Failed epidural for labor: what now?

Labor epidural failure is a challenging situation for the obstetric anesthetist, especially when associated to high risk of caesarean delivery, obesity, and difficult airway predictors. Labor epidural failure is still not standardly defined, consequently its incidence is uncertain: improving the knowledge of risk factors related to failure will increase epidural block success rate. Prolonged labors, previous history of epidural failure, and repeated top-ups needed during labor are recognized risk factors for failure. Clinical experience and the use of modern equipment (ultrasound guided blocks), as well as the choice of neuraxial technique (epidural versus combined spinal-epidural) may affect failure rate. Software-controlled infusion pumps seem to increase epidural analgesia success rate. Among non-technical skills, good communication among medical team members and parturient women is another pivotal point to achieve a satisfactory analgesia for labor. Clear algorithms should be promoted where epidural failure during labor or caesarean delivery may occur.

Continuous spinal anaesthesia with minimally invasive haemodynamic monitoring for surgical hip repair in two patients with severe aortic stenosis

BACKGROUND AND OBJECTIVES

Aortic stenosis increases perioperative morbidity and mortality, perioperative invasive monitoring is advised for patients with an aortic valve area <1.0 cm(2) or a mean aortic valve gradient >30 mmHg and it is important to avoid hypotension and arrhythmias. We report the anaesthetic management with continuous spinal anaesthesia and minimally invasive haemodynamic monitoring of two patients with severe aortic stenosis undergoing surgical hip repair.

CASE REPORT

Two women with severe aortic stenosis were scheduled for hip fracture repair. Continuous spinal anaesthesia with minimally invasive haemodynamic monitoring was used for anaesthetic management of both. Surgery was performed successfully after two consecutive doses of 2mg of isobaric bupivacaine 0.5% in one of them and four consecutive doses in the other. Haemodynamic conditions remained stable throughout the intervention. Vital signs and haemodynamic parameters remained stable throughout the two interventions.

CONCLUSION

Our report illustrates the use of continuous spinal anaesthesia with minimally invasive haemodynamic monitoring as a valid alternative to general or epidural anaesthesia in two patients with severe aortic stenosis who are undergoing lower limb surgery. However, controlled clinical trials would be required to establish that this technique is safe and effective in these type or patients.

[Multidisciplinary consensus document on the management of massive haemorrhage (HEMOMAS document)]

Massive haemorrhage is common and often associated with high morbidity and mortality. We perform a systematic review of the literature, with extraction of the recommendations from the existing evidences because of the need for its improvement and the management standardization. From the results we found, we wrote a multidisciplinary consensus document. We begin with the agreement in the definitions of massive haemorrhage and massive transfusion, and we do structured recommendations on their general management (clinical assessment of bleeding, hypothermia management, fluid therapy, hypotensive resuscitation and damage control surgery), blood volume monitoring, blood products transfusion (red blood cells, fresh frozen plasma, platelets and their best transfusion ratio), and administration of hemostatic components (prothrombin complex, fibrinogen, factor VIIa, antifibrinolytic agents).

Multidisciplinary consensus document on the management of massive haemorrhage (HEMOMAS document)

Massive haemorrhage is common and often associated with high morbidity and mortality. We perform a systematic review of the literature, with extraction of the recommendations from the existing evidences because of the need for its improvement and the management standardization. From the results we found, we wrote a multidisciplinary consensus document. We begin with the agreement in the definitions of massive haemorrhage and massive transfusion, and we do structured recommendations on their general management (clinical assessment of bleeding, hypothermia management, fluid therapy, hypotensive resuscitation and damage control surgery), blood volume monitoring, blood products transfusion (red blood cells, fresh frozen plasma, platelets and their best transfusion ratio), and administration of hemostatic components (prothrombin complex, fibrinogen, factor VIIa, antifibrinolytic agents).

Treatment of Postpartum Hemorrhage With Blood Products in a Tertiary Hospital: Outcomes and Predictive Factors Associated With Severe Hemorrhage

Postpartum hemorrhage (PPH) remains a leading cause of maternal mortality and morbidity worldwide. This retrospective observational study describes patient characteristics and hemostatic therapies administered to 352 parturients experiencing PPH and analyzes risk factors for developing severe PPH. During the study period, bleeding was controlled in all cases and 99.4% survived. The majority (98%) of patients received packed red blood cells. The most frequent hemostatic therapies administered were fibrinogen concentrate (56%), fresh frozen plasma (49%), and platelets (30%). A total of 124 (35%) women experienced severe PPH. Significant independent predictors for evolution to severe PPH were age, obstetric comorbidity, and plasma fibrinogen concentration. The latter was based on records from 267 (76%) patients. Plasma fibrinogen concentration before labor was the only modifiable prepartum risk factor independently associated with severe PPH, indicating that fibrinogen monitoring is warranted in these patients.

[Iliac artery occlusion balloons for suspected placenta accreta during cesarean section]

Massive obstetric hemorrhage still remains a major cause of maternal mortality and morbidity. The risk factors associated with this pathology must be identified in order to schedule the appropriate delivery with the necessary resources. A case is presented of an iliac artery occlusion with intravascular balloons for suspected placenta accreta during cesarean section. The perioperative treatment, as well as an analysis of the treatment options is described, along with their advantages and disadvantages, from the use of postpartum hemorrhage protocols, blood transfusion and procoagulant factors, and other maneuvers to control bleeding, until the hysterectomy.

[General anaesthesia and obstetric bleeding in caesarean section. One year's experience in a university hospital]

INTRODUCTION

Obstetric haemorrhage is an important worldwide cause of morbidity and mortality. General anaesthesia for caesarean section is rarely used. Our goal is to analyse the incidence, causes and risk factors associated with general anaesthesia for caesarean section, and the prevalence of obstetric haemorrhage (HO), its risk factors and predictors of post-caesarean HO together with the use of blood in our hospital population.

METHODS

A retrospective study was conducted on all caesarean section discharge reports from PACU in 2008.

RESULTS

General anaesthesia was required in 12.4% of the patients. Epidural catheter failure as a cause of general anaesthesia was infrequent (2.8%) and within the recommended standards.

CONCLUSIONS

The most frequent indications for caesarean section under general anaesthesia included mainly life-threatening emergencies, and the most important risk factors for general anaesthesia, including coagulation disorders, bleeding in the third trimester, foetal distress and severe pre-eclampsia. General anaesthesia is a risk factor for transfusion, as is abruptio placentae, placenta previa and pre-eclampsia.

A randomized control trial of patient-controlled epidural analgesia (PCEA) with and without a background infusion using levobupivacaine and fentanyl

BACKGROUND

Continuous infusion associated with patient-controlled epidural analgesia (PCEA) is used in many maternal units. This randomized controlled study evaluated the effect of a 10 mL/h background infusion associated with a 10 mL-20 minutes lockout time demand-only PCEA protocol using L-bupivacaine plus fentanyl in terms of local anaesthetic consumption, pain management and maternal satisfaction.

METHODS

Forty consenting parturients were randomly assigned to receive a 0.125% levobupivacaine plus 1.5 mcg/mL fentanyl PCEA (10 mL bolus with a 20 min lock time) with or without a 10 mL/h background infusion. The total volume of local anesthetic, the number of PCEA demand boluses, pain levels, delivery outcome and maternal satisfaction were evaluated.

RESULTS

The total volume of local anaesthetic was 35[20-120] mL in demand-only PCEA group versus 63.8[22.5-123] mL in PCEA plus background infusion group (P<0.001). This decrease in total volume was associated with an increase of self-administrated boluses in demand-only group (3.5[2-12] boluses, versus 1[0-3] bolus in PCEA plus background infusion group) (P<0.001). Pain scores were comparable between groups at any time of the study (P>0.05). Maternal satisfaction did not differ between groups (10[8-10] vs. 10[7-10]; P=0.11).

CONCLUSION

When a levobupivacaine plus fentanyl PCEA protocol with high volume boluses and long lockout interval is used for labour analgesia, the background infusion increased the total local anesthetic dose with no change in pain management and maternal satisfaction.

[Estimating the angle of left lateral decubitus position during cesarean section: observational study of anesthesiologists' estimates and of midwives and nurses' level of understanding]

OBJECTIVES

To determine the difference between the estimated and measured values of the left lateral decubitus (LLD) angle in the positioning of patients for scheduled cesarean section; to determine whether the accuracy of estimates differs between staff anesthesiologists and residents; and to assess the angle estimates of midwives and surgical nurses as well as their level of knowledge with respect to the utility of the LLD position.

METHODS

This was a prospective, observational, double-blind study comparing staff anesthesiologists working in obstetrics to residents in their second, third, or fourth-year of training. We also presented a task and questions to midwives and surgical nurses who assisted during categories 3 and 4 cesarean sections (elective and scheduled procedures) according to the classification system of he National Institute of Clinical Excellence. The anesthesiologist was asked to place the patient in LLD position after onset of anesthesia and to estimate the LLD angle. A second anesthesiologist measured the angle. The midwives and nurses were asked to place a vacant surgical table at approximately 15 degrees; the angle was then measured. Patient variables (weight, height, anesthetic technique) and staff variables (position, understanding of the purpose of the maneuver, estimated DLL angle, and measured angle) were recorded.

RESULTS

Of 55 women who underwent cesarean sections (98.18% under regional anesthesia), 25 were assessed by staff anesthesiologists and 30 by residents. A total of 14 midwives and 10 surgical nurses participated in the surgical table positioning task and answered questions. The mean (SD) DLL angle estimate of the anesthesiologists was 12.4 degrees (3.4 degrees); the mean measured angle was 7.8 degrees (3.1 degrees). The estimates of staff anesthesiologists were significantly more accurate (P < .001). All the midwives understood the reason for using the DLL position in cesarean section, while only 1 nurse (10%) did (P < .05).

CONCLUSION

The DLL position angle is overestimated by resident anesthesiologists and midwives. It seems that the use and understanding of DLL positioning could be improved.

[Maternal hypotension with low doses of spinal bupivacaine or levobupivacaine and epidural volume expansion with saline for cesarean section]

BACKGROUND AND OBJECTIVE

Epidural volume extension (EVE) with saline solution can contribute to greater cephalad spread of drugs injected into the subarachnoid space during cesarean section. We studied the incidence of material hypotension with spinal bupivacaine or levobupivacaine (L-bupivacaine) and the spread after epidural saline injection.

MATERIAL AND METHODS

After ethics committee approval, we randomized women scheduled for cesarean section to 4 groups to receive 5 mg of 0.25% bupivacaine with (n=51) or without (n=6) saline EVE; 5 mg of 025% L-bupivacaine (n=50); or 6 mg of 03% L-bupivacaine (n=50). All patients also received 25 microg of fentanyl per 2 mL of local hyperbaric spinal anesthetic. In all except the non-EVE group, 10 mL of saline was infused through an epidural catheter 5 minutes after anesthetic infusion. We recorded patient demographic data, procedural and anesthetic times, incision-clamping times, occurrence of hypotension, ephedrine dose required, motor and sensory blockade, requirement for rescue analgesics, and neonatal outcome.

RESULTS

After 6 patients had been randomized to the non-EVE group, no further patients were assigned because all the women required rescue analgesics. Demographic data, duration of procedure, time between. incision and delivery, and Apgar scores were similar in all the groups. The incidence of hypotension was lower in the group receiving 5 mg of L-bupivacaine (26% vs. 52.9% in the bupivacaine 5-mg group, and 56% in the 6-mg L-bupivacaine group, P = .04). More women given 5 mg of L-bupivacaine required rescue analgesia (46%) than did those receiving 5 mg of bupivacaine (235%) or 6 mg of L-bupivacaine (28%) (P = .039). Hypotension was associated with a lower umbilical cord pH (P = .001). Ephedrine doses over 20 mg were also associated with a lower umbilical cord pH (P = .031).

CONCLUSIONS

The incidence of hypotension was lowest in the group anesthetized with 5 mg of L-bupivacaine, but the need for rescue analgesia was greater in this group. Doses of 5 mg and 6 mg may be sufficient for cesarean section, as they provide a good level of sensory blockade.

[Monitoring skill acquisition in obstetric epidural puncture at a university hospital using the cumulative sum method]

BACKGROUND AND OBJECTIVE

Skill acquisition in anesthesiology is subject to a great deal of interindividual variability. Our aim was to develop and test an individualized tool for monitoring acquisition of technical skills based on the cumulative sum (CUSUM) approach. This system objectively assesses whether an individual has acquired a minimum skill level and identifies the moment when the skill has been learned.

MATERIAL AND METHODS

Nine third-year residents in anesthesiology and postoperative recovery care participated. The residents anonymously recorded their first 100 obstetric epidural analgesia procedures in a database. The data were then analyzed with the CUSUM method. We considered acceptable skill acquisition to be reflected by a first-attempt success rate of 80% and a rate of success with help of 20%.

RESULTS

A total of 765 epidural blocks were analyzed, giving a mean (SD) of 84.7 (2.8) procedures per resident (range, 47-100 procedures per resident). Seven residents became competent with the skill after 23 procedures and 2 residents were not successful in learning the skill. At the end of the study, 3 residents had required help with more than 20% of the procedures. Data collection from the trainees seemed to vary, leading to possible under- or overestimation of failures and/or need for help. Accidental dural puncture occurred 6 times (0.78%) and blood vessel puncture 40 times (5.2%).

CONCLUSIONS

Although some third-year residents reach the targeted rate of success quickly, we believe that close supervision is useful to control progress along the learning curve for individuals who need more help.

[Failure of extension of epidural analgesia to anesthesia for emergency cesarean section]

Epidural analgesia provides effective control of labor pain and allows emergency cesarean section to be performed without recourse to general anesthesia. This technique is subject to failure, however. We sought to determine the incidence of failure of extension of epidural analgesia for labor to epidural anesthesia for emergency cesarean section. We also analyzed possible risk factors for failure. A 2-month observational study was carried out in a tertiary-care university hospital in patients who had an epidural catheter inserted for labor analgesia and who later underwent emergency cesarean section. Epidural catheter failure was defined if additional analgesia was required during surgery or if general anesthesia was required. Data were gathered on possible risk factors, such as obesity, difficult epidural puncture, leakage of blood on insertion, history of cesarean delivery, need for rescue analgesia, and level of satisfaction with analgesia during dilation. In total, 134 emergency cesareans were performed in women carrying an epidural catheter. The catheter failed to administer the anesthetic in 18 patients (13.4%). General anesthesia was required in 9 cases (6.7%). Difficult insertion (more than 2 attempts) was associated with a higher failure rate (P=.064). The relative risk of epidural catheter failure was 2.86-fold higher when rescue analgesia was needed during delivery than in cases when no supplement was required (P=.021). Receiving adequate analgesia during labor seems to be a protective factor (80%) against anesthetic catheter failure during cesarean section (P=.01). We conclude that high demand for rescue analgesia and signs of inadequate analgesia during labor should warn of epidural catheter failure if extension to anesthesia becomes necessary for a cesarean delivery.

[Assessment of agreement between anesthesiologists' location of anatomical landmarks]

OBJECTIVE

The main objective of this study was to evaluate agreement between anesthesiologists' location of specific anatomical landmarks in regional anesthesia.

MATERIAL AND METHODS

We administered an anonymous written questionnaire asking for the location of the T5 and T10 dermatomes, Tuffier's line (L3-L4 space), and the T7-T8 and C6-C7 spaces on an anatomical drawing. We asked about each anesthesiologist's number of years of experience and type of block most commonly performed and in what type of surgery, number of blocks performed per year, whether or not levels of sensory and motor blocks were assessed, and whether training had been received. Relative frequencies were then calculated. The relationships between years of experience and number of blocks performed and number of correct identifications of anatomical points were analyzed using the chi2 test.

RESULTS

We studied 100 doctors (66 residents and 24 staff anesthesiologists). The landmark for which agreement was highest was T10 (91.8%); agreement was lowest for T5 (38.1%). Forty-five percent of anesthesiologists performed between 100 and 250 neuraxial blocks per year. The most commonly performed procedure was a lumbar block (98% of the anesthesiologists). Level of sensory block was evaluated by 95% of the respondents and level of motor block by 83%. Response to heat and cold was used by 94.8%; the Bromage scale was used by 81%. The number of years of experience and the number of correctly located points appeared to be unrelated (P=.76). Nor was there a correlation between the number of blocks performed and number of correctly located points (P=.2).

CONCLUSIONS

T10 was the landmark correctly identified by the largest number of respondents; T5 was correctly identified by the fewest respondents, with answers differing by as much as 4 dermatomes.

Comparison of epidural analgesia with combined spinal-epidural analgesia for labor: a retrospective study of 6497 cases

BACKGROUND

Combined spinal-epidural analgesia provides rapid-onset analgesia with minimal motor block, but it is a more invasive technique than epidural analgesia and the risk of complications may be increased. This study compared the safety and effect on delivery of combined spinal-epidural and epidural analgesia in labor.

METHODS

A retrospective observational study was performed. Data were collected from 6497 women who received regional analgesia in our tertiary hospital in 2005. The incidence of complications during labor and the day after delivery was compared. The effect on labor outcome with both techniques was also assessed.

RESULTS

1964 received combined spinal-epidural (30.2%) and 4533 epidural analgesia (69.8%). Quality of analgesia was better in the combined spinal-epidural group. Labor outcome was similar in the two groups. Pruritus, paresthesia and back pain were more frequent in the combined spinal-epidural group. No differences were observed in the incidence of accidental dural puncture or post dural puncture headache.

CONCLUSIONS

We found that epidural and combined spinal-epidural analgesia were comparable in terms of safety, and had a similar effect on delivery type.

[Difficulty of epidural puncture for obstetric analgesia: risk factors]

INTRODUCTION

Predicting technical difficulties in performing an epidural block can affect the anesthesiologist's choice of technique or decisions about who should carry it out. Our aim was to determine patient characteristics associated with difficulty in performing an epidural block for obstetric analgesia.

MATERIAL AND METHODS

We designed a prospective observational study in 540 pregnant women who requested epidural analgesia for obstetric labor. Patient characteristics (age, weight, height), anatomical features (body constitution, visible and/or palpable spinal apophyses, structural anomalies), technical features (number of attempts, repositioning of the needle), anesthesiologist's experience (resident or staff), block success, time taken to accomplish the procedure, and obstetrical variables (parity, gestational age, cervical dilatation).

RESULTS

The factor that best correlates with puncture difficulty in the obstetric patient is the presence of visible or palpable spinal apophyses and palpation prior to carrying out the block. Factors like weight, body constitution, or anesthesiologist's experience seem to influence the rate of success or failure of the epidural block for obstetric analgesia, although to a lesser degree.

CONCLUSIONS

The most important factor for predicting success of an epidural block for obstetric analgesia in our practice is the presence of palpable spinal apophyses.

[Randomized controlled trial comparing a low dose to a conventional dose of hyperbaric bupivacaine for scheduled cesarean section]

INTRODUCTION

Spinal anesthesia is the technique most often applied in cases of scheduled cesarean section. Many authors have tried decreasing the local anesthetic dose by adding opioids to achieve adequate analgesia with greater hemodynamic stability, although the ideal dose remains to be established. Our aim was to analyze hemodynamic stability and quality of analgesia with 2 different regimens for administering spinal hyperbaric bupivacaine.

METHODS

We designed a controlled, double-blind trial comparing 2 doses of spinal hyperbaric bupivacaine with fentanyl in 42 patients undergoing elective cesarean section randomized to 2 groups to receive either the low dose or the conventional one. One group received an 11 mg dose of bupivacaine and the other group received a 6.5 mg dose, combined with 20 microg of fentanyl in both cases.

RESULTS

The hemodynamic profile and the level of maximum sensory block obtained were similar in the two groups. The motor block was less intense in patients receiving the lower dose and it was necessary to convert 2 patients (10%) to general anesthesia in that group.

CONCLUSIONS

Spinal anesthesia with low doses of bupivacaine and fentanyl provides acceptable intraoperative conditions for a high percentage of patients undergoing cesarean section, with a similar incidence of hypotension. The low dose generates a less intense intraoperative motor blockade with similar spread of the sensory block. The low dose was not efficacious for 10% of the patients who received it.