Dural puncture epidural analgesia for labor: a randomized comparison between 25-gauge and 27-gauge pencil point spinal needles

Abstract

BackgroundThis double-blind, randomized trial compared dural puncture epidural analgesia (DPEA) for labor using 25-gauge and 27-gauge pencil point spinal needles. We hypothesized that both needle sizes would result in similar onset time (equivalence margin=2.5 min) and therefore designed the study as an equivalence trial.MethodsOne hundred and forty patients undergoing labor were randomized to DPEA with 25-gauge (n=70) or 27-gauge (n=70) pencil point spinal needles. After the placement of the epidural catheter, a bolus of 20 mL of bupivacaine 0.125% and fentanyl 2 µg/mL was administered to all subjects. Thereafter, patients received boluses of 12 mL of bupivacaine 0.125% every 2 hours as needed.A blinded investigator recorded the onset time (defined as the temporal interval required to achieve a pain score ≤1 on a 0–10 scale), S2 block, sensory block height (30 min after the initial bolus of local anesthetic), presence of motor block (30 min after the initial bolus of local anesthetic), number of top-up doses required during labor and incidence of postural headache.ResultsOut of the 140 recruited patients, 135 were retained for analysis. Compared with their 27-gauge counterparts, 25-gauge pencil point spinal needles provided a 1.6 min shorter DPEA onset (95% CI of the difference of the means: −3.2 to −0.1 min). However, there were no intergroup differences in terms of S2 block, sensory block height, motor block, number of top-up doses and incidence of postural headache.ConclusionDural puncture epidural analgesia with 25-gauge pencil point spinal needles provides a 1.6 min shorter onset time than DPEA with 27-gauge spinal needles. Although statistically significant, such a difference may not be clinically relevant. Further investigation is required to compare 25-gauge and 27-gauge spinal needles for DPEA in the setting of different local anesthetic infusion strategies.Trial registration number NCT03389945.

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.…”

“…The DPE technique is a modified anesthesia method based on CSE; the dura is punctured using a spinal needle, and local anesthetics are introduced into the epidural space via an epidural catheter instead of directly into the subarachnoid space[ 14 ]. The theoretical basis is that perforation of the spinal dura facilitates the infiltration of local anesthetics into the subarachnoid space[ 15 ]. 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.…”

“…The local anesthetic volume might affect the transmeningeal flux of anesthetics by altering the pressure gradient between the epidural space and the subarachnoid space. Chau et al [ 28 ] used an identical DPE technique via a 25-G Whitacre needle with different epidural dosing regimens (20 mL of 0.125% bupivacaine and 12 mL of 0.25% bupivacaine) in different studies and suggested that a more dilute, higher-volume initial bolus was associated with a more rapid onset of thoracic sensory blockade and greater median cranial spread[ 15 ]. 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 ].…”

“…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. We did not record the hemodynamic data since a previous study reported that the hemodynamic stability produced by the DPE technique was better than that of the CSE technique and comparable to that of the EA technique[ 15 ]. The rate of vasopressor administration in our study was observed to be comparable between the two groups, which indirectly supports this result.…”

“…The dural puncture epidural (DPE) technique is a modification of the CSE technique that was first described for use in nonobstetric surgical patients in 1996 by Suzuki et al [ 13 ] and was subsequently applied by other investigators in obstetric patients[ 14 ]. It is performed by creating a perforation in the dura mater using a spinal needle (25-27 G) through the shaft of an epidural needle[ 15 ]. After the dural perforation is created and the free flow of cerebrospinal fluid (CSF) is confirmed, the spinal needle is withdrawn without local anesthetic injection into the subarachnoid space.…”