Guideline for general anaesthesia for caesarean section

Transcription

1 Guideline for general anaesthesia for caesarean section Full Title of Guideline: Author (include and role): Division & Speciality: Version: 1 Ratified by: Scope (Target audience, state if Trust wide): Review date (when this version goes out of date): Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis): Changes from previous version (not applicable if this is a new guideline, enter below if extensive): Summary of evidence base this Guideline for general anaesthesia for caesarean section Dr Rachel Lawton, Consultant Anaesthetist Anaesthesia, Clinical support Anaesthetists 31/03/2023 Includes patients having caesarean section N/A Nap4, NAP5 and literature search regarding anaesthesia for caesarean section guideline has been created from: This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date or outside of the Trust. Page 1 of 8

2 Anaesthesia for caesarean section general anaesthesia General anaesthesia for caesarean section may be used for emergency caesarean, immediate threat to life of mother or baby, elective caesarean, regional not possible or patient request, or due to failure of regional anaesthesia, either before skin incision or during the procedure. Pre-operative assessment Focused history and examination with particular attention to the airway 1. Also pre-eclampsia, risk of bleeding, current volaemic status and obesity. If any anticipated difficulty, summon help immediately. Intrauterine fetal resuscitation if necessary 2. Preparation for GA skilled airway assistant (ODP/nurse) consider sodium citrate 3,4 30ml 0.3 Molar IV access 16 or 14G, check patent with free flowing drip Patient position 15 o left lateral tilt, optimise head and neck position ( sniffing the morning air or Oxford HELP, especially if raised BMI 5 ) Full monitoring as per AAGBI guidelines Suction Airway plan discuss with ODP WHO checklist whilst preoxygenating Consider cell salvage Preoxygenation Tight fitting facemask and high flow oxygen 10-15l/min Preoxygenate to Et O 2 > Consider nasal oxygenation(5 L/min increased to 15 L/min post induction) 7 8 or THRIVE 9 (only if experienced in use) Have a low threshold for gentle bag-mask ventilation Cricoid Recommended initial 10N force then increase to 30N Adjust or remove if airway difficulty Page 2 of 8

3 Induction Propofol 10 (if more familiar with it as an induction agent) or Thiopentone 5-7mg/kg. High risk of awareness so ensure adequate dose and consider further dose if difficult intubation (may need reduced dose if cardiovascularly unstable). 11 Rocuronium 1-1.2mg/kg IBW max 100mg (if using for suspected difficult airway or high BMI ensure 16mg/kg dose of sugammadex available for immediate reversal - Appendix A) 12,13 or Suxamethonium 1.5mg/kg Consider opioid (essential if preeclampsia or CVS disease) e.g. 1-2mg alfentanil. Inform neonates if given Intubation Make first attempt the best attempt position, anaesthesia, relaxation, laryngoscope COETT Failed intubation call for help, follow OAA/DAS guidelines 14 Maintenance Oxygen to maintain sats >95% Sevoflurane/isoflurane consider overpressure initially as high risk of awareness, then decrease after cord clamping and opioid administration. Volatiles cause decrease in uterine tone. Consider N 2 O, as allows anaesthesia with decreased use of volatile. (up to 67% N 2 O) Antibiotics should be given as per NUH antibiotic guidelines (but after induction as risk drug errors and lack of time) Vasopressors give mcg phenylephrine boluses if needed (ensure hypotension not due to bleeding) Muscle relaxant may need further doses of rocuronium during surgery Analgesia 1g paracetamol iv, morphine 10-15mg, consider TAP blocks or wound infiltration of local anaesthetic by surgeon, consider PR diclofenac 100mg if consented and no contraindication Uterotonics give 5 units oxytocin by slow iv infusion after cord clamping then oxytocin infusion as per NUH guidelines Fluids give 1000ml Hartmanns via fluid warmer, give further fluid as per clinical need, consider blood if blood loss Antiemetics give ondansetron 4mg after cord clamping Page 3 of 8

4 Document whole anaesthetic including reason for GA and timings Extubation Reversal Train of four should be monitored and appropriate reversal given. Consider sugammadex for reversal of rocuronium if any airway concerns or obese. 15. (Appendix B 16 ) Extubate awake and sitting (or in left lateral) High risk of regurgitation, airway obstruction and hypoventilation so extubate fully awake and fully reversed with good oxygen saturations and tidal volumes in head up position. 17,18 Postoperative Care Analgesia Oramorph prn, regular paracetamol +/- regular ibuprofen QDS (as per clinical picture) as first line. Consider PCA if operation more extensive than usual or unable to take medication orally. Antiemetics prescribe prn Enoxaparin prescribe 4 hours after end of operation, or removal of epidural, at nearest drug round ERAS is patient suitable for enhanced recovery?(see ERAS checklist) Where? The patient must meet the recovery criteria for transfer of patient out of recovery to the postnatal wards. 19 If there are any concerns about the clinical condition of the patient then they should be transferred to labour ward or considered for CCU. Review all patients should be reviewed when fully awake. If there are any concerns about possible intraoperative awareness then the consultant in charge should be informed, the patient should be debriefed and follow up arranged as per the NAP5: Anaesthesia Awareness Pathway 20. Page 4 of 8

5 APPENDIX A Obstetric Sugammadex Dosing Guide Emergency reversal following RSI Weight Dose to be given Number of large 5ml vials <60kg 1000mg kg 1500mg kg 2000mg 4 >125kg 2500mg 5 Sugammadex can also be given for routine reversal of rocuronium-induced neuromuscular blockade. Depth of neuromuscular blockade Dose Shallow Train of four count of 2 2mg/kg Deep No response to train of four but post-tetanic count of 1-2 4mg/kg Page 5 of 8

6 APPENDIX B Qualitative PNS Quantitative PNS PTC 0-15 PTC 0-15 WAIT (until TOF count 4) TOF Count TOF Count 1 WAIT 1 or 2 or 2 TOF Count 3 or 4 TOF Count 4 with fade TOF Count 4 No fade TOF Count 3 or 4 TOF ratio <40% TOF ratio 40-90% TOF ratio >90% NEO 50mcg/kg * NEO 50mcg/kg* NEO 30mcg/kg** NO REVERSAL WAIT or Sug 2-4 mg/kg WAIT or Sug 2mg/kg (max 1 200mg vial) USE NEO 50mcg/kg* (or Sug 2mg/kg) USE NEO 50mcg/kg* (or Sug 2mg/kg) USE NEO 30mcg/kg **(or Sug 2mg/kg) NO REVERSAL * Time from Neostigmine administration to extubation allow 20 minutes ** Time from Neostigmine administration to extubation allow minutes Sugammadex is 150 times more expensive than neostigmine so use as per NUH Sugammadex guideline Page 6 of 8

7 References 1 Quinn AC, Milne D, Columb M, Gorton H, Knight M. Failed tracheal intubation in obstetric anaesthesia: 2 yr national case-control study in the UK. British Journal of Anaesthesia 2013; 110: Thurlow JA, Kinsella SM. Intrauterine resuscitation: active management of fetal distress. International Journal of Obstetric Anesthesia 2002; 11: Schneck H, Scheller M. Acid aspiration prophylaxis and caesarean section. Current Opinion in Anesthesiology 2000; 13: Paranjothy S, Griffiths JD, Broughton HK, Gyte GML, Brown HC, Thomas J. Interventions at caesarean section for reducing the risk of aspiration pneumonitis. International Journal of Obstetric Anesthesia 2011; 20: Collins JS, Lemmens HJ, Brodsky JB, Brock-Utne JG, Levitan RM. Laryngoscopy and morbid obesity: a comparison of the sniff and ramped positions. Obesity Surgery 2004; 14: Russell EC, Wrench I, Feast M, Mohammed F. Pre-oxygenation in pregnancy: the effect of fresh gas flow rates within a circle breathing system. Anaesthesia 2008; 63: Wimalasena Y, Burns B, Reid C, Ware S, Habig K. Apneic oxy- genation was associated with decreased desaturation rates during rapid sequence intubation by an Australian helicopter emergency medicine service. Ann Emerg Med 2015; 65: Levitan RM. NO DESAT! Nasal Oxygen During Efforts Securing A Tube Patel A and Nouraei S. Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE): a physiological method of increasing apnoea time in patients with difficult airways. Anaesth 2015, 70(3): Lucas DN, Yentis SM. Unsettled weather and the end for thiopental? Obstetric general anaesthesia after the NAP5 and MBRRACE-UK reports. Anaesthesia 2015; 70: NAP5 5th National Audit Project of The Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland, Chapter 16 AAGA in obstetric anaesthesia 12 Girard T. Pro: rocuronium should replace succinylcholine for rapid sequence induction. European Journal of Anaesthesiology 2013; 30: Sorensen MK, Bretlau C, Gatke MR, Sorensen AM, Rasmussen LS. Rapid sequence induction and intubation with rocuronium-sugammadex compared with succinylcholine: a randomized trial. British Journal of Anaesthesia2012; 108: Mushambi, M. C., Kinsella, S. M., Popat, M., Swales, H., Ramaswamy, K. K., Winton, A. L. and Quinn, A. C. (2015), Obstetric Anaesthetists' Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics. Anaesthesia, 70: doi: /anae Page 7 of 8

8 15 Royal College of Anaesthetists and Difficult Airway Society. Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society (NAP4). Major complications of airway management in the UK. Report and findings, Rodney, G., Raju, P. K. B. C. and Ball, D. R. (2015), Not just monitoring; a strategy for managing neuromuscular blockade. Anaesthesia, 70: McDonnell NJ, Paech MJ, Clavisi OM, Scott KL, ANZCA Trials Group. Difficult and failed intubation in obstetric anaesthesia: an observational study of airway management and complications associated with general anaesthesia for caesarean section. International Journal of Obstetric Anesthesia 2008; 17: Popat M, Mitchell V, Dravid R, Patel A, Swampillai C, Higgs A. Difficult Airway Society Guidelines for the management of tracheal extubation. Anaesthesia 2012; 67: NUH Obstetric recovery guideline nity/1739.pdf 20 NAP5: Anaesthesia Awareness Pathway Anaesthetia-Awareness-Pathway Page 8 of 8