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Effectiveness of Different Dosages of Programmed Epidural Boluses for Labor Analgesia. A Randomized Single-Blind Study in Parturient Women
Abstract Number: T-33
Abstract Type: Original Research
BACKGROUND: Current standards of labor epidural analgesia consist of local anesthetic in combination with opioids delivered via parturient-controlled epidural analgesia with basal infusion. In this prospective randomized single-blind controlled study, we compared the effectiveness of different dosages of preset scheduled epidural boluses to standard continuous epidural infusion evaluating clinical outcome, patient comfort and satisfaction, the need for manual anesthesia interventions, other analgesic outcomes, labor progression, and mode of delivery in healthy laboring women.
We hypothesized that epidural local anesthetic consumption would be lower with increased patient satisfaction if programmed intermittent boluses were used instead of basal infusion.
METHODS: Nulliparous, term women in spontaneous labor and cervical dilation 4cm were consented. Epidural analgesia was then initiated and maintained with Bupivacaine-0.125% with fentanyl 2mcg/ml. After an initial loading dose of 5mL of epidural solution, patients were randomized to one of three groups receiving either programmed intermittent epidural bolus 5ml every 30 minutes (Group 1), 10mL every hour beginning 60 minutes (Group 2), or continuous epidural infusion 10 mL/h (Group 3). Breakthrough pain was treated with manual boluses with Bupivacaine-0.125% with fentanyl 2mcg/ml or Lidocaine-2% if necessary.
The degree of motor block was assessed in lower extremities using modified Bromage score; total local anesthetic requirement, total analgesic solution consumption, and maternal satisfaction as primary outcomes. Secondary outcomes such as, sensory anesthesia to cold sensation using the ice glove test at regular intervals throughout labor, verbal pain scores, incidence of side effects, and outcome of labor also compared among groups.
RESULTS: We studied 126 patients. Patient demographics, labor characteristics, and side effects were similar in each group. We found a reduction in verbal pain scores during labor in Group 1, but not significantly. There were no differences in pain scores in Group 2 and Group 3. However, Group 1 was significantly more likely to receive a bolus dose for breakthrough pain than Group 2. Group 3 was more likely to receive a bolus than Group 2, and less likely than Group 1, but was not significantly different from either of them. There was no difference between the groups in the likelihood of a patient having a block T9 or higher.
CONCLUSIONS: The results of this study suggest that the use of programmed intermittent epidural anesthetic bolus technique slightly reduces local anesthetic usage, total analgesic consumption and improves maternal comfort and satisfaction. More studies are required to conceptualize the ideal intermittent epidural anesthetic bolus technique and further investigate its effect on labor analgesia and obstetric outcomes.