Computer-integrated Patient-controlled Epidural Analgesia Research Articles

Maintenance of epidural labour analgesia: The old, the new and the future.

Neuraxial analgesia is considered the gold standard in labour analgesia, providing the most effective pain relief during childbirth. Improvements have enhanced the efficacy and safety of epidural analgesia through better drugs, techniques and delivery systems. This review describes the history of epidural labour analgesia and recent improvements in labour epidural analgesia. We discuss the role of the combined spinal epidural technique, low-concentration local anaesthetic-opioid epidural solutions, patient-controlled epidural analgesia, and programmed intermittent or automated mandatory boluses in the maintenance of epidural labour analgesia. We also review the newer interactive techniques for drug delivery, such as computer-integrated patient-controlled epidural analgesia and variable frequency automated mandatory bolus. Finally, we discuss future clinical research developments, including the use of data analytics and long-term outcomes associated with childbirth pain management.

Obstetric analgesia - update 2016.

Neuraxial labor analgesia can be initiated via combined spinal-epidural (CSE) or stand-alone epidural. Pros and cons of these techniques are outlined in this review. In recent years computer-integrated patient-controlled epidural analgesia (CI-PCEA) and programed intermittent epidural boluses (PIEB) have been developed, adding to continuous infusion and PCEA for the maintenance of neuraxial analgesia. Postdural puncture headache (PDPH) and fever can occur secondary to labor epidural that both have clinical relevance for the care givers. Insights into the mechanism of epidural fever and treatment strategies for PDPH are outlined. Due to the increase in obesity the specific considerations for this patient group are discussed. New data have been presented for remifentanil, an ultra-shortly acting opioid, that is used in obstetric analgesia. Without breaking new data, the use of nitrous oxide especially by midwives has a kind of renaissance, and this will be discussed, too.

Modern neuraxial labour analgesia.

Neuraxial analgesia is considered the gold standard of labour analgesia as it provides the most effective method of pain relief during childbirth. In this article, we explore the recent advances in the initiation and maintenance of epidural analgesia. Patient-controlled epidural analgesia, computer-integrated patient-controlled epidural analgesia, intermittent epidural bolus (programmed intermittent bolus, automated mandatory bolus) and variable frequency automated mandatory bolus administration are techniques that allow the individualized titration and optimization of labour analgesia. The debate has moved on to finding the optimal settings for epidural bolus dosing, time intervals and frequency for epidural analgesia with the hope of improving safety and efficacy as well as patient satisfaction. We examine these recent developments in pump technology and epidural delivery systems and evaluate how these have enhanced the mothers' birthing experiences.

Incidence and characteristics of breakthrough pain in parturients using computer-integrated patient-controlled epidural analgesia

IntroductionThe computer-integrated patient-controlled epidural analgesia (CIPCEA) system can automatically adjust the background infusion rate during combined spinal-epidural analgesia based on the parturient's need, as labor progresses. ObjectivesThe objective is to identify risk factors associated with breakthrough pain during labor as well as identify obstetric and fetal outcomes that are affected by breakthrough pain. DesignThis is a retrospective review of prospectively collected data. SettingThe setting is in a delivery room. ParticipantsThe participants are 280 nulliparous women in early labor (≤5 cm cervical dilatation) who received combined spinal-epidural analgesia with CIPCEA. InterventionsThe intervention is CIPCEA. MeasurementsThe primary outcome is the incidence of breakthrough pain (≥1 episodes of pain or pressure that required supplemental epidural medications) during labor. Relevant demographic, anesthetic, obstetric, and fetal characteristics were also measured. Univariate and multivariate analyses were performed to identify obstetric and anesthetic factors that were associated with increased incidence of breakthrough pain as well as to evaluate the impact of breakthrough pain on obstetric and fetal outcomes. ResultsThe incidence of breakthrough pain was 9.6%. Independent factors associated with incidence of breakthrough pain are the presence of dysfunctional labor, increased maternal body mass index, and decreased successful-to-total-bolus-demand ratio. The postlabor characteristics independently associated with breakthrough pain were increased duration of labor, decreased duration of effective analgesia, increased total local anesthetic consumption, and decreased maternal satisfaction. ConclusionsLow successful to total patient demand bolus ratio was the factor with the strongest association with breakthrough pain. Breakthrough pain was also associated with dysfunctional labor and poorer maternal satisfaction.

Comparison of computer-integrated patient-controlled epidural analgesia with no initial basal infusion versus moderate basal infusion for labor and delivery: A randomized controlled trial.

Background and Aims:Computer-integrated patient-controlled epidural analgesia (CIPCEA) is a novel epidural drug delivery system. It automatically adjusts the basal infusion based on the individual's need for analgesia as labor progresses.Materials and Methods:This study compared the time-weighted local anesthetic (LA) consumption by comparing parturients using CIPCEA with no initial basal infusion (CIPCEA0) with CIPCEA with initial moderate basal infusion of 5 ml/H (CIPCEA5). We recruited 76 subjects after ethics approval. The computer integration of CIPCEA titrate the basal infusion to 5, 10, 15, or 20 ml/H if the parturient required respectively, one, two, three, or four patient demands in the previous hour. The basal infusion reduced by 5 ml/H if there was no demand in the previous hour. The sample size was calculated to show equivalence in LA consumption.Results:The time-weighted LA consumption between both groups were similar with CIPCEA0 group (mean [standard deviation (SD)] 8.9 [3.5] mg/H) compared to the CIPCEA5 group (mean [SD] 9.9 [3.5] mg/H), P = 0.080. Both groups had a similar incidence of breakthrough pain, duration of the second stage, mode of delivery, and patient satisfaction. However, more subjects in the CIPCEA0 group required patient self-bolus. There were no differences in fetal outcomes.Discussion:Both CIPCEA regimens had similar time-weighted LA consumption and initial moderate basal infusion with CIPCEA may not be required.

Techniques for the maintenance of epidural labor analgesia

After initiating neuraxial labor analgesia, there are many techniques that can be used to maintain analgesia for the duration of labor. In this review, we have examined the new techniques of maintenance of epidural labor analgesia recently proposed to overcome the undesirable effects of continuous infusion and patient-controlled epidural analgesia (PCEA). As labor progresses, there is a greater need for analgesia. PCEA with basal infusion, automated intermittent mandatory boluses, programmed intermittent epidural boluses and computer-integrated PCEA have been introduced to combine the advantages of a manual bolus and continuous infusion, thus matching infusion rate and bolus modality to the patient's analgesic needs. Increased maternal satisfaction, reduced anesthetic consumption and decreased incidence of motor block are features of these new maintenance techniques. Technology has now provided us with more advanced drug delivery systems that may have the potential to fulfill the maternal requirements of a safe, natural, and painless childbirth, tailoring the analgesic regimen for each parturient's need.

Labour analgesia: Recent advances

Advances in the field of labour analgesia have tread a long journey from the days of ether and chloroform in 1847 to the present day practice of comprehensive programme of labour pain management using evidence-based medicine. Newer advances include introduction of newer techniques like combined spinal epidurals, low-dose epidurals facilitating ambulation, pharmacological advances like introduction of remifentanil for patient-controlled intravenous analgesia, introduction of newer local anaesthetics and adjuvants like ropivacaine, levobupivacaine, sufentanil, clonidine and neostigmine, use of inhalational agents like sevoflourane for patient-controlled inhalational analgesia using special vaporizers, all have revolutionized the practice of pain management in labouring parturients. Technological advances like use of ultrasound to localize epidural space in difficult cases minimizes failed epidurals and introduction of novel drug delivery modalities like patient-controlled epidural analgesia (PCEA) pumps and computer-integrated drug delivery pumps have improved the overall maternal satisfaction rate and have enabled us to customize a suitable analgesic regimen for each parturient. Recent randomized controlled trials and Cochrane studies have concluded that the association of epidurals with increased caesarean section and long-term backache remains only a myth. Studies have also shown that the newer, low-dose regimes do not have a statistically significant impact on the duration of labour and breast feeding and also that these reduce the instrumental delivery rates thus improving maternal and foetal safety. Advances in medical technology like use of ultrasound for localizing epidural space have helped the clinicians to minimize the failure rates, and many novel drug delivery modalities like PCEA and computer-integrated PCEA have contributed to the overall maternal satisfaction and safety.

Comparison of Computer-integrated Patient-controlled Epidural Analgesia and Patient-controlled Epidural Analgesia with a Basal Infusion for Labour and Delivery

Computer-integrated patient-controlled epidural analgesia (CIPCEA) is a novel epidural drug delivery system. It automatically adjusts the background infusion based on the individual parturient's need for analgesia as labour progresses. In this randomised controlled trial, we compared the local anaesthetic consumption by parturients using either CIPCEA or patient-controlled epidural analgesia with a moderate basal infusion (PCEABI) of 5 ml/hour. We recruited 60 parturients after receiving ethics committee approval. Group CIPCEA (n = 30) received a similar patient-controlled epidural analgesia regimen but the computer integration titrated the background infusion to 5, 10 or 15 ml/hour if the patient required respectively one, two or three demand boluses in the previous hour. The background infusion was decreased by 5 ml/hour if there was no demand in the previous hour. Group PCEABI received patient-controlled epidural analgesia with a basal infusion of 5 ml/hour. The sample size was calculated to show equivalence in local anaesthetic use. The time-weighted consumption of local anaesthetic was similar in both groups (mean difference 0.3 mg/hour 95% confidence interval: -1.8, 1.3, P = 0.755). The CIPCEA group had higher maternal satisfaction scores: mean (SD) 94.8 (6.32) vs. 85.5 (9.41), P = 0.0001. The CIPCEA group had a higher infusion rate during the second stage of labour (mean (SD) 7.0 (4.1) ml/hour vs. 4.5 (1.5) ml/hour P = 0.008), but did not have a longer duration of this stage. There were no differences between the groups in obstetric or foetal outcomes or side-effect profiles. The CIPCEA system has similar time-weighted, hourly consumption of local anaesthetic to PCEABI and may increase patient satisfaction.

Maintaining labour epidural analgesia: what is the best option?

The intensity of labour pain is influenced by a multitude of factors. In this article, we discuss recent advances in the administration of labour epidural analgesia which have been targeted at creating a more satisfactory birthing experience for the parturient while safeguarding maternal and fetal well being. Induction of analgesia by the combined spinal epidural technique provides rapid onset of profound analgesia with minimal motor blockade, although the impact of the technique on overall maternal satisfaction with analgesia is equivocal. Patient-controlled epidural analgesia has gained acceptance among clinicians and parturients alike, and research has been focused on elucidating the optimal patient-controlled epidural analgesia programme settings. Results from laboratory and clinical studies suggest that intermittent epidural boluses may produce a more uniform block than a continuous basal infusion. Attempts have been made to incorporate background automated intermittent boluses into a patient-controlled epidural analgesia programme, with encouraging results. Computer-integrated patient-controlled epidural analgesia is a novel system that records the history of the patient's analgesic requirement over the past hour and increases its basal infusion rate proportionally to the number of demand-boluses made. The computer-integrated patient-controlled epidural analgesia programme appears to reduce the incidence of breakthrough pain without increasing drug consumption or side effects. Recent advances in medical technology have equipped us with many novel drug delivery modalities, which will enable us to customize a suitable analgesic regimen for each parturient.

Maternal satisfaction with computer integrated patient controlled epidural analgesia

We wish to comment upon the recent paper by Lim et al. [1] which compared a computer integrated-patient controlled epidural analgesia (CI-PCEA) system with demand only patient controlled epidural analgesia (PCEA) for pain relief in labour. One of the main conclusions was that CI-PCEA improved maternal satisfaction despite there being no difference in local anaesthetic consumption. To assess maternal satisfaction the authors used a 101-point scale ranging from 0 (very dissatisfied) to 100 (extremely satisfied). The 20 patients who received CI-PCEA reported a mean (standard deviation, SD) satisfaction score of 93 (7) compared with the 20 patients in PCEA group who reported a mean satisfaction of 86 (11), with a p-value of 0.042. As labour pain is often severe, analgesic interventions are likely to be associated with high maternal satisfaction scores. There are many components which influence maternal satisfaction with labour analgesia. Experience of labour pain, feeling of control, fears and expectations and pain and physical condition after delivery are all likely to be contributory [2]. A subjective measure such as maternal satisfaction will have great interindividual variation in reported scores. These factors mean that careful consideration is needed when designing qualitative studies of satisfaction [3, 4] both in terms of sample size and study design. We feel that the use of a 101-point scale produced a statistically significant difference that is not clinically important. The large number of points on the scale improves statistical power, but does not make the measure any more valid. Furthermore, the original power calculation for the study estimated sample sizes to show differences in local anaesthetic consumption, not to compare maternal satisfaction, where there is likely to be a greater variance in reported ratings. We therefore feel that the authors' conclusion that CI-PCEA improves maternal satisfaction is not supported by the evidence given in the paper. Measures of maternal satisfaction with neuraxial analgesia in other studies have ranged from the use of similar numerical scales with a varying number of points, to detailed questionnaires and semistructured interviews [2, 5-7]. Unfortunately, this makes the literature regarding the effect of neuraxial blockade during labour upon maternal satisfaction rather difficult to interpret. We suggest that a consensus be reached about the most valid method of assessing satisfaction following obstetric anaesthetic procedures.

Comparison of computer integrated patient controlled epidural analgesia vs. conventional patient controlled epidural analgesia for pain relief in labour

Computer integrated-patient controlled epidural analgesia (CI-PCEA) is a novel drug delivery system. It automatically titrates the background infusion rate based on the individual parturient's need. In this randomised trial, we compared the local anaesthetic consumption by parturients using CI-PCEA with demand only patient controlled epidural analgesia (PCEA) for labour analgesia. We recruited 40 parturients after approval by the ethics committee. Group PCEA (n = 20) received demand only PCEA. Group CI-PCEA (n = 20) received a similar PCEA regimen but the computer integration titrated the background infusion to 5, 10 or 15 ml x h(-1) if the patient required one, two or three demand boluses, respectively, in the previous hour. The background infusion decreased by 5 ml x h(-1) if there was no demand bolus in the previous hour. The sample size was calculated to show equivalence in local anaesthetic used. The time weighted consumption of local anaesthetic was similar in both groups (mean difference 0.7 mg x h(-1), 95% confidence interval [CI: -2.5, 1.1]; p = 0.425). The CI-PCEA group had higher maternal satisfaction scores: mean (SD) 93 (7) vs. 86 (11), p = 0.042. CI-PCEA does not increase the use of local anaesthetic when compared with demand only PCEA but does increase patient satisfaction.