Update in Update in Obstetric Obstetric

Anesthesia: Part Anesthesia: Part II

ObjectivesObjectives

Expose staff to current practices and Expose staff to current practices and trends in the area of Obstetric Anesthesiatrends in the area of Obstetric Anesthesia

Share practical applications related to Share practical applications related to these topics that can be incorporated into these topics that can be incorporated into our routine practice at MHMCour routine practice at MHMC

Compare/contrast our practices with Compare/contrast our practices with those of other tertiary care facilitiesthose of other tertiary care facilities

Give references for various topicsGive references for various topics Time will not permit critical review of all Time will not permit critical review of all

references and this will NOT be attempted.references and this will NOT be attempted.

Update in OB AnesthesiaUpdate in OB Anesthesia

Part I: CSE and PCEAPart I: CSE and PCEA

Part II: All other topics in OB Part II: All other topics in OB Anesthesia Anesthesia More diverse and interesting topics More diverse and interesting topics

(Date to be (Date to be announced……)announced……)

CSE Kits/NeedlesCSE Kits/Needles

Why so many choices??Why so many choices?? (We currently have 5 different kits or (We currently have 5 different kits or

combinations of CSE needles at MHMCcombinations of CSE needles at MHMC ----enough is enough!)----enough is enough!) What would make one CSE needle What would make one CSE needle

better or more effective than another?better or more effective than another? Aren’t all 25 g needles created equal?Aren’t all 25 g needles created equal? Why do we fail to get the CSF when we Why do we fail to get the CSF when we

want to during CSEs, (and far too often want to during CSEs, (and far too often get the gusher when we don’t want to get the gusher when we don’t want to see it!---during regular epidurals)see it!---during regular epidurals)

Incidence of Failure to Incidence of Failure to obtain CSF during CSEobtain CSF during CSE

Most commonly quoted figure of failed Most commonly quoted figure of failed CSEs (failure to obtain CSF during CSEs (failure to obtain CSF during CSE): Reported incidence 10%CSE): Reported incidence 10%

Reported incidence varies from 8%-Reported incidence varies from 8%-38% depending on needles used38% depending on needles used

MHMC Feb 2006 Woodring and Sheth, MHMC Feb 2006 Woodring and Sheth, incidence of failure to get CSF 30-40% incidence of failure to get CSF 30-40% (Their technique was excellent---but (Their technique was excellent---but their results were poor)their results were poor)

Why is our success rate so low?????Why is our success rate so low?????

March 2006 March 2006 Virginia Apgar Obstetric Virginia Apgar Obstetric Anesthesia Conference, Anesthesia Conference,

Orlando FLOrlando FL Spinal needle Spinal needle must protrude 15 mmmust protrude 15 mm beyond beyond

epidural needle to have high likelihood for epidural needle to have high likelihood for success in obtaining CSF!success in obtaining CSF!

Length of spinal needle alone cannot be used as Length of spinal needle alone cannot be used as sole determinant as to if spinal needle is long sole determinant as to if spinal needle is long enough for CSE success with a given epidural enough for CSE success with a given epidural needle.needle.

Hubs of spinal needles inserted thru Tuohys Hubs of spinal needles inserted thru Tuohys varies considerably with manufacturer. You must varies considerably with manufacturer. You must actually measure to make sure that your spinal actually measure to make sure that your spinal needle protrudes 15 mm beyond your epidural needle protrudes 15 mm beyond your epidural needle.needle.

Length of Spinal Needle for Length of Spinal Needle for CSE very important (as is the CSE very important (as is the

hub)!hub)! A comparison of 24 g Sprotte and Gertie A comparison of 24 g Sprotte and Gertie

Marx Spinal Needles for CSE during laborMarx Spinal Needles for CSE during labor

Riley et al, Anesthesiology, 2002;97:574-7Riley et al, Anesthesiology, 2002;97:574-7 24 g Sprotte (N = 36)24 g Sprotte (N = 36) 24 g Gertie 24 g Gertie Marx (N = Marx (N =

37)37) (120 mm long—protrudes 9 mm) ( 127 mm long----protrudes (120 mm long—protrudes 9 mm) ( 127 mm long----protrudes

17mm)17mm)

No CSF *6/36 (17%) 0/37No CSF *6/36 (17%) 0/37

*(In all 6 cases where the sprotte needle did not produce CSF, the longer *(In all 6 cases where the sprotte needle did not produce CSF, the longer Gertie Marx needle was inserted and CSF was obtained)Gertie Marx needle was inserted and CSF was obtained)

NB search: Espocan CSE NB search: Espocan CSE needlesneedles

(Less failures, less (Less failures, less paresthesias)paresthesias) 50 patients Espocan, 50 patients Conventional Epidural 50 patients Espocan, 50 patients Conventional Epidural

Tuohy + Gertie Marx spinal needleTuohy + Gertie Marx spinal needle

Espocan Espocan ConvConv Epid Epid

+ Gertie + Gertie MarxMarx

Intravascular CatheterIntravascular Catheter 2% 2% 6% 6% ParesthesiaParesthesia (or Pain)(or Pain) 14%14% 42%42% Wet tap 2% Wet tap 2% 2% 2% Failure to obtain CSF Failure to obtain CSF 8%8%

28%28% Intrathecal Cath Placement 0% Intrathecal Cath Placement 0%

0%0%

Brown, Birnbach, Stein et al Anesth Analg 2005;101:535-40Brown, Birnbach, Stein et al Anesth Analg 2005;101:535-40

Our success rate was lower than Our success rate was lower than expected because our CSE needles expected because our CSE needles were too short!were too short!

Most of our CSE needles only Most of our CSE needles only protruded 13 mm beyond the protruded 13 mm beyond the epidural needle, rather than the epidural needle, rather than the recommended 15 mm.recommended 15 mm.

Review of Currently Review of Currently Available Options for Available Options for

CSEs at MHMC:CSEs at MHMC:

MHMC CSE OptionsMHMC CSE Options

Please take a look at the two trays Please take a look at the two trays being passed around, each with being passed around, each with various CSE needles.various CSE needles.

Please feel the resistance with Please feel the resistance with Pencan thru conventional Tuohy, vs. Pencan thru conventional Tuohy, vs. no resistance with Espocan CSE set. no resistance with Espocan CSE set. This will take some getting used to.This will take some getting used to.

Durasafe CSE needles Durasafe CSE needles with different whitacre with different whitacre

needlesneedles

Durasafe CSE needles Durasafe CSE needles with different 25 g with different 25 g

WhitacresWhitacres

25 g Pencan thru 18g Braun 25 g Pencan thru 18g Braun Tuohy Tuohy

(our usual Epidural needle)(our usual Epidural needle)

25 g Espocan CSE 25 g Espocan CSE NeedleNeedle

25 g Espocan Epidural 25 g Espocan Epidural and Spinal needle with and Spinal needle with

sheathsheath

What about CSE for the What about CSE for the Obese???Obese???

Most CSE kits packaged with only 9 cm Most CSE kits packaged with only 9 cm TuohyTuohy

At OB conference, I asked what do At OB conference, I asked what do others do when they want to do a CSE in others do when they want to do a CSE in the really obese (many MHMC patients)the really obese (many MHMC patients)

3 from panel said they just don’t do 3 from panel said they just don’t do them as needles not long enough.them as needles not long enough.

One panelist said “Biggie size it with One panelist said “Biggie size it with Gertie Marx!”Gertie Marx!”

13 cm Gertie Marx vs. 9 cm 13 cm Gertie Marx vs. 9 cm Espocan (Arnie’s “Biggie Size” Espocan (Arnie’s “Biggie Size”

Needle)Needle)

Gertie Marx CSE for the Gertie Marx CSE for the ObeseObese

Needle is very flimsyNeedle is very flimsy Wings on needle easily come offWings on needle easily come off Epidural space often encountered Epidural space often encountered

9.5-12 cm in obese patients so 9.5-12 cm in obese patients so regular CSE needles ineffective even regular CSE needles ineffective even with indenting skin.with indenting skin.

25 g Pencan thru Durasafe 25 g Pencan thru Durasafe Epidural needle (Whoa----careful Epidural needle (Whoa----careful

now!)now!) For those that don’t For those that don’t

like the espocan, like the espocan, but want to increase but want to increase success ratesuccess rate

Extends 20 mmExtends 20 mm Very wasteful Very wasteful

(Braun epidural kit, (Braun epidural kit, Durasafe CSE Durasafe CSE needle, Pencan needle, Pencan needle)needle)

MHMC CSE Series since MHMC CSE Series since March 2006March 2006

Pencan thru Durasafe needle (20mm)Pencan thru Durasafe needle (20mm) Success: Success: 4 of 4 (no failures)4 of 4 (no failures) Paresthesias:Paresthesias: 1 of 4 (25%)1 of 4 (25%)

Espocan CSE Needles (15mm):Espocan CSE Needles (15mm): Success:Success: 27 of 3027 of 30 Paresthesias:Paresthesias: 5 of 30 (17%) 5 of 30 (17%)

Since routinely utilizing spinal needles which Since routinely utilizing spinal needles which protrude protrude at leastat least 15 mm beyond the epidural 15 mm beyond the epidural needle, we have had greater success with the needle, we have had greater success with the CSE technique, and our success rate now mirrors CSE technique, and our success rate now mirrors that reported by others with high success rates. that reported by others with high success rates. (Currently failure to obtain CSF in 10%)(Currently failure to obtain CSF in 10%)

Failure to obtain CSF Failure to obtain CSF thru spinal needle during thru spinal needle during

CSE: ExplanationsCSE: Explanations

Needle too short Needle too short

(Recommend 15 mm protrusion of (Recommend 15 mm protrusion of spinal thru epidural needle)spinal thru epidural needle)

Needle off midlineNeedle off midline Tenting of DuraTenting of Dura

CSE FailuresCSE Failures

Tenting of Dura by Tenting of Dura by NeedleNeedle

Why all the fuss with CSEs? Are they Why all the fuss with CSEs? Are they worth the H/A----and by the way, are worth the H/A----and by the way, are

there more H/As with CSEs?there more H/As with CSEs?

Many large academic centers perform Many large academic centers perform 75-90% CSEs for labor pain relief75-90% CSEs for labor pain relief

MHMC performs ~ 15% CSEs for laborMHMC performs ~ 15% CSEs for labor Last week of every OB rotation Last week of every OB rotation

consists of ALL CSEs. This provides consists of ALL CSEs. This provides residents with exposure to technique, residents with exposure to technique, and allows them to form their own and allows them to form their own opinions about the technique.opinions about the technique.

Labor CSE Advantages:Labor CSE Advantages:

Rapid onset of effective labor analgesia. 2-3 Rapid onset of effective labor analgesia. 2-3 mins vs. ~ 15 minutes with conventional mins vs. ~ 15 minutes with conventional epiduralsepidurals

Less LA and opioid requiredLess LA and opioid required Less motor block. Allows for “walking Less motor block. Allows for “walking

epidurals”.epidurals”. ? Improved success of subsequent epidural ? Improved success of subsequent epidural

(probably NOT!)---let’s look at this……(probably NOT!)---let’s look at this…… May speed progress of laborMay speed progress of labor Greater patient satisfactionGreater patient satisfaction

? Improved success of ? Improved success of epidurals as part of CSEepidurals as part of CSE

Failure to get CSF in ~ 10% of cases (Higher Failure to get CSF in ~ 10% of cases (Higher failure rate if spinal needle not long enough)failure rate if spinal needle not long enough)

Randomized studyRandomized study11 of 2183 patients of 2183 patients receiving either CSE or a standard epidural receiving either CSE or a standard epidural found no significant difference of successful found no significant difference of successful epidural between the two groups.epidural between the two groups.

11Norris MC< et al: Anesthesiology 2001: 95: Norris MC< et al: Anesthesiology 2001: 95: 913-29913-29

Labor CSE Advantages:Labor CSE Advantages:

Rapid onset of effective labor analgesia. 2-3 Rapid onset of effective labor analgesia. 2-3 mins vs. ~ 15 minutes with conventional mins vs. ~ 15 minutes with conventional epiduralsepidurals

Less LA and opioid requiredLess LA and opioid required Less motor block. Allows for “walking Less motor block. Allows for “walking

epidurals”.epidurals”. ? Improved success of subsequent epidural ? Improved success of subsequent epidural

(probably NOT!)(probably NOT!) May speed progress of labor—let’s look at May speed progress of labor—let’s look at

this…this… Greater patient satisfactionGreater patient satisfaction

CSE and progress of CSE and progress of laborlabor

Is combined spinal-epidural Analgesia Associated with more Rapid Cervical Is combined spinal-epidural Analgesia Associated with more Rapid Cervical Dilation in Nulliparous Patients when Compaired with Conventional Epidural Dilation in Nulliparous Patients when Compaired with Conventional Epidural AnalgesiaAnalgesia??

Tsen et al Anesthesiology 91: No 4, Oct 1999Tsen et al Anesthesiology 91: No 4, Oct 1999

Cervical Dilation (after 3 cm) N=100 (50 each group)Cervical Dilation (after 3 cm) N=100 (50 each group)

CSE mean dilation 2.1 +/- 2.1 cm/hr , Epid mean dilation 1.1 +/- 1 cm/hrCSE mean dilation 2.1 +/- 2.1 cm/hr , Epid mean dilation 1.1 +/- 1 cm/hr

(5 pts had initial dilation > 5cm/h in CSE group, none in Epid)(5 pts had initial dilation > 5cm/h in CSE group, none in Epid)

The Risk of Cesarean Delivery with Neuraxial Analgesia Given Early versus Late The Risk of Cesarean Delivery with Neuraxial Analgesia Given Early versus Late in Laborin Labor

Wong et al, NEJM Feb 2005 Vol 352. No 7 P655-665Wong et al, NEJM Feb 2005 Vol 352. No 7 P655-665

No difference in C/S rateNo difference in C/S rate

Median time from initiation to complete dilation significantly shorter after Median time from initiation to complete dilation significantly shorter after intrathecal analgesia than systemic analgesia (295 minutes vs. 385 minutes P < intrathecal analgesia than systemic analgesia (295 minutes vs. 385 minutes P < 0.001)0.001)

Labor CSE Advantages:Labor CSE Advantages: Rapid onset of effective labor analgesia. 2-3 mins Rapid onset of effective labor analgesia. 2-3 mins

vs. ~ 15 minutes with conventional epiduralsvs. ~ 15 minutes with conventional epidurals Less LA and opioid requiredLess LA and opioid required Less motor block. Allows for “walking epidurals”.Less motor block. Allows for “walking epidurals”. ? Improved success of subsequent epidural ? Improved success of subsequent epidural

(probably NOT!)(probably NOT!) May speed progress of laborMay speed progress of labor Greater patient satisfaction (Higher Greater patient satisfaction (Higher

satisfaction with CSE vs. Conventional, but satisfaction with CSE vs. Conventional, but high with both)high with both)

Labor CSE Labor CSE Disadvantages:Disadvantages:

Pruritus, N/V Pruritus, N/V

(Mild symptoms and less frequent with (Mild symptoms and less frequent with smaller doses).smaller doses).

Respiratory Depression (Rare with Respiratory Depression (Rare with doses)doses)

? Increase in PDPH (NOT!)? Increase in PDPH (NOT!) ? Increase in intrathecal catheters (NOT!)? Increase in intrathecal catheters (NOT!) Fetal DecelerationsFetal Decelerations Untested EpiduralUntested Epidural More costlyMore costly Paresthesia/Pain during spinal insertionParesthesia/Pain during spinal insertion

Respiratory Depression Respiratory Depression and CSEsand CSEs

Reference Doses of IT Reference Doses of IT narcotics for labornarcotics for labor

Previous DosesPrevious Doses Sufentanil 10-15 mcgSufentanil 10-15 mcg Fentanyl 50 mcgFentanyl 50 mcg

Current DosesCurrent Doses Sufentanil 2.5-5 mcgSufentanil 2.5-5 mcg Fentanyl 15-25 mcgFentanyl 15-25 mcg

Labor CSE Labor CSE Disadvantages:Disadvantages:

Pruritis, N/V Pruritis, N/V

(Mild symptoms and less frequent with (Mild symptoms and less frequent with smaller doses).smaller doses).

Respiratory Depression (Rare with doses)Respiratory Depression (Rare with doses) ? Increase in PDPH (NOT!)? Increase in PDPH (NOT!) ? Increase in intrathecal catheters ? Increase in intrathecal catheters

(NOT!)(NOT!) Untested EpiduralUntested Epidural Fetal DecelerationsFetal Decelerations More costlyMore costly Paresthesia/Pain during spinal insertionParesthesia/Pain during spinal insertion

Status of Epidural not Status of Epidural not knownknown

We like to have functioning epidurals. If the We like to have functioning epidurals. If the epidural is not working properly, we suggest early epidural is not working properly, we suggest early replacementreplacement

Epidural not immediately dosed after CSE so Epidural not immediately dosed after CSE so there is no way to know if epidural will function there is no way to know if epidural will function for an urgent C/S.for an urgent C/S.

Epidural test dose not initially performed as this Epidural test dose not initially performed as this additional LA would lead to increased incidence of additional LA would lead to increased incidence of hypotension and unwanted excessive motor block. hypotension and unwanted excessive motor block. (This potentially makes the CSE more labor (This potentially makes the CSE more labor intensive if personnel must return to “test” the intensive if personnel must return to “test” the catheter and administer the epidural bolus catheter and administer the epidural bolus

(usually after 1.5-2 hours)(usually after 1.5-2 hours)

Labor CSE Labor CSE Disadvantages:Disadvantages:

Pruritis, N/V Pruritis, N/V

(Mild symptoms and less frequent with (Mild symptoms and less frequent with smaller doses).smaller doses).

Respiratory Depression (Rare with doses)Respiratory Depression (Rare with doses) ? Increase in PDPH (NOT!)? Increase in PDPH (NOT!) ? Increase in intrathecal catheters (NOT!)? Increase in intrathecal catheters (NOT!) Untested EpiduralUntested Epidural Fetal DecelerationsFetal Decelerations More costlyMore costly

CSE and Fetal CSE and Fetal BradycardiaBradycardia

Numerous reports documenting severe Numerous reports documenting severe bradycardia after IT fentanyl or sufentanil bradycardia after IT fentanyl or sufentanil sometimes in association with documented sometimes in association with documented uterine hypertonus. uterine hypertonus.

Proposed mechanism: rapid onset of analgesia Proposed mechanism: rapid onset of analgesia with IT opioids causes acute decrease in with IT opioids causes acute decrease in catecholamines, especially epi, which is catecholamines, especially epi, which is tocolytic. The resulting disinhibition may tocolytic. The resulting disinhibition may cause increased uterine tone with subsequent cause increased uterine tone with subsequent placental ischemia and fetal bradycardia.placental ischemia and fetal bradycardia.

Though FHR abnormalities usually resolve, Though FHR abnormalities usually resolve, one must always be prepared for urgent C/S.one must always be prepared for urgent C/S.

Risk Factors for Fetal Risk Factors for Fetal Decelerations following Decelerations following

CSE for laborCSE for labor Predicting prolonged fetal heart rate deleration following Predicting prolonged fetal heart rate deleration following

intrathecal fentanyl/bupivicaineintrathecal fentanyl/bupivicaineGaiser et al, International Journal of Obstetric Anesthesia (IJOA) Gaiser et al, International Journal of Obstetric Anesthesia (IJOA)

(2005) Vol 14, 208-211(2005) Vol 14, 208-211

33/151 patients (21%) had fetal decelerations 33/151 patients (21%) had fetal decelerations (mean 4.1 minutes) following CSE for labor. (mean 4.1 minutes) following CSE for labor. None of these patients underwent C/S.None of these patients underwent C/S.

Lack of fetal engagementLack of fetal engagement (zero station) (odds (zero station) (odds ratio 5.5) and ratio 5.5) and presence of heart rate presence of heart rate decelerations within 30 minutes prior to decelerations within 30 minutes prior to CSECSE (odds ratio 3.6) were associated with (odds ratio 3.6) were associated with prolonged fetal heart rate decelerations after prolonged fetal heart rate decelerations after CSE.CSE.

Intrathecal Sufentanil and Fetal Heart Rate Abnormalities: A Double-Intrathecal Sufentanil and Fetal Heart Rate Abnormalities: A Double-Blind, Double Placebo-Controlled Trial comparing Two Forms of Blind, Double Placebo-Controlled Trial comparing Two Forms of Combined Spinal Epidural Analgesia with Epidural Analgesia in Combined Spinal Epidural Analgesia with Epidural Analgesia in LaborLabor

Van de Velde et al, Anesth Analg 2004;98:1153-9Van de Velde et al, Anesth Analg 2004;98:1153-9

Three Hundred Paturients randomized to three groups:Three Hundred Paturients randomized to three groups:Group 1: Epidural with 12.5 mg Bupivicaine, 12.5 mcg Epi, 7.5 mcg Group 1: Epidural with 12.5 mg Bupivicaine, 12.5 mcg Epi, 7.5 mcg

SufentanilSufentanilGroup 2: CSE with Sufentanil 1.5 mcg, Epi 2.5 mcg, and Bupivicaine 2.5 Group 2: CSE with Sufentanil 1.5 mcg, Epi 2.5 mcg, and Bupivicaine 2.5

mgmgGroup 3: CSE with Sufentanil 7.5 mcgGroup 3: CSE with Sufentanil 7.5 mcg

Fetal DecelsFetal Decels Group 1:Group 1: 11% 11% (Within first hour of initiation) (Within first hour of initiation) Group 2: Group 2: 12%12%

Group 3:Group 3: 24%24%

Uterine HyperactivityUterine Hyperactivity Groups 1 & 2Groups 1 & 2 2%2%Group 3 Group 3 22%22%

HypotensionHypotension Group 1Group 1 7%7%(Requiring Ephedrine)(Requiring Ephedrine) Group 2Group 2 29% (29% ( Bupi) Bupi)

Group 3Group 3 12%12%

CSE and Fetal BradycardiaCSE and Fetal BradycardiaSummary by Dr. Richard Smiley Summary by Dr. Richard Smiley

(Virginia Apgar Conference Mar 2006)(Virginia Apgar Conference Mar 2006)

Fairly clear that incidence of fetal heart Fairly clear that incidence of fetal heart rate abnormalities is similar between CSE rate abnormalities is similar between CSE and most epidural techniques (though time and most epidural techniques (though time course is different—more rapid with CSEs)course is different—more rapid with CSEs)

Cesarean sections are NOT more common Cesarean sections are NOT more common with CSE analgesia (if OB’s are “trained”)with CSE analgesia (if OB’s are “trained”)

More recent randomized series suggest More recent randomized series suggest bradycardias are associated with higher bradycardias are associated with higher doses of opioids than generally used today, doses of opioids than generally used today, with lower dose opioid/LA mixtures with lower dose opioid/LA mixtures resulting in same incidence as standard resulting in same incidence as standard epidurals.epidurals.

Temporarily Changing Temporarily Changing Course…..Course…..

Hang in there while I cover this related Hang in there while I cover this related topic.topic.

We will return to the pros and cons of CSEs We will return to the pros and cons of CSEs shortly…….shortly…….

What can be done if the fetal What can be done if the fetal decelerations after CSE are in fact decelerations after CSE are in fact due to increased uterine tone????? due to increased uterine tone????? ---NTG may be the answer!---NTG may be the answer!

Nitroglycerin: Nitroglycerin: Tocolysis now!Tocolysis now!

The precise mechanism by which NTG The precise mechanism by which NTG causes uterine relaxation (tocolysis) causes uterine relaxation (tocolysis) remains unclearremains unclear

Ususal dosage 100-500 mcg IV, 400-Ususal dosage 100-500 mcg IV, 400-800mcg SL (1-2 metered sprays)800mcg SL (1-2 metered sprays)---(---(published published reports from 50 mcg-1850 mcg)reports from 50 mcg-1850 mcg)

Relaxation of the uterus is typically Relaxation of the uterus is typically reported within 90 secondsreported within 90 seconds

ASA Task Force on OB Anesthesia: ASA Task Force on OB Anesthesia: Practice guidelines for OB AnesthesiaPractice guidelines for OB Anesthesia Recommends NTG as effective agent for Recommends NTG as effective agent for uterine relaxation for retained placenta uterine relaxation for retained placenta tissuetissue

Nitroglycerin: TocolysisNitroglycerin: Tocolysis(Uses)(Uses)

Retained PlacentaRetained Placenta Internal and External VersionsInternal and External Versions Entrapped Fetuses at Vaginal Delivery Entrapped Fetuses at Vaginal Delivery

and Cesarean Sectionand Cesarean Section Fetal SurgeryFetal Surgery *Fetal Distress (Bradycardia) *Fetal Distress (Bradycardia)

associated with hyperstimulation or associated with hyperstimulation or tetany (whether or not caused or tetany (whether or not caused or associated with CSE!)associated with CSE!)

Nitroglycerin as Rx CSE Nitroglycerin as Rx CSE associated Fetal associated Fetal DecelerationsDecelerations

Small doses of I.V. Nitroglycerine Small doses of I.V. Nitroglycerine

(60-180 mcg) are associated with (60-180 mcg) are associated with resolution of severe fetal distress resolution of severe fetal distress related to uterine hyperactivity related to uterine hyperactivity along with negligible side effects.along with negligible side effects.

Mercier et al, Anesth Anal Mercier et al, Anesth Anal 1997;84:1117-11201997;84:1117-1120

Labor CSE Labor CSE Disadvantages:Disadvantages:

Pruritis, N/V Pruritis, N/V (Mild symptoms and less frequent with (Mild symptoms and less frequent with

smaller doses).smaller doses). Respiratory Depression (Rare with Respiratory Depression (Rare with

doses)doses) ? Increase in PDPH (NOT!)? Increase in PDPH (NOT!) ? Increase in intrathecal catheters (NOT!)? Increase in intrathecal catheters (NOT!) Untested EpiduralUntested Epidural Fetal DecelerationsFetal Decelerations More costlyMore costly Paresthesia/Pain during spinal insertionParesthesia/Pain during spinal insertion

Labor CSEs Labor CSEs are are more more costly costly

Current Braun Perifix Epidural Tray:Current Braun Perifix Epidural Tray: $17.97$17.97 Pencan NeedlePencan Needle $ 5.25$ 5.25 Individual Durasafe CSE Kit (Needles Only)Individual Durasafe CSE Kit (Needles Only) $ 9.00$ 9.00 Individual Espocan CSE Kit (Needles Only)Individual Espocan CSE Kit (Needles Only) $15.50$15.50

(Prepacked $7.03 or 45% less) (Prepacked $7.03 or 45% less)

Braun Kit with Espocan CSE Needle added:Braun Kit with Espocan CSE Needle added: $25.00$25.00 (Add’l $7.03 or 39%) (Add’l $7.03 or 39%)

(We will soon have a large stock of our current Braun/Perfix (We will soon have a large stock of our current Braun/Perfix Epidural kits, and have a smaller supply of epidural trays Epidural kits, and have a smaller supply of epidural trays prepackaged with the Espocan Needle)prepackaged with the Espocan Needle)

Labor CSE Labor CSE Disadvantages:Disadvantages:

Pruritis, N/V Pruritis, N/V (Mild symptoms and less frequent with (Mild symptoms and less frequent with

smaller doses).smaller doses). Respiratory Depression (Rare with Respiratory Depression (Rare with

doses)doses) ? Increase in PDPH (NOT!)? Increase in PDPH (NOT!) ? Increase in intrathecal catheters (NOT!)? Increase in intrathecal catheters (NOT!) Untested EpiduralUntested Epidural Fetal DecelerationsFetal Decelerations More costlyMore costly Paresthesia/Pain during spinal Paresthesia/Pain during spinal

insertioninsertion

Higher incidence of “Paresthesias/Pain” Higher incidence of “Paresthesias/Pain” during spinal advancement with CSE during spinal advancement with CSE

than with single shot spinalsthan with single shot spinals

89 woman for elective C/S randomized 89 woman for elective C/S randomized to single shot spinal or needle thru to single shot spinal or needle thru needle spinal (CSE).needle spinal (CSE).

Paresthesias in 37% needle thru needleParesthesias in 37% needle thru needle Paresthesias in 9% single shot spinalParesthesias in 9% single shot spinal No patients had persistent neurological No patients had persistent neurological

symptoms on postop day #1symptoms on postop day #1

McCandrew CR- Anaesth Intensive Care – 01-Oct-2003: 31(5): McCandrew CR- Anaesth Intensive Care – 01-Oct-2003: 31(5): 514-7514-7

Epidural lidocaine Epidural lidocaine decreases paresthesias/pain decreases paresthesias/pain

associated with dural associated with dural puncture during CSEspuncture during CSEs

3cc 2% Xylocaine with 1:200 K epi (vs. 3cc 2% Xylocaine with 1:200 K epi (vs. saline) given via Tuohy needle after LOR, saline) given via Tuohy needle after LOR, and then spinal needle advanced. and then spinal needle advanced.

Pain/Paresthesias in Lidocaine GroupPain/Paresthesias in Lidocaine Group 9 % 9 %Pain/Paresthesias in Saline GroupPain/Paresthesias in Saline Group 81%81%

Van den Berg et al, Anesth Analg 2005: 101: 882-5Van den Berg et al, Anesth Analg 2005: 101: 882-5

Note: This should NOT be done for labor Note: This should NOT be done for labor CSEs!CSEs!

When should the epidural When should the epidural test dose be administered test dose be administered

with CSE?with CSE? Administering the 3cc test dose of 1.5% Administering the 3cc test dose of 1.5%

Xylo with epi immediately after the Xylo with epi immediately after the labor CSE leads to an increased labor CSE leads to an increased incidence of hypotension (spinal Bup + incidence of hypotension (spinal Bup + Epidural Xylo) and leads to undesired Epidural Xylo) and leads to undesired (excessive) motor block (excessive) motor block

Options include:Options include: 1. Administer epidural test dose after 1. Administer epidural test dose after

spinal dose wears off.spinal dose wears off. 2. Start Continuous Infusion immediately 2. Start Continuous Infusion immediately

after CSE performedafter CSE performed

CSE test dose options CSE test dose options (Continued—Option 1)(Continued—Option 1)

Test dose administered prior to dosing Test dose administered prior to dosing epidural. epidural.

Very labor intensive as one must Very labor intensive as one must monitor VS after spinal dose, and then monitor VS after spinal dose, and then return (1.5 – 2 hours) to administer return (1.5 – 2 hours) to administer test dose and epidural bolus and test dose and epidural bolus and monitor VS.monitor VS.

Pain allowed to return so less patient Pain allowed to return so less patient satisfaction.satisfaction.

Not Resident/CRNA friendly overnight Not Resident/CRNA friendly overnight during calls.during calls.

CSE test dose options CSE test dose options (Continued---Option 2)(Continued---Option 2)

One can immediately start the continuous One can immediately start the continuous infusion after spinal dose giveninfusion after spinal dose given Experience > 5 years Rationale:Experience > 5 years Rationale: If intravascular, patient will c/o pain. Can test catheter If intravascular, patient will c/o pain. Can test catheter

at that time prior to epid re-bolus, and if +, pull at that time prior to epid re-bolus, and if +, pull catheter.catheter.

Low dose of Bupivicaine administered so very low Low dose of Bupivicaine administered so very low possibility of toxicity (~ 10 mg of Bupivicaine in an possibility of toxicity (~ 10 mg of Bupivicaine in an hour vs. toxic dose of 150mg)hour vs. toxic dose of 150mg)

If intrathecal cath, patient will slowly develop motor If intrathecal cath, patient will slowly develop motor block and hypotension (10 mg Bupi in an hour). block and hypotension (10 mg Bupi in an hour). Patients instructed to call nurse for increased motor Patients instructed to call nurse for increased motor block and/or hypotension and we must follow up on block and/or hypotension and we must follow up on patients.patients.

Anesthesia “friendly”, patients more satisfied as pain Anesthesia “friendly”, patients more satisfied as pain doesn’t return and anesthesia personnel don’t have to doesn’t return and anesthesia personnel don’t have to stay and check VS for two prolonged periods.stay and check VS for two prolonged periods.

What the heck is What the heck is in our CSE in our CSE

cocktail cocktail anyway????anyway????

(I’d put my money on the residents over the (I’d put my money on the residents over the attendings)attendings)

(gift certificate)(gift certificate)

MHMC CSE “Cocktail”MHMC CSE “Cocktail”

Fentanyl 15 mcgFentanyl 15 mcg Bupivicaine 1.25 mg Bupivicaine 1.25 mg

(Do we really need this?---not used in (Do we really need this?---not used in NEJM study)NEJM study)

Epinephrine .1 mg Epinephrine .1 mg (Is there a downside to epi?)(Is there a downside to epi?)

Saline diluent to make total volume 3ccSaline diluent to make total volume 3cc

LAs added to CSE LAs added to CSE solutionssolutions

Intrathecal narcotics alone can produce Intrathecal narcotics alone can produce effective relief of labor pain for the first stage effective relief of labor pain for the first stage of laborof labor

Intrathecal narcotics alone are Intrathecal narcotics alone are ineffectiveineffective in in relieving pain associated with the 2relieving pain associated with the 2ndnd stage of stage of laborlabor

LAs (bupivicaine) combined with spinal LAs (bupivicaine) combined with spinal narcotics provide effective relief of pain narcotics provide effective relief of pain associated with the second stage of laborassociated with the second stage of labor

Patients receiving bupivicaine added to spinal Patients receiving bupivicaine added to spinal narcotics often report better relief of perineal narcotics often report better relief of perineal pain/pressure throughout labor, and also pain/pressure throughout labor, and also require fewer physician administered top up require fewer physician administered top up doses.doses.

What about the downside to adding epi?What about the downside to adding epi?

Epinephrine in CSE Epinephrine in CSE solutionssolutions

Prolongs duration of block/pain relief from Prolongs duration of block/pain relief from intrathecal narcotic + LA solutions for labor pain intrathecal narcotic + LA solutions for labor pain reliefrelief

Produces additional motor block, compared to Produces additional motor block, compared to solutions without epinephrinesolutions without epinephrine

Goal in OB anesthesia to have as little motor Goal in OB anesthesia to have as little motor block as possible, while maintaining satisfactory block as possible, while maintaining satisfactory pain reliefpain relief

Though epinephrine is associated with additional Though epinephrine is associated with additional motor block, this motor block is minimal, and motor block, this motor block is minimal, and most patients are still able to “walk” after a CSE most patients are still able to “walk” after a CSE with Bupivicaine.with Bupivicaine.

But why would they want to??????But why would they want to??????

NB Suggestions for labor NB Suggestions for labor CSEsCSEs

1.1. Use CSE needle that protrudes 15 mm Use CSE needle that protrudes 15 mm beyond the Epidural needle (preferably beyond the Epidural needle (preferably with a low incidence of paresthesias) with a low incidence of paresthesias) Currently suggest Espocan at MHMCCurrently suggest Espocan at MHMC

2.2. Do NOT perform CSE technique in Do NOT perform CSE technique in patients with bad fetal tracings or patients with bad fetal tracings or patients expected to go to the OR soon. patients expected to go to the OR soon. You will have a higher incidence of fetal You will have a higher incidence of fetal bradycardias in the setting of bad tracings bradycardias in the setting of bad tracings and you will not know if epidural catheter and you will not know if epidural catheter works immediatley following the CSE.works immediatley following the CSE.

3.3. Advance Espocan needle slowly thru Advance Espocan needle slowly thru epidural needle (to decrease paresthesias) epidural needle (to decrease paresthesias) and first LOR is subarachnoid space.and first LOR is subarachnoid space.

4.4. Stabilize spinal needle. It WILL move!Stabilize spinal needle. It WILL move!5.5. If no CSF obtained, withdraw spinal If no CSF obtained, withdraw spinal

needle and advance epidural needle 1 needle and advance epidural needle 1 mm.mm.

6.6. Reinsert spinal needle. If no CSF, thread Reinsert spinal needle. If no CSF, thread epidural catheter, give test dose and epidural catheter, give test dose and bolus. (Remember, ~ 10% incidence of bolus. (Remember, ~ 10% incidence of failure to get CSF)failure to get CSF)

7.7. Inject 15 mcg Fentanyl, 1.25 mg Inject 15 mcg Fentanyl, 1.25 mg Bupivicaine (less n/v/itching/respiratory Bupivicaine (less n/v/itching/respiratory depression and less hypotension)depression and less hypotension)

8.8. Do NOT administer the 3cc Xylocaine Do NOT administer the 3cc Xylocaine (1.5%) epidural test dose immediately (1.5%) epidural test dose immediately after spinal dose as this will increase after spinal dose as this will increase incidence of hypotension and lead to incidence of hypotension and lead to unwanted motor block.unwanted motor block.

9.9. After spinal dose administered, two After spinal dose administered, two options:options:

A.A. Wait > 1 hour to administer Epidural test dose Wait > 1 hour to administer Epidural test dose and bolus epiduraland bolus epidural

1.1. Pain will returnPain will return

2.2. Anesthesia personnel labor intensiveAnesthesia personnel labor intensive

B.B. Start continuous epidural infusion immediatelyStart continuous epidural infusion immediately1.1. Notify patient if legs become very heavy to contact Notify patient if legs become very heavy to contact

nurse as patient may be receiving too much nurse as patient may be receiving too much medicationmedication

2.2. Do not place patients on PCEA who have a language Do not place patients on PCEA who have a language barrier or who cannot comprehend nuances of barrier or who cannot comprehend nuances of PCEA.PCEA.

3.3. Greater patient satisfactionGreater patient satisfaction

4.4. Less labor intensive---less physician administered Less labor intensive---less physician administered top up dosed.top up dosed.

10.10. If Hypotension develops RX with If Hypotension develops RX with Neosynephrine or EphedrineNeosynephrine or Ephedrine

11.11. If Fetal Decelerations are noted:If Fetal Decelerations are noted:A.A. LUD, Oxygen, Rx BP (even if BP is LUD, Oxygen, Rx BP (even if BP is

marginal rx BP to eliminate this as a marginal rx BP to eliminate this as a variable)variable)

B.B. 2 metered sprays of sublingual 2 metered sprays of sublingual NitroglycerinNitroglycerin

C.C. Decelerations should resolve in 5-10 Decelerations should resolve in 5-10 minutes. If patient taken to OR, minutes. If patient taken to OR, prepare for urgent C/S.prepare for urgent C/S.

Patient Controlled Epidural Patient Controlled Epidural Analgesia (PCEA)Analgesia (PCEA)

Overall greater patient satisfaction with Overall greater patient satisfaction with PCEA vs. continuous infusionPCEA vs. continuous infusion

Lower drug usage with PCEA (no basal rate) Lower drug usage with PCEA (no basal rate) vs. continuous infusionvs. continuous infusion

PCEA with basal rate is associated with 30% PCEA with basal rate is associated with 30% more drug usage compared with PCEA and more drug usage compared with PCEA and no basal rate.no basal rate.

PCEA with basal rate associated with PCEA with basal rate associated with decreased physician “top-ups”.decreased physician “top-ups”.

Only physician administered “top-ups” Only physician administered “top-ups” associated with hypotension.associated with hypotension.

PCEAPCEA

Majority of academic tertiary care Majority of academic tertiary care facilities routinely utilize PCEA for facilities routinely utilize PCEA for labor pain relieflabor pain relief

When new epidural pumps obtained, When new epidural pumps obtained, we will routinely use PCEA at MHMC. we will routinely use PCEA at MHMC. Current pumps have few patient Current pumps have few patient administration buttons, and therefore, administration buttons, and therefore, difficult to consistently employ PCEA.difficult to consistently employ PCEA.

MHMC PCEA Settings MHMC PCEA Settings (Various centers polled last year by Drs. Bolden/Lahud):(Various centers polled last year by Drs. Bolden/Lahud):

Basal 8-10 cc/hr. Bolus 5ccBasal 8-10 cc/hr. Bolus 5cc # Boluses/hr =4. Lockout = 10 minutes# Boluses/hr =4. Lockout = 10 minutes

Confused?Confused?

I hope to eliminate some of the confusion…….I hope to eliminate some of the confusion……. We will primarily be ordering espocan CSE needles We will primarily be ordering espocan CSE needles

for non-obese patients, and retain Long Gertie Marx for non-obese patients, and retain Long Gertie Marx CSE kits for the obese patient.CSE kits for the obese patient.

We will stop ordering the durasafe CSE kits. I am We will stop ordering the durasafe CSE kits. I am sure some attendings would have objected, so I sure some attendings would have objected, so I wanted everyone to know the reason/rationale for wanted everyone to know the reason/rationale for this change.this change.

When we obtain new PCEA pumps, we will be using When we obtain new PCEA pumps, we will be using PCEA on the majority of our patients (except those PCEA on the majority of our patients (except those patients with a language barrier or those unable to patients with a language barrier or those unable to comprehend the instructions)comprehend the instructions)

Stay tuned for more exciting topics in the world of Stay tuned for more exciting topics in the world of OB Anesthesia in OB Anesthesia in “Update in Obstetric Anesthesia-- “Update in Obstetric Anesthesia-- Part II”Part II”