Chau Anthony, Bibbo Carolina, Huang Chuan-Chin, Elterman Kelly G, Cappiello Eric C, Robinson Julian N, Tsen Lawrence C
From the *Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, Canada; †Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts; ‡Harvard Medical School, Boston, Massachusetts; §Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts; and [REPLACEMENT CHARACTER]Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas.
Anesth Analg. 2017 Feb;124(2):560-569. doi: 10.1213/ANE.0000000000001798.
The dural puncture epidural (DPE) technique is a modification of the combined spinal epidural (CSE) technique, where a dural perforation is created from a spinal needle but intrathecal medication administration is withheld. The DPE technique has been shown to improve caudal spread of analgesia compared with epidural (EPL) technique without the side effects observed with the CSE technique. We hypothesized that the onset of labor analgesia would follow this order: CSE > DPE > EPL techniques.
A total of 120 parturients in early labor were randomly assigned to EPL, DPE, or CSE groups. Initial dosing for EPL and DPE consisted of epidural 20 mL of 0.125% bupivacaine plus fentanyl 2 μg/mL over 5 minutes, and for CSE, intrathecal 0.25% bupivacaine 1.7 mg and fentanyl 17 μg. Upon block completion, a blinded coinvestigator assessed the outcomes. Two blinded obstetricians retrospectively interpreted uterine contractions and fetal heart rate tracings 1 hour before and after the neuraxial technique. The primary outcome was time to numeric pain rating scale (NPRS) ≤ 1 analyzed by using Kaplan-Meier curves and Cox proportional hazard model. Secondary outcomes included block quality, maternal adverse effects, uterine contraction patterns, and fetal outcomes analyzed by using the χ test with Yates continuity correction.
There was no significant difference in the time to NPRS ≤ 1 between DPE and EPL (hazard ratio 1.4; 95% confidence interval [CI] 0.83-2.4, P = .21). DPE achieved NPRS ≤ 1 significantly slower than CSE (hazard ratio 0.36; 95% CI 0.22-0.59, P = .0001). The median times (interquartile range) to NPRS ≤ 1 were 2 (0.5-6) minutes for CSE, 11 (4-120) minutes for DPE, and 18 (10-120) minutes for EPL. Compared with EPL, DPE had significantly greater incidence of bilateral S2 blockade at 10 minutes (risk ratio [RR] 2.13; 95% CI 1.39-3.28; P < .001), 20 minutes (RR 1.60; 95% CI 1.26-2.03; P < .001), and 30 minutes (RR 1.18; 95% CI 1.01-1.30; P < .034), a lower incidence of asymmetric block after 30 minutes (RR 0.19; 95% CI 0.07-0.51; P < .001) and physician top-up intervention (RR 0.45; 95% CI 0.23-0.86; P = .011). Compared with CSE, DPE had a significantly lower incidence of pruritus (RR 0.15; 95% CI 0.06-0.38; P < .001), hypotension (RR 0.38; 95% CI 0.15-0.98; P = .032), combined uterine tachysystole and hypertonus (RR 0.22; 95% CI 0.08-0.60; P < .001), and physician top-up intervention (RR 0.45; 95% CI 0.23-0.86; p = .011).
Analgesia onset was most rapid with CSE with no difference between DPE and EPL techniques. The DPE technique has improved block quality over the EPL technique with fewer maternal and fetal side effects than the CSE technique for parturients requesting early labor analgesia.
硬膜穿破硬膜外（DPE）技术是对腰麻-硬膜外联合阻滞（CSE）技术的一种改良，即通过脊麻针造成硬膜穿孔，但不进行鞘内给药。与硬膜外（EPL）技术相比，DPE技术已被证明能改善镇痛药物向尾端扩散，且无CSE技术所观察到的副作用。我们假设分娩镇痛的起效顺序为：CSE＞DPE＞EPL技术。
共120例初产妇被随机分为EPL组、DPE组或CSE组。EPL组和DPE组的初始剂量为硬膜外注射20 mL 0.125%布比卡因加2 μg/mL芬太尼，在5分钟内注射完毕；CSE组为鞘内注射0.25%布比卡因1.7 mg和芬太尼17 μg。阻滞完成后，由一位不知情的共同研究者评估结果。两位不知情的产科医生回顾性解读神经轴技术操作前后1小时的子宫收缩和胎儿心率曲线。主要结局指标为采用Kaplan-Meier曲线和Cox比例风险模型分析的数字疼痛评分量表（NPRS）≤1的时间。次要结局指标包括阻滞质量、产妇不良反应、子宫收缩模式以及采用Yates连续性校正的χ检验分析的胎儿结局。
DPE组和EPL组达到NPRS≤1的时间无显著差异（风险比1.4；95%置信区间[CI] 0.83 - 2.4，P = 0.21）。DPE组达到NPRS≤1的时间显著慢于CSE组（风险比0.36；95% CI 0.22 - 0.59，P = 0.0001）。CSE组、DPE组和EPL组达到NPRS≤1的中位时间（四分位间距）分别为2（0.5 - 6）分钟、11（4 - 120）分钟和18（10 - 120）分钟。与EPL组相比，DPE组在10分钟（风险比[RR] 2.13；95% CI 1.39 - 3.28；P < 0.001）、20分钟（RR 1.60；95% CI 1.26 - 2.03；P < 0.001）和30分钟（RR 1.18；95% CI 1.01 - 1.30；P < 0.034）时双侧S2阻滞的发生率显著更高，30分钟后不对称阻滞（RR 0.19；95% CI 0.07 - 0.51；P < 0.001）和医生追加干预（RR 0.45；95% CI 0.23 - 0.86；P = 0.011）的发生率更低。与CSE组相比，DPE组瘙痒（RR 0.15；95% CI 0.06 - 0.38；P < 0.001）、低血压（RR 0.38；95% CI 0.15 - 0.98；P = 0.032）、子宫收缩过速合并高张（RR 0.22；95% CI 0.08 - 0.60；P < 0.001）以及医生追加干预（RR 0.45；95% CI 0.23 - 0.86；P = 0.011）的发生率显著更低。
CSE组镇痛起效最快，DPE组和EPL组之间无差异。对于要求早期分娩镇痛的产妇，DPE技术比EPL技术改善了阻滞质量，且母婴副作用比CSE技术更少。
