Ultrasound in Obstetric Anaesthesia-Neuraxial Blockade

Dr John Loughrey

The Rotunda HospitalDublin

•Dober dan

•To bo dobro predavanje !

Labour Epidural Rates

The Rotunda Hospital 67%

USA 66%

Ireland 33%

Europe 25%

‘labour results in severe pain for many

women. There is no other circumstance where it is considered acceptable for a person to experience untreated severe pain,

amenable to safe intervention, while under a physician's care.’

American College of Obstetrics & Gynecology

Methods of Maintaining Epidural Analgesia

• Intermittent ‘Top-Ups’• Continuous infusions (8-12 mls/hr)• Patient Controlled (PCEA)

– ± Background infusion

Epidural Patient-Controlled Analgesia

PCEA use: ~40% USA

Bucklin BA. Anesthesiology 2005;103:645-53Bucklin BA. Anesthesiology 2005;103:645-53

PCEA vs Continuous Epidural infusion van der Vyver. BJA. 2002

• 9 Studies of 640 patients• Continuous vs PCEA with no basal rate• PCEA groups

– Less local anaesthetic– Less leg weakness– Fewer anaesthetic interventions

Benefits of Minimising Local Anaesthetic Usage

• Patient Satisfaction• Ability to Void increased• Less Hypotension • Obstetric Outcome improved• Ambulation

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Ultrasound in Obstetric Anaesthesia

• Central Vascular Access• Abdominal field blocks eg: TAP• Pre-Anaesthesia clinic eg: scoliosis• Neuraxial Imaging• Pain Procedures eg: Sacroiliac/ Symphysis Injection

– Arch Physical Med & Rehab. Sept 2007.88(9) E45-6.– SOAP. 2009. A-206. Shannon J, Harmon D.

Technique

Equipment Cost

“In the kingdom of the blind, the one-eyed man is King.”

D. Erasmus 1466-1536.

“An idiot with an ultrasound probe is still an idiot.”

“ Evidence on Ultrasound-guided catheterisation of the epidural space is limited in amount, but suggests that it is safe and may be helpful in achieving correct placement.”

Ultrasound in Neuraxial Anaesthesia

• Identifying Correct Lumbar Interspace• Identifying Skin Puncture site• Measuring depth to Epidural Space• Identifying aberrant Anatomy

Lumbar Interspace Selection

Schlotterbeck H, Schaeffer R, Dow WA, et al (2008). Ultrasonographic control of the puncture level for lumbar neuraxial block in obstetric anaesthesia. British Journal of Anaesthesia 2008; 100: 230-4.

Reynolds F (2001). Damage to the conus medullaris following spinal anaesthesia. Anaesthesia 2001; 56: 238-247.

Technique

Technique

Technique

Efficacy of ultrasound imaging in obstetric epidural anesthesia . J Clin Anesth. 2002Thomas Grau, Rudiger Wolfgang Leipold , Renate Conradi, Eike Martin , Johann Motsch.

Ultrasound Using the Transverse Approach to the Lumbar Spine Provides Reliable Landmarks for Labor Epidurals. Anesthesia & Analgesia. May.2007.Cristian Arzola, Sharon Davies, Ayman Rofaeel, Jose Carvalho.

Arzola et al. A&A. May 2007.

May2008

Gaining Experience

• Appropriate specification equipment• Use in non-neuraxial anaesthesia• Outpatient evaluations• Pre-puncture imaging

“ Gentlemen…this is no humbug!”

Hvala lepa !