Jill Cooley, MD Department of Anesthesiology

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Presentation transcript:

Epidurals and spinals: Is that all we have to offer for obstetrical pain? Jill Cooley, MD Department of Anesthesiology University of Tennessee Health Science Center Regional One Health

No Disclosures

-Describe role of Lumbar Epidural in Labor analgesia Objectives -Describe role of Lumbar Epidural in Labor analgesia -Identify alternatives to neuraxial labor analgesia -Discuss treatment options for acute post-cesarean pain control -Identify risk factors for development of Chronic Pain -Discuss practice measures for pain management in opioid crisis era

600 B.C.

Lumbar Epidural -60% of deliveries -Continuous + PCEA - PIDB +/- PCEA most common method of labor analgesia -60% of deliveries optimal method of delivery still questioned -Continuous + PCEA - PIDB +/- PCEA - Dural Puncture for Sacral Spread CSE-provider dependent

Remifentanil Dosing: PCA only, no background delivery of 20-50micrograms per dose optimal timing is dose delivery at onset of contraction can titrate lockout of 2mins Patient Variability Additional monitoring/personnel Potential for sedation, respiratory depression Not approved; lacking established standard dosing

Nitrous Oxide -Cost effective -Good Safety Profile -Viable alternative to neuraxial -Implementation Obstacles -diversion -staff exposure -

Post cesarean pain management Intrathecal -Duramorph 150-300ug -analgesia for up to 24hrs -pruritus, nausea -management of breakthrough pain -Clonidine 50-150ug -increased duration of sensory block, improved analgesia -dose dependant hypotension reported - Epidural clonidine 2-4mcg/ml + 0.0625% bupi for post operative pain control

Post cesarean pain management Regional Transverse Abdominal Plane Quadratus Laborum Field Infiltration

Transverse Abdominal plane block -Less effective than ITM -Improved analgesia when combined with ITM -Consideration when ITM contraindicated -Visceral Sparing Continous catheter for 24-48 hrs Local Anesthetic Caution

Quadratus Lumborum -visceral? -more effective than TAP for analgesia -Patient positioning more challenging -multi-modal componant

OPIOID CRISIS -Pain management in opioid crisis MMA, avoid the pain number, focus on function, communicate expectations -Poorly managed acute pain leads to chronic pain

Perception and Pain -Identify patients with risk factors for development of chronic pain -Compare what patient wanted to what they received

THE END

References: McKenzie CP, Cobb B, Riley ET, Carvalho B. Programmed intermittent epidural boluses for maintenance of labor analgesia: an impact study. Int J Obstet Anesth. 2016 May;26:32-8. Bonnet, M.P.; Prunet, C.; Baillard, C.; Kpéa, L.; Blondel, B.; Le Ray, C. Anesthetic and Obstetrical Factors Associated With the Effectiveness of Epidural Analgesia for Labor Pain Relief: An Observational Population-based Study. Obstetric Anesthesia Digest: December 2017 - Volume 37 - Issue 4 - p 213 péa, L.; Bonnet, M.; Ray, C.; Prunet, C.; Ducloy-Bouthors, A.; Blondel, B.IInitial Preference for Labor Without Neuraxial Analgesia and Actual Use: Results from a National Survey in France. Obstetric Anesthesia Digest: September 2016 - Volume 36 - Issue 3 - p 157–158 Heesen, Michael; Böhmer, Johannes; Klöhr, Sven; Hofmann, Thomas; Rossaint, Rolf; Straube, Sebastian. The Effect of Adding a Background Infusion to Patient-Controlled Epidural Labor Analgesia on Labor, Maternal, and Neonatal Outcomes: A Systematic Review and Meta-Analysis. Obstetric Anesthesia Digest: June 2016 - Volume 36 - Issue 2 - p 105–106 Richardson MG1, Lopez BM, Baysinger CL, Shotwell MS, Chestnut DH. Nitrous Oxide During Labor: Maternal Satisfaction Does Not Depend Exclusively on Analgesic Effectiveness. Anesth Analg. 2017 Feb;124(2):548-553. Tawfik MM1, Mohamed YM, Elbadrawi RE, Abdelkhalek M, Mogahed MM, Ezz HM. Transversus Abdominis Plane Block Versus Wound Infiltration for Analgesia After Cesarean Delivery: A Randomized Controlled Trial. Anesth Analg. 2017 Apr;124(4):1291-1297. doi: 10.1213/ANE.0000000000001724. Eisenach, J.C., Pan, P.H., Smiley, R., Lavand’homme, P., Landau, R., and Houle, T.T. Severity of acute pain after childbirth, but not type of delivery, predicts persistent pain and postpartum depression. Pain. 2008; 140: 87–94 Chong MA1, Wang Y2, Dhir S3, Lin C. . Programmed intermittent peripheral nerve local anesthetic bolus compared with continuous infusions for postoperative analgesia: A systematic review and meta-analysis J Clin Anesth. 2017 Nov;42:69-76.