- Email: [email protected]
Solutions for patient-controlled epidural analgesia
262 International Journal of Obstetric Anesthesia an uncertain risk.6 Leucoreduction of blood products does not completely eliminate this risk.7 Therefore, universal leucoreduction for all non-leukocyte transfusion components is not justified and has not yet been adopted as standard practice in the US and many other countries.8 In conclusion, the decision to apply allogeneic blood for epidural blood patch in rare specific conditions should be based on an individual risk-to-benefit ratio. After receiving information as to the risks and benefits, the patient should make her own decision. In a patient with a severe headache requesting active treatment but with a contraindication to autologous blood patching, after written informed consent, 10 mL of allogeneic blood from appropriate family members may not carrier a significant risk compared to the benefit. The use of special leukocyte filters (as epidural bacterial filters) and other precautionary measures for allogeneic donation can help to reduce the concern of this complication. Mehmet Cesur Haci A. Alici Ali F. Erdem Mustafa S. Yksek Department of Anesthesiology and Reanimation Medical Faculty, Ataturk University Erzurum, TURKEY E-mail: [email protected]
anesthetic solutions (e.g. bupivacaine less than or equal to 0.0625%).” This is incorrect. We have used this concentration of bupivacaine, combined with fentanyl, as a PCEA solution for over 15 years and described its use during clinical trials in 1993 and 2000.2,3 Other investigators in the United States and in Europe have also reported using PCEA with this concentration of bupivacaine.4,5 The findings reported by Carvalho et al. support the results of two studies in which 0.0625% plain bupivacaine was compared with bupivacaine 0.125%. Ferrante et al. found no difference in pain scores, the need for physician-administered supplemental bupivacaine or motor block, but the mode of delivery of drug also differed, with the higher concentration administered by continuous infusion alone.4 My randomized trial compared PCEA solutions containing 0.25% bupivacaine, 0.125% bupivacaine with fentanyl and 0.0625% bupivacaine with fentanyl and epinephrine.2 There were no differences between groups in the quality of analgesia, the need for supplementation or maternal satisfaction, but dose rates (4, IQR 3–8 mg/h) were significantly lower with the 0.0625% solution. This trial evaluated only a small number of parturients and used different adjuvants, but other studies also indicate that a similar concentration range of local anesthetic can provide effective PCEA with minimal motor block.3–5 Michael Paech FANZCA, DM The University of Western Australia Perth, Western Australia E-mail: [email protected]
REFERENCES 1. Lybecker H, Djernes M, Schmidt J F. Postdural puncture headache (PDPH): onset, duration, severity, and associated symptoms. An analysis of 75 consecutive patients with PDPH. Acta Anaesthesiol Scan 1995; 39: 605–612. 2. Reynolds F. Dural puncture and headache. Avoid the first but treat the second. BMJ 1993; 306: 874–876. 3. Jack T M. Post-partum intracranial subdural haematoma: a possible complication of epidural analgesia. Anaesthesia 1979; 34: 176–180. 4. Shearer V E, Jhaveri H S, Cunningham F G. Puerperal seizures after post-dural puncture headache. Obstet Gynecol 1995; 85: 255–260. 5. Park K W, Chandhok D. Transfusion-associated complications. Int Anesthesiol Clin 2004; 42: 11–26. 6. Ludlam C A, Turner M L. Managing the risk of transmission of variant Creutzfeldt Jakob disease by blood products. Br J Haematol 2006; 132: 13–24. 7. Gregori L, McCombie N, Palmer D, et al. Effectiveness of leucoreduction for removal of infectivity of transmissible spongiform encephalopathies from blood. Lancet 2004; 364: 529–531. 8. Ratko T A, Cummings J P, Oberman H A, et al. Evidence-based recommendations for the use of WBC-reduced cellular blood components. Transfusion 2001; 41: 1310–1319. doi:10.1016/j.ijoa.2006.03.002
REFERENCES 1. Carvalho B, Cohen S E, Giarrusso K, Durbin M, Riley E T, Lipman S. “Ultra-light” patient-controlled epidural analgesia during labor: effects of varying regimens on analgesia and physician workload. Int J Obstet Anesth 2005; 14: 223–229. 2. Paech M J. Patient-controlled epidural analgesia during labour: choice of solution. Int J Obstet Anesth 1993; 2: 65–72. 3. Paech M J, Pavy T J G, Orlikowski C E P, Evans S F. Patient-controlled epidural analgesia in labor. The addition of clonidine to bupivacaine-fentanyl. Reg Anesth Pain Med 2000; 25: 34–40. 4. Ferrante F M, Barber M J, Segal M, Hughes N J, Datta S. 0.0625% bupivacaine with 0.0002% fentanyl via patient-controlled epidural analgesia for pain of labor and delivery. Clin J Pain 1995; 11: 121–126. 5. Pirbudak L, Tuncer S, Kocoglu H, Goksu S, Celik C. Fentanyl added to bupivacaine 0.05% or ropivacaine 0.05% in patientcontrolled epidural analgesia in labour. Eur J Anaesthesiol 2002; 19: 271–275.
Solutions for patient-controlled epidural analgesia Carvalho et al. recently reported on regimens for “ultralight” patient-controlled epidural analgesia (PCEA) during labor.1 They commented that “no previous studies have evaluated PCEA settings of the more dilute local
doi:10.1016/j.ijoa.2006.03.001
In reply We thank Dr Paech for his comments and feedback on our study.1 We are aware of Dr Paech’s study focusing on the
anesthetic solutions (e.g. bupivacaine less than or equal to 0.0625%).” This is incorrect. We have used this concentration of bupivacaine, combined with fentanyl, as a PCEA solution for over 15 years and described its use during clinical trials in 1993 and 2000.2,3 Other investigators in the United States and in Europe have also reported using PCEA with this concentration of bupivacaine.4,5 The findings reported by Carvalho et al. support the results of two studies in which 0.0625% plain bupivacaine was compared with bupivacaine 0.125%. Ferrante et al. found no difference in pain scores, the need for physician-administered supplemental bupivacaine or motor block, but the mode of delivery of drug also differed, with the higher concentration administered by continuous infusion alone.4 My randomized trial compared PCEA solutions containing 0.25% bupivacaine, 0.125% bupivacaine with fentanyl and 0.0625% bupivacaine with fentanyl and epinephrine.2 There were no differences between groups in the quality of analgesia, the need for supplementation or maternal satisfaction, but dose rates (4, IQR 3–8 mg/h) were significantly lower with the 0.0625% solution. This trial evaluated only a small number of parturients and used different adjuvants, but other studies also indicate that a similar concentration range of local anesthetic can provide effective PCEA with minimal motor block.3–5 Michael Paech FANZCA, DM The University of Western Australia Perth, Western Australia E-mail: [email protected]
REFERENCES 1. Lybecker H, Djernes M, Schmidt J F. Postdural puncture headache (PDPH): onset, duration, severity, and associated symptoms. An analysis of 75 consecutive patients with PDPH. Acta Anaesthesiol Scan 1995; 39: 605–612. 2. Reynolds F. Dural puncture and headache. Avoid the first but treat the second. BMJ 1993; 306: 874–876. 3. Jack T M. Post-partum intracranial subdural haematoma: a possible complication of epidural analgesia. Anaesthesia 1979; 34: 176–180. 4. Shearer V E, Jhaveri H S, Cunningham F G. Puerperal seizures after post-dural puncture headache. Obstet Gynecol 1995; 85: 255–260. 5. Park K W, Chandhok D. Transfusion-associated complications. Int Anesthesiol Clin 2004; 42: 11–26. 6. Ludlam C A, Turner M L. Managing the risk of transmission of variant Creutzfeldt Jakob disease by blood products. Br J Haematol 2006; 132: 13–24. 7. Gregori L, McCombie N, Palmer D, et al. Effectiveness of leucoreduction for removal of infectivity of transmissible spongiform encephalopathies from blood. Lancet 2004; 364: 529–531. 8. Ratko T A, Cummings J P, Oberman H A, et al. Evidence-based recommendations for the use of WBC-reduced cellular blood components. Transfusion 2001; 41: 1310–1319. doi:10.1016/j.ijoa.2006.03.002
REFERENCES 1. Carvalho B, Cohen S E, Giarrusso K, Durbin M, Riley E T, Lipman S. “Ultra-light” patient-controlled epidural analgesia during labor: effects of varying regimens on analgesia and physician workload. Int J Obstet Anesth 2005; 14: 223–229. 2. Paech M J. Patient-controlled epidural analgesia during labour: choice of solution. Int J Obstet Anesth 1993; 2: 65–72. 3. Paech M J, Pavy T J G, Orlikowski C E P, Evans S F. Patient-controlled epidural analgesia in labor. The addition of clonidine to bupivacaine-fentanyl. Reg Anesth Pain Med 2000; 25: 34–40. 4. Ferrante F M, Barber M J, Segal M, Hughes N J, Datta S. 0.0625% bupivacaine with 0.0002% fentanyl via patient-controlled epidural analgesia for pain of labor and delivery. Clin J Pain 1995; 11: 121–126. 5. Pirbudak L, Tuncer S, Kocoglu H, Goksu S, Celik C. Fentanyl added to bupivacaine 0.05% or ropivacaine 0.05% in patientcontrolled epidural analgesia in labour. Eur J Anaesthesiol 2002; 19: 271–275.
Solutions for patient-controlled epidural analgesia Carvalho et al. recently reported on regimens for “ultralight” patient-controlled epidural analgesia (PCEA) during labor.1 They commented that “no previous studies have evaluated PCEA settings of the more dilute local
doi:10.1016/j.ijoa.2006.03.001
In reply We thank Dr Paech for his comments and feedback on our study.1 We are aware of Dr Paech’s study focusing on the