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2019 CSA Fall Anesthesia Conference
The Modern Labor Analgesia
Alphabet: PIEB, CSE & DPE
Ronald B. George, MD FRCPC
Profes...
#IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
๏Describe the current knowledge ...
@Ron_George #CSAHSFall2019
(C) Ronald George, MD FRCPC
@Ron_George #CSAHSFall2019
(C) Ronald George, MD FRCPC
@Ron_George #CSAHSFall2019
Clinician Bolus
(CSE or Epi)
Dosage
(C) Ronald George, MD FRCPC
@Ron_George #CSAHSFall2019
P
C
E
A
P
C
E
A
P
C
E
A
PCEA
Lockout
Clinician Bolus
(CSE or Epi)
Dosage
(C) Ronald George, MD ...
@Ron_George #CSAHSFall2019
(C) Ronald George, MD FRCPC
@Ron_George #CSAHSFall2019
Patients who receive PCEA
bolus analgesia:
Less anesthetic interventions
Higher satisfaction
Le...
@Ron_George #CSAHSFall2019
(C) Ronald George, MD FRCPC
@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...
@Ron_George #CSAHSFall2019
Kaynar et al, Anesth Analg 1999;89
Rusha et al. SOAP 2019 T210-187
Hogan, Reg Anesth Pain Med 2...
@Ron_George #CSAHSFall2019
Kaynar et al, Anesth Analg 1999;89
Rusha et al. SOAP 2019 T210-187
Hogan, Reg Anesth Pain Med 2...
@Ron_George #CSAHSFall2019
Kaynar et al, Anesth Analg 1999;89
Rusha et al. SOAP 2019 T210-187
Hogan, Reg Anesth Pain Med 2...
#IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
(C) Ronald George, MD FRCPC
@Ron_George #CSAHSFall2019
P
I
E
B
Next Bolus
Interval
PIEB
Interval
30 60 90 120
Clinician Bolus
(CSE or Epi)
P
I
E
B
P
I...
#IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
Capogna, Fernando, and van de Ve...
#IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
Wong et al. A&A 2013
PIEB: 6ml q...
@Ron_George #CSAHSFall2019
A&A 2011;113:826-31
(C) Ronald George, MD FRCPC
@Ron_George #CSAHSFall2019
CEI : 10 ml/hour
PIEB : 10 ml q1hour
(C) Ronald George, MD FRCPC
@Ron_George #CSAHSFall2019
IVD: 20% CEI vs 7% PIEB
(p=0.03)
RR 2.9 (95% CI: 1.1–7.9)
(C) Ronald George, MD FRCPC
@Ron_George #CSAHSFall2019
CEI / PIEB : 0.0625% Bupiv
PCEA : 1.25% Bupiv
(C) Ronald George, MD FRCPC
#IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
Capogna et al. Curr Opin Anesthe...
@Ron_George #CSAHSFall2019
(C) Ronald George, MD FRCPC
@Ron_George #CSAHSFall2019
Meta-analysis comparing PIEB and CEI +/- PCEA
for Labor Analgesia
Local anesthetic consumption ...
@Ron_George #CSAHSFall2019
Local Anesthesia consumption (mg/hr)
Maternal Satisfaction
(C) Ronald George, MD FRCPC
@Ron_George #CSAHSFall2019
(C) Ronald George, MD FRCPC
@Ron_George #CSAHSFall2019
Jiqian Xu, et al. Scientific Reports 2019
(C) Ronald George, MD FRCPC
@Ron_George #CSAHSFall2019
(C) Ronald George, MD FRCPC
@Ron_George #CSAHSFall2019
0%
6%
13%
19%
25%
Rescue Bolus Unilateral Block
CEI PIEB
(C) Ronald George, MD FRCPC
@Ron_George #CSAHSFall2019
(C) Ronald George, MD FRCPC
@Ron_George #CSAHSFall2019
(C) Ronald George, MD FRCPC
@Ron_George #CSAHSFall2019
Labor Epidural
PIEB + PCEA
Ropivacaine + fentanyl
PIEB Bolus
PIEB Interval
PCEA Bolus
PCEA Lock...
@Ron_George #CSAHSFall2019
(C) Ronald George, MD FRCPC
@Ron_George #CSAHSFall2019
(C) Ronald George, MD FRCPC
@Ron_George #CSAHSFall2019
0
4
8
12
2.5/15 5/30 10/60
Bupiv mg/h
(C) Ronald George, MD FRCPC
@Ron_George #CSAHSFall2019
PIEB Volume - 10ml
PIEB Interval - 60min
0
4
8
12
2.5/15 5/30 10/60
Bupiv mg/h
(C) Ronald Georg...
@Ron_George #CSAHSFall2019
(C) Ronald George, MD FRCPC
@Ron_George #CSAHSFall2019
The optimal time interval between PIEB
of 10 mL of bupivacaine 0.0625% with
fentanyl 2 µg/mL is...
@Ron_George #CSAHSFall2019
10 ml
5 ml
0.0625%
0.125%
40 minutes
35 minutes
(C) Ronald George, MD FRCPC
#IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
(C) Ronald George, MD FRCPC
#IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
EV90 = 10.7 (95%CI 10.3–11.0) ml...
@Ron_George #CSAHSFall2019
CEI : 10 ml/hour
PIEB : 10 ml q1hour
(C) Ronald George, MD FRCPC
@Ron_George #CSAHSFall2019
Capogna, Fernando, and van de Velde. Eur School of OB Anesthesia 2016
(C) Ronald George, MD FRC...
@Ron_George #CSAHSFall2019
Klumpner et al. J Clin Anesth 2016;34
Anesthesia & Analgesia 2018; PMID 30028347
(C) Ronald Geo...
@Ron_George #CSAHSFall2019
Epidural flow rate
Detected pressures
⁇ Anesthetic spread
(C) Ronald George, MD FRCPC
@Ron_George #CSAHSFall2019
Anesthesiology 2018; 128(4): 745-753
PIEB : 10 ml q1hour
Low —> 100 ml/hour
High —> 300 ml/hour...
@Ron_George #CSAHSFall2019
A&A 2016; 123: 965-71
(C) Ronald George, MD FRCPC
@Ron_George #CSAHSFall2019
A&A 2016; 123: 965-71
PIEB + PCEA
Ropivacaine + fentanyl
PIEB Bolus
PIEB Interval
PCEA Bolus
PC...
@Ron_George #CSAHSFall2019
© Smiths Medical
© Smiths Medical
(C) Ronald George, MD FRCPC
(C) Ronald George, MD FRCPC
@Ron_George #CSAHSFall2019
P
I
E
B
Dosage
PIEB
Interval
30 min
Clinician Bolus
(CSE or Epi)
30 60 90 120
(C) Ronald George...
@Ron_George #CSAHSFall2019
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
...
(C) Ronald George, MD FRCPC
@Ron_George #CSAHSFall2019
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) Ronald George, MD FRCPC
@Ron_George #CSAHSFall2019
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 dos...
@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 PC...
@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 PC...
@Ron_George #CSAHSFall2019
Lockout Interval
Labor Epidural
PIEB + PCEA
PIEB Bolus
PIEB Interval
PCEA Bolus
PCEA Lockout
? ...
@Ron_George #CSAHSFall2019
Lockout Interval
(C) Ronald George, MD FRCPC
@Ron_George #CSAHSFall2019
Lockout Interval
(C) Ronald George, MD FRCPC
@Ron_George #CSAHSFall2019
Lockout Interval
(C) Ronald George, MD FRCPC
@Ron_George #CSAHSFall2019
P
I
E
B
P
I
E
B
P
I
E
B
PCEA Lockout
P
C
E
A
PIEB dose denied due to
the proximity to PCEA
bolu...
@Ron_George #CSAHSFall2019
(C) Ronald George, MD FRCPC
#IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
P
I
E
B
30 60 90 120
Clinician B...
@Ron_George #CSAHSFall2019
(C) Ronald George, MD FRCPC
@Ron_George #CSAHSFall2019
(C) Ronald George, MD FRCPC
#IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
(C) Ronald George, MD FRCPC
@Ron_George #CSAHSFall2019
(C) Ronald George, MD FRCPC
#IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
(C) Ronald George, MD FRCPC
#IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
Anesth Analg 2017;124:560–9
(C) ...
#IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
(C) Ronald George, MD FRCPC
#IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
(C) Ronald George, MD FRCPC
#IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
(C) Ronald George, MD FRCPC
#IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
(C) Ronald George, MD FRCPC
#IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
(C) Ronald George, MD FRCPC
#IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
(C) Ronald George, MD FRCPC
#IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
(C) Ronald George, MD FRCPC
#IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
(C) Ronald George, MD FRCPC
#IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
(C) Ronald George, MD FRCPC
#IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
(C) Ronald George, MD FRCPC
CSE DPE Epi
Onset
Catheter Testing /
Catheter Replacement
Block Symmetry
Failed block
Pruritus
Motor Block
Fetal Bradycard...
(C) Ronald George, MD FRCPC
@Ron_George #CSAHSFall2019
(C) Ronald George, MD FRCPC
#IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
(C) Ronald George, MD FRCPC
@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...
@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...
@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...
@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...
@Ron_George#OBAnesRussia
The Effect of Combined Use of Dural Puncture Epidural
and Programmed Intermittent Epidural Bolus ...
@Ron_George #CSAHSFall2019Sia et al. Anaesthesia (2013)
(C) Ronald George, MD FRCPC
@Ron_George #CSAHSFall2019
(C) Ronald George, MD FRCPC
#IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
Data / Quality
Improvement
(C) R...
#IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
Data / Quality
Improvement
(C) R...
#IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
๏PIEB > CEI - battery consumptio...
#IARS2019
2019 CSA FALL ANESTHESIA CONFERENCE
Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019
๏Improved satisfaction
๏Less loc...
(C) Ronald George, MD FRCPC
Questions?
ronald.george@ucsf.edu
@Ron_George
(C) Ronald George, MD FRCPC
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Update labor analgesia - PIEB, CSE, DPE

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Update labor analgesia - PIEB, CSE, DPE

  1. 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. 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
  3. 3. @Ron_George #CSAHSFall2019 (C) Ronald George, MD FRCPC
  4. 4. @Ron_George #CSAHSFall2019 (C) Ronald George, MD FRCPC
  5. 5. @Ron_George #CSAHSFall2019 Clinician Bolus (CSE or Epi) Dosage (C) Ronald George, MD FRCPC
  6. 6. @Ron_George #CSAHSFall2019 P C E A P C E A P C E A PCEA Lockout Clinician Bolus (CSE or Epi) Dosage (C) Ronald George, MD FRCPC
  7. 7. @Ron_George #CSAHSFall2019 (C) Ronald George, MD FRCPC
  8. 8. @Ron_George #CSAHSFall2019 Patients who receive PCEA bolus analgesia: Less anesthetic interventions Higher satisfaction Less motor block (C) Ronald George, MD FRCPC
  9. 9. @Ron_George #CSAHSFall2019 (C) Ronald George, MD FRCPC
  10. 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. 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. 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. 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. 14. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 (C) Ronald George, MD FRCPC
  15. 15. @Ron_George #CSAHSFall2019 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, MD FRCPC
  16. 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. 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
  18. 18. @Ron_George #CSAHSFall2019 A&A 2011;113:826-31 (C) Ronald George, MD FRCPC
  19. 19. @Ron_George #CSAHSFall2019 CEI : 10 ml/hour PIEB : 10 ml q1hour (C) Ronald George, MD FRCPC
  20. 20. @Ron_George #CSAHSFall2019 IVD: 20% CEI vs 7% PIEB (p=0.03) RR 2.9 (95% CI: 1.1–7.9) (C) Ronald George, MD FRCPC
  21. 21. @Ron_George #CSAHSFall2019 CEI / PIEB : 0.0625% Bupiv PCEA : 1.25% Bupiv (C) Ronald George, MD FRCPC
  22. 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
  23. 23. @Ron_George #CSAHSFall2019 (C) Ronald George, MD FRCPC
  24. 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
  25. 25. @Ron_George #CSAHSFall2019 Local Anesthesia consumption (mg/hr) Maternal Satisfaction (C) Ronald George, MD FRCPC
  26. 26. @Ron_George #CSAHSFall2019 (C) Ronald George, MD FRCPC
  27. 27. @Ron_George #CSAHSFall2019 Jiqian Xu, et al. Scientific Reports 2019 (C) Ronald George, MD FRCPC
  28. 28. @Ron_George #CSAHSFall2019 (C) Ronald George, MD FRCPC
  29. 29. @Ron_George #CSAHSFall2019 0% 6% 13% 19% 25% Rescue Bolus Unilateral Block CEI PIEB (C) Ronald George, MD FRCPC
  30. 30. @Ron_George #CSAHSFall2019 (C) Ronald George, MD FRCPC
  31. 31. @Ron_George #CSAHSFall2019 (C) Ronald George, MD FRCPC
  32. 32. @Ron_George #CSAHSFall2019 Labor Epidural PIEB + PCEA Ropivacaine + fentanyl PIEB Bolus PIEB Interval PCEA Bolus PCEA Lockout NEXT Bolus ? ml ? min ? ml ? min ? min (C) Ronald George, MD FRCPC
  33. 33. @Ron_George #CSAHSFall2019 (C) Ronald George, MD FRCPC
  34. 34. @Ron_George #CSAHSFall2019 (C) Ronald George, MD FRCPC
  35. 35. @Ron_George #CSAHSFall2019 0 4 8 12 2.5/15 5/30 10/60 Bupiv mg/h (C) Ronald George, MD FRCPC
  36. 36. @Ron_George #CSAHSFall2019 PIEB Volume - 10ml PIEB Interval - 60min 0 4 8 12 2.5/15 5/30 10/60 Bupiv mg/h (C) Ronald George, MD FRCPC
  37. 37. @Ron_George #CSAHSFall2019 (C) Ronald George, MD FRCPC
  38. 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
  39. 39. @Ron_George #CSAHSFall2019 10 ml 5 ml 0.0625% 0.125% 40 minutes 35 minutes (C) Ronald George, MD FRCPC
  40. 40. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 (C) Ronald George, MD FRCPC
  41. 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
  42. 42. @Ron_George #CSAHSFall2019 CEI : 10 ml/hour PIEB : 10 ml q1hour (C) Ronald George, MD FRCPC
  43. 43. @Ron_George #CSAHSFall2019 Capogna, Fernando, and van de Velde. Eur School of OB Anesthesia 2016 (C) Ronald George, MD FRCPC
  44. 44. @Ron_George #CSAHSFall2019 Klumpner et al. J Clin Anesth 2016;34 Anesthesia & Analgesia 2018; PMID 30028347 (C) Ronald George, MD FRCPC
  45. 45. @Ron_George #CSAHSFall2019 Epidural flow rate Detected pressures ⁇ Anesthetic spread (C) Ronald George, MD FRCPC
  46. 46. @Ron_George #CSAHSFall2019 Anesthesiology 2018; 128(4): 745-753 PIEB : 10 ml q1hour Low —> 100 ml/hour High —> 300 ml/hour (C) Ronald George, MD FRCPC
  47. 47. @Ron_George #CSAHSFall2019 A&A 2016; 123: 965-71 (C) Ronald George, MD FRCPC
  48. 48. @Ron_George #CSAHSFall2019 A&A 2016; 123: 965-71 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, MD FRCPC
  49. 49. @Ron_George #CSAHSFall2019 © Smiths Medical © Smiths Medical (C) Ronald George, MD FRCPC
  50. 50. (C) Ronald George, MD FRCPC
  51. 51. @Ron_George #CSAHSFall2019 P I E B Dosage PIEB Interval 30 min Clinician Bolus (CSE or Epi) 30 60 90 120 (C) Ronald George, MD FRCPC
  52. 52. @Ron_George #CSAHSFall2019 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 George, MD FRCPC
  53. 53. (C) Ronald George, MD FRCPC
  54. 54. @Ron_George #CSAHSFall2019 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, MD FRCPC
  55. 55. (C) Ronald George, MD FRCPC
  56. 56. @Ron_George #CSAHSFall2019 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, MD FRCPC
  57. 57. @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 “Bolus interval type” (C) Ronald George, MD FRCPC
  58. 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
  59. 59. @Ron_George #CSAHSFall2019 Lockout Interval Labor Epidural PIEB + PCEA PIEB Bolus PIEB Interval PCEA Bolus PCEA Lockout ? ml ? min ? ml ? min (C) Ronald George, MD FRCPC
  60. 60. @Ron_George #CSAHSFall2019 Lockout Interval (C) Ronald George, MD FRCPC
  61. 61. @Ron_George #CSAHSFall2019 Lockout Interval (C) Ronald George, MD FRCPC
  62. 62. @Ron_George #CSAHSFall2019 Lockout Interval (C) Ronald George, MD FRCPC
  63. 63. @Ron_George #CSAHSFall2019 P I E B P I E B P I 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 “Bolus interval type” (C) Ronald George, MD FRCPC
  64. 64. @Ron_George #CSAHSFall2019 (C) Ronald George, MD FRCPC
  65. 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
  66. 66. @Ron_George #CSAHSFall2019 (C) Ronald George, MD FRCPC
  67. 67. @Ron_George #CSAHSFall2019 (C) Ronald George, MD FRCPC
  68. 68. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 (C) Ronald George, MD FRCPC
  69. 69. @Ron_George #CSAHSFall2019 (C) Ronald George, MD FRCPC
  70. 70. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 (C) Ronald George, MD FRCPC
  71. 71. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 Anesth Analg 2017;124:560–9 (C) Ronald George, MD FRCPC
  72. 72. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 (C) Ronald George, MD FRCPC
  73. 73. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 (C) Ronald George, MD FRCPC
  74. 74. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 (C) Ronald George, MD FRCPC
  75. 75. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 (C) Ronald George, MD FRCPC
  76. 76. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 (C) Ronald George, MD FRCPC
  77. 77. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 (C) Ronald George, MD FRCPC
  78. 78. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 (C) Ronald George, MD FRCPC
  79. 79. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 (C) Ronald George, MD FRCPC
  80. 80. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 (C) Ronald George, MD FRCPC
  81. 81. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 (C) Ronald George, MD FRCPC
  82. 82. CSE DPE Epi Onset Catheter Testing / Catheter Replacement Block Symmetry Failed block Pruritus Motor Block Fetal Bradycardia Cesarean CSE DPE Epi Rapid Intermediate Slow Delayed / Low Immediate / Low Immediate / Higher ✅ ✅ ❌ ✅ ✅ ❌ ❌ ✅ ✅ ✅ ✅ ❌ ❌ ✅ ✅ ✅ ✅ ✅ (C) Ronald George, MD FRCPC
  83. 83. (C) Ronald George, MD FRCPC
  84. 84. @Ron_George #CSAHSFall2019 (C) Ronald George, MD FRCPC
  85. 85. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 (C) Ronald George, MD FRCPC
  86. 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
  87. 87. @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% (C) Ronald George, MD FRCPC
  88. 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. 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. 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
  91. 91. @Ron_George #CSAHSFall2019Sia et al. Anaesthesia (2013) (C) Ronald George, MD FRCPC
  92. 92. @Ron_George #CSAHSFall2019 (C) Ronald George, MD FRCPC
  93. 93. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 Data / Quality Improvement (C) Ronald George, MD FRCPC
  94. 94. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 Data / Quality Improvement (C) Ronald George, MD FRCPC
  95. 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. 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
  97. 97. (C) Ronald George, MD FRCPC
  98. 98. Questions? ronald.george@ucsf.edu @Ron_George (C) Ronald George, MD FRCPC
  • serabitanabe

    Dec. 3, 2019

Updates on PIEB, CSE and DPE for labour analgesia

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