Labour Regional Analgesia for the 21st Century

Transcription

1 Labour Regional Analgesia for the 21st Century What Really Matters? A Darwinian Adventure Obstetric Anaesthesia 2012 Lawrence C. Tsen, MD Vice Chair, Department of Anesthesiology, Perioperative & Pain Medicine Associate Director, Center for Professionalism & Peer Support Brigham & Women s Hospital Associate Professor in Anaesthesia Harvard Medical School

2 Labor Analgesia No Disclosures...from so simple a beginning, endless forms most beautiful and most wonderful have been and are being evolved. Origin of the Species Darwin

3 A Darwinian Adventure 1809 Shrewsbury 1825 Edinburgh Limb amputation Cambridge 1831 HMS Beagle

4 A Darwinian Adventure

5 A Darwinian Adventure techniques agents equipment

6 techniques

7 Variability is not actually caused by man...but man can and does select the variations given to him by nature. Darwin

8 Neuraxial Techniques Epidural Spinal CSE DPE

9 CSE Equipment cm 17G Weiss 8.5 cm 25G Whitacre 12 cm difference (+hubs) 1.5 cm 17G Weiss 15 cm 25G Whitacre 18.5 cm difference (+hubs) 1.5 cm

10 CSE Advantage? Epidural CSE Confirmation Absent Present Onset 5-15 min 3-5 min Quality Patchy, Fail <4-13% Fail <4% Motor Deficit Moderate Limited Fetal Effects Minimal Minimal Failed Blocks Eappen n=4240 Norris n=1660 van de Velde Thomas n=248 Epidural CSE Needle 13.1% 7.2% 25G 1.3% 0.2% 25G 3.18% 1.49% 27, 29G 9.3% 8% 27G Thomas, Anesthesiology 2005 Norris, IJOA 2000;9:3-6 Eappen, IJOA 1998;7:220-5 Nageotte NEJM 1997;337: Thomas, Anesthesiology 2005 van de Velde, Anaesth Intensive Care 2001 Norris, IJOA 2000 Eappen, IJOA 1998

11 CSE + PCEA 3.0 Interventions Average VAS O Rourke, SOAP 2004 n = 525, p < Epid/CEI CSE/CEI Epid/PCEA CSE/PCEA

12 CSE: Labor Progress CSE vs Epidural; Bolus Lower instrumental delivery; technique Matters? CSE vs Epidural; CEI 100 Nulliparous < 3 cm CSE: Shorter labor; Delivery 30 min faster CSE vs Parenteral Opioids; CEI 750 Nulliparous < 4 cm CSE: Shorter labor; Delivery 80 min faster Collis, Lancet 1995; Tsen, Anesthesiology 1999; Wong, NEJM 2005

13 CSE Complications Cochrane Review: CSE v Epidural in Labor 19 Trials, 2658 Women CSE Simmons SW, et al. Cochrane 2007 No increase in Maternal Hypotension No increase in Post Dural Puncture Headache Less Urinary Retention

14 CSE: Fetal Outcomes Meta-analysis: 24 Trials (3513 women) Intrathecal Opioids IT opioid Control RR NNH FHR abnl 7.7% 6.7% FHR brady 7.3% 4.8% CS FHR 6.0% 7.8% CS Any 17% 16.6% Apgar < 7 1% 0.9% Increase FHR bradycardia; No change in CS, Fetal Outcome No FHR issues if doses fent (<50 µg) & sufenta (<7.5 µg) Mardirosoff BJOG 2002, Van de Velde RAPM 2001, Fun Minerva Anestesiol 2008

15 CSE:affect analgesia? Does the CSE technique reduce subsequent epidural bupivacaine requirements? MLAC (EC50) Mixed parity, dilation at cse, dilation at 2nd dose, duration of labor epidural 0.1% B + 2 mcg/ml F (n = 36) CSE 2.5 B + 5 mcg F (n = 38) up/down Probit Patel et al. Anaesthesia 2012;67:584-93

16 Neuraxial Techniques Epidural Spinal CSE DPE

17 Dural Puncture Epidural Spinal Epidural Subcutaneous Dura Ligamentum Flavum Skin

18 Dural Puncture Epidural Spinal Epidural Subcutaneous Dura Ligamentum Flavum Skin

19 Dural Puncture Epidural Thomas, Anesthesiology G Suzuki, A&A G Cappiello, Tsen, A&A G DPE group (2% Mepivacaine 18 ml) Faster Sacral Onset Greater Sacral Spread No difference in hypotension or highest Sensory Block (T4) No PDPH

20 Dural Puncture Epidural Thomas, Anesthesiology G Suzuki, A&A G Cappiello, Tsen, A&A G DPE group (2% Lidocaine 10 ml) No difference in inadequate, unilateral or sacral sparing No difference in catheter manipulation or replacement No difference in hypotension or highest Sensory Block (T4) No PDPH

21 Dural Puncture Epidural Thomas, Anesthesiology G Suzuki, A&A G Cappiello, Tsen, A&A G DPE group (0.25% Bupivacaine 12 ml) Faster Onset: VAS < 10 in 20 min Greater Sacral Coverage at any time Reduced unilateral block No difference in Motor Block or highest Sensory Block (T10) No FHR Bradycardia, No PDPH

22 DPE Advantage Epidural DPE Confirmation Absent Present Onset 5-15 min Faster Quality Patchy, Fail <4-13% Less Motor Deficit Moderate Moderate Fetal Effects Minimal Less Failed Blocks Eappen n=4240 Norris n=1660 van de Velde Thomas n=248 Epidural CSE Needle 13.1% 7.2% 25G 1.3% 0.2% 25G 3.18% 1.49% 27, 29G 9.3% 8% 27G Suzuki, Anesth Analg 1996 Cappiello, Tsen. Anesth Analg 2008 Thomas, Anesthesiology 2005 van de Velde, Anaesth Intensive Care 2001 Norris, IJOA 2000 Eappen, IJOA 1998

23 Continuous Spinal Advantages Minimal dosage; lower systemic and fetal issues Well-defined endpoint Alternative route of action; failed epidural Hemodynamic stability if co-morbidities Faster transition/readiness for urgent C/S Ability to Titrate Disadvantages PDPH Infection?

24 Continuous Spinal Year Needle Catheter 1907 Dean,BJA 1944 Tuohy, Anesth 17, 18 G Silver needle 15 G Ureteral G 27-32G micro 2008 Arkoosh, Anesth 22G 28G Micro Continuous Spinal Group More pruritus Better early analgesia 1992: FDA withdrawal 1996: Investigational device exemption Less Motor Blockade Better Maternal Satisfaction

25 Neuraxial Techniques Workforce Surveys 1300 hospitals in United States geography #births: 3 strata Gibbs et al. Anesthesiology 1986 Hawkins et al. Anesthesiology 1997 Bucklin et al. Anesthesiology births/yr births/yr None IV, IM Epidural Spinal

26 Neuraxial Techniques Epidural Spinal CSE DPE

27 agents

28 Agents What a trifling difference must often determine which should survive...and which perish Darwin

29 Local Anesthetics Extrapolate (probit) SIA, VdV ED95 B 3.3 R L Finds B<R<L Onset Parpaglioni l 1.56 l 2.27 Spont Induce bupivacaine ropivacaine l-bupivacaine Sia anesthesiology 2005 Parpaglioni Anesthesiology 2005 van de velde Anesthesiology 2007 Whitty IJOA 2007 Loubert Anaesthesia 2011

30 Opioids Single nucleotide polymorphism (SNP) 304A-G Opioid M receptor (OPRM1) gene CSE Fent ED50 Adenine 26.8 mcg Guanine 17.7 mcg Finds Request Later Landau, Kraft: Current Opinions in Anesthesiology 2010

31 Adjuvants Neostigmine Analgesia, Less Hypotension, No FHR effects N/V, Prolonged block CI: mcg/hr Clonidine Analgesia, Less shiver Sedation, Mild Hypotension C 75 mcg = S 5 mcg Dexmedetomidine Owen Anesth 2000; D Angelo A&A 2001; Paech A&A 2002; Landau A&A 2002; Missant CJA 2004; Roelants Anesth 2005; Parker J Anesth 2007; Belhadj Ann Fr Anesth Reanim 2007; Van de Velde IJOA 2009;Palanisamy,Tsen IJOA 2009; Eisenach A&A 2009; Paech IJOA 2009

32 equipment

33 Equipment Natural selection is daily and hourly scrutinizing, rejecting those that are bad, preserving all that are good We see nothing of these slow changes in progress, until the hand of time has marked the lapse of ages Darwin

34 Equipment Identification of Space Ultrasound Syringes/Devices Catheters Pumps

35 Epidural Ultrasound Landmarks LF: Ligamentum Flavum AP: Articular Process TP: Transverse Process VB: Vertebral Body

36 Epidural Ultrasound Landmarks LF: Ligamentum Flavum AP: Articular Process TP: Transverse Process VB: Vertebral Body

37 Epidural Ultrasound Ultrasound Requires > 60 uses to be experienced May only reduce mechanical trauma Cannot reduce vascular trauma Needle Tip not seen: 43% Novice, 10% Expert HEBL, ANESTHESIOLOGY 2008

38 Epidural Ultrasound Ultrasound Needle Single Crystal 18G Epidural Needle Ligamentum/Dural Sac 3.5 to 7.5 mm Window real-time guidance (not just assistance) No need for assistant Chiang HK, et al, Anesthesiology 2011 Tsen LC. Anesthesiology 2011

39 Episure Syringe Zero resistance Spring Continuous pressure Both Hands on Needle; Visual Signal N=30 Episure Pass # 1 (1-7) Riley ET, Carvalho B, A&A 2007;105: DP 0

40 Episure Syringe Habib et al. A&A 2008 n=157/168 Glass Episure P Attempts Wet 2.6% 0% 0.05 Blood 4.5% 5.4% 0.8 Time (s) Failed 3.2% 0% Seconds Glass Episure Attempts Similar Success Rate Shorter Insertion Time Similar Learning Curve Carabuena, Tsen, A&A In Press

41 Catheter Evolution 70 s: Uniport Polyurethane, Polyethylene, Nylon, Vinyl 80 s: Stylet Plastic & Wire Stylet 90 s: Multiport Multiport: D Angelo AA 1997, Segal JCA 1997, Collier RAPM 1994, Michael Anaesthesia Uniport: Dickson BJA 1997, Magides Anaesthesia 1996, Morrison BJA : Steel Spiral, Soft Tip Arrow FlexTip (19G, 20G: Open Tip Uniport); Braun Springwound (19G: Open Tip Uniport or closed Tip Multi); Braun Soft Tip (20G: closed tip Multi, 5mm)

42 Flex Tip Benefits Factor Study Flex Non- Flex P Paresthesia vein Cannulation One Sided Blocks Infection rates Banwell et al, CJA 1998 Jaime et al., JCA 2000 Junega et al, RAPM 1995 Steffen et al. JCA % 11-44% < % 5-10% < % 4.4% 0.2

43 Flex-Tip Venopuncture Flex Tip vs Nylon catheter during pregnancy Study Banwell 1998 (87) Odds ratio (95% CI) 0.04 (0.00,0.63) Cohen 2006 (88) 0.30 (0.12,0.74) One RCT, 200 pts Juneja 1996 Sakr 2005 (89) 0.10 (0.04,0.23) 0.04 (0.00,0.69) Sarna (0.01,4.37) Four unpublished RCT, 5703 pts Overall (95% CI) Favors Arrow Odds ratio 0.14 (0.06,0.30) Mhyre JM, Greenfield ML, Tsen lc, Polley LS. A&A, 2009;108:

44 Pump vs Practitioner continuous infusion (0.125% bupiv, 10 ml/hr) vs intermittent bolus (o.25% bupiv, 10 ml) Study Bolus Infuse Comments Bogod 1987 Smedstad 1988 Boutros ± ± 83* 87 ± ± 71* 10.6 ± 2.4/h 14.6 ± 3.8/h* Motor 44% v 64% Forcep 24% v 54% Motor 4% v 22% CEI Pump: Risk: more bupivacaine, motor block, instrumented delivery Benefit: greater patient & provider satisfaction, fewer top-ups

45 Pump2 ± Patient CEI Pump ± PCEA PCEA Benefits fewer top-ups less bupivacaine More Patient Satisfaction van der vyver, BJA 2002 Collis BJA 1999 Purdie BJA 1992

46 Pump2 ± Patient Bolus differs from CEI Recruitment of multihole catheter Epidural spread Kaynar, Kodali A&A 1999 Solution 0.5% 4mL 0.2% 10 ml 0.1% 20 ml 100% Relief n = 119 n = 1119 n = 1520 > 50% Motor Relief Block Greater Greater Duration 43 ± 21 min 100 ± 26 min 120 ± 21 min Christiaens F, RAPM 1998;23:134-41

47 Pump3 ± Patient Automated mandatory bolus AMB vs CEI + PCEA Less drug, less pain greater Satisfaction Computer Integrated PCEA Novel Smart System Evaluates demands Algorithm increases or decreases infusion Less drug, less pain Greater satisfaction Sia A&A 2007, Wong A&A 2006, Fettes BJA 2006, Lim IJOA 2005, Chua CJA 2004,

48 Pump4 ± Patient Computer Integrated PCEA + Automated mandatory bolus Evaluates demands Algorithm increases or decreases infusion AMD Bolus Does not allow PCEA bolus + Mandatory bolus Photos and information courtesy of Alex Sia, KK Women s Hospital Singapore

49 Pump4 ± Patient Computer Integrated PCEA + Automated mandatory bolus Evaluates demands Algorithm increases or decreases infusion AMD Bolus Does not allow PCEA bolus + Mandatory bolus WIFI Streaming Central Data Monitor Photos and information courtesy of Alex Sia, KK Women s Hospital Singapore

50 Equipment Identification of Space Ultrasound Syringes/Devices Catheters Pumps

51 Labour Regional Analgesia for the 21st Century What Really Matters? A Darwinian Adventure The key is man s power of accumulative selection; nature gives successive variations; Man adds them up in certain directions useful to him Darwin

52 Society for Obstetric Anesthesia and Perinatology Sol Shnider Meeting March 14-17, 2013 San Francisco, CA 43rd Annual Meeting April 25-28, 2013 San Juan, Puerto Rico

53 Questions?