Effect Of Epidural Analgesia Research Articles

Epidural Analgesia During Labor: Impact on Delivery Outcome, Neonatal Well-Being, and Early Breastfeeding

The effect of epidural analgesia on labor and effective breastfeeding is still being debated. The aim of this study is to define its impact on the trend of labor, the newborns' well-being, and early breastfeeding. We considered first-term physiologic pregnant women who delivered by the vaginal route. We divided them into two groups: group A received epidural analgesia during labor, whereas group B received no analgesia. We recorded maternal age, gestational age, modality of delivery, length of labor, and length of active labor. All newborns received skin-to-skin contact; early breastfeeding was encouraged. We recorded data on birth weight and length, Apgar score at minutes 1 and 5, type of crying, neonatal reactivity, and time between birth and exposure to the breast. Statistical significance was considered for p<0.05. Of 934 pregnant women who delivered by the vaginal route, 317 patients required labor analgesia, and 245 patients agreed to participate in our study. Only 128 patients met inclusion criteria. We randomized them in 64 women in group A and 64 women in group B. Data on maternal age, gestational age, type of delivery, neonatal birth weight and length, and Apgar score showed no significant differences. Total length of labor was 363.58±62.20 minutes in Group A versus 292.30±64.75 minutes in group B (p<0.001). The length of active labor showed no significant difference. Among neonatal parameters we found a statistically significant difference only for length of first breastfeeding, with a mean duration of <30 minutes in 62.2% in group A versus 29.3% in Group B (p<0.001). Epidural analgesia has little effect on trend of labor and duration of first breastfeed and none on neonatal outcome. A new protocol of epidural analgesia may solve these side effects.

Whether awake coronary artery bypass grafting is contrary to fast-track surgery?

We read with interest the recent paper of Go Watanabe et al [1], regarding awake off-pump coronary artery bypass grafting (OPCAB) under thoracic epidural anaesthesia (TEA). They compared 72 patients who underwent awake OPCAB under only TEA with 67 patients who underwent OPCAB under general anaesthesia (GA) and found that the time to drink water, the time to walk, and hospital stay were significantly shorter in awake OPCAB group. However, whether awake OPCAB is contrary to the concept of fast recovery surgery (FTS)? FTS using multimodal perioperative rehabilitation programs was introduced in the early 1990s, including preoperative optimization and information, ‘stress reduced’ surgery, efficient postoperative pain treatment, adjustment of perioperative care principles to existing evidence, and nursing care focusing on early mobilization and oral nutrition to enhance recovery, decrease morbidity and hospital stay [2]. The ultimate goal of FTS is to provide the ‘stress, pain and risk-free’ operation, its centre is to minimize stress. The reduction of stress during an elective surgical procedure, as characterized by attenuation of the neurohormonal response to the operation, not only provides a rational basis for increased recovery but also diminishes the risk of organ dysfunctions and complications [3]. During awake OPCAB, the tension and anxiety which will increase the patients’ stress and reduce the patient’s’ comfort and satisfaction are inevitable because the patients remain conscious. It is contrary to the concept of fast recovery surgery. We think the main benefit of awake OPCAB is achieved by the TEA, but not keeping conscious during operation. TEA recently gained popularity because of its potential beneficial effects on the perioperative stress response, analgesia and postoperative pulmonary function. Studies had shown that intraoperative use of TEA combined with GA will allow decreased use of opioids and permit earlier extubation [4], will alleviate perioperative stress and enable effective postoperative epidural analgesia which have favourable effects on pulmonary function parameters [5], and will have beneficial effects in cardiac risk patients [6]. In addition, there is a lack of evidence-based data that patients who have a risk of cerebral ischaemia or chronic pulmonary diseases are benefit from awake OPCAB. Whether it is the optimal method to use propofol or dexmedetomidine keeping patients sedation during OPCAB under TEA?

Prospective observational study of postoperative epidural analgesia for major abdominal surgery

To describe the incidence and intensity of pain, hypotension and other epidural-related side-effects after major abdominal surgery and to identify factors associated with effective epidural analgesia. Evidence exists that up to 30% of patients with epidural analgesia still experience severe pain in clinical practice. When epidurals produce good pain relief, potentially harmful side effects can result. Data were collected prospectively from 480 consecutive general surgical patients in a large District General Hospital in the UK. Fifty-six per cent of patients were hypotensive on day one. Low pain scores were found to be a predicator for postoperative hypotension. Severe pain was associated with emergency patients, male gender, the absence of hypotension and an epidural that did not continue until planned removal. Significantly lower mean pain scores were found in patients who were 70 years of age and over. No correlation exists between chronic pain before surgery and the level of postoperative pain. This study contributes to the epidural versus standard analgesia debate by describing the population in whom epidurals are used and identifies factors associated with both the success and failure of the technique in everyday practice. The Audit Commission has proposed a standard whereby less than 5% of patients should suffer severe pain following surgery. This may prove to be an unrealistic goal with currently available techniques. Relevance to clinical practice. As it is ward nursing staff who are primarily responsible for monitoring the effectiveness of the technique, it is important for nursing professionals to know the potential risks of postoperative epidural analgesia to be able to respond appropriately. The important measurements of an optimum acute pain assessment have been identified, based on the study results, allowing the development of a national acute pain registry to inform future practice.

Intraoperative Epidural Analgesia Prevents the Early Proinflammatory Response to Surgical Trauma. Results from a Prospective Randomized Clinical Trial of Intraoperative Epidural Versus General Analgesia

The intraoperative epidural analgesia (EA) has the potential to reduce stress response to surgical trauma which induces a transient immunoactivation that has a negative impact on the outcome. This study investigates the effect of intraoperative EA versus intravenous analgesia (IA) on the immune function. A total of 35 consecutive patients candidated to undergo major surgery for colon cancer were randomly assigned to intraoperative EA (n = 18) or IA (n = 17). Blood samples for TNF-α, IFN-γ, IL-1, IL-2, IL-4, IL-6, IL-10, IL-12, and GM-CSF were obtained before surgery (T(pre)), 3 h (T(3h)), and 24 h (T(24h)) after skin incision. Data on postoperative complications were prospectively collected and analyzed. In the EA group, IL-4 increased from T(pre) to T(3h) and from T(3h) to T(24h), IL-10 increased from T(pre) to T(3h) and persisted unmodified thereafter. At all time-points, IL-4 and IL-10 serum levels were significantly higher than those in the IA group. Conversely, in the IA group, IL-4 and IL-10 serum levels did not change while all other cytokines levels were significantly higher compared with the EA group. In particular, IL-6 progressively reached a 7-fold increase of its basal value at T(24h). Complications were significantly more common in IA patients (13 of 17) compared with EA patients (7 of 18) (P = .024). Our results indicate that in cancer patients undergoing major elective colon surgery, the EA attenuates the surgery-induced proinflammatory response and the typical postoperative transient immunosuppression and seems associated with a reduced rate of postoperative complications compared with IA.

Effectiveness of epidural analgesia following open liver resection

ObjectivesEpidural analgesia is often considered the reference standard for pain relief following major abdominal surgery; however, the provision of analgesia in the context of liver surgery raises unique challenges. This study investigated the effectiveness of analgesia and the postoperative course of patients who did or did not receive epidural analgesia following liver resection. MethodsData were collected retrospectively on 177 patients who underwent open liver resection between June 2007 and June 2009. Patients were divided into two groups consisting, respectively, of those who received epidural analgesia (Epidural group, n= 148) and those who did not (No-Epidural group, n= 29). ResultsIn the Epidural group, 27 patients (18%) required i.v. opiate analgesia on the day of surgery (DoS) or the first postoperative day (POD1). The Epidural group received significantly more i.v. colloid solution on the DoS (median: 1500ml vs. 750ml, range: 0–12000ml vs. 0–3500ml; P= 0.004) and POD1 (median: 0ml vs. 0ml, range: 0–5000ml vs. 0–1000ml; P= 0.018), and total fluid on the DoS and POD1 combined (median: 6522ml vs. 5453ml, range: 2150–21300ml vs. 2875–15886ml; P= 0.032). ConclusionsEpidural analgesia provided inadequate postoperative pain relief in approximately 20% of liver resection patients and was associated with the administration of significantly greater volumes of i.v. colloid solution.

Effects of epidural analgesia on colonic motility and patients’ outcome in colorectal surgery: a retrospective study

Aim: To explore the hypothesis that epidural medication stimulates colonic motility, shortens hospital stay and causes fewer complications than general anaesthesia alone, we conducted a retrospective study on patients undergoing colorectal surgery. Material and methods: Sixty-two adult patients who underwent colectomy or proctocolectomy at Vakif Gureba Training Hospi tal between June 2006 and December 2008 were divided into two groups retrospectively: an general anaesthesia only group (group 1) and a combined epidural and general anaesthesia group (group 2). First faecal and gas discharge time, first mobiliza tion time, length of hospital stay and postoperative complications in 30 days after surgery were obtained from patients’ med ical records. Results: Between the patients in the two groups matched and found similar for preoperative characteristics, there were no dif ferences for gas and faecal discharge time, mobilization time, length of hospital stay or complications.

Effect of epidural analgesia on labor and delivery: a retrospective study

Two groups of women have been retrospectively compared: 155 women who received analgesia and 1355 women who delivered without analgesia. The duration of the first stage, second stage, and total duration of labor was longer in epidural group, however epidural analgesia was not demonstrated as an independent risk factor for a prolonged labor. The variable most influencing the total duration of labor and the duration of the first stage was nulliparity; the variables most influencing the duration of the second stage were the older age, a reduced body mass index, a high newborn weight and nulliparity.

Effect of epidural analgesia with different methods on intestinal peristalsis

Objective To explore the effect of PCEA on intestinal peristalsis.Methods 120 patients with ASA Ⅰ～Ⅱ lower abdominal or lower limbs surgery were randomly divided into four groups with 30 cases each and received PCEA at the end of operation sespectively.Group A were given 0.0002% fentanyl,0.2% Ropivacaine and 0.005 % Droperidol;0.01% morphine,0.2% Ropivacaine and 0.005% droperidol in group B;0.2% Ropivacaine in group C;0.9% saline in group D.Postoperative analgesia was provided by PCA pump with LCP model.Results Satisfactory analgesia in group A was 93%,97% in group B 47% in group C and 13% in group D.Both group A and B did not show any significant difference in the analgesic effects(P＞ 0.05).Satisfactory analgesia in group A and B were significantly better than in group C and D(P＜0.05).The renewal of intestinal peristalsis were significantly faster in lower limbs surgery patients than lower abdominal patients(P＜ 0.01),but it did not show any significant difference in the same kinds of surgery in four groups (P＞0.05).Conclusion Both group A and B can get a satisfied analgesia effect;intestinal peristalsis of lower limbs surgery patients renewed were shorter than in lower abdominal patients. Key words: Anesthesia and analgesia; Gastrointestinal motility

Walking epidurals for labour analgesia: do they benefit anyone?

The ‘‘walking epidural’’ first appeared in the early 1990s. In some ways, it tested our widely held beliefs about how to provide effective and safe labour epidural analgesia and responded to women’s requests to have effective labour analgesia without being confined to bed. In the first versions of the walking epidural, the combined spinalepidural (CSE) technique was used. It provided initial analgesia with intrathecal narcotic, which was followed by a more standard continuous epidural infusion. This novel technique challenged our assumptions about the amount of neuraxial medication needed to initiate and maintain labour analgesia. Many labour analgesia studies ensued that resulted in significant changes to both the technique and the dosing strategies, and they led to a deeper understanding of the way in which local anesthetics and opioids work alone and synergistically in the neuraxium. Critical assessment of ambulation in labour with an epidural in situ has provided enormous benefit to women in labour, has changed how anesthesiologists provide labour epidural analgesia, and has added to the body of literature to convince our skeptical colleagues in obstetrics that epidurals don’t necessarily mean an operative delivery. The end result of this scientific activity is patient-controlled labour epidural analgesia with low-dose solutions—there are so many benefits in that simple phrase. So, why has the enthusiasm for walking epidurals faded? While it is true that ambulation per se has not been shown to alter labour outcome, maintaining mobility appeals to women although they may be at the point of requiring neuraxial analgesia. The fact that they may not take full advantage of this opportunity does not negate its other benefit of minimizing motor block. It is also true that the ‘‘mobile mom’’ can create more work for staff; however, once anesthesiologists establish management and safety protocols for ambulation, the added work belongs to the nurse and/or the midwife, many of whom support maintaining mobility. Safety of the perambulating parturient with an epidural has been established—her balance is just as good as any pregnant woman’s is at term, blood pressure is possibly more stable than in the woman who remains lying in bed and the fetus probably benefits from complete absence of aortocaval compression. So, why has the movement to mobility stalled? Have anesthesiologists lost their taste for the CSE because of fetal bradycardia and maternal pruritus? While CSEs opened the door to mobility, it has been clearly proven that low-dose epidurals with no intrathecal component work incredibly well and allow for safe ambulation. Perhaps we should reflect on the reason this ‘‘fad’’ started. Standard (aka dense) epidural analgesia did not always lead to maternal satisfaction with the analgesia because of the sense of loss of body control and the increased need for an instrumental vaginal delivery, especially if the mother was primiparous. So, intrepid obstetrical anesthesiologists began to challenge the status quo and experiment with the techniques of using intrathecal lipid soluble narcotics for initial analgesia, progressively more dilute solutions in the epidural space for subsequent analgesia, and then applying patient-controlled analgesia technology. Many studies used the ability to ambulate as one of the required outcomes, as it R. Preston, MD (&) Department of Anesthesia, BC Women’s Hospital and Health Centre, Rm 1Q72, 4500 Oak Street, Vancouver, BC V6H 3N1, Canada e-mail: rpreston@cw.bc.ca

OP11.11: Effects of epidural analgesia on uterine artery Doppler in labour

OP11.11: Effects of epidural analgesia on uterine artery Doppler in labour

The impact of throughout patient-controlled epidural analgesia on labor progress and delivery mode

Objective To explore the impact of throughout patient-controlled epidural analgesia(PCEA) on labor progress and delivery mode. Methods We enrolled 120 nulliparous women with term cephalic singleton preg-nancies. They were divided into two groups ,throughout analgesia group(n=60):when they are in labor,we started an-algesia and continued to the end of second stage of labor. While 60 nulliparous were selected to non-analgesia group as the control group. Data were collected about duration of the first, second stage of labor, oxytocin dosage, postpartum hemorrhage,outcome of delivery, neonatal Apgar scores, umbilical cord vein and artery blood gas analysis and the effect of epidural analgesia, etc. Results There wsa is significant difference in the duration of the first stage delivery, the utilization rates of oxytocin, delivery mode (P 0.05) Conclusion The throughout patient-controlled epidural analgesia can shorten labor progress, cut down uterine-incision delivery and reach satisfying analgesis effect, without commidng any impact on the outcome of delivery. Key words: Analgesia, patient-controlled; Labor, obstetric; Pregnancy outcome

Effect of epidural analgesia in patients with traumatic rib fractures: a systematic review and meta-analysis of randomized controlled trials

A consensus group recently proposed epidural analgesia as the optimal analgesic modality for patients with multiple traumatic rib fractures. However, its beneficial effects are not consistently recognized in the literature. We performed a systematic review and a meta-analysis of randomized controlled trials (RCT) of epidural analgesia in adult patients with traumatic rib fractures. A systematic search strategy was applied to MEDLINE, EMBASE, the Cochrane Library and to the annual meeting of relevant societies (up to July 2008). All randomized controlled trials comparing epidural analgesia with other analgesic modalities in adult patients with traumatic rib fractures were included. Primary outcomes were mortality, ICU length of stay (LOS), hospital LOS and duration of mechanical ventilation. Eight studies (232 patients) met eligibility criteria. Epidural analgesia did not significantly affect mortality (odds ratio [OR] 1.6, 95% CI, 0.3, 9.3, 3 studies, n = 89), ICU LOS (weighted mean difference [WMD] -3.7 days, 95% CI, -11.4, 4.0, 4 studies, n = 135), hospital LOS (WMD -6.7, 95% CI, -19.8, 6.4, 4 studies, n = 140) or duration of mechanical ventilation (WMD -7.5, 95% CI, -16.3, 1.2, 3 studies, n = 101). Duration of mechanical ventilation was decreased when only studies using thoracic epidural analgesia with local anesthetics were evaluated (WMD -4.2, 95% CI, -5.5, -2.9, 2 studies, n = 73). However, hypotension was significantly associated with the use of thoracic epidural analgesia with local anesthetics (OR 13.76, 95% CI, 2.89, 65.51, 3 studies, n = 99). No significant benefit of epidural analgesia on mortality, ICU and hospital LOS was observed compared to other analgesic modalities in adult patients with traumatic rib fractures. However, there may be a benefit on the duration of mechanical ventilation with the use of thoracic epidural analgesia with local anesthetics. Further research is required to evaluate the benefits and harms of epidural analgesia in this population before being considered as a standard of care therapy.

Mesures à prendre pendant le travail pour réduire le nombre d’extractions instrumentales

Several interventions have been demonstrated, with high evidence levels (EL), to be associated with reduced instrumental deliveries and should therefore be undertaken during labor for increasing spontaneous vaginal deliveries. Using a partogram (EL1) and continuous support during labor and childbirth (EL1) lead to fewer operative vaginal deliveries. Systematic early amniotomy increases the frequency of fetal heart rate abnormalities (EL2) without decreasing the incidence of instrumental deliveries (EL1) and should thus be avoided. Early oxytocin in dysfunctional labor (EL2) and manual rotation of posterior and transverse presentations (EL3) may reduce operative vaginal deliveries. Even without epidural analgesia, any upright or lateral positions compared to supine or lithotomy positions do not reduce instrumental deliveries (EL2). Epidural analgesia alters significantly instrumental delivery rates and therefore patient management in the labor ward. Indeed, when used with high concentration of local anesthetic, epidural analgesia is associated with increased operative vaginal deliveries (EL1), at least in part because of increased posterior presentations (EL2). However, the effect of epidural analgesia on instrumental delivery rates closely depends from the type of anesthetic and concentrations used. This effect is reduced when low concentrations of local anesthetic are used in combination with fat-soluble morphinated agent (EL1). Finally, for nulliparous women with continuous epidural analgesia, unless irresistible urge to push or medical indication to shorten second stage of labor, delayed pushing is associated with reduced difficult instrumental deliveries (EL1). Fundal pressure maneuvers should be prohibited because of their inefficiency (EL2) and dangerousness (EL4).

A Fast-Track Program Reduces Complications and Length of Hospital Stay After Open Colonic Surgery

A fast-track program is a multimodal approach for patients undergoing colonic surgery that combines stringent regimens of perioperative care (fluid restriction, optimized analgesia, forced mobilization, and early oral feeding) to reduce perioperative morbidity, hospital stay, and cost. We investigated the impact of a fast-track protocol on postoperative morbidity in patients after open colonic surgery. A randomized trial of patients in 4 teaching hospitals in Switzerland included 156 patients undergoing elective open colonic surgery who were assigned to either a fast-track program or standard care. The primary end point was the 30-day complication rate. Secondary end points were severity of complications, hospital stay, and compliance with the fast-track protocol. The fast-track protocol significantly decreased the number of complications (16 of 76 in the fast-track group vs 37 of 75 in the standard care group; P = .0014), resulting in shorter hospital stays (median, 5 days; range, 2-30 vs 9 days, respectively; range, 6-30; P < .0001). There was a trend toward less severe complications in the fast-track group. A multiple logistic regression analysis revealed fluid administration greater than the restriction limits (odds ratio, 4.198; 95% confidence interval, 1.7-10.366; P = .002) and a nonfunctioning epidural analgesia (odds ratio, 3.365; 95% confidence interval, 1.367-8.283; P = .008) as independent predictors of postoperative complications. The fast-track program reduces the rate of postoperative complications and length of hospital stay and should be considered as standard care. Fluid restriction and an effective epidural analgesia are the key factors that determine outcome of the fast-track program.

784: Effects of Epidural Analgesia on the Feto-Placental Blood Flow as Evidenced by Doppler Velocimetry

784: Effects of Epidural Analgesia on the Feto-Placental Blood Flow as Evidenced by Doppler Velocimetry

Effects of Epidural Analgesia on the Feto-Placental Blood Flow as Evidenced by Doppler Velocimetry

Effects of Epidural Analgesia on the Feto-Placental Blood Flow as Evidenced by Doppler Velocimetry

784. Effects of Epidural Analgesia on the Feto-Placental Blood Flow as Evidenced by Doppler Velocimetry

784. Effects of Epidural Analgesia on the Feto-Placental Blood Flow as Evidenced by Doppler Velocimetry

EPIDURAL ANALGESIA;

Introduction. The influence of epidural analgesia on the length of labourremains a source of controversy in literature. Objectives. To see the effect of epidural analgesia on the duration ofactive first stage and second stage of labour. Setting: Obstetric Department of CMH Kharian. Period: From 1 January st2005 to 31 March 2006. Material and methods. One hundred pregnant full term, women were included in the study. stFifty primiparous reporting at full term, half were given epidural analgesia the other half were control. Another fiftymultiparous reporting at full term, twenty five women were given epidural the other twenty five were control. Results.The mean duration of active first stage of labour in primiparous women after 3 – 4 centimeter cervical dilatation was5.10 hrs in the epidural group while it was 6.65 hrs in the control group (p less than 0.001). In the multiparous womenthe mean duration of active first stage of labour after 3 – 4 centimeter cervical dilatation was 2.40 hrs in the epiduralgroup while it was 3.43 hrs in the control group (p less than 0.001). In the primiparous women the mean second stagewas 23.76 minutes in the epidural group, and 37.33 minutes in the control group (p less than 0.001). In the multiparousgroup, the mean second stage was 17.58 minutes in the epidural group, and 22.00 minutes in the control group (p lessthan 0.001). Conclusion. Epidural analgesia decreases the duration of active first stage and second stage of labour.

The Effects of Epidural Analgesia on the Progression of Labor during Childbirth and Method of Delivery

硬膜外無痛分娩が, 分娩経過や分娩様式に及ぼす影響とその対策について, 現在まで行われてきた多くの研究をもとに述べる. 硬膜外無痛分娩中にオキシトシン使用頻度は増え, 分娩第 I 期は延長するという報告が多いが, 分娩第 I 期の長さについては, いまだ議論が続いている. 分娩第 II 期まで十分な鎮痛を行うかぎり, 分娩第 II 期は延長し, 器械分娩は増える. しかし, 帝王切開術は増加しない. 母体と胎児両方の状態が良いことが確認されているかぎり, 時間のみを根拠に分娩を完了させようとしないことが大切である. また, 陣痛が始まっていれば, 子宮頸管開大のみを基準に硬膜外麻酔開始を遅らせる必要はない.

The effect of epidural analgesia on labor progress and outcome in nulliparous women

Objective. The present study was designed to investigate the influence of epidural analgesia on labor progress and outcome in nulliparous women.Methods. A population-based study comparing women with and without epidural analgesia was conducted. Deliveries occurred during 1988–2006 at the Soroka University Medical Center. A multivariable logistic regression model with backward elimination was constructed to control for confounders.Results. During the study period there were 39 498 deliveries; epidural analgesia was given in 9960 (25.2%) of these. Using a multivariable analysis with backward elimination, the following conditions were significantly associated with the use of epidural analgesia: advanced maternal age, oligohydramnios, premature rupture of membranes, induction of labor, and Jewish (vs. Bedouin) ethnicity. These patients were more likely to deliver by cesarean delivery (CD; OR = 1.4, 95% CI 1.3–1.5; p < 0.001) and vacuum extraction (OR = 1.5, 95% CI 1.4–1.7; p < 0.001). After controlling for possible confounders such as macrosomia, failed induction, hypertensive disorders, gestational diabetes, maternal age, labor dystocia, and ethnicity, epidural analgesia was not found to be an independent risk factor for CD but rather a protective factor (OR = 0.9, 95% CI 0.8–0.9; p = 0.038). When vacuum extraction was the outcome variable, epidural analgesia was documented as an independent risk factor (OR = 1.1, 95% CI 1.01–1.3; p = 0.04).Conclusions. Epidural analgesia in nulliparous parturients increases the risk for labor dystocia and accordingly is an independent risk factor for vacuum extraction. Nevertheless, it does not pose an independent risk for cesarean delivery.