Transcript Neuraksiaaliset opioidit ja vastasyntynyt

Neuraxial opioids and
the newborn
Petter Kainu
7.10.11
SOAT, Tartto
 Epidural
analgesia in the latent
phase of labor and the risk of
cesarean delivery: a five-year
randomized controlled trial.
 Wang F. Shen X. Guo X. Peng Y. Gu
X. Labor Analgesia Examining Group.
 Anesthesiology 2009. 111(4):871-80
Labour analgesia and the baby: good news is no news
Felicity Reynolds, IJOA 2011
Backround
 newborn
is very sensitive to opioids
 newborn metabolizes opioids slowly
 no balancing pain
Assessing newborn
 Apgar-scores
– are developed originally to assess druginfluence
– unsensitive
 Neonatal
acid-base status
– reflects the function of placenta
– reflects poorly drug influences
Assessing newborn

NACS (Neurologic and Adaptive Capacity
Scoring System) + and other scoring
systems
– muscular tone, reactivity ,reaction to different
stimuli
beginning of spontaneous breathing
 pCO2
 pulseoximetry
 drug concentrations from blood samples

Kinetics of epidural opioid
 epidurally
administered opioids enter
rapidly circulation
 lipophilic opioids rapidly cross the
placenta
 ion trapping (acidotic fetus)
Kinetics of epidural opioid

if ≥ 150-200 µg of fentanyl is used, the
baby has measurable amouts of fentanyl
in circulation
– Epidural fentanyl in labour. Carrie LE.
O'Sullivan GM. Seegobin R. Anaesthesia 1981.
36(10):965-9

if epidural-infusions are used, fentanyl
does not seem to accumulate
– Maternal and neonatal fentanyl and
bupivacaine concentrations after epidural
infusion during labor. Bader AM. Fragneto R.
Terui K. Arthur GR. Loferski B. Datta S.
Anesthesia & Analgesia 1995. 81(4):829-32
Epidural opioid & respiratory
depression
 case
reports
 Epidural Opioid Analgesia and
Neonatal Respiratory Depression.
Kumar M, Paes B. Journal of
Perinatology 2003. 23(5):425-7
Epidural opioid & NACS

with epid-/iv-opioid. vs no analgesic in
some studies babies have had lower NACS
– Maternal analgesia during labor disturbs
newborn behavior: effects on
breastfeeding, temperature, and crying.
Ransjo-Arvidson AB. Matthiesen AS. Lilja G.
Nissen E. Widstrom AM. Uvnas-Moberg K. Birth
2001. 28(1):5-12
– observational study (n=28)
– unmedicated infants were more active (video
recorded and analyzed by experts)
Epidural opioid & NACS
Effect of labor epidural analgesia with
and without fentanyl on infant breastfeeding: a prospective, randomized,
double-blind study. Beilin Y. Bodian CA.
Weiser J. Hossain S. Arnold I. Feierman
DE. Martin G. Holzman I. Anesthesiology
2005: 103(6):1211-7
 when ≥ 150 μg fentanyl was used, NACS
were slightly lower (p=0,03)

Breast feeding & epidural analgesia
 the
initiation of breast feeding is
crucial for breast feeding to be
succesfull
 if infant is less active or ”tired” the
interaction may become disturbed
 opioid may supress activity of the
infant
Breast feeding & epidural analgesia
 Breast-feeding
problems after
epidural analgesia for labour: a
retrospective cohort study of
pain, obstetrical procedures and
breast-feeding practices.
Volmanen P. Valanne J. Alahuhta S.
International Journal of Obstetric
Anesthesia 2004. 13(1):25-9
Volmanen et al.
 only
part of the epidurals had
fentanyl
 bupivacaine?
 The
impact of intrapartum
analgesia on infant feeding.
Jordan S. Emery S. Bradshaw
C.Watkins A. Friswell W.
International Journal of Obstetrics &
Gynaecology 2005. 112(7):927-34
 retrospective review, 18165 pts
 Intrapartum
epidural analgesia
and breastfeeding: a prospective
cohort study
Torvaldsen S. Roberts CL. Simpson
JM. Thompson JF. Ellwood DA.
International Breastfeeding Journal
2006, 1:24
 n=1280
 Epidural
analgesia and
breastfeeding: a randomised
controlled trial of epidural
techniques with and without
fentanyl and a non-epidural
comparison group.
Wilson M. J. A. MacArthur C. Cooper
G. M. Bick D. Moore P. A. S. Shennan
A.
Anaesthesia 2010. 65(2):145-153

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n=1064
Study groups:
Low dose infusion-group (LDI group): bolus (30 µg fent +15
mg bupiv in 15 ml), followed by infusion (10 ml/h)
CSE-group: Spinal (Bup 5mg + Fent 25 µg) follwed by epidural
infusion as in LDI-group
Control group: Epidural bolus (15 mg bup without fentanyl),
infusion without fentanyl
Two comparison groups without epidural analgesia (pethidin/no
pethidin- not randomized)
Rescue medication:
– Control group: Epidural fentanyl 50µg
Results:
– Epidural fentanyl did not affect breast feeding
– Pethidine had negative influence on breast feeding
Conclusions




epidural labour analgesia/opioid can influence
infant
serious influences are unlikely
breast feeding seems to be adversely affected
most studies are non-randomized cohort studies
– except
 Beilin
et al 2005
 Wang et al 2009
 Wilson et al 2010
Conclusions

Editorial in Anesthesiology in regard to
Beilin study:
– ”We should continue to use medications that
are known to be effective and are satisfactory
to patients, and provide the best obstetric
outcome possible.”

Obstetric Anesthesia Diggest:
– ”As lower consentrations of local anesthetic are
assosiated with many benefical effects for
mother and baby, fentanyl should not be
discarded based on weak links.”

Reynolds F: Labour analgesia and the
baby: good news is no news. International
Journal of Obstetric Anesthesia 2011.
20(1):38-50
– ”The effect on breast feeding has yet to be
established, though it is certainly no worse
than that of systemic opioid analgesia.”
However,

should we restrict larger doses of epidural
opioids?
– not > 150 µg of fentanyl?
 More
studies are warranted!