Journal Report:

A Comparison of Minimum
Local Anesthetic Volumes and
Doses of Epidural
Bupivacaine (0.125% and
0.25%) for Analgesia in Labor
Waldemar P. Siahaan, M.D.

If the pharmacological sleeve is extended to

bathe all the available nerve root within the
epidural space, then a lower concentration
of local anesthetic will be sufficient to
block nerve transmission.

Fink BR. Toward The mathematization of Spinal anesthesia. Reg Anesth Pain Med
1992;17:263-73

Extending the pharmacological sleeve

requires that the volume of injectate is
increased at the expense of concentration.

Christiaens F. Effects of diluent volume of a single dose of epidural bupivacaine in the

parturients during the first stage of labor. Reg Anesth Pain Med 1998;23:134-41

In fixed dose study:

Higher volumes and lower concentrations are
more effective for nerve blockade when
compared with lower volumes of higher
concentration local anesthetics.
Potential benefits in differential blockade, such
as motor sparing, when higher concentrations
are exchanged for lower concentrations given
in larger volumes
Whiteside R. Epidural ropivacaine with fentanyl following major gynaecological surgery: the effect of
volume and concetration on pain relief and motor impairment. Br J Anaesth 2000;84:720-4

OBJECTIVES:
To Quantify any dose reduction which might
have potential implications for safety.
AIM:
To determine the median effective volumes and
doses, which were defined as the MLAV and
MLAD of bupivacaine 0.125% and 0.25% for
epidural bupivacaine given as the first bolus
to women for analgesia in labor.

METHODS:
I.
PATIENTS:

Women in labor requesting neuraxial analgesia

ASA 1 or 2 patients
Singleton pregnancy more than 36 wk AOG
<110 kg in weight
Between 150-180cm in height
Aged between 18yo and 40yo
No more than 5 cm cervical dilation

METHODS:
II.
EPIDURAL TECHNIQUE

18 g Tuohy needly and 20 G catheter

At the L2/3 or 3/4 level, in a sitting position
Using LORTA
No epidural test dose was given
Prepared not more than 4 h previously
Injected slowly over approximately 5 min.

VAPS
0 no pain 100 worst pain ever

METHODS:
III. GROUPS

Bupivacaine 0.125%
Bupivacaine 0.25%
Volume in the first syringe of each group set at
15ml
Efficacy of the first dose was assessed using a
VAPS at 0,15, and 30 min after injection of the
test solution (first bolus)

METHODS:
IV. EFFECTIVE

Regardless of the baseline, VAPS decreased to

10mm or less within 30 min of injection,
indicating the end of the study, and directed a
decrement of 2 ml local anesthetic for the next
woman

METHODS:
V.
INEFFECTIVE

Failure of the VAPS to reach 10mm within 30

min
Rescue analgesia consisting of 12ml
bupivacaine 0.25% was given.
A reduction in VAPS to 10 mm or less
indicated the end of the study
Directed a 2 ml increment for the next woman.

METHODS:
VI. REPEAT

Failure to 10 mm after rescue directed that the

same concentration be repeated for the next
woman.
Each day, 2 test syringes were made up, one
for each group and placed in refrigerator.
The syringes were placed side by side, the
operator chose one or the other at random.

OBSERVATIONS

Use of prostin and oxytocin infusion, VAPS,

and efficacy of the local anesthetic solution
were recorded.

SAMPLE SIZE

Sample size estimations were based on the

results of the first studies that showed the
minimum local analgesic concentration of
bupivacaine to be 0.065%

Columb MO Clinical trials: up-down sequential allocation. Regional analgesia in obstetric

a millennium update. 2000:157-165

SAMPLE SIZE

A minimum of 39 women would be required

per group.

RESULTS
Bupivacaine
0.125 %

Bupivacaine
0.25 %

MLAV (ml) 13.6 (12.4 14.8)

9.2 (6.9 11.5)

MLAD (mg) 17.0 (15.5 18.5)

23.1 (17.2 28.9)

CONCLUSION

Bupivacaine 0.125% when compared with

0.25% produced equivalent analgesia with a
50% increase in volume, but with a 25%
reduction in dose.
Any reduction in dose, without loss of
efficacy, reduces risk of toxicity and improves
safety.

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