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Xu H, Li H, Zuo Y, Yang B, Tian Y, Guo Q, Xu J, Wu C. A multicenter study of the analgesic effects of epidural chloroprocaine after lower limb orthopedic surgery. J Clin Anesth 2016; 35:313-320. [PMID: 27871549 DOI: 10.1016/j.jclinane.2016.08.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 07/20/2016] [Accepted: 08/09/2016] [Indexed: 02/05/2023]
Abstract
STUDY OBJECTIVE To investigate the effects and optimal concentration of chloroprocaine for epidural analgesia after lower limb orthopedic surgery. DESIGN Prospective, randomized, observational, multicenter clinical study. SETTING Operating room, postoperative recovery area, university hospital. PATIENTS One hundred and twenty patients from 4 hospitals were enrolled and randomized into 5 groups after lower limb orthopedic surgery under epidural anesthesia with lidocaine. INTERVENTIONS Epidural chloroprocaine mixed with 0.4μg/mL fentanyl was administered via a patient-controlled analgesia pump at the concentration of 0.6%, 0.8%, 1.0%, 1.2%, or 1.4% after the surgery. MEASUREMENTS Systolic blood pressure, heart rate, visual analog score at rest and during activity, as well as the Bromage score at 0 minute, 30 minutes, 1 hour, 2 hours, 4 hours, 8 hours, 24 hours, and 48 hours after the surgery were recorded and compared. Use of morphine and incidence of adverse effects were also recorded. MAIN RESULTS Patients given 1.2% chloroprocaine showed the lowest visual analog score compared with other groups. There was no significant difference in the Bromage score among 5 groups. The Bromage score returned to 0 in 89.7% of the patients 48 hours after surgery. No difference in postoperative morphine usage, blood pressure, or heart rate was found among 5 groups. CONCLUSIONS Epidural 1.2% chloroprocaine with 0.4μg/mL fentanyl could generate proper analgesic effects with little influence on mobility in patients undergoing lower limb orthopedic surgery. In addition, it could generate a good sense and movement separation, facilitating the early functional training.
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Affiliation(s)
- Hongwei Xu
- Department of Anesthesiology, Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Center, West-China Hospital of Sichuan University, Guoxuexiang 37, Chengdu, Sichuan, 610041, China
| | - Huiping Li
- Department of Anesthesiology, Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Center, West-China Hospital of Sichuan University, Guoxuexiang 37, Chengdu, Sichuan, 610041, China
| | - Yunxia Zuo
- Department of Anesthesiology, Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Center, West-China Hospital of Sichuan University, Guoxuexiang 37, Chengdu, Sichuan, 610041, China
| | - Baxian Yang
- Department of Anesthesiology, Peking University People's Hospital, No. 11 Xizhimen South St, Xicheng District, Beijing, 100044, China
| | - Yuke Tian
- Department of Anesthesiology, Huazhong University of Science and Technology Affiliated Tongji Hospital, 1095 Jie Fang Ave, Wuhan 430030, China
| | - Qulian Guo
- Department of Anesthesiology, Xiangya Hospital of Central-South University, 87 Xiangya Rd, Changsha, Hunan, 410008, China
| | - Jianguo Xu
- Department of Anesthesiology, Nanjing General Hospital of Nanjing Military Command, 305 East Zhongshan Rd, Xuanwu District, Nanjing, Jiangsu, 210002, China
| | - Chaoran Wu
- Department of Anesthesiology, Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Center, West-China Hospital of Sichuan University, Guoxuexiang 37, Chengdu, Sichuan, 610041, China.
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Li H, Li Y, He R. Sparing effects of sufentanil on epidural ropivacaine in elderly patients undergoing transurethral resection of prostate surgery. Yonsei Med J 2015; 56:832-7. [PMID: 25837193 PMCID: PMC4397457 DOI: 10.3349/ymj.2015.56.3.832] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE This study examined the sparing effect of sufentanil on the median effective concentration (EC₅₀) of epidural ropivacaine in elderly patients undergoing elective transurethral resection of prostate (TURP). MATERIALS AND METHODS This was a prospective randomized double-blind dose-response study. Fifty eight elderly patients with American Society of Anesthesiologists physical status I-II who were scheduled for TURP surgery under epidural anesthesia were randomly allocated to a group receiving 15 mL of ropivacaine (group R) or a group receiving ropivacaine plus 5 μg of sufentanil (group RS). The concentration of ropivacaine was determined by a Dixon's up-and-down sequential allocation. The first participant received 0.3% of ropivacaine in both groups and subsequent concentrations were determined by the response of the previous patient in the same group. The EC₅₀ of epidural ropivacaine was analyzed using the Dixon and Massey method. RESULTS The EC₅₀ of ropivacaine during TURP surgery was 0.186% (95% confidence interval, 0.173-0.200%) in group R, and 0.136% (95% confidence interval, 0.127-0.144%) in group RS (p<0.01). No differences in Bromage scale of motor block examination and the onset time of sensory block were observed. CONCLUSION Administration of 5 μg of epidural sufentanil caused a 37% reduction in the EC₅₀ of epidural ropivacaine in elderly patients who underwent TURP surgery. Thus, sufentanil addition during surgery of TURP can decrease the dose of ropivacaine anesthesia required.
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Affiliation(s)
- Huiling Li
- Department of Anesthesiology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, P.R. China
| | - Yuhong Li
- Department of Anesthesiology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, P.R. China.; Department of Anesthesiology, Shaoxing People's Hospital, Shaoxing, Zhejiang, P.R. China.; Medical Research Center, Shaoxing People's Hospital, Shaoxing, Zhejiang, P.R. China.
| | - Rui He
- Department of Anesthesiology, Shaoxing People's Hospital, Shaoxing, Zhejiang, P.R. China
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Feng S, Cao Y, Wang W, Liu Y, Shen X. Addition of Adrenaline to Chloroprocaine Provides a Moderate Duration Time for Epidural Anaesthesia in Elective Caesarean Section. J Int Med Res 2012; 40:1099-107. [PMID: 22906283 DOI: 10.1177/147323001204000329] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE: Epidural anaesthesia using chloroprocaine with or without adrenaline and lidocaine with adrenaline were compared. METHODS: Sixty parturients undergoing elective caesarean section under epidural anaesthesia were randomized to receive 3% chloroprocaine (group C), 3% chloroprocaine with adrenaline (group CA) or 2% lidocaine with adrenaline (group LA). Onset time, duration time and various maternal, fetal and neonatal parameters were monitored. Pain was assessed using a visual analogue scale. RESULTS: The onset time of analgesia in group CA was similar to that in group C but was shorter than that in group LA. Duration of analgesia, loss of cold sensation and motor blockade in group CA were prolonged compared with group C, but were shorter than those in group LA. No differences in maternal, fetal or neonatal effects were seen. A higher pain score was reported in group C than in groups CA or LA at the end of surgery. CONCLUSIONS: Epidural anaesthesia using chloroprocaine with adrenaline has a quick onset and moderate duration and is an attractive alternative to lidocaine and adrenaline or chloroprocaine alone for caesarean section.
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Affiliation(s)
- Sw Feng
- State Key Laboratory of Reproductive Medicine, Department of Anaesthesiology, Nanjing Maternity and Child Health Care Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Y Cao
- State Key Laboratory of Reproductive Medicine, Department of Anaesthesiology, Nanjing Maternity and Child Health Care Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Wg Wang
- State Key Laboratory of Reproductive Medicine, Department of Anaesthesiology, Nanjing Maternity and Child Health Care Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Ys Liu
- State Key Laboratory of Reproductive Medicine, Department of Anaesthesiology, Nanjing Maternity and Child Health Care Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Xf Shen
- State Key Laboratory of Reproductive Medicine, Department of Anaesthesiology, Nanjing Maternity and Child Health Care Hospital Affiliated to Nanjing Medical University, Nanjing, China
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Parpaglioni R, Baldassini B, Barbati G, Celleno D. Adding sufentanil to levobupivacaine or ropivacaine intrathecal anaesthesia affects the minimum local anaesthetic dose required. Acta Anaesthesiol Scand 2009; 53:1214-20. [PMID: 19650807 DOI: 10.1111/j.1399-6576.2009.02033.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND We carried out this prospective, randomized, double-blind study in order to evaluate whether the intrathecal addition of sufentanil 3.3 mcg affects both the minimum local anaesthetic dose (MLAD) of spinal levobupivacaine and ropivacaine for a caesarean section and enhances the spinal block characteristics. METHODS One hundred and eighty women were randomly allocated into four groups: levobupivacaine (Group L), levobupivacaine plus sufentanil (Group L+S), ropivacaine (Group R) and ropivacaine plus sufentanil (Group R+S). Each received 3 ml of the study solution intrathecally as part of a combined spinal/epidural technique. The initial dose was 12 mg for Groups L and L+S, and 15 mg for Groups R and R+S. The test solution was required to achieve a visual analogue pain score (VAPS) of 30 mm or less to be considered effective at skin incision, uterine incision, birth, peritoneal closure and at the conclusion of surgery. Effective or ineffective responses determined a 0.5 mg decrease or increase of the same drug, respectively, for the next patient in the same group, using an up-down sequential allocation. RESULTS Using the Dixon and Massey formula, the MLAD was 10.65 mg [confidence interval (CI) 95%: 10.14-11.56] in Group L, 4.73 mg (CI 95%: 4.39-5.07) in Group L+S, 14.12 mg (CI 95%: 13.50-14.60) in Group R and 6.44 mg (CI 95%: 5.86-7.02) in Group R+S. CONCLUSIONS The addition of sufentanil reduced the MLAD of both the local anaesthetics. It did not affect their potency ratio significantly and resulted in enhanced spinal anaesthesia.
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Affiliation(s)
- R Parpaglioni
- Department of Anaesthesia and Intensive Care, Fatebenefratelli General Hospital, 00186 Rome, Italy.
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Landau R, Kern C, Columb MO, Smiley RM, Blouin JL. Genetic variability of the mu-opioid receptor influences intrathecal fentanyl analgesia requirements in laboring women. Pain 2008; 139:5-14. [PMID: 18403122 DOI: 10.1016/j.pain.2008.02.023] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2007] [Revised: 02/21/2008] [Accepted: 02/22/2008] [Indexed: 10/22/2022]
Abstract
Labor initiates one of the most intensely painful episodes in a woman's life. Opioids are used to provide analgesia with substantial interindividual variability in efficacy. mu-Opioid receptor (muOR, OPRM1) genetic variants may explain differences in response to opioid analgesia. We hypothesized that OPRM1 304A/G polymorphism influences the median effective dose (ED(50)) of intrathecal fentanyl via combined spinal-epidural for labor analgesia. Nulliparous women were prospectively recruited around 35 weeks gestation (n=224), and genotyped for 304A/G polymorphism. Those requesting neuraxial labor analgesia were enrolled in one of the two double-blinded trials: up-down sequential allocation (SA, n=50) and a separate confirmatory random-dose allocation trial (RA, n=97). Effective analgesia from intrathecal fentanyl was defined by >or=60 min analgesia with verbal rating score <or=1 (scale 0-10) and was compared between mu OR 304A homozygotes (Group A) and women carrying at least one 304G allele (Group G). OPRM1 304G allele frequency f(-) was 0.18. Using SA, intrathecal fentanyl ED(50) was 26.8 microg (95% CI 22.7-30.9) in Group A and 17.7 microg (95% CI 13.4-21.9) in Group G (p<0.001; 304A homozygosity increased the ED(50) 1.5-fold). RA confirmed that 304A homozygosity significantly increases intrathecal fentanyl ED(50) (27.4 microg in Group A and 12.8 microg in Group G [p<0.002; 2.1-fold]). We demonstrate for the first time that the muOR 304G variant significantly reduces intrathecal fentanyl ED(50) for labor analgesia, suggesting women with the G variant may be more responsive to opioids and require less analgesic drugs. These findings for intrathecal fentanyl pharmacogenetics may have implications for patients receiving opioids in other settings.
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Affiliation(s)
- Ruth Landau
- Department of Anesthesia, University Hospital of Geneva, Geneva, Switzerland Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA Department of Anaesthesia, University Hospital of South Manchester Wythenshawe, UK Department of Genetic Medicine and Laboratory, University Hospital of Geneva, Geneva, Switzerland
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Buyse I, Stockman W, Columb M, Vandermeersch E, Van de Velde M. Effect of sufentanil on minimum local analgesic concentrations of epidural bupivacaine, ropivacaine and levobupivacaine in nullipara in early labour. Int J Obstet Anesth 2007; 16:22-8. [PMID: 17125998 DOI: 10.1016/j.ijoa.2006.07.008] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/01/2006] [Indexed: 11/19/2022]
Abstract
BACKGROUND The aim was to assess the effect of epidural sufentanil on relative analgesic potencies of epidural bupivacaine, ropivacaine and levobupivacaine by determining the minimum local analgesic concentrations during labour. METHODS In a randomised, double-blind study, 171 parturients were allocated to one of six groups receiving a 10-mL bolus of bupivacaine, ropivacaine or levobupivacaine alone or with sufentanil 0.75 microg/mL. The concentration of local anaesthetic was determined by the response of the previous parturient using up-down sequential allocation starting at a concentration of 0.13% wt/vol with a testing interval of 0.01%. Effective analgesia was defined as a visual analogue pain score < or = 15/100 mm within 30 min and lasting for 30 min. Median effective concentrations were estimated and two-sided P < 0.05 was significant. RESULTS Local anaesthetic concentration, use of sufentanil and local anaesthetic drug were independent significant predictors of effective and ineffective analgesia. Bupivacaine was significantly more potent than levobupivacaine and ropivacaine. The relative potency ratios without sufentanil of 0.77:0.83:1.00 were reduced to 0.36:0.38:1.00 by the addition of sufentanil. The major factor influencing local anaesthetic requirements was the addition of sufentanil, which reduced overall requirements by a factor of 4.2 (95% CI 3.6-4.8); this effect was proportionately more enhanced for bupivacaine. CONCLUSIONS Local anaesthetic requirements for bupivacaine, levobupivacaine and ropivacaine follow an analgesic potency hierarchy. Any potency differences are small when compared to the effect of sufentanil, which resulted in a four-fold reduction in local anaesthetic requirements. Sufentanil may also enhance the potency differences between bupivacaine and the two S-enantiomer agents.
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Affiliation(s)
- I Buyse
- Departments of Anaesthesiology, Heilig Hart Hospital, Roeselare, and University Hospital Gasthuisberg, Leuven, Belgium and South Manchester University Hospital, Wythenshawe, UK
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Affiliation(s)
- M O Columb
- South Manchester University Hospital, Wythenshawe, UK.
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Hess PE, Snowman CE, Hahn CJ, Kunze LJ, Ingold VJ, Pratt SD. Chloroprocaine may not affect epidural morphine for postcesarean delivery analgesia. J Clin Anesth 2006; 18:29-33. [PMID: 16517329 DOI: 10.1016/j.jclinane.2005.05.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2004] [Accepted: 05/16/2005] [Indexed: 11/26/2022]
Abstract
STUDY OBJECTIVE The purpose of this study is to assess the independent effect of epidural chloroprocaine on morphine used for pain relief after cesarean delivery. DESIGN We used a randomized, double blind, placebo-controlled trial. SETTING The study took place at the labor and delivery ward of an academic medical center. PATIENTS Forty pregnant women undergoing elective cesarean delivery under spinal-epidural anesthesia. INTERVENTIONS Patients were randomized to receive either 150 mg of 3% chloroprocaine or placebo, followed by 3 mg of epidural morphine. MEASUREMENTS The primary outcome for this investigation was the duration of pain relief after morphine administration, defined as the time at first use of supplemental opioids for analgesia. Secondary outcomes included pain scores, blood pressure, heart rate, respiratory rate, anesthetic sensory level, nausea and vomiting, pruritus, supplemental use of nonsteroidal anti-inflammatory medications, and satisfaction. MAIN RESULTS The groups were similar in demographics and duration of spinal anesthesia. Using Kaplan-Meier survival analysis of the duration of morphine analgesia, we found no difference between the groups (chloroprocaine, 1191 minutes, vs placebo, 1267 minutes, P = 0.52). There was no difference in pain scores or the need for supplemental analgesics. Side effects of epidural morphine were similar between the groups. CONCLUSIONS We found that epidural chloroprocaine did not reduce the duration or effectiveness of postoperative analgesia from epidural morphine.
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Affiliation(s)
- Philip E Hess
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA.
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Panni MK, Columb MO. Obese parturients have lower epidural local anaesthetic requirements for analgesia in labour †. Br J Anaesth 2006; 96:106-10. [PMID: 16311280 DOI: 10.1093/bja/aei284] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND There are no studies comparing local anaesthetic requirements for obese and normal parturients. Obesity has been associated with a higher incidence of Caesarean section and higher levels of epidural block have also been found in obese obstetric patients, suggesting they may require less local anaesthetic. The aim of our study was to estimate the minimum local analgesic concentration (MLAC) of bupivacaine for obese and non-obese parturients. METHODS Otherwise healthy parturients (n=32) requesting epidural analgesia were enrolled in this up-down sequential allocation study. Women were in active labour (3-6 cm cervical dilatation) with visual analogue pain scores (VAPS) >40/100 mm. Subjects with BMI >30 kg m(-2) were allocated to the obese group and BMI < or = 30 kg m(-2) were allocated to the normal group. The initial epidural dose for both groups was 20 ml 0.1% w/v bupivacaine (20 mg), with a dosing increment of 0.01% w/v VAPS < or = 10/100 mm defined effective analgesia. The MLAC was estimated using up-down reversals and probit regression with P<0.05 as significant. RESULTS Groups were similar except for BMI and weight (P<0.001). Local anaesthetic requirements were significantly (P<0.001) reduced by a factor of 1.68 (95% CI 1.32-2.29) in the obese group, with significantly higher initial level of block (P<0.001). CONCLUSION We found obese parturients to have significantly decreased epidural bupivacaine analgesic requirements. A contributing factor to obese patients having more difficult labours may be that relatively larger doses of local anaesthetic are administered than actually required. It may be worth considering lowering the concentrations and doses with which we initiate analgesia in obese parturients.
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Affiliation(s)
- M K Panni
- Division of Women's Anesthesia, Department of Anesthesiology, Duke University Medical Centre, Durham, NC 27710, USA.
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Graf BM, Zausig Y, Zink W. Current status and clinical relevance of studies of minimum local-anaesthetic concentration (MLAC). Curr Opin Anaesthesiol 2005; 18:241-5. [PMID: 16534344 DOI: 10.1097/01.aco.0000169228.68314.07] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Studies comparing the effects of epidural local anaesthetics have been limited by the lack of knowledge of their relative potencies. In 1995 the concept of the minimum local-anaesthetic concentration (MLAC) was introduced, this has been defined primarily as the median effective analgesic concentration in the first stage of labour. Pharmacologically, this model aims to determine equipotent analgesic concentrations of local anaesthetics, to compare motor effects and to evaluate the relative toxicity during labour. However, results of recent MLAC studies are not uniform and rather confusing, and thus, the basic validity of the MLAC concept for determining local-anaesthetic potency is increasingly discussed. RECENT FINDINGS MLAC studies have postulated that ropivacaine is up to 40% less potent than bupivacaine, but as potent as levo-bupivacaine. Intriguingly, bupivacaine has been shown to be as effective as levo-bupivacaine in identical experimental protocols. Modified MLAC studies resulted additionally in local anaesthetic-sparing effects of epidural/intrathecal opioids, clonidine and epinephrine. MLAC studies have also been applied to compare the relative analgesic as well as relative motor-blocking potency of local anaesthetics. SUMMARY Relative differences in local anaesthetics' potencies derived from MLAC examinations are meaningful and correct from the pharmacological point of view, but they cannot simply be transferred to daily clinical practice. Thus, MLAC values should not be misinterpreted as these data are not suggested to be suitable to define and quantify the pharmacodynamics of local anaesthetics, nor to unequivocally predict their toxicological profile in clinically relevant concentrations.
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Affiliation(s)
- Bernhard M Graf
- Department of Anaesthesiology, University of Heidelberg, Germany.
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Abstract
Interest in the use of regional anaesthesia, particularly peripheral nerve blocks (PNBs) and continuous PNBs, has increased in recent years. Accompanying this resurgence in interest has been the development of new local anaesthetics and additives designed to enhance block duration and quality. This manuscript provides a literature-based review on accepted uses of local anaesthetics and adjuncts for a variety of regional anaesthesia techniques. A brief review of local anaesthetic pharmacodynamics describes the action of these drugs in preventing nerve depolarisation, thus blocking nerve impulses. Toxic adverse effects of local anaesthetics, specifically CNS and cardiac manifestations of excessive local anaesthetic blood concentrations and the direct neurotoxic properties of local anaesthetics, are discussed generally and specifically for many commonly used local anaesthetics. Clinically useful ester and amide local anaesthetics are evaluated individually in terms of their physical properties and toxic potential. How these properties impact on the clinical uses of each local anaesthetic is explored. Particular emphasis is placed on the long-acting local anaesthetic toxic potential of racemic bupivacaine compared with levobupivacaine and ropivacaine, which are both levorotatory stereoisomers. Guidelines for using ropivacaine and mepivacaine, based on the authors' experience using advanced regional anaesthesia in a busy practice, is provided. Finally, epinephrine (adrenaline), clonidine and other local anaesthetic additives and their rationale for use is covered along with other future possibilities.
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Ginosar Y, Columb MO, Cohen SE, Mirikatani E, Tingle MS, Ratner EF, Angst MS, Riley ET. The Site of Action of Epidural Fentanyl Infusions in the Presence of Local Anesthetics: A Minimum Local Analgesic Concentration Infusion Study in Nulliparous Labor. Anesth Analg 2003; 97:1439-1445. [PMID: 14570662 DOI: 10.1213/01.ane.0000081792.84877.a2] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED We have previously demonstrated that continuous epidural infusions of fentanyl without local anesthetics elicit analgesia by a systemic mechanism. In this study, we examined the hypothesis that, in the presence of epidural bupivacaine, continuous infusions of epidural fentanyl elicit analgesia by a spinal mechanism. Forty-eight nulliparous women in active labor participated in this prospective, randomized, double-blinded study. Women received lumbar epidural analgesia with 20-30 mL bupivacaine 0.125% until pain free. Subjects were then randomized to either IV or epidural (EPI) fentanyl infusion groups. Each infusion delivered fentanyl 30 microg/h. All women received an epidural infusion of bupivacaine at a rate of 20 mL/h, the concentration of which was determined by the response of the previous woman in the same group to the analgesic regimen used. Unlike previous studies that assessed the minimum local analgesic concentration (MLAC) for bolus administration at the initiation of analgesia, this study assessed MLAC(infusion) for the maintenance of analgesia throughout the first stage of labor. MLAC(infusion) was determined using the up-down sequential analysis described by Dixon and Massey. The MLAC(infusion) of epidural bupivacaine was 0.063% (95% confidence interval, 0.058-0.068) and 0.019% (95% confidence interval, 0.000-0.038) in the IV and EPI groups respectively. A continuous infusion of fentanyl was more than three times as potent when administered by the epidural than by the IV route. This marked increase in potency for the epidural route is highly suggestive for a predominantly spinal mechanism of action for infused epidural fentanyl under the conditions of this study. IMPLICATIONS This study determined the median effective concentration for epidural infusions of bupivacaine during labor analgesia. Coadministered epidural fentanyl infusions were more than three times more potent than IV fentanyl infusions, suggesting a predominantly spinal mechanism of opioid action under these study conditions.
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Affiliation(s)
- Yehuda Ginosar
- *Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University School of Medicine, Jerusalem, Israel, the †Department of Anaesthesia and Intensive Care Medicine, South Manchester University Hospitals, Wythenshawe, UK, and the ‡Department of Anesthesia, Stanford University, Stanford, California
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Aveline C, El Metaoua S, Masmoudi A, Boelle PY, Bonnet F. The Effect of Clonidine on the Minimum Local Analgesic Concentration of Epidural Ropivacaine During Labor. Anesth Analg 2002. [DOI: 10.1213/00000539-200209000-00037] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Aveline C, El Metaoua S, Masmoudi A, Boelle PY, Bonnet F. The effect of clonidine on the minimum local analgesic concentration of epidural ropivacaine during labor. Anesth Analg 2002; 95:735-40, table of contents. [PMID: 12198062 DOI: 10.1097/00000539-200209000-00037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
UNLABELLED On the basis of the determination of minimum local analgesic concentration (MLAC), ropivacaine has been demonstrated to be less potent than bupivacaine during the first stage of labor. In this study we assessed the effect of clonidine on the MLAC of ropivacaine. Seventy-seven parturients of mixed parity requesting epidural analgesia for labor (cervical dilation, 3-7 cm) were included in the study. They received an epidural bolus of either ropivacaine (n = 30), ropivacaine plus clonidine 30 microg (n = 28), or ropivacaine plus clonidine 60 microg (n = 19) in the second part of the study. The concentration of the ropivacaine solution was determined by the response of the previous parturient in that group by using an up-down sequential allocation. A visual analog pain score of < or =10 mm within 30 min after the epidural bolus (20 mL) was considered an effective response. An effective result directed a 0.01% wt/vol decrement for the next patient. An ineffective result directed a 0.01% wt/vol increment. The MLAC of ropivacaine was 0.097% wt/vol (95% confidence interval, 0.085%-0.108%). It was unaffected by a 30-microg dose of epidural clonidine (0.081% [0.045%-0.117%]) but was significantly decreased by a 60-microg clonidine dose (0.035% [0.024%-0.046%]) (P < 0.001). This study documents a decrease in the MLAC of ropivacaine by clonidine, significant for a 60- microg dose. IMPLICATIONS Epidural ropivacaine potency in labor can be increased by the addition of epidural clonidine. This study demonstrates that 60 microg of epidural clonidine significantly decreases the minimum local analgesic concentration of ropivacaine during the first stage of labor but is associated with sedation.
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Affiliation(s)
- Chritophe Aveline
- Département d'Anesthésie-Réanimation Chirurgicale, Hôpital TENON, Assistance Publique Hôpitaux de Paris, 4 Rue de la Chine, 75020 Paris, France
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D’Angelo R, Owen MD. Potency, Impotency, and Importance! Anesth Analg 2000. [DOI: 10.1213/00000539-200009000-00062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Potency, Impotency, and Importance! Anesth Analg 2000. [DOI: 10.1097/00000539-200009000-00062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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