Dewandre, P.Y.*
CHU, Liege, Belgium
ESRA Academy. Dewandre P. Sep 15, 2017; 195857
Topic: Caesarean Section
Pierre-Yves Dewandre
Pierre-Yves Dewandre

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After viewing this presentation the participant will be able to:

- Review the benefits and side effects of using lipophilic opioids in top-ups for elective and non-elective C section surgery
- Evaluate optimal top-up solutions for non-elective C-section surgery


P.Y. Dewandre, MD, PhD



Converting an epidural  labour analgesia to an epidural surgical anaesthesia for cesarean section is a very common procedure. Many different  local anaesthetic solutions and various adjuvants have been proposed to achieve this goal and a wide variation in practice is reported (1,2).No general agreement does exist about the optimal solution, ideally providing a  rapid onset and good quality of block for the entire duration of the surgical procedure. One part of the controversy is related to the beneficit of adding a lipophilic opioid to the LA solution in order to optimize the quality of the epidural anaesthesia. The present lecture will be dedicated  to demonstrate the absence of benefit of adding a lipohilic opioid in the particular setting of providing a surgical anaesthesia for c-section in a patient with an epidural catheter in-situ for labour analgesia.


Variation in practice in several surveys

Different surveys have investigated the current parctice  in converting an epidural analgesia to an epidural anaesthesia for an unplanned cesarean section. In a 2008 survey in UK investigating 209 obsteric units, 13 different combinations of LA with or without epinephrine and/or bicarbonate were reported but none with lipophilic opioids (1)

Conversely, in a 2016 scandinavian survey investigating the same procedure, a lipophilic opioid was added in 50% of the cases (2)


Efficacy of lipohilic opioids combined to local anesthetics for epidural anaesthesia in elective cesarean section.

In elective caesarean sections, adding fentanyl 75-100 mg to bupivacaine 0.5% has been demonstrated to increase the quality of intraoperative analgesia without altering the speed of onset  nor the duration of the sensory and motor blockade but with an increase in maternal pruritus (3).

Adding 100 mg fentanyl to the epidural solution has also been demonstrated to improve the quality of postoperative analgesia and to decrease the need for intraoperative suplementation with alfentanyl or entonox (4,5) without depression of the term neonate (6).

Similarily, adding sufentanil 20 to 30 mcg to  0.5% bupivacaine has beeen demonstrated to improve the quality of anesthesia without jeopardizing the safety of the neonate (7).


Lack of efficacy of lipohilic opioids combined to local anaesthetics administered in an epidural top-up for unplanned cesarean section during labour

Converting  an epidural labour analgesia to an anaesthesia for cesarean section is very common.

Lipophilic opioids (fentanyl or sufentanil) are commonly used as adjuvants for labour epidural analgesia. Their use allows a reduction of the LA concentrations required to achieve an effective labour analgesia and a reduction in the incidence of motor blockade associated with instrumental extractions (8,9). Their efficacy is dose related (10,11). They increase the success rate of epidural analgesia (12).

It is questionnable wether additional administration of a lipophilic opioid in a top up to achieve surgical anesthesia for a cesrean section in a patient already receiving  this opioid during labour analgesia would confer additional benefit or if the repeated epidural administration of this lipophilic opioid during labour produces a near-maximal effect and that additional dosing would not provide additional benefit. Many anesthethists add a lipohilic opioid to the LA solution when topping up an epidural, expecting a better quality of block and a reduction in the need for any analgesic supplementation as wel as a reduction in onset time. However, in non elective cesarean-section in women  receiving  fentanyl containing epidural analgesia , the addition of fentanyl 75 mcg to 0.5% levobupivacaine for epidural anesthesia did not alter the onset time nor the need for intra-operative supplementation but increased the incidence of nausea and vomiting (13)

In a  meta-analysis adressing the question of the best epidural solution for emergency cesarean section, the authors concluded that adding fentanyl 50-75 mcg to a lidocaine epinephrine reduces the onset time without altering the need for intra-operative supplementation (14).

This meta-analysis can be criticized due to the diversity of protocols and end-points, particularily concerning onset time and all the trial investigating lidocaine epinephrine  with or without fentanyl showed a median onset time shorter than 15 min making surgical readiness comparable with general anesthesia. (15) The authors of this meta-analysis conclude that if the speed of onset is important, then lidocaine epinephrine solution, with or without fentanyl, appears optimal (14).

In a prospective audit of regional anaesthesia failure for 5080 cesarean sections, a 24% failure rate was reported with epidural top-up . The use of many different solutions precluded the analysis of the impact of adding or not a lipohilic opioid  (16).

Similarily, in a review and meta-analysis on risk factors for failed conversion of labour epidural analgesia to cesarean delivery anesthesia, the use of lipohilic opioid in the top-up solution was not evaluated and therefore not identified as a factor reducing the failure rate (17).

In addition, it must be kept in mind that any hypothetic potential benefit in speed of onset could be negated by the increase in time taken to prepare the mixture. Moreover, the use of a combination of various drugs increase the risk of errors, especially when prepared under the presure of time.



The benefit of adding a lipophilic opioid to the local anesthetic solution when converting an epidural analgesia to an epidural anaethesia for a cesarean section is maginal if not nul when the patient is already receiving an epidural analgesia with a local anesthetic combined with an lipohilic opioid.

This hypothetic benefit must be balanced against the time taken to prepare the mixture and the risk of error when mixing drugs under the pressure of time.

For these reasons, epidural lipophilic opioids are not needed when an epidural top-up is given to achieve anaesthesia for c-section.




  1. 1)    Regan K J, O ‘Sullivan G. The extension of epidural blockade for emergency caesarean section : a survey of Current UK practice. Anaesthesia 2008 ; 63 : 136-142.
  2. 2)    Wildgaard K,  Hetmann F,  Ismaiel M. The extension of epidural blockade for emergency caesarean section : a Survey of scandinavian practice. Int J Obstet Anesth 2016; 25 : 45-52
  3. 3)    Paech MJ, Westmore MD, Speirs HM. A double-blind comparison of  epidural bupivacaine and bupivacaine –fentanyl for caesarean section. Anaesth Intensive Care 1990 ; 18 :20-30
  4. 4)    King MJ, Bowden MI, Cooper GM. Epidural fentanyl and 0.5% bupivacaine for elective caesarean section. Anaesthesia 1990 ; 45 : 285-288
  5. 5)    Helbo-Hansen HS, Bang U, Lindhom P et al. Maternal effects of adding epidural fentanyl to 0.5% bupivacaine for cesarean section. Int J Obstet Anesth 1993 ; 2 : 21-26
  6. 6)    Helbo-Hansen HS, Bang U, Lindhom P et al. Neonatal effects of adding epidural fentanyl to 0.5% bupivacaine for cesarean section. Int J Obstet Anesth 1993 ; 2 : 27-33
  7. 7)    Vertommen JD, Van Aken H, Vandermeulen E et al. Maternal and néonatal effects of adding epidural sufentanil to 0.5% bupivacaine for cesarean delivery. J Clin Anesth 1991 ; 3 : 371-376
  8. 8)    Comparative Obstetric Mobile Epidural Trial (COMET) study group UK. Effect of low-dose mobile versus traditional epidural techniques on mode of delivery : a randomised controlled trial. Lancet 2001 Jul 7 ; 358 (9275) : 19-23
  9. 9)    Wilson MJ, Cooper G, MacArthur et al COMET study group UK. Randomized controlled trial comparing traditional with two « mobile » epidural technique : anesthetic and analgesic efficacy. Anesthesiology 2002 ; 97 (6) : 1567-75.

10)Polley LS, Columb MO, Wagner DS et al. Dose-dependent reduction of the minimum local analgesic concentration of bupivacaine by sufentanil for epidural analgesia in labor. Anesthesiology 1998 ; 89 (3) : 626-32

11)Lyons G, Columb M, Hawthorne L et al. Extradural pain relief in labour : bupivacaine sparing by extradural fentanyl is dose-dependent. Br J Anaesth 1997 ; 78 (5) : 493-7.

12)Hermanides J, Hollmann MW, Stevens MT et al. Failed epidural : causes and management. Br J Anaesth 2012 ;109 : 144-154.

13)Malhotra S, Yentis SM. Extending low-dose epidural analgesia in labour for emergency caesarean section : a comparison of levobupivacaine with or without fentanyl. Anaesthesia 2007 ; 62 : 667-671.

14)Hillyard S G, Bate T E, Corcoran T B.  Extending epidural analgesia for emergency caesarean section : a meta-analysis. Br J Anaesth 2011 ; 107(5) : 668-678

15)Depuyt E, Van de Velde M. Unplanned cesarean section in parturients with an epidural catheter in situ : how to obtain surgical anesthesia ? Acta Anaesth Belg 2013 ; 64 : 61-74

16)Kinsella S M. A prospective audit of regional anaesthesia failure in 5080 caesarean sections. Anaesthesia 2008 ; 63 : 822-832

17)Bauer ME, Kountanis JA, Tsen LC et al. Risk fa tors for failed conversion of labor epidural analgesia to cesarean delivery anesthesia : a systematic review  and a meta-analysis of observational trials. Int J Obstet Anesth 2012 ; 21 : 294-309.




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