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Labor Analgesia When Neuraxial Anesthesia Is Relatively Contraindicated: Comparison Of I.V. Fentanyl PCA And Intermittent I.V. Nalbuphine Boluses.
Abstract Number: T-26
Abstract Type: Original Research
In 2009, we implemented an I.V. Fentanyl PCA protocol (initial 250 mcg per hour limit) to be used for those parturients that had relative contraindications to neuraxial anesthesia. Nurse administered IV Nalbuphine boluses are routinely used at our institution for patients not receiving epidural analgesia.
The primary objective of this study is to compare the effectiveness of I.V. Fentanyl PCA to Nalbuphine boluses for management of labor pain. The secondary goals are to examine adherence to the protocol over time and compare maternal and fetal adverse events associated with IV Fentanyl PCA versus I.V. Nalbuphine boluses.
We identified all patients at our institution utilizing IV Fentanyl PCA for labor from August 2009 though August 2015. We then performed a chart review to determine pain control and maternal/fetal adverse events experienced throughout labor for patients receiving IV Fentanyl PCA. We compared this cohort of patients with similar patients in labor during this time period that received IV Nalbuphine boluses.
There were no significant differences in pain scores between the IV Fentanyl PCA and Nalbuphine bolus groups (p=0.43) (Figure 1). Following an initial modest decline, all groups showed a significant increase in pain scores with time (p <.0001). Adherence to the fentanyl protocol progressively decreased with each ensuing year from 2009 -2015 (80%, 59%, 56%, 50%, 33%, 25%, 0%) with the obstetric team usually requesting a much lower fentanyl dose than recommended by protocol. There were no maternal complications (maternal desaturations, Narcan, bag mask ventilation, intubation) observed in any group. Fetal adverse events were not significantly different between the Fentanyl vs. Nalbuphine groups: fetal bag/mask ventilation 3/42 vs. 2/44, intubation 2/42 vs. 0/44, and NICU admissions 2/42 vs. 2/44 for gestation >35 weeks.
Parturients continued to have high pain scores with both Fentanyl PCA and Nalbuphine boluses during labor. We could not detect improvement in pain scores with use of the Fentanyl PCA compared to Nalbuphine boluses. Adherence to the protocol progressively decreased with time suggesting the need for ongoing education of both the obstetric and anesthesia staffs regarding the details of the Fentanyl PCA protocol. Maternal and fetal adverse events were very uncommon and not significantly different between the Fentanyl PCA and Nalbuphine groups.