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Comparison of speed of onset of epidural versus spinal anesthesia for elective Cesarean sections
Abstract Number: T-30
Abstract Type: Original Research
Regional anesthesia is strongly preferred for Cesarean section surgery. Advantages with single shot spinal over epidural anesthesia include: faster onset with a solid and reliable block. Advantages of epidural anesthesia include; possibility to prolong the block via the epidural catheter, however there may be a delayed onset. Combined spinal epidural (CSE) could potentially combine the advantages of each technique but has potential disadvantages such as an untested epidural catheter, lower spinal level due to prolonged placement, failure of spinal (partial dosing), enhanced sympathectomy and difficulty with the technique in larger BMI patients. Labor epidural analgesia dosing has changed over the years, moving to lower concentration and higher volume dosing, which may lead to a faster block initiation. Using this approach with epidural dosing for surgical anesthesia may be similarly beneficial, particularly for larger BMIs. We report the preliminary results of a study that compares single shot spinal dosing with volume epidural dosing for elective Cesarean-section patients.
Methods: After IRB approval and informed consent, study patients were randomized to 4 treatment groups: 1) BMI <35 (spinal) 2) BMI <35 (epidural) 3) BMI >35 (spinal) 4) BMI >35 (epidural). Demographic, hemodynamic data (pressor consumption), block heights, block duration, supplementation medications, pain scores and post operative follow up were recorded. Spinal anesthesia group was 12mg bupivacaine, 200 mcg morphine, 10 mcg fentanyl; epidural anesthesia group was 10ml premixed dosing volumes (6ml 2% lidocaine / 5mcg/ml epinephrine, 2 ml sodium bicarbonate, 2 ml 100mcg fentanyl) with further boluses as necessary; using a standard anesthetic approach for each.
Results: Preliminary results show in the <35 BMI group a significantly (p<0.01) faster average time from block placement to T6 level with spinal placement 6.92 (+/-2.43) compared to 10.1 (+/-3.5) minutes with an epidural; however an absolute difference of less than 3 minutes. In the >35 BMI group there was no significant (p>0.05) difference in average time from block placement to T6 level with spinal placement 8.5 (+/-4.9) compared to 7.27 (+/-1.7) minutes with epidural placement.
Discussion: For time to appropriate block, there was a statistical significant difference between spinal and epidural, for BMI group <35 and no statistical significant difference between spinal and epidural for BMI group >35, however, in relation to clinical significance of a time of < 3 minutes for an elective C-section; there would be little difference in the techniques with regards to time of onset.
Conclusion: There are a number of techniques that achieve the goal of safety and clinical efficacy. Epidural anesthesia could be considered in patients undergoing elective C-section, especially in high BMI or cases that may be prolonged, and if volume dosing is used may lead to an acceptable onset time of surgical anesthesia.