Programmed intermittent epidural bolus versus continuous epidural infusion for postoperative analgesia after major abdominal and gynecological cancer surgery: a randomized, triple-blinded clinical trial

Abstract

BackgroundContinuous epidural infusion (CEI) is the standard application setting for epidural infusion. A new mode, the programmed intermittent epidural bolus (PIEB) technique, showed reduced local anesthetic (LA) consumption and improved analgesia in obstetric analgesia. Goal of this trial was to evaluate the effects of PIEB versus CEI [combined with patient-controlled bolus (PCEA)] on LA consumption and pain scorings in major abdominal cancer surgery.MethodsFollowing ethical approval, patients scheduled for major abdominal cancer surgery under general anesthesia in combination with epidural analgesia were randomized to receive either a PIEB mode of 6 mL/h or a CEI mode set at 6 mL/h of ropivacaine 0.2%, both combined with a PCEA mode set at a 4 mL bolus. LA consumptions and pain scorings were documented until the second postoperative evening.ResultsEighty-four datasets were analyzed (CEI: n = 40, PIEB: n = 44). Regarding the primary endpoint, cumulative LA PCEA bolus volumes until day 2 differed significantly between the groups [PIEB 10 mL (2–28 mL) versus CEI, 28 mL (12–64 mL), median (25th–75th percentiles), p = 0.002]. Overall, LA consumption volumes were significantly lower in the PIEB group versus in the CEI group [PIEB: 329 mL (291–341 mL) vs. CEI: 350 mL (327–381 mL), p = 0.003]. Pain scores were comparable at each time point.ConclusionsThis trial demonstrates reduced needs for PCEA bolus in the PIEB group. There were no clinically relevant benefits regarding morphine consumption, pain scorings, or other secondary outcome parameters.Trial registrationThis study has been registered retrospectively in the ClinicalTrials.gov registry (NCT03378804), date of registration: December, 20th 2017.Electronic supplementary materialThe online version of this article (10.1186/s12871-018-0613-6) contains supplementary material, which is available to authorized users.

Efficacy of programmed intermittent bolus epidural analgesia in thoracic surgery: a randomized controlled trial

“…The reduction in the total amount of local anesthetic with intermittent bolus infusion compared with continuous infusion is consistent with the findings in labor analgesia reports and postoperative reports. In major abdominal and gynecological surgery, the beneficial effect of PIB is noted on the first postoperative day and not on the day of the operation [9]. Sequential epidural bolus infusion provides superior epidural block compared with CEI [2].…”

“…With regard to the incidence of hypotension, the difference between our results and those of previous reports might be associated with differences in the site of epidural anesthesia and dose of local anesthetic. Hypotension occurred but was not significant in both groups, and there was a need for noradrenalin when epidural anesthesia involved puncture at Th8–10 [9]. On the other hand, when epidural anesthesia involved puncture at Th10–12 in open gynecological surgery [8] or L3–5 in total knee arthroplasty, [8] there was no hypotension requiring intervention.…”

“…On the other hand, when epidural anesthesia involved puncture at Th10–12 in open gynecological surgery [8] or L3–5 in total knee arthroplasty, [8] there was no hypotension requiring intervention. The bolus dose was 6 mL every hour in the major surgical study that reported hypotension, [9] and among studies that did not report hypotension, the doses were 4 mL every hour for open gynecological surgery [10] and 3 mL every hour for total knee arthroplasty [8]. We used a bolus of 5.1 mL every 90 min (3.4 mL every hour).…”

Programmed Intermittent Epidural Bolus versus Continuous Epidural Infusion in Major Upper Abdominal Surgery: A Retrospective Comparative Study

“…However, because of different pain entities and the target spinal level in major abdominal surgery compared with labor analgesia, the clinical application of PIEB in abdominal surgery might be limited. Few studies have compared the use of PIEB versus CEI after major abdominal surgery, [7,8] and two studies showed inconsistent postoperative outcomes. One study showing the difference between the two groups reported that the PCEA bolus needs were decreased in the PIEB group.…”

Intraoperative management of combined general anesthesia and thoracic epidural analgesia: A survey among German anesthetists

“…Especially, the anesthetic regimens of both, combined GA and EA and general anesthesia alone (systemic analgesia) deviate significantly regarding substance use, mode of application (bolus vs. continuous; provider‐controlled vs. patient‐controlled) and timing of EA initiation 6 . Indeed, there is a wide range of possible variation within combined GA and EA and although some aspects have been addressed in trials and meta‐analyses, 13–16 guidelines on the optimal performance do not exist. Recently, The Royal College of Anaesthetists published an updated version of their “Best practice recommendations,” which refers mainly to organizational aspects of EA 17 .…”