what‘s new in obstetric anesthesia? - sgar-ssar.ch · conclusions: in patients with severe...

What‘s new in obstetric anesthesia?

SAOA 2013 - SPRING MEETING – BERN

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 ?

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

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

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

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 !

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

Connell H et al.; Br J Anaesth; 59: 1375-1380, 1987

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

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

Yoo KJ et al. IJOA (2013) 22, 10–18

Systolic Arterial Pressure Heart Rate

Dose–response curve for success of iv remifentanil in attenuating the pressor response

Yoo KJ et al. IJOA (2013) 22, 10–18

2 patients in gp 1 mcg/kg and in gp 1.25mcg/kg had SAP<90 mmHG

ED50: 0.59 (95% CI 0.47– 0.70) mcg/kg ED95: 1.34 (1.04–2.19) mcg/kg

Success = no episodes of SAP <160 mmHg for more than 1 min following intubation

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

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

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.

Outcomes of 10,000 hypothetical patients using a lidocaine

30-mg test dose.

False negative using lower bound

Outcomes of 10,000 hypothetical patients using a lidocaine

30-mg test dose.

False negative using lower bound

Outcomes of 10,000 hypothetical patients using a lidocaine

30-mg test dose.

False negative using lower bound

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

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

Clear description

of the 4 management

steps

Clear description of clinical symptoms, patient care and Drugs for each step

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