Conversion of epidural labour analgesia to anaesthesia for Caesarean section: a prospective study of the incidence and determinants of failure

Halpern, Stephen H.; Soliman, Ahmed Z.; Yee, Jennifer; Angle, Pamela; Ioscovich, A.

doi:10.1093/bja/aen352

Cited by 71 publications

(50 citation statements)

References 14 publications

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“…A BMI > 50 kg/m 2 and ineffective analgesia during labor increased the odds of failure. Inadequate labor analgesia has consistently been identified as a factor associated with extension failure7, 20, 21, 22, 23, 24 and this relationship is also demonstrated in this cohort. Published data on pregnant women with ‘extreme obesity’ (BMI 50 kg/m 2 ) have estimated a prevalence of 1 : 1000 in the United Kingdom28 and 2.1 : 1000 in Australia 29.…”

Section: Discussionsupporting

confidence: 61%

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Epidural extension failure in obese women is comparable to that of non‐obese women

Eley

Chin

Tham

et al. 2018

Acta Anaesthesiol Scand

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BackgroundManagement of labor epidurals in obese women is difficult and extension to surgical anesthesia is not always successful. Our previous retrospective pilot study found epidural extension was more likely to fail in obese women. This study used a prospective cohort to compare the failure rate of epidural extension in obese and non‐obese women and to identify risk factors for extension failure.MethodsOne hundred obese participants (Group O, body mass index ≥ 40 kg/m2) were prospectively identified and allocated two sequential controls (Group C, body mass index ≤ 30 kg/m2). All subjects utilized epidural labor analgesia and subsequently required anesthesia for cesarean section. The primary outcome measure was failure of the labor epidural to be used as the primary anesthetic technique. Risk factors for extension failure were identified using Chi‐squared and logistic regression.ResultsThe odds ratio (OR) of extension failure was 1.69 in Group O (20% vs. 13%; 95% CI: 0.88–3.21, P = 0.11). Risk factors for failure in obese women included ineffective labor analgesia requiring anesthesiologist intervention, (OR 3.94, 95% CI: 1.16–13.45, P = 0.028) and BMI > 50 kg/m2 (OR 3.42, 95% CI: 1.07–10.96, P = 0.038).ConclusionThe failure rate of epidural extension did not differ significantly between the groups. Further research is needed to determine the influence of body mass index > 50 kg/m2 on epidural extension for cesarean section.

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Section: Discussionsupporting

confidence: 61%

“…The clinical significance of these failure rates is important, given that higher rates of cesarean section and instrumental delivery are observed in obese pregnant women 19. The epidural extension failure rates of 13% and 20% in our two groups are both within the wide range of published failure rates (0–21%) 15, 20, 21, 22, 23, 24…”

Section: Discussionsupporting

confidence: 51%

Epidural extension failure in obese women is comparable to that of non‐obese women

Eley

Chin

Tham

et al. 2018

Acta Anaesthesiol Scand

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“…12 However, in recent studies, inadequate surgical anesthesia after conversion of ELA to ESA for CD necessitated conversion to GA in 2.5-20% of cases and provision of additional analgesia was even more frequent. [13][14][15][16][17][18][19] Only one underpowered study reported a conversion rate to GA of 0%. 20 In fact, inadequate ESA has led to litigation against anesthesiologists.…”

Section: Discussionmentioning

confidence: 99%

“…9 Breakthrough pain during labor and the number of top-ups required to maintain ELA were demonstrated as being important factors in predicting failure of the same epidural catheter for anesthesia during intrapartum CD. 13,15,19,21 Furthermore, although likely seldom, extension of epidural blockade for intrapartum CD may result in high blocks and intravascular injections with seizures or cardiac arrest. 22 This likelihood has prompted us to choose SA for intrapartum CD, regardless whether the patient received ELA.…”

Section: Discussionmentioning

confidence: 99%

Spinal anesthesia for intrapartum Cesarean delivery following epidural labor analgesia: a retrospective cohort study

Visser

Dijkstra

Albayrak

et al. 2009

Can J Anesth/J Can Anesth

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Purpose Failed conversion of epidural labor analgesia (ELA) to epidural surgical anesthesia (ESA) for intrapartum Cesarean delivery (CD) has been observed in clinical practice. However, spinal anesthesia (SA) in parturients experiencing failed conversion of ELA to ESA has been associated with an increased incidence of serious side effects. In this retrospective cohort analysis, we examined our routine clinical practice of removing the in situ epidural, rather than attempting to convert to ESA, prior to administering SA for intrapartum CD. Methods Hemodynamic data, frequencies of either high or total spinal block, and maternal and neonatal outcome data were gathered from the anesthesia records of all parturients at the Amphia Hospital, undergoing intrapartum CD between January 1, 2001 and May 1, 2005. Results Complete data were available for 693 patients (97.6%) of the 710 medical records that were identified. Of the 693 patients, 508 (73.3%) had no ELA and received SA, 128 patients (18.5%) received SA following epidural anesthesia for labor, 19 (2.7%) underwent conversion of ELA to ESA, and 38 (5.5%) received general anesthesia. When comparing both SA groups, no clinically relevant differences were observed regarding the incidence of total spinal block (0% in both groups) or high spinal block (0.2 vs 0.8%, P = 0.36). The number of hypotensive episodes, the total amount of ephedrine administered, and the Apgar scores recorded at 5 and 10 min were similar amongst groups. Conclusions The incidence of serious side effects associated with SA for intrapartum CD following ELA is low and not different compared to SA only. RésuméObjectif Dans la pratique clinique, l'e´chec du passage d'une analge´sie pe´ridurale pour le travail obste´trical a`une anesthe´sie pe´ridurale chirurgicale pour un accouchement par ce´sarienne a e´te´observe´. Cependant, la rachianesthe´sie re´alise´e chez les parturientes chez qui la conversion de la pe´ridurale avait e´choue´a e´te´associe´e à une incidence accrue d'effets secondaires graves. Dans cette analyse de cohorte re´trospective, nous avons examineń otre pratique clinique habituelle, qui consistait a`retirer le cathe´ter pe´ridural avant de re´aliser une rachianesthe´sie pour un accouchement par ce´sarienne, plutôt que de tenter une conversion de la pe´ridurale.

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“…Başarısızlık için hastaların demografik özellikler ve yandaş sorunları ile ilgili kaynak verilerine bakıldığında; vücut yapısı ve spinal anatomi, (9) anatomik işaret noktalarının kalitesi, (1,9) vücut kitle indeksi (≥30) ve vücut ağırlığının fazla olması (≥66), eşlik eden preeklampsi, pulmoner ödem, taşikardi gibi sağlık sorunları, önceki sezaryen öyküsü, akut fetal distres, (19) morbid obezite, (9,16,20) anne ve bebeğin sağlık sorunları, (19) hasta boyunun uzun olması (21) gibi etkenler bildirilmiştir. Bizim çalışma-mızda da uygulama öncesi bulgular başa-rısızlık için değerlendirildiğinde hastanın ağırlığı, vücut kitle indeksi ve yandaş sağ-lık sorunlarının varlığı başarısızlık için risk faktörü olarak tespit edilmiştir.…”

Section: Discussionunclassified

Failure of Neuraxial Blocks and Etiologic Factors

Özdemir¹,

Kayhan²

2011

J Turk Anaesth Int Care

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ÖZETAmaç: Anestezi, postoperatif analjezi ve ağrı tedavisi amacı ile kullanımları giderek artan nöroaksiyel bloklardaki gelişmelere karşın başarısızlık söz konusu olabilmektedir. Planlanan blok tekniğinin gerçekleştirilememesi, yetersiz ya da eksik kalması şeklinde tanımlanabilecek başarısızlık konusundaki veriler, başarısızlığın tanımı ve yöntem farklılıkları nedeniyle değişken olabilmektedir. Bu çalışmada nöroaksiyel bloklarda başarısızlık oranlarını ve nedensel ilişkilerini tespit edip sonraki girişimlere yol gösterici olmayı hedefledik.Gereç ve Yöntem: Araştırma kurulu onayı ile 1998-2008 yılları arasında, 18 yaş ve üzeri hastalarda cerrahi amaçla uygulanan 7.263 nöraksiyel blok incelendi. Genel anestezi eşliğinde yapılan 297 epidural blok değerlendirme dışı bırakılarak 6966 hastanın demografik ve özgeçmiş özellikleri, yandaş sorunları, yöntem ve uygulama özellikleri, başarı-sızlık kriterleri ve nedenleri, cerrahi özellikleri değerlendirildi. İstatistiksel değerlendirme için Chi-Square, Student-T ve Mann-Whitney U testleri kullanıldı. Anlamlı başarısızlık etkeni olarak bulunan parametrelerde lojistik regresyon analizi ile bağımsız risk faktörleri belirlendi.Bulgular: Hastaların %10,69'unda nöroaksiyel blok uygulanmış olup, tüm bloklarda başarısızlık hızı %5,4; spinal anestezi (SA)'de %3,9, epidural anestezi (EA)'de %10,9, kombine spinal epidural (KSE) blokta %6,4 tespit edilmiştir. Bağımsız risk etkenleri, blokların tümünde ilişki gücüne göre, paramediyan yaklaşım (p<0,001/OR 30,8), periferik damar hastalığı (p<0,001/OR 2,5), epidural blok (p<0,001/OR 2,6), cerrahi girişim süresi (p<0,001/OR 2,3), uzman deneyimi gereksinimi (p<0,001/OR 1,9), kronik obstrüktif akciğer hastalığı (p=0,014/OR 1,7), nörolojik hastalık (p<0,001/ OR 2,6) ve vücut ağırlığı (p=0,023/OR 1,0) olarak tespit edilmiştir.Sonuç: Sonuç olarak; dikkatli değerlendirme, girişime uygun yöntem seçilmesi, güçlük öngörüldüğünde erkenden uzman deneyimine başvurulması ve kayıtların düzenli tutulmasının başarısızlık oranını azaltıp hasta güvenliğini artıra-cağı kanısına varıldı.Anahtar kelimeler: Nöroaksiyel bloklar, spinal, epidural, kombine spinal epidural SUMMARY Failure of Neuraxial Blocks and Etiologic FactorsObjective: Neuraxial blocks are increasingly used for anesthesia, postoperative analgesia, and pain management. In spite of advancements in neuroaxial block procedures, difficulty or failure to obtain satisfactory block is still the main isue. Data on operational failure which can be defined as inability to achieve planned blockade technique, its inadequacy or deficiency, differ due to the variability in description of the criteria of failure, and also methodologic differences. In this study we aimed to determine the rates of failure and causal correlations in cases with neuraxial blocks as to guide future attempts.Material and Method: After the approval of Research Committee, records of 7263 patients aged ≥18 years who had received neuraxial blocks between 1998-2008 were examined. Patients (n=297) who were given epidural blocks under genera...

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Conversion of epidural labour analgesia to anaesthesia for Caesarean section: a prospective study of the incidence and determinants of failure

Abstract: Intraoperative conversion to GA may increase both maternal and fetal risks. Strategies to reduce the incidence may include early recognition of inadequate labour analgesia and reliable assessment of adequacy of surgical anaesthesia.

Cited by 71 publications

References 14 publications

Epidural extension failure in obese women is comparable to that of non‐obese women

Epidural extension failure in obese women is comparable to that of non‐obese women

Spinal anesthesia for intrapartum Cesarean delivery following epidural labor analgesia: a retrospective cohort study

Failure of Neuraxial Blocks and Etiologic Factors

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