Effect of Dural Puncture Epidural Technique Combined With Programmed Intermittent Epidural Bolus on Labor Analgesia Onset and Maintenance: A Randomized Controlled Trial

Abstract

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.

Quality of Labor Analgesia with Dural Puncture Epidural versus Standard Epidural Technique in Obese Parturients: A Double-blind Randomized Controlled Study

“…Layera et al 4 postulated that the diffusion gradient generated by dilute epidural solutions and smaller drug masses may be insufficient to drive drug transfer across the meninges or dural plus intermittent boluses, and standard epidural plus continuous infusion reported that treatment with dural puncture epidural plus intermittent boluses was associated with the greatest analgesia quality and drug-sparing effect compared to the other two techniques. 21 It is possible that the higher injectate pressures used in the intermittent bolus technique may increase drug transfer through the dural puncture, although this technique did not significantly increase analgesia efficacy with dural puncture epidural compared to standard epidural in our study. Another possibility is that the increased epidural drug spread associated with the intermittent bolus technique 1 may obscure any analgesic improvement resulting from increased drug transfer through the dural conduit with the dural puncture epidural technique.…”

Impact of Intraspinal Nerve Block Anesthesia on Intrapartum Fever and the Neonate

“…It reduces maternal pain by blocking the sensory nerves that innervate the uterus in the body through intermittent or continuous infusion of local anesthetic drugs and analgesic drugs into the spinal canal. Due to the small amount of anesthesia used, the women can still feel the contractions [ 10 ]. Qiu et al revealed that the analgesic effect of epidural self-administered analgesic pump analgesia is favorable with rapid efficacy [ 11 ], and the placenta is less affected by the drug, which indicates the safety of the fetus during delivery [ 12 ].…”

A Randomized Clinical Trial Comparing Different Concentrations of Chloroprocaine with Lidocaine for Activating Epidural Analgesia During Labor

“…"Adequate analgesia" was defined as a VAS score ≤3 during each active uterine contraction. 12 Secondary outcomes were as follows: the VAS score, the interval and duration of uterine contractions during the first 12 contractions (baseline, 2nd, 4th, 6th, 8th, 10th and 12th contractions) after the administration of the initial dose; the number of failures to reach adequate analgesia in the first 15 min; cold sensory blockade level; motor blockade score; total number of PCEA boluses administered during labor; the time from epidural initiating dose to first demand for PCEA; epidural drug consumption; delivery mode; durations of the first and second labor stages; Apgar score; umbilical vein pH; score of analgesia satisfaction; and adverse effects, including maternal hypotension, shivering, pruritus, nausea and vomiting, fetal bradycardia within 30 min after analgesia, and active phase stagnation.…”