Combined spinal-epidural analgesia in advanced labour

Abouleish, Amr E.; Abouleish, Ezzat; Camann, William

doi:10.1007/bf03009995

Cited by 68 publications

(13 citation statements)

References 15 publications

(3 reference statements)

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“…5,6 While for the average woman requesting an epidural for labour a five-to ten-minute variance in onset time may not make much difference, for women approaching the second stage of labour, CSE provides rapid sacral analgesia without sacrificing pushing power. 7 How about the functioning of the epidural catheter? Several studies provide evidence that analgesia from the subsequent epidural infusion appears to be superior in women who received IT opioids.…”

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confidence: 99%

“…5,6 Bien que, pour une femme moyenne demandant une péridurale pour le travail obstétrical, une variation de cinq à dix minutes jusqu'au début de l'analgésie ne fasse pas une grande différence, pour les femmes s'approchant de la deuxième phase de travail, la RPC fournit une analgésie sacrale rapide sans pour autant sacrifier la force d'expulsion. 7 Qu'en est-il du fonctionnement du cathéter péridural ? De nombreuses études apportent des preuves que l'analgésie par perfusion péridurale ultérieure semble être supérieure chez les femmes ayant reçu des opiacés IT.…”

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The role of combined spinal epidural analgesia for labour: is there still a question?

Preston

2007

Can J Anesth/J Can Anesth

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confidence: 99%

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The role of combined spinal epidural analgesia for labour: is there still a question?

Preston

2007

Can J Anesth/J Can Anesth

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“…following intrathecal injection (1,2,(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29). Following conventional epidural analgesia, initial analgesia is usually achieved between 15 and 25 minutes.…”

Section: Initiation Of Neuraxial Analgesiamentioning

confidence: 99%

Modern neuraxial labor analgesia: options for initiation, maintenance and drug selection

Velde

2009

Revista Española de Anestesiología y Reanimación

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Most authors would agree that central neuraxial analgesia is the best form to manage labor pain. When neuraxial analgesia is administered to the parturient in labor, different management choices must be made by theanesthetist: how will we initiate analgesia, how will analgesia be maintained, which local anesthetic will we use for neuraxial analgesia and which adjuvant drugs will we combine? The present manuscript tries to review the literature to answer these questions. INITIATION OF NEURAXIAL ANALGESIAA lmost two decades have passed since French and American trials evaluated the use of spinal opioids during labor and since European randomized trials compared conventional epidural analgesia with combined spinal epidural (CSE) analgesia (1-3). CSE analgesia has gained worldwide acceptance and is becoming increasingly popular as the method of choice for labor pain relief (4-9). Obstetric anesthetists are divided when questioned on the place of CSE in labor analgesia. Whilst some authors feel it should be the technique of choice, others reserve CSE for certain indications (10-15). Recently, Simmons et al. published a Cochrane review concluding that CSE offers little benefit as compared to conventional epidural analgesia (16). However, the authors of this meta-analysis did acknowledge that CSE produced faster analgesia, resulted in less need for rescue analgesia and was associated with less urinary retention. Apart from a slight increase in the incidence of pruritus, these beneficial effects were not associated with more complications. The three demonstrated benefits of CSE are sufficient to promotes it's use if the side-effect profile remains unaltered. Furthermore it must be stressed that this Cochrane review can be criticized. Firstly, a number of well performed studies were excluded from analysis because of uncertain reasons. Inclusion of these well performed studies into the analysis might have affected the overall conclusions. Secondly, a number of outcomes were not considered in the analysis such as one-sided analgesia, epidural catheter reliability, anesthetist intervention rate, local anesthetic consumption and the occurrence of fetal heart abnormalities. Finally, very different types of CSE were used in the various studies. They were all considered to be a generic procedure and analyzed combined.Arguably the most obvious advantage of the CSE technique is the rapid and spectacular onset of effective analgesia with minute concentrations of local anesthetics with or without adjuvant drugs (16). Consistently, effective labor analgesia is accomplished within 4-6 minutes

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“…For example, early adopters of the CSE technique for labor analgesia used only opioids in the intrathecal injection, and used in this manner, the CSE technique did not offer much advantage over the standard epidural technique for advanced labor pain management (10). Once it was determined that adding local anesthetic to the intrathecal injection of opioid was effective in late labor (11), the CSE technique become widely adopted (7). For those considering the change to PIEB, there is a price to pay beyond the cost of pump capable of delivering PIEB.…”

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confidence: 99%

Programmed Intermittent Epidural Boluses (PIEB) for Maintenance of Labor Analgesia: An Incremental Step Before the Next Paradigm Shift?

Carvalho¹,

Riley²

2017

Turk J Anaesth Reanim

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W e agree with the evidence comparing programmed intermittent epidural boluses (PIEB) to conventional continuous epidural infusions (CEI) for maintaining epidural labor analgesia presented by Munro and George, (1) showing advantages with PIEB for both the patient (with less local anesthetic consumption, improved maternal satisfaction, potentially shorter duration of labor) and the anesthesia team (with decreased workload requirements) (2). However we disagree with their interpretation of the data, specifically the effect size of the demonstrated improvements (3). As we previously stated, the observed differences are modest and of limited clinical impact (4). The epidural analgesic technique of PIEB therefore needs to be considered only an incremental improvement over CEI for the maintenance of epidural labor analgesia. As such rather than focusing on the limited improvement of PIEB, perhaps we need to shift our overall perspective.A paradigm shift is a fundamental change in the basic concepts and practices of a discipline (5). In our opinion, there have only been a few paradigm shifts for labor pain management, for example, the discovery of local anesthetics and their utilization to provide spinal and/ or epidural analgesia; and the finding of opioid receptors in the spinal cord that has facilitated the use of neuraxial opioids. These changes moved labor pain control from practices involving inhalational anesthesia, twilight sleep or relying on systemic opioids (6), to epidural labor analgesic techniques that many laboring women request and receive during childbirth (7). However within these paradigm shifts, there have been many significant improvements in the analgesia and safe care that we provide laboring women. Examples of such improvements would include the use of epidural catheters instead of a single-shot spinal, epidural or caudal techniques, utilization of dilute local anesthetic opioid-containing solutions, smart volumetric epidural pumps, patient-controlled epidural analgesia (PCEA), combined spinal-epidural (CSE) analgesia, and flexible wire-reinforced epidural catheters. Some of these changes were major improvements and others incremental, but cumulatively these changes are substantive and have fundamentally improved our practices.So where does PIEB fit into these paradigms shifts and stepwise improvements? We agree with Munro and George, (1) that PIEB is superior to CEI for delivering local anesthetics to the epidural space and maintaining epidural labor analgesia. However, the improvement PIEB for Labor Analgesia RILEY vs. MUNRO Second Round DEBATE 73

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Combined spinal-epidural analgesia in advanced labour

Cited by 68 publications

References 15 publications

The role of combined spinal epidural analgesia for labour: is there still a question?

The role of combined spinal epidural analgesia for labour: is there still a question?

Modern neuraxial labor analgesia: options for initiation, maintenance and drug selection

Programmed Intermittent Epidural Boluses (PIEB) for Maintenance of Labor Analgesia: An Incremental Step Before the Next Paradigm Shift?

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