AMBULATORY ANESTHESIA AMBULATORY ANESTHESIA AND AND

OBSTETRIC ANESTHESIAOBSTETRIC ANESTHESIA

Berrin Günaydın, MD, PhDBerrin Günaydın, MD, PhDGazi University Gazi University Faculty of MedicineFaculty of MedicineDepartment of AnesthesiologyDepartment of AnesthesiologyObstetric AnesthesiaObstetric AnesthesiaAnkara - TurkeyAnkara - Turkey

GAZI UNIVERSITY FACULTY OF MEDICINEGAZI UNIVERSITY FACULTY OF MEDICINE

ObjectivesObjectives Definition of ambulatory anesthesiaDefinition of ambulatory anesthesia Preoperative EvaluationPreoperative Evaluation

History taking Physical examination Fasting & medications Laboratory screening

PremedicationPremedication MonitorizationMonitorization Anesthesia choicesAnesthesia choices Postoperative Care Postoperative Care for obstetric procedures done on ambulatory basisfor obstetric procedures done on ambulatory basis

DefinitionDefinition Ambulatory (outpatient) surgeryAmbulatory (outpatient) surgery Basic advantagesBasic advantages

Economic savingsEconomic savings Earlier ambulationEarlier ambulation Lessened risk of nosocomial infectionsLessened risk of nosocomial infections

Anesthesia for ambulatory surgery Anesthesia for ambulatory surgery Patients return home within 24 hours of an Patients return home within 24 hours of an

operative procedureoperative procedure

Procedures done Procedures done on ambulatory basison ambulatory basis Evacuation of incomplete miscarriageEvacuation of incomplete miscarriage Surgical treatment of tubal ectopic pregnancySurgical treatment of tubal ectopic pregnancy Cervical cerclage Cervical cerclage External cephalic versionExternal cephalic version Hysterosalpingography (HSG) - HysteroscopyHysterosalpingography (HSG) - Hysteroscopy Assisted reproductive technologies - proceduresAssisted reproductive technologies - procedures

Transvaginal ultrasound guided oocyte retrieval Transvaginal ultrasound guided oocyte retrieval (TUGOR)(TUGOR)

Preoperative EvaluationPreoperative EvaluationHistory taking

Questionnaires for screening & detecting common medical problems

Maternal death & anesthetic history Relevant obstetric history

Preoperative EvaluationPreoperative EvaluationPPhysical examination

Measurement of vital signs

(pulse, blood pressure, respiratory rate, temperature) Airway, heart & lung examination Back examination (when neuraxial anesthesia is planned)

Preoperative EvaluationPreoperative EvaluationFasting & Chronic medications

Clear fluidsClear fluids Modest amount is allowed up toModest amount is allowed up to 2 h prior to induction of 2 h prior to induction of

anesthesia anesthesia

Solids Solids should be avoided 6-8 h depending on the type of should be avoided 6-8 h depending on the type of

ingestion (e.g.fat) ingestion (e.g.fat)

PPaattientients should bring their own medicationss should bring their own medications AAntihypertensives should be taken ntihypertensives should be taken OOral hypoglycaemics should be omittedral hypoglycaemics should be omitted

White P. Ambulatory anesthesia advances into the new ilennium. Anesth Analg 2000

Hawkins. ASA Practice Guidelines for Obstetric Anesthesia IJOA 2007Hawkins. ASA Practice Guidelines for Obstetric Anesthesia IJOA 2007

Preoperative EvaluationPreoperative EvaluationLaboratory screening

Platelet countPlatelet count Maternal historyMaternal history Physical examinationPhysical examination Clinical signsClinical signs

Blood type & cross-matchBlood type & cross-match Maternal historyMaternal history Anticipated hemorrhageAnticipated hemorrhage Institutional policiesInstitutional policies

ASA Task Force on Obstetric Anesthesia Practice Guidelines Anesthesiology 2007

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, BUNChest radiograph

Hb/ Htc

ECG, BUNChest radiograph

White & Freire. Ambulatory (outpatient) Anesthesia. Anesthesia 2005

PremedicationPremedication BenzodiazepinesBenzodiazepines if indicated

Small dose of midazolam IVSmall dose of midazolam IV (1-3 mg)(1-3 mg)

Alpha-2 agonistsAlpha-2 agonists Clonidine (0.1-0.3 PO)Clonidine (0.1-0.3 PO) Dexmedetomidine (50-70 Dexmedetomidine (50-70 µµg IM or 50 g IM or 50 µµg IV)g IV)

Aspiration prophylaxis Aspiration prophylaxis (for (for diabetics & morbid obeses)diabetics & morbid obeses) HH22--receptor receptor antagonistsantagonists (ranitidine) (ranitidine) Nonparticulate aNonparticulate antacids ntacids (sodium citrate)(sodium citrate) Gastrokinetic agents (metoclopramide)Gastrokinetic agents (metoclopramide)

Hawkins JL. ASA Practice Guidelines for Obstetric Anesthesia. IJOA 2007Hawkins JL. ASA Practice Guidelines for Obstetric Anesthesia. IJOA 2007White P. Ambulatory Anesthesia. Anesthesia 2005

MonitorizationMonitorization Heart rate (maternal & Heart rate (maternal & fetal)fetal) and ECG and ECG Blood pressure Blood pressure (noninvasive)(noninvasive)

Pulse oximetry (SpOPulse oximetry (SpO22))

Capnometry (ETCOCapnometry (ETCO22)) BISBIS

ASA Task Force on Obstetric Anesthesia Prcatice GuidelinesAnesthesiology 2007

White P. Ambulatory anesthesia advances into the new ilennium. Anesth Analg 2000

Anesthesia TechniquesAnesthesia Techniques General Anesthesia Regional anesthesia Monitored Anesthesia Care (MAC)

Borkowski. Cleveland Clin J Med 2006

General AnesthesiaGeneral Anesthesia Induction agentInduction agentss

Propofol (1.5-2.5 mg/kg) is used widely

(easy +quick recovery, clear head, lacks PONV) Sevoflurane (8% in 50% NN22OO-O-O22)

non-irritant to airway, rapid induction, minimal side-effects, but more PONV

Borkowski. Cleveland Clin J Med 2006White. Anesth Analg 2000

Russell R. Summer Update on Obstetric Anesthesia, 2006Levy D. Three day course on obstetric anesthesia, 2007

ThiopentoneThiopentone (3-6 mg/kg) (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)

General AnesthesiaGeneral Anesthesia MaintMainteenancenance

TIVA (pTIVA (propofol ropofol && rremifentanilemifentanil or alfentanil)- or alfentanil)-TCITCI ((BIS < 60)BIS < 60)

Borkowski. Cleveland Clin J Med 2006White. Anesth Analg 2000

Russell R. Summer Update on Obstetric Anesthesia, 2006Levy D. Three day course on obstetric anesthesia, 2007

General AnesthesiaGeneral Anesthesia MaintMainteenancenance

IsofluraneIsoflurane Sevoflurane Sevoflurane DesfluraneDesflurane ? N? N22OO

General Anesthesia General Anesthesia

MuscleMuscle relaxants relaxants (short and intermediate acting drugs)(short and intermediate acting drugs)

Mivacurium

Rocuronium

Cisatracurium AirwayAirway

Face mask LMA Endotracheal intubation

Borkowski. Cleveland Clin J Med 2006White. Anesth Analg 2000

Russell R. Summer Update on Obstetric Anesthesia, 2006Levy D. Three day course on obstetric anesthesia, 2007

General AnesthesiaGeneral Anesthesia

Reversal agentsReversal agents Benzodiazepin antagonist (flumazenil) Antichoinesterase drugs Sugammadex (rocuronium antagonist) Opioid antagonists (naloxone)

Spinal aSpinal anesthesianesthesia AdvantagesAdvantages

Simple-quick procedureSimple-quick procedure Short turnover timeShort turnover time Patients are alert Patients are alert Less nausea-vomiting Less nausea-vomiting

DisadvantagesDisadvantages 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 2003Mordecai & Brull Curr Opin Anaesthesiol 2005, Korhonen. Curr Opin Anaesthesiol 2006

Spinal aSpinal anesthesianesthesia

Prevention against disadvantagesPrevention 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 2005Korhonen. Curr Opin Anaesthesiol 2006

Neuraxial anestheticsNeuraxial anesthetics

Ideal neuraxial anestheticIdeal 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 UnconsciousConscious (MAC) vs Unconscious SedationSedation

ConsciousConscious UnconsciousUnconscious

MoodMood Alert-cooperative No cooperation

Protective reflexesProtective reflexes Active-intact Obtunded

Vital signsVital signs Stable Labile

AnalgesiaAnalgesia Regional/local analgesia

Central analgesia

Recovery room stayRecovery room stay Not prolonged Prolonged/admission

Complication riskComplication risk Low High

Postop.complicationPostop.complication Infrquent Frequent

Mentally incompetent Mentally incompetent patientspatients

Not suitable Suitable

Drugs used for MACDrugs used for MAC

DrugDrug Loading dose (Loading dose (µµg/kgg/kg)) Maintenance (Maintenance (µµg/kg/ming/kg/min))

AlfentanilAlfentanil 10-25 0.25-1

FentanilFentanil 1-3 0.01-0.03

SufentanilSufentanil 0.1-0.5 0.005-0.01

RemifentanilRemifentanil - 0.025-0.1

KetamineKetamine 500-1000 10-20

PropofolPropofol 250-1000 10-50

MidazolamMidazolam 25-100 0.25-1

Postoperative CarePostoperative CarePainPain

Multimodal approachMultimodal approach NSAID and/or nonopioid analgesicsNSAID and/or nonopioid analgesics (local anesthetics, (local anesthetics,

acetaminophen, proparacetamol)acetaminophen, proparacetamol) COXCOX22 inhibitors inhibitors (celecoxib)(celecoxib)

LA wound infiltrationLA wound infiltration at the time of surgeryat the time of surgery patient controlled elastomeric pumppatient controlled elastomeric pump

Neuraxial opioidsNeuraxial opioids

White P. Anesth Analg 2000 Carvalho B. Summer Update on Obstetric Anesthesia, 2006

Postoperative CarePostoperative CarePONVPONV

ProphylacticProphylactic antiemetics antiemetics Multimodal Multimodal treatmenttreatment regimen regimen

ButyrophenonesButyrophenones PhenotiazinesPhenotiazines Gastrokinetic drugs Gastrokinetic drugs AnticholinergicsAnticholinergics AntihistaminesAntihistamines Serotonin antagonists Serotonin antagonists (4-8 mg IV)(4-8 mg IV)

NK-1 antagonistsNK-1 antagonists Dexametazone Dexametazone (4-8 mg IV)(4-8 mg IV)

Acupuncture (P6 and others)Acupuncture (P6 and others)

White P. Anesth Analg 2000White & Freire. Anesthesia 2005

Discharge CriteriaDischarge Criteria

Aldrete Activity Respiration Circulation Conscious level Color of the skin

Postanesthesia Discharge Scoring System (PDSS) 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 miscarriageSurgical treatment of miscarriage(vacuum aspiration or D&C)(vacuum aspiration or D&C)

Anesthetic optionsAnesthetic 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 2006Fassoulaki et al. No change in plasma endorphine and melatonine levels after sevoflurane anesthesia. JCA 2007

Hysterosalpingography (HSG) 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 Hysteroscopy

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. 2005Farid et al. JCA 2001

Tubal ectopic pregnancyTubal 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 CerclageCervical 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 CerclageCervical Cerclage

Neuraxial anesthesia (spinal or epidural)Neuraxial anesthesia (spinal or epidural) Use of low-dose epiduralUse of low-dose epidural

0.125% bupivacaine with epinephrine & fentanyl 0.125% bupivacaine with epinephrine & fentanyl

Spinal anesthesiaSpinal anesthesia

lidocaine 30 mg or bupivacaine 5.25 mg both with lidocaine 30 mg or bupivacaine 5.25 mg both with fentanyl 20 fentanyl 20 µµg have been used successfully for g have been used successfully for cervical cerclagecervical cerclage

Tsen. What’s new and novel in obstetric anesthesia?IJOA 2005Schumann & Rafique. Low dose epidural anesthesia for cervical cerclage. CJA 2003; 50:424

External Cephalic VersionExternal 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

TUGORTUGOR General

Inhalational anesthesia TIVA

Regional blocks Spinal Epidural PCB

Conscious sedation (MAC)

PCB + IV remifentanil

Tsen. Int Anaesthesiol Clin 2007Gunaydin et al.J Opioid Manag 2007

Gunaydin et al.J Opioid Manag 2007

CONCLUSIONSCONCLUSIONS Ambulatory surgery aims the best patient carepossible at the reasonable cost, ambulatory anesthesiamust meet these requirements

Issues that prolong stay in PACU primarily

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