Clinical trial NCT05068661: Comparing Effectiveness of CSE Versus DPE for Labor Analgesia
Official title: A Randomized Controlled Trial of Combined Spinal Epidural Versus Dural Puncture Epidural Techniques for Labor Analgesia
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: PHASE4
Conditions: Labor Pain
Keywords: labor analgesia
neuraxial technique
combined spinal epidural
dural puncture epidural
Lead sponsor: Duke University
Sponsor class: OTHER
First posted: 2021-10-06
Enrollment: 101
Sex: FEMALE
Minimum age (years): 18
Maximum age (years): 45
Standard ages: ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: SEQUENTIAL
Primary purpose: TREATMENT

Brief summary: The primary purpose of this study is to determine if there are differences in block quality between the CSE and DPE techniques for labor analgesia in parturients in active labor. We hypothesize that when compared to the CSE technique, the DPE technique will significantly improve block quality in this population and require fewer "top-ups" and catheter replacements.

Detailed description: This will be a prospective, double-blinded, randomized trial.

Subject identification and recruitment:

Women admitted to the Duke Birthing Center for spontaneous or induced labor will be screened. After usual consultation with the anesthesia team is completed and consent for anesthesia services are obtained, eligible patients will be approached to by a member of the study team. As indicated below, we will plan to enroll up to 120 patients to have 100 patients with complete data (50 for the CSE group and 50 for the DPE group).

Assignment of Study Cohorts:

Study participants will be randomized by computer-generated sequence to CSE or DPE arms, stratified by parity (nulliparous versus multiparous). After the consented and enrolled participant requests labor epidural, a study member will give the anesthesia provider a sealed envelope with study assignment for either standard CSE or DPE technique.

Epidural technique:

Once the patient requests labor analgesia, the usual standard of care for epidural placement will be initiated. The patient will receive 500-1000 mL fluid preload. Vitals will be monitored by the labor nurse, including continuous pulse oximetry, non-invasive blood-pressure monitoring, and external tocodynamometry. Anesthesia time-out will be performed by the anesthesia provider with participation from the nurse and the patient.

All patients will receive a neuraxial technique in the sitting position at L3/4 or L4/5 using loss of resistance to saline. In both the CSE and DPE groups, a 25-G Whitacre needle will be used to puncture the dura. In the CSE group, 10 mcg of preservative-free fentanyl and 2 mg of preservative-free isobaric 0.25% bupivacaine will be administered into the intrathecal space. In both groups, the epidural catheter will be threaded 5 cm into the epidural space. In the DPE group, an initiation dose of 20 mL of ropivacaine 0.1% with fentanyl (2 mcg/mL) over 6 minutes. This would not be administered in the CSE group. Labor analgesia will be maintained by programmed intermittent bolus with 8 mL of the same solution every 45 minutes starting 30 minutes after the initial dose. Patients will have patient-controlled epidural analgesia (PCEA) available with an 10 mL dose per demand, every 10 minutes, for a maximum dose of 50 mL for every hour.

Data Collection:

After the block is placed, a blinded provider will enter the room to collect data. Data will be collected every 3 minutes for the first 30 minutes or until pain score is 1 or 0 with uterine contractions. Subsequent assessments will be every 2 hours until delivery.

Management of breakthrough pain will be standardized.

Eligibility criteria: Inclusion Criteria:

* Ages 18-45, singleton, vertex fetuses at 37-41 weeks' gestation, nulliparous and multiparous women, cervical dilation of 2-7cm, pain score \> 4, and English-speaking ability

Exclusion Criteria:

* Women with major cardiac disease, chronic pain, chronic opioid use

Primary outcomes:
measure: Number of Participants With the Presence of Any of the Five Block Quality Components (or More Than One)
timeFrame: From placement of epidural to delivery of baby, up to 32 hours
Secondary outcomes:
measure: Maternal Adverse Events
timeFrame: From placement of epidural to delivery, up to 32 hours
measure: Number of Participants With Motor Block as Measured by the Modified Bromage Score
timeFrame: From placement of epidural to delivery, up to 32 hours
measure: Duration of the Second Stage of Labor
timeFrame: From start of second stage of labor to delivery, up to 6 hours
measure: Total Labor Epidural Time
timeFrame: From placement of epidural to delivery, up to 32 hours
measure: Total Anesthetic Dose Required
timeFrame: From placement of epidural to delivery, up to 32 hours
measure: Number of Participants Who Self-administered PCEA (Patient-controlled Epidural Analgesia) Boluses
timeFrame: From placement of epidural to delivery, up to 32 hours
measure: Mode of Delivery
timeFrame: Through completion of the study, up to 32 hours from epidural placement
measure: Postpartum: Satisfaction With Analgesia Overall
timeFrame: From placement of epidural to delivery, up to 32 hours
Other outcomes:
Locations:
city: Durham
country: United States
facility: Duke University Hospital
state: North Carolina
Study officials:
affiliation: Duke University Hospital
name: Ashraf S Habib, MD
role: PRINCIPAL_INVESTIGATOR
References: