Combination Of An Epidural Opioid With A Local Anesthetic

When opioids alone are used in obstetric anesthesia, adequate analgesia is only achieved in the treatment of visceral pain in the first stage of labor. Somatic pain in the second stage is more difficult to manage. Nowadays because of the faster onset of action, especially in obstetrics, the rapidly acting lipophilic opioids sufentanil and fentanyl, which have a duration of effect of 2-3 h, have replaced the more hydrophilic morphine (duration of effect 8-24 h). The agents of choice are low-dose sufentanil or fentanyl in combination with low-dose bupivacaine in the form of an epidural infusion. This results in advantages with a faster onset, and a longer duration of analgesia, it lowers the total dose of a local anesthetic and opioid by about 20-25%, and reduces motor block, which is commonly seen after the sole epidural use of a local. In addition, there are lesser significant side effects for the mother and child when using such co-administration. The following combinations of an opioid with a local anesthetic are recommended:

1. Sufentanil and ropivacaine. After administering a test dose and incremental bolus administration of 15 mL 0.1% ropivacaine and 1-2 ^g/mL sufentanil (10-20 ^g), the continuous infusion can be started: 0.1% ropivacaine and 0.2-0.3 ^g/mL sufentanil using a speed of 10ml/h.

2. Fentanyl and ropivacaine. After administering a test dose and incremental bolus administration of 15mL 0.1% ropivacaine and 30^g fentanyl, the continuous infusion can be started: 0.1% ropivacaine and 2 ^/ml sufentanil, using a speed of 10-12 ml/h.

3. Sufentanil and bupivacaine (levobupivacaine). After administering a test dose and bolus administration of 10 mL 0.125-0.0625% bupivacaine (0.125-0.0625% levobupivacaine) and 1-2 ^g/ml sufentanil (10-20 ^g), the continuous infusion can be started after about 30 min: 0.0625-0.125% bupivacaine (0.0625-0.125% levobupivacaine) and 0.2-0.3 ^g/ml sufentanil, using a speed of 6-10 ml/h.

4. Fentanyl and bupivacaine (levobupivacaine). After administering a test dose and bolus administration of 10 ml 0.25% bupivacaine (0.25% levobupivacaine) and 50 ^g fentanyl, the continuous infusion can be started after about 30 min: 0.0625% bupivacaine (0.0625% levobupivacaine) and 1-2 ^g/ml fentanyl, using a speed of 10 ml/h.

Epinephrine is added mostly in obstetrical anesthesia where it has both alpha-adrenergic and beta-adrenergic effects. Adding epinephrine causes a dose-dependent reduction in uterine activity and leads to a delay in delivery. If there is an inadvertent intravascular injection of a local anesthetic with epinephrine, adverse circulatory reactions can occur both in the mother (hypertonia, cardiac arrhythmia) and in the child (reduced placental perfusion due to vasoconstriction). Any addition of epinephrine in obstetrics must therefore be strictly indicated.

When a cesarean section is to be performed, lumbar catheter epidural anesthesia for pain control can be used. The spread of the injected local anesthetic must reach segments T4-T6. The higher the spread of the local anesthetic, the greater the risk of severe hypotension. Segments L5, S 1 and S2 are not always adequately anesthetized and there is often a delay in anesthesia in this area.

When using a Patient-controlled epidural analgesia (PCEA) the opioid is combined with a local anesthetic [243]. The following combinations have been shown to be of clinical relevance:

1. Sufentanil and ropivacaine. 0.1% ropivacaine and 1 pg/ml sufentanil. Speed: 5-10 ml/h. Bolus dose: 5mL. Lockout period: 10-20 min.

2. Fentanyl and ropivacaine. 0.1% ropivacaine and 2 pg/mL fentanil. Speed: 10 ml/h. Bolus dose: 10 ml. Lockout period: 10-20 min.

3. Sufentanil and bupivacaine (levobupivacaine). After administering a test dose with a bolus administration of 5-10 ml, 0.125% bupivacaine (0.125% levobupi-vacaine) and 10-30 pg/ml sufentanil, the continuous infusion can be started: 0.0625% bupivacaine (0.0625% levobupivacaine) and 1 pg/mL sufentanil. Basic setting: Speed 5 ml/h (5 pg sufentanil) Bolus dose 5 mL (5 pg sufentanil) Lockout period: 20 min.

4. Fentanyl and bupivacaine (levobupivacaine). After administering a test dose and bolus administration of 6-10 mL, 0.125-0.25% bupivacaine (0.125-0.25% levobupivacaine), and 10 pg fentanyl, incremental, doses until segment T10 is reached. Now the continuous infusion can be started: 0.125% bupivacaine (0.125% levobupivacaine) and 0.0001% fentanyl. Basic setting: Speed 4 ml/h Bolus dose 4 mL Lockout period: 20 min.

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