1. Update in Obstetric Anesthesia: Part I

2. Objectives Expose staff to current practices and trends in the area of Obstetric Anesthesia Expose staff to current practices and trends in the area of Obstetric Anesthesia Share practical applications related to these topics that can be incorporated into our routine practice at MHMC Share practical applications related to these topics that can be incorporated into our routine practice at MHMC Compare/contrast our practices with those of other tertiary care facilities Compare/contrast our practices with those of other tertiary care facilities Give references for various topics Give references for various topics Time will not permit critical review of all references and this will NOT be attempted. Time will not permit critical review of all references and this will NOT be attempted.

3. Update in OB Anesthesia Part I: CSE and PCEA Part I: CSE and PCEA Part II: All other topics in OB Anesthesia Part II: All other topics in OB Anesthesia More diverse and interesting topics (Date to be announced……) More diverse and interesting topics (Date to be announced……)

4. CSE Kits/Needles Why so many choices?? Why so many choices?? (We currently have 5 different kits or combinations of CSE needles at MHMC (We currently have 5 different kits or combinations of CSE needles at MHMC ----enough is enough!) ----enough is enough!) What would make one CSE needle better or more effective than another? What would make one CSE needle better or more effective than another? Aren’t all 25 g needles created equal? Aren’t all 25 g needles created equal? Why do we fail to get the CSF when we want to during CSEs, (and far too often get the gusher when we don’t want to see it!---during regular epidurals) Why do we fail to get the CSF when we want to during CSEs, (and far too often get the gusher when we don’t want to see it!---during regular epidurals)

5. Incidence of Failure to obtain CSF during CSE Most commonly quoted figure of failed CSEs (failure to obtain CSF during CSE): Reported incidence 10% Reported incidence varies from 8%-38% depending on needles used Reported incidence varies from 8%-38% depending on needles used MHMC Feb 2006 Woodring and Sheth, incidence of failure to get CSF 30-40% (Their technique was excellent---but their results were poor) MHMC Feb 2006 Woodring and Sheth, incidence of failure to get CSF 30-40% (Their technique was excellent---but their results were poor) Why is our success rate so low????? Why is our success rate so low?????

6. March 2006 Virginia Apgar Obstetric Anesthesia Conference, Orlando FL Spinal needle must protrude 15 mm beyond epidural needle to have high likelihood for success in obtaining CSF! Spinal needle must protrude 15 mm beyond epidural needle to have high likelihood for success in obtaining CSF! Length of spinal needle alone cannot be used as sole determinant as to if spinal needle is long enough for CSE success with a given epidural needle. Length of spinal needle alone cannot be used as sole determinant as to if spinal needle is long enough for CSE success with a given epidural needle. Hubs of spinal needles inserted thru Tuohys varies considerably with manufacturer. You must actually measure to make sure that your spinal needle protrudes 15 mm beyond your epidural needle. Hubs of spinal needles inserted thru Tuohys varies considerably with manufacturer. You must actually measure to make sure that your spinal needle protrudes 15 mm beyond your epidural needle.

7. Length of Spinal Needle for CSE very important (as is the hub)! A comparison of 24 g Sprotte and Gertie Marx Spinal Needles for CSE during labor A comparison of 24 g Sprotte and Gertie Marx Spinal Needles for CSE during labor Riley et al, Anesthesiology, 2002;97:574-7 24 g Sprotte (N = 36) 24 g Gertie Marx (N = 37) 24 g Sprotte (N = 36) 24 g Gertie Marx (N = 37) (120 mm long—protrudes 9 mm) ( 127 mm long----protrudes 17mm) (120 mm long—protrudes 9 mm) ( 127 mm long----protrudes 17mm) No CSF *6/36 (17%) 0/37 *(In all 6 cases where the sprotte needle did not produce CSF, the longer Gertie Marx needle was inserted and CSF was obtained)

8. NB search: Espocan CSE needles (Less failures, less paresthesias) 50 patients Espocan, 50 patients Conventional Epidural Tuohy + Gertie Marx spinal needle 50 patients Espocan, 50 patients Conventional Epidural Tuohy + Gertie Marx spinal needle Espocan Conv Epid Espocan Conv Epid + Gertie Marx + Gertie Marx Intravascular Catheter 2% 6% Intravascular Catheter 2% 6% Paresthesia(or Pain) 14% 42% Paresthesia(or Pain) 14% 42% Wet tap 2% 2% Wet tap 2% 2% Failure to obtain CSF 8% 28% Failure to obtain CSF 8% 28% Intrathecal Cath Placement 0% 0% Intrathecal Cath Placement 0% 0% Brown, Birnbach, Stein et al Anesth Analg 2005;101:535-40 Brown, Birnbach, Stein et al Anesth Analg 2005;101:535-40

9. Our success rate was lower than expected because our CSE needles were too short! Our success rate was lower than expected because our CSE needles were too short! Most of our CSE needles only protruded 13 mm beyond the epidural needle, rather than the recommended 15 mm. Most of our CSE needles only protruded 13 mm beyond the epidural needle, rather than the recommended 15 mm.

10. Review of Currently Available Options for CSEs at MHMC:

11. MHMC CSE Options Please take a look at the two trays being passed around, each with various CSE needles. Please take a look at the two trays being passed around, each with various CSE needles. Please feel the resistance with Pencan thru conventional Tuohy, vs. no resistance with Espocan CSE set. This will take some getting used to. Please feel the resistance with Pencan thru conventional Tuohy, vs. no resistance with Espocan CSE set. This will take some getting used to.

16. Durasafe CSE needles with different whitacre needles

17. Durasafe CSE needles with different 25 g Whitacres

19. 25 g Pencan thru 18g Braun Tuohy (our usual Epidural needle)

20. 25 g Espocan CSE Needle

21. 25 g Espocan Epidural and Spinal needle with sheath

22. What about CSE for the Obese??? Most CSE kits packaged with only 9 cm Tuohy Most CSE kits packaged with only 9 cm Tuohy At OB conference, I asked what do others do when they want to do a CSE in the really obese (many MHMC patients) At OB conference, I asked what do others do when they want to do a CSE in the really obese (many MHMC patients) 3 from panel said they just don’t do them as needles not long enough. 3 from panel said they just don’t do them as needles not long enough. One panelist said “Biggie size it with Gertie Marx!” One panelist said “Biggie size it with Gertie Marx!”

23. 13 cm Gertie Marx vs. 9 cm Espocan (Arnie’s “Biggie Size” Needle)

24. Gertie Marx CSE for the Obese Needle is very flimsy Needle is very flimsy Wings on needle easily come off Wings on needle easily come off Epidural space often encountered 9.5-12 cm in obese patients so regular CSE needles ineffective even with indenting skin. Epidural space often encountered 9.5-12 cm in obese patients so regular CSE needles ineffective even with indenting skin.

25. 25 g Pencan thru Durasafe Epidural needle (Whoa----careful now!) For those that don’t like the espocan, but want to increase success rate Extends 20 mm Very wasteful (Braun epidural kit, Durasafe CSE needle, Pencan needle)

26. MHMC CSE Series since March 2006 Pencan thru Durasafe needle (20mm) Pencan thru Durasafe needle (20mm) Success: 4 of 4 (no failures) Success: 4 of 4 (no failures) Paresthesias:1 of 4 (25%) Paresthesias:1 of 4 (25%) Espocan CSE Needles (15mm): Espocan CSE Needles (15mm): Success:27 of 30 Success:27 of 30 Paresthesias: 5 of 30 (17%) Paresthesias: 5 of 30 (17%) Since routinely utilizing spinal needles which protrude at least 15 mm beyond the epidural needle, we have had greater success with the CSE technique, and our success rate now mirrors that reported by others with high success rates. (Currently failure to obtain CSF in 10%)

27. Failure to obtain CSF thru spinal needle during CSE: Explanations Needle too short Needle too short (Recommend 15 mm protrusion of spinal thru epidural needle) (Recommend 15 mm protrusion of spinal thru epidural needle) Needle off midline Needle off midline Tenting of Dura Tenting of Dura

28. CSE Failures

30. Tenting of Dura by Needle

31. Why all the fuss with CSEs? Are they worth the H/A----and by the way, are there more H/As with CSEs? Many large academic centers perform 75-90% CSEs for labor pain relief Many large academic centers perform 75-90% CSEs for labor pain relief MHMC performs ~ 15% CSEs for labor MHMC performs ~ 15% CSEs for labor Last week of every OB rotation consists of ALL CSEs. This provides residents with exposure to technique, and allows them to form their own opinions about the technique. Last week of every OB rotation consists of ALL CSEs. This provides residents with exposure to technique, and allows them to form their own opinions about the technique.

32. Labor CSE Advantages: Labor CSE Advantages: Rapid onset of effective labor analgesia. 2-3 mins vs. ~ 15 minutes with conventional epidurals Rapid onset of effective labor analgesia. 2-3 mins vs. ~ 15 minutes with conventional epidurals Less LA and opioid required Less LA and opioid required Less motor block. Allows for “walking epidurals”. Less motor block. Allows for “walking epidurals”. ? Improved success of subsequent epidural (probably NOT!)---let’s look at this…… ? Improved success of subsequent epidural (probably NOT!)---let’s look at this…… May speed progress of labor May speed progress of labor Greater patient satisfaction Greater patient satisfaction

33. ? Improved success of epidurals as part of CSE Failure to get CSF in ~ 10% of cases (Higher failure rate if spinal needle not long enough) Failure to get CSF in ~ 10% of cases (Higher failure rate if spinal needle not long enough) Randomized study 1 of 2183 patients receiving either CSE or a standard epidural found no significant difference of successful epidural between the two groups. Randomized study 1 of 2183 patients receiving either CSE or a standard epidural found no significant difference of successful epidural between the two groups. 1 Norris MC< et al: Anesthesiology 2001: 95: 913-29 1 Norris MC< et al: Anesthesiology 2001: 95: 913-29

34. Labor CSE Advantages: Labor CSE Advantages: Rapid onset of effective labor analgesia. 2-3 mins vs. ~ 15 minutes with conventional epidurals Rapid onset of effective labor analgesia. 2-3 mins vs. ~ 15 minutes with conventional epidurals Less LA and opioid required Less LA and opioid required Less motor block. Allows for “walking epidurals”. Less motor block. Allows for “walking epidurals”. ? Improved success of subsequent epidural (probably NOT!) ? Improved success of subsequent epidural (probably NOT!) May speed progress of labor—let’s look at this… May speed progress of labor—let’s look at this… Greater patient satisfaction Greater patient satisfaction

35. CSE and progress of labor Is combined spinal-epidural Analgesia Associated with more Rapid Cervical Dilation in Nulliparous Patients when Compaired with Conventional Epidural Analgesia? Is combined spinal-epidural Analgesia Associated with more Rapid Cervical Dilation in Nulliparous Patients when Compaired with Conventional Epidural Analgesia? Tsen et al Anesthesiology 91: No 4, Oct 1999 Cervical Dilation (after 3 cm) N=100 (50 each group) CSE mean dilation 2.1 +/- 2.1 cm/hr, Epid mean dilation 1.1 +/- 1 cm/hr (5 pts had initial dilation > 5cm/h in CSE group, none in Epid) The Risk of Cesarean Delivery with Neuraxial Analgesia Given Early versus Late in Labor The Risk of Cesarean Delivery with Neuraxial Analgesia Given Early versus Late in Labor Wong et al, NEJM Feb 2005 Vol 352. No 7 P655-665 No difference in C/S rate Median time from initiation to complete dilation significantly shorter after intrathecal analgesia than systemic analgesia (295 minutes vs. 385 minutes P < 0.001)

36. Labor CSE Advantages: Labor CSE Advantages: Rapid onset of effective labor analgesia. 2-3 mins vs. ~ 15 minutes with conventional epidurals Rapid onset of effective labor analgesia. 2-3 mins vs. ~ 15 minutes with conventional epidurals Less LA and opioid required Less LA and opioid required Less motor block. Allows for “walking epidurals”. Less motor block. Allows for “walking epidurals”. ? Improved success of subsequent epidural (probably NOT!) ? Improved success of subsequent epidural (probably NOT!) May speed progress of labor May speed progress of labor Greater patient satisfaction (Higher satisfaction with CSE vs. Conventional, but high with both) Greater patient satisfaction (Higher satisfaction with CSE vs. Conventional, but high with both)

37. Labor CSE Disadvantages: Pruritus, N/V Pruritus, N/V (Mild symptoms and less frequent with smaller doses). (Mild symptoms and less frequent with smaller doses). Respiratory Depression (Rare with doses) Respiratory Depression (Rare with doses) ? Increase in PDPH (NOT!) ? Increase in PDPH (NOT!) ? Increase in intrathecal catheters (NOT!) ? Increase in intrathecal catheters (NOT!) Fetal Decelerations Fetal Decelerations Untested Epidural Untested Epidural More costly More costly Paresthesia/Pain during spinal insertion Paresthesia/Pain during spinal insertion

38. Respiratory Depression and CSEs

39. Reference Doses of IT narcotics for labor Previous Doses Previous Doses Sufentanil 10-15 mcg Sufentanil 10-15 mcg Fentanyl 50 mcg Fentanyl 50 mcg Current Doses Current Doses Sufentanil 2.5-5 mcg Sufentanil 2.5-5 mcg Fentanyl 15-25 mcg Fentanyl 15-25 mcg

40. Labor CSE Disadvantages: Pruritis, N/V Pruritis, N/V (Mild symptoms and less frequent with smaller doses). (Mild symptoms and less frequent with smaller doses). Respiratory Depression (Rare with doses) Respiratory Depression (Rare with doses) ? Increase in PDPH (NOT!) ? Increase in PDPH (NOT!) ? Increase in intrathecal catheters (NOT!) ? Increase in intrathecal catheters (NOT!) Untested Epidural Untested Epidural Fetal Decelerations Fetal Decelerations More costly More costly Paresthesia/Pain during spinal insertion Paresthesia/Pain during spinal insertion

41. Status of Epidural not known We like to have functioning epidurals. If the epidural is not working properly, we suggest early replacement We like to have functioning epidurals. If the epidural is not working properly, we suggest early replacement Epidural not immediately dosed after CSE so there is no way to know if epidural will function for an urgent C/S. Epidural not immediately dosed after CSE so there is no way to know if epidural will function for an urgent C/S. Epidural test dose not initially performed as this additional LA would lead to increased incidence of hypotension and unwanted excessive motor block. (This potentially makes the CSE more labor intensive if personnel must return to “test” the catheter and administer the epidural bolus Epidural test dose not initially performed as this additional LA would lead to increased incidence of hypotension and unwanted excessive motor block. (This potentially makes the CSE more labor intensive if personnel must return to “test” the catheter and administer the epidural bolus (usually after 1.5-2 hours) (usually after 1.5-2 hours)

42. Labor CSE Disadvantages: Pruritis, N/V Pruritis, N/V (Mild symptoms and less frequent with smaller doses). (Mild symptoms and less frequent with smaller doses). Respiratory Depression (Rare with doses) Respiratory Depression (Rare with doses) ? Increase in PDPH (NOT!) ? Increase in PDPH (NOT!) ? Increase in intrathecal catheters (NOT!) ? Increase in intrathecal catheters (NOT!) Untested Epidural Untested Epidural Fetal Decelerations Fetal Decelerations More costly More costly

43. CSE and Fetal Bradycardia Numerous reports documenting severe bradycardia after IT fentanyl or sufentanil sometimes in association with documented uterine hypertonus. Numerous reports documenting severe bradycardia after IT fentanyl or sufentanil sometimes in association with documented uterine hypertonus. Proposed mechanism: rapid onset of analgesia with IT opioids causes acute decrease in catecholamines, especially epi, which is tocolytic. The resulting disinhibition may cause increased uterine tone with subsequent placental ischemia and fetal bradycardia. Proposed mechanism: rapid onset of analgesia with IT opioids causes acute decrease in catecholamines, especially epi, which is tocolytic. The resulting disinhibition may cause increased uterine tone with subsequent placental ischemia and fetal bradycardia. Though FHR abnormalities usually resolve, one must always be prepared for urgent C/S. Though FHR abnormalities usually resolve, one must always be prepared for urgent C/S.

44. Risk Factors for Fetal Decelerations following CSE for labor Predicting prolonged fetal heart rate deleration following intrathecal fentanyl/bupivicaine Predicting prolonged fetal heart rate deleration following intrathecal fentanyl/bupivicaine Gaiser et al, International Journal of Obstetric Anesthesia (IJOA) (2005) Vol 14, 208-211 33/151 patients (21%) had fetal decelerations (mean 4.1 minutes) following CSE for labor. None of these patients underwent C/S. Lack of fetal engagement (zero station) (odds ratio 5.5) and presence of heart rate decelerations within 30 minutes prior to CSE (odds ratio 3.6) were associated with prolonged fetal heart rate decelerations after CSE.

45. Intrathecal Sufentanil and Fetal Heart Rate Abnormalities: A Double-Blind, Double Placebo-Controlled Trial comparing Two Forms of Combined Spinal Epidural Analgesia with Epidural Analgesia in Labor Intrathecal Sufentanil and Fetal Heart Rate Abnormalities: A Double-Blind, Double Placebo-Controlled Trial comparing Two Forms of Combined Spinal Epidural Analgesia with Epidural Analgesia in Labor Van de Velde et al, Anesth Analg 2004;98:1153-9 Van de Velde et al, Anesth Analg 2004;98:1153-9 Three Hundred Paturients randomized to three groups: Group 1: Epidural with 12.5 mg Bupivicaine, 12.5 mcg Epi, 7.5 mcg Sufentanil Group 2: CSE with Sufentanil 1.5 mcg, Epi 2.5 mcg, and Bupivicaine 2.5 mg Group 3: CSE with Sufentanil 7.5 mcg Fetal Decels Group 1:11% (Within first hour of initiation) Group 2: 12% Group 3:24% Group 3:24% Uterine Hyperactivity Groups 1 & 22% Group 3 22% HypotensionGroup 17% (Requiring Ephedrine)Group 229% ( Bupi) Group 312%

46. CSE and Fetal Bradycardia Summary by Dr. Richard Smiley (Virginia Apgar Conference Mar 2006) Fairly clear that incidence of fetal heart rate abnormalities is similar between CSE and most epidural techniques (though time course is different—more rapid with CSEs) Fairly clear that incidence of fetal heart rate abnormalities is similar between CSE and most epidural techniques (though time course is different—more rapid with CSEs) Cesarean sections are NOT more common with CSE analgesia (if OB’s are “trained”) Cesarean sections are NOT more common with CSE analgesia (if OB’s are “trained”) More recent randomized series suggest bradycardias are associated with higher doses of opioids than generally used today, with lower dose opioid/LA mixtures resulting in same incidence as standard epidurals. More recent randomized series suggest bradycardias are associated with higher doses of opioids than generally used today, with lower dose opioid/LA mixtures resulting in same incidence as standard epidurals.

47. Temporarily Changing Course….. Hang in there while I cover this related topic. Hang in there while I cover this related topic. We will return to the pros and cons of CSEs shortly……. We will return to the pros and cons of CSEs shortly……. What can be done if the fetal decelerations after CSE are in fact due to increased uterine tone????? ---NTG may be the answer! What can be done if the fetal decelerations after CSE are in fact due to increased uterine tone????? ---NTG may be the answer!

48. Nitroglycerin: Tocolysis now! The precise mechanism by which NTG causes uterine relaxation (tocolysis) remains unclear The precise mechanism by which NTG causes uterine relaxation (tocolysis) remains unclear Ususal dosage 100-500 mcg IV, 400-800mcg SL (1-2 metered sprays) ---(published reports from 50 mcg-1850 mcg) Ususal dosage 100-500 mcg IV, 400-800mcg SL (1-2 metered sprays) ---(published reports from 50 mcg-1850 mcg) Relaxation of the uterus is typically reported within 90 seconds Relaxation of the uterus is typically reported within 90 seconds ASA Task Force on OB Anesthesia: Practice guidelines for OB Anesthesia Recommends NTG as effective agent for uterine relaxation for retained placenta tissue ASA Task Force on OB Anesthesia: Practice guidelines for OB Anesthesia Recommends NTG as effective agent for uterine relaxation for retained placenta tissue

49. Nitroglycerin: Tocolysis (Uses) Retained Placenta Retained Placenta Internal and External Versions Internal and External Versions Entrapped Fetuses at Vaginal Delivery and Cesarean Section Entrapped Fetuses at Vaginal Delivery and Cesarean Section Fetal Surgery Fetal Surgery *Fetal Distress (Bradycardia) associated with hyperstimulation or tetany (whether or not caused or associated with CSE!) *Fetal Distress (Bradycardia) associated with hyperstimulation or tetany (whether or not caused or associated with CSE!)

50. Nitroglycerin as Rx CSE associated Fetal Decelerations Small doses of I.V. Nitroglycerine Small doses of I.V. Nitroglycerine (60-180 mcg) are associated with resolution of severe fetal distress related to uterine hyperactivity along with negligible side effects. (60-180 mcg) are associated with resolution of severe fetal distress related to uterine hyperactivity along with negligible side effects. Mercier et al, Anesth Anal 1997;84:1117-1120

51. Labor CSE Disadvantages: Pruritis, N/V Pruritis, N/V (Mild symptoms and less frequent with smaller doses). (Mild symptoms and less frequent with smaller doses). Respiratory Depression (Rare with doses) Respiratory Depression (Rare with doses) ? Increase in PDPH (NOT!) ? Increase in PDPH (NOT!) ? Increase in intrathecal catheters (NOT!) ? Increase in intrathecal catheters (NOT!) Untested Epidural Untested Epidural Fetal Decelerations Fetal Decelerations More costly More costly Paresthesia/Pain during spinal insertion Paresthesia/Pain during spinal insertion

52. Labor CSEs are more costly Current Braun Perifix Epidural Tray:$17.97 Current Braun Perifix Epidural Tray:$17.97 Pencan Needle$ 5.25 Pencan Needle$ 5.25 Individual Durasafe CSE Kit (Needles Only)$ 9.00 Individual Durasafe CSE Kit (Needles Only)$ 9.00 Individual Espocan CSE Kit (Needles Only)$15.50 Individual Espocan CSE Kit (Needles Only)$15.50 (Prepacked $7.03 or 45% less) (Prepacked $7.03 or 45% less) Braun Kit with Espocan CSE Needle added:$25.00 Braun Kit with Espocan CSE Needle added:$25.00 (Add’l $7.03 or 39%) (Add’l $7.03 or 39%) (We will soon have a large stock of our current Braun/Perfix Epidural kits, and have a smaller supply of epidural trays prepackaged with the Espocan Needle)

53. Labor CSE Disadvantages: Pruritis, N/V Pruritis, N/V (Mild symptoms and less frequent with smaller doses). (Mild symptoms and less frequent with smaller doses). Respiratory Depression (Rare with doses) Respiratory Depression (Rare with doses) ? Increase in PDPH (NOT!) ? Increase in PDPH (NOT!) ? Increase in intrathecal catheters (NOT!) ? Increase in intrathecal catheters (NOT!) Untested Epidural Untested Epidural Fetal Decelerations Fetal Decelerations More costly More costly Paresthesia/Pain during spinal insertion Paresthesia/Pain during spinal insertion

54. Higher incidence of “Paresthesias/Pain” during spinal advancement with CSE than with single shot spinals 89 woman for elective C/S randomized to single shot spinal or needle thru needle spinal (CSE). 89 woman for elective C/S randomized to single shot spinal or needle thru needle spinal (CSE). Paresthesias in 37% needle thru needle Paresthesias in 37% needle thru needle Paresthesias in 9% single shot spinal Paresthesias in 9% single shot spinal No patients had persistent neurological symptoms on postop day #1 No patients had persistent neurological symptoms on postop day #1 McCandrew CR- Anaesth Intensive Care – 01-Oct-2003: 31(5): 514-7

55. Epidural lidocaine decreases paresthesias/pain associated with dural puncture during CSEs 3cc 2% Xylocaine with 1:200 K epi (vs. saline) given via Tuohy needle after LOR, and then spinal needle advanced. 3cc 2% Xylocaine with 1:200 K epi (vs. saline) given via Tuohy needle after LOR, and then spinal needle advanced. Pain/Paresthesias in Lidocaine Group 9 % Pain/Paresthesias in Saline Group81% Van den Berg et al, Anesth Analg 2005: 101: 882-5 Note: This should NOT be done for labor CSEs!

56. When should the epidural test dose be administered with CSE? Administering the 3cc test dose of 1.5% Xylo with epi immediately after the labor CSE leads to an increased incidence of hypotension (spinal Bup + Epidural Xylo) and leads to undesired (excessive) motor block Administering the 3cc test dose of 1.5% Xylo with epi immediately after the labor CSE leads to an increased incidence of hypotension (spinal Bup + Epidural Xylo) and leads to undesired (excessive) motor block Options include: Options include: 1. Administer epidural test dose after spinal dose wears off. 1. Administer epidural test dose after spinal dose wears off. 2. Start Continuous Infusion immediately after CSE performed 2. Start Continuous Infusion immediately after CSE performed

57. CSE test dose options (Continued—Option 1) Test dose administered prior to dosing epidural. Test dose administered prior to dosing epidural. Very labor intensive as one must monitor VS after spinal dose, and then return (1.5 – 2 hours) to administer test dose and epidural bolus and monitor VS. Very labor intensive as one must monitor VS after spinal dose, and then return (1.5 – 2 hours) to administer test dose and epidural bolus and monitor VS. Pain allowed to return so less patient satisfaction. Pain allowed to return so less patient satisfaction. Not Resident/CRNA friendly overnight during calls. Not Resident/CRNA friendly overnight during calls.

58. CSE test dose options (Continued---Option 2) One can immediately start the continuous infusion after spinal dose given One can immediately start the continuous infusion after spinal dose given Experience > 5 years Rationale: Experience > 5 years Rationale: If intravascular, patient will c/o pain. Can test catheter at that time prior to epid re-bolus, and if +, pull catheter. If intravascular, patient will c/o pain. Can test catheter at that time prior to epid re-bolus, and if +, pull catheter. Low dose of Bupivicaine administered so very low possibility of toxicity (~ 10 mg of Bupivicaine in an hour vs. toxic dose of 150mg) Low dose of Bupivicaine administered so very low possibility of toxicity (~ 10 mg of Bupivicaine in an hour vs. toxic dose of 150mg) If intrathecal cath, patient will slowly develop motor block and hypotension (10 mg Bupi in an hour). Patients instructed to call nurse for increased motor block and/or hypotension and we must follow up on patients. If intrathecal cath, patient will slowly develop motor block and hypotension (10 mg Bupi in an hour). Patients instructed to call nurse for increased motor block and/or hypotension and we must follow up on patients. Anesthesia “friendly”, patients more satisfied as pain doesn’t return and anesthesia personnel don’t have to stay and check VS for two prolonged periods. Anesthesia “friendly”, patients more satisfied as pain doesn’t return and anesthesia personnel don’t have to stay and check VS for two prolonged periods.

59. What the heck is in our CSE cocktail anyway???? (I’d put my money on the residents over the attendings) (gift certificate)

60. MHMC CSE “Cocktail” Fentanyl 15 mcg Fentanyl 15 mcg Bupivicaine 1.25 mg Bupivicaine 1.25 mg (Do we really need this?---not used in NEJM study) (Do we really need this?---not used in NEJM study) Epinephrine.1 mg Epinephrine.1 mg (Is there a downside to epi?) (Is there a downside to epi?) Saline diluent to make total volume 3cc Saline diluent to make total volume 3cc

61. LAs added to CSE solutions Intrathecal narcotics alone can produce effective relief of labor pain for the first stage of labor Intrathecal narcotics alone can produce effective relief of labor pain for the first stage of labor Intrathecal narcotics alone are ineffective in relieving pain associated with the 2 nd stage of labor Intrathecal narcotics alone are ineffective in relieving pain associated with the 2 nd stage of labor LAs (bupivicaine) combined with spinal narcotics provide effective relief of pain associated with the second stage of labor LAs (bupivicaine) combined with spinal narcotics provide effective relief of pain associated with the second stage of labor Patients receiving bupivicaine added to spinal narcotics often report better relief of perineal pain/pressure throughout labor, and also require fewer physician administered top up doses. Patients receiving bupivicaine added to spinal narcotics often report better relief of perineal pain/pressure throughout labor, and also require fewer physician administered top up doses. What about the downside to adding epi? What about the downside to adding epi?

62. Epinephrine in CSE solutions Prolongs duration of block/pain relief from intrathecal narcotic + LA solutions for labor pain relief Prolongs duration of block/pain relief from intrathecal narcotic + LA solutions for labor pain relief Produces additional motor block, compared to solutions without epinephrine Produces additional motor block, compared to solutions without epinephrine Goal in OB anesthesia to have as little motor block as possible, while maintaining satisfactory pain relief Goal in OB anesthesia to have as little motor block as possible, while maintaining satisfactory pain relief Though epinephrine is associated with additional motor block, this motor block is minimal, and most patients are still able to “walk” after a CSE with Bupivicaine. Though epinephrine is associated with additional motor block, this motor block is minimal, and most patients are still able to “walk” after a CSE with Bupivicaine. But why would they want to?????? But why would they want to??????

63. NB Suggestions for labor CSEs 1. Use CSE needle that protrudes 15 mm beyond the Epidural needle (preferably with a low incidence of paresthesias) Currently suggest Espocan at MHMC 2. Do NOT perform CSE technique in patients with bad fetal tracings or patients expected to go to the OR soon. You will have a higher incidence of fetal bradycardias in the setting of bad tracings and you will not know if epidural catheter works immediatley following the CSE. 3. Advance Espocan needle slowly thru epidural needle (to decrease paresthesias) and first LOR is subarachnoid space.

64. 4. Stabilize spinal needle. It WILL move! 5. If no CSF obtained, withdraw spinal needle and advance epidural needle 1 mm. 6. Reinsert spinal needle. If no CSF, thread epidural catheter, give test dose and bolus. (Remember, ~ 10% incidence of failure to get CSF) 7. Inject 15 mcg Fentanyl, 1.25 mg Bupivicaine (less n/v/itching/respiratory depression and less hypotension) 8. Do NOT administer the 3cc Xylocaine (1.5%) epidural test dose immediately after spinal dose as this will increase incidence of hypotension and lead to unwanted motor block.

65. 9. After spinal dose administered, two options: A. Wait > 1 hour to administer Epidural test dose and bolus epidural 1. Pain will return 2. Anesthesia personnel labor intensive B. Start continuous epidural infusion immediately 1. Notify patient if legs become very heavy to contact nurse as patient may be receiving too much medication 2. Do not place patients on PCEA who have a language barrier or who cannot comprehend nuances of PCEA. 3. Greater patient satisfaction 4. Less labor intensive---less physician administered top up dosed.

66. 10. If Hypotension develops RX with Neosynephrine or Ephedrine 11. If Fetal Decelerations are noted: A. LUD, Oxygen, Rx BP (even if BP is marginal rx BP to eliminate this as a variable) B. 2 metered sprays of sublingual Nitroglycerin C. Decelerations should resolve in 5-10 minutes. If patient taken to OR, prepare for urgent C/S.

67. Patient Controlled Epidural Analgesia (PCEA) Overall greater patient satisfaction with PCEA vs. continuous infusion Overall greater patient satisfaction with PCEA vs. continuous infusion Lower drug usage with PCEA (no basal rate) vs. continuous infusion Lower drug usage with PCEA (no basal rate) vs. continuous infusion PCEA with basal rate is associated with 30% more drug usage compared with PCEA and no basal rate. PCEA with basal rate is associated with 30% more drug usage compared with PCEA and no basal rate. PCEA with basal rate associated with decreased physician “top-ups”. PCEA with basal rate associated with decreased physician “top-ups”. Only physician administered “top-ups” associated with hypotension. Only physician administered “top-ups” associated with hypotension.

68. PCEA Majority of academic tertiary care facilities routinely utilize PCEA for labor pain relief Majority of academic tertiary care facilities routinely utilize PCEA for labor pain relief When new epidural pumps obtained, we will routinely use PCEA at MHMC. Current pumps have few patient administration buttons, and therefore, difficult to consistently employ PCEA. When new epidural pumps obtained, we will routinely use PCEA at MHMC. Current pumps have few patient administration buttons, and therefore, difficult to consistently employ PCEA. MHMC PCEA Settings (Various centers polled last year by Drs. Bolden/Lahud): MHMC PCEA Settings (Various centers polled last year by Drs. Bolden/Lahud): Basal 8-10 cc/hr. Bolus 5cc Basal 8-10 cc/hr. Bolus 5cc # Boluses/hr =4. Lockout = 10 minutes # Boluses/hr =4. Lockout = 10 minutes

69. Confused? I hope to eliminate some of the confusion……. I hope to eliminate some of the confusion……. We will primarily be ordering espocan CSE needles for non- obese patients, and retain Long Gertie Marx CSE kits for the obese patient. We will primarily be ordering espocan CSE needles for non- obese patients, and retain Long Gertie Marx CSE kits for the obese patient. We will stop ordering the durasafe CSE kits. I am sure some attendings would have objected, so I wanted everyone to know the reason/rationale for this change. We will stop ordering the durasafe CSE kits. I am sure some attendings would have objected, so I wanted everyone to know the reason/rationale for this change. When we obtain new PCEA pumps, we will be using PCEA on the majority of our patients (except those patients with a language barrier or those unable to comprehend the instructions) When we obtain new PCEA pumps, we will be using PCEA on the majority of our patients (except those patients with a language barrier or those unable to comprehend the instructions) Stay tuned for more exciting topics in the world of OB Anesthesia in “Update in Obstetric Anesthesia-- Part II” Stay tuned for more exciting topics in the world of OB Anesthesia in “Update in Obstetric Anesthesia-- Part II”