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Sun Y, Ma W, Xu T, Zheng J. 90% effective volume of 0.1% ropivacaine combined with 0.4 µg/ml sufentanil for epidural labour analgesia with push pump at a rate of 400 mL/hr and a bolus interval of 30 min: a double-blind sequential dose-finding study. BMC Anesthesiol 2024; 24:295. [PMID: 39192175 PMCID: PMC11348673 DOI: 10.1186/s12871-024-02678-4] [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: 12/04/2023] [Accepted: 08/09/2024] [Indexed: 08/29/2024] Open
Abstract
BACKGROUND It was reported that either shorter programmed intermittent epidural bolus (PIEB) intervals or high-speed bolus can produce more extensive epidural spread. We hypothesized that a combination of shortened time interval and increased speed of epidural bolus might further improve analgesic effect and therefore reduce the hourly volume for epidural labour analgesia. METHODS This double-blind dose-finding study used a biased coin up-and-down sequential allocation method to determine the 90% effective bolus volume of ropivacaine combined with sufentanil while using the push pump at a rate of 400 mL/hr and interval of 30 min to provide effective analgesia without breakthrough pain. We used 0.1% ropivacaine with 0.4 µg/mL sufentanil, with bolus volumes ranging from 3 to 6 mL. The first patient was assigned a volume of 3 mL, and the remaining volumes were assigned according to the biased coin-up-and-down method. RESULTS The estimated 90% effective volume (EV90) of ropivacaine combined with sufentanil for epidural labour analgesia at a time interval of 30 min was 4.88 mL (95% confidence interval 4.83-5.38). CONCLUSIONS The optimum bolus volume of ropivacaine with sufentanil while using push pump at a time interval of 30 min is approximately 5 mL. It could probably further reduce the hourly bolus volume for epidural labour analgesia.
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Affiliation(s)
- Yuanqing Sun
- Department of Anaesthesiology, the International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China
- Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Wei Ma
- Department of Anaesthesiology, the International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China
- Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Tao Xu
- Department of Anaesthesiology, the International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
- Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China.
- Shanghai Municipal Key Clinical Specialty, Shanghai, China.
| | - Jing Zheng
- Department of Anaesthesiology, the International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
- Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China.
- Shanghai Municipal Key Clinical Specialty, Shanghai, China.
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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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Tan HS, Zeng Y, Qi Y, Sultana R, Tan CW, Sia AT, Sng BL, Siddiqui FJ. Automated mandatory bolus versus basal infusion for maintenance of epidural analgesia in labour. Cochrane Database Syst Rev 2023; 6:CD011344. [PMID: 37276327 PMCID: PMC10240562 DOI: 10.1002/14651858.cd011344.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Epidural analgesia is often used for pain relief during labour and childbirth, and involves administration of local anaesthetics (LA) into the epidural space resulting in sensory blockade of the abdomen, pelvis, and perineum. Epidural opioids are often co-administered to improve analgesia. Administration of epidural medications can be accomplished by basal infusion (BI) or automated mandatory bolus (AMB). With BI, medications are administered continuously, while AMB involves injecting medications at set time intervals. Patient-controlled epidural analgesia (PCEA) on top of AMB or BI enables patients to initiate additional boluses of epidural medications. The superior method of delivering epidural medications would result in lower incidence of pain requiring anaesthesiologist intervention (breakthrough pain). Also, it should be associated with lower incidence of epidural-related adverse effects including caesarean delivery, instrumental delivery (use of forceps or vacuum devices), prolonged duration of labour analgesia, and LA consumption. However, clear evidence of the superiority of one technique over the other is lacking. Also, differences in the initiation of epidural analgesia such as combined spinal-epidural (CSE) (medications given into the intrathecal space in addition to the epidural space) compared to epidural only, and medications used (types and doses of LA or opioids) may not have been accounted for in previous reviews. Our prior systematic review suggested that AMB reduces the incidence of breakthrough pain compared to BI with no significant difference in the incidence of caesarean delivery or instrumental delivery, duration of labour analgesia, and LA consumption. However, several studies comparing AMB and BI have been performed since then, and inclusion of their data may improve the precision of our effect estimates. OBJECTIVES To assess the benefits and harms of AMB versus BI for maintaining labour epidural analgesia in women at term. SEARCH METHODS We searched CENTRAL, Wiley Cochrane Library), MEDLINE, (National Library of Medicine), Embase(Elseiver), Web of Science (Clarivate), the WHO-ICTRP (World Health Organization) and ClinicalTrials.gov (National Library of Medicine) on 31 December 2022. Additionally, we screened the reference lists of relevant trials and reviews for eligible citations, and we contacted authors of included studies to identify unpublished research and ongoing trials. SELECTION CRITERIA We included all randomised controlled studies that compared bolus dosing AMB with continuous BI during epidural analgesia. We excluded studies of women in preterm labour, with multiple pregnancies, with fetal malposition, intrathecal catheters, those that did not use automated delivery of medications, and those where AMB and BI were combined. DATA COLLECTION AND ANALYSIS We used standard methodology for systematic review and meta-analysis described by Cochrane. Primary outcomes included: incidence of breakthrough pain requiring anaesthesiologist intervention; incidence of caesarean delivery; and incidence of instrumental delivery. Secondly, we assessed the duration of labour; hourly LA consumption in bupivacaine equivalents, maternal satisfaction after fetal delivery, and neonatal Apgar scores. The following subgroup analyses were chosen a priori: epidural alone versus CSE technique; regimens that used PCEA versus those that did not; and nulliparous versus combination of nulli- and multi-parous women. We used the GRADE system to assess the certainty of evidence associated with our outcome measures. MAIN RESULTS We included 18 studies of 4590 women, of which 13 enrolled healthy nulliparous women and five included healthy nulli- and multiparous women. All studies excluded women with preterm or complicated pregnancies. Techniques used to initiate epidural analgesia differed between the studies: seven used combined spinal epidural, 10 used epidural, and one used dural puncture epidural (DPE). There was also variation in analgesics used. Eight studies utilised ropivacaine with fentanyl, three used ropivacaine with sufentanil, two utilised levobupivacaine with sufentanil, one used levobupivacaine with fentanyl, and four utilised bupivacaine with fentanyl. Most of the studies were assessed to have low risk of randomisation, blinding, attrition, and reporting biases, except for allocation concealment where eight studies were assessed to have uncertain risk and three with high risk. Our results showed that AMB was associated with lower incidence of breakthrough pain compared to BI (risk ratio (RR) 0.71; 95% confidence interval (CI) 0.55 to 0.91; I2 = 57%) (16 studies, 1528 participants), and lower hourly LA consumption in bupivacaine equivalents (mean difference (MD) -0.84 mg/h; 95% CI -1.29 to -0.38, I2 = 87%) (16 studies, 1642 participants), both with moderate certainty. AMB was associated with an estimated reduction in breakthrough pain incidence of 29.1% (incidence 202 per 1000, 95% CI 157 to 259), and was therefore considered clinically significant. The incidence of caesarean delivery (RR 0.85; 95% CI 0.69 to 1.06; I2 = 0%) (16 studies, 1735 participants) and instrumental delivery (RR 0.85; 95% CI 0.71 to 1.01; I2 = 0%) (17 studies, 4550 participants) were not significantly, both with moderate certainty. There was no significant difference in duration of labour analgesia (MD -8.81 min; 95% CI -19.38 to 1.77; I2 = 50%) (17 studies, 4544 participants) with moderate certainty. Due to differences in the methods and timing of outcome measurements, we did not pool data for maternal satisfaction and Apgar scores. Results reported narratively suggest AMB may be associated with increased maternal satisfaction (eight studies reported increased satisfaction and six reported no difference), and all studies showed no difference in Apgar scores. WIth the exception of epidural alone versus CSE which found significant subgroup differences in LA consumption between AMB and BI, no significant differences were detected in the remaining subgroup analyses. AUTHORS' CONCLUSIONS Overall, AMB is associated with lower incidence of breakthrough pain, reduced LA consumption, and may improve maternal satisfaction. There were no significant differences between AMB and BI in the incidence of caesarean delivery, instrumental delivery, duration of labour analgesia, and Apgar scores. Larger studies assessing the incidence of caesarean and instrumental delivery are required.
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Affiliation(s)
- Hon Sen Tan
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yanzhi Zeng
- Department of Anaesthesiology, Singapore Health Services, Singapore, Singapore
| | - Yueyue Qi
- Duke-NUS Medical School, Singapore, Singapore
| | | | - Chin Wen Tan
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore, Singapore
| | - Alex T Sia
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore, Singapore
| | - Ban Leong Sng
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore, Singapore
| | - Fahad J Siddiqui
- Duke-NUS Medical School, National University Singapore, Singapore, Singapore
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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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Wydall S, Zolger D, Owolabi A, Nzekwu B, Onwochei D, Desai N. Comparison of different delivery modalities of epidural analgesia and intravenous analgesia in labour: a systematic review and network meta-analysis. Can J Anaesth 2023; 70:406-442. [PMID: 36720838 DOI: 10.1007/s12630-022-02389-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 09/15/2022] [Accepted: 09/16/2022] [Indexed: 02/02/2023] Open
Abstract
PURPOSE In labour, neuraxial analgesia is the standard in the provision of pain relief. However, the optimal mode of delivering epidural solution has not been determined, and some parturients may need an alternative to epidural analgesia. We sought to conduct a systematic review and network meta-analysis to compare continuous epidural infusion (CEI), programmed intermittent epidural bolus (PIEB), computer-integrated CEI, computer-integrated PIEB, patient-controlled epidural bolus (PCEA), fentanyl patient-controlled analgesia (PCA), and remifentanil PCA, either alone or in combination. METHODS We searched CENTRAL, CINAHL, Ovid Embase, Ovid Medline, and Web of Science for randomized controlled trials that included nulliparous and/or multiparous parturients in spontaneous or induced labour. The maintenance epidural solution had to include a low concentration local anesthetic and an opioid. Specific subgroups in the obstetric population such as preeclampsia were excluded. Network meta-analysis was performed with a frequentist method, and continuous and dichotomous outcomes are presented as mean differences and odds ratios, respectively, with 95% confidence intervals. RESULTS Overall, 73 trials were included. For the first coprimary outcome, the need for rescue analgesia, CEI was inferior to PIEB and PIEB + PCEA was superior to PCEA alone, with a low certainty of evidence given the presence of serious limitations and imprecision. The second coprimary outcome, the maternal satisfaction, was improved by PIEB + PCEA compared with CEI + PCEA and PCEA alone, with a low quality of evidence in view of the presence of serious limitations and imprecision. Fentanyl PCA increased the requirement for rescue analgesia and decreased maternal satisfaction relative to many methods of delivering epidural solution. In terms of secondary outcomes, PIEB increased analgesic efficacy compared with CEI, and PCEA reduced local anesthetic consumption at the expense of inferior analgesia relative to CEI and PIEB. PIEB + PCEA was superior to CEI + PCEA in regard to the pain score at 2 h and 4 h, consumption of local anesthetic, incidence of lower lower limb motor blockade and the rate of spontaneous vaginal delivery. Fentanyl and remifentanil PCA did not provide the same level of analgesia as all epidural methods, resulted in increasing analgesic ineffectiveness with time spent in labour, and predisposed to a higher incidence of side effects such as nausea and/or vomiting and sedation. Remifentanil PCA was superior to fentanyl PCA for analgesia at an early time point, and it increased the incidence of oxygen desaturation relative to other strategies of delivering epidural solution. CONCLUSIONS Opioid PCA did not provide the same level of analgesia as epidural methods with a higher incidence of side effects. We interpret the findings of our systematic review and network meta-analysis as suggesting PIEB + PCEA to be the optimal delivery mode of epidural solution. Nevertheless, the potential differing importance of the various maternal, fetal, and neonatal outcomes in determining which is optimal has not, to our knowledge, been elucidated yet. STUDY REGISTRATION PROSPERO (CRD42021254978); registered 27 May 2021.
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Affiliation(s)
- Simon Wydall
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK.
| | - Danaja Zolger
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Adetokunbo Owolabi
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Bernadette Nzekwu
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Desire Onwochei
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - Neel Desai
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK
- King's College London, London, UK
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Priyadarshini P, Verma R, Singh P, Gautam S, Singh D, Kohli M, Kabi S, Singh R. Comparison of Continuous Infusion of Ropivacaine and Fentanyl With Intermittent Bolus Doses of Ropivacaine and Fentanyl for Epidural Labor Analgesia: A Randomized Open-Label Study. Cureus 2022; 14:e28243. [PMID: 36158428 PMCID: PMC9489989 DOI: 10.7759/cureus.28243] [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] [Accepted: 08/15/2022] [Indexed: 11/05/2022] Open
Abstract
Background The purpose of this study was to compare the efficacy of continuous epidural infusion with intermittent bolus doses for labour analgesia using ropivacaine 0.2% and opioids. Methods In this study, 70 primigravida patients were randomly divided into two groups of 35 each. Both groups received a loading dose of 10ml of 0.2% ropivacaine and 1μg/ml fentanyl in 5ml incremental doses while monitoring blood pressure and heart rate. Subsequently, Group I received a continuous epidural infusion of 0.2% ropivacaine with fentanyl at 10ml/hr, while Group II received 10 ml of 0.2% ropivacaine with fentanyl in bolus form every hour manually, with the first dose given after one hour of the initial loading dose. A rescue bolus dose of 5ml of 0.2% ropivacaine was given in both groups when they complained of breakthrough pain (VAS score >3). An additional 5ml bolus dose was given in both groups at the time of crowning. The blood pressure, heart rate, and severity of pain using the visual analogue scale (VAS) were assessed. Total drug volume utilized, the number of bolus doses, duration of the first and second stage of labour, rate of instrumental delivery and cesarean section, and neonatal Apgar scores were also recorded. Results The total volume of drugs consumed and the number of boluses required for breakthrough pain were both significantly lower in Group II. There was a similar decrease in hemodynamic parameters (systolic blood pressure, diastolic blood pressure, and mean arterial pressure) from baseline in both the groups with no significant difference between them. The onset of analgesia was significantly faster in Group I with both groups achieving optimum analgesia (VAS ≤ 3) within 20 minutes of the loading dose. Maternal motor blockade scores, the duration of the first and second stage of labour, the rate of instrumental delivery, cesarean section, and neonatal Apgar scores, did not show any statistically significant difference between the two groups. Conclusion Both techniques, i.e. continuous epidural infusion and intermittent epidural boluses are effective for providing labour analgesia. But consumption of drugs and episodes of breakthrough pain was higher in the continuous infusion group (Group I).
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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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9
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Haidl F, Arne Rosseland L, Rørvik A, Dahl V. Programmed intermittent boluses vs continuous epidural infusion in labor using an adrenaline containing solution: A randomized trial. Acta Anaesthesiol Scand 2020; 64:1505-1512. [PMID: 32812652 DOI: 10.1111/aas.13689] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 06/16/2020] [Accepted: 07/27/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Traditionally, epidural analgesia has been maintained using a continuous infusion (CEI) with the addition of patient-controlled boluses (PCEA). In recent years, programmed intermittent boluses (PIEB) has emerged as an alternative showing better efficacy in randomized studies. In this study, the aim was to test PIEB + PCEA vs CEI + PCEA using an epidural solution containing adrenaline. METHODS In total, 150 nulliparous and multiparous laboring women were randomized to maintain epidural analgesia with either PIEB + PCEA (5 ml bolus every hour, 5 ml PCEA bolus lockout 20 minutes) or CEI + PCEA (5 ml/h, 5 ml PCEA bolus, lockout 20 minutes) using a solution of bupivacaine 1mg/ml, fentanyl 2 mcg/ml and adrenaline 2 mcg/ml. The primary outcome was total hourly consumption of the epidural solution. Secondary outcomes included hourly pain scores, motor block at 60 minutes and 10 cm cervical dilation, maternal satisfaction, and the need for anesthetist intervention and time to this intervention. RESULTS We found no differences in hourly drug consumption between the groups (mean 9.0 ml/h (SD 3.7) (CEI group) vs. 8.1 ml/h (SD 2.0) (PIEB group), P = .08). We found a significant difference in number of successfully administered PCEA boluses (mean no. 3.9 (SD 4.1) (CEI group) vs. 1.9 (SD 2.0) (PIEB group), P < .001). We found no significant differences in pain score, motor block, maternal satisfaction and the need for anesthetist intervention. CONCLUSION In this study, we found no clinically relevant differences using PIEB + PCEA compared to CEI + PCEA when using an epidural solution containing adrenaline. EDITORIAL COMMENT For labor epidural analgesia infusions, to optimize the analgesic effect, additional programmed intermittent boluses can be used as an alternative to patient-controlled boluses only. In this clinical trial, no differences in drug consumption or analgesic effect was observed when comparing these two different epidural bolus controls programs.
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Affiliation(s)
- Felix Haidl
- Department of Anesthesia Akershus University hospital Lørenskog Norway
- Institute of Clinical Medicine University of Oslo Oslo Norway
| | - Leiv Arne Rosseland
- Institute of Clinical Medicine University of Oslo Oslo Norway
- Department of Research and Development Division of Emergencies and Critical Care Oslo University Hospital Nydalen Norway
| | - Anne‐Marte Rørvik
- Department of Anesthesia Akershus University hospital Lørenskog Norway
| | - Vegard Dahl
- Department of Anesthesia Akershus University hospital Lørenskog Norway
- Institute of Clinical Medicine University of Oslo Oslo Norway
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Tzeng IS, Kao MC, Pan PT, Chen CT, Lin HY, Hsieh PC, Kuo CY, Hsieh TH, Kung WM, Cheng CH, Chen KH. A Meta-Analysis of Comparing Intermittent Epidural Boluses and Continuous Epidural Infusion for Labor Analgesia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17197082. [PMID: 32992642 PMCID: PMC7579642 DOI: 10.3390/ijerph17197082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 09/18/2020] [Accepted: 09/23/2020] [Indexed: 02/05/2023]
Abstract
With the development of medical equipment and techniques in labor anesthesia, it is a major issue to investigate the risks and treatment effects among techniques such as continuous epidural infusion (CEI) and intermittent epidural bolus (IEB). However, there is a controversial result regarding two techniques. This study was conducted through meta-analysis of randomized controlled trials (RCTs) for labor analgesia between the CEI and IEB techniques. The pooled results were presented as weighted mean differences (WMDs) together with 95% confidence intervals (CIs) and odds ratios (ORs) together with 95% CIs, respectively. Eleven RCTs were included in this meta-analysis. Four hundred sixty-five parturients accepted CEI, whereas 473 parturients accepted IEB labor analgesia. Elven identified low- risk bias studies were recruited for meta-analysis. The results presented no statistical difference in cesarean delivery rate between IEB and CEI (OR, 0.96; 95% CI, 0.67-1.37) and duration of second stage of labor (WMD, -3.82 min; 95% CI, -8.28 to 0.64). IEB had statistically significant lessened risk of instrumental delivery (OR, 0.59; 95% CI, 0.39-0.90) and for the use in local anesthetic (WMD, -1.71 mg bupivacaine equivalents per hour; 95% CI, -1.88 and -1.55). Accepted IEB had a higher score of maternal satisfaction (WMD, -6.95 mm; 95% CI, -7.77 to -6.13). Based on evidence, IEB showed a greater benefit for slightly reducing the use in local anesthetic, reduced risk of instrumental delivery, and improved maternal satisfaction for the requirement of labor epidural analgesia for healthy women. In the future, more studies need to be conducted to practice the IEB regimen and explore its influence on labor analgesia.
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Affiliation(s)
- I-Shiang Tzeng
- Department of Research, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City 23142, Taiwan; (C.-Y.K.); (T.-H.H.)
- Department of Statistic, National Taipei University, Taipei 10478, Taiwan
- Department of Applied Mathematics; Department of Exercise and Health Promotion, Chinese Culture University, Taipei 11114, Taiwan
- Correspondence: (I.-S.T.); (K.-H.C.)
| | - Ming-Chang Kao
- Department of Anesthesiology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City 23142, Taiwan; (M.-C.K.); (P.-T.P.); (C.-T.C.); (H.-Y.L.)
- School of Medicine, Tzu Chi University, Hualien 97004, Taiwan
| | - Po-Ting Pan
- Department of Anesthesiology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City 23142, Taiwan; (M.-C.K.); (P.-T.P.); (C.-T.C.); (H.-Y.L.)
| | - Chu-Ting Chen
- Department of Anesthesiology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City 23142, Taiwan; (M.-C.K.); (P.-T.P.); (C.-T.C.); (H.-Y.L.)
| | - Han-Yu Lin
- Department of Anesthesiology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City 23142, Taiwan; (M.-C.K.); (P.-T.P.); (C.-T.C.); (H.-Y.L.)
| | - Po-Chun Hsieh
- Department of Chinese Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City 23142, Taiwan;
- School of Post-Baccalaureate Chinese Medicine, Tzu Chi University, Hualien 97004, Taiwan
| | - Chan-Yen Kuo
- Department of Research, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City 23142, Taiwan; (C.-Y.K.); (T.-H.H.)
| | - Tsung-Han Hsieh
- Department of Research, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City 23142, Taiwan; (C.-Y.K.); (T.-H.H.)
| | - Woon-Man Kung
- Division of Neurosurgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City 23142, Taiwan;
| | - Chu-Hsuan Cheng
- Department of Nursing, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City 23142, Taiwan;
| | - Kuo-Hu Chen
- School of Medicine, Tzu Chi University, Hualien 97004, Taiwan
- Department of Obstetrics and Gynecology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City 23142, Taiwan
- Correspondence: (I.-S.T.); (K.-H.C.)
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11
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Hussain N, Lagnese CM, Hayes B, Kumar N, Weaver TE, Essandoh MK, Reno J, Small RH, Abdallah FW. Comparative analgesic efficacy and safety of intermittent local anaesthetic epidural bolus for labour: a systematic review and meta-analysis. Br J Anaesth 2020; 125:560-579. [PMID: 32703549 DOI: 10.1016/j.bja.2020.05.060] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 04/14/2020] [Accepted: 05/08/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Continuous epidural infusion (CEI) is commonly used for labour analgesia, but concerns over potential motor block, second-stage labour complications, and ineffective analgesia in late labour have prompted examining intermittent epidural bolus (IEB) as an alternative. However, evidence comparing these modalities is conflicting. The meta-analysis evaluates the analgesic efficacy of CEI vs IEB. METHODS Databases were searched for trials comparing CEI to IEB for labour analgesia. The two co-primary outcomes were risk of breakthrough pain and difference in area under the curve (AUC) for pain scores during the first 4 h post-epidural initiation. Local anaesthetic consumption, maternal outcomes (i.e. delivery mode, labour duration, and maternal satisfaction), and side-effects of epidural analgesia were also evaluated. Results were pooled using random-effects modelling. Trial sequential analysis (TSA) was used to evaluate evidence reliability. RESULTS Twenty-seven studies (3133 patients) were analysed. Compared with CEI, IEB decreased risk of breakthrough pain by 38% (risk ratio [95% confidence interval {CI}] of 0.62 [0.48, 0.81]; P=0.0004; I2=47%; 1164 patients) and reduced AUC of pain during the 4 h interval by 32.9% (mean difference [95% CI] of -16.7 mm h-1 [-18.9, -14.4]; P<0.0001; 1638 patients). Intermittent epidural bolus enhanced maternal satisfaction, shortened labour duration, decreased motor block, and reduced local anaesthetic consumption. The difference between the two groups was not statistically significant for epidural side-effects or mode of delivery. The TSA indicated adequate power for reliable inferences. CONCLUSIONS Intermittent epidural bolus provides improved labour pain control during the first 4 h after epidural initiation with less breakthrough pain. Moderate- to high-quality evidence of intermittent epidural bolus superiority support its use as a safe and effective continuous epidural infusion alternative for labour analgesia.
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Affiliation(s)
- Nasir Hussain
- Department of Anesthesiology, Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Christopher M Lagnese
- Department of Anesthesiology, Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Blair Hayes
- Department of Anesthesiology, Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Nicolas Kumar
- Department of Anesthesiology, Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Tristan E Weaver
- Department of Anesthesiology, Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Michael K Essandoh
- Department of Anesthesiology, Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Joseph Reno
- Department of Anesthesiology, Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Robert H Small
- Department of Anesthesiology, Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Faraj W Abdallah
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada; The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; The Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, North York General Hospital, University of Toronto, ON, Canada.
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12
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Does programmed intermittent epidural bolus improve childbirth conditions of nulliparous women compared with patient-controlled epidural analgesia?: A multicentre, randomised, controlled, triple-blind study. Eur J Anaesthesiol 2020; 36:755-762. [PMID: 31335447 DOI: 10.1097/eja.0000000000001053] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Epidural analgesia may change the mechanics of childbirth. These changes are related to the concentration of the local anaesthetic used epidurally but probably also to its mode of delivery into the epidural space. OBJECTIVE To determine whether the administration of programmed intermittent epidural boluses (PIEB) improves the mechanics of second-stage labour compared with patient-controlled epidural analgesia (PCEA) with a background infusion. DESIGN A randomised, controlled, triple-blind study. SETTING Multicentre study including four level III maternity units, January 2014 until June 2016. PATIENTS A total of 298 nulliparous patients in spontaneous labour were randomised to a PIEB or PCEA group. INTERVENTION After epidural initiation with 15 ml of 0.1% levobupivacaine containing 10 μg of sufentanil, patients received either an hourly bolus of 8 ml (PIEB) or a continuous rate infusion of 8 ml h (PCEA): the drug mixture used was levobupivacaine 0.1% and sufentanil 0.36 μg ml. MAIN OUTCOME MEASURES The primary outcome was a composite endpoint of objective labour events: a posterior occiput position in the second stage, an occiput position at birth, waiting time at full cervical dilatation before active maternal pushing more than 3 h, maternal active pushing duration more than 40 min, and foetal heart rate alterations. Vaginal instrumental delivery rates, analgesia and motor blockade scores were also recorded. RESULTS From the 298 patients randomised, data from 249 (124 PIEB, 125 PCEA) were analysed. No difference was found in the primary outcome: 48.0% (PIEB) and 45.5% (PCEA) of patients, P = 0.70. In addition, no difference was observed between the groups for each of the individual events of the composite endpoint, nor in the instrumental vaginal delivery rate, nor in the degree of motor blockade. Despite an equivalent volume of medication in the groups, a significantly higher analgesia score at full dilatation was observed in the PIEB group, odds-ratio = 1.9 (95% confidence interval, 1.0 to 3.5), P = 0.04. CONCLUSION The mechanics of the second stage did not differ whether PIEB or PCEA was used. Analgesic conditions appeared to be superior with PIEB, especially at full dilation. TRIAL REGISTRATION NCT01856166.
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13
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Liu X, Zhang H, Zhang H, Guo M, Gao Y, Du C. Intermittent epidural bolus versus continuous epidural infusions for labor analgesia: A meta-analysis of randomized controlled trials. PLoS One 2020; 15:e0234353. [PMID: 32530935 PMCID: PMC7292420 DOI: 10.1371/journal.pone.0234353] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 05/22/2020] [Indexed: 11/29/2022] Open
Abstract
There are inconsistent results regarding the efficacy and safety of intermittent epidural bolus (IPB) versus continuous epidural infusions (CPI) for labor analgesia. This study used a meta-analytic approach to assess the safety and treatment efficacy of IPB versus CPI for labor analgesia based on randomized controlled trials (RCTs). Four electronic databases were used to identify eligible RCTs. Pooled effect estimates at 95% confidence intervals (CIs) were calculated using a random-effects model. Twenty-two RCTs with 2,573 parturients were selected for final analysis. The findings revealed no significant differences between IPB and CPI for the incidences of cesarean and instrumental delivery. IPB was shown to be associated with shorter total duration of labor [weighted mean difference (WMD): −21.46; 95% CI: −25.07 to −17.85; P < 0.001], duration of the first of stage of labor (WMD: −13.41; 95% CI: −21.01 to −5.81; P = 0.001), and duration of the second stage of labor (WMD: −4.98; 95% CI: −9.32 to −0.63; P = 0.025). Furthermore, IPB significantly reduced the incidences of required anesthetic interventions compared with CPI [relative risk (RR): 0.61; 95% CI: 0.39–0.95; P = 0.030], whereas there was no significant difference between IPB and CPI for the time required in the first anesthetic intervention (WMD: 7.73; 95% CI: −33.68–49.15; P = 0.714). The local anesthetic IPB (bupivacaine equivalents) was associated with lower milligrams per hour of local anesthetic (WMD: −0.89; 95% CI: −1.41 to −0.36; P = 0.001) and better maternal satisfaction (WMD: 8.76; 95% CI: 4.18–13.35; P < 0.001). There were no significant differences between IPB and CPI for the risk of adverse events. This study found that parturients with IPB have short total duration of labor and duration of the first and second stage of labor, reduced requirements for additional anesthetic interventions, and improved maternal satisfaction.
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Affiliation(s)
- Xian Liu
- Department of Anesthesiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Huan Zhang
- Department of Anesthesiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
- * E-mail:
| | - Haijing Zhang
- Department of Anesthesiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Mengzhuo Guo
- Department of Anesthesiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Yuanchao Gao
- Department of Anesthesiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Chunyan Du
- Department of Anesthesiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
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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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Aragão FFD, Aragão PWD, Martins CA, Leal KFCS, Tobias AF. Neuraxial labor analgesia: a literature review. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2019. [PMID: 30777350 PMCID: PMC9391899 DOI: 10.1016/j.bjane.2018.12.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The use of analgesia techniques for labor has become increasingly frequent, with neuraxial techniques being the most commonly used and most effective. Labor pain entails a number of physiological consequences that may be negative for the mother and fetus, and therefore must be treated. This literature review was performed through a search in the PubMed database, from July to November 2016, and included articles in English or Portuguese, published between 2011 and 2016 or anteriorly, if relevant to the topic. The techniques were divided into the following topics: induction (epidural, combined epidural-spinal, continuous spinal, and epidural with dural puncture) and maintenance of analgesia (continuous epidural infusion, patient-controlled epidural analgesia, and intermittent epidural bolus). Epidural analgesia does not alter the incidence of cesarean sections or fetal prognosis, and maternal request is a sufficient indication for its initiation. The combined technique has the advantage of a faster onset of analgesia; however, patients are subject to a higher incidence of pruritus resulting from the intrathecal administration of opioids. Patient-controlled analgesia seems to be an excellent technique, reducing the consumption of local anesthetics, the number of anesthesiologist interventions, and increasing maternal satisfaction.
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Aragão FFD, Aragão PWD, Martins CA, Leal KFCS, Ferraz Tobias A. [Neuraxial labor analgesia: a literature review]. Rev Bras Anestesiol 2019; 69:291-298. [PMID: 30777350 DOI: 10.1016/j.bjan.2018.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 11/09/2018] [Accepted: 12/03/2018] [Indexed: 12/19/2022] Open
Abstract
The use of analgesia techniques for labor has become increasingly frequent, with neuraxial techniques being the most commonly used and most effective. Labor pain entails a number of physiological consequences that may be negative for the mother and fetus, and therefore must be treated. This literature review was performed through a search in the PubMed database, from July to November 2016, and included articles in English or Portuguese, published between 2011 and 2016 or anteriorly, if relevant to the topic. The techniques were divided into the following topics: induction (epidural, combined epidural-spinal, continuous spinal, and epidural with dural puncture) and maintenance of analgesia (continuous epidural infusion, patient-controlled epidural analgesia, and intermittent epidural bolus). Epidural analgesia does not alter the incidence of cesarean sections or fetal prognosis, and maternal request is a sufficient indication for its initiation. The combined technique has the advantage of a faster onset of analgesia; however, patients are subject to a higher incidence of pruritus resulting from the intrathecal administration of opioids. Patient-controlled analgesia seems to be an excellent technique, reducing the consumption of local anesthetics, the number of anesthesiologist interventions, and increasing maternal satisfaction.
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Affiliation(s)
- Fábio Farias de Aragão
- Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil; Universidade Federal do Maranhão (UFMA), Ciências da Saúde, São Luís, MA, Brasil; Maternidade Natus Lumine, Serviço de Anestesiologia, São Luís, MA, Brasil.
| | | | - Carlos Alberto Martins
- Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil; Universidade Federal do Maranhão (UFMA), Ciências da Saúde, São Luís, MA, Brasil; Clínica São Marcos, São Luís, MA, Brasil
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Continuous epidural infusion vs programmed intermittent epidural bolus for labour analgesia: a prospective, controlled, before-and-after cohort study of labour outcomes. Br J Anaesth 2018; 121:432-437. [DOI: 10.1016/j.bja.2018.03.038] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Revised: 03/23/2018] [Accepted: 05/09/2018] [Indexed: 11/23/2022] Open
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Sng BL, Zeng Y, de Souza NNA, Leong WL, Oh TT, Siddiqui FJ, Assam PN, Han NR, Chan ESY, Sia AT. Automated mandatory bolus versus basal infusion for maintenance of epidural analgesia in labour. Cochrane Database Syst Rev 2018; 5:CD011344. [PMID: 29770432 PMCID: PMC6494589 DOI: 10.1002/14651858.cd011344.pub2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Childbirth may cause the most severe pain some women experience in their lifetime. Epidural analgesia is an effective form of pain relief during labour and is considered to be the reference standard. Traditionally epidural analgesia has been delivered as a continuous infusion via a catheter in the epidural space, with or without the ability for the patient to supplement the analgesia received by activating a programmable pump to deliver additional top-up doses, known as patient-controlled epidural analgesia (PCEA). There has been interest in delivering maintenance analgesic medication via bolus dosing (automated mandatory bolus - AMB) instead of the traditional continuous basal infusion (BI); recent randomized controlled trials (RCTs) have shown that the AMB technique leads to improved analgesia and maternal satisfaction. OBJECTIVES To assess the effects of automated mandatory bolus versus basal infusion for maintaining epidural analgesia in labour. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, the World Health Organization International Clinial Trials Registry Platform (WHO-ICTRP) and ClinicalTrials.gov on 16 January 2018. We screened the reference lists of all eligible trials and reviews. We also contacted authors of included studies in this field in order to identify unpublished research and trials still underway, and we screened the reference lists of the included articles for potentially relevant articles. SELECTION CRITERIA We included all RCTs that compared the use of bolus dosing AMB with continuous BI for providing pain relief during epidural analgesia for labour in women. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. Our primary outcomes were: risk of breakthrough pain with the need for anaesthetic intervention; risk of caesarean delivery; risk of instrumental delivery. Secondary outcomes included: duration of labour; local anaesthetic consumption. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS We included 12 studies with a total of 1121 women. Ten studies enrolled healthy nulliparous women only and two studies enrolled healthy parous women at term as well. All studies excluded women with complicated pregnancies. There were variations in the technique of initiation of epidural analgesia. Seven studies utilized the combined spinal epidural (CSE) technique, and the other five studies only placed an epidural catheter without any intrathecal injection. Seven studies utilized ropivacaine: six with fentanyl and one with sufentanil. Two studies used levobupivacaine: one with sufentanil and one with fentanyl. Three used bupivacaine with or without fentanyl. The overall risk of bias of the studies was low.AMB probably reduces the risk of breakthrough pain compared with BI for maintaining epidural analgesia for labour (from 33% to 20%; risk ratio (RR) 0.60; 95% confidence interval (CI) 0.39 to 0.92, 10 studies, 797 women, moderate-certainty evidence). AMB may make little or no difference to the risk of caesarean delivery compared to BI (15% and 16% respectively; RR 0.92; 95% CI 0.70 to 1.21, 11 studies, 1079 women, low-certainty evidence).AMB may make little or no difference in the risk of instrumental delivery compared to BI (12% and 9% respectively; RR 0.75; 95% CI 0.54 to 1.06, 11 studies, 1079 women, low-certainty evidence). There is probably little or no difference in the mean duration of labour with AMB compared to BI (mean difference (MD) -10.38 min; 95% CI -26.73 to 5.96, 11 studies, 1079 women, moderate-certainty evidence). There is probably a reduction in the hourly consumption of local anaesthetic with AMB compared to BI for maintaining epidural analgesia during labour (MD -1.08 mg/h; 95% CI -1.78 to -0.38, 12 studies, 1121 women, moderate-certainty evidence). Five out of seven studies reported an increase in maternal satisfaction with AMB compared to BI for maintaining epidural analgesia for labour; however, we did not pool these data due to their ordinal nature. Seven studies reported Apgar scores, though there was significant heterogeneity in reporting. None of the studies showed any significant difference between Apgar scores between groups. AUTHORS' CONCLUSIONS There is predominantly moderate-certainty evidence that AMB is similar to BI for maintaining epidural analgesia for labour for all measured outcomes and may have the benefit of decreasing the risk of breakthrough pain and improving maternal satisfaction while decreasing the amount of local anaesthetic needed.
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Affiliation(s)
- Ban Leong Sng
- KK Women's and Children's HospitalDepartment of Women's Anaesthesia100 Bukit Timah RoadSingaporeSingapore229899
| | - Yanzhi Zeng
- Singapore Health ServicesDepartment of AnaesthesiologyOutram RoadSingaporeSingapore169608
| | - Nurun Nisa A de Souza
- Singapore Clinical Research Institute Pte LtdEpidemiologyNanos #02‐0131, Biopolis WaySingaporeSingaporeSingapore138669
| | - Wan Ling Leong
- KK Women's and Children's HospitalDepartment of Women's Anaesthesia100 Bukit Timah RoadSingaporeSingapore229899
| | - Ting Ting Oh
- KK Women's and Children's HospitalDepartment of Women's Anaesthesia100 Bukit Timah RoadSingaporeSingapore229899
| | - Fahad Javaid Siddiqui
- The Hospital for Sick Children (SickKids)Centre for Global Child Health686 Bay StTorontoOntarioCanadaM5G 1X8
| | - Pryseley N Assam
- Duke‐NUS Graduate Medical SchoolCentre for Quantitative Medicine, Office of Clinical SciencesSingaporeSingapore138669
| | - Nian‐Lin R Han
- KK Women’s and Children’s HospitalDivision of Clinical Support Services100 Bukit Timah RoadSingaporeSingapore229899
| | - Edwin SY Chan
- Singapore Clinical Research InstituteDepartment of EpidemiologyNanos Building #02‐0131 Biopolis WaySingaporeSingapore138669
| | - Alex T Sia
- KK Women's and Children's HospitalDepartment of Women's Anaesthesia100 Bukit Timah RoadSingaporeSingapore229899
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Carvalho B, George RB, Cobb B, McKenzie C, Riley ET. Implementation of Programmed Intermittent Epidural Bolus for the Maintenance of Labor Analgesia. Anesth Analg 2017; 123:965-71. [PMID: 27464978 DOI: 10.1213/ane.0000000000001407] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Programmed intermittent epidural bolus (PIEB) is an exciting new technology that has the potential to improve the maintenance of epidural labor analgesia. PIEB compared with a continuous epidural infusion (CEI) has the potential advantage of greater spread within the epidural space and therefore better sensory blockade. Studies have demonstrated a local anesthetic-sparing effect, fewer instrumental vaginal deliveries, less motor blockade, and improvements in maternal satisfaction with PIEB compared with CEI. However, the optimal PIEB regimen and pump settings remain unknown, and there are a number of logistical issues and practical considerations that should be considered when implementing PIEB. The PIEB bolus size and interval, PIEB start time delay period, and patient-controlled epidural analgesia bolus size and lockout time can influence the efficacy of PIEB used for epidural labor analgesia. Educating all members of the health care team is critical to the success of the technique. This review summarizes the role of PIEB for the maintenance of labor analgesia, outlines implementation strategies, suggests optimal settings, and presents potential limitations of the technique.
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Affiliation(s)
- Brendan Carvalho
- From the *Department of Anesthesia, Stanford University School of Medicine, Stanford, CA; and †Department of Women's & Obstetric Anesthesia, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada
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Onuoha OC. Epidural Analgesia for Labor: Continuous Infusion Versus Programmed Intermittent Bolus. Anesthesiol Clin 2017; 35:1-14. [PMID: 28131113 DOI: 10.1016/j.anclin.2016.09.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Despite the traditional practice to maintain labor analgesia with a combination of continuous epidural infusion and patient-controlled epidural analgesia using an automated epidural pump; compelling data now shows that bolus injection through the epidural catheter may result in better distribution of anesthetic solution in the epidural space. The programmed intermittent epidural bolus technique is proposed as a better maintenance mode and may represent a more effective mode of maintaining epidural analgesia for labor, especially prolonged labor. Additional prospective and adequately powered studies are needed to confirm findings and determine the optimal combination of volume, rate, time, and drug concentration.
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Affiliation(s)
- Onyi C Onuoha
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, Hospital of the University of Pennsylvania, 3400 Spruce Street, Dulles 6, Philadelphia, PA 19104, USA.
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McKenzie CP, Cobb B, Riley ET, Carvalho B. Programmed intermittent epidural boluses for maintenance of labor analgesia: an impact study. Int J Obstet Anesth 2015; 26:32-8. [PMID: 26775896 DOI: 10.1016/j.ijoa.2015.11.005] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 11/18/2015] [Accepted: 11/23/2015] [Indexed: 12/01/2022]
Abstract
INTRODUCTION The aim of this impact study was to compare the analgesic efficacy and side effect profile of programmed intermittent epidural boluses (PIEB)+patient-controlled epidural analgesia (PCEA) to continuous epidural infusion (CEI)+PCEA for maintenance labor analgesia after the introduction of PIEB at our institution. METHODS We conducted a retrospective analysis after replacing the background CEI with PIEB for our labor PCEA. Pre-change pump settings were CEI 12mL/h with PCEA (12mL bolus, lockout 15min); PIEB settings were a 9mL bolus every 45min with PCEA (10mL bolus, lockout 10min). We compared medical records of all women receiving epidural or combined spinal-epidural labor analgesia for vaginal delivery for two months before PIEB implementation to a two-month period of PIEB utilization following a five-month introductory familiarization period. The primary outcome was the proportion of women requiring rescue clinician boluses. RESULTS Fewer patients in the PIEB group required rescue clinician boluses compared to the CEI group (12% vs. 19%, P=0.012). Time to first rescue bolus request and total bolus dose were not different. Peak (median [IQR]) pain scores were 2[0-5] with CEI and 0[0-4] with PIEB. There was no difference in instrumental delivery rates. CONCLUSIONS Using PIEB compared to CEI as the background maintenance epidural analgesia method in conjunction with PCEA reduced the number of women requiring clinician rescue boluses while providing comparable labor analgesia. The findings of this clinical care impact study confirm the results of randomized controlled studies and suggest PIEB may be a preferable technique to CEI for the maintenance of labor analgesia.
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Affiliation(s)
- C P McKenzie
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA
| | - B Cobb
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA
| | - E T Riley
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA
| | - B Carvalho
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA.
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Patkar CS, Vora K, Patel H, Shah V, Modi MP, Parikh G. A comparison of continuous infusion and intermittent bolus administration of 0.1% ropivacaine with 0.0002% fentanyl for epidural labor analgesia. J Anaesthesiol Clin Pharmacol 2015; 31:234-8. [PMID: 25948908 PMCID: PMC4411841 DOI: 10.4103/0970-9185.155155] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND AND AIMS Minimal consumption of local anesthetic and opioid for epidural labor analgesia has been advocated for safe obstetric outcome and superior maternal satisfaction. The primary objective of this study was to evaluate and compare the analgesic efficacy of mode of administration of epidural 0.1% ropivacaine with 0.0002% fentanyl via continuous infusion or intermittent boluses during labor. MATERIAL AND METHODS Sixty term primi or second gravida healthy parturients in labor requesting epidural analgesia were recruited in this study. Lumbar epidural catheter was inserted, and analgesia initiated with 0.2% ropivacaine. Patients were randomized to receive ropivacaine 0.1% with fentanyl 0.0002% via either continuous infusion (Group A) or intermittent boluses (Group B) on an hourly basis. If the parturient complained of pain and visual analog scale (VAS) score was >3, an additional bolus of the study drug was given. VAS score, motor blockade, maternal hemodynamics and fetal heart sounds were frequently monitored. Side effects, mode of delivery and neonatal outcome were noted. RESULTS To achieve similar VAS, the mean total dose of ropivacaine was 18.78 ± 3.88 mg in Group A and 16.86 ± 4.3 mg in Group B, the difference being statistically significant (P = 0.04). Seventeen out of 30 patients in Group A that is, 56.6% and nine patients in Group B that is, 30% required additional top-ups, and this was significantly higher (P = 0.037). Side effects, mode of delivery and neonatal outcome were comparable in both groups. CONCLUSION Intermittent bolus administration provides a more efficacious route of drug delivery when compared to continuous infusion by significantly decreasing the total amount of local anesthetic plus opioid without adversely affecting patient safety or maternal satisfaction.
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Affiliation(s)
- Chinmayi Surendra Patkar
- Department of Anaesthesia and Critical Care, G. R. Doshi and K. M. Mehta Institute of Kidney Diseases and Research Centre and Dr. H. L. Trivedi Institute of Transplantation Sciences, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat, India
| | - Kalpana Vora
- Department of Anaesthesia and Critical Care, G. R. Doshi and K. M. Mehta Institute of Kidney Diseases and Research Centre and Dr. H. L. Trivedi Institute of Transplantation Sciences, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat, India
| | - Harshal Patel
- Department of Anaesthesia and Critical Care, G. R. Doshi and K. M. Mehta Institute of Kidney Diseases and Research Centre and Dr. H. L. Trivedi Institute of Transplantation Sciences, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat, India
| | - Veena Shah
- Department of Anaesthesia and Critical Care, G. R. Doshi and K. M. Mehta Institute of Kidney Diseases and Research Centre and Dr. H. L. Trivedi Institute of Transplantation Sciences, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat, India
| | - Manisha Pranjal Modi
- Department of Anaesthesia and Critical Care, G. R. Doshi and K. M. Mehta Institute of Kidney Diseases and Research Centre and Dr. H. L. Trivedi Institute of Transplantation Sciences, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat, India
| | - Geeta Parikh
- Department of Anaesthesia and Critical Care, G. R. Doshi and K. M. Mehta Institute of Kidney Diseases and Research Centre and Dr. H. L. Trivedi Institute of Transplantation Sciences, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat, India
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Eugenio Canessa B, Rodrigo Añazco G, Jorge Gigoux M, Jorge Aguilera S. Anestesia para el trabajo de parto. REVISTA MÉDICA CLÍNICA LAS CONDES 2014. [DOI: 10.1016/s0716-8640(14)70647-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Sng BL, Zeng Y, Leong WL, Oh TT, Siddiqui FJ, Assam PN, Chan ESY, Sia AT. Automated mandatory bolus versus basal infusion for maintenance of epidural analgesia in labour. Hippokratia 2014. [DOI: 10.1002/14651858.cd011344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Ban Leong Sng
- KK Women's and Children's Hospital; Department of Women's Anaesthesia; 100 Bukit Timah Road Singapore Singapore 229899
| | - Yanzhi Zeng
- National University of Singapore; Yong Loo Lin School of Medicine; NUHS Tower Block Level 11, 1E Kent Ridge Road Singapore Singapore 119228
| | - Wan Ling Leong
- KK Women's and Children's Hospital; Department of Women's Anaesthesia; 100 Bukit Timah Road Singapore Singapore 229899
| | - Ting Ting Oh
- KK Women's and Children's Hospital; Department of Women's Anaesthesia; 100 Bukit Timah Road Singapore Singapore 229899
| | - Fahad Javaid Siddiqui
- Duke-NUS Graduate Medical School; Centre for Quantitative Medicine, Office of Clinical Sciences; Academia, #06-69, 20, College Road Singapore Singapore 169856
| | - Pryseley N Assam
- Duke-NUS Graduate Medical School; Centre for Quantitative Medicine, Office of Clinical Sciences; Academia, #06-69, 20, College Road Singapore Singapore 169856
| | - Edwin SY Chan
- Singapore Clinical Research Institute; Epidemiology; Nanos Building #02-01 31 Biopolis Way Singapore Singapore 138669
| | - Alex T Sia
- KK Women's and Children's Hospital; Department of Women's Anaesthesia; 100 Bukit Timah Road Singapore Singapore 229899
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Iyer SJ, Sia ATH. Impact of Drug Delivery Systems on Neuraxial Labor Analgesia. CURRENT ANESTHESIOLOGY REPORTS 2013. [DOI: 10.1007/s40140-013-0030-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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George RB, Allen TK, Habib AS. Intermittent Epidural Bolus Compared with Continuous Epidural Infusions for Labor Analgesia. Anesth Analg 2013; 116:133-44. [DOI: 10.1213/ane.0b013e3182713b26] [Citation(s) in RCA: 140] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Wong CA, McCarthy RJ, Hewlett B. The Effect of Manipulation of the Programmed Intermittent Bolus Time Interval and Injection Volume on Total Drug Use for Labor Epidural Analgesia. Anesth Analg 2011; 112:904-11. [DOI: 10.1213/ane.0b013e31820e7c2f] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Loubert C, Hinova A, Fernando R. Update on modern neuraxial analgesia in labour: a review of the literature of the last 5 years. Anaesthesia 2011; 66:191-212. [DOI: 10.1111/j.1365-2044.2010.06616.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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