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OBSTETRIC ANESTHESIA

The Primary Action of Epidural Fentanyl After Cesarean Delivery is Via a Spinal Mechanism

Shaul Cohen, MD^*, Carol B. Pantuck, BA, David Amar, MD, Elizabeth Burley, PA-S, BS^*, and Eugene J. Pantuck, MD

*Department of Anesthesiology, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, New Jersey; Department of Anesthesiology, College of Physicians and Surgeons of Columbia University, New York, New York; and Department of Anesthesiology, Weill Medical College of Cornell University, New York, New York

Address correspondence to Shaul Cohen, MD, Chief of Obstetric Anesthesia, Department of Anesthesia, UMDNJ-Robert Wood Johnson Medical School, CAB, Suite 3100, 125 Paterson Street, New Brunswick, NJ 08903. Address e-mail to cohensh{at}umdnj.edu

We tested the hypotheses that the primary mechanism of action of epidural fentanyl after cesarean delivery is spinal and that very small dose epidural bupivacaine with epinephrine enhances this effect. After elective cesarean delivery, 100 parturients were randomized in a double-blinded design to four groups. Group I and II patients received a continuous 12 mL/h epidural infusion of bupivacaine 0.015% with epinephrine 1 µg/mL for 48 h and Groups III and IV received a 12 mL/h saline epidural infusion instead. Fentanyl 20 µg/mL was administered via a patient-controlled analgesia device either into the epidural infusion (Groups I and IV) or IV (Groups II and III). When compared to patients receiving epidural fentanyl, those receiving IV fentanyl required larger mean infused and total dose of fentanyl (P < 0.0001), reported more pain (P < 0.001), and had a more frequent incidence of excessive sedation (P < 0.01), nausea (P < 0.01), and vomiting (P < 0.01). Plasma concentrations of fentanyl were larger for Group II and III than for Groups I and IV (P < 0.001) at 24 and 48 h. Our results support the hypothesis that the primary mechanism of analgesia of epidural fentanyl after cesarean delivery is spinal. Our data also show that the total required dose of epidural, but not IV, fentanyl is reduced by very small dose epidural bupivacaine and epinephrine (Group I versus Group IV, P < 0.02 and Group II vs Group III, not significant).

IMPLICATIONS: Fentanyl administered epidurally to parturients after cesarean delivery has a primarily spinal mechanism of action and this effect is enhanced by very small dose epidural bupivacaine and epinephrine.

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Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999