The use of general anesthesia for cesarean delivery has declined in the last decades due to the widespread utilization of neuraxial techniques and the understanding that neuraxial anesthesia can be provided even in urgent circumstances. In fact, the role of general anesthesia for cesarean delivery has been revisited, because despite recent devices facilitating endotracheal intubation and clinical algorithms, guiding anesthesiologists facing challenging scenarios, risks, and complications of general anesthesia at the time of delivery for both mother and neonate(s) remain significant. In this review, we will discuss clinical scenarios and risk factors associated with general anesthesia for cesarean delivery and address reasons why anesthesiologists should apply strategies to minimize its use. Unnecessary general anesthesia for cesarean delivery is associated with maternal complications, including serious anesthesia-related complications, surgical site infection, and venous thromboembolic events. Racial and socioeconomic disparities and low-resource settings are major contributing factors in the use of general anesthesia for cesarean delivery, with both maternal and perinatal mortality increasing when general anesthesia is provided. In addition, more significant maternal pain and higher rates of postpartum depression requiring hospitalization are associated with general anesthesia for cesarean delivery. Rates of general anesthesia for cesarean delivery have overall decreased, and while general anesthesia no longer is a contributing factor to anesthesia-related maternal deaths, further opportunities to reduce its use should be emphasized. Raising awareness in identifying situations and patients at risk to help avoid unnecessary general anesthesia remains crucial.

/pdf/the-current-role-of-general-anesthesia-for-cesarean-delivery-1mdhrftftq.pdf

The Current Role of General Anesthesia for Cesarean Delivery

The incidence of pain during cesarean delivery (PDCD) remains unclear. Most studies evaluated PDCD using interventions suggesting inadequate analgesia: neuraxial replacement, unplanned intravenous medication (IVM), or conversion to general anesthesia. Few assess self-reported pain. This study evaluates the incidence of and risk factors for self-reported PDCD and IVM administration. Between May and September 2022, English-speaking women undergoing cesarean delivery under neuraxial anesthesia were approached within the first 48 h. Participants answered a 16-question survey about intraoperative anesthesia care. Clinical characteristics were extracted from electronic medical records. The primary outcome was PDCD. Secondary outcomes were analgesic IVM (opioids alone or in combination with ketamine, midazolam, or dexmedetomidine) and conversion to general anesthesia. Risk factors for PDCD and analgesic IVM were identified using multivariable logistic regression models. Pain was reported by 46/399 (11.5%; 95% CI: 8.6, 15.1) participants. Analgesic IVM was administered to 16 (34.8%) women with PDCD and 45 (12.6%) without. Conversion to general anesthesia occurred in 3 (6.5%) women with and 4 (1.1%) without PDCD. Risk factors associated with PDCD were substance use disorder and intrapartum epidural extension. Risk factors associated with analgesic IVM were PDCD, intrapartum epidural extension when ≥2 epidural top-ups were given for labor analgesia, and longer surgical duration. In our cohort of scheduled and unplanned cesarean deliveries, the incidence of PDCD was 11.5%. A significant proportion of women (15.1%) received analgesic IVM, of which some but not all reported pain, which requires further evaluation to identify triggers for IVM administration and strategies optimizing shared decision-making. 

Pain during cesarean delivery: a patient-related prospective observational study assessing the incidence and risk factors for intraoperative pain and intravenous medication administration

Abstract It is unclear why some patients experience pain during cesarean delivery despite receiving appropriate regional anesthesia. Our primary aim was to determine what demographic and clinical variables predict intraoperative pain during cesarean delivery with neuraxial anesthesia. From July 2019 through March 2020, we administered a previously validated patient satisfaction survey to parturients who had a cesarean delivery under regional anesthesia for nonemergent obstetric indications. We performed a post hoc analysis restricted to subjects who had single injection spinal and combined spinal-epidural anesthesia. Parturients who did and did not report pain differed in height, intrathecal hyperbaric bupivacaine dose, and the time from incision to wound closure. We performed an ordinal logistic regression analysis on the 168 subjects with complete data using the aforementioned variables along with the time of day of cesarean delivery. Incision to wound closure time (P < 0.01) predicted intraoperative pain. The multivariate logistic regression model was statistically significant (P < 0.01) and had a receiver operator curve value of 0.74. The duration of time from incision to wound closure predicted intraoperative pain during cesarean delivery under regional anesthesia.

Predictors of intraoperative pain during cesarean delivery under regional anesthesia

Abstract A combined spinal epidural anesthetic technique allows an anesthesia provider to administer local anesthetic through an epidural catheter in the event of a failed spinal anesthetic. Prior to May 2019, our hospital performed single-shot spinal anesthesia exclusively for cesarean deliveries. In May 2019, anesthesia providers at our hospital were encouraged to perform combined spinal epidural anesthesia for cesarean delivery. We hypothesized that subjects who received combined spinal epidural anesthesia would have superior anesthetic outcomes compared to subjects who received single-shot spinal anesthesia. We performed a retrospective review of subjects who had cesarean deliveries at our hospital from May 15, 2019, through April 15, 2021, who received either single-shot spinal anesthesia or combined spinal epidural anesthesia. Subjects who received combined spinal epidural anesthesia were older, had a higher body mass index, had higher parity, were more likely to have had a cesarean delivery in the past, were more likely to have had the neuraxial anesthetic technique performed by a junior resident, and had a lower intrathecal dose of hyperbaric bupivacaine. Combined spinal epidural anesthesia had similar anesthetic outcomes to single-shot spinal anesthesia for cesarean delivery despite more complex subjects with less experienced operators.

Effect of encouraging a combined spinal epidural technique for cesarean delivery anesthesia

Endoscopic submucosal dissection (ESD) is a minimally invasive technique to completely peel the pathological mucosa from the submucosa under endoscopy, which has been often utilized to treat early gastric cancer. During the operation, anesthesia is required to reduce the discomfort due to the complexity, high risk, and longtime operation of ESD. In this study, we compared different anesthesia methods on anesthetic effect and postoperative pain in patients (≥65 years old) with early gastric cancer during ESD. For this purpose, 60 patients with early gastric cancer who were more than 65 years old were selected from January 2019 to December 2021, where 30 patients treated with simple intravenous general anesthesia were divided into the simple group and 30 patients treated with intravenous combined inhalation general anesthesia were regarded as the composite group. The hemodynamic index, wake-up time, postoperative pain intensity, operation time, and the incidence of adverse reactions were compared between the two groups. For the hemodynamic index before incision, after incision, and at the end of the operation, the mean arterial pressure (MAP) in the composite group was higher than that in the simple group (P < 0.05) and the heart rate (HR) was lower than that in the simple group (P < 0.05). After the ESD operation, the wake-up time and visual analogue scale (VAS) in the composite group were lower than those in the simple group (P < 0.05). In addition, the ESD operation time and incidence of adverse reactions in the composite group was significantly lower than that in the simple group (P < 0.05). These results showed that intravenous combined inhalation general anesthesia had a good anesthetic effect, stable hemodynamics during ESD operation, and slight postoperative pain.

https://downloads.hindawi.com/journals/jo/2022/7299360.pdf

Comparing Different Anesthesia Methods on Anesthetic Effect and Postoperative Pain in Patients with Early Gastric Cancer during Endoscopic Submucosal Dissection

The number of cesarean deliveries performed with a general anesthetic decreased when regional anesthesia for cesarean delivery was reported to be associated with lower maternal mortality. Anesthetic adjunct administration for cesarean deliveries performed with regional anesthesia is typically not reported alongside general anesthesia rates for cesarean delivery. This retrospective study analyzed rates of general anesthesia and systemic anesthetic adjunct administration for cesarean deliveries performed under regional anesthesia at a community hospital from 2014 to 2018. We used the hospital electronic medical record system to collect data on cesarean deliveries during the study period. A total of 1867 cesarean deliveries were performed, corresponding to a cesarean delivery rate of 30.4%. Of the subjects, 104 (5.6%) received general anesthesia and 333 (17.8%) received regional anesthesia with at least one systemic anesthetic adjunct. These adjuncts included a variety of intravenous agents-midazolam (1.7%), fentanyl (5.2%), morphine (6.6%), propofol (7.9%), and ketamine (1.7%)-as well as inhaled nitrous oxide (1.4%) and sevoflurane (0.1%). These data on anesthetic adjunct administration with regional anesthesia provide clinical context for the rates of general anesthesia reported for cesarean delivery.

The use of adjunct anesthetic medication with regional anesthesia and rates of general anesthesia for 1867 cesarean deliveries from 2014 to 2018 in a community hospital.

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The use of adjunct anesthetic medication with regional anesthesia and rates of general anesthesia for 1867 cesarean deliveries from 2014 to 2018 in a community hospital.