REVIEW URRENT C OPINION
General anesthesia for caesarean section Sarah Devroe a, Marc Van de Velde a,b, and Steffen Rex a,b
Purpose of review For most anaesthesiologists, the clinical experience with general anaesthesia for caesarean section is very low. General anaesthesia is mostly performed for emergency grade 1 caesarean section and due to a lack of time to apply a neuraxial anaesthesia technique. Unfortunately, the majority of anaesthesiologists rely on historical and partly outdated approaches in this stressful situation. We propose an evidence-based approach to general anaesthesia for caesarean section. Recent findings Rapid sequence induction using propofol and rocuronium should become the standard for general anaesthesia in the obstetric patient. Short-acting opioids are still not given routinely but should never be withheld in case of severe preeclampsia. Cricoid pressure can only be accurately performed by trained caregivers and should be released if intubation appears to be difficult. Supra-glottic airway devices may safely be used in fasted, nonobese elective caesarean section, but endotracheal intubation remains the gold standard, especially in emergency caesarean section in labouring women. Both sevoflurane and propofol are appropriate for the maintenance of general anaesthesia during caesarean section. Awareness remains a major concern in obstetric anaesthesia. Summary We present a review of recent evidence on general anaesthesia for caesarean section. Keywords caesarean section, general anaesthesia, propofol, rapid sequence induction, rocuronium
INTRODUCTION Due to its rapid and predictable onset, general anaesthesia for caesarean section (CS) is nowadays virtually exclusively used in emergency situations, or when neuraxial anaesthesia techniques have failed or are contraindicated. With the widespread use of neuraxial anaesthesia, the frequency of caesarean section performed under general anaesthesia has decreased so dramatically that the routine of the individual anaesthesiologist with this procedure becomes insufficient. The overall effect of this phenomenon is that increasingly less anaesthesiologists feel confident with this procedure and that often historical and outdated approaches are applied. This is a concerning situation, as anaesthesia is – in comparison to other surgical conditions – still overrepresented as a cause of maternal death in pregnancy: 1–2% of maternal deaths could be directly or indirectly attributed to anaesthesia [1]. In this review, we overview recent evidence and propose a modified technique of general anaesthesia for caesarean section. www.co-anesthesiology.com
PREPARATION: ASPIRATION PROPHYLAXIS AND ANTIBIOTIC ADMINISTRATION The publication of Mendelson [2] in 1946, in which all obstetric patients are considered at a high risk for pulmonary aspiration when undergoing general anaesthesia, is so ingrained in the anaesthetic literature that most anaesthesiologists ignore that evidence has changed dramatically since then. High risk of aspiration injury of the lungs is reported in the presence of a high intragastric volume and a low intragastric pH (
General anesthesia for caesarean section Sarah Devroe a, Marc Van de Velde a,b, and Steffen Rex a,b
Purpose of review For most anaesthesiologists, the clinical experience with general anaesthesia for caesarean section is very low. General anaesthesia is mostly performed for emergency grade 1 caesarean section and due to a lack of time to apply a neuraxial anaesthesia technique. Unfortunately, the majority of anaesthesiologists rely on historical and partly outdated approaches in this stressful situation. We propose an evidence-based approach to general anaesthesia for caesarean section. Recent findings Rapid sequence induction using propofol and rocuronium should become the standard for general anaesthesia in the obstetric patient. Short-acting opioids are still not given routinely but should never be withheld in case of severe preeclampsia. Cricoid pressure can only be accurately performed by trained caregivers and should be released if intubation appears to be difficult. Supra-glottic airway devices may safely be used in fasted, nonobese elective caesarean section, but endotracheal intubation remains the gold standard, especially in emergency caesarean section in labouring women. Both sevoflurane and propofol are appropriate for the maintenance of general anaesthesia during caesarean section. Awareness remains a major concern in obstetric anaesthesia. Summary We present a review of recent evidence on general anaesthesia for caesarean section. Keywords caesarean section, general anaesthesia, propofol, rapid sequence induction, rocuronium
INTRODUCTION Due to its rapid and predictable onset, general anaesthesia for caesarean section (CS) is nowadays virtually exclusively used in emergency situations, or when neuraxial anaesthesia techniques have failed or are contraindicated. With the widespread use of neuraxial anaesthesia, the frequency of caesarean section performed under general anaesthesia has decreased so dramatically that the routine of the individual anaesthesiologist with this procedure becomes insufficient. The overall effect of this phenomenon is that increasingly less anaesthesiologists feel confident with this procedure and that often historical and outdated approaches are applied. This is a concerning situation, as anaesthesia is – in comparison to other surgical conditions – still overrepresented as a cause of maternal death in pregnancy: 1–2% of maternal deaths could be directly or indirectly attributed to anaesthesia [1]. In this review, we overview recent evidence and propose a modified technique of general anaesthesia for caesarean section. www.co-anesthesiology.com
PREPARATION: ASPIRATION PROPHYLAXIS AND ANTIBIOTIC ADMINISTRATION The publication of Mendelson [2] in 1946, in which all obstetric patients are considered at a high risk for pulmonary aspiration when undergoing general anaesthesia, is so ingrained in the anaesthetic literature that most anaesthesiologists ignore that evidence has changed dramatically since then. High risk of aspiration injury of the lungs is reported in the presence of a high intragastric volume and a low intragastric pH (
