Propofol for GA c-sections

[zippy2u]

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I say it's OK to use dip for the GA c-sections. I haven't used na pent in years. The little kiddie poos are growin up and passin the FCAT-- can't be all that bad despite what the dip insert says. What say you? -----Zippy

 

[Gimlet]

I say long time no see....always good to know the Zipster is hangin' around!

 

[militarymd]

My L&D ward doesn't even have STP.

 

[militarymd]

And I'm one of those snobby attendings who think GA for C-section is OK.

 

[Noyac]

I'm not a fan of GA for c/s in the first place. Not because of the airway issues or the meds getting to the baby or any of the usual things. I just find that these pts do much much better (in my hands) with a SAB. Husband can join mom in the OR also.

There is some recent literature stating that propofol may not be the best induction agent for c/s. Is this what you are getting at, Zippy?

 

[jwk]

All STP at my main job, either/or at my PRN place.

 

[militarymd]

I'm not a fan of GA for c/s in the first place. Not because of the airway issues or the meds getting to the baby or any of the usual things. I just find that these pts do much much better (in my hands) with a SAB. Husband can join mom in the OR also.

There is some recent literature stating that propofol may not be the best induction agent for c/s. Is this what you are getting at, Zippy?

Please define "do much much better"

 

[zippy2u]

Why isn't it the best induction agent for c- sections, Noyac? Is it adequate? I mean I can't afford the best car to get me from point A to B ,sometimes that 10 year pickup will just have to do, ya know? ---Zip

 

[The_Sensei]

And I'm one of those snobby attendings who think GA for C-section is OK.

Join the crowd.

 

[militarymd]

I'm not a fan of GA for c/s in the first place. Not because of the airway issues or the meds getting to the baby or any of the usual things. I just find that these pts do much much better (in my hands) with a SAB. Husband can join mom in the OR also.

There is some recent literature stating that propofol may not be the best induction agent for c/s. Is this what you are getting at, Zippy?

what's wrong with propofol?

 

[EV-Stentor]

what's wrong with propofol?

Based on UBF studies Propofol @ 2-2.5 mg/ml for induction has been shown to not decrease UBF whereas STP will consistently decrease UBF by 20-30% even though this is only transcient (Shnider: Aneth For Obstetrics, ed 4).
However most anesthesiologists including myself (just a lowly CA2 resident🙂 prefers STP b/c of the severe brady caused by propofol when used with sux in pregnant pts. Remember Propofol causes a centrally mediated brady (albeit rare) so that adding sux will only potentiate this risk.....
STP all the way with a nice stick of ephedrine handy...this is what you will do after SAB induced hypotension anyway. JJP you give the ephedrine prophilactically after the SAB right?
Zippy welcome back dude.

 

[Noyac]

Please define "do much much better"

I like when the moms go to the PACU completely comfortable asking how much the baby weighed, not nauseated, coughing or anything else. In my experience, GA's for c/s on occassion come out hormonal (not a true diagnosis), occasionally nauseated, flailing from place to place even. Now, I am not saying that this is all that often but it is more often than in the spinal pts. I find pregnant women are hard to please sometimes (hope not to offend some of you but I am talking strickly anesthesia wise). They are emotional and anxious.
I'm sure your Ga's are fine, Mil. I am just giving my preference.

 

[Noyac]

Why isn't it the best induction agent for c- sections, Noyac? Is it adequate? I mean I can't afford the best car to get me from point A to B ,sometimes that 10 year pickup will just have to do, ya know? ---Zip

Zip, I still use it as well when I do a GA. But some recent literature and debate has started to point a finger at propofol. It has been shown to worsen acidosis in the umb. cord blood when compared to STP. I don't think that the outcome is any different but I am not sure. Like you say the kids are still thriving.

 

[jetproppilot]

I say it's OK to use dip for the GA c-sections. I haven't used na pent in years. The little kiddie poos are growin up and passin the FCAT-- can't be all that bad despite what the dip insert says. What say you? -----Zippy

Have used it ever since I can remember.

Good to see you, Zipster.

 

[jetproppilot]

JJP you give the ephedrine prophilactically after the SAB right?
.

I do.

 

[Noyac]

And I'm one of those snobby attendings who think GA for C-section is OK.

Listen Mil, I am not about to criticize your anesthetic. That would be ridiculous on my part.

But, I would like to proved a little info to those out there trying to may sense of all this. I am talking about "Elective Cesareans" here. Hawkin's et al Anesthesiology 1997, found that the case fatality was 32 per million vs 2 per million when Ga was used vs regional. This was based on their feeling that airway management skills were decreasing among American-trained physicians. How many of you in training have actually intubated a c/s? I know I only intubated 1 or 2 in training and the parturient airway is predicted to be 10 times more difficult (but you guys know how some of us in private practice feel about the airway 😀 ).
The more interesting studies to me are the ones looking at fetal outcome. There have been a number of retrospective studies evaluating type of anesthetic used in c/s. Roberts et al, Obstet Gynecol, 1995 found that umb artery pH was greater in the neonate delivered with GA, but clinical parameters (ie: Apgars, need for mech. ventilation) was better when regional was used. The acidemia was about 80% respiratory, which does not increase neonatal complications.

2 prospective randomized studies looked at the same thing and found not only that Apgars were better in the regional group but they also found less acidemia.

 

[militarymd]

Listen Mil, I am not about to criticize your anesthetic. That would be ridiculous on my part.

But, I would like to proved a little info to those out there trying to may sense of all this. I am talking about "Elective Cesareans" here. Hawkin's et al Anesthesiology 1997, found that the case fatality was 32 per million vs 2 per million when Ga was used vs regional. This was based on their feeling that airway management skills were decreasing among American-trained physicians. How many of you in training have actually intubated a c/s? I know I only intubated 1 or 2 in training and the parturient airway is predicted to be 10 times more difficult (but you guys know how some of us in private practice feel about the airway 😀 ).
The more interesting studies to me are the ones looking at fetal outcome. There have been a number of retrospective studies evaluating type of anesthetic used in c/s. Roberts et al, Obstet Gynecol, 1995 found that umb artery pH was greater in the neonate delivered with GA, but clinical parameters (ie: Apgars, need for mech. ventilation) was better when regional was used. The acidemia was about 80% respiratory, which does not increase neonatal complications.

2 prospective randomized studies looked at the same thing and found not only that Apgars were better in the regional group but they also found less acidemia.

The studies you have cited just goes to support what I have always criticized about academic anesthesia practice.

Two words: Surrogate Endpoints.

As long as we measure surrogate endpoints, we'll just be wasting time.

 

[militarymd]

The studies you have cited just goes to support what I have always criticized about academic anesthesia practice.

Two words: Surrogate Endpoints.

As long as we measure surrogate endpoints, we'll just be wasting time.

Your other study's problem goes back to interpretation of literature.....You have to have the same patient population. ....

There have been NO...NONE....ZERO studies looking at elective GA for c-sections.

The study you quoted looked at all comers...and in N.American practice...essentially all GAs for c-section is because of some kind of emergency.....which is correlated with increased mortality...no matter what surgery you're doing...whehter you are pregnant or not.

 

[Noyac]

Point well taken , Mil. I am not disagreeing with you at all.

There was a study by Ratcliffe et al, Eur Jn Anesth 1993, "Neonatal well being after elective ceserean delivery with general, spinal, and epidural aneaesthesia." It found the same results.

The info is out there but surrogate end points are the barometer. What would you look at if you did a study?

 

[militarymd]

Point well taken , Mil. I am not disagreeing with you at all.

There was a study by Ratcliffe et al, Eur Jn Anesth 1993, "Neonatal well being after elective ceserean delivery with general, spinal, and epidural aneaesthesia." It found the same results.

The info is out there but surrogate end points are the barometer. What would you look at if you did a study?

neuropsychiatric testing at one year of age.....there is no difference at 1 week.

Anesthesia literature is filled with useless surrogate endpoints that are for the most part utterly meaningless!!!

Why do we look at cord gas pH??? because it reflects fetal well-being....who cares what the pH is when you use whatever induction agent if the child is well at 1 week, 6 months, 1 year????

That's what needs to be evaluated....The difference in 1 week, 6 month , 1 year outcomes when you use stp vs propofol for GA....not some silly, utterly useless surrogate endpoint like cord gas pH....or some other inane measurable parameter.