Failing Epidural Guideline

Towards a European improvement in the management of failing epidural analgesia during labour

Recent History of labour epidural analgesia. 

Labour Epidural Analgesia (LEA) has been the gold standard for pain relief during delivery for several decades¹. In the last years, advancements in the techniques and administration methods of LEA made delivery safer and more comfortable for our parturients. Continuous research in this field promises further improvements ². Today, an efficient and safe analgesia service during labour has become an essential aspect of modern obstetric care.  

A wide variability in LEA use exists across Europe, with published epidural rates ranging from 40 to more than 80% of parturients depending on the countries³. Nevertheless, a primary concern of anaesthesiologists in the obstetric environment is to ensure that analgesia remains satisfactory from the catheter placement until delivery and the postpartum period. Despite new efforts to reduce LEA failures, 10-20% of parturients still experience inadequate epidural analgesia during delivery ^4-7. 

Why a failing epidural guideline was necessary? 

The failure of LEA after previously established success remains a concern that has not been addressed in recent guidance documents. Recognising the lack of comprehensive recommendations for managing failing epidural analgesia during labour was the first step to initiating this consensus document for Failing Epidural Guidelines. Thus, the European Society of Anaesthesiology and Intensive Care (ESAIC) established a diverse joint task force in 2022 with experts from different European countries and regions. The panellists of the Failing Epidural Guidelines included members of the ESAIC Obstetric subforum, the ESAIC Guidelines Committee and also European experts in Obstetric Anaesthesia.  The task force aimed to address the critical issue of the failing epidural in previously established and working LEA, by creating the first ESAIC guideline on this topic. 

Focus of the Failing Epidural Guideline. 

In the 2010’s, the concept of breakthrough pain in parturients with LEA progressively evolved into the broader issue of failing epidural ^{8, 9}. Recent studies published have used this concept to explore new techniques, administration modes and local anaesthetic dosages and concentrations ¹⁰.  

Until now, investigations have mostly focused on increasing the incidence of successful onset of epidural analgesia, thus decreasing the rate of primary failure of LEA. To prevent the occurrence of failing epidurals, some risk factors for primary or secondary failure were identified.  

The ESAIC task force’s first meeting identified the need for evidence-based recommendations for managing a failing epidural in parturients who initially received adequate pain relief yet experienced secondary failure after one or two inefficient top-up epidural doses. 

Methodology employed. 

Following ESAIC’s methodological recommendations for focused guidelines ¹¹, the task force held multiple meetings and consultations between January 2022 and March 2024. 

They developed six PICO questions centred on the diagnosis and management of failing epidural analgesia during labour (Table 1). 

Table 1: PICO questions of the Failing Epidural Guideline: 

1. How to primarily rescue a failing epidural analgesia: Top up or re-site the catheter? 

2. Which is the best technique for re-siting the catheter? 

3. Does proactive management of LEA improve detection and management of a failing epidural analgesia? 

4. Which healthcare providers should manage a failing epidural analgesia? 

5. What are the training requirements for healthcare providers in the management of a failing epidural analgesia? 

6. How should a failing epidural analgesia be managed for an intrapartum caesarean delivery? 

A systematic search of the literature identified 56 relevant articles. Task force members were divided into subgroups, reviewed these papers and formulated recommendations, suggestions and Clinical practice statements (CPS) when appropriate, followed by a three-round Delphi process and further comments during an open peer review process. 

How to Manage a failing epidural analgesia? 

The task force faced challenges due to limited evidence published on managing failing epidural analgesia. Consequently, only two recommendations and 11 clinical practice statements were formulated.  

The Guideline, available on the ESAIC website and soon to be published in the European Journal of Anaesthesiology, includes the key conclusions summarised below in Table 2. 

Table 2: recommendations and Clinical Practice Statements of Failing epidural guideline: 

Recommendations:  

1. Direct medical supervision versus delegation to midwives, nurses or trainees: Anaesthesiologists must consistently take responsibility for initiating and executing suitable corrective strategies for addressing failing LEA. (Strong recommendation, very low quality of evidence) 
2. Management of failing epidural for intrapartum caesarean delivery: Each instance of failed augmentation of LEA for intrapartum caesarean delivery (CD) should be addressed on an individual basis. Depending on the circumstances, both neuraxial anaesthesia options (such as epidural top-up, new spinal, or combined spinal-epidural techniques) and general anaesthesia may be appropriate choices. (Conditional recommendation, very low quality of evidence) 

Clinical Practice Statements:  

1. Top up versus re-siting of epidural catheter: The attending anaesthesiologist should assess the proper placement of the epidural catheter, the management of LEA so far, and the obstetric condition of the parturient. The rescue intervention should be performed according to the likely cause of the epidural failure, following a clear algorithm. 
2. Best technique to re-site a failing epidural: Combined Spinal-Epidural (CSE) technique should be considered when re-siting a catheter, to decrease onset time, and increase efficiency of the block. Dural Puncture Epidural (DPE) technique may serve as an effective strategy for catheter re-siting, especially in high-risk parturients when CSE may not be preferred. 
3. Proactive management of LEA: Motor and sensory block, pain, and clinical status should be monitored with objective scales and recorded periodically (every 1-to-2 hour depending on the clinical situation) in high-risk, but also in healthy parturients with LEA.  
4. Direct medical supervision versus delegation to midwives, nurses or trainees: The healthcare provider responsible for the provision of LEA is an anaesthesiologist (trainee or specialist). LEA management is always under their direct authority. Supervision can be delegated to other healthcare providers. An appropriate training should be ensured to support optimal management of the failing epidural if maintenance of LEA is delegated to other healthcare personnel.  
5. Institutional protocol and training for the management of pain during labour: Each centre should have a local multidisciplinary protocol regarding the detection and treatment of failing epidural after initially adequate LEA has been achieved.  Multidisciplinary education and simulation training should be organized on a periodic basis to increase adherence to the protocol and awareness and communication with other healthcare providers and parturients.  
6. Management of failing epidural for intrapartum caesarean delivery: A proactive early management of failing LEA is the preferred technique to facilitate a successful conversion to anaesthesia for intrapartum caesarean delivery (CD). 

Conclusions and ways of improvement in failing epidural care. 

This Failing Epidural Guideline document provides a tool for improving patient care when epidural analgesia fails to achieve satisfactory analgesia. While most recommendations are based on experts’ opinions, further primary research is urgently required to include evidence-based recommendations in this field. We believe that implementing Patient-Reported Experience Measures (PREMs) and Patient-Reported Outcome Measures  (PROMs) in obstetric anaesthesia care can improve future research and will enhance future guidelines ¹².  

Acknowledgement 

We extend our gratitude to the authors of this document, including Isabel Valbuena Gómez, Arash Afshari, Kim Ekelund, Peter Kranke, Carolyn F Weiniger, Nuala Lucas, Pierre-Yves Dewandre, Emilia Guasch Arevalo, Alexander Ioscovich, Andrea Kollmann, Kim Lindelof, Sharon Orbach-Zinger, Stephanie Reis, Oscar Van den Bosch, Marc Van de Velde, and Carolina S Romero. We also acknowledge the external reviewers that have thoroughly reviewed this document, Ruth Landau and Sng Ban Leong, and also all ESAIC members that have submitted their feedback to make this document widely available. 

Special thanks to Janne Vendt for bibliographic support and to Pierre Harlet, Sophie Debouche and Saman Sepehr at ESAIC secretariat.  

On behalf of the ESAIC Failing Epidural Task Force 

Authors

• Nicolas Brogly (MD) – Lead of the Obstetric Subforum, Patient forum, ESAIC Scientific Committee 

References 

1. Halliday L, Kinsella M, Shaw M, Cheyne J, Nelson SM, Kearns RJ. Comparison of ultra-low, low and high concentration local anaesthetic for labour epidural analgesia: a systematic review and network meta-analysis. Anaesthesia 2022; 77:910-918. 
2. Baghirzada L, Archer D, Walker A, Balki M. Anesthesia-related adverse events in obstetric patients: a population-based study in Canada. Can J Anaesth 2022; 69:72-85. 
3. Ezeonu PO, Anozie OB, Onu FA et al. Perceptions and practice of epidural analgesia among women attending antenatal clinic in FETHA. Int J Womens Health 2017; 9:905-911. 
4. Sia A, Sng BL, Ramage S, Armstrong S, Sultan P. Failed Epidural Analgesia During Labour. In Fernando R, Sultan P, Phillips S (editors): Quick Hits in Obstetric Anesthesia. Cham: Springer International Publishing; 2022, pp. 359-364. 
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9. Hermanides J, Hollmann MW, Stevens MF, Lirk P. Failed epidural: causes and management. Br J Anaesth 2012; 109:144-154. 
10. Tan HS, Sng BL, Sia ATH. Reducing breakthrough pain during labour epidural analgesia: an update. Curr Opin Anaesthesiol 2019; 32:307-314. 
11. Romero CS, Afshari A, Kranke P. Adapt or perish: Introducing focused guidelines. Eur J Anaesthesiol 2021; 38:803-805. 
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