Combined spinal-epidural analgesia represents the gold standard for regional analgesia in labour

Transcription

1 Combined spinal-epidural analgesia represents the gold standard for regional analgesia in labour Felicity Plaat Queen Charlotte s Hospital, Imperial College NHS Trust London

2 Combined spinal-epidural analgesia represents the gold standard for regional analgesia in labour Declaration: I practice what I preach.. I do s for labour most of the time Felicity Plaat Queen Charlotte s Hospital, Imperial College NHS Trust London

3 Combined spinal-epidural analgesia represents the gold standard for regional analgesia in labour A barely perceptible sensory block that maintains sensation, alleviates pain, and does not inhibit mobility A fast effective way to obtain continuous pain relief throughout labour & delivery, whilst maintaining ability to move /push in 2 nd stage Effective analgesia that does increase need for intervention, improves dysfunctional labour and can be easily topped up for obstetric intervention.

4 Combined spinal-epidural analgesia represents the gold standard for regional analgesia in labour

5 Combined spinal-epidural analgesia represents the gold standard for regional analgesia in labour Effective analgesia within 1 minutes Faster onset of analgesia More pruritis

6 Speed of onset Vernis '4 Van de Velde '4 COMET '1 Hughes '1 Vercauteren '1 Nickells ' Van de Velde '99 Palmer '98 Gautier '97 Joos '95 Collis '95 Abouleish '94 Collis '94 Camann '93 Stacey '93 EPIDURAL 1 2 3

7 Speed of onset Breen 21

8 v epidural n = Successful 135 Unsuccessful 9 [6.3%] Successful 65 Unsuccessful 1 [13%] Bedson, Crowhurst, Plaat 1999

9 Reliability of epidural catheter Incidence of breakthrough pain Rate of breakthrough pain [episodes/ hr] Hess 21

10 % or epidural Time in pain /75 9/144 < 4 Time / Minutes / /75

11 Retrospective studies. Heesen, Van de Velde et al. Unpublished.

12 Prospective studies. Heesen, Van de Velde et al. Unpublished.

13 Reliability epidural catheters Lee Anesth Analg 29 Cappiello Anesth Analg 28 Miro IJOA 28 Norris. IJOA 2 COMET Anesthesiology 22 Pratt Anesthesiology 1999 Vernis Eur J Anaesth 24 Van de Velde Anaesth Intens Care 21 Eappen IJOA e Catheter failure rate failure rate (%) catheter failure replacement rate (%) Unilateral analgesia catheter failure catheter failure replacement rate (%) % patients with catheter replacement.5 e

14 Reliability epidural catheters Lee Anesth Analg 29 Cappiello Anesth Analg 28 Miro IJOA 28 Norris. IJOA 2 COMET Anesthesiology 22 Pratt Anesthesiology 1999 Vernis Eur J Anaesth 24 Van de Velde Anaesth Intens Care 21 Eappen IJOA e Catheter failure rate failure rate (%) catheter failure replacement rate (%) Unilateral analgesia catheter failure catheter failure replacement rate (%) % patients with catheter replacement.5 e

15 % converted to GA Pain during Caesarean section - failed regional anaesthesia spinal Shibli 2

16 Effect on labour Wong 25 Kayacan 26 Tsen 1999

17 Do the risks associated with analgesia outweigh the benefits? [Is the dura really too vulnerable to be breached?] Fetal heart rate abnormalities Neurological trauma Infection

18 Fetal heart rate abnormalities associated with CNB opioid Nielsen 1996 Sufentanil 15.4% 18.8% Eberle 1998 Sufentanil 3.9% 3.9% Kahn 1998 Fentanyl 5.6% 2.5% Palmer 1999 Fentanyl 12% 6% Van de Velde Sufentanil 11.4% 5.9%

19 Regional anaesthesia and neuropathy 7 cases of cord neuropathy 3 Single shot spinals, 4 s ALL at L2-3 (1 also at L1-2; 1 also L3-4) Poly-segmental neuropathies ALL had dysaesthesia on needle insertion Reynolds Anaesthesia 21

20 Direct trauma Lower end of spinal cord Tuffier s line L4 L5

21 Common features of meningitis case reports Difficulty with the procedure / bleeding Poor aseptic technique Multiple needling

22 Neurological sequelae Permanent damage after obstetric CNB x 1 95% CI Spinal

23 Infection Neuraxial infection can occur despite full aseptic technique. Multiple attempts at CNB, especially when accompanied by significant bleeding, may well be a factor NAP 3

24 Infection In many obstetric anesthesia units today, standards of prudent surgical hygeine have regressed to almost pre-listerian indifference Bromage 1999

25 Cost Introduction of mobile epidurals : rate went up from <5% to >6% (>8% nullips.) 9% women who had a regional block want one again. 49% woman who did not have a regional block would have one next time <$1 for spinal needle

26 Is [closer to] the gold standard for Reliable faster onset of analgesia with little inter patient variability regional labour analgesia? Requires a more perfect midline approach More reliable subsequent analgesia Shorter labour compared to epiduralpossibly Demands the highest standard of asepsis More reliable for anaesthesia

27 Which do you want for your women? Fast Reliable Requires a skilled driver [OK Expensive] Really?

28 Combined spinal-epidural analgesia does represents the gold standard for regional analgesia in labour An imperfect epidural should be a spur to the active pursuit of perfection rather than remain as an object of regretful contemplation. VOTE Andrew Doughty

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30 Methodology Analgesia Definition Subsequent dose in up/down seq. allocation Effective VAS 1 < 3mins.1% [bupivacaine] Ineffective Repeat VAS but responded to rescue EA Rescue EA failed to reduce VAS 1.1% [bupivacaine] Use same [bupivacaine]

31 Discussion Statistical not clinical significant difference Only studied 2 nd injection not overall analgesia These results do not influence the established clinical indications for a technique

32 1994