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Update labor analgesia - PIEB, CSE, DPE
1. 2019 CSA Fall Anesthesia Conference
The Modern Labor Analgesia
Alphabet: PIEB, CSE & DPE
Ronald B. George, MD FRCPC
Professor, Anesthesia & Perioperative Care
Chief, Obstetric Anesthesia
Betty Irene Moore Women’s Hospital at Mission Bay
University of California San Francisco(C) Ronald George, MD FRCPC
2. #IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
๏Describe the current knowledge regarding PIEB impact on
analgesia & obstetrical outcomes
๏Describe implementation strategies for PIEB to optimize effective
and safe utilization on your labour units
๏Describe alternate routes of epidural initiation
๏Discuss future considerations for DPE, CSE, & PIEB in labour
analgesia
Learning Objectives
(C) Ronald George, MD FRCPC
8. @Ron_George #CSAHSFall2019
Patients who receive PCEA
bolus analgesia:
Less anesthetic interventions
Higher satisfaction
Less motor block
(C) Ronald George, MD FRCPC
10. @Ron_George #CSAHSFall2019
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, MD FRCPC
11. @Ron_George #CSAHSFall2019
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, MD FRCPC
12. @Ron_George #CSAHSFall2019
Kaynar et al, Anesth Analg 1999;89
Rusha et al. SOAP 2019 T210-187
Hogan, Reg Anesth Pain Med 2002;27
(C) Ronald George, MD FRCPC
13. @Ron_George #CSAHSFall2019
Kaynar et al, Anesth Analg 1999;89
Rusha et al. SOAP 2019 T210-187
Hogan, Reg Anesth Pain Med 2002;27
(C) Ronald George, MD FRCPC
14. #IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
(C) Ronald George, MD FRCPC
16. #IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
Capogna, Fernando, and van de Velde. Eur School of OB Anesthesia 2016
(C) Ronald George, MD FRCPC
17. #IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
Wong et al. A&A 2013
PIEB: 6ml q30min
CEI: 12ml per hour
(C) Ronald George, MD FRCPC
22. #IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
Capogna et al. Curr Opin Anesthesiol 2013, 26:261–267 Capogna, Fernando, and van de Velde. Eur School of OB Anesthesia 2016
(C) Ronald George, MD FRCPC
24. @Ron_George #CSAHSFall2019
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, MD FRCPC
38. @Ron_George #CSAHSFall2019
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, MD FRCPC
40. #IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
(C) Ronald George, MD FRCPC
41. #IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
EV90 = 10.7 (95%CI 10.3–11.0) ml
Zakus et al. Anaesthesia 2017
(C) Ronald George, MD FRCPC
58. @Ron_George #CSAHSFall2019
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, MD FRCPC
65. #IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
P
I
E
B
30 60 90 120
Clinician Bolus
(CSE or Epi)
Dosage
(C) Ronald George, MD FRCPC
85. #IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
(C) Ronald George, MD FRCPC
86. @Ron_George #CSAHSFall2019
P
I
E
B
P
I
E
B
Dosage
30 60 90 120
P
I
E
B
P
C
E
A
P
C
E
A
P
C
E
A
Clinician Bolus
(CSE or Epi)
Dosage P
C
E
A
Standard Group
CEI = 5 ml/hr
PCEA = 10 ml
Lockout = 20 min
PIEB Group
CEI = 5 ml/hr
PCEA = 10 ml
Lockout = 20 min
PIEB = 10 ml
PIEBi = 60 min
(C) Ronald George, MD FRCPC
88. @Ron_George #CSAHSFall2019
P
I
E
B
P
I
E
B
Dosage
30 60 90 120
P
I
E
B
P
C
E
A
P
C
E
A
P
C
E
A
Clinician Bolus
(CSE or Epi)
Dosage P
C
E
A
Clinician Bolus
Standard
89%
P < 0.001
PIEB/CEI
30%
Sensory > T10
Standard
0
P = 0.057
PIEB/CEI
7.5%
(C) Ronald George, MD FRCPC
89. @Ron_George #CSAHSFall2019
P
I
E
B
P
I
E
B
Dosage
30 60 90 120
P
I
E
B
P
C
E
A
P
C
E
A
P
C
E
A
Clinician Bolus
(CSE or Epi)
Dosage P
C
E
A
Clinician Bolus
Standard
89%
P < 0.001
PIEB/CEI
30%
Sensory > T10
Standard
0
P = 0.057
PIEB/CEI
7.5%
Bromage < 4
Standard
0
P = 0.495
PIEB/CEI
2%
(C) Ronald George, MD FRCPC
90. @Ron_George#OBAnesRussia
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, MD FRCPC
93. #IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
Data / Quality
Improvement
(C) Ronald George, MD FRCPC
94. #IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
Data / Quality
Improvement
(C) Ronald George, MD FRCPC
95. #IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
๏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
(C) Ronald George, MD FRCPC
96. #IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
๏Improved satisfaction
๏Less local anesthetic
๏Less anesthesia interventions
๏??? Less IVD
๏??? Safety concerns
Programmed Intermittent Epidural Bolus
for labour analgesia - is this the future?
(C) Ronald George, MD FRCPC