Use of Opioids and Epidural Anaesthesia in Labor Analgesia as Important Risk Factors for Apparent Postpartum Urinary Retention: A Case-Control Study.

BACKGROUND: Labor analgesic interventions, particularly the use of opioids and epidural anaesthesia, have raised concerns regarding their potential impact on postpartum urinary retention (PUR), necessitating a comprehensive investigation into their association with this clinical outcome. METHODS: This retrospective case-control study analysed clinical data from postpartum patients at our hospital from January 2023 to December 2023. Anaesthetic methods, including opioid and non-opioid drug usage, epidural analgesia and non-use of analgesia, were assessed. Logistic regression analysis was also performed to determine important associations with apparent PUR. RESULTS: This study included clinical data from 54 postpartum patients with PUR and 54 without urinary retention. A higher percentage of women with apparent PUR received opioids during labour compared with those without PUR (p = 0.033). Conversely, a lower percentage of women with apparent PUR received non-opioid analgesics compared with those without PUR (p = 0.026). In addition, a higher percentage of women with apparent PUR received epidural analgesia compared with those without PUR (p = 0.041). Logistic regression analysis demonstrated that opioid consumption during labour was significantly associated with apparent PUR (odds ratio (OR) = 2.469, p = 0.022). By contrast, non-opioid consumption during labour was inversely associated with apparent PUR (OR = 0.297, 95% CI = 0.123-0.681, p = 0.005). In addition, the use of epidural analgesia during labour showed a remarkable association with apparent PUR (OR = 2.857, 95% CI = 1.289-6.552, p = 0.011). CONCLUSIONS: Opioid use during labour and the use of epidural analgesia were identified as important risk factors for apparent PUR. These findings emphasise the need for a thoughtful and balanced approach to analgesic management during labour to minimise the risk of PUR in obstetric patients.

Impact of Epidural Catheter-Incision Congruency on Postoperative Analgesia after Major Abdominal Surgery: An Observational Study in a Teaching Hospital.

OBJECTIVE: To determine the frequency of appropriate epidural catheter-incision congruency in adult patients undergoing major abdominal surgeries, as well as the frequency of ineffective postoperative analgesia with continuous epidural infusion, side effects, and complications of epidural insertion and epidural catheter infusion. STUDY DESIGN: Observational study. Place and Duration of the Study: Department of Anaesthesiology, The Aga Khan University Hospital, Karachi, Pakistan, from September to November 2022. METHODOLOGY: All adult patients who underwent elective major abdominal surgery under general anaesthesia with epidural analgesia were included in this study. Data were collected by chart review of the patients enrolled in Acute Pain Service for the study period. Intraoperative anaesthesia form, epidural infusion form and all records of acute pain service for the postoperative period were reviewed and recorded. RESULTS: One hundred and eighty-two patients were included in this study. The epidural catheter was inserted congruent to the surgical incision i.e. T10-T11 level or above in 43 (23.6%) patients only. In the postoperative period, overall effective epidural analgesia was observed in 79 (43.4%) of the patients. Motor block in lower limbs was observed in 66 (36.26%) of patients in the immediate postoperative period. CONCLUSION: The present study shows appropriate epidural catheter-incision congruency in only 23.6% of the patients. This could be one of the common reasons for ineffective postoperative pain relief via epidural analgesia in 56.6% of patients. KEY WORDS: Epidural catheter insertion site, Major abdominal surgeries, Postoperative analgesia.

Subdural Spread of Local Anesthetic Mimicking Cerebrovascular Accident: A Case Report of Horner's Syndrome, Upper Limb Paresthesia, and Motor Weakness After Thoracic Epidural Analgesia.

A 53-year-old woman underwent a thoracic epidural placement for a scheduled laparotomy. Postoperatively the patient had no appreciable epidural level after multiple epidural boluses and was noted to be severely hypotensive with right upper extremity weakness and numbness. She subsequently developed right-sided Horner's syndrome with worsening right upper extremity weakness and decreased sensation from C6 to T1. She regained full motor and sensory function in her right upper extremity with epidural removal. This unusual case raises awareness of the variability in the presentation of subdural spread and provides an example of an epidural complication that can mimic a cerebrovascular accident (CVA).

Association between neutrophil-to-lymphocyte ratio and epidural-related maternal fever in Chinese parturients: a prospective cohort study.

OBJECTIVE: Epidural analgesia could increase the risk of maternal fever during labor, and the potential mechanisms involved inflammation. Neutrophil-to-lymphocyte ratio (NLR) was a sensitive inflammatory composite indicator and related to adverse outcomes in parturients. This study aimed to investigate the association between NLR levels and epidural related maternal fever (ERMF). METHODS: This prospective cohort study included 614 parturients who underwent epidural analgesia at the Women's Hospital School of Medicine Zhejiang University from November 2021 to May 2023. NLR level was calculated before epidural analgesia for women. The outcome was ERMF. Univariate and multivariate logistic regression models were utilized to explore the association between NLR level and ERMF. And the association was further investigated in subgroups of age, body mass index (BMI) before pregnancy, and parity of delivery. The results were presented as odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: Totally, 614 parturients, of whom 171 (27.85%) had ERMF. High NLR level was associated with higher incidence of ERMF (OR = 2.70, 95% CI: 1.58-4.69). Parturients with ERMF had higher proportion of postpartum hemorrhage, longer labor times, and other adverse outcomes in parturients. The association also observed in subgroups of age <35 years old (OR = 2.74, 95% CI: 1.55-4.29), BMI <24 kg/m2 before pregnancy (OR = 2.32, 95% CI: 1.32-4.13), BMI ≥24 kg/m2 before pregnancy (OR = 38.28, 95%CI: 3.67-854.66), primipara (OR = 2.26, 95% CI:1.27-4.04), and multipara (OR = 30.60, 95% CI: 3.73-734.03). CONCLUSION: High NLR levels were associated with ERMF in women. It indicated that physicians may measure NLR levels as a regular measurement, which may beneficial for pregnancy outcomes.

Headache that will not go away...Third ED visit is the charm?

Subdural hematoma is an uncommon complication of epidural analgesia or diagnostic lumbar puncture. Headache is a common complaint for patients with either a subdural hematoma or a post-dural puncture headache. Because post-dural puncture headaches are commonly seen in the Emergency Department, the potential to miss more serious pathology arises. We present the case of a young female who suffered bilateral subdural hematomas following epidural analgesia during childbirth. She presented twice to the Emergency Department and was treated for a post-dural puncture headache before computed tomography imaging revealed the diagnosis on the third Emergency Department encounter. This case highlights the importance of exploring all potential diagnoses when a patient presents with a headache after either epidural analgesia or a diagnostic lumbar puncture, especially if the patient returns after unsuccessful treatment for a presumptive post-dural puncture headache.

Effect of dural puncture epidural block technique on fetal heart rate variability during labor analgesia.

PURPOSE: To explore the effect of dural puncture epidural (DPE) block technique on fetal heart rate variability (HRV) during labor analgesia. METHODS: Sixty full-term primiparas who were in our hospital from April 2021 to October 2021 were selected and randomized into epidural analgesia (CEA) and dural puncture epidural analgesia (DPEA) groups (n = 30). After a successful epidural puncture, routine epidural catheter (EC) was performed in CEA group, and spinal anesthesia needle (as an EC) was used to puncture the dura mater to subarachnoid space in DPE group. Anesthetics were injected through EC. The time when the temperature sensation plane reached T10 (W1) and visual analog pain score (VAS), baseline heart rate score, amplitude variation score, cycle variation score, acceleration score, deceleration score, and total score of the first contraction after W1 were recorded. Apgar scores at 1 min, 5 min, and 10 min of neonates after delivery were recorded. RESULTS: The onset time of anesthesia in CEA group was significantly longer than that in DPEA group (p < .05). However, there are no significant differences in W1, VAS, baseline heart rate score, amplitude variation score, cycle variation score, acceleration score, deceleration score, and total score of the first contraction after W1 between the two groups (p > .05). Moreover, the Apgar scores at 1 min, 5 min and 10 min of neonates after delivery were not notably different between the two groups (p > .05). CONCLUSION: Compared with CEA, DPE block technique in labor analgesia relieves maternal pain without adverse effects on fetal HRV and newborns.

Epidural analgesia and neonatal short-term outcomes during routine childbirth: a 10-year retrospective analysis from the national birth registry of Austria.

BACKGROUND: Epidural analgesia (EA) is well-accepted for pain relief during labor. Still, the impact on neonatal short-term outcome is under continuous debate. This study assessed the outcome of neonates in deliveries with and without EA in a nationwide cohort. METHODS: We analyzed the National Birth Registry of Austria between 2008 and 2017 of primiparous women with vaginal birth of singleton pregnancies. Neonatal short-term morbidity was assessed by arterial cord pH and base excess (BE). Secondary outcomes were admission to a neonatological intensive care unit, APGAR scores, and perinatal mortality. Propensity score-adjusted regression models were used to investigate the association of EA with short-term neonatal outcome. RESULTS: Of 247,536 included deliveries, 52 153 received EA (21%). Differences in pH (7.24 vs. 7.25; 97.5% CI -0.0066 to -0.0047) and BE (-5.89±3.2 vs. -6.15±3.2 mmol/L; 97.5% CI 0.32 to 0.40) with EA could be shown. APGAR score at five minutes <7 was more frequent with EA (OR 1.45; 95% CI: 1.29 to 1.63). Admission to a neonatological intensive care unit occurred more often with EA (4.7% vs. 3.4%) with an OR for EA of 1.2 (95% CI: 1.14 to 1.26). EA was not associated with perinatal mortality (OR 1.33; 95% CI: 0.79 to 2.25). CONCLUSIONS: EA showed no clinically relevant association with neonatal short-term outcome. Higher rates of NICU admission and APGAR score after five minutes <7 were observed with EA. The overall use of EA in Austria is low, and an investigation of causes may be indicated.

Epidural analgesia in labour: separating fact from fiction for autism and neurodevelopment.

Having epidural analgesia in labour has been associated with a later diagnosis of autism spectrum disorder in the offspring, resulting in concerns about childhood wellbeing. Neurodevelopmental changes are inconsistently reported in the literature, creating challenges in the interpretation of these findings. Here we explore the limitations of the current evidence base, and why findings differ between studies, concluding that the current body of evidence does not support a causal association between use of epidural analgesia in labour and autism spectrum disorder.

Programmed Intermittent Epidural Bolus Reduces Workloads in Labor Analgesia: A Single Center's Experience.

Background and Objectives: Labor epidural analgesia can be maintained through programmed intermittent epidural bolus (PIEB), continuous epidural infusion (CEI), or patient-controlled epidural analgesia (PCEA). Our department changed from CEI+PCEA to PIEB+PCEA as the maintenance method. The higher hourly dose setting in the current regimen brought to our concern that side effects would increase with proportional staff workloads. This study aimed to investigate the validity of our proposal that PIEB+PCEA may function as a feasible tool in reducing the amount of work in the obstetrics anesthesia units. Materials and methods: This 2-year retrospective review included parturients with vaginal deliveries under epidural analgesia. We compared the staff burden before and after the switch from CEI (6 mL/h, PCEA 6 mL lockout 15 min, group A) to PIEB (8 mL/h, PCEA 8 mL lockout 10 min, group B). The primary outcome was the difference of proportion of parturients requiring unscheduled visits between groups. Side effects and labor and neonatal outcomes were compared. Results: Of the 694 parturients analyzed, the proportion of those requiring unscheduled visits were significantly reduced in group B (20.8% vs. 27.7%, chi-square test, p = 0.033). The multivariate logistic regression showed that PIEB was associated with fewer unscheduled visits than CEI (OR = 0.53, 95% CI [0.36-0.80], p < 0.01). Group B exhibited a significantly lower incidence of asymmetric blockade, as well as motor blockade. In nulliparous subjects, obstetric anal sphincter injury occurred less frequently when PIEB+PCEA was used. Significantly more multiparous women experienced vacuum extraction delivery in group B than in group A, and they had a longer second stage of labor. Conclusions: The PIEB+PCEA protocol in our study reduced workloads in labor epidural analgesia as compared to CEI+PCEA, despite that a higher dose of analgesics was administered. Future studies are warranted to investigate the effect of manipulating the PIEB settings on the labor outcomes.

The application of DPE, CSEA, and EA in labor analgesia for nulliparous women and their impact on maternal and infant safety.

This work compared the effects of dural puncture epidural (DPE), combined spinal epidural analgesia (CSEA) and epidural analgesia (EA) on labor analgesia for primiparae and their impacts on maternal and infant safety. A total of 204 primiparae in need of labor analgesia for vaginal delivery were allocated to DPE, CSEA and EA groups. At 10 min, 30 min and 1 h after analgesia, the DPE and CSEA groups showed lower VAS scores and quicker onset of action than EA group. There was no significant difference in the duration of analgesia and labor and fetal decelerations among the 3 groups. At 1 min and 5 min after childbirth, the neonatal Apgar scores showed no significant difference between the 3 groups. The Bromage scores of DPE and EA groups were lower than those of CSEA group. The incidence of pruritus, hypotension, and postpartum headache in DPE and EA groups were lower than those in CSEA group. To sum up, the efficacy of DPE in labor analgesia for primiparae is similar to that of CSEA, with no obvious effect on labor stage and neonatal Apgar score, no additional complications and less LLMB, pruritus, hypotension and postpartum headache.

Programmed intermittent epidural bolus regimen vs continuous epidural infusion: a retrospective study of motor block and obstetric outcomes using the Robson's Ten Group Classification System.

BACKGROUND: Use of a programmed intermittent epidural bolus (PIEB) regimen during labour is associated with several benefits over a continuous epidural infusion (CEI), including reduced local anaesthetic consumption and reduced risk of motor block. We hypothesise that the benefits of a PIEB regimen may vary according to the Robson Ten Group Classification System (TGCS). The aim of this study was to determine if introduction of a PIEB regimen was associated with reduced incidence of motor block. We also wished to examine changes in obstetric outcomes following PIEB introduction across the Robson TGCS. METHODS: This was a single-centre retrospective cohort study. Data were collected over two three-month periods before and after PIEB introduction. The primary outcome was the incidence of motor block. Maternal and obstetric outcomes across Robson Groups 1-4 were analysed. RESULTS: Introduction of PIEB was associated with reduced incidence of motor block (28.4% (95% CI 25.7% to 31.3%) vs 22.4%, (95% CI 19.9% to 25.2%), difference 5.9% (95% CI 1.0% to 21.1%), P=0.003), with no association with changes in rates of caesarean section, operative vaginal delivery or other obstetric outcomes. Use of a PIEB regimen was associated with reduced incidence of motor block in Robson Group 4a (20.3% (16.0%, 28.0%) vs 12.0%, (7.6%, 16.4%), difference 9.9% (95% CI -17.4% to -2.4%) P=0.009). There were no significant changes in other outcomes assessed across Robson TGCS. CONCLUSION: Introduction of PIEB for maintenance of labour analgesia was associated with reduced incidence of motor block in our institution compared with CEI. Presenting results according to Robson's TGCS in future studies may allow better elucidation of the impact of neuraxial analgesia on maternal and obstetric outcomes.