Continuous Epidural Infusion Group Research Articles

Comparison of analgesic effects between programmed intermittent epidural boluses and continuous epidural infusion after cesarean section: a randomized controlled study.

This study aimed to compare the analgesic effects of programmed intermittent epidural boluses (PIEB) and continuous epidural infusion (CEI) for postoperative analgesia after elective cesarean section (CS). Seventy-four women who underwent elective CS were randomized to receive either PIEB or CEI. The PIEB group received 4 ml-intermittent boluses of 0.11% ropivacaine every hour at a rate of 120 ml/h. The CEI group received a constant rate of 4 ml/h of 0.11% ropivacaine. The primary outcome was the pain score at rest at 36 h after CS. Secondary outcomes included the pain scores during mobilization, time-weighted pain scores, the incidence of motor blockade, and complications-related epidural analgesia during 36 h after CS. The pain score at rest at 36 h after CS was significantly lower in the PIEB group compared with that in the CEI group (3.0 vs. 0.0; median difference: 2, 95% CI [1, 2], P < 0.001). The mean time-weighted pain scores at rest and during mobilizations were also significantly lower in the PIEB group than in the CEI group (pain at rest; mean difference [MD]: 37.5, 95% CI [24.6, 50.4], P < 0.001/pain during mobilization; MD: 56.6, 95% CI [39.8, 73.5], P < 0.001). The incidence of motor blockade was significantly reduced in the PIEB group compared with that in the CEI group (P < 0.001). PIEB provides superior analgesia with less motor blockade than CEI in postpartum women after CS, without any apparent adverse events.

Assessing Continuous Epidural Infusion and Programmed Intermittent Epidural Bolus for Their Effectiveness in Providing Labor Analgesia: A Mono-Centric Retrospective Comparative Study.

Background and Objectives: Local anesthetics administered via epidural catheters have evolved from intermittent top-ups to simultaneous administration of continuous epidural infusion (CEI) and patient-controlled epidural analgesia (PCEA) using the same device. The latest programmed intermittent epidural bolus (PIEB) model is believed to create a wider and more even distribution of analgesia inside the epidural space. The switch from CEI + PCEA to PIEB + PCEA in our department began in 2018; however, we received conflicting feedback regarding workload from the quality assurance team. This study aimed to investigate the benefits and drawbacks of this conversion, including the differences in acute pain service (APS) staff workload, maternal satisfaction, side effects, and complications before and after the changeover. Materials and Methods: Items from the APS records included total delivery time, average local anesthetic dosage, and the formerly mentioned items. The incidence of side effects, the association between the duration of delivery and total dosage, and hourly medication usage in the time subgroups of the CEI and PIEB groups were compared. The staff workload incurred from rescue bolus injection, catheter adjustment, and dosage adjustment was also analyzed. Results: The final analysis included 214 and 272 cases of CEI + PCEA and PIEB + PCEA for labor analgesia, respectively. The total amount of medication and average hourly dosage were significantly lower in the PIEB + PCEA group. The incidences of dosage change, manual bolus, extra visits per patient, and lidocaine use for rescue bolus were greater in the PIEB + PCEA group, indicating an increased staff workload. However, the two groups did not differ in CS rates, labor time, maternal satisfaction, and side effects. Conclusions: This study revealed that while PIEB + PCEA maintained the advantage of decreasing total drug doses, it inadvertently increased the staff burden. Increased workload might be a consideration in clinical settings when choosing between different methods of PCEA.

Comparison of three analgesic regimens in women undergoing cervical brachytherapy

PURPOSEEffective periprocedural analgesia is an important aspect of cervical brachytherapy delivery, with implications for patient comfort and attendance for subsequent fractions. We compared the efficacy and safety of three analgesic modalities: intravenous patient-controlled analgesia (IV-PCA), continuous epidural infusion (CEI) and programmed-intermittent epidural bolus with patient-controlled epidural analgesia (PIEB-PCEA). METHODS AND MATERIALSNinety-seven brachytherapy episodes involving 36 patients between July 2016 and June 2019 in a single tertiary center were retrospectively reviewed. Episodes were divided into two key phases: Phase 1 (while applicator remained in situ) and Phase 2 (following applicator removal until discharge or 4 h). For the primary endpoint, pain scores were retrieved and analyzed by analgesic modality with respect to median score and an internally defined “unacceptable” pain experience (>20% of scores being ≥4/10; i.e., moderate or greater). Total nonepidural oral morphine equivalent dose (OMED) and toxicity/complication events were reported as secondary endpoints. RESULTSIn Phase 1, there was a significantly higher median pain score (p < 0.001) and more episodes with unacceptable pain scores (46%) in the IV-PCA group compared with either epidural modality (6–14%; p < 0.001).In Phase 2, we observed a greater median pain score (p = 0.007) and higher proportion of patient episodes with unacceptable pain scores (38%) in the CEI group compared with both the IV-PCA (13%) and PIEB-PCEA (14%) groups (p = 0.001).There was a significant difference in median OMED used throughout all phases across the PIEB-PCEA (0 mg), IV-PCA (70 mg), and CEI (15 mg) groups (p < 0.001). CONCLUSIONSPIEB-PCEA is safe and offers superior analgesia compared to IV-PCA or CEI for pain control after applicator placement in cervical brachytherapy.

Programmed Intermittent Epidural Bolus in Comparison with Continuous Epidural Infusion for Uterine Contraction Pain Relief After Cesarean Section: A Randomized, Double-Blind Clinical Trial.

PurposeProgrammed intermittent epidural bolus (PIEB) was reported to provide superior maintenance of labour analgesia with better pain relief and less motor block than continuous epidural infusion (CEI). Whether this is also evident for uterine contraction pain relief after cesarean section remains unknown.Patients and MethodsParturients scheduled for cesarean section were recruited for the study. At the end of the surgery, after a similar epidural loading dose given, patients received either PIEB (6 mL·h−1) or CEI (6 mL·h−1) of 0.1% ropivacaine. The primary outcome was the uterine contraction pain assessed with visual analog scale (VAS-U) at the postoperative 36 h. Secondary outcomes included incision pain at the rest (VAS-R) and in the movement-evoked (VAS-P), and lower extremity motor block (defined as Bromage score > 0). The whole profile of VAS scores between groups was analyzed using linear mixed model. When significant differences were found, the pairwise comparison was done with the Mann Whitney U-test followed by Bonferroni correction.ResultsOne hundred and twenty parturients were studied (PIEB, 60; CEI, 60). VAS-U at the postoperative 36 h in the PIEB group was lower than in the CEI group (Bonferroni-adjusted P < 0.01). The linear mixed model indicated that VAS-U, VAS-R and VAS-P were lower in the PIEB group compared with the CEI group (all P < 0.01). Motor block was higher in the CEI group than in the PIEB group during the study period except 2 h (all P < 0.05). No differences of adverse events such as hypotension and urinary retention were observed between the two groups.ConclusionProgrammed intermittent epidural bolus provides more effective uterine contraction and incision pain relief and less motor block after cesarean section than continuous epidural infusion without an increased risk of urinary retention and blood pressure instability.

Programmed intermittent epidural bolus for post-cesarean delivery analgesia: a randomized controlled double-blind trial.

The aim of this study was to assess the efficacy of programmed intermittent epidural boluses (PIEB) in postoperative pain management compared with continuous epidural infusion (CEI) after cesarean delivery. A total of 58 participants were randomly allocated to receive PIEB (3mL bolus every 60min) or CEI (3mL/h) for postoperative analgesia after undergoing elective cesarean section under combined spinal-epidural anesthesia. Both groups had the same epidural solution containing ropivacaine 0.2% plus fentanyl 2µg/mL. The primary outcome was postoperative pain score at rest and mobilization at 6, 12, 24, and 48h. The secondary outcomes were the total amount of ropivacaine used in the 48h study period and the time to the first PCEA bolus. Data from 58 women were analyzed. There was a reduction in pain verbal numerical rating scores at 12h in patients receiving PIEB compared with CEI at rest [2 (1.75-3) vs. 3 (2-4), p = 0.011]; and on movement [4 (3-5) vs. 5 (4-6), p = 0.038]. No differences were found in pain scores at any other time-point up to 48h. Total ropivacaine consumption at 48h was less in the PIEB group compared with the CEI group [316mg (304-321) vs. 336mg (319-344), p = 0.001]. Postoperative epidural analgesia for patients who underwent cesarean delivery with PIEB compared with CEI resulted in less ropivacaine usage while providing comparable analgesia.

Postoperative pain management in gynecologic oncology: regional anesthesia effects on time to pain control and achieving postoperative milestones

<h3>Objectives:</h3> We investigated the time to achieve postoperative milestones in patients who underwent exploratory laparotomy for suspected gynecologic malignancy and received either patient-controlled analgesia alone (PCA), PCA with transversus abdominus plane block (TAP), or PCA with continuous epidural infusion (CEI). <h3>Methods:</h3> A retrospective cohort study of patients who underwent open gynecologic oncology surgery in a university was conducted over 18 months. Our primary outcomes included time to achieve the following postoperative milestones: pain control (mean pain score ≤ 5), foley catheter removal, ambulation, flatus, tolerating a regular diet, and control of nausea and emesis. All milestones, except for foley catheter removal, were measured using postoperative day (POD). Foley catheter removal was measured in hours after insertion and analyzed as a categorical variable using quartiles. All postoperative milestones were compared using Fisher's Exact Test. <h3>Results:</h3> Of 214 eligible patients, 127 received PCA alone, 76 received additional TAP block, and 11 received additional CEI. 19 patients without PCA or regional, and 13 patients without PCA, were excluded. Pain control took longer in the CEI group as over half of those who received PCA alone (54%) or TAP (57%) achieved pain control on POD 0 compared to 30% in CEI (p=0.02). Similarly, by POD 3, only 80% of the CEI group had pain controlled compared to 96% in PCA and 85% in TAP (p=0.02). CEI also lagged in time to foley removal as none (0%) of the CEI group had foley removal within the first quartile, 0-15 hours, whereas 23% of the PCA group and 27% of the TAP group had achieved successful removal by that time (p=0.02). This trend continued with 73%, 28%, and 20% of the CEI, PCA, and TAP groups, respectively had foley removal within the last quartile, 41-503 hours (p=0.02). The CEI group also took longer to ambulate with 18% ambulating by POD 1 compared to 59% in PCA and 64% in TAP (p=0.01). Similarly, by POD 2, only 54% of the CEI patients were ambulating compared to 89% in PCA and 90% in TAP (p=0.01). The CEI group lagged in time to regular diet, as only 9% were eating by POD 1 vs 35% in PCA and 29% in TAP, although this finding was not statistically significant (p=0.07). The CEI group also experienced increased time to flatus with 9% on POD 1 compared to 17% in PCA and 7% in TAP (p=0.02). Only 9% of the CEI patients had nausea controlled by POD 1, whereas 48% in PCA and 49% in TAP groups met that milestone by then (p=0.02). It took 3 or more postoperative days for 82% of the CEI group to have controlled nausea. When reviewing these results in the combined regional group (TAP and CEI) vs PCA alone, there were no statistically significant differences except in time to flatus, with 17% of the PCA group passing flatus by POD 1 compared to 7% in the regional group (p=0.03). <h3>Conclusions:</h3> Our study showed that regional anesthesia increased time to flatus in patients who underwent open gynecologic surgery. Although limited by small sample size, CEI was an outlier in time to postoperative milestones, including pain control, ambulation, control of nausea and emesis, and foley removal. Benefits and drawbacks of CEI anesthesia should be considered using full assessment of the effect on postoperative milestones. Further study of costs of CEI vs TAP anesthesia, while not in the scope of this study, can provide further context for decision making. Our results merit future investigation into the effects of regional anesthesia, especially epidural, on time to postoperative milestones.

Epidural Analgesia for Labour: Comparing the Effects of Continuous Epidural Infusion (CEI) and Programmed Intermittent Epidural Bolus (PIEB) on Obstetric Outcomes.

In the last few years there is a trend of transiting from the continuous epidural infusion (CEI) method for epidural analgesia to a new method - programmed intermittent epidural analgesia (PIEB). This change improves the quality of epidural analgesia, thanks to an increased spread of the anaesthetic in the epidural space and higher maternal satisfaction. Nevertheless, we must make sure that such change of method does not lead to worse obstetric and neonatal outcomes. This is a retrospective observational case control study. We compared several obstetrical outcomes between the CEI and PIEB groups, such as the rates of instrumental delivery, rates of caesarean section, duration of first and second stages of labour well as APGAR scores. We further segmented the subjects and examined them in groups of nulliparous and multiparous parturients. 2696 parturients were included in this study: 1387 (51.4%) parturients in the CEI group and 1309 (48.6%) parturients in the PIEB group. No significant difference was found in instrumental or caesarean section delivery rates between groups. This result held even when the groups were differentiated between nulliparous and multiparous. No differences were revealed regarding first and second stage duration or APGAR scores. Our study demonstrates transition from the CEI to the PIEB method does not lead to any statistically significant effects on either obstetric or neonatal outcomes.

Continuous wound infusion as an alternative to continuous epidural infusion for postoperative analgesia in renal transplant surgery: A prospective randomized controlled trial

Background: Pain management is often challenging in patients undergoing renal transplant owing to the various comorbidities. Epidural analgesia is currently the standard technique but is not without complications. Continuous wound infusion (CWI) is emerging as a simple and effective technique of postoperative analgesia. Therefore, the purpose of our study was to compare the efficacy of CWI with continuous epidural infusion (CEI). Methods: Forty-two patients undergoing renal transplant surgery were randomized to receive either CEI or CWI. The visual analogue score at rest and on movement was assessed. Opioid consumption, patient satisfaction, and complications were also assessed. Results: The pain scores measured at rest 4, and 8 h postoperatively were significantly lower in the CWI group.(2.45 ± 1.317) in CWI versus (3.45 ± 1.050) in CEI, P = 0.012 at 4 h, and (1.95 ± 1.146) in CWI versus (2.75 ± 0.786) in CEI, P = 0.014 at 8 h. The pain scores at other time points were lower in the CWI group but not statistically significant. The morphine used in the first 8 h was significantly higher in the CEI group. There was a higher incidence of hypotension in the CEI group (P = 0.028). The patient satisfaction and other side effects were comparable between the groups. Conclusion: Continuous wound infiltration is an effective technique for postoperative analgesia in renal transplant surgery and can be used as an alternative to epidural analgesia.

Programmed intermittent epidural boluses (pieb) for labor analgesia: study of the sensor block and effects on maternal motor function

Background. Programmed intermittent epidural boluses (PIEB) technique is a promising approach that demonstrates certain advantages over traditional techniques of epidural analgesia. We compared the dynamics of the sensory block of PIEB + parturient-controlled epidural analgesia (PCEA) with continuous epidural infusion (CEI) + PCEA for maintenance labor analgesia and the incidence of motor block (MB) in women who received PIEB or traditional techniques.&#x0D; Methods. A total of 165 subjects were studied. All parturients were divided into five groups: manual boluses, PCEA, PCEA + CEI, PIEB + PCEA; levobupivacaine 0.25 mg/mL; 1.25 mg/mL; 0.625 mg/mL. The level of the MB was evaluated by the classic Bromage scale (0-1-2-3). The level of the sensor block was evaluated by the pin-prick test.&#x0D; Results. MB was reported in 80% in group 1 120 min after analgesia, 78% and 52% in groups 2 and 3 at the 150th min (p 0.001); in group 4, the MB frequency was 6% 15 min after the start and was increasing to 40% at full cervical dilation (p 0.001). In group 5, the relative MB frequency did not exceed 10% at the 120th min and was 0% at full cervical dilation (p 0.00001). The results indicate that in the PIEB group, the level of sensory block in patients was higher 15 min after the start of analgesia and remained so until the end of the observation period [median PIEB Th5 versus Th8 in the CEI group, (p 0.0004)].&#x0D; Conclusions. PIEB + PCEA technique maintained a consistently high level of sensor block throughout the study compared to PCEA + CEI, which ensured effective analgesia in the first and second stages of labor with minimal MB.

Continuous preperitoneal infusion of ropivacaine for postoperative analgesia in patients undergoing major abdominal or pelvic surgeries. A prospective controlled randomized study.

Background and Aims:This study was conducted to compare continuous preperitoneal infusion (CPI) with continuous epidural infusion (CEI) of ropivacaine for pain relief and effect on pulmonary functions after major abdominal and pelvic surgeries.Material and Methods:One hundred patients were randomized into two equal groups. Patients in CPI group (n = 50) received analgesia by continuous infusion of 0.2% ropivacaine, whereas those in the CEI group (n = 50) received continuous epidural infusion of 0.2% ropivacaine. The primary outcome was the first request of analgesia. The secondary outcome was the influence on the pulmonary functions.Results:The time for the first request of analgesia was longer in the CPI group compared with that in the CEI group (7.3 ± 1.6 vs. 4.1 ± 1.1 h with P value = 0.001). The daily dose of morphine was lesser in CPI versus CEI group (11.3 ± 1 against 17.4 ± 0.9 mg). The pulmonary function tests were comparable except peak expiratory flow rate, which was better in CPI (170 ± 5.4) than CEI group (148.1 ± 5.8; with P value = 0.001).Conclusion:Continuous preperitoneal infusion provides a superior analgesic effect than the continuous epidural infusion as regards delayed first request of analgesia, better pain scores, lesser usage of additional analgesics with better respiratory function.

Programmed intermittent epidural bolus decreases the incidence of intra-partum fever for labor analgesia in primiparous women: a randomized controlled study.

To evaluate whether programmed intermittent epidural bolus (PIEB) reduces the incidence of maternal intra-partum fever compared with continuous epidural infusion (CEI) during labor. Parturients were randomized to receive CEI (CEI group) or PIEB (PIEB group) with 10ml per hour for epidural labor analgesia with 1500 subjects in each group. The maintaining dose of two groups is 0.08% ropivacaine with 0.4μg/ml sufentanil, with patient-controlled epidural analgesia (PCEA) dose of 5ml and lockout interval of 30min. The incidence of maternal fever, pain score, epidural sensory levels, the number and proportion of PCEA demand, anesthetics consumption, satisfaction score, neonatal Apgar scale, and maternal and neonatal side effects were recorded. It was significantly lower of the incidence of maternal fever beginning at 4h post-analgesia and continuing until delivery in the PIEB group than the CEI group (4h: 2.6% vs. 4.2%; 5h: 7.3% vs. 10.2%; delivery: 5.6% vs. 7.9%; 1h post-delivery: 3.9% vs. 6.2%; 2h post-delivery: 2.1 vs. 3.5%; total: 5.8% vs. 8.4% in PIEB and CEI, respectively). Compared with CEI group, pain scores at 3, 4, 5h post-analgesia and delivery (3h: 2 [1, 2] vs. 2 [1-3]; 4h: 2 [2, 3] vs. 3 [2-4]; 5h: 2 [2, 3] vs. 3 [2-4]; delivery: 3 [2-4] vs. 4 [3, 4] in PIEB and CEI, respectively), the number and proportion of PCEA demand (number: 0.7 ± 0.9 vs. 2.2 ± 1.9; proportion: 42.0% vs. 80.3% in PIEB and CEI, respectively), and anesthetics consumption significantly decreased in the PIEB group (Ropivacaine: 60 ± 13mg vs. 76 ± 17mg; Sufentanil: 26 ± 4mg vs. 32 ± 6mg in PIEB and CEI, respectively), without severe maternal and neonatal side effects and any difference in neonatal Apgar scale. The epidural sensory levels 2h post-analgesia (2h: 8[8, 9] vs. 9[8, 9] in PIEB and CEI) and satisfaction score (9 [9, 10] vs. 7 [6, 7] in PIEB and CEI) were significantly higher in the PIEB group compared with those in the CEI group. PIEB with 10ml of 0.08% ropivacaine and 0.4μg/ml sufentanil hourly provided a lower incidence of intra-partum fever with a better analgesic effect compared with CEI, without any severe maternal and neonatal adverse reactions.

Comparison of Continuous Wound Infusion versus Continuous Epidural Infusion in Upper Abdominal Surgery: Noninferiority Randomized Controlled Trial.

Context:Wound catheter offers a less invasive alternative for postoperative analgesia in the abdominal surgery. Methods:We conducted a single-center, prospective, open-label noninferiority randomized controlled trial. A total of 40 patients who consented to this trial, undergoing upper abdominal surgery via an upper midline incision, were randomized into two groups. In the continuous wound infusion (CWI) group, the wound catheter was placed in the subcutaneous plane of the surgical incision; the continuous epidural infusion (CEI) group received thoracic epidural with a catheter placed. After the surgery, both the groups received 0.2% ropivacaine infusion at 10 mL/h following a 10 mL bolus for 48 h postsurgery. Postoperatively, the pain scores were noted at multiple time points, along with a record of morphine consumption and adverse effects.Results:There was no significant difference in pain scores both at rest and on movement between the two groups at all the time points assessed. The mean difference in numerical rating scale score 24 h postsurgery at rest (0.1, 95% confidence interval [CI] = −0.45, 0.65) and on movement (0.05, 95% CI = −0.73, 0.83), with 95% CI in both the groups, was within the noninferiority limit. Morphine consumption was less in the CEI group, though not significant. The time to appearance of bowel movement, time to ambulate, and length of hospital stay were significantly lower in the CWI group. The incidence of hypotension requiring intervention was higher in the CEI group.Conclusion:Hence, analgesia provided by continuous wound catheter infusion is not inferior to CEI with better preservation of hemodynamics and faster recovery.

The Efficacy of Programmed Intermittent Epidural Bolus for Postoperative Analgesia after Open Gynecological Surgery: A Randomized Double-Blinded Study.

Background It is well known that the programmed intermittent epidural bolus (PIEB) technique effectively provides epidural anesthesia in labor. This randomized double-blind trial compared the postoperative analgesic efficacy of PIEB with that of continuous epidural infusion (CEI) in patients undergoing gynecological surgery under combined general-epidural anesthesia. Methods Patients undergoing open gynecological surgery under combined general-epidural anesthesia were randomized at a 1 : 1 ratio to receive PIEB or CEI. In the PIEB group, the pump delivered 4 mL ropivacaine 0.2% plus fentanyl 2 μg/mL every hour. In the CEI group, the pump delivered the same solution at a rate of 4 mL/h. In both groups, additional 4 mL boluses of ropivacaine 0.2% plus fentanyl 2 μg/mL were provided, when necessary, by patient-controlled epidural analgesia after surgery. The primary outcome was the total ropivacaine dose 40 hours after surgery. The secondary outcomes were the number of PCEA boluses and postoperative pain (evaluated on an 11-point numerical rating scale) 3, 24, and 48 hours after surgery. Results In total, 57 patients were randomized (n = 28 and 29 in the PIEB and CEI groups, resp.). The two groups differ significantly in terms of the total ropivacaine dose 40 hours after surgery (mean (standard deviation): 155.38 (4.55) versus 159.73 (7.87) mL, P = 0.016). Compared to the CEI group, the PIEB group had significantly lower numerical rating scale scores 3 hours (median [lower–upper quartiles]: 0 [0–0.5] versus 3 [0–5.5], P = 0.002), 24 hours (1 [0–2] versus 3 [1–4], P = 0.003), and 48 hours (1 [0–2] versus 2 [2–3.5], P = 0.002) after surgery. Conclusion PIEB was better than CEI in terms of providing postoperative analgesia after open gynecological surgery under combined general-epidural anesthesia.

Continuous epidural infusion versus programmed intermittent epidural bolus for labor analgesia: optimal configuration of parameters to reduce physician-administered top-ups

Background and objectives: Programmed intermittent epidural bolus (PIEB) is a delivery mode associated with decreased local analgesia dosing, motor block, and physician-administered top-ups (PATUs) during labor analgesia. We hypothesized that PIEB delivery at different settings will result in fewer PATUs for labor analgesia than the same hourly volume of a continuous epidural infusion (CEI).Methods: “Before and after” study design of combined spinal–epidural (CSE) for labor, with bupivacaine 0.0625%–fentanyl 2 mcg/ml and patient-controlled epidural analgesia (PCEA; 5 ml bolus with 10 min lock-out). The “before” group (N = 120) received a CEI at 10 ml/hour. PIEB groups received a programmed bolus of 10 ml: every 60 min (PIEB60, N = 120), every 45 min (PIEB45, N = 140), or every 45 min with high flow (500 ml/hour) (PIEB45HF, N = 25).Main outcome measures: Number of women requesting a PATU, time intervals from CSE to PATU and to delivery, and obstetric outcomes.Results: There was no difference in the proportion of women requesting PATUs between the CEI and PIEB60 groups (45/120 versus 52/120, respectively; p > .05). The PATU rate was lower in the PIEB45 group compared with the PIEB60 and CEI groups (23/140 versus 52/120 and 45/120, p < .005 and p < .05, respectively), and in the PIEB45HF versus PIEB60 groups (5/25 versus 52/120, p < .05). No difference in other outcomes was observed.Conclusions: The number of women requesting a PATU was lowest with the PIEB45 and PIEB45HF settings. There were no differences in any other outcomes between groups. This study emphasizes the many variations in programming that need to be further tested to establish the benefits of PIEB delivery compared with traditional CEI with PCEA.

Comparison of continuous epidural infusion and programmed intermittent epidural bolus in labor analgesia.

BackgroundThis study aims to investigate differences between continuous epidural infusion (CEI) and programmed intermittent epidural bolus (IEB) analgesia for the Chinese parturients undergoing spontaneous delivery and to approach their safety to parturients and neonates.MethodsTwo hundred healthy American Society of Anesthesiologists class I or II, term (≥37 weeks’ gestation), nulliparous women who requested analgesia for labor were recruited. Epidural analgesia was initiated with a solution of 0.15% ropivacaine 10 mL and maintained with 0.1% ropivacaine mixed with sufentanil 0.3 μg/mL by CEI at a rate of 5 mL/h combined with a patient-controlled epidural analgesia (PCEA) bolus of 5 mL of ropivacaine sufentanil mixture or IEB of 5 mL of ropivacaine sufentanil mixture combined with a PCEA bolus of 5 mL of ropivacaine sufentanil mixture. The lockout interval was 20 minutes in each arm between the CEI and the IEB group. After 20 minutes of first dosage, visual analog scale (VAS) score was obtained every 60 minutes. The maternal and fetal outcome and total consumption of analgesic solution were compared.ResultsThere was no difference in demographic characteristics, duration of first and second stages, delivery methods, sensory block, fetal Apgar scores, and the maternal outcomes between the CEI and IEB groups. There was a significant difference in VAS scores and epidural ropivacaine total consumption between the two groups (IEB vs CEI: 51.27±9.61 vs 70.44±12.78 mg, P<0.01).ConclusionThe use of programmed IEB mixed with PCEA improved labor analgesia compared to CEI mixed with PCEA, which could act as maintenance mode for epidural labor analgesia.

Programmed intermittent epidural boluses for maintenance of labor analgesia: an impact study

IntroductionThe aim of this impact study was to compare the analgesic efficacy and side effect profile of programmed intermittent epidural boluses (PIEB)+patient-controlled epidural analgesia (PCEA) to continuous epidural infusion (CEI)+PCEA for maintenance labor analgesia after the introduction of PIEB at our institution. MethodsWe conducted a retrospective analysis after replacing the background CEI with PIEB for our labor PCEA. Pre-change pump settings were CEI 12mL/h with PCEA (12mL bolus, lockout 15min); PIEB settings were a 9mL bolus every 45min with PCEA (10mL bolus, lockout 10min). We compared medical records of all women receiving epidural or combined spinal-epidural labor analgesia for vaginal delivery for two months before PIEB implementation to a two-month period of PIEB utilization following a five-month introductory familiarization period. The primary outcome was the proportion of women requiring rescue clinician boluses. ResultsFewer patients in the PIEB group required rescue clinician boluses compared to the CEI group (12% vs. 19%, P=0.012). Time to first rescue bolus request and total bolus dose were not different. Peak (median [IQR]) pain scores were 2[0–5] with CEI and 0[0–4] with PIEB. There was no difference in instrumental delivery rates. ConclusionsUsing PIEB compared to CEI as the background maintenance epidural analgesia method in conjunction with PCEA reduced the number of women requiring clinician rescue boluses while providing comparable labor analgesia. The findings of this clinical care impact study confirm the results of randomized controlled studies and suggest PIEB may be a preferable technique to CEI for the maintenance of labor analgesia.

The Postoperative Analgesic Efficacy of Preperitoneal Continuous Wound Infusion Compared to Epidural Continuous Infusion with Local Anesthetics After Colorectal Cancer Surgery

Open colorectal cancer (CRC) surgery induces severe and prolonged postoperative pain. The optimal method of postoperative analgesia in CRC surgery has not been established. We evaluated the efficacy of preperitoneal continuous wound infusion (CWI) of ropivacaine for postoperative analgesia after open CRC surgery in a multicenter randomized controlled trial. Candidates for open CRC surgery randomly received preperitoneal CWI analgesia or continuous epidural infusion (CEI) analgesia with ropivacaine 0.2% 10 mL/h for 48 hours after surgery. Fifty-three patients were allocated to each group. All patients received patient-controlled IV morphine analgesia. Over the 72-hour period after the end of surgery, CWI analgesia was not inferior to CEI analgesia. The difference of the mean visual analog scale score between CEI and CWI patients was 1.89 (97.5% confidence interval = -0.42, 4.19) at rest and 2.76 (97.5% confidence interval = -2.28, 7.80) after coughing. Secondary end points, morphine consumption and rescue analgesia, did not differ between groups. Time to first flatus was 3.06 ± 0.77 days in the CWI group and 3.61 ± 1.41 days in the CEI group (P = 0.002). Time to first stool was shorter in the CWI than the CEI group (4.49 ± 0.99 vs 5.29 ± 1.62 days; P = 0.001). Mean time to hospital discharge was shorter in the CWI group than in the CEI group (7.4 ± 0.41 and 8.0 ± 0.38 days, respectively). More patients in the CWI group reported excellent quality of postoperative pain control (45.3% vs 7.6%). Quality of night sleep was better with CWI analgesia, particularly at the postoperative 72-hour evaluation (P = 0.009). Postoperative nausea and vomiting was significantly less frequent with CWI analgesia at 24 hours (P = 0.02), 48 hours (P = 0.01), and 72 hours (P = 0.007) after surgery evaluations. Preperitoneal CWI analgesia with ropivacaine 0.2% continuous infusion at 10 mL/h during 48 hours after open CRC surgery provided effective postoperative pain relief not inferior to CEI analgesia.

Programmed Intermittent Epidural Bolus Versus Continuous Epidural Infusion for Labor Analgesia

Programmed intermittent epidural anesthetic bolus (PIEB) technique may result in reduced total local anesthetic consumption, fewer manual boluses, and greater patient satisfaction compared with continuous epidural infusion (CEI). In this randomized, double-blind study, we compared the incidence of motor block and labor outcome in women who received PIEB or CEI for maintenance of labor analgesia. The primary outcome variable was maternal motor function and the secondary outcome was mode of delivery. Nulliparous, term women with spontaneous labor and cervical dilation <4 cm were eligible to participate in the study. Epidural analgesia was initiated and maintained with a solution of levobupivacaine 0.0625% with sufentanil 0.5 μg/mL. After an initial epidural loading dose of 20 mL, patients were randomly assigned to receive PIEB (10 mL every hour beginning 60 minutes after the initial dose) or CEI (10 mL/h, beginning immediately after the initial dose) for the maintenance of analgesia. Patient-controlled epidural analgesia (PCEA) using a second infusion pump with levobupivacaine 0.125% was used to treat breakthrough pain. The degree of motor block was assessed in both lower extremities using the modified Bromage score at regular intervals throughout labor; the end point was any motor block in either limb. We also evaluated PCEA bolus doses and total analgesic solution consumption. We studied 145 subjects (PIEB = 75; CEI = 70). Motor block was reported in 37% in the CEI group and in 2.7% in the PIEB group (P < 0.001; odds ratio = 21.2; 95% CI: 4.9-129.3); it occurred earlier (P = 0.008) (hazard ratio = 7.8; 95% CI: 1.9-30.8; P = 0.003) and was more frequent at full cervical dilation in the CEI group (P < 0.001). The incidence of instrumental delivery was 20% for the CEI group and 7% for the PIEB group (P = 0.03). Total levobupivacaine consumption, number of patients requiring additional PCEA boluses, and mean number of PCEA boluses per patient were lower in the PIEB group (P < 0.001). No differences in pain scores and duration of labor analgesia were observed. Maintenance of epidural analgesia with PIEB compared with CEI resulted in a lower incidence of maternal motor block and instrumental vaginal delivery.

Comparison of Automated Intermittent Low Volume Bolus with Continuous Infusion for Labour Epidural Analgesia

Delivery of local anaesthetics via automated intermittent bolus has been shown to improve epidural analgesia compared to delivery via continuous epidural infusion. However the optimal bolus volume has not been investigated. This randomised, double-blind study compared the analgesic efficacy of automated intermittent bolus (volume 2.5 ml every 15 minutes) with that of a continuous epidural infusion (10 ml/hour) for the maintenance of labour epidural analgesia, to determine whether the advantages previously demonstrated for automated intermittent bolus over continuous epidural infusion are retained at this low bolus volume. With the approval of the Hospital Ethics Committee, we recruited 50 parturients who received combined spinal epidural analgesia with intrathecal ropivacaine 2 mg and fentanyl 15 microg. For epidural maintenance, participants were randomised to either the automated intermittent bolus group (2.5 ml automated intermittent epidural boluses of ropivacaine 0.1% plus fentanyl 2 microg/ml delivered over a two-minute period every 15 minutes) or the continuous epidural infusion group (continuous epidural infusion of ropivacaine 0.1% plus fentanyl 2 microg/ml at 10 ml/hour). The primary study outcome was the incidence of pain during labour that required management with supplemental epidural analgesia. There were no significant differences between the two regimens in terms of breakthrough pain (automated intermittent bolus 36% [9/25] vs continuous epidural infusion 32% [8/25], P = 0.77). At the doses used in this study, maintenance of labour analgesia using automated intermittent bolus at a bolus volume of 2.5 ml every 15 minutes does not decrease the incidence of breakthrough pain or improve analgesic efficacy compared to continuous epidural infusion.

Randomized, double-blind comparison of patient-controlled epidural infusion vs nurse-administered epidural infusion for postoperative analgesia in patients undergoing colonic resection

There is little published evidence of the analgesic efficacy of patient-controlled epidural analgesia (PCEA) for postoperative pain relief. The aim of this study was to compare the analgesic efficacy of epidural infusion of bupivacaine 0.125% and fentanyl 4 microg ml(-1) administered by either PCEA with a background infusion or nurse-administered continuous epidural infusion (CEI) after major intra-abdominal surgery. In a double-blind, randomized clinical trial, 205 adult patients undergoing colonic resection by laparotomy received either PCEA or CEI. Pain scores were recorded via a four-point verbal rating scale at 1, 2, 3, 4, 8, 12, 24, 48, and 72 h after surgery. The administration of epidural top-ups and systemic analgesia over the same period was also recorded, and patient satisfaction questionnaires completed. The median area under the curve of pain against time was significantly lower in the PCEA group (2 vs 24, P<0.001) as were median summary pain scores on movement (0.67 vs 1.33, P<0.001). Significantly fewer patients in the PCEA group received one or more epidural top-ups (13 vs 36%, P = 0.0002) or any systemic analgesics (41 vs 63%, P = 0.0021). Patients in the PCEA group were significantly more likely to be very satisfied than in the CEI group (76 vs 43%, P<0.0001). PCEA provides greater analgesic efficacy than CEI for postoperative analgesia after major intra-abdominal surgery, and a decreased requirement for physician or nurse intervention.