A comparison of three doses of sufentanil in combination with bupivacaine-adrenaline in continuous epidural analgesia during labour

The Effect of Epidural Nalbuphine Combined With Ropivacaine on Epidural Analgesia During Labor: A Multicenter, Randomized, Double-blind, Controlled Study

OBJECTIVES

The addition of a small dose of opioids during epidural labor analgesia can enhance the local analgesic effect, reduce the dose of local anaesthetic required, and minimize motor blockade. For the treatment of visceral pain, studies have shown that κ-opioid receptor agonist are more effective than μ-receptor agonists. This study compared the effectiveness of epidural nalbuphine and sufentanil in combination with ropivacaine for labor analgesia, respectively.

MATERIALS AND METHODS

We conducted a prospective, randomized, double-blind, multicentre clinical trial. Parturients who requested labor pain relief were randomly assigned to either the nalbuphine group or sufentanil group. After 5 minutes of initial dose, parturients in nalbuphine group received 10 mL 0.1% ropivacaine plus 0.3 mg/mL nalbuphine solution. The sufentanil group received the same ropivacaine dose plus 0.3 μg/mL sufentanil. The primary outcome was the duration of analgesia (the time to the first requirement for additional medication). Secondary outcomes included the ropivacaine dose per hour, and adverse reactions.

RESULTS

Between November 2018 and February 2019, 180 parturients were recruited for the study. The study showed that the duration of analgesia was shorter in the nalbuphine group as compared with the sufentanil group (P=0.040). The ropivacaine dose per hour in nalbuphine group 9.3 (2.4) mg was significantly greater versus sufentanil group 8.4 (2.5) mg (P=0.024). No serious adverse events directly associated with the analgesics were observed.

DISCUSSION

The analgesia effects of 0.3 mg/mL nalbuphine with ropivacaine are inferior to 0.3 μg/mL sufentanil with ropivacaine in labor analgesia. No serious side effects, either in the mother or in the fetus, were observed.

Single-shot intrathecal sufentanil with bupivacaine in late labour--analgesic quality and obstetric outcome

OBJECTIVES

To investigate the analgesic effect and obstetric outcome after single-shot intrathecal sufentanil with bupivacaine in late labour.

STUDY DESIGN

Forty multiparous women in advanced labour were given a spinal injection of sufentanil 7.5 microg and bupivacaine 2 mg. Pain intensity was recorded by the parturient on a visual analogue scale. The quality of pain relief was also rated with a verbal score directly after delivery. Side effects, such as hypotension, pruritus, sedation, nausea and motor block were noted. Obstetric parameters were followed and recorded. Apgar score and umbilical artery pH were noted.

RESULTS

Median visual analogue scores after 5, 15, 30, 60, 90, 120 and 150 min were 1.5, 0.5, 0, 1, 1.5, 2 and 3, respectively. Seventy-seven percent of the parturients scored the analgesic quality as excellent. Six parturients had hypotension. Motor block, sedation and nausea were rare. Pruritus was seen in 85% of the cases. No ceasarean section was performed. Vacuum extraction was done in six (15%) cases. Oxytocin augmentation was needed in 26 (65%) of the parturients. Fetal heart rate disturbances following the spinal block were seen in four cases. Apgar scores were high. No neonate had Apgar < 7.

CONCLUSIONS

Intrathecal block with sufentanil 7.5 microg in combination with bupivacaine 2 mg is a very effective pain relief in late labour. Due to its limited duration it is important to select women in rapid progress of labour, and active obstetric management is necessary. It is also very important that the obstetrician is aware of the risk of non-reassuring fetal heart rate changes after intrathecal block.

PCEA compared to continuous epidural infusion in an ultra-low-dose regimen for labor pain relief: a randomized study

BACKGROUND

Patient-controlled epidural analgesia, PCEA, has been introduced in obstetric analgesia during the past decade. Many studies have shown that the consumption of analgesic is reduced when the parturient requests her own doses. This study investigates whether this is also true when using an ultra-low-dose regimen.

METHODS

Eighty parturients were prospectively randomized to have either continuous epidural infusion (CEI) with ropivacaine 1 mg ml-1 and sufentanil 0.5 micro g ml-1, 6 ml h-1, or patient-controlled epidural analgesia (PCEA) with 4 ml demand doses with 20 min' lockout. The epidural start dose was the same for the two groups, 8 ml of the study solution. Rescue bolus doses were given when needed and the continuous infusion could be increased, which gave the two groups the same maximum possible dose. The consumption of local ropivacaine in combination with sufentanil during labor was registered. Hourly assessments made throughout labor included pain intensity documented with visual analog score, VAS, the patient's opinion on epidural efficacy, motor block, pruritus and need for nitrous oxide.

RESULTS

The PCEA group consumed 33% less of the study solution than the CEI group. Mean total consumption was 35 ml (SD 18.0) and 52 ml (SD 19.6), respectively. Mean hourly consumption was 5.2 ml h-1 (SD 2.54) in the PCEA group and 6.9 ml h-1 (SD 1.31) in the CEI group. There were no significant differences between the two groups in pain relief, epidural efficacy, side-effects or obstetric outcome.

CONCLUSION

PCEA reduces doses compared to continuous infusion even when ultra-low-dose local anesthetic with opioid is used. The PCEA technique provides individual titration of doses to an acceptable degree of pain relief.

Ropivacaine 2 mg/mL vs. bupivacaine 1.25 mg/mL with sufentanil using patient-controlled epidural analgesia in labour

BACKGROUND

In recent studies, minimum local analgesic concentrations have been defined as 0.93 mg/mL for bupivacaine and 1.56 mg/mL for ropivacaine for epidural analgesia for the first stage of labour, resulting in an analgesic potency ratio of 1 : 0.6. In the current study we compared ropivacaine and bupivacaine in a PCEA system (combined with sufentanil) taking this potency ratio into account but administering drug doses providing sufficient analgesia for all stages of labour.

METHODS

In a prospective, double-blinded study 114 parturients were randomised to receive either ropivacaine 2 mg/mL with sufentanil 0.75 microg/mL or bupivacaine 1.25 mg/with sufentanil 0.75 microg/mL. After epidural catheter placement, PCEA was available with boluses of 4 mL, a lock-out time of 20 min and no basal infusion rate. We evaluated pain intensity during contractions, sensory and motor function, duration of labour, mode of delivery and neonatal outcome. Consumption of local anaesthetic and opioid drugs and PCEA system variables were recorded.

RESULTS

Mean total consumption as well as mean hourly drug consumption was significantly increased in the ropivacaine-sufentanil group. No differences in analgesic quality, sensory or motor blocking potencies or neonatal outcome variables between groups were detected. Frequency of instrumental deliveries was significantly increased in the ropivacaine-sufentanil group.

CONCLUSIONS

The results support the findings of previously published studies postulating ropivacaine to be 40-50% less potent for labour epidural analgesia compared to bupivacaine. However, we observed an increased frequency of instrumental deliveries with ropivacaine. To evaluate the clinical relevance of these findings, further investigations are warranted.