Morbidity review
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Transcript of Morbidity review
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Morbidity review
By Noorfarahnaduwah Nurdin
Supervisor Dr Tuan Norizan
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•Madam F, G2 P0+1•No known medical illness•Height 151cm, weight 80kg, BMI 35.09
•Admitted to labour room at 9pm▫Os 3cm, contraction 2:10
•Was referred for epidural anaesthesia
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Upon review @ 1am•Patient was on entonox•Bp 130/68 mmhg, pr 90/min•Epidural inserted at level L3L4•Anchored at 10cm•Skin to space 5cm•Test dose 3mls lignocaine 2%•Loading dose 8 mls 0.2% ropi + 50mcg
fentanyl•Started on infusion ropi 0.1% + 2mcg/ml
fentanyl 6mls/hr
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5.00 am
Pain score 7-8/10 Increase infusion 13 mls/hr
3.00 amPain score 7-8/10
Increase infusion 10 mls/hr + bolus 3 mls
lignocaine 2%
1.30 am
Pain score 7-8/10 Increase infusion 8 mls/hr
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10.45 am
Posted for EMLSCS for fetal distress
10.30 amPain score 7-8/10 Bolus 3 mls ropi 0.2% +
cont infusion 13 ms/hr
7.30 am
Pain score 7-8/10 Bolus 3 mls ropi 0.2% + cont infusion 13 ms/hr
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In OT•Epidural was removed •Spinal anaesthesia was given at level L3L4▫Heavy marcaine 0.5% + morphine 0.1mg
+ fentanyl 20mcg (total volume 2.2mls)
•About 4 minutes after spinal, complaint of perioral & upper limbs numbness
•Bp dropped down to 70/40mmhg -> responded with phenylephrine
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In OT•Spo2 dropped to 88-90%•Also complaint of difficulty in breathing•GCS 15/15•Converted to GA•Intubated with RSI technique
▫STP 250mg▫Scoline 100mg▫CL 1
•bp prior to intubation 120/57mmhg, pr 118/min
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Intraoperative•Uterus on/off atony•Resuscitated with
▫1 pint gela▫1 pint sterofundin▫3 pints hartmann
•Other meds▫iv pitocin 10u▫Im ergometrine 0.5mg▫Im hemabate 250 mcg▫Iv morphine 3mg▫Iv pitocin infusion 40u
•EBL 1.4L
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Post operative •Transferred to ICU for weaning•Hemodinamically not on inotropes•Extubated upon arrival to ICU
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Issues •Inadequate epidural in labour as pain relief
•How to manage patient with epidural proceed with emergency c-sec▫Choices of drugs & doses
•Non functioning epidural in patient proceed with emergency c-sec▫Role of spinal, CSE & GA
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Managing failed epidural analgesia for labour
•Failed?▫Partial block▫Unilateral block ▫Patchy block▫Inadequate block
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Principle of management•Understand causes & factors predictive of
failed epidural
•Understand why functioning epidural catheter for labour becomes non-functional for c-sec
•Enumerate approaches to manage failed epidural for labour analgesia & operative delivery
•Recognize possible consequences of spinal anaesthesia following failed epidural block
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Causes of failed
analgesia
Anatomical factors
Technique, methodology & equipment-
related factors
Initial catheter
misplacement
Catheter migration & malfunction
Catheter malfunction
& defect Patient-
related & other risk
factorsTechnical
skills/performance factors
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Anatomical factors•Presence of midline epidural band/connective
tissue -> difficult to thread epidural catheter through Touhy needle -> coiling catheter during introduction
•> lumbar lordosis -> decrease intervertebral space
•Ligamentum flavum ‘softer’ & less dense due to hormonal changes & edema
•Difficulty blocking larger spinal nerve root e.g: sacral nerve root (17.53% failure rate)
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Technique, methodology & equipment-related factors
1. Initial catheter misplacement ▫ Accidental transforaminal passage▫ Migration of catheter into anterior
epidural space▫ Unintended placement of catheter in
paravertebral space
*increased distance from skin to space correlates to higher incidence of unilateral block
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Technique, methodology & equipment-related factors
2. Catheter migration & malfunction
▫ Up to 50% catheters migrate during labour.
▫ Greatest change in position occur in
BMI >30; change position from sitting to supine
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Technique, methodology & equipment-related factors
3. Catheter malfunction & defects▫ Catheter knotting/kinking, blocked catheter
‘eyes’▫ Blocked terminal eye -> higher incidence of
unsatisfactory blocks (32%) compared to lateral eyes blocked
▫ Loss of resistance to air method -> higher incidence of inadequate analgesia compared to saline method
▫ Optimal length catheter left in space 2-6cm
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Technique, methodology & equipment-related factors
4. Patient-related & other risk factors▫ Morbidly obese; BMI >30 higher risk failed
block & inadequate analgesia
▫ Presence of radicular pain during needle/catheter insertion
▫ Occipital posterior presentation of fetal head
▫ Inadequate analgesia from initial dose
▫ Labour duration >6 hours
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Management of failed/inadequate epidural catheter in labour
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Management of failed/inadequate epidural catheter in labour
• Reassure patient
• block inadequate, unilateral or if some dermatomes are spared?
1. Withdraw catheter until 2-3cm left in space then give another dose of analgesic
2. Change patient position when administrating the epidural. eg:
Supine position for unilateral block Sitting up position for sacral block*results of effectiveness mixed
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Management of failed/inadequate epidural catheter in labour
3. Changing loading dose Bigger volume of bolus dose of dilute
epidural analgesic (eg 0.125% ropi/less) shown to be >effective than smaller volume but >concentrated dose (eg 0.2% ropi)
4. Add opiates & other adjuvants Boluses epidural fentanyl 25-50mcg Others, boluses clonidine 150mcg
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Management of failed/inadequate epidural catheter in labour
•If failed to get sensory block after 30 minutes, consider:
1. Resite epidural catheter
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Management of failed/inadequate epidural catheter in labour
2. Perform CSE▫ Risk high block if spinal dose is too large &
extend of block may be unpredictable
▫ If desired dermatome level not reached after spinal, upper sensory level may be increased by injecting 5mls saline epidurally ( epidural volume extension (EVE))
▫ Upper sensory block tends to be several dermatomes higher after CSE than in plain epidural top-ups, especially if done after induction of analgesia.
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Management of failed/inadequate epidural catheter in labour
3. Perform single shot spinal• May be considered if delivery is imminent & risk
for c-sec is minimal
• Use of hyperbaric LA solution given in sitting position very effective
• Progression of block should be monitored closely
• Epidural top-ups should not be administered during the last 30 minutes(if time permits)
• May need to reduce dose by 20-30% than usual
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Management of failed/inadequate epidural catheter in labour
4. Supplemental caudal anaesthesia
• Performed when the unblocked segments are sacral
• Should be done by experienced practitioner with carefully calibrated doses
• Generally not recommended due to high risk of local toxicity & accidental injected to foetus
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Management of failed/inadequate epidural catheter in labour
5. If insufficient time to resite epidural, • supplementary systemic analgesic e.g. • small doses fentanyl/remifentanil every
1-2 mins;• entonox,• local (perineal anaesthesia)
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Extending epidural analgesia for caesarean
section
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Principles of management•Patient should be transferred quickly to OT for top ups where monitoring & resuscitation equipment available▫Potential adverse effect -> excessive high
block requiring intubation & accidental intravascular injection may result in seizures & cardiac event
•Performing test dose before epidural top ups may avoid potential complications, but may cause delay
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Principles of management•Regular follow up patient receiving epidural anaesthesia in labour
▫Identify patients with suboptimal block -> may have inadequate intraoperative anaesthesia after top-up lead to intraoperative convertion to GA
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Principles of management▫If c-sec is required, consider removing epidural catheter & convert to spinal/CSE
Reduce risk of inadequate anaesthesia & ad hoc conversion to GA.
*Risk of excessively high block, may considered lower dose of intrathecal drugs
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Agents used to extend epidural blockade for caesarean section
•Usually 15-20mls of local anaesthesia needed to produce adequate block for c-sec
•Using combination of drugs & adjuvants produces faster onset anaesthesia
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Local anaesthesiaI. Lidocaine 2%
▫ Recent study showed that alkalanized 2% lidocaine mixed with epinephrine 1:200,000 reduced onset time of anaesthesia & produced better quality anaesthesia
II. Ropivacaine 0.75%-1%, levobupivacaine 0.5%
▫ Less likely produce cardiac complications compared to bupivacaine
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Adjuvants I. Epinephrine
▫ Reduces toxicity risk by decreasing systemic absorption of local anaesthetics from extradural space
▫ Confer some additional analgesic property
▫ Cause tachycardia if injected intravascular, hence warn the intravascular migration of epidural catheter
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Adjuvants II. Sodium bicarbonate
▫ May increases speed of onset of surgical anaesthesia by increasing pH -> increase proportion of non-ionized lipid soluble LA that can diffuse into the axon
III.Opioids ▫ Improve quality of anaesthesia
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Inadequate regional anaesthesia for caesarean section
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•Regional anaesthesia recommended for caesarean section
▫Provide effective postoperative analgesia via intrathecal/epidural opioids
▫Avoiding GA hazards eg difficult/failed airway, aspiration of gastric contents
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Prevention a. Preexisting epidural analgesia
b. Choice of regional anaesthesia technique
c. Use of opioids
d. Testing of block
e. Time consideration
f. Miscellaneous consideration
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Pre-existing epidural analgesia
•Functioning epidural allows sufficient time to top up for pain free emergency c-sec
•Epidural catheter should be checked to ensure that its functioning well.
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Pre-existing epidural analgesia•If amount of LA to maintain analgesia
during labour significantly higher than usual
▫may due to non functioning epidural catheter & may need to be replaced
•Regular review & identifying high risk parturient early can help reduce incidence of emergency surgery that needed GA
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Choice of regional anaesthesia technique
•Single shot spinal anaesthesia ▫ not extendible in event of inadequate
anaesthesia
•If surgery expected to be longer & difficult than usual -> CSE may be a better option
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Use of opioids•Fentanyl + intrathecal bupivacaine
faster onset improve perioperative anaesthesia without increase in side effects if moderate doses are used
•Intrathecal morphine/diamorphine prolonged postoperative analgesia
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Testing of block•Usual ways
▫Loss sensation to touch/pressure,▫Cold temperature &▫Pin prick
•Light touch > reliable predictor for adequate SA
•Loss of pinprick sensation to T4 acceptable in epidural anaesthesia▫Bilateral LL weakness -> indicator top ups
in epidural taking effect
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Time consideration•Time should be given for surgical anaesthesia to develop, particularly for epidural block▫May not be feasible in extremely emergent
situation eg cord prolapse/severe foetal distress
•Patients with epidural catheter in situ for labour analgesia, additional bolus doses may be administered once the decision for caesarean delivery made.
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Miscellaneous consideration•Presence of patient’s partner in OT may be reassuring & have calming effect on patient
•Sympathetic approach by anaesthesiologist + gentle approach at surgical dissection & manipulation by surgeon can help ensure patient comfort
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Management of inadequate regional anaesthesia for caesarean section
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•Management option depends on▫The indication & urgency of caesarean
section
▫The time of diagnosis of inadequate regional block
▫Pre-existing regional blockade (if any)
▫The nature & severity of the pain experienced
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•Risk of GA & regional anaesthesia must be considered for patients▫morbidly obese
▫exhibit features of potential difficult airway
▫have active respiratory tract infection
*in such situation, GA must be undertaken with extreme caution
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Before surgery•Problems with epidural anaesthesia
▫A failed block
▫A unilateral or patchy block
▫A block height remains persistently below required T4 level
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Before surgery•Measures that can be done to improve block▫Provide additional doses of LA
with/without opioids
▫Adjusting epidural catheter
▫Positioning the patient on unblocked side before top-ups
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Before surgery
•Its crucial to identify non-functional epidural block perioperatively before administering maximum volume of local anaesthetic
•If there’s no time constraint & no technical difficulty in administering the first epidural block -> possible to replace epidural catheter. ▫Risk of excessive local anaesthetic
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Before surgery•Use of spinal anaesthesia following failed epidural block -> highly controversial.
*may cause high block requiring tracheal intubation, ventilation & cardiovascular resuscitation.
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•However, it still can be an option if appropriate precautions & technique modifications are taken such as▫Avoiding epidural boluses immediately
before spinal injection
▫Using a lower spinal dose
▫Intentionally delaying the placement of patient in a supine position following spinal injection of hyperbaric of LA in sitting position
Before surgery
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Before surgery •Failed spinal block can occur despite
presence of CSF backflow due to anatomical anomalies or drug failure
•Management include ▫CSE placement at different lumbar
interspaces▫If needed, proceed to GA
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During surgery before delivery of foetus•Some patients may be anxious about being
fully awake during procedure -> often requiring reassurance
•If an epidural catheter is present▫Additional top ups 3-5 mls of LA (eg 2%
lidocaine with 1:200,000 adrenaline & NaHCO3) may be given together with 50mcg fentanyl
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During surgery before delivery of foetus
•Other options include ▫Entonox▫small iv doses of ketamine or▫ short acting opioids (eg alfentanil)
•Conversion to GA should be strongly considered in patients whose pain persist despite of the above interventions
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During surgery after delivery of foetus•Management option include
▫the previous measures▫use of iv longer acting opioids (eg meperidine,
morphine)
•Patient must not be over sedated to maintain airway & protect against gastric aspiration
*explain to patient post delivery to explain regarding failed blocks & management option available if she presents again in future.
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Conclusions •Using combination of drugs & adjuvants
produce faster onset but may delay time•Mixing several drugs together may lead to
drug errors•Epidural has multiple benefit but has up to
14-20% failure rate•In situation where epidural anaesthesia not
functioning in patient posted for EMLSCS, decisions regarding other modalities need to be discussed with specialist
•Documentation
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Reference