Failed Epidural Catheter what now Nathaniel Hsu MD
- Slides: 46
Failed Epidural Catheter: what now? Nathaniel Hsu, MD Assistant Professor Department of Anesthesiology and Critical Care Hospital of the University of Pennsylvania Presented: AAAA Meeting Austin April 2017
Disclosures I have no financial relationships to disclose related to this educational content
Learning Objectives • Describe why epidural catheter fails to provide adequate analgesia/anesthesia • Develop plan for epidural that is not providing appropriate labor analgesia • Develop plan for when an epidural catheter fails to provide adequate anesthesia for cesarean delivery
Why the Increase in Cesarean Section? • National Center for Healthcare Statistics – 32. 0% cesarean section rate for 2015 (decrease from 32. 9% in 2009) • Puerto Rico 48. 0% • Louisiana 38. 3% • Utah 22. 3% • Decrease in VBAC National Center for Health Statistics 2015
Why the Increase in Cesarean Section? • • Advanced Maternal Age Multiple gestation Increasing maternal BMI Increasing use of intrapartum FHR monitoring • Liberal use of induction of labor • Increasing primary c-section rate • Cesarean sections are being perceived by the public as increasingly safe and acceptable
Not An Atypical Case • 24 -year old G 1 P 0 • Lumbar epidural catheter • • placed at 3 cm cervical dilation Required 4 boluses throughout her 10 hour labor Cesarean section for dystocia Unluckily for you…after bolusing with epidural lidocaine, patient has a questionably patchy block. NOW WHAT? ? ?
How would you manage her anesthetic? A. Bolus epidural catheter with lidocaine with epinephrine B. Remove epidural catheter and do spinal anesthesia C. Replace epidural with new epidural D. General anesthesia with RSI E. Perform hypnosis for cesarean section
Can Labor Epidurals Be Used for Cesarean Sections? • 182 parturients undergoing elective cesarean section • 2% lidocaine with epi 1: 200, 000 • Volume: 14 -16 m. L • 170 none or minor discomfort • 12 required supplemental analgesia • Surgeon able to operate on an awake patient Milne MK and Murray Lawson JI. Br J Anaesth. 1978; 45: 1206 -10.
• If an epidural catheter worked for labor, won’t it work for cesarean delivery?
Failed Epidurals are like Meconium • Health records of parturients receiving epidural and required conversion for CD • 895 cases over 3 year period – 775 success • 120 failures (13%) • Risk factor: inadequate labor analgesia Catheter pulled back 1 cm 22% Success after pulling back 85% Epidural replaced 1. 7% SAB 59% No epi med prior to SAB 83% Failed SAB 16% Campbell DC. Can J Anesth. 2009; 56: 19 -26.
Failed Epidurals are like Meconium OB • Management patterns differed between OB and GEN • OB more likely to pull back catheter or perform spinal GEN Catheter pulled back 1 cm 58% 6% GA (overall) 1% 6% GA w/o SAB attempted 0% 75% Multiple intubation attempts 0% 15% Campbell DC. Can J Anesth. 2009; 56: 19 -26.
What to Bolus For an Emergent Cesarean? • Meta-analysis of 11 studies including 779 parturients • Optimal top-up medication • Lidocaine with epinephrine • Ropivacaine 0. 75% • Bupivacaine 0. 5% • Lidocaine resulted in faster onset, 3 -5 min • Adding fentanyl increased speed of onset, but did not affect need for intraop supplementation Hillyard SG. Br J Anaesth 2011; 107: 668
Physiochemical Properties of Local Anesthetics • Speed of onset – p. Ka • Weak bases • p. H = p. Ka + log (unionized/ionized) • Bupivacaine – 8. 1 • Lidocaine – 7. 9
What is the sensory level required for cesarean delivery that will keep 95% of patients comfortable? • • A. T 6 B. T 4 C. T 2 D. C 8
What is the Sensory Level Required for Cesarean Delivery? • Varies from T 8 to T 2 • Sensory innervation from pelvic organs enter T 10 to L 1 • Peritoneum – can be as high as T 2
How to Determine Sensory Level • 15 obstetric anesthesiologists determined height of spinal by: touch, pinprick, and cold • 81% only had block to touch below T 6 • 5% needed intervention, but all comfortable and satisfied • Wide variation to touch • Testing with cold and pinprick Ousley al. Anaesthesia • Isetblock behaving 2012; 67: 1356 -63.
A patient complains of pain during insertion of bladder blade. Etiology? • • A. Level isn’t high enough B. Level isn’t low enough C. Pain is due to peritoneal tugging D. Not possible to block visceral discomfort
Is the Sensory Blockade Low Enough? • Sacral Sparing • Sacral innervation to the uterus, fallopian tubes, and bladder • Large sacral fibers • Size of the caudal space
Epidural Catheters Do NOT Always Work • 260 parturients • 17% failed epidural labor analgesia • Odds Ratios: • • Cervix > 7 cm: 3. 18 Hx failed epidural: 5. 55 Opioid tolerance: 7. 24 Inserted by trainee: 2. 03 Agaram R. Int J Obstet Analg 2009; 18: 10 -14
Did the Epidural Catheter Ever Work? • 456 parturients undergoing vaginal delivery with epidural analgesia • Risk factor for inadequate pain relief: • Inadequate analgesic efficacy of the first dose Le Coq G. Can J Anaesth 1998; 45: 719 -23.
Was It Ever Working? • Prospective study over 6 months • 20/101 required conversion to general anesthesia • Inversely correlated with age • Directly correlated with weight, NUMBER OF TOP-UPS, VAS 2 hours before C-section Orbach-Zinger S. Acta Anaesthesiol Scand 2006; 50: 793
Was It Ever Working? • Retrospective Study • 1025 parturients required cesarean section • Failure Rate – 1. 7% • Predictor • > 2 episodes breakthrough pain Lee S. Anesth Analg 2009; 108: 252 -4
The Number of Boluses • Retrospective review of 4493 parturients receiving epidural analgesia • Epidural: 0. 125%, 0. 0625%, and 0. 04% • Boluses >3 had an odds ratio for cesarean section of 2. 3 as compared to those who received 2 or less Hess PR. Anesth Analg 2000; 90: 881
Pain • Dystocia – abnormal progress of labor • MLAC – minimum local analgesic concentration • 57 nulliparous patients assigned to vaginal delivery or cesarean section • MLAC in CS – 0. 10% • MLAC in VD – 0. 08% Panni MK. Anesthesiology 2003; 98: 957
Risk Factors for Failed Epidural • Meta-analysis and systematic review of 13 trials • Possible risks: • Duration of epidural analgesia • CSE vs epidural • Cervical dilation at placement • BMI • Risk factors of failed epidural • Breakthrough pain/Number of boluses (>2 boluses) • Enhanced urgency for cesarean delivery • Care being provided by non-obstetric anesthesiologist Bauer ME. Int J Obstet Anesth 2012; 21: 294
Did the Epidural Catheter Migrate? • 211 parturients with epidural catheters • Measured length of catheter in space at taping and at removal • 114 catheters (54%) migrated during labor • 80 outward and 34 inward • 26 moved greater than 2 cm Crosby ET. Can J Anaesth 1990; 37: 789 -93
Did the Epidural Catheter Migrate?
Quality of Analgesia and Catheter Migration Good Analgesia Poor Analgesia Total Migrating Catheter Stable Catheter Total 91 82 173 26 12 38 117 94 211
Did My Catheter Become Dislodged? • 153 parturients undergoing epidural analgesia • 1 cm migration resulted in no effect on success • 2. 5 cm migration resulted in 6 failed epidurals • Risk of catheter migration • Weight, BMI, depth of epidural space Bishton IM. Anaesthesia 1992; 47: 610 -2
What is the most common cause of one-sided analgesia? • • A. inadequate local anesthetic B. patient lying on side C. transforaminal escape D. catheter located in anterior epidural space
One Sided Block: Etiology • 236 lumbar epidural patients • 7 developed unilateral loss (repeat epidural) • Epidurography (inject 0. 5 to 4 ml contrast dye) • 4 catheters located in anterior epidural space • 3 catheters located paravertebral Asato F. Anesth Analg 1996; 83: 519 -22
Anterior Epidural Space
One Sided Block: Etiology • 35 parturients with epidural anesthesia or analgesia underwent epidurograms • 10 without complications (control) • 18 unsatisfactory blocks • 7 complicated blocks (subdural, subarachnoid) Collier CB. Int J Obstet Anesth 1996; 5: 19 -31
One Sided Block: Etiology • Transforaminal Escape (5) • Midline Barrier (5) • Dorsomedian connective tissue band • Dorsal midline septum • Epidural fat • Spinal Deformity (2) • Catheter Malfunction (4) • Normal (2) Collier CB. Int J Obstet Anesth 1996; 5: 19 -31
CONSIDER • Repeat the epidural, general anesthesia, spinal anesthesia • Spinal anesthesia following failed epidural anesthesia is a hotly debated subject
Epidural Volume Extension • Spinal anesthesia may be extended by administering fluid into the epidural space • normal saline • local anesthetic • Compression on the intrathecal space Mc. Naught AF. Int J Obstet Anesth 2007; 16: 346
If the epidural injection fails to provide satisfactory anesthesia, I would do: • • A. general anesthesia B. spinal anesthesia C. repeat epidural anesthetic D. combined spinal/epidural anesthetic
Spinal Anesthesia Following Failed Epidural Anesthesia Author Pt Ht (cm) Pt Wt (kg) Epid Inject Spinal Inject Outcome Dell 158 78 45 cc 0. 5% Bup 12. 5 mg Bup Intubated Stone 153 54 33 cc 0. 5% 8 mg Bup bup Goldstein 162 96 ? 167 67 20+cc 30 mg lido High level 0. 25% bup 155 98 33 cc 0. 5% 11. 2 mg bup Metts Intubated 40 mg lido Intubated
Spinal Anesthesia Following Failed Epidural Anesthesia Author Pt Ht (cm) Pt Wt (kg) Epid Inject Spinal Inject Furst 175 78 34 cc 2% lido 12 mg bup intubated 165 71 20+cc 2% 9 mg bup lido 25 cases Beck Outcome High level 1 intubation 150 52. 6 32 cc 10 mg bup intubated 0. 5% bup 150 69. 5 18 cc 12. 5 mg 0. 5% bup intubated
Spinal Anesthesia Following Failed Epidural Anesthesia • Appropriate to adjust dose of spinal anesthetic • • by 20 -30% 28 patients for cesarean section 1. 6 ml 0. 5% hyperbaric bupivacaine spinal Group A – no injection; Group B – 10 cc bupivacaine; Group C – 10 cc saline Group B & C higher but quality the same, both faster than A Blumgart C. Br J Anaesth 1992; 69: 457
Largest Series of Spinal Following Failed Epidural • 636 spinal anesthetics over a 4 year period • 508 no epidural, 128 had epidural before • No difference in incidence of total spinals or high spinal block (1 high spinal in each group) • No difference in amount of ephedrine, hypotension, or Apgars Visser WA. Can J Anesth 2009; 56: 577
What Would I Do? • Cesarean section is starting • Clearly, not working, convert to general anesthesia considering the airway • Mild discomfort • Consider sedation • • • Nitrous oxide Ketamine Fentanyl Midazolam Propofol
What Would I do? • IF there is time prior to starting…and you find a patchy block after 15 m. L bolus of lidocaine, options are: • Pull back catheter 1 cm and bolus another 5 m. L • Remove epidural and perform spinal with lower intrathecal dose • Remove epidural and perform CSE with lower intrathecal dose • Remove and replace epidural • Provide a general anesthetic
What Would I Do? • In the literature, 8 of the high spinals after failed epidural had drug dosages presented: • Seven received amounts greater than 20 cc • There are 118 cases of successful spinal anesthesia following failed epidural • I would not give additional epidural medication if spread is already fairly questionable • I would perform a spinal anesthetic with a 25% decrease in dose and keep the patient sitting up a little longer than usual
Summary For Failed Epidural • Recognize the failed epidural early in the course • Consider spinal anesthesia • Consider the airway and risks of GA(aspiration, awareness, failed intubation) • Consider the risk of PTSD from high spinal/patchy epidural • Most cases result from denial early in labor; it is not a failure to admit failure
Thank you! Questions?
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