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    Home > Active Ingredient News > Anesthesia Topics > How do we choose the anesthesia method for labor analgesia and transfer to cesarean section?

    How do we choose the anesthesia method for labor analgesia and transfer to cesarean section?

    • Last Update: 2021-05-10
    • Source: Internet
    • Author: User
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    With the promotion and popularization of labor analgesia in the country, it is believed that more and more labor analgesia are available in various hospitals.
    The night emergency department often encounters labor analgesia for patients who have difficulty in delivery and turn to cesarean section.
    For such patients, we should How to choose anesthesia method, I try to discuss.

    First of all, the "Stanford University Obstetric Anesthesia Emergency Handbook" specially produced by the New Youth Forum and translated by Professor Huang Jianhong and others, specifically elaborates the detailed process of "the failure of epidural anesthesia in cesarean section", which is very practical.

    This article briefly summarizes the three possible anesthesia methods we may use, analyzes the pros and cons of each method and when to use them, and welcomes criticism and discussion.

    1.
    Spinal anesthesia [Prerequisite] There is no emergency for the parturient, no fetal distress, and sufficient time to operate; [Advantages] Fast onset, good effect, and precise effect; [Operation suggestion] Choose a puncture below the epidural catheter, optional Local anesthetics include 15-20mg of ropivacaine and 10-12mg of bupivacaine.

    The use of spinal anesthesia for cesarean section should be justified.
    Because of the indwelling of the epidural catheter, in fact, only a single spinal anesthesia is needed to achieve the surgical conditions.

    However, since the last indwelling catheter will cause the spinal anesthesia puncture point to be too low, which may result in insufficient block planes, it is recommended to inject spinal anesthetics toward the head, and at the same time, the puncture point for painless delivery should be L2/3 or above; of course, directly It is not impossible to remove the epidural catheter and puncture again, but it will increase the puncture injury.

    Due to the accumulation of a large number of low-concentration local anesthetics in the epidural, there is theoretically erroneous entry of the epidural and leading to failure of spinal anesthesia.
    It is recommended that heavier bupivacaine is the first choice.
    The sacral nerve block may appear immediately after the spinal anesthetic is administered (will Pussy fever) to determine the effect of spinal anesthesia.

    2.
    Continuous epidural anesthesia [Prerequisite] The catheter is well positioned, the block plane is equal to the left and right, and the labor analgesia effect is good; [Advantages] It can be directly administered to achieve sufficient block, and it can also provide intraoperative analgesia for emergency women; [ Operational recommendations] After entering the room, check whether the epidural catheter is prolapsed and evaluate whether the labor analgesia is good; the above two are very important.
    As long as one is unqualified, it is recommended to change to spinal anesthesia (no emergency) or general anesthesia (emergency).

    It is recommended to push 2% lidocaine by hand (1:200,000 epinephrine, 50~100ug of fentanyl or 10~20ug of sufentanyl), the first dose is 10ml, and 5ml is added every 5 minutes.
    Generally, the total amount is not If the volume exceeds 20ml, ropivacaine or bupivacaine may be added after the fetus is dissected.

    The biggest problem of continuous epidural anesthesia for cesarean section is incomplete block, analgesia and muscle relaxation are not as good as spinal anesthesia, which is also the reason why most anesthesiologists do not choose this method; analysis of the main reasons for insufficient block plane There are: low puncture point, one side of the catheter, dislocation or discount, etc.
    , strict inspection of the catheter and evaluation of the effect of labor analgesia can reduce the probability of epidural anesthesia failure.

    Generally speaking, a good block level for labor analgesia is above T10, and the first dose of 2% lidocaine 10ml can assess whether the block level rises rapidly after 5 minutes.

    In order to minimize the probability of finding insufficiency during the operation, it is strongly recommended that no emergency cesarean section epidural anesthesia start skin disinfection after reaching a satisfactory block level, so that there is a chance to change the epidural block when the epidural block is insufficient.
    Spinal anesthesia, for emergency parturients, can be administered epidurally while disinfecting.

    3.
    General anesthesia is suitable when there is not enough time to transform epidural analgesia into anesthesia; it should be used as an emergency or backup anesthesia.
    General anesthesia should be avoided as the ultimate method.
    See "Cesarean section dural Failure of external anesthesia"; meanwhile, indwelling an epidural catheter in a parturient who is turned to cesarean can provide perfect intraoperative and postoperative analgesia.

    "After inserting an epidural catheter, it may take 10 minutes for fast-acting local anesthetics such as 3% 2-chloroprocaine to reach the T4 level.
    Use 3% 2-chloroprocaine or 2% alkali It takes about 5 minutes for sexual lidocaine to rise from T10 for labor analgesia to T4"-"Miller's Anesthesiology" 8th edition; and true emergency cesarean section generally requires cesarean delivery within 5 minutes, so spinal anesthesia and hard The extra-membrane is only suitable for non-emergency cesarean section.

    Regardless of spinal anesthesia or epidural, as long as the expected block level can be achieved, I think there is no difference between the advantages and disadvantages of the two for pregnant women who have undergone a painless delivery and transferred to a cesarean section.

    Although spinal anesthesia takes effect quickly, it requires re-sterilization and puncture.
    The total time spent will not save too much.
    In theory, there is a possibility that spinal anesthesia may be mistakenly entered into the epidural; epidural anesthesia is impacted by large doses of high-concentration lidocaine The onset time will also be greatly shortened, but the block level that can be reached is somewhat unpredictable.
    I think 2% lidocaine 10ml is inserted epidurally, and after 5 minutes, the absolute block level still cannot be left or right.
    More than T8 (personal opinion, can be discussed), should give up epidural and immediately change spinal anesthesia.

    Everyone will have their own strengths and preferences, but spinal anesthesia and epidural anaesthesia will have the probability of failure.
    It is best to master the above three methods and have their own A, B, and C programs to achieve a targeted and easy-to-use strategy.
    .

    Based on the above, I have summarized a set of simple methods for non-emergency labor analgesia to switch to cesarean section anesthesia, please consider yourself! 1.
    Check the position of the epidural catheter immediately after entering the room and evaluate whether the labor analgesia is satisfactory.
    If there is a negative item, change to spinal anesthesia; 2.
    Extradural hand push 2% lidocaine 10ml, 5 minutes later, evaluate the absolute block level bilaterally Can all reach T8 or above; 3.
    Start disinfection when the expected level is reached, otherwise immediately change spinal anesthesia; continue epidural with 2% lidocaine 5ml (add fentanyl 50~100ug or sufentanil 10~ 20ug), up to 20ml; 4.
    Regardless of spinal anesthesia or epidural anesthesia, if analgesia is insufficient, you can also consider epidural additional medium and long-acting local anesthetics, inhaled sevoflurane, or intravenous injection of ketamine 10-20mg; 5.
    The above two methods can not achieve satisfactory anesthesia effect, change to general anesthesia.

    Do a small survey.
    If you encounter non-emergency labor analgesia and switch to cesarean section at work, your choice is: Recommendation: What index is the best entry point for painless gastroscopy?
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