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PIEB ASRA Meeting Spring 2019

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Slides from #ASRASpring19 in Las Vegas - April 13, 2019

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PIEB ASRA Meeting Spring 2019

  1. 1. (c) Ronald B. George, MD FRCPC
  2. 2. An Evolution of Labour Analgesia Programmed Intermittent Bolus versus Continuous Infusion for Obstetric Epidurals (c) Ronald B. George, MD FRCPC
  3. 3. ๏ 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 Learning Objectives (c) Ronald B. George, MD FRCPC
  4. 4. #ASRASpring19@Ron_George No Financial Disclosures(c) Ronald B. George, MD FRCPC
  5. 5. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
  6. 6. #ASRASpring19@Ron_George Clinician Bolus (CSE or Epi) Dosage (c) Ronald B. George, MD FRCPC
  7. 7. #ASRASpring19@Ron_George P C E A P C E A P C E A PCEA Lockout Clinician Bolus (CSE or Epi) Dosage (c) Ronald B. George, MD FRCPC
  8. 8. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
  9. 9. #ASRASpring19@Ron_George Patients who receive PCEA bolus analgesia were less likely to require anesthetic interventions (c) Ronald B. George, MD FRCPC
  10. 10. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
  11. 11. #ASRASpring19@Ron_George LC was associated with a reduction in the incidence of IVD (OR = 0.70; 95%CI 0.56 to 0.86) (c) Ronald B. George, MD FRCPC
  12. 12. #ASRASpring19@Ron_George Kaynar et al, Anesth Analg 1999;89 10.5 ml/hour 3.5 ml bolus (c) Ronald B. George, MD FRCPC
  13. 13. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
  14. 14. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
  15. 15. #ASRASpring19@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 B. George, MD FRCPC
  16. 16. #ASRASpring19@Ron_George Capogna, Fernando, and van de Velde. Eur School of OB Anesthesia 2016 (c) Ronald B. George, MD FRCPC
  17. 17. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
  18. 18. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
  19. 19. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
  20. 20. #ASRASpring19@Ron_George A&A 2011;113:826-31 (c) Ronald B. George, MD FRCPC
  21. 21. #ASRASpring19@Ron_George A&A 2011;113:826-31 (c) Ronald B. George, MD FRCPC
  22. 22. #ASRASpring19@Ron_George A&A 2011;113:826-31 IVD: 20% CEI vs 7% PIEB (p=0.03) RR 2.9 (95% CI: 1.1–7.9) (c) Ronald B. George, MD FRCPC
  23. 23. #ASRASpring19@Ron_George A&A 2011;113:826-31 (c) Ronald B. George, MD FRCPC
  24. 24. #ASRASpring19@Ron_George Capogna et al. Curr Opin Anesthesiol 2013, 26:261–267 Capogna, Fernando, and van de Velde. Eur School of OB Anesthesia 2016 (c) Ronald B. George, MD FRCPC
  25. 25. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
  26. 26. #ASRASpring19@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 B. George, MD FRCPC
  27. 27. #ASRASpring19@Ron_George Local Anesthesia consumption (mg/hr) (c) Ronald B. George, MD FRCPC
  28. 28. #ASRASpring19@Ron_George Local Anesthesia consumption (mg/hr) Maternal Satisfaction (c) Ronald B. George, MD FRCPC
  29. 29. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
  30. 30. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
  31. 31. #ASRASpring19@Ron_George ??? NEXT dose PCEA dose PCEA lock-out PIEB dose PIEB interval (c) Ronald B. George, MD FRCPC
  32. 32. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
  33. 33. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
  34. 34. #ASRASpring19@Ron_George PIEB Volume - 10ml PIEB Interval - 60min (c) Ronald B. George, MD FRCPC
  35. 35. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
  36. 36. #ASRASpring19@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. Anesthesia & Analgesia 2017;124:537-41 (c) Ronald B. George, MD FRCPC
  37. 37. #ASRASpring19@Ron_George SOAP 2017 Abstract # O-01 10 ml 5 ml 0.0625% 0.125% 40 minutes 35 minutes (c) Ronald B. George, MD FRCPC
  38. 38. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
  39. 39. #ASRASpring19@Ron_George EV90 = 10.7 (95%CI 10.3–11.0) ml (c) Ronald B. George, MD FRCPC
  40. 40. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
  41. 41. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
  42. 42. #ASRASpring19@Ron_George Capogna, Fernando, and van de Velde. Eur School of OB Anesthesia 2016 (c) Ronald B. George, MD FRCPC
  43. 43. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
  44. 44. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
  45. 45. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
  46. 46. #ASRASpring19@Ron_George Anesthesia & Analgesia 2018; PMID 30028347 (c) Ronald B. George, MD FRCPC
  47. 47. #ASRASpring19@Ron_George Anesthesia & Analgesia 2018; PMID 30028347 (c) Ronald B. George, MD FRCPC
  48. 48. #ASRASpring19@Ron_George Anesthesiology 2018; 128(4): 745-753 (c) Ronald B. George, MD FRCPC
  49. 49. #ASRASpring19@Ron_George Anesthesiology 2018; 128(4): 745-753 (c) Ronald B. George, MD FRCPC
  50. 50. #ASRASpring19@Ron_George A&A 2016; 123: 965-71 (c) Ronald B. George, MD FRCPC
  51. 51. #ASRASpring19@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 B. George, MD FRCPC
  52. 52. #ASRASpring19@Ron_George © Smiths Medical © Smiths Medical (c) Ronald B. George, MD FRCPC
  53. 53. (c) Ronald B. George, MD FRCPC
  54. 54. #ASRASpring19@Ron_George P I E B Dosage PIEB Interval 30 min Clinician Bolus (CSE or Epi) 30 60 90 120 (c) Ronald B. George, MD FRCPC
  55. 55. #ASRASpring19@Ron_George P C E A P C E A Denied PCEA Request P I E B P I E B Dosage PCEA Lockout 15 min Clinician Bolus (CSE or Epi) 30 60 90 120 (c) Ronald B. George, MD FRCPC
  56. 56. (c) Ronald B. George, MD FRCPC
  57. 57. (c) Ronald B. George, MD FRCPC
  58. 58. #ASRASpring19@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 B. George, MD FRCPC
  59. 59. #ASRASpring19@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 B. George, MD FRCPC
  60. 60. (c) Ronald B. George, MD FRCPC
  61. 61. (c) Ronald B. George, MD FRCPC
  62. 62. #ASRASpring19@Ron_George P I E B P I E B Dosage 30 60 90 120 “Bolus interval type” (c) Ronald B. George, MD FRCPC
  63. 63. #ASRASpring19@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 B. George, MD FRCPC
  64. 64. #ASRASpring19@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 B. George, MD FRCPC
  65. 65. #ASRASpring19@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 B. George, MD FRCPC
  66. 66. #ASRASpring19@Ron_George • Shrink the change • Tweak the environment • Build habits • Script critical points (c) Ronald B. George, MD FRCPC
  67. 67. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
  68. 68. #ASRASpring19@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 Restroom Bromage 4 Safety Concerns(c) Ronald B. George, MD FRCPC
  69. 69. #ASRASpring19@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 B. George, MD FRCPC
  70. 70. #ASRASpring19@Ron_George P I E B 30 60 90 120 Clinician Bolus (CSE or Epi) Dosage (c) Ronald B. George, MD FRCPC
  71. 71. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
  72. 72. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
  73. 73. #ASRASpring19@Ron_George OPTIMAL (c) Ronald B. George, MD FRCPC
  74. 74. #ASRASpring19@Ron_George PIEB Volume PIEB Interval NEXTInterval (c) Ronald B. George, MD FRCPC
  75. 75. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
  76. 76. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
  77. 77. #ASRASpring19@Ron_George Sia et al. Anaesthesia (2013) (c) Ronald B. George, MD FRCPC
  78. 78. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
  79. 79. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
  80. 80. #ASRASpring19@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 B. George, MD FRCPC
  81. 81. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
  82. 82. #ASRASpring19@Ron_George •Improved satisfaction •Less local anesthetic •? Less anesthesia interventions •??? Less IVD •??? Safety concerns •??? Patient Engagement •??? Personalized labour analgesia (c) Ronald B. George, MD FRCPC
  83. 83. (c) Ronald B. George, MD FRCPC
  • GraceLim34

    Apr. 13, 2019

Slides from #ASRASpring19 in Las Vegas - April 13, 2019

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