- Continuous spinal epidural (CSE), dual-puncture epidural (DPE), and traditional epidural (Epi) are techniques for labor analgesia initiation. - Studies have found that CSE provides the fastest onset but is associated with higher risk of fetal bradycardia. DPE provides faster onset than Epi and better block symmetry. - Recent randomized controlled trials have compared 25G and 27G needles for DPE, finding the 25G needle was associated with a slightly faster time to catheter secure and analgesic bolus.

1. #IsraelAnes19
Ronald B. George, MD FRCPC
Professor, Anesthesia & Perioperative Care
Chief, Obstetric Anesthesia
Betty Irene Moore Women’s Hospital at Mission Bay
University of California San Francisco
TheLabourAnalgesia
Alphabet:
CSE,DPE,EPI

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๏Describe the current knowledge regarding CSE
analgesia
๏Describe the concerns expressed regarding CSE for
labour analgesia
๏Describe the newest modality for analgesia initiation
- DPE
๏Provide some insight into what is clinically suitable
LearningObjectives

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Spinal labor analgesia
Fentanyl 25 mcg
Morphine 250 mcg

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Clarke VT, et al. Anesthesiology 1994;81:1083
“…high incidence of uterine hyperactivity”
“…appropriate action (tocolysis) taken”

14. #IsraelAnes19Eisenach et al. Anesthesiology 1999;91:299-302
Fast
Reliable
Hypotension
FHR

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๏ The allocated anesthetic, had NO significant effect
on mode of delivery

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๏Accidental dural puncture - no difference
๏Failed analgesia - no difference
๏Non-reassuring fetal condition - no difference
SecondaryOutcomes

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ED50 of intrathecal
fentanyl for 60 min
of labor analgesia =
18.2mcg
A single transient
FHR deceleration

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๏Group Epidural
๏IT saline
๏EPI 10 mL bupivacaine 0.125% + sufentanil
7.5mcg + Epinephrine
๏Group CSE
๏IT 1.5 mcg sufentanil and 2.5 mg
bupivacaine + Epinephrine
๏EPI saline
๏Group SUF
๏IT 7.5 mcg sufentanil
๏EPI saline
Van de Velde et al. A&A 2004;98;1153-9

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22. #IsraelAnes19Van de Velde et al. A&A 2004;98;1153-9

23. #IsraelAnes19Van de Velde et al. A&A 2004;98;1153-9
EPD CSE SUF
Cesarean 13% 17% 4%
Instrumental 16% 13% 21%

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Rofaeel et al. CJA 2007;54:15
Whitty et al. IJOA 2007;16:341

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๏ Among those without initial clear fluid return the
epidural catheter replacement rate within first 4
hours was;
• 28.6% (95% CI 7.6–65%) versus
• 3.6% (95% CI 1.98–6.17%)

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Unpublished Data - Harding et al. SOAP 2019 Abstract

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31. #IsraelAnes19Bernards et al. Anesthesiology 1994;80;853-8
Tuohy

32. #IsraelAnes19Bernards et al. Anesthesiology 1994;80;853-8
Tuohy
15%

33. #IsraelAnes19Bernards et al. Anesthesiology 1994;80;853-8

34. #IsraelAnes19Bernards et al. Anesthesiology 1994;80;853-8

35. #IsraelAnes19Heesen M, et al. IJOA 2019;40:24-31

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๏ Significant heterogeneity
๏ Inconsistently analgesic outcomes
๏ Too few events to draw conclusions re: FHR
Heesen M, et al. IJOA 2019;40:24-31

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๏ 230 parturients - RCT —> DP versus NoDP
๏ DP - 27G Whitacre
๏ Test dose - 2ml - 2% Lidocaine
๏ Bolus - 5ml + 3ml - 2% Lidocaine
๏ Maintenance - 0.11% bupivacaine + fent 2µg/mL
๏ 10 mL/h, PCEA 5 mL, 10 minute lockout
Thomas JA, et al. Anesthesiology 2005;103:1046-51

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๏ Inadvertent dural puncture rate = 1.2%
๏ Intravenous catheter rate = 6-10%
๏ No CSF return = 14.4%
Thomas JA, et al. Anesthesiology 2005;103:1046-51

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DP NoDP
Catheter adjusted 37% 28%
Catheter replaced 9% 8%
Sacral sparing 30% 25%
Inadequate analgesia 21% 30%
AnalgesicOutcomes
Thomas JA, et al. Anesthesiology 2005;103:1046-51

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๏ 79 parturients - RCT —> EPI versus DPE
๏ DPE - 25G Whitacre
๏ Bolus - 12ml of 0.25% bupivacaine
๏ Maintenance - 0.125% bupivacaine + fent 2µg/mL
๏ 6 mL/h, PCEA 6 mL, 15 minute lockout
Eric Cappiello, Nollag O’Rourke, Scott Segal, and Lawrence C. Tsen A&A 2008;107:1646-51
Cappiello E, et al. A&A 2008;107:1646-51

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Primary Outcome
Sacral dermatome (S1) blockade
Cappiello E, et al. A&A 2008;107:1646-51

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DPE EPI
S1 blocked (%) at 20 min 46 37
Bilateral S1 (%) at 20 min 41 30
S1 blocked (%) 92* 70
S2 blocked (%) 77 65
Bilateral S1 block (%) 83 82
Bilateral S2 block (%) 90 76
Highest Level T10 (T9–T11) T10 (T9–T11)
AnalgesicOutcomes
Cappiello E, et al. A&A 2008;107:1646-51

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DPE EPI
VAS < 10 obtained (%) at
20 min
85%* 65%
Unilateral block 8%* 25%
Catheter adjusted 13% 28%
Catheter replaced 3% 13%
AnalgesicOutcomes
Cappiello E, et al. A&A 2008;107:1646-51

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๏ 120 parturients - RCT —> EPI / CSE / DPE
๏ Epidural - 20ml 0.125% Bupivacaine + 2mcg/
ml fentanyl
๏ Spinal - 1.7mg bupivacaine + 17mcg fentanyl
Anesth Analg 2017;124:560–9

45. #IsraelAnes19Chau et al. Anesth Analg 2017;124:560–9

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CSE - 2 (0.5 to 6.0) minutes
DPE - 11 (4 to 120) minutes
Epi - 18 (10 to 120) minutes
Chau et al. Anesth Analg 2017;124:560–9

47. #IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019

48. #IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019

49. @Ron_George #IsraelAnes19Chau et al. Anesth Analg 2017;124:560–9

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NICHDCategoryIIPattern
๏ Cat 1 = normal, Cat 3 = abnormal
๏ Cat 2 = “atypical” (SOGC)
๏ Late decelerations without loss
of variability
๏ Uterine tachysystole
๏ Maternal hypotension

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๏ 80 parturients - RCT —> EPI versus DPE
๏ Epidural - 12 ml 0.125% Bupivacaine + 50 mcg
Fentanyl
๏ DPE - 26G Whitacre confirmed dural puncture
๏ ALL CATHETERS - 3-mL test dose (1.5% lido + epi 5
µg/mL)

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12-mL bolus
(0.125% bupiv + 50 µg fent)
4-mL aliquots each minute
Adequate analgesia
=
VAS score ≤ 10mm
Bupiv 0.1% + 2µg/mL
fentanyl at 10 mL/h
Wilson et al. A&A 2018;126;545-51

53. #IsraelAnes19Wilson et al. A&A 2018;126;545-51

54. #IsraelAnes19Wilson et al. A&A 2018;126;545-51
LE DPE

55. #IsraelAnes19Contreras F, et al. Reg Anesth Pain Med 2019;44:750–753
๏ 140 parturients - RCT —> 25g or 27g DPE
๏ Bolus - 20ml of 0.125% bupivacaine + fent 2µg/mL
๏ Maintenance - 12mL of bupivacaine 0.125% q2h PRN

56. #IsraelAnes19Contreras F, et al. Reg Anesth Pain Med 2019;44:750–753
DPE
Catheter
Secured
Bolus
NRS ≤ 1
Primary Outcome

57. #IsraelAnes19Contreras F, et al. Reg Anesth Pain Med 2019;44:750–753
DPE
Catheter
Secured
Bolus
NRS ≤ 1
Primary Outcome
CSE
Zone

58. #IsraelAnes19Contreras F, et al. Reg Anesth Pain Med 2019;44:750–753
0
5
10
15
25 Gauge 27 Gauge
9.1 (3.9) minutes
10.7 (5.0) minutes
MD 1.6 minutes P = 0.037 95%CI [ 0.1 to 3.16 ]

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? Epidural bolus volume
? Epidural bolus time
? Epidural solution

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CSE DPE Epi
Onset
Catheter Replacement
Block Symmetry
Failed block
Pruritus
Fetal Bradycardia*
Cesarean
CSE DPE Epi
Rapid Slow Slow
Low Low Higher
✅ ✅ ❌
✅ ✅ / ❌ ❌
❌ ✅ ✅
✅ / ❌ ✅ ✅
✅ ✅ ✅

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Questions?
ronald.george@ucsf.edu
@Ron_George