Brazilian Journal of Anesthesiology
Brazilian Journal of Anesthesiology
Clinical Research

Clinical utility of epidural volume extension following reduced intrathecal doses: a randomized controlled trial

Asha Tyagi, Mukundan Ramanujam, Ashok Kumar Sethi, Medha Mohta

Downloads: 0
Views: 30


Background and objectives
Epidural Volume Extension (EVE) involves instillation of normal saline into the epidural space soon after an intrathecal injection, with the aim to augment the sensory block height. Its clinical relevance lies in the possibility of using reduced intrathecal dose and yet achieving the desired sensory block level. Intrathecal dose is a known determinant of the level of sensory block. Whether EVE is dependent on intrathecal dose is not known.

We conducted a randomized, controlled, double-blind study to compare the maximum sensory level (Smax) achieved with or without application of EVE to two different reduced intrathecal doses. Eighty four adult male patients of ASA status I or II with body weight between 50–70 kg and height in the range of 150–180 cm, scheduled for orthopedic lower limb surgery using combined spinal epidural anesthesia were randomized to receive, either intrathecal dose (5 or 8 mg) with or without EVE, in accordance to group allocation.

Smax was lowered by application of EVE to 5 mg intrathecal bupivacaine (T8.9±4.3 vs. T6.4±1.9 with and without EVE respectively; p = 0.030). Smax was similar when EVE was applied to 8 mg intrathecal bupivacaine than without it (T5.8±1.8 vs. T6.4±2.2 respectively; p =  0.324).

EVE should not be applied to 5 mg plain bupivacaine during a combined spinal epidural block in patients undergoing lower limb orthopedic surgery as it may result in a decrease in the maximum sensory level.


Epidural volume extension;  Combined spinal epidural anesthesia;  Orthopedic anesthesia


1 A.F. McNaught, G.M. Stocks Epidural volume extension and low-dose sequential combined spinal-epidural blockade: two ways to reduce spinal dose requirement for caesarean section Int J Obstet Anesth., 16 (2007), pp. 346-353

2 M. Heesen, S. Weibel, M. Klimek, R. Rossaint, L.R. Arends, P. Kranke Effects of epidural volume extension by saline injection on the efficacy and safety of intrathecal local anaesthetics: systematic review with meta-analysis, meta-regression and trial sequential analysis Anaesthesia., 72 (2017), pp. 1398-1411

3 A. Tyagi, C.S. Sharma, S. Kumar, D.K. Sharma, A.K. Jain, A.K. Sethi Epidural volume extension: a review Anaesth Intensive Care., 40 (2012), pp. 604-613

4 A. Mohan, P.M. Singh, D. Malviya, S.K. Arya, D.K. Singh Reinforcement of subarachnoid block by epidural volume effect in lower abdominal surgery: A comparison between fentanyl and tramadol for efficacy and block properties Anesth essays Res., 6 (2012), pp. 189-194

5 A. Tyagi, A. Kumar, G. Girotra, Ak. Sethi Combined spinal epidural and epidural volume extension: Interaction of patient position and hyperbaric bupivacaine J Anaesthesiol Clin Pharmacol., 27 (2011), pp. 459-464

6 A. Tyagi, S. Kumar, R. Salhotra, A.K. Sethi Minimum effective volume of normal saline for epidural volume extension J Anaesthesiol Clin Pharmacol., 30 (2014), pp. 228-232

7 D.H. Choi, N.K. Park, H.S. Cho, T.S. Hahm, I.S. Chung Effects of epidural injection on spinal block during combined spinal and epidural anesthesia for cesarean delivery Reg Anesth Pain Med., 25 (2000), pp. 591-595

8 C.H. Blumgart, D. Ryall, B. Dennison, L.M. Thompson-Hill Mechanism of extension of spinal anaesthesia by extradural injection of local anaesthetic Br J Anaesth., 69 (1992), pp. 457-460

9 R. Stienstra, B.Z. Dilrosun-Alhadi, A. Dahan, J.W. van Kleef, B.T. Veering, A.G. Burm The epidural top-up in combined spinal-epidural anesthesia: the effect of volume versus dose Anesth Analg., 88 (1999), pp. 810-814

10 R. Stienstra, A. Dahan, B.Z. Alhadi, J.W. van Kleef, A.G. Burm Mechanism of action of an epidural top-up in combined spinal epidural anesthesia Anesth Analg., 83 (1996), pp. 382-386

11 N. Doganci, A. Apan, Ö Tekin, Ç Kaymak Epidural volume expansion: is there a ceiling effect? Minerva Anestesiol., 76 (2010), pp. 334-339

12 V. Zaphiratos, R.B. George, B. Macaulay, P. Bolleddula, D.M. McKeen Epidural Volume Extension During Combined Spinal-Epidural Labor Analgesia Does Not Increase Sensory Block Anesth Analg., 123 (2016), pp. 684-689

13 C. Loubert, P.J. O’Brien, R. Fernando, N. Walton, S. Philip, T. Addei, et al. Epidural volume extension in combined spinal epidural anaesthesia for elective caesarean section: a randomised controlled trial Anaesthesia., 66 (2011), pp. 341-347

14 E.L. Hamlyn, C.A. Douglass, F. Plaat, J.A. Crowhurst, G.M. Stocks Low-dose sequential combined spinal-epidural: an anaesthetic technique for caesarean section in patients with significant cardiac disease Int J Obstet Anesth., 14 (2005), pp. 355-361

15 P. Richardson, S. Whittaker, U. Rajesh, M. Bonduelle, J. Morgan, M. Garry, et al. Caesarean delivery in a parturient with a femoro-femoral crossover graft and congenital aortic stenosis repaired by the Ross procedure Int J Obstet Anesth., 18 (2009), pp. 387-391

16 A.K. Tiwari, R.R. Singh, R.P. Anupam, S. Ganguly, G.S. Tomar Epidural volume extension: A novel technique and its efficacy in high risk cases Anesth essays Res., 6 (2012), pp. 233-235

17 A. Tyagi, A. Kumar, A.K. Sethi, M. Mohta Epidural volume extension and intrathecal dose requirement: plain versus hyperbaric bupivacaine Anesth Analg., 107 (2008), pp. 333-338

18 T.W. Breen, T. Shapiro, B. Glass, D. Foster-Payne, N.E. Oriol Epidural anesthesia for labor in an ambulatory patient Anesth Analg., 77 (1993), pp. 919-924

19 M. Chen, C. Chen, Q. Ke The effect of age on the median effective dose (ED50) of intrathecally administered plain bupivacaine for motor block Anesth Analg., 118 (2014), pp. 863-868

20 A.K. Tiwari, J. Agrawal, S. Tayal, M. Chadha, A. Singla, G. Valson, et al. Anaesthetic management of peripartum cardiomyopathy using epidural volume extension technique: a case series Ann Card Anaesth., 15 (2012), pp. 44-46

21 E. Guasch, E. Alsina, A. Domínguez, J. Díaz, F. Gilsanz Epidural volume extension with low dose spinal anesthesia for cesarean section Eur J Anaesthesiol., 24 (2007), pp. 143-144

22 E.L. Hamlyn, C.A. Douglass, F. Plaat, J.A. Crowhurst, G.M. Stocks Low-dose sequential combined spinal-epidural: an anaesthetic technique for caesarean section in patients with significant cardiac disease Int J Obstet Anesth., 14 (2005), pp. 355-361

23 E. Lew, S.-W. Yeo, E. Thomas Combined spinal-epidural anesthesia using epidural volume extension leads to faster motor recovery after elective cesarean delivery: a prospective, randomized, double-blind study Anesth Analg., 98 (2004), pp. 810-814

24 M.J. Yun, M.Y. Kwon, D.H. Kim, J.W. Lee Combined spinal-epidural anesthesia using a reduced-dose of spinal bupivacaine and epidural top up leads to faster motor recovery after lower extremity surgeries Korean J Anesthesiol., 66 (2014), pp. 28-33

25 D.-H. Choi, H.-J. Ahn, J.-A. Kim Combined low-dose spinal-epidural anesthesia versus single-shot spinal anesthesia for elective cesarean delivery Int J Obstet Anesth., 15 (1) (2006), pp. 13-17

26 Sherin A. Mohamed Epidural volume expansion and single shot spinal anesthesia, for elective caesarean section Al-Azhar Assiut Med JAAMJ., 10 (2003)

27 S. Kucukguclu, H. Unlugenc, F. Gunenc, B. Kuvaki, N. Gokmen, S. Gunasti, et al. The influence of epidural volume extension on spinal block with hyperbaric or plain bupivacaine for Caesarean delivery Eur J Anaesthesiol., 25 (2008), pp. 307-313

28 C. Salman, N. Kayacan, F. Ertuğrul, Z. Bıgat, B. Karslı Combined Spinal-Epidural Anesthesia with Epidural Volume Extension causes a Higher Level of Block than Single-Shot Spinal Anesthesia Brazilian J Anesthesiol., 63 (2013), pp. 267-272

29 C. Mardirosoff, L. Dumont, P. Lemédioni, P. Pauwels, J. Massaut Sensory block extension during combined spinal and epidural Reg Anesth Pain Med., 23 (1998), pp. 92-95

30 A. Kumar, C. Sinha, A. Kumar, P. Kumari Epidural volume extension for caesarean section in a patient with severe pulmonary stenosis and moderate tricuspid regurgitation Indian J Anaesth., 63 (2019), p. 242

31 G. Hocking, J.A.W. Wildsmith Intrathecal drug spread Br J Anaesth., 93 (2004), pp. 568-578

600874d20e8825b14a345c19 rba Articles
Links & Downloads

Rev. Bras. Anestesiol.

Share this page
Page Sections