Written information about epidural analgesia for women in labour: did it improve knowledge?

There is evidence that despite a distressed appearance, women in labour should be informed about the side effects and risks associated with epidural analgesia. An audit of 100 women who had used epidural analgesia for labour in our hospital and who had received a verbal explanation of the benefits, risks and side effects of epidural analgesia showed that the level of knowledge was low. An A5 laminated epidural information card was prepared summarising this information. The midwife and the anaesthetist used the card during labour as a focus for verbal discussion and as written reinforcement for the woman and her partner. A repeat audit of a further 100 women showed a statistically significant improvement in the level of knowledge about epidural analgesia. This audit suggests that the use of a written information card is beneficial. It improves and reinforces the process of giving information thus assisting the consent process.     

Combined spinal epidural vs epidural labour analgesia: does initial intrathecal analgesia reduce the subsequent minimum local analgesic concentration of epidural bupivacaine?

Labour analgesia initiated using a combined spinal-epidural (CSE) technique may reduce subsequent epidural bupivacaine requirements compared with an epidural-only technique. We compared the minimum local analgesic concentrations (MLAC) of epidural bupivacaine following initial intrathecal or epidural injection. In a prospective, double-blind study, 115 women requesting epidural analgesia were randomly assigned to receive either an epidural with bupivacaine 20 mg and fentanyl 40 μg or a CSE with intrathecal bupivacaine 2.5 mg and fentanyl 5 μg. Analgesia was assessed using a visual analogue pain score. When further analgesia was requested, bupivacaine 20 ml was given, and the concentration was determined using the technique of up-down sequential allocation. The MLAC of bupivacaine in the epidural group was 0.032% wt/vol (95% CI 0.020-0.044) compared with 0.047% wt/vol (95% CI 0.042-0.052) in the CSE group. Bupivacaine requirements for the second injection were increased following intrathecal analgesia by a factor of 1.45 (p = 0.026) compared with epidural analgesia.     

The epidural test dose in obstetrics: is it necessary?

One must distinguish between what is medically safe and what is legally safe. The authors have the impression that in order to be "legally safe" one must perform a test dose. This is despite the fact that it has not been conclusively shown that the use of test doses improve the safety margin of epidural anaesthesia, when administered by a competent person, with the proper resuscitative equipment immediately available. Until a controlled study is performed, test doses should be done for continuous epidural anaesthesia with the understanding that they are neither 100 per cent sensitive nor specific in preventing complications. It is however one more manoeuvre that may be useful in recognizing some of the patients with accidental subarachnoid placement of epidural catheters. The literature suggests that lidocaine 1.5 per cent in dextrose 7.5 per cent should be the test dose of choice in obstetric epidural anaesthesia in an amount known to produce spinal anaesthesia (30-50 mg). The use of epinephrine in test doses in unpremedicated healthy women in active labour is neither sensitive nor specific in signalling intravascular injection, and it may also be detrimental to fetal wellbeing. Epinephrine 15 micrograms as a test dose for intravenous injection appears to create more problems than it solves.     

Is the clinical efficacy of epidural diamorphine concentration-dependent when used as analgesia for labour?

Background. The physicochemical properties of diamorphine (3,6-diacetylmorphine)enhance its bioavailability compared with more lipid-solubleopioids when administered into the epidural space. However,the influence of concentration, volume or mass on the clinicalefficacy of diamorphine is not known. Method. In this double-blind, randomized, prospective study,62 women in active labour and     

Programmed intermittent epidural bolus vs. patient-controlled epidural analgesia for maintenance of labour analgesia: a two-centre,double-blind,randomised study†

The programmed intermittent epidural bolus technique has shown superiority to continuous epidural infusion techniques, with or without patient-controlled epidural analgesia for pain relief, reduced motor block and patient satisfaction. Many institutions still use patient-controlled epidural analgesia without a background infusion, and a comparative study between programmed intermittent epidural bolus and patient-controlled epidural analgesia without a background infusion has not yet been performed. We performed a randomised, two-centre, double-blind, controlled trial of these two techniques. The primary outcome was the incidence of breakthrough pain requiring a top-up dose by an anaesthetist. Secondary outcomes included: motor block; pain scores; patient satisfaction; local anaesthetic consumption; and obstetric and neonatal outcomes. We recruited 130 nulliparous women who received initial spinal analgesia, and then epidural analgesia was initiated and maintained with either programmed intermittent epidural bolus or patient-controlled epidural analgesia using ropivacaine 0.12% with sufentanil 0.75 µg·ml^-1. The programmed intermittent epidural bolus group had a programmed bolus of 10 ml every hour, with on-demand patient-controlled epidural analgesia boluses of 5 ml with a 20 min lockout, and the patient-controlled epidural analgesia group had a 5 ml bolus with a 12 min lockout interval; the potential maximum volume per hour was the same in both groups. The patients in the programmed intermittent epidural bolus group had less frequent breakthrough pain compared with the patient-controlled epidural analgesia group, 7 (10.9%) vs. 38 (62.3%; p < 0.0001), respectively. There was a significant difference in motor block (modified Bromage score ≤ 4) frequency between groups, programmed intermittent epidural bolus group 1 (1.6%) vs. patient-controlled epidural analgesia group 8 (13.1%); p = 0.015. The programmed intermittent epidural bolus group had greater local anaesthetic consumption with fewer patient-controlled epidural analgesia boluses. Patient satisfaction scores and obstetric or neonatal outcomes were not different between groups. In conclusion, we found that a programmed intermittent epidural bolus technique using 10 ml programmed boluses and 5 ml patient-controlled epidural analgesia boluses was superior to a patient-controlled epidural analgesia technique using 5 ml boluses and no background infusion.     

Fully endoscopic lumbar spinal surgery: Is it time to change?

Spinal surgery is becoming safer and progressively less invasive with advances in optical and instrument technology. The amount of decompression achievable with endoscopic approaches is now comparable to open approaches with the advantage of much less tissue trauma. This review aims at examining the status of endoscopic approaches in lumbar decompressive surgery.     

Unintentional intrapleural insertion of an epidural catheter: should we remove it or leave it in situ to provide perioperative analgesia?

We report three patients who had intrapleural insertion of an intended thoracic epidural catheter. These misplaced catheters were used for local anesthetic administration. Bupivacaine injection via these catheters in two cases was effective for reducing postoperative pain. We conclude that if an intended thoracic epidural catheter is found to be in the intrapleural cavity at the time of surgery and if correct replacement of the catheter into the epidural space is not believed to be feasible after surgery, then the administration of local anesthetic through the intrapleural catheter could be considered as a potential alterative analgesic method.     

Is obstetric epidural anaesthesia technically possible after spinal surgery and does it work?

OBJECTIVE: Previous spine surgery theoretically exposes the obstetric patient to a greater technical difficulty during regional analgesia for labour or during anaesthesia for caesarean delivery. Published experience suggests that epidural puncture is however technically possible in the majority of cases. STUDY DESIGN: Retrospective study. PATIENTS: Analysis of the files of parturients who gave birth in a maternity hospital during a six year period and who had previously undergone spine surgery. METHODS: Technical failures (during puncture), analgesic failures (complete block inefficiency and/or requirement of a general anaesthetic) and complications (important bleeding at the puncture site, dural tap, infection) observed during epidural analgesia/anaesthesia were recorded. RESULTS: Except for two paraplegic parturients who had been operated for dorsocervical traumatic injuries and who were excluded from the analysis, 31 parturients had undergone spine surgery and delivered during the period of analysis. Twenty patients underwent 22 epidural punctures. Technical failure were noted in two cases (9%) and analgesic failure in two other cases (9%). No significant complication was recorded. CONCLUSION: With an overall 18% failure rate, epidural anaesthesia is not contra-indicated in these patients but appears to be less reliable than in patients with normal spine. Psychological and technical preparation to the occurrence of failure is necessary.     

Sacral examination in spinal cord injury: Is it really needed?

Objective: To determine if a self-report measure of S4-5 motor and sensory function in patients with chronic SCI accurately predicts sacral examination results.

Design: Prospective, single-blinded self-report survey compared with sacral exam.

Setting: Outpatient SCI clinic.

Participants: 116 patients aged 18+ with chronic SCI > 6 months who have undergone sacral exam.

Interventions: The survey included demographic/clinical and sacral function information such as light tough (LT), pinprick sensation (PP), deep anal pressure (DAP) and voluntary anal contraction (VAC). Survey results and sacral exam were compared and stratified by the patient’s American Spinal Cord Injury Association Impairment Scale (AIS) category.

Outcome Measures: Sacral self-report survey, AIS examination.

Results: Mean age was 41.3?±?14.4 years with majority male (69%) and Caucasian (71.6%). Overall, Positive Predictive Value (PPV) ranged between 48% (VAC) to 73% (DAP) and Negative Predictive Value (NPV) between 92% (VAC) to 100% (LT). AIS-A had NPV of 100% across all categories, and AIS-D had PPV of 100% across all categories.

Conclusion: Patient report of sacral sparing can predict negative sensation in patients with AIS-A and predict positive sensation in persons with AIS-D. Overall, the self-report of sacral sparing of motor and sensory function is not predictive enough to rely on for accurate classification.     

Pneumocephalus with headache complicating labour epidural analgesia: should we still be using air?

Pneumocephalus is a rare complication of epidural block which typically occurs when the loss of resistance to air technique is used to identify the epidural space. We present a case of pneumocephalus with headache in a parturient following apparently uncomplicated labour epidural analgesia.