|
Davies (1997)
Maternal
experience during epidural or combined spinal-epidural anaesthesia for
caesarean section: A prospective randomized trial
Anesthesia
and Analgesia, 1997. 85(3): p. 607-613.
|
inclusion criteria
–
healthy parturients
–
cephalic fetus
exclusion criteria
–
cardiovascular disease
–
preeclampsia
–
placenta previa
–
uterine contractions
demographic data
no
significant differences in baseline characteristics
maternal
age [yr]: mean ± SD
CSEA:
29 ± 7
EA:
28 ± 10
weight
[kg]: mean ± SD
CSEA: 80 ± 17
EA:
75 ± 27
nulliparity
[n (%)]
CSEA:
14 (24)
EA:
14 (26)
previous
caesarean section [n (%)]
CSEA:
40 (68)
EA:
38 (69)
patient flow and follow up
total
patient number included:
120
randomised
in:
CSEA
:60
EA:
60
excluded:
CSEA:
– 1
for incomplete data
EA:
– 3
for incomplete data
– 2
for failed block
analysed:
CSEA:
59
EA:
55
follow
up:
24
hours
|
premedication
–
ranitidine 150 mg PO the night before and the morning of surgery
prior to anaesthesia
–
metoclopramide 10 mg
– 10
mL/kg of warmed crystalloid IV
–
prophylactic ephedrine infusion (30 mg in 500 ml normal saline)
intervention and control group
CSEA
group
–
hyperbaric 0.5% bupivacaine 2.5 mL with fentanyl 10 µg in 0.2 mL
(total 2.5 mL) IT
– 3 mL
of 2% lidocaine with epinephrine 1: 200,000 epidural (at the of the
operation)
EA
group
–
20 mL 2% lidocaine with epinephrine 1: 200,000
–
2 mL 8.4% sodium bicarbonate
– 2 mL
fentanyl 50 µg/mL (total 24 mL) was prepared. A 3 mL test dose was
followed by 12 mL incrementally over a 10-min period. Further doses permitted
15 min after initial injection.
surgical approach
not reported.
intraoperative pain management
–
bolus of synthetic oxytocin 5-10 U was followed by an infusion at
approx. 4 U/h
–
supplementary epidural drugs or opioid IV were permitted at any time during
surgery.
postoperative pain management
epidural
pethidine (50 mg bolus doses administered by a nurse every 2 h as
needed)
|
intraoperative pain score [VAS]
CSEA
significantly reduced:
–
block insertion (p=0.02)
– during delivery (p=0.01)
no
significant differences between the two groups:
–
skin insertion
–
peritoneal closure
–
global intraoperative pain score
women
reporting zero pain scores [%]:
EA:
44
CSEA:
63
(p=0.09)
additional
intraoperative analgesics (epidural opioid or local anaesthetic, IV opioid)
[%]:
EA: 42
CSEA:
27
(p=0.12)
intraoperative
epidural or IV opioid [%]:
EA:
13
CSEA:
7
(p=0.36)
maternal pain 24 hour score [VAS]
no
significant differences between the groups
pethidine consumption
no
significant differences between the groups
APGAR-Score
no
significant differences between the groups
anxiety and satisfaction scores 24 hours postpartum
no
significant differences between the groups.
adverse effects/ events:
no
significant differences in:
–
nausea
–
vomiting
–
shivering
–
incidence of headache or postural headache.
backache at some stage during the first 3
postpartum days [%]:
EA:
55
CSEA:
62
(p=0.45)
|
methodological
shortcomings
–
allocation concealment not reported
– no
sample size calculation
–
selective outcome reporting unclear
level of evidence: 1
authors’ conclusion
“Both
EA and CSEA have low failure rates, provide good operative conditions, and
confer high levels of maternal satisfaction. Maternal advantages
with
CSEA include greater satisfaction after block placement
before
surgery and reduced pain during delivery of the fetus. Increased ephedrine
requirements with CSEA are unlikely to be of clinical importance.”
|
|
Karaman (2004)
Comparison
of the maternal and neonatal effects of epidural block and of combined
spinal-epidural block of Cesarean section
European
Journal of Obstetrics Gynecology and Reproductive Biology, 2005. 121(1): p.
18-23.
|
inclusion criteria
– ASA
status I-II
– 18
to 40 year-old
–
unpremedicated
–
uncomplicated singleton pregnancies
–
wished to be conscious during surgery
exclusion criteria
–
twins pregnancy
–
placenta previa
–
pregnancy- induced hypertension
demographic data
no
significant differences in baseline characteristics
age
[yr.]: mean ± SD
CSEA:
28.9 ± 3.32
EA:
30.4 ± 4.94
BMI
[kg/m²]: mean ± SD
CSEA:
28.15 ± 4.72
EA:
28.4 ± 5.31
para
0 [n (%)]
CSEA:
16 (40)
EA:
14 (35)
previous
caesarean section [n (%)]
CSEA:
20 (50)
EA:
22 (55)
patient flow and follow up
total
patient number included:
80
randomised
in:
CSEA:
40
EA:
40
excluded:
0
analysed:
80
follow
up:
3
days
|
prior to anaesthesia
–
metoclopramide 10 mg
–
10 mL/kg warmed (37°C) Ringer lactate solution IV
–
Oxygen 6 L/min
intervention and control group
CSEA
group
-1.5–1.8 mL
0.5% hyperbaric bupivacaine IT (varying with patient’s height over 30 s)
– if
block does not reach T4 after 10 min: additional 10 mL 0.25% plain
bupivacaine and 50 µg fentanyl (top-up) epidural
EA
group
–
3 mL 2% lidocaine as test dose
– 14–16 mL
0.5% bupivacaine and 100 µg fentanyl
–
until a sensory block extended to T4 additional 2 mL 0.5% bupivacaine
was given
surgical approach
not
reported.
intraoperative pain management
–
fentanyl IV in 50-µg increments if pain VAS?40
postoperative pain management
–
epidural morphine if needed in both groups
|
intraoperative complete analgesia [VAS=0]
– no
women in CSEA group complained of pain or needed fentanyl
– but
3 of 11 woman in EA group who complained of pain required fentanyl
(p=0.001)
onset of postoperative pain [min]: mean ± SD
CSEA:
167 ± 42.4
EA:
210 ± 37.2
(p<0.01)
APGAR-Score
no
significant differences between the groups
morphine consumption
not
reported
adverse effects/ events:
no
significant differences between the groups:
– hypotension
– nausea
– vomiting
– none developed postdural puncture headaches
shivering [n (%)]
CSEA: 2 (5)
EA: 14 (35)
(p=0.001)
|
methodological shortcomings
–
allocation concealment not reported
– no
blinding of participants and personnel
– no
sample size calculation
–
selective outcome reporting
level of evidence: 1
authors’ conclusion
“CSEA,
in which spinal anesthesia is combined with a lower dose of bupivacaine and
supporting
epidural
top-up with 0.25% bupivacaine, has greater efficacy
and
fewer side effects than EA in Cesarean sections.”
|
|
Norman (1998)
Analgesia
produced by epidural diamorphine is better following cesarean section under
spinal anesthesia than under epidural anesthesia
International
Journal of Obstetric Anesthesia, 1998. 7(2): p. 98-102.
|
inclusion criteria
– ASA
status I–II
–
singleton pregnancy of greater than 36 weeks duration
exclusion criteria
– in
labor
– had
received analgesia in the last 6 h
–
contraindications to diclofenac
demographic data
no
significant differences in baseline characteristics
age
[yr.]: mean ± SD
CSEA:
32 ± 5
EA:
34 ± 6
height
[cm]: mean ± SD
CSEA:
163 ± 8
EA:
165 ± 7
weight
[kg]: mean ± SD
CSEA:
66.4 ± 14.0
EA:
69.4 ± 13.3
previous
caesarean section [n (%)]
CSEA:
15 (42.3)
EA:
11 (46.8)
patient flow and follow up
total
patient number included:
70
randomised
in:
not
reported
excluded:
12
– 2
because epidural space could not be located
– 3
had epidural catheters removed before epidural diamorphine was required
– 1
did not require epidural diamorphine throughout 24 h study period
– 6
patients as their record cards were unavailable
analysed:
56
CSEA:
32
EA: 26
follow
up:
24
hours
|
prior to anaesthesia
–
ranitidine 150 mg PO
– metoclopramide
10 mg PO
–
Hartmann’s solution 500 ml IV
intervention and control group
CSEA
group
–
2.2 mL of 0.5% hyperbaric bupivacaine IT
– if
sensory block incomplete to T4 increments of 0.5% of plain bupivacaine
epidural
EA
group
–
increments of 0.5% plain bupivacaine
surgical approach
not
reported
postoperative pain management
all
patients:
-100 mg
diclofenac rectal
at
first request
–
2.5 mg diamorphine made up to 10 mL in 0.9% saline epidural
other
given analgesia
–
diclofenac 50 mg PO 8-hourly
additional
analgesic requirements
–
co-dydramol PO (dihydrocodeine tartrate 10 mg, paracetamol 500 mg)
–
morphine 10 mg IM
|
intraoperative analgesia requirements [n (%)]:
CSEA:11
(34.4)
EA:
9 (34.6)
median postoperative pain score
consistently
lower in CSEA but only significant difference at 24h (p=0.021)
onset of block for surgery and
postoperative administration of epidural diamorphine: mean time [h] ± SD
CSEA: 4.1 ± 2.2
EA: 5.3 ± 2.2
(p=0.016)
requirement of postoperative morphine IM
[n/%]
CSEA:
11 (34.4)
EA: 9
(34.6)
(p=NS)
time to administration of morphine IM: [h]
± SD
CSEA:
12.6 ± 5.9
EA:
6.6 ± 3.1
(p=0.01)
adverse effects/ events:
no significant differences between the
groups:
– sedation score = 2 (heavily sedated)
– nausea
– vomiting
– itching
|
methodological shortcomings:
–
allocation concealment not reported
–
selective outcome reporting unclear
level of evidence: 1
authors’ conclusion
“In
conclusion, epidural diamorphine 2.5 mg produced
better
analgesia after combined epidural-spinal anaesthesia than after epidural
anaesthesia for caesarean section. Regular administration of diclofenac and
availability of co-dydramol may have reduced the requirement for stronger
analgesia, although this was not addressed by our study design.”
|
|
Lew (2004) Combined
spinal-epidural anesthesia using epidural volume extension leads to faster
motor recovery after elective cesarean delivery: A prospective, randomized,
double-blind study
Anesthesia
and Analgesia, 2004. 98(3): p. 810-814.
|
inclusion criteria
– ASA
status I–II
–
body weight 50–95 kg
–
height 150–170 cm
–
singleton pregnancy
exclusion criteria
–
contraindications to regional anaesthesia
–
emergent caesarean deliveries
–
hypertensive disorders
–
peripartum haemorrhagic conditions
demographic data
no
significant differences in baseline characteristics
age
[yr.]: mean ± SD
SpA:
33 ± 5
CSEA
2: 32 ± 5
height
[cm]: mean ± SD
SpA:
157 ± 6
CSEA:
158 ± 4
weight
[kg]: mean ± SD
SpA:
69 ± 11
CSEA:
69 ± 10
patient flow and follow up
total
patient number included:
62
randomised
in:
SpA:
31
CSEA:
31
excluded:
0
analysed:
62
follow
up:
24
hours
|
prior to anaesthesia
–
ranitidine PO
–
sodium citrate PO
intervention and control group
SpA
group
– 9.0
mg of hyperbaric 0.5% bupivacaine
–
fentanyl 10 µg IT over 10 s without barbotage
CSEA
group
– 5.0
mg of hyperbaric 0.5% bupivacaine
–
fentanyl 10 µg IT over 10 s without barbotage
– 5
min from completion of IT injection: 6.0 mL of 0.9% saline over 30 s
epidurally
surgical approach
not
reported.
intraoperative pain management
CSEA
group:
– If VAS >30 epidural boluses of 3 mL of 1.5% lidocaine
both
groups:
– IV
adjuncts such as fentanyl 25 µg and ketorolac 30 mg after delivery
postoperative pain management
pethidine
IM
|
modified Bromage score
significantly
lower in patients of the CSEA group
(p<0.05)
intraoperative pain
no
significant differences between the groups
first request for postoperative
analgesia
no significant differences between the groups
APGAR-Score
no significant
differences between the groups
adverse effects/ events:
no
significant differences in:
– nausea
– vomiting
– pruritus
– shivering
– postspinal headache
|
methodological shortcomings:
–
allocation concealment not reported
–
selective outcome reporting
level of evidence: 1
authors’ conclusion
“The
study shows that CSEA with epidural volume extension (EVE provided adequate
anesthesia for elective cesarean delivery with only 55% of the bupivacaine
dose and allows a more rapid motor recovery of the lower limbs, which may
have an impact on shortening PACU stay. Moreover, the use of saline for
epidural boluses is economical. With modification, the epidural catheter
could be retained to provide postoperative analgesia. These data suggest that
CSEA with EVE should be considered a novel alternative to spinal anesthesia
for cesarean delivery”
|
|
Thoren (1994)
Sequential
combined spinal epidural block versus spinal block for cesarean section: effects on maternal
hypotension and neurobehavioral function of the newborn
Anesthesia
and Analgesia, 1994. 78(6): p. 1087-1092.
|
inclusion criteria
– ASA
physical status I
–
full-term pregnancy
–
unpremedicated
–
wished to be awake during surgery
–
uncomplicated, singleton pregnancies
exclusion criteria
not
reported.
demographic data
no
significant differences in baseline characteristics
age
[yr.]: mean ± SD
SpA:
28.8 ± 0.9
CSEA:
31.1 ± 1.0
height
[cm]:mean ± SD
SpA:
164.0 ± 1.6
CSEA:
166.1 ± 1.3
weight
[kg];mean ± SD
SpA:
75.9 ± 2.2
CSEA:
75.1 ± 2.4
gestation
age [weeks] ± SD
SpA:
38.7 ± 0.1
CSEA:38.6
± 0.1
patient flow and follow up
total
patient number included:
42
randomised
in:
SpA:
21
CSEA: 21
excluded: 1
not
reported.
analysed:
41
SpA:
20
CSEA:
21
Follow
up:
24
hours
|
prior to anaesthesia
–
1500–2000 mL acetated Ringer´s solution
intervention and control group
SpA
–
hyperbaric bupivacaine 0.5% 12.5 mg in 8% glucose IT
CSEA
–
hyperbaric bupivacaine 0.5% (1.5 mL; 7.5 mg) IT
– if
T4 level is not reached after 15 min additional bupivacaine was injected
epidurally: after a test dose (2 mL 0.5%) an additional 2 mL per
unblocked segment was given until T4 level was achieved
intraoperative pain management
–
fentanyl 50-µg-increments IV
surgical approach
not
reported.
postoperative pain management
– ketobemidone
IM
|
supplementary dose to obtain a T4 sensory
block
all
patients in the CSEA group needed supplementary epidural bupivacaine.
intraoperative supplementary drugs
no supplementary drugs were needed.
postoperative drug requirement
no
difference between groups in the need for fentanyl and/ or dixyrazine.
time
between induction of block and first request of postoperative pain relief
[min] ± SD
CSEA:
208 ± 18.2
SpA:
151 ± 21.7
(p<0.05)
total
dose of ketobemidone [mg] ± SD
no
differences between the groups.
CSEA:
23.7 ± 1.5
SpA:
22.1 ± 1.7
(p=NS)
APGAR Scores
similar in both groups.
adverse effects/ events
no
postdural puncture headache
|
methodological shortcomings
–
generation of sequence generation unclear
–
allocation concealment not reported
–
blinding of participants, personnel unclear
–
selective outcome reporting
– no
sample size calculation
level of evidence: 2
authors’ conclusion
“In
conclusion, the sequential CSEA technique proved to be as safe and as
effective as spinal anesthesia for cesarean section. There is a risk of
hypotension with both techniques, although it is more precipitous after
conventional spinal block. Provided that hypotension is aggressively treated,
neonatal outcome is good after both anesthetic techniques. With the CSEA
technique, the presence of an epidural catheter provides a capability to
extend or prolong an inadequate spinal block. The
sequential
CSEA technique may be particularly advantageous
in
high-risk parturients.“
|