Combined Spinal-epidural Group Research Articles

The application of combined spinal-epidural anesthesia and combined Midazolam used for laparoscopic gynecology Operation

Objective To evaluate the safety and feasibility of combined spinal-epidural anesthesia and Combined Midazolam used for laparoscopic gynecology Operation.Methods 500 patients of ASA grade Ⅰ-Ⅱundergoing laparoscopic gynecology surgery were randomly devided into combined spinal-epidural anesthesia group(group CSEA,n=250)and general anesthesia group(group GA,n=250),The variation of peri-anesthesia mean heart rate(HR),respiration rate(RR),arterial pressure(MAP),pulse oxygen saturation(SpO2)were tested and recorded.The wake time and the post-operative(in24hour)complications were observed.Results Referring to all patients,there were not any significant differences in BP,HR,RR,SpO2(P>0.05).The wake time was significantly shorter in Group CSEA than in Group GA(P<0.01),The incidence of postoperative complication(nausea,vomiting,restlessness)was significantly lower in Group CSEA than in Group GA(P<0.05).Conclusion The combined spinal-epidural anesthesia and combined Midazolam used for laparoscopie gynecology Operation is safe and feasible,and easier and more economical general anesthesia. Key words: Combined spinal-epidural anesthesia; Midazolam,Laparoscopic gynecology Operation

Ambulation in Labor and Delivery Mode: A Randomized Controlled Trial of High-dose Versus Mobile Epidural Analgesia

In the comparative obstetric mobile epidural trial (COMET), the rate of instrumental vaginal delivery (IVD) was reduced among nulliparous women with 2 mobile epidural analgesic techniques, combined spinal epidural (CSE) or low-dose infusion (LDI), in comparison with the high-dose epidural technique. There was no loss of efficacy in pain relief with either mobile procedure. It is unclear whether maternal ambulation (women walking or adopting upright postures) during labor is causally related to a reduction in IVD or an increased likelihood of spontaneous vaginal delivery. The few randomized controlled trials have examined the effect of continuous epidural pain relief on maternal mobility in labor and not necessarily on labor outcome. This randomized trial investigated the effect of 2 mobile epidural techniques, CSE and LDI, on maternal motor power and ambulation as a predefined secondary outcome of the COMET trial in nulliparous women during labor. The 1054 study subjects were randomly allocated to 1 of 3 groups. The control group (n = 353) received high-dose epidural analgesia and was compared with the CSE group (n = 351) and the LDI group (n = 350). The mode of delivery (spontaneous vaginal delivery, IVD, or cesarean section) was the predefined study outcome. To determine the level of ambulation achieved by the study subjects after epidural insertion during first and second stages of labor, motor function was assessed hourly using modified Breen's Bromage power scores, until delivery. Compared to the control group, normal leg power was maintained throughout labor in significantly more women in the CSA and LDI groups (P < 0.01 for each hour). A greater proportion of women in the CSA group than in the LDI group maintained normal leg power during labor (P < 0.01 for each hour). However, there was no association between the level of ambulation and the delivery method. These findings do not support the assertion that a greater level of ambulation after epidural insertion during labor has a beneficial effect on the mode of delivery.

Satisfaction, control and pain relief: short- and long-term assessments in a randomised controlled trial of low-dose and traditional epidurals and a non-epidural comparison group

Background Childbirth is an important life event for which a positive experience is important to many women. Methods As secondary outcomes from the randomised controlled Comparative Obstetric Mobile Epidural Trial, various aspects of satisfaction were assessed in women who had one of three types of regional analgesia (two of which were low-dose techniques and a high-dose control using 0.25% epidural bupivacaine) and a comparison group who did not have epidural analgesia, shortly after delivery and 12 months later. Results The predominant finding was satisfaction with spontaneous vaginal delivery whatever the mode of analgesia. The overall immediate and long-term satisfaction was similar for all three neuraxial techniques. Satisfaction with the speed of pain relief and the amount of mobility were significantly greater for the combined spinal-epidural technique compared with the low-dose infusion ( P<0.001). The degree of control felt by women who had combined spinal-epidural analgesia was greater than with the high-dose ( P<0.05). Women in the non-epidural comparison group did not report a greater feeling of control. Among those who delivered spontaneously, more women in the combined spinal-epidural group (30%) felt in full control compared with the high-dose group (17%) ( P<0.05). By comparison 22% in the low-dose infusion group and only 15% who had no epidural felt in full control. Conclusions Whilst satisfaction with the experience of childbirth appears intimately related to the attainment of a spontaneous delivery, mobile epidurals enhance women’s feeling of control in labour and are popular for future choice of regional analgesia.

A randomized controlled trial of the effect of combined spinal-epidural analgesia on the success of external cephalic version for breech presentation

Background Improving the success of external cephalic version (ECV) for breech presentation may help avoid some cesarean deliveries. The results of randomized trials comparing the success of ECV with neuraxial analgesia compared to control are inconsistent. We hypothesized that combined spinal-epidural (CSE) analgesia would increase the success of ECV when compared with systemic opioid analgesia. Methods Parturients with singleton breech presentation (n = 96) were randomized to receive CSE analgesia with bupivacaine 2.5 mg and fentanyl 15 μg (CSE group) or intravenous fentanyl 50 μg (SYS group) before ECV attempt. The primary outcome was ECV success. Results The success rate of ECV was 47% with CSE and 31% in the SYS group ( P = 0.14). Subsequent vaginal delivery was 36% for CSE and 25% for SYS ( P = 0.27). Median [IQR] visual analog pain scores (0-100 mm scale) were lower with CSE (3 [0-12]) compared to SYS analgesia (36 [16 to 54]) ( P < 0.005) and patient satisfaction (0-10 scale) was higher (CSE 10 [9 to 10] versus SYS 7 [4 to 9]) ( P < 0.005). There were no differences in fetal heart rate patterns, but median time to return to fetal heart rate reactivity after analgesia was shorter with CSE (13 [IQR 9-21] min) compared to the SYS group (39 [IQR 23-51] min) ( P = 0.02). Conclusions There was no difference in the rate of successful ECV or vaginal delivery with CSE compared to intravenous fentanyl analgesia. Pain scores were lower and satisfaction higher with CSE analgesia, and median time to fetal heart rate reactivity was shorter in the CSE group.

Ambulation in Labor and Delivery Mode: A Randomized Controlled Trial of High-Dose Versus Mobile Epidural Analgesia

In the comparative obstetric mobile epidural trial (COMET), the rate of instrumental vaginal delivery (IVD) was reduced among nulliparous women with 2 mobile epidural analgesic techniques, combined spinal epidural (CSE) or low-dose infusion (LDI), in comparison with the high-dose epidural technique. There was no loss of efficacy in pain relief with either mobile procedure. It is unclear whether maternal ambulation (women walking or adopting upright postures) during labor is causally related to a reduction in IVD or an increased likelihood of spontaneous vaginal delivery. The few randomized controlled trials have examined the effect of continuous epidural pain relief on maternal mobility in labor and not necessarily on labor outcome. This randomized trial investigated the effect of 2 mobile epidural techniques, CSE and LDI, on maternal motor power and ambulation as a predefined secondary outcome of the COMET trial in nulliparous women during labor. The 1054 study subjects were randomly allocated to 1 of 3 groups. The control group (n = 353) received high-dose epidural analgesia and was compared with the CSE group (n = 351) and the LDI group (n = 350). The mode of delivery (spontaneous vaginal delivery, IVD, or cesarean section) was the predefined study outcome. To determine the level of ambulation achieved by the study subjects after epidural insertion during first and second stages of labor, motor function was assessed hourly using modified Breen's Bromage power scores, until delivery. Compared to the control group, normal leg power was maintained throughout labor in significantly more women in the CSA and LDI groups (P < 0.01 for each hour). A greater proportion of women in the CSA group than in the LDI group maintained normal leg power during labor (P < 0.01 for each hour). However, there was no association between the level of ambulation and the delivery method. These findings do not support the assertion that a greater level of ambulation after epidural insertion during labor has a beneficial effect on the mode of delivery.

Adverse effects of combined spinal–epidural versus traditional epidural analgesia during labor

Objective To compare two neuraxial block techniques during labor for maternal and fetal effects. Methods Women in labor at term with cephalic singleton fetuses were randomized (nonblinded) to receive either labor epidural (EPI) or combined spinal–epidural (CSE) analgesia. Primary outcome was prolonged deceleration (PD) of fetal heart rate. Outcomes also included hypotension, mode of delivery, and efficacy of analgesia by visual analog pain scale (VAPS) before and after block placement. Results Randomization occurred in 127 patients: 63 received EPI, 64 received CSE. There was no difference in the rate of PD in the EPI group compared with the CSE group (3.2% vs 6.2% respectively; P = 0.43, RR 2.0; 95% CI 0.4–9.3), rate of cesarean delivery, or mean epidural duration. VAPS ratings were significantly lower in the CSE group. Conclusions There were no differences in the rate of PD or other adverse outcomes. Hypotension occurred more frequently with CSE during labor at term. The study supports both EPI and CSE during labor as safe and effective techniques for neuraxial analgesia.

Continuous spinal anesthesia versus combined spinal epidural block for major orthopedic surgery: prospective randomized study.

In major orthopedic surgery of the lower limbs, continuous spinal anesthesia (CSA) and combined spinal epidural anesthesia (CSE) are safe and reliable anesthesia methods. In this prospective randomized clinical study, the blockading properties and side effects of CSA were compared with single interspace CSE, among patients scheduled for major hip or knee surgery. Prospective clinical study conducted at the Institute for Regional Anesthesia, Hospital de Base, São José do Rio Preto. 240 patients scheduled for hip arthroplasty, knee arthroplasty or femoral fracture treatment were randomly assigned to receive either CSA or CSE. Blockades were performed in the lateral position at the L3-L4 interspace. Puncture success, technical difficulties, paresthesia, highest level of sensory and motor blockade, need for complementary doses of local anesthetic, degree of technical difficulties, cardiocirculatory changes and postdural puncture headache (PDPH) were recorded. At the end of the surgery, the catheter was removed and cerebrospinal fluid leakage was evaluated. Seven patients were excluded (three CSA and four CSE). There was significantly lower incidence of paresthesia in the CSE group. The resultant sensory blockade level was significantly higher with CSE. Complete motor blockade occurred in 110 CSA patients and in 109 CSE patients. Arterial hypotension was observed significantly more often in the CSE group. PDPH was observed in two patients of each group. Our results suggest that both CSA and CSE provided good surgical conditions with low incidence of complications. The sensory blockade level and hemodynamic changes were lower with CSA.

Effects on mother and fetus of epidural and combined spinal-epidural techniques for labor analgesia

Epidural (EA) and combined spinal-epidural (CSE) techniques have both been utilized for labor analgesia. This study compared the effects on the mother and newborn of these techniques in labor analgesia and anesthesia. Forty pregnant women received epidural analgesia with 15 mL of 0.125% ropivacaine (EA group) and 5 microg of sufentanil plus 2.5mg bupivacaine in the subarachnoid space (CSE group). Pain intensity, sensory blockade level, latency time, motor block intensity, labor analgesia duration, epidural analgesia duration, maternal hypotension, and pruritus were evaluated. The newborns were evaluated by Apgar and the neurological and adaptive capacity score (NACS) developed by Amiel-Tison. There were no significant statistical differences between groups for pain scores, latency time, sensory blockade level, and Apgar score. Motor block, labor analgesia duration, and epidural analgesia duration were greater in the CSE group, whose seven mothers had mild pruritus. The NACS were greater in the EA group after half, two, and 24 hours. Ninety five percent of EA group newborns and 60% of CSE group newborns were found to be neurologically healthy at the 24 hour examination. EA and CSE analgesia relieved maternal pain during obstetric analgesia, but CSE mothers had pruritus and a longer labor. Newborns of mothers who received epidural analgesia showed the best NACS.

A Randomized Trial of Maximum Cephalad Sensory Blockade with Single-Shot Spinal Compared with Combined Spinal-Epidural Techniques for Cesarean Delivery

Previous studies have shown more extensive cephalad sensory blockade in women receiving combined spinal-epidural (CSE) anesthesia compared with single-shot spinal (SSS) anesthesia for elective cesarean delivery. It has been postulated that introduction of the epidural needle during CSE disturbs the negative pressure in the epidural space, resulting in relatively greater cerebrospinal fluid (CSF) pressure and increased spread of intrathecal local anesthetic. We tested the hypothesis that CSE results in more extensive cephalad sensory blockade than SSS anesthesia and that loss-of-resistance during initiation of CSE anesthesia increases CSF pressure compared with SSS. Thirty parturients scheduled for elective cesarean delivery were enrolled in this randomized, double-blind study. Patients received either SSS or CSE anesthesia with equal doses of intrathecal anesthetic (hyperbaric bupivacaine 12 mg, fentanyl 10 microg and morphine 200 microg). Before the intrathecal injection, the CSF pressure was measured with a fiberoptic pressure sensor. Maximum cephalad sensory blockade to pinprick, cold and touch was measured. The total dose of phenylephrine required to maintain baseline arterial blood pressure was also recorded. There were no significant differences in the median (interquartile range) pinprick sensory block height [T4 (T4-2) vs T3 (T4-1)] or CSF pressures [6 (4-12) vs 9 (8-12) mm Hg] between the SSS and CSE groups. There were no significant correlations between CSF pressure and block height or total dose of phenylephrine. The SSS and CSE techniques inserted in the lateral decubitus position resulted in similar extent of sensory blockade and CSF pressure. These findings suggest that altering the intrathecal dose is not necessary and that any difference in intrathecal pressure associated with initial placement of an epidural needle in the epidural space during CSE anesthesia is clinically inconsequential.

Urinary catheterization in labour with high-dose vs mobile epidural analgesia: a randomized controlled trial

BackgroundDense perineal block from epidural analgesia increases the risk of urinary catheterization in labour. Mobile epidurals using low-dose local anaesthetic in combination with opioid preserve maternal mobility and may reduce the risk of bladder dysfunction. We conducted a three-arm randomized controlled trial to compare high-dose epidural pain relief with two mobile epidural techniques. MethodsA total of 1054 primparous women were randomized to receive high-dose bupivacaine, epidural analgesia (Control), combined spinal epidural (CSE), or low-dose infusion (LDI). The requirement for urinary catheterization during labour and postpartum was recorded. Both end points were pre-specified secondary trial outcomes. Women were evaluated by postnatal interview, when their bladder function had returned to normal. ResultsRelative to Control, more women who received mobile epidural techniques maintained the ability to void urine spontaneously at any time (Control 11%, CSE 31% and LDI 32%) and throughout labour (Control 3.7%, CSE 13% and LDI 14%), for both mobile techniques P<0.01. There was no difference in the requirement for catheterization after delivery. Women in the CSE group reported a more rapid return of normal voiding sensation, relative to high-dose Control (P=0.02). ConclusionsRelative to conventional high-dose block, mobile epidural techniques encourage the retention of normal bladder function and reduce the risk of urinary catheterization in labour.

Comparison of epidural analgesia with combined spinal-epidural analgesia for labor: a retrospective study of 6497 cases

Combined spinal-epidural analgesia provides rapid-onset analgesia with minimal motor block, but it is a more invasive technique than epidural analgesia and the risk of complications may be increased. This study compared the safety and effect on delivery of combined spinal-epidural and epidural analgesia in labor. A retrospective observational study was performed. Data were collected from 6497 women who received regional analgesia in our tertiary hospital in 2005. The incidence of complications during labor and the day after delivery was compared. The effect on labor outcome with both techniques was also assessed. 1964 received combined spinal-epidural (30.2%) and 4533 epidural analgesia (69.8%). Quality of analgesia was better in the combined spinal-epidural group. Labor outcome was similar in the two groups. Pruritus, paresthesia and back pain were more frequent in the combined spinal-epidural group. No differences were observed in the incidence of accidental dural puncture or post dural puncture headache. We found that epidural and combined spinal-epidural analgesia were comparable in terms of safety, and had a similar effect on delivery type.

Detection of Epithelial Cell Transfer in Spinal Areas by Light Microscopy and Determining Any Tissue Coring via Cell Culture During Combined Spinal-Epidural Interventions

Epithelial tissue coring by spinal needles during subarachnoid injections may cause intraspinal epidermal tumors. Previous studies have investigated tissue transfer with different needle types during subarachnoid or epidural injection. This study deals with the transfer of epithelial tissue during combined spinal-epidural (CSE) anesthesia. We studied 68 American Society of Anesthesiologists I to III adult patients. CSE anesthesia was induced under aseptic conditions at the L2-3 or L3-4 interspace with patients in the lateral decubitus position. Cerebral spinal fluid, spinal needle stylet, fluid used to flush the interior of the spinal needle, fluid used to wash the exterior of the spinal needle, fluid used to flush the interior of the epidural needle, and fluid used to wash the exterior tip of the epidural needle were examined under light microscopy (n = 30 patients) or incubated in a cell-culture medium (n = 38 patients). Samples were incubated in cell-culture medium alone (n = 13) or in a cell-culture medium for 3 weeks and then in a medium with epidermal growth factor (n = 25). As a positive control, skin tissue samples were taken by punch biopsy from 10 randomly chosen patients who underwent CSE interventions. These samples were incubated in an enriched medium serum. Light microscopy revealed that there was cell transfer in all phases in various rates: samples 1, 2, 3, 4, 5, and 6 contained epithelial cells and debris in ratios of 6.9%, 20.7%, 6.9%, 20.7%, 26.7%, and 33.3%, respectively. Epithelial cell colonization was detected in the cell-culture samples taken from the control group but not in the samples taken from the CSE group. We could not reproduce the cells or cell debris obtained during the CSE interventions in vivo, which can be explained by a possible structural deformation of cells or the inadequacy of the amount of cells that were transferred.

Combined low-dose spinal-epidural anesthesia versus single-shot spinal anesthesia for elective cesarean delivery

Combined spinal-epidural anesthesia balancing low-dose intrathecal bupivacaine/fentanyl and low-dose epidural bupivacaine may be more useful than single-shot spinal anesthesia for cesarean delivery in reducing incidences of adverse effects such as hypotension and nausea and in shortening motor recovery. Combined spinal-epidural anesthesia (n=50) or spinal anesthesia (n=50) was randomly performed in 100 parturients. Intrathecal bupivacaine 6 mg added by fentanyl 20 mug followed after 5 min by 10 mL of 0.25% epidural bupivacaine were used for combined spinal-epidural and intrathecal bupivacaine 9 mg with fentanyl 20 mug for spinal anesthesia. The initial sensory block level was higher in the spinal group (P<0.001), although the maximum levels were the same (T3). Complete surgical anesthesia was achieved and no patient complained of intraoperative pain in either group. Patients in the spinal group had denser motor block in the extremities and a higher incidence of hypotension (P<0.05) and nausea and vomiting (P<0.05). Motor recovery was faster in the combined spinal-epidural group (P<0.001). We concluded that combined spinal-epidural anesthesia using low-dose local anesthetic-opioid spinal anesthesia and routine epidural supplementation before surgery had some potential advantages over single-shot spinal anesthesia in the lower incidences of adverse effects and quicker recovery.

Perispinal analgesia for labour followed by patient-controlled infusion with bupivacaine and sufentanil: combined spinal-epidural vs. epidural analgesia alone

Background and objective: Combined spinal-epidural is an alternative technique to epidural analgesia for labour, but its benefits are not clearly identified. Methods: A prospective, blinded, randomized study was undertaken involving 113 women attending a university hospital obstetric department. Analgesia was initiated with intrathecal bupivacaine 0.25% 1 mL + sufentanil 5 μg in the combined spinal-epidural group (n = 54), and with bupivacaine 0.125% + epinephrine 2.5 μg mL−1 + sufentanil 7.5 μg in the epidural group (n = 59). In both cases this was followed by patient-controlled epidural analgesia with bupivacaine 0.125% (+sufentanil 0.25 μg mL−1). Duration of labour, quality of analgesia and side-effects were compared between groups. Results: In the combined spinal-epidural group, the onset of analgesia was faster (5 vs. 15 min, P < 0.001), the consumption of bupivacaine was lower (7.5 vs. 11.3 mg h−1, P = 0.003) and there was less unilateral analgesia (14.8% vs. 40.7%, P = 0.002) than in the epidural group. The characteristics of labour were similar in both groups. However, in the combined spinal-epidural group, there was a higher incidence of posterior presentation (25.9% vs. 10%, P = 0.03), pruritus (P < 0.001), hypotension (P = 0.002), somnolence (P = 0.01), nausea (P = 0.02) and one case of meningitis. Conclusions: The combined spinal-epidural technique provided more effective analgesia during labour than epidural analgesia alone but offered no other advantage. It induced more adverse effects and this should be considered before routinely using the combined spinal-epidural technique.

The effect of combined spinal-epidural (CSE) anaesthesia and size of spinal needle on postoperative hearing loss after elective caesarean section.

The exact aetiology of vestibulocochlear dysfunction after spinal anaesthesia is unknown. Low-frequency hearing loss occurs after spinal anaesthesia. The aim of this study was to investigate the effects of combined spinal-epidural (CSE) anaesthesia and size of spinal needle on vestibulocochlear dysfunction, using pure tone audiometry performed pre- and on the first and the second day postoperatively. Forty-five patients who were to undergo elective caesarean section were evaluated. In group I, CSE anaesthesia (18 G Tuohy, 25 G Whitacre pencil-point-design spinal needles) was performed in 15 patients. In group II, spinal anaesthesia was performed in 15 patients with 25 G Whitacre pencil-point-design spinal needles and, in group III, spinal anaesthesia was performed in 15 patients with 22 G Whitacre pencil-point-design spinal needles. In the pre- and on the first and the second day postoperatively, the pure tone audiogram was performed in the audiology laboratory of our hospital, using a calibrated Kamplex Diagnostic Audiometer AC 40 in a noise-free room. When the CSE anaesthesia group and 22 G spinal group were compared for change in hearing between the pre- and postoperative periods, a statistically significant difference was observed at R-right ear 125 Hz (P < 0.025) and at L-left ear 125 Hz (P < 0.023), and at L-left ear 1000 Hz (P < 0.036) and at R-right ear 1500 Hz (P < 0.006), and at L-left ear 1500 Hz (P < 0.022). At other frequencies, the difference was insignificant. When the CSE anaesthesia group and 25 G spinal group were compared for change in hearing between the pre- and postoperative periods, no statistically significant difference was detected at any frequency tested. When 22 G spinal group and 25 G spinal group were compared for change in hearing between the pre- and postoperative periods, there was some hearing loss at low frequency, although this difference did not reach statistical significance. The positive correlation of low-frequency hearing loss and increased pressure in the epidural space (which decrease the risk of cerebrospinal fluid leakage through the dura) suggests that cerebrospinal fluid leakage via the spinal puncture hole is not the only factor involved. Perioperative fluid replacement alone may not prevent hearing loss but CSF loss through the dural puncture site should also be prevented.

Differing incidences of relevant hypotension with combined spinal-epidural anesthesia and spinal anesthesia.

In this investigation we assessed whether patients receiving spinal anesthesia (SPA) as part of combined spinal-epidural anesthesia (CSE) more often experience relevant hypotension than patients receiving SPA alone. From January 1, 1997, until August 5, 2000, electronic anesthesia records from 1596 patients having received SPA and 1023 patients having received CSE for elective surgery were collected by using a computerized anesthesia record-keeping system. Relevant hypotension was defined as a decrease of mean arterial blood pressure of more than 30% within a 10-min interval and a therapeutic action of the attending anesthesiologist within 20 min after onset. Electronic patient charts were reviewed by using logistic regression with a forward stepwise algorithm to identify independent risk factors that were associated with an increased incidence of hypotension after CSE. Univariate analysis was performed to assess differences in biometric data and relevant risk factors for hypotension between the two procedures. The incidence of relevant hypotension was more frequent with CSE than with SPA alone (10.9% versus 5.0%; P < 0.001). In the multivariate analysis, arterial hypertension (odds ratio, 1.83; 95% confidence interval, 1.21-2.78) and sensory block height >T6 (odds ratio, 2.81; 95% confidence interval, 1.88-4.22) were found to be factors associated with hypotension in the CSE group. Compared with patients receiving SPA alone, patients undergoing CSE had a significantly more frequent prevalence of arterial hypertension and higher sensory block levels (P < 0.01) despite smaller amounts of local anesthetics. In this study, patients receiving CSE had an increased risk for relevant hypotension as compared with patients with SPA alone. Part of this effect seems to be due to the procedure alone and not only because this population is at higher risk. This study, based on a large number of patients with a retrospective design by using on-line recorded data, suggests that spinal anesthesia as part of combined spinal-epidural anesthesia may more often lead to relevant hypotension than spinal anesthesia alone. Preexisting arterial hypertension and a sensory block height exceeding T6 are major risk factors for the development of this complication.

Comparison of Three Modalities for Assessing Block Levels during Spinal or Combined Spinal Epidural Anesthesia for a Cesarean Delivery

Background: Assessing block levels during regional anesthesia has been mainly performed by three sensory modalities: cold, sharp pinprick (analgesia), and pinprick touch (anesthesia). Though sharp pinprick is more commonly used, pinprick touch has been emphasized to be more accurate and predictive by some. We compared block levels and discriminating power between the three modalities in spinal anesthesia (SA) and combined spinal epidural anesthesia (CSEA). Methods: Forty-six cesarean parturients were randomly given SA (n = 23) or CSEA (n = 23). SA was performed with intrathecal hyperbaric bupivacaine 0.5%-9 mg and fentanyl 20, and CSEA with intrathecal hyperbaric bupivacaine 0.5%-6 mg and fentanyl 20 followed by epidural bupivacaine 0.25%-10 ml 5 min later. Upper block levels were measured withe old (alcohol swab), sharp pinprick (25G Whitacre) and pinprick touch (25G Whitacre) at 5, 10, 15, 20, 30, 60, 90, and 120 min after intrathecal injections. Results: There were no complaints of pain through the operation by any patient, The maximum levels (median) using cold, sharp pinprick, or pinprick touch were T1, T2, and T4 in SA and T1, T3, and T4 in the CSEA group and there was no differences between group At every measuring time, there were significant differences in block heights of the three modlities in the upper mentioned order. In 5 patients (3 in SA, 2 in CSEA), there was a reverse order between the levels of cold sensation and analgesia. Pinprick touch was kept at the lowest levels at all times, and could discriminate the two blocks at two onset times (5, 10 min), sharp pinprick at one me (5 min) but cold sensation could not. Conclusions: There were marked differences in block heights measured by the three modalities in the decreasing order of cold, sharp pinprick, and pinprick touch. At the onset of the blocks, pinprick touch was the most discriminating to differentiate the two blocks, followed by a sharp pinprick.

Spinal and epidural versus general anesthesia for elective Cesarean section at term: effect on the acid–base status of the mother and newborn

Objective: To compare general, epidural and combined spinal-epidural anesthesia with respect to short-term outcome of newborns delivered by elective Cesarean section of healthy parturients with normalpregnancies.Study design: A total of 238 eight pregnant women admitted to our institution between January 1998 and July 2002, for whom elective Cesarean section was planned after 38 weeks' gestation,were grouped according to the kind of anesthesia used for the procedure. Maternal characteristics, birth weight, Apgar scores, and maternal and umbilical artery (UA) acid-base parameters were analyzed.Results: Maternal pH was significantly lower and pCO2 and pO2 were significantly higher in the general anesthetic group, compared to the other two groups (7.38± 0.03 vs. 7.43 ± 0.02 and 7.43 ± 0.05, respectively; 35.03 ± 3.88 mmHg vs. 29.25 ± 5.05 mmHg and 29.64 ± 4.16 mmHg, respectively; and 224.56 ± 86.77 mmHgvs. 151.28 ± 38 mmHg and 157.36 ± 53.51 mmHg, respectively, p < 0.05). The pH of the UA was higher in the general anesthetic group, compared to the spinal-epidural group (7.29 ±0.02 vs. 7.26 ± 0.06, p < 0.05). The pO2 as well as O2 saturation of the UA were higher when general anesthetic was administered, compared to the two regionalmodalities (15.60 ± 5.48 mmHg vs. 9.29 ± 4.41 mmHg and 9.20 ± 4.06 mmHg, respectively; and 17.37 ± 9.79% vs. 7.87 ± 4.98% and 6.90 ± 5.22%, respectively, p< 0.05). UA O2 saturation fell to zero in some cases in the combined spinal-epidural group, without an evident effect on fetal well-being. No fetal acidemia was noted in any group. Neonataloutcomes were similar in the three groups studied.Conclusions: Type of anesthesia does not influence short-term outcomes in infants born via elective Cesarean section, although differences inacid-base status of both the mother and especially the newborn recommend careful use of spinal anesthesia.

Comparison of Combined Spinal Epidural Anesthesia and Spinal Anesthesia Using Small-dose Bupivacaine in Cesarean Delivery

Background: Combined spinal-epidural anesthesia (CSEA) using a small-dose spinal anesthetic has been a new method recommended for cesarean delivery since the advents of fine pencil-point spinal needles and the combined spinal-epidural technique. The aim of this study was to compare CSEA with single-shot spinal anesthesia (SA) using as small doses of hyperbaric bupivacaine as possible mixed with an opioid in both methods. Methods: One hundred parturients were divided into two groups: CSEA (n = 50) and SA (n = 50) groups. The CSEA Group received 6 mg of 0.5% hyperbaric bupivacaine and 20g fentanyl followed by 10 ml of 0.25% bupivacaine 5 min later. The SA Group was given 9 mg of 0.5% hyperbaric bupivacaine and 20 fentanyl. We compared sensory and motor block variables, incidences of intraoperative side effects such as hypotension, nausea & vomiting and shivering, and recovery time variables in the PACU. Results: The anesthetic procedure took longer in the CSEA group. Sensory block was more rapid (P

Speed of Onset of Regional Analgesia in Labour: A Comparison of the Epidural and Spinal Routes

This study compares the speed of onset of effective analgesia in two randomly assigned groups of patients requesting analgesia in labour. Patients in the combined spinal-epidural group (n = 69) were given a subarachnoid injection of 1.5 ml containing bupivacaine 2.5 mg and fentanyl 25 microg for initiation of analgesia. Patients in the epidural group (n = 73) were given an epidural injection of 10 ml containing bupivacaine 12.5 mg and fentanyl 50 microg. Mean (SD) onset times to the first pain-free contraction were 10.0 (5.7) min in the combined spinal-epidural group and 12.1 (6.5) min in the epidural group (p = 0.054). Patients in the combined spinal-epidural group suffered a higher incidence of motor weakness and proprioceptive deficit than those in the epidural group (p = 0.01). The incidence of technique failure and side-effects was similar in the two groups. It is our contention that the statistically nonsignificant difference in onset times does not justify the additional potential for side-effects and the extra cost of the equipment involved in the combined spinal-epidural technique.