Recommendations:

1. An intrathecal catheter may be inserted for the provision of analgesia and anaesthesia following inadvertent dural puncture during attempted epidural catheter placement. This decision must be made with consideration of potential risks and benefits (Grade C, moderate level of certainty).
2. Whether using intermittent boluses or a continuous infusion technique, use the same local anaesthetic solution throughout labour (Grade I, low level of certainty).
3. Maternal blood pressure should be checked every 5 min for 15 min following the first dose, and after every subsequent bolus given via an intrathecal catheter (Grade A, high level of certainty).
4. As with epidural analgesia, sensory and motor block should be checked every hour during intrathecal catheter analgesia (Grade B, moderate level of certainty).
5. Fetal heart rate should be continuously monitored during intrathecal analgesia (Grade B, moderate level of certainty).
6. Top-ups of local anaesthetic for caesarean delivery should be given incrementally, with each bolus limited to 2.5 mg bupivacaine (or equivalent) (Grade I, low level of certainty).
7. Extension of labour analgesia for caesarean delivery via an intrathecal catheter should be performed in an operating theatre (Grade B, moderate level of certainty).
8. Non-invasive blood pressure, ECG and oxygen saturations should be monitored throughout the duration of intrathecal anaesthesia (Grade A, high level of certainty).
9. All departments should have clear guidelines for the management of intrathecal catheters in labour and for delivery. These should highlight key risks, monitoring protocols and other safety measures (Grade A, low level of certainty).
10. Only anaesthetists should administer top-ups through an intrathecal catheter, and connect, disconnect or reconnect the catheter and tubing (Grade A, low level of certainty).
11. Anaesthetists should account for the dead space of the intrathecal catheter and filter when administering top-ups in labour or for operative delivery (Grade B, low level of certainty).
12. An intrathecal catheter should be clearly labelled adjacent to the filter and on the front of any infusion pump (Grade A, low level of certainty).
13. The multidisciplinary team (including any non-resident staff who may be called to attend the patient during labour or delivery), must be made aware of the intrathecal catheter through both verbal and written communication, including at every handover (Grade A, low level of certainty).
14. Intrathecal catheters should be removed at the earliest opportunity following delivery to reduce the risk of accidental overdose and infectious complications (Grade B, low level of certainty).
15. When patients who experience inadvertent dural puncture, with or without intrathecal catheter insertion, are discharged from hospital, follow-up should be in line with established guidance and include written information on headaches, ‘red flag’ symptoms, hospital contact information and communication with primary care (Grade B, low level of certainty).

summary

• Sarah K Griffiths, Robin Russell, Malcolm A Broom, Sarah Devroe, Marc Van de Velde, and D N Lucas.
• Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
• Anaesthesia. 2024 Dec 1; 79 (12): 134813681348-1368.

BackgroundAnaesthetists of all grades who work on a labour ward are likely to be involved in the insertion or management of an intrathecal catheter after inadvertent dural puncture at some point in their careers. Although the use of intrathecal catheters after inadvertent dural puncture in labour has increased in popularity over recent decades, robust evidence on best practice has been lacking.MethodsThe Obstetric Anaesthetists' Association set up an expert working party to review the literature. A modified Delphi approach was used to produce statements and recommendations on insertion and management of intrathecal catheters for labour and operative delivery following inadvertent dural puncture during attempted labour epidural insertion. Statements and recommendations were graded according to the US Preventive Services Task Force grading methodology.ResultsA total of 296 articles were identified in the initial literature search. Further screening identified 111 full text papers of relevance. A structured narrative review was produced which covered insertion of an intrathecal catheter; initial dosing; maintenance of labour analgesia; topping-up for operative delivery; safety features; complications; and recommended follow-up. The working party agreed on 17 statements and 26 recommendations. These were generally assigned a low or moderate level of certainty. The safety of mother and baby were a key priority in producing these guidelines.ConclusionsWith careful management, intrathecal catheters can provide excellent labour analgesia and may also be topped-up to provide anaesthesia for caesarean or operative vaginal delivery. The use of intrathecal catheters, however, also carries the risk of significant drug errors which may result in high- or total-spinal anaesthesia, or even cardiorespiratory arrest. It is vital that all labour wards have clear guidelines on the use of these catheters, and that staff are educated as to their potential complications.© 2024 The Author(s). Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists.

This article appears in the collection: Interesting obstetric epidural articles.

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