49
Options for analgesia when a regional technique is not possible Damien Hughes Ulster Hospital Belfast [email protected]
Options for analgesia when a regional technique is not
possible
Damien HughesUlster Hospital
Belfast
DamienHughessetrusthscninet
Historyhelliphellip
Progresshelliphellip
Plus ccedila changehellip
bull Basic choiceshellip
bull Pharmacological or non-pharmacological
bull Systemic or regional
bull Opioid based or local anaesthetic based
Plus ccedila changehellip
bull Basic choiceshellip
bull Pharmacological or non-pharmacological
bull Systemic or regional
bull Opioid based or local anaesthetic based
Non-pharmacological analgesia
bull Usually not us
ndash TENS water acupuncture etc buthellip
Non-pharmacological analgesia
bull Hypnosishellip
bull Antenatal self-hypnosis for labour and childbirth A pilot studyndash 77 women (control 3249)
ndash Nulliparous fewer epidurals fewer augmentations
ndash Possible benefit further research neededbull AM Cyna et al
ndash Anaesthesia and Intensive Care 2006 34 (4)464-469 Australian Society of Anaesthetists
Howeverhellip
bull Hypnosis for pain management during labour and childbirth (Review)
ndash Madden K Middleton P Cyna AM Matthewson M Jones L bull The Cochrane Library 2012
Issue 11
bull No benefit shown for analgesia requirements
Pharmacological options
bull Systemicndash Entonox
ndash IM opioid
ndash Opioid PCA bull remifentanil
bull Regionalndash Epidural
ndash CSE
ndash Spinal
Pharmacological options
bull Systemicndash Entonox
ndash IM opioid
ndash Opioid PCA bull remifentanil
bull Regionalndash Epidural
ndash CSE
ndash Spinal
Labour with opioids
Labour with opioids
50 donrsquot have an epidural
bull Patient preference
bull No ldquoepidural servicerdquo
bull Thrombocytopenia
bull Anticoagulation
bull ldquoBack problemsrdquo
bull ldquoNeurologicalrdquo
bull ldquoSepsisrdquo
Systemic analgesiahellip
bull Not like an epidural labour
bull Different collaborative relationships
bull Maternal choice issues
bull Midwifery rather than anaesthesia
Systemic analgesia
bull Nitrous Oxide
ndash Ubiquitous UK (not USA)
ndash Patient controlbull Psychological benefit
ndash Low blood-gas solubilitybull Ideal for intermittent use
bull Rapid on-off effect
bull Doesnrsquot accumulate with intermittent use
ndash Often as an adjunct
Opioids
bull Mainstay of systemic analgesia
bull Intermittent bolus regimen
bull Administered by midwives
IM Pethidinebull ldquomore sedation than analgesiardquo1
bull gastric stasis amp hypoventilation 2
bull fetal effects after 40 mins 3
bull dose-delivery lt2-3hrs 4
bull modifies CTG amp EEG 5
bull fetal acidosis 6
bull active metabolites for days 7
1 Olofsson et al B J Obs Gynaecol 1996103968-72
2 Nimmo et al Lancet 19751(7912)890-3
3 Tomson G et al B J Clinical Pharmacology 198213653-9
4 Shnider SM Moya F Am J Obstet Gynecol 1964891009-15
5 Kariniemi V ammala P B J Ob Gynaecol 198188718-20
6 Kariniemi V Rosti J J Perinatal Med 198614131-5
7 Hodgkinson R Farkhanda JH Anesthesiology 19825651-2
What do women wantSytematic review of 137 reports of the views of 14000 women in 9 countries
Satisfaction
ndash Expectations
ndash Support
ndash Quality of relationship with midwife
ndash Involvement in decision making
Dissatisfaction
ndash Failure of timing amp lack of availability of analgesia
Hodnett 2002 Saisto 2001 Ranta 2002 May 2000
Complete analgesia did not rate highly
bull REVIEW
bull Maternal satisfaction
bull PN Robinson P Salmon SM Yentisndash International Journal of Obstetric
Anesthesia (1998) 7 32-37
bull ldquoSatisfaction is multidimensionaland therefore difficult to define assess and measurerdquo
bull ldquoStudies assume that satisfaction with anaesthetic practice equates with good analgesia although as we have shown this is only one dimension of satisfactionrdquo
Regional analgesia ndashthe be all and end all
bull Epidural versus non-epidural or no analgesia in labour
bull Anim-Somuah M1 Smyth RM Jones L
ndash Cochrane Database Syst Rev 2011 Dec 7(12)
Cochrane Conclusionhellip
bull Epidural analgesia appears to be effective in reducing pain during labour
bull However women who use this form of pain relief are at increased risk of having an instrumental delivery
bull Epidural analgesia had no statistically significant impact on the risk of caesarean section maternal satisfaction with pain relief and long-term backache and did not appear to have an immediate effect on neonatal status as determined by Apgar scores
bull Further research may be helpful to evaluate rare but potentially severe adverse effects of epidural analgesia on women in labour and long-term neonatal outcomes
What do women wantSytematic review of 137 reports of the views of 14000 women in 9 countries
Satisfaction
ndash Expectations
ndash Support
ndash Quality of relationship with midwife
ndash Involvement in decision making
Dissatisfaction
ndash Failure of timing amp lack of availability of analgesia
Hodnett 2002 Saisto 2001 Ranta 2002 May 2000
Complete analgesia did not rate highly
The search for an alternative
bull Match time course of labour
bull Not midwife delivered patient control
bull Few maternal amp neonatal adverse effects
Rapid onset and offset amp intravenous
PCA device
Non cumulative
o
f p
eak
eff
ect
site
con
centr
atio
n
Fentanyl
Alfentanil
100
0
Time since bolus (min)
2 4 6
Effect site concentration after opioid bolus
80 10
Remifentanil
Remifentanil pharmacokinetics in neonates
bull Infants under 2 months
bull Pharmacokinetics similar
ndash to older children
ndash to adults
Davis Ross Henson et al Remifentanil pharmacokinetics in neonates
Anesthesiology 1997 87 A 1054
Remifentanil PCA
bull Theory behind techniquendash PCA giving control improves
satisfaction
bull Theory behind choice of drugndash Ultra short-acting rapidly
metabolised
ndash Placental transfer but rapid metabolism in neonatebull Kan et al Anesthesiology1998
88 1467-74
ndash Context sensitive t12 3-5min
ndash Ideal for intermittent pain of labour
Remi pca in practicebull Feasibility for labour analgesia
2001 ndash Blair et al BJA 2001
bull Optimum bolus 05mcgkg no background infusionndash Superior to pethidine
bull Blair et al BJA 2005
bull Shown superior to pethidinendash efficacy satisfaction conversion to
epiduralbull Thurlow et al BJA 2002 Douma et al
BJA 2010
bull No difference in neonatal outcomesndash Review by Leong et al Anes amp Analg
2011
Remi pca in practice
bull Strict protocol
ndash Dedicated IV cannula
ndash Dedicated pumps
ndash Locked pump programmebull 40mcg bolus 2min lockout
ndash Observation chart
Safety with remi
bull One-to-one midwifery care
bull Anaesthetist prescribes and starts pca
bull Strict monitoring
bull Observation chart
bull Immediate oxygen and resuscitation availability
bull Continuous audit
Side effects
bull Nausea
ndash approx 90 use Entonox
bull Itch
bull Sedation
bull Respiratory depression
bull Episode of desaturation lt94 40-50
bull Almost all recover with nasal specs oxygen
Patient info sheet
bull Salient points
ndash Unlicensed use
ndash Audit data re safety
bull Given out at ante-natal clinic
bull Laminated copy in rooms
bull Reiterate in labour ward at request
Remifentanil PCA documentation bullInformed about Remifentanil At least 37 weeks bullInformation leaflet read No recent opiate use bullAware unlicensed use bullPCA technique explained ndash lockouttiming of demandspatient use only bull
bullRisks discussedbullSedation Respiratory depression Epidural conversion bullItch Supplementary oxygen bullNausea Failureinadequate pain relief Verbal consent bull
bullPrerequisites KardexbullDedicated IV canula Remi pump no PCA prescribed bullSpO2 monitoring Anaesthetist present Naloxone bull At initiation bullMidwife present Anti emetic bull
bullSignature _________________ Date amp time ______________________
Remi PCA in Belfast
bull 4000 deliveries ndash Elective LSCS 14
bull Routine use since 2004
bull 100-120 remi pcamth
bull 40 of labouring women choose remi pca
bull Epidural rate dropped to 35
Complications and controversyhellip
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40ndash Pruefer C Bewlay A Anaesthesia
2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesiabull Kinsella 2013
Complications and controversyhellip
Recent adverse reports
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40
ndash Pruefer C Bewlay A Anaesthesia 2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesia bull Kinsella 2013
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
Complications and controversyhellip
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
RESPITE trial 2014
bull Multicentre trial 400 women over 24 months
bull Comparing Remifentanil PCA with IM pethidine
bull Primary aim efficacy ndash VAS
ndash Proportion of women requiring an epidural for pain relief VAS
bull Secondary data adverse effects ndash Maternal sedation
ndash Unwanted effects on mother and baby
bull Clinical guidelines on the use of remifentanil
bull RESPITEtrialsbhamacuk
ldquohot off the pressrdquo
bull May - July 2014 audit data
bull 412 women
bull Efficacy and side effects
bull Outcomes
Satisfaction and efficacy
bull 80 satisfied or very satisfied
bull 87 ldquowould use againrdquo
bull Pain scores
ndash 48 none or mild pain
ndash 36 moderate pain
bull Conversion rate to epidural 129
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
Historyhelliphellip
Progresshelliphellip
Plus ccedila changehellip
bull Basic choiceshellip
bull Pharmacological or non-pharmacological
bull Systemic or regional
bull Opioid based or local anaesthetic based
Plus ccedila changehellip
bull Basic choiceshellip
bull Pharmacological or non-pharmacological
bull Systemic or regional
bull Opioid based or local anaesthetic based
Non-pharmacological analgesia
bull Usually not us
ndash TENS water acupuncture etc buthellip
Non-pharmacological analgesia
bull Hypnosishellip
bull Antenatal self-hypnosis for labour and childbirth A pilot studyndash 77 women (control 3249)
ndash Nulliparous fewer epidurals fewer augmentations
ndash Possible benefit further research neededbull AM Cyna et al
ndash Anaesthesia and Intensive Care 2006 34 (4)464-469 Australian Society of Anaesthetists
Howeverhellip
bull Hypnosis for pain management during labour and childbirth (Review)
ndash Madden K Middleton P Cyna AM Matthewson M Jones L bull The Cochrane Library 2012
Issue 11
bull No benefit shown for analgesia requirements
Pharmacological options
bull Systemicndash Entonox
ndash IM opioid
ndash Opioid PCA bull remifentanil
bull Regionalndash Epidural
ndash CSE
ndash Spinal
Pharmacological options
bull Systemicndash Entonox
ndash IM opioid
ndash Opioid PCA bull remifentanil
bull Regionalndash Epidural
ndash CSE
ndash Spinal
Labour with opioids
Labour with opioids
50 donrsquot have an epidural
bull Patient preference
bull No ldquoepidural servicerdquo
bull Thrombocytopenia
bull Anticoagulation
bull ldquoBack problemsrdquo
bull ldquoNeurologicalrdquo
bull ldquoSepsisrdquo
Systemic analgesiahellip
bull Not like an epidural labour
bull Different collaborative relationships
bull Maternal choice issues
bull Midwifery rather than anaesthesia
Systemic analgesia
bull Nitrous Oxide
ndash Ubiquitous UK (not USA)
ndash Patient controlbull Psychological benefit
ndash Low blood-gas solubilitybull Ideal for intermittent use
bull Rapid on-off effect
bull Doesnrsquot accumulate with intermittent use
ndash Often as an adjunct
Opioids
bull Mainstay of systemic analgesia
bull Intermittent bolus regimen
bull Administered by midwives
IM Pethidinebull ldquomore sedation than analgesiardquo1
bull gastric stasis amp hypoventilation 2
bull fetal effects after 40 mins 3
bull dose-delivery lt2-3hrs 4
bull modifies CTG amp EEG 5
bull fetal acidosis 6
bull active metabolites for days 7
1 Olofsson et al B J Obs Gynaecol 1996103968-72
2 Nimmo et al Lancet 19751(7912)890-3
3 Tomson G et al B J Clinical Pharmacology 198213653-9
4 Shnider SM Moya F Am J Obstet Gynecol 1964891009-15
5 Kariniemi V ammala P B J Ob Gynaecol 198188718-20
6 Kariniemi V Rosti J J Perinatal Med 198614131-5
7 Hodgkinson R Farkhanda JH Anesthesiology 19825651-2
What do women wantSytematic review of 137 reports of the views of 14000 women in 9 countries
Satisfaction
ndash Expectations
ndash Support
ndash Quality of relationship with midwife
ndash Involvement in decision making
Dissatisfaction
ndash Failure of timing amp lack of availability of analgesia
Hodnett 2002 Saisto 2001 Ranta 2002 May 2000
Complete analgesia did not rate highly
bull REVIEW
bull Maternal satisfaction
bull PN Robinson P Salmon SM Yentisndash International Journal of Obstetric
Anesthesia (1998) 7 32-37
bull ldquoSatisfaction is multidimensionaland therefore difficult to define assess and measurerdquo
bull ldquoStudies assume that satisfaction with anaesthetic practice equates with good analgesia although as we have shown this is only one dimension of satisfactionrdquo
Regional analgesia ndashthe be all and end all
bull Epidural versus non-epidural or no analgesia in labour
bull Anim-Somuah M1 Smyth RM Jones L
ndash Cochrane Database Syst Rev 2011 Dec 7(12)
Cochrane Conclusionhellip
bull Epidural analgesia appears to be effective in reducing pain during labour
bull However women who use this form of pain relief are at increased risk of having an instrumental delivery
bull Epidural analgesia had no statistically significant impact on the risk of caesarean section maternal satisfaction with pain relief and long-term backache and did not appear to have an immediate effect on neonatal status as determined by Apgar scores
bull Further research may be helpful to evaluate rare but potentially severe adverse effects of epidural analgesia on women in labour and long-term neonatal outcomes
What do women wantSytematic review of 137 reports of the views of 14000 women in 9 countries
Satisfaction
ndash Expectations
ndash Support
ndash Quality of relationship with midwife
ndash Involvement in decision making
Dissatisfaction
ndash Failure of timing amp lack of availability of analgesia
Hodnett 2002 Saisto 2001 Ranta 2002 May 2000
Complete analgesia did not rate highly
The search for an alternative
bull Match time course of labour
bull Not midwife delivered patient control
bull Few maternal amp neonatal adverse effects
Rapid onset and offset amp intravenous
PCA device
Non cumulative
o
f p
eak
eff
ect
site
con
centr
atio
n
Fentanyl
Alfentanil
100
0
Time since bolus (min)
2 4 6
Effect site concentration after opioid bolus
80 10
Remifentanil
Remifentanil pharmacokinetics in neonates
bull Infants under 2 months
bull Pharmacokinetics similar
ndash to older children
ndash to adults
Davis Ross Henson et al Remifentanil pharmacokinetics in neonates
Anesthesiology 1997 87 A 1054
Remifentanil PCA
bull Theory behind techniquendash PCA giving control improves
satisfaction
bull Theory behind choice of drugndash Ultra short-acting rapidly
metabolised
ndash Placental transfer but rapid metabolism in neonatebull Kan et al Anesthesiology1998
88 1467-74
ndash Context sensitive t12 3-5min
ndash Ideal for intermittent pain of labour
Remi pca in practicebull Feasibility for labour analgesia
2001 ndash Blair et al BJA 2001
bull Optimum bolus 05mcgkg no background infusionndash Superior to pethidine
bull Blair et al BJA 2005
bull Shown superior to pethidinendash efficacy satisfaction conversion to
epiduralbull Thurlow et al BJA 2002 Douma et al
BJA 2010
bull No difference in neonatal outcomesndash Review by Leong et al Anes amp Analg
2011
Remi pca in practice
bull Strict protocol
ndash Dedicated IV cannula
ndash Dedicated pumps
ndash Locked pump programmebull 40mcg bolus 2min lockout
ndash Observation chart
Safety with remi
bull One-to-one midwifery care
bull Anaesthetist prescribes and starts pca
bull Strict monitoring
bull Observation chart
bull Immediate oxygen and resuscitation availability
bull Continuous audit
Side effects
bull Nausea
ndash approx 90 use Entonox
bull Itch
bull Sedation
bull Respiratory depression
bull Episode of desaturation lt94 40-50
bull Almost all recover with nasal specs oxygen
Patient info sheet
bull Salient points
ndash Unlicensed use
ndash Audit data re safety
bull Given out at ante-natal clinic
bull Laminated copy in rooms
bull Reiterate in labour ward at request
Remifentanil PCA documentation bullInformed about Remifentanil At least 37 weeks bullInformation leaflet read No recent opiate use bullAware unlicensed use bullPCA technique explained ndash lockouttiming of demandspatient use only bull
bullRisks discussedbullSedation Respiratory depression Epidural conversion bullItch Supplementary oxygen bullNausea Failureinadequate pain relief Verbal consent bull
bullPrerequisites KardexbullDedicated IV canula Remi pump no PCA prescribed bullSpO2 monitoring Anaesthetist present Naloxone bull At initiation bullMidwife present Anti emetic bull
bullSignature _________________ Date amp time ______________________
Remi PCA in Belfast
bull 4000 deliveries ndash Elective LSCS 14
bull Routine use since 2004
bull 100-120 remi pcamth
bull 40 of labouring women choose remi pca
bull Epidural rate dropped to 35
Complications and controversyhellip
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40ndash Pruefer C Bewlay A Anaesthesia
2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesiabull Kinsella 2013
Complications and controversyhellip
Recent adverse reports
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40
ndash Pruefer C Bewlay A Anaesthesia 2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesia bull Kinsella 2013
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
Complications and controversyhellip
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
RESPITE trial 2014
bull Multicentre trial 400 women over 24 months
bull Comparing Remifentanil PCA with IM pethidine
bull Primary aim efficacy ndash VAS
ndash Proportion of women requiring an epidural for pain relief VAS
bull Secondary data adverse effects ndash Maternal sedation
ndash Unwanted effects on mother and baby
bull Clinical guidelines on the use of remifentanil
bull RESPITEtrialsbhamacuk
ldquohot off the pressrdquo
bull May - July 2014 audit data
bull 412 women
bull Efficacy and side effects
bull Outcomes
Satisfaction and efficacy
bull 80 satisfied or very satisfied
bull 87 ldquowould use againrdquo
bull Pain scores
ndash 48 none or mild pain
ndash 36 moderate pain
bull Conversion rate to epidural 129
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
Progresshelliphellip
Plus ccedila changehellip
bull Basic choiceshellip
bull Pharmacological or non-pharmacological
bull Systemic or regional
bull Opioid based or local anaesthetic based
Plus ccedila changehellip
bull Basic choiceshellip
bull Pharmacological or non-pharmacological
bull Systemic or regional
bull Opioid based or local anaesthetic based
Non-pharmacological analgesia
bull Usually not us
ndash TENS water acupuncture etc buthellip
Non-pharmacological analgesia
bull Hypnosishellip
bull Antenatal self-hypnosis for labour and childbirth A pilot studyndash 77 women (control 3249)
ndash Nulliparous fewer epidurals fewer augmentations
ndash Possible benefit further research neededbull AM Cyna et al
ndash Anaesthesia and Intensive Care 2006 34 (4)464-469 Australian Society of Anaesthetists
Howeverhellip
bull Hypnosis for pain management during labour and childbirth (Review)
ndash Madden K Middleton P Cyna AM Matthewson M Jones L bull The Cochrane Library 2012
Issue 11
bull No benefit shown for analgesia requirements
Pharmacological options
bull Systemicndash Entonox
ndash IM opioid
ndash Opioid PCA bull remifentanil
bull Regionalndash Epidural
ndash CSE
ndash Spinal
Pharmacological options
bull Systemicndash Entonox
ndash IM opioid
ndash Opioid PCA bull remifentanil
bull Regionalndash Epidural
ndash CSE
ndash Spinal
Labour with opioids
Labour with opioids
50 donrsquot have an epidural
bull Patient preference
bull No ldquoepidural servicerdquo
bull Thrombocytopenia
bull Anticoagulation
bull ldquoBack problemsrdquo
bull ldquoNeurologicalrdquo
bull ldquoSepsisrdquo
Systemic analgesiahellip
bull Not like an epidural labour
bull Different collaborative relationships
bull Maternal choice issues
bull Midwifery rather than anaesthesia
Systemic analgesia
bull Nitrous Oxide
ndash Ubiquitous UK (not USA)
ndash Patient controlbull Psychological benefit
ndash Low blood-gas solubilitybull Ideal for intermittent use
bull Rapid on-off effect
bull Doesnrsquot accumulate with intermittent use
ndash Often as an adjunct
Opioids
bull Mainstay of systemic analgesia
bull Intermittent bolus regimen
bull Administered by midwives
IM Pethidinebull ldquomore sedation than analgesiardquo1
bull gastric stasis amp hypoventilation 2
bull fetal effects after 40 mins 3
bull dose-delivery lt2-3hrs 4
bull modifies CTG amp EEG 5
bull fetal acidosis 6
bull active metabolites for days 7
1 Olofsson et al B J Obs Gynaecol 1996103968-72
2 Nimmo et al Lancet 19751(7912)890-3
3 Tomson G et al B J Clinical Pharmacology 198213653-9
4 Shnider SM Moya F Am J Obstet Gynecol 1964891009-15
5 Kariniemi V ammala P B J Ob Gynaecol 198188718-20
6 Kariniemi V Rosti J J Perinatal Med 198614131-5
7 Hodgkinson R Farkhanda JH Anesthesiology 19825651-2
What do women wantSytematic review of 137 reports of the views of 14000 women in 9 countries
Satisfaction
ndash Expectations
ndash Support
ndash Quality of relationship with midwife
ndash Involvement in decision making
Dissatisfaction
ndash Failure of timing amp lack of availability of analgesia
Hodnett 2002 Saisto 2001 Ranta 2002 May 2000
Complete analgesia did not rate highly
bull REVIEW
bull Maternal satisfaction
bull PN Robinson P Salmon SM Yentisndash International Journal of Obstetric
Anesthesia (1998) 7 32-37
bull ldquoSatisfaction is multidimensionaland therefore difficult to define assess and measurerdquo
bull ldquoStudies assume that satisfaction with anaesthetic practice equates with good analgesia although as we have shown this is only one dimension of satisfactionrdquo
Regional analgesia ndashthe be all and end all
bull Epidural versus non-epidural or no analgesia in labour
bull Anim-Somuah M1 Smyth RM Jones L
ndash Cochrane Database Syst Rev 2011 Dec 7(12)
Cochrane Conclusionhellip
bull Epidural analgesia appears to be effective in reducing pain during labour
bull However women who use this form of pain relief are at increased risk of having an instrumental delivery
bull Epidural analgesia had no statistically significant impact on the risk of caesarean section maternal satisfaction with pain relief and long-term backache and did not appear to have an immediate effect on neonatal status as determined by Apgar scores
bull Further research may be helpful to evaluate rare but potentially severe adverse effects of epidural analgesia on women in labour and long-term neonatal outcomes
What do women wantSytematic review of 137 reports of the views of 14000 women in 9 countries
Satisfaction
ndash Expectations
ndash Support
ndash Quality of relationship with midwife
ndash Involvement in decision making
Dissatisfaction
ndash Failure of timing amp lack of availability of analgesia
Hodnett 2002 Saisto 2001 Ranta 2002 May 2000
Complete analgesia did not rate highly
The search for an alternative
bull Match time course of labour
bull Not midwife delivered patient control
bull Few maternal amp neonatal adverse effects
Rapid onset and offset amp intravenous
PCA device
Non cumulative
o
f p
eak
eff
ect
site
con
centr
atio
n
Fentanyl
Alfentanil
100
0
Time since bolus (min)
2 4 6
Effect site concentration after opioid bolus
80 10
Remifentanil
Remifentanil pharmacokinetics in neonates
bull Infants under 2 months
bull Pharmacokinetics similar
ndash to older children
ndash to adults
Davis Ross Henson et al Remifentanil pharmacokinetics in neonates
Anesthesiology 1997 87 A 1054
Remifentanil PCA
bull Theory behind techniquendash PCA giving control improves
satisfaction
bull Theory behind choice of drugndash Ultra short-acting rapidly
metabolised
ndash Placental transfer but rapid metabolism in neonatebull Kan et al Anesthesiology1998
88 1467-74
ndash Context sensitive t12 3-5min
ndash Ideal for intermittent pain of labour
Remi pca in practicebull Feasibility for labour analgesia
2001 ndash Blair et al BJA 2001
bull Optimum bolus 05mcgkg no background infusionndash Superior to pethidine
bull Blair et al BJA 2005
bull Shown superior to pethidinendash efficacy satisfaction conversion to
epiduralbull Thurlow et al BJA 2002 Douma et al
BJA 2010
bull No difference in neonatal outcomesndash Review by Leong et al Anes amp Analg
2011
Remi pca in practice
bull Strict protocol
ndash Dedicated IV cannula
ndash Dedicated pumps
ndash Locked pump programmebull 40mcg bolus 2min lockout
ndash Observation chart
Safety with remi
bull One-to-one midwifery care
bull Anaesthetist prescribes and starts pca
bull Strict monitoring
bull Observation chart
bull Immediate oxygen and resuscitation availability
bull Continuous audit
Side effects
bull Nausea
ndash approx 90 use Entonox
bull Itch
bull Sedation
bull Respiratory depression
bull Episode of desaturation lt94 40-50
bull Almost all recover with nasal specs oxygen
Patient info sheet
bull Salient points
ndash Unlicensed use
ndash Audit data re safety
bull Given out at ante-natal clinic
bull Laminated copy in rooms
bull Reiterate in labour ward at request
Remifentanil PCA documentation bullInformed about Remifentanil At least 37 weeks bullInformation leaflet read No recent opiate use bullAware unlicensed use bullPCA technique explained ndash lockouttiming of demandspatient use only bull
bullRisks discussedbullSedation Respiratory depression Epidural conversion bullItch Supplementary oxygen bullNausea Failureinadequate pain relief Verbal consent bull
bullPrerequisites KardexbullDedicated IV canula Remi pump no PCA prescribed bullSpO2 monitoring Anaesthetist present Naloxone bull At initiation bullMidwife present Anti emetic bull
bullSignature _________________ Date amp time ______________________
Remi PCA in Belfast
bull 4000 deliveries ndash Elective LSCS 14
bull Routine use since 2004
bull 100-120 remi pcamth
bull 40 of labouring women choose remi pca
bull Epidural rate dropped to 35
Complications and controversyhellip
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40ndash Pruefer C Bewlay A Anaesthesia
2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesiabull Kinsella 2013
Complications and controversyhellip
Recent adverse reports
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40
ndash Pruefer C Bewlay A Anaesthesia 2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesia bull Kinsella 2013
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
Complications and controversyhellip
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
RESPITE trial 2014
bull Multicentre trial 400 women over 24 months
bull Comparing Remifentanil PCA with IM pethidine
bull Primary aim efficacy ndash VAS
ndash Proportion of women requiring an epidural for pain relief VAS
bull Secondary data adverse effects ndash Maternal sedation
ndash Unwanted effects on mother and baby
bull Clinical guidelines on the use of remifentanil
bull RESPITEtrialsbhamacuk
ldquohot off the pressrdquo
bull May - July 2014 audit data
bull 412 women
bull Efficacy and side effects
bull Outcomes
Satisfaction and efficacy
bull 80 satisfied or very satisfied
bull 87 ldquowould use againrdquo
bull Pain scores
ndash 48 none or mild pain
ndash 36 moderate pain
bull Conversion rate to epidural 129
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
Plus ccedila changehellip
bull Basic choiceshellip
bull Pharmacological or non-pharmacological
bull Systemic or regional
bull Opioid based or local anaesthetic based
Plus ccedila changehellip
bull Basic choiceshellip
bull Pharmacological or non-pharmacological
bull Systemic or regional
bull Opioid based or local anaesthetic based
Non-pharmacological analgesia
bull Usually not us
ndash TENS water acupuncture etc buthellip
Non-pharmacological analgesia
bull Hypnosishellip
bull Antenatal self-hypnosis for labour and childbirth A pilot studyndash 77 women (control 3249)
ndash Nulliparous fewer epidurals fewer augmentations
ndash Possible benefit further research neededbull AM Cyna et al
ndash Anaesthesia and Intensive Care 2006 34 (4)464-469 Australian Society of Anaesthetists
Howeverhellip
bull Hypnosis for pain management during labour and childbirth (Review)
ndash Madden K Middleton P Cyna AM Matthewson M Jones L bull The Cochrane Library 2012
Issue 11
bull No benefit shown for analgesia requirements
Pharmacological options
bull Systemicndash Entonox
ndash IM opioid
ndash Opioid PCA bull remifentanil
bull Regionalndash Epidural
ndash CSE
ndash Spinal
Pharmacological options
bull Systemicndash Entonox
ndash IM opioid
ndash Opioid PCA bull remifentanil
bull Regionalndash Epidural
ndash CSE
ndash Spinal
Labour with opioids
Labour with opioids
50 donrsquot have an epidural
bull Patient preference
bull No ldquoepidural servicerdquo
bull Thrombocytopenia
bull Anticoagulation
bull ldquoBack problemsrdquo
bull ldquoNeurologicalrdquo
bull ldquoSepsisrdquo
Systemic analgesiahellip
bull Not like an epidural labour
bull Different collaborative relationships
bull Maternal choice issues
bull Midwifery rather than anaesthesia
Systemic analgesia
bull Nitrous Oxide
ndash Ubiquitous UK (not USA)
ndash Patient controlbull Psychological benefit
ndash Low blood-gas solubilitybull Ideal for intermittent use
bull Rapid on-off effect
bull Doesnrsquot accumulate with intermittent use
ndash Often as an adjunct
Opioids
bull Mainstay of systemic analgesia
bull Intermittent bolus regimen
bull Administered by midwives
IM Pethidinebull ldquomore sedation than analgesiardquo1
bull gastric stasis amp hypoventilation 2
bull fetal effects after 40 mins 3
bull dose-delivery lt2-3hrs 4
bull modifies CTG amp EEG 5
bull fetal acidosis 6
bull active metabolites for days 7
1 Olofsson et al B J Obs Gynaecol 1996103968-72
2 Nimmo et al Lancet 19751(7912)890-3
3 Tomson G et al B J Clinical Pharmacology 198213653-9
4 Shnider SM Moya F Am J Obstet Gynecol 1964891009-15
5 Kariniemi V ammala P B J Ob Gynaecol 198188718-20
6 Kariniemi V Rosti J J Perinatal Med 198614131-5
7 Hodgkinson R Farkhanda JH Anesthesiology 19825651-2
What do women wantSytematic review of 137 reports of the views of 14000 women in 9 countries
Satisfaction
ndash Expectations
ndash Support
ndash Quality of relationship with midwife
ndash Involvement in decision making
Dissatisfaction
ndash Failure of timing amp lack of availability of analgesia
Hodnett 2002 Saisto 2001 Ranta 2002 May 2000
Complete analgesia did not rate highly
bull REVIEW
bull Maternal satisfaction
bull PN Robinson P Salmon SM Yentisndash International Journal of Obstetric
Anesthesia (1998) 7 32-37
bull ldquoSatisfaction is multidimensionaland therefore difficult to define assess and measurerdquo
bull ldquoStudies assume that satisfaction with anaesthetic practice equates with good analgesia although as we have shown this is only one dimension of satisfactionrdquo
Regional analgesia ndashthe be all and end all
bull Epidural versus non-epidural or no analgesia in labour
bull Anim-Somuah M1 Smyth RM Jones L
ndash Cochrane Database Syst Rev 2011 Dec 7(12)
Cochrane Conclusionhellip
bull Epidural analgesia appears to be effective in reducing pain during labour
bull However women who use this form of pain relief are at increased risk of having an instrumental delivery
bull Epidural analgesia had no statistically significant impact on the risk of caesarean section maternal satisfaction with pain relief and long-term backache and did not appear to have an immediate effect on neonatal status as determined by Apgar scores
bull Further research may be helpful to evaluate rare but potentially severe adverse effects of epidural analgesia on women in labour and long-term neonatal outcomes
What do women wantSytematic review of 137 reports of the views of 14000 women in 9 countries
Satisfaction
ndash Expectations
ndash Support
ndash Quality of relationship with midwife
ndash Involvement in decision making
Dissatisfaction
ndash Failure of timing amp lack of availability of analgesia
Hodnett 2002 Saisto 2001 Ranta 2002 May 2000
Complete analgesia did not rate highly
The search for an alternative
bull Match time course of labour
bull Not midwife delivered patient control
bull Few maternal amp neonatal adverse effects
Rapid onset and offset amp intravenous
PCA device
Non cumulative
o
f p
eak
eff
ect
site
con
centr
atio
n
Fentanyl
Alfentanil
100
0
Time since bolus (min)
2 4 6
Effect site concentration after opioid bolus
80 10
Remifentanil
Remifentanil pharmacokinetics in neonates
bull Infants under 2 months
bull Pharmacokinetics similar
ndash to older children
ndash to adults
Davis Ross Henson et al Remifentanil pharmacokinetics in neonates
Anesthesiology 1997 87 A 1054
Remifentanil PCA
bull Theory behind techniquendash PCA giving control improves
satisfaction
bull Theory behind choice of drugndash Ultra short-acting rapidly
metabolised
ndash Placental transfer but rapid metabolism in neonatebull Kan et al Anesthesiology1998
88 1467-74
ndash Context sensitive t12 3-5min
ndash Ideal for intermittent pain of labour
Remi pca in practicebull Feasibility for labour analgesia
2001 ndash Blair et al BJA 2001
bull Optimum bolus 05mcgkg no background infusionndash Superior to pethidine
bull Blair et al BJA 2005
bull Shown superior to pethidinendash efficacy satisfaction conversion to
epiduralbull Thurlow et al BJA 2002 Douma et al
BJA 2010
bull No difference in neonatal outcomesndash Review by Leong et al Anes amp Analg
2011
Remi pca in practice
bull Strict protocol
ndash Dedicated IV cannula
ndash Dedicated pumps
ndash Locked pump programmebull 40mcg bolus 2min lockout
ndash Observation chart
Safety with remi
bull One-to-one midwifery care
bull Anaesthetist prescribes and starts pca
bull Strict monitoring
bull Observation chart
bull Immediate oxygen and resuscitation availability
bull Continuous audit
Side effects
bull Nausea
ndash approx 90 use Entonox
bull Itch
bull Sedation
bull Respiratory depression
bull Episode of desaturation lt94 40-50
bull Almost all recover with nasal specs oxygen
Patient info sheet
bull Salient points
ndash Unlicensed use
ndash Audit data re safety
bull Given out at ante-natal clinic
bull Laminated copy in rooms
bull Reiterate in labour ward at request
Remifentanil PCA documentation bullInformed about Remifentanil At least 37 weeks bullInformation leaflet read No recent opiate use bullAware unlicensed use bullPCA technique explained ndash lockouttiming of demandspatient use only bull
bullRisks discussedbullSedation Respiratory depression Epidural conversion bullItch Supplementary oxygen bullNausea Failureinadequate pain relief Verbal consent bull
bullPrerequisites KardexbullDedicated IV canula Remi pump no PCA prescribed bullSpO2 monitoring Anaesthetist present Naloxone bull At initiation bullMidwife present Anti emetic bull
bullSignature _________________ Date amp time ______________________
Remi PCA in Belfast
bull 4000 deliveries ndash Elective LSCS 14
bull Routine use since 2004
bull 100-120 remi pcamth
bull 40 of labouring women choose remi pca
bull Epidural rate dropped to 35
Complications and controversyhellip
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40ndash Pruefer C Bewlay A Anaesthesia
2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesiabull Kinsella 2013
Complications and controversyhellip
Recent adverse reports
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40
ndash Pruefer C Bewlay A Anaesthesia 2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesia bull Kinsella 2013
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
Complications and controversyhellip
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
RESPITE trial 2014
bull Multicentre trial 400 women over 24 months
bull Comparing Remifentanil PCA with IM pethidine
bull Primary aim efficacy ndash VAS
ndash Proportion of women requiring an epidural for pain relief VAS
bull Secondary data adverse effects ndash Maternal sedation
ndash Unwanted effects on mother and baby
bull Clinical guidelines on the use of remifentanil
bull RESPITEtrialsbhamacuk
ldquohot off the pressrdquo
bull May - July 2014 audit data
bull 412 women
bull Efficacy and side effects
bull Outcomes
Satisfaction and efficacy
bull 80 satisfied or very satisfied
bull 87 ldquowould use againrdquo
bull Pain scores
ndash 48 none or mild pain
ndash 36 moderate pain
bull Conversion rate to epidural 129
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
Plus ccedila changehellip
bull Basic choiceshellip
bull Pharmacological or non-pharmacological
bull Systemic or regional
bull Opioid based or local anaesthetic based
Non-pharmacological analgesia
bull Usually not us
ndash TENS water acupuncture etc buthellip
Non-pharmacological analgesia
bull Hypnosishellip
bull Antenatal self-hypnosis for labour and childbirth A pilot studyndash 77 women (control 3249)
ndash Nulliparous fewer epidurals fewer augmentations
ndash Possible benefit further research neededbull AM Cyna et al
ndash Anaesthesia and Intensive Care 2006 34 (4)464-469 Australian Society of Anaesthetists
Howeverhellip
bull Hypnosis for pain management during labour and childbirth (Review)
ndash Madden K Middleton P Cyna AM Matthewson M Jones L bull The Cochrane Library 2012
Issue 11
bull No benefit shown for analgesia requirements
Pharmacological options
bull Systemicndash Entonox
ndash IM opioid
ndash Opioid PCA bull remifentanil
bull Regionalndash Epidural
ndash CSE
ndash Spinal
Pharmacological options
bull Systemicndash Entonox
ndash IM opioid
ndash Opioid PCA bull remifentanil
bull Regionalndash Epidural
ndash CSE
ndash Spinal
Labour with opioids
Labour with opioids
50 donrsquot have an epidural
bull Patient preference
bull No ldquoepidural servicerdquo
bull Thrombocytopenia
bull Anticoagulation
bull ldquoBack problemsrdquo
bull ldquoNeurologicalrdquo
bull ldquoSepsisrdquo
Systemic analgesiahellip
bull Not like an epidural labour
bull Different collaborative relationships
bull Maternal choice issues
bull Midwifery rather than anaesthesia
Systemic analgesia
bull Nitrous Oxide
ndash Ubiquitous UK (not USA)
ndash Patient controlbull Psychological benefit
ndash Low blood-gas solubilitybull Ideal for intermittent use
bull Rapid on-off effect
bull Doesnrsquot accumulate with intermittent use
ndash Often as an adjunct
Opioids
bull Mainstay of systemic analgesia
bull Intermittent bolus regimen
bull Administered by midwives
IM Pethidinebull ldquomore sedation than analgesiardquo1
bull gastric stasis amp hypoventilation 2
bull fetal effects after 40 mins 3
bull dose-delivery lt2-3hrs 4
bull modifies CTG amp EEG 5
bull fetal acidosis 6
bull active metabolites for days 7
1 Olofsson et al B J Obs Gynaecol 1996103968-72
2 Nimmo et al Lancet 19751(7912)890-3
3 Tomson G et al B J Clinical Pharmacology 198213653-9
4 Shnider SM Moya F Am J Obstet Gynecol 1964891009-15
5 Kariniemi V ammala P B J Ob Gynaecol 198188718-20
6 Kariniemi V Rosti J J Perinatal Med 198614131-5
7 Hodgkinson R Farkhanda JH Anesthesiology 19825651-2
What do women wantSytematic review of 137 reports of the views of 14000 women in 9 countries
Satisfaction
ndash Expectations
ndash Support
ndash Quality of relationship with midwife
ndash Involvement in decision making
Dissatisfaction
ndash Failure of timing amp lack of availability of analgesia
Hodnett 2002 Saisto 2001 Ranta 2002 May 2000
Complete analgesia did not rate highly
bull REVIEW
bull Maternal satisfaction
bull PN Robinson P Salmon SM Yentisndash International Journal of Obstetric
Anesthesia (1998) 7 32-37
bull ldquoSatisfaction is multidimensionaland therefore difficult to define assess and measurerdquo
bull ldquoStudies assume that satisfaction with anaesthetic practice equates with good analgesia although as we have shown this is only one dimension of satisfactionrdquo
Regional analgesia ndashthe be all and end all
bull Epidural versus non-epidural or no analgesia in labour
bull Anim-Somuah M1 Smyth RM Jones L
ndash Cochrane Database Syst Rev 2011 Dec 7(12)
Cochrane Conclusionhellip
bull Epidural analgesia appears to be effective in reducing pain during labour
bull However women who use this form of pain relief are at increased risk of having an instrumental delivery
bull Epidural analgesia had no statistically significant impact on the risk of caesarean section maternal satisfaction with pain relief and long-term backache and did not appear to have an immediate effect on neonatal status as determined by Apgar scores
bull Further research may be helpful to evaluate rare but potentially severe adverse effects of epidural analgesia on women in labour and long-term neonatal outcomes
What do women wantSytematic review of 137 reports of the views of 14000 women in 9 countries
Satisfaction
ndash Expectations
ndash Support
ndash Quality of relationship with midwife
ndash Involvement in decision making
Dissatisfaction
ndash Failure of timing amp lack of availability of analgesia
Hodnett 2002 Saisto 2001 Ranta 2002 May 2000
Complete analgesia did not rate highly
The search for an alternative
bull Match time course of labour
bull Not midwife delivered patient control
bull Few maternal amp neonatal adverse effects
Rapid onset and offset amp intravenous
PCA device
Non cumulative
o
f p
eak
eff
ect
site
con
centr
atio
n
Fentanyl
Alfentanil
100
0
Time since bolus (min)
2 4 6
Effect site concentration after opioid bolus
80 10
Remifentanil
Remifentanil pharmacokinetics in neonates
bull Infants under 2 months
bull Pharmacokinetics similar
ndash to older children
ndash to adults
Davis Ross Henson et al Remifentanil pharmacokinetics in neonates
Anesthesiology 1997 87 A 1054
Remifentanil PCA
bull Theory behind techniquendash PCA giving control improves
satisfaction
bull Theory behind choice of drugndash Ultra short-acting rapidly
metabolised
ndash Placental transfer but rapid metabolism in neonatebull Kan et al Anesthesiology1998
88 1467-74
ndash Context sensitive t12 3-5min
ndash Ideal for intermittent pain of labour
Remi pca in practicebull Feasibility for labour analgesia
2001 ndash Blair et al BJA 2001
bull Optimum bolus 05mcgkg no background infusionndash Superior to pethidine
bull Blair et al BJA 2005
bull Shown superior to pethidinendash efficacy satisfaction conversion to
epiduralbull Thurlow et al BJA 2002 Douma et al
BJA 2010
bull No difference in neonatal outcomesndash Review by Leong et al Anes amp Analg
2011
Remi pca in practice
bull Strict protocol
ndash Dedicated IV cannula
ndash Dedicated pumps
ndash Locked pump programmebull 40mcg bolus 2min lockout
ndash Observation chart
Safety with remi
bull One-to-one midwifery care
bull Anaesthetist prescribes and starts pca
bull Strict monitoring
bull Observation chart
bull Immediate oxygen and resuscitation availability
bull Continuous audit
Side effects
bull Nausea
ndash approx 90 use Entonox
bull Itch
bull Sedation
bull Respiratory depression
bull Episode of desaturation lt94 40-50
bull Almost all recover with nasal specs oxygen
Patient info sheet
bull Salient points
ndash Unlicensed use
ndash Audit data re safety
bull Given out at ante-natal clinic
bull Laminated copy in rooms
bull Reiterate in labour ward at request
Remifentanil PCA documentation bullInformed about Remifentanil At least 37 weeks bullInformation leaflet read No recent opiate use bullAware unlicensed use bullPCA technique explained ndash lockouttiming of demandspatient use only bull
bullRisks discussedbullSedation Respiratory depression Epidural conversion bullItch Supplementary oxygen bullNausea Failureinadequate pain relief Verbal consent bull
bullPrerequisites KardexbullDedicated IV canula Remi pump no PCA prescribed bullSpO2 monitoring Anaesthetist present Naloxone bull At initiation bullMidwife present Anti emetic bull
bullSignature _________________ Date amp time ______________________
Remi PCA in Belfast
bull 4000 deliveries ndash Elective LSCS 14
bull Routine use since 2004
bull 100-120 remi pcamth
bull 40 of labouring women choose remi pca
bull Epidural rate dropped to 35
Complications and controversyhellip
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40ndash Pruefer C Bewlay A Anaesthesia
2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesiabull Kinsella 2013
Complications and controversyhellip
Recent adverse reports
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40
ndash Pruefer C Bewlay A Anaesthesia 2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesia bull Kinsella 2013
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
Complications and controversyhellip
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
RESPITE trial 2014
bull Multicentre trial 400 women over 24 months
bull Comparing Remifentanil PCA with IM pethidine
bull Primary aim efficacy ndash VAS
ndash Proportion of women requiring an epidural for pain relief VAS
bull Secondary data adverse effects ndash Maternal sedation
ndash Unwanted effects on mother and baby
bull Clinical guidelines on the use of remifentanil
bull RESPITEtrialsbhamacuk
ldquohot off the pressrdquo
bull May - July 2014 audit data
bull 412 women
bull Efficacy and side effects
bull Outcomes
Satisfaction and efficacy
bull 80 satisfied or very satisfied
bull 87 ldquowould use againrdquo
bull Pain scores
ndash 48 none or mild pain
ndash 36 moderate pain
bull Conversion rate to epidural 129
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
Non-pharmacological analgesia
bull Usually not us
ndash TENS water acupuncture etc buthellip
Non-pharmacological analgesia
bull Hypnosishellip
bull Antenatal self-hypnosis for labour and childbirth A pilot studyndash 77 women (control 3249)
ndash Nulliparous fewer epidurals fewer augmentations
ndash Possible benefit further research neededbull AM Cyna et al
ndash Anaesthesia and Intensive Care 2006 34 (4)464-469 Australian Society of Anaesthetists
Howeverhellip
bull Hypnosis for pain management during labour and childbirth (Review)
ndash Madden K Middleton P Cyna AM Matthewson M Jones L bull The Cochrane Library 2012
Issue 11
bull No benefit shown for analgesia requirements
Pharmacological options
bull Systemicndash Entonox
ndash IM opioid
ndash Opioid PCA bull remifentanil
bull Regionalndash Epidural
ndash CSE
ndash Spinal
Pharmacological options
bull Systemicndash Entonox
ndash IM opioid
ndash Opioid PCA bull remifentanil
bull Regionalndash Epidural
ndash CSE
ndash Spinal
Labour with opioids
Labour with opioids
50 donrsquot have an epidural
bull Patient preference
bull No ldquoepidural servicerdquo
bull Thrombocytopenia
bull Anticoagulation
bull ldquoBack problemsrdquo
bull ldquoNeurologicalrdquo
bull ldquoSepsisrdquo
Systemic analgesiahellip
bull Not like an epidural labour
bull Different collaborative relationships
bull Maternal choice issues
bull Midwifery rather than anaesthesia
Systemic analgesia
bull Nitrous Oxide
ndash Ubiquitous UK (not USA)
ndash Patient controlbull Psychological benefit
ndash Low blood-gas solubilitybull Ideal for intermittent use
bull Rapid on-off effect
bull Doesnrsquot accumulate with intermittent use
ndash Often as an adjunct
Opioids
bull Mainstay of systemic analgesia
bull Intermittent bolus regimen
bull Administered by midwives
IM Pethidinebull ldquomore sedation than analgesiardquo1
bull gastric stasis amp hypoventilation 2
bull fetal effects after 40 mins 3
bull dose-delivery lt2-3hrs 4
bull modifies CTG amp EEG 5
bull fetal acidosis 6
bull active metabolites for days 7
1 Olofsson et al B J Obs Gynaecol 1996103968-72
2 Nimmo et al Lancet 19751(7912)890-3
3 Tomson G et al B J Clinical Pharmacology 198213653-9
4 Shnider SM Moya F Am J Obstet Gynecol 1964891009-15
5 Kariniemi V ammala P B J Ob Gynaecol 198188718-20
6 Kariniemi V Rosti J J Perinatal Med 198614131-5
7 Hodgkinson R Farkhanda JH Anesthesiology 19825651-2
What do women wantSytematic review of 137 reports of the views of 14000 women in 9 countries
Satisfaction
ndash Expectations
ndash Support
ndash Quality of relationship with midwife
ndash Involvement in decision making
Dissatisfaction
ndash Failure of timing amp lack of availability of analgesia
Hodnett 2002 Saisto 2001 Ranta 2002 May 2000
Complete analgesia did not rate highly
bull REVIEW
bull Maternal satisfaction
bull PN Robinson P Salmon SM Yentisndash International Journal of Obstetric
Anesthesia (1998) 7 32-37
bull ldquoSatisfaction is multidimensionaland therefore difficult to define assess and measurerdquo
bull ldquoStudies assume that satisfaction with anaesthetic practice equates with good analgesia although as we have shown this is only one dimension of satisfactionrdquo
Regional analgesia ndashthe be all and end all
bull Epidural versus non-epidural or no analgesia in labour
bull Anim-Somuah M1 Smyth RM Jones L
ndash Cochrane Database Syst Rev 2011 Dec 7(12)
Cochrane Conclusionhellip
bull Epidural analgesia appears to be effective in reducing pain during labour
bull However women who use this form of pain relief are at increased risk of having an instrumental delivery
bull Epidural analgesia had no statistically significant impact on the risk of caesarean section maternal satisfaction with pain relief and long-term backache and did not appear to have an immediate effect on neonatal status as determined by Apgar scores
bull Further research may be helpful to evaluate rare but potentially severe adverse effects of epidural analgesia on women in labour and long-term neonatal outcomes
What do women wantSytematic review of 137 reports of the views of 14000 women in 9 countries
Satisfaction
ndash Expectations
ndash Support
ndash Quality of relationship with midwife
ndash Involvement in decision making
Dissatisfaction
ndash Failure of timing amp lack of availability of analgesia
Hodnett 2002 Saisto 2001 Ranta 2002 May 2000
Complete analgesia did not rate highly
The search for an alternative
bull Match time course of labour
bull Not midwife delivered patient control
bull Few maternal amp neonatal adverse effects
Rapid onset and offset amp intravenous
PCA device
Non cumulative
o
f p
eak
eff
ect
site
con
centr
atio
n
Fentanyl
Alfentanil
100
0
Time since bolus (min)
2 4 6
Effect site concentration after opioid bolus
80 10
Remifentanil
Remifentanil pharmacokinetics in neonates
bull Infants under 2 months
bull Pharmacokinetics similar
ndash to older children
ndash to adults
Davis Ross Henson et al Remifentanil pharmacokinetics in neonates
Anesthesiology 1997 87 A 1054
Remifentanil PCA
bull Theory behind techniquendash PCA giving control improves
satisfaction
bull Theory behind choice of drugndash Ultra short-acting rapidly
metabolised
ndash Placental transfer but rapid metabolism in neonatebull Kan et al Anesthesiology1998
88 1467-74
ndash Context sensitive t12 3-5min
ndash Ideal for intermittent pain of labour
Remi pca in practicebull Feasibility for labour analgesia
2001 ndash Blair et al BJA 2001
bull Optimum bolus 05mcgkg no background infusionndash Superior to pethidine
bull Blair et al BJA 2005
bull Shown superior to pethidinendash efficacy satisfaction conversion to
epiduralbull Thurlow et al BJA 2002 Douma et al
BJA 2010
bull No difference in neonatal outcomesndash Review by Leong et al Anes amp Analg
2011
Remi pca in practice
bull Strict protocol
ndash Dedicated IV cannula
ndash Dedicated pumps
ndash Locked pump programmebull 40mcg bolus 2min lockout
ndash Observation chart
Safety with remi
bull One-to-one midwifery care
bull Anaesthetist prescribes and starts pca
bull Strict monitoring
bull Observation chart
bull Immediate oxygen and resuscitation availability
bull Continuous audit
Side effects
bull Nausea
ndash approx 90 use Entonox
bull Itch
bull Sedation
bull Respiratory depression
bull Episode of desaturation lt94 40-50
bull Almost all recover with nasal specs oxygen
Patient info sheet
bull Salient points
ndash Unlicensed use
ndash Audit data re safety
bull Given out at ante-natal clinic
bull Laminated copy in rooms
bull Reiterate in labour ward at request
Remifentanil PCA documentation bullInformed about Remifentanil At least 37 weeks bullInformation leaflet read No recent opiate use bullAware unlicensed use bullPCA technique explained ndash lockouttiming of demandspatient use only bull
bullRisks discussedbullSedation Respiratory depression Epidural conversion bullItch Supplementary oxygen bullNausea Failureinadequate pain relief Verbal consent bull
bullPrerequisites KardexbullDedicated IV canula Remi pump no PCA prescribed bullSpO2 monitoring Anaesthetist present Naloxone bull At initiation bullMidwife present Anti emetic bull
bullSignature _________________ Date amp time ______________________
Remi PCA in Belfast
bull 4000 deliveries ndash Elective LSCS 14
bull Routine use since 2004
bull 100-120 remi pcamth
bull 40 of labouring women choose remi pca
bull Epidural rate dropped to 35
Complications and controversyhellip
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40ndash Pruefer C Bewlay A Anaesthesia
2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesiabull Kinsella 2013
Complications and controversyhellip
Recent adverse reports
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40
ndash Pruefer C Bewlay A Anaesthesia 2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesia bull Kinsella 2013
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
Complications and controversyhellip
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
RESPITE trial 2014
bull Multicentre trial 400 women over 24 months
bull Comparing Remifentanil PCA with IM pethidine
bull Primary aim efficacy ndash VAS
ndash Proportion of women requiring an epidural for pain relief VAS
bull Secondary data adverse effects ndash Maternal sedation
ndash Unwanted effects on mother and baby
bull Clinical guidelines on the use of remifentanil
bull RESPITEtrialsbhamacuk
ldquohot off the pressrdquo
bull May - July 2014 audit data
bull 412 women
bull Efficacy and side effects
bull Outcomes
Satisfaction and efficacy
bull 80 satisfied or very satisfied
bull 87 ldquowould use againrdquo
bull Pain scores
ndash 48 none or mild pain
ndash 36 moderate pain
bull Conversion rate to epidural 129
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
Non-pharmacological analgesia
bull Hypnosishellip
bull Antenatal self-hypnosis for labour and childbirth A pilot studyndash 77 women (control 3249)
ndash Nulliparous fewer epidurals fewer augmentations
ndash Possible benefit further research neededbull AM Cyna et al
ndash Anaesthesia and Intensive Care 2006 34 (4)464-469 Australian Society of Anaesthetists
Howeverhellip
bull Hypnosis for pain management during labour and childbirth (Review)
ndash Madden K Middleton P Cyna AM Matthewson M Jones L bull The Cochrane Library 2012
Issue 11
bull No benefit shown for analgesia requirements
Pharmacological options
bull Systemicndash Entonox
ndash IM opioid
ndash Opioid PCA bull remifentanil
bull Regionalndash Epidural
ndash CSE
ndash Spinal
Pharmacological options
bull Systemicndash Entonox
ndash IM opioid
ndash Opioid PCA bull remifentanil
bull Regionalndash Epidural
ndash CSE
ndash Spinal
Labour with opioids
Labour with opioids
50 donrsquot have an epidural
bull Patient preference
bull No ldquoepidural servicerdquo
bull Thrombocytopenia
bull Anticoagulation
bull ldquoBack problemsrdquo
bull ldquoNeurologicalrdquo
bull ldquoSepsisrdquo
Systemic analgesiahellip
bull Not like an epidural labour
bull Different collaborative relationships
bull Maternal choice issues
bull Midwifery rather than anaesthesia
Systemic analgesia
bull Nitrous Oxide
ndash Ubiquitous UK (not USA)
ndash Patient controlbull Psychological benefit
ndash Low blood-gas solubilitybull Ideal for intermittent use
bull Rapid on-off effect
bull Doesnrsquot accumulate with intermittent use
ndash Often as an adjunct
Opioids
bull Mainstay of systemic analgesia
bull Intermittent bolus regimen
bull Administered by midwives
IM Pethidinebull ldquomore sedation than analgesiardquo1
bull gastric stasis amp hypoventilation 2
bull fetal effects after 40 mins 3
bull dose-delivery lt2-3hrs 4
bull modifies CTG amp EEG 5
bull fetal acidosis 6
bull active metabolites for days 7
1 Olofsson et al B J Obs Gynaecol 1996103968-72
2 Nimmo et al Lancet 19751(7912)890-3
3 Tomson G et al B J Clinical Pharmacology 198213653-9
4 Shnider SM Moya F Am J Obstet Gynecol 1964891009-15
5 Kariniemi V ammala P B J Ob Gynaecol 198188718-20
6 Kariniemi V Rosti J J Perinatal Med 198614131-5
7 Hodgkinson R Farkhanda JH Anesthesiology 19825651-2
What do women wantSytematic review of 137 reports of the views of 14000 women in 9 countries
Satisfaction
ndash Expectations
ndash Support
ndash Quality of relationship with midwife
ndash Involvement in decision making
Dissatisfaction
ndash Failure of timing amp lack of availability of analgesia
Hodnett 2002 Saisto 2001 Ranta 2002 May 2000
Complete analgesia did not rate highly
bull REVIEW
bull Maternal satisfaction
bull PN Robinson P Salmon SM Yentisndash International Journal of Obstetric
Anesthesia (1998) 7 32-37
bull ldquoSatisfaction is multidimensionaland therefore difficult to define assess and measurerdquo
bull ldquoStudies assume that satisfaction with anaesthetic practice equates with good analgesia although as we have shown this is only one dimension of satisfactionrdquo
Regional analgesia ndashthe be all and end all
bull Epidural versus non-epidural or no analgesia in labour
bull Anim-Somuah M1 Smyth RM Jones L
ndash Cochrane Database Syst Rev 2011 Dec 7(12)
Cochrane Conclusionhellip
bull Epidural analgesia appears to be effective in reducing pain during labour
bull However women who use this form of pain relief are at increased risk of having an instrumental delivery
bull Epidural analgesia had no statistically significant impact on the risk of caesarean section maternal satisfaction with pain relief and long-term backache and did not appear to have an immediate effect on neonatal status as determined by Apgar scores
bull Further research may be helpful to evaluate rare but potentially severe adverse effects of epidural analgesia on women in labour and long-term neonatal outcomes
What do women wantSytematic review of 137 reports of the views of 14000 women in 9 countries
Satisfaction
ndash Expectations
ndash Support
ndash Quality of relationship with midwife
ndash Involvement in decision making
Dissatisfaction
ndash Failure of timing amp lack of availability of analgesia
Hodnett 2002 Saisto 2001 Ranta 2002 May 2000
Complete analgesia did not rate highly
The search for an alternative
bull Match time course of labour
bull Not midwife delivered patient control
bull Few maternal amp neonatal adverse effects
Rapid onset and offset amp intravenous
PCA device
Non cumulative
o
f p
eak
eff
ect
site
con
centr
atio
n
Fentanyl
Alfentanil
100
0
Time since bolus (min)
2 4 6
Effect site concentration after opioid bolus
80 10
Remifentanil
Remifentanil pharmacokinetics in neonates
bull Infants under 2 months
bull Pharmacokinetics similar
ndash to older children
ndash to adults
Davis Ross Henson et al Remifentanil pharmacokinetics in neonates
Anesthesiology 1997 87 A 1054
Remifentanil PCA
bull Theory behind techniquendash PCA giving control improves
satisfaction
bull Theory behind choice of drugndash Ultra short-acting rapidly
metabolised
ndash Placental transfer but rapid metabolism in neonatebull Kan et al Anesthesiology1998
88 1467-74
ndash Context sensitive t12 3-5min
ndash Ideal for intermittent pain of labour
Remi pca in practicebull Feasibility for labour analgesia
2001 ndash Blair et al BJA 2001
bull Optimum bolus 05mcgkg no background infusionndash Superior to pethidine
bull Blair et al BJA 2005
bull Shown superior to pethidinendash efficacy satisfaction conversion to
epiduralbull Thurlow et al BJA 2002 Douma et al
BJA 2010
bull No difference in neonatal outcomesndash Review by Leong et al Anes amp Analg
2011
Remi pca in practice
bull Strict protocol
ndash Dedicated IV cannula
ndash Dedicated pumps
ndash Locked pump programmebull 40mcg bolus 2min lockout
ndash Observation chart
Safety with remi
bull One-to-one midwifery care
bull Anaesthetist prescribes and starts pca
bull Strict monitoring
bull Observation chart
bull Immediate oxygen and resuscitation availability
bull Continuous audit
Side effects
bull Nausea
ndash approx 90 use Entonox
bull Itch
bull Sedation
bull Respiratory depression
bull Episode of desaturation lt94 40-50
bull Almost all recover with nasal specs oxygen
Patient info sheet
bull Salient points
ndash Unlicensed use
ndash Audit data re safety
bull Given out at ante-natal clinic
bull Laminated copy in rooms
bull Reiterate in labour ward at request
Remifentanil PCA documentation bullInformed about Remifentanil At least 37 weeks bullInformation leaflet read No recent opiate use bullAware unlicensed use bullPCA technique explained ndash lockouttiming of demandspatient use only bull
bullRisks discussedbullSedation Respiratory depression Epidural conversion bullItch Supplementary oxygen bullNausea Failureinadequate pain relief Verbal consent bull
bullPrerequisites KardexbullDedicated IV canula Remi pump no PCA prescribed bullSpO2 monitoring Anaesthetist present Naloxone bull At initiation bullMidwife present Anti emetic bull
bullSignature _________________ Date amp time ______________________
Remi PCA in Belfast
bull 4000 deliveries ndash Elective LSCS 14
bull Routine use since 2004
bull 100-120 remi pcamth
bull 40 of labouring women choose remi pca
bull Epidural rate dropped to 35
Complications and controversyhellip
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40ndash Pruefer C Bewlay A Anaesthesia
2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesiabull Kinsella 2013
Complications and controversyhellip
Recent adverse reports
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40
ndash Pruefer C Bewlay A Anaesthesia 2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesia bull Kinsella 2013
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
Complications and controversyhellip
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
RESPITE trial 2014
bull Multicentre trial 400 women over 24 months
bull Comparing Remifentanil PCA with IM pethidine
bull Primary aim efficacy ndash VAS
ndash Proportion of women requiring an epidural for pain relief VAS
bull Secondary data adverse effects ndash Maternal sedation
ndash Unwanted effects on mother and baby
bull Clinical guidelines on the use of remifentanil
bull RESPITEtrialsbhamacuk
ldquohot off the pressrdquo
bull May - July 2014 audit data
bull 412 women
bull Efficacy and side effects
bull Outcomes
Satisfaction and efficacy
bull 80 satisfied or very satisfied
bull 87 ldquowould use againrdquo
bull Pain scores
ndash 48 none or mild pain
ndash 36 moderate pain
bull Conversion rate to epidural 129
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
Howeverhellip
bull Hypnosis for pain management during labour and childbirth (Review)
ndash Madden K Middleton P Cyna AM Matthewson M Jones L bull The Cochrane Library 2012
Issue 11
bull No benefit shown for analgesia requirements
Pharmacological options
bull Systemicndash Entonox
ndash IM opioid
ndash Opioid PCA bull remifentanil
bull Regionalndash Epidural
ndash CSE
ndash Spinal
Pharmacological options
bull Systemicndash Entonox
ndash IM opioid
ndash Opioid PCA bull remifentanil
bull Regionalndash Epidural
ndash CSE
ndash Spinal
Labour with opioids
Labour with opioids
50 donrsquot have an epidural
bull Patient preference
bull No ldquoepidural servicerdquo
bull Thrombocytopenia
bull Anticoagulation
bull ldquoBack problemsrdquo
bull ldquoNeurologicalrdquo
bull ldquoSepsisrdquo
Systemic analgesiahellip
bull Not like an epidural labour
bull Different collaborative relationships
bull Maternal choice issues
bull Midwifery rather than anaesthesia
Systemic analgesia
bull Nitrous Oxide
ndash Ubiquitous UK (not USA)
ndash Patient controlbull Psychological benefit
ndash Low blood-gas solubilitybull Ideal for intermittent use
bull Rapid on-off effect
bull Doesnrsquot accumulate with intermittent use
ndash Often as an adjunct
Opioids
bull Mainstay of systemic analgesia
bull Intermittent bolus regimen
bull Administered by midwives
IM Pethidinebull ldquomore sedation than analgesiardquo1
bull gastric stasis amp hypoventilation 2
bull fetal effects after 40 mins 3
bull dose-delivery lt2-3hrs 4
bull modifies CTG amp EEG 5
bull fetal acidosis 6
bull active metabolites for days 7
1 Olofsson et al B J Obs Gynaecol 1996103968-72
2 Nimmo et al Lancet 19751(7912)890-3
3 Tomson G et al B J Clinical Pharmacology 198213653-9
4 Shnider SM Moya F Am J Obstet Gynecol 1964891009-15
5 Kariniemi V ammala P B J Ob Gynaecol 198188718-20
6 Kariniemi V Rosti J J Perinatal Med 198614131-5
7 Hodgkinson R Farkhanda JH Anesthesiology 19825651-2
What do women wantSytematic review of 137 reports of the views of 14000 women in 9 countries
Satisfaction
ndash Expectations
ndash Support
ndash Quality of relationship with midwife
ndash Involvement in decision making
Dissatisfaction
ndash Failure of timing amp lack of availability of analgesia
Hodnett 2002 Saisto 2001 Ranta 2002 May 2000
Complete analgesia did not rate highly
bull REVIEW
bull Maternal satisfaction
bull PN Robinson P Salmon SM Yentisndash International Journal of Obstetric
Anesthesia (1998) 7 32-37
bull ldquoSatisfaction is multidimensionaland therefore difficult to define assess and measurerdquo
bull ldquoStudies assume that satisfaction with anaesthetic practice equates with good analgesia although as we have shown this is only one dimension of satisfactionrdquo
Regional analgesia ndashthe be all and end all
bull Epidural versus non-epidural or no analgesia in labour
bull Anim-Somuah M1 Smyth RM Jones L
ndash Cochrane Database Syst Rev 2011 Dec 7(12)
Cochrane Conclusionhellip
bull Epidural analgesia appears to be effective in reducing pain during labour
bull However women who use this form of pain relief are at increased risk of having an instrumental delivery
bull Epidural analgesia had no statistically significant impact on the risk of caesarean section maternal satisfaction with pain relief and long-term backache and did not appear to have an immediate effect on neonatal status as determined by Apgar scores
bull Further research may be helpful to evaluate rare but potentially severe adverse effects of epidural analgesia on women in labour and long-term neonatal outcomes
What do women wantSytematic review of 137 reports of the views of 14000 women in 9 countries
Satisfaction
ndash Expectations
ndash Support
ndash Quality of relationship with midwife
ndash Involvement in decision making
Dissatisfaction
ndash Failure of timing amp lack of availability of analgesia
Hodnett 2002 Saisto 2001 Ranta 2002 May 2000
Complete analgesia did not rate highly
The search for an alternative
bull Match time course of labour
bull Not midwife delivered patient control
bull Few maternal amp neonatal adverse effects
Rapid onset and offset amp intravenous
PCA device
Non cumulative
o
f p
eak
eff
ect
site
con
centr
atio
n
Fentanyl
Alfentanil
100
0
Time since bolus (min)
2 4 6
Effect site concentration after opioid bolus
80 10
Remifentanil
Remifentanil pharmacokinetics in neonates
bull Infants under 2 months
bull Pharmacokinetics similar
ndash to older children
ndash to adults
Davis Ross Henson et al Remifentanil pharmacokinetics in neonates
Anesthesiology 1997 87 A 1054
Remifentanil PCA
bull Theory behind techniquendash PCA giving control improves
satisfaction
bull Theory behind choice of drugndash Ultra short-acting rapidly
metabolised
ndash Placental transfer but rapid metabolism in neonatebull Kan et al Anesthesiology1998
88 1467-74
ndash Context sensitive t12 3-5min
ndash Ideal for intermittent pain of labour
Remi pca in practicebull Feasibility for labour analgesia
2001 ndash Blair et al BJA 2001
bull Optimum bolus 05mcgkg no background infusionndash Superior to pethidine
bull Blair et al BJA 2005
bull Shown superior to pethidinendash efficacy satisfaction conversion to
epiduralbull Thurlow et al BJA 2002 Douma et al
BJA 2010
bull No difference in neonatal outcomesndash Review by Leong et al Anes amp Analg
2011
Remi pca in practice
bull Strict protocol
ndash Dedicated IV cannula
ndash Dedicated pumps
ndash Locked pump programmebull 40mcg bolus 2min lockout
ndash Observation chart
Safety with remi
bull One-to-one midwifery care
bull Anaesthetist prescribes and starts pca
bull Strict monitoring
bull Observation chart
bull Immediate oxygen and resuscitation availability
bull Continuous audit
Side effects
bull Nausea
ndash approx 90 use Entonox
bull Itch
bull Sedation
bull Respiratory depression
bull Episode of desaturation lt94 40-50
bull Almost all recover with nasal specs oxygen
Patient info sheet
bull Salient points
ndash Unlicensed use
ndash Audit data re safety
bull Given out at ante-natal clinic
bull Laminated copy in rooms
bull Reiterate in labour ward at request
Remifentanil PCA documentation bullInformed about Remifentanil At least 37 weeks bullInformation leaflet read No recent opiate use bullAware unlicensed use bullPCA technique explained ndash lockouttiming of demandspatient use only bull
bullRisks discussedbullSedation Respiratory depression Epidural conversion bullItch Supplementary oxygen bullNausea Failureinadequate pain relief Verbal consent bull
bullPrerequisites KardexbullDedicated IV canula Remi pump no PCA prescribed bullSpO2 monitoring Anaesthetist present Naloxone bull At initiation bullMidwife present Anti emetic bull
bullSignature _________________ Date amp time ______________________
Remi PCA in Belfast
bull 4000 deliveries ndash Elective LSCS 14
bull Routine use since 2004
bull 100-120 remi pcamth
bull 40 of labouring women choose remi pca
bull Epidural rate dropped to 35
Complications and controversyhellip
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40ndash Pruefer C Bewlay A Anaesthesia
2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesiabull Kinsella 2013
Complications and controversyhellip
Recent adverse reports
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40
ndash Pruefer C Bewlay A Anaesthesia 2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesia bull Kinsella 2013
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
Complications and controversyhellip
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
RESPITE trial 2014
bull Multicentre trial 400 women over 24 months
bull Comparing Remifentanil PCA with IM pethidine
bull Primary aim efficacy ndash VAS
ndash Proportion of women requiring an epidural for pain relief VAS
bull Secondary data adverse effects ndash Maternal sedation
ndash Unwanted effects on mother and baby
bull Clinical guidelines on the use of remifentanil
bull RESPITEtrialsbhamacuk
ldquohot off the pressrdquo
bull May - July 2014 audit data
bull 412 women
bull Efficacy and side effects
bull Outcomes
Satisfaction and efficacy
bull 80 satisfied or very satisfied
bull 87 ldquowould use againrdquo
bull Pain scores
ndash 48 none or mild pain
ndash 36 moderate pain
bull Conversion rate to epidural 129
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
Pharmacological options
bull Systemicndash Entonox
ndash IM opioid
ndash Opioid PCA bull remifentanil
bull Regionalndash Epidural
ndash CSE
ndash Spinal
Pharmacological options
bull Systemicndash Entonox
ndash IM opioid
ndash Opioid PCA bull remifentanil
bull Regionalndash Epidural
ndash CSE
ndash Spinal
Labour with opioids
Labour with opioids
50 donrsquot have an epidural
bull Patient preference
bull No ldquoepidural servicerdquo
bull Thrombocytopenia
bull Anticoagulation
bull ldquoBack problemsrdquo
bull ldquoNeurologicalrdquo
bull ldquoSepsisrdquo
Systemic analgesiahellip
bull Not like an epidural labour
bull Different collaborative relationships
bull Maternal choice issues
bull Midwifery rather than anaesthesia
Systemic analgesia
bull Nitrous Oxide
ndash Ubiquitous UK (not USA)
ndash Patient controlbull Psychological benefit
ndash Low blood-gas solubilitybull Ideal for intermittent use
bull Rapid on-off effect
bull Doesnrsquot accumulate with intermittent use
ndash Often as an adjunct
Opioids
bull Mainstay of systemic analgesia
bull Intermittent bolus regimen
bull Administered by midwives
IM Pethidinebull ldquomore sedation than analgesiardquo1
bull gastric stasis amp hypoventilation 2
bull fetal effects after 40 mins 3
bull dose-delivery lt2-3hrs 4
bull modifies CTG amp EEG 5
bull fetal acidosis 6
bull active metabolites for days 7
1 Olofsson et al B J Obs Gynaecol 1996103968-72
2 Nimmo et al Lancet 19751(7912)890-3
3 Tomson G et al B J Clinical Pharmacology 198213653-9
4 Shnider SM Moya F Am J Obstet Gynecol 1964891009-15
5 Kariniemi V ammala P B J Ob Gynaecol 198188718-20
6 Kariniemi V Rosti J J Perinatal Med 198614131-5
7 Hodgkinson R Farkhanda JH Anesthesiology 19825651-2
What do women wantSytematic review of 137 reports of the views of 14000 women in 9 countries
Satisfaction
ndash Expectations
ndash Support
ndash Quality of relationship with midwife
ndash Involvement in decision making
Dissatisfaction
ndash Failure of timing amp lack of availability of analgesia
Hodnett 2002 Saisto 2001 Ranta 2002 May 2000
Complete analgesia did not rate highly
bull REVIEW
bull Maternal satisfaction
bull PN Robinson P Salmon SM Yentisndash International Journal of Obstetric
Anesthesia (1998) 7 32-37
bull ldquoSatisfaction is multidimensionaland therefore difficult to define assess and measurerdquo
bull ldquoStudies assume that satisfaction with anaesthetic practice equates with good analgesia although as we have shown this is only one dimension of satisfactionrdquo
Regional analgesia ndashthe be all and end all
bull Epidural versus non-epidural or no analgesia in labour
bull Anim-Somuah M1 Smyth RM Jones L
ndash Cochrane Database Syst Rev 2011 Dec 7(12)
Cochrane Conclusionhellip
bull Epidural analgesia appears to be effective in reducing pain during labour
bull However women who use this form of pain relief are at increased risk of having an instrumental delivery
bull Epidural analgesia had no statistically significant impact on the risk of caesarean section maternal satisfaction with pain relief and long-term backache and did not appear to have an immediate effect on neonatal status as determined by Apgar scores
bull Further research may be helpful to evaluate rare but potentially severe adverse effects of epidural analgesia on women in labour and long-term neonatal outcomes
What do women wantSytematic review of 137 reports of the views of 14000 women in 9 countries
Satisfaction
ndash Expectations
ndash Support
ndash Quality of relationship with midwife
ndash Involvement in decision making
Dissatisfaction
ndash Failure of timing amp lack of availability of analgesia
Hodnett 2002 Saisto 2001 Ranta 2002 May 2000
Complete analgesia did not rate highly
The search for an alternative
bull Match time course of labour
bull Not midwife delivered patient control
bull Few maternal amp neonatal adverse effects
Rapid onset and offset amp intravenous
PCA device
Non cumulative
o
f p
eak
eff
ect
site
con
centr
atio
n
Fentanyl
Alfentanil
100
0
Time since bolus (min)
2 4 6
Effect site concentration after opioid bolus
80 10
Remifentanil
Remifentanil pharmacokinetics in neonates
bull Infants under 2 months
bull Pharmacokinetics similar
ndash to older children
ndash to adults
Davis Ross Henson et al Remifentanil pharmacokinetics in neonates
Anesthesiology 1997 87 A 1054
Remifentanil PCA
bull Theory behind techniquendash PCA giving control improves
satisfaction
bull Theory behind choice of drugndash Ultra short-acting rapidly
metabolised
ndash Placental transfer but rapid metabolism in neonatebull Kan et al Anesthesiology1998
88 1467-74
ndash Context sensitive t12 3-5min
ndash Ideal for intermittent pain of labour
Remi pca in practicebull Feasibility for labour analgesia
2001 ndash Blair et al BJA 2001
bull Optimum bolus 05mcgkg no background infusionndash Superior to pethidine
bull Blair et al BJA 2005
bull Shown superior to pethidinendash efficacy satisfaction conversion to
epiduralbull Thurlow et al BJA 2002 Douma et al
BJA 2010
bull No difference in neonatal outcomesndash Review by Leong et al Anes amp Analg
2011
Remi pca in practice
bull Strict protocol
ndash Dedicated IV cannula
ndash Dedicated pumps
ndash Locked pump programmebull 40mcg bolus 2min lockout
ndash Observation chart
Safety with remi
bull One-to-one midwifery care
bull Anaesthetist prescribes and starts pca
bull Strict monitoring
bull Observation chart
bull Immediate oxygen and resuscitation availability
bull Continuous audit
Side effects
bull Nausea
ndash approx 90 use Entonox
bull Itch
bull Sedation
bull Respiratory depression
bull Episode of desaturation lt94 40-50
bull Almost all recover with nasal specs oxygen
Patient info sheet
bull Salient points
ndash Unlicensed use
ndash Audit data re safety
bull Given out at ante-natal clinic
bull Laminated copy in rooms
bull Reiterate in labour ward at request
Remifentanil PCA documentation bullInformed about Remifentanil At least 37 weeks bullInformation leaflet read No recent opiate use bullAware unlicensed use bullPCA technique explained ndash lockouttiming of demandspatient use only bull
bullRisks discussedbullSedation Respiratory depression Epidural conversion bullItch Supplementary oxygen bullNausea Failureinadequate pain relief Verbal consent bull
bullPrerequisites KardexbullDedicated IV canula Remi pump no PCA prescribed bullSpO2 monitoring Anaesthetist present Naloxone bull At initiation bullMidwife present Anti emetic bull
bullSignature _________________ Date amp time ______________________
Remi PCA in Belfast
bull 4000 deliveries ndash Elective LSCS 14
bull Routine use since 2004
bull 100-120 remi pcamth
bull 40 of labouring women choose remi pca
bull Epidural rate dropped to 35
Complications and controversyhellip
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40ndash Pruefer C Bewlay A Anaesthesia
2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesiabull Kinsella 2013
Complications and controversyhellip
Recent adverse reports
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40
ndash Pruefer C Bewlay A Anaesthesia 2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesia bull Kinsella 2013
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
Complications and controversyhellip
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
RESPITE trial 2014
bull Multicentre trial 400 women over 24 months
bull Comparing Remifentanil PCA with IM pethidine
bull Primary aim efficacy ndash VAS
ndash Proportion of women requiring an epidural for pain relief VAS
bull Secondary data adverse effects ndash Maternal sedation
ndash Unwanted effects on mother and baby
bull Clinical guidelines on the use of remifentanil
bull RESPITEtrialsbhamacuk
ldquohot off the pressrdquo
bull May - July 2014 audit data
bull 412 women
bull Efficacy and side effects
bull Outcomes
Satisfaction and efficacy
bull 80 satisfied or very satisfied
bull 87 ldquowould use againrdquo
bull Pain scores
ndash 48 none or mild pain
ndash 36 moderate pain
bull Conversion rate to epidural 129
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
Pharmacological options
bull Systemicndash Entonox
ndash IM opioid
ndash Opioid PCA bull remifentanil
bull Regionalndash Epidural
ndash CSE
ndash Spinal
Labour with opioids
Labour with opioids
50 donrsquot have an epidural
bull Patient preference
bull No ldquoepidural servicerdquo
bull Thrombocytopenia
bull Anticoagulation
bull ldquoBack problemsrdquo
bull ldquoNeurologicalrdquo
bull ldquoSepsisrdquo
Systemic analgesiahellip
bull Not like an epidural labour
bull Different collaborative relationships
bull Maternal choice issues
bull Midwifery rather than anaesthesia
Systemic analgesia
bull Nitrous Oxide
ndash Ubiquitous UK (not USA)
ndash Patient controlbull Psychological benefit
ndash Low blood-gas solubilitybull Ideal for intermittent use
bull Rapid on-off effect
bull Doesnrsquot accumulate with intermittent use
ndash Often as an adjunct
Opioids
bull Mainstay of systemic analgesia
bull Intermittent bolus regimen
bull Administered by midwives
IM Pethidinebull ldquomore sedation than analgesiardquo1
bull gastric stasis amp hypoventilation 2
bull fetal effects after 40 mins 3
bull dose-delivery lt2-3hrs 4
bull modifies CTG amp EEG 5
bull fetal acidosis 6
bull active metabolites for days 7
1 Olofsson et al B J Obs Gynaecol 1996103968-72
2 Nimmo et al Lancet 19751(7912)890-3
3 Tomson G et al B J Clinical Pharmacology 198213653-9
4 Shnider SM Moya F Am J Obstet Gynecol 1964891009-15
5 Kariniemi V ammala P B J Ob Gynaecol 198188718-20
6 Kariniemi V Rosti J J Perinatal Med 198614131-5
7 Hodgkinson R Farkhanda JH Anesthesiology 19825651-2
What do women wantSytematic review of 137 reports of the views of 14000 women in 9 countries
Satisfaction
ndash Expectations
ndash Support
ndash Quality of relationship with midwife
ndash Involvement in decision making
Dissatisfaction
ndash Failure of timing amp lack of availability of analgesia
Hodnett 2002 Saisto 2001 Ranta 2002 May 2000
Complete analgesia did not rate highly
bull REVIEW
bull Maternal satisfaction
bull PN Robinson P Salmon SM Yentisndash International Journal of Obstetric
Anesthesia (1998) 7 32-37
bull ldquoSatisfaction is multidimensionaland therefore difficult to define assess and measurerdquo
bull ldquoStudies assume that satisfaction with anaesthetic practice equates with good analgesia although as we have shown this is only one dimension of satisfactionrdquo
Regional analgesia ndashthe be all and end all
bull Epidural versus non-epidural or no analgesia in labour
bull Anim-Somuah M1 Smyth RM Jones L
ndash Cochrane Database Syst Rev 2011 Dec 7(12)
Cochrane Conclusionhellip
bull Epidural analgesia appears to be effective in reducing pain during labour
bull However women who use this form of pain relief are at increased risk of having an instrumental delivery
bull Epidural analgesia had no statistically significant impact on the risk of caesarean section maternal satisfaction with pain relief and long-term backache and did not appear to have an immediate effect on neonatal status as determined by Apgar scores
bull Further research may be helpful to evaluate rare but potentially severe adverse effects of epidural analgesia on women in labour and long-term neonatal outcomes
What do women wantSytematic review of 137 reports of the views of 14000 women in 9 countries
Satisfaction
ndash Expectations
ndash Support
ndash Quality of relationship with midwife
ndash Involvement in decision making
Dissatisfaction
ndash Failure of timing amp lack of availability of analgesia
Hodnett 2002 Saisto 2001 Ranta 2002 May 2000
Complete analgesia did not rate highly
The search for an alternative
bull Match time course of labour
bull Not midwife delivered patient control
bull Few maternal amp neonatal adverse effects
Rapid onset and offset amp intravenous
PCA device
Non cumulative
o
f p
eak
eff
ect
site
con
centr
atio
n
Fentanyl
Alfentanil
100
0
Time since bolus (min)
2 4 6
Effect site concentration after opioid bolus
80 10
Remifentanil
Remifentanil pharmacokinetics in neonates
bull Infants under 2 months
bull Pharmacokinetics similar
ndash to older children
ndash to adults
Davis Ross Henson et al Remifentanil pharmacokinetics in neonates
Anesthesiology 1997 87 A 1054
Remifentanil PCA
bull Theory behind techniquendash PCA giving control improves
satisfaction
bull Theory behind choice of drugndash Ultra short-acting rapidly
metabolised
ndash Placental transfer but rapid metabolism in neonatebull Kan et al Anesthesiology1998
88 1467-74
ndash Context sensitive t12 3-5min
ndash Ideal for intermittent pain of labour
Remi pca in practicebull Feasibility for labour analgesia
2001 ndash Blair et al BJA 2001
bull Optimum bolus 05mcgkg no background infusionndash Superior to pethidine
bull Blair et al BJA 2005
bull Shown superior to pethidinendash efficacy satisfaction conversion to
epiduralbull Thurlow et al BJA 2002 Douma et al
BJA 2010
bull No difference in neonatal outcomesndash Review by Leong et al Anes amp Analg
2011
Remi pca in practice
bull Strict protocol
ndash Dedicated IV cannula
ndash Dedicated pumps
ndash Locked pump programmebull 40mcg bolus 2min lockout
ndash Observation chart
Safety with remi
bull One-to-one midwifery care
bull Anaesthetist prescribes and starts pca
bull Strict monitoring
bull Observation chart
bull Immediate oxygen and resuscitation availability
bull Continuous audit
Side effects
bull Nausea
ndash approx 90 use Entonox
bull Itch
bull Sedation
bull Respiratory depression
bull Episode of desaturation lt94 40-50
bull Almost all recover with nasal specs oxygen
Patient info sheet
bull Salient points
ndash Unlicensed use
ndash Audit data re safety
bull Given out at ante-natal clinic
bull Laminated copy in rooms
bull Reiterate in labour ward at request
Remifentanil PCA documentation bullInformed about Remifentanil At least 37 weeks bullInformation leaflet read No recent opiate use bullAware unlicensed use bullPCA technique explained ndash lockouttiming of demandspatient use only bull
bullRisks discussedbullSedation Respiratory depression Epidural conversion bullItch Supplementary oxygen bullNausea Failureinadequate pain relief Verbal consent bull
bullPrerequisites KardexbullDedicated IV canula Remi pump no PCA prescribed bullSpO2 monitoring Anaesthetist present Naloxone bull At initiation bullMidwife present Anti emetic bull
bullSignature _________________ Date amp time ______________________
Remi PCA in Belfast
bull 4000 deliveries ndash Elective LSCS 14
bull Routine use since 2004
bull 100-120 remi pcamth
bull 40 of labouring women choose remi pca
bull Epidural rate dropped to 35
Complications and controversyhellip
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40ndash Pruefer C Bewlay A Anaesthesia
2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesiabull Kinsella 2013
Complications and controversyhellip
Recent adverse reports
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40
ndash Pruefer C Bewlay A Anaesthesia 2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesia bull Kinsella 2013
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
Complications and controversyhellip
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
RESPITE trial 2014
bull Multicentre trial 400 women over 24 months
bull Comparing Remifentanil PCA with IM pethidine
bull Primary aim efficacy ndash VAS
ndash Proportion of women requiring an epidural for pain relief VAS
bull Secondary data adverse effects ndash Maternal sedation
ndash Unwanted effects on mother and baby
bull Clinical guidelines on the use of remifentanil
bull RESPITEtrialsbhamacuk
ldquohot off the pressrdquo
bull May - July 2014 audit data
bull 412 women
bull Efficacy and side effects
bull Outcomes
Satisfaction and efficacy
bull 80 satisfied or very satisfied
bull 87 ldquowould use againrdquo
bull Pain scores
ndash 48 none or mild pain
ndash 36 moderate pain
bull Conversion rate to epidural 129
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
Labour with opioids
Labour with opioids
50 donrsquot have an epidural
bull Patient preference
bull No ldquoepidural servicerdquo
bull Thrombocytopenia
bull Anticoagulation
bull ldquoBack problemsrdquo
bull ldquoNeurologicalrdquo
bull ldquoSepsisrdquo
Systemic analgesiahellip
bull Not like an epidural labour
bull Different collaborative relationships
bull Maternal choice issues
bull Midwifery rather than anaesthesia
Systemic analgesia
bull Nitrous Oxide
ndash Ubiquitous UK (not USA)
ndash Patient controlbull Psychological benefit
ndash Low blood-gas solubilitybull Ideal for intermittent use
bull Rapid on-off effect
bull Doesnrsquot accumulate with intermittent use
ndash Often as an adjunct
Opioids
bull Mainstay of systemic analgesia
bull Intermittent bolus regimen
bull Administered by midwives
IM Pethidinebull ldquomore sedation than analgesiardquo1
bull gastric stasis amp hypoventilation 2
bull fetal effects after 40 mins 3
bull dose-delivery lt2-3hrs 4
bull modifies CTG amp EEG 5
bull fetal acidosis 6
bull active metabolites for days 7
1 Olofsson et al B J Obs Gynaecol 1996103968-72
2 Nimmo et al Lancet 19751(7912)890-3
3 Tomson G et al B J Clinical Pharmacology 198213653-9
4 Shnider SM Moya F Am J Obstet Gynecol 1964891009-15
5 Kariniemi V ammala P B J Ob Gynaecol 198188718-20
6 Kariniemi V Rosti J J Perinatal Med 198614131-5
7 Hodgkinson R Farkhanda JH Anesthesiology 19825651-2
What do women wantSytematic review of 137 reports of the views of 14000 women in 9 countries
Satisfaction
ndash Expectations
ndash Support
ndash Quality of relationship with midwife
ndash Involvement in decision making
Dissatisfaction
ndash Failure of timing amp lack of availability of analgesia
Hodnett 2002 Saisto 2001 Ranta 2002 May 2000
Complete analgesia did not rate highly
bull REVIEW
bull Maternal satisfaction
bull PN Robinson P Salmon SM Yentisndash International Journal of Obstetric
Anesthesia (1998) 7 32-37
bull ldquoSatisfaction is multidimensionaland therefore difficult to define assess and measurerdquo
bull ldquoStudies assume that satisfaction with anaesthetic practice equates with good analgesia although as we have shown this is only one dimension of satisfactionrdquo
Regional analgesia ndashthe be all and end all
bull Epidural versus non-epidural or no analgesia in labour
bull Anim-Somuah M1 Smyth RM Jones L
ndash Cochrane Database Syst Rev 2011 Dec 7(12)
Cochrane Conclusionhellip
bull Epidural analgesia appears to be effective in reducing pain during labour
bull However women who use this form of pain relief are at increased risk of having an instrumental delivery
bull Epidural analgesia had no statistically significant impact on the risk of caesarean section maternal satisfaction with pain relief and long-term backache and did not appear to have an immediate effect on neonatal status as determined by Apgar scores
bull Further research may be helpful to evaluate rare but potentially severe adverse effects of epidural analgesia on women in labour and long-term neonatal outcomes
What do women wantSytematic review of 137 reports of the views of 14000 women in 9 countries
Satisfaction
ndash Expectations
ndash Support
ndash Quality of relationship with midwife
ndash Involvement in decision making
Dissatisfaction
ndash Failure of timing amp lack of availability of analgesia
Hodnett 2002 Saisto 2001 Ranta 2002 May 2000
Complete analgesia did not rate highly
The search for an alternative
bull Match time course of labour
bull Not midwife delivered patient control
bull Few maternal amp neonatal adverse effects
Rapid onset and offset amp intravenous
PCA device
Non cumulative
o
f p
eak
eff
ect
site
con
centr
atio
n
Fentanyl
Alfentanil
100
0
Time since bolus (min)
2 4 6
Effect site concentration after opioid bolus
80 10
Remifentanil
Remifentanil pharmacokinetics in neonates
bull Infants under 2 months
bull Pharmacokinetics similar
ndash to older children
ndash to adults
Davis Ross Henson et al Remifentanil pharmacokinetics in neonates
Anesthesiology 1997 87 A 1054
Remifentanil PCA
bull Theory behind techniquendash PCA giving control improves
satisfaction
bull Theory behind choice of drugndash Ultra short-acting rapidly
metabolised
ndash Placental transfer but rapid metabolism in neonatebull Kan et al Anesthesiology1998
88 1467-74
ndash Context sensitive t12 3-5min
ndash Ideal for intermittent pain of labour
Remi pca in practicebull Feasibility for labour analgesia
2001 ndash Blair et al BJA 2001
bull Optimum bolus 05mcgkg no background infusionndash Superior to pethidine
bull Blair et al BJA 2005
bull Shown superior to pethidinendash efficacy satisfaction conversion to
epiduralbull Thurlow et al BJA 2002 Douma et al
BJA 2010
bull No difference in neonatal outcomesndash Review by Leong et al Anes amp Analg
2011
Remi pca in practice
bull Strict protocol
ndash Dedicated IV cannula
ndash Dedicated pumps
ndash Locked pump programmebull 40mcg bolus 2min lockout
ndash Observation chart
Safety with remi
bull One-to-one midwifery care
bull Anaesthetist prescribes and starts pca
bull Strict monitoring
bull Observation chart
bull Immediate oxygen and resuscitation availability
bull Continuous audit
Side effects
bull Nausea
ndash approx 90 use Entonox
bull Itch
bull Sedation
bull Respiratory depression
bull Episode of desaturation lt94 40-50
bull Almost all recover with nasal specs oxygen
Patient info sheet
bull Salient points
ndash Unlicensed use
ndash Audit data re safety
bull Given out at ante-natal clinic
bull Laminated copy in rooms
bull Reiterate in labour ward at request
Remifentanil PCA documentation bullInformed about Remifentanil At least 37 weeks bullInformation leaflet read No recent opiate use bullAware unlicensed use bullPCA technique explained ndash lockouttiming of demandspatient use only bull
bullRisks discussedbullSedation Respiratory depression Epidural conversion bullItch Supplementary oxygen bullNausea Failureinadequate pain relief Verbal consent bull
bullPrerequisites KardexbullDedicated IV canula Remi pump no PCA prescribed bullSpO2 monitoring Anaesthetist present Naloxone bull At initiation bullMidwife present Anti emetic bull
bullSignature _________________ Date amp time ______________________
Remi PCA in Belfast
bull 4000 deliveries ndash Elective LSCS 14
bull Routine use since 2004
bull 100-120 remi pcamth
bull 40 of labouring women choose remi pca
bull Epidural rate dropped to 35
Complications and controversyhellip
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40ndash Pruefer C Bewlay A Anaesthesia
2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesiabull Kinsella 2013
Complications and controversyhellip
Recent adverse reports
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40
ndash Pruefer C Bewlay A Anaesthesia 2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesia bull Kinsella 2013
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
Complications and controversyhellip
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
RESPITE trial 2014
bull Multicentre trial 400 women over 24 months
bull Comparing Remifentanil PCA with IM pethidine
bull Primary aim efficacy ndash VAS
ndash Proportion of women requiring an epidural for pain relief VAS
bull Secondary data adverse effects ndash Maternal sedation
ndash Unwanted effects on mother and baby
bull Clinical guidelines on the use of remifentanil
bull RESPITEtrialsbhamacuk
ldquohot off the pressrdquo
bull May - July 2014 audit data
bull 412 women
bull Efficacy and side effects
bull Outcomes
Satisfaction and efficacy
bull 80 satisfied or very satisfied
bull 87 ldquowould use againrdquo
bull Pain scores
ndash 48 none or mild pain
ndash 36 moderate pain
bull Conversion rate to epidural 129
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
Labour with opioids
50 donrsquot have an epidural
bull Patient preference
bull No ldquoepidural servicerdquo
bull Thrombocytopenia
bull Anticoagulation
bull ldquoBack problemsrdquo
bull ldquoNeurologicalrdquo
bull ldquoSepsisrdquo
Systemic analgesiahellip
bull Not like an epidural labour
bull Different collaborative relationships
bull Maternal choice issues
bull Midwifery rather than anaesthesia
Systemic analgesia
bull Nitrous Oxide
ndash Ubiquitous UK (not USA)
ndash Patient controlbull Psychological benefit
ndash Low blood-gas solubilitybull Ideal for intermittent use
bull Rapid on-off effect
bull Doesnrsquot accumulate with intermittent use
ndash Often as an adjunct
Opioids
bull Mainstay of systemic analgesia
bull Intermittent bolus regimen
bull Administered by midwives
IM Pethidinebull ldquomore sedation than analgesiardquo1
bull gastric stasis amp hypoventilation 2
bull fetal effects after 40 mins 3
bull dose-delivery lt2-3hrs 4
bull modifies CTG amp EEG 5
bull fetal acidosis 6
bull active metabolites for days 7
1 Olofsson et al B J Obs Gynaecol 1996103968-72
2 Nimmo et al Lancet 19751(7912)890-3
3 Tomson G et al B J Clinical Pharmacology 198213653-9
4 Shnider SM Moya F Am J Obstet Gynecol 1964891009-15
5 Kariniemi V ammala P B J Ob Gynaecol 198188718-20
6 Kariniemi V Rosti J J Perinatal Med 198614131-5
7 Hodgkinson R Farkhanda JH Anesthesiology 19825651-2
What do women wantSytematic review of 137 reports of the views of 14000 women in 9 countries
Satisfaction
ndash Expectations
ndash Support
ndash Quality of relationship with midwife
ndash Involvement in decision making
Dissatisfaction
ndash Failure of timing amp lack of availability of analgesia
Hodnett 2002 Saisto 2001 Ranta 2002 May 2000
Complete analgesia did not rate highly
bull REVIEW
bull Maternal satisfaction
bull PN Robinson P Salmon SM Yentisndash International Journal of Obstetric
Anesthesia (1998) 7 32-37
bull ldquoSatisfaction is multidimensionaland therefore difficult to define assess and measurerdquo
bull ldquoStudies assume that satisfaction with anaesthetic practice equates with good analgesia although as we have shown this is only one dimension of satisfactionrdquo
Regional analgesia ndashthe be all and end all
bull Epidural versus non-epidural or no analgesia in labour
bull Anim-Somuah M1 Smyth RM Jones L
ndash Cochrane Database Syst Rev 2011 Dec 7(12)
Cochrane Conclusionhellip
bull Epidural analgesia appears to be effective in reducing pain during labour
bull However women who use this form of pain relief are at increased risk of having an instrumental delivery
bull Epidural analgesia had no statistically significant impact on the risk of caesarean section maternal satisfaction with pain relief and long-term backache and did not appear to have an immediate effect on neonatal status as determined by Apgar scores
bull Further research may be helpful to evaluate rare but potentially severe adverse effects of epidural analgesia on women in labour and long-term neonatal outcomes
What do women wantSytematic review of 137 reports of the views of 14000 women in 9 countries
Satisfaction
ndash Expectations
ndash Support
ndash Quality of relationship with midwife
ndash Involvement in decision making
Dissatisfaction
ndash Failure of timing amp lack of availability of analgesia
Hodnett 2002 Saisto 2001 Ranta 2002 May 2000
Complete analgesia did not rate highly
The search for an alternative
bull Match time course of labour
bull Not midwife delivered patient control
bull Few maternal amp neonatal adverse effects
Rapid onset and offset amp intravenous
PCA device
Non cumulative
o
f p
eak
eff
ect
site
con
centr
atio
n
Fentanyl
Alfentanil
100
0
Time since bolus (min)
2 4 6
Effect site concentration after opioid bolus
80 10
Remifentanil
Remifentanil pharmacokinetics in neonates
bull Infants under 2 months
bull Pharmacokinetics similar
ndash to older children
ndash to adults
Davis Ross Henson et al Remifentanil pharmacokinetics in neonates
Anesthesiology 1997 87 A 1054
Remifentanil PCA
bull Theory behind techniquendash PCA giving control improves
satisfaction
bull Theory behind choice of drugndash Ultra short-acting rapidly
metabolised
ndash Placental transfer but rapid metabolism in neonatebull Kan et al Anesthesiology1998
88 1467-74
ndash Context sensitive t12 3-5min
ndash Ideal for intermittent pain of labour
Remi pca in practicebull Feasibility for labour analgesia
2001 ndash Blair et al BJA 2001
bull Optimum bolus 05mcgkg no background infusionndash Superior to pethidine
bull Blair et al BJA 2005
bull Shown superior to pethidinendash efficacy satisfaction conversion to
epiduralbull Thurlow et al BJA 2002 Douma et al
BJA 2010
bull No difference in neonatal outcomesndash Review by Leong et al Anes amp Analg
2011
Remi pca in practice
bull Strict protocol
ndash Dedicated IV cannula
ndash Dedicated pumps
ndash Locked pump programmebull 40mcg bolus 2min lockout
ndash Observation chart
Safety with remi
bull One-to-one midwifery care
bull Anaesthetist prescribes and starts pca
bull Strict monitoring
bull Observation chart
bull Immediate oxygen and resuscitation availability
bull Continuous audit
Side effects
bull Nausea
ndash approx 90 use Entonox
bull Itch
bull Sedation
bull Respiratory depression
bull Episode of desaturation lt94 40-50
bull Almost all recover with nasal specs oxygen
Patient info sheet
bull Salient points
ndash Unlicensed use
ndash Audit data re safety
bull Given out at ante-natal clinic
bull Laminated copy in rooms
bull Reiterate in labour ward at request
Remifentanil PCA documentation bullInformed about Remifentanil At least 37 weeks bullInformation leaflet read No recent opiate use bullAware unlicensed use bullPCA technique explained ndash lockouttiming of demandspatient use only bull
bullRisks discussedbullSedation Respiratory depression Epidural conversion bullItch Supplementary oxygen bullNausea Failureinadequate pain relief Verbal consent bull
bullPrerequisites KardexbullDedicated IV canula Remi pump no PCA prescribed bullSpO2 monitoring Anaesthetist present Naloxone bull At initiation bullMidwife present Anti emetic bull
bullSignature _________________ Date amp time ______________________
Remi PCA in Belfast
bull 4000 deliveries ndash Elective LSCS 14
bull Routine use since 2004
bull 100-120 remi pcamth
bull 40 of labouring women choose remi pca
bull Epidural rate dropped to 35
Complications and controversyhellip
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40ndash Pruefer C Bewlay A Anaesthesia
2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesiabull Kinsella 2013
Complications and controversyhellip
Recent adverse reports
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40
ndash Pruefer C Bewlay A Anaesthesia 2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesia bull Kinsella 2013
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
Complications and controversyhellip
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
RESPITE trial 2014
bull Multicentre trial 400 women over 24 months
bull Comparing Remifentanil PCA with IM pethidine
bull Primary aim efficacy ndash VAS
ndash Proportion of women requiring an epidural for pain relief VAS
bull Secondary data adverse effects ndash Maternal sedation
ndash Unwanted effects on mother and baby
bull Clinical guidelines on the use of remifentanil
bull RESPITEtrialsbhamacuk
ldquohot off the pressrdquo
bull May - July 2014 audit data
bull 412 women
bull Efficacy and side effects
bull Outcomes
Satisfaction and efficacy
bull 80 satisfied or very satisfied
bull 87 ldquowould use againrdquo
bull Pain scores
ndash 48 none or mild pain
ndash 36 moderate pain
bull Conversion rate to epidural 129
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
50 donrsquot have an epidural
bull Patient preference
bull No ldquoepidural servicerdquo
bull Thrombocytopenia
bull Anticoagulation
bull ldquoBack problemsrdquo
bull ldquoNeurologicalrdquo
bull ldquoSepsisrdquo
Systemic analgesiahellip
bull Not like an epidural labour
bull Different collaborative relationships
bull Maternal choice issues
bull Midwifery rather than anaesthesia
Systemic analgesia
bull Nitrous Oxide
ndash Ubiquitous UK (not USA)
ndash Patient controlbull Psychological benefit
ndash Low blood-gas solubilitybull Ideal for intermittent use
bull Rapid on-off effect
bull Doesnrsquot accumulate with intermittent use
ndash Often as an adjunct
Opioids
bull Mainstay of systemic analgesia
bull Intermittent bolus regimen
bull Administered by midwives
IM Pethidinebull ldquomore sedation than analgesiardquo1
bull gastric stasis amp hypoventilation 2
bull fetal effects after 40 mins 3
bull dose-delivery lt2-3hrs 4
bull modifies CTG amp EEG 5
bull fetal acidosis 6
bull active metabolites for days 7
1 Olofsson et al B J Obs Gynaecol 1996103968-72
2 Nimmo et al Lancet 19751(7912)890-3
3 Tomson G et al B J Clinical Pharmacology 198213653-9
4 Shnider SM Moya F Am J Obstet Gynecol 1964891009-15
5 Kariniemi V ammala P B J Ob Gynaecol 198188718-20
6 Kariniemi V Rosti J J Perinatal Med 198614131-5
7 Hodgkinson R Farkhanda JH Anesthesiology 19825651-2
What do women wantSytematic review of 137 reports of the views of 14000 women in 9 countries
Satisfaction
ndash Expectations
ndash Support
ndash Quality of relationship with midwife
ndash Involvement in decision making
Dissatisfaction
ndash Failure of timing amp lack of availability of analgesia
Hodnett 2002 Saisto 2001 Ranta 2002 May 2000
Complete analgesia did not rate highly
bull REVIEW
bull Maternal satisfaction
bull PN Robinson P Salmon SM Yentisndash International Journal of Obstetric
Anesthesia (1998) 7 32-37
bull ldquoSatisfaction is multidimensionaland therefore difficult to define assess and measurerdquo
bull ldquoStudies assume that satisfaction with anaesthetic practice equates with good analgesia although as we have shown this is only one dimension of satisfactionrdquo
Regional analgesia ndashthe be all and end all
bull Epidural versus non-epidural or no analgesia in labour
bull Anim-Somuah M1 Smyth RM Jones L
ndash Cochrane Database Syst Rev 2011 Dec 7(12)
Cochrane Conclusionhellip
bull Epidural analgesia appears to be effective in reducing pain during labour
bull However women who use this form of pain relief are at increased risk of having an instrumental delivery
bull Epidural analgesia had no statistically significant impact on the risk of caesarean section maternal satisfaction with pain relief and long-term backache and did not appear to have an immediate effect on neonatal status as determined by Apgar scores
bull Further research may be helpful to evaluate rare but potentially severe adverse effects of epidural analgesia on women in labour and long-term neonatal outcomes
What do women wantSytematic review of 137 reports of the views of 14000 women in 9 countries
Satisfaction
ndash Expectations
ndash Support
ndash Quality of relationship with midwife
ndash Involvement in decision making
Dissatisfaction
ndash Failure of timing amp lack of availability of analgesia
Hodnett 2002 Saisto 2001 Ranta 2002 May 2000
Complete analgesia did not rate highly
The search for an alternative
bull Match time course of labour
bull Not midwife delivered patient control
bull Few maternal amp neonatal adverse effects
Rapid onset and offset amp intravenous
PCA device
Non cumulative
o
f p
eak
eff
ect
site
con
centr
atio
n
Fentanyl
Alfentanil
100
0
Time since bolus (min)
2 4 6
Effect site concentration after opioid bolus
80 10
Remifentanil
Remifentanil pharmacokinetics in neonates
bull Infants under 2 months
bull Pharmacokinetics similar
ndash to older children
ndash to adults
Davis Ross Henson et al Remifentanil pharmacokinetics in neonates
Anesthesiology 1997 87 A 1054
Remifentanil PCA
bull Theory behind techniquendash PCA giving control improves
satisfaction
bull Theory behind choice of drugndash Ultra short-acting rapidly
metabolised
ndash Placental transfer but rapid metabolism in neonatebull Kan et al Anesthesiology1998
88 1467-74
ndash Context sensitive t12 3-5min
ndash Ideal for intermittent pain of labour
Remi pca in practicebull Feasibility for labour analgesia
2001 ndash Blair et al BJA 2001
bull Optimum bolus 05mcgkg no background infusionndash Superior to pethidine
bull Blair et al BJA 2005
bull Shown superior to pethidinendash efficacy satisfaction conversion to
epiduralbull Thurlow et al BJA 2002 Douma et al
BJA 2010
bull No difference in neonatal outcomesndash Review by Leong et al Anes amp Analg
2011
Remi pca in practice
bull Strict protocol
ndash Dedicated IV cannula
ndash Dedicated pumps
ndash Locked pump programmebull 40mcg bolus 2min lockout
ndash Observation chart
Safety with remi
bull One-to-one midwifery care
bull Anaesthetist prescribes and starts pca
bull Strict monitoring
bull Observation chart
bull Immediate oxygen and resuscitation availability
bull Continuous audit
Side effects
bull Nausea
ndash approx 90 use Entonox
bull Itch
bull Sedation
bull Respiratory depression
bull Episode of desaturation lt94 40-50
bull Almost all recover with nasal specs oxygen
Patient info sheet
bull Salient points
ndash Unlicensed use
ndash Audit data re safety
bull Given out at ante-natal clinic
bull Laminated copy in rooms
bull Reiterate in labour ward at request
Remifentanil PCA documentation bullInformed about Remifentanil At least 37 weeks bullInformation leaflet read No recent opiate use bullAware unlicensed use bullPCA technique explained ndash lockouttiming of demandspatient use only bull
bullRisks discussedbullSedation Respiratory depression Epidural conversion bullItch Supplementary oxygen bullNausea Failureinadequate pain relief Verbal consent bull
bullPrerequisites KardexbullDedicated IV canula Remi pump no PCA prescribed bullSpO2 monitoring Anaesthetist present Naloxone bull At initiation bullMidwife present Anti emetic bull
bullSignature _________________ Date amp time ______________________
Remi PCA in Belfast
bull 4000 deliveries ndash Elective LSCS 14
bull Routine use since 2004
bull 100-120 remi pcamth
bull 40 of labouring women choose remi pca
bull Epidural rate dropped to 35
Complications and controversyhellip
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40ndash Pruefer C Bewlay A Anaesthesia
2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesiabull Kinsella 2013
Complications and controversyhellip
Recent adverse reports
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40
ndash Pruefer C Bewlay A Anaesthesia 2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesia bull Kinsella 2013
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
Complications and controversyhellip
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
RESPITE trial 2014
bull Multicentre trial 400 women over 24 months
bull Comparing Remifentanil PCA with IM pethidine
bull Primary aim efficacy ndash VAS
ndash Proportion of women requiring an epidural for pain relief VAS
bull Secondary data adverse effects ndash Maternal sedation
ndash Unwanted effects on mother and baby
bull Clinical guidelines on the use of remifentanil
bull RESPITEtrialsbhamacuk
ldquohot off the pressrdquo
bull May - July 2014 audit data
bull 412 women
bull Efficacy and side effects
bull Outcomes
Satisfaction and efficacy
bull 80 satisfied or very satisfied
bull 87 ldquowould use againrdquo
bull Pain scores
ndash 48 none or mild pain
ndash 36 moderate pain
bull Conversion rate to epidural 129
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
Systemic analgesiahellip
bull Not like an epidural labour
bull Different collaborative relationships
bull Maternal choice issues
bull Midwifery rather than anaesthesia
Systemic analgesia
bull Nitrous Oxide
ndash Ubiquitous UK (not USA)
ndash Patient controlbull Psychological benefit
ndash Low blood-gas solubilitybull Ideal for intermittent use
bull Rapid on-off effect
bull Doesnrsquot accumulate with intermittent use
ndash Often as an adjunct
Opioids
bull Mainstay of systemic analgesia
bull Intermittent bolus regimen
bull Administered by midwives
IM Pethidinebull ldquomore sedation than analgesiardquo1
bull gastric stasis amp hypoventilation 2
bull fetal effects after 40 mins 3
bull dose-delivery lt2-3hrs 4
bull modifies CTG amp EEG 5
bull fetal acidosis 6
bull active metabolites for days 7
1 Olofsson et al B J Obs Gynaecol 1996103968-72
2 Nimmo et al Lancet 19751(7912)890-3
3 Tomson G et al B J Clinical Pharmacology 198213653-9
4 Shnider SM Moya F Am J Obstet Gynecol 1964891009-15
5 Kariniemi V ammala P B J Ob Gynaecol 198188718-20
6 Kariniemi V Rosti J J Perinatal Med 198614131-5
7 Hodgkinson R Farkhanda JH Anesthesiology 19825651-2
What do women wantSytematic review of 137 reports of the views of 14000 women in 9 countries
Satisfaction
ndash Expectations
ndash Support
ndash Quality of relationship with midwife
ndash Involvement in decision making
Dissatisfaction
ndash Failure of timing amp lack of availability of analgesia
Hodnett 2002 Saisto 2001 Ranta 2002 May 2000
Complete analgesia did not rate highly
bull REVIEW
bull Maternal satisfaction
bull PN Robinson P Salmon SM Yentisndash International Journal of Obstetric
Anesthesia (1998) 7 32-37
bull ldquoSatisfaction is multidimensionaland therefore difficult to define assess and measurerdquo
bull ldquoStudies assume that satisfaction with anaesthetic practice equates with good analgesia although as we have shown this is only one dimension of satisfactionrdquo
Regional analgesia ndashthe be all and end all
bull Epidural versus non-epidural or no analgesia in labour
bull Anim-Somuah M1 Smyth RM Jones L
ndash Cochrane Database Syst Rev 2011 Dec 7(12)
Cochrane Conclusionhellip
bull Epidural analgesia appears to be effective in reducing pain during labour
bull However women who use this form of pain relief are at increased risk of having an instrumental delivery
bull Epidural analgesia had no statistically significant impact on the risk of caesarean section maternal satisfaction with pain relief and long-term backache and did not appear to have an immediate effect on neonatal status as determined by Apgar scores
bull Further research may be helpful to evaluate rare but potentially severe adverse effects of epidural analgesia on women in labour and long-term neonatal outcomes
What do women wantSytematic review of 137 reports of the views of 14000 women in 9 countries
Satisfaction
ndash Expectations
ndash Support
ndash Quality of relationship with midwife
ndash Involvement in decision making
Dissatisfaction
ndash Failure of timing amp lack of availability of analgesia
Hodnett 2002 Saisto 2001 Ranta 2002 May 2000
Complete analgesia did not rate highly
The search for an alternative
bull Match time course of labour
bull Not midwife delivered patient control
bull Few maternal amp neonatal adverse effects
Rapid onset and offset amp intravenous
PCA device
Non cumulative
o
f p
eak
eff
ect
site
con
centr
atio
n
Fentanyl
Alfentanil
100
0
Time since bolus (min)
2 4 6
Effect site concentration after opioid bolus
80 10
Remifentanil
Remifentanil pharmacokinetics in neonates
bull Infants under 2 months
bull Pharmacokinetics similar
ndash to older children
ndash to adults
Davis Ross Henson et al Remifentanil pharmacokinetics in neonates
Anesthesiology 1997 87 A 1054
Remifentanil PCA
bull Theory behind techniquendash PCA giving control improves
satisfaction
bull Theory behind choice of drugndash Ultra short-acting rapidly
metabolised
ndash Placental transfer but rapid metabolism in neonatebull Kan et al Anesthesiology1998
88 1467-74
ndash Context sensitive t12 3-5min
ndash Ideal for intermittent pain of labour
Remi pca in practicebull Feasibility for labour analgesia
2001 ndash Blair et al BJA 2001
bull Optimum bolus 05mcgkg no background infusionndash Superior to pethidine
bull Blair et al BJA 2005
bull Shown superior to pethidinendash efficacy satisfaction conversion to
epiduralbull Thurlow et al BJA 2002 Douma et al
BJA 2010
bull No difference in neonatal outcomesndash Review by Leong et al Anes amp Analg
2011
Remi pca in practice
bull Strict protocol
ndash Dedicated IV cannula
ndash Dedicated pumps
ndash Locked pump programmebull 40mcg bolus 2min lockout
ndash Observation chart
Safety with remi
bull One-to-one midwifery care
bull Anaesthetist prescribes and starts pca
bull Strict monitoring
bull Observation chart
bull Immediate oxygen and resuscitation availability
bull Continuous audit
Side effects
bull Nausea
ndash approx 90 use Entonox
bull Itch
bull Sedation
bull Respiratory depression
bull Episode of desaturation lt94 40-50
bull Almost all recover with nasal specs oxygen
Patient info sheet
bull Salient points
ndash Unlicensed use
ndash Audit data re safety
bull Given out at ante-natal clinic
bull Laminated copy in rooms
bull Reiterate in labour ward at request
Remifentanil PCA documentation bullInformed about Remifentanil At least 37 weeks bullInformation leaflet read No recent opiate use bullAware unlicensed use bullPCA technique explained ndash lockouttiming of demandspatient use only bull
bullRisks discussedbullSedation Respiratory depression Epidural conversion bullItch Supplementary oxygen bullNausea Failureinadequate pain relief Verbal consent bull
bullPrerequisites KardexbullDedicated IV canula Remi pump no PCA prescribed bullSpO2 monitoring Anaesthetist present Naloxone bull At initiation bullMidwife present Anti emetic bull
bullSignature _________________ Date amp time ______________________
Remi PCA in Belfast
bull 4000 deliveries ndash Elective LSCS 14
bull Routine use since 2004
bull 100-120 remi pcamth
bull 40 of labouring women choose remi pca
bull Epidural rate dropped to 35
Complications and controversyhellip
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40ndash Pruefer C Bewlay A Anaesthesia
2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesiabull Kinsella 2013
Complications and controversyhellip
Recent adverse reports
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40
ndash Pruefer C Bewlay A Anaesthesia 2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesia bull Kinsella 2013
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
Complications and controversyhellip
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
RESPITE trial 2014
bull Multicentre trial 400 women over 24 months
bull Comparing Remifentanil PCA with IM pethidine
bull Primary aim efficacy ndash VAS
ndash Proportion of women requiring an epidural for pain relief VAS
bull Secondary data adverse effects ndash Maternal sedation
ndash Unwanted effects on mother and baby
bull Clinical guidelines on the use of remifentanil
bull RESPITEtrialsbhamacuk
ldquohot off the pressrdquo
bull May - July 2014 audit data
bull 412 women
bull Efficacy and side effects
bull Outcomes
Satisfaction and efficacy
bull 80 satisfied or very satisfied
bull 87 ldquowould use againrdquo
bull Pain scores
ndash 48 none or mild pain
ndash 36 moderate pain
bull Conversion rate to epidural 129
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
Systemic analgesia
bull Nitrous Oxide
ndash Ubiquitous UK (not USA)
ndash Patient controlbull Psychological benefit
ndash Low blood-gas solubilitybull Ideal for intermittent use
bull Rapid on-off effect
bull Doesnrsquot accumulate with intermittent use
ndash Often as an adjunct
Opioids
bull Mainstay of systemic analgesia
bull Intermittent bolus regimen
bull Administered by midwives
IM Pethidinebull ldquomore sedation than analgesiardquo1
bull gastric stasis amp hypoventilation 2
bull fetal effects after 40 mins 3
bull dose-delivery lt2-3hrs 4
bull modifies CTG amp EEG 5
bull fetal acidosis 6
bull active metabolites for days 7
1 Olofsson et al B J Obs Gynaecol 1996103968-72
2 Nimmo et al Lancet 19751(7912)890-3
3 Tomson G et al B J Clinical Pharmacology 198213653-9
4 Shnider SM Moya F Am J Obstet Gynecol 1964891009-15
5 Kariniemi V ammala P B J Ob Gynaecol 198188718-20
6 Kariniemi V Rosti J J Perinatal Med 198614131-5
7 Hodgkinson R Farkhanda JH Anesthesiology 19825651-2
What do women wantSytematic review of 137 reports of the views of 14000 women in 9 countries
Satisfaction
ndash Expectations
ndash Support
ndash Quality of relationship with midwife
ndash Involvement in decision making
Dissatisfaction
ndash Failure of timing amp lack of availability of analgesia
Hodnett 2002 Saisto 2001 Ranta 2002 May 2000
Complete analgesia did not rate highly
bull REVIEW
bull Maternal satisfaction
bull PN Robinson P Salmon SM Yentisndash International Journal of Obstetric
Anesthesia (1998) 7 32-37
bull ldquoSatisfaction is multidimensionaland therefore difficult to define assess and measurerdquo
bull ldquoStudies assume that satisfaction with anaesthetic practice equates with good analgesia although as we have shown this is only one dimension of satisfactionrdquo
Regional analgesia ndashthe be all and end all
bull Epidural versus non-epidural or no analgesia in labour
bull Anim-Somuah M1 Smyth RM Jones L
ndash Cochrane Database Syst Rev 2011 Dec 7(12)
Cochrane Conclusionhellip
bull Epidural analgesia appears to be effective in reducing pain during labour
bull However women who use this form of pain relief are at increased risk of having an instrumental delivery
bull Epidural analgesia had no statistically significant impact on the risk of caesarean section maternal satisfaction with pain relief and long-term backache and did not appear to have an immediate effect on neonatal status as determined by Apgar scores
bull Further research may be helpful to evaluate rare but potentially severe adverse effects of epidural analgesia on women in labour and long-term neonatal outcomes
What do women wantSytematic review of 137 reports of the views of 14000 women in 9 countries
Satisfaction
ndash Expectations
ndash Support
ndash Quality of relationship with midwife
ndash Involvement in decision making
Dissatisfaction
ndash Failure of timing amp lack of availability of analgesia
Hodnett 2002 Saisto 2001 Ranta 2002 May 2000
Complete analgesia did not rate highly
The search for an alternative
bull Match time course of labour
bull Not midwife delivered patient control
bull Few maternal amp neonatal adverse effects
Rapid onset and offset amp intravenous
PCA device
Non cumulative
o
f p
eak
eff
ect
site
con
centr
atio
n
Fentanyl
Alfentanil
100
0
Time since bolus (min)
2 4 6
Effect site concentration after opioid bolus
80 10
Remifentanil
Remifentanil pharmacokinetics in neonates
bull Infants under 2 months
bull Pharmacokinetics similar
ndash to older children
ndash to adults
Davis Ross Henson et al Remifentanil pharmacokinetics in neonates
Anesthesiology 1997 87 A 1054
Remifentanil PCA
bull Theory behind techniquendash PCA giving control improves
satisfaction
bull Theory behind choice of drugndash Ultra short-acting rapidly
metabolised
ndash Placental transfer but rapid metabolism in neonatebull Kan et al Anesthesiology1998
88 1467-74
ndash Context sensitive t12 3-5min
ndash Ideal for intermittent pain of labour
Remi pca in practicebull Feasibility for labour analgesia
2001 ndash Blair et al BJA 2001
bull Optimum bolus 05mcgkg no background infusionndash Superior to pethidine
bull Blair et al BJA 2005
bull Shown superior to pethidinendash efficacy satisfaction conversion to
epiduralbull Thurlow et al BJA 2002 Douma et al
BJA 2010
bull No difference in neonatal outcomesndash Review by Leong et al Anes amp Analg
2011
Remi pca in practice
bull Strict protocol
ndash Dedicated IV cannula
ndash Dedicated pumps
ndash Locked pump programmebull 40mcg bolus 2min lockout
ndash Observation chart
Safety with remi
bull One-to-one midwifery care
bull Anaesthetist prescribes and starts pca
bull Strict monitoring
bull Observation chart
bull Immediate oxygen and resuscitation availability
bull Continuous audit
Side effects
bull Nausea
ndash approx 90 use Entonox
bull Itch
bull Sedation
bull Respiratory depression
bull Episode of desaturation lt94 40-50
bull Almost all recover with nasal specs oxygen
Patient info sheet
bull Salient points
ndash Unlicensed use
ndash Audit data re safety
bull Given out at ante-natal clinic
bull Laminated copy in rooms
bull Reiterate in labour ward at request
Remifentanil PCA documentation bullInformed about Remifentanil At least 37 weeks bullInformation leaflet read No recent opiate use bullAware unlicensed use bullPCA technique explained ndash lockouttiming of demandspatient use only bull
bullRisks discussedbullSedation Respiratory depression Epidural conversion bullItch Supplementary oxygen bullNausea Failureinadequate pain relief Verbal consent bull
bullPrerequisites KardexbullDedicated IV canula Remi pump no PCA prescribed bullSpO2 monitoring Anaesthetist present Naloxone bull At initiation bullMidwife present Anti emetic bull
bullSignature _________________ Date amp time ______________________
Remi PCA in Belfast
bull 4000 deliveries ndash Elective LSCS 14
bull Routine use since 2004
bull 100-120 remi pcamth
bull 40 of labouring women choose remi pca
bull Epidural rate dropped to 35
Complications and controversyhellip
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40ndash Pruefer C Bewlay A Anaesthesia
2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesiabull Kinsella 2013
Complications and controversyhellip
Recent adverse reports
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40
ndash Pruefer C Bewlay A Anaesthesia 2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesia bull Kinsella 2013
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
Complications and controversyhellip
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
RESPITE trial 2014
bull Multicentre trial 400 women over 24 months
bull Comparing Remifentanil PCA with IM pethidine
bull Primary aim efficacy ndash VAS
ndash Proportion of women requiring an epidural for pain relief VAS
bull Secondary data adverse effects ndash Maternal sedation
ndash Unwanted effects on mother and baby
bull Clinical guidelines on the use of remifentanil
bull RESPITEtrialsbhamacuk
ldquohot off the pressrdquo
bull May - July 2014 audit data
bull 412 women
bull Efficacy and side effects
bull Outcomes
Satisfaction and efficacy
bull 80 satisfied or very satisfied
bull 87 ldquowould use againrdquo
bull Pain scores
ndash 48 none or mild pain
ndash 36 moderate pain
bull Conversion rate to epidural 129
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
Opioids
bull Mainstay of systemic analgesia
bull Intermittent bolus regimen
bull Administered by midwives
IM Pethidinebull ldquomore sedation than analgesiardquo1
bull gastric stasis amp hypoventilation 2
bull fetal effects after 40 mins 3
bull dose-delivery lt2-3hrs 4
bull modifies CTG amp EEG 5
bull fetal acidosis 6
bull active metabolites for days 7
1 Olofsson et al B J Obs Gynaecol 1996103968-72
2 Nimmo et al Lancet 19751(7912)890-3
3 Tomson G et al B J Clinical Pharmacology 198213653-9
4 Shnider SM Moya F Am J Obstet Gynecol 1964891009-15
5 Kariniemi V ammala P B J Ob Gynaecol 198188718-20
6 Kariniemi V Rosti J J Perinatal Med 198614131-5
7 Hodgkinson R Farkhanda JH Anesthesiology 19825651-2
What do women wantSytematic review of 137 reports of the views of 14000 women in 9 countries
Satisfaction
ndash Expectations
ndash Support
ndash Quality of relationship with midwife
ndash Involvement in decision making
Dissatisfaction
ndash Failure of timing amp lack of availability of analgesia
Hodnett 2002 Saisto 2001 Ranta 2002 May 2000
Complete analgesia did not rate highly
bull REVIEW
bull Maternal satisfaction
bull PN Robinson P Salmon SM Yentisndash International Journal of Obstetric
Anesthesia (1998) 7 32-37
bull ldquoSatisfaction is multidimensionaland therefore difficult to define assess and measurerdquo
bull ldquoStudies assume that satisfaction with anaesthetic practice equates with good analgesia although as we have shown this is only one dimension of satisfactionrdquo
Regional analgesia ndashthe be all and end all
bull Epidural versus non-epidural or no analgesia in labour
bull Anim-Somuah M1 Smyth RM Jones L
ndash Cochrane Database Syst Rev 2011 Dec 7(12)
Cochrane Conclusionhellip
bull Epidural analgesia appears to be effective in reducing pain during labour
bull However women who use this form of pain relief are at increased risk of having an instrumental delivery
bull Epidural analgesia had no statistically significant impact on the risk of caesarean section maternal satisfaction with pain relief and long-term backache and did not appear to have an immediate effect on neonatal status as determined by Apgar scores
bull Further research may be helpful to evaluate rare but potentially severe adverse effects of epidural analgesia on women in labour and long-term neonatal outcomes
What do women wantSytematic review of 137 reports of the views of 14000 women in 9 countries
Satisfaction
ndash Expectations
ndash Support
ndash Quality of relationship with midwife
ndash Involvement in decision making
Dissatisfaction
ndash Failure of timing amp lack of availability of analgesia
Hodnett 2002 Saisto 2001 Ranta 2002 May 2000
Complete analgesia did not rate highly
The search for an alternative
bull Match time course of labour
bull Not midwife delivered patient control
bull Few maternal amp neonatal adverse effects
Rapid onset and offset amp intravenous
PCA device
Non cumulative
o
f p
eak
eff
ect
site
con
centr
atio
n
Fentanyl
Alfentanil
100
0
Time since bolus (min)
2 4 6
Effect site concentration after opioid bolus
80 10
Remifentanil
Remifentanil pharmacokinetics in neonates
bull Infants under 2 months
bull Pharmacokinetics similar
ndash to older children
ndash to adults
Davis Ross Henson et al Remifentanil pharmacokinetics in neonates
Anesthesiology 1997 87 A 1054
Remifentanil PCA
bull Theory behind techniquendash PCA giving control improves
satisfaction
bull Theory behind choice of drugndash Ultra short-acting rapidly
metabolised
ndash Placental transfer but rapid metabolism in neonatebull Kan et al Anesthesiology1998
88 1467-74
ndash Context sensitive t12 3-5min
ndash Ideal for intermittent pain of labour
Remi pca in practicebull Feasibility for labour analgesia
2001 ndash Blair et al BJA 2001
bull Optimum bolus 05mcgkg no background infusionndash Superior to pethidine
bull Blair et al BJA 2005
bull Shown superior to pethidinendash efficacy satisfaction conversion to
epiduralbull Thurlow et al BJA 2002 Douma et al
BJA 2010
bull No difference in neonatal outcomesndash Review by Leong et al Anes amp Analg
2011
Remi pca in practice
bull Strict protocol
ndash Dedicated IV cannula
ndash Dedicated pumps
ndash Locked pump programmebull 40mcg bolus 2min lockout
ndash Observation chart
Safety with remi
bull One-to-one midwifery care
bull Anaesthetist prescribes and starts pca
bull Strict monitoring
bull Observation chart
bull Immediate oxygen and resuscitation availability
bull Continuous audit
Side effects
bull Nausea
ndash approx 90 use Entonox
bull Itch
bull Sedation
bull Respiratory depression
bull Episode of desaturation lt94 40-50
bull Almost all recover with nasal specs oxygen
Patient info sheet
bull Salient points
ndash Unlicensed use
ndash Audit data re safety
bull Given out at ante-natal clinic
bull Laminated copy in rooms
bull Reiterate in labour ward at request
Remifentanil PCA documentation bullInformed about Remifentanil At least 37 weeks bullInformation leaflet read No recent opiate use bullAware unlicensed use bullPCA technique explained ndash lockouttiming of demandspatient use only bull
bullRisks discussedbullSedation Respiratory depression Epidural conversion bullItch Supplementary oxygen bullNausea Failureinadequate pain relief Verbal consent bull
bullPrerequisites KardexbullDedicated IV canula Remi pump no PCA prescribed bullSpO2 monitoring Anaesthetist present Naloxone bull At initiation bullMidwife present Anti emetic bull
bullSignature _________________ Date amp time ______________________
Remi PCA in Belfast
bull 4000 deliveries ndash Elective LSCS 14
bull Routine use since 2004
bull 100-120 remi pcamth
bull 40 of labouring women choose remi pca
bull Epidural rate dropped to 35
Complications and controversyhellip
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40ndash Pruefer C Bewlay A Anaesthesia
2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesiabull Kinsella 2013
Complications and controversyhellip
Recent adverse reports
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40
ndash Pruefer C Bewlay A Anaesthesia 2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesia bull Kinsella 2013
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
Complications and controversyhellip
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
RESPITE trial 2014
bull Multicentre trial 400 women over 24 months
bull Comparing Remifentanil PCA with IM pethidine
bull Primary aim efficacy ndash VAS
ndash Proportion of women requiring an epidural for pain relief VAS
bull Secondary data adverse effects ndash Maternal sedation
ndash Unwanted effects on mother and baby
bull Clinical guidelines on the use of remifentanil
bull RESPITEtrialsbhamacuk
ldquohot off the pressrdquo
bull May - July 2014 audit data
bull 412 women
bull Efficacy and side effects
bull Outcomes
Satisfaction and efficacy
bull 80 satisfied or very satisfied
bull 87 ldquowould use againrdquo
bull Pain scores
ndash 48 none or mild pain
ndash 36 moderate pain
bull Conversion rate to epidural 129
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
IM Pethidinebull ldquomore sedation than analgesiardquo1
bull gastric stasis amp hypoventilation 2
bull fetal effects after 40 mins 3
bull dose-delivery lt2-3hrs 4
bull modifies CTG amp EEG 5
bull fetal acidosis 6
bull active metabolites for days 7
1 Olofsson et al B J Obs Gynaecol 1996103968-72
2 Nimmo et al Lancet 19751(7912)890-3
3 Tomson G et al B J Clinical Pharmacology 198213653-9
4 Shnider SM Moya F Am J Obstet Gynecol 1964891009-15
5 Kariniemi V ammala P B J Ob Gynaecol 198188718-20
6 Kariniemi V Rosti J J Perinatal Med 198614131-5
7 Hodgkinson R Farkhanda JH Anesthesiology 19825651-2
What do women wantSytematic review of 137 reports of the views of 14000 women in 9 countries
Satisfaction
ndash Expectations
ndash Support
ndash Quality of relationship with midwife
ndash Involvement in decision making
Dissatisfaction
ndash Failure of timing amp lack of availability of analgesia
Hodnett 2002 Saisto 2001 Ranta 2002 May 2000
Complete analgesia did not rate highly
bull REVIEW
bull Maternal satisfaction
bull PN Robinson P Salmon SM Yentisndash International Journal of Obstetric
Anesthesia (1998) 7 32-37
bull ldquoSatisfaction is multidimensionaland therefore difficult to define assess and measurerdquo
bull ldquoStudies assume that satisfaction with anaesthetic practice equates with good analgesia although as we have shown this is only one dimension of satisfactionrdquo
Regional analgesia ndashthe be all and end all
bull Epidural versus non-epidural or no analgesia in labour
bull Anim-Somuah M1 Smyth RM Jones L
ndash Cochrane Database Syst Rev 2011 Dec 7(12)
Cochrane Conclusionhellip
bull Epidural analgesia appears to be effective in reducing pain during labour
bull However women who use this form of pain relief are at increased risk of having an instrumental delivery
bull Epidural analgesia had no statistically significant impact on the risk of caesarean section maternal satisfaction with pain relief and long-term backache and did not appear to have an immediate effect on neonatal status as determined by Apgar scores
bull Further research may be helpful to evaluate rare but potentially severe adverse effects of epidural analgesia on women in labour and long-term neonatal outcomes
What do women wantSytematic review of 137 reports of the views of 14000 women in 9 countries
Satisfaction
ndash Expectations
ndash Support
ndash Quality of relationship with midwife
ndash Involvement in decision making
Dissatisfaction
ndash Failure of timing amp lack of availability of analgesia
Hodnett 2002 Saisto 2001 Ranta 2002 May 2000
Complete analgesia did not rate highly
The search for an alternative
bull Match time course of labour
bull Not midwife delivered patient control
bull Few maternal amp neonatal adverse effects
Rapid onset and offset amp intravenous
PCA device
Non cumulative
o
f p
eak
eff
ect
site
con
centr
atio
n
Fentanyl
Alfentanil
100
0
Time since bolus (min)
2 4 6
Effect site concentration after opioid bolus
80 10
Remifentanil
Remifentanil pharmacokinetics in neonates
bull Infants under 2 months
bull Pharmacokinetics similar
ndash to older children
ndash to adults
Davis Ross Henson et al Remifentanil pharmacokinetics in neonates
Anesthesiology 1997 87 A 1054
Remifentanil PCA
bull Theory behind techniquendash PCA giving control improves
satisfaction
bull Theory behind choice of drugndash Ultra short-acting rapidly
metabolised
ndash Placental transfer but rapid metabolism in neonatebull Kan et al Anesthesiology1998
88 1467-74
ndash Context sensitive t12 3-5min
ndash Ideal for intermittent pain of labour
Remi pca in practicebull Feasibility for labour analgesia
2001 ndash Blair et al BJA 2001
bull Optimum bolus 05mcgkg no background infusionndash Superior to pethidine
bull Blair et al BJA 2005
bull Shown superior to pethidinendash efficacy satisfaction conversion to
epiduralbull Thurlow et al BJA 2002 Douma et al
BJA 2010
bull No difference in neonatal outcomesndash Review by Leong et al Anes amp Analg
2011
Remi pca in practice
bull Strict protocol
ndash Dedicated IV cannula
ndash Dedicated pumps
ndash Locked pump programmebull 40mcg bolus 2min lockout
ndash Observation chart
Safety with remi
bull One-to-one midwifery care
bull Anaesthetist prescribes and starts pca
bull Strict monitoring
bull Observation chart
bull Immediate oxygen and resuscitation availability
bull Continuous audit
Side effects
bull Nausea
ndash approx 90 use Entonox
bull Itch
bull Sedation
bull Respiratory depression
bull Episode of desaturation lt94 40-50
bull Almost all recover with nasal specs oxygen
Patient info sheet
bull Salient points
ndash Unlicensed use
ndash Audit data re safety
bull Given out at ante-natal clinic
bull Laminated copy in rooms
bull Reiterate in labour ward at request
Remifentanil PCA documentation bullInformed about Remifentanil At least 37 weeks bullInformation leaflet read No recent opiate use bullAware unlicensed use bullPCA technique explained ndash lockouttiming of demandspatient use only bull
bullRisks discussedbullSedation Respiratory depression Epidural conversion bullItch Supplementary oxygen bullNausea Failureinadequate pain relief Verbal consent bull
bullPrerequisites KardexbullDedicated IV canula Remi pump no PCA prescribed bullSpO2 monitoring Anaesthetist present Naloxone bull At initiation bullMidwife present Anti emetic bull
bullSignature _________________ Date amp time ______________________
Remi PCA in Belfast
bull 4000 deliveries ndash Elective LSCS 14
bull Routine use since 2004
bull 100-120 remi pcamth
bull 40 of labouring women choose remi pca
bull Epidural rate dropped to 35
Complications and controversyhellip
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40ndash Pruefer C Bewlay A Anaesthesia
2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesiabull Kinsella 2013
Complications and controversyhellip
Recent adverse reports
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40
ndash Pruefer C Bewlay A Anaesthesia 2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesia bull Kinsella 2013
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
Complications and controversyhellip
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
RESPITE trial 2014
bull Multicentre trial 400 women over 24 months
bull Comparing Remifentanil PCA with IM pethidine
bull Primary aim efficacy ndash VAS
ndash Proportion of women requiring an epidural for pain relief VAS
bull Secondary data adverse effects ndash Maternal sedation
ndash Unwanted effects on mother and baby
bull Clinical guidelines on the use of remifentanil
bull RESPITEtrialsbhamacuk
ldquohot off the pressrdquo
bull May - July 2014 audit data
bull 412 women
bull Efficacy and side effects
bull Outcomes
Satisfaction and efficacy
bull 80 satisfied or very satisfied
bull 87 ldquowould use againrdquo
bull Pain scores
ndash 48 none or mild pain
ndash 36 moderate pain
bull Conversion rate to epidural 129
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
What do women wantSytematic review of 137 reports of the views of 14000 women in 9 countries
Satisfaction
ndash Expectations
ndash Support
ndash Quality of relationship with midwife
ndash Involvement in decision making
Dissatisfaction
ndash Failure of timing amp lack of availability of analgesia
Hodnett 2002 Saisto 2001 Ranta 2002 May 2000
Complete analgesia did not rate highly
bull REVIEW
bull Maternal satisfaction
bull PN Robinson P Salmon SM Yentisndash International Journal of Obstetric
Anesthesia (1998) 7 32-37
bull ldquoSatisfaction is multidimensionaland therefore difficult to define assess and measurerdquo
bull ldquoStudies assume that satisfaction with anaesthetic practice equates with good analgesia although as we have shown this is only one dimension of satisfactionrdquo
Regional analgesia ndashthe be all and end all
bull Epidural versus non-epidural or no analgesia in labour
bull Anim-Somuah M1 Smyth RM Jones L
ndash Cochrane Database Syst Rev 2011 Dec 7(12)
Cochrane Conclusionhellip
bull Epidural analgesia appears to be effective in reducing pain during labour
bull However women who use this form of pain relief are at increased risk of having an instrumental delivery
bull Epidural analgesia had no statistically significant impact on the risk of caesarean section maternal satisfaction with pain relief and long-term backache and did not appear to have an immediate effect on neonatal status as determined by Apgar scores
bull Further research may be helpful to evaluate rare but potentially severe adverse effects of epidural analgesia on women in labour and long-term neonatal outcomes
What do women wantSytematic review of 137 reports of the views of 14000 women in 9 countries
Satisfaction
ndash Expectations
ndash Support
ndash Quality of relationship with midwife
ndash Involvement in decision making
Dissatisfaction
ndash Failure of timing amp lack of availability of analgesia
Hodnett 2002 Saisto 2001 Ranta 2002 May 2000
Complete analgesia did not rate highly
The search for an alternative
bull Match time course of labour
bull Not midwife delivered patient control
bull Few maternal amp neonatal adverse effects
Rapid onset and offset amp intravenous
PCA device
Non cumulative
o
f p
eak
eff
ect
site
con
centr
atio
n
Fentanyl
Alfentanil
100
0
Time since bolus (min)
2 4 6
Effect site concentration after opioid bolus
80 10
Remifentanil
Remifentanil pharmacokinetics in neonates
bull Infants under 2 months
bull Pharmacokinetics similar
ndash to older children
ndash to adults
Davis Ross Henson et al Remifentanil pharmacokinetics in neonates
Anesthesiology 1997 87 A 1054
Remifentanil PCA
bull Theory behind techniquendash PCA giving control improves
satisfaction
bull Theory behind choice of drugndash Ultra short-acting rapidly
metabolised
ndash Placental transfer but rapid metabolism in neonatebull Kan et al Anesthesiology1998
88 1467-74
ndash Context sensitive t12 3-5min
ndash Ideal for intermittent pain of labour
Remi pca in practicebull Feasibility for labour analgesia
2001 ndash Blair et al BJA 2001
bull Optimum bolus 05mcgkg no background infusionndash Superior to pethidine
bull Blair et al BJA 2005
bull Shown superior to pethidinendash efficacy satisfaction conversion to
epiduralbull Thurlow et al BJA 2002 Douma et al
BJA 2010
bull No difference in neonatal outcomesndash Review by Leong et al Anes amp Analg
2011
Remi pca in practice
bull Strict protocol
ndash Dedicated IV cannula
ndash Dedicated pumps
ndash Locked pump programmebull 40mcg bolus 2min lockout
ndash Observation chart
Safety with remi
bull One-to-one midwifery care
bull Anaesthetist prescribes and starts pca
bull Strict monitoring
bull Observation chart
bull Immediate oxygen and resuscitation availability
bull Continuous audit
Side effects
bull Nausea
ndash approx 90 use Entonox
bull Itch
bull Sedation
bull Respiratory depression
bull Episode of desaturation lt94 40-50
bull Almost all recover with nasal specs oxygen
Patient info sheet
bull Salient points
ndash Unlicensed use
ndash Audit data re safety
bull Given out at ante-natal clinic
bull Laminated copy in rooms
bull Reiterate in labour ward at request
Remifentanil PCA documentation bullInformed about Remifentanil At least 37 weeks bullInformation leaflet read No recent opiate use bullAware unlicensed use bullPCA technique explained ndash lockouttiming of demandspatient use only bull
bullRisks discussedbullSedation Respiratory depression Epidural conversion bullItch Supplementary oxygen bullNausea Failureinadequate pain relief Verbal consent bull
bullPrerequisites KardexbullDedicated IV canula Remi pump no PCA prescribed bullSpO2 monitoring Anaesthetist present Naloxone bull At initiation bullMidwife present Anti emetic bull
bullSignature _________________ Date amp time ______________________
Remi PCA in Belfast
bull 4000 deliveries ndash Elective LSCS 14
bull Routine use since 2004
bull 100-120 remi pcamth
bull 40 of labouring women choose remi pca
bull Epidural rate dropped to 35
Complications and controversyhellip
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40ndash Pruefer C Bewlay A Anaesthesia
2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesiabull Kinsella 2013
Complications and controversyhellip
Recent adverse reports
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40
ndash Pruefer C Bewlay A Anaesthesia 2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesia bull Kinsella 2013
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
Complications and controversyhellip
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
RESPITE trial 2014
bull Multicentre trial 400 women over 24 months
bull Comparing Remifentanil PCA with IM pethidine
bull Primary aim efficacy ndash VAS
ndash Proportion of women requiring an epidural for pain relief VAS
bull Secondary data adverse effects ndash Maternal sedation
ndash Unwanted effects on mother and baby
bull Clinical guidelines on the use of remifentanil
bull RESPITEtrialsbhamacuk
ldquohot off the pressrdquo
bull May - July 2014 audit data
bull 412 women
bull Efficacy and side effects
bull Outcomes
Satisfaction and efficacy
bull 80 satisfied or very satisfied
bull 87 ldquowould use againrdquo
bull Pain scores
ndash 48 none or mild pain
ndash 36 moderate pain
bull Conversion rate to epidural 129
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
bull REVIEW
bull Maternal satisfaction
bull PN Robinson P Salmon SM Yentisndash International Journal of Obstetric
Anesthesia (1998) 7 32-37
bull ldquoSatisfaction is multidimensionaland therefore difficult to define assess and measurerdquo
bull ldquoStudies assume that satisfaction with anaesthetic practice equates with good analgesia although as we have shown this is only one dimension of satisfactionrdquo
Regional analgesia ndashthe be all and end all
bull Epidural versus non-epidural or no analgesia in labour
bull Anim-Somuah M1 Smyth RM Jones L
ndash Cochrane Database Syst Rev 2011 Dec 7(12)
Cochrane Conclusionhellip
bull Epidural analgesia appears to be effective in reducing pain during labour
bull However women who use this form of pain relief are at increased risk of having an instrumental delivery
bull Epidural analgesia had no statistically significant impact on the risk of caesarean section maternal satisfaction with pain relief and long-term backache and did not appear to have an immediate effect on neonatal status as determined by Apgar scores
bull Further research may be helpful to evaluate rare but potentially severe adverse effects of epidural analgesia on women in labour and long-term neonatal outcomes
What do women wantSytematic review of 137 reports of the views of 14000 women in 9 countries
Satisfaction
ndash Expectations
ndash Support
ndash Quality of relationship with midwife
ndash Involvement in decision making
Dissatisfaction
ndash Failure of timing amp lack of availability of analgesia
Hodnett 2002 Saisto 2001 Ranta 2002 May 2000
Complete analgesia did not rate highly
The search for an alternative
bull Match time course of labour
bull Not midwife delivered patient control
bull Few maternal amp neonatal adverse effects
Rapid onset and offset amp intravenous
PCA device
Non cumulative
o
f p
eak
eff
ect
site
con
centr
atio
n
Fentanyl
Alfentanil
100
0
Time since bolus (min)
2 4 6
Effect site concentration after opioid bolus
80 10
Remifentanil
Remifentanil pharmacokinetics in neonates
bull Infants under 2 months
bull Pharmacokinetics similar
ndash to older children
ndash to adults
Davis Ross Henson et al Remifentanil pharmacokinetics in neonates
Anesthesiology 1997 87 A 1054
Remifentanil PCA
bull Theory behind techniquendash PCA giving control improves
satisfaction
bull Theory behind choice of drugndash Ultra short-acting rapidly
metabolised
ndash Placental transfer but rapid metabolism in neonatebull Kan et al Anesthesiology1998
88 1467-74
ndash Context sensitive t12 3-5min
ndash Ideal for intermittent pain of labour
Remi pca in practicebull Feasibility for labour analgesia
2001 ndash Blair et al BJA 2001
bull Optimum bolus 05mcgkg no background infusionndash Superior to pethidine
bull Blair et al BJA 2005
bull Shown superior to pethidinendash efficacy satisfaction conversion to
epiduralbull Thurlow et al BJA 2002 Douma et al
BJA 2010
bull No difference in neonatal outcomesndash Review by Leong et al Anes amp Analg
2011
Remi pca in practice
bull Strict protocol
ndash Dedicated IV cannula
ndash Dedicated pumps
ndash Locked pump programmebull 40mcg bolus 2min lockout
ndash Observation chart
Safety with remi
bull One-to-one midwifery care
bull Anaesthetist prescribes and starts pca
bull Strict monitoring
bull Observation chart
bull Immediate oxygen and resuscitation availability
bull Continuous audit
Side effects
bull Nausea
ndash approx 90 use Entonox
bull Itch
bull Sedation
bull Respiratory depression
bull Episode of desaturation lt94 40-50
bull Almost all recover with nasal specs oxygen
Patient info sheet
bull Salient points
ndash Unlicensed use
ndash Audit data re safety
bull Given out at ante-natal clinic
bull Laminated copy in rooms
bull Reiterate in labour ward at request
Remifentanil PCA documentation bullInformed about Remifentanil At least 37 weeks bullInformation leaflet read No recent opiate use bullAware unlicensed use bullPCA technique explained ndash lockouttiming of demandspatient use only bull
bullRisks discussedbullSedation Respiratory depression Epidural conversion bullItch Supplementary oxygen bullNausea Failureinadequate pain relief Verbal consent bull
bullPrerequisites KardexbullDedicated IV canula Remi pump no PCA prescribed bullSpO2 monitoring Anaesthetist present Naloxone bull At initiation bullMidwife present Anti emetic bull
bullSignature _________________ Date amp time ______________________
Remi PCA in Belfast
bull 4000 deliveries ndash Elective LSCS 14
bull Routine use since 2004
bull 100-120 remi pcamth
bull 40 of labouring women choose remi pca
bull Epidural rate dropped to 35
Complications and controversyhellip
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40ndash Pruefer C Bewlay A Anaesthesia
2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesiabull Kinsella 2013
Complications and controversyhellip
Recent adverse reports
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40
ndash Pruefer C Bewlay A Anaesthesia 2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesia bull Kinsella 2013
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
Complications and controversyhellip
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
RESPITE trial 2014
bull Multicentre trial 400 women over 24 months
bull Comparing Remifentanil PCA with IM pethidine
bull Primary aim efficacy ndash VAS
ndash Proportion of women requiring an epidural for pain relief VAS
bull Secondary data adverse effects ndash Maternal sedation
ndash Unwanted effects on mother and baby
bull Clinical guidelines on the use of remifentanil
bull RESPITEtrialsbhamacuk
ldquohot off the pressrdquo
bull May - July 2014 audit data
bull 412 women
bull Efficacy and side effects
bull Outcomes
Satisfaction and efficacy
bull 80 satisfied or very satisfied
bull 87 ldquowould use againrdquo
bull Pain scores
ndash 48 none or mild pain
ndash 36 moderate pain
bull Conversion rate to epidural 129
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
Regional analgesia ndashthe be all and end all
bull Epidural versus non-epidural or no analgesia in labour
bull Anim-Somuah M1 Smyth RM Jones L
ndash Cochrane Database Syst Rev 2011 Dec 7(12)
Cochrane Conclusionhellip
bull Epidural analgesia appears to be effective in reducing pain during labour
bull However women who use this form of pain relief are at increased risk of having an instrumental delivery
bull Epidural analgesia had no statistically significant impact on the risk of caesarean section maternal satisfaction with pain relief and long-term backache and did not appear to have an immediate effect on neonatal status as determined by Apgar scores
bull Further research may be helpful to evaluate rare but potentially severe adverse effects of epidural analgesia on women in labour and long-term neonatal outcomes
What do women wantSytematic review of 137 reports of the views of 14000 women in 9 countries
Satisfaction
ndash Expectations
ndash Support
ndash Quality of relationship with midwife
ndash Involvement in decision making
Dissatisfaction
ndash Failure of timing amp lack of availability of analgesia
Hodnett 2002 Saisto 2001 Ranta 2002 May 2000
Complete analgesia did not rate highly
The search for an alternative
bull Match time course of labour
bull Not midwife delivered patient control
bull Few maternal amp neonatal adverse effects
Rapid onset and offset amp intravenous
PCA device
Non cumulative
o
f p
eak
eff
ect
site
con
centr
atio
n
Fentanyl
Alfentanil
100
0
Time since bolus (min)
2 4 6
Effect site concentration after opioid bolus
80 10
Remifentanil
Remifentanil pharmacokinetics in neonates
bull Infants under 2 months
bull Pharmacokinetics similar
ndash to older children
ndash to adults
Davis Ross Henson et al Remifentanil pharmacokinetics in neonates
Anesthesiology 1997 87 A 1054
Remifentanil PCA
bull Theory behind techniquendash PCA giving control improves
satisfaction
bull Theory behind choice of drugndash Ultra short-acting rapidly
metabolised
ndash Placental transfer but rapid metabolism in neonatebull Kan et al Anesthesiology1998
88 1467-74
ndash Context sensitive t12 3-5min
ndash Ideal for intermittent pain of labour
Remi pca in practicebull Feasibility for labour analgesia
2001 ndash Blair et al BJA 2001
bull Optimum bolus 05mcgkg no background infusionndash Superior to pethidine
bull Blair et al BJA 2005
bull Shown superior to pethidinendash efficacy satisfaction conversion to
epiduralbull Thurlow et al BJA 2002 Douma et al
BJA 2010
bull No difference in neonatal outcomesndash Review by Leong et al Anes amp Analg
2011
Remi pca in practice
bull Strict protocol
ndash Dedicated IV cannula
ndash Dedicated pumps
ndash Locked pump programmebull 40mcg bolus 2min lockout
ndash Observation chart
Safety with remi
bull One-to-one midwifery care
bull Anaesthetist prescribes and starts pca
bull Strict monitoring
bull Observation chart
bull Immediate oxygen and resuscitation availability
bull Continuous audit
Side effects
bull Nausea
ndash approx 90 use Entonox
bull Itch
bull Sedation
bull Respiratory depression
bull Episode of desaturation lt94 40-50
bull Almost all recover with nasal specs oxygen
Patient info sheet
bull Salient points
ndash Unlicensed use
ndash Audit data re safety
bull Given out at ante-natal clinic
bull Laminated copy in rooms
bull Reiterate in labour ward at request
Remifentanil PCA documentation bullInformed about Remifentanil At least 37 weeks bullInformation leaflet read No recent opiate use bullAware unlicensed use bullPCA technique explained ndash lockouttiming of demandspatient use only bull
bullRisks discussedbullSedation Respiratory depression Epidural conversion bullItch Supplementary oxygen bullNausea Failureinadequate pain relief Verbal consent bull
bullPrerequisites KardexbullDedicated IV canula Remi pump no PCA prescribed bullSpO2 monitoring Anaesthetist present Naloxone bull At initiation bullMidwife present Anti emetic bull
bullSignature _________________ Date amp time ______________________
Remi PCA in Belfast
bull 4000 deliveries ndash Elective LSCS 14
bull Routine use since 2004
bull 100-120 remi pcamth
bull 40 of labouring women choose remi pca
bull Epidural rate dropped to 35
Complications and controversyhellip
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40ndash Pruefer C Bewlay A Anaesthesia
2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesiabull Kinsella 2013
Complications and controversyhellip
Recent adverse reports
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40
ndash Pruefer C Bewlay A Anaesthesia 2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesia bull Kinsella 2013
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
Complications and controversyhellip
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
RESPITE trial 2014
bull Multicentre trial 400 women over 24 months
bull Comparing Remifentanil PCA with IM pethidine
bull Primary aim efficacy ndash VAS
ndash Proportion of women requiring an epidural for pain relief VAS
bull Secondary data adverse effects ndash Maternal sedation
ndash Unwanted effects on mother and baby
bull Clinical guidelines on the use of remifentanil
bull RESPITEtrialsbhamacuk
ldquohot off the pressrdquo
bull May - July 2014 audit data
bull 412 women
bull Efficacy and side effects
bull Outcomes
Satisfaction and efficacy
bull 80 satisfied or very satisfied
bull 87 ldquowould use againrdquo
bull Pain scores
ndash 48 none or mild pain
ndash 36 moderate pain
bull Conversion rate to epidural 129
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
Cochrane Conclusionhellip
bull Epidural analgesia appears to be effective in reducing pain during labour
bull However women who use this form of pain relief are at increased risk of having an instrumental delivery
bull Epidural analgesia had no statistically significant impact on the risk of caesarean section maternal satisfaction with pain relief and long-term backache and did not appear to have an immediate effect on neonatal status as determined by Apgar scores
bull Further research may be helpful to evaluate rare but potentially severe adverse effects of epidural analgesia on women in labour and long-term neonatal outcomes
What do women wantSytematic review of 137 reports of the views of 14000 women in 9 countries
Satisfaction
ndash Expectations
ndash Support
ndash Quality of relationship with midwife
ndash Involvement in decision making
Dissatisfaction
ndash Failure of timing amp lack of availability of analgesia
Hodnett 2002 Saisto 2001 Ranta 2002 May 2000
Complete analgesia did not rate highly
The search for an alternative
bull Match time course of labour
bull Not midwife delivered patient control
bull Few maternal amp neonatal adverse effects
Rapid onset and offset amp intravenous
PCA device
Non cumulative
o
f p
eak
eff
ect
site
con
centr
atio
n
Fentanyl
Alfentanil
100
0
Time since bolus (min)
2 4 6
Effect site concentration after opioid bolus
80 10
Remifentanil
Remifentanil pharmacokinetics in neonates
bull Infants under 2 months
bull Pharmacokinetics similar
ndash to older children
ndash to adults
Davis Ross Henson et al Remifentanil pharmacokinetics in neonates
Anesthesiology 1997 87 A 1054
Remifentanil PCA
bull Theory behind techniquendash PCA giving control improves
satisfaction
bull Theory behind choice of drugndash Ultra short-acting rapidly
metabolised
ndash Placental transfer but rapid metabolism in neonatebull Kan et al Anesthesiology1998
88 1467-74
ndash Context sensitive t12 3-5min
ndash Ideal for intermittent pain of labour
Remi pca in practicebull Feasibility for labour analgesia
2001 ndash Blair et al BJA 2001
bull Optimum bolus 05mcgkg no background infusionndash Superior to pethidine
bull Blair et al BJA 2005
bull Shown superior to pethidinendash efficacy satisfaction conversion to
epiduralbull Thurlow et al BJA 2002 Douma et al
BJA 2010
bull No difference in neonatal outcomesndash Review by Leong et al Anes amp Analg
2011
Remi pca in practice
bull Strict protocol
ndash Dedicated IV cannula
ndash Dedicated pumps
ndash Locked pump programmebull 40mcg bolus 2min lockout
ndash Observation chart
Safety with remi
bull One-to-one midwifery care
bull Anaesthetist prescribes and starts pca
bull Strict monitoring
bull Observation chart
bull Immediate oxygen and resuscitation availability
bull Continuous audit
Side effects
bull Nausea
ndash approx 90 use Entonox
bull Itch
bull Sedation
bull Respiratory depression
bull Episode of desaturation lt94 40-50
bull Almost all recover with nasal specs oxygen
Patient info sheet
bull Salient points
ndash Unlicensed use
ndash Audit data re safety
bull Given out at ante-natal clinic
bull Laminated copy in rooms
bull Reiterate in labour ward at request
Remifentanil PCA documentation bullInformed about Remifentanil At least 37 weeks bullInformation leaflet read No recent opiate use bullAware unlicensed use bullPCA technique explained ndash lockouttiming of demandspatient use only bull
bullRisks discussedbullSedation Respiratory depression Epidural conversion bullItch Supplementary oxygen bullNausea Failureinadequate pain relief Verbal consent bull
bullPrerequisites KardexbullDedicated IV canula Remi pump no PCA prescribed bullSpO2 monitoring Anaesthetist present Naloxone bull At initiation bullMidwife present Anti emetic bull
bullSignature _________________ Date amp time ______________________
Remi PCA in Belfast
bull 4000 deliveries ndash Elective LSCS 14
bull Routine use since 2004
bull 100-120 remi pcamth
bull 40 of labouring women choose remi pca
bull Epidural rate dropped to 35
Complications and controversyhellip
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40ndash Pruefer C Bewlay A Anaesthesia
2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesiabull Kinsella 2013
Complications and controversyhellip
Recent adverse reports
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40
ndash Pruefer C Bewlay A Anaesthesia 2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesia bull Kinsella 2013
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
Complications and controversyhellip
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
RESPITE trial 2014
bull Multicentre trial 400 women over 24 months
bull Comparing Remifentanil PCA with IM pethidine
bull Primary aim efficacy ndash VAS
ndash Proportion of women requiring an epidural for pain relief VAS
bull Secondary data adverse effects ndash Maternal sedation
ndash Unwanted effects on mother and baby
bull Clinical guidelines on the use of remifentanil
bull RESPITEtrialsbhamacuk
ldquohot off the pressrdquo
bull May - July 2014 audit data
bull 412 women
bull Efficacy and side effects
bull Outcomes
Satisfaction and efficacy
bull 80 satisfied or very satisfied
bull 87 ldquowould use againrdquo
bull Pain scores
ndash 48 none or mild pain
ndash 36 moderate pain
bull Conversion rate to epidural 129
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
What do women wantSytematic review of 137 reports of the views of 14000 women in 9 countries
Satisfaction
ndash Expectations
ndash Support
ndash Quality of relationship with midwife
ndash Involvement in decision making
Dissatisfaction
ndash Failure of timing amp lack of availability of analgesia
Hodnett 2002 Saisto 2001 Ranta 2002 May 2000
Complete analgesia did not rate highly
The search for an alternative
bull Match time course of labour
bull Not midwife delivered patient control
bull Few maternal amp neonatal adverse effects
Rapid onset and offset amp intravenous
PCA device
Non cumulative
o
f p
eak
eff
ect
site
con
centr
atio
n
Fentanyl
Alfentanil
100
0
Time since bolus (min)
2 4 6
Effect site concentration after opioid bolus
80 10
Remifentanil
Remifentanil pharmacokinetics in neonates
bull Infants under 2 months
bull Pharmacokinetics similar
ndash to older children
ndash to adults
Davis Ross Henson et al Remifentanil pharmacokinetics in neonates
Anesthesiology 1997 87 A 1054
Remifentanil PCA
bull Theory behind techniquendash PCA giving control improves
satisfaction
bull Theory behind choice of drugndash Ultra short-acting rapidly
metabolised
ndash Placental transfer but rapid metabolism in neonatebull Kan et al Anesthesiology1998
88 1467-74
ndash Context sensitive t12 3-5min
ndash Ideal for intermittent pain of labour
Remi pca in practicebull Feasibility for labour analgesia
2001 ndash Blair et al BJA 2001
bull Optimum bolus 05mcgkg no background infusionndash Superior to pethidine
bull Blair et al BJA 2005
bull Shown superior to pethidinendash efficacy satisfaction conversion to
epiduralbull Thurlow et al BJA 2002 Douma et al
BJA 2010
bull No difference in neonatal outcomesndash Review by Leong et al Anes amp Analg
2011
Remi pca in practice
bull Strict protocol
ndash Dedicated IV cannula
ndash Dedicated pumps
ndash Locked pump programmebull 40mcg bolus 2min lockout
ndash Observation chart
Safety with remi
bull One-to-one midwifery care
bull Anaesthetist prescribes and starts pca
bull Strict monitoring
bull Observation chart
bull Immediate oxygen and resuscitation availability
bull Continuous audit
Side effects
bull Nausea
ndash approx 90 use Entonox
bull Itch
bull Sedation
bull Respiratory depression
bull Episode of desaturation lt94 40-50
bull Almost all recover with nasal specs oxygen
Patient info sheet
bull Salient points
ndash Unlicensed use
ndash Audit data re safety
bull Given out at ante-natal clinic
bull Laminated copy in rooms
bull Reiterate in labour ward at request
Remifentanil PCA documentation bullInformed about Remifentanil At least 37 weeks bullInformation leaflet read No recent opiate use bullAware unlicensed use bullPCA technique explained ndash lockouttiming of demandspatient use only bull
bullRisks discussedbullSedation Respiratory depression Epidural conversion bullItch Supplementary oxygen bullNausea Failureinadequate pain relief Verbal consent bull
bullPrerequisites KardexbullDedicated IV canula Remi pump no PCA prescribed bullSpO2 monitoring Anaesthetist present Naloxone bull At initiation bullMidwife present Anti emetic bull
bullSignature _________________ Date amp time ______________________
Remi PCA in Belfast
bull 4000 deliveries ndash Elective LSCS 14
bull Routine use since 2004
bull 100-120 remi pcamth
bull 40 of labouring women choose remi pca
bull Epidural rate dropped to 35
Complications and controversyhellip
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40ndash Pruefer C Bewlay A Anaesthesia
2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesiabull Kinsella 2013
Complications and controversyhellip
Recent adverse reports
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40
ndash Pruefer C Bewlay A Anaesthesia 2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesia bull Kinsella 2013
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
Complications and controversyhellip
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
RESPITE trial 2014
bull Multicentre trial 400 women over 24 months
bull Comparing Remifentanil PCA with IM pethidine
bull Primary aim efficacy ndash VAS
ndash Proportion of women requiring an epidural for pain relief VAS
bull Secondary data adverse effects ndash Maternal sedation
ndash Unwanted effects on mother and baby
bull Clinical guidelines on the use of remifentanil
bull RESPITEtrialsbhamacuk
ldquohot off the pressrdquo
bull May - July 2014 audit data
bull 412 women
bull Efficacy and side effects
bull Outcomes
Satisfaction and efficacy
bull 80 satisfied or very satisfied
bull 87 ldquowould use againrdquo
bull Pain scores
ndash 48 none or mild pain
ndash 36 moderate pain
bull Conversion rate to epidural 129
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
The search for an alternative
bull Match time course of labour
bull Not midwife delivered patient control
bull Few maternal amp neonatal adverse effects
Rapid onset and offset amp intravenous
PCA device
Non cumulative
o
f p
eak
eff
ect
site
con
centr
atio
n
Fentanyl
Alfentanil
100
0
Time since bolus (min)
2 4 6
Effect site concentration after opioid bolus
80 10
Remifentanil
Remifentanil pharmacokinetics in neonates
bull Infants under 2 months
bull Pharmacokinetics similar
ndash to older children
ndash to adults
Davis Ross Henson et al Remifentanil pharmacokinetics in neonates
Anesthesiology 1997 87 A 1054
Remifentanil PCA
bull Theory behind techniquendash PCA giving control improves
satisfaction
bull Theory behind choice of drugndash Ultra short-acting rapidly
metabolised
ndash Placental transfer but rapid metabolism in neonatebull Kan et al Anesthesiology1998
88 1467-74
ndash Context sensitive t12 3-5min
ndash Ideal for intermittent pain of labour
Remi pca in practicebull Feasibility for labour analgesia
2001 ndash Blair et al BJA 2001
bull Optimum bolus 05mcgkg no background infusionndash Superior to pethidine
bull Blair et al BJA 2005
bull Shown superior to pethidinendash efficacy satisfaction conversion to
epiduralbull Thurlow et al BJA 2002 Douma et al
BJA 2010
bull No difference in neonatal outcomesndash Review by Leong et al Anes amp Analg
2011
Remi pca in practice
bull Strict protocol
ndash Dedicated IV cannula
ndash Dedicated pumps
ndash Locked pump programmebull 40mcg bolus 2min lockout
ndash Observation chart
Safety with remi
bull One-to-one midwifery care
bull Anaesthetist prescribes and starts pca
bull Strict monitoring
bull Observation chart
bull Immediate oxygen and resuscitation availability
bull Continuous audit
Side effects
bull Nausea
ndash approx 90 use Entonox
bull Itch
bull Sedation
bull Respiratory depression
bull Episode of desaturation lt94 40-50
bull Almost all recover with nasal specs oxygen
Patient info sheet
bull Salient points
ndash Unlicensed use
ndash Audit data re safety
bull Given out at ante-natal clinic
bull Laminated copy in rooms
bull Reiterate in labour ward at request
Remifentanil PCA documentation bullInformed about Remifentanil At least 37 weeks bullInformation leaflet read No recent opiate use bullAware unlicensed use bullPCA technique explained ndash lockouttiming of demandspatient use only bull
bullRisks discussedbullSedation Respiratory depression Epidural conversion bullItch Supplementary oxygen bullNausea Failureinadequate pain relief Verbal consent bull
bullPrerequisites KardexbullDedicated IV canula Remi pump no PCA prescribed bullSpO2 monitoring Anaesthetist present Naloxone bull At initiation bullMidwife present Anti emetic bull
bullSignature _________________ Date amp time ______________________
Remi PCA in Belfast
bull 4000 deliveries ndash Elective LSCS 14
bull Routine use since 2004
bull 100-120 remi pcamth
bull 40 of labouring women choose remi pca
bull Epidural rate dropped to 35
Complications and controversyhellip
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40ndash Pruefer C Bewlay A Anaesthesia
2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesiabull Kinsella 2013
Complications and controversyhellip
Recent adverse reports
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40
ndash Pruefer C Bewlay A Anaesthesia 2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesia bull Kinsella 2013
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
Complications and controversyhellip
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
RESPITE trial 2014
bull Multicentre trial 400 women over 24 months
bull Comparing Remifentanil PCA with IM pethidine
bull Primary aim efficacy ndash VAS
ndash Proportion of women requiring an epidural for pain relief VAS
bull Secondary data adverse effects ndash Maternal sedation
ndash Unwanted effects on mother and baby
bull Clinical guidelines on the use of remifentanil
bull RESPITEtrialsbhamacuk
ldquohot off the pressrdquo
bull May - July 2014 audit data
bull 412 women
bull Efficacy and side effects
bull Outcomes
Satisfaction and efficacy
bull 80 satisfied or very satisfied
bull 87 ldquowould use againrdquo
bull Pain scores
ndash 48 none or mild pain
ndash 36 moderate pain
bull Conversion rate to epidural 129
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
o
f p
eak
eff
ect
site
con
centr
atio
n
Fentanyl
Alfentanil
100
0
Time since bolus (min)
2 4 6
Effect site concentration after opioid bolus
80 10
Remifentanil
Remifentanil pharmacokinetics in neonates
bull Infants under 2 months
bull Pharmacokinetics similar
ndash to older children
ndash to adults
Davis Ross Henson et al Remifentanil pharmacokinetics in neonates
Anesthesiology 1997 87 A 1054
Remifentanil PCA
bull Theory behind techniquendash PCA giving control improves
satisfaction
bull Theory behind choice of drugndash Ultra short-acting rapidly
metabolised
ndash Placental transfer but rapid metabolism in neonatebull Kan et al Anesthesiology1998
88 1467-74
ndash Context sensitive t12 3-5min
ndash Ideal for intermittent pain of labour
Remi pca in practicebull Feasibility for labour analgesia
2001 ndash Blair et al BJA 2001
bull Optimum bolus 05mcgkg no background infusionndash Superior to pethidine
bull Blair et al BJA 2005
bull Shown superior to pethidinendash efficacy satisfaction conversion to
epiduralbull Thurlow et al BJA 2002 Douma et al
BJA 2010
bull No difference in neonatal outcomesndash Review by Leong et al Anes amp Analg
2011
Remi pca in practice
bull Strict protocol
ndash Dedicated IV cannula
ndash Dedicated pumps
ndash Locked pump programmebull 40mcg bolus 2min lockout
ndash Observation chart
Safety with remi
bull One-to-one midwifery care
bull Anaesthetist prescribes and starts pca
bull Strict monitoring
bull Observation chart
bull Immediate oxygen and resuscitation availability
bull Continuous audit
Side effects
bull Nausea
ndash approx 90 use Entonox
bull Itch
bull Sedation
bull Respiratory depression
bull Episode of desaturation lt94 40-50
bull Almost all recover with nasal specs oxygen
Patient info sheet
bull Salient points
ndash Unlicensed use
ndash Audit data re safety
bull Given out at ante-natal clinic
bull Laminated copy in rooms
bull Reiterate in labour ward at request
Remifentanil PCA documentation bullInformed about Remifentanil At least 37 weeks bullInformation leaflet read No recent opiate use bullAware unlicensed use bullPCA technique explained ndash lockouttiming of demandspatient use only bull
bullRisks discussedbullSedation Respiratory depression Epidural conversion bullItch Supplementary oxygen bullNausea Failureinadequate pain relief Verbal consent bull
bullPrerequisites KardexbullDedicated IV canula Remi pump no PCA prescribed bullSpO2 monitoring Anaesthetist present Naloxone bull At initiation bullMidwife present Anti emetic bull
bullSignature _________________ Date amp time ______________________
Remi PCA in Belfast
bull 4000 deliveries ndash Elective LSCS 14
bull Routine use since 2004
bull 100-120 remi pcamth
bull 40 of labouring women choose remi pca
bull Epidural rate dropped to 35
Complications and controversyhellip
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40ndash Pruefer C Bewlay A Anaesthesia
2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesiabull Kinsella 2013
Complications and controversyhellip
Recent adverse reports
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40
ndash Pruefer C Bewlay A Anaesthesia 2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesia bull Kinsella 2013
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
Complications and controversyhellip
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
RESPITE trial 2014
bull Multicentre trial 400 women over 24 months
bull Comparing Remifentanil PCA with IM pethidine
bull Primary aim efficacy ndash VAS
ndash Proportion of women requiring an epidural for pain relief VAS
bull Secondary data adverse effects ndash Maternal sedation
ndash Unwanted effects on mother and baby
bull Clinical guidelines on the use of remifentanil
bull RESPITEtrialsbhamacuk
ldquohot off the pressrdquo
bull May - July 2014 audit data
bull 412 women
bull Efficacy and side effects
bull Outcomes
Satisfaction and efficacy
bull 80 satisfied or very satisfied
bull 87 ldquowould use againrdquo
bull Pain scores
ndash 48 none or mild pain
ndash 36 moderate pain
bull Conversion rate to epidural 129
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
Remifentanil pharmacokinetics in neonates
bull Infants under 2 months
bull Pharmacokinetics similar
ndash to older children
ndash to adults
Davis Ross Henson et al Remifentanil pharmacokinetics in neonates
Anesthesiology 1997 87 A 1054
Remifentanil PCA
bull Theory behind techniquendash PCA giving control improves
satisfaction
bull Theory behind choice of drugndash Ultra short-acting rapidly
metabolised
ndash Placental transfer but rapid metabolism in neonatebull Kan et al Anesthesiology1998
88 1467-74
ndash Context sensitive t12 3-5min
ndash Ideal for intermittent pain of labour
Remi pca in practicebull Feasibility for labour analgesia
2001 ndash Blair et al BJA 2001
bull Optimum bolus 05mcgkg no background infusionndash Superior to pethidine
bull Blair et al BJA 2005
bull Shown superior to pethidinendash efficacy satisfaction conversion to
epiduralbull Thurlow et al BJA 2002 Douma et al
BJA 2010
bull No difference in neonatal outcomesndash Review by Leong et al Anes amp Analg
2011
Remi pca in practice
bull Strict protocol
ndash Dedicated IV cannula
ndash Dedicated pumps
ndash Locked pump programmebull 40mcg bolus 2min lockout
ndash Observation chart
Safety with remi
bull One-to-one midwifery care
bull Anaesthetist prescribes and starts pca
bull Strict monitoring
bull Observation chart
bull Immediate oxygen and resuscitation availability
bull Continuous audit
Side effects
bull Nausea
ndash approx 90 use Entonox
bull Itch
bull Sedation
bull Respiratory depression
bull Episode of desaturation lt94 40-50
bull Almost all recover with nasal specs oxygen
Patient info sheet
bull Salient points
ndash Unlicensed use
ndash Audit data re safety
bull Given out at ante-natal clinic
bull Laminated copy in rooms
bull Reiterate in labour ward at request
Remifentanil PCA documentation bullInformed about Remifentanil At least 37 weeks bullInformation leaflet read No recent opiate use bullAware unlicensed use bullPCA technique explained ndash lockouttiming of demandspatient use only bull
bullRisks discussedbullSedation Respiratory depression Epidural conversion bullItch Supplementary oxygen bullNausea Failureinadequate pain relief Verbal consent bull
bullPrerequisites KardexbullDedicated IV canula Remi pump no PCA prescribed bullSpO2 monitoring Anaesthetist present Naloxone bull At initiation bullMidwife present Anti emetic bull
bullSignature _________________ Date amp time ______________________
Remi PCA in Belfast
bull 4000 deliveries ndash Elective LSCS 14
bull Routine use since 2004
bull 100-120 remi pcamth
bull 40 of labouring women choose remi pca
bull Epidural rate dropped to 35
Complications and controversyhellip
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40ndash Pruefer C Bewlay A Anaesthesia
2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesiabull Kinsella 2013
Complications and controversyhellip
Recent adverse reports
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40
ndash Pruefer C Bewlay A Anaesthesia 2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesia bull Kinsella 2013
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
Complications and controversyhellip
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
RESPITE trial 2014
bull Multicentre trial 400 women over 24 months
bull Comparing Remifentanil PCA with IM pethidine
bull Primary aim efficacy ndash VAS
ndash Proportion of women requiring an epidural for pain relief VAS
bull Secondary data adverse effects ndash Maternal sedation
ndash Unwanted effects on mother and baby
bull Clinical guidelines on the use of remifentanil
bull RESPITEtrialsbhamacuk
ldquohot off the pressrdquo
bull May - July 2014 audit data
bull 412 women
bull Efficacy and side effects
bull Outcomes
Satisfaction and efficacy
bull 80 satisfied or very satisfied
bull 87 ldquowould use againrdquo
bull Pain scores
ndash 48 none or mild pain
ndash 36 moderate pain
bull Conversion rate to epidural 129
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
Remifentanil PCA
bull Theory behind techniquendash PCA giving control improves
satisfaction
bull Theory behind choice of drugndash Ultra short-acting rapidly
metabolised
ndash Placental transfer but rapid metabolism in neonatebull Kan et al Anesthesiology1998
88 1467-74
ndash Context sensitive t12 3-5min
ndash Ideal for intermittent pain of labour
Remi pca in practicebull Feasibility for labour analgesia
2001 ndash Blair et al BJA 2001
bull Optimum bolus 05mcgkg no background infusionndash Superior to pethidine
bull Blair et al BJA 2005
bull Shown superior to pethidinendash efficacy satisfaction conversion to
epiduralbull Thurlow et al BJA 2002 Douma et al
BJA 2010
bull No difference in neonatal outcomesndash Review by Leong et al Anes amp Analg
2011
Remi pca in practice
bull Strict protocol
ndash Dedicated IV cannula
ndash Dedicated pumps
ndash Locked pump programmebull 40mcg bolus 2min lockout
ndash Observation chart
Safety with remi
bull One-to-one midwifery care
bull Anaesthetist prescribes and starts pca
bull Strict monitoring
bull Observation chart
bull Immediate oxygen and resuscitation availability
bull Continuous audit
Side effects
bull Nausea
ndash approx 90 use Entonox
bull Itch
bull Sedation
bull Respiratory depression
bull Episode of desaturation lt94 40-50
bull Almost all recover with nasal specs oxygen
Patient info sheet
bull Salient points
ndash Unlicensed use
ndash Audit data re safety
bull Given out at ante-natal clinic
bull Laminated copy in rooms
bull Reiterate in labour ward at request
Remifentanil PCA documentation bullInformed about Remifentanil At least 37 weeks bullInformation leaflet read No recent opiate use bullAware unlicensed use bullPCA technique explained ndash lockouttiming of demandspatient use only bull
bullRisks discussedbullSedation Respiratory depression Epidural conversion bullItch Supplementary oxygen bullNausea Failureinadequate pain relief Verbal consent bull
bullPrerequisites KardexbullDedicated IV canula Remi pump no PCA prescribed bullSpO2 monitoring Anaesthetist present Naloxone bull At initiation bullMidwife present Anti emetic bull
bullSignature _________________ Date amp time ______________________
Remi PCA in Belfast
bull 4000 deliveries ndash Elective LSCS 14
bull Routine use since 2004
bull 100-120 remi pcamth
bull 40 of labouring women choose remi pca
bull Epidural rate dropped to 35
Complications and controversyhellip
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40ndash Pruefer C Bewlay A Anaesthesia
2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesiabull Kinsella 2013
Complications and controversyhellip
Recent adverse reports
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40
ndash Pruefer C Bewlay A Anaesthesia 2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesia bull Kinsella 2013
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
Complications and controversyhellip
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
RESPITE trial 2014
bull Multicentre trial 400 women over 24 months
bull Comparing Remifentanil PCA with IM pethidine
bull Primary aim efficacy ndash VAS
ndash Proportion of women requiring an epidural for pain relief VAS
bull Secondary data adverse effects ndash Maternal sedation
ndash Unwanted effects on mother and baby
bull Clinical guidelines on the use of remifentanil
bull RESPITEtrialsbhamacuk
ldquohot off the pressrdquo
bull May - July 2014 audit data
bull 412 women
bull Efficacy and side effects
bull Outcomes
Satisfaction and efficacy
bull 80 satisfied or very satisfied
bull 87 ldquowould use againrdquo
bull Pain scores
ndash 48 none or mild pain
ndash 36 moderate pain
bull Conversion rate to epidural 129
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
Remi pca in practicebull Feasibility for labour analgesia
2001 ndash Blair et al BJA 2001
bull Optimum bolus 05mcgkg no background infusionndash Superior to pethidine
bull Blair et al BJA 2005
bull Shown superior to pethidinendash efficacy satisfaction conversion to
epiduralbull Thurlow et al BJA 2002 Douma et al
BJA 2010
bull No difference in neonatal outcomesndash Review by Leong et al Anes amp Analg
2011
Remi pca in practice
bull Strict protocol
ndash Dedicated IV cannula
ndash Dedicated pumps
ndash Locked pump programmebull 40mcg bolus 2min lockout
ndash Observation chart
Safety with remi
bull One-to-one midwifery care
bull Anaesthetist prescribes and starts pca
bull Strict monitoring
bull Observation chart
bull Immediate oxygen and resuscitation availability
bull Continuous audit
Side effects
bull Nausea
ndash approx 90 use Entonox
bull Itch
bull Sedation
bull Respiratory depression
bull Episode of desaturation lt94 40-50
bull Almost all recover with nasal specs oxygen
Patient info sheet
bull Salient points
ndash Unlicensed use
ndash Audit data re safety
bull Given out at ante-natal clinic
bull Laminated copy in rooms
bull Reiterate in labour ward at request
Remifentanil PCA documentation bullInformed about Remifentanil At least 37 weeks bullInformation leaflet read No recent opiate use bullAware unlicensed use bullPCA technique explained ndash lockouttiming of demandspatient use only bull
bullRisks discussedbullSedation Respiratory depression Epidural conversion bullItch Supplementary oxygen bullNausea Failureinadequate pain relief Verbal consent bull
bullPrerequisites KardexbullDedicated IV canula Remi pump no PCA prescribed bullSpO2 monitoring Anaesthetist present Naloxone bull At initiation bullMidwife present Anti emetic bull
bullSignature _________________ Date amp time ______________________
Remi PCA in Belfast
bull 4000 deliveries ndash Elective LSCS 14
bull Routine use since 2004
bull 100-120 remi pcamth
bull 40 of labouring women choose remi pca
bull Epidural rate dropped to 35
Complications and controversyhellip
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40ndash Pruefer C Bewlay A Anaesthesia
2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesiabull Kinsella 2013
Complications and controversyhellip
Recent adverse reports
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40
ndash Pruefer C Bewlay A Anaesthesia 2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesia bull Kinsella 2013
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
Complications and controversyhellip
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
RESPITE trial 2014
bull Multicentre trial 400 women over 24 months
bull Comparing Remifentanil PCA with IM pethidine
bull Primary aim efficacy ndash VAS
ndash Proportion of women requiring an epidural for pain relief VAS
bull Secondary data adverse effects ndash Maternal sedation
ndash Unwanted effects on mother and baby
bull Clinical guidelines on the use of remifentanil
bull RESPITEtrialsbhamacuk
ldquohot off the pressrdquo
bull May - July 2014 audit data
bull 412 women
bull Efficacy and side effects
bull Outcomes
Satisfaction and efficacy
bull 80 satisfied or very satisfied
bull 87 ldquowould use againrdquo
bull Pain scores
ndash 48 none or mild pain
ndash 36 moderate pain
bull Conversion rate to epidural 129
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
Remi pca in practice
bull Strict protocol
ndash Dedicated IV cannula
ndash Dedicated pumps
ndash Locked pump programmebull 40mcg bolus 2min lockout
ndash Observation chart
Safety with remi
bull One-to-one midwifery care
bull Anaesthetist prescribes and starts pca
bull Strict monitoring
bull Observation chart
bull Immediate oxygen and resuscitation availability
bull Continuous audit
Side effects
bull Nausea
ndash approx 90 use Entonox
bull Itch
bull Sedation
bull Respiratory depression
bull Episode of desaturation lt94 40-50
bull Almost all recover with nasal specs oxygen
Patient info sheet
bull Salient points
ndash Unlicensed use
ndash Audit data re safety
bull Given out at ante-natal clinic
bull Laminated copy in rooms
bull Reiterate in labour ward at request
Remifentanil PCA documentation bullInformed about Remifentanil At least 37 weeks bullInformation leaflet read No recent opiate use bullAware unlicensed use bullPCA technique explained ndash lockouttiming of demandspatient use only bull
bullRisks discussedbullSedation Respiratory depression Epidural conversion bullItch Supplementary oxygen bullNausea Failureinadequate pain relief Verbal consent bull
bullPrerequisites KardexbullDedicated IV canula Remi pump no PCA prescribed bullSpO2 monitoring Anaesthetist present Naloxone bull At initiation bullMidwife present Anti emetic bull
bullSignature _________________ Date amp time ______________________
Remi PCA in Belfast
bull 4000 deliveries ndash Elective LSCS 14
bull Routine use since 2004
bull 100-120 remi pcamth
bull 40 of labouring women choose remi pca
bull Epidural rate dropped to 35
Complications and controversyhellip
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40ndash Pruefer C Bewlay A Anaesthesia
2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesiabull Kinsella 2013
Complications and controversyhellip
Recent adverse reports
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40
ndash Pruefer C Bewlay A Anaesthesia 2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesia bull Kinsella 2013
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
Complications and controversyhellip
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
RESPITE trial 2014
bull Multicentre trial 400 women over 24 months
bull Comparing Remifentanil PCA with IM pethidine
bull Primary aim efficacy ndash VAS
ndash Proportion of women requiring an epidural for pain relief VAS
bull Secondary data adverse effects ndash Maternal sedation
ndash Unwanted effects on mother and baby
bull Clinical guidelines on the use of remifentanil
bull RESPITEtrialsbhamacuk
ldquohot off the pressrdquo
bull May - July 2014 audit data
bull 412 women
bull Efficacy and side effects
bull Outcomes
Satisfaction and efficacy
bull 80 satisfied or very satisfied
bull 87 ldquowould use againrdquo
bull Pain scores
ndash 48 none or mild pain
ndash 36 moderate pain
bull Conversion rate to epidural 129
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
Safety with remi
bull One-to-one midwifery care
bull Anaesthetist prescribes and starts pca
bull Strict monitoring
bull Observation chart
bull Immediate oxygen and resuscitation availability
bull Continuous audit
Side effects
bull Nausea
ndash approx 90 use Entonox
bull Itch
bull Sedation
bull Respiratory depression
bull Episode of desaturation lt94 40-50
bull Almost all recover with nasal specs oxygen
Patient info sheet
bull Salient points
ndash Unlicensed use
ndash Audit data re safety
bull Given out at ante-natal clinic
bull Laminated copy in rooms
bull Reiterate in labour ward at request
Remifentanil PCA documentation bullInformed about Remifentanil At least 37 weeks bullInformation leaflet read No recent opiate use bullAware unlicensed use bullPCA technique explained ndash lockouttiming of demandspatient use only bull
bullRisks discussedbullSedation Respiratory depression Epidural conversion bullItch Supplementary oxygen bullNausea Failureinadequate pain relief Verbal consent bull
bullPrerequisites KardexbullDedicated IV canula Remi pump no PCA prescribed bullSpO2 monitoring Anaesthetist present Naloxone bull At initiation bullMidwife present Anti emetic bull
bullSignature _________________ Date amp time ______________________
Remi PCA in Belfast
bull 4000 deliveries ndash Elective LSCS 14
bull Routine use since 2004
bull 100-120 remi pcamth
bull 40 of labouring women choose remi pca
bull Epidural rate dropped to 35
Complications and controversyhellip
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40ndash Pruefer C Bewlay A Anaesthesia
2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesiabull Kinsella 2013
Complications and controversyhellip
Recent adverse reports
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40
ndash Pruefer C Bewlay A Anaesthesia 2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesia bull Kinsella 2013
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
Complications and controversyhellip
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
RESPITE trial 2014
bull Multicentre trial 400 women over 24 months
bull Comparing Remifentanil PCA with IM pethidine
bull Primary aim efficacy ndash VAS
ndash Proportion of women requiring an epidural for pain relief VAS
bull Secondary data adverse effects ndash Maternal sedation
ndash Unwanted effects on mother and baby
bull Clinical guidelines on the use of remifentanil
bull RESPITEtrialsbhamacuk
ldquohot off the pressrdquo
bull May - July 2014 audit data
bull 412 women
bull Efficacy and side effects
bull Outcomes
Satisfaction and efficacy
bull 80 satisfied or very satisfied
bull 87 ldquowould use againrdquo
bull Pain scores
ndash 48 none or mild pain
ndash 36 moderate pain
bull Conversion rate to epidural 129
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
Side effects
bull Nausea
ndash approx 90 use Entonox
bull Itch
bull Sedation
bull Respiratory depression
bull Episode of desaturation lt94 40-50
bull Almost all recover with nasal specs oxygen
Patient info sheet
bull Salient points
ndash Unlicensed use
ndash Audit data re safety
bull Given out at ante-natal clinic
bull Laminated copy in rooms
bull Reiterate in labour ward at request
Remifentanil PCA documentation bullInformed about Remifentanil At least 37 weeks bullInformation leaflet read No recent opiate use bullAware unlicensed use bullPCA technique explained ndash lockouttiming of demandspatient use only bull
bullRisks discussedbullSedation Respiratory depression Epidural conversion bullItch Supplementary oxygen bullNausea Failureinadequate pain relief Verbal consent bull
bullPrerequisites KardexbullDedicated IV canula Remi pump no PCA prescribed bullSpO2 monitoring Anaesthetist present Naloxone bull At initiation bullMidwife present Anti emetic bull
bullSignature _________________ Date amp time ______________________
Remi PCA in Belfast
bull 4000 deliveries ndash Elective LSCS 14
bull Routine use since 2004
bull 100-120 remi pcamth
bull 40 of labouring women choose remi pca
bull Epidural rate dropped to 35
Complications and controversyhellip
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40ndash Pruefer C Bewlay A Anaesthesia
2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesiabull Kinsella 2013
Complications and controversyhellip
Recent adverse reports
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40
ndash Pruefer C Bewlay A Anaesthesia 2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesia bull Kinsella 2013
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
Complications and controversyhellip
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
RESPITE trial 2014
bull Multicentre trial 400 women over 24 months
bull Comparing Remifentanil PCA with IM pethidine
bull Primary aim efficacy ndash VAS
ndash Proportion of women requiring an epidural for pain relief VAS
bull Secondary data adverse effects ndash Maternal sedation
ndash Unwanted effects on mother and baby
bull Clinical guidelines on the use of remifentanil
bull RESPITEtrialsbhamacuk
ldquohot off the pressrdquo
bull May - July 2014 audit data
bull 412 women
bull Efficacy and side effects
bull Outcomes
Satisfaction and efficacy
bull 80 satisfied or very satisfied
bull 87 ldquowould use againrdquo
bull Pain scores
ndash 48 none or mild pain
ndash 36 moderate pain
bull Conversion rate to epidural 129
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
Patient info sheet
bull Salient points
ndash Unlicensed use
ndash Audit data re safety
bull Given out at ante-natal clinic
bull Laminated copy in rooms
bull Reiterate in labour ward at request
Remifentanil PCA documentation bullInformed about Remifentanil At least 37 weeks bullInformation leaflet read No recent opiate use bullAware unlicensed use bullPCA technique explained ndash lockouttiming of demandspatient use only bull
bullRisks discussedbullSedation Respiratory depression Epidural conversion bullItch Supplementary oxygen bullNausea Failureinadequate pain relief Verbal consent bull
bullPrerequisites KardexbullDedicated IV canula Remi pump no PCA prescribed bullSpO2 monitoring Anaesthetist present Naloxone bull At initiation bullMidwife present Anti emetic bull
bullSignature _________________ Date amp time ______________________
Remi PCA in Belfast
bull 4000 deliveries ndash Elective LSCS 14
bull Routine use since 2004
bull 100-120 remi pcamth
bull 40 of labouring women choose remi pca
bull Epidural rate dropped to 35
Complications and controversyhellip
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40ndash Pruefer C Bewlay A Anaesthesia
2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesiabull Kinsella 2013
Complications and controversyhellip
Recent adverse reports
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40
ndash Pruefer C Bewlay A Anaesthesia 2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesia bull Kinsella 2013
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
Complications and controversyhellip
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
RESPITE trial 2014
bull Multicentre trial 400 women over 24 months
bull Comparing Remifentanil PCA with IM pethidine
bull Primary aim efficacy ndash VAS
ndash Proportion of women requiring an epidural for pain relief VAS
bull Secondary data adverse effects ndash Maternal sedation
ndash Unwanted effects on mother and baby
bull Clinical guidelines on the use of remifentanil
bull RESPITEtrialsbhamacuk
ldquohot off the pressrdquo
bull May - July 2014 audit data
bull 412 women
bull Efficacy and side effects
bull Outcomes
Satisfaction and efficacy
bull 80 satisfied or very satisfied
bull 87 ldquowould use againrdquo
bull Pain scores
ndash 48 none or mild pain
ndash 36 moderate pain
bull Conversion rate to epidural 129
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
Remifentanil PCA documentation bullInformed about Remifentanil At least 37 weeks bullInformation leaflet read No recent opiate use bullAware unlicensed use bullPCA technique explained ndash lockouttiming of demandspatient use only bull
bullRisks discussedbullSedation Respiratory depression Epidural conversion bullItch Supplementary oxygen bullNausea Failureinadequate pain relief Verbal consent bull
bullPrerequisites KardexbullDedicated IV canula Remi pump no PCA prescribed bullSpO2 monitoring Anaesthetist present Naloxone bull At initiation bullMidwife present Anti emetic bull
bullSignature _________________ Date amp time ______________________
Remi PCA in Belfast
bull 4000 deliveries ndash Elective LSCS 14
bull Routine use since 2004
bull 100-120 remi pcamth
bull 40 of labouring women choose remi pca
bull Epidural rate dropped to 35
Complications and controversyhellip
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40ndash Pruefer C Bewlay A Anaesthesia
2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesiabull Kinsella 2013
Complications and controversyhellip
Recent adverse reports
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40
ndash Pruefer C Bewlay A Anaesthesia 2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesia bull Kinsella 2013
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
Complications and controversyhellip
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
RESPITE trial 2014
bull Multicentre trial 400 women over 24 months
bull Comparing Remifentanil PCA with IM pethidine
bull Primary aim efficacy ndash VAS
ndash Proportion of women requiring an epidural for pain relief VAS
bull Secondary data adverse effects ndash Maternal sedation
ndash Unwanted effects on mother and baby
bull Clinical guidelines on the use of remifentanil
bull RESPITEtrialsbhamacuk
ldquohot off the pressrdquo
bull May - July 2014 audit data
bull 412 women
bull Efficacy and side effects
bull Outcomes
Satisfaction and efficacy
bull 80 satisfied or very satisfied
bull 87 ldquowould use againrdquo
bull Pain scores
ndash 48 none or mild pain
ndash 36 moderate pain
bull Conversion rate to epidural 129
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
Remi PCA in Belfast
bull 4000 deliveries ndash Elective LSCS 14
bull Routine use since 2004
bull 100-120 remi pcamth
bull 40 of labouring women choose remi pca
bull Epidural rate dropped to 35
Complications and controversyhellip
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40ndash Pruefer C Bewlay A Anaesthesia
2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesiabull Kinsella 2013
Complications and controversyhellip
Recent adverse reports
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40
ndash Pruefer C Bewlay A Anaesthesia 2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesia bull Kinsella 2013
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
Complications and controversyhellip
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
RESPITE trial 2014
bull Multicentre trial 400 women over 24 months
bull Comparing Remifentanil PCA with IM pethidine
bull Primary aim efficacy ndash VAS
ndash Proportion of women requiring an epidural for pain relief VAS
bull Secondary data adverse effects ndash Maternal sedation
ndash Unwanted effects on mother and baby
bull Clinical guidelines on the use of remifentanil
bull RESPITEtrialsbhamacuk
ldquohot off the pressrdquo
bull May - July 2014 audit data
bull 412 women
bull Efficacy and side effects
bull Outcomes
Satisfaction and efficacy
bull 80 satisfied or very satisfied
bull 87 ldquowould use againrdquo
bull Pain scores
ndash 48 none or mild pain
ndash 36 moderate pain
bull Conversion rate to epidural 129
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
Complications and controversyhellip
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40ndash Pruefer C Bewlay A Anaesthesia
2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesiabull Kinsella 2013
Complications and controversyhellip
Recent adverse reports
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40
ndash Pruefer C Bewlay A Anaesthesia 2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesia bull Kinsella 2013
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
Complications and controversyhellip
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
RESPITE trial 2014
bull Multicentre trial 400 women over 24 months
bull Comparing Remifentanil PCA with IM pethidine
bull Primary aim efficacy ndash VAS
ndash Proportion of women requiring an epidural for pain relief VAS
bull Secondary data adverse effects ndash Maternal sedation
ndash Unwanted effects on mother and baby
bull Clinical guidelines on the use of remifentanil
bull RESPITEtrialsbhamacuk
ldquohot off the pressrdquo
bull May - July 2014 audit data
bull 412 women
bull Efficacy and side effects
bull Outcomes
Satisfaction and efficacy
bull 80 satisfied or very satisfied
bull 87 ldquowould use againrdquo
bull Pain scores
ndash 48 none or mild pain
ndash 36 moderate pain
bull Conversion rate to epidural 129
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
Complications and controversyhellip
Recent adverse reports
bull Case reports of respiratory arrestndash Bonner JC McClymont W
Anaesthesia 2012 67 538ndash40
ndash Pruefer C Bewlay A Anaesthesia 2012 67 1044ndash5
bull Recent editorials ndash College Bulletin
bull Hughes Foley March 2013
ndash Anaesthesia bull Kinsella 2013
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
Complications and controversyhellip
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
RESPITE trial 2014
bull Multicentre trial 400 women over 24 months
bull Comparing Remifentanil PCA with IM pethidine
bull Primary aim efficacy ndash VAS
ndash Proportion of women requiring an epidural for pain relief VAS
bull Secondary data adverse effects ndash Maternal sedation
ndash Unwanted effects on mother and baby
bull Clinical guidelines on the use of remifentanil
bull RESPITEtrialsbhamacuk
ldquohot off the pressrdquo
bull May - July 2014 audit data
bull 412 women
bull Efficacy and side effects
bull Outcomes
Satisfaction and efficacy
bull 80 satisfied or very satisfied
bull 87 ldquowould use againrdquo
bull Pain scores
ndash 48 none or mild pain
ndash 36 moderate pain
bull Conversion rate to epidural 129
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
Complications and controversyhellip
Issues arising
bull Systemic maternal effects an issuendash Also management of the
cases lack of dedicated midwifery care recent opioid administration
ndash Prompt assessment and management essential
ndash Training and familiarity
bull No room for complacency
RESPITE trial 2014
bull Multicentre trial 400 women over 24 months
bull Comparing Remifentanil PCA with IM pethidine
bull Primary aim efficacy ndash VAS
ndash Proportion of women requiring an epidural for pain relief VAS
bull Secondary data adverse effects ndash Maternal sedation
ndash Unwanted effects on mother and baby
bull Clinical guidelines on the use of remifentanil
bull RESPITEtrialsbhamacuk
ldquohot off the pressrdquo
bull May - July 2014 audit data
bull 412 women
bull Efficacy and side effects
bull Outcomes
Satisfaction and efficacy
bull 80 satisfied or very satisfied
bull 87 ldquowould use againrdquo
bull Pain scores
ndash 48 none or mild pain
ndash 36 moderate pain
bull Conversion rate to epidural 129
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
RESPITE trial 2014
bull Multicentre trial 400 women over 24 months
bull Comparing Remifentanil PCA with IM pethidine
bull Primary aim efficacy ndash VAS
ndash Proportion of women requiring an epidural for pain relief VAS
bull Secondary data adverse effects ndash Maternal sedation
ndash Unwanted effects on mother and baby
bull Clinical guidelines on the use of remifentanil
bull RESPITEtrialsbhamacuk
ldquohot off the pressrdquo
bull May - July 2014 audit data
bull 412 women
bull Efficacy and side effects
bull Outcomes
Satisfaction and efficacy
bull 80 satisfied or very satisfied
bull 87 ldquowould use againrdquo
bull Pain scores
ndash 48 none or mild pain
ndash 36 moderate pain
bull Conversion rate to epidural 129
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
ldquohot off the pressrdquo
bull May - July 2014 audit data
bull 412 women
bull Efficacy and side effects
bull Outcomes
Satisfaction and efficacy
bull 80 satisfied or very satisfied
bull 87 ldquowould use againrdquo
bull Pain scores
ndash 48 none or mild pain
ndash 36 moderate pain
bull Conversion rate to epidural 129
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
Satisfaction and efficacy
bull 80 satisfied or very satisfied
bull 87 ldquowould use againrdquo
bull Pain scores
ndash 48 none or mild pain
ndash 36 moderate pain
bull Conversion rate to epidural 129
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
Side effects
bull Nausea 449
bull Itch 209
bull Sedation 04
bull Respiratory depression
bull Episode of desaturation lt94 519
bull All except one case recovered with nasal specs oxygen
ndash 024
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
Neonatal outcomes
bull Apgars 5min992 8 or above
bull No difference in NICU SCBU admission rates
bull Slightly higher SVD rate
bull Lower rate of needing resuscitation breaths at birth
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
Remi pca offershellip
bull Modest analgesia
bull High maternal satisfaction
ndash 1400 per year
bull Safe for mothers and babies
bull Reduced epidural rate
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
But you must havehellip
bull Strict protocolndash One to one care
ndash Trained midwives
ndash Intensive monitoring
bull Familiarity with regimen (good and bad points)
bull Audit of practice and outcomes
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
So finallyhellip
bull Always a role for systemic analgesia
bull New opioid analgesia techniques
bull Anaesthetists involved
bull PCA remifentanil can be a positive addition but strict protocol essential
Thank you
Thank you
