GENERAL ANAESTHESIA FOR CAESAREAN SECTION - CLINICAL GUIDELINE 1. Aim/Purpose of this Guideline

Transcription

1 GENERAL ANAESTHESIA FOR CAESAREAN SECTION - CLINICAL GUIDELINE 1. Aim/Purpose of this Guideline 1.1. General anaesthesia for caesarean section carries considerable risk and is frequently performed out of hours by relatively junior anaesthetists. The aim of this guideline is to provide guidance for safely performing general anaesthesia for caesarean section. 2. The Guidance 2.1. Indications The only absolute indication for caesarean section under general anaesthesia is maternal refusal of regional anaesthesia. Other possible indications include: Contraindication to regional anaesthesia e.g. coagulopathy / thrombocytopenia, local or systemic infection Uncorrected hypovolaemia e.g. from blood loss Clinical urgency, at the discretion of the anaesthetist 2.2. Preoperative Assessment General Previous General Anaesthetic (GA) PMH/Co-morbidities Allergies High BMI Fasting status Airway Standard airway assessment, paying particular attention to problems more common in obstetric patients e.g. large breasts, airway oedema Specific pregnancy problems Pre-eclampsia Reflux Placental position Explain Rapid Sequence Induction (RSI)/cricoid pressure to the patient and if time allows obtain informed consent Conduct of Emergency Anaesthesia Preparation Intra-uterine resuscitation (left lateral, 100% O2, rapid IV fluid) may buy time by relieving fetal distress. Aim for rapid transfer to theatre. Machine and equipment should have been checked according to AAGBI guidelines2. Ensure difficult airway equipment, emergency drugs available. Page 1 of 8

2 Summon assistance ODP +/- senior anaesthetist, especially if difficult airway or other problem is anticipated Partners are not allowed in theatre Give sodium citrate +/- ranitidine Induction & Maintenance Begin pre-oxygenation whilst inserting 16G grey cannula, setting up IV fluid and attaching monitors Position carefully; consider ramping if obese. Remember left lateral tilt or wedge Ensure surgeon has scrubbed, prepped and draped before starting anaesthesia Thiopentone and suxamethonium are routinely used for Rapid Sequence Induction in obstetrics. Remember to give >100mg (up to 150mg) of suxamethonium if the woman weighs >100kg Perform RSI see separate Failed intubation guideline for guidance on conduct of intubation, and Failed Intubation Drill Secure the airway, inflate the cuff, confirm placement with capnography. Inform the surgeon they may proceed Use sevoflurane with 50% N2O unless specifically contraindicated or a very high FiO2 is required. N2O is MAC sparing and provides some analgesia pre delivery Aim for combined MAC >1.2, especially immediately post induction. This can be reduced once opioids have been given. Aiming for low fresh gas flows is unnecessary. Remember that caesarean sections carry a high risk of awareness Further paralysis MAY not be required if surgeon quick and access optimal Remember antibiotics, and oxytocin at delivery End of Procedure Check reversal with nerve stimulator Consider multimodal analgesia: Opioid Paracetamol IV/PR Diclofenac PR if no C/I Epidural if catheter in-situ Transversus abdominis plane (TAP) block or other regional technique Advise the surgeon to administer local anaesthetic to the skin and the rectus sheath The risk of aspiration at extubation is high. Consider draining stomach contents before extubation. Extubate in left lateral position, or supine head up, when fully awake with airway reflexes recovered. Monitor in recovery for at least 60 min with an anaesthetist immediately available (See guideline: Post-operative care & transfer from recovery) Page 2 of 8

3 2.4. Special Circumstances Prescribe post op analgesia, fluids, thrombo- prophylaxis & antiemetics Pre-eclampsia Involve senior help early, consider an arterial line Decision to deliver should only be made once the patient is stabilised and blood pressure has been treated Consider Magnesium, IV opioids, Esmolol or Labetalol to blunt pressor response to intubation Do not give Ergometrine or NSAIDS Fetal compromise Remember in utero resuscitation Treat hypotension aggressively with vasopressors and fluid 3. Monitoring compliance and effectiveness Element to be monitored Lead Tool Frequency Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared Clinical Guideline for General Anaesthesia for Caesarean Section Indications Lead Obstetric Anaesthetist Indication for General Anaesthesia Caesarean Section tool kit If GA sections flag red on the dashboard audit to be undertaken Maternity Risk Management and Clinical Audit Forum Develop an action plan and assign and action plan lead Required changes to practice will be identified and actioned within a time frame agreed on the action plan A lead member of the forum will be identified to take each change forward where appropriate. The results of the audits will be distributed to all staff through the Risk Management Newsletter and Audit Forum as per the action plan 4. Equality and Diversity 4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2. Page 3 of 8

4 Appendix 1. Governance Information Document Title Date Issued/Approved: 5 th June 2014 General Anaesthesia for Caesarean Section Clinical Guideline Date Valid From: 5 th June 2014 Date Valid To: 5 th June 2017 Directorate / Department responsible Obs and Gynae Directorate Contact details: Brief summary of contents Guidelines for general anaesthesia for caesarean sections Suggested Keywords: Target Audience Executive Director responsible for Policy: General anaesthesia, caesarean section, GA, airway, difficult, intubation, fluid, resuscitation, RSI, Rapid Sequence Induction RCHT PCH CFT KCCG Medical Director Date revised: 5 th June 2014 This document replaces (exact title of previous version): Approval route (names of committees)/consultation: Divisional Manager confirming approval processes Name and Post Title of additional signatories Signature of Executive Director giving approval Publication Location (refer to Policy on Policies Approvals and Ratification): Document Library Folder/Sub Folder Clinical guideline for general anaesthesia for caesarean section indications Maternity Guideline Group Obs & Gynae Directorate Divisional Board Head of Midwifery Not Required {Original Copy Signed} Internet & Intranet Links to key external standards CNST 2.6 Intranet Only Clinical/Midwifery and Obstetrics Page 4 of 8

5 Related Documents: McGlennan A, Mustafa A. General anaesthesia for Caesarean section. Contin Educ Anaesth Crit Care Pain (2009) 9 (5): s/checking_anaesthetic_equipment_ 2012.pdf rary/royalcornwallhospitalstrust/cli nical/anaesthetics/failedintubationf ortheobstetricpatient.pdf J.G. McDonnell, G. Curley, J. Carney, A. Benton, J. Costello, C.H. Maharaj, J.G. Laffey The analgesic efficacy of transversus abdominis plane block after cesarean delivery: a randomized controlled trial. Anesthesia and Analgesia (2008) 106: Rawlinson E, Mincon A. Pulmonary aspiration. Anaesth Intensive Care (2007) 8: rary/royalcornwallhospitalstrust/cli nical/midwiferyandobstetrics/preecl ampsiaeclampsiaguidelineforthem anagementofsevere.pdf Training Need Identified? None Version Control Table Date 5 th June 2014 Version No 2.0 Summary of Changes "Discuss with patient" section largely removed. Not relevant in emergency In utero resuscitation included in preparation section Emphasis on positioning for intubation Direct reference to failed intubation guideline Instruction on gas mixture rewritten for clarity Antibiotics/oxytocin instruction updated to reflect current practice Extubation section expanded with suggestion to drain stomach contents Pre-eclampsia section rewritten to emphasise need to stabilise patient before theatre Changes Made by (Name and Job Title) Alexander Ishimaru Page 5 of 8

6 All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager. Page 6 of 8

7 Appendix 2. Initial Equality Impact Assessment Form Name of Name of the strategy / policy /proposal / service function to be assessed (hereafter referred to as policy) (Provide brief description): GENERAL ANAESTHESIA FOR CAESAREAN SECTION - CLINICAL GUIDELINE Directorate and service area: Is this a new or existing Policy? Obs and Gynae Directorate Existing Name of individual completing Telephone: assessment: Elizabeth Anderson 1. Policy Aim* Who is the strategy / policy / proposal / service function aimed at? The aim of this guideline is to provide guidance for anaesthetists to safely perform a general anaesthesia for caesarean section. 2. Policy Objectives* Ensure appropriate and safe management of general anaesthesia for caesarean section. 3. Policy intended Outcomes* 4. *How will you measure the outcome? 5. Who is intended to benefit from the policy? 6a) Is consultation required with the workforce, equality groups, local interest groups etc. around this policy? b) If yes, have these *groups been consulted? C). Please list any groups who have been consulted about this procedure. Good outcome for the mother undergoing caesarean section under general anaesthesia. Compliance monitoring tool. All pregnant women. No N/A N/A 7. The Impact Please complete the following table. Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Rationale for Assessment / Existing Evidence Age Page 7 of 8

8 Sex (male, female, transgender / gender reassignment) Race / Ethnic communities /groups Disability - Learning disability, physical disability, sensory impairment and mental health problems Religion / other beliefs Marriage and civil partnership Pregnancy and maternity Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian You will need to continue to a full Equality Impact Assessment if the following have been highlighted: You have ticked Yes in any column above and No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or Major service redesign or development 8. Please indicate if a full equality analysis is recommended. Yes No 9. If you are not recommending a Full Impact assessment please explain why. N/A Signature of policy developer / lead manager / director Alexander Ishimaru Date of completion and submission 5 th June 2014 Names and signatures of members carrying out the Screening Assessment 1. Alexander Ishimaru 2. Elizabeth Anderson Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead, c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD A summary of the results will be published on the Trust s web site. Signed: Elizabeth Anderson Date: 5 th June 2014 Page 8 of 8