sedationstation

The Epidural Re-Dose Checklist – this checklist will assist you in epidural labor analgesia management.    Is the patient experiencing pain or discomfort?    Is her pain Verbal Rating Scale (VRS) ≥ 4 (out of 10)?    Did the patient obtain previous relief with the current epidural catheter?    Does the patient have a bilateral T-10 level?    When was the patient’s last vaginal exam? What is her cervical dilatation?    Does the patient have complete cervical dilatation? Is it time to push?    Does the patient have a full bladder? Does her bladder need emptied?    Does the patient have a 1-sided block? Is she turning every hour?    Is the PCEA infusion running/working adequately?    Is patient pushing her PCEA button appropriately?    Has dyst...

Prior cesarean delivery and the presence of placenta previa in a current pregnancy are particularly important risk factors for placenta accreta.  In a multicenter study of more than 30,000 patients who had cesarean delivery without labor, the risk of placenta accreta was approximately 0.2%, 0.3%, 0.6%, 2.1%, 2.3%, and 7.7% for women experienc- ing their first through sixth cesarean deliveries, respectively.  In patients with placenta previa in the current pregnancy, the risk of accreta was 3%, 11%, 40%, 61%, and 67% for those undergoing their first through their fifth or greater cesarean deliveries, respectively  1-Silver RM, Landon MB, Rouse DT, Leveno KJ, Song CY, Thom EA, et al. Maternal morbidity associated with mul- tiple repeat cesarean delivery. Obstet Gynecol 2006;107: 1226–32. (Level II-2) 

Ten tip to make your epidural more successful  .... click on the following link                                                      Click here  

Characteristics of Ligamentum Flavum at Different Vertebral Levels Site Skin to Ligament (cm) Thickness of Ligament (mm) Cervical — 1.5–3.0 Thoracic — 3.0–5.0 Lumbar 3.0–8.0 5.0–6.0 Caudal Variable 2.0–6.0

Weight gain (12-20 kg) Enlarging gravid uterus Increasing total body water and interstitial fluid Increasing blood volume Deposition of new fat Enlargement of the breasts Respiratory system Decrease in respirator reserve volume Decrease in functional residual capacity (20%-30%) Increased oxygen consumption More rapid desaturation Airway Increased oral, nasal, pharyngeal, and tracheal mucosal edema Vascular engorgement of oral, pharyngeal, and nasal capillaries Edema of face and neck Advancement of Mallampati classification with pregnancy Advancement of Mallampati classification with bearing down during labor Cardiovascular system Inferior caval syndrome (supine hypotensive syndrome) requiring left uterine tilt Gastrointestinal system Steadily increasing intragastric pressure as pregnancy progresses Decreased lower esophageal sphincter tone due to increasing progesterone Symptomatic gastroesophageal reflux Distortion of gastric anatomy Increased gastric...

Postural headache   Think low CSF pressure headache, Postdural puncture headache (PDPH). History of similar headaches Think migrane ,1/3 to half of women with migraine will have a postpartum headache and the nature of symptoms are similar to their previous headaches. Headache associated with antenatal/post-natal history of hypertension, proteinuria or seizure  Think  Postpartum Preeclampsia. Abrupt headache   think aneurysm subarachnoid haemorrhage, cerebral venous thrombosis and a vascular cause.

Reduction in spinal-induced hypotension with ondansetron in parturients undergoing caesarean section: a double-blind randomised, placebo-controlled study. Abstract BACKGROUND : Subarachnoid block is the preferred method of anaesthesia for caesarean section, but is associated with hypotension and bradycardia, which may be deleterious to both parturient and baby. Animal studies suggest that in the presence of decreased blood volume, 5-HT may be an important factor inducing the Bezold Jarisch reflex via 5-HT3 receptors located in intracardiac vagal nerve endings. In this study, we evaluated the effect of ondansetron, as a 5-HT3 receptor antagonist, on the haemodynamic response following subarachnoid block in parturients undergoing elective caesarean section. METHODS : Fifty-two parturients scheduled for elective caesarean section were randomly allocated into two groups. Before induction of spinal anaesthesia Group O (n=26) received intravenous ondansetron 4 mg; Grou...

- One third of asthmatic patients will experience an improvement in their symptoms during pregnancy, one third will suffer a worsening and one third notice no change. - In those that deteriorate, the peak severity is between weeks 24 and 36 after which symptoms improve with attacks being very unusual in labour because of endogenous steroid production. - No adverse outcomes have been demonstrated with the use of inhaled β2 agonists, inhaled steroids, theophyllines or magnesium during pregnancy. Oral steroids do not have convincing evidence of harm and the British Thoracic Society concludes that the detriment to mother and foetus by not adequately treating acute severe asthma outweighs the potential, unproven risk of systemic steroids in pregnancy. - Uncontrolled asthma during pregnancy is associated with hyperemesis, hypertension, pre-eclampsia, premature delivery and low birthweight babies. Emphasis is therefore on maintaining good control with t...

Excessive doses of vasopressor can cause hypertension , but the increase in arterial pressure is  limited by a baroreceptor-mediated reflex decrease  in HR, which is more sensitive in pregnancy  . If the vagus nerve is blocked, this protective reflex is lost and dangerously high pressures can ensue.  Two worrying case reports of hypertensive crises induced in women undergoing spinal anaesthesia for caesarean delivery have been reported. In both, a combination of atropine and vasopressor was given to treat bradycardia associated with hypotension, resulting in severe hypertension and tachycardia.  This caused acute coronary artery dissection in one  and, in the other, a myocardial infarction and pituitary  haemorrhage . These studies suggest that when vagolytics are, quite rightly, given to treat bradycardia associated with hypotension, further vasopressor should be admin...

This is from Anesthesiology in August 2006, but still important. click here Ruppen et al. present a meta-analysis of well over one million parturients describing the incidence of serious neurologic injuries, including infection, after epidural analgesia and anesthesia. 1.37 million women are included in this risk analysis. This is the largest study to date on these complications. An associated editorial comments on the importance of risk factors, and standards of care including full sterile precautions and allowing adequate time for antiseptics to work ( 2 minutes is quoted) The Key findings are Epidural haematoma 1 in 168,000 Deep epidural infection, 1 in 145,000 Persistent neurologic injury, 1 in 240,000 Transient neurologic injury, 1 in 6,700

Once the fluid and fetal cells enter the maternal pulmonary circulation, usually AFE presents as 2 phases . First phase: The patient experiences acute shortness of breath which may lead to hypotension and cardiac arrest. It is said that half of women does not provide beyond this phase. Second phase : S urvivors of first phase will pass onto the second phase. This is known as the hemorrhagic phase and may be accompanied by severe shivering, coughing, vomiting, and the sensation of a bad taste in the mouth. This is accompanied by excessive bleeding due to DIC. Regardless the phase the treatment is mostly supportive.

For the first time, doctors have imaged a live birth using a special MRI machine, hoping to illuminate the birthing process and understand how complications may develop. The mother and baby — who was born Nov. 20 — are both doing fine, according to doctors at Berlin's Charité hospital, who announced the results today. The mother agreed to give birth inside the MRI machine, which was specially designed to be larger than the typical narrow cylinder. She still had to wear earmuffs to block out the high-frequency noise, as CNET points out . To protect the baby’s hearing, the machine was shut off just before the amniotic sac opened.

Cesarean Section is about 20% of all deliveries. Severe pain for 48 hrs. Two components; Visceral and Somatic Possible chronicization of pain (10-15%) Multimodol analgesia :neuroaxial morphine,paracetamol,NSAIDs,Tramal TAP Block is effective..But maybe intrathecal morphine is superior(Kanazi et al).. TAP is probably interesting in CS under General anesthesia. More abstracts: www.lsanesthesia.org

Intrathecal Morphine for post operative pain : Doses from 0.075 mg to 5 mg have been tested . limited effectiveness of doses less than 0.1mg ceiling effect at 0.2 mg and more. Duration of analgesia is 27 hours..(11-29 hrs) Dose dependent side effects: pruritis  ,Nausea,Vomiting..significantly decreased with dose of 0.1mg Clinically significant respiratory depression rarely if dose < 0.2mg..Obesity is a risk factor  For more abstracts...                                                www.lsanesthesia.org

There is no evidence that bed rest is beneficial in the treatment and prevention of postdural puncture (Level 1 evidence (cochrane review)) The incidence of postdural puncture headache is reduced by using small-gauge spinal needles and/or a non-cutting bevel.level 1 evidence. Further high quality trials are required to determine the efficacy of epidural blood patch administration in the treatment of postdural puncture headache (Level 1).However benefit is likely Frequent use of analgesics, triptans and ergot derivatives in the treatment of recurrent acute headache may lead to medication overuse headache.

In a cochrane review, 11,444 women in 15 randomized trials were recruited from a mix of high, middle, and low income countries. The largest is the 33-country MagPie Trial comparing intravenous magnesium to placebo. The study was published in 2002 and at >10,000 subjects accounts for more than 87% of those in the review. The use of magnesium sulfate was associated with a greater than 50% relative reduction in the risk of eclampsia (RR 0.41).  As noted by the reviewers, a similar reduction in maternal mortality (RR 0.54) was also found, though the absolute number of deaths was small which may have kept this reduction from reaching statistical significance.  A reduction in placental abruption was also noted (RR 0.64) as well as a small increase in the rate of cesarian section. No differences were seen in child outcomes. As a secondary outcome, magnesium sulfate was more effective than phenytoin for reducing risk of eclampsia in 3 trials (RR 0.08) but also increase...

Anesthetic Plan... Fetal surgical cases require team work. These include: pediatric general surgery, obstetrics, pediatric anaesthesia, obstetric anaesthesia, cardiology, radiology, neonatology, neonatal nursing and operating room nursing. Preoperative preparation Standard anesthtic history, physical examination and history of symptoms of aortocaval compression or gastroesphageal reflux. Cross-matched blood for the mother. O-negative blood for the fetus. Maternal antibodies to blood antigens can cross the placenta. Specific fetal information as location of the placenta, fetal weight, the actual disease process and pathophysiology. Anesthesia for minimally invasive These cases are the most variable in need for maternal analgesia and anesthesia and in the need for fetal analgesia or immobility. An anesthestic plan can range from local infiltration to sedation to neuroaxial to general anesthesia. The current practice include maternal fasting, IV catheter, aspiration prophylaxis and tocoly...

In 1963 Sir William Liley performed the first successful fetal procedure, consisting of an intraperitoneal blood transfusion. In the past two decades, fetal surgery has become popularized in the management of congenital anomalies that may lead to complication at delivery. Fetal surgical procedures can be divided into: 1.Minimally invasive intervention. These are the most frequently performed fetal surgical procedure. The access may be as minor as one small gauge radio frequency probe; the timing of these procedures is early or mid-gestation. 2. Open mid-gestation surgery. A maternal laporotomy is performed; the incision is usually transverse and cephalic than that performed in c/section, the necessary anatomy of the fetus is only delivered via the hysterotomy. 3. EX-utero intrapartum therapy (EXIT) procedure. These procedures are performed at or near term to optimize lung maturity. Surgical intervention is performed before the umbilical cord is clamped while on placental bypass. The ne...

After passing the epidural catheter through the Ligamentum Flavum we expect the catheter to end up in the epidural space (best)..somtimes intrathecal( sure less good)..and rarely in the subdural(even more less good)...but now there is another place that epidural catheter may end up.... According to a study publised in Anaesthesia intensive care 2011 Nov;39(6):1038-42 .The authors (Collier, Reina et al) suggest the existence of a fourth space. Failed epidurals In some of these patients, radiological studies showed restricted spread of contrast injected into the failed epidurals.  This striking compartmentalisation that you see in the above photo  , didn’t look at all like any spread you would expect from epidural or subdural injections. The fourth space The authors realized this could represent ‘a fourth space’, more precisely located within the dura . Next, the authors obtained samples of the epidural sac from cadavers and analyzed them. After preparing the...