1. NATIONAL CONGRESS
of the
VIETNAM SOCIETY of
ANESTHESIOLOGISTS
Associate Professor Stephen Gatt, OAM, MOM, KM, KC*HS, JP;
MD, LRCP, DCH, CHE, MASCH, MRACMA, MRCS, AFACHSEM AFRACMA, FFARACS, FANZCA, FFICANZCA, FJFICM, FCICM, FRCA
Director of Anaesthesia, Operational & Administrative, Wales Anaesthesia
Senior Staff Specialist , The Royal - for Women & Sydney Children’s Hospitals,
Visiting Medical Practitioner, Prince of Wales Private Hospital,
President ,Obstetric Anaesthesia Society of Asia and Oceania
Conjoint Associate Professor in Anaesthesia, Discipline of Anaesthesia, Critical Care and Emergency Medicine,
University of New South Wales, Sydney, Australia
2.
3. Triennium
Number of
maternities
Number of
Caesarean
sections
Caesarean
rate as
percentage of
maternities
Number of
direct deaths
due to
anaesthesia
Number of
direct deaths
due to
anaesthesia
for Caesarean
section
Rate of direct
deaths due to
anaesthesia
per 100 000
Caesarean
section
1964–6 2 600 000 88 000 3.4 50 32 36
1982–4 1 884 000 190 000 10.1 19 11 6
2000–2 1 997 000 425 000 21 7 4 1
.Acknowledgement: Cooper et al: 2014: BJA. Online ISSN 1743-1824
6. What did the old GA CS
technique consist of?
• optimal pre-oxygenation
• thiopentone induction
• suxamethonium (succinylcholine) depolarising neuromuscular block
• endotracheal intubation under cricoid pressure
• 2/3 MAC volatile in 50% N2O for maintenance until delivery
DELIVERY
volatile concentration reduced to 1/2 MAC
opiate + non-depolarising muscle relaxant
syntocinon/oxytocin
fraction of N2O increased to 67%
7. The ‘Old’ Standard
GA CS which lasted from 1960s to
mid-noughties (~2005)
• Taught as a standard technique for over four
decades.
• Reliable
• Easily reproducible formula
• Reduced the incidence of acid aspiration
syndrome and awareness
• Ensures optimal intubating conditions
• Lowest possible adverse impact on the newborn
8. Why did this sequence work for
so long?
Generations of anaesthetists and
their anaesthetic assistants
have been trained to make this
hazardous undertaking a slick
and efficient process.
9. What has changed over the last
three decades?
VIRTUALLY
EVERYTHING
10. ‘Standard’ GA CS: What has changed?
• Preoperative Resuscitation
• Pre-oxygenation
• Induction sequence
• Notion of ‘Urgency’
• Rapid Sequence and Difficult Airway Algorithm
• Maintenance sequence
• Philosophy, eg. techniques modified to suit
– local conditions
– tailor-made for to individual patient.
• Postop pain management
13. In Utero Fetal Resuscitation Prior to Declaring
Cat 1/2 GA CS
• Turn oxytocic (syntocinon) infusion off.
• Turn mother into left lateral position.
• O2 from Midogas mouthpiece or a facemask.
• 1 lit crystalloid – Plasmalyte 148 Rep or
Hartmann’s LR or N Saline.
• IV vasopressor if MAP low: 100mcg
phenylephrine or 9mg ephedrine first dose.
• Tocolysis: GTN 400mcg sublingual aerosol or
terbutaline 250mcg SC.
14. Retrospective Study: 1 & 5 min Apgars following CS for FD
Evaluation of anaesthesia methods in caesarean section for foetal distress.
Wahjoeningsih S, Witjaksono W
SAB > Ketamine GA > thiopental GA for fetal
distress
2007 Indonesia: Dr. Soetomo Hospital, Surabaya. Malays J Med Sci. Jul;14(2):41-6, 2007.
15.
16. Choice of Neuromuscular
Blocker in RSI for CS GA
• withdraw the short-acting low potency
depolarising muscle relaxants
eg. suxamethonium
• replace them with ‘cleaner’ non-depolarisers
with fewer side-effects
eg. rocuronium
17. “So many modifications to the GA CS*
have been put in place that, when the
modern GA CS* is reviewed in its
entirety, it would seem that the time has
come to question if the ‘standard’ GA
CS* is still valid and whether it is due
for a major revamp.”
* Rapid sequence induction
Failed intubation drill
GA maintenance
Gatt, 2006.
18.
19. Succinylcholine Suxamethonium
in Obstetrics
;
•maternal hyperkalaemia (eg. in Guillain Barre)
•interacts with Mg++ (eg. in pre-eclampsia )
•muscle ‘after-pain’
(7.5% for CS vs 30% in the non-pregnant group)
•ileus (?)
•suxamethonium apnoea
•problems with storage -
•inactivation at high temperature
•freezing from cold storage
•leakage from pre-filled syringes
•high incidence of complications – very low potency drug
20.
21. Change in philosophy on the safety
of suxamethonium for GA CS
• Pre-oxygenation + suxamethonium may not offer
a great degree of protection against the, albeit
rare, scenario of inability to intubate and inability
to ventilate
• Increased emphasis on the timing of the
individual components of the RSI
– variation in the timing and application of cricoid
pressure
– alteration in choice and dose of RSI drugs used and
the timing of their administration
25. Solutions
– vecuronium
• vecuronium RSI in which the vecuronium precedes the
thiopentone and atropine
– atracurium
– rapacuronium (withdrawn from the market)
– rocuronium
• rocuronium RSI in which the rocuronium precedes the
ketamine and propofol
– suxamethonium
• pretreated with vecuronium or d-tubocurarine
• augmented with Tacrine (tetrahydroaminacrine)
– sugammadex + rocuronium
38. BEST PROTECTION
150mg ranitidine x2 po
or
50mg ranitidine IV
(for emergencies)
+
Na citrate
30mL 1/3 Molar
39. My belt & braces
recipe – ALL CSs
• Night before CS
Esomeprazole (Nexium)
• Morning of surgery
Ranitidine (Zantac)
• On call to OR (standing order)
Na citrate
PPI
+
H2 blocker
+
antacid
40. 1
‘NEW’ Gatt
Rule of 100s
RSI for GA
CS
2
‘OLD’ Thio-
Sux-Halo
RSI for GA
CS
41. The Gatt Rule of 100s GA CS
NDMR RSI Induction Sequence
Cricoid Pressure
Intubate
Secure Airway
Deliver infant
46. Success with these sequences
• EXPERIENCE WITH KETAMINE –
PROPOFOL: >15 years
• and with KETAMINE – THIOPENTONE:
since 1984
• EXPERIENCE WITH THE ROCURONIUM
– SUGAMMADEX SEQUENCE:
>7 years
47. WHAT DO
THE DODO
AND THE
“OLD”
GA CS
SEQUENCE
S HAVE IN
COMMON ?
