National Board Ex- 6 Book .pmd - National Board Of Examination

LSCS is taken, patient shouldbe kept nil per orally (NPO)Methods to increase gastricpHl H 2receptor antagonists likeRanitidine at night and in themorningl Atropine/ glycopyrrolatepremedication is controversialas it decreases oesophagealsphincter tone thusnegative the effect ofmetoclopromidel Sodium citrate orally 30 to 45min preoperativelyFactors that decrease LOSPressure (increased risk ofregurgitation)l Thiopentone, inhalationagents, anticholinergicsl Stomach tube for emptyingthe stomachl Apomorphine to inducevomiting (to reduce gastricvolume)Increase LOS pressure barrierl Metoclopramidel Antacidsl Ranitidinel NeostigmineAnesthesia technique –precaution and carel Timely decision for LSCSl Treat all parturients as fullstomachl Prefer SAB/ epidural block.Avoid GA.l Aspiration prophylaxis in alll Remove gastric tube / Rylestube at induction of anesthesia.l Patient positioning (slighthead up – decreased regurgitation)l Skilled assistance should beavailablel Adequate and appropriateequipment. Proper trolleypreparationl Use of correct cricoid Pressure/ Sellick’s maneuverl Avoid high pressures & volumesfor IPPV before intubationl Familiarize one self with thefailed intubation drilll Care at intubation/ extubationRecommendationsl Withhold oral feeds duringlaborl Regional anesthesia as far aspossiblel Take measures to decreasegastric volume & increase pHl GA by competent anesthetist,with full appreciation of aspirationriskl Well equipped delivery roomsfor administration of safeanesthesiaRapid sequence / Crashinduction of GAAdvantage – decreases risk ofregurgitation & aspirationTechniquel Patient lying supine, in neutralposition, on OT table(parallel to floor)l Pre oxygenation for 3 to 5min, normal tidal breathsl Check for application ofSellick’s maneuverl Precalculated dose of Thiopentone(5-7mg/Kg)l Assistant places thumb & fingeron Cricoid cartilagel Apply Cricoid pressure afterloss of eyelash reflexl Succinyl choline 2mg/Kg IVl Continue oxygen by maskl No Nitrous oxidel No IPPVl Direct laryngoscopy at 1 minafter suxamethonium chloride.Intubate with 7.0 ETTl Once ET in situ, inflate thecuffl Reconnect circuit and ventilatel Release cricoid pressurel Auscultate for equal air entrySellick’s maneuverl Occludes cervical esophagusbetween cricoid cartilage &cervical vertebrael Pressure applied = 40 Newtonforce (100 cm H 2O or 74mm Hg)l Check for pressure to be applied(without discomfort topatient) preoperativelyl Apply pressure with thumb &index fingerl Remove only once ET in situl Double handed modificationl Disadvantage – 50% decreasein LESPAmniotic Fluid Embolism(AFE)-AFE was first reportedby Meyer in 1926. It is the mostdangerous untreatable conditionwith mortality of 80-100%. Itleads to sudden death in theperipartum period (failure to diagnosethe cause & 25% deathsoccur within 1 hour of onset ofsymptoms). It is also termed as“obstetric shock”. Its incidence14Journal of Postgraduate Medical Education, Training & ResearchVol. II, No. 5, September-October 2007