General Anesthesia for Emergency C-Section: When Do You Let OB Make Incision?

[macmgi]

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You've induced general anesthesia via rapid sequence induction for an emergency c-section. Do you let the obstetrician make incision before endotracheal intubation?

 

[HollywdAnesth]

I haven't done OB in a while, but my stance then was no. I would tell the OB to cut after I had CO2 return. My argument was that saving the life of the mother was ultimately more important should the airway prove to be difficult.

That being said we took every precaution to avoid this scenario. If a mother with a presumably difficult airway was in labor we made sure she had an epidural was in place (unless contraindicated), and we had plenty of ramps and blankets for super obese women. I thankfully never had any airway problems in OB.

 

[Idiopathic]

polls from first time posters always make me curious

 

[caligas]

as a general rule, i find it best not to respond to polls from first time posters

Please explain

 

[Southpaw]

You've induced general anesthesia via rapid sequence induction for an emergency c-section. Do you let the obstetrician make incision before endotracheal intubation?

OP, it's your first post, and from an anesthesiology standpoint it's a pretty straightforward decision to say No and yet you voted Yes. At this point I'm pretty suspicious as to your motives here. Please explain a little more.

 

[macmgi]

OP, it's your first post, and from an anesthesiology standpoint it's a pretty straightforward decision to say No and yet you voted Yes. At this point I'm pretty suspicious as to your motives here. Please explain a little more.

My motivation is to gather opinions from a broad group of professionals.

I don't think the decision is straightforward.

My thought is that if there is fetal distress, minimizing time to delivery is important. Increasing the time to delivery while dealing with a difficult airway could negatively impact the baby.The mother might be effectively oxygenated and ventilated via mask or LMA. The baby could be delivered contemporaneous with airway management.

I apologize to those who may have found my post suspicious or ill-intentioned.

 

[narcusprince]

You sound like a lawyer or obstetrician. Cut after airway is secured!

 

[pgg]

Please explain

It's sort of suspicious for legal research from a plaintiff's attorney, and some of us have an aversion to helping or even acknowledging the existence of such wretched human beings.

I don't see any harm in discussing or answering, though. If he is a lawyer, and his case is so weak that he thinks "expert" opinion pulled off an internet chat board might help the suit, well, I think he's boned anyway, and may as well be surfing 4chan for all the good it's going to do him.


I voted no. If you lose the airway, better that the OB is free to cut the neck instead of the uterus. The best argument for cutting early I've heard is that if there is a lost airway and mom arrests, technically ACLS says CPR with a gravid uterus interfering with blood return to the heart is useless, and emergent/expectant c-section is indicated. This thought process doesnt concern itself with fetal outcome, just mom's survival. On the other hand, I think we should be very flexible with adhering to ACLS guidelines, which are based on data from out-of-hospital cardiac events, not in-OR respiratory arrests.

 

[BLADEMDA]

It's sort of suspicious for legal research from a plaintiff's attorney, and some of us have an aversion to helping or even acknowledging the existence of such wretched human beings.

I don't see any harm in discussing or answering, though. If he is a lawyer, and his case is so weak that he thinks "expert" opinion pulled off an internet chat board might help the suit, well, I think he's boned anyway, and may as well be surfing 4chan for all the good it's going to do him.


I voted no. If you lose the airway, better that the OB is free to cut the neck instead of the uterus. The best argument for cutting early I've heard is that if there is a lost airway and mom arrests, technically ACLS says CPR with a gravid uterus interfering with blood return to the heart is useless, and emergent/expectant c-section is indicated. This thought process doesnt concern itself with fetal outcome, just mom's survival. On the other hand, I think we should be very flexible with adhering to ACLS guidelines, which are based on data from out-of-hospital cardiac events, not in-OR respiratory arrests.

Correct PGG. Follow ACLS guidelines even on pregnant patients. Secure the Airway First as that is Priority number one. If you fail to secure the airway on the first or second attempt then consider an LMA (Proseal) or mask ventilation. I would then allow the OB Physician to cut. Over the past several decades thousands of sections have been performed safely under LMA or mask ventilation so there is no need to cut the neck for a failed intubation only failed ventilation.

 

[macmgi]

Correct PGG. Follow ACLS guidelines even on pregnant patients. Secure the Airway First as that is Priority number one. If you fail to secure the airway on the first or second attempt then consider an LMA (Proseal) or mask ventilation. I would then allow the OB Physician to cut. Over the past several decades thousands of sections have been performed safely under LMA or mask ventilation so there is no need to cut the neck for a failed intubation only failed ventilation.

My question wasn't to focus on a respiratory arrest/ACLS as much as on the thought process regarding the decision on when to allow the incision to occur. I'm not convinced that endotracheal intubation takes priority over delivery of the fetus.

I agree with you regarding the efficacy of other means of airway management short of a surgical airway.

The thought of an obstetrician wielding a scalpel over a patient's neck gives me pause.

 

[BLADEMDA]

My question wasn't to focus on a respiratory arrest/ACLS as much as on the thought process regarding the decision on when to allow the incision to occur. I'm not convinced that endotracheal intubation takes priority over delivery of the fetus.

I agree with you regarding the efficacy of other means of airway management short of a surgical airway.

The thought of an obstetrician wielding a scalpel over a patient's neck gives me pause.

An average intubation takes 20 seconds. 20 seconds. You should secure the airway prior to incision as the airway takes priority over the incision. My average time from induction to cut is about 45 seconds.

If you need longer than 90 seconds then perhaps cutting prior to intubation makes sense.

 

[macmgi]

An average intubation takes 20 seconds. 20 seconds. You should secure the airway prior to incision as the airway takes priority over the incision. My average time from induction to cut is about 45 seconds.

If you need longer than 90 seconds then perhaps cutting prior to intubation makes sense.

Do you mean that your average time from intubating conditions to cut is 45 seconds?

Are you saying that after 90 seconds of attempting to intubate, you would let the OB cut or are you saying that if one anticipates longer that 90 seconds, cutting prior to intubation make sense?

And why 90 seconds?

 

[pgg]

For a truly emergent section, it still takes (at best) some number of minutes to get from the L&D labor room, to the OR, onto the table, on monitors, prepped, draped ...

a) What am I really gaining by cutting after induction/succ, but before the tube is in the trachea? A delivery 10 seconds earlier? 20?

b) What am I really losing by letting the OB cut immediately after induction when the fasciculations stop? Well, if things go to hell with the airway, the 2nd-most skilled person in the room is now elbow deep in a different problem and of no use to me.

c) How many angels can we fit on that pin, anyway?


People are usually wound up and freaked out in these cases anyway. 10 or 20 seconds of forced idleness might be good for everyone. 😉

 

[IlDestriero]

I voted no. If you lose the airway, better that the OB is free to cut the neck instead of the uterus.

I would cut the neck myself anyday before I let the OB take a whack. They're often marginal in the belly, which is their area of expertise.:what: During a crash C/S they're already way too distracted and occasionally freaking out and borderline out of control. (I've seen that way too much!) At least I'm intimately familiar with the head and neck anatomy. It's not rocket science.
I voted yes BTW. I tell them to cut when I DL and see cords. If I can't see the cords, and it hasn't happened to me in a C/S yet, I'd wait until I secured the tube with the glide or bougie. How much time might it save? 10 or 20 seconds? I'll take it.

 

[Laryngophed]

People are usually wound up and freaked out in these cases anyway. 10 or 20 seconds of forced idleness might be good for everyone. 😉

Are you proposing the observation of law #3? 😉

 

[pgg]

I voted yes BTW. I tell them to cut when I DL and see cords. If I can't see the cords, and it hasn't happened to me in a C/S yet, I'd wait until I secured the tube with the glide or bougie. How much time might it save? 10 or 20 seconds? I'll take it.

DL & see cords is as good as intubated. 🙂

Are you proposing the observation of law #3? 😉

Yes, yes I am. 🙂

 

[BLADEMDA]

Do you mean that your average time from intubating conditions to cut is 45 seconds?

Are you saying that after 90 seconds of attempting to intubate, you would let the OB cut or are you saying that if one anticipates longer that 90 seconds, cutting prior to intubation make sense?

And why 90 seconds?

Here is how it goes:

Patient in room. hooked up and belly prepped. Ob standing over mommy with knife in hand; or, I'm faster than OB and inducing patient while OB is getting gowned up. Either way I push the drugs and RN or RT applies cricoid pressure while holding facemask.
About 30 seconds after pushing drugs I intubate the patient which takes under 20 seconds. The OB then cuts the belly. If I can't intubate the patient (only happened once) I'll mask the patient while telling OB to cut the belly. I then place the LMA and get the glidescope along with extra help. I always make sure the anesthesia is "on" as I want to avoid recall.

On average the time it takes to intubate a patient and get a secure airway is about 20 seconds longer than your method of just allowing the OB to cut prior to intubation. I do not believe that extra 20 seconds makes a difference in fetal outcome and I want a secure airway prior to surgical incision.

 

[sevoflurane]

Mom always comes first (higher priority than fetus).

So what if she's 400 lbs and a known difficult AW? Prop sux tube?
Hmmm... Whose taking the boards? 😉

 

[imfrankie]

Mom always comes first (higher priority than fetus).

So what if she's 400 lbs and a known difficult AW? Prop sux tube?
Hmmm... Whose taking the boards? 😉

Spinal, Touhy if necessary

 

[ssmallz]

Mom always comes first (higher priority than fetus).

So what if she's 400 lbs and a known difficult AW? Prop sux tube?
Hmmm... Whose taking the boards? 😉

That situation should never end up as a crash section w/out prior knowledge. I say should b/c depending on the strength of your ob staff they may drop things on you w/out warning and you should have adequate time to place an epidural prior to c-section or at least section the pt in a nonemergent manor. W/that being said mom always comes first before the fetus and a stat c-section is usually to save the fetus, not the mother. To put mom in jeopardy by inducing GA on a difficult airway is risking moms life to save what may or may not be a viable fetus. Secure the airway or pop a spinal in before inducing, at least ensure make sure you can mask ventilate or LMA before cutting. I'd rather defend a dead fetus and a living mom then a dead mom any day.

If the case is so emergent that mom is actively dying, I.E. gunshot to the belly hypovolemic shock then that is the only situation in which I would let them cut before securing the airway and in that situation I may not even need to induce GA.

 

[countingdays]

I let them cut as soon as she's paralyzed because I don't think anything they are doing up there will make intubation more difficult.

 

[Ignatius J]

Macmgi,

I am not trying to be disrespectful, but I agree with others. It is very suspicious that you aren't an anesthesiologist as your shield indicates. Can you please just clarify that for us? Are you a licensed anesthesiologist? Apologies if I seem disrespectful again.

 

[countingdays]

Macmgi,

I am not trying to be disrespectful, but I agree with others. It is very suspicious that you aren't an anesthesiologist as your shield indicates. Can you please just clarify that for us? Are you a licensed anesthesiologist? Apologies if I seem disrespectful again.

Yeah. A patient can take 2 days to present, then an Obstetrician can take 3 hours to see the patient, but any problem will be due to the 20 seconds the anesthesiologist said to wait until the tube is in place.

 

[macmgi]

Macmgi,

I am not trying to be disrespectful, but I agree with others. It is very suspicious that you aren't an anesthesiologist as your shield indicates. Can you please just clarify that for us? Are you a licensed anesthesiologist? Apologies if I seem disrespectful again.

I'm ABA certified and have been in practice for close to twenty years.

 

[Ignatius J]

Gotcha. Okay. My apologies again.