Awake fibreoptic intubation following failed regional anaesthesia for caesarean section in a parturient with Still's disease

The anaesthetic management of a 25-year-old parturient with juvenile rheumatoid arthritis (Still's disease) and a difficult airway presenting for elective Caesarean section is described. Inadequate block after epidural anaesthesia necessitated general anaesthesia. This was safely accomplished by securing the airway with awake oral fibreoptic intubation before general anaesthesia was induced. The problems of performing an awake fibreoptic intubation in a pregnant patient are discussed and a simple method for performing the technique is described.     

A prospective audit of regional anaesthesia failure in 5080 Caesarean sections

Anaesthesia for Caesarean section was audited over a 5 year period: 5080 cases were performed using spinal 63%, epidural top-up 26%, combined spinal-epidural 5% and primary general anaesthesia 5%. The rate of general anaesthesia conversion of regional anaesthesia was 0.8% for elective and 4.9% for emergency Caesarean section compared to Royal College of Anaesthetists targets of 1% and 3%. The rate of conversion of regional to general anaesthesia in category 1 Caesarean section was 20%. A total of 8% of women had general anaesthesia when both primary general and conversion of regional anaesthesia were combined. The rate of failure to achieve a pain-free operation was 6% with spinals, 24% with epidural top-up and 18% with combined spinal-epidural. Besides the type of anaesthesia and operative urgency, other factors associated with pre-operative failure of regional anaesthesia included body mass index, no previous Caesareans, and indication for Caesarean of acute fetal distress or maternal medical condition. Inadequacy of pre-operative anaesthetic block and duration of surgery were important risk factors for intra-operative failure. For spinal anaesthesia, use of a spinal opioid was associated with less pre-operative failure. For epidural top-up anaesthesia, lower epidural top-up volume was associated with less pre-operative failure, and use of adrenaline was associated with both less pre-operative and intra-operative failure. The rate of serious adverse incidents was 1 : 126 with general anaesthesia and 1 : 501 with regional anaesthesia.     

The impact of increasing the use of regional anaesthesia for emergency caesarean section

BACKGROUND AND OBJECTIVE: In 1991 general anaesthesia was used extensively for emergency Caesarean section at Haukeland University Hospital even in patients with an ongoing epidural infusion. With increased knowledge of the potential safety benefits of regional anaesthesia and increased experience with the technique, we decided to use indwelling epidural catheters for emergency Caesarean section. METHODS: We conducted a retrospective analysis of a full annual data set on emergency Caesarean section in parturients with ongoing epidural analgesia in 1997 and compared it with a similar data set from 1991. RESULTS: Epidural anaesthesia was used significantly more often in 1997 with 115 (78%) cases than in 1991 with five (12%) cases (P < 0.001). Elapsed time before adequate anaesthesia and the start of surgery was significantly shorter in 1991 (mean 8.3 min) compared to 1997 (mean 13 min) (P < 0.001). No deaths or major complications were observed in either group. Intraoperative minor complications were observed more frequently in 1997 with 70 cases (47%) than in 1991 with two cases (6%) (P < 0.001). The principal complications were hypotension and nausea. Postoperative complications in mother and neonate were similar in both groups. There was a significantly shorter mean hospital stay in 1997 (6 days), compared with 1991 (8 days) (P < 0.001). CONCLUSION: The increase in the use of indwelling epidural catheters for emergency Caesarean section has resulted in a significant increase in the use of regional anaesthesia. A modest increase in time elapsed before start of surgery was observed although there were no significant differences in the number of neonates with low Apgar scores. No major complications were observed, but there was an increased frequency of minor complications in 1997.     

Sciatic nerve palsy following childbirth

Two cases are reported of sciatic nerve palsy after delivery by Caesarean section in primigravidae. One mother was slender and had an emergency Caesarean section for failure to progress with a breech presentation. Epidural analgesia during labour was extended for operative delivery. The other mother was obese, mildly hypertensive, had a large baby with a high head and was delivered by elective Caesarean section under epidural anaesthesia. She experienced severe intrapartum hypotension. Both patients suffered right sided sciatic nerve palsy. The aetiologies of obstetric palsies and those following regional block are reviewed and the importance of careful diagnosis and of avoiding peripheral nerve compression during regional block are emphasised.     

Do we have to monitor foetal heart rate during general anesthesia?

We present a case of an emergency Caesarean section due to misinterpretation of the cardiotocography (CTG) trace during general anaesthesia for treatment of dental abscess. Following failure of the dental abscess treatment under local anaesthesia, a 29-year-old female in the 36th week of a twin pregnancy was to undergo general anaesthesia. Foetal well-being was monitored with ultrasonographic evaluations of foetal heart rate. During surgery, senior obstetrician recorded a lack of beat-to-beat variability of the cardiotocography trace. The CTG pattern was interpreted as foetal distress and an emergency Caesarean section was performed under general anaesthesia. That was probably due to general anaesthesia. Then, two infants were extracted without neonatal distress necessitating intubation. This case report underlines the risk to misread an intraoperative CTG monitoring and if the CTG monitoring is normal before anaesthesia, reduced foetal beat-to-beat variability with a normal baseline heart rate during general anaesthesia is probably normal.     

Extension of epidural blockade in labour for emergency Caesarean section using 2% lidocaine with epinephrine and fentanyl, with or without alkalinisation

In a randomised, double-blind study, we investigated rapid extension of epidural analgesia to surgical anaesthesia for emergency Caesarean section. Parturients receiving epidural analgesia in labour who subsequently required Caesarean section were given a test dose of 3 ml lidocaine 2% with epinephrine 1 : 200 000, followed 3 min later by 12 ml lidocaine 2% with epinephrine 1 : 200 000 and fentanyl 75 microg, to which was added 1.2 ml sodium bicarbonate 8.4% (bicarbonate group; n = 20) or saline (saline group; n = 20). Mean (SD [range]) time to surgical anaesthesia was less in the bicarbonate group (5.2 (1.5) [2-8] min) than the saline group (9.7 (1.6) [6-12] min; mean difference 4.5 min (95% CI 3.5-5.5) min; p < 0.001). Maternal side-effects and neonatal outcome were similar between groups. We conclude that pH-adjusted lidocaine 2% with epinephrine and fentanyl is effective for rapidly establishing surgical anaesthesia in patients with a functioning epidural catheter for labour who require emergency Caesarean section.     

Anaesthesia for Caesarean section in a patient with myotonic dystrophy receiving warfarin therapy

A 31-yr-old parturient with myotonic dystrophy and asthma presented for elective Caesarean section. The patient was receiving warfarin having had two previous episodes of thromboembolism. Anticoagulation was subsequently provided by heparin in the weeks prior to delivery. The combination of the patient’s medical conditions and the continuing need for anticoagulation presented a considerable anaesthetic problem in planning anaesthesia and analgesia for both elective and emergency delivery. Heparin was discontinued on the day prior to surgery and restarted immediately after surgery. During surgery flowtron anti-embolitic boots were used. Warfarin therapy was recommenced on the seventh postoperative day. Anaesthesia for Caesarean section was provided using a combined spinal epidural technique using a separate needle, separate interspace method. Postoperative pain was relieved by using a continuous epidural infusion, transcutaneous nerve stimulation and diclofenac. No new neurological problems arose despite the use of epidural analgesia in the presence of heparin anticoagulation. This method of providing anaesthesia and postoperative analgesia without the use of opioids in an anticoagulated, asthmatic, myotonic parturient has not been described elsewhere.     

Epidural and spinal (subarachnoid) anaesthesia for Caesarean section

Regional anaesthesia for Caesarean section is increasing in popularity — a trend encouraged by obstetric anaesthetists because of its greater safety and the emotional benefits tomother and baby. Such anaesthesia is easier to provide for elective cases, but even in the case of many emergency or semi-emergency Caesarean sections there may be time to extend an epidural already in use, or to use spinal anaesthesia.The reason for the difficulty in providing effective epidural anaesthesia in some cases has been clarified with the identification of variable bands and septa in the epidural space. Spinal block gives more reliable anaesthesia but carries a higher risk of hypotension so that monitoring to detect, and measures to prevent it must be particularly rigorous.Two new developments which are likely to play a part in improving regional anaesthesia for Caesarean section and post-operative pain relief are continuous spinal and combined spinal-epidural techniques. In the case of the former, particular interest is being focused on very fine microcatheters, but the incidence of post-spinal headache with larger catheters is also being reassessed. The combined technique gives the speed of onset and reliability of the spinal block with the flexibility of analgesia provided by the epidural catheter, as well as the advantage of the Tuohy needle acting as guide for the very fine spinal needles.     

Plasma cholinesterase changes during the puerperium

Changes in plasma cholinesterase activity during the puerperium were studied in 16 women who received epidural analgesia for labour followed by vaginal delivery, and in five women who underwent elective Caesarean section under epidural analgesia. A consistent fall in cholinesterase activity was demonstrated during the first 2 to 3 days post partum, followed by a rise to approximately normal nonpregnant values by the end of the puerperium. An additional patient who manifested prolonged paralysis following an emergency Caesarean section under general anaesthesia, including a suxamethonium infusion, was also studied. Possible mechanisms by which the transient decrease in cholinesterase activity is produced, and its clinical significance, are discussed.     

Epidural anaesthesia for labour and Caesarean section in a parturient with a single ventricle and transposition of the great arteries

We describe a case of a 29-year-old parturient with a single ventricle and transposition of the great arteries who had lumbar epidural analgesia/anaesthesia with a local anaesthetic for labour, emergency Caesarean section and postoperative pain. Her outcome and that of her baby was successful. The anaesthetic techniques used in other parturients with similar congenital cardiac anomalies are reviewed.     

Combined epidural/spinal anaesthesia for Caesarean section

An evaluation of a 30 gauge spinal needle in a combined epidural/spinal anaesthetic technique for Caesarean section revealed a 25% failure rate of the spinal element. In this unit, no more than 4% of spinal anaesthetics might be expected to fail. One of the reasons for the higher failure rate was that, when using the Tuohy needle as an introducer, the dura was not identified. This prompted us to compare the 'through-the-Tuohy' or needle within needle approach for combined epidural/spinal anaesthesia, with a technique that involved siting the epidural and spinal sequentially in separate spaces. One hundred women requiring elective Caesarean section under spinal anaesthesia were randomised into single or double space groups. The technique failed in 16% of through-the-needle cases, and in 4% of sequential sitings. Combined spinal/epidural anaesthesia for Caesarean section is more successful if each procedure is performed using separate spaces.     

Topical nasopharyngeal anaesthesia with vasoconstriction in preeclampsia-eclampsia

We report the case of a 38-year-old eclamptic patient undergoing emergency Caesarean section who required awake nasotracheal intubation because of her massively swollen and lacerated tongue. Vasoconstriction, in addition to topical anaesthesia, was required due to thrombocytopaenia. The use of three per cent lidocaine with 0.125 per cent phenylephrine for anaesthesia and vasoconstriction is described with successful maternal and neonatal outcome.     

The extension of epidural blockade for emergency Caesarean section: a survey of current UK practice

The conversion of epidural analgesia during labour to surgical anaesthesia for Caesarean section can have important medical and medicolegal implications. This survey sought to establish the current management for extending epidural blockade for emergency Caesarean section. A postal questionnaire was sent to the lead obstetric anaesthetist in all maternity units in the UK (n = 254). The response rate was 82% (n = 209). Of those surveyed, 68% (136) give the full dose of the local anaesthetic mixture in the delivery room, whilst 12.5% (25) initiate the top-up in the delivery room and give the remainder of the dose in theatre. Fifteen per cent (30) transfer the woman to theatre before commencing anaesthesia and 34% (68) give a test dose before the full anaesthetic dose. Guidelines for converting labour analgesia to anaesthesia for emergency Caesarean section were available in 64% (128) units. Bupivacaine 0.5% was the most commonly used agent, being used as the sole agent by 41.5% (81) units and in combination by a further 18% (36). Adrenaline was added to the chosen local anaesthetic by 30% (60) whilst 12% (24) added bicarbonate. In all, 13 combinations of local anaesthetics and adjuncts were used. The mode time to transfer the patient to theatre was 1 min. Of the 161 respondents who commenced anaesthesia in the delivery room, 71% (114) did not monitor the patient during transfer, whilst 87% (140) had ephedrine immediately available. Thirty-three respondents reported a total of 43 adverse incidents associated with the extension of epidural blockade. These included high blocks, inadequate blocks and possible intravascular injections, the latter resulting in two seizures and one cardiac arrest.     

Low-dose combined spinal-epidural anaesthesia vs. conventional epidural anaesthesia for Caesarean section in pre-eclampsia: a retrospective analysis

BACKGROUND AND OBJECTIVE: Epidural anaesthesia is the preferred technique of anaesthesia for Caesarean section in pre-eclampsia. Spinal anaesthesia is considered by some as a safe and effective alternative, which is especially useful in emergency situations. Combined spinal-epidural anaesthesia, using low doses of local anaesthetics with opioids, is effective and reduces the incidence of hypotension in normal pregnancy. We performed a retrospective chart analysis to evaluate the effects of combined spinal-epidural anaesthesia on maternal haemodynamics and fetal outcome compared to conventional epidural anaesthesia. METHODS: A retrospective anaesthesia chart analysis of all pre-eclamptic patients who underwent Caesarean section over a 4 yr period was performed. Patient characteristic, obstetric, haemodynamic, fetal and neonatal data were gathered and analysed according to the anaesthetic technique used. RESULTS: Seventy-seven pre-eclamptic parturients undergoing Caesarean section were identified (26 women were severely pre-eclamptic and 51 demonstrated mild pre-eclampsia). Epidural anaesthesia was performed in 62 patients and combined spinal-epidural anaesthesia was performed in 15. No differences in patient characteristic and obstetric data were noted. Highest mean arterial pressure prior to anaesthesia was comparable between the groups (epidural: 106 +/- 12 vs. combined spinal-epidural anaesthesia: 109 +/- 18 mmHg) as well as the lowest recorded mean arterial pressure following anaesthesia (epidural: 93 +/- 13 vs. combined spinal-epidural anaesthesia: 98 +/- 17 mmHg). In the combined spinal-epidural anaesthesia group more ephedrine was used compared to the epidural group (14.6 +/- 4.4 vs. 3.6 +/- 4.6 mg, P < 0.05). However, more lactated Ringer's was used in the epidural group. Umbilical artery pH was lower in the epidural group (7.26 +/- 0.01 vs. 7.29 +/- 0.02, P < 0.05). Similar results were noted in 26 severely pre-eclamptic patients. Seven women underwent combined spinal-epidural anaesthesia and 19 underwent epidural anaesthesia in the severely pre-eclamptic group. Also more ephedrine was used in the combined spinal-epidural anaesthesia group. A tendency towards a lower umbilical artery pH was observed in the epidural group but this difference did not reach statistical significance. CONCLUSIONS: Combined spinal-epidural anaesthesia appears to be safe as anaesthetic technique for pre-eclampsia and severe pre-eclampsia. However, it is important to consider the retrospective design of the study and the large number of epidural anaesthetics performed.     

The influence of anaesthetic techniques and type of delivery on peripartum serum interleukin-6 concentrations

Background: Interleukin-6 is a pleiotropic cytokine with a wide range of physiological activities. It plays an important role in the immuno-neuro-humoral axis during stress and surgery.
Methods: Serum interleukin-6 in parturients was measured on hospital admission, immediately after birth and 12 and 24 hours later. All parturients had uncomplicated pregnancies, and delivered vaginally without (n=31) or with (n=20) epidural analgesia, or underwent Caesarean section under epidural (n=20) or general (n=10) anaesthesia.
Results: Serum interleukin-6 assayed immediately following Caesarean section was low, but peaked 12 hours later, irrespective of the anaesthetic technique or other foetomaternal characteristics. Patients who delivered vaginally showed the highest interleukin-6 levels immediately after delivery. These were positively correlated with serum interleukin-6 on admission and duration of labour. Serum interleukin-6 was significantly higher in parturients who had epidural analgesia, and was significantly lower in those receiving intravaginal prostaglandins compared to those without prostaglandins.
Conclusion: The interleukin-6 response after Caesarean section can be explained by a generalized acute phase response to surgery, with no anaesthetic, maternal or neonatal interference. The rapid increase in peripartum serum interleukin-6 levels after vaginal delivery reflects, in part, cervical ripening or labour, their physiological triggers and psychological or physical stress. Regional anaesthesia, duration of labour and exogenous prostaglandin administration can modulate the peripartum interleukin-6 response and subsequently the physiological effects of this cytokine.     

Obstetrical anaesthesia in Ontario

The purpose of this study was to determine the availability of regional anaesthesia for Caesarean section, of epidural opioids and patient-controlled analgesia after Caesarean section, and of epidural and other forms of analgesia in labour. A mail survey was sent to the “Head Nurse, Department of Obstetrics” at each of the 142 hospitals in Ontario with designated obstetric beds. Responses were obtained from 100% of hospitals. For Caesarean Section, general anaesthesia was used in all hospitals, and was the only option in seven. Epidural anaesthesia was used in 93% of hospitals, and spinal anaesthesia in 48%. Postoperatively, patient-controlled analgesia was used in 31% of hospitals and spinal opioids in 28%. In 66 hospitals, im or iv opioids were the only types of analgesia available. For analgesia in labour, im or iv opioids were used in 96% of hospitals, nitrous oxide was used in 75%, epidural analgesia in 75%, transcutaneous electrical nerve stimulation in 52% and patient-controlled analgesia in 10%. The overall epidural rate was 38%. Although the average rate in the 73 hospitals with fewer than 500 births per year was only 6% 14 large hospitals had an epidural rate of 60% or higher. It is concluded that regional techniques for peripartum analgesia have been widely accepted. Analgesia after Caesarean section could be improved. Epidural analgesia should be more widely available, especially in the many small hospitals in Ontario.     

Circulatory collapse following epidural bolus for Caesarean section a profound vasovagal reaction? A case report

IntroductionReduced blood pressure is commonly seen associated to spinal anaesthesia for Caesarean section and efforts to reduce its occurrence and its magnitude is common practice. Cardiovascular collapse requiring cardio-pulmonary resuscitation after putting the spinal/epidural block for Caesarean section is however a rare but most dramatic event.Presentation of caseWe describe a case with sudden short loss of circulation, circulatory collapse, short after start of emergency Caesarean section in top up epidural anaesthesia (3 + 12 ml ropivaciane 7.5 mg/ml), requiring CPR. The neonate was delivered during CPR with Apgar 1, 10, 10 at 1, 5 and 10 min. Circulation was restored following 60–90 s of CPR and administration of 0.5 mg adrenaline. No cardioversion was administered sinus rhythm was regained spontaneously. The mother and child had a further uncomplicated course. No signs of cardiac damage/anomaly, emboli, septicaemia, pereclampisa or local anaesthetic toxicity was found. The patient had prior to the decision about Caesarean section had fever and was subsequently relatively dehydrated.DiscussionThe patient had a fast return of sinus rhythm following birth of the child, without cardioversion. None of common causes for cardiac arrest was found and the patient an uncomplicated post Caesarean section course. The combination of epidural induced sympathetic block and reduced preload possibly triggered a Bezold-Jarisch reflex with a profound vasovagal reaction.ConcluiosnA structured plan for the handling of cardiovascular crisis must be available wherever Caesarean section are performed. Adequate volume loading, left tilt and vigilant control of circulation following regional block performance is of outmost importance.     

Extending low-dose epidural analgesia for emergency Caesarean section. A comparison of three solutions

We conducted a prospective double-blind randomised trial to compare bupivacaine 0.5%; a 50 : 50 mixture of bupivacaine 0.5%/lignocaine 2% with 1 : 200 000 adrenaline (final concentration); and lignocaine 2% with 1 : 200 000 adrenaline for converting a low-dose labour epidural into a block adequate for emergency Caesarean section. Ninety patients were studied, 30 in each group. There was no difference between the groups in the time taken for bilateral loss of cold sensation to reach T4. Onset time was unaffected by the existing sensory level pre-Caesarean section top-up; the number of low-dose top-ups in labour; the total dose of bupivacaine in labour; or maternal weight or height. Three patients in the lignocaine with adrenaline group had blocks that reached the cervical dermatomes and three in the same group required general anaesthesia for inadequate anaesthesia, compared with none in the other groups (both p = 0.04).     

Successful epidural anaesthesia for a patient with Takayasu’s arteritis presenting for caesarean section

The management of a 24-yr-old parturient with Takayasu’s arteritis (TA) presenting at term for Caesarean section is discussed. The best anaesthetic management for the patient with TA is controversial, but avoiding regional anaesthesia has been suggested by some authors because of the risk of hypotension and the subsequent need for vasopressors. We report the use of regional anaesthesia in a term parturient with severe TA undergoing Caesarean section. Anaesthesia was provided with chloroprocaine 3%, via a lumbar epidural catheter. The initial doses of 60 mg and 150 mg were followed by a decrease in BP (from 110/70 to 70/40) which was corrected with iv fluids and ephedrine 25 mg. Additional doses of chloroprocaine, 150 and 90 mg, were uneventful. It is concluded that an epidural can be made in safety to provide anaesthesia for Caesarean section in patients with TA.     

Anaesthetic management of a parturient with severe muscular dystrophy,lumbar lordosis and a difficult airway

Purpose

This case describes the management of a 19-yr-old wheelchair bound primigravida with severe muscular dystrophy who presented for Caesarean section after spontaneous rupture of membranes. Anaesthesia was influenced by several features of her systemic disease which were impediments to both neuraxial and general anaesthesia.

Clinical features

Other than for a prenatal record and the history obtainable from the patient, little additional medical information was available. Physical examination showed diffuse muscular weakness and an anatomically abnormal airway. Examination of the spine showed slight 10–15° thoracolumbar scoliosis and > 45° lumbar lordosis. Fetal assessment was normal. Echocardiography revealed mildly decreased left ventricular function and was consistent with pulmonary hypertension. After discussion with the patient and her obstetrician, elective Caesarean delivery was deemed the best management. Neuroaxial anaesthesia was at an increased risk of failure due to the profound lumbar lordosis. A plan for awake intubation and general anaesthesia was described to the patient in case regional anaesthesia could not be initiated. A fibreoptic bronchoscope and difficult intubation kit were made available. General anaesthesia was expected to have increased risk of postoperative pulmonary complications, hence epidural anaesthesia was attempted. After difficult catheter insertion, a sensory block was titrated to a T₄ level. This was well tolerated by both mother and fetus. A healthy baby was delivered with Apgar scores of 9 and 9. Postoperatively the mother was transferred to the intensive care unit. After 72 hr, the patients respiratory status allowed transfer to the ward.

Conclusion

This case illustrates the use of epidural anaesthesia in the successful management of a severely compromised patient with limb-girdle muscular dystrophy undergoing elective Caesarean section.