Development and Evaluation of a Score to Predict Difficult Epidural Placement During Labor

Guglielminotti, Jean; Bedairia, E.; Montravers, Philippe; Longrois, Dan

doi:10.1097/aap.0b013e31828887a6

Cited by 20 publications

(11 citation statements)

References 25 publications

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“…In this study, set in California, USA, 53.6% of 90 369 normal weight primiparous women and 62.1% of 3706 super obese (BMI ≥ 50 kg/m 2 ) women had regional analgesia. These rates are moderate to high relative to those reported globally (as low as 18% in parts of Australia up to 87% reported in France). The results of this study reflect a whole range of factors that uniquely influence local clinical anaesthetic and obstetrical practice, and the findings should be considered in geographical context.…”

contrasting

confidence: 54%

Obesity and Complications from Neuraxial Analgesia – We Need to Know More

Callaway

Eley

2017

Paediatric Perinatal Epid

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In this issue of Paediatric and Perinatal Epidemiology is an important paper by Biel and colleagues, 1 which explores the relationship between maternal body mass index (BMI), the use of regional anaesthesia and complications arising from regional anaesthesia in maternity care. In this study, set in California, USA, 53.6% of 90 369 normal weight primiparous women and 62.1% of 3706 super obese (BMI ≥ 50 kg/m 2 ) women had regional analgesia. These rates are moderate to high relative to those reported globally (as low as 18% in parts of Australia 2 up to 87% reported in France 3 ). The results of this study reflect a whole range of factors that uniquely influence local clinical anaesthetic and obstetrical practice, and the findings should be considered in geographical context.A novel aspect to this paper is the attempt to explore the association between BMI and the incidence of complications of regional anaesthesia. This is of interest to childbearing women, and the midwives, obstetricians and anaesthetists who care for them. The complications of neuraxial anaesthesia in obstetrical care range from mild complications that occur frequently (e.g. hypotension 1 in 50, or 2%) to severe complications that occur rarely (e.g. epidural haematoma 1 in 170 000). 4,5 Large cohort studies such as this one, are the only way to detect such infrequent adverse events. Although the results presented in this paper may be subject to the limitations of clinical coding, to date, this is the first cohort (with 1 815 087 pregnancies), to examine the influence of BMI on rare but extremely serious complications. 4-7 The authors report that the incidence of complications was greater in women with BMI (kg/m 2 ) for both primiparous women (odds ratio [OR] 2.34, 95% confidence interval [CI] 1.37, 4.02) and multiparous women (OR 2.00, 95% CI 1.26, 3.16). Future work will be required to build on these results, using clinically relevant and accurate outcome definitions and distinguishing between neuraxial needle types and sizes.The authors report that women with class III obesity were more likely to have regional anaesthesia, with 60.9% of primiparous women with BMI 40-49.9 kg/m 2 receiving epidural analgesia. The significance of this is complex, and likely to be influenced by the practice patterns of the treating anaesthetists, the epidural usage rate in the underlying population, obstetrical, maternal and fetal indications for regional anaesthesia, and preferences of treating obstetricians. 8 Practice guidelines internationally refer to the early insertion of epidurals in women with BMI >40 kg/m 2 , 9-11 a practice which is supported by expert opinion 12,13 and known to be adopted by anaesthetists in Australia. 14 If treating anaesthetists adhere to this practice suggestion, it is not surprising to see this result. In contrast, overweight and obese women had a lower rate of regional anaesthesia than women with normal weight with an increased risk of complications seen only in those with class III obesity. More nuanced exploration is needed to un...

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contrasting

confidence: 54%

Obesity and Complications from Neuraxial Analgesia – We Need to Know More

Callaway

Eley

2017

Paediatric Perinatal Epid

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“…2,12 However, only a few studies focused on difficulty in initial placement of neuraxial analgesia or specific definitions of difficulty. 12,18,21,22,23 We defined difficulty as more than six epidural needle redirections in total in addition to a note mentions difficulty in the chart. Another commonly used measure is the number of attempts.…”

Section: Discusssionmentioning

confidence: 99%

Increasing body mass index predicts increasing difficulty, failure rate, and time to discovery of failure of epidural anesthesia in laboring patients

Kula

Riess

Ellinas

2017

Journal of Clinical Anesthesia

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Study Objective: Obese parturients both greatly benefit from neuraxial techniques, and may represent a technical challenge to obstetric anesthesiologists. Several studies address the topic of obesity and neuraxial analgesia in general, but few offer well described definitions or rates of “difficulty” and “failure” of labor epidural analgesia. Providing those definitions, we hypothesized that increasing body mass index (BMI) is associated with negative outcomes in both categories and increased time needed for epidural placement. Design: Single center retrospective chart review. Setting: Labor and Delivery Unit of an inner city academic teaching hospital. Patients: 2485 parturients, ASA status 2 to 4, receiving labor epidural analgesia for anticipated vaginal delivery. Interventions: none. Measurements: We reviewed quality assurance and anesthesia records over a 12-month period. “Failure” was defined as either inadequate analgesia or a positive test dose, requiring replacement, and/or when the anesthesia record stated they failed. “Difficulty” was defined as six or more needle redirections or a note indicating difficulty in the anesthesia record. Main Results: Overall epidural failure and difficulty rates were 4.3% and 3.0%, respectively. Patients with a BMI of 30 kg/m2 or higher had a higher chance of both failure and difficulty with two and almost three fold increases, respectively. Regression analysis indicated that failure was best predicted by BMI and less provider training while difficulty was best predicted by BMI. Additionally, increased BMI was associated with increased time of discovery of epidural catheter failure. Conclusions: Obesity is associated with increasing technical difficulty and failure of neuraxial analgesia for labor. Practitioners should consider allotting extra time for obese parturients in order to manage potential problems.

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“…It is customary to palpate the back to perform a block therefore inspection of the photos without palpation limited reviewer information received. 17 In conclusion, we found a strong to moderate correlation between measured BMI, subscapular fatpad and midarm fatpad thickness, and epidural depth measured by ultrasound. Our findings suggest that specific and more sophisticated measurements of body habitus and fat distribution such as subscapula fatpad and midarm thickness do not appear to add additional information beyond measured BMI to anticipate greater epidural depth.…”

Section: Discussionmentioning

confidence: 48%

Prospective observational investigation of body habitus measurements and relationship to epidural depth in term pregnant women

Weiniger

Cohen

Aptekman

et al. 2020

Acta Anaesthesiol Scand

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Background High body mass index (BMI) can predict difficult neuraxial block; however, fat distribution may also be important. The primary study aim was to identify body habitus and fat distribution measurements that correlated with ultrasound measured epidural depth. We hypothesized that measurements such as midarm and subscapular fatpad thicknesses and length of cervical spine may correlate better with ultrasound measured epidural depth than a global measure of BMI. Methods Prospective IRB approved study of term pregnant women requiring neuraxial block. We measured height, weight (BMI, kg/m2), subscapular, midarm fatpad thickness (digital caliper, mm), vertebral column length (C7 to sacral hiatus, cm) and epidural depth (ultrasound, mm). Four experts assessed photographs to assign anticipated difficult neuraxial block in sitting and lateral positions (5‐point Likert scale, 1 = very easy, 5 = very difficult). Results In all, 131 women completed body habitus measurements. Measured mean (standard deviation) BMI was 30.3 (5.4) kg/m2. Measured BMI, subscapular fatpad and midarm fatpad thickness were significantly correlated with ultrasound depth to epidural space (R2 0.733, 0.626 and 0.633, respectively, P < .0001) but vertebral column length was not. The experts had a high level of agreement (Cronbach's alpha >0.7) for assessment of anticipated difficult block in the sitting and lateral positions; however, anticipated difficult block was not correlated with epidural depth measured by ultrasound for sitting position, R2 = −0.015, P = .87; and lateral position, R2 = −0.087, P = .33. Conclusions Measurements of body habitus and fat distribution were no better than measured BMI to anticipate greater ultrasound measured depth to epidural space. Clinical trial number: Non‐interventional observational study, not registered.

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Development and Evaluation of a Score to Predict Difficult Epidural Placement During Labor

Abstract: This study confirms risk factors for DEP and proposes a score to predict DEP. The score identifies high-risk patients who may benefit from an intervention to decrease DEP. This hypothesis should be evaluated in an impact study.

Cited by 20 publications

References 25 publications

Obesity and Complications from Neuraxial Analgesia – We Need to Know More

Obesity and Complications from Neuraxial Analgesia – We Need to Know More

Increasing body mass index predicts increasing difficulty, failure rate, and time to discovery of failure of epidural anesthesia in laboring patients

Prospective observational investigation of body habitus measurements and relationship to epidural depth in term pregnant women

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