Bupivacaine 0.01 % and/or Epinephrine 0.5 ??g/ml Improve Epidural Fentanyl Analgesia after Cesarean Section

The minimally effective concentration of adrenaline in a low‐concentration thoracic epidural analgesic infusion of bupivacaine, fentanyl and adrenaline after major surgery A randomized, double‐blind, dose‐finding study.

“…Pruritus was always limited to the trunk and chest, with no patient experiencing facial pruritus. These findings are in agreement with some studies (14–18) but are not in agreement with others (19–22). This disagreement in findings could be the result of several factors: study design, mode of administration (bolus or infusion), the type of opioid used (lipophilic or hydrophilic), the dose of both the opioid and adrenaline, and the addition of a local anaesthetic or not (23).…”

“…This explains why Cohen et al . (14, 16) found no effect on pain relief or side‐effects and only a reduction in the infusion rate when adding adrenaline 0.5 µg·ml − 1 or 1.0 µg·ml − 1 to a lumbar bupivacaine‐fentanyl epidural infusion after caesarean section. Likewise, the serum concentrations of fentanyl did not differ with or without adrenaline, although there was a non‐significant increase in the fentanyl concentration after termination of the adrenaline‐containing epidural infusions.…”

Epidural fentanyl markedly improves thoracic epidural analgesia in a low‐dose infusion of bupivacaine, adrenaline and fentanyl

“…As far as we know, these two studies are the only studies that have been done with such a triple epidural mixture after major surgery and with thoracic epidural catheters. Other studies with similar triple mixtures containing bupivacaine, fentanyl and adrenaline have been in obstetrical patients with lumbar catheters ( 11, 38, 39).…”

“…Adding bupivacaine to epidural fentanyl has similarly demonstrated an additive fentanyl‐sparing effect ( 44), often with improved pain relief ( 45, 46). Adding bupivacaine and adrenaline to epidural fentanyl by PCEA or continuous infusion has also demonstrated an improvement in analgesia and a fentanyl‐sparing effect ( 38, 39). However, in studies using large doses of epidural fentanyl, adding bupivacaine did not cause any demonstrable improvement in pain relief, only more side effects such as hypotension, nausea and leg‐weakness, compared with fentanyl alone ( 14, 15).…”

Epinephrine adjuvant reduced epidural blood vessel penetration incidence in a randomized, double‐blinded trial

“…2,3 Epinephrine has been added to local anesthetic solutions with the twofold goal of enhancing the effects of the local anesthetic and opioid as well as delaying their systemic absorption hence improving epidural block quality, intensity, and duration while reducing opiates requirements. [4][5][6][7] We have been routinely applying the gravity flow epidural technique using a 22 inch extension tubing and administering epidural local anesthetics instead of injecting it with a syringe. [8][9][10] The use of epidural epinephrine adjuvant was previously reported in obstetric patients, by injection through an epidural needle, but to our knowledge, was never documented administered by gravity flow into the epidural space.…”