title: A randomized trial of breakthrough pain during combined spinal-epidural versus epidural labor analgesia in parous women.
abstract: BACKGROUND
  There is controversy regarding the benefits and risks of combined spinal-epidural compared with epidural analgesia (CSE, EPID) for labor analgesia. We hypothesized that CSE would result in fewer patient requests for top-up doses compared to EPID.
  
  
  METHODS
  One-hundred ASA physical status I or II parous women at term in early labor (<5 cm cervical dilation) requesting analgesia were randomized in double-blind fashion to the EPID group (epidural bupivacaine 2.5 mg/mL, 3 mL, followed by bupivacaine 1.25 mg/mL, 10 mL with fentanyl 50 microg) or the CSE group (intrathecal bupivacaine 2.5 mg with fentanyl 25 microg). Both groups received identical infusions of bupivacaine 0.625 mg/mL with fentanyl 2 microg/mL at 12 mL/h. The primary outcome variable was the number of top-up doses requested to treat breakthrough pain.
  
  
  RESULTS
  There was no significant difference between the two groups in the percentage of patients requesting top-up doses (44% CSE vs 51% EPID; 95% confidence interval of the difference -28% to +14%) nor in the need for multiple top-up doses (14% CSE vs 15% EPID). Visual analog scale scores were lower in the CSE group compared to the EPID group at 10 min after initiation of analgesia [median 0 cm (0, 0) vs 4 cm (1, 6) respectively, P < 0.001] and at 30 min [0 cm (0, 0) vs 0 cm (0, 1), respectively, P = 0.03].
  
  
  CONCLUSIONS
  We did not find a difference in the need for top-up doses in parous patients; however, CSE provided better analgesia in the first 30 min compared to EPID.
authors.affiliation: Department of Anesthesiology, Columbia University Medical Center, New York City, New York 10032, USA. srg24@columbia.ed
authors.forename: Stephanie R
authors.initials: SR
authors.lastname: Goodman
authors.forename: Richard M
authors.initials: RM
authors.lastname: Smiley
authors.forename: Maria A
authors.initials: MA
authors.lastname: Negron
authors.forename: Paula A
authors.initials: PA
authors.lastname: Freedman
authors.forename: Ruth
authors.initials: R
authors.lastname: Landau
mesh_terms: D000328:Adult; D015360:Analgesia, Epidural; D016362:Analgesia, Obstetrical / Q000379:methods*; D000701:Analgesics, Opioid / Q000008:administration & dosage* / Q000009:adverse effects; D000779:Anesthetics, Local / Q000008:administration & dosage* / Q000009:adverse effects; D002045:Bupivacaine / Q000008:administration & dosage; D004311:Double-Blind Method; D005260:Female; D005283:Fentanyl / Q000008:administration & dosage; D006801:Humans; D007263:Infusions, Parenteral; D048949:Labor Pain / Q000188:drug therapy*; D010147:Pain Measurement; D010148:Intractable Pain / Q000188:drug therapy*; D010298:Parity; D011247:Pregnancy; D011446:Prospective Studies; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000701:Analgesics, Opioid; D000779:Anesthetics, Local; D005283:Fentanyl; D002045:Bupivacaine