Maternal oxygenation is mandatory during regional anaesthesia for caesarean section Pro

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Maternal oxygenation is mandatory during regional anaesthesia for caesarean section Pro Pr Dan BENHAMOU Département d Anesthésie-Réanimation Université Paris-Sud Hôpital Bicêtre France Charuluxanan S et
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Maternal oxygenation is mandatory during regional anaesthesia for caesarean section Pro Pr Dan BENHAMOU Département d Anesthésie-Réanimation Université Paris-Sud Hôpital Bicêtre France Charuluxanan S et al, Anesth Analg 2008;107: Prospective registry of patients receiving anesthesia in 20 hospital 11 cardiac arrests among 40,271 spinal anesthesia procedures 5 cases of cesarean delivery and 4 deaths ASA I-II patients High sympathectomy and local anesthetic overdose (n = 3), bleeding after uterine atony (n = 2) Cardiac arrest delayed ( 60 min) in two cases Direct measurement of wound and tissue oxygen tension in postoperative patients Chang N et al, Ann Surg 1983,197:470-8 Tissue PO 2 (mmhg) Tissue PO 2 (mmhg) Postop days after abd surgery FiO 2 (%) Supplemental oxygen reduces the incidence of postoperative nausea and vomiting Greif R et al, Anesthesiology 1999,91: Nausea and vomiting (% patients) * * * p 0.05, FiO 2 30% vs 80 % Neonatal status in cesarean section under epidural anesthesia with supplementary oxygen. Yu CC et al, Ma Zui Xue Za Zhi 1992;30: Epidural anesthesia Room air O2 6l/min face mask O2 10 l/mn face mask FiO2 (%) UV PO 2 (mmhg) * 36.5 * UV ph (mmhg) UA PO 2 (mmhg) * 19.5 * UA ph Oxygen flow rate in spontaneously ventilating patients Torda TA, Crit Care Int Oct 1984:8-10 FiO 2 FiO2 (%) = 21% + 4 % x (each O 2 L/min) O 2 flow rate (L/min) Supplemental maternal oxygen therapy during caesarean section under epidural anaesthesia: a comparison of nasal prongs and facemask. Crosby ET, Halpern SH. Can J Anaesth 1992;39:313-6 Epidural anesthesia O2 8 l/min Face mask n = 20 O2 4l/min Nasal prongs n = 20 FiO2 (%) UA PO 2 (mmhg) UA ph UV SO 2 (%) 54 ± ± 18 (NS) UV PO 2 (mmhg) (NS) Apgar score 1 7 (n) 3 2 (NS) A comparison of 3 variable performance devices for postoperative oxygen therapy McBrien ME, Anaesthesia 1995,50:136-8 PaO 2 (kpa) Incomfort scale * In all patients, O 2 4 L/min * 11 = very comfortable, 33 = very incomfortable Maternal FiO 2 and neonatal status for caesarean section under general anaesthesia. Comparison of 33% or 50% oxygen in N 2 O Lawes EG et al, Br J Anaesth 1988; 61: General anesthesia FiO2 50 % n = 16 FiO2 33 % n = 19 UV PO 2 (mmhg) (NS) UV ph (NS) 1 min Apgar score 8 (%) TSR (sec) (NS) Supplementary oxygen administration for elective Caesarean section under spinal anaesthesia Cogliano MS et al, Anaesthesia 2002;57:66-9 Spinal anesthesia Room air Face mask O2 2l/min Nasal cannula O2 4 l/min Face mask FiO2 (%) UA PO 2 (mmhg) UV PVO 2 (mmhg) Patient comfort (0-10) (NS) (NS) * 6 A comparison of 3 variable performance devices for postoperative oxygen therapy McBrien ME, Anaesthesia 1995,50:136-8 PaO 2 (kpa) Incomfort scale * In all patients, O 2 4 L/min * 11 = very comfortable, 33 = very incomfortable Maternal inspired oxygen concentration and fetal oxygenation during caesarean section. Perreault C et al. Can J Anaesth 1992;39:155-7 General anesthesia FiO2 before hysterotomy (%) FiO2 50 % at hysterotomy FiO2 100 % at hysterotomy Mat PO 2 (mmhg) * UV PO 2 (mmhg) UA PO 2 (mmhg) (NS) Oxygen 60 % through a high-flow venturi mask UVPO 2 increased significantly in the 60 % oxygen group Oxygen 60 % through a high-flow venturi mask UVPO 2 increased significantly in the 60 % oxygen group Normal cephalic presentation Kaya H et al, Br J Obstet Gynaecol 2000;107;982-6 Free oxygen radicals: friend or foe? Free oxygen radical production is a physiologic response and their production can be beneficial in the response to agression Can eradicate bacteriae Oxygen increases the efficacy of bactericidal antibiotics Superoxide production by leukocytes related to tissue PO 2 Lipid peroxidation in cord blood at birth Rogers MS et al, Gynecol Obstet Invest 1997;44: Rogers MS et al, Br J Obstet Gynaecol 1998;105: Significantly higher cord arterial lipid peroxide concentrations in term infants after normal vaginal delivery than in those delivered following elective CS (most marked for MDA, increased by 105%) High levels of free oxygen radical activity in the fetus are a function of the labour process. In 13 babies classified as severely asphyxiated at birth (umbilical arterial ph 7.15, BE -8), xanthine and organic hydroperoxides (OHP) levels were significantly elevated when compared with non-asphyxiated babies. We propose OHP is a better measure of perinatal outcome than acid-base balance. Supplementary oxygen for emergency Caesarean section under regional anaesthesia Ngan Kee WD et al, Br J Anaesth 2009;102:90-6 Regional anesthe sia UA PO 2 (mmhg) UA O 2 content (ml.dl -1 ) UV PO 2 (mmhg) UV O 2 content (ml.dl -1 ) Air FiO2 60 % No difference between groups regarding: Apgar scores UA ph Lipid peroxidation compounds in maternal or UA or UV blood No difference in results whether or not fetal compromise was considered present Maximum FIO2 during caesarean section Bogod DG et al. Br J Anaesth 1988;61: patients undergoing elective and emergency Caesarean section (excluding severe fetal distress) divided into four groups : 50% O 2, 50% N 2 O, and 0.5% halothane (group 1) 100% O 2 supplemented by x MAC of halothane, enflurane or isoflurane (groups 2,3,4) UV PO 2 higher in the oxygen-only groups (p 0.05) Improved cardiovascular stability in the elective high-oxygen groups Isoflurane with either 100% oxygen or 50% nitrous oxide in oxygen for caesarean section Piggott SE et al. Br J Anaesth 1990;65: mothers undergoing general anaesthesia for Caesarean section allocated randomly to receive: either 100% oxygen (group FiO2=1 ) or 50% nitrous oxide in oxygen (group FiO2=0.5), both supplemented with isoflurane UV PO 2 was greater in group 100 for emergency sections (P = 0.001) lower incidence of neonatal resuscitation in group FiO2=1 (p= 0.04) Conclusion Large increase in FiO2 (from 30 to %) has benefit for both the mother and the neonate Mother Increases maternal oxygenation Possibly reduces infection and other maternal outcomes might improve cardiovascular stability Improves neonatal outcome and reduces the need of neonatal resuscitation Minor increase in FiO2 (30-50 %) Increases maternal oxygenation but has no impact on neonatal surrogate endpoints (oxygenation and ph) or outcomes Might increase maternal cardiovascular reserve and prevent or increase tolerance to unexpected complications Surgical site infection and the routine use of perioperative oxygen. Pryor KO R et al, JAMA 2004, 291: patients opérés de chirurgie abdominale majeure Antibioprophylaxie péri-opératoire mais pas de détails Administration randomisée d un FiO 2 variable (35 ou 80 %) au cours de l intervention(avec N 2, c.a.d. sans N 2 O) et des 2ères heures post-opératoires Taux d infection post-opératoire (sur dossiers) FiO 2 80 %: 11 % FiO 2 30 % 25 %(p = 0,01) Supplemental perioperative oxygen to reduce the incidence of surgical wound infection. Greif R et al, NEJM 2000, 342: patients opérés de chirurgie colorectale Antibioprophylaxie péri-opératoire: 2-3 jours Administration randomisée d un FiO 2 variable (30 ou 80 %) au cours de l intervention(avec N 2, c.a.d. sans N 2 O) et des 2ères heures post-opératoires Taux d infection post-opératoire : FiO 2 80 %: 5,2 % FiO 2 30 % 11,2 %(p = 0,01) SpO 2 et PO 2 tissulaire plus élevées dans le groupe FiO 2 80 % Benefits of oxygen administration Oxygen improves maternal oxygenation Oxygen reduces the rate of maternal infection and complications through improved tissue oxygenation and increased free oxygen radicals production Oxygen increases fetal oxygen delivery (UV PO 2 ) High FiO2 improves neonatal outcome If oxygen is to be administered, high FiO2 ( 60 %) should be advocated
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