1
|
Frassanito L, Filetici N, Piersanti A, Vassalli F, Van De Velde M, Tsen LC, Zanfini BA, Catarci S, Ciancia M, Scorzoni M, Olivieri C, Draisci G. Sacral sensory blockade from 27-gauge pencil-point dural puncture epidural analgesia or epidural analgesia in laboring nulliparous parturients: a randomized controlled trial. Int J Obstet Anesth 2024; 60:104217. [PMID: 39024984 DOI: 10.1016/j.ijoa.2024.104217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 05/14/2024] [Accepted: 06/06/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND The dural puncture epidural (DPE) technique has been associated with better sacral analgesia compared with a traditional epidural (EPL) technique in laboring parturients. The aim of this study was to investigate whether DPE with a 27-gauge pencil-point needle compared with a traditional EPL technique produces more rapid bilateral sacral blockade in nulliparous parturients. METHODS Patients were randomized to a DPE or EPL technique. Epidural analgesia in both groups was initiated with ropivacaine 0.1% and sufentanil 0.5 μg/mL (15 mL) and maintained via programmed intermittent epidural boluses. Analgesic blockade was tested bilaterally beginning 10 min after initiation, and then at predefined intervals until delivery. The presence of an S2 blockade at 20 min was the primary outcome. RESULTS Among 108 (54 per group) patients enrolled, bilateral sacral (S2) blockade at 20 min was significantly more common in the DPE than in the EPL group [47 (87%) vs. 23 (43%), absolute risk reduction (ARR) 44%, 95% CI 28 to 60; P < 0.001]. Time to a numeric pain rating scale score (0-10 scale) ≤ 3 (20 [20,30] min in both groups, HR 1.15, 95% CI 0.77 to 1.15; P = 0.50), number of rescue doses [0 (0, 1) vs 0 (0, 1); P 0.08], and presence of bilateral S2 blockade at delivery were not significantly different between groups. CONCLUSIONS The DPE technique with a 27-gauge pencil-point spinal needle more often provides bilateral sacral blockade at 20 min following block initiation compared with the EPL technique. The time to adequate analgesia and need for supplemental analgesia did not appear to differ between techniques.
Collapse
Affiliation(s)
- L Frassanito
- Department of Emergency, Anesthesiologic and Intensive Care Sciences, IRCCS Fondazione Policlinico A. Gemelli - Largo A, Roma, Italy.
| | - N Filetici
- Department of Emergency, Anesthesiologic and Intensive Care Sciences, IRCCS Fondazione Policlinico A. Gemelli - Largo A, Roma, Italy
| | - A Piersanti
- Department of Emergency, Anesthesiologic and Intensive Care Sciences, IRCCS Fondazione Policlinico A. Gemelli - Largo A, Roma, Italy
| | - F Vassalli
- Department of Critical Care and Perinatal Medicine, IRCCS Istituto G. Gaslini, Genova, Italy
| | - M Van De Velde
- Department of Anaesthesiology and Pain Medicine, University Hospital, Leuven, Belgium
| | - L C Tsen
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital - Harvard Medical School, Boston, MA, USA
| | - B A Zanfini
- Department of Emergency, Anesthesiologic and Intensive Care Sciences, IRCCS Fondazione Policlinico A. Gemelli - Largo A, Roma, Italy
| | - S Catarci
- Department of Emergency, Anesthesiologic and Intensive Care Sciences, IRCCS Fondazione Policlinico A. Gemelli - Largo A, Roma, Italy
| | - M Ciancia
- Department of Emergency, Anesthesiologic and Intensive Care Sciences, IRCCS Fondazione Policlinico A. Gemelli - Largo A, Roma, Italy
| | - M Scorzoni
- Department of Emergency, Anesthesiologic and Intensive Care Sciences, IRCCS Fondazione Policlinico A. Gemelli - Largo A, Roma, Italy
| | - C Olivieri
- Department of Emergency, Anesthesiologic and Intensive Care Sciences, IRCCS Fondazione Policlinico A. Gemelli - Largo A, Roma, Italy
| | - G Draisci
- Department of Emergency, Anesthesiologic and Intensive Care Sciences, IRCCS Fondazione Policlinico A. Gemelli - Largo A, Roma, Italy
| |
Collapse
|
2
|
Lin W, Lin J, Yang Y, Lin L, Lin Q. Dural puncture epidural with 25-G spinal needles versus conventional epidural technique for labor analgesia: A systematic review of randomized controlled trials. Technol Health Care 2024; 32:495-510. [PMID: 37545267 DOI: 10.3233/thc-230059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
BACKGROUND Dural mater is punctured by using a spinal needle without drugs administrated into intrathecal space directly in dural puncture epidural (DPE) analgesia. OBJECTIVE This study aimed to summarize the evidence of benefits and risks of DPE analgesia with 25-G spinal needles for labor pain relief. METHODS DPE analgesia with EP analgesia for labor pain relief were systematically searched. The Embase, MEDLINE, Cochrane Central Register of Controlled Trials, Scopus and Web of Science databases were systematically searched till 6th November 2022 to find out randomized controlled trials (RCTs) comparing DPE (using 25-G spinal needles) with conventional epidural (EP) analgesia. The risk of bias was assessed with the Cochrane tool. Risk ratio, mean difference, and 95% confidence intervals were calculated. RESULTS Seven RCTs with 761 parturients were identified. Pool data showed that DPE technique was associated with shorter time to pain score ⩽ 3/10, higher percentage with pain score ⩽ 3/10 at 10 min and 20 min, lower incidence of epidural top-up bolus and no S2 block, higher incidence of bilateral S2 blockade at 10 min and during labor, lower incidence of epidural top-up bolus and incidence of asymmetric block. No statistical difference in side effect and parturient satisfaction between DPE and EP technique. CONCLUSION DPE technique with 25-G spinal needles was associated with faster analgesia onset and sacral coverage, greater sacral spread, lesser requirement of epidural top-up and lower incidence of asymmetric block. DPE technique with 25-G spinal needles showed a greater benefit to parturients.
Collapse
Affiliation(s)
- Wenqian Lin
- Department of Anesthesiology, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
- Department of Anesthesiology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
- Anesthesiology Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Jun Lin
- Department of Anesthesiology, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
- Department of Anesthesiology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
- Anesthesiology Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Yongyong Yang
- Department of Anesthesiology, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
- Department of Anesthesiology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
- Anesthesiology Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Lianhe Lin
- Department of Ultrasound, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Qun Lin
- Department of Anesthesiology, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
- Department of Anesthesiology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
- Anesthesiology Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
| |
Collapse
|
3
|
Chau A, Tsen L. Neuraxial labor analgesia: Initiation techniques. Best Pract Res Clin Anaesthesiol 2022; 36:3-15. [PMID: 35659957 DOI: 10.1016/j.bpa.2022.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/06/2022] [Accepted: 04/12/2022] [Indexed: 11/16/2022]
Abstract
The ideal technique for labor analgesia would have a quick onset, predictable quality, and adjustable depth and duration. Moreover, it would be easy to perform and have minimal maternal and fetal side effects. A catheter-based neuraxial approach encompasses these desirable characteristics and includes the epidural, combined spinal epidural, dural puncture epidural, and intrathecal catheter techniques. In this review, we outline the unique technical considerations, analgesic characteristics, and side effect profiles for each technique that can ultimately impact the maternal-fetal dyad. The selection of neuraxial analgesia techniques should consider the patient and team's goals and expectations, the clinical context, and the institutional culture. Labor analgesic techniques that initiate with an intentional dural puncture component have a faster onset, greater bilateral and sacral spread, and lower rates of epidural catheter failure. Further elucidation of the mechanisms, benefits, and risks of each neuraxial initiation technique will continue to benefit patients and care providers.
Collapse
Affiliation(s)
- Anthony Chau
- BC Women's Hospital, Department of Anesthesia, Vancouver, BC, Canada; Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Lawrence Tsen
- Brigham and Women's Hospital, Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
4
|
Zhou Y, Chen W, Zhou S, Tao Y, Xu Z, Liu Z. Comparison of different approaches to combined spinal epidural anesthesia (CSEA) under the guidance of ultrasound in cesarean delivery of obese patients: a randomized controlled trial. Eur J Med Res 2021; 26:106. [PMID: 34526101 PMCID: PMC8444585 DOI: 10.1186/s40001-021-00577-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 09/03/2021] [Indexed: 01/17/2023] Open
Abstract
Background Combined spinal epidural anesthesia (CSEA) is commonly performed in cesarean deliveries. However, it is difficult to perform in obese parturients because of positioning challenges. The aim of this study was to compare the effect of different approaches to CSEA under the guidance of ultrasound. Methods One hundred obese patients (BMI ≥ 30 kg/m2) who underwent elective cesarean section were randomly enrolled. Patients were assigned to a median approach group and a paramedian approach group randomly. Clinical characteristics were compared between groups. First-attempt success rate, the median positioning time and total operation time, ultrasonic predicted anesthesia puncture depth, actual puncture depth, anesthesia adverse reactions, complications after anesthesia, and patients’ satisfaction with the epidural puncture were recorded. Results The first-attempt success rate was significantly different between the two groups [92% (46/50) vs. 76% (38/50), P = 0.029]. The median positioning time and total operation time in the paramedian approach group were higher than those in the median approach group (227.7 s vs. 201.6 s, P = 0.037; 251.3 s vs. 247.4 s, P = 0.145). The incidence of postanesthesia complications in the paramedian approach group was significantly lower than that in the median approach group (2% vs. 12%, P = 0.026), and patient satisfaction was higher in the paramedian approach group than in the median approach group (P = 0.032). Conclusion The ultrasound-guided paramedian approach for CSEA is time-consuming, but it can effectively improve the success rate of the first puncture, reduce the incidence of anesthesia-related adverse reactions, and improve patient satisfaction. Trial registration: This study was registered with the Chinese Clinical Trial Registry (ChiCTR1900024722) on July 24, 2019
Collapse
Affiliation(s)
- Yilu Zhou
- Department of Anesthesiology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, 200092, Shanghai, China
| | - Wei Chen
- Deparment of Operation Room, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, 200092, Shanghai, China
| | - Shuangqiong Zhou
- Department of Anesthesiology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, 200092, Shanghai, China
| | - Yiyi Tao
- Department of Anesthesiology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, 200092, Shanghai, China
| | - Zhendong Xu
- Department of Anesthesiology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, 200092, Shanghai, China
| | - Zhiqiang Liu
- Department of Anesthesiology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, 200092, Shanghai, China. .,Department of Anesthesiology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, 200092, Shanghai, China.
| |
Collapse
|
5
|
Pre-Procedural Lumbar Neuraxial Ultrasound-A Systematic Review of Randomized Controlled Trials and Meta-Analysis. Healthcare (Basel) 2021; 9:healthcare9040479. [PMID: 33920621 PMCID: PMC8072649 DOI: 10.3390/healthcare9040479] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/11/2021] [Accepted: 04/15/2021] [Indexed: 12/29/2022] Open
Abstract
A pre-procedural ultrasound of the lumbar spine is frequently used to facilitate neuraxial procedures. The aim of this review is to examine the evidence sustaining the utilization of pre-procedural neuraxial ultrasound compared to conventional methods. We perform a systematic review of randomized controlled trials with meta-analyses. We search the electronic databases Medline, Cochrane Central, Science Direct and Scopus up to 1 June 2019. We include trials comparing a pre-procedural lumbar spine ultrasound to a non-ultrasound-assisted method. The primary endpoints are technical failure rate, first-attempt success rate, number of needle redirections and procedure time. We retrieve 32 trials (3439 patients) comparing pre-procedural lumbar ultrasounds to palpations for neuraxial procedures in various clinical settings. Pre-procedural ultrasounds decrease the overall risk of technical failure (Risk Ratio (RR) 0.69 (99% CI, 0.43 to 1.10), p = 0.04) but not in obese and difficult spinal patients (RR 0.53, p = 0.06) and increase the first-attempt success rate (RR 1.5 (99% CI, 1.22 to 1.86), p < 0.0001, NNT = 5). In difficult spines and obese patients, the RR is 1.84 (99% CI, 1.44 to 2.3; p < 0.0001, NNT = 3). The number of needle redirections is lower with pre-procedural ultrasounds (SMD = −0.55 (99% CI, −0.81 to −0.29), p < 0.0001), as is the case in difficult spines and obese patients (SMD = −0.85 (99% CI, −1.08 to −0.61), p < 0.0001). No differences are observed in procedural times. Ιn conclusion, a pre-procedural ultrasound provides significant benefit in terms of technical failure, number of needle redirections and first attempt-success rate. Τhe effect of pre-procedural ultrasound scanning of the lumbar spine is more significant in a subgroup analysis of difficult spines and obese patients.
Collapse
|