ABSTRACT
Objective: To describe the different anesthetic
techniques used for cesarean section at the Royal Medical Services Hospitals.
Methods: We retrospectively reviewed the anesthetic techniques used for Cesarean sections performed between 1st of January
to the 31st of December 2007 at Royal Medical Services Hospitals.
Data collection aimed at anesthetic techniques used for scheduled and
non-scheduled Cesarean sections.
Results: Out of a total of 5,314 Cesarean sections performed in the year 2007 at our institution,
81.6% were performed under general anesthesia, 18.3% under spinal anesthesia,
and 0.1% under epidural anesthesia. General anesthesia still predominated in
our hospitals, the percentage of general anesthesia performed by different
hospitals varied from 41% to 96%.
Conclusion: This review of anesthetic techniques used for Cesarean
section shows an overuse of general anesthesia and low use of regional
anesthesia. There is a need to adjust
clinical practice at the Royal Medical
Services Hospitals in accordance with recent scientific data.
Key words: Cesarean section, Clinical practice, General
anesthesia, Regional anesthesia, Standards
JRMS
September 2010; 17(3): 25-28
Introduction
The choice of
anesthesia for Cesarean section may depend on several factors including perioperative
morbidity and mortality, patient and surgeon preferences, feasibility of the technique
in a given patient, effects on intraoperative and postoperative pain control,
effects on early recovery and monitoring requirements as well as costs.(1-4)
Anesthetic practice for Cesarean section has changed during the last decades
world-wide with a remarkable shift in favor of regional anesthesia, most often
spinal anesthesia in Western Europe and the United States of America, since it
has lower maternal morbidity and mortality rates.(2-8) Reference
values for the practice of obstetric anesthesia at the Royal Medical Services
Hospitals have not been determined yet. This investigation was performed to
obtain data on anesthetic techniques used for Cesarean section so as to
evaluate current anesthetic practices adopted, in relation to international standards
of obstetric anesthesia.
Methods
After ethical
committee approval, a phone call request was done to all anesthesia units at
the Royal Medical Services Hospitals to collect retrospective data on anesthetic techniques used for Cesarean
section between the 1st of January to the 31st of December
2007. All units sent the data obtained from operating room logbooks. Data collection
aimed at anesthetic techniques used for scheduled and non-scheduled Cesarean
sections only.
In our institution,
anesthetic options for Cesarean section include general anesthesia, spinal anesthesia
or epidural anesthesia. A standard general anesthesia technique would comprise
pre-oxygenation 3-5 minutes, followed by the administration of Sodium thiopental
(3-5mg/kg) or Propofol (2-3mg/kg) and Succinylcholine (1-2mg/kg) for rapid
sequence induction.
After
orotracheal intubation with cricoid pressure, a non-depolarizing neuromuscular
blocking agent such as Atracurium (0.5mg/kg) or Vecuronium (0.1mg/kg) or
Pancuronium (0.1mg/kg) is administered. Anesthesia is maintained with Halothane
or Isoflurane in a mixture of 50% nitrous oxide in oxygen. Opioid analgesics
are routinely given after delivery of the baby. Single-shot spinal anesthesia
is performed using 0.5% hyperbaric Bupivacaine 8-13mg and with or without
intrathecal Fentanyl 10-25µg via a 25 or 27 gauge Whitacre or Quincke spinal needle.
For epidural anesthesia, 0.5% plain Bupivacaine 10-15ml that could be
supplemented with epidural boluses of 0.5% plain Bupivacaine 3-5ml when
necessary is used.
Ultimately, the
choice of anesthesia is determined by patient factors, surgical conditions and
the preference of the individual anesthetist.
Results
Out of total 5,314 Cesarean Sections performed in the year
2007 at our hospitals, 81.6% were performed under general anesthesia, 18.3%
under spinal anesthesia and 0.1% under epidural anesthesia. No failed spinal anesthesia was reported (see
Table I). General anesthesia still predominated in our hospitals, the
percentage of general anesthesia performed by different hospitals varied from
41.4% which was at Prince Hashem hospital to 96.2% at Prince Ali hospital.
Spinal anesthesia performed by different hospitals varied from 58.4% at Prince Hashem
hospital to 3.3 % at Prince Ali hospital. Epidural anesthesia was rarely performed.
Discussion
General anesthesia has the advantage of having no absolute
contraindications because of a large variety of intravenous and inhalational
agents, and remains the method of choice in some conditions.(2,3,8) These
include severe fetal distress, maternal hypovolemia, coagulopathy, acute diseases
of the spine and its contents,
increased intracranial pressure, failure of regional anesthesia and patient
refusal of regional anesthesia.(3,9) Increased incidence of pulmonary
aspiration of gastric contents and failed endotracheal intubation (incidence is
1:238) are the two major causes of maternal morbidity and mortality associated
with general
anesthesia.(2,9-11)
Of course, maternal changes as the result of such outcomes as hypoxia and
hypotension affect the outcome of the fetus.(2) Use of
halogenated volatile agents may be associated with a greater risk of maternal
blood loss.(11,12)
Regional
anesthesia is a more recent development avoiding the major complications of general
anesthesia but having
several of its own.(3) These include maternal hypotension,
accidental total spinal anesthesia, urinary retention, post-partum headache and
epidural abscess or hematoma.(2,3,9) Spinal anesthesia has
become the preferred technique since it is easy to perform, inexpensive, safe
and has a high level of patient satisfaction.(3,4,6) By
adding opioids to spinal anesthesia, a reduction in local anesthetic dose is
possible. Reports on low-dose spinal anesthesia suggest that this may reduce
maternal hypotension.(13) Improved needle design
has reduced the incidence of postdural puncture headache and accounts for the
increased popularity of spinal anesthesia.(3,14)
Our study reviewing anesthetic techniques used for 5,314 elective and nonelective Cesarean sections performed at our hospitals
during the year 2007 revealed that the majority (81.6%) were performed under
general anesthesia, around a fifth (18.3%) were performed under spinal
anesthesia, and only 0.1% were performed under epidural anesthesia. This
analysis was based on a retrospective review of operating room logbooks and has
limitations, including the lack of some key maternal and perinatal variables
(parity, age, elective or nonelective, and 5-minute Apgar scores).
In the United
States of America, the use of regional anesthesia increased from
51% to 85%, between1981 and 1992, a period of 11 years. In 2001, 95%
of elective
and
70% of nonelective Cesarean sections were performed under regional anesthesia.(15)
Table I. Anesthetic techniques used for
cesarean section in the RMS hospitals in 2007
Hospital
|
Cesarean
section
|
General
Anesthesia
|
Spinal
Anesthesia
|
Epidural
Anesthesia
|
Prince
Zaid
|
353
|
289 (81.86%)
|
64 (18.14%)
|
0
|
Prince
Ali
|
780
|
750 (96.16%)
|
26 (3.33%)
|
4 (0.51%)
|
Prince
Rashed
|
1410
|
1324 (93.90%)
|
86 (6.10%)
|
0
|
Princess
Haya
|
346
|
324 (93.64%)
|
22 (6.36%)
|
0
|
Prince
Hashem
|
640
|
265 (41.41%)
|
374 (58.44%)
|
1 (0.15%)
|
Queen
Alia
|
1400
|
1050 (75%)
|
350 (25%)
|
0
|
King
Hussein
|
385
|
335 (87%)
|
50 (13%)
|
0
|
Total
number
|
5314
|
4337 (81.6%)
|
972 (18.3%)
|
5 (0.1%)
|
Data are presented as numbers
In Germany, in
1978, 94% of all operative deliveries were being done under general anesthesia,
which decreased to 61% for elective cases in 1996. However, 83% of urgent cases
and 98% of emergency cases were still being done under general anesthesia.(16)
The 2002 re-evaluation indicated that the
rate of regional anesthesia for elective Cesarean section had increased to
73.5% from a value of 39% six years previously, Spinal anesthesia became the
preferred technique and was performed in 50%, 35% and 5% of the patients
presenting for elective, urgent and emergency caesarean delivery, respectively.(5)
The use of general anesthesia for cesarean section in the United Kingdom has also
declined, falling from 77% in 1982 to 44% by 1992.(17) In
1997, of all caesarean
sections 22% were completed with general anesthesia, 47% with spinal, 22% with
epidural, and 9% with combined spinal-epidural anesthesia.(6) In parts of the United Kingdom,
use of regional anesthesia has reached nearly 95% as of 2002.(18)
A successful and rapid change of anesthetic
practice for Cesarean sections at our institution is needed to be in line with global
standards. This may be implemented through the (a) implementation of an antenatal
education program explaining anesthetic choices and expectations so that
expectant mothers may start preferring regional anesthesia; (b) creating a dedicated
obstetric anesthesia team to care for laboring patients which can provide
epidural analgesia for normal deliveries and use epidurals in case of urgent or
emergency Cesarean
section if needed; (c) encouraging a change in the culture of operation room
team who mainly prefer general anesthesia as it takes less time than regional
anesthesia to set up. Further work needs
to be done to change the behavior of surgical, nursing and anesthetic staff; and
(d) taking the decision to have change through application of international
obstetric anesthetic protocols and guidelines.
Some of these steps are being implemented
at Prince Hashem Hospital
and this explains the higher rate of Cesarean sections done under spinal anesthesia in
comparison with other hospitals in our institution.
Conclusion
This
review of anesthetic techniques used for Cesarean section shows an overuse of
general anesthesia and a low use of regional anesthesia, calling for an
adjustment of clinical practice in accordance with recent scientific data.
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