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Combined Spinal Epidural Versus Single Shot Spinal for Postpartum Tubal Ligation With Intrathecal Isobaric Bupivacaine 0.5%: A Retrospective Review
Abstract Number: T2H-254
Abstract Type: Original Research
A predicted shortage of hyperbaric bupivacaine 0.75% prompted the Society for Obstetric Anesthesia and Perinatology (SOAP) to issue an advisory suggesting that isobaric bupivacaine (IB) 0.5% be used in doses of 2.5-2.6 ml when combined with opioids or up to 3.0 ml when not combined with opioids for cesarean delivery (CD) spinal anesthesia1. While there was no specific mention of postpartum tubal ligations (PPTL), we used the CD recommendations as a proxy and recommended that a combined spinal epidural (CSE) be used in place of a single shot spinal (SSS), a departure from our practice. Our hypothesis was that subjects who received CSE for PPTL would have a lower conversion rate to GA compared to subjects who received SSS.
We used billing data from our electronic medical record to search for subjects undergoing PPTL from April 1, 2018 to November 30, 2018. Subjects were included if IB 0.5% was used as a spinal anesthetic for PPTL. Demographic data was recorded along with the dose in ml of IB, dose of subarachnoid opioids, whether a CSE or SSS was used, use of anesthetic adjuncts, and whether the subject needed conversion to GA.
63 subjects met inclusion criteria and 12 (19.0%) required conversion to GA. 28 and 35 subjects had CSE and SSS for PPTL, respectively. One CSE subject and 11 SSS subjects required conversion to GA, corresponding to conversion rates of 3.7% and 31.4%, for the respective groups (p=0.0051). No subjects with SSS had a subsequent epidural placed after a failed spinal anesthetic and nine CSE subjects received supplemental epidural analgesia. Table 1 describes the demographics and clinical variables of the two groups.
The advantage of the CSE over the SSS is the ability to provide supplemental epidural anesthesia if the spinal component fails. Anesthesiologists who chose CSE had a statistically and clinically significant lower rate of conversion to GA despite no difference in IB 0.5% spinal dose. CSE should strongly considered over SSS as an anesthetic technique when IB 0.5% is used as a spinal anesthetic for PPTL.
Society for Obstetric Anesthesia and Perinatology. Society for Obstetric Anesthesia and Perinatology (SOAP) Advisory in Response to Shortages of Local Anesthetics in North America. https://soap.org/2018-bupivacaine-shortage-statement.pdf Published April 2018. Accessed January 30, 2019.