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Continuous Spinal Analgesia for Labor with Infusion of 0.0625% Bupivacaine and 2 μg/mL Fentanyl
Abstract Number: T 16
Abstract Type: Original Research
From November 2011 through January 2013, we used an infusion of 0.0625% bupivacaine with 2μg/mL fentanyl via a previously-reported 23-gauge spinal catheter (Wiley, Epimed, Johnstown, NY, Lot No. 12404147) for labor analgesia and delivery in 87 patients. Inclusion criteria were spontaneous term labor with zero or one prior vaginal delivery at cervical dilation of six cm or less without preeclampsia or meconium-stained amniotic fluid. All patients received 2.5 mg of bupivacaine upon catheter insertion followed by a continuous infusion at a rate of 2 mL/hr, with a 1 mL/hr demand bolus every 20 minutes. If cesarean delivery was necessary, 0.5% bupivacaine, up to 30 mg, was given via the catheter along with 20 mcg of fentanyl. Mean arterial blood pressure, body temperature, visual analog scale (VAS) score, Bromage score, number of physician boluses, and number of pump adjustments were recorded. The spinal catheters were kept in place to achieve a minimum indwelling time of 12 hours.
In one patient, threading of the catheter was not successful. In 10 patients, the spinal catheter was removed prior to delivery and exchanged for an epidural catheter, due to catheter kinking or migration. Of the remaining 76 patients, 52 had spontaneous vaginal deliveries, 10 had instrument-assisted vaginal deliveries, and 14 had cesarean deliveries. The average VAS score was 8.93 ± 2.4 at analgesia request, 0.42 ± 1.5 at 30 minutes after insertion, and 1.60 ± 5.4 at complete cervical dilation. The average Bromage score was 6.00 ± 0.0 at analgesia request, 3.42 ± 1.9 at 30 minutes after insertion, and 3.54 ± 2.5 at complete cervical dilation. Use of the spinal catheter was successful in all instrument-assisted deliveries and in all but one cesarean delivery.
The average mean arterial blood pressure decrease was 13.2%. Four patients required 500 mL IV fluid boluses and/or vasopressor support. In 30 patients, physician bolus or pump adjustment was required. Eleven patients had a temperature over 38 °C while the catheter was in place. In two patients the catheter was removed ahead of schedule, one due to operator misunderstanding, the other due to patient complaints of unilateral leg pain. Three patients experienced post dural puncture headaches which were successfully treated with an epidural blood patch. There were no apparent infectious or neurological complications.
We conclude that infusion of 0.0625% bupivacaine with 2 μg/mL fentanyl via a 23-gauge spinal catheter provides adequate labor analgesia and appears effective for both instrument-assisted and cesarean deliveries. With a continuous infusion and a demand dose, most patients can be managed with minimal physician intervention. With a target indwelling time of 12 hours, the incidence of headache is low at 3.95% (3.56% – 4.34% 95% CI). Challenges remain in regard to device failure with the version of the catheter we studied.