Remifentanil in labor - sfai.se€¦ · Remifentanil in labour analgesia – where are we in 2017 –an update. Vegard Dahl, Head of Dept of Anaesthesia and Intensive Care, Professor,

Remifentanil in labour analgesia ndashwhere are we in 2017 ndash an update

Vegard Dahl Head of Dept ofAnaesthesia and Intensive Care

Professor Akershus University Hospital Norway

SSAI Malmoslash 2017

Disclosures

bull Nonehellip


Agenda

bull Pharmacology

bull Does it work

bull Whys use it at all

bull Conclusion


Remifentanil - Pharma


Pharmacology

bull Highly lipid soluble micro-receptor agonist opioid

bull 70 proteinbound

bull Esther linkage - undergoes rapid hydrolysis to remifentanil acid by tissue and plasma estherase T12 1-5min

bull Context sensitive half-life 3-4 minutes

bull Potency = 2x fentanyl 100-200x morphine

bull Lower plasma concentration in pregnants versus non-pregnants ndash large variability


Fetal exposure

bull Uterine veinMaternal artery ratio 088

bull Umbilical arteryumbilical vein ratio 029

ndash Redistribution rapid fetal metabolism


Is it in use



RemiPCA SAFE NetworkcopyRegimenConcentration of Remifentanil 20mcgml (2mg Remifentanil in 100ml NaCl 09)Bolus 10-30 μgLockout interval 2 minNo additional infusion of remifentanil No application of any other opioid or analgesicdrug

httpswwwgooglecommapsdviewermid=1BrSGgixaIx0JjdvPPBPbHjzlkUAampusp=sharing

2017 7800 deliveries

266 Hypoxia26 Sedation17 Nausea



Labor or Delivery Opioids cross the placenta and may produce respiratory depression and psycho-physiologic effects in neonates An opioid antagonist such as naloxone must be available for reversal of opioid-induced respiratory depression in the neonate ULTIVA is not recommended for use in pregnant women during or immediately prior to labor when other analgesic techniques are more appropriate Opioid analgesics including ULTIVA can prolong labor through actions which temporarily reduce the strength duration and frequency of uterine contractions However this effect is not consistent and may be offset by an increased rate of cervical dilation which tends to shorten labor Monitor neonates exposed to opioid analgesics during labor for signs of excess sedation and respiratory depression

USA2015 36 occasionally

Bhatia K Unknowns in the use of remifentanil PCA for labour analgesia Anaesthesia 201368(6)641-2

Birnbach DJ Ranasinghe JS Is remifentanil a safe and effective alternative to neuraxial labor analgesia It all depends Anesth Analg 2014118(3)491-3

Bonner JC McClymont W Respiratory arrest in an obstetric patient using remifentanil patient-controlled analgesia Anaesthesia 201267(5)538-40

Daly O Kelly KP McCormack JG Heidemann BH Remifentanil PCA in labour Anaesthesia 201368(7)780-1

Devabhakthuni S Efficacy and safety of remifentanil as an alternative labor analgesic Clin Med Insights Womens Health 2013637-49

Freeman LM Bloemenkamp KW Franssen MT et al Patient controlled analgesia with remifentanil versus epidural analgesia in labour randomised multicentreequivalence trial BMJ 2015350(7997)11

Kranke P Girard T Lavandhomme P Melber A Jokinen J Muellenbach RM et al Must we press on until a young mother dies Remifentanil patient controlled analgesia in labourmay not be suited as a poor mans epidural BMC Pregnancy Childbirth 201313139

Muchatuta NA Kinsella SM Remifentanil for labour analgesia time to draw breath Anaesthesia 201368(3)231-5


The ideal opioid delivery


Time

Pain

intensity

and effect

Contraction pain

Pain relief

Does not exist

Opioids and labour analgeisahellip



Tramadol meptazinol pethidine diamorphine pentazocine nalbuphinefentanylIMIV Pca vs bolus



Van De Velde and Carvalho IJOA 2016 15 66-74


Remi 40microg2minsFenta 20microg + loadingPet 5 mg + loading


Other opioids better

bull CONCLUSIONS Intravenous patient-controlled analgesia with either remifentanil or fentanyl provides a moderate degree of labour analgesia whereas transient maternal oxygen desaturation is observed more commonly with remifentanil Fentanyl is associated with a higher need for neonatal resuscitation Marwah R

Hassan S Carvalho JC Balki M Remifentanil versus fentanyl for intravenous patient-controlled labour analgesia an observational study Canadian Journal of Anaesthesia 201259(3)246-54


Remifentanil provides betterpain relief than other opioids but only during the first twohours


Does it work


From M Van De Velde B Carvalho IJOA 2016 25 66-74


In women in labour patient controlled analgesia with remifentanil is not equivalent to epidural analgesia with respect to scores on satisfaction with pain relief Satisfaction with pain relief was significantly higher in women who were allocated to and received epidural analgesia TRIAL REGISTRATION Netherlands Trial Register NTR2551

CONCLUSION In terms of labor duration average VAS pain scores and maternal overall satisfaction score with analgesia CSE analgesia is superior to that provided by epidural analgesia or PCIA with remifentanil for pain relief in early labor in nulliparous women However there were no differences in the mode of delivery side effects or neonatal outcomes between the three techniques

Efficacy of Remifentanil PCA as compared to CSEEpidural


Oxygen saturation was significantly lower (SpO2 lt92) in women who used remifentanil (relative risk 15 14 to 17)

Remifentanil IVPCA provides poorer efficacy on labor analgesia than epidural analgesia with more sedation on parturients and a trend of newborn acidosis

Lin R Tao Y Yu Y Xu Z Su J Liu Z Intravenous remifentanil versus epidural ropivacaine with sufentanil for labour analgesia a retrospective study PLoS ONE [Electronic Resource] 20149(11)e112283


Meta Analyses

bull This meta-analysis suggests that remifentanil PCIA is not superior to epidural analgesia in analgesic efficacy during labor Given the wide CIs of the pooled results for secondary maternal and neonatal outcomes definite conclusions cannot be drawn for those outcomes Further studies are still warranted to validate these conclusions Liu ZQ Chen XB Li HB Qiu MT Duan T A comparison of remifentanil parturient-controlled intravenous analgesia with

epidural analgesia a meta-analysis of randomized controlled trials Anesth Analg 2014118(3)598-603

bull CONCLUSION During labour remifentanil-PCA provided superior analgesia and higher patient satisfactioncompared with pethidine with a comparable degree of adverse events Epidural analgesia providedsuperior pain relief in comparison with remifentanil Due to a low number of reported adverse events thesafety issue of remifentanil use in labour remains an open question that needs to be addressed in futuretrials Schnabel A Hahn N Broscheit J Muellenbach RM Rieger L Roewer N et al Remifentanil for labour analgesia a meta-analysis of

randomised controlled trials European Journal of Anaesthesiology 201229(4)177-85

bull Conclusions Pooled assessment of remifentanil intervention seems an attractive strategy for controlling labor pain in health term parturients but it is not supported by strong evidence Current evidencesuggests that it may produce effective analgesia by only a modest level HealthMED 20126(7)2407-18

Effect size difference 3 cm



APRIL 2017

20 RCTrsquos 3569 women

Results Weibel et al

bull Based on the current systematic review there is mostly low-quality evidence to inform practiceand future research may significantly alter thecurrent situation The quality of evidence is mainly limited by poor quality of the studies inconsistency and imprecision More research is needed on maternal and neonatal safetyoutcomes (maternal apnoe and respiratorydepression Apgar score) and on the optimal mode and regimen of remifentanil administrationto provide highets efficacy with reasonableadverse effects for mother and their newborns


Always satisfied

Off course they are Who wouldnrsquot


Optimal administration of remi



bull Protocols varies (bolus dose lock-out background infusion TCI etc)

bull Fixed bolus 20-50 microg without backgroundinfusion lock-out 2-3 minutes

bull If background ndash small dose lt 005microgkgxmin

bull TCI 05-15 ngml

bull New systems VPIA (Vital signs patientcontrolled intravenous analgesia)


SIA et al IJOA correspondence 2014 23 196-8


Cont infusion or PCA

bull Shen MK Wu ZF Zhu AB et al Remifentanil for labour analgesia a double-blinded randomised controlled trial of maternal and neonatal effects ofpatient-controlled analgesia versus continuous infusion (0005-02 microgkgxmin) Anaesthesia 201368(3)236-44 The results suggest thatremifentanil PCA (01-04 microgkg) provides better pain relief and similarplacental transfer compared with continuous infusion (Author)

bull Per protocol TCI Norwegian National Hospital (Oslo University Hospital)

ndash 05 ndash 2 ngml + nurse controlled boluses) ndash easier for anaesthesia personell


Remifentanil TCI

bull Why notbull Acta Anaesthesiol Scand 2013 Jul57(6)802-8 doi 101111aas12096 Epub 2013 Mar 15

bull Remifentanil target-controlled infusion during second stage labour in high-risk parturients a case series Schwarz GL1 Volmanen P Albrechtsen S Bjoernestad E

bull 1ngml start incremental doses of 05 ngml titrated untill satisfied mother or side-effects(1-6 ngml)


Why use remifentanil

The boss


In conclusionhellip


When to use it

bull For parturients with contraindications to regional analgesia

ndash Bleeding disorders

ndash Infections

ndash Mother does not want regional

bull In places with reduced anaesthesia service


Then remifentanil is the best choice

bull Continuous monitoring

bull Including capnography or RR counting

bull Well educated staff


Remifentanil PCA

bull Is cheap

bull Easy to administer

bull Gives (some) pain relief


BUT

bull Has a poor analgesic effect compared to thegolden standard of regional analgesia

bull May cause a lot of harm

bull Andhellip


AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS

Is too dangerous to be used as routineanalgesia in the labour ward



Thank you


Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd

Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6


Disclosures

bull Nonehellip


Agenda

bull Pharmacology

bull Does it work


bull Conclusion




Pharmacology








Fetal exposure





Is it in use






















Time

Pain

intensity

and effect

Contraction pain

Pain relief

Does not exist

















Does it work












Meta Analyses









APRIL 2017





Always satisfied









bull TCI 05-15 ngml










Remifentanil TCI






The boss


In conclusionhellip


When to use it



ndash Infections









Remifentanil PCA

bull Is cheap




BUT



bull Andhellip






Thank you





Agenda

bull Pharmacology

bull Does it work


bull Conclusion




Pharmacology








Fetal exposure





Is it in use






















Time

Pain

intensity

and effect

Contraction pain

Pain relief

Does not exist

















Does it work












Meta Analyses









APRIL 2017





Always satisfied









bull TCI 05-15 ngml










Remifentanil TCI






The boss


In conclusionhellip


When to use it



ndash Infections









Remifentanil PCA

bull Is cheap




BUT



bull Andhellip






Thank you







Pharmacology








Fetal exposure





Is it in use






















Time

Pain

intensity

and effect

Contraction pain

Pain relief

Does not exist

















Does it work












Meta Analyses









APRIL 2017





Always satisfied









bull TCI 05-15 ngml










Remifentanil TCI






The boss


In conclusionhellip


When to use it



ndash Infections









Remifentanil PCA

bull Is cheap




BUT



bull Andhellip






Thank you





Pharmacology








Fetal exposure





Is it in use






















Time

Pain

intensity

and effect

Contraction pain

Pain relief

Does not exist

















Does it work












Meta Analyses









APRIL 2017





Always satisfied









bull TCI 05-15 ngml










Remifentanil TCI






The boss


In conclusionhellip


When to use it



ndash Infections









Remifentanil PCA

bull Is cheap




BUT



bull Andhellip






Thank you





Fetal exposure





Is it in use






















Time

Pain

intensity

and effect

Contraction pain

Pain relief

Does not exist

















Does it work












Meta Analyses









APRIL 2017





Always satisfied









bull TCI 05-15 ngml










Remifentanil TCI






The boss


In conclusionhellip


When to use it



ndash Infections









Remifentanil PCA

bull Is cheap




BUT



bull Andhellip






Thank you





Is it in use






















Time

Pain

intensity

and effect

Contraction pain

Pain relief

Does not exist

















Does it work












Meta Analyses









APRIL 2017





Always satisfied









bull TCI 05-15 ngml










Remifentanil TCI






The boss


In conclusionhellip


When to use it



ndash Infections









Remifentanil PCA

bull Is cheap




BUT



bull Andhellip






Thank you

























Time

Pain

intensity

and effect

Contraction pain

Pain relief

Does not exist

















Does it work












Meta Analyses









APRIL 2017





Always satisfied









bull TCI 05-15 ngml










Remifentanil TCI






The boss


In conclusionhellip


When to use it



ndash Infections









Remifentanil PCA

bull Is cheap




BUT



bull Andhellip






Thank you
























Time

Pain

intensity

and effect

Contraction pain

Pain relief

Does not exist

















Does it work












Meta Analyses









APRIL 2017





Always satisfied









bull TCI 05-15 ngml










Remifentanil TCI






The boss


In conclusionhellip


When to use it



ndash Infections









Remifentanil PCA

bull Is cheap




BUT



bull Andhellip






Thank you



















Time

Pain

intensity

and effect

Contraction pain

Pain relief

Does not exist

















Does it work












Meta Analyses









APRIL 2017





Always satisfied









bull TCI 05-15 ngml










Remifentanil TCI






The boss


In conclusionhellip


When to use it



ndash Infections









Remifentanil PCA

bull Is cheap




BUT



bull Andhellip






Thank you
















Time

Pain

intensity

and effect

Contraction pain

Pain relief

Does not exist

















Does it work












Meta Analyses









APRIL 2017





Always satisfied









bull TCI 05-15 ngml










Remifentanil TCI






The boss


In conclusionhellip


When to use it



ndash Infections









Remifentanil PCA

bull Is cheap




BUT



bull Andhellip






Thank you







Time

Pain

intensity

and effect

Contraction pain

Pain relief

Does not exist

















Does it work












Meta Analyses









APRIL 2017





Always satisfied









bull TCI 05-15 ngml










Remifentanil TCI






The boss


In conclusionhellip


When to use it



ndash Infections









Remifentanil PCA

bull Is cheap




BUT



bull Andhellip






Thank you





















Does it work












Meta Analyses









APRIL 2017





Always satisfied









bull TCI 05-15 ngml










Remifentanil TCI






The boss


In conclusionhellip


When to use it



ndash Infections









Remifentanil PCA

bull Is cheap




BUT



bull Andhellip






Thank you



















Does it work












Meta Analyses









APRIL 2017





Always satisfied









bull TCI 05-15 ngml










Remifentanil TCI






The boss


In conclusionhellip


When to use it



ndash Infections









Remifentanil PCA

bull Is cheap




BUT



bull Andhellip






Thank you


















Does it work












Meta Analyses









APRIL 2017





Always satisfied









bull TCI 05-15 ngml










Remifentanil TCI






The boss


In conclusionhellip


When to use it



ndash Infections









Remifentanil PCA

bull Is cheap




BUT



bull Andhellip






Thank you
















Does it work












Meta Analyses









APRIL 2017





Always satisfied









bull TCI 05-15 ngml










Remifentanil TCI






The boss


In conclusionhellip


When to use it



ndash Infections









Remifentanil PCA

bull Is cheap




BUT



bull Andhellip






Thank you















Does it work












Meta Analyses









APRIL 2017





Always satisfied









bull TCI 05-15 ngml










Remifentanil TCI






The boss


In conclusionhellip


When to use it



ndash Infections









Remifentanil PCA

bull Is cheap




BUT



bull Andhellip






Thank you













Does it work












Meta Analyses









APRIL 2017





Always satisfied









bull TCI 05-15 ngml










Remifentanil TCI






The boss


In conclusionhellip


When to use it



ndash Infections









Remifentanil PCA

bull Is cheap




BUT



bull Andhellip






Thank you











Does it work












Meta Analyses









APRIL 2017





Always satisfied









bull TCI 05-15 ngml










Remifentanil TCI






The boss


In conclusionhellip


When to use it



ndash Infections









Remifentanil PCA

bull Is cheap




BUT



bull Andhellip






Thank you







Does it work












Meta Analyses









APRIL 2017





Always satisfied









bull TCI 05-15 ngml










Remifentanil TCI






The boss


In conclusionhellip


When to use it



ndash Infections









Remifentanil PCA

bull Is cheap




BUT



bull Andhellip






Thank you





Does it work












Meta Analyses









APRIL 2017





Always satisfied









bull TCI 05-15 ngml










Remifentanil TCI






The boss


In conclusionhellip


When to use it



ndash Infections









Remifentanil PCA

bull Is cheap




BUT



bull Andhellip






Thank you















Meta Analyses









APRIL 2017





Always satisfied









bull TCI 05-15 ngml










Remifentanil TCI






The boss


In conclusionhellip


When to use it



ndash Infections









Remifentanil PCA

bull Is cheap




BUT



bull Andhellip






Thank you













Meta Analyses









APRIL 2017





Always satisfied









bull TCI 05-15 ngml










Remifentanil TCI






The boss


In conclusionhellip


When to use it



ndash Infections









Remifentanil PCA

bull Is cheap




BUT



bull Andhellip






Thank you









Meta Analyses









APRIL 2017





Always satisfied









bull TCI 05-15 ngml










Remifentanil TCI






The boss


In conclusionhellip


When to use it



ndash Infections









Remifentanil PCA

bull Is cheap




BUT



bull Andhellip






Thank you





Meta Analyses









APRIL 2017





Always satisfied









bull TCI 05-15 ngml










Remifentanil TCI






The boss


In conclusionhellip


When to use it



ndash Infections









Remifentanil PCA

bull Is cheap




BUT



bull Andhellip






Thank you






APRIL 2017





Always satisfied









bull TCI 05-15 ngml










Remifentanil TCI






The boss


In conclusionhellip


When to use it



ndash Infections









Remifentanil PCA

bull Is cheap




BUT



bull Andhellip






Thank you








Always satisfied









bull TCI 05-15 ngml










Remifentanil TCI






The boss


In conclusionhellip


When to use it



ndash Infections









Remifentanil PCA

bull Is cheap




BUT



bull Andhellip






Thank you





Always satisfied









bull TCI 05-15 ngml










Remifentanil TCI






The boss


In conclusionhellip


When to use it



ndash Infections









Remifentanil PCA

bull Is cheap




BUT



bull Andhellip






Thank you











bull TCI 05-15 ngml










Remifentanil TCI






The boss


In conclusionhellip


When to use it



ndash Infections









Remifentanil PCA

bull Is cheap




BUT



bull Andhellip






Thank you









bull TCI 05-15 ngml










Remifentanil TCI






The boss


In conclusionhellip


When to use it



ndash Infections









Remifentanil PCA

bull Is cheap




BUT



bull Andhellip






Thank you












Remifentanil TCI






The boss


In conclusionhellip


When to use it



ndash Infections









Remifentanil PCA

bull Is cheap




BUT



bull Andhellip






Thank you










Remifentanil TCI






The boss


In conclusionhellip


When to use it



ndash Infections









Remifentanil PCA

bull Is cheap




BUT



bull Andhellip






Thank you





Remifentanil TCI






The boss


In conclusionhellip


When to use it



ndash Infections









Remifentanil PCA

bull Is cheap




BUT



bull Andhellip






Thank you






The boss


In conclusionhellip


When to use it



ndash Infections









Remifentanil PCA

bull Is cheap




BUT



bull Andhellip






Thank you





In conclusionhellip


When to use it



ndash Infections









Remifentanil PCA

bull Is cheap




BUT



bull Andhellip






Thank you





When to use it



ndash Infections









Remifentanil PCA

bull Is cheap




BUT



bull Andhellip






Thank you










Remifentanil PCA

bull Is cheap




BUT



bull Andhellip






Thank you





Remifentanil PCA

bull Is cheap




BUT



bull Andhellip






Thank you





BUT



bull Andhellip






Thank you









Thank you






Thank you





Thank you








Documents

Remifentanil in labor - sfai.se€¦ · Remifentanil in labour analgesia – where are we in 2017 –an update. Vegard Dahl, Head of Dept of Anaesthesia and Intensive Care, Professor,