key: cord-0859761-4h0vspug
authors: Agegnehu, Abatneh Feleke; Gebregzi, Amare Hailekiros; Endalew, Nigussie Simeneh
title: Review of Evidences for management of rapid sequence spinal anesthesia for category one cesarean section, in resource limiting setting
date: 2020-09-03
journal: International journal of surgery open
DOI: 10.1016/j.ijso.2020.08.013
sha: f773f52694070066ff3186168efaf850dd6c8fae
doc_id: 859761
cord_uid: 4h0vspug

Background Globally obstetric anesthesia is being done under spinal and epidural than general anesthesia (GA) for most caesarean sections (CSs). This is because GA is associated with failed endotracheal intubation and aspiration of gastric contents. Eventhough general anesthesia is the fastest method for anesthetizing a category 1 cesarean section, it is associated with increased maternal mortality and morbidity. Spinal anesthesia is the preferred regional technique for cesarean section but failure sometimes occurs. To minimize the time factor of spinal anesthesia as well as to avoid the side effects of general anesthesia ‘rapid sequence spinal ‘(RSS) has developed as a novel approach in cases of category one cesarean sections. Methods The study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. Search engines like PubMed through HINARI, Cochrane database and Google Scholars were used to find high-level evidences that help to draw appropriate conclusions. Discussion Neuraxial anesthetic techniques have several advantages which include low risk of aspiration and failed intubation, avoidance of central nervous system (CNS) and respiratory depressant drugs, the ability to maintain a wakeful state of mother enjoying the experience of delivery of baby and also lower incidence of blood loss. ‘Rapid sequence spinal’ described to minimize anesthetic time. This consists of a no-touch spinal technique, consideration of omission of the spinal opioid, limiting spinal attempts, allowing the start of surgery before full establishment of the spinal block, and being prepared for conversion to general anesthesia if there are delays or problems. To do rapid sequence spinal anesthesia safely and timely, cooperative work is mandatory with good team relation for those simultaneous and necessary tasks. Conclusion The choice of anesthetic in Cesarean section has long been recognized as one of prime importance, because there are two lives to safeguard instead of one. A balance must be struck between the anesthetic dictated by the general condition of the mother and that suited to the needs of the fetal respiratory system.

To reduce general anesthetic related maternal and neonatal morbidity and mortality To identify and give evidence based anesthetic services for pregnant mothers coming for cesarean delivery

To have best possible maternal and neonatal outcome. Internationally, obstetric anesthesia guidelines recommend spinal and epidural over general anesthesia (GA) for most caesarean sections (CSs). The primary reason for recommending regional blocks is the risk of failed endotracheal intubation and aspiration of gastric contents.

General anesthesia is the fastest method for anesthetizing a category 1 cs associated with increased maternal mortality and morbidity and Spinal anesthesia is the preferred regional technique for cs but failure sometimes occurs. While regional anesthesia or general anesthesia are both acceptable for cesarean delivery, the use of general anesthesia has become less common in the past few decades. While most cesarean sections are performed under regional anesthesia, general anesthesia should always be considered as it is occasionally necessary(1, 2)**,**.

To minimize the time factor of spinal anesthesia as well as to avoid the side effects of general anesthesia 'rapid sequence spinal '(RSS) has developed as a novel approach in cases of category one cesarean sections. neuraxial anesthetic techniques have several advantages which include low risk of aspiration and failed intubation, avoidance of central nervous system and respiratory depressant drugs, the ability to maintain a wakeful state of mother enjoying the experience of delivery of baby, lower incidence of blood loss, early ambulation and low risk of DVT, early return of gastrointestinal function and short hospital stay length. Amongst the various neuraxial techniques, spinal anesthesia has been popular for cesarean delivery because of ease of administration, effectiveness and faster onset providing dense motor block with minimal drug toxicity to mother and to fetus due to limited placental transfer(1, 2)**,**.

The rapid sequence spinal (RSS), first described in 2003, consists of measures aimed at reducing the time to establish spinal anesthesia in urgent obstetric cases and We all know that category-1 caesarean sections are a challenge and the anesthetic we provide has to be safe, effective and fast. The concept of rapid sequence spinal (RSS) evolved as an alternative to both emergency general anesthesia, which carries risks of several fatal complications and also the conventional spinal anesthesia, which is time consuming. It is actually a conjugation of the two which is based on the principles of performing as fast as possible carrying out only the absolute essential steps thereby cutting the permissible time and on the other hand, limiting the attempts of administering J o u r n a l P r e -p r o o f 4 the block or even abandoning it in favor of other alternative techniques as is done during rapid sequence induction including multiple drug exposure during general anesthesia(3, 4)*,*.

The choice of anesthetic in Cesarean section has long been recognized as one of prime importance, because there are two lives to safeguard instead of one. A balance must be struck between the anesthetic dictated by the general condition of the mother and that suited to the needs of the fetal respiratory system because fetal distress is one of the indications to fasten the delivery process and the diagnosis of fetal distress is based on the fetal heart beats, whether they are fast, slow, irregular and whether there is meconium present during delivery. There have been many reasons to develop and adopt rapid sequence spinal anesthesia for category 1 cesarean section and this can be generally justified by weighing risk and benefits of general and spinal anesthesia. Clinical investigations and reviews done in different countries with time period showed, the death due to g anesthesia related death is high even though spinal anesthesia related deaths decreased (5-7)*,*,*. According to NAP3 (national audit project 3) with met analysis of 141 trials there is 30% reduction of mortality by using CNB compared with general anesthesia 

This study was carried out in accordance with the Preferred reporting Items for Systematic Reviews and Meta-Analyses. A computerized systematic search of the PubMed, Google Scholar, and Science Direct databases were used to find articles. Prospective observational, interventional studies, meta-analysis, systematic review and audit studies were included in the review using the 

Difficult air way and intubation risk is more profound in pregnancy and obesity almost double risk when it is compared with other normal patients as it is supported by the systematic review(10)*. The risk is high in pregnancy because of pregnancy related physiologic and anatomic changes such as large breast, edematous air way and frequent hypoxia, which is due to limited diaphragmatic excursion due to gravid uterus, high oxygen consumption and high risk of aspiration to have standard laryngoscopy by repeated attempts. As this was supported by many evidences previously that here are still risk of difficult intubation, difficult laryngoscopy, failed intubation, regurgitation during intubation trials and aspiration of gastric contents during emergency cesarean section under general anesthesia(11)**. Due to these all factors, difficult and failed intubation after general anesthesia are found to be major contributing factors for the anesthesia related maternal complications (12). As it is shown in multicenter observational study done on 895 women, the incidence of hypoxemia was 19% and it was significantly associated with difficult and failed intubation during general anesthesia for emergency cesarean section (13)**. Poor airway assessment contributed to poor airway outcomes because of omission, incomplete assessment or a failure to alter the airway management technique in response to findings at assessment. Studies from difficult air way society of united kingdom recommended that ,assessment to predict both potential airway difficulty and aspiration risk were equally important and this all were due to in adequate time during category 1 emergency cesarean section cases (14, 15) *.

In addition to this when we see risk of aspiration during general anesthetic where the risk is higher than normal, consideration should be given to minimizing volume and raising pH of gastric contents and protecting the airway through Rapid Sequence Induction (RSI). Morbidity will arise where the risk of aspiration is not taken into account, the 'no-risk' assessment is incorrect or the elements of RSI fail to protect the airway. Cricoid force applied as part of RSI may itself cause problems with intubation and oxygenation, particularly when applied force is The main controversies which have been argued in different centers and literatures was time of anesthesia ,time of surgical readiness and emergence which were found to be significantly shorter during rapid sequence spinal anesthesia than rapid sequence induction of General anesthesia but the incision to delivery time and APGAR score were not significantly different between groups(3, 20)*,*. Conversely the decision to delivery interval was longer during spinal anesthesia but the low APGAR score and other worse perinatal outcomes were more associated with general anesthesia (21-23)**,**,**. There is study showing longer time of decision to delivery interval than the recommended time (30minutes) for category 1-cesarean section and this was more associated with time taken to collect surgical materials), time taken from decision and arrival to the operation theater and time taken from arrival at the operation theater to the immediate start of skin incision (24)**. Neonatal morbidity have been compared for general and spinal anesthesia during emergency cesarean section and the General anesthesia was more associated with low 1-minute APGAR score, longer time of hospitalization, higher incidence of morbidity, and lower umbilical blood pH(25)*.

22 studies from Cochrane review showed that there was significant decrement of blood loss and post-operative pain relief during regional anesthesia than general anesthesia even though other parameters such as recovery times, effects on breastfeeding, effects on the mother-child relationship and length of time before mother feels well enough to care for her baby are not It is known that spinal anesthesia is not without risk eventhough it has been considered for urgent cesarean section and failed block was found to be 6%(28)***. Other potential complications of spinal anesthesia were hypotension, backache, headache, bradycardia, nausea and vomiting and urinary retention eventhough its simplicity and absence of severe complications for more than >50% of patients (29) **.

Nowadays we are suffering with corona virus (covid- 19) pandemic. In addition to limited time to assess the airways of pregnant mothers decided for emergent cesarean section with corona virus confirmed, the is risk of disease transmission to so. As it has been mentioned about higher rates of difficult airway during general anesthesia for cesarean section, the corona virus transmission is very high during any aerosol transmission and the rapid sequence spinal anesthesia is becoming new and novel approach for those patients indicated for cesarean section with category1 indication (30)**. This disease is associated with wide ranges of respiratory compromization which could potentially be affected or aggravated by the drugs during general anesthesia and it is recommended to proceed with rapid sequence spinal anesthesia to prevent the mentioned problems (31)*.

Great controversy is timing to attain rapid sequence spinal anesthesia when compared with rapid sequence general anesthesia because of there are some factors for inability to attain rapid 

Neuraxial anesthetic techniques have several advantages which include low risk of aspiration and failed intubation, avoidance of central nervous system (CNS) and respiratory depressant drugs, the ability to maintain a wakeful state of mother enjoying the experience of delivery of baby and also lower incidence of blood loss. 'Rapid sequence spinal' described to minimize anesthetic time. This consists of a no-touch spinal technique, consideration of omission of the spinal opioid, limiting spinal attempts, allowing the start of surgery before full establishment of the spinal block, and being prepared for conversion to general anesthesia if there are delays or problems.

To do rapid sequence spinal anesthesia safely and timely, cooperative work is mandatory with good team relation for those simultaneous and necessary tasks. The task of IV cannulation most of the time is experienced midwife but anybody from the team members can do so to avoid unnecessary delay. Regarding with dose of local anesthetics, it is recommended that better to use slightly higher doses than usual which is 3ml of 0.5% hyperbaric bupivacaine or 2.5 ml of 0.5% hyperbaric bupivacaine with 25microgram fentanyl if it readily available. Finally it is possible to convert to general anesthesia if spinal block fails without taking additional time for preoxygenation and general anesthetic preparation because the client was on 100% oxygen as it is shown on flow diagram of the tasks and procedures of it and the drugs were already prepared.

Awareness should be created among the team members i.e. obstetric residents, obstetricians, midwifes and assistants in addition to Anesthetists' should be training about its essential steps and overall objectives J o u r n a l P r e -p r o o f 

Be prepared to convert to general anesthesia -keep mother informed.

No touch' technique -gloves only with glove packet as sterile surface for equipment. Prepare skin with alcoholic providone iodine.

Consider increased dose of hyperbaric bupivacaine 0.5% (up to 2.5-3 ml) Add fentanyl 25 micg if procuring it does not produce unacceptable delay Local infiltration not mandatory. One attempt at spinal unless obvious correction allows a second Preoxygenate during procedures all the time

Rapid sequence spinal anaesthesia for category-1 urgency caesarean section: a case series

Regional block versus general anaesthesia for caesarean section and neonatal outcomes: a population-based study

Rapid sequence spinal anesthesia versus general anesthesia: A prospective randomized study of anesthesia to delivery time in category-1 caesarean section

Standard preoxygenation technique versus two rapid techniques in pregnant patients

A series of anesthesia-related maternal deaths in Michigan

Anaesthesia-related maternal mortality in low-income and middle-income countries: a systematic review and meta-analysis. The Lancet Global Health

Caesarean delivery and postpartum maternal mortality: a population-based case control study in Brazil

The United Kingdom National Audit Projects: a narrative review

Implementation of the Four-Category Classification of Cesarean Section Urgency in Clinical Practice. A Prospective Study. Gynecologic and obstetric investigation

Magnitude and predisposing factors of difficult airway during induction of general anaesthesia

Difficult and failed intubation in obstetric anaesthesia: an observational study of airway management and complications associated with general anaesthesia for caesarean section

Challenges of Obstetric Anesthesia: Difficult Laryngeal Visualization

Incidence and risk factors for maternal hypoxaemia during induction of general anaesthesia for non-elective Caesarean section: a prospective multicentre study

Major complications of airway management in the United Kingdom. 4th National Audit Project of The Royal College of Anaesthetists and The Difficult Airway Society

Guidelines for the management of tracheal intubation in critically ill adults

Rapid sequence induction in obstetrics revisited. Current Opinion in Anesthesiology

Aspiration prophylaxis and rapid sequence induction for elective cesarean delivery: time to reassess old dogma?

Rapid sequence induction: a national survey of practice

The rapid sequence spinal for category 1 caesarean section

Rapid Sequence Spinal Anesthesia Vs General Anesthesia for Category-I Urgency Caesarean Section

The decision to delivery interval in emergency caesarean sections: Impact of anaesthetic technique and work shift

Evaluation of timings and outcomes in category-one caesarean sections: A retrospective cohort study. Indian journal of anaesthesia

The effect of type of anesthesia on mother and neonatal health during Cesarean section

Evaluation of decision to delivery time interval and its effect on feto-maternal outcomes and associated factors in category-1 emergency caesarean section deliveries: prospective cohort study

Effect of anaesthetic technique on neonatal morbidity in emergency caesarean section for foetal distress

General versus Spinal Anesthesia During Caesarean Section; A Narrative Review

Randomized clinical trial of multimodal optimization and standard perioperative surgical care

To determine the frequency of failed spinal anaesthesia during cesarean section

Complication of Spinal Anesthesia in Caesarean Section

New indication for an old anesthetic technique: could we consider now rapid sequence spinal anesthesia in a COVID-19 time? Regional Anesthesia & Pain Medicine

Staying Ahead of the Curve: Modified Approach to Emergency Caesarean Section Under General Anaesthesia in COVID-19 Pandemic

Rapid sequence spinal anaesthesia with 11mg and 12.5 mg of hyperbaric bupivacaine for Category 1 caesarean section

Recommending AAGBI antisepsis guidance to other medical professionals

Skin antisepsis guidelines-time to rethink the 'rapid sequence spinal'?

The effect of spinal versus general anesthesia on quality of life in women undergoing cesarean delivery on maternal request

All India Difficult Airway Association 2016 guidelines for the management of unanticipated difficult tracheal intubation in obstetrics

Comparison of the effects of general vs spinal anesthesia on neonatal outcome. Anaesthesia, Pain & Intensive Care

Skin antisepsis guidelines-presentation or concentration?

Best Practice Policy Recommendation for Neuraxial Anesthesia Skin Antiseptic Solutions

International Journal of Surgery Author Disclosure Form The following additional information is required for submission. Please note that failure to respond to these questions/statements will mean your submission will be returned

There is no conflict of interest among the participants of the review article.

Please state whether Ethical Approval was given, by whom and the relevant Judgement's reference numberThe ethical approval was obtained from ethical review committee of University of Gondar with reference uog/102/2019.

Author contribution Please specify the contribution of each author to the paper, e.g. study design, data collections, data analysis, writing. Others, who have contributed in other ways should be listed as contributors. 

The Guarantor is the one or more people who accept full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish. Please note that providing a guarantor is compulsory.