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Neuraxial Labour Analgesia: current concepts.
Marc Van de Velde, MD, PhD, EDRA Professor of Anaesthesia, Department Cardiovascular sciences KUL Chair Department of Anaesthesiology, University Hospitals Leuven (UZL) ESRA President Leuven, Belgium
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Central Neuraxial Labour Analgesia
Maintenance of Analgesia: CEI – ITU – PCEA – modern PCEA ? Initiation of Analgesia: CSE or epidural ? Central Neuraxial Labour Analgesia Choice of Local Anesthetic: Bupivacaine versus Newer Adjuvant drugs: Neostigmine Opioids Clonidine ….. Dose and concentration.
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HISTORIC TIMELINE < 1980 Eighties Early Nineties Nineties > 2000
Large epidural bolus Less concentrated solution Intermittent Top Ups or Infusion Opioid addition CSE Less concentrated solution PCEA Opioid addition Newer local anesthetics Large epidural bolus Less concentrated solution PCEA Opioid addition CSE Less concentrated solution Intelligent PCEA Opioid addition Newer local anesthetics Neostigmine - Clonidine Large epidural bolus High concentrated solution Intermittent Top Ups No adjuvants
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HISTORIC TIMELINE BUPIVACAINE 225 mg < 1980 Eighties Early Nineties
> 2000 Large epidural bolus High concentrated solution Intermittent Top Ups No adjuvants BUPIVACAINE 225 mg
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HISTORIC TIMELINE < 1980 Eighties Early Nineties Nineties > 2000
Large epidural bolus Less concentrated solution Intermittent Top Ups or Infusion Opioid addition CSE Less concentrated solution PCEA Opioid addition Newer local anesthetics Large epidural bolus Less concentrated solution PCEA Opioid addition CSE Less concentrated solution Intelligent PCEA Opioid addition Newer local anesthetics Neostigmine - Clonidine Large epidural bolus High concentrated solution Intermittent Top Ups No adjuvants
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Epidural Analgesia: low doses of local anesthetics.
Lidocaine 2%. Bupivacaine – 0.75%. Intermittent top-ups. Bupivacaine % in obstetric epidural analgesia. Bleyaert et al. Anesthesiology 1979; 51, 435 – 438.
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High Volume – Low Concentration
Anesth Analg 2007; 104, 412 – 415.
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Opioids added to epidural local anesthetic agents.
Shorter onset of analgesia. Prolonged duration of analgesia. Less local anaesthetic consumption. Less problems with insufficient analgesia. Less motor block. Higher spontanuous delivery rate. Vertommen et al. Anesthesiology 1991; 74, 809 – 814. Polley et al. Anesthesiology 1998; 89, 626 – 632.
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< 1980 Eighties Early Nineties Nineties > 2000
Large epidural bolus Less concentrated solution Intermittent Top Ups or Infusion Opioid addition CSE Less concentrated solution PCEA Opioid addition Newer local anesthetics Large epidural bolus Less concentrated solution PCEA Opioid addition CSE Less concentrated solution Intelligent PCEA Opioid addition Newer local anesthetics Neostigmine - Clonidine Large epidural bolus High concentrated solution Intermittent Top Ups No adjuvants
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Anaesthetist intervention rate.
Van der Vyver et al. Br J Anaesth 2002; 89,
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Local anaesthetic requirements.
Another example comes from Curry and coworkers who reduced his hourly bupivacaine consumption from 14 mg to 8.1 mg changing from Continuous infusion to PCEA. Van der Vyver et al. Br J Anaesth 2002; 89, 459 – 465.
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Incidence of spontaneous delivery.
CIE vs PCEA Eddleston et al. Br J Anaesth 1992; 69, 154: 47% vs 60% Gambling et al. Can J Anaesth 1993; 40, 211: % vs 51% Ferrante et al. Anesth Analg 1994; 79, 80: 60% vs 87% Curry et al. Pain 1994; 57, 125: 47% vs 57% It remains unclear whether the reductions in local anesthetic requirements and the reduced incidence of motor block, produce a more favourable labour outcome. Most investigations cannot differentiate for this aspect between PCEA and other techniques. However, No studies show a worse outcome for PCEA while four studies demonstrate a significant increase in spontanuous delivery rate associated with the PCEA modality. PCEA increase the spontanuous delivery rate with 10 to 30 %. This increase is not due to less C-sections performed but due to less outlet forceps or vacuum deliveries. Less outlet forceps deliveries
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< 1980 Eighties Early Nineties Nineties > 2000
Large epidural bolus Less concentrated solution Intermittent Top Ups or Infusion Opioid addition CSE Less concentrated solution PCEA Opioid addition Newer local anesthetics Large epidural bolus Less concentrated solution PCEA Opioid addition CSE Less concentrated solution Intelligent PCEA Opioid addition Newer local anesthetics Neostigmine - Clonidine Large epidural bolus High concentrated solution Intermittent Top Ups No adjuvants
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Faster analgesia with CSE. Less rescue analgesia needed with CSE.
Simmons et al. Cochrane database of systematic reviews 2007; Issue 3, CD Faster analgesia with CSE. Less rescue analgesia needed with CSE. Less urinary retention with CSE. More pruritus with CSE. Conclusion: « There appears to be little basis for offering CSE over conventional epidurals in labour …. »
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VAS for pain. Breen. Techn RAPM 2001; 5, 1,
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Analgesic requirements.
Van de Velde et al. Acta Anaesth Belg 1999; 50,
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Recurrent breakthrough pain.
Hess et al. Anesth Analg 2001; 93,
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Reliability epidural catheters.
Van de Velde et al. Anaesth Intens Care 2001; 29, 6, 595 – 599.
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Meta-Analysis retrospective studies.
Heesen, Van de Velde et al. Anaesthesia 2014
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Meta-Analysis prospective studies.
Heesen, Van de Velde et al. Anaesthesia 2014
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Fetal heart rate changes with IT opioids.
Retrospective – reported as a letter. Intrathecal fentanyl 50 μg, early labor. 9/30 parturients: fetal bradycardia. No hypotension. Within 30 minutes of IT injection. Duration 5 – 10 minutes. 6/9 patients: uterine hyperactivity ! Terbutaline. 2/9: C-section. Clarke et al. Anesthesiology 1994; 81, 1083.
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FHR changes and IT opioids. Randomized trials.
3513 women Relative risk 1.81 (1.04 – 3.14) Mardirossof C et al. BJOG 2002; 109, 274 – 281.
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Uterine hyperactivity
What is the mechanism ? Exogenous oxytocin Advanced labor Vasodilation Ruptured membranes Uterine hyperactivity Direct fetal effects Rapid analgesia Oxytocin release
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Motor block. Wilson et al. Anaesthesia 2009; 64,
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Number of study subjects
Epidural ropivacaine versus bupivacaine for labor: number of patients with motor block using similar, low concentrations of local anaesthetic in both groups. Study Bupivacaine Ropivacaine Number of study subjects Campbell et al. 5 0 * 40 Meister et al. 18 8 * 50 Gautier et al. 15 3 * 90 Lee et al. 21 10 346 Owen et al. 12 8 Gogarten et al. 11 4 109 Chua et al. 3 32 Fischer et al. 19 189 TOTAL 106 46 906 Number of patients with motor block. * P < 0.05 versus bupivacaine.
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Epidural ropivacaine versus bupivacaine: Incidence of motor block using higher ropivacaine concentrations. Gautier et al Anesthesiology 1999; 90,
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< 1980 Eighties Early Nineties Nineties > 2000
Large epidural bolus Less concentrated solution Intermittent Top Ups or Infusion Opioid addition CSE Less concentrated solution PCEA Opioid addition Newer local anesthetics Large epidural bolus Less concentrated solution PCEA Opioid addition CSE Less concentrated solution Intelligent PCEA Opioid addition Newer local anesthetics Neostigmine - Clonidine Large epidural bolus High concentrated solution Intermittent Top Ups No adjuvants
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Computer Integrated PCEA (CI-PCEA)
Programmed Intermittent or Automated Mandatory Epidural Boluses (PIEB-PCEA or AMB-PCEA)
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Computer integrated patient controlled epidural analgesia.
Results: PCEA-CI resulted in: Less breakthrough pain. Higher maternal satisfaction. Sia et al. Singapore Med J 2006; 47, Lim et al. Anaesthesia 2006; 61, 339 – 344. Sng et al. Anaesth Intens Care 2009; 37, 46 – 53.
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Epidural clonidine 75 μg. This was recently demonstrated by Landau and coworkers who demonstrated that clonidine 75 micrograms prolongs analgesia, reduces the total dose of ropivacaine used, reduces the number of additional epidural doses required and reduces the onset time of epidural analgesia. Landau et al. Anesth Analg 2002; 95,
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Epidural neostigmine. Roelants et al. Anesthesiology 2005; 102,
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HISTORIC TIMELINE BUPIVACAINE: 225 mg ROPIVACAINE: 15 mg < 1980
Eighties Early Nineties Nineties > 2000 Large epidural bolus High concentrated solution Intermittent Top Ups No adjuvants CSE Less concentrated solution Intelligent PCEA Opioid addition Newer local anesthetics Neostigmine - Clonidine BUPIVACAINE: 225 mg ROPIVACAINE: 15 mg
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HISTORIC TIMELINE ROPIVACAINE: 15 mg
< 1980 Eighties Early Nineties Nineties > 2000 CSE Less concentrated solution Intelligent PCEA Opioid addition Newer local anesthetics Neostigmine - Clonidine ROPIVACAINE: 15 mg Sharma et al. Anesthesiology 1997; 87, Halpern et al. JAMA 1998; 280,
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True or false ?! More C-sections Longer labour duration
More oxytocin use More instrumental deliveries Maternal fever Back pain Neurologic injury Breastfeeding
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Neuraxial Labour Analgesia: current concepts.
Marc Van de Velde, MD, PhD, EDRA Professor of Anaesthesia, Department Cardiovascular sciences KUL Chair Department of Anaesthesiology, University Hospitals Leuven (UZL) ESRA President Leuven, Belgium
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