Contrôle des voies

aériennes en obstétrique

Pourquoi est-il

(serait-il) possible de

voir les choses

différemment?

Félicitations les IADEs pour le niveau master….

La Genèse en 1946…..anesthésie àl’éther

Mendelson CL.The aspiration of stomach contents intothe lung during obstetrics anesthesia. AmJ Obstet Gynecol 1946;52:191-205

Décès liés aux particules alimentaires

Mortalité par inhalation a chuté…

pourquoi?

Les réponses politiquement correctes

sont:• Place de l’ ALR

• Intubation séquence rapide

• Respect des règles de jeun

• Tamponnement gastrique

• Meilleure gestion des voies aériennes

Quand fait-on une AG en obstétrique ?

ACTUELLEMENT…….. QUAND ON NE PEUT PAS FAIRE UNE ALR

(sauf avis contraire de la patiente)

• En cours de grossesse (0,3-2,2% des grossesses)

• Au décours de l’accouchement:

-césarienne: environ 1% des césariennes en France sous AG (n=1.400)

-extraction

-DARU

-HPP

pourquoi l’ALR est-elle l’ option

privilégiée?

Hawkins JL, Koonin LM, Palmer SK, Gibbs CP. Anesthesia-related deaths during obstetric delivery in the United States,1979-1990. Anesthesiology. 1997;86(2):277-84.

The anesthesia-related maternal mortality rate decreased from 4.3 per million livebirths in the first triennium (1979-1981) to 1.7 per million in the last (1988-1990).The number of deaths involving general anesthesia have remained stable, but thenumber of regional anesthesia-related deaths have decreased since 1984.

The case-fatality risk ratio for general anesthesia was 2.3 (95% confidenceinterval [CI], 1.9-2.9) times that for regional anesthesia before 1985,increasing to 16.7 (95% CI, 12.9-21.8) times that after 1985.

risque de décès sup avec AG vs ALR…..

D'Angelo R, Smiley RM, Riley ET, Segal S. Serious complications related to

obstetric anesthesia: the serious complication repository project of the society

for obstetric anesthesia and perinatology. Anesthesiology. 2014 ;120(6):1505-1

• Data were captured on more than257,000 anesthetics, including5,000 general anesthetics forcesarean delivery. There were 157total serious complicationsreported, 85 of which wereanesthesia related. High neuraxialblock, respiratory arrest in labor anddelivery, and unrecognized spinalcatheter were the most frequentcomplications encountered. Aserious complication occurs inapproximately 1:3,000 (1:2,443 to1:3,782) obstetric anesthetics.

Quelle corrélation entre le contenugastrique et le risque pulmonaire?

• 25 ml (ou 0,4ml/kg) et pH inf à 2,5…..chez le singe

• 1 et 2 ml/kg selon le pH.…..chez le singe

• 8-41 ml/kg pour obtenir une régurgitation chez le chat anesthésié

• 0,8 ml/kg avec pH acide chez l’homme (estimation)

• Présence de particules solides et /ou volume liquide sup à 0,8 ml/kgchez l’homme…….

Et la généralisation de l’échographie va bientôt passer par là!!!

Physiologie digestive « classique »durant la grossesse

• L’élévation de la progesterone entraine un retard à la vidange gastrique etune augmentation de transit du grêle de 30-50%

• Chute du tonus du sphincter du bas oesophage, augmentation de la pressionintragastrique favorisant le reflux gastrique

• Sécretion gastrine placentaire entrainant modification pH et volume desécretion gastrique

Liu CY, Chen LB, Liu PY, Xie DP, Wang PSEffects of progesterone on gastric emptying and intestinaltransit in male rats. World J Gastroenterol. 2002 ;8(2):338-41.

To study the dose-dependent of progesterone (P)effect and the interaction between the oxytocin(OT) and P on gastrointestinal motility.

• METHODS:

In order to monitor the gastric emptying andintestinal transit, the SD male rats wereintubated via a catheter with normal saline (3ml/kg) containing Na(2)(51)CrO(4) (0.5microCi/ml) and 10% charcoal. OT was dissolvedinto normal saline and P was dissolved into 75%alcohol.

• RESULTS:

Évolution hormonale durant lagrossesse

Et que dit le dogme en obstétrique?

« A partir de 16 SA, une femme enceinte est considérée comme un « estomacplein ». Une induction en séquence rapide avec intubation endotrachéale estdonc recommandée lors d’une AG. De même, la prophylaxie de l’inhalationpulmonaire de liquide gastrique est recommandée, l’association antiacide et ant-H2 étant la plus pertinente »…….

Boutonnet M, Faitot V, Keïta H. Gestion des voies aériennes en obstétrique. Ann Fr AnesthReanim. 2011;30(9):651-64

…… « A l’heure actuelle, les AG en fin de travail donnent lieu à des pratiquesdiscordantes par rapport à ce qu’il est admis être la norme, c’est-à-direl’intubation trachéale systématique »

Que dit l’ASA sur la technique d’ag…….

•RIEN

Et maintenant on va se demander s’il y

a d’autres « vérités » possibles ????!!!!

1.Vacuité gastrique en obstétrique

En dehors du travail

Sandhar BK, Elliott RH, Windram I, Rowbotham DJ.Peripartum changes in gastric emptying.Anaesthesia 1992;47(3):196-8.

Applied potential tomography was used to measure changes in gastric emptyingduring the peripartum period. Gastric emptying was measured sequentially ineach of 10 healthy patients at 37-40 weeks gestation, 2-3 days postpartum andafter the 6-week postnatal assessment (control).

Mean (SD) times to 50% emptying were 15 (6.05), 11 (5.9) and 15 (5.5) min,respectively.

There was no statistically significant change in gastric emptying as a result

of pregnancy in this group of women.

Retrospective power analysis (assuming alpha = 0.05 and beta = 0.20) shows thestudy design was adequate to detect a difference of 8 min.

Chiloiro M, Darconza G, Piccioli E, De Carne M, Clemente C,

Riezzo G. Gastric emptying and orocecal transit time in

pregnancy.

J Gastroenterol. 2001;36(8):538-43

To evaluate the effects of pregnancy on gastrointestinal function, we

determined gastric emptying time, orocecal transit time, and fasting

gastrointestinal hormone levels (cholecystokinin, gastrin, pancreatic

polypeptide, neurotensin) in 11 women with mild dyspeptic symptoms duringthe first and third trimesters of their pregnancies, and again 4-6 months afterdelivery.

• METHODS:

After the women ingested a disaccharide solution, orocecal transit time was

determined by monitoring breath hydrogen concentrations at 10-min intervals,

and values were compared with the postpartum value. Ultrasound examinationsof gastric emptying were performed during the same intervals.

• RESULTS:

The half-emptying time and the final gastric emptying time did not differ inthe first and third trimesters and postpartum, but gastrointestinal transit time

was significantly longer in the third trimester of pregnancy than postpartum

(100.0 min [range, 50.5-240.0 min] vs 70.0 min [range, 40.5-240.0 min; P <

Macfie AG, Magides AD, Richmond MN, Reilly CS.Gastric emptying in pregnancy.Br J Anaesth. 1991;67(1):54-7

• The rate of gastric emptying in pregnancy was measured indirectly using therate of paracetamol absorption in four groups of 15 patients: non-pregnantcontrols, first trimester patients presenting for termination of pregnancy,second trimester patients presenting for prostaglandin termination ofpregnancy, and patients presenting for elective Caesarean section.

• All patients were fasted for 6 h and then received paracetamol tablets 1.5 gorally with water 50 ml. Blood samples were taken at 15-min intervals for 120min and analysed for paracetamol concentration.

• There was no significant difference between the groups in the maximumconcentration and time to maximum concentration (ANOVA). The AUC wasreduced for the first trimester group at 60 and 120 min (P less than 0.05).

• No significant delay in gastric emptying was demonstrated in any of the

three trimesters of pregnancy compared with the control group.

Whitehead EM, Smith M, Dean Y, O'Sullivan G. An evaluation ofgastric emptying times in pregnancy and the puerperium.

Anaesthesia 1993;48(1):53-7.

• In a controlled study, gastric emptying was measured during the threetrimesters of pregnancy and after delivery, using an indirect paracetamolabsorption technique. The peak plasma paracetamol concentration, time toreach the peak, and the area under the plasma paracetamol concentration-time curve, were determined.

• As compared to nonpregnant controls, there were no significant differencesin the gastric emptying times of women in the three trimesters of pregnancyand of mothers from 18 h after delivery onwards. Gastric emptying wassignificantly delayed in mothers within 2 h after delivery (p < 0.01); median(range) values of peak paracetamol concentration, time to reach the peakand the area under the paracetamol concentration-time curve for this groupwere 12.5 (0.2-30.5) mg.l-1, 120 (30-120) min and 3.8 (0.1-16.6) mg.l-1 x hrespectively, and 20.8 (8.6-64.5) mg.l-1, 40 (10-120) min and 13.5 (5.5-28.8)mg.l-1 x h respectively, for the nonpregnant control group (p < 0.01).

• Repeated measurements of gastric emptying in these women on the secondpostpartum day showed no significant delay.

Wong CA, Loffredi M, Ganchiff JN, Zhao J, Wang Z,Avram MJ. Gastric emptying of water in term pregnancy.Anesthesiology. 2002 ;96:1395-400.

Healthy nonpregnant patientsmay ingest clear liquids until 2 hbefore induction of anesthesiawithout adversely affectinggastric volume. The purpose of

this study was to compare

gastric emptying in term,

Vidange gastrique chez l’ obese

• Wong CA, McCarthy RJ, Fitzgerald PC, Raikoff K, Avram MJ. Gastric emptying of water in obese

pregnant women at term. Anesth Analg. 2007;105(3):751-5.

Gastric emptying in obese, nonlaboring term pregnant women is not delayed after

ingestion of 300 mL compared with 50 mL of water. Gastric antral volume after ingestion

of 300 mL of water is similar to the baseline fasting level at 60 min.

Durant le travail…….

1992….contrôle échographique ducontenu gastrique de parturientes entravailCarp H, Jayaram A, Stoll M. Ultrasound examination of the stomach contents ofparturients. Anesth Analg. 1992;74(5):683-7.

two-thirds of the patients in active labor who were scanned had solid food presentin the stomach independent of the interval between last oral intake and theultrasound scan.

MAIS

Fourteen additional pregnant volunteers (mean maternal age 28 +/- 6 yr; meangestational age 35+/- 8 wk) not yet in labor had a single ultrasound examinationperformed at varying times after eating solid food. In all cases, these patients didnot have solid food detected in the stomach, provided that they had not eaten for atleast 4 h before the ultra- sound scan.

Vidange gastrique durant le travail

• Scrutton MJ, Metcalfe GA, Lowy C, Seed PT, O'Sullivan G. Eating in labour. Arandomised controlled trial assessing the risks and benefits. Anaesthesia.1999;54(4):329-34

The aim of this study was to determine whether permitting women inlabour to eat a light diet would: (i) alter their metabolic profile, (ii)influence the outcome of labour, and (iii) increase residual gastric

volume and consequent risk of pulmonary aspiration. Women wererandomised to receive either a light diet (eating group, n = 48) or wateronly (starved group, n = 46) during labour. Relative gastric volumesestimated by ultrasound measurement of gastric antral cross-sectionalarea were larger (p = 0.001) in the eating group.

Donc de nouvelles « vérités »

émergent…..

• La grossesse ne ralentit pas la vidange

gastrique…… sauf durant le travail si

aliments solides

• [L’analgésie perimedullaire n’ a pas d’effet

sur le transit …..sauf si morphinique

associés]

2-INTUBATION SEQUENCE RAPIDE???

En obstétrique l’ISR fait l’objet dedébat: 3 éditoriaux de revues internationales• de Souza DG, Doar LH, Mehta SH,

Tiouririne M. Aspiration prophylaxisand rapid sequence induction forelective cesarean delivery: time toreassess old dogma? Anesth Analg.2010 ;110(5):1503-5

• Paech MJ. "Pregnant women having

caesarean delivery under generalanaesthesia should have a rapid

Que peut-on reprocher à l’ISR?

L’ISR un concept variable…. »chacun faitce qu’il veut »

• Rohsbach C, Wirth S, Lenz K, Priebe H. Survey on the current management ofrapid sequence induction in Germany. Minerva Anestesiol. 2013;79(7):716-26

• Schlesinger S, Blanchfield D. Modified rapid-sequence induction ofanesthesia: a survey of current clinical practice. AANA J. 2001;69(4):291-8

• Guirro UB, Martins CR, Munechika M.Assessment of anesthesiologists' rapidsequence induction technique in an university hospital.Rev Bras Anestesiol.2012;62(3):335-45

• Theiler L, Fischer H, Voelke N, Basciani R, Hasty F, Greif R. Survey oncontroversies in airway management among anesthesiologists in the UK,Austria and Switzerland. Minerva Anestesiol. 2012 Oct;78(10):1088-94.

• Thwaites AJ, Rice CP, Smith I. Rapid sequence induction: a questionnairesurvey of its routine conduct and continued management during a failedintubation. Anaesthesia. 1999;54(4):376-81

La médecine factuelle (EBM) passe par là…

Neilipovitz DT, Crosby ET. No evidence for decreased

incidence of aspiration after rapid sequence induction.

Can J Anaesth. 2007 ;54(9):748-64

A total of 184 clinical trials were identified of which 163 were randomized controlled trials (RCTs).Of these clinical trials, 126 evaluated different drug regimens with 114 being RCTs. Only 21 clinicaltrials evaluated non-pharmacologic aspects of the RSI with 18 RCTs identified. A parallel searchfound 52 trials evaluating cricoid pressure (outside of the context of an RSI technique) with 44classified as RCTs. Definitive outcomes such as prevention of aspiration and mortality benefit couldnot be evaluated from the trials. Likewise, the impact on adverse outcomes of the differentcomponents of RSI could not be ascertained.

CONCLUSION:

An absence of evidence from RCTs suggests that the decision to use RSI during management can

neither be supported nor discouraged on the basis of quality evidence.

Manœuvre de Sellick• Efficacité évaluée sur cadavre

• Pas d’étude contrôlée (impossible en réalité)

• Entraine un relâchement du tonus du bas œsophage

• Des cas d’ échec avec inhalation

• L œsophage n est pas exactement postérieur au cricoide

• Rupture œsophagienne

• Gêner ventilation et intubation

Fenton PM, Reynolds F. Life-saving or ineffective? An observational study of the useof cricoid pressure and maternal outcome in an African setting. Int J ObstetAnesth. 2009 ;18(2):106-10.Data were collected for 4891 general anaesthetics that involved intubation. Cricoid pressure was applied in 61%; 139women vomited or regurgitated, but only 30 on induction of anaesthesia, in 24 of whom cricoid pressure was applied.

Succinylcholine

• Allergie

• Augmente la pression gastrique

De nouvelles alternatives avec le rocuronium/sugammadex

Agents d’inductionPropofol, kétamine, etomidate….TPL

Sonde d’intubation vs DSL

• Yu SH, Beirne OR. Laryngeal mask airways have a lower risk of airwaycomplications compared with endotracheal intubation: a systematic review. JOral Maxillofac Surg. 2010 Oct;68(10):2359-76

When an ETT was used to protect the airway, a statistically significant greaterincidence of hoarse voice (RR 2.59, 95% confidence interval [CI] 1.55 to 4.34), agreater incidence of laryngospasm during emergence (RR 3.16, 95% CI 1.38 to7.21), a greater incidence of coughing (RR 7.12, 95% CI 4.28 to 11.84), and agreater incidence of sore throat (RR 1.67, 95% CI 1.33 to 2.11) was foundcompared with when an LMA was used to protect the airway. The differences inthe risk of regurgitation (RR 0.84, 95% CI 0.27 to 2.59), vomiting (RR 1.56, 95% CI0.74 to 3.26), nausea (RR 1.59, 95% CI 0.91 to 2.78), and the success of insertionon the first attempt (RR 1.08, 95% CI 0.99 to 1.18) were not statisticallysignificant between the 2 groups.

CONCLUSIONS:

For the patients receiving general anesthesia, the use of the LMA resulted in astatistically and clinically significant lower incidence of laryngospasm duringemergence, postoperative hoarse voice, and coughing than when using an ETT.The risk of aspiration could not be determined because only 1 study reported a

En obstétrique 1 intubation/10 est une

intubation difficile

……..et une sur 250 impossible

3-DES EXEMPLES DE CHOIX ALTERNATIFS…. où l’on n’ intube pas!!!!!

Enquête « trois jours en

anesthésie »(SFAR 1996)…….seulement

8% des parturientes justifiant d’une AG

en fin d’accouchement étaient intubées

Première « atypie »: pas de sécurisation en

péripartum

un autre exemple français (2009)

Zieleskiewicz L, Bellefleur JP, AntoniniF, Ortega D, Leone M, Martin C.Gestion des voies aériennessupérieures en fin d’accouchement :enquête de pratique. Ann Fr AnesthRéanim, 2009; 28:119-123

Parmi 111 parturientes ayant eu uneAG en fin d’accouchement, le tauxd’intubation orotrachéale était de 5%. La durée de l’anesthésie variait de5 à 60 minutes (moyenne = 16 min).Aucun incident n’a été recensé dansles limites méthodologiques de cetteétude rétrospective.

Propofol Kétamine Thiopental Succinylcholine

IOT+ (n = 6) 1 1 5 5

IOT− (n = 105) 90 39 0 0

Total (n = 111) 91 40 5 5

Dose (mg)m ± DS

196 ± 88 86 ± 51 318 ± 80 70 ± 11

Spatules(n = 21)

DA/RU(n = 90)

Total (n = 111)

IOT oui(n) (%)

2 (10) 4 (4) 6 (5)

IOT non(n) (%)

19 (90) 86 (96) 105 (95)

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un exemple israélien (2000)

Ezri T, Szmuk P, Stein A, Konichezky S,Hagai T, Geva D. Peripartum generalanasthesia without trachealintubation: incidence of aspirationpneumonia. Anaesthesia.2000;55(5):421-6

1870 patients , 80% received ketamineand a benzodiazepine, and theremaining 20% received methohexitalor thiopental and fentanyl. No cricoidpressure or tracheal intubation wasperformed. A single case of mildaspiration was detected in a womananasthetised with methohexital (anincidence of 0.053%).

DARU…. Que dit l’ASA?

The Task Force notes that, in general, there is no

preferred anesthetic technique for removal of retained

placenta.

However, if an epidural catheter is in place and the patientis hemodynamically stable, epidural anesthesia ispreferable. Hemodynamic status should be assessed beforeadministering neuraxial anesthesia.

Aspiration prophylaxis should be considered.

Sedation/analgesia should be titrated carefully due to the

potential risks of respiratory depression and pulmonary

aspiration during the immediate postpartum period. Incases involving major maternal hemorrhage, GA with anendotracheal tube may be preferable to neuraxial

Deuxième « atypie »: DSL et césarienne

Césarienne et DSL:

Intubation difficile ou impossibleTrès nombreux cas cliniques:

• McClune S, Regan M, Moore J. Laryngeal mask airway for caesarean section.

Anaesthesia. 1990;45(3):227-8.

• Priscu V, Priscu L, Soroker D.Laryngeal mask for failed intubation in

emergency caesarean section. Can J Anaesth. 1992;39(8):893

• Awan R, Nolan JP, Cook TM. Use of a ProSeal laryngeal mask airway for airway

maintenance during emergency Caesarean section after failed tracheal

intubation. Br J Anaesth. 2004;92(1):144-6

• Bullingham A. Use of the ProSeal laryngeal mask airway for airway

maintenance during emergency Caesarean section after failed intubation. Br J

Anaesth. 2004;92(6):903

• Cook TM, Brooks TS, Van der Westhuizen J, Clarke M. The Proseal LMA is a

useful rescue device during failed rapid sequence intubation: two additional

cases. Can J Anaesth. 2005; 52(6):630-3.

L’algorithme français en cas de

difficultésBoutonnet M, Faitot V, Keïta H. Gestion des voies aériennes en obstétrique. Ann Fr Anesth Reanim.2011;30(9):651-64

DSG : dispositif supra glottique

Césarienne programmée Césarienne urgente

Des algorithmes différents…

Balki M, Cooke ME, Dunington S, Salman A, Goldszmidt E. Unanticipated difficult airway in

obstetricpatients: development of a new algorithm for formative assessment in high-fidelity

simulation. Anesthesiology. 2012;117(4):883-97.

DSL et césariennes programmées et urgentes

3 SERIES……REGROUPANT ENVIRON 5000 CESARIENNES

Han TH, Brimacombe J, Lee EJ, Yang HS. The laryngeal mask airway is effective(and probably safe) in selected healthy parturients for elective Cesarean section:a prospective study of 1067 cases. Can J Anaesth. 2001; 48(11):1117-21.

Halaseh BK, Sukkar ZF, Hassan LH, Sia AT, Bushnaq WA, Adarbeh H. The use ofProSeal laryngeal mask airway in caesarean section--experience in 3000 cases.Anaesth Intensive Care. 2010; 38(6):1023-8.

Yao WY, Li SY, Sng BL, Lim Y, Sia AT. The LMA Supreme™ in 700 parturientsundergoing Cesarean delivery: an observational study. Can J Anaesth. 2012;59(7):648-54.

Critères d’exclusion communs

• Moins de 6 heures de jeun pour les césariennes programmées (4 heures pour

les urgences)

• Intubation difficile potentielle

• IMC sup a 35 kg/m²

• Reflux gastro-oesophagien

DSL et césariennes programmées et urgentes

N

Type de DSL

Mode d’induction

et entretienManœuvre de Sellick Tamponnement gastrique

Reflux gastrique/

inhalation

Han (2001) 1067LMA

Classic®

Thiopentone+

succcinylcholineEnflurane ou isoflurane

oui citrate 0/0

Hallaseh (2010) 3000 LMA Proseal®

Propofol+

rocuroniumSevoflurane

oui Ranitidine 1/0

Yao (2012) 700 LMA Supreme®

Propofol+

rocuroniumSevoflurane

oui citrate 0/0

Notre expérience lors de césariennesprogrammées (2011-2013)

Age parité imc DSL INDICATIONS

Induction AG (min) Inhalationrégurgitation

1 34 ans P2 26 Proseal myélopathie post-traumatique, vessie neurogène

KétaminePropofol

45 non

2 33 ans P4 19 Proseal Echec RA puis IOT (cormack 4) PropofolSuccinylcholine

50 non

3 32 ansP2

38 Proseal Echec RA-APD séquentielle

Propofol 45 non

4 26 ansP1

30 LMA classic Panique avant ALR Propofol 40 non

5 31 ansP1

26 Proseal Cavernome occipital(ALR contre-indiquée par neurologue)

KétaminePropofol

51 non

Le débat sera peut être tranché par

l’échographie pré-induction (aire

antrale)

• Apport de l’échographie pour

l’évaluation préopératoire du

contenu gastrique. Bouvet L,

Chassard D. Ann Fr Anesth Reanim.

2014;33(4):240-7.

Valeur critique: 340 mm² Pourquoi comment ???

Une « nouvelle vérité » est sortie du

puits ??

• La vérité sortant du puits

Tableau de JL Gerôme…dreyfusard