Continuous spinal anesthesia and postoperative analgesia for elective cesarean section in a parturient with Eisenmenger's syndrome

Continuous Spinal Anesthesia for Obstetric Anesthesia and Analgesia

The widespread use of continuous spinal anesthesia (CSA) in obstetrics has been slow because of the high risk for post-dural puncture headache (PDPH) associated with epidural needles and catheters. New advances in equipment and technique have not significantly overcome this disadvantage. However, CSA offers an alternative to epidural anesthesia in morbidly obese women, women with severe cardiac disease, and patients with prior spinal surgery. It should be strongly considered in parturients who receive an accidental dural puncture with a large bore needle, on the basis of recent work suggesting significant reduction in PDPH when intrathecal catheters are used. Small doses of drug can be administered and extension of labor analgesia for emergency cesarean delivery may occur more rapidly compared to continuous epidural techniques.

Complications of 761 short-term intrathecal macrocatheters in obstetric patients: a retrospective review of cases over a 12-year period

BACKGROUND

A continuous spinal catheter is a reliable alternative to standard neuraxial techniques in obstetric anesthesia. Despite the potential advantages of intrathecal catheters, they remain underutilized due to fear of infection, nerve damage or post-dural puncture headache. In our tertiary care center, intrathecal catheters are either placed intentionally in high-risk obstetric patients or following inadvertent dural puncture using a 19-gauge macrocatheter passed through a 17-gauge epidural needle.

METHODS

A retrospective review of 761 intrathecal catheters placed from 2001 to 2012 was conducted. An institutional obstetric anesthesia database was used to identify patients with intrathecal catheters. Medical records were reviewed for procedural details and complications.

RESULTS

There were no serious complications, including meningitis, epidural or spinal abscess, hematoma, arachnoiditis, or cauda equina syndrome, associated with intrathecal catheters. The failure rates were 2.8% (3/108) for intentional placements and 6.1% (40/653) for placements following accidental dural puncture. The incidence of post-dural puncture headache was 41% (312/761) and the epidural blood patch rate was 31% (97/312).

CONCLUSIONS

This review demonstrates that intrathecal catheters are dependable and an option for labor analgesia and surgical anesthesia for cesarean delivery. Serious long-lasting complications are rare.

[Continuous spinal anesthesia in obstetrics]

Despite the theoretical advantages of continuous anesthesia in obstetric patients (good-quality blockade at low doses, good hemodynamic stability, rapid onset of effect, and no risk of toxicity), little has been published on this technique and its use in pregnancy. Moreover, few descriptive studies or comparative trials have evaluated the efficacy and safety of continuous spinal anesthesia, probably because of concerns about potential adverse effects-principally neurologic complications and postdural puncture headache. We review the literature on the use of continuous spinal anesthesia in obstetric patients, analyzing the advantages and disadvantages, indications, and adverse effects of this technique.

Continuous spinal anesthesia and analgesia in obstetrics

The development of the technique of continuous spinal anesthesia as it relates to the obstetric population is recounted. The advantages and disadvantages of continuous spinal anesthesia are examined, currently available catheters and kits are reviewed, and strategies for the management of continuous spinal techniques for labor analgesia and surgical anesthesia are discussed. Continuous spinal anesthesia may have particular value over other regional techniques in several specific clinical circumstances.

Observational study of continuous spinal anesthesia with the catheter-over-needle technique for cesarean delivery

BACKGROUND

Few studies have assessed the efficacy and safety of continuous spinal anesthesia in obstetrics, although placement of a catheter in the intrathecal space theoretically offers advantages in these patients.

METHODS

Ninety-two women scheduled for elective cesarean delivery using continuous spinal anesthesia with the catheter-over-needle technique (22- or 24-gauge Spinocath) were included in the study. The doses of local anesthetic used, hemodynamic variables, use of ephedrine and other drugs, and incidence of complications such as technical failure and postdural puncture headache (PDPH) were recorded.

RESULTS

The mean (+/-SD) dose of hyperbaric bupivacaine used was 8.2+/-1.8 mg. The incidence of hypotension was 30% and the mean total dose of ephedrine was 4+/-7 mg. The continuous spinal anesthetic technique failed in 18 women (20%). The overall incidence of post-dural-puncture headache was 29%; 18% of patients with post-dural-puncture headache required a blood patch.

CONCLUSIONS

Compared to previous reports, the incidence of block failure and PDPH in this study was unacceptably high and therefore the risks of the technique appear to outweigh the advantages of continuous spinal anesthesia in obstetric practice.