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A retrospective audit comparing the effect of sodium bicarbonate on decision to delivery interval in patients receiving lidocaine and epinephrine epidural top ups
Abstract Number: F-21
Abstract Type: Original Research
Epidural top up is a common method of anaesthesia for emergency lower segment caesarean section and there has been much debate about the best combination of drugs for this purpose, both in regards to speed of onset of block and quality of anaesthesia. In our institution we routinely use 2% lidocaine with 5 micrograms/ml epinephrine, with or without alkalinisation for such cases. Shortages of sodium bicarbonate in the past have necessitated the administration of epidural top ups without this addition. We have evaluated whether this has altered the decision to delivery interval (DDI).
Three groups of 25 consecutive patients who had an epidural for labour and needed an emergency caesarean section were studied; the first group received an epidural top up mixture of 2% lidocaine, epinephrine 5 micrograms/ml and 2 ml 8.4% sodium bicarbonate (LBE1) in May 2013. The second group of patients received a mixture of 2% lidocaine and epinephrine 5 micrograms/ml (LE) in November to December 2013 and a third group received 2% lignocaine, epinephrine 5 micrograms/ml and 2 ml 8.4% sodium bicarbonate between November and December 2015 (LBE2). The number of patients in each group was determined using a power calculation.
A retrospective audit was performed. Category of lower segment caesarean section, adjuncts used intra operatively for pain, conversion to general anaesthesia and DDI were noted. Information was collected from patient notes and the E3 electronic maternity notes system.
In the 75 patients, 1 patient from LBE1 and 1 patient from LBE2 were converted to general anaesthesia, following failure of top up with bicarbonate. The mean DDI in the LBE1 group was 40.8 min, in the LE group was 35.6 min and in the LBE2 group was 44.2 min.
Lidocaine, bicarbonate and epinephrine and lidocaine and epinephrine mixture has been shown to be associated with a faster onset of anaesthesia for caesarean section than levobupivacaine (1). However the addition of bicarbonate to lidocaine mixture is controversial, it may introduce mixing errors and cause precipitation of lidocaine. A meta-analysis of published data suggested the use of ropivacaine as an alternative (2). Although there are theoretical reasons why onset of anaesthesia may be faster with the addition of bicarbonate this did not shorten decision to delivery time in this audit. We suggest a formal randomised controlled trial to examine this in more detail.
In this audit, addition of bicarbonate to lidocaine and epinephrine did not appear to reduce DDI in emergency section.
1. Allam J1, Malhotra S, Hemingway C, Yentis SM Anaesthesia. 2008 Mar;63(3):243-9 Epidural lidocaine-bicarbonate-adrenaline vs levobupivacaine for emergency Caesarean section: a randomised controlled trial.
2. Hillyard SG1, Bate TE, Corcoran TB, Paech MJ, O'Sullivan G Extending epidural analgesia for emergency Caesarean section: a meta-analysis. Br J Anaesth. 2011 Nov;107(5):668-78