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Choice of epidural local anesthesia for cesarean delivery: A Bayesian network meta-analysis of comparative speed and quality of block.
Abstract Number: T2B-238
Abstract Type: Original Research
Introduction: The use of rapid-onset drugs for epidural local anesthesia (LA) can facilitate urgent cesarean delivery avoiding general anesthesia and its associated risks for mother and baby. In an era of medication shortages, it is important to have precise comparative information on all available medications. The objective of this network meta-analysis (NMA) was to compare and rank the local anesthetics most commonly utilized for the urgent conversion of epidural analgesia for labor to an epidural anesthetic for cesarean delivery. This study expanded upon the most recent meta-analysis performed in 2011 which omitted both buffered lidocaine and 3% chloroprocaine1.
Methods: Medical databases were searched for randomized trials comparing different epidural LAs for onset-time to surgical anesthesia. Pooled estimates for onset time were calculated by Bayesian modeling. The risk of bias in the included trials was assessed based upon the Cochrane Collaboration recommendations.
Results: Sixteen randomized-controlled-trials with a total of 862 patients matched our inclusion criterion for the six most common LAs. NMA was performed using a random-effect model. The deviance information criterion for the model was 32.9 (34 data points). Pooled onset time was fastest for 3% chloroprocaine, followed sequentially by 2% lidocaine with epinephrine (buffered with bicarbonate), 2% lidocaine with epinephrine, 0.75% ropivacaine, 0.5% bupivacaine, and 0.5% levobupivacaine which were 0.36, 3.32, 4.93, 5.51 and 6.63 minutes slower respectively. No difference was found in incidence of intraoperative hypotension or need for supplementation.
Conclusions: This network meta-analysis used data from both direct and indirect comparisons of LAs, for the first time, to provide a rank-order of time to onset of epidural anesthesia. When rapid conversion for cesarean is warranted, 3% chloroprocaine has the fastest onset followed by buffered lidocaine with epinephrine then unbuffered lidocaine with epinephrine, ropivacaine, bupivacaine and levobupivacaine. This analysis can be used by clinicians to improve maternal and neonatal outcomes by selecting the fastest-acting LA available in their healthcare setting.
1. 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.