Dural-puncture epidural extension anaesthesia superior to standard epidural in elective Cesarean surgery

This study, “Effect of Dural-Puncture Epidural vs Standard Epidural for Epidural Extension on Onset Time of Surgical Anesthesia in Elective Cesarean Delivery A Randomized Clinical Trial”, is published by Dr Nadir Sharawi, MBBS, MSc and colleagues.

It is already known that Dural-puncture epidural (DPE) and standard epidural are common modes of neuraxial labor analgesia. There needs to be more data available to know about the conversion of DPE-initiated labor analgesia to surgical anaesthesia for cesarean delivery.

This background was further investigated in this double-blind RCT conducted at a tertiary care university hospital. A T10 sensory block was achieved and maintained using a low bupivacaine concentration with fentanyl through the epidural catheter until surgery. Epidural extension anaesthesia was initiated in the operating room.

The primary outcome was the time taken from chloroprocaine administration to surgical anaesthesia (T6 sensory block). In contrast, secondary outcomes were failure to achieve a T10 bilateral block preoperatively in the delivery room, failure to accomplish a surgical block at T6 within 15 minutes of chloroprocaine administration, intraoperative analgesia requirements, repeat the neuraxial procedure, and conversion to general anaesthesia.

The summary of this study includes:

• There were 140 women of mean age of 30 years scheduled for elective cesarean delivery.
• Seventy women were in the Dural-puncture epidural or DPE group; analgesia was initiated using the DPE technique in the labor and delivery room.
• Seventy women were in the standard epidural group in which analgesia was initiated using a standard epidural technique in the labor and delivery room.
• The DPE group had a statistically significantly faster onset time to surgical anaesthesia than the standard epidural group.
• The median time to surgical anaesthesia for DPE and the standard group was 422 seconds and 655 seconds, respectively.

Our study indicates that the flow of chloroprocaine may have been promoted through the dural puncture owing to the rapid administration of a relatively large mass of the drug.

Chloroprocaine was chosen in this study because of its ease of administration without the need for opioids and other additives and the low risk of systemic toxic effects, favouring rapid administration for emergent cesarean delivery they addressed.

They said, “ In this RCT of 140 participants, the onset time to surgical anaesthesia was faster in the DPE group than the standard epidural group with a value of 422 vs 655 seconds.

The results of this study have proven the superiority of DPE epidural extension anaesthesia over standard epidural.

They noted that these findings need to be confirmed in women requiring intrapartum cesarean delivery.

Further reading:

Sharawi N, Williams M, Athar W, et al. Effect of Dural-Puncture Epidural vs Standard Epidural for Epidural Extension on Onset Time of Surgical Anesthesia in Elective Cesarean Delivery: A Randomized Clinical Trial. JAMA Netw Open. 2023;6(8):e2326710. doi:10.1001/jamanetworkopen.2023.26710