Topping up the epidural for the emergency CS. Jim Bamber The Rosie Hospital Cambridge

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1 Topping up the epidural for the emergency CS Jim Bamber The Rosie Hospital Cambridge

2 Declarations and Disclaimers No conflict of interest to declare Personal interpretation of evidence Risk of biases and prejudices

3 Emergency CS RCOG Good Practice No.11; Lucas et al 2000 Category 1 CS = 10% of all CS in UK (Kinsella et al 2010) Category 1 CS = 13% of all emergency CS (Kinsella 2008) Category 1 CS = 50% have GA in UK (Kinsella et al 2010) Category 1-3 CS = 12% have GA in UK (Kinsella et al 2010)

4 Epidural Analgesia and Emergency CS Kinsella (2008) 1029 epidural top-up for CS 64 (6.2%) of epidural top-up converted to GA For Category 1 CS, 25% converted to GA 1275 spinal for emergency CS 32 (2.5%) of spinal converted to GA For category 1 CS, 8% converted to GA

5 What Top-Up?

6 The Spread Goring_Morris and Russell et al 2004 Sanders et al 2004

7 Top-up Adjuncts Epinephrine Take 0.1ml of 1ml of 1:1000 epinephrine and add to 20mls LA Bicarbonate Take 2ml of 8.4% bicarbonate to add to 20mls lidocaine Take 0.1ml of 8.4% bicarbonate to add to 20mls 0.5% bupivacaine Opioids Fentanyl mcg Diamorphine 2-5mg

8 What does everybody else do? Regan and O Sullivan 2008

9 How should you assess your block? Russell 2004

10 Why are epidurals converted to GA Tortosa et al (2003) Intraoperative pain after top-up 5/194 3% conversion rate Halpern et al (2009) 21/501 labour epidurals for CS (4%) had GA No time to top-up 3/21 (14%) Intraoperative pain after top-up 15/21 (71%) - 3% conversion rate Maternal request 2/21 ((10%) Other (haemorrhage) 1/21 ((5%) Kumar and Bamber (2012) 53/688 labour epidurals for CS (8%) had GA No time 18/53 (34%) Inadequate block before CS 11/53 (21%) Intraoperative pain after top-up 21/53 (40%) 4% conversion rate Maternal request 2/53(4%) Other (collapse) 1/53 (2%)

11 Risk factors for failed epidural conversion Unsatisfactory epidural analgesia in labour (supplementary top-ups required) Orbach-Zinger et al 2006, Campbell and Tran 2009, Lee et al 2009, Riley and Papasin 2012, Bauer et al 2012 Taller, younger and bigger patients Carvalho 2012 But what about epidural insertion level? Paramedian versus midline? Adequate LA top-up dosing? Epidural intraoperative opioids?

12

13 The problem with epidurals Epidural Catheter Tip Position and Distribution of Injectate Evaluated by Computed Tomography Figure 1. Locations of 19 catheter tips (circled x) placed by a midline approach. The position of six catheter tips that did not lie at the longitudinal level of the intervertebral foramen and disc shown in the drawing are indicated in their correct position in the axial plane. In this and other images, anterior is at the top of the image, and anatomic left is at the right of the image. LF = ligamentum flavum; SAP = superior articular process. Hogan, Quinn Anesthesiology

14 Brookman et al 2010

15 Top-ups: Room or Theatre Safety Monitoring Delay

16 Tuffnell 2001 Russell 2004

17 Where does everybody top-up? Regan and O Sullivan 2008

18 What if the top-up doesn t work? Plan B Plan depends on urgency General anaesthesia Spinal anaesthesia What dose of spinal anaesthetic? Risk of high block versus risk of inadequate block High block incidence varies <1% to 11% (Carvalho 2012) Repeat epidural / CSE

19 A failed epidural top-up strategy if time Failed epidural top-up No evidence of block Inadequate block level Consider spinal with 27G Repeat epidural with 5ml incremental dosing

20 Rapid Response Epidural Top-up Pre-prepared tray 20mls LA mixture 10mls 3mg/ml ephedrine ethyl chloride spray anaesthetic chart Phone call Patient name and room number Working epidural or not Urgency of CS Attend patient immediately

21 The Question to be answered Why should I not give my patient a spinal anaesthetic? Because I am confident that I can top-up the epidural

22 Epidural Confidence Check List Evidence of good effective analgesia From patient, midwife and epidural record Check epidural site Check for catheter dislodgement or leakage Evidence of a symmetrical block e.g both feet warm Pre-top reference points Block height to cold Presence and severity of motor block

23 The Top-up Discuss and explain to patient Check patency iv access Position bed flat Turn patient to left lateral position (recovery position) Commence top-up with LA whilst inspecting epidural site Proceed immediately to theatre maintaining verbal contact with patient Once patient on operating table and monitored give epidural opioid (e.g diamorphine)

24 Fig 1. Venogram before CS delivery Fig 2. Venogram after CS delivery Kerr et al. BMJ 1964

25 Summary Most emergency CS are category 2-3 Most epidurals top-up successfully Don t top-up the doubtful epidurals do a spinal Look after the labour epidurals and they will look after you

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