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The Effect of Combined Use of Dural Puncture Epidural and Programmed Intermittent Epidural Bolus for Labor Analgesia: A Randomized Controlled Clinical Trial
Abstract Number: GM-03
Abstract Type: Original Research
BACKGROUND: The dural puncture epidural (DPE) is a technical modification of combined spinal epidural (CSE), where the dura mater is punctured by a spinal needle, but without direct injection of drugs. The DPE has been found to improve block quality over the Epidural (EP) with fewer side effects than the CSE. Besides the initiation of neuraxial labor analgesia, using PIEB as the maintenance epidural analgesia method compared to continuous epidural infusion (CEI) is believed to reduce anesthetic consumption and fewer manual boluses. The aim of this study was to evaluate the analgesia onset, drug consumption and side effects of the combination of DPE and PIEB technique. Adequate analgesia was defined as visual numerical rating scale (VNRS) measurement ≤ 10 mm on a 100-mm scale during active contractions.
METHODS: Nulliparous women with VNRS >50 mm and cervical dilation <5 cm were randomly assigned to receive EP + CEI, DPE + CEI, DPE + PIEB. A 25G Whitacre needle (BD medical) was utilized to puncture the dural. Analgesia was initiated and maintained with a solution of 0.1% ropivacaine plus 0.3 µg·ml-1sufentanil. After a loading dose of 10 mL followed by an epidural test dose (lidocaine 45 mg), PIEB pump (8 mL every hour beginning 1 hour after epidural initiation) or CEI pump (8 mL/h, beginning immediately after epidural initiation) was connected to patients according to the group assignment. All pumps were set to deliver a 5ml patient-controlled epidural analgesia (PCEA) bolus with a lockout time of 20 minutes. Breakthrough pain was treated with PCEA initially, followed by a manual bolus of 5 ml of 0.125% ropivacaine plus 0.3 µg·ml-1sufentanil if necessary. The primary outcome was time to achieve adequate analgesia analyzed by Kaplan-Meier curves. Secondary outcomes included block quality, drug consumption, and maternal adverse effects.
RESULTS: We studied 116 subjects (EP+CEI=38, DPE+CEI=40, DPE+PIEB=38). The mean time [95% Confidence Interval] to adequate analgesia was 17 min [16-19 min] in group EP+CEI compared with 14 min [12-16 min] in group DPE+CEI and 14 min [12-16 min] in group DPE+PIEB (p=0.04). A significant difference was noted in the incidence of bilateral S2 blockade at 30 minutes between group EP+CEI, group DPE+CEI, and group DPE+PIEB (42.1%, 67.5% and 68.4% respectively, p=0.029). The hourly consumption of ropivacaine and sufentanil was significantly lower in group DPE+PIEB than those in group DPE+CEI or group EP+CEI (p all<0.001). There were no differences in the duration of labor, delivery mode, new born Apgar scores, the incidence of adverse effects or the satisfaction score of labor.
CONCLUSIONS: DPE with a 25G needle was associated with rapid analgesia onset and greater sacral spread. Combined use of DPE and PIEB reduced anesthetics consumption without additional side effects. The combined use of DPE and PIEB appears to offer a favorable paradigm of initiation and maintenance for labor analgesia.