Obstetric Anaesthesia Annual Scientific Meeting 2024

Introducing a standard operating procedure for the use of remifentanil PCAs on St George’s Hospital Delivery Suite

Introduction

Remifentanil Patient Controlled Analgesia is offered to labouring women on our delivery suite who are unsuitable for epidural analgesia. As such it is used relatively infrequently in our unit, and an anaesthetist unfamiliar with remifentanil PCAs may be required to set up a remifentanil PCA out-of-hours. A brief guide existed for anaesthetists delivering remifentanil PCAs. No guideline existed for midwives. We wrote a standard operating procedure (SOP), reducing the concentration of remifentanil and simplifying the suggested starting doses. We included a ‘Quick Set up Guide’ for anaesthetists and a ‘Management of Complications’ flow chart for midwives. We introduced a ‘Grab Box’ containing equipment for immediate management of complications in the room.

Objectives

•Ensure processes are in place for the safe use of remifentanil PCAs on labour ward, as per GPAS standard [1] and NICE guidance [2]

•Introduce guidance for multi-disciplinary team on labour ward on their use

•Simplify the process of setting up a remifentanil PCA for anaesthetists

•Improve safety for patients using remifentanil PCAs

Methods

Midwives and anaesthetists were surveyed on their confidence with various aspects of remifentanil PCAs. Midwives lacked confidence in management of complications, and which of their patients might be suitable for remifentanil PCAs. Anaesthetists found existing guidance overcomplicated, and lacked confidence that complications would be managed well. Concerns were raised about the strength of remifentanil preparation in use at 100mcg/ml, and a standard bolus dose rather than a dose per kg was preferred. Anaesthetists and midwives were surveyed again following the introduction of our new standard operating procedure, and comparison of some of the results can be seen in the graphs below.

We reviewed guidelines from two other trusts [3, 4] which have been part of the RemiPCA Safe network [4], and therefore had a track record of applying high standards of care, and adopted aspects of those protocols that were also applicable in our unit. We adapted from Southampton General Hospital’s remifentanil guideline a ‘Management of Complications’ flowchart to guide midwives in case of complications whilst using remifentanil PCAs. We worked with senior midwives in our unit to create a flowchart that would be useable by our delivery suite midwives.

Shortly before before the introduction of the new guideline there was a maternal respiratory cardiac arrest on our delivery suite whilst a patient was using a remifentanil PCA. An incident review concluded this was likely due to an inadvertent bolus following a line occlusion. Whilst we had already planned to reduce the concentration of remifentanil in use to reduce the impact of any such inadvertent bolus, we also reviewed the lines in use and procured specific an-siphon single infusion line PCA giving sets.

As well as delivering teaching to midwives on delivery suite, we have created a video teaching presentation for non-anaesthetists, and a video introductory guide for anaesthetists. Both of these can be freely accessed on YouTube [5]. Remifentanil PCA and respiratory arrest will form part of multidisciplinary team skills and drills training from next year.

Changes Introduced

•Reduced the dilution of remifentanil to 50mcg/ml, in keeping with that used throughout the rest of the hospital.

•Simplified starting dose from mcg/kg calculation to either 30mcg or 20mcg (depending on BMI and gestation), to reduce risk of calculation error and simply set-up procedure

•Produced single page flowchart on setting up a Remifentanil PCA on delivery suite

•Procured dedicated single line anti-siphon giving sets for use with all PCAs on labour ward

•Simplified and adjusted frequency of recorded observations required during remifentanil PCA use to every 30mins

•Produced ’Management of Complications’ flowchart to guide midwives

•Introduced a ’Grab Box’ to stay with the patient, containing self-inflating BVM, ‘Management of Complications’ Flowchart, naloxone, and oxygen delivery devices

•Specified that morphine PCA should be used instead of remifentanil PCAs for women labouring following an intrauterine death

Conclusion

We have introduced a comprehensive guideline for the use of remifentanil PCAs in labour on our delivery suite. We have brought in measures to reduce the chance of calculation error, and the risk of inadvertent large boluses of remifentanil. We have clarified and simplified the set-up process for anaesthetists and given clear advice on immediate management of complications to midwives. By introducing a ‘grab box’ to stay with the patient throughout, we ensure that life saving resuscitation equipment as well as reversal agent is on hand. PCA training will soon form part of mandatory training for all of our midwives, in line with NICE guidelines [2]. We expect to see midwives’ confidence in using remifentanil PCAs and managing their complications increase with this training, and as they become more familiar with our new guidelines.

Obstetric Anaesthesia Annual Scientific Meeting 2024

Introducing a standard operating procedure for use of remifentanil PCAs in St George's Hospital Delivery Suite

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