ESMOE - Protocol for C/S Under Spinal Anaesthesia

Question 1

Main summary points

Answer 1

1. Preparation:
2. 1 Full Hx & examination
3. 2 Prepare pt.
4. 3 Prepare theatre
5. Technique:
6. 1 Administration of spinal
7. 2 Positioning after spinal
8. 3 Monitoring after spinal
9. 4 Failed spinal
10. 5 After delivery
11. Recovery:
12. 1 Monitoring
13. 2 D/C from recovery

Question 2

Main points of Preparation:

Answer 2

1. Full Hx and examination
2. Prepare the patient
3. Prepare the theatre

Question 3

Main points of Technique:

Answer 3

1. Administration of spinal
2. Positioning after spinal injection
3. Monitoring after spinal injection
4. Failed spinal
5. After Delivery

Question 4

Main points of Recovery:

Answer 4

1. Monitoring

2. Discharge from recovery room

Question 5

Preparation phase details:

Answer 5

1. Full history and examination:
   1.1 NB CIs to spinal anaesthesia
   1.2 NB signs of hypovolaemia - decide whether
   the patient requires fluid resus first
2. Prepare the patient:
3. 1 Premedication – sodium citrate 30ml PO + maxalon 10 mg IVI, 30 minutes pre-op
4. 2 Good IV access, preload with 500ml clear fluid
5. 3 U-catheter
6. Prepare the theatre:
   3.1 Full machine check + check vent settings
   3.2 Check essential equipment & monitoring
   3.3 Draw up essential drugs -
   ephedrine, atropine, suxamethonium, induction agent

Question 6

Technique phase details:

Answer 6

1. Administration of spinal:
   1.1 Measure NIBP before starting & at 1 min intervals
   1.2 Monitor ECG and Sats
   1.3 O2 supplementation w/ 40% facemask
   1.4 Co-load w/ 500ml of MRL
   1.5 Position patient sitting
   1.6 Use aseptic technique
   1.7 Inject 2-3ml of 2% lignocaine into the subcut tissue over the L3/L4 interspace
   1.8 Perform dural puncture - w/ 25 or 26g pencil point needle w/ introducer
   1.9 Inject hyperbaric, adrenaline-free
   bupivacaine 0,5% 1.8ml (=9mg) with 0,2ml (=10ug) fentanyl
   1.10 Opsite spray over injection site
2. Positioning after spinal injection:
3. 1 Supine with wedge under right buttock
4. 2 Head and shoulders raised on a pillow
5. Monitoring after spinal injection:
6. 1 Remain with patient, in direct communication with her
7. 2 Measure NIBP every minute for at least 10 minutes, or until delivery (then every 2-3 minutes)
8. 3 Expect the drop in BP and Rx hypotension aggressively with ephedrine or phenylephrine.
9. 4 Actively monitor for signs of low CO
10. 5 Monitor level of block, watch out for high spinal
11. Failed Spinal:
    4.1 If no effects after 20 min = repeat spinal
    4.2 If repeat spinal has no effect = convert to
    GA
    4.3 If partial block, decide on:
    Conversion to GA
    Or LA/ketamine supplementation
    Or delay surgery for spinal later
12. After delivery:
    5.1 Ask obstetrician to rule out second baby
    5.2 Give 2.5 IU oxytocin IVI slowly, over 1
    minute

Question 7

Recovery phase details:

Answer 7

1. Monitoring:
   1.1 Administer oxygen via 40% venturi mask
   1.2 Monitor NIBP and SpO2
   1.3 Make sure that the patient is not bleeding
   1.4 Make sure that the patient is adequately analgesed
   1.5 Infuse 20U oxytocin in one litre of clear fluid
   over 8 hours (125mls/hr)
2. Discharge from recovery room:
3. 1 When height of spinal has decreased by 2 segments
4. 2 Vital signs are normal