Ropivacaine Versus Bupivacaine for Epidural Labor Analgesia

Comparative efficacy of opioid and non-opioid analgesics in labor pain management: A network meta-analysis

BACKGROUND

Effective labor pain management is crucial for parturient well-being, as it can improve the delivery experience of pregnant women and reduce anxiety and tension. This systematic review and network meta-analysis compared the efficacy and safety of various analgesics, classified by drug category and individual treatment methods, for labor pain control.

METHODS

A comprehensive literature search was conducted in Pubmed, EMBASE, Cochrane Library, and Web of Science databases. All searches commenced from the database's inception to the date of the literature search (May 31, 2023). The Cochrane Risk of Bias 2 tool assessed study bias risk. Network meta-analyses using a random-effects model and odds ratios (ORs) with 95% confidence intervals (CIs) were performed.

RESULTS

Fifteen randomized controlled trials evaluating analgesic interventions in ASA I or II parturients were included. Combination therapies (OR: 5.81; 95% CI, 3.76-7.84; probability: 60%) and non-opioid analgesics (OR: 5.61; 95% CI, 2.91-8.30; probability: 39.2%) were superior to placebo for labor pain relief. Specifically, dexmedetomidine/ropivacaine/sufentanil (OR: 7.32; 95% CI, 2.73-11.89; probability: 40.6%) and dexmedetomidine/ropivacaine (OR: 6.50; 95% CI, 2.51-10.33; probability: 11.9%) combinations, bupivacaine/fentanyl and ropivacaine/sufentanil combinations, and remifentanil monotherapy showed improved analgesic efficacy versus placebo. Dexmedetomidine/ropivacaine reduced parturient nausea and vomiting versus alternatives.

CONCLUSION

Non-opioids, opioids and combinations thereof effectively relieved labor pain. In addition, dexmedetomidine/ropivacaine combination demonstrated analgesic efficacy and lower nausea and vomiting incidence.

Whole-course application of dexmedetomidine as an adjuvant to spinal-epidural anesthesia for cesarean section: A randomized, controlled trial

Background

Dexmedetomidine is known to prolong the analgesic duration of spinal anesthesia, but it can be challenging to achieve further extension without opioids. Therefore, this study aimed to investigate a novel analgesic strategy using dexmedetomidine as an adjuvant to spinal-epidural anesthesia for elective cesarean surgery.

Methods

The study was a randomized, double-blind, controlled trial conducted at a single center. Sixty parturients who underwent elective cesarean were randomly assigned to either group C or group D. Group D received an intrathecal injection of 12.5 mg ropivacaine and 5 μg dexmedetomidine followed by continuous epidural patient-controlled analgesia (PCA) infusion with a total volume of 100 ml, containing 0.2 % ropivacaine and 0.5 μg/kg dexmedetomidine. Group C received an intrathecal injection of 12.5 mg ropivacaine with an equivalent saline placebo followed by a similar PCA infusion, containing 0.2 % ropivacaine and an equivalent saline placebo.

Results

The primary outcome was visual analog scale score on movement at 24 h after surgery. The results showed that the rest and motion pain scores in group D were significantly lower than those in group C at 6 h, 12 h, and 24 h after surgery (P < 0.05), with the differences at 24 h were 5.0 (5.0, 5.0)in group D versus 5.0 (5.0, 6.0) in group C (P = 0.04). Additionally, the time to the first PCA in group D was significantly longer than that in group C (P < 0.05), as well as the time of sensory and motor recovery.

Conclusions

Whole-course application of dexmedetomidine as an adjuvant to spinal-epidural anesthesia could effectively extend the analgesic duration of ropivacaine to 24 h following elective cesarean surgery.

Effect of esketamine on postpartum depression after labor analgesia and potential mechanisms: a randomized, double-blinded controlled trial

BACKGROUND

To evaluate the effect of esketamine combined with ropivacaine hydrochloride on the occurrence of postpartum depression (PPD) after labor analgesia under epidural analgesia pump and explore the possible mechanisms.

METHODS

A total of 120 women aged 24 to 36 years old who underwent labor analgesia by epidural analgesia pump, with American Society of Anesthesiologists (ASA) physical status II were enrolled. According to the formula of epidural analgesia pump, all participants were randomly divided into two groups: esketamine group (Group E) and control group (Group C). Epidural anaesthesia were operated in all women between L2 and L3 after cervical dilation up to 2 ~ 3 cm. After successful puncture, the epidural catheter was placed 3.5 cm toward the head and 1% lidocaine was injected for 3 ml. The epidural analgesia pump was connected. Esketamine (0.2 mg/kg) combined with 0.75% ropivacaine hydrochloride (20 ml) were diluted by normal saline up to 100 ml in Group E, when only the equal dose of ropivacaine hydrochloride was used in Group C. The visual analogue scale (VAS) before analgesia (T1), 5 (T2), 10 (T3) and 20 (T4) minutes after analgesia were measured. The duration of the first and second stage of labor, the Apgar score of fetus at delivery, postpartum hemorrhage, consumption of esketamine and ropivacaine were recorded. The incidence of PPD was recorded at 1 week and 6 weeks after delivering. The occurrence of side effects such as nausea and vomiting, dizziness, and nightmares were also recorded for 48 h after delivering. The levels of leptin, norepinephrine(NE), and epinephrine(E) in the peripheral venous blood were measured before labor analgesia and at 24 h, 1 week, and 6 weeks after delivering.

RESULTS

Compared with Group C, the VAS score at T2, T3 and T4 were significantly lower in Group E (P < 0.01). Compared with Group C, the incidence of PPD was significantly lower at 1 week and 6 weeks after delivering in Group E (P < 0.01). Compared with Group C, the levels of leptin were significantly higher at 24 h and 1 week after delivering in Group E (P < 0.01), while NE and E (P < 0.01) were lower at the same time (P < 0.01). There were no significant difference of the duration of the first and second stage of labor, the Apgar score of fetus at delivery, postpartum hemorrhage, consumption of ropivacaine and the side effects for 48 h after delivering between the two groups.

CONCLUSION

Esketamine combined with ropivacaine hydrochloride used in labor analgesia can significantly reduce the incidence of postpartum depression after delivering without increasing related side effects, which may be related to the regulation of leptin, norepinephrine, and epinephrine in the serum.

TRIAL REGISTRATION

The trial was registered at the Chinese Clinical Trial Registry on 30/05/2022 (CTRI registration number-ChiCTR2200060387). URL of registry: https://www.chictr.org.cn/bin/home .

Onset Time of Lumbar Erector Spinae Plane Block Compared with Its Thoracic Counterpart: Case Reports

The erector spinae plane block (ESPB) at the level of the fifth thoracic vertebra (T5) is a novel technique, first published in 2016, which was found to be effective in both acute and chronic pain control. The mechanism of action and spread of local anesthetic of the ESPB at the lumbar region are thought to differ from those of the thoracic ESPB; however, the difference in onset time has never been evaluated. As for the onset of lumbar ESPBs, we presented three cases: two received lumbar ESPBs (one with chronic low back pain and one with acute postoperative hip pain), and the third one with chronic back pain received a thoracic ESPB. We administered 30 mL of 0.3% ropivacaine in all three patients, but the analgesic effect did not reach its maximum until 3 and 1.5 h, respectively, in the lumbar ESPB cases. On the contrary, the thoracic ESPB case experienced noticeable pain relief within 30 min. The onset time was considerably longer than that reported in earlier reports on ESPBs, and the lumbar ESPB achieved its peak effect much later than the thoracic ESPB using the same formula of local anesthetic. While the delayed-onset lumbar ESPB may have some drawbacks for treating acute postoperative pain, it still could produce significant analgesia, once it took effect, when given to patients suffering from hip surgery with large incisions and intractable low back pain. The current data suggested that the onset time of a lumbar ESPB may be delayed compared with its thoracic counterpart. Therefore, the local anesthetic formula and injection timing should be adjusted for a lumbar ESPB when applied in the perioperative period to make the onset of the analgesic effect coincide with the immediate postoperative pain. Without this concept in mind, clinicians may consider a lumbar ESPB to be ineffective before it takes effect, and consequently treat the patients inadequately with this technique. Future randomized controlled trials should be designed according to our observations to compare lumbar ESPB with its thoracic counterpart regarding onset time.

Neuraxial labor analgesia: Maintenance techniques

Since the advent of neuraxial analgesia for labor, approaches to maintaining intrapartum pain relief have seen significant advancement. Through pharmacologic innovations and improved drug delivery mechanisms, current neuraxial labor analgesia maintenance techniques have been shaped by efforts to maximize patient comfort during the birthing process, while minimizing undesirable side effects and promoting the unimpeded progress of labor. To these ends, a modern anesthesiologist may avail themselves of several techniques, including programmed intermittent epidural bolus (PIEB), patient controlled epidural analgesia (PCEA) and dilute concentration local anesthetic + opioid epidural solutions. We explore the historical development and the evidential underpinnings of these techniques, in addition to several contemporary neuraxial labor analgesia practices. We also summarize current understanding of the effects these interventions have on maternal/fetal health and the labor course, as well as several important aspects of analgesic safety and monitoring.

Epidural analgesia in labor: A narrative review

Lumbar epidural is the most effective form of pain relief in labor with around 30% of laboring women in the UK and 60% in the USA receiving epidural analgesia. Associations of epidural on maternal, obstetric, and neonatal outcomes have been the subject of intense study, though a number of uncertainties persist. The present narrative review explores important areas of research surrounding epidural analgesia in obstetric patients including methods of initiation and administration, choice of local anesthetic solution, and the addition of adjuvants. Key meta-analyses exploring associations of epidural analgesia on maternal and neonatal outcomes are identified and summarized.

Impact of epidural labor analgesia using sufentanil combined with low-concentration ropivacaine on maternal and neonatal outcomes: a retrospective cohort study

BACKGROUND

Whether epidural administered sufentanil combined with low-concentration ropivacaine affected labor progress as well as maternal and neonatal outcomes still remained unknown. The aim of this study was to assess the impact of epidural sufentanil plus ropivacaine on maternal and neonatal outcomes.

METHODS

This is a retrospective cohort study. Data of singleton full-term pregnancy women who received epidural labor analgesia for vaginal delivery from May 2018 to June 2020 were collected. Parturients were divided into two groups (the R group and the SR group) according to different medication regimens for epidural labor analgesia. The implementation of epidural analgesia during labor was performed with 0.167 % ropivacaine in the R group and 0.1 % ropivacaine in combination with 0.5 µg/ml sufentanil in the SR group. The primary outcome of our study included the duration of labor progress and the incidence of maternal fever, postpartum hemorrhage, fetal distress and neonatal Apgar scores less than 7 at 1 and 5 min. The secondary outcome included the incidence of episiotomy, instrumental delivery, caesarean section and grade III meconium-stained amniotic fluid.

RESULTS

There were a total 3778 deliveries during the study period, 1994 and 1784 parturients were included in the R group and in the SR group, respectively. The length of the first stage of labor was remarkably shorter in the R group in comparison to the SR group (548.0 ± 273.0 vs. 570.9 ± 273.0, P = 0.013). No significant difference was found in the incidence of maternal fever, postpartum hemorrhage, fetal distress and in the neonatal Apgar scores less than 7 at 1 and 5 min between two groups. Other Maternal outcomes were comparable in the R group and the SR group.

CONCLUSIONS

0.5 µg/ml sufentanil plus 0.1 % ropivacaine for epidural labor analgesia prolonged the duration of the first stage of labor, but did not have additional impact on maternal and neonatal outcomes compared with the sole 0.167 % ropivacaine.

TRIAL REGISTRATION

Clinical Research Information Service with registration number ChiCTR2100045162 . Registered 7 April 2021.

Simultaneous Determination of Ropivacaine and 3-Hydroxy Ropivacaine in Cerebrospinal Fluid by UPLC-MS/MS

In this paper, a UPLC-MS/MS method was developed for the determination of ropivacaine and its metabolite 3-hydroxy ropivacaine in cerebrospinal fluid. The cerebrospinal fluid was processed by ethyl acetate liquid-liquid extraction. The multiple reaction monitoring (MRM) mode was used for quantitative analysis by monitoring the transitions of m/z 275.3 → 126.2 for ropivacaine, m/z 291.0 → 126.0 for 3-hydroxy ropivacaine, and m/z 290.2 → 198.2 for the internal standard. Standard curves for ropivacaine and 3-hydroxy ropivacaine in cerebrospinal fluid were conducted over the concentration range of 0.2–2000 ng/mL, demonstrating excellent linearity, and the lower limit of quantification was 0.2 ng/mL. The intraday precision of ropivacaine and 3-hydroxy ropivacaine was less than 11%, while the interday precision was less than 7%. The accuracy ranged between 87% and 107%, the average extraction efficiency was higher than 79%, and the matrix effect was between 89% and 98%. The developed method was then applied to a case of suspected poisoning of ropivacaine.

Regional Anesthetic Blocks for Donor Site Pain in Burn Patients: A Meta-Analysis on Efficacy, Outcomes, and Cost

Background

Skin graft donor site pain significantly affects pain management, narcotic use, and hospital length of stay. This study is intended to evaluate the efficacy of regional anesthesia in the burn population to decrease narcotic consumption and to assess the impact on hospitalization costs.

Methods

PubMed/MEDLINE, Embase, and ScienceDirect were searched with the following inclusion criteria: comparative studies, adult populations, burn patients, autologous skin grafting, regional nerve blocks, and traditional narcotic regimens. Outcomes assessed included narcotic consumption, pain scores, and opioid side effects. Meta-analysis obtained pooled values for morphine consumption and side effects. Cost analysis was performed using published data in the literature.

Results

Final analysis included 101 patients. Cumulative morphine consumption at 72 hours was lower for patients treated with regional anesthesia versus patient-controlled analgesia (PCA; single shot 25 ± 12 mg, continuous regional 23 ± 16 mg, control 91.5 ± 24.5 mg; P < .05). Regional anesthesia decreased nausea/vomiting (P < .05) and lowered subjective pain scores. Regional anesthesia interventions cost less than PCA, single shot less than continuous (P < .05).

Conclusion

Regional anesthesia at skin graft donor sites significantly decreases narcotic consumption in burn patients. Regional anesthesia is cost-effective, decreases side effects, and may result in shorter hospital stays due to improved pain management.

Comparative Effectiveness of Transversus Abdominis Plane Blocks in Abdominally Based Autologous Breast Reconstruction: A Systematic Review and Meta-analysis

BACKGROUND

The abdomen is the most common donor site in autologous microvascular free flap breast reconstruction and contributes significantly to postoperative pain, resulting in increased opioid use, length of stay, and hospital costs. Enhanced Recovery After Surgery (ERAS) protocols have demonstrated multiple clinical benefits, but these protocols are widely heterogeneous. Transversus abdominis plane (TAP) blocks have been reported to improve pain control and may be a key driver of the benefits seen with ERAS pathways.

METHODS

A systematic review and meta-analysis of studies reporting TAP blocks for abdominally based breast reconstruction were performed. Studies were extracted from 6 public databases before February 2019 and pooled in accordance with the PROSPERO registry. Total opioid use, postoperative pain, length of stay, hospital cost, and complications were analyzed using a random effects model.

RESULTS

The initial search yielded 420 studies, ultimately narrowed to 12 studies representing 1107 total patients. Total hospital length of stay (mean difference, -1.00 days; P < 0.00001; I = 81%) and opioid requirement (mean difference, -133.80 mg of oral morphine equivalent; P < 0.00001; I = 97%) were decreased for patients receiving TAP blocks. Transversus abdominis plane blocks were not associated with any significant differences in postoperative complications (P = 0.66), hospital cost (P = 0.22), and postoperative pain (P = 0.86).

CONCLUSIONS

Optimizing postoperative pain management after abdominally based microsurgical breast reconstruction is invaluable for patient recovery. Transversus abdominis plane blocks are associated with a reduction in length of stay and opioid use, representing a safe and reasonable strategy for decreasing postoperative pain.

Involvement of TREK-1 Channel in Cell Viability of H9c2 Rat Cardiomyoblasts Affected by Bupivacaine and Lipid Emulsion

Lipid emulsion (LE) therapy has been used to reduce overdose of bupivacaine (BPV)-induced cardiotoxicity. The TWIK-related potassium channel-1 (TREK-1) is inhibited by BPV and activated by polyunsaturated fatty acids, which are the main component in LE. These pharmacological properties inspired us to investigate whether the TREK-1 channel is associated with cell viability of H9c2 cardiomyoblasts affected by BPV and LE. Consistent with previous studies, BPV-induced cell death was reduced by LE treatment. The reduction in the TREK-1 expression level by BPV was alleviated by LE. The BPV cytotoxicity highly decreased in TREK-1 overexpressed cells but was the opposite in TREK-1 knocked-down cells. TREK-1 channel activators and inhibitors increased and decreased cell viability, respectively. BPV-induced depolarization of the plasma and mitochondrial membrane potential and increase in intracellular Ca²⁺ level were blocked by LE treatment. BPV-induced depolarization of membrane potential was reduced in TREK-1 overexpressed cells, indicating that TREK-1 channels mediate setting the resting membrane potentials as a background K⁺ channel in H9c2 cells. These results show that TREK-1 activity is involved in the BPV cytotoxicity and the antagonistic effect of LE in H9c2 cells and suggest that TREK-1 could be a target for action of BPV and LE.

Neuraxial labor analgesia: a literature review

The use of analgesia techniques for labor has become increasingly frequent, with neuraxial techniques being the most commonly used and most effective. Labor pain entails a number of physiological consequences that may be negative for the mother and fetus, and therefore must be treated. This literature review was performed through a search in the PubMed database, from July to November 2016, and included articles in English or Portuguese, published between 2011 and 2016 or anteriorly, if relevant to the topic. The techniques were divided into the following topics: induction (epidural, combined epidural-spinal, continuous spinal, and epidural with dural puncture) and maintenance of analgesia (continuous epidural infusion, patient-controlled epidural analgesia, and intermittent epidural bolus). Epidural analgesia does not alter the incidence of cesarean sections or fetal prognosis, and maternal request is a sufficient indication for its initiation. The combined technique has the advantage of a faster onset of analgesia; however, patients are subject to a higher incidence of pruritus resulting from the intrathecal administration of opioids. Patient-controlled analgesia seems to be an excellent technique, reducing the consumption of local anesthetics, the number of anesthesiologist interventions, and increasing maternal satisfaction.

Comparison of dexmedetomidine and sufentanil as adjuvants to local anesthetic for epidural labor analgesia: a randomized controlled trial

Background

The epidural dexmedetomidine combined with ropivacaine has been successfully used for labor analgesia. We compared the effects of dexmedetomidine and sufentanil as adjuvants to local anesthetic for epidural labor analgesia.

Methods

Eighty nulliparous women were enrolled in the double-blind study and randomly divided into two groups. Group D received 0.5 µg/mL dexmedetomidine with 0.1% ropivacaine for epidural labor analgesia, and group S (control group) received 0.5 µg/mL sufentanil with 0.1% ropivacaine for labor analgesia. Hemodynamic parameters were monitored. Pain was assessed using a visual analog scale. The onset of epidural analgesia, duration of stages of labor, Ramsay Sedation Scale, blood loss, neonatal Apgar scores, umbilical artery blood pH and adverse effects, such as respiratory depression, nausea, vomiting, pruritus, and bradycardia, were recorded.

Results

Compared with the control group, visual analog scale values after cervical dilation >3 cm were lower in group D (P<0.05) and first-stage labor duration was shorter in group D (378.5±52.6 vs 406.5±58.2, P<0.05). Ramsay Sedation Scale values were higher in group D compared to the control group (2.8±0.6 vs 2.4±0.5, P<0.05). No significant differences in side effects were observed between the groups.

Conclusion

Dexmedetomidine is superior to sufentanil in analgesic effect and duration in first-stage labor during epidural analgesia when combined with 0.1% ropivacaine (www.chictr.org.cn, registration ChiCTR-OPC-16008548).

Ropivacaína isolada ou associada à metadona ou à morfina, pela via epidural, em cadelas submetidas à ovário-histerectomia

RESUMO Objetivou-se avaliar os efeitos fisiológicos, sedativos e analgésicos da administração peridural de ropivacaína isolada ou associada à morfina ou à metadona. Para tal, 24 cadelas submetidas à ovário-histerectomia receberam acepromazina, e a anestesia foi induzida e mantida com propofol e isoflurano (FiO2 = 1,0), respectivamente. De acordo com o protocolo peridural, formaram-se três grupos de igual número: GR (ropivacaína - 2,0mg/kg); GRMETA (ropivacaína - 2,0mg/kg e metadona - 0,3mg/kg) e GRMORF (ropivacaína - 2,0mg/kg e morfina - 0,1mg/kg). Registraram-se os parâmetros fisiológicos intraoperatórios e os graus de sedação e analgesia pós-operatórios. No GR constataram-se maiores médias de pressões arteriais 30 minutos após a anestesia epidural em relação ao GRMETA (sistólica e média) e ao final do procedimento cirúrgico comparativamente ao GRMORF (sistólica, diastólica e média). Não foram observadas diferenças significativas entre os grupos relativamente à analgesia e ao grau de sedação pós-operatórios. A administração epidural de ropivacaína é segura e eficaz e proporciona boa analgesia, independentemente da sua associação com morfina ou metadona.

[Neuraxial labor analgesia: a literature review]

The use of analgesia techniques for labor has become increasingly frequent, with neuraxial techniques being the most commonly used and most effective. Labor pain entails a number of physiological consequences that may be negative for the mother and fetus, and therefore must be treated. This literature review was performed through a search in the PubMed database, from July to November 2016, and included articles in English or Portuguese, published between 2011 and 2016 or anteriorly, if relevant to the topic. The techniques were divided into the following topics: induction (epidural, combined epidural-spinal, continuous spinal, and epidural with dural puncture) and maintenance of analgesia (continuous epidural infusion, patient-controlled epidural analgesia, and intermittent epidural bolus). Epidural analgesia does not alter the incidence of cesarean sections or fetal prognosis, and maternal request is a sufficient indication for its initiation. The combined technique has the advantage of a faster onset of analgesia; however, patients are subject to a higher incidence of pruritus resulting from the intrathecal administration of opioids. Patient-controlled analgesia seems to be an excellent technique, reducing the consumption of local anesthetics, the number of anesthesiologist interventions, and increasing maternal satisfaction.

Preoperative Assessment of the Pregnant Patient Undergoing Nonobstetric Surgery

The anesthetic management of pregnant patients can present a variety of challenges and a thorough preoperative assessment is necessary before initiating any anesthetic services. Both the mother and the fetus need to be considered when formulating an anesthetic plan and discussing informed consent. The overall aims in assessing a pregnant patient are to identity potential issues that can lead to catastrophic complications, provide adequate information allowing the mother to make informed decisions, and to obtain knowledge for tailoring an anesthetic that maintains maternal and fetal homeostasis.

Effect of operative local anesthesia on postoperative pain outcomes of inflatable penile prosthesis: prospective comparison of two medications

Few studies have examined the roles of dorsal penile nerve block (DPNB) and penile ring block (PRB) in surgery of inflatable penile prosthesis (IPP) placement. We sought to compare the postoperative pain outcomes of two different medications used in DPNB plus PRB. We thus carried out a prospective study of patients with erectile dysfunction who underwent "de novo" IPP placement between January 2013 and June 2013. Patients were divided to one of three groups: 1-DPNB plus PRB with bupivacaine injection; 2-DPNB plus PRB with ropivacaine injection and, 3-Control group without DPNB or PRB injection. Postoperative pain score and pain medication usage were recorded 2 h postoperatively, and every 24 h, for a week. The Visual Analog Scale (VAS) was used as pain scale measurement. A total of 131 patients were included in this study: 40 to bupivacaine, 47 to ropivacaine, and the rest were controls. Two hours postoperatively, mean VAS was significantly different (p < 0.0001) between medicated patients and the control group, however, no significant differences were observed between medication groups. Mean VAS was not significantly different among the groups from post-surgical day 2 thru 7. In conclusion, DPNB plus PRB during IPP provided effective analgesia in the immediate post-operative recovery.

Effect of Thoracic Epidural Ropivacaine versus Bupivacaine on Lower Urinary Tract Function

Background

Thoracic epidural analgesia with bupivacaine resulted in clinically relevant postvoid residuals due to detrusor underactivity. This study aimed to compare the risk of bladder dysfunction with ropivacaine versus bupivacaine using postvoid residuals and maximum flow rates. Our hypothesis was that ropivacaine would result in lower postvoid residuals, because ropivacaine has been shown to have less effect on motor blockade.

Methods

In this single-center, parallel-group, randomized, double-blind superiority trial, 42 patients undergoing open renal surgery were equally allocated to receive epidural bupivacaine 0.125% or ropivacaine 0.2%, and 36 were finally included. Inclusion criterion was normal bladder function. Patients underwent urodynamic investigations preoperatively and during thoracic epidural analgesia. Primary outcome was the difference in postvoid residual preoperatively and during thoracic epidural analgesia postoperatively. Secondary outcomes were changes in maximum flow rate between and within the groups.

Results

Median difference in postvoid residual (ml) from baseline to postoperatively was 300 (range, 30 to 510; P &lt; 0.001) for bupivacaine and 125 (range, −30 to 350; P = 0.011) for ropivacaine, with a significant mean difference between groups (−175; 95% CI, −295 to −40; P = 0.012). Median difference in maximum flow rate (ml/s) was more pronounced with bupivacaine (−12; range, −28 to 3; P &lt; 0.001) than with ropivacaine (−4; range, −16 to 7; P = 0.025) with a significant mean difference between groups (7; 95% CI, 0 to 12; P = 0.028). Pain scores were similar. No adverse events occurred.

Conclusions

Postvoid residuals were significantly lower using ropivacaine compared to bupivacaine for thoracic epidural analgesia reflecting less impairment of detrusor function with ropivacaine.

Effect of Epidural Dexmedetomidine Combined With Ropivacaine in Labor Analgesia: A Randomized Double-Blinded Controlled Study

BACKGROUND

The purpose of our study is to evaluate the effect of adding dexmedetomidine to epidural ropivacaine in patients undergoing labor epidural analgesia.

METHODS

Eighty healthy women were randomly assigned to 2 groups: control group (R; n=40) received epidural 0.125% ropivacaine for labor analgesia, whereas the study group (D; n=40) received epidural 0.125% ropivacaine with dexmedetomidine in addition. The blood pressure, heart rate, and the severity of pain of the parturient was assessed, the duration of the first stage and the second stage of labor time, the rate of instrumental delivery and the rate of cesarean section were recorded. The side effects (nausea and vomiting), intensity of maternal sedation, and neonatal Apgar scores were also recorded.

RESULTS

The visual analog scales, systolic blood pressure, diastolic blood pressure, and heart rates of D group were significant lower than that of R group at most time intervals after epidural analgesia. The duration of the first and second stage of labor, the rate of instrumental delivery and cesarean section, neonatal 1- and 5-minute Apgar scores, umbilical artery pH, maternal motor blockade scores, intensity of maternal sedation, and the incidence of maternal complications did not show significant difference between 2 groups.

CONCLUSIONS

Low concentration of epidural ropivacaine (0.125%) combined with dexmedetomidine (0.5 μg/kg) reduces the feeling of pain, and does not show the problems of motor blockage, hemodynamic instability, extension of production process, and complications such as nausea and vomiting. Our study was registered with Chinese Clinical Trial Registry (ChiCTR-IOR-15007263).

Comparison of bupivacaine and ropivacaine in combination with fentanyl used for walking epidural anesthesia in labor

Objective:

Effective pain relief during labor is essential to reduce maternal and perinatal morbidity arising due to pain-induced maternal sympathetic activation, and to avoid unnecessary cesarean sections performed due to maternal anxiety. Walking epidural analgesia on labor reveals lower pain scores, leading to higher maternal satisfaction with better cardiovascular and pulmonary physiology. Despite the extensive use and relative safety of bupivacaine, newer drugs such as ropivacaine have been developed as alternative agents to decrease the risk for cardiac and central nervous system toxicity.

Materials and Methods:

One hundred women who requested epidural analgesia in active labor were randomly allocated into two groups; one group received 20 mL of ropivacaine 0.125% with fentanyl 50 µg and the other received 20 mL of bupivacaine 0.125% with fentanyl 50 µg. The efficacy of analgesia, adverse effects, and obstetric and neonatal outcomes of both groups were compared.

Results:

There were no differences between the two study groups in the measured obstetric and neonatal outcomes. The onset time, duration of analgesia, and sensory levels were similar between the groups. Visual analog pain scale scores did not differ between the groups before analgesia or at any of the subsequent evaluation periods.

Conclusion:

Both ropivacaine and bupivacaine provide equivalent labor analgesia with high maternal satisfaction and tolerable adverse effects in the clinically used dose range. No adverse obstetric or neonatal outcomes were observed in either group. Therefore, either drug is a reasonable choice for labor analgesia and can be used without jeopardizing the safety of the mother and fetus.

Practice Bulletin No. 177: Obstetric Analgesia and Anesthesia

Labor causes severe pain for many women. There is no other circumstance in which it is considered acceptable for an individual to experience untreated severe pain that is amenable to safe intervention while the individual is under a physician's care. Many women desire pain management during labor and delivery, and there are many medical indications for analgesia and anesthesia during labor and delivery. In the absence of a medical contraindication, maternal request is a sufficient medical indication for pain relief during labor. A woman who requests epidural analgesia during labor should not be deprived of this service based on the status of her health insurance. Third-party payers that provide reimbursement for obstetric services should not deny reimbursement for labor analgesia because of an absence of "other medical indications." Anesthesia services should be available to provide labor analgesia and surgical anesthesia in all hospitals that offer maternal care (levels I-IV) (). Although the availability of different methods of labor analgesia will vary from hospital to hospital, the methods available within an institution should not be based on a patient's ability to pay.The American College of Obstetricians and Gynecologists believes that in order to allow the maximum number of patients to benefit from neuraxial analgesia, labor nurses should not be restricted from participating in the management of pain relief during labor. Under appropriate physician supervision, labor and delivery nursing personnel who have been educated properly and have demonstrated current competence should be able to participate in the management of epidural infusions.The purpose of this document is to review medical options for analgesia during labor and anesthesia for surgical procedures that are common at the time of delivery. Nonpharmacologic options such as massage, immersion in water during the first stage of labor, acupuncture, relaxation, and hypnotherapy are not covered in this document, though they may be useful as adjuncts or alternatives in many cases.

Ropivacaine versus levobupivacaine in peripheral nerve block: A PRISMA-compliant meta-analysis of randomized controlled trials

BACKGROUND

To determine which is more potent in peripheral nerve block between ropivacaine and levobupivacaine.

METHODS

A literature search was performed in the EMBASE, Medline, the Cochrane Library, and the Web of Science. The trials that were found were then evaluated for eligibility. The Cochrane Collaboration's Review Manager software was used to perform the meta-analyses.

RESULTS

Twelve studies including 556 patients were included for final analysis. No statistically significant difference was observed between the 2 drugs with respect to onset time of surgical anesthesia, onset time of sensory block, onset time of motor block, duration of motor block, and patients overall satisfaction. Levobupivacaine provided more long-term anesthesia (weighted mean difference [WMD], -2.94; 95% confidence interval [CI], -5.56 to -0.32; I = 93%) and significantly lower incidence of postoperative rescue analgesia (odds ratio [OR], 2.11; 95% CI 1.18-3.74; I = 21%) than ropivacaine. There was a trend toward greater duration of sensory block in the levobupivacaine group (WMD, -1.16; 95% CI, -1.89 to -0.43; I = 14%).

CONCLUSION

Levobupivacaine is more potent than ropivacaine in peripheral nerve block to some extent. Otherwise, more rigorous randomized control trials are required in the future.

Comparison between Epidural Ropivacaine versus Ropivacaine with Clonidine in Patients Undergoing Abdominal Hysterectomy: A Randomized Study

CONTEXT

Regional anesthesia has emerged as one of the preferred and convenient modes for intra- and post-operative management owing to its advantage of not interfering with the metabolic functions, better tolerability, and decrease in reflex activity. In recent years, ropivacaine has increasingly replaced bupivacaine as a preferred local anesthetic because of its similar analgesic properties, lesser motor blockade, and decreased propensity of cardiotoxicity. Neuraxial adjuvant such as clonidine used in epidural anesthesia offers advantage by augmenting the local anesthetic effect and reducing the anesthetic and analgesic requirement.

AIMS AND OBJECTIVES

Comparison of onset, duration of sensory and motor block, and any adverse effects between 0.5% ropivacaine with normal saline versus 0.5% ropivacaine with clonidine (75 μg/kg).

MATERIALS AND METHODS

This prospective randomized study was carried out in 50 patients (25 in each group) of American Society of Anesthesiologist Grade 1 and 2 scheduled for abdominal hysterectomy under epidural block. Group-1 (ropivacaine-clonidine [RC]): Epidural ropivacaine 20 ml (0.5%) with 0.75 μg/kg clonidine. Group-2 (ropivacaine [R]): Epidural ropivacaine 20 ml (0.5%) with normal saline. Onset, duration of sensory-motor block, heart rate, blood pressure, oxygen saturation, and respiratory rate were recorded.

STATISTICAL ANALYSIS

The statistical analysis was done using Statistical Package for Social Sciences version 15.0. Chi-square test, ANOVA, Student's t-test, and paired t-test were used.

RESULTS

Groups were comparable with regard to demographic data and hemodynamic stability. Onset of sensory and motor blockade was faster in RC group as compared to R group. Duration of postoperative analgesia was significantly prolonged in RC group. No potential side effect was seen in either group.

CONCLUSION

On account of faster onset, hemodynamic stability, and prolonged postoperative analgesia, ropivacaine with clonidine is a better option than ropivacaine alone.

Neuraxial blockade for external cephalic version: Cost analysis

AIM

Neuraxial blockade (epidural or spinal anesthesia/analgesia) with external cephalic version increases the external cephalic version success rate. Hospitals and insurers may affect access to neuraxial blockade for external cephalic version, but the costs to these institutions remain largely unstudied. The objective of this study was to perform a cost analysis of neuraxial blockade use during external cephalic version from hospital and insurance payer perspectives. Secondarily, we estimated the effect of neuraxial blockade on cesarean delivery rates.

METHODS

A decision-analysis model was developed using costs and probabilities occurring prenatally through the delivery hospital admission. Model inputs were derived from the literature, national databases, and local supply costs. Univariate and bivariate sensitivity analyses and Monte Carlo simulations were performed to assess model robustness.

RESULTS

Neuraxial blockade was cost saving to both hospitals ($30 per delivery) and insurers ($539 per delivery) using baseline estimates. From both perspectives, however, the model was sensitive to multiple variables. Monte Carlo simulation indicated neuraxial blockade to be more costly in approximately 50% of scenarios. The model demonstrated that routine use of neuraxial blockade during external cephalic version, compared to no neuraxial blockade, prevented 17 cesarean deliveries for every 100 external cephalic versions attempted.

CONCLUSIONS

Neuraxial blockade is associated with minimal hospital and insurer cost changes in the setting of external cephalic version, while reducing the cesarean delivery rate.

Effects of intrathecal hyperbaric ropivacaine versus hyperbaric bupivacaine for lower limb orthopedic surgery

Background:

Regional anesthesia, increasingly used for infraumbilical surgery, has advantages of decreased stress response to surgery, nausea, vomiting, and cardio-respiratory depression with improved postoperative analgesia, in comparison to general anesthesia. Intrathecal isobaric ropivacaine (RP) had been found, in various clinical studies, to be shorter acting in comparison to bupivacaine (BP). Our present study was, hence, aimed to compare the anesthetic and analgesic efficacy of intrathecal hyperbaric RP relative to hyperbaric BP in lower limb orthopedic surgery.

Materials and Methods:

A total of 100 patients aged ranges between 18 and 60 years of either sex, ASAPS 1 and 2, undergoing elective lower limb orthopedic surgeries were divided into two groups, RP group and BP group receiving intrathecal 0.75% RP 3 ml and glucose 50%, 0.5 ml and 0.5% hyperbaric BP 3 ml and 0.9% normal saline 0.5 ml, respectively. The efficacy in terms of onset and duration of anesthesia and analgesia were assessed along with the heart rate, blood pressure at regular intervals throughout the perioperative period.

Result:

The two study groups were comparable in terms of demography and duration of surgery. Patients in group RP experienced significantly late onset and shorter duration of sensory and motor block in comparison to patients in group BP. There were clinically insignificant differences in perioperative hemodynamics and side-effects noted in each group. Hence, it was observed in this study that equipotent dose of hyperbaric RP had shorter duration of analgesia and anesthesia than with equipotent dose of hyperbaric BP.

The effect of epidural analgesia on labour, mode of delivery and neonatal outcome in nullipara of India, 2011-2014

AIMS

This study aimed to evaluate the effect of ropivacaine epidural analgesia on duration and outcome of labour in nulliparous parturients of India with parturient not receiving any analgesia.

SETTINGS AND DESIGN

One hundred and twenty nulliparous parturient in established labour at full term with a singleton vertex presentation were assigned to the study. Parturients who request epidural analgesia were allocated in the epidural group (n=60), whereas those not enthusiastic to labour analgesia were allocated in the control group (n=60).

MATERIALS AND METHODS

Epidural analgesia was provided by a bolus injection of 10 ml of ropivacaine 0.2% and 50μg fentanyl and maintained by using a continuous infusion of ropivacaine 0.1% with fentanyl 2μl/ml at a 10ml/hour rate. The outcomes were duration of labour, incidence of cesarean sections and instrumental vaginal delivery and neonatal outcome.

STATISTICAL ANALYSIS USED

Statistical analysis was conducted using unpaired student t-test and chi-square test as required. All tests of significance were performed using two-tailed probability tests. Differences were considered significant when p-value was <0.05.

RESULTS

The two groups were comparable in terms of socio-demographic data. The mean duration of first stage of labour was shorter in epidural group (4.83 ± 1.59 h) compared with control group (5.48 ± 1.56 h) while the duration of second stage of labour was prolong in epidural group (33.13 ± 12.78 min) as compared to control (27.53 ± 11.73 min). Instrumental vaginal or caesarean delivery rate did not increase in the epidural group. The APGAR scores at 5 min were statistically similar in both groups.

CONCLUSION

Epidural analgesia by ropivacaine in Indian nulliparous resulted in shorter duration of first stage and prolongs duration of second stage of labour compared with parturients without analgesia; however, instrumental vaginal or caesarean delivery rate does not increase in the epidural group.

Bupivacaine-induced Vasodilation Is Mediated by Decreased Calcium Sensitization in Isolated Endothelium-denuded Rat Aortas Precontracted with Phenylephrine

BACKGROUND

A toxic dose of bupivacaine produces vasodilation in isolated aortas. The goal of this in vitro study was to investigate the cellular mechanism associated with bupivacaine-induced vasodilation in isolated endotheliumdenuded rat aortas precontracted with phenylephrine.

METHODS

Isolated endothelium-denuded rat aortas were suspended for isometric tension recordings. The effects of nifedipine, verapamil, iberiotoxin, 4-aminopyridine, barium chloride, and glibenclamide on bupivacaine concentration-response curves were assessed in endothelium-denuded aortas precontracted with phenylephrine. The effect of phenylephrine and KCl used for precontraction on bupivacaine-induced concentration-response curves was assessed. The effects of verapamil on phenylephrine concentration-response curves were assessed. The effects of bupivacaine on the intracellular calcium concentration ([Ca(2+)]i) and tension in aortas precontracted with phenylephrine were measured simultaneously with the acetoxymethyl ester of a fura-2-loaded aortic strip.

RESULTS

Pretreatment with potassium channel inhibitors had no effect on bupivacaine-induced relaxation in the endothelium-denuded aortas precontracted with phenylephrine, whereas verapamil or nifedipine attenuated bupivacaine-induced relaxation. The magnitude of the bupivacaine-induced relaxation was enhanced in the 100 mM KCl-induced precontracted aortas compared with the phenylephrine-induced precontracted aortas. Verapamil attenuated the phenylephrine-induced contraction. The magnitude of the bupivacaine-induced relaxation was higher than that of the bupivacaine-induced [Ca(2+)]i decrease in the aortas precontracted with phenylephrine.

CONCLUSIONS

Taken together, these results suggest that toxic-dose bupivacaine-induced vasodilation appears to be mediated by decreased calcium sensitization in endothelium-denuded aortas precontracted with phenylephrine. In addition, potassium channel inhibitors had no effect on bupivacaine-induced relaxation. Toxic-dose bupivacaine- induced vasodilation may be partially associated with the inhibitory effect of voltage-operated calcium channels.

Safety of liposome extended-release bupivacaine for postoperative pain control

BACKGROUND

Ideal postoperative pain management requires a multidisciplinary approach in combination with a variety of dosage regimens. Approximately 21-30% of patients experience moderate to severe pain in the postoperative period, which may have a significant impact on recovery rate, standard of living, psychological health, and postoperative complications.

OBJECTIVE

Analysis of the incidence and characterization of reported adverse effects with DepoFoam bupivacaine compared to conventional bupivacaine or placebo.

METHODS

A systematic review of prospective studies on the use of DepoFoam versus bupivacaine or placebo was performed in order to answer the clinically relevant question: is DepoFoam a safer formulation in place of bupivacaine single injection or continuous local infusion techniques for postoperative pain management? Inclusion criteria required randomized, controlled, double-blind trials in patients 18 years old or older, single dose used for postoperative pain control, and a primary procedure performed.

RESULTS

Six studies fitted the inclusion criteria for analysis, DepoFoam bupivacaine used in therapeutic doses was well-tolerated, had a higher safety margin, and showed a favorable safety profile compared to bupivacaine and control groups.

CONCLUSION

Extended drug delivery system DepoFoam bupivacaine is a promising drug formulation that may significantly improve postoperative care and pain control in surgical patients.

Fluid therapy in critical illness: a special focus on indication, the use of hydroxyethyl starch and its different raw materials

PURPOSE OF REVIEW

Fluid therapy is a complex intervention with insufficient resuscitation, as well as overinfusion and fluid accumulation being associated with adverse outcomes. Early goal-directed therapy with later conservative fluid management (i.e. prevention of positive fluid balance and weight gain) appears to markedly improve the survival of patients with severe sepsis. The impact of colloids in resuscitation of patients with sepsis has been the topic of several recently published studies. The purpose of the present review is to outline the indication of fluid administration in critically ill patients, discuss the recent findings of trials involving hydroxyethyl starch (HES) solutions and highlight the impact of different raw materials for HES synthesis.

RECENT FINDINGS

Pragmatic trials of modern HES solutions versus crystalloids in critically ill patients show either no difference or adverse outcomes associated with HES infusion. However, fluid therapy was not protocolized in most of these studies and probably associated with overinfusion and hemodilution. Data on the use of waxy maize-derived 6% HES 130/0.4 during early goal-directed therapy show no evidence for harm and an improvement in microvascular blood flow. In addition, experimental data suggest that waxy maize-derived 6% HES 130/0.4 may have different biological effects compared to potato-derived 6% HES 130/0.42 with potentially reduced pulmonary inflammation.

SUMMARY

Adverse effects of fluid resuscitation in critically ill patients appear to be a consequence of dose and timing rather than the type of fluid itself. Modern waxy maize-derived 6% HES 130/0.4 may have advantages over crystalloids in the very early course of the disease. Clinical trials of early, goal-directed and protocolized therapy with innovative endpoints of resuscitation comparing balanced crystalloids and balanced, waxy maize-derived 6% HES 130/0.4 as the initial resuscitation fluid are warranted.

Thoracic epidural anesthesia improves early outcome in patients undergoing cardiac surgery for mitral regurgitation: a propensity-matched study

OBJECTIVE

There are no large studies that investigate the effect of thoracic epidural anesthesia (TEA) combined with general anesthesia (GA) in patients undergoing valvular surgery. The authors hypothesized that TEA might improve clinically relevant endpoints in patients with primary mitral regurgitation.

DESIGN

Propensity-matched study.

SETTING

Cardiac surgery.

PARTICIPANTS

Patients scheduled for mitral valve repair or replacement were studied.

INTERVENTIONS

A propensity model was constructed to match 33 patients receiving TEA combined with GA with 33 patients receiving standard GA alone.

MEASUREMENTS AND MAIN RESULTS

Overall, the TEA group suffered fewer adverse events than the GA group: 10 (30%) v 23 (10%) with p = 0.002. In particular, the TEA group had a lower incidence of pulmonary events, 6 (18%) v 15 (45%) with p = 0.02, and of cardiac events, 8 (24%) v 16 (49%) with p = 0.04. Median (interquartile) time on mechanical ventilation was reduced in the TEA group, 11 (9-15) v 17 (12-36) with p = 0.007.

CONCLUSIONS

This propensity-matched study suggested that TEA might be advantageous in patients undergoing surgery for mitral regurgitation.

Nicotinamide adenine dinucleotide (NAD+) repletion attenuates bupivacaine-induced neurotoxicity

Bupivacaine is one of the most toxic local anesthetics but the mechanisms underlying its neurotoxicity are still unclear. Intracellular nicotinamide adenine dinucleotide (NAD(+)) depletion has been demonstrated to play an essential role in neuronal injury. In the present study, we investigated whether intracellular NAD(+) depletion contributes to bupivacaine-induced neuronal injury and whether NAD(+) repletion attenuates the injury in SH-SY5Y cells. First, we evaluated the intracellular NAD(+) content after bupivacaine exposure. We also examined the cellular NAD(+) level after pretreatment with exogenous NAD(+). We next determined cell viability and the apoptosis rate after bupivacaine treatment in the presence or absence of NAD(+) incubation. Finally, cell injuries such as nuclear injury, reactive oxygen species (ROS) production, and mitochondrial depolarization were detected after bupivacaine treatment with or without NAD(+) pretreatment. Bupivacaine caused intracellular NAD(+) depletion in a time- and concentration-dependent manner. Cellular NAD(+) replenishment prevented cell death and apoptosis induced by bupivacaine. Importantly, exogenous NAD(+) attenuated bupivacaine-induced nuclear injury, ROS production, and mitochondrial depolarization. Our results suggest that NAD(+) depletion is necessary for bupivacaine-induced neuronal necrosis and apoptosis, and that NAD(+) repletion attenuates neurotoxicity resulting from bupivacaine-treatment.

The efficacy of intra-articular injections for pain control following the closed reduction and percutaneous pinning of pediatric supracondylar humeral fractures: a randomized controlled trial

BACKGROUND

The purpose of this single-blinded, randomized, controlled trial was to compare the analgesic efficacy of intra-articular injections of bupivacaine or ropivacaine with that of no injection for postoperative pain control after the operative treatment of supracondylar humeral fractures in a pediatric population.

METHODS

Subjects (n=124) were randomized to treatment with 0.25% bupivacaine (Group B) (n=42), 0.20% ropivacaine (Group R) (n=39), or no injection (Group C) (n=43). The opioid doses and the times of administration as well as child-reported pain severity (Faces Pain Scale-Revised) and parent-reported pain severity (Total Quality Pain Management survey) were recorded.

RESULTS

The proportion of subjects who required morphine and/or fentanyl injections was significantly (p=0.004) lower in Group B (10%) as compared with Group R (36%) and Group C (44%). On the basis of the log-rank test, the opioid-free survival rates were significantly greater in Group B as compared to Groups C and R. Total opioid consumption (morphine equivalent mg/kg) in the first seventy-two hours postoperatively was significantly less in Group B as compared with Group C (mean difference, 0.225; [95% confidence interval (CI), 0.0152 to 0.435]; p=0.036). Parent-reported pain scores were also significantly lower in Group B as compared with both Group C (mean difference, 1.81 [95% CI, 0.38 to 3.25]; p=0.014) and Group R (mean difference, 1.66; 95% CI, 0.20 to 3.12; p=0.027). There were no significant differences across the three groups in terms of self-reported pain. Differences between Groups R and C were not significant for any of the outcome variables.

CONCLUSIONS

The intra-articular injection of 0.25% bupivacaine significantly improves postoperative pain control following the closed reduction and percutaneous pinning of supracondylar humeral fractures in pediatric patients.

Intravenous regional anesthesia: a review of common local anesthetic options and the use of opioids and muscle relaxants as adjuncts

Purpose

To provide a review of local anesthetic (LA) agents and adjuncts, opioids and muscle relaxants, and their intraoperative effects and postoperative outcomes in intravenous regional anesthesia (IVRA).

Source

A search for prospective, double-blind, randomized controlled trials evaluating LA agents, opioids and muscle relaxants as adjuvants for IVRA, was conducted (MEDLINE^®, Embase). Intraoperative benefits (onset/recovery of sensory and motor block, intraoperative analgesia, tourniquet pain), postoperative benefits (pain score, analgesic consumption, time to first analgesia), and side effects were recorded. A conclusion for overall benefit was made based on statistical significance and clinical relevance.

Findings

Thirty-one studies were evaluated, with data collected on 1523 subjects. LA agents evaluated were lidocaine, ropivacaine, and prilocaine. Adjuncts evaluated were opioids ( morphine, fentanyl, meperidine, sufentanil, tramadol) and muscle relaxants (pancuronium, atracurium, mivacurium, cisatacurium). There was good evidence that ropivacaine provided effective IVRA and improved postoperative analgesia. Lidocaine and prilocaine were effective LA agents, however they lacked postoperative benefits. Morphine, fentanyl, and meperidine as sole adjuncts did not demonstrate clinically significant benefits or result in an increased risk of side effects. Sufentanil data was limited, but appeared to provide faster onset of sensory block. Tramadol provided faster onset of sensory block and tourniquet tolerance, however postoperative benefits were not consistent and the risk of minor side effects increased. Muscle relaxants improved the quality of motor block, but at the expense of delayed motor recovery. The combination of fentanyl and muscle relaxants can achieve an equivalent quality of IVRA with 50% reduction in LA dose, but at the expense of a potentially slower onset of sensory block.

Conclusion

Ropivacaine is effective for IVRA and improves postoperative analgesia. Muscle relaxants enhance the motor block and when combined with fentanyl allow for an equivalent quality of IVRA with 50% reduction in LA dose.

Epidural analgesia for labor: Current techniques

Epidural analgesia is an extremely effective and popular treatment for labor pain. In this review, we trace the history of the use of epidural analgesia and its refinements. We then outline the goals of treatment and methods used to attain those goals. The use of low concentrations of local anesthetics, combined with lipid-soluble opioids, does not impede the progress of labor or depress the newborn. The incidence of side effects is low. Maintenance of analgesia that allows patient control enhances patient satisfaction.