Vascular Access: Umbilical Venous Cannula and Intra Osseous Access: Volume replacement in resuscitation is rarely needed medicine for nausea order 1mg kytril fast delivery. Inserting a Acknowledgements: We would like to medicine 7 year program 1mg kytril otc thank Sabrina Bhandari and small nasogastric tube 5cms into an umbilical vein is probably the Sophie Bunce symptoms intestinal blockage generic 1 mg kytril visa, medical students medicine for stomach pain 1mg kytril free shipping, Queens University, Belfast for their quickest method of establishing venous access at birth. Levels and the use of an intraosseous needle, you may fnd the 25 minute video trends in Child Mortality 2017. In order to provide safe anaesthesia for mother and fetus, it is essential for the anesthetist to have thorough understanding of the physiological and pharmacological changes that characterize the three trimesters of pregnancy. A multidisciplinary team approach involving the anesthetist, obstetrician, neonatologist and surgeon is highly recommended to ensure an adequate standard of care. Anaesthesia management, including post-operative analgesia, should be planned well to preserve the pregnancy and to ensure the safety of the mother as well as the foetus. Regional anaesthesia minimizes fetal drug exposure, airway management is simplifed, blood loss may be decreased, and overall risks to the mother and fetus are less. Tese patients do The anaesthetist has the following goals:5 present with surgical illness requiring surgery under (i) Optimize and maintain normal maternal general or regional anaesthesia. With advances in physiological function; fetal surgeries the number is only likely to increase in future. Incidence of non-obstetric surgery being (ii) Optimize and maintain utero-placental blood 1-2%. In the largest single series concerning (iv) Avoid stimulating the myometrium surgery and anaesthesia during pregnancy, 42% of (oxytocic efects); surgery during pregnancy occurred during the frst (v) Avoid awareness during general anaesthesia; trimester, 35% during the second trimester, and 23% during the third. The incidence of Appendicitis is around 1 3 regardless of trimester, pregnant woman should in 1500-2000 pregnancies. Elective surgery Non-obstetric surgery during pregnancy presents should be postponed until after delivery. The anaesthetist nonurgent surgery should be performed in the second has to take care of two lives. The goal being safe trimester when preterm contractions and spontaneous Madhusudan Upadya anaesthesia for both pregnant woman and the fetus. The choice of anaesthetic Kasturba Medical College To ensure maternal safety, the anaesthetist must technique(s), and the selection of appropriate drugs of Mangalore have a thorough understanding of the physiological anaesthesia should be guided by maternal indications Karnataka and pharmacological adaptations to pregnancy. Tese problems can occur during anaesthesia and surgery (2mg/kg iv titrated doses may be used. However, in cases of failed intubation, Concerns about anaesthetic efects on the developing human fetus laryngeal mask airway has been used to ventilate successfully and have been considered for many years Anaesthetic drugs afect intra safely in the reverse Trendelenburg’s position for brief periods. Terefore, all anaesthetic agents can hold great potential in the management of the obstetric airway. Despite years of animal studies and can be used in carefully selected patients to maintain the airway. As observational studies in humans, no anaesthetic drug has been shown changes in maternal position can have profound haemodynamic to be clearly dangerous to the human fetus and there is no optimal efects, positioning during anaesthesia should be carried out slowly. Tough all volatile on pregnant patients and no animal model perfectly mimics human agents (<1. Low concentration sevofurane would be the preferred 10 administering high concentrations for prolonged periods. Ephedrine has traditionally been the vasopressor of choice for However, some recommend avoiding nitrous oxide in pregnant hypotension. However, many recent controlled studies catecholamine surge with resulting impaired uteroplacental have countered this association. Positive avoid benzodiazepine use throughout gestation and most especially pressure ventilation should be used with care and end-tidal carbon during the frst trimester. However, it may be appropriate to provide dioxide levels should be maintained within the limits. Hyperventilation should be avoided as this adversely opioids, muscle relaxants, and local anaesthetics have been widely afects uterine blood fow. Oxygenation should be optimized to used during pregnancy with a good safety record. Pregnant surgical patient Fetal safety Depending on the dose administered, the timing of exposure with Elective Essential Emergency respect to development, and the route of administration of any drug surgery surgery surgery given during pregnancy can potentially jeopardise the development of the foetus. Until date, no anaesthetic drug has been proven to Delay until First trimester Second/third postpartum trimester be clearly hazardous to the human foetus. It may be noted that no animal model perfectly simulates human gestation and a randomised If no or minimal increased trial on pregnant patients in this regard would be defnitely unethical. Teratogenicity of anaesthetic drugs If greater than minimal Proceed with optimal anesthetic for mother, increased risk to mother modifed by considerations for maternal A teratogen is defned as a substance that causes an increase in the proceed with surgery physiologic changes and fetal well-being Consult a perinatologist or an obstetrician incidence of a particular defect in a foetus that cannot be attributed Intraopertaive and postoperative fetal and to chance. The teratogen must be given in a sufcient dose for a uterine monitoring may be useful substantial period at a critical developmental point to produce the defect. When considering the possible teratogenicity of various Figure 1: Decision-Making Algorithm for Non-Obstetric Surgery During anaesthetic agents, several important points must be kept in mind. The 2012 days of human gestation an all or nothing phenomenon occurs: the American College of Chest Physicians clinical practice guideline on fetus is lost or the fetus is preserved fully intact. During the time prevention and treatment of thrombosis recommends mechanical of organogenesis (15-56 days) structural abnormalities may occur. Prophylactic tocolytics: Tere is no proven beneft to routine Decision-Making Algorithm for Non-Obstetric Surgery During administration of prophylactic perioperative tocolytic therapy. Pregnancy Minimising uterine manipulation may reduce the risk of development of uterine contractions and preterm labour. Tocolytics Whenever a pregnant woman undergoes nonobstetric are indicated for the treatment of preterm labour until resolution surgery, consultations among her obstetrical team, surgeon(s), of the underlying, self-limited condition that may have caused the anesthesiologist(s), and neonatologist(s) are important to coordinate contractions. Conduct of Anaesthesia General principles of anaesthesia management No studies have shown a benefcial efect on the outcome of pregnancy Pre-operative preparation after regional compared with general anaesthesia. However, regional this should always involve close liaison with the obstetricians anaesthesia minimizes fetal drug exposure, airway management and include ultrasound assessment of the fetus when delivery is is simplifed, blood loss may be decreased, and overall risks to the anticipated. The largest risk of regional anaesthesia signs and symptoms often associated with cardiac disease, such as is hypotension resulting from sympathetic nerve blockade, which dyspnoea, heart murmurs and peripheral oedema are common reduces uterine blood fow and perfusion to the fetus. Pregnant After 6–8 weeks gestation, cardiac, haemodynamic, respiratory, patients who require surgery should be evaluated pre-operatively metabolic and pharmacological parameters are considerably altered. Laboratory and With the increase in minute ventilation and oxygen consumption other testing should be performed as indicated by the patient’s and a decrease in oxygen reserve (decreased functional residual comorbidities and the proposed surgery. In addition to standard capacity and residual volume), pregnant women become hypoxaemic pre-operative procedures, preparation of pregnant women takes into more rapidly. Supplementary oxygen must always be given during account risks of aspiration, difcult intubation, thromboembolism, vulnerable periods to maintain oxygenation. Aortocaval compression is a major hazard from 20 weeks onwards Aspiration prophylaxis: The gastric emptying has recently been (and sometimes even earlier); this compromises uterine blood fow shown to be normal during pregnancy until the onset of labour. This efect However, the risk of aspiration is still higher due to reduced gastric may be exacerbated by regional or general anaesthesia when normal barrier pressure and lower oesophageal sphincter tone (a progesterone 17 compensatory mechanisms are attenuated or abolished. The presence of additional risk for regurgitation and compression is only efectively avoided by the use of the 150 lateral aspiration, including active refux or obesity should be surveyed. It can be decreased by uterine displacement through Prophylaxis against aspiration pneumonitis should be administered wedging or manual displacement. Venacaval compression results from 16 weeks gestation with H2-receptor antagonists and non in distension of the epidural venous plexus, increasing the risk of particulate antacids. The capacity of Antibiotic prophylaxis: The need for antibiotic prophylaxis depends the epidural space is reduced, which probably contributes to the on the specifc procedure. However, attention should be paid in enhanced spread of local anaesthetics in pregnancy. Pregnancy is associated with a hypercoagulable state because of Prophylactic glucocorticoids: Administration of a course of antenatal increased pro-coagulant factors. The incidence of thromboembolic glucocorticoids 24-48hrs before surgery between 24 and 34 weeks complications is at least fve times greater during pregnancy; of gestation can reduce perinatal morbidity/mortality if preterm thromboprophylaxis is essential. Despite the potential benefts to the foetus, however, During third trimester, delivery by caesarean section before major antenatal glucocorticoids are best avoided in the setting of systemic surgery is often recommended. Where possible, surgery should infection (such as sepsis or a ruptured appendix), because they may be delayed 48hr to allow steroid therapy to enhance fetal lung impair the ability of the maternal immune system to contain the maturation.
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