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Bang YJ, Jeong H, Kang R, Sung JH, Choi SJ, Oh SY, Hahm TS, Shin YH, Jeong YW, Choi SJ, Ko JS. Comparison of analgesic effects between programmed intermittent epidural boluses and continuous epidural infusion after cesarean section: a randomized controlled study. Korean J Anesthesiol 2024; 77:374-383. [PMID: 38481356 PMCID: PMC11150112 DOI: 10.4097/kja.23726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 03/14/2024] [Accepted: 03/14/2024] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND This study aimed to compare the analgesic effects of programmed intermittent epidural boluses (PIEB) and continuous epidural infusion (CEI) for postoperative analgesia after elective cesarean section (CS). METHODS Seventy-four women who underwent elective CS were randomized to receive either PIEB or CEI. The PIEB group received 4 ml-intermittent boluses of 0.11% ropivacaine every hour at a rate of 120 ml/h. The CEI group received a constant rate of 4 ml/h of 0.11% ropivacaine. The primary outcome was the pain score at rest at 36 h after CS. Secondary outcomes included the pain scores during mobilization, time-weighted pain scores, the incidence of motor blockade, and complications-related epidural analgesia during 36 h after CS. RESULTS The pain score at rest at 36 h after CS was significantly lower in the PIEB group compared with that in the CEI group (3.0 vs. 0.0; median difference: 2, 95% CI [1, 2], P < 0.001). The mean time-weighted pain scores at rest and during mobilizations were also significantly lower in the PIEB group than in the CEI group (pain at rest; mean difference [MD]: 37.5, 95% CI [24.6, 50.4], P < 0.001/pain during mobilization; MD: 56.6, 95% CI [39.8, 73.5], P < 0.001). The incidence of motor blockade was significantly reduced in the PIEB group compared with that in the CEI group (P < 0.001). CONCLUSIONS PIEB provides superior analgesia with less motor blockade than CEI in postpartum women after CS, without any apparent adverse events.
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Affiliation(s)
- Yu Jeong Bang
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Heejoon Jeong
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - RyungA Kang
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji-Hee Sung
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Suk-Joo Choi
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Soo-Young Oh
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tae Soo Hahm
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Hee Shin
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yeon Woo Jeong
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Soo Joo Choi
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Justin Sangwook Ko
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Bang S. Programmed intermittent epidural bolus: a viable alternative to traditional methods? Korean J Anesthesiol 2024; 77:287-288. [PMID: 38777568 PMCID: PMC11150121 DOI: 10.4097/kja.24306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 05/16/2024] [Indexed: 05/25/2024] Open
Affiliation(s)
- Seunguk Bang
- Department of Anesthesiology and Pain Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Howle R, Ragbourne S, Zolger D, Owolabi A, Onwochei D, Desai N. Influence of different volumes and frequency of programmed intermittent epidural bolus in labor on maternal and neonatal outcomes: A systematic review and network meta-analysis. J Clin Anesth 2024; 93:111364. [PMID: 38176084 DOI: 10.1016/j.jclinane.2023.111364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 12/11/2023] [Accepted: 12/14/2023] [Indexed: 01/06/2024]
Abstract
STUDY OBJECTIVE In labor, programmed intermittent epidural bolus (PIEB) can be defined as the bolus administration of epidural solution at scheduled time intervals. Compared to continuous epidural infusion (CEI) with or without patient controlled epidural analgesia (PCEA), PIEB has been associated with decreased pain scores and need for rescue analgesia and increased maternal satisfaction. The optimal volume and dosing interval of PIEB, however, has still not been determined. DESIGN Systematic review and network meta-analysis registered with PROSPERO (CRD42022362708). SETTINGS Labor. PATIENTS Pregnant patients. INTERVENTIONS Central, CINAHL, Global Health, Ovid Embase, Ovid Medline and Web of Science were searched for randomized controlled trials that examined pregnant patients in labor who received CEI or PIEB with or without a PCEA component. Network meta-analysis was performed with a frequentist method, facilitating the indirect comparison of PIEB with different volumes and dosing intervals through the common comparator of CEI and substituting or supplementing direct comparisons with these indirect ones. Continuous and dichotomous outcomes were presented as mean differences and odds ratios, respectively, with 95% confidence intervals. The risk of bias was evaluated using the Cochrane risk of bias 2 tool. MAIN RESULTS Overall, 30 trials were included. For the first primary endpoint, need for rescue analgesia, PIEB delivered at a volume of 4 ml and frequency of 45 min (4/45) was inferior to PIEB 8/45 (OR 3.55; 95% CI 1.12-11.33), PIEB 10/60 was superior to PIEB 2.5/15 (OR 0.36; 95% CI 0.16-0.82), PIEB 4/45 (OR 0.14; 95% CI 0.03-0.71) and PIEB 5/60 (OR 0.23; 95% CI 0.08-0.70), and PIEB 5/30 was not inferior to PIEB 10/60 (OR 0.61; 95% CI 0.31-1.19). For the second primary endpoint, maternal satisfaction, no differences were present between the various PIEB regimens. The quality of evidence for these multiple primary endpoints was low owing to the presence of serious limitations and imprecision. Importantly, PIEB 5/30 decreased the pain score at 4 h compared to PIEB 2.5/15 (MD 2.45; 95% CI 0.13-4.76), PIEB 5/60 (MD -2.28; 95% CI -4.18--0.38) and PIEB 10/60 (MD 1.73; 95% CI 0.31-3.16). Mean ranking of interventions demonstrated PIEB 10/60 followed by PIEB 5/30 to be best placed to reduce the cumulative dose of local anesthetic, and this resulted in an improved incidence of lower limb motor blockade for PIEB 10/60 in comparison to CEI (OR 0.30; 95% CI 0.14-0.67). No differences in neonatal outcomes were found. Some concerns were present for the risk of bias in two thirds of trials and the risk of bias was shown to be high in the remaining one third of trials. CONCLUSIONS Future research should focus on PIEB 5/30 and PIEB 10/60 and how the method of analgesia initiation, nature and concentration of local anesthetic, design of epidural catheter and rate of administration might influence outcomes related to the mother and neonate.
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Affiliation(s)
- Ryan Howle
- Department of Anaesthesia, Rotunda Hospital, Dublin, Ireland; Department of Anaesthesia, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Sophie Ragbourne
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Danaja Zolger
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Adetokunbo Owolabi
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Desire Onwochei
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; King's College London, London, United Kingdom
| | - Neel Desai
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; King's College London, London, United Kingdom.
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Kim D, Kim J, Choo H, Choi DH. Programmed intermittent epidural bolus as an ideal method for labor analgesia: a randomized controlled trial. Korean J Anesthesiol 2024; 77:106-114. [PMID: 37312414 PMCID: PMC10834717 DOI: 10.4097/kja.23173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 06/12/2023] [Accepted: 06/13/2023] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND Although programmed intermittent epidural bolus (PIEB) is effective for labor analgesia, an appropriate flow rate has not been established. Therefore, we investigated the analgesic effect based on different epidural injection flow rates. METHODS Nulliparous women scheduled for spontaneous labor were enrolled in this randomized trial. After injection of intrathecal 0.2% ropivacaine 3 mg with fentanyl 20 μg, participants were randomized to three study groups. Epidural analgesics, 10 ml during one hour, were administered with patient controlled epidural analgesia as follows (0.2% ropivacaine 60 ml, fentanyl 180 μg, and 0.9% saline 40 ml): continuous (n = 28, 10 ml/h for continuous infusion), PIEB (n = 29, 240 ml/h for bolus infusion of 10 ml), or manual (n = 28, 1200 ml/h for bolus injection of 10 ml). The primary outcome was hourly consumption of the epidural solution. The time interval between labor analgesia and the first breakthrough pain was investigated. RESULTS The median (Q1, Q3) hourly consumption of epidural anesthetics was significantly different among the groups (continuous: 14.3 [8.7, 16.9] ml, PIEB: 9.4 [6.2, 9.8] ml, manual: 8.6 [7.6, 9.9] ml; P < 0.001). The time to breakthrough pain for the PIEB group was longer than that for the other groups (continuous: 78.5 [35.8, 185.0] min, PIEB: 200.0 [88.5, 441.5] min, manual: 60.5 [37.3, 162.0] min, P = 0.027). CONCLUSIONS PIEB, with a low-flow rate, provided more adequate labor analgesia than a continuous epidural infusion or manual injection with a high-flow rate.
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Affiliation(s)
- Doyeon Kim
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Jeayoun Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyeonju Choo
- Department of Anesthesiology and Pain Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Duck Hwan Choi
- Department of Anesthesiology and Pain Medicine, Dongtan Sacred Heart Hospital, Hallym University School of Medicine, Hwaseong, Korea
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Moaveni D, Toledo P. Programmed Intermittent Intrathecal Bolus for Maintenance of Labor Analgesia in an Obstetric Patient: A Case Report. A A Pract 2023; 17:e01739. [PMID: 38088757 DOI: 10.1213/xaa.0000000000001739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Maintenance of labor analgesia with programmed intermittent epidural boluses (PIEBs) has demonstrated benefits over the use of continuous infusions. While programmed intermittent boluses have been used for the maintenance of epidural analgesia, it has not been reported for the maintenance of intrathecal analgesia. Approximately 25% of intrathecal catheters (ITC) ultimately fail, often due to inadequate analgesic coverage. We describe the use of programmed intermittent intrathecal boluses for a laboring parturient who received an ITC. She reported excellent pain relief without significant motor block, high anesthetic block, hypotension, or respiratory distress. This delivery modality may increase the rate of ITC after unintentional dural puncture (UDP).
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Affiliation(s)
- Daria Moaveni
- From the Department of Anesthesiology, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, Florida
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Ni F, Wu Z, Zhao P. Programmed intermittent epidural bolus in maintenance of epidural labor analgesia: a literature review. J Anesth 2023; 37:945-960. [PMID: 37733073 DOI: 10.1007/s00540-023-03253-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 08/29/2023] [Indexed: 09/22/2023]
Abstract
Programmed intermittent epidural bolus (PIEB), administered by the infusion pump programmed to deliver boluses of epidural solution at certain intervals, is gradually gaining more attention as a technique to maintain the labor analgesia in recent years. Many studies find that it may have some advantages when compared with other methods. However, its exact effectiveness and optimal regimen are still unclear. We conducted a literature search in PubMed, Web of Science, and Cochrane Database of Systematic Reviews for studies published between January 2010 and June 2022. Of the 263 publications identified, 27 studies were included. The purpose of this review is to discuss the effects of PIEB with continuous epidural infusion (CEI) and patient-controlled epidural analgesia (PCEA) in maintenance of epidural labor analgesia on labor outcomes and elucidate the latest research progress of implementation strategies.
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Affiliation(s)
- Fanshu Ni
- Department of Anesthesiology, Shengjing Hospital of China Medical University, No. 36 Sanhao Street Heping District, Shenyang, CN 110004, Liaoning Province, China
| | - Ziyi Wu
- Department of Anesthesiology, Shengjing Hospital of China Medical University, No. 36 Sanhao Street Heping District, Shenyang, CN 110004, Liaoning Province, China
| | - Ping Zhao
- Department of Anesthesiology, Shengjing Hospital of China Medical University, No. 36 Sanhao Street Heping District, Shenyang, CN 110004, Liaoning Province, China.
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Du W, Liu Z. Comparison of Peak Bulk Flow Rate of Programmable Intermittent Epidural Bolus and Manual Epidural Bolus Using a Closed-End Multiorifice Catheter. Anesth Analg 2023; 137:e1. [PMID: 37326870 DOI: 10.1213/ane.0000000000006365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Affiliation(s)
- Weijia Du
- Shanghai First Maternity and Infant Hospital School of Medicine Tongji University, Shanghai, China,
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Younger JD, Faryami A, Prasad M, Viar D, Menkara A, Tang A, Harris CA. Direct Comparison of Peak Bulk Flow Rate of Programmable Intermittent Epidural Bolus and Manual Epidural Bolus Using a Closed-End Multiorifice Catheter: An Experimental Study. Anesth Analg 2023; 136:1198-1205. [PMID: 36730916 DOI: 10.1213/ane.0000000000006268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The programmable intermittent epidural bolus (PIEB) has been popularized as the optimal delivery technique for labor analgesia. Suggested advantages of this method are less local anesthetic consumption, improved maternal satisfaction, potentially shorter duration of labor, and decreased workload requirements for the anesthesia providers. However, a manual bolus is still routinely used for breakthrough pain when the PIEB is underperforming. METHODS We conducted a laboratory-based study to quantify the flow through a multiorifice epidural catheter using the PIEB setting on an epidural pump compared to the manual epidural bolus. Four syringe volumes, 3, 5, 10, and 20 mL, were selected for this experiment. The flow in a manual bolus was also studied with and without the presence of an epidural catheter filter. A generalized estimating equation analysis was done to compare data between the groups. RESULTS Regardless of the syringe size, there was a several-fold increase in flow when a manual bolus was used compared to a pump-administered dose, with the highest difference in the peak flow rate observed in 3-mL boluses with up to a 12-fold difference, while the difference was, at most, 7-fold in 5-mL and 10-mL boluses. Manual boluses without a filter achieve a mean peak flow rate higher than manual boluses with a filter. CONCLUSIONS Our study found that manual boluses produced a higher flow rate compared to the CADD-Solis epidural pump (Smiths Medical). This study also found that the placement of a particulate filter reduces the flow rates generated while bolusing. Bulk flow rate is directly correlated with induced pressure and solution spread. Because higher bolus pressure has been shown to provide a more efficient distribution of local anesthetic and more efficient pain relief, these results may have impactful clinical significance and will pave the way for future studies.
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Affiliation(s)
- Joshua D Younger
- From the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health, Detroit, Michigan
| | - Ahmad Faryami
- Department of Biomedical Engineering, Wayne State University, Detroit, Michigan
| | - Monica Prasad
- Department of Medical Education, Wayne State University School of Medicine, Detroit, Michigan
| | - Daniel Viar
- Department of Computer Science and Engineering, University of Toledo, Toledo, Ohio
| | - Adam Menkara
- Department of Biomedical Engineering, Wayne State University, Detroit, Michigan
| | - Amy Tang
- Department of Public Health Science, Henry Ford Health, Detroit, Michigan
| | - Carolyn A Harris
- Department of Chemical Engineering and Materials Science, Wayne State University, Detroit, Michigan
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Liu SK, Wu SC, Hung SC, Chen KB, Illias AM, Tsai YF. Combined Programmed Intermittent Bolus and Patient-Controlled Bolus Is a More Favorable Setting for Epidural Pain Relief Than Continuous Infusion. Healthcare (Basel) 2023; 11:1350. [PMID: 37174892 PMCID: PMC10177816 DOI: 10.3390/healthcare11091350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 04/30/2023] [Accepted: 05/05/2023] [Indexed: 05/15/2023] Open
Abstract
Epidural analgesia is a suitable and effective treatment for labor pain. However, the preferable modality setting for delivery remains debatable. This study adopted a programmed intermittent epidural bolus (PIEB) setting in conjunction with a patient-controlled epidural analgesia (PCEA) setting to improve the quality of labor analgesia and reduce the number of medical staff. We conducted a prospective observational analysis of primigravida parturients scheduled for spontaneous labor, which required epidural analgesia for painless labor. A total of 483 healthy primigravida parturients with singleton pregnancies were included in this cohort; 135 nulliparous patients were assigned to the continuous infusion setting (CEI) group and 348 to the PIEB + PCEA group. Compared to the CEI setting, the PIEB + PCEA setting significantly reduced the manual rescue by the clinician, extended the time required for the first manual rescue dose, and acclaimed good maternal satisfaction. The use of the CEI mode increased for poor performance requiring more than two rescues with an odds ratio of 2.635 by a binary logistic regression analysis. Using the PIEB + PCEA setting as the maintenance infusion had a longer duration for the first requested manual rescue, fewer manual rescue boluses, excellent satisfaction, and no significant increase in adverse events compared to the CEI setting.
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Affiliation(s)
- Shih-Kai Liu
- Department of Anesthesiology, China Medical University Hospital and China Medical University, Taichung 404327, Taiwan; (S.-K.L.)
| | - Shao-Chun Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial and College of Medicine, Chang Gung University, Kaohsiung 833401, Taiwan;
| | - Shao-Chi Hung
- Department of Anesthesiology, China Medical University Hospital and China Medical University, Taichung 404327, Taiwan; (S.-K.L.)
| | - Kuen-Bao Chen
- Department of Anesthesiology, China Medical University Hospital and China Medical University, Taichung 404327, Taiwan; (S.-K.L.)
| | - Amina M. Illias
- Department of Anesthesiology, Linko Chang Gung Memorial Hospital and Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 333423, Taiwan
| | - Yung-Fong Tsai
- Department of Anesthesiology, Linko Chang Gung Memorial Hospital and Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 333423, Taiwan
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Wei Y, Wang Y, Zhao Y, Wu C, Liu H, Yang Z. High Dosage of Patient-Controlled Epidural Analgesia (PCEA) with Low Background Infusion during Labor: A Randomized Controlled Trial. J Pers Med 2023; 13:jpm13040600. [PMID: 37108986 PMCID: PMC10144857 DOI: 10.3390/jpm13040600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/14/2023] [Accepted: 03/19/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Patient-controlled epidural analgesia (PCEA) is well documented; however, it is unclear whether a high dosage of PCEA with a low dosage of background infusion during labor can be a safe and effective application. METHODS Group LH was administered a continuous infusion (CI) of 0.084 mL/kg/h with PCEA of 5 mL every 40 min. Group HL was given a CI of 0.028 mL/kg/h and PCEA of 10 mL every 40 min; Group HH was given a CI of 0.084 mL/kg/h and PCEA of 10 mL every 40 min. The primary outcomes were VAS pain score, the number of supplemental boluses, incidence of pain outbreaks, drug dose for pain outbreaks, PCA times, effective PCA times, anesthetic consumption, duration of analgesia, duration of labor and delivery outcome. Secondary outcomes included adverse reactions such as itching, nausea and vomiting during analgesia and neonatal Apgar scores 1 min and 5 min after birth. RESULTS A total of 180 patients, 60 in each group were randomly assigned to one of three groups included group LH, group HL or group HH. The VAS scores were obviously decreased in HL group and HH group in comparison with LL group at 2 h after analgesia and the time point of full cervical dilation and delivery of baby. The time for third stage of labor in HH group was increased compared with LH group and HL group. Incidence of pain outbreaks in LH group was obviously increased compared with HL and HH group. The effective PCA times in HL group and HH group were remarkably reduced compared with those in LH group. CONCLUSIONS High dose of PCEA with a low background infusion can reduce effective PCA times, incidence of outbreak pain and the total amount of anesthetics without diminishing analgesia effects. However, high dose of PCEA with a high background infusion can enhance analgesia effect but increase the third stage of labor, instrumental delivery ratio and the total amount of anesthetics.
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Affiliation(s)
- Yu Wei
- Department of Anesthesiology, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
- Shanghai Key Laboratory of Embryo Original Disease, Shanghai 200030, China
- Shanghai Municipal Key Clinical Specialty, Huashan Rd. 1961, Shanghai 200030, China
| | - Yilong Wang
- Department of Anesthesiology, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
- Shanghai Key Laboratory of Embryo Original Disease, Shanghai 200030, China
- Shanghai Municipal Key Clinical Specialty, Huashan Rd. 1961, Shanghai 200030, China
| | - Yanhong Zhao
- Department of Anesthesiology, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
- Shanghai Key Laboratory of Embryo Original Disease, Shanghai 200030, China
- Shanghai Municipal Key Clinical Specialty, Huashan Rd. 1961, Shanghai 200030, China
| | - Chaomin Wu
- Department of Pulmonary Medicine, Qingpu Branch, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Henry Liu
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, The University of Pennsylvania, 3401 Spruce Street, Philadelphia, PA 19104, USA
| | - Zeyong Yang
- Department of Anesthesiology, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
- Shanghai Key Laboratory of Embryo Original Disease, Shanghai 200030, China
- Shanghai Municipal Key Clinical Specialty, Huashan Rd. 1961, Shanghai 200030, China
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Yi J, Li Y, Yuan Y, Xu Z, Song Y, Ye B, Zhao Q, Yang Y, Du W, Liu Z. Comparison of labor analgesia efficacy between single-orifice and multiorifice wire-reinforced catheters during programmed intermittent epidural boluses: a randomized controlled clinical trial. Reg Anesth Pain Med 2023; 48:61-66. [PMID: 36351740 DOI: 10.1136/rapm-2022-103723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 10/20/2022] [Indexed: 11/11/2022]
Abstract
AIMS We compared analgesic outcomes between single-orifice and multiorifice wire-reinforced catheters under 480 mL/hour delivery rate with programmed intermittent epidural bolus administration. METHODS Between August and November 2021, 182 nulliparous and healthy women with singleton pregnancy, 2-5 cm cervical dilation, and requesting neuraxial analgesia were randomized to receive either single-orifice or multiorifice catheters. Epidural analgesia was initiated and maintained with 0.1% ropivacaine and 0.3 µg/mL sufentanil. Programmed intermittent epidural bolus volume of 10 mL was administered every 45 min at 480 mL/hour beginning immediately after the test dose. Primary outcome was the percentage of parturients in the two groups with adequate analgesia 20 min after the initial bolus. RESULTS Compared with multiorifice catheters, single-orifice catheters were associated with a higher proportion of parturients with adequate analgesia (71.8% vs 56.0%, respectively; 95% CI 1.3% to 29%, p=0.03) and more frequent S2 sensory blockade (37.6% vs 22.6%, respectively; 95% CI -30% to 1%, p=0.03) 20 min after block initiation. Median time (IQR) to adequate analgesia was 12 (8-30) min and 20 (10-47) min with single-orifice and multiorifice catheters, respectively (95% CI 0.1 to 0.7 min, p<0.01). The median (IQR) ropivacaine consumption per hour was higher in parturients receiving multiorifice catheters than those with single-orifice catheters (15.3 (13.3-17.0) mg/hour vs 13.3 (13.3-15.4) mg/hour, respectively; 95% CI 0.2 to 0.8 mg/hour, p<0.001). CONCLUSION Single-orifice catheters used for programmed intermittent epidural bolus at 480 mL/hour for epidural labor analgesia had improved analgesic efficacy than multiorifice catheters. TRIAL REGISTRATION NUMBER ChiCTR2100049872.
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Affiliation(s)
- Juan Yi
- Department of Anesthesiology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China.,Department of Anesthesiology, Ningbo First Hospital, Ningbo, China
| | - Yujie Li
- Department of Anesthesiology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yawei Yuan
- Department of Anesthesiology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Zhendong Xu
- Department of Anesthesiology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yujie Song
- Department of Anesthesiology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Binglu Ye
- Department of Anesthesiology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Qingsong Zhao
- Department of Anesthesiology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yingying Yang
- Clinical Research Center, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Weijia Du
- Department of Anesthesiology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Zhiqiang Liu
- Department of Anesthesiology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
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Dural Puncture Epidural in Obese Parturients: Reply. Anesthesiology 2022; 137:654-655. [PMID: 36095047 DOI: 10.1097/aln.0000000000004348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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13
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Yin H, Tong X, Huang H. Dural puncture epidural versus conventional epidural analgesia for labor: a systematic review and meta-analysis of randomized controlled studies. J Anesth 2022; 36:413-427. [PMID: 35445869 DOI: 10.1007/s00540-022-03061-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 04/01/2022] [Indexed: 01/14/2023]
Abstract
Dural puncture epidural (DPE) technique is a modification of the conventional epidural (EP) technique in that the dura is intentionally punctured with a spinal needle but without any spinal injection. This meta-analysis aimed to evaluate the benefits and risks associated with the DPE technique for labor analgesia. Randomized trials comparing DPE analgesia with EP analgesia for labor pain relief were systematically searched in the database of Medline, Embase, Cochrane Controlled Trials Register, Web of Science, and China Biology Medicine till 1st August 2021. The primary outcome was the percentage of patients with satisfactory pain relief following DPE or EP analgesia, which was defined as visual analog scale (VAS) pain scores ≤ 3/10 (or 30/100) measured 10 min and 20 min after initiation of labor analgesia. Totally ten trials with 1099 patients were included in this review. DPE technique increased the percentage of patients with VAS pain score ≤ 3/10 (or 30/100) both at 10 min (RR 1.43; 95% CI 1.17, 1.74; p < 0.001; I2 = 0%) and 20 min (RR 1.13; 95% CI 1.04, 1.22; p = 0.005; I2 = 0%) after labor analgesia. No adverse event was found with DPE analgesia. We conclude that compared with EP analgesia, DPE analgesia is beneficial for labor pain relief by shortening the time to achieve satisfactory pain control. Meanwhile, DPE analgesia is not associated with increased adverse maternal/fetal events.
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Affiliation(s)
- Haiying Yin
- Department of Anesthesiology, West China Second University Hospital, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, 20#, 3rd Segment, Ren Min Nan Lu, Chengdu, 610041, People's Republic of China
| | - Xin Tong
- Department of Anesthesiology, West China Second University Hospital, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, 20#, 3rd Segment, Ren Min Nan Lu, Chengdu, 610041, People's Republic of China
| | - Han Huang
- Department of Anesthesiology, West China Second University Hospital, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, 20#, 3rd Segment, Ren Min Nan Lu, Chengdu, 610041, People's Republic of China.
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Wang XX, Zhang XL, Zhang ZX, Xin ZQ, Guo HJ, Liu HY, Xiao J, Zhang YL, Yuan SZ. Programmed intermittent epidural bolus in parturients: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2022; 101:e28742. [PMID: 35119026 PMCID: PMC8812607 DOI: 10.1097/md.0000000000028742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 01/11/2022] [Accepted: 01/12/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND To evaluate the efficacy and safety of programmed intermittent epidural bolus (PIEB) in parturients. METHODS The PubMed, Embase, and the Cochrane Library (from inception to July 2021) were searched for identification of randomized placebo-controlled trials in which PIEB was applied in parturients. The outcomes were the effect of analgesia, satisfaction score, mode of delivery, duration of labor, neonatal condition, and adverse events. The pooled odds ratios (OR), weighted mean difference (WMD), and 95% confidence intervals (CIs) were calculated using random- and fixed-effects models. RESULTS PIEB was found to be associated with decreased total consumption of ropivacaine (WMD = -15.83, 95% CI: -19.06 to -12.60, P < .00001; I2 = 61%; P for heterogeneity = .04), total consumption of sufentanil (WMD = -4.93, 95% CI: -6.87 to 2.98, P < .00001; I2 = 68%; P for heterogeneity = .05), numbers of patients who require patient-controlled epidural analgesia bolus (OR = 0.27, 95% CI: 0.14-0.51, P < .0001; I2 = 65%; P for heterogeneity = .01), the number of attempts (WMD = -4.12, 95% CI: -7.21 to -1.04, P = .009; I2 = 100%; P for heterogeneity < .00001), rate of breakthrough pain (OR = 0.47, 95% CI: 0.28-0.80, P = .005; I2 = 47%; P for heterogeneity = .09). Eight studies focus on the duration of analgesia. After by meta-analysis, we found that the pain visual analogue scale (VAS) score at 30 minutes, 2 hours, 4 hours, and 5 hours in PIEB group was significantly lower when compared with control group, (WMD = -0.15, 95% CI: -0.26 to -0.04, P = .006; I2 = 0%; P for heterogeneity = .64), (WMD = -0.79, 95% CI: -1.32 to 0.25, P = .004; I2 = 97%; P for heterogeneity < .00001), (WMD = -1.00, 95% CI: -1.08 to -0.91, P < .00001; I2 = 0%; P for heterogeneity = .67), (WMD = -1.81, 95% CI: -3.23 to -0.39, P = .01; I2 = 98%; P for heterogeneity < .00001), respectively. Nineteen studies discussed the mode of delivery between 2 groups. The results suggest that the rate of normal delivery is significantly higher in PIEB group compared with control group (OR = 1.37, 95% CI: 1.08-1.75, P = .01). The time of first and second stage of labor are significantly shorter in PIEB group compared with control group, the result is (WMD = -10.52, 95% CI: -14.74 to 4.76, P < .00001; I2 = 0%; P for heterogeneity = .86), (WMD = -1.48, 95% CI: -2.26 to -0.69, P = .0002; I2 = 35%; P for heterogeneity = .10), respectively. Thirteen studies concerned the satisfaction score of patients. The satisfaction score of patients in the PIEB group was significantly higher when compared with control group (WMD = 0.91, 95% CI: 0.42-1.39, P = .0003; I2 = 98%; P for heterogeneity < .00001). The Apgar score at 1, 5 minutes in PIEB group are significantly higher (WMD = 0.07, 95% CI: 0.02-0.13 P = .007; I2 = 55%; P for heterogeneity = .04), (WMD = -0.08, 95% CI: -0.12 to -0.05, P < .00001; I2 = 21%; P for heterogeneity = .27), respectively. CONCLUSIONS PIEB is a good alternative for labor analgesia with better analgesic effect, maternal and infant outcome.
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Affiliation(s)
- Xian-xue Wang
- Department of Anesthesiology of The First People's Hospital of Changde City, Changde, Hunan, China
| | - Xiao-lan Zhang
- Obstetrical Department of The First People's Hospital of Changde City, Changde, Hunan, China
| | - Zhao-xia Zhang
- Obstetrical Department of The First People's Hospital of Changde City, Changde, Hunan, China
| | - Zi-qin Xin
- Obstetrical Department of The First People's Hospital of Changde City, Changde, Hunan, China
| | - Hua-jing Guo
- Department of Anesthesiology of The First People's Hospital of Changde City, Changde, Hunan, China
| | - Hai-yan Liu
- Obstetrical Department of The First People's Hospital of Changde City, Changde, Hunan, China
| | - Jing Xiao
- Obstetrical Department of The First People's Hospital of Changde City, Changde, Hunan, China
| | - Yun-lin Zhang
- Obstetrical Department of The First People's Hospital of Changde City, Changde, Hunan, China
| | - Shu-zhen Yuan
- Obstetrical Department of The First People's Hospital of Changde City, Changde, Hunan, China
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15
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Du W, Song Y, Zhao Q, Xu Z, Liu Z. The effect of open-end versus closed-end epidural catheter design on injection pressure and dye diffusion under various programmed intermittent epidural delivery rates: an in vitro study. Int J Obstet Anesth 2022; 51:103252. [DOI: 10.1016/j.ijoa.2022.103252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 10/01/2021] [Accepted: 01/05/2022] [Indexed: 10/19/2022]
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16
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Mazda Y, Arzola C, Downey K, Ye XY, Carvalho JCA. Programmed intermittent epidural bolus for labour analgesia: a randomized controlled trial comparing bolus delivery speeds of 125 mL·hr -1 versus 250 mL·hr -1. Can J Anaesth 2021; 69:86-96. [PMID: 34725792 DOI: 10.1007/s12630-021-02132-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 08/23/2021] [Accepted: 08/24/2021] [Indexed: 11/28/2022] Open
Abstract
PURPOSE Programmed intermittent epidural bolus (PIEB) provides better analgesia for labour pain than continuous epidural infusion does. Nevertheless, commonly used PIEB regimens are associated with high sensory block. We hypothesized that a PIEB technique with slower bolus delivery speed would produce lower sensory levels. METHODS We recruited term nulliparous women with singleton pregnancies during the first stage of labour. All participants had an American Society of Anesthesiologists Physical Status score of II-III, had epidural catheters placed at L3/4, and had epidural analgesia maintained with PIEB 10 mL every 40 min using 0.0625% bupivacaine with fentanyl 2 µg·mL-1. Women were randomized to receive PIEB delivered at 250 mL·hr-1 (G250) or 125 mL·hr-1 (G125). The study was completed six hours after the loading dose or at full cervical dilatation, whichever occurred first. The primary outcome was the presence of sensory block to ice ≥ T6 in at least one assessment during the study period (maximum six hours). RESULTS We analyzed data from 90 women. The proportion of women presenting sensory block ≥ T6 at any time was not different between G125 and G250 groups (60.0% vs 64.4%; difference, -4.4%; 95% confidence interval [CI], -24.5 to 15.6; P = 0.66). The median [interquartile range] highest sensory block level was also not different between G125 and G250 groups (T6 [T7-T5] vs T5 [T7-T5], P = 0.39). Women in the G125 group had a lower incidence of hypotension than women in the G250 group did (11.1% vs 33.3%; difference, -22.2%; 95% CI, -38.8 to -5.67; P = 0.01). Quality of analgesia and patient satisfaction were not different between groups. CONCLUSION The maintenance of epidural analgesia with a PIEB delivery speed of 125 mL·hr-1 did not produce lower sensory block levels when compared with 250 mL·hr-1. The slower injection speed regimen was associated with lower incidence of hypotension, but this secondary finding warrants confirmation in a future trial. TRIAL REGISTRATION www.ClinicalTrials.gov (NCT03236298); registered 1 August 2017.
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Affiliation(s)
- Yusuke Mazda
- Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto, 600 University Avenue, Room 7-405, Toronto, ON, M5G 1X5, Canada.
| | - Cristian Arzola
- Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto, 600 University Avenue, Room 7-405, Toronto, ON, M5G 1X5, Canada
| | - Kristi Downey
- Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto, 600 University Avenue, Room 7-405, Toronto, ON, M5G 1X5, Canada
| | - Xiang Y Ye
- Department of Pediatrics, Micare Research Centre, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Jose C A Carvalho
- Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto, 600 University Avenue, Room 7-405, Toronto, ON, M5G 1X5, Canada.,Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
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17
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Roofthooft E, Barbé A, Schildermans J, Cromheecke S, Devroe S, Fieuws S, Rex S, Wong CA, Van de Velde M. Programmed intermittent epidural bolus vs. patient-controlled epidural analgesia for maintenance of labour analgesia: a two-centre, double-blind, randomised study†. Anaesthesia 2020; 75:1635-1642. [PMID: 32530518 DOI: 10.1111/anae.15149] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2020] [Indexed: 11/28/2022]
Abstract
The programmed intermittent epidural bolus technique has shown superiority to continuous epidural infusion techniques, with or without patient-controlled epidural analgesia for pain relief, reduced motor block and patient satisfaction. Many institutions still use patient-controlled epidural analgesia without a background infusion, and a comparative study between programmed intermittent epidural bolus and patient-controlled epidural analgesia without a background infusion has not yet been performed. We performed a randomised, two-centre, double-blind, controlled trial of these two techniques. The primary outcome was the incidence of breakthrough pain requiring a top-up dose by an anaesthetist. Secondary outcomes included: motor block; pain scores; patient satisfaction; local anaesthetic consumption; and obstetric and neonatal outcomes. We recruited 130 nulliparous women who received initial spinal analgesia, and then epidural analgesia was initiated and maintained with either programmed intermittent epidural bolus or patient-controlled epidural analgesia using ropivacaine 0.12% with sufentanil 0.75 µg·ml-1 . The programmed intermittent epidural bolus group had a programmed bolus of 10 ml every hour, with on-demand patient-controlled epidural analgesia boluses of 5 ml with a 20 min lockout, and the patient-controlled epidural analgesia group had a 5 ml bolus with a 12 min lockout interval; the potential maximum volume per hour was the same in both groups. The patients in the programmed intermittent epidural bolus group had less frequent breakthrough pain compared with the patient-controlled epidural analgesia group, 7 (10.9%) vs. 38 (62.3%; p < 0.0001), respectively. There was a significant difference in motor block (modified Bromage score ≤ 4) frequency between groups, programmed intermittent epidural bolus group 1 (1.6%) vs. patient-controlled epidural analgesia group 8 (13.1%); p = 0.015. The programmed intermittent epidural bolus group had greater local anaesthetic consumption with fewer patient-controlled epidural analgesia boluses. Patient satisfaction scores and obstetric or neonatal outcomes were not different between groups. In conclusion, we found that a programmed intermittent epidural bolus technique using 10 ml programmed boluses and 5 ml patient-controlled epidural analgesia boluses was superior to a patient-controlled epidural analgesia technique using 5 ml boluses and no background infusion.
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Affiliation(s)
- E Roofthooft
- Department of Anaesthesiology, GZA Sint Augustinus Hospital, Antwerp, Belgium.,Department of Cardiovascular Sciences, KU Leuven, Belgium
| | - A Barbé
- Department of Anaesthesiology, University Hospitals Leuven, Belgium
| | - J Schildermans
- Department of Anaesthesiology, University Hospitals Leuven, Belgium
| | - S Cromheecke
- Department of Anaesthesiology, ZNA Middelheim Hospital, Antwerp, Belgium
| | - S Devroe
- Department of Cardiovascular Sciences, KU Leuven, Belgium.,Department of Anaesthesiology, University Hospitals Leuven, Belgium
| | - S Fieuws
- Department of I-Biostat, KU Leuven, Belgium
| | - S Rex
- Department of Cardiovascular Sciences, KU Leuven, Belgium.,Department of Anaesthesiology, University Hospitals Leuven, Belgium
| | - C A Wong
- Department of Anesthesia, University of Iowa, Iowa City, IA, USA
| | - M Van de Velde
- Department of Cardiovascular Sciences, KU Leuven, Belgium.,Department of Anaesthesiology, University Hospitals Leuven, Belgium
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18
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Ojo OA, Mehdiratta JE, Gamez BH, Hunting J, Habib AS. Comparison of Programmed Intermittent Epidural Boluses With Continuous Epidural Infusion for the Maintenance of Labor Analgesia: A Randomized, Controlled, Double-Blind Study. Anesth Analg 2020; 130:426-435. [PMID: 30882524 DOI: 10.1213/ane.0000000000004104] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Programmed intermittent epidural boluses may improve the spread of local anesthetics compared to continuous epidural infusion, improving labor analgesia and obstetric outcomes. However, there are limited data from studies using commercially available pumps capable of coadministering programmed intermittent epidural boluses or continuous epidural infusion with patient-controlled epidural analgesia. Therefore, we performed this prospective, randomized, double-blind study to compare the impact of programmed intermittent epidural boluses versus continuous epidural infusion on labor analgesia and maternal/neonatal outcomes. We hypothesized that programmed intermittent epidural boluses will result in lower patient-controlled epidural analgesia consumption compared to that with continuous epidural infusion. METHODS Following standardized initiation of epidural labor analgesia, women were randomized to receive 0.1% ropivacaine with 2 µg/mL fentanyl as 6-mL programmed intermittent epidural boluses every 45 minutes or continuous epidural infusion at 8 mL/h in a double-blind fashion with similar patient-controlled epidural analgesia settings in both groups. The primary outcome was patient-controlled epidural analgesia consumption per hour. Secondary outcomes included a need for physician interventions, patterns of patient-controlled epidural analgesia use, motor blockade, number of patients who developed hypotension, pain scores, duration of second stage of labor, mode of delivery, and maternal satisfaction. RESULTS We included 120 patients (61 in programmed intermittent epidural boluses group and 59 in continuous epidural infusion group) in the analysis. The median (interquartile range) patient-controlled epidural analgesia volume consumed per hour was not significantly different between the groups: 4.5 mL/h (3.0-8.6 mL/h) for the continuous epidural infusion group and 4.0 mL/h (2.2-7.1 mL/h) for the programmed intermittent epidural boluses group (P = .17). The Hodges-Lehmann location shift estimate of the difference (95% CI) from the continuous epidural infusion to the programmed intermittent epidural boluses group is 0.9 mL/h (-0.4 to 2.2 mL/h). There were also no significant differences between the groups in any of the secondary outcomes except for higher median (interquartile range) patient-controlled epidural analgesia attempts per given ratio per hour in the programmed intermittent epidural bolus group (0.17 [0.10-0.30] vs 0.12 [0.08-0.18]; P = .03) and more motor block in the continuous epidural infusion group (those with Bromage score <5, 27.5% vs 50.0%; P = .03). CONCLUSIONS Under the conditions of our study, we did not find improved outcomes with programmed intermittent epidural boluses compared to continuous epidural infusion except for less motor block with programmed intermittent epidural boluses. Future studies should assess whether smaller but clinically important differences exist and evaluate different parameters of programmed intermittent epidural boluses to optimize analgesia and outcomes with this mode of analgesia.
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Affiliation(s)
- Oluremi A Ojo
- From the Department of Anesthesiology, Duke University, Durham, North Carolina
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19
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Lee B, Lee JH, Kim MS, Kim SJ, Song J, Kim DH, Choi YS. Epidural bolus versus continuous epidural infusion analgesia on optic nerve sheath diameter in paediatric patients: A prospective, double-blind, randomised trial. Sci Rep 2020; 10:5477. [PMID: 32214139 PMCID: PMC7096447 DOI: 10.1038/s41598-020-62273-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 03/11/2020] [Indexed: 11/24/2022] Open
Abstract
The use of programmed intermittent epidural bolus for postoperative analgesia may have greater analgesic efficacy than continuous epidural infusion. However, the rapid delivery speed used with an epidural bolus is more likely to increase intracranial pressure. We compared the effects of lumbar epidural bolus versus continuous infusion epidural analgesia on intracranial pressure in children using optic nerve sheath diameter as a marker. We randomly assigned 40 paediatric patients to bolus or infusion groups. Epidural analgesia (0.15% ropivacaine 0.3 ml·kg−1) was administered via bolus or infusion. Ultrasonography was used to measure the optic nerve sheath diameter before (T0), at 3 min (T1), 10 min (T2), and 70 min (T3) after starting the pump. There were statistically significant between-group differences in optic nerve sheath diameter over time (PGroup x Time = 0.045). From T0–T3, the area under the curve values were similar between the two groups. Although there were differences in the patterns of optic nerve sheath diameter change according to the delivery mode, the use of lumbar epidural bolus did not increase the risk of intracranial pressure increase over that of continuous infusion. Further research is needed to investigate intracranial pressure changes after continuous application of each delivery mode.
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Affiliation(s)
- Bora Lee
- Department of Anaesthesiology and Pain Medicine, Severance Hospital and Anaesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea
| | - Jae Hoon Lee
- Department of Anaesthesiology and Pain Medicine, Severance Hospital and Anaesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea
| | - Min-Soo Kim
- Department of Anaesthesiology and Pain Medicine, Severance Hospital and Anaesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea
| | - Seon Ju Kim
- Department of Anaesthesiology and Pain Medicine, Severance Hospital and Anaesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea
| | - Jeehyun Song
- Department of Anaesthesiology and Pain Medicine, Severance Hospital and Anaesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea
| | - Do-Hyeong Kim
- Department of Anaesthesiology and Pain Medicine, Anaesthesia and Pain Research Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, Republic of Korea
| | - Yong Seon Choi
- Department of Anaesthesiology and Pain Medicine, Severance Hospital and Anaesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea.
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20
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Darás Orenga MÁ, Gellida Vilarroig M, Vives Piqueres L, Sanz García M, Inoges RT, Nicolau Gozalbo A. Comparative study of different epidural infusion sets at maximum speeds for labor analgesia. ACTA ACUST UNITED AC 2020; 67:179-186. [PMID: 31926658 DOI: 10.1016/j.redar.2019.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 07/21/2019] [Accepted: 11/05/2019] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The higher injection pressure obtained with epidural boluses give greater anaesthetic spread, and therefore better sensory block. Therefore, it stands to reason that anaesthetic administered at greater injection pressure and a higher flow rate would spread to a higher sensory level. OBJECTIVE Our aim was to compare the sensory level reached with the high flow. and standard flow set at maximum rates. MATERIAL AND METHODS We included 73 primiparous women who requested epidural analgesia for labour using programmed intermittent epidural boluses of 0.1% ropivacaine at a flow rate of 10ml/h and 2 ug/ml fentanyl plus patient-controlled epidural analgesia. The boluses were administered with a standard (250ml/h) or high-flow (500ml/h) infusion set, according to the usual clinical practice of each anaesthesiologist. The primary objective was to evaluate the sensory level reached. Secondary objectives were pain on a visual analogue scale, motor block measured on the modified Bromage scale, and anaesthesia consumption in terms of rescue analgesia (patient-controlled epidural analgesia) and anaesthesiologist-administered boluses. RESULTS The median maximum sensory level reached was T9 in the high flow group and T7 in the standard flow group; this difference was statistically significant (p=.0002). There were no significant differences in visual analogue scale, Bromage or rescue analgesia between groups. CONCLUSION Our results show that the high flow set does not offer benefits. The use of such sets need to be evaluated due to their higher cost.
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Affiliation(s)
- M Á Darás Orenga
- Servicio de Anestesiología, Reanimación y Terapéutica del dolor, Hospital Universitario La Plana Villarreal, Castellón, España.
| | - M Gellida Vilarroig
- Servicio de Anestesiología, Reanimación y Terapéutica del dolor, Hospital General Universitario de Castellón, Castellón, España
| | - L Vives Piqueres
- Servicio de Anestesiología, Reanimación y Terapéutica del dolor, Hospital Universitario La Plana Villarreal, Castellón, España
| | - M Sanz García
- Servicio de Anestesiología, Reanimación y Terapéutica del dolor, Hospital Arnau de Vilanova
| | - R T Inoges
- Servicio de Anestesiología, Reanimación y Terapéutica del dolor, Hospital Universitario La Plana Villarreal, Castellón, España
| | - A Nicolau Gozalbo
- Servicio de Anestesiología, Reanimación y Terapéutica del dolor, Hospital Universitario La Plana Villarreal, Castellón, España
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21
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Cole J, Hughey S. Epidural contrast spread in the porcine model: bolus versus infusion. Reg Anesth Pain Med 2019; 45:rapm-2019-101138. [PMID: 31796501 DOI: 10.1136/rapm-2019-101138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 11/19/2019] [Accepted: 11/20/2019] [Indexed: 11/03/2022]
Affiliation(s)
- Jacob Cole
- Anesthesiology and Pain Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
| | - Scott Hughey
- Anesthesiology and Pain Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
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22
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Krawczyk P, Piwowar P, Sałapa K, Lonc T, Andres J. Do Epidural Catheter Size and Flow Rate Affect Bolus Injection Pressure in Different Programmed Intermittent Epidural Bolus Regimens? An In Vitro Study. Anesth Analg 2019; 129:1587-1594. [PMID: 31743179 DOI: 10.1213/ane.0000000000003650] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The optimal programmed intermittent epidural bolus regimen for labor analgesia remains unknown. Some studies indicate that better drug spread in the epidural space results from greater injection pressure; however, there is a lack of data regarding the maximum pressure generated by epidural bolus injection using different catheters and flow rates. METHODS We evaluated the flow and pressure characteristics of 11 commonly used epidural catheters combined with 3 different infusion pumps that deliver epidural infusions according to the programmed intermittent epidural bolus regimen. Pressure changes were measured over time at flow rates of 100, 250, and 400 mL·hour and with a bolus volume of 10 mL. To account for repeated measures, linear mixed models were used. Features were selected with a backward stepwise procedure continued until only statistically significant variables were left in the model. RESULTS We performed 660 measurements. The mean maximal pressure generated during bolus injection ranged from 86 to 863 mm Hg for different flow rates and catheter designs. The interaction between flow rate and catheter gauge resulted in 1.31, 1.65, and 2.00 mm Hg of pressure increase for 18G, 19G, and 20G catheters, respectively, per 1 mL·hour of increased flow rate (P< .001). Analyses including wire-reinforced catheters revealed a 1.16, 1.76, and 2.36 mm Hg pressure increase for 18G, 19G, and 20G catheters, respectively, per 1 mL·hour of increased flow rate (P< .001). In some cases, it triggered the occlusion pump alarm. CONCLUSIONS Significant differences were observed in the in vitro maximum pressure value among the various catheter and flow rate combinations with a higher pressure value for wire-reinforced catheters used in the study. The optimal flow rate and epidural catheter combination may allow for delivery of the bolus with high flow rate without triggering the occlusion alarm.
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Affiliation(s)
- Paweł Krawczyk
- From the Department of Anesthesiology and Intensive Care Medicine, Jagiellonian University Medical College, Cracow, Poland
| | - Piotr Piwowar
- Department of Measurements and Electronic, AGH University of Science and Technology, Cracow, Poland
| | - Kinga Sałapa
- Department of Bioinformatics and Telemedicine, Jagiellonian University Medical College, Cracow, Poland
| | - Tomasz Lonc
- From the Department of Anesthesiology and Intensive Care Medicine, Jagiellonian University Medical College, Cracow, Poland
| | - Janusz Andres
- From the Department of Anesthesiology and Intensive Care Medicine, Jagiellonian University Medical College, Cracow, Poland
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Kwak KH. Need for an optimal regimen of programmed intermittent epidural bolus administration for maintenance of labor analgesia. Korean J Anesthesiol 2019; 72:407-408. [PMID: 31591857 PMCID: PMC6781211 DOI: 10.4097/kja.19357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 08/21/2019] [Indexed: 11/19/2022] Open
Affiliation(s)
- Kyung-Hwa Kwak
- Department of Anesthesiology and Pain Medicine, Kyungpook National University School of Medicine, Daegu, Korea
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Rodríguez González IP, Espinosa Domínguez E, Quesada García C, Rodríguez Chimeno Á, Borges R. Comparison between different epidural analgesia modalities for labor. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2019; 66:417-424. [PMID: 31138442 DOI: 10.1016/j.redar.2019.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 02/28/2019] [Accepted: 03/04/2019] [Indexed: 06/09/2023]
Abstract
INTRODUCTION In recent years new modalities of epidural analgesia maintenance (EA) have been introduced. OBJECTIVE The objective of this study is to compare different modalities of EA maintenance for childbirth relating the time of expulsive and dilatation, motor blockade and delivery instrumentation (caesarean section, sucker, forceps, eutocic delivery or non-instrumented delivery). MATERIAL AND METHODS Patients admitted for labor in the University Hospital Nuestra Señora de Candelaria between January 2013 and December 2015 were included. Independent modalities of EA, continuous infusion (CI), continuous infusion plus analgesia patient controlled epidural analgesia were determined as independent variables (CI+PCEA) and intermittent programmed epidural boluses plus patient controlled epidural analgesia (PIEB+PCEA). RESULTS There are no differences in expulsive time or dilation. There is a difference in the type of instrumentation, caesarean section, sucker, forceps, eutocic delivery or non-instrumented delivery (P>.05), with the percentage of eutocic deliveries in PIEB+PCEA of 66 versus 60 in CI and 65 in CI+PCEA. The percentage of caesarean sections was 23 in CI, in CI+PCEA and PIEB+PCEA of 17. CI increases by 27% the possibility of instrumented deliveries respect to PIEB+PCEA, there is no difference between CI+PCEA and PIEB+PCEA. The motor blockade at 60 and 90minutes reaches lower values with PIEB+PCEA with an average of 0 and a range of 0-1, compared to CI+PCEA 0 (0-4). Satisfaction with CI+PCEA ranges from 2-10 and with PIEB+PCEA 0-10. CONCLUSION It is possible to say that PIEB+PCEA is associated with higher frequency of non-instrumented deliveries. The possibility of instrumented deliveries increases with CI versus PIEB+PCEA. There is less motor block with PIEB+PCEA than with CI+PCEA. There are no differences in time of dilatation, expulsion, or patient satisfaction.
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Affiliation(s)
- I P Rodríguez González
- Servicio de Anestesiología y Reanimación, Hospital Universitario Nuestra Señora de Candelaria, Tenerife, España.
| | - E Espinosa Domínguez
- Servicio de Anestesiología y Reanimación, Hospital Universitario Nuestra Señora de Candelaria, Tenerife, España
| | - C Quesada García
- Servicio de Anestesiología y Reanimación, Hospital Universitario Nuestra Señora de Candelaria, Tenerife, España
| | - Á Rodríguez Chimeno
- Servicio de Anestesiología y Reanimación, Hospital Universitario Nuestra Señora de Candelaria, Tenerife, España
| | - R Borges
- Cátedra de Farmacología, la Universidad de la Laguna, Tenerife, España
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Short AJ, Ghosh M, Jin R, Chan VWS, Chin KJ. Intermittent bolus versus continuous infusion popliteal sciatic nerve block following major foot and ankle surgery: a prospective randomized comparison. Reg Anesth Pain Med 2019:rapm-2018-100301. [PMID: 31570495 DOI: 10.1136/rapm-2018-100301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 09/07/2019] [Accepted: 09/18/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND OBJECTIVES Foot and ankle surgery is associated with severe pain that can be reduced with continuous popliteal sciatic nerve block. We tested the hypothesis that programmed intermittent bolus (PIB) delivery of local anesthetic provides superior analgesia to a continuous infusion (CI) regimen. METHODS 60 patients undergoing major foot and ankle surgery were randomized to receive PIB (10 mL of ropivacaine 0.2% every 2 hours) or CI (5 mL/hour) continuous popliteal sciatic nerve block with patient-controlled regional analgesia (5 mL every 30 min as needed) provided for all. Primary outcome was the average of static and dynamic numerical rating scale (NRS) pain scores through 48 hours. Secondary outcomes included rest and movement NRS pain scores at different timepoints, opioid consumption, local anesthetic consumption, intensity of sensory and motor block, patient satisfaction and the incidence of opioid-related side effects. RESULTS There was no significant difference in the primary outcome of average NRS pain score through 48 hours, opioid consumption or the volume of local anesthetic administered. Patients in group PIB had significantly decreased strength of toe dorsiflexion at 6 hours (p=0.007) and 12 hours (p=0.001) and toe plantarflexion at 12 hours (p=0.004). Patient satisfaction and the incidence of side effects was similar between groups. CONCLUSIONS Both CI and PIB regimens provided excellent analgesia, low opioid consumption and high patient satisfaction. While there was no difference in analgesic outcomes, PIB dosing resulted in a more profound motor block. TRIAL REGISTRATION NUMBER NCT02707874.
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Affiliation(s)
- Anthony James Short
- Department of Anaesthetics, Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK
| | - Meela Ghosh
- Department of Anaesthetics, Freeman Hospital, Newcastle upon Tyne, Newcastle upon Tyne, UK
| | - Rongyu Jin
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Vincent W S Chan
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Ki Jinn Chin
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
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Lee MJ, Hung CJ. The benefits of radiological imaging for postoperative orthostatic headache: a case report. BMC Med Imaging 2019; 19:61. [PMID: 31390998 PMCID: PMC6686484 DOI: 10.1186/s12880-019-0365-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 07/31/2019] [Indexed: 11/17/2022] Open
Abstract
Background Traditionally, the diagnosis of post-dural puncture headache (PDPH) relied upon the patient’s history regarding dural puncture and symptoms, such as orthostatic headache. However, such evidence may not always be reliable or specific. We report an unexpected diagnosis with spontaneous intracranial hypotension (SIH), which was confirmed upon examination of Magnetic Resonance (MR) images in a patient who was initially suspected to have PDPH because he had recently undergone a uncertain dural puncture. Case presentation A 45-year-old man had undergone a thoracic epidural catheter insertion for perioperative analgesia prior to general anesthesia induction. Due to intermittent dripping of fluid while the epidural needle was being advanced, a dural puncture was suspected. The patient complained of an orthostatic headache after recovery from surgery, therefore a PDPH was suspected. MR images revealed signs of SIH: dural sinus engorgement, contrast enhancement along the neural sleeves of the left C6–7, bilateral C7-T1, T1–2, T2–3, T3–4, T4–5, and T5–6. Computed tomography-guided epidural blood patching (EBP) was performed the following day, with the patient experiencing immediate relief of the headache. Conclusion The benefits of radiological imaging in this case included confirming the correct diagnosis, guiding the accurate level and proper approach of EBP, distinguishing the epidural space from the intrathecal space, and ultimately increasing the likelihood of successful EBP.
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Affiliation(s)
- Mu-Jung Lee
- Department of Anesthesiology, Shin Kong Wu Ho-Su Memorial Hospital, No.95, Wenchang Rd., Shilin Dist, Taipei City, 111, Taiwan, Republic of China
| | - Chih-Jen Hung
- Department of Anesthesiology, Taichung Veterans General Hospital, No.1650, Sec. 4, Taiwan Blvd., Xitun Dist, Taichung City, 407, Taiwan, Republic of China.
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Diez-Picazo LD, Guasch E, Brogly N, Gilsanz F. Is breakthrough pain better managed by adding programmed intermittent epidural bolus to a background infusion during labor epidural analgesia? A randomized controlled trial. Minerva Anestesiol 2019; 85:1097-1104. [PMID: 31213040 DOI: 10.23736/s0375-9393.19.13470-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Breakthrough pain (BTP) is a common problem during labor analgesia. Programmed intermittent epidural bolus (PIEB) has demonstrated superior to background epidural infusion (BEI) concerning BTP, but the effect of combining both modes remains unknown. We hypothesized that this combination could reduce BTP incidence. METHODS Nulliparous parturients with early cervical dilation were randomized to receive 5 mL/h BEI of levobupivacaine 0.125% plus fentanyl 1.45 µg/mL (standard group) or 5 mL/h BEI + 10 mL/h PIEB (PIEB group). In case of BTP, patient-controlled epidural analgesia (PCEA) boluses of 10 mL (20-min lockout interval) were administered. If PCEA was insufficient, a 10-mL clinician bolus was delivered. The primary endpoint was the percentage of parturients who required supplementary epidural boluses. RESULTS One hundred and twenty women were recruited. Eighty-nine percent of parturients required supplementary boluses in standard group versus 30% in PIEB group (RR=3.07; 95% CI: 1.99-4.76; P<0.001). Adding PIEB prevented BTP in 70% of cases. Duration of effective analgesia was longer in PIEB than in standard group (P=0.003). Supplementary boluses were decreased (P<0.001), while local anesthetic consumption increased (P<0.001) by PIEB addition. Sensory-motor block, mode of delivery, maternal satisfaction and neonatal outcomes were equally distributed in both groups. CONCLUSIONS Adding PIEB to BEI+PCEA improved labor analgesia by significantly reducing the needs of rescue analgesia and prolonging the duration of effective analgesia. This combination provoked a higher consumption of local anesthetic with no detected clinical consequences.
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Affiliation(s)
- Luis D Diez-Picazo
- Department of Anesthesia, Critical Care and Pain Treatment, La Paz University Hospital, Madrid, Spain -
| | - Emilia Guasch
- Department of Anesthesia, Critical Care and Pain Treatment, La Paz University Hospital, Madrid, Spain
| | - Nicolas Brogly
- Department of Anesthesia, Critical Care and Pain Treatment, La Paz University Hospital, Madrid, Spain
| | - Fernando Gilsanz
- Department of Anesthesia, Critical Care and Pain Treatment, La Paz University Hospital, Madrid, Spain
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Jagannathan R, Niesen AD, D'Souza RS, Johnson RL. Intermittent bolus versus continuous infusion techniques for local anesthetic delivery in peripheral and truncal nerve analgesia: the current state of evidence. Reg Anesth Pain Med 2019; 44:447-451. [DOI: 10.1136/rapm-2018-100082] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 12/16/2018] [Accepted: 12/27/2018] [Indexed: 12/15/2022]
Abstract
Manually delivered intermittent bolus (MIB) and programmable intermittent bolus (PIB), alternatives to continuous infusion (CI), involve administering a set volume of solution at a set interval of time. The benefits of intermittent bolus techniques in truncal and peripheral nerve blockade (TPNB) are unclear, and studies have largely demonstrated conflicting results. Using MEDLINE, Embase, Google Scholar, and the Cochrane Library, we conducted an evidenced-based review of published randomized controlled trials comparing intermittent bolus and CI methods in TPNB. In total, 13 randomized controlled trials were identified and evaluated. Outcomes data addressed in these studies included assessments of pain, opioid and local anesthetic consumption, patient satisfaction, adverse events, and physical therapy metrics. The overall quality of current evidence was found to be low given the small sample sizes, heterogeneity of data, and the variations in intermittent bolus techniques between studies. At this time, we found limited supportive data to endorse MIB or PIB over CI in TPNB. While unable to provide data-driven conclusions for local anesthetic delivery methods at this time, we propose that future studies and quantitative analysis between techniques should be on an anatomic, site-specific basis, with greater focus on evaluation of opioid use, adverse events, patient satisfaction, and rehabilitative metrics.
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Wiesmann T, Hoff L, Prien L, Torossian A, Eberhart L, Wulf H, Feldmann C. Programmed intermittent epidural bolus versus continuous epidural infusion for postoperative analgesia after major abdominal and gynecological cancer surgery: a randomized, triple-blinded clinical trial. BMC Anesthesiol 2018; 18:154. [PMID: 30376810 PMCID: PMC6208106 DOI: 10.1186/s12871-018-0613-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 10/09/2018] [Indexed: 11/24/2022] Open
Abstract
Background Continuous epidural infusion (CEI) is the standard application setting for epidural infusion. A new mode, the programmed intermittent epidural bolus (PIEB) technique, showed reduced local anesthetic (LA) consumption and improved analgesia in obstetric analgesia. Goal of this trial was to evaluate the effects of PIEB versus CEI [combined with patient-controlled bolus (PCEA)] on LA consumption and pain scorings in major abdominal cancer surgery. Methods Following ethical approval, patients scheduled for major abdominal cancer surgery under general anesthesia in combination with epidural analgesia were randomized to receive either a PIEB mode of 6 mL/h or a CEI mode set at 6 mL/h of ropivacaine 0.2%, both combined with a PCEA mode set at a 4 mL bolus. LA consumptions and pain scorings were documented until the second postoperative evening. Results Eighty-four datasets were analyzed (CEI: n = 40, PIEB: n = 44). Regarding the primary endpoint, cumulative LA PCEA bolus volumes until day 2 differed significantly between the groups [PIEB 10 mL (2–28 mL) versus CEI, 28 mL (12–64 mL), median (25th–75th percentiles), p = 0.002]. Overall, LA consumption volumes were significantly lower in the PIEB group versus in the CEI group [PIEB: 329 mL (291–341 mL) vs. CEI: 350 mL (327–381 mL), p = 0.003]. Pain scores were comparable at each time point. Conclusions This trial demonstrates reduced needs for PCEA bolus in the PIEB group. There were no clinically relevant benefits regarding morphine consumption, pain scorings, or other secondary outcome parameters. Trial registration This study has been registered retrospectively in the ClinicalTrials.gov registry (NCT03378804), date of registration: December, 20th 2017. Electronic supplementary material The online version of this article (10.1186/s12871-018-0613-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Thomas Wiesmann
- Department of Anesthesiology and Intensive Care Medicine, Philipps University Marburg, University Hospital Marburg (UKGM - Campus Marburg), Baldinger Strasse, 35033, Marburg, Germany.
| | - Lilli Hoff
- Department of Anesthesiology and Intensive Care Medicine, Philipps University Marburg, University Hospital Marburg (UKGM - Campus Marburg), Baldinger Strasse, 35033, Marburg, Germany
| | - Lara Prien
- Department of Anesthesiology and Intensive Care Medicine, Philipps University Marburg, University Hospital Marburg (UKGM - Campus Marburg), Baldinger Strasse, 35033, Marburg, Germany
| | - Alexander Torossian
- Department of Anesthesiology and Intensive Care Medicine, Philipps University Marburg, University Hospital Marburg (UKGM - Campus Marburg), Baldinger Strasse, 35033, Marburg, Germany
| | - Leopold Eberhart
- Department of Anesthesiology and Intensive Care Medicine, Philipps University Marburg, University Hospital Marburg (UKGM - Campus Marburg), Baldinger Strasse, 35033, Marburg, Germany
| | - Hinnerk Wulf
- Department of Anesthesiology and Intensive Care Medicine, Philipps University Marburg, University Hospital Marburg (UKGM - Campus Marburg), Baldinger Strasse, 35033, Marburg, Germany
| | - Carsten Feldmann
- Department of Anesthesiology and Intensive Care Medicine, Philipps University Marburg, University Hospital Marburg (UKGM - Campus Marburg), Baldinger Strasse, 35033, Marburg, Germany
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Satomi S, Kakuta N, Murakami C, Sakai Y, Tanaka K, Tsutsumi YM. The Efficacy of Programmed Intermittent Epidural Bolus for Postoperative Analgesia after Open Gynecological Surgery: A Randomized Double-Blinded Study. BIOMED RESEARCH INTERNATIONAL 2018; 2018:6297247. [PMID: 29862280 PMCID: PMC5976943 DOI: 10.1155/2018/6297247] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 03/27/2018] [Accepted: 04/10/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND It is well known that the programmed intermittent epidural bolus (PIEB) technique effectively provides epidural anesthesia in labor. This randomized double-blind trial compared the postoperative analgesic efficacy of PIEB with that of continuous epidural infusion (CEI) in patients undergoing gynecological surgery under combined general-epidural anesthesia. METHODS Patients undergoing open gynecological surgery under combined general-epidural anesthesia were randomized at a 1 : 1 ratio to receive PIEB or CEI. In the PIEB group, the pump delivered 4 mL ropivacaine 0.2% plus fentanyl 2 μg/mL every hour. In the CEI group, the pump delivered the same solution at a rate of 4 mL/h. In both groups, additional 4 mL boluses of ropivacaine 0.2% plus fentanyl 2 μg/mL were provided, when necessary, by patient-controlled epidural analgesia after surgery. The primary outcome was the total ropivacaine dose 40 hours after surgery. The secondary outcomes were the number of PCEA boluses and postoperative pain (evaluated on an 11-point numerical rating scale) 3, 24, and 48 hours after surgery. RESULTS In total, 57 patients were randomized (n = 28 and 29 in the PIEB and CEI groups, resp.). The two groups differ significantly in terms of the total ropivacaine dose 40 hours after surgery (mean (standard deviation): 155.38 (4.55) versus 159.73 (7.87) mL, P = 0.016). Compared to the CEI group, the PIEB group had significantly lower numerical rating scale scores 3 hours (median [lower-upper quartiles]: 0 [0-0.5] versus 3 [0-5.5], P = 0.002), 24 hours (1 [0-2] versus 3 [1-4], P = 0.003), and 48 hours (1 [0-2] versus 2 [2-3.5], P = 0.002) after surgery. CONCLUSION PIEB was better than CEI in terms of providing postoperative analgesia after open gynecological surgery under combined general-epidural anesthesia.
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Affiliation(s)
- Shiho Satomi
- Department of Anesthesiology, Tokushima University, Kuramoto, Tokushima, Japan
| | - Nami Kakuta
- Department of Anesthesiology, Tokushima University, Kuramoto, Tokushima, Japan
| | - Chiaki Murakami
- Department of Anesthesiology, Tokushima University, Kuramoto, Tokushima, Japan
| | - Yoko Sakai
- Department of Anesthesiology, Tokushima University, Kuramoto, Tokushima, Japan
| | - Katsuya Tanaka
- Department of Anesthesiology, Tokushima University, Kuramoto, Tokushima, Japan
| | - Yasuo M. Tsutsumi
- Department of Anesthesiology, Tokushima University, Kuramoto, Tokushima, Japan
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Lange EMS, Wong CA, Fitzgerald PC, Davila WF, Rao S, McCarthy RJ, Toledo P. Effect of Epidural Infusion Bolus Delivery Rate on the Duration of Labor Analgesia. Anesthesiology 2018; 128:745-753. [DOI: 10.1097/aln.0000000000002089] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Abstract
Background
Programmed intermittent boluses of local anesthetic have been shown to be superior to continuous infusions for maintenance of labor analgesia. High-rate epidural boluses increase delivery pressure at the catheter orifice and may improve drug distribution in the epidural space. We hypothesized that high-rate drug delivery would improve labor analgesia and reduce the requirement for provider-administered supplemental boluses for breakthrough pain.
Methods
Nulliparous women with a singleton pregnancy at a cervical dilation of less than or equal to 5 cm at request for neuraxial analgesia were eligible for this superiority-design, double-blind, randomized controlled trial. Neuraxial analgesia was initiated with intrathecal fentanyl 25 μg. The maintenance epidural solution was bupivacaine 0.625 mg/ml with fentanyl 1.95 μg/ml. Programmed (every 60 min) intermittent boluses (10 ml) and patient controlled bolus (5 ml bolus, lockout interval: 10 min) were administered at a rate of 100 ml/h (low-rate) or 300 ml/h (high-rate). The primary outcome was percentage of patients requiring provider-administered supplemental bolus analgesia.
Results
One hundred eight women were randomized to the low- and 102 to the high-rate group. Provider-administered supplemental bolus doses were requested by 44 of 108 (40.7%) in the low- and 37 of 102 (36.3%) in the high-rate group (difference –4.4%; 95% CI of the difference, –18.5 to 9.1%; P = 0.67). Patient requested/delivered epidural bolus ratio and the hourly bupivacaine consumption were not different between groups. No subject had an adverse event.
Conclusions
Labor analgesia quality, assessed by need for provider- and patient-administered supplemental analgesia and hourly bupivacaine consumption was not improved by high-rate epidural bolus administration.
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Affiliation(s)
- Elizabeth M. S. Lange
- From the Department of Anesthesiology (E.M.S.L., P.C.F., W.F.D., S.R., R.J.M., P.T.) and the Center for Healthcare Studies (P.T.), Northwestern University Feinberg School of Medicine, Chicago, Illinois; and the Department of Anesthesia, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa (C.A.W.)
| | - Cynthia A. Wong
- From the Department of Anesthesiology (E.M.S.L., P.C.F., W.F.D., S.R., R.J.M., P.T.) and the Center for Healthcare Studies (P.T.), Northwestern University Feinberg School of Medicine, Chicago, Illinois; and the Department of Anesthesia, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa (C.A.W.)
| | - Paul C. Fitzgerald
- From the Department of Anesthesiology (E.M.S.L., P.C.F., W.F.D., S.R., R.J.M., P.T.) and the Center for Healthcare Studies (P.T.), Northwestern University Feinberg School of Medicine, Chicago, Illinois; and the Department of Anesthesia, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa (C.A.W.)
| | - Wilmer F. Davila
- From the Department of Anesthesiology (E.M.S.L., P.C.F., W.F.D., S.R., R.J.M., P.T.) and the Center for Healthcare Studies (P.T.), Northwestern University Feinberg School of Medicine, Chicago, Illinois; and the Department of Anesthesia, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa (C.A.W.)
| | - Suman Rao
- From the Department of Anesthesiology (E.M.S.L., P.C.F., W.F.D., S.R., R.J.M., P.T.) and the Center for Healthcare Studies (P.T.), Northwestern University Feinberg School of Medicine, Chicago, Illinois; and the Department of Anesthesia, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa (C.A.W.)
| | - Robert J. McCarthy
- From the Department of Anesthesiology (E.M.S.L., P.C.F., W.F.D., S.R., R.J.M., P.T.) and the Center for Healthcare Studies (P.T.), Northwestern University Feinberg School of Medicine, Chicago, Illinois; and the Department of Anesthesia, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa (C.A.W.)
| | - Paloma Toledo
- From the Department of Anesthesiology (E.M.S.L., P.C.F., W.F.D., S.R., R.J.M., P.T.) and the Center for Healthcare Studies (P.T.), Northwestern University Feinberg School of Medicine, Chicago, Illinois; and the Department of Anesthesia, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa (C.A.W.)
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Zakus P, Arzola C, Bittencourt R, Downey K, Ye XY, Carvalho JC. Determination of the optimal programmed intermittent epidural bolus volume of bupivacaine 0.0625% with fentanyl 2 μg.ml -1 at a fixed interval of forty minutes: a biased coin up-and-down sequential allocation trial. Anaesthesia 2017; 73:459-465. [PMID: 29197080 DOI: 10.1111/anae.14159] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2017] [Indexed: 12/01/2022]
Abstract
The optimum time interval for 10 ml boluses of bupivacaine 0.0625% + fentanyl 2 μg.ml-1 as part of a programmed intermittent epidural bolus regimen has been found to be 40 min. This regimen was shown to be effective without the use of supplementary patient-controlled epidural analgesia boluses in 90% of women during the first stage of labour, although with a rate of sensory block to ice above T6 in 34% of women. We aimed to determine the optimum programmed intermittent epidural bolus volume at a 40 min interval to provide effective analgesia in 90% of women (EV90 ) during the first stage of labour, without the use of patient-controlled epidural analgesia. We performed a prospective double-blind dose-finding study using the biased coin up-and-down sequential allocation method in 40 women. The estimated EV90 was 11.0 (95%CI 10.0-11.7) ml with the isotonic regression method and 10.7 (95%CI 10.3-11.0) ml with the truncated Dixon and Mood method. Overall, 18 women had a sensory block above T6, and 37 women exhibited no motor block. No women required treatment for hypotension. In conclusion, it is not possible to reduce the programmed intermittent epidural bolus volume from 10 ml, used in our current regimen, without compromising the quality of analgesia. Using this regimen, a high proportion of women will develop a sensory block above T6.
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Affiliation(s)
- P Zakus
- Department of Anesthesia and Pain Management, Micare Research Centre, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - C Arzola
- Department of Anesthesia and Pain Management, Micare Research Centre, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - R Bittencourt
- Department of Anesthesia and Pain Management, Micare Research Centre, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - K Downey
- Department of Anesthesia and Pain Management, Micare Research Centre, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - X Y Ye
- Department of Pediatrics, Micare Research Centre, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - J C Carvalho
- Department of Anesthesia and Pain Management, Micare Research Centre, Mount Sinai Hospital, University of Toronto, Toronto, Canada
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Steagall PVM, Simon BT, Teixeira Neto FJ, Luna SPL. An Update on Drugs Used for Lumbosacral Epidural Anesthesia and Analgesia in Dogs. Front Vet Sci 2017; 4:68. [PMID: 28553642 PMCID: PMC5427076 DOI: 10.3389/fvets.2017.00068] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 04/20/2017] [Indexed: 12/20/2022] Open
Abstract
This review aims to report an update on drugs administered into the epidural space for anesthesia and analgesia in dogs, describing their potential advantages and disadvantages in the clinical setting. Databases searched include Pubmed, Google scholar, and CAB abstracts. Benefits of administering local anesthetics, opioids, and alpha2 agonists into the epidural space include the use of lower doses of general anesthetics (anesthetic “sparing” effect), perioperative analgesia, and reduced side effects associated with systemic administration of drugs. However, the potential for cardiorespiratory compromise, neurotoxicity, and other adverse effects should be considered when using the epidural route of administration. When these variables are considered, the epidural technique is useful as a complementary method of anesthesia for preventive and postoperative analgesia and/or as part of a balanced anesthesia technique.
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Affiliation(s)
- Paulo V M Steagall
- Faculty of Veterinary Medicine, Department of Clinical Sciences, Université de Montréal, Saint-Hyacinthe, QC, Canada
| | - Bradley T Simon
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX, USA
| | - Francisco J Teixeira Neto
- Faculty of Veterinary Medicine and Animal Science, Department of Veterinary Surgery and Anaesthesiology, Universidade Estadual Paulista (UNESP), Botucatu, Brazil
| | - Stelio P L Luna
- Faculty of Veterinary Medicine and Animal Science, Department of Veterinary Surgery and Anaesthesiology, Universidade Estadual Paulista (UNESP), Botucatu, Brazil
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