Effects of epidural injection on spinal block during combined spinal and epidural anesthesia for cesarean delivery

Choi, Duck Hwan; Park, Nam Kee; Cho, Hyun Sung; Hahm, Tae Soo; Chung, Ilsub

doi:10.1053/rapm.2000.8934

Cited by 15 publications

(24 citation statements)

References 31 publications

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“…In most clinical trials on the subject of EVE conducted in nonobstetric patients, the volume of epidural injectate used is 10 mL;[781718] while in obstetric patients it ranges from 5[1920] to 10 mL. [25621] Higher volumes of 15 and 20 mL have also been evaluated in nonobstetric patients in a recent study in nonobstetric patients. [8]…”

Section: Discussionmentioning

confidence: 99%

“…[4] However, the minimum effective volume (MEV) of normal saline required to produce a rapid increase in the sensory level has not been investigated. In previously published studies on the subject of EVE, the volume of normal saline used for EVE ranges from 5 to 20 m,[3567] but there is very little data comparing the effect of various volumes of normal saline on the sensory block level per se . [38]…”

Section: Introductionmentioning

confidence: 99%

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Minimum effective volume of normal saline for epidural volume extension

Tyagi

Kumar

Salhotra

et al. 2014

J Anaesthesiol Clin Pharmacol

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Background:Rescue strategies like changes in tilt of table are used to raise the level of an inadequate sensory block following intrathecal injection. Epidural volume extension (EVE) refers to an injection of normal saline through epidural catheter following an intrathecal block. It results in a rapid increase in the sensory level of subarachnoid block. Thus, it has been postulated that EVE may be used as a rescue strategy for an inadequate post-spinal sensory block. However, the minimum effective volume (MEV) of normal saline for EVE induced increase in level of spinal block has not been researched till date. We proposed to determine the MEV of normal saline required for EVE induced increase in post-spinal block sensory level.Materials and Methods:This prospective sequential allocation study was conducted in consenting adult males after institutional ethical committee approval scheduled for lower limb surgery under combined spinal epidural (CSE) anesthesia, who had an inadequate level of sensory block. Herein, an inadequate level was defined as lower than T10 at 10 min after the intrathecal injection, with no ascent for two consecutive readings taken 2 min apart. The EVE was performed with normal saline injected through epidural catheter, and was considered successful if the level of sensory block increased by two or more dermatomal segments within 5 min of the injection. The volume of normal saline for EVE was decided by using the up-and-down method, with the first patient receiving 10 mL and a dosing interval of 1 mL in subsequent patients. The analysis was done using the formula of Dixon and Massey, which enabled calculation of the MEV with 95% CI. Quantitative parametric data is represented as mean ± SD and nonparametric data as median (range).Results and Conclusion:The MEV of normal saline to raise the level of sensory block by two or more dermatomal segments within 5 min of EVE is 7.4 mL (95% CI: 5.5-9.9 mL).

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Minimum effective volume of normal saline for epidural volume extension

Tyagi

Kumar

Salhotra

et al. 2014

J Anaesthesiol Clin Pharmacol

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“…). Fifteen studies reporting on 1177 patients were considered eligible for quantitative analysis. The risk of bias assessment of the included studies is given in Table .…”

Section: Resultsmentioning

confidence: 99%

“…Nine trials included parturients undergoing caesarean section , and six trials reported on other surgical procedures . In 12 out of 15 studies , the same anaesthetic mixture was used in the treatment and control arms. In three studies , all on caesarean section, a lower spinal anaesthetic dose plus epidural volume extension was applied in one group (epidural volume extension group) compared with a higher spinal anaesthetic dose without epidural volume extension (control group).…”

Section: Resultsmentioning

confidence: 99%

“…Spinal anaesthesia was performed in the sitting position in eight studies and in the lateral position in seven studies . Plain bupivacaine was used in four studies and hyperbaric bupivacaine was used in eight studies . Kucukguclu et al studied the effect of epidural volume extension in two groups of patients, one group receiving isobaric bupivacaine and the other group receiving hyperbaric bupivacaine.…”

Section: Resultsmentioning

confidence: 99%

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Effects of epidural volume extension by saline injection on the efficacy and safety of intrathecal local anaesthetics: systematic review with meta‐analysis, meta‐regression and trial sequential analysis

et al. 2017

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Epidural volume extension, a modification of combined spinal-epidural anaesthesia, involves the epidural injection of saline in order to increase the spread of drugs given intrathecally. Results from individual studies have so far been contradictory and we aimed to gather the available evidence for this technique. We performed a systematic literature search for randomised, controlled trials comparing epidural volume extension after spinal injection with a control group without epidural injection in patients undergoing surgery. Conventional meta-analyses, trial sequential analyses and meta-regression were performed, with the Grading of Recommendations on Assessment, Development and Evaluation (GRADE) approach used to express reliability of outcome estimates. We included 15 studies with 1177 participants. Meta-analyses for the primary outcomes, such as maximum sensory height (6 studies, 274 participants, mean difference (MD) (95%CI) -0.59 (-1.24 to 0.07) dermatomes, low-quality evidence) and hypotension (10 studies, 683 participants, risk ratio (95%CI) 0.84 (0.66-1.07), low-quality evidence), did not differ significantly between the two treatment arms, but trial sequential analysis suggested insufficient evidence to be certain of these findings. Meta-regression suggested a volume-dependent effect, with higher volumes causing a higher spread of intrathecal drugs and a higher incidence of hypotension. A sub-group analysis indicated a pronounced effect on motor block recovery time when a lower anaesthetic dose plus epidural volume extension was compared with a higher anaesthetic dose without epidural volume extension, the MD (95%CI) being -66.75 (-76.0 to -57.5) min, with trial sequential analysis suggesting the evidence was sufficient to draw this conclusion. In trials using the same anaesthetic mixture in the epidural volume extension and the control groups, motor block recovery time did not differ between groups, with a MD (95%CI) of -1.06 (-5.48 to 3.36) min, although trial sequential analysis suggested insufficient evidence. In summary, there is not enough evidence to draw definite conclusions on the effect of epidural volume extension. The quality of the current evidence is low for both efficacy (maximum sensory height) and safety (hypotension). However, there may be a significantly shorter motor block recovery time when different anaesthetic mixtures are used in epidural volume extension and control groups; this warrants further investigation.

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