Anestesi vid kejsarsnitt

Anesthesia for Cesarean Section
Lars Irestedt
Karolinska University Hospital,
Stockholm, Sweden
Three important questions
1. Indication and emergency
2. Airway problems expected?
3. GA really necessary?
Indication for GA at CS
•
•
•
•
CNB contraindicated
Patient refuses CNB
Immediate CS
CNB failure
Disadvantages with GA for CS
‰Higher mortality
‰Airway problems?
‰Aspiration?
‰Awareness - recall?
‰Hemodynamics?
‰Atonia of the uterus?
‰Neonatal effects?
1964-66
2000-02
CS %
3.4
21
CNB%
~0
~80
Anesthesia related
mortality per million
anesthetics
360
10
Why mothers die
www.cemach.org.uk
Anesthesia related maternal
mortality per million anesthetics
2000-2002
GA
50
CNB
3
Why mothers die
www.cemach.org.uk
Anesthesia related maternal mortality
per million anesthetics 2000-2002
General anesthesia
50
Regional anesthesia
3
Selection bias!
Why mothers die
www.cemach.org.uk
Failed intubation
Obstetric population
1/280
General population
1/2200
Anaesthesia 1987:42:487-490
23 failed tracheal intubations occurred in
5802 obstetric general anesthetics
between 1981 and 1994 corresponding to
1/252
BJA 1996:76:680-684
20 failed tracheal intubations occurred in
4768 obstetric general anesthetics
between 1999 and 2003 corresponding to
1/238
Anaesthesia 2005:60:168-171
4 failed tracheal intubations occurred in
1095 obstetric general anesthetics
between 2005 and 2006 corresponding to
1/273
Int J Obst Anesth 2008:17:292-297
Why is airway handling more difficult in the
obstetric patient?
• Anatomical changes
• Physiological changes
• Increased risk for aspiration
• Often an emergency situation
PaO2 after 60 sec of apnea
PaO2 before
apnea (kPa)
PaO2 after
apnea (kPa)
(%)
Pregnant
63.1
44.5
30
Non
pregnant
67.6
59.9
11
Br J Anaesth 1974:46:358-360
CNB and CS
•
Spinal anesthesia
•
Epidural anesthesia
•
Combined spinal epidural
anesthesia (CSE)
Optimal technique
•
•
•
•
•
•
•
•
Subarachnoidal injection L3-L4
Check BP and HR every minute until delivery
Position, left lateral tilt
Vasopressor readily avalible
Rapid isotonic saline infusion
Careful preop testing of blockade height
Optimal height of blockade – above T5
Slow inj. of oxytocin 5 IU after cord clamping
Contraindication, SPA
•
•
•
•
•
Uncompensated hypovolemia
Severe Coagulopathies
Local infection
Patient refuses
Septicemia
CNB and CS
Majority of cases
• Spinal anesthesia
• Epidural anesthesia (if already on board)
GA and CS
• Always RSI
• Preoxygenation
• Emergency contra elective
• Cricoid pressure?
• What is good for the mother is good for the baby
Bild Stockholm