qns regarding literature on time to delivery after C section under GETA

[AKMD_1984]

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Greetings:

I was wondering if you guys can help me with this and can share some links on articles.

1) What is the 'acceptable' or 'safe' time between anesthetic induction til uterine incision, and also induction to delivery of baby?
2) If the mother is anesthetized with propofol and succinylcholine, but as long as the hemodynamics are stable, and blood pressure is normal, will that really affect UBF and perfusion?
3) Lets say, the induction dose of propofol crosses the placenta (assume 1.75 mg/kg dose), how long do we expect the baby to be in respiratory distress or apneic? Baby is full term.
I though this was transient

 

[izzygoer]

I think incision should be once reflexes are lost. Is ob getting the baby out changing the ability to secure the airway? Worst case scenario airway is lost the baby has to come out anyway. Delaying them gives them and the lawyer another reason if that kid hiccups on the way out. anesthetics still theoretically depress the baby irrespective of hemodynamics.

 

[pgg]

Greetings:

I was wondering if you guys can help me with this and can share some links on articles.

1) What is the 'acceptable' or 'safe' time between anesthetic induction til uterine incision, and also induction to delivery of baby?

Presumably if you're inducing general anesthesia then you're in a hurry for some reason related to fetal distress. In that case it's less the anesthesia, and more the hypoxia/whatever that should be driving the OB to hurry up. We typically give the OBs the signal to go ahead as soon as the patient is induced and the tube placed, and they'll usually deliver within a minute or two.

2) If the mother is anesthetized with propofol and succinylcholine, but as long as the hemodynamics are stable, and blood pressure is normal, will that really affect UBF and perfusion?

UBF and perfusion will be fine if you preserve normal hemodynamics. If anything, that first whiff of volatile will improve UBF by putting a halt to any uterine contractions.

3) Lets say, the induction dose of propofol crosses the placenta (assume 1.75 mg/kg dose), how long do we expect the baby to be in respiratory distress or apneic? Baby is full term.
I though this was transient

It is transient at worst, possibly nearly non-existent, but it's a convenient thing for the OB and pediatrician to blame for a floppy baby. It is very well established that a normal induction dose of either thiopental or propofol has no clinically significant effect upon neonates. Certainly none by the 5 and 10 minute APGARs. However, repeated doses prior to cord clamping (why would anyone do this?) might result in neonatal plasma levels high enough to cause depression.

The main reason IV induction agents don't have much (if any) clinically significant effect on neonates beyond a minute or two of life, is that the drug rapidly redistributes from vessel-rich organs to peripheral tissues. Also, there is some degree of first pass metabolism in effect, as blood flow from the placenta via the umbilical vein mostly passes through the fetal liver first (some will bypass the liver through the ductus venosus shunt direct to the IVC). Regardless, the drug's effect on the neonate is ended by the same mechanism as the mother - rapid redistribution, not metabolism.

As for references ... every OB anesthesia textbook covers this. See Chestnut, Datta's high risk OB anesthesia book, or Ginosaur's fetus & anesthesia book. Most of the historical research concerns thiopental but it appears propofol is an equivalent substitute in just about every regard.

 

[AKMD_1984]

Thank you pgg.

I did look at chestnut, barash as well, but I really could not find a safe time which specifies this.
Lets say that between induction and incision, 5 minutes elapsed, as long as hemodynamics are normal, is there any risk to the neonate vs incision at 20 seconds?

 

[Mman]

I think incision should be once reflexes are lost. Is ob getting the baby out changing the ability to secure the airway? Worst case scenario airway is lost the baby has to come out anyway. Delaying them gives them and the lawyer another reason if that kid hiccups on the way out. anesthetics still theoretically depress the baby irrespective of hemodynamics.

Are you suggesting they start performing major abdominal surgery on your patient with a massive full stomach before you have secured the airway? Really?????????

That's insane. Want to know what changes your ability to secure the airway? When that lady starts vomiting everywhere after they make their incision. If you find an expert witness that testifies that they make incision prior to intubation for emergency c-sections in this country, I will be impressed.

 

[AKMD_1984]

Are you suggesting they start performing major abdominal surgery on your patient with a massive full stomach before you have secured the airway? Really?????????

That's insane. Want to know what changes your ability to secure the airway? When that lady starts vomiting everywhere after they make their incision. If you find an expert witness that testifies that they make incision prior to intubation for emergency c-sections in this country, I will be impressed.

See, I believe that they should really make the incision after the airway is secured as well. Otherwise you are running into a possible disaster situation - what if you are not able to intubate immediately and the OB patient by default is full stomach and DAW.

We have this arbitrary policy that the baby needs to be delivered within 2 minutes. What about preexisting scarring? - like today, for repeat C section (4th one) under spinal, it took 25 minutes just to get through the abdominal wall.

 

[deleted162650]

what if you are not able to intubate immediately and the OB patient by default is full stomach and DAW

You know there’s a published algorithm for this very scenario right?

 

[AKMD_1984]

You know there’s a published algorithm for this very scenario right?

I’m sure there is.
I don’t think algorithms are always useful.

 

[MoMoGesiologist]

Are you suggesting they start performing major abdominal surgery on your patient with a massive full stomach before you have secured the airway? Really?????????

That's insane. Want to know what changes your ability to secure the airway? When that lady starts vomiting everywhere after they make their incision. If you find an expert witness that testifies that they make incision prior to intubation for emergency c-sections in this country, I will be impressed.

So if you induce for an c-section and are unable to place the ETT, you ask OB to hold off on incision (while you mask, LMA, fiberoptic, etc)? Let’s say you are able to mask or LMA, do you wait for definitive ETT?

On the one hand, if you wait for a secured airway, baby is at risk as I’m assuming this is a crash section for decreased fetal tones.

On the other hand, if you don’t have a secured airway, you risk emesis and aspiration especially when the OBs start pushing down on the uterus and trying to get baby out. The uterus is kind of far from the stomach, and on awake women with neuraxial, I haven’t had them really throw up from the physical pressure of the OBs doing their surgery.

I figured people would just continue masking or with the LMA and tell the OBs to cut and not delay. Is the right answer to delay, do an aintree or fiber optic first?

 

[Mman]

I figured people would just continue masking or with the LMA and tell the OBs to cut and not delay. Is the right answer to delay, do an aintree or fiber optic first?

The odds of going down that scenario are probably low enough that the overwhelming majority of anesthesiologists will not see that scenario in a 35 year career. We do about 5K deliveries a year at this point and have had that maybe once or twice in the last 30 years and that was before widespread use of glidescopes.

 

[NightNight]

So if you induce for an c-section and are unable to place the ETT, you ask OB to hold off on incision (while you mask, LMA, fiberoptic, etc)? Let’s say you are able to mask or LMA, do you wait for definitive ETT?

On the one hand, if you wait for a secured airway, baby is at risk as I’m assuming this is a crash section for decreased fetal tones.

On the other hand, if you don’t have a secured airway, you risk emesis and aspiration especially when the OBs start pushing down on the uterus and trying to get baby out. The uterus is kind of far from the stomach, and on awake women with neuraxial, I haven’t had them really throw up from the physical pressure of the OBs doing their surgery.

I figured people would just continue masking or with the LMA and tell the OBs to cut and not delay. Is the right answer to delay, do an aintree or fiber optic first?

Had this scenario once in my (relatively short) career. Crash section, specifically asked OB in the OR (in front of all staff) if there was time for neuraxial, he said no, induce can’t intubate can mask,told OB to cut 2nd attempt w/ glide still no dice, place LMA confirm ventilation, once baby/placenta delivered told the OB to stop and placed ETT via FOI. A few butt puckering moments to be sure.

 

[deleted162650]

I’m sure there is.
I don’t think algorithms are always useful.

While I agree with you to some extent, I think this algorithm is pretty damn useful. As pointed out by @Mman, this is an exceedingly rare occurrence. Why would you not follow the outline put forth by our national society? It seems to me to be the most prudent path to follow both medically, and certainly medico-legally. Instead of trying to lead us down this rabbit hole circle-jerk of a discussion, our time would be better spent discussing exactly which scenarios you feel warrant deviation from the algorithm.