Neuraxial opioids and the newborn Petter Kainu 7.10.11 SOAT, Tartto.

Neuraxial opioids and Neuraxial opioids and the newbornthe newborn

Petter KainuPetter Kainu

7.10.117.10.11

SOAT, TarttoSOAT, Tartto

EpiduralEpidural analgesiaanalgesia in the in the latentlatent phasephase of of laborlabor and the and the riskrisk of of cesareancesarean deliverydelivery: a : a five-yearfive-year randomizedrandomized controlledcontrolled trial. trial.

Wang F. Shen X. Guo X. Peng Y. Gu Wang F. Shen X. Guo X. Peng Y. Gu X. Labor Analgesia Examining Group. X. Labor Analgesia Examining Group.

Anesthesiology 2009. 111(4):871-80Anesthesiology 2009. 111(4):871-80

Labour analgesia and the baby: good news is no newsLabour analgesia and the baby: good news is no newsFelicity Reynolds, IJOA 2011Felicity Reynolds, IJOA 2011

BackroundBackround

newborn is very sensitive to opioidsnewborn is very sensitive to opioids newborn metabolizes opioids slowlynewborn metabolizes opioids slowly no balancing painno balancing pain

Assessing newbornAssessing newborn

Apgar-scoresApgar-scores– are developed originally to assess drug-are developed originally to assess drug-

influenceinfluence– unsensitiveunsensitive

Neonatal acid-base statusNeonatal acid-base status– reflects the function of placentareflects the function of placenta– reflects poorly drug influencesreflects poorly drug influences

Assessing newbornAssessing newborn

NACS (Neurologic and Adaptive Capacity NACS (Neurologic and Adaptive Capacity Scoring System) + and other scoring Scoring System) + and other scoring systemssystems– muscular tone, reactivity ,reaction to different muscular tone, reactivity ,reaction to different

stimulistimuli beginning of spontaneous breathingbeginning of spontaneous breathing pCO2pCO2 pulseoximetry pulseoximetry drug concentrations from blood samplesdrug concentrations from blood samples

Kinetics of epidural opioidKinetics of epidural opioid

epidurally administered opioids enter epidurally administered opioids enter rapidly circulationrapidly circulation

lipophilic opioids rapidly cross the lipophilic opioids rapidly cross the placentaplacenta

ion trapping (acidotic fetus)ion trapping (acidotic fetus)

Kinetics of epidural opioidKinetics of epidural opioid if ≥ 150-200 µg of fentanyl is used, the baby if ≥ 150-200 µg of fentanyl is used, the baby

has measurable amouts of fentanyl in has measurable amouts of fentanyl in circulationcirculation– Epidural fentanyl in labour.Epidural fentanyl in labour. Carrie LE. O'Sullivan Carrie LE. O'Sullivan

GM. Seegobin R. Anaesthesia 1981. 36(10):965-9GM. Seegobin R. Anaesthesia 1981. 36(10):965-9 if epidural-infusions are used, fentanyl does if epidural-infusions are used, fentanyl does

not seem to accumulatenot seem to accumulate– Maternal and neonatal fentanyl and Maternal and neonatal fentanyl and

bupivacaine concentrations after epidural bupivacaine concentrations after epidural infusion during labor.infusion during labor. Bader AM. Fragneto R. Bader AM. Fragneto R. Terui K. Arthur GR. Loferski B. Datta S. Anesthesia & Terui K. Arthur GR. Loferski B. Datta S. Anesthesia & Analgesia 1995. 81(4):829-32Analgesia 1995. 81(4):829-32

Epidural opioid Epidural opioid && respiratory respiratory depression depression

case reportscase reports EpiduralEpidural OpioidOpioid AnalgesiaAnalgesia and and

NeonatalNeonatal RespiratoryRespiratory Depression. Depression.Kumar M, Paes B. Journal of Kumar M, Paes B. Journal of Perinatology 2003. 23(5):425-7Perinatology 2003. 23(5):425-7

Epidural opioid Epidural opioid && NACS NACS

with epid-/iv-opioid. vs no analgesic in with epid-/iv-opioid. vs no analgesic in some studies babies have had lower NACSsome studies babies have had lower NACS– MaternalMaternal analgesiaanalgesia duringduring laborlabor disturbsdisturbs

newbornnewborn behaviorbehavior: : effectseffects on on breastfeedingbreastfeeding, , temperaturetemperature, and , and cryingcrying.. Ransjo-Arvidson AB. Ransjo-Arvidson AB. Matthiesen AS. Lilja G. Nissen E. Widstrom AM. Matthiesen AS. Lilja G. Nissen E. Widstrom AM. Uvnas-Moberg K. Birth 2001. 28(1):5-12Uvnas-Moberg K. Birth 2001. 28(1):5-12

– observational study (n=28)observational study (n=28)– unmedicated infants were more active (video unmedicated infants were more active (video

recorded and analyzed by experts)recorded and analyzed by experts)

Epidural opioid Epidural opioid && NACS NACS

EffectEffect of of laborlabor epiduralepidural analgesiaanalgesia withwith and and withoutwithout fentanylfentanyl on on infantinfant breast-feedingbreast-feeding: a : a prospectiveprospective, , randomizedrandomized, , double-blinddouble-blind studystudy.. Beilin Y. Bodian CA. Weiser J. Beilin Y. Bodian CA. Weiser J. Hossain S. Arnold I. Feierman DE. Martin G. Hossain S. Arnold I. Feierman DE. Martin G. Holzman I. Anesthesiology 2005: Holzman I. Anesthesiology 2005: 103(6):1211-7103(6):1211-7

when ≥ 150 when ≥ 150 μμg fentanyl was used, NACS g fentanyl was used, NACS were slightly lower (p=0,03)were slightly lower (p=0,03)

Breast feeding Breast feeding && epidural analgesia epidural analgesia

the initiation of breast feeding is the initiation of breast feeding is crucial for breast feeding to be crucial for breast feeding to be succesfullsuccesfull

if infant is less active or ”tired” the if infant is less active or ”tired” the interaction may become disturbedinteraction may become disturbed

opioid may supress activity of the opioid may supress activity of the infantinfant

Breast feeding Breast feeding && epidural analgesia epidural analgesia

Breast-feedingBreast-feeding problemsproblems afterafter epiduralepidural analgesiaanalgesia for labour: a for labour: a retrospectiveretrospective cohortcohort studystudy of pain, of pain, obstetricalobstetrical proceduresprocedures and and breast-feedingbreast-feeding practicespractices.. Volmanen Volmanen P. Valanne J. Alahuhta S. P. Valanne J. Alahuhta S. International Journal of Obstetric International Journal of Obstetric Anesthesia 2004. 13(1):25-9Anesthesia 2004. 13(1):25-9

Volmanen et al.Volmanen et al.

only part of the epidurals had only part of the epidurals had fentanylfentanyl

bupivacaine?bupivacaine?

The The impactimpact of of intrapartumintrapartum analgesiaanalgesia on on infantinfant feedingfeeding..

Jordan S. Emery S. Bradshaw Jordan S. Emery S. Bradshaw C.Watkins A. Friswell W. C.Watkins A. Friswell W.

International Journal of Obstetrics & International Journal of Obstetrics & Gynaecology 2005. 112(7):927-34Gynaecology 2005. 112(7):927-34

retrospective review, 18165 ptsretrospective review, 18165 pts

IntrapartumIntrapartum epiduralepidural analgesiaanalgesia and and breastfeedingbreastfeeding: a : a prospectiveprospective cohortcohort studystudyTorvaldsen S. Roberts CL. Torvaldsen S. Roberts CL. Simpson JM. Thompson JF. Ellwood Simpson JM. Thompson JF. Ellwood DA.DA.International Breastfeeding Journal International Breastfeeding Journal 2006, 1:24 2006, 1:24

n=1280n=1280

Epidural analgesia and Epidural analgesia and breastfeeding: a randomised breastfeeding: a randomised controlled trial of epidural controlled trial of epidural techniques with and without techniques with and without fentanyl and a non-epidural fentanyl and a non-epidural comparison group.comparison group.

Wilson M. J. A. MacArthur C. Cooper G. Wilson M. J. A. MacArthur C. Cooper G. M. Bick D. Moore P. A. S. Shennan A. M. Bick D. Moore P. A. S. Shennan A. Anaesthesia 2010. 65(2):145-153Anaesthesia 2010. 65(2):145-153

n=1064n=1064 Study groups:Study groups: Low dose infusion-group (LDI group):Low dose infusion-group (LDI group): bolus (30 µg fent +15 mg bolus (30 µg fent +15 mg

bupiv in 15 ml), followed by infusion (10 ml/h)bupiv in 15 ml), followed by infusion (10 ml/h) CSE-group:CSE-group: Spinal (Bup 5mg + Fent 25 µg) follwed by epidural Spinal (Bup 5mg + Fent 25 µg) follwed by epidural

infusion as in LDI-group infusion as in LDI-group Control groupControl group: Epidural bolus (15 mg bup without fentanyl), : Epidural bolus (15 mg bup without fentanyl),

infusion without fentanylinfusion without fentanyl Two comparison groups without epidural analgesiaTwo comparison groups without epidural analgesia (pethidin/no (pethidin/no

pethidin- not randomized) pethidin- not randomized) Rescue medication:Rescue medication:

– Control group: Epidural fentanyl 50µgControl group: Epidural fentanyl 50µg

Results: Results: – Epidural fentanyl did not affect breast feedingEpidural fentanyl did not affect breast feeding– Pethidine had negative influence on breast feedingPethidine had negative influence on breast feeding

ConclusionsConclusions epidural labour analgesia/opioid can influence epidural labour analgesia/opioid can influence

infantinfant serious influences are unlikelyserious influences are unlikely breast feeding seems to be adversely affectedbreast feeding seems to be adversely affected most studies are non-randomized cohort studies most studies are non-randomized cohort studies

– except except Beilin et al 2005Beilin et al 2005 Wang et al 2009Wang et al 2009 Wilson et al 2010Wilson et al 2010

ConclusionsConclusions Editorial in AnesthesiologyEditorial in Anesthesiology in regard to in regard to

Beilin study:Beilin study:– ””We should continue to use medications that We should continue to use medications that

are known to be effective and are satisfactory are known to be effective and are satisfactory to patients, and provide the best obstetric to patients, and provide the best obstetric outcome possible.”outcome possible.”

Obstetric Anesthesia DiggestObstetric Anesthesia Diggest::– ””As lower consentrations of local anesthetic As lower consentrations of local anesthetic

are assosiated with many benefical effects for are assosiated with many benefical effects for mother and baby, fentanyl should not be mother and baby, fentanyl should not be discarded based on weak links.”discarded based on weak links.”

Reynolds F:Reynolds F: Labour analgesia and the Labour analgesia and the baby: good news is no news.baby: good news is no news. International International Journal of Obstetric Anesthesia 2011. Journal of Obstetric Anesthesia 2011. 20(1):38-5020(1):38-50– ””The effect on breast feeding has yet to be The effect on breast feeding has yet to be

established, though it is certainly no worse established, though it is certainly no worse than that of systemic opioid analgesia.”than that of systemic opioid analgesia.”

However,However,

should we restrict larger doses of epidural should we restrict larger doses of epidural opioids?opioids?– not > 150 µg of fentanyl?not > 150 µg of fentanyl?

More studies are warranted!More studies are warranted!