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

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
Ambulatory surgery-anesthesia facilities can be hospital based, freestanding or office based.
Primary objective of preop.assessment for the ADULT ambulatory anesthesia is to identfy patients who have concurrent medical problems requiring further diagnostic evaluation or active treatment before surgery. Specific anesthetic concerns (difficult airway orMH susceptibility) or preexisitng medical conditions that may be associated with adverse events include hypertension, obesity, asthma, smoking, and gastroesophageal reflux diseases.

4. Definition Ambulatory (outpatient) surgery Basic advantages
Economic savings
Earlier ambulation
Lessened risk of nosocomial infections
Anesthesia for ambulatory surgery
Patients return home within 24 hours of an operative procedure
Ambulatory surgery-anesthesia facilities can be hospital based, freestanding or office based.
Primary objective of preop.assessment for the ADULT ambulatory anesthesia is to identfy patients who have concurrent medical problems requiring further diagnostic evaluation or active treatment before surgery. Specific anesthetic concerns (difficult airway orMH susceptibility) or preexisitng medical conditions that may be associated with adverse events include hypertension, obesity, asthma, smoking, and gastroesophageal reflux diseases.

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)
Selection of surgical procedures commonly undertaken as day-cases
Gynae: D&C, laparoscopy, VTOP, colposcopy

6. Preoperative Evaluation History taking
Questionnaires for screening & detecting common medical problems
Maternal death & anesthetic history
Relevant obstetric history
Medical history is clearly the most valuable of the 3 primary components of preop.assessment (1. history, p. Exam, laboratory testing).MH susceptible patients can be successfully managed with non-trigering anesthetics under local anesthesia.After uneventful surgery-anesthesia, MH susceptible patients should be observed for at least 4 hours postoperatively and their families should be advised about the signs of MH in addition to the usual postoperative instructions.

7. 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 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
Nil by mouth:NPO. Fasting policies have allowed patients to continue taking chronic medications (up to 30 min before surgery) and avoid uncomfortable symptoms of dehydration, hypoglycemia, and cafeine withdrawal.
White P. Ambulatory anesthesia advances into the new ilennium. Anesth Analg 2000
Hawkins. ASA Practice Guidelines for Obstetric Anesthesia IJOA 2007

9. Preoperative Evaluation Laboratory screening
Platelet count
Maternal history
Physical examination
Clinical signs
Blood type & cross-match
Anticipated hemorrhage
Institutional policies
Age
Men ♂
Women ♀
<40
None
Pregnancy test
40-49
ECG
Htc
50-64
Hb/ Htc, ECG
65-74
Hb/ Htc
ECG, BUN
Glucose
>75
Chest radiograph
Laboratory test recommendations for outpatients under general anesthesia are shown in the table. Patients with chronic diseases like hypertension and diabetes require additional laboratory studies (electrolytes or glucose). Unexplianed Hb < 10 g/dl should undergo further evaluation before elective surgery.
Routine platelet count and blood cross-match are not necessary in the healthy and uncomplicated parturients.
Hemorrhagic complications are anticipated in placenta accreta in a patient with plasenta previa and previous uterine surgery.
White & Freire. Ambulatory (outpatient) Anesthesia. Anesthesia 2005
ASA Task Force on Obstetric Anesthesia Practice Guidelines Anesthesiology 2007

10. Premedication Benzodiazepines if indicated Alpha-2 agonists
Small dose of midazolam IV (1-3 mg)
Alpha-2 agonists
Clonidine ( PO)
Dexmedetomidine (50-70 µg IM or 50 µg IV)
Aspiration prophylaxis (for diabetics & morbid obeses)
H2-receptor antagonists (ranitidine)
Nonparticulate antacids (sodium citrate)
Gastrokinetic agents (metoclopramide)
White P. Ambulatory Anesthesia. Anesthesia 2005
Hawkins JL. ASA Practice Guidelines for Obstetric Anesthesia. IJOA 2007

11. Monitorization Heart rate (maternal & fetal) and ECG
Blood pressure (noninvasive)
Pulse oximetry (SpO2)
Capnometry (ETCO2)
BIS
Use of electroencephalographic bispectral index monitoring can improve maintenance of anesthesia, thereby facilitate the early recovery process. FHR should be monitored by a qualified individual before and after adminstration of neuraxial labor analgesia but continuous monitoring may not be necessary in every clinical setting and may not be possible during initiation of neuraxila anesthesia.
White P. Ambulatory anesthesia advances into the new ilennium. Anesth Analg 2000
ASA Task Force on Obstetric Anesthesia Prcatice Guidelines
Anesthesiology 2007

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

13. General Anesthesia Induction agents
Propofol ( mg/kg) is used widely
(easy +quick recovery, clear head, lacks PONV)
Sevoflurane (8% in 50% N2O-O2)
non-irritant to airway, rapid induction, minimal side-effects, but more PONV
Thiopentone (3-6 mg/kg)
Midazolam ( mg/kg)
Etomidate ( mg/kg)
Ketamine ( mg/kg)
Endtidal vapor concentration>0.75 MAC (+50% N2O)
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

14. General Anesthesia Maintenance
TIVA (propofol & remifentanil or alfentanil)-TCI
(BIS < 60)
Endtidal vapor concentration>0.75 MAC (+50% N2O)
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

16. General Anesthesia Maintenance
Isoflurane
Sevoflurane
Desflurane
? N2O

17. General Anesthesia
Muscle relaxants (short and intermediate acting drugs)
Mivacurium
Rocuronium
Cisatracurium
Airway
Face mask
LMA
Endotracheal intubation
Endtidal vapor concentration>0.75 MAC (+50% N2O)
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 Disadvantages Simple-quick procedure
Short turnover time
Patients are alert
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
Mood
Alert-cooperative
No cooperation
Protective reflexes
Active-intact
Obtunded
Vital signs
Stable
Labile
Analgesia
Regional/local analgesia
Central analgesia
Recovery room stay
Not prolonged
Prolonged/admission
Complication risk
Low
High
Postop.complication
Infrquent
Frequent
Mentally incompetent patients
Not suitable
Suitable

23. Maintenance (µg/kg/min)
Drugs used for MAC
Drug
Loading dose (µg/kg)
Maintenance (µg/kg/min)
Alfentanil
10-25
0.25-1
Fentanil
1-3
Sufentanil
Remifentanil -
Ketamine
10-20
Propofol
10-50
Midazolam
25-100

24. Postoperative Care Pain
Multimodal approach
NSAID and/or nonopioid analgesics (local anesthetics, acetaminophen, proparacetamol)
COX2 inhibitors (celecoxib)
LA wound infiltration
at the time of surgery
patient controlled elastomeric pump
Neuraxial opioids
NSAIDs are effective in relieving the visceral cramping pain. Diclophenac appears particularly efficacious. NSAIDs reduce need for opioid analgesics up to 30% and opioid related effects (nausea, pruritis, respiratory depression, sedation) and may augment analgesic effect of spinal morphine. NSAIDs are generally safe in breastfeeding parturient due to the large molecular size and high protein binding properties of NSAIDs, there is minimal transfer to breastfeeding neonate compared to opioids. However, potential maternal side effects (gastric bleeding, renal dysfunction, delayed wound healing and bleeding due to impaired platelet function) have raised questions about their use andeffects on breatfeeding neonate especially NSAIDs with long half-lives.
When neuraxial block has not been used wound infiltration or ilioinguinal block imprves quality of initial postoperative pain relief.
White P. Anesth Analg 2000
Carvalho B. Summer Update on Obstetric Anesthesia, 2006

25. Postoperative Care PONV
Prophylactic antiemetics
Multimodal treatment regimen
Butyrophenones
Phenotiazines
Gastrokinetic drugs
Anticholinergics
Antihistamines
Serotonin antagonists (4-8 mg IV)
NK-1 antagonists
Dexametazone (4-8 mg IV)
Acupuncture (P6 and others)
NK:Neurokinin
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/N2O mask ventilation or LMA
Termination of pregnancy
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
HSG is a method of testing tubal patency.Various pharmacological strategies are available that may reduce the pain during the procedure.
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
HSG is a method of testing tubal patency.Various pharmacological strategies are available that may reduce the pain during the procedure.
Lotfallah et al. J Reprod Med. 2005
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 N2O/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
Procedure used to temporarily stitch the cervix closed in pregnant women with a history of miscarriage or premature.

32. Cervical Cerclage Neuraxial anesthesia (spinal or epidural)
Use of low-dose epidural
0.125% bupivacaine with epinephrine & fentanyl
Spinal anesthesia
lidocaine 30 mg or bupivacaine 5.25 mg both with fentanyl 20 µg have been used successfully for cervical cerclage
Procedure used to temporarily stitch the cervix closed in pregnant women with a history of miscarriage or premature.
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
Procedure used to temporarily stitch the cervix closed in pregnant women with a history of miscarriage or premature.
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 Regional blocks Conscious sedation (MAC)
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

36. Gunaydin et al.J Opioid Manag 2007

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