Levobupivacaine-sufentanil with or without epinephrine during epidural labor analgesia

In a prospective, randomized, double-blind study, we investigated whether epinephrine increased the efficacy of levobupivacaine and sufentanil during epidural labor analgesia. Seventy term parturients received an epidural injection of levobupivacaine 0.125% and sufentanil 0.75 microg/mL with or without 1:800,000 epinephrine. After an initial dose of 10 mL, a patient-controlled analgesia pump was started. Total and hourly drug consumption, pain scores using the visual analog scale, sensory and motor block, duration of labor, vital variables, maternal and neonatal outcome, and side effects were compared. If the parturients experienced insufficient pain relief during the study, even after a rescue dose of 10 mL, they were excluded from further study and received 10 mL of bupivacaine 0.125% and sufentanil 0.75 microg/mL with 1:800,000 epinephrine. Hourly drug consumption, rescue dosing, and pain scores at 15 min and 20 min were lower in the epinephrine group. The incidence of motor block and duration of the second stage of labor tended to be higher in the epinephrine group and were associated with lower Apgar scores at 1 and 5 min. These findings suggest that the addition of epinephrine intensifies the effects of epidural levobupivacaine and sufentanil but may cause more motor block.     

Effect of epidural clonidine added to epidural sufentanil for labor pain management

Labor analgesia with intrathecal sufentanil has been shown to be prolonged by the addition of intrathecal clonidine. The current study was designed to determine if epidural clonidine would prolong labor analgesia provided by epidural sufentanil. Forty laboring primiparous women at less than 5 cm cervical dilation requesting epidural analgesia were enrolled. Following a 3 mL test dose of lidocaine with epinephrine, patients were randomized to receive 10 mL of either sufentanil 20 microg (S) or sufentanil 20 microg with clonidine 75 microg (SC). After administration of the analgesic, pain scores and side-effects were recorded for each patient at 5, 10, 15, 20 and 30 min, and every 30 min thereafter, by an observer blinded to the technique used. There were no demographic differences between the two groups. Pain relief was rapid for all patients. The mean duration of analgesia was similar between the S group (153 +/- 78 min) and the SC group (178 +/- 55 min). Side-effects were similar between the two groups. There was no difference between the two groups in time from sufentanil administration to delivery, incidence of operative or assisted delivery, or cervical dilation at the time of redose. For early laboring patients, epidural sufentanil 20 microg after a lidocaine test dose provides analgesia comparable to that of sufentanil 20 microg with clonidine 75 microg; there was no significant difference in analgesic duration between the two groups.     

Neostigmine combined with bupivacaine, clonidine, and sufentanil for spinal labor analgesia.

We previously found that spinal clonidine prolongs labor analgesia when combined with spinal bupivacaine and sufentanil. We sought to determine whether the addition of spinal neostigmine to these drugs would further enhance labor analgesia. By use of a combined spinal/epidural technique, 36 patients were randomized to receive a hyperbaric spinal injection of bupivacaine 2.5 mg plus clonidine 50 microg and sufentanil 10 microg with or without neostigmine 10 microg. Pain, maternal hemodynamics, fetal heart rate, nausea, pruritus, sedation, motor block, sensory levels to pinprick, and maternal oxygen saturation were assessed at regularly specified intervals after spinal injection until additional analgesia was requested. The duration of spinal analgesia was similar between groups (215 +/- 60 min in the Control group versus 205 +/- 62 min in the Neostigmine group). Likewise, pain scores, the duration of labor, Apgar scores, and side effects were similar between groups except that patients administered neostigmine experienced significantly more nausea and vomiting (53% vs 7%, P = 0.01). We conclude that spinal neostigmine 10 microg produces severe nausea and does not potentiate the duration of spinal analgesia in laboring women from spinal bupivacaine, clonidine, and sufentanil. IMPLICATIONS: Spinal neostigmine 10 microg as an adjunct to spinal bupivacaine, clonidine, and sufentanil produces severe nausea and fails to potentiate analgesia in laboring women.     

Comparison of epidural fentanyl versus epidural sufentanil for analgesia in ambulatory patients in early labor

Epidural sufentanil, after a lidocaine and epinephrine test dose, provides adequate analgesia and allows for ambulation during early labor. Epidural fentanyl has not been evaluated in this setting. The current study was designed to determine whether there is an analgesic difference between epidural fentanyl and epidural sufentanil in laboring patients. Forty-six laboring nulliparous women, at <5-cm cervical dilation, who requested epidural analgesia were enrolled. After a 3-mL test dose of lidocaine with epinephrine, patients were randomized to receive either sufentanil 20 microg or fentanyl 100 microg. After administration of the analgesic, pain scores and side effects were recorded for each patient at 5, 10, 15, 20, and 30 min and every 30 min thereafter, by an observer blinded to the technique used. There were no demographic differences between the two groups. Pain relief was rapid for all patients. The mean durations of analgesia were similar between the sufentanil group (138 +/- 50 min) and the fentanyl group (124 +/- 42 min). Side effects were similar between the two groups. In early laboring patients, epidural fentanyl 100 microg, after a lidocaine and epinephrine test dose, provides analgesia comparable to that of sufentanil 20 microg. Implications: In early laboring patients, epidural fentanyl 100 microg, after a lidocaine and epinephrine test dose, provides analgesia comparable to that of sufentanil 20 microg.     

Intrathecal labor analgesia with bupivacaine and sufentanil: the effect of adding 2.25 microg epinephrine

BACKGROUND AND OBJECTIVES: Epinephrine, 25 microg and 200 microg, has been found to prolong the duration of intrathecal labor analgesia when added to an opioid. In our hospital we use the standard epidural mixture, prepared by the pharmacist, containing epinephrine 1:800,000; i.e., 1.25 microg/mL for both spinal and epidural labor analgesia. We wanted to evaluate whether such a low dose, depending on its effect on duration or quality of analgesia, should be maintained or deleted in future mixtures. METHODS: Forty-five term parturients were randomly assigned to receive 1.8 mL intrathecally of a mixture containing bupivacaine 0.125% and sufentanil 0.75 microg/mL with or without epinephrine 1.25 microg/mL. The quality and duration of analgesia, side effects, and obstetric/neonatal outcome were compared. RESULTS: For both combinations, the onset until the first painless contraction was between 5 and 6 minutes. Most patients were pain free during the second uterine contraction. The duration of complete analgesia was 93.2 +/- 24.2 minutes in the epinephrine group and 79.3 +/- 18.1 minutes for patients not receiving epinephrine (P = .014). The quality of the block, bupivacaine consumption, side effects, and obstetric/neonatal outcome were not different between groups. CONCLUSIONS: It was concluded that epinephrine in a dose as low as 2.25 microg significantly prolonged the duration of intrathecal analgesia of bupivacaine-sufentanil by 15 minutes. No other differences were noticed. Diluting the commercially available bupivacaine 0.5% with epinephrine 1:200,000 may avoid the need of freshly prepared epinephrine solutions.     

Perispinal analgesia for labour followed by patient-controlled infusion with bupivacaine and sufentanil: combined spinal-epidural vs. epidural analgesia alone

BACKGROUND AND OBJECTIVE: Combined spinal-epidural is an alternative technique to epidural analgesia for labour, but its benefits are not clearly identified. METHODS: A prospective, blinded, randomized study was undertaken involving 113 women attending a university hospital obstetric department. Analgesia was initiated with intrathecal bupivacaine 0.25% 1 mL + sufentanil 5 microg in the combined spinal-epidural group (n = 54), and with bupivacaine 0.125% + epinephrine 2.5 microg mL(-1) + sufentanil 7.5 microg in the epidural group (n = 59). In both cases this was followed by patient-controlled epidural analgesia with bupivacaine 0.125% (+ sufentanil 0.25 microg mL(-1)). Duration of labour, quality of analgesia and side-effects were compared between groups. RESULTS: In the combined spinal-epidural group, the onset of analgesia was faster (5 vs. 15 min, P < 0.001), the consumption of bupivacaine was lower (7.5 vs. 11.3 mg h(-1), P = 0.003) and there was less unilateral analgesia (14.8% vs. 40.7%, P = 0.002) than in the epidural group. The characteristics of labour were similar in both groups. However, in the combined spinal-epidural group, there was a higher incidence of posterior presentation (25.9% vs. 10%, P = 0.03), pruritus (P < 0.001), hypotension (P = 0.002), somnolence (P = 0.01), nausea (P = 0.02) and one case of meningitis. CONCLUSIONS: The combined spinal-epidural technique provided more effective analgesia during labour than epidural analgesia alone but offered no other advantage. It induced more adverse effects and this should be considered before routinely using the combined spinal-epidural technique.     

Two doses of intrathecal sufentanil (2.5 and 5 microg) combined with bupivacaine and epinephrine for labor analgesia.

In this study, we evaluated the effect of two doses of intrathecal sufentanil combined with bupivacaine and epinephrine on the incidence of pruritus and on the duration and quality of analgesia. One hundred five parturients were enrolled in this randomized, double-blinded, placebo-controlled study. They received either intrathecal 1.25 mg bupivacaine and 25 microg epinephrine (control group); 1.25 mg bupivacaine, 25 microg epinephrine, and 2.5 microg sufentanil (2.5-microg group); or 1.25 mg bupivacaine, 25 microg epinephrine, and 5 microg (5-microg group). Pain relief was assessed 10 min after injection, and pruritus was recorded at 30 min by a blinded observer. The study ended when the parturients requested further analgesia. There were no demographic differences among groups. Ninety of 103 parturients achieved complete pain relief with the initial dose, 11 patients in the control group (P < 0.004, control versus both sufentanil groups), and 2 patients in the 2.5-microg group needed a supplemental epidural bupivacaine. Pruritus was absent in the control group (P < 0.0001, control versus both sufentanil groups), whereas it was present in 36% of the 2.5-microg group and in 66% of the 5-microg group (P = 0.015, 2.5-microg versus 5-microg group). The mean duration of analgesia was similar in patients receiving sufentanil (2.5-microg group: 133 +/- 55 min; 5-microg group: 142 +/- 52 min) but was significantly higher than the control group (56 +/- 32 min). Reducing the sufentanil dose from 5 microg to 2.5 microg when combined with bupivacaine and epinephrine, decreases the incidence of pruritus without impeding the quality or duration of analgesia. IMPLICATIONS: We evaluated two different doses of intrathecal sufentanil combined with bupivacaine and epinephrine for labor analgesia. Sufentanil 2.5 microg offered an advantage over sufentanil 5 microg because, while providing the same quality and duration of analgesia, it was associated with a reduced incidence of pruritus.     

Intrathecal sufentanil and fetal heart rate abnormalities: a double-blind, double placebo-controlled trial comparing two forms of combined spinal epidural analgesia with epidural analgesia in labor

Combined spinal epidural analgesia (CSE) for labor pain relief has become increasingly popular. However, the effect of intrathecal sufentanil on the incidence of uterine hyperactivity and fetal heart rate (FHR) abnormalities remains controversial. We hypothesized that the use of intrathecal sufentanil in a dose of 7.5 microg is more likely to induce a nonreassuring FHR tracing than a small dose of spinal sufentanil combined with bupivacaine or epidural analgesia. Three-hundred parturients were randomized into three groups. In the first group, epidural analgesia was initiated with 12.5 mg of bupivacaine, 12.5 microg of epinephrine, and 7.5 microg of sufentanil in a volume of 10 mL (EPD group). In Group 2, initial intrathecal analgesia consisted of 2.5 mg of bupivacaine, 2.5 microg of epinephrine, and 1.5 microg of sufentanil (BSE group); in Group 3, spinal analgesia consisted of 7.5 microg of sufentanil (SUF group). Analgesia was maintained in all groups with patient-controlled epidural analgesia using bupivacaine 0.125%, 1.25 microg/mL of epinephrine, and 0.75 microg/mL of sufentanil (bolus, 4 mL; lockout, 15 min). Cardiotocography was monitored continuously 15 min before analgesia and for 60 min after the start of analgesia. The quality of analgesia, labor, and neonatal outcome and side effects were recorded. Twenty-four percent of patients in the SUF group developed FHR abnormalities (bradycardia or late decelerations) during the first hour after initiation of analgesia compared with 12% in the BSE group and 11% in the EPD group. Uterine hyperactivity occurred in 12% of parturients in the SUF group but in only 2% in the other groups. Onset of analgesia was more rapid in both CSE groups as compared with the EPD group. However, 29% of patients in the BSE group developed severe hypotension, requiring IV ephedrine (29% in the BSE group versus 7% and 12% in the EPD and SUF groups, respectively). All these differences reached statistical significance. The present data corroborate previous recommendations of caution when performing CSE using a large dose (7.5 microg or more) of spinal sufentanil because of the risk of uterine hyperactivity and FHR abnormalities. IMPLICATIONS: Combined spinal epidural analgesia (CSE) produces pain relief during labor. Fetal heart rate changes after CSE using intrathecal sufentanil have been reported. We performed a randomized, blinded trial confirming that fetal heart rate changes are more frequent after CSE using 7.5 micro g of intrathecal sufentanil as compared with other forms of neuraxial labor analgesia.     

The dose-range effects of sufentanil added to 0.125% bupivacaine on the quality of patient-controlled epidural analgesia during labor

To determine the minimal sufentanil concentration required to improve the quality of patient-controlled epidural analgesia during labor, we compared the efficacy of a combination of 0.125% bupivacaine with 1:800,000 epinephrine and different concentrations of sufentanil in a double-blinded randomized study. Concentrations were no sufentanil (n = 66), 0.078 microg/mL sufentanil (n = 65), 0.156 microg/mL sufentanil (n = 65), 0.312 microg/mL sufentanil (n = 65), and 0.468 microg/mL sufentanil (n = 67). The patient-controlled epidural analgesia setting was a 12-mL bolus dose and a 25-min lockout interval. Pain was scored at 5-6 cm, 7-8 cm, and full cervical dilation by using a 10-cm visual analog scale. At full cervical dilation, the pain scores were lower in the groups receiving a solution of at least 0.156 microg/mL sufentanil. Few differences were observed when using the larger concentrations, except for increased pruritus intensity. The duration of labor and the mode of delivery were similar in each group. Rescue analgesia, which consisted of 6 mL of 0.25% bupivacaine, was infrequent and comparable between groups. The use of the pump did not differ between groups. Adding a small concentration of sufentanil to 0.125% bupivacaine for patient-controlled epidural analgesia during labor improved the quality of analgesia but did not modify the bupivacaine requirement. Reducing the sufentanil concentrations to 0.156 microg/mL decreased the pruritus intensity without reducing analgesia. Implications: Adding a small concentration of sufentanil to 0.125% bupivacaine for patient-controlled epidural analgesia during labor improved the quality of analgesia but did not modify the bupivacaine requirement. Reducing the sufentanil concentrations to 0.156 microg/mL decreased the pruritus intensity without reducing analgesia.     

The analgesic effect of sufentanil combined with ropivacaine 0.2% for labor analgesia: a comparison of three sufentanil doses

The combination of opioids with local anesthetics is commonly used for epidural labor analgesia. We examined whether increasing sufentanil in doses of 5, 10, and 15 microg prolonged the duration of labor analgesia produced by ropivacaine. One hundred healthy parturients in the first stage of labor who requested epidural analgesia were enrolled. Parturients were randomized to receive 12 mL ropivacaine 0.2% alone or with sufentanil 5 microg, sufentanil 10 microg, or sufentanil 15 microg. The duration of analgesia, pain score, degree of motor blockade (using a four-point Bromage scale), heart rate, blood pressure, respiratory rate, oxygen saturation, and incidence of nausea and pruritus were recorded. The mean duration of epidural analgesia was 96 +/- 32 min for patients without sufentanil, 134 +/- 27 min for Group 5 (p < 0.01 versus control), 135 +/- 33 min for Group 10 (p < 0.01 versus control), 130 +/- 33 min for Group 15 (p < 0.01 versus control) without differences among sufentanil groups. Between 30 and 90 min, the sufentanil groups (5 microg, 10 microg, and 15 microg) had lower pain scores than the control group (p < 0.01 versus control) but there were no differences among the sufentanil groups. No patient in any group had a Bromage score more than 1. No significant difference was found for opioid-related side effects. We conclude that 5-10 or 15 microg sufentanil induced a similar prolongation of analgesia when combined with ropivacaine 0.2% for initiation of labor analgesia. Implications: We studied the effect of adding one of three possible sufentanil doses to epidural ropivacaine 0.2% for labor analgesia. Adding sufentanil increased the duration of analgesia but there was no advantage in adding more than 5 microg of sufentanil.     

The dose-response of intrathecal sufentanil added to bupivacaine for labor analgesia

BACKGROUND: Regional analgesia for labor often is initiated with an intrathecal injection of a local anesthetic and opioid. The purpose of this prospective, randomized, blinded study was to determine the optimal dose of intrathecal sufentanil when combined with 2.5 mg bupivacaine for labor analgesia. METHODS: One hundred seventy parous parturients with cervical dilation between 3-5 cm were randomized to receive intrathecal 0 (control), 2.5, 5.0, 7.5, or 10.0 microg sufentanil combined with 2.5 mg bupivacaine, followed by a lidocaine epidural test dose, for initiation of analgesia (34 patients in each group). Visual analog scores and the presence of nausea, vomiting, and pruritus were determined every 15 min until the patient requested additional analgesia. Fetal heart rate tracings were compared between groups. RESULTS: Groups were similar for age, height, weight, oxytocin dose, duration of labor, and baseline visual analog scores. Duration of action was significantly shorter for control patients (39 +/- 25 min [mean +/- SD]) compared with those administered sufentanil, all doses (93 +/- 32, 93 +/- 47, 94 +/- 33, 97 +/- 39 min), but was not different among groups administered 2.5, 5.0, 7.5, or 10.0 microg sufentanil. More patients who received 10 microg sufentanil reported nausea and vomiting than did control patients. The severity of pruritus increased with administration of 7.5 and 10.0 microg sufentanil. There was no difference in fetal heart rate changes among groups. CONCLUSIONS: Intrathecal bupivacaine (2.5 mg) without sufentanil did not provide satisfactory analgesia for parous patients. However, bupivacaine combined with 2.5 microg sufentanil provided analgesia comparable to higher doses, with a lower incidence of nausea and vomiting and less severe pruritus.     

Epidural combination of ropivacaine with sufentanil for postoperative analgesia after total knee replacement: a pilot study

BACKGROUND AND OBJECTIVE: We assessed the analgesic efficacy of postoperative epidural infusions of ropivacaine 0.1 and 0.2% combined with sufentanil 1 microg mL(-1) in a prospective, randomized, double-blinded study. METHODS: Twenty-two ASA I-III patients undergoing elective total-knee replacement were included. Lumbar epidural blockade using ropivacaine 0.75% was combined with either propofol sedation or general anaesthesia for surgery. After surgery, the epidural infusion was commenced. Eleven patients in each group received either an epidural infusion of ropivacaine 0.1% with 1 microg mL(-1) sufentanil (Group 1) or ropivacaine 0.2% with 1 microg mL(-1) sufentanil (Group 2) at a rate of 5-9 mL h(-1). All patients had access to intravenous pirinatrimide (piritramide) via a patient-controlled analgesia (PCA) device. RESULTS: Motor block was negligible for the study duration in both groups. There was no significant difference with the 100 mm visual analogue scale (VAS) scores, with the consumption of rescue analgesia or with patient satisfaction. Patients in Group 1 experienced significantly less nausea (P < 0.05) than those in Group 2. Both treatment regimens provided effective postoperative analgesia with only a minimal use of supplemental opioid PCA. CONCLUSIONS: We recommend the use of ropivacaine 0.1% with 1 microg mL(-1) sufentanil for postoperative analgesia after total knee replacement as it provides efficient pain relief with no motor block of the lower limbs. In addition, compared with 0.2% ropivacaine with sufentanil, the mixture reduces local anaesthetic consumption without compromise in patient satisfaction or VAS scores. Patients even experience less nausea.     

A multicentre trial comparing different concentrations of ropivacaine plus sufentanil with bupivacaine plus sufentanil for patient-controlled epidural analgesia in labour

BACKGROUND AND OBJECTIVE: To determine the optimal concentration of ropivacaine for bolus-only patient-controlled epidural labour analgesia, three different doses of ropivacaine were evaluated in comparison with bupivacaine in a double-blinded multicentre study. METHODS: Four hundred-and-fifty labouring parturients at term in three different academic institutions were randomized to four groups receiving bupivacaine 0.125% with sufentanil 0.75 microg mL(-1), ropivacaine 0.125% or 0.175% with sufentanil 0.75 microg mL(-1), or ropivacaine 0.2%. After an initial bolus of 10 mL of the study solution, and once visual analogue scores (VAS) were below 30 mm, patient-controlled epidural analgesia was initiated with a bolus of 4 mL, a lockout interval of 15 min and without a background infusion. Variables studied were the quality of analgesia, incidence of side-effects, the degree of motor blockade, and the mode of delivery. RESULTS: Bupivacaine 0.125% and ropivacaine 0.125% with sufentanil proved equally effective in providing labour analgesia without a difference in local anaesthetic consumption (48.6 +/- 23 mg bupivacaine vs. 52.1 +/- 38 mg ropivacaine), motor blockade or mode of delivery. Ropivacaine 0.175% plus sufentanil enhanced the quality of analgesia of the initial loading dose, whereas ropivacaine 0.2% without sufentanil increased the consumption of local anaesthetics (80.2 +/- 34 mg; P < 0.05) and the degree of motor blockade. CONCLUSION: Despite recent studies indicating that bupivacaine and ropivacaine may not be equipotent, both local anaesthetics provided equi-effective analgesia at equal doses without a difference in side-effects.     

Low dose intrathecal ropivacaine with or without sufentanil provides effective analgesia and does not impair motor strength during labour: a pilot study

PURPOSE: Although ropivacaine has been used to provide spinal anesthesia in the surgical population, its intrathecal administration for labour analgesia has only recently been described. We evaluated the effects of low dose intrathecal ropivacaine with or without sufentanil for labour analgesia. METHODS: Thirty-six term parturients in active labour were randomly assigned to receive 3 mg of intrathecal ropivacaine (group R) or 3 mg ropivacaine with 10 microg of sufentanil (group RS). Patients were evaluated by a blinded observer for hypotension, linear analogue score (VAS 0-100) for labour pain, motor power in the lower limbs, onset of analgesia, sensation to cold and pin prick, duration of analgesia, and neonatal Apgar scores. The following day patients were assessed for satisfaction, headache and neurologic deficit. RESULTS: The mean duration of analgesia in the R group was 41.4 +/- 4.9 min and 95.0 +/- 6.1 min in the RS group (mean +/- SEM, P=0.0001). All subjects had satisfactory analgesia at five minutes, although analgesia from the ropivacaine- sufentanil combination was superior to that provided by ropivacaine alone. Total duration of labour was no different between the groups (R- 306 +/- 34, RS- 384 +/- 44 min, P=0.17). No patient showed evidence of motor block. All patients were satisfied with the labour analgesia. No neurological complications were observed. CONCLUSIONS: Low dose ropivacaine provides effective analgesia during labour via the intrathecal route. It can be mixed with sufentanil in the above-mentioned concentrations to improve both the quality and duration of analgesia. Fetal outcome remains favourable. It may provide minimal or no motor block, to facilitate ambulation.     

Addition of Epinephrine to Intrathecal Bupivacaine and Sufentanil for Ambulatory Labor Analgesia

Background: The intrathecal combination of sufentanil and bupivacaine provides rapid, effective analgesia for labor with a limited duration. Many anesthesiologists have concerns that the use of intrathecal local anesthetics precludes maternal ambulation. This prospective, randomized, double-blind study was designed to determine whether the addition of epinephrine to the combination of sufentanil and bupivacaine would prolong intrathecal analgesia for labor. Patients' ability to ambulate was also assessed.

Methods: Thirty-nine patients received either an intrathecal control dose of 10 micro gram sufentanil plus 2.5 mg bupivacaine plus 0.2 ml normal saline (control group); or 10 micro gram sufentanil plus 2.5 mg bupivacaine plus 0.2 ml (0.2 mg) of epinephrine (EPI group).

Results: Seven patients (3 control, 4 EPI) delivered vaginally and two (1 control, 1 EPI) required cesarean delivery before requesting epidural analgesia. The duration (mean +/- SD) of intrathecal labor analgesia was prolonged significantly by the addition of epinephrine: control (n = 15): 145 +/- 23 min; EPI (n = 15): 188 +/- 25 min (P <0.0001). Maternal ambulation was demonstrated in 100% (19 of 19) of the control group and in 80% (16 of 20) of the EPI group (P = NS).     

Injecting saline through the epidural needle decreases theiv epidural catheter placement rate during combined spinal-epidural labour analgesia

PURPOSE: To determine if injecting 10 mL saline before epidural catheter threading (pre-cannulation epidural fluid injection) can decrease the incidence of iv epidural catheter placement during combined spinal-epidural (CSE) labour analgesia. METHODS: One hundred healthy women requesting CSE labour analgesia with either fentanyl 20 microg or sufentanil 10 microg were prospectively randomized to receive either no epidural injection (dry group, n = 50) or epidural 10 mL saline injection (saline group, n = 50) before epidural catheter placement. A nylon multiport catheter was then threaded 3-5 cm into the epidural space and the needle was removed. We diagnosed iv catheter placement if blood was freely aspirated, if the mother became tachycardic after injection of epinephrine 15 microg, or if intracardiac air was heard (using ultrasound) after injection of air 1.5 mL. RESULTS: Intravenous epidural catheter placement occurred in one saline and ten dry group patients (P < 0.01). No complications of excessive cephalad intrathecal opioid spread (i.e., difficulty swallowing, hypoxemia, or respiratory arrest) occurred. CONCLUSIONS: Injecting 10 mL or saline through the epidural needle after intrathecal opioid injection and before threading the catheter significantly decreased accidental venous catheter placement without any apparent increase in complications from excessive cephalad intrathecal opioid spread.     

The influence of a bupivacaine and fentanyl epidural infusion after epidural fentanyl in patients allowed to ambulate in early labor

Epidural fentanyl after a lidocaine and epinephrine test dose provides adequate analgesia and allows for ambulation during early labor. This study was designed to determine the influence of an epidural infusion of bupivacaine plus fentanyl administered after initiation of epidural labor analgesia with fentanyl. Specifically, we evaluated whether there is an increase in motor block or an increased time to request for further analgesic medication. Fifty-one laboring primigravid women at <5 cm cervical dilation who requested epidural analgesia were enrolled. After a 3-mL epidural test dose of 1.5% lidocaine with epinephrine (5 microg/mL), patients received fentanyl 100 microg via the epidural catheter. They then randomly received either an infusion (10 mL/h) of 0.0625% bupivacaine with fentanyl (3 microg/mL) or an infusion of preservative-free saline. After the administration of the initial analgesic, pain scores and side effects were recorded for each patient at 10, 20, and 30 min, every 30 min thereafter, and at the time of request for additional analgesic medication, by an observer blinded to the technique used. There were no demographic differences between the two groups. The mean duration of analgesia (time from initial dose to request for additional analgesia) was increased in the group that received a continuous infusion of bupivacaine and fentanyl compared with the Saline group (198 +/- 86 vs 145 +/- 50 min; P < 0.009). Side effects were similar between the two groups. No patient in either group experienced any detectable motor block. Fourteen patients chose to ambulate in the Saline group, and 12 patients chose to ambulate in the Infusion group. In early laboring patients, a continuous infusion of 0.0625% bupivacaine infusion with fentanyl (3 microg/mL) prolonged the duration until top-up was required, after epidural fentanyl 100 microg after a lidocaine and epinephrine test dose, and did not cause any clinically detectable motor block. IMPLICATIONS: A 0.0625% bupivacaine and fentanyl (3 microg/mL) infusion, when added to epidural fentanyl (100 microg), prolongs the analgesic duration without increasing motor block in women in early labor.     

Intrathecal clonidine prolongs labour analgesia but worsens fetal outcome: a pilot study

PURPOSE: Intrathecal clonidine prolongs total duration of spinal bupivacaine analgesia. However, there are contradictory reports about its effect on maternal blood pressure and only limited data are available on fetal and neonatal outcome. In this study, we evaluated the efficacy of spinal clonidine combined with ropivacaine and sufentanil and its effects on maternal and fetal outcome. METHODS: Fifty patients requesting combined spinal epidural analgesia for labour pain relief were randomly assigned to receive intrathecal ropivacaine 3 mg, sufentanil 1.5 microg with or without clonidine 30 microg. Onset time and duration of analgesia, visual analogue scores for pain, blood pressure, ephedrine requirements, heart rate, incidence of nausea, pruritus and motor blockade, umbilical artery pH, fetal heart rate abnormalities and Apgar scores were noted and analyzed. RESULTS: Patients receiving spinal clonidine had significantly longer lasting analgesia compared to patients treated without clonidine (122 +/- 56 min vs 90 +/- 36 min, P < 0.05). Clonidine-treated patients experienced a more pronounced decrease in mean arterial pressure as compared to patients treated without clonidine (25 +/- 10% vs 15 +/- 12%, P < 0.05). The groups also differed in ephedrine requirement (4.91 mg vs 0.75 mg, P < 0.05), number of new onset fetal heart rate abnormalities (28% vs 0%, P < 0.05) and umbilical artery pH (7.219 +/- 0.096 vs 7.289 +/- 0.085, P < 0.05). CONCLUSION: Intrathecal clonidine prolongs spinal analgesia with ropivacaine and sufentanil at the expense of maternal hypotension, worse fetal well being and worse neonatal umbilical artery pH. We do not recommend routine administration of spinal clonidine 30 microg to sufentanil and ropivacaine for labour pain relief.     

Either sufentanil or fentanyl, in addition to intrathecal bupivacaine, provide satisfactory early labour analgesia

PURPOSE: The study was aimed primarily at comparing the duration of analgesia produced by intrathecal fentanyl 25 microg with sufentanil 5 microg when added to bupivacaine 1.25 mg as the initial component of the combined spinal epidural (CSE) technique in early labour. METHODS: Forty healthy parturients were randomly assigned into two groups to receive either intrathecal sufentanil 5 microg plus bupivacaine 1.25 mg (Group S) or intrathecal fentanyl 25 microg plus bupivacaine 1.25 mg (Group F). Apart from the duration of analgesia, pain scores and side effects were also evaluated. RESULTS: There was no significant difference in the duration of analgesia (mean 109 +/- SD 49 min in Group F vs 118 +/- 54 min in Group S, P=0.9). Group F had a more rapid onset of analgesia (P <0.05) and a higher cephalad block (median T4 vs T7, P <0.05) in the first 30 min after the block. No difference in the side effects was detected. CONCLUSION: Fentanyl 25 microg is a good alternative to sufentanil 5 microg when added to bupivacaine 1.25 mg for early labour analgesia.     

The addition of hydromorphone to epidural fentanyl does not affect analgesia in early labour

PURPOSE: Epidural fentanyl after a lidocaine and epinephrine test dose, provides adequate analgesia and allows for ambulation during early labour. The current study was designed to determine the influence of hydromorphone added to an epidural fentanyl bolus (e.g., whether there is an increase in duration of analgesia). METHODS: Forty-four labouring primigravid women, at less than 5 cm cervical dilation, who requested epidural analgesia were enrolled in this randomized, double-blind study. After a 3 mL test dose of lidocaine with epinephrine, patients received fentanyl 100 microgram (in 10 mL volume). They randomly received the fentanyl with either saline or hydromorphone (300 microgram). After administration of the initial analgesic, pain scores and side effects were recorded for each patient at ten, 20, and 30 min, and every 30 min thereafter, by an observer blinded to the technique used. RESULTS: The patients were taller in the hydromorphone group (P < 0.04). There were no other demographic differences between the two groups. The mean duration prior to re-dose was not significantly different in the group that received hydromorphone (135 +/- 52 min) compared to the control group (145 +/- 46 min). Side effects were similar between the two groups. No patient in either group experienced any detectable motor block. CONCLUSION: In early labouring patients, the addition of hydromorphone (300 microgram) to epidural fentanyl (100 microgram after a lidocaine and epinephrine test dose) neither prolongs the duration of analgesia nor affects the ability to ambulate, and cannot be recommended according to the current study.