Tanya Lucas

Epidural clonidine added to a bupivacaine infusion increases analgesic duration in labor without adverse maternal or fetal effects

PurposeMany obstetric patients receiving epidural analgesia are encouraged to ambulate. This current study was designed to determine the potential for maximizing the time to first epidural supplement when adding clonidine to a 0.625 mg·ml−1 bupivacaine continuous epidural infusion following epidural fentanyl bolus in early labor for patients allowed to ambulate. Maternal and fetal effects secondary to clonidine were also evaluated.MethodsSixty-eight laboring primigravid women received a 3-ml epidural test dose of lidocaine with epinephrine, followed by a fentanyl 100-µg bolus (in a 10 ml-volume). The patients then received a 0.625 mg·ml−1 bupivacaine continuous epidural infusion, either with or without clonidine (5 µg·ml−1), at a rate of 10 ml·h−1. Pain scores and side effects were recorded for each patient.ResultsThe overall quality of analgesia was similar in both groups. The mean duration prior to request for additional analgesia was significantly longer in the clonidine group (269 ± 160 min), compared to the control group (164 ± 64 min). No patient in either group experienced any detectable motor block; one patient (clonidine group) complained of mild thigh numbness and was not allowed to ambulate. While mean blood pressure was approximately 6 mmHg lower in the clonidine group at 1, 1.5, and 3.5 h, this was not clinically significant. No adverse effects on maternal heart rate or fetal heart rate were noted.ConclusionIn early laboring patients, addition of clonidine prolongs the analgesia duration of a 0.625 mg·ml−1 bupivacaine continuous epidural infusion following 100 µg epidural fentanyl (after a lidocaine-epinephrine test dose) without a clinically significant increase in side effects.

The Influence of a Bupivacaine and Fentanyl Epidural Infusion After Epidural Fentanyl in Patients Allowed to Ambulate in Early Labor

Epidural fentanyl after a lidocaine and epinephrine test dose provides adequate analgesia and allows for ambulation during early labor. This study was designed to determine the influence of an epidural infusion of bupivacaine plus fentanyl administered after initiation of epidural labor analgesia with fentanyl. Specifically, we evaluated whether there is an increase in motor block or an increased time to request for further analgesic medication. Fifty-one laboring primigravid women at <5 cm cervical dilation who requested epidural analgesia were enrolled. After a 3-mL epidural test dose of 1.5% lidocaine with epinephrine (5 &mgr;g/mL), patients received fentanyl 100 &mgr;g via the epidural catheter. They then randomly received either an infusion (10 mL/h) of 0.0625% bupivacaine with fentanyl (3 &mgr;g/mL) or an infusion of preservative-free saline. After the administration of the initial analgesic, pain scores and side effects were recorded for each patient at 10, 20, and 30 min, every 30 min thereafter, and at the time of request for additional analgesic medication, by an observer blinded to the technique used. There were no demographic differences between the two groups. The mean duration of analgesia (time from initial dose to request for additional analgesia) was increased in the group that received a continuous infusion of bupivacaine and fentanyl compared with the Saline group (198 ± 86 vs 145 ± 50 min;P < 0.009). Side effects were similar between the two groups. No patient in either group experienced any detectable motor block. Fourteen patients chose to ambulate in the Saline group, and 12 patients chose to ambulate in the Infusion group. In early laboring patients, a continuous infusion of 0.0625% bupivacaine infusion with fentanyl (3 &mgr;g/mL) prolonged the duration until top-up was required, after epidural fentanyl 100 &mgr;g after a lidocaine and epinephrine test dose, and did not cause any clinically detectable motor block.

The addition of hydromorphone to epidural fentanyl does not affect analgesia in early labour.

PurposeEpidural fentanyl after a lidocaine and epinephrine test dose, provides adequate analgesia and allows for ambulation during early labour. The current study was designed to determine the influence of hydromorphone added to an epidural fentanyl bolus (e.g., whether there is an increase in duration of analgesia).MethodsForty-four labouring primigravid women, at less than 5 cm cervical dilation, who requested epidural analgesia were enrolled in this randomized, double-blind study. After a 3 mL test dose of lidocaine with epinephrine, patients received fentanyl 100 μg (in 10 mL volume). They randomly received the fentanyl with either saline or hydromorphone (300 μg).After administration of the initial analgesic, pain scores and side effects were recorded for each patient at ten, 20, and 30 min, and every 30 min thereafter, by an observer blinded to the technique used.ResultsThe patients were taller in the hydromorphone group (P < 0.04). There were no other demographic differences between the two groups. The mean duration prior to re-dose was not significantly different in the group that received hydromorphone ( 135 ± 52 min) compared to the control group (145 ± 46 min). Side effects were similar between the two groups. No patient in either group experienced any detectable motor block.ConclusionIn early labouring patients, the addition of hydromorphone (300 μg) to epidural fentanyl (100 μg after a lidocaine and epinephrine test dose) neither prolongs the duration of analgesia nor affects the ability to ambulate, and cannot be recommended according to the current study.RésuméObjectifLadministration épidurale de fentanyl suivant une dose test de lidocaine et d’épinéphrine fournit une analgésie adéquate et permet de marcher au début du travail obstétrical. La présente étude cherchait à déterminer l’influence d’un ajout d’hydromorphone au bolus de fentanyl épidural. Entre autres, l’analgésie est-elle prolongée?MéthodeQuarante-quatre primigestes en travail chez qui la dilatation du col était de moins de 5 cm et qui avaient demandé une analgésie épidurale ont été recrutées pour l’étude randomisée et à double insu. Après avoir reçu une dose test de 3 mL de lidocaine avec de l’épinéphrine, les patientes ont eu 100 μg de fentanyl (dans un volume 10 mL). Elles ont reçu de façon aléatoire le fentanyl et, soit une solution salée, soit de l’hydromorphone (300 μg). Après l’administration de l’analgésique initial, les scores de douleur et les effets secondaires ont été enregistrés pour chaque patiente à dix, 20 et 30 min et à toutes les 30 min par la suite par un observateur objectif.RésultatsLa seule caractéristique personnelle différente entre les patientes des deux groupes était que les patientes ayant reçu l’hydromorphone étaient plus grandes (P < 0,04). Que ce soit avec l’hydromorphone (135 ± 52 min) ou la substance témoin (145 ± 46 min), le temps moyen précédant une seconde dose était comparable. Les effets secondaires ont été similaires dans les deux groupes. Aucune patiente n’a expérimenté de blocage moteur détectable.ConclusionAu début du travail, l’ajout d’hydromorphone (300 μg) à l’administration péridurale de fentanyl (100 μg après une dose test de lidocaine et d’épinéphrine) ne prolonge pas l’analgésie et n’affecte pas la capacité de marcher. Il ne peut être recommandé selon la présente étude.

Addition of epinephrine to epidural bupivacaine infusions following initiation of labor analgesia with epidural fentanyl

STUDY OBJECTIVE To evaluate the analgesic effects of the addition of epinephrine to a bupivacaine epidural infusion in early labor after a fentanyl bolus, following a lidocaine-epinephrine test dose. DESIGN Randomized, double-blinded study. SETTING Labor suite of a tertiary care hospital. PATIENTS 60 ASA physical status 1 and 2, laboring, nulliparous women. INTERVENTIONS All laboring women received a 3 mL epidural test dose of 1.5% lidocaine with 1:200,000 epinephrine, followed by a fentanyl 100 μg bolus in 10 mL of diluent volume. Patients were randomized to receive one of two continuous epidural infusions: bupivacaine 0.625 mg/mL at 10 mL/hr (control group) or bupivacaine 0.625 mg/mL with epinephrine 5 μg/mL at 10 mL/hr (epinephrine group). MEASUREMENTS Time to re-dose, pain scores, and side effects were recorded. MAIN RESULTS The mean duration of satisfactory analgesia prior to re-dose was 159 ± 62 min for the control group and 221 ± 111 min for the epinephrine group (P < 0.02). Pain scores were significantly higher in the control group than the epinephrine group at two time periods: 2.5 hours and 4.5 hours (P < 0.04). CONCLUSIONS The administration of 0.625 mg/mL bupivacaine with epinephrine 5 μg/mL at 10 mL/hr, compared with plain 0.625 mg/mL bupivacaine at 10 mL/hr, provided a longer time to re-dose, decreased pain scores at two time intervals, and had no significant difference in duration of labor or side effects.