D. John Doyle
Epidural narcotics without concurrent use of epidural local anesthetics (ELAs) relieve labour pains poorly, especially after stage 1 of labour, although they may help where epidural LAs are relatively contraindicated (e.g. pulmonary hypertension, Eisenmenger's syndrome)[1]. Much better results may be obtained with ELA/narcotic mixtures, resulting in a more rapid onset, longer duration, and more intense analgesia.
Fentanyl/bupivicaine combinations are the most popular, usually given by infusion. A typical recipe 0.125% bupivicaine with 1-2 mcg/ml fentanyl at 10-15 ml/hr. I personally use 0.2% bupivicainewith 2 mcg/ml fentanyl at 8-10 ml/hr. Very dilute concentrations have been studied (0.0625% bupivicaine with 2 mcg/ml fentanyl at 12.5 ml/hr)[2-4]. Sufentanil bupivicaine combinations (e.g. 0.625% bupivicaine with 0.25 mcg/ml sufentanil) [5-7], butorphanol-bupivicaine combinations [8] and alfentanil-bupivicaine combinations [9] have also been studied. Bupivicaine is the most popular LA to use with epidural narcotics; chloroprocaine appears to antagonize the narcotic effect and increases the incidence of pruritus and nausea[5].
The major advantage of such EN/ELA combinations is reduced motor blockade, which theoretically translates into less use of forceps and C/sections, but the lower concentrations of ELA used would also be expected to reduce the likelihood of systemic LA toxicity. Potential drawbacks to the use of EN/ELA combinations are the theoretical fetal and maternal complications of systemically absorbed narcotics.
When when epidural infusions of any kind are used, it is important tohave a nursing protocol in place to continually monitor the levelof blockade achieved.
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