Remifentanil PCA Midwifes Needtoknow Introduction Very short acting

Remifentanil PCA Midwife’s Need-to-know

Introduction • Very short acting opioid • Alternative to epidural if it’s contraindicated or unable to be sited • Better satisfaction and less neonatal depression than diamorphine or fentanyl • Must be started and prescribed by anaesthetist

Contraindications and Precautions • Allergy to opioid drugs • <37 weeks gestation (unless documented intrauterine death) • Other opioids (eg diamorphine) within last 4 hours • Unable to provide one to one midwife care • Caution if BMI>40, patient critically unwell has low body weight or obstructive sleep apnoea

Patient Preparation • She should have read the Remifentanil information leaflet • Oxygen SPO 2 monitoring, continuous CTG • Nasal O 2 2 L/min • Side effects to warn of – Itch, nausea, dizziness, sedation, respiratory depression • One to one midwife care

Practicalities • Remifentanil needs a separate cannula • Anaesthetist will prepare infusion and set up PCA pump • Timing of pushing the button is key – encourage usage as soon as the contraction starts to achieve peak effect at peak of contraction • A specific prescription/observation chart will be provided with advice and guidance • Entonox may be used at the same time

How many mothers will experience side effects? • Desaturation 12 -17. 7% • Sedation 11 -50% • Termination due to persistent desaturation despite oxygen therapy 0. 66 -0. 8% • Nausea + Vomiting 11 -60% • Pruritus 10 -50% • Crossover rate ~ 10%

Monitoring • EVERY 30 MINUTES the following observations should be measured and recorded on the Remifentanil PCA Chart: – Respiratory rate – Pulse – Blood pressure – Sedation Score – Pain score – Nausea & Vomiting Score

Troubleshooting PROBLEM Oxygen saturations below 95% ACTION TO TAKE Hypotension Systolic blood pressure less than 100 mm. Hg OR Pulse less than 50 Increase nasal Oxygen to 4 l/min Stop PCA Shake & verbally stimulate Oxygen 15 l/min via facemask Contact Obstetric Anaesthetist Ensure Naloxone 0. 4 mg available, give 0. 10. 2 mg if respiratory rate less than 4 APNOEA- BLS and dial 2222 Stop PCA Shake & verbally stimulate Increase intravenous fluid rate Oxygen 15 l/min via facemask Contact Obstetric Anaesthetist PULSELESS- BLS and dial 2222 Other problems Inadequate analgesia Nausea & vomiting score 2 or 3 Contact Obstetric Anaesthetist who may Check PCA technique Prescribe an antiemetic Contacting the Obstetric Anaesthetist Bleep 7402 Severe Respiratory Depression Oxygen saturation below 93% OR Respiratory rate less than 8 OR Sedation Score 3

Further Practicalities • For replacement syringe please call anaesthetist • When discontinued, remove cannula WITHOUT flushing • Discard and sign for wasted drug when discontinued

Summary • • A safe and effective alternative when epidural not possible Quick and simple to initiate One to one monitoring is vital as per the guideline Please sign that you’ve seen the presentation! • Lucy. Mc. Manamon@boltonft. nhs. uk • Inese. Kutovaja@boltonft. nhs. uk • Peter. Sandbach@boltonft. nhs. uk