Epidural Technique Research Articles

Development and validation of a predictive risk factor model for epidural re-siting in women undergoing labour epidural analgesia: a retrospective cohort study

BackgroundEpidural catheter re-siting in parturients receiving labour epidural analgesia is distressing to the parturient and places them at increased complications from a repeat procedure. The aim of this study was to develop and validate a clinical risk factor model to predict the incidence of epidural catheter re-siting in labour analgesia.MethodsThe data from parturients that received labour epidural analgesia in our centre during 2014–2015 was used to develop a predictive model for epidural catheter re-siting during labour analgesia. Multivariate logistic regression analysis was used to identify factors that were predictive of epidural catheter re-siting. The forward, backward and stepwise variable selection methods were applied to build a predictive model, which was internally validated. The final multivariate model was externally validated with the data collected from 10,170 parturients during 2012–2013 in our centre.ResultsNinety-three (0.88%) parturients in 2014–2015 required re-siting of their epidural catheter. The training data set included 7439 paturients in 2014–2015. A higher incidence of breakthrough pain (OR = 4.42), increasing age (OR = 1.07), an increased pain score post-epidural catheter insertion (OR = 1.35) and problems such as inability to obtain cerebrospinal fluid in combined spinal epidural technique (OR = 2.06) and venous puncture (OR = 1.70) were found to be significantly predictive of epidural catheter re-siting, while spontaneous onset of labour (OR = 0.31) was found to be protective. The predictive model was validated internally on a further 3189 paturients from the data of 2014–2015 and externally on 10,170 paturients from the data of 2012–2013. Predictive accuracy of the model based on C-statistic were 0.89 (0.86, 0.93) and 0.92 (0.88, 0.97) for training and internal validation data respectively. Similarly, predictive accuracy in terms of C-statistic was 0.89 (0.86, 0.92) based on 2012–2013 data.ConclusionOur predictive model of epidural re-siting in parturients receiving labour epidural analgesia could provide timely identification of high-risk paturients required epidural re-siting.

Necessity of Combined Spinal Epidural Technique Duringopen Abdominal Myomectomy for Huge Uterine Fibroids

Background: Open abdominal myomectomy is commonly done to remove uterine fibroids which plague several Africans and people of African origin especially at the prime of their reproductive careers. Various anaesthetic techniques have been described for this surgical procedure. Some of the techniques have disadvantages.
 Objective: The aim of this study was to demonstrate the necessity and safety of the combined spinal epidural technique during open abdominal myomectomy for huge uterine fibroids.
 Methodology. A 5 years prospective study of 100 women with huge uterine fibroids, who had open abdominal myomectomy with combined spinal epidural (CSE) technique at Nimley Medical Consultants hospital, Kelsey Harrison hospital and the University of Port-Harcourtteaching hospital, was done. Data collected were analyzed with statistical package for social sciences (SPSS) version 17.0.P value < 0.05 was regarded as statistically significant.
 Results. The mean age of the women was 32.53 ± 0.66 years. The mean fibroid size was 30.15 ± 0.68 weeks and the mean surgical duration was 178 .98 ±3.31 minutes. The epidural component of the CSE was activated after a meantime of 106.15±3.22minutes from the initiation of spinal anaesthesia at a mean numeric pain rating score (NRS) of ? 3cm. The rate of perioperative complications was low.
 Conclusion. Combined spinal epidural technique is a safe and necessary technique with relatively low rate of perioperative complications when used during open abdominal myomectomy for commonly found huge African fibroids.

Necessity of combined spinal epidural technique duringopen abdominal myomectomy for huge uterine fibroids

Background: Open abdominal myomectomy is commonly done to remove uterine fibroids which plague several Africans and people of African origin especially at the prime of their reproductive careers. Various anaesthetic techniques have been described for this surgical procedure. Some of the techniques have disadvantages.
 Objective: The aim of this study was to demonstrate the necessity and safety of the combined spinal epidural technique during open abdominal myomectomy for huge uterine fibroids. Methodology. A 5 years prospective study of 100 women with huge uterine fibroids, who had open abdominal myomectomy with combined spinalepidural (CSE) technique at Nimley Medical Consultants hospital, Kelsey Harrison hospital and the University of Port-Harcourtteaching hospital, was done. Data collected were analyzed with statistical package for social sciences (SPSS) version 17.0.P value < 0.05 was regarded as statistically significant.
 Results. The mean age of the women was 32.53 ± 0.66 years. The mean fibroid size was 30.15 ± 0.68 weeks and the mean surgical duration was 178 .98 ± 3.31 minutes. The epidural component of the CSE was activated after a mean time of 106.15 ± 3.22minutes from the initiation of spinal anaesthesia at a mean numeric pain rating score (NRS) of > 3cm. The rate of perioperative complications was low.
 Conclusion. Combined spinal epidural technique is a safe and necessary technique with relatively low rate of perioperative complications when used during open abdominal myomectomy for commonly found huge African fibroids.

Epidural anesthesia and cancer outcomes in bladder cancer patients: is it the technique or the medication? A matched-cohort analysis from a tertiary referral center

BackgroundThe perioperative period can be a critical period with long-term implications on cancer-related outcomes. In this study, we evaluate the influence of regional anesthesia on cancer-specific outcomes in a radical cystectomy (RC) cohort of patients.MethodsWe performed a retrospective analysis of patients with clinically-nonmetastatic urothelial carcinoma of the bladder who underwent RC at our institution from 2008 to 2012. Patients were retrospectively registered and stratified based on two anesthetic techniques: perioperative epidural analgesia with general anesthesia (epidural) versus general anesthesia alone (GA). Epidural patients received a sufentanil-based regimen (median intraoperative sufentanil dose 50 mcg (45,85). Propensity-score was used to make 1:1 case-control matching. Cumulative risk of recurrence with competing risks was calculated based on anesthetic technique. Kaplan-Meier curves were used to compare recurrence-free (RFS) and cancer-specific survival (CSS). Univariable and multivariable analyses were performed with Cox proportional hazard regression models for RFS and CSS.ResultsOnly patients with complete data on anesthetic technique were included. Out of 439 patients, 215-pair samples with complete follow-up were included in the analysis. Median follow-up was 41.4 months (range: 0.20–101). Patients with epidurals received higher median total intravenous morphine equivalents (ivMEQ) versus those in the GA group (75 (11–235) vs. 50 ivMEQ (7–277), p < 0.0001). Cumulative risk of recurrence at two years was 25.2% (19.6, 31.2) for epidural patients vs. 20.0% (15.0, 25.7) for GA patients (Gray test p = 0.0508). Epidural analgesic technique was a significant predictor of worse RFS (adjusted HR = 1.67, 1.14–2.45; p = 0.009) and CSS (HR = 1.53, 1.04–2.25; p = 0.030) on multivariable analyses.ConclusionsEpidural anesthesia using sufentanil was associated with worse recurrence and disease-free survival in bladder cancer patients treated with surgery. This may be due use of epidural sufentanil or due to the increased total morphine equivalents patient received as a consequence of this drug.

Comparative Study of Segmental Thoracic Spinal Versus Thoracic Epidural Anesthesia for Laparoscopic Cholecystectomy

Background: Laparoscopic cholecystectomy the standard surgery for gallstone disease have been successfully performed under regional anesthetic techniques.In our study we compared thoracic epidural anaesthesia versus segmental thoracic spinal anaesthesia in healthy patients regarding safety, efficacy and complication. Aim and objective: This study was designed to compare and evaluate safety, efficacy ,benefits and complications of conducting laparoscopic cholecystectomy under segmental thoracic spinal versus thoracic epidural anesthesia. Method: Seventy ASA I or II patients undergoing laparoscopic cholecystectomy were randomized into two groups, one group received segmental thoracic spinal anesthesia (TSA) T8-T9 level using 7.5 mg isobaric bupivacaine 0.5% and 25 μg fentanyl with total volume 2ml, other group received thoracic epidural anesthesia (TEA) T8-T9 10 ml of 0.5% isobaric bupivacaine and 25μg fentanyl. Results: Segmental thoracic spinal technique was less technical difficulty (p value 0.017), less shoulder pain (p value0.017 ) more abdominal relaxation ( p value 0.015) than epidural technique (two cases were converted to general anaesthesia in epidural group and one patient in spinal group duo to uncontrollable patient discomfort. The two blocks were effective for surgery with better patient and surgical satisfaction in spinal group recovery. Conclusion: Both segmental thoracic spinal and thoracic epidural anaethesia were safe and effective anaethetic technique for laparoscopic cholecystectomy with less technical difficulty and better abdominal relaxation in spinal group.

Comparison of Epidural and Spinal Anesthesia Techniques for Transurethral Resections

Purpose: Transurethral resections (TUR) are commonly performed for elderly population who have multiple comorbidities which can cause intraoperative and postoperative complications. The type of anesthesia has an impact on patient outcome. The aim of the study is to compare the effectiveness of epidural and spinal anesthesia techniques for TUR. Methods: A total of 158 elective TUR cases were evaluated. The patients were randomized into 2 groups: Epidural anesthesia was applied to Group I (n=82) and spinal anesthesia was applied to Group II (n=76). Both groups were compared for intraoperative hemodynamic parameters (mean arterial pressure, heart rate, peripheral oxygen saturations), total duration of hospital stay, perioperative complications, and satisfaction of the patients and surgeons. Results: The patients in the spinal anesthesia group experienced more frequent intraoperative hypotensive episodes during TUR (n=2 vs. n=10; p=0.026) and had lower mean arterial pressure values for the first 30 minutes of anesthesia compared to epidural anesthesia group. The postoperative duration of bed stay was longer in the spinal anesthesia group (402.96±49.61 min) than the epidural anesthesia group (205.91±28.27 min) (p&lt;0.001). The patient satisfaction score was significantly higher in the epidural anesthesia group (2.54±0.63) than the spinal anesthesia group (2.23±1.22) (p=0.04) where as the surgeon satisfaction score were similar in both groups. Conclusion: Epidural anesthesia can be considered as an effective and safe technique for ambulatory interventions especially for elderly patients providing perioperative hemodynamic stability and postoperative early mobilization.

Epidural Space Identification With Loss of Resistance Technique for Epidural Analgesia During Labor: A Randomized Controlled Study Using Air or Saline: New Arguments for an Old Controversy

(Anesth Analg. 2018;126:532–536) The saline loss of resistance (SLOR) technique was established as the preferred method for epidural space identification in the 1980s, after air LOR (ALOR) was found to have a higher incidence of adverse effects. However, in review of the literature, the authors of the present study discovered that many of the studies had methodological issues. Furthermore, recent meta-analyses based on these studies have been unable to demonstrate superiority of SLOR over ALOR. Consequently, the authors assessed the effect of epidural space identification technique on the onset of anesthetic block, as well as screened for possible variables related to analgesia quality during labor and delivery, which might be affected by use of the ALOR or SLOR technique.

Labor Analgesia Onset With Dural Puncture Epidural Versus Traditional Epidural Using a 26-G Whitacre Needle and 0.125% Bupivacaine Bolus: A Randomized Clinical Trial

(Anesth Analg. 2018;126:545–551) Lumbar epidural (LE) and combined spinal epidural are 2 techniques commonly used for labor analgesia. However, they are not without their disadvantages. An alternative may be the dural puncture epidural (DPE) technique, which allows medication to migrate into the intrathecal space via the epidural space. In the present study, the authors evaluated neuraxial labor analgesia onset following epidural bolus with a dilute local anesthetic solution (0.125% bupivacaine with 50 μg fentanyl) in active laboring parturients with and without DPE. The primary outcome of this study was the percentage of parturients in each group with adequate analgesia during active contraction 10 minutes after administering the epidural bolus.

Epidural technique with use of lidocaine and bupivacaine associated with fentanyl in bitches submitted to ovarian oysterectomy

The increasing interest in veterinary anesthesiology observed in recent years is the result of the recognition of this specialty as fundamental to the practice of veterinary medicine, since the more extensive the knowledge about existing anesthetic techniques, the better the choice to be made. The objective of this study was to compare the effects of two anesthetic protocols on bitches submitted to ovarian oysterectomy, with acepromazine and tramadol, midazolam and propofol as an anesthetic inducing agent together with epidural combinations with lidocaine-fentanyl and bupivacaine-fentanyl , in order to observe the effects caused by the physiological variables, duration and quality of the anesthesia, 15 undefined (SRD) bitches with a mean weight of 12.26, healthy, were used from shelters that were allocated in three groups according to the protocol to be applied. Heart rate, respiratory rate and body temperature were evaluated; as well as the average dose of anesthetics, sensory, motor and anal reflex. The heart rate values, although slightly altered, remained within the normal physiological parameters for the canine species. The respiratory rate in the fentanyl-lidocaine group had a significant change from baseline. Discrete hypothermia was recorded in animals of all groups, more severely in the fentanyl-bupivacaine group. The motor and sensory reflex in the fentanyl-bupivacaine group occurred more delayed than in the fentanyl-lidocaine group and that some animals in the fentanyl lidocaine group had adverse effects such as salivation and relaxation of the anal sphincter to the point of defecation. Therefore, it is concluded that the technique that uses fentanyl associated with bupivacaine is more advisable for ovarian resection surgery, because it has a greater nociceptive block, greater relaxation and consequently results in greater comfort for the animal during trans and post-surgery.

Epidural catheter replacement and intrathecal catheter techniques for preventing post-dural puncture headache following an inadvertent dural puncture in labour

Epidural catheter replacement and intrathecal catheter techniques for preventing post-dural puncture headache following an inadvertent dural puncture in labour

Epidural multi-slitted microporous non-absorbable patch in decompressive craniectomy to facilitate cranioplasty: a preliminary study

Developing a surgical plane between the temporalis muscle and the dura is the most technically challenging step when performing cranioplasty for post-decompressive craniectomy defects. The authors report a simple technique to demarcate this surgical plane by laying a multi-slitted, microporous polyesterurethane (MPU) patch during decompressive craniectomy. Specifically, they tried to avoid creating potential spaces around the patch, which is the inherent drawback of published anti-adhesive techniques. In 21 patients undergoing decompressive craniectomy, and in 11 of them subsequently undergoing cranioplasty, there was no wound related complications. During cranioplasty, no epidural fluid collection was found; the patch could be separated from the temporalis muscle and the dura with blunt dissection leaving the muscle intact. They conclude that their epidural MPU patch technique is a safe technique, and appears useful to facilitate cranioplasty by helping the surgeon in developing the surgical plane between the temporalis muscle and the dura during cranioplasty.

Neuraxial labor analgesia: a focused narrative review of the 2017 literature.

Neuraxial labor analgesia remains the most effective and one of the most commonly utilized methods for pain relief during labor. This narrative review article is a summary of the literature published in 2017 on neuraxial analgesia for labor. From a total of 41 identified articles, 13 were included in the review. The topics have been structured into three categories: initiation of neuraxial analgesia, maintenance of neuraxial analgesia, and neuraxial analgesia and obstetric outcomes. Maintenance regimens, such as program intermittent epidural bolus (PIEB) techniques, remain a focus of extensive research with the potential to optimize analgesia for each individual patient. In a similar way, the dural puncture epidural technique could improve the quality of labor analgesia with fewer side effects compared with standard epidural and combined spinal epidural (CSE) techniques. Finally, the increased use of modern technology using portable ultrasound devices with automated imaging software to facilitate epidural catheter placement may offer potential advantages to the obstetric anesthesiologist, especially when dealing with technically difficult cases. Recent advances, as well as refinements, of current neuraxial analgesia techniques could improve women's experience of labor.

Combined Spinal Epidural in a Parturient With Tinea Versicolor

(J Clin Anesth. 2017;43:63–64) In this correspondence, the authors discussed the case of a 33-year-old parturient who presented for labor analgesia (combined spinal epidural technique) with a history of recurrent lumbar tinea versicolor, as well as a maculopapular rash from the cervical to the sacral area on physical examination. Tinea versicolor is a benign condition in which Malassezia globosa, a yeast found in normal flora, becomes pathogenic following exposure to heat and humidity in immunosuppressed individuals. Following informed consent, combined spinal epidural labor analgesia was administered with a 27-G Pencan spinal needle following sterile skin preparation and using a needle-through-needle technique. The epidural catheter remained in situ for 13 hours. The authors reported an uneventful delivery and postoperative course.

Automated mandatory bolus versus basal infusion for maintenance of epidural analgesia in labour.

Childbirth may cause the most severe pain some women experience in their lifetime. Epidural analgesia is an effective form of pain relief during labour and is considered to be the reference standard. Traditionally epidural analgesia has been delivered as a continuous infusion via a catheter in the epidural space, with or without the ability for the patient to supplement the analgesia received by activating a programmable pump to deliver additional top-up doses, known as patient-controlled epidural analgesia (PCEA). There has been interest in delivering maintenance analgesic medication via bolus dosing (automated mandatory bolus - AMB) instead of the traditional continuous basal infusion (BI); recent randomized controlled trials (RCTs) have shown that the AMB technique leads to improved analgesia and maternal satisfaction. To assess the effects of automated mandatory bolus versus basal infusion for maintaining epidural analgesia in labour. We searched CENTRAL, MEDLINE, Embase, the World Health Organization International Clinial Trials Registry Platform (WHO-ICTRP) and ClinicalTrials.gov on 16 January 2018. We screened the reference lists of all eligible trials and reviews. We also contacted authors of included studies in this field in order to identify unpublished research and trials still underway, and we screened the reference lists of the included articles for potentially relevant articles. We included all RCTs that compared the use of bolus dosing AMB with continuous BI for providing pain relief during epidural analgesia for labour in women. We used the standard methodological procedures expected by Cochrane. Our primary outcomes were: risk of breakthrough pain with the need for anaesthetic intervention; risk of caesarean delivery; risk of instrumental delivery. Secondary outcomes included: duration of labour; local anaesthetic consumption. We used GRADE to assess the certainty of evidence for each outcome. We included 12 studies with a total of 1121 women. Ten studies enrolled healthy nulliparous women only and two studies enrolled healthy parous women at term as well. All studies excluded women with complicated pregnancies. There were variations in the technique of initiation of epidural analgesia. Seven studies utilized the combined spinal epidural (CSE) technique, and the other five studies only placed an epidural catheter without any intrathecal injection. Seven studies utilized ropivacaine: six with fentanyl and one with sufentanil. Two studies used levobupivacaine: one with sufentanil and one with fentanyl. Three used bupivacaine with or without fentanyl. The overall risk of bias of the studies was low.AMB probably reduces the risk of breakthrough pain compared with BI for maintaining epidural analgesia for labour (from 33% to 20%; risk ratio (RR) 0.60; 95% confidence interval (CI) 0.39 to 0.92, 10 studies, 797 women, moderate-certainty evidence). AMB may make little or no difference to the risk of caesarean delivery compared to BI (15% and 16% respectively; RR 0.92; 95% CI 0.70 to 1.21, 11 studies, 1079 women, low-certainty evidence).AMB may make little or no difference in the risk of instrumental delivery compared to BI (12% and 9% respectively; RR 0.75; 95% CI 0.54 to 1.06, 11 studies, 1079 women, low-certainty evidence). There is probably little or no difference in the mean duration of labour with AMB compared to BI (mean difference (MD) -10.38 min; 95% CI -26.73 to 5.96, 11 studies, 1079 women, moderate-certainty evidence). There is probably a reduction in the hourly consumption of local anaesthetic with AMB compared to BI for maintaining epidural analgesia during labour (MD -1.08 mg/h; 95% CI -1.78 to -0.38, 12 studies, 1121 women, moderate-certainty evidence). Five out of seven studies reported an increase in maternal satisfaction with AMB compared to BI for maintaining epidural analgesia for labour; however, we did not pool these data due to their ordinal nature. Seven studies reported Apgar scores, though there was significant heterogeneity in reporting. None of the studies showed any significant difference between Apgar scores between groups. There is predominantly moderate-certainty evidence that AMB is similar to BI for maintaining epidural analgesia for labour for all measured outcomes and may have the benefit of decreasing the risk of breakthrough pain and improving maternal satisfaction while decreasing the amount of local anaesthetic needed.

Reducing risk of spinal haematoma from spinal and epidural pain procedures.

Central neuraxial blocks (CNB: epidural, spinal and their combinations) and other spinal pain procedures can cause serious harm to the spinal cord in patients on antihaemostatic drugs or who have other risk-factors for bleeding in the spinal canal. The purpose of this narrative review is to provide a practise advisory on how to reduce risk of spinal cord injury from spinal haematoma (SH) during CNBs and other spinal pain procedures. Scandinavian guidelines from 2010 are part of the background for this practise advisory. We searched recent guidelines, PubMed (MEDLINE), SCOPUS and EMBASE for new and relevant randomised controlled trials (RCT), case-reports and original articles concerning benefits of neuraxial blocks, risks of SH due to anti-haemostatic drugs, patient-related risk factors, especially renal impairment with delayed excretion of antihaemostatic drugs, and specific risk factors related to the neuraxial pain procedures. Epidural and spinal analgesic techniques, as well as their combination provide superior analgesia and reduce the risk of postoperative and obstetric morbidity and mortality. Spinal pain procedure can be highly effective for cancer patients, less so for chronic non-cancer patients. We did not identify any RCT with SH as outcome. We evaluated risks and recommend precautions for SH when patients are treated with antiplatelet, anticoagulant, or fibrinolytic drugs, when patients' comorbidities may increase risks, and when procedure-specific risk factors are present. Inserting and withdrawing epidural catheters appear to have similar risks for initiating a SH. Invasive neuraxial pain procedures, e.g. spinal cord stimulation, have higher risks of bleeding than traditional neuraxial blocks. We recommend robust monitoring routines and treatment protocol to ensure early diagnosis and effective treatment of SH should this rare but potentially serious complication occur. When neuraxial analgesia is considered for a patient on anti-haemostatic medication, with patient-related, or procedure-related risk factors, the balance of benefits against risks of bleeding is decisive; when CNB are offered exclusively to patients who will have a reduction of postoperative morbidity and mortality, then a higher risk of bleeding may be accepted. Robust routines should ensure appropriate discontinuation of anti-haemostatic drugs and early detection and treatment of SH. There is an on-going development of drugs for prevention of thromboembolic events following surgery and childbirth. The present practise advisory provides up-to-date knowledge and experts' experiences so that patients who will greatly benefit from neuraxial pain procedures and have increased risk of bleeding can safely benefit from these procedures. There are always individual factors for the clinician to evaluate and consider. Increasingly it is necessary for the anaesthesia and analgesia provider to collaborate with specialists in haemostasis. Surgeons and obstetricians must be equally well prepared to collaborate for the best outcome for their patients suffering from acute or chronic pain. Optimal pain management is a prerequisite for enhanced recovery after surgery, but there is a multitude of additional concerns, such as early mobilisation, early oral feeding and ileus prevention that surgeons and anaesthesia providers need to optimise for the best outcome and least risk of complications.

Postoperative Pain Management Surgery

Optimal pain management in the perioperative period is essential to improving patient quality of life, preventing postoperative complications, and ensuring improved surgical outcomes.1 This review discusses the optimal clinical approach to pain management in the acute setting, centering on the concept of multimodal analgesia. Various opioid and nonopioid medications available for treating acute pain are discussed, with a focus on the “pain ladder,” adverse effects of pain medications, epidural and regional anesthetic techniques, and common pitfalls to avoid when managing postoperative pain. This review does not discuss chronic pain management.

Comparison of dural puncture epidural technique versus conventional epidural technique for labor analgesia in primigravida

Background: Dural puncture epidural (DPE) is a method in which a dural hole is created prior to epidural injection. This study was planned to evaluate whether dural puncture improves onset and duration of labor analgesia when compared to conventional epidural technique. Methods and Materials: Sixty term primigravida parturients of ASA grade I and II were randomly assigned to two groups of 30 each (Group E for conventional epidural and Group DE for dural puncture epidural). In group E, epidural space was identified and 18-gauge multi-orifice catheter was threaded 5 cm into the epidural space. In group DE, dura was punctured using the combines spinal epidural (CSE) spinal needle and epidural catheter threaded as in group E followed by 10 ml of injection of Ropivacaine (0.2%) with 20 mcg of Fentanyl (2 mcg/ml) in fractions of 2.5 ml. Later, Ropivacaine 10 ml was given as a top-up on patient request. Onset, visual analouge scale (VAS), sensory and motor block, haemodynamic variables, duration of analgesia of initial dose were noted along with mode of delivery and the neonatal outcome. Results: Six parturients in group DE achieved adequate analgesia in 5 minutes while none of those in group E (P 0.05). Conclusions: Both techniques of labor analgesia are efficacious; dural puncture epidural has the potential to fasten onset and improve quality of labor analgesia when compared with conventional epidural technique.

Simultaneous combined spinal epidural anesthesia technique without catheter

Simultaneous combined spinal epidural anesthesia technique without catheter

Simultaneous combined spinal epidural anesthesia technique without catheter

Simultaneous combined spinal epidural anesthesia technique without catheter

A randomized clinical trial of intrathecal magnesium sulfate versus midazolam with epidural administration of 0.75% ropivacaine for patients with preeclampsia scheduled for elective cesarean section.

Background and Aims:Magnesium sulfate and midazolam have been used as adjuvants to local anesthetics via intrathecal and epidural routes to augment the quality of block and prolong postoperative analgesia. This study compares addition of intrathecal magnesium sulfate versus intrathecal midazolam to epidurally administered isobaric ropivacaine as a part of combined spinal epidural technique in pre-eclamptic parturients undergoing elective cesarean section.Material and Methods:After institutional ethics committee approval and written informed consent, 50 pre-eclamptic parturients were randomly allocated to one of the two groups of 25 each to either receive intrathecal magnesium sulfate (50 mg) or intrathecal midazolam (1 mg) in combination with epidural ropivacaine (0.75%; 14–16 ml). The onset and duration of sensory and motor blockade, duration of postoperative analgesia, postoperative visual analogue scores for pain, and perioperative side effects were noted. Data were analyzed statistically using Graphpad.com software.Results:Onset times to sensory and motor blockade were faster in midazolam than in magnesium group (P < 0.01). Duration of sensory and motor blockade, and time to first request of analgesia were significantly longer in the magnesium group compared to the midazolam group (P < 0.01). The fetal outcomes according to APGAR scores were comparable in both the groups, the median APGAR score at 1 minute was 8 and at 5 minutes was 10 in both the groups.Conclusion:Intrathecal magnesium with epidural ropivacaine significantly prolonged postoperative analgesia compared to intrathecal midazolam without any complications. Perioperative hemodynamics were comparable in both groups.