Update labor analgesia - PIEB, CSE, DPE

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

#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

@Ron_George #CSAHSFall2019

Clinician Bolus
(CSE or Epi)
Dosage

P
C
E
A
P
C
E
A
P
C
E
A
PCEA
Lockout
Clinician Bolus
(CSE or Epi)
Dosage

Patients who receive PCEA
bolus analgesia:
Less anesthetic interventions
Higher satisfaction
Less motor block

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

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

Kaynar et al, Anesth Analg 1999;89
Rusha et al. SOAP 2019 T210-187
Hogan, Reg Anesth Pain Med 2002;27

#IARS2019

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

#IARS2019
Capogna, Fernando, and van de Velde. Eur School of OB Anesthesia 2016

#IARS2019
Wong et al. A&A 2013
PIEB: 6ml q30min
CEI: 12ml per hour

A&A 2011;113:826-31

CEI : 10 ml/hour
PIEB : 10 ml q1hour

IVD: 20% CEI vs 7% PIEB
(p=0.03)
RR 2.9 (95% CI: 1.1–7.9)

CEI / PIEB : 0.0625% Bupiv
PCEA : 1.25% Bupiv

#IARS2019
Capogna et al. Curr Opin Anesthesiol 2013, 26:261–267 Capogna, Fernando, and van de Velde. Eur School of OB Anesthesia 2016

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

Local Anesthesia consumption (mg/hr)
Maternal Satisfaction

Jiqian Xu, et al. Scientific Reports 2019

0%
6%
13%
19%
25%
Rescue Bolus Unilateral Block
CEI PIEB

Labor Epidural
PIEB + PCEA
Ropivacaine + fentanyl
PIEB Bolus
PIEB Interval
PCEA Bolus
PCEA Lockout
NEXT Bolus
? ml
? min
? ml
? min
? min

0
4
8
12
2.5/15 5/30 10/60
Bupiv mg/h

PIEB Volume - 10ml
PIEB Interval - 60min
0
4
8
12
2.5/15 5/30 10/60
Bupiv mg/h

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

10 ml
5 ml
0.0625%
0.125%
40 minutes
35 minutes

#IARS2019
EV90 = 10.7 (95%CI 10.3–11.0) ml
Zakus et al. Anaesthesia 2017

Capogna, Fernando, and van de Velde. Eur School of OB Anesthesia 2016

Klumpner et al. J Clin Anesth 2016;34
Anesthesia & Analgesia 2018; PMID 30028347

Epidural flow rate
Detected pressures
⁇ Anesthetic spread

Anesthesiology 2018; 128(4): 745-753
PIEB : 10 ml q1hour
Low —> 100 ml/hour
High —> 300 ml/hour

A&A 2016; 123: 965-71

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

P
I
E
B
Dosage
PIEB
Interval
30 min
Clinician Bolus
(CSE or Epi)
30 60 90 120

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

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”

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”

P
I
E
B
P
I
E
B
P
I
E
B
Dosage
30 60 90 120
P
C
E
A
bolus

P
I
E
B
P
I
E
B
P
I
E
B
Dosage
30 60 90 120
P
C
E
A
bolus
P
C
E
A
P
C
E
A
PCEA use within
the PIEB interval
will continue to
delay the next PIEB
bolus

Lockout Interval
Labor Epidural
PIEB + PCEA
PIEB Bolus
PIEB Interval
PCEA Bolus
PCEA Lockout
? ml
? min
? ml
? min

Lockout Interval

P
I
E
B
P
I
E
B
P
I
E
B
PCEA Lockout
P
C
E
A
bolus
P
C
E
A
P
C
E
A
PCEA use within
the PIEB interval
will continue to
delay the next PIEB
bolus

#IARS2019
P
I
E
B
30 60 90 120
Clinician Bolus
(CSE or Epi)
Dosage

#IARS2019
Anesth Analg 2017;124:560–9

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
✅ ✅ ❌
✅ ✅ ❌
❌ ✅ ✅
✅ ✅ ❌
❌ ✅ ✅
✅ ✅ ✅

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

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%

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%

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%

@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

@Ron_George #CSAHSFall2019Sia et al. Anaesthesia (2013)

#IARS2019
Data / Quality
Improvement

#IARS2019
๏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

#IARS2019
๏Improved satisfaction
๏Less local anesthetic
๏Less anesthesia interventions
๏??? Less IVD
๏??? Safety concerns
Programmed Intermittent Epidural Bolus
for labour analgesia - is this the future?

Questions?
ronald.george@ucsf.edu
@Ron_George

Update labor analgesia - PIEB, CSE, DPE

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