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Safety and quality of neuraxial analgesia

Safety and quality of neuraxial analgesia. Ulla Sipiläinen 6.10. 2011 HUCS Jorvi hospital. Chestnut´s Checklist. Preparation for neuraxial labor analgesia 1.Communicate (early) with obst provider review parturient´s obst history 2.Perform focused preanesth eval:

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Safety and quality of neuraxial analgesia

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  1. Safety and quality of neuraxial analgesia Ulla Sipiläinen 6.10. 2011 HUCS Jorvi hospital

  2. Chestnut´s Checklist • Preparation for neuraxial labor analgesia 1.Communicate (early) with obst provider review parturient´s obst history 2.Perform focused preanesth eval: review maternal obst, anest, health history perform targeted physical exam (vital signs, airway, heart, lungs, back) 3.Review relevant lab and imaging studies

  3. 4.consider need for bloodtyping and screeningorcrossmatching • 5.formulate analgesiaplan • 6.obtain informedconsent • 7.perform equipmentcheck • Check routine equipment • Checkemergencyrecuscitationequipment 8.Obtain peripheralintravenousacces 9.Apply maternalmonitors ( Hr, BP, Pulseoximeter 10.Perform a teamtime-out.

  4. Real life checklist • Airway, airway, airway! • Trombosytes, if symptoms of pre-echlampsia • Position: BMI • Allergies

  5. maintain your skills • wet tap rate / dural puncture rate • teaching problematic • formal training programme for epidural analgesia? • simulator?

  6. Position • sitting/ on side • weight>height-100, examp, 170cm, 80kg • consider sitting position

  7. Skin preparation • meningitis • epidural infection • wear mask, sterile gloves, hat • skin preparation • infections are very rare • st viridans

  8. early vs late epidural • cervical dilatation less than 4 cm • with low-dose local anesthetic technique • no difference in cs rates • C. Wong 2005 and 2009

  9. CSE vs epidural analgesia • CSE when it is really needed • multiparous patients in advanced, rapidly progressing labour • even single-shot spinal • risk of cs, obese, very painful

  10. Air vs Saline • saline is recommended • saline with small air bubble • in Finland air is most popular • no differences in the incidence if PDPH between saline or air

  11. Continous vs intermittent • pressure in loss of resistance syringe • no difference • personal preferences

  12. Volume • high-volume • low concentration solutions • better analgesia with 20ml epidural than 13ml or 15ml • if one-sided or in-adequate analgesia, volume addition ad 5 ml before replacement

  13. PCEA, infusion, bolus? • maintaining • volume! • second dose intructions for midwife: 20ml • PCEA best, large bolus are needed to spread widely

  14. Intra-venous epidural • test dose!! • catether migrate into veins very easily and often • saline -injektion, aspiration • important to detect

  15. Obese partiturent • greater risk for cs • epidural space? • lumbar space? • position: sitting • G18/G27 120mm needle • CSE or epidural • favour early analgesia

  16. Taping • flexed position minimizes the distance between skin and epidural space • the catether can move up to 4 cm • leave the catether 5-6 cm into the epidural space

  17. Routines • routines protect from mistakes • variation between phycisians • analgesia similar undependantly from person on call

  18. Incidence and chaceterics of failures in obstetr analgesia • Retrospective analysis of 19 259 deliveries • 12 590 analgesia • Overall failure rate 12% • 6.8 % imcomplete analgesia • 5.6% catether replacement for inadequate analgesia • 98.8% adequate analgesia • Pan P. et al Int J Obst Anest 2004:13; 227-233

  19. Inadequate analgesia • Consider other causes of pain: distended bladder, ruptured uterus • Evaluation: catether in epidural space? -> not-> replacement or consider CSE • Inadequate analgesia, asymmetric block-> inject saline 5ml • CSE has lower failure rate than epidural

  20. Intrathecal catether • important to detect • test dose always via catether • immediate analgesia • total spinal anaesthesia may be disasterous

  21. Accidental dural puncture • earlier: catether placed for 24 hrs • now: new epidural analgesia from another lumbar space and epidural blood patch if needed after 24 -36 hrs • delayd application of EBP may cause problems, be aware!

  22. Neuraxial analgesia and neuraxial injury • common claim • indirect injury: longer second stage of labour • relaxation of pelvic muscles -> delays rotation of head • no pain-> encourage to push without changing body position

  23. Adverse delivery outcomes • weakened desire to push • increases the risk of instrumental delivery • risk of vaginal/ perineal trauma • back pain is common

  24. Recommendations • instructions • also for potential complications • iv line, hydration • hypotension • anesthesia for CS • fasting • dural puncture

  25. Conclusion 1 • ”Unreasonable to expect, that neuroblocade of the half lower body NOT have any affect on labour process..” • Chestnut`s

  26. dose examples • Ropivacaine 2 mg/ml 10ml • Fentanyl 0.05mg/ml 2ml • Saline ad 20ml • 2-dose, given by midwife: • 10ml ropivacaine • fentanyl 0.05mg/ml 1ml (Sic!) • Saline 9ml, total dose 20ml.

  27. dose examples • CSE: • Bupivacain 2.5mg • Fentanyl 25mcg • saline ad 2ml

  28. Conclusion • Instructions for own hospital • Analgesia should be given early enough • Does not increase cs rate

  29. Thank you!

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