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

(Anesth Analg. 2017;124(2):560–569) Epidural (EPL) and combined spinal epidural (CSE) are commonly used and effective labor analgesia neuraxial techniques. EPL has minimal adverse effects, but has a slow onset time and may result in insufficient sacral spread/patchy sensory blockade. In contrast, CSE has rapid onset and excellent sacral coverage but has greater risk of adverse effects. The dural puncture epidural (DPE) technique (passing a spinal needle through the EPL needle, puncturing the dura but not injecting medication into the intrathecal space) has been shown to improve caudal spread of analgesia compared with the EPL technique, without the side effects seen with CSE. In the present study, the authors determined whether or not overall analgesia characteristics and side effects would favor the DPE technique, and hypothesized that onset of labor analgesia is most rapid with CSE, followed by DPE and EPL.

Dural puncture epidural analgesia for labor: a randomized comparison between 25-gauge and 27-gauge pencil point spinal needles

“…Our main outcome was onset time, defined as the temporal interval required to obtain a pain score ≤1 using a 0–10 numeric rating scale (NRS) 5. We hypothesized that both needle sizes would result in similar onset (equivalence margin=2.5 min) and therefore designed the study as an equivalence trial.…”

“…After obtaining ethics committee approval (Hospital Clínico Universidad de Chile and Hospital De La Florida, Santiago, Chile) and written informed consent, we enrolled 140 women requiring lumbar epidural analgesia for labor. Exclusion criteria included: inability to consent to the study, American Society of Anesthesiologists (ASA) status >3, coagulopathy, allergy to LA, prior surgery in the lumbosacral spine, body mass index <20 m/kg 2 or >35 m/kg 2 , presence of pregnancy-related comorbidity (eg, gestational hypertension), gestational age <37 weeks or >42 weeks, known fetal anomalies, active labor with cervical dilation ≥5 cm5 and increased risk of cesarean delivery (eg, vaginal birth after cesarean delivery).…”

“…After the performance of DPEA, pain scores were assessed every 2 min during 30 min by a single, blinded investigator who was not involved in patient care 5. Pain was evaluated using an 11-point NRS (from 0 to 10) where 0 represented no pain and 10, the worst imaginable pain.…”

“…The latter was evaluated with a modified Bromage score: 0=full flexion of knees and ankles, 1=partial flexion of knees, full flexion of ankles, 2=inability to flex knees and partial flexion of ankles and 3=inability to flex knees and ankles). 5 Motor block was defined as a score ≥1. The blinded investigator also assessed blockade of the S2 dermatome (with pinprick) every 2 min during the first 30 min.…”

“…The blinded investigator also assessed blockade of the S2 dermatome (with pinprick) every 2 min during the first 30 min. 5 …”