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• W4234570671 abstract "In Response: We thank Dr. Kempen for his interest in and comments on our recent article [1]. We feel that we did indeed define the optimal distance that an epidural catheter should be threaded into the epidural space for the woman in labor receiving 13 mL 0.25% bupivacaine. We used epidural needles and catheters with centimeter markings (Perifix Registered Trademark; B. Braun Medical Inc., Bethlehem, PA) and were extremely careful about the amount of catheter threaded into the epidural space. The quotation from our paper, no strict guidelines were met, was in regard to how much epidural catheter was initially threaded through the epidural needle. Obviously more catheter should initially be threaded through the needle if 7 cm will remain in the space than if only 3 cm has to remain in the space. All patients enrolled in the study were in active labor, with contractions at least once every 5 min, and were randomly assigned to their respective groups; the time of failure was documented 15 min after the last dose of local anesthetic. We felt that 15 min was an appropriate amount of time to wait prior to assessing the block. Although 0.25% bupivacaine is a slow-acting local anesthetic, Eisenach et al. [2] found the onset time of 10 mL of 0.25% bupivacaine to be 8.7 +/- 0.8 (mean +/- SD) min. Even if the onset time of bupivacaine is longer, the women were randomized into their respective groups and there was a statistically significant difference in failure rate among the three groups. Most of the other variables that Dr. Kempen mentioned were either considered and revealed or not felt to be important for the outcome of our study. The patients' age and parity may impact on the process and course of labor, but once the woman is in active labor they are no longer important variables. Whether the woman ultimately has a vaginal delivery or cesarean section is impossible to control for at the time one initiates the block. However, since this was a randomized study, any impact from this variable should be mitigated. We did not feel it necessary to document the dermatomal distribution of the block, as all blocks were bilateral, with the missed segments below the highest dermatomal level achieved. Perhaps this should have been more clearly stated in the paper. Although the visual analog scale (VAS) scale is a useful instrument to quantify pain in many situations, we did not feel that the VAS was appropriate for this particular study. If VAS scores are obtained, one may interpret a score of 10 or 20 mm as a success, especially if the woman started with scores of 70 or 80 mm. But this may not be the case. If a woman has a one-sided or partial block, she may have had a decrease in VAS score but the block is still inadequate from her point of view. Thus, we felt that asking the woman if she has pain was the most important end point, and VAS scores may cloud the picture. We felt that using bupivacaine without narcotics was the best way to perform our study. Narcotics diffuse into the subarachnoid space where they bind to (spinal) opioid receptors. Diffusion into the subarachnoid space is dependent on many factors including drug penetration of the dura and pia mater, absorption by epidural fat, and vascular uptake and redistribution to supraspinal sites. Analgesia from narcotics is probably not related to catheter position, so using narcotics in our study would have only confused the issue. Yaakov Beilin, MD Howard Bernstein, MD Barbara Zucker-Pinchoff, MD Department of Anesthesiology The Mount Sinai Medical Center New York, NY 10029" @default.
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• W4234570671 date "1996-04-01" @default.
• W4234570671 modified "2023-09-26" @default.
• W4234570671 title "How Far Should a Catheter Be Inserted into the Epidural Space?" @default.
• W4234570671 doi "https://doi.org/10.1213/00000539-199604000-00062" @default.
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