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Interscapular Pain associated with Epidural Anesthesia for Labor & 2 Different Outcomes
Abstract Number: RF4BD-227
Abstract Type: Case Report Case Series
Interscapular pain associated with medication administration may complicate the management of epidural anesthesia. Knowing how to effectively manage this complication can help provide effective analgesia to laboring patients.(1,3) We present two patients who had severe interscapular back pain associated with epidural anesthesia with different outcomes.
Patient A was a 24 yo G4P3 who presented at 39w1d. Patient B was a 34 yo G1P0 who presented at 38w0d. Epidural anesthesia with patient controlled epidural analgesia (PCEA) was initiated in both patients in anticipation of spontaneous vaginal delivery. In both patients, the epidural space was found with loss of resistance to saline. Each had adequate labor analgesia for the first 8 hours of their labor until developing interscapular pain. Management strategies following the onset of pain in these patients included adjusting epidural infusion rates, bolus injections of local anesthetics and opioids via epidural catheter, and ultimately replacing their epidurals with a combined spinal epidural (CSE). Patient A had resolution of pain symptoms following replacement with CSE and had adequate epidural analgesia for cesarean section. Interestingly patient B, had initial relief of labor pain following replacement with CSE, but redeveloped interscapular pain and had inadequate analgesia. She ultimately underwent general anesthesia for cesarean. There were no long term adverse outcomes associated with either patient.
It is critical to treat all types of pain in the peripartum period as this may help avoid adverse outcome to the mother and fetus. Interscapular pain associated with epidural analgesia is uncommonly reported and little is understood on the mechanism of this anesthetic complication. It is important to understand the different management strategies for epidurals that are not giving patients pain relief and may actually be causing more harm than benefit.(1,2,3) Proposed mechanisms include increased epidural pressure from increased volume or poor compliance, visceral pain that may not be related to the epidural itself, loss of resistance technique with saline versus air.(1,2,3) Patient positional changes, replacement of epidural, and delivery of infant have been reported to relieve pain in some cases.(3) Further investigation into patients who are at risk may find patients who experienced prior episodes of interscapular pain, prior complication with epidural, prolonged labor with epidural. Understanding when to adjust medications, dosing and rates, the epidural catheter versus replacing the epidural catheter, can help avoid undesired labor outcomes and may provide more effective epidural anesthesia for our patients.
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Rajanna P. Anaesthesia 1989; 44: 1014.
McKeown KJ et al. Int J Obstet Anesth 2010; 19: 463-4.