Gerhardt MA, Gunka VB, Miller RJ. Hemodynamic Stability During Labor and Delivery With Continuous Epidural Infusion. J Am Osteopath Assoc 2006;106(12):692–698. doi: 10.7556/jaoa.2006.106.12.692.
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Context: Epidural anesthesia for labor pain is frequently complicated by maternal hypotension.
Objective: To test whether continuous epidural infusion (CEI) of local anesthetic, without bolus administration, lowers the incidence of hypotension in parturient patients.
Methods: In a single-blind clinical study, subjects were randomly assigned to CEI-only (10 mL/h of 0.2% ropivacaine hydrochloride without bolus) or control (10 mL of 0.2% ropivacaine hydrochloride per hour with 10-mL bolus) epidural dosing groups. The incidence of hypotension (20% decrease in systolic blood pressure or mean arterial pressure (MAP), systolic blood pressure lower than 100 mm Hg, or MAP lower than 65 mm Hg) was recorded for 2 hours after dosing. Statistical analysis included a 2×2 χ2 analysis, the Fisher exact test, and paired two-tailed t tests.
Results: Fifty subjects were studied, with 25 randomly assigned to each study group (CEI-only vs control). Baseline blood pressure was not different between groups (CEI-only, 127 /77 [8.7] mm Hg; control, 131 /78 ). The incidence of hypotension was lower in the CEI-only group than in the control group (5 [20%] vs 15 [60%]; P=.009), with intervention required in 1 (20%) of 5 CEI-only subjects and 7 (47%) of 15 control subjects. Sensory block reached the T10 dermatome in 54.4 (18) minutes in the CEI-only group and 38 (24) minutes in the control group (P=.04). Pain scores and maternal and fetal pulse rates were not different between groups. Analgesic supplementation (250 μg of epidural fentanyl) was used more frequently in the CEI-only group (72% vs 32%; P=.01), without adverse effects.
Conclusions: Continuous epidural infusion of 0.2% ropivacaine hydrochloride without bolus administration reduces the incidence of hypotension by 67% and is safer than traditional bolus dosing for routine labor. This method requires further study in high-risk patients, including those with preeclampsia and cardiovascular disease.
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