It is estimated that approximately 75% of women experience nausea or vomiting during pregnancy. In fact, nausea and vomiting are the most common symptoms experienced in the first trimester of pregnancy. Although it usually is limited to the first trimester of pregnancy, nausea and/or vomiting can unfortunately persist for the entire duration of pregnancy.

Why do you get nauseous during pregnancy?

The actual causes of nausea and vomiting remain unknown, which is why it’s difficult to prevent and treat. However, there are several theories proposed for the cause of nausea and/or vomiting during pregnancy. Some of these include:

·         Hormonal changes (possibly progesterone or hCG levels)

·         Imbalances in blood sugar levels

·         Emotional factors (especially stress)

·         Rapid stretching of the uterine muscles

·         Elevated levels of the bacteria called helicobacter pylori (H. Pylori)

Is it Dangerous?

If your symptoms are severe, you may experience excessive loss of fluids and nutrients that could lead to dehydration. Prolonged dehydration can be very serious and affect the available nutrients to your baby. If this occurs it is very important to tell your doctor. If you suffer from hyperemesis gravidarum (severe form of morning sickness that causes unrelenting, nausea and/or vomiting that prevents adequate intake of food and fluid) you likely are suffering from fluid and electrolyte disturbances and should contact your doctor immediately. You may require hospitalization for intravenous fluids and/or observation.

Signs that you should contact your doctor include losing weight, vomiting many times during the day for many days, vomit with blood or a brownish color, or dark/concentrated urine.

What can I do to help with nausea and/or vomiting:

·         Start taking a multivitamin from the time of conception

·         Take your time getting out of bed, it may help to have a small meal/snack before getting out of bed

·         Eat smaller meals and more frequently (every 2-3 hours), even if your not hungry

·         Drink plenty of liquids l(10-12 glasses of water/day) between meals and not during the meals themselves

·         Avoid greasy, fried, and/or spicy food

·         Avoid foul smelling odors or any odor that triggers nausea

·         Rest. Extreme tiredness and fatigue can lead to nausea and vomiting during pregnancy

·         Ginger or products that contain ginger have proven beneficial in the treatment of nausea and vomiting during pregnancy

Basically, there are many things you can try to help with nausea and vomiting during pregnancy. Of course, most of these are not evidenced-based. However, if it is not harmful and it works… keep doing it! I know most women will try anything to help with severe nausea/vomiting. 

What if nothing helps…Is it safe to take medications?

It’s always safer to try the alternatives to medication, as most people are concerned about giving any medication to a developing fetus. Women want definitive answers on the safety of these medications, but unfortunately the research is lacking when it comes to any long term outcomes.  That being said, there are several medications where there is sufficient evidence to suggest that taking these medications will not cause harm to a developing fetus.  Some of these include:

Non-Prescription

·         Although not officially approved for morning sickness, Emetrol is the only nonprescription nausea medication that’s considered safe during pregnancy.

·         Reflux medications such as Zantac or Pepcid sometimes work for women whose nausea and vomiting is triggered by gastrointestinal distress.

·         Vitamin B6 supplements (10 to 25 mg three to four times per day) have been found to reduce symptoms of mild to moderate nausea, but do not significantly reduce vomiting.

Prescription Drugs

As for prescription drugs, your practitioner may suggest nausea medications when symptoms are severe or nothing else has been helpful.

·         Anti-histamines such as promethazine (Phenergan®) is available in pill, injectable solution, or suppository form. It is usually taken every four hours, and may cause drowsiness and dry mouth. Rare side effects include muscle contractions that cause twisting or jerking movements.

·         Metoclopramide (Reglan®) speeds emptying of the stomach and may help to reduce nausea and vomiting. It is usually taken by mouth or injection every eight hours.

·         Ondansetron (Zofran®) — Ondansetron is an anti-nausea medication, originally designed to control nausea in chemotherapy patients, is usually taken by mouth or injection every eight to 12 hours. Ondansetron is very expensive, although a generic form has recently become available.

When in Doubt…Contact your Heath-Care Provider

If you think morning sickness is keeping you from eating properly or gaining the weight necessary for a healthy pregnancy consult your health-care provider. Untreated, severe vomiting can cause dehydration and can cause serious complications in either you or your unborn baby.

So you just had an epidural or spinal, and are basking in the joy of your new baby, when suddenly you get up to use the restroom and realize you have a terrible headache… Unfortunately you may be one of the unlucky women experiencing a Post-Dural Puncture Headache (PDPH) or “spinal headache”. This month at the “Ask the Doctors” forum we review spinal headaches and specifically their causes and treatments… Don’t forget you can always ask questions about this or other medical topics through the “Ask a Question” link on the website located here.

What is a Post-Dural Puncture Headache (PDPH)?

A spinal headache can occur in anyone who has an epidural or spinal anesthetic. In fact, it can happen any time a hole is made in the “dura” (the tough layer of the tissue surrounding the brain and spinal cord. As we previously discussed on other “Ask the Doctors” topics the difference between an epidural and spinal is based on the location and the type of needle used to enter around the spinal cord space.

A post-dural puncture headache or PDPH, was first described by August Bier in 1898. Over the next 50 years the occurrence of PDPH was quite common, but as we have learned more about the causes of PDPH and with the introduction of much smaller pencil point needles the incidence of PDPH has decreased significantly.

If an epidural is being performed, the area before the spinal space or “epidural space” is entered to deliver medication. A larger needle is typically used for epidurals and if the spinal space in inadvertently entered (“wet-tap”), large amount of spinal fluid (cerebrospinal fluid) may leak out of the space and result in a “spinal headache”. When performing a spinal anesthetic, the “spinal” space is purposefully entered to deliver medication. A very small needle is used to limit the size of the hole and the amount of cerebrospinal fluid that can leak out of this space. Regardless of the technique (epidural or spinal) if cerebrospinal fluid leaks through the puncture site, there is an associated decrease in pressure that normally surrounds the brain and spinal cord. It is this decrease in pressure that is believed to be the cause for developing a “spinal” or “post-dural puncture headache” (PDPH).

What are the symptoms of a Post-Dural Puncture Headache (PDPH)?

Spinal headaches vary in intensity from mild to completely incapacitating, which can be quite frustrating when you’re trying to devote time and energy for your new baby. The headache is typically severe and throbbing and located in the front of the head radiating toward the back. The pain typically gets worse when you sit up or stand and decreases or goes away when you lie down. These headaches are frequently associated with other symptoms including photophobia, dizziness, neck stiffness, ringing in the ears, nausea, vomiting or changes in vision.

How is a Post-Dural Puncture Headache Diagnosed (PDPH)?

Ninety-nine percent of PDPH patients have symptoms within three days of their epidural or spinal, however most have a variable duration. A PDPH is typically diagnosed based on clinical history alone. The defining feature of a PDPH is the postural component of the headache (worsens with sitting or standing up and is relieved with laying flat). It is very important to also consider other possible causes for headache including caffeine withdrawal headaches, migraines, meningitis, sinus headaches, pre-eclampsia, drug use (amphetamine, cocaine), pneumocephalus-related headache, or possible intracranial pathology (hemorrhage, venous thrombosis).

What are the risk factors for a Post-Dural Puncture Headache (PDPH)?

The factors associated with an increase in the occurrence of spinal headaches are very common among pregnant patients. These include: younger age, female gender, pregnancy, using a larger needle size, the number of dural punctures (attempts at the spinal/epidural space in a current pregnancy) and the position in which the needle bevel is inserted.

The issue of whether a previous PDPH is a risk factor for a future PDPH in subsequent pregnancies is controversial. There is no data to support that if you developed a PDPH in a prior pregnancy, you are more likely to develop one in the future.

What is the treatment for a Post-Dural Puncture Headache?

The good news is that most spinal headaches resolve without treatment. However, a PDPH lasting more than 24 hours may require further care. Treatment of a PDPH begins conservatively and moves toward more aggressive measures. Some of these measures include lying in a comfortable position, hydration, and oral pain relievers. However, when symptoms do not improve with conservative measures an epidural blood patch (EBP) is considered the gold standard of treatment.

• Bed Rest – Although bed rest is advocated by many because symptoms generally improve by lying flat, there is no evidence to support using bed rest as a treatment for PDPH. Bed rest may simply be a mechanism to improve the severity of symptoms for those PDPH that resolve on their own.

• Caffeine – Caffeine is a stimulant that causes vessels in the brain to constrict, which has been previously shown in the medical literature to treat headaches. It is available in both oral and intravenous preparations. One of the problems with caffeine therapy is that relief of symptoms is usually not permanent. Another concern for caffeine supplementation during the early post-partum period is that caffeine can appear in breast milk, although usually in very small amounts.

• Sumatriptan – Sumatriptan is a medication currently available for the treatment of migraine headaches. Similar to caffeine, it is used to treat headaches by causing vessels in the brain to constrict. One of the limitations of this medication is its high cost and need to administer it subcutaneously.

• Epidural saline - Many have encouraged injecting saline into the epidural space (the space outside the membrane that covers your spinal cord) to cause pressure on the lumbar puncture site and stop the suspected cerebrospinal fluid leak. But because saline solution is absorbed so quickly by the body, spinal headaches often recur after this treatment. To date, there have been no research studies that show that this treatment actually raises this pressure or causes the suspected hole in dura to close more quickly.

• Epidural blood patch (EBP) - An epidural blood patch is the only treatment that has been shown to equivocally improve symptoms of a PDPH. The medical literature quotes a wide range of improvement after performing an EBP (65%-95%), however many women require a second EBP for complete resolution of symptoms. An EBP is performed by sterilely injecting a small amount of your blood into the epidural space. It is believed that this extra volume of blood will raise the pressure in the space and form a clot over suspected hole causing the leak in the cerebrospinal fluid (CSF). When an EBP is successful many symptoms disappear instantly, while it may take anywhere from 6-24 hours for symptoms to improve. There is always the risk however, of sustaining a second “wet-tap” during this procedure causing a worsening or prolongation of PDPH symptoms.

If you are one of the unfortunate women who are affected by a PDPH, I hope you find this entry useful. If you have any questions relating to this or other topics on “Ask the Doctors” please email them to askthedrs@thebumblecollection.com. Remember you can also submit a question to the website through the "Ask a Question" link.

See you next month!

What is a Spinal Anesthetic?

A spinal is not the same as an epidural (for information on epidurals - see January ‘08 archive). Although somewhat similar, a spinal for labor is done with a needle inserted into the lower back. However, the epidural delivers anesthetic medicines into the space just above the dural membrane (which covers the spinal cord, nerve roots and spinal fluid), where as a “spinal” advances into this space and directs the medicine into the clear fluid (CSF) that surrounds the spinal cord.

Whereas a working epidural can be used for both relief of labor pain and for a c-section; spinal anesthesia is typically used only for c-sections or instrumented delivery. Spinal anesthesia delivers a small amount of concentrated anesthetic directly into the space that contains the spinal cord, which allows it to mix with the cerebrospinal fluid (CSF) and directly bathe the spinal cord. This creates a concentrated anesthetic at the lower levels of the spinal cord, which causes a numbing sensation to the lower half of the body and provides the necessary anesthesia for a c-section.

Unlike an epidural, a “spinal” has a quicker onset and is a stronger, denser anesthetic which can be used for c-sections. There is no attached catheter with a spinal, as there is with an epidural (unless a CSE is used – see below), so once the medication is administered, there is no option for re-dosing. Depending on the type and amount of anesthetic used, a spinal anesthetic will last anywhere from 1½-3 hours, which is usually long enough for most c-sections. Your anesthesiologist will always test your spinal or epidural before a c-section, so there is no need to worry about feeling any of the pain related to a c-section (although it is still common for women to feel “pulling” or “pushing” sensations during their section). You should also be aware that there is always the risk that your spinal will not work effectively, and other anesthetic types such as general anesthesia may be necessary (although rare).

Is it safe?

As you might imagine, it might be very frightening to enter the spinal space with a needle; however anesthesiologists use several techniques to minimize the risks to patients having a spinal anesthetic (notice how in this picture the husbands look more nervous than their wives… which is a common portrayal on the obstetric ward).

1. Level – The spinal cord is surrounded by several structures that not only encase it, but serve to protect it. The actual “spinal cord” ends at what is referred to as the L2 level (see picture – just below the middle of the back); and typically puncture in the area above this L2 level can be associated with a slight risk of damaging the spinal cord. Fortunately, during a spinal anesthetic the L3-L4 inter-space or below this level, is used which significantly reduces the possibility of accidentally injuring one of the spinal nerves or its roots during a spinal anesthetic.
   

2. Smaller needle – You’ll be happy to know that the size of a spinal needle (thickness) is much smaller than the needle for an epidural. It should not really make a difference because your anesthesiologist will inject plenty of local anesthetic into the skin before the introduction of this needle but it will make a difference in terms of your safety. Using a smaller needle there is less chance of injuring an adjacent structure or nerve and a lower possibility of developing a “spinal headache”, which can still occur (more on this next month…).

3. Less Drugs – Many women are concerned about the effects of anesthetics on their baby; a spinal technique delivers medication directly into the area incasing the spinal cord, which is the area that modulates the interpretation of sensation and pain. By delivering medication directly to this area, lower amounts of medications are needed to achieve their desired effects.

4. Speak Up! - You are the best help to your anesthesiologist! If you feel a certain sharp pain, numbness or tingling sensation when the spinal is being placed, you should AVOID SUDDEN MOVEMENT and let them know so they can adjust the position of their needle and prevent any possible injury.

Risks of Spinal Anesthesia

1. Effects on blood pressure and heart rate –Hypotension (low blood pressure) and bradycardia (low heart rate) can both occur with spinal anesthesia. The effect on blood pressure is enhanced in dehydrated patients, and usually requires the administration of intravenous fluids. If you develop nausea or lightheadedness, it may be a sign that your blood pressure is low and requires treatment.

2. Headache – A postdural puncture headache (PDPH) or “spinal headache” can occur. This headache typically worsens when trying to sit upright, and is relieved with lying flat. The headache is typically located in the back of the head and radiated into the neck, and when severe can be accompanied by ringing in the ears, blurred or double vision. This headache typically starts 24-48 hours postoperatively and is thought to occur due to the leakage of fluid (CSF) out of the spinal space which creates a change in pressure - from the hole created by the spinal needle (reason why such a thin needle is used). The risk of PDPH following a spinal anesthetic is approximately 1-5%. The headache is not permanent and typically resolves with either conservative measures (bed rest, IV fluids, or analgesics) and/or caffeine. When severe or if symptoms persist, an epidural blood patch may be performed (More information on spinal headaches and their treatments next month…). Other causes of severe headache should be considered in these situations including meningitis and arachnoiditis.

3. Paresthesias – A paresthesia is a sensation of tingling, pricking, or numbness (pins and needles) in the skin which typically has no apparent long-term physical effect, and is due to direct trauma from placement of the spinal needle or injection of anesthetic into a spinal nerve. Although rare, permanent neurologic impairment can occur, and requires prompt evaluation by a neurologist which can significantly improve outcome.

4. Backache – Mild pain in the area of the back where the needle was inserted can occur. Generalized back pain is also common, however it usually resolves on its own. The etiology of this pain is believed to be secondary to changes that occur with pregnancy and labor as the rates of back pain are equal in women who had epidurals and spinals compared to those who did not.

5. Infection – The risk of infection with spinal anesthesia is exceedingly rare due to improvements in sterile technique. Nevertheless, meningitis, arachnoiditis, and epidural abscess although very rare can still occur – see below.

6. Meningitis – Meningitis is an inflammation of the membranes that cover the brain and spinal cord, which is a serious but treatable complication. The risk of meningitis is the most common of the “rare neurological complications” occurring in an estimated 1 out of 100,000 patients or at a rate of 0.001%.

7. Epidural Abscess - The development of spinal epidural abscess after an epidural is extremely rare and estimated to occur in 1 out of 505,000 patients or at a rate of 0.0001%. This rare complication can be life threatening and can present with signs of back pain, incontinence and neurological symptoms.

What is a Combined Spinal Epidural (CSE)?

A combined spinal–epidural has the benefits of both types of anesthetics. The needle is inserted into the epidural space and then a thinner needle is guided into the spinal space to inject medicine into the spinal canal. Once this is done, the spinal needle is removed but a thin catheter (just like in a regular epidural) is left in place. The spinal part helps provide immediate pain relief; the epidural portion allows drugs to be continuously given and for longer periods of time. A CSE is ideal in repeat c-sections or situations of a prolonged or more complicated labor. Although it is still a bit controversial, it does not appear that a CSE increases the risk of developing a PDPH or “spinal headache”. It is not believed that the risks involved in a CSE are any greater than those associated with the placement of an epidural.

For those of you who want to see the steps involved in a spinal anesthetic here is a video that accurately portrays this process. Click here to view: http://www.operationalmedicine.org/ed2/Video/Spinal.mpg (courtesy of Operational Obstetrics & Gynecology).

I hope this helped clarify some of the differences between a spinal and an epidural for labor. If you have any questions or comments please email them to askthedrs@thebumblecollection.com. Remember you can also submit a question to the website through the "Ask a Question" link.

Next month, we will review post-dural puncture headaches (PDPH) a.k.a. "spinal headaches" and their treatments.

What is an epidural?

An epidural is a procedure that numbs pain fibers and prevents transmission of pain signals to the brain. The name ‘epidural’ comes from its place of delivery into the body, “the epidural space” which lies in front of the spine (see picture). It is not required in any way for the process of having a child, and many women elect to forego an epidural, as there are other methods and alternatives for enduring labor.  I believe that it’s helpful to just know that it’s available as the thought of a backup for pain control reduces the anxiety and fear of childbirth. 
It is important to remember that an epidural can take up to about half an hour to be administered and start having an effect. An epidural can be given at any stage during labor, but may be limited by a woman’s ability to sit or lie still for the procedure. Although many people debate that an epidural medicalizes the birthing process, it is presumed safe for mother and baby. There is no evidence that the use of epidurals affects the oxygen delivery or the neurobehavioral activity or development of the baby.
There are few reasons that a women would not qualify for the placement of an epidural during labor. These include patient refusal, active bleeding, infection in the blood, infection at or near the site of needle insertion, and problems related to blood clotting or taking blood thinners (anticoagulants). A thorough examination by an anesthesiologist should be required before any epidural is considered or placed. 

What are the advantages/benefits of an epidural for labor?

1. Pain relief (partial to complete) - A good epidural will relieve the pain associated with labor without removing the sensation of pressure that a woman requires to labor. Most anesthesiologists will start with a standard dose of anesthetic and specifically tailor it to each patient. The more anesthetic that is delivered, the denser the epidural becomes to the extent that a temporary numbness an inability to move the legs can occur, which can actually delay childbirth.  Therefore, I encourage all women to have realistic goals about an epidural… “pressure not pain” and keep a close communication with their anesthesiologist about the levels of their comfort.
2. Increased wakefulness and alertness – The effects on epidural are typically localized rather than systemic, so while a patient is provided with pain relief during their labor they will be awake and alert. In addition, as their pain in well controlled, a women can rest if they want (or even sleep!) as their cervix dilates. As a result, they will have more energy when it comes time to push.
3. Effects are localized – Unlike receiving systemic narcotics, which a patient would get through an IV or pill form, the effects of an epidural remain targeted to the area in need, without significantly affecting other areas of their body. This allows less medication to be administered which is safe for the baby and the mother.
4. Can be used for caesarean section – In the event that a c-section is needed after a failed trial of labor, a working epidural can be dosed in higher concentrations to provide anesthesia. This would prevent the need for general anesthesia, and allow a woman to be awake for their c-section. (An epidural is different from a “spinal” and will be discussed in a future topic in upcoming months.) The epidural can also be used as the anesthetic for other procedures after labor (i.e. tubal ligation).
5. May relieve anxiety and facilitate a prolonged labor - Anxiety related to the birthing experience and pain can cause an excess production of stress hormones in a mother, which can ultimately slow contractions. In this case, an epidural could help facilitate labor by alleviating pain and anxiety by allowing a patient to rest, as their labor progresses.

Debunking Epidural Myths

There are many myths surrounding epidurals; although I am not entirely sure where they come from, many have been disproved in recent clinical research. I feel it is important to discuss these myths as many women believe them and are persuaded to forego their epidurals because of them…

One of these statements are that “epidurals cause a prolongation of Labor” (56 minutes to be exact) and the “increased use of pitocin”  (a medication used to enhance and promote uterine contractions).”  These statements come from several research studies were different groups of women were compared. However, it is impossible to establish a direct link as the women who were compared in the epidural group were more likely to be having their first child, come to the hospital earlier, have a higher fetal station (location within the birth canal), deliver larger babies, and have smaller pelvic outlets; all factors that independently cause longer labors.

There is also the concern of timing for an epidural. It was previously thought that an epidural placed too early in labor could increase the risk of caesarean section. This has been disproven, and a woman can reasonably receive an epidural at any point during labor, provided there is enough time and she is willing to lie still for the procedure.  Another concern is regarding chronic back pain following the placement of an epidural. Epidural anesthesia does not appear to be associated with chronic back pain, and any discomfort of the back is believed to be due to the stress of labor.

Finally, there was a concern at one point that the use of epidurals was associated with babies having difficulty "latching on" leading to breastfeeding difficulties. This has been disproven, and there is currently no evidence that the use of epidurals causes a problem with breastfeeding of the neonate.

What are the disadvantages/risks of an epidural for labor?

1. Higher incidence of “assisted deliveries” – Although the use of epidurals does not increase the rate of c-section, it does increase the possibility for an “assisted delivery” requiring the use of forceps or vacuum extraction to help deliver the baby.
2. Effects on blood pressure - The medications used in epidurals may cause a decrease in blood pressure. For this reason your blood pressure is routinely checked and may require treatment with IV fluids, medications, and oxygen. If you develop nausea or lightheadedness with your epidural, it may be a sign that your blood pressure requires evaluation and you should contact your nurse or physician immediately. 
3. Headache – A postdural puncture headache (PDPH) or “spinal headache” can occur if the epidural needle is inadvertently inserted through the epidural space into dural area.  The risk of accidental dural puncture occurs 1.5% of the time, but only half of these (0.75%) result in headache.  A PDPH can occur as early as one day and as late as seven days after dural puncture and lasts anywhere from12hrs to seven days.  If symptoms persist, a special procedure called a “blood patch”, an injection of your blood into the epidural space, can be done to relieve the headache. (The topic of PDPH will be covered in a future month at “Ask the doctors”.)
4. Fever – The use of epidurals is associated with an elevation in temperature in approximately 15% of women with epidurals. This increase in temperature is not believed to be from infectious causes and consensus among most obstetricians is that no treatment be initiated. 
5. May not work effectively – Occasionally an epidural does not work effectively and a woman may still feel pain, or pain on one side. In this event, different medications can be administered, but may ultimately require replacement of the catheter.
6. Meningitis – Meningitis is an inflammation of the membranes that cover the brain and spinal cord, which is a serious but treatable complication. The risk of meningitis is the most common of the “rare neurological complications” occurring in an estimated 1 out of 100,000 patients or at a rate of 0.001%.
7.  Epidural Hematoma – Another rare complication is the accumulation of blood in the epidural space that can cause neurological symptoms. This is a surgical emergency and is typically linked to the concurrent use of blood thinners (anti-coagulants); One of the reasons that women on blood thinners (anticoagulants) are typically not candidates for epidurals.
8. Epidural Abscess - The development of spinal epidural abscess after an epidural is extremely rare and estimated to occur in 1 out of 505,000 patients or at a rate of 0.0001%. This rare complication can be life threatening and can present with signs of back pain, incontinence and neurological symptoms. 

I hope you enjoyed this month’s topic at Ask the doctors, and if you have any questions or comments please forward them to askthedrs@thebumblecollection.com . Remember you can also submit any questions to the website through the “ask a question” link located here. See you next month!

With the recent release of the movie “Awake” - a movie that portrays a patient who is anesthetized without proper levels of anesthesia resulting in a paralyzed yet awake patient there has been a recent media frenzy surrounding this topic. I have received numerous questions about the possibility and frequency of this rare and unfortunate event, and having seen many of these sensationalized portrayals, I feel it is extremely important for people to understand the truths about awareness under general anesthesia. So this month, I invite one of my esteemed colleagues in the field of anesthesia at the Massachusetts General Hospital – Dr. Shahzad Shaefi, M.D., to discuss the topic in detail…

Dr. Shaefi is a clinical fellow in Anesthesiology at the Massachusetts General Hospital and the recipient of many honorable distinctions including the National Royal Society of Medicine Anaesthesia Prize, the National MSSVD research prize and the GlaxoSmithKline 14th International AIDS Conference Scholarship. We are very honored that Dr. Shaefi has taken the opportunity to share his thoughts on the topic of awareness under general anesthesia with visitors to the Bumble Collection’s website and thank him for his efforts.
I hope you enjoy this month’s topic as I feel it is current and an especially relevant concern for women who undergo caesarean sections, which carries an increased risk of awareness (0.4% of cases), where light anesthesia is purposefully used to minimize the risk to newborns and their mothers.

For more information on the topic of awareness please visit the American Society of Anesthesiologists at http://www.asahq.org/
Keep your questions coming… and again Happy Holidays and a Wonderful New Year to everyone!
Sincerely,
Dr. Sal Maya

Hello, my name is Dr. Shaefi and I am pleased that Dr. Maya has asked me to discuss a very important topic that is on the mind of many patients before general anesthesia – awareness under general anesthesia. The issue of awareness has received significant attention in recent months and I feel it is important that patients understand the issues from a healthcare professional. If you have been affected by intra-operative awareness under general anesthesia, I urge you to contact your healthcare professional for additional treatment and resources.
Awareness under anesthesia is a rare complication of general anesthesia that occurs when surgical patients can recall their surroundings or an event— sometimes even pain—related to their surgery. This should not be mistaken with other forms of anesthesia such as local, sedation (MAC – monitored anesthesia care) or regional anesthesia, where it is expected that patients have some recollection of their procedure.

Awareness is quite rare. Studies are not conclusive on the frequency of awareness under general anesthesia, but it is estimated to occur in anywhere from 0.05% - 0.13%, or in 1 out of 2,000 cases. This risk is increased for cardiac surgery (1-1.5% awareness), trauma surgery (11-43% awareness) and Caesarean section under general anesthesia (0.4% awareness). When it does occur, it is often fleeting and not traumatic to the patient. Awareness can range from brief, hazy recollections to some specific awareness of your surroundings during surgery. When awareness during general anesthesia does occur, it is usually just prior to the anesthetic completely taking effect or as the patient is emerging (or “awaking”) from anesthesia. In very few instances, it may occur during the surgery itself.

In order to help prevent awareness, patients should meet with their anesthesia professional to discuss anesthesia options. Should there be concerns regarding awareness, this is an ideal time to express them and to ask questions. Patients should share with their anesthesia professional any problems they may have experienced with previous anesthetics, and also discuss any prescription medications or over-the-counter medications they are taking.

While the safety of anesthesia has increased markedly over the last 20 years, people may react differently to the same level or type of anesthesia. Sometimes different medications can mask important signs that anesthesia professionals monitor to help determine the depth of anesthesia. In other rare instances, technical failure or human error may contribute to unexpected episodes
of awareness.

In some high-risk surgeries or in situations involving patients whose condition is unstable, using a deep anesthetic may not be in the best interest of the patient as it can lower the blood pressure and cause hemodynamic instability in a patient who is already unstable. In emergency caesarean sections, where general anesthesia is used due to the urgency of the situation, the focus is directed on the newborn. In these cases, lower levels of anesthesia are used to protect the baby and mother in these emergency situations, and unfortunately, awareness may not be completely avoidable.

Many physicians and researchers have been studying the issue of awareness under general anesthesia and are in the process of evaluating the effectiveness of various technologies and techniques to decrease the likelihood of this unfortunate event. At the present time, none of these new technologies has been perfected.

If you have experienced awareness under general anesthesia I urge you to talk with your
anesthesia professional, who can explain to you the events that took place in the operating
room at any stage of your surgery and why you might have been aware at certain times. Research has shown that early counseling after an episode of awareness can help to lessen feelings of confusion, stress or trauma associated with the experience. If you have distinct recollections of your surgery and want to discuss them, your anesthesia professional can help you or refer you to a counselor or to other appropriate resources for treatment.

Infant CPR

Infant CPR is a lifesaving procedure for anyone under the age of 12 months. It is performed when an infant’s breathing or heartbeat has stopped, as in cases of drowning, suffocation, choking, head trauma, electrical shock or poisoning.
Infants, just as children, have a much better chance of survival if CPR is performed immediately. This is because permanent brain damage can occur within minutes after the infant’s blood flow or breathing stops. Therefore, it is of the utmost importance to start infant CPR immediately and attempt resuscitation before leaving to call 9-1-1 (If someone else is with you, have them call 911, but do not leave the child to call for help!); It is most important to continue these procedures until the infant’s heartbeat and breathing return. So let’s focus on the basics of infant CPR or as I like to call them… the A.B.C.’s = AIRWAY, BREATHING and CIRCULATION.
Prior to doing you’re A.BC.’s you need to assess the situation.

Assess the baby

Is the baby conscious? In the medical-anesthesia community we have a saying “a crying baby is a happy baby” because it means that the baby’s airway is open and they can breathe. This is an obvious situation, but to assess a baby gently tap them and call out. If they don’t respond, and they are not breathing have someone call 911. Again, do not leave your baby to call 911… timing is very important at this stage! If you determine that the baby is not breathing, gently place them on their back on a firm surface.
Now it’s time to do the ABC’s!

STEPS OF INFANT CPR

• Step 1: A = AIRWAY. Open the baby’s mouth or AIRWAY.
  Tilt the baby’s head back with one hand and lift their chin up. Positioning the head in this manner will open up the infant’s airway if an obstruction is the cause of the lack of breathing. Briefly check for any movement or breathing.  People typically refer to this step as “look, listen and feel”. To check for breathing put your head next to the baby’s mouth. Look toward the chest for any evidence of a chest rise or breath sounds, you may feel their breaths against your cheek. See the illustration below for details. 
• 
• Step 2:  B = BREATHING.  Give the infant two gentle breaths.
  If your baby isn’t breathing, give two little breaths, each lasting just one second. Cover your baby’s nose and mouth with your mouth and exhale into the lungs only until you see the chest rise (See picture below). Many people are afraid to hurt an infant with their strong breaths… to determine how strong of a breath to give, slowly give a breath until you see the infant’s chest rise, which is just the right amount of air necessary. It is very easy to let your adrenaline take cover and deliver massive breaths which will only fill an infant’s stomach with air or damage their lungs.
  If the chest doesn’t rise, the airway may be blocked. At this point consider changing the position of the head or assess the infant for choking.
• 
• Step 3: C= CIRCULATION. Give the infant 30 chest compressions.
  With the infant in the same position, place the pads of two fingers just below an imaginary line connecting an infant’s nipples.

  With the pads of these fingers just below the nipple line, compress the chest 1/2 to 1 inch. Make sure to make this a smooth rhythmic process. Keep your other hand on the infant’s forehead, keeping the head tilted back. It is very important to give these 30 chest compressions at a rate of 100 per minute. This means giving compressions at a rate just below 2 per second.
  Give her 30 chest compressions at the rate of 100 per minute. When you complete 30 compressions, give two more rescue breaths (step 2, above).
  Now just repeat the cycles…

  Repeat the above steps of 30 compressions and two breaths. Continue the cycles for a minimum of 2 minutes. After 2 minutes, if you’re alone and no help has arrived call 911.  Periodically re-check for breathing until help arrives… If the infant starts breathing do not continue chest compressions.

• 

Again, about calling for help…

If you have help, tell one person to call 911 while another person administers CPR.
If you are alone, shout loudly for help and begin CPR. After doing CPR for about 2 minutes, if no help has arrived, call 911. You may carry the infant with you to the nearest phone (unless you suspect a spinal injury – in which case you should not move the infant.).  

Here are some keys in preventing these types of situations…

Never underestimate what an infant can do. Most infants will surprise you with what they are capable of. PLAY IT SAFE! Never leave an infant unattended. Always use safety straps on high chairs and strollers.
Choose age-appropriate toys. Do not give infants toys that contain small pieces. Inspect toys for small or loose parts, sharp edges, points, loose batteries, and other hazards.
Create a safe environment and constantly supervise your child. Be especially careful around electrical outlets, stove tops, and medicine cabinets.  
To reduce the risk of choking, make sure small objects are out of reach from children. Do not leave coins, nuts, buttons, or grapes near children as their first reaction will be to place these objects in their mouth. Do not allow an infant to crawl or walk while eating or drinking.
Never tie pacifiers, jewelry, chains, bracelets, or anything else around an infant’s neck or wrists.

And Finally…

CPR is best performed by those who have been trained in an accredited CPR course; the procedures described above are not a substitute for CPR training. I encourage all parents to become certified in CPR and ask that you visit http://www.americanheart.org/presenter.jhtml?identifier=3011764  for a class near you.

I look forward to receiving all your questions for next month’s “Ask the Doctors”!
Sincerely,
Dr. Sal Maya

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