308Page 3
PATIENT CONTROLLED EPIDURAL ANALGESIA (PCEA)
PCEA may provide several advantages, including the ability to minimize drug dosage, flexibility and benefits of self administration, and reduced demand on professional time (13). This technique may be of great benefit since self control and maintenance of self esteem may be vital to a positive experience in childbirth. It has been suggested thatPCEA during labor is now a useful alternative and safe when small doses of dilute bupivacaine are administeredwith each bolus, reasonable hourly limits are prescribed, and periodic assessments by anesthesiologists are made(14). Controversy still exists regarding the use of a continuous basal infusion in addition to patient controlled boluses. Although basal infusion plus patient demand may be associated with larger doses than if the basal infusionis withheld, the addition of a basal infusion provides for a more even block and may therefore produce greater patient satisfaction.
CONTINUOUS SPINAL ANALGESIA WITH MICROCATHETERS
Due to an association with cauda equina syndrome, spinal microcatheters have been restricted by the FDA. Anongoing multi-institutional study which is being undertaken with FDA approval is evaluating the safety and efficacyof delivering sufentanil and/or bupivacaine into the intrathecal space via a 28g catheter. Although results are still preliminary, to date it appears that continuous spinal analgesia for labor using a 28g microcatheter is safe and mayoffer several advantages (15). Currently, for very high risk parturients, many anesthesiologists are using spinal“macrocatheters” (standard epidural catheters placed in the spinal space following an intentional “wet tap”).Although this technique has a high incidence of spinal headache, it gives the greatest control in providing neuraxialanalgesia and anesthesia. This topic will also be covered in a discussion of anesthesia for cesarean delivery.
NEW DRUGS
Although not in common clinical use, the following drugs have been described for neuraxial administration for laboring women:
•
Clonidine,
increased anesthesia duration and produced dose sparing when compared with ropivacainealone. There was, however, a trend towards hypotension in the clonidine group
(16).
•
Neostigmine,
Spinal neostigmine 10 mcg as an adjunct to spinal bupivacaine, clonidine, and sufentanil produced severe nausea and fails to potentiate analgesia in laboring women
(17).
•
Midazolam-2 mg preservative-free intrathecal midazolam was found to enhance the analgesic effect of fentanyl (18).
WARNING:
The formulation of midazolam commercially available in the US is not preservative-free and therefore should not be used intrathecally as it may present a risk of neurotoxicity.
NEURAXIAL ANESTHESIA FOR CESAREAN DELIVERY
The use of regional anesthesia has dramatically increased and data suggest that the use of general anesthesia for cesarean section has been steadily decreasing in the United States. Although epidural, spinal, continuous spinal andCSE techniques have all been advocated, most straightforward cesarean sections are now performed under single-shot spinal anesthesia, which has been found to be faster, provide a superior block, and be more cost effective (19).The two newer techniques, CSE and Continuous Spinal Anesthesia, will be discussed in further detail.
Combined Spinal Epidural Technique for Cesarean Delivery
The combined epidural technique, first reported as an option for cesarean section in 1984, has dramatically increasedin popularity. The advantage of this technique is that it provides rapid onset of dense surgical anesthesia whileallowing the ability to prolong the block with an epidural catheter. In addition, because the block can besupplemented at any time, the CSE technique allows the use of smaller doses of spinal local anesthetics which may,in turn, reduce the incidence of high spinal and hypotension (20). For further detail, the reader is referred to acomprehensive review of the subject by Rawal and colleagues (21).
Continuous Spinal Anesthesia
Continual spinal anesthesia has many potential advantages as compared to single shot spinal or continuous epiduraltechniques. While the classical technique required use of large bore epidural needles, a 32-gauge microcatheter inserted through a 26-gauge spinal needle was described in 1987 and subsequently removed from the market by theFDA. Since spinal microcatheters are not available for clinical use in the US, in order to perform a continuousspinal anesthetic, the anesthesiologist intentionally pierces the dura with an epidural needle and then threads theepidural catheter 3-4cm within the intrathecal space. Catheter placement can be tested by aspiration of CSF. Sincea catheter is being used, smaller doses of local anesthetic can be given in an incremental fashion. This is particularlyadvantageous in the high risk parturient such as those with cardiac disease, respiratory disease, morbid obesity, and
Leave a Comment