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Why Bolus Epidurals with Bupivacaine?
Abstract Number: T 12
Abstract Type: Original Research
Introduction: Labor analgesia often begins with a local anesthetic bolus via epidural catheter. Adverse sequelae of inadvertent intravenous bupivacaine injection (1) lead some to bolus with lidocaine. Does bolus lidocaine associate with quicker pain relief, hypotension, rescue vasopressor administration, or urgent Cesarean section (CS) compared to bupivacaine?
Methods: We analyzed demographic, pre-anesthetic, and outcome data on all labor epidurals over 17 months (9/2007-1/2009). By anesthesiologist choice, patients received 10mL bolus of either 0.25% plain bupivacaine or 2% lidocaine with 1:200,000 epinephrine. Then all patients received ropivacaine 0.125% + fentanyl 2 mcg/ml at 10mL/hr with at most one 10mL bolus every 20 min on demand. Time to achieve pain-free labor was assessed every minute. We recorded non-reassured fetal heart rate, low blood pressure, ephedrine use, and urgent CS within 30 min of bolus.
Results: Of 623 labor epidurals placed, 23 also had intrathecal dosing and were excluded, 159 received bupivacaine bolus, and 441 lidocaine bolus. Groups differed only in mL of preload given (table 1). Time to pain relief was 5 min median (IQR 5-30) for each group. Choice of bolus drug did not associate with hypotension, ephedrine use, non-reassured fetal heart rate, or CS within 30 min of bolus (table 2). No recorded variable predicted any complication by multivariate logistic regression using either the entire cohort, or using a “greedy”-matched propensity scored cohort.
Conclusion: Substituting lidocaine for bupivacaine bolus may not impact clinically the course of labor analgesia. These observational data suggest the need for a randomized controlled double-blind trial.
Reference: (1) Karaca S, Unlüsoy EO. Eur J Anaesthesiol. 2002; 9:616