Presentation is loading. Please wait.

Presentation is loading. Please wait.

AMBULATORY ANESTHESIA AND OBSTETRIC ANESTHESIA Berrin Günaydın, MD, PhD Gazi University Faculty of Medicine Department of Anesthesiology Obstetric Anesthesia.

Similar presentations


Presentation on theme: "AMBULATORY ANESTHESIA AND OBSTETRIC ANESTHESIA Berrin Günaydın, MD, PhD Gazi University Faculty of Medicine Department of Anesthesiology Obstetric Anesthesia."— Presentation transcript:

1 AMBULATORY ANESTHESIA AND OBSTETRIC ANESTHESIA Berrin Günaydın, MD, PhD Gazi University Faculty of Medicine Department of Anesthesiology Obstetric Anesthesia Ankara - Turkey

2 GAZI UNIVERSITY FACULTY OF MEDICINE

3 Objectives  Definition of ambulatory anesthesia  Preoperative Evaluation  History taking  Physical examination  Fasting & medications  Laboratory screening  Premedication  Monitorization  Anesthesia choices  Postoperative Care for obstetric procedures done on ambulatory basis

4 Definition  Ambulatory (outpatient) surgery  Basic advantages Economic savings Economic savings Earlier ambulation Earlier ambulation Lessened risk of nosocomial infections Lessened risk of nosocomial infections  Anesthesia for ambulatory surgery Patients return home within 24 hours of an operative procedure Patients return home within 24 hours of an operative procedure

5 Procedures done on ambulatory basis  Evacuation of incomplete miscarriage  Surgical treatment of tubal ectopic pregnancy  Cervical cerclage  External cephalic version  Hysterosalpingography (HSG) - Hysteroscopy  Assisted reproductive technologies - procedures Transvaginal ultrasound guided oocyte retrieval (TUGOR) Transvaginal ultrasound guided oocyte retrieval (TUGOR)

6 Preoperative Evaluation Preoperative Evaluation History taking  Questionnaires for screening & detecting common medical problems  Maternal death & anesthetic history  Relevant obstetric history

7 Preoperative Evaluation P Preoperative Evaluation Physical examination  Measurement of vital signs (pulse, blood pressure, respiratory rate, temperature)  Airway, heart & lung examination  Back examination (when neuraxial anesthesia is planned)

8 Preoperative Evaluation Preoperative Evaluation Fasting & Chronic medications  Clear fluids  Modest amount is allowed up to 2 h prior to induction of anesthesia Solids  should be avoided 6-8 h depending on the type of ingestion (e.g.fat) Patients should bring their own medications  Antihypertensives should be taken  Oral hypoglycaemics should be omitted White P. Ambulatory anesthesia advances into the new ilennium. Anesth Analg 2000 Hawkins. ASA Practice Guidelines for Obstetric Anesthesia IJOA 2007

9 Preoperative Evaluation Preoperative Evaluation Laboratory screening  Platelet count Maternal history Maternal history Physical examination Physical examination Clinical signs Clinical signs  Blood type & cross-match Maternal history Maternal history Anticipated hemorrhage Anticipated hemorrhage Institutional policies Institutional policies ASA Task Force on Obstetric Anesthesia Practice Guidelines Anesthesiology 2007 AgeMen ♂Women ♀ <40NonePregnancy test 40-49ECGHtc Pregnancy test 50-64ECGHb/ Htc, ECG 65-74Hb/ Htc ECG, BUN Glucose Hb/ Htc ECG, BUN Glucose >75Hb/ Htc ECG, BUN Chest radiograph Hb/ Htc ECG, BUN Chest radiograph White & Freire. Ambulatory (outpatient) Anesthesia. Anesthesia 2005

10 Premedication  Benzodiazepines  Benzodiazepines if indicated Small dose of midazolam IV (1-3 mg) Small dose of midazolam IV (1-3 mg)  Alpha-2 agonists Clonidine ( PO) Clonidine ( PO) Dexmedetomidine (50-70 µg IM or 50 µg IV) Dexmedetomidine (50-70 µg IM or 50 µg IV)  Aspiration prophylaxis (for diabetics & morbid obeses) H 2 -receptor antagonists (ranitidine) H 2 -receptor antagonists (ranitidine) Nonparticulate antacids (sodium citrate) Nonparticulate antacids (sodium citrate) Gastrokinetic agents (metoclopramide) Gastrokinetic agents (metoclopramide) Hawkins JL. ASA Practice Guidelines for Obstetric Anesthesia. IJOA 2007 White P. Ambulatory Anesthesia. Anesthesia 2005

11 Monitorization  Heart rate (maternal & fetal) and ECG  Blood pressure (noninvasive)  Pulse oximetry (SpO 2 )  Capnometry (ETCO 2 )  BIS ASA Task Force on Obstetric Anesthesia Prcatice Guidelines Anesthesiology 2007 White P. Ambulatory anesthesia advances into the new ilennium. Anesth Analg 2000

12 Anesthesia Techniques  General Anesthesia  Regional anesthesia  Monitored Anesthesia Care (MAC) Borkowski. Cleveland Clin J Med 2006

13 General Anesthesia Induction agents Propofol ( mg/kg) is used widely (easy +quick recovery, clear head, lacks PONV) N 2 O-O 2 Sevoflurane (8% in 50% N 2 O-O 2 ) non-irritant to airway, rapid induction, minimal side- effects, but more PONV Borkowski. Cleveland Clin J Med 2006 White. Anesth Analg 2000 Russell R. Summer Update on Obstetric Anesthesia, 2006 Levy D. Three day course on obstetric anesthesia, 2007 Thiopentone (3-6 mg/kg) Thiopentone (3-6 mg/kg) Midazolam ( mg/kg) Etomidate ( mg/kg) Ketamine ( mg/kg)

14 General Anesthesia Maintenance  TIVA (propofol & remifentanil or alfentanil)-TCI (BIS < 60) Borkowski. Cleveland Clin J Med 2006 White. Anesth Analg 2000 Russell R. Summer Update on Obstetric Anesthesia, 2006 Levy D. Three day course on obstetric anesthesia, 2007

15

16 General Anesthesia Maintenance  Isoflurane  Sevoflurane  Desflurane  ? N 2 O

17 General Anesthesia  Muscle relaxants (short and intermediate acting drugs) Mivacurium Rocuronium Cisatracurium  Airway Face mask LMA Endotracheal intubation Borkowski. Cleveland Clin J Med 2006 White. Anesth Analg 2000 Russell R. Summer Update on Obstetric Anesthesia, 2006 Levy D. Three day course on obstetric anesthesia, 2007

18 General Anesthesia Reversal agents  Benzodiazepin antagonist (flumazenil)  Antichoinesterase drugs  Sugammadex (rocuronium antagonist)  Opioid antagonists (naloxone)

19 Spinal anesthesia  Advantages Simple-quick procedure Simple-quick procedure Short turnover time Short turnover time Patients are alert Patients are alert Less nausea-vomiting Less nausea-vomiting  Disadvantages Incidence of headache and radiating back pain Slow return of motor power Difficulty in micturition might delay discharge Rare but significant advers events (neurologic injury, infection) Chakravorty et al. Spinal anesthesia in the ambulatory setting. Ind J Anaesth 2003 Mordecai & Brull Curr Opin Anaesthesiol 2005, Korhonen. Curr Opin Anaesthesiol 2006

20 Spinal anesthesia  Prevention against disadvantages 27 G Whitacre spinal needle is associated with lower incidence of PDPH Older (chloroprocaine) & newer (ropivacaine & levobupivacaine) local anesthetics in conjuction with adjuvant intrathecal medications (opioids, vasopressors) help fast resolution of motor function and ability to micturate Mordecai & Brull Curr Opin Anaesthesiol 2005 Korhonen. Curr Opin Anaesthesiol 2006

21 Neuraxial anesthetics Ideal neuraxial anesthetic  Adaequate analgesia and duration  Short recovery  Minimal side effects  7.5 mg of spinal hyperbaric bupivacaine is with low incidence of TNS  Epidural with 2-chloroprocaine is preferable to spinal anesthesia

22 Conscious (MAC) vs Unconscious Sedation ConsciousUnconscious MoodAlert-cooperativeNo cooperation Protective reflexes Active-intactObtunded Vital signs StableLabile AnalgesiaRegional/local analgesia Central analgesia Recovery room stay Not prolongedProlonged/admission Complication risk LowHigh Postop.complicationInfrquentFrequent Mentally incompetent patients Not suitableSuitable

23 Drugs used for MAC Drug Loading dose (µg/kg) Maintenance (µg/kg/min) Alfentanil Fentanil Sufentanil Remifentanil Ketamine Propofol Midazolam

24 Postoperative Care Pain Multimodal approach  NSAID and/or nonopioid analgesics (local anesthetics, acetaminophen, proparacetamol)  COX 2 inhibitors (celecoxib)  LA wound infiltration at the time of surgery at the time of surgery patient controlled elastomeric pump patient controlled elastomeric pump  Neuraxial opioids White P. Anesth Analg 2000 Carvalho B. Summer Update on Obstetric Anesthesia, 2006

25 Postoperative Care PONV  Prophylactic antiemetics  Multimodal treatment regimen Butyrophenones Butyrophenones Phenotiazines Phenotiazines Gastrokinetic drugs Gastrokinetic drugs Anticholinergics Anticholinergics Antihistamines Antihistamines Serotonin antagonists (4-8 mg IV) Serotonin antagonists (4-8 mg IV) NK-1 antagonists NK-1 antagonists Dexametazone (4-8 mg IV) Dexametazone (4-8 mg IV) Acupuncture (P6 and others) Acupuncture (P6 and others) White P. Anesth Analg 2000 White & Freire. Anesthesia 2005

26 Discharge Criteria  Aldrete Activity Respiration Circulation Conscious level Color of the skin  Postanesthesia Discharge Scoring System (PDSS) Vital signs Activity level Nausea &vomiting Pain Surgical bleeding Chakravorty et al. Spinal anesthesia in the ambulatory setting. Ind J Anaesth 2003

27 Surgical treatment of miscarriage (vacuum aspiration or D&C) Anesthetic options  Target-controlled intravenous sedation-analgesia with propofol & remifentanil  Paracervical block (PCB)  Sedation + PCB (MAC)  Short acting iv induction or inhalation agent (sevoflurane) with short acting opioid/N 2 O mask ventilation or LMA Nanda K et al. Cochrane Data Base Syst Rev 2006 Fassoulaki et al. No change in plasma endorphine and melatonine levels after sevoflurane anesthesia. JCA 2007

28 Hysterosalpingography (HSG)  Any analgesics (oral or topical) vs placebo or no treatment  Topical analgesics vs placebo or no treatment  Opioid vs non-opioid analgesics  Topical analgesics vs oral analgesics  Intaruterine local anesthetic vs PCB Ahmad G et al. Cochrane Data Base Syst Rev 2007

29 Hysteroscopy  Local  MAC  General  Regional Spinal anesthesia to T7 level was achieved using 3 mL of 2% isobaric lidocaine (60 mg) with 100 µ epinephrine *TNS was associated with single shot spinal anesthesia Lotfallah et al. J Reprod Med Farid et al. JCA 2001

30 Tubal ectopic pregnancy  Treatment options requiring anesthesia are salpingectomy or salpingostomy either laparoscopically or open surgery  General anesthesia Induction with short acting iv agent (usually propofol) Maintenance with TIVA or sevo/desflurane in N 2 O/opioid Hajenius PJ et al. Cochrane Data Base Syst Rev 2007

31 Cervical Cerclage  Prevents miscarriage or premature delivery due to cervical incompetence in 85-90% of cases and requires anesthesia  Regional usually spinal anesthesia epidural  General anesthesia

32 Cervical Cerclage Neuraxial anesthesia (spinal or epidural) Use of low-dose epidural Use of low-dose epidural 0.125% bupivacaine with epinephrine & fentanyl Spinal anesthesia Spinal anesthesia lidocaine 30 mg or bupivacaine 5.25 mg both with fentanyl 20 µg have been used successfully for cervical cerclage Tsen. What’s new and novel in obstetric anesthesia?IJOA 2005 Schumann & Rafique. Low dose epidural anesthesia for cervical cerclage. CJA 2003; 50:424

33 External Cephalic Version  Spinal analgesia with 7.5 mg bupivacaine (n=36) vs with no analgesia (n=34)  Success rate Spinal (66.7%) vs no analgesia (32.4%) (p=0.0004)  Spinal analgesia significantly increases success rate of external cephalic version among parturients at term which allows possible normal vaginal delivery Weiniger et al. External cephalic version for breech presentation with or without spinal analgesia in nulliparous women at term: a randomized controlled trial. Obstet Gynecol. 2007;110:

34 TUGOR  General Inhalational anesthesia TIVA  Regional blocks Spinal Epidural PCB  Conscious sedation (MAC) PCB + IV remifentanil Tsen. Int Anaesthesiol Clin 2007 Gunaydin et al.J Opioid Manag 2007

35

36

37 CONCLUSIONS  Ambulatory surgery aims the best patient care possible at the reasonable cost, ambulatory anesthesia must meet these requirements  Issues that prolong stay in PACU primarily Pain & PONV after general anesthesia or MAC Unresolved blocks & urinary retention after neuraxial blocks should be managed by choosing appropriate pharmacologic agents (mainly short acting agents with less side effects)

38 Terimah Kasih


Download ppt "AMBULATORY ANESTHESIA AND OBSTETRIC ANESTHESIA Berrin Günaydın, MD, PhD Gazi University Faculty of Medicine Department of Anesthesiology Obstetric Anesthesia."

Similar presentations


Ads by Google