Epidural Top-up Research Articles

Are labor epidural catheters after a combined spinal epidural (CSE) technique more reliable than after a traditional epidural? A retrospective review of 9153 labor epidural catheters.

The combined spinal epidural (CSE) technique may associate with a lower failure rate of epidural catheters compared to traditional epidural catheters. This may be significant for the parturients as failure of neuraxial analgesia has been associated with a negative impact on birth experience. In this one-year retrospective study, the failure rate of epidural catheters was compared between 3201 and 5952 epidural catheters after initiation of neuraxial analgesia by the CSE or traditional epidural technique, respectively. Parturient background information, labor parameters, and neuraxial interventions were collected from 9153 parturients. Failure was defined as replacement of a used epidural catheter by new regional analgesia procedures or general anesthesia during intrapartum cesarean delivery. The primary outcome was the failure rate of epidural catheters. The secondary outcome was the time from the initial analgesia intervention to the epidural catheter replacement and progression of labor during this time. The CSE method was used at an earlier stage of labor, and the parturients were more often primiparous and undergoing induced labor. Earlier onset of analgesia, obesity, induced labor, anesthesiologist experience, and cesarean delivery were found to be significant cofactors for catheter failure. The unadjusted failure rate was 168/3201 (5.2%) and 223/5952 (3.7%) (OR 1.42 [1.16-1.75]) after initiation of analgesia by CSE or traditional epidural method. After controlling for the stage of labor, body mass index, induction of labor, and anesthesiologist's experience level, the adjusted OR for epidural catheter replacement was 1.04 (0.83-1.29) p = .736. The mean (SD) time until epidural catheter failure was 6.3 (4.4) and 4.0 (4.1) hours following initiation of analgesia by CSE or traditional epidural technique, respectively (p < .001). Cervical dilatation progressed from 4.3 (1.4) to 6.4 (2.1) cm and 5.1 (1.5) to 6.7 (1.7) cm between primary neuraxial analgesia and epidural catheter replacement. CSE technique was not associated with a better survival rate of epidural catheters for provision of analgesia or epidural top-up anesthesia for intrapartum CD. In addition, the time to replacement of the catheter was significantly longer when analgesia was initiated with the CSE technique. Maternal satisfaction scores were lower if catheters required replacement.

Implementation of a standardized epidural top-up algorithm for inadequate labor epidural analgesia: a single-center retrospective study

Background We hypothesized that implementation of a labor epidural management algorithm would increase the labor epidural catheter replacement rate at our hospital. Methods Our institutional review board approved this study and waived the requirement for informed consent. Patients who had labor epidural analgesia and delivered vaginally or had replacement of an epidural catheter prior to vaginal delivery from August 1, 2022 to December 31, 2022 and from August 1, 2023 to December 31, 2023 were included in the study. Study investigators entered data from the electronic medical record into REDCap. Results A total of 530 and 740 patients received labor epidural analgesia and met inclusion criteria before and after implementation of the algorithm, respectively. Patients who received labor epidural analgesia after implementation of the protocol had an absolute increase of 1.0% in the catheter replacement rate, which was not statistically significant (P = 0.34). A multivariate logistic regression found that the number or rescue analgesia boluses (odds ratio 2.68; 95% confidence interval 2.092, 3.434; P < 0.001) and operator level of training (odds ratio 0.41; 95% confidence interval 0.226, 0.743; P = 0.003) were associated with catheter replacement. Conclusion After implementation of a labor epidural catheter management algorithm, patients had an increase in labor epidural catheter replacement that was not statistically significant.

6289256 Failed epidural top-up due to a kinked epidural catheter

6289256 Failed epidural top-up due to a kinked epidural catheter

Effects of different neuraxial analgesia modalities on the need for physician interventions in labour: A network meta-analysis.

Neuraxial labour analgesia can be initiated with epidural (EPL), combined spinal epidural (CSE) or dural puncture epidural (DPE) and maintained with continuous epidural infusion (CEI), patient-controlled epidural analgesia (PCEA) or programmed intermittent epidural bolus (PIEB), but the optimal analgesia modality is still controversial. To compare the effects of commonly used neuraxial analgesia modalities on the proportion of women needing physician interventions, as defined by the need for physician-administered epidural top-ups for inadequate analgesia in labour. Bayesian network meta-analysis. PubMed, Embase, CENTRAL, Web of Science and Wanfang Data were searched from January 1988 to August 2023 without language restriction. Randomised controlled trials comparing two or more modalities of the following six neuraxial analgesia modalities in healthy labouring women: EPL+CEI+PCEA, EPL+PIEB+PCEA, CSE+CEI+PCEA, CSE+PIEB+PCEA, DPE+CEI+PCEA and DPE+PIEB+PCEA. Thirty studies with 8188 women were included. Compared with EPL+CEI+PCEA, EPL+PIEB+PCEA [odds ratio (OR) = 0.44; 95% credible interval (CrI), 0.22 to 0.86], CSE+PIEB+PCEA (OR = 0.29; 95% CrI, 0.12 to 0.71) and DPE+PIEB+PCEA (OR = 0.19; 95% CrI, 0.08 to 0.42) significantly reduced the proportion of women needing physician interventions. DPE+PIEB+PCEA had fewer women needing physician interventions than all other modalities, except for CSE+PIEB+PCEA (OR = 0.63; 95% CrI, 0.25 to 1.62). There were no significant differences in local anaesthetic consumption, maximum pain score, and the incidence of instrumental delivery between the different neuraxial modalities. PIEB+PCEA is associated with a lower risk of physician interventions in labour than CEI+PCEA. DPE or CSE and PIEB+PCEA may be associated with a lower likelihood of physician interventions than other neuraxial modalities. Otherwise, the new neuraxial analgesia techniques do not appear to offer significant advantages over traditional techniques. However, these results should be interpreted with caution due to limited data and methodological limitations. PROSPERO (CRD42023402540).

COMPARISON OF EPIDURAL VOLUME EXTENSION USING 2% LIGNOCAINE WITH STANDARD EPIDURAL VOLUME EXTENSION TECHNIQUE FOR HYSTERECTOMY UNDER COMBINED SPINAL EPIDURAL ANESTHESIA

Objectives: We compared epidural volume extension (EVE) using 2% Xylocaine with standard EVE technique and studied characteristics of neuraxial block along with hemodynamic stability and recovery profile in total abdominal hysterectomy surgery under combined spinal-epidural (CSE) anesthesia. Methods: 50 patients undergoing hysterectomy were randomly assigned into two groups. Group M (EVE with 2% 10 mL lignocaine) and Group C (EVE with 10 mL NS). Patients were anesthetized using CSE with 0.75% hyperbaric ropivacaine 2.5 mL and EVE, as per drug assigned to group. Anesthesia was maintained with epidural top-up with 2% lignocaine in 6 mL aliquot. Conscious sedation was provided. Perioperative data and recovery profile were recorded. Results: The amount of epidural anesthesia required to maintain block was less in Group M (17.7±4.5 mL in comparison to 26.9±7.3 mL in Group C p&lt;0.001). Time for first epidural top-up required was early in Group C (62.1±26.2 min) than in Group M (83.718±.3 min). Onset of motor blockade was earlier in Group M (8.4±4.8 min). Quality of anesthesia was better in Group M. Pain and recovery from neuraxial block was earlier in Group C (31.02±13 min) in comparison to 49.88±12.01 min in Group M. Safe level of block was achieved without affecting cardiorespiratory function in all patients. Conclusion: CSE with modified EVE is a feasible technique, is associated with early onset of neuraxial block, and had longer time of two-segment regression with the need of less anesthesia drugs.

Comparison of Epidural, Combined Spinal Epidural, and Dural Puncture Epidural Techniques for Labor Analgesia

Background: Lumbar epidural analgesia is a safe, effective, and beneficial technique for both the parturient and the fetus. Dural puncture epidural has been claimed to be better than combined spinal epidural and epidural techniques by many. We undertook this study to compare the three techniques regarding duration, quality of analgesia, and side effects. Debate regarding the best neuraxial technique for labor analgesia continues. Materials and Methods: The parturients of ASA grade I and II of age group 20–35 years were randomly divided into three groups of 20 each. Group E (epidural group) received 15 ml of 0.125% isobaric levobupivacaine with 30 µg fentanyl in the epidural space. Group CSE (combined spinal epidural group) received 2.5 mg of intrathecal isobaric levobupivacaine with 25 µg fentanyl and epidural top up of 15 ml of 0.125% levobupivacaine with 30 µg fentanyl. Group DPE (dural puncture epidural group) received 15 ml of 0.125% isobaric levobupivacaine with 30 µg fentanyl in epidural space; intrathecal medication was withheld. Epidural top-up doses were given as per Visual Analog Scale (VAS). Analgesic efficacy, extent of sensory and motor block, maternal and fetal outcome, duration of analgesia, and maternal satisfaction score were compared among three groups and analyzed statistically. Results: The onset and symmetry of sensory blockade and VAS score were better in CSE group. DPE group had better sacral coverage and less asymmetric blockade. Groups CSE and DPE had superior maternal and surgeon satisfaction scores in comparison to group E. Both groups E and DPE provided analgesia with minimal motor blockade and ambulation.

Epidural nalbuphine versus dexmedetomidine as adjuvants to bupivacaine in lower limb orthopedic surgeries for postoperative analgesia: a randomized controlled trial

BackgroundAdministration of adjuvant drugs epidurally in combination with local anesthetics offers new dimensions in the management of postoperative pain. This study aimed to compare the addition of either nalbuphine or dexmedetomidine to epidural bupivacaine for postoperative analgesia in lower limb orthopedic surgeries under combined spinal-epidural anesthesia.MethodsThis prospective randomized double-blind study included 69 patients scheduled for lower limb orthopedic surgeries. Anesthesia was started with 15 mg hyperbaric bupivacaine 0.5% intrathecally, and then an epidural bolus dose of 12 ml (10 ml 0.25% bupivacaine with 2 ml normal saline in group C, 2 ml (10 mg) nalbuphine in group N or dexmedetomidine 2 ml (100 µg) in group D was administered when sensory regression to T10. Postoperatively, when visual analogue scale (VAS) was ≥ 3, an epidural top-up dose of 8 ml (6 ml 0.25% bupivacaine plus 2 ml normal saline in group C, 2 ml (2 mg) nalbuphine in group N or 20 µg dexmedetomidine (2 ml) in group D was given. The primary outcome was to evaluate the duration of postoperative analgesia and secondary outcomes were any side effects and patient satisfaction.ResultsThe onset of epidural analgesia was 17.83 ± 2.53 versus 13.39 ± 1.27 versus 12.17 ± 1.27 min in groups C, N and D, respectively (p value < 0.001). The mean duration of analgesia was 241.3 ± 14.24 versus 318.38 ± 22.54 versus 365.87 ± 18.01 min in groups C, N and D, respectively (p value < 0.001). The mean sedation score was less in group C than group N and D (P < 0.001). The patient satisfaction score showed the lowest degree of satisfaction in group C (p value < 0.001). Top-up doses consumed and total analgesic requirements were lower in groups N and D than in group C. There was a statistically significant difference between the studied groups regarding VAS over time (p value < 0.001), intraoperative bradycardia (p value 0.029), and shivering (p value 0.029).ConclusionThe addition of either nalbuphine or dexmedetomidine to epidural bupivacaine was effective for postoperative analgesia in terms of onset, duration, and patient satisfaction with the superiority of dexmedetomidine over nalbuphine.Trial registrationApproval from the research ethics committee of the Faculty of Medicine, Zagazig University was obtained with the reference number (ZU-IRB#:7045-15-8-2021) and it was registered under clinicaltrials.gov (NCT05041270) on registration date 13/09/2021.

Pain during cesarean delivery: A patient-related prospective observational study assessing the incidence and risk factors for intraoperative pain and intravenous medication administration

IntroductionThe incidence of pain during cesarean delivery (PDCD) remains unclear. Most studies evaluated PDCD using interventions suggesting inadequate analgesia: neuraxial replacement, unplanned intravenous medication (IVM), or conversion to general anesthesia. Few assess self-reported pain. This study evaluates the incidence of and risk factors for self-reported PDCD and IVM administration. MethodsBetween May and September 2022, English-speaking women undergoing cesarean delivery under neuraxial anesthesia were approached within the first 48 h. Participants answered a 16-question survey about intraoperative anesthesia care. Clinical characteristics were extracted from electronic medical records. The primary outcome was PDCD. Secondary outcomes were analgesic IVM (opioids alone or in combination with ketamine, midazolam, or dexmedetomidine) and conversion to general anesthesia. Risk factors for PDCD and analgesic IVM were identified using multivariable logistic regression models. ResultsPain was reported by 46/399 (11.5%; 95% CI: 8.6, 15.1) participants. Analgesic IVM was administered to 16 (34.8%) women with PDCD and 45 (12.6%) without. Conversion to general anesthesia occurred in 3 (6.5%) women with and 4 (1.1%) without PDCD. Risk factors associated with PDCD were substance use disorder and intrapartum epidural extension. Risk factors associated with analgesic IVM were PDCD, intrapartum epidural extension when ≥2 epidural top-ups were given for labor analgesia, and longer surgical duration. DiscussionIn our cohort of scheduled and unplanned cesarean deliveries, the incidence of PDCD was 11.5%. A significant proportion of women (15.1%) received analgesic IVM, of which some but not all reported pain, which requires further evaluation to identify triggers for IVM administration and strategies optimizing shared decision-making.

Quick Epidural Top-up with Alkalinized Lidocaine for emergent caesarean delivery (QETAL study): protocol for a randomized, controlled, bicentric trial

BackgroundGeneral anesthesia in pregnant women can be associated with significant maternal and fetal morbidity. Emergency caesarean section can be performed by converting labor epidural analgesia to surgical anesthesia by injecting high-dose short-acting local anesthetics through the epidural catheter. The effectiveness and the delay to obtain surgical anesthesia depends upon the protocol used. Data indicate that alkalinization of local anesthetics may shorten their onset of action and increase their effectiveness. This study investigates whether alkalinization of adrenalized lidocaine could increase the efficacy and decrease the delay of onset of surgical anesthesia via an indwelling epidural catheter, thus decreasing the necessity to resort to general anesthesia for emergency caesarean deliveries.MethodsThis study will be a bicentric, double-blind, randomized, controlled trial with two parallel groups of 66 women who require emergency caesarian deliveries and who have been receiving epidural labor analgesia. The number of subjects in groups will be unbalanced with a 2:1 ratio of experimental:control. In both groups, all eligible patients will have had an epidural catheter placed for labor analgesia with levobupicaine or ropivacaine. Patient randomization will occur when the decision is made by the surgeon that an emergency caesarean delivery is indicated. Surgical anesthesia will be obtained by injecting 20 mL of 2% lidocaine with epinephrine 1:200,000, or 10 mL 2% lidocaine with epinephrine 1:200,000 plus 2 mL sodium bicarbonate 4.2% (total of 12 mL). The primary outcome will be the rate of conversion to general anesthesia for failure of the epidural to provide adequate analgesia. This study will be powered to detect a 50% reduction in the incidence of general anesthesia, from 80 to 40%, with a confidence ratio of 90%.DiscussionSodium bicarbonate could be used to avoid general anesthesia for emergency caesarean deliveries by providing reliable and effective surgical anesthesia in women with pre-existing labor epidural catheters is promising. This randomized controlled trial seeks to determine the optimal local anesthetic mixture for converting epidural analgesia to surgical anesthesia for emergency caesarean sections. This may decrease the need for general anesthesia for emergency caesarian section, shorten the time to fetal extraction, and improve safety and patient satisfaction.Trial registrationClinicalTrials.gov NCT05313256. Registered on 6 April 2022

A Study of the Clinical Effects of Sequential Combined Spinal Epidural Anesthesia and Spinal Anesthesia in Patients Undergoing Orthopedic Surgeries.

In orthopedic surgeries, there has been an increase in the usage of the neuraxial blockade to provide excellent surgical conditions and prolonged postoperative analgesia. The introduction of the sequential combined spinal epidural anesthesia (SCSEA) technique provides benefits for both spinal anesthesia (SA) and epiduralanesthesia. The focus of this study was to analyze the time needed to attain a desired level of sensory block, to compare the period of sensory block, and to study the intraoperative hemodynamics in the SCSEA and SA groups. The study was conducted on patients admitted for elective lower limb orthopedic surgeries. The sample size for this prospective randomized study is two groups of 67 subjects each. Patients aged between 18 and 65 years, posted for orthopedic surgeries for two to three hours, and of American Society of Anaesthesiologists (ASA) Grades 1 and 2 were included and divided into two groups. Group A patients received SCSEA with an epidural-test dose of 3 ml lignocaine (2%) with adrenaline and spinal bupivacaine (0.5%) of 1.5 ml-7.5 mg + fentanyl .25 mic if the sensory level was below T8. An epidural top-up was given with 2 ml per segment of 0.5% bupivacaine to bring the sensory level to T8. Group B patients received SA with spinal bupivacaine (0.5%) of 3 ml-15 mg + fentanyl .25 mic. Intraoperative hemodynamics, the duration to achieve a sensory level of T8, the time for two-segment regression of sensory block, and the complications that occurred were recorded. The study included a total of 134 subjects with each group having 67 subjects admitted for lower limb surgery. The mean value (SD) of the time taken to attain sensory block in the SCSEA group was prolonged when compared to the SA group (7.15 ± 0.75 and 5.01 ± 0.88). The time for two-segment regression in the SCSEA group was 86.77 ± 3.60and the SA group was 106.4 ± 8.01, which indicated that the SA group has a longer and better sensory block. Substantially, the study shows that the SCSEA group (P< 0.05) has better hemodynamics when compared to the SA group. The SCSEA technique has better intraoperative hemodynamic stability with a longer analgesic effect when compared to SA. SA shows a sudden change in hemodynamics but reveals a greatersensory block.

P145 Epidural top-up rates of obesity class three patients at Grange University Hospital

P145 Epidural top-up rates of obesity class three patients at Grange University Hospital

P78 “Fastmix” epidural top-up anaesthesia - fast, but too furious?

P78 “Fastmix” epidural top-up anaesthesia - fast, but too furious?

Anaesthetic Management of Parturient with Severe Mitral Stenosis Planned for Elective Caesarean Section for Safe Confinement

Perioperative management of pregnant women with cardiac disease is challenging. The physiological cardiac changes that occur during late pregnancy leads to haemodynamic stress to the patient with the cardiac disease during and immediately after parturition. Pregnant women with severe valvular disease do not tolerate haemodynamic changes associated with pregnancy. The choice of anaesthesia technique either general anaesthesia or regional anaesthesia is depending on the haemodynamic goals, cardiac status of the patient, and mode of delivery. A 23-year-old female patient was planned for elective caesarean section for safe confinement. She was an operated case of Balloon Mitral Valvuloplasty (BMV). General anaesthesia was preferred due to the severity of mitral stenosis. Incorporation of epidural analgesia with general anaesthesia provided intraoperatively haemodynamic stability during laryngoscopy, intubation, and extubation. Also, postoperatively analgesia could be achieved due to epidural top-ups. Ultimately, a good perioperative outcome has been achieved due to haemodynamic stability which reduces perioperative morbidity and mortality of the patient.

Comparative Evaluation of Dexmedetomidine, Ketamine &amp; their Combination for Epidural Analgesia in Orthopedic Surgeries of the lower Limb

Background: Epidural anesthesia is a perioperative pain control treatment that has a variety of applications in anaesthesiology. It could be used as as a primary anaesthetic, although it's most usually utilised as an adjuvant for management of pain. It could be a one-time shot or a continuous infusion for a long-drawn therapeutic intervention. Apart from the potential for significant analgesia, its use minimises the need for other anaesthetics and analgesics, lowering the risk of adverse effects. It has also been proven to lower the level of cortisol, to facilitate the resumption of bowel function, reduce the risk of Pulmonary embolism and deep vein thrombosis in the post-operative phase, while minimizing the duration of institutional stays.&#x0D; Aim: Comparison and Evaluation of the effect of the drugs dexmedetomidine , ketamine &amp; them together as a combination in addition to bupivacaine, as an adjuvant for intermittent epidural top ups for lower limb orthopaedic surgeries .&#x0D; Study Design: Prospective observational study.&#x0D; Place and duration of Study: The study will be conducted over a period of 2 years and 6 months in the department of anaesthesiology, Jawaharlal Nehru medical college and Acharya vinoba bhave rural hospital, wardha.&#x0D; Methodology: Our prospective, comparitive observational study included 90 patients randomly assigned into 3 sets of 30 each, one was administered dexmedetomidine epidurally, one was given ketamine and one was given their combination epidurally [1]. The quality and duration of analgesia provided by all 3 groups were then compared to find out which of them provides better and prolonged pain relief. Along with analgesia, the other parameters assessed were hemodynamic response, sedation and any other side effects.&#x0D; Expected Results: We're attempting to establish the hypothesis that the combination of both the drugs is better than dexmedetomidine or ketamine administered individually. It has been proved in various researches that epidural ketamine prolonged the duration of analgesia, [2] but it was less than epidural dexmedetomidine. We expect that the combination would decrease the postoperative rescue analgesics requirements and less hemodynamic alterations hence providing greater patient satisfaction as compared to the two drugs separately.

P.43 Time to update the guidance? Motor block may be an unreliable sign of effective epidural top-up for caesarean section

P.43 Time to update the guidance? Motor block may be an unreliable sign of effective epidural top-up for caesarean section

P.106 Epidural top-ups for surgical anaesthesia: a survey to investigate variation in practice between consultants and trainees in a tertiary maternity unit

P.106 Epidural top-ups for surgical anaesthesia: a survey to investigate variation in practice between consultants and trainees in a tertiary maternity unit

P.107 Survey on practice of epidural top-up for caesarean section among anaesthetists

P.107 Survey on practice of epidural top-up for caesarean section among anaesthetists

This Month in Anesthesiology

This Month in Anesthesiology

Abstract No.: ABS3221: Comparison of Fentanyl and Dexmedetomidine as adjuvants to 0.2 % Ropivacaine Epidurally in Labour Analgesia

Background & Aims:Childbirth being the most exciting event in the life of a female gets ruined because of cruciating and intolerable labour pain. This study compared quality of labour analgesia by using fentanyl and dexmedetomidine as adjuvants to 0.2% ropivacaine epidurally .Methods:Institutional Ethical Committee approval and patient consent was obtained. 60 enroled patients were divided into 2 groups Group RF: 0.2% ropivacaine + fentanyl 15µg (15ml) Group RD: 0.2% ropivacaine + dexmedetomidine 7.5 µg (15ml) Epidural catheter was inserted at the L2-L3 space and drug was administered. VAS, sensory, motor levels were assessed. Maternal and foetal adverse effects were noted. Maternal satisfaction was evaluated after 24 h. The results were expressed as mean ± standard deviation for continuous variables while frequency and percentage for discrete data. Continuous variables were analysed by using unpaired two-tailed Student t- test. Discrete data was analysed using Chi-square test. P<0.05 considered as statistically significant.Results:The demographical data like age, weight and height were comparable and had no influence on outcome of the study. Quality of analgesia was comparable in both groups (p>0.05) with no patient having poor quality. Early onset and longer duration of analgesia, less epidural top-ups, shorter duration of labour, less incidence of instrumental delivery and adverse effects were observed in Group RD compared with Group RF (p<0.05). Neonatal APGAR score was comparable between the groups.Conclusion:Both fentanyl and dexmedetomidine with 0.2% ropivacaine epidurally provide safe, effective and excellent quality of labour analgesia and equal foetal well-being and neonatal outcomes. Dexmedetomidine as adjuvant prolongs labour analgesia and shortens duration of labour.

Breakthrough pain during cesarean section under neuraxial anesthesia: a two-center prospective audit

Worldwide, most Cesarean sections (CS) are performed under neuraxial anesthesia. However, neuraxial anesthesia can fail and intraoperative breakthrough pain can occur. The aim of the present investigation was to evaluate the incidence of breakthrough pain in consecutive CS and to describe the potential risk factors for breakthrough pain. In a two center, prospective audit all CS performed under neuraxial anesthesia were included and the occurrence of breakthrough pain as well as all possible risk factors of breakthrough pain were recorded as well as the alternative anesthetic strategy. A total of 393 patients were enrolled in the study over 6 months, 206 in UZ Leuven and 187 in ZNA Middelheim, 295 elective CS and 98 secondary CS. Of all 393 participants, 65 experienced breakthrough pain during the CS (16.5%). Twoo significant risk factors for breakthrough pain during CS were observed: the duration of surgery (p &lt;0.001) and the epidural drug used (p=0.0032). Breakthrough pain during a CS is extremely uncomfortable for the mother. In this observational study, the incidence of breakthrough pain during CS was 16.5%. Duration of surgery and epidural drug used were both significant risk factors of breakthrough pain during CS in this audit. A pro-active policy is required in order to prevent breakthrough pain or discomfort during CS. Early identification of problematic epidural catheters for labor analgesia, adequate level of anesthetic block before surgery, and administration of a prophylactic epidural top-up if duration of surgery is prolonged as opposed to the choice of local anesthetic used, could be essential in the prevention. Further high-quality studies are needed to evaluate the many potential risk factors associated with breakthrough pain during CS.