Combined spinal-epidural analgesia in advanced labour

The combined spinal-epidural technique is a modification of epidural analgesia which combines the rapid onset of spinal analgesia with the flexibility of an epidural catheter. We sought to evaluate the effectiveness of an intrathecal opioid — low-dose local anaesthetic combination for parturients in advanced labour, a setting where satisfactory epidural analgesia is often difficult to achieve. The technique was evaluated in an open-label, non-randomized trial using parturients in advanced, active labour for the provision of pain relief during the late first stage and second stage of labour. Thirty-eight term parturients in active, advanced labour received a spinal injection of bu-pivacaine 2.5 mg and sufentanil, 10 μg, via a 25- or 27-gauge Whitacre needle placed into the subarachnoid space through a 17- or 18- gauge Weiss epidural needle which had been placed into the epidural space. This was followed by placement of an epidural catheter for supplemental analgesia if required. Onset of analgesia was noted by asking patients if their contractions were comfortable. Motor blockade was assessed using the Bromage criteria. Patients were asked if they experienced either pruritus or nausea on a four-point scale (none, mild, moderate, severe). The mean cervical dilatation at placement of the spinal medication was 6.1 ± 2.2 cm. Thirty-two patients had spontaneous vaginal delivery, two were delivered by outlet forceps, and four by Caesarean section. Onset of analgesia was rapid (< five minutes) in all cases. Twenty-three patients (60%) delivered vaginally with no additional anaesthetic. The remaining 15 had supplemental local anaesthetic given via the epidural catheter, a mean of 123 ± 33 min after the original spinal dose. Side effects were limited to pruritus in eight (21%) patients, and mild lower extremity motor weakness in one patient. One patient experienced transient hypotension. No patient developed postdural puncture headache. This technique allows for profound analgesia with a rapid onset and few bothersome side effects. In particular, the absence of motor blockade may facilitate maternal expulsive efforts or positioning during the second stage of labour.     

Fluid through the epidural needle does not reduce complications of epidural catheter insertion

Epidural catheter insertion may be associated with blood vessel trauma or nerve root irritation. The purpose of this study was to assess whether the injection of small amounts of fluid through the Tuohy needle prior to catheter insertion reduced the incidence of these and other minor complications. Two hundred patients in labour, requesting epidural analgesia, were randomly assigned to one of three groups: Group I--the catheter was inserted without previous injection of fluid; Group II--3 ml, 1.5 per cent lidocaine hydrochloride was injected through the needle prior to catheter insertion; Group III--3 ml, saline was injected prior to catheter insertion. There were no differences among the groups in the incidence of blood vessel trauma or paraesthesiae. We conclude that there is no advantage in injecting of fluid routinely into the epidural space prior to catheter insertion.     

Repeat epidural analgesia and unilateral block

The use of epidural analgesia has become so widespread in recent years that many women are now requesting repeat epidural analgesia for their second or subsequent labour. This study examines the incidence of problems at insertion and of inadequate block in 71 multiparae having second epidurals compared with 150 primiparae having their first epidural. Unilateral block occurred in 6.66% of primiparae and 18.3% of multiparae (P) <0.02). There was no association between difficulty of insertion of catheter, blood in needle/catheter or paraesthesia and unilateral blockade. Epidurals were inserted at a greater dilatation (P <0.05 and there was a shorter time to delivery (P < 0.01) in the multiparous group. We conclude that unilateral block is thus more common in women receiving repeat epidurals.     

A comparative study of patient-controlled epidural fentanyl and single dose epidural morphine for post-caesarean analgesia

In a prospective, randomized, double-blinded study, 23 patients who had undergone Caesarean delivery under epidural anaesthesia were assessed to evaluate the effectiveness of patientcontrolled epidural analgesia (PCEA) with fentanyl compared with a single dose of epidural morphine for postoperative analgesia. Group A (n = 11) received epidural fentanyl 100 μg intraoperatively, then self-administered a maximum of two epidural fentanyl boluses 50 μg (10 μg · ml^?1) with a lockout period of five minutes for a maximum of two doses per hour. Group B (n = 11) received a single bolus of epidural morphine 3 mg (0.5 mg · ml^?1) intraoperatively and received the same instructions as Group A but had their PCA devices filled with 0.9% NaCl. Patients were assessed up to 24 hr for pain, satisfaction with pain relief, nausea and pruritus using visual analogue scales (VAS). The treatments for inadequate analgesia, nausea and pruritus as well as time to first independent ambulation were recorded. The ventilatory response to carbon dioxide challenge was measured at four and eight hours. Pain relief, satisfaction with pain relief, and the use of supplemental analgesics were similar in both groups. The mean 24 hr dose of epidural fentanyl used by group A patients was 680 μg. Pruritus was less common in Group A patients at the 8 and 24 hr observation periods (P < 0.0125). Both groups experienced the same degree of nausea and clinically unimportant respiratory depression. We conclude that PCEA with fentanyl provides analgesia equal to a single dose of epidural morphine and may be suitable for patients who have experienced considerable pruritus after epidural morphine adminstration.     

Combined spinal epidural block versus spinal and epidural block for orthopaedic surgery

In a controlled study a single segment combined spinal epidural (CSE) block was compared with spinal or epidural block for major orthopaedic surgery. Seventy-five patients, age 52–86 yr, were randomly assigned to receive one of the three blocks. Bupivacaine 0.5% was used for surgical analgesia. The postoperative pain relief after 4.0 mg epidural morphine was compared with the analgesic effect of 0.2 or 0.4 mg morphine administered intrathecally. With the spinal technique good or excellent surgical analgesia and muscle relaxation were achieved rapidly (11.8 ± 1.1 min). The time taken to provide an equally effective and reliable block with the CSE technique was no longer (14.9 ± 2.2 min). For epidural block with the catheter technique more time was required (35.9 ± 3.9 min) to provide acceptable surgical conditions (P < 0.05). Perioperative sedatives and concomitant analgesics were required more frequently and in larger doses by the patients undergoing surgery with epidural block (P < 0.05) than with CSE or spinal block. Our study demonstrated that the analgesia after surgery provided by 0.2 and 0.4 mg morphine administered intrathecally was comparable to that provided by 4.0 mg of epidural morphine. It is concluded that the analgesia and surgical conditions provided by the spinal and CSE blocks were similar and were superior to those provided by an epidural block.     

Epidural morphine for analgesia after Caesarean section: a report of 4880 patients

This retrospective study was undertaken to assess the efficacy and safety of epidural morphine in providing analgesia following Caesarean section under epidural anaesthesia. The morphine was administered as a single bolus, following delivery, in doses ranging from 2 to 5 mg. The charts of 4880 Caesarean sections, performed on 4500 patients, were reviewed. The duration of analgesia and the occurrence of any symptoms which might be side-effects of the epidural morphine were recorded. The duration of analgesia was 22.9 +/- 10.1 hr and was not correlated with the dose of epidural morphine. Eleven per cent of the patients required no supplemental analgesia during the first 48 hr. Twelve patients (0.25 per cent) had respiratory rates less than 10 breaths per minute, on at least one occasion. No serious sequelae resulted from these periods of bradypnoea. Pruritus occurred in 58 per cent of patients, nausea and vomiting in 39.9 per cent and dizziness in ten per cent. Herpes simplex labialis was recorded in 3.5 per cent of patients. Epidural morphine is thus confirmed as an effective analgesic technique post-Caesarean section with 3 mg being the optimal dose. Even in this young healthy patient population, clinically detectable respiratory depression occurs so clinical respiratory monitoring is indicated.     

Transforaminal escape of a lumbar epidural catheter

A patient is presented whose lumbar epidural catheter was found to lie in the paravertebral tissues during a right radical nephrectomy. The catheter had been placed with the patient awake and the procedure performed in a routine fashion without difficulty or indication of catheter malposition. Four ml of 2% CO2 lidocaine were initially injected as a test dose without any demonstrable effect. After the induction of general anaesthesia, fentanyl 100 mu and 0.25% bupivacaine 10 ml were injected slowly into the catheter. Previous studies suggest that transforaminal escape of an epidural catheter occurs after 1-6% of insertions. It may occur without nerve root symptoms during catheter placement. The authors recommend that epidural catheters be introduced whilst the patients are awake and an effective block demonstrated before induction of general anaesthesia.     

Anaesthetic management of a complex morbidly obese parturient

A case is presented of a morbidly obese parturient who had multiple medical problems. She had angina and was receiving nitrate therapy, had insulin-dependent diabetes mellitus, hypertension, asthma and benign intracranial hypertension (pseudotumour cerebri). Lumbar epidural analgesia was chosen for labour and delivery and resulted in an uneventful outcome.     

Early respiratory depression during Caesarean section following epidural meperidine

A case of respiratory depression which occurred following administration of epidural meperidine during Caesarean section is described. Epidural meperidine, 75 mg (10 mg.ml-1) was given after delivery of the infant to provide postoperative analgesia. Oxygen desaturation (SaO2 90%) and a decrease in respiratory rate (4.min-1) were noted 30 min after epidural meperidine was administered. Naloxone, 0.1 mg, was given iv which resulted in prompt improvement in both respiratory rate and oxygen saturation. Vascular absorption of meperidine from the epidural venous plexus is the most probable explanation for this case of early respiratory depression. We recommend a maximum bolus dose of 50 mg of epidural meperidine for pain management after Caesarean section. It is also important to monitor oxygen saturation continuously during the intraoperative period, and to monitor the patient closely in the recovery room for at least one hour for evidence of respiratory depression.     

Anaesthetic management of a child with Bartter’s syndrome

We report the anaesthetic management of an eight-year-old asthmatic boy with Bartter’s syndrome who had bilateral orchidopexy with caudal epidural analgesia. Bartter’s syndrome is a rare congenital disorder characterized by hypokalaemic hypochloraemic metabolic alkalosis, hyperaldosteronism, hyperreninaemia and hyperplasia of the juxtaglomerular apparatus of the kidneys. Characteristically, although these patients are normotensive they may be hypovolaemic. They may have unstable baroreceptor responses and show marked resistance to vasopressors. Hence, fluid, acid-base and electrolyte imbalances along with haemodynamic instability pose particular problems in their anaesthetic management. Previous case reports have described the management of these patients with general anaesthesia, our patient had his orchidopexy with caudal epidural analgesia using plain bupivacaine 0.5%. The patient was haemodynamically stable throughout surgery and was comfortable with caudal analgesia as the sole anaesthetic. Hypovalaemia, acid-base status and electrolyte imbalance were treated before instituting caudal epidural analgesia. We present this case report which describes the anaesthetic considerations in the light of the pathophysiology of Bartter’s syndrome.     

Autonomic hyperreflexia during labour

We present two cases of automatic hyperreflexia (AH) during labour in women with spinal cord damage, in whom AH developed before and after delivery. The AH was successfully controlled using epidural anaesthesia in Case #1, but failed in Case #2. The blood pressure was controlled with nicardipine. However, overdose of nicardipine produces vasodilatation and its side effects include headache, flushing and palpitation similar to AH¹. Considering these effects, we recommend epidural anaesthesia to control AH, because epidural anaesthesia does not only reduce BP, but also blocks the noxious stimuli and relieves the symptoms of AH. Our experience suggests that the epidural catheter can be placed two to three weeks before the date of predicted childbirth, because the onset of labour in a patient with spinal cord damage is difficult to predict and can proceed very rapidly. Also, the epidural catheter is available after the delivery. We recommended the epidural catheter is maintained for 24–48 hr postpartum.     

Severe hypotension from epidural meperidine in a high-risk patient after thoracotomy

A sixty-eight-year-old female developed severe hypotension immediately after the administration of epidural meperidine for post-thoracotomy pain. Two preceding injections of epidural opiates had been uneventful. The cardiovascular collapse was difficult to reverse and may have contributed to the patient's subsequent death. Cardiovascular complications have not been reported frequently as a possible side effect of epidural opiate analgesia.     

Epidural analgesia for a parturient with herpes gestationis

A 23-yr-old parturient with herpes gestationis spontaneously delivered a normal healthy infant under epidural analgesia. She received five injections of bupivacaine 0.5 per cent over a ten-hour period. There was no infection at the lumbar region, even though her body was covered with vesicles and bullae including the face and neck. Eight months after delivery the patient still has a vesicular eruption which occurs mainly during her menses.     

Epidural anaesthesia for labour and Caesarean section in a parturient with a single ventricle and transposition of the great arteries

We describe a case of a 29-year-old parturient with a single ventricle and transposition of the great arteries who had lumbar epidural analgesia/anaesthesia with a local anaesthetic for labour, emergency Caesarean section and postoperative pain. Her outcome and that of her baby was successful. The anaesthetic techniques used in other parturients with similar congenital cardiac anomalies are reviewed.     

Continuous lumbosacral block using a Tuohy needle and catheter technique

Three cases are reported where continuous lumbosacral block was performed using a catheter through an epidural needle technique. Good unilateral lower limb surgical anaesthesia was achieved in all three cases with successful blockade of the lumbar and sacral plexuses. A 17-gauge Tuohy needle was positioned between the transverse processes of L4 and L5 and an epidural catheter inserted into the space between the quadratus lumborum and psoas muscles. Forty to seventy millilitres of local anaesthetic were injected and resulted in good surgical anaesthesia within 12-20 min. Radiographic studies in these patients confirmed placement of the catheter in close proximity to the lumbosacral plexus. Experience in a further 12 cases is also reported. There were no side-effects. The technique is successful and is recommended when unilateral lower limb anaesthetic is required and when spinal and epidural anaesthesia are contraindicated.     

Continuous suprascapular nerve block for analgesia of scapular fracture

Fracture of the scapular is uncommon but painful. A case is described in which a comminuted scapular fracture was treated with a continuous suprascapular nerve block. With the patient lying supine an epidural needle was directed towards the scapular notch via a superior approach and an epidural catheter was placed when the notch was believed to have been identified. Repeat injections of 10 ml bupivacaine 0.25 per cent with 1/200,000 epinephrine provided analgesia within minutes and a duration of 8-10 hr. Injection of 10 ml radio-opaque dye demonstrated the catheter to be lateral to the scapular notch. However, dye dispersed throughout the supraspinous fossa including the scapular notch thus blocking the suprascapular nerve. This case demonstrates that continuous suprascapular nerve block can be performed for five days and that location of the scapular notch is less important than previously thought.     

Lumbar and thoracic epidural analgesia via the caudal approach for postoperative pain relief in infants and children

Thirty infants scheduled for a variety of gastrointestinal, genitourinary and thoracic surgical procedures were selected for insertion of lumbar or thoracic epidural catheters via the caudal approach using either an Intracath or a Burron continuous brachial plexus kit. The catheters were inserted with ease by residents in training and no catheter-related complications were encountered. Lidocaine 0.5 per cent with 1:200,000 epinephrine was then injected to assure proper placement of the catheter before narcotics were administered. Postoperative analgesia was adequate in all patients using preservative-free morphine 0.05 mg.kg-1. The mean dosing interval was 15 hr and no episodes of nausea, vomiting, hypotension or histamine release were noted. Urinary retention occurred in two infants and one infant became apnoeic three hours after epidural morphine administration but responded to naloxone and pulmonary ventilation with bag and mask. In conclusion, epidural catheters placed via the caudal approach are a safe and effective means of providing postoperative pain control in infants using preservative-free morphine. However, the use of epidural narcotics in infants less than two years of age is restricted to those who will receive intensive care unit monitoring postoperatively so that if apnoea occurs, rapid intervention can be taken by skilled nursing personnel.     

Successful treatment of chronic pancreatitis pain with interpleural analgesia

Interpleural analgesia has recently been shown to be effective in the management of various chronic pain syndromes. We have used interpleural analgesia successfully in 11 patients with severe chronic pancreatitis of 24-38 months' duration. Daily injections of 30 ml of 0.5 per cent bupivacaine with epinephrine 5 mu.ml-1, were given through a percutaneously inserted pleural catheter over a five- to ten-day period. Patients have remained pain-free during follow up which ranges from 24 to 40 weeks. This method of providing analgesia for the patient suffering from the pain of chronic pancreatitis is simple, safe, effective and can be provided on an outpatient basis.     

Bupivacaine 0.1% does not improve postoperative epidural fentanyl analgesia after abdominal or thoracic surgery

Epidural infusions of fentanyl, in a 10 micrograms.ml-1 concentration, combined with bupivacaine 0.1% were compared with epidural infusions of fentanyl alone for postoperative analgesia following abdominal or thoracic surgery. There were no detectable differences between the two groups in analgesia (mean visual analogue scale pain scores ranging between 15-35 mm), average infusion rates of 7-9 ml.hr-1, and serum fentanyl concentrations which reached 1-2 ng.ml-1. There was no difference in postoperative pulmonary function (pH, PaCO2, SaO2), or bowel function (time to flatus or po fluids). The incidence of side-effects including somnolence, nausea and vomiting, pruritus and postural hypotension was also similar. Of the patients receiving fentanyl and bupivacaine 0.1%, three developed a transient unilateral sensory loss to pinprick and ice, and two of these patients had unilateral leg weakness equal to a Bromage 1 score. The addition of bupivacaine 0.1% does not improve epidural infusions of fentanyl using a 10 micrograms.ml-1 concentration following abdominal or thoracic surgery.     

A comparison of two doses of epidural fentanyl during Caesarean section

A prospective, randomized, double-blind study was performed to compare the analgesic efficacy and side effects of epidural fentanyl, 25 pg vs 50 pg, when used to supplement epidural anaesthesia for elective Caesarean section. Fifty ASA I and II patients were randomized into two groups: Group I (n =24) received 25 pg and Group II (n = 26) received 50 pg of epidural fentanyl after the epidural test dose. No differences between the two groups were found on any measures of intraoperative pain, nausea, drowsiness, respiratory depression, hypotension, pruritus and neonatal outcome. The low levels of pain experienced by patients indicates that doses higher than 50 μg of epidural fentanyl are usually unnecessary for optimal analgesia.