N. Berends

Ten years of experience with accidental dural puncture and post-dural puncture headache in a tertiary obstetric anaesthesia department

BACKGROUND Accidental dural puncture (ADP) and post-dural puncture headache (PDPH) are important complications of obstetric regional anaesthesia. METHODS Between January 1997 and October 2006 in our tertiary obstetric referral centre 17 198 neuraxial blocks were recorded; 965 epidural, 16193 combined spinal-epidural and 40 spinal. Records of all parturients who experienced either ADP or PDPH were reviewed. RESULTS There were 89 ADPs (0.5%), 55 observed and 34 in which PDPH followed unrecognised dural puncture. Following known ADP, 28 women had epidural catheters re-sited at a different lumbar interspace and 27 had intrathecal catheters for at least 24 h. Thirty-one women developed PDPH after observed ADP; the incidence of PDPH was similar after puncture with needle and catheter, after epidural and CSE techniques, after 27- and 29-gauge pencil-point spinal needles and after spinal and epidural catheter insertion (61% vs 52%; P>0.05). All headaches presented within 72 h. A blood patch was needed in 26/55 women after known ADP and 27/34 unrecognised ADP. A repeat blood patch was needed in 8 (15%). DISCUSSION The incidence of ADP, PDPH, blood patching and repeat blood patching is similar to previous studies. Many ADPs are unrecognised during epidural insertion. CSE does not appear to increase the risk of ADP or PDPH; 29-gauge rather than 27-gauge pencil-point spinal needles conferred no benefit. Inserting the epidural catheter intrathecally did not significantly reduce the incidence of PDPH and blood patching in our series.

Effects of epidural clonidine and neostigmine following intrathecal labour analgesia: a randomised, double-blind, placebo-controlled trial

BACKGROUND The limited duration of spinal labour analgesia combined with problems associated with maintenance of epidural analgesia, have prompted the search for combinations that could prolong spinal analgesia. A randomised, double-blind trial was carried out to test the hypotheses (a) that initial spinal labour analgesia is prolonged by administering clonidine and neostigmine epidurally whilst (b) the hourly local anaesthetic consumption is reduced. METHODS Seventy labouring patients received spinal analgesia with ropivacaine and sufentanil. Fifteen minutes after spinal injection, 10 mL of study solution was administered epidurally. The study solution was plain saline or neostigmine 500 microg combined with clonidine 75 microg. Outcome parameters were duration of spinal analgesia, local anaesthetic consumption and number of patients delivering without additional epidural analgesia. RESULTS Epidural clonidine and neostigmine significantly prolonged initial analgesia: 144 (105-163) min vs. 95 (70-120) min in the placebo group and reduced hourly ropivacaine consumption: 7.5 (3.0-11.9) mg vs. 12.7 (9.6-16.9) mg. More patients in the experimental group delivered before the first request for additional analgesia (9 vs. 2). CONCLUSION Epidural administration of neostigmine 500 microg and clonidine 75 microg, following the intrathecal injection of ropivacaine and sufentanil, prolongs analgesia and reduces hourly ropivacaine consumption.

Low-dose combined spinal-epidural anaesthesia vs. conventional epidural anaesthesia for Caesarean section in pre-eclampsia: a retrospective analysis.

Background and objective: Epidural anaesthesia is the preferred technique of anaesthesia for Caesarean section in pre-eclampsia. Spinal anaesthesia is considered by some as a safe and effective alternative, which is especially useful in emergency situations. Combined spinal-epidural anaesthesia, using low doses of local anaesthetics with opioids, is effective and reduces the incidence of hypotension in normal pregnancy. We performed a retrospective chart analysis to evaluate the effects of combined spinal-epidural anaesthesia on maternal haemodynamics and fetal outcome compared to conventional epidural anaesthesia. Methods: A retrospective anaesthesia chart analysis of all pre-eclamptic patients who underwent Caesarean section over a 4 yr period was performed. Patient characteristic, obstetric, haemodynamic, fetal and neonatal data were gathered and analysed according to the anaesthetic technique used. Results: Seventy-seven pre-eclamptic parturients undergoing Caesarean section were identified (26 women were severely pre-eclamptic and 51 demonstrated mild pre-eclampsia). Epidural anaesthesia was performed in 62 patients and combined spinal-epidural anaesthesia was performed in 15. No differences in patient characteristic and obstetric data were noted. Highest mean arterial pressure prior to anaesthesia was comparable between the groups (epidural: 106 ± 12 vs. combined spinal-epidural anaesthesia: 109 ± 18 mmHg) as well as the lowest recorded mean arterial pressure following anaesthesia (epidural: 93 ± 13 vs. combined spinal-epidural anaesthesia: 98 ± 17 mmHg). In the combined spinal-epidural anaesthesia group more ephedrine was used compared to the epidural group (14.6 ± 4.4 vs. 3.6 ± 4.6 mg, P < 0.05). However, more lactated Ringers was used in the epidural group. Umbilical artery pH was lower in the epidural group (7.26 ± 0.01 vs. 7.29 ± 0.02, P < 0.05). Similar results were noted in 26 severely pre-eclamptic patients. Seven women underwent combined spinal-epidural anaesthesia and 19 underwent epidural anaesthesia in the severely pre-eclamptic group. Also more ephedrine was used in the combined spinal-epidural anaesthesia group. A tendency towards a lower umbilical artery pH was observed in the epidural group but this difference did not reach statistical significance. Conclusions: Combined spinal-epidural anaesthesia appears to be safe as anaesthetic technique for pre-eclampsia and severe pre-eclampsia. However, it is important to consider the retrospective design of the study and the large number of epidural anaesthetics performed.

Effects of Epidural Clonidine and Neostigmine Following Intrathecal Labor Analgesia: A Randomized, Double-blind, Placebo-controlled Trial

Combined spinal-epidural (CSE) analgesia is often used to relieve the pain of labor, but the duration of the spinal component depends upon the spinal drug mixture and clinical factors such as parity, stage, and progression of labor. Only about 50% of women who receive a CSE late in the first stage of labor deliver within the period of time that the spinal component provides adequate analgesia. New combinations of analgesic drugs to prolong the duration of spinal analgesia are needed. This randomized, double-blind trial tested the hypotheses that spinal labor analgesia with a ropivacaine/sufentanil mixture can be prolonged by administering epidural clonidine and neostigmine and that epidural clonidine/neostigmine can reduce the local anesthetic administered during CSE. Seventy nulliparous women at term, with uncomplicated, singleton pregnancies presenting in the vertex position, were enrolled in the study. For the spinal component of the CSE, 0.175% ropivacaine 2.5mL with sufentanil 0.75 mg/mLwere injected intrathecally. If pain relief was adequate 15 minutes later, the study solution of either plain saline (P group) or 50mg neostigmine combined with 75 mg clonidine (NC group) was administered epidurally. Pain was assessed at 5, 10, 20, 30, 40, 50, and 60 minutes after the end of the spinal injection and every 60 minutes until delivery. The duration of initial analgesia was defined as the time between the end of the spinal injection and the first request for additional analgesia. Outcome measures were the duration of spinal analgesia, the total epidural local anesthetic consumption, and the number of patients who delivered without additional epidural analgesia. The 2 groups of 35 patients each were similar in demographic characteristics and baseline obstetric data. Obstetric outcomes were similar between the P and NC groups. The use of epidural clonidine and neostigmine prolonged the duration of initial spinal analgesia from 95 minutes [interquartile range (IQR), 70-120] in the P group to 144 minutes (IQR, 105-163) in the NC group (P<0.05). Nine patients in the NC group delivered before epidural analgesia was needed compared with 2 in the P group (P<0.05). Ropivacaine consumption was 12.7mg/h (IQR, 9.6-16.9) in the P group compared with 7.5mg/h (IQR, 3.011.9) in the NC patients. Pain scores were lower in the NC group compared with the NC group from 40 minutes until 120 minutes after initiation of analgesia (P<0.05). The rate of maternal hypotension after spinal analgesia and administration of study medication was similar between the two groups.Maternalmean blood pressure and heart rate did not differ between the groups nor were nausea and pruritus rates different. New onset of fetal heart rate changes did not differ between the groups and no differences in neonatal outcomes were found. Use of epidural clonidine and neostigmine can prolong the duration of the initial spinal analgesia during a CSE technique for labor but larger trials are needed to assess the safety of these drugs in obstetric patients.

The use of Remifentanil during Cesarean section under general anaesthesia: maternal and neonatal effects: A-637

change significantly, nor did Hb loss. The shortening of SuTP in vaginal delivery did not affect the prevalence of massive haemorrhage, i.e. leading to transfusion, artery embolisation or surgical management (21.5% in G1, 22.2% in G2), and did not lead to significant difference in Hb loss (44.4% in G1, 35.3% in G2). Conclusion(s): Earlier infusion of sulprostone leads to significant reduction of Hb loss in moderate postpartum haemorrhage after vaginal delivery but does not avoid incidence and magnitude of massive haemorrhage. References: 1 Goffinet F. J Gynecol Biol Reprod 1995; 24(4):209–16. 2 Reyal F. J Gynecol Obstet Biol Reprod 2002 Jun; 31(4):358–64.