Ultrasound in Obstetric Anaesthesia- Neuraxial Blockade

1. Ultrasound in Obstetric Anaesthesia-Neuraxial Blockade Dr John Loughrey The Rotunda Hospital Dublin

2. Dober dan • To bo dobro predavanje !

4. Labour Epidural Rates • The Rotunda Hospital 67% • USA 66% • Ireland 33% • Europe 25%

5. American College of Obstetrics & Gynecology ‘labour results in severe pain for manywomen. There is no other circumstance where it is consideredacceptable for a person to experience untreated severe pain,amenable to safe intervention, while under a physician's care.’

6. Methods of Maintaining Epidural Analgesia • Intermittent ‘Top-Ups’ • Continuous infusions (8-12 mls/hr) • Patient Controlled (PCEA) • ± Background infusion

7. Epidural Patient-Controlled Analgesia

8. PCEA use: ~40% USA Bucklin BA. Anesthesiology 2005;103:645-53

9. PCEA vs Continuous Epidural infusion van der Vyver. BJA. 2002 • 9 Studies of 640 patients • Continuous vs PCEA with no basal rate • PCEA groups • Less local anaesthetic • Less leg weakness • Fewer anaesthetic interventions

10. Benefits of Minimising Local Anaesthetic Usage • Patient Satisfaction • Ability to Void increased • Less Hypotension • Obstetric Outcome improved • Ambulation

12. Ultrasound in Obstetric Anaesthesia • Central Vascular Access • Abdominal field blocks eg: TAP • Pre-Anaesthesia clinic eg: scoliosis • Neuraxial Imaging • Pain Procedures eg: Sacroiliac/ Symphysis Injection • Arch Physical Med & Rehab. Sept 2007.88(9) E45-6. • SOAP. 2009. A-206. Shannon J, Harmon D.

13. Technique

14. Equipment Cost

15. “In the kingdom of the blind, the one-eyed man is King.” D. Erasmus 1466-1536. “An idiot with an ultrasound probe is still an idiot.”

17. “ Evidence on Ultrasound-guided catheterisation of the epidural space is limited in amount, but suggests that it is safe and may be helpful in achieving correct placement.”

18. Ultrasound in Neuraxial Anaesthesia • Identifying Correct Lumbar Interspace • Identifying Skin Puncture site • Measuring depth to Epidural Space • Identifying aberrant Anatomy

19. Lumbar Interspace Selection Reynolds F (2001). Damage to the conus medullaris following spinal anaesthesia. Anaesthesia 2001; 56: 238-247. Schlotterbeck H, Schaeffer R, Dow WA, et al (2008). Ultrasonographic control of the puncture level for lumbar neuraxial block in obstetric anaesthesia. British Journal of Anaesthesia 2008; 100: 230-4.

22. Technique

25. Technique

37. Technique

39. Efficacy of ultrasound imaging in obstetric epidural anesthesia . J Clin Anesth. 2002Thomas Grau, Rudiger Wolfgang Leipold , Renate Conradi, Eike Martin , Johann Motsch. Ultrasound Using the Transverse Approach to the Lumbar Spine Provides Reliable Landmarks for Labor Epidurals. Anesthesia & Analgesia. May.2007. Cristian Arzola, Sharon Davies, Ayman Rofaeel, Jose Carvalho.

40. Arzola et al. A&A. May 2007.

41. May2008

42. Gaining Experience • Appropriate specification equipment • Use in non-neuraxial anaesthesia • Outpatient evaluations • Pre-puncture imaging

43. “ Gentlemen…this is no humbug!”

44. Hvala lepa !