H J Huffnagle

Complications of labor analgesia : epidural versus combined spinal epidural techniques

Both epidural and combined spinal epidural (CSE) analgesia can provide maternal pain relief during labor. Currently, there are few data comparing the risks and complications of these two techniques. We recorded the incidence and severity of anesthetic-related complications in 1022 laboring parturients. Ninety-eight women opted for either no or parenteral analgesia, 388 chose epidural, and 536 requested CSE analgesia. Women choosing CSE analgesia most often received an intrathecal injection of sufentanil 10 micrograms at the time of epidural catheter insertion. The epidural catheters were then dosed as needed as the intrathecal analgesia waned. Women who received CSE analgesia were more likely to itch (41.4% vs 1.3%) or complain of nausea (2.4% vs 1.0%) or vomiting (3.2% vs 1.0%) than those receiving solely epidural analgesia. Patients who requested only epidural analgesia were more likely to suffer an unintended dural puncture (4.2% vs 1.7%). Fewer than 10% developed hypotension with either technique. The risk of headache was the same with both anesthetics (4%-10%) and did not differ from the incidence of headache in women not receiving neuraxial analgesia (10%-14%). Six patients required epidural blood patch for moderate to severe postural headache. Four of these women suffered a dural puncture with the 18-gauge Hustead epidural needle. The other two women had reportedly uncomplicated epidural and CSE analgesia. These data suggest either neuraxial analgesic technique can safely relieve the pain of labor. CSE analgesia is a safe alternative to epidural analgesia for labor and delivery.

The dermatomal spread of epidural bupivacaine with and without prior intrathecal sufentanil.

Clinicians often use a technique combining intrathecal sufentanil and epidural bupivacaine to provide labor analgesia.This study determines the effect of 27- or 24-gauge dural puncture and intrathecal sufentanil 10 micro gram on the dermatomal spread of epidural bupivacaine. Healthy laboring women received no dural puncture (n = 77) (no puncture group [NPG]) or dural puncture with a 27-gauge Whitacre needle (n = 33) or a 24-gauge Sprotte needle (n = 37) and intrathecal sufentanil 10 micro gram (dural puncture group [DPG]) before epidural injection of 13 mL bupivacaine 0.25%. More dermatomes were anesthetized in the DPG, 16.6 +/- 7.5 vs 13.6 +/- 6.6 in the NPG (P < 0.02). More patients in the DPG had sensory blockade T-4 or higher (17 of 70 DPG patients vs 8 of 77 NPG patients; P < 0.05). No patient in either group showed clinical evidence of respiratory compromise. In conclusion, epidural bupivacaine anesthetized more dermatomes when administered 104 +/- 42 min after dural puncture and intrathecal sufentanil 10 micro gram than when given without prior dural puncture and intrathecal injection. (Anesth Analg 1996;83:526-9)

The Influence of Epidural Needle Bevel Orientation on Spread of Sensory Blockade in the Laboring Parturient

Both asymmetrical sensory blockade and dural puncture are undesirable outcomes of epidural analgesia.Identifying the epidural space with the needle bevel oriented parallel to the longitudinal axis of the patients back limits the risk of headache in the event of dural puncture. However, rotating the bevel to direct a catheter cephalad may risk dural puncture. We prospectively studied the effects of needle rotation on the success of labor epidural analgesia and on the incidence of dural puncture. One hundred sixty ASA physical status I or II laboring parturients were randomly assigned to one of four groups. The epidural space was identified with the bevel of an 18-gauge Hustead needle directed to the patients left. It was then rotated as follows: Group 0 = no rotation, final bevel orientation left (n = 39); Group 90 = rotation 90[degree sign] clockwise, bevel cephalad (n = 43); Group 180 = rotation 180[degree sign] clockwise, bevel right (n = 36); Group 270 = rotation 270[degree sign] clockwise, bevel caudad (n = 42). A single-orifice catheter was inserted 3 cm, and analgesia was induced in a standardized fashion. Dural puncture was evenly distributed among the groups (4.4%). There were more dermatomal segments blocked, fewer one-sided blocks, and more patients comfortable at 30 min with the needle bevel directed cephalad. Using a catheter inserted through a needle oriented in the cephalad direction increases the success of epidural analgesia. Implications: This prospective study shows that an epidural catheter inserted through a needle oriented in the cephalad direction increases the success of labor analgesia in the parturient. Carefully rotating the needle cephalad does not increase the risk of dural puncture, intravascular catheters, or failed blocks. (Anesth Analg 1998;87:326-30)

Anesthetic management of a parturient with type III Klippel–Feil syndrome

Klippel-Feil syndrome is believed to occur from failure of normal segmentation of cervical somites during gestation. We present the case of a 38-year-old primiparous woman with type III Klippel-Feil syndrome for elective cesarean delivery. Our patient had a short webbed neck, short stature, limited neck flexion and extension, and thoraco-lumbar abnormalities. A multidisciplinary approach, involving obstetrics, medical subspecialties, anesthesiology, otolaryngology, and radiology, were utilized to evaluate and manage this patient. Pulmonary function testing revealed a restrictive defect, but transthoracic echocardiography was normal without pulmonary hypertension. We planned a combined spinal-epidural technique; however, only the epidural technique was obtained. Cesarean delivery was commenced with favorable maternal and fetal outcomes. Post-operative pain management was provided with intravenous morphine patient-controlled analgesia.