Original ArticleThe optimal concentration of bupivacaine and levobupivacaine for labor pain management using patient-controlled epidural analgesia: a double-blind, randomized controlled trial
Introduction
Patient-controlled epidural analgesia (PCEA), with or without background infusion, is commonly used to maintain labor analgesia.1 It results in greater maternal satisfaction when compared with a continuous infusion, presumably because women enjoy a certain level of control.2 Nevertheless, epidural analgesia has side effects and limiting the dose of local anesthetic (LA) may reduce some risks.3 Low concentrations of LA are now popular for epidural labor analgesia4, 5, 6 and optimize obstetric outcomes.3, 7 Patient-controlled epidural analgesia with dilute LA solutions and opioids is safe, provides less motor block, and increases patient satisfaction.5, 8 However, the efficacy of pain management decreases if very low concentrations of LA are used.
The aim of this study was to compare the efficacy and safety of bupivacaine and levobupivacaine at concentrations that are the standards for labor pain management with PCEA at our institution. To evaluate precisely the effect of LA concentration, the same concentration was used in all steps of analgesia (initial bolus, PCEA pump, rescue boluses), and the patient population was restricted to healthy nulliparous women with uncomplicated pregnancy and the spontaneous onset of labor. Our hypothesis was that the optimum choice for bupivacaine and levobupivacaine is the 0.1% concentration.
Section snippets
Methods
This single-center, double-blind, randomized controlled trial was carried out at a teaching hospital from the 18 September 2014 to 28 February 2017. Ethical approval was provided by the Kaunas Regional Ethics Committee of Biomedical Researches (number: BE-2-24). The trial was registered with the Australian and New Zealand Clinical Trials Registry (ANZCTR, trial ID: ACTRN12614001033639) and Universal Trial Number (UTN) – U1111-1160-0268. Written consent was obtained from all participants.
Results
During the study period, 246 patients were recruited and allocated into six groups. Nine patients were discontinued from the trial according to the protocol and data for 237 patients were analyzed. The CONSORT flow chart shows the number eligible, recruited, followed-up and the number in the final analysis (Fig. 1). All study groups were comparable with regard to the demographic characteristics and obstetric outcomes (Table 1).
The volume of the LA infused did not differ between groups (P=0.969)
Discussion
This prospective, randomized, double-blind trial compared three concentrations (0.0625%, 0.1%, and 0.125%, all with fentanyl) of two local anesthetics (bupivacaine and levobupivacaine) for labor epidural analgesia. Lower concentrations of local anesthetics reduced the dose used, caused less motor block and were associated with less effective analgesia, but that had no influence on patient satisfaction.
Most studies of low LA concentrations for labor epidural pain management have used higher
Acknowledgements
We would like to thank the medical staff from the Anesthesiology and Obstetric departments for their help.
Conflict of interest notification
The authors declare no conflict of interests.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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