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Programmed Intermittent Epidural Bolus Labor Analgesia in a parturient with Idiopathic Intracranial Hypertension and Papilledema
Abstract Number: S4C-10
Abstract Type: Case Report/Case Series
Introduction: Idiopathic intracranial hypertension (IIH) is a disorder of raised intracranial pressure (ICP) (>20cmH2O) with normal cerebrospinal fluid (CSF) composition and no detected underlying cause. (1) Several authors report sudden increases in ICP after rapid administration of manual epidural injectate boluses. (2) This raises the concern that employing high flow rate programmed intermittent epidural bolus (PIEB) for labor epidural analgesia (LEA) in patients with IIH may also lead to a rise in ICP. We describe the successful use of PIEB LEA in a parturient with IIH who underwent uncomplicated labor and vaginal delivery.
Case: A 30 year old G4P2 with a history of IIH presented at term in spontaneous labor. IIH was diagnosed 3 years prior following episodes of headaches and blurry vision. Diagnosis prompted acetazolamide therapy, which improved her headache but visual changes persisted; acetazolamide was stopped prior to pregnancy. At 36 weeks, she developed papilledema; plan was made for early LEA (cervix <4cm dilated) and assisted second-stage delivery. Epidural was placed at presentation in spontaneous labor (cervix 3cm dilated) and a manual bolus of 0.125% bupivacaine with 5mcg/mL fentanyl (5+5+3mL) was administered slowly over 10 min. We discussed the theoretical concerns with the PIEB setting (Table 1) but the patient was willing to proceed. Six h post-epidural insertion, 4 PIEB boluses and 4 PCEA doses had been delivered. The patient was stable throughout labor and postpartum with no changes in vision and no headache, nausea, vomiting or other signs of raised ICP.
Discussion: The PIEB technique provides better quality analgesia, lower pain scores, more uniform epidural spread, and reduced local anesthetic consumption compared to epidural infusions. (3) These characteristics are beneficial in patients with IIH since a greater rise in ICP is expected if analgesia is suboptimal. Pain can exaggerate ICP increases, and animal models have reported that this increase is even greater in the presence of IIH. The theoretical concerns of PIEB LEA with high-pressure boluses causing raised ICP was not demonstrated in this patient, and we therefore suggest that high flow rate PIEB may be considered in parturients with IIH.
1. Karmaniolou et al. J Can Anesth 2011
2. Leffert et al. Anesthesiology 2013
3. Carvalho B et al. Anesth Analg 2016