title: The effect of bupivacaine with fentanyl temperature on initiation and maintenance of labor epidural analgesia: a randomized controlled study.
abstract: BACKGROUND
  Labor epidural analgesia is highly effective, but can be limited by slow onset and incomplete blockade. The administration of warmed, compared to room temperature, bupivacaine has resulted in more rapid onset epidural anesthesia. We hypothesized that the administration of bupivacaine with fentanyl at 37°C versus 20°C would result in improved initial and ongoing labor epidural analgesia.
  
  
  METHODS
  In this prospective, randomized, doubled blinded study, 54 nulliparous, laboring women were randomized to receive epidural bupivacaine 0.125% with fentanyl 2 μg/mL (20 mL initial and 6 mL hourly boluses) at either 37°C or 20°C. Pain verbal rating scores (VRS), sensory level, oral temperature, and side effects were assessed after epidural loading (time 0), at 5, 10, 15, 20, 30, 60 min, and at hourly intervals. The primary outcome was the time to achieve initial satisfactory analgesia (VRS ⩽3). Secondary outcomes included ongoing quality of sensory blockade, body temperature and shivering.
  
  
  RESULTS
  There were no differences between groups in patient demographics, initial pain scores, cervical dilatation, body temperature or mode of delivery. Epidural bupivacaine at 37°C resulted in shorter mean (±SD) analgesic onset time (9.2±4.7 vs. 16.0±10.5 min, P=0.005) and improved analgesia for the first 15 min after initial bolus (P=0.001-0.03). Although patient temperature increased during the study (P<0.01), there were no differences between the groups (P=0.09). Six (24%) and 10 (40%) patients experienced shivering in the 37°C and 20°C groups, respectively (P=0.23).
  
  
  CONCLUSIONS
  The administration of epidural 0.125% bupivacaine with fentanyl 2μg/mL at 37°C versus 20°C resulted in more rapid onset and improved labor analgesia for the first 15 min. There was no evidence of improved ongoing labor analgesia or differences in side effects between groups.
authors.affiliation: Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA. Electronic address: sviggum.hans@mayo.edu.
authors.forename: H P
authors.initials: HP
authors.lastname: Sviggum
authors.affiliation: Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
authors.forename: S
authors.initials: S
authors.lastname: Yacoubian
authors.affiliation: Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
authors.forename: X
authors.initials: X
authors.lastname: Liu
authors.affiliation: Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA. Electronic address: ltsen@zeus.bwh.harvard.edu.
authors.forename: L C
authors.initials: LC
authors.lastname: Tsen
mesh_terms: D000328:Adult; D016362:Analgesia, Obstetrical / Q000379:methods*; D000701:Analgesics, Opioid / Q000494:pharmacology; D000779:Anesthetics, Local / Q000494:pharmacology; D001831:Body Temperature; D002045:Bupivacaine / Q000494:pharmacology*; D004311:Double-Blind Method; D004359:Drug Therapy, Combination / Q000379:methods; D005260:Female; D005283:Fentanyl / Q000494:pharmacology*; D006801:Humans; D007743:Labor, Obstetric; D011247:Pregnancy; D011446:Prospective Studies; D013696:Temperature
chemical_list: D000701:Analgesics, Opioid; D000779:Anesthetics, Local; D005283:Fentanyl; D002045:Bupivacaine
keywords: Bupivacaine; Epidural; Fentanyl; Labor analgesia; Obstetric; Temperature