Yuji Kamimura1, Toshiyuki Nakanishi1, Kazuya Sobue1, Motoshi Tanaka1. 1. Department of Anesthesiology and Intensive Care Medicine, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Japan.
To the Editor,We herein recommend a systematic evaluation and treatment protocol using point-of-care ultrasound (PoCUS) in the cesarean delivery setting. PoCUS has been developed and effectively used to manage obstetric anesthesia.[1] In emergency cesarean delivery, in particular, PoCUS can be crucial due to the paucity of preoperative assessments; however, to our knowledge, the PoCUS protocol in this particular setting has not been described.We propose the ultrasound-guided “SUCCESS” approach [Figure 1]. Spinal anesthesia is the gold standard for cases without any contraindications or the need for immediate delivery. First, we should use a low-frequency convex transducer and evaluate the spine (S) structure as spinal anesthesia is sometimes difficult in patients undergoing emergency surgery. Second, even if spinal anesthesia seems feasible, we should be prepared for emergency transition to general anesthesia. PoCUS enables the assessment of the risk of needing general anesthesia by evaluating the upper abdomen (U) (gastric contents), cricothyroid membrane, (C) and cardiac function (C). PoCUS can assess the presence of gastric contents,[2] predict airway difficulty, and identify the cricothyroid membrane during the induction of anesthesia.[34] The assessment of known cardiac disease or exclusion of peripartum cardiomyopathy can also be included under “C”. We should use convex, linear, and phased array probes and select the best anesthetic method by these evaluations. If general anesthesia is induced using rapid sequence intubation, we can then perform ultrasound-guided endotracheal intubation (E) and Selick's maneuver (S) to reliably occlude the esophagus.[5] Finally, in cases of massive bleeding, we should secure (S) arterial and peripheral venous access under ultrasound guidance.
Figure 1
The ultrasound-guided SUCCESS approach
The ultrasound-guided SUCCESS approachIn summary, we introduced the ultrasound-guided SUCCESS approach. Ultrasound equipment with multiple probes should be kept beside during an emergency cesarean delivery. By implementing “visualized” anesthesia, we can avoid preventable complications and facilitate smooth and safe anesthesia.
Figure 1