Initiation of labor analgesia with injection of local anesthetic through the epidural needle compared to the catheter.

BACKGROUND: The rationale for injection of epidural medications through the needle is to promote sooner onset of pain relief relative to dosing through the epidural catheter given that needle injection can be performed immediately after successful location of the epidural space. Some evidence indicates that dosing medications through the epidural needle results in faster onset and improved quality of epidural anesthesia compared to dosing through the catheter, though these dosing techniques have not been compared in laboring women. This investigation was performed to determine whether dosing medication through the epidural needle improves the quality of analgesia, level of sensory blockade, or onset of pain relief measured from the time of epidural medication injection. METHODS: In this double-blinded prospective investigation, healthy term laboring women (n=60) received labor epidural placement upon request. Epidural analgesia was initiated according to the assigned randomization group: 10 mL loading dose (0.125% bupivacaine with fentanyl 2 µg/mL) through either the epidural needle or the catheter, given in 5 mL increments spaced 2 minutes apart. Verbal rating scale (VRS) pain scores (0-10) and pinprick sensory levels were documented to determine the rates of analgesic and sensory blockade onset. RESULTS: No significant differences were observed in onset of analgesia or sensory blockade from the time of injection between study groups. The estimated difference in the rate of pain relief (VRS/minute) was 0.04 (95% CI: -0.01 to 0.11; p=0.109), and the estimated difference in onset of sensory blockade (sensory level/minute) was 0.63 (95% CI: -0.02 to 0.15; p=0.166). The time to VRS ≤3 and level of sensory block 20 minutes after dosing were also similar between groups. No differences in patient satisfaction, or maternal or fetal complications were observed. CONCLUSION: This investigation observed that epidural needle and catheter injection of medications result in similar onset of analgesia and sensory blockade, quality of labor analgesia, patient satisfaction, and complication rates.

The Gap Between Clinical Research and Standard of Care: A Review of Frailty Assessment Scales in Perioperative Surgical Settings.

The elderly population in the United States is increasing exponentially in tandem with risk for frailty. Frailty is described by a clinically significant state where a patient is at risk for developing complications requiring increased assistance in daily activities. Frailty syndrome studied in geriatric patients is responsible for an increased risk for falls, and increased mortality. In efforts to prepare for and to intervene in perioperative complications and general frailty, a universal scale to measure frailty is necessary. Many methods for determining frailty have been developed, yet there remains a need to define clinical frailty and, therefore, the most effective way to measure it. This article reviews six popular scales for measuring frailty and evaluates their clinical effectiveness demonstrated in previous studies. By identifying the most time-efficient, criteria comprehensive, and clinically effective scale, a universal scale can be implemented into standard of care and reduce complications from frailty in both non-surgical and surgical settings, especially applied to the perioperative surgical home model. We suggest further evaluation of the Edmonton Frailty Scale for inclusion in patient care.