Patient-controlled Epidural Analgesia Bolus Research Articles

Optimum programmed intermittent epidural bolus interval time of ropivacaine 0.0625% with dexmedetomidine 0.4μg/ml at a fixed volume of 10mL: a randomized controlled trial.

The aim of our study was to administer adequate local anesthetic in programmed intermittent epidural bolus (PIEB) to avoid breakthrough pain and decrease the use of manual and PCEA boluses. We, therefore, conducted this study to determine the effective PIEB interval time between boluses of ropivacaine 0.0625% with dexmedetomidine 0.4μg/ml at a fixed volume of 10mL in 90% of subjects (EI90), without the use of patient-controlled epidural analgesia (PCEA). A total of 80 subjects were included in the final statistical analysis from 23 August 2022 to 22 November 2022. The subjects were randomly assigned to one of four different PIEB time intervals: 40, 50, 60, and 70min (groups 40, 50, 60, and 70), respectively. The primary outcome was the effective epidural labor analgesia, defined as no use of PCEA bolus or a manual bolus until the end of the first stage of labor or within 6hours after loading dose administration. The PIEB EI90 (95% CI) between boluses of ropivacaine 0.0625% with dexmedetomidine 0.4μg/ml at a fixed volume of 10mL was estimated using probit regression. The effective PIEB interval time between boluses of ropivacaine 0.0625% with dexmedetomidine 0.4μg/ml at a fixed volume of 10mL in 90% of subjects without the use of PCEA was 45.4 (35.5-50.5) minutes using probit regression. No statistical differences were found in the proportion of subjects with Bromage score > 0, hypotension, pruritus, nausea, and vomiting between groups. However, the highest sensory block (pinprick) in the 40-min group was significantly higher than that in the other groups. The estimated value for EI90 for PIEB between boluses of ropivacaine 0.0625% with dexmedetomidine 0.4μg/ml at a fixed volume of 10mL using probit regression was 45.4 (35.5-50.5) minutes. Furthermore, future studies are warranted to be established to determine the optimal parameters for different regimens in clinical practice.

High-volume patient-controlled epidural vs. programmed intermittent epidural bolus for labour analgesia: a randomised controlled study.

The aim of neuraxial analgesia is to achieve excellent pain relief with the fewest adverse effects. The most recently introduced technique for epidural analgesia maintenance is the programmed intermittent epidural bolus. In a recent study, we compared this with patient-controlled epidural analgesia without a background infusion and found that a programmed intermittent epidural bolus was associated with less breakthrough pain, lower pain scores, higher local anaesthetic consumption and comparable motor block. However, we had compared 10 ml programmed intermittent epidural boluses with 5 ml patient-controlled epidural analgesia boluses. To overcome this potential limitation, we designed a randomised, multicentre non-inferiority trial using 10 ml boluses in each group. The primary outcome was the incidence of breakthrough pain and total analgesic intake. Secondary outcomes included motor block; pain scores; patient satisfaction; and obstetric and neonatal outcomes. The trial was considered positive if two endpoints were met: non-inferiority of patient-controlled epidural analgesia with respect to breakthrough pain; and superiority of patient-controlled epidural analgesia with respect to local anaesthetic consumption. A total of 360 nulliparous women were allocated randomly to patient-controlled epidural analgesia-only or programmed intermittent epidural bolus groups. The patient-controlled group received 10 ml boluses of ropivacaine 0.12% with sufentanil 0.75 μg.ml-1 ; the programmed intermittent group received 10 ml boluses supplemented by 5 ml patient-controlled boluses. The lockout period was 30 min in each group and the maximum allowed hourly local anaesthetic/opioid consumption was identical between the groups.Breakthrough pain was similar between groups (11.2% patient controlled vs. 10.8% programmed intermittent, p = 0.003 for non-inferiority). Total ropivacaine consumption was lower in the PCEA-group (mean difference 15.3 mg, p < 0.001). Motor block, patient satisfaction scores and maternal and neonatal outcomes were similar across both groups. In conclusion, patient-controlled epidural analgesia is non-inferior to programmed intermittent epidural bolus if equal volumes of patient-controlled epidural analgesia are used to maintain labour analgesia and superior with respect to local anaesthetic consumption.

Analgesic efficacy of programmed intermittent epidural bolus vs patient-controlled epidural analgesia in laboring parturients.

Background and Aims:Programmed intermittent epidural boluses (PIEB) may produce more extensive spread of epidural bolus rather than continuous epidural infusion (CEI). Previous studies compared PIEB with CEI and concluded that PIEB shows better outcome when combined with patient controlled epidural analgesia (PCEA), but these studies lack any comparison between PCEA and PIEB in the absence of CEI.Material and Methods:In this open labeled, prospective, randomized, controlled study 50 parturient were randomly assigned to two groups of 25 each. Group 1 received PCEA bolus of 5 ml (0.1% levobupivacaine plus 2mcg/ml fentanyl) with 15 min lockout interval with provision of rescue clinician bolus of 5 ml of same drug for breakthrough pain. Group 2 received physician-administered PIEB with same parameters as Group 1. The primary outcome was to assess total consumption of levobupivacaine plus fentanyl mixture, in PIEB vs. PCEA group, corrected for duration of labor (ml/h) and secondary outcomes included pain score, maternal satisfaction, maternal, and neonatal characteristics.Results:The hourly mean drug consumption in the PCEA group was significantly lower as compared with the physician-administered PIEB group (5.46 ml/h, SD 2.01 vs. 6.55 ml/h, SD 1.28; P = 0.03). The median total number of rescue boluses consumed were less in the PCEA group when compared with the PIEB group (0 vs. 1; P < 0.001). There was no significant difference between groups with regard to pain scores, maternal hemodynamics, maternal and fetal outcome and adverse effects.Conclusion: PCEA may be better than physician-administered PIEB in providing effective labor analgesia with comparable safety.

Oral acetaminophen as an adjunct to continuous epidural infusion and patient-controlled epidural analgesia in laboring parturients: a randomized controlled trial.

Intravenous acetaminophen is safe and effective as an adjunct to labor analgesia with combined spinal-epidural (CSE) analgesia and patient-controlled epidural analgesia (PCEA). Oral acetaminophen is a much cheaper and safe option but has not been studied as an adjunct to labor analgesia till date. The aim of the present study is to evaluate the effect of oral acetaminophen as an adjunct in patients receiving local anesthetic-opioid combination using CSE analgesia. In this ethically approved randomized double-blind placebo-controlled trial, 60 consenting parturients were randomly allocated to two groups of 30 each: acetaminophen (who received oral acetaminophen 1g) or placebo, 45min before the procedure. CSE was administered as per hospital protocol. All the patients received continuous epidural infusion (CEI) of levobupivacaine 0.1% and fentanyl 2 mcg/mL at 5ml/h and PCEA boluses of 5mL of the same drug with a lockout interval of 15min if needed. The primary outcome was hourly mean consumption of levobupivacaine and fentanyl mixture (mL/h). Secondary outcomes included pain score, sensory and motor block, hemodynamic parameters of mother, duration of the second stage of labor, mode of delivery, maternal satisfaction, Apgar scores, fetal heart rate, and adverse effects. The mean drug consumption per hour was significantly less in the acetaminophen group than in the placebo group (7.66mL/h, SD 2.01 vs. 9.01mL/h, SD 2.83; p = 0.04). The requirement for bolus was also significantly less in the acetaminophen group than in the placebo group (median 2.5, IQR 3 vs. median 3.5, IQR 2; p = 0.04). The use of 1g of oral acetaminophen could be a cheap, safe, and effective adjunct to CEI plus PCEA in labor analgesia.

Labor outcomes with epidural analgesia: an observational before-and-after cohort study comparing continuous infusion versus programmed intermittent bolus plus patient-controlled analgesia.

Scientific evidence shows that programmed intermittent epidural bolus (PIEB) for labor analgesia achieves good obstetric outcomes. After implementing our institutional standard for epidural analgesia, we compared PIEB + patient-controlled epidural analgesia (PCEA) versus continuous epidural infusion (CEI). In an observational cohort study, we compared CEI with 0.2% ropivacaine + 100-μg fentanyl initial bolus versus PIEB+PCEA with 0.1% ropivacaine + 2 μg mL-1 fentanyl in primiparous women. The primary outcome was mode of delivery. Secondary outcomes were duration of the second stage of labor and total ropivacaine and fentanyl doses. Other outcomes, in the PIEB+PCEA group only, were motor block, use of PCEA and rescue bolus, maternal mobility and maternal satisfaction. Univariate statistical analysis was performed using the χ2 Test, analysis of variance or nonparametric Kruskal-Wallis Test. Multivariate analysis was performed using multiple logistic regression analysis. The study included 221 patients (CEI 116; PIEB+PCEA 105). Multiple logistic regression showed that the PIEB+PCEA group had significantly fewer caesarean sections (CEI [14%] vs. PIEB+PCEA [5%], P=0.015) and instrumental deliveries, after correcting for confounders (OR=0.49; 95% CI: 0.27-0.89). The second stage of labor did not significantly differ between groups. Total ropivacaine dose was significantly lower with PIEB+PCEA. There was no relationship between mild motor block and increased use of PCEA in the PIEB+PCEA group. Mode of delivery and duration of the second stage of labor were not influenced by motor block either. Maternal satisfaction was high. PIEB+PCEA offers obstetric and analgesic advantages over CEI in daily clinical practice.

Labor epidural analgesia onset time and subsequent analgesic requirements: a prospective observational single-center cohort study

BackgroundWe investigated the correlation between lumbar epidural analgesia onset time and pain intensity at 60 and 120 min after initiation. MethodsWe conducted a prospective observational study of nulliparous women receiving lumbar epidural analgesia (initial bolus 15 mL bupivacaine 0.1% with fentanyl 3.33 μg/mL), followed by patient-controlled epidural analgesia (PCEA). The measured variable was lumbar epidural analgesia onset time (time to pain numerical rating score ≤3). Secondary outcomes were pain score at 60 and 120 min and at full dilatation; and analgesic requirements through the labor. ResultsOne-hundred-and-five women were eligible for analysis. There was a significant correlation between lumbar epidural analgesia onset time and pain intensity at 60 min (Spearman’s R2=0.286, P=0.003), but not at 120 min (R2=0.030, P=0.76). Women who requested more PCEA boluses during the first 120 min had a longer lumbar epidural analgesia onset time (R2=0.321, P=0.001) and reported higher pain scores at 60 min (R2=0.588, P <0.001) and at 120 min (R2=0.539, P <0.001). Women who reported higher pain scores at 60 min had more pain at 120 min (R2=0.47, P <0.001) and higher analgesic consumption during labor (R2=0.403, P <0.001). Women who were at a greater cervical dilatation at 60 and 120 min had higher pain scores at the same time point (R2=0.259, P=0.008 and R2=0.243, P=0.013 respectively). ConclusionThere was a correlation between the onset time of lumbar epidural analgesia during labor and the pain score 60 min later but this had disappeared by 120 min.

Determination of the Optimal Programmed Intermittent Epidural Bolus Volume of Bupivacaine 0.0625% With Fentanyl 2 μg/mL at a Fixed Interval of 40 Minutes: A Biased Coin Up-and-down Sequential Allocation Trial

(Anaesthesia. 2018;73:459–465) The use of programmed intermittent epidural bolus (PIEB) to provide labor analgesia has been increasing in popularity as commercially available pumps have become available. A variety of dosing strategies have been evaluated but the optimal settings for PIEB have not yet been established. The majority of studies have included PIEB in conjunction with patient controlled epidural analgesia (PCEA). The current investigators had previously investigated which PIEB dosing strategy would minimize breakthrough pain and the need for PCEA boluses. They determined the optimal regimen was 10 mL of bupivacaine 0.0625% with fentanyl 2 µg/ml administered every 40 minutes. However, 34% of women exhibited a sensory block to ice above T6, which might indicate an unnecessarily high spread of local anesthetic. Therefore, they conducted this prospective, double-blind, dose-finding study to investigate whether it was possible to reduce the PIEB volume without compromising the efficacy of the technique.

Pre-emptive multimodal analgesic regimen reduces post-operative epidural demand boluses in traumatic shaft of femur fracture - A randomised controlled trial.

Background and Aims:The efficacy of preemptive multimodal analgesia in post-traumatic patients has not been elucidated. Our aim was to evaluate the efficacy of preemptive MMA regimen in reducing the epidural demand boluses in the first 48 hours following the traumatic shaft of femur fractures.Methods:Patients scheduled for traumatic femur fracture surgery were randomised (n = 135) into two groups in this double blind, placebo controlled trial. Patients received either (Preemptive multimodal group) intravenous acetaminophen 1 gm, diclofenac 75 mg, morphine 3 mg, 75 mg Pregabalin (per oral) or a placebo 30 minutes pre-operatively. Intra-operatively, all patients were managed with spinal and epidural anaesthesia. Post-operatively, patients received patient-controlled epidural analgesia (PCEA) programmed to deliver a bolus of 5 ml of 0.2% Ropivacaine with 2 μg/ml of Fentanyl with lockout interval time of 15 min. Primary outcome was number of PCEA boluses received post-operatively over 48 h. Secondary outcomes measures were time to receive first epidural bolus, postoperative VAS scores and episodes of post-operative nausea, vomiting and sedation. Total number of PCEA bolus doses over 48 hours and VAS scores were analysed using Mann-Whitney test.Results:Significant reduction in median number of demand boluses were observed in preemptive multimodal group (3 [2-4]) compared to placebo group (5 [4-7]); P = 0.00. Time to first rescue epidural bolus was significantly greater in preemptive multimodal group than placebo group.Conclusion:The use of preemptive MMA regimen reduced the requirement of demand epidural bolus doses.

A comparative study of ropivacaine and bupivacaine with fentanyl for postoperative patient-controlled epidural analgesia after major abdominal oncosurgery

Aim: To compare the analgesic efficacy of epidural ropivacaine–fentanyl with bupivacaine–fentanyl combination administered by patient-controlled epidural analgesia (PCEA) technique for postoperative pain relief after major abdominal oncosurgery. Materials and Methods: A prospective, randomized, interventional, parallel group, active control study was conducted on 60 patients with American Society of Anesthesiologists physical status I–III. Random allocation was carried out into two groups of 30 patients each. Intraoperatively, after administering a loading dose (10mL of 0.5% bupivacaine) in both the groups, continuous infusions of 0.1% bupivacaine plus fentanyl (2 µg/mL) (Group BF) or 0.1% ropivacaine plus fentanyl (2 µg/mL) (Group RF) were started at the rate of 5mL/h. Postoperatively, same drug concentrations were administered via PCEA pump at 4mL/h as a baseline infusion (bolus dose, 3mL; lockout interval, 15min). Visual analog scale (VAS) score at rest and on coughing was recorded at specific time points. Rescue analgesia was administered as per protocol. Results: VAS scores at rest and on coughing were higher in Group BF as compared to Group RF. Group RF had less drug consumption, required fewer PCEA boluses, and had minimal motor blockade as compared to Group BF. Conclusion: Good analgesic efficacy with lower drug consumption makes Group RF well suited for postoperative PCEA with hemodynamic stability and minimal motor blockade.

Determination of the optimal programmed intermittent epidural bolus volume of bupivacaine 0.0625% with fentanyl 2 μg.ml-1 at a fixed interval of forty minutes: a biased coin up-and-down sequential allocation trial.

The optimum time interval for 10 ml boluses of bupivacaine 0.0625% + fentanyl 2 μg.ml-1 as part of a programmed intermittent epidural bolus regimen has been found to be 40 min. This regimen was shown to be effective without the use of supplementary patient-controlled epidural analgesia boluses in 90% of women during the first stage of labour, although with a rate of sensory block to ice above T6 in 34% of women. We aimed to determine the optimum programmed intermittent epidural bolus volume at a 40 min interval to provide effective analgesia in 90% of women (EV90 ) during the first stage of labour, without the use of patient-controlled epidural analgesia. We performed a prospective double-blind dose-finding study using the biased coin up-and-down sequential allocation method in 40 women. The estimated EV90 was 11.0 (95%CI 10.0-11.7) ml with the isotonic regression method and 10.7 (95%CI 10.3-11.0) ml with the truncated Dixon and Mood method. Overall, 18 women had a sensory block above T6, and 37 women exhibited no motor block. No women required treatment for hypotension. In conclusion, it is not possible to reduce the programmed intermittent epidural bolus volume from 10 ml, used in our current regimen, without compromising the quality of analgesia. Using this regimen, a high proportion of women will develop a sensory block above T6.

Implementation of Programmed Intermittent Epidural Bolus for the Maintenance of Labor Analgesia.

Programmed intermittent epidural bolus (PIEB) is an exciting new technology that has the potential to improve the maintenance of epidural labor analgesia. PIEB compared with a continuous epidural infusion (CEI) has the potential advantage of greater spread within the epidural space and therefore better sensory blockade. Studies have demonstrated a local anesthetic-sparing effect, fewer instrumental vaginal deliveries, less motor blockade, and improvements in maternal satisfaction with PIEB compared with CEI. However, the optimal PIEB regimen and pump settings remain unknown, and there are a number of logistical issues and practical considerations that should be considered when implementing PIEB. The PIEB bolus size and interval, PIEB start time delay period, and patient-controlled epidural analgesia bolus size and lockout time can influence the efficacy of PIEB used for epidural labor analgesia. Educating all members of the health care team is critical to the success of the technique. This review summarizes the role of PIEB for the maintenance of labor analgesia, outlines implementation strategies, suggests optimal settings, and presents potential limitations of the technique.

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.

The Value of Programmed Intermittent Epidural Bolus in Labor Analgesia

Objective: To identify whether programmed intermittent epidural bolus analgesia is effective and safe to the parturients and neonates. Methods: Sixty healthy ASA class I or II, term (?37weeks’ gestation), nulliparous women were recruited in our study. Epidural analgesia was initiated with a solution of 0.15% ropivacaine 10 mL and maintained with 0.12% ropivacaine combined with fentanyl 2ug/mL by continuous epidural infusion at a rate of 5mL/h and combined with a patient-controlled epidural analgesia bolus of 5 mL and intermittent bolus of 5mL and combined with a patient-controlled epidural analgesia bolus of 5 mL, lockout interval was 20 minutes. After 20 minutes of the first dosage the VAS score was obtained in every 60 minutes. The maternal and fetal outcome, total consumption of analgesic solution and were oxytocin compared among the groups. Result: There was no difference of the maternal and fetal outcomes among the groups. The dosage consumption of oxytocin in non-labor analgesia group was significant lower than analgesia groups, the first and second stage of labor in non-labor analgesia group was significant longer than two analgesia groups. There was a significant difference in the epidural ropivacaine total consumption between the two analgesia groups. (51.27±9.61mg vs 70.44±12.78 mg, P=0.00 ) Conclusion: The use of programmed intermittent bolus combined with PECA was more effective than continuous infusion combined with PECA, it could be useful as the mode of maintenance for epidural labor analgesia.

&lt;b&gt;Evaluation of postoperative pain intensity and side effects caused by fentanyl administered during patient-controlled &lt;/b&gt;&lt;b&gt;epidural analgesia in elderly patients who undergo laparoscopic-assisted colon surgery for colon cancer &lt;/b&gt;

We conducted a retrospective study to evaluate postoperative pain intensity and side effects caused by fentanyl administered during patient–controlled epidural analgesia (PCEA) with a mixture of ropivacaine (1.5 mg/ml) and fentanyl (1 µg/ml or 2 µg/ml) in elderly patients who underwent laparoscopic–assisted colon surgery (LAC) for colon cancer. A total of 68 elderly patients aged >70 years were divided into 4 groups by gender and fentanyl dose administered during PCEA with 1.5 mg/ml of ropivacane: an LM group, which included 6 males who received fentanyl at a dose of 1 µg/ml during PCEA; an LF group, which included 18 females who received fentanyl at a concentration of 1 µg/ml during PCEA; an HM group, which included 27 males who received fentanyl at a concentration of 2 µg/ml during PCEA; and an HF group, which included 17 females who received fentanyl at a concentration of 2 µg/ml during PCEA. PCEA was admin­istered at the rate of 3 ml/h using the CADD–Legacy® PCA machine type. The bolus dose was 2 ml, the lock–out period was 15 min, and the maximum effective number of bolus was 2 times/h. Pain intensity at rest and during movement was measured twice daily for 4 days following surgery using a 100–mm nongraduated visual analog scale (VAS). One–way analysis of variance, the Kruskal–Wallis test, and the chi–square test were used for statistical analyses depending on the type of data. A p–value of <0.05 was considered statistically significant. If a significant difference was observed, a multiple comparison test of Bonferroni or Dunn’s post–test was used. Pain intensity at rest and during movement was not significantly different among the 4 groups. The number of PCEA bolus injections administered and the number of requests for PCEA were comparable among the 4 groups. The incidence of postoperative itching was 88.2％ in the HF group; this was significantly higher than that in the HM (51.9％) and LF groups (33.3％). The incidence of postoperative nausea and vomiting were 47.1％ in the HF group; this was significantly higher than that in the HM group (11.1％). There was no case of lower limb paralysis after 1 postoperative day in all groups. In conclusion, the findings of this study suggest that the degree and frequency of postoperative itching caused by fentanyl administered during PCEA can be potentially decreased, without altering postoperative pain intensity, by lowering the concentration of fentanyl combined with a low dose of ropivacane following LAC in elderly female patients.

Perioperative infusion of dexmedetomidine at a high dose reduces postoperative analgesic requirements: a randomized control trial

We hypothesized that a high dose of dexmedetomidine (1 μg/kg/h) could reduce postoperative analgesic requirements of patients. This was a prospective, randomized, double-blind, placebo-controlled study carried out in Tohoku University Hospital. Thirty-two patients who underwent open gynecological abdominal surgery were randomly divided into a control (group C) and a dexmedetomidine group (group D). In both groups of patients, an epidural catheter was put in position prior to the induction of anesthesia, and continuous epidural infusion was started using a patient-controlled epidural analgesia (PCEA) pump. During the induction of anesthesia, group D patients received a loading dose of dexmedetomidine (1 μg/kg over 10 min), followed by a continuous infusion at a rate of 1 μg/kg/h. The patients in group C received a volume-matched infusion of normal saline as placebo. Consumption of PCEA bolus (local anesthetics) during the first postoperative 24 h, postoperative pain scores, and side effects related to the use of dexmedetomidine were recorded. Dexmedetomidine (1 μg/kg/h) significantly reduced PCEA bolus consumption [15.9 ± 6.5 (group C) vs. 5.3 ± 5.0 ml (group D); P = 0.0001] and postoperative pain scores. The infusion of dexmedetomidine produced no serious side effects, such as hemodynamic changes. Among this small patient cohort, perioperative infusion of dexmedetomidine (1 μg/kg/h) resulted in antinociception without severe side effects. These results suggest that this method could be of interest with respect to improving postoperative pain status.

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.

Obstetric outcomes and maternal satisfaction in nulliparous women using patient-controlled epidural analgesia

The purpose of this study was to compare obstetric outcomes and maternal satisfaction in nulliparous women in spontaneous labor who used patient-controlled epidural analgesia (PCEA) vs continuous epidural infusion (CEI). We conducted a double-masked trial of 270 nulliparous women who were assigned randomly to 3 groups (with a concentration 0.1% bupivacaine and 2 μg/mL fentanyl): group I, CEI-only (10 mL/h); group II, CEI + PCEA (CEI 10 mL/h plus PCEA 10 mL, at 20 minutes); group III, PCEA-only (10 mL, at 20 minutes). A PCEA bolus button was given to each subject. The primary outcome was the dosage of local anesthetic that was used. The total milligrams of bupivacaine that were used was less in the PCEA-only group compared with CEI: group I. 74.8 ± 36 mg; group II, 97.3 ± 53 mg; group III, 52.4 ± 42 mg (P < .001). Pain with pushing, however, was worse in the PCEA-only group. Median satisfaction scores were similar (scale, 0 [best] to 100 [worst]: group I, 0; group II, 0; group III, 0 (P = .23). PCEA results in less anesthetic used, and maternal satisfaction remains high without a continuous infusion. Pain with pushing, however, was worse with the PCEA alone.

The use of patient-controlled epidural fentanyl in elderly patients*

We studied whether delivering postoperative analgesia, using a patient-controlled epidural analgesia (PCEA) device was effective and safe in elderly patients. We enrolled 40 patients aged > 65 years (elderly group) and 40 patients aged 20-64 years (young group) scheduled for elective major abdominal surgery. PCEA infusion was started following completion of surgery. Mean (SD) fentanyl consumption (10.7 (3.7) compared with 10.5 (2.7) microg.kg(-1), p = 0.76) and number of times patients pressed the bolus switch (32 (36) compared with 44 (38), p = 0.16) during the first 24 h postoperatively were similar in the two groups. Pain scores, which were similar in both groups at rest, were significantly lower in the elderly on coughing (at 24 h, p < 0.05). In addition, average pain scores were similar at the time of PCEA bolus demands in the two groups. Elderly and young adult patients therefore required similar amounts of patient-controlled epidural fentanyl to produce satisfactory pain relief.

“Ultra-light” patient-controlled epidural analgesia during labor: effects of varying regimens on analgesia and physician workload

Patient-controlled epidural analgesia (PCEA) offers many advantages over continuous epidural infusions for maintenance of labor analgesia. Some of these benefits may depend on the PCEA settings. This study evaluated several regimens for "ultra-light" (0.125%) PCEA with basal continuous infusion (CI) in labor with goals of minimizing physician interventions while providing good analgesia. Two hundred and twenty ASA I-II women receiving epidural analgesia during active labor (cervical dilation <5 cm) were randomly assigned in a double-blind manner to four treatment groups (n=30 in each). Analgesia was maintained with a PCEA/CI pump using bupivacaine 0.0625% + sufentanil 0.35 microg/mL. PCEA settings were: group A: CI 10 mL/h, PCEA bolus 6 mL, 8-min lockout; group B: CI 10 mL/h, PCEA bolus 12 mL, 16-min lockout; group C: CI 15 mL/h, PCEA bolus 6 mL, 8-min lockout; group D: CI 15 mL/h, PCEA bolus 12 mL, 16-min lockout. In groups A, B, C and D, 76, 77, 75 and 85% of parturients respectively, required no physician rescue boluses. Pain scores were low and maternal satisfaction was high in all groups, with minimal differences among them. Spontaneous vaginal delivery occurred in 78% of patients overall, instrumental (forceps or vacuum) delivery in 10% and cesarean section in 12%. These ultra-light PCEA regimens provided excellent analgesia with minimal physician workload and a high spontaneous delivery rate. Use of moderate to high-volume, ultra-light PCEA/CI techniques should facilitate provision of labor analgesia in busy obstetric units.

A randomized comparison of a five-minute versus fifteen-minute lockout interval for PCEA during labor

Background: The best combination of bolus size and lockout interval for patient-controlled epidural analgesia (PCEA) is not known. This study compared a 5-min with a 15-min lockout interval. Methods: Parturients were randomly assigned to receive PCEA with either a 5-min or a 15-min interval. All had a 15-mL loading dose, continuous background infusion 6 mL/h of 0.125% bupivacaine plus fentanyl 2 μg/mL, PCEA bolus volume 5 mL, maximum hourly dose 26 mL. Visual analogue scores for pain, nausea and pruritus, sensory levels to ice, sacral analgesia, motor power, blood pressure and fetal heart rate were assessed pre-epidural and regularly thereafter until delivery. The numbers of boluses and attempts and patient satisfaction were recorded. Results: 29 patients were assigned to the 5-min group and 31 to the 15-min group, but the 15-min group contained twice as many nulliparous women. Side-effect and complication rates did not differ between groups. VAS pain scores were reduced from a median of 79 in the 15-min group and 82 in the 5-min group to a median of zero 30 min after epidural insertion. Bolus/attempt ratio was 0.88 in the 5-min vs. 0.70 in the 15-min group. The numbers of requests for physician intervention were similar. No differences in pain scores, side-effects, drug use or patient satisfaction were demonstrated. Conclusion: The 5-min lockout interval appears the more efficient and has been used safely in our practice for 15 000 parturients, although a larger study is required to confirm the relative efficacy, efficiency and safety of this regimen.