Introduction

• This recipe uses Total Intravenous Anaesthesia (TIVA) TCI.
• The main ingredients are Propofol and Remifentanil.
• Safe anaesthetic management and good postoperative analgesia is our goal.
• Patient weight, airway management and OSA have rarely caused anaesthetic issues.
• Although patients are well motivated and walk to operating theatre, those with bad arthritis and difficult mobility should be offered a wheelchair (or a bed).
• Reconfirm HDU bed if deemed necessary and don’t start the case unless it is available.
• Venous access could be difficult in few but often it is not a problem, we suggest 2 accesses.
• Measurement of blood pressure on the forearm with a normal arm cuff is all you need.
• Preexisting pressure effects on skin should be documented.
• Early postoperative mobilisation should be emphasised to avoid postoperative complications.
• Prescribe 2g of Paracetamol ± 400mg Ibuprofen ± PPI and other premeds in SAL.

Preparation

• Always get ready before your patient has arrived in theatre.
• Never get distracted when preparing anaesthetics and setting the infusions.
• Know your patient’s parameters (weight / age / height / sex / BMI) in advance to save time.
• Draw Propofol 2% in two 50ml syringes (you will need the second one sooner than you thought) and maybe a third one.
• Reconstitute 2mg of Remifentanil in 40mls of saline/water for injection (=50mcg/ml)
• Draw 2 vials of Rocuronium (10mls=100mg) as you will need more than just one dose. Always have Suxamethonium 200mg drawn and ready.
• Administer 4-8mg Ondansetron before induction and 3.3-6.6mg Dexamethasone after induction (to avoid perineal pain/heat).
• Get 20mg of Morphine drawn.
• Get 10mg of Metaraminol and 30mg Ephedrine drawn separately.

Setting the TCI Pump

• Use Propofol and Remifentanil in 2 separate pumps.

• How to calculate the Adjusted Body Weight for the TCI

• Men:	Height cm – 100	= Ideal Body Weight
  Women:	Height cm – 105

• Extra Body Weight is the Actual Body Weight – Ideal Body Weight
• The Adjusted Body Weight is Ideal Body Weight + 1/3 Extra Body Weight.
• Example
• If Mrs. Lone weighs 148 kg and is 168cm tall then his Ideal Body Weight will be: 168 – 100 = 68kg,
  IBW♂ = ht - 100, IBW♀ = ht - 105
• Thus he weighs 80kg (Extra Body Weight) more than he should.
  EBW = weight - IBW
• His Adjusted Body Weight will then be: 68 + 27 = 95kg.
  ABW = IBW + ⅓ x EBW
• Wt kg Ht cm

  Male Female

Meanwhile your patient has arrived.

• Help ID Check and positioning the patient on the table.
• The patient should sit first, then put feet on the foot rest before stretching up towards the pillow.
• The reverse Trendelenburg position makes the airway easier.
• Once patient is positioned, ask if there is any need of readjustment.
• The table has the Hover Mattress under the sheet, so there is a risk of patient sliding down if knees are bent or feet off the rest.
• Consider using Awareness Monitors and Arterial lines in difficult cases
• This diagram will help patients to understand and anaesthetist to plan

• Welcome your patient
• Check the ID band
• Always position patient’s feet on the feet rest
• IV access / monitors
• Antibiotics/Antiemetics
• Preoxygenate/Flowtrons
• Induction/NMB/Intubation
• No BMV

Getting Ready for Take-off

1. Put a 20-18G IV access in the arm away from the surgical instruments (monitors, cautery and suction) as the crowd will limit your IV access.
2. Putting Flowtrons on before patient is asleep gives a feeling of good caring.
3. Use normal BP cuff (blue) on the FOREARM near the surgical monitors.
4. Record basic measurements before your patient is asleep.
5. Administration of antibiotics and antiemetic before your patient is asleep gives the patient a feeling of care and buys you time for a final check: give them while preoxygenating (3 min), it saves time.
6. Start FIRST the Remifentanil …target at 4-7nanogram (Minto).
7. Once the Remifentanil has reached the target, start the Propofol at 5--7 microgram (Marsh): this makes intubation possible earlier and smoother.
8. Administer the NMB once both Propofol and Remi have reached the targets.
9. After one minute of NMB laryngoscope and intubate (avoid BMV).
10. Once safely intubated, level the table to help the surgical team.
11. Reduce the infusion rate by 1-2 nano/micrograms on both pumps until a minute before knife to skin as it helps to recover the drop of bp.
12. Increase the infusion by couple of nano/micrograms if bp allows one minute before KTS.
13. If KTS tolerated, reduce the TCI infusion.
14. Always keep the Remifentanil infusion 1- 2 nanograms above the Propofol microgram as it helps CV and respiratory stability.
15. If you have done BMV, the surgeon may ask to deflate the stomach. Use orally a big bore NG tube, make sure you remove it before the gastric part of the procedure commences.
16. The table will be as low as possible with a side tilt so mind your IV line.

While Cruising…

1. Avoid too much IV fluid, as blood loss will be amazingly low.
2. Get oesophageal bougie and blue dye ready for bypass procedures.
3. Dilute 10mls Methylene Blue in 150 to 250 mls of distilled Water.
4. Fill the dye in two 50 mls bladder syringes to avoid accidental spillage.
5. Get some KY Jelly ready.
6. Before you are asked to put the bougie in, make sure you have topped up your NMB otherwise patient will cough.
7. Watch the tip of your bougie arriving in on the surgeon’s monitor.
8. Before taking it out, gently roll it between your fingers to “make sure it is not accidentally sutured”, Don’t just pull it out”.
9. After the bougie is out insert the NG tube orally and watch on the screen for its tip arriving near the anastomosis.
10. Before you inject the dye, make sure the ETT cuff is not leaky.
11. Don’t force hard the dye syringe nozzle into the NG tube as you will then struggle to disconnect it if a second dye syringe is needed. Keep the second syringe handy to enhance the filling test/leak test if needed.
12. Leave the suction ON inside the patient’s mouth before injecting the dye to avoid regurgitation on the pillow and patient’s face.
13. By now you should have administered 2-3 doses of Morphine (5+5+5mgs) at good intervals.
14. If Paracetamol was missed on SAL, this is the time to administer it IV.
15. After the dye test you are left with 45 minutes to land so get your postop advice documentation and drug chart ready.

Getting Ready for Landing

1. Always reverse NMB drugs to avoid any residual block.
2. Stop Remifentanil once the abdominal ports are out, and reduce Propofol to half the maintenance infusion rate (2 microgram or less).
3. Doxapram works well to stimulate respiration in case breathing is slow.
4. Make sure your surgeon uses local anaesthetics (40ml bupivacine 0.25% or L-bupivacaine) around the port sites.
5. Extubate (sat up) once respiration and SpO₂ acceptable (consider a Guedel).
6. Before sliding on to the bed make sure Hover mattress loops are free on all sides.
7. As the patient needs to be sat up, transfer the patient towards the head end of the bed, otherwise patient slips down south once sat up (see diagram).

You Landed

1. Prescribe IV Morphine

2. Prescribe an antiemetic for use in the recovery and ward.
3. Prescribe oral analgesia for ward (Oromorph/Paracetamol/Tramadol). IV rarely needed.

4. Make sure patient on CPAP has his machine available on the ward.

Notes

• A Gastric Bypass usually takes more than 2 hours and Gastric band less than two hours.
• A Gastric Band patient is likely to be sent home same day, so “Consider Fentanyl Analgesia” in PACU.
• These patients will need an hour in the recovery to get fit for transfer to ward.
• Always See your patient and recovery staff before they are transferred.
• Make sure you complete the documents before your patient is transferred to the ward.

References

1. Anaesthesia for the Overweight and Obese Patient by M Bellamy and M Struys (Oxford University Press 2007 ISBN-13:9780199233953)
2. An overview of TCI & TIVA by A Absolam and M Struys (Academia Press, 2007 ISBN-13 9789038211077)
3. Lecture Notes: M Bellamy, M Margarson (Recent Advances in Anaesthesia, Critical Care and Pain Management 2-4 Feb 2011, Pages 103-7)
4. Designing intelligent anesthesia for a changing patient demographic: a consensus statement to provide guidance for specialist and non-specialist anesthetists written by members of and endorsed by the Society for Obesity and Bariatric Anaesthesia (SOBA) Bellamy and Margason - Perioperative Medicine 2013, 2:12 http://www.perioperativemedicinejournal.com/content/2/1/12
5. Peri-operative Management of the Morbidly Obese Patient - AAGBI 2007 www.aagbi.org/sites/default/files/Obesity07.pdf
6. My personal experience over the past ten years of more than 100 patients at MPH Taunton
7. SOBA guideline

Acknowledgments

• Prepared by Mohammad Lone for use by occasional bariatric anaesthetic colleagues

Introduction

• This is guidance and not a protocol and it is up to the treating clinicians to prescribe and treat as they feel is appropriate.
• Studies have shown that analgesia for this procedure is all about marginal gains from careful perioperative patient education, multimodal analgesia, avoiding prolonged fluid fasting, optimising surgical technique and timely post-op analgesia administration.

For all Patients

• Please could you use an inpatient MAR chart for all pre and post-op medication (including nurse led PGD) so that we have sufficient space for all of the medications that they may need during their recovery time on the unit.
• Before the list starts, please could you prescribe TTO codeine phosphate prn (unless contraindicated e.g. breastfeeding) at the start of a list on a blue TTO form (on ward) it costs 14 times less for the hospital if these tablets are dispensed by our pharmacy than as an out of hours FP10 prescription.

Preoperative

• Paracetamol 1g
• Ibuprofen at least 400mg
• If NSAID intolerant or pain issues; consider 300mg Gabapentin.

Intraoperative

• Fentanyl is the appropriate opiate of choice for a day case procedure.
• Dexamethasone is an extremely effective antiemetic and has some pain benefits too.

Postoperative

• All patients will have a pain score performed in recovery and on the ward. If they score 4 or above, please ensure that they are given some analgesia in a timely fashion.
• In addition to the fentanyl protocol for recovery please prescribe regular paracetamol qds and ibuprofen (or alternative 2nd agent) regularly.
• Please could you prescribe some further analgesia, oral morphine and anti-emetics to be given prn by the ward staff?

• The patients will be given an advice sheet which includes a ‘drug chart’ for them to keep track of their self-medication with paracetamol and ibuprofen. The ward nurses will advise the patients of the timings of their most recent dose of these drugs to ensure that they know when to take the next doses. They then have the codeine/alternative TTO as a rescue analgesic.

Preoperative

• Timely surgery reduces morbidity and mortality – Cancellation is consultant only decision. Please clearly document reasons for delaying surgery, with a clear plan to rectify problems and parameters to re-list.
• All patients will receive preoperative glucose drink.
• Paracetamol usually given regularly preoperatively. If not, give pre- or perioperatively.
• Review analgesia already given - opiate doses, timing of last block (re-administer if >4 hours)
• Consider acid reflux prophylaxis as high risk group (i.e. ranitidine 150mg po, metoclopramide 10mg po)
• Carefully assess and clearly document ASA grade - refer to printed definitions and examples in Trauma Theatre

Nerve Block

• Nerve block (or local infiltration) for ALL patients
  • Reducing opiate use will reduce delirium and post-operative respiratory complications
• Nerve block should be used prior to spinal to aid positioning.
  • Fascia Iliaca compartment block is simple, quick and can be performed with a landmark technique (see here or ‘How To’ guide in trauma theatre) or US guidance. Use L-bupivacaine 20ml 0.375% or 30ml 0.25%
  • Femoral nerve ± lateral cutaneous nerve of thigh is an effective alternative block technique.
• OR
• Trained surgeon to infiltrate 0.2% Ropivacaine into operative field intra-operatively.
  If patient < 60 kg use 80 mls, 61-79 kg use 100mls, >80kg use 120mls.

Anaesthesia

• Tight blood pressure control is vital and reduces intra-op and post-op mortality 
  • Beware Bone Cement Implantation Syndrome. A well oxygenated patient with good BP has lower risk.
  • NIBP every minute during induction then 2.5 minutes throughout.
  • Low threshold for arterial line.
  • Aim for BP within 10-20% of pre-op BP value. No patient should have BP<100mmmHg.
  • Start Metaraminol infusion (0.5mg/ml) in the anaesthetic room for ALL patients.
  • Tranexamic acid 15mg/kg (975mg) up to 1g before the start of surgery. Contraindicated with previous VTE.
  • Antibiotics according to trust protocols. Note changes for weight <60kg or eGFR <60ml/min.
  • Aim to give 10-20ml/kg (650-1300ml) Hartmann’s intra-op.
  • Warm air blanket and fluid warmer for ALL patients.
• Spinal anaesthesia
  • Plain bupivacaine 10 mg or less (<2ml of 0.5%). 1.6 - 1.8 ml sufficient. No intrathecal opiates (not needed, associated post-op morbidity).
  • Face mask oxygen for all patients.
  • Sedation with propofol TCI (aim <1 mcg/ml) (Avoid midazolam or ketamine – high risk of delirium).
  • Use short acting opioids i.e. Alfentanil for positioning if required.
• GA (only if spinal contraindicated)
  • Induce slowly (IV ± inhalational). For frail patients Alfentanil 0.5mg plus Propofol 0.5mg/kg (32.5mg) may be adequate.
  • Maintain anaesthesia with sevoflurane or desflurane (<1.0 age adjusted MAC) or propofol TCI
  • Consider BIS monitoring
  • Spontaneous ventilation ± PSVPro if using an LMA (high risk of aspiration with IPPV and LMA)
  • Low threshold for intubation. Must ensure complete reversal of neuromuscular blockade (ToF n=4, no fade).

Postoperative

• All patients should be prescribed the following:  
  • Regular paracetamol (if <50kg reduce dose to 750mg)
  • Laxido one sachet bd or Senna two tablets at night regularly
  • Oramorph 5 – 10mg 4 hourly PRN
  • Ondansetron 4mg PRN. No cyclizine (please cross off if previously prescribed)

• Omit anti-hypertensives for at least 24hrs post-op. Cross drug chart accordingly.
• Prescribe 2x 250ml boluses of Hartmann’s or 0.9% saline for hypotension on the ward. Specify parameters.
• Prescribe maintenance fluids 1ml/kg/hr (65ml/hr)
• Inform outreach of high risk cases and consider HDU for persistent post-operative hypotension (ie BP >20% less than pre-op value). No patient should return to the ward with BP <100mmHg.

Documents

• AAGBI Management of NOF 2020 Guidelines.pdf
• AAGBI Management of NOF 2020 anticoagulation appendix S1.pdf

About

• These are quick, easy & safe to perform, and provide #NOF patients with good analgesia both to re-position for a spinal, and post-operatively

Technique

• Identify the location of the femoral artery beforehand.
• Use 4 fingers to divide a line between ASIS and the pubic tubercle into thirds (see below)
• Find the junction of the lateral 1/3 and medial 2/3. Puncture site is 1cm inferior and lateral to this (see below) - if this is near the location of the femoral artery then reassess landmarks
• Use a blunt fill needle, filter needle or a block needle
• Insert perpendicular to skin* and feel for two ‘pops’
• After negative aspiration, inject large volume of local anaesthetic: eg. 20mls of 0.375% levobupivacaine or 30mls of 0.25%

Troubleshooting

Problem
Suggested action

---

No distinct "pops" felt during needle advancement.
Withdraw needle, check landmarks, change angle to be more perpendicular or caudal.
Hitting bone on needle advancement.
Too deep. Withdraw ± change angle directing more cranially.
Blood on aspiration.
Remove needle, apply pressure for 2 minutes. Reattempt directing ore laterally.
Resistance to injection.
Withdraw needle slightly and try again. The needle may be positioned within muscle.

Preoperative

• All patients to receive clear fluids up until 2 hours pre-op.
• Premedication with
  • Paracetamol 20mg/kg up to 1g max po.
  • Ibuprofen1 200mg po (usual cautions - https://cks.nice.org.uk/topics/nsaids-prescribing-issues).
  • Omeprazole 20mg po if ibuprofen prescribed.

Anaesthesia

• Spinal anaesthesia with low dose plain bupivacaine 10mg is often sufficient.
  • Preferably no intrathecal opioids.2 Use fentanyl if necessary.

• Sedation with propofol TCI.
• Ketamine 0.5mg/kg (35 mg) once sedation started. This is useful if the spinal is not fully established.
• Dexamethasone 6.6mg.
• Tranexamic acid 15mg/kg (105) mg up to 1g given at the start of surgery. Contraindicated if previous VTE.
• Hartmann's 1 - 2 litres intraoperatively.
• Antibiotics as per trust protocol.

• If a GA is used it does not preclude patients benefitting from the above regimen.

Surgical - Local Infiltration Anaesthesia (LIA)

• Surgeon to infiltrate Ropivacaine 0.2% into operative field intra-operatively (toxic dose is 3 - 4mg/kg [1.5 - 2 ml/kg]) (210 - 280mg [105 - 140ml]).

  Patient Weight	Volume Ropivacaine 0.2%
  <60kg	80ml
  61 - 79kg	100ml
  >80kg	120ml

• Do not use Ambit pump for ongoing administration.
• Avoid using femoral nerve blocks, nor other peripheral nerve blocks that cause a motor block

Postoperative

• All patients should be prescribed:
  • Regular paracetamol.
  • Regular ibuprofen1 200mg po tds for 72 hours (usual cautions).
  • Omeprazole 20mg po od for 72 hours if prescribing ibuprofen.
  • Regular Oramorph at 0800, 1200, 1800, 2200 for 48 hours (use age-based prescribing, use oxycodone if eGFR<50).

    Patients Age	Dose of Oramorph	Dose of Oxycodone IR
    <70	10mg	5mg
    70 - 89	5mg	2.5mg
    >89	2.5mg	1.5mg

  • Oramorph prn max 2 hourly (use age-based prescribing, use oxycodone if eGFR<50.
  • As required antiemetics.
• Aim for patient to return to ward with no oxygen nor IV fluids.
• Prescribe 1 litre Hartmanns IV to give over 2 hours if patient becomes hypotensive or faint on mobilising.
• Patients taking regular opioids on admission may need an indivdual analgesic regimen.
• Reserve PCAs for patients with complex analgesic requirements.

Notes

• 1 Ibuprofen should be used with usual cautions (NNT of 400mg v 200mg, 2.5 v 2.7). Co-prescribe Omeprazole. Not contraindicated in combination with dabigatran.
• 2 Diamorphine: Delays mobilisation. If you are concerned about a block wearing off then adding fentanyl does the job.

Acknowledgments

• The CALEDonian technique is an enhance recovery pathway for hips (and knees).
• It was indeed developed in Scotland, but note the capitals in the name which stand for "Clinical Attitudes Leading to Early Discharge".
• It was adapted by Matthew Ward and James Heal for use in Musgrove. Latest revision by Edward Keevil February 2022.

Preoperative

• All patients to receive clear fluids up until 2 hours pre-op.
• Premedication with
  • Paracetamol 20mg/kg up to 1g max po.
  • Ibuprofen1 200mg po (usual cautions - https://cks.nice.org.uk/topics/nsaids-prescribing-issues).
  • Omeprazole 20mg po if ibuprofen prescribed.

Anaesthesia

• Spinal anaesthesia with low dose plain bupivacaine 7.5mg is often sufficient.
  • Preferably no intrathecal opioids.2 Use fentanyl if necessary.

• Sedation with propofol TCI.
• Ketamine 0.5mg/kg (35 mg) once sedation started. This is useful if the spinal is not fully established.
• Dexamethasone 6.6mg.
• Tranexamic acid 15mg/kg (105) mg up to 1g given at the start of surgery. Contraindicated if previous VTE.
• Hartmann's 1 - 2 litres intraoperatively.
• Antibiotics as per trust protocol.

• If a GA is used it does not preclude patients benefitting from the above regimen.

Surgical - Local Infiltration Anaesthesia (LIA)

• Surgeon to infiltrate Ropivacaine 0.2% into operative field intra-operatively (toxic dose is 3 - 4mg/kg [1.5 - 2 ml/kg]) (210 - 280mg [105 - 140ml]).

  Patient Weight	Volume Ropivacaine 0.2%
  <60kg	80ml
  61 - 79kg	100ml
  >80kg	120ml

• Do not use Ambit pump for ongoing administration.
• LIA provides equivalent analgesia to regional anaesthesia and allow early mobiisation.
• Adductor canal block can be used in conjunction with LIA as it rarely causes motor block.
• Avoid using femoral nerve blocks or other peripheral blocks that cause a motor block.

Postoperative

• All patients should be prescribed:
  • Regular paracetamol.
  • Regular ibuprofen1 200mg po tds for 72 hours (usual cautions).
  • Omeprazole 20mg po od for 72 hours if prescribing ibuprofen.
  • Regular Oramorph at 0800, 1200, 1800, 2200 for 48 hours (use age-based prescribing, use oxycodone if eGFR<50).

    Patients Age	Dose of Oramorph	Dose of Oxycodone IR
    <70	10mg	5mg
    70 - 89	5mg	2.5mg
    >89	2.5mg	1.5mg

  • Oramorph prn max 2 hourly (use age-based prescribing, use oxycodone if eGFR<50.
  • As required antiemetics.
• Aim for patient to return to ward with no oxygen nor IV fluids.
• Prescribe 1 litre Hartmanns IV to give over 2 hours if patient becomes hypotensive or faint on mobilising.
• Patients taking regular opioids on admission may need an indivdual analgesic regimen.
• Reserve PCAs for patients with complex analgesic requirements.

Notes

Acknowledgments

• The CALEDonian technique is an enhance recovery pathway for knees (and hips).
• It was indeed developed in Scotland, but note the capitals in the name which stand for "Clinical Attitudes Leading to Early Discharge".
• It was adapted by Matthew Ward and James Heal for use in Musgrove. Latest revision by Edward Keevil February 2022.

Preoperative

• Paracetamol 1g
• Ibuprofen 600mg (normal caveats)
• Gabapentin 300mg (if you think patient can tolerate)

Intraoperative

• Induction
  • Fentanyl 150-200mcg
  • Propofol
  • Rocuronium
  • Dexamethasone 6.6mg
  • Ondansetron
• Maintenance
  • Air/oxygen/Desflurane
  • more fentanyl if required
• 2mg/kg bupivacaine 0.25% infiltration by surgeon at the end - works amazingly well.

Postoperative

• Recovery
  • Additional fentanyl if needed - usually not
  • IV fluids discontinued if CVS stable.
• Regular Analgesia
  • Paracetamol
  • Ibuprofen
  • Tramadol
  • They get all 3 to take home and take regularly for 1st 24 hours

• As required Analgesia
  • Oramorph 20mg prn for breakthrough and to take home just in case they get into severe pain overnight.( about 1:10 use it)

Notes

• Do as you see fit (e.g. TIVA) but the key parts of the recipe are LA infiltration, no morphine, give dexamethasone, mobilise quickly post-operatively and give breakthrough analgesia to take home in case required.

Acknowledgments

• Written by Dr Mike B Walburn

Preamble

• (David Ray - Edinburgh, 60% of UK experience)
• Managing the patient's expectations is as important as giving them the sedation/analgesia
  • tell them they will be awake with some sedation and pain relief
  • tell them if is vital to report nerve pain going into their leg (when extracting pieces of disc)

Surgeon

• Key is to get surgeon to put lots of local anaesthetic in early
• Supplement this with more LA when about to dilate the tract or do the facetectomy
• Generally L4/5 discs are relatively easy but L5/S1 can be more awkward and painful - it is not easy to get the dilator and sheath in the right place

Anaesthetist

• IV 2-3 mg midazolam
• Reminfentanil infusion at 0.1 mcg/kg/min, totrted against the effect. Occasionally increase it to 0.2 mcg/kg/min when dilating the tract or when the facetectomy is being done
• DO NOT use propofol, if they get too deep and can't comply they end up moving too much and you end up giving them a GA
• Some colleagues have resorted to a low dose propofol infusion for the more difficult patients but I have never had to use this
• Music in the background also helps!
• Supplemental oxygen by mask
• Antibiotic prophylaxis
• 1 litre fluid running

Postoperative analgesia

• Ibuprofen 200-400mg tds
• Paracetamol 1g qds
• Tramadol of Oromorph for breakthrough
• Start a reducing gabapentin regimen (if using preoperatively)

Conversion calculator

Preparation

• Discuss anaesthetic procedure options including relevant risks and complications with the patient as appropriate, obtaining informed oral consent.
• Anaesthetic assessment, pre-medication, shaving and catheterization may be performed in theatre depending on urgency: see appropriate guideline.
• Ensure that antacid prophylaxis has been given as per guideline.
• The degree of urgency of delivery must be established: see classification guideline.
• Category 1 (or 2) emergency (or urgent):
  • Ensure that recent blood samples have been sent to the lab for FBC, Group and Save.
  • Mother may be given “Regional anaesthetic for unplanned Caesarean Sections (CS) – information card”
    http://www.oaa-anaes.ac.uk/assets/_managed/editor/File/Info%20for%20Mothers/RA%20for%20unplanned%20CS/RA%20for%20unplanned%20CS_English.pdf
    or “General Anaesthetic for unplanned Caesarean Section (CS) – information card”
    http://www.oaa-anaes.ac.uk/assets/_managed/editor/File/Info%20for%20Mothers/GA%20for%20unplanned%20CS/GA_Unplanned_CS.pdf.pdf
  • Intra-Uterine Resuscitation (IUR) should be instituted if there are signs of fetal
    compromise. See IUR guidelines.
  • Obtain advice or help from the consultant anaesthetist as early as possible if
    problems are anticipated.

• Category 3 or 4 elective:
  • Bloods sent from Pre-Op Assessment Clinic (POAC) as appropriate. Ensure that Hb is checked same day and action is taken if low: see appendix (Peri-operative Hb and transfusion)
  • In POAC mothers should be given “Your anaesthetic for Caesarean Section” (OAA 2009)
    http://www.oaa-anaes.ac.uk/assets/_managed/editor/File/Info%20for%20Mothers/CS_leaflets/CS_ed2_english.pdf
  • All three of the above OAA info leaflets are available in multiple languages from
    http://www.oaa-anaes.ac.uk/content.asp?ContentID=221

General Considerations

• Keep full written legible records - the minimum data set recorded on the anaesthetic chart should include maternal Hb, recent BP before labour, weight, airway assessment, ASA grade and recording that antacid premedication have been given.
• Share problems with the obstetricians and midwives, involving senior help early.
• Check anaesthetic equipment and emergency drugs.
• Connect appropriate monitoring.
• Establish IV access and start IV fluid infusion. Use fluid warmer if large volumes required.
• Blood pressure to be maintained at pre-operative level. Phenylephrine is the preferred vasoconstrictor to maintain blood pressure (BP) in regional anaesthesia for LSCS. Phenylephrine 40 micrograms is equivalent to ephedrine 3mg. Phenylephrine is available in 10mg/ml ampoules only. This must be diluted before administration (add 10mg phenylephrine to 250mls N/Saline 100ml making a solution of 40 mcg/ml). This may be given as a bolus to restore blood pressure, or by infusion starting at 60ml/h and titrated to effect. Ephedrine and metaraminol may also be used.
• Give antibiotics before delivery as per guideline, record dose on drug chart.
• Oxytocin 5 units is given by slow IV bolus injection after delivery of the baby (N.B. wait for the arrival of the last of any twins or triplets!). Routinely commence infusion of oxytocin 40 units in N/Saline 500ml at 125ml/h unless surgeon requests otherwise.
• Estimate blood loss frequently during and after delivery, replacing volume etc as appropriate.
• Thromboprophylaxis (follow maternity guideline):
  • In theatre may be by graduated compression stockings or sequential compression / decompression leggings if appropriate.
  • In the recovery room may be by continuation of sequential compression / decompression leggings or application of graduated compression stockings, followed by enoxaparin at an appropriate time.

Acknowledgments

• Written by Dr John Clear.

Indications

• Elective and urgent / emergency LSCS when time allows (discuss with obstetrician).
  

Contraindications

• Patient refusal
• Coagulopathy (see guideline)
• Hypovolaemia
• Infection at insertion site
• Acute CNS disease
• Known neurological conditions that might complicate spinal insertion e.g.neurofibromatosis, spina bifida (unless occult with no problems)

Relative Contraindications

• Septicaemia / bacteraemia (it is acceptable to proceed if blood cultures are take and antibiotics are given)
• Placenta previa
• Aortic stenosis / other severe cardiac problem. Specialist advice required. A Combined Spinal Epidural (CSE) or general anaesthetic might be better, depending on severity. Referral to Bristol for delivery under spinal catheter anaesthetic may be planned in advance.
• Multiple sclerosis (risk/benefit to be fully discussed – seek senior advice)

Technique

• Perform with mother sitting or lateral according to experience / preference.
• IV fluid loading of approximately 500mls warmed crystalloid before establishing the block is appropriate, with further volume replacement as required.
• Insertion at L3/4 or below if possible. The spinal cord terminates at L1/2 in most people, so it is essential to be below that level.
• Clean skin with 0.5% chlorhexidine in alcohol 70% spray. Gently rub the skin with a swab during cleaning, then allow skin to dry while preparing spinal equipment and before applying sterile drape. Chlorhexidine contamination has been associated with disabling arachnoiditis, so it is essential that spinal equipment is not contaminated in any way by this liquid. (see ref: Bogod)
• Full sterile technique – mask, hat, scrub, gown and glove.
• Hyperbaric bupivicaine 2.3-2.7 mls. Usually 2.5mls
• Opioids as per guideline for pain relief after LSCS. Diamorphine is the opioid of choice with good postoperative analgesia.
  • Fentanyl: add 25 mcg (0.5ml) to the bupivacaine. Fentanyl has a similar duration to the bupivacaine but is less beneficial post-op. The ampoules are for single patient us only.
  • Diamorphine: dilute 5mg in 5mls normal saline to make a concentration of 1mg/ml. Add 0.3ml of this solution (300 mcg) to the bupivacaine.
• Spinal needle: Whitacre 25G (or 27G if preferred, but note the flow of CSF is very slow in the lateral position)
• Ensure that aorto-caval compression is minimized. Position mother in left tilt of approximately 15° (clinometer at attached to head of table) with head section of table raised slightly. Ensure side supports are in situ.
• Commence infusion of phenlyephrine 40mcg/ml infusion at 60ml/h as soon as possible after the spinal injection.

Test the Block

• Test the skin with ice after 5 minutes to ensure that a block is developing.
• If the block is not above T10 after 5 minutes, tilt the table head down, and review after a further 5 minutes. The positioning of the mother for insertion of urinary catheter by the midwife usually helps to increase cephalad spread of the spinal medication, so encourage early catheterisation after while further adjustments to position can be made as required.
• Check the block to light touch. Ask the mother to touch her abdomen, moving upwards on both sides in the nipple line until it feels ‘normal’. The aim is to ensure a block to light touch up to and including T6 (xiphisternum level). Record final block height to touch on the anaesthetic record.
• If there is no block present, consider repeating the spinal.
• If a block is present but inadequate for surgery, consider spinal anaesthetic supplement. Beware high spinal anaesthesia (requiring conversion to general anaesthesia with ventilation and vasopressor support), incidence uncertain. The spinal dose should be limited to bupivacaine 0.5% heavy approx 1ml (See references: Levy).

Further Management

• Oxygen (4 to 10 l/min by Hudson mask) is indicated if there is maternal hypoxia or fetal distress.
• Hypotension (which often presents as nausea)
  • Ensure that aorto-caval compression is minimized (as above).
  • Treat by bolus administration of phenylephrine 40mcg IV (peak response in 40 seconds) or ephedrine 3-6mg IV (peak response in 80 seconds) and titration of rate of phenylephrine infusion.

Supplementary Analgesia

• If the mother experiences discomfort, assess the problem and reassure. If there is a problem, ask the surgeon to stop. Rescue regimens include:
  • Nitrous oxide in oxygen, between 20% to 70% via Hudson mask
  • Alfentanil 100-250mcg increments up to 1mg
• General anaesthesia for inadequate block: this must be offered promptly – document clearly in the notes with times, especially if declined by patient.

Acknowledgments

• Written by Dr John Clear.

Indications

• Elective LSCS
• Urgent / emergency LSCS when labour analgesia effective and time allows (discuss with obstetrician). 15 minutes may be required to establish an effective block, so top up may not be appropriate in very urgent cases.

Contrandications

• Incomplete analgesia. There must be evidence of sacral as well as cephalad spread of labour analgesia mixture. A patchy epidural / missed segment epidural, even if it is topped up, may be inadequate for operative delivery. In this situation, either remove the epidural and put in a spinal if the patient is willing, or perform the Caesarean section under a GA.
• Patient refusal

Technique

• Test the block. Note when the last top-up was given. Remember that a dilute ‘analgesic’ solution has been used to achieve sensory blockade with minimal motor blockade. To achieve a good quality block for Caesarean section an ‘anaesthetic’ concentration of local anaesthetic must cover the nerve roots, so a ‘full’ dose is used unless a stronger top-up has been given recently.
• Remember to check for potential airway etc. problems when you first see the mother so that you can call for advice / assistance early in case of the need for GA etc.
• Top ups should be given in theatre with monitoring in place (category 1 & 2 CS). In particular cases it may be appropriate for the anaesthetist to start topping up to in the delivery room. If this is done in the room, the anaesthetist must stay with the mother, taking all responsibility for appropriate monitoring so that the midwives can concentrate on their preparations and transfer to theatre.
• Sit the mother upright, give 15-20mls of one of the following solutions over 5 minutes. A test dose is not usually required, but if the labour block was unexpectedly high or dense then give 3 ml of the solution and check at 5 minutes before giving the full dose. A 3 ml lumbar epidural catheter test dose should produce minimal or no change in the power of plantar flexion of the foot (S1 innervation) at 5 or 10 minutes.

• After the dose has been given, lie the mother on her left or right side, or supine with left tilt of approximately 15° until the block is established. The head section of table can be raised slightly. Ensure side supports are in situ.

Choice of local anaesthetic

• Bupivacaine 0.5% with adrenaline 1 in 200,000
• Lidocaine 2% with adrenaline 1 in 200,000. Sodium bicarbonate 8.4% 2ml may be added to this to reduce the onset time of the block.
• Levobupivacaine 0.5% plain solution
  Notes:
  • Adrenaline-containing solutions produce a denser, more prolonged block and fewer inadequate blocks (see ref: Hillyard)
  • The commercial adrenaline-containing ready-mix bupivacaine and lidocaine preparations in maternity contain sodium metabisulphite (anti-oxidant) which is safe for epidural use. Preparations containing benzoate (preservative) are not acceptable for epidural use. (see ref: Ankcorn)
  • Adrenaline-containing solutions should be used with caution in the presence of severe pre-eclampsia.

Opioids

• Provided that there has not been a recent top-up with high dose fentanyl during labour, add the following to the top up:
  • Fentanyl 50-75mcg or
• Diamorphine 3mg may be given before or after delivery.

Test the Block

• Test the skin with ice after 10 minutes to ensure that a block is developing.
• Check the upper level of block. Ask the mother to lightly touch her abdomen moving upwards on both sides in the nipple line until it feels normal. The aim is to ensure a block to touch up to including T6.
• Check the lower level of block to ensure sacral segments are blocked.
• If there is no sign of a dense block approaching the required dermatomal level at 10 minutes, discuss the options with the surgeon involved and the mother:
  • Epidural supplement (local anaesthetic as for main dose, 1.5ml per unblocked segment). Allowing for recent administration during labour, the maximum dose of lidocaine plain = 3mg/kg, lidocaine with adrenaline 7mg/kg, bupivacaine plain 2mg/kg, bupivacaine with adrenaline 3mg/kg. For levobupivacaine 150mg maximum (= 2mg/kg for a 75 kg woman).
  • General anaesthesia.
  • Spinal anaesthetic supplement. Beware high spinal anaesthesia (requiring conversion to general anaesthesia with ventilation and vasopressor support), incidence uncertain. The normal spinal dose should be reduced to bupivacaine 0.5% heavy 1ml (See references: Levy).
• Record final block height and technique used (light touch block to include T6 to S5 is the accepted standard) on the anaesthetic record.

Supplementary Analgesia

• If the mother experiences discomfort, ask the surgeon to stop, assess the problem and reassure. Offer:
• Epidural top up. Do not exceed maximum dose of LA. May take up to 10 minutes to work.
• Nitrous oxide in oxygen, between 20% to 70% via Hudson mask, Entonox cylinders are available in theatres
• Alfentanil 100-250mcg increments up to 1mg
• General anaesthesia:
  • Must be offered promptly. Document clearly in the notes with times, especially if declined by patient.

Lipid Rescue

• Use to treat cardiac arrest caused by accidental systemic local anaesthetic overdose as per guidelines. Green box is kept on the labour ward crash trolley along with instructions.

Acknowledgments

• Written by Dr John Clear.

About

• This combines the advantages of rapid onset spinal anaesthesia with the flexibility of the epidural for top ups. There can be better haemodynamic stability with fewer adverse side effects and faster recovery if spinal dose is less than normally given for a spinal anaesthetic alone.

Indications

• Predicted prolonged surgery (known anatomical abnormalities, multiple caesareans in the past, additional sterilisation etc)

Contraindications

• Patient refusal
• Coagulopathy (see guideline)
• Hypovolaemia
• Infection at insertion site
• Acute CNS disease
• Known neurological conditions that might complicate spinal insertion e.g.neurofibromatosis, spina bifida (unless occult with no problems)

Technique

• Perform with mother sitting or lateral according to experience / preference.
• IV fluid loading of approximately 500mls warmed crystalloid before establishing the block is appropriate, with further volume replacement as required.
• Insertion at L3/4 or below if possible. The spinal cord terminates at L1/2 in most people, so it is essential to be below that level.
• Clean skin with 0.5% chlorhexidine in alcohol 70% spray. Gently rub the skin with a swab during cleaning, then allow skin to dry while preparing spinal equipment and before applying sterile drape. Chlorhexidine contamination has been associated with disabling arachnoiditis, so it is essential that spinal equipment is not contaminated in any way by this liquid.
• Full sterile technique – mask, hat, scrub, gown and glove.
• Approaches:
  • Single intervertebral space needle-through-needle (epidural-spinal-epidural) Unable to ‘test-dose’ epidural
  • Double intervertebral space (epidural then spinal in a more caudad space). Can ‘test dose’ epidural catheter before spinal
  • Single intervertebral space two needle (spinal-epidural-spinal). Can ‘test-dose’ epidural catheter before spinal (Cook)

Doses

• Spinal as per spinal guideline. Note that epidural saline or local anaesthetic injected within 10 minutes of the spinal may cause a significant rise in the sensory level by a volume effect.
  • Low dose spinal 1ml 0.5% heavy bupivicaine can be used with incremental epidural dosing to achieve surgical anaesthesia.
  • Opioids can be added to either spinal OR epidural

Assessment

• Assess and manage according to guidance for spinals and epidurals.

Acknowledgments

• Written by Dr John Clear.

Indications

• Elective LSCS (maternal request, or regional technique contraindicated)
• Emergency LSCS when there is no time for establishing regional anaesthesia.

Relative Indication

• Elective LSCS with placenta previa (anterior). Discuss with senior anaesthetist and operating obstetrician.

Cautions

• Anticipated difficult airway
• Previous anaesthetic problems / relevant family history of problems?
• Pre-pregnancy medical problems
• Pregnancy-related problems such as pre-eclampsia
• Hypovolaemia

Induction

• Ensure that aorto-caval compression is minimized. Position mother in left tilt of approximately 15 degrees (clinometer at attached to head of table) with head +/- upper body section of table raised slightly (“ramped” position is ideal for bariatrics). Ensure side supports are in situ.
• Monitoring must include capnography / gas analyser
• Pre-oxygenate for Rapid Sequence Induction aim for end tidal oxygen at or near 90% with a good mask fit and high oxygen flow.
• Cricoid ring to be identified by ODP while mother awake
• Full surgical team in theatre and scrubbed, mother catheterised and fully prepped if category 1 emergency, otherwise discuss order of events at safety brief.
• IV induction agents:
  • Propofol approx 2.5 mg/kg. This is widely used internationally, and many units in the UK are converting to it rather than using thio, especially following shortages of thio. Risk of awareness with lower doses, so for larger patients have a second syringe to hand in case a supplement is required. Higher doses may be associated with neonatal depression, especially if given as part of Target Controlled Infusion regimen.
  • Thiopentone 4 to 7mg/kg
  • Ketamine (good CVS stability, but unpleasant dreams, and dose > 1.5 mg/kg causes neonatal depression)
  • Etomidate 0.3mg/kg (neonatal and maternal cortisol levels lowered)
• Opioids:
  • Alfentanil 10mcg/kg should be given to pre-eclamptic mothers with induction (inform neonatal SHO – possible neonatal respiratory depression.
• Muscle relaxants:
  • Suxamethonium 1 – 1.5mg/kg IV
  • Rocuronium 1mg/kg (reversal agent sugammadex available in maternity theatre, see guideline)
• Trained assistant provides cricoid pressure as mother loses consciousness.
• Intubate trachea and confirm correct placement
• Follow hospital guideline for failed obstetric intubation if this occurs.

Induction

• Maintain anaesthesia with nitrous oxide 50-66% or air in oxygen with isoflurane 0.75-1.5% (using overpressure initially) for elective LSCS to achieve adequate MAC. Use 100% oxygen with isoflurane for fetal distress, placental insufficiency, PET etc. Sevoflurane is an acceptable alternative.
• Ventilate to end tidal carbon dioxide 4-4.5kPa
• Maintain neuromuscular block with atracurium 0.3mg/kg
• Give morphine 10-20mg IV as soon as possible after clamping of the cord ( See guideline for analgesia for LSCS) and adjust isoflurane accordingly.
• Check that blood loss is not excessive, and replace volume as required.
• If major haemorrhage occurs, consider changing from isoflurane to TIVA with propofol
• Consider TAP block. Perform whilst mother still anaesthetised. See appropriate guideline
• Turn patient on to left side at the end and extubate when awake, muscle relaxant reversed and breathing satisfactorily. Alternative, especially for the morbidly obese, is sitting awake extubation.

Recovery

• Ensure adequate recovery facility with monitoring and one-to-one care.
• Request assistance from general theatre recovery staff before the caesarean or as soon as possible.
• Give oxygen as required, check HR, BP, oxygen saturation and respiratory rate as per recovery guideline.
• Prescribe fluids and complete audit data base and anaesthetic record

Acknowledgments

• Written by Dr John Clear.

Pointers

• This may be performed under epidural top-up, spinal or GA.
• Follow general principles and precautions in other Maternity recipes.
• Remember there is risk of hypovolaemia in these patients. Full pre-operative assessment is essential. Regional techniques are contraindicated in the hypovolaemic patient, and take care to ensure adequate fluid replacement if siting spinal in sitting position. Consider risk / benefit of GA v regional technique.
• Check Hb / platelets / clotting if excessive blood loss.
• Aim for block to T6 (light touch) if under spinal or epidural.
  12
• Hyperbaric bupivicaine 0.5% 2.3 – 2.7 mls. Usually 2.5 mls
• Fentanyl 25 mcg is preferable to spinal diamorphine.

Acknowledgments

• Written by Dr John Clear.

Pointers

• This may be performed under epidural, spinal or GA.
• Follow general principles and precautions as per other Maternity recipes.
• Remember there is risk of hypovolaemia in these patients. Full pre-operative assessment is essential.
• Regional techniques are contraindicated in the hypovolaemic patient, and take care to ensure adequate fluid replacement if siting spinal in sitting position. Consider risk / benefit of GA v regional technique.
• Check Hb / platelets / clotting if excessive blood loss.
• If possibility of uterine manipulation for removal of products, treat as for manual removal of placenta.
• A saddle block may be sufficient for a repair alone. Site the spinal with the mother sitting up (if able) using heavy bupivicaine, or site it in the lateral position, and position the whole table slightly head-up.
• Hyperbaric bupivicaine 0.5% 1.5 – 2.0 mls.
• Epidural and spinal opioids may not be necessary, especially if rectal diclofenac can be used for post-op analgesia.

Acknowledgments

• Written by Dr John Clear.