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OPINION General anesthesia for caesarean section
Sarah Devroe a, Marc Van de Velde a,b, and Steffen Rex a,b
Purpose of review
For most anaesthesiologists, the clinical experience with general anaesthesia for caesarean section is very
low. General anaesthesia is mostly performed for emergency grade 1 caesarean section and due to a lack
of time to apply a neuraxial anaesthesia technique. Unfortunately, the majority of anaesthesiologists rely on
historical and partly outdated approaches in this stressful situation. We propose an evidence-based
approach to general anaesthesia for caesarean section.
Recent findings
Rapid sequence induction using propofol and rocuronium should become the standard for general
anaesthesia in the obstetric patient. Short-acting opioids are still not given routinely but should never be
withheld in case of severe preeclampsia. Cricoid pressure can only be accurately performed by trained
caregivers and should be released if intubation appears to be difficult. Supra-glottic airway devices may
safely be used in fasted, nonobese elective caesarean section, but endotracheal intubation remains the
gold standard, especially in emergency caesarean section in labouring women. Both sevoflurane and
propofol are appropriate for the maintenance of general anaesthesia during caesarean section. Awareness
remains a major concern in obstetric anaesthesia.
Summary
We present a review of recent evidence on general anaesthesia for caesarean section.
Keywords
caesarean section, general anaesthesia, propofol, rapid sequence induction, rocuronium
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Propofol, in a dose sufficient for induction and good intubation conditions was still slower than that
to prevent maternal awareness (2.5 mg/kg), of succinylcholine. Increasing the initial dose to
depresses the infant more than thiopental and 1 mg/kg not only accelerated the onset time of neuro-
causes a reduction in maternal blood pressure muscular blockade but also significantly prolonged
[17–19]. The latter effect can be advantageous in its duration of action, frequently beyond the end of
the hypertensive patient as compared with thiopen- surgery. In addition, the fear of the long duration of
tal, propofol reduces the cardiovascular response to action in case of a difficult airway initially withheld
laryngoscopy and tracheal intubation [20]. This most anaesthesiologists from using rocuronium in
might prevent complications arising from a hyper- the pregnant population. Hence, the optimal rocuro-
tensive emergency. nium dose has been controversial over the last years.
Neither the use of propofol in general nor a Pühringer et al. [22] reported seven RSI for caesarean
thiopental dose exceeding 250 mg are licenced for section using thiopental (6 mg kg 1) and rocuronium
the use in pregnancy. Hence, their use is off-label 0.6 mg/kg and found acceptable intubation con-
[16]. ditions in most of the cases. Interestingly, the
Despite no proven clinical superiority of propo- ED95 in nonobstetric patients is higher, that is
fol in obstetric anaesthesia, thiopental is increas- 0.9 mg/kg. Pühringer et al. [22] attributed their find-
ingly replaced by propofol, as thiopental is no ings to the higher sensitivity of the obstetric patient
longer available on the American market and to muscle relaxants and the higher cardiac output.
becomes more difficult and expensive to obtain in McGuigan et al. [23], in contrast, suggested a higher
a lot of European countries. Moreover, the use of dose of rocuronium of 1 mg/kg in order to achieve
thiopental has recently been suggested as a risk faster and better intubating conditions, without the
factor for accidental awareness during general need to increase the doses of the hypnotic agent and
anaesthesia. In this survey, thiopental was used in consequently compromising cardiovascular stability.
3% of anaesthetic inductions, but implicated in 23% The fear of the prolonged duration of action of
&&
of the awareness reports [11 ]. rocuronium lasted until the introduction of sugga-
In conclusion, there is a reasonable body of evi- madex, a selective relaxant-binding agent, which
dence to support the use of propofol as a standard has been developed to rapidly reverse rocuro-
induction agent for general anaesthesia in caesarean nium-induced neuromuscular block. The sugamma-
section in healthy, noncompromised patients. In the dex–rocuronium interaction reduces the amount of
presence of haemodynamic instability, ketamine free rocuronium in plasma and leads to a shift of
(1–1.5 mg/kg), etomidate (0.3 mg/kg) and a reduced rocuronium into the plasma, dramatically reducing
dose of propofol in association with a low dose of the level of rocuronium at the neuromuscular
opioids or ketamine are appropriate alternatives. junction.
Nauheimer et al. [24] were the first to describe
the use of sugammadex to reverse rocuronium block
Muscle relaxants in caesarean section patients. Using 1.0 mg/kg of
Muscle relaxants are used to facilitate endotracheal rocuronium for induction, the recommended dose
intubation and to provide optimal surgical con- of sugammadex to achieve a reversal of profound
ditions. Until recently, succinylcholine 1 mg/kg neuromuscular block (4 mg/kg) or moderate block
was standardly used for RSI because of its rapid (2 mg/kg) was given at end of surgery and provided a
onset. Succinylcholine is highly ionized and poorly rapid and sufficient reversal to a train-of-four ratio of
lipid soluble, and only small amounts undergo 0.9 in all patients within 2 min. The speed of recov-
trans-placental transfer. However, possibly life- ery was dose-dependent, and reversal was sustained
threatening and well known side-effects stimulated without any signs of recurarization [24].
the search for a muscle relaxant with a more benign Of note, the safety profile of sugammadex has
safety profile. not been completely established in parturients yet,
Rocuronium was introduced in 1994. Due to its and there are still concerns regarding hypersensitiv-
rapid onset in higher doses, it soon gained popularity ity and allergic reactions [25,26].
for the RSI in the obstetric patient. Abouleish et al. In conclusion, we suggest the use of rocuronium
[21] showed that rocuronium 0.6 mg/kg in combi- 1.0 mg/kg for RSI, followed by the application of
nation with thiopental 6 mg/kg provided acceptable 2–4 mg/kg sugammadex if no train-of-four ratio of
intubating conditions in 90% of the obstetric 0.9 is achieved at the end of surgery. In our experi-
patients. Rocuronium did not adversely affect neo- ence, this combination allows rapid onset and rever-
natal Apgar-scores, acid–base measurements, time to sal of neuromuscular blockade with excellent
sustained respiration or neurobehavioural scores intubation conditions and avoidance of serious
[21]. However, the onset time of rocuronium for side-effects [23,24].
0952-7907 Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved. www.co-anesthesiology.com 243
releasing it in case of difficult intubation is a wise laryngoscopy, intubation and skin incision. This
and well tolerated approach [34]. IFT responsiveness could not be predicted by the
Three studies reported the well tolerated and BIS-monitoring. Only very low BIS values (<30) were
successful use of different types of laryngeal mask associated with the absence of responses to verbal
airways (LMAs) (standard [39], LMAProseal [40], commands, suggesting that BIS monitoring is unre-
LMASupreme [6]) in nearly 5000 patients as a routine liable to detect IFT responsiveness during caesarean
airway device for elective caesarean section under section. However, the significance of these findings
general anaesthesia. These observations should be remains controversial. Of note, no patient had evi-
interpreted cautiously and cannot be extrapolated dence of explicit recall of intraoperative events. More
to emergency situations because above-mentioned studies are required to determine long-term con-
studies exclusively included slim, fasted and non- sequences of IFT responsiveness and to compare
obese parturients for elective caesarean section. In IFT responsiveness using different anaesthetic tech-
our practice, patients undergoing caesarean section niques [44].
under general anaesthesia are seldom fasted, slim or In our practice, the majority of parturients
not in labour [41]. appreciate if they are preoperatively informed that
Gold standard for airway management in obstet- the goal for general anaesthesia in caesarean section
ric patients should remain cricoid pressure and is to provide well tolerated anaesthesia for both
tracheal intubation. However, the insertion of an mother and child and that the safety of the child
LMA is a valuable alternative in case of a difficult is achieved/maximized at the possible expense of an
intubation or when maternal risks are associated increased risk of maternal awareness.
with tracheal intubation (e.g. in hypertensive emer- Because of the increased risk of postpartum
gencies or in patients with severe cardiopathies) haemorrhage and uterine atony in case of caesarean
[41]. section, prophylactic uterotonic agents are incorp-
orated in the routine anaesthetic management. A
recent meta-analysis advised a slow 0.3–1 IU-bolus
MAINTENANCE OF ANAESTHESIA of oxytocin for elective caesarean section and a slow
Notwithstanding limited evidence, sevoflurane has 3 IU-bolus of oxytocin for caesarean section in the
become the maintenance agent of choice in general labouring parturient, followed by a 4-h infusion of
anaesthesia for caesarean section. In the survey by 5–10 IU/h in both settings [45]. If uterine atony
Murdoch et al. [16], sevoflurane was used in 52%, occurs despite preventive measurements, Butwick
&
followed by isoflurane (45%) and desflurane (1.6%). et al. [46 ] found an increased risk of haemor-
Only 0.3% of the anaesthesiologists used propofol rhage-related morbidity if the caesarean section
for the maintenance of anaesthesia during caesarean was performed under general anaesthesia. This
section. effect was attributed to uterine relaxation caused
Concentrations of volatile anaesthetics higher by volatile anaesthetics. Unfortunately, this study
than 1 minimum alveolar concentration (MAC) did not mention specific drugs, doses or concen-
should be avoided throughout the entire anaesthe- trations used during the procedures.
sia for caesarean section: before the delivery of the Maintenance with propofol can be safely used in
baby because of the transplacental drug transfer and obstetric anaesthesia and could be an interesting
consequent foetal depression; and after the delivery alternative to reduce the incidence of uterine atony
of the baby due to the dose-dependent myometrial- or when uterine atony is present [47]. However,
relaxing properties of volatile anaesthetics [42]. propofol also crosses the placenta with subsequent
Although anaesthetic requirements for volatile dose-dependent foetal depression and was overre-
anaesthetics are diminished by 25–40% during preg- presented in the audit on preoperative awareness
&&
nancy, maintenance of general anaesthesia for cae- [11 ,42].
sarean section with low concentrations of volatile
anaesthetics places parturients at an increased risk of
&&
intraoperative awareness [11 ]. Nowadays, bispectral CONCLUSION
index (BIS) monitoring is commonly used to monitor RSI with cricoid pressure and endotracheal intuba-
depth of anaesthesia, whereas the isolated forearm tion remains the gold standard for all labouring
technique (IFT) is still the scientific gold standard for women undergoing emergency caesarean section
detecting wakefulness during anaesthesia with neu- and for the majority of women having elective cae-
romuscular blockade. After administration of thio- sarean section under general anaesthesia. Because of
pental 4–5 mg/kg and succinylcholine 1–2 mg/kg, the limited availability of thiopental and the non-
&
Zand et al. [43 ] found 41, 46 and 23% of the inferiority of propofol, the latter becomes increas-
parturients still obeying verbal commands at ingly popular for induction. The combination of
12. Pandit JJ, Andrade J, Bogod DG, et al. The 5th National Audit Project (NAP5)
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14. Heesen M, Klöhr S, Hofmann T, et al. Maternal and foetal effects of remifentanil
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