Effect of epidural volume extension with colloid on dose requirement for intrathecal spinal block: a double blind prospective study

Radhey Shyam, Ajay Kumar Chaudhary, Prithvi K. Singh, Gaurav Jain, Dinesh Singh, Girish Chandra, Vinod K. Bhatia


Background: Epidural volume extension (EVE) is a modification of combined- spinal epidural anaesthesia (CSEA) in which fluid is injected in epidural space after the intrathecal block. Fluid in epidural space compress subarachnoid space and causes cephalic spread of intrathecal drug to increase block height. Purpose of study is to determine efficacy of EVE on dose requirement of intrathecal bupivacaine when colloid was used for EVE.

Methods: Sixty patients of ASA physical status I or II, scheduled for elective caesarean sections were recruited and randomized into two groups (30 each group). Group 1: CSEA in which spinal block is followed by 10 ml Colloid (HES 6%) in epidural space; Group 2: CSEA but no fluid in epidural space. Onset of sensory block and hemodynamic variables were measured at 5 min. intervals up to 40 minutes then at 10 min. intervals till end of surgery. Ineffective block was top- up by epidural 0.5% bupivacaine in incremental doses.

Results: Median effective dose of intrathecal bupivacaine was significantly lower, 4.0 mg (95% CI 4.40-5.60) in group 1 versus 7.0 mg (95% CI 6.93-7.61) in group 2. Only 11 patients required ephedrine in group 1 versus 20 in group 2. Requirement of ephedrine was significantly lower 2.20 (±2.94) mg in group 1 versus 4.0 (±2.88) mg groups 2. Changes in haemodynamic variables from baseline were significantly lower in group 1 than those in group 2.

Conclusions: EVE with colloid was effective in lowering dose requirement of spinal bupivacaine while patients hemodynamically were more stable.



Bupivacaine, Colloid, Epidural, Fentanyl, Haemodynamic, Spinal

Full Text:



Loubert C, O'Brien PJ, Fernando R, Walton N, Philip S, Addei T, et al. Epidural volume extension in combined spinal epidural anaesthesia for elective caesarean section: a randomised controlled trial. Anaesthesia. 2011;66:341-7.

Blanshard HJ, Cook TM. Use of combined spinal-epidural by obstetric anaesthetists. Anaesthesia. 2004;59:922-3.

Dureja GP, Madan R, Kaul HL. Combined spinal epidural anaesthesia. In: Regional anaesthesia and pain management (current perspectives) B. I. Churchill Livingstone Pvt. Ltd. 2000;139-45.

Blumgart CH, Ryall D, Dennison B, Thompson-Hill LM. Mechanism of extension of spinal anesthesia by extradural injection of local anaesthetic. Br. J. Anaesth. 1992;69:457-60.

Bromage PR. Mechanism of action of extradural anesthesia. Br. J. Anaesth. 1975;47:199-212.

Rawal N. Single segment combined subarachnoid and epidural block for cesarean section. Can Anaesth Soc J. 1986;33:254-5.

Carrie LES. Epidural versus combined spinal epidural block for cesarean section (Letter). Acta Anaesthesiol Scand. 1988;32:595-6.

Lander CJ, Korbon GA. Histopathologic consequences of epidural blood patch and epidurally administered Dextran 40. Anesthesiology Suppl. 1988;69:A410.

Salvador L, Carrero E, Castillo J, Villalonga A, Nalda MA. Prevention of post dural puncture headache with epidural-administered dextran 40. Reg Anesth. 1992;17:357-8.

Souron V, Hamza J. Treatment of Postdural Puncture Headaches with Colloid Solutions: An Alternative to Epidural Blood Patch. Anesth Analg. 1999;89:1333.

Chiron B, Laffon M, Ferrandière M, Pittet J. Postdural puncture headache in a patient with sickle cell disease: use of an epidural colloid patch. Can J Anaesth. 2003;50:812-4.

Stienstra R, Dahan A, Alhadi BZ, van Kleef JW, Burm AG. Mechanism of action of an epidural top-up in combined spinal-epidural anesthesia. Anesth Analg. 1996;83:382-6.

Takiguchi T, Okane T, Egwa H, Okubo Y, Saito K, Kitajima T. The effect of epidural saline injection on analgesic level during combined spinal and epidural anesthesia assessed clinically and myelographically. Anesth Analg. 1997;85:1097-100.

Mardirosoff C, Dumont L, Lemedioni P, Pauwels P, Massaut J. Sensory block extension during combined spinal and epidural anesthesia. Reg Anaesth Pain Med. 1998;23:92-5.

Choi DH, Park NK, Cho HS, Hahm TS, Chung IS. Effects of epidural injection on spinal block during combined spinal and epidural anesthesia for cesarean delivery. Reg Anaesth Pain Med. 2000;25:591-5.

Eileen Lew, Thomas E. Combined spinal-epidural anesthesia using epidural volume extension (EVE) leads to faster motor recovery after elective cesarean delivery. Anesth Analg. 2004;98:810-4.

Beale N, Evans B, Plaat F, Columb MO, Lyons G, Stocks GM Stocks. Effect of epidural volume extension on dose requirement of intrathecal hyperbaric bupivacaine at Caesarean section. Br J Anaesth. 2005;95:500-3.

Van de Velde M, Van Schoubroeck D, Jani J, Teunkens A, Missant C, Deprest J. Combined spinal-epidural anesthesia for cesarean delivery: dose-dependent effects of hyperbaric bupivacaine on maternal hemodynamics. Anesth Analg. 2006;103:187-90.

Teoh WH, Thomas E, Tan HM. Ultra-low dose combined spinal-epidural anesthesia with intrathecal bupivacaine 3.75 mg for cesarean delivery: a randomized controlled trial. Int J Obstet Anesth. 2006;15:273-8.

David BB, Miller G, Gavriel R, Gurevitch A. Low dose bupivacaine-fentanyl spinal anesthesia for cesarean delivery. Reg Anaesth Pain Med. 2000;25:235-9.