Evaluation of service provision of patient controlled epidural analgesia in a district general hospital with a change in local anaesthetic concentration.
IM Walker, Specialist Registrar; S Jeyanthan, Specialist Registrar; N Parry, Consultant; CE Brennan, Consultant
Department of Anaesthetics, The Dudley Group NHS Foundation Trust, Russells Hall Hospital, Dudley, West Midlands, UK. DY1 2HQ
The COMET trial1 in 2001 showed that lower dose bupivacaine solutions in epidurals for labour dropped instrumental delivery rates with good analgesia.
Work by Van der Vywer2 showed that patient controlled epidural analgesia (PCEA) resulted in lower consumption of local anaesthetic (LA) and fewer interventions. PCEA has therefore gained popularity and a local project at Russells Hall Hospital found that PCEA reduced workload for midwives and was associated with increased maternal satisfaction (using 0.125% bupivacaine and 2mcg/ml fentanyl).
We audited current practice with regards to PCEA to establish levels of maternal satisfaction and to find out if a change in the concentration of bupivacaineto 0.1% would result in a change in outcomes.
The evaluation took place over a 2 month period and was carried out prospectively.
Data was collected on a proforma.
Labouranalgesia was established via either epidural or combined spinal-epidural (CSE).
Initial top up was via 15 ml of epidural solution (0.1% bupivacaine/2mcg/ml fentanyl).
The regimen was set to 5ml boluses with 10min lockout.
The primary outcome was to assess satisfaction with epidural analgesia via questionnaire at follow up and to review observations with regard to Bromage score to evaluate maximum motor block.
Secondary outcomes included consumption of LA, delivery outcome ( normal vaginal delivery, instrumental delivery, c-section) and a comparison to results from 2012 where a slightly higher dose of LA was used.
Data was collected for 50 epidurals. 88% were ‘very satisfied’ which supports the level of satisfaction has been maintained despite lower concentration of LA.
Figures 1 and 2a & 2bshow the outcomes. Interestingly there appeared to be more motor block (higher Bromage scores) with the lower LA concentration. This may be due to improved measurement of the Bromage scores.
The number of instrumental deliveries decreased which you would expect with lower dose LA although the number of caesarean sections increased.
The population requiring epidurals may be more likely to need a caesarean section.
The number of CSEs performed has dropped significantly.
Our evaluation showed that patient satisfaction was very high with PCEAs and that patients would recommend the service.
Interestingly we noticed a move away from CSEs with all the patients receiving an epidural only in the recent study.
This is probably understood in terms of the perceived disadvantages of CSEs and reports concerning them in NAP3.
The reduction in concentration did have the expected effect of reducing instrumental deliveries.
LSCS deliveries increased. Further studies to look at other patient factors may be able to explain this.