Rapid Sequence Spinal Anesthesia

Pro-Con Debate: Contra

Bambang Suryono S
Dept of Anaesthesiology & Intensive Care
Sardjito Hospital/School of Medicine Gajah Mada
University
Anestesi Umum
versus
Anestesi Regional (SAB)
RA vs GA
• GA - tidak ada kontra-indikasi
• yang ada RISIKO – tidak ada gagal GA
• RA - ada kontra-indikasi – bisa gagal blok syaraf

• Pilihan anestesi selain rekomendasi dari dokter

anestesi maka dokter harus menghargai hak
OTONOMI pasien, yang mana pasien berhak
menentukan jenis tehnik anestesi yang
dijalaninya.
Indikasi Sectio Caesarea
• Category 1 SC : Ada ancaman mendadak
kehidupan ibu dan/atau anak

• Category 2 SC : Ada masalah kesehatan ibu/anak

tetapi tidak mengancam jiwa mendadak
• Category 3 SC : bayi perlu lahir lebih awal tanpa
ada risiko mendadak pada ibu/anak
• Category 4 SC : SC elektif
Pilihan GA
• Emergent (Category 1) delivery e.g
• fetal bradycardia
• ruptur uteri
• prolaps tali pusat
• Gagal blok neuraksial
• Pasien menolak RA
Indikasi kontra anestesi neuraksial
• Koagulopati
• -perdarahan hebat
• -solusio plasenta dengan koagulopati
• Pembedahan spinal ekstensif
• Pasien menolak neuraksial
• Placenta accreta
Difficult Spine
 Caution
• Even in expert hands a well-executed spinal block
may fail:
• 1.Difficult in achieving the lumbar puncture
• 2.Inadequte/complete lack of free flow of CSF
• 3.Inadequte block?
• Wrong : place/drug/dose/concentration/volume

• One has to analyze, the exact etiology of the

failure
Difficult spine
• Unsuccessful/difficult or inadequate/failed
spinal
• *an anticipated or un-anticipated
• *failure of introduction of the needle
• getting “wet up” or free flow of CSF
• *multiple attempts at lumbar puncture
• *sub-sequent consequences/problem
Failed/inadequate spinal
• In spite of
• a successful lumbar puncture
• satisfactory flow of CSF
• injection of correct concentration/volume/dose
• Un-anticipated, complete/failed or
• Incomplete/patchy/lower the required level of the
subarachnoid or even epidural block
Etiopathogenesis
• Failed spinal:
• Operator
• Patient
• Equipment
• Miscellaneous

• Operator factor:
• Not so gentle handling the patient
Patient factor
• Female spine : pronounced lordosis
• more subcutaneous fat
• Weight: overweight
• Height: shorter patient
• Anatomical variations: kyphosis, scoliosis
• Abnormalities: spine stenosis
• ankylosing spondylitis
Management
• The true difficult spine is truly difficult to
manage
•  General Anesthesia

• Note: previous spine surgery is relative contra

• -indication
Informed Consent
&
Etika Kedokteran
Kaidah etika dalam klinik
• Hak otonomi pasien
• Beneficence dan non-maleficence
• Justice
• Veracity
• Confidentiality
Setiap tindakan medik
• Perlu informed consent
• Sesuai kebutuhan medik pasien (UUPK, disiplin
kedokteran)
• Bila tanpa IC  BATTERY

• SALUS AEGROTI SUMMA LEX

• VOLUNTUS AEGROTI SUMMA LEX
• How can a woman facing the emotional and
physical distress around a category 1 caesarean
section be expected to give informed consent to a
rapid spinal anesthetic?
• trauma....... bonding

• East Anaesthesi 2010 online

http://www.respond2articles.com/ANA/forum/645/ShowThread.aspx
#645
Berpacu dengan waktu/
Time constraints
SC Emergensi
• Epidemiologi : 2 diantara 5 SC tidak
direncanakan (emergensi)
• Harus dikerjakan cepat (tergantung indikasi
SC)  C1 CS
• Tidak banyak waktu tersedia untuk
menentukan pilihan
Indikasi SC Emergensi
• Bayi kembar dengan komplikasi
• Partus tidak maju
• Ada emergensi medik: perdarahan hebat
antepartum, PEB
• Kesehatan bayi terancam : fetal distress
• Bayi besar

•  TIDAK TERSEDIA WAKTU CUKUP

UNTUK EPIDURAL/SPINAL ANALGESIA?
Regional analgesia pada SC
• Pasien mungkin tetap sadar
• Mendengar pembicaraan tim operasi
• Didaerah leher tertutup tabir
•  tidak nyaman bagi yang
• KLAUSTROPHOBIA
n
Waktu mengerjakan anesthesia
• ‘Code Green’’ CS
• Rerata Decision-Delivery Interval (DDI)
• 26 min spinal 17 min GA
• Popham et al. Anaesth Int Care 2007;35:74

• Speed of spinal vs GA for C1-CS : a simulation and

clinical observation based study
• Spinal GA
• --------------------------------------------------------------------------------
• Simulasi Klinik Total Waktu
• 2:52 (2:32-3:32) 5:56(4:23-7:39) 8:52 (3:31-17:22) 1:56(1:39-2:9)
Rapid Sequence Spinal (Anesthesia)
Rapid Sequence Spinal

• Described to minimize anesthetic time:

• no-touch spinal technique
• consideration of omission of the spinal opioid
• limiting spinal attempts
• allowing the start of surgery before full
• establishment of the spinal block
• being prepared for conversion to GA if there
• are delays or problems
To do RSSA safely and timely need?
• Cooperative work mandatory with good team
relation for those simultaneous and necessary task
• Task of IV cannulation  avoid unnecessary delay
• Use slightly higher doses than usual
• 3 ml bupivacaine 0,5% or 2,5 ml
• or
• 2 ml bupivacaine 0.5%
• Fentanyl 25 ug
Regional analgesia pada SC
• Pasien mungkin tetap sadar
• Mendengar pembicaraan tim operasi
• Didaerah leher tertutup tabir
•  tidak nyaman bagi yang
• KLAUSTROPHOBIA
RSSA untuk C1-SC urgen
• Teamwork
• Siapkan GA
• Tehnik “no-touch”
• Fentanyl ±
• Infiltrasi kulit ±
• Sekali tusuk, kecuali yang kedua
sukses
• Operasi dimulai tanpa tunggu
blok T4
Psikologis pasien
Regional analgesia pada SC
• Pasien mungkin tetap sadar
• Mendengar kegiatan dan pembicaraan tim
operasi
• Didaerah leher tertutup tabir
•  tidak nyaman bagi yang
• KLAUSTROPHOBIA
Merawat emosi ibu post-SC
• Biasanya post-SC : anak sehat  ibu bahagia
• Beberapa ibu kesal dan kecewa karena:
• *kelahiran tidak sesuai rencana
• *tidak terpenuhinya harapan sebelum
• melahirkan
• Perlu pemulihan emosi:
• Diskusi dengan bidan, dokter atau obstetri
sebelum pulang/diatur setelah pulang tentang
• *kenapa perlu SC
• *bagaimana kehamilan berikut
PTSD
• Bila persalinan traumatik  bisa terjadi PTSD
• Gejala PTSD:
• Intrusive memories or flashback  cemas & panik
• Gangguan tidur, marah yang meledak, susah
konsentrasi
• Hindari pencetus kembalinya memori atau
pembicaraan tentang persalinan

• GA preferrable
The 3-6-9-12-15 min. “rule” for
immediate CS
• Prolonged bradycardia (< 80 bpm for > 3 min)

• Singkirkan diagnosis solutio dll 3

• Detil klinik –fetal reserve, perdarahan dll 6
• Cek FHR terakhir 9
• Tidak pulih 9 min  putuskan SC  OK 12
• Proses persalinan 15
Time saving: statistically and
clinically significant?
• About time constraints
• Different from spinal anesthesia for elective CS
• the methods of sterilization
• dose of anesthetics
• required level of spinal anesthesia before
• starting surgery for shortening the D-DI
• For C1-CS
• it is important to multidisciplinary discuss to
• all staff
• make local protocol
• simulate the procedure
• 2016 J of Anaesthesia and Critical Care
Infeksi
Regional analgesia pada SC
• Pasien mungkin tetap sadar
• Mendengar pembicaraan tim operasi
• Didaerah leher tertutup tabir
•  tidak nyaman bagi yang
• KLAUSTROPHOBIA
Infeksi
• ..sekali usapan lidi kapas dgn 0.5% chlorhexidin
diatas kulit yang ditusuk tidak meyakinkan
sebagai dekontaminasi yang memuaskan .....
• Wlliamson, Anesthesia 2010;65:1142
• Punggung pasien dan tangan anesthetist dibersihkan
methylated spirit-soaked cotton swab
• No drape
• No touch spinal 3,690 pts antara 1991 dan 1999
• Tanpa infeksi
• Ajmal. Anaesth Analg 2011;12:S282
Pain/opinions/consent
• Cat 4 Cat 1-3 Cat 1
• SC dengan RA >95% >85% >50%
• Nyeri waktu SC < 5% <15% <20%
• Konversi RA ke GA < 1% <5% <15%

• 3/25 kegagalan spinal/ konversi ke GA preop

• 3/25 tidak nyaman/nyeri (tanpa terapi)
 Anaesthetic mortality & morbidity
• Case Fatality Rate & Rate Ratios of Anaesthetic-
Related Deaths during CS by type of Anaesthesia in
the USA, 1979-2002

• Year of death GA RA Rate Ratios

• 1979-1984 20.0 8.6 2.3(95% CI 1.9-2.9)
• 1985-1990 32.3 1.9 16.7(95% CI 12.9-21.8)
• 1991-1996 16.8 2.5 6.7(95% CI 3.0-14.9)
• 1997-2002 6.2 3.8 1.7(95% CI 0.6-4.6)
Case Fatality Rate
• Life threatening incidents
• 28,900 spinal
• 11 GA conversion
• -7 high spinal
• -2 severe maternal bradycardia
• -1 faint
• -1 thiopentone instead of antibiotica
• 13,300 GA
• 38 life threat incidents
• -15 failed intubation [1 hypoxic cardiac arrest]
• -10 difficult intubation
• -10 broncho/laryngospasme [1 hypoxic c.a]
• -3 anaphylaxis
• RSSA are described for emergency cesarean
deliveries, wherein patients are placed in a left
lateral position, with supplemental oxygen, and
single shot SAB is administered by the most
experienced prescrubbed anesthetist.
• The time required for surgical readiness is
comparable with that for general anesthesia,
and neonatal outcomes better.
Hi Mom, what’s your
preferred, GA or RSS?
Take home message
• Difficult spine
• Informed consent and ethical
• Infection risk
• Psychological trauma – PTSD?
• Time constraints Category 1 SC
Statistically significant, but not clinically
significant?
Conclusions
• Tehnik anestesi yang baik:
•  memenuhi kebutuhan medik pasien +
• (patient safety)

• The important role is

The Man Behind The GUN