Epidural Infusion

Kaynar, A. Murat; Shankar, K.B.

doi:10.1213/00000539-199908000-00063

Cited by 21 publications

(16 citation statements)

References 6 publications

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“…When using PCEA, some experts avoid a high background infusion rate because it has been associated with increased local anaesthetic consumption and increased motor block, especially in prolonged labour [15]. doses [7,[16][17][18], whereas most PCEA regimens use lower bolus volumes (4-6 ml) [10]. In the current study, we wanted to compare two regimens that reflected current practice, but it is possible that a higher volume PCEA bolus would have been more effective.…”

Section: Discussionmentioning

confidence: 99%

Programmed intermittent epidural bolus vs. patient‐controlled epidural analgesia for maintenance of labour analgesia: a two‐centre, double‐blind, randomised study†

et al. 2020

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Summary The programmed intermittent epidural bolus technique has shown superiority to continuous epidural infusion techniques, with or without patient‐controlled epidural analgesia for pain relief, reduced motor block and patient satisfaction. Many institutions still use patient‐controlled epidural analgesia without a background infusion, and a comparative study between programmed intermittent epidural bolus and patient‐controlled epidural analgesia without a background infusion has not yet been performed. We performed a randomised, two‐centre, double‐blind, controlled trial of these two techniques. The primary outcome was the incidence of breakthrough pain requiring a top‐up dose by an anaesthetist. Secondary outcomes included: motor block; pain scores; patient satisfaction; local anaesthetic consumption; and obstetric and neonatal outcomes. We recruited 130 nulliparous women who received initial spinal analgesia, and then epidural analgesia was initiated and maintained with either programmed intermittent epidural bolus or patient‐controlled epidural analgesia using ropivacaine 0.12% with sufentanil 0.75 µg·ml‐1. The programmed intermittent epidural bolus group had a programmed bolus of 10 ml every hour, with on‐demand patient‐controlled epidural analgesia boluses of 5 ml with a 20 min lockout, and the patient‐controlled epidural analgesia group had a 5 ml bolus with a 12 min lockout interval; the potential maximum volume per hour was the same in both groups. The patients in the programmed intermittent epidural bolus group had less frequent breakthrough pain compared with the patient‐controlled epidural analgesia group, 7 (10.9%) vs. 38 (62.3%; p < 0.0001), respectively. There was a significant difference in motor block (modified Bromage score ≤ 4) frequency between groups, programmed intermittent epidural bolus group 1 (1.6%) vs. patient‐controlled epidural analgesia group 8 (13.1%); p = 0.015. The programmed intermittent epidural bolus group had greater local anaesthetic consumption with fewer patient‐controlled epidural analgesia boluses. Patient satisfaction scores and obstetric or neonatal outcomes were not different between groups. In conclusion, we found that a programmed intermittent epidural bolus technique using 10 ml programmed boluses and 5 ml patient‐controlled epidural analgesia boluses was superior to a patient‐controlled epidural analgesia technique using 5 ml boluses and no background infusion.

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Section: Discussionmentioning

confidence: 99%

Programmed intermittent epidural bolus vs. patient‐controlled epidural analgesia for maintenance of labour analgesia: a two‐centre, double‐blind, randomised study†

et al. 2020

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“…Hogan found that the spread of liquids in the epidural space is highly non-uniform, following multiple small channels and suggested that the spread is most uniform when using large bolus volumes and a correspondingly high injection pressure near the site of injection to recruit the most channels [29]. Kaynar and Shankar compared the spread of solution through a multiorifice epidural catheter administered by a bolus and infusion and found that boluses resulted in wider and more uniform spread [30]. Mowat et al showed that at multiple vertebral levels, bolus administration resulted in a better spread compared with continuous infusion and a study in gynaecological patients also confirmed improved spread with bolus administration, with more extensive sensory loss [31,32].…”

Section: Discussionmentioning

confidence: 99%

High‐volume patient‐controlled epidural vs. programmed intermittent epidural bolus for labour analgesia: a randomised controlled study

et al. 2023

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Summary The aim of neuraxial analgesia is to achieve excellent pain relief with the fewest adverse effects. The most recently introduced technique for epidural analgesia maintenance is the programmed intermittent epidural bolus. In a recent study, we compared this with patient‐controlled epidural analgesia without a background infusion and found that a programmed intermittent epidural bolus was associated with less breakthrough pain, lower pain scores, higher local anaesthetic consumption and comparable motor block. However, we had compared 10 ml programmed intermittent epidural boluses with 5 ml patient‐controlled epidural analgesia boluses. To overcome this potential limitation, we designed a randomised, multicentre non‐inferiority trial using 10 ml boluses in each group. The primary outcome was the incidence of breakthrough pain and total analgesic intake. Secondary outcomes included motor block; pain scores; patient satisfaction; and obstetric and neonatal outcomes. The trial was considered positive if two endpoints were met: non‐inferiority of patient‐controlled epidural analgesia with respect to breakthrough pain; and superiority of patient‐controlled epidural analgesia with respect to local anaesthetic consumption. A total of 360 nulliparous women were allocated randomly to patient‐controlled epidural analgesia‐only or programmed intermittent epidural bolus groups. The patient‐controlled group received 10 ml boluses of ropivacaine 0.12% with sufentanil 0.75 μg.ml‐1; the programmed intermittent group received 10 ml boluses supplemented by 5 ml patient‐controlled boluses. The lockout period was 30 min in each group and the maximum allowed hourly local anaesthetic/opioid consumption was identical between the groups. Breakthrough pain was similar between groups (11.2% patient controlled vs. 10.8% programmed intermittent, p = 0.003 for non‐inferiority). Total ropivacaine consumption was lower in the PCEA–group (mean difference 15.3 mg, p < 0.001). Motor block, patient satisfaction scores and maternal and neonatal outcomes were similar across both groups. In conclusion, patient‐controlled epidural analgesia is non‐inferior to programmed intermittent epidural bolus if equal volumes of patient‐controlled epidural analgesia are used to maintain labour analgesia and superior with respect to local anaesthetic consumption.

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“…A higher bolus pressure has been shown to provide a more efficient distribution of local anesthetic and enhanced analgesia. 3,6,10 This improved distribution results in a reduction in local anesthetic consumption, greater patient satisfaction, and faster recovery. 4,11 Kaynar and Shankar 10 evaluated the spread of epidural solution and noted a 5-fold wider spread for a machine bolus compared to continuous epidural dosing.…”

Section: Discussionmentioning

confidence: 99%

Direct Comparison of Peak Bulk Flow Rate of Programmable Intermittent Epidural Bolus and Manual Epidural Bolus Using a Closed-End Multiorifice Catheter: An Experimental Study

Younger¹,

Faryami

Prasad

et al. 2022

Anesthesia &Amp; Analgesia

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BACKGROUND:The programmable intermittent epidural bolus (PIEB) has been popularized as the optimal delivery technique for labor analgesia. Suggested advantages of this method are less local anesthetic consumption, improved maternal satisfaction, potentially shorter duration of labor, and decreased workload requirements for the anesthesia providers. However, a manual bolus is still routinely used for breakthrough pain when the PIEB is underperforming. METHODS: We conducted a laboratory-based study to quantify the flow through a multiorifice epidural catheter using the PIEB setting on an epidural pump compared to the manual epidural bolus. Four syringe volumes, 3, 5, 10, and 20 mL, were selected for this experiment. The flow in a manual bolus was also studied with and without the presence of an epidural catheter filter. A generalized estimating equation analysis was done to compare data between the groups. RESULTS: Regardless of the syringe size, there was a several-fold increase in flow when a manual bolus was used compared to a pump-administered dose, with the highest difference in the peak flow rate observed in 3-mL boluses with up to a 12-fold difference, while the difference was, at most, 7-fold in 5-mL and 10-mL boluses. Manual boluses without a filter achieve a mean peak flow rate higher than manual boluses with a filter. CONCLUSIONS: Our study found that manual boluses produced a higher flow rate compared to the CADD-Solis epidural pump (Smiths Medical). This study also found that the placement of a particulate filter reduces the flow rates generated while bolusing. Bulk flow rate is directly correlated with induced pressure and solution spread. Because higher bolus pressure has been shown to provide a more efficient distribution of local anesthetic and more efficient pain relief, these results may have impactful clinical significance and will pave the way for future studies.

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Epidural Infusion

Cited by 21 publications

References 6 publications

Programmed intermittent epidural bolus vs. patient‐controlled epidural analgesia for maintenance of labour analgesia: a two‐centre, double‐blind, randomised study†

Programmed intermittent epidural bolus vs. patient‐controlled epidural analgesia for maintenance of labour analgesia: a two‐centre, double‐blind, randomised study†

High‐volume patient‐controlled epidural vs. programmed intermittent epidural bolus for labour analgesia: a randomised controlled study

Direct Comparison of Peak Bulk Flow Rate of Programmable Intermittent Epidural Bolus and Manual Epidural Bolus Using a Closed-End Multiorifice Catheter: An Experimental Study

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