Epidural Technique: Does it Really Matter to the Patient?

Study Overview
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Brief Summary
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The main objective of this study will be to determine if the dural puncture epidural (DPE) provides superior analgesia and better patient satisfaction when compared to traditional epidurals for cesarean sections, and to also determine if patient satisfaction in the DPE group is comparable to that of the CSE technique.

Detailed Description
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There are approximately 4 million child birth deliveries in US hospitals per year, and 1.3million of those births are via cesarean section (c-section). With this type of surgery, obstetric anesthesiology plays an important role. The main objective of this study will be to determine if the dural puncture epidural (DPE) provides superior analgesia and better patient satisfaction when compared to traditional epidurals for cesarean sections, and to also determine if patient satisfaction in the DPE group is comparable to that of the CSE technique.

Official Title
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Dural Puncture Epidural Technique vs. Standard Epidurals vs. Combined-Spinal Epidurals for Cesarean Sections: Does it Really Matter to the Patient?

Conditions
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Anesthesia

Intervention / Treatment
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* Procedure: Dural puncture epidurals (DPE)
* Procedure: Traditional epidurals (EPI)
* Procedure: Combined-spinal epidural technique (CSE)


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Female parturient at Grady Memorial Hospital must meet one of the following: Parturient having a scheduled or elective cesarean section Parturient not having primary cesarean-section At least 18 years of age Subject has signed the informed consent Exclusion Criteria: Parturient who is unable or unwilling to sign the consent form Parturient having primary cesarean section Parturient with known complex cardiac disease (ex…aortic/mitral stenosis, aortic aneurysms, congenital heart disease with residual defects…etc) Parturient with any contraindication to neuraxial anesthesia such as coagulopathy, infection, or patient refusal Parturient having a fourth or more cesarean section

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 60 Years

Sexes Eligible for Study
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Female

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Triple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Dural puncture epidurals (DPE)<br>Dural puncture epidurals for cesarean section. | Procedure: Dural puncture epidurals (DPE)<br>* Using the Arrow Epidural Kit (AK-05560) an epidural will be placed using the LOR to saline or air technique. A 26g Gertie Marx needle will be inserted through the Touhy epidural needle and used to puncture the dura; clear, free flowing CSF will return in the needle, but no medications will be injected. The 26g spinal needle will be removed, and the epidural catheter inserted through the epidural needle 3-5cm in the epidural space. A test dose with 3mL 1.5% Lidocaine with 1:200,000 epinephrine will be used to confirm the absence of intrathecal or intravascular catheter placement. The epidural catheter will then be dosed with 0.5% Bupivacaine in 5mL increments until a T4 dermatome level is reached. Epidural fentanyl 100mcg will be administered during initial dosing, and morphine-PF 3mg will be given via epidural after delivery of the fetus.<br>|
| Active Comparator: Traditional epidurals (EPI)<br>Traditional epidurals (EPI) for cesarean section. | Procedure: Traditional epidurals (EPI)<br>* Using the Arrow Epidural Kit (AK-05560) an epidural will be placed using the LOR to saline or air technique. The catheter will be inserted 3-5cm in the epidural space. A test dose with 3mL 1.5% Lidocaine with 1:200,000 epinephrine will be used to confirm the absence of intrathecal or intravascular catheter placement. The epidural catheter will then be dosed with 0.5% Bupivacaine in 5mL increments until a T4 dermatome level is reached. Epidural fentanyl 100mcg will be administered during initial dosing, and morphine-preservative free (PF) 3mg will be given via epidural after delivery of the fetus.<br>|
| Active Comparator: Combined-spinal epidural technique (CSE)<br>Combined-spinal epidural technique (CSE) for cesarean section. | Procedure: Combined-spinal epidural technique (CSE)<br>* Using the Arrow Epidural Kit (AK-05560) an epidural will be placed using the LOR to saline or air technique. A 26g Gertie Marx needle will be inserted through the Touhy epidural needle and used to puncture the dura; clear, free flowing CSF will return in the needle and 12mg bupivacaine, 10mcg fentanyl, 200mcg morphine-PF. The 26g spinal needle will be removed, and the epidural catheter inserted through the epidural needle 3-5cm in the epidural space. No epidural test dose will be given immediately compared to the above procedures secondary to intrathecal injection of local anesthetic with this CSE technique. Only after approximately 1 hour after intrathecal injection will a test dose of 3mL 1.5% Lidocaine with 1:200,000 epinephrine will be used to confirm the absence of intrathecal or intravascular catheter placement. The epidural catheter will then be dosed with 0.5% Bupivacaine for the remainder of the procedure if necessary.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Percent of patients with Numeric Pain Rating Score (NPRS)<1 in the DPE vs. EPI group | The blinded investigator will visit the patient within 1hour of block placement and ask to select Numeric Pain Rating Score (NPRS) (1-10) during procedure. The 11-point numeric scale ranges from '0' representing one pain extreme (e.g. no pain) to '10' representing the other pain extreme (e.g. pain as bad as you can imagine or worst pain imaginable). Scores range from 0-10 points, with higher scores indicating greater pain intensity. | 1 hour after procedure | 
| Percent of patients with Numeric Pain Rating Score (NPRS) <3 in the DPE vs. EPI group. | The blinded investigator will visit the patient 3 hours within 1hour of block placement and ask to select Numeric Pain Rating Score (NPRS) (1-10) during procedure.The 11-point numeric scale ranges from '0' representing one pain extreme (e.g. no pain) to '10' representing the other pain extreme (e.g. pain as bad as you can imagine or worst pain imaginable). Scores range from 0-10 points, with higher scores indicating greater pain intensity. | 1 hour after procedure | 
| Percent of patients with Numeric Pain Rating Score (NPRS)<1 in the DPE vs. CSE group | The blinded investigator will visit the patient within 1hour of block placement and ask to select Numeric Pain Rating Score (NPRS) (1-10) during procedure.The 11-point numeric scale ranges from '0' representing one pain extreme (e.g. no pain) to '10' representing the other pain extreme (e.g. pain as bad as you can imagine or worst pain imaginable). Scores range from 0-10 points, with higher scores indicating greater pain intensity. | 1 hour after procedure | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Percent of patients required rescue analgesia in the DPE vs. EPI group | Additional sedation administered during procedure will be documented. | During labor/delivery (up to 24 hours) | 
| Percent of patients required rescue analgesia in the DPE vs. CSE group | Additional sedation administered during procedure will be documented. . | During labor/delivery (up to 24 hours) | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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dural puncture epidurals, DPE, combined-spinal epidural, CSE, cesarean section, patient satisfaction