David R. Gambling

Practice guidelines for obstetric anesthesia: An updated report by the American Society of Anesthesiologists Task Force on obstetric anesthesia

PRACTICE guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints and are not intended to replace local institutional policies. In addition, practice guidelines are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome. Practice guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. They provide basic recommendations that are supported by a synthesis and analysis of the current literature, expert opinion, open forum commentary, and clinical feasibility data. This update includes data published since the “Practice Guidelines for Obstetrical Anesthesia” were adopted by the American Society of Anesthesiologists in 1998; it also includes data and recommendations for a wider range of techniques than was previously addressed.

Randomized trial of epidural versus intravenous analgesia during labor

Objective To compare the effects of epidural analgesia with intravenous (IV) analgesia on the outcome of labor. Methods Thirteen hundred thirty women with uncomplicated term pregnancies and in spontaneous labor were randomized to be offered epidural bupivacaine-fentanyl or IV meperidine analgesia during labor. Results Comparison of the allocation groups by intent to treat revealed a significant association between epidural allocation and operative delivery for dystocia. However, only 65% of each randomization group accepted the allocated treatment. Four hundred thirty-seven women accepted and received meperidine as allocated, and they were compared with 432 women accepting epidural allocation. Significant associations resulted between epidural administration and prolongation of labor, increased rate of oxytocin administration, chorioamnionitis, low forceps, and cesarean delivery. Because of the high rate of noncompliance with treatment allocation, a multifactorial regression analysis was performed on the entire cohort, and a twofold relative risk of cesarean delivery persisted in association with epidural treatment. The impact of epidural treatment on cesarean delivery was significant for both nulliparous and parous women (risk ratios 2.55 and 3.81, respectively). Epidural analgesia provided significantly better pain relief in labor than did parenteral meperidine. Conclusion Although labor epidural analgesia is superior to meperidine for pain relief, labor is prolonged, uterine infection is increased, and the number of operative deliveries are increased. A two- to fourfold increased risk of cesarean delivery is associated with epidural treatment in both nulliparous and parous women.

A randomized study of combined spinal-epidural analgesia versus intravenous meperidine during labor: Impact on cesarean delivery rate

Background Combined spinal‐epidural (CSE) analgesia produces rapid‐onset pain relief and allows ambulation in early labor. Epidural local anesthetics may contribute to an increase in operative deliveries by decreasing perineal sensation and causing motor weakness. Operative delivery rates might be reduced with CSE, by avoiding or delaying administration of local anesthetics. This study compares the operative delivery rates associated with a CSE technique and those associated with intravenous meperidine for labor analgesia. Methods Healthy parturients at full term were assigned randomly to receive CSE or intravenous meperidine analgesia. The CSE group received 10 [micro sign]g intrathecal sufentanil, followed by epidural bupivacaine and fentanyl at their next request for analgesia. Parturients receiving intravenous meperidine had 50 mg on demand (maximum, 200 mg in 4 h). Labor and delivery outcomes in both groups were recorded and compared. Results An intent‐to‐treat analysis of 1,223 women indicated that CSE does not increase the rate of cesarean delivery for dystocia in nulliparous and parous women (CSE, 3.5% vs. intravenous meperidine, 4; P = not significant) or in nulliparous women alone (CSE, 7% vs. intravenous meperidine, 8%; P = not significant). Profound fetal bradycardia that necessitated emergency cesarean delivery within 1 h of the time the mother received sufentanil occurred in 8 of 400 parturients (compared with 0 of 352 who received meperidine; P < 0.01). However, the method of fetal monitoring differed between the two groups. Despite this, neonatal outcomes were similar overall. Conclusions Combined spinal‐epidural analgesia during labor does not increase the cesarean delivery rate for dystocia in healthy parturient patients at full term, regardless of parity. However, an unexpected increase in the number of cesarean deliveries for profound fetal bradycardia after intrathecal sufentanil was observed. Further investigation is warranted.

Practice Guidelines for Obstetric Anesthesia: An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia and the Society for Obstetric Anesthesia and Perinatology ∗

<zdoi;10.1097/ALN.0000000000000935> Anesthesiology, V 124 • No 2 270 February 2016 P RACTICE guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to the clinical needs and constraints and are not intended to replace local institutional policies. In addition, practice guidelines developed by the American Society of Anesthesiologists (ASA) are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome. Practice guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. They provide basic recommendations that are supported by a synthesis and analysis of the current literature, expert and practitioner opinion, open-forum commentary, and clinical feasibility data. This document updates the “Practice Guidelines for Obstetric Anesthesia: An Updated Report by the ASA Task Force on Obstetric Anesthesia,” adopted by ASA in 2006 and published in 2007.†

Comparison of 26-gauge Atraucan® and 25-gauge Whitacre needles: insertion characteristics and complications

Ninety-six women undergoing post-partum tubal ligation under spinal anaesthesia were studied to compare 26G Atraucan® with 25G Whitacre spinal needles for ease of insertion, number of attempts at needle insertion, cerebrospinal fluid (CSF) flow characteristics through the needles, quality of subsequent analgesia, and incidence of perioperative complications. A higher rale of successful durai puncture at the first attempt (40/50 vs 27/46, P < 0.05) and faster (mean ± SD, 11.5 ± 2.2 vs 13.5 ± 2.4, P < 0.001) CSF flow through the needle was achieved with the Atraucan® than with the Whitacre needle. The incidence of failed spinal (4% vs 5%) and post-dural puncture headache (PDPH) (4% vs 4.3%) was similar with both needles, but more patients experienced paraesthesiae during needle insertion with the Whitacre than with the Atraucan® needle (15% vs 2%, P < 0.05). We conclude that the use of the 26G Atraucan® needle is associated with a higher rate of successful identification of the subarachnoid space at the first attempt, faster CSF backflow, and fewer paraesthesia when compared with the 25G Whitacre needle.RésuméCette étude vise à comparer les aiguilles 26G® Atraucan et Whitacre 25G auprès de 96 femmes soumises à une ligature tubaire pendant le post-partum sous anesthésie rachidienne au regard de la facilité d’insertion, du nombre de tentatives d’insertions, des caractéristiques de l’écoulement du liquide céphalorachidien (LCR) par l’aiguille, de la qualité de l’analgésie subséquente et de l’incidence des complications périopératoires. Un taux plus élevé de succès de première tentative (40/50 vs 27/ 46, P < 0,05) et un écoulement plus facile ont été notés avec l’Atraucan® qu’avec la Whitacre. L’incidence de rachidiennes ratées (4% vs 5%) et de céphalées postdurales (4% vs 4,3%) est la même pour les deux aiguilles, mais plus de patients ont éprouvé des paresthésies pendant l’insertion avec l’aiguille Whitacre qu’avec l’aiguille Atraucan® (15% vs 2%, P < 0,05). Nous concluons que l’utilisation de l’aiguille Atraucan® 26G est associée à un taux de succès plus élevé pour ce qui est de l’identification à la première tentative de l’espace sousarachnoïdien, de la facilité de l’écoulement du LCR, et du nombre moins important des paresthésies, lorsqu’on la compare avec l’aiguille Whitacre 25G.

Role of patient-controlled epidural analgesia in obstetrics

Many of the early studies of intravenous (IV) patientcontrolled analgesia (PCA) involved parturients [1-7] and women following cesarean birth [8-10]. In addition, PCA has been used in antenatal patients (e.g., for renal colic) and in parturients who have a contraindication to lumbar epidural analgesia [11-13]. Since epidural analgesia is regarded as the most effective means of providing pain relief during labor, there has been recent interest by a number of investigators in applying the PCA concept to the epidural route, so-called patientcontrolled epidural analgesia (PCEA) [14-29]. PCEA (also referred to as epidural PCA) has also been widely investigated for the management of post-cesarean delivery pain [30-35]. This review article will discuss published reports regarding the use of PCEA in the labor room and the post-partum unit for the management of acute pain.

Anesthetic management of a parturient with mixed mitral valve disease and uncontrolled atrial fibrillation

This case report describes the anesthetic management of a 32-year-old parturient with combined severe mitral regurgitation and moderate mitral stenosis, complicated by fast atrial fibrillation. The advantageous effects of epidural analgesia during labor and vaginal delivery and the importance of invasive monitoring are discussed. We also report the rare complication of right bundle branch block related to the use of a pulmonary artery catheter.

Ephedrine and Phenylephrine Use during Cesarean Delivery

1. Ngan Kee WD, Khaw KS, Tan PE, Ng FF, Karmakar MK: Placental transfer and fetal metabolic effects of phenylephrine and ephedrine during spinal anesthesia for cesarean delivery. ANESTHESIOLOGY 2009; 111:506 –12 2. Dyer RA, Reed AR, Van Dyk D, Arcache MJ, Hodges O, Lombard CJ, Greenwood J, James MF: Hemodynamic effects of ephedrine, phenylephrine, and the coadministration of phenylephrine with oxytocin during spinal anesthesia for elective cesarean delivery. ANESTHESIOLOGY 2009; 111:753–65 3. Smiley RM: Burden of proof. ANESTHESIOLOGY 2009; 111:470–2 4. Yeomans ER, Hauth JC, Gilstrap LC III, Strickland DM: Umbilical cord pH, pCO2, and bicarbonate following uncomplicated term vaginal deliveries. Am J Obstet Gynecol 1985; 151:798 – 800 5. Casey BM, McIntire DD, Leveno KJ: The continuing value of the APGAR score for the assessment of newborn infants. N Engl J Med 2001; 344:467–71 6. Cooper DW, Carpenter M, Mowbray P, Desira WR, Ryall DM, Kokri MS: Fetal and maternal effects of phenylephrine and ephedrine during spinal anesthesia for cesarean delivery. ANESTHESIOLOGY 2002; 97:1582–90 7. LaPorta RF, Arthur GR, Datta S: Phenylephrine in treating maternal hypotension due to spinal anesthesia for cesarean delivery: Effect on neonatal catecholamine concentrations, acid base status, and APGAR scores. Acta Anaesthesiol Scand 1995; 39:901–5 8. Mercier FJ, Riley ET, Frederickson WL, Roger-Christoph S, Benhamou D, Cohen SE: Phenylephrine added to prophylactic ephedrine infusion during spinal anesthesia for elective cesarean section. ANESTHESIOLOGY 2001; 95:668 –74 9. Moran DH, Perillo M, LaPorta RF, Bader AM, Datta S: Phenylephrine in the prevention of hypotension following spinal anesthesia for cesarean delivery. J Clin Anesth 1991; 3:310–5 10. Ngan Kee WD, Khaw KS, Lau TK, Ng FF, Chui K, Ng KL: Randomized double-blinded comparison of phenylephrine versus ephedrine for maintaining blood pressure during spinal anesthesia for non-elective caesarean section. Anaesthesia 2008; 63:1319–26 11. Lee A, Ngan Kee WD, Gin T: A quantitative, systematic review of randomized controlled trials of ephedrine versus phenylephrine for the management of hypotension during spinal anesthesia for cesarean delivery. Anesth Analg 2002; 94:20–6 12. Hall PA, Bennett A, Wilkes MP, Lewis M: Spinal anesthesia for cesarean section: Comparison of infusions of phenylephrine and ephedrine. Br J Anaesth 1994; 73:471– 4 13. Alahuhta S, Rasanen J, Jouppila P, Jouppila R, Hollmen AI: Ephedrine and phenylephrine for avoiding maternal hypotension due to spinal anaesthesia for caesarean section. Effects on uteroplacental and fetal haemodynamics. Int J Obstet Anesth 1992; 1:129 –34

EMLA Cream Effectively Relieves the Pain of Spinal Needle Insertion

Background and Objective. EMLA cream is an effective topical anesthetic, which is commonly used for analgesia during venous cannulation in the pediatric population. This study was designed to compare the efficacy of EMLA cream with that of infiltration with lidocaine in relieving the pain associated with administration of spinal anesthesia. Methods. The patient population consisted of 41 ASA status I and II women scheduled for postpartum tubal ligation. Spinal anesthesia was administered with a 25‐gauge spinal needle via a 20‐gauge introducer. The patients were randomly allocated to receive either EMLA cream for a minimum of 30 minutes or infiltration with 3 mL of 1% lidocaine prior to spinal needle insertion. Pain during spinal needle insertion was assessed immediately after each procedure by a 10‐cm visual analog scale. Results. Pain scores were significantly lower in the EMLA group (mean, 1.5) than in the lidocaine group (mean, 3.52) (P < .001). The number of patients satisfied with the method of analgesia was significantly higher in the EMLA than in the lidocaine group (90% vs 55%, P < .05). Conclusion. EMLA cream is an effective alternative to lidocaine infiltration for analgesia during the administration of spinal anesthesia when using a 25‐gauge spinal needle via a 20‐gauge introducer. Application of EMLA cream for at least 30 minutes prior to spinal needle insertion is adequate to provide good anlagesia during needle insertion.