Safety and quality of neuraxial analgesia Ulla Sipilinen

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: review maternal obst, anest, health history perform targeted physical exam (vital signs, airway, heart, lungs, back) 3. Review relevant lab and imaging studies

• 4. consider need for blood typing and screening or crossmatching • 5. formulate analgesia plan • 6. obtain informed consent • 7. perform equipment check • Check routine equipment • Check emergency recuscitation equipment 8. Obtain peripheral intravenous acces 9. Apply maternal monitors ( Hr, BP, Pulseoximeter 10. Perform a team time-out.

Real life checklist • Airway, airway! • Trombosytes, if symptoms of preechlampsia • Position: BMI • Allergies

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

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

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

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

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

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

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

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

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

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

Obese partiturent • • greater risk for cs epidural space? lumbar space? position: sitting G 18/G 27 120 mm needle CSE or epidural favour early analgesia

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

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

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

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 5 ml • CSE has lower failure rate than epidural

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

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!

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

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

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

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

dose examples • • • Ropivacaine 2 mg/ml 10 ml Fentanyl 0. 05 mg/ml 2 ml Saline ad 20 ml • • 2 -dose, given by midwife: 10 ml ropivacaine fentanyl 0. 05 mg/ml 1 ml (Sic!) Saline 9 ml, total dose 20 ml.

dose examples • • CSE: Bupivacain 2. 5 mg Fentanyl 25 mcg saline ad 2 ml

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

Thank you!