advancesInLaborAnalgesia

advancesInLaborAnalgesia - Advances in Labor Analgesia Luis...

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Unformatted text preview: Advances in Labor Analgesia Luis Lahud, M.D. Norman Bolden, M.D. Department of Anesthesiology MetroHealth Medical Center May 3 rd , 2005 Cleveland, OH Contents Introduction PCEA CSE Pros Cons Review article Protocols and Cocktails Discussion INTRODUCTION From 1985 to present use of epidural analgesia for labor has increased from 10% to over 50% of laboring women in the U.S. Advances include low dose epidurals, walking epidurals, PCEA, and CSE Early: increased doses of LA = increased SE PDPH 7-10% OB/GYN perspective Adding opioids < MB Walking epidurals: < MB meant better outcomes No evidence of improved labor pattern/outcome with ambulation Women dont walk even if they can Monitoring problems Techniques that allow walking may be better whether or not patient ambulates Effect of Low-Dose Mobile vs. Traditional Epidural Techniques on Mode of Delivery: A Randomized Controlled Trial COMET Study, Lancet 2001 1054 nulliparous women were randomized into 3 groups to receive either a traditional epid (0.25% BUP), a low-dose CSE, or a low-dose infusion epid Increased rate of normal vaginal delivery with CSE and low-dose infusion Decreased rate of instrumental vaginal delivery Increased rate of CS with traditional epidural PCEA Introduced in 1988 Small basal dose PCEA less med overall PCEA VS. CONTINUOUS Gambling et al., Can J Anaesth 1988 Epidural initiated: 8 ml 0.25% BUP 0.125% BUP PCA: 4 ml basal, 4 ml bolus, Lockout 20 min, 16 ml/hr max CIEA: 12 ml/hr infusion PCEA VS. CONTINUOUS Gambling et al., Can J Anaesth 1988 PCEA (n=14) CIEA (n=11) ______________________________________________________________ Duration (h) 7.0 0.6 5.8 0.6 # demands/hr 1.9 0.4 1.2 0.2 Dose of BUP/hr 11.2 0.85 15.2 0.5 PCEA + CI vs. PCEA only Both groups provide good analgesia Both use less than continuous No benefit with basal rate over demand only Ferrante et al. 1994 Background infusion increases drug use by 30% No obvious benefit in pain relief Background infusion decreases physician top-ups Only physician administer top-ups associated with hypotension BACKGROUND VS. DEMAND ONLY? Ferrante et al. 1994 Group N CI (ml/h) DD (ml) Lockout (min) BUP/hr (mg)-1rst stage BUP/hr (mg)-2nd stage # Physician visits/doses DO 15 3 10 9.7 1.3 6.7 1.5 12 4.2 CI (3) 15 3 3 10 11.8 1.4 8.9 0.8 8.3 3 CI (6) 15 6 3 10 11.7 0.9 12.2 1.0 1.6 1.2 CI (12) 15 12 N/A 16.0 0.7 16.7 1.1 7.0 3.1 Bupivacaine 0.125% with 2 mcg/ml fentanyl Loading dose: 0.5% bupivacaine for S5 T10 level PCEA compared to CEI in an ultra-low- dose regimen for labor pain relief : a randomized study Eriksson, Gentele and Olofsson Acta Anaesthesiologica Scandinavica 2003 80 parturients (40 per group) Ropivacaine 0.1% + SUF 0.5mcg/ml Test dose + 5ml loading dose PCEA: 4ml doses, 20min lockout CEI: 6ml/hr Rescue: 5ml if VAS > 5...
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advancesInLaborAnalgesia - Advances in Labor Analgesia Luis...

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