Dear Editor,
Dural puncture epidural (DPE) is a relatively new technique for labour analgesia (LA) performed by creating an intentional dural hole using a spinal needle, followed by insertion of an epidural catheter in the epidural space through which local anaesthetics with or without adjuvants are injected.[1] The dural hole acts as a passage for medications to slowly pass from epidural space into subarachnoid space, which provides improved block quality with fewer maternal and foetal side effects.[2,3] Previously, a bolus of 20 ml of 0.125% bupivacaine was found effective in DPE for LA. At our institute, a randomised controlled trial of DPE in LA comparing 0.125% of ropivacaine and 0.125% levobupivacaine was undertaken by the present authors.
In the original protocol, DPE was performed in L2-L3 or L3-L4 interspace with a 16-G Tuohy epidural needle and 26-G Whitacre spinal needle with an initial bolus of epidural 20 ml of 0.125% ropivacaine with 2 μg/ml fentanyl or 20 ml of 0.125% levobupivacaine with 2 μg/ml fentanyl. The drug was fractionated into four 5 ml boluses injected over 5 minutes as previously described.[1] In seven of first ten patients, complications of hypotension, motor blockade, and foetal heart rate variability developed [Table 1]. This prompted us to look for possible overlooked causes. On minute analysis, the height of the parturient was found more than that of the present group.[1] The protocol was modified to a maximal drug injection of 20 ml with the end point specified as a decrease in numerical rating scale (NRS) labour pain to 50% of baseline. Thus, about 4 ml of the drug was injected every 2 minutes till the end point was reached. With the modified protocol, considerably less volume of DPE drug was required (about 12 ml) in the next 20 parturients with no further reported morbidity [Table 2].
Table 1.
Data of first ten patients of DPE with 20 ml of 0.125% ropivacaine or 20 ml of 0.125% levobupivacaine
| Height (cm) Mean±SD 156.25±2.76 | Weight (kgs) Mean±SD 64.6±5.85 | BMI (kg/m2) Mean±SD 26.51±2.34 | Drug (20 ml of 0.125% local anaesthetic) | Maternal complications | FHR variations | Mode of delivery |
|---|---|---|---|---|---|---|
| 157.5 | 50 | 20.2 | Ropivacaine | No | No | Normal vaginal delivery |
| 157.5 | 60 | 24.2 | Ropivacaine | No | Variable decelerations | Cesarean section |
| 155 | 63 | 26.2 | Levobupivacaine | No | Early decelerations | Normal vaginal delivery |
| 145 | 60 | 28.5 | Ropivacaine | No | No | Caesarean delivery (pt preference) |
| 157.5 | 62 | 25 | Levobupivacaine | No | Yes, variable decelerations | Caesarean section |
| 157.5 | 68 | 27.4 | Levobupivacaine | No | No | Normal vaginal delivery |
| 157.5 | 85 | 34.3 | Ropivacaine | No | No | Normal vaginal delivery |
| 162.5 | 58 | 22 | Levobupivacaine | No | Early decelerations | Normal vaginal delivery |
| 155 | 68 | 28.3 | Ropivacaine | Motor blockade for 1 h Hypotension | No | Normal vaginal delivery |
| 157.5 | 72 | 29 | Ropivacaine | Hypotension | Late decelerations | Caesarean section |
Morbidity (in bold): Maternal morbidity/Foetal morbidity/Caesarean section; Seen in 6 out of 10 patients. FHR: Foetal heart rate; Pt: Patient
Table 2.
Data of ten patients of DPE with 20 ml of 0.125% ropivacaine or 20 ml of 0.125% levobupivacaine with the modified protocol: Graded epidural of 0.125% local anaesthetics, with a maximum limit of 20 ml
| Height (cm) Mean±SD 157.775±1.54 | Weight (kg) Mean±SD 63.2±5.936 | BMI (kg/m2) Mean±SD 25.36±2.011 | 0.125% of local anaesthetic/volume (ml) | Maternal complications | FHR variability | Mode of delivery |
|---|---|---|---|---|---|---|
| 157.5 | 61 | 24.6 | Ropivacaine/12 ml | No | No | Normal vaginal delivery |
| 162.5 | 84 | 31.8 | Ropivacaine/12 ml | No | No | Normal vaginal delivery |
| 157.5 | 64 | 25.8 | Levobupivacaine/14 ml | No | No | Instrumental vaginal delivery |
| 160 | 70 | 27.3 | Ropivacaine/12 ml | No | No | Normal vaginal delivery |
| 155 | 65 | 27.1 | Levobupivacaine/12 ml | No | No | Normal vaginal delivery |
| 155 | 60 | 25 | Ropivacaine/12 ml | No | Variable decelerations | Caesarean section |
| 157.5 | 67 | 27 | Ropivacaine/14 ml | No | No | Normal vaginal delivery |
| 160 | 49 | 19.1 | Levobupivacaine/12 ml | No | No | Normal vaginal delivery |
| 157.5 | 54 | 21.8 | Ropivacaine/12 ml | No | Variable decelerations | Caesarean section |
| 155 | 58 | 24.1 | Ropivacaine/12 ml | No | No | Normal vaginal delivery |
Maternal morbidity/Foetal morbidity/Caesarean section (in bold): Seen in 2 out of 10 patients. FHR: Foetal heart rate; Pt: Patient
Epidural injection for LA is associated with slow onset, inadequate sacral spread, and epidural catheter failure, whereas a combined spinal epidural technique gives rapid onset of blockade but is associated with maternal pruritus, maternal hypotension, and foetal bradycardia.[1] To retain the advantages of both and decrease the disadvantages, DPE for LA has been studied with the most effective results seen with a bolus of 20 ml of 0.125% bupivacaine.[2-4] In all previous studies, the height or body mass index (BMI) was more than that of the present study group[2-4] [Table 3]. After reported morbidity, the present protocol was modified to slower injections of the drug with a ceiling to the injected volume targeted to till 50% reduction in labour NRS rather than a fixed volume as previously reported. This significantly decreased the morbidity.
Table 3.
Studies comparing DPE to Epidural for LA
| Author/Year | Study | Type of Surgery | Sample Size | Drug Volume | Mean Height (cm)/Weight/BMI (kg/m2) of patients | Complications | Conclusion |
|---|---|---|---|---|---|---|---|
| Thomas et al. 2005[5] | DPE with 27G Whitacre needle vs Epidural | Labour Analgesia | 251 | Test dose of 2 ml 2% plain lidocaine followed by 5 ml + 3 ml 2% plain lidocaine | *Ht: 165±7 cm Weight and BMI Not mentioned | Hypotension in 32% DPE, c/t epidural. Instrumental and Caesarean delivery comparable. No comments on foetal complications | Epidural catheter manipulation, sacral sparing, unilateral block, LA quality comparable b/w groups. |
| Cappiello et al. 2008[2] | DPE vs Epidural | Labour analgesia | 80 | 12 ml of 0.25% Bupivacaine | *Ht: 165±8 cm | No difference in hypotension, nausea, and pruritus. Instrumental delivery significantly higher than epidural. Caesarean delivery in 31% DPE, c/t epidural. No foetal bradycardia in either group | DPE improves sacral spread, onset, and bilateral pain relief. |
| Deepak Gupta et al. 2013[4] | DPE vs Epidural | Labour analgesia | 131 | Test dose of 3 ml of 1.5% lidocaine with 5 µg/ml epinephrine followed by 5 ml + 5 ml of 0.125% Bupivacaine with 10 µg/ml fentanyl | Height and weight not mentioned. @BMI: 33.48±8.97 | No difference in incidence of hypotension, postpartum headache, neckache, and backache between groups. Caesarean delivery (20%) in DPE comparable to the epidural group (16%). No comments on foetal complications. | DPE did not provide superior analgesia compared to epidural. Higher incidence of paresthesias observed with DPE. |
| Chau et al. 2018[1] | DPE vs Epidural vs CSE | Labour analgesia=A | 120 | 20 ml of 0.125% Bupivacaine with 2 µg/ml fentanyl | *Ht: 166.6±5.8 cm Weight and BMI Not mentioned | Motor blockade in 15% DPE, significantly lesser than epidural (37.5%) DPE had hypotension (12.5%), pruritus (10%) significantly lower than CSE | Onset of analgesia Rapid with CSE. No difference b/w DPE and Epidural. Quality of analgesia DPE better than Epidural Side effects lesser in DPE than in CSE. |
| Wilson et al. 2018[3] | DPE with 26 G Whitacre needle vs Epidural | Labour analgesia | 80 | Test dose 3 ml of 1.5% Lidocaine with Epinephrine 5 µg/ml followed by 12 ml of 0.125% Bupivacaine+ 50 µg Fentanyl | Height and weight not mentioned @BMI: 33.7±7.86 | Mode of delivery, incidence of hypotension, pruritus, and PDPH not different between groups. No foetal bradycardia in DPE and comparable to the epidural group | DPE faster time to VAS ≤10 mm c/t Epidural. |
Ht: Height, #Height of patients lesser than that of present study (oriental study/abdominal surgeries); *Height more than that of present study, @BMI more than that of present study
To conclude, DPE with 0.125% of a local anaesthetic agent for LA in Indian parturients should be given in a graded manner till labour pain NRS reduces by 50% of baseline rather than a bolus of 20 ml. The proposal of a graded local anaesthetic for DPE for LA has never been reported previously.
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Conflicts of interest
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References
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