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

Abstract

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).

Spinal anesthesia for intrapartum Cesarean delivery following epidural labor analgesia: a retrospective cohort study

“…12 However, in recent studies, inadequate surgical anesthesia after conversion of ELA to ESA for CD necessitated conversion to GA in 2.5-20% of cases and provision of additional analgesia was even more frequent. [13][14][15][16][17][18][19] Only one underpowered study reported a conversion rate to GA of 0%. 20 In fact, inadequate ESA has led to litigation against anesthesiologists.…”

Extending low‐dose epidural analgesia in labour for emergency Caesarean section – a comparison of levobupivacaine with or without fentanyl*

“…These have been in varying study populations with different epidural regimens in labour, and have used different sensory modalities and end-points for surgical anaesthesia [1,2,4,5,14], making it difficult to compare studies. We attempted to define our end-points more clearly by specifying 'icy' cold sensation and 'strong' touch sensation, i.e.…”

“…A power analysis was performed with values for alpha and beta of 0.05 and 0.2, respectively, based on a 50% relative decrease in intra-operative supplementation, and a 30% reduction in onset time, using data from previous studies [1,2]. This indicated sample sizes of 82 and 86, respectively, hence the planned sample size of 100 per group to account for drop-outs.…”

“…Various solutions of local anaesthetic are used for this purpose. Previous work at our hospital has shown that lidocaine and ropivacaine offer no consistent advantage over bupivacaine for extending epidural analgesia for emergency Caesarean section [1,2]. Recently in our unit, levobupivacaine has replaced bupivacaine as the standard top-up solution for Caesarean section on account of its similar efficacy with less cardiotoxicity [3].…”

“…Recently in our unit, levobupivacaine has replaced bupivacaine as the standard top-up solution for Caesarean section on account of its similar efficacy with less cardiotoxicity [3]. Addition of other drugs to the local anaesthetic has also been described, for example adrenaline, bicarbonate and opioids such as fentanyl [1,4,5]. However, mixing drugs in emergency situations risks errors [6] and mixing itself may cause delay [7].…”