Converting labour epidural analgesia to surgical anaesthesia for emergency caesarean section is commonly undertaken on the labour ward. The main goals for the anaesthetist are to convert analgesia to anaesthesia as rapidly and safely as possible to assist with minimising the decision to delivery interval and secondly to ensure that the woman has a comfortable experience. If not managed appropriately, intraoperative breakthrough pain can have serious psychological sequelae for a woman and is an important medicolegal issue in obstetric anaesthesia. The best way to convert labour epidural analgesia to anaesthesia in this situation remains unclear. Several randomised controlled trials have examined the efficacy of different local anaesthetic solutions and adjuncts, but none has clarified the optimal approach. Opinion remains divided about the choice of local anaesthetic, where to administer the epidural top-up and whether opioids should be routinely used as part of the top-up on this situation.
During ESRA 2021, a well-attended session discussed this problem. The high-quality platform used for ESRA 2021 enabled live polls to be conducted during the sessions. We used this facility for polling delegates on their strategies around labour epidural conversion for emergency caesarean section, including choice of local anaesthetic, where the top-up is administered, and lastly, whether they routinely use an opioid as part of their top-up strategy.
Most ESRA delegates used ropivacaine 7.5mg/ml or a lidocaine/adrenaline/bicarbonate solution to extend labour analgesia, suggesting a practice supported by a recent network meta-analysis. Most respondents initiated the top-up in the delivery room and administered the remainder either en route to theatre or once the woman had arrived in theatre, suggesting a desire to balance reducing anaesthetic time (and therefore decision-to-delivery interval), alongside prioritising maternal safety. Regarding whether opioids were added routinely to the local anaesthetic top-up, the delegates were equally split on this question, with a small percentage only occasionally adding opioids to the local anaesthetic top-up.
This snapshot survey provides an interesting insight into practice in this area. We hope to repeat the poll at future ESRA meetings. Our thanks to Eleni, Thomas, Alain, and Clara and the whole ESRA team for their efforts in putting on a fantastic and innovative meeting!
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