General anesthesia in Caesarean section

1. Good morning po doctors, in this opportunity I will presenting case of general anesthesia on

caesarean section
2. The objectives are :
 To present a case of General Anesthesia on Caesarean section
 To discuss perioperative management of General Anesthesia on Caesarean Section
3. This is a case of 33 years old Female, Filipino from Silang Cavite, she was admitted : September

29, 2018, For repeat caesarean section

4. She was G3P2 (2002) Pregnancy uterine 39 weeks by last menstrual period , multiple slip disc

from vertebral L2 to S1, morbid obese

5. She was previously smoker and alcohol drinker, with no history of allergies, hypertension,

diabetic , asthmatic. Her first menstrual period since she was 11 years old, and it was regular

until 2016, she started to have irregular menstrual period, no dysmenorrhea

6. She has family history of hypertension on her mother side, not known for diabetic, asthmatic,

tumor and malignancy, heart disease nor neuromuscular disorder on her family history
7. She was previously gave birth under caesarean section with spinal anesthesia for two times, the

first one was due to arrest of cervical dilatation, also she had 2 times diagnostic dilatation and

curettage, physical therapy for her lower back injury, that caused her to quit from her work at

that time due to severe shooting pain on lower back, spreading to her left leg
8. This is her pregnancy history, with two times caesarean section under spinal anesthesia, this was

happened before she had her lower back injury

9. She had essentially normal review of general systems, and had slightly change in bowel

movement, which made her constipation

10. From pre operative evaluation, we found she was fully awake, not in cardiovascular distress with

normal vital sign, the BMI was 43.34 kg/m2 which classified her into morbid obese, the other

physical examination also essentially normal, with not decreased in physiological reflexes on her

lower limb. Although she was complained that she still having mild numbness on her left leg ever

since
11. On admission day CBC, urinalysis and baseline CTG was ordered, also she had to has fasting start

at 3 am
12. The CBC result was in normal range
13. Also with the urinalysis result
14. From MRI result that she brought, she had multiple deformities on her lumbar to sacral area, as

we can see at slide :

 L5/S1 degenerative disc, posterior annular fissure and left subarticular disc extrusion
 L4/L5 degenerative disc, posterior annular fissure and central disc protrusion
 L3/L4 posterior disc bulge
 L2/L3 degenerative disc, left extra foraminal disc bulge
 S2 peri-neural cyst
15. As the pre operative evaluation done, and anesthesia plan, risk and benefit explained, we also

ordered to give her ranitidine metoclopramide at 9 am as premedication, and put her on fasting

at 3 am
16. And she was classified as ASA 3P patient due to her obesity
17. The plan from Ob doctor were to do repeat CS , as from anesthesia the plan was to do General

Anesthesia
18. At the OR day she was received at OR, awake, not sedated, with increased of blood pressure,

meanwhile other vital sign was within normal range

19. The sequence was: patient preoxygenated with 5 LPM, 100% oxygen with GA mask, then after all

monitor was placed, patient also done be prepared also draped. All the surgeon were also ready
 to do the procedure, then we began to induct patient. The drug administered was fentanyl

rocuronium then propofol in sequence, then we were rapidly intubate patient with ETT size 7

mm internal diameter, mark 23 cm at lipline then ETT was cuffed and secured . Anesthesia

maintained with sevoflurane 2% and oxygen 2 LPM .

20. This is the record of patient intra op monitoring. The baby was delivered 5 minute after

intubation, then 30 unit of oxytocin incorporated to her present IV . then the anesthesia

maintained with low concentration of sevoflurane , then given additional fentanyl to deepened

it, paracetamol 600mg and tramadol 50 mg was also given as additional analgesic. Then

methergine was administered about 30 minute after the baby was out, and around 45 minute

since the procedure begun patient seem to gained consciousness, then propofol 60 mg and 5 mg

of rocuronium administered. The sevoflurane concentration was increased to 3 % for a few

minutesthen ketorolac 30 mg and additional paracetamol 300 mg given as post op analgesia. The

procedure was done in 1.5 hour , sevoflurane concentration gradually decreased to zero, then

sugamadex was administered to reverse rocuronium effect. After patient awake, the tracheal

extubation was initiate, then patient was transferred to PACU

21. This was her post operating medication that been ordered, as for post operative analgesia

Tramadol 50 mg IV q8 x 3 doses, Ketorolac 30 mg IV q6 x 4 doses, Paracetamol 600 mg IV q6 x 4

doses ordered
22. On her first post OR day she was able to eat as tolerated, and all the pain reliever shifted to oral

ny ob doctor, the vital sign within normal range and the pain was tolerable. On second day she

was discharged
23. Discussion
24. Previously before 1990s maternal mortality rate related to anesthesia was high, which is 32

death per 1 million live birth that undergo GA , 1.9 death per 1 million live birth with regional

anesthesia. Then recent survey showed significant decrease on maternal mortality rate to 1.2 %

of live birth, which possibly due to greater use regional anesthesia on CS

25. In current practice neuraxial block are more preferable option to GA
26. That might be because of the advantage that offered by regional anesthesia, also bedside of the

disadvantage that found on general anesthesia such as

GA advantages disadvantages

Very rapid & reliable onset > pulmonary aspiration

> Control over airway & ventilation Inability to ventilate & intubate

< hypotension Drug induced fetal depression

Neuraxial < Neonatal exposure of depressant drug > hypotension

< pulmonary aspiration Possibility of PDPH

> post-op pain relief + intrathecal opioid

27. On obstetric we should always considered them to have full stomach , so if the patient will

undergo CS under GA we have to give them premedication for preventing gastric contain

pulmonary aspiration. We also have to do pre operative evaluation as early as possible.we have
 also to put in mind that maternal mortality and morbidity for CS under GA is higher. The

morbidity mostly because of difficulty to maintain the airway, such as ventilation and intubation.

And one of our consideration to do GA for CS is the existence of contraindication for regional

anesthesia
28. The contraindication of neuraxial block can be differentiate to absolute and relative. This is the

table of contraindication to do regional anasthesia

29. To do CS under GA we have to give premedication to prevent aspiration as we speak earlier.

Giving adequate denitrogenation wit O@ 100% for 3-5 minute. Cautiously on giving drugs that

can cause fetal depression, such as opioids and benzodiazepines. Then do rapid sequence

induction, using low concentration of volatile agent to maintain anesthesia. And the induction to

delivery time window has to be less than 10 minutes to decrease the significant effect of drugs

related fetal depression, also awake extubation to avoid pulmonary aspiration

30. On obstetric patient iv opioids proven can cross placenta and causing fetal depression, that’s

why we should limiting the use of this agent intravenously. The degrees of fetal depression

depend on:
a. Specific agent
b. Dose
c. Time elapsed – administration to delivery [ < 10minutes → (-) significant effect ]
d. Fetal maturity
IV opioids also cause maternal respiratory depression , delay gastric emptying, nausea and

vomiting that can lead to increase in incidence of pulmonary aspiration . agent that usually use

on obstetric patient is:

• Meperidine 10-25 mg (max 100mg) - Max. Maternal & fetal depression in 10 -20

minutes
• Fentanyl 25- 100 mcg - analgesia onset 3-5 min, duration to 60 minutes – duration of

maternal & fetal depression > analgesic

• Mixed agonist & antagonist ( butorphanol 1-2 mg, nalbuphine 10-20 mg) – effective, <<

respiratory depression, >> sedation

• Ketamine 10 – 15 mg – onset of analgesia 2-5 minute, (-) loss concioussness
31. This is the sequence that recommended to do GA on CS:
a. Supine + wedge on R hip
b. Denitrogenation 3-5 minutes- placing monitors, patient prepared & draped for surgery
c. Surgeon ready – Rapid sequence induction ( cricoid pressure; propofol 2 mg/kg or

Ketamine 1-2 mg/kg, succinylcholine 1.5 mg/kg)

d. Start procedure after proper placement of ETT
e. Low dose of volatile agent. ( volatile agent – uterine relaxation, prevent contraction

following oxytocin).
f. Intermediate duration muscle relaxant – addition to low dose of volatile agent
g. 20-80 unit oxytocin after neonate & placenta delivered
h. Inadequate uterus contraction – methergine 200 mcg IM
i. Attempt to aspirate gastric content via OGT
 j. Awake extubation
32. This is the scheme for failed intubation on obstetrics patient that will undergo CS

33. As conclusion
a. GA for CS should be done cautiously
b. IV Opioid use also should be administered cautiously
34. Thank you po