Use of epidural clonidine for the management of analgesia in the opioid addicted parturient on buprenorphine maintenance therapy: an observational study.

OBJECTIVES: Management of labor analgesia and post-cesarean delivery pain is challenging in the patient taking buprenorphine as opioid addiction maintenance therapy. We observed whether substituting clonidine for fentanyl in an epidural solution would provide adequate analgesia for labor and after cesarean delivery. METHODS: We substituted our standard 2 µg/mL fentanyl in 0.0625% bupivacaine epidural solution with 2 µg/mL clonidine in 0.0625% bupivacaine, or 1.2 µg/mL clonidine in 0.1% bupivacaine, for labor and post-cesarean analgesia in parturients on buprenorphine therapy. All cesarean deliveries were performed with a combined spinal-epidural technique and the catheters maintained for immediate postoperative analgesia using an epidural infusion. Catheters were discontinued the next day and patients were then managed with other analgesics based on obstetric preference. We recorded pain scores during labor and in the immediate post-surgical period; and supplemental medications given after epidural catheter removal. RESULTS: Fourteen patients were included in the study, of whom seven presented in spontaneous labor and seven had elective cesarean delivery. All laboring patients achieved good analgesia, and five of seven avoided supplemental opioid use in the postpartum phase. Of the postsurgical patients, six of seven had pain scores less than 5/10 at epidural catheter removal and three of seven avoided supplemental opioids postoperatively. CONCLUSIONS: The combination of clonidine and bupivacaine appears effective in parturients on buprenorphine therapy for opioid addiction maintenance. As study numbers were small and several factors were not examined, further confirmatory research is needed, including to determine the ideal dose of epidural clonidine in this setting.

Epidural lipomatosis causing new debilitating back pain in a patient with human immunodeficiency virus on highly active antiretroviral therapy.

Spinal epidural lipomatosis is a rare condition of adipose tissue hypertrophy in the epidural space. Through nerve root and spinal canal compression, it may lead to both sensory and motor compromise. Chronic steroid use, obesity and other metabolic derangements are known causes of spinal epidural lipomatosis. Recently, several cases have been attributed to antiretrovirals taken to treat human immunodeficiency virus, given their side effects of lipodystrophy and altered fat metabolism. We report a patient on highly active antiretroviral therapy (HAART) who developed debilitating back, hip and thigh pain during the third trimester of pregnancy that prevented ambulation. Epidural lipomatosis was diagnosed by magnetic resonance imaging. Given her evolving symptoms, neuraxial anesthesia was considered to be contraindicated. We present her management and labor course.