No abstract

No abstract

from the standard PCEA study, although the discussion considers other PCEA study regimes in some detail.Wong study was very cleverly designed where women were assigned to epidural regimes with boluses were given automatically of different volumes and time intervals, no background infusion and a rescue PCEA via a separate pump. The study specifically wanted to answer the question whether it was better to give frequent small boluses, which is more common in many PCEA regimes or more infrequent larger doses. The total hourly dose given automatically was the same between the groups and the mother's use of her rescue PCEA was one of the markers of satisfactory analgesia. The authors' conclusion was that maintenance analgesia was better when the automatic delivery of epidural solution were given as a larger volume bolus with the longest time interval between doses, that is 10 mL given automatically every hour. The mother's overall use of bupivacaine was the least with no compromise in analgesia.I particularly liked this study because it reflects my own practice. In a paper I published in 1999 (Br J Anaesth. 1999;82(2):233-236) it was shown that 10 mL boluses given either by a trained midwife or via a PCEA pump provided very good analgesia, very little motor block and the mothers were highly satisfied. Although the boluses were given on demand up to every 30 minutes in my study, the reality was that the time interval between top-ups was around an hour. Since 1999 midwives in the hospital I work in have been trained to give hourly top-ups, more or less by the clock, and the result has been very many highly satisfied women. We dispensed with the PCEA pumps because they were not necessary and it saved money.Wong et al have very cleverly shown that 10 mL boluses given every hour for labor analgesia is more effective than giving smaller doses more often. I will continue to encourage the midwives I work with to give regular hourly 10 mL top-ups with the added satisfaction that there is a really good study to back this up. Comment by Rachel Collis, MBBSE pidural analgesia that allows the preservation of motor function allows ambulation. The use of epidural fentanyl or sufentanil allows early ambulation after epidural catheter placement, and the addition of clonidine significantly lengthens the time to redose in nulliparous women receiving epidural fentanyl. However, clonidine has a "black box" warning for use in obstetrics. This randomized, double-blind study was conducted to determine the analgesic effects of epinephrine added in early labor after a fentanyl bolus.Sixty-five nulliparous patients were randomized to receive a bupivacaine infusion with or without epinephrine after an epidural fentanyl bolus. Vital signs were recorded and a baseline pain assessment was made using a 100-mm visual analog scale (VAS) for pain. After the lumbar epidural catheter was placed, patients received a test dose of lidocaine with epinephrine after which they received 100 mg fentanyl in 10 mL volume. Within 10 minutes, they were randomized to ...