Transcript Team Work
How Do I Meet Expectations of Mother Opting for Labor Analgesia Bhavani Shankar Kodali, M.D. Interim Chair and Anesthesiologist-In-Chief Brigham and Women’s Hospital Associate Professor Harvard Medical School Boston, Massachusetts Science Knowledge Art Skills Communication 2 Science Knowledge Art Skills Communication 3 4 5 Team Work 6 7 High Risk Referral Service • It is beneficial • Increases awareness of obstetric anesthesia problems to everyone • Better planning is usually associated with good outcomes • Paves the way for multi-disciplinary approach 8 Should you sit or stand? April 2010 Use nice words Positive spin! Warning the patient in terms of pain or undesirable experiences resulted in greater pain and greater anxiety than not doing so. This has implications for training in medical communication skills. Pain 2005; 114: 303-9 • March 2010 Results When to place an epidural Maternal Request is Good Enough 17 What is the position of the patient? Sitting versus Lateral If Lateral, Right vs. Left • Which is better? Sitting versus Lateral • Sitting • Lateral • Vagal reflux • Less vascular • Decreased aortocatheter in lateral caval compression – position sitting • Complex fetal • Ease of technique positions • CSE may work • Blood flow to fetus – better lateral Sitting versus Lateral • Both are good in slim patients • Sitting is better in obese patients • Scoliosis patients (sitting) • Important to know the inherent flaws of lateral positioning Right versus Left • Left is better Local infiltration ? Local infiltration ? • Bicarbonate mix to local infiltration • Obese patients – needs more local Preferred technique Air vs. Saline? Loss of resistance to air or saline Both are good How much catheter should go in? Epidural Catheter • 4 to 5 cm only • Make sure it will stay despite positioning changes • Fixation is important • Keep connection away from the sweaty skin Changes in the position of epidural catheters associated with patient movement Anesthesiology 1997;86:778-84. BMI <25 25-30 N=46 N=116 >30 N=92 Flex-Up cm 0.23 (0.17) 0.33 (0.28) 0.38 (0.30) Up-Lat 0.48 (0.41) 0.51 (0.41) 0.69 (0.68) Flex-Lat 0.67 (0.42) 0-1.9 0.75 (0.48) 0-2.72 1.04 (0.69) -0.114.28 Range Multi-orifice or Single-orifice 4 to 5 cm Single-orifice – Arrow • Less parasthesia • Less vascular • Good results What is the mix you use for epidural analgesia ? • Bupivacaine 0.125% loading dose 20 ml • Infusion 0.125% with fentanyl 2 mic /ml • Intermittent technique • CEA -- 10 ml/hr • PCEA -- 6 ml continuous / 6 ml bolus / 15 minute lock out interval PCEA versus CEA • Superior • Your interventions are decreased • Patient feels as if she has control over her labor • Boluses have better spread over slow infusion i 38 Programmed Intermittent Bolus Anesth Anal 2006 Anesth Analg 2011 Programmed bolus injection: –Improved analgesia –Less local anesthetic used –Improved patient satisfaction Local anesthetic agent • Test dose – yes or no • Rapid onset with lidocaine • Fentanyl to initial loading dose • Epinephrine • Fentanyl to running mix Unilateral block ? Unilateral block • Positional changes • Pull the catheter • Replacement • Check the flow chart regarding number of top ups. Dural puncture epidural Dry dural puncture, (no drug) improves quality of labor epidural analgesia Anesth Analg November 2008 Epidural vs. CSE • Late stages: CSE • Success rate may be marginally better with CSE epidurals. • Epidural with initial 5 ml 1.5% Lidocaine followed by 15 ml Bup. 0.125% Failed CSE Failed CSE Postoperative Check • Valuable contribution • An avenue for acknowledgment • Measure of our performance • Side effects and complications • Quality Assurance 49 Documentation • Follow the progress • Handover of patients from one team to the other • Avenue to pickup impending complications • Medico legal purposes 50 Skills Team Infrastructure Obstetric Anesthesia Safety Diagnose Complications Resuscitation Manage Complications Proactive planning