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Wei Y, Wang Y, Zhao Y, Wu C, Liu H, Yang Z. High Dosage of Patient-Controlled Epidural Analgesia (PCEA) with Low Background Infusion during Labor: A Randomized Controlled Trial. J Pers Med 2023; 13:jpm13040600. [PMID: 37108986 PMCID: PMC10144857 DOI: 10.3390/jpm13040600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/14/2023] [Accepted: 03/19/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Patient-controlled epidural analgesia (PCEA) is well documented; however, it is unclear whether a high dosage of PCEA with a low dosage of background infusion during labor can be a safe and effective application. METHODS Group LH was administered a continuous infusion (CI) of 0.084 mL/kg/h with PCEA of 5 mL every 40 min. Group HL was given a CI of 0.028 mL/kg/h and PCEA of 10 mL every 40 min; Group HH was given a CI of 0.084 mL/kg/h and PCEA of 10 mL every 40 min. The primary outcomes were VAS pain score, the number of supplemental boluses, incidence of pain outbreaks, drug dose for pain outbreaks, PCA times, effective PCA times, anesthetic consumption, duration of analgesia, duration of labor and delivery outcome. Secondary outcomes included adverse reactions such as itching, nausea and vomiting during analgesia and neonatal Apgar scores 1 min and 5 min after birth. RESULTS A total of 180 patients, 60 in each group were randomly assigned to one of three groups included group LH, group HL or group HH. The VAS scores were obviously decreased in HL group and HH group in comparison with LL group at 2 h after analgesia and the time point of full cervical dilation and delivery of baby. The time for third stage of labor in HH group was increased compared with LH group and HL group. Incidence of pain outbreaks in LH group was obviously increased compared with HL and HH group. The effective PCA times in HL group and HH group were remarkably reduced compared with those in LH group. CONCLUSIONS High dose of PCEA with a low background infusion can reduce effective PCA times, incidence of outbreak pain and the total amount of anesthetics without diminishing analgesia effects. However, high dose of PCEA with a high background infusion can enhance analgesia effect but increase the third stage of labor, instrumental delivery ratio and the total amount of anesthetics.
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Affiliation(s)
- Yu Wei
- Department of Anesthesiology, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
- Shanghai Key Laboratory of Embryo Original Disease, Shanghai 200030, China
- Shanghai Municipal Key Clinical Specialty, Huashan Rd. 1961, Shanghai 200030, China
| | - Yilong Wang
- Department of Anesthesiology, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
- Shanghai Key Laboratory of Embryo Original Disease, Shanghai 200030, China
- Shanghai Municipal Key Clinical Specialty, Huashan Rd. 1961, Shanghai 200030, China
| | - Yanhong Zhao
- Department of Anesthesiology, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
- Shanghai Key Laboratory of Embryo Original Disease, Shanghai 200030, China
- Shanghai Municipal Key Clinical Specialty, Huashan Rd. 1961, Shanghai 200030, China
| | - Chaomin Wu
- Department of Pulmonary Medicine, Qingpu Branch, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Henry Liu
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, The University of Pennsylvania, 3401 Spruce Street, Philadelphia, PA 19104, USA
| | - Zeyong Yang
- Department of Anesthesiology, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
- Shanghai Key Laboratory of Embryo Original Disease, Shanghai 200030, China
- Shanghai Municipal Key Clinical Specialty, Huashan Rd. 1961, Shanghai 200030, China
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Wydall S, Zolger D, Owolabi A, Nzekwu B, Onwochei D, Desai N. Comparison of different delivery modalities of epidural analgesia and intravenous analgesia in labour: a systematic review and network meta-analysis. Can J Anaesth 2023; 70:406-442. [PMID: 36720838 DOI: 10.1007/s12630-022-02389-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 09/15/2022] [Accepted: 09/16/2022] [Indexed: 02/02/2023] Open
Abstract
PURPOSE In labour, neuraxial analgesia is the standard in the provision of pain relief. However, the optimal mode of delivering epidural solution has not been determined, and some parturients may need an alternative to epidural analgesia. We sought to conduct a systematic review and network meta-analysis to compare continuous epidural infusion (CEI), programmed intermittent epidural bolus (PIEB), computer-integrated CEI, computer-integrated PIEB, patient-controlled epidural bolus (PCEA), fentanyl patient-controlled analgesia (PCA), and remifentanil PCA, either alone or in combination. METHODS We searched CENTRAL, CINAHL, Ovid Embase, Ovid Medline, and Web of Science for randomized controlled trials that included nulliparous and/or multiparous parturients in spontaneous or induced labour. The maintenance epidural solution had to include a low concentration local anesthetic and an opioid. Specific subgroups in the obstetric population such as preeclampsia were excluded. Network meta-analysis was performed with a frequentist method, and continuous and dichotomous outcomes are presented as mean differences and odds ratios, respectively, with 95% confidence intervals. RESULTS Overall, 73 trials were included. For the first coprimary outcome, the need for rescue analgesia, CEI was inferior to PIEB and PIEB + PCEA was superior to PCEA alone, with a low certainty of evidence given the presence of serious limitations and imprecision. The second coprimary outcome, the maternal satisfaction, was improved by PIEB + PCEA compared with CEI + PCEA and PCEA alone, with a low quality of evidence in view of the presence of serious limitations and imprecision. Fentanyl PCA increased the requirement for rescue analgesia and decreased maternal satisfaction relative to many methods of delivering epidural solution. In terms of secondary outcomes, PIEB increased analgesic efficacy compared with CEI, and PCEA reduced local anesthetic consumption at the expense of inferior analgesia relative to CEI and PIEB. PIEB + PCEA was superior to CEI + PCEA in regard to the pain score at 2 h and 4 h, consumption of local anesthetic, incidence of lower lower limb motor blockade and the rate of spontaneous vaginal delivery. Fentanyl and remifentanil PCA did not provide the same level of analgesia as all epidural methods, resulted in increasing analgesic ineffectiveness with time spent in labour, and predisposed to a higher incidence of side effects such as nausea and/or vomiting and sedation. Remifentanil PCA was superior to fentanyl PCA for analgesia at an early time point, and it increased the incidence of oxygen desaturation relative to other strategies of delivering epidural solution. CONCLUSIONS Opioid PCA did not provide the same level of analgesia as epidural methods with a higher incidence of side effects. We interpret the findings of our systematic review and network meta-analysis as suggesting PIEB + PCEA to be the optimal delivery mode of epidural solution. Nevertheless, the potential differing importance of the various maternal, fetal, and neonatal outcomes in determining which is optimal has not, to our knowledge, been elucidated yet. STUDY REGISTRATION PROSPERO (CRD42021254978); registered 27 May 2021.
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Affiliation(s)
- Simon Wydall
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK.
| | - Danaja Zolger
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Adetokunbo Owolabi
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Bernadette Nzekwu
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Desire Onwochei
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - Neel Desai
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK
- King's College London, London, UK
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Choudhary G, Chaudhary K, Sharma RS, Ujwal S, Kumawat J, Syal R. Parturient Controlled Epidural Analgesia with and without Basal Infusion of Ropivacaine and Fentanyl: A Randomized Trial. Anesth Essays Res 2021; 14:390-394. [PMID: 34092847 PMCID: PMC8159052 DOI: 10.4103/aer.aer_116_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 01/08/2021] [Accepted: 01/08/2021] [Indexed: 11/19/2022] Open
Abstract
Introduction: Parturient controlled epidural analgesia (PCEA) is an established method of providing safe and effective labor analgesia. Objective: The aim of this single-blind, randomized controlled trial was to compare the efficacy of PCEA with or without basal infusion (BI) of ropivacaine and fentanyl for the effective management of labor pain associated with normal vaginal delivery. Materials and Methods: A total of 78 nulliparous parturients with vertex presentation at term and with cervical dilatation of 3–5 cm demanding for epidural analgesia (EA) were enrolled in the study. EA was initiated and maintained with ropivacaine 0.125% and fentanyl 2 μg/mL. Following an initial epidural loading volume of 8–10 mL, parturients were randomly allocated in two groups of 39 each. PCEA group received bolus of 5 mL at 200 mL/h with lockout interval of 15 min and with maximum volume of local anaesthetic was 20 mL/h and PCEA + BI group – receiving added BI rate of 5 mL/h along with same programmed parameters of PCEA pump. Results: No statistically significant difference was observed between the groups in terms of demographic characteristics, duration of labor, delivery methods, maternal satisfaction as well as Apgar score. Mean demand bolus in group PCEA + BI was 0.39 ± 0.59, whereas in group PCEA was 3.31 ± 0.77 (P < 0.05). Mean volume of drug used in group PCEA + BI was 25.57 ± 2.75 mL, while in group PCEA was 22.42 ± 4.56 mL (P = 0.0005). In PCEA + BI group, Visual Analog Scale (VAS) score was 0.07 ± 0.35 at 60 min and 0.06 ± 0.33 at 120 min, whereas in PCEA group, VAS was 0.32 ± 0.62 at 60 min and 0.26 ± 0.50 at 120 min (P = 0.05), respectively. Conclusion: BI when added to PCEA, it significantly reduces breakthrough labor pain and demand boluses without prolonging labor duration but at the cost of increased requirement of drug volume when compared to PCEA only group.
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Affiliation(s)
- Garima Choudhary
- Department of Anesthesiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Kriti Chaudhary
- Department of Anesthesiology and Critical Care, A.I.I.M.S. Jodhpur, Rajasthan, India
| | - Ravi Shankar Sharma
- Department of Anaesthesiology and Critical Care, A.I.I.M.S, Rishikesh, Uttarakhand, India
| | - Shobha Ujwal
- Department of Anesthesiology and Critical Care, Dr. S. N. Medical Collage, Jodhpur, Rajasthan, India
| | - Jagdish Kumawat
- Department of Anesthesiology, Government Medical Collage, Barmer, Rajasthan, India
| | - Rashmi Syal
- Department of Anesthesiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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Roofthooft E, Barbé A, Schildermans J, Cromheecke S, Devroe S, Fieuws S, Rex S, Wong CA, Van de Velde M. Programmed intermittent epidural bolus vs. patient-controlled epidural analgesia for maintenance of labour analgesia: a two-centre, double-blind, randomised study†. Anaesthesia 2020; 75:1635-1642. [PMID: 32530518 DOI: 10.1111/anae.15149] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2020] [Indexed: 11/28/2022]
Abstract
The programmed intermittent epidural bolus technique has shown superiority to continuous epidural infusion techniques, with or without patient-controlled epidural analgesia for pain relief, reduced motor block and patient satisfaction. Many institutions still use patient-controlled epidural analgesia without a background infusion, and a comparative study between programmed intermittent epidural bolus and patient-controlled epidural analgesia without a background infusion has not yet been performed. We performed a randomised, two-centre, double-blind, controlled trial of these two techniques. The primary outcome was the incidence of breakthrough pain requiring a top-up dose by an anaesthetist. Secondary outcomes included: motor block; pain scores; patient satisfaction; local anaesthetic consumption; and obstetric and neonatal outcomes. We recruited 130 nulliparous women who received initial spinal analgesia, and then epidural analgesia was initiated and maintained with either programmed intermittent epidural bolus or patient-controlled epidural analgesia using ropivacaine 0.12% with sufentanil 0.75 µg·ml-1 . The programmed intermittent epidural bolus group had a programmed bolus of 10 ml every hour, with on-demand patient-controlled epidural analgesia boluses of 5 ml with a 20 min lockout, and the patient-controlled epidural analgesia group had a 5 ml bolus with a 12 min lockout interval; the potential maximum volume per hour was the same in both groups. The patients in the programmed intermittent epidural bolus group had less frequent breakthrough pain compared with the patient-controlled epidural analgesia group, 7 (10.9%) vs. 38 (62.3%; p < 0.0001), respectively. There was a significant difference in motor block (modified Bromage score ≤ 4) frequency between groups, programmed intermittent epidural bolus group 1 (1.6%) vs. patient-controlled epidural analgesia group 8 (13.1%); p = 0.015. The programmed intermittent epidural bolus group had greater local anaesthetic consumption with fewer patient-controlled epidural analgesia boluses. Patient satisfaction scores and obstetric or neonatal outcomes were not different between groups. In conclusion, we found that a programmed intermittent epidural bolus technique using 10 ml programmed boluses and 5 ml patient-controlled epidural analgesia boluses was superior to a patient-controlled epidural analgesia technique using 5 ml boluses and no background infusion.
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Affiliation(s)
- E Roofthooft
- Department of Anaesthesiology, GZA Sint Augustinus Hospital, Antwerp, Belgium.,Department of Cardiovascular Sciences, KU Leuven, Belgium
| | - A Barbé
- Department of Anaesthesiology, University Hospitals Leuven, Belgium
| | - J Schildermans
- Department of Anaesthesiology, University Hospitals Leuven, Belgium
| | - S Cromheecke
- Department of Anaesthesiology, ZNA Middelheim Hospital, Antwerp, Belgium
| | - S Devroe
- Department of Cardiovascular Sciences, KU Leuven, Belgium.,Department of Anaesthesiology, University Hospitals Leuven, Belgium
| | - S Fieuws
- Department of I-Biostat, KU Leuven, Belgium
| | - S Rex
- Department of Cardiovascular Sciences, KU Leuven, Belgium.,Department of Anaesthesiology, University Hospitals Leuven, Belgium
| | - C A Wong
- Department of Anesthesia, University of Iowa, Iowa City, IA, USA
| | - M Van de Velde
- Department of Cardiovascular Sciences, KU Leuven, Belgium.,Department of Anaesthesiology, University Hospitals Leuven, Belgium
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Zhang Y, Qin QR, Hui LT. Motor blocks and operative deliveries with ropivacaine and fentanyl for labor epidural analgesia: A meta-analysis. J Obstet Gynaecol Res 2018; 44:2156-2165. [PMID: 30084116 DOI: 10.1111/jog.13772] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 07/04/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Yang Zhang
- 2nd Inpatient Department; Binzhou People's Hospital; Binzhou China
| | - Qing-Rong Qin
- School of Nursing, Binzhou Polytechnic College; Binzhou China
| | - Liang-Tu Hui
- 2nd Inpatient Department; Binzhou People's Hospital; Binzhou China
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Angle PJ, Kurtz Landy C, Djordjevic J, Barrett J, Kibbe A, Sriparamananthan S, Lee Y, Hamata L, Zaki P, Kiss A. Performance of the Angle Labor Pain Questionnaire During Initiation of Epidural Analgesia in Early Active Labor. Anesth Analg 2016; 123:1546-1553. [DOI: 10.1213/ane.0000000000001679] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Jordan S, Murphy FA, Boucher C, de Lloyd LJ, Morgan G, Roberts AS, Leslie D, Edwards DJ. High dose versus low dose opioid epidural regimens for pain relief in labour. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2016. [DOI: 10.1002/14651858.cd012135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Susan Jordan
- Department of Nursing, College of Human & Health Sciences; Swansea University; Swansea UK
| | - Fiona A Murphy
- Department of Nursing and Midwifery; Faculty of Education and Health Sciences, University of Limerick; Limerick Ireland
| | | | - Lucy J de Lloyd
- Department of Anaesthetics; Cardiff and Vale UHB, Heath Hospital; Cardiff UK
| | | | - Anna S Roberts
- Department of Anaesthetics; Abertawe Bro Morgannwg University Health Board; Swansea UK
| | - David Leslie
- Department of Anaesthesia; Cardiff and Vale University Health Board; Cardiff UK
| | - Darren J Edwards
- Department of Public Health and Social Sciences; Swansea University; Swansea UK
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Heesen M, Böhmer J, Klöhr S, Hofmann T, Rossaint R, Straube S. The Effect of Adding a Background Infusion to Patient-Controlled Epidural Labor Analgesia on Labor, Maternal, and Neonatal Outcomes. Anesth Analg 2015; 121:149-158. [DOI: 10.1213/ane.0000000000000743] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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9
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Zhang X, Shu L, Lin C, Yang P, Zhou Y, Wang Q, Wu Y, Xu X, Cui X, Lin X, Jin L, Li T. Comparison Between Intraoperative Two-Space Injection Thoracic Paravertebral Block and Wound Infiltration as a Component of Multimodal Analgesia for Postoperative Pain Management After Video-Assisted Thoracoscopic Lobectomy: A Randomized Controlled Trial. J Cardiothorac Vasc Anesth 2015; 29:1550-6. [PMID: 26409920 DOI: 10.1053/j.jvca.2015.06.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To compare paravertebral block under thoracoscopy with wound infiltration at an early stage after video-assisted thoracic lobectomy surgery. DESIGN A prospective, randomized, triple-blinded, placebo-controlled trial. SETTING A single-center university hospital. PARTICIPANTS Patients scheduled for video-assisted thoracic lobectomy surgery between February 20, 2014 and June 1, 2014 randomly were allocated into paravertebral block (PVB) (n = 35) and infiltration (n = 35) groups. INTERVENTIONS In the PVB group, 0.5% ropivacaine was injected into the paravertebral space by the surgeon under direct vision with placebo infiltration of saline in the wounds. In the infiltration group, the wounds were infiltrated with 0.5% ropivacaine by the surgeon with a placebo paravertebral block. Subsequently, patient-controlled intravenous morphine analgesia and paracoxib were administered. MEASUREMENTS AND MAIN RESULTS The primary endpoints were visual analog scale (VAS) pain scores at rest and on cough 0, 2, 6, and 24 hours after surgery. The secondary endpoints were the total morphine during postoperative 0 hours to 24 hours, adverse events, and patient satisfaction with the analgesia. Sixty-one patients completed the study. VAS score on cough at each time point was significantly lower (p<0.05) and median (25th, 75th) morphine consumption was lower in the PVB group than in the infiltration group (26 [10, 35] mg and 42 [29, 58] mg, p<0.001, respectively). There was no difference in VAS score at rest. Patients in the PVB group had higher satisfaction with analgesia than in the infiltration group (p = 0.003). CONCLUSIONS As part of the multimodal postoperative analgesia, intraoperative paravertebral block provided better dynamic pain relief and reduced morphine consumption compared with local wound infiltration.
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Affiliation(s)
- Xuezheng Zhang
- Department of Anesthesiology, Affiliated Beijing Tongren Hospital, Capital Medical University, Beijing, China; Department of Anesthesiology, First Affiliated Hospital, Wenzhou Medical University, Wenzhou, China
| | - Luowa Shu
- Department of Anesthesiology, First Affiliated Hospital, Wenzhou Medical University, Wenzhou, China
| | - Chaoxi Lin
- Department of Cardiothoracic Surgery, First Affiliated Hospital, Wenzhou Medical University, Wenzhou, China
| | - Pei Yang
- Department of Anesthesiology, First Affiliated Hospital, Wenzhou Medical University, Wenzhou, China
| | - Ying Zhou
- Department of Pulmonary Medicine, First Affiliated Hospital, Wenzhou Medical University, Wenzhou, China
| | - Quanguang Wang
- Department of Anesthesiology, First Affiliated Hospital, Wenzhou Medical University, Wenzhou, China
| | - Yiquan Wu
- Department of Anesthesiology, First Affiliated Hospital, Wenzhou Medical University, Wenzhou, China
| | - Xuzhong Xu
- Department of Anesthesiology, First Affiliated Hospital, Wenzhou Medical University, Wenzhou, China
| | - Xu Cui
- Department of Anesthesiology, Affiliated Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Xiaoming Lin
- Department of Cardiothoracic Surgery, First Affiliated Hospital, Wenzhou Medical University, Wenzhou, China
| | - Lielie Jin
- Department of Anesthesiology, First Affiliated Hospital, Wenzhou Medical University, Wenzhou, China.
| | - Tianzuo Li
- Department of Anesthesiology, Affiliated Beijing Tongren Hospital, Capital Medical University, Beijing, China
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Specially Trained Registered Nurses Can Safely Manage Epidural Analgesia Infusion in Laboring Patients. J Perianesth Nurs 2015; 30:209-14. [DOI: 10.1016/j.jopan.2015.01.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 01/21/2015] [Accepted: 01/28/2015] [Indexed: 11/20/2022]
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Bajwa SJS, Bajwa SK. Anaesthetic challenges and management during pregnancy: Strategies revisited. Anesth Essays Res 2015; 7:160-7. [PMID: 25885826 PMCID: PMC4173524 DOI: 10.4103/0259-1162.118945] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
During pregnancy, an obstetrician can encounter various complications and sometimes require surgery or operative intervention for delivery. However, the role of anaesthesiologists during such clinical scenario is grossly under-estimated. Without any close coordination and team work among obstetricians, neonatologists and an anaesthesiologist, morbidity and mortality can increase during these surgical interventions. The clinical scenario can become more challenging if the parturient suffers from any comorbid diseases. The present article reviews some of the common challenging scenarios during pregnancy that an anaesthesiologist frequently encounters during routine practice. Anaesthetic management has been discussed briefly and separately for each trimester and post-partum period. The article also aims at gaining in-depth knowledge of these obstetrical and surgical emergencies so as to ensure close-knit team work among obstetricians, anaesthesiologists, intensivists and a neonatologist.
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Affiliation(s)
- Sukhminder Jit Singh Bajwa
- Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, Punjab, India
| | - Sukhwinder Kaur Bajwa
- Department of Obstetrics and Gynaecology, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, Punjab, India
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13
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Sng BL, Woo D, Leong WL, Wang H, Assam PN, Sia AT. Comparison of computer-integrated patient-controlled epidural analgesia with no initial basal infusion versus moderate basal infusion for labor and delivery: A randomized controlled trial. J Anaesthesiol Clin Pharmacol 2014; 30:496-501. [PMID: 25425774 PMCID: PMC4234785 DOI: 10.4103/0970-9185.142842] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Background and Aims: Computer-integrated patient-controlled epidural analgesia (CIPCEA) is a novel epidural drug delivery system. It automatically adjusts the basal infusion based on the individual's need for analgesia as labor progresses. Materials and Methods: This study compared the time-weighted local anesthetic (LA) consumption by comparing parturients using CIPCEA with no initial basal infusion (CIPCEA0) with CIPCEA with initial moderate basal infusion of 5 ml/H (CIPCEA5). We recruited 76 subjects after ethics approval. The computer integration of CIPCEA titrate the basal infusion to 5, 10, 15, or 20 ml/H if the parturient required respectively, one, two, three, or four patient demands in the previous hour. The basal infusion reduced by 5 ml/H if there was no demand in the previous hour. The sample size was calculated to show equivalence in LA consumption. Results: The time-weighted LA consumption between both groups were similar with CIPCEA0 group (mean [standard deviation (SD)] 8.9 [3.5] mg/H) compared to the CIPCEA5 group (mean [SD] 9.9 [3.5] mg/H), P = 0.080. Both groups had a similar incidence of breakthrough pain, duration of the second stage, mode of delivery, and patient satisfaction. However, more subjects in the CIPCEA0 group required patient self-bolus. There were no differences in fetal outcomes. Discussion: Both CIPCEA regimens had similar time-weighted LA consumption and initial moderate basal infusion with CIPCEA may not be required.
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Affiliation(s)
- Ban Leong Sng
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore ; Anesthesiology Program, Duke-NUS Graduate Medical School, Singapore
| | - David Woo
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore
| | - Wan Ling Leong
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore
| | - Hao Wang
- Anesthesiology Program, Duke-NUS Graduate Medical School, Singapore
| | - Pryseley Nkouibert Assam
- Centre for Quantitative Medicine, Duke-NUS Graduate Medical School, Singapore ; Singapore Clinical Research Institute, Singapore
| | - Alex Th Sia
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore ; Anesthesiology Program, Duke-NUS Graduate Medical School, Singapore
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Update on best available options in obstetrics anaesthesia: perinatal outcomes, side effects and maternal satisfaction. Fifteen years systematic literature review. Arch Gynecol Obstet 2014; 290:21-34. [PMID: 24659334 DOI: 10.1007/s00404-014-3212-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2013] [Accepted: 03/04/2014] [Indexed: 12/18/2022]
Abstract
PURPOSE In modern obstetrics, different pharmacological and non-pharmacological options allow to obtain pain relief during labour, one of the most important goals in women satisfaction about medical care. The aim of this review is to compare all the analgesia administration schemes in terms of effectiveness in pain relief, length of labour, mode of delivery, side effects and neonatal outcomes. METHODS A systematic literature search was conducted in electronic databases in the interval time between January 1999 and March 2013. Key search terms included: “labour analgesia”, “epidural anaesthesia during labour” (excluding anaesthesia for Caesarean section), “epidural analgesia and labour outcome” and “intra-thecal analgesia”. RESULTS 10,331 patients were analysed: 5,578 patients underwent Epidural-Analgesia, 259 patients spinal analgesia, 2,724 combined spinal epidural analgesia, 322 continuous epidural infusion (CEI), 168 intermittent epidural bolus, 684 patient-controlled infusion epidural analgesia and 152 intra-venous patient-controlled epidural analgesia. We also considered 341 women who underwent patient-controlled infusion epidural analgesia in association with CEI and 103 patients who underwent patient-controlled infusion epidural analgesia in association with automatic mandatory bolus. CONCLUSION No significant differences occurred among all the available administration schemes of neuraxial analgesia. In absence of obstetrical contraindication, neuraxial analgesia has to be considered as the gold standard in obtaining maternal pain relief during labour. The options available in the administration of analgesia should be known and evaluated together by both gynaecologists and anaesthesiologists to choose the best personalized scheme and obtain the best women satisfaction. Since it is difficult to identify comparable circumstances during labour, it is complicate to standardize drugs schemes and their combinations.
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Patient-controlled epidural levobupivacaine with or without fentanyl for post-cesarean section pain relief. BIOMED RESEARCH INTERNATIONAL 2014; 2014:965152. [PMID: 24982917 PMCID: PMC4055260 DOI: 10.1155/2014/965152] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 05/07/2014] [Indexed: 11/17/2022]
Abstract
PURPOSE The purpose of this study was to compare the analgesic properties of levobupivacaine with or without fentanyl for patient-controlled epidural analgesia after Cesarean section in a randomized, double-blinded study. METHODS We enrolled American Society of Anesthesiologists class I/II, full-term pregnant women at National Taiwan University Hospital who received patient-controlled epidural analgesia after Cesarean section between 2009 and 2010. Eighty women were randomly assigned into two groups. In group A, the 40 subjects received drug solutions made of 0.6 mg/ml levobupivacaine plus 2 mcg/ml fentanyl, and in group B the 40 subjects received 1 mg/ml levobupivacaine. Maintenance was self-administered boluses and a continuous background infusion. RESULTS There were no significant differences in the resting and dynamic pain scales and total volume of drug used between the two groups. Patient satisfaction was good in both groups. CONCLUSION Our study showed that pure epidural levobupivacaine can provide comparative analgesic properties to the levobupivacaine-fentanyl combination after Cesarean section. Pure levobupivacaine may serve as an alternative pain control regimen to avoid opioid-related adverse events in parturients.
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Azmude A, Agha'amou S, Yousefshahi F, Berjis K, Mirmohammad'khani M, Sadaat'ahmadi F, Ghods K, Dabbagh A. Pregnancy outcome using general anesthesia versus spinal anesthesia for in vitro fertilization. Anesth Pain Med 2013; 3:239-42. [PMID: 24282775 PMCID: PMC3833042 DOI: 10.5812/aapm.11223] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Revised: 04/16/2013] [Accepted: 06/18/2013] [Indexed: 11/16/2022] Open
Abstract
Background There is a considerable rate of fertility failure and this causes a great burden of untoward effects for patients. Usually a considerable number of these patients undergo anesthesia for their treatment. Objectives This study was designed to compare the effects of general and spinal anesthesia on these patients. Patients and Methods In a randomized clinical trial, after taking informed written consent from the patients, 200 patients entered the study; 100 in each. During a 2 year period, women aged 20 to 40 years entered the study (one group receiving spinal anesthesia and the other, receiving general anesthesia). Ovum retrieval protocols were the same. Nonparametric and parametric analyses were used for data analysis. P value less than 0.05 was considered significant. Results There was no difference between the two groups regarding demographic variables. 15 of 100 patients (15%) in the general anesthesia group and 27 of 100 patients (27%) in the spinal anesthesia group had successful pregnancy after IVF; so, spinal anesthesia increased significantly the chance of IVF success (P value < 0.001; Chi Square). Conclusions The results of this study demonstrated that spinal anesthesia increased the chance of fertilization success.
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Affiliation(s)
- Azra Azmude
- Department of OBGYN, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahrzad Agha'amou
- Department of OBGYN, Tehran University of Medical Sciences, Tehran, Iran
| | - Fardin Yousefshahi
- Department of Anesthesiology, Tehran University of Medical Sciences, Tehran, Iran
| | - Katayoun Berjis
- Department of OBGYN, Tehran University of Medical Sciences, Tehran, Iran
| | - Majid Mirmohammad'khani
- Research Center for Social Determinants of Health, Department of Community Medicine , Semnan University of Medical Sciences, Semnan, Iran
| | | | - Kamran Ghods
- Department of Cardiac Surgery, Semnan University of Medical Sciences, Semnan, Iran
| | - Ali Dabbagh
- Anesthesiology Research Center, Shahid Beheshti University of Medicine, Tehran, Iran
- Corresponding author: Ali Dabbagh, Anesthesiology Research Center, Shahid Beheshti University of Medicine, Tehran, Iran. Tel: +98-9121972368, Fax: +98-2122432572, E-mail:
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Sultan P, Murphy C, Halpern S, Carvalho B. The effect of low concentrations versus high concentrations of local anesthetics for labour analgesia on obstetric and anesthetic outcomes: a meta-analysis. Can J Anaesth 2013; 60:840-54. [DOI: 10.1007/s12630-013-9981-z] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Revised: 06/13/2013] [Accepted: 06/13/2013] [Indexed: 02/01/2023] Open
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Hermanides J, Hollmann M, Stevens M, Lirk P. Failed epidural: causes and management. Br J Anaesth 2012; 109:144-54. [DOI: 10.1093/bja/aes214] [Citation(s) in RCA: 234] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Haydon ML, Larson D, Reed E, Shrivastava VK, Preslicka CW, Nageotte MP. Obstetric outcomes and maternal satisfaction in nulliparous women using patient-controlled epidural analgesia. Am J Obstet Gynecol 2011; 205:271.e1-6. [PMID: 22071061 DOI: 10.1016/j.ajog.2011.06.041] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2011] [Revised: 05/02/2011] [Accepted: 06/09/2011] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The purpose of this study was to compare obstetric outcomes and maternal satisfaction in nulliparous women in spontaneous labor who used patient-controlled epidural analgesia (PCEA) vs continuous epidural infusion (CEI). STUDY DESIGN We conducted a double-masked trial of 270 nulliparous women who were assigned randomly to 3 groups (with a concentration 0.1% bupivacaine and 2 μg/mL fentanyl): group I, CEI-only (10 mL/h); group II, CEI + PCEA (CEI 10 mL/h plus PCEA 10 mL, at 20 minutes); group III, PCEA-only (10 mL, at 20 minutes). A PCEA bolus button was given to each subject. The primary outcome was the dosage of local anesthetic that was used. RESULTS The total milligrams of bupivacaine that were used was less in the PCEA-only group compared with CEI: group I. 74.8 ± 36 mg; group II, 97.3 ± 53 mg; group III, 52.4 ± 42 mg (P < .001). Pain with pushing, however, was worse in the PCEA-only group. Median satisfaction scores were similar (scale, 0 [best] to 100 [worst]: group I, 0; group II, 0; group III, 0 (P = .23). CONCLUSION PCEA results in less anesthetic used, and maternal satisfaction remains high without a continuous infusion. Pain with pushing, however, was worse with the PCEA alone.
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Matsota P, Batistaki C, Apostolaki S, Kostopanagiotou G. Patient-controlled epidural analgesia after Caesarean section: levobupivacaine 0.15% versus ropivacaine 0.15% alone or combined with fentanyl 2 µg/ml: a comparative study. Arch Med Sci 2011; 7:685-93. [PMID: 22291806 PMCID: PMC3258763 DOI: 10.5114/aoms.2011.24140] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2010] [Revised: 10/13/2010] [Accepted: 12/14/2010] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The aim of this study was to compare the postoperative analgesic efficacy of epidural ropivacaine 0.15%, levobupivacaine 0.15% and ropivacaine 0.15% plus fentanyl 2 µg/ml, used with a patient-controlled epidural analgesia (PCEA) device after Caesarean section. MATERIAL AND METHODS Sixty women undergoing elective Caesarean section under combined spinal-epidural anaesthesia were enrolled. Postoperatively, patients received PCEA with either ropivacaine or levobupivacaine 0.15% (basal rate 6 ml/h, bolus 5 ml/20 min), or ropivacaine 0.15% plus fentanyl 2 µg/ml (basal rate 6 ml/h, bolus 4 ml/20 min). Sympathetic and sensory level of analgesia, motor ability (Bromage 0-3), and pain scores at rest, movement and cough (VAS 0-10), haemodynamic parameters, oxygenation, side effects and total doses of local anaesthetic were documented every 6 h for 24 h. Patient satisfaction was assessed using a descriptive scale. RESULTS No significant difference was observed in pain scores at all time intervals. A significantly higher sympathetic and sensory blockade occurred with levobupivacaine and ropivacaine 0.15% compared to ropivacaine 0.15% plus fentanyl, with no significant difference in total local analgesic consumption at 24 h (p = 0.08). Rescue analgesic requirements did not differ between the groups (p = 0.8) while patients' satisfaction was significantly higher in the ropivacaine 0.15% plus fentanyl group (p = 0.02). Haemodynamics, oxygenation, nausea, pruritus and numbness did not differ between the groups. CONCLUSIONS Dilute local anaesthetic solutions provided satisfactory postoperative analgesia after Caesarean section when used with a PCEA device. The combination of ropivacaine 0.15% with fentanyl 2 µg/ml appeared superior, since it provided higher patient satisfaction with statistically equal pain scores and local anaesthetic consumption.
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Affiliation(s)
- Paraskevi Matsota
- 2 Department of Anaesthesiology, University of Athens, School of Medicine, "Attikon" University Hospital, Athens, Greece
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Abstract
Advances in the field of labour analgesia have tread a long journey from the days of ether and chloroform in 1847 to the present day practice of comprehensive programme of labour pain management using evidence-based medicine. Newer advances include introduction of newer techniques like combined spinal epidurals, low-dose epidurals facilitating ambulation, pharmacological advances like introduction of remifentanil for patient-controlled intravenous analgesia, introduction of newer local anaesthetics and adjuvants like ropivacaine, levobupivacaine, sufentanil, clonidine and neostigmine, use of inhalational agents like sevoflourane for patient-controlled inhalational analgesia using special vaporizers, all have revolutionized the practice of pain management in labouring parturients. Technological advances like use of ultrasound to localize epidural space in difficult cases minimizes failed epidurals and introduction of novel drug delivery modalities like patient-controlled epidural analgesia (PCEA) pumps and computer-integrated drug delivery pumps have improved the overall maternal satisfaction rate and have enabled us to customize a suitable analgesic regimen for each parturient. Recent randomized controlled trials and Cochrane studies have concluded that the association of epidurals with increased caesarean section and long-term backache remains only a myth. Studies have also shown that the newer, low-dose regimes do not have a statistically significant impact on the duration of labour and breast feeding and also that these reduce the instrumental delivery rates thus improving maternal and foetal safety. Advances in medical technology like use of ultrasound for localizing epidural space have helped the clinicians to minimize the failure rates, and many novel drug delivery modalities like PCEA and computer-integrated PCEA have contributed to the overall maternal satisfaction and safety.
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Affiliation(s)
- Sunil T Pandya
- Department of Anaesthesia, Pain and Critical Care, Fernandez Hospital (Hospital for Women and Newborns) and Prerna Anaesthesia and Critical Care Services Pvt. Ltd., Hyderabad - 500 001, India
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Bazin M, Bonnin M, Storme B, Bolandard F, Vernis L, Lavergne B, Pereira B, Bazin JE, Dualé C. Addition of clonidine to a continuous patient-controlled epidural infusion of low-concentration levobupivacaine plus sufentanil in primiparous women during labour. Anaesthesia 2011; 66:769-79. [DOI: 10.1111/j.1365-2044.2011.06785.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Loubert C, Hinova A, Fernando R. Update on modern neuraxial analgesia in labour: a review of the literature of the last 5 years. Anaesthesia 2011; 66:191-212. [DOI: 10.1111/j.1365-2044.2010.06616.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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López de Hierro CF. [Obstetric anesthesia: a challenge now in our hands]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2011; 58:3-5. [PMID: 21348210 DOI: 10.1016/s0034-9356(11)70690-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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Tixier S, Bonnin M, Bolandard F, Vernis L, Lavergne B, Bazin JE, Dualé C. Continuous patient-controlled epidural infusion of levobupivacaine plus sufentanil in labouring primiparous women: effects of concentration*. Anaesthesia 2010; 65:573-580. [DOI: 10.1111/j.1365-2044.2010.06369.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Affiliation(s)
- Joy L Hawkins
- Department of Anesthesiology, University of Colorado Denver School of Medicine, Aurora, CO 80045, USA.
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Van de Velde M. Modern neuraxial labor analgesia: options for initiation, maintenance and drug selection. ACTA ACUST UNITED AC 2010; 56:546-61. [PMID: 20112546 DOI: 10.1016/s0034-9356(09)70457-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
In the present review we outline the state-of-the-art of neuraxial analgesia. As neuraxial analgesia remains the gold standar of analgesia during labor, we review the most recent literature on this topic. The neuraxial analgesia techniques, types of administration, drugs, adjuvants, and adverse effects are investigated from the references. Most authors would agree that central neuraxial analgesia is the best form to manage labor pain. When neuraxial analgesia is administered to the parturient in labor, different management choices must be made by the anesthetist: how will we initiate analgesia, how will analgesia be maintained, which local anesthetic will we use for neuraxial analgesia and which adjuvant drugs will we combine? The present manuscript tries to review the literature to answer these questions.
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Affiliation(s)
- M Van de Velde
- Department of Anesthesiology, University Hospitals Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium.
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Sullivan JT. What's New in Obstetric Anesthesia: The 2009 Gerard W. Ostheimer Lecture. Anesth Analg 2010; 110:564-9. [DOI: 10.1213/ane.0b013e3181c8513f] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Lim Y, Supandji M, Teoh W, Ocampo C, Sia AT. In Response:. Anesth Analg 2009. [DOI: 10.1213/ane.0b013e3181b763ff] [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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Turkstra TP, Jones PM. Is there evidence for improved maternal satisfaction with patient-controlled epidural anesthesia? Anesth Analg 2009; 109:1344; author reply 1345-6. [PMID: 19762768 DOI: 10.1213/ane.0b013e3181ad83c2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Lim Y, Ocampo CE, Supandji M, Teoh WHL, Sia AT. Patient-Controlled Epidural Analgesia Regimens for Labor Analgesia: Background Infusion or Demand-Only? Anesth Analg 2009. [DOI: 10.1213/ane.0b013e3181a670ab] [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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Koopmans N, Wietasch GJK, Struys MMRF. Patient-controlled epidural analgesia regimens for labor analgesia: background infusion or demand-only? Anesth Analg 2009; 109:284; author reply 284-5. [PMID: 19535723 DOI: 10.1213/ane.0b013e3181a67096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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