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Sequential spinal epidural analgesia for pain relief in labour
International Journal of Obstetric Anesthesia (1995) 4, 155-157 © 1995 Pearson Professional Ltd
L
I~ International ~l I JObstetric °urnal°f ! Anesthesia
Sequential spinal epidural analgesia for pain relief in labour An audit of 620 parturients
S. Joos, R. Servais, A. van Steenberge Department of Anaesthetics, Clinique Champeau, 34500 Beziers - France S U M M A R Y. This investigation was designed to evaluate sequential spinal epidural analgesia with a needle through needle technique for pain relief in labour. The spinal injection was made using a Becton Dickinson 29 gauge Quincke point needle. Bupivaca'ine 1 mg, sufentanil 5 lag and adrenaline 25 lag (2 ml) were injected intrathecally. Analgesia was maintained using bupivaca'/ne 12.5 rag, sufentanil 10 lag and adrenaline 12.5 lag in a 10 nd bolus given through an epidural catheter in the epidural space. This dosage was also used for the test dose. Pain relief was obtained in less than ten minutes and lasted for a mean of 134 min. Of the 620 parturients in the investigation, 500 had a mean dose of 4.3 mg bupivacaine per hour. Hypotension and paresis were of no concern. Patient satisfaction was excellent, 85% of the parturients being very satisfied and 10% satisfied.
Although epidural analgesia is an efficient method of pain relief during labour and delivery, it has its shortcomings. Motor block, although limited, interferes with the tonus of the pelvic floor muscles impeding rotation and flexion of the fetal head. This together with the inability of the mother to bear down increases the risk of instrument delivery. 1 Local anaesthetics when given epidurally or in the spinal fluid also induce loss of sympathetic tone. The ensuing vascular response causes hypotension. Opioids given intrathecally are devoid of motor block and the small doses have no apparent untoward effects on fetus or neonate. They provide adequate pain relief during the early stage of labour but additional local anaesthetics are normally required before delivery. 2-4 The combined spinal epidural technique allows the anaesthetist to give a low dose of intrathecal opioid with local anaesthetic, which gives the mother almost immediate pain relief, followed by top-up injections into the epidural space when necessary in the later stages of labour, s
pain relief during labour. All parturients were in at least their 37th week of pregnancy. Only 5 women belonged to ASA 3. (Preeclampsia 3, diabetes 1 and prolapse of the mitral valve 1). There were 422 primiparae. The protocol was approved by the ethics committee. When painful contractions occurred with the cervix 3 to 4cm dilated, analgesia was started using bupivaca'ine 1 mg, sufentanil 5 gg and adrenaline 25 Ixg in 2 ml injected intraspinally with a Quincke 29 gauge spinal needle introduced via an epidural needle. Further pain relief when needed, was provided via the epidural catheter with top-up injections of bupivacaine 12.5 mg, sufentanil 10 Ixg and adrenaline 12.5 gg in 10 ml of saline. Complete pain relief was the objective. Spinal analgesia was deemed successful when it gave the mother pain relief within 10 min and she did not request a top-up injection before 30 min. The quality of analgesia was assessed by the patient, using a verbal rating scale (excellent, good, insufficient) during the first and second stages of labour and noted by the anaesthetist. The duration of spinal analgesia was defined as the time from intrathecal drug administration until the demand for additional analgesia. The cumulative drug dosage, the number of top-up injections and the time of initial drug administration to delivery were recorded. Motor block was assessed according to the method described by Bromage. 6 The occurrence of maternal
M E T H O D S AND MATERIALS In this study, we reviewed 620 consecutive parturients who received sequential spinal epidural analgesia for Correspondence to: St6phane Joos, 7, rue Jean Aicard, 34500 Beziers - France. 155
156 InternationalJournal of Obstetric Anesthesia pruritus, drowsiness, nausea and emesis was noted. Hypotension was defined as a systolic blood pressure below 100 mmHg. The presence and severity of post dural puncture headache were analysed. Neonates were evaluated by Apgar scores. Women were interviewed postnataUy on day 2 or 3 and their satisfaction scores assessed using a verbal rating scale (very satisfied, satisfied, disappointed).
~S~TS Pain relief after spinal injection was excellent in 92% a n d good in 2%. In the remaining 37 parturients (6%) spinal analgesia was unsuccessful. In five of these there was no reflux of cerebrospinal fluid and the subsequent spinal block failed. In these cases, epidural analgesia was used alone. In the other 32 parturients pain relief from the spinal injection was incomplete and an epidural top-up injection was needed within 30 min (Table 1). These 37 parturients have been excluded from further analysis. Spinal analgesia was achieved within 5 min in 86% and within 10 min for all. Fifty-four parturients (9.4%) delivered within the first 90 min and only required the intrathecal injection. The mean duration of pain relief in the remainder was 134 min (range 30 to 260 min). 164 (28%) had one epidural top-up injection, 282 (48%) requested two and the remainder required 3-5. The mean time to delivery was 235 min (range 30 to 630 rain) and the mean dose of bupivaca'ine was 4.6 mg per hour. Among only the 54 mothers who delivered without epidural top-up injections, the mean dose of bupivaca'fne was 0.7 mg per hour (Table 2). The quality of pain relief for delivery was noted as excellent in 32% and good in 66% of all parturients Table 1. Characteristics of spinal analgesia
Number Failed subarachnoidblock Inadequate spinal analgesia Successfuloutcome Onset time: 5 min. Duration of spinal analgesia,rain. Deliveryunder spinal analgesia alone
5 (0.8%) 32 (5.1%) 583 (94%) 502 (86%) 134 (30 to 260) 54 (9.2%)
Table 2. Characteristics of the sequential spinal epidural technique in 583 labouring women
Number of top ups
n %0 (total= 583)
Meantime to Bupivaca'ine delivery,min. mg/h
0
54 164 282 58 19 6
87 197 294 384 510 605
1
2 3 4 5
9.3 28.1 48.4 9.9 3.2 1.1
0.7 4.1 5.3 6.0 6.0 6.3
with sequential spinal epidural analgesia. Postnatally 85% of parturients were very satisfied and 10% satisfied with this method. Sixty-four women (10.4%) underwent a caesarean section of which 48 (75%) were for fetopelvic problems and 16 (25%) for fetal distress. In 293 women instrumental delivery was used, 195 (31.4%) had vacuum extraction and 98 (15.8%) a forceps delivery. Motor block was never a problem. After the initial intrathecal dose all patients were able to move both legs freely. Twenty-five mothers had a Bromage score of 1 after one or more epidural top-up injections. Through the lack of telemetric monitoring equipment and according to normal hospital practice, parturients having spinal analgesia were not allowed to ambulate. Mild pruritus occurred in 283 mothers (48.5%), none of whom required any treatment. Seventy parturients (12%) experienced drowsiness and 47 (8%) vomiting or nausea. After intrathecal drug administration, hypotension with a systolic pressure 100 mmHg occurred in 24 patients (4.1%). Normotension was easily restored either by positioning of the mother or, in two cases, by intravenous ephedrine 5 mg. Five women suffered from post-dural puncture headache. Only one needed a blood patch. In this mother we suspected that the Tuohy needle breached the dura. At birth all babies were examined by a neonatologist. Four had Apgar scores of 6 or less at 5 rain. Their low scores were believed to be related to obstetric problems.
DISCUSSION Using the epidural technique, the dose of local anaesthetic may be reduced by blending with opioids with or without adrenaline or other ~2 antagonist, but the possible dose reduction is limited. The use of fine gauge spinal catheters (27 gauge or smaller) can permit titration with very low doses of drugs with only a small risk of post dural puncture headache. However, the technical difficulties during introduction and retrieval of the catheter, together with the possibility of cauda equina syndrome, compelled the U.S. food and drug administration to forbid the use of fine catheters. 7 The sequential spinal epidural technique is relatively easy to do, the rate of post dural puncture headache is low (0.8%) and the dose requirement is very greatly reduced. Hence this technique may be considered currently to be the best solution. Intraspinally sufentanil (10 gg) has been investigated as sole agent to provide sensory analgesia. The results have shown that analgesia is adequate only in the initial stages. 4 The co-administration of small doses of local anaesthetics may improve the outcome, as
Sequential spinal epidural analgesia for pain relief in labour: An audit of 620 parturients 157 f o u n d in e p i d u r a l analgesia. 8 W e felt t h a t 1 m g bupivaca~ne c o u l d have a synergetic effect w i t h o u t risk o f m o t o r b l o c k . T h e a d d i t i o n o f e p i n e p h r i n e to spinal o p i o i d s has also b e e n s h o w n to i m p r o v e the analgesic profile. 9 To p r o d u c e m i n i m a l side effects a n d b e c a u s e the c o m b i n a t i o n i n c l u d e d b o t h b u p i v a ca'fne a n d epinephrine, we l o w e r e d the d o s a g e o f i n t r a t h e c a l sufentanil to 5 gg. T h e m e a n d o s a g e o f bupivaca'fne, 4.3 m g / h , is low c o m p a r e d w i t h o t h e r studies 1-5'8-1° b u t the success rate a p p e a r s high. S e q u e n t i a l spinal e p i d u r a l a n a l g e s i a for p a i n relief d u r i n g v a g i n a l delivery is a new t e c h n i q u e designed to s h o r t e n the onset time, a n d to reduce the t o t a l a m o u n t o f d r u g a n d the degree o f m o t o r block. D i r e c t c o m p a r i s i o n s w i t h m o d e r n e p i d u r a l techniques are needed.
References 1. Chestnut D H. Epidural anesthesia and instrumental vaginal delivery. Anesthesiology 1991; 74: 805-808. 2. Abouleish E, Rawal N, Shaw J, Lorenz T, Rashad N. Intrathecal morphine 0.2 mg versus epidural bupivacaine 0.125% or their combination: effects on parturients. Anesthesiology 1991; 74: 711-716.
3. Cadwell L E, Rosen M A, Schnider S M. Subarachnoid morphine and fentanyl for labor analgesia. Efficacy and adverse effects. Regional Anesthesia 1994; 19(1): 2-8. 4. Camann W R, Minzter B H, Denney R A, Datta S. Intrathecal sufentanil for labor analgesia. Effects of added epinephrine. Anesthesiology 1993; 78: 870-874. 5. Colfis R E, Baxandall M L, Srikantharajah I D, Edge G, Kadim M Y, Morgan B M. Combined spinal epidural (CSE) analagesia: technique, management, and outcome of 300 mothers. International Journal of Obstetric Anesthesia 1994; 3: 75-81. 6. Bromage P R. A comparison of the hydrochloride and carbon dioxide salts of lidocaine and prilocaine in epidural analgesia. Acta Anaesthesiol Scand 1965; 16: $55-$69. 7. FDA safety alert: Cauda equina syndrome associated with the use of small-bore catheters in continuous spinal anesthesia. 29 May 1992. 8. Steinberg R B, Duma S M, Dixon D E, Rehm K, Pastides H, Hu X. Comparison of sufentanil, bupivacaine, and their combination for epidural analgesia in obstetrics. Regional Anesthesia 1992; 17: 131-138. 9. Batra M S. Adjuvants in epidural and spinal anesthesia. Anesthesiology Clinics of North America 1992; 10: 13-29. 10. Lysak S Z, Eisenach J C, Dobson C E. Patientcontrolled epidural analgesia during labor: a comparison of three solutions with a continuous infusion control. Anesthesiology 1990; 72: 44-49.
L
I~ International ~l I JObstetric °urnal°f ! Anesthesia
Sequential spinal epidural analgesia for pain relief in labour An audit of 620 parturients
S. Joos, R. Servais, A. van Steenberge Department of Anaesthetics, Clinique Champeau, 34500 Beziers - France S U M M A R Y. This investigation was designed to evaluate sequential spinal epidural analgesia with a needle through needle technique for pain relief in labour. The spinal injection was made using a Becton Dickinson 29 gauge Quincke point needle. Bupivaca'ine 1 mg, sufentanil 5 lag and adrenaline 25 lag (2 ml) were injected intrathecally. Analgesia was maintained using bupivaca'/ne 12.5 rag, sufentanil 10 lag and adrenaline 12.5 lag in a 10 nd bolus given through an epidural catheter in the epidural space. This dosage was also used for the test dose. Pain relief was obtained in less than ten minutes and lasted for a mean of 134 min. Of the 620 parturients in the investigation, 500 had a mean dose of 4.3 mg bupivacaine per hour. Hypotension and paresis were of no concern. Patient satisfaction was excellent, 85% of the parturients being very satisfied and 10% satisfied.
Although epidural analgesia is an efficient method of pain relief during labour and delivery, it has its shortcomings. Motor block, although limited, interferes with the tonus of the pelvic floor muscles impeding rotation and flexion of the fetal head. This together with the inability of the mother to bear down increases the risk of instrument delivery. 1 Local anaesthetics when given epidurally or in the spinal fluid also induce loss of sympathetic tone. The ensuing vascular response causes hypotension. Opioids given intrathecally are devoid of motor block and the small doses have no apparent untoward effects on fetus or neonate. They provide adequate pain relief during the early stage of labour but additional local anaesthetics are normally required before delivery. 2-4 The combined spinal epidural technique allows the anaesthetist to give a low dose of intrathecal opioid with local anaesthetic, which gives the mother almost immediate pain relief, followed by top-up injections into the epidural space when necessary in the later stages of labour, s
pain relief during labour. All parturients were in at least their 37th week of pregnancy. Only 5 women belonged to ASA 3. (Preeclampsia 3, diabetes 1 and prolapse of the mitral valve 1). There were 422 primiparae. The protocol was approved by the ethics committee. When painful contractions occurred with the cervix 3 to 4cm dilated, analgesia was started using bupivaca'ine 1 mg, sufentanil 5 gg and adrenaline 25 Ixg in 2 ml injected intraspinally with a Quincke 29 gauge spinal needle introduced via an epidural needle. Further pain relief when needed, was provided via the epidural catheter with top-up injections of bupivacaine 12.5 mg, sufentanil 10 Ixg and adrenaline 12.5 gg in 10 ml of saline. Complete pain relief was the objective. Spinal analgesia was deemed successful when it gave the mother pain relief within 10 min and she did not request a top-up injection before 30 min. The quality of analgesia was assessed by the patient, using a verbal rating scale (excellent, good, insufficient) during the first and second stages of labour and noted by the anaesthetist. The duration of spinal analgesia was defined as the time from intrathecal drug administration until the demand for additional analgesia. The cumulative drug dosage, the number of top-up injections and the time of initial drug administration to delivery were recorded. Motor block was assessed according to the method described by Bromage. 6 The occurrence of maternal
M E T H O D S AND MATERIALS In this study, we reviewed 620 consecutive parturients who received sequential spinal epidural analgesia for Correspondence to: St6phane Joos, 7, rue Jean Aicard, 34500 Beziers - France. 155
156 InternationalJournal of Obstetric Anesthesia pruritus, drowsiness, nausea and emesis was noted. Hypotension was defined as a systolic blood pressure below 100 mmHg. The presence and severity of post dural puncture headache were analysed. Neonates were evaluated by Apgar scores. Women were interviewed postnataUy on day 2 or 3 and their satisfaction scores assessed using a verbal rating scale (very satisfied, satisfied, disappointed).
~S~TS Pain relief after spinal injection was excellent in 92% a n d good in 2%. In the remaining 37 parturients (6%) spinal analgesia was unsuccessful. In five of these there was no reflux of cerebrospinal fluid and the subsequent spinal block failed. In these cases, epidural analgesia was used alone. In the other 32 parturients pain relief from the spinal injection was incomplete and an epidural top-up injection was needed within 30 min (Table 1). These 37 parturients have been excluded from further analysis. Spinal analgesia was achieved within 5 min in 86% and within 10 min for all. Fifty-four parturients (9.4%) delivered within the first 90 min and only required the intrathecal injection. The mean duration of pain relief in the remainder was 134 min (range 30 to 260 min). 164 (28%) had one epidural top-up injection, 282 (48%) requested two and the remainder required 3-5. The mean time to delivery was 235 min (range 30 to 630 rain) and the mean dose of bupivaca'ine was 4.6 mg per hour. Among only the 54 mothers who delivered without epidural top-up injections, the mean dose of bupivaca'fne was 0.7 mg per hour (Table 2). The quality of pain relief for delivery was noted as excellent in 32% and good in 66% of all parturients Table 1. Characteristics of spinal analgesia
Number Failed subarachnoidblock Inadequate spinal analgesia Successfuloutcome Onset time: 5 min. Duration of spinal analgesia,rain. Deliveryunder spinal analgesia alone
5 (0.8%) 32 (5.1%) 583 (94%) 502 (86%) 134 (30 to 260) 54 (9.2%)
Table 2. Characteristics of the sequential spinal epidural technique in 583 labouring women
Number of top ups
n %0 (total= 583)
Meantime to Bupivaca'ine delivery,min. mg/h
0
54 164 282 58 19 6
87 197 294 384 510 605
1
2 3 4 5
9.3 28.1 48.4 9.9 3.2 1.1
0.7 4.1 5.3 6.0 6.0 6.3
with sequential spinal epidural analgesia. Postnatally 85% of parturients were very satisfied and 10% satisfied with this method. Sixty-four women (10.4%) underwent a caesarean section of which 48 (75%) were for fetopelvic problems and 16 (25%) for fetal distress. In 293 women instrumental delivery was used, 195 (31.4%) had vacuum extraction and 98 (15.8%) a forceps delivery. Motor block was never a problem. After the initial intrathecal dose all patients were able to move both legs freely. Twenty-five mothers had a Bromage score of 1 after one or more epidural top-up injections. Through the lack of telemetric monitoring equipment and according to normal hospital practice, parturients having spinal analgesia were not allowed to ambulate. Mild pruritus occurred in 283 mothers (48.5%), none of whom required any treatment. Seventy parturients (12%) experienced drowsiness and 47 (8%) vomiting or nausea. After intrathecal drug administration, hypotension with a systolic pressure 100 mmHg occurred in 24 patients (4.1%). Normotension was easily restored either by positioning of the mother or, in two cases, by intravenous ephedrine 5 mg. Five women suffered from post-dural puncture headache. Only one needed a blood patch. In this mother we suspected that the Tuohy needle breached the dura. At birth all babies were examined by a neonatologist. Four had Apgar scores of 6 or less at 5 rain. Their low scores were believed to be related to obstetric problems.
DISCUSSION Using the epidural technique, the dose of local anaesthetic may be reduced by blending with opioids with or without adrenaline or other ~2 antagonist, but the possible dose reduction is limited. The use of fine gauge spinal catheters (27 gauge or smaller) can permit titration with very low doses of drugs with only a small risk of post dural puncture headache. However, the technical difficulties during introduction and retrieval of the catheter, together with the possibility of cauda equina syndrome, compelled the U.S. food and drug administration to forbid the use of fine catheters. 7 The sequential spinal epidural technique is relatively easy to do, the rate of post dural puncture headache is low (0.8%) and the dose requirement is very greatly reduced. Hence this technique may be considered currently to be the best solution. Intraspinally sufentanil (10 gg) has been investigated as sole agent to provide sensory analgesia. The results have shown that analgesia is adequate only in the initial stages. 4 The co-administration of small doses of local anaesthetics may improve the outcome, as
Sequential spinal epidural analgesia for pain relief in labour: An audit of 620 parturients 157 f o u n d in e p i d u r a l analgesia. 8 W e felt t h a t 1 m g bupivaca~ne c o u l d have a synergetic effect w i t h o u t risk o f m o t o r b l o c k . T h e a d d i t i o n o f e p i n e p h r i n e to spinal o p i o i d s has also b e e n s h o w n to i m p r o v e the analgesic profile. 9 To p r o d u c e m i n i m a l side effects a n d b e c a u s e the c o m b i n a t i o n i n c l u d e d b o t h b u p i v a ca'fne a n d epinephrine, we l o w e r e d the d o s a g e o f i n t r a t h e c a l sufentanil to 5 gg. T h e m e a n d o s a g e o f bupivaca'fne, 4.3 m g / h , is low c o m p a r e d w i t h o t h e r studies 1-5'8-1° b u t the success rate a p p e a r s high. S e q u e n t i a l spinal e p i d u r a l a n a l g e s i a for p a i n relief d u r i n g v a g i n a l delivery is a new t e c h n i q u e designed to s h o r t e n the onset time, a n d to reduce the t o t a l a m o u n t o f d r u g a n d the degree o f m o t o r block. D i r e c t c o m p a r i s i o n s w i t h m o d e r n e p i d u r a l techniques are needed.
References 1. Chestnut D H. Epidural anesthesia and instrumental vaginal delivery. Anesthesiology 1991; 74: 805-808. 2. Abouleish E, Rawal N, Shaw J, Lorenz T, Rashad N. Intrathecal morphine 0.2 mg versus epidural bupivacaine 0.125% or their combination: effects on parturients. Anesthesiology 1991; 74: 711-716.
3. Cadwell L E, Rosen M A, Schnider S M. Subarachnoid morphine and fentanyl for labor analgesia. Efficacy and adverse effects. Regional Anesthesia 1994; 19(1): 2-8. 4. Camann W R, Minzter B H, Denney R A, Datta S. Intrathecal sufentanil for labor analgesia. Effects of added epinephrine. Anesthesiology 1993; 78: 870-874. 5. Colfis R E, Baxandall M L, Srikantharajah I D, Edge G, Kadim M Y, Morgan B M. Combined spinal epidural (CSE) analagesia: technique, management, and outcome of 300 mothers. International Journal of Obstetric Anesthesia 1994; 3: 75-81. 6. Bromage P R. A comparison of the hydrochloride and carbon dioxide salts of lidocaine and prilocaine in epidural analgesia. Acta Anaesthesiol Scand 1965; 16: $55-$69. 7. FDA safety alert: Cauda equina syndrome associated with the use of small-bore catheters in continuous spinal anesthesia. 29 May 1992. 8. Steinberg R B, Duma S M, Dixon D E, Rehm K, Pastides H, Hu X. Comparison of sufentanil, bupivacaine, and their combination for epidural analgesia in obstetrics. Regional Anesthesia 1992; 17: 131-138. 9. Batra M S. Adjuvants in epidural and spinal anesthesia. Anesthesiology Clinics of North America 1992; 10: 13-29. 10. Lysak S Z, Eisenach J C, Dobson C E. Patientcontrolled epidural analgesia during labor: a comparison of three solutions with a continuous infusion control. Anesthesiology 1990; 72: 44-49.