Midwife’s Need-to-know Remifentanil PCA Midwife’s Need-to-know This is a short presentation on the remifentanil PCA which as you probably know is growing in popularity amongst staff and patients in many parts of the North West

Introduction Very short acting opioid Alternative to epidural if it’s contraindicated or unable to be sited Better satisfaction and less neonatal depression than diamorphine or fentanyl Must be started and prescribed by anaesthetist Remifentanil makes an excellent drug for use in patient controlled analgesia as it is fast acting and has a very short duration so can be used to cover the pain of contractions but wears off in between. We’re going to start offering it as an alternative for patients who are not suitable for an epidural, for example if they have a clotting disorder. It has better patient satisfaction than other opioids like diamorphine and because it is so short acting rarely effects the foetus. However, it differs from diamorphine in that it must be prescribed, set up and started by the anaesthetist.

Contraindications and Precautions Allergy to opioid drugs <37 weeks gestation (unless documented intrauterine death) Other opioids (eg diamorphine) within last 4 hours Unable to provide one to one midwife care Caution if BMI>40, patient critically unwell has low body weight or obstructive sleep apnoea Obviously we should not use remifentanil PCAs in patients who are allergic to opioids (although true allergy is rare). It is also contraindicated in patients of less than 37 weeks gestation, if they have had other opioids within the last four hours and crucially if we are not resourced to provide constant 1 2 1 midwife care. We also need to be aware that the effects of remifentanil can be unpredictable if the patient is morbidly obese, very thin or is unwell, for example sepsis.

Patient Preparation She should have read the Remifentanil information leaflet Oxygen SPO2 monitoring, continuous CTG Nasal O2 2L/min Side effects to warn of Itch, nausea, dizziness, sedation, respiratory depression One to one midwife care Prior to starting the PCA, the patient should be appropriately prepared, having discussed the issues with her midwife and anaesthetist and read the information leaflet. Continuous sats monitoring and CTG monitoring are required, as well as nasal cannulae delivering 2-4L Oxygen per minute. The main side effects listed here should also be discussed with the patient, and once again, we need to ensure that one to one midwife care is available at all times.

Practicalities Remifentanil needs a separate cannula Anaesthetist will prepare infusion and set up PCA pump Timing of pushing the button is key – encourage usage as soon as the contraction starts to achieve peak effect at peak of contraction A specific prescription/observation chart will be provided with advice and guidance Entonox may be used at the same time The anaesthetist will insert a separate cannula for the PCA (usually a 20G pink), and they will prepare the infusion and pump and connect it to the patient. It is crucial to encourage the patient to get the timing of pushing the button right. They should ideally push it as soon as they feel the start of the contraction so it reaches its peak when the contraction is most painful. This engenders most analgesic satisfaction. The prescription chart that the anaesthetist provides has some guidance for the midwife.

How many mothers will experience side effects? Desaturation 12-17.7% Sedation 11-50% Termination due to persistent desaturation despite oxygen therapy 0.66-0.8% Nausea + Vomiting 11-60% Pruritus 10-50% Crossover rate ~ 10% After looking after several patients with the remifentanil PCA you are likely to see some of these side effects. This gives an estimate of their frequency, including the crossover to epidural analgesia.

Monitoring EVERY 30 MINUTES the following observations should be measured and recorded on the Remifentanil PCA Chart: Respiratory rate Pulse Blood pressure Sedation Score Pain score Nausea & Vomiting Score In addition to continuous saturations monitoring, these parameters should be monitored and recorded every 30 minutes on the prescription chart.

Troubleshooting PROBLEM ACTION TO TAKE Oxygen saturations below 95% Increase nasal Oxygen to 4 l/min Severe Respiratory Depression Oxygen saturation below 93% OR Respiratory rate less than 8 OR Sedation Score 3 Stop PCA Shake & verbally stimulate Oxygen 15 l/min via facemask Contact Obstetric Anaesthetist Ensure Naloxone 0.4mg available, give 0.1-0.2mg if respiratory rate less than 4 APNOEA- BLS and dial 2222   Hypotension Systolic blood pressure less than 100mmHg OR Pulse less than 50 Increase intravenous fluid rate PULSELESS- BLS and dial 2222 Other problems Inadequate analgesia Nausea & vomiting score 2 or 3 Contact Obstetric Anaesthetist who may Check PCA technique Prescribe an antiemetic Contacting the Obstetric Anaesthetist Bleep 7402 If you are concerned about the patient this table gives some protocols to follow, and is also available on the prescription chart. The key advice is that if the patient becomes unresponsive, stops breathing or drops their blood pressure, stimulate them and call for help, following basic life support guidelines if necessary, and stopping the PCA. Often if a patient’s respiratory rate does drop, they respond readily to verbal stimulation, and since remifentanil is so short acting matters resolve themselves very quickly.

Further Practicalities For replacement syringe please call anaesthetist When discontinued, remove cannula WITHOUT flushing Discard and sign for wasted drug when discontinued If you need more remifentanil, give the anaesthetist plenty of warning as it takes time to prepare the syringe, and when the PCA is discontinued please remove the cannula without flushing it to ensure no drop is inadvertently bolussed into the patient.

Summary A safe and effective alternative when epidural not possible Quick and simple to initiate One to one monitoring is vital as per the guideline Please sign that you’ve seen the presentation! Lucy.McManamon@boltonft.nhs.uk Inese.Kutovaja@boltonft.nhs.uk Peter.Sandbach@boltonft.nhs.uk In summary, remifentanil is a safe and effective alternative when and epidural is not viable. It is quicker and simpler to set up. It must be remembered that one to one monitoring of the patient by the midwife is vital. Thank you for your time.