Safety and quality of neuraxial analgesia Ulla Sipiläinen 6.10. 2011 HUCS Jorvi hospital
Chestnut s Checklist Preparation for neuraxial labor analgesia 1.Communicate (early) with obst provider review parturient s obst history 2.Perform focused preanesth eval: review maternal obst, anest, health history perform targeted physical exam (vital signs, airway, heart, lungs, back) 3.Review relevant lab and imaging studies
4.consider need for blood typing and screening or crossmatching 5.formulate analgesia plan 6.obtain informed consent 7.perform equipment check Check routine equipment Check emergency recuscitation equipment 8.Obtain peripheral intravenous acces 9.Apply maternal monitors ( Hr, BP, Pulseoximeter 10.Perform a team time-out.
Real life checklist Airway, airway, airway! Trombosytes, if symptoms of preechlampsia Position: BMI Allergies
maintain your skills wet tap rate / dural puncture rate teaching problematic formal training programme for epidural analgesia? simulator?
Position sitting/ on side weight>height-100, examp, 170cm, 80kg consider sitting position
Skin preparation meningitis epidural infection wear mask, sterile gloves, hat skin preparation infections are very rare st viridans
early vs late epidural cervical dilatation less than 4 cm with low-dose local anesthetic technique no difference in cs rates C. Wong 2005 and 2009
CSE vs epidural analgesia CSE when it is really needed multiparous patients in advanced, rapidly progressing labour even single-shot spinal risk of cs, obese, very painful
Air vs Saline saline is recommended saline with small air bubble in Finland air is most popular no differences in the incidence if PDPH between saline or air
Continous vs intermittent pressure in loss of resistance syringe no difference personal preferences
Volume high-volume low concentration solutions better analgesia with 20ml epidural than 13ml or 15ml if one-sided or in-adequate analgesia, volume addition ad 5 ml before replacement
PCEA, infusion, bolus? maintaining volume! second dose intructions for midwife: 20ml PCEA best, large bolus are needed to spread widely
Intra-venous epidural test dose!! catether migrate into veins very easily and often saline -injektion, aspiration important to detect
Obese partiturent greater risk for cs epidural space? lumbar space? position: sitting G18/G27 120mm needle CSE or epidural favour early analgesia
Taping flexed position minimizes the distance between skin and epidural space the catether can move up to 4 cm leave the catether 5-6 cm into the epidural space
Routines routines protect from mistakes variation between phycisians analgesia similar undependantly from person on call
Incidence and chaceterics of failures in obstetr analgesia Retrospective analysis of 19 259 deliveries 12 590 analgesia Overall failure rate 12% 6.8 % imcomplete analgesia 5.6% catether replacement for inadequate analgesia 98.8% adequate analgesia Pan P. et al Int J Obst Anest 2004:13; 227-233
Inadequate analgesia Consider other causes of pain: distended bladder, ruptured uterus Evaluation: catether in epidural space? - > not-> replacement or consider CSE Inadequate analgesia, asymmetric block-> inject saline 5ml CSE has lower failure rate than epidural
Intrathecal catether important to detect test dose always via catether immediate analgesia total spinal anaesthesia may be disasterous
Accidental dural puncture earlier: catether placed for 24 hrs now: new epidural analgesia from another lumbar space and epidural blood patch if needed after 24-36 hrs delayd application of EBP may cause problems, be aware!
Neuraxial analgesia and common claim neuraxial injury indirect injury: longer second stage of labour relaxation of pelvic muscles -> delays rotation of head no pain-> encourage to push without changing body position
Adverse delivery outcomes weakened desire to push increases the risk of instrumental delivery risk of vaginal/ perineal trauma back pain is common
Recommendations instructions also for potential complications iv line, hydration hypotension anesthesia for CS fasting dural puncture
Conclusion 1 Unreasonable to expect, that neuroblocade of the half lower body NOT have any affect on labour process.. Chestnut`s
dose examples Ropivacaine 2 mg/ml 10ml Fentanyl 0.05mg/ml 2ml Saline ad 20ml 2-dose, given by midwife: 10ml ropivacaine fentanyl 0.05mg/ml 1ml (Sic!) Saline 9ml, total dose 20ml.
dose examples CSE: Bupivacain 2.5mg Fentanyl 25mcg saline ad 2ml
Conclusion Instructions for own hospital Analgesia should be given early enough Does not increase cs rate
Thank you!