Median effective dose of spinal ropivacaine in combined spinal and epidural anesthesia for emergency cesarean delivery following failed vaginal delivery with epidural labor analgesia: a single-blind, sequential dose-finding study

This study aimed to estimate the median effective dose of intrathecal isobaric ropivacaine without opioid required for adequate cesarean delivery anesthesia after epidural labor analgesia.

Patients aged 20–40 years with American Society of Anesthesiology scores of I–II, body mass index ≤ 36, who underwent emergency cesarean delivery after failed vaginal delivery with epidural analgesia of a duration ≤ 6 h were included in the study. After removal of the epidural used for labor analgesia, a new combined spinal epidural was performed, and a dose of intrathecal isobaric ropivacaine without opioid was administered. The dose was determined using up–down methodology, with the starting patient's dose set to 12 mg. Adequate anesthesia, defined as a pinprick level no lower than T6 at 5 min after ropivacaine administration, resulted in the next patient receiving a dose of ropivacaine 1 mg higher, and inadequate anesthesia 1 mg lower. The primary outcome was the median (95% confidence interval (CI)) dose of spinal ropivacaine required for adequate cesarean delivery anesthesia.

Of the 46 patients included in the study, 40 were analyzed. The median spinal ropivacaine dose was 8.11 mg (95% CI 7.29–8.93 mg) by the Dixon and Mood method and 8.06 mg (95% CI 6.93–9.00 mg) by isotonic regression. Two patients had high spinal anesthesia.

Our findings suggest that for 50% of patients undergoing cesarean delivery after failed vaginal delivery with epidural analgesia, an 8-mg spinal dose of isobaric ropivacaine without opioid provides an anesthesia level no lower than T6 at 5 min.