Obstetrícia

Question 1

Best practice the rate of conversion of regional to GA during cesarean delivery (CD)

Answer 1

According to the Royal College of Anaesthetists (RCoA) improvement compendium, the quality cri- teria of best practice the rate of conversion of regional to GA should be below 1% in elective CD and less than 5% in category 2–3

Question 2

Failure of neuraxial anesthesia for cesarean delivery

Answer 2

Failure of neuraxial anesthesia for cesarean delivery occurs in up to 12%.

Question 3

Definition spinal failure during cesariana

Answer 3

analgesic supplementation or intraoperative conversion to GA certainly underestimates the incidence of intraoperative pain

Question 4

Risk factors for spinal failure

Answer 4

Previous CD
Tubal ligation
Peripartum hemorrhage
Size of spinal needle 27 G vs. 25 G
Height of lumbar puncture (L4/5 vs. L3/4 or L2/3)
Emergency CD
Surgical duration (per minute)
Body mass index (per kg/m2)
Gestational age (per week)
Dose of bupivacaine
Lower birth weight
(Lower gestational age
Lower body mass index

Question 5

Why increased SA failure rates in neonates below 28 weeks of gestation or birth weight below 2500 g

Answer 5

pregnant women lower dose of intrathecal drugs are required because there is a decrease in subarachnoid and epidural volumes due to uterine enlargement, caval obstruction and epi- dural vein distension.

Question 6

phenylephrine to prevent hypotension appears to influence the spinal block?

Answer 6

The use of intravenous prophylactic phenylephrine to prevent hypotension appears to influence the spinal block. In a randomized trial, Xiao et al. [17] found a 20% higher ED95 for hyperbaric bupivacaine when combined with a prophylactic phenylephrine infusion, as compared to a placebo infusion

Question 7

Advantages lateral positioning cesarian

Answer 7

the lateral position leads to a significantly faster onset of sensory block by 3 min, while the motor block was only slightly faster [18]. The lateral position also led to less hypotension and higher maternal satisfaction scores

Question 8

Testing the block cesarian

Answer 8

straight leg test, where the patient is asked to lift the legs against gravity.
level of T5 to loss of touch sensation is required for CD . With a sensory level of T10 a forceps test is probably already negative.
forceps test at the site of incision before the sensory level required for surgery, i.e. loss of touch sensation at T5 or above, has been reached.

Question 9

Repeat neuraxial or general anesthesia after spinal failure?

Answer 9

1) total failure of the first intrathecal injection, that is, absence of any measurable effect, including sacral dermatomes, there is probably no additional risk in repeating the SA with the usual dosage
2)the use of 12mg of hyperbaric bupivacaine significantly increased the incidence of high spinal block, hypotension, brady- cardia and respiratory compromise when compared to 10 mg [20]. In case of a repeat injection, additives such as opioids should be omitted.
3) A reasonable approach in case of partial failure is to use CSE with a reduced intrathecal dose or to switch to a pure epidural technique.

Question 10

Management of intraoperative pain after failed spinal anesthesia for cesarian?

Answer 10

The surgeon should be asked to stop the surgery. Except for the moment between uterine incision and delivery, this should always be possible.
First line treatment should consist of repeated intravenous boluses of fast acting opioids, such as remifentanil (20 mcg), alfentanil (250 – 500 mcg) or fentanyl (25 – 50 mcg) since they alleviate intraoper- ative pain. Some do also recommend small doses of ketamine (10 mg)
midazolam and propofol should not be used without an analgesic
the case of early intraoperative pain, i.e. before delivery, intravenous opioids are unlikely to be effective. In this situation, the patient should be offered GA