1. Anesthesia for cesarean section
Tom Archer, MD, MBA
UCSD Anesthesia

2. A unique psychosocial surgery

3. Outline C-section – a unique psychosocial surgery
How the OB anesthetist should behave.
Evolution of techniques
Neuraxial block physiology and management
GA physiology and management.
Management of common problems

4. C-section – a unique psychosocial surgery
Psychological / interpersonal aspects
Unique surgery, happy event gone awry.
Strike a balance between “happy event” and “risky surgery”.
Most patients are awake– and want to be.
Team approach (patient, family, nursing, OB, anesthesia)
Support person present in OR.
Family members in the labor room (face them).
Discretion about medical info– JW, drug use, previous abortions, etc.

5. Anticipate and be available
Know every patient on the floor. Introduce yourself early.
Be accessible to OBs and nurses.
Get informed early about potential problems (airway, obesity, coagulopathy JW, congenital heart disease)
Remember the basics (IV access, airway)

6. Anticipate and be available
We need a certain knowledge of OB to know what is going to happen. Try to think one or two steps ahead.
“Placenta isn’t out yet in room 7”
“The lady in 6 has a pretty bad tear.”
“Strip review in 3, please.”
“We can’t get an IV on the lady in 4.”
“Can you give us a whiff of anesthesia in 8? We don’t need much.”

7. Evolution of technique
Last 30 years: decreasing use of GA, now about 5% of cases. Was 20-30% in 70’s at UCSD.
Epidural was “all the rage” in 70’s and 80’s.
SAB (or epidural) are now preferred anesthetics.

8. Anesthesia for C/S— basic interventions
Happy event (sort of)
Gastric acid neutralization
Left uterine displacement
Fluid loading
Supplemental oxygen
Support person in room (regional only)

9. Anesthesia for C/S— Complications
Sympathectomy / hypotension
Nausea
Bradycardia
High spinal / respiratory paralysis
Aspiration
Difficult intubation
Local anesthetic toxicity
Failed regional anesthesia
Persistent neurological deficit

10. C/S red flags
“I don’t feel so good…I think I’m going to throw up…” (Hypotension until proven otherwise).
“Doc, I feel like I’m not getting enough to breathe…”
The “floppy arm sign.”
The “shaking head sign.”

11. Spinal-- advantages Uniquely appropriate in C/S (happy event).
Really amazing when you think about it.
Awake and smiling.
Arms and hands are normal.
Major surgery inside the abdomen.
Quick, solid, simple, reliable, pretty safe.
LA + narcotic gives great block.
Can give long-acting analgesia (intrathecal MS)

12. Regional anesthesia for c/s in Turkey (SOAP outreach)

13. Spinal-- disadvantages
Fixed duration (unless continuous spinal).
Rapid onset of sympathectomy or high block.
Small chance of PDPH.

14. SAB– absolute contraindications
Patient refusal
Uncorrected hypovolemia
Clinical coagulopathy
Infection at site of injection

15. SAB– obsolete contraindication
Severe pre-eclampsia—
Not associated with increased chance of severe hypotension with neuraxial block.
Show me the literature if you disagree.

16. SAB– relative contraindications
Spinal cord, LE nerve disease.
Spinal deformity, instrumentation
Back problems / fear of block
Laboratory coagulopathy
Bacteremia

17. SAB– relative contraindications
Potential for hypovolemia
Stenotic cardiac valve lesions (?)
Pulmonary hypertension (?)

18. Basic C/S monitoring Talk with the patient!
Does her face display anxiety?
“Take a deep breath!”
Have her squeeze your fingers
What is her hand temperature?
Are the hand veins dilated?
“Do your hands feel normal or do they feel a little numb?”

19. SAB / epidural cause sympathectomy
Dilation of capacitance vessels (70-80% of blood volume)
May cause drop in CO
Dilation of resistance arterioles ( mm diameter).
Drop in SVR

20. SAB / epidural cause sympathectomy

21. SAB / epidural cause sympathectomy

22. SAB / epidural cause sympathectomy
rfumsphysiology.pbwiki.com/Characteristics+of...

23. 38 y.o. female, repeat c/s, 420 #, gestational hypertension, continuous spinal: fall in SVR, rise in CO with onset of block. Increased SVR with phenylephrine.

24. When is sympathectomy (low SVR) bad?
BP = CO x SVR
Whenever you can’t increase CO!
Uncorrected hypovolemia
IVC compression
Stenotic valve lesions
Pulmonary hypertension

25. Aortic stenosis at rest
Pulmonary capillaries
LV dilation / hypertrophy
Tricuspid
Aortic stenosis
Mitral
Pulmonic
Aortic stenosis at rest
Cardiac output not sufficient to cause critically high LV intracavitary pressure / LV failure.
Resistance arterioles

26. Pulmonary capillaries (edema)
LV failure / ischemia
Tricuspid
Aortic
Stenosis
Pulmonic
Mitral
Aortic stenosis with SAB: increased cardiac output / arteriolar vasodilation:
Decreased SVR Fall in systemic BP and / or increase in LV intracavitary pressure ischemia or LV failure.
Resistance arterioles– decreased SVR

27. 38 y. o. female, repeat c/s, 420#, continuous SAB
38 y.o. female, repeat c/s, 420#, continuous SAB. Delivery with increased CO at 17, oxytocin 3 U bolus at 18, phenylephrine at 19

28. When is sympathectomy (low SVR) bad?
With bolus of other vasodilator (oxytocin)

29. Oxytocin 10 u bolus

30. Both delivery and oxytocin cause increase in cardiac output.
Delivery of baby
Oxytocin 5U IV push
Phenylephrine bolus for hypotension
C/S under epidural in pt with previous peripartum cardiomyopathy (May 30, 2007)

31. When is sympathectomy (low SVR) bad?
When drop in SVR could exacerbate R > L shunt.
ASD
VSD
PDA

32. Decompensated patient with REAL RL shunt.LA LV
Decreased SVR desaturation Ao PA
Increased pulmonary vascular resistance desaturation RA RV
Decompensated patient with ASD, VSD or PDA-- Decreased SVR or increased pulmonary vascular resistance  increased RL shunt and increased arterial desaturation.

33. 38 y.o. female, repeat c/s, 420 #, gestational hypertension, continuous spinal: fall in SVR, rise in CO with onset of block. Increased SVR with phenylephrine.

34. Compensated patient with POTENTIAL RL shunt.LA LV
High SVR,
Minimal RL shunt Ao PA RA RV
Low pulmonary vascular resistance
Normal, compensated patient with ASD, VSD or PDA-- high SVR and low pulmonary vascular resistance minimal RL shunt.

35. JW with previa / accreta for c-hyst. GA
JW with previa / accreta for c-hyst. GA. Induction at 7, 8, intubation before 9, incision after 9. Note rise in SVR and fall in CO with GA.

36. How to prevent a sympathectomy from being a problem
Keep the SVR up with a vasopressor like phenylephrine.

37. Preventing or treating hypotension from sympathectomy: augment venous return (CO).
Trendelenburg (empty capacitance vessels into central thoracic veins)
LUD (get pressure off vena cava)
Fluid loading (fill capacitance vessels)
Crystalloid
Hetastarch
Arteriolar constrictors (inc SVR)
Ephedrine, phenylephrine
Venous constrictors (inc venous return)

38. Hypotension with SAB or epidural
Pre-load does not prevent reliably.
500 mL hetastarch better than 1500 mL crystalloid.
First symptom is nausea or “I don’t feel so good.”

39. Hypotension Use phenylephrine (neosynephrine) if tachycardia.
Use ephedrine if bradycardia.
Use atropine if severe bradycardia.
Glycopyrolate works slowly.

40.
Sympathectomy

41. Sympathectomy

42. Endoscopic transthoracic sympathectomy
Virtually all patients immediately develop warm, dry hands and leave the hospital the same day as surgery.

43. Hyperhydrosis Rx’d with T3 sympathectomy

44. Horner’s syndrome

45. Horner’s syndrome

46. Bradycardia
With hypotension: High block of “cardioaccelerator fibers” (T1-T5).
Also can be reflex bradycardia with hypertension from phenylephrine

47. Inc SVR and BP with bradycardia from neo 50 mcgm at 4
Inc SVR and BP with bradycardia from neo 50 mcgm at 4. Brady occurs after SVR and BP changes.

48. Left Uterine Displacement (LUD)

49. Colman-Brochu S 2004

51.
Manbit images

52. Chestnut chap. 2

53. www.siumed.edu/~dking2/erg/images/placenta.jpg from Google images

54. )
Normal placental function: fetal and maternal circulations separated by thin membrane (syncytiotrophoblast).
Umbilical artery (UA)
Umbilical vein (UV)
Fetus
“Lakes” of maternal blood
Fetal capillaries in chorionic villi
Precariously oxygenated environment
Mom
Uterine veins
Uterine arteries
Archer TL 2006 unpublished

55. Placenta blood flow (O2 delivery) =
Ohm’s Law of the placenta: O2 delivery = Placental blood flow = (P1 – P2) / R
Aorto-caval compression decreases P1 (“aorto”) and increases P2 (“caval”)
Therefore, aorto-caval compression decreases O2 delivery to fetus.
R = placental resistance (fixed in short term)
P1 = uterine artery pressure
Placenta blood flow (O2 delivery) =
(P1 – P2) / R
P2 = uterine vein pressure
Archer TL 2006

56. General anesthesia-- advantages
Fast
Reliable (if you get the tube in).
Doesn’t cause sympathectomy
Duration is flexible
Patient is not awake (to experience problems).
Can be given despite coagulopathy

57. General anesthesia-- disadvantages
Patient not awake for birth.
Unprotected airway.
Possible “can’t intubate, can’t ventilate” scenario.
Nausea, post-op pain, sore throat.

58. Functional residual capacity (FRC) is our “air tank” for apnea.
from Google images

59. Pregnant Mom has a smaller “air tank”.
Non-pregnant woman

60. GA for C/S— Thorough pre-oxygenation Cricoid pressure
Small tube ( )
RSI
50% N2O until delivery MAC volatile.
60-70% N2O after delivery + midazolam + narcotic.
Small dose non-depolarizing NMB, if needed.

61. General anesthesia-- advantages
SVR is maintained high (no need to increase CO)
Hypovolemia
Stenotic cardiac valve lesion
Pulmonary hypertension
Potential R>L shunt

62. JW with previa / accreta for c-hyst. GA
JW with previa / accreta for c-hyst. GA. Induction at 7, 8, intubation before 9, incision after 9. Note rise in SVR and fall in CO with GA.

63. Managing common problems

64. High block– patient can’t breathe
Move to anesthesia mask and circle system early. Don’t fuss around “assessing” the patient!
Reassure patient, tell them this happens, and tell them you will help them breathe.
You usually don’t have to intubate.
Sometimes patients will panic and shake head back and forth to get the mask off of their face.
Assume accompanying hypotension. Give ephedrine or neo as you reach for the mask.

65. High block– patient can’t breathe
If patient becomes unresponsive, you probably should intubate– BUT VENTILATE FIRST AND DON’T PANIC.
Assistant can give cricoid pressure– but VENTILATE, above all!
May not need relaxant to intubate.
Respiratory paralysis usually does not last long (5-15 minutes).

66. Failed regional anesthesia
Be honest with yourself– recognize failure.
Move on to plan B.

67. Aspiration
16 y.o. WF, “Crystal”, +Hx substance abuse, C/S for failure to progress.
Epidural, patchy block, supplemented with ketamine, fentanyl, diazepam.
I was vigilant with breath sounds (precordial stethoscope era).
Baby OK. Mother OK in PACU at 4PM.

68. Aspiration
Called at home next AM: Pt SOB, transferred to ICU and intubated.
I go to hospital, review nurses’ notes.
Nauseated during the night, got MS several doses. Lying flat during the night.
SOB at 4AM. Aspiration? When? My fault?
Died 10 days later of progressive ARDS, hypoxia.

69. Aspiration Not only during GA! Use “triple Rx” freely (on everybody?)
Beware with
High spinal
Heavy supplementation for bad block
“Never turn your back on a spinal.”

70. “STAT C/S” Often “a flail”. “We’ve got to go. NOW!”
Egos and emotions run high.
Does the patient know what is happening?
Talk to patient. Informed consent.
Don’t endanger the mother to “save” the baby.
Know when and how to say “no” to the OB.
Stay calm.
Cover the basics (H&P, IV access, airway, informed consent, patient asleep before incision.)

71. A stat C/S, once upon a time…
Fetal decels
Rush to the OR
Anesthesiologist is sure he can get the tube in fast
He skips the pre-O2.
He can’t intubate or ventilate
Patient arrests.
Code blue called, staff intubates.
Post op seizures, hypoxic encepalopathy.
Patient recovers after several days.

72. Summary
Regional anesthesia is elegant and uniquely suited to C-section.
GA still has its place, and its dangers.
Early warning, good communications and equanimity under pressure promote good outcomes.

73. The End