Alternative Approaches to Labor Analgesia - PowerPoint Presentation

Slide1

Alternative Approaches to Labor Analgesia

Jerrol B. Wallace, DNP, MSN, CRNA

Slide2

Disclaimer

The views presented here are those of the speaker and are not to be construed as official or reflecting the views of the Department of Defense, Uniformed Services University of the Health Sciences, AANA, or VANA

Slide3
Objectives

History of OB Analgesia

Review Anatomy for Labor AnalgesiaDiscuss Traditional Approaches to Labor AnalgesiaDiscuss Alternate Infusion Strategies

Discuss CSE, ITN, and DPI

Discuss Alternatives to

Neuraxial

Analgesia

Slide4

History of Obstetrical Anesthesia

1847: Simpson uses Diethyl Ether

1847: Fanny Longfellow receives Ether for delivery

1853: John Snow uses chloroform on Queen Victoria for birth of Prince Leopold

1857: First acknowledged OB Anesthetic Queen Victoria’s 9

th

child

Slide5
History of

Neuraxial Anesthesia

August Bier- “Painless” lower extremity surgery using cocaine1900- Oskar Kreis- “total Anesthesa

”

intrathecal

injection of cocaine

1931- Eugene

Bogdan

Aburel- Placed catheter in the epidural space1945- Touhy used for spinal catherization

Slide6
History of

Neuraxial Anesthesia cont.

1949- Epidural catheter used for labor and C/S1957- Bupivacaine synthesized1979- Morphine used in the epidural space1988- PCEA introduced

1993- CSE introduced

1996-

Ropivacaine

synthesized

Slide7
Obstetric Anatomy

Cephalad- From brain stem

Terminates at

Conus

Medularis

L1-Conus

Medularis

L2-Cauda

EquinaMembranesPia Mater

Subarachnoid Space

Subdural Space

Arachnoid Mater

Dura Mater

Slide8
Layers to Space

Skin

Subcutaneous layerSupraspinous LigamentInterspinous Ligament

Ligamentum

Flavum

Epidural Space

Dura

S

EVERALSURGEONS

S

USPECT

I

L

OVE

E

ASY

D

AYS

Slide9
Obstetric Pain Pathway

First Stage

Pain from lower uterine and cervix changesVisceral Afferent Nerve fibers

T10-L1 Segments

Second Stage

Pain from distension of pelvic floor, vagina, and perineum

Somatic Nerve fibers

S2-S4 Segments

Slide10

Why Do We Need Alternative Options

Contraindications for

neuraxial

anesthesia

Inability to perform

neuraxial

anesthesia

Patient requests for natural childbirth

Opioid crisis

Slide11

The Opioid Crisis

Over 20% of pregnant patients are prescribed an opioid

Approximately 3% receive a prescription for greater than 30 days

Maternal opioid use has more than doubled

Slide12

Analgesic Interventions

Non-pharmacological techniques

Hypnosis, TENS, and Acupuncture

Systemic Analgesia

Local Anesthetics

Neuraxial

Techniques

Alternative Approaches

Slide13

Hypnosis

BenefitsReduces anxiety

Increases pain tolerance

Reduces birth complications

Accelerates recovery

Gives women a sense of control of the labor process

Things to Consider

Must be open to hypnosis

Preparation must be completed prior to labor

Not a replacement for CLE for most women

Slide14

Transcutaneous Electrical Nerve Stimulation

Used as an adjunct to reduce labor pain

Placed on lower back or acupuncture points

Some relief noted

Slide15

Acupuncture

Good adjunct to conventional pain relief measures

Used for induction of labor, ripening the cervix, and to reduce pain

Slide16

Parental Analgesia

Systemic Medications

Opioids

Morphine Sulfate

Meperidine

Fentanyl

Sufentanil

Remifentanyl

Agonist-Antagonist Agents

Non-Opioids/NSAIDs

Anxiolytics

Ketamine

Slide17

Opioids

Morphine Sulfate

Fentanyl

Meperidine

Sufentanyl

??

Remifentanyl

Slide18

Remifentanil

Beneficial for neuraxial

placement

10-20 mcg initial

10 mcg incrementally

Cost

Use cautiously

Slide19

Agonist-Antagonist

Butorphanol

(

Stadol

)

Unlike

Meperidine

has a ceiling effect on respiratory depression

Given in doses of 1-2 mg IV or IM

Nalbuphine

HCL (

Nubain

)

Given in doses of 10 mg IV/IM

Causes less

dysphoria

than

butorphanol

Less N&V, dysphoria

Both agents cause significant sedation

Slide20

Non-Opioids/NSAID

s

IV Tylenol (

Ofirmev

)

Ketorolac

Primarily PP

Fetal issues

Slide21

Anxiolytics/Ketamine

Midazolam

Low doses (0.5 – 1 mg) IV given to help alleviate anxiety without causing detriment to parturient and fetus

Particularly useful in C-section patients

Ketamine

Occasionally intermittent doses of 10-15 mg IV useful to produce intense analgesia for 10-15 minutes without causing detriment to parturient & fetus

Routinely co-administer low dose midazolam

Slide22

Local Anesthetics

AmidesBupivacaine,

Ropivacaine

, Lidocaine

Esters

Chloroprocaine

(2-3%),

Tetracaine

Slide23

Amino-Amide Local Anesthetics

Lidocaine

– Most commonly used in 1-2% solutions

Not used for continuous infusions

Bupivacaine – Most commonly used in concentrations

≤ 0.05%

Infusion concentrations 0.0625% - 0.25%

with or without an opioid

Ropivacaine

– Most commonly used

in concentrations of 0.1% - 0.5%

(Less

cardiotoxic

than bupivacaine)

Less potency and duration than bupivacaine

Slide24

Bupivacaine vs Ropivacaine

Standard Concentrations

Bupivaciane

0.125% w/ Fentanyl 2 mcg/ml

or

Ropivacaine

0.2%

Slide25

Sequence of Local Anesthetic CNS Toxicity

*Apnea

*Coma

*Grand Mal Convulsion

*Unconsciousness

*Irrational Conversation

Increasing

*

Muscle Twitching

Concentration

*

Slurring of Speech

of Local Anesthetic

*

Visual Disturbances

*

Tinnitus

*

Lightheadedness

*

Circumoral

numbness

Slide26

Neuraxial Analgesia/Anesthesia

Techniques

Epidural analgesia/anesthesia

Intrathecal

opioids (narcotics)

ITN

’

s

Spinal analgesia/anesthesiaCombined Spinal-Epidural analgesia/anesthesia

Slide27

Epidural Anesthesia/Analgesia

Slide28
How Much Do I leave in?!

Slide29

Lumbar Epidural Analgesia

Can be delivered by intermittent or continuous infusion

Intermittent doses of 0.0625-0.25% bupivacaine or 0.1-0.2%

ropivacaine

with 50-100 mcg fentanyl, generally 3-5

mls

Infusion of 0.0625-0.2% bupivacaine or

ropivacaine with 1-2 mcg/ml fentanyl @ 8-12 ml/hr

PCEA-Combination of both methods

Slide30

PIEB VS CEI

Slide31
My Formula

Test Dose (3

mls)2 mls test dose + 3

mls

bag solution: 5 minutes after test dose

(5mls)

3

mls

bag solution after programming pump: 8 minutes

(8mls)2 mls bag solution (if necessary) after blood pressure and dermatome check: 12-15 minutes (10mls)

Slide32

Intrathecal Analgesia

Often used when epidural analgesia is not viable

Rapid onset of action

Most commonly given in combination

fentanyl (10-25 mcg)

Bupivacaine (2.5-5.0 mg)

Slide33

Goldilocks Approach to C/S Analgesic Dosing

How much do you use?

Combined dosing?

Alternative opioids?

Slide34

The CSE Technique

Viewed as most significant advancement in OB anesthesia in the last decade

Intrathecal opioids very effective in controlling 1st stage labor pain

Fentanyl 10-25 mcg

Less effective for 2nd stage labor pain (

bupivacaine 2.5-5 mg)

G

iven by needle-thru-needle technique

Slide35
CSE

Slide36
Criteria for CSE

Previously failed epidural/More Confirmation

Patient very uncomfortableLarger patientMultiple patients in queue

Slide37
Dural Puncture Technique

Capiello

et al. (2008)

Slide38

Other Anesthesia Blocks

Caudal Block

Paracervical

Block- First Stage Labor

Pudendal

Block- Second Stage Labor

Slide39
Analgesic Alternatives

Remifentanyl PCA and Nitrous Oxide

Only in selected patientsOnly in coordination with nursing, obstetrics, and anesthesia

Slide40
Remifentanyl PCA

Advantages

Fast Onset, PotentBlood Metabolism Minimal fetal effects

Pain reduced by 50% in stage 1

Disadvantages

Short acting

Not as effective as an epidural

Not as effective for stage 2

Extra vigilance required

1 to 1 nursingPulse ox monitoring

No other opioids during or 4 hours prior

Slide41
Remifentanyl PCA (cont.)

Basal0.025 mcg/kg/min to 0.05 mcg/kg/min

Bolus0.25 mcg/kg to 0.5 mcg/kg q 2-5 min100KG + ParturientBasal rate: 2.5-5 mcg/min

Bolus: 25 mcg- 50 mcg q 2 min

Slide42

Remifentanil Studies

Slide43
Nitrous

Used in stage 1 as a temporizing measure50:50 mix O2 and nitrous

Facility DependentNitronox MachineInstallation

Staff training

Slide44
Nitrous Continued

Slide45

Questions ??

Slide46
References

Barash

, P. G. (2013). Clinical Anesthesia. (7th ed.). Philadelphia, PA: Wolters Kluwer.

Butterworth, J. F., Mackey D. C., &

Wasnick

, J. D. (2013). Morgan & Mikhail’s Clinical Anesthesiology. (5

th

ed

). Connecticut: Appleton & Lange. Campogna, G., Camorcia, M.,

Stirparo

, S.,

Farcomeni

, A. (2011). Programmed intermittent epidural bolus versus continuous epidural infusion for labor analgesia: The effects on maternal motor function and labor outcome. A randomized double-blind study in nulliparous women.

Anesthesia and Analgesia,

113(4), 826-831.

Capiello

, E., O’Rourke, N., Scott, S., &

Tsen

, L. C. (2008). A randomized trial of

dural

puncture technique compared with the standard epidural technique for labor analgesia.

Anesthesia and Analgesia

, 107(5), 1646-1651.

Chestnut, D.H., et. al. (2014). Chestnut’s obstetric anesthesia: principles and practice, fifth edition. Elsevier Saunders. Philadelphia, PA.

Slide47
References

Collins, M. R., Starr, S. A., Bishop, J. T.,

Baysinger, C. L. (2012). Nitrous oxide for labor analgesia: Expanding options for women in the United States.

Review of Obstetrics and Gynecology,

5 (3-4), 126-131.

Francis, E. L. et al. (2014). Nitrous oxide for the management of labor pain: A systematic review.

Anesthesia and Analgesia

, 118(4), 885.

George, R. B., Allen, T. K., Habib, A. S. (2013). Intermittent epidural bolus compared with continuous epidural infusions for labor analgesia: A systematic review and meta-analysis.

Anesthesia and Analgesia,

116(1), 133-144

Schauble

P. G., Werner W. F., Rai S. H., Martin A. (1998). Childbirth preparation through hypnosis: The

hypnoreflexogenous

protocol. 

American Journal Clinical Hypnosis,

40, 273-283

Wong, C. A., Ratcliff, J. T., Sullivan, J. T.,

Scavone

, B. M., Toledo, P. McCarthy, R. J. (2006). A randomized comparison of programmed intermittent epidural bolus with continuous epidural infusion for labor analgesia.

Anesthesia and Analgesia,

102(3), 904-909.