Singh Preet Mohinder, Monks David T, Bhat Adithya D, Borle Anuradha, Kaur Manpreet, Yang Phillip, Kanakaraj Muthuraj
Department of Anaesthesiology, Washington University in Saint Louis/Barnes Jewish Hospital, Saint Louis, MO, USA.
Department of Anaesthesiology, Washington University in Saint Louis/Barnes Jewish Hospital, Saint Louis, MO, USA.
Br J Anaesth. 2025 May;134(5):1402-1414. doi: 10.1016/j.bja.2025.01.033. Epub 2025 Mar 22.
Epidural analgesia and dural puncture epidural (DPE) analgesia are widely used techniques for alleviating labour pain. This meta-analysis compared clinical outcomes between parturients receiving epidural analgesia vs DPE analgesia for labour pain.
Medical databases were searched to identify randomised controlled trials comparing epidural analgesia with DPE analgesia in labouring parturients published up to October 2024. Results were pooled using an inverse variance random-effects model, and 95% prediction intervals were calculated. Clinical outcomes were used as defined by individual trials. The primary outcome was time to onset of analgesia. Secondary outcomes were unilateral block, motor block, sacral sparing, adequate analgesia, Caesarean/operative vaginal delivery, additional doses, and hypotension. The certainty of evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation guidelines, and subgroup analyses were performed based on the types of local anaesthetics used.
Eighteen trials involving 2144 parturients were included. DPE labour analgesia slightly reduced the time to onset (mean difference: 3.4 min, 95% confidence interval: 2.1-4.7, P<0.01, I=97%; moderate certainty). All statistically significant results demonstrated clinical advantages for DPE analgesia, including fewer unilateral blocks, reduced motor block, improved sacral coverage, and higher rates of adequate analgesia. Substantial heterogeneity was observed in the outcome data for time to onset of analgesia, unilateral block, and sacral sparing. Pooled results for Caesarean/operative vaginal delivery, additional doses, and hypotension failed to achieve statistical significance.
DPE labour analgesia offers a slightly faster onset and reduced incidence of motor and unilateral blocks compared with traditional epidural analgesia. However, high heterogeneity in some outcomes, likely attributable to clinical and dosing variability, requires cautious interpretation. Although the clinical relevance of the faster onset with DPE analgesia might be modest, when considered alongside its benefits in secondary outcomes it supports the use of DPE analgesia over traditional epidural analgesia. Imputed prediction intervals cross zero for many outcomes, and further studies might alter these findings.
PROSPERO- CRD42024602115.
硬膜外镇痛和硬膜穿破硬膜（DPE）镇痛是缓解分娩疼痛的常用技术。本荟萃分析比较了接受硬膜外镇痛与DPE镇痛的产妇在分娩疼痛方面的临床结局。
检索医学数据库，以识别截至2024年10月发表的比较硬膜外镇痛与DPE镇痛在分娩产妇中的随机对照试验。使用逆方差随机效应模型汇总结果，并计算95%预测区间。临床结局根据各试验的定义确定。主要结局是镇痛起效时间。次要结局包括单侧阻滞、运动阻滞、骶部保留、充分镇痛、剖宫产/阴道助产、追加剂量和低血压。使用推荐分级评估、制定和评价指南评估证据的确定性，并根据所用局部麻醉药的类型进行亚组分析。
纳入了18项涉及2144名产妇的试验。DPE分娩镇痛略微缩短了起效时间（平均差：3.4分钟，95%置信区间：2.1 - 4.7，P<0.01，I² = 97%；中等确定性）。所有具有统计学意义的结果均显示DPE镇痛具有临床优势，包括单侧阻滞更少、运动阻滞减轻、骶部覆盖改善以及充分镇痛率更高。在镇痛起效时间、单侧阻滞和骶部保留的结局数据中观察到显著的异质性。剖宫产/阴道助产、追加剂量和低血压的汇总结果未达到统计学意义。
与传统硬膜外镇痛相比，DPE分娩镇痛起效稍快，运动和单侧阻滞的发生率降低。然而，某些结局的高度异质性可能归因于临床和剂量的变异性，需要谨慎解释。尽管DPE镇痛起效更快的临床相关性可能不大，但结合其在次要结局方面的益处，支持使用DPE镇痛而非传统硬膜外镇痛。许多结局的推算预测区间与零交叉，进一步的研究可能会改变这些结果。
PROSPERO - CRD42024602115
