Continuous Extradural Analgesia Research Articles

A survey of paediatric caudal extradural anaesthesia practice

Introduction: Caudal extradural anaesthesia (CEA) is a common technique with wide application in paediatric anaesthesia [1]. An ‘on line’ World Wide Web survey of paediatric anaesthetists was undertaken to delineate any differences in the practice of this procedure. Methods: A web based questionnaire was devised to survey the practice of caudal extradural anaesthesia in children by anaesthetists who were members of the Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI). The questionnaire was designed to collect information on the experience of the anaesthetist, techniques employed, drugs used and the use of the caudal extradural catheter technique for continuous extradural anaesthesia and analgesia. Results: E-mails were sent to 600 anaesthetists and there were 366 useable on-line replies. The majority of respondents had greater than 5 years of paediatric anaesthetic experience and performed up to ten caudal extradural procedures a month. The commonest device used was a cannula (69.7%) with 68.6% using a 22G device. Those with less than 15 years experience tended to employ a cannula while anaesthetists with greater than 15 years experience favoured a needle technique. Most anaesthetists (91.5%) did not believe that there was a clinically significant risk of implantation of dermoid tissue into the caudal extradural space. The majority of anaesthetists used a combination of clinical methods to confirm correct placement of a needle or cannula and injection of local anaesthetic into the caudal extradural space. Only 27 respondents indicated that they used ultrasound. The local anaesthetic agents used were bupivacaine (43.4%), levobupivacaine (41.7%), ropivacaine (13.4%) and lignocaine (1.5%). A total of 104 anaesthetists used more than one type of local anaesthetic. Drug additives used included clonidine (42.3%), ketamine (37.5%) and opioids (18.1%). The caudal catheter technique was used by 43.6% of anaesthetists. For a single shot caudal injection most anaesthetists (74%) used gloves only with fewer adopting the ‘no touch’ technique (15.2%) or use of glove, gown and mask (10.8%). Anaesthetists with greater than 10 years experience tended to use a ‘no touch’ technique. Discussion: Caudal extradural anaesthesia is an extremely common technique among those surveyed. Most anaesthetists use a cannula to access the caudal space which is in variance with the description of the technique in the peer review literature. However, the needle technique still tends to be used by anaesthetists with more than 15 years of experience. The majority of anaesthetists concur with the lack of evidence that there is a risk of implantation of dermoid tissue into the caudal extradural space. The anaesthetists surveyed tended to use a combination of simple clinical methods to identify correct placement of local anaesthetic in the caudal space. Ultrasound is rarely used. This may change when ultrasound become more readily available. Despite the greater safety margin of levobupivacaine, bupivacaine is used slightly more frequently. This may be due to cost. Ketamine and clonidine are the most commonly used additives. The caudal extradural catheter technique is used by a large proportion of anaesthetists despite there being few commercially available sets of equipment [2]. While most anaesthetists wear gloves for asepsis some still employ a more traditional no-touch technique. Conclusion: To our knowledge this is the first electronic large scale survey of anaesthetists who perform caudal extradural anaesthesia in children. The findings of this survey provides a snap shot of current practice and act as a useful reference for the development of enhanced techniques and new equipment to improve safety and efficacy in the future.

Continuous extradural analgesia in a cow with complex regional pain syndrome

A chronic pain syndrome, similar to the complex regional pain syndrome (CRPS) described in human beings, was diagnosed in a cow with persisting severe pelvic limb lameness. Diagnosis was based on the disproportionate relationship between the severity and duration of pain and the lesion, the failure of conventional analgesic and surgical therapy and the presence of characteristic clinical features. Multimodal therapy, i.e. a mixture of methadone, ketamine and bupivacaine was administered continuously for 17 days via an extradural catheter to counteract nociceptive hypersensitization. Doses were adjusted daily after assessing the effect, using a composite pain score. Physiotherapy was also performed. The diagnosis of CRPS in cattle is unusual. In this case, treatment was successful and the cow was discharged mildly lame and in improving physical condition. Long-term extradural analgesia proved to be safe and effective in the treatment of this syndrome, which was nonresponsive to conventional therapy.

Paediatric caudal extradural catheterisation: an evaluation of a purpose designed equipment set

Using a purpose designed set of equipment, the Caudal Extradural Catheter Tray, Oxford Set (B Braun Medical Ltd, Sheffield, UK) we have evaluated the ease of cannulation of the caudal space, and the subsequent success in threading extradural catheters and obtaining satisfactory analgesia via the caudal route. The set was evaluated in 91 children (age range: 1 day to 10 years). Cannulation of the caudal space was achieved in all patients, and catheterisation of the extradural space was successful in 96.7% of patients. Postoperative analgesia was satisfactory in 95% of children who had continuous extradural analgesia. There were no major complications or neurological sequelae associated with using the set. We found the Caudal Extradural Catheter Tray provides the necessary equipment to perform extradural anaesthesia and analgesia safely and successfully in children of a wide age range.

Midlatency auditory evoked potentials and motor signs of wakefulness during anaesthesia with midazolam

We have studied midlatency auditory evoked potentials (MLAEP) and motor signs of wakefulness during anaesthesia with midazolam in 10 patients undergoing elective laparotomy under continuous extradural analgesia. Anaesthesia was induced with midazolam 0.3 mg kg-1 and maintained with midazolam 0.3-0.9 mg kg-1 h-1. Motor signs of wakefulness were documented as spontaneous movements and movements after simple commands (open eyes or move arms). MLAEP were recorded continuously awake, and during anaesthesia until the end of anaesthesia. Latencies of the peaks V, Na, Pa, Nb and P1 (ms) and amplitudes of the peaks Na/Pa, Pa/Nb and Nb/P1 (microV) were measured. Twenty-five movements were observed during anaesthesia; 15 movements in six patients were in response to commands. In two patients supplementary isoflurane was given. Latencies of the MLAEP peaks Pa, Nb and P1 increased slightly during anaesthesia. Amplitudes for Na/Pa, Pa/Nb and Nb/P1 did not change significantly. The high incidence of motor signs of wakefulness associated with preserved MLAEP indicated a high level of cortical neural activity and none of the MLAEP variables predicted movement during anaesthesia with midazolam.

Continuous Extradural Analgesia

We have compared three techniques used to provide extradural analgesia during the first stage of labour: 0.25% plain bupivacaine 10ml demand top-ups delivered by the midwife; continuous infusion of 0.125% plain bupivacaine 10 ml h−1 and patient-controlled extradural analgesia (PCEA) delivering 3-ml boluses of 0.25% bupivacaine. Each technique produced comparable analgesia achieving equivalent maternal satisfaction, with no difference in mode of delivery and no complications. This regimen for PCEA proved a viable alternative for continuous extradural analgesia and was popular with the mothers, midwives and anaesthetists.

INFLUENCE OF TIMING ON THE EFFECT OF CONTINUOUS EXTRADURAL ANALGESIA WITH BUPIVACAINE AND MORPHINE AFTER MAJOR ABDOMINAL SURGERY

We have studied the effect of continuous extradural analgesia with bupivacaine and morphine, initiated before or after colonic surgery, in a double-blind, randomized study. Thirty-two patients were allocated randomly to receive an identical extradural block initiated 40 min before surgical incision (n = 16) or at closure of the surgical wound (n = 16). The extradural regimen consisted of a bolus of 7 ml of plain bupivacaine 7.5 mg ml-1 plus morphine 2 mg and continuous extradural infusion of a mixture of bupivacaine 7.5 mg ml-1 plus morphine 0.05 mg ml-1, 4 ml h-1 for 2 h, followed by a continuous extradural infusion of a mixture of bupivacaine 2.5 mg ml-1 plus morphine 0.05 mg ml-1, 4 ml h-1, continued for 72 h after operation. In addition, all patients received similar general anaesthesia. There was no significant difference in request for additional morphine and no significant differences between the groups in pain scores (visual analogue scale or verbal) during rest or ambulation at any time of measurement. These results do not suggest that timing of analgesia with a conventional extradural regimen is of major clinical importance in patients undergoing colonic surgery.

CONTINUOUS EXTRADURAL ANALGESIA: COMPARISON OF MIDWIFE TOP-UPS, CONTINUOUS INFUSIONS AND PATIENT CONTROLLED ADMINISTRATION

We have compared three techniques used to provide extradural analgesia during the first stage of labour: 0.25% plain bupivacaine 10 ml demand top-ups delivered by the midwife; continuous infusion of 0.125% plain bupivacaine 10 ml h-1; and patient-controlled extradural analgesia (PCEA) delivering 3-ml boluses of 0.25% bupivacaine. Each technique produced comparable analgesia achieving equivalent maternal satisfaction, with no difference in mode of delivery and no complications. This regimen for PCEA proved a viable alternative for continuous extradural analgesia and was popular with the mothers, midwives and anaesthetists.

THE LOADING DOSE IN CONTINUOUS INFUSION EXTRADURAL ANALGESIA IN OBSTETRICS

We have investigated the need for a loading dose of local anaesthetic before continuous extradural analgesia. After a standard test dose, patients received 0.08% bupivacaine 8 ml, isotonic saline 8 ml or nothing. A continuous infusion of 0.08% bupivacaine 20 ml h-1 was then commenced. The mean times to onset of satisfactory pain relief were similar in the first two groups, but prolonged significantly in the third. This group also required more interventions for inadequate analgesia, although not significantly so. Mean time to achieve highest level of block was significantly shorter in the first group.

Duplicate markings on an epidural catheter

AnaesthesiaVolume 46, Issue 9 p. 795-796 Free Access Duplicate markings on an epidural catheter G. Yau, G. Yau Department of Anaesthesia and Intensive Care, Chinese University of Hong Kong, Prince of Wales Hospital, Sha Tin, Hong KongSearch for more papers by this authorM.C. Ewart, M.C. Ewart Department of Anaesthesia and Intensive Care, Chinese University of Hong Kong, Prince of Wales Hospital, Sha Tin, Hong KongSearch for more papers by this authorT.E. Oh, T.E. Oh Department of Anaesthesia and Intensive Care, Chinese University of Hong Kong, Prince of Wales Hospital, Sha Tin, Hong KongSearch for more papers by this author G. Yau, G. Yau Department of Anaesthesia and Intensive Care, Chinese University of Hong Kong, Prince of Wales Hospital, Sha Tin, Hong KongSearch for more papers by this authorM.C. Ewart, M.C. Ewart Department of Anaesthesia and Intensive Care, Chinese University of Hong Kong, Prince of Wales Hospital, Sha Tin, Hong KongSearch for more papers by this authorT.E. Oh, T.E. Oh Department of Anaesthesia and Intensive Care, Chinese University of Hong Kong, Prince of Wales Hospital, Sha Tin, Hong KongSearch for more papers by this author First published: September 1991 https://doi.org/10.1111/j.1365-2044.1991.tb09804.xCitations: 3AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. Reference 1 Lee JA. A new catheter for continuous extradural analgesia. Anaesthesia 1962; 17: 248– 50. 2 Doughty A. A precise method of cannulating the lumbar epidural space. Anaesthesia 1974; 29: 63– 5. Citing Literature Volume46, Issue9September 1991Pages 795-796 ReferencesRelatedInformation

ANTITHROMBOTIC EFFICACY OF CONTINUOUS EXTRADURAL ANALGESIA AFTER KNEE REPLACEMENT

We have studied the effect of extradural analgesia on postoperative venous thrombosis in patients undergoing knee arthroplasty. Forty-eight patients were allocated randomly to receive either general anaesthesia or extradural analgesia with local anaesthetics for 3 days. All patients wore compressive elastic stockings and no anticoagulant drugs were administered. Bilateral venography was performed 10 days after surgery. Continuous extradural analgesia did not impede mobilization of the patients. One case of nonfatal pulmonary embolism occurred in a patient who received general anaesthesia. The use of continuous extradural analgesia resulted in a significant difference in the total incidence of deep vein thrombosis (18% compared with 59% after general anaesthesia (P = 0.02]. The incidence of calf vein thrombosis was 12% compared with 45% after general anaesthesia (P = 0.05).

Comparison of Bupivacaine and Bupivacaine with Fentanyl in Continuous Extradural Analgesia During Labor

Department of Anaesthetics, Royal Infirmary; Department of Anaesthetics, Western Infirmary; and Medical Statistics Unit, Edinburgh University Medical School, Edinburgh and Glasgow, Scotland

Comparison of Bupivacaine and Bupivacaine with Fentanyl in Continuous Extradural Analgesia during Labour

Comparison of Bupivacaine and Bupivacaine with Fentanyl in Continuous Extradural Analgesia during Labour

Continuous Extradural Analgesia in Labour. Comparison Between “On Demand” and Regular “Top-up” Injections

Division of Anaesthesia and University Department of Anaesthesia, Glasgow Royal Infirmary, Glasgow, Scotland

CONTINUOUS EXTRADURAL ANALGESIA: CATCH-UP OR TOP-UP?

CONTINUOUS EXTRADURAL ANALGESIA: CATCH-UP OR TOP-UP?

CONTINUOUS EXTRADURAL ANALGESIA IN LABOUR: Comparison Between “On Demand” and Regular “Top-up” Injections

In a prospective comparative study 240 patients received extradural bupivacaine, either by regular timed injections or "on demand", for pain relief during the first stage of labour. Three concentrations of bupivacaine were used (0.5%, 0.375% and 0.25%). Quality and continuity of analgesia, motor blockade, spread of sensory blockade, cardiovascular changes, fetal outcome and maternal sequelae were recorded. Overall, the analgesia provided by regular top-up injections was superior to the on demand technique, especially when 0.375% bupivacaine was used. This improved analgesia was achieved without causing an increased incidence of operative deliveries or deleterious sequelae, with respect to the mother or the neonate.

Changes in Fetal TCPo2 Values Occurring during Labour in Association with Lumbar Extradural Analgesia

Forty-six of 64 high risk labours were managed with continuous lumbar extradural analgesia. Fetal heart rate (FHR) and continuous transcutaneous PO2 (tcPO2) measurements were made in the 64 patients. Abnormal fetal heart rate patterns and low tcP02 values associated with the onset of the extradural block were noted in 9% of these cases A decrease in maternal arterial pressure and uterine hypertonus appeared to be responsible, singly or m combination, for the changes. These effects and the changes in FHR were not seen in the 18 mothers not receiving extradural analgesia. The supine position was associated with slightly smaller fetal tcPo2 values than the preferred lateral positions, with a significant worsening of the fetal tcPo2 values after induction of the extradural block although, overall, extradural analgesia neither improved nor impaired the fetal tcPo2

Changes in Fetal tcPO2 Values Occurring During Labour in Association with Lumbar Extradural Analgesia

Forty-six of 64 high risk labours were managed with continuous lumbar extradural analgesia. Fetal heart rate (FHR) and continuous transcutaneous PO2 (tcPO2) measurements were made in the 64 patients. Abnormal fetal heart rate patterns and low tcP02 values associated with the onset of the extradural block were noted in 9% of these cases A decrease in maternal arterial pressure and uterine hypertonus appeared to be responsible, singly or m combination, for the changes. These effects and the changes in FHR were not seen in the 18 mothers not receiving extradural analgesia. The supine position was associated with slightly smaller fetal tcPo2 values than the preferred lateral positions, with a significant worsening of the fetal tcPo2 values after induction of the extradural block although, overall, extradural analgesia neither improved nor impaired the fetal tcPo2

INFLUENCE OF EXTRADURAL MORPHINE ON THE ADRENOCORTICAL AND HYPERGLYCAEMIC RESPONSE TO SURGERY

Plasma cortisol and glucose concentrations were measured repeatedly from before the induction of anaesthesia until 9 h after skin incision in 36 patients undergoing abdominal hysterectomy. Twelve patients received general anaesthesia (halothane), and systemic opiates for postoperative pain; a further 12 patients underwent continuous extradural analgesia with a local anaesthetic agent (bupivacaine) and in the remaining 12 patients general anaesthesia (halothane) plus extradural morphine (4mg before skin incision and an additional 4mg at skin closure) were used. Patients receiving extradural morphine or bupivacaine were free of pain. The physiological cortisol and glucose response to surgery was blocked by the extradural analgesia with bupivacaine. Extradural morphine did not modify the initial increase in plasma cortisol and glucose concentrations during surgery, but suppressed the hyperglycaemic and cortisol response following surgery when compared with the general anaesthesia group receiving systemic opiates. However, cortisol and glucose concentrations were greater after operation in patients receiving extradural morphine compared with extradural bupivacaine, suggesting that the endocrine metabolic response to surgery is predominantly released by neurogenic stimuli other than pain stimuli involving opiate receptor-dependent nociceptive pathways.

MATERNAL AND NEONATAL EFFECTS OF 1% AND 2% MEPIVACAINE FOR LUMBAR EXTRADURAL ANALGESIA

Continuous lumbar extradural analgesia with mepivacaine was administered to two groups of patients in normal labour. One group (26 patients: 1% mepivacaine) received a mean total dose of 342 mg (4.93 mg/kg) per patient, and developed a mean blood concentration of mepivacaine at delivery of 1.82 mug/ml. The neonatal umbilical vein concentration was 0.84 mug/ml. The other group (30 patients: 2% mepivacaine) received a mean total dose of 776 mg (11.65 mg/kg) per patient, and developed a mean blood concentration of mepivacaine at delivery of 3.47 mug/ml. The neonatal umbilical vein concentration was 2.61 mug/ml. Four of the infants of mothers who received 1% mepivacaine were depressed (1-min Apgar score 6 or less), and six of the other group were depressed also. Usually, depression appeared to be related to obstetric factors, rather than to analgesia. Eleven of the 56 infants had umbilical vein mepivacaine concentrations of 3 mug/ml or greater; of these, three were depressed. This does not agree with the concept that the toxic threshold for mepivacaine is 3 mug/ml. In both groups a significant linear correlation was obtained between umbilical vein concentration and total dose of mepivacaine. A maximal dose of 12 mg/kg maternal weight in the non-obese or 12 mg/kg lean body mass in the obese is suggested for continuous extradural analgesia with mepivacaine, although healthy mothers and infants may tolerate much more.

A new catheter for continuous extradural analgesia.

AnaesthesiaVolume 17, Issue 2 p. 248-250 Free Access A new catheter for continuous extradural analgesia J. ALFRED LEE, J. ALFRED LEESearch for more papers by this author J. ALFRED LEE, J. ALFRED LEESearch for more papers by this author First published: April 1962 https://doi.org/10.1111/j.1365-2044.1962.tb13457.xCitations: 16AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Reference 1 CURBELO, M. M. (1949). Curr. Resear. Anæs, and Anal., 28, 13. 2 LEE, J. ALFRED. (1960). Anæsthesia, 15, 186. Citing Literature Volume17, Issue2April 1962Pages 248-250 ReferencesRelatedInformation