Shaul Cohen

Epidural patient-controlled analgesia after cesarean section: buprenorphine-0.015% bupivacaine with epinephrine versus fentanyl-0.015% bupivacaine with and without epinephrine.

We compared the analgesia, side effects, and plasma concentrations of buprenorphine and fentanyl in a double-blind study of 78 parturients receiving one of these drugs by patient-controlled epidural infusion after elective cesarean section with epidural anesthesia. Patients were randomized to three epidural infusion groups: group 1 (n = 26), 3 micrograms/mL buprenorphine with 0.015% bupivacaine and 1 microgram/mL epinephrine; group 2 (n = 26), 3 micrograms/mL fentanyl with 0.015% bupivacaine and 1 microgram/mL epinephrine; and group 3 (n = 26), 3 micrograms/mL fentanyl with 0.015% bupivacaine. Plasma for determination of opioid concentrations was obtained in some subjects in each group at intervals up to 48 h during the infusion and in some subjects from each group at intervals after the infusion was stopped. Pain relief was similar and satisfactory in all three groups. The median overall satisfaction scores were high for all three groups. Pruritus was more common in the fentanyl groups (P less than 0.05). However, vomiting was more disturbing to the patients and seen only with buprenorphine. No patient had a respiratory rate less than 12 breaths/min. Epinephrine use was associated with a slower infusion rate (P less than 0.05, group 2 vs 3). All patients were able to ambulate without difficulty. Mean opioid plasma concentrations did not exceed 1.5 ng/mL. Thus, epidural patient-controlled analgesia in all three groups provided excellent analgesia, permitted ambulation, and was without serious side effects. Epidural buprenorphine offered no advantages over epidural fentanyl.

Bupivacaine 0.01% and/or Epinephrine 0.5 [micro sign]g/ml Improve Epidural Fentanyl Analgesia after Cesarean Section

Background The authors studied the addition of bupivacaine and epinephrine, separately and together, to epidural fentayl to determine whether this improved postcesarean analgesia and reduced the incidence of side effects. Methods After elective cesarean section, 100 parturient patients who received fentanyl (3 [micro sign]g/ml) epidurally for 48 h were allocated randomly in a double‐blinded manner to four groups to receive, in addition to the study solution, 0.01% bupivacaine, 0.5 [micro sign]g/ml epinephrine, both, or neither. A neurologic assessment of breast‐fed neonates was made at 2 and 48 h of life. Plasma fentanyl concentrations were determined in a subset of patients at intervals after treatment. Results Patients receiving fentanyl alone made more attempts at patient‐controlled analgesia (P < 0.01), required a greater total dose of fentanyl (P < 0.01), reported more pain (P < 0.003) and less satisfaction (P < 0.003), and had more nausea and urinary retention (P < 0.05) than all other groups. Patients who received bupivacaine with or without epinephrine had better overall satisfaction scores than those who did not receive bupivacaine (P < 0.001), and they required less fentanyl (P < 0.02) than patients who received fentanyl with only epinephrine. Motor blockade or orthostatic hypotension did not develop in any patient, and all patients could ambulate without difficulty. Neurobehavioral scores, which were similar among all neonates, were within the normal range. Plasma concentrations of fentanyl increased after epinephrine‐containing solutions were discontinued. Conclusions During the conditions of this study, the addition of epinephrine and bupivacaine to a 3‐[micro sign]g/ml epidural fentanyl solution for postcesarean section pain relief provided superior analgesia compared with fentanyl alone or fentanyl with epinephrine. Whether increasing the concentration of fentanyl alone might improve the efficacy of fentanyl remains unclear.

Postcesarean delivery epidural patient-controlled analgesia. Fentanyl or sufentanil?

BackgroundThe highly lipid-soluble opioids, fentanyl and sufentanil, frequently are used in combination with local anesthetic agents and/or epinephrine to provide postoperative epidural analgesia. The authors compared the incidence of side effects and patient satisfaction during prolonged epidural patient-controlled analgesia (PCA) infusions of these opioids in combination with bupivacalne and eplnephrine. MethodsUsing a double-blind study design, 250 patients scheduled for elective cesarean delivery were, on arrival in the postanesthesia care unit, randomized into two epidural PCA infusion groups: group I (n = 125) received fentanyl 2 μg/ml with bupivacalne 0.01% and epinephrine 0.5 μg/ml and group II (n = 125) received sufentanil 0.8 μg/ml with bupi-vacaine 0.01% and epinephrine 0.5 μg/ml. The Initial Infusionrate was 16 ml/h with self-administered 3-ml boluses every 15 min by PCA as desired. At Intervals after discontinuation of the infusion, plasma samples were obtained to determine opioid concentrations. ResultsThe median overall satisfaction scores were 9.0 for group I and 10.0 for group II (difference not significant). Pain relief was satisfactory and comparable in both groups, and all patients could ambulate easily. The total number of times PCA requests were made was greater (P < 0.05, by Wilcoxon rank-sum test) for group I than for group II (106.7 ± 312 vs. 70.8 ± 138). There were no differences between the groups with respect to incidence of pruritus, sedation, and nausea; however, vomiting occurred more frequently with sufentanil than with fentanyl (12% vs. 4.8%, respectively; P < 0.05). At approximately 1–2 h after discontinuation of the infusion, 1 patient receiving fentanyl and 42 patients receiving sufentanil complained of lightheadedness and dizziness (P < 0.0001). ConclusionsEpidural PCA in both groups had no serious side effects and achieved a high level of patient satisfaction. Those receiving sufentanil made fewer PCA requests but had a significantly greater incidence of vomiting during the infusion and dizziness after the termination of the infusion. Epidural sufentanil offered no advantages over epidural fentanyl.

Epidural Analgesia for Labour and Delivery: Fentanyl or Sufentanil

PurposeThe highly lipid soluble opioids, fentanyl and sufentanil, are used in combination with local anaesthetics with/ without epinephrine to provide epidural analgesia during labour and delivery. Our aim was to determine whether either opioid was superior when used with low dose local anaesthetic.MethodsIn a double-blind study patients were randomized to two epidural infusion groups: Group I (n = 50) fentanyl 2 μg · ml−1 with bupivacaine 0.015% and epinephrine 2 μg · ml−1, Group II (n = 50) sufentanil 1 μg · ml−1 with bupivacaine 0.015% and epinephrine 2 μg · ml−1. Following a 20 ml bolus of the study solution an infusion was started at 10 ml · h−1. To achieve analgesia patients could receive two boluses of 5 ml of the study solution and if analgesia was still inadequate, a further 5 ml bupivacaine 0.25% was used. Pain and overall satisfaction were assessed with a 10-point visual scale. Plasma samples obtained from the mother at the time the infusion was discontinued and from the umbilical cord vein at delivery were assayed to determine opioid concentration.ResultsPain scores were greater for Group I than for Group II patients throughout the first and second stages of labour (P = 0.002). More patients in Group I (42%) requested a dose of bupivacaine 0.25% than in Group II (6%) (P < 0.0001) and the total dose of bupivacaine given to Group I patients was greater than that of Group II, 26.0 ± 22.0 mg vs. 13.4 ± 12.6 mg, P = 0.005. There were no differences with respect to first or second stage duration, incidence of side effects, infusion duration, outcome of labour or neonatal Apgar scores. There was no opioid accumulation in either maternal or foetal blood.ConclusionEpidural opioid infusion with very low dose bupivacaine (0.015%) achieved an overall high level of patient satisfaction in both groups without serious maternal or neonatal side effects. At the fentanyl-to-sufentanil ratio used here patients receiving sufentanil had lower pain scores and substantially fewer patients required bupivacaine rescue.RésuméObjectifLes morphiniques hautement liposolubles comme le fentanyl et le sufentanil sont utilisés avec les anesthésiques locaux pour procurer l’analgésie épidurale pendant le travail et l’accouchement avec ou sans épinéphrine. Cette étude visait à déterminer lequel des deux morphiniques était supérieur lorsqu’on l’associait à un anesthésiques local à faible dose.MéthodesL’étude randomisée et en double aveugle incluait deux groupes: le groupe I (n = 50) avait reçu du fentanyl 2 μg · ml−1 et de la bupivacaïne 0,015% avec épinéphrine 2 μg · ml−1 alors que le groupe II (n = 50) avait reçu sufentanil 1 μg · ml−1 et bupivacaïne 0,015 avec épinéphrine 2 μg · ml−1. Après un bolus de 20 ml de la solution à l’étude, une perfusion était débutée au rythme de 10 ml · h−1. Pour compléter l’analgésie, les patientes pouvaient recevoir deux bolus de 5 ml de la solution à l’étude. Si l’analgésie était toujours insuffisante, une dose additionnelle de 5 ml de bupivacaïne 0,25% était administrée. La douleur et le degré de satisfaction étaient évalués sur une échelle visuelle de dix points. Des échantillons de plasma maternal à l’arrêt de la perfusion et du cordon ombilical à l’accouchement ont été analysés pour déterminer la concentration du morphinique.RésultatsQuant à la douleur, les scores ont été plus élevés dans le groupe I que dans le groupe II pendant le premier et le deuxième stage du travail (P = 0,002). Plus de patients du groupe I (42%) ont eu besoin de bupivacaïne 0,25% que dans le groupe II (6%) (P < 0,001) et la dose totale de bupivacaïne administrée aux patientes du groupe I a été plus élevée que dans le groupe II, 26,0 ± 22,0 mg vs 13,3 ± 12,6 mg, P = 0,005. En ce qui concerne la durée du premier et du deuxième stage du travail, la différence était nulle, ainsi que l’incidence des effets secondaires, la durée de la perfusion, l’évolution du travail ou les scores sur l’échelle d’Apgar. On n’a pas noté d’accumulation de morphinique dans le sang maternel ni dans le sang foetal.ConclusionAvec une perfusion de morphinique associée à de très faibles doses de bupivacaïne (0,015%), en général, le degré élevé de satisfaction a été élevé dans les deux groupes, sans effets secondaires maternels et foetaux importants. Si on compare le fentanyl au sufentanil, les patientes qui recevaient du sufentanil ont rapportés pour la douleur des scores inférieurs et beaucoup moins de patientes ont eu besoin de bupivacaïne en supplément.

Adverse effects of epidural 0.03% bupivacaine during analgesia after Cesarean section

To develop a regimen that would provide good analgesia after cesarean section with minimal side effects in the setting of prolonged (> 24 h) epidural infusion, buprenorphine or fentanyl was combined with 0.03% bupivacaine in a double-blind study of 23 parturients. Patients were randomly assigned to two groups: group I (n = 12), patient-controlled analgesia by epidural infusion of buprenorphine (3 micrograms/mL) with 0.03% bupivacaine; group II (n = 11), patient-controlled analgesia by epidural infusion of fentanyl (2 micrograms/mL) with 0.03% bupivacaine. Plasma for determination of opioid concentrations was obtained at intermittent intervals. Pain relief was similar and satisfactory in both groups. The median overall satisfaction score was higher (10.0 vs 7.5; P < 0.03) for group II. Pruritus was mild in most patients. Nausea and vomiting, which were most disturbing to the patients, were seen only with buprenorphine. No patient had a respiratory rate of < 12 breaths/min. Mean plasma opioid concentrations did not exceed 1 ng/mL during the study. However, four patients (33%) in group I and six patients (55%) in group II experienced sensory loss in the lower extremities, which made ambulation difficult. One patient in each group developed extensive pressure blisters on both heels. These complications led us to terminate the study. We conclude that 0.03% bupivacaine used in combination with an opioid in prolonged epidural infusions produces a high incidence of sensory loss in the lower extremities and is unsuitable for situations in which early ambulation is desired.

Epidural Analgesia for Labor and Delivery: Fentanyl or Sufentanil?

PURPOSE The highly lipid soluble opioids, fentanyl and sufentanil, are used in combination with local anaesthetics with/without epinephrine to provide epidural analgesia during labour and delivery. Our aim was to determine whether wither opioid was superior when used with low dose local anaesthetic. METHODS In a double-blind study patients were randomized to two epidural infusion groups: Group I (n = 50) fentanyl 2 micrograms.ml-1 with bupivacaine 0.015% and epinephrine 2 micrograms.ml-1, Group II(n = 50) sufentanil 1 microgram.ml-1 with bupivacaine 0.015% and epinephrine 2 micrograms.ml-1. Following a 20 ml bolus of the study solution an infusion was started at 10 ml.h-1. To achieve analgesia patients could receive two boluses of 5 ml of the study solution and if analgesia was still inadequate, a further 5 ml bupivacaine 0.25% was used. Pain and overall satisfaction were assessed with a 10-point visual scale. Plasma samples obtained from the mother at the time the infusion was discontinued and from the umbilical cord vein at delivery were assayed to determine opioid concentration. RESULTS Pain scores were greater for Group I than for Group II patients throughout the first and second stages of labour (P = 0.002). More patients in Group I (42%) requested a dose of bupivacaine 0.25% than in Group II (6%) (P < 0.001) and the total dose of bupivacaine given to Group I patients was greater than that of Group II, 26.0 +/- 22.0 mg vs. 13.4 +/- 12.6 mg, P = 0.005. There were no differences with respect to first or second stage duration, incidence of side effects, infusion duration, outcome of labour or neonatal Apgar scores. There was no opioid accumulation in either maternal or foetal blood. CONCLUSION Epidural opioid infusion with very low dose bupivacaine (0.015%) achieved an overall high level of patient satisfaction in both groups without serious maternal or neonatal side effects. At the fentanyl-to-sufentanil ratio used here patients receiving sufentanil had lower pain scores and substantially fewer patients required bupivacaine rescue.

Epidural Analgesia for Labor and Delivery in a Patient with Von Willebrandʼs Disease

Patients with histories of bleeding disorders may still benefit from regional anesthetic techniques. The decision to perform the block should be individualized, based on coagulation tests. The authors describe a patient with von Willebrands disease in whom pregnancy itself improved factor VIII activity, enabling performance of an epidural block for labor and delivery.