Extending epidural blockade for emergency caesarean section Evaluation of 2% lignocaine with adrenaline

Price, Mary L.; Reynolds, F.; Morgan, B.

doi:10.1016/0959-289x(91)90024-k

Cited by 64 publications

(57 citation statements)

References 34 publications

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“…Over the three decades following the initial report by Milne et al, 17 several studies [6][7][8][9][10][11][12][13][14][15] described retrospective reviews of the anesthesia for intrapartum CD in parturients receiving ELA. Unfortunately, when the attempted conversion resulted in inadequate ESA, none of these studies focused on the anesthetic management in an attempt to identify interventions to potentially reduce the need for GA.…”

Section: Discussionmentioning

confidence: 99%

“…[2][3][4][5] One of the important advantages of epidural labour analgesia (ELA) is the potential for this analgesic modality to be rapidly converted to epidural surgical anesthesia (ESA). This capacity can facilitate CD thereby avoiding the inherent risks of GA. Several small studies [6][7][8][9][10][11][12] and three larger studies [13][14][15] have suggested a high conversion success rate (89-95%) of ELA to ESA for intrapartum CD. Unfortunately, the identification of significant risk factors for failed conversion of ELA to effective ESA, and the development of management strategies to improve conversion rates have not previously been elucidated.…”

Section: Résumémentioning

confidence: 99%

See 1 more Smart Citation

Conversion d’une analgésie péridurale pour travail obstétrical en une anesthésie péridurale pour césarienne

Campbell

Tran

2008

Can J Anesth/J Can Anesth

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Purpose To determine the rate of successful conversion of epidural labour analgesia (ELA) to epidural surgical anesthesia (ESA) for intrapartum Cesarean delivery (CD) with identification of potential risk factors for inadequate ESA. Secondary outcomes include a comparison of the management by subspecialist obstetric anesthesiologists (OB) vs. generalist anesthesiologists (GEN), when inadequate ESA was encountered, with an intention of identifying potential interventional strategies to reduce the need for general anesthesia (GA). Methods Health records of all parturients who received ELA and who underwent intrapartum CD during the 3-year period from April 01, 2001 to March 31, 2004 were manually reviewed. Data were analyzed using t test, Chisquare, Fisher's exact test, and analysis of variance where appropriate. A P \ 0.05 was considered significant. Results Eight hundred ninety-nine cases were identified. Four were excluded, as two received continuous spinal labour analgesia and two underwent emergency CD with insufficient time for conversion to ESA. Initially, 86.6% (775/895) of the 895 cases were successfully converted to ESA leaving 120 cases of inadequate ESA, 36 of these were managed by OB and 84 by GEN. Ineffective ELA was identified as a risk factor for unsuccessful conversion. Pulling the epidural catheter back 1 cm was identified as an effective intervention that resulted in the successful conversion in [80% of the 120 cases of inadequate ESA.Spinal anesthesia proved effective in 75% of cases. Both interventions reduced the need for GA to 1.2% for OB and 5.6% for GEN. Conclusions This investigation provides anesthesiologists with strategies to manage inadequate ESA for intrapartum CD that may reduce the need for GA.

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Section: Discussionmentioning

confidence: 99%

Section: Résumémentioning

confidence: 99%

Conversion d’une analgésie péridurale pour travail obstétrical en une anesthésie péridurale pour césarienne

Campbell

Tran

2008

Can J Anesth/J Can Anesth

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“…There are few published data in this area, but using figures from previous related work [2,3] we calculated our study would have 80% power to detect a 30% difference in the time taken to extend an existing low-dose epidural block to T 4 . In fact, we found much larger variability in onset times than that reported in other studies, possibly because we used lowdose bolus top-ups in labour instead of low-dose infusions or more concentrated solutions as in other studies.…”

Section: Discussionmentioning

confidence: 99%

“…Various solutions of local anaesthetic have been used for Caesarean section carried out under epidural anaesthesia. Pre-existing epidurals using 0.25-0.5% bupivacaine may be safely extended for Caesarean section with slow boluses of 20 ml 0.5% bupivacaine [1] or 20 ml 2% lignocaine with 1 : 200 000 adrenaline [2]. Because a 50 : 50 mixture of 0.5% bupivacaine and 2% lignocaine with 1 : 200 000 adrenaline may be superior to 2% lignocaine for elective Caesarean section [3], this mixture is often used to extend low-dose epidural analgesia for emergency Caesarean section.…”

mentioning

confidence: 99%

Extending low‐dose epidural analgesia for emergency Caesarean sectionA comparison of three solutions

Lucas

Ciccone²,

Yentis

1999

Anaesthesia

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SummaryWe conducted a prospective double-blind randomised trial to compare bupivacaine 0.5%; a 50 : 50 mixture of bupivacaine 0.5%/lignocaine 2% with 1 : 200 000 adrenaline (final concentration); and lignocaine 2% with 1 : 200 000 adrenaline for converting a low-dose labour epidural into a block adequate for emergency Caesarean section. Ninety patients were studied, 30 in each group. There was no difference between the groups in the time taken for bilateral loss of cold sensation to reach T 4 . Onset time was unaffected by the existing sensory level pre-Caesarean section top-up; the number of low-dose top-ups in labour; the total dose of bupivacaine in labour; or maternal weight or height. Three patients in the lignocaine with adrenaline group had blocks that reached the cervical dermatomes and three in the same group required general anaesthesia for inadequate anaesthesia, compared with none in the other groups (both p ¼ 0.04).

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“…We also find it interesting that no such difference was apparent in the sedation scores assigned by the anaesthetists. Lidocaine is commonly detected in maternal blood when used for epidural anaesthesia in both elective [13,23,24] and emergency [13,25] Caesarean section despite the concomitant use of adrenaline, as the latter reduces plasma levels but does not eliminate them entirely [23][24][25]. Our results therefore raise the possibility of increased sedation with lidocainebicarbonate-adrenaline but further studies would be required to explore this further, especially since there is currently scant documented evidence of an association between the use of epidural lidocaine and sedation, dizziness or dysphoria [26,27].…”

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

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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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Extending epidural blockade for emergency caesarean section Evaluation of 2% lignocaine with adrenaline

Cited by 64 publications

References 34 publications

Conversion d’une analgésie péridurale pour travail obstétrical en une anesthésie péridurale pour césarienne

Conversion d’une analgésie péridurale pour travail obstétrical en une anesthésie péridurale pour césarienne

Extending low‐dose epidural analgesia for emergency Caesarean sectionA comparison of three solutions

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

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