA

ANEMIA RECOMMENDATIONS FOR ORAL IRON THERAPY
| Period of gestation and severity of anemia will | Prophylaxis: 100mg elemental iron, 0.5mg Folic
determine the nature of treatment. acid during pregnancy and 3 months postpartum.
| Rx: 180mg elemental iron in 3 divided doses with

0 5mg folic acid.
0.5mg acid
Oral Iron: Parenteral Blood
Ferrous Iron:
sulphate, Fe Iron citrate | Response to therapy:
gluconate. sorbitol, iron
carbonyl iron, dextran, iron - subjective- feeling of well being, improved
iron ascorbate sucrose appetite
< 30 weeks 30-36 weeks > 36 weeks - Hematologically increase in Hb 0.3 -1.0gm%
Intolerance or
non compliance weekly, retic count inÏ 5-10 days.
to oral Iron
therapy
PARENTERAL THERAPY PARENTERAL IRON PREPARATIONS

Intramuscular intravenous
indications contraindications
Failure of oral therapy | Iron sorbitol citric acid | Iron dextran

| | Anaphylaxis complex(50mg/ml)
| Intolerance to oral | Iron sucrose(20mg/ml)
iron(gastritis, | Severe nephritis
| Iron dextran (50mg/ml ) | Side effects: chest pain,
constipation metallic
constipation, | Hepatic
H ti di
disease rigor,
i chills,
hill fall
f ll iin bl
blood
d
taste) | Side effects: headache,
pressure, dyspnoea,pain
| Non compliance to oral nausea, vomiting,
iron during injection and
anaphylactoid reaction,
Contraindication to oral anaphylactic reaction
|
abscess
iron- malabsorption | Newer preparations, Iron
syndrome. | Z track technique III carboxymaltose and
| Period of gestation(>30 Iron III isomaltoside(IV as
weeks)
single dose of 15-20mg/Kg)
INDICATIONS FOR BLOOD

SPECIAL CONSIDERATIONS IN AN ANEMIC
TRANSFUSION
PATIENT
| Rarely indicated in the stable patient when Hb is
| Preoperative transfusion atleast 24 hrs before
> 10 gm/dL and is almost always indicated when
surgery to restore 2,3 –DPG levels
< 6 gm/dL.
| Transfuse packed cells
| If the Hb is < 7-8
7 8 gm/dL in labour/ postpartum
period: transfuse according to the symptoms,
| CNAB: problems can be
coexisting medical conditions, surgery ,coronary
-hypotension
insufficiency continuing blood loss or threat of
bleeding. -hemodilution
-subsequent heart failure on return of vascular
tone.
| Severe/ refractory anemia in > 36 wks gestation
11
| Oxygen delivery to tissues: | Intravenous induction of anaesthesia should be

-Ensure preoxygenation with 100% O2 for 3 min slowly titrated to prevent fall in CO. Inhalational
-Maintainance of patent airway at all times. anaesthetic agents:not much change. Avoid N2O in
-Avoid leftward shift of ODC by maintaining macrocytic anemia.
normothermia, normotension, normocapnia.
| Minimize response to laryngoscopy and
O2 carried in blood in 2 forms: intubation.
y
-Physical solution in plasma
p ((dissolved fform))
-Reversible chemical combination with | Fluid management (good IV access)
haemoglobin (Oxyhaemoglobin)
-Titrate fluid replacement
Oxygen flux(DO2): C.O ✕CaO2= 1000ml -Avoid decompensation
CaO2 = SaO2✕ Hb conc ✕1.34+(0.003 -Minimize blood loss
✕PaO2) -Surgical stasis
-Blood loss replacement with packed cell/fresh blood
-Treat hypotension with vasopressors
| Aggressively treat and avoid conditions that

increase the O2 demands like fever, shivering, POST OPERATIVE CARE
acute massive blood losses.
| Preferrably in HDU
| Meticulous monitoring should be aimed at | Blood/packed cell replacement with continuous
assessing the adequacy of perfusion and monitoring.
oxygenation of vital organs. | Oxygen supplementation
| Repeat
R relevant
l investigations
i i i
| Routine monitors like ECG, NIBP, EtCO2, | Pain relief
temperature monitoring, pulse oximetry, urine | Avoid shivering
output and when required CVP, invasive arterial
blood pressure monitoring, ABG analysis.
| Serial Hb and Haematocrit values.
Sickle Cell Anemia Thalessemia

CASE SCENARIO 5
A 25 yr old multipara with previous two
Congenital Hematological
|
haemobloginopathy
| LSCS with 38 weeks pregnancy presented
disorder
| Parturients have in early labor with Hb of 8gm% is posted
| Chronic anemia with
incidence of preterm for LSCS.
labour placental
labour, tissue hypoxia
abruption, previa, PIH | Multiple transfusions,
| Dehydration, iron overload RA preferred wherever possible
hypotension,
hypothermia, acidosis | Difficult airway due to
predispose to sickling. maxillary prominence
| Marked ventricular and facial deformities
hypertrophy
12
CASE SCENARIO 6
A 29 yr old multipara with 37weeks pregnancy
presented with leaking PV, breathlessness for 2 days.
On examination palor +++
HR- 100/min
BP- 130/70
RR-24/min
Afebrile
On auscultation B/L fine crepts++
Hb 4gm%
GENERAL ANAESTHESIA
13
Objectives
Pregnant patient for non-obstetric
• Indications
surgery • Maternal physiology
• Teratogenicity of anesthetic drugs
Prof. Vimi Rewari • Fetal hypoxia
• Anesthetic management based on case scenarios
• Specific Surgical conditions
Introduction Common nonobstetric conditions

requiring surgery during pregnancy
• 0.75% - 2% of pregnant women require
• Appendicitis - 1:2000
nonobstetric surgery
• Cholecystectomy - 6:1000
• USA – 75, 000 ppregnant
g women/ yyr • Ovarian disorders (torsion,
(torsion neoplasm)
– 1st trimester - 42% • Trauma
– 2nd trimester - 35% • Breast or cervical disease
– 3rd trimester - 23% • Intestinal obstruction
Chestnut DH, ed. Obstetric Anesthesia: Principles and Practice .Philadelphia:

Elsevier Mosby, 2004; 255–72
Physiological changes of pregnancy Physiology- Respiratory system
• Early – hormonal changes • Reduced apnea time

• Later – 20% increase in oxygen consumption
– Mechanical effects of enlarging uterus – 20% decrease in FRC
– Increased metabolic demands of fetus • Increased risk of hypoxaemia
– Low resistance placental circulation
– Maternal obesity, pre-eclampsia
• Maternal hyperventilation - progesterone-enhanced
brainstem sensitivity to PaCO2
1
Physiology – CV System Physiology - Airway

• Difficult airway – mid 2nd trimester onwards
• 40–50% increase in blood volume and cardiac output
• 12 to 38 weeks - 34% increase in incidence of
MMP class IV
• 20% decrease in haematocrit – Swelling
S lli andd ffriability
i bilit off oropharyngeal
h l tissues
ti
– Glottic edema
• Aortocaval compression
• Mallampati classification more predictive of difficult
intubation in pregnancy than in non-pregnant
women
Physiology - Coagulation Physiology - Gastrointestinal system
• Hypercoagulable state • Gastroesophageal reflux - 30 to 50 %

– Increase in vitamin K dependent coagulation factors – Increase in intraabdominal pressure
– Decrease in protein C and S – Decreased lower esophageal sphincter tone
• Gastric emptying is not affected
Teratogenicity of anaesthetic drugs

Timing
• Affect cell differentiation/organogenesis
• Elective surgery – postponed after delivery • Alter cell signalling, mitosis, and DNA synthesis
• Urgent surgery - regardless of trimester • Effect depends on
• Nonurgent surgery – 2nd trimester – Dose
– Ist trimester miscarriage – 8 - 16 % – Route of administration
– Risk of preterm labor lower – Timing of exposure
– Uterus does not obliterate abdominal operative
field • Anaesthesia exposure
– No study to show excess birth defects
– Small increase in risk of miscarriage/preterm delivery
J Obstet Gynecol 1989; 161: 1178–85, Arch Gynecol Obstet 1998; 261: 193–9
2
Teratogenicity of anaesthetic drugs Nitrous oxide

• Pregnant rats - 75% N2O for 24 hrs vs xenon on
• Not possible to conclude whether preterm day 9 of gestation
delivery is due to anaesthesia, surgery, or the – 4- fold increase in resorptions
reason for surgery – 15- fold increase in anomalies
• Enhanced risk after abdominal and pelvic • Inactivates vitamin B12(coenzyme of methionine
surgeries synthetase)
– Mechanical perturbation, local inflammation • Depression of methionine synthetase activity
• Affects production of thymidine and DNA
Dig Surg 2001;18: 409–17 Science 1980;210:899
Nitrous oxide Benzodiazepines

• 24 hrs of high N2O conc. (75%) to cause
teratogenesis • Association with cleft palate and cardiac anomalies
• Possibly due to vasoconstriction and decreased • Meta-analysis of 7 cohort studies
uterine blood flow
• 1090 infants exposed to benzodiazepines
• Adverse effects never documented in human
studies • No increased risk of major malformations/oral
• No association with nitrous and adverse pregnancy BMJ 1998;317:839
outcomes in ORs with scavenging • Benzodiazepines – No evidence of significant risk of

teratogenicity Obstet Gynecol 2009;113:166
Anaesthetic-induced neuronal
Other anaesthetics
apoptosis
• Safe for use during pregnancy • Evidence of accelerated neuronal apoptosis in immature rodent
– Propofol brains exposed to anaesthetic agents
– Barbiturates • 7-day old rats received 6 hrs of GA (midazolam, nitrous oxide,
– Opioids isoflurane)
– Neuromuscular blocking agents • Evidence of memory/learning impairments, apoptotic

neurodegeneration, hippocampal synaptic function deficits.
– Local anaesthetics J Neuroscience 2003;23:876
• Act via NMDA and GABA receptors widely distributed in CNS

• Necessary for neuronal synaptogenesis, differentiation, and
survival during development.
3
Anaesthetic-induced neuronal Fetal hypoxia

apoptosis Maternal hypoxemia/Hyper or Hypocapnia
• Human studies not convincing

Uteroplacental vasoconstriction
• Extended pperiod of synaptogenesis
y p g in humans
Fetal hypoxemia
• Anaesthetic exposure brief
British Journal of Anaesthesia 107 (S1): i72–i78 (2011) Fetal acidosis
Death
Prevention of fetal hypoxia Case scenario -1

• 24 yr old at 30 wks of gestation is involved in a
• Hemodynamic stability road traffic accident
• Adequate intravascular volume • Presents with fracture of both bones of the R
• Vasopressors – Ephedrine /Phenylephrine lower limb
• Ephedrine - Neonatal acidosis • Scheduled for ORIF
Preoperative evaluation Antibiotic prophylaxis

• Document pregnancy - LMP • Safe antibiotics in pregnancy - cephalosporins,
penicillins, azithromycin, and clindamycin
• Same as nonpregnant patients
• Aminoglycosides – Safe but risk of ototoxicity and
• Additional testing not indicated
nephrotoxicity
• D t il d history
Detailed hi t - medical
di l andd obstetrical
b t ti l
• Doxycycline - Transient suppression of bone growth
conditions
and staining of teeth
• Physical examination – airway
• Trimethoprim and nitrofurantoin – increased
• Reassure her about risks to fetus or pregnancy incidence of congenital malformations
• Education - uterine displacement, preterm labor • Fluoroquinolones - toxic to developing cartilage
4
Prophylactic glucocorticoids Prophylactic tocolytics

• Antenatal glucocorticoids • No proven benefit to routine administration
– 24 - 34 weeks of gestation
• Indication
– 24 to 48 hours prior to surgery
– Treatment of preterm labor
– Reduce perinatal morbidity/mortality if preterm birth
– Till resolution of the underlying condition
occurs
• Obstetrician's opinion - Increased risk of preterm
birth
• Avoid in systemic infection
Patient preparation Choice of anesthetic

• Standard preoperative preparation
• Technique of choice - Regional anesthesia
• Anti aspiration prophylaxis – Fetal drug exposure
• Thromboprophylaxis – Maternal intubation
– Pneumatic compression devices – Maternal aspiration
– Pharmacological – No differences in neonatal outcome based on type of
• Length of procedure anesthetic
• Risk factors - Thrombophilia, prolonged immobilization, past
history of venous thrombosis, malignancy, varicose veins,
obesity
Case scenario -2 General anesthesia

• 24 yr old at 24 wks of gestation is involved in a road • Preoxygenation – Mandatory
traffic accident • Time to desaturation <90 %
• Presents with fracture both bones of the R lower – Non pregnant – 9 mins
limb – Term pregnant - 3 mins
• Scheduled for ORIF – Morbidly obese pregnant - 90 secs
• Refuses regional anaesthesia • Left lateral tilt / wedge under right hip
5

Fetal monitoring Prof. A. K. Sethi’s EORCAPS-2015
Induction • After 18 weeks

• Documentation pre and postoperatively
• Rapid sequence intubation (RSI)
• Thiopentone ,Propofol, ketamine, etomidate • From 25 weeks – Fetal heart rate variability
– Provider preference • Continuous monitoring throughout surgery
– Clinical
Cli i l status
t t – Electronic fetal heart rate monitor
– None shown to be teratogenic – Doppler ultrasound
– Transvaginal ultrasound
• Succinylcholine / Rocuronium
• Loss of fetal heart rate variability
• Cricoid pressure controversial
– Decrease in temperature, maternal respiratory acidosis,
anaesthetic agents BJA107 (S1): i72–i78 (2011)
Electronic fetal heart rate monitoring Electronic fetal heart rate monitoring
• 98% false positive rate • 30 wks gestation for femoral thrombectomy
• Has no effect on cerebral palsy or perinatal death – Emergency cesarean delivery for absent variability
• Associated with increase in cesarean rates – No neonatal acidosis
Ob t t Gynecol
Obstet G l 2006;108:656
2006 108 656
– Intubated for prematurity
• 34 weeks gestation for cholecystectomy. Br J Anaesth 2001; 87:791
– Severe persistent fetal bradycardia during skin prep • Modified ECTs at 19 wks gestation
– Emergency cesarean – Cord around the neck with – Severe deceleration - No intervention
neonatal acidosis Can J Anesth 2003;50:922
– Normal healthy baby at 38 weeks. Acta Anaesthesiol Scand 2003;47:101
Fetal monitoring Treatment of fetal heart variability

• Fetal bradycardia, tachycardia, or repetitive
• ACOG Committee recommendations decelerations
– Obstetric consultation before performing nonobstetric – Optimize uteroplacental oxygen delivery and blood flow
• Prevent aortocaval compression
surgery – Maintain maternal hyperoxia and normocarbia
– Fetal monitoring should be individualized • Adjust ventilation and FiO2
• gestational age, type of surgery, available resources – Correct hypovolemia and hypotension
• Fluids, blood, and/or vasopressors
– Team approach for optimal safety of the woman and her – Qualified personnel to monitor and interpret FHR
baby • Obstetrician readily available in case an emergency
cesarean delivery is indicated
6
Recovery from anesthesia

Postoperative analgesia
• Review of anesthesia related maternal mortality
– No maternal death during induction or maintenance of
anesthesia – Neuraxial opioids preferred
– Majority of deaths from hypoventilation or airway
– Parenteral opioids – Hypoventilation
obstruction during emergence, extubation, or recovery
• Continuous monitoring – NSAIDS
• Fetal assessment • Avoid after 32 weeks of gestation
– FHR • Premature closure of the fetal ductus arteriosus
– Uterine activity
• Maternal position — Left lateral position
Monitored anesthesia care (MAC) Case scenario - 3

• Minor injury, dental procedures, GI endoscopy
• 28 yr old primigravida at 28 wks of gestation
• Administration of analgesic /anxiolytic medication
• Presents with left sided chest pain and syncope
• Propofol, Midazolam, Ketamine, Opioids, Nitrous
oxide • Severe aortic stenosis planned for valve
replacement
• Local anesthetic
• Concerns
– Oxygenation, Airway, Hemodynamic stability
– Sedation induced hypoventilation
– Aspiration
Factors important during CPB in

Cardiac surgery
maternal cardiac surgery
• Pre-existing cardiac disease - severe cardiac stress in
2nd and 3rd trimesters • High pump flows (30–50% > non-pregnant state)
• Surgery for severe decompensation – severe mitral or • Mean arterial/perfusion pressure >65 mm Hg for
aortic valvular obstruction optimal uteroplacental perfusion
• CPB - increased perioperative risk for fetus
• Haematocrit
H t it >28%
28%
– Non-pulsatile perfusion
– Inadequate perfusion pressures • Limit hypothermia (<32.8 C associated with higher
– Inadequate pump flow fetal mortality)
– Embolic phenomena to uteroplacental bed • Monitor fetal heart rate continuously
– Release of renin and catecholamines
• Optimize acid–base, glucose, PaO2 , and PaCO2
7
Case scenario - 4 Neurosurgery in pregnancy

• A woman at 28 weeks gestation presented with • Intracranial aneurysm / AVM - increased risk of
rupture
severe headache and loss of vision
– Increased cardiac output, blood volume, softening of
• Large
g meningioma
g was found on MRI and an vascular connective tissue ,hypertensive
hypertensive conditions of
urgent craniotomy is planned pregnancy
• Neurosurgical anaesthetic management
– Controlled hypotension, hypothermia, hyperventilation,
and diuresis
Neurosurgery in pregnancy Neurosurgery in pregnancy

• Controlled hypotension - volatile anaesthetic, • Hypothermia - fetal bradycardia
SNP, NTG • Hyperventilation
– Reduction in uteroplacental blood flow – Uterine artery vasoconstriction
– Fetal transfer – Leftward
L ft d shift
hift off maternal
t l oxyhaemoglobin
h l bi dissociation
di i ti
• Fetal hypotension curve
• SNP – Hepatic metabolism to cyanide and thiocyanate
• Negative impact on outcome
• Cyanide toxicity and fetal death
• NTG - methaemoglobinaemia
• FHR monitoring
Neurosurgery in pregnancy Case scenario - 5

• Diuresis - Negative fluid balance
• Mannitol - Fetal hyperosmolality • A healthy pregnant woman at 30 weeks of
gestation presents with abdominal pain
– Reduced fetal lung fluid production and renal blood flow
– Hypernatremia • Acute appendicitis scheduled for emergency
– In animal models, transfer of water from fetus to mother appendectomy
- fetal dehydration
– 0.25–0.5 mg/ kg safe
• Loop diuretic used with fetal monitoring
8
Laparoscopy Factors important in maternal

laparoscopy
• Concerns
• Open technique to enter the abdomen
– Direct fetal/uterine trauma • Maternal end-tidal PCO2 - 30-35 mm Hg
– Fetal acidosis – CO2 absorption • Low pneumoperitoneum pressure (8-12 mm Hg) or use
– Increased IAP – Decrease in maternal CO and gasless technique
uteroplacental perfusion • Limit extent of Trendelenburg or reverse Trendelenburg
• SAGE guidelines • Initiate any position slowly
• Monitor fetal heart rate and uterine tone
British Journal of Anaesthesia 107 (S1): i72–i78 (2011)
BJA107 (S1): i72–i78 (2011)
Conclusion
• Multidisciplinary approach
Remember
• Maternal and fetal safety
Doing what is best for the mother will almost
• Understanding of physiological and
pharmacological adaptations to pregnancy always be best for the fetus and the
• Avoidance of potentially dangerous drugs at critical outcome of the pregnancy
times during fetal development
• Assurance of adequate uteroplacental perfusion
• Avoidance /treatment of preterm labour and delivery
9
Parturient For Painless Labour CASE 1

A 22 yr old primegravida is admitted with full term
pregnancy and labour pain with 3 cm cervical
dilatation. Patient was diagnosed to be suffering
from rheumatic heart disease at 2 months of
pregnancy when she consulted cardiologist for
PROF (Dr.)
PROF. (Dr ) PRADEEP JAIN progressively increasing dyspnoea on exertion.
Her 2D Echo showed moderate mitral stenosis
with left ventricular ejection fraction 46%.
Her pulse rate is 90/minute, blood pressure
125/78 mmHg, respiratory rate 24/minute and
peripheral oxygen saturation is 95%
WHAT ARE THE
PLAN OF ACTION ?
PLAN OF ACTION ? HARMFUL EFFECTS
HARMFUL EFFECTS
OF LABOUR PAIN ?
Loss of Morale PAIN

Suffering
Anxiety ↑Cardiac Output
↑O2 Consumption
↑Peripheral Resistance
WHAT ARE THE
Sympathetic Stimulation
↑Blood Pressure
Hyperventilation
Delayed gastric emptying
Hypocarbia
↑
↑Adrenocortical Output
BENEFICIAL EFFECTS
↑ Catecholamine release
↑Lactic Acid
Impaired uterine
contractions ↑Free fatty acid
OF RELIEVING LABOUR PAIN ?
↓ Uteroplacental Maternal metabolic
blood flow ↓Fetal pH acidosis
↓ Fetal O2
1
Labour Analgesia Pain In Labour – Stages ?

Dual Pathways ?
• Relieves pain , anxiety and fatigue First Stage of Labour
• Prevents dysfunctional labour • Beginning of uterine contraction to ¾ dilatation of the cervix
Visceral pain mechanism

• ↓ catecholamine and corticosteroid levels - utero
Uterine contraction
placental blood flow maintained Cervical dilatation
•Dull aching pain - abdomen, groin & back

• Reduces maternal O2 consumption (12 - 16%)
•Aδ & C visceral afferent nerve fibers
• Prevent hyperventilation accompanying sympathetic nerves going
from uterus to the spinal cord (T10-L1)

• Eliminates fetal acidosis and hypoxia
Second Stage of Labour Requirements of Labour Analgesia ?

• From ¾ dilatation of the cervix to the
• Adequate Analgesia
delivery of fetus
• Descent of presenting part • Safety to mother & fetus
• Somatic pain – distention , tearing of
• Minimal effect on the progress of labour
th pelvic
the l i fl
floor, vagina
i and
d perineum
i
• Pudendal nerves, enter the spinal column • Allows the mother to participate in birth experience
at S2,3,4 segment
• Genito femoral (L1,2)
• No weakening of muscles power
• llio inguinal L1,
• Capability of extension for emergency LSCS
• Posterior cutaneous nerve of thigh, S2, 3
Case 2
34 weeks pregnant executive in the
WHAT ARE THE
private firm, diagnosed case of PIH
presented to the PAC clinic for METHODS OF PAIN RELIEF
METHODS OF PAIN RELIEF
consultation and queries about the IN LABOUR?
labour analgesia
2
Contd… Prof. A. K. Sethi’s EORCAPS-2015 Prof. A. K. Sethi’s EORCAPS-2015
Non-pharmacological
• Non-pharmacological
Methods of Pain Relief
• Hypnosis
• Pharmacological • Biofeed back
• Acupuncture
- Systemic drugs • TENS
• Breathing & relaxation
- Inhalational agents • Hydrotherapy
• Aromatherapy
- Regional analgesia • Touch & massage
• Music
Non Pharmacological Methods

Grantly Dick – Read’s • Correct description of method
• Breathing exercises
• Relaxation technique
Pharmacological
Pavlovs Technique • Education of mother
• Cooperation during bearing down T h i
Techniques
Fernand Lamaze • Psychoprophylaxis
• Constant human support companion
Leboyer’s Theory • Semi dark tranquil environment

• Warm bath
How Pharmacological Methods of Pain Relief

Related to Cervical Dilatation ?
SYSTEMIC MEDICATIONS ?
• Opioids
PAIN
• Non-opioids
¼ ½ ¾
LABOUR 2ND STAGE • Ketamine
CERVICAL DILATATION
1ST STAGE
INHALATIONAL
• Benzodiazepines
SYSTEMIC MEDICATIONS AGENTS
ANALGESIA
• Phenothiazines
EPIDURAL BLOCKADE
• Barbiturates
1ST PERIOD 2ND PERIOD 3RD PERIOD
3
Fentanyl Remifentanil
• Potent short acting opioid • Ultra short acting synthetic opioid
• Onset 3-5 min Peak effect 5-15 min • Rapid onset
• Maternal T ½ <1 hour • Readily metabolised by plasma & tissue esterases
• No active metabolites • The effective analgesic half life 3 min
• Suitable for PCA •Dose 0.25-0.5 µg/kg
• Bolus dose 25-50 µg every hr • PCA dose 0.25 µg /kg
• Continuous infusion 0.25 µg/kg/hr • LOI 3 min,
• Less nausea, sedation, vomiting than morphine • Continuous infusion, initially 0.025 µg/kg/min, maximum 0.15 µg/kg/min
• Can cause hypotension, bradycardia, respiratory depression • Promising solution when neuraxial techniques are contraindicated
Ketamine Patient Controlled Analgesia

• Indications
• Never established for labour analgesia
– Imminent vaginal delivery
• Enables mother to tailor her analgesic needs
– Patchy epidural anesthesia
• Avoids high blood levels of narcotics
• Cheap and satisfactory
• Poor efficacy of intravenous opioids
• Bolus; 10-15mg IV
• Neonatal effects
• Infusion 0.25mcg/kg/hr
• Expensive
• Aspiration prophylaxis
Indications
• Maintain verbal contact & monitoring
Where regional contraindicated or technically difficult
Entonox
Inhalational Analgesics used ? • PCIIA :safe, self administered
• Onset of action 30 secs
• Maximum analgesic effect 45-60 secs
• Entonox
• Low B/G solubility of N2O (0. 46)
• Sevoflurane – Rapid diffusion, induction & recovery
Advantages
• Isoflurane • Ease of use
• Self titration
• Desflurane Disadvantages
• Lack of scavenging systems
• Trilene • Moderate analgesia
Side effects
• Methoxyflurane – Dizziness
– Nausea
• Chloroform – Dysphoria
– Lack of cooperation
4
Inhalational Analgesia
• Desflurane, enflurane & isoflurane,effectiveness is comparable to
that of N2O What neuraxial techniques can
• Recent studies suggest sevoflurane in inspired concentration of
0.8% to be acceptable & effective
• Provide superior pain relief but more intense sedation
be used for providing labour
be used for providing labour
• Isoflurane 0.2 - 0.25% with N2O (ISONOX)
• Desflurane 1 - 4.5% with N2O analgesia ?
- Use limited by drowsiness, unpleasant smell & high cost
Neuraxial Techniques Neuraxial Anatomy in Pregnancy

Changes ?
• Lumbar lordosis
• Reduction in intervertebral gap
• Widening & rotation of the pelvis
• Tuffiers line crosses spine at a
higher level ie L3-4 space • Enhanced rostral spread
• Engorgement of epidural veins • Narrow epidural space
• Difficult identification of
ligamentum flavum
• Increased sensitivity to local
anesthetics
Lumbar Epidural Analgesia Contraindications

Indications • Patient refusal
• Maternal indications
• Maternal request
• Obstetric indications • Uncooperative patient
- Incoordinate uterine contraction
• Reduce stress response during labour • Coagulopathy
- Dystocia
• Preeclampsia • Hypovolemia
• Diabetes • Fetal indications • Epidural site infections
• Morbid obesity - Prematurity
• Deformity of back
• Non reassuring fetal heart - Multiple pregnancies
- IUGR
• Lack of resuscitation equipment & drugs
• Maternal cardiovascular disease
• Unskilled or inexperienced anesthesiologist
5
Lumbar Epidural Analgesia

Epidural Methods ? Prerequisites?
• Preanaesthetic check up
• Intermittent bolus dose
• Consent of patient
• Intravenous access
• Continuous infusion
• Monitoring
• Asepsis
• PCEA • Test dose - intravascular, subarachnoid
• Trained staff
• CSEA • Resuscitation equipment and drugs
• Bed/ OT table maneuverable to
trendelenberg position
Low dose epidural regime ? Patient Controlled Epidural Analgesia

Traditionally bupivacaine (PCEA)
L.A. conc. 0.2-0.25% Advantages
Now MLAD & MLAV
Bupivacaine 0.0625% - 0.125% • Feeling of control
Ropivacaine 0.1% -0.2% • Immediate access to additional dose of epidural
p
↓Total dose of L.A.
• Less motor block - ambulation
↓Side effects such as motor blockade
Addition of Opioid • Lower drug use
Low dose mixture of L.A. & opioid • Minimal sympathetic block
(0.0625% - 0.125%) + 2µg/ml
• Lower staff workload
Infusion 6-8 ml/hr
Case 3 Combined Spinal-Epidural Analgesia

Subarachnoid component
Call received from obstetrician to Epidural component
anaesthesiologist about a primigravida Most important “new technique” in

obstetric analgesia dubbed as
with 5cm cervical dilatation in labour pain. Walking epidural
“Walking epidural”
Advantages
Doctor please do something, patient is
• Rapid onset of pain relief
very uncooperative with very low • Better perineal analgesia
threshold for pain. • Higher ambulatory potential

• Lower drug use
6
Dose Regimen for CSE Specific Complications of CSE

Initial • PDPH
Fentanyl : 25 – 50 µg
• Fetal bradycardia
Bupivacaine : 1.25--
1 25 2.5
2 5 mg
• Neurological injury
Followed by
Continuous infusion 0.0625% • Meningitis

bupivacaine with 2 µg/ml
Fentanyl- 8-10 ml/hr or PCEA 6—8ml with LOI of 20 min • High spinal
Epidural versus CSE ? CRITERIA FOR

“WALKING EPIDURALS”
Epidural CSE
• Slow onset of action • Sure technique
• Graded block • Rapid onset of action • No obstetrical contraindications
• Less hypotension • Epidural catheter placement
Disadvantage confirmatory
• Can be patchy • Reduced motor block • No change in lying-to-sitting BP
• Ineffective • Preservation of proprioception -
• Catheter dislodgement ambulation possible
Indications Indications • Ability to perform SLR
• CVS disease • Late labour
• Non reassuring fetal heart • Morbid obesity
• Some one available to walk with the patient
Modified Bromage Score Regional Techniques ?

Score Criteria
First Stage
1 Complete block (unable to move feet or knee) Paracervical Block
2 Almost complete block (able to move feet only)
3 Partial block (just able to move knees) Second Stage

4 Detectable weakness of hip flexion while supine Pudendal Nerve Block
(full flexion of knee)
Perineal Infiltration
5 No detectable weakness of hip flexion while supine
6 Able to perform partial knee bend
7
Paracervical Nerve Block Pudendal Nerve Block

• Alternative technique who can not receive neuraxial block
• Pain relief during 1st stage of labour
• Sensory innervation of lower
vagina, vulva , perineum,
• No somatic or motor block
motor to perineal muscles &
• Halts transmission of visceral afferent impulses from uterus & cervix external anal sphincter
through paracevical ganglia • 2nd stage
g of labour
• 5-10 ml of LA are deposited in left & right vaginal fornix • Transvaginal or transperineal
Side effects route
• LA toxicity, postpartum neuropathy, • 7-10 ml of LA on each side
sacral plexus trauma, hematoma
medial & posterior to ischial
spine
• Fetal bradycardia
• Forceps delivery, Episiotomy
Myths ? What is New ?

• ↑ Chances of LSCS • Maternal request alone is indication
• Ultrasound guided blocks

• Prolonged labour
• MLAD & MLAV
• ↑ Instrumentation delivery
• Fentanyl & Remifentanil
• Backache
• Ropivacaine
• Headache
• CSE technique
• Effect on baby
• More awareness
8
Case
— 24 years primigravida, 32 weeks gestation
Preeclampsia and Eclampsia — H/o headache and blurring of vision – 1 day
— HR- 88/min
— BP - 180/120 mmHg
Dr. Medha Mohta — Chest – clear
— Urine protein +
Preeclampsia
Differential Diagnosis
Pregnancy specific multisystem disease
— Preeclampsia
New onset of HT and proteinuria after 20 weeks gestation;
— Gestational HT resolves by 12 weeks postpartum
— Chronic HT Classified as
— Preeclampsia without severe features
— Chronic HT with superimposed preeclampsia — Severe preeclampsia
(ACOG Task Force on hypertension in pregnancy, 2013)
Severe Preeclampsia
Preeclampsia without severe features
— Sustained BP > 160 mmHg systolic or > 110 mmHg diastolic
(measured twice, at least 4 hrs apart, with patient on bed rest)
— BP > 140/90 mmHg on two or more occasions at least 4
— Thrombocytopenia (<100,000/mm3)
hrs apart (measured at rest, with an appropriately sized
BP cuff) — Elevated serum creatinine (>1.1 mg/dl or >2 times baseline)
— Pulmonary oedema
— Proteinuria > 300 mg/ 24 hrs or > 1+ dipstick (30 — New onset cerebral or visual disturbances
mg/dl) — Impaired liver function i.e. ↑ liver enzymes (>2 times normal)
and severe persistent epigastric or right upper quadrant pain
— Urine protein:creatinine ratio (UPCR) > 0.3
(with both measured in mg/dl) (Fetal growth restriction and severe proteinuria (> 5 g in 24 hours)
are no longer considered features of severe preeclampsia)
(ACOG Task Force on hypertension in pregnancy, 2013)
1
Gestational Hypertension Chronic Hypertension

— Systolic BP > 140 mmHg or diastolic BP > 90 mmHg — Systolic BP > 140 mmHg or diastolic BP > 90 mmHg
for first time after 20 weeks gestation before pregnancy or diagnosed before 20 weeks gestation
not attributable to gestational trophoblastic disease
— No proteinuria or other systemic findings
— HT persistent after 12 weeks postpartum
— HT resolves by 12 weeks postpartum
— Final diagnosis made only postpartum
Chronic HT with superimposed Our Patient

preeclampsia — 24 years, primigravida, 32 — Booked case
weeks gestation
— h/o headache and blurring of Last ANC visit 2 weeks back
— New onset proteinuria > 300 mg/24 hours after 20 vision x 1day
weeks gestation in hypertensive women, or — BP 130/80 mmHg
— HR- 88/min
— No antihypertensives
— BP - 180/120 mmHg
— Sudden increase in proteinuria and/or HT or other — Urine protein – nil
— Chest – clear
manifestations of preeclampsia after 20 weeks gestation — No other complaints
— Urine protein +
in women having chronic HT and proteinuria before 20
weeks
Severe Preeclampsia
Preeclampsia Pathogenesis
— Pathogenesis Exact mechanism not known
Placenta – pathogenetic focus of disease
— Risk factors
— Abnormal placentation
— Clinical manifestations — Genetic factors
— Immunologic factors
— Antiangiogenic proteins
2

Stage 1
Poor placentation
(early)
Stage 2
Placental oxidative
stress (late)
Fetal growth Systemic release of placental

restriction factors
Systemic inflammatory
response, endothelial activation
Preeclampsia syndrome
Genetic factors Immunologic factors
— Incidence higher among family members – women with a — Uterine natural killer cells interact with fetal trophoblast
first-degree relative who had preeclampsia more likely to cell markers via maternal killer immunoglobulin
develop disease receptors – influence trophoblastic invasion
— Men born from preeclamptic pregnancy more likely to be — Trophoblastic human leucocyte antigen C (HLA-C)
fathers in preeclamptic pregnancy
— Activated autoantibodies to angiotensin receptor-1 (AT1)
Antiangiogenic proteins
Endogenous antiangiogenic proteins of placental origin
— Soluble fms-like tyrosine kinase-1 (sflt-1) → antagonism What are the risk factors for
of angiogenic growth factors, vascular endothelial development of preeclampsia ?
growth factor (VEGF) and placental growth factor
(PIGF)
— Soluble endoglin (sEng) – elevated in HELLP syndrome
3
Risk factors
Risk factors...
— Maternal obstetric factors: nulliparity, H/o preeclampsia,
— Maternal lifestyle factors: obesity, smoking (↓risk)
multiple gestation, gestational HT, molar pregnancy
— Other maternal factors: race, age > 35 years

— Maternal comorbid conditions: chronic HT, DM, thrombotic
vascular disease
— Paternal obstetric factors: paternity by male who fathered a
previous pre-eclamptic pregnancy, limited preconceptional
— Maternal genetic factors: antiphospholipid antibody, Factor V
exposure to paternal sperm
Leiden mutation (protein C resistance), first-degree relative
with a pre-eclamptic pregnancy
Early onset (Type I) Late onset

Prof. A. K.(Type II)
Sethi’s EORCAPS-2015 Prof. A. K. Sethi’s EORCAPS-2015
Onset of clinical symptoms < 34 weeks gestation > 34 weeks gestation

Relative frequency 20 80
(% of cases)
Risk for adverse outcome High Negligible
Association with intrauterine Yes No
fetal growth retardation
Clear familial component

Placental morphology
Yes
Abnormal
No
Normal
Clinical Manifestations
Etiology Placental Maternal
Risk factors( relative risk) Family history Diabetes, multiple pregnancy,
increased BP at registration,
Increased BMI, Maternal age >
35 yrs, Cardiovascular disorders
Haemodynamics at 24 weeks Higher total vascular Lower total vascular resistance,
resistance, lower cardiac higher cardiac output
output
Clinical Manifestations
Clinical Manifestations...
CNS
CVS
— Headache, visual changes, hyperexcitability, hyperreflexia,
— Increased vascular tone and sensitivity to
coma, convulsions (eclampsia)
vasoconstrictors → HT, vasospasm, end-organ ischaemia
— Visual disturbances – photophobia, diplopia, blurred vision → ↑ BP and SVR
Due to ischaemia caused by vasospasm of posterior cerebral — Intravascular volume depletion
arteries or cerebral oedema in occipital regions
— Majority – hyperdynamic LV function
— Headache, hyperreflexia, clonus – warning signs of increased
— Smaller, high risk group – ↓LV function, markedly ↓
cerebral irritation
SVR, ↓ intravascular volume
4
Clinical Manifestations... Clinical Manifestations...

Respiratory system
Renal system
— Pharyngolaryngeal edema
— ↓GFR, ↑proteinuria, ↑ uric acid
— Increased risk of pulmonary edema due to lower colloid
— ↑ urine protein:creatinine ratio
oncotic pressure, increased hydrostatic pressure and increased
— Oliguria
vascular permeability
Hepatic system
Haematologic system
— Periportal hmg, fibrin deposition in hepatic sinusoids
— Thrombocytopenia in severe disease (15-20%) — ↑ serum transaminases
— Hypercoagulability in disease without severe features, — Hepatic edema/right upper quadrant abdominal pain;
hypocoagulability in severe disease rupture of Glisson’s capsule with hepatic hmg
— DIC
Clinical Manifestations...
Endocrine system
— Imbalance of prostacyclin relative to thromboxane
— Upregulation of systemic renin angiotensin aldosterone
system Prophylaxis
Uteroplacental system
— Persistence of a high-resistance circuit with ↓ blood flow
— IUGR; oligohydramnios
Eye
— Retinal arteriolar constriction, retinal detachment,
blindness
Prophylaxis Prophylaxis...
— The ACOG suggests daily low-dose aspirin, beginning in
— The ACOG does not recommend calcium supplementation
the late first trimester, specifically for women with a history
to prevent preeclampsia for women with normal dietary
of preeclampsia leading to prior preterm delivery before 34
calcium intake.
weeks gestation, or preeclampsia in more than one prior
pregnancy.
— The ACOG does not recommend administration of
antioxidants (Vitamin C or Vitamin E) to prevent
— Low-dose aspirin inhibits platelet thromboxane A2 synthesis
preeclampsia.
without affecting synthesis of vascular prostacyclin → avoids
imbalance in thromboxane to prostacyclin ratio
5
Management
— Delivery of fetus and placenta is the only cure
— Vaginal delivery preferable
— CS - maternal/fetal condition mandates immediate
delivery OR other indications for CS
Management of Preeclampsia
Preeclampsia without severe features
— Same as any other healthy pregnant woman
— Careful monitoring needed to detect progression to
severe preeclampsia
— Induction of labour beyond 37 weeks
Severe preeclampsia Management of Severe Preeclampsia...
— 34 weeks or later - Induction of labour

Supportive
— Less than 34 weeks – Expectant management, — Hospital admission
corticosteroids
— Treatment of hypertension
— Indications of expedited delivery – eclampsia,
— Seizure prophylaxis
pulmonary oedema, DIC, placental abruption, abnormal
foetal surveillance, IUD, refractory severe HT (on — Optimization of intravascular status
antihypertensives), persistent cerebral symptoms (on — Administration of corticosteroids
MgSO4) — Monitoring

Drug Mechanism Dose & route Onset Side-effects/caution
Treatment of hypertension of action of
action
— SBP>160 mmHg or DBP>110mmHg must be treated - Hydralazine Direct 5 mg IV every 15- 10-20 Hypotension, tachycardia,
vasodilator 20 min, max 30 mg min palpitations, headache, neonatal
prevents maternal complications e.g. myocardial ischaemia, thrombocytopenia
hypertensive encephalopathy, cerebrovascular hmg, CHF Labetalol α1 & β blocker 20 mg IV every 10 5-10 Less than hydralazine, avoid in
(1:7) min, max 220 mg min severe asthma, CHF
Nifedipine Calcium 10 mg oral, 30-45 Interactions with MgSO4 -
— Avoid precipitous fall in BP to maintain uteroplacental channel blocker repeated after 30 min severe hypotension,
perfusion and O2 delivery to fetus min, if needed neuromuscular blockade.
S/L not recommended.
Nicardipine Calcium IV infusion 5 mg/h, 10-15 Headache, hypotension,
— Lower MAP not > 15-25%, with target SBP 120-160 mmHg channel blocker ↑by 2.5 mg/h min tachycardia, nausea/vomiting
every 5 min to max
and DBP 80-105 mmHg 15 mg/h
Sodium nitro- Smooth muscle 0.25-5 μg/kg/min 0.5-1 Hypotension, bradycardia. Risk
prusside vasodilator – IV infusion min of fetal cyanide toxicity. Used
— Commonly used drugs – Labetalol, hydralazine, nifedipine releases NO for limited period only,
— Second line agents – Nicardipine, SNP, esmolol continuous intra-art
monitoring mandatory
6
— Cautious administration of upto 500 ml crystalloid is Seizure prophylaxis

recommended before or at same time as initial dose of IV
hydralazine to reduce the chance of a precipitous fall in BP.
(NICE clinical guidelines 107, August 2010) — Magnesium sulphate – DOC for prevention of recurrent
seizures in eclampsia
— Pharmacological agent of choice in women with — Effective (Magpie trial) and superior to diazepam and
preeclampsia and acute pulmonary oedema is glyceryl phenytoin (Collaborative eclampsia trial)
trinitrate. — Use extended to seizure prophylaxis in severe
Administered as an infusion of 5 μg/min, increasing every preeclampsia
3-5 min to a maximum dose of 100 μg/min. — Magnesium sulphate more than halves the risk of
(European Society of Cardiologists guidelines 2011) eclampsia, and probably reduces maternal death
(Cochrane Database Syst Rev. 2010; (11): CD000025)
Magnesium sulphate Magnesium sulphate MOA

— Cerebral vasodilator
— Mesentric vessels more sensitive to Mg induced vasodil
— Mechanism of anticonvulsant action – not well
than cerebral vessels → part of effect mediated through
understood decreasing peripheral vascular resistance
— Earlier – Eclamptic seizures thought to result from
cerebral vasospasm
— May protect BBB
— Recent evidence – Abrupt sustained BP elevation
overwhelms myogenic vasoconstriction – forced dilation
of cerebral vessels, hyperperfusion, cerebral oedema — May decrease cerebral edema
— Action at NMDA receptors to raise seizure threshold
Magnesium sulphate dosage schedule Magnesium sulphate dosage schedule...

Continuous IV infusion Intermittent IM injections
— Loading dose – 4-6 g IV in 100 ml fluid over 15-20 min — 4 g IV @ not to exceed 1g/min
— Maintenance infusion 1-2 g/hr — 5 g deep IM in each buttock
— Monitoring for Mg toxicity — 5 g deep IM every 4 hrs in alternate buttock after ensuring
- Assess DTR, urine output, RR and O2 saturation that
- S. Mg levels at 4-6 hrs or if S. creatinine > 1.0 mg/dl - Patellar reflex is present
— Discontinued 24 hrs after delivery - Respiration is not depressed
- Urine output in previous 4 hrs > 100 ml
— Discontinued 24 hrs after delivery
7
Magnesium toxicity Optimization of intravascular status

— Careful administration of fluids (high incidence of pulmonary
S. Mg conc.
oedema)
— Normal range – 1.7-2.4 mg/dl (1.4-2.2 meq/l or 0.7-1.1 mmol/l)
— Therapeutic range – 4.8-8.4 mg/dl (4-7 meq/l or 2.0-3.5 mmol/l)
— IV fluids to ↑ plasma volume or treat oliguria in a woman
— Loss of DTR – 12 mg/dl with normal renal fn and stable s. creatinine is not
— Respiratory arrest – 15-20 mg/dl recommended
— Cardiac arrest > 25 mg/dl
(mg/dl X 0.411 = mmol/l) — Limit maintenance fluids to 80 ml/hr unless there are other
Treatment ongoing fluid losses e.g. haemorrhage
(NICE clinical guideline 107, August 2010)
— Discontinuation of infusion
— IV Ca gluconate 1 g over 10 min
— If oxytocin is required → used in high concentration &
— O2, mechanical ventilation, if required volume of fluid included in total input
Monitoring
Monitoring...
Regular haemodynamic monitoring required
— Rapid changes in BP due to disease progression,
Invasive central monitoring
antihypertensive drugs and IV fluids
— Intravascular volume depletion
— Indications similar to those in other multisystem
disorders e.g. severe sepsis, MODS, pulmonary oedema,
Indications for intra-arterial BP cardiomyopathy
— Poorly controlled BP, need for continuous BP monitoring
— Use of SNP/NTG — Presence of severe preeclampsia per se not an indication
— Need for frequent ABG samples for CVP or PA pressure monitoring
— Need to monitor cardiac output using minimally-invasive
technique
Complications of severe preeclampsia HELLP Syndrome

Maternal Fetal — Variant of severe preeclampsia
— Antepartum hmg due to — Growth restriction — Haemolysis(H), elevated liver enzymes (EL),
placental abruption — Preterm birth low platelets (LP)
— Cerebrovascular — Right upper quadrant/ epigastric pain
— Intrauterine death
accidents
— Nausea, vomiting
— Eclampsia
— Headache
— Pulmonary edema
— Hypertension
— HELLP, DIC
— Hepatic failure/rupture — Proteinuria
— Renal failure
8
HELLP - Management
HELLP - Diagnostic Criteria
— Similar to severe preeclampsia (including antihypertensives,
— Haemolysis seizure prophylaxis)
Abnormal P/S – fragmented RBC, schistocytes — Stabilize maternal condition
Lactic dehydrogenase > 600 IU/L — Correct coagulation abnormalities – platelet transfusion in
Bilirubin > 1.2 mg/dl with decreasing Hct cases of significant bleeding, platelet count < 20,000/mm3
or < 50,000/mm3 undergoing surgery
— Elevated liver enzymes — Assess fetal condition
SGOT > 70 IU/L — GA- anaesthetic technique of choice for caesarean delivery if
Lactic dehydrogenase > 600 IU/L platelet count is <50,000/mm3
— Improvement in platelet count → neuraxial anaesthesia ??
— Thrombocytopenia – Platelet count < 100,000/mm3 → weigh risk of recurrent thrombocytopenia against risk for
a difficult airway and hypertension during GA
Role of corticosteroids in HELLP Pulmonary oedema

— Incidence 3%
— Corticosteroids can be given to accelerate fetal lung
maturity before 34 weeks, if time permits — Can occur postpartum (within 2-3 days of delivery)
— Only 30% cases occur before delivery
— Observational studies – corticosteroids shown to increase — Higher risk in older, multigravid women and in
platelet count if given in antenatal period preeclampsia superimposed on chronic HT or renal disease
— Causes - low colloid osmotic pressure,
— Insufficient evidence to support or to refute adjuvant ↑ intravascular hydrostatic pressure and
corticosteroid use with either dexamethasone (10-12 mg), ↑ pulmonary capillary permeability
betamethasone (12 mg) or prednisolone. — Treatment – similar principles as in non-obstetric
(Cochrane database of systematic reviews 2010) population
Pulmonary oedema...
— O2 saturation monitoring
— O2 supplementation via non-invasive methods or
intubation and ventilation What is the role of anaesthesiologist
— IV furosemide bolus 20-40 mg over 2 min – repeated in management of preeclamptic
doses of 40-60 mg after 30 min, if inadequate diuretic
response (max dose-120 mg/hr) patient ?
— IV morphine 2-5 mg
— Fluid restriction, strict fluid balance
— Positioning – elevated head, antenatal uterine
displacement
(Anaesthesia 2012;67:646-59)
9
Role of Anaesthesiologist
— To provide labour analgesia
— To provide anaesthesia for caesarean section Labour analgesia in severe pre-eclampsia

— Resuscitation
— Intensive care management
Labour analgesia
— In absence of C/I, lumbar neuraxial analgesia is appropriate for
women with preeclampsia during labour — Place early epidural catheter in parturients with
— Continuous lumbar epidural analgesia or CSE preeclampsia, which may even precede onset of labour
or the patient’s request for analgesia.
Early administration of epidural analgesia
— Avoids GA in event of emergency CS (ASA Task Force on Obstetric Anesthesia. Practice
— Beneficial effect on uteroplacental perfusion guidelines for obstetric anesthesia. Anesthesiology 2007;
106: 843-863)
— Good analgesia attenuates hypertensive response to pain
— Reduces circulating catecholamines, stress-related hormones
— Optimizes timing of catheter placement in setting of declining
platelet count
Considerations during neuraxial Coagulation status

analgesia in preeclampsia — Platelet count > 100,000/mm3 – further coagulation testing
not required
— Assessment of coagulation status — Platelet count < 100,000/mm3 – PT, PTT, fibrinogen levels
— Platelet count > 80,000/mm3 in absence of other coagulation
— IV hydration prior to LA administration abnormalities is not expected to increase likelihood of
neuraxial anaesthetic complications in setting of
— Treatment of hypotension preeclampsia– adequate for catheter insertion as well as
removal
— Platelet count < 50,000/mm3 – neuraxial procedure C/I
— Use of epinephrine-containing LA solutions
10
Intravenous hydration
— Platelet count 50,000-80,000/mm3 – weigh risk/benefit — ↑ risk of pulmonary oedema → careful attention to fluid
infusion rate
- Skilled anaesthesiologist — IV fluid loading not used in patients with severe
- Spinal technique preferred (smaller needle) preeclampsia before establishing low dose analgesia
- Careful neurologic monitoring
- Immediate neurosurgical consultation, if required
Treatment of hypotension
— Trends in platelet count important — Preeclampsia without severe features – routine doses of
Serial counts stable and within normal range during antenatal vasopressors
period – measure every 24-48 hours
— Severe preeclampsia – small doses of vasopressors initially
Decision to induce labour – measure every 6 hrs
(e.g. Ephedrine 2.5 mg or phenylephrine 25-50 μg) to assess
Falling trend – within 1-3 hrs before neuraxial procedure maternal BP response before giving larger doses
Use of Epinephrine
— No randomized controlled — No typical tachycardic response

trials in beta blocked patients
— Used for many decades — Addition to LA →only modest
without confirmed reports LA sparing effect Anaesthesia for CS in preeclampsia
of adverse effects — Consequences of intravascular
— Unlikely to pose significant administration of epinephrine
risk of hypertensive crisis containing test dose in
hypertensive patient
Appears better not to use epinephrine in pre-eclamptic patients
Anaesthetic considerations in
severe preeclampsia Anaesthetic management
— Hypertension, antihypertensive drugs — Pre-anaesthetic evaluation
— Risk of seizures
— Difficult airway — Choice of anaesthetic technique
— Reduced plasma volume
— Risk of pulmonary oedema
— Coagulopathy — Anaesthetic management
— Renal dysfunction
— Hypoproteinemia — Postoperative management
— Altered liver function
— Increased sensitivity to NMBA (MgSO4)
11
Pre-anaesthetic evaluation
History T/t History
Investigations
— Gravida — Medications (antihypertensives?)
— Headache Family History — Hb, Hct (haemoconcentration, haemolysis) with platelet
— Visual blurring, diplopia, — 1st deg relative with preeclamptic count (thrombocytopenia), P/S (if suspecting HELLP)
photophobia pregnancy — BG & CM (risk of PPH)
— Epigastric /rt upper quadrant pain GPE — Urine – albumin (proteinuria), sugar (DM)
— Urine output — Level of consciousness — KFT - Urea, creatinine, uric acid (severe preeclampsia)
— Abnormal bleeding — BMI — LFT – bilirubin, transaminases, LDH (severe preeclampsia,
— Seizures — Icterus HELLP), proteins (hypoproteinemia)
— Pre-existing HT/DM — Oedema — PT, PTT, fibrinogen (if coagulopathy suspected)
Obstetric History — BP — S. Magnesium conc. (if on MgSO4 and evidence of toxicity)
— Preeclampsia in previous — Airway exam — Fundus examination (severe cases)
pregnancy Systemic examination
— DTR important
Choice of anaesthetic technique Traditional view

— Epidural anaesthesia considered the optimal technique in
— Neuraxial anaesthesia is the preferred method
severe preeclampsia
— Spinal anaesthesia relatively C/I (rapid onset of sympathetic
— Avoids disadvantages of GA block – possibility of marked hypotension)
- Hypertensive response to intubation →intracranial hmg
- Airway oedema → possibility of difficult intubation Advantages of epidural
— Ability to titrate LA and fluids
— Single shot spinal / epidural / CSE — Stable maternal BP without precipitous fall
— Less risk of fluid overload & pulmonary oedema
— Optimization of uteroplacental perfusion
Recent Evidence Indications of GA

— Patients with severe preeclampsia experience less frequent,
less severe hypotension than healthy parturients — Coagulopathy/severe thrombocytopenia
— Spinal may cause greater degree of hypotension than epidural;
however hypotension is easily treated and short lived; no — Severe ongoing maternal haemorrhage
difference in outcome
— Spinal anaesthesia is reasonable anaesthetic option for CS in — Pulmonary oedema
severe preeclampsia when there is no indwelling epidural
catheter or C/I to spinal anaesthesia — Sustained fetal bradycardia
— Hypotension – titrated vasopressor doses (greater vascular
sensitivity to vasoconstrictors) — Eclampsia
(Anaesthesia and Analgesia 2013; 117: 686-693)
12
— Interactions of magnesium sulphate with non-depolarizing

Administration of GA to patient with muscle relaxants – increased potency & duration - give small
severe preeclampsia doses, monitor with peripheral nerve stimulator
(↓Ach release, ↓end-plate sensitivity to Ach, ↓muscle
— Preparation to deal with difficult airway (smaller tracheal tubes,
difficult airway equipment) membrane excitability)
— Avoid repeated intubation attempts – LMA reasonably safe
alternative (? Risk of aspiration)
— Onset and duration of succinylcholine not prolonged
— Attenuation of hypertensive response to laryngoscopy and
intubation/extubation (risk of cb hmg, pulm oedema)
Labetalol, esmolol, lidocaine, NTG, SNP, remifentanil (clinicians — Interaction of magnesium sulphate with nifedipine – greater
should use the drugs with which they are most familiar)
hypotensive effect and neuromuscular blockade reported but
Goal – to reduce BP to approx. 140/90 mmHg before
induction, to maintain SBP 140-160 mmHg and DBP 90-100 according to recent evidence can be safely used together
mmHg during laryngoscopy and intubation (Hypertension 2008; 51:960-9)
Use of oxytocic agents in severe

Monitoring
preeclampsia
— HR — EtCO2
— Oxytocin – drug of choice, carefully titrated to — ECG — Neuromuscular
haemodynamic responses — NIBP monitoring
— Ergometrine – not used (hypertensive crisis) — SpO2
— Prostaglandins (15 methyl PGF2α/ misoprostol)– — Urine output
second-line drugs
— Coagulation profile
Associated with elevations in BP, but to a lesser degree
— Fetal monitoring
than ergometrine
— Mg levels
Postoperative care — NSAIDs considered to contribute to HT

— Oxygen
— Vitals monitoring including NIBP, RR — Postpartum hypertension persisting longer than one day
— Analgesics → NSAIDs replaced by alternative analgesics
— Antihypertensives to be continued (ACOG Task Force on hypertension in pregnancy, 2013)
— MgSO4 for 24 hours
— Careful administration of IV fluids — Can be used in all but the most persistently hypertensive
— Urine output women
— Prophylaxis for VTE (intermittent pneumatic (Int J ObstetAnesth 2015 Aug;24(3):264-71)
compression devices)
13
Eclampsia
— Occurrence of generalized convulsions or unexplained coma
during pregnancy, labour or postpartum period in a woman
with signs and symptoms of preeclampsia in the absence of
Eclampsia epilepsy or another condition predisposing to convulsions
— Onset of convulsions in a woman with preeclampsia that

cannot be attributed to other causes
Until proven otherwise, occurrence of seizures during pregnancy should

be considered eclampsia
Eclampsia Complications of eclampsia

— Antepartum Maternal Fetal
— Intrapartum — Pulmonary oedema — Placental abruption
— Postpartum — Cerebrovascular accident — Severe IUGR
— Acute renal failure — Extreme prematurity
— Most common – intrapartum or within first 48 hours
— Pulmonary aspiration — Death
after delivery
— Cardiopulmonary arrest
Clinical presentation — Death

— Any pathophysiologic changes of preeclampsia
— Seizures – abrupt onset, tonic-clonic
Mechanism of eclamptic seizures Management
Previously suggested mechanisms — Stop seizures

— Vasospasm, ischaemia, haemorrhage, hypertensive — Establish patent airway
encephalopathy, cerebral oedema — Prevent complications e.g. Aspiration, hypoxemia
— Antihypertensives
Latest hypothesis — Expeditious delivery (preferably vaginal)
— Loss of normal cerebral autoregulatory mechanism →
hyperperfusion → cerebral oedema, decreased cerebral
blood flow
14
Management of seizures Anaesthetic management

Airway Drugs
— Left lateral, jaw thrust Considerations
— Nasopharyngeal airway, IV Magnesium sulfate — Considerations related to severe preeclampsia
if necessary — 4-6 g IV → 1-2 g/hr infusion
— Assessment of seizure control and neurologic function
— 2 g IV over 10 min for recurrent
Breathing seizures — Fluid balance – 75 to 100 ml/hr
— Bag and mask ventilation with — Antihypertensive therapy if BP > 160/110 mmHg
100% O2 Antihypertensive agents
— Continuous pulse oximetry monitoring of maternal
— Monitor O2 saturation — Labetalol 10-20 mg IV or hydralazine
5-10 mg IV oxygenation
Circulation — FHR monitoring
— IV access — Investigations – coagulation studies required irrespective
— Monitor BP of platelet count
— Monitor ECG
Conscious patient, seizures well controlled, no

evidence of increased intracranial pressure
— Neuraxial anaesthesia acceptable
(BJOG 2001; 108:378-82)
Signs/symptoms of cerebral oedema

— GA – intubate & ventilate for at least 24 hours after CS
to control haemodynamics and cerebral perfusion
— Avoid hyper/hypoventilation
— Avoid precipitous fall in BP
— Avoid hypoxia, hyperthermia, hyperglycemia
15
Introduction
Anaesthetic Considerations
y Foetus: a patient ǃ
For
y Integration of obstetric & paediatric
Foetal Surgery anaesthesia
Dr. Archna Koul y Two patients anaesthetised
y Little margin of error
y Based mainly on clinical experience
Foetal Surgery
• Indicated for malformations which lead to hydrops, foetal What’s unique in foetal surgery
demise, poor foetal outcome
• Advances in prenatal diagnostic technology

y Umbilical circulation
• Foetal surgery should only be performed when
• Diagnosed accurately
y Healing without scarring
• Severity assessed correctly
• Contraindications excluded
y Absence of foetal immune surveillance
• Maternal risk acceptably low
• Best option, than post natal surgery
History of Foetal Surgery Types of Foetal Surgery
• 1963: 1st successful therapy– Sir William Liley Open foetal procedures
Hysterotomy
• 1983: 1st successful surgery Ex Utero Intrapartum Therapy (EXIT)
y Airway Management on placental support (AMPS)
(Vesicostomy to treat B/L HDN)- y Operation on placental support (OOPS)
Minimally invasive procedures

Dr. Michael Harrison y Foetoscopic or FETENDO procedures
y Foetal image guided surgery (FIGS)
1
Open Foetal Surgery Indications of exit procedure

1) Hysterotomy y Head and neck masses
y Congenital cystic adenomatoid

y Congenital high airway obstruction syndrome
malformation
y Reversal of tracheal occlusion
y Sacrococcygeal teratoma
y Meningomyelocoele y EXIT to ECMO

2) Ex utero intrapartum therapy (EXIT)
y Unilateral pulmonary agenesis
y Bridge to separation in conjoint twins
Minimally Invasive Procedures Anaesthetic Considerations

• Maternal safety
1) Foetoscopic or FETENDO
• Maximal uterine relaxation
procedures
• Maintenance of UP blood flow
y Twin- twin transfusion syndrome
• Maintenance of uterine volume to prevent placental
y Twin reversed arterial perfusion
separation
y B/L HDN
• Adequate foetal anaesthesia
y CDH • Intraoperative foetal monitoring
2) Foetal image guided surgery (FIGS) • Postoperative tocolysis
y Shunt placement Reitman E et al. Br J Anaesth 2011
y Radio-frequency ablation
Maternal Anaesthetic Considerations

Tocolytic agents
y ß adrenergic agents: terbutaline, ritodrine • Aspiration
• Hypoxia
y MgSO4
y Halogenated volatile agents • Pulmonary oedema
y GTN • Supine hypotension
• Sensitivity to anaesthetics
y NSAIDS: indomethacin
• Hypercoaguable state
y Calcium antagonists
2
Foetal Anaesthetic Considerations Uteroplacental Considerations

• Low circulating blood volume y Foetal O2 delivery
• Immature coagulation system y Uterine artery blood flow
• Evaporative fluid loss y Umbilical artery blood flow

y Placental barrier
• Temperature homeostasis
y Avoid
• ↓ Myocardial contractility
y Maternal hypotension and hypoxia
• Cardiac output dependent on HR y Hyperventilation
• ↑ vagal tone ↓ baroreceptor activity y Increased uterine tone
• Sensitivity to volatile anaesthetics, analgesics and y Aortocaval compression
muscle relaxants y Kinking of umbilical cord
Open Foetal Surgeries Preoperative Preparation

Preoperative Maternal Evaluation • NPO – aspiration prophylaxis
• History and physical examination • Vascular access
• Routine investigations • Temperature of OR
• Foetus • Blood products
p
• Ultrasound (Foetal wt) • Resuscitation drugs
• Echo • Atropine 0.02 mg/kg
• MRI • Epinephrine 1μg/kg
• Karyotype • Vecuronium 0.2 mg/kg
• Psychosocial evaluation • Fentanyl 20 μg/kg
Hysterotomy for sacrococcygeal teratoma
• Informed consent • Tocolytic drugs – indomethacin
Prof. A. K. Sethi’s EORCAPS-2015 Contd… Prof. A. K. Sethi’s EORCAPS-2015
Intraoperative Management
Intraoperative Management
• Standard monitoring devices, IBP • Uterine relaxation – desflurane / isoflurane /
sevoflurane (2-3 MAC)/ IV NTG

• Lumbar epidural catheter
• Ephedrine/phenylephrine
• Amniotic fluid replacement (Ringer lactate)

• Left uterine displacement
• I/V fluids
• Rapid sequence induction • Placental localization
3
Foetal Anaesthesia Foetal Monitoring

• Placental transfer of inhalational agents
• Pulse oximetry
• Foetal medication IM/cord
• Intra-operative sonography
• Fentanyl 20 μg/kg
• Direct foetal ECG
• Vecuronium 0.2 mg/kg or
• Foetal echo
Pancuronium 0.3 mg/kg
• Atropine 0.02 mg/kg • Foetal ABG / VBG
• IV catheter in foetus • Foetal glucose, electrolytes
Subsequent Tocolysis Alternative Anaesthesia

y MgSO4 4-6 gm over 20 min, 2-3 gm/hr over 24
• Balanced anaesthesia with NTG in large dose (20
hrs
μg/kg/min) supplemented by vasopressor
y Postoperatively De Buck F, et al. Curr Opin Anesthesiol, 2008
• Tocolysis • Propofol and remifentanil (SIVA)

• MgSO4 with or without indomethacin Anne Boat et al. pediatric Anesthesia 2010
• S/C terbutaline • Neuraxial anaesthesia accompanying Inj of NTG

(epidural or CSE) George RB, et al. Can J Anesth,
• Oral nifedipine
2007
• Postoperative analgesia PCA
Ex Utero Intrapartum Therapy (EXIT) Minimally Invasive Procedures

• One peripheral line
• Foetus delivered
• No need of NG tube / arterial cannulation
• Tocolycis not required
• Small incisions
• Need for 2 operating rooms • Minimal postoperative pain & uterine activity
• Foetal anaesthesia: airway manipulation & • Length of hospital stay less

• Postoperative tocolytics rare
foetal pattern circulation
• Subsequent normal vaginal delivery
• Sterility of airway equipment
• Preterm PROM
• Reversal of uterine relaxation • prophylactic antibiotics & tocolytics
4
Factors Influencing Anaesthetic LA + Sedation

Management • Combination of opioids + BZP / propofol
• Combination of diazepam + remifentanil
y Location of placenta, cord & membrane (0.1mcg/kg)/min
• Supplemental O2 to mothers
• Remifentanil
y Foetal
F t l cardio-vascular
di l status
t t
• Excellent maternal sedation
• Easily reversible foetal immobilization
y H/O uterine activity • ↑ transplacental passage
• Only minimal maternal respiratory depression
y Volume of amniotic fluid • Short duration of action
Missant C et al. Acta Anaesth Belg 2004
Complications
Foetal UP blood Uterine
Anaesthesia Open EXIT FETENDO FIGS
depression flow relaxation
Pulmonary edema ++ ++ + ±
Regional
- - -
g
Bleeding ++ +++ + -
Balanced Preterm labour ++ NA + -

+ ± ±
GA+ epidural)
Preterm PROM ++ NA ++ -
Deep GA
++ ++ ++ Chorio-amnionitis ++ NA + -
Amniotic leak ++ NA + -
Foetal Pain
Open MIS EXIT
• Pain relief from mid gestation onwards
Gestational age 2-3 trimester 2-3 trimester Time of delivery
• Foetal stress response
Maternal GA + EA Local/Neuraxial GA +/- EA
anesthesia +/- IV sedation • ↑ cortisol
Uterine tone Complete Minimal Complete relaxation • ↑ β-endorphins
β p
relaxation
l i relaxation
l i
• Vigorous movements
Foetal TP- inhalational TP- opoids or Same as open
anesthesia or direct(IM/ direct (IM/ • Behavioural response
umbilical cord) umbilical cord)
• Movements (8 weeks)
IBP Yes No yes
• Reaction to sound 20 weeks
Amnio infusion Yes No Yes
Future labour No Yes yes • Response to painful stimuli 22 weeks
Lee SJ et al. Jama 2005
5
Foetal Analgesia Anaesthetic Effects on the Foetus

• Neural development y Teratogencity
• Peripheral nerve receptors 7 – 20 weeks y Volatile anaesthetics

y Depression of Foetal CVS
• Spinothalamic tract 16 – 20 weeks
y Intravenous agents (↓ HRV)
• Thalamocortical fibres 17 – 24 weeks
y Neurodevelopmental consequences
• Ways of providing analgesia
y Neuro apoptosis
• Transplacental y ↓ spatial recognition
• Direct IV/IM y Impaired memory
• Intra amniotic y Learning problems
Conclusion EXIT vs CS
EXIT CS
• Remember maternal safety
Uterine tone Maximal Minimal relaxation
• Communication is vital relaxation
Preferred GA Regional
g
• Medical social ethical legal question anesthesia
Anesthesia Deep Minimal to avoid
• Greater use of foetoscopic – procedures plane neonatal depression
PROCEED WITH CAUTION ---- & ENTHUSIASM Amnio infusion Required Not required
Number of Two One
Anethetists

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Prof. A. K.

Prof. A. K. Sethi’s EORCAPS-2015 Prof. A. K. Sethi’s EORCAPS-2015

Prof. A. K. Sethi’s EORCAPS-2015 Prof. A. K. Sethi’s EORCAPS-2015

Prof. A. K. Sethi’s EORCAPS-2015 Prof. A. K. Sethi’s EORCAPS-2015

Prof. A. K. Sethi’s EORCAPS-2015 Prof. A. K. Sethi’s EORCAPS-2015

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Viva Voce –How To Describe

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Low flow system High flow system

• Total gas flow is less than patient’s inspiratory flow rate • Total gas flow is more than patient’s inspiratory flow rate

• Variable performance (any exceptions?) • Usually fixed performance

• Factors that determine Fio2? • Fixed Fio2 delievered

Prof. A. K. Sethi’s EORCAPS-2015 Prof. A. K. Sethi’s EORCAPS-2015

Nasopharyngeal Oxygen Catheter

Prof. A. K. Sethi’s EORCAPS-2015 Prof. A. K. Sethi’s EORCAPS-2015

Nasopharyngeal Oxygen Catheter Nasopharyngeal Oxygen Catheter

Prof. A. K. Sethi’s EORCAPS-2015 Prof. A. K. Sethi’s EORCAPS-2015

Nasopharyngeal Oxygen Catheter

Prof. A. K. Sethi’s EORCAPS-2015 Prof. A. K. Sethi’s EORCAPS-2015

Nasal cannulae,Binasal cannula,Nasal prongs

Nasal cannulae, Binasal cannula, • No capacity

Prof. A. K. Sethi’s EORCAPS-2015 Prof. A. K. Sethi’s EORCAPS-2015

Nasal cannulae,Binasal cannula,Nasal prongs Nasal cannulae,Binasal cannula,Nasal prongs

2 ? beyond 0.4(40%)

Prof. A. K. Sethi’s EORCAPS-2015 Prof. A. K. Sethi’s EORCAPS-2015

Nasal cannulae,Binasal cannula,Nasal prongs

Fio2 increases by 4% for every 1 litre increase in flow rate