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The effects of epidural analgesia with low-dose equianalgesic concentrations ropivacaine and bupivacaine on the labour activity and neonatal outcome
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64. Epidural bolus administration through the Tuohy needle for labour analgesia Amemiya N, Oosthuysen S, Rhodes S Email: [email protected] James Paget Hospital, Lowestoft Road, Gorleston, Norflok, UK Epidural bolus administration through the Tuohy needle for labour analgesia Background:Epidural bolus administration of local anaesthetics directly through the Tuohy needle is the common practice in the out patient pain-clinic. We investigated whether this technique would provide a satisfactory pain relief to parturients concerning onset, quality, ability of ambulation, and the condition of mothers and neonates. Methods:70 women lied on the left side down with the electronic fetal monitoring. 500ml of colloid was infused while preparing the epidural. The epidural space, L4/5, was identified with a 16 G Tuohy needle by using the loss of resistance with saline. After confirming neither CSE nor blood coming back, 18ml of low dose mixtures (0.1% bupivacaine ⫹ fentanyl 2g/ml) and 2ml of fentanyl;100g were injected over one minute.１ At every 5mls, the aspiration was performed to confirm there was no blood or no CSF. The patients were also asked to inform if there was sudden loss of sensation or motor weakness in the legs. The epidural catheter was left for the further intermittent top-ups of low dose mixtures. 10 min after bolus injection, the number of painful contraction the patients felt was asked. Verbal analogue pain scores were asked. Straight leg raise against the resistance by anaesthetists, proprioception of big toes２, and change of cold sensation to the ethyl-chloride spray were assessed at 30 min after for the ambulation. Maternal blood pressure was measured at every 2.5 min and fetal heart rate was monitored continuously. Delivery method, Apgar score at 1 and 5 min, side effects; pruritus, nausea, and drowsiness were recorded Results: 45% of women experienced none or one episode of painful contraction. 91% of women felt painful contraction at most 3 times. VAS improved from 80mm to 18mm in 10 minutes. There was no unilateral block. None of the patients had motor weakness. None of them lost the proprioception of big toes. There was no maternal hypotension after the injection. There was one case of FHR deterioration which improvecd in 3 min. Neither mothers nor babies required Naloxone. Conclusion:Epidural bolus administration of the full dose of 20 ml of local anaesthetics; 18ml of low-dose of mixtures (bupivacaine 0.1%＋fentanyl 2g/ ml) and 2 ml of fentanyl(100g) provides fast and satisfactory pain relief to without affecting the ability of ambulation and few side effects on both fetal and maternal condition.
References: 1 Capogna G, et al. Anesth Analg 2003;96:1178-82 2 Calimaran A,et al. Anesth Analg 2003;96:1167-72
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Obstetric RA
71
83. The effects of epidural analgesia with low-dose equianalgesic concentrations ropivacaine and bupivacaine on the labour activity and neonatal outcome Tokuc¸ EC, Esra Cirpici T, Gu¨ du¨ l Z, Yumru C, Ayanoglu YT, Asci N Email: [email protected] Taksim Training and Research Hospital, Sıraselviler Cad. No:112 Beyolu-stanbul, Turkey Background: Ropivacaine and bupivacaine are amide local anesthetics similar in chemical structure, the first has a lower toxic effect to central nervous and cardiovascular system. In addition, ropivacaine has much more positive effects than bupivacaine regarding better neonatal neurologic adaptive score and decreased instrumental delivery rates 1, 2. We aimed to compare the effects of ropivacaine and bupivacaine on epidural labour analgesia and neonatal outcome. Methods: In this prospective, randomized, double blinded study we evaluated 30 primigravides who were scheduled for epidural labour analgesia. Grup R (n⫽15) received 0.075 % ropivacaine ⫹ 2 mcg mL-1 fentanyl, Grup B (n⫽15) received 0.075 % bupivakain ⫹ 2 mcg mL-1 fentanyl. We administered 20 mL of beginning epidural solution in four equal doses of five milliliters. After 20 minutes, we initiated the patient controlled epidural analgesia (PCEA) with setting of: 5 mL bolus dose, 10 min lockout period, no basal infusion. For inadequate analgesia during labour, 10 mL supplemental dose of study solution in 5 mL increments were added. Patients were excluded from this study, if they required more than 2 sequential supplemental doses. Vizual analog scale (VAS) pain scores, level of sensory block (ice tube), degree of motor block (Bromage score- BS), haemodynamic effects, frequency and intensity of uterine contractions, duration of first and second stage of labour, mode of delivery, umbilical cord blood gases, Apgar and neurologic adaptive capacity scores (NACS) were recorded. The data were analyzed using Student’s t test, Mann-Whitney U test, Mc Nemar test, Chi square test, Fisher’s exact test, t tests. p⬍0.05 is considered statistically significant. Results: There was a higher proportion of the neonates in the bupivacaine group, who had a NACS⬍35 2 h after delivery than in the ropivacaine group (p⫽0.005). No differences were detected between the two groups for umbilical cord blood gases and Apgar scores. The intensity of motor block, intensity and frequency of uterine contractions, oxytocin therapy were similiar and so were the modes of delivery. Conclusion: This study suggested that 0.075 % ropivacaine ⫹ 2 g mL-1 fentanyl and 0.075 % bupivakain ⫹ 2 mcg mL-1 fentanyl with PCEA technique produced similiar labour analgesia and were not affected modes of delivery but NACS scores in bupivacaine group were lower than ropivacaine group and thus we may conclude that ropivacaine can be the drug of choise for epidural labour analgesia.
References: 1. Stienstra R, Jonker TA, Bourdrez P, Kuijpers JC, van Kleef JW, Lundberg U. Anesth Analg 1995;80:285-9. 2.Writer WDR et al. Br J Anaesth 1998;81:713717.
64. Epidural bolus administration through the Tuohy needle for labour analgesia Amemiya N, Oosthuysen S, Rhodes S Email: [email protected] James Paget Hospital, Lowestoft Road, Gorleston, Norflok, UK Epidural bolus administration through the Tuohy needle for labour analgesia Background:Epidural bolus administration of local anaesthetics directly through the Tuohy needle is the common practice in the out patient pain-clinic. We investigated whether this technique would provide a satisfactory pain relief to parturients concerning onset, quality, ability of ambulation, and the condition of mothers and neonates. Methods:70 women lied on the left side down with the electronic fetal monitoring. 500ml of colloid was infused while preparing the epidural. The epidural space, L4/5, was identified with a 16 G Tuohy needle by using the loss of resistance with saline. After confirming neither CSE nor blood coming back, 18ml of low dose mixtures (0.1% bupivacaine ⫹ fentanyl 2g/ml) and 2ml of fentanyl;100g were injected over one minute.１ At every 5mls, the aspiration was performed to confirm there was no blood or no CSF. The patients were also asked to inform if there was sudden loss of sensation or motor weakness in the legs. The epidural catheter was left for the further intermittent top-ups of low dose mixtures. 10 min after bolus injection, the number of painful contraction the patients felt was asked. Verbal analogue pain scores were asked. Straight leg raise against the resistance by anaesthetists, proprioception of big toes２, and change of cold sensation to the ethyl-chloride spray were assessed at 30 min after for the ambulation. Maternal blood pressure was measured at every 2.5 min and fetal heart rate was monitored continuously. Delivery method, Apgar score at 1 and 5 min, side effects; pruritus, nausea, and drowsiness were recorded Results: 45% of women experienced none or one episode of painful contraction. 91% of women felt painful contraction at most 3 times. VAS improved from 80mm to 18mm in 10 minutes. There was no unilateral block. None of the patients had motor weakness. None of them lost the proprioception of big toes. There was no maternal hypotension after the injection. There was one case of FHR deterioration which improvecd in 3 min. Neither mothers nor babies required Naloxone. Conclusion:Epidural bolus administration of the full dose of 20 ml of local anaesthetics; 18ml of low-dose of mixtures (bupivacaine 0.1%＋fentanyl 2g/ ml) and 2 ml of fentanyl(100g) provides fast and satisfactory pain relief to without affecting the ability of ambulation and few side effects on both fetal and maternal condition.
References: 1 Capogna G, et al. Anesth Analg 2003;96:1178-82 2 Calimaran A,et al. Anesth Analg 2003;96:1167-72
•
Obstetric RA
71
83. The effects of epidural analgesia with low-dose equianalgesic concentrations ropivacaine and bupivacaine on the labour activity and neonatal outcome Tokuc¸ EC, Esra Cirpici T, Gu¨ du¨ l Z, Yumru C, Ayanoglu YT, Asci N Email: [email protected] Taksim Training and Research Hospital, Sıraselviler Cad. No:112 Beyolu-stanbul, Turkey Background: Ropivacaine and bupivacaine are amide local anesthetics similar in chemical structure, the first has a lower toxic effect to central nervous and cardiovascular system. In addition, ropivacaine has much more positive effects than bupivacaine regarding better neonatal neurologic adaptive score and decreased instrumental delivery rates 1, 2. We aimed to compare the effects of ropivacaine and bupivacaine on epidural labour analgesia and neonatal outcome. Methods: In this prospective, randomized, double blinded study we evaluated 30 primigravides who were scheduled for epidural labour analgesia. Grup R (n⫽15) received 0.075 % ropivacaine ⫹ 2 mcg mL-1 fentanyl, Grup B (n⫽15) received 0.075 % bupivakain ⫹ 2 mcg mL-1 fentanyl. We administered 20 mL of beginning epidural solution in four equal doses of five milliliters. After 20 minutes, we initiated the patient controlled epidural analgesia (PCEA) with setting of: 5 mL bolus dose, 10 min lockout period, no basal infusion. For inadequate analgesia during labour, 10 mL supplemental dose of study solution in 5 mL increments were added. Patients were excluded from this study, if they required more than 2 sequential supplemental doses. Vizual analog scale (VAS) pain scores, level of sensory block (ice tube), degree of motor block (Bromage score- BS), haemodynamic effects, frequency and intensity of uterine contractions, duration of first and second stage of labour, mode of delivery, umbilical cord blood gases, Apgar and neurologic adaptive capacity scores (NACS) were recorded. The data were analyzed using Student’s t test, Mann-Whitney U test, Mc Nemar test, Chi square test, Fisher’s exact test, t tests. p⬍0.05 is considered statistically significant. Results: There was a higher proportion of the neonates in the bupivacaine group, who had a NACS⬍35 2 h after delivery than in the ropivacaine group (p⫽0.005). No differences were detected between the two groups for umbilical cord blood gases and Apgar scores. The intensity of motor block, intensity and frequency of uterine contractions, oxytocin therapy were similiar and so were the modes of delivery. Conclusion: This study suggested that 0.075 % ropivacaine ⫹ 2 g mL-1 fentanyl and 0.075 % bupivakain ⫹ 2 mcg mL-1 fentanyl with PCEA technique produced similiar labour analgesia and were not affected modes of delivery but NACS scores in bupivacaine group were lower than ropivacaine group and thus we may conclude that ropivacaine can be the drug of choise for epidural labour analgesia.
References: 1. Stienstra R, Jonker TA, Bourdrez P, Kuijpers JC, van Kleef JW, Lundberg U. Anesth Analg 1995;80:285-9. 2.Writer WDR et al. Br J Anaesth 1998;81:713717.