Update Update on Anaesthesia for c-section Dr Kerry Litchfield Consultant Anaesthetist Princess Royal Maternity Glasgow, Scotland

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1 Update Update on Anaesthesia for c-section Dr Kerry Litchfield Consultant Anaesthetist Princess Royal Maternity Glasgow, Scotland Caesarean section is the most common surgical procedure in the world 1 in 5 women worldwide Increasing according to all health stats 1

2 Deliveries NHS England and Wales decreasing [646,904 in ] Increasing CS rate 26.2% [166,081] The category 4 Previous caesarean section Malpositions(Breech) Placenta praevia or morbidly adherent placenta Multiple pregnancy Maternal choice Planned delivery 39 weeks gestation Maternal choice Expectations The gentle c-section Enhanced recovery 2

3 Woman who are recovering well following caesarean section should be offered early discharge (after 24 hours) from hospital Guideline Caesarean Section 14 elements Preoperative Education Perioperative Care Bundle 14 elements Caesarean delivery Preparation class Updated information Leaflet Patient discharge criteria checklist Early oral nutrition IV fluids down Early mobilisation Catheter out ASAP 3

4 ERAS bundle compliance and length of stay LOS by Scottish hospitals Anaesthesia for CS SSS, CSE, epidural and general anaesthetic LA and long acting neuraxial opiates 4

5 Regional anaesthesia Safe and preferred Widely used indeveloped world Cat 4 RA >95% Pain requiring treatment <5% RA to GA conversion rate <1% Cochrane review RA vs GA no added benefit for neonate CSE vs single shot spinal Risk vs benefits Institutional preference NAP complications for CSE Standard LA vs short acting IT opiate dosing Other adjuncts Additional techniques for post op analgesia LA LA and long acting opiate Common practice hyperbaric bupivacaine 10-15mg ED mg with opiates Duration of 90 mins surgical time Looking for shorter acting...no u-catheter and earlier mobilisation 2-Chloroprocaine Hyperbaric Prilocaine 5

6 Additives Opiates... Very familiar Reduced doses to prevent SE Respiratory depression Combinations... New drugs... Dexmetomidine Clonidine IT opioids Current UK practice TAP survey Other surveys? ERAS stuff Rollins Ferns: survey 6

7 Depodur Pruritus 40-90% N&V 20-30% Respiratory depression 1: * [L Tsen] ITM 13% mild 4% severe DepDur 10mg vs Epi Morphine 4mg Limited use Epidural or CSE only Resp depression Side effects Cost Familiarity LA interaction IT Adjuncts Ketamine: small doses, opiate sparing, no increased SE Dexmedetomidine: opiate sparing, sedation without respiratory depression, prolongs motor block Clonidine IT Clonidine Prolongs sensory and motor block Sedation No hypotension APGARS unchanged Heesen M et all. Acta Anaesthesiol Scand 2015; 59 (4);: Nair AS et al. J Obstet Anaesth Crit Care 7

8 Patient preference for outcomes associated with CS Treatment of hypotension Maintain SAP >90% of baseline Alpha agonists are best Prophylactic phenylephrine infusion Lateral tilt and co-loading Use heart rate as surrogate for CO Less hypotension preeclampsia and EMCS Individualised treatment in cardiac 8

9 Nausea and vomiting Position matters? Cochrane review 2012 Prophylaxis advised Risk factors Ondansetron*, droperidol, cyclizine Corticosteroids Risk stratify and use local hospital policy Different to treatment... Surgical antibiotic prophylaxis Hold the oxytocin...for a minute Broad spectrum Pre-incision Larger doses >100kgs Repeat dosing: PPH* and longer surgery* Easy to miss* 9

10 Natural or gentle c section Mother and baby centred Improves STS, feeding, bonding Simple but requires active change by whole team Planning monitoring, IV access, no oxygen Fetal and maternal well being still paramount 1gr TXA reduces bleeding Give it early and repeat NO 1:1:1 transfusion ratios 10

11 Mean pain scores 1 st 24hrs post CS and SVD 11

12 Impact on daily activities Reduces chronic persistent CS pain Post partum depression Sng BL, et al. Anaesth Intens Care 2009 Kainu JP et al. Int J Obstet Anesth 2010 Post CS analgesia options Local experience Resources Nursing support Familiarity with techniques Original anaesthetic technique used Multimodal Oral 12

13 Opioids post CS we do not know the safest and most effective analgesic regimen to use after obstetric procedures such as caesarean section Codeine, Dihydrocodeine, Oxycodone Oral morphine preparations Sustained release Delayed release And the others Oral best RCT PCA morphine vs oral timed oral paracetamol/ oxycodone Oral opioids traditionally step-down Less pain, less N&V, less sedation Is oral best? YES Sustained release opioids Morphine sustained release [MST], Oxycontin Less yo-yo?beneficial for breast feeding Increase satisfaction Reduce workload? c_section. Davis K. Am J Obs Gynecol

14 Other opioids Morphine sparing... Minimal respiratory depression Sedation, confusion, interaction 5HT 3 Peripheral Nerve Blocks Blocking peripheral nerves with LA reduces opioid consumption Transversus abdominus plane (TAP) blocks Ilioinguinal/ illiohypogastric NB s LA infiltration Wound catheters Newer quadratus lumborum Kelly S, Malhotra R. Comparative Effectiveness Research 2011 TAP Evidence Opioid sparing Better than placebo IT morphine superior Limited duration unless catheter inserted Routine vs. selected use Kelly S, Malhotra R. Comparative Effectiveness Research 2011 Kanazi GE et al. Anesth Analg

15 LA in the wound Wound catheters opioid sparing, reduced pain scores Longer theatre time Cost offset by less use post op analgesia Long acting LA? 15

16 RSI with Cricoid since 1961 All change. Awareness and the difficult airway From: The future of general anaesthesia in obstetrics BJA Educ. 2016;17(3): doi: /bjaed/mkw046 BJA Educ The Author Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please 16

17 17

18 Roc rocks, I ll miss you sux THRIVE: a solution to the difficult intubation on labour ward? Transnasal humidified rapid-insufflation ventilatory exchange A solution for maintaining oxygenation during intubation? Optiflow system supplies flow rates of 70 litres per minute of humidified oxygen. Prolongs apnoea time on average by 17 minutes. 18

19 Questions 19

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