Comparative efficacy of epidural clonidine versus epidural fentanyl for treating breakthrough pain during labor: a randomized double-blind clinical trial

Lee, A.; Landau, Ruth; Lavin, Thomas; Goodman, Stephanie R.; Menon, Prahlad G.; Smiley, Richard M.

doi:10.1016/j.ijoa.2019.11.003

Cited by 8 publications

(6 citation statements)

References 23 publications

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“…Clonidine is an alpha‐2 receptor agonist which can be given via the epidural route, reducing requirements for local anesthesia by around 30%, and increasing duration of anesthesia with or without opioids 22 . Despite concerns about side effects of hypotension, bradycardia, and maternal sedation, a RCT of 98 parturients found no difference in analgesic efficacy between clonidine/bupivacaine and fentanyl/bupivacaine and no difference in adverse outcomes 22 …”

Section: Methodsmentioning

confidence: 99%

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Epidural analgesia in labor: A narrative review

Halliday

Nelson

Kearns

2022

Intl J Gynecology & Obste

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Lumbar epidural is considered the gold standard for analgesia in labor and is recommended by WHO, with estimates of use in the range of 10%-64% in high-income countries. 1 During labor, uterine contraction and cervical dilatation stimulate nociceptive afferent fibers that travel to spinal nerves T10-L1, producing poorly localized visceral pain. As the fetal head descends, stretching the perineum and vagina, pain fibers via the pudendal nerve and spinal roots S2-4 are also activated. 2 To modify these afferent pathways and achieve analgesia, local anesthetics, opioids, and other adjuvants can be administered to the epidural space by an epidural catheter. Despite widespread use, there are many uncertainties regarding the optimal epidural regime. Different combinations and concentrations of drugs administered epidurally have been shown to have varying effects in both the partum and postpartum periods. With so many variables surrounding childbirth, it can be difficult to separate association and causation. Epidurals are associated with, but probably do not cause, prolonged labor and increased risk of operative delivery. 3 These factors directly affect obstetric decision making. For certain maternal conditions that may be decompensated by labor and delivery, such as pre-eclampsia or cardiac disease, labor epidural is indicated. In cases where epidural is contraindicated (such as severe thrombocytopenia, coagulopathy, or sepsis) other analgesic regimes (e.g. patient-controlled remifentanil) may be available.Improving communication and understanding between anesthetists and obstetricians is mutually beneficial. The aim of the present narrative review was to provide an overview of epidural literature for the obstetric audience, incorporating techniques of insertion, medications used, and associations with maternal and neonatal outcomes.Spinal anesthesia, and the use of epidural anesthesia for cesarean/ operative delivery are outwith the scope of the present review. | ME THODS | Search strategyA literature search without language restriction was conducted (MEDLINE Ovid, Embase Ovid, CINAHL EBSCO, and Cochrane Central Register of Controlled Trials [CENTRAL]) from date of inception to October 5, 2020. Randomized controlled trials (RCTs), reviews, and relevant references were included. Search terms were "neuraxial analgesia," "epidural," "peridural," "combined spinal-epidural," "CSE,"

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Section: Methodsmentioning

confidence: 99%

“…22 Despite concerns about side effects of hypotension, bradycardia, and maternal sedation, a RCT of 98 parturients found no difference in analgesic efficacy between clonidine/bupivacaine and fentanyl/bupivacaine and no difference in adverse outcomes. 22…”

Section: Clonidinementioning

confidence: 99%

Epidural analgesia in labor: A narrative review

Halliday

Nelson

Kearns

2022

Intl J Gynecology & Obste

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“…For each patient, baseline systolic blood pressure (SBP) and heart rate (HR) were determined by calculating the mean of three separate measurements, assessed 3 min apart prior to the initiation of spinal anesthesia ( Xiao et al, 2018 ; Lee et al, 2020 ). After intrathecal injection of local anesthetic, NIBP and HR were measured at 1 min intervals, and at 5 min intervals after delivery of the newborn.…”

Section: Methodsmentioning

confidence: 99%

The ED50 and ED95 of Prophylactic Norepinephrine for Preventing Post-Spinal Hypotension During Cesarean Delivery Under Combined Spinal-Epidural Anesthesia: A Prospective Dose-Finding Study

Drzymalski

et al. 2021

Front. Pharmacol.

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Background: Hypotension commonly occurs with spinal anesthesia during cesarean delivery. Norepinephrine is an alternative to phenylephrine which can be used to prevent or treat hypotension, with better maintained cardiac output and less bradycardia. However, an appropriate initial prophylactic infusion dose of norepinephrine remains unclear. The aim of this study was to describe the dose-response relationship of prophylactic norepinephrine infusion during cesarean delivery under combined spinal-epidural anesthesia.Methods: We performed a prospective, randomized, double-blinded dose-finding study. One hundred patients undergoing elective cesarean delivery were randomly assigned to receive an infusion of norepinephrine at 0, 0.025, 0.05, 0.075 or 0.1 μg/kg/min initiated immediately after intrathecal injection of 10 mg bupivacaine combined with 5 µg sufentanil. An effective dose was considered when there was no hypotension (systolic blood pressure < 90 mm Hg or < 80% of baseline) during the time period from injection of intrathecal local anesthetic to delivery of the neonate. The primary aim was to determine the dose-response relationship of norepinephrine to prevent spinal anesthesia-induced hypotension. The median effective dose (ED50) and 95% effective dose (ED95) for norepinephrine were calculated utilizing probit analysis.Results: The proportion of patients with hypotension was 80, 70, 40, 15 and 5% at norepinephrine doses of 0, 0.025, 0.05, 0.075 and 0.1 μg/kg/min, respectively. The ED50 and ED95 were 0.042 (95% CI, 0.025–0.053) µg/kg/min and 0.097 (95% CI, 0.081–0.134) µg/kg/min, respectively. There were no differences in the Apgar scores (p = 0.685) or umbilical arterial pH (p = 0.485) measurements of the newborns among the treatment groups.Conclusion: A norepinephrine infusion of 0.1 μg/kg/min as an initial starting dose was effective for the prevention of spinal-induced hypotension.

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“…This randomized, double-blind trial aimed to investigate the onset of action and analgesic effect of chloroprocaine compared with ropivacaine in breakthrough pain relief. Unlike a previous study [ 12 ], we defined treatment success as a decrease in the NRS score by at least 4 from the baseline during active uterine contraction observed 9 min post-drug administration.…”

Section: Methodsmentioning

confidence: 99%

Efficacy and Safety of Epidural Chloroprocaine for Breakthrough Pain During Labor Analgesia: A Prospective, Double-Blind, Randomized Trial

Ji,

Jiang,

Liu

et al. 2024

Pain Ther

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Introduction A significant number of women who undergo neuraxial labor analgesia experience breakthrough pain. Prompt mitigation of breakthrough pain is essential to improve maternal and fetal outcomes. We evaluated epidural chloroprocaine compared with ropivacaine in alleviating labor breakthrough pain. Methods We performed a double-blind randomized controlled clinical trial between May and July 2023. Eligible parturients received epidural analgesia with ropivacaine and sufentanil. Those with breakthrough pain were randomized to receive either 0.125% epidural ropivacaine (group R) or chloroprocaine at concentrations of 0.5% (group C1), 1.0% (group C2), or 1.5% (group C3), all in a volume of 6 mL. The primary outcome was the treatment success rate, indicated by a decrease of at least 4 points on the numerical rating scale pain score 9 min after analgesic injection. Secondary outcomes and adverse effects were also recorded. Results Out of 323 patients receiving epidural analgesia, 192 experienced breakthrough pain. After exclusion of three patients because of protocol deviation, there were 47, 48, 47, and 47 patients in group R, C1, C2, and C3, respectively. Group C3 demonstrated a higher treatment success rate (39/47, 83.0%) in managing breakthrough pain than group R (26/47, 55.3%), group C1 (12/48, 25.0%), and group C2 (30/47, 63.8%) ( p < 0.001). Group C3 had lower numerical rating scale scores at 6 and 9 min after injection and required fewer patient-controlled epidural boluses than other groups. In addition, group C3 reported greater satisfaction than the other groups ( p < 0.001). No significant differences were observed in obstetric or neonatal outcomes across these groups. Conclusion Parturients experiencing breakthrough pain could receive 1.5% epidural chloroprocaine, rather than lower chloroprocaine concentrations and ropivacaine, to achieve more rapid and better pain relief with higher patient satisfaction. Trial Registration Chinese Clinical Trial Registry, ChiCTR2300071069, http://www.chictr.org.cn/index.aspx .

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Comparative efficacy of epidural clonidine versus epidural fentanyl for treating breakthrough pain during labor: a randomized double-blind clinical trial

Cited by 8 publications

References 23 publications

Epidural analgesia in labor: A narrative review

Epidural analgesia in labor: A narrative review

The ED50 and ED95 of Prophylactic Norepinephrine for Preventing Post-Spinal Hypotension During Cesarean Delivery Under Combined Spinal-Epidural Anesthesia: A Prospective Dose-Finding Study

Efficacy and Safety of Epidural Chloroprocaine for Breakthrough Pain During Labor Analgesia: A Prospective, Double-Blind, Randomized Trial

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