“Ultra-light” patient-controlled epidural analgesia during labor: effects of varying regimens on analgesia and physician workload

A comparison of fetomaternal outcome in PCEA using fentanyl, clonidine and dexmedetomidine as adjuvants with Ropivacaine in painless labor: a prospective, double blinded randomized study

Background: Patient controlled epidural analgesia has been associated with marked maternal satisfaction. Combination of local anesthetics with various adjuvants have been tried to ensure optimum analgesia with no or negligible fetomaternal side effects. Aim: To compare fentanyl, clonidine or dexmedetomidine as adjuvants with ropivacaine for labor epidural analgesia (LEA) using a PCEA pump with the objective to assess fetomaternal outcome in terms of analgesic effect, success rate of vaginal delivery, complications, neonatal APGAR score and maternal satisfaction. Materials and methods: Sixty full term laboring women received 10 ml 0.2% ropivacaine followed by continuous infusion of 0.1% ropivacaine with 2 μg/ml of either dexmedetomidine, fentanyl or clonidine respectively in Groups A, B, and C at 6 ml/hr. demand bolus setting was 2 ml with a lock out interval of 15 minutes. At full cervical dilatation another 10 ml bolus of respective solution were given. Parturients were monitored at 0, 10, 20, 30 min after giving 1st epidural bolus dose and then at 30 min interval for ongoing labor for pain relief (VAS), motor blockade (Bromage score), progress of labor (duration of 1st stage and 2nd stage), mode of delivery, fetal APGAR score (at 1 min and 5 min), vitals (HR, NIBP, RR, SpO2), overall patient satisfaction and complications. The statistical analysis was done both qualitatively (Fisher-exact test/Chi-square test) and quantitatively (one-way analysis of variance test with post-hoc intergroup comparisons using Bonferroni’s correction). Results: Onset of pain relief was earlier in fentanyl group, however after 1 h all three groups showed comparable pain relief (P>0.05). There was a significant reduction in HR in group C and B compared to group A (P<0.001) and MAP in group C compared to groups A and B. The motor- blocking potency was slightly higher in dexmedetomidine group, however no significant motor weakness observed in any parturient. Mean demand bolus need was more in group C compared to A and B (P<0.001). There was no significant difference in mode of delivery (either SVD or cesarean) in between the groups. There was not a single case of fetal distress and most of the parturients showed satisfactory response to PCEA. Conclusion: All three study drugs produced equipotent analgesia in combination with ropivacaine 0.1%. There was absolute pain relief without significant motor blockade or any increase in instrumentation/cesarean deliveries or any adverse fetal outcomes.

Analysis and evaluation of the effectiveness of epidural analgesia and its relationship with eutocic or dystocic delivery

OBJECTIVE

Numerous studies have demonstrated the difference in the verbal rating scale with regard to obstructed labour and induced labour, so that obstructed labour and foetal macrosomia have been related to a greater sensation of pain during labour, particularly in the first stage. Even the epidural analgesia is linked to the need for instrumented or caesarean section due to foetal obstruction. The goal of the study is to analyze and evaluate the effectiveness of epidural analgesia in normal versus obstructed labour.

PATIENTS AND METHODS

One hundred and eighty pregnant women were included in an observational, analytical, longitudinal and prospective study, that was performed in the Obstetrics Department of the Hospital Universitario Dexeus. All the nulliparous or multiparous over 36 weeks of pregnancy, after 3cm of cervical dilatation in spontaneous or induced labor were included. All the patients were given epidural analgesia according to protocol.

RESULTS

The basic descriptive methods were used for the univariate statistical analysis of the sample and the Mann-Whitney U test was used for the comparison of means between both groups. The correlations between variables were studied by means of the Spearman coefficient of correlation. The differences regarded as statistically significant are those whose P<.05.

CONCLUSION

In our population there were no statistically significant differences in the effectiveness of epidural analgesia in normal versus obstructed labour. Patients who got epidural analgesia and had obstructed labors have the same degree of verbal rating scale as patients that do not had obstructed labors (P>.05).

Programmed intermittent epidural boluses for maintenance of labor analgesia: an impact study

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.

Obstetric outcomes and maternal satisfaction in nulliparous women using patient-controlled epidural analgesia

OBJECTIVE

The purpose of this study was to compare obstetric outcomes and maternal satisfaction in nulliparous women in spontaneous labor who used patient-controlled epidural analgesia (PCEA) vs continuous epidural infusion (CEI).

STUDY DESIGN

We conducted a double-masked trial of 270 nulliparous women who were assigned randomly to 3 groups (with a concentration 0.1% bupivacaine and 2 μg/mL fentanyl): group I, CEI-only (10 mL/h); group II, CEI + PCEA (CEI 10 mL/h plus PCEA 10 mL, at 20 minutes); group III, PCEA-only (10 mL, at 20 minutes). A PCEA bolus button was given to each subject. The primary outcome was the dosage of local anesthetic that was used.

RESULTS

The total milligrams of bupivacaine that were used was less in the PCEA-only group compared with CEI: group I. 74.8 ± 36 mg; group II, 97.3 ± 53 mg; group III, 52.4 ± 42 mg (P < .001). Pain with pushing, however, was worse in the PCEA-only group. Median satisfaction scores were similar (scale, 0 [best] to 100 [worst]: group I, 0; group II, 0; group III, 0 (P = .23).

CONCLUSION

PCEA results in less anesthetic used, and maternal satisfaction remains high without a continuous infusion. Pain with pushing, however, was worse with the PCEA alone.

A randomized controlled trial using patient-controlled epidural analgesia with 0.25% versus 0.0625% bupivacaine in nulliparous labor: effect on analgesia requirement and maternal satisfaction

BACKGROUND

The effect of epidural local anesthetic concentration on analgesic action is still the subject of debate. This study compared the effect of a four-fold change in concentration of bupivacaine for epidural analgesia in labor.

METHODS

Nulliparous women in early active labor were recruited. All women received analgesic drugs via a lumbar epidural catheter, and all received fentanyl 1 microg/kg with the epidural induction dose and no further opioids throughout the study. Patients were randomized to receive either a 5-mL bolus followed by a 5-mL/h infusion of concentrated (0.25%) bupivacaine or a 20-mL bolus followed by a 20-mL/h infusion of dilute (0.0625%) bupivacaine. Patient-controlled epidural analgesia of the study solution was then used to assess additional analgesia requirements. Analgesic requirement, maternal satisfaction and obstetric outcome were compared.

RESULTS

For subjects receiving 0.25% bupivacaine, the median total dose of drug administered was greater (117 vs. 90 mg, P=0.0008), and the mean maternal satisfaction score was less (82 vs. 93, P=0.04) than with the 0.0625% solution.

CONCLUSIONS

Larger volumes of more dilute solutions may result in dose sparing and provide more effective labor analgesia. This study supports the continued trend towards dilute local anesthetic mixtures for labor epidural analgesia.

A randomized controlled trial of three patient-controlled epidural analgesia regimens for labor

BACKGROUND

Patient-controlled epidural analgesia (PCEA) is a safe and effective mode of maintaining labor analgesia; however, the ideal PCEA regimen is controversial.

METHODS

In this prospective, randomized, double-blind study, we examined the analgesic efficacy of demand-only PCEA and PCEA with background infusion. We recruited 300 nulliparous parturients. Analgesia was initiated with intrathecal ropivacaine 2 mg and fentanyl 15 microg and maintained with epidural ropivacaine 0.1% with fentanyl 2 microg/mL. Parturients were randomized to one of three groups. Group 0: demand-only PCEA, bolus of 5 mL, lockout interval of 15 min. Group 5: background infusion of 5 mL/h, bolus of 5 mL, lockout interval of 12 min. Group 10: background infusion of 10 mL/h, bolus of 5 mL, lockout interval of 10 min. The maximum dose of all groups was 20 mL/h. The primary outcome was incidence of breakthrough pain. Secondary outcomes included intrapartum pain scores, neuraxial blockade characteristics, side effects, the total and hourly volume of ropivacaine, neonatal outcomes, and obstetric outcomes.

RESULTS

The incidence of breakthrough pain and the maximum visual analog scale (0-100 mm scale) pain scores were higher in Group 0 versus Groups 5 and 10 (43% vs 17% and 11%, P < 0.001 and 37 +/- 28 vs 22 +/- 26 and 16 +/- 25 [mean +/- SD], P < 0.001), respectively. Group 10 had a longer duration of effective analgesia compared with Group 0 (mean 895 min, 95% CI 823-966 vs 565 min, 95% CI 454-677, P < 0.001) and increased ropivacaine consumption, and was associated with a longer duration of the second stage of labor.

CONCLUSION

Demand-only PCEA (5-mL bolus, 15-min lockout interval) resulted in less local anesthetic consumption but an increased incidence of breakthrough pain, higher pain scores, shorter duration of effective analgesia, and lower maternal satisfaction, when compared with PCEA with background infusion (5-mL bolus, 10-12-min lockout interval, and 5-10 mL/h infusion).

A double-blind randomized controlled trial of patient-controlled epidural analgesia with or without a background infusion following initial spinal analgesia for labor pain

BACKGROUND

Patient-controlled epidural analgesia (PCEA) combined with spinal analgesia is an option for pain relief in labor. However, the effect of a CBI on the analgesic requirements of laboring women is still debated. This double-blind study investigated the effect of CBI with PCEA following spinal analgesia on the local anesthetic requirements of parturients during labor.

METHODS

Sixty-six nulliparous women were randomly assigned to a standard PCEA protocol (5-mL demand bolus, 10-min lockout) with or without a CBI of 6 mL/h. The epidural solution consisted of 0.1% ropivacaine with fentanyl 2 microg/mL. Labor analgesia was initiated in both groups with intrathecal bupivacaine 2.5 mg plus fentanyl 25 microg. The number of demands per hour and the hourly dose of ropivacaine were calculated for both groups.

RESULTS

The median [range] number of analgesic boluses per hour in the PCEA group that were demanded: 2.4 [0.8-12.2] and delivered: 1.6 [0.8-2.6], were significantly greater than those in the PCEA+CBI group: 0.7 [0.4-4.2] and 0.6 [0.2-1.3] (P 0.05). However, the hourly ropivacaine dose in the PCEA group (7.9 [3.9-13.2] mg/h) was not significantly different from that in the PCEA+CBI group (8.4 [6.0-12.5] mg/h).

CONCLUSION

In laboring nulliparous patients provided initial labor analgesia with spinal anesthesia, the use of a continuous background infusion decreases PCEA demand dosing, but not the total hourly amount of ropivacaine and fentanyl used.

Epidural Labor Analgesia: Continuous Infusion Versus Patient-Controlled Epidural Analgesia With Background Infusion Versus Without a Background Infusion

The purpose of this study was to compare the total epidural dose of 3 commonly used labor epidural modalities. After local institutional review board approval, 195 laboring parturients received an epidural catheter for labor analgesia. All patients received an initial bolus of 0.1% ropivacaine (10 mL) and fentanyl (100 microg). Maintenance of labor analgesia consisted of ropivacaine 0.1% with fentanyl 2 microg/mL. Patients were then randomly assigned into 3 groups: Group 1 (continuous epidural infusion [CEI]), continuous infusion at 10 mL/h; group 2 (CEI + patient-controlled epidural analgesia [PCEA]), CEI at 5 mL/h with a demand dose of 5 mL allowed every 20 minutes with a 20 mL/h maximum dose; group 3 (PCEA), demand doses only of 5 mL every 15 minutes with a 20 mL/h maximum dose. Measured variables included total epidural dose, total bolus requests and boluses delivered, number of staff interventions, pain Visual Analog Scale (VAS; 0-100), modified Bromage scores, stage I and II labor duration, delivery outcome, and maternal satisfaction after delivery. No differences were noted with respect to pain VAS, modified Bromage scores, stage I and II labor duration, number of staff interventions, delivery outcome, and maternal satisfaction score. Total infusion dose was lower in demand dose only PCEA compared with CEI and CEI + PCEA groups (P = < .01). Demand dose-only PCEA results in less total epidural dose compared with CEI and CEI + PCEA without affecting labor duration, motor block, pain VAS, maternal and neonatal outcomes, and maternal satisfaction.

PERSPECTIVE

This article compares 3 commonly used labor epidural delivery modalities (traditional continuous epidural infusion, patient-controlled epidural analgesia with a background infusion, and demand dose-only patient-controlled epidural analgesia). Benefits in epidural dose reduction with demand dose only PCEA does not translate into improved maternal and neonatal outcome.

Efficacy of patient-controlled epidural analgesia after initiation with epidural or combined spinal-epidural analgesia

BACKGROUND

The aim of the present study was to compare the efficacy of patient-controlled epidural analgesia after initiation with either epidural or combined spinal-epidural analgesia.

METHODS

Forty ASA I parturients at 37-42 weeks' gestation and cervical dilatation <6 cm were randomly allocated to receive either epidural analgesia (group EA) or combined spinal-epidural analgesia (group CSEA). Analgesia was initiated with a 7-mL epidural bolus 0.1% bupivacaine containing fentanyl 50 mug (group EA, n=20) or with intrathecal fentanyl 20 mug (group CSEA, n=20). In both groups, analgesia was provided by a 5-mL bolus on demand via PCEA with a 10-min lock-out interval and a 15-mL/h limit.

RESULTS

No significant differences were observed in the rate of cervical dilatation, delivery type or duration of delivery between the groups. The time to first analgesic demand was shorter in the CSEA than in the EA group. Total bupivacaine dose was comparable in both groups, but total fentanyl dose in group CSEA was significantly lower than that of group EA because of the initial dose used for the induction of EA and CSEA. The incidence of pruritus in group CSEA was significantly higher than in group EA.

CONCLUSION

Both regional analgesia techniques followed by demand-only PCEA provided efficient pain relief for labor without changing the duration of labor or rate of cesarean section.

A survey of labor patient-controlled epidural anesthesia practice in California hospitals

BACKGROUND

Patient-controlled epidural analgesia (PCEA) offers many advantages over continuous epidural infusions for labor analgesia including fewer physician interventions, improved analgesia and satisfaction, and reduced local anesthetic doses. However, anesthesiologists have been slow to adopt this technique, first described in 1988. No previous studies have evaluated specific labor patient-controlled epidural analgesia practices in the United States. The aim of this study was to determine labor epidural and patient-controlled epidural analgesia practices among California hospitals.

METHODS

Following institutional review board exemption approval, an online survey was created using freeonlinesurveys.com. An anonymous survey was sent via e-mail to 230 California Society of Anesthesiologists' members chosen at random to represent their hospitals' labor analgesia practices.

RESULTS

We received 133 replies from the 230 survey requests sent, a 58% response rate. The median labor epidural rate among the hospitals involved was 65% (range 0-95%). Overall, only 25% of California hospitals use patient-controlled epidural analgesia for analgesia in labor, with greater use among hospitals with dedicated obstetric anesthesia coverage and larger numbers of deliveries. Reasons given for not using patient-controlled epidural analgesia include cost, clinician preference, safety concerns and the inconvenience of change.

CONCLUSIONS

Despite the potential advantages of patient-controlled epidural analgesia over continuous epidural infusions for labor analgesia, patient-controlled epidural analgesia has not been widely adopted in California hospitals. Education regarding this technique is needed to encourage its increased use.

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

OBJECTIVES

Update on patient controlled epidural analgesia for labour.

STUDY DESIGN

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

DATA COLLECTION

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

RESULTS

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

CONCLUSION

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