High-volume patient-controlled epidural vs. programmed intermittent epidural bolus for labour analgesia: a randomised controlled study.

The aim of neuraxial analgesia is to achieve excellent pain relief with the fewest adverse effects. The most recently introduced technique for epidural analgesia maintenance is the programmed intermittent epidural bolus. In a recent study, we compared this with patient-controlled epidural analgesia without a background infusion and found that a programmed intermittent epidural bolus was associated with less breakthrough pain, lower pain scores, higher local anaesthetic consumption and comparable motor block. However, we had compared 10 ml programmed intermittent epidural boluses with 5 ml patient-controlled epidural analgesia boluses. To overcome this potential limitation, we designed a randomised, multicentre non-inferiority trial using 10 ml boluses in each group. The primary outcome was the incidence of breakthrough pain and total analgesic intake. Secondary outcomes included motor block; pain scores; patient satisfaction; and obstetric and neonatal outcomes. The trial was considered positive if two endpoints were met: non-inferiority of patient-controlled epidural analgesia with respect to breakthrough pain; and superiority of patient-controlled epidural analgesia with respect to local anaesthetic consumption. A total of 360 nulliparous women were allocated randomly to patient-controlled epidural analgesia-only or programmed intermittent epidural bolus groups. The patient-controlled group received 10 ml boluses of ropivacaine 0.12% with sufentanil 0.75 µg.ml-1 ; the programmed intermittent group received 10 ml boluses supplemented by 5 ml patient-controlled boluses. The lockout period was 30 min in each group and the maximum allowed hourly local anaesthetic/opioid consumption was identical between the groups. Breakthrough pain was similar between groups (11.2% patient controlled vs. 10.8% programmed intermittent, p = 0.003 for non-inferiority). Total ropivacaine consumption was lower in the PCEA-group (mean difference 15.3 mg, p < 0.001). Motor block, patient satisfaction scores and maternal and neonatal outcomes were similar across both groups. In conclusion, patient-controlled epidural analgesia is non-inferior to programmed intermittent epidural bolus if equal volumes of patient-controlled epidural analgesia are used to maintain labour analgesia and superior with respect to local anaesthetic consumption.

A survey of obstetric anesthesia practices in Flanders - 10 year update.

We assessed the practice of obstetric anesthesia in Flanders through an on-line enquiry form and investigated the advancements by comparing the results with those of the 2004 survey. 54 (86%) structured forms were completed, representative for 94% of the accredited maternity beds in Flanders. Obstetric anesthesia is provided in all Flemish acute hospitals and 7/10 deliveries are performed nowadays with neuraxial analgesia. For labor analgesia, classical epidural remains the main neuraxial technique (62%) whereas CSE is used as default technique in 17% of the hospitals and upon indication in 21%. In half of the departments a test dose is used to validate the correct placement of the catheter, with lidocaine as the most (68%) commonly used test drug; this practice is comparable to 10 years ago. Ropivacaine (84%) with or without sufentanil is typically used as loading dose and ropivacaine with sufentanil (83%) to maintain the epidural analgesia. Patient-controlled epidural analgesia is the preferred maintenance mode (76%) for labor analgesia. CSE with hyperbaric bupivacaine and sufentanil is the most used anesthesia protocol when caesarean section is required (47%). There is no clear preference for postoperative analgesia after cesarean section as both epidural/regional and parenteral/per os analgesia regimens are almost equally used in Flemish obstetric care.

Ultrasound guided femoral nerve block and lateral femoral cutaneous nerve block for postoperative pain control after primary hip arthroplasty: a retrospective study.

PURPOSE: The purpose of this study was to evaluate the use of an ultrasound guided femoral nerve (FN) block together with an ultrasound guided lateral femoral cutaneous nerve (LFCN) block in addition to a patient controlled intravenous analgesia (PCIA) pump with piritramide as a strategy for postoperative pain-management after primary hip arthroplasty. METHODS: In a retrospective study, data recorded from 32 patients undergoing primary hip arthroplasty in 2008, before peripheral blocks were used, were compared with data from 38 patients undergoing primary hip arthroplasty in 2011, when an ultrasound guided single shot FN and LFCN block was used. As primary endpoint the total piritramide consumption after 48 hours was analyzed. A score on a visual analog pain scale at rest and during movement was included as a secondary outcome. RESULTS: Patients receiving the peripheral nerve blocks used significantly less piritramide in comparison to the patients who received no peripheral nerve blocks (p < 0.01). Moreover, pain scores at rest and during movement were significantly lower in the group with the peripheral nerve block (p-values respectively < 0.01 and < 0.05). CONCLUSIONS: This retrospective study indicates that a FN block in combination with a LFCN block as supplementary postoperative analgesia after primary hip arthroplasty, can reduce the piritramide consumption. Furthermore, patients receiving the peripheral nerve block report lower pain scores at rest and during movement compared with the patients who did not receive a peripheral block. However, as this is a retrospective study, conclusions have to be drawn cautiously.

Clinical guidelines for the practice of peripheral nerve blocks in the adult.

These guidelines, made by BARA, are, like the "Safety First Guidelines" of the SARB, clinical recomendations for a good and safe practice when performing peripheral nerve blocks (PNB). These recommendations were made according to the most recent literature and experts opinion and are therefore prone to changes due to evolution of literature. The guidelines deal with "Informed Consent", preoperative visit, monitoring, equipment and the PNB procedure itself regardless of using ultrasound or neurostimultion or both. Advise is given when combining a PNB with general anesthesia and when a catheter technique is used.

A survey of obstetric an aesthesia practice in Flanders.

The use of locoregional anaesthesia in obstetrics in Flanders was assessed by a postal questionnaire sent to the directors of the anaesthesia departments of the 72 hospitals with an obstetric unit. 59 (82%) answers were returned. In the group of parturients who had a vaginal delivery a neuraxial technique was requested by 65% of the patients and consisted of epidural analgesia in 84%, and combined spinal epidural analgesia in 16%. Test doses are used in labour in 67%. To perform the block--spinal as well as epidural--the sitting position is somewhat preferred over the left lateral (55 versus 45%). For caesarean section general anaesthesia was used in only 5% of the deliveries, whereas spinal, single or as a part of a CSE technique, was preferred in 80%; the epidural technique was applied in 15%. There is no clear preference in technique for postoperative analgesia after caesarean delivery as both parenteral and epidural analgesia are used in 50% of the cases.

Epidural PCA with bupivacaine 0.125%, sufentanil 0.75 microgram and epinephrine 1/800.000 for labor analgesia: is a background infusion beneficial?

Eighty term parturients requesting epidural analgesia for labor pain treatment were randomly assigned to receive bupivacaine 0.125%, sufentanil 0.75 microgram/ml and epinephrine 1/800.000 by PCA modality with or without a basal rate of 3 ml/hr. A loading of 10 ml using the same mixture was administered while the PCA-demand dose consisted of 3 ml (lock out time 12 minutes). Total consumption, duration of labor, pain scores during the first and second stage of labor, maternal satisfaction and side-effects did not differ among both groups. Only when short labours were considered total consumption was lower in those treated with the demand modality only but they tended to experience more pain during the second stage. We conclude that for shortlasting labors, a low dose epidural PCA regimen results in a dose-sparing effect when compared to PCEA combined with a background infuson. For longer-lasting labors no differences between the two modalities could be observed.

Isoflurane-fentanyl anesthesia for coronary bypass surgery in patients with good left ventricular function.

The hemodynamic effects of a balanced anesthetic technique where a moderate dose of fentanyl (32 micrograms/kg) is supplemented with isoflurane were studied in 15 patients with good left ventricular function. Mean inspired isoflurane concentration was 0.63% during induction and 0.74% during maintenance. Induction of anesthesia was associated with a significant decrease (p less than 0.05) in systolic and diastolic pressure and left ventricular stroke work index (LVSWI). During maintenance systolic blood pressure and LVSWI remained significantly depressed. It is concluded that isoflurane-fentanyl anesthesia has myocardial depressant properties. There is a reduced incidence of break-through hypertension during noxious stimuli, when compared with high-dose fentanyl anesthesia. During maintenance, clinical signs that could reflect myocardial ischemia were not observed. Heart enzymes remained within normal range postoperatively in all patients and ECG morphology was unchanged.