Dural puncture epidural technique improves labor analgesia quality with fewer side effects compared with epidural and combined spinal epidural techniques

A randomized clinical trial

Anthony Chau, Carolina Bibbo, Chuan Chin Huang, Kelly G. Elterman, Eric C. Cappiello, Julian N. Robinson, Lawrence C. Tsen

Research output: Contribution to journalArticle

28 Citations (Scopus)

Abstract

BACKGROUND: The dural puncture epidural (DPE) technique is a modification of the combined spinal epidural (CSE) technique, where a dural perforation is created from a spinal needle but intrathecal medication administration is withheld. The DPE technique has been shown to improve caudal spread of analgesia compared with epidural (EPL) technique without the side effects observed with the CSE technique. We hypothesized that the onset of labor analgesia would follow this order: CSE > DPE > EPL techniques. METHODS: A total of 120 parturients in early labor were randomly assigned to EPL, DPE, or CSE groups. Initial dosing for EPL and DPE consisted of epidural 20 mL of 0.125% bupivacaine plus fentanyl 2 μg/mL over 5 minutes, and for CSE, intrathecal 0.25% bupivacaine 1.7 mg and fentanyl 17 μg. Upon block completion, a blinded coinvestigator assessed the outcomes. Two blinded obstetricians retrospectively interpreted uterine contractions and fetal heart rate tracings 1 hour before and after the neuraxial technique. The primary outcome was time to numeric pain rating scale (NPRS) ≤ 1 analyzed by using Kaplan-Meier curves and Cox proportional hazard model. Secondary outcomes included block quality, maternal adverse effects, uterine contraction patterns, and fetal outcomes analyzed by using the χ 2 test with Yates continuity correction. RESULTS: There was no significant difference in the time to NPRS ≤ 1 between DPE and EPL (hazard ratio 1.4; 95% confidence interval [CI] 0.83-2.4, P =.21). DPE achieved NPRS ≤ 1 significantly slower than CSE (hazard ratio 0.36; 95% CI 0.22-0.59, P =.0001). The median times (interquartile range) to NPRS ≤ 1 were 2 (0.5-6) minutes for CSE, 11 (4-120) minutes for DPE, and 18 (10-120) minutes for EPL. Compared with EPL, DPE had significantly greater incidence of bilateral S2 blockade at 10 minutes (risk ratio [RR] 2.13; 95% CI 1.39-3.28; P <.001), 20 minutes (RR 1.60; 95% CI 1.26-2.03; P <.001), and 30 minutes (RR 1.18; 95% CI 1.01-1.30; P <.034), a lower incidence of asymmetric block after 30 minutes (RR 0.19; 95% CI 0.07-0.51; P <.001) and physician top-up intervention (RR 0.45; 95% CI 0.23-0.86; P =.011). Compared with CSE, DPE had a significantly lower incidence of pruritus (RR 0.15; 95% CI 0.06-0.38; P <.001), hypotension (RR 0.38; 95% CI 0.15-0.98; P =.032), combined uterine tachysystole and hypertonus (RR 0.22; 95% CI 0.08-0.60; P <.001), and physician top-up intervention (RR 0.45; 95% CI 0.23-0.86; p =.011). CONCLUSIONS: Analgesia onset was most rapid with CSE with no difference between DPE and EPL techniques. The DPE technique has improved block quality over the EPL technique with fewer maternal and fetal side effects than the CSE technique for parturients requesting early labor analgesia.

Original languageEnglish (US)
Pages (from-to)560-569
Number of pages10
JournalAnesthesia and Analgesia
Volume124
Issue number2
DOIs
StatePublished - Feb 1 2017

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Punctures
Analgesia
Randomized Controlled Trials
Confidence Intervals
Odds Ratio
Pain
Uterine Contraction
Bupivacaine
Fentanyl
Incidence
Parturition
Labor Onset
Physicians
Fetal Heart Rate
Pruritus
Proportional Hazards Models
Hypotension
Needles
Mothers

ASJC Scopus subject areas

  • Anesthesiology and Pain Medicine

Cite this

Dural puncture epidural technique improves labor analgesia quality with fewer side effects compared with epidural and combined spinal epidural techniques : A randomized clinical trial. / Chau, Anthony; Bibbo, Carolina; Huang, Chuan Chin; Elterman, Kelly G.; Cappiello, Eric C.; Robinson, Julian N.; Tsen, Lawrence C.

In: Anesthesia and Analgesia, Vol. 124, No. 2, 01.02.2017, p. 560-569.

Research output: Contribution to journalArticle

Chau, Anthony ; Bibbo, Carolina ; Huang, Chuan Chin ; Elterman, Kelly G. ; Cappiello, Eric C. ; Robinson, Julian N. ; Tsen, Lawrence C. / Dural puncture epidural technique improves labor analgesia quality with fewer side effects compared with epidural and combined spinal epidural techniques : A randomized clinical trial. In: Anesthesia and Analgesia. 2017 ; Vol. 124, No. 2. pp. 560-569.
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title = "Dural puncture epidural technique improves labor analgesia quality with fewer side effects compared with epidural and combined spinal epidural techniques: A randomized clinical trial",
abstract = "BACKGROUND: The dural puncture epidural (DPE) technique is a modification of the combined spinal epidural (CSE) technique, where a dural perforation is created from a spinal needle but intrathecal medication administration is withheld. The DPE technique has been shown to improve caudal spread of analgesia compared with epidural (EPL) technique without the side effects observed with the CSE technique. We hypothesized that the onset of labor analgesia would follow this order: CSE > DPE > EPL techniques. METHODS: A total of 120 parturients in early labor were randomly assigned to EPL, DPE, or CSE groups. Initial dosing for EPL and DPE consisted of epidural 20 mL of 0.125{\%} bupivacaine plus fentanyl 2 μg/mL over 5 minutes, and for CSE, intrathecal 0.25{\%} bupivacaine 1.7 mg and fentanyl 17 μg. Upon block completion, a blinded coinvestigator assessed the outcomes. Two blinded obstetricians retrospectively interpreted uterine contractions and fetal heart rate tracings 1 hour before and after the neuraxial technique. The primary outcome was time to numeric pain rating scale (NPRS) ≤ 1 analyzed by using Kaplan-Meier curves and Cox proportional hazard model. Secondary outcomes included block quality, maternal adverse effects, uterine contraction patterns, and fetal outcomes analyzed by using the χ 2 test with Yates continuity correction. RESULTS: There was no significant difference in the time to NPRS ≤ 1 between DPE and EPL (hazard ratio 1.4; 95{\%} confidence interval [CI] 0.83-2.4, P =.21). DPE achieved NPRS ≤ 1 significantly slower than CSE (hazard ratio 0.36; 95{\%} CI 0.22-0.59, P =.0001). The median times (interquartile range) to NPRS ≤ 1 were 2 (0.5-6) minutes for CSE, 11 (4-120) minutes for DPE, and 18 (10-120) minutes for EPL. Compared with EPL, DPE had significantly greater incidence of bilateral S2 blockade at 10 minutes (risk ratio [RR] 2.13; 95{\%} CI 1.39-3.28; P <.001), 20 minutes (RR 1.60; 95{\%} CI 1.26-2.03; P <.001), and 30 minutes (RR 1.18; 95{\%} CI 1.01-1.30; P <.034), a lower incidence of asymmetric block after 30 minutes (RR 0.19; 95{\%} CI 0.07-0.51; P <.001) and physician top-up intervention (RR 0.45; 95{\%} CI 0.23-0.86; P =.011). Compared with CSE, DPE had a significantly lower incidence of pruritus (RR 0.15; 95{\%} CI 0.06-0.38; P <.001), hypotension (RR 0.38; 95{\%} CI 0.15-0.98; P =.032), combined uterine tachysystole and hypertonus (RR 0.22; 95{\%} CI 0.08-0.60; P <.001), and physician top-up intervention (RR 0.45; 95{\%} CI 0.23-0.86; p =.011). CONCLUSIONS: Analgesia onset was most rapid with CSE with no difference between DPE and EPL techniques. The DPE technique has improved block quality over the EPL technique with fewer maternal and fetal side effects than the CSE technique for parturients requesting early labor analgesia.",
author = "Anthony Chau and Carolina Bibbo and Huang, {Chuan Chin} and Elterman, {Kelly G.} and Cappiello, {Eric C.} and Robinson, {Julian N.} and Tsen, {Lawrence C.}",
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language = "English (US)",
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TY - JOUR

T1 - Dural puncture epidural technique improves labor analgesia quality with fewer side effects compared with epidural and combined spinal epidural techniques

T2 - A randomized clinical trial

AU - Chau, Anthony

AU - Bibbo, Carolina

AU - Huang, Chuan Chin

AU - Elterman, Kelly G.

AU - Cappiello, Eric C.

AU - Robinson, Julian N.

AU - Tsen, Lawrence C.

PY - 2017/2/1

Y1 - 2017/2/1

N2 - BACKGROUND: The dural puncture epidural (DPE) technique is a modification of the combined spinal epidural (CSE) technique, where a dural perforation is created from a spinal needle but intrathecal medication administration is withheld. The DPE technique has been shown to improve caudal spread of analgesia compared with epidural (EPL) technique without the side effects observed with the CSE technique. We hypothesized that the onset of labor analgesia would follow this order: CSE > DPE > EPL techniques. METHODS: A total of 120 parturients in early labor were randomly assigned to EPL, DPE, or CSE groups. Initial dosing for EPL and DPE consisted of epidural 20 mL of 0.125% bupivacaine plus fentanyl 2 μg/mL over 5 minutes, and for CSE, intrathecal 0.25% bupivacaine 1.7 mg and fentanyl 17 μg. Upon block completion, a blinded coinvestigator assessed the outcomes. Two blinded obstetricians retrospectively interpreted uterine contractions and fetal heart rate tracings 1 hour before and after the neuraxial technique. The primary outcome was time to numeric pain rating scale (NPRS) ≤ 1 analyzed by using Kaplan-Meier curves and Cox proportional hazard model. Secondary outcomes included block quality, maternal adverse effects, uterine contraction patterns, and fetal outcomes analyzed by using the χ 2 test with Yates continuity correction. RESULTS: There was no significant difference in the time to NPRS ≤ 1 between DPE and EPL (hazard ratio 1.4; 95% confidence interval [CI] 0.83-2.4, P =.21). DPE achieved NPRS ≤ 1 significantly slower than CSE (hazard ratio 0.36; 95% CI 0.22-0.59, P =.0001). The median times (interquartile range) to NPRS ≤ 1 were 2 (0.5-6) minutes for CSE, 11 (4-120) minutes for DPE, and 18 (10-120) minutes for EPL. Compared with EPL, DPE had significantly greater incidence of bilateral S2 blockade at 10 minutes (risk ratio [RR] 2.13; 95% CI 1.39-3.28; P <.001), 20 minutes (RR 1.60; 95% CI 1.26-2.03; P <.001), and 30 minutes (RR 1.18; 95% CI 1.01-1.30; P <.034), a lower incidence of asymmetric block after 30 minutes (RR 0.19; 95% CI 0.07-0.51; P <.001) and physician top-up intervention (RR 0.45; 95% CI 0.23-0.86; P =.011). Compared with CSE, DPE had a significantly lower incidence of pruritus (RR 0.15; 95% CI 0.06-0.38; P <.001), hypotension (RR 0.38; 95% CI 0.15-0.98; P =.032), combined uterine tachysystole and hypertonus (RR 0.22; 95% CI 0.08-0.60; P <.001), and physician top-up intervention (RR 0.45; 95% CI 0.23-0.86; p =.011). CONCLUSIONS: Analgesia onset was most rapid with CSE with no difference between DPE and EPL techniques. The DPE technique has improved block quality over the EPL technique with fewer maternal and fetal side effects than the CSE technique for parturients requesting early labor analgesia.

AB - BACKGROUND: The dural puncture epidural (DPE) technique is a modification of the combined spinal epidural (CSE) technique, where a dural perforation is created from a spinal needle but intrathecal medication administration is withheld. The DPE technique has been shown to improve caudal spread of analgesia compared with epidural (EPL) technique without the side effects observed with the CSE technique. We hypothesized that the onset of labor analgesia would follow this order: CSE > DPE > EPL techniques. METHODS: A total of 120 parturients in early labor were randomly assigned to EPL, DPE, or CSE groups. Initial dosing for EPL and DPE consisted of epidural 20 mL of 0.125% bupivacaine plus fentanyl 2 μg/mL over 5 minutes, and for CSE, intrathecal 0.25% bupivacaine 1.7 mg and fentanyl 17 μg. Upon block completion, a blinded coinvestigator assessed the outcomes. Two blinded obstetricians retrospectively interpreted uterine contractions and fetal heart rate tracings 1 hour before and after the neuraxial technique. The primary outcome was time to numeric pain rating scale (NPRS) ≤ 1 analyzed by using Kaplan-Meier curves and Cox proportional hazard model. Secondary outcomes included block quality, maternal adverse effects, uterine contraction patterns, and fetal outcomes analyzed by using the χ 2 test with Yates continuity correction. RESULTS: There was no significant difference in the time to NPRS ≤ 1 between DPE and EPL (hazard ratio 1.4; 95% confidence interval [CI] 0.83-2.4, P =.21). DPE achieved NPRS ≤ 1 significantly slower than CSE (hazard ratio 0.36; 95% CI 0.22-0.59, P =.0001). The median times (interquartile range) to NPRS ≤ 1 were 2 (0.5-6) minutes for CSE, 11 (4-120) minutes for DPE, and 18 (10-120) minutes for EPL. Compared with EPL, DPE had significantly greater incidence of bilateral S2 blockade at 10 minutes (risk ratio [RR] 2.13; 95% CI 1.39-3.28; P <.001), 20 minutes (RR 1.60; 95% CI 1.26-2.03; P <.001), and 30 minutes (RR 1.18; 95% CI 1.01-1.30; P <.034), a lower incidence of asymmetric block after 30 minutes (RR 0.19; 95% CI 0.07-0.51; P <.001) and physician top-up intervention (RR 0.45; 95% CI 0.23-0.86; P =.011). Compared with CSE, DPE had a significantly lower incidence of pruritus (RR 0.15; 95% CI 0.06-0.38; P <.001), hypotension (RR 0.38; 95% CI 0.15-0.98; P =.032), combined uterine tachysystole and hypertonus (RR 0.22; 95% CI 0.08-0.60; P <.001), and physician top-up intervention (RR 0.45; 95% CI 0.23-0.86; p =.011). CONCLUSIONS: Analgesia onset was most rapid with CSE with no difference between DPE and EPL techniques. The DPE technique has improved block quality over the EPL technique with fewer maternal and fetal side effects than the CSE technique for parturients requesting early labor analgesia.

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