Simulated bupivacaine pharmacokinetics after labor epidural analgesia followed by transversus abdominis plane block with liposomal bupivacaine for intrapartum cesarean delivery.

STUDY OBJECTIVE: To simulate bupivacaine pharmacokinetics in scenarios of labor epidural analgesia (LEA) extended for intrapartum cesarean delivery (CD) with epidural or intrathecal boluses, followed by transversus abdominis plane (TAP) block with liposomal bupivacaine (LB) for postcesarean analgesia. DESIGN: Bupivacaine plasma concentrations were simulated using a 2-compartment distribution model fit to previous study data. SETTING: Virtual pharmacokinetic simulations. PATIENTS: Virtual individuals (1000, each scenario) had uniform weight (80 kg) but varying absorption parameters. INTERVENTIONS: The 6 scenarios varied in LEA infusion duration (6 or 24 h), local anesthetic used for bolus to extend LEA (epidural lidocaine or intrathecal bupivacaine), TAP block regimen, and time between bolus and TAP block. MEASUREMENTS: Scenario outcomes included geometric mean (GM) peak bupivacaine plasma concentration (Cmax) with 95% prediction interval (PI), median (range) Cmax, and number of virtual individuals (per 1000) with Cmax reaching estimated toxicity thresholds (neurotoxicity: 2000 µg/L; cardiotoxicity: 4000 µg/L). MAIN RESULTS: In simulated scenarios of LEA infusion for 24 h with an epidural bolus of lidocaine 400 mg for CD followed 1 h later by TAP block, the GM Cmax for the scenarios with TAP blocks including either LB 266 mg plus bupivacaine hydrochloride 52 mg or bupivacaine hydrochloride 104 mg was 1860 (95% PI, 1107-3124) and 1851 (95% PI, 1085-3157) µg/L, respectively. Among 1000 virtual individuals for each scenario, 404 and 401 had Cmax reaching 2000 µg/L, respectively; 1 and 0 had Cmax reaching 4000 µg/L, respectively. For other scenarios, GM Cmax remained <1000 µg/L. CONCLUSIONS: Across 6 different simulations of TAP blocks for intrapartum CD analgesia, LEA with bupivacaine (with or without boluses for extension and including a conservative modeling of lidocaine without epinephrine), followed by TAP block with LB and/or bupivacaine hydrochloride 0, 1, or 2 h after CD, is unlikely to result in bupivacaine plasma concentrations reaching local anesthetic systemic toxicity thresholds in healthy patients.

Comparative analysis of contrast distribution in cervical epidural steroid injections utilizing a modified paramedian interlaminar approach with varied needle tip positions: A randomized controlled trial.

BACKGROUND: Recent advancements in cervical interlaminar epidural steroid injections have given rise to the modified paramedian interlaminar (mPIL) approach. The objective of this study was to perform an analysis of the contrast spread pattern within the cervical epidural space, taking into account different needle tip positions in the mPIL approach. METHODS: A total of 48 patients were included in the study and randomly assigned to either the medial or lateral group based on the needle tip's position in the anterior-posterior view. The primary outcome measured was the contrast flow under fluoroscopic visualization. As a secondary outcome, we analyzed the location of the needle tip position in both lateral and contralateral oblique views. Clinical effectiveness was assessed by measuring pain intensity and functional disability post-procedure. RESULTS: Significant disparities were noted in the ventral distribution of contrast between the medial and lateral groups. In the lateral images, needle tips in the lateral group were positioned more ventrally compared to those in the medial group. Both groups exhibited statistically significant improvements in neck and radicular pain, as well as functional status, 4 weeks after treatment, with no significant differences between them. CONCLUSIONS: Our results suggest that the ventral dispersion of contrast material during cervical interlaminar epidural steroid injections using the mPIL approach may vary depending on the needle tip location.

Relation between neutrophil-to-lymphocyte ratio with epidural analgesia timing and thoracotomy pain.

OBJECTIVE: This study investigated the relationship of the pre-operative neutrophil/lymphocyte ratio (NLR) to the timing of epidural analgesia administration and post-operative acute and chronic pain in thoracotomy. MATERIALS AND METHODS: The study was conducted on 60 patients, with NLR ≥ 2 (Group A) and NLR < 2 (Group B). Each group was divided into subgroups pre-emptive analgesia (Group P) and control group (Group C). Epidural analgesic solution was administered as a bolus before the surgical incision in Group P and at the end of the operation in Group C. NRS was questioned postoperatively at the 2nd, 4th, 8th, 12th, 24th h, 1st, and 3rd months and also additional analgesic needs were recorded. RESULTS: In Group A, the pain scores of the patients who received pre-emptive epidural analgesia were lower at the post-operative 2nd, 4th, and 8th h and analgesic consumption was less in the post-operative first 24 h. CONCLUSION: It was observed that pre-emptive epidural analgesia reduced pain levels and additional analgesic consumption in the acute post-operative period in patients with pre-operative NLR ≥ 2.

OBJETIVO: Este estudio investigó la relación de la relación neutrófilos/linfocitos (NLR) preoperatoria con el momento de la administración de la analgesia epidural y el dolor agudo y crónico posoperatorio en la toracotomía. MATERIALES Y MÉTODOS: El estudio se realizó en 60 pacientes, como NLR ≥ 2 (Grupo A) y NLR < 2 (Grupo B). Cada grupo se dividió en subgrupos de analgesia preventiva (Grupo P) y grupo control (Grupo C). La solución analgésica epidural se administró en bolo antes de la incisión quirúrgica en el Grupo P y al final de la operación en el Grupo C. La NRS se cuestionó posoperatoriamente a las 2, 4, 8, 12, 24 horas, 1 y 3 meses también adicionales Se registraron las necesidades analgésicas. RESULTADOS: En el Grupo A, los puntajes de dolor de los pacientes que recibieron analgesia epidural preventiva fueron menores a las 2, 4 y 8 horas postoperatorias y el consumo de analgésicos fue menor en las primeras 24 horas postoperatorias. CONCLUSIÓN: Se observó que la analgesia epidural preventiva redujo los niveles de dolor y el consumo adicional de analgésicos en el postoperatorio agudo en pacientes con NLR preoperatorio ≥ 2.

Evaluation of a modified ultrasound-assisted technique for mid-thoracic epidural placement: a prospective observational study.

BACKGROUND: Although mid-thoracic epidural analgesia benefits patients undergoing major surgery, technical difficulties often discourage its use. Improvements in technology are warranted to improve the success rate on first pass and patient comfort. The previously reported ultrasound-assisted technique using a generic needle insertion site failed to demonstrate superiority over conventional landmark techniques. A stratified needle insertion site based on sonoanatomic features may improve the technique. METHODS: Patients who presented for elective abdominal or thoracic surgery requesting thoracic epidural analgesia for postoperative pain control were included in this observational study. A modified ultrasound-assisted technique using a stratified needle insertion site based on ultrasound images was adopted. The number of needle passes, needle skin punctures, procedure time, overall success rate, and incidence of procedure complications were recorded. RESULTS: One hundred and twenty-eight subjects were included. The first-pass success and overall success rates were 75% (96/128) and 98% (126/128), respectively. In 95% (122/128) of patients, only one needle skin puncture was needed to access the epidural space. The median [IQR] time needed from needle insertion to access the epidural space was 59 [47-122] seconds. No complications were observed during the procedure. CONCLUSIONS: This modified ultrasound-assisted mid-thoracic epidural technique has the potential to improve success rates and reduce the needling time. The data shown in our study may be a feasible basis for a prospective study comparing our ultrasound-assisted epidural placements to conventional landmark-based techniques.

Efficacy of different administration methods for labor analgesia / 中国基层医药

Objective:To investigate the clinical efficacy of different administration methods for labor analgesia.Methods:This randomized controlled study was conducted on 152 parturient women who underwent vaginal delivery at the Xinxiang Central Hospital from February to June 2023. These women were divided into a control group and an observation group, with 76 women per group. Women in the control group received 3 mL of 0.1% ropivacaine hydrochloride after routine epidural catheterization, followed by 3 mL of analgesic drugs after 3 minutes. For those without any special reactions, an analgesic pump containing 9 mL of medication was used after 3 minutes until the end of labor. In the observation group, 3 mL of 0.1% ropivacaine hydrochloride was administered as a trial dose before the epidural catheter was inserted into the epidural space. After 3 minutes, the postpartum woman lay flat and was given another 3 mL of analgesic pump medication. After 3 additional minutes, an additional 9 mL of the medication was administered. The analgesic pump was connected and turned on until the catheter was removed after delivery. The epidural catheter failure rate was assessed in each group. Before epidural puncture (T 1), within 30 minutes after the onset of anesthesia (T 2), and at the time of full dilation of the cervix (T 3), Visual Analogue Scale scores, the number of patient attempts to additionally use an analgesia pump, maternal satisfaction, the number of cases requiring cesarean section conversion, the incidence of adverse reactions (such as nausea, vomiting, and fever), and Apgar scores for newborns were recorded in each group. Results:The epidural catheter failure rate in the observation group was 1.3% (1/76), which was significantly lower than 10.5% (8/76) in the control group ( χ2 = 5.79, P < 0.05). At T 2 and T 3, the Visual Analogue Scale score in the observation group was (0.89 ± 0.08) points and (2.1 ± 0.07) points, respectively, which were significantly lower than (2.55 ± 0.07) points and (3.35 ± 0.07) points in the control group ( t = 238.54, 133.17, both P < 0.001). The number of patient attempts to additionally use an analgesia pump in the observation group was (1.00 ± 0.84) counts, which was significantly less than (4.00 ± 0.65) counts in the control group ( t = 29.47, P < 0.001). Maternal satisfaction in the observation group was 100% (76/76), which was significantly higher than 92.1% (70/76) in the control group ( χ2 = 6.25, P < 0.05). The number of cases requiring cesarean section conversion in the observation group was 0 (0/76), which was significantly lower than 52.6% (4/76) in the control group ( χ2 = 4.10, P < 0.05). Conclusion:Administering a trial dose (3 mL) of 0.1% ropivacaine hydrochloride before placing the epidural catheter during labor analgesia can greatly increase the placement success rate of the catheter and enhance pain relief effectiveness. This has a certain clinical application value.

Effects of epidural labor analgesia on early neonatal sucking and breastfeeding / 中华围产医学杂志

Objective:To investigate the effects of epidural labor analgesia on neonatal sucking ability and breastfeeding.Methods:This was a prospective cohort study. Convenience sampling was used to enroll women who delivered with or without epidural analgesia (epidural analgesia and non-analgesia groups) in the Affiliated Maternity and Child Health Care Hospital of Nantong University from January 2022 to December 2022. Intra-oral negative pressure values during breastfeeding were measured by a pressure measuring instrument within 3 d after birth (0-24 h, >24-48 h, and >48-72 h), and the mean, maximum, and minimum pressure values were recorded. The Infant Breastfeeding Assessment Tool (IBAT) (Chinese version) was used to evaluate sucking posture. Breastfeeding status during hospitalization and within 1, 4, and 6 months after discharge were followed up. Two independent samples t-test, Chi-square (Fisher's exact) test, and generalized estimating equations were used for data analysis. Results:A total of 156 mother-infant pairs were analyzed in this study, with 78 pairs in the epidural analgesia group and 78 pairs in the non-analgesia group. The whole, first, and second stages of labor were longer in the analgesia group than those in the non-analgesia group [ M( P25- P75), total: 430 min (353-541 min) vs. 300 min (235-422 min), Z=－5.65; first stage: 385 min (310-490 min) vs. 260 min (205-347 min), Z=－5.81; second stage: 40 min (26-67 min) vs. 33 min (18-45 min), Z=－2.33; all P<0.05], and more women in the analgesia group accepted oxytocin and doula before delivery [94.8% (74/78) vs. 43.6% (34/78), χ2=48.15; 42.3% (33/78) vs. 19.2% (15/78), χ2=9.75; both P<0.05]. There was no significant difference in scores on the Fatigue Scale-14, Edinburgh Postnatal Depression Scale, Pittsburgh Sleep Quality Index, and Life Events Scale for Pregnant Women between the two groups. After adjusting for confounding factors by generalized estimating equations, the mean intra-oral negative pressure values in the epidural analgesia group were lower than those in the non-analgesia group at 0-24 h, >24-48 h, and >48-72 h after birth [5.14 (3.39-6.52) vs. 6.39 (4.95-9.15) kPa, 5.07 (3.94-7.38) vs. 6.20 (5.08-8.54) kPa, and 6.19 (4.64-8.36) vs. 6.81 (5.88-8.05) kPa, Wald χ2=5.59, P=0.018]; the peak value in the epidural analgesia group was also lower than that in the non-analgesia group [15.81 (9.74-21.68) vs. 16.21 (13.58- 24.88) kPa, 13.50 (9.83-16.50) vs. 17.62 (14.01-22.40) kPa, and 14.66 (10.47-18.71) vs. 18.04 (15.33- 19.85) kPa, Wald χ2=7.25, P=0.007]; there were no significant differences in the trough value between the two groups. The daily IBAT scores for the sucking position of neonates in the epidural analgesia group were all lower than those in the non-analgesia group in the first three days after delivery [10 (9-10) vs. 10 (10- 11) scores, 10 (9-11) vs. 11 (10-11) scores, and 10 (10-11) vs. 11 (11-12) scores, Wald χ2=17.05, P=0.001]. The rates of early exclusive breastfeeding within postpartum 3 d were also lower in the epidural analgesia group than those in the non-analgesia group [67.9% (53/78) vs. 75.6% (59/78), 41.0% (32/78) vs. 44.9% (35/78), and 38.5% (30/78) vs. 55.1% (43/78), Wald χ2=4.21, P=0.040]. No significant differences were found in the exclusive breastfeeding rates between the two groups at 1, 4, and 6 months after delivery. Conclusion:Epidural labor analgesia can lead to decreased early intra-oral negative pressure in neonates, affect neonatal sucking posture, and reduce the rate of exclusive breastfeeding during hospitalization, but has no significant correlation with the exclusive breastfeeding rate within six months after delivery.

Mindfetalness: un método cualitativo de autoevaluación de movimientos fetales / Mindfetalness: a qualitative method for self-assessment of fetal movements

Maternal perception of fetal movements is a subjective indicator of fetal well-being. Pregnant women's awareness of their importance remains a subject of discussion because they can increase maternal anxiety and lead to an increase in consultations about their reduction. Quantitative methods have classically been used for self-assessment, although a new qualitative method called mindfetalness has recently been proposed. Its practice has been shown to promote a better relationship with the fetus and to strengthen the maternal-fetal bond, with pregnant women preferring it to classical methods. Although consultations may increase due to decreased fetal movements, the rate of caesarean section, induction of labour, and newborns with low weight for gestational age decreases, resulting in improved maternal, fetal, and newborn management compared to not reporting fetal movements. It has been shown that pregnant women of lower sociocultural status have worse pregnancy outcomes despite its use. There may be other benefits of practicing mindfetalness such as decreased use of epidural analgesia and improved professional pregnancy care.(AU)

La percepción materna de movimientos fetales es un indicador subjetivo de bienestar fetal. La concienciación de las gestantes sobre su importancia sigue siendo objeto de discusión dado que puede aumentar la ansiedad materna y motivar un aumento de las consultas sobre su disminución. Clásicamente se han usado métodos cuantitativos para realizar su autoevaluación aunque recientemente se ha propuesto un nuevo método cualitativo denominado mindfetalness. Se ha demostrado que su práctica promueve el desarrollo de una mejor relación con el feto y fortalece el vínculo maternofetal, prefiriendo las gestantes este método a los clásicos. Aunque pueden aumentar las consultas por disminución de movimientos fetales disminuye la tasa de cesárea, de inducción del parto y de recién nacidos con bajo peso para la edad gestacional, lo que consigue una mejoría del manejo y resultado tanto materno como fetal o del recién nacido en comparación con no informar sobre la importancia de los movimientos fetales. Se ha demostrado que las gestantes con menor nivel sociocultural tienen peores resultados del embarazo a pesar de su uso. Pueden existir otros beneficios de la práctica de mindfetalness como la disminución del uso de analgesia epidural y la mejoría de la atención profesional del embarazo.(AU)

Utilidad de las terapias complementarias en el manejo de dolor durante el parto: una revisión integradora / Utility of complementary therapies in pain management during childbirth: an integrative literature review

Introducción: El dolor de parto es uno de los aspectos que más preocupan a las futuras madres. La enfermería vela por el bienestar de las pacientes en todas sus vertientes y cabe tener presente que existen diversas opciones complementarias a la analgesia epidural. Objetivo: Identificar las terapias complementarias que puedan aplicarse de forma efectiva y segura en embarazadas, analizar los factores que contribuyan a un mayor bienestar para la parturienta y evaluar su utilidad. Método: Revisión integradora de la literatura realizada mediante la búsqueda en las bases de datos online: PubMed, Scopus y Dialnet. Se incluyeron artículos cuya fecha de publicación no fuese superior a los 10 años previos a la búsqueda, redactados en inglés, español o portugués y de acceso abierto. Resultados: Se analizaron un total de 16 artículos cuya temática giraba en torno a la aplicación de diferentes terapias complementarias utilizadas con seguridad en mujeres embarazadas. Se tuvieron en cuenta los resultados de la aplicación de diferentes técnicas complementarias en estudios previos y se agruparon según tipología: intervenciones cuerpo-mente, práctica médica alternativa, métodos de curación manual, inmersión en agua y pelota suiza, aromaterapia y auriculoterapia y estimulación nerviosa eléctrica transcutánea. Conclusión: Se evidencia la variedad de terapias complementarias cuya aplicación resulta efectiva y segura en el momento del parto, así como su utilidad para disminuir los inconvenientes presentes durante esta etapa, acrecentando así, la experiencia positiva del parto. (AU)

Introduction: Labour pain is one of the most worrying things for future mothers. Nurses ensure the well-being of patients in all these aspects and it should be noted that there are various complementary options to epidural analgesia. Objective: To identify the complementary therapies that could be applied effectively and safely in pregnant women, to analyse the contributing factors of greater well-being for the parturient and to evaluate their utility. Method: this integrative review were carried out in online databases: PubMed, Scopus and Dialnet, Articles whose publication date was not more than ten years ago, written in English, Spanish or Portuguese and open access were included. Results: 16 studies about the application of different complementary therapies used safely in pregnant were included and analysed. The obtained results of the application of complementary techniques in previous studies were taken into account and agruped according to typology: body-mind interventions, alternative medical practice, manual healing methods, immersion in water and swiss ball, aromatherapy and auriculotherapy and transcutaneous electrical nerve stimulation. Conclusion: The variety of effective and safe complementary therapies on labour is evidencied, as well as their usefulness to reduce the possible incoveniences that may appear during this process, increasing the positive experience of labour. (AU)

Epidural analgesia in a patient with factor XI deficit.

FXI deficiency is a rare bleeding disorder characterised by a decreased level or activity of factor. Pregnant women are at increased risk of uterine bleeding during childbirth. Neuroaxial analgesia may increase the risk of epidural hematoma in these patients. However, there is no consensus on the anaesthetic management. We present the clinical case of a 36-year-old woman with a personal history of factor XI deficiency, pregnant with 38 weeks gestation who is scheduled to perform birth induction. Pre-induction factor levels were measured. They were less than 40%, so it was decided to transfuse 20 ml/kg of fresh frozen plasma. After the transfusion it had levels greater than 40%, so epidural analgesia was performed without incident. The patient had no complications secondary to epidural analgesia or transfusion of a high volume of plasma.

Analgesia epidural en paciente con déficit de factor XI / Epidural analgesia in a patient with factor XI deficit

El déficit de factorXI es una enfermedad hemorrágica rara que se caracteriza por presentar disminución del nivel o de la actividad del factor. Las mujeres embarazadas con esta patología presentan mayor riesgo de sangrado uterino durante el parto. El uso de analgesia neuroaxial en estas pacientes puede aumentar el riesgo de producir hematoma epidural. Es necesario realizar un seguimiento multidisciplinar en el que participen activamente anestesiólogos, hematólogos y ginecólogos. Actualmente disponemos de escasa bibliografía sobre el manejo anestésico de este tipo de patología. Presentamos el caso clínico de una mujer de 36años con antecedentes personales de déficit de factorXI, embarazada de 38 semanas de gestación que es programada para realización de inducción del parto. Previamente a la inducción se midieron los niveles del factor, y al ser inferiores al 40% se decidió transfundir 20ml/kg de plasma fresco congelado. Tras la transfusión presentó niveles superiores al 40%, por lo que se realizó analgesia epidural sin incidencias. La paciente no presentó complicaciones secundarias a la analgesia epidural ni a la transfusión de un volumen elevado de plasma.(AU)

Factor XI deficiency is a rare bleeding disorder characterized by a decreased level or activity of factor. Pregnant women are at increased risk of uterine bleeding during childbirth. Neuroaxial analgesia may increase the risk of epidural hematoma in these patients. However, there is no consensus on the anesthetic management. We present the clinical case of a 36-year-old woman with a personal history of factorXI deficiency, pregnant with 38weeks gestation who is scheduled to perform birth induction. Pre-induction factor levels were measured. They were less than 40%, so it was decided to transfuse 20mL/kg of fresh frozen plasma. After the transfusion it had levels greater than 40%, so epidural analgesia was performed without incident. The patient had no complications secondary to epidural analgesia or transfusion of a high volume of plasma.(AU)

The effects of magnesium sulfate added to epidurally administered local anesthetic on postoperative pain: a systematic review.

BACKGROUND: This study evaluated the efficacy of epidurally administered magnesium associated with local anesthetics on postoperative pain control. METHODS: The study protocol was registered in PROSPERO as CRD42021231910. Literature searches were conducted on Medline, Cochrane, EMBASE, CENTRAL, and Web of Science for randomized controlled trials comparing epidural administration of magnesium added to local anesthetics for postoperative pain in elective surgical adult patients. Primary outcomes were the time to the first Postoperative (PO) Analgesic Request (TFAR), 24-hour postoperative opioid consumption, and Visual Analog Scale (VAS) scores at the first six and 24 postoperative hours. Secondary outcomes included Postoperative Nausea and Vomiting (PONV), pruritus, and shivering. Quality of evidence was assessed using GRADE criteria. RESULTS: Seventeen studies comparing epidural were included. Effect estimates are described as weighted Mean Differences (MD) and 95% Confidence Intervals (95% CI) for the main outcomes: TFAR (MD = 72.4 min; 95% CI = 10.22-134.58 min; p < 0.001; I2 = 99.8%; GRADE: very low); opioid consumption (MD = -7.2 mg (95% CI = -9.30 - -5.09; p < 0.001; I2 = 98%; GRADE: very low). VAS pain scores within the first six PO hours (VAS) (MD = -1.01 cm; 95% CI = -1.40-0.64 cm; p < 0.001; I2 = 88%; GRADE: very low), at 24 hours (MD = -0.56 cm; 95% CI = -1.14-0.01 cm; p = 0.05; I2 = 97%; GRADE: very low). CONCLUSIONS: Magnesium sulfate delayed TFAR and decreased 24-hour opioid consumption and early postoperative pain intensity. However, imprecision and inconsistency pervaded meta-analyses, causing very low certainty of effect estimates.

Effects of neuraxial analgesia technique on labor and maternal-fetal outcomes: a retrospective study.

PURPOSE: To compare the effects of epidural analgesia (EA) and combined spinal epidural analgesia (SEA) on labor and maternal-fetal outcomes. METHODS: We retrospectively identified and included 1499 patients with a single cephalic fetus who delivered at the study center from January 2015 to December 2018 and received neuraxial analgesia at the beginning of the active phase of labor (presence of regular painful contractions and cervical dilatation between 4 and 6 cm). Data including analgesia, labor characteristics, and maternal-fetal outcomes were retrieved from the prospectively collected delivery room database and medical records. RESULTS: SEA was associated with a shorter first stage of labor than EA, with a median difference of 60 min. On multivariable ordinal logistic regression analysis, neuraxial analgesia, gestational age, fetal weight, labor induction, and parity were independently associated with the first stage length: patients in the EA group were 1.32 times more likely to have a longer first stage of labor (95% CI 1.06-1.64, p = 0.012) than those in the SEA group. Additionally, a significantly lower incidence of fundal pressure was performed among patients who underwent SEA (OR 0.55, 95% CI 0.34-0.9, p = 0.017). No associations were observed between the used neuraxial analgesia technique and other outcomes. CONCLUSIONS: SEA was associated with a shorter length of the first stage of labor and a lower rate of fundal pressure use than EA. Further studies confirming the effects of SEA on labor management and clarifying differences in maternal-fetal outcomes will allow concluding about the superiority of one technique upon the other.

Programmed Intermittent Epidural Bolus in Comparison with Continuous Epidural Infusion for the Effects of Enhanced Recovery after Cesarean Section / 中山大学学报(医学科学版)

ObjectiveTo compare the effects of programmed intermittent epidural bolus （PIEB） and continuous epidural infusion （CEI） on enhanced recovery after cesarean section. MethodsTotally 120 women scheduled to undergo elective cesarean section under combined spinal and epidural anesthesia， aged 18-45 years， with single fetus， full-term pregnancy （≥37 weeks）， ASA grade II or III， were recruited， with 60 cases in each group. At the end of the surgery， after a similar epidural loading dose， patients were randomLy assigned to receive either PIEB （6 mL·h-1 beginning 30 minutes after the loading dose） or CEI （6 mL·h-1， beginning immediately after the loading dose） for the maintenance of analgesia with 0.1% ropivacaine. At 2， 6， 12， 24 and 36 h postoperatively， VAS score was used to evaluate the composite pain， and Bromage Score was used to evaluate the degree of lower extremity motor block. The time to first flatus， time to first ambulation and the satisfaction scores were also recorded. ResultsThe VAS scores at 12， 24 and 36 h postoperatively and the lower extremity motor block scores at 6， 12 and 24 h postoperatively in the PIEB group were significantly lower than those in the CEI group （P < 0.01）. The epidural analgesic dosage was less in the PIEB group than that of the CEI group （P=0.002）. The time to first flatus and time to first ambulation were significantly shorter than those in the CEI group （P < 0.05）. The satisfaction scores were significantly higher in the PIEB group than in the CEI group （P < 0.05）. There was no significant difference in the first urination time after urinary catheter removal and the length of hospital stay between the two groups （P > 0.05）. ConclusionCompared with CEI， PIEB provides better postoperative analgesia， less motor block scores， lower epidural analgesic dosage， shorter the time to first flatus and defecation and time to first ambulation， and greater patient satisfaction， which is more consistent with the ERAS concept of analgesia.

Optimization strategy of labor analgesia in obese parturients: dural puncture epidural combined with programmed intermittent epidural bolus / 中华麻醉学杂志

Objective:To evaluate the optimization strategy of labor analgesia in obese parturients using dural puncture epidural (DPE) combined with programmed intermittent epidural bolus (PIEB).Methods:Eighty American Society of Anesthesiologists Physical Status classification Ⅰ or Ⅱ obese primiparae, who were at full term with a singleton fetus in vertex presentation, aged 20-40 yr, with body mass index of 30-40 kg/m 2, at 37-42 week gestation, with cervical dilation of 2-5 cm, and with visual analogue scale score ≥50 mm, were divided into 2 groups ( n=40 each) using a random number table method: DPE plus PIEB group (DPEP group) and DPE plus continuous epidural infusion group (DPEC group). All parturients received DPE labor analgesia, and parturients received PIEB (DPEP group) and continuous epidural infusion (DPEC group) to maintain analgesia during labor. In DPEP group, the patient-controlled epidural analgesia pump was set up to deliver a 5 ml bolus dose with a 20-min lockout interval and background infusion at 2 ml/12 min after an initial dose of 8 ml. In DPEC group, the patient-controlled epidural analgesia pump was set up to deliver a 5 ml bolus dose with a 20-min lockout interval and background infusion at 10 ml/h after an initial dose of 8 ml. The analgesia solution contained 0.1% ropivacaine plus 0.3 μg/ml sufentanil. The time to achieve adequate analgesia, consumption of ropivacaine per unit time, height of sensory block at the thoracic vertebral level, modified Bromage score, effective pressing times of patient-controlled analgesia, the number of rescue analgesia, Apgar score, delivery mode, occurrence of adverse reactions and maternal satisfaction with labor analgesia were recorded. Results:Compared with DPEC group, the time to achieve adequate analgesia was significantly shortened, the consumption of ropivacaine per unit time was decreased, and the number of rescue analgesia and effective pressing times of patient-controlled analgesia were decreased in DPEP group ( P<0.05). There were no significant differences in the height of sensory block at the thoracic vertebral level, modified Bromage score, Apgar score, delivery mode, incidence of adverse reactions and maternal satisfaction with labor analgesia between the two groups ( P>0.05). Conclusions:DPE combined with PIEB offers faster onset and better effect and achieves a greater local anesthetics-sparing effect when used for labor analgesia in obese parturients.

Effect of esmketamine for labor analgesia on development of postpartum depression / 中华麻醉学杂志

Objective:To evaluate the effect of esmketamine for labor analgesia on the occurrence of postpartum depression (PPD).Methods:Two hundred and forty-two cases of nulliparous parturients who selected natural labor and agreed to receive labor analgesia were selected and divided into conventional labor analgesia group (C-LA group, n=119) and esmketamine-based labor analgesia group (E-LA group, n=123). The epidural labor analgesia solution contained ropivacaine 100 mg and sufentanil 30 μg in 100 ml of normal saline in C-LA group. The epidural labor analgesia solution contained ropivacaine 100 mg, sufentanil 30 μg and esketamine 50 mg in 100 ml of normal saline in E-LA group. The Edinburgh Postnatal Depression Scale (EPDS) was used to screen parturients for depression on admission to the predelivery room and at 2 h and 1, 7 and 42 days after delivery, and EPDS scores were recorded. The patients were diagnosed as having PPD when EPDS score ≥ 9 at 7-42 days after delivery. Peripheral venous blood samples were collected on admission to the predelivery room and at 1 day after delivery to determine the concentrations of serum estrogen, progesterone, 5-hydroxytryptamine and cortisol by enzyme linked inmunosorbent assay. Results:Compared with group C-LA, the EPDS scores were significantly decreased on the 1 and 42 days after delivery( P<0.01), no significant change was found in the incidence of PPD (1.7%/0.8%, P>0.05), no significant change was found in the concentrations of serum estrogen, progesterone, 5-hydroxytryptamine and cortisol on admission to the delivery room ( P>0.05), and the concentrations of serum progesterone and cortisol were significantly increased on 1 day after delivery in group E-LA ( P<0.05). Conclusions:Combination of esketamine is helpful in reducing the risk of postpartum depression when used for epidural labor analgesia, and the mechanism is related to slowing the declines in blood levels of sex hormones and stress hormones after delivery.

Potency of epidural ropivacaine in inhibiting breakthrough pain in primiparae undergoing epidural labor analgesia / 中华麻醉学杂志

Objective:To determine the potency of epidural ropivacaine in inhibiting breakthrough pain in primiparae undergoing labor analgesia with programmed intermittent epidural bolus (PIEB).Methods:American Society of Anesthesiologists Physical Status classification Ⅰ or Ⅱ primiparae of full-termpregnancy, with a singleton fetus in vertex presentation, aged ≥18 yr, with body mass index < 30 kg/m 2, presenting with breakthrough pain during labor analgesia with PIEB, were enrolled in this study. Ropivacaine 10 ml was epidurally administered, and the concentration was determined by up-and-down sequential allocation. The initial concentration was set at 0.15% in the first patient in each group. Each time the concentration increased/decreased in the next patient depending on whether the patients showed breakthrough pain relief, and the ratio between the two successive doses was 0.9. The criterion of breakthrough pain relief was defined as numerical rating scale score < 4 points within 30 min after epidural injection of ropivacaine. The median effective concentration (EC 50) and 95% confidence interval of ropivacaine in inhibiting breakthrough pain were calculated by Dixon-Massey′s method. Results:Twenty-six patients were finally included in this study.The EC 50 (95% confidence interval)of ropivacaine in inhibiting breakthrough pain was 0.102% (0.088%-0.117%). Conclusions:The EC 50(95% confidence interval) of epidurally administered ropivacaine 10 ml is 0.102%(0.088%-0.117%) when used for inhibiting breakthrough pain during labor analgesia with PIEB in primiparae.

Effects of epidural analgesia on breast-seeking behavior and breastfeeding during breast crawling in neonates / 中国实用护理杂志

Objective:To analyze the influence of epidural labor analgesia on neonatal breast-seeking behavior and first breastfeeding.Methods:This study was an observational study. According to the cross-sectional study formula and inclusion and exclusion criteria, 150 cases of puerperas and their full-term infants who underwent vaginal delivery in the Affiliated Hospital of Southwest Medical University from March to September 2020 were included as the research objects, and the time of breast searching behavior in newborn crawling was observed and recorded. According to whether epidural analgesia was used or not, the patients were divided into analgesic group and non-analgesic group (the specific names of the two groups), and the outcome variables were analyzed.Results:There were 81 cases of successful breast crawl, 69 cases of failure, including 94 cases of epidural analgesia, 56 cases of non-epidural analgesia. Epidural analgesia had no effect on breast crawl and the time of breast searching behavior ( P>0.05). For puerperas with epidural analgesia, the total score of Breastfeeding Assessment Tool (IBFAT) and the scores of its four dimensions such as feeding time, foraging, sucking and nipple holding behavior were 9(7, 10), 3(2, 3), 2(2, 3), 2(1, 2), 2(1, 2), which lower than those non-epidural analgesia puerperas, which were 10(8, 10), 3(3, 3), 3(2, 3), 2(2, 2), 2(1, 2), the differences were statistically significant ( Z values were -6.36- -4.32, all P<0.05). Conclusions:When epidural analgesia is used clinically, medical staff need to seize the best time of drug use, pay attention to continuous monitoring of drug use duration and dosage, while exerting drug analgesia effect, it is also necessary to minimize adverse outcomes and reduce the impact of analgesics on breastfeeding.

Analgesic effect and safety of using an epidural analgesia pump versus an intravenous analgesia pump for uterine artery embolization in the treatment of uterine fibroids / 中国基层医药

Objective:To investigate the analgesic effect and safety of using an epidural analgesia pump versus an intravenous analgesia pump for uterine artery embolization in the treatment of uterine fibroids. Methods:Fifty patients with uterine fibroids undergoing uterine artery embolization admitted to The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University from January 2019 to December 2021 were included in this study. They were divided into an observation group and a control group ( n = 25/group). Patients in the observation group used an epidural analgesia pump for pain relief, while patients in the control group used an intravenous analgesia pump for pain relief. At 1, 6, 12, and 24 hours after surgery, pain severity was compared between the two groups using the Visual Analogue Scale. Comfort level was compared between the two groups using the Bruggemann Comfort scale. Before and after surgery, respiratory rate, heart rate, blood pressure, and adverse reactions were compared between the two groups. Results:At 1 hour after surgery, the Visual Analogue Scale score in the observation group was significantly lower than that in the control group [3.00 (2.00, 5.50) vs. 7.00 (6.00, 8.00), Z = -3.84, P < 0.05]. At 6, 12, and 24 hours after surgery, there was a significant difference in the Visual Analogue Scale score between the two groups (all P > 0.05). Within 24 hours after surgery, the use of opioid analgesics in the observation group was less than that in the control group [16.00% (4/25) vs. 88.00% (22/25), χ2 = 25.96, P < 0.001]. At 1 hour after surgery, the Bruggemann Comfort Scale score in the observation group was significantly higher than that in the control group [0.00 (0.00, 0.50) vs. 0.00 (0.00, 0.00), Z = 2.08, P < 0.05]. At 6, 12, and 24 hours after surgery, there was no significant difference in the Bruggemann Comfort Scale score between the two groups (all P > 0.05). After surgery, heart rate was significantly decreased in each group compared with before surgery (both P < 0.05). There were no significant differences in respiratory rate and mean arterial pressure between the two groups before and after surgery (both P > 0.05). There were no significant differences in the incidences of postoperative nausea, vomiting, and fever between the two groups (all P > 0.05). Conclusion:The epidural analgesia pump used for uterine artery embolization in the treatment of uterine fibroids has a better analgesic effect and provides more comfort and is safer than the intravenous analgesia pump. The former is worthy of clinical promotion.

Effects of dezocine combined with sufentanil on continuous epidural analgesia after cesarean section / 中国基层医药

Objective:To investigate the effects of dezocine combined with sufentanil on continuous epidural analgesia after cesarean section.Methods:Eighty-six pregnant women who were scheduled for cesarean section in Guoyang Hospital of Traditional Chinese Medicine from February to December 2021 were included in this randomized controlled study. These women were divided into an observation group and a control group ( n = 43/group). The women in the observation group underwent epidural analgesia with dizocine, sufentanil, and ropivacaine, while those in the control group underwent epidural analgesia with dizocine and ropivacaine. The visual analogue score, Ramsay sedation score, Bruggrmann comfort scale score, and the incidence of adverse reactions were compared between the two groups. Results:At 4, 8, 12, 24 hours after surgery, the visual analogue score (VAS) in the observation group was significantly lower than that in the control group ( t = 2.34, 5.89, 15.36, 16.23, all P < 0.05). At 4, 8, 12, and 24 hours after surgery, Ramsay sedation score in the observation group was significantly higher than that in the control group ( t = -6.31, -7.64, -7.49, -7.41, all P < 0.001). At 4, 8, 12, and 24 hours after surgery, Bruggrmann comfort scale score in the observation group was significantly higher than that in the control group ( t = -7.60, -10.40, -14.53, -13.80, all P < 0.001). There was a significant difference in the number of effective analgesic pump compressions between the observation and control groups [(3.00 ± 1.41) times vs. (7.23 ± 1.31) times, t = 14.42, P < 0.001]. No adverse reactions were observed in the observation group within 24 hours after surgery. Conclusion:Dezocine combined with sufentanil for epidural analgesia can effectively improve the analgesic effects after cesarean section and is highly safe.

The effects of magnesium sulfate added to epidurally administered local anesthetic on postoperative pain: a systematic review

Abstract Background This study evaluated the efficacy of epidurally administered magnesium associated with local anesthetics on postoperative pain control. Methods The study protocol was registered in PROSPERO as CRD42021231910. Literature searches were conducted on Medline, Cochrane, EMBASE, CENTRAL, and Web of Science for randomized controlled trials comparing epidural administration of magnesium added to local anesthetics for postoperative pain in elective surgical adult patients. Primary outcomes were the time to the first Postoperative (PO) Analgesic Request (TFAR), 24-hour postoperative opioid consumption, and Visual Analog Scale (VAS) scores at the first six and 24 postoperative hours. Secondary outcomes included Postoperative Nausea and Vomiting (PONV), pruritus, and shivering. Quality of evidence was assessed using GRADE criteria. Results Seventeen studies comparing epidural were included. Effect estimates are described as weighted Mean Differences (MD) and 95% Confidence Intervals (95% CI) for the main outcomes: TFAR (MD = 72.4 min; 95% CI = 10.22-134.58 min; p < 0.001; I2= 99.8%; GRADE: very low); opioid consumption (MD = -7.2 mg (95% CI = -9.30 - -5.09; p < 0.001; I2= 98%; GRADE: very low). VAS pain scores within the first six PO hours (VAS) (MD = -1.01 cm; 95% CI = -1.40-0.64 cm; p < 0.001; I2= 88%; GRADE: very low), at 24 hours (MD = -0.56 cm; 95% CI = -1.14-0.01 cm; p= 0.05; I2= 97%; GRADE: very low). Conclusions Magnesium sulfate delayed TFAR and decreased 24-hour opioid consumption and early postoperative pain intensity. However, imprecision and inconsistency pervaded meta-analyses, causing very low certainty of effect estimates.