Hyperbaric Treatment Plan
Name Rahayanu binti Sarijo
MRN 90255
ID 761114-01-7342
Date of operation : 02/07/2013
36 years old malay lady, G3 P2 at 38 weeks and 2 days of POA . Antenataly had 2 previous scar caesarean sections done in HSI . First was in 2008 for poor progress and the second was for secondary arrest in 2009. She also had background history of threatened abortion during this pregnancy at 8 weeks of POA. This patient initially was planned for elective caesarean section with bilateral tubal ligation on 8/7/2013 , was seen in PAC on 1/7/2013 and fit for op, however she presented the next day with complaint of contraction pain, regular , 2 contractions in 10 minutes.She came in active phase of labour. However there were no show, leaking liquor …show more content…
and fetal movement was good. On examination patient was alert, well hydrated, BP was 121/87 other vital signs were stable. Vaginal examinations showed Os 4 cm and cervix 0.5 cm. Thus patient was pushed to OT for EMLSCS with BTL.
Intraoperatively patient was planned for Caesarean section under spinal anaesthesia. Blood pressure before spinal anaesthesia was 139/76 and patient was already loaded with 1 pint HM solution. The space between L3 and L4 spines identified. Pencan 27G needle introduced into the subarachnoid space with use of introducer. Spinal anaesthesia, Bupivacaine 0.5% plain with 0.2mg morphine injected after confirming CSF flow. Post spinal noted BP was 89/47 with 2nd pint HM ongoing. Thus 6mg IV Ephedrine was given and the BP picked up to 117/62. Caesarean section went uneventful.There were no hypotensive episodes intraoperatively. Estimated blood loss was 650 mls. Delivered baby boy with Apgar score 8@1 and 9@5 with weight of 3.1kg.
Post operatively patient pushed to recovery bay. 30 minutes post operative period patient was comfortable, not in respiratory disteress, not sedated, pain score was 3/10, BP was 123/75, PR 62 , RR was 12 , complained of minimal bilateral lower limb numbness. However no spinal headache, nausea or vomiting. Thus was discharged well to ward.
Today I’m going to discuss about Spinal Anaesthesia in caesarean section
Spinal anaesthesia is induced by injecting small amounts of local anaesthetic into the cerebro-spinal fluid (CSF). The injection is usually made in the lumbar spine below the level at which the spinal cord ends (L2). Local anaesthetic solution injected into the subarachnoid space blocks conduction of impulses along all nerves with which it comes in contact.There are three classes of nerve which are motor, sensory and autonomic. Generally, autonomic and pain fibres are blocked first and motor fibres last. This has several important consequences. For example, vasodilation and a drop in blood pressure may occur when the autonomic fibres are blocked and the patient may be aware of touch and yet feel no pain when surgery starts.
The patient should be well hydrated before the local anaesthetic is injected and should have an intravenous infusion in place so that further fluids or vasoconstrictors can be given if hypotension occurs .In my patient she was hydrated with 1 pint hartmann followed by spinal anaesthesia . However , there was drop of BP by 89/47 mmhg . Hence she was immediately loaded with 1 pint hartmann and was given 6 mg IV ephedrine. Then the BP picked up.
Ephedrine is a vasopressor which has moderate beta-1 & weak alpha effects resulting in alpha- and beta- adrenergic stimulation that increase CO & BP, decrease renal perfusion & variable PVR. The onset is within 10 – 20 min and half life is 2-3 hrs. However the common adverse effect is hypertension and tachycardia.
A single shot spinal should reliably produce adequate anaesthesia within 10-20 minutes of injection. It is the technique of choice for most obstetric anaesthetists for caesarean section where there is no existing labour epidural. Depending on additives used it may provide post operative analgesia for up to 24 hours. Spinal spread is greater in pregnant compared with non-pregnant women. This is due to the higher intra-abdominal pressures transmitted via the inferior vena cava to the epidural veins which compress the spinal space and produce a higher block for the same volume of local anaesthetic injected into the intrathecal space.
Pregnant women need smaller volumes of spinal anaesthetic solution than non-pregnant women in order to obtain a given height of block. For a caesarean section, anaesthesia should extend to T6 (about the bottom of the sternum) to be completely successful. This can usually be achieved with the following regimes :2.0-2.5 ml of a hyperbaric solution of 0.5% bupivacaine.
Local anaesthetic agents are either heavier (hyperbaric), lighter (hypobaric), or have the same specific gravity (isobaric) as the CSF.
Hyperbaric solutions tend to spread below the level of the injection, while isobaric solutions are not influenced in this way. It is easier to predict the spread of spinal anaesthesia when using a hyperbaric agent. Isobaric preparations may be made hyperbaric by the addition of dextrose. Hypobaric agents are not generally available.
In my patient we have used plain bupivacaine 0.5% with 0.2 mg morphine. Bupivacaine (Marcaine) is 0.5% hyperbaric (heavy) solution is the best agent to use if it is available. 0.5% plain bupivacaine is also popular. Bupivacaine lasts longer than most other spinal anaesthetics: usually 2-3 hours.Intrathecal morphine is administered to provide profound and prolonged analgesia, and to treat acute postoperative pain
The specific gravity of the local anaesthetic solution can be altered by the addition of dextrose. Concentrations of 7.5% dextrose make the local anaesthetic hyperbaric (heavy) relative to CSF and also reduce the rate at which it diffuses and mixes with the CSF. Isobaric and hyperbaric solutions both produce reliable blocks. The most controllable blocks are probably produced by injecting hyperbaric solutions and then altering the patient’s …show more content…
position.
There are several complications recorded in spinal anaesthesia for c- section. A characteristic headache may occur following spinal anaesthesia. It begins within 12-24 hours and may last a week or more. It is postural, being made worse by raising the head and relieved by lying down. The incidence of headache is related directly to the size of the needle used. A 16 gauge needle will cause headache in about 75% of patients, a 20 gauge needle in about 15% and a 25 gauge needle about 3%. It is, therefore, sensible to use the smallest needle available especially in high risk obstetric patients. In above metioned patient a 27 G pencan needle was used.
Other complication is urinary retention.
The sacral autonomic fibres are among the last to recover following a spinal anaesthetic, urinary retention may occur. If fluid pre-loading has been excessive, a painful distended bladder may result and the patient may need to be catherised. Permanent neurological complications are extremely rare. If inadequate sterile precautions are taken bacterial meningitis or an epidural abscess may result although it is thought that most such abscesses are caused by the spread of infection in the blood. Finally, permanent paralysis can occur due to 'anterior spinal artery syndrome'. This is most likely to affect elderly patients who are subjected to prolonged periods of hypotension and may result in permanent paralysis of the lower
limbs.
There are several reasons for preferring spinal anaesthesia to general anaesthesia for caesarean sections. Babies born to mothers having spinal (or epidural) anaesthesia may be more alert and less sedated as they have not received any general anaesthestic agents through the placental circulation. As the mother's airway is not compromised, there is a reduced risk of aspiration of gastric contents causing chemical pneumonitis (Mendelson's syndrome). Many mothers also welcome the opportunity of being awake during the delivery and being able to feed their child as soon as the operation is complete.
MRN 90255
ID 761114-01-7342
Date of operation : 02/07/2013
36 years old malay lady, G3 P2 at 38 weeks and 2 days of POA . Antenataly had 2 previous scar caesarean sections done in HSI . First was in 2008 for poor progress and the second was for secondary arrest in 2009. She also had background history of threatened abortion during this pregnancy at 8 weeks of POA. This patient initially was planned for elective caesarean section with bilateral tubal ligation on 8/7/2013 , was seen in PAC on 1/7/2013 and fit for op, however she presented the next day with complaint of contraction pain, regular , 2 contractions in 10 minutes.She came in active phase of labour. However there were no show, leaking liquor …show more content…
and fetal movement was good. On examination patient was alert, well hydrated, BP was 121/87 other vital signs were stable. Vaginal examinations showed Os 4 cm and cervix 0.5 cm. Thus patient was pushed to OT for EMLSCS with BTL.
Intraoperatively patient was planned for Caesarean section under spinal anaesthesia. Blood pressure before spinal anaesthesia was 139/76 and patient was already loaded with 1 pint HM solution. The space between L3 and L4 spines identified. Pencan 27G needle introduced into the subarachnoid space with use of introducer. Spinal anaesthesia, Bupivacaine 0.5% plain with 0.2mg morphine injected after confirming CSF flow. Post spinal noted BP was 89/47 with 2nd pint HM ongoing. Thus 6mg IV Ephedrine was given and the BP picked up to 117/62. Caesarean section went uneventful.There were no hypotensive episodes intraoperatively. Estimated blood loss was 650 mls. Delivered baby boy with Apgar score 8@1 and 9@5 with weight of 3.1kg.
Post operatively patient pushed to recovery bay. 30 minutes post operative period patient was comfortable, not in respiratory disteress, not sedated, pain score was 3/10, BP was 123/75, PR 62 , RR was 12 , complained of minimal bilateral lower limb numbness. However no spinal headache, nausea or vomiting. Thus was discharged well to ward.
Today I’m going to discuss about Spinal Anaesthesia in caesarean section
Spinal anaesthesia is induced by injecting small amounts of local anaesthetic into the cerebro-spinal fluid (CSF). The injection is usually made in the lumbar spine below the level at which the spinal cord ends (L2). Local anaesthetic solution injected into the subarachnoid space blocks conduction of impulses along all nerves with which it comes in contact.There are three classes of nerve which are motor, sensory and autonomic. Generally, autonomic and pain fibres are blocked first and motor fibres last. This has several important consequences. For example, vasodilation and a drop in blood pressure may occur when the autonomic fibres are blocked and the patient may be aware of touch and yet feel no pain when surgery starts.
The patient should be well hydrated before the local anaesthetic is injected and should have an intravenous infusion in place so that further fluids or vasoconstrictors can be given if hypotension occurs .In my patient she was hydrated with 1 pint hartmann followed by spinal anaesthesia . However , there was drop of BP by 89/47 mmhg . Hence she was immediately loaded with 1 pint hartmann and was given 6 mg IV ephedrine. Then the BP picked up.
Ephedrine is a vasopressor which has moderate beta-1 & weak alpha effects resulting in alpha- and beta- adrenergic stimulation that increase CO & BP, decrease renal perfusion & variable PVR. The onset is within 10 – 20 min and half life is 2-3 hrs. However the common adverse effect is hypertension and tachycardia.
A single shot spinal should reliably produce adequate anaesthesia within 10-20 minutes of injection. It is the technique of choice for most obstetric anaesthetists for caesarean section where there is no existing labour epidural. Depending on additives used it may provide post operative analgesia for up to 24 hours. Spinal spread is greater in pregnant compared with non-pregnant women. This is due to the higher intra-abdominal pressures transmitted via the inferior vena cava to the epidural veins which compress the spinal space and produce a higher block for the same volume of local anaesthetic injected into the intrathecal space.
Pregnant women need smaller volumes of spinal anaesthetic solution than non-pregnant women in order to obtain a given height of block. For a caesarean section, anaesthesia should extend to T6 (about the bottom of the sternum) to be completely successful. This can usually be achieved with the following regimes :2.0-2.5 ml of a hyperbaric solution of 0.5% bupivacaine.
Local anaesthetic agents are either heavier (hyperbaric), lighter (hypobaric), or have the same specific gravity (isobaric) as the CSF.
Hyperbaric solutions tend to spread below the level of the injection, while isobaric solutions are not influenced in this way. It is easier to predict the spread of spinal anaesthesia when using a hyperbaric agent. Isobaric preparations may be made hyperbaric by the addition of dextrose. Hypobaric agents are not generally available.
In my patient we have used plain bupivacaine 0.5% with 0.2 mg morphine. Bupivacaine (Marcaine) is 0.5% hyperbaric (heavy) solution is the best agent to use if it is available. 0.5% plain bupivacaine is also popular. Bupivacaine lasts longer than most other spinal anaesthetics: usually 2-3 hours.Intrathecal morphine is administered to provide profound and prolonged analgesia, and to treat acute postoperative pain
The specific gravity of the local anaesthetic solution can be altered by the addition of dextrose. Concentrations of 7.5% dextrose make the local anaesthetic hyperbaric (heavy) relative to CSF and also reduce the rate at which it diffuses and mixes with the CSF. Isobaric and hyperbaric solutions both produce reliable blocks. The most controllable blocks are probably produced by injecting hyperbaric solutions and then altering the patient’s …show more content…
position.
There are several complications recorded in spinal anaesthesia for c- section. A characteristic headache may occur following spinal anaesthesia. It begins within 12-24 hours and may last a week or more. It is postural, being made worse by raising the head and relieved by lying down. The incidence of headache is related directly to the size of the needle used. A 16 gauge needle will cause headache in about 75% of patients, a 20 gauge needle in about 15% and a 25 gauge needle about 3%. It is, therefore, sensible to use the smallest needle available especially in high risk obstetric patients. In above metioned patient a 27 G pencan needle was used.
Other complication is urinary retention.
The sacral autonomic fibres are among the last to recover following a spinal anaesthetic, urinary retention may occur. If fluid pre-loading has been excessive, a painful distended bladder may result and the patient may need to be catherised. Permanent neurological complications are extremely rare. If inadequate sterile precautions are taken bacterial meningitis or an epidural abscess may result although it is thought that most such abscesses are caused by the spread of infection in the blood. Finally, permanent paralysis can occur due to 'anterior spinal artery syndrome'. This is most likely to affect elderly patients who are subjected to prolonged periods of hypotension and may result in permanent paralysis of the lower
limbs.
There are several reasons for preferring spinal anaesthesia to general anaesthesia for caesarean sections. Babies born to mothers having spinal (or epidural) anaesthesia may be more alert and less sedated as they have not received any general anaesthestic agents through the placental circulation. As the mother's airway is not compromised, there is a reduced risk of aspiration of gastric contents causing chemical pneumonitis (Mendelson's syndrome). Many mothers also welcome the opportunity of being awake during the delivery and being able to feed their child as soon as the operation is complete.