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Labor epidural analgesia to cesarean section anesthetic conversion failure: a national survey in the United Kingdom
Abstract Number: T2I-76
Abstract Type: Original Research
Background: Conversion of labor epidural analgesia to surgical anesthesia for cesarean delivery can fail  and management of this situation continues to be debated . Our aim was to determine the most common obstetric anesthesia practice in this context.
Methods: All members of the Obstetric Anaesthetists’ Association in the United Kingdom were emailed an online survey in May 2017. It obtained information on factors influencing the decision to utilize an existing labor epidural for cesarean section and, in scenarios where epidural top up resulted in no objective sensory blockade, bilateral T10 sensory block or unilateral T6 sensory block, factors influencing management and selection of anesthetic technique. Differences in management options between respondents were compared using chi-square test.
Results: We received 710 survey questionnaires with an overall response rate of 41%. Most respondents (89%) would consider topping up a labor epidural for category one cesarean section. In evaluating whether or not to top up an existing labor epidural, the factors influencing decision making were how effective the epidural had been for labor pain (99%), category of cesarean section (73%) and dermatomal level of blockade (61%). In the setting of failed epidural top up, the most influential factors were the category of cesarean section (92%), dermatomal level of blockade (78%) and assessment of airway. Spinal anesthesia was commonly preferred if epidural top up resulted in no objective sensory blockade (74%), bilateral T10 sensory block (57%) or unilateral T6 sensory block (45%) (Table 1). If the sensory block level was higher or unilateral, then a lower dose of intrathecal local anesthetic was selected and alternative options such as combined-spinal epidural and general anesthesia were increasingly favored. Complications related to a repeat neuraxial technique after failed epidural top up were reported by a significant number of respondents. Twenty eight (4%) and 250 (35%) respondents, for instance, reported having encountered either a high or total spinal after a combined spinal-epidural and spinal, respectively.
Conclusions: Our survey revealed variations in the clinical management of a failed epidural top up for cesarean delivery, suggesting guidelines to aid decision making are needed.
1. Mankowitz SKW, et al. Anesth Analg 2016;123:1174-80.
2. Carvalho B. Anaesthesia 2012;21:357-9.