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2.
Anesthesiol Res Pract ; 2019: 5185901, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30863447

RESUMO

Background: The occurrence of false losses of resistance may be one of the reasons for inadequate or failed epidural block. A CompuFlo® epidural instrument has been introduced to measure the pressure of human tissues in real time at the orifice of a needle and has been used as a tool to identify the epidural space. The aim of this study was to investigate the sensitivity and the specificity of the ability of CompuFlo® to differentiate the false loss of resistance from the true loss of resistance encountered during the epidural space identification procedure. Method: We performed epidural block with the CompuFlo® epidural instrument in 120 healthy women who requested labor epidural analgesia. The epidural needle was considered to have reached the epidural space when an increase in pressure (accompanied by an increase in the pitch of the audible tone) was followed by a sudden and sustained drop in pressure for more than 5 seconds accompanied by a sudden decrease in the pitch of the audible tone, resulting in the formation of a low and stable pressure plateau. We evaluate the sensitivity, specificity, and positive and negative predictive values of the ability of CompuFlo® recordings to correctly identify the true LOR from the false LOR. Results: The drop in pressure associated with the epidural space identification was significantly greater than that recorded after the false loss of resistance (73% vs 33%) (P=0.000001). The sensitivity was 0.83, and the AUC was 0.82. Discussion: We have confirmed the ability of CompuFlo® to differentiate the false loss of resistance from the true loss of resistance and established its specificity and sensitivity. Conclusion: An easier identification of dubious losses of resistance during the epidural procedure is essential to reduce the number of epidural attempts and/or needle reinsertions with the potential of a reduced risk of accidental dural puncture especially in difficult cases or when the procedure is performed by trainees.

3.
Anesthesiol Res Pract ; 2018: 4710263, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30046305

RESUMO

Background: In this study, we describe a custom-made new epidural simulator, created by modifying the inner structure of a commercially available one, in the attempt to make it adequately realistic. To validate and evaluate the realism of our device, we used the Computerized Epidural Instrument CompuFlo. Method: The Compuflo CompuFlo curves obtained from 64 experiments on the epidural simulator were compared to 64 curves obtained from a previous human study, from consecutive laboring parturients requesting epidural analgesia. Results: Epidural simulator and human pressure curves were very similar. There was a significant difference between the drop of pressure due to false and true loss of resistance (LOR) in both the groups. Discussion: Our simulator can realistically reproduce the anatomical layers the needle must pass as demonstrated by the similarity between the simulator and human pressure curves and the small differences of pressure values recorded. CompuFlo may be used as an objective tool to create and assess and compare objectively the epidural task trainers.

4.
Curr Opin Anaesthesiol ; 26(3): 261-7, 2013 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-23563796

RESUMO

PURPOSE OF REVIEW: After initiating neuraxial labor analgesia, there are many techniques that can be used to maintain analgesia for the duration of labor. In this review, we have examined the new techniques of maintenance of epidural labor analgesia recently proposed to overcome the undesirable effects of continuous infusion and patient-controlled epidural analgesia (PCEA). RECENT FINDINGS: As labor progresses, there is a greater need for analgesia. PCEA with basal infusion, automated intermittent mandatory boluses, programmed intermittent epidural boluses and computer-integrated PCEA have been introduced to combine the advantages of a manual bolus and continuous infusion, thus matching infusion rate and bolus modality to the patient's analgesic needs. Increased maternal satisfaction, reduced anesthetic consumption and decreased incidence of motor block are features of these new maintenance techniques. SUMMARY: Technology has now provided us with more advanced drug delivery systems that may have the potential to fulfill the maternal requirements of a safe, natural, and painless childbirth, tailoring the analgesic regimen for each parturient's need.


Assuntos
Analgesia Epidural/métodos , Analgesia Obstétrica/métodos , Adulto , Analgesia Controlada pelo Paciente , Analgésicos/administração & dosagem , Analgésicos/uso terapêutico , Automação , Computadores , Feminino , Humanos , Recém-Nascido , Dor do Parto , Satisfação do Paciente , Gravidez
5.
Anesth Analg ; 113(4): 826-31, 2011 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-21788309

RESUMO

BACKGROUND: Programmed intermittent epidural anesthetic bolus (PIEB) technique may result in reduced total local anesthetic consumption, fewer manual boluses, and greater patient satisfaction compared with continuous epidural infusion (CEI). In this randomized, double-blind study, we compared the incidence of motor block and labor outcome in women who received PIEB or CEI for maintenance of labor analgesia. The primary outcome variable was maternal motor function and the secondary outcome was mode of delivery. METHODS: Nulliparous, term women with spontaneous labor and cervical dilation <4 cm were eligible to participate in the study. Epidural analgesia was initiated and maintained with a solution of levobupivacaine 0.0625% with sufentanil 0.5 µg/mL. After an initial epidural loading dose of 20 mL, patients were randomly assigned to receive PIEB (10 mL every hour beginning 60 minutes after the initial dose) or CEI (10 mL/h, beginning immediately after the initial dose) for the maintenance of analgesia. Patient-controlled epidural analgesia (PCEA) using a second infusion pump with levobupivacaine 0.125% was used to treat breakthrough pain. The degree of motor block was assessed in both lower extremities using the modified Bromage score at regular intervals throughout labor; the end point was any motor block in either limb. We also evaluated PCEA bolus doses and total analgesic solution consumption. RESULTS: We studied 145 subjects (PIEB = 75; CEI = 70). Motor block was reported in 37% in the CEI group and in 2.7% in the PIEB group (P < 0.001; odds ratio = 21.2; 95% CI: 4.9-129.3); it occurred earlier (P = 0.008) (hazard ratio = 7.8; 95% CI: 1.9-30.8; P = 0.003) and was more frequent at full cervical dilation in the CEI group (P < 0.001). The incidence of instrumental delivery was 20% for the CEI group and 7% for the PIEB group (P = 0.03). Total levobupivacaine consumption, number of patients requiring additional PCEA boluses, and mean number of PCEA boluses per patient were lower in the PIEB group (P < 0.001). No differences in pain scores and duration of labor analgesia were observed. CONCLUSIONS: Maintenance of epidural analgesia with PIEB compared with CEI resulted in a lower incidence of maternal motor block and instrumental vaginal delivery.


Assuntos
Analgesia Obstétrica/métodos , Analgesia Controlada pelo Paciente , Analgésicos Opioides/administração & dosagem , Anestésicos Locais/administração & dosagem , Extração Obstétrica , Dor do Parto/tratamento farmacológico , Atividade Motora/efeitos dos fármacos , Paridade , Sufentanil/administração & dosagem , Adulto , Analgesia Obstétrica/efeitos adversos , Analgesia Controlada pelo Paciente/efeitos adversos , Analgésicos Opioides/efeitos adversos , Anestésicos Locais/efeitos adversos , Bupivacaína/administração & dosagem , Bupivacaína/efeitos adversos , Bupivacaína/análogos & derivados , Distribuição de Qui-Quadrado , Método Duplo-Cego , Combinação de Medicamentos , Feminino , Humanos , Infusões Parenterais , Injeções Epidurais , Itália , Estimativa de Kaplan-Meier , Levobupivacaína , Razão de Chances , Medição da Dor , Gravidez , Modelos de Riscos Proporcionais , Estudos Prospectivos , Sufentanil/efeitos adversos , Resultado do Tratamento , Adulto Jovem
6.
Eur J Anaesthesiol ; 28(4): 240-4, 2011 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-21513074

RESUMO

BACKGROUND AND OBJECTIVE: The up-down sequential allocation model has been adapted to estimate the relative potency ratios for analgesia and motor block of the most commonly used epidural and intrathecal local anaesthetics. The aim of this study was to establish the median effective doses (ED50) for motor block with intrathecal bupivacaine and to estimate the ED50 ratios of these in male, female and pregnant patients. METHODS: In this prospective, double-blind, parallel group, up-down sequential allocation study, we enrolled 30 male patients, 30 female, non-pregnant patients and 30 pregnant patients undergoing elective surgery under combined spinal-epidural anesthesia. The first two groups consisted of male or female patients undergoing elective lower limb surgery and the third group consisted of pregnant women at term (>36 and <41 weeks) with singleton pregnancies undergoing elective caesarean delivery. Patients received intrathecal isobaric bupivacaine 0.5% as part of the spinal-epidural anaesthesia technique. The initial dose was 4 mg and the testing interval was 1 mg with subsequent doses being determined by the outcome in the previous patient in the same group. The end point for efficacy was the occurrence of motor block in the lower limbs within 5 min. RESULTS: There were significant (P < 0.0001) differences in ED50 estimates for motor block with intrathecal bupivacaine: 6.9 mg for men [95% confidence interval (CI), 5.2-8.6), 5.2 mg for women (95% CI, 4.5-5.8) and 3.4 mg for pregnant women (95% CI, 2.9-4.0). CONCLUSION: We have demonstrated a hierarchy of potencies for motor block with intrathecal bupivacaine for men, women and pregnant women suggesting possible relevant differences owing to the effects of both sex and pregnancy.


Assuntos
Anestesia Obstétrica/métodos , Raquianestesia/métodos , Anestésicos Locais/administração & dosagem , Bupivacaína/administração & dosagem , Atividade Motora/efeitos dos fármacos , Bloqueio Nervoso , Adulto , Análise de Variância , Cesárea , Relação Dose-Resposta a Droga , Método Duplo-Cego , Procedimentos Cirúrgicos Eletivos , Feminino , Humanos , Injeções Espinhais , Modelos Logísticos , Masculino , Procedimentos Ortopédicos , Gravidez , Estudos Prospectivos , Roma , Limiar Sensorial/efeitos dos fármacos , Fatores Sexuais , Fatores de Tempo
7.
Anesth Analg ; 104(4): 904-7, 2007 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-17377104

RESUMO

BACKGROUND: In this study, we sought to determine the median effective dose (ED50) for motor block of intrathecal ropivacaine, levobupivacaine, and bupivacaine and to define their motor-blocking potency ratios. METHODS: We enrolled 104 parturients undergoing elective cesarean delivery with combined spinal-epidural anesthesia and randomized them to one of three groups to receive intrathecal 0.5% (wt/vol) ropivacaine, levobupivacaine, or bupivacaine. The initial dose was 4 mg, and the testing interval was set at 1 mg. Efficacy was determined by the occurrence of any motor block in either lower limb (modified Bromage and hip motor function scale) within 5 min after the spinal injection. RESULTS: As assessed using up-down analysis, intrathecal ED50 for motor block was 5.79 mg for ropivacaine (95% CI 4.62-6.96), 4.83 mg for levobupivacaine (95% CI 4.35-5.32) and 3.44 mg for bupivacaine (95% CI 2.55-4.34) (P < 0.0007). The relative motor blocking potency ratios were ropivacaine/bupivacaine 0.59 (95% CI, 0.42-0.82), ropivacaine/levobupivacaine 0.83 (95% CI 0.64-1.09), and levobupivacaine/bupivacaine 0.71 (95% CI 0.51-0.98). CONCLUSIONS: There is a clinical profile of potency for motor block for the pipecolylxylidines when administered spinally: low, intermediate, and high for ropivacaine, levobupivacaine, and bupivacaine, respectively.


Assuntos
Amidas/administração & dosagem , Anestésicos Locais/administração & dosagem , Bupivacaína/administração & dosagem , Cesárea , Atividade Motora/efeitos dos fármacos , Bloqueio Nervoso , Adulto , Anestesia Epidural/métodos , Anestesia Obstétrica/métodos , Raquianestesia/métodos , Bupivacaína/análogos & derivados , Relação Dose-Resposta a Droga , Método Duplo-Cego , Procedimentos Cirúrgicos Eletivos , Feminino , Humanos , Injeções Espinhais , Levobupivacaína , Estudos Prospectivos , Ropivacaina
8.
Anesthesiology ; 102(3): 646-50, 2005 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-15731605

RESUMO

BACKGROUND: Doses for intrathecal opioid-local anesthetic mixtures have been arbitrarily chosen. The aim of this study was to compare the analgesic efficacies of intrathecal ropivacaine, levobupivacaine, and bupivacaine for labor analgesia and to determine the analgesic potency ratios for these three drugs. For this purpose, the authors used the up-down sequential allocation model, which estimates the minimum local analgesic dose for intrathecal local anesthetic. METHODS: Ninety-seven nulliparous term parturients in spontaneous labor, requesting combined spinal-epidural analgesia, were randomly allocated to one of three groups to receive 0.25% spinal ropivacaine, levobupivacaine, or bupivacaine. The initial dose of the local anesthetic drug was chosen to be 2.5 mg, and the testing interval was set at 0.25 mg. The subsequent doses were determined by the response of the previous parturient. Efficacy was accepted if the visual analog pain score decreased to 10 mm or less on a 100-mm scale within 30 min. The minimum local analgesic dose was calculated using the method of Dixon and Massey. RESULTS: The intrathecal minimum local analgesic dose was 3.64 mg (95% confidence interval, 3.33-3.96 mg) for ropivacaine, 2.94 (2.73-3.16) mg for levobupivacaine, and 2.37 (2.17-2.58) mg for bupivacaine. The relative analgesic potency ratios were 0.65 (0.56-0.76) for ropivacaine:bupivacaine, 0.80 (0.70-0.92) for ropivacaine:levobupivacaine, and 0.81 (0.69-0.94) for levobupivacaine:bupivacaine. There were significant trends (P levobupivacaine > ropivacaine.


Assuntos
Amidas/administração & dosagem , Analgesia Epidural , Analgesia Obstétrica , Anestésicos Locais/administração & dosagem , Bupivacaína/administração & dosagem , Adulto , Bupivacaína/análogos & derivados , Feminino , Humanos , Levobupivacaína , Gravidez , Ropivacaina
9.
Paediatr Drugs ; 6(6): 375-86, 2004.
Artigo em Inglês | MEDLINE | ID: mdl-15612838

RESUMO

New low-dose, local anesthetic-opioid combinations, combined spinal epidural analgesia, and new anesthetic drugs, such as ropivacaine and levobupivacaine, have modified the anesthetic practice in obstetric labor analgesia. These new analgesic techniques have less or no neonatal effects when compared with traditional epidural labor analgesia. They also have less effect on mode of delivery, which may in turn affect neonatal outcome. The use of very diluted or low concentrations of local anesthetic solutions may reduce their placental passage and thus the possible subtle neonatal effects. Small doses of epidural or spinal opioids alone or combined with low doses of local anesthetics does not affect the well-being of the neonate at birth. When considering the neonatal outcome, combined spinal epidural analgesia is as well tolerated as low-dose epidural analgesia. Transient fetal heart rate changes have been described immediately after the administration of intrathecal or epidural opioids. Maternal hypotension may also occur at the onset of epidural analgesia. Whether the occurrence of transient fetal heart rate changes or maternal hypotension immediately after the epidural block may influence the neonatal outcome at birth needs verification.


Assuntos
Analgesia Epidural , Parto Obstétrico , Assistência Perinatal/métodos , Assistência Perinatal/tendências , Analgesia Epidural/métodos , Analgesia Epidural/tendências , Parto Obstétrico/métodos , Parto Obstétrico/tendências , Feminino , Seguimentos , Humanos , Recém-Nascido , Itália , Metanálise como Assunto , Assistência Perinatal/normas , Ensaios Clínicos Controlados Aleatórios como Assunto
10.
Anesth Analg ; 98(6): 1779-82, table of contents, 2004 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-15155346

RESUMO

UNLABELLED: This study established the median effective dose (ED(50)) for motor block of intrathecal 1% and 0.1% ropivacaine and determined the effects of the concentration of the solution injected on the motor block obtained. We enrolled into this prospective, randomized, double-blind, sequential allocation study 54 parturients undergoing elective Cesarean delivery under combined spinal-epidural technique. Parturients were randomized to receive intrathecal ropivacaine either 1% or 0.1%. The initial dose was chosen to be 4 mg, with subsequent doses being determined by the response of the previous patient (testing interval, 1 mg). The occurrence of any motor block in either lower limb within 5 min from the intrathecal injection of the study solution was considered effective. The motor block at 5 min was 6.1 mg for 1% ropivacaine (95% confidence interval [CI], 5.1-7.1) and was 9.1 mg (95% CI, 7.8-10.3) for 0.1% ropivacaine (P = 0.0013; 95% CI difference, 1.3-4.7). The relative efficacy ratio of the 2 concentrations was 1.5 (95% CI difference, 1.2-1.9) in favor of the larger concentration. The ED(50) of spinal ropivacaine to produce motor block in pregnant patients was significantly influenced by the concentration of the local anesthetic, with dose requirements being increased by 50% for the smaller concentration. IMPLICATIONS: The minimum local anesthetic dose for motor block with 0.1% ropivacaine is 50% larger than the 1% concentration with a relative efficacy ratio of 1.5. Our findings suggest that more diluted local anesthetic solutions determine less motor block, and this may be considered in ambulant laboring parturients.


Assuntos
Amidas/administração & dosagem , Bloqueio Neuromuscular/métodos , Adulto , Intervalos de Confiança , Método Duplo-Cego , Feminino , Humanos , Injeções Espinhais , Gravidez , Estudos Prospectivos , Ropivacaina , Estatísticas não Paramétricas
11.
Anesth Analg ; 96(4): 1178-82, table of contents, 2003 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-12651680

RESUMO

UNLABELLED: In this study, we sought to determine the minimum analgesic doses and relative potencies of fentanyl and sufentanil when they are used as the sole epidural analgesic during the first stage of labor. Nulliparous parturients (n = 66) in spontaneous labor at term gestation and requesting epidural analgesia were enrolled into this prospective, double-blinded, randomized, sequential-allocation study. Each woman received fentanyl or sufentanil diluted with 0.9% wt/vol saline to a volume of 10 mL. The initial dose was arbitrarily chosen to be 125 microg for fentanyl and 25 microg for sufentanil, with subsequent doses being determined by the response of the previous patient (testing interval, 5 microg for fentanyl and 1 microg for sufentanil). Efficacy was accepted if the visual analog score decreased to < or =10 mm on a 100-mm scale within 30 min. The minimum analgesic dose or median effective dose was 21.1 microg (95% confidence interval [CI], 20.2-21.9 microg) for sufentanil and 124.2 microg (95% CI, 118.1-130.6 microg) for fentanyl (P < 0.0001). The sufentanil/fentanyl potency ratio was 5.9 (95% CI, 5.6-6.3). In conclusion, we have established the equivalent doses and relative potencies of fentanyl and sufentanil for epidural analgesia in the first stage of labor. IMPLICATIONS: This study determined the minimum analgesic doses of fentanyl and sufentanil for epidural anesthesia in the first stage of labor. The sufentanil/fentanyl potency ratio was 5.9. This ratio may be used to establish the equivalent doses for fentanyl and sufentanil for epidural analgesia in labor.


Assuntos
Analgesia Epidural , Analgesia Obstétrica , Anestésicos Intravenosos , Fentanila , Sufentanil , Adulto , Analgesia Epidural/efeitos adversos , Analgesia Obstétrica/efeitos adversos , Anestésicos Intravenosos/administração & dosagem , Anestésicos Intravenosos/efeitos adversos , Relação Dose-Resposta a Droga , Método Duplo-Cego , Feminino , Fentanila/administração & dosagem , Fentanila/efeitos adversos , Frequência Cardíaca/efeitos dos fármacos , Humanos , Oximetria , Medição da Dor , Gravidez , Estudos Prospectivos , Sufentanil/administração & dosagem , Sufentanil/efeitos adversos , Contração Uterina/efeitos dos fármacos
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