P-051 - (Poster #51) Dexmedetomidine for the Parturient: A Survey for Pioneering Safe and Effective Bolus Dosing in Labor Epidurals

Background: Dexmedetomidine, a selective alpha-2 adrenergic agonist, has gained attention for its off-label use in labor epidurals as an opioid-sparing analgesic. Studies suggest it enhances pain relief when combined with local anesthetics, reducing opioid-related side effects while demonstrating minimal placental transfer and ensuring neonatal safety. Its use in labor epidurals is increasing as providers seek safer, more effective pain management strategies.

Despite its benefits, there is no standardized bolus dose of dexmedetomidine for labor epidurals, leading to variability in clinical practice. Expert recommendations often cite a 25 mcg bolus with local anesthetics, which lacks large-scale validation. The most frequently used local anesthetics are ropivacaine (0.1–0.2%) and bupivacaine (0.0625–0.25%), typically in 10 mL volumes, but concentrations and dosing strategies vary widely. Some studies support a fixed dexmedetomidine concentration per mL of anesthetic, while others favor weight-based dosing. Research also explores combinations of epidural and intrathecal dexmedetomidine boluses, followed by maintenance infusions.

Purpose/Objectives: The objective of this study is to evaluate clinical practices among Certified Registered Nurse Anesthetists (CRNAs) regarding dexmedetomidine bolus dosing in labor epidurals compared to current literature. The study aims to identify dosing trends, barriers to implementation, and CRNA perceptions of dexmedetomidine's efficacy and safety. A comprehensive literature review and a national survey were conducted to gather data on dosing strategies, clinical effectiveness, and commonly observed side effects. Findings highlight significant variability in bolus dosing and a lack of standardized guidelines, underscoring the need for further research, evidence-based dosing recommendations, and formal CRNA education to improve clinical consistency and patient outcomes.

Methods: The study utilized a mixed-methods approach, combining a comprehensive literature review with a national survey of CRNAs specializing in obstetric anesthesia. The survey was designed using Microsoft Forms and included Likert-scale, multiple-choice, and open-ended questions to capture both quantitative and qualitative data. Questions focused on dexmedetomidine bolus dosing practices, perceived efficacy, safety, and barriers to implementation. Surveys were distributed via the American Association of Nurse Anesthesiologists (AANA) and CRNA professional social media platforms.

Responses were anonymized and securely stored. Quantitative data were analyzed using SPSS for descriptive statistics, while thematic analysis was applied to open-ended responses. Ethical considerations included participant confidentiality, informed consent, and IRB exemption due to minimal risk. The study followed SRQR guidelines for qualitative research reporting and recommended future consensus-building through Delphi methodology and the AGREE II framework for standardizing clinical practice recommendations.

Results: A total of 173 CRNAs met eligibility criteria and completed the survey, with 64.7% reporting frequent obstetric anesthesia practice. Dexmedetomidine was used at least occasionally by 83.2% of respondents, with 41.0% reporting frequent use. The most common bolus dose for breakthrough labor epidural pain was 16–20 mcg (35.4%), followed by doses greater than 20 mcg (27.1%). Lower doses of 1–5 mcg were rarely used (2.8%).

Barriers to dexmedetomidine use included lack of formal training (62.1%), perceived lack of need (20.7%), institutional restrictions (20.7%), and preference for clonidine (13.8%). Among respondents who did not currently use dexmedetomidine, 93.1% stated they would consider using it if training and institutional support were available.

Most CRNAs reported dexmedetomidine as “very effective” (84.0%) in labor epidurals, with 95.8% noting that a second bolus was rarely needed. Side effects were reported as minimal, with 74.3% stating maternal bradycardia was almost never observed, while 43.1% reported hypotension was rare. Increased motor block and sedation were occasionally observed in 31.9% and 31.3% of cases, respectively, though 27.1% reported no side effects.

Dexmedetomidine was commonly used in scenarios requiring multiple epidural redoses (47.9%) and as an adjunct to reduce local anesthetic use (15.3%). Respondents noted advantages such as improved analgesia during prolonged labor and reduced opioid-related side effects. Open-ended responses highlighted provider enthusiasm for dexmedetomidine, describing it as “a game-changer” and “the secret sauce.”

These results highlight significant variability in bolus dosing and widespread CRNA confidence in dexmedetomidine’s efficacy. Despite its frequent off-label use, the lack of standardized dosing guidelines underscores the need for further research, formal education, and clinical recommendations to improve consistency in labor epidural analgesia.

Conclusions/Implications for future research and/or clinical care: Dexmedetomidine has demonstrated promising benefits as an adjunct in labor epidurals, offering effective analgesia with a favorable side effect profile and minimal neonatal impact. Despite its growing use, current CRNA practice relies heavily on anecdotal experience with no dosing guidelines or consensus statements. Survey data confirmed frequent off-label use among CRNAs while highlighting provider variability in dexmedetomidine dosing and administration. For providers not using dexmedetomidine, the most significant barrier to implementation was a lack for formal education and training. These findings emphasize the need for standardized, evidence-based bolus dosing guidelines and education. Future research should prioritize protocol consistency, rigorous methodology, and education initiatives to ensure safe and effective implementation of dexmedetomidine bolus dosing in labor epidurals.