LEA-Mng - Unsatisfactory Epidural Block for Labor Analgesia...

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Unsatisfactory Epidural Block for Labor Analgesia Dmitry Portnoy, MD Anesthesiology Department
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Terms and Incidence of Unsatisfactory Epidural Block Term Incidence Author Year Initial failure rate 4.2% Dill-Russel P. 2001 Catheter failure rate 13.1% Eappen S. 1998 Epidural replacement rate 4.63% Pratt SD 1999 Epidural replacement rate 14.3 Segal S. 1997 Failure to produce anesthesia 4.1% Tanaka K 1993 Failed or inadequate block 0.9 to 13.1% Douglas J 2000 Failure to produce a block 1.2% Norris MC 1998 “Spotty” or unilateral anesthesia 8.2% Ducrow 1971 Inadequate anesthesia 18% Carp H. 1990 Inadequate block up to 25% Morgan BM 1983 Need for IV supplementation 38% Riley E. 1995 Intraoperative discomfort/ pain 10% to 50% Crawford J. 1976 Inadequate analgesia up to 50% Beck 1992 Incomplete analgesia 24% Beilin 1995 Intraoperative supplementation 42% Davies S. 1997 “Some discomfort” 33% Keohane M 1996 Visceral pain 56.5% Alahuhta S. 1990 Unsatisfactory block 1.5% to 21% Narang V. 1988 Unsatisfactory block 33% Michael 1990
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The Physiology of Pain in Labor 1 st stage of labor – mostly visceral Dilation of the cervix and distention of the lower uterine segment Dull, aching and poorly localized Slow conducting, visceral C fibers, enter spinal cord at T10 to L1 2 nd stage of labor – mostly somatic Distention of the pelvic floor , vagina and perineum Sharp, severe and well localized Rapidly conducting A-delta fibers, enter spinal cord at S2 to S4 T 10 L 1 S 2 S 4 http://www.manbit.com/oa/oaindex.htm
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The Intensity of Pain in Labor http://www.manbit.com/oa/oaindex.htm
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Boundaries of the Epidural Space Superior - the foramen magnum Inferior limit - the sacral hiatus and sacro-coccygeal membrane Anterior - the posterior longitudinal ligament covering the bodies of the vertebrae and the intervertebral discs Posterior - periosteum of laminae of the vertebrae and the ligamenta flava Lateral – periosteum of the pedicles and intervertebral foraminae From Cousins, Neural Blockade
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Spread of Epidurally Injected Solutions Epidurally administered drugs must travel through: dura matter arachnoid matter CSF pia matter white matter gray matter Rapid access via “dural cuff” Competing pathways: Uptake into epidural epidural fat Uptake into systemic circulation From Cousins, Neural Blockade
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This note was uploaded on 12/28/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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LEA-Mng - Unsatisfactory Epidural Block for Labor Analgesia...

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