regional analgesia for labour pain relief

7/28/2019 Regional Analgesia for Labour Pain Relief

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Regional Analgesia for Labour Pain Relief:n up a e

Marc Van de Velde

Anesthesiology

UZ Leuven

KUL



• Initiation of analgesia: • Choice of local anaesthetic:

• Conventional epidural. • Bupivacaine.

• Combined spinal epidural. • ew -enan omer:

• Ropivacaine.

• Levobupivacaine.

• Adjuvant:

•

• Maintenance of analgesia:

• -

• Dose vs

Concentration:

.

• Adrenaline.

• Clonidine.

•

• Continuous infusion.

• Patient controlled epidural analgesia.• HV – LC

•

other…..



Wh bother to use C E ?

Why change since epidural is so good ?

Problems with epidurals....... Slow onset, especially in late labor.

Failure: atch unilateral block ....: 1-10%.

Motor block, effects on labor outcome.

.

Local anesthetics required. Sometimes high doses required to

produce analgesia.



Onset Time of CSE analgesia

Van de Velde 2004

COMET 2001Van de Velde 2004

Vercauteren 2001

Nickells 2000

Van de Velde 1999

COMET 2001

Nickells 2000

Palmer 1998

Gautier 1997

Joos 1995

Collis 1 50 5 10 15 20 25 30

an e e e

Collis 1995

Abouleish 1994

Collis 1994

Camann 1993

Onset Time (minutes)

0 2 4 6 8 10 12 14

Onset Time (minutes)

Stacey 1993



VAS for pain.

Breen. Techn RAPM 2001; 5, 1, 9 - 13 .



Recurrent breakthrough pain.

16 0,25

10

12 0,2

6

8 Incidence of breakthroughpain 0,1

,

breakthroughpain

2

40,05

Epidural CSE Epidural CSE

Hess et al. Anesth Analg 2001; 93, 414 - 418.



Effect of dural puncture.

450 18

300

350

12

14

150

200 Morphineconcentration inCSF (ng/ml) 6

8 Blockeddermatomes (n)

0

50

0

2

o ura

puncture

puncture

puncture

Swenson et al. Anesth Analg 1996; 83, 523 – 525.

Leighton et al. Anesth Analg 1996; 83, 526 – 529.



Analgesic requirements.

Van de Velde et al. Acta Anaesth Belg 1999; 50, 129 - 136.



Reliability epidural catheters.

Van de Velde et al. Anaesth Intens Care 2001; 29, 6, 595 – 599.



Reliability epidural catheters.

1,2

1,4

6

7

5

6

0,4

0,6

0,8 Epiduralecatheter falen(% van depatienten)

2

3

4

5

Epidurale

catheter falen

(%)2

3

4

Catheter failure rate

0

0,2

CSE Epidurale01

CSE Epidurale

0

1

CSE Epidurale

25

30

35

40

Unilateral 2

2,5

3

,

% patients 8

10

12

14

Epidural

0

5

10

15analgesia

0

0,5

1

1,5 w ca e er replacement

0

2

4

6 replacementrate (%)

Norris. IJOA 2000; 9, 3 - 6. COMET study group. Anesthesiology 2002; 97, 1567 – 1575.Pratt et al. Anesthesiology 1999; SOAP A63. Vernis et al. Eur J Anaesth 2004; 21, 186 – 192.

Van de Velde et al. Anaesth Intens Care 2001; 29, 6, 595 – 599. Eappen et al. IJOA 1998; 7, 220 – 225.

p ura



Side effects.

• Complications related to IT drugs:•

Pruritus..

• Hypotension.• Respiratory depression.

• •

Central nervous system infections.• Neurologic complications.• Post dural puncture headache (PDPH).

• Complications related with the progress of labor.• Motor block.•

Progress and outcome of labor. .• Fetal heart rate changes.• Neonatal outcome.



Damage to the conus medullaris.

Several cases of conus damage. Inappropriate level of puncture.

- - - .

Reynolds F. Anaesthesia 2001; 56, 238 – 247.



Conus ends lower than L1, sometimes.

Reynolds F. Anaesthesia 2001; 56, 238 – 247.



Conus ends lower than L1, sometimes.

Broadbent et al. Anaesthesia 2000; 55, 1122 – 1126.



Correct identification of L3 – L4.

Broadbent et al. Anaesthesia 2000; 55, 1122 – 1126.Van Gessel et al. Anesth Analg 1993; 76, 1004 – 1007.



Ultrasound

Whitty et al. Anesth Analg 2008; 106, 536 - 540.



Ultrasound

Schlotterbeck et al. Brit J Anaesth 2008; 100, 230 - 234.






• Ropivacaine.


• Adjuvant:

•


• -

• Dose vs

Concentration:

.

• Adrenaline.

• Clonidine.

•



•

other…..






• Ropivacaine.


• Adjuvant:

•


• -

• Dose vs

Concentration:

.

• Adrenaline.

• Clonidine.

•



• other…..



e a ve po ency.

Van de Velde et al. Anesthesiology 2007; 106, 149 – 156.



bupivacaine 0.25% versus ropivacaine 0.25%.

Ropivacaine Bupivacaine

Spontaneous 58.3 % 48.9 % *

• With ropivacaine:

• Less motor block.

Instrumental 27.1 % 40.0 % **

Caesarean section 14.6 % 11.2 %

• More spontaneous deliveries.

• Better NACS scores.

7

8

50

60

Broma e

3

4

5

NACS <35 at 24 hours(%)

30

40 scoreropivacaine(%)

Bromage

0

1

Ropivacaine Bupivacaine 0

10

0 1 2 3

bupivacaine(%)

Writer et al. Brit J Anaesth 1998; 81, 713 - 717.



a meta-analysis.

Less motor block with ro ivacaine !!!!

Halpern et al. Anesth Analg 2003; 96, 1473 – 1479.



Epidural ropivacaine versus bupivacaine for labor:

,concentrations of local anaesthetic in both groups.

Study Bupivacaine Ropivacaine Number of study subjects

Cam bell et al. 5 0 * 40

Meister et al. 18 8 * 50

Gautier et al. 15 3 * 90

Lee et al. 21 10 346

Owen et al. 12 8 50

Gogarten et al. 11 4 109

Chua et al. 5 3 32

Fischer et al. 19 10 189

TOTAL 106 46 906

Number of patients with motor block.* P < 0.05 versus bupivacaine.



Epidural ropivacaine versus bupivacaine:

ropivacaine concentrations.

Gautier et al Anesthesiology 1999; 90, 772 - 778.



Spinal ropivacaine versus bupivacaine for labor:

,doses of local anaesthetic in both groups.

Study Bupivacaine Ropivacaine Number of study subjects

Levin et al. 0 0 40

Hughes et al. 8 1 * 50

Lim et al. 5 2 * 90

TOTAL 13 3 128

Number of patients with motor block.* P < 0.05 versus bupivacaine.



Is less motor block important ?

Increases the spontaneous vaginal delivery rate.

.

Reduces the incidence of bladder catheterization.

a es am u a on sa er.






• Ropivacaine.

•

Levobupivacaine.

• Adjuvant:

•


• -

• Dose vs

Concentration:

.

• Adrenaline.

• Clonidine.

•



• other…..






• Ropivacaine.

•

Levobupivacaine.

• Adjuvant:

•


• -

• Dose vs

Concentration:

.• Adrenaline.

• Clonidine.

•



• other…..



Maintenance of labour e idural anal esia:

Data from Flanders.

Van Houwe et al. Acta Anaesthesiol Belg 2006; 57, 29 - 37.



Maintenance of labour e idural anal esia:

Data from Belgium.

Petré et al. OAA annual meeting.



Quality of pain relief: VAS scores similar !!!

Gambling et al. Can J Anaesth 1988; 35, 249 – 254.

Lysak et al. Anesthesiology 1990; 72, 44 – 49.

–

Ferrante et al. Anesth Analg 1991; 73, 547 – 552.

Purdie et al. Br J Anaesth 1992; 68, 580 – 584.

. , – .

Ferrante et al. Anesth Analg 1994; 79, 80 – 84. Curry et al. Pain 1994; 57, 125 – 128.

. ; , – .

Sia et al. Anaesth Intens Care 1999; 27, 154 – 158.

Boutros et al. IJOA 1999; 8, 236 – 241.

Collis et al. Br J Anaesth 1999; 82, 233 – 236.

Smedvig et al. Acta Anaesthesiolo Scand 2001; 45, 595 – 599.

Ledin Eriksson et al. Acta Anaesthesiol Scand 2003; 47, 1085 – 1090.



Quality of pain relief: VAS scores.

Vandermeulen et al. Eur J Obst Gyn Reprod Biol 1995, S59, 47.



Anaesthetist intervention rate.

Continuous infusion epidural analgesia is

u ......

....... avoids delays in administration of top-ups and provides smooth analgesia ......



Anaesthetist intervention rate.

Van der Vyver et al. Br J Anaesth 2002; 89, 459 - 465.



Local anaesthetic requirements.

Van der Vyver et al. Br J Anaesth 2002; 89, 459 – 465.



Incidence of motor block.

100 P = 0.003

85

90

7075 % of patientswith no motor

block

55

60

50PCEA CEI

Van der Vyver et al. Br J Anaesth 2002; 89, 459 – 465.



Incidence of spontaneous delivery.

CIE vs PCEA

Eddleston et al. Br J Anaesth 1992; 69, 154: 47% vs 60%

Gambling et al. Can J Anaesth 1993; 40, 211: 21% vs 51%

Ferrante et al. Anesth Anal 1994; 79, 80: 60% vs 87%

Curry et al. Pain 1994; 57, 125: 47% vs 57%

Less outlet forceps deliveries



Maintenance of e idural anal esia

following the initial spinal dose.

80

60

70

40

50 Incidence of breakthrough

pain (% of patients with atleast 1 episode of breakthrough pain requiring

10

20anaesthetist intervention)

0PCEA alone PCEA + 2 ml/h

Van de Velde et al. Anaesth Intensive Care 2005; 33, 452.



Maintenance of e idural anal esia

following the initial spinal dose.

50

40

20

30Local anaestheticconsumption (mg)

10

0PCEA alone PCEA + 2 ml/h

Van de Velde et al. Anaesth Intensive Care 2005; 33, 452.



Some recent advances.

PCEA + Programmed intermittent epidural bolus.

.

Computer integrated patient-controlled epidural

.



PCEA with ro rammed intermittent

epidural bolus.

2 groups:

+ -

PCEA + 5 ml bolus automatically every hour. (PCEA-AMB)

Results: PCEA + AMB resulted in

.

Longer survival of spinal part of analgesia.

Sia et al. Anesth Analg 2007; 104, 673 - 678 .



PCEA with ro rammed intermittent

epidural bolus.

2 groups:

PCEA + 12 ml/h CEI. (PCEA-CEI)

PCEA + 6 ml bolus automatically every 30 minutes. (PCEA-AMB)

Results: PCEA + AMB resulted in

Less bupivacaine consumption. Less clinician administered rescue doses.

Higher patient satisfaction scores.

Wong et al. Anesth Analg 2006; 102, 904 - 909 .



Systematic intermittent boluses.

Chua et al.: CEI 5 ml/h vs AIB 5 ml/hour.

. .

resu e n:

Less pain.

.

Higher maternal satisfaction.

Lim et al. IJOA 2005; 14, 305 - 309.Chua et al. Can J Anaesth 2004; 51, 581 – 585.

C t i t t d ti t



Com uter inte rated atient

controlled epidural analgesia.

2 groups:

’, , - .

PCEA + background infusion according to PCEA demands in the

previous hour. (PCEA-CI)

Sia et al. Singapore Med J 2006; 47, 951 - 956.Lim et al. Anaesthesia 2006; 61, 339 – 344.

C t i t t d ti t



Com uter inte rated atient

controlled epidural analgesia.

Results:

PCEA-CI resulted in: Less breakthrough pain.

Higher maternal

satisfaction.

Sia et al. Singapore Med J 2006; 47, 951 - 956.Lim et al. Anaesthesia 2006; 61, 339 – 344.

I iti ti f l i • Choice of local anaesthetic:



• Initiation of analgesia: Choice of local anaesthetic:



• Ropivacaine.

•

Levobupivacaine.

• Adjuvant:

•


•-

• Dose vs

Concentration:

.• Adrenaline.

• Clonidine.

•



• other…..

Initiation of analgesia: • Choice of local anaesthetic:



• Initiation of analgesia: Choice of local anaesthetic:



• Ropivacaine.

•

Levobupivacaine.

• Adjuvant:

•


•-

• Dose vs

Concentration:

.• Adrenaline.

• Clonidine.

•



• other…..



Why combining drugs ?

Additive effects.100

70

80

90

30

4050

.

0

10

20

0 100 200 300 350 400

Clonidine dose (mcg).

Eisenach et al. Anesth Analg 1994; 79, 285 – 290.



Adjuvant drugs.

Opioids:

en any .

Sufentanil.

α2 - adrenergic agents: Clonidine.

Epinephrine.

Neostigmine.

enos ne.

Magnesium.

Pure e idural o ioid anal esia:



Pure e idural o ioid anal esia:

first stage labor.

250Dose log (mcg)

MLAD 124.2 mcg (118.1 – 130.6).

100

125

FentanylSufentanilPotency ratio: 5.9 (5.6 – 6.3)

15

30 MLAD 21.1 mcg (20.2 – 21.9).

1 6 11 16 21 26 31

Patient se uence

Capogna et al. Anesth Analg 2003; 96, 1178 - 1182.

O ioids added to e idural local



O ioids added to e idural local

anesthetic agents.

Shorter onset of analgesia.

Prolon ed duration of anal esia. Less local anaesthetic consumption.

Less problems with insufficient analgesia.

Less motor block.

Higher spontanuous delivery rate.

Vertommen et al. Anesthesiology 1991; 74, 809 – 814.Polley et al. Anesthesiology 1998; 89, 626 - 632.

Pure intrathecal o ioid anal esia:



Pure intrathecal o ioid anal esia:

fentanyl dose response curve.

Palmer et al. Anesthesiology 1998; 88, 355 - 361.

O ioids and local anesthetics



O ioids and local anesthetics

combined for intrathecal use.

MLAD

95% CI m

Duration of Analgesia

(min)

Bupivacaine plain 1.99 (1.71 – 2.27) 43.1

Bupivacaine +fentanyl 5 μg

0.69 (0.35 – 1.02) 56.1

Bupivacaine +

fentanyl 15 μg

0.71 (0.00 – 1.53) 68.5

Bupivacaine +

fentanyl 25 μg

0.85 (0.58 – 1.13) 77.2

Stocks et al. Anesthesiology 2001; 94, 593 – 598.



α2-receptor agonists.

Peripheral afferent fibers

α2-receptors. Spinal – dorsal hornPresynaptic:

inhibition of neuro-

α2A α2B α2C α2DSupraspinal

transmitter release

Postsynaptic:

Stimulation results in:

yperpo ar sa on

Inhibition of

transmission

•Analgesia.

•Sedation.

•Inhibition of autonomic outflow.



Epidural clonidine and spinal cord blood flow.

20

25 Epidural saline

Epidural clonidine

10

15

0

5

Gordh et al. Anesth Analg 1986; 65, 1303 - 1311.Eisenach and Grice. Anesthesiology 1988; 68, 335 - 340.



Clonidine and myometrial activity.

Sia et al. IJOA 2005; 14, 104 – 107.



Epidural clonidine 75 μg.

Landau et al. Anesth Analg 2002; 95, 728 - 734.

E idural continuous infusion of



E idural continuous infusion of

clonidine: 5 mcg/ml at 10 ml/hour.

Parker et al. J Anesth 2007; 21, 142 - 147.



Intrathecal clonidine.

Duration

(min)

No clonidine Clonidine

D’An elo 132 ± 39 197 ± 70 100

110

PLAIN-group

CLON-group

Mean arterial pressure (mmHg)

Sia 111 ± 22 144 ± 28

Paech 99 91–134 116 102-14270

80

90 * * * **

Van de Velde 90 ± 36 122 ± 56

0 5 10 20 30 40 50 60

60

* p <0.05 versus CLON-group. Time (minutes)

15 – 50 μg clonidine added to a local

anesthetic/sufentanil spinal mixture prolongs

analgesia duration.

Significant hypotension develops.

D’Angelo et al. Anesth Analg 1999; 88, 573 – 576. Sia et al. Can J Anaesth 2000; 47, 875.

Paech et al. Anesth Analg 2002; 95, 1396 - 1401. Van de Velde et al. Can J Anaesth 2004; 51, 696 - 701.

Belhadj Amor et al. Ann FrAnesth Reanim 2007; 26, 916 – 920.



Clonidine: conclusions.

Epidural:

p ma e ec ve ose - μg.

With this dose: no significant side effects.

Spinal:

Effective in a dose range from 15 – 200 μg.

Produces significant hypotension.



Neostigmine.

Neostigmine: cholinesterase inhibitor.

Stimulates acetylcholine mediated

mechanisms of analgesia.

Neosti mine:

Spinal analgesia.

.



Neostigmine: safety. No toxicity in rats and dogs

followin chronic intrathecaladministration.

30

35

40 Neostigmine 2 mg IT

o e ec s on reg ona sp na

cord perfusion.1520

25

0

5

10

Time (minutes)

Yaksh et al. Anesthesiology 1995; 82, 412 – 427.Hood et al. Anesthesiology 1995; 82, 428 – 435.



p ura neos gm ne.

Roelants et al. Anesthesiology 2005; 102, 1205 - 1210.



– – –

clonidine.

Owen No

neostigmine

Neostigmine

Duration of 123 ± 21 165 ± 32

D’Angelo No

neostigmine

Neostigmine

Analgesia

Hypotension 27 7

Analgesia

Hypotension 87 67

Nausea 0 33 Nausea 7 53

Owen et al. Anesthesiology 2000; 92, 361 – 366.D’Angelo et al. Anesth Analg 2001; 93, 1560 - 1564.



Neostigmine: conclusions.

Neostigmine should not be used intrathecally.

Î NAUSEA and VOMITING

It has beneficial effects on labour pain when



• Conventional epidural.•

Bupivacaine.


• Ropivacaine.


• Adjuvant:

•


•

-

• Dose vs

Concentration:

.• Adrenaline.

• Clonidine.

•



• other…..



High Volume – Low Concentration

Anesth Analg 2007; 104, 412 – 415.

The ideal central neuraxial labour



analgesia strategy.

Initiation: CSE.

– – low concentration (<0.2%).

–

mL/hour).

levobupivacaine.

Ad uvant dru s: O ioids ± e idural clonidine ±epidural neostigmine.

Clonidine and neostigmine: breakthrough pain.



Speakers include:



Ruth Landau, SwitserlandFrederic Mercier, France

Alex Sia Sin a ore

Patricia Lavand’Homme, Belgium

Roshan Fernando, UK

Frederik De Buck, Belgium

c ar ,Yves Jacquemin, Belgium

Mike James, South Africa

Linda Polle , US

Chris Verslype, Belgium

Steve Yentis, UKJose Carvalho, Canada

c ar arne ,

Robin Russel, UK

Gordon Lyons, UK

Poster sessions

Free papers

Lunch symposia



Social Programme

Wednesday evening reception.

Thursday:

.

Wednesday: ½ day tour of the island.

– holiday.

regional analgesia for labour pain relief

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