Anesthesia for the Obstetric Patient Undergoing Non ... · obstetric patient and their implications...
Transcript of Anesthesia for the Obstetric Patient Undergoing Non ... · obstetric patient and their implications...
Anesthesia for the Obstetric PatientUndergoing Non-Obstetric Surgery
Daniel Rohrer, CRNA, MS Pinnacle Health- Community General Osteopathic Hospital
Conflicts & Disclosures This presentation lacks any conflict of interest or commercial interest for disclosure
Objectives • Briefly review the physiologic changes in the
obstetric patient and their implications for anesthetic management
• Review common non-obstetric surgical procedures, techniques, and concerns surrounding fetal vulnerability
• Outline the anesthetic guidelines in managing the obstetric patient throughout non-obstetric surgery
Airway, Breathing…
VE/VO2
VE/VCO2
Airway, Breathing…
Cardiovascular & Circulation…
Cardiovascular & Circulation…
Gastrointestinal…
• Increased gastric volume
• Mechanical outflow obstruction
• Delayed gastric emptying
• Increased gastric pressure
• Decreased motility and esophageal sphincter tone
Other Changes…
Other Changes…
Non-Obstetric Surgery0.75-2% 1:500-635 75,000 per year
Appendicitis & Cholecystitis
You can do that?...
(Appendectomy)
Quick breather…
• Protection of Fetus
• Pre-Term Labor
• Principles & Guidelines
Fetal Vulnerability & Teratogenicity (Protection)
Timing
Physical & Chemical Properties• Size : < 500 Da (Daltons) • Charge: Non-ionized • Protein Binding: Unbound drugs • Lipophilic
Placental Drug Transfer (Protection)
Teratogenicity (Protection)
• Susceptibility • Dose • Duration • Timing of exposure
Important Factors: FDA categories: •A - known to be safe •B - appear to be safe •C - may cause problems •D - clear risks •X – confirmed defects
Teratogenicity (Protection)
“To the best of our knowledge, danger of teratogenic effects from currently available anesthetic or sedative drugs remains only
a potential risk” Dr. Rosen-ASA
Pre-Term Labor & Delivery
To use or not to use…?
Respiratory and Hemodynamic Stability (Principles)
28-32 mmHg
Uterine Blood Flow & Fetal Asphyxia
• Left uterine displacement
• Trendelenburg position
• Fluid administration as indicated
• Leg elevation
• Vasopressors (ephedrine & phenylephrine)
• Minimal SBP = 100mmHg
• Hypotension = < 2 minutes
Fetal Heart Monitoring(ACOG & ASA)
• Individualized
• Minimum before and after
• Obstetric consultation & interpretation
• Institution with neonatal services
• Consent for emergent C-section
• Physician with C-section privileges
Carefully…Consent…
Carefully…Consent…
Paravertrebral Block: An Option?
American College of Obstetricians and Gynecologists (ACOG)
• Cesarean section: 30 minutes • “Immediate” availability of personnel • Physician with anesthesia privileges • Resources for local anesthetic toxicity • Newborn resuscitation team
In Conclusion…• Physiological Changes • Protection of the fetus (timing, teratogenicity) • Pre-Term Labor prevention • Principles for maternal and fetal stability
…and anesthetists!!!
“Precision and circumspection must be had and utilized when dealing with general anesthesia and pregnancy”
References • American College of Obstetricians and Gynecologists . (2009). Optimal Goals for Anesthesia Care in Obstetrics . The American
College of Obstetricians and Gynecologists . Washington, DC: Women's Health Care Physicians . • American College of Obstetricians and Gynecologists. (2013). Nonobstetric Surgery During Pregnancy. The American College of
Obstetricians and Gynecologists. Washington, DC: Committee on Obstetric Practice. • Birnbach, D., & Browne, I. (2010). Anesthesia for Obstetrics . In R. Miller, L. Eriksson, L. Fleisher, J. Kronish, & W. Young, Miller's
Anesthesia (7th Edition ed., pp. 2203-2235). Philadelphia , Pennsylvania: Churchill Livingstone Elsevier . • Cheek, T., & Emily, B. (2009). Anesthesia for Nonobstetric Surgery: Maternal and Fetal Considerations . Clinical Obstetrics and
Gynecology , 535-545. • Corneille, M., Gallup, T., Bening, T., Wolf, S., Brougher, C., Myers, J., et al. (2010). The Use of Laparoscopic Surgery in
Pregnancy: Evaluation of Safety and Efficacy . The American Journal of Surgery , 363-367. doi:10.1016/j.amjsurg.2009.09.022 • Fardiazar, Z., Derakhshan, I., Torab, R., Vahedi, A., & Goldust, M. (2014). Maternal-Neonatal Outcome in Pregnancies with Non-
Obstetric Laparotomy During Pregnancy . Pakistan Journal of Biological Sciences , 260-264. doi: 10.3923/pjbs.2014.260.265 • Hannan, J., Hoque, M., & Begum, L. (2012). Laparoscopic Appendectomy in Pregnant Women: Experience in Chittagong,
Bangladesh. World Journal of Surgery , 767-770. doi:10.1007/s00268-012-1445-z • Kuczkowski, K. (2007). Laparoscopic Procedures During Pregnancy and the Risks of Anesthesia: What does an Obstetrician
Need to Know? . Archives of Gynecology Obstetricians , 276, 201-209. doi: 10.1007/s00404-007-0338-0 • Mhuircheartaigh, R., & Gorman, D. (2006). Nonobstetric Surgery in the Parturient: Anesthetic Considerations . Journal of Clinical
Anesthesia , 18, 5-7. • Mikami, D., Beery, P., & Ellison, C. (2012). Surgery in the Pregnant Patient . In C. Townsend, D. Beauchamp, M. Evers, & K.
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Anaesthesia. Critical Care & Pain , 203-206. doi:10.1093/bjaceaccp/mks022 • Noridelle, G., Dennis, A., & Landy, H. (2009). Appendicitis and Cholecystitis in Pregnancy . Clinical Obstetrics and Gynecology ,
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