DP23: OPTIMIZING INTRATHECAL CATHETER MANAGEMENT IN OBSTETRIC ANESTHESIA: A REVIEW OF CURRENT EVIDENCE AND CLINICAL PRACTICE
Mihir Desai, DO; Hannah Gregory, DO; Hiram Acevedo, MD
University of Florida - Jacksonville
Introduction/Background: Epidural catheter placement is a mainstay of obstetric anesthesia that can lead to inadvertent dural puncture. Clinicians may use this dural puncture as an opportunity to thread an intrathecal catheter (ITC) to provide reliable neuraxial analgesia and anesthesia. Compared to epidural management, ITC dosing requires careful titration in much smaller local anesthetic and opioid quantities to avoid hemodynamic compromise. ITC placement can provide effective labor analgesia and surgical anesthesia for cesarian section; however, there is no dosing consensus. This literature review aims to summarize current evidence and guidance for safe and effective ITC management.
Methods: A literature review was conducted using PubMed and OpenEvidence to identify various studies evaluating ITC dosing strategies for labor and cesarian delivery. Randomized trials, observational studies, retrospective reviews, review articles, relevant clinical practice guidelines were included. Studies outlining intrathecal dosing regimens for labor and cesarian delivery were analyzed and compared.
Results: Most studies regarding ITCs reported similar complications such as post-dural puncture headache, high spinal blockade, and catheter failure [1]. The literature showed using ITCs for labor analgesia after accidental dural puncture was often managed by manual top-ups or continuous infusion. A UK survey showed manual top-up solutions for labor that used were various concentrations of bupivacaine and levobupivacaine with fentanyl. When used for cesarian section, hyperbaric bupivacaine with fentanyl or diamorphine top-ups were used [2]. Other studies presented usage of intrathecal infusion at various concentrations of bupivacaine with fentanyl for labor [3-5]. A randomized trial showed effective intrathecal sufentanil infusion with breakthrough bupivacaine bolus for effective labor analgesia. In that same trial, bupivacaine of unknown baricity was used for cesarian delivery [6]. Various concentrations of isobaric and hyperbaric bupivacaine with intrathecal opioid were shown to be safely used in multiple studies by careful titration of anesthesia up to a T4 sensory level [3,7-8]. One prospective case series displayed successful cesarian delivery for patients with cardiac history using a lower concentration of hyperbaric bupivacaine with slow titration to a T8 sensory level [9].
Discussion/Conclusion: It is important for anesthesiologists to familiarize themselves with optimal management for ITC management due to their high-risk nature. Obstetric units should require written protocol for staff regarding monitoring and labeling ITCs, highlighting key signs of complications, and patient handoff. Current evidence shows that slow titration of low-dose local anesthetic and opioid combination for labor and cesarian delivery is ideal. Although this review highlights published ITC dosing strategies that were safely used in clinical practice, further prospective studies are needed to optimize ITC use in obstetric anesthesia.
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