History of Regional Anesthesia at The University of Western Ontario
Continuous Epidural Analgesia

A significant aspect of the history of regional anesthesia at UWO concerns the clinical development of continuous epidural analgesia in obstetrics at Victoria Hospital.

Dr. W. E. Spoerel started the use of “single shot” epidural analgesia in a limited number of cases in 1956.  By 1960, many of the Anaesthetic staff could provide this to obstetrical patients.  Dr. P. R. Bromage of McGill proposed that continuous epidural analgesia was a safe and satisfactory technique and published his study in the Canadian Medical Association Journal (CMAJ) in 1961.

This was also developed, utilized and studied at Victoria Hospital and a publication by Dr. John Nielsen and colleagues in 1962 (1)   confirmed its value in the obstetrical patient.  A larger study of 1000 cases was published by Dr. Pat Kandel and colleagues in 1966 (2).  This paper reviews the technique, patient selection, timing, method of delivery effect on labour, effect on the infant and complications.  In 1960 only 5% of deliveries received continuous epidural analgesia, whereas by 1965, the percentage had increased to over 50%.

This change in the early 1960's resulted in the need for training of experienced anesthetists, and adjustments in obstetrical management and nursing care.  The technique involved the intermittent injection of the local anesthetic at hourly intervals (bupivicaine was not yet available)  with a delivery dose of 10cc to 15cc at full cervical dilatation. To put this into perspective, I remember that on completion of my residency at University of Toronto in 1968, continuous epidural analgesia was not being used in Toronto.

For this method of analgesia to work, it required that obstetrical nurses learn to provide the intermittent injections.  This required special certification and training by anesthesia staff, one of the first delegated medical acts.

Later, because nurses could not always inject at the correct time interval, an electronic timed mechanical injection pump was developed for this purpose. A modified Harvard pump was used.  This was described in a paper by Dr. J.M.F. Cox and colleagues in 1964 (3).   However, patients managed in this way required care in the Recovery Room or Intensive Care Unit.

In a later publication by Dr. W. E. Spoerel  and colleagues in 1970 (4) the use of continuous or intermittent mechanical injections were studied in obstetrical as well as postoperative surgical patients.  It was concluded that mechanical injection devices are useful and safe provided there is good technical maintenance of the “cumbersome” pumps and adequate training of the nurses in their use and complications.

The Anesthesia Department at UWO were early pioneers in the development of obstetrical epidural analgesia as these four publications show.  What seems “second nature” today required a great deal of effort to prove that general anesthesia for deliveries and trilene analgesia for labour could be improve upon and that the epidural methods could provide greater safety and patient satisfaction.

Dr. Gord Sellery
June 2008

References:

1. Nielsen, J.S., Spoerel W.E., Keenleside H.B., Slater P.E. and Clancy P.R.
Continuous Epidural Analgesia for Labour and Delivery
Canad. Aneasth. Soc .J.  9: 143 – 152 (1962)

2. Kandel P.F., Spoerel W.E. And Kinch R.A.H.
Experience with Mechanical Injection Devices
CMAJ   95: 947 – 953  November 5 1966

3. Cox J.M.R., Spoerel W.E.
Continuous Epidural Analgesia: The Us of an Intermittent Injection Device
Canad. Anaesth, Soc. J. ll: 72-82 (1944)

4.  Spoerel W.E., Thomas, A., and Gerula G.R.
Continuous Epidural Analgesia: Experience with Mechanical Injection Devices
Canad Anesth, Soc. J. - Vol 17, No. 1  January 1970