SAN ANTONIO (EGMN) – Combined spinal-epidural anesthesia was superior to traditional epidural for first-stage anesthesia but there were no differences in second stage or in delivery pain in a randomized, controlled comparison of the two methods among 800 women.

The Epidural Analgesia and Spinal Epidural analgesia (EASE) study also showed that concerns about epidurals failing with combined spinal-epidural (CSE) because of the inability to provide a test dose are unfounded, Dr. David R. Gambling reported.

Previous studies comparing the techniques have had mixed results. A Cochrane review showed that CSE had less rescue analgesia and less urinary retention but more pruritis (Cochrane Database Syst. Rev. 2007 [doi:10.1002/14651858.CD003401.pub2]). Compared with low-dose epidural anesthesia (EA), CSE had faster-onset analgesia, more pruritis, and lower umbilical cord artery pH, but there was no mention of progress of cervical dilation, noted Dr. Gambling of the Sharp Mary Birch Hospital for Women and Newborns and the University of California, San Diego.

In EASE, 398 women received EA, consisting of 10 mL 0.125% bupivacaine with 2 mcg/mL fentanyl in two 5-mL doses via epidural needle, followed by 5mL of the same solution via epidural catheter (total dose 15 mL). The 402 in the spinal epidural (SE) group were given 2.5 mL 0.125% isobaric bupivacaine plus 2 mcg/mL fentanyl via 26 g GM spinal needle prior to epidural catheter placement.

In both groups, medications were administered at first request for neuraxial anesthesia. Labor was managed by registered nurses and obstetricians who were blinded to group assignment.

There were no significant differences between the groups in age, height, weight, body mass index, estimated gestational age, cervical dilation at epidural insertion, or pre-epidural verbal analog scale (VAS) pain scores. However, the time to complete analgesia (from initial EA and SE injection until patient reported VAS scores of 0 or 1 was significantly less with the SE group, 11 vs. 22 minutes.

The second stage of labor was statistically significantly shorter with EA (68 vs. 78 minutes), but the difference may not be clinically significant. There were no significant differences in time from epidural induction until cervical dilation reached 10 cm, duration of pushing, or rate of cervical dilation. There were also no differences in the use of instrumentation with vaginal delivery or need for cesarean section, Dr. Gambling reported.

During the first stage of labor, the mean VAS pain score was significantly less in the SE group. compared with EA (1.36 vs. 1.89) and also at 1 hour of labor (0.26 vs. 0.72), despite a slightly lower rate of patient-controlled analgesia use during the first stage (10 vs. 11 mL/hr). The proportion of women with mean VAS scores of zero at the end of stage 1 was significantly higher with SE (42% vs. 31% with EA), but the difference was not significant by the end of the second stage, he said.

Need for epidural top-up was greater in the EA group (26% vs. 16%), as was the need for more than one top-up (21% vs. 9%). Only a small proportion of each group (2% EA and 1.2% SE) required replacement of the epidural catheter, suggesting that there should not be concern about epidurals failing with SE because of inability to provide a test dose, he commented.

Fetal heart rate deceleration within 30 minutes of analgesic induction were more common in the SE group (8.5% vs. 4.5%), but none required emergency c-section. The proportions with Apgar scores below 7 at 1 and 5 minutes were less than 5% and less than 0.5%, respectively, in both groups.

Patient satisfaction with their mode of anesthesia did not differ, at 98% for SE and 96% for EA, Dr. Gambling reported.

Dr. Gamble said that he had no financial interests to disclose.

Copyright (c) 2009 Elsevier Global Medical News. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.

圣安东尼奥(EGMN)——一项在800名女性中对腰硬联合麻醉与传统硬膜外麻醉进行比较的随机对照试验显示，腰硬联合麻醉用于第一产程麻醉的效果优于硬膜外麻醉，但两者在第二产程或分娩镇痛方面的效果无差异。

 

David R. Gambling博士指出，这项硬膜外镇痛和腰硬膜外镇痛(EASE)研究还显示，不必担心因未能给予试验剂量而导致腰硬联合麻醉(CSE)失败。

 

既往比较这两种方法的研究结果不一。一篇Cochrane综述显示，CSE较少需要补救镇痛，尿潴留也较少，但较常引起瘙痒(Cochrane Database Syst. Rev. 2007 [doi:10.1002/14651858.CD003401.pub2])。圣地亚哥加利福尼亚大学和Sharp Mary Birch妇女-新生儿医院的 Gambling博士指出，与低剂量硬膜外麻醉(EA)相比，CSE的镇痛作用起效更快、更常导致瘙痒且脐动脉血pH更低，但其未提及宫颈扩张进展。

 

在EASE研究中，398名女性接受EA，即通过硬膜外针注射10 ml 0.125%布比卡因和2  μg/ml芬太尼，注射2剂，每剂5 ml，继以通过硬膜外导管给予5 ml相同溶液(总剂量为15 ml)。402名女性接受腰硬膜外麻醉(SE)，即在硬膜外导管置入前，通过26号GM腰穿针注射2.5 ml 0.125%等比重布比卡因和2 μg/ml芬太尼。

 

在这两个麻醉组中，药物的给予首先是为了满足轴索麻醉的需要。由对分组情况不知情的注册护士和产科医师处理分娩。

 

年龄、身高、体重、体重指数、估计胎龄、硬膜外麻醉导管插入时的宫颈扩张程度以及硬膜外麻醉前口述模拟量表(VAS)疼痛评分的组间差异均不显著。然而，SE组至完全镇痛时间(从初始EA和SE注射至患者自述VAS评分为0或1分的时间)明显少于EA组(11 min对22 min)。

 

Gambling博士表示，EA组的第二产程显著短于SE组(68 min对78 min)，该差异具有统计学意义，但无临床意义。两组在以下方面均无显著差异：从硬膜外诱导直至宫颈扩张达10 cm的时间、推挤持续时间和宫颈扩张率。在使用阴道分娩仪或需要实施剖宫产方面，两组也无差异。

 

SE组第一产程期间(1.36分对1.89分)和1h分娩时(0.26分对0.72分)的平均VAS疼痛评分均显著低于EA组，尽管SE组第一产程期间的患者自控镇痛应用率稍低于EA组(10 ml/h对 11 ml/h)。 他表示，第一产程结束时，SE组中平均VAS评分为0的女性比例显著高于EA组(42%对31%)，但该差异在第二产程结束时不显著。

 

EA组硬膜外追加用药的女性比例更高(26%对16%)，追加用药1次以上的比例也更高(21%对9%)。他表示，每组仅少数女性(EA组2% ，SE组1.2%)需要置入硬膜外导管，表明不应担心因未能给予试验剂量而导致SE麻醉失败。

 

镇痛诱导30 min内胎儿心率减速在SE组中更常见(8.5%对4.5%)，但无1名女性需要进行急诊剖宫产。在两组中，1 min时和5 min时Apgar评分<7分的比例分别不足5%和不足0.5%。

 

Gambling博士表示，SE组(98%)与EA组(96%)病人对麻醉方式的满意度无差别。

 

Gamble博士声明没有任何经济利益冲突。

 

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