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

Munro, Allana; George, Ronald B.

doi:10.5152/tjar.2017.09032

Cited by 4 publications

(6 citation statements)

References 18 publications

(9 reference statements)

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“…W e agree with the evidence comparing programmed intermittent epidural boluses (PIEB) to conventional continuous epidural infusions (CEI) for maintaining epidural labor analgesia presented by Munro and George, (1) showing advantages with PIEB for both the patient (with less local anesthetic consumption, improved maternal satisfaction, potentially shorter duration of labor) and the anesthesia team (with decreased workload requirements) (2). However we disagree with their interpretation of the data, specifically the effect size of the demonstrated improvements (3).…”

supporting

confidence: 80%

Programmed Intermittent Epidural Boluses (PIEB) for Maintenance of Labor Analgesia: An Incremental Step Before the Next Paradigm Shift?

Carvalho¹,

Riley²

2017

Turk J Anaesth Reanim

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W e agree with the evidence comparing programmed intermittent epidural boluses (PIEB) to conventional continuous epidural infusions (CEI) for maintaining epidural labor analgesia presented by Munro and George, (1) showing advantages with PIEB for both the patient (with less local anesthetic consumption, improved maternal satisfaction, potentially shorter duration of labor) and the anesthesia team (with decreased workload requirements) (2). However we disagree with their interpretation of the data, specifically the effect size of the demonstrated improvements (3). As we previously stated, the observed differences are modest and of limited clinical impact (4). The epidural analgesic technique of PIEB therefore needs to be considered only an incremental improvement over CEI for the maintenance of epidural labor analgesia. As such rather than focusing on the limited improvement of PIEB, perhaps we need to shift our overall perspective.A paradigm shift is a fundamental change in the basic concepts and practices of a discipline (5). In our opinion, there have only been a few paradigm shifts for labor pain management, for example, the discovery of local anesthetics and their utilization to provide spinal and/ or epidural analgesia; and the finding of opioid receptors in the spinal cord that has facilitated the use of neuraxial opioids. These changes moved labor pain control from practices involving inhalational anesthesia, twilight sleep or relying on systemic opioids (6), to epidural labor analgesic techniques that many laboring women request and receive during childbirth (7). However within these paradigm shifts, there have been many significant improvements in the analgesia and safe care that we provide laboring women. Examples of such improvements would include the use of epidural catheters instead of a single-shot spinal, epidural or caudal techniques, utilization of dilute local anesthetic opioid-containing solutions, smart volumetric epidural pumps, patient-controlled epidural analgesia (PCEA), combined spinal-epidural (CSE) analgesia, and flexible wire-reinforced epidural catheters. Some of these changes were major improvements and others incremental, but cumulatively these changes are substantive and have fundamentally improved our practices.So where does PIEB fit into these paradigms shifts and stepwise improvements? We agree with Munro and George, (1) that PIEB is superior to CEI for delivering local anesthetics to the epidural space and maintaining epidural labor analgesia. However, the improvement PIEB for Labor Analgesia RILEY vs. MUNRO Second Round DEBATE 73

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supporting

confidence: 80%

Programmed Intermittent Epidural Boluses (PIEB) for Maintenance of Labor Analgesia: An Incremental Step Before the Next Paradigm Shift?

Carvalho¹,

Riley²

2017

Turk J Anaesth Reanim

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“…A higher bolus pressure has been shown to provide a more efficient distribution of local anesthetic and enhanced analgesia. 3,6,10 This improved distribution results in a reduction in local anesthetic consumption, greater patient satisfaction, and faster recovery. 4,11 Kaynar and Shankar 10 evaluated the spread of epidural solution and noted a 5-fold wider spread for a machine bolus compared to continuous epidural dosing.…”

Section: Discussionmentioning

confidence: 99%

“…6,7 Wider spread in the epidural space is theorized to result in a greater sensory blockade, which contributes to enhanced analgesia and patient satisfaction. 3 The objective of this study was to quantify the flow through a closed-end multiorifice epidural catheter to identify future directions in our understanding of the mechanisms behind pain management using manual boluses and PIEB. As multiple syringe sizes may be used to inject medication through an epidural catheter, this study sought to determine the influence of varying syringe size and injection delivery speed on flow when used with and without the presence of the epidural filter.…”

mentioning

confidence: 99%

“…Suggested advantages are less breakthrough pain, less local anesthetic consumption, improved maternal satisfaction, potentially shorter duration of labor, and decreased workload requirements for anesthesia providers. [1][2][3][4][5] In addition to PIEB-capable infusion pumps, manual epidural boluses have been administered, particularly for underperforming epidural analgesia. The increase in bolus delivery speed may increase peak pressure and widen the spread of the local anesthetic.…”

mentioning

confidence: 99%

mentioning

confidence: 99%

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Direct Comparison of Peak Bulk Flow Rate of Programmable Intermittent Epidural Bolus and Manual Epidural Bolus Using a Closed-End Multiorifice Catheter: An Experimental Study

Younger¹,

Faryami

Prasad

et al. 2022

Anesthesia &Amp; Analgesia

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BACKGROUND:The programmable intermittent epidural bolus (PIEB) has been popularized as the optimal delivery technique for labor analgesia. Suggested advantages of this method are less local anesthetic consumption, improved maternal satisfaction, potentially shorter duration of labor, and decreased workload requirements for the anesthesia providers. However, a manual bolus is still routinely used for breakthrough pain when the PIEB is underperforming. METHODS: We conducted a laboratory-based study to quantify the flow through a multiorifice epidural catheter using the PIEB setting on an epidural pump compared to the manual epidural bolus. Four syringe volumes, 3, 5, 10, and 20 mL, were selected for this experiment. The flow in a manual bolus was also studied with and without the presence of an epidural catheter filter. A generalized estimating equation analysis was done to compare data between the groups. RESULTS: Regardless of the syringe size, there was a several-fold increase in flow when a manual bolus was used compared to a pump-administered dose, with the highest difference in the peak flow rate observed in 3-mL boluses with up to a 12-fold difference, while the difference was, at most, 7-fold in 5-mL and 10-mL boluses. Manual boluses without a filter achieve a mean peak flow rate higher than manual boluses with a filter. CONCLUSIONS: Our study found that manual boluses produced a higher flow rate compared to the CADD-Solis epidural pump (Smiths Medical). This study also found that the placement of a particulate filter reduces the flow rates generated while bolusing. Bulk flow rate is directly correlated with induced pressure and solution spread. Because higher bolus pressure has been shown to provide a more efficient distribution of local anesthetic and more efficient pain relief, these results may have impactful clinical significance and will pave the way for future studies.

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Regional and Parenteral Analgesia in Labour

Sacramento

Esteras

Torre

et al. 2022

Obstetric Anesthesia: Clinical Updates

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Labour pain is a complex phenomenon involving subjective psychological factors and physiological neurohormonal factors. Many different factors contribute to the perception of pain: cultural factors, bond, and trust in the delivery team, being able to take their own decisions, relaxation ability, previous labour, anatomical and fetal related factors. Pain relief is one of the elements involved in overall satisfaction but it is not the only one and is important to remember that pharmacological intervention is only a part of it.

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

Cited by 4 publications

References 18 publications

Programmed Intermittent Epidural Boluses (PIEB) for Maintenance of Labor Analgesia: An Incremental Step Before the Next Paradigm Shift?

Programmed Intermittent Epidural Boluses (PIEB) for Maintenance of Labor Analgesia: An Incremental Step Before the Next Paradigm Shift?

Direct Comparison of Peak Bulk Flow Rate of Programmable Intermittent Epidural Bolus and Manual Epidural Bolus Using a Closed-End Multiorifice Catheter: An Experimental Study

Regional and Parenteral Analgesia in Labour

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