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PIEB Labour Analgesia

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Labour analgesia grand rounds at University of Manitoba

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PIEB Labour Analgesia

  1. 1. The Evolution of Labour Analgesia
  2. 2. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR Learning Objectives 1. Describe the current knowledge regarding PIEB impact on analgesia & obstetrical outcomes 2. Demonstrate the limitations in evidence for PIEB for labour analgesia 3. Describe implementation strategies for PIEB to optimize effective and safe utilization on your labour units 4. Discuss future considerations for PIEB and labour analgesia
  3. 3. #AnesGR@Ron_George
  4. 4. #AnesGR@Ron_George
  5. 5. #PIEB#ANES17 @Ron_George@Ron_George #AnesGR Clinician Bolus (CSE or Epi) Dosage Call the Anesthesiologist
  6. 6. #AnesGR@Ron_George Dosage Clinician Bolus (CSE or Epi)
  7. 7. #PIEB#ANES17 @Ron_George@Ron_George #AnesGR Dosage P C E A P C E A P C E A PCEA Lockout Clinician Bolus (CSE or Epi)
  8. 8. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR
  9. 9. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR Patients who receive PCEA bolus analgesia were less likely to require anaesthetic interventions
  10. 10. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR
  11. 11. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR LC was associated with a reduction in the incidence of IVD (OR = 0.70; 95%CI 0.56 to 0.86)
  12. 12. #AnesGR@Ron_George Kaynar et al, Anesth Analg 1999;89 10.5 ml/hour 3.5 ml bolus
  13. 13. #AnesGR@Ron_George
  14. 14. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR
  15. 15. #PIEB#ANES17 @Ron_George@Ron_George #AnesGR 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
  16. 16. #AnesGR@Ron_George Capogna, Fernando, and van de Velde. Eur School of OB Anesthesia 2016
  17. 17. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR
  18. 18. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR
  19. 19. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR
  20. 20. #AnesGR@Ron_George
  21. 21. #AnesGR@Ron_George
  22. 22. #AnesGR@Ron_George IVD: 20% CEI vs 7% PIEB (p=0.03) RR 2.9 (95% CI: 1.1–7.9)
  23. 23. #AnesGR@Ron_George
  24. 24. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR Capogna et al. Curr Opin Anesthesiol 2013, 26:261–267
  25. 25. #AnesGR@Ron_George
  26. 26. #AnesGR@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
  27. 27. #AnesGR@Ron_George Local Anesthesia consumption (mg/hr)
  28. 28. #AnesGR@Ron_George Local Anesthesia consumption (mg/hr) Maternal Satisfaction
  29. 29. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR
  30. 30. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR
  31. 31. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR
  32. 32. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR
  33. 33. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR PIEB Volume - 10ml PIEB Interval - 60min
  34. 34. #AnesGR@Ron_George
  35. 35. #AnesGR@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)
  36. 36. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR SOAP 2017 Abstract # O-01 10 ml 5 ml 0.0625% 0.125% 40 minutes 35 minutes
  37. 37. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR
  38. 38. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR A&A 2016; 123: 965-71
  39. 39. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR 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
  40. 40. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR
  41. 41. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR
  42. 42. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR
  43. 43. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR
  44. 44. #PIEB#ANES17 @Ron_George@Ron_George #AnesGR P I E B P I E B Dosage Clinician Bolus (CSE or Epi) 30 60 90 120 “PCEA lockout type”
  45. 45. #PIEB#ANES17 @Ron_George@Ron_George #AnesGR 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”
  46. 46. #PIEB#ANES17 @Ron_George@Ron_George #AnesGR P I E B P I E B Dosage 30 60 90 120 “Bolus interval type”
  47. 47. #PIEB#ANES17 @Ron_George@Ron_George #AnesGR 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”
  48. 48. #PIEB#ANES17 @Ron_George@Ron_George #AnesGR 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”
  49. 49. #PIEB#ANES17 @Ron_George@Ron_George #AnesGR 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”
  50. 50. #PIEB#ANES17 @Ron_George@Ron_George #AnesGR
  51. 51. #PIEB#ANES17 @Ron_George@Ron_George #AnesGR 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
  52. 52. #PIEB#ANES17 @Ron_George@Ron_George #AnesGR P I E B P I E B P I E B P C E A Safety Concerns P I E B P C E A STAT C/S
  53. 53. #PIEB#ANES17 @Ron_George@Ron_George #AnesGR 30 60 90 120 Clinician Bolus (CSE or Epi) Dosage
  54. 54. #PIEB#ANES17 @Ron_George@Ron_George #AnesGR P I E B 30 60 90 120 Clinician Bolus (CSE or Epi) Dosage
  55. 55. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR
  56. 56. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR
  57. 57. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR
  58. 58. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR
  59. 59. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR • Shrink the change • Tweak the environment • Build habits • Script critical points
  60. 60. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR
  61. 61. #PIEB#ANES17 @Ron_George@Ron_George #AnesGR
  62. 62. #AnesGR@Ron_George PIEB Volume PIEB Interval PCEAVolume
  63. 63. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR
  64. 64. #AnesGR@Ron_George
  65. 65. #AnesGR@Ron_George Sia et al. Anaesthesia (2013)
  66. 66. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR
  67. 67. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR
  68. 68. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR P I E B P I E B P I E B P I E B P I E B P C E A
  69. 69. •Improved maternal satisfaction •Less local anesthetic •? Less anesthesia interventions •?? Less IVD •??? Safety concerns •??? Patient Engagement •??? Personalized labour analgesia
  70. 70. Internet Where people write on walls and worship cats
  • AlejandroJankelevich

    Jul. 3, 2019
  • ShanePelanda

    Jun. 3, 2019

Labour analgesia grand rounds at University of Manitoba

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