Severe back labor pain masks a scald caused by shower hydrotherapy: a case report

Shower hydrotherapy is generally considered benign during labor. We report a case of extensive scalds in a primigravida who used shower hydrotherapy to treat severe back labor pain from fetal malposition. Interestingly, her back pain was so severe that she felt no pain as her scald developed, describing the hot water from the showerhead as the only measure which "soothed" her pain. Her scald was diagnosed presumptively during assessment for epidural analgesia. The nature of her back labor pain, associated with occiput posterior fetal head position and her management are described. Severe pain from persistent fetal malposition may alter somatic pain perception during labor, increasing burn risks during shower hydrotherapy. These women are also at increased risk of operative delivery and infection risks from inadvertent neuraxial blockade after burns. Improved prevention strategies and vigilance for scalds are warranted in women with severe back labor undergoing shower hydrotherapy, including by anesthesiologists assessing them for neuraxial blockade.

High quality labour analgesia using small gauge epidural needles and catheters

PURPOSE

Inadvertent epidural needle punctures represent the leading cause of severe postdural puncture headache (PDPH) in parturients. Use of small gauge (G) epidural needles for continuous analgesia has received little attention despite possible important reductions in PDPH. We report the first study to examine the feasibility of using small G Tuohy needles and 23 G catheters for labour analgesia.

METHODS

Healthy parturients <or= 6 cm dilated were recruited. Epidural analgesia was established using a 19 G Tuohy epidural needle, a 23 G single port 40 cm catheter and bupivacaine 0.08% with fentanyl 2 microg x mL(-1) (15-20 mL). Breakthrough pain was treated by protocol. There was no formal in-training period for anesthesiologists. The primary outcome was the combined failure rate for initiation (failed needle/catheter placement or failed block <or= 30 min of drug administration). Secondary out-comes included late block failure (> 30 min), recognized dural puncture, PDPH, patient assessment of analgesia within 24 hr of delivery, complications and anesthesiologist satisfaction.

RESULTS

Twenty-seven parturients were recruited. Successful blocks were initiated and maintained in 24/27 who rated overall analgesia from good to excellent (19/24 very good to excellent). Three block failures occurred at the initiation phase only (two unilateral, one absent). There was no evidence of catheter kinking after placement. One patient developed PDPH after unrecognized dural puncture which was self-treated with acetaminophen for four days, followed by complete symptom resolution.

CONCLUSION

It is feasible to provide high quality labour analgesia using small G epidural needles and catheters. The effect of small G epidural needles on PDPH warrants future study.

Epidural Catheter Penetration of Human Dural Tissue

Background

Factors contributing to subarachnoid catheter passage after epidural placement are not well understood. This study explored mechanisms that might explain its occurrence.

Methods

Human cadaveric dura was mounted on a model and pressurized to physiologic levels. In a standardized fashion, a 20-gauge Portex three-port, closed end (nonflexible) tip catheter was passed through an epidural needle mounted on a micromanipulator at a 90 degree angle, attempting to penetrate dura with the catheter. Attempts then followed with a 19-gauge Arrow Flex Tip Plus single-port catheter. Subarachnoid catheter passage was compared in (1) intact dura, (2) clinically occult versus obvious epidural needle punctures, and (3) single 25-gauge Whitacre spinal needle punctures after combined spinal-epidural placement.

Results

Neither catheter penetrated intact dura: Portex, 0 of 300 attempts (0.0000; 95% confidence interval [CI]: 0.0000, 0.0158); Arrow, 0 of 300 attempts (0.0000; 95% CI: 0.0000, 0.0158). In clinically occult epidural needle punctures, the 20-gauge Portex catheter penetrated 1 of 3 specimens in 1 of 14 attempts (0.0714; 95% CI: 0.0021, 0.3583). The 19-gauge Arrow did not pass (0 of 15 attempts, 0.0000; 95% CI: 0.0000, 0.2535). In clinically obvious epidural needle punctures, the Portex passed in 6 of 33 attempts (0.1818; 95% CI: 0.0760, 0.3608) and the Arrow passed in 1 of 35 attempts (0.0286; 95% CI: 0.0012, 0.1662). Neither catheter passed through a single 25-gauge spinal needle puncture after an uncomplicated combined spinal-epidural: Portex, 0 of 90 attempts (0.0000; 95% CI: 0.0000, 0.0510); Arrow, 0 of 90 attempts (0.0000; 95% CI: 0.0000, 0.0510).

Conclusions

Catheter passage is unlikely in the presence of intact dura or after an uncomplicated combined spinal-epidural. Unintentional subarachnoid passage suggests dural damage with the epidural needle.

Dural Tissue Trauma and Cerebrospinal Fluid Leak after Epidural Needle Puncture

Background

The effects of epidural needle design, angle, and bevel orientation on cerebrospinal fluid leak after puncture have not been reported. The impact of these factors on leak rate was examined using a dural sac model. Dural trauma was examined using scanning electron microscopy.

Methods

Human cadaveric dura, mounted on a cylindrical model, was punctured with epidural needles using a micromanipulator. Tissue was punctured at 15 cm H2O (left lateral decubitus) system pressure, and leak was measured at 25 cm H2O (semisitting) pressure. Leak rates and trauma were compared for the following: (1) six different epidural needles at 90 degrees, bevel parallel to the dural long axis; (2) 18-gauge Tuohy and 18-gauge Special Sprotte epidural needles, 30 degrees versus 90 degrees; (3) 18-gauge Tuohy, bevel perpendicular versus parallel to the dural long axis.

Results

With the 90 degrees puncture, bevel parallel, the greatest leak occurred with a 17-gauge Hustead (516 +/- 319 ml/15 min), and the smallest leak occurred with a 20-gauge Tuohy (100 +/- 112 ml/15 min; P = 0.0018). A 20-gauge Tuohy puncture led to statistically significant reductions in leak (P value range, 0.0001-0.0024) compared with all needles except the Special Sprotte. With the 30 degrees versus 90 degrees angle, 30 degrees punctures with an 18-gauge Tuohy produced nonstatistically significant leak reductions compared with the 18-gauge Tuohy at 90 degrees. The puncture angle made no difference for the Special Sprotte. Nonsignificant reductions were found for the Special Sprotte compared with the Tuohy. With the 18-gauge Tuohy bevel orientation, perpendicular orientation produced nonstatistically significant reductions in leak compared with parallel orientation.

Conclusions

Cerebrospinal fluid leak after puncture was influenced most by epidural needle gauge. Leak rate was significantly less for the 20-gauge Tuohy needle.

A randomized controlled trial examining the effect of naproxen on analgesia during the second day after cesarean delivery

Whereas nonsteroidal antiinflammatory drugs augment spinal morphine on Day l, the analgesia gained by simply combining these drugs with conventional "on request" oral regimens on Day 2 is less clear. In this trial, we randomized 80 women undergoing elective cesarean delivery with spinal morphine (0.2 mg) to receive naproxen (500 mg) or placebo every 12 h after surgery. Both groups received conventional therapy with acetaminophen with codeine (on request) and rescue IM opioids. Incision pain on sitting (IPS), incision pain at rest, uterine cramping, and gas pain were evaluated with visual analog scales (0-100). Worst interval pain (0-10), analgesic use, and side effects were measured over 72 h. At 36 h (primary outcome), naproxen use was associated with reductions in IPS (38.2 +/- 26.0 versus 51.4 +/- 25.7; P = 0.05), incision pain at rest, uterine cramping, and worst interval pain scores. Clinically modest, statistically significant reductions in IPS (P = 0.0001) and opioid use were found over time (P < 0.0l). Reductions in the incidence of inadequate analgesia and improvements in overall pain relief (P = 0.0006) on Day l did not persist on Day 2 (overall pain relief, P = 0.057; inadequate analgesia, 24% naproxen versus 27% controls; P = 1.00). The addition of regular doses of naproxen to conventional oral pain therapy after cesarean delivery leads to reductions in IPS at 36 h and pain over Day 2 but does not reduce the incidence of inadequate analgesia.

IMPLICATIONS

This randomized trial suggests that adding regular doses of naproxen to conventional "on request" acetaminophen and codeine therapy provides small reductions in pain on the second day after cesarean delivery. The greatest effects occur at 36 h, when pain peaks.