20. Low Dose Spinal Anethesia For Sectio Cesarian Delivery With Cardiac Disease.docx

Low Dose Spinal Anethesia For Sectio Cesarian Delivery with cardiac disease

Isngadi Dept. Anesthesiology & Intensive Care Faculty of Medicine Brawijaya University Dr Saiful Anwar Hospital Malang 2018

Cardiac disease was significantly associated with a higher occurrence of severe maternal death and maternal near miss the third most common cause of maternal death

Effects of Pregnancy to Heart Diseases Pregnancy: Increase of blood volume Increase of cardiac output Decrease of SVR Change in vascular structure Hypercoagulopathy

Pregnancy complicatons with heart disease increases

Hemodinamic changes in pregnancy

In cardiac pregnant patients, these modification may lead to clinical decompensation & potentially life threatening.

Patients with cardiac disease :  advised against pregnancy  improved cardiac care  better obstetric & anaesthetic facilities

Pregnant cardiac patients are on rise :  joint efforts of cardiologist, obstetrician and anaesthetist.  specific technique  maintenance of haemodynamic stability  avoiding adverse physiological effects of parturition on maternal pathophysiology

Table 1. Maternal predictor of risks of cardiovascular compromise Criteria

Example

Points*

Heart failure, transient ischemic attack, stroke before present pregnancy, arrhythmia (defined

Prior cardiac events

as

symptomatic

tachyarrhythmia

or

sustained

1

bradyarrhythmia

requiring treatment) 1

NYHA III/IV or cyanosis

Valvular

and

outflow

tract

obstruction

Myocardial dysfunction

Aortic valve area <1.5 cm2, mitral valve area <2 cm2, or left ventricular outflow tract

1

peak gradient >30 mm Hg

LVEF <40% or restrictive cardiomyopathy or hypertrophic cardiomyopathy

1

* Maternal cardiac event rate for 0, 1, and >1 points is 5%, 27%, and 75%,

Pregnancy with heart disease •

Bad outcome for 2—4 times

•

Any type of congenital heart diseases with NYHA class III—IV -> mortality of 35%, morbidity of 50%, high risk pregnancy and not suggested to get pregnant

•

Neonatal death twice more often

•

Cyanotic congenital heart disease: increased fetal deaths, ( SpO2 < 85%  death in 1st semester)

Fetomaternal complications on pregnancy with heart disease Maternal complications •

Cardiovascular: •

Arrhythmia, heart failure, syncope, endocarditis thrombo-embolus, aortic dissection

•

Obstetric: •

pregnancy induced hypertension

•

Preeclampsia/eclampsia

•

HELLP syndrome

•

PROM

•

Post partum bleeding

Fetal-neonatal complications •

Abortion

•

Preterm birth

•

Low birth weight

•

Fetal death

•

ARDS

•

Neonatal death

•

Teratogenicity

Management of pregnancy with heart disease  Pre gestational counselling  Pre gestational evaluation  ANC  Management of labour  Management of anaesthesia Labour on pregnancy with heart disease •

Vaginal delivery: •

Heart disease with adequate left ventricular function

•

Analgesia

•

Heavy bupivacaine 0,25% (1 ml) + fentanyl 25 ug (intra-techal) and bupivacaine 0,1% (10--15 ml) + fentanyl 25 ug/ml peridural bolus / 30 minutes

•

Bupivacain 0,125 % + fentanyl 25 ug (3cc ) IT

•

Caesarean delivery: •

PAH

•

cyanotic congenital heart disease (34 weeks)

•

Anaesthesia:

•

GA and regional anaesthesia

•

More preferably CSEA:

•

Bupivacain 5 mg + Fentanyl 50ug (IT).

•

Low dose + Epidural bupivacain 0,125% (10-15 cc) + fentanyl 2ug /cc

•

Heavy bupivacaine 5 mg + morphin 300 ug (intra-techal), followed by bupivacaine 0,5% (5 ml) + adrenaline 5 ug/ml peridural bolus

Anesthesia choices for cesarean delivery General, epidural, spinal or combined spinal epidural (CSE) anesthesia

General vs Regional Anesthesia General •

Airway

•

Aspiration

•

Awarness

•

Uterine atony

•

Mortality rate > RA

Regional •

Analgesia

•

Rapid Onset

•

Less medication /economical

•

Sensory & motor block complete

•

Simple perform

•

Minimal neonatal depression

•

Awake

•

Lesser incidences of aspiration

•

Hypotension

•

CSF leakage (PDPH)

•

Nausea & Vomiting

•

Fixed duration

•

Lesser control of block heigt

Neuraxial techniques are frequently used in women with cardiac disease undergoing caesarean section

In women with pulmonary hypertension, there is a trend towards lower mortality during caesarean section with neuraxial compared with general anaesthesia

Spinal anesthesia is the preferred method in cesarean section as general anesthesia Spinal anesthesia was associated with higher incidence of hypotension

Hypotension is a very common consequence of the sympathetic vasomotor block caused by spinal anaesthesia for caesarean section

poorly tolerated (Cardiac disease)

The Incidence of hypotension in women who receive spinal anaesthesia for Caesarean delivery : 71%.

Fetal-maternal adverse outcome

Hypotension is a very common consequence of the sympathetic vasomotor block caused by spinal anaesthesia for caesarean section

Fetal/Neonatal Adverse Effects

How to prevent spinal induces hypotension ?  Preloading/Colloading fluids  Uterine displacement

 Vasoconstrictor  Low-dose Bupivacain

The incidence of spinal anesthesia induced hypotension is local anesthetic dose dependent

spinal anaesthesia for Caesarean delivery •

Conventional dose (CD) : Bupivacain > 8 mg

•

Low dose (LD)

:

Bupivacain < 8 mg ‘LD’ is a viable option without compromising the anaesthetic efficacy

intrathecal bupivacaine 5 and 7 mg are suficient to provide suficient anaesthesia for a caesarean section We recommend spinal block with low-dose bupivacaine and sufentanil (7,5 mg hyperbaric bupivacain + 5ug sufentanyl) in patients with coronary artery disease and especially in patients with low EF.

Decreasing the spinal dose of local anesthetics for cesarean section has been advocated to improve maternal hemodynamic stability, and decrease the incidence of hypotension However, reducing the local anesthetic dose runs the risk of inadequate anesthesia using small dose

of

local

anesthetic

could

be

minimized

hypotension

of

spinal

anesthesia

but Low-dose of local anesthetic may not provide acceptable anesthesia, then opioids and local anesthetic administered together because of potent synergistic analgesic effect

Since the discovery of opiate receptors in the brain and spinal cord, the use of intrathecal opioids has become common practice as on effective method of analgesia Fentanyl is the most commonly used spinal lipophilic opioids. The combination therefore, has, the advantage of a prompt onset of analgesia and a long action, and has been used for spinal anesthesia in obstetric

Intrathecal fentanyl doses (6.25 ug – 50 ug)  to improve intraoperative analgesia in doses ≥6.25 µg  No additional benefit was found by increasing the intrathecal fentanyl dose > 50 ug  Recommend using 20-30 ug suplement bupivacain IT

Postoperative analgesia increased in duration with increasing fentanyl doses, while spinal anesthetic motor and sensory recovery times were not prolonged Cesarean delivery requires traction of peritoneum and handling of intraperitoneal organs, resulting in intraoperative visceral pain. With higher doses of hyperbaric bupivacaine, incidence of intraoperative visceral pain associated with higher blocks is reduced Fentanyl is able to reduce the dose of bupivacaine

Cesarean delivery Traction of peritoneum •

intraoperative visceral pain.

Bupivacaine •

Higher dose

higher blocks

Adverse effect +++ •

intraoperative visceral pain is reduced

low dose + Fentanyl Fentanyl is able to reduce the dose of bupivacaine Hemodynamic Stability Adverse effect - - -

low dose bupivacaine + opioid  maternal hemodynamic is stable  equally efficacious anesthesia  duration of adequate surgical block is limited Still enough for obstetrician in Malang

Several trials have reported a low incidence of hypotension when low doses of bupivacaine were used Lowering the spinal dose to less then 7.5 mg of bupivacaine intrathecally might reduce the incidence and severity of hypotension

Addition of Fentanyl Intrathecal 1. Reduse baricity 2. Reduce the supplementary analgesia requirement 3. Produces satisfactory level of anaesthesia 4. Extent of sensory & motor block 5. Hemodinamic stability

The Addition of opioids intrathecaly 1) Reducing of the density 2) Increase mean spread and delay regression

The use of a lower dose Spinal Anaesthesia •

Decreases maternal side effect : •

Hypotension

•

Nausea

•

Vomiting

•

Reduce the time to discharge

•

Improve maternal satisfaction

•

compromise the adequacy of anaesthesia

•

supplementary analgesia

•

conversion to general anaesthesia

Low dose Spinal + Epidural

Opioids as adjuvants to neuraxial anaesthesia improve the quality of the

block without

producing a higher level of analgesia to pinprick Low-dose CSE anaesthesia may not be the optimal technique for all patients and institutions

Summary 1) Hypotension is a very common consequence of spinal anaesthesia for caesarean section, it’s porrly tolerated in cardiac disease 2) Low dose of local anesthetic + Fentanyl (IT) could be minimized hypotension of spinal anesthesia but not be the optimal technique for all patients and institutions 3) Fentanyl is able to reduce the dose of bupivacaine