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Ji T, Jiang C, Liu H, Cai Z, Liu R, Xie L, Xu C. Efficacy and Safety of Epidural Chloroprocaine for Breakthrough Pain During Labor Analgesia: A Prospective, Double-Blind, Randomized Trial. Pain Ther 2024; 13:227-239. [PMID: 38300394 DOI: 10.1007/s40122-024-00577-7] [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: 10/25/2023] [Accepted: 01/11/2024] [Indexed: 02/02/2024] Open
Abstract
INTRODUCTION A significant number of women who undergo neuraxial labor analgesia experience breakthrough pain. Prompt mitigation of breakthrough pain is essential to improve maternal and fetal outcomes. We evaluated epidural chloroprocaine compared with ropivacaine in alleviating labor breakthrough pain. METHODS We performed a double-blind randomized controlled clinical trial between May and July 2023. Eligible parturients received epidural analgesia with ropivacaine and sufentanil. Those with breakthrough pain were randomized to receive either 0.125% epidural ropivacaine (group R) or chloroprocaine at concentrations of 0.5% (group C1), 1.0% (group C2), or 1.5% (group C3), all in a volume of 6 mL. The primary outcome was the treatment success rate, indicated by a decrease of at least 4 points on the numerical rating scale pain score 9 min after analgesic injection. Secondary outcomes and adverse effects were also recorded. RESULTS Out of 323 patients receiving epidural analgesia, 192 experienced breakthrough pain. After exclusion of three patients because of protocol deviation, there were 47, 48, 47, and 47 patients in group R, C1, C2, and C3, respectively. Group C3 demonstrated a higher treatment success rate (39/47, 83.0%) in managing breakthrough pain than group R (26/47, 55.3%), group C1 (12/48, 25.0%), and group C2 (30/47, 63.8%) (p < 0.001). Group C3 had lower numerical rating scale scores at 6 and 9 min after injection and required fewer patient-controlled epidural boluses than other groups. In addition, group C3 reported greater satisfaction than the other groups (p < 0.001). No significant differences were observed in obstetric or neonatal outcomes across these groups. CONCLUSION Parturients experiencing breakthrough pain could receive 1.5% epidural chloroprocaine, rather than lower chloroprocaine concentrations and ropivacaine, to achieve more rapid and better pain relief with higher patient satisfaction. TRIAL REGISTRATION Chinese Clinical Trial Registry, ChiCTR2300071069, http://www.chictr.org.cn/index.aspx .
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Affiliation(s)
- Tianzhen Ji
- Department of Anesthesiology, Anhui Provincial Maternal and Child Health Hospital, Maternal and Child Medical Center of Anhui Medical University, Hefei, 230011, China
| | - Can Jiang
- Department of Anesthesiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hongxia Liu
- Department of Anesthesiology, Anhui Provincial Maternal and Child Health Hospital, Maternal and Child Medical Center of Anhui Medical University, Hefei, 230011, China
| | - Zhehao Cai
- Department of Anesthesiology, Anhui Provincial Maternal and Child Health Hospital, Maternal and Child Medical Center of Anhui Medical University, Hefei, 230011, China
| | - Rongrong Liu
- Department of Anesthesiology, Anhui Provincial Maternal and Child Health Hospital, Maternal and Child Medical Center of Anhui Medical University, Hefei, 230011, China
| | - Lei Xie
- Department of Anesthesiology, Anhui Provincial Maternal and Child Health Hospital, Maternal and Child Medical Center of Anhui Medical University, Hefei, 230011, China.
| | - Cheng Xu
- Department of Anesthesiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Kim D, Kim J, Choo H, Choi DH. Programmed intermittent epidural bolus as an ideal method for labor analgesia: a randomized controlled trial. Korean J Anesthesiol 2024; 77:106-114. [PMID: 37312414 PMCID: PMC10834717 DOI: 10.4097/kja.23173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 06/12/2023] [Accepted: 06/13/2023] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND Although programmed intermittent epidural bolus (PIEB) is effective for labor analgesia, an appropriate flow rate has not been established. Therefore, we investigated the analgesic effect based on different epidural injection flow rates. METHODS Nulliparous women scheduled for spontaneous labor were enrolled in this randomized trial. After injection of intrathecal 0.2% ropivacaine 3 mg with fentanyl 20 μg, participants were randomized to three study groups. Epidural analgesics, 10 ml during one hour, were administered with patient controlled epidural analgesia as follows (0.2% ropivacaine 60 ml, fentanyl 180 μg, and 0.9% saline 40 ml): continuous (n = 28, 10 ml/h for continuous infusion), PIEB (n = 29, 240 ml/h for bolus infusion of 10 ml), or manual (n = 28, 1200 ml/h for bolus injection of 10 ml). The primary outcome was hourly consumption of the epidural solution. The time interval between labor analgesia and the first breakthrough pain was investigated. RESULTS The median (Q1, Q3) hourly consumption of epidural anesthetics was significantly different among the groups (continuous: 14.3 [8.7, 16.9] ml, PIEB: 9.4 [6.2, 9.8] ml, manual: 8.6 [7.6, 9.9] ml; P < 0.001). The time to breakthrough pain for the PIEB group was longer than that for the other groups (continuous: 78.5 [35.8, 185.0] min, PIEB: 200.0 [88.5, 441.5] min, manual: 60.5 [37.3, 162.0] min, P = 0.027). CONCLUSIONS PIEB, with a low-flow rate, provided more adequate labor analgesia than a continuous epidural infusion or manual injection with a high-flow rate.
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Affiliation(s)
- Doyeon Kim
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Jeayoun Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyeonju Choo
- Department of Anesthesiology and Pain Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Duck Hwan Choi
- Department of Anesthesiology and Pain Medicine, Dongtan Sacred Heart Hospital, Hallym University School of Medicine, Hwaseong, Korea
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Grote D, Zeitz J, Sorrels C, Russell RC, Raiyani C, Hofkamp MP. Effect of programmed intermittent epidural bolus protocol on physician-administered rescue boluses of labor analgesia. Proc AMIA Symp 2023; 36:687-691. [PMID: 37829233 PMCID: PMC10566424 DOI: 10.1080/08998280.2023.2254201] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 08/29/2023] [Indexed: 10/14/2023] Open
Abstract
Background Prior studies have shown that programmed intermittent epidural bolus (PIEB) techniques, with or without patient-controlled epidural analgesia (PCEA) boluses, provide better pain relief, reduced motor block, and better patient satisfaction compared to continuous epidural infusion (CEI) techniques. We hypothesized that patients who had labor epidural analgesia (LEA) maintained with PIEB and PCEA would be less likely to receive a physician-administered rescue analgesia bolus compared to patients who had CEI and PCEA. Methods We searched our electronic medical record for patients who had CEI and PCEA from August 1, 2021 to December 31, 2021 and for patients who had PIEB and PCEA from August 2, 2022 to December 31, 2022. Results A total of 792 and 665 patients had maintenance of LEA with CEI/PCEA and PIEB/PCEA, respectively. A multivariate logistic regression was performed and, after adjusting for variables of interest, patients who had PIEB and PCEA were less likely to receive one or more physician-administered rescue analgesia boluses (odds ratio 0.504; 95% confidence interval 0.392, 0.649; P < 0.001) compared to patients who had CEI and PCEA. Conclusion PIEB/PCEA was associated with fewer physician-administered boluses of rescue analgesia compared to CEI/PCEA when used for LEA.
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Affiliation(s)
- Dylan Grote
- Texas A&M Health Science Center College of Medicine, Temple, Texas, USA
| | - Jack Zeitz
- Texas A&M Health Science Center College of Medicine, Temple, Texas, USA
| | - Cole Sorrels
- Texas A&M Health Science Center College of Medicine, Temple, Texas, USA
| | - Ryan C. Russell
- Department of Anesthesiology, Baylor Scott & White Medical Center –Temple, Temple, Texas, USA
| | - Chandni Raiyani
- Biostatistics Core, Baylor Scott & White Research Institute, Temple, Texas, USA
| | - Michael P. Hofkamp
- Department of Anesthesiology, Baylor Scott & White Medical Center –Temple, Temple, Texas, USA
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Lange EMS, Kim J, Klumpner TT, McCarthy RJ, Wong CA, Thakkar K, Toledo P. Association between breakthrough labor pain, patient-controlled epidural analgesia use, and numeracy: A pilot observational study. Midwifery 2023; 124:103730. [PMID: 37302247 DOI: 10.1016/j.midw.2023.103730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 04/04/2023] [Accepted: 05/12/2023] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Labor analgesia can be maintained with a continuous epidural infusion, supplemented by patient-controlled epidural boluses. patient-controlled epidural boluses use and timing require numeric understanding, as patients need to understand when they can administer supplemental boluses, lockout intervals, and total doses. We hypothesized that women with lower numeric literacy have a higher rate of provider-administered supplemental boluses for breakthrough pain because they do not understand the concept behind patient-controlled epidural boluses. DESIGN Pilot observational study SETTING: Labor and Delivery Suite PARTICIPANTS: Nulliparous, English-speaking patients with singleton, vertex pregnancies admitted for postdates (gestational age ≥ 41 weeks) induction of labor requesting neuraxial labor analgesia. INTERVENTIONS Combined spinal-epidural labor analgesia was initiated with intrathecal fentanyl and epidural analgesia was maintained using continuous epidural infusion with patient-controlled epidural boluses. MEASUREMENTS AND FINDINGS Numeric literacy was assessed using the Lipkus 7-item expanded numeracy test. Patients were stratified by whether or not they required supplemental provider-administered analgesia and patient-controlled epidural boluses use patterns were evaluated. A total of 89 patients completed the study. There were no demographic differences between patients who required supplemental analgesia compared with those who did not. Patients that required supplemental analgesia were more likely to request and receive patient-controlled epidural boluses (P<0.001). Hourly bupivacaine requirement was higher in women with breakthrough pain. There were no differences in numeric literacy between the two groups. KEY CONCLUSIONS Patients who required treatment of breakthrough pain had higher patient-controlled epidural boluses demands-to-delivery ratio. Numeric literacy was not correlated with the need for provider-administered supplemental boluses. IMPLICATIONS FOR PRACTICE Easy to understand scripts on how to use patient-controlled epidural boluses allows for understanding of patient-controlled epidural boluses use.
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Affiliation(s)
- Elizabeth M S Lange
- Department of Anesthesiology, Emory University School of Medicine, Clifton Atlanta, GA 1364, United States.
| | - Jennifer Kim
- Formerly of the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Thomas T Klumpner
- Department of Anesthesiology, University of Michigan, 1540 E. Hospital Dr, Ann Arbor, MI 48109, United States
| | - Robert J McCarthy
- Department of Anesthesiology, Rush University, 1653 W. Congress Parkway, Chicago, IL 60612, United States
| | - Cynthia A Wong
- Department of Anesthesiology, University of Iowa Roy J. and Lucille A. Carver College of Medicine, 200 Hawkins Drive, 6618 John Colloton Pavilion, Iowa City, IA 52242, United States
| | - Kavisha Thakkar
- School of Medicine, University of Connecticut, 200 Academic Way, Farmington, CT 06032, United States
| | - Paloma Toledo
- Department of Anesthesiology, University of Medicine, Miller School of Medicine, 1611 NW 112th Ave, C-301, Miami, FL 33136, United States
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Callahan E, Yeh P, Carvalho B, George RB. A survey of labour epidural practices at obstetric anesthesia fellowship programs in the United States. Can J Anaesth 2022; 69:591-596. [PMID: 35089544 PMCID: PMC9068633 DOI: 10.1007/s12630-022-02192-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 11/16/2021] [Accepted: 11/17/2021] [Indexed: 12/03/2022] Open
Abstract
Purpose Labour epidural analgesia (LEA) is an evolving field. Various neuraxial techniques and dosing regimens are available to the modern obstetric anesthesia provider, allowing for significant practice variability. To begin a search for consensus on optimal care, we sought to query fellowship training practices for LEA. Methods We conducted an electronic survey of institutions with American Council for Graduate Medical Education-accredited obstetric anesthesiology fellowship programs. We studied the frequency of epidural initiation techniques, including combined spinal epidural (CSE), dural puncture epidural, and epidural bolus. For maintenance techniques, we appraised the use of continuous epidural infusion, programmed intermittent bolus (PIEB), and patient-controlled epidural analgesia (PCEA). Results Of 40 institutions surveyed, we received 32 responses (80% response rate). Twenty-eight of 40 (70%) were included in the analysis. A plurality of institutions (12/28; 43%) preferred CSE, and among those who used CSE, 23/27 (85%) included intrathecal opioids. A majority of institutions used protocols with PIEB (55%), while almost all (92%) used PCEA. Most participants (88%) reported using dilute concentration maintenance infusions of 0.1% bupivacaine/ropivacaine or less. Conclusion Despite significant variability in LEA practice, some clear patterns emerged in our survey, including preference for opioid-containing CSE and maintenance with PIEB, PCEA, and dilute epidural solutions. Supplementary Information The online version contains supplementary material available at 10.1007/s12630-022-02192-6.
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Affiliation(s)
- Elliott Callahan
- Department of Anesthesia and Perioperative Care, University of California San Francisco (UCSF), 513 Parnassus Ave, MSB, 436, Box 0427, San Francisco, CA, 94143, USA.
| | - Peter Yeh
- Department of Anesthesia and Perioperative Care, University of California San Francisco (UCSF), 513 Parnassus Ave, MSB, 436, Box 0427, San Francisco, CA, 94143, USA
| | | | - Ronald B George
- Department of Anesthesia and Perioperative Care, University of California San Francisco (UCSF), 513 Parnassus Ave, MSB, 436, Box 0427, San Francisco, CA, 94143, USA
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Callahan EC, Lim S, George RB. Neuraxial labor analgesia: Maintenance techniques. Best Pract Res Clin Anaesthesiol 2022; 36:17-30. [PMID: 35659953 DOI: 10.1016/j.bpa.2022.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 03/12/2022] [Indexed: 11/17/2022]
Abstract
Since the advent of neuraxial analgesia for labor, approaches to maintaining intrapartum pain relief have seen significant advancement. Through pharmacologic innovations and improved drug delivery mechanisms, current neuraxial labor analgesia maintenance techniques have been shaped by efforts to maximize patient comfort during the birthing process, while minimizing undesirable side effects and promoting the unimpeded progress of labor. To these ends, a modern anesthesiologist may avail themselves of several techniques, including programmed intermittent epidural bolus (PIEB), patient controlled epidural analgesia (PCEA) and dilute concentration local anesthetic + opioid epidural solutions. We explore the historical development and the evidential underpinnings of these techniques, in addition to several contemporary neuraxial labor analgesia practices. We also summarize current understanding of the effects these interventions have on maternal/fetal health and the labor course, as well as several important aspects of analgesic safety and monitoring.
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Affiliation(s)
- Elliott C Callahan
- Department of Anesthesia and Perioperative Care, University of California San Francisco (UCSF), 513 Parnassus Ave, MSB, 436, Box 0427, San Francisco, CA 94143, USA.
| | - Stephanie Lim
- Department of Anesthesia and Perioperative Care, UCSF, San Francisco, CA, USA
| | - Ronald B George
- Department of Anesthesia and Perioperative Care, UCSF, San Francisco, CA, USA
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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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [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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Toledano RD, Leffert L. What's New in Neuraxial Labor Analgesia. CURRENT ANESTHESIOLOGY REPORTS 2021; 11:340-347. [PMID: 34466127 PMCID: PMC8390543 DOI: 10.1007/s40140-021-00453-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2021] [Indexed: 11/30/2022]
Abstract
Purpose of Review This article provides an update of recent practice trends in neuraxial labor analgesia. It reviews available evidence regarding management of labor pain in obstetric patients with COVID-19, serious adverse events in obstetric anesthesia to help inform risk/benefit decisions, and increasingly popular neuraxial labor analgesia techniques and adjuvants. State-of-the-art modes of epidural drug delivery are also discussed. Recent Findings There has recently been a focus on several considerations specific to obstetric anesthesia, such as anesthetic management of obstetric patients with COVID-19, platelet thresholds for the safe performance of neuraxial analgesia in obstetric patients with thrombocytopenia, and drug delivery modes for initiation and maintenance of neuraxial labor analgesia. Summary Neuraxial labor analgesia (via standard epidural, dural puncture epidural, and combined spinal epidural techniques) is the most effective therapy to alleviate the pain of childbirth. SARS-CoV-2 infection is not, in and of itself, a contraindication to neuraxial labor analgesia or cesarean delivery anesthesia. Early initiation of neuraxial labor analgesia in patients with COVID-19 is recommended if not otherwise contraindicated, as it may reduce the need for general anesthesia should emergency cesarean delivery become necessary. Consensus regarding platelet thresholds for safe initiation of neuraxial procedures has historically been lacking. Recent studies have concluded that the risk of spinal epidural hematoma formation after neuraxial procedures is likely low at or above an imprecise range of platelet count of 70–75,000 × 106/L. Thrombocytopenia has been reported in obstetric patients with COVID-19, but severe thrombocytopenia precluding initiation of neuraxial anesthesia is extremely rare. High neuraxial blockade has emerged as one of the most common serious complications of neuraxial analgesia and anesthesia in obstetric patients. Growing awareness of factors that contribute to failed conversion of epidural labor analgesia to cesarean delivery anesthesia may help avoid the risks associated with performance of repeat neuraxial techniques and induction of general anesthesia after failed epidural blockade. Dural puncture techniques to alleviate the pain of childbirth continue to become more popular, as do adjuvant drugs to enhance or prolong neuraxial analgesia. Novel techniques for epidural drug delivery have become more widely disseminated.
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Affiliation(s)
- Roulhac D. Toledano
- NYU Langone Health, Department of Anesthesiology, Perioperative Care & Pain Medicine, NYU Langone Hospital, Brooklyn, USA
| | - Lisa Leffert
- Department of Anesthesia, Critical Care & Pain Medicine, Harvard Medical School, Boston, USA
- Obstetric Anesthesia Division, Massachusetts General Hospital, Boston, MA USA
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Li L, Yang Z, Zhang W. Epidural Dexmedetomidine for Prevention of Intrapartum Fever During Labor Analgesia: A Randomized Controlled Trial. Pain Ther 2021; 10:391-400. [PMID: 33188493 PMCID: PMC8119513 DOI: 10.1007/s40122-020-00215-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 10/28/2020] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Intrapartum fever occurs frequently during labor. The purpose of this study was to investigate the effects of epidural dexmedetomidine on maternal temperature, pain score and adverse effects during labor analgesia. METHODS A total of 600 full-term primiparous parturients were randomly divided into two groups. The dexmedetomidine group (Group Dex, n = 300) received 0.1% ropivacaine with 0.5 µg/mL dexmedetomidine for epidural analgesia during labor, while the control group (Group C, n = 300) received 0.1% ropivacaine alone. The maternal temperature, visual analogue scale (VAS) and Ramsay sedation score (RSS) were recorded, and the systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) were monitored. Side effects, if any, were also recorded. RESULTS The incidence of intrapartum fever was lower in Group Dex than in Group C (4.1% vs. 8.7%, χ2 = 5.07, P = 0.024). VAS values from the time of 3 cm cervical dilatation to 10 cm cervical dilatation were also lower in Group Dex than in Group C (1.0 ± 0.9 vs. 1.3 ± 0.7, t = 3.62, P < 0.001; 2.8 ± 0.8 vs. 3.3 ± 0.8, t = 8.09, P < 0.001; 3.1 ± 0.9 vs. 3.3 ± 0.8, t = 3.88, P < 0.001; 3.6 ± 0.8 vs. 4.1 ± 1.0, t = 5.86, P < 0.001, respectively). HR from the time of 3 cm cervical dilatation to 10 cm cervical dilatation was lower during labor in Group Dex than in Group C (80.0 ± 4.3 vs. 83.1 ± 5.4 beats/min, t = 7.58, P < 0.001; 81.1 ± 4.0 vs. 83.7 ± 5.5 beats/min, t = 6.48, P < 0.001; 78.9 ± 5.4 vs. 81.5 ± 6.3 beats/min, t = 5.41, P < 0.001; 83.1 ± 5.3 vs. 84.8 ± 5.6 beats/min, t = 3.75, P < 0.001, respectively), while SBP and DBP were similar between the two groups. The incidence of adverse events during labor was also similar between the two groups. CONCLUSION The present study showed that dexmedetomidine could reduce the incidence of intrapartum fever and relieve pain during labor without increasing adverse events. TRIAL REGISTRATION ChiCTR-OPC-16008548.
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Affiliation(s)
- Li Li
- Department of Anesthesiology, Wenzhou Central Hospital, Wenzhou, 325000, China
| | - Zeyong Yang
- Department of Anesthesiology, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200030, China
| | - Wangping Zhang
- Department of Anesthesiology, Women and Children's Hospital of Jiaxing University, Jiaxing, 314000, China.
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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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Roofthooft E, Barbé A, Schildermans J, Cromheecke S, Devroe S, Fieuws S, Rex S, Wong CA, Van de Velde M. Programmed intermittent epidural bolus vs. patient-controlled epidural analgesia for maintenance of labour analgesia: a two-centre, double-blind, randomised study†. Anaesthesia 2020; 75:1635-1642. [PMID: 32530518 DOI: 10.1111/anae.15149] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2020] [Indexed: 11/28/2022]
Abstract
The programmed intermittent epidural bolus technique has shown superiority to continuous epidural infusion techniques, with or without patient-controlled epidural analgesia for pain relief, reduced motor block and patient satisfaction. Many institutions still use patient-controlled epidural analgesia without a background infusion, and a comparative study between programmed intermittent epidural bolus and patient-controlled epidural analgesia without a background infusion has not yet been performed. We performed a randomised, two-centre, double-blind, controlled trial of these two techniques. The primary outcome was the incidence of breakthrough pain requiring a top-up dose by an anaesthetist. Secondary outcomes included: motor block; pain scores; patient satisfaction; local anaesthetic consumption; and obstetric and neonatal outcomes. We recruited 130 nulliparous women who received initial spinal analgesia, and then epidural analgesia was initiated and maintained with either programmed intermittent epidural bolus or patient-controlled epidural analgesia using ropivacaine 0.12% with sufentanil 0.75 µg·ml-1 . The programmed intermittent epidural bolus group had a programmed bolus of 10 ml every hour, with on-demand patient-controlled epidural analgesia boluses of 5 ml with a 20 min lockout, and the patient-controlled epidural analgesia group had a 5 ml bolus with a 12 min lockout interval; the potential maximum volume per hour was the same in both groups. The patients in the programmed intermittent epidural bolus group had less frequent breakthrough pain compared with the patient-controlled epidural analgesia group, 7 (10.9%) vs. 38 (62.3%; p < 0.0001), respectively. There was a significant difference in motor block (modified Bromage score ≤ 4) frequency between groups, programmed intermittent epidural bolus group 1 (1.6%) vs. patient-controlled epidural analgesia group 8 (13.1%); p = 0.015. The programmed intermittent epidural bolus group had greater local anaesthetic consumption with fewer patient-controlled epidural analgesia boluses. Patient satisfaction scores and obstetric or neonatal outcomes were not different between groups. In conclusion, we found that a programmed intermittent epidural bolus technique using 10 ml programmed boluses and 5 ml patient-controlled epidural analgesia boluses was superior to a patient-controlled epidural analgesia technique using 5 ml boluses and no background infusion.
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Affiliation(s)
- E Roofthooft
- Department of Anaesthesiology, GZA Sint Augustinus Hospital, Antwerp, Belgium.,Department of Cardiovascular Sciences, KU Leuven, Belgium
| | - A Barbé
- Department of Anaesthesiology, University Hospitals Leuven, Belgium
| | - J Schildermans
- Department of Anaesthesiology, University Hospitals Leuven, Belgium
| | - S Cromheecke
- Department of Anaesthesiology, ZNA Middelheim Hospital, Antwerp, Belgium
| | - S Devroe
- Department of Cardiovascular Sciences, KU Leuven, Belgium.,Department of Anaesthesiology, University Hospitals Leuven, Belgium
| | - S Fieuws
- Department of I-Biostat, KU Leuven, Belgium
| | - S Rex
- Department of Cardiovascular Sciences, KU Leuven, Belgium.,Department of Anaesthesiology, University Hospitals Leuven, Belgium
| | - C A Wong
- Department of Anesthesia, University of Iowa, Iowa City, IA, USA
| | - M Van de Velde
- Department of Cardiovascular Sciences, KU Leuven, Belgium.,Department of Anaesthesiology, University Hospitals Leuven, Belgium
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13
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Nanji JA, Carvalho B. Pain management during labor and vaginal birth. Best Pract Res Clin Obstet Gynaecol 2020; 67:100-112. [PMID: 32265134 DOI: 10.1016/j.bpobgyn.2020.03.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 02/18/2020] [Accepted: 03/03/2020] [Indexed: 11/20/2022]
Abstract
Neuraxial analgesia provides excellent pain relief in labor. Optimizing initiation and maintenance of neuraxial labor analgesia requires different strategies. Combined spinal-epidurals or dural puncture epidurals may offer advantages over traditional epidurals. Ultrasound is useful in certain patients. Maintenance of analgesia is best achieved with a background regimen (either programmed intermittent boluses or a continuous epidural infusion) supplemented with patient-controlled epidural analgesia and using dilute local anesthetics combined with opioids such as fentanyl. Nitrous oxide and systemic opioids are also used for pain relief. Nitrous oxide may improve satisfaction despite variable effects on pain. Systemic opioids can be administered by healthcare providers or using patient-controlled analgesia. Appropriate choice of drug should take into account the stage and progression of labor, local safety protocols, and maternal and fetal/neonatal side effects. Pain in labor is complex, and women should fully participate in the decision-making process before any one modality is selected.
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Affiliation(s)
- Jalal A Nanji
- Department of Anesthesiology and Pain Medicine, University of Alberta Faculty of Medicine and Dentistry, Royal Alexandra Hospital, 10240 Kingsway Avenue NW, Edmonton, AB, T5H 3V9, Canada.
| | - Brendan Carvalho
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 300 Pasteur Drive MC: 5640, Stanford, CA, 94305, USA.
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14
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Rodríguez González IP, Espinosa Domínguez E, Quesada García C, Rodríguez Chimeno Á, Borges R. Comparison between different epidural analgesia modalities for labor. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2019; 66:417-424. [PMID: 31138442 DOI: 10.1016/j.redar.2019.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 02/28/2019] [Accepted: 03/04/2019] [Indexed: 06/09/2023]
Abstract
INTRODUCTION In recent years new modalities of epidural analgesia maintenance (EA) have been introduced. OBJECTIVE The objective of this study is to compare different modalities of EA maintenance for childbirth relating the time of expulsive and dilatation, motor blockade and delivery instrumentation (caesarean section, sucker, forceps, eutocic delivery or non-instrumented delivery). MATERIAL AND METHODS Patients admitted for labor in the University Hospital Nuestra Señora de Candelaria between January 2013 and December 2015 were included. Independent modalities of EA, continuous infusion (CI), continuous infusion plus analgesia patient controlled epidural analgesia were determined as independent variables (CI+PCEA) and intermittent programmed epidural boluses plus patient controlled epidural analgesia (PIEB+PCEA). RESULTS There are no differences in expulsive time or dilation. There is a difference in the type of instrumentation, caesarean section, sucker, forceps, eutocic delivery or non-instrumented delivery (P>.05), with the percentage of eutocic deliveries in PIEB+PCEA of 66 versus 60 in CI and 65 in CI+PCEA. The percentage of caesarean sections was 23 in CI, in CI+PCEA and PIEB+PCEA of 17. CI increases by 27% the possibility of instrumented deliveries respect to PIEB+PCEA, there is no difference between CI+PCEA and PIEB+PCEA. The motor blockade at 60 and 90minutes reaches lower values with PIEB+PCEA with an average of 0 and a range of 0-1, compared to CI+PCEA 0 (0-4). Satisfaction with CI+PCEA ranges from 2-10 and with PIEB+PCEA 0-10. CONCLUSION It is possible to say that PIEB+PCEA is associated with higher frequency of non-instrumented deliveries. The possibility of instrumented deliveries increases with CI versus PIEB+PCEA. There is less motor block with PIEB+PCEA than with CI+PCEA. There are no differences in time of dilatation, expulsion, or patient satisfaction.
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Affiliation(s)
- I P Rodríguez González
- Servicio de Anestesiología y Reanimación, Hospital Universitario Nuestra Señora de Candelaria, Tenerife, España.
| | - E Espinosa Domínguez
- Servicio de Anestesiología y Reanimación, Hospital Universitario Nuestra Señora de Candelaria, Tenerife, España
| | - C Quesada García
- Servicio de Anestesiología y Reanimación, Hospital Universitario Nuestra Señora de Candelaria, Tenerife, España
| | - Á Rodríguez Chimeno
- Servicio de Anestesiología y Reanimación, Hospital Universitario Nuestra Señora de Candelaria, Tenerife, España
| | - R Borges
- Cátedra de Farmacología, la Universidad de la Laguna, Tenerife, España
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15
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Fidkowski CW, Shah S, Alsaden MR. Programmed intermittent epidural bolus as compared to continuous epidural infusion for the maintenance of labor analgesia: a prospective randomized single-blinded controlled trial. Korean J Anesthesiol 2019; 72:472-478. [PMID: 31216846 PMCID: PMC6781207 DOI: 10.4097/kja.19156] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 06/06/2019] [Indexed: 02/05/2023] Open
Abstract
Background Programmed intermittent epidural bolus (PIEB) techniques are a new area of interest for maintaining labor analgesia due to the potential to decrease motor block and improve labor analgesia. This study compares continuous epidural infusion (CEI) to 2 PIEB regimens for labor analgesia. Methods One hundred fifty patients undergoing scheduled induction of labor at term gestation having epidural labor analgesia were randomized to receive an epidural analgesia regimen of bupivacaine 0.125% with fentanyl 2 μg/ml at either PIEB 5 ml every 30 min (Group 5q30), PIEB 10 ml every 60 min (Group 10q60), or 10 ml/h continuous infusion (Group continuous epidural infusion [CEI]). The primary outcome is the pain scores throughout labor. Secondary outcomes include degree of motor block, dermatomal sensory levels, the number of physician-administered boluses, and patient satisfaction. Results While the average pain scores throughout labor did not differ significantly between groups, fewer patients in group 10q60 received physician-administered boluses for breakthrough pain (34.9% in 10q60 vs. 61.0% in 5q30 and 61.9% in CEI, P = 0.022). Dermatomal sensory levels, degree of motor block, and patient satisfaction did not differ significantly between groups. Conclusions Our study suggests that high volume PIEB regimens for labor analgesia decrease breakthrough pain and physician-administered boluses.
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Affiliation(s)
| | - Sonalee Shah
- Department of Anesthesiology, Henry Ford Hospital, Detroit, MI, USA
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16
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17
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Nevo A, Aptekman B, Goren O, Matot I, Weiniger CF. Labor epidural analgesia onset time and subsequent analgesic requirements: a prospective observational single-center cohort study. Int J Obstet Anesth 2019; 40:39-44. [PMID: 31230990 DOI: 10.1016/j.ijoa.2019.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 03/26/2019] [Accepted: 05/10/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND We investigated the correlation between lumbar epidural analgesia onset time and pain intensity at 60 and 120 min after initiation. METHODS We conducted a prospective observational study of nulliparous women receiving lumbar epidural analgesia (initial bolus 15 mL bupivacaine 0.1% with fentanyl 3.33 μg/mL), followed by patient-controlled epidural analgesia (PCEA). The measured variable was lumbar epidural analgesia onset time (time to pain numerical rating score ≤3). Secondary outcomes were pain score at 60 and 120 min and at full dilatation; and analgesic requirements through the labor. RESULTS One-hundred-and-five women were eligible for analysis. There was a significant correlation between lumbar epidural analgesia onset time and pain intensity at 60 min (Spearman's R2=0.286, P=0.003), but not at 120 min (R2=0.030, P=0.76). Women who requested more PCEA boluses during the first 120 min had a longer lumbar epidural analgesia onset time (R2=0.321, P=0.001) and reported higher pain scores at 60 min (R2=0.588, P <0.001) and at 120 min (R2=0.539, P <0.001). Women who reported higher pain scores at 60 min had more pain at 120 min (R2=0.47, P <0.001) and higher analgesic consumption during labor (R2=0.403, P <0.001). Women who were at a greater cervical dilatation at 60 and 120 min had higher pain scores at the same time point (R2=0.259, P=0.008 and R2=0.243, P=0.013 respectively). CONCLUSION There was a correlation between the onset time of lumbar epidural analgesia during labor and the pain score 60 min later but this had disappeared by 120 min.
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Affiliation(s)
- A Nevo
- Division of Anesthesia, Intensive Care and Pain, Tel Aviv Medical Center, Tel Aviv, Israel.
| | - B Aptekman
- Division of Anesthesia, Intensive Care and Pain, Tel Aviv Medical Center, Tel Aviv, Israel
| | - O Goren
- Division of Anesthesia, Intensive Care and Pain, Tel Aviv Medical Center, Tel Aviv, Israel
| | - I Matot
- Division of Anesthesia, Intensive Care and Pain, Tel Aviv Medical Center, Tel Aviv, Israel
| | - C F Weiniger
- Division of Anesthesia, Intensive Care and Pain, Tel Aviv Medical Center, Tel Aviv, Israel; Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel
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18
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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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19
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Gabriel L, Young J, Hoesli I, Girard T, Dell-Kuster S. Generalisability of randomised trials of the programmed intermittent epidural bolus technique for maintenance of labour analgesia: a prospective single centre cohort study. Br J Anaesth 2019; 123:e434-e441. [PMID: 31331592 DOI: 10.1016/j.bja.2019.02.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 01/25/2019] [Accepted: 02/02/2019] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Several randomised controlled trials show that maintenance of labour epidural analgesia with programmed intermittent epidural bolus reduces the maternal motor block compared with maintenance with a continuous infusion. However, these trials were usually restricted to healthy nulliparous parturients. To assess the generalisability of these randomised controlled trials to 'real-world' conditions, we compared maternal motor function (modified Bromage score) over time between healthy nulliparous and parous women using routinely collected quality-control data. METHODS After ethical approval, all parturients receiving programmed intermittent epidural bolus labour analgesia between June 2013 and October 2014 were included in this prospective cohort study. Bupivacaine 0.1% with fentanyl 2 μg ml-1 was used allowing for patient-controlled bolus every 20 min. The maternal motor function (primary outcome) was regularly assessed from insertion of the epidural catheter until delivery. RESULTS Of the 839 parturients included, 553 (66%) were nulliparous and 286 (34%) were parous. The parous women had a shorter median duration of epidural analgesia (3 h 59 min vs 5 h 45 min) and a higher incidence of spontaneous delivery (66% vs 37%). The probability of being in a certain Bromage category at birth was similar in nulliparous and parous women in a general additive model adjusting for duration of epidural analgesia, number of rescue top-ups, and number of catheter manipulations (cumulative odds ratio: 1.18; 95% confidence interval: 0.98-1.41). Parous women required a higher time-weighted number and volume of rescue top-ups. CONCLUSIONS The results of the randomised controlled trials on a reduced motor block with programmed intermittent epidural bolus seem generalisable to parturients typically not included in these trials.
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Affiliation(s)
- L Gabriel
- University of Basel, Basel, Switzerland
| | - J Young
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - I Hoesli
- University of Basel, Basel, Switzerland; Department of Obstetrics and Antenatal Care, University Hospital Basel, Basel, Switzerland
| | - T Girard
- University of Basel, Basel, Switzerland; Department of Anaesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - S Dell-Kuster
- University of Basel, Basel, Switzerland; Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland; Department of Anaesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland.
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20
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Xu J, Zhou J, Xiao H, Pan S, Liu J, Shang Y, Yao S. A Systematic Review and Meta-Analysis Comparing Programmed Intermittent Bolus and Continuous Infusion as the Background Infusion for Parturient-Controlled Epidural Analgesia. Sci Rep 2019; 9:2583. [PMID: 30796286 PMCID: PMC6384894 DOI: 10.1038/s41598-019-39248-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 01/14/2019] [Indexed: 11/09/2022] Open
Abstract
The programmed intermittent epidural bolus (PIEB) technique offers multiple benefits over continuous epidural infusion (CEI), but controversy still exists when it is used in conjunction with a parturient-controlled epidural analgesia (PCEA) regimen. A systematic review and meta-analysis was thus conducted using the Medline, EMBASE, CENTRAL and Web of Science databases with the aim of identifying those randomized controlled trials (RCTs) that performed a comparison between PIEB and CEI in healthy parturients using a PCEA regimen with regard to the duration of labor, labor pain, anesthesia interventions, maternal satisfaction and main side effects. The data were analyzed using a random-effects model. Eleven eligible trials were included, in which 717 participants were allocated to the PIEB + PCEA group and 650 patients were allocated to the CEI + PCEA group. The rate of instrumental delivery, incidence of breakthrough pain, PCEA usage rates and local anesthetic usage were significantly reduced, the labor duration was statistically shorter, and the maternal satisfaction score was significantly improved in the PIEB + PCEA group compared with that in the CEI + PCEA group. There were no differences in the side effects between the two groups. The results of the present study suggest that the PIEB technique in conjunction with the PCEA regimen was more advantageous than CEI + PCEA, but additional studies should be conducted to consistently demonstrate an improvement in the maternal and fetal obstetric outcomes.
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Affiliation(s)
- Jiqian Xu
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Department of Anesthesiology, North Sichuan Medical College Affiliated Hospital, Nanchong, 637000, China.,Institute of Anesthesiology and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Jie Zhou
- Red Cross central blood station of Nanchong, Sichuan, Nanchong, 637000, China
| | - Hairong Xiao
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Institute of Anesthesiology and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Shangwen Pan
- Institute of Anesthesiology and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Jie Liu
- Department of Anesthesiology, North Sichuan Medical College Affiliated Hospital, Nanchong, 637000, China
| | - You Shang
- Institute of Anesthesiology and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Shanglong Yao
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China. .,Institute of Anesthesiology and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
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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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Rodríguez-Campoó MB, Curto A, González M, Aldecoa C. Patient intermittent epidural boluses (PIEB) plus very low continuous epidural infusion (CEI) versus patient-controlled epidural analgesia (PCEA) plus continuous epidural infusion (CEI) in primiparous labour: a randomized trial. J Clin Monit Comput 2018; 33:879-885. [PMID: 30506299 DOI: 10.1007/s10877-018-0229-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 11/23/2018] [Indexed: 10/27/2022]
Abstract
Epidural maintenance technique for labour analgesia updates constantly. Thanks to infusion pumps, the recently developed programmed intermittent epidural bolus (PIEB) may reduce the use of anesthetic drugs and minimize unintended consequences such as cardio or neurotoxicity. Nevertheless, it is not yet a general practice. So far, there are no comparative studies in the literature that address levobupivacaine-based CEI + PCEA versus CEI + PIEB + PCEA. A randomized double-blind trial was carried out to evaluate if PIEB could reduce local anesthetic use compare to PCEA. Primiparous pregnant patients were divided into two groups: PIEB group (continuous infusion plus intermittent automatic doses) and PCEA group (continuous infusion plus PCEA). The primary objective was to analyze the differences between both groups regarding levobupivacaine total dose. The secondary objectives were to find out the differences concerning pain control, motor blockage, satisfaction score, labour time and delivery outcomes. Statistical analyses were done by protocol. The study recruited 200 patients (103 PIEB, 97 PCEA). The total dose administered was significantly higher in PIEB group: PCEA group 52.97 mg, IC 95% 45.65-60.28 mg and PIEB group 62.04 mg, IC 95% 55.46-68.61 mg (p = 0.021). PIEB group required fewer top up boluses (median value1; range 0-2) than CEI + PCEA group (median value 6; range 3-9) p < 0.05. Satisfaction scores were higher in PIEB group (p = 0.039, CI 95% 1.23-1.42). CEI + PIEB was found to be a good alternative to CEI + PCEA with very high rates of satisfaction in both groups although it was higher in PIEB group. PIEB group required fewer PCEA boluses. Further studies are needed to determine the best approach for epidural pain management.Clinical Trial Number and Registry URL: NCT03133091 ( https://clinicaltrials.gov/ct2/show/NCT03133091?term=MB+Rodriguez&rank=1) .
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Affiliation(s)
- Maria Belen Rodríguez-Campoó
- Department of Anesthesia and Surgical Critical Care, Hospital Universitario Rio Hortega (HURH), C/Dulzaina 2, 47012, Valladolid, Spain
| | - Antonio Curto
- Department of Anesthesia and Surgical Critical Care, Hospital Universitario Rio Hortega (HURH), C/Dulzaina 2, 47012, Valladolid, Spain
| | - Manuel González
- Research Unit. Hospital Universitario Rio Hortega (HURH), C/Dulzaina2, 47012, Valladolid, Spain
| | - Cesar Aldecoa
- Department of Anesthesia and Surgical Critical Care, Hospital Universitario Rio Hortega (HURH), C/Dulzaina 2, 47012, Valladolid, Spain.
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Abstract
In recent years, many neuraxial techniques have been introduced to initiate and maintain labour analgesia, with low-dose mixtures of local anaesthetics and opioids, which have improved the quality of analgesia and made it safer for both mother and neonate. An independent search of the databases of PubMed, Medline, and Cochrane controlled trial data was conducted by two researchers, and randomized controlled trials that compared different methods of neuraxial analgesia and the different techniques of maintaining labor analgesia were retrieved and analyzed. The advantages, disadvantages, and indications of each technique along with the doses of intrathecal and epidural drugs are discussed. The myths and controversies involving neuraxial labor analgesia and the current consensus on their effect on the maternal and foetal outcomes are also outlined.
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Affiliation(s)
- Sunanda Gupta
- Department of Anaesthesiology, Geetanjali Medical College and Hospital, Udaipur, Rajasthan, India
| | - Seema Partani
- Department of Anaesthesiology, Geetanjali Medical College and Hospital, Udaipur, Rajasthan, India
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Logtenberg SLM, Verhoeven CJ, Rengerink KO, Sluijs AM, Freeman LM, Schellevis FG, Mol BW. Pharmacological pain relief and fear of childbirth in low risk women; secondary analysis of the RAVEL study. BMC Pregnancy Childbirth 2018; 18:347. [PMID: 30144796 PMCID: PMC6109320 DOI: 10.1186/s12884-018-1986-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 08/16/2018] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Fear of childbirth may reduce the womens' pain tolerance during labour and may have impact on the mother-infant interaction. We aimed to assess (1) the association between fear of childbirth antepartum and subsequent request for pharmacological pain relief, and (2) the association between the used method of pain relief and experienced fear of childbirth as reported postpartum in low risk labouring women. METHODS Secondary analysis of the RAVEL study, a randomised controlled trial comparing remifentanil patient controlled analgesia (PCA) and epidural analgesia to relieve labour pain. The RAVEL study included 409 pregnant women at low risk for obstetric complications at 18 midwifery practices and six hospitals in The Netherlands (NTR 3687). We measured fear of childbirth antepartum and experienced fear of childbirth reported postpartum, using the Wijma Delivery Expectancy/Experience Questionnaire. RESULTS Women with fear of childbirth antepartum more frequently requested pain relief compared to women without fear of childbirth antepartum, but this association did not reach statistical significance (adjusted odds ratio (aOR2.0; 95% confidence interval (CI) 0.8-4.6). Women who received epidural analgesia more frequently reported fear of childbirth postpartum compared to women who did not receive epidural analgesia (aOR3.5; CI 1.5-8.2), while the association between remifentanil-PCA and fear of childbirth postpartum was not statistically significant (aOR1.7; CI 0.7-4.3). CONCLUSIONS Women with fear of childbirth antepartum more frequently requested pain relief compared to women without fear of childbirth antepartum, but this association was not statistically significant. Women who received pharmacological pain relief more frequently reported that they had experienced fear of childbirth during labour compared to women who did not receive pain relief. Based on our data epidural analgesia with continuous infusion does not seem to be preferable over remifentanil-PCA as method of pain relief when considering fear of childbirth postpartum. TRIAL REGISTRATION Netherlands Trial Register 3687 ; Register date: 5 Nov 2012.
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Affiliation(s)
- Sabine L. M. Logtenberg
- Department of Obstetrics and Gynaecology, Amsterdam UMC, Academic Medical Centre Amsterdam, Meibergdreef 9, 1105 ZA Amsterdam, The Netherlands
- Department of Midwifery Science, AVAG, Amsterdam Public Health research institute, Amsterdam, the Netherlands
| | - Corine J. Verhoeven
- Department of Midwifery Science, AVAG, Amsterdam Public Health research institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Obstetrics and Gynaecology Maxima Medical Centre, Veldhoven, The Netherlands
| | - Katrien Oude Rengerink
- Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, the Netherlands
| | - Anne-Marie Sluijs
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Liv M. Freeman
- Department of Obstetrics and Gynaecology, Ikazia Medical Centre, Rotterdam, The Netherlands
| | - François G. Schellevis
- Department of General Practice & Elderly Care Medicine, Amsterdam Public Health research institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
| | - Ben Willem Mol
- Department of Obstetrics and Gynaecology, Amsterdam UMC, Academic Medical Centre Amsterdam, Meibergdreef 9, 1105 ZA Amsterdam, The Netherlands
- Monash University Clayton, Clayton, Victoria Australia
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Nanji JA, Carvalho B. Modern techniques to optimize neuraxial labor analgesia. Anesth Pain Med (Seoul) 2018. [DOI: 10.17085/apm.2018.13.3.233] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Jalal A. Nanji
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Brendan Carvalho
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Baliuliene V, Macas A, Rimaitis K. The optimal concentration of bupivacaine and levobupivacaine for labor pain management using patient-controlled epidural analgesia: a double-blind, randomized controlled trial. Int J Obstet Anesth 2018; 35:17-25. [PMID: 29914785 DOI: 10.1016/j.ijoa.2018.05.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Revised: 04/29/2018] [Accepted: 05/09/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND The study aim was to evaluate the efficacy and safety of different low concentrations of two local anesthetics for labor analgesia using patient-controlled epidural analgesia. METHODS A double-blind, randomized controlled trial recruiting healthy nulliparous women was conducted from 2014 to 2017. Epidural analgesia was provided using local anesthetic and fentanyl. Patients were allocated to six groups, according to the concentration of bupivacaine or levobupivacaine (0.0625%, 0.1%, 0.125%). Analgesic efficacy, vital parameters, and side effects were evaluated at different time points. Satisfaction was evaluated using verbal and written scores. The primary outcome was the total dose of local anesthetic used. RESULTS Two-hundred-and-thirty-seven cases were analyzed. The total dose of local anesthetic was significantly lower in the two lower concentration groups (P <0.0001). The rate of cesarean section was lower in 0.1% bupivacaine versus 0.1% levobupivacaine (P=0.005), 0.125% levobupivacaine (P=0.049) and 0.125% bupivacaine (P=0.002) groups. Pain breakthrough, patient-controlled and rescue boluses were significantly different between groups (P=0.03, P=0.003 and P <0.0001 respectively). The rate of motor block increased with higher concentrations (P=0.033), but the incidence of other maternal and fetal side effects was not significantly different. Satisfaction with labor analgesia did not differ across groups. Satisfaction score 72 hours after delivery was significantly lower than that two hours after delivery (P <0.0001). CONCLUSIONS Higher local anesthetic concentration resulted in higher total doses infused and greater motor block. Labor analgesia was less effective when the lowest concentrations were used, but patient satisfaction was unaffected.
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Affiliation(s)
- V Baliuliene
- Department of Anesthesiology, Lithuanian University of Health Sciences, Academy of Medicine, A. Mickeviciaus 9, 44307 Kaunas, Lithuania; Department of Anesthesiology, The Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Eiveniu 2, 50161 Kaunas, Lithuania.
| | - A Macas
- Department of Anesthesiology, Lithuanian University of Health Sciences, Academy of Medicine, A. Mickeviciaus 9, 44307 Kaunas, Lithuania; Department of Anesthesiology, The Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Eiveniu 2, 50161 Kaunas, Lithuania
| | - K Rimaitis
- Department of Anesthesiology, Lithuanian University of Health Sciences, Academy of Medicine, A. Mickeviciaus 9, 44307 Kaunas, Lithuania; Department of Anesthesiology, The Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Eiveniu 2, 50161 Kaunas, Lithuania
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Vedagiri Sai R, Singh SI, Qasem F, Nguyen D, Dhir S, Marmai K, Adam R, Jones PM. Onset of labour epidural analgesia with low-dose bupivacaine and different doses of fentanyl. Anaesthesia 2017; 72:1371-1378. [DOI: 10.1111/anae.14000] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2017] [Indexed: 11/30/2022]
Affiliation(s)
- R. Vedagiri Sai
- Department of Anesthesia and Peri-operative Medicine; Western University; London Ontario Canada
| | - S. I. Singh
- Department of Anesthesia and Peri-operative Medicine; Western University; London Ontario Canada
| | - F. Qasem
- Department of Anesthesia and Peri-operative Medicine; Western University; London Ontario Canada
| | - D. Nguyen
- Department of Anesthesia and Peri-operative Medicine; Western University; London Ontario Canada
| | - S. Dhir
- Department of Anesthesia and Peri-operative Medicine; Western University; London Ontario Canada
| | - K. Marmai
- Department of Epidemiology and Biostatistics; Schulich School of Medicine and Dentistry; Western University; London Ontario Canada
| | - R. Adam
- Department of Epidemiology and Biostatistics; Schulich School of Medicine and Dentistry; Western University; London Ontario Canada
| | - P. M. Jones
- Department of Anesthesia and Peri-operative Medicine; Western University; London Ontario Canada
- Department of Epidemiology and Biostatistics; Schulich School of Medicine and Dentistry; Western University; London Ontario Canada
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29
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Sodha S, Reeve A, Fernando R. Central neuraxial analgesia for labor: an update of the literature. Pain Manag 2017; 7:419-426. [PMID: 28936908 DOI: 10.2217/pmt-2017-0010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Numerous techniques are in use to provide analgesia for labor, of which central neuraxial block is widely considered superior to non-neuraxial options. Central neuraxial techniques have evolved over many years to provide greater efficacy, safety and maternal satisfaction. This narrative review focuses on the literature relating to central neuraxial labor analgesia from the past 5 years, from November 2010 to October 2015. We discuss the evidence related to the various central neuraxial techniques used, the increasingly widespread use of ultrasound guidance and the evidence surrounding other novel methods of central neuraxial block insertion. The timing of institution of central neuraxial analgesia in labor is considered, as are the advances in maintenance regimens for labor analgesia.
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Affiliation(s)
- Serena Sodha
- Obstetric Anaesthesia Research Fellow, Department of Anesthesia, University College Hospital, London, UK
| | - Alexandra Reeve
- Consultant, Department of Anesthesia, University College Hospital, London, UK
| | - Roshan Fernando
- Consultant, Department of Anesthesia, University College Hospital, London, UK
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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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Koh JC, Song Y, Kim SY, Park S, Ko SH, Han DW. Postoperative pain and patient-controlled epidural analgesia-related adverse effects in young and elderly patients: a retrospective analysis of 2,435 patients. J Pain Res 2017; 10:897-904. [PMID: 28442931 PMCID: PMC5396922 DOI: 10.2147/jpr.s133235] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
In this retrospective study, data of 2,435 patients who received fentanyl and ropivacaine-based patient-controlled epidural analgesia (PCEA) for pain relief after elective surgery under general or spinal anesthesia were reviewed. Differences in postoperative pain, incidence of patient-controlled analgesia (PCA)-related adverse effects, and risk factors for the need for rescue analgesics for 48 hours postsurgery in young (age 20–39 years) and elderly (age ≥70 years) patients were evaluated. Although there were no significant differences in postoperative pain intensity between the two groups until 6 hours postsurgery, younger patients experienced greater postoperative pain intensity compared with older patients 6–48 hours postsurgery. While younger patients exhibited greater incidence of numbness, motor weakness, and discontinuation of PCA postsurgery, elderly patients exhibited greater incidence of hypotension, nausea/vomiting, rescue analgesia, and antiemetic administration. Upon multivariate analysis, low fentanyl dosage and history of smoking were found to be associated with an increased need for rescue analgesia among younger patients, while physical status classification III/IV and thoracic surgery were associated with a decreased need for rescue analgesia among the elderly. Discontinuation of PCA was more frequent among younger patients than the elderly (18.5% vs 13.5%, P=0.001). Reasons for discontinuation of PCA among young and elderly patients, respectively, were nausea and vomiting (6.8% vs 26.6%), numbness or motor weakness (67.8% vs 11.5%), urinary retention (7.4% vs 8.7%), dizziness (2.2% vs 5.2%), and hypotension (3.1% vs 20.3%). In conclusion, PCEA was more frequently associated with numbness, motor weakness, and discontinuation of PCA in younger patients and with hypotension, nausea/vomiting, and a greater need for rescue analgesics/antiemetics among elderly patients. Therefore, in order to minimize the adverse effects of PCEA and enhance pain relief, different PCEA regimens and administration/prevention strategies should be considered for young and elderly patients.
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Affiliation(s)
- Jae Chul Koh
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Young Song
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - So Yeon Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Sooyeun Park
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Seo Hee Ko
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Dong Woo Han
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
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Riley ET, Carvalho B. Programmed Intermittent Epidural Boluses (PIEB) for Maintenance of Labor Analgesia: A Superior Technique to Continuous Epidural Infusion? Turk J Anaesthesiol Reanim 2017; 45:65-66. [PMID: 28439433 DOI: 10.5152/tjar.2017.09031] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Edward T Riley
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA
| | - Brendan Carvalho
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA
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Sng BL, Sia ATH. Maintenance of epidural labour analgesia: The old, the new and the future. Best Pract Res Clin Anaesthesiol 2017. [DOI: 10.1016/j.bpa.2017.01.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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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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Labor Pain. PAIN MEDICINE 2017. [DOI: 10.1007/978-3-319-43133-8_137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Lee L, Dy J, Azzam H. Prise en charge du travail spontané chez les femmes en santé, à terme. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2016; 38:866-890. [DOI: 10.1016/j.jogc.2016.04.096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Lee L, Dy J, Azzam H. Management of Spontaneous Labour at Term in Healthy Women. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2016; 38:843-865. [DOI: 10.1016/j.jogc.2016.04.093] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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38
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Clonidine versus sufentanil as an adjuvant to ropivacaine in patient-controlled epidural labour analgesia: A randomised double-blind trial. Eur J Anaesthesiol 2016; 32:805-11. [PMID: 26426577 DOI: 10.1097/eja.0000000000000347] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Adjuvants to local anaesthetics for epidural labour analgesia are useful if they reduce side-effects or personnel requirements. Epidural clonidine improves analgesia and provides a significant local anaesthetic-sparing effect. OBJECTIVE To compare the number of rescue doses administered by the anaesthesiologist when clonidine or sufentanil is added to epidural ropivacaine. DESIGN A randomised double-blind trial. SETTING Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium, from June 2009 to June 2010. PATIENTS One hundred and ninety-five women in labour. INTERVENTION Epidural analgesia initiated with 10 ml ropivacaine 0.1%, women randomised to receive patient-controlled epidural analgesia (5 ml demand bolus, 15 min lockout) with ropivacaine 0.1% and sufentanil 0.25 μg ml⁻¹ (RS group; n = 65), or ropivacaine 0.1% and clonidine 1.5 μg ml⁻¹ (RC1.5 group; n = 65) or ropivacaine 0.1% and clonidine 3 μg ml⁻¹ (RC3 group; n = 65). Rescue analgesia was available as needed – 10 ml ropivacaine 0.1% (numerical rating scale <6/10) or ropivacaine 0.2% (numerical rating scale ≥6/10). MAIN OUTCOME Comparison of the total number of rescue doses. RESULTS The total number of rescue doses was similar among the groups [median (interquartile range): 1 (0 to 1) in the RC1.5 group, 1 (1 to 2) in the RC3 group and 2 (1 to 2) in the RS group; overall P = 0.056]. However, fewer patients in both the RC1.5 and RC3 groups needed two or more rescue doses (25 and 29% versus 52% in the RS group, P = 0.01). The rate of instrumental delivery was higher in both clonidine groups (13 and 12% versus 0%, P = 0.03). Nausea was significantly less frequent in both the clonidine groups. Satisfaction scores, total ropivacaine consumption, maternal sedation, and hypotension and neonatal outcomes were similar among the groups. CONCLUSION Compared with sufentanil 0.25 μg ml⁻¹, addition of clonidine (1.5 to 3 μg ml⁻¹) to patient-controlled epidural analgesia with ropivacaine 0.1% provided similar labour analgesia and a similar need for anaesthesiologist-administered rescue doses. Clonidine 3 μg ml⁻¹ did not offer any advantage over clonidine 1.5 μg ml⁻¹. The instrumentation rate was higher in both the clonidine groups.
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Traynor AJ, Aragon M, Ghosh D, Choi RS, Dingmann C, Vu Tran Z, Bucklin BA. Obstetric Anesthesia Workforce Survey. Anesth Analg 2016; 122:1939-46. [DOI: 10.1213/ane.0000000000001204] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Koyyalamudi V, Sidhu G, Cornett EM, Nguyen V, Labrie-Brown C, Fox CJ, Kaye AD. New Labor Pain Treatment Options. Curr Pain Headache Rep 2016; 20:11. [DOI: 10.1007/s11916-016-0543-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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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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Heesen M, Böhmer J, Klöhr S, Hofmann T, Rossaint R, Straube S. The Effect of Adding a Background Infusion to Patient-Controlled Epidural Labor Analgesia on Labor, Maternal, and Neonatal Outcomes. Anesth Analg 2015; 121:149-158. [DOI: 10.1213/ane.0000000000000743] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Specially Trained Registered Nurses Can Safely Manage Epidural Analgesia Infusion in Laboring Patients. J Perianesth Nurs 2015; 30:209-14. [DOI: 10.1016/j.jopan.2015.01.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 01/21/2015] [Accepted: 01/28/2015] [Indexed: 11/20/2022]
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Han C, Zhou Q, Ding Z, Qian Y. Effects of epinephrine in the epidural space on the incidence of blood vessel injury by epidural catheter insertion for cesarean section: a prospective, randomized, double-blind study. J Clin Anesth 2014; 27:7-11. [PMID: 25468590 DOI: 10.1016/j.jclinane.2014.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Revised: 08/30/2014] [Accepted: 09/14/2014] [Indexed: 11/26/2022]
Abstract
STUDY OBJECTIVE To evaluate the effects of epinephrine (1:200,000) in the epidural space on the incidence of blood vessel injury by epidural catheter insertion for cesarean section. DESIGN Prospective observational study. SETTING University-affiliated teaching hospital. PATIENTS Four hundred laboring women with singleton cephalic presentations at term who underwent cesarean section and requested continuous epidural analgesia. INTERVENTIONS Predistension of 5 mL of isotonic sodium chloride solution containing epinephrine (1:200,000) or 5 mL of isotonic sodium chloride solution through an epidural needle before catheter insertion. MEASUREMENTS Cases with bloody fluid in the epidural needle or catheter during catheter insertion, aspiration of frank blood from the epidural catheter, and blood noted in the caudal end of the epidural catheter upon removal were recorded. MAIN RESULTS Eight parturients were excluded from the analysis for technical reasons. There were no significant differences between patients in the 2 groups with respect to cases with bloody fluid in the epidural needle during catheter insertion (7.6% vs 9.8%, P = .44), the epidural catheter during catheter placement (6.0% vs 6.7%, P = .80), aspiration of frank blood in the epidural catheter (1.0% vs 1.0 %, P = .98), and blood noted in the caudal end of the epidural catheter upon removal (27.3% vs 30.4 %; P > .49). CONCLUSION Twenty-five micrograms of epinephrine (1:200,000) in the epidural space does not reduce the incidence of blood vessel injury induced by insertion of an epidural catheter.
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Affiliation(s)
- Chuanbao Han
- Department of Anesthesiology, First Affiliated Hospital, Nanjing Medical University, Nanjing, China.
| | - Qinhai Zhou
- Department of Anesthesiology, First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Zhengnian Ding
- Department of Anesthesiology, First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Yanning Qian
- Department of Anesthesiology, First Affiliated Hospital, Nanjing Medical University, Nanjing, China
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Sng BL, Woo D, Leong WL, Wang H, Assam PN, Sia AT. Comparison of computer-integrated patient-controlled epidural analgesia with no initial basal infusion versus moderate basal infusion for labor and delivery: A randomized controlled trial. J Anaesthesiol Clin Pharmacol 2014; 30:496-501. [PMID: 25425774 PMCID: PMC4234785 DOI: 10.4103/0970-9185.142842] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Background and Aims: Computer-integrated patient-controlled epidural analgesia (CIPCEA) is a novel epidural drug delivery system. It automatically adjusts the basal infusion based on the individual's need for analgesia as labor progresses. Materials and Methods: This study compared the time-weighted local anesthetic (LA) consumption by comparing parturients using CIPCEA with no initial basal infusion (CIPCEA0) with CIPCEA with initial moderate basal infusion of 5 ml/H (CIPCEA5). We recruited 76 subjects after ethics approval. The computer integration of CIPCEA titrate the basal infusion to 5, 10, 15, or 20 ml/H if the parturient required respectively, one, two, three, or four patient demands in the previous hour. The basal infusion reduced by 5 ml/H if there was no demand in the previous hour. The sample size was calculated to show equivalence in LA consumption. Results: The time-weighted LA consumption between both groups were similar with CIPCEA0 group (mean [standard deviation (SD)] 8.9 [3.5] mg/H) compared to the CIPCEA5 group (mean [SD] 9.9 [3.5] mg/H), P = 0.080. Both groups had a similar incidence of breakthrough pain, duration of the second stage, mode of delivery, and patient satisfaction. However, more subjects in the CIPCEA0 group required patient self-bolus. There were no differences in fetal outcomes. Discussion: Both CIPCEA regimens had similar time-weighted LA consumption and initial moderate basal infusion with CIPCEA may not be required.
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Affiliation(s)
- Ban Leong Sng
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore ; Anesthesiology Program, Duke-NUS Graduate Medical School, Singapore
| | - David Woo
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore
| | - Wan Ling Leong
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore
| | - Hao Wang
- Anesthesiology Program, Duke-NUS Graduate Medical School, Singapore
| | - Pryseley Nkouibert Assam
- Centre for Quantitative Medicine, Duke-NUS Graduate Medical School, Singapore ; Singapore Clinical Research Institute, Singapore
| | - Alex Th Sia
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore ; Anesthesiology Program, Duke-NUS Graduate Medical School, Singapore
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Meisenzahl D, Souquet J, Kessler P. [Perioperative pain management: what is evidence based?]. DER ORTHOPADE 2014; 43:1079-81, 1084-8. [PMID: 25380683 DOI: 10.1007/s00132-014-3039-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Adequate post-operative acute pain therapy after spinal surgical procedures is essential for many patients. However, patients already receiving chronic opioid therapy pre-operatively present a special challenge for the treating physician during the post-operative period when managing their acute pain. The team must consider multiple approaches of acute pain management and it is important to proceed according to current evidence-based methods. THERAPY A wide spectrum of options for pain management after spinal surgery is currently available. This includes various therapeutic methods as well as regional anesthesia. Considering the various options, the method of choice for post-operative analgesia depends on the expected pain, therapy effectiveness, and the applicability with regard to potential side-effects. METHOD In addition to the basic analgesic therapy consisting of opioid and non-opioid drugs, chronic pain patients may require co-analgesics or combination analgesics from this class. CONCLUSION Regional anesthesia is currently the predominant method of choice for post-operative acute pain management. Neuraxial blockage is especially important when considering all spinal procedures.
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Affiliation(s)
- D Meisenzahl
- Abteilung für Anästhesiologie, Intensiv- und Schmerzmedizin, Orthopädische Universitätsklinik Friedrichsheim gGmbH (Stiftung Friedrichsheim), Leiter: Professor P. Kessler, Marienburgstr. 2, 60528, Frankfurt, Deutschland,
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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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