Severe back labor pain masks a scald caused by shower hydrotherapy: a case report.

Shower hydrotherapy is generally considered benign during labor. We report a case of extensive scalds in a primigravida who used shower hydrotherapy to treat severe back labor pain from fetal malposition. Interestingly, her back pain was so severe that she felt no pain as her scald developed, describing the hot water from the showerhead as the only measure which "soothed" her pain. Her scald was diagnosed presumptively during assessment for epidural analgesia. The nature of her back labor pain, associated with occiput posterior fetal head position and her management are described. Severe pain from persistent fetal malposition may alter somatic pain perception during labor, increasing burn risks during shower hydrotherapy. These women are also at increased risk of operative delivery and infection risks from inadvertent neuraxial blockade after burns. Improved prevention strategies and vigilance for scalds are warranted in women with severe back labor undergoing shower hydrotherapy, including by anesthesiologists assessing them for neuraxial blockade.

The 90% effective concentration of alfentanil combined with 0.075% ropivacaine for epidural labor analgesia: a single-center, prospective, double-blind sequential allocation biased-coin design.

PURPOSE: More literature studies have reported that alfentanil is safe and effective for labor analgesia. However, there is no unified consensus on the optimal dosage of alfentanil used for epidural analgesia. This study explored the concentration at 90% of minimum effective concentration (EC90) of alfentanil combined with 0.075% ropivacaine in patients undergoing epidural labor analgesia to infer reasonable drug compatibility and provide guidance for clinical practice. METHODS: In this prospective, single-center, double-blind study, a total of 45 singleton term primiparas with vaginal delivery who volunteered for epidural labor analgesia were recruited. The first maternal was administered with 3 µg/mL alfentanil combined with 0.075% ropivacaine with the infusion of 10 mL of the mixture every 50 min at a background dose of 3 mL/h. In the absence of PCEA, a total of 15 mL of the mixture is injected per hour. The subsequent alfentanil concentration was determined on the block efficacy of the previous case, using an up-down sequential allocation with a bias-coin design. 30 min after epidural labor analgesia, the block of patient failed with visual analog score (VAS) > 3, the alfentanil concentration was increased in a 0.5 µg/mL gradient for the next patient, while the block was successful with VAS ≤ 3, the alfentanil concentration was remained or decreased in a gradient according to a randomized response list for the next patient. EC90 and 95% confidence interval were calculated by linear interpolation and prediction model with R statistical software. RESULTS: In this study, the estimated EC90 of alfentanil was 3.85 µg/mL (95% confidence interval, 3.64-4.28 µg/mL). CONCLUSION: When combined with ropivacaine 0.075%, the EC90 of alfentanil for epidural labor analgesia is 3.85 µg/mL in patients undergoing labor analgesia.

Influence of different volumes and frequency of programmed intermittent epidural bolus in labor on maternal and neonatal outcomes: A systematic review and network meta-analysis.

STUDY OBJECTIVE: In labor, programmed intermittent epidural bolus (PIEB) can be defined as the bolus administration of epidural solution at scheduled time intervals. Compared to continuous epidural infusion (CEI) with or without patient controlled epidural analgesia (PCEA), PIEB has been associated with decreased pain scores and need for rescue analgesia and increased maternal satisfaction. The optimal volume and dosing interval of PIEB, however, has still not been determined. DESIGN: Systematic review and network meta-analysis registered with PROSPERO (CRD42022362708). SETTINGS: Labor. PATIENTS: Pregnant patients. INTERVENTIONS: Central, CINAHL, Global Health, Ovid Embase, Ovid Medline and Web of Science were searched for randomized controlled trials that examined pregnant patients in labor who received CEI or PIEB with or without a PCEA component. Network meta-analysis was performed with a frequentist method, facilitating the indirect comparison of PIEB with different volumes and dosing intervals through the common comparator of CEI and substituting or supplementing direct comparisons with these indirect ones. Continuous and dichotomous outcomes were presented as mean differences and odds ratios, respectively, with 95% confidence intervals. The risk of bias was evaluated using the Cochrane risk of bias 2 tool. MAIN RESULTS: Overall, 30 trials were included. For the first primary endpoint, need for rescue analgesia, PIEB delivered at a volume of 4 ml and frequency of 45 min (4/45) was inferior to PIEB 8/45 (OR 3.55; 95% CI 1.12-11.33), PIEB 10/60 was superior to PIEB 2.5/15 (OR 0.36; 95% CI 0.16-0.82), PIEB 4/45 (OR 0.14; 95% CI 0.03-0.71) and PIEB 5/60 (OR 0.23; 95% CI 0.08-0.70), and PIEB 5/30 was not inferior to PIEB 10/60 (OR 0.61; 95% CI 0.31-1.19). For the second primary endpoint, maternal satisfaction, no differences were present between the various PIEB regimens. The quality of evidence for these multiple primary endpoints was low owing to the presence of serious limitations and imprecision. Importantly, PIEB 5/30 decreased the pain score at 4 h compared to PIEB 2.5/15 (MD 2.45; 95% CI 0.13-4.76), PIEB 5/60 (MD -2.28; 95% CI -4.18--0.38) and PIEB 10/60 (MD 1.73; 95% CI 0.31-3.16). Mean ranking of interventions demonstrated PIEB 10/60 followed by PIEB 5/30 to be best placed to reduce the cumulative dose of local anesthetic, and this resulted in an improved incidence of lower limb motor blockade for PIEB 10/60 in comparison to CEI (OR 0.30; 95% CI 0.14-0.67). No differences in neonatal outcomes were found. Some concerns were present for the risk of bias in two thirds of trials and the risk of bias was shown to be high in the remaining one third of trials. CONCLUSIONS: Future research should focus on PIEB 5/30 and PIEB 10/60 and how the method of analgesia initiation, nature and concentration of local anesthetic, design of epidural catheter and rate of administration might influence outcomes related to the mother and neonate.

Effect of Dural-Puncture Epidural vs Standard Epidural for Epidural Extension on Onset Time of Surgical Anesthesia in Elective Cesarean Delivery: A Randomized Clinical Trial.

Importance: Dural-puncture epidural (DPE) and standard epidural are common modes of neuraxial labor analgesia. Little is known about conversion of DPE-initiated labor analgesia to surgical anesthesia for cesarean delivery. Objective: To determine whether DPE provides a faster onset and better-quality block compared with the standard epidural technique for cesarean delivery. Design, Setting, and Participants: This double-blind, randomized clinical trial was conducted between April 2019 and October 2022 at a tertiary care university hospital (University of Arkansas for Medical Sciences). Participants included women aged 18 years and older undergoing scheduled cesarean delivery with a singleton pregnancy. Interventions: Participants were randomized to receive DPE or standard epidural in the labor and delivery room. A T10 sensory block was achieved and maintained using a low concentration of bupivacaine with fentanyl through the epidural catheter until the time of surgery. Epidural extension anesthesia was initiated in the operating room. Main Outcomes and Measures: The primary outcome was the time taken from chloroprocaine administration to surgical anesthesia (T6 sensory block). The secondary outcome was the quality of epidural anesthesia, as defined by a composite of the following factors: (1) failure to achieve a T10 bilateral block preoperatively in the delivery room, (2) failure to achieve a surgical block at T6 within 15 minutes of chloroprocaine administration, (3) requirement for intraoperative analgesia, (4) repeat neuraxial procedure, and (5) conversion to general anesthesia. Results: Among 140 women (mean [SD] age, 30.1 [5.2] years), 70 were randomized to the DPE group, and 70 were randomized to the standard epidural group. The DPE group had a faster onset time to surgical anesthesia compared with the standard epidural group (median [IQR], 422 [290-546] seconds vs 655 [437-926] seconds; median [IQR] difference, 233 [104-369] seconds). The composite rates of lower quality anesthesia were 15.7% (11 of 70 women) in the DPE group and 36.3% (24 of 66 women) in the standard epidural group (odds ratio, 0.33; 95% CI, 0.14-0.74; P = .007). Conclusions and Relevance: Anesthesia initiated following a DPE technique resulted in faster onset and improved block quality during epidural extension compared with initiation with a standard epidural technique. Further studies are needed to confirm these findings in the setting of intrapartum cesarean delivery. Trial Registration: ClinicalTrials.gov Identifier: NCT03915574.

Dual epidural catheters for labor analgesia in a spinal cord injury patient: a case report

Abstract Impediment to local anesthetic solution in the epidural space results in unsatisfactory pain relief during labor epidural. Patients with a history of back trauma and spinal instrumentation have increased rates of epidural failure due to patchy spread of local anesthetic with obliterated epidural space. Dual Epidural Catheters (DEC) can be used in such clinical scenarios with complete labor analgesia and improved patient satisfaction. We present the successful management of a parturient with vertebral fracture at risk for epidural failure and neurologic injury due to bone fragments and inserted cranial and caudal to the fractured vertebra using ultrasound to avoid neurologic sequelae.

Changes in sensory block level during a programmed intermittent epidural bolus regimen for labour analgesia: a prospective observational cohort study.

PURPOSE: In the context of a programmed intermittent epidural bolus (PIEB) regimen for labour analgesia, one can identify an upper sensory block level (USBL), defined as the highest dermatome with any altered sensation to cold, and a lower sensory block level (LSBL), defined as the highest dermatome with complete sensory block to cold. This study investigated whether and how these sensory block levels vary within PIEB cycles. METHODS: We enrolled patients requesting epidural analgesia. An epidural catheter was placed at L2/L3 or L3/L4. A test dose of 3 mL of bupivacaine 0.125% with fentanyl 3.3 µg·mL-1 was administered, followed by 12 mL of the same solution as the loading dose. A PIEB plus patient-controlled epidural analgesia (PCEA) regimen was initiated 40 min after the loading dose, with bupivacaine 0.0625% with fentanyl 2 µg·mL-1: PIEB 10 mL, PIEB interval 40 min, PCEA 5 mL, lockout interval 10 min, maximum hourly 30 mL. As per institutional protocol, sensory block levels to ice were assessed 20 min after the loading dose and then hourly. Patients included in the study underwent eight extra assessments: immediately before the second and fourth PIEB and 10, 20, and 30 min after the second and third PIEB. RESULTS: We studied 30 patients. The USBL and LSBL achieved their peak value 100 min after the loading dose. The median [interquartile range] USBL was T8 [T9-T7] and T6 [T7-T4] 20 and 100 min after the loading dose, respectively; LSBL was T10 [T11-T6] and T8 [T9-T6], respectively. There was no significant variation in USBL or LSBL within the PIEB cycle between the second and the third or the third and the fourth PIEB. CONCLUSION: Once peak sensory block levels are established, there is no significant variation in the USBL and LSBL within the PIEB cycles. STUDY REGISTRATION: www. CLINICALTRIALS: gov (NCT04716660); registered 21 January 2021.

RéSUMé: OBJECTIF: Dans le contexte du schéma de bolus périduraux intermittents programmés (PIEB) pour l'analgésie du travail, on peut identifier un niveau de bloc sensoriel haut (USBL) défini comme étant le dermatome le plus haut ayant une quelconque modification de la sensation au froid et un niveau de bloc sensoriel bas (LSBL) défini comme étant le dermatome le plus haut ayant un bloc sensoriel complet au froid. Cette étude a cherché à savoir si et comment ces niveaux de blocs sensoriels varient au cours des cycles de PIEB. MéTHODES: Nous avons recruté des patientes demandant une analgésie péridurale. Un cathéter péridural a été placé au niveau L2/L3 ou au niveau L3/L4. Une dose test de 3 mL de bupivacaïne 0,125% avec fentanyl 3,3 µg·ml−1 était administrée, suivie de 12 mL de la même solution représentant la dose de base. Un protocole de PIEB plus analgésie péridurale contrôlée par la patiente (PCEA) a débuté 40 min après l'administration de la dose de base, comportant de la bupivacaïne 0,0625% et du fentanyl 2 µg·ml−1: PIEB 10 mL; intervalle de PIEB 40 min.; PCEA 5 ml; intervalle de verrouillage 10 min.; maximum par heure 30 mL. Conformément au protocole de l'établissement, les niveaux de bloc sensoriel à la glace ont été évalués 20 min après l'administration de la dose de base, puis toutes les heures. Les patientes incluses dans l'étude ont eu huit évaluations supplémentaires: immédiatement avant le deuxième et le quatrième PIEB et 10, 20 et 30 min après les deuxième et troisième PIEB. RéSULTATS: Nous avons étudié 30 patientes. L'USBL et le LSBL ont atteint leur valeur pic 100 min après l'administration de la dose de base. L'USBL médian [plage interquartile] était T8 [T9­T7] et T6 [T7­T4], respectivement 20 et 100 min après la dose de base; Le LSBL était, respectivement, T10 [T11­T6] et T8 [T9­T6]. Il n'y avait pas de variation significative de l'USBL ou du LSBL dans le cycle de PIEB entre le deuxième et le troisième ou le troisième et le quatrième PIEB. CONCLUSION: Une fois les niveaux maximums de blocs sensoriels établis, il n'y a pas de variation significative dans l'USBL et le LSBL dans les cycles de PIEB. ENREGISTREMENT DE L'éTUDE: www.clinicaltrials.gov (NCT04716660); enregistrée le 21 janvier 2021.

Optimization of programmed intermittent epidural bolus volume for different concentrations of ropivacaine in labor analgesia: a biased coin up-and-down sequential allocation trial.

BACKGROUND AND OBJECTIVES: To date, programmed intermittent epidural bolus (PIEB) has been widely used in obstetric analgesia, while no optimal PIEB regimen has been proposed. This study aimed to assess effective analgesia in 90% of women (EV90) with different concentrations of ropivacaine (0.075% and 0.1%) combined with 0.5 µg/mL sufentanil, at an interval of 40 min using the biased coin design-up-and-down method (BCD-UDM), and to explore whether there is a difference in EV90 with the increase of ropivacaine concentration. METHODS: In total, 103 primiparous women were assigned to two groups, including group A (n = 52) and group B (n = 51). Parturients in group A were treated with 0.075% ropivacaine and 0.5 µg/mL sufentanil, while those in group B were treated with 0.1% ropivacaine and 0.5 µg/mL sufentanil. Used the biased coin up-and-down sequential allocation method to determine the EV90. The secondary outcomes were sensory block level, motor block, and adverse events (hypotension, urinary retention, and pruritus). RESULTS: The results revealed that EV90 was 10 mL (95% confidence interval (CI):8.03-11.54) in group A, and EV90 was 9 mL (95% CI:7.49-10.51) in group B by the isotonic regression method. The highest level of the sensory block was T8, and the lowest was T12. No case of hypotension was recorded,and only 4 parturients complained of motor block. CONCLUSION: With an interval of 40 min, the optimal PIEB bolus volume of 0.075% ropivacaine and 0.5 µg/mL sufentanil was 10 mL, 0.1% ropivacaine and 0.5 µg/mL sufentanil was 9 mL. Moreover, the PIEB volume decreased along with the higher concentration of ropivacaine. TRIAL REGISTRATION: ChiCTR registration number: ChiCTR2000040917 . Registration date: December 15, 2020.

Optimum programmed intermittent epidural bolus interval time between 8 mL boluses of Ropivacaine 0.1% with sufentanil 0.3 µg/mL with dural puncture epidural technique for labor analgesia: A biased-coin up-and-down sequential allocation trial.

OBJECTIVE: The combination of dural puncture epidural (DPE) technique and programmed intermittent epidural bolus (PIEB) is a novel alternative labor analgesia regimen providing rapid analgesia onset and improved analgesia quality. However, the optimum PIEB settings for using the DPE technique remain unclear. DESIGN: Biased-coin up-and-down sequential allocation design. SETTING: Labor analgesia. PATIENTS: Forty nulliparous women requesting labor analgesia. INTERVENTIONS: Dural was punctured using a 25-gauge Whitacre needle. 12 mL of 0.1% ropivacaine with 0.3 µg/mL of sufentanil was used for initiation. Labor analgesia was maintained using the same solution with a fixed 8 mL volume beginning 1 h after initiation. The interval for the first patient was 60 min and varied for subsequent patients according to the biased-coin design (groups 60, 50, 40, and 30; interval 60, 50, 40, and 30 min, respectively). MEASUREMENTS: The primary outcome was adequate analgesia, defined as no request of patient-controlled epidural analgesia or provider boluses for 6 h after the epidural analgesia initiation or until the maternal cervix was fully dilated, whichever came first. The secondary outcomes included sensory blockade level, motor strength, maternal hypotension, and pruritus. RESULTS: The estimated effective interval in 90% of participants was 41.5 min (95% CI 39.5-43.5 min) and 40.5 min (95% CI 33.7-47.5 min) by the truncated Dixon and Mood method and the isotonic regression method, respectively, for the 40 women included. The proportions of patients with the highest sensory block level achieving or above T6 were 60%, 26%, 27%, and 0% in groups 30, 40, 50, and 60, respectively. One patient presented a Bromage score of 1. There was a low incidence of hypotension in all the groups with no need for vasopressor treatment. CONCLUSIONS: The optimum PIEB interval time between 8 mL boluses of ropivacaine 0.1% and sufentanil 0.3 µg/mL when using the DPE technique was approximately 41 min.

A comparison of two versus four sterile water injections for the relief of back pain in labour: A multicentre randomised equivalence trial.

BACKGROUND: Recent trials demonstrated the safety and efficacy of sterile water injections to provide relief from labour back pain. While four injections is the most common approach variations in technique, such as employing two injections, are also used. AIM: To determine if the analgesic effect of two sterile water injections is clinically equivalent to four. METHODS: 238 women in labour with a Visual Analogue Scale pain score (VAS) of 70 millimetres (mm) (0 = no pain; 100 = worst pain imaginable) were randomised to two or four sterile water injections. The primary outcome was pain measured on a VAS at 30 min post treatment. A priori margin of equivalence was set at ±10 mm. Secondary outcomes included the likelihood of achieving an at least 30% and 50% reduction in pain, birth and neonatal outcomes. RESULTS: At 30 min post-injection the difference in VAS scores between the techniques was -5.97 (95% Confidence Interval [CI] -13.18-1.22). As the lower end of the CI exceeds the margin of -10 mm equivalence was not demonstrated. Both techniques achieved an at least 30% reduction in pain in over 75% of participants though duration of effect was longer in the four injection group. There was no difference in other birth related secondary outcomes. CONCLUSION: Four injections provided a margin of benefit over two injections in level and duration of analgesia. DISCUSSION: Four injections remains the technique of choice though two injections still provided significant pain relief and would be suitable where it was not possible or desirable to provide four.

Programmed intermittent epidural bolus for post-cesarean delivery analgesia: a randomized controlled double-blind trial.

PURPOSE: The aim of this study was to assess the efficacy of programmed intermittent epidural boluses (PIEB) in postoperative pain management compared with continuous epidural infusion (CEI) after cesarean delivery. METHODS: A total of 58 participants were randomly allocated to receive PIEB (3 mL bolus every 60 min) or CEI (3 mL/h) for postoperative analgesia after undergoing elective cesarean section under combined spinal-epidural anesthesia. Both groups had the same epidural solution containing ropivacaine 0.2% plus fentanyl 2 µg/mL. The primary outcome was postoperative pain score at rest and mobilization at 6, 12, 24, and 48 h. The secondary outcomes were the total amount of ropivacaine used in the 48 h study period and the time to the first PCEA bolus. RESULTS: Data from 58 women were analyzed. There was a reduction in pain verbal numerical rating scores at 12 h in patients receiving PIEB compared with CEI at rest [2 (1.75-3) vs. 3 (2-4), p = 0.011]; and on movement [4 (3-5) vs. 5 (4-6), p = 0.038]. No differences were found in pain scores at any other time-point up to 48 h. Total ropivacaine consumption at 48 h was less in the PIEB group compared with the CEI group [316 mg (304-321) vs. 336 mg (319-344), p = 0.001]. CONCLUSION: Postoperative epidural analgesia for patients who underwent cesarean delivery with PIEB compared with CEI resulted in less ropivacaine usage while providing comparable analgesia.

Comparison of opioid local anesthetic combination regimens using the number of self-administrated boluses in patient-controlled epidural analgesia after cesarean section: A retrospective single-center study.

ABSTRACT: The aim of this study was to assess the efficacy of combined opioids by comparing four regimens of patient-controlled epidural analgesia (PCEA) after cesarean section.Parturient patients who underwent elective or emergent cesarean section under combined spinal and epidural anesthesia from April 2013 to March 2016 were retrospectively analyzed. Based on PCEA, they were assigned to one of 4 groups: local anesthetic alone (LA), epidural single morphine administration during surgery followed by local anesthetic alone (M), local anesthetic combined with fentanyl 10 µg/h (F10), or local anesthetic combined with fentanyl 20 µg/h (F20). The primary outcome was the number of PCEA boluses used. Secondary outcomes included the use of rescue analgesia, postoperative nausea and vomiting, and postoperative pruritus.A total of 250 parturients were analyzed. Whereas the number of PCEA boluses in the LA group was significantly higher than in the other combined opioid groups on the day of surgery and postoperative day 1 (LA: 3 [1-6] and 7 [4-9] vs M: 2 [0-4] and 4 [0-7] vs F10: 1 [0-4] and 3 [0-6] vs F20: 1 [0-3] and 2 [0-8], P = .012 and 0.010, respectively), within the combined opioid groups, the number was not significantly different. Significantly fewer patients in the F20 group required rescue analgesia on postoperative day 1 and 2 (25 and 55%) than those in the M (66 and 81%) and F10 (62 and 66%) groups (P < .001 and P = .007, respectively). Postoperative nausea and vomiting and pruritus were significantly higher in the M group (P < .008 and P = .024, respectively).The results of the present study suggest that local anesthetic alone after a single administration of morphine, or local anesthetic combined with fentanyl 10 µg/h would generally be adequate for PCEA, whereas local anesthetic combined with fentanyl 20 µg/h would be suitable for conventional epidural analgesia.

The analgesic efficacy of ultrasound-guided transversus abdominis plane (TAP) block combined with oral multimodal analgesia in comparison with oral multimodal analgesia after caesarean delivery: a randomized controlled trial.

BACKGROUND: The transversus abdominis plane (TAP) block is used increasingly in parturients after caesarean delivery. This is a randomized controlled trial to evaluate the effectiveness of bilateral single-shot of TAP blocks in patients who received multimodal oral analgesia for postoperative pain relief. METHODS: Parturients who were scheduled for elective caesarean delivery under spinal anaesthesia were recruited and randomized to receive bilateral single-shot of TAP blocks or placebo in addition to multimodal oral analgesia which consisted of regular tramadol, celecoxib and paracetamol, with oral oxycodone used as a rescue for breakthrough pain. Only parturients in the TAP group would receive the TAP blocks with an injection of 15 ml (0.25%) ropivacaine on each side under aseptic techniques. All the parturients were evaluated for pain or related complications in the first 24 h after surgery. The primary outcome is the percentage of parturients who required oxycodone as a rescue analgesia. RESULTS: Eighty and 79 parturients were allocated to the TAP and placebo group respectively. Nine out of 79 (11.4%) parturients in the TAP group and 15 out of 73 (20.5%) parturients in the placebo group required oxycodone for breakthrough pain, P = 0.122. CONCLUSIONS: Bilateral single-shot of TAP blocks confer little additional benefit when a multimodal oral analgesic regimen is used for pain control after caesarean section under spinal anaesthesia. TRIAL REGISTRATION: Clinical Trial Registry of China ( http://www.chictr.org.cn ) identifier: ChiCTR-INR-16010130 , retrospectively registered on Dec 12, 2016.

Maternal safety: recent advances and implications for the obstetric anesthesiologist.

PURPOSE OF REVIEW: Recognition of the increasing maternal mortality rate in the United States has been accompanied by intense efforts to improve maternal safety. This article reviews recent advances in maternal safety, highlighting those of particular relevance to anesthesiologists. RECENT FINDINGS: Cardiovascular and other chronic medical conditions contribute to an increasing number of maternal deaths. Anesthetic complications associated with general anesthesia are decreasing, but complications associated with neuraxial techniques persist. Obstetric early warning systems are evolving and hold promise in identifying women at risk for adverse intrapartum events. Postpartum hemorrhage rates are rising, and rigorous evaluation of existing protocols may reveal unrecognized deficiencies. Development of regionalized centers for high-risk maternity care is a promising strategy to match women at risk for adverse events with appropriate resources. Opioids are a growing threat to maternal safety. There is growing evidence for racial inequities and health disparities in maternal morbidity and mortality. SUMMARY: Anesthesiologists play an essential role in ensuring maternal safety. While continued intrapartum vigilance is appropriate, addressing the full spectrum of contributors to maternal mortality, including those with larger roles beyond the immediate peripartum time period, will be essential to ongoing efforts to improve maternal safety.

Intra-operative ketorolac 15 mg versus 30 mg for analgesia following cesarean delivery: a retrospective study.

BACKGROUND: Ketorolac is a nonsteroidal anti-inflammatory drug used as part of multimodal analgesia in women undergoing cesarean delivery. The lowest effective dose of ketorolac that best optimizes analgesia without increasing side effects is unclear. We performed this retrospective study to compare the analgesic efficacy of 15 mg or 30 mg ketorolac administered intra-operatively to our obstetric population. METHODS: We included patients who underwent cesarean delivery under neuraxial anesthesia and received 15 mg or 30 mg of ketorolac intra-operatively. Our multimodal analgesic regimen is standardized and includes 150 µg spinal or 3 mg epidural morphine, 975 mg rectal acetaminophen, and 15-30 mg intravenous ketorolac within 15 min of surgery completion. The primary outcome was opioid use in the first 6 h after surgery. Secondary outcomes were opioid use at 24 and 48 h, opioid dose, pain scores, breastfeeding, postoperative serum creatinine and need for rescue anti-emetics. RESULTS: One-thousand-three-hundred and forty-nine patients were analyzed (15 mg ketorolac n=999; 30 mg n=350). There was no difference between the two groups in patient demographics or intra-operative characteristics. There was no significant difference between groups for opioid use at 6 h after surgery (50.3% vs 52.0%, odds ratio [95% confidence interval] 1.13 [0.87 to 1.47]). There were also no significant differences between the groups for secondary outcomes. CONCLUSIONS: There was no difference in opioid use between patients receiving either a 15 mg or a 30 mg dose of ketorolac given intra-operatively for postoperative analgesia following cesarean delivery.

Programmed intermittent epidural bolus vs. patient-controlled epidural analgesia for maintenance of labour analgesia: a two-centre, double-blind, randomised study†.

The programmed intermittent epidural bolus technique has shown superiority to continuous epidural infusion techniques, with or without patient-controlled epidural analgesia for pain relief, reduced motor block and patient satisfaction. Many institutions still use patient-controlled epidural analgesia without a background infusion, and a comparative study between programmed intermittent epidural bolus and patient-controlled epidural analgesia without a background infusion has not yet been performed. We performed a randomised, two-centre, double-blind, controlled trial of these two techniques. The primary outcome was the incidence of breakthrough pain requiring a top-up dose by an anaesthetist. Secondary outcomes included: motor block; pain scores; patient satisfaction; local anaesthetic consumption; and obstetric and neonatal outcomes. We recruited 130 nulliparous women who received initial spinal analgesia, and then epidural analgesia was initiated and maintained with either programmed intermittent epidural bolus or patient-controlled epidural analgesia using ropivacaine 0.12% with sufentanil 0.75 µg·ml-1 . The programmed intermittent epidural bolus group had a programmed bolus of 10 ml every hour, with on-demand patient-controlled epidural analgesia boluses of 5 ml with a 20 min lockout, and the patient-controlled epidural analgesia group had a 5 ml bolus with a 12 min lockout interval; the potential maximum volume per hour was the same in both groups. The patients in the programmed intermittent epidural bolus group had less frequent breakthrough pain compared with the patient-controlled epidural analgesia group, 7 (10.9%) vs. 38 (62.3%; p < 0.0001), respectively. There was a significant difference in motor block (modified Bromage score ≤ 4) frequency between groups, programmed intermittent epidural bolus group 1 (1.6%) vs. patient-controlled epidural analgesia group 8 (13.1%); p = 0.015. The programmed intermittent epidural bolus group had greater local anaesthetic consumption with fewer patient-controlled epidural analgesia boluses. Patient satisfaction scores and obstetric or neonatal outcomes were not different between groups. In conclusion, we found that a programmed intermittent epidural bolus technique using 10 ml programmed boluses and 5 ml patient-controlled epidural analgesia boluses was superior to a patient-controlled epidural analgesia technique using 5 ml boluses and no background infusion.

Ultrasound-guided transmuscular quadratus lumborum catheters for elective caesarean section: A protocol for a single-centre, double-blind randomised trial.

BACKGROUND: Management of moderate-to-severe post-operative pain after elective caesarean section (ECS) is internationally primarily based on either epidural catheters or opioids. However, both techniques are associated with some undesirable adverse events. Bilateral transmuscular quadratus lumborum (TQL) block has proven to reduce opioid consumption significantly in the first 24 post-operative hours following ECS and prolong time to first opioid (TFO) (Hansen CKD, Steingrimsdottir M, Laier GE, et al. Reg Anesth Pain Med. 2019; 10.1136/rapm-2019-100540). We present a randomised controlled trial aiming to investigate whether continuous analgesia via bilateral TQL catheters can prolong TFO after ECS. METHODS: This study is a double-blind, randomised, placebo-controlled trial. Patients should be 18 years or older and scheduled for ECS under spinal anaesthesia to be included. Main exclusion criteria are inability to cooperate, excessive daily intake of opioids and difficult ultrasound visualisation of muscular and fascial structures. Participants are randomised to receive ultrasound-guided injection of either 30 mL ropivacaine 0.2% bilaterally and an elastomeric pump containing 0.2% ropivacaine, or 30 mL saline bilaterally and an elastomeric pump containing saline, 2 hours after catheter placement. The primary endpoint is TFO. Secondary outcomes include pain intensity on a numeric rating scale (NRS), accumulated morphine consumption during 24 hours, displacement frequency of catheters and morphine-related adverse events. RECRUITMENT PERIOD: Four patients were included from September 2018 to November 2018. Inclusion was resumed in June 2019 and will continue until 24 patients with useful data have been included in the trial. Expected inclusion period is 10-14 months. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03663478. EudraCT: 2017-003625-15.

Anticipated difficult airway during obstetric general anaesthesia: narrative literature review and management recommendations.

We reviewed the literature on management of general and regional anaesthesia in pregnant women with anticipated airway difficulty. We identified 138 publications comprising 158 cases; these either described equipment or techniques for the provision of general anaesthesia, or the management of women with regional analgesia or anaesthesia, with the aim of avoiding general anaesthesia. Most of the former group described women requiring caesarean section alone, or in combination with other surgery, which was sometimes airway-related. Management techniques were largely similar to those in non-obstetric patients requiring surgery who have airway difficulties, although suggested differences related to physiological changes of pregnancy and avoidance of nasal intubation. In the reports discussing regional anaesthesia, consideration was often given to the possible requirement for urgent out-of-hours anaesthetic intervention, and the predicted difficulty of management of general anaesthesia should it be required. In a number of reported cases, multidisciplinary planning led to the conclusion that elective caesarean section should be performed in order to avoid emergency airway management. Based on this literature review, we advise antenatal planning that includes: assessment of the patient's clinical characteristics; consideration of the equipment and personnel available to provide safe airway management out-of-hours; and elective caesarean section should these be lacking. If general anaesthesia is required, a risk assessment must be made as to the probability of safe airway management after the induction of anaesthesia, and awake tracheal intubation should be used if this cannot be assured. Decision aids are provided to illustrate these points. Online appendices include a comprehensive compendium of case reports on the management of a number of rare syndromes and airway conditions.

Ropivacaine and Ketorolac Wound Infusion for Post-Cesarean Delivery Analgesia: A Randomized Controlled Trial.

OBJECTIVE: To evaluate the efficacy of wound infusion with ropivacaine plus ketorolac compared with placebo for post-cesarean delivery analgesia in women who received a multimodal analgesic regimen including intrathecal morphine. METHODS: In a randomized double-blind study, women undergoing scheduled cesarean delivery under spinal or combined spinal epidural anesthesia were randomized to wound infusion with ropivacaine 0.2% plus ketorolac, or saline placebo using an elastometric pump for 48 hours. The primary outcome was pain score with movement at 24 hours after surgery (0-10 scale, 0=no pain and 10=worst possible pain). Secondary outcomes included pain scores at rest at 24 hours, pain scores at rest and with movement at 2 and 48 hours, opioid consumption, and time to first rescue analgesic. A sample size of 35 per group (n=70) was planned. RESULTS: From November 8, 2016, to May 17, 2019, 247 women were screened, and 71 completed the study per protocol: 38 in the placebo group and 33 in the ropivacaine plus ketorolac group. Patient demographics and intraoperative characteristics were comparable between the groups. There was no significant difference between the groups in the primary outcome of pain score with movement at 24 hours (difference in median score 0, 95% CI -1 to 2, P=.94). There were also no significant differences between the placebo and ropivacaine plus ketorolac groups in pain scores at other time points, in total opioid consumption (difference in median consumption -12.5 mg, 95% CI -30 to 5, P=.11), or in time to rescue analgesics (median [interquartile range] 660 [9-1,496] vs 954 [244-1,710] minutes, hazard ratio 0.69, 95% CI 0.41 to 1.17, P=.16). CONCLUSION: There was no benefit of wound infusion with ropivacaine and ketorolac in women who received intrathecal morphine and a multimodal analgesic regimen. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02829944. FUNDING SOURCE: The study was supported in part by Avanos Medical Inc.