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Efficacy of a programmed intermittent epidural bolus regimen compared to a continuous epidural infusion regimen at a high volume tertiary care obstetric unit: a before-after study
Abstract Number: S1B-6
Abstract Type: Original Research
Introduction: The current practice of neuraxial labor analgesia is thought to be evidence based. This evidence comes from studies conducted in very controlled settings and does not account for the variability of the daily practice. Prospective observational studies assessing quality and safety of analgesia during the entire labor and delivery process, including a focus on maternal satisfaction are rare. In 2011 we conducted one such study, at a time when our standard labor epidural analgesia technique was a continuous epidural infusion (CEI) regimen plus patient controlled epidural analgesia (PCEA)(1). In 2016 we changed our practice to a programmed intermittent epidural bolus (PIEB) regimen plus PCEA(2). We wanted to compare the two regimens and hypothesized that the new regimen would outperform the former.
Methods: We performed a before-after study, comparing data of women enrolled before (Nov 2011) and after (Nov-Dec 2017). All women requesting neuraxial analgesia for labor during the study periods were approached and included in the study if consenting. Women in 2017 received a test dose and a loading dose, followed by a PIEB regimen with bupivacaine 0.0625% with fentanyl 2 mcg/ml (PIEB 10 ml, interval 40 minutes, PCEA 5mL, lockout 10 min, maximum 30 mL/h). Women in 2011 also received a test dose and a loading dose, followed by CEI of 0.0625% with fentanyl 2 mcg/ml, 10 mL/h, plus same PCEA settings and maximum 20 mL/h. Top-ups were given as required by nurses and/or physicians. If required, the maintenance solution could be changed to bupivacaine 0.125% with fentanyl 2 mcg/ml. After delivery, women were given a satisfaction questionnaire comprising 10 statements to be classified according to a Likert scale ranging from strongly agree to strongly disagree. Furthermore, physicians’ and nurses’ notes were reviewed to ensure that all data pertaining to the quality of analgesia and complications in all stages of labor and delivery had been captured. The primary outcome was the presence of pain > 3 (VAS 0-10) at any time during 1st or 2nd stage of labor. The outcomes were compared between before and after groups using univariate analyses.
Results: 294 and 247 women were enrolled in before and after groups respectively. The number of women reporting pain >3 at any time during labor and delivery was significantly reduced in the after group (30.3% vs 40.5%; P=0.001). Women in the after group received fewer top-ups by both by nurses (6.9% vs 36.0%) and physicians (18.6% vs 24.5%)(P<0.0001). Mode of delivery and incidence of hypotension was similar. Motor block was not recorded in 2011, but 92% of women in the after group exhibited no motor block. Satisfaction was high and similar in both groups.
Conclusion: The implementation of a PIEB regimen very likely contributed to an improvement in the quality of labor analgesia compared to our previous practice with a CEI regimen.
Reference:1)Can J Anesth.2013;60:787-95; 2)Anesth Analg.2017;124:537-541