2015 Sol Shnider, MD Obstetric Anesthesia Meeting Syllabus

224 Pages·2015·18.51 MB·English

2015 Sol Shnider, M.D.
Obstetric Anesthesia Meeting
The premier review meeting for clinical
obstetric anesthesia, established in 1976
Syllabus
Jointly provided by American Society of Anesthesiologists
and the Society for Obstetric Anesthesia and Perinatology
March 12-15, 2015
Grand Hyatt Hotel on Union Square
San Francisco, California
Welcome to the SOAP 2015 Sol Shnider, M.D.
Obstetric Anesthesia Meeting
Sol Shnider, M.D., Samuel C. Hughes, M.D., and Mark A. Rosen, M.D., from the
University of California San Francisco first offered an obstetric anesthesia meeting in
beautiful San Francisco almost 40 years ago. SOAP is proud to continue the tradition
those pioneers began, once again hosting the Sol Shnider, M.D. Obstetric Anesthesia
Meeting March 13-15, 2015. The day before the program there will be the Fetal Heart
Rate Monitoring Interpretation Workshop at the hotel or the High Risk Simulation
Workshop on the UCSF campus.
Sincerely,
Barbara M. Scavone, M.D.
SOAP Immediate Past President and Program Chair
Table of Contents
2 Welcome Program Materials
3 Program Committee Friday, March 13, 2015
9 Session I: Update Your Practices
3 Program Faculty
46 Session II: What’s New?
4-5 Program Information
Saturday, March 14, 2015
5 Faculty Disclosures
60 Session III: Clinical Challenges
127 Session IV: Labor Analgesia and Beyond
6 Pre-Meeting Workshops
170 Session V: Managing Your Practice
Information
Sunday, March 15, 2015
7-8 Program Schedule
196 Session VI: Difficulties and
Controversies
Program
Back to Table of Contents
Faculty
Committee
Barbara Scavone, M.D. Alexander Butwick, MBBS, FRCA, Jill Mhyre, M.D.
Chair M.S. University of Arkansas for Medical Sciences
University of Chicago Stanford University School of Medicine
Michael Orosco, M.D.
Brendan Carvalho, M.B., B.Ch., FRCA, Brendan Carvalho, M.B., B.Ch., FRCA, Kaiser Permanente San Diego Medical
M.D.C.H. M.D.C.H. Center
Stanford University School of Medicine Stanford University School of Medicine
Craig Palmer, M.D.
Robert D’Angelo, M.D. Robert D’Angelo, M.D. University of Arizona
Wake Forest University School of Medicine Wake Forest University School of Medicine
Mark Rollins, M.D., Ph.D.
Robert Gaiser, M.D. Robert Gaiser, M.D. Univeristy of California San Francisco
University of Pennsylvania Health and University of Pennsylvania Health and
Barbara Scavone, M.D.
Sciences Sciences
University of Chicago
McCallum Hoyt, M.D., M.B.A. Gillian Hilton, M.B., Ch.B., FRCA
Scott Segal, M.D.
Cleveland Clinic Foundation Stanford University School of Medicine
Tufts Medical Center
Lisa Leffert, M.D. Lisa Leffert, M.D.
John Sullivan, M.D., M.B.A.
Massachusetts General Hospital Massachusetts General Hosptial
Northwestern University Feinberg School
Michael Orosco, M.D. David Liang, M.D., Ph.D. of Medicine
Kaiser Permanente San Diego Medical Center Stanford University School of Medicine
Lawrence Tsen, M.D.
Mark Rollins, M.D., Ph.D. Elliott Main, M.D. Brigham & Women’s Hospital
University of California San Francisco Sutter Pacific Medical Foundation
Lawrence Tsen, M.D.
Brigham & Women’s Hospital
Future Meetings
SOAP 47th Annual SOAP 2016 Sol Shnider, M.D. SOAP 48th Annual
Meeting Obstetric Anesthesia Meeting Meeting
May 13-17, 2015 March 10-13, 2016 May 18-22, 2016
The Broadmoor Grand Hyatt Hotel Seaport Boston Hotel
Colorado Springs, CO San Francisco, CA Boston, MA
Program Information Back to Table of Contents
Jointly Provided by:

Mission of SOAP Mission of SOAP Program Committee
The mission of this Society is to improve the pregnancy-related outcomes of
The mission of the Society’s Program Committee is to provide anesthesiologists,
women and neonates through the support of obstetric anesthesiology research, the
obstetricians, and other physicians and members of related allied health specialties
provision of education to its members, other providers, and pregnant women, and
with the knowledge that will reinforce past learning as well as disseminate new
the promotion of excellence in clinical anesthetic care.
concepts, practices, and skills involving anesthesia and analgesia for the pregnant
woman.
ACCME Accreditation
Participation in the SOAP 2015 Sol Shnider, M.D.
This activity has been planned and implemented in accordance with the
accreditation requirements and policies of the Accreditation Council for Continuing Obstetric Anesthesia Meeting
Medical Education (ACCME) through the joint providership of the American Society
of Anesthesiologists and the Society for Obstetric Anesthesia and Perinatology. Attendance shall be open to all health practitioners, provided that they have
The American Society of Anesthesiologists is accredited by the ACCME to provide registered for the meeting. CME credit will only be offered to M.D.s, D.O.s, and AAs
continuing medical education for physicians. or the equivalent. CE credit will be offered to CRNAs.
The American Society of Anesthesiologists designates this live activity for a Evaluations
maximum of 26.5 AMA PRA Category 1 Credits™. Physicians should claim only
the credit commensurate with the extent of their participation in the activity. Electronic evaluations by questionnaire will address program content,
presentations, and possible bias.
AANA Credits
Special Needs Statement
(Program offering Friday through Sunday)
This program has been approved by the American Association of Nurse Anesthetists The Society for Obstetric Anesthesia and Perinatology is committed to making its
for 19.25 CE credits; Code Number: 1030757; Expiration Date: 3/15/2015. activities accessible to all individuals and fully complies with the legal requirements of
the Americans with Disabilities Act and the rules and regulations thereof. If you are in
need of an accommodation, please do not hesitate to call the SOAP office at
Fetal Heart Rate Monitoring Interpretation
414-389-8611 and/or submit a description of your needs in writing to [email protected].
Pre-Meeting Workshop Designation
Statement of Need
This workshop has been approved by the American Association of Nurse
Anesthetists for 3 CE credits; Code Number: 1030759; Expiration Date: 3/12/2015. The SOAP Sol Shinder, M.D. Obstetric Anesthesia Meeting provides a forum
devoted exclusively to obstetric anesthesia at which leaders in the field present
High Risk Simulation recent clinical updates and other relevant clinical information.
Pre-Meeting Workshop Designation
Commercial Support Acknowledgement
This workshop has been approved by the American Association of Nurse
Anesthetists for 4 CE credits; Code Number: 1030758; Expiration Date: 3/12/2015. This CME activity is supported by educational grants. A complete list of supporters
will be available in the course syllabus.
Target Audience
Disclosure
This meeting is intended for specialists in anesthesiology to include
anesthesiologists, nurse anesthetists, residents and fellows. Pediatricians, The American Society of Anesthesiologists remains strongly committed to
neonatologists, perinatologists, obstetricians, general practitioners, delivery room providing the best available evidence-based clinical information to participants of
nurses, nurse midwives, and clinical pharmacologists may also find educational this educational activity and requires an open disclosure of any potential conflict
benefit. The program is generated from member requests and an assessment of of interest identified by our faculty members. It is not the intent of the American
need by the program committee. Attendance at this meeting does not guarantee Society of Anesthesiologists to eliminate all situations of potential conflict of
competency or proficiency in the performance of any procedures which may be interest, but rather to enable those who are working with the American Society
discussed or taught during the meeting. of Anesthesiologists to recognize situations that may be subject to question by
others. All disclosed conflicts of interest are reviewed by the educational activity
course director/chair to ensure that such situations are properly evaluated and,
Educational Format
if necessary, resolved. The American Society of Anesthesiologists educational
CME activities may include the following formats: plenary sessions, debates, standards pertaining to conflict of interest are intended to maintain the professional
lectures, problem-based learning, and skill-set workshops. autonomy of the clinical experts inherent in promoting a balanced presentation of
science. Through our review process, all American Society of Anesthesiologists
CME activities are ensured of independent, objective, scientifically balanced
presentations of information. Disclosure of any or no relationships will be made
available for all educational activities.
Disclaimer
The information provided at this CME activity is for continuing education purposes
only and is not meant to substitute for the independent medical judgment of
a healthcare provider relative to diagnostic and treatment options of a specific
4 patient’s medical condition.
Program Information Back to Table of Contents
SOAP is proud to offer the 2015 Sol Shnider, M.D. Obstetric Anesthesia Meeting, which was first
established by Dr. Sol Shnider, Dr. Sam Hughes and Dr. Mark Rosen in 1976. The 2015 Sol Shnider
Meeting promises to be an exceptional CME program. The content is based on evolving practice
and latest information from the national society, scientific meetings and peer-reviewed publications.
Exhibits will be open during the following times:
Exhibits Information
Friday, March 13, 2015: Saturday, March 14, 2015:
7:15 – 8:00 a.m. 7:15 – 8:00 a.m.
10:15 – 10:45 a.m. 9:45 – 10:15 a.m.
3:15 – 3:45 p.m. 3:25 – 3:55 p.m.
Disclosures
Back to Table of Contents
Key
Each presenter is required to disclose the existence of any financial
interest and/or other relationship(s) (e.g. employee, consultant, 1 Salary 4 Equity Position 7 Consulting Fees
grant recipient/research support) he/she might have with a.) the
manufacturer(s) of any commercial product(s) to be discussed during his/ 2 Ownership 5 Stock Options 8 Honoraria
her presenation and/or b.) the commercial contributor(s) of the activity. 3 Royalties 6 Funded Research 9 Other Material
Support
Planner/Faculty Disclosure
Alexander Butwick, MBBS, FRCA, Brendan Carvalho, M.B., B.Ch.,
The following planning committee members and/or faculty have indicated M.S. FRCA, MDCH
that they have relationship with industry to disclose relative to the 6 - Masimo Corp. 7 - Smiths Medical
content of this CME activity: 8 - Masimo Corp.
The following planning committee members and/or faculty have indicated that they do not have relationships with industry to disclose relative to the
content of this CME activity:
Adam Collins, M.D. Lisa Leffert, M.D. Craig Palmer, M.D. Barbara Scavone, M.D.
Robert D’Angelo, M.D. David Liang, M.D., Ph.D. Manuel Pardo Jr., M.D Scott Segal, M.D.
Maurice Druzin, M.D. Jennifer Lucero, M.D. Aleshi Pedram, M.D. Devon Smith, M.D.
Robert Gaiser, M.D. Elliott Main, M.D. Katja Radke, M.D. John Sullivan, M.D., M.B.A.
Gillian Hilton, M.B.,Ch.B., FRCA Jill Mhyre, M.D. Beth Riefe Lawrence Tsen, M.D
McCallum Hoyt, M.D., M.B.A. Michael Orosco, M.D. Mark Rollins, M.D., Ph.D. Matthew Ufberg, M.D.
Resolutions of Conflicts of Interest
In accordance with the ACCME Standards for Commercial Support
of CME, the American Society of Anesthesiologist has implemented
mechanisms, prior to the planning and implementation of this CME
activity, to identify and resolve conflicts of interest for all individuals in a
position to control content of this CME activity. 5
Pre-Meeting Workshops Back to Table of Contents
Thursday, March 12, 2015
SOAP is offering the Fetal Heart Rate Monitoring Interpretation Workshop and the High Risk Simulation Workshop the day before
the full 2015 SOAP Sol Shnider, M.D. Obstetric Anesthesia Meeting begins.
Fetal Heart Rate Monitoring
High Risk Simulation Workshop
Interpretation Workshop
Activity Director: introductory lecture, Dr. Druzin will Activity Director: DESCRIPTION
Maurice Druzin, M.D. present short vignettes of real-life Adam Collins, M.D. The workshop will use four immersive
cases from his extensive library. Jennifer Lucero, M.D. simulation scenarios to improve
(Limited to 30 participants)
Each case consists of a short clinical practitioner competency in the
Additional Workshop Instructors:
8:00 - 11:00 a.m. description, followed by a series of management of major maternal
Pedram Aleshi, M.D.
Additional Fee: $225.00 electronic fetal heart rate monitoring Lee-Lynn Chen, M.D. obstetrical events. Critical events in
reproductions. The session is an and out of the operating room will
LOCATION Katja Radke, M.D.
interactive one. Dr. Druzin will interact be presented in small groups, using
2nd Floor, Belvedere Room Devon Smith, M.D.
with the audience and ask for their high fidelity simulation as well as part
Matt Ufberg, M.D.
interpretation and advice during task simulation and the PBLD format.
DESCRIPTION each vignette. The vignette ends A.M. Session: 8:00 a.m. – 12:00 p.m. The UCSF Department of Anesthesia
The workshop will consist of an with the obstetrical outcome and a (Limited to 16 participants) simulation faculty and the division
introductory 45 minute didactic
short discussion on the methods of P.M. Session: 1:00 p.m. – 5:00 p.m. of Obstetric Anesthesiology will lead
lecture to familiarize the audience
assessing electronic monitoring and (Limited to 16 participants) each session, offering post-scenario
with the most updated guidelines for
the incorporation of this information debriefing, and expert guidance.
electronic fetal heart rate monitoring Additional Fee: $295.00
into clinical management decisions.
interpretation published by the NICHD
LOCATION
Workshop in 2010. Following the
SFGH Campus, Building 30,
2nd Floor, Suite 3200
6
Program Schedule Back to Table of Contents
FETAL HEART RATE MONITORING INTERPRETATION
Pre-Meeting Workshops:
-OR- HIGH-RISK SIMULATION
Fetal Heart Rate Monitoring Interpretation High-Risk Simulation
2nd Floor, Belvedere Room SFGH Campus, Building 30, 2nd Floor, Suite 3200
Session: 8:00 a.m. - 11:00 a.m. (Limited to 30 participants) A.M. Session: 8:00 a.m. - 12:00 p.m. (Limited to 16 particpants)
Activity Director: Maurice Druzin, M.D. P.M. Session: 1:00 p.m. - 5:00 p.m. (Limited to 16 particpants)
Activity Director: Adam Collins, M.D.; Jennifer Lucero, M.D.
Please note that registration for the workshops requires a separate, additional fee from the full
SOAP 2015 Sol Shnider, M.D. Obstetric Anesthesia Meeting registration.
1:00 - 2:15 p.m. Hosted Lunch
Friday, March 13, 2015
Grand Ballroom Foyer
Session II: What’s New?
*Opportunities for questions and answers will be provided during the panel
discussions. Moderator: Robert D’Angelo, M.D.
7:00 - 7:50 a.m. Registration and Continental Breakfast 2:15 - 2:45 p.m. Timed Intermittent Bolus Labor
Grand Ballroom Foyer Analgesia
Mark Rollins, M.D., Ph.D.
7:50 - 8:00 a.m. Welcome/Introduction
Barbara Scavone, M.D. 2:45 - 3:15 p.m. Point of Care Devices for Assessing
Hemoglobin and the Coagulation
Session I: Update Your Practices Profile
Moderator: Alexander Butwick, MBBS, FRCA, M.S. Alexander Butwick, MBBS, FRCA, M.S.
3:15 - 3:45 p.m. COFFEE BREAK
8:00 - 8:30 a.m. Continuous Spinal Labor Analgesia
Craig Palmer, M.D. 3:45 - 4:20 p.m. Perioperative Blood Management:
Updated ASA Guidelines
8:30 - 8:55 a.m. Can you do an epidural in
John Sullivan, M.D., M.B.A.
a patient with…?
Lisa Leffert, M.D. 4:20 - 5:00 p.m. Panel Discussion
8:55 - 9:25 a.m. General Anesthesia for Cesarean 6:00 - 7:30 p.m. Wine and Cheese Reception
Delivery: Time to Reevaluate? 36th Floor, Bayview/Skyline/Sunset
Craig Palmer, M.D.
Saturday, March 14, 2015
9:25 - 9:50 a.m. Epidural Anesthesia: Tricks of the
Trade
Session III: Clinical Challenges
Scott Segal, M.D.
Moderator: Scott Segal, M.D.
9:50 - 10:15 a.m. Epidural Blood Patch: An Update
Barbara Scavone, M.D. 7:15 - 8:00 a.m. Registration and Continental Breakfast
10:15 - 10:45 a.m. COFFEE BREAK Grand Ballroom Foyer
10:45 - 11:35 a.m. Pro-Con #1: Solid Food in Labor 8:00 - 8:30 a.m. Maternal Morbidity and Mortality
Let her eat cake: Craig Palmer, M.D. Elliott Main, M.D.
Nothing but clears: Scott Segal, M.D.. 8:30 - 8:55 a.m. Labor Analgesia in the Obese
11:35 a.m. - 12:20 p.m. Sam Hughes, MD Lecture: What’s New Parturient
in Clinical Obstetric Anesthesia? Barbara Scavone, M.D.
Lisa Leffert, M.D.
12:20 - 1:00 p.m. Panel Discussion
7
Program continued on next page
Program Schedule Back to Table of Contents
8:55 - 9:20 a.m. Anesthesia for Cesarean Delivery
Sunday, March 15, 2015
in the Obese Parturient
Robert D’Angelo, M.D.
9:20 - 9:45 a.m. High Spinal Prevention and
Session V: Managing Your Practice
Treatment
Moderator: Brendan Carvalho, M.B.,B.Ch., FRCA, M.D.C.H.
Robert D’Angelo, M.D.
7:15 - 8:00 a.m. Continental Breakfast
9:45 - 10:15 a.m. COFFEE BREAK Grand Ballroom Foyer
8:00 - 8:30 a.m. Cost-Effective Practice and Value-
SOAP Endowment Fund Special Session: The National
Based Delivery in Obstetric Anesthesia
Partnership for Maternal Safety
John Sullivan, M.D., M.B.A.
10:15 - 10:45 a.m. #1 The Hemorrhage Safety Bundle
8:30 - 8:55 a.m. Motivating the Rat: Managing the
Elliott Main, M.D.
Disruptive Co-worker
10:45 - 11:15 a.m. #2 The Hypertension Safety
Lawrence Tsen, M.D.
Bundle
8:55 - 9:20 a.m. From the Ivory Tower to the Real
Elliott Main, M.D.
World: Initiating New Processes,
11:15 - 11:45 a.m. #3 The Maternal Early Warning
Protocols, and Staffing in Private
System
Practice
Jill Mhyre, M.D.
Michael Orosco, M.D.
11:45 a.m. - 12:30 p.m. Panel Discussion
9:20 - 9:45 a.m. Watching Out for Ourselves
12:30 - 1:45 p.m. Lunch on Your Own Robert Gaiser, M.D.
9:45 - 10:15 a.m. Panel Discussion
Session IV: Labor Analgesia and Beyond
10:15 - 10:30 a.m. COFFEE BREAK
Moderator: John Sullivan, M.D., M.B.A.
1:45 - 2:10 p.m. What is labor pain? Session VI: Difficulties and Controversies
Robert Gaiser, M.D. Moderator: Barbara M. Scavone, M.D.
2:10 - 3:00 p.m. Pro-Con #2: CSE Labor Analgesia 10:30 - 10:55 a.m. Spinal-Induced Hypotension During
Forevermore: Barbara M. Scavone, M.D. Cesarean Delivery
Nevermore: Robert R. Gaiser, M.D. Brendan Carvalho, M.B.,B.Ch., FRCA, M.D.C.H.
3:00 - 3:25 p.m. A Perfect Epidural: On One Side! 10:55 - 11:20 a.m. Substance Abuse in Pregnancy
Lawrence Tsen, M.D. John Sullivan, M.D., M.B.A.
3:25 - 3:55 p.m. COFFEE BREAK 11:20 - 11:45 a.m. Airway Management for Maternal CPR
3:55 - 4:20 p.m. Preeclampsia: The Evolving Role Jill Mhyre, M.D.
of the Anesthesiologist 11:45 a.m. - 12:15 p.m. The Pregnant Patient with
Gillian Hilton, M.B., Ch.B., FRCA Valvular Heart Disease
4:20 - 4:50 p.m. Epidural Fever: Still A Hot Topic David Liang, M.D., Ph.D.
Scott Segal, M.D. 12:15 - 12:45 p.m. Everything Old is New Again: Nitrous
Oxide Labor Analgesia
4:50 - 5:15 p.m. Disaster Planning for Obstetrics
Gillian Hilton, M.B., Ch.B., FRCA Mark Rollins, M.D., Ph.D.
12:45 - 1:15 p.m. Panel Discussion
5:15 - 5:45 p.m. Panel Discussion
1:15 p.m. Closing Comments
Adjourn
8
Program Material
Friday, March 13, 2015 Back to Table of Contents
Session I: Update Your Practices
Moderator: Alexander Butwick, MBBS, FRCA, M.S.
Continuous Spinal Labor Analgesia
Craig Palmer, M.D.
Can you do an epidural in a patient with...?
Lisa Leffert, M.D.
General Anesthesia for Cesarean Delivery: Time to Reevaluate?
Craig Palmer, M.D.
Epidural Anesthesia: Tricks of the Trade
Scott Segal, M.D.
Epidural Blood Patch: An Update
Barbara Scavone, M.D.
Pro-Con #1: Solid Food in Labor
Let her eat cake: Craig Palmer, M.D.
Nothing but clears: Scott Segal, M.D..
Sam Hughes, MD Lecture: What’s New in Clinical Obstetric Anesthesia?
Lisa Leffert, M.D.
9
Continuous Spinal Labor Analgesia
Craig M. Palmer, M.D.
Learning Objectives: patients, spread of injected local anesthetic is often restricted
due to scarring or obliteration of the epidural space. Use of
1. Critically evaluate current literature on continuous spinal continuous subarachnoid analgesia/anesthesia may overcome
analgesia for labor. this problem.
2. Understand the benefits and risks associated with con- • Significant cardiac disease. The continuous spinal technique
tinuous spinal analgesia for labor, and application of risk/ can be used to provide excellent analgesia or anesthesia with
benefit ratios for patients. minimal hemodynamic effects. The fragile cardiovascular bal-
ance of some parturients with serious cardiac disease requires
3. Recognize patient populations particularly suitable for
that the stresses of labor, delivery, and analgesic interventions
continuous spinal analgesia during labor and delivery.
themselves, have limited impact. Continuous spinal analgesia
for labor can be managed with intrathecal opioids alone, which
4. Describe pharmacologic management of continuous
usually have negligible cardiovascular effects. For surgical anes-
spinal analgesia for labor.
thesia for delivery, local anesthetics can be administered in small
Summary: incremental doses, allowing the anesthesiologist (and patient) to
Continuous spinal anesthesia (CSA) is one of the most useful, compensate for undesirable effects.
versatile and reliable techniques available for providing analgesia
• Morbid obesity. In this group, the rate of failed induction and
and anesthesia, in both obstetric and non-obstetric populations.
cesarean delivery is high, and the need for urgent or emergent
Though the use of CSA in the obstetric population dates back
cesarean delivery during labor is higher than the non-obese
almost 7 decades, wider use and acceptance has been hampered
poulation. The rate of epidural failure is higher in morbidly
primarily by limitations of the available equipment.
obese parturients; a continuous spinal catheter provides a highly
In the early 1990’s, a resurgence of interest in the technique was reliable route to induce surgical anesthesia if required. An-
aborted by reports of cauda equina syndrome associated with the other advantage of continuous spinal techniques over epidural
use of CSA. This prompted the FDA to require the withdrawal of anesthesia is the shorter time required to know if the catheter is
all the recently marketed catheters from the market. Subsequent working as intended. Finally, the incidence of PDPH is lower in
investigation revealed that the complication was the result of this population.
local anesthetic toxicity, and was not inherent in the technique
• Difficult epidural catheter placement. This category covers both
of CSA, but few the device manufacturers were willing to submit
situations in which an unintended dural puncture occurs, and
their catheters to the lengthy and expensive FDA approval process
when the palpable landmarks for epidural placement as so poor
subsequently required.
that it becomes essentially a “blind,” best-guess needle place-
Late in the decade of the 2000’s, several reports of the use of CSA ment. In the former, the dural puncture has already occurred, so
in the obstetric population had been published, for both labor it is logical to use the CSA technique, and possibly avoid a PDPH
analgesia and cesarean delivery. All indicated that the technique by retaining the catheter for 24 hours after delivery. In the latter,
was safe and effective, with very high maternal satisfaction. The an intentional dural puncture unequivocally confirms the appro-
primary drawback to the technique is the slightly higher incidence priate placement of the catheter for subsequent use.
of post-dural puncture headache (PDPH) with CSA when com-
• Difficult airway. Though somewhat controversial, placing a
pared to epidural catheter techniques, almost entirely attributable
spinal catheter in a parturient with a difficult airway provides a
to the larger diameter of the needles and catheters used.
reliable route to safely induce surgical anesthesia, very rapidly if
Currently, only a single catheter system is being marketed for use necessary, without worry about loss of the airway.
in the U.S., though other products are available in the European
In summary, continuous spinal anesthesia can provide excellent
and Pacific Rim markets. The primary devices used for CSA in the
labor analgesia and surgical anesthesia if required, and is a very
U.S. are standard epidural catheters, advanced intentionally (or
reliable, flexible technique.
unintentionally) into the subarachnoid space.
Regrettably, CSA will probably continue to be an infrequently uti- References:
lized option in the obstetric population for the foreseeable future,
Palmer CM. Continuous spinal anesthesia and analgesia in ob-
due the limited availability of suitable catheters and reluctance of
stetrics. Anesth Analg 2010; 111:1478-79.
many practitioners to consider the technique. There are a number
of situations and comorbidities where CSA becomes an attractive Arkoosh VA, Palmer CM, Yun EM, et.al. A double-masked,
option: randomized, multi-center comparison of the safety of continuous
intrathecal labor analgesia using a 28-guage catheter versus con-
• Previous spinal surgery. A small population of patients present- tinuous epidural labor analgesia. Anesthesiology 2008;108:286-
ing for delivery have had previous surgery for correction or sta- 298.
bilization of scoliosis or other idiopathic problems, or occasion-
ally trauma. Even if the epidural space can be identified in such
10