Thread by @Ron_George

How frequently do you round on each labour epidural patient?

#CASAM2022 #OBAnes

This afternoon at #CASAM2022 @ammunro2 & myself will talk about the management of labour epidurals to reduce failure #LaborDoesntHaveToHurt #OBAnes

There are some QI indicators to guide our work

Great evidence informed recommendations from @ammunro2 today to manage the failed catheter for cesarean at #CASAM2022 • honoured to shared the stage with her and @CAS_OBSection Chair @ValZaph

Failure is not fatal, BUT Labour Epidurals are not final - the ongoing management of low-concentration epidural analgesia for the pain of childbirth requires systematic care #LaborDoesntHaveToHurt #CASAM2022 #OBAnes #MedTwitter #MedThread

Epidural failure can be inconsistently defined which is why there is some variance in the incidence; catheter replacement rates 0.7-2.0%; Breakthrough pain 12-25% #CASAM2022 #OBAnes #MedThread

Pan et al. failure rate 12% - defined as epidural or CSE resulting in inadequate analgesia or no sensory block after adequate dosing; incidence of failed catheters, IV catheters, IT catheters higher in the traditional epidural group compared to CSE #CASAM2022 #OBAnes #MedThread

.@DalAnesthesia & @Stanford_obanes asked preferences & what leads to dissatisfaction…achieving desired pain relief & overall satisfaction were priorities….delays getting labour analgesia & having breakthrough pain addressed lead to dissatisfaction #CASAM2022 #OBAnes #MedThread

High rates of breakthrough pain not only leads to patient dissatisfaction, it leads to low faculty morale, low nursing morale, higher general anesthesia rates and can lead to legal implications #LaborDoesntHaveToHurt #CASAM2022 #OBAnes #MedThread

Factors that play a role in failure to deliver optimal labour analgesia include OB factors such as abnormal fetal presentation, inductions & prolonged labour & maternal factors like obesity and increasing age - also non-#OBAnes and standard epidural (v CSE) #CASAM2022 #MedThread

Confirmation of CSF with DPE (vs Epidural) showed the rate of unilateral catheters was significantly less, they needed adjustment less frequently and ultimately were replaced less frequently #CASAM2022 #OBAnes #MedThread

Booth et al. dispelled untested catheter myth while showing improve failures rates with CSE - Cumulative incidence of epidural catheter failures was 7% for CSE and 12% for EPID...EPID failed more frequently at cesarean, and they failed later #CASAM2022 #OBAnes #MedThread

We know that labour epidural analgesia is all about spread and distribution of the anesthetic...Can the manner in which we add medication to the epidural space alter our reduce our failure rate #CASAM2022 #OBAnes #Medthread

PCEA and PIEB lead to better analgesia and less interventions

#CASAM2022 #OBAnes #Medthread

Recent, abstract presented at #CASAM2022 showed in 15,000 cohort that PIEB and CSE associated with less catheter interventions #OBAnes #Medthread

Do you "round" on labour epidural patients??

Quality metrics suggest we track the % of epidurals providing adequate analgesia at 45 mins from placement

#CASAM2022 #OBAnes #Medthread

Evaluate factors increasing analgesic requirement

-Nature, severity and location of the pain
-Rate of labour progression
-Consider obstetric causes, eg. uterine rupture, dystocia, placenta abruption

#CASAM2022 #OBAnes #Medthread

Evaluate extent of analgesia

-Catheter location / length within epidural space
-Drug concentration and infusion parameters
-Errors in drug delivery, eg. disconnection or pump failure

#CASAM2022 #OBAnes #MedThread

This is our @UCSFAnesthesia strategy for the management of breakthrough analgesia and evaluation of labour analgesia catheters #CASAM2022 #OBAnes #MedThread

Consider adjuncts appropriately

Epinephrine

MLAC of bupivacaine alone 0.091% and with epi 1:300,000 significantly reduced MLAC by 30%

Soetens et al. hourly drug consumption, rescue dosing, and pain scores were lower in the epinephrine group

#CASAM2022 #OBAnes #MedThread

Clonidine

Enhances analgesia by the direct stimulation of α2-adrenergic receptors. Clonidine 60 μg, but not 30 μg, decreased the MLAC of ropivacaine boluses.

Clonidine 75 μg or sufentanil 5 μg both reduced the MLAC of ropivacaine #CASAM2022 #OBAnes #MedThread

.@AllisonLeeNYC et al. compared efficacy of clonidine vs fentanyl -RCT 10mL of 0.125% bupiv & either clonidine 100mcg or fentanyl 100mcg when the pain >=5 during a contraction - Epidural clonidine not superior to fentanyl - no magic bullet

#CASAM2022 #OBAnes #MedThread

Success is not final & vigilance is required
✅Start smart - CSE
✅Provide best analgesia - PIEB/PCEA
✅Watched pot never boils over - Objective evaluations
✅Sometimes you need a little help from friends - Consider adjuncts
#CASAM2022 #OBAnes #MedThread #LaborDoesntHaveToHurt

Slides and references can be found at this link

dropbox.com/t/p2neGOyqfK8E…

#CASAM2022 #OBAnes #MedThread