Safety and quality of Safety and quality of neuraxial analgesianeuraxial analgesia

Ulla Sipiläinen Ulla Sipiläinen

6.10. 20116.10. 2011

HUCS Jorvi hospitalHUCS Jorvi hospital

Chestnut´s ChecklistChestnut´s Checklist• Preparation for neuraxial labor analgesiaPreparation for neuraxial labor analgesia1.Communicate (early) with obst provider 1.Communicate (early) with obst provider

review parturient´s obst historyreview parturient´s obst history2.Perform focused preanesth eval: 2.Perform focused preanesth eval:

review maternal obst, anest, health review maternal obst, anest, health historyhistoryperform targeted physical exam (vital perform targeted physical exam (vital signs, airway, heart, lungs, back)signs, airway, heart, lungs, back)

3.Review relevant lab and imaging studies3.Review relevant lab and imaging studies

• 4.consider need for blood typing and 4.consider need for blood typing and screening or crossmatchingscreening or crossmatching

• 5.formulate analgesia plan5.formulate analgesia plan• 6.obtain informed consent6.obtain informed consent• 7.perform equipment check7.perform equipment check• Check routine equipmentCheck routine equipment• Check emergency recuscitation Check emergency recuscitation

equipmentequipment8.Obtain peripheral intravenous acces8.Obtain peripheral intravenous acces9.Apply maternal monitors ( Hr, BP, 9.Apply maternal monitors ( Hr, BP,

PulseoximeterPulseoximeter10.Perform a team time-out. 10.Perform a team time-out.

Real life checklistReal life checklist

• Airway, airway, airway!Airway, airway, airway!• Trombosytes, if symptoms of pre-Trombosytes, if symptoms of pre-

echlampsiaechlampsia• Position: BMIPosition: BMI• AllergiesAllergies

maintain your skillsmaintain your skills

• wet tap rate / dural puncture ratewet tap rate / dural puncture rate• teaching problematicteaching problematic• formal training programme for formal training programme for

epidural analgesia?epidural analgesia?• simulator?simulator?

PositionPosition

• sitting/ on side sitting/ on side • weight>height-100, examp, weight>height-100, examp,

170cm, 80kg 170cm, 80kg • consider sitting positionconsider sitting position

Skin preparationSkin preparation

• meningitismeningitis• epidural infectionepidural infection• wear mask, sterile gloves, hatwear mask, sterile gloves, hat• skin preparationskin preparation• infections are very rareinfections are very rare• st viridansst viridans

early vs late epiduralearly vs late epidural

• cervical dilatation less than 4 cmcervical dilatation less than 4 cm• with low-dose local anesthetic with low-dose local anesthetic

techniquetechnique• no difference in cs ratesno difference in cs rates

• C. Wong 2005 and 2009C. Wong 2005 and 2009

CSE vs epidural CSE vs epidural analgesiaanalgesia

• CSE when it is really neededCSE when it is really needed• multiparous patients in advanced, multiparous patients in advanced,

rapidly progressing labourrapidly progressing labour• even single-shot spinaleven single-shot spinal• risk of cs, obese, very painfulrisk of cs, obese, very painful

Air vs SalineAir vs Saline

• saline is recommendedsaline is recommended• saline with small air bubblesaline with small air bubble• in Finland air is most popularin Finland air is most popular• no differences in the incidence if no differences in the incidence if

PDPH between saline or airPDPH between saline or air

Continous vs Continous vs intermittentintermittent

• pressure in loss of resistance pressure in loss of resistance syringesyringe

• no difference no difference • personal preferencespersonal preferences

VolumeVolume

• high-volume high-volume • low concentration solutionslow concentration solutions• better analgesia with 20ml better analgesia with 20ml

epidural than 13ml or 15mlepidural than 13ml or 15ml• if one-sided or in-adequate if one-sided or in-adequate

analgesia, volume addition ad 5 ml analgesia, volume addition ad 5 ml before replacement before replacement

PCEA, infusion, bolus?PCEA, infusion, bolus?

• maintainingmaintaining• volume!volume!• second dose intructions for second dose intructions for

midwife: 20mlmidwife: 20ml• PCEA best, large bolus are needed PCEA best, large bolus are needed

to spread widelyto spread widely

Intra-venous epiduralIntra-venous epidural

• test dose!!test dose!!• catether migrate into veins very catether migrate into veins very

easily and ofteneasily and often• saline -injektion, aspirationsaline -injektion, aspiration• important to detectimportant to detect

Obese partiturentObese partiturent• greater risk for csgreater risk for cs• epidural space?epidural space?• lumbar space?lumbar space?• position: sittingposition: sitting• G18/G27 120mm needleG18/G27 120mm needle• CSE or epiduralCSE or epidural• favour early analgesiafavour early analgesia

TapingTaping

• flexed position minimizes the flexed position minimizes the distance between skin and distance between skin and epidural spaceepidural space

• the catether can move up to 4 cmthe catether can move up to 4 cm• leave the catether 5-6 cm into the leave the catether 5-6 cm into the

epidural spaceepidural space

RoutinesRoutines

• routines protect from mistakesroutines protect from mistakes• variation between phycisiansvariation between phycisians• analgesia similar undependantly analgesia similar undependantly

from person on callfrom person on call

Incidence and chaceterics Incidence and chaceterics of failures in obstetr of failures in obstetr

analgesiaanalgesia• Retrospective analysis of 19 259 Retrospective analysis of 19 259

deliveriesdeliveries• 12 590 analgesia12 590 analgesia• Overall failure rate 12% Overall failure rate 12% • 6.8 % imcomplete analgesia 6.8 % imcomplete analgesia • 5.6% catether replacement for 5.6% catether replacement for

inadequate analgesiainadequate analgesia• 98.8% adequate analgesia98.8% adequate analgesia• Pan P. et al Int J Obst Anest 2004:13; 227-233Pan P. et al Int J Obst Anest 2004:13; 227-233

Inadequate analgesiaInadequate analgesia

• Consider other causes of pain: Consider other causes of pain: distended bladder, ruptured uterusdistended bladder, ruptured uterus

• Evaluation: catether in epidural space? Evaluation: catether in epidural space? -> not-> replacement or consider CSE-> not-> replacement or consider CSE

• Inadequate analgesia, asymmetric Inadequate analgesia, asymmetric block-> inject saline 5mlblock-> inject saline 5ml

• CSE has lower failure rate than epiduralCSE has lower failure rate than epidural

Intrathecal catether Intrathecal catether

• important to detectimportant to detect• test dose always via catethertest dose always via catether• immediate analgesiaimmediate analgesia• total spinal anaesthesia may be total spinal anaesthesia may be

disasterousdisasterous

Accidental dural Accidental dural puncturepuncture

• earlier: catether placed for 24 hrsearlier: catether placed for 24 hrs• now: new epidural analgesia from now: new epidural analgesia from

another lumbar space and epidural another lumbar space and epidural blood patch if needed after 24 -36 blood patch if needed after 24 -36 hrshrs

• delayd application of EBP may delayd application of EBP may cause problems, be aware!cause problems, be aware!

Neuraxial analgesia and Neuraxial analgesia and neuraxial injuryneuraxial injury

• common claimcommon claim• indirect injury: longer second stage indirect injury: longer second stage

of labourof labour• relaxation of pelvic muscles -> relaxation of pelvic muscles ->

delays rotation of headdelays rotation of head• no pain-> encourage to push no pain-> encourage to push

without changing body positionwithout changing body position

Adverse delivery Adverse delivery outcomes outcomes

• weakened desire to pushweakened desire to push• increases the risk of instrumental increases the risk of instrumental

deliverydelivery• risk of vaginal/ perineal traumarisk of vaginal/ perineal trauma

• back pain is commonback pain is common

RecommendationsRecommendations

• instructionsinstructions• also for potential complicationsalso for potential complications• iv line, hydrationiv line, hydration• hypotensionhypotension• anesthesia for CSanesthesia for CS• fastingfasting• dural puncturedural puncture

Conclusion 1Conclusion 1

• ””Unreasonable to expect, that Unreasonable to expect, that neuroblocade of the half lower neuroblocade of the half lower body NOT have any affect on body NOT have any affect on labour process..labour process..””

• Chestnut`sChestnut`s

dose examplesdose examples• Ropivacaine 2 mg/ml 10mlRopivacaine 2 mg/ml 10ml• Fentanyl 0.05mg/ml 2ml Fentanyl 0.05mg/ml 2ml • Saline ad 20ml Saline ad 20ml

• 2-dose, given by midwife:2-dose, given by midwife:• 10ml ropivacaine10ml ropivacaine• fentanyl 0.05mg/ml 1ml (Sic!)fentanyl 0.05mg/ml 1ml (Sic!)• Saline 9ml, total dose 20ml.Saline 9ml, total dose 20ml.

dose examplesdose examples

• CSE: CSE: • Bupivacain 2.5mgBupivacain 2.5mg• Fentanyl 25mcgFentanyl 25mcg• saline ad 2mlsaline ad 2ml

ConclusionConclusion

• Instructions for own hospital Instructions for own hospital • Analgesia should be given early Analgesia should be given early

enoughenough• Does not increase cs rateDoes not increase cs rate

Thank you!Thank you!