Sharon Orbach-Zinger

Risk factors for failure to extend labor epidural analgesia to epidural anesthesia for Cesarean section

Aim::  To identify parturients at risk of inability to extend labor epidural analgesia in whom alternative methods of anesthesia should be considered for Cesarean section (CS).

Uneventful spinal anesthesia for a patient with carcinoid syndrome managed with long-acting octreotide.

PurposeTo present a case of spinal anesthesia in a patient suffering from carcinoid syndrome undergoing an inguinal hernia repair. In the past, regional anesthesia was considered unacceptable in these patients because of the possibility of intraoperative hypotension, hypertension, or bronchospasm. Recently, however, the preoperative use of octreotide, the synthetic analogue of the naturally occurring hormone somastatin, has been found to prevent these complications. Nevertheless, it remains unclear whether the use of this drug in patients with carcinoid syndrome allows the possibility of regional anesthesia.Clinical findingsWe report the uneventful use of spinal anesthesia in a patient suffering from carcinoid syndrome treated with longacting octreotide. With careful attention to volume status of the patient and low volume of local anesthetics (10 mg hyperbaric bupivacaine 0.5%) supplemented with intrathecal narcotics (fentanyl 20μg), we were able to prevent any episodes of intraoperative hypotension in this patient. Octreotide was available in the operating theatre in case of an emergency. One of the original aspects of this case report is that the patient received long-acting octreotide (once a month administration) instead of the usual daily dose. In addition this is one of the few reports of spinal anesthesia administered to a patient with carcinoid syndrome.ConclusionPreoperative octreotide may result in more favourable conditions for regional anesthesia in patients with carcinoid syndrome. However, further studies will be required to confirm the favourable outcome observed in this patient.RésuméObjectifPrésenter un cas de rachianesthésie chez un patient, atteint d’un syndrome carcinoïde, qui devait subir une herniorraphie inguinale. Dans le passé, on considérait l’anesthésie régionale comme inacceptable chez ce type de patient, étant donné la possibilité d’hypotension peropératoire, d’hypertension ou de bronchospasme. Récemment, toutefois, l’usage préopératoire d’octréotide, analogue synthétique de la somastatine naturelle, a montré qu’il prévient ces complications. Néanmoins, on ne sait pas encore avec certitude si l’emploi de ce médicament chez des patients atteints de carcinoïde permet d’utiliser une anesthésie régionale.Constatations principalesUn examen consciencieux de l’état volumique du patient et l’administration d’un faible volume d’anesthésiques locaux (10 mg de bupivacaïne hyperbare à 0,5 %) complétés par un narcotique intrathécal (20 μg de fentanyl), ont permis de prévenir tout épisode d’hypotension peropératoire. L’octréotide était disponible en salle d’opération en cas d’urgence. L’originalité de cette présentation de cas est que le patient a reçu de l’octréotide à action prolongée une fois par mois plutôt que la dose quotidienne habituelle. C’est aussi l’un des rares articles sur la rachianesthésie administrée à un patient atteint d’un syndrome carcinoïde.ConclusionL’octréotide préopératoire peut améliorer les conditions de l’anesthésie régionale chez des patients atteints d’un syndrome carcinoïde. Cependant, d’autres études devront confirmer l’évolution positive observée chez ce patient.

Partner's presence during initiation of epidural labor analgesia does not decrease maternal stress: a prospective randomized controlled trial.

BACKGROUND: Epidural analgesia reduces pain and anxiety during childbirth. In this randomized controlled trial, we sought to determine whether partner presence during the initiation of epidural analgesia reduces stress of both the mother and her partner and their perception of maternal pain. METHODS: Healthy, nulliparous women who were accompanied by their partners and requested neuraxial analgesia were enrolled into the study. The study took place in the Labor and Delivery Unit of a large tertiary hospital in Israel. Upon request for epidural analgesia, both partners were assessed for baseline anxiety (numerical rating scale, 0 to 10), systolic blood pressure, heart rate, estimated contraction pain of parturient (verbal rating scale for pain, 0 to 10), and salivary amylase. After measurements, couples were randomized into 1 of 2 groups: “partner in” and “partner out.” Immediately after epidural catheter insertion, anxiety, arterial blood pressure, heart rate, and salivary amylase were measured again in both partners. Both partners were asked to complete the State Anxiety Inventory questionnaire measuring current anxiety. The parturient was asked to rate the pain of epidural catheter insertion. The primary outcome measurement was parturient and partner anxiety as assessed by the numerical rating scale. RESULTS: Eighty-four couples were randomized (partner in 41, partner out 42, protocol violation 1). At baseline there was no difference in self-reported anxiety of parturients between the partner-in and partner-out groups (median interquartile range 7.5 [6.0 to 9.0] versus 7.0 [3.5 to 8.5]; P = 0.26, difference in medians = −1.0; 95% confidence interval [CI] of difference −2.0 to 1.0). After epidural catheter insertion, parturients in the partner-in group had a higher level of anxiety than those in the partner-out group (8.0 [7.0 to 10.0] versus 7.0 [5.0 to 9.0]; P = 0.03, difference in medians −1.0; 95% CI of difference −2.0 to 0.0). Pain scores during epidural catheter placement were higher in partner-in than in partner-out groups (7.0 [4.0 to 8.0] versus 4.0 [3.0 to 6.0]; P = 0.004, difference in medians = −2.0; 95% CI of difference −3.0 to −1.0). CONCLUSION: Partner presence during epidural catheter insertion for labor analgesia did not decrease anxiety levels. To the contrary, anxiety and pain of epidural catheter placement were greater if the partner remained in the room.

Israeli survey of anesthesia practice related to placenta previa and accreta

Anesthesia practices for placenta previa (PP) and accreta (PA) impact hemorrhage management and other supportive strategies. We conducted a survey to assess reported management of PP and PA in all Israeli labor and delivery units.

A survey of attitudes of expectant first-time fathers and mothers toward epidural analgesia for labor.

OBJECTIVE To evaluate the attitude of expectant fathers to the use of epidural analgesia during labor and to compare it to the attitude of their partner. METHODS The study group consisted of consecutive expectant, first-time parents who presented at the delivery room of a major medical center over a 3-month period. Only those with a single, term fetus in cephalic presentation were included. Both partners were asked to complete a questionnaire on desire to receive epidural analgesia firstly on admission and again later during labor at first discussion of the use of epidural analgesia with medical staff. Findings were compared between partners, between the two time points and with the actual use of epidural analgesia in labor. The effect of various socio-demographic variables on this decision was analyzed. RESULTS One hundred fifty couples completed the study. On admission, 64.1% of the expectant fathers and 78.6% of the expectant mothers expressed a preference for epidural analgesia (P=0.01). Later in labor, the corresponding rates were 77.9% and 87.4%. In total 95.3% of the women received epidural analgesia. There was no effect of age, level of education, salary, or attendance in a birth preparatory course on the decision to use epidural analgesia by either partner. CONCLUSION The decision to use epidural analgesia differs between partners, changes during the course of labor and is unrelated to socio-demographic factors.

The Relationship Between Women’s Intention to Request a Labor Epidural Analgesia, Actually Delivering With Labor Epidural Analgesia, and Postpartum Depression at 6 Weeks: A Prospective Observational Study

BACKGROUND: Postpartum depression (PPD) is associated with pain during and after delivery, with studies showing reduced rates among women delivering with labor epidural analgesia (LEA). We hypothesized that women who intend to deliver with LEA but do not receive it are at higher risk for PPD at 6 weeks due to the combined experience of untreated labor pain and unmatched expectations during labor, and evaluated the interaction between labor plans related to LEA, satisfaction with pain control when actually delivering with LEA, and PPD at 6 weeks after delivery. METHODS: A total of 1497 women with a vaginal delivery were enrolled into this prospective longitudinal study. Women’s initial intention to deliver with or without LEA, how they subsequently delivered, and satisfaction with pain relief were recorded on postpartum day 1. Primary aim was selected as PPD at 6 weeks among women intending to deliver with but subsequently delivering without LEA compared with the rest of the cohort. Primary outcome was PPD at 6 weeks using the Edinburgh Postnatal Depression Scale; PPD was defined with a score ≥10 (scale from 0 to 30). Demographic and obstetric data were recorded. Fisher exact test was used for comparisons between groups. The interaction between intention and actual delivery with regard to LEA and PPD was tested. RESULTS: Overall, 87 of 1326 women completing the study at 6 weeks had PPD (6.6%). For the primary aim, 439 (29.3%) delivered without LEA, of which 193 (12.9%) had intended to deliver with LEA; the PPD rate among these women was 8.1%, which was not statistically different from the rest of the cohort (6.3%; odds ratio [OR], 1.30; 95% confidence interval [CI], 0.72–2.38; P = .41). A total of 1058 women (70.7%) delivered with LEA and 439 (29.3%) delivered without; therefore, 1169 (78.1%) delivered as intended and 328 (21.9%) did not (unmatched expectations). Evaluating the interaction between effects, there was a strong negative additive interaction between intending to deliver without LEA and actually delivering with LEA (risk difference = −8.6%, 95% CI, 16.2%–1.6%; P = .014) suggesting that unmatched intention effect is significantly associated with negative outcome. In multiple regression analysis, while intending to deliver with LEA (OR, 1.06; 95% CI, 1.01–1.11; P = .029) and actually delivering with LEA (OR, 1.07; 95% CI, 1.01–1.13; P = .018) both increased the odds for PPD, the multiplicative interaction was protective (OR, 0.92; 95% CI, 0.86–0.99; P = .022), after adjusting for cofactors. CONCLUSIONS: Our study results did not demonstrate a significant increase in the odds for PPD at 6 weeks among women who intended to deliver with LEA but subsequently delivered without. However, we identified a protective interaction between intended LEA use and actual use on the incidence of PPD. Our data suggest an increased risk when women do not deliver as intended, particularly when not initially intending to deliver with LEA. The relationship between unplanned LEA and PPD may be mediated by a physically difficult delivery rather than or in addition to negative emotions related to unmet expectations or a sense of personal failure; therefore, counseling women after delivery to address any negative perceptions may be useful.

Peripartum anesthetic management of patients with Factor XI deficiency

Abstract Introduction: Factor XI deficiency is predominantly found in the Ashkenazi Jewish population with a prevalence of 9%, but also seen in other ethnicities. Little information is available on obstetric anesthesia management in women with Factor XI deficiency. Therefore, we undertook a study to evaluate obstetric, anesthetic and perinatal outcomes in parturients with Factor XI deficiency. Methods: A retrospective study was conducted with chart reviews from 1996 to 2011 resulted in 74 women with Factor XI level deficiency. We compared anesthetic and obstetric management in parturients with low (≤30%) level of Factor XI to those with higher levels. Results: Ninety-one pregnancy outcomes were reviewed in these 74 women with Factor XI deficiency. Forty-three women had levels ≤30% in 46 labors while 31 women had levels >30% in 45 labors. Women with low levels of Factor XI were significantly more likely to receive FFP and less likely to receive neuroaxial anesthesia. There were no anesthetic complications and no difference in mode of delivery or neonatal outcomes. Discussion: This study is the first step in building a national database for anesthetic cases and outcomes of parturients with Factor XI deficiency. Further efforts must be made to provide safe analgesia for these women.

Effect of early versus conventional epidural analgesia during labor on cytokine production

Abstract Objective. To compare the effect of early epidural analgesia (EEA) vs. conventional epidural analgesia (CEA) on cytokine production in mother and neonate. Methods. Healthy parturients with uncomplicated term pregnancies were randomized into two groups: EEA – parturients who would receive epidural analgesia before onset of pain and the control group, CEA – parturients who would receive epidural analgesia after onset of pain. Cytokines were measured in maternal blood at randomization Visual Analog Scale (VAS) < 30], 24 h postpartum, and in cord blood. Results. Forty-one women were studied. Epidural was performed in EEA when VAS was 23 ± 10 and in CEA when VAS was77 ± 10 (p < 0.0001). Background data were similar except for ruptured membranes at admission (EEA 15%, CEA 46.6%; p = 0.03), transient hypotension (EEA 20%, CEA 0%; p = 0.03), and meconium (EEA 25%, CEA 0%; p = 0.01). No significant differences were found in cytokine levels between groups at any time. Interleukin (IL)-6 levels changed significantly only in the control group (p = 0.046). There was significant correlation between baseline maternal IL-6 level and cord blood level in CEA (r = 0.59, p = 0.005), while no significant correlation existed in EEA (r = 0.33, p = 0.16). Conclusion. Although there was no significant difference in cytokine levels between the groups, EEA prevented the significant increase in IL-6 during labor and interrupted IL-6 fetal-maternal dependency.

Tramadol-metoclopramide or remifentanil for patient-controlled analgesia during second trimester abortion: a double-blinded, randomized controlled trial ☆

STUDY OBJECTIVE To compare patient-controlled analgesia (PCA) with tramadol with PCA with remifentanil in second trimester abortion. DESIGN Prospective, randomized double-blinded study SETTING University-affiliated medical center. PATIENTS 30 ASA physical status 1 and 2 patients undergoing a second trimester abortion. INTERVENTIONS Patients received PCA with either tramadol or remifentanil. Analgesia was initiated in the tramadol group by an initial loading dose of tramadol 1.0 mg/kg with 10 mg of metoclopramide followed by a PCA bolus of 0.3 mg/kg/mL of tramadol every 5 minutes. For remifentanil, which does not require a loading dose, a placebo of 100 mL of 0.9% normal saline was given followed by PCA of 0.4 μg/kg/mL every two minutes. MEASUREMENTS Women were evaluated for pain via verbal analog score (VAS; 0-100), sedation, nausea, blood pressure, pulse, and respiratory rate. On the day of discharge, women were analyzed for overall satisfaction. Primary outcome was pain scores and general satisfaction. MAIN RESULTS Analysis by time yielded no statistically significant difference in VAS scores between the groups at any point except 16-20 hours after induction of labor, when pain was lower in the tramadol group (11.3 ± 18.1 vs. 36.7 ± 27.4; P = 0.04). The average VAS score was low in both groups, with no significant differences noted between groups (P = 0.74). Satisfaction scores were high in both groups, with no significant differences noted between them (P = 0.89). CONCLUSION Both drugs are acceptable choices for pain control in patients undergoing second trimester abortions.

Risk Factors for Unintended Dural Puncture in Obstetric Patients: A Retrospective Cohort Study.

BACKGROUND:Unintended dural puncture (UDP) is one of the main risks of epidural analgesia, with a reported incidence of approximately 1.5% among the obstetric population. UDP is associated with maternal adverse outcomes, with the most frequent adverse outcome being postdural puncture headache (PDPH). Our retrospective cohort study objective was to identify demographic and obstetric risk factors that increase the risk of unintentional dural puncture as well as describing the obstetric outcome once a dural puncture has occurred. METHODS:We retrospectively reviewed all cases of UDPs during attempted vaginal delivery between the years 2004 and 2013 in a single Israeli hospital. Each UDP case was matched with the 2 parturients who received epidural analgesia before and 2 parturients after performed by the same anesthesiologist (control group). Demographic, anesthetic, and obstetric variables were compared between the UDP and control groups. RESULTS:Out of 46,668 epidural procedures, 177 cases of UDPs were documented (0.4%). One hundred seven women (60.5%) developed PDPH, and 38 (35.5%) required an epidural blood patch. In multivariate logistic regression, the degree of cervical dilation in centimeters at the time of epidural insertion was associated with an increased rate of UDP (P < .001). Multiparity was associated with PDPH after UDP (P = .004). Women with UDP had longer length of hospital stay than those without UDP (P < .001). CONCLUSIONS:UDP, an uncommon complication, is associated with obstetric factors. Nevertheless, it does not seem to be associated with adverse obstetric outcomes except for prolonged duration of hospital stay.