Comparison of Dural Puncture Epidural, Epidural and Combined Spinal-Epidural Anesthesia for Cesarean Delivery: A Randomized Controlled Trial

Abstract

Purpose Catheter-based techniques such as combined spinal-epidural (CSE) anesthesia which are sometimes indicated for obstetric anesthesia have a complex mechanism of action. The application of the dural puncture epidural (DPE) anesthesia for cesarean section (CS) has not been well investigated. The present study compared the relatively novel DPE technique with epidural (EA) and CSE anesthesia. Patients and Methods We randomly assigned 150 parturients who underwent elective CS to receive DPE, EA or CSE anesthesia. The primary outcome was the onset of sensory anesthesia to the T5 dermatome assessed using the Cox proportional hazards model. Secondary outcomes included median time to sensory block, quality of block, patient and surgeon satisfaction, APGAR scores and other side effects. Results For DPE anesthesia versus EA anesthesia, the onset of anesthesia was faster (hazard ratio 2.47 [95% CI 1.56 to 3.90], adjusted P < 0.001) and the median time to surgical level was shorter (16 [IQR 14–18] min versus 19 [15.5–21] min, adjusted P < 0.001); the incidence of intraoperative pain was lower (7/48 versus 17/47, adjusted P = 0.046) and the median patient satisfaction score was higher (9 [IQR 9–10] versus 8 [8–9.5], adjusted P = 0.004). In the CSE group, the onset of anesthesia was faster than in the other two but the incidence of hypotension was higher (P < 0.001) and the phenylephrine requirement was greater (P < 0.001). Conclusion DPE anesthesia had a faster onset and better quality of block than EA anesthesia and provided less influence to maternal hemodynamic parameters than CSE anesthesia for CS. These results suggest that the dural puncture plays a significant role in enhancing the effectiveness of epidural top-ups during CSE anesthesia and indicates enlightenment that contributes to the satisfaction of anesthetic effect in DPE technique labor analgesia transferred to CS.

Fluid Leak From the Spinal-Epidural Puncture Site: Is That Cerebrospinal Fluid?

“…Neuraxial techniques are widely regarded as the preferred choice for obstetric anesthesia [1]. Among these techniques, the combined spinal-epidural (CSE) approach is frequently used to promptly initiate anesthesia and allow for the sustained management of anesthesia and postoperative analgesia via epidural [1].…”

“…Neuraxial techniques are widely regarded as the preferred choice for obstetric anesthesia [1]. Among these techniques, the combined spinal-epidural (CSE) approach is frequently used to promptly initiate anesthesia and allow for the sustained management of anesthesia and postoperative analgesia via epidural [1]. With an incidence of 0.16%, cutaneous cerebrospinal fluid (CSF) fistula is a rare complication that manifests as a fluid leak through the insertion site, which can be accompanied by symptoms of CSF hypotension and may also lead to complications such as meningitis among others [2].…”

Dural Puncture Epidural with 25-G Spinal Needles versus Conventional Epidural Technique in Conjunction with PIEB for Labor Analgesia: A Randomized Trial

“…It also serves as a viable option for surgical anesthesia in case of cesarean delivery. 1,2 The prevailing methods for providing neuraxial analgesia are conventional epidural (EP) and combined spinal-epidural (CSE) techniques. 3 However, the EP technique is associated with slow onset and motor blockade, while the CSE technique often leads to more adverse effects such as pruritus and fetal bradycardia.…”

“…3 However, the EP technique is associated with slow onset and motor blockade, while the CSE technique often leads to more adverse effects such as pruritus and fetal bradycardia. 1,4,5 Thus, dural puncture epidural (DPE) technique has been introduced with the aim of improving analgesic efficacy and reducing adverse effects. 2,6 DPE involves dural puncture using a spinal needle, without directly delivering local anesthetic into the subarachnoid space.…”