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Patterns of patient-controlled epidural analgesia use in laboring women
Abstract Number: SAT-42
Abstract Type: Original Research
Introduction: Maintenance of labor analgesia with timed intermittent bolus (TIB), in addition to patient-controlled epidural analgesia (PCEA), results in superior analgesia compared to continuous infusion with PCEA. However, as epidural pumps capable of delivering timed boluses only recently became available, an alternative strategy is to use a low-rate infusion with a large PCEA volume in order to simulate the TIB effect. The typical pattern of PCEA use using this maintenance strategy is unknown. The objective of this study was to evaluate the patterns of PCEA use, and differences in PCEA use patterns among women that required clinician interventions for breakthrough pain.
Methods: Nulliparous women with a singleton pregnancy, undergoing a post-dates induction, and at a cervical dilation of <5cm at request for neuraxial analgesia, were eligible for this prospective observational study. Combined spinal-epidural analgesia was initiated with an intrathecal dose of 25mcg fentanyl. Epidural analgesia was maintained using a continuous infusion of 0.0625% bupivacaine with fentanyl (8mL/hr) and a PCEA (8mL, up to three times/hr). Instructions on PCEA use were provided using a standard script. Patients were stratified into adequate and inadequate labor analgesia (i.e. required supplemental analgesia) and PCEA patterns were evaluated (number of requests, deliveries and request/delivery ratio). Numeric literacy was assessed using the Lipkus 7-item expanded numeracy test. Categorical data between groups were evaluated using the chi-squared or Fisher’s exact tests. Continuous data were compared using a student’s t-test or rank sum test.
Results: A total of 89 patients completed the study. Patients required a median of 2.3 PCEA requests per hour (interquartile range: 1.2-3.3). There were no demographic differences between the two groups. Patients that required supplemental analgesia were more likely to request and receive PCEA boluses. They were also more likely to have a higher hourly bupivacaine requirement during labor. There were no differences in numeric literacy between groups.
Conclusions: Using a low-rate maintenance infusion requires active patient engagement to maintain analgesia. Patients who ultimately require treatment of breakthrough pain have higher PCEA demands and deliveries. It would be useful to utilize PCEA utilization data to identify patients with higher maintenance requirements and better match the maintenance rate based on patient pain demands.