PregnancyPhase 4NCT03335293
RCT of Epinephrine (None, 100mcg, and 200mcg) in a Hyperbaric Bupivacaine, Fentanyl and Morphine Spinal in C-sections.
A Phase 4 study testing 100 mcg Epinephrine, normal saline and 200 mcg Epinephrine in people with Pregnancy and Cesarean Section, run by University of Florida.
Trial summary
This is a prospective, randomized, double blind study of 75 patients (n=25 for each group) in which epinephrine (100mcg or 200mcg) or normal saline vehicle is added to intrathecal hyperbaric bupivacaine (0.75% bupivacaine hydrochloride in 8.25% dextrose), fentanyl, and morphine to prolong the duration of the spinal… Read more about this study
- Who is it for?
- Ages 18 to 50 years, women onlyHealthy volunteers can take part
- Conditions the study is for
- Pregnancy, Cesarean Section
- What is being tested?
- 100 mcg Epinephrine, normal saline and 200 mcg Epinephrine
- Could I receive a placebo?
- Yes, some participants may receive a placebo
- How many people
- 0 participants
- Where
- No sites listed yet
- Study dates
- Oct 2019to Dec 2019
- Phase
- Phase 4
- Are there results?
- None posted in the registry
Key requirements
Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.
- Ages 18 to 50 years
- Women only
- Healthy volunteers accepted
- Adult
Who may be able to join
- Elective C-section patients
- ASA physical status class 1-3
- Age >18 years
- Height 140-180 cm
- Singleton pregnancy
- Gestational age ≥35 weeks
Who cannot join
- Age < 18 yo
- Prisoner status
- BMI > 45 Laboring patients with epidural going for emergency C-section Opioid abuse in the past 6 months Allergies to any of the adjuncts added to the spinal drug. Ruptured membranes four or more previous cesarean deliveries intrauterine growth retardation, abnormal placentation
About this study
Official title: A Randomized Clinical Trial to Compare the Addition of Epinephrine (no Epinephrine, 100mcg, and 200mcg) to the Standard Dose of Hyperbaric Bupivacaine 12mg, Fentanyl 20mcg and Morphine 150mcg in Scheduled C-sections.
This is a prospective, randomized, double blind study of 75 patients (n=25 for each group) in which epinephrine (100mcg or 200mcg) or normal saline vehicle is added to intrathecal hyperbaric bupivacaine (0.75% bupivacaine hydrochloride in 8.25% dextrose), fentanyl, and morphine to prolong the duration of the spinal anesthetic in scheduled cesarean deliveries. The primary outcome of duration will be the time to T10 level sensory regression as well as motor level regression that will be graded via the modified Bromage scale.
Repeat cesarean sections, in particular, are associated with increased operative time and thus often performed with a spinal-epidural (CSE) technique. The epidural component is, however, untested and may not provide adequate anesthesia, thus the higher risk of conversion to a general anesthesia. Epinephrine is routinely used to prolong spinal anesthesia. If effective for the duration of a repeat cesarean section it would obviate the additional time and risks of performing the epidural and still avoid sufficient duration to avoid conversion to a general anesthetic.
Read the detailed description
Spinal anesthesia is the most common type of anesthetic for C-section, but its major limitation is that the duration of the anesthesia may be less than the operative time. Repeat C-section is particularly associated with increased operative time and is often performed under a continuous spinal-epidural (CSE) technique. The epidural component is, however, untested and may not provide adequate anesthesia, thus necessitating the risk general anesthesia. Epinephrine may be used to prolong spinal anesthesia. This study will evaluate the optimal dose of epinephrine as an adjunct to usual spinal doses of 1.6 mL hyperbaric bupivacaine + 20 mcg preservative free fentanyl + 150 mcg preservative free morphine.
Adding epinephrine to hyperbaric bupivacaine helps in prolonging the duration of anesthesia and the quality of analgesia. However, the time to regression of the block effective for surgical anesthesia is not known for a C-section. Better quantification of this factor would help in choosing a spinal technique over a CSE in obstetric patients. This study seeks to quantify the duration of effective spinal anesthesia with the addition of either 100 or 200 mcg of epinephrine to an intrathecal mixture of hyperbaric bupivacaine and narcotics.
With early local anesthetics such as metycaine, nupercaine, or tetracaine, epinephrine was shown to intensify and prolonged their effects. Subsequent studies suggest that subarachnoid anesthesia with a combination of hyperbaric bupivacaine combined with an opioid and an adrenergic drug may be superior to techniques relying solely on local anesthetic drug. However, most of the studies were conducted in an orthopedic population for ambulatory and total joint arthroplasty for elderly patients.
Currently, it is well accepted that the addition of intrathecal narcotics will enhance the quality and duration of a spinal block.
Two investigations sought to determine the ED 95 dose of hyperbaric bupivacaine in combination with fentanyl and morphine to provide surgical anesthesia for operative success for cesarean delivery. Despite differences in spinal technique (sitting vs. lateral) the ED95 dose was 11.2 and 12 respectively. However, the mean duration of surgeries in those studies were significantly less (41 ± 15 and 64 ± 16 min respectively) than the mean duration of an elective C-section in our institution (90 ± 27 min with a 95th percentile of 135 min).
Since 12mg hyperbaric bupivacaine is the upper limit of acceptable doses for an elective C-section this study will evaluate the efficacy of epinephrine to extend the duration of effective surgical anesthesia.
- Conditions
- Pregnancy, Cesarean Section
- Being tested
- 100 mcg Epinephrine, normal saline, 200 mcg Epinephrine
- Keywords
- pregnancy, repeat cesarean section, spinal anesthesia, bupivacaine, epinephrine, intrathecal, analgesia
- Medical subject headings
- Agnosia
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
100 mcg EpinephrineDrug
This study will evaluate the optimal dose of epinephrine as an adjunct to spinal doses of 1.6 mL hyperbaric bupivacaine + 20 mcg preservative free fentanyl + 150 mcg preservative-free morphine.
normal salineOther
placebo comparator
200 mcg EpinephrineDrug
This study will evaluate the optimal dose of epinephrine as an adjunct to spinal doses of 1.6 mL hyperbaric bupivacaine + 20 mcg preservative free fentanyl + 150 mcg preservative-free morphine.
| Study group | Role | What they receive |
|---|---|---|
| Placebo | Placebo comparator | normal saline vehicle added to subarachnoid block Receives: Other: normal saline |
| 100 mcg epinephrine | Experimental | 100 mcg epinephrine added to subarachnoid block Receives: Drug: 100 mcg Epinephrine |
| 200 mcg epinephrine | Experimental | 200 mcg epinephrine added to subarachnoid block Receives: Drug: 200 mcg Epinephrine |
What is being measured
The primary outcome is the main question the study is designed to answer.
T4 sensory level
Time to T4 sensory level (this will be assessed by pin prick at the anterior axillary line)
Measured: 15 minutes
T10 sensory regression
Time to regression to a T10 sensory level (this will be assessed by pinprick at the anterior axillary line)
Measured: 120 minutes
Analgesia
Analgesia levels of the patient during the surgery (Pain scores will be measured at the beginning of surgery and during delivery, uterine manipulation, peritoneal suturing and skin closure. 0-10 pan scale)
Measured: 120 minutes
Epidural dosing
Time elapsed after the spinal dose to the start of epidural dosing (this will be be assessed by review of the anesthesia record as the first recorded supplemental does of local anesthetic)
Measured: 120 minutes
Satisfaction
Satisfaction levels of the patient during the surgery. (Maternal satisfaction will be quantified using a VAS score (0=no satisfaction and 100=full satisfaction) at the end of surgery and during a postoperative patient examination. )
Measured: 120 minutes and up to 24 hours after surgery
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted7 Nov 2017
- Study startOct 2019 (estimated)
- Primary completionDec 2019 (estimated)
- Study completionDec 2019 (estimated)
Why it stopped: Due to FDA constraints on the off label use of the medications we will not be able to conduct this evaluation.
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Publications (9)Papers the sponsor has linked to this study.
- Other trials for PregnancyStudies of the same condition, open and under way.
- More trials run by University of FloridaThe sponsor's other registered studies.
- What the trial phases meanHow a treatment moves from first tests in people to approval.
More details
For doctors and researchers: how the study is designed, who runs it, and its registry IDs.
Study design
- Study type
- Interventional
- Phase
- Phase 4
- Primary purpose
- Basic science
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- Quadruple blind
- Who is masked
- Participant, Care provider, Investigator, Outcomes assessor
- Enrolment
- 0 participants (actual)
Sponsor and investigators
- Lead sponsor
- University of Florida
- Sponsor type
- University, hospital or other
- Responsible party
- Sponsor
- Investigators
- Paul Mongan, MD, Principal investigator, UF COMJ Department of Anesthesiology
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT03335293
- Sponsor's protocol ID
- IRB201702657 - A
- Status last verified
- Nov 2019
- First submitted
- 25 Oct 2017
- Last updated
- 25 Nov 2019
- Results posted
- No
- Data monitoring committee
- Yes
- FDA-regulated drug
- Yes
- FDA-regulated device
- No
- Individual data sharing
- No
Publications
Abouleish E, Rawal N, Fallon K, Hernandez D. Combined intrathecal morphine and bupivacaine for cesarean section. Anesth Analg. 1988 Apr;67(4):370-4.
PubMed 3354872Abouleish E, Rawal N, Rashad MN. The addition of 0.2 mg subarachnoid morphine to hyperbaric bupivacaine for cesarean delivery: a prospective study of 856 cases. Reg Anesth. 1991 May-Jun;16(3):137-40.
PubMed 1883770Abouleish E, Rawal N, Tobon-Randall B, Rivera-Weiss M, Meyer B, Wu A, Rashad MN. A clinical and laboratory study to compare the addition of 0.2 mg of morphine, 0.2 mg of epinephrine, or their combination to hyperbaric bupivacaine for spinal anesthesia in cesarean section. Anesth Analg. 1993 Sep;77(3):457-62. doi: 10.1213/00000539-199309000-00007.
PubMed 8368545Ginosar Y, Mirikatani E, Drover DR, Cohen SE, Riley ET. ED50 and ED95 of intrathecal hyperbaric bupivacaine coadministered with opioids for cesarean delivery. Anesthesiology. 2004 Mar;100(3):676-82. doi: 10.1097/00000542-200403000-00031.
PubMed 15108985Gurbet A, Turker G, Kose DO, Uckunkaya N. Intrathecal epinephrine in combined spinal-epidural analgesia for labor: dose-response relationship for epinephrine added to a local anesthetic-opioid combination. Int J Obstet Anesth. 2005 Apr;14(2):121-5. doi: 10.1016/j.ijoa.2004.12.002.
PubMed 15795147LEIMDORFER A, METZNER WR. Analgesia and anesthesia induced by epinephrine. Am J Physiol. 1949 Apr;157(1):116-21. doi: 10.1152/ajplegacy.1949.157.1.116. No abstract available.
PubMed 18144412Moore JM, Liu SS, Pollock JE, Neal JM, Knab JH. The effect of epinephrine on small-dose hyperbaric bupivacaine spinal anesthesia: clinical implications for ambulatory surgery. Anesth Analg. 1998 May;86(5):973-7. doi: 10.1097/00000539-199805000-00011.
PubMed 9585279Onishi E, Murakami M, Hashimoto K, Kaneko M. Optimal intrathecal hyperbaric bupivacaine dose with opioids for cesarean delivery: a prospective double-blinded randomized trial. Int J Obstet Anesth. 2017 May;31:68-73. doi: 10.1016/j.ijoa.2017.04.001. Epub 2017 Apr 13.
PubMed 28623089PRIDDLE HD, ANDROS GJ. Primary spinal anesthetic effects of epinephrine. Curr Res Anesth Analg. 1950 May-Jun;29(3):156-62. No abstract available.
PubMed 15414611
Study at a glance
From the registry record, last updated by the sponsor on 25 Nov 2019. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- A Randomized Clinical Trial to Compare the Addition of Epinephrine (no Epinephrine, 100mcg, and 200mcg) to the Standard Dose of Hyperbaric Bupivacaine 12mg, Fentanyl 20mcg and Morphine 150mcg in Scheduled C-sections.
- ClinicalTrials.gov ID
- NCT03335293
- Acronym / sponsor ID
- IRB201702657 - A
- Conditions
- Pregnancy, Cesarean Section
- Keywords
- pregnancy, repeat cesarean section, spinal anesthesia, bupivacaine, epinephrine, intrathecal, analgesia
- Phase
- Phase 4
- Study type
- Interventional
- Recruitment status
- WithdrawnReason stopped: Due to FDA constraints on the off label use of the medications we will not be able to conduct this evaluation.
- Enrolment
- 0 participants (actual)
- Lead sponsor
- University of FloridaUniversity, hospital or other
- Study start
- Oct 2019 (estimated)
- Primary completion
- Dec 2019 (estimated)
- Study completion
- Dec 2019 (estimated)
- First posted
- 7 Nov 2017 (actual)
- Results
- Not posted in the source record
Clinical summary
The research question as the sponsor registered it. This describes what the study plans to test, not what it found.
This is a prospective, randomized, double blind study of 75 patients (n=25 for each group) in which epinephrine (100mcg or 200mcg) or normal saline vehicle is added to intrathecal hyperbaric bupivacaine (0.75% bupivacaine hydrochloride in 8.25% dextrose), fentanyl, and morphine to prolong the duration of the spinal anesthetic in scheduled cesarean deliveries. The primary outcome of duration will be the time to T10 level sensory regression as well as motor level regression that will be graded via the modified Bromage scale.
Repeat cesarean sections, in particular, are associated with increased operative time and thus often performed with a spinal-epidural (CSE) technique. The epidural component is, however, untested and may not provide adequate anesthesia, thus the higher risk of conversion to a general anesthesia. Epinephrine is routinely used to prolong spinal anesthesia. If effective for the duration of a repeat cesarean section it would obviate the additional time and risks of performing the epidural and still avoid sufficient duration to avoid conversion to a general anesthetic.
Detailed description
Spinal anesthesia is the most common type of anesthetic for C-section, but its major limitation is that the duration of the anesthesia may be less than the operative time. Repeat C-section is particularly associated with increased operative time and is often performed under a continuous spinal-epidural (CSE) technique. The epidural component is, however, untested and may not provide adequate anesthesia, thus necessitating the risk general anesthesia. Epinephrine may be used to prolong spinal anesthesia. This study will evaluate the optimal dose of epinephrine as an adjunct to usual spinal doses of 1.6 mL hyperbaric bupivacaine + 20 mcg preservative free fentanyl + 150 mcg preservative free morphine.
Adding epinephrine to hyperbaric bupivacaine helps in prolonging the duration of anesthesia and the quality of analgesia. However, the time to regression of the block effective for surgical anesthesia is not known for a C-section. Better quantification of this factor would help in choosing a spinal technique over a CSE in obstetric patients. This study seeks to quantify the duration of effective spinal anesthesia with the addition of either 100 or 200 mcg of epinephrine to an intrathecal mixture of hyperbaric bupivacaine and narcotics.
With early local anesthetics such as metycaine, nupercaine, or tetracaine, epinephrine was shown to intensify and prolonged their effects. Subsequent studies suggest that subarachnoid anesthesia with a combination of hyperbaric bupivacaine combined with an opioid and an adrenergic drug may be superior to techniques relying solely on local anesthetic drug. However, most of the studies were conducted in an orthopedic population for ambulatory and total joint arthroplasty for elderly patients.
Currently, it is well accepted that the addition of intrathecal narcotics will enhance the quality and duration of a spinal block.
Two investigations sought to determine the ED 95 dose of hyperbaric bupivacaine in combination with fentanyl and morphine to provide surgical anesthesia for operative success for cesarean delivery. Despite differences in spinal technique (sitting vs. lateral) the ED95 dose was 11.2 and 12 respectively. However, the mean duration of surgeries in those studies were significantly less (41 ± 15 and 64 ± 16 min respectively) than the mean duration of an elective C-section in our institution (90 ± 27 min with a 95th percentile of 135 min).
Since 12mg hyperbaric bupivacaine is the upper limit of acceptable doses for an elective C-section this study will evaluate the efficacy of epinephrine to extend the duration of effective surgical anesthesia.
Study design
- Primary purpose
- Basic science
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- Quadruple blind (participant, care provider, investigator, outcomes assessor)
- Number of arms
- 3
| Arm | Type | Receives |
|---|---|---|
| Placebo | Placebo comparator | Other: normal salinenormal saline vehicle added to subarachnoid block |
| 100 mcg epinephrine | Experimental | Drug: 100 mcg Epinephrine100 mcg epinephrine added to subarachnoid block |
| 200 mcg epinephrine | Experimental | Drug: 200 mcg Epinephrine200 mcg epinephrine added to subarachnoid block |
Who may qualify
- Ages
- 18 to 50 years
- Sex
- Female only
- Healthy volunteers
- Accepted
- Age groups
- Adult
Key inclusion criteria (6 listed)
- Elective C-section patients
- ASA physical status class 1-3
- Age >18 years
- Height 140-180 cm
- Singleton pregnancy
Key exclusion criteria (3 listed)
- Age < 18 yo
- Prisoner status
- BMI > 45 Laboring patients with epidural going for emergency C-section Opioid abuse in the past 6 months Allergies to any of the adjuncts added to the spinal drug. Ruptured membranes four or more previous cesarean deliveries intrauterine growth retardation, abnormal placentation
Eligibility is decided by the study team after screening; this overview does not establish that a patient qualifies. Full inclusion and exclusion criteria.
Interventions
| Intervention | Type | Arms |
|---|---|---|
| 100 mcg EpinephrineThis study will evaluate the optimal dose of epinephrine as an adjunct to spinal doses of 1.6 mL hyperbaric bupivacaine + 20 mcg preservative free fentanyl + 150 mcg preservative-free morphine. | Drug | 100 mcg epinephrine |
| normal salineplacebo comparator | Other | Placebo |
| 200 mcg EpinephrineThis study will evaluate the optimal dose of epinephrine as an adjunct to spinal doses of 1.6 mL hyperbaric bupivacaine + 20 mcg preservative free fentanyl + 150 mcg preservative-free morphine. | Drug | 200 mcg epinephrine |
Primary outcome
T4 sensory level
Time frame: 15 minutes
Time to T4 sensory level (this will be assessed by pin prick at the anterior axillary line)
T10 sensory regression
Time frame: 120 minutes
Time to regression to a T10 sensory level (this will be assessed by pinprick at the anterior axillary line)
Analgesia
Time frame: 120 minutes
Analgesia levels of the patient during the surgery (Pain scores will be measured at the beginning of surgery and during delivery, uterine manipulation, peritoneal suturing and skin closure. 0-10 pan scale)
Epidural dosing
Time frame: 120 minutes
Time elapsed after the spinal dose to the start of epidural dosing (this will be be assessed by review of the anesthesia record as the first recorded supplemental does of local anesthetic)
Satisfaction
Time frame: 120 minutes and up to 24 hours after surgery
Satisfaction levels of the patient during the surgery. (Maternal satisfaction will be quantified using a VAS score (0=no satisfaction and 100=full satisfaction) at the end of surgery and during a postoperative patient examination. )
Results and safety
The study was withdrawn before enrolling participants, so there are no results.
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 25 Nov 2019.
- Background: PubMed 3354872Abouleish E, Rawal N, Fallon K, Hernandez D. Combined intrathecal morphine and bupivacaine for cesarean section. Anesth Analg. 1988 Apr;67(4):370-4.
- Background: PubMed 1883770Abouleish E, Rawal N, Rashad MN. The addition of 0.2 mg subarachnoid morphine to hyperbaric bupivacaine for cesarean delivery: a prospective study of 856 cases. Reg Anesth. 1991 May-Jun;16(3):137-40.
- Background: PubMed 8368545Abouleish E, Rawal N, Tobon-Randall B, Rivera-Weiss M, Meyer B, Wu A, Rashad MN. A clinical and laboratory study to compare the addition of 0.2 mg of morphine, 0.2 mg of epinephrine, or their combination to hyperbaric bupivacaine for spinal anesthesia in cesarean section. Anesth Analg. 1993 Sep;77(3):457-62. doi: 10.1213/00000539-199309000-00007.
- Background: PubMed 15108985Ginosar Y, Mirikatani E, Drover DR, Cohen SE, Riley ET. ED50 and ED95 of intrathecal hyperbaric bupivacaine coadministered with opioids for cesarean delivery. Anesthesiology. 2004 Mar;100(3):676-82. doi: 10.1097/00000542-200403000-00031.
- Background: PubMed 15795147Gurbet A, Turker G, Kose DO, Uckunkaya N. Intrathecal epinephrine in combined spinal-epidural analgesia for labor: dose-response relationship for epinephrine added to a local anesthetic-opioid combination. Int J Obstet Anesth. 2005 Apr;14(2):121-5. doi: 10.1016/j.ijoa.2004.12.002.
- Background: PubMed 18144412LEIMDORFER A, METZNER WR. Analgesia and anesthesia induced by epinephrine. Am J Physiol. 1949 Apr;157(1):116-21. doi: 10.1152/ajplegacy.1949.157.1.116. No abstract available.
- Background: PubMed 9585279Moore JM, Liu SS, Pollock JE, Neal JM, Knab JH. The effect of epinephrine on small-dose hyperbaric bupivacaine spinal anesthesia: clinical implications for ambulatory surgery. Anesth Analg. 1998 May;86(5):973-7. doi: 10.1097/00000539-199805000-00011.
- Background: PubMed 28623089Onishi E, Murakami M, Hashimoto K, Kaneko M. Optimal intrathecal hyperbaric bupivacaine dose with opioids for cesarean delivery: a prospective double-blinded randomized trial. Int J Obstet Anesth. 2017 May;31:68-73. doi: 10.1016/j.ijoa.2017.04.001. Epub 2017 Apr 13.
- Background: PubMed 15414611PRIDDLE HD, ANDROS GJ. Primary spinal anesthetic effects of epinephrine. Curr Res Anesth Analg. 1950 May-Jun;29(3):156-62. No abstract available.
- Individual participant dataSharing planned: No
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Referral and contact
AzTrials does not enrol participants or take referrals. Contact the study team or a site listed below; they decide who can take part. This study is not recruiting at the moment.
Paul Mongan, MD principal investigator
UF COMJ Department of Anesthesiology
Questions about this trial
What is this clinical trial studying?
A Phase 4 study testing 100 mcg Epinephrine, normal saline and 200 mcg Epinephrine in people with Pregnancy and Cesarean Section, run by University of Florida.
The full registered description is in the About this study section and the official record.
Who may be eligible to take part?
The sponsor lists 6 inclusion and 3 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.
Is this clinical trial currently recruiting?
The record says: withdrawn, as of the sponsor's last update on 25 Nov 2019. Status can change between updates, so confirm with the study contact before making plans.
What are the possible benefits and risks?
They depend on the study and the treatment, and no study can promise a benefit. Some participants in this study may receive a placebo. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.
What does this phase mean?
Phase 4 studies take place after a treatment is approved, to learn more about its long-term benefits and risks in everyday use.
Not every study follows the same path, and some studies (observational studies, device studies) have no phase.
Are results available for this study?
The study was withdrawn before enrolling participants, so there are no results.
How can a doctor refer a patient or contact the research team?
The record lists no contact. The official record names the sponsor, who can be asked directly. AzTrials does not enrol participants or take referrals.
What does the primary outcome measure?
T4 sensory level (time frame: 15 minutes). The study lists 5 primary outcomes in all. It is what the study was designed to measure, not a finding.
Where can I read the original study information?
On the ClinicalTrials.gov record for NCT03335293, which also lists 9 linked publications.
Does a listing mean the treatment is approved or proven to work?
No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.
How often is this information updated?
AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 25 Nov 2019.