Intermittent epidural bolus versus continuous epidural infusions for labor analgesia: A meta-analysis of randomized controlled trials

Lu, Xian; Zhang, Huan; Zhang, Haijing; Guo, Mengzhuo; Gao, Yuanchao; Du, Chunyan

doi:10.1371/journal.pone.0234353

Cited by 9 publications

(10 citation statements)

References 42 publications

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“…Both obstetric and anaesthetic practice has changed during this time, with rates of assisted vaginal delivery falling [21] and caesarean section rates increasing 4% per year worldwide [22]. Evidence is accumulating supporting the use of intermittent bolus and patientcontrolled epidural analgesia rather than continuous epidural regimes to reduce the total dose of local anaesthetic given [23,24]. Reducing the concentration of local anaesthetic is a straightforward intervention that would be easy to unknown and this may be a key area for future work.…”

Section: Discussionmentioning

confidence: 99%

“…All methods of epidural maintenance were included in this meta-analysis. This may influence our results as there is evidence that women require lower total doses of local anaesthetic when using patient-controlled epidural analgesia, or intermittent bolus rather than continuous infusions [23,24]. However, only two of the studies used different methods of administration of epidural maintenance for different groups of the trial meaning that the variable being assessed was the local anaesthetic concentration rather than the method of administration [14,15].…”

Section: Discussionmentioning

confidence: 99%

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Comparison of ultra‐low, low and high concentration local anaesthetic for labour epidural analgesia: a systematic review and network meta‐analysis

et al. 2022

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Summary Lumbar epidural is the gold standard for labour analgesia. Low concentrations of local anaesthetic are recommended. This network meta‐analysis investigated whether further reducing the concentration of local anaesthetic can improve maternal and neonatal outcomes without compromising analgesia. We conducted a systematic search of relevant databases for randomised controlled trials comparing high (>0.1%), low (>0.08% to ≤0.1%) or ultra‐low (≤0.08%) concentration local anaesthetic (bupivacaine or equivalent) for labour epidural. Outcomes included mode of delivery, duration of labour and maternal/neonatal outcomes. Bayesian network meta‐analysis with random‐effects modelling was used to calculate odds ratios or weighted mean differences and 95% credible intervals. A total of 32 studies met inclusion criteria (3665 women). The total dose of local anaesthetic received increased as the concentration increased; ultra‐low compared with low (weighted mean difference −14.96 mg, 95% credible interval [−28.38 to −1.00]) and low compared with high groups (weighted mean difference −14.99 [−28.79 to −2.04]), though there was no difference in the number of rescue top‐ups administered between the groups. Compared with high concentration, ultra‐low concentration local anaesthetic was associated with increased likelihood of spontaneous vaginal delivery (OR 1.46 [1.18 to 1.86]), reduced motor block (Bromage score >0; OR 0.32 [0.18 to 0.54]) and reduced duration of second stage of labour (weighted mean difference −13.02 min [−21.54 to −4.77]). Compared with low, ultra‐low concentration local anaesthetic had similar estimates for duration of second stage of labour (weighted mean difference −1.92 min [−14.35 to 10.20]); spontaneous vaginal delivery (OR 1.07 [0.75 to 1.56]; assisted vaginal delivery (OR 1.35 [0.75 to 2.26]); caesarean section (OR 0.76 [0.49 to 1.22]); pain (scale 1–100, weighted mean difference −5.44 [−16.75 to 5.93]); and maternal satisfaction. Although a lower risk of an Apgar score < 7 at 1 min (OR 0.43 [0.15 to 0.79]) was reported for ultra‐low compared with low concentration, this was not sustained at 5 min (OR 0.12 [0.00 to 2.10]). Ultra‐low concentration local anaesthetic for labour epidural achieves similar or better maternal and neonatal outcomes as low and high concentration, but with reduced local anaesthetic consumption.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Comparison of ultra‐low, low and high concentration local anaesthetic for labour epidural analgesia: a systematic review and network meta‐analysis

et al. 2022

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“…The difference in treatment efficacy between IEB and CEI for labor analgesia has been addressed in previous systematic reviews and meta-analyses [ 47 , 48 , 49 ]. In 2013, a well-conducted meta-analysis [ 47 ] of nine studies that showed minor reduction in local anesthetic usage and improvement of maternal satisfaction were related to receiving IEB.…”

Section: Discussionmentioning

confidence: 99%

“…Specifically, for the IEB with PCEA group, the results showed shorter labor duration and maternal satisfaction improvement compared to the CEI with PCEA group. The latest and final meta-analysis [ 49 ] recruited 22 RCTs with 2573 parturients. Among these meta-analyses, Liu et al evidently conducted a meta-analysis with the largest sample size.…”

Section: Discussionmentioning

confidence: 99%

A Meta-Analysis of Comparing Intermittent Epidural Boluses and Continuous Epidural Infusion for Labor Analgesia

Tzeng

Kao

Pan

et al. 2020

IJERPH

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With the development of medical equipment and techniques in labor anesthesia, it is a major issue to investigate the risks and treatment effects among techniques such as continuous epidural infusion (CEI) and intermittent epidural bolus (IEB). However, there is a controversial result regarding two techniques. This study was conducted through meta-analysis of randomized controlled trials (RCTs) for labor analgesia between the CEI and IEB techniques. The pooled results were presented as weighted mean differences (WMDs) together with 95% confidence intervals (CIs) and odds ratios (ORs) together with 95% CIs, respectively. Eleven RCTs were included in this meta-analysis. Four hundred sixty-five parturients accepted CEI, whereas 473 parturients accepted IEB labor analgesia. Elven identified low- risk bias studies were recruited for meta-analysis. The results presented no statistical difference in cesarean delivery rate between IEB and CEI (OR, 0.96; 95% CI, 0.67–1.37) and duration of second stage of labor (WMD, −3.82 min; 95% CI, −8.28 to 0.64). IEB had statistically significant lessened risk of instrumental delivery (OR, 0.59; 95% CI, 0.39–0.90) and for the use in local anesthetic (WMD, −1.71 mg bupivacaine equivalents per hour; 95% CI, −1.88 and −1.55). Accepted IEB had a higher score of maternal satisfaction (WMD, −6.95 mm; 95% CI, −7.77 to −6.13). Based on evidence, IEB showed a greater benefit for slightly reducing the use in local anesthetic, reduced risk of instrumental delivery, and improved maternal satisfaction for the requirement of labor epidural analgesia for healthy women. In the future, more studies need to be conducted to practice the IEB regimen and explore its influence on labor analgesia.

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“…Programmed intermittent epidural boluses (PIEB), a newly established technology, provides better analgesia, less motor block and lower local anesthetic drug consumption compared with traditional continuous epidural infusion (CEI), which has being used in labour analgesia. 18–21 Therefore, we hypothesized that PIEB may provide superior uterine contraction pain and incision pain relief and less motor block than CEI. Our primary aim was to evaluate the effectiveness of uterine contraction pain relief assessed with visual analog scale (VAS) score at the postoperative 36 h.…”

Section: Introductionmentioning

confidence: 99%

Programmed Intermittent Epidural Bolus in Comparison with Continuous Epidural Infusion for Uterine Contraction Pain Relief After Cesarean Section: A Randomized, Double-Blind Clinical Trial

Mo¹,

Zhao²,

Chen³

et al. 2022

DDDT

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Purpose Programmed intermittent epidural bolus (PIEB) was reported to provide superior maintenance of labour analgesia with better pain relief and less motor block than continuous epidural infusion (CEI). Whether this is also evident for uterine contraction pain relief after cesarean section remains unknown. Patients and Methods Parturients scheduled for cesarean section were recruited for the study. At the end of the surgery, after a similar epidural loading dose given, patients received either PIEB (6 mL·h −1 ) or CEI (6 mL·h −1 ) of 0.1% ropivacaine. The primary outcome was the uterine contraction pain assessed with visual analog scale (VAS-U) at the postoperative 36 h. Secondary outcomes included incision pain at the rest (VAS-R) and in the movement-evoked (VAS-P), and lower extremity motor block (defined as Bromage score > 0). The whole profile of VAS scores between groups was analyzed using linear mixed model. When significant differences were found, the pairwise comparison was done with the Mann Whitney U -test followed by Bonferroni correction. Results One hundred and twenty parturients were studied (PIEB, 60; CEI, 60). VAS-U at the postoperative 36 h in the PIEB group was lower than in the CEI group (Bonferroni-adjusted P < 0.01). The linear mixed model indicated that VAS-U, VAS-R and VAS-P were lower in the PIEB group compared with the CEI group (all P < 0.01). Motor block was higher in the CEI group than in the PIEB group during the study period except 2 h (all P < 0.05). No differences of adverse events such as hypotension and urinary retention were observed between the two groups. Conclusion Programmed intermittent epidural bolus provides more effective uterine contraction and incision pain relief and less motor block after cesarean section than continuous epidural infusion without an increased risk of urinary retention and blood pressure instability.

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Intermittent epidural bolus versus continuous epidural infusions for labor analgesia: A meta-analysis of randomized controlled trials

Cited by 9 publications

References 42 publications

Comparison of ultra‐low, low and high concentration local anaesthetic for labour epidural analgesia: a systematic review and network meta‐analysis

Comparison of ultra‐low, low and high concentration local anaesthetic for labour epidural analgesia: a systematic review and network meta‐analysis

A Meta-Analysis of Comparing Intermittent Epidural Boluses and Continuous Epidural Infusion for Labor Analgesia

Programmed Intermittent Epidural Bolus in Comparison with Continuous Epidural Infusion for Uterine Contraction Pain Relief After Cesarean Section: A Randomized, Double-Blind Clinical Trial

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