Uma Munnur

Airway problems in pregnancy.

Objectives:To provide a current review of the literature regarding airway problems in pregnancy and management. Background:Obstetrical anesthesia is considered to be a high-risk practice that exposes the anesthesiologist to increased medicolegal liability. Anesthetic management of a parturient is a challenge because it involves simultaneous care of both mother and baby. Failure to appropriately manage a difficult or failed intubation increases the risk of hypoxemic cardiopulmonary arrest and/or pulmonary aspiration, resulting in a high probability of maternal morbidity and mortality. Data:Anesthesia is the seventh leading cause of maternal mortality in the United States. Anatomic and physiologic changes during pregnancy place the parturient at increased risk for airway management problems. It is essential to perform a thorough preanesthetic evaluation and identify the factors predictive of difficult intubation. Airway devices such as the laryngeal mask airway, ProSeal, intubating laryngeal mask airway, Combitube, and laryngeal tube are described and have been used during failed intubation in pregnant patients. Conclusion:Teamwork between an anesthesiologist and an obstetrician is absolutely essential for the safety of both the mother and baby. Most of us tend to agree that airway emergencies have a way of occurring at the worst possible times. It is essential that all anesthesia care practitioners must have a preconceived and well thought-out algorithm and emergency airway equipment to deal with airway emergencies during difficult or failed intubation of a parturient.

Backache, headache, and neurologic deficit after regional anesthesia

Back pain, chemical backache, PDPH, and neurologic deficit all may be reported after regional anesthesia for childbirth. Back pain is common during pregnancy, but epidural analgesia during labor does not increase the incidence of long-term back pain. Chemical backache caused by 2-chloroprocaine is probably a result of hypocalcemic tetany of paraspinous muscles. The mechanism is presumed to be chelation of calcium by sodium bisulfite, an antioxidant present in nesacaine-MPF. PDPH after dural puncture is caused by leakage of CSF, which causes cerebral hypotension. Cerebral hypotension leads to traction on pain-sensitive intracranial structures and cerebral vasodilation. Initial therapy includes hydration, caffeine, and sumatriptan. EBP is the most effective treatment in severe PDPH. If the first EBP fails, a second blood patch can be performed. Neurologic deficits after regional anesthesia are rare. Meticulous technique and vigilance are the keystones in avoiding major neurologic complications of regional anesthesia. Rapid diagnosis and appropriate treatment are essential to optimize a successful outcome if complications do develop.

Airway problems in patients with rheumatologic disorders

The intensivist should be aware of the upper airway manifestations of the common rheumatologic disorders which may lead to ICU admission or which may potentially pose a problem during airway management. Information should be obtained from the patient, the patients family, and the patients primary physician, if possible. One should be fully prepared with various options in case a problem arises with an airway. Equipment for managing a difficult airway should be available. Alternate methods of managing the airway (e.g., the laryngeal mask airway, fiberoptic scopes, and the WU Scope) (Achi Corporation, Fremont, CA) are of great help in dealing with airway problems. The potential for cervical spine instability exists in patients with rheumatologic disorders. Intubating with care and avoiding spinal movement both seem to be more important than any particular mode of intubation in preserving neurologic function. One should make a concentrated and serious effort to be as gentle as possible and to avoid even minimal trauma to the mucosa in these patients, because they are at risk for mucosal edema and subsequent postextubation stridor. In cases of stridor, helium-oxygen mixtures may be of help and may eliminate the need for reintubation. When difficulty in establishing an airway is anticipated, it is prudent to attempt airway control in the operating room with surgical assistance standing by should cervical tracheotomy is required.

Management Principles of the Critically Ill Obstetric Patient

The goals in management of critically ill obstetric patients involve intensive monitoring and physiologic support for patients with life-threatening but potentially reversible conditions. Management principles of the mother should also take the fetus and gestational age into consideration. The most common reasons for intensive care admissions (ICU) in the United States and United Kingdom are hypertensive disorders, sepsis, and hemorrhage. The critically ill obstetric patient poses several challenges to the clinicians involved in her care, because of the anatomic and physiologic changes that take place during pregnancy.

Airway Management and Mechanical Ventilation in Pregnancy

Anesthesia-related maternal mortality rates have improved in the United States, but it still remains a prominent cause of maternal mortality. Anesthesia is the seventh leading cause of maternal mortality in the United States with the top six causes being embolism, hypertensive disorders, hemorrhage, infection, cardiomyopathy, and cerebrovascular accident (1). General anesthesia is more likely to be associated with maternal mortality than regional anesthesia in the obstetric patient for the following reasons: (1) airway management tends to be more difficult in pregnant patients due to altered anatomy and physiology; (2) general anesthesia is chosen in emergency surgeries when there is no time for adequate preoperative evaluation and aspiration prophylaxis; (3) conversion of regional anesthetic to general anesthesia for inadequate block, hemorrhage, etc., with the patient not in the optimal position for intubation; and (4) increased usage of regional anesthesia in obstetrics with minimal exposure of trainees to general anesthesia for cesarean sections, resulting in decreased airway management skills for training and maintenance in the obstetric patient.

The effectiveness of a multidisciplinary, team‐based approach to cesarean hysterectomy in modern obstetric practice

To examine the effectiveness of a multidisciplinary, team‐based approach to management of cesarean hysterectomy.