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Comparison of Programmed Intermittent Epidural Boluses with Continuous Epidural Infusion for the Maintenance of Labor Analgesia: A randomized controlled double-blind study
Abstract Number: GM-4
Abstract Type: Original Research
Programmed Intermittent Epidural Boluses (PIEB) may improve the spread of local anesthetic compared to continuous epidural infusion (CEI) possibly resulting in improved labor analgesia and obstetrical outcomes. Most of the available evidence comes from retrospective studies or studies that predated the availability of pumps capable of co-delivering PIEB with patient controlled epidural analgesia (PCEA). Many earlier studies used two pumps, one to administer PIEB or CEI and one to administer PCEA, or pumps not available in North America. We performed this study to compare PIEB vs CEI for labor analgesia. We hypothesized that PIEB would lower PCEA consumption compared to CEI.
Women requesting epidural analgesia at 2-7 cm cervical dilatation were enrolled. Analgesia was initiated and maintained with ropivacaine 0.1% with fentanyl 2 mcg/ml. After 20 mL loading dose, patients were randomized to PIEB 6 mL every 45 minutes (first bolus 30 minutes after epidural initiation) or CEI 8mL/h. Randomization was stratified by parity. Patients received 8mL PCEA boluses, with 10-minute lockout period. Patients and providers were blinded to the regimen used. Rescue boluses of 5 mL of 0.2 % ropivacaine were administered for inadequate analgesia. Primary outcome was PCEA consumption/h. Secondary outcomes included need for physician interventions, PCEA attempts, ratio of total /successful PCEA attempts, time to first PCEA attempt, motor blockade, frequency of hypotensive events, pain scores, duration of second stage, mode of delivery, and maternal satisfaction. Continuous data were analyzed with Wilcoxon-Rank or t-test and categorical data with chi-squared or Fisher’s exact test. Pain and Bromage scores were assessed longitudinally between groups with mixed modeling while accounting for patient level clustering.
We included 120 patients, 86 were primiparous. There were no significant differences in patient demographics between the groups. There were also no significant differences between the groups in the primary outcome or any of the secondary outcomes except for a higher PCEA attempts/given ratio/h in the PIEB group (Table). Differences between groups in pain and Bromage scores as repeated measures were insignificant (p= 0.06; 0.81 respectively).
Under the conditions of our study, we did not find improved outcomes with PIEB compared to CEI. Future studies should evaluate different settings of PIEB to optimize analgesia and outcomes.