The relative and absolute numbers of very old patients increased over the study period, as did the severity of illness. Despite this, risk-adjusted hospital mortality improved over the study period. Females dominated in the very old patients and exhibited moreover a better outcome compared with males.

SummaryObservational studies suggest that combined spinal-epidural analgesia (CSE) is associated with more reliable positioning, lower epidural catheter replacement rates, and a lower incidence of unilateral block compared with epidural analgesia. However, evidence from high-quality trials still needs to be assessed systematically. We performed a systematic review that included 10 randomised controlled trials comparing CSE and epidural analgesia in 1722 labouring women in labour. The relative risk of unilateral block was significantly reduced after CSE vs epidural analgesia (0.48, 95% CI 0.24-0.97), but significant between-study heterogeneity was present (I 2 = 69%, p = 0.01). No differences were found for rates of epidural catheter replacement, epidural top-up, and epidural vein cannulation. On the basis of current best evidence, a consistent benefit of CSE over epidural analgesia cannot be demonstrated for the outcomes assessed in our review. A large randomised controlled trial with adequate power is required. Combined spinal-epidural analgesia (CSE) has emerged as an alternative to epidural analgesia for pain relief during labour [1]. During a needle-through-needle CSE, the epidural space is first identified with an epidural needle, followed by insertion of a long spinal needle and injection of the spinal dose. The spinal needle is then removed and an epidural catheter is inserted through the epidural needle. A Cochrane review comparing the CSE technique with traditional (bupivacaine ≥ 0.25%) and low-dose epidural analgesia in labour [2] found that CSE was associated with a higher incidence of pruritus, but a lower incidence of urinary retention and need for rescue analgesia compared with traditional epidural, as well as a faster onset of analgesia when compared with low-dose epidural.No differences in labour outcome were found. Several observational studies reported that CSE was associated with a lower rate of unilateral block [3,4] and epidural catheter replacement [3][4][5]. These findings could be due to the spinal component's having a clear endpoint of flow of cerebrospinal fluid through the needle, indicating correct positioning of the epidural needle. Unilateral block and the need for re-siting the catheter during labour imply that the parturient continues to suffer from pain, and are stressful for both parturient and anaesthetist. If caesarean section becomes neces-64

C ombined spinal-epidural (CSE) analgesia is a pain relief option during labor and an alternative to epidural block. Previous research suggests that CSE analgesia may offer more reliable catheter positioning, lower epidural catheter replacement rates, and a lower frequency of unilateral block compared with epidural analgesia alone. While quality evidence from trials does exist, that information needs systematic assessment.For the present study, researchers searched medical databases PubMed, EMBASE, CINAHL, LILACS, CENTRAL, and ISI WOS between June 2012 and February 2013, which returned 90 studies. The team systematically reviewed 10 randomized controlled trials comparing CSE analgesia and epidural block in 1722 woman in active labor.A meta-analysis of the data found the relative risk (RR) of unilateral block was reduced after CSE analgesia compared with epidural analgesia at 0.48 (95% confidence interval [CI], 0.24-0.97). However, substantial nonuniformity between the studies was noted (I 2 = 69%, P = 0.01). Data from the studies showed that in comparing CSE analgesia with epidural block alone, there is an RR of 0.57 (95% CI, 0.32-1.03) for epidural catheter replacement, an RR of 0.95 (95% CI, 0.74-1.23) for epidural top-up, and an RR of 1.71 for epidural vein cannulation.This research provides a basis for sample size calculation in future trials. Although this research suggests a lower rate of unilateral block using CSE analgesia versus epidural, it could not confirm lower epidural catheter replacement rates that had been previously reported in earlier observational studies. The authors suggest that a larger trial is needed to understand which pain relief option-CSE analgesia or epidural-offers the better analgesic quality with the fewest adverse effects. COMMENTA recent Cochrane review contrasting the CSE analgesia approach with traditional (bupivacaine ≥0.25%) and low-dose epidural analgesia in labor identified that CSE analgesia was associated with a greater incidence of pruritus, but a lower incidence of urinary retention and need for rescue analgesia, than epidural analgesia alone. 1 Moreover, CSE analgesia had a faster onset of pain relief, and there were no differences in labor outcome detected between the 2 techniques. The current meta-analysis from Germany confirmed a lower rate of unilateral block in parturients managed with CSE analgesia, but there was considerable between-study heterogeneity. In addition, epidural catheter replacement and epidural failure rates were not substantially different between the 2 approaches to pain management. It is important to point out, however, that none of the prospective studies included in the meta-analysis had epidural catheter replacement as a primary outcome measure. Furthermore, this analysis cannot conclude which technique provides superior quality of analgesia and has fewer adverse effects. To compare these aspects of CSE analgesia and epidural analgesia, a large, adequately powered investigation is necessary. Comment by Kathryn E. McGoldrick, MD, FCAI(Hon) Di...

Summary Observational studies suggest that combined spinal‐epidural analgesia (CSE) is associated with more reliable positioning, lower epidural catheter replacement rates, and a lower incidence of unilateral block compared with epidural analgesia. However, evidence from high‐quality trials still needs to be assessed systematically. We performed a systematic review that included 10 randomised controlled trials comparing CSE and epidural analgesia in 1722 labouring women in labour. The relative risk of unilateral block was significantly reduced after CSE vs epidural analgesia (0.48, 95% CI 0.24–0.97), but significant between‐study heterogeneity was present (I2 = 69%, p = 0.01). No differences were found for rates of epidural catheter replacement, epidural top‐up, and epidural vein cannulation. On the basis of current best evidence, a consistent benefit of CSE over epidural analgesia cannot be demonstrated for the outcomes assessed in our review. A large randomised controlled trial with adequate power is required.