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AMBULATORY ANESTHESIA
AND
OBSTETRIC ANESTHESIA
Berrin Günaydın, MD, PhD
Gazi University
Faculty of Medicine
Department of Anesthesiology
Obstetric Anesthesia
Ankara - Turkey
GAZI UNIVERSITY FACULTY OF MEDICINE
Objectives
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Definition of ambulatory anesthesia
Preoperative Evaluation
 History taking
 Physical examination
 Fasting & medications
 Laboratory screening
 Premedication
 Monitorization
 Anesthesia choices
 Postoperative Care
for obstetric procedures done on ambulatory basis
Definition
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Ambulatory (outpatient) surgery
Basic advantages
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Economic savings
Earlier ambulation
Lessened risk of nosocomial infections
Anesthesia for ambulatory surgery
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Patients return home within 24 hours of an
operative procedure
Procedures done on ambulatory basis
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Evacuation of incomplete miscarriage
Surgical treatment of tubal ectopic pregnancy
Cervical cerclage
External cephalic version
Hysterosalpingography (HSG) - Hysteroscopy
Assisted reproductive technologies - procedures
 Transvaginal ultrasound guided oocyte retrieval
(TUGOR)
Preoperative Evaluation
History taking
 Questionnaires for screening & detecting common
medical problems
 Maternal death & anesthetic history
 Relevant obstetric history
Preoperative Evaluation
Physical examination
 Measurement of vital signs
(pulse, blood pressure, respiratory rate, temperature)
 Airway, heart & lung examination
 Back examination (when neuraxial anesthesia is planned)
Preoperative Evaluation
Fasting & Chronic medications
 Clear fluids
 Modest amount is allowed up to 2 h prior to induction of
anesthesia
Solids
 should be avoided 6-8 h depending on the type of
ingestion (e.g.fat)
Patients should bring their own medications
 Antihypertensives should be taken
 Oral hypoglycaemics should be omitted
White P. Ambulatory anesthesia advances into the new ilennium. Anesth Analg 2000
Hawkins. ASA Practice Guidelines for Obstetric Anesthesia IJOA 2007
Preoperative Evaluation
Laboratory screening
Age Men ♂
Women ♀
<40
None
Pregnancy test
40-49
ECG
Htc
Pregnancy test
50-64
ECG
Hb/ Htc, ECG
65-74
Hb/ Htc
ECG, BUN
Glucose
Hb/ Htc
ECG, BUN
Glucose
>75
Hb/ Htc
ECG, BUN
Hb/ Htc
ECG, BUN
Chest radiograph
Chest radiograph
 Platelet count
 Maternal history
 Physical examination
 Clinical signs
 Blood type & cross-match
 Maternal history
 Anticipated hemorrhage
 Institutional policies
White & Freire. Ambulatory (outpatient) Anesthesia. Anesthesia 2005
ASA Task Force on Obstetric Anesthesia Practice Guidelines Anesthesiology 2007
Premedication
 Benzodiazepines if indicated
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Small dose of midazolam IV (1-3 mg)
 Alpha-2 agonists
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Clonidine (0.1-0.3 PO)
Dexmedetomidine (50-70 µg IM or 50 µg IV)
 Aspiration prophylaxis (for diabetics & morbid obeses)
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H2-receptor antagonists (ranitidine)
Nonparticulate antacids (sodium citrate)
Gastrokinetic agents (metoclopramide)
White P. Ambulatory Anesthesia. Anesthesia 2005
Hawkins JL. ASA Practice Guidelines for Obstetric Anesthesia. IJOA 2007
Monitorization
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Heart rate (maternal & fetal) and ECG
Blood pressure (noninvasive)
Pulse oximetry (SpO2)
Capnometry (ETCO2)
BIS
White P. Ambulatory anesthesia advances into the new ilennium.
Anesth Analg 2000
ASA Task Force on Obstetric Anesthesia Prcatice Guidelines
Anesthesiology 2007
Anesthesia Techniques
 General Anesthesia
 Regional anesthesia
 Monitored Anesthesia Care (MAC)
Borkowski. Cleveland Clin J Med 2006
General Anesthesia
Induction agents
 Propofol (1.5-2.5 mg/kg) is used widely
(easy +quick recovery, clear head, lacks PONV)
 Sevoflurane (8% in 50% N2O-O2)
non-irritant to airway, rapid induction, minimal sideeffects, but more PONV
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Thiopentone (3-6 mg/kg)
Midazolam (0.2-0.4 mg/kg)
Etomidate (0.2-0.3 mg/kg)
Ketamine (0.75-1.5 mg/kg)
Borkowski. Cleveland Clin J Med 2006
White. Anesth Analg 2000
Russell R. Summer Update on Obstetric Anesthesia, 2006
Levy D. Three day course on obstetric anesthesia, 2007
General Anesthesia
Maintenance
 TIVA (propofol & remifentanil or alfentanil)-TCI
(BIS < 60)
Borkowski. Cleveland Clin J Med 2006
White. Anesth Analg 2000
Russell R. Summer Update on Obstetric Anesthesia, 2006
Levy D. Three day course on obstetric anesthesia, 2007
General Anesthesia
Maintenance
 Isoflurane
 Sevoflurane
 Desflurane
 ? N2O
General Anesthesia
 Muscle relaxants (short and intermediate acting drugs)
Mivacurium
Rocuronium
Cisatracurium
 Airway
 Face mask
 LMA
 Endotracheal intubation
Borkowski. Cleveland Clin J Med 2006
White. Anesth Analg 2000
Russell R. Summer Update on Obstetric Anesthesia, 2006
Levy D. Three day course on obstetric anesthesia, 2007
General Anesthesia
Reversal agents
 Benzodiazepin antagonist (flumazenil)
 Antichoinesterase drugs
 Sugammadex (rocuronium antagonist)
 Opioid antagonists (naloxone)
Spinal anesthesia
 Advantages
 Simple-quick procedure
 Short turnover time
 Patients are alert
 Less nausea-vomiting
 Disadvantages
 Incidence of headache and radiating back pain
 Slow return of motor power
 Difficulty in micturition might delay discharge
 Rare but significant advers events (neurologic injury, infection)
Chakravorty et al. Spinal anesthesia in the ambulatory setting. Ind J Anaesth 2003
Mordecai & Brull Curr Opin Anaesthesiol 2005, Korhonen. Curr Opin Anaesthesiol 2006
Spinal anesthesia
Prevention against disadvantages
 27 G Whitacre spinal needle is associated with
lower incidence of PDPH
 Older (chloroprocaine) & newer (ropivacaine & levobupivacaine) local
anesthetics in conjuction with adjuvant intrathecal
medications (opioids, vasopressors) help fast resolution of
motor function and ability to micturate
Mordecai & Brull Curr Opin Anaesthesiol 2005
Korhonen. Curr Opin Anaesthesiol 2006
Neuraxial anesthetics
Ideal neuraxial anesthetic
 Adaequate analgesia and duration
 Short recovery
 Minimal side effects
 7.5 mg of spinal hyperbaric bupivacaine is with
low incidence of TNS
 Epidural with 2-chloroprocaine is preferable to
spinal anesthesia
Conscious (MAC) vs Unconscious
Sedation
Conscious
Unconscious
Mood
Alert-cooperative
No cooperation
Protective reflexes
Active-intact
Obtunded
Vital signs
Stable
Labile
Analgesia
Regional/local
analgesia
Central analgesia
Recovery room stay
Not prolonged
Prolonged/admission
Complication risk
Low
High
Postop.complication
Infrquent
Frequent
Mentally incompetent Not suitable
patients
Suitable
Drugs used for MAC
Drug
Alfentanil
Loading dose (µg/kg) Maintenance (µg/kg/min)
10-25
0.25-1
1-3
0.01-0.03
0.1-0.5
0.005-0.01
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0.025-0.1
Ketamine
500-1000
10-20
Propofol
250-1000
10-50
25-100
0.25-1
Fentanil
Sufentanil
Remifentanil
Midazolam
Postoperative Care
Pain
Multimodal approach
 NSAID and/or nonopioid analgesics (local anesthetics,
acetaminophen, proparacetamol)
 COX2 inhibitors (celecoxib)
 LA wound infiltration
 at the time of surgery
 patient controlled elastomeric pump
 Neuraxial opioids
White P. Anesth Analg 2000
Carvalho B. Summer Update on Obstetric Anesthesia, 2006
Postoperative Care
PONV
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Prophylactic antiemetics
Multimodal treatment regimen
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Butyrophenones
Phenotiazines
Gastrokinetic drugs
Anticholinergics
Antihistamines
Serotonin antagonists (4-8 mg IV)
NK-1 antagonists
Dexametazone (4-8 mg IV)
Acupuncture (P6 and others)
White P. Anesth Analg 2000
White & Freire. Anesthesia 2005
Discharge Criteria
 Aldrete
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Activity
Respiration
Circulation
Conscious level
Color of the skin
 Postanesthesia Discharge
Scoring System (PDSS)
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Vital signs
Activity level
Nausea &vomiting
Pain
Surgical bleeding
Chakravorty et al. Spinal anesthesia in the ambulatory setting.Ind J Anaesth 2003
Surgical treatment of miscarriage
(vacuum aspiration or D&C)
Anesthetic options
 Target-controlled intravenous sedation-analgesia with
propofol & remifentanil
 Paracervical block (PCB)
 Sedation + PCB (MAC)
 Short acting iv induction or inhalation agent (sevoflurane)
with short acting opioid/N2O mask ventilation or LMA
Nanda K et al. Cochrane Data Base Syst Rev 2006
Fassoulaki et al. No change in plasma endorphine and melatonine levels after sevoflurane anesthesia. JCA 2007
Hysterosalpingography (HSG)
 Any analgesics (oral or topical) vs placebo or no
treatment
 Topical analgesics vs placebo or no treatment
 Opioid vs non-opioid analgesics
 Topical analgesics vs oral analgesics
 Intaruterine local anesthetic vs PCB
Ahmad G et al. Cochrane Data Base Syst Rev 2007
Hysteroscopy
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Local
MAC
General
Regional
Spinal anesthesia to T7 level was achieved using 3 mL of 2%
isobaric lidocaine (60 mg) with 100 µ epinephrine
*TNS was associated with single shot spinal anesthesia
Lotfallah et al. J Reprod Med. 2005
Farid et al. JCA 2001
Tubal ectopic pregnancy
Treatment options requiring anesthesia are
salpingectomy or salpingostomy either
laparoscopically or open surgery
General anesthesia
 Induction
with short acting iv agent (usually propofol)
 Maintenance
with TIVA or sevo/desflurane in N2O/opioid
Hajenius PJ et al. Cochrane Data Base Syst Rev 2007
Cervical Cerclage
Prevents miscarriage or premature delivery due to
cervical incompetence in 85-90% of cases and
requires anesthesia
Regional
usually spinal anesthesia
epidural
General anesthesia
Cervical Cerclage
Neuraxial anesthesia (spinal or epidural)
 Use of low-dose epidural
0.125% bupivacaine with epinephrine & fentanyl
 Spinal anesthesia
lidocaine 30 mg or bupivacaine 5.25 mg both with
fentanyl 20 µg have been used successfully for
cervical cerclage
Tsen. What’s new and novel in obstetric anesthesia?IJOA 2005
Schumann & Rafique. Low dose epidural anesthesia for cervical cerclage. CJA 2003; 50:424
External Cephalic Version
 Spinal analgesia with 7.5 mg bupivacaine (n=36)
vs with no analgesia (n=34)
 Success rate
 Spinal (66.7%) vs no analgesia (32.4%) (p=0.0004)
 Spinal analgesia significantly increases success
rate of external cephalic version among
parturients at term which allows possible normal
vaginal delivery
Weiniger et al. External cephalic version for breech presentation with or without spinal analgesia in nulliparous
women at term: a randomized controlled trial. Obstet Gynecol. 2007;110:1343-50
TUGOR
 General
 Inhalational anesthesia
 TIVA
 Regional blocks
 Spinal
 Epidural
 PCB
 Conscious sedation (MAC)
PCB + IV remifentanil
Tsen. Int Anaesthesiol Clin 2007
Gunaydin et al.J Opioid Manag 2007
Gunaydin et al.J Opioid Manag 2007
CONCLUSIONS
 Ambulatory surgery aims the best patient care
possible at the reasonable cost, ambulatory anesthesia
must meet these requirements
 Issues that prolong stay in PACU primarily
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Pain & PONV after general anesthesia or MAC
Unresolved blocks & urinary retention after neuraxial blocks
should be managed by choosing appropriate pharmacologic
agents (mainly short acting agents with less side effects)
Terimah Kasih