Epidural test dose in obstetric patients: should we still use it?

Curr Opin Anaesthesiol. 2019 Jun;32(3):263-267. doi: 10.1097/ACO.0000000000000721.

Abstract

Purpose of review: As the application of a test dose after epidural catheter insertion in obstetrics has recurrently been associated with serious adverse events affecting both maternal and foetal outcomes, the question whether to test or not remains a controversial issue.

Recent findings: Present guidelines do not provide clear recommendations in this regard and several recent surveys indicate a heterogeneity in clinical routine.

Summary: Physiological alterations during pregnancy and labour restrict the use and also the validity of traditional test agents. Epinephrine is not appropriate to detect a vascular insertion in labour and the application of a local anaesthetic test dose may lead to dose-dependent fatal consequences should the catheter be intrathecal, due to an increased sensitivity in parturients. Given the current practice of opioid-amended-low-concentration epidurals, the waiving of a test dose results at worst in a failed epidural, a stark contrast to the potentially severe to fatal complications of a 'traditional' test dose. Hence, an originally preventive measure providing potentially more harm than the consequences of the situation aimed to prevent, should not be recommended. A simple fractionated administration of the initial analgesic dose seems reasonable though.

Publication types

  • Review

MeSH terms

  • Analgesia, Epidural / adverse effects
  • Analgesia, Epidural / instrumentation
  • Analgesia, Epidural / methods*
  • Analgesia, Epidural / standards
  • Analgesia, Obstetrical / adverse effects
  • Analgesia, Obstetrical / instrumentation
  • Analgesia, Obstetrical / methods*
  • Analgesia, Obstetrical / standards
  • Anesthetics, Local / administration & dosage*
  • Anesthetics, Local / adverse effects
  • Catheterization / adverse effects
  • Catheterization / instrumentation
  • Catheterization / methods*
  • Catheterization / standards
  • Catheters / adverse effects
  • Dose-Response Relationship, Drug
  • Epidural Space
  • Epinephrine / administration & dosage*
  • Epinephrine / adverse effects
  • Female
  • Humans
  • Injections, Epidural / adverse effects
  • Injections, Epidural / instrumentation
  • Injections, Epidural / methods
  • Injections, Epidural / standards
  • Practice Guidelines as Topic
  • Pregnancy

Substances

  • Anesthetics, Local
  • Epinephrine