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Institution of Remifentanil PCA Protocol in a Large Academic Institution
Abstract Number: S1C-5
Abstract Type: Case Report/Case Series
Introduction: Epidural anesthesia is still considered the gold standard for labor analgesia. However, in the setting congenital AV malformations, it is important to consider alternatives to epidural analgesia; specifically using a remifentanil PCA and the protocol associated with implementation.
Case: A 22-year-old, G1P0, with a history of Klippel-Trenaunay-Weber syndrome at 38 weeks for induction of labor due to oligohydramnios at term. MRI with contrast for AVM’s of the spine was unable to be completed prior to labor. The patient continued to have labor pains despite trials of Nalbuphine and Butorphanol. After discussion with OBGYN team, remifentanil PCA was started at 20 mcg Q 5 min, with 1 to 1 nursing, auxiliary oxygen via nasal cannula at 2L. We made the concentration at 5mcg/ml so standard fentanyl PCA template settings could be used. PCA was using successfully used for labor pains and during subsequent laceration repairs.
In our institution, similar to most institutions, the majority of laboring patients desire an epidural for labor pain. However, in a subset of the labor population there can be a contraindication to place a labor epidural, in our case it was due to systemic AVMs. In patients unable to have a labor epidural, remifentanil PCA has proven to be a safe alternative (1). Remifentanil PCA is ideal as it is has rapid onset (within 1 minute) is eliminated quickly in neonates by redistribution and rapid metabolism (1). The rapid metabolism of remifentanil allows the PCA to be used safely in a laboring patient for a prolonged duration of time without worry of the drug building up as it has a low context-sensitive half-life (3 minutes) over a prolonged period of time.
Our case highlights the basic foundation needed to form a safe protocol for the institution of a remifentanil PCA. The first hurdle was mixing the solution at 1000 mcg/200 ml and to have the initial settings at 0.2mcg/kg with a lockout of Q5 minutes. The second backbone to the institution of remifentanil PCA was to have dedicated 1 to 1 nursing to monitor for respiratory depression, which is also the reason we had the patient on continuous oxygen via nasal cannula at 2L and continuous pulse oximetry. One additional step that could have been made was to have end tidal CO2 if the patient was at high risk for respiratory depression. In an effort to minimize drug interactions or inadvertent drug administration we also started the PCA on a dedicated second IV either 20g or 22g. As remifentanil has a rapid onset and reaches a steady state quickly, an anesthesia provider should be in the room for the first 15 minutes the PCA is started to evaluate for effectiveness and side effects.
1. Devabhakthuni, Sandeep. “Efficacy and Safety of Remifentanil as an Alternative Labor Analgesic.” Clinical medicine insights. Women’s health 6 (2013): 37–49. PMC. Web. 29 Jan. 2018.