The effect of programmed intermittent epidural bolus compared with continuous epidural infusion in labor analgesia with ropivacaine: a meta-analysis of randomized controlled trials.

BACKGROUND: Programmed intermittent epidural bolus (PIEB) as a new technique for labor analgesia has aroused extensive attention. The character of separation of the motor block to sensory block makes ropivacaine becoming an important local anesthetic for labor analgesia. In this meta-analysis, we aimed to assess the efficiency and safety of PIEB regime compared to continuous epidural infusion (CEI) regime on labor analgesia with ropivacaine following the evidence emerged newly. METHODS: PubMed, EMBASE and the Cochrane library were searched for potential articles. Eligible studies should meet these criterions: (I) healthy women; (II) it should compare PIEB and CEI; (III) ropivacaine should be use as local anesthetic for the maintenance of analgesia; (IV) the study should report the any of the outcomes we need. Maternal satisfaction, consumption of ropivacaine and duration of labor as well as the adverse effect were used to measure the efficacy and safety of those two regimes. Mean difference (MD), relative risk (RR), 95% confidence intervals (CI) were used to present the final results. RESULTS: Ten articles of randomized controlled trials and 3,790 subjects were eventually included in study. The pooled results showed that PIEB with ropivacaine significantly improved satisfaction (MD, 7.87; 95% CI: 6.02 to 9.72; I2 =0%; P<0.001), reduced the local anesthetic (milligram) in total (MD, -10.37 milligrams; 95% CI: -17.70 to -3.03; I2 =94%; P<0.001) and hourly (MD, -1.80 milligrams; 95% CI: -2.62 to -0.98; I 2 =56%; P<0.001). PIEB shortened the second stage of labor but has similar total duration of labor and it also decrease the incidence of motor block compare to CEI. There were no differences in mode of delivery and rescue bolus between two groups. CONCLUSIONS: This study shows that PIEB regime was associated with higher satisfaction, lower consumption of ropivacaine in hours and totally, and shorter duration of second stage of labor compared to CEI in analgesia with ropivacaine during childbirth. PIEB regime has greater safety on fetus and maternity than CEI regime and it decreased the incidence of motor block without increasing other side effects compared to CEI.

A randomized trial of the dural puncture epidural technique combined with programmed intermittent epidural boluses for labor analgesia.

BACKGROUND: Continuous epidural infusion (CEI) can provide analgesia during labor. The dural puncture epidural (DPE) technique is used to accelerate the onset of neuraxia anesthesia. The primary objective of this study was to compare the percentage of patients that received adequate labor analgesia following an injection of 0.08% epidural ropivacaine via the DPE and CEI techniques combined with the PIEB mode of maintenance. METHODS: Patients who were laboring were randomly allocated to receive either CEI + PIEB or DPE + PIEB. Subjects indicated a VAS score immediately prior to epidural placement, and parturients with a VAS score of ≤50 mm were excluded. A 25-gauge needle was used for dural puncture. Analgesia was provided with 10 mL of 0.08% ropivacaine and 0.4 µg/mL of sufentanil, and was maintained at 10 mL/h in both groups with the same solution. All pumps were programmed for patient-controlled epidural analgesia (PCEA) boluses of 5 mL with a 20-minute lockout. VAS measurements were collected at 2-minute intervals for up to 20 minutes after initiation of the epidural bolus. The median time to adequate analgesia was analyzed using Kaplan-Meier curves and Cox proportional hazard models. RESULTS: Data were collected and analyzed from 200 participants (n=100 per group). Adequate analgesia at 10 minutes was higher in the DPE + PIEB group compared to the CEI + PIEB group (DPE + PIEB =58.4% vs. CEI + PIEB =41.6%; P=0.007). The DPE + PIEB group also had a shorter median time to adequate analgesia [median (95% confidence interval (CI), 8 minutes (7-9 minutes) vs. 12 minutes (10-14 minutes)] compared to the CEI + PIEB group [hazard ratio (HR) =1.488; 95% CI, 1.105-2.002; P=0.002]. CONCLUSIONS: The percentage of parturients with adequate analgesia at 10 minutes was higher with DPE + PIEB compared to CEI + PIEB. Furthermore, the DPE + PIEB mode was associated with a faster time to a VAS score ≤30 mm.

A Meta-Analysis of Comparing Intermittent Epidural Boluses and Continuous Epidural Infusion for Labor Analgesia.

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.

Epidural Analgesia for Labor: Continuous Infusion Versus Programmed Intermittent Bolus.

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.