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PIEB (programmed intermittent epidural bolus) versus CEI (continuous epidural infusion) for labor analgesia: results of a pilot set-up and where to go from there
Abstract Number: GM-02
Abstract Type: Original Research
Evidence that an epidural bolus provides a better spread of the injectate in the epidural space than a continuous infusion has emerged.1 Programmed intermittent epidural bolus (PIEB) results in lower local analgesia dosing, reduced motor block, instrumentation rates and physician-administered top-ups for breakthrough pain.2 In July 2014, each L&D room was equipped with a CADD®-Solis PIB Ambulatory Infusion System. We compared our continuous epidural infusion (CEI) protocol (10ml/h bupivacaine 0.0625%-fentanyl 2mcg/ml, 5ml PCEA bolus, 10min lock-out) with a PIEB setting using the exact same hourly & PCEA dose and lock-out time. The 1st PIEB was set to start 45min after initiation of analgesia with spinal dose (CSE), followed by 10ml PIEB q60min, 5ml PCEA bolus, 10min lock-out and a reset of the PIEB. The bolus rate was 250 ml/h (max speed with standard tubing). We hypothesized that PIEB would result in less physician-administered top-ups compared with CEI & PCEA.
Data was collected from April to December 2014 allowing a ‘before & after’ comparison. Demographics, anesthetic interventions (time to 1st physician-administered top-up, number of top-ups) and obstetric data (duration of 2nd stage, time to delivery, delivery mode) were recorded.
Data from 240 cases were analyzed (120 PIEB vs 120 CEI). There was no difference in demographics, time from spinal analgesia to delivery, duration of 2nd stage or mode of delivery between groups (24% cesareans with PIEB vs 27% with CEI; p>0.05). There was no difference in the number of women requesting a top-up (50 with PIEB vs 45 with CEI group; p>0.05), median time until top-up or hourly top-up rate (Figure).
Contrary to our expectations, there was no difference in number or timing of top-up request between groups. This may be explained by the long interval between programmed boluses (60min), the 45min interval between spinal dose and 1st PIEB dose, and the low volume of PCEA bolus (5ml); this setting was chosen to keep the exact same hourly dose and PCEA settings. This pilot emphasizes the many variations in programming that need to be further tested, such as evaluating the analgesic effects of a shorter interval (45min) and larger PIEB & PCEA bolus (8ml). It also remains to be defined whether longer intervals offer other advantages besides improved analgesia such better voiding and maternal temperature profiles.
1. Reg Anesth Pain Med 2002;27:150-6
2. Anesth Analg 2006;102:904-9