Articles: analgesia.
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Randomized Controlled Trial Clinical Trial
Dorsal column function after epidural and spinal blockade: implications for the safety of walking following low-dose regional analgesia for labour.
Walking after regional blockade for labour using low-dose combinations of bupivacaine and fentanyl is possible due to the maintenance of lower limb motor power. In order to investigate concerns that dorsal column function, important in maintaining balance, is impaired after such techniques, clinical assessment of lower limb proprioception and vibration sense was evaluated in parturients after either low-dose epidural (n = 30) or spinal blockade (n = 30) for labour analgesia and compared with spinal anaesthesia (n = 30) for elective Caesarean section using a larger total dose of local anaesthetic. Of the patients receiving low-dose regional labour analgesia 7% (n = 4) had abnormal dorsal column function compared with 97% (n = 29) receiving spinal anaesthesia for Caesarean section (p < 0.001). ⋯ There were no significant differences between the low-dose groups with respect to sensory block, motor block or dorsal column function. Overall, 90% of patients receiving low-dose bupivacaine/fentanyl regional labour analgesia had both normal lower limb motor power and dorsal column function. Assessment of these parameters is recommended before allowing patients to walk after low-dose regional techniques for labour.
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Int J Obstet Anesth · Apr 1998
Neonatal effects of patient-controlled analgesia using fentanyl in labor.
Patient-controlled analgesia (PCA) has been used at our institution for the past 5 years, as an alternative labor analgesic when epidural analgesia is contraindicated. This retrospective study evaluates the effects of maternal PCA fentanyl on infants of greater than 32 weeks gestational age. The neonatal charts (n=32) were reviewed for birth weight, gestational age, 1 min and 5 min Apgar scores, use of naloxone and umbilical venous gases. ⋯ Three infants with a 1 min Apgar of 4 required naloxone. The total fentanyl received by mothers of infants who required naloxone was significantly higher than the group of mothers whose infants did not require naloxone (770 +/- 233 microg vs 298 +/- 287 microg, P = 0.027) Use of PCA fentanyl in this high-risk obstetric population was associated with a 44% incidence of moderately depressed neonates with an Apgar score
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Comparative Study
The effect of epidural analgesia on the second stage of labor.
A retrospective review of 202 randomly selected records of parturient labors examined the relationship between cervical dilation at epidural analgesia administration and length of the second stage of labor. The epidural group received bupivacaine 0.11% or 0.125% with sufentanil 1 to 2 micrograms/mL using a Bard Patient Controlled Anesthesia II pump. Labor management and outcomes were compared with a nonepidural group who chose unmedicated childbirth, intravenous narcotics, or pudendal block. ⋯ The epidural group experienced a significantly longer mean length of the second stage. Labors in the epidural group were 3.5 times more likely to have oxytocin induction or augmentation and 4.5 times more likely to experience instrument-assisted delivery. There were no significant differences in Apgar scores between the two infant groups.
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Anesthesia and analgesia · Apr 1998
Comparative StudyThe effect of prior dural puncture on cerebrospinal fluid sufentanil concentrations in sheep after the administration of epidural sufentanil.
Sufentanil is a highly lipid soluble opioid that provides potent analgesia when administered in the subarachnoid space. Unfortunately, the penetration of sufentanil into the cerebrospinal fluid (CSF) after epidural administration is poor, and limits its effectiveness for epidural analgesia. Dural puncture may enhance the movement of epidural sufentanil into the subarachnoid space and increase its effectiveness. To determine whether the administration of epidural sufentanil adjacent to a dural puncture results in significantly greater CSF concentrations, 18 adult ewes were studied. Animals in the control group had an epidural catheter placed at the superior border of the pelvis without dural puncture. Animals in the study group had an epidural catheter placed, followed by a dural puncture performed using an 18-gauge Touhy needle. The dural puncture was performed one interspace cephalad to the epidural catheter. One hour after dural puncture, each animal received a loading dose of 0.35 microg/kg of sufentanil (5 microg/mL) through the epidural catheter, followed by an infusion of epidural sufentanil 0.15 microg x kg(-1) x h(-1) for a period of 4 h. After 4 h, CSF was sampled from a site one interspace caudad to the epidural catheter as well as at the cisterna magna. The mean CSF concentration of sufentanil at the level of the pelvis for animals with a dural puncture was 12.1 +/- 3.0 ng/mL compared with 1.8 ng/mL in controls with intact dura. Sufentanil concentrations at the cisterna magna were below the level of detection (0.08 ng/mL) for all animals in both groups. We conclude that an 18-gauge dural puncture significantly increases movement of sufentanil from the epidural to the intrathecal space. This increase in sufentanil concentration at the level of the pelvis was not associated with detectable levels of sufentanil at the brainstem. ⋯ This study addresses the effect of dural puncture on spinal fluid concentrations of sufentanil after epidural administration. A sheep model was used to measure drug concentrations in the spinal fluid at the levels of the pelvis and brainstem after epidural administration. Dural puncture significantly enhanced movement of sufentanil into the spinal fluid at the level of the pelvis, but brainstem concentrations were below the level of detection. Analgesic concentrations of spinal sufentanil in the clinical setting, as well as brainstem concentrations associated with respiratory depression, have yet to be defined.
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A prospective survey of one thousand and sixty-two patients receiving epidural analgesia in surgical wards was undertaken over a two-year period. The duration of infusion ranged from one to fourteen days, with a mode of three days. There were 1131 episodes where a local anaesthetic and opioid mixture was used and 160 where opioids were used alone. ⋯ Epidural analgesia can be used safely in surgical wards provided that regular review of the patients is undertaken. It must be anticipated however, that up to 20% of patients will not receive adequate analgesia for the first 48 hours postoperatively. The failure rate could be halved if accidental dislodgement of epidural catheters could be eliminated.