The selection of labour analgesia options, all catheter based and similar with slight differences. Value propositions of DPE: confirmation, translocation and improved safety - value over EPL and CSE. #SOAPAM2023
Value proposition 1: confirmation. #DPE adds visual confirmation to LOR - midline and epidural tip.
Why do #OBAnes get equivocal LOR? There’s an anatomic basis. #SOAPAM2023
Anatomic basis: interspinous ligament midline gaps. Ligamentum Flavum midline gap due to incomplete fusion leading to absence of crisp LOR. #OBAnes#SOAPAM2023
Incidence of Ligamentum Flavum midline gaps, varies by level. DPE confirms location decreasing risk of catheter failure. Data from CSE’s. #OBAnes#SOAPAM2023
Berger et al @IJOA_Journal: #DPE lower failure, lower replacement. No difference in failure around initiation, but less failure during maintenance phase. #DPE longer catheter survival times. #OBAnes#SOAPAM2023
Coming soon: multicentre retrospective cohort study (@emilysharpe) - what are risks of failed catheter conversion to surgical anesthesia for cesarean delivery? Data being collected… #OBAnes#SOAPAM2023
#DPE value proposition #2: Translocation. @Anaes_Journal incl @MarcVandeVelde6 meta-analysis CSE vs epidural: unilateral block reduced after CSE. Transdural flux compensates for non-uniform spread? Mechanistic evaluation. #OBAnes#SOAPAM2023
Translocation dependent on size of dural puncture. 27G too small. 25/26G #DPE superior to epidural. #OBAnes#SOAPAM2023
Physician epidural top-ups, equivalent of breakthrough pain, lower with #DPE. With CSE, transition from spinal to epidural interpreted as breakthrough pain (is my experience). Translocation harnesses spinal and epidural spaces. #OBAnes#SOAPAM2023
#DPE value proposition #3: improve safety profile compared to CSE. CSE very rapid onset which may have consequences. More pruritis with CSE. Transient fetal bradycardia associated with CSE, NOT lead to higher cesarean section rate, but worse neonatal outcomes. Exact mechanism… twitter.com/i/web/status/1…
Okay, practical considerations for #DPE. Not need new kit, likely have what’s required. Note: needle deflection (especially 26/27G - false dry tap, wait). Shearing metal fragments is NOT a concern. #OBAnes#SOAPAM2023
Protrusion of spinal needle beyond tip of Epidural needle is important - preferably >13mm (15mm+?). Compare needles in your own setting? #OBAnes#SOAPAM2023
Barriers to implementation: perceived lack of benefits & perceived risks. Risk of PDPH for CSE and epidural same - #DPE similar? Need larger studies. #OBAnes#SOAPAM2023
Another Barrier to clinical adoption = conflicting evidence #OBAnes#SOAPAM2023
Target mismatch: #DPE may be beneficial in specific situations, difficult to demonstrate in RCT. Matching the value of DPE to target situations, including faster conversion to surgical block? #OBAnes#SOAPAM2023
@antonchau1 acceptably excited with #SOAPAM2023 best paper abstract. Statistically faster vs. clinically faster onset? #OBAnes
Summary. Maximize success. One size will not fit all. @antonchau1 believes residents/registrars should be taught all 3 techniques. Their use is a balance of culture, experience and context. #OBAnes#SOAPAM2023
And what about future directions? Refine and improve neuraxial initiation techniques. #OBAnes#SOAPAM2023
Next up at #CASAM2023 - fittingly keeping the most important academic session to last: #OBAnes @ValZaph moderating the Maternal Experience and Outcomes: Improving the care we provide. @DrWesleyEdwards
Dr Christina Lamontagne kicks off the session with: Use of Dexmedetomidine in improving maternal experience and outcomes. Nothing to disclose. Then an important disclosure: All indications discussed are OFF LABEL in Canada. Objectives. #OBAnes#CASAM2023
Why does Dr Lamontagne use a lot of dexmedetomidine (not only in #OBAnes mind)? Clinical pharmacology of dexmedetomidine (1): highly selective alpha-2 agonist; sedation WITHOUT amnesia at locus coeruleus. #CASAM2023
Dr Ning Nan Wang introduces @harshamd5 to open the chronic pain session: Perioperative use of opioid in the context of Opioid Epidemic. #CASAM2023
The opioid crisis isn’t new - China probably remembers the Opium wars that helped establish a British foothold on the continent. Opioids and OUR crisis. Is what we fear the real crisis? Are opioid-related deaths due to surgical prescriptions? No, mostly due to street fentanyl.… twitter.com/i/web/status/1…
Opioid use around the time of surgery. Understanding nociception vs pain. Does eliminating opioids during surgery make a difference - no definitive conclusions. #CASAM2023
PPH: a focus on coagulation is kicked off by Dr Karine Doyon (a hematologist). Objectives. Canada ranked 39th in world in maternal mortality - not sure if that’s good. We’re doing better than USA. #OBAnes#CASAM2023
Causes of coagulopathy in pregnancy - Dr Doyon won’t be discussing inherited disorders. The focus will be on the acquired hemorrhagic disorders. #OBAnes#CASAM2023
Pregnancy-associated mortality ≈ maternal mortality. #OBAnes 0.2% - doing well (wonder what the denominator is?), so Elmo could ask why are we worried? #SOAPAM2023