PIEB Labour Analgesia

Labour analgesia grand rounds at University of Manitoba

1. The Evolution of Labour Analgesia

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

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17. #PIEB#ANES17 @Ron_George@Ron_George #AnesGR
Clinician Bolus
(CSE or Epi)
Dosage
Call the
Anesthesiologist

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Dosage
Clinician Bolus
(CSE or Epi)

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

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Patients who receive
PCEA bolus analgesia
were less likely to
require anaesthetic
interventions

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LC was associated with a
reduction in the incidence of IVD
(OR = 0.70; 95%CI 0.56 to 0.86)

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Kaynar et al, Anesth Analg 1999;89
10.5 ml/hour
3.5 ml bolus

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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

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

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

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Capogna et al. Curr Opin Anesthesiol 2013, 26:261–267

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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 interventions0.56 (95% CI, 0.29 to 1.06)0.08

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Local Anesthesia consumption (mg/hr)

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Local Anesthesia consumption (mg/hr)
Maternal Satisfaction

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PIEB Volume - 10ml
PIEB Interval - 60min

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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)

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SOAP 2017 Abstract # O-01
10 ml
5 ml
0.0625%
0.125%
40 minutes
35 minutes

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A&A 2016; 123: 965-71

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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

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P
I
E
B
P
I
E
B
Dosage
Clinician Bolus
(CSE or Epi)
30 60 90 120
“PCEA lockout type”

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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”

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P
I
E
B
P
I
E
B
Dosage
30 60 90 120
“Bolus interval type”

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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”

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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”

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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”

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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

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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

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30 60 90 120
Clinician Bolus
(CSE or Epi)
Dosage

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

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•Shrink the change
•Tweak the environment
•Build habits
•Script critical points

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PIEB Volume
PIEB Interval
PCEA Volume

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Sia et al. Anaesthesia (2013)

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P
I
E
B
P
I
E
B
P
I
E
B
P
I
E
B
P
I
E
B
P
C
E
A

83. •Improved maternal
satisfaction
•Less local anesthetic
•? Less anesthesia
interventions
•?? Less IVD
•??? Safety concerns
•??? Patient Engagement
•??? Personalized labour
analgesia

84. Internet
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