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The labour analgesia alphabet: CSE / DPE / EPI - what does the evidence suggest #MedThread #Tweetorial #IsraelAnes19 #OBAnes #CSEvDPE
I hope to review key literature in the development of CSE and DPE to allow readers to make their decision of what is best for their patients #MedThread #Tweetorial #IsraelAnes19 #OBAnes
Getting the drug to the site is the name of the game, fast or slow, in or out #LaborDoesntHaveToHurt #MedThread #Tweetorial #IsraelAnes19 #OBAnes
30 years ago B.Leighton hypothesized the IT admin of fentanyl and morphine would provide satisfactory labor analgesia #MedThread #Tweetorial #IsraelAnes19 #OBAnes #LaborDoesntHaveToHurt
A SSS with M&F provided reasonable analgesia for the duration of labor in many women in this case series - one igniter to jumpstart interest in IT opioids so #LaborDoesntHaveToHurt
#MedThread #Tweetorial #IsraelAnes19 #OBAnes
#MedThread #Tweetorial #IsraelAnes19 #OBAnes
Clarke et al. (1994) reported several episodes of uterine hyperactivity with fetal bradycardia following IT fentanyl #MedThread #Tweetorial #IsraelAnes19 #OBAnes
They questioned whether rapid analgesia led to rapid decrease in maternal catecholamines increasing the incidence of uterine hyperactivity #MedThread #Tweetorial #IsraelAnes19 #OBAnes
Points raised in the Eisenach (1999) CSE Review in @aln...
remain, it provides fast, reliable analgesia while the āpossibleā disadvantages continue to provide reasoning to not use the technique #MedThread #Tweetorial #IsraelAnes19 #OBAnes
remain, it provides fast, reliable analgesia while the āpossibleā disadvantages continue to provide reasoning to not use the technique #MedThread #Tweetorial #IsraelAnes19 #OBAnes
In 2001 Norris et al. Hypothesized that CSE would have no effect on the mode of delivery and anesthetic complications #MedThread #Tweetorial #IsraelAnes19 #OBAnes
This quasirandomized (pragmatic) trial provided CSE or EPI dependent on the day of the procedure #MedThread #Tweetorial #IsraelAnes19 #OBAnes
They provided analgesia dependent on the stage of labor ā¢ OB care was as per labor unit protocols #MedThread #Tweetorial #IsraelAnes19 #OBAnes
2,183 parturients were assigned to either CSE or EPI ā¢ the allocated anesthetic had NO sig effect on mode of delivery #MedThread #Tweetorial #IsraelAnes19 #OBAnes
There was no difference b/w CSE & EPI wrt accidental dural punctures, failed analgesia, or non-reassuring fetal condition #MedThread #Tweetorial #IsraelAnes19 #OBAnes
In 2002, Nelson et al. From @wake... enrolled women in a 2-phase up-down dosing finding study #MedThread #Tweetorial #IsraelAnes19 #OBAnes
The ED50 of IT fentanyl for 60 min of labor analgesia was 18mcg ā¢ the was a single transient FHR deceleration #MedThread #Tweetorial #IsraelAnes19 #OBAnes
In phase 2 women randomly received 2xED50 IT fentanyl versus known dose of IT sufentanil ā¢ side effects similar ā¢ sufentanil sig longer effect (104 v 79 min) #MedThread #Tweetorial #IsraelAnes19 #OBAnes
In 2004 @MarcVandeVelde6... et al. conducted RCT to determine if the use of IT sufentanil (7.5mcg) has a higher incidence of NRFHR #MedThread #Tweetorial #IsraelAnes19 #OBAnes
3 groups ā¢ EPI group is inadvertently DPE (ahead of his time 
) #MedThread #Tweetorial #IsraelAnes19 #OBAnes
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CSE groups (IT suf alone & LA opioid combo) provided rapid analgesia #MedThread #Tweetorial #IsraelAnes19 #OBAnes
Took 30 minutes for the EPI group to receive similar analgesia #LaborDoesntHaveToHurt #MedThread #Tweetorial #IsraelAnes19 #OBAnes
IT sufentanil (7.5mcg) did lead to greater incidence of NRFHR ā¢ BUT CSE (local+opioid) was similar to EPI group #MedThread #Tweetorial #IsraelAnes19 #OBAnes
The number of cesareans was less in the IT SUF group but this translated to more operative vaginal deliveries #MedThread #Tweetorial #OBAnes #IsraelAnes19
There was no significant difference in CD rate due to FHR issues and none of the cesareans for FHR abnormalities occurred in the first hour following labour analgesia #MedThread #Tweetorial #OBAnes #IsraelAnes19
Two fo the studies that tries to identify the correct LA and dose for CSE include Rofaeel et al. CJA 2007;54:15
Whitty et al. IJOA 2007;16:341 #MedThread #Tweetorial #OBAnes #IsraelAnes19 https://rdcu.be/bX8ea https://www.sciencedirect.com/science/article/pii/S0959289X07001252
Whitty et al. IJOA 2007;16:341 #MedThread #Tweetorial #OBAnes #IsraelAnes19 https://rdcu.be/bX8ea https://www.sciencedirect.com/science/article/pii/S0959289X07001252
Rafaeel randomized 62 women in labour to receive 2.5mg of either hyperbaric or plain bupiv both combined with 15Āµg of fentanyl as CSE. Primary outcome = failure of satisfactory analgesia within 10min #MedThread #Tweetorial #OBAnes #IsraelAnes19
Plain rather than hyperbaric solution of bupivacaine 2.5mg + fent 15mcgg provides a faster onset of analgesia, higher sensory levels & less motor block #MedThread #Tweetorial #OBAnes #IsraelAnes19
Plain group demonstrated an increased incidence of pruritus & fetal brady for >60s - a rate much higher than shown in previous studies & contradicts 2 older studies evaluating these meds where no appreciable differences was noted #MedThread #Tweetorial #OBAnes #IsraelAnes19
40 women were given CSE for labor analgesia with intrathecal plain bupiv + fentanyl 15mcg - sequential allocation designed to cluster the dose around the ED95 #MedThread #Tweetorial #OBAnes #IsraelAnes19
The combination of a lower dose of bupivacaine, 1.75mg with fentanyl 15mcg rapidly and reliably alleviated pain in the active phase of labor with a 7% incidence of transient fetal bradycardia #MedThread #Tweetorial #OBAnes #IsraelAnes19
