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Chapter: Clinical Cases in Anesthesia : Anesthesia For Nonobstetric Surgery During Pregnancy

What general recommendations can be made when anesthetizing the pregnant patient for nonobstetric surgery?

Whenever possible, anesthesia and surgery should be avoided during the first trimester.

What general recommendations can be made when anesthetizing the pregnant patient for nonobstetric surgery?

 

Whenever possible, anesthesia and surgery should be avoided during the first trimester. Prior to initiating any anesthetic, an obstetrician should be consulted and fetal heart rate tones should be documented. Precautions against aspiration should be taken from as early as the 12th week by administering a clear nonparticulate oral antacid, H2 receptor blocker, and metoclopramide. Apprehension should be allayed by personal reassurance rather than with premedication, if possible. The patient should be informed that there is no known risk to the baby regarding congenital malformations but that there is an increased risk of miscarriage or premature labor. The patient should be transported to the operating room with left uterine displacement to avoid aortocaval compression.

 

In addition to the routine intraoperative monitors, the fetal heart rate and uterine tone should be monitored, and should continue to be monitored into the postoperative period.

 

The type of anesthesia is determined by maternal indica-tions, the site and nature of the surgery, and the anesthesiol-ogist’s experience. The dose of all anesthetic agents for general or regional anesthesia should be reduced. Unless otherwise contraindicated, local or regional anesthesia may be preferable to general anesthesia to avoid the risk of aspira-tion and to decrease fetal drug exposure.

 

If a spinal or an epidural anesthetic is to be conducted then adequate prehydration (at least 1000 cc of a crystalloid solution) should be administered to prevent hypotension. If hypotension does occur, it must be treated immediately with the administration of additional crystalloid or by using a drug with predominantly β-adrenergic effects, such as ephedrine.

 

General anesthesia should be preceded by careful eval-uation of the airway, denitrogenation, and a rapid sequence induction with the application of cricoid pres-sure. Since tracheal intubation may be technically difficult an array of laryngoscope blades, handles, and other emergency airway management equipment should be available. Extreme care should be taken during manipula-tion of the airway and a smaller-than-normal tracheal tube should be inserted. The use of a nasal airway and nasotracheal intubation should be avoided. A high concentration of oxygen should be used (at least 50%) and PaCO2 should be maintained at normal pregnancy levels (30–35 mmHg). End-tidal carbon dioxide (ETCO2) is an excellent approximation of PaCO2 in the pregnant patient because the PaCO2–ETCO2 gradient decreases during pregnancy.

Cardiopulmonary bypass, hypothermia, and hypotensive techniques have all been performed successfully during pregnancy and should not be withheld, if necessary.

 

Epidural or subarachnoid opioids are an excellent choice for pain management because they cause minimal sedation and smaller doses can be utilized compared with the intramuscular or intravenous routes. Nonsteroidal anti-inflammatory drugs should be avoided because they may cause premature closure of the ductus arteriosus.

 

Regardless of the technique, maintenance of a normal intrauterine physiologic milieu throughout the perioperative period, including the avoidance of hypotension, hypox-emia, hypercarbia, hypocarbia, and hypothermia is the key to a successful outcome.




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Clinical Cases in Anesthesia : Anesthesia For Nonobstetric Surgery During Pregnancy : What general recommendations can be made when anesthetizing the pregnant patient for nonobstetric surgery? |


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