Labor Analgesia when Neuraxial Anesthesia is Relatively Contraindicated: Comparison of Patient-Controlled Fentanyl and Intermittent Nalbuphine Boluses

Background: Use of an in situ epidural catheter has been suggested to be efficient to provide anesthesia for postpartum tubal ligation (PPTL). Reported epidural reactivation success rates vary from 74% to 92%. Predictors for reactivation failure include poor patient satisfaction with labor analgesia, increased delivery-to-reactivation time and the need for top-ups during labor. Some have suggested that this high failure rate precludes leaving the catheter in situ after delivery for subsequent reactivation attempts. In this study, we sought to evaluate the success rate of neuraxial techniques for PPTL and to determine if predictors of failure can be identified. Methods: After obtaining IRB approval, a retrospective chart review of patients undergoing PPTL after vaginal delivery from July 2010 to July 2016 was conducted using CPT codes, yielding 93 records for analysis. Demographic, obstetric and anesthetic data (labor analgesia administration, length of epidural catheter in epidural space, top-up requirements, time of catheter reactivation, final anesthetic technique and corresponding doses for spinal and epidural anesthesia) were obtained. Results: A total of 70 patients received labor neuraxial analgesia. Reactivation was attempted in 33 with a success rate of 66.7%. Patient height, epidural volume of local anesthetic and administered fentanyl dose were lower in the group that failed reactivation. Overall, spinal anesthesia was performed in 60 patients, with a success rate of 80%. Conclusions: Our observed rate of successful postpartum epidural reactivation for tubal ligation was lower than the range reported in the literature. Our success rates for both spinal anesthesia and epidural reactivation for PPTL were lower than the generally accepted rates of successful epidural and spinal anesthesia for cesarean delivery. This gap may reflect a lower level of motivation on behalf of both the patients and anesthesia providers to tolerate “imperfect” neuraxial anesthesia once fetal considerations are removed.

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Epidural Labor Analgesia for a Patient with Neuromyelitis Optica: A Case Report and Review of the Literature

Case Reports in Anesthesiology ◽

10.1155/2018/2404756 ◽

2018 ◽

Vol 2018 ◽

pp. 1-3

Author(s):

Alexandra Chang ◽

Brian Chung ◽

Rashmi Vandse

Keyword(s):

Multiple Sclerosis ◽

Spinal Cord ◽

Case Report ◽

Neuromyelitis Optica ◽

Neuraxial Anesthesia ◽

Labor Analgesia ◽

Disease Entity ◽

Review Of The Literature ◽

Demyelinating Disorder ◽

The Impact

Neuromyelitis optica (NMO) is a rare demyelinating disorder affecting the spinal cord and optic nerves. Like multiple sclerosis (MS), it predominantly affects women during childbearing years. The impact of neuraxial anesthesia on the course of NMO is uncertain. There are no large studies available to draw definitive conclusions regarding the safety of neuraxial anesthesia in this population. A review of the current literature suggests that neuraxial anesthesia is unlikely to exacerbate neurologic symptoms in pregnant patients with NMO. However, given the rarity of this disease entity among patients requesting epidural labor analgesia, we recommend taking a cautious approach.

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Establishing Obstetric Anesthesiology Practice Guidelines in the Republic of Armenia

Anesthesiology ◽

10.1097/aln.0000000000001707 ◽

2017 ◽

Vol 127 (2) ◽

pp. 220-226 ◽

Cited By ~ 2

Author(s):

Gordon Yuill ◽

Ashot Amroyan ◽

Simon Millar ◽

Emil Vardapetyan ◽

Ashraf S. Habib ◽

...

Keyword(s):

Cesarean Delivery ◽

Practice Guidelines ◽

Clinical Care ◽

Obstetric Anesthesia ◽

Neuraxial Anesthesia ◽

Labor Analgesia ◽

Capital City ◽

Anesthesia Care ◽

The Republic ◽

The Impact

Abstract Background Disparity exists in anesthesia practices between high- and low-to-middle income countries, and awareness has been raised within the global health community to improve the standards of anesthesia care and patient safety. The establishment of international collaborations and appropriate practice guidelines may help address clinical care deficiencies. This report’s aim was to assess the impact of a multiyear collaboration on obstetric anesthesia practices in the Republic of Armenia. Methods An invited multinational team of physicians conducted six visits to Armenia between 2006 and 2015 to observe current practice and establish standards of obstetric anesthesia care. The Armenian Society of Anaesthesiologists and Intensive Care specialists collected data on the numbers of vaginal delivery, cesarean delivery, and neuraxial anesthesia use in maternity units during the period. Data were analyzed with the Fisher exact or chi-square test, as appropriate. Results Neuraxial anesthesia use for cesarean delivery increased significantly (P < 0.0001) in all 10 maternity hospitals within the capital city of Yerevan. For epidural labor analgesia, there was sustained or increased use in only two hospitals. For hospitals located outside the capital city, there was a similar increase in the use of neuraxial anesthesia for cesarean delivery that was greater in hospitals that were visited by an external team (P < 0.0001); however, use of epidural labor analgesia was not increased significantly. Over the course of the collaboration, guidelines for obstetric anesthesia were drafted and approved by the Armenian Ministry of Health. Conclusions Collaboration between Armenian anesthesiologists and dedicated visiting physicians to update and standardize obstetric anesthesia practices led to national practice guidelines and sustained improvements in clinical care in the Republic of Armenia.

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Labor Analgesia in a Patient with Severe Dystrophic Calcinosis Cutis

Pain Medicine ◽

10.1093/pm/pnaa249 ◽

2020 ◽

Vol 21 (11) ◽

pp. 3237-3239

Author(s):

Ashley V Wong ◽

Arnoley S Abcejo ◽

Ashley R D Dahl ◽

Emily E Sharpe

Keyword(s):

Informed Consent ◽

High Risk ◽

Autoimmune Disease ◽

Obstetric Anesthesia ◽

Neuraxial Anesthesia ◽

Labor Analgesia ◽

Anesthesia Provider ◽

Calcium Deposition ◽

Calcinosis Cutis

Abstract Introduction Calcinosis cutis is a condition characterized by pathologic calcium deposition into superficial dermal skin layers. It is often associated with an autoimmune disease. However, it may also occur after minor localized trauma and infection. Description of Problem We report a case of lumbar epidural placement of labor analgesia in a parturient with severe dystrophic calcinosis cutis without apparent complications. Clinical Solution We recommend fastidious optimization of epidural placement conditions for all patients who may be at high risk for neuraxial anesthesia, including consideration of ultrasound use, use of an experienced anesthesia provider for neuraxial placement, and placement in early labor. Additionally, judicious discussion of risks, benefits, and alternatives when obtaining informed consent is critical, ideally with the patient identified for a comprehensive visit in a preoperative obstetric anesthesia clinic before delivery.

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