What is New in 2007 ASAPractice nbs
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The first edition of ASA Practice Guidelines for Obstetric Anesthesia was initially developed in 1998 and published in 1999. I discussed the first edition during the 2005 CSA Annual Conference in Guangzhou. As expected, ASA revised the Practice Guidelines and this updated version was approved in October 2006 during the ASA Annual Conference in Chicago and published in Anesthesiology, April 2007. So, what has changed since 1999?
After carefully comparing both documents, I have discovered many interesting additions in the updated version. Now let us review the new guidelines one by one.
I. Perianesthetic Evaluation
History and Physical Examination. The new guidelines still recommend a focused history and physical examination before providing anesthesia care. This should include a maternal health and anesthesia, a relevant obstetric history, a baseline blood pressure measurement, and an examination of back and spine when a neuraxial anesthetic is planned or placed.
Besides an airway examination, the new guidelines now recommend examination of the heart and lungs. Obstetric patients should not receive a different standard of care than other surgical patients coming for non-OB surgeries.
The new guidelines also emphasize an early, continual, and effective communication among anesthesiologists, obstetricians, and other members of the multidisciplinary team.
There is no significant change in the next three sections.
Intrapartum Platelet Count. As in the first edition, the new guidelines indicate that a platelet count is clinically useful for parturients with hypertensive disorders and other disorders associated with coagulopathy. But routinely checking platelet count for healthy parturients is not necessary and the decision to order platelets should be individualized and based on a patient’s history, physical examination and clinical presentation.
Blood Type and Screen. Similarly, a routine blood cross-match is not necessary for healthy and uncomplicated parturients for vaginal or operative delivery. The decision for blood type and screen, or cross-match, should be individualized and depend on maternal history and anticipated hemorrhagic complications. But an intrapartum blood sample should be sent to the blood bank for all parturients.
Perianesthetic Recording of the Fetal Heart Rate. The fetal heart rate should be monitored after 20 weeks of gestation by a qualified personnel before and after regional anesthesia.
II. Aspiration Prevention
Clear Liquids. There is essentially no change in the recommendation. Oral intake of modest amounts of clear liquid during labor improves maternal comfort and satisfaction. Clear liquids is allowed for uncomplicated laboring patients and up to two hours prior to induction of anesthesia for uncomplicated patient undergoing elective Cesarean delivery. The quantity of the liquid is less important than the quality of the liquid.
However, patients with additional risk factors for aspiration, or patients at increased risk for operative delivery may need restrictions of oral intake.
Solid. Solid food should be avoided in laboring patients. The patients undergoing elective surgery should undergo food fasting, nothing-by-mouth (NPO), similar to patients in non-OB elective surgery.
The new guidelines repeatedly emphasize the six to eight-hour fasting of solids. There is a range of flexibility because the longer time interval applies to fatty foods that do not empty as quickly.
Antacids, H2 Receptor Antagonists, and Metoclopramide. This is a new section was not in the 1999 practice guidelines. A list of pharmacologic agents for aspiration prophylaxis should be considered to be used in a timely fashion before surgical procedures.
III. Anesthetic Care for Labor and Vaginal Delivery
This entire division has been modified in the new guidelines. The selected analgesic/anesthetic techniques should reflect the patient needs and preferences, practitioner preferences or skills, and available resources.
Timing of Neuraxial Analgesia and Outcome of Labor. The new guidelines indicate the timing of neuraxial analgesia does not affect the frequency of Cesarean delivery, nor other delivery outcomes (i.e., instrumented delivery).
Patients in early labor should be given the option of neuraxial analgesia when this service is available. The new guidelines emphasize that neuraxial analgesia should not be withheld on the basis of achieving an arbitrary cervical dilation and should be offered on an individualized basis.
The new guidelines reinstate the first version statement, which was adopted by American College of Obstetrics and Genecology in its 2002 guidelines: maternal request represents sufficient justification for pain relief. In addition, maternal medical and obstetric conditions may warrant the provision of neuraxial techniques to improve maternal and neonatal outcome.
Neuraxial Analgesia and Trial of Labor after Prior Cesarean Delivery. Vaginal birth after Cesarean (VBAC) has become popular in the US. The new guidelines add a special section for VBAC. Neuraxial techniques should be offered to VBAC patients. For these patients, it is also appropriate to consider early placement of a neuraxial catheter that can be used later for labor analgesia, or for anesthesia in the event of operative delivery.
Early Insertion of a Spinal or Epidural Catheter for Complicated Parturients.
One of the major addition in the new guidelines is to recognize that early ion of a spinal or epidural catheter for obstetric (e.g., twin gestation or preeclampsia) or anesthetic indications (e.g., anticipated difficult airway or obesity) may reduce the need for general anesthesia if an emergent procedure becomes necessary and the treatment of complications. In these cases, the ion of a spinal or epidural catheter may precede the onset of labor or may start before patient request for labor analgesia.
Continuous Infusion Epidural Analgesia. The new guidelines suggest that when a continuous epidural infusion of local anesthetic is selected, an opioid may be added to reduce the concentration of local anesthetic, improve the quality of analgesia, and minimize motor block. The lowest concentration of local anesthetic infusion that provides adequate maternal analgesia and satisfaction should be administered.
Single-Injection Spinal Opioids With or Without Local Anesthetics. This technique may be used to provide rapid, effective, although time-limited, analgesia for labor when spontaneous vaginal delivery lasting shorter than the analgesic effects of the injected spinal drugs. Adding a local anesthetic to a spinal opioid may increase duration and improve quality of analgesia.
Pencil-Point Spinal Needles. Pencil-point spinal needles should be used instead of cutting-bevel spinal needles to minimize the risk of post-dural puncture headache.
Combined Spinal-Epidural Analgesia (CSE). CSE techniques can provide effective, long lasting, and rapid onset of analgesia for labor.
Patient-Controlled Epidural Analgesia (PCEA). The new guidelines indicate that PCEA, with or without a basal infusion, may lead to fewer anesthetic interventions, lower dosages of local anesthetics, and less motor blockade than fixed-rate continuous epidural infusions.
IV. Removal of Retained Placenta
Anesthetic Techniques. It is obvious that, if an epidural catheter is in place and the patient is hemodynamically stable, epidural anesthesia is the choice of technique. Spinal anesthesia can be chosen if epidural catheter is not in place. However, for a hemodynamically instable patient, general anesthesia with an endotra
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