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Failed Epidural Catheter: what now?

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Presentation on theme: "Failed Epidural Catheter: what now?"— Presentation transcript:

1 Failed Epidural Catheter: what now?
Nathaniel Hsu, MD Assistant Professor Department of Anesthesiology and Critical Care Hospital of the University of Pennsylvania Presented: AAAA Meeting Austin April 2017

2 Disclosures I have no financial relationships to disclose related to this educational content

3 Learning Objectives Describe why epidural catheter fails to provide adequate analgesia/anesthesia Develop plan for epidural that is not providing appropriate labor analgesia Develop plan for when an epidural catheter fails to provide adequate anesthesia for cesarean delivery

4 Why the Increase in Cesarean Section?
National Center for Healthcare Statistics – 32.0% cesarean section rate for 2015 (decrease from 32.9% in 2009) Puerto Rico 48.0% Louisiana 38.3% Utah 22.3% Decrease in VBAC State rates from cesareanrates.com (2014 data). TOLAC rates – 51.8% in 1995 declined to 15.9% in Increased from VBAC successful 60-80% of the time. VBAC success has been decreasing from % in 2000, down to 38% in 2008. National Center for Health Statistics 2015

5 Why the Increase in Cesarean Section?
Advanced Maternal Age Multiple gestation Increasing maternal BMI Increasing use of intrapartum FHR monitoring Liberal use of induction of labor Increasing primary c-section rate Cesarean sections are being perceived by the public as increasingly safe and acceptable

6 Not An Atypical Case 24-year old G1P0
Lumbar epidural catheter placed at 3 cm cervical dilation Required 4 boluses throughout her 10 hour labor Cesarean section for dystocia Unluckily for you…after bolusing with epidural lidocaine, patient has a questionably patchy block. NOW WHAT???

7 How would you manage her anesthetic?
Bolus epidural catheter with lidocaine with epinephrine Remove epidural catheter and do spinal anesthesia Replace epidural with new epidural General anesthesia with RSI Perform hypnosis for cesarean section

8 Can Labor Epidurals Be Used for Cesarean Sections?
182 parturients undergoing elective cesarean section 2% lidocaine with epi 1:200,000 Volume: 14-16mL 170 none or minor discomfort 12 required supplemental analgesia Surgeon able to operate on an awake patient Initially used both 2% lido and 0.5% bupi, but with more experience changed to 2% lido. Our experience with lignocaine suggests that an increment of 8-12 ml is sufficient in most patients coming to Caesarean section with an established epidural block. If the last top-up injection is still effective it is reasonable to add a volume of lignocaine which will increase the total volume of local anaesthetic in the epidural space to ml. If the nerve block is wearing off, a total of 1,416 ml of lignocaine may be necessary. Similarly, patients undergoing epidural block for the operation alone require about 15 ml of local analgesia. In a follow-up review in 1979, Milne et al.15 described the anesthetic management of 722 consecutive cases of an intrapartum CD and reported an overall 69% (533/772) success rate of conversion of ELA to ESA. 7% failure rate. (12/182). The causative factors included insufficient time for the analgesic to act in patients with acute foetal distress, an inadequate dose of local analgesic and the persistence of unblocked segments. Milne MK and Murray Lawson JI. Br J Anaesth. 1978;45:

9 If an epidural catheter worked for labor, won’t it work for cesarean delivery?

10 Failed Epidurals are like Meconium
Catheter pulled back 1 cm 22% Success after pulling back 85% Epidural replaced 1.7% SAB 59% No epi med prior to SAB 83% Failed SAB 16% Health records of parturients receiving epidural and required conversion for CD 895 cases over 3 year period – 775 success 120 failures (13%) Risk factor: inadequate labor analgesia All women had ELA initiated and maintained with 0.08% ropivacaine +2 mcg ml -1 fentanyl16 utilizing patient-controlled epidural analgesia (PCEA), with or without continuous infusion epidural analgesia (CIEA), which is consistent with routine clinical practice at our institution. All used 100mcg epidural fentanyl Campbell DC. Can J Anesth. 2009;56:19-26.

11 Failed Epidurals are like Meconium
OB GEN Catheter pulled back 1 cm 58% 6% GA (overall) 1% GA w/o SAB attempted 0% 75% Multiple intubation attempts 15% Management patterns differed between OB and GEN OB more likely to pull back catheter or perform spinal However, an anesthesiologist must be aware that this success rate, although high, is much lower than that observed with SAB with elective CD, i.e., >97%.Consequently, these observations do not support the ‘‘routine’’ practice of removing all epidural catheters when presented with inadequate ESA and proceeding immediately to a single shot SAB. Considering the observed SAB failure rate of 15–22% that has not previously been reported, the present investigation suggests that pulling the epidural catheter back should be considered prior to undertaking SAB. Other good articles: Riley et al. Int J Obstet Anesth. 2002 Apr;11(2):81-4. Orbach-Zinger et al. Acta Anaesthesiol Scand. 2006 Aug;50(7): They found that younger, more obese parturients at a higher gestational week, requiring more top-ups during labor and having a higher VAS score in the 2 h before CS are at risk for inability to extend labor epidural analgesia to epidural anesthesia for CS. Campbell DC. Can J Anesth. 2009;56:19-26.

12 What to Bolus For an Emergent Cesarean?
Meta-analysis of 11 studies including 779 parturients Optimal top-up medication Lidocaine with epinephrine Ropivacaine 0.75% Bupivacaine 0.5% Lidocaine resulted in faster onset, 3-5 min Adding fentanyl increased speed of onset, but did not affect need for intraop supplementation Bupi/levobupi associated w significantly increased risk of intraop supplementation compared w other groups (esp Ropi). 2-3x as likely. Bupi 0.5% least effective solution. 0.75% ropi Hillyard SG. Br J Anaesth 2011;107:668

13 Physiochemical Properties of Local Anesthetics
Speed of onset – pKa Weak bases pH = pKa + log (unionized/ionized) Bupivacaine – 8.1 Lidocaine – 7.9 Picture:

14 What is the sensory level required for cesarean delivery that will keep 95% of patients comfortable?
B. T4 C. T2 D. C8

15 What is the Sensory Level Required for Cesarean Delivery?
Varies from T8 to T2 Sensory innervation from pelvic organs enter T10 to L1 Peritoneum – can be as high as T2

16 How to Determine Sensory Level
15 obstetric anesthesiologists determined height of spinal by: touch, pinprick, and cold 81% only had block to touch below T6 5% needed intervention, but all comfortable and satisfied Wide variation to touch Testing with cold and pinprick Is block behaving normally? 94 women for c-section w spinal. The block heights for each modality were assessed and recorded when the anaesthetist considered that the woman had a satisfactory spinal anaesthesia block for caesarean to proceed. Anaesthetists also recorded whether the patient reported discomfort or needed an analgesic⁄anaesthetic intervention at any time during surgery, as well as the time and stage of the intervention. It may be more helpful to assess whether the progression of the block is behaving as would be expected, with the modality of choice, and the way it is tested, the one that is most familiar and provides most reassurance to the anaesthetist. Use the modality you’re most familiar with. But don’t just use one method. Ousley et al. Anaesthesia 2012;67:

17 A patient complains of pain during insertion of bladder blade. Etiology?
A. Level isn’t high enough B. Level isn’t low enough C. Pain is due to peritoneal tugging D. Not possible to block visceral discomfort

18 Is the Sensory Blockade Low Enough?
Sacral Sparing Sacral innervation to the uterus, fallopian tubes, and bladder Large sacral fibers Size of the caudal space

19 Epidural Catheters Do NOT Always Work
260 parturients 17% failed epidural labor analgesia Odds Ratios: Cervix > 7cm: 3.18 Hx failed epidural: 5.55 Opioid tolerance: 7.24 Inserted by trainee: 2.03 Just learning to walk Prospective study looking at factors for inadequate labor analgesia. Univariate testing showed: multiparity, previous failure, LOR to air, cervical dilation > 7cm Picture: Agaram R. Int J Obstet Analg 2009;18:10-14

20 Did the Epidural Catheter Ever Work?
456 parturients undergoing vaginal delivery with epidural analgesia Risk factor for inadequate pain relief: Inadequate analgesic efficacy of the first dose Other risk factors: posterior presentation, radicular pain during placement, duration of epidural < 1 hour and >6 hours Le Coq G. Can J Anaesth 1998;45:

21 Was It Ever Working? Prospective study over 6 months
20/101 required conversion to general anesthesia Inversely correlated with age Directly correlated with weight, NUMBER OF TOP-UPS, VAS 2 hours before C-section Orbach-Zinger S. Acta Anaesthesiol Scand 2006;50:793

22 Was It Ever Working? Retrospective Study
1025 parturients required cesarean section Failure Rate – 1.7% Predictor > 2 episodes breakthrough pain Lee S. Anesth Analg 2009;108:252-4

23 The Number of Boluses Retrospective review of 4493 parturients receiving epidural analgesia Epidural: 0.125%, %, and 0.04% Boluses >3 had an odds ratio for cesarean section of 2.3 as compared to those who received 2 or less Hess PR. Anesth Analg 2000;90:881

24 Pain Panni MK. Anesthesiology 2003;98:957
Dystocia – abnormal progress of labor MLAC – minimum local analgesic concentration 57 nulliparous patients assigned to vaginal delivery or cesarean section MLAC in CS – 0.10% MLAC in VD – 0.08% Panni MK. Anesthesiology 2003;98:957

25 Risk Factors for Failed Epidural
Meta-analysis and systematic review of 13 trials Possible risks: Duration of epidural analgesia CSE vs epidural Cervical dilation at placement BMI Risk factors of failed epidural Breakthrough pain/Number of boluses (>2 boluses) Enhanced urgency for cesarean delivery Care being provided by non-obstetric anesthesiologist Bauer ME. Int J Obstet Anesth 2012;21:294

26 Did the Epidural Catheter Migrate?
211 parturients with epidural catheters Measured length of catheter in space at taping and at removal 114 catheters (54%) migrated during labor 80 outward and 34 inward 26 moved greater than 2 cm Crosby ET. Can J Anaesth 1990;37:789-93

27 Did the Epidural Catheter Migrate?

28 Quality of Analgesia and Catheter Migration
Migrating Catheter Stable Catheter Total Good Analgesia 91 82 173 Poor 26 12 38 117 94 211

29 Did My Catheter Become Dislodged?
153 parturients undergoing epidural analgesia 1 cm migration resulted in no effect on success 2.5 cm migration resulted in 6 failed epidurals Risk of catheter migration Weight, BMI, depth of epidural space Bishton IM. Anaesthesia 1992;47:610-2

30 What is the most common cause of one-sided analgesia?
A. inadequate local anesthetic B. patient lying on side C. transforaminal escape D. catheter located in anterior epidural space

31 One Sided Block: Etiology
236 lumbar epidural patients 7 developed unilateral loss (repeat epidural) Epidurography (inject 0.5 to 4 ml contrast dye) 4 catheters located in anterior epidural space 3 catheters located paravertebral Asato F. Anesth Analg 1996;83:519-22

32 Anterior Epidural Space

33 One Sided Block: Etiology
35 parturients with epidural anesthesia or analgesia underwent epidurograms 10 without complications (control) 18 unsatisfactory blocks 7 complicated blocks (subdural, subarachnoid) Collier CB. Int J Obstet Anesth 1996;5:19-31

34 One Sided Block: Etiology
Transforaminal Escape (5) Midline Barrier (5) Dorsomedian connective tissue band Dorsal midline septum Epidural fat Spinal Deformity (2) Catheter Malfunction (4) Normal (2) Collier CB. Int J Obstet Anesth 1996;5:19-31

35 CONSIDER Repeat the epidural, general anesthesia, spinal anesthesia
Spinal anesthesia following failed epidural anesthesia is a hotly debated subject

36 Epidural Volume Extension
Spinal anesthesia may be extended by administering fluid into the epidural space normal saline local anesthetic Compression on the intrathecal space McNaught AF. Int J Obstet Anesth 2007;16:346

37 If the epidural injection fails to provide satisfactory anesthesia, I would do:
A. general anesthesia B. spinal anesthesia C. repeat epidural anesthetic D. combined spinal/epidural anesthetic

38 Spinal Anesthesia Following Failed Epidural Anesthesia
Author Pt Ht (cm) Pt Wt (kg) Epid Inject Spinal Inject Outcome Dell 158 78 45cc 0.5% Bup 12.5 mg Bup Intubated Stone 153 54 33cc 0.5% bup 8 mg Bup Goldstein 162 96 ? 40mg lido 167 67 20+cc 0.25% bup 30 mg lido High level Metts 155 98 11.2 mg bup

39 Spinal Anesthesia Following Failed Epidural Anesthesia
Author Pt Ht (cm) Pt Wt (kg) Epid Inject Spinal Inject Outcome Furst 175 78 34cc 2% lido 12mg bup intubated 165 71 20+cc 2% lido 9mg bup High level 25 cases 1 intubation Beck 150 52.6 32cc 0.5% bup 10mg bup 69.5 18cc 0.5% bup 12.5mg bup

40 Spinal Anesthesia Following Failed Epidural Anesthesia
Appropriate to adjust dose of spinal anesthetic by % 28 patients for cesarean section 1.6 ml 0.5% hyperbaric bupivacaine spinal Group A – no injection; Group B – 10 cc bupivacaine; Group C – 10 cc saline Group B & C higher but quality the same, both faster than A Blumgart C. Br J Anaesth 1992;69:457

41 Largest Series of Spinal Following Failed Epidural
636 spinal anesthetics over a 4 year period 508 no epidural, 128 had epidural before No difference in incidence of total spinals or high spinal block (1 high spinal in each group) No difference in amount of ephedrine, hypotension, or Apgars Visser WA. Can J Anesth 2009;56:577

42 What Would I Do? Cesarean section is starting
Clearly, not working, convert to general anesthesia considering the airway Mild discomfort Consider sedation Nitrous oxide Ketamine Fentanyl Midazolam Propofol

43 What Would I do? IF there is time prior to starting…and you find a patchy block after 15mL bolus of lidocaine, options are: Pull back catheter 1cm and bolus another 5mL Remove epidural and perform spinal with lower intrathecal dose Remove epidural and perform CSE with lower intrathecal dose Remove and replace epidural Provide a general anesthetic

44 What Would I Do? In the literature, 8 of the high spinals after failed epidural had drug dosages presented: Seven received amounts greater than 20 cc There are 118 cases of successful spinal anesthesia following failed epidural I would not give additional epidural medication if spread is already fairly questionable I would perform a spinal anesthetic with a 25% decrease in dose and keep the patient sitting up a little longer than usual

45 Summary For Failed Epidural
Recognize the failed epidural early in the course Consider spinal anesthesia Consider the airway and risks of GA(aspiration, awareness, failed intubation) Consider the risk of PTSD from high spinal/patchy epidural Most cases result from denial early in labor; it is not a failure to admit failure

46 Thank you! Questions?


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