Hot topics: obstetric anaesthesia and analgesia

Hot topics: obstetric anaesthesia and analgesia

Monday 3 June, 1100-1145H, Piano Hall

One of our popular ‘hot topics’ sessions at Euroanaesthesia 2019 is on obstetric anaesthesia and analgesia, and will be presented by Professor Dominque Chassard, Hôpital femme mère enfant, Bron, France; Université de Lyon, Lyon, France. Some excellent papers from the past 12 months will be highlighted, including those below.

Postpartum headache (PDPH) is one of the most common complications of neuraxial anaesthesia. It limits patients’ general activities, baby care and increases hospital length of stay. In 2018, several investigators had new approaches to treat this complication, such as the sphenopalatin block, the great and third occipital nerve block and the intravenous administration neostigmine. All new options aim to decrease the rate of epidural blood patch.

A least 60% of patients decrease their systolic blood pressure following spinal anaesthesia. Norepinephrine is probably the vasopressor of choice to treat hypotension following spinal anaesthesia because its alpha and beta mimetic activities maintaining cardiac output without bradycardia and without risk of acidosis for the fetus. A prophylactic dose at a rate of 0.05 µg kg min following spinal anesthesia has been advocated by Hasanin AM et alas the minimal dose in pregnant patients.

In low income countries, 70.000 pregnant patients die each year from postpartum hemorrhage (PPH). Oxytocin is the first line treatment to PPH but it requires cold storage. In the vast majority of these countries, cold-chain transport and storage is not feasible rending oxytocin less effective. Widmer et al in NEJM showed that heat stable carbetocin is equivalent to oxytocin to prevent PPH during vaginal delivery. They concluded that carbetocin could save thousands of women’s lives. In another issue of NEJM Sentilhes et al showed that tranexamic acid is not of interest as a prophylactic treatment to decrease the rate of haemorrhage during caesarean section.

New data concerning pain relief at delivery has been publishedFor labor analgesia, the DPE (Dural Puncture Epidural) is a promising analgesic technique which needs further clinical studies. Dexmedetomedine is a new adjuvant for epidural analgesia but few studies report its use. Quadratus lumborum, i-TAP and Erector spinae blocks are new blocks available for post caesarean section analgesia.

The use of ultrasound is expanding in the field of obstetric anaesthesia. Siddiqui et al showed that ultrasound is superior to palpation in identifying cricoid membrane. This is a very important information in pregnant women with anticipated difficult intubation/ventilation, a situation where cricoid access is sometimes needed. Desgranges et al reported that around 30% of pregnant women have a full stomach at full cervical dilatation during labor analgesia, a time where general anaesthesia is sometimes required. This study confirms that gastric ultrasound is more reliable than clinical signs for the diagnosis of full stomach.

Finally, a new algorithm (YEARS) published in NEJM decreased the need for CT scan for suspected pulmonary embolism, averting fetal harm from radiation exposure (65% less CT scan during the first trimester of pregnancy).

 

References:

Hasanin AM, Amin SM, Agiza NA, Elsayed MK, Refaat S, Hussein HA, Rouk TI, Alrahmany M, Elsayad ME, Elshafaei KA, Refaie A. Norepinephrine Infusion for Preventing Postspinal Anesthesia Hypotension during Cesarean Delivery: A Randomized Dose-finding Trial.Anesthesiology. 2019;130:55-62
Sentilhes L, Winer N, Azria E, Sénat MV, Le Ray C, Vardon D, Perrotin F, Desbrière R, Fuchs F, Kayem G, Ducarme G, Doret-Dion M, Huissoud C, Bohec C, Deruelle P, Darsonval A, Chrétien JM, Seco A, Daniel V, Deneux-Tharaux C Tranexamic Acid for the Prevention of Blood Loss after Vaginal Delivery.N Engl J Med. 2018 23;379 :731-742
Widmer M, Piaggio G, Nguyen TMH, Osoti A, Owa OO, Misra S, Coomarasamy A, Abdel-Aleem H, Mallapur AA, Qureshi Z, Lumbiganon P, Patel AB, Carroli G, Fawole B, Goudar SS, Pujar YV, Neilson J, Hofmeyr GJ, Su LL, Ferreira de Carvalho J, Pandey U, Mugerwa K, Shiragur SS, Byamugisha J, Giordano D, Gülmezoglu AM; WHO CHAMPION Trial Group.Heat-Stable Carbetocin versus Oxytocin to Prevent Hemorrhage after Vaginal Birth.  N Engl J Med. 2018 23;379:743-752.
Siddiqui N, Yu E, Boulis S, You-Ten KE. Ultrasound Is Superior to Palpation in Identifying the Cricothyroid Membrane in Subjects with Poorly Defined Neck Landmarks: A Randomized Clinical Trial.Anesthesiology. 2018;129:1132-1139.
Desgranges FP, Simonin M, Barnoud S, Zieleskiewicz L, Cercueil E, Erbacher J, Allaouchiche B, Chassard D, Bouvet L. Prevalence and prediction of higher estimated gastric content in parturients at full cervical dilatation: A prospective cohort study.Acta Anaesthesiol Scand.2019;63:27-33