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Labour Analgesia - CSE and DPE

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Review of evidence for initiation of labour epidurals

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Labour Analgesia - CSE and DPE

  1. 1. #IsraelAnes19 Ronald B. George, MD FRCPC Professor, Anesthesia & Perioperative Care Chief, Obstetric Anesthesia Betty Irene Moore Women’s Hospital at Mission Bay University of California San Francisco TheLabourAnalgesia Alphabet: CSE,DPE,EPI
  2. 2. #IsraelAnes19 ๏Describe the current knowledge regarding CSE analgesia ๏Describe the concerns expressed regarding CSE for labour analgesia ๏Describe the newest modality for analgesia initiation - DPE ๏Provide some insight into what is clinically suitable LearningObjectives
  3. 3. #IsraelAnes19
  4. 4. #IsraelAnes19 Spinal labor analgesia Fentanyl 25 mcg Morphine 250 mcg
  5. 5. #IsraelAnes19 Clarke VT, et al. Anesthesiology 1994;81:1083 “…high incidence of uterine hyperactivity” “…appropriate action (tocolysis) taken”
  6. 6. #IsraelAnes19Eisenach et al. Anesthesiology 1999;91:299-302 Fast Reliable Hypotension FHR
  7. 7. #IsraelAnes19
  8. 8. #IsraelAnes19 ๏ The allocated anesthetic, had NO significant effect on mode of delivery
  9. 9. #IsraelAnes19 ๏Accidental dural puncture - no difference ๏Failed analgesia - no difference ๏Non-reassuring fetal condition - no difference SecondaryOutcomes
  10. 10. #IsraelAnes19 ED50 of intrathecal fentanyl for 60 min of labor analgesia = 18.2mcg A single transient FHR deceleration
  11. 11. #IsraelAnes19
  12. 12. #IsraelAnes19 ๏Group Epidural ๏IT saline ๏EPI 10 mL bupivacaine 0.125% + sufentanil 7.5mcg + Epinephrine ๏Group CSE ๏IT 1.5 mcg sufentanil and 2.5 mg bupivacaine + Epinephrine ๏EPI saline ๏Group SUF ๏IT 7.5 mcg sufentanil ๏EPI saline Van de Velde et al. A&A 2004;98;1153-9
  13. 13. #IsraelAnes19
  14. 14. #IsraelAnes19Van de Velde et al. A&A 2004;98;1153-9
  15. 15. #IsraelAnes19Van de Velde et al. A&A 2004;98;1153-9 EPD CSE SUF Cesarean 13% 17% 4% Instrumental 16% 13% 21%
  16. 16. #IsraelAnes19 Rofaeel et al. CJA 2007;54:15 Whitty et al. IJOA 2007;16:341
  17. 17. #IsraelAnes19 ๏ Among those without initial clear fluid return the epidural catheter replacement rate within first 4 hours was; • 28.6% (95% CI 7.6–65%) versus • 3.6% (95% CI 1.98–6.17%)
  18. 18. #IsraelAnes19 Unpublished Data - Harding et al. SOAP 2019 Abstract
  19. 19. #IsraelAnes19
  20. 20. #IsraelAnes19
  21. 21. #IsraelAnes19
  22. 22. #IsraelAnes19Bernards et al. Anesthesiology 1994;80;853-8 Tuohy
  23. 23. #IsraelAnes19Bernards et al. Anesthesiology 1994;80;853-8 Tuohy 15%
  24. 24. #IsraelAnes19Bernards et al. Anesthesiology 1994;80;853-8
  25. 25. #IsraelAnes19Bernards et al. Anesthesiology 1994;80;853-8
  26. 26. #IsraelAnes19Heesen M, et al. IJOA 2019;40:24-31
  27. 27. #IsraelAnes19 ๏ Significant heterogeneity ๏ Inconsistently analgesic outcomes ๏ Too few events to draw conclusions re: FHR Heesen M, et al. IJOA 2019;40:24-31
  28. 28. #IsraelAnes19 ๏ 230 parturients - RCT —> DP versus NoDP ๏ DP - 27G Whitacre ๏ Test dose - 2ml - 2% Lidocaine ๏ Bolus - 5ml + 3ml - 2% Lidocaine ๏ Maintenance - 0.11% bupivacaine + fent 2µg/mL ๏ 10 mL/h, PCEA 5 mL, 10 minute lockout Thomas JA, et al. Anesthesiology 2005;103:1046-51
  29. 29. #IsraelAnes19 ๏ Inadvertent dural puncture rate = 1.2% ๏ Intravenous catheter rate = 6-10% ๏ No CSF return = 14.4% Thomas JA, et al. Anesthesiology 2005;103:1046-51
  30. 30. #IsraelAnes19 DP NoDP Catheter adjusted 37% 28% Catheter replaced 9% 8% Sacral sparing 30% 25% Inadequate analgesia 21% 30% AnalgesicOutcomes Thomas JA, et al. Anesthesiology 2005;103:1046-51
  31. 31. #IsraelAnes19 ๏ 79 parturients - RCT —> EPI versus DPE ๏ DPE - 25G Whitacre ๏ Bolus - 12ml of 0.25% bupivacaine ๏ Maintenance - 0.125% bupivacaine + fent 2µg/mL ๏ 6 mL/h, PCEA 6 mL, 15 minute lockout Eric Cappiello, Nollag O’Rourke, Scott Segal, and Lawrence C. Tsen A&A 2008;107:1646-51 Cappiello E, et al. A&A 2008;107:1646-51
  32. 32. #IsraelAnes19 Primary Outcome Sacral dermatome (S1) blockade Cappiello E, et al. A&A 2008;107:1646-51
  33. 33. #IsraelAnes19 DPE EPI S1 blocked (%) at 20 min 46 37 Bilateral S1 (%) at 20 min 41 30 S1 blocked (%) 92* 70 S2 blocked (%) 77 65 Bilateral S1 block (%) 83 82 Bilateral S2 block (%) 90 76 Highest Level T10 (T9–T11) T10 (T9–T11) AnalgesicOutcomes Cappiello E, et al. A&A 2008;107:1646-51
  34. 34. #IsraelAnes19 DPE EPI VAS < 10 obtained (%) at 20 min 85%* 65% Unilateral block 8%* 25% Catheter adjusted 13% 28% Catheter replaced 3% 13% AnalgesicOutcomes Cappiello E, et al. A&A 2008;107:1646-51
  35. 35. #IsraelAnes19 ๏ 120 parturients - RCT —> EPI / CSE / DPE ๏ Epidural - 20ml 0.125% Bupivacaine + 2mcg/ ml fentanyl ๏ Spinal - 1.7mg bupivacaine + 17mcg fentanyl Anesth Analg 2017;124:560–9
  36. 36. #IsraelAnes19Chau et al. Anesth Analg 2017;124:560–9
  37. 37. #IsraelAnes19 CSE - 2 (0.5 to 6.0) minutes DPE - 11 (4 to 120) minutes Epi - 18 (10 to 120) minutes Chau et al. Anesth Analg 2017;124:560–9
  38. 38. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
  39. 39. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
  40. 40. @Ron_George #IsraelAnes19Chau et al. Anesth Analg 2017;124:560–9
  41. 41. #IsraelAnes19 NICHDCategoryIIPattern ๏ Cat 1 = normal, Cat 3 = abnormal ๏ Cat 2 = “atypical” (SOGC) ๏ Late decelerations without loss of variability ๏ Uterine tachysystole ๏ Maternal hypotension
  42. 42. #IsraelAnes19 ๏ 80 parturients - RCT —> EPI versus DPE ๏ Epidural - 12 ml 0.125% Bupivacaine + 50 mcg Fentanyl ๏ DPE - 26G Whitacre confirmed dural puncture ๏ ALL CATHETERS - 3-mL test dose (1.5% lido + epi 5 µg/mL)
  43. 43. #IsraelAnes19 12-mL bolus (0.125% bupiv + 50 µg fent) 4-mL aliquots each minute Adequate analgesia = VAS score ≤ 10mm Bupiv 0.1% + 2µg/mL fentanyl at 10 mL/h Wilson et al. A&A 2018;126;545-51
  44. 44. #IsraelAnes19Wilson et al. A&A 2018;126;545-51
  45. 45. #IsraelAnes19Wilson et al. A&A 2018;126;545-51 LE DPE
  46. 46. #IsraelAnes19Contreras F, et al. Reg Anesth Pain Med 2019;44:750–753 ๏ 140 parturients - RCT —> 25g or 27g DPE ๏ Bolus - 20ml of 0.125% bupivacaine + fent 2µg/mL ๏ Maintenance - 12mL of bupivacaine 0.125% q2h PRN
  47. 47. #IsraelAnes19Contreras F, et al. Reg Anesth Pain Med 2019;44:750–753 DPE Catheter Secured Bolus NRS ≤ 1 Primary Outcome
  48. 48. #IsraelAnes19Contreras F, et al. Reg Anesth Pain Med 2019;44:750–753 DPE Catheter Secured Bolus NRS ≤ 1 Primary Outcome CSE Zone
  49. 49. #IsraelAnes19Contreras F, et al. Reg Anesth Pain Med 2019;44:750–753 0 5 10 15 25 Gauge 27 Gauge 9.1 (3.9) minutes 10.7 (5.0) minutes MD 1.6 minutes P = 0.037 95%CI [ 0.1 to 3.16 ]
  50. 50. #IsraelAnes19 ? Epidural bolus volume ? Epidural bolus time ? Epidural solution
  51. 51. @Ron_George #IsraelAnes19 CSE DPE Epi Onset Catheter Replacement Block Symmetry Failed block Pruritus Fetal Bradycardia* Cesarean CSE DPE Epi Rapid Slow Slow Low Low Higher ✅ ✅ ❌ ✅ ✅ / ❌ ❌ ❌ ✅ ✅ ✅ / ❌ ✅ ✅ ✅ ✅ ✅
  52. 52. #IsraelAnes19 Questions? ronald.george@ucsf.edu @Ron_George
  • JoseAugustoMorgado

    Dec. 4, 2019

Review of evidence for initiation of labour epidurals

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