Difficult and failed intubation in Caesarean general anaesthesia: a four-year retrospective review

INTRODUCTIONGeneral anaesthesia is associated with higher maternal morbidity and mortality when compared with regional anaesthesia, related mainly to failure of intubation, hypoxia and aspiration. The aim of this retrospective review was to define the incidence of failed and difficult intubation in parturients undergoing general anaesthesia for Caesarean delivery at a high-volume obstetric hospital in Singapore.METHODSAll parturients who underwent Caesarean delivery under general anaesthesia from 2013 to 2016 were identified and their medical records were reviewed to extract pertinent data. Difficult intubation was defined as ‘requiring more than one attempt at intubation or documented as such, based on the opinion of the anaesthetist’. A failed intubation was defined as ‘inability to intubate the trachea, with subsequent abandonment of intubation as a means of airway management’.RESULTSRecords of 660 Caesarean sections under general anaesthesia were extracted. The mean age of the parturients was 32.1 ± 5.5 years and the median body mass index was 27.5 (interquartile range 24.6–31.1) kg/m². Rapid sequence induction with cricoid pressure was employed for all patients, with thiopentone and succinylcholine being administered for 91.2% and 98.1% of patients, respectively. There were 33 difficult intubations among 660 patients, yielding an incidence of 5.0%. Junior trainees performed about 90% of all intubations and 28 (84.8%) out of 33 difficult intubations. Repeat intubations were performed by senior residents/fellows (57.1%) and consultants (14.3%). No instance of failed intubation was reported.CONCLUSIONThe local incidence of difficult obstetric intubation was one in 20. No failure of intubation was observed.     

孕产妇创伤的特点与救治策略

创伤是非产科因素导致孕产妇死亡的首要原因,并伴随着较高的孕产妇和胎儿死亡率。孕产妇创伤以钝性伤常见,救治时需要考虑胎儿,但首先应评估和救治孕妇,并遵循与其他成人一致的创伤评估处理流程。本文就孕产〖JP2〗妇的解剖学和生理学变化及其对创伤救治的影响做一评述,包括孕产妇创伤评估、胎儿评估和紧急手术等,以供临床借鉴。     

Preoperative starvation and pulmonary aspiration. New perspectives and guidelines

The fear of aspiration of gastric contents and its life-threatening consequences in patients(aspiration pneumonitis and respiratory failure), has caused many medical practitioners, particularly anaesthetists, to rigidly follow conservative (i.e. prolonged) preoperative fasting standards. This is the nil per os (NPO) order for clear fluids/liquids and solids overnight or six to eight hours preceding the induction of anaesthesia. This practice neither takes into account the differences in the rate of gastric emptying for solid food (which may exceed six hours) and clear liquids (which is one to two hours), nor the differences in scheduled times of surgery. Long-term prospective studies and retrospective reviews have shown that the incidence of significant clinical aspiration is low: 1.4-6.0 per 100,00 anaesthetics for elective general surgery. Risk factors for pulmonary aspiration include: a high American Society of Anaesthesiologists (ASA) physical status score; emergency surgery; difficult airway management; increased gastric volume and acidity; increased intra-abdominal pressure; gastro-oesophageal reflux; oesophageal disease; head injury with impaired consciousness and extremes of age. Experimental studies and reviews have consistently shown the safety of clear liquid ingestion up to two hours before induction of anaesthesia in healthy patients without risk factors, and the fact that a longer fluid fast does not necessarily offer any added protection against pulmonary aspiration. The conservative pre-operative fasting standard causes discomfort and in some cases, suffering of patients and is therefore unnecessary for patients without risk factor(s). Anecdotal reports at the University Hospital of the West Indies (UHWI) have shown that application of the liberalized guidelines for preoperative fasting and fluid intake has not resulted in increased pulmonary aspiration, morbidity or mortality. Instead it has resulted in decreased irritability, anxiety, thirst and hunger in the peri-operative period. Patients, especially children are more comfortable and the perioperative period is better tolerated. It is therefore time that all medical personnel adopt the liberalized guidelines.     

翠屏区孕产妇死亡原因分析与干预对策

目的：通过对辖区内近5年的孕产妇死亡原因分析，探讨降低孕产妇死亡率的干预措施。方法：采取回顾性调查方法，对11例孕产妇死亡病例进行相关分析。结果：翠屏区孕产妇死亡率下降不理想且不稳定，其前三位死亡原因依次是：产科出血、妊娠期高血压疾病、妊娠合并症。死因与经济收入、文化程度、医疗保健机构、生育等因素有关。结论：应高度重视产科规范化建设，提高助产机构和人员的素质，加强高危妊娠的管理，加强健康宣传和健康促进，对农村及贫困孕产妇提高补助资金，提高住院分娩率。     

广州地区一九九七年孕产妇死亡原因分析

目的：分析广州地区１９９７年２７例孕产妇死亡原因。方法：对广州地区１９９７年孕产妇死亡资料进行回顾性分析并与１９８１～１９８７年资料进行对比。结果：产后出血是直接产科致死原因的首位原因。结论：加强围产保健是降低孕产妇死亡的重要手段。     

Medico-legal aspects of anaesthesia practice.

The public especially in West Malaysia are becoming more aware of their rights and litigations are on the increase. Fortunately in East Malaysia there are fewer cases. The legal aspects of anaesthesia practice are very much on the lines of British system. Here the cause for compensation or legal action depends on the proof of negligence. Currently in West Malaysia all anaesthetics are being given by medical practitioners. In East Malaysia the anaesthetics are being given mainly by Medical Assistant's who have been trained for about six months to give anaesthesia in all government hospitals. There are guidelines on minimum standard of safety for patients undergoing general anaesthesia, though this is not as elaborate as those in Western countries.     

Anaphylaxis: diagnosis and management

Anaphylaxis is a serious, rapid-onset, allergic reaction that may cause death. Severe anaphylaxis is characterised by life-threatening upper airway obstruction, bronchospasm and/or hypotension. Anaphylaxis in children is most often caused by food. Bronchospasm is a common symptom, and there is usually a background of atopy and asthma. Venom- and drug-induced anaphylaxis are more common in adults, in whom hypotension is more likely to occur. Diagnosis can be difficult, with skin features being absent in up to 20% of people. Anaphylaxis must be considered as a differential diagnosis for any acute-onset respiratory distress, bronchospasm, hypotension or cardiac arrest. The cornerstones of initial management are putting the patient in the supine position, administering intramuscular adrenaline into the lateral thigh, resuscitation with intravenous fluid, support of the airway and ventilation, and giving supplementary oxygen. If the response to initial management is inadequate, intravenous infusion of adrenaline should be commenced. Use of vasopressors should be considered if hypotension persists. The patient should be observed for at least 4 hours after symptom resolution and referred to an allergist to assist with diagnosis, allergen avoidance measures, risk assessment, preparation of an action plan and education on the use of self-injectable adrenaline. Provision of a MedicAlert bracelet should also be arranged.     

AIDS in obstetric practice

After a brief review of the AIDS virus, its transmission, and clinical aspects, the obstetric implications of HIV infections for a developing country like India are summarized. HIV, the virus that causes AIDS, is transmissible in utero with a 66% risk of infecting the fetus, and may cause intrauterine growth retardation or prematurity. HIV positive pregnant women may become immunosuppressed, so they should be offered pregnancy termination. A woman in labor infected with HIV should be managed like a woman with hepatitis B: intrauterine catheters, fetal scalp electrodes, and fetal blood sampling are contraindicated. Forceps and episiotomy should be used only if needed. Cesarean section to prevent intrapartum infection of the fetus is controversial. While breastfeeding is allowed, breast milk should not be donated to other infants. Nursing staff should be informed that HIV is much less transmissible than hepatitis.     

46例孕产妇死亡原因分析

目的:了解射洪县孕产妇死亡原因及影响因素。方法:对县妇幼保健院收集我县1996年-2008年度孕产妇死亡病例进行回顾分析。结果:1996年-2008年活产婴儿数87571人,孕产妇死亡46例,死亡率52.53/10万,死亡原因首位是产科出血27例(58.7%),妊娠期高血压病4例(8.7%),羊水栓塞1例(2.1%),合并内科疾病14例(30.4%);死亡地点在家及个体诊所14例(30.4%)、乡镇卫生院13例(28.3%)、县城医疗机构19例(41.2%)。结论:加强孕产妇保健管理,取缔非法接生,提高基层产科人员和医疗机构处理妊娠合并症与并发症的急救能力,是降低孕产妇死亡的关键。     

医麻密切配合在小儿气道异物取出中的关键作用

目的回顾14年小儿气道异物取出术105例的点滴经验,手术医师和麻醉师完美配合是手术成功的关键。准确诊断异物部位,麻醉及用药选择、手术步骤、手术时机等均应仔细研讨。方法小儿气道异物取出中,气管支气管异物大多用全麻：1）眯达唑仑异丙酚复合麻醉。2）异丙酚瑞芬太尼复合麻醉。3）氯胺酮γ-羟基丁酸钠复合麻醉;鼻道异物和咽、喉部异物用无麻或表麻。结果105例小儿气道异物中,气管支气管异物28例,咽、喉及声门区异物24例,鼻道异物53例,一次性取出96例,再次取出9例。无一例术中死亡。结论小儿气道异物应尽快取出,麻醉是关键,深度要足,若全麻深度不足比无麻更危险。要诊断准确,作好术前各项准备,手术时机正确把握。手术医师和麻醉师密切配合,共同预防术中并发症,正确选好异物钳,术者精心操作。预防呼吸和心跳骤停的并发症,及时发现异常征兆和正确处理,就能保证手术的成功。广泛宣传、普及卫生知识、改掉不良习惯,预防误吸异物,减少小儿气道异物的发生率。     

The use of single dose of sodium citrate as a prophylaxis against acid aspiration syndrome in obstetric patients undergoing caesarean section.

The effectiveness of sodium citrate as a prophylaxis against acid aspiration syndrome was studied in 3 groups of obstetric patients. Group I was the control group which consisted of 20 patients in established labour who were not likely to require caesarean section. No antacid had been given to these patients. Group II consisted of 20 patients who underwent elective caesarean section, while Group III consisted of another 20 patients who underwent emergency caesarean section. Group II and III were given 30ml of 0.3M sodium citrate as soon as they arrived in the operation theatre. The gastric content was aspirated after the induction of anaesthesia and at the end of surgery just before extubation. The volume was measured and a sample sent for pH analysis. Sodium citrate was found to increase the gastric pH significantly in both Group II and III patients when compared with Group I patients who underwent emergency caesarean section. We conclude that 30ml of 0.3M sodium citrate is effective in increasing gastric pH though it tends to be associated with an increase in gastric volume.     

Deaths within 24 hours of surgical procedures at the Port-of-Spain General Hospital (January, 1976 to December, 1987)

Mortality, possibly related to anaesthesia, was reviewed prospectively over a 12-year period. There were 186 deaths in 129,107 anaesthetics. Mortality was predominantly confined to the 15-44, and 45-64-year age groups. The overall mortality rate was 1:694. Sixteen deaths were directly related to regional and local anaesthesia and three were directly related to general anaesthetic management. In 66 deaths, general anaesthesia was considered to be contributory, and 101 deaths were considered to be unassociated with anaesthesia.     

25例剖宫产儿死亡原因分析

目的：对２５例剖宫产儿死亡原因进行分析。方法：对我科１９８９年１月至１９９６年１２月３１日间２５例剖宫产死亡新生儿的情况进行回顾性分析。结果：２５例均为高危妊娠。新生儿死亡主要为胎粪吸入综合征引起的缺血、缺氧性脑病，其次为畸形儿，颅内出血占第３位。结论：加强产前、产时监测，提高超声仪器的分辨力和产前诊断的水平，正确掌握剖宫产指征和手术时机。孕妇在术前及术中应取左侧１５度倾斜位，以避免血压突然下降而诱发或加重胎儿窒息     

CONSERVATIVE MANAGEMENT OF TWIN PREGNANCY WITH SINGLE FETAL DEATH

Objective. Analysis of the cause of intrauterine death of one fetus of twin and to evaluate the outcome of conservative management of twin pregnancy with single fetal death. Method. A retrospective review was undertaken on PUMC hospital records of women who delivered twin between Jan. 1987 and Dec. 1998. Result. During the recent 12 years, 99 pregnant women were documented as twin pregnancies. Of the twin pregnancies during this period, 13 were complicated by a single intrauterine death. Four women suffered this complication during their first trimester. In the remain 9 cases one fetus died dm-ing second or third trimester.The cesarean section was given in three pregnant women soon after a single intrauterine death because of the survival fetal distress. No consumptive coagulopathy was apparent in all 13 pregnant women. It is wise that the pregnancy was managed conservatively, with regular coagulation parameters obtained. Condosion. Our results suptmrt conservative management in twin pregnancies complicated by single fetal death.     

创伤及腹部术后并发急性胆囊炎22例

本病病情发展快,危重,死亡率高。本组病死率为23％。当病人出现发热,上腹部痛,白细胞升高时,医师能想到本病的可能而做相应检查。确立诊断后应积极手术切除胆囊。另外,对外伤及腹部手术后并发结石和非结石性胆囊炎及发病因素,死亡原因也作了讨论。     

Recombinant tissue plasminogen activator for acute ischemic stroke

Stroke is a leading cause of serious and long-term disability and death worldwide, with approximately 750,000 strokes occurring annually in the United States of America. The risk of stroke doubles each decade for people over 55 years. Cerebral angiography conducted soon after the onset of stroke demonstrates arterial occlusion in 70%-80% of cases. Recanalization of an occluded cerebral artery may assist in the recovery of reversibly ischemic tissue and limit the neurological disability. In June 1996, the recombinant tissue plasminogen activator was approved as a safe and an effective intravenous treatment for acute ischemic stroke, especially if given within 3 hours of onset of symptoms. Since approval, less than 5% of all stroke patients are receiving recombinant tissue plasminogen activator. In this review we try to answer the question of whether recombinant tissue plasminogen activator therapy should be the first-line treatment for acute ischemic stroke. The result of major recombinant tissue plasminogen activator trials will be summarized and reviewed critically.     

新生儿肺炎与产科相关因素的探讨

目的：为探讨新生儿肺炎的病因和降低病死率。方法：对１１２例住院患儿进行临床分析。结果：发病与产科相关者７８例占６９４３％,各种产科因素致胎儿宫内或产时缺氧直接造成各类吸入性肺炎。孕母产前感染、早破水、产时消毒不严可致感染性肺炎。呼吸衰竭（呼衰）是各类肺炎主要的合并症（２５％）和死亡原因（８０％）。结论：加强产科有关因素的防治可降低新生儿肺炎的发病率,掌握窒息后复苏技术可预防呼衰发生,减少病死率。     

A serological study of cytomegalovirus infection in pregnant and non-pregnant women at Gauhati Medical College and Hospital

Primary cytomegalovirus infection is the most common infection during pregnancy that may have long-term neurodevelopmental sequelae in children born to these mothers. It is also associated with many obstetric complications. So the aim of this study was to determine the seroprevalence of cytomegalovirus infection in local antenatal population with bad obstetric history and to see the effects, if any, of age, socio-economic status, presenting features and different gestational periods. Seventy-five pregnant women with bad obstetric history were screened for the presence of cytomegalovirus specific IgM and IgG antibodies by doing enzyme-linked immunosorbent assay, out of which 17(22.66%) had evidence of recurrent cytomegalovirus infection as demonstrated by the presence of cytomegalovirus specific IgM antibodies. All were found to be positive for cytomegalovirus specific IgG antibodies. This indicates that the presence of cytomegalovirus specific IgM antibodies in this population is an evidence of reactivation of a latent infection or re-infection with a different strain of cytomegalovirus. Increased IgM seropositivity was found to be associated with advancing age, poor, socio-economic status, third trimester of pregnancy and bad obstetric history like premature delivery, stillbirth, recurrent spontaneous abortions, intra-uterine growth retardation. Out of 25 randomly selected non-pregnant women of childbearing age, all showed presence of cytomegalovirus specific IgG antibodies and none was found to be positive for primary or recurrent cytomegalovirus infection.