A comparison of epidural and cerebrospinal fluid glucose in parturients at term: an observational study

BackgroundDetecting inadvertent dural puncture during labour epidural insertion can be difficult when using a loss of resistance to saline technique. Testing fluid for glucose that leaks from a Tuohy needle may confirm the presence of cerebrospinal fluid and infer inadvertent dural puncture. This study compared the glucose content of intrathecal fluid obtained during spinal anaesthesia for elective caesarean delivery with that of fluid from a Tuohy needle or epidural catheter when establishing epidural analgesia for labour.MethodsWomen aged ?18 years undergoing elective caesarean delivery and labouring parturients who requested epidural analgesia were recruited prospectively in a tertiary referral centre over a three-month period. Fluid was collected into a sterile container either during spinal anaesthesia or from a labour epidural needle. Glucose content was evaluated using a bedside blood glucometer and laboratory colorimetric analyzer.ResultsOf the 118 women approached, 115 participated. All 40 women having spinal anaesthesia and 2/75 (2.7%) women having epidural analgesia, in whom inadvertent dural puncture was subsequently confirmed, had fluid samples testing positive for glucose. Median [range] laboratory glucose readings were 2.9 [1.3–5.1] mmol/L for cerebrospinal fluid and <0.3 mmol/L in fluid that leaked from a Tuohy needle (P = 0.0001).ConclusionWhen using a loss of resistance to saline technique for epidural catheter placement, bedside glucometer testing of fluid leaking from the epidural needle may be of value in the early detection of inadvertent dural puncture.     

A prospective controlled study of continuous spinal analgesia versus repeat epidural analgesia after accidental dural puncture in labour

BackgroundAfter accidental dural puncture in labour it is suggested that inserting an intrathecal catheter and converting to spinal analgesia reduces postdural puncture headache and epidural blood patch rates. This treatment has never been tested in a controlled manner.MethodsThirty-four hospitals were randomised to one of two protocols for managing accidental dural puncture during attempted labour epidural analgesia: repeating the epidural procedure or converting to spinal analgesia by inserting the epidural catheter intrathecally. Hospitals changed protocols at six-month intervals for two years.ResultsOne hundred and fifteen women were recruited but 18 were excluded from initial analysis because of practical complications which had the potential to affect the incidence of headache and blood patch rates. Of the remaining 97 women, 47 were assigned to the repeat epidural group and 50 to the spinal analgesia group. Conversion to spinal analgesia did not reduce the incidence of postdural puncture headache (spinal 72% vs. epidural 62%, P = 0.2) or blood patch (spinal 50% vs. epidural 55%, P = 0.6). Binary logistic analysis revealed the relative risk of headache increased with 16-gauge vs. 18-gauge epidural needles (RR = 2.21, 95% CI 1.4–2.6, P = 0.005); anaesthetist inexperience (RR = 1.02 per year difference in experience, 95% CI 1.001–1.05, P = 0.043), and spontaneous vaginal compared to caesarean delivery (RR = 1.58, 95% CI 1.14–1.79, P = 0.02). These same factors also increased the risk of a blood patch: 16-gauge vs. 18-gauge needles (RR = 2.92, 95% CI 1.37–3.87, P = 0.01), anaesthetist inexperience (RR = 1.06 per year difference in experience, 95% CI 1.02–1.09, P = 0.006), spontaneous vaginal versus caesarean delivery (RR = 2.22, 95% CI 1.47–2.63, P = 0.002). When all patients were included for analysis of complications, there was a significantly greater requirement for two or more additional attempts to establish neuraxial analgesia associated with repeating the epidural (41% vs. 12%, P = 0.0004) and a 9% risk of second dural puncture.ConclusionsConverting to spinal analgesia after accidental dural puncture did not reduce the incidence of headache or blood patch, but was associated with easier establishment of neuraxial analgesia for labour. The most significant factor increasing headache and blood patch rates was the use of a 16-gauge compared to an 18-gauge epidural needle.     

A retrospective review of an epidural blood patch database: the incidence of epidural blood patch associated with obstetric neuraxial anesthetic techniques and the effect of blood volume on efficacy

BackgroundThe optimal volume of blood required to treat post-dural puncture headache remains in question. In our institution a target volume of 30 mL is used for an epidural blood patch unless the patient experiences pain during injection.MethodsThe institutional database was retrospectively reviewed for epidural blood patch and delivery statistics over a 15-year period to determine if the volume of blood administered during the procedure directly correlated with the number of epidural blood patches administered. The primary endpoint was defined as the need for a repeat epidural blood patch.ResultsThere were 466 epidural blood patches performed on 394 patients, associated with 84 804 obstetric neuraxial procedures. Thirty-two percent (95% CI 28.3 to 34.9%) of patients who had an inadvertent dural puncture with an epidural needle received an epidural blood patch versus 0.19% (0.16% to 0.22%) of patients who received neuraxial anesthesia with no documented dural puncture with an epidural needle. All patients experienced relief of post-dural puncture headache, although 17% required two and 1.5% required three epidural blood patches. The mean ± SD volume of blood administered was 20.5 ± 5.4 mL and only 35 patients (8.9%) received 30 mL.ConclusionIncreasing blood volumes up to 30 mL did not reduce the need for repeat epidural blood patch. Although the optimal volume of blood to administer during epidural blood patch placement remains unknown, our institution will continue to administer up to 30 mL or until the patient experiences pain during epidural injection.     

Sequential higher epidural catheter re-insertion after accidental dural puncture ameliorates the frequency and severity of post-dural puncture headache

ObjectivesThis cohort study aimed to evaluate the outcome of a hypothesis to use higher level for epidural catheter insertion and activation when an epidural tap was encountered at a lower level during epidural analgesia for labor pain.MethodsEpidural analgesia for labor pain was conducted using a mixture of 0.125% bupivacaine and fentanyl 5 μg/ml (10–15 ml) in 5-ml increments and maintained using continuous epidural infusion of 0.125% bupivacaine and fentanyl 2 μg/ml at rate of (5–15 ml/h), subsequently adjusted according to the patients needs. All cases had accidental dural puncture (ADP) were managed immediately with re-insertion of the needle at a higher level and completion of the procedure and maintained using continuous epidural infusion of 0.0625% bupivacaine and fentanyl 2 μg/ml at rate of (6–12 ml/h) for 24 h after delivery. Postpartum follow-up was conducted for 30 days to comment on the occurrence and severity of post-dural puncture headache (PDPH). All patients developed PDPH were followed daily until resolution of their headache.ResultsAbout 4800 parturient were enrolled in the study, ADP occurred in 24 patients with a frequency of 0.5%. All cases were immediately managed by re-insertion of the needle at a higher level and the procedure was successfully completed without new dural puncture, with 100% re-insertion success rate, and patients were maintained on continuous epidural infusion for 24 h. Throughout 30-day follow-up; only six of 24 patients developed PDPH with a success rate of re-insertion procedure as a prophylactic modality for PDPH after ADP of 75%. PDPH was relieved with bed rest, liberal fluids and paracetamol for 4 days in four patients, while the 5th patient continued to complain but the patient refused to undergo epidural blood patch (EBP) and headache started to subside and patient stopped to complain by the 10th day, and the last patient agreed to undergo EBP; and headache was relived immediately after 2 h.ConclusionIt could be concluded that re-insertion of epidural catheter at higher level of accidental dural puncture with epidural continuous infusion for 24 h could be considered as an efficient prophylactic modality to safe guard against PDPH with success rate of 75% and minimizes its severity if occurred.     

Estudio comparativo de diferentes sets de infusión epidural a velocidades máximas para analgesia del parto

IntroductionThe higher injection pressure obtained with epidural boluses give greater anaesthetic spread, and therefore better sensory block.Therefore, it stands to reason that anaesthetic administered at greater injection pressure and a higher flow rate would spread to a higher sensory level.ObjectiveOur aim was to compare the sensory level reached with the high flow. and standard flow set at maximum rates.Material and methodsWe included 73 primiparous women who requested epidural analgesia for labour using programmed intermittent epidural boluses of 0.1% ropivacaine at a flow rate of 10 ml/h and 2 ug/ml fentanyl plus patient-controlled epidural analgesia. The boluses were administered with a standard (250 ml/h) or high-flow (500 ml/h) infusion set, according to the usual clinical practice of each anaesthesiologist. The primary objective was to evaluate the sensory level reached. Secondary objectives were pain on a visual analogue scale, motor block measured on the modified Bromage scale, and anaesthesia consumption in terms of rescue analgesia (patient-controlled epidural analgesia) and anaesthesiologist-administered boluses.ResultsThe median maximum sensory level reached was T9 in the high flow group and T7 in the standard flow group; this difference was statistically significant (p = .0002). There were no significant differences in visual analogue scale, Bromage or rescue analgesia between groups.ConclusionOur results show that the high flow set does not offer benefits. The use of such sets need to be evaluated due to their higher cost.     

Ultrasound decreases the failed labor epidural rate in resident trainees

BackgroundEpidural analgesia is widely used for pain relief during labor. The purpose of this study was to determine if ultrasound measurement of the depth from skin to epidural space before the epidural technique decreases the failure rate of labor analgesia. A secondary objective was to correlate ultrasound depth to the epidural space with actual depth of the needle at placement.MethodsIn this prospective, randomized, non-blinded study, 370 parturients requesting labor epidural analgesia were randomized to receive their epidural technique by first year anesthesia residents with or without prior ultrasound determination of epidural space depth. Outcome variables included the incidence of epidural catheter replacement for failed analgesia and the number of epidural attempts and accidental dural punctures.ResultsThe ultrasound group had fewer epidural catheter replacements (P < 0.02), and epidural placement attempts (P < 0.01) compared to the control group. Pearson’s correlation coefficients comparing the actual versus ultrasound estimated depth to the epidural space in the longitudinal median and transverse planes were 0.914 and 0.909, respectively. Pearson’s correlation coefficient comparing the ultrasound estimated depths to the epidural space in the transverse and longitudinal median planes was 0.940. No significant differences were noted with respect to staff interventions, top-ups, accidental dural punctures, and delivery outcome.ConclusionsUltrasound measurement of the epidural space depth before epidural technique placement decreases the rate of epidural catheter replacements for failed labor analgesia, and reduces the number of epidural attempts when performed by first year residents and compared to attempts without ultrasound guidance.     

Single-shot spinal anaesthesia, combined spinal-epidural and epidural volume extension for elective caesarean section: a randomized comparison

BackgroundSingle-shot spinal and combined spinal-epidural block, with or without epidural volume extension, can be used for caesarean section. There is no trial comparing their block characteristics and adverse effects under identical conditions.Methods60 ASA I or II parturients with gestational age 37 weeks or more, scheduled for elective caesarean section under regional anaesthesia, were included in the trial. Women were randomized to three groups: group SSS: single-shot spinal; group CSE: combined spinal-epidural; group EVE: epidural volume extension of a combined spinal-epidural. Intrathecal injection was identical in the three groups (0.5% hyperbaric bupivacaine 9 mg with fentanyl 10 μg) and was injected via a 25-gauge pencil-point spinal needle, either as a single-shot spinal or through the spinal needle of the needle-through-needle CSE set. In group EVE, 5 mL of normal saline was injected through the epidural catheter. All blocks were performed with the women sitting. Haemodynamic parameters and block characteristics were assessed.ResultsThe onset of maximum sensory and motor block was significantly faster in the SSS group than in the other two. Extent and duration of sensory and motor block and the incidence of adverse effects were similar in the three groups (P > 0.05).ConclusionsIntrathecal block is similar in extent and duration whether given as a single-shot spinal or a combined spinal-epidural with or without epidural volume extension when performed for elective caesarean section using hyperbaric bupivacaine in the sitting position.     

Programmed intermittent epidural boluses for maintenance of labor analgesia: an impact study

IntroductionThe aim of this impact study was to compare the analgesic efficacy and side effect profile of programmed intermittent epidural boluses (PIEB) + patient-controlled epidural analgesia (PCEA) to continuous epidural infusion (CEI) + PCEA for maintenance labor analgesia after the introduction of PIEB at our institution.MethodsWe conducted a retrospective analysis after replacing the background CEI with PIEB for our labor PCEA. Pre-change pump settings were CEI 12 mL/h with PCEA (12 mL bolus, lockout 15 min); PIEB settings were a 9 mL bolus every 45 min with PCEA (10 mL bolus, lockout 10 min). We compared medical records of all women receiving epidural or combined spinal-epidural labor analgesia for vaginal delivery for two months before PIEB implementation to a two-month period of PIEB utilization following a five-month introductory familiarization period. The primary outcome was the proportion of women requiring rescue clinician boluses.ResultsFewer patients in the PIEB group required rescue clinician boluses compared to the CEI group (12% vs. 19%, P=0.012). Time to first rescue bolus request and total bolus dose were not different. Peak (median [IQR]) pain scores were 2[0–5] with CEI and 0[0–4] with PIEB. There was no difference in instrumental delivery rates.ConclusionsUsing PIEB compared to CEI as the background maintenance epidural analgesia method in conjunction with PCEA reduced the number of women requiring clinician rescue boluses while providing comparable labor analgesia. The findings of this clinical care impact study confirm the results of randomized controlled studies and suggest PIEB may be a preferable technique to CEI for the maintenance of labor analgesia.     

Risk factors for failed conversion of labor epidural analgesia to cesarean delivery anesthesia: a systematic review and meta-analysis of observational trials

BackgroundThis systematic review and meta-analysis evaluates evidence for seven risk factors associated with failed conversion of labor epidural analgesia to cesarean delivery anesthesia.MethodsOnline scientific literature databases were searched using a strategy which identified observational trials, published between January 1979 and May 2011, which evaluated risk factors for failed conversion of epidural analgesia to anesthesia or documented a failure rate resulting in general anesthesia.Results1450 trials were screened, and 13 trials were included for review (n = 8628). Three factors increase the risk for failed conversion: an increasing number of clinician-administered boluses during labor (OR = 3.2, 95% CI 1.8–5.5), greater urgency for cesarean delivery (OR = 40.4, 95% CI 8.8–186), and a non-obstetric anesthesiologist providing care (OR = 4.6, 95% CI 1.8–11.5). Insufficient evidence is available to support combined spinal–epidural versus standard epidural techniques, duration of epidural analgesia, cervical dilation at the time of epidural placement, and body mass index or weight as risk factors for failed epidural conversion.ConclusionThe risk of failed conversion of labor epidural analgesia to anesthesia is increased with an increasing number of boluses administered during labor, an enhanced urgency for cesarean delivery, and care being provided by a non-obstetric anesthesiologist. Further high-quality studies are needed to evaluate the many potential risk factors associated with failed conversion of labor epidural analgesia to anesthesia for cesarean delivery.     

The influence of timing on the effectiveness of epidural blood patches in parturients

BackgroundPostdural puncture headache is common in parturients following lumbar puncture. If headache is severe and persistent, an epidural blood patch is recommended. In this paper we reviewed the efficacy of epidural blood patches over a 13-year period at two hospitals in Finland with a particular emphasis on its timing.MethodsThe hospitals’ databases were searched to identify parturients who underwent an epidural blood patch from March 1998 to June 2011. Parturients’ records were reviewed to establish the characteristics and associated symptoms of headache and the effectiveness of the epidural blood patch.ResultsA total of 129 parturients received 151 epidural blood patches. These followed spinal (n = 49), epidural (n = 47) or combined spinal–epidural blocks (n = 33). The success rate of the first procedure was 89%, with permanent relief in 76%. The first procedure provided permanent relief of postdural puncture headache for 86% of 78 patients having the procedure after 48 h, compared to 65% of 37 patients when it was performed between 24 and 48 h, and 50% of 14 patients with the procedure within the first 24 h after dural puncture (P = 0.003). A second procedure was performed for 22 parturients due to incomplete relief (n = 5) or recurrent symptoms (n = 17); all had complete resolution of symptoms.ConclusionsEpidural blood patch performed later than 48 h following lumbar puncture or accidental dural puncture is effective in parturients with postdural puncture symptoms. The recurrence rate of symptoms after an initially successful epidural blood patch is high, and therefore patients should be provided with counselling and contact information.     

Impact of obesity on post-dural puncture headache

IntroductionPrevious studies have suggested an inverse relationship between obesity and development of post-dural puncture headache following spinal anesthesia. However, few have investigated the relationship between obesity and headaches after accidental dural puncture with an epidural needle. This study explored whether obesity has any association with headaches following an accidental dural puncture.MethodsRecords of patients who received epidural analgesia for labor and vaginal delivery between January 2011 and June 2015 were reviewed. Body mass index, American Society of Anesthesiologists Physical Status and age were analyzed. Chi-squared analysis was performed to determine the relationship between the incidence and severity of post-dural puncture headaches and body mass index.ResultsA total of 17 497 epidurals were placed for vaginal deliveries. Of these, 164 patients met our criteria for accidental dural puncture, of whom 51.2% developed post-dural puncture headaches. Of patients who developed a post-dural puncture headache 35.7% required an epidural blood patch. Data analysis showed no significant relationship between body mass index and incidence of post-dural puncture headaches regardless of body mass index classification (P>0.05). There was no association between body mass index and the intensity of post-dural puncture headache (P=0.29).ConclusionPatients with a high body mass index do not appear to be protected from experiencing a post-dural puncture headache after an accidental dural puncture during placement of labor epidural analgesia. Additionally, the intensity of post-dural puncture headache does not vary with body mass index.     

The finding of glucose in the fluid obtained by epidural catheter after its insertion during combined intradural-epidural anaesthesia with hyperbaric bupivacaine is a usual occurrence

ObjectivesTo determine whether the appearance of glucose in the fluid spontaneously obtained by the epidural catheter after its insertion during combined intradural-epidural anaesthesia with hyperbaric bupivacaine is a usual occurrence.Patients and methodsA prospective, observational study was conducted on 34 patients with combined intradural-epidural anaesthesia in whom an epidural catheter was introduced, after locating the epidural space with a saline solution, inserting a spinal needle and injecting hyperbaric bupivacaine. After observing whether any fluid was spontaneously dripping from it, it was determined if this contained glucose. Withdrawal of the needle and washing its lumen with saline solution, it was checked whether there was glucose in washout. The samples were analysed using a glucose meter. When the motor block disappeared a dose of local anaesthetic was administered through the epidural catheter. The relationship of the demographic parameters with the spontaneous dripping of the epidural catheter was evaluated.ResultsSpontaneous dripping by the epidural catheter after its insertion was observed in 22 patients. All the samples obtained contained glucose. There was glucose in 9 out of 34 epidural needle wash samples. None of the patients suffered from excessive motor-sensory block. There was a statistically significant relationship between patient age (P < .05) and spontaneous dripping by the catheter (the higher the age, more dripping).ConclusionThe finding of glucose in the fluid obtained by the epidural catheter is a frequent occurrence and is of no clinical significance. We propose that it could be due to a leak of cerebrospinal fluid by the dural puncture needle during or after the administering of the hyperbaric bupivacaine and the spillage of this into the epidural space.     

Differences in maternal temperature during labour with remifentanil patient-controlled analgesia or epidural analgesia: a randomised controlled trial

BackgroundEpidural analgesia and remifentanil patient-controlled analgesia are two popular techniques for the treatment of labour pain, each with its own efficacy and toxicity.MethodsParturients requesting analgesia were randomly assigned to either patient-controlled intravenous remifentanil or epidural analgesia. Control patients consisted of parturients not requesting pain medication. The primary objective was to compare the incidence of maternal fever (temperature ⩾38°C); secondary outcomes included the incidence of low oxygen saturation, pain scores, nausea and vomiting, sedation scores, pruritus and neonatal outcome.ResultsData from 140 parturients were analysed: 49 received remifentanil analgesia, 49 epidural analgesia and 42 no analgesia (controls). Fever (temperature ⩾38°C) developed in 10% of remifentanil patients compared to 37% of epidural patients and 7% of control patients (P <0.001). One or more hypoxaemic events (oxygen saturation <90% for at least 1 min) occurred in 48% of patients on remifentanil versus 15% of patients on epidural analgesia and 20% of control patients (P=0.003). Although pain intensity scores differed significantly between the two groups in favour of the epidural, mean satisfaction scores were similar in both analgesia groups (remifentanil 8.1 ± 1.2 vs. epidural 8.4 ± 1.2). Remifentanil analgesia was associated with a higher incidence of nausea and deeper levels of sedation. The differences in haemodynamic parameters between groups were small and clinically insignificant.ConclusionsDuring treatment of labour pain, epidural analgesia is associated with a higher incidence of maternal fever, while remifentanil analgesia results in more frequent and deeper hypoxaemic events.     

Awareness and desirability of labor epidural analgesia: a survey of Nigerian women

BackgroundPain relief is an integral part of labor management. Epidural analgesia is the most effective form of pain relief, but in most Nigerian obstetric units it is not available. There is little information on the views of pregnant women about epidural analgesia during labor.MethodsA cross-sectional survey using a structured questionnaire was conducted in the antenatal clinic of University College Hospital, Ibadan, Nigeria to assess women’s views about epidural analgesia.ResultsOf the 650 women surveyed, 523 (80.5%) had knowledge of labour pain while only 127 women (19.5%) were aware of epidural analgesia. Knowledge was affected by parity. Awareness of epidural analgesia was related to occupational status (OR 11.00, 95% CI 5.31-22.83) and having previously experienced childbirth on one previous occasion (OR 1.75, 1.05-2.92). A total of 103 (15.8%) respondents wanted to receive epidural analgesia in their next labor. Occupation (P = 0.006), knowledge of epidural analgesia (P = 0.017) and previous use (P < 0.001) significantly influenced desire for epidural analgesia but only knowledge (OR 2.4 95% CI 1.4-4.3) and previous use (OR 5.3 95% CI 2.1-13.5) were of statistical significance on multivariate analysis.ConclusionThis study shows that the knowledge of labor epidural analgesia amongst Nigerian women is low. Despite limited availability, women who are aware of epidural analgesia and those who have received it in a previous labor were more likely to want it in their forthcoming labor. Some women may refuse its use despite their knowledge.     

Survey of nulliparous parturients' attitudes regarding timing of epidural analgesia initiation

Study objectiveAt our hospital, although > 90% of nulliparous parturients eventually choose epidural analgesia for labor, many delay its initiation, experiencing considerable pain in the interim. This survey probed parturients' views about the timing of initiation of epidural labor analgesia.DesignSingle-center, nonrandomized quantitative survey.SettingLabor and delivery suite in a large tertiary academic medical center.PatientsTwo hundred laboring nulliparous women admitted to the labor and delivery suite.Interventions: After their pain was relieved, parturients completed a questionnaire regarding their decision to request labor epidural analgesia.MeasurementsA variety of factors regarding epidural use were assessed including the influence of painful contractions and of childbirth education class attendance on the decision to request epidural analgesia, and parturients' perception of the timing of epidural initiation on the progress and outcome of labor.Main resultsAnalysis revealed that the desire of parturients to use epidural analgesia was increased from 27.9% before the onset of painful contractions to 48.2% after (p < 0.01). Two-thirds of participants attended a non-physician taught childbirth education class. An antepartum plan to definitely forgo an epidural was 1.8 times more likely among women who attended a childbirth class when compared to those who did not attend. (OR = 1.8; 95%CI:1.1–3.1; p = 0.04). The most common views affecting decision-making were that epidural analgesia should not be administered “too early” (67.5%), and that it would slow labor (68.5%). Both of these views were more likely to be held if the parturient had attended a childbirth class, OR = 2.0 (95%CI:1.1–3.8; p = 0.03) and OR = 2.0 (95% CI: 1.1 to 3.7; p = 0.03), respectively.ConclusionsWe found that nulliparous parturients have misconceptions about epidurals, which are not supported by evidence-based medicine. Moreover, we found that attendance at childbirth education classes was associated with believing these misconceptions.     

Catheter failure rates and time course with epidural versus combined spinal-epidural analgesia in labor

BackgroundThe combined spinal-epidural technique for labor analgesia has several advantages over the traditional epidural technique, including faster onset, greater maternal satisfaction, and decreased need for physician boluses. Proponents of the epidural technique criticize the combined spinal-epidural technique, arguing that the epidural catheter remains untested and thus may not be reliable if needed for surgical intervention. We compared failure rates and time of failure between techniques in our tertiary-care academic practice.MethodsData regarding failed catheters were collected from October 2012 to September 2014 as part of our Quality Assurance program. Failed catheters were defined as any catheter replaced after it was considered to be properly placed and then determined to be intravascular, one sided or resulting in poor maternal analgesia or anesthesia.ResultsA total of 5487 analgesics were performed (3980 combined spinal-epidural; 1507 epidural). Eighty-five combined spinal-epidural catheters (2.1%) and 59 epidural catheters (3.9%) were replaced during labor (P<0.001). Mean time to replacement was 512 ± 422 min and 354 ± 300 min for the combined spinal-epidural (n=80) and epidural (n=57) groups, respectively (P=0.02). Median time to replacement was 398 [IQR 131–578] min and 281 [IQR 186–767] min for combined spinal-epidural and epidural groups, respectively (P<0.0001).ConclusionWe were able to demonstrate that catheters placed using a combined spinal-epidural technique were less likely to fail during labor and that the time to detection of a failed catheter was significantly longer in the combined spinal-epidural group. Our findings validate the combined spinal-epidural technique as reliable for labor analgesia and tend to refute the theory of the untested catheter.     

Preemptive use of epidural magnesium sulphate to reduce narcotic requirements in orthopedic surgery

Background and objectivesAs pain is one of the most common problems challenging the anesthetist, and as regional anesthesia is a safe, inexpensive technique with the advantage of prolonged postoperative analgesia. Also, we all know that Magnesium is the fourth most plentiful cation in the body with antinociceptive properties arising from being the natural physiological calcium antagonist and the antagonism to N-methyl-d-aspartate (NMDA) receptor. Thus, the study is a prospective, randomized, double-blind study designed to evaluate analgesic efficacy of magnesium sulphate when added to epidural bupivacaine in patients undergoing orthopedic surgery in the lower limb.MethodsAfter approval of the ethical committee and informed written consent 60 patients ASA I and II, undergoing orthopedic surgery in the lower limb were enrolled to receive either bupivacaine 0.5% or bupivacaine 0.5% plus magnesium sulphate 50 mg as an initial bolus dose followed by a continuous infusion of 10 mg/h as intraoperative epidural analgesia. Postoperatively, all patients were equipped with a patient-controlled epidural analgesia device. Heart rate, mean arterial pressure, oxygen saturation, respiratory rate, pain assessment using a visual analogue scale (VAS), sedation score, the first time patient ask for analgesics and postoperative fentanyl consumption were recorded.ResultsVAS was significantly less in the magnesium group during 15 and 30 min intra-operatively and in the first and third hour post-operatively. The postoperative rescue analgesia, as well as the PCEA fentanyl consumption, was significantly reduced in the magnesium group.ConclusionCo-administration of epidural magnesium provides better intraoperative analgesia as well as the analgesic-sparing effect on PCEA consumption without increasing the incidence of side-effects.     

The effects of meperidine and epidural analgesia in labor on maternal heart rate variability

BackgroundEpidural and parenteral opioid analgesia are two common methods of pain relief in labor that may influence the autonomic nervous system. However, these effects on laboring women have not yet been adequately studied. The aim of our study was to assess the effects of these two methods of analgesia on autonomic nervous system modulation of maternal heart rate variability in laboring women.MethodsA prospective observational study was conducted on 64 laboring women; 33 received epidural analgesia with bupivacaine and fentanyl and 31 intravenous meperidine and promethazine. Power spectral analysis and nonlinear methods were applied to digitized electrocardiograms performed before and after administration of analgesia, to assess maternal heart rate variability and autonomic equilibrium.ResultsMaternal heart rate significantly increased in women who received meperidine compared to those who had epidural analgesia. There was a significant increase in the low-frequency to high-frequency ratio (3.7 ± 3.9 vs. 1.8 ± 1.6, P < 0.05), and a significant decrease of high-frequency spectral power in women who had meperidine compared to those who received epidural analgesia (163 ± 91 vs. 98 ± 100 ms²/Hz, P < 0.05).ConclusionsMeperidine caused an autonomic nervous system shift towards sympathetic activation with abolition of respiratory sinus arrhythmia high-frequency spectral band. Conversely epidural analgesia had no significant effect on autonomic nervous system control of heart rate.     

Optimal epidural analgesia for patients diagnosed as having gynecologic cancer undergoing interstitial brachytherapy

Study objectiveTo determine the optimal epidural analgesia for patients receiving interstitial brachytherapy (ISBT) for gynecologic cancers.DesignRetrospective analysis.SettingOperating room and hospital ward.PatientsSeventy-three patients diagnosed as having gynecologic cancer and undergoing ISBT.InterventionsTwelve patients received ropivacaine alone, 14 patients received ropivacaine with fentanyl, and 45 patients received ropivacaine with hydromorphone by epidural infusion.MeasurementsNumeric Rating Scale pain scores, amounts of nonnarcotic and narcotic pain medications used in intravenous morphine equivalents (IVMEs), and amount of antiemetic or antipruritic medications used.Main resultsPatients receiving ropivacaine alone had higher pain scores the morning of day 2 (4.2 vs 1.71 vs 0.6, P = .001), the afternoon of day 2 (4.9 vs 2.5 vs 1.7, P = .005), and the night of day 2 (2.4 vs 2.0 vs 0.6, P < .001). Patients receiving opioids in their epidural had lower pain scores on the night of placement (P = .050), the morning of day 2 (P < .001), the afternoon of day 2 (P = .002), and the night of day 2 (P < .001). Patients receiving ropivacaine alone used more oral narcotics than did those receiving ropivacaine with fentanyl or ropivacaine with hydromorphone on day 3 (5.9 vs 3.8 vs 2.8 mg IVME) and received more intravenous opioids day 1 (5.8 vs 0.0 vs 0.7 mg IVME, P = .004) and day 2 (20.6 vs 4.8 vs 1.0 mg IVME, P = .042). There were no differences in antiemetic or diphenhydramine usage at any time point. No epidural complications occurred.ConclusionsFor patients receiving ISBT for gynecologic cancer, epidural analgesia provides safe and effective pain control. Combined modality epidural analgesia improves pain control and lessens oral and intravenous opioid requirements without increased risk of adverse effects compared with epidural analgesia with local anesthetic alone.     

An observational study of agreement between percentage pain reduction calculated from visual analog or numerical rating scales versus that reported by parturients during labor epidural analgesia

BackgroundThis study aimed to determine the level of agreement between calculated percentage pain reduction, derived from visual analog or numerical rating scales, and patient-reported percentage pain reduction in patients having labor epidural analgesia.MethodsIn a prospective observational study, parturients were asked to rate their pain intensity on a visual analog scale and numerical rating scale, before and 30 min after initiation of epidural analgesia. The percentage pain reduction 30 min after epidural analgesia was calculated by the formula: 100 × (score before epidural analgesia − score 30 min after epidural analgesia)/score before epidural analgesia. To evaluate agreement between calculated percentage pain reduction and patient-reported percentage pain reduction, we computed the concordance correlation coefficient and performed Bland-Altman analysis.ResultsNinety-seven women in labor were enrolled in the study, most of whom were nulliparous, with a singleton fetus and in spontaneous labor. The concordance correlation coefficient with patient-reported percentage pain reduction was 0.76 (95% CI 0.6 to 0.8) and 0.77 (95% CI 0.6 to 0.8) for the visual analog and numerical rating scale, respectively. The Bland-Altman mean difference between calculated percentage pain reduction and patient-reported percentage pain reduction for the visual analog and numerical rating scales was −2.0% (limits of agreement at 29.8%) and 0 (limits of agreement at 28.2%), respectively.ConclusionThe agreement between calculated percentage pain reduction from a visual analog or numerical rating scale and patient-reported percentage pain reduction in the context of labor epidural analgesia was moderate. The difference could range up to 30%. Patient-reported percentage pain reduction has advantages as a measurement tool for assessing pain management for childbirth but differences compared with other assessment methods should be taken into account.