Cesarean section Perioperative nausea and vomiting under spinal

Cesarean sectionPerioperative nausea and vomiting under spinal anesthesia Present by R1陳世鴻/V.S.韓吟宜 2007.10.09 Cesarean section  Cesarean section這個名詞首先出現在西元一五八一和 一五九八年的兩篇醫學報告中 Cesarean是出現于前一 篇報告，而Section則出現於後一篇報告，Cesarean 一 詞有人以為是因為凱撒大帚（Julius Caesar）是經剖腹 而生產，因而得名，不 過經仔細的查證，則與史實不 合。Cesarean section的由來很可能是從拉丁文動 詞 中的”Cadere”有關，其意思是切開﹔藉此生下的小孩 的拉丁文”Caesones ”，二者合組而來的﹔另有一說 是源於古羅馬的法律”LexRogis”中的一個持 殊條 文”Lex Cesare”而來，其規定是，孕婦如不幸死亡， 需要接受 手術生出小孩，然後再分別加以埋葬。 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 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 Major indication for cesarean section  Immediate or emergent delivery necessary 1. 2. 3. 4. 5. 6. Fetal distress Umbilical cord prolapse Maternal hemorrhage Amnionitis Genital herpes with rupture membrane Impending maternal death Clinical anesthesiology 4th edit. 2006 Anesthesia for cesarean section   1. 2. 3. General anesthesia Regional anesthesia Spinal anesthesia Epidural anesthesia Combined spinal and epidural anesthesia Clinical anesthesiology 4th edit. 2006 Spinal anesthesia in cesarean section  1. 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 2.   Duration : 1.5 to 2 hours Does: ??, >15mg increase complication Miller 6th edit 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 89:1009–1015, 1964.) Miller 6th edit Spinal anesthesia in cesarean section  1. 2. Adequate block: T6~T4 Should receive 1000~1500mL bolus L/R Doesn’t help hypotension but useful in some patient  Supine, left uterine displacement, O2, NBP 1~2/min, ephedrine keeps SBP>100mmHg (prophylactic administration is not recommended), slight Trendelenburg position Miller 6th edit clinical anesthesiology 4th edit. 2006 Cesarean section Perioperative nausea and vomiting 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 2007;104:679 –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 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 Thinking……     Position? Manual? Prophylactic drug Perioperative drug: gas, intrathecal and IV drug Fetus safe? 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 2007;104:679 –83 Position associates with BP Manual displacement of the uterus during Caesarean section Anaesthesia, 2007, 62, pages 460–465 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 Volatile agent Nitrous oxide anxiolysis for elective cesarean section Journal of Clinical Anesthesia (2005) 17, 543–548 Method 1. 2. 3. 4. Prospective, randomized, double-blinded study. 60 ASA status I and II patients scheduled for elective cesarean section under spinal anesthesia Randomized to 2 groups to receive either 100% O2 via facemask or 40% N2O in O2 via facemask. 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 patient’s face. Nitrous oxide has a rapid onset of clinical effects (less than 2 minutes) Discussion    N2O not slow delivery, not interfere uterine tone Side effect shows up when >70% Supplemental oxygen did not increase fetal oxygenation in patients undergoing elective cesarean section under spinal anesthesia (Recently, Khaw et al ) Prophylactic drug usage?       Primperan Droperidol 5-HT3 antagonist Opioid Propofol Other intrathecal injection The Prophylactic Granisetron Does Not Prevent Postdelivery Nausea and Vomiting During Elective Cesarean Delivery Under Spinal Anesthesia Anesth Analg 2007;104:679 –83 Method       Randomized, double-blind, placebocontrolled trial in 176 parturients. Fluid:10 mL/kg of lactated Ringer’s 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. Discussion    no difference between the granisetron group (20.4%) and the control group (17%) Various study: 22%~55% ￬ In this study, INOV in control group may be under-estimated Prophylactic drug usage?       Primperan Droperidol 5-HT3 antagonist Opioid Propofol Other intrathecal injection A single dose of fentanyl and midazolam prior to Cesarean section have no adverse neontal effects CAN J ANESTH 2006 / 53: 1 / pp 79–85 Method    Double-blinded,randomized,placebocontrolled trial 60 healthy women received either a combination of 1 μg·kg–1 fentanyl and 0.02 mg·kg–1 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 Discussion   Maternal more pleasant No obvious effect on neonatal Prophylactic drug usage?       Primperan Droperidol 5-HT3 antagonist Opioid Propofol Other intrathecal injection Dose-Range Effects of Propofol for Reducing Emetic Symptoms During Cesarean Delivery Obstet Gynecol 2002;99:75–9. 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 Discussion   Reduced the incidence of intraoperative, postdelivery nausea, and vomiting Mechanism unclear Prophylactic drug usage?       Primperan Droperidol 5-HT3 antagonist Opioid Propofol Other intrathecal injection Influence of injection rate of hyperbaric bupivacaine on spinal block in parturients: a randomized trial CAN J ANESTH 2007 / 54: 4 / pp 290–295 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. Other drug combined…    Morphine Epinephrine Sufentanyl or fentanyl Combined with morphine Combined Intrathecal Morphine and Bupivacaine for Cesarean Section; ANESTH ANALG 1988;6737&4 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) 20:274–278 Combined with epinephrine Epinephrine Improves the Quality of Spinal Hyperbaric Bupivacaine for Cesarean Section; ANESTH ANAL.C 39s 1987;66:095-400 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 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 Reference             clinical anesthesiology 4th edit. 2006 Miller 6th edit Manual displacement of the uterus during Caesarean section;Anaesthesia, 2007, 62, pages 460–465 The Prophylactic Granisetron Does Not Prevent Postdelivery Nausea and Vomiting During Elective Cesarean Delivery Under Spinal Anesthesia; Anesth Analg 2007;104:679 –83 Nitrous oxide anxiolysis for elective cesarean section; Journal of Clinical Anesthesia (2005) 17, 543–548 A single dose of fentanyl and midazolam prior to Cesarean section have no adverse neontal effects; CAN J ANESTH 2006 / 53: 1 / pp 79–85 Dose-Range Effects of Propofol for Reducing Emetic Symptoms During Cesarean Delivery; Obstet Gynecol 2002;99:75–9. 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 1987;66:095-400 Influence of injection rate of hyperbaric bupivacaine on spinal block in parturients: a randomized trial; CAN J ANESTH 2007 / 54: 4 / pp 290–295 Combined Intrathecal Morphine and Bupivacaine for Cesarean Section; ANESTH ANALG 1988;6737&4 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) 20:274–278