Why obstetric epidurals fail: a study of epidurograms

Collier, Clive

doi:10.1016/s0959-289x(96)80070-7

Cited by 55 publications

(28 citation statements)

References 28 publications

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“…Proposed theories include slow injection of small volumes of local anesthetic, presence of an epidural septum, midline adhesions, placement of the epidural catheter through an intervertebral foramen, and placement of the epidural catheter into the anterior epidural space. 13 We have also confirmed that patient position plays a role in determining the spread of local anesthetic. Women in the lateral group had incomplete analgesia more often than women in the tilt group, and in both Groups the highest dermatomal level of analgesia was significantly higher on the left side than the right.…”

Section: Discussionsupporting

confidence: 68%

Improved epidural analgesia in the parturient in the 30° tilt position

Beilin

Abramovitz

Zahn

et al. 2000

Can J Anesth/J Can Anesth

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Purpose: To compare the incidence of incomplete analgesia when epidural local anesthetic is administered with the parturient supine in a 30° leftward tilt or in the left lateral decubitus position.Methods: After placement of a multiorifice catheter 5 cm into the epidural space, 293 women in active labour were randomly positioned either to the left lateral decubitus position (lateral group) or supine with a 30° leftward tilt (tilt group) and then received 13 mL bupivacaine 0.25%. The success of the epidural block was determined by asking the patient if she required additional medication 15 min later. The incidence of complications (fetal heart rate decelerations, hypotension, and ephedrine usage) was noted.Results: In the lateral group, 38% required additional medication compared with 24% in the tilt group (P = 0.006). There were no differences between groups in the incidence of maternal hypotension or fetal heart rate decelerations, but more women (10%) received ephedrine in the lateral than in the tilt group (4%), P = 0.035. Conclusions:Placing the parturient supine with a 30° leftward tilt is associated with a greater success rate of labour epidural analgesia without an increase in complications than in women in the left lateral decubitus position. This advantage should be considered when positioning the parturient after epidural catheter placement.Objectif: Comparer l'incidence d'analgésie incomplète lorsqu'un anesthésique local épidural est administré chez une parturiente installée en décubitus dorsal, inclinée à 30 o vers la gauche, ou en décubitus latéral gauche.Méthode : Après la mise en place d'un cathéter à orifices multiples à 5 cm dans l'espace épidural, 293 femmes en travail actif ont été installées, en décubitus latéral gauche (groupe latéral), ou en décubitus dorsal avec une inclinaison de 30 o vers la gauche (groupe incliné) et ont reçu 13 mL de bupivacaïne à 0,25 %. La réussite du blocage épidural a été établie en demandant aux patientes, 15 min plus tard, si l'analgésie était suffisante. L'incidence de complications (décélération de la fréquence cardiaque foetale, hypotension et usage d'éphédrine) a été notée.Résultats : Dans le groupe latéral, 38 % des femmes ont demandé des médicaments supplémentaires en comparaison de 24 % dans le groupe incliné (P = 0,006). Il n'y a pas eu de différence intergroupe quant à l'incidence d'hypotension maternelle ou de décélération de la fréquence cardiaque foetale, mais davantage de femmes (10 %) ont reçu de l'éphédrine dans le groupe latéral, comparé au groupe incliné (4 %), P = 0,035.Conclusion : L'installation d'une parturiente en décubitus dorsal, inclinée à 30 o vers la gauche, comparée à la position de décubitus latéral gauche, est associée à un taux de succès plus élevé d'analgésie épidurale pendant le travail sans complications additionnelles. C'est un avantage à considérer quand on cherche une position appropriée pour une parturiente après la mise en place d'un cathéter épidural.

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Section: Discussionsupporting

confidence: 68%

Improved epidural analgesia in the parturient in the 30° tilt position

Beilin

Abramovitz

Zahn

et al. 2000

Can J Anesth/J Can Anesth

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“…More common causes are escape of an epidural catheter through an intervertebral foramen, an obstructive septum and bony anomalies, such as scoliosis, or previous spinal surgery. 17 The aetiology of intradural injection is unknown, but one explanation may possibly involve the presence of scarring or adhesions in the epidural space or dural and arachnoid membranes following previous catheter insertion. Long-term epidural catheter use is known to be associated with fibrosis in the epidural space.…”

Section: Discussionmentioning

confidence: 99%

The intradural space: the fourth place to go astray during epidural block

Collier

2010

International Journal of Obstetric Anesthesia

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“…Sin embargo, la analgesia resultante puede no ser satisfactoria ( Fig. 1) en aproximadamente el 3,5-32% de las pacientes [3][4][5][6][7][8][9] , incidencia bastante mayor que en el caso de los pacientes quirúrgicos (2-4%) 10,11 , en gran parte debido a los cambios anatómicos acaecidos durante la gestación (aumento de peso, edemas, dificultad de flexión y de localización del espacio epidural, ingurgitación de las venas epidurales...). La etiología de la analgesia inadecuada epidural obstétrica es multifactorial y no se ha determinado completamente (Tabla 2).…”

Section: Diagnóstico Y Tratamiento Del Fracaso De La Técnica Epiduralunclassified

“…A menudo se atribuyen a alteraciones anatómicas del espacio epidural, aunque no debemos olvidar que puede ser por un fallo del emplazamiento del catéter, como el escape transforaminal del catéter, que se manifiesta como un bloqueo parcial limitado a uno o dos dermatomas, y que proporciona analgesia sólo en una pequeña área, acompañado a veces de un bloqueo simpático lumbar unilateral y cierta debilidad del cuádriceps 7 .…”

Section: Analgesia Parcheadaunclassified

Técnicas analgésicas para el parto: alternativas en caso de fallo de la epidural

Ortiz-Gómez

Palacio-Abizanda

Fornet-Ruiz

2014

Anales Sis San Navarra

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Se insiste en la necesidad de aplicar una aproximación terapéutica multifactorial a la embarazada, no limitándonos solo a eliminar el dolor del parto.Palabras clave: Analgesia obstétrica. Dolor del parto. Epidural. Analgesia controlada por el paciente. Remifentanilo. AbsTrAcTEpidural analgesia is now the method of choice for the treatment of pain in labour and delivery. However, this technique may fail and provide inadequate or null alleviation to the mother. This paper reviews the risk factors, possible causes and possible therapeutic alternatives to inadequate analgesia, whether pharmacological therapies (neuroaxial, peripheral blocks or analgesic administration via intravenous or inhalational routes) or non-pharmacological ones (relaxation techniques, psychological or mechanical).In all possible cases the efficacy and indications of alternative therapies based on the published literature are reviewed, especially from the point of view of evidence-based medicine.The need is underscored of a multifactorial therapeutic approach to the pregnant woman, not just restricting ourselves to eliminating the pain of childbirth.

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Why obstetric epidurals fail: a study of epidurograms

Cited by 55 publications

References 28 publications

Improved epidural analgesia in the parturient in the 30° tilt position

Improved epidural analgesia in the parturient in the 30° tilt position

The intradural space: the fourth place to go astray during epidural block

Técnicas analgésicas para el parto: alternativas en caso de fallo de la epidural

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