Patient-controlled epidural analgesia in obstetrics

Patient-controlled Epidural Analgesia following Combined Spinal-epidural Analgesia in Labour: The Effects of Adding a Continuous Epidural Infusion

Patient-controlled epidural analgesia (PCEA) is used to maintain epidural analgesia following initial intrathecal analgesia. This trial investigated whether a continuous background infusion with PCEA provides superior analgesia to PCEA alone among patients who received combined spinal-epidural (CSE) analgesia during labour.

Eighty parturients were randomized to either PCEA alone (PCEA) or PCEA with a background infusion of ropivacaine 0.15% with sufentanil 0.75 μg/ml at 2 ml/h (PCEA+CEI). PCEA settings were a bolus of 4 ml of the same analgesic solution with a lockout interval of 15 minutes.

Significantly more patients in the PCEA group required at least one anaesthetist intervention for breakthrough pain (27 [71%] vs 10 [25%] in the PCEA+CEI group, P<0.05). Consumption of local anaesthetic (excluding manually administered boluses) was similar between the groups. If anaesthetist-administered boluses were included, more local anaesthetic was consumed by the PCEA group (47.1±19.4 mg vs 35.6±12.0 mg in the PCEA+CEI group, P<0.05).

We conclude that PCEA with a background infusion provides effective analgesia with less anaesthetist workload and reduced local anaesthetic consumption as compared with PCEA without a background infusion.

[Patient-controlled epidural analgesia for labour: in practice]

OBJECTIVES

Update on patient controlled epidural analgesia for labour.

STUDY DESIGN

Literature review of the recent data on local anaesthetics, additional analgesics and of publications on the various protocols used.

DATA COLLECTION

Pubmed database was checked with the following key words: PCEA, labour, opioids, clonidine. The abstracts of the ASA meetings from 2000 to 2005 were also examined.

RESULTS

Patient controlled epidural analgesia (PCEA) is the method of choice for optimal labour pain management. The advantages of this technique are numerous. Some of them are established: consistent reduction in overall local anathetic requirement, less motor blockade, safety of the technique and team workload reduction. A better adequacy with the analgesic requirements and an increase in overall patient satisfaction are frequently retrieved, provided that the choice of the analgesics and the PCEA parameters are adequately chosen.

CONCLUSION

The use of PCEA improves the quality of analgesic management offered to the parturients who are more and more willing to have a "more natural" childbirth. The PCEA gives them more autonomy and, in fine, enables them to better enjoy this unique event. The main barrier to a more widespread diffusion of PCEA in many institutions remains the financial issue, although a well-selected device and low cost disposables allow a reduction of indirect costs by decreasing care giver workload.

Parturient-controlled epidural analgesia during labour: bupivacaine vs. ropivacaine

In this randomised, controlled study, we compared the hourly dose requirement of ropivacaine 0.125% (group R, n = 16) with bupivacaine 0.125% (group B, n = 16) provided by demand-only (bolus 5 ml, lockout 10 min) parturient-controlled epidural analgesia during labour. The hourly dose requirement was comparable although group R had a lower successful to total demands ratio (p < 0.05). We also found that both groups were clinically indistinguishable in terms of pain relief and side-effects. No difference in maternal or fetal outcome was detected. We conclude that, at a concentration of 0.125%, ropivacaine and bupivacaine were equally effective when self-administered using this patient-controlled regimen.

Obstetric anesthesia practice in Canada

PURPOSE

To describe obstetric anesthesia in Canada as practiced in 1997: to identify practices at variance with the literature and the opinions of experts: and to identify questions for future research.

METHODS

In 1997, a detailed postal questionnaire asking about the practice of obstetric anesthesia was mailed to all 1,539 specialist anesthesiologist members of the Canadian Anaesthetists' Society residing in Canada. Nonresponders were mailed a second questionnaire three months later

RESULTS

There were 865 completed questionnaires returned for analysis (56.2%). Of these, 522 anesthesiologists practiced obstetric anesthesia (60.3%). The data were subdivided into those from anesthesiologists with a full or part-time university based practice (40.1%) and those from a community based practice (59.9%). University based and community-based anesthesiologists have very similar patterns of practice. Specific areas where anesthesia practice was different from current recommendations included: (1) information provided when obtaining consent for labour epidural analgesia, (2) use of opioids and local anesthetics for initiation of epidural analgesia, (3) use of coagulation testing in preeclampsia, (4) the common use of cutting spinal needles, (5) use of neuraxial morphine and nonsteroidal anti-inflammatory agents after Cesarean deliveries, (6) optimal treatment of neuraxial opioid side effects, (7) when to insert an endotracheal tube for general anesthesia after delivery, and (8) withdrawing epidural catheters through epidural needles.

CONCLUSIONS

This survey presents reference data on the practice of obstetric anesthesia in Canada in 1997. Anesthesiologists with university affiliation have very similar practices to those without university affiliations.

Patient-controlled epidural analgesia or continuous infusion: advantages and disadvantages of different modes of delivering epidural analgesia for labour

Patient-controlled epidural analgesia, intermittent top-up and continuous infusion are equally effective in providing epidural pain relief during labour. Patient-controlled epidural analgesia is associated with a significant reduction in hourly dose requirements when compared with continuous infusion, and by transferring the responsibility for epidural top-up, it offers the parturient the psychological benefit of being in control. For these reasons, patient-controlled epidural analgesia may become the method of choice for epidural pain relief during labour. However, the safety of the method needs to be documented more extensively, and the advantage of a reduction in hourly dose requirements needs to be visualized in terms of an improvement in labour or neonatal outcome. Moreover, the optimal dose, drug combination and settings still remain to be determined.

Motor blockade is reduced with ropivacaine 0.125% for parturient-controlled epidural analgesia during labour

PURPOSE

To compare the effect on the incidence of motor block by reducing the concentration of ropivacaine from 0.2% to 0.125% in parturient-controlled epidural analgesia (PCEA) for labour.

METHODS

Randomized, controlled and double-blind trial involving parturients in early labour who received demand-only PCEA regimen (bolus 5 ml, lockout 10 min, maximum volume per hour of 20 ml) with either 0.2% (R0.2 group, n = 25) or 0.125% (R0.125 group, n = 25) ropivacaine. Pain scores, the degree of motor block, the rate of drug consumption, the proportion of good to total PCEA demands and the overall satisfaction scores were documented.

RESULTS

Fewer parturients in the R0.125 group had lower limb motor block (4 vs. 11, P<0.05) although the degree of block was mild in all the affected parturients. The ratio of good to total PCEA demands was more favourable in the R0.2% group (median 0.72 vs. 0.52, P<0.01) although the hourly rate of ropivacaine consumption, the degree of pain relief, the maternal-fetal outcome and the overall satisfaction scores were similar.

CONCLUSION

Both ropivacaine 0.2% and 0.125% provided comparably effective analgesia but motor block occurred more commonly in the 0.2% group.

A survey of epidural analgesia for labour in the United Kingdom

A postal survey of obstetric units throughout the UK was conducted to obtain information about the provision of epidural analgesia for labour. Ninety per cent of units offered a 24-h epidural service and the average epidural rate was 24%. The most commonly administered epidural test dose was 3 ml of bupivacaine 0.5% and bupivacaine 0. 25% was most often used as the initial epidural top-up. Continuous infusions of low-dose bupivacaine and opioid mixtures were the most popular method of maintenance epidural analgesia. Twenty-four per cent of units offered combined spinal-epidural analgesia in addition to standard epidural analgesia. Midwives played a prominent role in the administration of epidural bolus top-ups and also in the assessment and maintenance of continuous epidural infusions.

Maternal satisfaction with labour analgesia

Satisfaction with childbirth is a multidimensional issue, of which analgesia is but one component. The importance of analgesia as a contribution to overall satisfaction has been recognized increasingly in the last 50 years, but improvement in quality of available analgesia has not always resulted in commensurate improvement in satisfaction. Satisfaction by its very nature has proved to be difficult both to define and to quantify, and no reliable standards of measurement have been accepted. Pain relief in childbirth is subject to many social and cultural modifiers, which continue to change. Control of pain rather than absolute amelioration is seen by many to provide greater satisfaction. Analgesia issues still do not figure prominently in the overall satisfaction of the birthing process for the vast majority of women, despite the availability of and demand for improved methods of relief. The interpersonal relationships established between patient and healthcare providers may ultimately be of more importance in the determination of satisfaction with management.

Alternating patient position following the induction of obstetric epidural analgesia does not affect local anaesthetic spread

To assess the influence of gravity on epidural-induced sensory blockade during the first stage of labour, 60 parturients were recruited to a randomized, controlled, single-blinded study. In all cases an epidural catheter was placed with the patient in the left lateral position. Thereafter, patients were randomized to one of three groups. In group supine (S), the epidural injection was performed in the supine position with a 15-20 degrees right flank elevation and the patient remained supine. In group left (L) patients remained in the left lateral position for 10 min after injection. In group left and right (L+R) patients remained in the left lateral position for 5 min and then assumed the right lateral position for 5 min. Thereafter, in groups L and L+R patients lay supine with a 15-20 degrees right flank elevation. All patients received 50 microg fentanyl in 10 ml of 0.125% bupivacaine. Ten minutes after injection loss of pinprick and temperature sensation were assessed and pain scores measured. Height of sensory deficit 10 min after injection and after maximal blockade were unaffected by patient position. In all cases maximal blockade reached T8 or higher. Time to maximal block was 14.7 +/- 2.3 min, 14.1 +/- 1.6 min and 13.9 +/- 1.5 min for groups L, L+R and S respectively. After maximal blockade, pain scores were significantly (P<0.0001) decreased in all groups, with no differences between them. We conclude that position immediately following local anaesthetic drug administration has little effect on onset and distribution of epidural analgesia.