Umfrage zur aktuellen Situation der Regionalanästhesie im deutschsprachigen Raum

The practice of regional anaesthesia in German speaking countries was investigated by a survey. The last part of the trilogy contains the presentation and evaluation of the data about the methods in obstetric anaesthesia. In 2002 questionnaires were mailed to 750 randomly selected departments of anaesthesia, 384 hospitals (51.2%) responded of which 278 had an obstetric unit. Caesarean section rate was 22.5+/-8.2% and for elective caesarean section spinal anaesthesia was mostly used. General anaesthesia was never used in 58.3% of Swiss, 10.2% of German, and 21.1% of Austrian hospitals. For non-elective caesarean section 42.1% of the hospitals often used a spinal anaesthesia, and 44.8% sometimes, in Switzerland these were 92.9% and 7.1%, respectively. Pain relief for labour was usually achieved with epidural anaesthesia or drugs. The trend from general to regional anaesthesia for caesarean section is continued, as is the trend from local infiltrative techniques to epidural anaesthesia for vaginal delivery. Switzerland was in the forefront for these developments.     

Emergency Caesarean section: best practice

Good multidisciplinary communication is crucial to the safe management of women requiring non-elective Caesarean section. Anaesthetists should participate actively in resuscitation of the fetus in utero; relief of aortocaval compression is paramount. Epidural top-up with levobupivacaine 0.5% is the anaesthetic of choice for women who have been receiving labour epidural analgesia. If epidural top-up fails to provide bilateral light touch anaesthesia from S5 - T5, a combined spinal-epidural technique with small intrathecal dose of local anaesthetic is a useful approach. Pre-eclampsia is not a contra-indication to single-shot spinal anaesthesia, which is the technique of choice for most women presenting for Caesarean section without an epidural catheter in situ. Induction and maintenance doses of drugs for general anaesthesia should not be reduced in the belief that the baby will be harmed. Early postoperative observations are geared towards the detection of overt or covert haemorrhage.     

Practice of epidural analgesia for labour pain: a German survey.

Epidural analgesia is one of the preferred methods of analgesia for labour. The aim of the present survey was to evaluate current practice in obstetric analgesia in departments of anaesthesia and to make a comparison with former surveys from Germany and other countries. Questionnaires on the practice of pain relief, especially epidural analgesia, during labour and delivery were sent to 1178 anaesthetic departments in Germany in the second half of 1996. Five hundred and thirty-two completed replies were received, which represent 46.9% of all German obstetric units. The majority of the departments of anaesthesia practising epidural analgesia have an epidural rate of less than 10% and 10.2% of the departments do not offer this method to their parturients. In 86.8% of all units performing epidural analgesia, the epidural catheter is placed by an anaesthetist. Only 6.5% of the units provide a 24-h epidural service which is exclusively assigned to labour and delivery. In 77.8% of the units, this service is not exclusively assigned to obstetrics, but also to other duties. Of the obstetric units offering epidural analgesia, 14.7% have no epidural service at night. Plain local anaesthetics for epidural analgesia are used by 55.9% of the departments, a combination of local anaesthetics with epidural opioids by 28.7%. Epidural analgesia is predominantly (82.2%) maintained by intermittent bolus administration. Although the rate of epidural analgesia increased during recent decades, this method is not offered to all parturients. Further improvements in the use of epidural analgesia for labour seem to be necessary.     

Analgesie und Anästhesie zur Geburtshilfe in der Schweiz 1999

QUESTION: This survey investigated the common practice of obstetric analgesia and anaesthesia in Swiss hospitals and evaluated the influence of the Swiss interest group for obstetric anaesthesia. METHODS: In March 1999 we submitted 145 questionnaires to all Swiss hospitals providing an obstetric service. RESULTS: The rate of epidural analgesia (EA) was higher in large hospitals (> 1,000 births/year) than in small services. EA was maintained by continuous infusion techniques in 53% of the responding hospitals. For elective caesarean section, spinal anaesthesia (SA) and EA were performed in 77% and 16% of the patients, respectively. General anaesthesia (5%) was only used in small hospitals (< 500 births/year). Emergency caesarean section was performed under SA in 75% of all hospitals and only in 25% was a general anaesthesia used. An already existing EA for labour analgesia was continued for anaesthesia for caesarean section in 63% of Swiss hospitals. CONCLUSIONS: Regional anaesthesia was most commonly used for obstetric anaesthesia in Swiss hospitals. Epidemiological studies, recommendations of the Swiss interest group for obstetric anaesthesia, as well as the expectations of pregnant women, increased the numbers of regional anaesthesia compared with the first survey in 1992.     

A comparison of postoperative analgesia following spinal or epidural anaesthesia for Caesarean section

Postoperative analgesia, using a patient-controlled analgesia system, was studied in 32 women after elective Caesarean section performed under either spinal or epidural anaesthesia. Patients who had spinal anaesthesia had significantly higher pain scores and morphine consumption during the first 4 h postoperatively than patients who had epidural anaesthesia. This situation was reversed between 4 to 8 h postoperatively with patients who had had epidurals having significantly higher pain scores despite higher morphine consumption. After 8 h there was little difference in pain scores or morphine use between the two groups. Total morphine consumption in the first 24 h postoperatively was not significantly different between the two groups.     

Walking epidurals: mobilisation during neuraxial labour analgesia

Neuraxial anaesthesia offers the most effective form of obstetric pain relief and is superior to other methods of analgesia, and it does not increase the risk of caesarean section. In daily practice, various techniques are used including the options of patient-controlled epidural analgesia (PCEA) and combined spinal epidural analgesia (CSEA). Risk information is one of the prerequisites for 'informed consent'. Omitting the epidural test dose and using low-dose local anaesthetics with lipophilic opioids enhances early mobilisation.     

Challenges that opioid-dependent women present to the obstetric anaesthetist

A retrospective casenote review was performed to identify anaesthetic challenges relevant to the opioid-dependent obstetric population. Medical records showed that of the 7,449 deliveries during a 24 month period, 85 women (1.1%) were taking regular opioids such as methadone and/or heroin. Of these 67 (79%) received anaesthetic services, ten of whom (11.7%) were referred antenatally. Forty opioid-dependent women (47%) received epidural analgesia in labour compared with the overall hospital rate of 38%. Twenty-three women (27%) delivered by caesarean section: five received general anaesthesia, five combined spinal anaesthesia, five spinal anaesthesia and eight epidural anaesthesia. Twenty opioid-dependent women (23.5%) had documented problems related to labour analgesia and 17 (74%) had problems with analgesia after caesarean section. A variety of postoperative analgesia methods were administered in addition to maintenance methadone. Fourteen patients (16.5%) had difficult intravenous access and seven "arrest" calls were documented. One anaesthetist was exposed to hepatitis C. This review demonstrates the demands placed on obstetric anaesthetic services by opioid-dependent women. Early antenatal referral for anaesthetic review is recommended.     

Sciatic nerve palsy following childbirth

Two cases are reported of sciatic nerve palsy after delivery by Caesarean section in primigravidae. One mother was slender and had an emergency Caesarean section for failure to progress with a breech presentation. Epidural analgesia during labour was extended for operative delivery. The other mother was obese, mildly hypertensive, had a large baby with a high head and was delivered by elective Caesarean section under epidural anaesthesia. She experienced severe intrapartum hypotension. Both patients suffered right sided sciatic nerve palsy. The aetiologies of obstetric palsies and those following regional block are reviewed and the importance of careful diagnosis and of avoiding peripheral nerve compression during regional block are emphasised.     

Dorsal column function after epidural and spinal blockade: implications for the safety of walking following low-dose regional analgesia for labour

Walking after regional blockade for labour using low-dose combinations of bupivacaine and fentanyl is possible due to the maintenance of lower limb motor power. In order to investigate concerns that dorsal column function, important in maintaining balance, is impaired after such techniques, clinical assessment of lower limb proprioception and vibration sense was evaluated in parturients after either low-dose epidural ( n  = 30) or spinal blockade ( n  = 30) for labour analgesia and compared with spinal anaesthesia ( n  = 30) for elective Caesarean section using a larger total dose of local anaesthetic. Of the patients receiving low-dose regional labour analgesia 7% ( n  = 4) had abnormal dorsal column function compared with 97% ( n  = 29) receiving spinal anaesthesia for Caesarean section (p < 0.001). All patients in the Caesarean section group developed lower limb motor weakness, compared with only 10% ( n  = 6) in the low-dose groups (p < 0.001). There were no significant differences between the low-dose groups with respect to sensory block, motor block or dorsal column function. Overall, 90% of patients receiving low-dose bupivacaine/fentanyl regional labour analgesia had both normal lower limb motor power and dorsal column function. Assessment of these parameters is recommended before allowing patients to walk after low-dose regional techniques for labour.     

A survey of obstetric an aesthesia practice in Flanders

The use of locoregional anaesthesia in obstetrics in Flanders was assessed by a postal questionnaire sent to the directors of the anaesthesia departments of the 72 hospitals with an obstetric unit. 59 (82%) answers were returned. In the group of parturients who had a vaginal delivery a neuraxial technique was requested by 65% of the patients and consisted of epidural analgesia in 84%, and combined spinal epidural analgesia in 16%. Test doses are used in labour in 67%. To perform the block--spinal as well as epidural--the sitting position is somewhat preferred over the left lateral (55 versus 45%). For caesarean section general anaesthesia was used in only 5% of the deliveries, whereas spinal, single or as a part of a CSE technique, was preferred in 80%; the epidural technique was applied in 15%. There is no clear preference in technique for postoperative analgesia after caesarean delivery as both parenteral and epidural analgesia are used in 50% of the cases.     

Anaesthetic management of labour and delivery in the parturient with mitochondrial myopathy

Purpose

We describe the anaesthetic management for Caesarean section in a parturient with a defect in complex III of the respiratory chain who had increased lactate concentrations at rest and with exercise.

Clinical features

We administered effective epidural anaesthesia with lidocaine for Caesarean delivery. The serum lactate concentration was less than the preoperative value both during and after surgery. Shivering during the perioperative period was avoided by administering warm iv fluids, warm local anaesthetic solution and epidural meperidine. Pain relief after surgery was provided with iv PCA morphine augmented by local infiltration with bupivacaine to fascia and skin edges and epidural injection with meperidine.

Conclusion

Mitochondrial myopathies are an uncommon group of disorders in which mitochondrial dysfunction leads to clinical disease of muscle and sometimes of other organs with high energy requirements. The management of labour and delivery in women with mitochondrial myopathies should be individualized according to severity of disease and formulated by consultation between attending physicians and the anaesthetist. Epidural analgesia reduces stress and work associated with labour and reduces oxygen demand during labour. However, parturients with defects of the respiratory chain with documented increased lactate concentrations at rest and with exercise are best managed with elective Caesarean delivery with regional anaesthesia to prevent life-threatening lactic acidosis during labour. The association between malignant hyperthermia and these disorders has not been proved, but it appears prudent to consider these women as MH susceptible until definitive data regarding this possible relationship are available.     

Epidural analgesia-anaesthesia in obstetrics

Epidural analgesia is the most effective and innocuous technique for obstetrics. Pain relief is its main indication but maternal diseases that might be decompensated by labour and delivery are also accepted indications. Low doses of long-acting local anaesthetics alone or in combination with low doses of fentanyl or sufentanil provide good quality analgesia and are safe for mother and fetus. Test doses in parturients lack sufficient specificity and sensitivity for detecting inadvertent intravascular injection, and subarachnoid migration of the catheter is possible at any time during the procedure. Therefore, every injection must be considered as a test dose and only fractionated injections must be made. Epidural block to T10 is needed for labour and to level T4 for Caesarean section. Maintenance of the block with a continuous infusion, or patient-controlled epidural analgesia with a background continuous infusion, provides more stable analgesia than by intermittent injection. Technical difficulties, dural tap, bloody tap, hypotension and insufficient block are most frequent complications of epidural block in obstetrics. Excessive motor block prolongs the second stage of labour and increases the frequency for instrumental delivery and is therefore considered a complication.     

A history of neuraxial administration of local analgesics and opioids

The history of intrathecal and epidural anaesthesia is in parallel with the development of general anaesthesia. As ether anaesthesia (1846) is considered the first modern anaesthetic since its use by Morton 157 yr ago, so Bier made history by using cocaine for intrathecal anaesthesia in 1898. The first published report on opioids for intrathecal anaesthesia belongs to a Romanian surgeon, Racoviceanu-Pitesti, who presented his experience at Paris in 1901. It was almost a century before the opioids were used for epidural analgesia. Behar and his colleagues published the first report on the epidural use of morphine for the treatment of pain in The Lancet in 1979. Epidural and intrathecal opioids are today part of a routine regimen for intra- and postoperative analgesia. Over the last 30 yr, the use of epidural opioids has became a standard for analgesia in labour and delivery, and for the management of chronic pain. Finally, epidural opioids have been shown to have a pre-emptive effect, when used before major surgery. We present the evolution of neuraxial anaesthesia and the history of intrathecal and epidural administration of opioids.     

Patient-controlled epidural fentanyl following spinal fentanyl at Caesarean section

Spinal fentanyl can improve analgesia during Caesarean section. However, there is evidence that, following its relatively short-lived analgesic effect, there is a more prolonged spinal opioid tolerance effect. The effectiveness of postoperative epidural fentanyl analgesia may therefore be reduced following the use of spinal fentanyl at operation. This randomised, double-blind study was designed to assess whether patient-controlled epidural fentanyl could produce effective analgesia following 25 microg of spinal fentanyl at operation. Patients undergoing elective Caesarean section received spinal bupivacaine combined with either fentanyl 25 microg (fentanyl group; n = 18) or normal saline (saline group; n = 18). Patient-controlled epidural fentanyl was used for postoperative analgesia. The fentanyl group used a mean of 23.4 (SD 14.5) microg x h(-1) of fentanyl, compared with 27.0 (10.8) microg x h(-1) for the saline group (p =0.41). Using a 0-100 mm visual analogue score for pain, the maximum pain score recorded at rest for the fentanyl group was median 24 [IQR 15-35] mm, compared with 15 [13-45] mm for the saline group (p = 0.41). The maximum pain score recorded on coughing for the fentanyl group was 29 [24-46] mm, compared with 27 [19-47] mm for the saline group (p = 0.44). Nine of the fentanyl group rated postoperative analgesia as excellent and nine as good, compared with 10 of the saline group who rated it as excellent and eight as good (p = 0.74). Epidural fentanyl can produce effective analgesia following the use of 25 microg spinal fentanyl at Caesarean section.     

Aktuelle Praxis der Analgesie in der Geburtshilfe an den deutschen Universitätsklinika Ergebnisse einer Umfrage 1996. Teil 2

Obviously there is a world-wide trend towards regional analgesia for pain relief during delivery. Data on the current practice in Germany are lacking. Methods: In 1996 questionnaires on obstetric anaesthesia and analgesia were mailed to all university departments of anaesthesia. Results: All 38 university hospitals with obstetric units replied (100%). Mean annual delivery rate was 1156. Epidural analgesia (EA) (n=22), intramuscular injection of opioids (n=18), and non-opioids as a suppository (n=17) were often used for pain relief during labour. Intravenous injections (n=12) or pudendus anaesthesia (n=7) were practised as well. Entonox (N₂O/O₂), paracervical blocks or transcutaneous electrical stimulation (TENS) was rarely used. EA for relief of labour pain was offered in all university hospitals. Twelve of them had an epidural rate of less than 10%, in nine the rate was 10–19%, in eight hospitals 20–29% and 30% or more in nine. Indication for EA was a demand by the parturient (n=34), by the obstetrician (n=26) or the midwife (n=18), predominantly because of prolonged labour (n=32) or significant pain (n=21). Half of the university departments used an epidural combination of local anaesthetics (bupivacaine) and opioids (sufentanil (n=12) and/or fentanyl (n=9)). In all but one department the application of an epidural catheter was performed by anaesthesiologists exclusively. In some hospitals obstetricians (n=10) or midwives (n=4) were allowed to give epidural top-up injections. Of the 38 university departments 11 had an anaesthesiologists on duty 24 h a day responsible for the obstetric unit exclusively. Conclusion: In 1977, 14 of 18 university departments of anaesthesiology offered epidural analgesia for parturients. This option was available in all university departments in 1996. A mean rate of 10–20% epidurals for vaginal delivery is well within the limits reported from other countries, whereas the rate of regional anaesthesia for scheduled caesarean section (40%) still is rather low in Germany, as reported in part 1 of this survey (Anaesthesist 1998; 47:59–63).     

Patient-controlled spinal analgesia for labour and caesarean delivery

Continuous spinal anaesthesia has not been widely used in Australia. Epidural anaesthesia is often inadequate in patients with previous spinal surgery, as distribution of local anaesthetic in the epidural space is unpredictable. Two cases are presented where continuous spinal anaesthesia enabled satisfactory analgesia and anaesthesia to be obtained for labour and caesarean delivery respectively.     

Anaesthesia for Caesarean section in a patient with myotonic dystrophy receiving warfarin therapy

A 31-yr-old parturient with myotonic dystrophy and asthma presented for elective Caesarean section. The patient was receiving warfarin having had two previous episodes of thromboembolism. Anticoagulation was subsequently provided by heparin in the weeks prior to delivery. The combination of the patient’s medical conditions and the continuing need for anticoagulation presented a considerable anaesthetic problem in planning anaesthesia and analgesia for both elective and emergency delivery. Heparin was discontinued on the day prior to surgery and restarted immediately after surgery. During surgery flowtron anti-embolitic boots were used. Warfarin therapy was recommenced on the seventh postoperative day. Anaesthesia for Caesarean section was provided using a combined spinal epidural technique using a separate needle, separate interspace method. Postoperative pain was relieved by using a continuous epidural infusion, transcutaneous nerve stimulation and diclofenac. No new neurological problems arose despite the use of epidural analgesia in the presence of heparin anticoagulation. This method of providing anaesthesia and postoperative analgesia without the use of opioids in an anticoagulated, asthmatic, myotonic parturient has not been described elsewhere.     

Failed epidural: causes and management

Failed epidural anaesthesia or analgesia is more frequent than generally recognized. We review the factors known to influence the success rate of epidural anaesthesia. Reasons for an inadequate epidural block include incorrect primary placement, secondary migration of a catheter after correct placement, and suboptimal dosing of local anaesthetic drugs. For catheter placement, the loss of resistance using saline has become the most widely used method. Patient positioning, the use of a midline or paramedian approach, and the method used for catheter fixation can all influence the success rate. When using equipotent doses, the difference in clinical effect between bupivacaine and the newer isoforms levobupivacaine and ropivacaine appears minimal. With continuous infusion, dose is the primary determinant of epidural anaesthesia quality, with volume and concentration playing a lesser role. Addition of adjuvants, especially opioids and epinephrine, may substantially increase the success rate of epidural analgesia. Adjuvant opioids may have a spinal or supraspinal action. The use of patient-controlled epidural analgesia with background infusion appears to be the best method for postoperative analgesia.     

L'anesthésie comme cause de souffrance fœtale ?

ObjectiveTo describe the effects of anaesthetic techniques and agents on the risk of foetal distress during labour pain relief and anaesthesia for caesarean section.Study designData on obstetric anaesthesia- and analgesia-induced fœtal distress were searched in Medline database using Mesh terms: foetal distress, anaesthesia, analgesia, labour, caesarean section, and umbilical artery pH. Trials published in English or French language were selected.ResultsBecause of their haemodynamic effects, regional anaesthesia and analgesia, especially spinal anaesthesia for Caesarean section, could induce a decrease in umbilical artery pH (UApH). Moreover, intravenous ephedrine, especially when used in large doses can worsen the acidosis. Labour epidural analgesia is associated with a better acid-base balance than systemic analgesia. Experimental studies have demonstrated harmful effects of systemic opioids and hypnotic drugs on UApH and the foetal brain respectively. Clinical implications of these potentially detrimental effects remain to be determined.ConclusionAll obstetric anaesthesia and analgesia techniques are associated with a theoretical risk of fetal distress, but given the fact that regional anaesthesia techniques are also associated with well-demonstrated benefits for the mother and the newborn, the latter remain the preferred choice in obstetric practice.     

Obstetric anaesthesia in Hungary

A nation-wide survey of pain relief in childbirth in Hungary was carried out in 1993. Information was provided on 104 137 deliveries in 98 units. The frequencies of different methods of pain relief for vaginal delivery were as follows: systemic opiates in 7387 cases (8.3%), epidural analgesia in 4611 cases (5.2%) and inhalational analgesia (nitrous oxide) in 4470 cases (5%). Epidural analgesia was available in 36 units (36.7%). For 71 744 vaginal deliveries (80.5%) no pain relief was provided at all. For caesarean section (n = 13240) the rate of spinal or epidural anaesthesia was 36.7%. It was concluded that despite an increasing rate of pain relief in labour elsewhere, the numbers of epidurals are still rather low in Hungary.