Monitoring epidural analgesia in the parturient

Appropriate monitoring during obstetric epidural analgesia consists of: 1. Indirect BP and pulse monitoring before epidural insertion, frequently after every dose, and intermittently thereafter. 2. The aspiration test before all injections. 3. Frequent clinical monitoring for signs of intravascular injection during administration of small intermittent doses (not more than 3-5 ml at a time). 4. Frequent clinical monitoring for sympathetic, sensory and motor signs indicating upward extension of the block. 5. Frequent monitoring of the fetal heart rate (FHR) and other signs of fetal welfare. In many instances continuous tocogram with fetal heart rate (CTG) monitoring is useful. We do not believe CTG use is mandatory for epidural analgesia in the uncomplicated pregnancy, but we do advocate that it (and other appropriate fetal monitoring techniques) be used when risk factors or complications, either fetal or maternal, are present or suspected. The anaesthetist should be familiar with fetal monitoring techniques, their use and interpretation. He or she should be prepared to recommend their use when it is considered appropriate to do so.     

Bupivicaine-fentanyl epidural analgesia for a parturient in status asthmaticus

Regional anaesthesia is a suitable technique for the management of the asthmatic parturient. We report the case of an asthmatic gravida in labour in whom prompt institution of bupivacaine-fentanyl epidural analgesia was associated with enhancement of the effectiveness of concurrent medical therapy for bronchospasm. Prior to the initiation of epidural blockade, inhaled atropine was employed in an effort to reduce parasympathetic tone in the bronchial smooth muscle. Sustained clinical improvement did not occur until after delivery of the fetus and placenta.     

Patient-controlled epidural analgesia in a parturient with hypertrophic obstructive cardiomyopathy

We describe the use of patient-controlled epidural analgesia (PCEA) using fentanyl in the management of a labouring parturient with hypertrophic obstructive cardiomyopathy (HOCM). With non-invasive monitoring, PCEA was started in the early first stage of labour with a bolus dose of fentanyl 20 microg, lockout 5 min and 4-h maximum dose of 500 microg. Analgesia was satisfactory during the early first stage but was poor subsequently, despite a total fentanyl consumption of 760 microg during the 6-h labour. The maternal cardiovascular condition was stable throughout labour and delivery and the baby was born in good condition without subsequent respiratory depression. Opioid-based PCEA is an alternative to systemic analgesia in labouring parturients with HOCM. However, although its use avoids the potential adverse effects of sympathetic block associated with conventional epidural analgesia, our regimen had limited analgesic efficacy in the latter stage of labour.     

Bacterial meningitis following combined spinal–epidural analgesia for labour

We report a case of Streptococcus salivarius meningitis following combined spinal–epidural analgesia for labour. Although rare, bacterial meningitis following combined spinal–epidural anaesthesia is being increasingly described. We review the previously reported cases and discuss the possible aetiological causes and the aseptic precautions likely to reduce the incidence of infectious complications.     

Paraplegia following epidural analgesia

A case of neurological damage associated with lumbar epidural block is presented. Muscle paralysis and sensory loss were found in the immediate postoperative period and there was partial recovery of muscle power. The possible mechanisms of nerve damage are discussed.     

The use of a paraspinal field block before epidural analgesia for labour

The purpose of this study was to determine whether paraspinal field block (PSFB) reduced the pain of epidural needle insertion and the incidence of prolonged post partum back pain in patients receiving epidural analgesia for labour. Patients were randomly assigned to receive local infiltration only with 1-1.5 ml of 1.5% lidocaine (group C, N = 27) or PSFB consisting of an additional 1 ml of 1.5% (group S, N = 30) through the midline skin wheal, on either side of the midline (total 2 ml), near the lamina, before needle insertion. Back pain was measured at the time of needle insertion, before discharge from hospital and 6 weeks post partum, by a blinded observer. There were no differences between groups in maternal or neonatal demographic data. There was no difference in back pain at any of the times measured. The incidence of severe back pain 6 weeks post partum was 0% in group C and 6.6% in group S (combined incidence group C+group S = 3.5%). The cause of post partum back pain is multifactorial and is not dependent on technique of epidural insertion. We conclude that PSFB is ineffective in reducing the pain of epidural needle insertion in labouring patients. Although this study was too small to detect a difference in incidence of late post partum back pain, it appears to be less common than previously reported.     

A Staphylococcus aureus paraspinal abscess associated with epidural analgesia in labour

A case is described in which a parturient developed a Staphylococcus aureus paraspinal abscess following epidural analgesia in labour. We compared this case with other reported cases of paraspinal abscesses in obstetric patients. The presentation, diagnosis and management of these cases were reviewed. Anaesthetists need to be aware that non-spinal-epidural abscesses can occur in patients with an associated labour epidural.     

Failed epidural analgesia in a parturient with advanced ankylosing spondylitis: a novel explanation

Purpose

Ankylosing spondylitis (AS) is a chronic progressive multisystemic disease. Patients with AS present a specific set of anesthesia-related challenges, and the parturient with AS presents particular anesthetic considerations. We report our experience with a parturient with advanced AS and offer a novel explanation for the high incidence of epidural failures in this patient population.

Clinical features

We present the case of a 36-yr-old primigravida parturient with a very difficult airway and a history of severe AS. The initial treatment plan was to use a continuous epidural for labour analgesia. Despite two successful placements of lumbar epidural catheters, adequate rostral spread of local anesthesia to control her labour pain was never achieved via the epidural route. Thus, continuous spinal anesthesia was used, which provided effective labour analgesia in this patient.

Conclusion

We hypothesize that this patient??s advanced calcified posterior longitudinal ligament caused a physical barrier to rostral spread of local anesthesia solution within her epidural space. This hypothesis is supported by a recent study highlighting the importance of this ligament in allowing adequate distribution of solution within the epidural space. In addition, the successful use of continuous spinal analgesia adds to the growing body of literature supporting the safety and efficacy of intrathecal catheters for labour analgesia in specific situations.     

A paraspinal abscess following spinal anaesthesia for caesarean section and patient-controlled epidural analgesia for postoperative pain

We present a rare case in which a healthy parturient developed a paraspinal abscess after spinal anaesthesia for caesarean section and epidural analgesia for postoperative pain management. The catheter was in situ for 58 h. Backache was the initial and major symptom. A concealed course with no neurological deficit resulted in a delayed diagnosis and treatment in this case. The infection was not diagnosed until 20 days after the removal of the epidural catheter when there was a purulent discharge from the epidural puncture site. Surgical drainage was required. Anaesthesiologists should be aware that serious epidural analgesia-related infections can happen in extra spinal-epidural spaces. Vigilance for these infections, especially in postpartum patients with backache, is needed.     

Transient blindness following epidural analgesia

A 43-year-old woman was given an epidural injection of steroid mixed with local anaesthetic, under general anaesthesia, for treatment of low back pain. In the recovery room she complained of blindness in one eye. Fundoscopy revealed retinal and vitreous haemorrhages in both eyes. Retinal haemorrhages can be caused by an increase in intracranial pressure and are therefore a possible complication of epidural anaesthesia.