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8/9/2019 Journal Report Epidural for Analgesia in Labor
1/17
Journal Report:
A Comparison of Minimum
Local Anesthetic Volumes and
Doses of Epidural
Bupivacaine (0!"#$ and
0"#$% for Anal&esia in La'or
Waldemar P. Siahaan, M.D.
8/9/2019 Journal Report Epidural for Analgesia in Labor
2/17
“If the pharmacological sleeve is extended to
bathe all the available nerve root within the
epidural space, then a lower concentration
of local anesthetic will be sufficient to
block nerve transmission.”
Fink BR. Toward The mathematization of Spinal anesthesia. Reg Anesth Pain Med
19921!"2#$%!$
8/9/2019 Journal Report Epidural for Analgesia in Labor
3/17
“Extending the pharmacological sleeve
requires that the volume of injectate is
increased at the expense of concentration.”
&hristiaens F. 'ffe(ts of dil)ent *ol)me of a single dose of epid)ral +)pi*a(aine in the
part)rients d)ring the first stage of la+or. Reg Anesth Pain Med 199,2$"1$-%-1
8/9/2019 Journal Report Epidural for Analgesia in Labor
4/17
In fixed dose stud!
"igher volumes and lower concentrations are
more effective for nerve blockade when
compared with lower volumes of higher
concentration local anesthetics.#otential benefits in differential blockade, such
as motor sparing, when higher concentrations
are exchanged for lower concentrations givenin larger volumes
hiteside R. 'pid)ral ropi*a(aine with fentan/l following ma0or g/nae(ologi(al s)rger/" the effe(t of
*ol)me and (on(etration on pain relief and motor impairment. Br Anaesth 2,-"!2%-
8/9/2019 Journal Report Epidural for Analgesia in Labor
5/17
$%&E'(I)E*!
(o +uantif an dose reduction which might
have potential implications for safet.
I-!
(o determine the median effective volumes and
doses, which were defined as the -) and
-/ of bupivacaine 0.1234 and 0.234 for
epidural bupivacaine given as the first bolus
to women for analgesia in labor.
8/9/2019 Journal Report Epidural for Analgesia in Labor
6/17
-E("$/*!
I. #(IE5(*! 6omen in labor requesting neuraxial analgesia
* 1 or 2 patients
*ingleton pregnanc more than 78 wk $9
:110 kg in weight
%etween 130;1
8/9/2019 Journal Report Epidural for Analgesia in Labor
7/17
-E("$/*!
II. E#I/>? (E'"5I+>E 1< g (uoh needl and 20 9 catheter
t the 2@7 or 7@= level, in a sitting position
>sing $?( 5o epidural test dose was given
#repared not more than = h previousl
Injected slowl over approximatel 3 min.
)#*
0 “no pain” 100 “worst pain ever”
8/9/2019 Journal Report Epidural for Analgesia in Labor
8/17
-E("$/*!
III. 9?$>#* %upivacaine 0.1234
%upivacaine 0.234
)olume in the first sringe of each group set at13ml
Efficac of the first dose was assessed using a
)#* at 0,13, and 70 min after injection of thetest solution Afirst bolusB
8/9/2019 Journal Report Epidural for Analgesia in Labor
9/17
-E("$/*!
I). ECCE'(I)E ?egardless of the baseline, )#* decreased to
10mm or less within 70 min of injection,
indicating the end of the stud, and directed adecrement of 2 ml local anesthetic for the next
woman
8/9/2019 Journal Report Epidural for Analgesia in Labor
10/17
-E("$/*!
). I5ECCE'(I)E Cailure of the )#* to reach 10mm within 70
min
?escue analgesia consisting of 12ml bupivacaine 0.234 was given.
reduction in )#* to 10 mm or less
indicated the end of the stud
/irected a 2 ml increment for the next woman.
8/9/2019 Journal Report Epidural for Analgesia in Labor
11/17
-E("$/*!
)I. ?E#E( Cailure to 10 mm after rescue directed that the
same concentration be repeated for the next
woman. Each da, 2 test sringes were made up, one
for each group and placed in refrigerator.
(he sringes were placed side b side, the
operator chose one or the other at random.
8/9/2019 Journal Report Epidural for Analgesia in Labor
12/17
$%*E?)(I$5*
>se of prostin and oxtocin infusion, )#*,and efficac of the local anesthetic solution
were recorded.
8/9/2019 Journal Report Epidural for Analgesia in Labor
13/17
*-#E *IDE
*ample sie estimations were based on theresults of the first studies that showed the
minimum local analgesic concentration of
bupivacaine to be 0.0834
&ol)m+ M3 &lini(al trials" )p%down se4)ential allo(ation. Regional analgesia in o+stetri(
5 a millenni)m )pdate. 2"16!%1#6
8/9/2019 Journal Report Epidural for Analgesia in Labor
14/17
*-#E *IDE
minimum of 7F women would be required per group.
8/9/2019 Journal Report Epidural for Analgesia in Labor
15/17
RE)L*
Bupivacaine
0!"# $
Bupivacaine0"# $
-) AmlB 17.8 A12.= G 1=.
8/9/2019 Journal Report Epidural for Analgesia in Labor
16/17
'$5'>*I$5
%upivacaine 0.1234 when compared with0.234 produced equivalent analgesia with a
304 increase in volume, but with a 234
reduction in dose.
n reduction in dose, without loss of
efficac, reduces risk of toxicit and improves
safet.
8/9/2019 Journal Report Epidural for Analgesia in Labor
17/17
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