What s new in obstetric anesthesia?

SAOA 2013 - SPRING MEETING BERN What s new in obstetric anesthesia? PD Dr. Med Georges Savoldelli Médecin Adjoint Unité d anesthésiologie gynéco-obstétricale Service d Anesthésiologie, HUG

An objectively subjective selection of articles from 2012/2013! TAP block and postoperative pain after CD Assessment of pain after CD Failed EA for CD GA for pre-eclampsia Epidural test dose and detection of IT catheter PPH

524 patients included: 261 received TAP block 263 served as controls

Studies were grouped in 3 categories TAP block versus inactive control patients who did not received Intrathecal Morphine (ITM) patient who received ITM TAP block versus ITM

Pain scores on movement at 24 hr.

Opioid consumption at 24 hr.

Side effects

Conclusions: The use of TAP block for CD Significantly improved postoperative analgesia in women undergoing CD who did not receive ITM Showed no improvement in those who received ITM ITM was associated with improved analgesia compared with TAP block alone at the expense of an increased incidence of side effects Unresolved issues: Adjuvant? Impact on the incidence of chronic pain post CD? TAP versus continuous wound infiltration?

Aim of the study was to investigate how standard pain scores compare with comfort scores after CD and determine whether the way pain is assessed affects patient reports of their perceptions and experiences after operation.

Results

Conclusions Direct questioning and rating of pain after CD may adversely affect pain and patient perception of recovery The words used by staff after operation may alter the pain experience for patients It seems reasonable to conduct post-anaesthesia interviews using more permissive open questions such as How are you feeling rather than How much pain have you got? Avoidance of the use of the pain or similar negative words until they are expressed by the patient may be a consideration

Several observational studies have indicated that risk factors may include: 1. An increased number of top-ups or breakthrough pain during labor 2. Increased urgency for cesarean delivery 3. Higher body mass index (BMI) or weight 4. Care being provided by a non-obstetric anesthesiologist 5. Increased duration of epidural analgesia 6. Use of an epidural versus CSE technique for analgesia 7. Lower cervical dilation at the time of epidural placement Study goal: to evaluate the evidence associated with these risk factors

Conclusions: current evidence for risk factors associated with failed conversion of labor epidural Clear evidence for: 1. Number of top-ups or breakthrough pain during labor 2. Urgency for cesarean delivery 3. Care provided by a non-obstetric anesthesiologist Insufficient evidence for: 1. Higher body mass index (BMI) or weight 2. Use of an epidural versus CSE technique for analgesia No evidence for: 1. Duration of epidural analgesia 2. Cervical dilation at the time of epidural placement It is likely that other risk factors exist but they have not been studied!

Hypertensive response to laryngoscopy and intubation in severely preeclamptic women undergoing CD Blood Pressure during Induction of GA in a preeclamptic patient Laryngoscopy and intubation Connell H et al.; Br J Anaesth; 59: 1375-1380, 1987

Attenuation of the hypertensive response to DL and intubation in severely preeclamptic women undergoing CD Dose response study of Remifentanil (Ultiva ) 0,25-1.25 μg/kg RCT 5 x 15 patients Systolic Arterial Pressure Heart Rate Yoo KJ et al. IJOA (2013) 22, 10 18

Dose response curve for success of iv remifentanil in attenuating the pressor response Success = no episodes of SAP <160 mmhg for more than 1 min following intubation ED50: 0.59 (95% CI 0.47 0.70) mcg/kg ED95: 1.34 (1.04 2.19) mcg/kg 2 patients in gp 1 mcg/kg and in gp 1.25mcg/kg had SAP<90 mmhg Yoo KJ et al. IJOA (2013) 22, 10 18

Neonatal effects Yoo KJ et al. IJOA (2013) 22, 10 18

Conclusions: in patients with severe pre-eclampsia undergoing GA for CD Laryngoscopy and intubation may be accomplished without an excessive pressor response when a remifentanil dose of 1.34 mcg/kg is given during RSI (thiopental 5 mg/kg and sux 1.5 mg/kg) in 95% of patients However, respiratory depression requiring ventilatory assistance was observed in many neonates with all doses of remifentanil studied Remifentanil is a useful adjunct in this context but should be used with adequate facilities for neonatal resuscitation Yoo KJ et al. IJOA (2013) 22, 10 18

Epidural test dose and detection of IT catheter Do you use an epidural test dose? What drug and dosage do you use? Anesth Analg 2013;116:125 32 Study goal: to determine whether lidocaine 30 mg was as effective as 45 mg in creating objective and rapid evidence of a sensory or motor block diagnostic of IT injection

Study design 100 patient randomized to 4 groups (all received CSE for elective CD) Group IT30: 3 ml 1% lidocaine (30 mg) + epi 5 μg/ml (15 μg) spinal Group IT45: 3 ml 1.5% lidocaine (45 mg) + epi 5 μg/ml (15 μg) spinal Group EP30: 3 ml 1% lidocaine (30 mg) with epi 5 μg/ml (15 μg) epidural Group EP45: 3 ml 1.5% lidocaine (45 mg) + epi 5 μg/ml (15 μg) epidural Anesth Analg 2013;116:125 32

Results All patients in both IT groups had a motor block by 5 minutes.

False negative using lower bound Outcomes of 10,000 hypothetical patients using a lidocaine 30-mg test dose.

Conclusions Unlikely to be a large difference in the ability of the two doses to detect unintentional IT catheter placement. While the NPVfor IT injection is very high for both doses, the 95% CI for the sensitivity of either dose is too wide to demonstrate clinical safety to identify all intrathecal catheters A much larger study is warranted to assess whether there is a lower sensitivity with the 30-mg dose, or a propensity toward high cephalad motor block levels with the 45-mg dose. Anesth Analg 2013;116:125 32

Clear description of clinical symptoms, patient care and Drugs for each step Clear description of the 4 management steps Higher doses of Tranexanic acid and Fibrinogen Use of Bakri Balloon in Step 3! Criteria for Patient transfer Embolization? Position in the algorithm is not clear!

Do you want to learn more about PPH? See you in Lausanne! Thursday 7.11.2013 SAOA 2013 - FALL MEETING Lausanne Main topic: PPH