A randomized trial of the dural puncture epidural technique combined with programmed intermittent epidural boluses for labor analgesia

Abstract

Background: Continuous epidural infusion (CEI) can provide analgesia during labor. The dural puncture epidural (DPE) technique is used to accelerate the onset of neuraxia anesthesia. The primary objective of this study was to compare the percentage of patients that received adequate labor analgesia following an injection of 0.08% epidural ropivacaine via the DPE and CEI techniques combined with the PIEB mode of maintenance.Methods: Patients who were laboring were randomly allocated to receive either CEI + PIEB or DPE + PIEB. Subjects indicated a VAS score immediately prior to epidural placement, and parturients with a VAS score of ≤50 mm were excluded. A 25-gauge needle was used for dural puncture. Analgesia was provided with 10 mL of 0.08% ropivacaine and 0.4 μg/mL of sufentanil, and was maintained at 10 mL/h in both groups with the same solution. All pumps were programmed for patient-controlled epidural analgesia (PCEA) boluses of 5 mL with a 20-minute lockout. VAS measurements were collected at 2-minute intervals for up to 20 minutes after initiation of the epidural bolus. The median time to adequate analgesia was analyzed using Kaplan-Meier curves and Cox proportional hazard models.Results: Data were collected and analyzed from 200 participants (n=100 per group). Adequate analgesia at 10 minutes was higher in the DPE + PIEB group compared to the CEI + PIEB group (DPE + PIEB =58.4% vs. CEI + PIEB =41.6%; P=0.007). The DPE + PIEB group also had a shorter median time to adequate analgesia [median (95% confidence interval (CI), 8 minutes (7-9 minutes) vs. 12 minutes (10-14 minutes)] compared to the CEI + PIEB group [hazard ratio (HR) =1.488; 95% CI, 1.105-2.002; P=0.002].

Dural puncture epidural technique provides better anesthesia quality in repeat cesarean delivery than epidural technique: Randomized controlled study

“…Although the motor block degree reported by previous studies was comparable between the DPE and EA techniques for labor analgesia [ 15 , 18 , 24 ], the DPE technique resulted in significantly higher motor block scores at each time point than the EA technique in our study. One possible reason is that the concentration of local anesthetics was significantly higher than that in other studies applied for labor analgesia, in which a low concentration of ropivacaine produced motor-sensory separation.…”

“…As early as 1998, Leach et al [ 23 ] observed the translocation of epidural dye into the subarachnoid space through an accidental dural puncture via a tuohy needle (gauge not documented), which verified the theory. Previous studies have shown that the DPE technique using a 25-G or 26-G Whitacre needle resulted in earlier and greater sacral spread than the EA technique[ 12 , 13 , 24 ]. In addition, an in vitro study demonstrated notable lidocaine flux into the subarachnoid space via an 18-G or 24-G needle puncture but no flux via a 27-G needle puncture[ 25 ].…”

“…The concentration of the local anesthetic solution and transferability of local anesthetics may also affect the translocation of the medications from the epidural space to the subarachnoid space[ 18 ]. A low concentration of ropivacaine was used by Wang et al [ 24 ] and Song et al [ 18 ] in the DPE technique for labor analgesia and resulted in a faster onset and better sacral block than the EA technique. In our study, a 15-ml mixture of 1% lidocaine and 0.5% ropivacaine as the epidural loading dose was used for the first time to induce anesthesia and resulted in a faster onset of surgical anesthesia and better spread than the EA technique.…”

Analgesic Effects, Birth Process, and Prognosis of Pregnant Women in Normal Labor by Epidural Analgesia Using Sufentanil in Combination with Ropivacaine: A Retrospective Cohort Study

“…e high rate of cesarean section has become not only a medical problem faced by the medical profession but also a serious "public health problem" faced by our country. Among the social factors of cesarean section, maternal inability to bear labor pain is the first cause [19]. In addition, some studies have indicated that labor analgesia can reduce the rate of cesarean section, so the promotion of labor analgesia has important social significance to change the current situation of high cesarean section rate in China [20].…”

Dural Puncture Epidural for Labor Analgesia: Is It Really an Improvement over Conventional Labor Epidural Analgesia?

“…7 Other groups found no or minimal differences between dural puncture epidural and conventional epidural blocks, and two meta-analyses published in 2019 concluded the differences were minor at best. 8,9 Subsequently, published studies from several international groups once again found slightly faster onset of adequate analgesia with dural puncture epidural, 10–12 but other studies found trivial or no differences. 13 While it is unclear why such disparate results have been observed, variations in spinal needle size, epidural drug administered, patient population studied, method of analgesia assessment, and other unknown confounders or random variation may be responsible.…”