The use of neuraxial adjuvant drugs (neostigmine, clonidine) in obstetrics.

PURPOSE OF REVIEW: Neuraxial adjuvant drugs are used to improve analgesia and to decrease complications associated with a high dose of a single drug. Opioids are used in routinely, but alpha2-agonists, such as clonidine or cholinesterase inhibitors (neostigmine), have also been used for labour analgesia or to relieve pain following caesarean section. Both drugs possess a common mechanism of action that can be beneficial. RECENT FINDINGS: Small doses of intrathecal clonidine (30 microg), combined with local anaesthetics and opioids, prolong labour analgesia. Hypotension can occur and must be promptly treated by ephedrine to avoid fetal side effects. Epidural clonidine (60 to 75 microg) produces prolonged analgesia from local anaesthetics and opioids and allows a ropivacaine sparing effect. Intrathecal neostigmine has analgesic properties, but its gastro-intestinal side effects contraindicate its clinical use. Epidural neostigmine, combined with sufentanil or clonidine, initiates labour analgesia (minimum 6 to 7 microg/kg; 500 microg) without side effects, however, and allows a 'mobile epidural'. Epidural and spinal clonidine can be used to improve postcaesarean section analgesia. Epidural neostigmine at the doses studied produces modest analgesia following caesarean section. SUMMARY: Co-administration of neuraxial drugs may enhance analgesia and reduce the side effects of each drug. Clonidine and neostigmine may be used in obstetrics, under some conditions

Patient-controlled intravenous analgesia as an alternative to epidural analgesia during labor: questioning the use of the short-acting opioid remifentanil. Survey in the French part of Belgium (Wallonia and Brussels).

Childbirth ranks among the most intense experiences of acute pain. Neuraxial analgesia (i.e. epidural or combined spinal-epidural technique) is the most effective way to relieve that pain but it is contraindicated or impossible to perform for some parturients. We designed a survey of the current use of analgesic alternatives to epidural analgesia (EA) for labor pain, specifically the use of opioid patient-controlled intravenous analgesia (PCIA), in the French part of Belgium (Wallonia and Brussels). A questionnaire was mailed to the departmental chair of the hospitals with an obstetric unit, both in university and non-university centers (total of 53 centers). The questionnaire evaluated the availability of EA, the alternatives used when EA was contraindicated, the use of opioid-based PCIA for labor analgesia as well as opioid preference and doses, and finally the reasons for not using opioid PCIA. The response rate was 67.5% (36 centers). Among the responding hospitals, EA was available for 68% (range 25-85%) of labors and deliveries. When EA was not available or contraindicated, a parenteral opioid (piritramide, tramadol or pethidine) was proposed in 19% (7/36) of the centers, Entonox in 11% (4/36), a pudendal block by obstetricians in 28% (10/36) and non-pharmacologic alternatives (i.e. hypnosis, sophrology, baths and massages) in 19% (7/36). In 28% (10/36) of the centers however, no analgesic alternative was proposed. Opioid PCIA was employed in 36% (13/36) of the centers and for an additional 11% (4/36) only in case of intrauterine death. Remifentanil was the first choice (76.5% of the PCIA), followed by sufentanil (23.5%). Other opioids (piritramide, morphine, fentanyl) and ketamine were also administered by PCIA. Forty-five percents of the centers reported never using opioid PCIA by either lack of knowledge (7%), fear of maternal or fetal side effects (48%) and unability to provide a correct supervision of the parturient during PCIA use (48%), opposition from the pediatricians or obstetricians (17%) or because they considered the technique as ineffective to relieve labor pain (17%). In conclusion, the survey demonstrated that, when EA is contraindicated, systemic opioid administered by PCIA is used in almost half of the centers (47%) and that remifentanil is the first choice, particularly when a live birth is expected

Epidural neostigmine combined with sufentanil provides balanced and selective analgesia in early labor

BACKGROUND: This study evaluated the efficacy of an epidural single dose of neostigmine combined with sufentanil to provide selective and balanced analgesia at the beginning of labor. METHODS: After informed consent, 125 healthy parturients were randomly allocated to receive, after a test dose, a single injection of either epidural sufentanil 20 micrograms (minimal analgesic dose) or 10 micrograms or a combination of sufentanil 10 micrograms with neostigmine 250, 500, or 750 micrograms in a total volume of 12 ml. Pain scores were recorded at regular intervals to determine onset and duration of analgesia. Maternal and fetal vital parameters as well as side effects were closely monitored. RESULTS: Parturients did not differ concerning demographic data. Epidural neostigmine 500 micrograms with sufentanil 10 micrograms produced effective analgesia (visual analog scale <30 mm within 10 min in 72% parturients and within 15 min in 85% parturients; average duration of 119 min, confidence interval 96-142 min) that was as effective as epidural sufentanil 20 micrograms. Epidural combination with neostigmine 250 micrograms was ineffective, whereas 750 micrograms did not produce higher effect than 500 micrograms. No motor block was recorded. Maternal and fetal vital parameters remained stable during labor. CONCLUSIONS: Epidural combination of neostigmine 500 micrograms (e.g., 6-7 micrograms/kg) with sufentanil 10 micrograms provides similar duration of analgesia as epidural sufentanil 20 micrograms and allows effective and selective analgesia devoid of side effects in the first stage of labor

Patient-controlled intravenous analgesia using remifentanil in two parturients with twin pregnancies : case report

PURPOSE: We report the use of Patient-Controlled Intravenous Analgesia (PCIA) with remifentanil in two parturients with twin pregnancies in whom epidural analgesia was contraindicated. CLINICAL FEATURES: Two patients with a twin pregnancy were admitted to the labor ward at 36 weeks of gestation. Epidural analgesia was contraindicated because of anticoagulation therapy or because of severe thrombocytopenia. PCIA remifentanil was offered to these patients. In the first case, pain from contractions was well controlled during labor, and the first twin was easily delivered. On the other hand, the second twin was in the breech position and an internal version was required rapidly because of fetal bradycardia to deliver the baby as soon as possible. Pain increased in intensity during this maneuver and PCIA remifentanil was insufficient. In the second case, the course of labor was uneventful and the patient easily delivered twins. CONCLUSION: In the case of twin pregnancy, we recommend remifentanil PCIA only if epidural analgesia is contraindicated (and not as a routine) because of the high risk of obstetrical maneuvers or potential cesarean delivery for the second twin, and the lack of efficacy of remifentanil, at the dose used in this report

INNOVATIONS 2018 EN ANESTHÉSIOLOGIE

Le rôle de l’anesthésiste est d’accompagner le patient durant toute la période péri-opératoire et d’assurer, entre autres, son bien-être par une anxiolyse et une gestion efficace de la douleur. A côté des moyens médicamenteux classiques, une technique, pour le moins innovante, fait petit à petit ses preuves dans le milieu médical : la réalité virtuelle. Déjà bien connue du grand public pour ses vertus récréatives, elle semble devenir dans un futur proche un outil incontournable dans la gestion de la douleur et de l’anxiété dans une grande variété de procédures médicales douloureuses. Déjà étudiée avec succès, tant chez l’adulte que chez l’enfant, dans toute une série de procédures médicales potentiellement douloureuses telles que le traitement des plaies chez les grands brûlés, les interventions dentaires et les interventions médicales de routine, elle commence à faire son apparition en anesthésiologie

Clonidine versus sufentanil as an adjuvant to ropivacaine in patient-controlled epidural labour analgesia: A randomised double-blind trial.

BACKGROUND: Adjuvants to local anaesthetics for epidural labour analgesia are useful if they reduce side-effects or personnel requirements. Epidural clonidine improves analgesia and provides a significant local anaesthetic-sparing effect. OBJECTIVE: To compare the number of rescue doses administered by the anaesthesiologist when clonidine or sufentanil is added to epidural ropivacaine. DESIGN: A randomised double-blind trial. SETTING: Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium, from June 2009 to June 2010. PATIENTS: One hundred and ninety-five women in labour. INTERVENTION: Epidural analgesia initiated with 10 ml ropivacaine 0.1%, women randomised to receive patient-controlled epidural analgesia (5 ml demand bolus, 15 min lockout) with ropivacaine 0.1% and sufentanil 0.25 μg ml⁻¹ (RS group; n = 65), or ropivacaine 0.1% and clonidine 1.5 μg ml⁻¹ (RC1.5 group; n = 65) or ropivacaine 0.1% and clonidine 3 μg ml⁻¹ (RC3 group; n = 65). Rescue analgesia was available as needed – 10 ml ropivacaine 0.1% (numerical rating scale <6/10) or ropivacaine 0.2% (numerical rating scale ≥6/10). MAIN OUTCOME: Comparison of the total number of rescue doses. RESULTS: The total number of rescue doses was similar among the groups [median (interquartile range): 1 (0 to 1) in the RC1.5 group, 1 (1 to 2) in the RC3 group and 2 (1 to 2) in the RS group; overall P = 0.056]. However, fewer patients in both the RC1.5 and RC3 groups needed two or more rescue doses (25 and 29% versus 52% in the RS group, P = 0.01). The rate of instrumental delivery was higher in both clonidine groups (13 and 12% versus 0%, P = 0.03). Nausea was significantly less frequent in both the clonidine groups. Satisfaction scores, total ropivacaine consumption, maternal sedation, and hypotension and neonatal outcomes were similar among the groups. CONCLUSION: Compared with sufentanil 0.25 μg ml⁻¹, addition of clonidine (1.5 to 3 μg ml⁻¹) to patient-controlled epidural analgesia with ropivacaine 0.1% provided similar labour analgesia and a similar need for anaesthesiologist-administered rescue doses. Clonidine 3 μg ml⁻¹ did not offer any advantage over clonidine 1.5 μg ml⁻¹. The instrumentation rate was higher in both the clonidine groups

Evaluation of pregabalin as an adjuvant to patient-controlled epidural analgesia during late termination of pregnancy

INTRODUCTION:: Late termination of pregnancy combines psychological distress with severe physical pain. The present study evaluated the benefit of adding oral pregabalin to epidural analgesia during this procedure. METHODS:: Healthy women were randomly allocated to receive either oral pregabalin 150 mg/12 h or prazepam 10 mg/12 h at the induction of the late termination of pregnancy procedure. When they felt abdominal pain (numerical rating scale ranging from 0 [no pain] to 100 [worst pain possible]), patient-controlled epidural analgesia was activated and set to deliver ropivacaine 0.1% with sufentanil 0.25 μg/ml, 5 ml/h with a bolus dose of 5 ml/30 min. Rescue analgesia was available as needed by administration of 10 ml ropivacaine 0.1% (pain score less than 60/100) or 0.2% (at least 60/100). The primary outcome was the consumption of epidural analgesics. RESULTS:: Forty-eight patients participated in the study. Demographic and obstetric data were similar. Pregabalin reduced total ropivacaine consumption 11.3 ± 3.2 mg/h (mean ± SD) versus 15.1 ± 4.9 mg/h in the prazepam group (P = 0.005), an effect related to a decrease in the need for rescue analgesia. In the pregabalin group, fewer women asked for rescue dose (75 vs. 96%; P = 0.048), and the number of rescue doses per patient was reduced (1 [0-2] vs. 2 [1-3]); median [interquartile range], P = 0.005), particularly the need for ropivacaine 0.2%. DISCUSSION:: This is the first study considering the use of pregabalin for labor pain associated with late termination of pregnancy, showing that pregabalin 150 mg/12 h is a helpful adjuvant to epidural analgesia. Modulation of both visceral sensitization and affective component of pain may contribute to the benefits observed