Pharmacologic Approaches to Obstetrical Anesthesia

53 Pages·2013·10.98 MB·English

Pharmacologic Approaches to
OObbsstteettrriiccaall AAnneesstthheessiiaa
MMiicchhaaeell RRiieekkeerr, DDNNPP, CCRRNNAA
Director, Nurse Anesthesia Program
Wake Forest Baptist Health
WWaakkee FFoorreesstt BBaappttiisstt MMeeddiiccaall CCeenntteerr

Options
 Bupivacaine
 Load 10-15ml 0.125 - 0.25%
 Infuse 0.625% (cid:1) 0.125%
 Ropiivacaiine
 Load 10-15ml 0.1 (cid:1) 0.2%
 Infuse 0.2% - 0.5%
 AAdddd Fentanyll or SSuffentaniill to abbove 22(cid:181)g//mll or
0.05(cid:181)g/ml
 Add epinepherine 1:200,000 to 1:800,000
 Fentanyl
 Load 50-100(cid:181)g in 10ml
 Infuse 1-4 (cid:181)g/ml
What(cid:1)s the
ddiiffffeerreennccee??
Heavy local anesthetic
solutions
 0.25% bupivacaine
 Great analgesia
 GGoodd ffor OOPP bbabbiies
 Reason to avoid opioids?
 CC--sseeccttiioonn ppootteennttiiaall-- yyoouu(cid:2)rree aallrreeaaddyy tthheerree!!
 (cid:3)Laboring down(cid:4)- the time that we want the
epidural to slow labor.
Heavy local anesthetic
solutions‐ Big Guns
 Downside:
Immobility- even in bed
TTooxxiicciittyy ppootteennttiiaall
Push-ability? A sensory or motor defect?
Positioning injury potential
Breastfeeding
Lighter concentration +
opioid
 00.112255%% BBuuppiivvaaccaaiinnee ++ ffeennttaannyyll 22(cid:181)(cid:181)gg//mmll
 0.2% Ropivacaine + fentanyl 2(cid:181)g/ml
 OOpiioiidds (cid:3)(cid:3)smootthh outt(cid:4)(cid:4) epiiddurall
 0.1 Ropivacaine + fent equal to 0.2% Rop
aalloonnee
(Lee et al. Regional Anes & Pain Manage 27(1) 2002 Jan-Feb)
 Sufenta reduces dosage of Ropivacaine 30%
((eeppiidduurraall)) ttoo 5500%% ((iinnttrraatthheeccaall))
 Palm et al. Anaesthesia. 56(6):526-9, 2001. Ortner CM et al, On the ropivacaine-reducing
effect of low-dose sufentanil in intrathecal labor analgesia, Acta Anaesthesiol Scand
54(8):1000-6, 2010.
 Ortner CM et al,, On the roppivacaine-reducingg effect of low-dose sufentanil in intrathecal labor
analgesia, Acta Anaesthesiol Scand 54(8):1000-6, 2010.
Lighter concentration +
epinephrine
 EEffffects:
familiar: reduce blood flow; prolong action
aannaallggeessiicc:: aaggoonniisstt aatt -22 rreecceeppttoorrss
 Increases analgesia
eeppiidduurraall eeppiinneepphhrriinnee 11::330000,000000 rreessuulltteedd iinn aa 2299%%
reduction in the MLAC of bupivacaine
epi prolonged time to re-dose by 90 min.
 Increases motor block
 Increases compplications?
Lighter concentration +
epinephrine
 7700 partturiientts- epiiddurall llevobbupiivacaiine 00.112255%% andd
sufentanil 0.75 mcg/ml with or without 1:800,000
epinephrine.
 motor block, duration of the second stage of labor tended
to be higher in the epinephrine group and were associated
with lower Apggar scores
 Soetens, Filiep M (2006). "Levobupivacaine-sufentanil with or
without eppinepphrine duringg eppidural labor analggesia.". Anesthesia
and analgesia 103 (1), p. 182-6