Regional analgesia for the obstetric patient

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Regional Analgesia for the Obstetric Patient By Eeman Aboubakr Lecturer of Anesthesia and Intensive care Ain Shams University Cairo

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Case Presentation A 25 years old nulliparous woman at 38 weeks gestation had undergone induction of labor because of premature rupture of membranes. Upon her request for labor analgesia the attending anesthesiologist was consulted and history and examination revealed that she was medically free and she agreed to having epidural analgesia. Unfortunately during attempted epidural placement at L3-L-4 intervertebral space with an 18 G Touhy needle, dural puncture occurred and epidural placement at that level was abandoned. A second trial at L4-L5 level was taken and the epidural was succesfully placed. An initial loading dose of 15 ml of 0.25%bupivacaine was injected and an infusion rate of 8ml/hr of 0.125% bupivacine offered her

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sufficient analgesia. Several hours after delivery the patient experienced gradual onset of severe throbbing fronto-occipital headache that improved on lying down. It was associated with nausea and vomiting and vertigo .The patient was afebrile. She was given the NSAID Ibuprofen and paracetamol tablets but only slightly improved so she was referred to the anesthesiologist. What is the pain pathway during labor? What are the physiological changes during pregnancy and what are their anesthetic implications? What are the labor analgesic techniques , indications, and contraindications? What could have possibly occurred to the patient? What are the other complications of regional anesthesia?

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1- What are the Physiological Changes During Pregnancy and What Are Their Anesthetic Implications?

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Some physiological changes relevant to regional analgesia Cardiovascular system Change: Increased heart rate 15% COP 50% Decreased vascular resistance(hyperdynamic ciculation) Augmented by aortocaval compression maximum 36-38 wks gestation Effect: More hypotension with anesthesia liability for fetal asphxia Management: Left lateral tit or uterine displacement Increased need for proper volume load and vassopressors. Fetal monitoring

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2-Central nervous system Change: Increased ß-endorphin level Increase in progesterone mediated sensitivity to LA. Anatomical changes in vertebral column. Effect and management: Increased pain threshold Decreased local anesthetic requirement per dermatomal level so….. RULE: LOCAL ANESTHETIC REQUIREMENTS ARE REDUCED BY ABOUT ONE THIRD

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2-What is the pain pathway during labor?

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Pain Pathways and Cervical Dilatation During Delivery

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Dermatomal Level of the Lower abomen hip and thighs Pain Pathway in a Parturient

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Anesthetic Implications of Pain Pathways Analgesia during the first stage of labor is achieved by blocking the T10-Ll dermatomes. Analgesia for the second stage of labor and delivery requires the block of the S2-4 segments because of pain due to vaginal distention and perineal pressure.

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Effect of Unrelieved Maternal Pain on Fetal Well-Being

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3-What are the labor analgesic techniques, indications , and contraindications?

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Classifcation of Labor Analgesia

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Regional Analgesic Techniques a)Local infiltration of the perineum b)Regional anesthetic techniques: Paracervical block Pudendal nerve block caudal block Spinal block (and CSA) Epidural(infusion and PCEA) CSEA

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Paracervical Block Provides analgesia for the first stage of labor on Injected through lat vaginal fornices Increased risk of systemic LA toxicity Uterine VC may cause Fetal acidosis Hypoxia and bradycardia Rarely used

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Pudendal Nerve Block Provides analgesia for the second stage of labor 10ml of LA injected on both sides of ischeal spines to block pudendal nerve S2-S4. Done in addition to perineal infiltration by obstetrician .

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Neuraxial Blocks(Spinal, Epidural, and Caudal) Indications by ASA and ACOG “in the absence of a medical contraindication, maternal request is a sufficient medical indication for pain relief…” Reduces maternal catecholamines especially beneficial to maintain CVS stability in preeclamptic and some cardiac patients

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Contraindications ABSOLUTE Patients refusal Inability to cooperate Increased intracranial pressure Infection Severe coagulopathy Severe hypovolemia Inadequate training RELATIVE Systemic maternal infection Preexisting neurological deficiency Mild or isolated coagulation abnormalities Relative (and correctable) hypovolemia

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Advantages of neuraxial analgesia Avoids the risks of general anesthesia as maternal aspiration and difficult intubation. Allows the mother to participate in the birth giving experience Minimal effect on the fetus.

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Disadvantages of neuraxial analgesia Prolongs labor by 40-90min Approx increase of two folds need for oxytocin augmentation. Increases the incidence of operative delivery(controversial) Predisposes to persistent occipitoposterior.

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BUT Hollllld on!!! Before You Proceed…… Keep in mind the following precautions: According to the ASA guidelines: GUIDELINE I NEURAXIAL ANESTHESIA SHOULD BE INITIATED AND MAINTAINED ONLY IN LOCATIONS IN WHICH APPROPRIATE RESUSCITATION EQUIPMENT AND DRUGS ARE IMMEDIATELY AVAILABLE TO MANAGE PROCEDURALLY RELATED PROBLEMS GUIDELINE II NEURAXIAL ANESTHESIA SHOULD BE INITIATED BY A PHYSICIAN WITH APPROPRIATE PRIVILEGES AND MAINTAINED BY OR UNDER THE MEDICAL DIRECTION OF SUCH AN INDIVIDUAL.

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Neuraxial Anesthesia Performed by an Anesthetist in the OR

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GUIDELINE III NEURAXIAL ANESTHESIA SHOULD NOT BE ADMINISTERED UNTIL: 1) THE PATIENT HAS BEEN EXAMINED BY A QUALIFIED INDIVIDUAL AND 2) A PHYSICIAN WITH OBSTETRICAL PRIVILEGES TO PERFORM OPERATIVE VAGINAL OR CESAREAN DELIVERY, WHO HAS KNOWLEDGE OF THE MATERNAL AND FETAL STATUS AND THE PROGRESS OF LABOR AND WHO APPROVES THE INITIATION OF LABOR ANESTHESIA, IS READILY AVAILABLE TO SUPERVISE THE LABOR AND MANAGE ANY OBSTETRIC COMPLICATIONS THAT MAY ARISE. GUIDELINE IV AN INTRAVENOUS INFUSION SHOULD BE ESTABLISHED BEFORE THE INITIATION OF NEURAXIAL ANESTHESIA AND MAINTAINED THROUGHOUT THE DURATION OF THE NEURAXIAL ANESTHETIC.

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GUIDELINE V NEURAXIAL ANESTHESIA FOR LABOR AND/OR VAGINAL DELIVERY REQUIRES THAT THE PARTURIENT'S VITAL SIGNS AND THE FETAL HEART RATE BE MONITORED AND DOCUMENTED BY A QUALIFIED INDIVIDUAL. ADDITIONAL MONITORING APPROPRIATE TO THE CLINICAL CONDITION OF THE PARTURIENT AND THE FETUS SHOULD BE EMPLOYED WHEN INDICATED. WHEN EXTENSIVE NEURAXIAL BLOCKADE IS ADMINISTERED FOR COMPLICATED VAGINAL DELIVERY, THE STANDARDS FOR BASIC ANESTHETIC MONITORING SHOULD BE APPLIED. GUIDELINE VI NEURAXIAL ANESTHESIA FOR CESAREAN DELIVERY REQUIRES THAT THE STANDARDS FOR BASIC ANESTHETIC MONITORING BE APPLIED AND THAT A PHYSICIAN WITH PRIVILEGES IN OBSTETRICS BE IMMEDIATELY AVAILABLE.

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Fetal heart rate monitoring in a patient given neuraxial block

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Neuraxial Analgesia(Spinal Block) Single shot spinal given just before delivery to provides rapid onset analgesia for the second stage of labor. Blocks S1-S5 by saddle block and T10-S5 by standard block for caesarian section. Limited use in labor due to inability to extend duration of action.

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Using smaller gauge and pencil point needles reduces the incidence of PDPH

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Continuous spinal anesthesia Restricted use of 28G or smaller microcatheters due to reports of cauda equina syndrome. Infrequently used due “to unacceptably high rates of PDPH”. can be done by Touhy needle and classical epidural kit or better by “pediatric”G20 Touhy and G24 epidural catheter. Good option in some situations as: Previous spine surgery(scarred obliterated epidural space) Some significant cardiac disease(small increments or opioid only) Morbidly obese patients Difficult epidural and accidental dural puncture Difficult airway(controversial)

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Anesth Analg2010;111:1476-79.

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Neuraxial Analgesia(Caudal Block) Provides analgesia for first and second stages of labor. Can block from T10-S5. 10 -15ml of LA eg. Bupivacaine0.25% (Pictures show anatomical landmarks for caudal analgesia).

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Continuous caudal analgesia can be provided by caudal epidural catheter. Rarely used: Highest incidence of LA toxicity Difficult in adults complications like those of epidural Incidece of fetal or rectal trauma (Picture shows continuous caudal analgesia)

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Neuraxial Block(Epidural analgesia) “The method of choice” routinely used for pain relief. Excellent pain relief with ability to vary the “duration” and the “extent” and “intensity” of the motor block. Provides analgesia for the first stage:T10-L1 block and second stage T10-S5 block. Could be extended to T4 for caesarian section. 10-20ml of 0.25-0.125%bupivacaine or 0.1-0.2%ropivacaine(better differentiation between motor and sensory block)+1-2ug /ml fentanyl. In PG when cervix is 5-6 cm. In MG when cervix is 3-4 cm

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Maintenance by : -Top up injections -Continuous infusion of 8-12ml/hr by syringe pump PCEA. Perineal dose 10-12ml of 0.125-0.0625 bupivacaine. (Figure shows eidural needle passing through skin supraspinous ligament, interspinous ligament then ligamentum flavum to reach epidural space)

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SAFETY PREAUTIONS with epidural analgesia Use loss of resistance to saline better than air. Caution with intrathecal placement(0.5-3%) Caution with intravenous placement(3-15%) Aspiration of blood or CSF is a reliable sign. Adrenaline test dose in not sensitive in obstetrics(controversial). Test dose with lidocaine adrenaline is better(motor changes within 5 minutes and rapid onset of intense analgesia are indicators of intrathecal placement) DOSE FRACTIONATION Give 3ml every 1-2 minutes.

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Epidural catheter placement Epidural test dose done with saline after which epidural catheter is threaded through epidural needle.

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About epidurals….What’s new? Walking (mobile epidural) Continuous infusion of dilute local anesthetic and opioids. Eg 0.125%to 0.0625% bupivacaine +1-2ug/ml fentanyl. Allows better pain relief, minimal motor block, and minimal fetal drug concentrations. Lower incidence of instrumental delivery

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About epidurals….What’s new? Patient controlled epidural analgesia(PCEA) PCEA with basal infusion rates provide superior analgesia, less motor block, less LA consumption, lower anesthesia personnel work load. No fixed infusion regimen eg. Basal rate:4ml/hr Bolus:5ml/hr Lockout:5 min Limit:24ml/hr

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Patient controlled epidural analgesia

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Disposable PCEA System A single use PCEA system has been recently developed

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Other advances in PCEA Programmed intermittent or Automated Mandatory Epidural Boluses: delivers same amount as infusion but more effective analgesia In the future: Computer Integrated PCEA. Automatically Adjusts background infusion rate based in PCEA demands

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Combined Spinal Epidural….Is it the ideal labor analgesic? Rapid onset of profound analgesia Effective sacral analgesia Better quality of block This makes it of choice in late or painful rapidly progressing labor Fewer failed or patchy blocks Better in difficult backs Less motor block( mobile or walking epidural Faster cervical dilatation in early nulliparas.

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Techniques of CSE Needle through needle Needle beside needle

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Techniques of CSE Needle through needle 25G spinal needle through Touhy Needle through needle 25gG spinal needle has a separate port

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CSE epidural in the obese patient The 13cm Gertie Marx vs the 9 cm Escopan needle The longer Gertie Marx needles may be used in obese patients as epidural space is encountered at 9-12 cm.

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Disadvantagesof CSE Higher incidence of fetal HR decelerations (but no effect on fetal outcome). Higher incidence of neurotrauma. Failure of spinal More expensive Actual and Recorded puncture sites

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Failure of spinal with CSE

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And Now….. what’s after delivery of the baby? GUIDELINE VI NEURAXIAL ANESTHESIA FOR CESAREAN DELIVERY REQUIRES THAT THE STANDARDS FOR BASIC ANESTHETIC MONITORING BE APPLIED AND THAT A PHYSICIAN WITH PRIVILEGES IN OBSTETRICS BE IMMEDIATELY AVAILABLE. GUIDELINE VII QUALIFIED PERSONNEL, OTHER THAN THE ANESTHESIOLOGIST ATTENDING THE MOTHER, SHOULD BE IMMEDIATELY AVAILABLE TO ASSUME RESPONSIBILITY FOR RESUSCITATION OF THE NEWBORN

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GUIDELINE VIII A PHYSICIAN WITH APPROPRIATE PRIVILEGES SHOULD REMAIN READILY AVAILABLE DURING THE NEURAXIAL ANESTHETIC TO MANAGE ANESTHETIC COMPLICATIONS UNTIL THE PATIENT’S POSTANESTHESIA CONDITION IS SATISFACTORY AND STABLE. GUIDELINE IX ALL PATIENTS RECOVERING FROM NEURAXIAL ANESTHESIA SHOULD RECEIVE APPROPRIATE POSTANESTHESIA CARE. FOLLOWING CESAREAN DELIVERY AND/OR EXTENSIVE NEURAXIAL BLOCKADE, THE STANDARDS FOR POST-ANESTHESIA CARE SHOULD BE APPLIED.

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The PACU Obstetric patient should receive appropriate care in the PACU until ready for discharge.

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What could have possibly occurred to the patient?

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Postdural Puncture Headache May occur after any procedure involving piercing of the dura. Incidence 40-80% an epidural “wet tap”. Vascular headache caused by cerebral vasodilatation and decreased ICP. CCC by: Usually begins 6-72 hours after lumbar puncture. Throbbing frontal or occipital relieved on lying down headache. Worsens on sitting or standing

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Postdural Puncture Headache May be associated with: Nausea and vomiting Hearing loss/tinnitus Photophobia/diplopia Rarely may lead to cranial nerve affection and subdural hematoma if left untreated Increased risk in: Young and female Pregnant Cutting bevelled needles

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Treatment of PDPH 1-Prophylactic(What could be done if wet tap occurred?) Reposition in different intervertebral space Pass epidural catheter through dural hole.It may be left for 12-24 hours. Convert it to single bolus or continuous spinal. 2-Conservative: Bed rest and supine position Aggressive hydration NSAID, paracetamol, and opioid analgesics. But what if conservative therapy fails?

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3-Active therapy(failure of conservative therapy for 24-72 hours) Epidural blood patch (15-20 ml of patients own blood at same level of lumbar puncture)

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3-Active therapy(others) Epidural saline bolus or infusion Epidural dextran Epidural catheter in intrathecal space Caffeine 300-500mg oral or IV/1-2 times daily Sumatriptan Dexamethsone IV Neuraxial opioids

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What are the other complications of regional anesthesia?

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1.Cardiovascular complications Hypotension and bradycadria Cardiac arrest (still less than GA) High total spinal anesthesia 2. Neurological Complications(Spinal cord, nerve root, and conus medullaris injury) Direct trauma Compression by epidural hematoma or abscess Neural ischemia by vasoconstrictors, prolonged hypotension, intraneural injection

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Other neurological complications Horner’s syndrome Phrenic nerve paralysis Cranial nerve palsies 3.Misplacement Inadequate anesthesia Subdural block(patchy delayed block) Inadvertent subarachnoid block Inadvertent intraosseous injection(caudal)(toxicity) Inadvertent intravascular injection(epidural)(toxicity)

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4-Miscellaneous Catheter knotting and breakage Needle breakage Urinary retension Vasovagal attacks 5- Side effects of adjuvant opioids Respiratory depression Pruritis Nausea and vomiting Urinary retension Hypertonic uterus and fetal decelerations

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5-Toxicity of local anesthetics

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Treatment of local anesthetic toxicity From www.anesthesiawest.com

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Thank You

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