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Risk Factors for Failed Conversion of a Labor Epidural to a Surgical Block for Postpartum Tubal Ligation
Abstract Number: T-21
Abstract Type: Original Research
Background: Postpartum tubal ligation (PPTL) is a popular method of birth control, and neuraxial anesthesia is routinely performed for these procedures. Since the majority of PPTL occur within 24 hours of delivery, a common practice is to attempt labor epidural reactivation for surgical anesthesia. However, the failure rate of labor epidural reactivation is 8-26%, and failure to successfully reactivate the epidural can lead to maternal morbidity and increased health care costs [1-4]. Therefore, a decision must be made to either attempt labor epidural reactivation or pull the catheter and perform the procedure under general or spinal anesthesia. The aim of this study is to identify risk factors for failed conversion of a labor epidural to a surgical block for PPTL.
Methods: This is an observational study. 73 women requesting PPTL with a labor epidural secured within 2 cm of initial placement were recruited for the study. Informed consent was obtained. Patient data including body mass index (BMI), depth at loss of resistance (LOR), number of epidural top-ups requested during labor, and patient satisfaction were recorded. All epidural catheters were tested with 3cc 1.5% lidocaine with epinephrine and then dosed with 3% 2-chloroprocaine at 5cc increments to achieve a T6 sensory level. A failed reactivation was defined as a catheter unable to achieve a T6 level, perceived pain requiring IV opioids or local infiltration by surgeon, or conversion to general anesthesia.
Results: There were 17 patients in the failed epidural group (23%) and 56 patients in the successful reactivation group (77%). Groups differed significantly by weight (p=0.032); failure: 93±21 kg / reactivation: 83±14 kg. There was a trend toward significance with LOR (p=0.067); failure: 6.5 cm (3,10) / reactivation: 6.0 cm (3,9). Groups did not differ significantly with respect to BMI (p=0.150), patient satisfaction (p=0.125), or the number of top-ups requested during labor (p=0.104). The time from delivery to PPTL did not differ between groups (p=0.627); failure: 22.3± 11.3 hr / reactivation: 18.7± 10.3 hr.
Conclusions: In this study, we were able to show a significant relationship between weight and failure to reactivate a labor epidural for PPTL. There was a trend towards significance with increasing depth to LOR and epidural failure. Our epidural failure rate was similar to previous studies at 23% for PPTL, but interestingly, we were unable to show any significant difference in regards to the interval between delivery and PPTL as previous studies indicate [1-3]. This data may be used to support either pulling an epidural in preference for a spinal in a larger parturient or reactivating an epidural despite a prolonged time since delivery.
1. Goodman EJ, Dumas SD. Reg Anesth Pain Med 1998; 23:258-61.
2. Vincent RD, Reid RW. J Clin Anesth 1993; 5:289-91.
3. Viscomi CM, Rathmell JP. J Clin Anesth 1995; 7:380-83.
4. Bucklin BA, Smith CV. Anesth Analg 1999; 89:1269-74.