Comparison of pH-Adjusted Lidocaine Solutions for Epidural Anesthesia

DiFazio, Cosmo A.; Carron, Harold; Grosslight, K. R.; Moscicki, Jeffrey C.; Bolding, W. R.; Johns, Robert

doi:10.1097/00132582-198704000-00033

Cited by 22 publications

(31 citation statements)

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“…Median (IQR [range]) time to reach a block to touch to T5 was 7 (6-9 [5][6][7][8][9][10][11][12][13][14][15][16][17]) min for lidocaine-bicarbonate-adrenaline and 14 (10-17 [9-31]) min for levobupivacaine. Time to reach a block to cold to T4 was also faster with lidocaine-bicarbonate-adrenaline (7 (5-8 [4][5][6][7][8][9][10][11][12][13][14][15][16][17]) min than with levobupivacaine (11 (9-14 [6-30]) min; p = 0.001). Epidural supplementation before the start of surgery was required only in the levobupivacaine group, although this difference was not statistically significant ( Table 2).…”

Section: Resultsmentioning

confidence: 99%

“…Few data have been published on onset times with lidocaine for emergency Caesarean section. Lam et al reported a block to pinprick to T6 within a mean (SD [range]) of 5.2 (1.5 [2][3][4][5][6][7][8]) min of an epidural top-up with lidocainebicarbonate-adrenaline with 75 lg fentanyl; the onset time without bicarbonate was 9.7 (1.6 [6][7][8][9][10][11][12]) min [14].…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Epidural lidocaine‐bicarbonate‐adrenaline vs levobupivacaine for emergency Caesarean section: a randomised controlled trial*

Allam¹,

Malhotra

Hemingway³

et al. 2008

Anaesthesia

109

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SummaryEpidural mixtures containing lidocaine with or without additives are commonly used to convert epidural analgesia in labour to anaesthesia for emergency Caesarean section, but direct comparisons with alternative, single agents in this situation are few. In a prospective double-blinded trial, we compared a freshly prepared lidocaine-bicarbonate-adrenaline mixture (final concentrations 1.8%, 0.76% and 1 : 200,000, respectively) with our standard agent, levobupivacaine 0.5%, for extending epidural blockade for emergency Caesarean section. Using a sequential analysis technique, with data analysed in blocks of 40, women receiving epidural analgesia in labour who required top-up for Caesarean section were randomly assigned to receive 20 ml of epidural solution over 3 min. The first analysis (n = 40) indicated that the study should be stopped, as significant differences were found in our primary outcome data. Median (IQR [range]) times to reach a block to touch to T5 and cold to T4 were, respectively, 7 (6-9 [5-17]) min and 7 (5-8 [4-17]) min for lidocainebicarbonate-adrenaline, and 14 (10 )17 [9-31]) min and 11 (9-14 [6-30]) min for levobupivacaine (p = 0.00004 and 0.001, respectively). Pre-and intra-operative supplementation ⁄ pain, maternal side-effects and neonatal outcomes (excluding five women who underwent instrumental delivery) were similar between the groups. Intra-operative maternal sedation (scored by the mother on a 10-point scale) was greater with lidocaine-bicarbonate-adrenaline (4.5 (3-8 [1-9])) than with levobupivacaine (3 (1-4 [1-7])), but not significantly so (p = 0.07). We conclude that epidural lidocaine-bicarbonate-adrenaline halves the onset time when extending epidural analgesia for Caesarean section although there is a possibility of increased maternal sedation. When extending epidural analgesia in labour for emergency Caesarean section, the most appropriate choice of local anaesthetic for achieving rapid and reliable epidural anaesthesia remains unclear. A recent survey of leading UK obstetric anaesthetists [1] found that 13 combinations of local anaesthetics and adjuncts are used in this situation, with 2% lidocaine (alone or in combination) used by 40% of respondents and 0.5% levobupivacaine or bupivacaine used by 72% of respondents (some respondents using more than one in their practice). In our unit, levobupivacaine is the standard agent used in this situation and was adopted as a result of previous studies that showed no consistent advantage of alternatives [2][3][4], and because of the superior safety profile of levobupivacaine compared with bupivacaine [5,6]. Use of levobupivacaine has recently been recommended as best practice when extending epidural analgesia for emergency Caesarean section [7].We have found that trainees rotating to our unit often report the use of a lidocaine-bicarbonate-adrenaline mixture in other units when a faster onset of block is required, for example when there is fetal compromise.

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Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Epidural lidocaine‐bicarbonate‐adrenaline vs levobupivacaine for emergency Caesarean section: a randomised controlled trial*

Allam¹,

Malhotra

Hemingway³

et al. 2008

Anaesthesia

109

View full text Add to dashboard Cite

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“…Christoph et al did show a trend towards greater interstitial spread of LA but this was not statistically significant. 7 There are some studies that show a reduction in time to the onset of LA effect, increased duration of action and increased quality of the block, though these are studies involving techniques not often used in the ED such as epidural anaesthesia, 35,36 plexus blocks 37,38 and median nerve blocks. 39 Local anaesthetic solutions have been shown previously to have antimicrobial effects and these have been quantified in the past.…”

Section: Efficacymentioning

confidence: 99%

Buffering the pain of local anaesthetics: A systematic review

Davies

2003

Emergency Medicine

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Objective: To review the evidence that buffering of local anaesthetics with sodium bicarbonate reduces the pain of injection whilst not affecting efficacy. Methods: Medline search from 1966 to December 2001. Articles in all languages were included. Bibliographies were examined for papers. Results: The search identified 63 publications. All were retrieved. Of these, 22 were human prospective randomized controlled trials directly assessing the pain of infiltration. Three papers were based on observations. No case series, case reports, or retrospective studies were identified. One animal study was found. Conclusion: The evidence is that buffering with sodium bicarbonate significantly reduces the pain of local anaesthetic injection. The buffered solutions retain the efficacy of local anaesthetics and are stable in the mixtures used in the trials. Adrenaline‐containing buffered solutions need refrigeration in closed containers for storage. Buffering will be particularly useful where pain of local anaesthetic injection may not be well tolerated such as in large areas of infiltration, sensitive areas such as the face and in children. It is recommended that sodium bicarbonate and tables of stable dilutions are readily available in the emergency department to facilitate this.

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“…Previously, lidocaine 2% with epinephrine has been used to extend epidural block rapidly [1, 2]. Because commercial preparations of lidocaine are acidic [3], increasing the pH towards the physiological range can theoretically increase the speed of onset. This was shown in previous studies in which sodium bicarbonate was added to lidocaine [3–5].…”

mentioning

confidence: 99%

Extension of epidural blockade in labour for emergency Caesarean section using 2% lidocaine with epinephrine and fentanyl, with or without alkalinisation*

Lam¹,

Kee

Khaw

2001

Anaesthesia

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In a randomised, double-blind study, we investigated rapid extension of epidural analgesia to surgical anaesthesia for emergency Caesarean section. Parturients receiving epidural analgesia in labour who subsequently required Caesarean section were given a test dose of 3 ml lidocaine 2% with epinephrine 1 : 200 000, followed 3 min later by 12 ml lidocaine 2% with epinephrine 1 : 200 000 and fentanyl 75 microg, to which was added 1.2 ml sodium bicarbonate 8.4% (bicarbonate group; n = 20) or saline (saline group; n = 20). Mean (SD [range]) time to surgical anaesthesia was less in the bicarbonate group (5.2 (1.5) [2-8] min) than the saline group (9.7 (1.6) [6-12] min; mean difference 4.5 min (95% CI 3.5-5.5) min; p < 0.001). Maternal side-effects and neonatal outcome were similar between groups. We conclude that pH-adjusted lidocaine 2% with epinephrine and fentanyl is effective for rapidly establishing surgical anaesthesia in patients with a functioning epidural catheter for labour who require emergency Caesarean section.

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Comparison of pH-Adjusted Lidocaine Solutions for Epidural Anesthesia

Cited by 22 publications

References 0 publications

Epidural lidocaine‐bicarbonate‐adrenaline vs levobupivacaine for emergency Caesarean section: a randomised controlled trial*

Epidural lidocaine‐bicarbonate‐adrenaline vs levobupivacaine for emergency Caesarean section: a randomised controlled trial*

Buffering the pain of local anaesthetics: A systematic review

Extension of epidural blockade in labour for emergency Caesarean section using 2% lidocaine with epinephrine and fentanyl, with or without alkalinisation*

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