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Anesthesiology, V 124 • No 2 270 February 2016

Practice Guidelines for Obstetric Anesthesia An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia and the Society for Obstetric Anesthesia and Perinatology. Anesthesiology, V 124 • No 2 270 February 2016. Purposes of the Guidelines.

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Anesthesiology, V 124 • No 2 270 February 2016

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  1. Practice Guidelines for Obstetric Anesthesia An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia and the Society for Obstetric Anesthesia and Perinatology Anesthesiology, V 124 • No 2 270 February 2016

  2. Purposes of the Guidelines • ⬆︎ quality of anesthetic care • ⬆︎ patient safety • ⬇︎incidence/severity of anesthesia- related complications • ⬆︎ patient satisfaction

  3. Availability and Strength of Evidence Scientific Evidence Level 1: RCTs ⇒ meta-analysis literature Category A Level 2: RCTs RCTs Level 3: single RCT Level 1: comparative statistics Category B Level 2: associative statistics nonrandomized study designs Level 3: descriptive statistics RCTs without pertinent comparison groups Level 4: case reports

  4. Availability and Strength of Evidence Scientific Evidence literature unavailable evidences Insufficient Literature beneficial (B) harmful (H) Evidence direction equivocal (E)

  5. Availability and Strength of Evidence Opinion-based Evidence Category A • Strongly Agree • Agree • Equivocal • Disagree • Strongly Disagree Expert Opinion • survey data • Internet-based comments • letters • editorials Task Force –appointed expert consultants • Strongly Agree • Agree • Equivocal • Disagree • Strongly Disagree Category B Membership Opinion active ASA members Category C Informal Opinion

  6. Guidelines 2

  7. Anesthetic Care for Labor and Vaginal Delivery Dr. Dariush Abtahi • timing of neuraxial analgesia and outcome of labor • neuraxial analgesia and trial of labor after prior cesarean delivery • anesthetic/analgesic techniques

  8. Timing of Neuraxial Analgesia and Outcome of Labor (spontaneous, instrumented, and cesarean delivery) late (cervical dilations> 4-5 cm) early (cervical dilations< 4-5 cm) epidural analgesia 🆚 ? A1-E cervical dilations > 2 cm epidural analgesia cervical dilations < 2 cm ? A3-E 🆚 combined spinal–epidural (CSE) analgesia early (cervical dilations< 4-5 cm) late (cervical dilations> 4-5 cm) ? 🆚 A2-E

  9. Timing of Neuraxial Analgesia and Outcome of Labor • Recommendations: • Provide patients in early labor(< 5cm dilation) the option of neuraxial analgesia. • Offer neuraxial analgesia on an individualized basis regardless of cervical dilation. • Reassure patients that the use of neuraxial analgesia does not increase the incidence of cesarean delivery.

  10. Recommendations: Offer neuraxial techniques Consider early placement of a neuraxial catheter (labor analgesia/anesthesia in the event of operative delivery) Neuraxial Analgesia and Trial of Labor after Prior Cesarean Delivery { mode of delivery duration of labor ? B1-E epidural analgesia adverse outcomes

  11. early insertion of a neuraxial catheter for complicated parturients CIE analgesia epidural LAs + opioids high vs. low concentrations of LAs single-injection spinal opioids ± LAs pencil-point spinal needles CSE analgesia PCEA Anesthetic/analgesic techniques

  12. Recommendations: Consider early insertion of a neuraxial catheter for obstetric (twin gestation/preeclampsia) or anesthetic indications (anticipated difficult airway/obesity) to reduce the need for GA if an emergent procedure becomes necessary. In these cases, the insertion of a neuraxial catheter may precede the onset of labor or a patient’s request for labor analgesia. Early Insertion of a Neuraxial Catheter for Complicated Parturients ⬆︎ maternal / neonatal outcomes ?

  13. CIE Analgesia ⬇︎ maternal pain and discomfort single-shot IV opioids A2-B 🆚 continuous infusion of IV opioids A3-B ? 🆚 CIE local anesthetics ⬆︎ pain relief 🆚 A3-B IM opioids duration of labor and mode of delivery A3-E 🆚 ? single-injection spinal opioids duration of labor and mode of delivery B1-E ?

  14. CIE Analgesia • Recommendations: • Continuous epidural infusion may be used. • When a continuous epidural infusion of local anesthetic is selected, an opioid may be added to: • ⬇︎ concentration of local anesthetic • ⬆︎ quality of analgesia • ⬇︎ motor block

  15. Analgesic Concentrations ⬆︎ analgesic quality A1-B + opioids epidural local anesthetics spontaneous delivery, hypotension, pruritus, and 1-min Apgar scores 🆚 ? A1-E _ opioids analgesic efficacy and duration of labor CEI of low concentrations of local anesthetics + opioids ? A2-E 🆚 spontaneous delivery and neonatal Apgar scores CEI of high concentrations of local anesthetics _ opioids ? A1-E

  16. Recommendations: Use dilute concentrations of local anesthetics with opioids to produce as little motor block as possible. Analgesic Concentrations low concentrations of local anesthetics ⬇︎ frequency of motor block A1-B other maternal outcomes (hypotension, nausea, pruritus, respiratory depression, and urinary retention) epidural local anesthetics + opioids ?

  17. Single-injection Spinal Opioids ± Local Anesthetics ⬆︎ duration of analgesia A1-B spinal opioid duration of labor, mode of delivery, and other adverse outcomes: nausea, vomiting, headache, and pruritus 🆚 ? B1-E IV opioid + local anesthetics single-injection spinal opioids 🆚 ? _ local anesthetics

  18. Single-injection Spinal Opioids ± Local Anesthetics • Recommendations: • effective/time- limited, analgesia • If labor duration is anticipated to be longer than the analgesic effects of the spinal drugs chosen, or if there is a reasonable possibility of operative delivery, then consider a catheter technique instead of a single-injection technique. • A local anesthetic may be added to a spinal opioid to ⬆︎ duration and ⬆︎ quality of analgesia.

  19. Pencil-point Spinal Needles cutting-bevel spinal needles 🆚 Pencil-point Spinal Needles ⬇︎ frequency of post-dural puncture headache A1-B

  20. Recommendations: Use pencil-point spinal needles instead of cutting-bevel spinal needles ⬇︎ post-dural puncture headache. Pencil-point Spinal Needles

  21. CSE Analgesia CSE local anesthetics + opioids epidural local anesthetics + opioids 🆚 • analgesia • mode of delivery • hypotension • pruritus • 1-min Apgar scores ⬆︎ analgesia ⬇︎ onset time A2-B ? A1-E

  22. CSE Analgesia • Recommendations: • If labor duration is anticipated to be longer than the analgesic effects of the spinal drugs chosen, or if there is a reasonable possibility of operative delivery, then consider a catheter technique instead of a single-injection technique. • CSE techniques may be used to provide effective and rapid onset of analgesia for labor.

  23. CSE Analgesia

  24. Patient-controlled Epidural Analgesia ⬇︎ analgesic consumption A1-B • duration of labor • mode of delivery • motor block • 1- and 5-min Apgar scores 🆚 PCEA CIE ? A1-E PCEA + background infusion A1-B ⬆︎ analgesic efficacy 🆚 mode of delivery, frequency of motor block PCEA _ background infusion ? A1-E

  25. Patient-controlled Epidural Analgesia • Recommendations: • An effective and flexible approach for the maintenance of labor analgesia. • preferable to fixed-rate CIE,⬇︎ dosages of local anesthetics • PCEA may be used ± background infusion

  26. Patient-controlled Epidural Analgesia

  27. Removal of Retained Placenta • anesthetic techniques for removal of retained placenta • nitroglycerin for uterine relaxation

  28. Anesthetic Techniques • Recommendations: • No preferred anesthetic technique. If an epidural catheter in place + stable hemodynamics⇒ epidural anesthesia • Assess hemodynamic status before neuraxial anesthesia • Aspiration prophylaxis • Titrate sedation/analgesia (respiratory depression/pulmonary aspiration) • Major maternal hemorrhage + hemodynamic instability⇒ GA + endotracheal tube

  29. Recommendations: Alternate to terbutaline sulfate/GA + halogenated agents incremental doses (IV/sublingual) to sufficiently relax the uterus Nitroglycerin for Uterine Relaxation inconsistent findings A2-E Successful uterine relaxation B3/B4

  30. Equipment, facilities, support personnel General, epidural, spinal, CSE anesthesia IV fluid preloading/co-loading Ephedrine/phenylephrine Neuraxial opioids for postoperative analgesia after neuraxial anesthesia Anesthetic Care for Cesarean Delivery

  31. Equipment, Facilities, and Support Personnel • Recommendations: • Equipment, facilities, support personnel available in the labor and delivery operating suite = main operating suite

  32. Equipment, Facilities, and Support Personnel • Resources for the treatment of potential complications: • failed intubation • inadequate analgesia/anesthesia • hypotension • respiratory depression • local anesthetic systemic toxicity • pruritus, and vomiting • Equipment and personnel for obstetric patients recovering from neuraxial or GA.

  33. General, Epidural, Spinal, or CSE Anesthesia ⬆︎ Apgar scores at 1 and 5 min epidural anesthesia A2-B umbilical artery pH values 🆚 ? GA A2-E Apgar scores at 1 and 5 min ? spinal anesthesia A1-E umbilical artery pH values ? 🆚 GA epidural anesthesia ? total time in the operating room GA A2-E 🆚 🆚 spinal anesthesia

  34. General, Epidural, Spinal, or CSE Anesthesia • Recommendations: • Anesthetic technique should be individualized: anesthetic, obstetric, fetal risk factors (elective vs. emergency), the preferences of the patient, and the judgment of the anesthesiologist. • Uterine displacement should be maintained until delivery • Neuraxial techniques in preference to GA for most cesarean deliveries

  35. General, Epidural, Spinal, or CSE Anesthesia • Pencil-point spinal needles instead of cutting-bevel spinal needles. • For urgent cesarean delivery, an indwelling epidural catheter may be used as an alternative to initiation of spinal or GA. • GA may be the most appropriate choice in some circumstances (profound fetal bradycardia, ruptured uterus, severe hemorrhage, and severe placental abruption).

  36. IV Fluid Preloading or Co-loading IV fluid preloading or co-loading frequency of hypotension after SA ? A2-E 🆚 no fluids IV fluid preloading frequency of hypotension after SA 🆚 ? A2-E IV fluid co-loading

  37. IV Fluid Preloading or Co-loading • Recommendations: • IV fluid preloading/co-loading: ⬇︎ frequency of hypotension after spinal anesthesia • Do not delay the initiation of spinal anesthesia in order to administer a fixed volume of IV fluid.

  38. Ephedrine/Phenylephrine ⬇︎ maternal hypotension 🆚 IV ephedrine placebo A1-B maternal hypotension 🆚 ? IM ephedrine placebo A2-E higher dosages of phenylephrine ⬇︎ maternal hypotension A2-B Lower dosages of phenylephrine maternal hypotension ? A2-E ⬇︎ frequency of maternal hypotension phenylephrine A1-B 🆚 ephedrine A1-H ⬆︎ umbilical artery pH values

  39. Ephedrine or Phenylephrine • Recommendations: • Either IV ephedrine or phenylephrine may be used. • In the absence of maternal bradycardia, consider selecting phenylephrine (improved fetal acid–base status in uncomplicated pregnancies).

  40. Neuraxial Opioids for Postoperative Analgesia 🆚 epidural opioids A2-B ⬆︎ postoperative analgesia intermittent IV/IM opioids nausea, vomiting, pruritus ? A1-E ⬆︎ postoperative analgesia A2-B 🆚 PCEA PCA nausea, vomiting, pruritus, sedation ? A2-E

  41. Neuraxial Opioids for Postoperative Analgesia • Recommendations: • For postoperative analgesia after neuraxial anesthesia, consider selecting neuraxial opioids rather than intermittent injections of parenteral opioids.

  42. Postpartum Tubal Ligation

  43. Recommendations: NPO for solid foods (6 - 8h), depending on the type of food ingested (fat content). Aspiration prophylaxis Timing of the procedure - anesthetic technique should be individualized: anesthetic and obstetric risk factors (blood loss), and patient preferences 🆚 ? neuraxial anesthesia GA impact of the timing of a postpartum tubal ligation on maternal outcome ?

  44. Neuraxial techniques in preference to GA for most postpartum tubal ligations. • Gastric emptying will be delayed in patients who have received opioids during labor. • An epidural catheter placed for labor may be more likely to fail with longer post-delivery time intervals.

  45. Management of Obstetric and Anesthetic Emergencies • resources for management of hemorrhagic emergencies • equipment for management of airway emergencies • cardiopulmonary resuscitation

  46. Recommendations: Resources available to manage hemorrhagic emergencies In an emergency, type-specific or O-negative blood is acceptable. Intractable hemorrhage + banked blood is not available ⇒ intraoperative cell salvage Resources for Management of Hemorrhagic Emergencies ⬇︎ maternal complications

  47. Table 1. Suggested Resources for Obstetric Hemorrhagic Emergencies • Large-bore IV catheters • Fluid warmer • Forced-air body warmer • Availability of blood bank resources • Massive transfusion protocol • Equipment for infusing IV fluids and blood products rapidly. • hand-squeezed fluid chambers, hand-inflated pressure bags, and automatic infusion devices

  48. Recommendations: pulse oximeter and carbon dioxide detector. Basic airway management equipment should be immediately available during neuraxial analgesia. Portable equipment for difficult airway management Equipment for Management of Airway Emergencies ⬇︎ maternal, fetal, and neonatal complications B4-B

  49. Equipment for Management of Airway Emergencies • A pre formulated strategy for intubation of the difficult airway • failed tracheal intubation⇒ ventilation with mask + cricoid pressure or a supraglottic airway device (laryngeal mask airway, intubating laryngeal mask airway, or laryngeal tube) • Not possible to ventilate or awaken the patient, ⇒ surgical airway

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