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A case-series of Programmed Intermittent Epidural Boluses (PIEB) using High-Flow Delivery for Labor Analgesia
Abstract Number: T-31
Abstract Type: Original Research
Epidural bolus injections for labor analgesia have been proven to provide superior pain relief and maternal satisfaction compared with continuous infusions. In 2014, the FDA approved commercially available pumps (CADD®) that deliver programmed intermittent bolus (PIEB) along with patient-controlled epidural analgesia (PCEA). These pumps can be programmed to deliver the boluses at different flows ranging from 150ml/h to 500ml/h, however the default flow is usually programmed at 250 ml/h, because higher flows require specific tubing (high-flow tubing). Currently, there is no available data on PIEB delivered at the maximum high-flow of 500ml/h for labor analgesia. It has been reported that occlusions may be occurring which may counteract the possible advantages of high flow delivery. We report here on our case-series of 25 cases using a CADD®-Solis PIB Ambulatory Infusion System with high flow tubing.
Data from 25 women receiving a combined-spinal epidural (CSE) for labor analgesia using a CADD® Solis PIEB pump with high-flow tubing cases were collected from July to November 2015. PIEB protocol was as reported previously (1): 10ml PIEB bolus every 45minutes (bupivacaine 0.0625%-fentanyl 2mcg/ml), 5ml PCEA bolus, 10min lock-out for both boluses, delivered at high-flow of 500ml/h. 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.
Among 25 women, only 5 (20%) requested a physician top-up, with a median time from CSE to 1st top-up of 235 minutes (IQR 81-227). No episodes of hypotension requiring physician intervention were recorded. There were no cases of tubing occlusion and no technical issues were reported by nursing or providers.
Use of PIEB with PCEA set-up to deliver boluses at 500ml/h with high-flow tubing appears to be providing effective analgesia without any technical problems requiring any troubleshooting during labor and delivery. With only 20% of women requesting a physician top-up, which is somewhat lower than expected, our experience with this novel delivery mode is extremely promising. However, because of the higher cost of the high-flow tubing, randomized clinical trials are needed to evaluate whether this additional cost is justified by substantial advantages in analgesia parameters, motor block, and possibly obstetric outcomes.