Thread by @OBsleepmerchant

@girardDev discusses initiation of #OBanes for labour analgesia at #OAA3dc2022 QR codes rule! Links to references!

What are #OBAnes doing? 2% didn’t have a preference @CarvalB @Ron_George in @CJA_Journal. A complex plan for the lecture, culminating in @girardDev’s expert personal opinion at #OAA3dc2022

@girardDev expands on potential pro’s & cons of CSE vs epidural in #OBAnes. A meta-analysis of success of block (Heesen et al, @Anaes_Journal) couldn’t demonstrate a benefit for CSE. Ask @cochranecollab? (Authors incl. @AliciaTDennis)
#OAA3dc2022

@cochranecollab found little basis for offering CSE over epidurals (back in 2012). However, around this time, fetal heart rate abnormalities seemed the 🐘 in the room. #OAA3dc2022

There is an argument for CSE causing uterine hyperactivity - by removing pain, circulating catechamines would drop, removing their tocolytic effect. #OAA3dc2022

Uterine hypertonicity and fetal heart rate abnormalities were evaluated, and CSE was associated with hypertony and abnormal fetal heart rate. #OAA3dc2022

Work in 2009 had shown uterine hypertonus & abnormal FHR to be transient, either self limiting or responsive to simple measures, but NNH 4.2. Caution with initiation, care with concurrent oxytocin infusion. #OAA3dc2022

Fetal effects of CSE (@Anaes_Journal) and their relationship to oxytocin became more clear (suspicious & pathological traces seen for both CSE and epidural) - oxytocin independently increased risk (hyping the hypertonus?) #OAA3dc2022

Enter sufentanil (@MarcVandeVelde6 in @IARS_Journals) - a significant factor in non-reassuring FHR - uterine hypertonus with rapid analgesia may not be most NB factor? #OAA3dc2022

Further 2016 meta-analysis and systematic review showed increased OR, especially for fetal bradycardia. However, they made an important observation - epidural has similar effect, just seen later. #OAA3dc2022

A 2020 meta-analysis “focused” on opioids in CSE showed definite evidence of increased risk of FHR abnormalities, maternal hypotension and pruritis. #OAA3dc2022

Most recent 2022 work suggests the timing and patient selection for receiving CSE (labour with ROM or late active phase) may predispose to FHR abnormalities secondary uterine hypertonus #OAA3dc2022

What about DPE? @antonchau1 et al (incl. @BrighamOBAnes Lawrence Tsen) in @IARS_Journals compared DPE to LEA and CSE. Top-ups are surprising, rest somewhat predictable. #OAA3dc2022

DPE faster onset than epidural (statistically not clinically significant?) no other difference. A procedure in search of an indication - @bscottsegal in @_Anesthesiology 2022 questions if any real value to DPE #OAA3dc2022

@ashrafhabib5’s group, also @_Anesthesiology, found no advantage 4 DPE. Heesen et al, in @IJOA_Journal, found less epidural top ups, shorter onset (is this clinically relevant?) & better sacral analgesia. Of note, failed DO in 1/8 patients - wonder if epidural worked? #OAA3dc2022

@hnixon147 supervised a #ANES18 submission, where inability to obtain CSF predicts catheter failure. #OAA3dc2022

This makes sense - @girardDev illustrates this in terms of midline. #OAA3dc2022

Needle THROUGH needle vs needle through needle technique, was evaluated in 1994. Personally have never had the former, does anyone have experience to share. I prefer sprotte to whitacre for the later (more distinct dural pop) #OAA3dc2022

@girardDev’s excellent summary and QR code for references. There is a potential place for everything - except perhaps the standard epidural. Consider DPE if history of AFHR or at risk (eg IUGR) (@SafePartum thread above 😉) #OAA3dc2022

@threadreaderapp unroll please