NEURAXIAL LABOR ANALGESIA. Thierry Girard

Transcription

1 NEURAXIAL LABOR ANALGESIA Thierry Girard

2 7 April 1853 Prince Leopold, Duke of Albany

3 Proc (Bayl Univ Med Cent) 2006;19:24 28

4 07/2013

5 Hypnosis for pain management during labour and childbirth (Review) Madden K, Middleton P, Cyna AM, Matthewson M, Jones L This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2012, Issue 11

6 Authors conclusions... Although the intervention shows some promise, further research is needed before recommendations can be made regarding its clinical usefulness for pain management in maternity care.

7 Inhaled analgesia for pain management in labour (Review) Klomp T, van Poppel M, Jones L, Lazet J, Di Nisio M, Lagro-Janssen ALM This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2012, Issue 9

8 Authors conclusions Inhaled analgesia appears to be effective in reducing pain intensity and in giving pain relief in labour.... nitrous oxide appears to result in even more side effects such as nausea, vomiting, dizziness and drowsiness...

9 N Engl J Med (2010) vol. 326 (16) pp The new england journal of medicine clinical therapeutics Epidural Analgesia for Labor and Delivery Joy L. Hawkins, M.D. (ASA) state, There is no other circumstance where it is considered acceptable for an individual to experience untreated severe pain, amenable to safe intervention, while under a physician s care. In the absence of a medical contraindication, maternal request is a sufficient medical indication for pain relief during labor. 2 Although severe pain is not life-threatening in healthy parturient women, it can

10 Epidural versus non-epidural or no analgesia in labour (Review) 2011 Anim-Somuah M, Smyth RMD, Howell CJ risk ratio 95% CI NNT cesarean section backache instrumental vaginal delivery

11 Analysis 1.2. Comparison 1 Epidural versus non-epidural analgesia in labour, Outcome 2 Instrumental instrumental delivery. delivery Study or subgroup Epidural analgesia Non-epidural Risk Ratio Risk Ratio n/n n/n M-H,Fixed,95% CI M-H,Fixed,95% CI Bofill /49 28/ [ 1.09, 1.93 ] Clark /156 20/ [ 0.72, 2.16 ] Dickinson / / [ 0.96, 1.39 ] Gambling /616 34/ [ 0.97, 2.25 ] Grandjean /30 12/ [ 0.81, 3.41 ] Head /56 3/ [ 0.23, 5.09 ] Howell /184 36/ [ 1.06, 2.22 ] Jain /43 8/ [ 1.28, 6.54 ] Loughnan /304 81/ [ 0.86, 1.43 ] Lucas /372 27/ [ 1.19, 2.90 ] Muir /28 0/ [ 0.0, 0.0 ] Nikkola /10 0/ [ 0.55, ] Philipsen % 14/57 vs. 14/54 17 % 0.95 [ 0.50, 1.80 ] Sharma /358 15/ [ 0.93, 3.21 ] Sharma /226 7/ [ 1.70, 8.64 ] Thalme /14 4/ [ 0.54, 4.18 ] Thorp /48 5/ [ 0.61, 4.66 ] Total (95% CI) [ 1.24, 1.53 ] Total events: 587 (Epidural analgesia), 442 (Non-epidural) Heterogeneity: Chi 2 =22.09,df=15(P=0.11);I 2 =32% Test for overall effect: Z = 5.85 (P < ) Favours epidural Favours control

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13 The new england journal of medicine established in 1812 february 17, 2005 vol. 352 no. 7 The Risk of Cesarean Delivery with Neuraxial Analgesia Given Early versus Late in Labor Cynthia A. Wong, M.D., Barbara M. Scavone, M.D., Alan M. Peaceman, M.D., Robert J. McCarthy, Pharm.D., John T. Sullivan, M.D., Nathaniel T. Diaz, M.D., Edward Yaghmour, M.D., R-Jay L. Marcus, M.D., Saadia S. Sherwani, M.D., Michelle T. Sproviero, M.D., Meltem Yilmaz, M.D., Roshani Patel, R.N., Carmen Robles, R.N., and Sharon Grouper, B.S. conclusions Neuraxial analgesia in early labor did not increase the rate of cesarean delivery, and it provided better analgesia and resulted in a shorter duration of labor than systemic analgesia.

14 Anesthesiology (2009) vol. 111 (4) pp Anesthesiology 2009; 111: Copyright 2009, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc. Epidural Analgesia in the Latent Phase of Labor and the Risk of Cesarean Delivery A Five-year Randomized Controlled Trial FuZhou Wang, Ph.D., M.Sc.,* XiaoFeng Shen, M.Sc., M.P.H., XiRong Guo, M.D., YuZhu Peng, M.D., M.P.H., XiaoQi Gu, M.D., The Labor Analgesia Examining Group (LAEG) 12793

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16 Lancet (2001) vol. 358 (9275) pp ARTICLES Effect of low-dose mobile versus traditional epidural techniques on mode of delivery: a randomised controlled trial Comparative Obstetric Mobile Epidural Trial (COMET) Study Group UK* Delivery Traditional Combined spinal Low-dose infusion epidural (n=353) epidural (n=351) epidural (n=350) Normal vaginal 124 (35%) 150 (43%) 150 (43%) Instrumental vaginal 131 (37%) 102 (29%) 98 (28%) Caesarean section 98 (28%) 99 (28%) 102 (29%) *p=0 04, 1DF for normal vs other deliveries. Table 3: Mode of delivery

17 Anaesthesia, 2009, 64, pages doi: /j x... Ambulation in labour and delivery mode: a randomised controlled trial of high-dose vs mobile epidural analgesia* M. J. A. Wilson, 1 C. MacArthur, 2 G. M. Cooper 3 and A. Shennan 4 on behalf of the COMET Study Group UK 1 Consultant Anaesthetist, Royal Hallamshire Hospital, Sheffield, UK 2 Professor of Maternal and Child Epidemiology, 3 Senior Lecturer in Anaesthesia, University of Birmingham, Birmingham, UK 4 Professor of Obstetrics, Kings and St Thomas School of Medicine, London, UK

18 100 Percentage of women with Power 5 or LDI CSE 30 min 1 h 2 h 3 h 4 h 5 h 6 h 7 h 8 h 9 h 10 h Time after epidural insertion Figure 2 Percentage women with normal leg power after epidural insertion. *Denotes significant difference CSE vs LDI (p < 0.01).

19 Table 3 Observational analysis of first stage ambulatory and sedentary women by epidural technique and delivery mode. CSE n = 351 LDI n = 352 Delivery mode Ambulatory 133 Sedentary 218 Ambulatory 128 Sedentary 222 SVD 61 (46%) 89 (41%) 54 (42%) 96 (43%) Instrumental* 36 (27%) 66 (30%) 37 (29%) 61 (28%) Caesarean 36 (27%) 63 (29%) 37 (29%) 65 (29%) *Instrumental vaginal delivery: includes simple forceps, rotational forceps and ventouse.

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22 INCREDIBLE PAIN continued all night - I eventually got on Remifentanil - the new morphine based drug which you self-administer, dosing yourself when you need it. It was absolutely WONDERFUL. Didn't actually stop you feeling pain but does stop you caring about it. I got absolutely sky high, thoroughly amused the midwife by talking utter rubbish,., I even started seeing things - including Nelson Mandela on a bicycle... blooming weird but there you go.

23 Remifentanil PCA is perfectly safe for the baby just make sure that Mum doesn t stop breathing! Dr Bernard Norman, OAA 3day course, London 2011

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25 REPORT AND FINDINGS JANUARY 2009 P3: 3rd National Audit of the RCoA Major complications of central neuraxial block in the UK NAP The 3rd National Audit Project of The Royal College of Anaesthetists Major complications of central neuraxial block in the united kingdom 100,000

26 Anaesthesia 2012, 67, Editorial The sting in the tail: antiseptics and the neuraxis revisited

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28 Journal of Clinical Anesthesia (2011) 23, The management of accidental dural puncture and postdural puncture headache: a North American survey Curtis L. Baysinger MD (Associate Professor) a,, Jason E. Pope MD (Partner) a,b, Ellen M. Lockhart MD (Associate Professor) c, Nathaniel D. Mercaldo MS (Biostatistician III) d Main Results: responses were collected. Respondents reported placing an epidural 75% of the time and an intrathecal catheter 25% of the time following ADP. Common prophylactic and conservative treatment strategies included hydration, caffeine, and opioids by mouth; 76% of respondents leave an intrathecal catheter in place for 24 hours to reduce the frequency of headache. Epidural blood patches are placed by 81% of practitioners less than 24 hours after headache onset. Conclusions: Protocols for ADP management are rare. There is wide variation in catheter management

29 British Journal of Anaesthesia 105 (3): (2010) Advance Access publication 3 August doi: /bja/aeq191 Prevention of postdural puncture headache after accidental dural puncture: a quantitative systematic review C. C. Apfel 1 *, A. Saxena 1, O. S. Cakmakkaya 2, R. Gaiser 3,4,5, E. George 1 and O. Radke 6 1 Key points PDPH occurs in.50% of cases of accidental dural puncture. Various treatments including intrathecal catheter, epidural saline or morphine, and prophylactic blood patch have been studied. All have shown some efficacy; no clear recommendation can be made. Large, multicentre randomized controlled trials are needed to identify best treatment option.

30 Can J Anaesth. 1999;46(9): REPORTS OF INVESTIGATION 861 Pamela Angle MD FRCPC DABA, Dorothy Thompson MB FRCPC, Stephen Halpern MD FRCPC MSc, Donna B. Wilson RN BSL BSCN MN Second stage pushing correlates with headache after unintentional dural puncture in parturients 74 % vs. 10 %

31 Society for Obstetric Anesthesia and Perinatology Section Editor: Cynthia A. Wong 80 % The Volume of Blood for Epidural Blood Patch in Obstetrics: A Randomized, Blinded Clinical Trial Michael J. Paech, DM,* Dorota A. Doherty, PhD, Tracey Christmas, FRCA, Cynthia A. Wong, MD, and Epidural Blood Patch Trial Group 60 % 40 % 20 % 0 % 15 ml 20 ml 30 ml 15 ml 20 ml 30 ml partial complete

32 Int J Obstet Anesth; 20121;21(1):7 16. International Journal of Obstetric Anesthesia (2012) 21, X/$ - see front matter c 2011 Elsevier Ltd. All rights reserved. doi: /j.ijoa ORIGINAL ARTICLE 9% I.F. Russell Department of Anaesthesia, Hull Royal Infirmary, Hull, East Yorkshire, UK A prospective controlled study of continuous spinal analgesia versus repeat epidural analgesia after accidental dural puncture in labour

33 Int J Obstet Anesth; 20121;21(1): % vs. 72 %

34 Int J Obstet Anesth; 20121;21(1): % vs. 50 %

35 Int J Obstet Anesth; 20121;21(1):7 16. Table 3 Odds ratios and relative risk of factors significantly affecting postdural puncture headac patch rates Odds ratio Relative risk Postdural puncture headache Per year difference in experience or more years or more years or more years Epidural needle (16- vs. 18-gauge) Spontaneous vaginal vs. caesarean delivery Epidural blood patch Per year difference in experience * or more years or more years or more years Epidural needle (16- vs. 18-gauge) Spontaneous vaginal vs. caesarean delivery *

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37 Anesth Analg. 2009;108(3): Patient-Controlled Epidural Analgesia for Labor Stephen H. Halpern, MD, MSc, FRCPC* Brendan Carvalho, MBBCh, FRCA

38 Anesth Analg. 2009;108(3): motor block local anesthetics

39 Anesth Analg. 2009;108(3): clinician interventions

40 Combined spinal-epidural versus epidural analgesia in labour (Review) Simmons SW, Taghizadeh N, Dennis AT, Hughes D, Cyna AM 2012

41 Authors conclusions There appears to be little basis for offering CSE over epidurals in labour... However, the significantly higher incidence of urinary retention, rescue interventions and instrumental deliveries with traditional techniques would favour the historical use of low-dose epidurals...

42 Int J Obstet Anesth. 2000;9(1):3 6. International Journal of Obstetric Anesthesia (2000) 9, Harcourt Publishers Ltd ORIGINAL ARTICLE Are combined spinal-epidural catheters reliable? M. C. Norris Department of Anesthesiology, Section of Obstetric Anesthesia, Washington University Schoo

43 Int J Obstet Anesth. 2000;9(1): % % 0.5% 0% Epidural Failure 0.2 CSEA

44 Int J Obstet Anesth. 2004;13(4): International Journal of Obstetric Anesthesia (2004) 13, Ó 2004 Elsevier Ltd. All rights reserved. doi: /j.ijoa ORIGINAL ARTICLE Incidence and characteristics of failures in obstetric neuraxial analgesia and anesthesia: a retrospective analysis of 19,259 deliveries P. H. Pan, T. D. Bogard, M. D. Owen Department of Anesthesiology, Division of Obstetric Anesthesia, Wake Forest University School of Medicine, Winston-Salem, NC, USA

45 Table 2. Characteristics of neuraxial labor analgesia failures Types of failures Epidural CSE Neuraxial labor analgesia (n) Overall failure rate (%) Initial placement failure Intravenous epidural catheter (%) 7 5 a Cleared with manipulation (%) Known wet tap or intrathecal catheter (%) Known wet tap required EBP (%) b Occult wet tap (%) b Occult wet tap required EBP (%) Subsequent failure Catheter migrated i.v. (%) a Cleared with manipulation (%) 21 8 c Catheter migrated intrathecally (%) 0 0 Other failure d No CSF or spinal analgesia (%) 2.4 Inadequate analgesia with epidural catheter (%) e Catheter replacement for poor analgesia (%) Multiple replacement of epidural (%)

46 Anesth Analg. 2008;107(5): A Randomized Trial of Dural Puncture Epidural Technique Compared with the Standard Epidural Technique for Labor Analgesia Eric Cappiello, MD unilateral block: 8% vs. 25% Nollag O Rourke, FFARCSI Scott Segal, MD Lawrence C. Tsen, MD VAS<10: 90% vs. 80% Instrumental delivery: 31% vs. 13%

47 Anesthesiology. 2005;103(5): Anesthesiology 2005; 103: American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc. Dural Puncture with a 27-Gauge Whitacre Needle as Part of a Combined Spinal Epidural Technique Does Not Improve Labor Epidural Catheter Function John A. Thomas, M.D.,* Peter H. Pan, M.D., Lynne C. Harris, B.S.N., Medge D. Owen, M.D., Robert D Angelo, M.D. 14% (95% CI: 9-22%) ity, were not different between groups. A subgroup of 18 patients without cerebral spinal fluid return during dural puncture had a higher catheter replacement rate than those of groups DP and NoDP, but it did not reach statistical significance. Conclusions: 22% vs. 9%

48 Anesthesia and analgesia (2011) vol. 113 (4) pp Programmed Intermittent Epidural Bolus Versus Continuous Epidural Infusion for Labor Analgesia: The Effects on Maternal Motor Function and Labor Outcome. A Randomized Double-Blind Study in Nulliparous Women Giorgio Capogna, MD, Michela Camorcia, MD, Silvia Stirparo, MD, and Alessio Farcomeni, PhD

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50 Anesthesia and analgesia (2011) vol. 113 (4) pp Figure 2. Percentage of patients from programmed intermittent epidural bolus (PIEB) or continuous epidural infusion (CEI) groups who had any motor block versus time after induction of labor analgesia. Data were censored for delivery. The groups were significantly different, P

51 continuous infusion n=70 intermittend bolus n=75 21% 17% 7% 20% 59% 76% SVG IVG Cesarean

52 Anesth Analg; ahead of print Intermittent Epidural Bolus Compared with Continuous Epidural Infusions for Labor Analgesia: A Systematic Review and Meta-Analysis Ronald B. George, MD, FRCPC, * Terrence K. Allen, MBBS, FRCA, and Ashraf S. Habib, MB, ChB, MSc, MHS, FRCA

53 cesarean section Figure 2. Forest plot for mode of delivery (cesarean). CEI = continuous epidural infusion; IEB = intermittent epidural bolus. instrumental delivery Figure 3. Forest plot for mode of delivery (instrumental). CEI = continuous epidural infusion; IEB = intermittent epidural bolus.

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56 Anesth Analg. 2012;114(3): Partner s Presence During Initiation of Epidural Labor Analgesia Does Not Decrease Maternal Stress: A Prospective Randomized Controlled Trial Sharon Orbach-Zinger, MD,* Yehuda Ginosar, BSc, MBBS, Julia Sverdlik, MD,* Claudio Treitel, MD,* Kiri MacKersey, MD,* Ron Bardin, MD, Dan Peleg, MD, and Leonid A. Eidelman, MD*

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