Swiss Association of Obstetric Anesthesia Swiss Association of Anesthesia & Resuscitation Satellite Meeting Interlaken, Switzerland 2007 Lawrence C.

CSE s for Labor Analgesia PRO! Swiss Association of Obstetric Anesthesia Swiss Association of Anesthesia & Resuscitation Satellite Meeting Interlaken, Switzerland 2007 Lawrence C. Tsen, MD Director of Anesthesia Center for Reproductive Medicine Associate Professor Harvard Medical School

An Easier Life? Patient Obstetric Provider OB Anesthesia Provider Hospital Administrator

While Eeyore Frets, And Piglet Hesitates, And Tigger Calculates, Pooh Just Is. The Tao of Pooh

Eeyore (Patient) Frets Patient Concerns during Labor: Pain Control Maintain Active Participation Minimize Fetal Effects Cook, Anaesthesia 2000 Eltzschig, NEJM 2003

CSE Initial 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 Thomas, Anesthesiology 2005 Norris, IJOA 2000;9:3-6 Eappen S, IJOA 1998;7:220-5 Nageotte NEJM 1997;337:1715-9

Epidural Initial Disadvantage Epidural Analgesic Gap No Technical Confirmation Disconnect in patientprovider perception Delay in Response Quality of Response JCAHO Pain Guidelines Carr, RAPM 2005

CSE Initial Advantage Definitive Technical Marker Definitive Analgesic Marker Bypass Language/Cultural Barriers Limits Clinician Interpretation Minimizes Time to Analgesia Gambling, CJA 1988 Ledin, Acta Anesth Scand 2003

CSE Ongoing Advantage? Failed Blocks Epidural CSE Needle Eappen n=4240 Norris n=1660 13.1% 7.2% 25G 1.3% 0.2% 25G van de Velde 3.18% 1.49% 27, 29G Thomas n=248 9.3% 8% 27G Eappen S, IJOA 1998; Norris, IJOA 2000; van de Velde, Anaesth Intensive Care 2001; Thomas, Anesthesiology 2005

CSE Ongoing Advantage Conduit for Epidural Meds to the Spinal Sac Sacral Spread Better Coverage Suzuki, A&A 1996 26G Thomas, Anesth 2005 27G Cappiello, Tsen 2007 25G

Patient s Life More Easy? YES!!! CSE gives better: Pain Control Technical Confirmation Faster Onset, Greater Reliability Improved Sacral, Bilateral Analgesia Active Participation Minimal Fetal Effects

Piglet (OB) Hesitates... OB Provider Concerns Safe and Timely Delivery Progress and Outcome of Labor Good Maternal and Fetal Outcomes Fetal Bradycardia

Progress of Labor Dilation (cm) Hours

Progress of Labor Meta-Analysis RCT: Epidural vs. Opioids Mixed Parity 1st Stage: 42 min 2nd Stage: 14 min Total Time: 56 min No Change in C/S Halpern: JAMA 1998

Progress: CSE Advantage CSE vs. Epidural Boluses Lower Instrumental Delivery Technique Matters? CSE vs Epidural; Epidural Continuous Infusion 100 Nulliparous < 3 cm dilation CSE: Shorter Duration Labor, Delivery: 30 min faster CSE vs. Parenteral Opioids; Epidural Continuous 750 Nulliparous < 4 cm dilation 110 min neuraxial CSE: Shorter Duration Labor, Delivery: 80 min faster Collis, Lancet 1995; Tsen, Anesthesiology 1999; Wong, NEJM 2005

Outcome CSE: FHR? Meta-analysis: 24 Trials (3513 women) Intrathecal Opioids IT opioid Control RR NNH FHR abnl 7.7% 6.7% 1.17 75 FHR brady 7.3% 4.8% 1.81 28 CS FHR 6.0% 7.8% 0.86-87 CS Any 17% 16.6% 1.03 208 Apgar < 7 1% 0.9% 1.17 623 Increase in FHR bradycardia, No change in CS, Fetal Outcomes Mardirosoff: BJOG 2002

Outcome: CSE Advantage Evaluation, Intervention Possible Intervention, Possible Further Intervention Retained Placenta External Cephalic Version Cerclage Removal CSE Spinal Anesthetic Timely discharge Epidural Catheter Analgesia if labor Anesthesia if C/S Anesthesia if O.R. Cherayil, Tsen. Anesth Analg 2002

OB Life More Easy? YES!!! CSE Safe and (more!) timely delivery Bradycardia, but no CS; Good maternal and fetal outcomes More Flexibility

Pooh (OB Anes) just is... OB Anesthesia Provider Concerns: Fast, Efficacious, Reliable Analgesia/Anesthesia Limited Maternal/Fetal Impact Limited Failure Rate, especially if CS Work Load Sensitive

Workload: CSE Advantage CSE...A Few Extra Steps, but... Faster Onset: 7 min x 5000 techniques = 600 hrs Confirmation of Space: High BMI, Scoliosis 15-40 min x 5000 techniques = 3333 hrs Less Replacements 20 min x 5% x 5000 techniques = 83 hrs TOTAL = 11 hours/day!!! D Angelo: Handbook OB Anes 2002 Farragher, Tsen: SOAP Abstract, 2001

Eappen S, IJOA 1998;7:220-5 Norris, IJOA 2000;9:3-6 Thomas, Anesthesiology 2005 Workload: CSE Advantage Failed Blocks Eappen n=4240 Norris n=1660 Thomas n=248 Epidural CSE DP no CSF 13.1% 7.2% 25G 1.3% 0.2% 25G 9.3% 8% 27G 22.2%

Workload: CSE + PCEA O Rourke, SOAP 2004 n = 525, p < 0.0001

CSE Protocols Brigham and Women s Hospital CSE: 25g Whitacre Bupiv 2.5 mg + Fentanyl 25 µg Stanford CSE: 26g Gertie Marx Bupiv 2.0 mg + Sufenta 5 µg Wake Forest CSE: 27g Whitacre Bupiv 2.5 mg + Sufenta 5 µg

CSE Complications? Cochrane Review: CSE vs Epidural in Labour 19 Trials, 2658 women CSE No increase in maternal hypotension No increase in postdural puncture headache No increase in blood patch use Less urinary retention Simmons SW, et al. Cochrane 2007

OB Anesthesia Life Easier? CSE Fast, Efficacious, Reliable Analgesia/Anesthesia Limited Maternal/Fetal Impact Limited Failure Work Load Sensitive YES!!!

Tigger (Admin)Calculates... Hospital Administrator PROFIT: CSE Benefit? Good Maternal/Fetal Outcome Standard of Care: JCAHO Patient Recruitment LOSS: CSE Costs Pump, Disposable Costs Manpower Costs

CSE: Advantage LOSS: Cost of 25-27 G Spinal Needle -$5.00 Cost of pre-drawn CSE syringe -$5.00 TOTAL -$10.00 PROFIT: Less Failures, Fewer Replacement Kits +$30.00 Less General Anesthesia, Morbidity/Mortality? + Less Recovery Room Time + Satisfied OBs, OB Anesthesia Providers + Satisfied Patients, Word of Mouth +Priceless!

Tigger s Life Easier? YES!!! Hospital Administrator CSE/PCEA Profit: Non-Specific Good Maternal/Fetal Outcome Standard of Care: JCAHO Patient Word of Mouth CSE/PCEA Loss: Fixed Needle, Pump, Disposable Costs

Conclusion CSE s Make Life Easier! Patients Obstetric Providers Ob Anesthesia Providers Hospital Administrators

Questions?

SOAP 40th Annual Meeting Chicago, April 30-May 4, 2008

Outcome: CS C/S Rate