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About a third of women receiving pethidine for labour pain subsequently require an epidural, which provides effective pain relief but increases the risk of instrumental vaginal delivery. Remifentanil patient-controlled analgesia (PCA) in labour is an alternative to pethidine, but is not widely used. We aimed to evaluate epidural analgesia progression among women using remifentanil PCA compared with pethidine. We did an open-label, multicentre, randomised controlled trial in 14 UK maternity units. We included women aged 16 years or older, beyond 37 weeks' gestation, in labour with a singleton cephalic presentation, and who requested opioid pain relief. We randomly assigned eligible participants (1:1) to either the intravenous remifentanil PCA group (40 μg bolus on demand with a 2 min lockout) or the intramuscular pethidine group (100 mg every 4 h, up to 400 mg in 24 h), using a web-based or telephone randomisation service with a minimisation algorithm for parity, maternal age, ethnicity, and mode of labour onset. Because of the differences in routes of drug administration, study participants and health-care providers were not masked to the group allocation. The primary outcome was the proportion of women who received epidural analgesia after enrolment for pain relief in labour. Primary analyses were unadjusted and analysed by the intention-to-treat principle. This study is registered with the ISRCTN registry, number ISRCTN29654603. Between May 13, 2014, and Sept 2, 2016, 201 women were randomly assigned to the remifentanil PCA group and 200 to the pethidine group. One participant in the pethidine group withdrew consent, leaving 199 for analyses. The proportions of epidural conversion were 19% (39 of 201) in the remifentanil PCA group and 41% (81 of 199) in the pethidine group (risk ratio 0·48, 95% CI 0·34–0·66; p<0·0001). There were no serious adverse events or drug reactions directly attributable to either analgesic during the study. Intravenous remifentanil PCA halved the proportion of epidural conversions compared with intramuscular pethidine. This finding challenges routine pethidine use as standard of care in labour. National Institute for Health Research Clinician Scientist Award.

BackgroundThe dural puncture epidural technique has been shown in some studies to improve the onset and quality of the initiation of labor analgesia compared with the standard epidural technique. However, few studies have investigated whether this technique confers advantages during the maintenance of analgesia. This randomized double-blinded controlled study compared dural puncture epidural analgesia with standard epidural analgesia when analgesia was maintained using programmed intermittent epidural boluses.Methods400 parturients requesting epidural labor analgesia were randomized to have analgesia initiated with a test dose of 3 mL lidocaine 1.5% with epinephrine 15 µg, followed by 12 mL ropivacaine 0.15% mixed with sufentanil 0.5 µg/mL using the dural puncture epidural or the standard epidural technique. After confirming satisfactory analgesia, analgesia was maintained with ropivacaine 0.1% and sufentanil 0.5 µg/mL via programmed intermittent epidural boluses (fixed volume 8 mL, intervals 40 min). We compared local anesthetic consumption, pain scores, obstetric and neonatal outcomes and patient satisfaction.ResultsA total of 339 patients completed the study and had data analyzed. There were no differences between the dural puncture epidural and standard epidural groups in ropivacaine consumption (mean difference −0.724 mg, 95% CI of difference −1.450 to 0.001 mg, p=0.051), pain scores, time to first programmed intermittent epidural bolus, the number of programmed intermittent epidural boluses, the number of manual epidural boluses, obstetric outcome or neonatal outcome. Patient satisfaction scores were statistically higher in the dural puncture epidural group but the absolute difference in scores was small.ConclusionOur findings suggest that when labor analgesia is maintained using the programmed intermittent epidural bolus method, there is no significant advantage to initiating analgesia using the dural puncture epidural compared with the standard epidural technique.Trial registration numberChiCTR2200062349.

Erector spinae plane (ESP) block is a novel regional anesthesia technique and gaining importance for postoperative pain management. Since it was first described, the clinicians wonder if this new simple technique can replace paravertebral block (PVB). We aimed to compare the postoperative analgesic effect of ESP block and PVB with a control group in breast surgeries. Randomized controlled trial. Operating room. Seventy-five ASA I–II patients aged 25–65, who were scheduled to go under elective unilateral breast surgery for breast cancer were included to the study. Patients were randomized into three groups as ESP, PVB, and Control group. Ultrasound (US) guided ESP block and PVB with 20 ml 0.25% bupivacaine was done preoperatively to the patients according to their groups. All patients were provided with iv patient-controlled analgesia device for postoperative analgesia. Morphine consumptions and numeric rating scale (NRS) scores for pain were recorded at 1st, 6th, 12th and 24th hours postoperatively. There was a statistically significant difference between ESP and Control groups (p < 0,001) and between PVB and Control groups (p < 0,001), while there was no difference between ESP and PVB groups (p > 0,05) for 24-hour morphine consumptions. There was a significant difference between PVB and Control groups for NRS at postoperative 1st and 6th hour (p = 0.018 and p = 0.027 respectively). This study has shown that US guided ESP block and PVB provided adequate analgesia in patients undergoing breast surgery and have an opioid sparing effect by reducing morphine consumption. Clinical Trials Registry: NCT03480958. •ESP block provides effective analgesia in breast surgery.•ESP block has lower risk of complications compared to TPV block.•Both ESP block and TPV block have a similar analgesic effect in breast surgery.

To test the hypothesis that thoracic epidural anesthesia and analgesia (TEA) reduces the incidence of chronic postoperative pain (CPSP) after video-assisted thoracoscopic surgery (VATS). A single-center, single-blind, randomized controlled trial was conducted. The study was conducted in the operating room, with follow-up assessments performed in the ward. Telephone was used to follow the long-term outcomes. 231 patients ≥18 years of age and scheduled for VATS. Patients were randomized into two groups, including an epidural block (EPI) group (general anesthesia with patient-controlled epidural analgesia) and a general anesthesia with patient-controlled intravenous analgesia (PCIA) group. The primary endpoint was the incidence of CPSP at 3 months postoperatively. CPSP data, including acute pain, neuropathic pain, depression, and side effects, were collected at 3 and 6 months postoperatively through telephone follow-up. A total of 231 patients were analyzed, including 114 in the PCIA group and 117 in the EPI group. Sixty-six patients (56.4 %) in the PCIA group and 33 patients (28.9 %) in the EPI group experienced chronic pain at 3 months postoperatively. The odds ratio (OR) was 0.31 (95 % confidence interval [CI], 0.18 to 0.54; P < 0.0001). After adjusting for confounding factors, the adjusted OR was 0.28 (95 % CI, 0.16 to 0.50, P < 0.001). Six months postoperatively, 50 (42.7 %) and 17 (14.9 %) patients in the PCIA and EPI groups, respectively, were diagnosed with CPSP (P < 0.0001). •Thoracic epidural analgesia can reduce the incidence of chronic pain after VATS.•Thoracic epidural analgesia can reduce the severity of acute pain after 24 h of VATS.•Thoracic epidural analgesia should be superior considered for patients with high risks of CPSP.

PurposeContinuous epidural infusion and programmed intermittent epidural boluses are analgesic techniques routinely used for pain relief in laboring women. We aimed to assess both techniques and compare them with respect to labor analgesia and obstetric outcomes.MethodsAfter Institutional Review Board approval, 132 laboring women aged between 18 and 45 years were randomized to epidural analgesia of 10 mL of a mixture of 0.1% bupivacaine plus 2 µg/mL of fentanyl either by programmed intermittent boluses or continuous infusion (66 per group). Primary outcome was quality of analgesia. Secondary outcomes were duration of labor, total drug dose used, maternal satisfaction, sensory level, motor block level, presence of unilateral motor block, hemodynamics, side effects, mode of delivery, and newborn outcome.ResultsPatients in the programmed intermittent epidural boluses group received statistically less drug dose than those with continuous epidural infusion (24.9 vs 34.4 mL bupivacaine; P = 0.01). There was no difference between groups regarding pain control, characteristics of block, hemodynamics, side effects, and Apgar scores.ConclusionsOur study evidenced a lower anesthetic consumption in the programmed intermittent boluses group with similar labor analgesic control, and obstetric and newborn outcomes in both groups.

Background Abnormal cardiotocogram (CTG) tracing may appear after induction of neuraxial labor analgesia. Non-reassuring fetal status (NRFS) indicated by severely abnormal tracings, such as prolonged deceleration (PD) or bradycardia, can necessitate immediate operative delivery. Combined spinal epidural analgesia (CSEA) is known to result in more frequent abnormal tracings than epidural analgesia (EA); however, the corresponding data related to dural puncture epidural (DPE) are unclear. We aimed to evaluate the rates of incidence of severe abnormal CTG after induction of DPE and CSEA. Methods In this study of nulliparous women with full-term pregnancy, data for the DPE intervention group were prospectively collected, while those for the CSEA control group were obtained from medical records. Neuraxial analgesia was performed with cervical dilation ≤ 5 cm, administering initial epidural dosing of 15 mL of 0.125% levobupivacaine with fentanyl 2.5µg/mL for DPE, and intrathecal 0.5% bupivacaine 2.5 mg (0.5ml), fentanyl 10 µg (0.2ml), and 1.3 mL of saline for CSEA. The primary outcome was the incidence of PD, defined as a fetal heart rate reduction ≥ 15 bpm below the baseline and with a lowest value < 80 bpm, and lasting for ≥ 2 min but < 10 min (fetal heart rate < 80 bpm does not have to last for ≥ 2 min), within 90 min after induction of neuraxial labor analgesia. Results A total of 302 patients were analyzed, with 151 in each group. The incidence of PD after DPE induction was significantly lower than that after CSEA induction (4.0% vs. 14.6%, P  = 0.0015, odds ratio = 0.243, 95% confidence interval = 0.095–0.617). Conclusion DPE appears to be a safer method compared to CSEA for neuraxial labor analgesia in the early stages of labor for nulliparous women. Trial registration UMIN-CTR: UMIN000035153 . Date registered: 01/01/2019.

Shortening analgesic onset has been researched and it has been documented that prewarming epidural medications to body temperature (37°C) prior to administration increases medication efficacy. Our double-blind randomized controlled trial was designed to investigate if a lower degree of prewarming in providers’ pockets could achieve similar results without the need of a bedside incubator. A total of 136 parturients were randomized into either the pocket-warmed group or the room temperature group to receive 10 mL of 0.125% bupivacaine with 2 μg/mL fentanyl epidural bolus at either the 27.8 ±1.7°C or 22.1 ±1.0°C temperatures, respectively. Primary outcome, time to analgesic onset (verbal rating scale pain score ≤ 3) was recorded in 0-, 5-, 10-, 15-, 20-, 30-, and 60-minutes intervals. It was observed that the pocket-warming group (n = 64) and room temperature group (n = 72) had no significant difference of analgesic onset time (median 8 vs. 6.2 minutes; p = 0.322). The incidence of adverse events such as hypotension, fever (≥ 38°C), nausea, vomiting, and number of top-off epidural boluses, as well as patient satisfaction rates and mode of delivery, were not significantly different between the groups as well. Further research is warranted to confirm these findings and explore the impact of different temperatures on analgesic onset time as well as the logistical issues associated with their clinical implementations.

Background Although laparoscopic surgery significantly reduces surgical trauma compared to open surgery, postoperative ileus is a frequent and significant complication after abdominal surgery. Unlike laparoscopic colorectal surgery, the effects of epidural analgesia on postoperative recovery after laparoscopic gastrectomy are not well established. We compared the effects of epidural analgesia to those of conventional intravenous (IV) analgesia on the recovery of bowel function after laparoscopic gastrectomy. Method Eighty-six patients undergoing laparoscopic gastrectomy randomly received either patient-controlled epidural analgesia with ropivacaine and fentanyl (Epi PCA group) or patient-controlled IV analgesia with fentanyl (IV PCA group), beginning immediately before incision and continuing for 48 h thereafter. The primary endpoint was recovery of bowel function, evaluated by the time to first flatus. The balance of the autonomic nervous system, pain scores, duration of postoperative hospital stay, and complications were assessed. Results The time to first flatus was shorter in the epidural PCA group compared with the IV PCA group (61.3 ± 11.1 vs. 70.0 ± 12.3 h, P  = 0.001). Low-frequency/high-frequency power ratios during surgery were significantly higher in the IV PCA group, compared with baseline and those in the epidural PCA group. The epidural PCA group had lower pain scores during the first 1 h postoperatively and required less analgesics during the first 6 h postoperatively. Conclusions Compared with IV PCA, epidural PCA facilitated postoperative recovery of bowel function after laparoscopic gastrectomy without increasing the length of hospital stay or PCA-related complications. This beneficial effect of epidural analgesia might be attributed to attenuation of sympathetic hyperactivation, improved analgesia, and reduced opioid use.

OBJECTIVES: Conventional loss of resistance (LOR) technique for identifying the epidural space (EDS) predominantly depends on experience of the anaesthetist. A technique using automated syringe for EDS identification was invented as an alternative to the traditional method. The aim of the study was to compare the efficacy and risk for complications between automatic LOR syringe — Epimatic® (Vygon, Ecouen, France) and conventional LOR — Perifix® (B.Braun Melsungen AG, Melsungen, Germany) techniques for EDS identification. MATERIAL AND METHODS: A total of 170 patients were enrolled into the study and 153 cases were analysed. Number of at- tempts, time to EDS identification, ease of EDS identification, complication rate and patient procedure-related discomfort were evaluated and compared. RESULTS: No statistically significant differences were found in the number of needle insertion attempts (1.3 in both groups), time to EDS identification (31 sec. vs. 27 sec.), efficacy of epidural analgesia (100% in both groups), or complication rate between both groups. CONCLUSIONS: The automatic and the conventional LOR techniques are comparable in terms of efficacy and safety for the epidural space identification.

Epidural maintenance technique for labour analgesia updates constantly. Thanks to infusion pumps, the recently developed programmed intermittent epidural bolus (PIEB) may reduce the use of anesthetic drugs and minimize unintended consequences such as cardio or neurotoxicity. Nevertheless, it is not yet a general practice. So far, there are no comparative studies in the literature that address levobupivacaine-based CEI + PCEA versus CEI + PIEB + PCEA. A randomized double-blind trial was carried out to evaluate if PIEB could reduce local anesthetic use compare to PCEA. Primiparous pregnant patients were divided into two groups: PIEB group (continuous infusion plus intermittent automatic doses) and PCEA group (continuous infusion plus PCEA). The primary objective was to analyze the differences between both groups regarding levobupivacaine total dose. The secondary objectives were to find out the differences concerning pain control, motor blockage, satisfaction score, labour time and delivery outcomes. Statistical analyses were done by protocol. The study recruited 200 patients (103 PIEB, 97 PCEA). The total dose administered was significantly higher in PIEB group: PCEA group 52.97 mg, IC 95% 45.65–60.28 mg and PIEB group 62.04 mg, IC 95% 55.46–68.61 mg (p = 0.021). PIEB group required fewer top up boluses (median value1; range 0–2) than CEI + PCEA group (median value 6; range 3–9) p < 0.05. Satisfaction scores were higher in PIEB group (p = 0.039, CI 95% 1.23–1.42). CEI + PIEB was found to be a good alternative to CEI + PCEA with very high rates of satisfaction in both groups although it was higher in PIEB group. PIEB group required fewer PCEA boluses. Further studies are needed to determine the best approach for epidural pain management.Clinical Trial Number and Registry URL: NCT03133091 (https://clinicaltrials.gov/ct2/show/NCT03133091?term=MB+Rodriguez&rank=1).