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Retrospective analysis of the safety and efficacy of epidural fentanyl bolus immediately prior to cesarean delivery
Abstract Number: T-42
Abstract Type: Original Research
A well-functioning labor epidural is often used to deliver surgical anesthesia for a cesarean delivery. In addition to a concentrated local anesthetic, many providers also administer a bolus dose of fentanyl through the epidural to improve the quality of pain relief for cesarean delivery. This may decrease the need for intraoperative supplementation or conversion to general anesthesia. There is concern, however, that larger boluses of epidural fentanyl administered just prior to delivery lead to adverse neonatal outcomes. The limited data that currently exists shows no difference in neonatal Apgar scores with a bolus dose of 100 mcg epidural fentanyl administered prior to cesarean delivery (Hong et al., J Kor Med Sci, 2010 Feb;25(2):287-92). However, more sensitive measures of potential opioid effect including the need for supplemental oxygen, positive pressure ventilation (PPV), intubation, or umbilical cord gas results have not been investigated. The aim of this retrospective chart review is to examine the effect of epidural fentanyl on maternal and neonatal outcomes when administered to a pre-existing labor epidural for cesarean delivery anesthesia.
A retrospective chart review from June 2012 to December 2016 yielded 770 patients who had a labor epidural dosed to provide surgical anesthesia for cesarean delivery. Primary maternal outcomes included the need for supplemental IV sedation/analgesia and conversion to general anesthesia. Primary neonatal outcomes included Apgar scores, umbilical artery cord gases, and need for intraoperative support or resuscitation (supplemental oxygen, PPV, intubation, chest compressions). Data were compared for those who received an epidural fentanyl bolus before delivery to those who did not.
In the group who received an epidural fentanyl bolus, there was a lower rate of propofol sedation (0% vs 2.1%, p=0.04). There was no difference in any other maternal outcome between the two groups including conversion to general anesthesia before delivery and need for additional analgesia.
In the group who did not receive an epidural fentanyl bolus, there was a higher rate of neonatal intubation (5.2% vs 1.9%, p=0.047) and a greater base deficit via uterine artery blood gas (-3.7 vs -3.1, p=0.04). However, there was no difference in the need for blow-by oxygen, PPV, or other resuscitative measures.
Based on the retrospective data presented, administration of an epidural fentanyl bolus prior to cesarean delivery is not associated with adverse maternal or neonatal outcomes. Moreover, the need for intraoperative sedation with propofol may be decreased. One potential limitation of the study is that urgency of cesarean delivery is not accounted for. This may explain the increased rate of intubation and worse base deficit in the group who did not receive an epidural fentanyl bolus prior to delivery due to time limitations.