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Anesthetic Management of Patients undergoing Postpartum Tubal Ligation: A Retrospective Analysis
Abstract Number: F-15
Abstract Type: Original Research
Introduction: The optimal anesthetic technique and timing for postpartum tubal ligation (PPTL) remains controversial. (1, 2) The aim of this study was to evaluate the success rate of epidural catheter reactivation and compare anesthetic and analgesic outcomes among various anesthetic techniques.
Methods: We conducted a retrospective chart review of patients with ICD-9 billing codes for PPTL over a 2 year period (Aug 2012-Aug 2014). PPTLs at the time of cesarean delivery were excluded. Data collected included: demographic and obstetric characteristics; labor analgesia; timing of PPTL; anesthetic management; postpartum and postoperative pain scores and analgesic use.
Results: A flow diagram of PPTLs is provided in the Figure. 69 epidural catheters were dosed for PPTL; 18 (26%) failed to provide adequate anesthesia. Median (IQR;range) time since delivery was 20 hrs (9-27;1-36) and 13 hrs (6-19;1-50) respectively for the failed and successful epidural catheter reactivations (P=0.09). Age, BMI, epidural space depth, epidural labor analgesia duration, time since delivery, labor CSE vs. labor epidural, and obstetric vs. non-obstetric anesthesiologists were not found to be significant predictors of successful epidural catheter reactivation. There was a trend towards higher failed reactivations with more physician top-ups required during labor (P=0.07). Median [IQR] time to provide anesthesia for PPTL was 15 mins [12-21], 41 mins [33-54] and 19 mins [15-24] for successful epidural reactivation, failed epidural (with secondary anesthetic technique) and primary spinal techniques respectively (P<0.0001). There was no difference in PACU duration, hospital length of stay, pain scores, or analgesic use for any of the anesthetic techniques used.
Conclusion: We found unexpectedly high epidural catheter reactivation failure rates despite our practice of limiting the time since delivery, confirming previously well-functioning labor epidurals, and checking catheter insertion and integrity of the dressing before attempting an epidural top-up for PPTL. Failed epidural catheter reactivations resulted in significant operating room delays and unnecessary general anesthetics. Given the high failure rate and lack of reliable predictors for successful epidural catheter reactivation, the practice of leaving labor epidurals in-situ for PPTL beyond the immediate post-delivery period should be challenged.
1. J Clin Anesth 1995;7:380-383
2. Reg Anesth Pain Med 1998;23:258