This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lee, J. S. Articles by de Velde, M. V. Search for Related Content PubMed PubMed Citation Articles by Lee, J. S. Articles by de Velde, M. V.

---

LETTERS TO THE EDITOR

Does Intrathecal Sufentanil Really Cause More Episodes of Fetal Bradycardia?

LAC+USC Medical Center, Women’s & Children’s Hospital, Los Angeles, CA, dchavez@usc.edu

To the Editor:

I read with interest the Van de Velde et al. article (1). Epinephrine absorbed from the neuraxial space may have exerted inhibitory ß-mimetic effects on the myometrium in the first two groups, possibly accounting for the greater frequency of uterine hyperactivity and nonreassuring fetal heart rate changes in the group receiving intrathecal sufentanil alone (without epinephrine).

Perhaps all three groups should have received the same dose of epinephrine (or none) administered by the same route (spinal or epidural) to make them comparable.

Reference

1. Van de Velde M, Teunkens A, Hanssens M, et al. Intrathecal sufentanil and fetal heart rate abnormalities: a double-blind, double placebo-controlled trial comparing two forms of combined spinal epidural analgesia with epidural analgesia in labor. Anesth Analg 2004; 98: 1153–9.[Abstract/Free Full Text]

Response

Department of Anesthesiology, University Hospital Leuven, Leuven, Belgium, Marc.vandevelde@uz.kuleuven.ac.be

In Response:

We thank Dr. Lee for his interest and comments on our article. We acknowledge that epinephrine absorbed from the epidural and spinal space exerts inhibitory effects on the myometrium (1,2). Theoretically, this may have introduced bias in our study because no epinephrine was present in the intrathecal sufentanil alone group. However, we feel this is highly unlikely based on the doses of epinephrine used and the timeframe in which uterine hyperactivity occurred following intrathecal sufentanil. Especially in the group in which spinal sufentanil, bupivacaine, and epinephrine were combined, the epinephrine dose was only 2.5 µg. Vercauteren et al. (3) showed no effects on progress of labor and labor outcome in patients with intrathecal epinephrine in this dose. Moreover, most of the problems of uterine hyperactivity and nonreassuring fetal heart rate developed within the first 30 minutes (although we recorded for a longer period). This is also what has been described in the initial reports (4). We question that absorption from the spinal and epidural space occurred that rapidly to induce uterine relaxation in the two groups in which epinephrine was added. Sufentanil is only detected in maternal plasma after more then 30 minutes following an intrathecal injection (5).

We chose these three groups for our study since they were also the drugs we were using in day-to-day clinical practice. We had retrospective data that intrathecal sufentanil caused more problems then both other combinations (6). So drug selection was partly based on our clinical experience. If indeed epinephrine absorption prevented uterine hypertonicity following spinal analgesia, this remains an important finding, as this is of clinical benefit to the patient. Epinephrine then protects uteroplacental blood flow and improves the quality of analgesia and the duration of spinal analgesia (3).

References

1. Okutomi T, Amano K, Morishima HO. Effect of standard diluted epinephrine infusion on epidural anesthesia in labor. Reg Anesth Pain Med 2000; 25: 529–34.[Medline]
2. Okutomi T, Mochizuki J, Amano K, Hoka S. Effect of epidural epinephrine infusion with bupivacaine on labor pain and mother-fetus outcome in humans. Reg Anesth Pain Med 2000; 25: 228–34.[Medline]
3. Vercauteren M, Jacobs J, Jacquemyn Y, Adriaensen HA. Intrathecal labor analgesia with bupivacaine and sufentanil: the effect of adding 2.25 µg epinephrine. Reg Anesth Pain Med 2001; 26: 473–7.[Medline]
4. Clarke VT, Smiley RM, Finster M. Uterine hyperactivity after intrathecal injection of fentanyl for analgesia during labor: a cause of fetal bradycardia? Anesthesiology 1994; 81: 1083.[Web of Science][Medline]
5. Hansdottir V, Hedner T, Woestenborghs R, Nordberg G. The CSF and plasma pharmacokinetics of sufentanil after intrathecal administration. Anesthesiology 1991; 74: 264–9.[Web of Science][Medline]
6. Van de Velde M, Vercauteren M, Vandermeersch E. Fetal heart rate abnormalities after regional analgesia for labor pain: the effect of intrathecal opioids. Reg Anesth Pain Med 2001; 26: 257–62.[Web of Science][Medline]

This article has been cited by other articles:

				T. M. Hemmerling, G. Djaiani, P. Babb, and J. P. Williams The Use of Epidural Analgesia in Cardiac Surgery Should Be Encouraged Anesth. Analg., December 1, 2006; 103(6): 1592 - 1592. [Full Text] [PDF]

				J. F. Olivier, N. Le, J. L. Choiniere, I. Prieto, F. Basile, and T. Hemmerling Comparison of three different epidural solutions in off-pump cardiac surgery: pilot study Br. J. Anaesth., November 1, 2005; 95(5): 685 - 691. [Abstract] [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lee, J. S. Articles by de Velde, M. V. Search for Related Content PubMed PubMed Citation Articles by Lee, J. S. Articles by de Velde, M. V.