High-volume patient-controlled epidural vs. programmed intermittent epidural bolus for labour analgesia: a randomised controlled study.

The aim of neuraxial analgesia is to achieve excellent pain relief with the fewest adverse effects. The most recently introduced technique for epidural analgesia maintenance is the programmed intermittent epidural bolus. In a recent study, we compared this with patient-controlled epidural analgesia without a background infusion and found that a programmed intermittent epidural bolus was associated with less breakthrough pain, lower pain scores, higher local anaesthetic consumption and comparable motor block. However, we had compared 10 ml programmed intermittent epidural boluses with 5 ml patient-controlled epidural analgesia boluses. To overcome this potential limitation, we designed a randomised, multicentre non-inferiority trial using 10 ml boluses in each group. The primary outcome was the incidence of breakthrough pain and total analgesic intake. Secondary outcomes included motor block; pain scores; patient satisfaction; and obstetric and neonatal outcomes. The trial was considered positive if two endpoints were met: non-inferiority of patient-controlled epidural analgesia with respect to breakthrough pain; and superiority of patient-controlled epidural analgesia with respect to local anaesthetic consumption. A total of 360 nulliparous women were allocated randomly to patient-controlled epidural analgesia-only or programmed intermittent epidural bolus groups. The patient-controlled group received 10 ml boluses of ropivacaine 0.12% with sufentanil 0.75 µg.ml-1 ; the programmed intermittent group received 10 ml boluses supplemented by 5 ml patient-controlled boluses. The lockout period was 30 min in each group and the maximum allowed hourly local anaesthetic/opioid consumption was identical between the groups. Breakthrough pain was similar between groups (11.2% patient controlled vs. 10.8% programmed intermittent, p = 0.003 for non-inferiority). Total ropivacaine consumption was lower in the PCEA-group (mean difference 15.3 mg, p < 0.001). Motor block, patient satisfaction scores and maternal and neonatal outcomes were similar across both groups. In conclusion, patient-controlled epidural analgesia is non-inferior to programmed intermittent epidural bolus if equal volumes of patient-controlled epidural analgesia are used to maintain labour analgesia and superior with respect to local anaesthetic consumption.

Changes in sensory block level during a programmed intermittent epidural bolus regimen for labour analgesia: a prospective observational cohort study.

PURPOSE: In the context of a programmed intermittent epidural bolus (PIEB) regimen for labour analgesia, one can identify an upper sensory block level (USBL), defined as the highest dermatome with any altered sensation to cold, and a lower sensory block level (LSBL), defined as the highest dermatome with complete sensory block to cold. This study investigated whether and how these sensory block levels vary within PIEB cycles. METHODS: We enrolled patients requesting epidural analgesia. An epidural catheter was placed at L2/L3 or L3/L4. A test dose of 3 mL of bupivacaine 0.125% with fentanyl 3.3 µg·mL-1 was administered, followed by 12 mL of the same solution as the loading dose. A PIEB plus patient-controlled epidural analgesia (PCEA) regimen was initiated 40 min after the loading dose, with bupivacaine 0.0625% with fentanyl 2 µg·mL-1: PIEB 10 mL, PIEB interval 40 min, PCEA 5 mL, lockout interval 10 min, maximum hourly 30 mL. As per institutional protocol, sensory block levels to ice were assessed 20 min after the loading dose and then hourly. Patients included in the study underwent eight extra assessments: immediately before the second and fourth PIEB and 10, 20, and 30 min after the second and third PIEB. RESULTS: We studied 30 patients. The USBL and LSBL achieved their peak value 100 min after the loading dose. The median [interquartile range] USBL was T8 [T9-T7] and T6 [T7-T4] 20 and 100 min after the loading dose, respectively; LSBL was T10 [T11-T6] and T8 [T9-T6], respectively. There was no significant variation in USBL or LSBL within the PIEB cycle between the second and the third or the third and the fourth PIEB. CONCLUSION: Once peak sensory block levels are established, there is no significant variation in the USBL and LSBL within the PIEB cycles. STUDY REGISTRATION: www. CLINICALTRIALS: gov (NCT04716660); registered 21 January 2021.

RéSUMé: OBJECTIF: Dans le contexte du schéma de bolus périduraux intermittents programmés (PIEB) pour l'analgésie du travail, on peut identifier un niveau de bloc sensoriel haut (USBL) défini comme étant le dermatome le plus haut ayant une quelconque modification de la sensation au froid et un niveau de bloc sensoriel bas (LSBL) défini comme étant le dermatome le plus haut ayant un bloc sensoriel complet au froid. Cette étude a cherché à savoir si et comment ces niveaux de blocs sensoriels varient au cours des cycles de PIEB. MéTHODES: Nous avons recruté des patientes demandant une analgésie péridurale. Un cathéter péridural a été placé au niveau L2/L3 ou au niveau L3/L4. Une dose test de 3 mL de bupivacaïne 0,125% avec fentanyl 3,3 µg·ml−1 était administrée, suivie de 12 mL de la même solution représentant la dose de base. Un protocole de PIEB plus analgésie péridurale contrôlée par la patiente (PCEA) a débuté 40 min après l'administration de la dose de base, comportant de la bupivacaïne 0,0625% et du fentanyl 2 µg·ml−1: PIEB 10 mL; intervalle de PIEB 40 min.; PCEA 5 ml; intervalle de verrouillage 10 min.; maximum par heure 30 mL. Conformément au protocole de l'établissement, les niveaux de bloc sensoriel à la glace ont été évalués 20 min après l'administration de la dose de base, puis toutes les heures. Les patientes incluses dans l'étude ont eu huit évaluations supplémentaires: immédiatement avant le deuxième et le quatrième PIEB et 10, 20 et 30 min après les deuxième et troisième PIEB. RéSULTATS: Nous avons étudié 30 patientes. L'USBL et le LSBL ont atteint leur valeur pic 100 min après l'administration de la dose de base. L'USBL médian [plage interquartile] était T8 [T9­T7] et T6 [T7­T4], respectivement 20 et 100 min après la dose de base; Le LSBL était, respectivement, T10 [T11­T6] et T8 [T9­T6]. Il n'y avait pas de variation significative de l'USBL ou du LSBL dans le cycle de PIEB entre le deuxième et le troisième ou le troisième et le quatrième PIEB. CONCLUSION: Une fois les niveaux maximums de blocs sensoriels établis, il n'y a pas de variation significative dans l'USBL et le LSBL dans les cycles de PIEB. ENREGISTREMENT DE L'éTUDE: www.clinicaltrials.gov (NCT04716660); enregistrée le 21 janvier 2021.

Programmed intermittent epidural bolus vs. patient-controlled epidural analgesia for maintenance of labour analgesia: a two-centre, double-blind, randomised study†.

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.

[Pain therapy during labour]. / Schmerztherapie während der Geburt.

To date the gold standard of treating labour pain is regional analgesia by application of epidural analgesia. When offering epidural analgesia, the programmed intermittent epidural bolus (PIEB) is more effective in terms of pain reduction, less motor blocks and higher satisfaction of the parturient compared to continuous application via perfusor pump. An upcoming alternative to epidural analgesia is remifentanil, a short acting and potent opioid. Remifentanil, however, requires haemodynamic monitoring as cardiac and respiratory impairment has been described. Nitrous oxide has been used for decades in the Anglosphere but it is a greenhouse gas, and interactions with Vitamin B12 are possible. Using novel extraction systems, nitrous oxide has become more attractive for treatment of the initial phase of labour pain in Central Europe. In order to provide the parturient with the best possible and with a tailored pain concept an interdisciplinary approach with obstetricians, midwives and anaesthesiologists is required.

Programmed Intermittent Epidural Boluses of 0.1% Ropivacaine Versus 0.2% Ropivacaine for the Maintenance of Epidural Analgesia in Labor.

Objective The gold standard for pain management during labor is epidural analgesia, which can be administered in two different ways to the parturients, either by bolus doses or continuous infusions of local anesthetic solutions with opioids. Recently, programmed intermittent epidural boluses (PIEBs) via a pump are gaining popularity as a very effective method with minimal side effects. The aim of this study was to evaluate the optimum ropivacaine concentration between two different regimens (0.1% or 0.2% both with fentanyl 2 µg/ml) that can provide satisfactory analgesia with the minimum degree of motor blockade, using PIEBs. Methods A prospective randomized controlled study was performed from March 2020 to March 2022. Two different concentrations of ropivacaine 0.1% and 0.2% via PIEBs were equally allocated to two groups of parturients with an additional patient control epidural rescue bolus if needed. Our primary endpoint was motor blockade, as assessed by the modified Bromage scale (MBS). We also recorded visual analog scale (VAS) scores, heart rate, blood pressure, total local anesthetic consumption, labor duration and method of delivery, and APGAR score of the newborns. Results All patients presented Bromage scores equal to 6, and the total consumption of the anesthetic solution was comparable between the two groups. Women in the 0.2% group showed higher pain relief and satisfaction compared to the 0.1% group. Concerning the 0,2% group, diastolic blood pressure and APGAR scores were lower alongside with a lower satisfactory extrusion stage observed by the obstetrician. Conclusion Both ropivacaine regimens provide satisfactory labor epidural analgesia for the expectant mother without any motor blockade.

Optimum programmed intermittent epidural bolus interval time of ropivacaine 0.0625% with dexmedetomidine 0.4 µg/ml at a fixed volume of 10 mL: a randomized controlled trial.

Background: The aim of our study was to administer adequate local anesthetic in programmed intermittent epidural bolus (PIEB) to avoid breakthrough pain and decrease the use of manual and PCEA boluses. We, therefore, conducted this study to determine the effective PIEB interval time between boluses of ropivacaine 0.0625% with dexmedetomidine 0.4 µg/ml at a fixed volume of 10 mL in 90% of subjects (EI90), without the use of patient-controlled epidural analgesia (PCEA). Methods: A total of 80 subjects were included in the final statistical analysis from 23 August 2022 to 22 November 2022. The subjects were randomly assigned to one of four different PIEB time intervals: 40, 50, 60, and 70 min (groups 40, 50, 60, and 70), respectively. The primary outcome was the effective epidural labor analgesia, defined as no use of PCEA bolus or a manual bolus until the end of the first stage of labor or within 6 hours after loading dose administration. The PIEB EI90 (95% CI) between boluses of ropivacaine 0.0625% with dexmedetomidine 0.4 µg/ml at a fixed volume of 10 mL was estimated using probit regression. Results: The effective PIEB interval time between boluses of ropivacaine 0.0625% with dexmedetomidine 0.4 µg/ml at a fixed volume of 10 mL in 90% of subjects without the use of PCEA was 45.4 (35.5-50.5) minutes using probit regression. No statistical differences were found in the proportion of subjects with Bromage score > 0, hypotension, pruritus, nausea, and vomiting between groups. However, the highest sensory block (pinprick) in the 40-min group was significantly higher than that in the other groups. Conclusion: The estimated value for EI90 for PIEB between boluses of ropivacaine 0.0625% with dexmedetomidine 0.4 µg/ml at a fixed volume of 10 mL using probit regression was 45.4 (35.5-50.5) minutes. Furthermore, future studies are warranted to be established to determine the optimal parameters for different regimens in clinical practice.

Effect of adding dexmedetomidine on two methods of labor analgesia via epidural among parturient patients.

Background: Continuous epidural infusion (CEI) has been an optimal and acceptable technique for inducing epidural anesthesia. This study compared two methods of programmed intermittent epidural bolus (PIEB) with CEI in labor analgesia among patients receiving epidural dexmedetomidine. Methods: This study was a randomized clinical trial. The target population was term women candidates for epidural anesthesia. After selection of sample size based on inclusion criteria, a total of 3 cc of dexmedetomidine (0.5 µg/ml) and Ropivacaine 0.1% was injected. Furthermore, 5 ml was injected as a loading dose of dexmedetomidine 0.5 µg /ml and Ropivacaine 0.1%. Then the pain score was recorded. SPSS software Version 23 was used for statistical analysis of data. Results: The neonatal Apgar score in PIEB method was more improved (P = 0.003) and the use of assisted delivery tools such as vacuum, in PIEB method was reduced. (p=0.038) Duration of the first phase of the labor in this method was more reduced than CEI.(p=0.015) Patients in the group undergoing epidural anesthesia by PIEB method were associated with a higher level of satisfaction with the delivery process (p < 0.05) than patients undergoing CEI protocol. Conclusion: PIEB method is associated with further improvement in neonatal Apgar score and maternal outcomes (reduction in the duration of the first phase of labor and no need to use assisted delivery methods) compared to the CEI protocol, but has little effect on hemodynamic conditions or drug dosage.

Neuraxial labor analgesia: Maintenance techniques.

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.

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.

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.