Intravenous Remifentanil Patient-controlled Analgesia Research Articles

Duration of labor, delivery mode and maternal and neonatal morbidity after remifentanil patient-controlled analgesia compared with epidural analgesia.

ObjectiveThe objective of this study was to compare duration of active labor, delivery mode, maternal and neonatal morbidity and women’s satisfaction with delivery after intravenous remifentanil patient-controlled analgesia (PCA) or standard epidural analgesia (EDA). Based on clinical observations, we hypothesized that women with PCA would have shorter labor.Study designAn observational study at a university hospital in Sweden 2009–16. Maternal and neonatal outcomes with PCA (n = 69) and EDA (n = 138) were compared.ResultsWomen with PCA had shorter active labor 5.6 ± 3.3 compared to 8.5 ± 4.4 h (p < 0.001) with EDA, and a higher rate of spontaneous delivery 94% (65/69) compared to 65% (n = 90/138) with EDA (p < 0.001). Intrapartum temperature >38 °C (p = 0.001) and signs of fetal asphyxia (p < 0.001) were less common with PCA. No maternal or neonatal sedation was observed. The rates of transient oxygen desaturation <95%, bleeding > 1000 mL and women’s satisfaction with delivery did not differ between the groups.ConclusionPCA had several advantages over EDA, as it was associated with shorter active labor and a higher rate of spontaneous delivery without worsening maternal or neonatal morbidity or women’s satisfaction with delivery. Therefore, we suggest an increased availability of PCA for labor analgesia. We recommend continuous one-to-one care and oxygen saturation monitoring for all women during active labor.

Remifentanil Patient-controlled Analgesia (PCA) in Labour–in the Eye of the Storm

(Anaesthesia. 2019;74:277–279) A recent study published by Wilson and colleagues in the Lancet has attracted a lot of media attention regarding the use of intravenous remifentanil patient-controlled analgesia (PCA) to replace intramuscular pethidine for labor analgesia. The study reported that the need for conversion to neuraxial analgesia was approximately halved with remifentanil compared with pethidine, and the rate of instrumental delivery was decreased from 26% to 15%. The conclusions of this study contradicted previous recommendations that remifentanil PCA not be considered a standard analgesic option in labor due to safety concerns. This editorial addressed the ramifications of implementing routine remifentanil PCA labor analgesia and the measures that would need to be taken to ensure maternal and neonatal safety.

Remifentanil patient-controlled intravenous analgesia during labour: a retrospective observational study of 10 years’ experience

BackgroundIntravenous remifentanil patient-controlled analgesia (PCA) has been routinely available for labouring women in our unit since 2004, the regimen using a 40 µg bolus available two minutely on demand, continuous pulse oximetry and mandatory one-to-one care. We examined remifentanil use and compared, with the other analgesic options available in our unit, outcomes such as mode of delivery, Apgar scores, neonatal resuscitation and admission to the neonatal intensive care unit. MethodsWe retrospectively identified women who delivered in our unit between 2005 and 2014 and received remifentanil, diamorphine or epidural analgesia during labour. Data were drawn from the Northern Ireland Maternity System electronic database, which records birth details from all obstetric units in Northern Ireland. Additional data were identified from paper survey forms, completed by the midwife post delivery for all women who received remifentanil in our unit. Outcomes were compared between women who received remifentanil, diamorphine or an epidural technique for labour analgesia. ResultsOver the 10-year period, remifentanil was the most popular form of analgesia, being selected by 31.9% (8170/25617) women. Compared with women selecting diamorphine or epidural analgesia, those having remifentanil had similar rates of instrumental and operative delivery. Neonatal Apgar scores were also similar. Neonatal resuscitation or neonatal unit admission were not more likely in women choosing remifentanil PCA. ConclusionWe found remifentanil PCA to be neither less safe nor associated with poorer outcomes than other analgesic options offered in our unit, when used within our guidelines for more than a 10-year period.

Labor analgesia: Comparison of epidural patient-controlled analgesia and intravenous patient-controlled analgesia

In our study, patient controlled epidural analgesia (PCEA) and patient controlled intravenous remifentanil analgesia (PCIVA) were compared for VAS, and also their side effects on mother and newborn. In this study, 37 pregnant women with a single fetus, who had labor analgesia, were divided into groups of PCIVA (Group 2) and PCEA (Group 1). Bupivacaine 1.25 mg/ml and fentanyl 2 mcg/ml in 100 ml epidural solution were prepared for Group 1. The infusion dose was 15 ml, 5 ml divided doses. We set 5 ml/h basal infusion, 5 ml patient-controlled bolus and 20 min lock time. We prepared 2 mg remifentanil in 100 ml intravenous solution for Group 2. We set 20 mcg/h infusion, 0.05mcg/kg patient-controlled bolus and five min lock time. VAS, maternal-fetal heart rate, blood pressure, oxygen saturation, nausea-vomiting and sedation were recorded during labor. We recorded Apgar scores and maternal satisfaction at the end of labor. The findings showed that both groups could provide adequate analgesia. However, VAS scores were higher in Group PCIVA. The mother satisfaction and newborn's Apgar scores were similar. In both groups, desaturation, which is requiring oxygen support, was not determined. The oxygen saturations were lower in Group 2. The side effects and patient satisfaction were similar in both groups. Although PCIVA was found to be satisfactory concerning maternal satisfaction, VAS after 2nd hour were higher compared to PCEA. PCEA is the gold standard in labor analgesia. However, we believe that PCIVA is a good alternative to epidural analgesia in cases where epidural analgesia is contraindicated or where the patient does not want an epidural.

Patient-Controlled Analgesia With Remifentanil Versus Alternative Parenteral Methods for Pain Management in Labour: A Cochrane Systematic Review

(Anaesthesia. 2017;72(8):1016–1028) Guidelines from both the American Society of Anesthesiologists (ASA) and the American College of Obstetricians and Gynecologists (ACOG) recommend epidural analgesia as the most effective and flexible analgesic option for labor pain management, but some laboring women have contraindications to neuraxial analgesia and others may prefer alternatives. This Cochrane systematic review analyzed the effectiveness of intravenous remifentanil patient-controlled analgesia (PCA) compared with other labor analgesia techniques as measured by patient satisfaction and adverse maternal or neonatal effects.

Case Series of Vital Signs-controlled, Patient-assisted Intravenous Analgesia (VPIA) Using Remifentanil for Labor and Delivery

(Anaesthesia. 2017;72(7):845–852) Intravenous remifentanil patient-controlled analgesia (PCA) is an alternative to epidural analgesia for labor pain management. Compared with other systemic opioids, its unique pharmacokinetic properties make it a preferred alternate analgesic. These properties included fast onset, an ultra-short context-sensitive half-life, and rapid redistribution and elimination by the fetus. Remifentanil is known, however, to cause maternal respiratory depression when used for labor analgesia. This leads to maternal oxygen desaturation in a significant proportion of women, although it is generally short-lived. Rarely respiratory arrest has been reported. It is thus strongly recommended that when administering remifentanil PCA, maternal respiratory rate and oxygen saturation be continuously monitored.

A case series of vital signs-controlled, patient-assisted intravenous analgesia (VPIA) using remifentanil for labour and delivery.

Intravenous remifentanil patient-controlled analgesia can be used during labour as an alternative to epidural analgesia. Adverse effects of opioids, including hypoxia and bradycardia, may lead to maternal morbidity and mortality. We devised an interactive feedback system based on a clinical proportional algorithm, to continuously monitor for adverse effects to enhance safety and better titrate analgesia. This vital signs-controlled, patient-assisted intravenous analgesia with remifentanil used a prototype delivery system linked to a pulse oximeter that evaluated maternal oxygen saturation and heart rate continuously. With this system, we detected oxygen saturation < 95% for more than 60 s in 15 of 29 subjects (52%); and heart rate < 60 min-1 for more than 60 s in 7 of 29 subjects (24%) during use. The system automatically responded appropriately by reducing the dosages and temporarily halting remifentanil administration, thus averting further hypoxia and bradycardia.

Patient-controlled analgesia with remifentanil versus alternative parenteral methods for pain management in labour.

Multiple analgesic strategies for pain relief during labour are available. Recently remifentanil, a short-acting opioid, has recently been used as an alternative analgesic due to its unique pharmacological properties. To systematically assess the effectiveness of remifentanil intravenous patient-controlled analgesia (PCA) for labour pain, along with any potential harms to the mother and the newborn. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (9 December 2015), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP), handsearched congress abstracts (November 2015), and reference lists of retrieved studies. Randomised controlled trials (RCTs) and cluster-randomised trials comparing remifentanil (PCA) with another opioid (intravenous (IV)/intramuscular (IM)), or with another opioid (PCA), or with epidural analgesia, or with remifentanil (continuous IV), or with remifentanil (PCA, different regimen), or with inhalational analgesia, or with placebo/no treatment in all women in labour including high-risk groups with planned vaginal delivery. Two review authors independently assessed trials for inclusion, extracted data, and appraised study quality.We contacted study authors for additional information other than incomplete outcome data. We performed random-effects meta-analysis.To reduce the risk of random error in meta-analysis we performed trial sequential analysis. We included total zero event trials and used a constant continuity correction of 0.01 (ccc 0.01) for meta-analysis. We applied the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach to assess the quality of evidence. Twenty RCTs with 3569 women were included. Of those, 10 trials (2983 participants) compared remifentanil (PCA) to an epidural, four trials (216 participants) to another opioid (IV/IM), three trials (215 participants) to another opioid (PCA), two trials (135 participants) to remifentanil (continuous IV), and one trial (20 participants) to remifentanil (PCA, different regimen). No trials were identified for the remaining comparisons.Methodological quality of studies was moderate to poor. We assessed risk of bias as high for blinding issues and incomplete outcome data in 65% and 45% of the included studies, respectively.There is evidence of effect that women in the remifentanil (PCA) group were more satisfied with pain relief than women in the other opioids (IV/IM) group (standardised mean difference (SMD) 2.11, 95% confidence interval (CI) 0.72 to 3.49, four trials, very low-quality evidence), and that women were less satisfied compared to women in the epidural group (SMD -0.22, 95% CI -0.40 to -0.04, seven trials, very low-quality evidence).There is evidence of effect that remifentanil (PCA) provided stronger pain relief at one hour than other opioids administered IV/IM (SMD -1.58, 95% CI -2.69 to -0.48, three trials, very low-quality evidence) or via PCA (SMD -0.51, 95% CI -1.01 to -0.00, three trials, very low-quality evidence). Pain intensity was higher in the remifentanil (PCA) group compared to the epidural group (SMD 0.57, 95% CI 0.31 to 0.84, six trials, low-quality evidence).Data were limited on safety aspects for both the women and the newborns. Only one study analysed maternal apnoea in a comparison of remifentanil (PCA) versus epidural and reported that half of the women in the remifentanil and none in the epidural group had an apnoea (very low-quality evidence). There is no evidence of effect that remifentanil (PCA) was associated with an increased risk for maternal respiratory depression when compared to epidural analgesia (RR 0.91, 95% CI 0.51 to 1.62, ccc 0.01, three trials, low-quality evidence) and no reliable conclusion might be reached compared to remifentanil (continuous IV) (all study arms included zero events, two trials, low-quality evidence). In one trial of remifentanil (PCA) versus another opioid (IM) three out of 18 women in the remifentanil and none out of 18 in the control group had a respiratory depression (very low-quality evidence).There is no evidence of effect that remifentanil (PCA) was associated with an increased risk for newborns with Apgar scores less than seven at five minutes compared to epidural analgesia (RR 1.26, 95% CI 0.62 to 2.57, ccc 0.01, five trials, low-quality evidence) and no reliable conclusion might be reached compared to another opioid (IV) and compared to remifentanil (PCA, different regimen) both with zero events in all study arms (one trial, very-low quality evidence). In one trial of remifentanil (PCA) versus another opioid (PCA) none out of nine newborns in the remifentanil and three out of eight in the opioid (PCA) group had Apgar scores less than seven (very-low quality evidence).There is evidence that remifentanil (PCA) was associated with a lower risk for the requirement of additional analgesia when compared to other opioids (IV/IM) (RR 0.57, 95% CI 0.40 to 0.81, three trials, moderate-quality evidence) and that it was associated with a higher risk compared to epidural analgesia (RR 9.27, 95% CI 3.73 to 23.03, ccc 0.01, six trials, moderate-quality evidence). There is no evidence of effect that remifentanil (PCA) reduced the requirement for additional analgesia compared to other opioids (PCA) (RR 0.76, 95% CI 0.45 to 1.28, three trials, low-quality evidence).There is evidence that there was no difference in the risk for caesarean delivery between remifentanil (PCA) and other opioids (IV/IM) (RR 0.63, 95% CI 0.30 to 1.32, ccc 0.01, four trials, low-quality evidence) and epidural analgesia (RR 1.0, 95% CI 0.82 to 1.22, ccc 0.01, nine trials, moderate-quality evidence), respectively. Pooled meta-analysis revealed an increased risk for caesarean section under remifentanil (PCA) compared to other opioids (PCA) (RR 2.78, 95% CI 0.99 to 7.82, two trials, very low-quality evidence). However, a wide range of clinically relevant and non-relevant treatment effects is compatible with this result. Based on the current systematic review, there is mostly low-quality evidence to inform practice and future research may significantly alter the current situation. The quality of evidence is mainly limited by poor quality of the studies, inconsistency, and imprecision. More research is needed on maternal and neonatal safety outcomes (maternal apnoea and respiratory depression, Apgar score) and on the optimal mode and regimen of remifentanil administration to provide highest efficacy with reasonable adverse effects for mothers and their newborns.

Parenteral opioid analgesia: Does it still have a role?

Parenteral opioids have been used in labour analgesia for many years, but the ideal opioid in this setting is yet to be found. We review the properties of currently used opioids, their analgesic properties and side effects to mother and foetus. Parenteral opioids can be administered as intermittent boluses or through a patient-controlled intravenous administration system. A wide range of opioid drugs are currently used and provide a variable degree of analgesia. All opioids can cause unwanted maternal side effects such as nausea, vomiting, sedation and respiratory depression. They cross the placenta and have the potential to cause neonatal respiratory depression. Remifentanil patient-controlled intravenous analgesia is becoming increasingly available and popular on some delivery suites. It can provide adequate analgesia and is useful when epidural analgesia is contraindicated. Remifentanil patient-controlled analgesia requires close monitoring in an environment familiar with the technique to avoid maternal hypoxia due to respiratory depression.

Remifentanil for labor analgesia: a comprehensive review.

Japan has seen significant developments in obstetric anesthesia in recent years, including the establishment of the Japanese Society of Obstetric Anesthesia and Perinatology. However, labor pain, which is one of the most important issues in obstetric practice, is still not treated aggressively. The rate of epidural administration for labor analgesia is very low in Japan as compared to other developed countries. Remifentanil has been used for labor analgesia, as part of general anesthesia for cesarean delivery, as well as for various fetal procedures around the world. Intravenous patient-controlled analgesia (IVPCA) with remifentanil is considered to be a reasonable option for labor pain relief. Several studies have demonstrated its efficacy with minimal maternal and neonatal adverse effects. On the other hand, reports of cases of maternal cardiac and respiratory arrest with remifentanil IVPCA within the past couple of years have redirected our attention to its safe use. Remifentanil IVPCA warrants one-to-one nursing monitoring, appropriate education of healthcare providers, continuous maternal oxygen saturation monitoring, end-tidal CO2 monitoring, and availability of both maternal and neonatal resuscitation equipment. This article provides an overview of knowledge and principles of using remifentanil IVPCA for labor analgesia and introduces its potential usage in Japan.

Differences in Maternal Temperature During Labour With Remifentanil Patient-controlled Analgesia or Epidural Analgesia: A Randomised Controlled Trial

(Int J Obstet Anesth. 2015;24(4):313–322) Two popular techniques for the treatment of labor pain are epidural analgesia (EA) and intravenous remifentanil patient-controlled analgesia (RPCA). Remifentanil is a μ-opioid receptor agonist with a rapid onset of action and short latency to peak analgesic effect. This randomized, controlled trial was performed to compare the rate of maternal fever (temperature ≥38°C) in parturients receiving RPCA with those receiving either EA or no analgesia. The authors hypothesized that fever would be more prevalent in patients receiving EA compared with patients receiving either RPCA or no analgesia. The secondary objectives studied included differences in maternal oxygen saturation (SpO2), nausea, vomiting, sedation, pruritus, hypotension, and neonatal outcome.

Impact of water analgesia on the pain relief for primiparas in labor

Objective To explore the effect of water analgesia on the pain relief for primiparas in labor, especially on the point of the acutest pain and total time of severe pains by tracking and comparing with remifentanil patient-controlled intravenous analgesia and the conventional vaginal delivery. Methods A total of 139 singleton and full-term primiparas who chosed analgesia labor were selected. There were 3 groups: 56 cases in water analgesia group (hereinafter referred to shortly as water group), 37 cases in remifentanil patient-controlled intravenous analgesia group (hereinafter referred to shortly as vein group ) and 46 cases in traditional vaginal delivery group (hereinafter referred to shortly as traditional group). In addition, labor pain intensity was assessed with numerical rating scale (NRS). All groups were evaluated by NRS score in five different time points during the delivery: cervical dilation to 2-3 cm or 1 minute before labor analgesia; labor analgesia after 10 minutes; labor analgesia after 30 minutes; labor analgesia after 60 minutes; point of acutest pain. Meanwhile, total time of acutest pain, progress of labor, use of oxytocin, mode of delivery, postpartum hemorrhage and neonatal asphyxia were all observed. Results Comparison of labor progress and postpartum bleeding, mode of delivery and neonatal Apgar score in three groups of primipara showed no significant difference (P>0.05). Compared with the traditional group, the NRS score and point of acutest pain in water group obviously declined, the total time of severe pain shortened 36.58 min on average, which showed significant difference (t=-4.400, P < 0.05). Compared with the vein group, the NRS score of water group at 10 minutes after labor analgesia was below the vein group (t=-2.358, P < 0.05), so was point of acutest pain (t=-2.703, P < 0.05). But the score of water group was higher than intravenous analgesia after 60 minutes, which showed significant difference (t=2.833, P<0.01). The rate of oxytocin application in water group was only 12.5% (7/56), significantly less than the rate in vein group, which was 37.84% (14/37), there were significant differences (χ2=8.182, P < 0.05). Conclusions Water analgesia can effectively alleviate maternal pain and reduce intrapartum intervention, and more, less influence on maternal and newborn, and is a safe and effective analgesia method. Key words: Labouring in water; Remifentanil patient-controlled intravenous analgesia; Point of acutest pain; Total time of the severe pain

A Randomized Controlled Trial of the Efficacy and Respiratory Effects of Patient-controlled Intravenous Remifentanil Analgesia and Patient-controlled Epidural Analgesia in Laboring Women

BACKGROUND:Safe and effective alternatives are required in labor when epidural analgesia is not appropriate. We hypothesized that patient-controlled IV remifentanil labor analgesia would not be inferior to patient-controlled epidural labor analgesia.METHODS:This randomized nonblinded controlled noni

A Randomized Controlled Trial of the Efficacy and Respiratory Effects of Patient-Controlled Intravenous Remifentanil Analgesia and Patient-Controlled Epidural Analgesia in Laboring Women

Stocki, Daniel*†; Matot, Idit†; Einav, Sharon‡; Eventov-Friedman, Smadar§; Ginosar, Yehuda*; Weiniger, Carolyn F.*∥ Author Information

A Randomized Controlled Trial of the Efficacy and Respiratory Effects of Patient-Controlled Intravenous Remifentanil Analgesia and Patient-Controlled Epidural Analgesia in Laboring Women

Safe and effective alternatives are required in labor when epidural analgesia is not appropriate. We hypothesized that patient-controlled IV remifentanil labor analgesia would not be inferior to patient-controlled epidural labor analgesia. This randomized nonblinded controlled noninferiority study in healthy women with a singleton fetus and vertex presentation was performed at 1 site. Women were randomized to receive patient-controlled IV analgesia titrated from 20 mcg up to a maximum bolus dose of 60 mcg with a lockout interval of 1 to 2 minutes, or patient-controlled epidural analgesia 0.1% bupivacaine with 2 mcg/mL fentanyl (initiation bolus 15 mL; maintenance bolus 10 mL, lockout interval 20 minutes, basal infusion 5 mL/h). Crossover was permitted after 30 minutes. The primary study outcome was efficacy (assessed as hourly numerical rating scale [NRS] pain score [11-point NRS] and maternal satisfaction [11-point NRS]); the secondary outcome was safety (maternal apnea). Supplementary oxygen was administered continuously during the respiratory monitoring period. During the first hour of analgesia, the heart rate, respiratory rate, pulse oximetry (SpO2), and end-tidal CO2, as an indication of apnea, were compared. Apnea lasting >40 seconds was managed by light stimulation by the attending anesthesiologist. Forty women were recruited to the following groups: remifentanil n = 19 (1 exclusion), epidural n = 20. Four crossed over: 3 from the remifentanil to epidural group and 1 from the epidural to remifentanil group. Mean (± SD) baseline NRS pain scores were similar, 8.4 ± 1.5 for remifentanil and 8.7 ± 1.2 for epidural analgesia, P = 0.52. Baseline adjusted mean NRS reduction at 30 minutes for remifentanil was -4.5 (± 0.6) vs -7.1(± 0.6) for epidural analgesia, P < 0.0001 for both. Pain score at 30 minutes was 3.7 ± 2.8 for remifentanil and 1.5 ± 2.2 for epidural analgesia, P = 0.009. Remifentanil was inferior to epidural analgesia with respect to the NRS at all time points, because the observed difference in NRS was greater than the expected -1.5 units. Maternal satisfaction was 8.6 ± 1.4 for the remifentanil group and 9.1 ± 1.5 for epidural group, P = 0.26. Mean respiratory rate was lower in the remifentanil group, 18 ± 4 vs 21 ± 4 breaths/min in the epidural group, P = 0.03. Mean SpO2 was lower in the remifentanil group 96.8% ± 1.4 vs 98.4 ± 1.2 for epidural group, P < 0.0001. There were 9 apnea events; all occurred in 5 women receiving remifentanil (5/19 [26.3%], P = 0.046). Apgar scores and neonatal respiratory outcomes were similar. IV remifentanil is inferior to epidural analgesia for provision of labor analgesia; however, remifentanil does provide a satisfactory level of labor analgesia. Laboring women receiving remifentanil require suitable monitoring to detect and alert for apnea.

Efficacy and Side-effects of Intravenous Remifentanil Patient-controlled Analgesia Used in a Stepwise Approach for Labor

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Remifentanil as analgesia for labour pain

BackgroundTo collect updated information about pharmacological labour analgesia in Norway, especially systemic opioids and epidural. Evaluation of efficacy and safety with remifentanil intravenous patient‐controlled analgesia (IVPCA) for pain relief during labour. To compare remifentanil IVPCA with epidural analgesia (EDA) regarding efficacy and safety during labour.MethodsIn paper I, two national surveys identified Norwegian labour analgesia methods and changes during the study period (2005–2008). Paper II is a prospective, observational study of analgesic efficacy and safety with remifentanil IVPCA. Paper III is a prospective, randomized controlled trial comparing remifentanil IVPCA with EDA regarding analgesic efficacy and safety.ResultsThe surveys in paper I found the frequency of EDA in Norwegian hospitals to be increasing, but still low (25.9%) compared with other western countries. Nitrous oxide and traditional systemic opioids, like pethidine, were frequently used. In paper II, remifentanil IVPCA was found to give satisfactory labour analgesia in more than 90% of the parturients with an average maximal pain reduction of 60%. Maternal oxygen desaturation and sedation were acceptable, and neonatal data reassuring. In paper III, a randomized controlled trial found remifentanil IVPCA and EDA to be comparable both regarding analgesic efficacy (pain reduction; Fig. ) and maternal satisfaction. Remifentanil IVPCA produced more maternal sedation and oxygen desaturation; neonatal outcome was reassuring in both groups.Reduction in pain score [visual analogue scale (VAS)] during labour analgesia with patient‐controlled intravenous remifentanil and continuous epidural infusion with ropivacaine and fentanyl.figureConclusionThe frequency of epidural labour analgesia in Norway has increased, but is still relatively low. Nitrous oxide and traditional systemic opioids are frequently used. The clinical practice seems conservative; newer short‐acting opioids are seldom used for systemic labour analgesia. The studies on remifentanil IVPCA revealed adequate pain relief, high maternal satisfaction, and no serious neonatal side effects. There were no differences in analgesic efficacy, maternal satisfaction, and neonatal outcome when comparing remifentanil IVPCA with EDA. However, remifentanil caused maternal sedation and oxygen desaturation. We recommend the use of IVPCA remifentanil as labour analgesia instead of traditional opioids as pethidine and morphine when EDA is not an option. The presence of skilled personnel and close monitoring is mandatory.

Efficacy and side effects of intravenous remifentanil patient-controlled analgesia used in a stepwise approach for labour: an observational study

BackgroundRemifentanil has a suitable pharmacological profile for labour analgesia. In this prospective, observational study, intravenous patient-controlled analgesia with remifentanil, using stepwise bolus doses without background infusion, was examined during the first and second stages of labour. Outcomes were pain reduction, maternal satisfaction, maternal and neonatal side effects and remifentanil metabolism in the neonate. MethodsParturients with normal term singleton pregnancies were recruited. The initial remifentanil bolus dose was 0.15μg/kg, increasing in steps of 0.15μg/kg, with a 2-min lock-out. Pain scores using a 100mm visual analogue scale, systolic and diastolic blood pressures, respiratory rate and maternal sedation were recorded every 15min. Maternal oxygen saturation and heart rate were monitored continuously. Neonatal data included Apgar scores, clinical examination, naloxone use, resuscitation, umbilical cord blood gases and remifentanil concentrations. ResultsForty-one parturients were enrolled. Pain scores were significantly reduced in the first 3h of patient-controlled analgesia use compared to baseline, and at the end of the first and second stages of labour (P<0.05). Maximal pain reduction was 60% (P<0.01). One patient had inadequate pain relief and converted to epidural analgesia. The mean highest dose of remifentanil was 0.7μg/kg [range 0.3–1.05]. Ninety-three percent of patients were satisfied with their analgesia. The lowest oxygen saturation was 91% and the lowest respiratory rate was 9 breaths/min. Eleven parturients (27%) received supplemental oxygen due to oxygen saturations <92%. Maternal sedation was moderate, and neonatal data reassuring. ConclusionsRemifentanil intravenous patient-controlled analgesia provides adequate pain relief and high maternal satisfaction during the first and second stages of labour. Maternal sedation and respiratory depression may occur, but no serious neonatal side effects were recorded. Careful monitoring is mandatory.

Labour analgesia

To compare the analgesic efficacy and side-effects of remifentanil intravenous patient-controlled analgesia (IVPCA) with walking epidural analgesia (EDA) during labour. Thirty-nine parturient patients of mixed parity, with normal singleton pregnancies, were randomised to receive either remifentanil IVPCA (RA group) or EDA (EA group). The epidural solution contained ropivacaine 1 mg ml⁻¹ and fentanyl 2 μg ml⁻¹, and the initial dose was 10 ml h⁻¹. Starting bolus of remifentanil was 0.15 μg kg⁻¹, with subsequent steps of 0.15 μg kg⁻¹. Lock-out time was 2 min, bolus infusion speed 2 ml min⁻¹ (100 μg min⁻¹) and there was no background infusion. Visual analogue scale was used for pain assessment. Maternal heart rate, blood pressure, oxygen saturation, respiratory rate, sedation, nausea/vomiting, itching, satisfaction and fetal/neonatal outcome were recorded. Thirty-seven parturient patients were analysed. Both treatments provided good analgesia, but with higher pain scores in the RA group. Pain reduction at the end of first and during second stage and maximum pain reduction were similar (RA/EA group): 27/26 (P = 0.920), 31/29 (P = 0.909) and 61/59 (P = 0.855), respectively. Maternal satisfaction was similar. Two parturients receiving remifentanil (6%) converted to epidural, one because of inadequate analgesia. Remifentanil produced more maternal sedation, desaturation (SaO₂ < 92%) and need for supplemental oxygen. Neonatal outcome was reassuring. Highest mean total dose of remifentanil was 0.70 μg kg⁻¹ (range 0.30-1.05). Remifentanil IVPCA and epidural provided effective analgesia, with high maternal satisfaction scores and reassuring neonatal outcome. Remifentanil produced more maternal sedation and oxygen desaturation. Close monitoring is, therefore, mandatory.

A randomised comparison of intravenous remifentanil patient-controlled analgesia with epidural ropivacaine/sufentanil during labour

Background The μ-opioid agonist remifentanil has a rapid onset and offset and a short half-life making it an attractive option for intravenous patient-controlled labour analgesia. We aimed to compare the efficacy of intravenous remifentanil patient-controlled analgesia with epidural ropivacaine/sufentanil during labour. Methods Parturients were randomly assigned to receive intravenous patient-controlled analgesia with remifentanil ( n = 10) or epidural analgesia ( n = 10). Pain and satisfaction scores were assessed every hour by means of visual analogue scale, together with an observer sedation score. Side effects and neonatal outcome were noted. Results After one hour, visual analogue pain scores had decreased significantly in both groups (remifentanil: −3.8 ± 2.6, P < 0.01; epidural −6.7 ± 2.0, P < 0.01). The decrease in pain scores in the epidural group was significantly greater than the remifentanil group at all time intervals. The decrease in pain scores was sustained in the epidural group whereas in the remifentanil group pain scores increased over time. Oxygen saturation was significantly lower in the remifentanil group after one hour of treatment compared to the epidural group (95.2 ± 2.4% vs. 99.0 ± 1.1%, P < 0.01). Patient satisfaction scores during and after delivery were similar in both groups. No differences were found in neonatal outcome. Conclusions In the 20 patients recruited to this study, pain relief in labour with epidural ropivacaine/sufentanil was more effective than with intravenous remifentanil patient-controlled analgesia.