Options for analgesia when a regional technique is not possible

Transcription

1 Options for analgesia when a regional technique is not possible Damien Hughes Ulster Hospital Belfast Damien.Hughes@setrust.hscni.net

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3 History

4 Progress.

5 Plus ça change.. Basic choices.. Pharmacological or non-pharmacological Systemic or regional Opioid based or local anaesthetic based

6 Plus ça change.. Basic choices.. Pharmacological or non-pharmacological Systemic or regional Opioid based or local anaesthetic based

7 Non-pharmacological analgesia Usually not us, TENS, water, acupuncture etc but

8 Non-pharmacological analgesia Hypnosis?! Antenatal self-hypnosis for labour and childbirth: A pilot study 77 women (control 3249) Nulliparous: fewer epidurals, fewer augmentations Possible benefit, further research needed AM Cyna et al Anaesthesia and Intensive Care, 2006; 34 (4): , Australian Society of Anaesthetists

9 However Hypnosis for pain management during labour and childbirth (Review) Madden K, Middleton P, Cyna AM, Matthewson M, Jones L The Cochrane Library 2012, Issue 11 No benefit shown for analgesia requirements

10 Pharmacological options Systemic Entonox IM opioid Opioid PCA remifentanil Regional Epidural CSE Spinal

11 Pharmacological options Systemic Entonox IM opioid Opioid PCA remifentanil Regional Epidural CSE Spinal

12 Labour with opioids??!!

13 Labour with opioids??!!

14 50% don t have an epidural Patient preference No epidural service Thrombocytopenia Anticoagulation Back problems Neurological Sepsis

15 Systemic analgesia. Not like an epidural labour Different collaborative relationships Maternal choice issues Midwifery rather than anaesthesia?!

16 Systemic analgesia Nitrous Oxide Ubiquitous UK (not USA!) Patient control Psychological benefit Low blood-gas solubility Ideal for intermittent use Rapid on-off effect Doesn t accumulate with intermittent use Often as an adjunct

17 Opioids Mainstay of systemic analgesia Intermittent bolus regimen Administered by midwives

18 I.M Pethidine more sedation than analgesia 1 gastric stasis & hypoventilation 2 fetal effects after 40 mins 3 dose-delivery <2-3hrs 4 modifies CTG & EEG 5 fetal acidosis 6 active metabolites for days 7 1. Olofsson et al. B J Obs Gynaecol 1996;103: Nimmo et al. Lancet 1975;1(7912): Tomson G et al. B J Clinical Pharmacology 1982;13: Shnider SM, Moya F. Am J Obstet Gynecol 1964;89: Kariniemi V, ammala P. B J Ob Gynaecol 1981;88: Kariniemi V, Rosti J. J Perinatal Med 1986;14: Hodgkinson R, Farkhanda JH. Anesthesiology 1982;56:51-2

19 What do women want? Sytematic review of 137 reports of the views of 14,000 women in 9 countries Satisfaction Expectations Support Quality of relationship with midwife Involvement in decision making Dissatisfaction Failure of timing & lack of availability of analgesia Complete analgesia did not rate highly Hodnett 2002, Saisto 2001, Ranta 2002, May 2000

20 Satisfaction is multidimensional and therefore difficult to define, assess and measure. REVIEW Maternal satisfaction P.N. Robinson, P. Salmon, S.M. Yentis International Journal of Obstetric Anesthesia (1998) 7, Studies assume that satisfaction with anaesthetic practice equates with good analgesia, although as we have shown this is only one dimension of satisfaction.

21 Epidural versus nonepidural or no analgesia in labour. Regional analgesia the be all and end all??? Anim-Somuah M1, Smyth RM, Jones L. Cochrane Database Syst Rev Dec 7;(12)

22 Cochrane Conclusion. Epidural analgesia appears to be effective in reducing pain during labour. However, women who use this form of pain relief are at increased risk of having an instrumental delivery. Epidural analgesia had no statistically significant impact on the risk of caesarean section, maternal satisfaction with pain relief and long-term backache and did not appear to have an immediate effect on neonatal status as determined by Apgar scores. Further research may be helpful to evaluate rare but potentially severe adverse effects of epidural analgesia on women in labour and long-term neonatal outcomes.

23 What do women want? Sytematic review of 137 reports of the views of 14,000 women in 9 countries Satisfaction Expectations Support Quality of relationship with midwife Involvement in decision making Dissatisfaction Failure of timing & lack of availability of analgesia Complete analgesia did not rate highly Hodnett 2002, Saisto 2001, Ranta 2002, May 2000

24 The search for an alternative... Match time course of labour Not midwife delivered, patient control Rapid onset and offset & intravenous PCA device Few maternal & neonatal adverse effects Non cumulative

25 % of peak effect site concentration Effect site concentration after opioid bolus 100 Fentanyl Alfentanil 0 Remifentanil Time since bolus (min)

26 Remifentanil pharmacokinetics in neonates Infants under 2 months Pharmacokinetics similar to older children to adults Davis, Ross Henson et al, Remifentanil pharmacokinetics in neonates. Anesthesiology 1997; 87: A 1054

27 Theory behind technique PCA giving control improves satisfaction Theory behind choice of drug Ultra short-acting, rapidly metabolised Placental transfer, but rapid metabolism in neonate Kan et al Anesthesiology1998; 88: Context sensitive t 1/2 3-5min Ideal for intermittent pain of labour? Remifentanil PCA

28 Remi pca in practice Feasibility for labour analgesia 2001 Blair et al, BJA 2001 Optimum bolus 0.5mcg/kg, no background infusion Superior to pethidine Blair et al, BJA 2005 Shown superior to pethidine efficacy, satisfaction, conversion to epidural Thurlow et al BJA 2002, Douma et al BJA 2010 No difference in neonatal outcomes Review by Leong et al Anes & Analg 2011

29 Remi pca in practice Strict protocol Dedicated IV cannula Dedicated pumps Locked pump programme 40mcg bolus, 2min lockout Observation chart

30 Safety with remi One-to-one midwifery care Anaesthetist prescribes and starts pca Strict monitoring Observation chart Immediate oxygen and resuscitation availability Continuous audit

31 Side effects Nausea approx 90% use Entonox Itch Sedation Respiratory depression Episode of desaturation <94%: 40-50% Almost all recover with nasal specs oxygen

32 Patient info sheet Salient points Unlicensed use Audit data re safety Given out at ante-natal clinic Laminated copy in rooms Reiterate in labour ward at request

33 Remifentanil PCA documentation Informed about Remifentanil At least 37 weeks Information leaflet read No recent opiate use Aware unlicensed use PCA technique explained lockout/timing of demands/patient use only Risks discussed: Sedation Respiratory depression Epidural conversion Itch Supplementary oxygen Nausea Failure/inadequate pain relief Verbal consent Prerequisites: Kardex: Dedicated IV canula Remi pump no. PCA prescribed SpO2 monitoring Anaesthetist present Naloxone At initiation Midwife present Anti emetic Signature: Date & time:

34 Remi PCA in Belfast 4000 deliveries Elective LSCS 14% Routine use since remi pca/mth 40% of labouring women choose remi pca Epidural rate dropped to 35%

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37 Complications and controversy Case reports of respiratory arrest Bonner JC, McClymont W. Anaesthesia 2012; 67: Pruefer C, Bewlay A. Anaesthesia 2012; 67: Recent editorials: College Bulletin Hughes, Foley. March 2013, Anaesthesia Kinsella, 2013

38 Complications and controversy Recent adverse reports Case reports of respiratory arrest Bonner JC, McClymont W. Anaesthesia 2012; 67: Pruefer C, Bewlay A. Anaesthesia 2012; 67: Recent editorials: College Bulletin Hughes, Foley. March 2013, Anaesthesia Kinsella, 2013 Issues arising Systemic maternal effects an issue Also management of the cases: lack of dedicated midwifery care, recent opioid administration Prompt assessment and management essential Training and familiarity No room for complacency

39 Complications and controversy Issues arising Systemic maternal effects an issue Also management of the cases: lack of dedicated midwifery care, recent opioid administration Prompt assessment and management essential Training and familiarity No room for complacency

40 RESPITE trial 2014 Multicentre trial, 400 women over 24 months Comparing Remifentanil PCA with IM pethidine Primary aim: efficacy VAS Proportion of women requiring an epidural for pain relief, VAS Secondary data: adverse effects Maternal sedation Unwanted effects on mother and baby. Clinical guidelines on the use of remifentanil

41 hot off the press May - July 2014 audit data 412 women Efficacy and side effects Outcomes

42 Satisfaction and efficacy 80% satisfied or very satisfied Pain scores: 48% none or mild pain 36% moderate pain 87% would use again Conversion rate to epidural 12.9%

43 Side effects Nausea 44.9% Respiratory depression Itch 20.9% Sedation 0.4% Episode of desaturation <94%: 51.9% All except one case recovered with nasal specs oxygen 0.24%

44 Side effects Nausea 44.9% Respiratory depression Itch 20.9% Sedation 0.4% Episode of desaturation <94%: 51.9% All except one case recovered with nasal specs oxygen 0.24%

45 Neonatal outcomes 5min 99.2%: 8 or above No difference in NICU / SCBU admission rates Slightly higher SVD rate Lower rate of needing resuscitation breaths at birth

46 Remi pca offers Modest analgesia High maternal satisfaction 1400 per year Safe for mothers and babies Reduced epidural rate

47 But you must have. Strict protocol One to one care Trained midwives Intensive monitoring Familiarity with regimen (good and bad points) Audit of practice and outcomes

48 So finally.! Always a role for systemic analgesia New opioid analgesia techniques Anaesthetists involved PCA remifentanil can be a positive addition but strict protocol essential

49 Thank you!