title: Low-dose epidural top up for emergency caesarean delivery: a randomised comparison of levobupivacaine versus lidocaine/epinephrine/fentanyl.
abstract: BACKGROUND
  Levobupivacaine has a greater safety margin for cardiotoxicity than bupivacaine; consequently it has been recommended as the agent of choice for extending low-dose epidural analgesia for emergency caesarean section. We wished to compare the onset of levobupivacaine with that of a 2% lidocaine/epinephrine/fentanyl mixture.
  
  
  METHODS
  In a prospective, single blind study, we compared the speed of onset and efficacy of 20 mL of plain 0.5% levobupivacaine with 2% lidocaine/epinephrine 100 mug/fentanyl 100 mug for extending a previous low-dose labour epidural for emergency caesarean section in 100 patients.
  
  
  RESULTS
  The median [interquartile range] onset time for block of the T7 dermatome to touch from the end of the top up for 2% lidocaine /epinephrine/fentanyl mixture and levobupivacaine was 10 [8, 13] vs. 15 [10, 20] min respectively (P<0.0009). There was a significantly longer preparation time for the 2% lidocaine/epinephrine/fentanyl mixture than for levobupivacaine (median 145 s [120, 200] vs. 60 s [44, 60] P<0.0009). Even with the inclusion of the longer preparation time, 2% lidocaine/epinephrine/fentanyl still had a more rapid onset than levobupivacaine: 15 [15, 19] vs. 18 [13.8, 22.4] min (P<0.05). General anaesthesia was not required for inadequate blocks but additional local anaesthetic or intraoperative analgesic supplements were needed more frequently in the levobupivacaine group: 9% vs. 29%, (P<0.01).
  
  
  CONCLUSIONS
  A freshly prepared mixture of 2% lidocaine 20 mL plus epinephrine 100 mug and fentanyl 100 mug provides a more rapid onset and superior quality T7 block to touch than 0.5% levobupivacaine 20 mL.
authors.affiliation: Department of Anaesthesia, Hull Royal Infirmary, Hull HU3 2JZ, UK.
authors.forename: P
authors.initials: P
authors.lastname: Balaji
authors.forename: P
authors.initials: P
authors.lastname: Dhillon
authors.forename: I F
authors.initials: IF
authors.lastname: Russell
mesh_terms: D000328:Adult; D000767:Anesthesia, Epidural; D000773:Anesthesia, Obstetrical; D018686:Anesthetics, Intravenous; D000779:Anesthetics, Local; D001034:Apgar Score; D002045:Bupivacaine / Q000031:analogs & derivatives; D002585:Cesarean Section; D004632:Emergency Medical Services; D004837:Epinephrine; D005260:Female; D005283:Fentanyl; D006340:Heart Rate, Fetal; D006801:Humans; D007231:Infant, Newborn; D000077554:Levobupivacaine; D008012:Lidocaine; D016014:Linear Models; D010147:Pain Measurement; D010149:Postoperative Pain / Q000188:drug therapy; D017060:Patient Satisfaction; D011247:Pregnancy; D016019:Survival Analysis; D014662:Vasoconstrictor Agents
chemical_list: D018686:Anesthetics, Intravenous; D000779:Anesthetics, Local; D014662:Vasoconstrictor Agents; D008012:Lidocaine; D000077554:Levobupivacaine; D005283:Fentanyl; D002045:Bupivacaine; D004837:Epinephrine