ANESTHESIA FOR

OBSTETRICS
 PHYSIOLOGICAL CHANGES IN
PREGNANCY
• Cardiovascular system:

Intravascular fluid volume ↑ by 35%

Cardiac output ↑ by 40%
Systemic vascular resistance ↓ by 15%
Heart rate ↑ by 15%
Systolic blood pressure No change

The implication is that these patients due to hyperdynamic circulation can go in congestive
heart failure.
 PHYSIOLOGICAL CHANGES IN
PREGNANCY
• Respiratory system:

Tidal volume ↑ by 40%

Respiratory rate ↑ by 10%
Minute ventilation ↑ by 50%
Functional residual capacity ↓ by 20%
Expiratory reserve volume (due to gravid uterus causing diaphragmatic
Residual volume elevation)
Vital capacity No change
Lung volume
Airway resistance ↓ by 35%
Oxygen consumption ↑ by 20%
Blood gases
PaO2 ↑ by 10 mmHg Due to hyperventilation
PCO2 ↓ by 10 mmHg
pH No change due to compensatory mechanism
 PHYSIOLOGICAL CHANGES IN
PREGNANCY
• Anesthetic implications of respiratory changes:
Due to increased MV the induction with inhalational agents is faster and dose requirement is
less making pregnant patients more susceptible to anesthetic overdosage.
Due to decreased FRC, ERV and increased oxygen requirement these patients are vulnerable
to go in hypoxia and preoxygenation for 5 to 6 min is required. This is the time required for
maternal to fetal equilibrium.
Due to capillary engorgement in upper airways chances of trauma and bleeding during
intubation are high.
Laryngeal edema may be a prominent feature in pregnancy induced hypertension (PIH)
patients, making intubation difficult.
 PHYSIOLOGICAL CHANGES IN
PREGNANCY
• Nervous system:
Progesterone has got sedative effect decreasing the anesthetic requirement by 25 to 40%.
There is decrease in local anesthetic requirement by 30 to 40% for spinal and epidural
anesthesia. This decrease in dosage for spinal is because of increased CSF pressure which is
because of decreased subdural and epidural space and this decrease in subdural and epidural
space is due to increased intra-abdominal pressure by gravid uterus and engorged veins in
epidural space. This can lead to high spinal and epidural in pregnancy.
 PHYSIOLOGICAL CHANGES IN
PREGNANCY
• GIT:
Parturient are very vulnerable for aspiration due to following reasons:
 Gastric emptying is delayed due to progesterone.
 Gravid uterus changes the angle of gastroesophageal juncton making lower esophageal
sphincter incompetent.
 Progesterone relaxes the lower esophageal sphincter.
 Gastric contents are more acidic.
 PHYSIOLOGICAL CHANGES IN
PREGNANCY
• Anesthetic implications for GIT:
A pregnant patient should be considered full stomach even if she is fasting and all measures
like:
 Preoperative antacids
 Metoclopramide(it increases the time of lower esophageal sphincter and increases gastric
emptying)
 Selik’s manoeuvre while intubating, should be taken.
 PHYSIOLOGICAL CHANGES IN
PREGNANCY
• Hepatic system:
Plasma cholinesterase level is decreased by 25% prolonging the effect of succinylcholine.
• Kidneys:
Because of increase in cardiac output there is increase in renal flood flow and GFR.
 PHYSIOLOGICAL CHANGES IN
PREGNANCY
• Uterus:
If a pregnant patient lies in supine position gravid uterus can compress the inferior vena cava
and aorta decreasing the cardiac output and blood pressure causing supine hypotension
syndrome and this can cause severe hypotension or even cardiac arrest after spinal
anesthesia.
To prevent this the pregnant patient should lie in left lateral position. This can be
accomplished by:
 Putting a 15˚ wedge under right buttock.
 Tilting the delivery table by 15˚ to left.
 Manually displacing the uterus to left.
 UTEROPLACENTAL CIRCULATION
AND ANESTHETIC DRUGS
• Uterine blood flow is 500 to 700 ml/min (10% of cardiac output) and placental flow is directly
dependent on maternal blood flow.
• Hypotension and drugs causing vasoconstriction can severely compromise fetal well being.
Ephedrine does not decrease placental flow so it is sympathomimetic of choice for treating
hypotension after spinal anesthesia in pregnancy.
• Positive pressure ventilation (IPPV) can decrease cardiac output by decreasing venous return and
thus can compromise placental blood flow.
• Inhalational agents in higher concentration can compromise uterine flow by their effect of
producing hypotension and decreased cardiac output.
• Intravenous agents: Thiopental and propofol decrease uterine blood flow in proportion to decrease
in blood pressure. Ketamine by producing uterine hypertonicity can decrease the uterine blood flow.
• Spinal/epidural anesthesia can compromise uterine blood flow by producing hypotension.
 TRANSFER OF ANESTHETIC
DRUGS TO FETAL CIRCULATION
• All anesthetic drugs except muscle relaxants (only gallamine has significant transfer) and
glycopyrrolate can be transferred to fetus from maternal circulation. So all drugs should be
used in minimum concentration and dosage.
• A large fraction of drug which is coming from placenta to fetus is metabolized by fetal liver
(75% of umbilical vein blood flows through liver), so less drug reaches to vital structures
like brain and heart. This is a protective mechanism but drugs like local anesthetics and
opioids which are bases, cross the placenta in unionized form, becomes ionized in fetal
circulation (which has low pH) and cannot come back to maternal circulation leading to
accumulation in fetus.
 ANALGESIA FOR LABOR
(PAINLESS LABOR)
• Pain afferents from uterus and cervix travel up to T10-L1.
• Most commonly used technique is continuous lumbar epidural.
Lumbar epidural is instituted only when first stage of labor is well established i.e., cervix is
at least 4 to 6 cm dilated. Epidural catheter is placed in lumbar space (usually L3-L4) and 6
to 8 ml of bupivacaine (0.25%) and 50 to 100 mg of fentanyl is given as bolus, then
continuous infusion of bupivacaine (0.25%) and fentanyl 100 mg is maintained through
epidural catheter. At this concentration of bupivacaine only sensory fibres are blocked. So
patient can easily bear down during delivery.
 ANALGESIA FOR LABOR
(PAINLESS LABOR)
• Other techniques
Double catheter technique - no more used now-a-days. In this technique analgesia of first stage
is achieved with lumbar epidural and second stage by sacral epidural catheter.
Saddle block – can provide analgesia for second stage only. A slightly strong concentration can
block motor fibres and difficulty in bearing down.
Pudendal block – bilateral pudendal nerve block provides only a perineal analgesia blocking only
sacral segment.
Paracervical block – can block sensory fibres from first stage (upto T10) but does not block
fibres from perineum. The disadvantage of paracervical block is that there are high chances of
intravascular injection (as this area is very vascular) which can cause fetal bradycardia and
cardiotoxicity. Injections are given at 3 and 9 o’clock position into vaginal fornix lateral to cervix.
 ANALGESIA FOR LABOR
(PAINLESS LABOR)
• Inhalational techniques:
By administration of nitrous oxide (30 to 40%) but this can cause fetal diffusion hypoxia. So
newborn should be given oxygen for 1 to 2 minutes.
Intermittent administration of methoxyflurane (0.1 to 0.3%) or enflurane (0.5%).
Self administration of trielene by parturient was a popular technique in the past.
 ANESTHESIA FOR CESAREAN
SECTION
Regional anesthesia is preferred over general anesthesia.

• Advantages of regional (spinal/epidural) over general anesthesia:

Risk of pulmonary aspiration is obviated.
Effect of anesthetic drugs on fetus is not seen.
Awake mother can interact with her newborn immediately after surgery.
High inspired concentration of oxygen to mother can be delivered.
 ANESTHESIA FOR CESAREAN
SECTION
• Disadvantages:
There can be significant hypotension with spinal (less with epidural) anesthesia.
Difficulty in controlling sensory level with spinal anesthesia (chances of high spinal are
more in pregnancy).
High incidence of nausea and vomiting.
Post spinal headache.
Time take is more than general anesthesia, so not ideal for fetal distress.
 ANESTHESIA FOR CESAREAN
SECTION
• General considerations:
Sensory level upto T6 is required for CS.
Dose reduction of local anesthetic is required due to decreased epidural and subarachnoid
space.
Hypotension is not acceptable. To prevent it preloading with 500 to 1000 ml of ringer lactate
or i.m. ephedrine may be given. If hypotension occurs it should be immediately managed
with i.v. ephedrine.
Oxygen by mask should be given.
 ANESTHESIA FOR CESAREAN
SECTION
• General considerations:
Patient is nursed in slight (15˚) left lateral position.
If bradycardia occurs it is managed with glycopyrolate.
If there is significant fetal distress time should not be wasted in giving regional anesthesia
and general anesthesia is instituted immediately.
Onset of epidural takes a long time (15 to 20 min) so it is reserved for elective cases only or
for specific conditions like pregnancy induced hypertension (PIH).
 ANESTHESIA FOR CESAREAN
SECTION
• General anesthesia for Cesarean section:
Usually given for fetal distress or if there is contraindication for spinal anesthesia.
Due to high chances of aspiration, prophylaxis against aspiration should be taken.
Intubation with Selik’s manoeuvre (cricoid pressure) is done. Ventilation with bag and mask
should be avoided as for all other full stomach patients.
One should anticipate difficult intubation and should be ready for management of difficult
intubation.
Patient should be nursed in left lateral position.
All drugs should be given in minimum doses as all drugs cross the placenta and attain
equilibrium between mother and fetus is 10 to 15 min.
 ANESTHESIA FOR CESAREAN
SECTION
• Premedication: To be avoided as it can effect fetus.
• Preoxygenation: For 5 to 6 min.
• Induction: Thiopental in minimum doses, crash intubation is done by applying cricoid
pressure.
• Maintenance: Oxygen, nitrous oxide and isoflurane or sevoflurane in very low
concentration till the delivery of baby. Opioids can only be given after the delivery of baby.
Halothane should not be used as it can cause uterine atony and post partum haemorrhage.
• Muscle relaxant: Any muscle relaxant except gallamine can be used. Reversed with
neostigmine and glycopyrrolate.
 ANESTHESIA FOR PREGNANCY INDUCED
HYPERTENSION/
PRE-ECLAMPSIA
• The technique of choice is epidural anesthesia for the following reasons:
These patients can manifest severe, uncontrollable hypotension with spinal anesthesia
(hypertensives are more prone for hypotension after spinal).
Intubation may be very difficult in PIH patients as these patients have laryngeal edema.
• Technique:
The most important factor before giving regional anesthesia (lumbar/epidural) is to rule out
coagulation abnormality (DIC and HELLP syndrome). If there is abnormal profile general
anesthesia should be given.
 ANESTHESIA FOR PREGNANCY INDUCED
HYPERTENSION/
PRE-ECLAMPSIA
• General anesthesia:
In addition to protocol followed for CS, the extra precaution to be taken in PIH patient are:
 Intubation should be done by expert hands with minimum trauma.
 Attenuation of cardiovascular response to intubation must be blunted, otherwise intracranial
haemorrhage can occur.
 These patients are on magnesium which potentiates the action of nondepolarizing muscle
relaxants. So dose of nondepolarizing muscle relaxant should be reduced.
 Patient of PIH can have decreased pseudocholinesterase, prolonging the effect of
succinylcholine.
 ECLAMPSIA
• Many a time patient with active seizures.
• Induction should be done with Thiopental (anticonvulsant) and followed by general
anesthesia in same way as for PIH patient.
 ANESTHESIA FOR SURGERIES
DURING PREGNANCY
Elective surgery should be deferred until delivery.
Urgent surgeries should be performed during second trimester. In first trimester there are very high
chances of abortion and congenital abnormalities of newborn. During third trimester there are
increased chances of preterm labor so only emergency operations should be taken in first and third
trimester.
• Choice of anesthesia:
The aim should be to avoid general anesthesia.
So if possible operation should be performed under local/regional anesthesia and if general
anesthesia has to be given then don’t use nitrous oxide in first trimester (nitrous oxide is teratogenic)
and use inhalational and intravenous agents in minimum doses.
If spinal anesthesia is to be given hypotension should not be allowed to occur at it can compromise
uteroplacental blood flow.
PEDIATRIC ANESTHESIA
 PEDIATRIC PATIENTS
• Pediatric patients have number of physiologic differences from adults which can alter the
anesthesia technique and outcome.
• Pediatric anesthesia has special consideration with distinct sub-groups viz pre-term, neonate,
infant and child:
Anatomical variations in airway like the larynx, narrow cricoid ring, body weight and surface
area ratio.
Physiological variations as regards temperature homeostasis, vagal preponderance and greater
stress response.
Pharmacokinetic differences regarding dosage due to greater amount of extracellular fluid, there
is larger volume of distribution of many drugs, so dosages are higher according to body weight.
Other factors like dependence on parents and inability to express.
 RESPIRATORY SYSTEM
• Airway anatomical differences:
Large head size.
Large tongue.
Epiglottis is mobile.
Larynx is anteriorly place.
Subglottis (at the level of cricoid) is the narrowest part (while in adults glottis is the
narrowest part of larynx).
 RESPIRATORY SYSTEM
• Anesthetic implications:
Due to large head and anteriorly place larynx the intubation is better in neutral or slightly
flexed position of head (while in adults there is extension at atlanto-occipital joint during
intubation).
Due to anatomical configuration laryngoscope with straight blade (Magill) is used for
intubation in infants.
Large tongue can obscure the view.
Since subglottis is the narrowest part so uncuffed endotracheal tubes should be used in
children < 5 years of age in older children when cuffed tube is used it should not be airtight
and should allow some leakage when airway pressure is raised above 30 cm H2O.
 RESPIRATORY SYSTEM
• Physiological changes:
Tidal volume – 6 to 8 ml/kg
Frequency (respiratory rate) – 35/min
Alveolar ventilation – 120-140 ml/kg/min
Oxygen consumption – 6ml/kg/min
Calorie requirement – 100 kcal/kg
Blood gases
 pH – 7.34 to 7.4
 pO2 – 65-85 mmHg (at birth; intrauterine pO2 is 25 to 40 mmHg)
 pCO2 – 30 to 36 mmHg (due to high respiratory rate.
Oxygen consumption is twice of adults and calorie requirement is thrice. The tidal volume on body weight basis is
same so important determinant of high alveolar ventilation is respiratory rate.
 RESPIRATORY SYSTEM
• Anesthetic implications of physiological changes:
Because of high alveolar ventilation induction with inhalational agent is faster.
Children are very prone to go in hypoxia due to high oxygen requirement and low reserves.
The control of ventilation is poor so can go in hypoventilation in postoperative period.
 CARDIOVASCULAR SYSTEM
• Blood pressure in neonate is 60/40 mmHg (50% of adult value) so cardiac output is mainly
determined by heart rate which is 120/min at birth.
• Vasoconstriction response is not so well developed so these patients cannot tolerate shock.
• Anesthetic implications:
Bradycardia is not acceptable at any cost.
Infants can develop sever hypotension with the use of inhalational agents.
 BODY WATER
• Extracellular fluid constitutes 40% of body weight (in adults it is 20%). The high volume of
distribution can dilute the initial intravenous drug making the initial dose requirement (on per kg
weight basis) slightly higher than adults.
• Fluid administration is very tricky in children. Less fluids can make them easily dehydrated
(because of their high metabolic rate) and slightly excessive fluid can lead to fluid overload. So
fluid administration should be strictly on the recommended guidelines.
• Hourly requirement is calculated by formula of 4-2-1:
Upto 0-10kg = 4 ml/kg/hr
10-20kg = 2 ml/kg/hr
>20kg = 1ml/kg/hr
• For pediatric patient isolyte solutions with less dextrose are available.
 METABOLIC
• Children are very prone to hypoglycemia so intraoperative fluids must contain glucose and
the fasting requirement in children are:

Age Milk and solid Clear liquid (water)

< 6 months 4 hours 2 hours
6 months-3 years 6 hours 3 hours
> 3 years 8 hours 3 hours
 THERMOREGULATION
• Children are very prone to hypothermia because of their:
Decreased ability to produce heat.
Decreased ability to conserve heat because shivering is not developed.
Increased heat loss due to large body surface area relative to body weight and high metabolic
rate.
The only mechanism left for heat production is metabolism of brown fat which is special fat
present in posterior neck, interscapular and vertebral areas and around kidneys and adrenal
glands.
So the operation theatre temperature should be maintained at 28˚C.
 BLOOD
• Haemoglobin at birth is 180 g/l which falls to 120g/l till the first age. Thereafter is steadily
increases with adult value attained at 12 to 13 years.
• Neonates have increased content of fetal haemoglobin which shifts the oxygen dissociation
curve to left.
• Children have less capacity to compensate for loss so blood transfusion should be
considered if loss is more than 10% of blood volume (in adults transfusion is considered if
loss is >20%).
• Prolonged coagulation time is expected in neonates due to deficiency of vit K dependent
factors which are synthesized by liver. Prolonged prothrombin time (PT) and prolonged
partial thromboplastin time (PTT) is seen for the same reason but bleeding time is normal in
neonates.
 CENTRAL NERVOUS SYSTEM
• The neonates have immature brain, poorly developed blood brain barrier and high levels of
progesterone.
• Anesthetic implications:
Due to these effects in newborns anesthetic requirements are less and so can be easily
overdosed with inhalational agents (but supersignly minimum alveolar concentration is
maximum at 3 months of age due to unknown reasons).
 HEPATIC
• Most of the anesthetic drugs are dependent on liver for their metabolism, since hepatic
system is not so well developed, pediatric patients can have prolonged and toxic effects.
• Secondly drugs bound to albumin will have more unbound fraction.
 RENAL
• Renal function is not so well developed so drugs dependent on renal excretion can have
prolonged and toxic effects.
• Neonate is an obligate sodium loser and cannot conserve sodium, consequently they develop
hyponatriemia, so fluid rich in sodium should be transfused intraoperatively.
 NEUROMUSCULAR JUNCTION
• Functional maturation of neuromuscular junction is not complete until 2 months of age so
newborns are very sensitive to nondepolarizing muscle relaxants.
• Atracurium is the relaxant of choice as it does not depend on hepatic and renal functions.
• Succinylcholine should be avoided in newborns due to presence of extrajunctional receptors.
 MONITORING
• Besides routine monitoring, temperature monitoring is very important in children.
 INDUCTION IN CHILDREN
• Induction in children is a difficult task. Most commonly used techniques are:
Inhalational induction: Inhalational induction is the method of choice for induction in children and
sevoflurane is the inhalational agent of choice.
The most commonly used breathing circuit is Jackson Rees system.
Important precaution is to put an intravenous line once the child falls asleep before proceeding to deeper
plane.
Intramuscular: Ketamine 5mg/kg is used. I.m. injection can be given in preoperative room with child in
parent’s lap.
Rectal: 10% methohexital and midazolam can be used by this route. But this is not used now.
Intravenous: Older children allow putting an intravenous line. In small children when inhalational
induction is contraindicated i.v. line can be put by distracting the attention of child and by applying
EMLA cream.
 MANAGEMENT OF NEONATAL SURGICAL
EMERGENCES
DIAPHRAGMATIC HERNIA
• It result from incomplete closure of diaphragm leading to herniation of abdominal contents in thorax resulting
in pulmonary hypoplasia, pulmonary hypertension and hypoplasia of left ventrivcle. Prognosis is very poor.
• Anesthetic management:
After preoxygenation awake intubation is done.
Bag and mask ventilation is contraindicated (as it will increase the distention oof bowels and embrass thee
respiration).
Positive pressure ventilation should be done with airway pressure <20 cm H20 otherwise pneumothorax can
occur in hypoplastic lund.
Anesthesia is maintained on oxygen and low dose volatile anesthetics or opioids like fentanyl. Nitrous oxide
is contraindicated as it can diffuse into gut loop causing their distension which can further compress the lung
tissue.
Postoperative elective ventilation should be sought.
 MANAGEMENT OF NEONATAL SURGICAL
EMERGENCES
TRACHEO-ESOPHAGEAL FISTULA
• It is of five types, most common is upper end of esophagus is blind with fistula between lower esophagus
and trachea.
• Anesthetic management:
Rule out associated abnormalities like VSD, ASD, tetralogy of Fallot, coarctation of aorta.
Nurse the baby in propped up position to minimize gastric regurgitation.
Aspirate the upper blind pouch to remove secretion from it.
Ventilation with bag and mask is contraindicated as it can increase the gastric pressure (air reaching the
abdomen through fistula) and can cause aspiration.
Intubation can be awake or after intravenous anesthetic. The position of tube is important, it should be
below the fistula but above carina.
Maintain oxygenation as surgery is performed in lateral position (increased V/Q mismatch in lateral
position).
 MANAGEMENT OF NEONATAL SURGICAL
EMERGENCES
PYLORIC STENOSIS (INTESTINAL OBSTRUCTION)
• Patient with intestinal obstruction have repeated vomiting which makes them dehydrated and
there is electrolyte imbalance.
• Patients with pyloric stenosis are dehydrated with hypokalemic, hypochloremic alkalosis so
metabolic, fluid and electrolyte correction should be done before taking these patients for
surgery.
• Either awake intubation or rapid sequence intubation (crash intubation with Sellik’s
manoeuvre) is performed.
• Ventilation with bag and mask is contraindicated (can cause aspiration).
GERIATRIC ANESTHESIA
 GERIATRIC PATIENTS
• Geriatric anesthesia is more problematic as old patients have an increased incidence of
concurrent diseases like diabetes, myocardial ischemia, infarction, hypertension.
• There may be malnutrition.
• Osteoporosis, muscle weakness, fragile veins and lowered pulmonary function.
• Hence anesthetic requirements are reduced.
• Regional anesthesia is preferable, whenever indicated.
 ORGAN FUNCTION CHANGES IN
GERIATRICS
• Cardiovascular system: cardiac output is usually maintained inspite of bradycardia and
decrease in myocardial contractility due to increase in stroke volume which is because of
increased left ventricular end diastolic pressure and volume. Blood pressure increases with
aging.
• CNS: loss of neurons and dementia.
• Respiratory system: kyphosis, scoliosis can cause difficulty in ventilation. There is
decrease in vital capacity and PaO2, increase in residual volume and functional residual
capacity, V/Q mismatch.
• Renal and hepatic: there is age related decrease in renal and hepatic functions.
 ANESTHETIC MANAGEMENT
• Commonly coexisting diseases in old age are:
Hypertension
Ischemic heart disease
Cardiomyopathies and conduction disturbances
Diabetes mellitus
Cerebrovascular diseases
Chronic obstructive pulmonary disease (COPD)
Rheumatoid arthritis/osteoarthritis
Parkinson’s disease
Malignancies
 ANESTHETIC MANAGEMENT
• These patients are on chronic medication like antihypertensives, antianginals,
antiarrhytmics, β-blockers, oral hypoglicemics, diuretics, aspirin.
• Therefore perioperative evaluation with extra care should be done in these old age patients
and intructions are made accordingly.
 DRUG REQUIREMENTS
• Anesthetic drug requirements are decrease in old age due to:
Loss of neurons in CNS.
Decreased metabolism and excretion: there are increase chances of drug toxicity due to
decreased metabolism.
 INTUBATION
• Difficult intubation may be anticipated because of edentulous jaw and decreased neck
movements (du to rheumatoid arthritis and osteoarthritis).
• Stress response to cope up with haemodynamic changes during surgery and anesthesia
decreases, so high level of monitoring (especially ECG) is required.
 REGIONAL ANESTHESIA
• May be technically difficult due to spine deformities.
• Dose requirement in spinal and epidural block is decreased due to narrowing of spaces.