Abstract
This study investigates safety and efficacy of a large-dose, needle-based epidural technique where the anesthetic dose is administered through an epidural needle prior to insertion of the epidural catheter. Using a data-driven machine learning (ML) approach, the findings show that the needle-based approach is faster and more dose-effective in achieving sensory level than the catheter-based approach. The authors also find that injecting large doses in the epidural space through the needle is safe. And a needle dose of at most 18 ml offers lower hypotension complication. ML predicts hypotension with 85% accuracy and shows that total dose, injection duration, weight, and physician experience are top features impacting sensory level. The findings facilitate pain relief improvement and establish new clinical practice guideline for training and dissemination of safe administration. The successful prediction of hypotension allows for early intervention. Although almost 50% of drug combinations used involve fentanyl, the findings show that fentanyl has little effect on outcome and should be avoided.
TopBackground
Traditionally, the epidural catheter is placed, aspirated, and a test dose of medication is given to detect the possibility of an intravascular (IV) or intrathecal (IT) catheter prior to administering additional doses of local anesthetic and opioids. More rapid injection is often possible through the epidural needle given the relatively larger gauge and shorter length compared to a catheter (Omote et al., 1992), which could potentially enhance the spread of medication within the epidural space. However, there have been very few studies in which anesthesia providers have initiated labor analgesia by injecting medications through the epidural needle immediately after loss of resistance to achieve faster onset of pain relief (Gambling et al., 2013). The rationale for potentially improved analgesia onset with epidural needle injection is uncertain. In addition to faster onset of analgesia, it has been reported that dosing through the epidural needle may result in improved quality of epidural anesthesia compared to dosing through the catheter (Cesur et al., 2005). However, other investigations in obstetric (Husain et al., 1997) and non-obstetric (Yun et al., 2004) patients receiving epidural anesthesia have observed a similar onset and quality of surgical anesthesia as well as a similar level of sensory blockade when dosing through the needle versus the catheter. In a small double-blind prospective investigation (n=60), Raster et al. 2017 directly compared needle and catheter injection of epidural medications for the initiation of labor analgesia. Their results showed that epidural needle and catheter injection of medications result in similar onset of analgesia and sensory blockade, quality of labor analgesia, patient satisfaction, and complication rates. To date little is known regarding practice and patient outcome related to large doses of local anesthetic injected through the epidural needle.
Key Terms in this Chapter
Opioids: A broad group of pain-relieving drugs that work by interacting with opioid receptors in the cells.
Epidural Anesthesia: A regional anesthesia that blocks pain in a particular region of the body. It is performed where a medicine is injected into the epidural space around the spinal cord. The goal of an epidural is to provide analgesia, or pain relief, rather than anesthesia, which leads to a total lack of feeling. Epidurals block the nerve impulses from the lower spinal segments. This results in decreased sensation in the lower half of the body.
Simulation: A model that mimics the operation of an existing or proposed system, providing evidence for decision-making by being able to test different scenarios or process changes.
Machine Learning: A method of data analysis that automates analytical model building. It is a branch of artificial intelligence based on the idea that systems can learn from data, identify patterns, and make decisions with minimal human intervention.
Pain Management: An aspect of medicine and health care involving relief of pain in various dimensions, from acute and simple to chronic and challenging.
Clinical Practice Guidelines: “Systematically developed statements to assist practitioner decisions about appropriate health care for specific clinical circumstances” (Field & Lohr, 1990 AU41: The in-text citation "Field & Lohr, 1990" is not in the reference list. Please correct the citation, add the reference to the list, or delete the citation. ). They can be used to reduce inappropriate variations in practice and to promote the delivery of high quality, evidence-based health care. They may also provide a mechanism by which healthcare professionals can be made accountable for clinical activities. The Institute of Medicine (IOM) (2012) defines clinical practice guidelines as “statements that include recommendations, intended to optimize patient care, which are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.”
Cesarean Section: C-section, or Cesarean birth is the surgical delivery of a baby through a cut (incision) made in the mother's abdomen and uterus. Health care providers use it when they believe it is safer for the mother, the baby, or both. The incision made in the skin may be: Up-and-down (vertical).
Practice Variance in Healthcare: A deviation from normal standards of care. Medical practice variation reflects practice differences among health care clinicians and includes overuse and underuse, both of which can have negative consequences for patients.
Hypotension: Also known as low blood pressure, is a blood pressure under 90/60 mm/Hg. In many people, it has no symptoms. When it does cause symptoms, these are usually unpleasant or disruptive, including dizziness, fainting and more.