walking epidurals epidurals MYTHS BSA 2008.ppt

regional anaesthesia

1. Walking Epidurals
For
Painless Labor
Associated Side Effects
Bundle of MYTHS &
Misconceptions
Dr. AnkitSharma
Specialist
Department of Anaesthesia & Intensive Care
Dr. B. S. A. Hospital, Rohini
Brief Review of the Newer Techniques

2. Journey of painless labor has not been
SMOOTH
Sir John Snow & Queen Victoria 1853
Secretly called to Buckingham Palace by Queen Victoria for her delivery of
Prince Leopold
Religious Acceptance
1855: Queen’s acceptance of “that blessed chloroform” for childbirth.
Pain Relief
in labor
A Sinful
Act

3. A Large RCT conducted by Christopher Viscomi, MD.
Director: Acute Pain Medicine and Regional Anesthesia
University of Virginia., 2001
Pain & Outcome of Labor :
A Valuable Insight
Had epidurals been available…
??????The “horrible/excruciating” group was heading for a
long labor and high chance of Cesarean delivery.
??????The Horrible/excruciating group would very likely have
requested epidurals in great numbers in early labor.
??????If this had happened, then epidurals would have been
blamed for long labors, C/S.

4. Neurotrauma
Infection
Others
Pruritus
PDPH
↓FHR
CSE

5. A high spinal block
A post-dural puncture headache
Fetal bradycardia
Meningitis
Increased risk for a spinal catheter
Cost
Incidence of all these risks is either less or
comparable with that of epidurals alone
Robert D’ Angelo :
ASRA NEWS NOV,2004

6. CSE technique might actually decrease the incidence of
duralpuncture with the epidural needle by allowing
the anesthesiologist to confirm an equivocal loss of
resistance by passage of a pencil point 27G spinal
needle rather than advancing the large bore 16G
epidural needle further
Post Dural Puncture Headache
Incidence ~ 1%
MYTH
Every Dural puncture is associated with a little or less headache
Reality
Multiple punctures with thin gauge spinal or large bore
epidurals are the main culprits

7. 985 women were followed postpartum for 3 days after delivery with a
structured interview.10 of them developed headaches with median onset
after 2 days.
Risk factors were:
known inadvertent duralpuncture with the epidural needle (but this
only accounted for 4 of them)
previous headache history
Multiparity
and increasing age.
Not all headaches are due to an anesthetic!
Mostly self remitting
Supine position, plenty of oral fluids generally suffice
NSAIDS, Paracetamol
Rarely do we need a epidural blood patch

8. Case series of 30 patients
50 µg of IT fentanyl
2 patients with fetal bradycardia
4 patients with evidence of uterine hypertonus
Spontaneous resolution or response to terbutaline
in 3 of the above cases
1 Cesarean section
Neonatal outcome good in all cases

9. 1993Cohen AnesthAnalg 15%(11/73)
1994Clark Anesth’logy 30%(9/30)
1997Campbell DC Anesth’logy15%(6/39)
1998Gambling Anesth’logy 18%(72/400)
1999Palmer AnesthAnalg 12%(12/100)
2000Wong Anesth’logy 17%(28/67)
2001Van de VeldeRegAn Pain Man
11%(40/351)

10. Fetal Bradycardia
After Labor Analgesia
Pain Relief
Decreased Circulating Epinephrine
Increased Uterine Tone
Decreased Uterine Blood Flow
Fetal Bradycardia
Caused by opiates : spinal/epidural
Real Myth
Fact

11. -60
-40
-20
0
BL5 min10 15 20 25 30
Epidural
CSE
% Change Epinephrine Levels after Analgesia
Cascioet al. Can J Anaesth1997; 44:605-609

12. Left uterine displacement
Maternal position change
O
2administration
STOP OXYTOCIN!
Fetal scalp stimulation
Nitroglycerin: 400 µg sublingual X 2 (or more)
 100 µg IV repeated as needed
Terbutaline0.25 mg, subcutaneous
Treat hypotension
Ephedrine -epinephrine level; UBF

13. NO:CSE vs. Systemic opioids / No analgesia
(Albright and Foster, 1997)
NO:CSE vs. Epidural (greater risk for C/S in both
groups if new FHR changes occurred)
(Nielsen et al, 1996)
NO:CSE vs. Epidural
(Van de Velde et al 2001, 2002)
NO:CSE vs. Epidural
(Norris et al. 2001)

14. Unrealistic expectations of the Parturients
A Dramatic increase in the success rate along with reduction of complications
was noted when the
Expecting ladies were educated at the time of ANC
& were briefed about the procedure of epidurals as well as there doubts and
queries were answered by the Anaesthetists
Ignorance is the biggest threat
Accidentally or Voluntarily increasing the drug doses for better effect
Improper “timing” of the CSE
Some of them are destined for a section
Blame it on global warming or ISI but not the epidurals !

15. From 1985 to present use of epidural analgesia for
labor has increased from 10% to over 50% of
laboring women in the U.S.
-40% OPTING FOR PARENTERAL
MEDICATIONS
-10% RECEIVED NO ANALGESIA
Or NATURAL CHILDBIRTH TECHNIQUES
WHAT ABOUT THE REST?
Proof of SAFETY

16. Use lowest effective dose of opioid, don’t repeat
Monitor BP, FHR, Respiration, (SpO2 if indicated)
Expect potentiationof epidural doses
All mixtures hypobaric -avoid prolonged sitting
position after block
Treat hypotension and uterine hypertonus
Naloxone and resuscitation equipment available
Same or greater surveillance as after epidural

17. 3-95% of patients
Effect is time limited, peak at
30min and largely resolved
within 1hr
Reassurance is usually sufficient
Prophylactic Ondansetron
Pruritus

18. Neuro-Trauma & Infection
Reports of Transient Neurological Symtoms
All associated with Hyperbaric Lignocainewhich is obsolete these days
Mild Discomfort at the site of injection
Operator’s experience
Patients co-operation
Factis that: All Back aches tend to be attributed to that very Injection
Definite Risk of Infections
Only if you don’t follow Strict ASEPSIS PROTOCOL
Careful patient selection
Inobstetrics,nerveinjuryintheparturientisusuallynotrelatedto
anesthesiabuteithertocompressionofthelumbosacraltrunkbetween
theheadofthefetusandthesacrumortokinkingorcompressionofthe
femoral,lateralfemoralcutaneous,orperonealnerveswhenthepatient
isinthelithotomyposition

19. Can the Procedure
FAIL
To provide adequate analgesia ?
Total failure
Catheter in wrong place
Given too late in labour
Partial failure
Unilateral block
Missed segment
Inadequate
dose/concentration
Low backache
Full bladder
Rectal pain
Pathological pain: uterine
rupture
Failure to give top-ups

20. Journey of Labor Analgesia
does not halt with Walking Epidurals……..............
Newer techniques
Continuous spinal analgesia with microcatheters(28 G)
I/V PCA Analgesia using Remifentanil 0.25 –0.5 µg/kg
Single Isomer L. A. such as levo-Bupivacaine and Ropivacaine

21. Newer Epidural
needles
Spinal conduit serves as a break against
inadvertent epidural needle protrusion into spinal space .
Epidural catheter can be inserted before
the spinal anesthesia injection
Test dose through the epidural catheter to check malposition
before inserting the spinal dose
www.csen.com/benefits.htm

22. ……….
Newer Drug Delivery Systems
Programmed intermittent Epidural Bolus
with Continuous Epidural Infusion
for Labor Analgesia
Wonget al Anesthesia & Analgesia 2006; 102(3):904-0

23. It is the Expertise of the Anaesthesiologist, Technique, Technology
and
the Advancement in Pharmacology
which
are likely to contribute together
In order to evolve something beyond
WALKING EPIDURALS

24. YES
CSE IS THE IDEAL LABOR ANALGESIA TECHNIQUE
Answer to the Q. asked in previous
presentation

25. “Man endures pain as an
undeserved punishment,
woman accepts it as a
natural heritage”
Thank You