[Remifentanil-PCA to alleviate labor-pain - a true and safe alternative to epidural labor analgesia?].
Labor-pain analgesia in the absence of epidural analgesia is difficult to achieve with the commonly used analgesic interventions. If epidural analgesia is not feasible due to coagulation disorders, anticoagulation, inability to insert an epidural catheter or on the mother?s request, there is a need for interventions to cope with labor-pain. For a decade, anaesthesiologists have experienced the unique properties of remifentanil in the settings of surgical anaesthesia, sedation and postoperative analgesia since its introduction into labor analgesia. The fast onset and offset without accumulation is largely due to its elimination by tissue esterases. These features are also key enabling factors that make remifentanil suitable for labor analgesia administered by a patient controlled analgesia device in a bolus dose of 20-40 microg [DOSAGE ERROR CORRECTED]with an initial 2-min lockout and no background infusion. Although remifentanil crosses the placenta, it is eliminated quickly in neonates by rapid metabolism and redistribution. Unfortunately, remifentanil does not have a licence for administration to the pregnant patient, and it is unlikely that the manufacturers would consider the cost justified. However, in labor and pediatric anaesthesia the off-label use of drugs is not uncommon. As it stands remifentanil is the best opioid for obstetric use so far. Therefore it is the onus on us to justify the use of remifentanil as off-label drug for obstetric analgesia on the basis that the benefit outweighs the risk. Proper informed consent, appropriate monitoring for the mother and the newborn, one-to-one nursing or midwifery care as well as the availability of an attending physician experienced in neonatal resuscitation and an anaesthesiologist with experience regarding the use of remifentanil is important to ensure that this method retains its credit for obstetric analgesia. These issues are discussed in an interdisciplinary approach.
Kranke
Peter
P
Oberarzt, Klinik und Poliklinik für Anästhesiologie, Universitätsklinikum Würzburg.
Schelling
Philip
P
Frambach
Torsten
T
Wirbelauer
Johannes
J
D000328:Adult; D015360:Analgesia, Epidural; D016362:Analgesia, Obstetrical; D000701:Analgesics, Opioid / Q000008:administration & dosage / Q000627:therapeutic use*; D002404:Catheterization; D005260:Female; D005858:Germany; D006801:Humans; D008991:Monitoring, Physiologic; D056687:Off-Label Use; D010092:Oximetry; D010880:Piperidines / Q000008:administration & dosage / Q000627:therapeutic use*; D011247:Pregnancy; D000077208:Remifentanil
D000701:Analgesics, Opioid; D010880:Piperidines; D000077208:Remifentanil