Must we press on until a young mother dies? Remifentanil patient controlled analgesia in labour may not be suited as a “poor man’s epidural”

Abstract

BackgroundThe epidural route is still considered the gold standard for labour analgesia, although it is not without serious consequences when incorrect placement goes unrecognized, e.g. in case of intravascular, intrathecal and subdural placements. Until now there has not been a viable alternative to epidural analgesia especially in view of the neonatal outcome and the need for respiratory support when long-acting opioids are used via the parenteral route. Pethidine and meptazinol are far from ideal having been described as providing rather sedation than analgesia, affecting the cardiotocograph (CTG), causing fetal acidosis and having active metabolites with prolonged half-lives especially in the neonate. Despite these obvious shortcomings, intramuscular and intravenously administered pethidine and comparable substances are still frequently used in delivery units.Since the end of the 90ths remifentanil administered in a patient-controlled mode (PCA) had been reported as a useful alternative for labour analgesia in those women who either don’t want, can’t have or don’t need epidural analgesia.DiscussionIn view of the need for conversion to central neuraxial blocks and the analgesic effect remifentanil has been demonstrated to be superior to pethidine. Despite being less effective in terms of the resulting pain scores, clinical studies suggest that the satisfaction with analgesia may be comparable to that obtained with epidural analgesia. Owing to this fact, remifentanil has gained a place in modern labour analgesia in many institutions.However, the fact that remifentanil may cause harm should not be forgotten when the use of this potent mu-agonist is considered for the use in labouring women. In the setting of one-to-one midwifery care, appropriate monitoring and providing that enough experience exists with this potent opioid and the treatment of potential complications, remifentanil PCA is a useful option in addition to epidural analgesia and other central neuraxial blocks. Already described serious consequences should remind us not refer to remifentanil PCA as a “poor man’s epidural” and to safely administer remifentanil with an appropriate indication.SummaryTherefore, the authors conclude that economic considerations and potential cost-savings in conjunction with remifentanil PCA may not be appropriate main endpoints when studying this valuable method for labour analgesia.

Intravenous Remifentanil Analgaesia for an Obstetric Patient with Type I Neurofibromatosis and a Factor V Leiden Mutation

“…meperidine) or inhaled nitrous oxide are usually considered instead. 10 However, previous research indicates that remifentanil is more effective than either of these options. 7 In a multicentre study of pregnant women with FVL deficiency, Martinelli et al noted a significant increase in the prevalence of venous thrombosis both during and after pregnancy.…”

“…[7][8][9][10] Tolerance and hyperalgaesia have also been described. 7,8 The concurrence of type I NF and FVL deficiency in a pregnant patient is an unusual challenge both from an obstetric point of view and in relation to the choice of analgaesia.…”

“…Although the use of remifentanil is gradually becoming more common among obstetric patients, it is still a subject of some debate. [7][8][9][10] Moreover, remifentanil infusions are rarely reported among obstetric patients with comorbidities. In cases similar to the one described in this report, intramuscular or intravenous analgaesia with opiates (i.e.…”

Commentary to "Remifentanil for labour pain relief"

“…Experts have pointed out "significant side effects" and recommend very scrupulous and continuous monitoring of vital signs, as stated by Van Der Velde in his article in Current Opinion in Anesthesiology of March 2015 entitled "Patient-controlled intravenous analgesia remifentanil for labor analgesia: time to stop, think and reconsider. " [9,10].…”

“…However, it should also be pointed out that during the second decade of the 21st century, opinions as to the administration of this drug are no longer so clear [4,9,10].…”