A Randomized Comparison of Programmed Intermittent Epidural Bolus with Continuous Epidural Infusion for Labor Analgesia

Wong, Cynthia A.; Ratliff, John T.; Sullivan, John T.; Scavone, Barbara M.; Toledo, Paloma; McCarthy, Robert J.

doi:10.1213/01.ane.0000197778.57615.1a

Cited by 191 publications

(156 citation statements)

References 10 publications

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“…Our results confirm those of other studies that have compared AMB (PIEB) with CEI in combination with a PCEA with the use of a dual pump system: one pump administering either AMB or CEI for the maintenance of analgesia, while the second pump is used to administer PCEA to treat breakthrough pain [30][31][32]. Epidural infusion tubing from both pumps are then connected via a three-way stopcock to the hub of the epidural catheter.…”

Section: Automated Intermittent Mandatory Boluses (Amb)supporting

confidence: 85%

Impact of Drug Delivery Systems on Neuraxial Labor Analgesia

Iyer

Sia

2013

Curr Anesthesiol Rep

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Neuraxial analgesia for the treatment of labor pain has proven to be efficacious and safe over the past few decades. At present, several new strategies are being developed to further enhance pain relief and maternal satisfaction of our parturients while providing them with greater autonomy over their own analgesic regimen. The recent years have witnessed the development of new infusion pumps that are more interactive, flexible and allow titration of analgesia according to an individual parturient's need for pain relief as labor progresses. In this review, we examine the several strategies for maintenance of neuraxial labor analgesia with a focus on the impact of drug delivery systems in the past, present and future.

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Section: Automated Intermittent Mandatory Boluses (Amb)supporting

confidence: 85%

Impact of Drug Delivery Systems on Neuraxial Labor Analgesia

Iyer

Sia

2013

Curr Anesthesiol Rep

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“…It has been documented that PIEB is associated with less need for clinician intervention for inadequate pain control. There has been observed an increase in time to the first rescue bolus (5-7, 9, 10) and a lower number of manual boluses (5,11,12) in several studies. This has impact for both the parturient and the anesthesia work load.…”

mentioning

confidence: 98%

Programmed Intermittent Epidural Boluses (PIEB): A Superior Technique for Maitenance of Labor Analgesia

Munro¹,

George²

2017

Turk J Anaesth Reanim

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“…However, over a decade ago, evidence began to emerge showing that epidural pumps programmed to deliver intermittent epidural boluses (PIEB) of local anesthetic provide more effective analgesia that CEI (2)(3)(4). The suggested mechanism of superior epidural analgesia with PIEB compared to CEI is greater spread of anesthetic solution within the epidural space, and therefore better sensory blockade compared to CEI.…”

mentioning

confidence: 99%

Programmed Intermittent Epidural Boluses (PIEB) for Maintenance of Labor Analgesia: A Superior Technique to Continuous Epidural Infusion?

Riley¹,

Carvalho²

2017

Turk J Anaesth Reanim

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C ontinuous epidural infusions (CEI) of local anesthetics with patient-controlled epidural analgesia (PCEA) is the most popular method of maintaining epidural labor analgesia in the United States (1). However, over a decade ago, evidence began to emerge showing that epidural pumps programmed to deliver intermittent epidural boluses (PIEB) of local anesthetic provide more effective analgesia that CEI (2-4). The suggested mechanism of superior epidural analgesia with PIEB compared to CEI is greater spread of anesthetic solution within the epidural space, and therefore better sensory blockade compared to CEI. These clinical observations are consistent findings of more uniform spread with large volumes and correspondingly high injectate pressures in cadavers (5), and observations of greater dye solution spread in semi-absorbent paper with boluses compared to continuously infused solution (despite the same hourly volume being administered) (6). The importance of bolus administration of epidural local anesthetics with or without opioids may also explain why PCEA compared to CEI reduces the need for manual clinician boluses for breakthrough pain, and decreased amount of local anesthetic used (7), and why PIEB regimes with larger boluses and longer lockouts (10 mL every 60 min) are more effective than smaller boluses and shorter lockouts (2.5 mL every 15 min) (8).All studies that have compared PIEB with CEI for labor epidural maintenance have found either better or equivalent analgesic and obstetric outcomes with PIEB. Specifically, studies have shown a local anesthetic sparing effect, shorter duration of labor, and improvements in maternal satisfaction with PIEB compared to CEI (9). However, while clinical studies have clearly demonstrated superiority of PIEB over CEI, we must question how important these differences are. The local anesthetic-sparing effect with PIEB compared to CEI from meta-analysis data of pooled comparative studies was found to be 1.2 mg of bupivacaine per hour (95% CI, -2.2, -0.3) (9). That dose sparing difference is the equivalent to 1 ml of 0.125% bupivacaine per hour. While this local anesthetic difference reaches the threshold of statistical significance, is this 1 mL per hour difference clinically important? In comparison, adding opioids into the local anesthetic solution has a much greater impact on reducing local anesthetic consumption (10). The epidural delivery technique is comparatively less important for local anesthetic sparing than the concentration of local anesthetic epidural solution utilized.An advantage of less local anesthetic use and wider spread of local anesthetic solution with PIEB is less motor block. This can result in better maternal expulsive efforts during the second stage of labor, and potentially lead to a shorter second stage and reduce the requirements for instrumental delivery. A meta-analysis of PIEB compared to CEI for labor analgesia found that on average the use of PIEB was associated with a 12 minute shorter second stage (9). The clinical significance of this ...

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A Randomized Comparison of Programmed Intermittent Epidural Bolus with Continuous Epidural Infusion for Labor Analgesia

Cited by 191 publications

References 10 publications

Impact of Drug Delivery Systems on Neuraxial Labor Analgesia

Impact of Drug Delivery Systems on Neuraxial Labor Analgesia

Programmed Intermittent Epidural Boluses (PIEB): A Superior Technique for Maitenance of Labor Analgesia

Programmed Intermittent Epidural Boluses (PIEB) for Maintenance of Labor Analgesia: A Superior Technique to Continuous Epidural Infusion?

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