BACKGROUND: The dural puncture epidural (DPE) technique is associated with faster onset than the conventional epidural (EP) technique for labor analgesia. The programmed intermittent epidural bolus (PIEB) mode for maintaining labor analgesia allows for lower anesthetic drug consumption than the continuous epidural infusion (CEI) mode. Whether DPE technique with PIEB mode offers additional benefits for analgesia onset, local anesthetic drug consumption, and side effects versus EP or DPE techniques with CEI mode remains unclear. METHODS: Nulliparous women with a visual analog scale (VAS) pain score >50 mm and cervical dilation <5 cm were randomly assigned to receive EP + CEI, DPE + CEI, or DPE + PIEB for labor analgesia. A 25-gauge needle was used for dural puncture. Analgesia was initiated with 10 mL of 0.1% ropivacaine with 0.3 µg/mL of sufentanil and maintained with the same solution at 8 mL/h in all groups. A 5-mL patient-controlled epidural analgesia (PCEA) bolus was programmed with a 20-minute lockout. Breakthrough pain not amendable by PCEA was treated with provider boluses of 5 mL of 0.125% ropivacaine. The primary outcome was “time to adequate analgesia,” defined as a VAS pain score ≤30 mm during 2 consecutive contractions, and was analyzed using Kaplan–Meier curves and a Cox proportional hazard model. Secondary outcomes included the VAS scores, ropivacaine consumption, sensory block level to ice, PCEA and provider boluses intervention, mode of delivery, duration of labor, Bromage scores, Apgar scores, occurrence of side effects, and maternal satisfaction with the anesthesia. RESULTS: A total of 116 women were included (38 in the EP + CEI group, 40 in the DPE + CEI group, and 38 in the DPE + PIEB group). Adequate anesthesia was achieved faster in the DPE + CEI and DPE + PIEB groups than in the EP + CEI group (hazard ratio = 1.705; 95% confidence interval [CI], 1.039–2.800; P = .015; and hazard ratio = 1.774; 95% CI, 1.070–2.941; P = .012, respectively). DPE technique with PIEB mode was associated with the fewest PCEA boluses and the lowest hourly ropivacaine consumption (both P < .001). There were no differences in the duration of labor, mode of delivery, Bromage scores, newborn Apgar scores, incidence of side effects, and maternal satisfaction scores among the groups. CONCLUSIONS: The use of DPE technique for neuraxial analgesia was associated with faster onset than the use of the EP technique. DPE technique with PIEB mode achieved the greatest drug-sparing effect without increasing maternal or neonatal side effects.

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Remifentanil with appropriate pharmacological properties seems to be an ideal alternative to epidural analgesia during labour. A retrospective cohort study was undertaken to assess the efficacy and safety of remifentanil intravenous patient-controlled analgesia (IVPCA) compared with epidural analgesia. Medical records of 370 primiparas who received remifentanil IVPCA or epidural analgesia were reviewed. Pain and sedation scores, overall satisfaction, the extent of pain control, maternal side effects and neonatal outcome as primary observational indicators were collected. There was a significant decline of pain scores in both groups. Pain reduction was greater in the epidural group throughout the whole study period (0∼180 min) (P<0.0001), and pain scores in the remifentanil group showed an increasing trend one hour later. The remifentanil group had a lower SpO2 (P<0.0001) and a higher sedation score (P<0.0001) within 30 min after treatment. The epidural group had a higher overall satisfaction score (3.8±0.4 vs. 3.7±0.6, P = 0.007) and pain relief score (2.9±0.3 vs. 2.8±0.4, P<0.0001) compared with the remifentanil group. There was no significant difference on side effects between the two groups, except that a higher rate of dizziness (1% vs. 21.8%, P<0.0001) was observed during remifentanil analgesia. And logistic regression analysis demonstrated that nausea, vomiting were associated with oxytocin usage and instrumental delivery, and dizziness was associated to the type and duration of analgesia. Neonatal outcomes such as Apgar scores and umbilical-cord blood gas analysis were within the normal range, but umbilical pH and base excess of neonatus in the remifentanil group were significantly lower. Remifentanil IVPCA provides poorer efficacy on labor analgesia than epidural analgesia, with more sedation on parturients and a trend of newborn acidosis. Despite these adverse effects, remifentanil IVPCA can still be an alternative option for labor analgesia under the condition of one-to-one bedside care, continuous monitoring, oxygen supply and preparation for neonatal resuscitation.

Background: Postoperative pulmonary infection is a serious complication in elderly patients with hip fracture, it’s necessary to identify the influencing factors of pulmonary infection in patients with hip fracture.Methods: Elderly patients with hip fractures admitted from January 1, 2020 to July 31, 2021 were included. The characteristics of patients with pulmonary infection and no infection were evaluated and compared. Logistic multivariate regression analyses were conducted to assess the risk factors of pulmonary infection.Results: 267 patients with hip fracture were included, the incidence of pulmonary infection in patients with hip fracture was 13.11%. There were significant differences in the age, diabetes mellitus, anemia, hypoalbuminemia, anesthesia method and duration of surgery between infection and no infection group, no significant differences in the gender, BMI, hypertension, hyperlipidemia, type of fracture, preoperative oxygen saturation, white blood cell count, platelet count, red blood cell count, creatinine, alanine aminotransferase, aspartate aminotransferase, estimated blood loss during surgery were detected between infection and no infection group. Logistic regression analysis showed that age≥70y(OR2.326 , 95%CI1.248~3.129), diabetes mellitus(OR2.123, 95%CI1.021~3.551), anemia(OR3.199,95%CI1.943~5.024), hypoalbuminemia(OR2.377, 95%CI1.211~3.398), general anesthesia(OR1.947, 95%CI1.115~3.038), duration of surgery≥120min(OR1.621 , 95%CI1.488~2.534) were the risk factors of pulmonary infection in elderly patients with hip fracture(all p<0.05). Escherichia Coli(33.33%), Klebsiella pneumoniae(28.57%), Staphylococcus aureus(21.43%) were the most common bacteria of pulmonary infection.Conclusion: There are many risk factors for pulmonary infection in elderly patients with hip fractures after surgery. In clinical practice, medical workers should take targeted interventions for those risk factors to reduce the risk of pulmonary infection.