Efficacy of augmentation of epidural analgesia for Caesarean section

Risk factors for failure of conversion from epidural labor analgesia to cesarean section anesthesia and general anesthesia incidence: an updated meta-analysis

OBJECTIVES

Ongoing controversies persist regarding risk factors associated with the failure of transition from epidural labor analgesia to cesarean section anesthesia, including the duration of labor analgesia, gestational age, and body mass index (BMI). This study aims to provide an updated analysis of the incidence of conversion from epidural analgesia to general anesthesia, while evaluating and analyzing potential risk factors contributing to the failure of this transition to cesarean section anesthesia.

METHODS

We conducted an extensive literature search utilizing databases such as PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), WANGFANG, and the Chinese Biomedical Literature Database (CBM) up to September 30, 2022. The meta-analysis was performed using STATA 15.1 software. The quality of the included studies was assessed using the 11-item quality assessment scale recommended by the Agency for Healthcare Research and Quality (AHRQ).

RESULTS

A total of 9,926 studies were initially retrieved, and after rigorous selection, 19 studies were included in the meta-analysis. The overall incidence of conversion from epidural analgesia to general anesthesia was found to be 6% (95% confidence interval [CI]: 5-8%). Our findings indicate that, when compared to patients in the successful conversion group, those in the failure group tended to be younger (weighted mean difference [WMD] = -1.571, 95% CI: -1.116 to -0.975) and taller (WMD = 0.893, 95% CI: 0.018-1.767). Additionally, the failure group exhibited a higher incidence of incomplete block in epidural anesthesia, received a higher dosage of additional epidural administration, experienced a greater rate of emergency cesarean sections, and received anesthesia more frequently from non-obstetric anesthesiologists. However, no statistically significant differences were observed in gestational age, depth of the catheter insertion into the skin, epidural catheter specifics, duration of epidural analgesia, infusion rate of epidural analgesia, primiparity status, cervical dilatation during epidural placement, BMI, or weight.

CONCLUSION

Our study found that the incidence of conversion from epidural analgesia to cesarean section under general anesthesia was 6%. Notably, the failure group exhibited a higher rate of incomplete block in epidural anesthesia, a greater incidence of emergency cesarean sections, a more frequent provision of anesthesia by non-obstetric anesthesiologists, a higher dosage of epidural administration, and greater height when compared to the success group. Conversely, women in the failure group were younger in age compared to their counterparts in the success group.

Defining the decision-to-delivery interval at caesarean section: narrative literature review and proposal for standardisation

The decision-to-delivery interval is a widely used term at non-elective caesarean section. While the definition may appear self-evident, there is no universally agreed consensus about when this period begins and ends. We reviewed the literature for original research utilising the terms 'decision-to-delivery', 'decision-to-incision' or 'incision-to-delivery' and examined definitions used for decision, delivery, incision, as well as any additional time intervals that were assessed. Our analysis demonstrated an inconsistent non-standardised approach to defining these intervals, which might have clinical practice and medicolegal ramifications. We propose that the decision-to-delivery interval should be defined as follows: the interval between the time at which the senior obstetrician makes the decision that a caesarean section is required and the time at which the fetus (or first fetus in the case of multiples) is delivered. The decision time should ideally be recorded contemporaneously in the medical notes or partogram.

Impact of anesthesiologist's fellowship status on the risk of general anesthesia for unplanned cesarean delivery

BACKGROUND

Neuraxial analgesia is preferred over general anesthesia for cesarean delivery (CD), particularly in the presence of a labor epidural catheter. We hypothesize that care by a non-obstetric anesthesiologist as compared to care by an obstetric anesthesiologist is associated with a higher risk for use of general anesthesia for CD for patients with a preexisting labor epidural catheter.

METHODS

To determine whether fellowship status of the covering anesthesiologist was a risk factor for general anesthesia, we retrospectively investigated the rate of general anesthesia use in patients with epidural catheters placed for labor analgesia who subsequently required CD. To standardize the practice environment under which these cases occurred, we examined only cases which occurred during coverage by the call team on nights, weekends, and holidays.

RESULTS

There were 1820 cases in which a patient had epidural labor analgesia followed by a CD. Nine hundred and twelve cases were covered by an obstetric anesthesiologist and 908 cases were covered by a non-obstetric anesthesiologist. General anesthesia was used in only 16 of these cases. General anesthesia was more likely to be performed by non-obstetric fellowship trained anesthesiologists (1.54% or 14/908 compared to 0.22% or 2/912; P = 0.002).

CONCLUSIONS

This investigation suggests that the presence of an obstetric fellowship-trained anesthesiologist may be a predictor of decreased rate of general anesthesia use in patients with preexisting indwelling labor epidural catheters.

THE COMPLICATIONS OF SPINAL ANESTHESIA IN OBSTETRIC AND GYNECOLOGICAL SURGICAL PROCEDURES

Background: The proper use of spinal anesthesia in surgical procedures will minimize patient’s referral. The objectives of the study were to determine the immediate and late complications of spinal anesthesia in obstetric and gynecological surgical procedures in our population. Material and Methods: This cross-sectional study was conducted in the Department of Gynecology and Obstetrics, Moulvi Ameer Shah Memorial Hospital, Peshawar, Pakistan from January 2014 to December 2014. Sample size was 790, selected through consecutive sampling technique. All routine and emergency obstetrical and gynecological cases were included. The exclusion criteria were those having hypotension, shock, coagulopathy, prolonged surgeries, patient’s refusal and local spinal disease. The demographic variables were; number of attempts, failure of anesthesia, vomiting, hypotension, respiratory problems, pain, Puncture site pain, and post dural puncture headache. All variables being categorical were analyzed by frequency and percentages using SPSS Version 16.0. Results: Out of 790 obstetrics and gynecology patients undergoing spinal anesthesia, there were 752 (95.2%) patients anaesthetized on first attempt whereas 38 (4.8%) required >1 attempts. Spinal anesthesia failed in 17 (2.1%) cases, partially failed in 15(1.9%). Post-operative mild hypotension was observed in 25 (3.1%) patients and severe hypotension in 4 (0.5%) cases. Respiratory problems were noted among 12 (1.9%). Patient’s Post-operative pain was observed in 28 (3.5%) patients. Nausea and vomiting were noted in 68 patients (8.6%).Late complications include post-operative mild to moderate pain in 65 (8.2%), severe in 15 (1.9%). Puncture site pain was observed in 8 (1.0%) of patients. Severe post dural puncture headache was noted in 3 (.38%). Conclusion: Spinal anesthesia in obstetric and gynecological surgical patients is easy to administer, safer and effective.

Algorithm for the anesthetic management of cesarean delivery in patients with unsatisfactory labor epidural analgesia

The management of a patient presenting with unsatisfactory labor epidural analgesia poses a severe challenge for the anesthetist wanting to provide safe anesthetic care for a cesarean delivery. Early recognition of unsatisfactory labor analgesia allows for replacement of the epidural catheter. The decision to convert labor epidural analgesia to anesthesia for cesarean delivery is based on the urgency of the cesarean delivery, airway examination, and the existence of a residual sensory and motor block.  We suggest an algorithm which is implemented in our department, based on the urgency of the cesarean delivery.

Effects of epidural fentanyl on speed and quality of block for emergency cesarean section in extending continuous epidural labor analgesia using ropivacaine and fentanyl

We performed a prospective, randomized, and double-blind study comparing the top-up effects of 2% lidocaine/100 microg fentanyl/epinephrine (n=31) and 2% lidocaine/saline/epinephrine (n=30) when extending an epidural labor analgesia using low-dose ropivacaine and fentanyl. Survival analysis for the sensory blocks to the T4 level showed no statistically significant differences in onset time to T4 between the 2 groups. Onset times (min) to T4-sensory blocks for cold and pinprick were not different between the two groups. However, median maximum sensory level in the lidocaine-fentanyl group (T1 for cold and T2 for pinprick) was significantly higher than that in the lidocaine-saline group (T3 and T4, respectively). The lidocaine-fentanyl group exhibited less visceral pain (6.5% vs. 36.7%), less supplementation of lidocaine (6.5% vs. 43.3%), and less nausea (6.5% vs. 26.7%) compared with the lidocaine-saline group during the intraoperative period. It is concluded that adding fentanyl to 2% lidocaine does not speed up the onset of the block when the onset is tested with cold or sharp pinprick but improves the quality of analgesia with fewer side effects in emergency top-up for cesarean section.

Failure of augmentation of labor epidural analgesia for intrapartum cesarean delivery: a retrospective review

In this study, we aimed to identify the incidence and predictive factors associated with failed labor epidural augmentation for cesarean delivery. Data of parturients, who had received neuraxial labor analgesia and who subsequently required intrapartum cesarean delivery during an 18-mo period, were retrospectively studied. Predictors associated with failure of extension of epidural analgesia in the presence of adequate time for onset of epidural anesthesia were identified by univariate logistic regression. Of the 1025 parturients, 1.7% had failed epidural extension. Predictors of failed epidural anesthesia included initiation of labor analgesia with plain epidural technique (compared to combined spinal-epidural) (P = 0.001), >or=2 episodes of breakthrough pain during labor (P < 0.001) and prolonged duration of neuraxial labor analgesia (P = 0.02).

Prise en charge anesthésique d'une souffrance fœtale aiguë

The application and documentation of foetal surveillance in labour that will decrease the incidence of birth asphyxia while maintaining the lowest possible rate of obstetrical intervention remains discussed. The occurrence of abnormal foetal heart rate is a frequent indication for urgent Caesarean section and subsequent associated risks. Prevention, early recognition, and prompt intervention are the keys to minimizing the risks of anaesthetic mortality and morbidity, mainly from general anaesthesia. Definitions of safe standards of equipment and practices to prevent Mendelson's syndrome and to cope with a failed intubation drill are of major importance. Comprehensive communication between well-coordinated anaesthetic and obstetrical teams is one of the most important elements in the care of a compromised foetus.

Risk factors for failure to extend labor epidural analgesia to epidural anesthesia for Cesarean section

OBJECTIVE

To identify parturients at risk of inability to extend labor epidural analgesia in whom alternative methods of anesthesia should be considered for Cesarean section (CS).

METHODS

For 6 months, we prospectively studied women undergoing a CS with a functioning epidural catheter in place from the delivery ward. All parturients received the same epidural protocol: bolus of bupivacaine 0.1% and fentanyl, then bupivacaine 0.1% and fentanyl (2 microg/ml) 10-15 ml/h and an additional 5 ml of bupivacaine 0.125% top-ups according to patient request. Sixteen millilitres of lidocaine 2%, 1 ml of bicarbonate, and 100 microg of fentanyl were given for CS. Failed epidural analgesia was defined as the need to convert to general anesthesia.

RESULTS

Of the 101 parturients studied, 20 (19.8%) required conversion to general anesthesia. In univariate analysis, the likelihood of failed epidural anesthesia was inversely correlated with parturient's age (P = 0.014) and directly correlated with pre-pregnancy weight (P = 0.019), weight at the end of pregnancy (P = 0.003), body mass index (BMI) at the end of pregnancy (P = 0.0004), gestational week (P = 0.008), number of top-ups (P = 0.0004) and visual analog scale (VAS) 2 h before CS (P = 0.03). In multivariate analysis, the number of top-ups in the delivery ward was the best predictor of epidural anesthesia failure (odds ratio 4.39, P = 0.005).

CONCLUSION

Younger, more obese parturients at a higher gestational week, requiring more top-ups during labor, having a higher VAS in the 2 h before CS are at risk of inability to extend labor epidural analgesia to epidural anesthesia for CS.

Risk factors for failure to extend labor epidural analgesia to epidural anesthesia for Cesarean section

AIM

To identify parturients at risk of inability to extend labor epidural analgesia in whom alternative methods of anesthesia should be considered for Cesarean section (CS).

METHODS

For 6 months, we prospectively studied women undergoing CS with a functioning epidural catheter in place from the delivery ward. All parturients received the same epidural protocol: bolus of bupivacaine 0.1% and fentanyl, followed by bupivacaine 0.1% and fentanyl (2 microg/ml) 10-15 ml/h and an additional 5 ml of bupivacaine 0.125% as top-up according to patient request. Sixteen milliliters of lidocaine 2%, 1 ml of bicarbonate and 100 microg of fentanyl were given for CS. Failed epidural analgesia was defined as the need to convert to general anesthesia.

RESULTS

Of the 101 parturients studied, 20 (19.8%) required conversion to general anesthesia. In univariate analysis, the likelihood of failed epidural anesthesia was inversely correlated with parturient age (P = 0.014) and directly correlated with pre-pregnancy weight (P = 0.019), weight at the end of pregnancy (P = 0.003), body mass index at the end of pregnancy (P = 0.0004), gestational week (P = 0.008), number of top-ups (P = 0.0004) and visual analog scale (VAS) score 2 h before CS (P = 0.03). In multivariate analysis, the number of top-ups in the delivery ward was the best predictor of epidural anesthesia failure (odds ratio, 4.39; P = 0.005).

CONCLUSION

Younger, more obese parturients at a higher gestational week, requiring more top-ups during labor and having a higher VAS score in the 2 h before CS are at risk for inability to extend labor epidural analgesia to epidural anesthesia for CS.

Decision analysis in anaesthesia: a tool for developing and analysing clinical management plans

Traditional medical decision making is unstructured and incorporates evidence haphazardly. I present a more structured approach based on decision analysis, a model that considers all relevant options and outcomes informed by evidence where appropriate. This method is useful both for planning clinical management and for analysing decisions already taken.

A randomised comparison of 0.5% bupivacaine with a lidocaine/epinephrine/fentanyl mixture for epidural top-up for emergency caesarean section after "low dose" epidural for labour

BACKGROUND

When extending a fentanyl-containing, low-dose labour epidural for emergency caesarean section it has been shown that there is no difference in time to surgical readiness between plain bupivacaine 0.5% and mixtures of lidocaine/epinephrine or lidocaine/bupivacaine/epinephrine. However, it is not known whether adding fentanyl to the lidocaine/epinephrine mixture would increase speed of onset or improve the efficacy of the mixture when topping up for an emergency caesarean section.

METHODS

In a prospective, single blind study we compared plain 0.5% bupivacaine with a lidocaine/epinephrine/fentanyl mixture for extending previous low-dose epidural analgesia for emergency caesarean section in 68 patients.

RESULTS

There was a significantly longer median preparation time for the mixture than for the single drug (3.0 v 1.25 min: P < 0.0005). The median onset time for block of T7 to touch from the start of the top-up was 13.8 min for the mixture and 17.5 min for plain bupivacaine. This difference was not statistically significant and was offset by the longer preparation time. No general anaesthetics were required for poor blocks and the need for other intraoperative supplementation was not significantly different between the groups (bupivacaine 5/34, lidocaine mixture 2/26).

CONCLUSIONS

The use of a lidocaine/epinephrine/fentanyl mixture conferred no clear statistically significant benefit over the use of plain 0.5% bupivacaine when used to extend fentanyl containing low-dose labour epidural analgesia for emergency caesarean section, but the lidocaine solution is cheaper and less toxic than the alternatives.