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EuroAnaesthesia 2019 - PIEB Labour Analgesia

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An overview of the evidence in support of PIEB and PCEA for labour analgesia. Presented at the 2019 European Society of Anaesthesiology annual meeting in Vienna, Austria #EA19

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EuroAnaesthesia 2019 - PIEB Labour Analgesia

  1. 1. (C) Ronald George
  2. 2. @Ron_George An Evolution of Labour Analgesia Programmed Intermittent Epidural Bolus (PIEB) with PCEA for #OBAnes Ronald B. George, MD FRCPC Professor, Anaesthesiology Dalhousie University (C) Ronald George
  3. 3. @Ron_George Describe the current knowledge regarding PIEB impact on analgesia & obstetrical outcomes Demonstrate the limitations in evidence for PIEB for labour analgesia Describe implementation strategies for PIEB to optimize effective and safe utilization on your labour units Discuss future considerations for PIEB and labour analgesia Learning Objectives (C) Ronald George
  4. 4. @Ron_George Clinician Bolus (CSE or Epi) Dosage (C) Ronald George
  5. 5. @Ron_George P C E A P C E A P C E A PCEA Lockout Clinician Bolus (CSE or Epi) Dosage (C) Ronald George
  6. 6. @Ron_George (C) Ronald George
  7. 7. @Ron_George (C) Ronald George
  8. 8. @Ron_George Patients who receive PCEA bolus analgesia: Less anesthetic interventions Higher satisfaction Less motor block (C) Ronald George
  9. 9. @Ron_George (C) Ronald George
  10. 10. @Ron_George LC was associated with a reduction in the incidence of IVD OR = 0.70 95%CI, 0.56 to 0.86 Sultan et al. CJA 2013;60 (C) Ronald George
  11. 11. @Ron_George Kaynar et al, Anesth Analg 1999;89 Rusha et al. SOAP 2019 T210-187 Hogan, Reg Anesth Pain Med 2002;27 10.5 ml/hour 3.5 ml bolus (C) Ronald George
  12. 12. @Ron_George Kaynar et al, Anesth Analg 1999;89 Rusha et al. SOAP 2019 T210-187 Hogan, Reg Anesth Pain Med 2002;27 (C) Ronald George
  13. 13. @Ron_George Kaynar et al, Anesth Analg 1999;89 Rusha et al. SOAP 2019 T210-187 Hogan, Reg Anesth Pain Med 2002;27 (C) Ronald George
  14. 14. @Ron_George (C) Ronald George
  15. 15. @Ron_George P I E B Next Bolus Interval PIEB Interval 30 60 90 120 Clinician Bolus (CSE or Epi) P I E B P I E B P I E B Dosage (C) Ronald George
  16. 16. @Ron_George (C) Ronald George
  17. 17. @Ron_George (C) Ronald George
  18. 18. @Ron_George (C) Ronald George
  19. 19. @Ron_George Wong et al. A&A 2013 PIEB: 6ml q30min CEI: 12ml per hour (C) Ronald George
  20. 20. @Ron_George A&A 2011;113:826-31 (C) Ronald George
  21. 21. @Ron_George CEI : 10 ml/hour PIEB : 10 ml q1hour (C) Ronald George
  22. 22. @Ron_George IVD: 20% CEI vs 7% PIEB (p=0.03) RR 2.9 (95% CI: 1.1–7.9) (C) Ronald George
  23. 23. @Ron_George CEI / PIEB : 0.0625% Bupiv PCEA : 1.25% Bupiv (C) Ronald George
  24. 24. @Ron_George (C) Ronald George
  25. 25. @Ron_George (C) Ronald George
  26. 26. @Ron_George Meta-analysis comparing PIEB and CEI +/- PCEA for Labor Analgesia Local anesthetic consumption –1.2 mg/h (95% CI, –2.2 to –0.3) 0.01 Maternal satisfaction scores 7.0 mm (95% CI, 6.20 to 7.8) <0.00001 Duration of 2nd stage of labor –12 min (95% CI, –23 to 0) 0.04 Mode of delivery Cesarean delivery 0.87 (95% CI, 0.56 to 1.35) 0.54 Instrumented delivery 0.59 (95% CI, 0.35 to 1.00) 0.05 Total duration of labor –12 min (95% CI, –23 to 0) 0.04 Anesthesia interventions 0.56 (95% CI, 0.29 to 1.06) 0.08 (C) Ronald George
  27. 27. @Ron_George Local Anesthesia consumption (mg/hr) Maternal Satisfaction (C) Ronald George
  28. 28. @Ron_George (C) Ronald George
  29. 29. @Ron_George Jiqian Xu, et al. Scientific Reports 2019 (C) Ronald George
  30. 30. @Ron_George (C) Ronald George
  31. 31. @Ron_George (C) Ronald George
  32. 32. @Ron_George 0% 6% 13% 19% 25% Rescue Bolus Unilateral Block CEI PIEB 2% 12% 5% 19% (C) Ronald George
  33. 33. @Ron_George (C) Ronald George
  34. 34. @Ron_George OR 1.15 95%CI (1.04, 1.27) (C) Ronald George
  35. 35. @Ron_George Labor Epidural PIEB + PCEA Ropivacaine + fentanyl PIEB Bolus PIEB Interval PCEA Bolus PCEA Lockout NEXT Bolus ? ml ? min ? ml ? min ? min (C) Ronald George
  36. 36. @Ron_George (C) Ronald George
  37. 37. @Ron_George (C) Ronald George
  38. 38. @Ron_George (C) Ronald George
  39. 39. @Ron_George 0 4 8 12 2.5/15 5/30 10/60 8.8 10.010.4 Bupiv mg/h (C) Ronald George
  40. 40. @Ron_George PIEB Volume - 10ml PIEB Interval - 60min 0 4 8 12 2.5/15 5/30 10/60 8.8 10.010.4 Bupiv mg/h (C) Ronald George
  41. 41. @Ron_George (C) Ronald George
  42. 42. @Ron_George Kanczuk et al. Anesth Analg 2017;124 (C) Ronald George
  43. 43. @Ron_George Kanczuk et al. Anesth Analg 2017;124 The optimal time interval between PIEB of 10 mL of bupivacaine 0.0625% with fentanyl 2 μg/mL is approximately 40 minutes 42.6 minutes (95% CI 38.9–46.4) (C) Ronald George
  44. 44. @Ron_George The optimal time interval between PIEB of 10 mL of bupivacaine 0.0625% with fentanyl 2 μg/mL is approximately 40 minutes 42.6 minutes (95% CI 38.9–46.4) Kanczuk et al. Anesth Analg 2017;124 (C) Ronald George
  45. 45. @Ron_George SOAP 2017 Abstract # O-01 10 ml 5 ml 0.0625% 0.125% 40 minutes 35 minutes (C) Ronald George
  46. 46. @Ron_George (C) Ronald George
  47. 47. @Ron_George EV90 = 10.7 (95%CI 10.3–11.0) ml Zakus et al. Anaesthesia 2017 (C) Ronald George
  48. 48. @Ron_George (C) Ronald George
  49. 49. @Ron_George CEI : 10 ml/hour PIEB : 10 ml q1hour (C) Ronald George
  50. 50. @Ron_George (C) Ronald George
  51. 51. @Ron_George Klumpner et al. J Clin Anesth 2016;34 (C) Ronald George
  52. 52. @Ron_George Klumpner et al. J Clin Anesth 2016;34 (C) Ronald George
  53. 53. @Ron_George Anesthesia & Analgesia 2018; PMID 30028347 (C) Ronald George
  54. 54. @Ron_George (C) Ronald George
  55. 55. @Ron_George Anesthesia & Analgesia 2018; PMID 30028347 (C) Ronald George
  56. 56. @Ron_George Anesthesiology 2018; 128(4): 745-753 (C) Ronald George
  57. 57. @Ron_George Anesthesiology 2018; 128(4): 745-753 PIEB : 10 ml q1hour Low —> 100 ml/hour High —> 300 ml/hour (C) Ronald George
  58. 58. @Ron_George A&A 2016; 123: 965-71 (C) Ronald George
  59. 59. @Ron_George A&A 2016; 123: 965-71 Labor Epidural PIEB + PCEA Ropivacaine + fentanyl PIEB Bolus PIEB Interval PCEA Bolus PCEA Lockout NEXT Bolus 8 ml 45 min 6 ml 10 min 15 min (C) Ronald George
  60. 60. @Ron_George © Smiths Medical © Smiths Medical (C) Ronald George
  61. 61. (C) Ronald George
  62. 62. @Ron_George PCEA Lockout P C E A P C E A Denied PCEA Request P I E B P I E B Dosage PIEB Interval 30 min 15 min Clinician Bolus (CSE or Epi) 30 60 90 120 (C) Ronald George
  63. 63. (C) Ronald George
  64. 64. @Ron_George P I E B P I E B Dosage Clinician Bolus (CSE or Epi) 30 60 90 120 “PCEA lockout type” (C) Ronald George
  65. 65. @Ron_George P I E B P I E B Dosage Clinician Bolus (CSE or Epi) 30 60 90 120 P C E A “PCEA lockout type” (C) Ronald George
  66. 66. @Ron_George P I E B P I E B P I E B Dosage PCEA Lockout 15 min Clinician Bolus (CSE or Epi) 30 60 90 120 P C E A P I E B “PCEA lockout type” (C) Ronald George
  67. 67. (C) Ronald George
  68. 68. @Ron_George P I E B P I E B Dosage 30 60 90 120 “Bolus interval type” (C) Ronald George
  69. 69. @Ron_George P I E B P I E B P I E B Dosage PCEA Lockout 30 60 90 120 P C E A P I E B PIEB Interval PIEB dose denied due to the proximity to PCEA bolus PIEB dose delayed for duration of PIEB interval “Bolus interval type” (C) Ronald George
  70. 70. @Ron_George P I E B P I E B P I E B Dosage 30 60 90 120 P C E A PIEB dose denied due to the proximity to PCEA bolus “Bolus interval type” (C) Ronald George
  71. 71. @Ron_George P I E B P I E B P I E B Dosage 30 60 90 120 P C E A PIEB Interval PIEB dose denied due to the proximity to PCEA bolus P C E A “Bolus interval type” (C) Ronald George
  72. 72. @Ron_George P I E B P I E B P I E B Dosage 30 60 90 120 P C E A PIEB dose denied due to the proximity to PCEA bolus P C E A P C E A PCEA use within the PIEB interval will continue to delay the next PIEB bolus “Bolus interval type” (C) Ronald George
  73. 73. @Ron_George Lockout Interval Labor Epidural PIEB + PCEA Ropivacaine + fentanyl PIEB Bolus PIEB Interval PCEA Bolus PCEA Lockout NEXT Bolus ? ml ? min ? ml ? min ? min (C) Ronald George
  74. 74. @Ron_George Lockout Interval (C) Ronald George
  75. 75. @Ron_George Lockout Interval Gabriel et al. BJA 2019; ePub doi:10.1016/j.bja.2019.02.016 (C) Ronald George
  76. 76. @Ron_George Lockout Interval Gabriel et al. BJA 2019; ePub doi:10.1016/j.bja.2019.02.016 (C) Ronald George
  77. 77. @Ron_George P I E B PI E B PI E B PCEA Lockout P C E A PIEB dose denied due to the proximity to PCEA bolus P C E A P C E A PCEA use within the PIEB interval will continue to delay the next PIEB bolus PIEB & PCEA (C) Ronald George
  78. 78. @Ron_George PIEB & PCEA PIEB 5 ml q60min PCEA 5 ml 20 min lockout P I E B P I E B P I E B Dosage PCEA Lockout 30 60 90 120 P C E A P C E A P C E A PIEB Interval Gabriel et al. BJA 2019; ePub doi:10.1016/j.bja.2019.02.016 Wong & Mercier. BJA 2019 doi:10.1016/j.bja.2019.02.008 (C) Ronald George
  79. 79. @Ron_George Rodriguez-Campoo et al. J Clin Monit Comp 2018 PMID 30506299 (C) Ronald George
  80. 80. @Ron_George Rodriguez-Campoo et al. J Clin Monit Comp 2018 PMID 30506299 PIEB group — 2ml/h + 7ml q30min + PCEA CEI — 5ml/h + PCEA Outcome — Total dose (C) Ronald George
  81. 81. @Ron_George P I E B P I E B P I E B P C E A P I E B P C E A STAT C/S Safety Concerns (C) Ronald George
  82. 82. @Ron_George P I E B 30 60 90 120 Clinician Bolus (CSE or Epi) Dosage (C) Ronald George
  83. 83. @Ron_George (C) Ronald George
  84. 84. @Ron_George (C) Ronald George
  85. 85. @Ron_George The Effect of Combined Use of Dural Puncture Epidural and Programmed Intermittent Epidural Bolus for Labor Analgesia SOAP 2019 Abstract GM-03 17 min [16-19 min] 14 min [12-16 min] 14 min [12-16 min] METHODS: EPI + CEI DPE + CEI DPE + PIEB Ropiv/Sufent + PCEA 8ml q1hour or 8ml/h T I M E DPE Bolus 8 ml/hour 8 ml/hour DPE Bolus 8 q1hour (C) Ronald George
  86. 86. @Ron_George P I E B 30 60 90 120 Clinician Bolus (CSE or Epi) P I E B P I E B P I E B Dosage Next Bolus Interval ‘NEXT’ Bolus Study - Munro & George (C) Ronald George
  87. 87. #EA19 @Ron_George PIEB Volume PIEB Interval NEXTInterval (C) Ronald George
  88. 88. #EA19 @Ron_George (C) Ronald George
  89. 89. @Ron_George (C) Ronald George
  90. 90. @Ron_George Sia et al. Anaesthesia (2013) (C) Ronald George
  91. 91. @Ron_George (C) Ronald George
  92. 92. @Ron_George Data / Quality Improvement (C) Ronald George
  93. 93. @Ron_George PIEB > CEI - battery consumption A/C power prevents disposal of thousands of AA batteries/year in each labour suite 4.2 years cost recovery $$$ #ORGreening - @CAS_EnviroSus Dinges et al. IJOA 2018; 33: 100-101 (C) Ronald George
  94. 94. @Ron_George P I E B P I E B P I E B P I E B P I E B P C E A (C) Ronald George
  95. 95. @Ron_George PIEB Interval – 45-60 minutes PIEB volume – 6-10 ml First Bolus – TBD PIEB + PCEA ✅ PCEA Lockout – 10 minutes PIEB/PCEA Interaction ✅ An Evolution of Labour Analgesia (C) Ronald George
  96. 96. @Ron_George Improved satisfaction Less local anesthetic Less anesthesia interventions ??? Less IVD ??? Safety concerns Opportunity - Patient Engagement Opportunity - Personalized analgesia An Evolution of Labour Analgesia (C) Ronald George
  97. 97. (C) Ronald George
  98. 98. @Ron_George (C) Ronald George
  • ShanePelanda

    Jun. 3, 2019
  • carawthomson

    Jun. 2, 2019

An overview of the evidence in support of PIEB and PCEA for labour analgesia. Presented at the 2019 European Society of Anaesthesiology annual meeting in Vienna, Austria #EA19

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