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LETTER TO EDITOR
Year : 2021  |  Volume : 11  |  Issue : 2  |  Page : 130-131

Extension of labor epidural analgesia for emergency cesarean section: A survey of practice in the United Kingdom


Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom

Date of Submission18-May-2021
Date of Acceptance21-May-2021
Date of Web Publication01-Oct-2021

Correspondence Address:
Dr. Thomas E Potter
Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London
United Kingdom
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JOACC.JOACC_36_21

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How to cite this article:
Potter TE, Desai N. Extension of labor epidural analgesia for emergency cesarean section: A survey of practice in the United Kingdom. J Obstet Anaesth Crit Care 2021;11:130-1

How to cite this URL:
Potter TE, Desai N. Extension of labor epidural analgesia for emergency cesarean section: A survey of practice in the United Kingdom. J Obstet Anaesth Crit Care [serial online] 2021 [cited 2021 Nov 28];11:130-1. Available from: https://www.joacc.com/text.asp?2021/11/2/130/327407



Dear Editor,

Extension of existing labor epidural analgesia to achieve surgical anesthesia for emergency cesarean section is a well-established yet non-standardized technique.[1] Historical surveys have demonstrated much variation in the approaches to epidural test doses as well as top-ups.[2],[3] Since the publication of these surveys, meta-analyses have revealed lidocaine to be associated with the fastest onset, and ropivacaine to need the least intraoperative supplementation, and such findings could have influenced obstetric practice.[4] Interestingly, bupivacaine has been traditionally most commonly chosen for epidural extension,[3] but has now been shown to be slower in onset and require more intraoperative supplementation.[4]

In conjunction with the Obstetric Anesthetists' Association, we designed an electronic survey that was emailed to all their members between June and September 2020. In response, 430 surveys were completed, achieving a response rate of 23%.

Guidelines for the extension of labor epidural analgesia in emergency caesarean section were available to responding anesthetists in 76% of the obstetric units. Just over half of the anesthetists (52%) always administered a test dose before an epidural top-up, 43% with epinephrine, and more than a quarter (26%) never used one. Motivations for the administration of the epidural test dose included identification of the intrathecal (42%), intravascular (20%), epidural (10%), or the subdural (10%) placement or migration of the catheter, all of which can occur. The effects of the epidural test dose were assessed at 0–2 min (11%), 2–5 min (64%), or 5–10 min (23%) by evaluation of the cranial and cephalad extension (20%), blood pressure (19%), and the motor function of the lower limbs (19%). Compared to a national survey in 2000, our findings indicate that anesthetists may now be more likely to administer an epidural test dose.

To extend a labor epidural for cesarean section, lidocaine was reported to be the most commonly administered local anesthetic (41%), followed by levobupivacaine (17%), ropivacaine (15%), levobupivacaine with lidocaine (9%), bupivacaine (8%), and bupivacaine with lidocaine (8%). Fentanyl was co-administered as an adjunct by 41%. The rationale for the selection of local anesthetic included familiarity (82%), speed of onset (76%), and quality of block (67%) [Table 1]. Compared to a national survey in 2003,[3] the use of bupivacaine has reduced, but bupivacaine and levobupivacaine, perhaps surprisingly in view of their inferiority in recent meta-analyses,[4],[5] were still incorporated into the top-up solution by 42% of anesthetists. It is possible that the familiarity of anesthetists with these local anesthetics has inadvertently restricted the transition to the adoption of other local anesthetics as the evidence for lidocaine and ropivacaine has strengthened.
Table 1: Rationale for using chosen epidural top-up solution (original)

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In conclusion, the obstetric practice in regard to labor epidural analgesia for emergency cesarean section is varied. We recommend that guidelines on the obstetric unit, particularly with respect to local anesthetics, are representative of the latest evidence in order to produce neuraxial anesthesia of fast onset, where needed, and with the lowest risk of intraoperative supplementation. It is the opinion of the authors that the combination of lidocaine and ropivacaine should be investigated further.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Desai N, Carvalho B. Conversion of labour epidural analgesia to surgical anaesthesia for emergency intrapartum Caesarean section. Br J Anaesth Educ 2020;20:26-31.  Back to cited text no. 1
    
2.
Gardner IC, Kinsella SM. Obstetric epidural test doses: A survey of UK practice. Int J Obstet Anesth 2005;14:96-103.  Back to cited text no. 2
    
3.
Regan KJ, O'Sullivan G. The extension of epidural blockade for emergency Caesarean section: A survey of current UK practice. Anaesthesia 2008;63:136-42.  Back to cited text no. 3
    
4.
Hillyard SG, Bate TE, Corcoran TB, Paech MJ, O'Sullivan G. Extending epidural analgesia for emergency Caesarean section: A meta-analysis. Br J Anaesth 2011;107:668-78.  Back to cited text no. 4
    
5.
Reschke MM, Monks DT, Varaday SS, Ginosar Y, Palanisamy A, Singh PM. Choice of local anaesthetic for epidural caesarean section: A bayesian network meta-analysis. Anaesthesia 2020;75:674-82.  Back to cited text no. 5
    



 
 
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