Airway management and pulmonary aspiration during surgical interventions in pregnant women in the 2nd/3rd trimester and immediate postpartum - a retrospective study in a tertiary care university hospital

BACKGROUND

Pregnancy is associated with an increased risk of pulmonary aspiration during general anaesthesia, but the incidence of this complication is not well defined.

METHODS

We performed a retrospective database review in a tertiary care university hospital to determine the incidence of pulmonary aspiration in pregnant patients undergoing endotracheal intubation, with and without Rapid Sequence Induction (RSI), as well as face-mask ventilation and supraglottic airway devices. We included Patients in the 2nd or 3rd trimester of pregnancy and immediate postpartum undergoing surgical procedures. The primary endpoint was the occurrence of pulmonary aspiration.

RESULTS

Data from 2,390 patients undergoing general anaesthesia for cerclage of cervix uteri, manual removal of retained placenta, repair of obstetric laceration, or postpartum bleeding were retrospectively evaluated. A supraglottic airway device or face-mask ventilation was used in 1,425/2,390 (60%) of patients, while 638/2,390 (27%) were intubated. RSI was used in 522/638 (82%) of patients undergoing tracheal intubation, or 522/2,390 (22%) of the entire cohort. In-depth review of the charts, including 54 patients who had been initially classified as "possible pulmonary aspiration" by anaesthetists, revealed that this adverse event did not occur in the cohort.

CONCLUSIONS

In conclusion, in this obstetric surgery patient population at risk for pulmonary aspiration, supraglottic airway devices were used in approximately 60% of cases. Yet, no aspiration event was detected with either a supraglottic airway or endotracheal intubation.

The Prevalence of Acceptance Between General Anesthesia and Spinal Anesthesia Among Pregnant Women Undergoing Elective Caesarean Sections in Saudi Arabia

Background The choice of anesthesia for an elective cesarean section should be based on an individual benefit-risk assessment, considering the pregnant woman's preferences, concerns, and the available medical expertise. This study aimed to determine the preferences for general and spinal anesthesia among women undergoing elective cesarean sections and the factors affecting their choice. Methods The study design is a cross-sectional study, and it was conducted on pregnant women to measure the acceptance of general anesthesia and spinal anesthesia in patients with elective cesarean sections in Saudi Arabia. Random pregnant women were invited to participate in this study across Saudi Arabia after fulfilling the inclusion criteria. A digital questionnaire was distributed across Saudi Arabia to be filled out by female residents. A Microsoft Excel (Microsoft Corporation, Redmond, Washington, USA) sheet was used for data entry, while IBM SPSS software version 27.0.1 (IBM Corp., Armonk, New York, USA) was used for statistical analysis. Results The study included 813 participants; most (28%) of them were 25-30 years old. Of the study participants, 54% had chosen spinal anesthesia before, 22% had chosen general anesthesia, and 24% had chosen neither. Reasons to choose general anesthesia were reported as follows: 21.6% feared pain during surgery, 24.2% feared watching the surgical procedures on their bodies, 16.6% feared back pain, 12.8% feared being paralyzed, and 15.1% feared needles used to administer anesthesia in the lower back. Reasons for choosing spinal anesthesia were reported as follows: 26.3% had back pain concerns; 13% feared prolonged unconsciousness; 9.6% feared having a headache after surgery; 17% had post-surgery pain concerns; 30.1% wanted to be alert at the time of the birth of the baby; 10.6% feared the chances of experiencing nausea and vomiting; and 7.4% feared not being able to breastfeed. Conclusion Spinal anesthesia was chosen by more participants than general anesthesia. There was a statistically significant association between choosing spinal anesthesia and the number of previous pregnancies, parity, history of preterm labor, and recommendation to undergo general or spinal anesthesia by non-medical staff. It was also significant with the older age and higher educational level of participants. This decision may be influenced by a number of variables, the most significant of which are prior experience with general anesthesia or spinal anesthesia, educational attainment, and non-medical advice.

Improving Pain Management After Cesarean Birth Using Transversus Abdominis Plane Block With Liposomal Bupivacaine as Part of a Multimodal Regimen

As educators, advocates, and champions for women's health, nurses play pivotal roles throughout a woman's pregnancy and childbirth journey. Most women experience postsurgical pain after cesarean birth and are prescribed opioids. Caution around opioid use warrants opioid-reducing strategies, particularly because exposure to opioids exacerbates risk for developing persistent postsurgical opioid use. Multimodal approaches can help address this concern. Regional anesthesia using transversus abdominis plane blocks with aqueous formulations of local anesthetics can reduce opioid consumption and pain but has a short duration of action. Liposomal formulation of bupivacaine prolongs its release, overcoming this obstacle. Transversus abdominis plane blocks with liposomal bupivacaine can reduce opioid use and pain after cesarean birth, improving recovery. These findings represent numerous implications for nursing practice to improve postcesarean pain management.

Epidural augmentation for urgent Cesarean Section : a nationwide Israeli survey

Background : Epidural augmentation to convert analgesia to emergency cesarean delivery anesthesia is a common practice. In this survey we examined the common augmentation practices in different hospitals in Israel. We investigated whether practices vary by hospital size and if written protocols for conversion correlate with intra-hospital homogeneity. Methods : A questionnaire containing 39 questions was sent to obstetric anesthesia unit heads and to four additional anesthesiologists (attending and residents) in 24 obstetric anesthesia units nationwide. Answers were received online anonymously using web-based survey site. Results : 99/120 participants responded to the survey. 80% of large hospitals have a detailed epidural augmentation protocol. The existence of a written protocol does not affect intrahospital management variability. Overall, 18 different drug mixtures for epidural augmentation were reported, and the most used drug combination is lidocaine, fentanyl and bicarbonate. In large hospitals, 72% add epinephrine and 96% initiate augmentation before operating room arrival. Most respondents reported a final administered total volume of 15-20 ml. In most hospitals there is no maternal or fetal monitoring during patient transfer from delivery room to the operating room, lasting 3.68 minutes on average, with a relative low risk of significant complication as a result of augmentation. Conclusion : We report variations in common practices, depending on hospital size. We recognized low rate of intra-hospital concordance between centers with or without a written protocol of augmentation. Regarding points for improvement, we would recommend adhering to the accepted institutional protocol.

A prospective, up-down sequential allocation study investigating the effectiveness of vital capacity breaths using high-flow nasal oxygenation versus a tight-fitting face mask to pre-oxygenate term pregnant women

BACKGROUND

The role of high flow nasal oxygenation (HFNO) for pre-oxygenation before obstetric general anaesthesia remains unclear. This study aimed to determine the number of vital capacity breaths using HFNO required to pre-oxygenate 90% of parturients to an end-tidal oxygen concentration fraction (F_ETO₂) of ≥0.90 (termed EN90).

METHODS

Using up-down, sequential allocation trial design, volunteer term parturients undergoing caesarean delivery were investigated with HFNO with their mouth closed, followed by mouth open, and if F_ETO₂ ≥0.90 was not achieved after a maximum of 20 vital capacity breaths, pre-oxygenation was attempted with a face mask. The primary outcome was the number of vital capacity breaths required using HFNO (mouth open and closed) to achieve EN90. Secondary outcomes included assessment of EN90 using mouth open versus mouth closed and face mask pre-oxygenation, maternal satisfaction and evaluation of fetal cardiotocography.

RESULTS

Twenty women at term were recruited. Successful pre-oxygenation occurred in 4 (20%), 3 (15%) and 14 (70%) women with HFNO mouth closed, HFNO mouth open, and via face mask respectively. At up to 20 vital capacity breaths, face mask pre-oxygenation was more successful at achieving EN90 compared with both HFNO with a closed (P=0.006) or open (P=0.001) mouth. Closed mouth HFNO did not outperform open mouth pre-oxygenation.

CONCLUSION

Face mask pre-oxygenation is more effective at achieving EN90 compared with to HFNO within a clinically acceptable number of vital capacity breaths. Further studies are needed to determine the role of HFNO in optimising the time before desaturation and for apnoeic oxygenation in term parturients.

A retrospective review of 10-year trends in general anesthesia for cesarean delivery at a university hospital: the impact of a newly launched team on obstetric anesthesia practice

BACKGROUND

The indications for general anesthesia (GA) in obstetric settings, which are determined in consideration of maternal and fetal outcome, could be affected by local patterns of clinical practice grounded in unique situations and circumstances that vary among medical institutions. Although the use of GA for cesarean delivery has become less common with more frequent adoption of neuraxial anesthesia, GA was previously chosen for pregnancy with placenta previa at our institution in case of unexpected massive hemorrhage. However, the situation has been gradually changing since formation of a team dedicated to obstetric anesthesia practice. Here, we report the results of a review of all cesarean deliveries performed under GA, and assess the impact of our newly launched team on trends in clinical obstetric anesthesia practice at our institution.

METHODS

Our original database for obstetric GA during the period of 2010 to 2019 was analyzed. The medical records of all parturients who received GA for cesarean delivery were reviewed to collect detailed information. Interrupted time series analysis was used to evaluate the impact of the launch of our obstetric anesthesia team.

RESULTS

As recently as 2014, more than 10% of cesarean deliveries were performed under GA, with placenta previa accounting for the main indication in elective and emergent cases. Our obstetric anesthesia team was formed in 2015 to serve as a communication bridge between the department of anesthesiology and the department of obstetrics. Since then, there has been a steady decline in the percentage of cesarean deliveries performed under GA, decreasing to a low of less than 5% in the latest 2 years. Interrupted time series analysis revealed a significant reduction in obstetric GA after 2015 (P = 0.04), which was associated with decreased use of GA for pregnancy with placenta previa. On the other hand, every year has seen a number of urgent cesarean deliveries requiring GA.

CONCLUSIONS

There has been a trend towards fewer obstetric GA since 2015. The optimized use of GA for cesarean delivery was made possible mainly through strengthened partnerships between anesthesiologists and obstetricians with the support of our obstetric anesthesia team.

Magnesium in obstetric anesthesia and intensive care

Magnesium, one of the essential elements in the human body, has numerous favorable effects that offer a variety of possibilities for its use in obstetric anesthesia and intensive care. Administered as a single intravenous bolus dose or a bolus followed by continuous infusion during surgery, magnesium attenuates stress response to endotracheal intubation, and reduces intraoperative anesthetic and postoperative analgesic requirements, while at the same time preserving favorable hemodynamics. Applied as part of an intrathecal or epidural anesthetic mixture, magnesium prolongs the duration of anesthesia and diminishes total postoperative analgesic consumption with no adverse maternal or neonatal effects. In obstetric intensive care, magnesium represents a first-choice medication in the treatment and prevention of eclamptic seizures. If used in recommended doses with close monitoring, magnesium is a safe and effective medication.

Efficacy and safety of low-dose ketamine as an adjunct analgesic and amnesic during caesarean section under general anaesthesia

Background and Aims:

The practice of avoiding sedatives or anxiolytics during caesarean section under general anaesthesia (GA) until delivery of the baby could result in exaggerated haemodynamic responses and an increased risk of awareness. We aimed to assess the efficacy and safety of low-dose ketamine, used as an adjunct analgesic and amnesic, in attenuating these responses during caesarean section under GA.

Methods:

This prospective, randomised study was conducted in 40 patients. Group K (n = 20) received 0.25 mg/kg ketamine, whereas Group C received 5 ml normal saline intravenously (IV) just before induction of anaesthesia. After intubation, patients were ventilated with O₂ and N₂O (40:60%) with 0.7% end-tidal isoflurane. Fentanyl and midazolam were given following delivery of the baby. Mann–Whitney and Fisher's exact tests were used for statistical analysis.

Results:

Preinduction haemodynamic parameters and those recorded at 1 min after induction were comparable in both groups. However, heart rate and systolic blood pressure recorded after intubation (at 3, 5, 7, 9, 12, 15, 20, 30 and 45 min after induction) showed significantly high values in Group C (P < 0.05). Mean arterial pressure also showed a similar pattern. Umbilical vein pO₂, pCO₂ and pH were comparable in both groups. Though Apgar score at 1 min showed a higher scoring in Group K, at 5 min both groups had comparable scores. In Group C, intraoperative lacrimation (50% vs. 0%) and hallucinations/recall of intraoperative events (10% vs. 0%) were high.

Conclusion:

IV ketamine 0.25 mg/kg can be safely used as an adjunct analgesic and amnesic to attenuate haemodynamic responses during caesarean section under GA without affecting the foetal outcome.