Remifentanil For Labour Analgesia Research Articles

Remifentanil patient-controlled analgesia in labour: six-year audit of outcome data of the RemiPCA SAFE Network (2010–2015)

BackgroundThe RemiPCA SAFE Network was established to set standards and monitor maternal and neonatal outcomes when using remifentanil for labour analgesia. The aim of this analysis was to describe the development of the network standard and to report maternal and neonatal outcome data, including severe adverse events. MethodsData sets of the RemiPCA SAFE Network database from the initial six consecutive years (2010–2015) were retrospectively analysed. The data were analysed on an annual basis and set in context with changes of the network standard, i.e. adaptations of the network’s standard operating procedure. Main outcomes reported are maternal and neonatal data regarding effectiveness and safety, such as satisfaction, need for bag/mask ventilation and/or cardiopulmonary resuscitation. ResultsAmong 5740 data sets, no need for maternal ventilation or cardiopulmonary resuscitation was registered. Neonatal cardiopulmonary resuscitations, potentially related to remifentanil, occurred in 0.3%. In parallel with adaptations of the network standard, a moderate rate of maternal hypoxia (oxygen saturation <94% in 24.7%) was found, together with a low rate of supplemental oxygen requirement in neonates (5.0%). ConclusionThe RemiPCA SAFE Network data show that remifentanil patient-controlled analgesia can be applied safely. There is bias when data from real clinical settings are analysed retrospectively. Notwithstanding, the approach taken by the RemiPCA SAFE Network, with constant, systematic and standardised evaluation of multiple parameters during the course of labour, might identify trends and anomalies and guide the development and application of safety standards, when translating knowledge from scientific trials into clinical practice.

Serious adverse events attributed to remifentanil patient-controlled analgesia during labour in The Netherlands

BackgroundDuring labour, remifentanil patient-controlled analgesia is used as an alternative to neuraxial analgesia. Remifentanil is associated with hypoventilation and respiratory depression but the frequency of serious maternal and neonatal adverse events is unknown. The aim of this study was to estimate the number of serious adverse events attributed to the use of remifentanil patient-controlled analgesia during labour in The Netherlands and to investigate the circumstances (e.g. monitoring, practice deviations) of these events and the subsequent management. MethodsIn a nationwide survey among obstetricians, anaesthetists and clinical midwives the frequency of serious adverse events was assessed. A questionnaire was sent by email to all 61 Dutch hospitals in which remifentanil patient-controlled analgesia is, or has been, available for labour analgesia. All reported cases were assessed independently by two expert teams. ResultsWe received information from all hospitals. After independent assessments, 17 cases of single maternal desaturation; 10 maternal cases of apnoea, bradycardia and/or cardiac arrest; and two neonatal cases of respiratory depression, over a period of more than 10 years of remifentanil patient-controlled analgesia use, were identified as a serious adverse event. All serious adverse events were resolved without irreversible damage. ConclusionsThe risk of a potentially life-threatening serious adverse event attributed to remifentanil patient-controlled analgesia seems to be low. All patients recovered without deficit. Adherence to strict monitoring and the attendance of trained healthcare providers is required to safely use remifentanil for labour analgesia.

Clinical application of intravenous remifentanil administration for labor analgesia

Background Intravenous infusion of remifentanil(REM) is commonly used for labor analgesia. However, its appropriate usage poses challenges in obstetrics which requires balancing analgesia sufficiency and safety of mothers and neonates. Objective The purpose of this review is to provide information to optimize intravenous administration of REM for labor analgesia. Content Rapid onset, fast clearance, and non-effect on uterine contraction are demanding properties of analgesics to reduce suffering of puerperants during labor. Either pethidine or inhaled anesthetics has adverse effects on neonates and mothers. Intrathecal analgesia has minor effects on neonates but may cause low back pain in mothers. REM has many beneficial pharmacological properties, such as, high potency and selectivity to μ-opioid receptors, high lipophilicity, and fast metabolism. Compared with other analgesics, REM has better analgesia efficiency and higher levels of satisfaction. It is, however, not rarely reported that REM has similar side-effects as other opioid agents, such as, nausea, vomiting, muscle stiffness, and respiration and circulation inhibition, etc. Note that these side-effects of REM are dose-dependent and can be reversed by adjusting drug administration. Therefore, real-time monitoring of respiratory parameters, etc. is necessary to use remifentanil for labor analgesia. Trend Intravenous administration of REM for labor analgesia can obtain high degree of satisfaction, but further investigations are warranted to evaluate its safety and effectiveness before it is routinely applied in clinical practice. Key words: Remifentanil; Labor analgesia; Patient-controlled intravenous analgesia

A Survey of Intravenous Remifentanil Use for Labor Analgesia at Academic Medical Centers in the United States

(Anesth Analg. 2017;124(4):1208–1210) Currently, there is no standardized protocol regarding the optimal administration, dosing strategy, and maternal monitoring requirements of intravenous (IV) remifentanil for labor analgesia. As this drug has the potential to cause sedation, respiratory depression, oxygen desaturation, and more, it is essential that clear recommendations are established. The authors of the present study surveyed and evaluated current practices for IV remifentanil administration for labor analgesia across academic medical centers in the United States.

Erratum to: Remifentanil for labor analgesia: a comprehensive review.

Erratum to: Remifentanil for labor analgesia: a comprehensive review.

The analgesic efficacy of remifentanil for labour. Systematic review of the recent literature.

Although epidural analgesia is still regarded as the gold standard for labour analgesia due to its efficacy, in cases of contraindication, systemic remifentanil is an alternative. Since the first demonstration of the safety of remifentanil in obstetric analgesia in 1996, this has been repeatedly confirmed for both mother and newborn. The aim of this meta-analysis is to evaluate recently published studies (up to December 2014) on the analgesic efficacy of remifentanil during labour (as a Visual Analogue Scale (VAS) decrease in the first hour by 2 or more). Search of the US National Library of Medicine, National Institutes of Health (www.pubmed.gov), SCOPUS database (www.scopus.com) and Web of Science database (www.webofknowledge.com) using the key words "labour" and "remifentanil". 44 identified articles were included in the review and 15 published randomised controlled studies were incorporated into the meta-analysis. This was based on the fixed model and described by differences in the VAS between t=0 and t=1 hour after remifentanil administration using the 95% confidence interval (CI). The analysis was computed using the Comprehensive meta-analysis version 2.2.064. The combined data from the meta-analysis showed a statistically significant decrease in VAS in the remifentanil group. From a comparison of the CIs of summary estimates with a cut-off decrease of VAS 2, for the fixed model, there was a statistically significantly greater decrease in VAS than the cut-off. In the systematic review, we describe possible modes of application, dosage and side-effects for mother, fetus/ newborn. The meta-analysis presented here confirms that remifentanil for labour analgesia is effective but questions remain which can only be answered by further randomized trials.

Comments on "combination of dexmedetomidine and remifentanil for labor analgesia: A double-blinded, randomized, controlled study".

Comments on "combination of dexmedetomidine and remifentanil for labor analgesia: A double-blinded, randomized, controlled study".

Combination of dexmedetomidine and remifentanil for labor analgesia: A double-blinded, randomized, controlled study.

Background:Satisfactory analgesia is of great importance in the labor. The clinical efficacy and side effects of remifentanil in the management of labor pain had been evaluated. Dexmedetomidine (DMET) demonstrates an antinociceptive effect in visceral pain conditions. Aims of the study were to assess whether the combination of DMET with remifentanil would produce a synergistic effect that results in lower analgesic requirements. Furthermore, whether this combination would have less maternal and neonatal adverse effects.Patients and Methods:Sixty American Society of Anesthesiologists physical status I-II pregnant women had been enrolled into this study. All were full term (37-40 weeks’ gestation), singleton fetus with cephalic presentation in the first stage of spontaneous labor. They were divided into two groups group (I) Patient-controlled IV remifentanil analgesia (bolus dose 0.25 μg/kg, lockout interval 2 min) increased by 0.25 μg/kg to a maximum bolus dose 1 μg/kg in addition to a loading dose of DMET 1 μg/kg over 20 min, followed by infusion at 0.5 μg/kg/h group (II) Patient-controlled IV remifentanil analgesia (PCA) (bolus dose 0.25 μg/kg, lockout interval 2 min) increased by 0.25 μg/kg to a maximum bolus dose 1 μg/kg in addition to a the same volume of normal saline as a loading dose, followed by a continuous saline infusion. Visual analog scale score, maternal, and fetal complications and patients’ satisfaction were recorded.Results:Patients receiving a combination of PCA remifentanil and DMET had a lower pain score compared with remifentanil alone in the second stage of labor (P = 0.001). The Total consumption of remifentanil was reduced by 53.3% in group I. There was an increased incidence of maternal complications and a lower patient satisfaction score in group II.Conclusion:DMET has an opioid sparing effect; a combination of DMET and remifentanil produces a synergistic effect that results in lower analgesic requirements and less maternal and neonatal adverse events.

Remifentanil for labour analgesia: time to draw breath?

Remifentanil for labour analgesia: time to draw breath?

Remifentanil for labour analgesia: a double‐blinded, randomised controlled trial of maternal and neonatal effects of patient‐controlled analgesia versus continuous infusion

This trial aimed to compare the maternal and neonatal effects of remifentanil given by patient-controlled analgesia (PCA) or continuous infusion for labour analgesia. Patient controlled analgesia was administered using increasing stepwise boluses from 0.1 to 0.4 μg.kg(-1) (0.1 μg.kg(-1) increment, 2 min lockout, n = 30). Continuous infusion used rates from 0.05 to 0.2 μg.kg(-1) .min(-1) (0.05 μg.kg(-1) .min(-1) increment, n = 30). Dose increments were given on request. Women reported lowest pain scores (median (IQR [range]) of 3 (2-4 [2-5]) for PCA and 4 (3-5.25 [3-7]) for continuous infusion (p = 0.004) at 60 min after the beginning of analgesia. The mean (SD) remifentanil umbilical vein/maternal artery ratio in the PCA and infusion groups were 0.74 (0.45) vs 0.70 (0.52), respectively (p = 0.776). The mean (SD) umbilical artery/umbilical vein ratios were 0.31 (0.12) vs 0.26 (0.07), respectively (p = 0.088). Maternal and neonatal adverse reactions of remifentanil were similar between the two groups. The total remifentanil consumption (median (IQR [range]) during PCA administration was lower than continuous infusion, 1.34 (1.22-1.48 [0.89-1.69]) mg vs 1.49 (1.35-1.61 [1.12-1.70] mg; p = 0.011). The results suggest that remifentanil PCA provides better pain relief and similar placental transfer compared with continuous infusion.

Remifentanil patient-controlled analgesia for labour: optimizing drug delivery regimens.

A pilot study was undertaken to compare the efficacy of two regimens of intravenous patient-controlled analgesia (PCA) with remifentanil for labour analgesia. Twenty term parturients requesting labour analgesia were randomized to receive one of two regimens of intravenous remifentanil. The initial settings in both groups consisted of an infusion of 0.025 μg·kg-1·min-1, a PCA bolus of 0.25 μg·kg-1 and a lockout interval of two minutes. In Group A, the infusion was increased in a stepwise manner from 0.025 to 0.05, 0.075 and 0.1 μg·kg-1·min-1 as required; the bolus was kept constant at 0.25 μg·kg-1. In Group B, the bolus was increased from 0.25 to 0.5, 0.75 and 1 μg·kg-1 as necessary; the infusion was kept constant at 0.025 μg·kg-1·min-1. Maternal pain, satisfaction and sedation scores, remifentanil requirement, and side effects were recorded. Mean pain and patient satisfaction scores, and cumulative doses of remifentanil were similar in the two groups. The overall incidence of side effects was greater in Group B (P = 0.0007), with drowsiness observed in 100% of patients, as compared to 30% in Group A (P = 0.003). The minimum oxygen saturation levels were 94.3% ± 2.6% and 92.2% ± 3.8% in Groups A and B respectively (P = 0.19). Although pain and satisfaction scores were similar in both groups, the regimen used in Group A was associated with fewer side effects compared to the Group B dosing regimen. This pilot study suggests that remifentanil intravenous PCA is efficacious for labour analgesia as a bolus of 0.25 μg·kg-1, with a lockout interval of two minutes and continuous infusion of 0.025-0.1 μg·kg-1·min-1. The potential for respiratory depression mandates close respiratory monitoring. Large-scale trials to evaluate safety issues are warranted.

A reply

We are grateful for the comments of Dr Jones and colleagues. We were aware of one case report by Rosaeg et al. [1] as well as the study by Nikkola et al. [2] that involved six patients. Both the case report, as well as the study, showed some benefit of using fentanyl patient-controlled analgesia for pain relief in labour. We felt it was not appropriate to make a conclusion on the use of fentanyl PCA for labour analgesia on the basis of studies that included only seven patients, but we admit we should have included those studies in our editorial. Regarding the use of fentanyl or remifentanil for labour analgesia, we think it is too early to suggest either is superior over the other and agree that further large studies are needed to establish the efficacy as well as the safety of these drugs.