Sufentanil versus fentanyl for pain relief in labor involving combined spinal-epidural analgesia: a systematic review and meta-analysis of randomized controlled trials

Technical aspects of neuraxial analgesia during labor and maternity care: an updated overview

Labor analgesia is increasingly widespread throughout the world with a rate ranging from 10 to 60%. The benefits regarding clinical and non-clinical maternal-fetal outcomes are currently discussed in international scientific literature. Even stage of labor needs a different and appropriate approach to control the pain; however, different techniques are reported in literature. The following study intends to give a brief overview of the characteristics of the different neuraxial and non-neuraxial techniques currently available and the non-technical skills necessary for effective assistance to pregnant women, providing insights on the topic to understand critical issues at the same time. After bibliographic research since 2018 to 2023, many randomized controlled trials, literature reviews, systematic reviews, and metanalysis were evaluated to create this brief overview. The following pharmacological and non-pharmacological approaches were assessed: spinal techniques, such as epidural analgesia (EA), combined spinal-epidural (CSE), dural puncture epidural (DPE), and continuous spinal anesthesia (CSA); pharmacological administration of nitrous oxide (N2O) and systemic opioids (morphine, fentanyl, and pethidine); as the third one transcutaneous electric nerve stimulation (TENS), acupressure/acupuncture, aromatherapy, and breathing exercises. All the assessed approaches are relatively safe and effective, but the association of technical and non-technical skills is needed to improve the maternal and fetus outcome. More studies are needed to clarify what is the best approach to labor analgesia.

Esketamine administered epidurally as an adjuvant to epidural ropivacaine for labour analgesia: a prospective, double-blind dose-response study

OBJECTIVE

To investigate the efficacy of esketamine as an adjuvant to epidural ropivacaine for labour analgesia by determining its effect on the median effective concentration (EC50) in a 20 ml volume of ropivacaine.

DESIGN

A prospective, double-blind dose-response study.

SETTING

This study was conducted in Women's Hospital, School of Medicine, Zhejiang University, China.

PARTICIPANTS

One hundred and fifty parturients who requested epidural analgesia were recruited in this study to randomly receive epidural ropivacaine alone or with esketamine of 0.2 mg ml-1, 0.3 mg ml-1, 0.4 mg ml-1 or 0.5 mg ml-1, respectively.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome, EC50 of ropivacaine, was determined using an up-down sequential allocation technique. The secondary outcomes were analgesia characteristics, Ramsay Sedation Scale score, labour duration, caesarean section rate and adverse effects.

RESULTS

The EC50 of ropivacaine with the addition of esketamine at concentrations of 0.3 mg ml-1, 0.4 mg ml-1 and 0.5 mg ml-1 resulted in significant reductions in the EC50 of ropivacaine to 0.050%, 0.044% and 0.043%, respectively, from baseline (esketamine 0 mg ml-1) (p<0.0001). However, reductions of the EC50 of ropivacaine were similar among the groups with esketamine of 0.3 mg ml-1, 0.4 mg ml-1 and 0.5 mg ml-1 (p>0.05). The Ramsay Sedation Scale score was higher and more dizziness was observed in the Group of esketamine 0.5 mg ml-1 compared with all other groups (p<0.0001). During the peripartum period, no differences in sensory blockade level, Bromage score, labour duration and percentage of caesarean delivery were found among the groups.

CONCLUSIONS

Under the conditions of this study, the addition of epidural esketamine of 0.3 mg⋅mL-1, 0.4 mg⋅mL-1 and 0.5 mg⋅mL-1 offered a similar ropivacaine dose-sparing effect; 0.5 mg⋅mL-1 of esketamine produced more adverse effects.

TRIAL REGISTRATION NUMBER

ChiCTR2100054348.

Pharmacologic Analgesia for Cesarean Section: An Update in 2024

PURPOSE OF THE REVIEW

With the increasing prevalence of cesarean section globally, the importance of perioperative analgesia for cesarean section is becoming increasingly evident. This article provides an overview and update on the current status of cesarean section worldwide and associated analgesic regimens.

RECENT FINDINGS

Some recent studies unveiled potential association of neuraxial analgesia might be associated with children's autism, pharmacologic analgesia in obstetric will potentially gain some more attention. Various commonly used techniques and medications for analgesia in cesarean section are highlighted. While neuraxial administration of opioid remains the most classic method, the use of multimodal analgesia, particularly integration of nonsteroidal anti-inflammatory drugs, acetaminophen, peripheral nerve blocks has provided additional and better options for patients who are not suitable for intrathecal and neuraxial techniques and those experiencing severe pain postoperatively. Optimal pain management is crucial for achieving better clinical outcomes and optimal recovery, and with the continuous development of medications, more and better pharmacologic regimen will be available in the future.

A Randomised Clinical Trial to Compare the Efficacy and Safety of Dexmedetomidine-Ropivacaine Versus Fentanyl-Ropivacaine for Epidural Labour Analgesia

Background An epidural block is a superior potent approach to labour analgesia, and ropivacaine combined with fentanyl has been successfully practised for it. Dexmedetomidine, as a novel form of labour analgesia, must be researched further. Our study results give insight into the epidural block and come up with a pioneering approach for labour analgesia. Methodology A total of 68 parturients were assigned to two equal groups and received either dexmedetomidine with ropivacaine (Group RD) or fentanyl with ropivacaine (Group RF). Parturients received a loading dose and maintenance was given using a patient-controlled analgesia (PCA) pump. Analgesia onset time, labour duration, rescue dose requirement, and Visual Analogue Scale (VAS) pain scores were noted. Appearance, Pulse, Grimace, Activity and Respiration (APGAR) scores of newborns, Ramsay Sedation Scale (RSS) scores of mothers, and maternal side effects were observed. Results Group RD showed a shorter onset time of analgesia (group RD: 12.50 ± 1.31 minutes vs. group RF: 15.26 ± 1.46 min), less local anaesthetics requirement (group RD: 47.54 ±5.37 ml vs. group RF: 59.05 ± 6.62 ml), less number of bolus doses (group RD: 0.15 ± 0.36 vs. group RF: 1.21 ± 0.95), and shorter duration from the epidural administration to the delivery (group RD: 312.97 ± 42.40 minutes vs. group RF: 345.94 ±14.67 minutes) than group RF. VAS values of the RD group were significantly less than the RF group. The RSS scores were comparably low in both groups, and excessive sedation was not seen in any group. Newborn APGAR values were comparably on the higher side in the two groups. Adverse effects were observed in the two groups, like hypotension, nausea/vomiting, bradycardia, shivering, and pruritus, which were insignificant. Conclusion The RD group showed an improved analgesic effect with a quicker onset of action, reduced requirement of local anaesthetics, and lower VAS scores compared to the RF group. With ropivacaine, dexmedetomidine shows more efficacy than fentanyl during epidural block and is a safe alternative for labour pain management.

Application of Dexmedetomidine in Epidural Labor Analgesia: A Systematic Review and Meta-Analysis on Randomized Controlled Trials

OBJECTIVES

To summarize and appraise the use of dexmedetomidine in epidural labor analgesia, we conducted a systematic review and meta-analysis of randomized controlled trials (RCTs).

METHODS

We conducted the literature search about the RCTs of epidural labor analgesia with or without dexmedetomidine from inception until November 1, 2022, in the following databases: PubMed, Cochrane Library, and Embase. The primary outcome was visual analog scale (VAS) within 2 hours after epidural intubation. The secondary outcomes included the duration of the first and second labor stages, Apgar score, umbilical blood pH, dosage of analgesics, and side effects.

RESULTS

Eight RCTs including 846 parturients were included. The VAS score of the dexmedetomidine group was significantly lower than that of the control group at the time of 15 minutes (mean difference [MD] -1.41, 95% confidence interval [CI] -2.23, -0.59), 30 minutes (MD -1.02, 95% CI -1.70, -0.33), 60 minutes (MD -0.90, 95% CI -1.36, -0.44), and 90 minutes (MD -0.70, 95% CI -1.16, -0.23). The incidence of pruritus in the dexmedetomidine group was lower than that of the control group （MD 0.28, 95% CI 0.11, 0.74), but the incidence of maternal bradycardia was higher (MD 6.41, 95% CI 1.64, 25.04). There were no significant difference in other outcomes.

DISCUSSION

Dexmedetomidine combined with local anesthetic for epidural labor analgesia can improve the VAS score of parturients. Except for the increased incidence of maternal bradycardia, it seems to be safe for the parturients and fetuses.

Post-cesarean Delivery Analgesia Using Spinal Anesthesia: Ropivacaine-Fentanyl vs. Ropivacaine-Sufentanil

Background

To improve the quality of intraoperative and postoperative analgesia during spinal anesthesia, intrathecal opioids are used as adjuvant drugs in combination with local anesthetics.

Objectives

This study aimed to compare the intrathecal injection of ropivacaine-fentanyl with ropivacaine-sufentanil in terms of the duration of analgesia after cesarean section (CS).

Methods

This randomized, double-blind clinical trial study was conducted on women referred to Imam Khomeini Hospital of Ahvaz City for elective CS in 2021. A total of 51 patients were randomly divided into 2 groups. The first group (n = 25) received ropivacaine (17.5 mg) + fentanyl (25 μg), while the second group (n = 26) received ropivacaine (17.5 mg) + sufentanil (2.5 μg) for spinal anesthesia. Eventually, several parameters were investigated, including the duration of sensory and motor block, duration of analgesia (based on the Visual Analog Scale (VAS)), hemodynamic parameters, and possible complications.

Results

The duration of surgery (P = 0.059) and the duration of motor block (P = 0.962) were not significantly different between the 2 groups. The mean duration of analgesia (from the time of entering recovery to reaching VAS = 3) was 203.12 ± 72.93 and 207.46 ± 69.59 minutes in the fentanyl and sufentanil groups, respectively (P = 0.658). Systolic and diastolic blood pressure (SBP/DBP) drops in minute 5 were observed more frequently in the sufentanil group than in the fentanyl group (P = 0.027 and P = 0.002, respectively). At the other time points, however, no significant difference was observed between the 2 groups in terms of hemodynamic variables (P > 0.05). Finally, the frequency of pruritus was higher in the sufentanil group than in the fentanyl group (26.9% vs. 4.0%; P = 0.024).

Conclusions

Adding fentanyl or sufentanil to intrathecal ropivacaine provides a similar duration of analgesia. However, fentanyl was associated with better hemodynamic stability and a lower incidence of pruritus.

Effect of OPRM1/COMT gene polymorphisms on sufentanil labor analgesia: a cohort study based on propensity score matching

Background: This study investigated the use of COMT G1947A and OPRM1 A118G polymorphisms as predictive markers for sufentanil epidural analgesia. Methods: The visual analogue scale (VAS) score, and sufentanil consumption of 136 pairs of parturients using sufentanil with lidocaine and ropivacaine for epidural analgesia were used for analysis. Results: OPRM1 AG/GG had lower VAS score difference between fifth and 0 min (1.55 vs 1.87; p = 0.012) and higher consumption (19.65 μg vs 17.11 μg; p = 0.049) than AA carriers. COMT GA/AA had higher VAS score difference than GG carriers (1.86 vs 1.55; p = 0.021). Conclusion: Sufentanil may provide better epidural labor analgesia in OPRM1 AA and COMT GA/AA carriers compared with OPRM1 AG/GG and COMT GG carriers. Clinical Trial Registration: ChiCTR1900026897 (Chinese Clinical Trial Center Registry).

The Effect of Painless Delivery with Intrathecal Sufentanil on Labor Progress and Neonatal Outcomes: A Single Center Study on Pregnant Women

Background

Delivery pain is the most unbearable pain and can be relieved with intrathecal opioids. This study aimed to investigate the effect of intrathecal sufentanil for painless delivery on labor progress and neonatal outcomes in pregnant women.

Methods

This was a single-arm observational cohort study on 1055 pregnant women candidates for vaginal delivery with spinal analgesia referred to the Akbarabadi Hospital. First, 0.1 µg/kg of intrathecal sufentanil was used, and maternal blood pressure and maternal and fetal heart rates were recorded after analgesia. During delivery, the mothers were monitored for nausea, pruritus, motor block, apnea, urinary retention, or the possibility of an emergency cesarean section. The duration of the analgesia, the duration of the second stages of labor, and the mother's pain scores were recorded based on the Visual Analogue Scale (VAS). 1- and 5-minute Apgar scores and arterial blood gas (ABG) of the umbilical cord were also recorded.

Results

The most common station was -3 for 723 women, followed by -2 for 229 women. Fifty-two women underwent cesarean section, and fetal distress was the most common reason for cesarean section (57.7%). The mean time for initiating analgesia was 5.93 ± 2.87 minutes, and the mean visual analog scale was 1.08 ± 0.16. The mean Apgar was 9.0 ± 0.47; the mean weight at birth was 2917.39 ± 449.90 gr; PH was 7.31 ± 2.03; HCO₃ was 22.67 ± 3.08mEq/liter, and PaCo₂ was 43.36 ± 7.06 mmHg. Regarding complications, the patients just developed itching (n = 78), and hypotension, bradycardia, apnea, and decreased consciousness were overlooked.

Conclusions

Intrathecal sufentanil is safe and efficient in painless delivery, resulting in normal Apgar and normal PH with no specific side-effect.

Effectiveness of Patient-Controlled Intravenous Analgesia (PCIA) with Sufentanil Background Infusion for Post-Cesarean Analgesia: A Randomized Controlled Trial

Purpose

To investigate the effectiveness of sufentanil patient-controlled intravenous analgesia pump (PCIA) and background infusion in patients of post-cesarean analgesia.

Patients and Methods

This trial compared two groups of women undergoing cesarean section and receiving PCIA: no background infusion group (n=30), 6-min lockout time, and background infusion group (n=30), 2 mL/h infusion, 10-min lockout time. Both groups with 2 μg/kg sufentanil was diluted to 100 mL with normal saline. VAS scores at rest at 36 h was the primary endpoint. The secondary endpoints were the VAS scores at rest at 6, 12, and 24 h, the total amount of sufentanil consumed, the Ramsay sedation score (RSS) assessed at the same time points, postpartum bleeding within 24 h, the injection/attempt (I/A) ratio, BP and HR, PONV, side effects of sufentanil.

Results

Compared with the no background infusion group, the background infusion group showed lower VAS pain scores at 6, 12, and 24 h (P<0.01), but no differences at 36 h (95% CI = -0.5-0.8. P>0.05). Attempts, injections, and total sufentanil consumption were significantly different between the two groups (P<0.001), but without difference in I/A. Bleeding was less in the background infusion group at 1 h (P=0.03). The minimal respiration rates were not significantly different between groups.

Conclusion

Background infusion increased the total consumption of sufentanil within 36 h after cesarean section. Although it did not reduce uterine contraction pain and wound pain at 36 h, it significantly reduced the pain at 6, 12, and 24 h after cesarean section. It improved patient satisfaction and reduced the amount of bleeding after 1 h. Importantly, it did not increase the incidence of hypertension, PONV and respiratory depression.

Neuraxial labor analgesia: is there a place for neuraxial adjuvants beyond opioids

Neuraxial labor analgesia is considered the gold standard technique for analgesia. Ideally, a good neuraxial technique uses dilute local anesthetic solutions to produce effective pain relief with no or minimal motor impairment. Adjuvant drugs that are co-administered with the local anesthetic either epidurally or intrathecally are useful in achieving this goal. The current review focuses on the effectivity and side-effect profile of various commonly used or tested adjuvants.

Opioid-Free Labor Analgesia: Dexmedetomidine as an Adjuvant Combined with Ropivacaine

Background

Side effects of the use of opioid analgesics during painless delivery are the main factors that affect rapid postpartum recovery. Opioid use can result in dangerous respiratory depression in the patient. Opioids can also disrupt the baby's breathing and heart rate. The nonopioid analgesic dexmedetomidine, a new a2-adrenergic agonist, possesses higher selectivity, greater analgesic effects, and fewer side effects. Moreover, epidural administration of dexmedetomidine also reduces local anesthetic consumption.

Objective

Our study aims to compare the analgesic effects as well as the side effects of ropivacaine with dexmedetomidine against sufentanyl as an epidural labor analgesia.

Methods

This study is a randomized, double-blinded, controlled trial (registration no. ChiCTR2200055360) involving 120 primiparous (a woman who has given birth once), singleton pregnancy women who are greater than 38 weeks into gestation and have requested epidural labor analgesia. The participants were randomized to receive 0.1% ropivacaine with sufentanyl (0.4 μg/ml) or dexmedetomidine (0.4 μg/ml). The primary outcomes included Visual Analogue Score (VAS), duration of first epidural infusions, the requirement of additional PCEA bolus, and adverse reactions during labor analgesia.

Results

Of the 120 subjects who consented, 91 parturient women (women in the condition of labor) had complete data for analysis. Demographics and VAS, as well as maternal and fetal outcomes, were similar between the groups. The duration of first epidural infusions in dexmedetomidine was significantly longer than sufentanyl (median value: 115 vs 68 min, P < 0.01); the parturient women who received dexmedetomidine and who required additional PCEA bolus were fewer in comparison to those who received sufentanyl (27.5% vs 49.0%, P < 0.05). Furthermore, the incidence of pruritus in the dexmedetomidine group was lower in comparison to the sufentanyl group (0% vs 11.8%, P < 0.05).

Conclusions

Dexmedetomidine, a nonopioid, is superior to the opioid analgesic sufentanyl in providing a prolonged analgesic effect as an epidural during labor. It also reduces local anesthetic consumption and has fewer side effects. The trial is registered with ChiCTR2200055360.

Intrathecal dexmedetomidine improves epidural labor analgesia effects: a randomized controlled trial

OBJECTIVE

α2‑agonists and opioids have been used as intrathecal adjuvants to local anesthetics for several years, but the effect of intrathecal dexmedetomidine (Dex) or sufentanil combined with epidural ropivacaine in labor analgesia is not fully understood.

METHODS

A total of 108 parturient women receiving combined spinal-epidural labor analgesia were randomly divided into three groups. Group C received l mL saline (0.9%) intrathecally, Group D received 5 µg Dex intrathecally, and Group S received 5 µg sufentanil intrathecally. All parturient women then received 0.1% epidural ropivacaine and 0.2 µg/mL sufentanil for patient-controlled epidural analgesia with standard settings. The visual analog scale score, onset time, duration of intrathecal injection, local anesthetic requirements, and side effects were recorded.

RESULTS

The labor analgesia effects in Groups D and S were better than those in Group C. Groups D and S displayed significantly shorter onset times, longer durations of intrathecal injection, and reduced local anesthetic requirements compared with Group C. The incidence of shivering and pruritus in Group D was lower than that in Group S.

CONCLUSION

Intrathecal administration of 5 µg Dex could improve epidural labor analgesia effects.This randomized controlled clinical trial was registered with the Chinese Clinical Registry Center (ChiCTR-1800014943, http://www.chictr.org.cn/).

The Analgesic Effect of Different Concentrations of Epidural Ropivacaine Alone or Combined With Sufentanil in Patients After Cesarean Section

Background: Patients experience moderate-high intensity postoperative pain after cesarean section (CS). The aim of this study was to investigate the optimal concentrations of ropivacaine and sufentanil for use in controlling pain after CS. Methods: One hundred and seventy-four women undergoing elective CS were randomly allocated to four groups. Epidural analgesia was administered with 0.1% ropivacaine in the R₁ group, 0.15% ropivacaine in the R₂ group, a combination of 0.1% ropivacaine and 0.5 μg/ml of sufentanil in the R₁S group, and a combination of 0.15% ropivacaine and 0.5 μg/ml of sufentanil in the R₂S group (at a basal rate of 4 ml/h, bolus dose of 4 ml/20 min as needed). Pain scores (numerical rating scale [NRS]: 0-10 cm) at rest (NRS-R), during movement (NRS-M), and when massaging the uterus (NRS-U) were documented at 6 and 24 h. We also recorded patient satisfaction scores, time to first flatus, motor deficits, and adverse drug reactions. Results: NRS (NRS-R, NRS-M, NRS-U) scores in the R₂S group (2 [1-3], 4 [3-5], 6 [5-6], respectively) were lower than in the R₁ group (3 [3-4], 5 [4-6], 7 [6-8], respectively) (p < 0.001, p < 0.05, p < 0.01, respectively) at 6 h; and patient satisfaction (9 [8-10]) was improved compared to the R₁ group (8 [6-8]) (p < 0.01). The time to first flatus (18.7 ± 11.8 h) was reduced relative to the R₁ group (25.9 ± 12.0 h) (p < 0.05). The time to first ambulation was not delayed (p > 0.05). However, the incidence of pruritus (4 [9.3%]) was increased compared to the R₂ group (0 [0]) (p < 0.05) at 6 h, and the incidence of numbness (23 [53.5%], 23 [53.5%]) was increased compared to the R₁ group (10 [23.3%], 10 [23.3%]) (all p < 0.01) at both 6 and 24 h. Conclusions: Although we observed a higher incidence of pruritus and numbness, co-administration of 0.15% ropivacaine and 0.5 μg/ml of sufentanil administered epidurally optimized pain relief after CS, with treated subjects exhibiting lower NRS scores, shorter time to first flatus, and higher patient-satisfaction scores.

Current Resources for Evidence-Based Practice, March 2021

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of men's experiences of pregnancy loss and commentaries on reviews focused on the effects of perineal massage on perineal trauma and air pollution and heat exposure on birth outcomes.