Efficacy Of Epidural Analgesia Research Articles

Randomized comparison of two methods of the epidural space identification during regional labour analgesia.

Conventional loss of resistance (LOR) technique for identifying the epidural space (EDS) predominantly depends on experience of the anaesthetist. A technique using automated syringe for EDS identification was invented as an alternative to the traditional method. The aim of the study was to compare the efficacy and risk for complications between automatic LOR syringe - Epimatic® (Vygon, Ecouen, France) and conventional LOR - Perifix® (B.Braun Melsungen AG, Melsungen, Germany) techniques for EDS identification. A total of 170 patients were enrolled into the study and 153 cases were analysed. Number of at- tempts, time to EDS identification, ease of EDS identification, complication rate and patient procedure-related discomfort were evaluated and compared. No statistically significant differences were found in the number of needle insertion attempts (1.3 in both groups), time to EDS identification (31 sec. vs. 27 sec.), efficacy of epidural analgesia (100% in both groups), or complication rate between both groups. The automatic and the conventional LOR techniques are comparable in terms of efficacy and safety for the epidural space identification.

Comparison of Continuous Epidural Analgesia and Intravenous Patient-Controlled Analgesia with Opioids in Terms of Postoperative Pain and Their Complications in Mega-Prosthesis Total Knee Arthroplasty for Bone Cancers.

Total knee arthroplasty with mega-prosthesis in oncologic patients is a painful surgery and may be associated with nerve injury. Epidural analgesia (EA) with local anaesthetics (LA) is routinely used for pain relief in these patients. At our institute, we came across a high incidence of motor weakness in these patients compelling to shift to patient-controlled analgesia (PCA) with intravenous opioids. We retrospectively analysed our data to find the incidence and reasons for motor weakness and also to compare the efficacy of EA and PCA as analgesics. Over a period of 15months, 68 patients were operated; out of these, 41 were in EA and 27 in PCA. Demographic details, level of epidural placement, drug used, pain scores, degree of motor weakness, measures taken to relieve the motor weakness and the improvement in symptoms after treatment were recorded. In the IV PCA group, details of drug used, dose of bolus, pain and sedation scores were analysed. Groups were comparable demographically. Motor weaknesses were present in 9 (22%) and 0 patients in EA and IV PCA groups respectively (p = 0.009). Average and maximum pain scores were significantly higher on day 1 in the IV PCA group (p of 0.00 and 0.001 respectively). Maximum pain scores were also significantly higher in the IV PCA group on day 2 (p = 0.010). Two patients out of 27 in IV PCA were found drowsy. Motor weakness is known with EA but can be managed effectively using a lower concentration of LA or by stopping the infusion of LA.

Epidural analgesia in latent phase of labor for preeclamptic women attempting vaginal delivery

Objective To evaluate the efficacy of epidural analgesia in latent phase of labor for preeclamptic women undergoing vaginal delivery. Methods A prospective study was conducted on 80 nulliparae of singleton pregnancy with preeclampsia and cephalic presentation in Tianjin Central Hospital of Gynecology Obstetrics from August 2016 to July 2017. All subjects were randomly divided into two groups including labor analgesia in active phase group (labor analgesia was commenced at cervical dilation over≥4 cm, n=40, group 1) and the whole labor analgesia in latent phase group (labor analgesia was comenced at the onset of labor, n=40, group 2). Visual analogue score (VAS) was used to evaluate pain intensity at different time points. Maternal venous blood samples were collected at the time of parturient and fetal delivery to determine the serum concentrations of cortisol (Cor) and adrenocorticotropic hormone (ACTH) by enzyme-linked immunosorbent assay (ELISA). Clinical data was statistically analyzed using t-test or Chi-square test. Results (1) Compared with group 1, the duration of the first stage of labor [(521.3±103.5) vs (570.3±116.2) min, t=0.366, P<0.05], the VAS scores immediately after analgesic administration and at cervical dilation of 2 and 3 cm [4.1±1.1 vs 7.3±1.2, 3.5±0.9 vs 7.6±1.7, 3.7±0.7 vs 8.1±1.4; t=4.387, 9.652, 5.321; all P<0.05], the mean arterial pressure at cervical dilation of 2 and 3 cm [(98.3±9.1) vs (125.3±10.6) mmHg (1 mmHg=0.133 kPa), (98.6±10.4) vs (127.5±9.6) mmHg; t=8.014, 5.496; both P<0.05] and the cesarean delivery rate [15.0% (6/40) vs 27.5% (11/40), χ2=4.012, P<0.05] were all lower in group 2. (2) The serum levels of Cor [(565±76) vs (231±64) nmol/L, (457±79) vs (233±55) nmol/L; t=6.028, 5.126; both P<0.05] and ACTH [(81±14) vs (38±11) pg/ml, (71±16) vs (39±10) pg/ml, t=5.984, 6.028; both P<0.05] in group 1 and group 2 were both increased significantly after delivery as compared with those at the time of parturient, and they also showed significant differences between the two groups after delivery (t=5.009, 3.862; both P<0.05). Conclusions Epidural analgesia in latent phase of labor can be implemented in preeclamptic women attempting vaginal delivery through alleviating labor pain as sooner and earlier as possible, reducing their stress responses and maintain hemodynamic stability. Key words: Pre-eclampsia; Analgesia, epidural; Analgesia, obstetrical; Natural childbirth; Labor stage, first

Randomised Controlled Trial to Compare the Efficacy of Epidural Analgesia versus Intravenous Analgesia during Thoracotomy for Repair of Oesophageal Atresia

Randomised Controlled Trial to Compare the Efficacy of Epidural Analgesia versus Intravenous Analgesia during Thoracotomy for Repair of Oesophageal Atresia

Efficacy of Epidural Analgesia and Intravenous Tramadol in Relieving Labour Pain: A Prospective Hospital Based Study

Background: Labour Pain during pregnancy is a painful experience for nearly all women. The aim of this study is to compare the efficacy, safety and adverse effects of epidural analgesia, tramadol in pain relief. Material and Methods: A total of 90 cases were studied. They included primi- as well as multigravidae, belonging to ASA grade 1 and 2 between the ages of 20-40 years, 37-41 weeks of pregnancy were selected. They were in established active stage of labor (uterine contraction 3 per 10 minutes, lasting for 30 to 40 seconds, cervical dilation more than 3 cm and up to 5 cm and cervical effacement more than or equal to 60%) with singleton fetus presenting by vertex and agreeable for analgesia. The selected patients were divided into three groups of Group I (control group, n=30), labour was carried out without using any analgesic technique, Group II (epidural Group, n=30) – Inj. bupivacaine 0.25% was given epidurally for analgesia, Group III (Tramadol Group, n=30) – Inj. Tramadol was given intravenously for analgesia. Result: From the observations gathered from this study, this can concluded that epidural analgesia provides much better analgesia than non-conventional methods of analgesia during labour. Conclusion: Tramadol have also a fair to good role in pain relief in labour, but mainly in first stage of labour when the pain is not severe enough.

Safety and efficacy of epidural analgesia.

Epidural analgesia remains a widely used analgesic technique. This article aims to assess the safety of epidural analgesia by balancing efficacy and complications, of epidural analgesia for acute, labor and chronic pain. Main indications for epidural analgesia include major open abdominal surgery, thoracotomy and labor analgesia. Past and current literature show that epidural analgesia leads to statistically significant, but possibly clinically less meaningful, reductions in pain scores compared with intravenous analgesia. The debate continues whether epidural analgesia leads to decreased complications and improved outcome. Noninferiority of alternative regional analgesic approaches, that is continuous-wound-infiltration, peripheral nerve blocks or surgical site infiltration, appears to be present and is promising for the future. Serious adverse events after epidural analgesia seem to occur more often than was previously thought and clinicians must realize that incidence rates differ in specific perioperative patient populations. Epidural analgesia for obstetric analgesic purposes is considered to be well tolerated in young, healthy women, since efficacy has been proven and complications leading to permanent neurological damage seldomly occur. Safety of epidural analgesia for perioperative and chronic pain treatment is more difficult to balance; careful selection of appropriate patients cannot be over-emphasized.

Efficacy of Epidural Analgesia During Labour

Although labour is considered as a normal physiological process, it can produce significant pain, requiring appropriate pain management. A painful labour also had detrimental effects on the mother and fetus. Ideal labour analgesia technique should dramatically reduce the pain of labour, while allowing the parturient to actively participate in birthing experience and have minimal adverse effects on the fetus and progress of labour. Epidural analgesia and opioids are often used for management of labour pain. Epidural analgesia is an effective method for managing labour pain. Studies have indicated that the procedure has few contraindications and few side-effects. The study was done to see the efficacy and safety of epidural analgesia with conventional analgesia (Inj. Pethidine and phenergan) during labour. In this study, pregnant women with active labour (Cervical dilation 4cm) were grouped into two A &amp; B. Group A received epidural analgesia (0.125% Bupivacaine &amp; 50 microgram Fentanyl) &amp; group B received conventional analgesia (Inj. Pethidine &amp; phenergan). Then the subjects were followed up and outcomes were recorded in a preformed data collection sheet. All data were analyzed by computer based software SPSS version 15. The study demonstrated a significantly earlier onset of effective analgesia in epidural group than that in the conventional group. The pain score at onset of analgesia and at different time intervals following induction and at the time of delivery were appreciably lower in women receiving epidural analgesia than those receiving conventional analgesia (p&lt;0.001). There was no significant difference between epidural and conventional groups in terms of complications like nausea and/or vomiting (p=0.431), prolonged 2nd stage of labour (p=0.127), mode of delivery (Normal / Instrumental / Cesarean) (p=0.455). Neonatal outcome was evaluated in terms of APGAR score at 1&amp; 5 minutes of birth in both groups which showed no significant differences (p=0.401and p=0.536 respectively). So, epidural analgesia is an effective analgesia during labour.&#x0D; JCMCTA 2016 ; 27 (2) : 12 - 17

Long-Term Evaluation of Continuous Epidural Anesthesia in an Improved Canine Model.

BackgroundContinuous epidural analgesia with catheterization is a useful technique, because it has a wide adaptation range and provides prolonged analgesia. Problems that may arise from long-term epidural analgesia are changes in the analgesic area, duration of analgesia and catheter-related problems. Few articles have evaluated gradual changes of long-term epidural analgesia. In the animal models used in those studies, the catheter was inserted by an invasive surgical procedure. In the present study, we evaluated changes in a canine model in which the catheter was inserted by a minimally invasive procedure.ObjectivesTo evaluate long-term changes in the efficacy of epidural analgesia in an improved canine model in which the epidural catheter was inserted and fixed for 5 weeks using a minimally invasive procedure.Materials and MethodsSix beagles underwent epidural catheterization under general anaesthesia. The catheter tip was located in the sixth lumbar region; the catheter peripheral end was passed subcutaneously through the neck. Physiological saline was continuously infused (1.0 mL/h) via the catheter throughout the study. The efficacy of epidural analgesia was assessed weekly with 2% lidocaine once a week in 5 weeks. Peripheral blood analysis including interleukin-6 (IL-6) level in the cerebrospinal fluid (CSF), histological evaluations and epidurography were performed to evaluate the mechanisms underlying the changes.ResultsNo dog died and the catheters were kept in place. The efficacy of analgesia was well maintained until 4 weeks; at 5th week, the efficacy decreased by half. The spread of injected medium was not observed in the cranial direction at 5th week and the tip of catheter was capped with granulation tissue. Throughout the study period, white blood cell counts and C-reactive protein levels were slightly high for catheterization and the IL-6 level in CSF was below detectable limits.ConclusionsThis was the longest study period with continuous epidural analgesia administered in canines. The effective period of epidural anesthesia was 4 weeks in this study. We speculate that time-dependent decrease in the anaesthetic efficacy was attributed to formation of granulation tissue surrounding the catheter tip.

Epidural catheter fixation. A comparison of subcutaneous tunneling versus device fixation technique.

Background and Aims:The technique of securing the epidural catheter has a major bearing on the efficacy of epidural analgesia. Specific fixator devices, for e.g., Lockit epidural catheter clamp, which successfully prevents catheter migration, are available. The possibility of catheter snapping and surgical retrieval has been reported with tunneling of catheters. These techniques have not been compared for safety, efficacy and appropriateness of achieving secure epidural catheter fixation in the postoperative period.Material and Methods:A total of 200 patients who required postoperative epidural analgesia were included. They were randomized into two groups: Group I (n = 100) in whom epidural catheters were tunneled vertically in the paravertebral subcutaneous tissue and group II (n = 100) wherein a Lockit device was used to fix the catheter. Likert score was used to quantify patient's comfort during procedure. The techniques were compared for migration, catheter dislodgement, local trauma, catheter snapping and catheter obstruction.Results:12% of tunneled catheters had migrated significantly outward. 22% of patients had erythema and 77% had significant procedural discomfort in group I. In group II, 3% catheters had kinked and 14% had erythema from device adhesive.Conclusion:Our results support the use of Lockit device as a safe and comfortable fixation device compared to subcutaneous tunneling of catheters.

Efficacy of Epidural Analgesia in Patients with Cancer Pain: A Retrospective Observational Study

PurposePain in terminal cancer patients may be refractory to systemic analgesics or associated with adverse drug reactions to analgesics. Epidural analgesia has been effectively used in such patients for pain control. However, this method does not provide pain relief to all patients. The efficacy and complications of continuous epidural analgesia were evaluated for expanding efficacy in terminal cancer patients.Materials and MethodsThe charts of patients who received epidural analgesia for over 5 years for the control of terminal cancer pain were reviewed retrospectively.ResultsNinety-six patients received 127 epidural catheters. The mean duration for epidural catheterization was 31.5±55.6 (5-509) days. The dose of epidural morphine increased by 3.5% per day. The efficacy of epidural analgesia at 2 weeks follow up revealed improved pain control (n=56), as the morphine equivalent drug dose dropped from 213.4 mg/day to 94.1 mg/day (p<0.05) at 2 weeks follow up. Accordingly, after 2 weeks institution of epidural analgesia, there was a significant reduction in the proportion of patients with severe pain, from 78.1% to 19.6% (p<0.05).ConclusionEpidural analgesia was an effective pain control method in patients with terminal cancer pain, however, a systematized algorithm for the control of cancer-related pain in needed.

Ultrasonography of the lumbar spine for neuraxial and lumbar plexus blocks

Ultrasonography of the spine has evolved into a well described technique that can be applied to facilitate neuraxial and lumbar plexus blockade. There is increasing evidence for the clinical benefits of ultrasound imaging prior to administration of neuraxial blockade. Recent randomized controlled trials have shown that efficacy of epidural analgesia is improved, and the technical difficulty of spinal and epidural anaesthesia is reduced. Ultrasound imaging may also permit more accurate prediction of the depth to epidural and intrathecal spaces and more accurate identification of intervertebral levels. The use of ultrasound in lumbar plexus blockade has been described in the context of both preprocedural imaging and real-time needle guidance; however, its clinical benefit in this setting has not yet been clearly established. Preprocedural ultrasound imaging of the spine may reduce the technical difficulty of neuraxial blockade and also improve clinical efficacy. Similar benefits are expected in the setting of lumbar plexus blockade although there is currently no evidence to confirm this. Real-time ultrasound-guided neuraxial and lumbar plexus blockade are challenging techniques that need further validation.

Effect of parecoxib on efficacy of epidural analgesia with different doses of morphine after cesarean section

Objective To evaluate the effects of parecoxib on efficacy of patient-controlled epidural analgesia(PCEA) with different doses of morphine after cesarean section.Methods Three hundred ASA Ⅰ or Ⅱ parturients at full term aged 20-40 yr weighing 54-89 kg undergoing elective cesarean section were randomly divided into 3 morphine groups-regular,median and small dose (groups Ⅰ,Ⅱ[ and Ⅲ) ( n ＝ 100 each).Each group was further divided into 2 subgroups ( n ＝ 50 each):parecoxib group (groups P1.2.3 ) and control group (groups C1,2.3 ).In groups P1.2.3 psrecoxib 40 mg was administered iv at the end of operation while in groups C1.2.3 normal saline (NS) was administered instead of parecoxib.Groups Ⅰ,Ⅱ and Ⅱ received a loading dose of morphine 2.0/1.5/1.0 mg+ 0.15％ ropivacaine 8 ml respectively.The PCEA solution contained morphine 3.0/2.0/1.5mg+ ropivacaine 150 mg + granisetron 3 mg+ dexamethasone 5 mg in 100 ml of NS in groups Ⅰ,Ⅱ,and Ⅲ respectively.PCEA pump was set up with a background infusion of 2 ml/h,and a bolus dose of 0.5 ml with a lockout-interval of 15 min.VAS was used to assess intensity of pain (0 ＝ no pain,10 ＝ worst pain).VAS score ≤4 was considered as effective analgesia.Adverse effects including nausea and vomiting and pruritus were recorded.Results There was no significant difference in the rate of effective analgesia between groups P1,P2 and C1,C2 The rate of effective analgesia during movement was significant higher in group P3 than in group C3.The incidence of nausea and vomiting and pruritis were significantly lower in group P3 than in groups P1 and P2.Conclusion Parecoxib can enhance the efficacy of PCEA with small dose of morphine. Key words: Cyclooxygenase inhibitors; Morphine; Pain,postoperative; Analgesia,epidural; Cesarean section

A reply

Dr Scott has raised some interesting issues and I think these are worth exploring. Firstly, I refer Dr Scott to a review done the same year on the same topic with very similar references [1] to the one that he has quoted. It found very little benefit of epidural analgesia in colorectal surgery. The authors in the reference quoted by Dr Scott state that they were unable to comment on the increase or decrease in anastomotic dehiscence using thoracic epidural analgesia and also comment on the fact that many of the proposed benefits to epidural analgesia were unable to be proven [2]. So we do not believe that the evidence that he has provided supports the safety or efficacy of epidural analgesia in patients who have had colorectal surgery. Regarding the use of the study by Gould et al. [3], we chose this as it is the only study that we are aware of that has clearly demonstrated the relationship between cardiac output, blood pressure and gastro-intestinal tract perfusion. Gould et al. clearly showed that gut perfusion is not related to cardiac output but is related to an increase in perfusion pressure. Most therapies used to treat epidural induced hypotension are based on either fluid loading or decreasing the epidural infusion rate. Fluid loading will optimise cardiac output but will do very little to improve vascular resistance and relying on pain driven catecholamines to increase the blood pressure seems somewhat perverse. It is, of course, very difficult for us to comment on Dr Scott’s 3500 cardiac patients who have had thoracic epidural analgesia. As far as we are aware he has not published any data regarding these patients. This is not the group that we were addressing and they will have different levels of post operative monitoring and therapy to standard laparotomy patients. Without knowing Dr Scott’s definitions, therapy and completeness of the data set, it is impossible to draw any conclusions on the safety of epidurals from his data. The review quoted earlier found an odds ratio of 13.5 for hypotension with epidural analgesia compared to opioid techniques [1]. We would therefore say there is quite a high level of concern. Thirdly we reiterate our point made in the editorial about the MASTER study. We did not say it was a perfect study. We said that it was the most credible study in this area that has been performed. It demonstrates a number of important points but most significantly, how difficult it is to provide adequate epidural analgesia in these patients. Regarding the significant reduction in pulmonary morbidity and pain, we commented in our editorial that there was a statistically significant reduction in pain scores, but that in both groups the pain scores were low. We still feel that a reduction in pain score of 1 cm on a visual analogue score was not clinically significant. Our comment on the MASTER study being a victim of its own success refers to the fact that it is very difficult to prove benefit in terms of pain scores if your background pain score is so low. Failure rates for post-operative epidurals are high. The failure rate in the MASTER study was 42.5%. This is in the context of a study with enthusiasts involved. It is difficult to see that it will be any less in the UK. The study that you quoted suggesting a 20% failure rate in UK hospitals is not reflective of normal UK practice [4]. This survey was performed when patients with epidural analgesia were routinely admitted to High Dependency Unit for post operative care. This, as you pointed out, is no longer the case. The authors also only looked at epidural analgesia for 48 h which we consider to be inadequate. We therefore stand by our figures of 50% of epidurals failing and possibly even higher. We do however agree with Dr Scott that if you are going to provide an epidural service you must have the ability to adequately assess the effect of your epidural analgesia, strive for total dynamic analgesia and be able to rapidly resite or adjust the epidural. This is both costly and time consuming to provide this service on a 24 h basis. Considering both the decrease in the numbers and experience of junior trainees, it is likely that this role is going to fall to consultants. We are not sure that the cost of providing this service is justified.

Epidural analgesia during brachytherapy for cervical cancer patients

To find out the efficacy of epidural analgesia in providing continuous pain relief for patients undergoing brachytherapy for cervical cancer. Teaching Hospital. Retrospective Study. A total of 152 patients of cervical cancer received epidural analgesia during 18 to 21 hours of pelvic brachytherapy. Epidural top up was given using 60-100 microg of buprenorphine every 08-10 hrs. Additional top up or systemic analgesics were given for breakthrough pain. Majority of patients 119 out of 152 received epidural top up twice during their stay in the brachytherapy ward. Only 20 out of 152 needed additional analgesics. Epidural analgesia is safe and provides satisfactory pain relief during brachytherapy and makes patient's stay more comfortable.

Can epidural catheter progression influence the clinical efficacy of epidural analgesia?

Can epidural catheter progression influence the clinical efficacy of epidural analgesia?

Efficacy of epidural analgesia during labour and delivery: a comparison between singleton vertex presentation, singleton breech presentation and twin pregnancies

Efficacy of epidural analgesia during labour and delivery: a comparison between singleton vertex presentation, singleton breech presentation and twin pregnancies

A comparison of continuous epidural infusion and intermittent intravenous bolus doses of morphine in children undergoing selective dorsal rhizotomy

Background and Objectives. Selective dorsal rhizotomy (SDR) is associated with moderate to severe postoperative pain. Although the efficacy of epidural analgesia in this population has been demonstrated, it has not been compared with conventional intravenous (i.v.) analgesia. This prospective study compared the effects of epidural and i.v. morphine regarding postoperative analgesia, side effects, and outcomes in children following SDR. Methods. Twenty-seven children were randomized to receive either epidural or i.v. analgesia. Children in the epidural group had a catheter placed by the neurosurgeon and received preservative-free morphine (Duramorph) 30 μg/kg, followed by an infusion of 3 μg/kg/h for 3 days. Children in the i.v. group received morphine 0.05-0.1 mg/kg intraoperatively, followed by 0.02 mg/kg doses postoperatively administered by nurses via a patient-controlled analgesia device. Results. The epidural group experienced lower pain scores ( P = .04) and fewer muscle spasms ( P ≤ .04), and tolerated activity better ( P ≤ .02) during the early postoperative period than the i.v. group. Side effects were similar between groups, with no respiratory depression in either group. Parents of children in both groups perceived an adequate level of comfort and were very satisfied with the analgesic technique. Additionally, parents believed that their child's postoperative pain was less than anticipated ( P ≤ .01). Conclusions. Both techniques provided effective postoperative analgesia with a similar incidence of side effects; however, our findings suggest that continuous infusions of epidural morphine improved overall comfort with lower pain scores, fewer muscle spasms, and improved tolerance of activity during the initial postoperative period.

Epidural Analgesia for Pain Relief After Scoliosis Surgery in a Patient with Rett's Syndrome

Epidural Analgesia for Pain Relief After Scoliosis Surgery in a Patient with Rett's Syndrome

Safety and Efficacy of Epidural Analgesia in Spine Surgery

Department of Neurosurgery and Anesthesia, University of Oklahoma School of Medicine, Oklahoma City, Oklahoma

Safety and Efficacy of Epidural Analgesia in Spine Surgery

Over the last 4 years, the authors have had experience with epidural analgesia for a variety of spinal operations in 24 patients. It has proved to be safe, reliable, and effective. No patient has had a new neurological deficit as a result of the epidural technique, and 18 of 22 patients with neurological deficit improved. Thus, epidural analgesia should not be excluded from the anesthesiologist's consideration simply because of the presence of spine disease or neurological deficit.