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Intraoperative Sedation after Conversion of Neuraxial Labor Analgesia for Cesarean Delivery
Abstract Number: SA-23
Abstract Type: Original Research
BACKGROUND: Between 57-77% of patients having vaginal delivery in the US choose neuraxial labor analgesia.(1) One advantage of neuraxial labor analgesia is the ability to quickly extend the blockade for cesarean delivery (CD), thus avoiding administration of general anesthesia (GA). Unfortunately, failure to extend blockade sometimes occurs, and in those cases, clinicians may administer GA, generally considered higher risk than neuraxial in this population.(2) Alternatively, one may provide systemic or inhalational sedative/analgesic supplementation, but parturients are at increased risk for airway difficulties and aspiration,(3) and supplementation may elevate these risks, especially at high doses. Meta-analysis reveals that 5% (95% CI 3.5-6.5%) of patients having CD after neuraxial labor analgesia receive GA; risk factors include high number of epidural catheter redoses during labor, urgent vs non-urgent CD, and non-obstetric specialist anesthesiologist.(4) Supplementation occurs at a rate of 10.7% (95% CI 4.2-17.3%), but risk factors for this outcome have not been as clearly delineated as those for GA.4 We undertook this study to determine GA and systemic/inhalational supplementation rates in this clinical setting and to determine risk factors for both outcomes.
METHODS: In this IRB-approved study, as part of a departmental Quality Improvement project, we identified patients who had CD after neuraxial labor analgesia through billing records. We reviewed medical records for relevant demographic (age, BMI), obstetric (decision to incision time interval), and anesthetic (epidural vs CSE labor analgesia, duration labor analgesia, number of times patient seen by anesthesiologist per hour labor analgesia, number of redoses per hour labor analgesia, details of local anesthetic used, supplement type/dose administered, intraoperative time interval, and obstetric specialist vs non-specialist attending anesthesiologist) variables.
RESULTS: GA rate was 4.5%; supplementation rate, 53%. High-dose supplementation (other than < 2 mg Midazolam and < 100 mcg Fentanyl) occurred in 23% of cases. Risk factors for high-dose supplementation included lack of additives in local anesthetic solution and care by non-obstetric specialist faculty members. Longer duration labor analgesia increased risk of both GA and high-dose supplementation. Patients whose epidural catheters were replaced during labor had evidence of poor results intraoperatively: (40% GA, 40% high-dose supplementation).
CONCLUSIONS: Risk factors for systemic/inhalational supplementation during attempted conversion of epidural labor analgesia to CD anesthesia are similar but not identical to those for GA. Patients who require replacement of neuraxial analgesia catheters should be warned of risk for poor results after repeat neuraxial procedures.
1. Bucklin: Anesthesiology 2005;103:645
2. Hawkins: Anesthesiology 2016;124:epub ahead of print
3. McDonnell: IJOA 2009;17:292
4. Bauer: IJOA 2012;21:294