Cesarean section-Perioperative nausea and vomiting under spinal anesthesia

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Cesarean section-Perioperative nausea and
vomiting under spinal anesthesia

• Present by R1???/V.S.???
• 2007.10.09

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Cesarean section

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Major indication for cesarean section

• Labor unsafe for mother and fetus
• 1. Increased risk of uterine rupture
• --previous classic cesarean section
• --previous extensive myomectomy or
  uterine reconstruction
• 2. Increased risk of maternal hemorrhage
• --central or partial placenta previa
• --abruptio placentae
• --previous vaginal reconstruction

Clinical anesthesiology 4th edit. 2006
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Major indication for cesarean section

• Dystocia
• 1. Abnormal fetopelvic relations
• --fetopelvic dispropotion
• --abnoemal fetal presentation transverse
• or oblique line, breech presentation
• --dysfunctional uterine activity
  
  

Clinical anesthesiology 4th edit. 2006
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Major indication for cesarean section

• Immediate or emergent delivery necessary
• 1. Fetal distress
• 2. Umbilical cord prolapse
• 3. Maternal hemorrhage
• 4. Amnionitis
• 5. Genital herpes with rupture membrane
• 6. Impending maternal death

Clinical anesthesiology 4th edit. 2006
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Anesthesia for cesarean section

• General anesthesia
• Regional anesthesia
• Spinal anesthesia
• Epidural anesthesia
• Combined spinal and epidural anesthesia

Clinical anesthesiology 4th edit. 2006
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Spinal anesthesia in cesarean section

• Hyperbaric bupivacaine
• Concentration 0.5, 0.75, and 1 not involve
  extent, but effect the density of block
• 0.75 is equal to 1, less headache
• Duration 1.5 to 2 hours
• Does ??, gt15mg increase complication

Miller 6th edit
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Figure 58-10  Relationship between patient
weight and height and block height during spinal
anesthesia with 12 mg hyperbaric bupivacaine in
50 term parturients undergoing cesarean section.
Circles represent one patient squares, two
patients triangles, three patients and
diamonds, four patients.  (From Shnider SM, Moya
F Effects of meperidine on the newborn infant.
Am J Obstet Gynecol 8910091015, 1964.)
Miller 6th edit
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Spinal anesthesia in cesarean section

• Adequate block T6T4
• Should receive 10001500mL bolus L/R
• Doesnt help hypotension but useful in some
  patient
• Supine, left uterine displacement, O2, NBP
  12/min, ephedrine keeps SBPgt100mmHg
  (prophylactic administration is not recommended),
  slight Trendelenburg position

clinical anesthesiology 4th edit. 2006 Miller 6th
edit
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Cesarean section

• Perioperative nausea and vomiting

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Background

• Incidence 66
• Etiology
• 1. Surgical procedure surgical stimuli, such
  as peritoneal traction and exteriorization of the
  uterus, vagal hyperactivity, hypotension
• 2. Drugs systemic opioid, uterotonic drug
• Accompany visceral pain, despite of adequate
  dermatome sensory block.

• The Prophylactic Granisetron Does Not Prevent
  Postdelivery Nausea and Vomiting During Elective
  Cesarean Delivery Under Spinal Anesthesia Anesth
  Analg 2007104679 83
• Intrathecal fentanyl is superior to intravenous
  ondansetron for the prevention of perioperative
  nausea during cesarean delivery with spinal
  anesthesia International anesthesia Research
  Society Volume 90(5), May 2000, pp1162-1166

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In the Miller..

• Despite achieving an adequate (T4) block, some
  women under spinal anesthesia will experience
  some degree of visceral discomfort during
  cesarean section, particularly in situations in
  which the obstetrician exteriorizes the uterus.
  The quality of the spinal anesthesia has been
  reported to be improved by the addition of
  epinephrine, morphine, fentanyl, or sufentanil.

Miller 6th edit
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Thinking

• Position? Manual?
• Prophylactic drug
• Perioperative drug gas, intrathecal and IV drug
• Fetus safe?

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Thinking

• Hypotension is well correlated to intraoperative
  nausea and vomiting
• Maintain BP is another thinking process
• Pain management

The Prophylactic Granisetron Does Not Prevent
Postdelivery Nausea and Vomiting During Elective
Cesarean Delivery Under Spinal Anesthesia Anesth
Analg 2007104679 83
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Position associates with BP
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Manual displacement of the uterus during
Caesarean section

• Anaesthesia, 2007, 62, pages 460465

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Method

• 90 ASA 1 and 2 pregnant women with term singleton
  pregnancies and no maternal and fetal
  complications, scheduled for elective or
  emergency Caesarean section, were randomly
  allocated to group LT (15 left lateral table
  tilt, n 45) and group MD (leftward manual
  displacement, n 45)
• Median block sensory level of T6

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Volatile agent
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Nitrous oxide anxiolysis for elective cesarean
section

• Journal of Clinical Anesthesia (2005) 17, 543548

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Method

1. Prospective, randomized, double-blinded study.
2. 60 ASA status I and II patients scheduled for
   elective cesarean section under spinal anesthesia
3. Randomized to 2 groups to receive either 100 O2
   via facemask or 40 N2O in O2 via facemask.
4. After entering the operating room and before the
   administration of the spinal, the patient was
   given 30 mL PO sodium bicitrate, and a facemask
   supplying the study medication was strapped to
   the patients face. Nitrous oxide has a rapid
   onset of clinical effects (less than 2 minutes)

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no difference!
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Discussion

• N2O not slow delivery, not interfere uterine tone
• Side effect shows up when gt70
• Supplemental oxygen did not increase fetal
  oxygenation in patients undergoing elective
  cesarean section under spinal anesthesia
  (Recently, Khaw et al )

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Prophylactic drug usage?

• Primperan
• Droperidol
• 5-HT3 antagonist
• Opioid
• Propofol
• Other intrathecal injection

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The Prophylactic Granisetron Does Not
PreventPostdelivery Nausea and Vomiting During
ElectiveCesarean Delivery Under Spinal
Anesthesia

• Anesth Analg 2007104679 83

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Method

• Randomized, double-blind, placebocontrolled trial
  in 176 parturients.
• Fluid10 mL/kg of lactated Ringers solution,
• Spinal anesthesia 0.75 hyperbaric bupivacaine
  15 mg, fentanyl 10 g, and morphine 100 g
• SBP maintained at 100 of baseline with aliquots
  of phenylephrine.
• Oxytocin 0.5 IU was administered IV upon delivery
  followed by a maintenance infusion.
• Either granisetron 1 mg or normal saline IV
  immediately after cord clamping.

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Discussion

• no difference between the granisetron group
  (20.4) and the control group (17)
• Various study 2255 ?
• In this study, INOV in control group may be
  under-estimated

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Prophylactic drug usage?

• Primperan
• Droperidol
• 5-HT3 antagonist
• Opioid
• Propofol
• Other intrathecal injection

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A single dose of fentanyl and midazolam prior to
Cesarean section have no adverse neontal effects

• CAN J ANESTH 2006 / 53 1 / pp 7985

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Method

• Double-blinded,randomized,placebo-controlled
  trial
• 60 healthy women received either a combination of
  1 µgkg1 fentanyl and 0.02 mgkg1 midazolam
  intravenously or an equal volume of iv saline at
  the time of their skin preparation for a
  bupivacaine spinal anesthetic.
• Non-parametric power analysis

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Discussion

• Maternal more pleasant
• No obvious effect on neonatal

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Prophylactic drug usage?

• Primperan
• Droperidol
• 5-HT3 antagonist
• Opioid
• Propofol
• Other intrathecal injection

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Dose-Range Effects of Propofol for Reducing
Emetic Symptoms During Cesarean Delivery

• Obstet Gynecol 200299759.

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Method

• Randomized, double-masked trial
• 80 patients
• Received lidocaine I.V. 0.1 mg/kg (for injection
  pain relief) followed by either placebo or
  propofol at three different doses (0.5
  mg/kg/hour, 1.0 mg/kg/hour, 2.0 mg/kg/hour) (n
  20 in each group) immediately after clamping of
  the umbilical cord

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Discussion

• Reduced the incidence of intraoperative,
  postdelivery nausea, and vomiting
• Mechanism unclear

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Prophylactic drug usage?

• Primperan
• Droperidol
• 5-HT3 antagonist
• Opioid
• Propofol
• Other intrathecal injection

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Influence of injection rate of hyperbaric
bupivacaine on spinal block in parturients a
randomized trial

• CAN J ANESTH 2007 / 54 4 / pp 290295

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Method

• Prospective, randomized, double-blind clinical
  trial
• 90 ASA I and II term parturients
• Randomized to receive either fast injection (over
  4 seconds, Group F) or slow injection (over 40
  sec, Group S) of 0.75 hyperbaric bupivacaine 12
  mg morphine 200 µg.

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Other drug combined

• Morphine
• Epinephrine
• Sufentanyl or fentanyl

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Combined with morphine
Combined Intrathecal Morphine and Bupivacaine for
Cesarean Section ANESTH ANALG 198867374
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Combined with sufentanyl
Intrathecal sufentanil (1.5mg) added to
hyperbaric bupivacaine (0.5) for elective
cesarean section provides adequate analgesia
without need for pruritus therapy J Anesth
(2006) 20274278
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Combined with epinephrine
Epinephrine Improves the Quality of Spinal
Hyperbaric Bupivacaine for Cesarean Section
ANESTH ANAL.C 39s 198766095-400
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Intrathecal fentanyl is superior to intravenous
ondansetron for the prevention of perioperative
nausea during cesarean delivery with spinal
anesthesia

• International anesthesia Research Society Volume
  90(5), May 2000, pp1162-1166

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Conclusion-what we can do?

• Manual displacement?BP-stable induces less
  perioperative nausea and vomiting?
• N2O?for anxiety
• Prophylatic 5HT3?expensive and controversial
• Fentanyl and Midazolam?further study
• Propofol?1mg/kg/hr after birth
• Intrathecal injection with opioid

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Reference

• clinical anesthesiology 4th edit. 2006
• Miller 6th edit
• Manual displacement of the uterus during
  Caesarean sectionAnaesthesia, 2007, 62, pages
  460465
• The Prophylactic Granisetron Does Not Prevent
  Postdelivery Nausea and Vomiting During Elective
  Cesarean Delivery Under Spinal Anesthesia Anesth
  Analg 2007104679 83
• Nitrous oxide anxiolysis for elective cesarean
  section Journal of Clinical Anesthesia (2005)
  17, 543548
• A single dose of fentanyl and midazolam prior to
  Cesarean section have no adverse neontal effects
  CAN J ANESTH 2006 / 53 1 / pp 7985
• Dose-Range Effects of Propofol for Reducing
  Emetic Symptoms During Cesarean Delivery Obstet
  Gynecol 200299759.
• Intrathecal fentanyl is superior to intravenous
  ondansetron for the prevention of perioperative
  nausea during cesarean delivery with spinal
  anesthesia International anesthesia Research
  Society Volume 90(5), May 2000, pp1162-1166
• Epinephrine Improves the Quality of Spinal
  Hyperbaric Bupivacaine for Cesarean Section
  ANESTH ANAL.C 39s 198766095-400
• Influence of injection rate of hyperbaric
  bupivacaine on spinal block in parturients a
  randomized trial CAN J ANESTH 2007 / 54 4 / pp
  290295
• Combined Intrathecal Morphine and Bupivacaine for
  Cesarean Section ANESTH ANALG 198867374
• Intrathecal sufentanil (1.5mg) added to
  hyperbaric bupivacaine (0.5) for elective
  cesarean section provides adequate analgesia
  without need for pruritus therapy J Anesth
  (2006) 20274278