Management of Epidural-Associated Interscapular Pain
PresentingAuthor: Christine Chen, MD
PresentingAuthor's Institution: Mount Sinai West
Co-Authors: Michael S. Balot, DO - MountSinai West
Ghislaine C. Echevarria, MD, M.S. - MountSinai West
Brian Taussig, MD - Mount Sinai West
Introduction
Interscapular pain is a common yetinfrequently discussed complication of epidural analgesia. The exact etiologyof epidural-associated interscapular pain is unknown. Some postulate that rapidepidural infusion of fluid may cause pain by stretching the meninges, whileothers suggest epidural air entrapment may lead to the discomfort. Here wepresent our institution’s technique for managing this complication and review itseffectiveness in the setting of 9 affected parturients.
Methods
After placement of neuraxial anesthesia,all laboring parturients are started on a patient controlled epidural analgesia(PCEA) infusion. A standard solution of bupivacaine 0.0625% with fentanyl 2mcg/mL is infused at a rate of 12 mL/hr with a demand dose of 6 mL and a10-minute lockout interval. When parturients endorse interscapular pain, theyare immediately evaluated by the anesthesia team. If the symptoms areconsistent with epidural-associated interscapular pain, a new PCEA infusion isstarted consisting of bupivacaine 0.0625% with fentanyl 4 mcg/mL. The PCEAsettings are adjusted to an infusion rate of 6 mL/hr, demand dose of 3 mL, anda lockout interval of 10 minutes. Following infusion adjustment, parturientsare continually reevaluated for improvement in interscapular pain as well asany changes to their uterine contraction pain.
Results
Table 1 depicts the BMI, neuraxialtechnique, and pain scores of the 9 parturients identified as havingepidural-associated interscapular pain. Eight parturients had completeresolution of their interscapular pain 2 hours after infusion adjustment, howevertwo of these parturients endorsed worsening labor contraction pain. One parturienthad no improvement and developed worsening interscapular and contraction painafter the adjustment.
Discussion
This case series describes the managementof interscapular pain associated with an epidural infusion. By utilizing ourtreatment method, the volume that is infused into the epidural space isdecreased. This decrease in volume may lead to a reduction in pressure withinthe epidural space resulting in an improvement in interscapular pain. A limitationof our technique is the possibility that the decrease in the volume ofanesthetic delivered may lead to an inadequate analgesic level for uterinecontractions, as demonstrated in two of our patients. Given the lack of medicalliterature regarding the management of this topic, we hope that our case seriescan help guide providers who encounter this problem.
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发表于 2024-3-29 16:11:02
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