A randomized comparison of epidural, dural puncture epidural, and combined spinal-epidural without intrathecal opioids for labor analgesia

Wahba Z Bakhet, Wahba Z Bakhet

Abstract

Background and aims: Dural puncture epidural (DPE) has been shown to improve labor analgesia over epidural (EPL), with fewer side effects than a combined spinal-epidural (CSE). However, there is some debate regarding the superiority of DPE over EPL and CSE. Therefore, we aimed to compare the effects of EPL, DPE, and CSE without intrathecal opioids on the epidural local anesthetic (LA) consumption and occurrence of side effects in early labor.

Material and methods: We randomly assigned parturient to one of the 3 groups; EPL, DPE, or CSE. EPL and DPE groups received a 10 mL loading dose of 0.1% bupivacaine with fentanyl 2 μg/mL. CSE group received intrathecal 2.5 mg bupivacaine (without opioids). Labor analgesia was maintained in all patients via patient-controlled epidural analgesia (PCEA). The primary outcome was the mean hourly consumption of epidural LA.

Results: The mean hourly consumption of epidural LA anesthetic was significantly lower in CSE (9.55 mL), compared with the EPL (11 mL), and DPE (10.5 mL), P < 0.01; but no significant difference was seen between EPL and DPE. Compared with EPL and DPE, CSE achieved faster time to complete analgesia defined as a numeric rating pain scale (NRPS) ≤1 and sensory block, lower NRPS in the first hour and higher frequencies of complete analgesia. There were no differences between groups in terms of physician top-up boluses, the occurrence of side-effects, mode of delivery, Apgar scores, and maternal satisfaction.

Conclusion: Compared with EPL and DPE, CSE without intrathecal opioids, had a less epidural LA consumption, faster onset of analgesia, with no difference in the incidence of side effects.

Trial registration: This study was registered at www.clinicaltrials.gov (NCT03980951).

Keywords: Bupivacaine; combined spinal-epidural; dural puncture epidural; epidural; labor analgesia.

Conflict of interest statement

There are no conflicts of interest.

Copyright: © 2021 Journal of Anaesthesiology Clinical Pharmacology.

Figures

Figure 1
Figure 1
Kaplan-Meier curves for time to complete analgesia (NRPS of 0 or 1) following completion of the neuraxial drug injection. EPL, epidural; DPE, dural-puncture epidural; CSE, combined-spinal epidural with intrathecal bupivacaine alone; NPRS, numeric pain rating scale
Figure 2
Figure 2
Box plots of the total NRPS scores for the EPL, DPE, and CSE group. Median and mean values are shown as a solid line () and (×) mark within the box of 25th and 75th percentile values, respectively. Whiskers represent 5th and 95th percentile values. EPL, epidural; DPE, dural-puncture epidural; CSE, combined-spinal epidural with intrathecal bupivacaine alone; NPRS, numeric pain rating scale. Data were compared using the Kruskal-Wallis test. P < 0.05 considered significant. * Significant to the CSE group

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Source: PubMed

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