Anesthesia for Ophthalmic Perioperative Medicine Associate Chief, - - PowerPoint PPT Presentation

Anesthesia for Ophthalmic Surgery in Pregnancy

By: Melissa Kreso M.D. Associate Professor in Anesthesiology and Perioperative Medicine Associate Chief, Obstetric Anesthesia Division Medical Director, Strong Ambulatory Surgery Center University of Rochester Medical Center

Disclosures None

Outline

Incidence Concerns with operating while pregnant Fetal Effects Physiologic changes in pregnancy Practical Considerations

Incidence of Pregnancy & Surgery

All women of child-bearing age should have routine pregnancy testing prior to surgery 0.3-2.6% of women of childbearing age have positive UPTs on the day of surgery 2% of pregnant women undergo surgery during pregnancy

Kahn RL, Stanton MA, Tong-Ngork S, et al. One-year experience with day-of-surgery pregnancy testing before elective orthopedic procedures. Anesth Analg 2008; 106:1127-31. Manley S, de Kelaita G, Joseph NJ, et al. Preoperative pregnancy testing in ambulatory surgery: incidence and impact of positive results. Anesthesiology 1995; 83:690-3. Kasliwal A, Farquharson RG. Pregnancy testing prior to sterilisation. BJOG 2000; 107:1407-9.

Concerns with

• perating

while pregnant

EARLY Potential for altered

• rganogenesis

Toxic manifestations

Organogenesis in Pregnancy

Chestnut, David H. Chestnut's Obstetric Anesthesia: Principles and Practice. Philadelphia: Mosby/Elsevier, 2009: 17; p363 Figure 17.2 redrawn from Moor Kl. The Developing Human. 4th Edition. Philadelphia WB Saunders 1993; 156.

Toxic manifestations

Wilson JG. Environment and Birth defects New York, Academic Press, 1973:31. Chestnut, David H. Chestnut's Obstetric Anesthesia: Principles and Practice. Philadelphia: Mosby/Elsevier, 2009: Chapter 17; p361.

Concerns with

• perating

while pregnant

EARLY Potential for altered organogenesis Toxic manifestations LATER ON Fetal hypoxia (as metabolic demands increase) Accidental induction of labor

Physiologic Changes in Pregnancy

Gastrointestinal

Anatomical Progesterone effects Give bicitra prior to induction Consider full stomach by 18-20 weeks gestation

Spalluto LB, Woodfield CA, Debenedectis CM, Lazarus E. “MR Imaging Evaluation of Abdominal Pain during Pregnancy:Appendicitis and Other Nonobstetric Causes” Radiographics2012; 32(2):317-34.

Hematologic

• Blood volume expands by 30-45%
• Hypercoaguable state
• WBC count is not a reliable marker for

infection

• Consider to be high risk for clotting

postoperatively

• Thromboembolism prophylaxis

recommended

Chestnut's Obstetric Anesthesia: Principles and Practice, 5th Edition (2014) Chestnut D, Wong C, Tsen L, Kee W, Beilin Y , Mhyre J/Elsevier Saunders. Chapter 2. p22

Respiratory

Clinical Anesthesia, 8th Edition (2017) Barash P , Cullen B, Stoelting R, Cahalan M, Stock M, Ortega R, Sharar S, Holt N/Wolters Kluwer Lippincott Williams and Wilkins Chapter 3. p376. Chestnut's Obstetric Anesthesia: Principles and Practice, 5th Edition (2014) Chestnut D, Wong C, Tsen L, Kee W, Beilin Y , Mhyre J/Elsevier Saunders. Chapter 2. p21

Airway

• Weight gain
• Capillary engorgement
• Increased adipose tissue of the chest
•  mask ventilation & tracheal intubation

difficulties

Kodali BS, Chandrasekhar S, Bulich LN, Topulos GP , Datta S. Airway Changes during Labor and Delivery. Anesthesiology 2008; 108(3):357-62.

Cardiac

Chestnut's Obstetric Anesthesia: Principles and Practice, 5th Edition (2014) Chestnut D, Wong C, Tsen L, Kee W, Beilin Y , Mhyre J/Elsevier Saunders. Chapter 2. p17

Cardiac

Cardiac Output Stroke Volume Heart Rate

Chestnut's Obstetric Anesthesia: Principles and Practice, 5th Edition (2014) Chestnut D, Wong C, Tsen L, Kee W, Beilin Y , Mhyre J/Elsevier Saunders. Chapter 2. p17

Aortocaval Compression

Chestnut, David H. Chestnut's Obstetric Anesthesia: Principles and Practice. Philadelphia: Mosby/Elsevier, 2009: 2; p29. redrawn from Camann WR, Ostheimer GW. Physiologic adaptations during pregnancy. Int Anesthesiol Clin 1990;28:2-10.

Timing of Surgery

Elective surgery should NOT be performed during pregnancy However, IF surgery is indicated a parturient should never be DENIED said surgery on the basis of being pregnant

Timing of Surgery

1st trimester - Organogenesis Increased fetal risk of teratogenicity & abortion 3rd trimester - Peak of physiologic changes in pregnancy Increased maternal risk Increased risk of preterm labor 2nd trimester is ideal time for non-emergent, essential surgeries

Timing of Surgery

Incidence (%s) of Surgery in each Trimester

1st trimester 2nd Trimester 3rd Trimester

Mazze RI, Källén B. Reproductive outcome after anesthesia and operation during pregnancy: a registry study of 5405

• cases. Am J Obstet Gynecol. 1989 Nov; 161(5):1178-85.

Timing of Surgery

Upadya M, Saneesh PJ. Anaesthesia for non-obstetric surgery during pregnancy. Indian J Anaesth 2016; 60(4):234-41

Where should surgery take place?

Needs to be done at a place that has both

• bstetric, neonatal & pediatrics services

If patient’s obstetrician does not have privileges at the institution, then an alternative obstetrician with privileges needs to be identified Qualified individual whom can interpret fetal heart monitoring strips needs to be readily available

Fetal Monitoring

If previable, ascertaining fetal heart tones via doppler preoperatively and postoperatively is sufficient If viable, fetal heart rate monitoring should be done preoperatively & postoperatively BUT can be done intraoperatively as well

Monicahealthcare.com

Fetal Monitoring

• ACOG:
• “decision to use [intraoperative] fetal monitoring should be

individualized and, if used, should be based on gestational age, type of surgery, and facilities available”

General Anesthesia at +18-20weeks

Quicker inductions

• ccur inhalationally

and parenterally Viable agents reach equilibrium faster due to increased alveolar hyperventilation and decreased FRC Decreased MAC occurs (by 30-40%) Decreased albumin causes low protein binding --> increased free fraction of drugs into the blood stream Unconsciousness will happen quicker and more unexpectedly with sedation medications

Full Stomach Precautions at +18-20 weeks

After 18-20 weeks gestation, consider full stomach Administer bicitra (nonparticulate antacid) 30ml RSI with/without cricoid

Drugs with a history of safety behind them

Thiopental Propofol Morphine/fentanyl Succinylcholine Nondepolarizing muscle relaxants Nitrous oxide (particularly after the 6th week of gestation)

Drugs that do not cross the placenta

Glycopyrrolate (too big) Succinylcholine (too ionized) Insulin ( too big) Heparin ( too big) All non depolarizing muscle relaxants ( too big)