EuroAnaesthesia 2019 - PIEB Labour Analgesia

@Ron_George
An Evolution of
Labour Analgesia
Programmed Intermittent
Epidural Bolus (PIEB) with
PCEA for #OBAnes
Ronald B. George, MD FRCPC
Professor, Anaesthesiology
Dalhousie University
(C) Ronald George

@Ron_George
Describe the current knowledge regarding PIEB impact on analgesia
& obstetrical outcomes
Demonstrate the limitations in evidence for PIEB for labour analgesia
Describe implementation strategies for PIEB to optimize effective
and safe utilization on your labour units
Discuss future considerations for PIEB and labour analgesia
Learning Objectives
(C) Ronald George

@Ron_George
Clinician Bolus
(CSE or Epi)
Dosage
(C) Ronald George

@Ron_George
P
C
E
A
P
C
E
A
P
C
E
A
PCEA
Lockout
Clinician Bolus
(CSE or Epi)
Dosage
(C) Ronald George

@Ron_George
Patients who receive PCEA
bolus analgesia:
Less anesthetic interventions
Higher satisfaction
Less motor block
(C) Ronald George

@Ron_George
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

@Ron_George
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

@Ron_George
Kaynar et al, Anesth Analg 1999;89
Rusha et al. SOAP 2019 T210-187
Hogan, Reg Anesth Pain Med 2002;27
(C) Ronald George

@Ron_George
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

@Ron_George
Wong et al. A&A 2013
PIEB: 6ml q30min
CEI: 12ml per hour
(C) Ronald George

@Ron_George
A&A 2011;113:826-31
(C) Ronald George

@Ron_George
CEI : 10 ml/hour
PIEB : 10 ml q1hour
(C) Ronald George

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

@Ron_George
CEI / PIEB : 0.0625% Bupiv
PCEA : 1.25% Bupiv
(C) Ronald George

@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
(C) Ronald George

@Ron_George
Local Anesthesia consumption (mg/hr)
Maternal Satisfaction
(C) Ronald George

@Ron_George
Jiqian Xu, et al. Scientific Reports 2019
(C) Ronald George

@Ron_George
0%
6%
13%
19%
25%
Rescue Bolus Unilateral Block
CEI PIEB
2%
12%
5%
19%
(C) Ronald George

@Ron_George
OR 1.15 95%CI (1.04, 1.27)
(C) Ronald George

@Ron_George
Labor Epidural
PIEB + PCEA
Ropivacaine + fentanyl
PIEB Bolus
PIEB Interval
PCEA Bolus
PCEA Lockout
NEXT Bolus
? ml
? min
? ml
? min
? min
(C) Ronald George

@Ron_George
0
4
8
12
2.5/15 5/30 10/60
8.8
10.010.4 Bupiv mg/h
(C) Ronald George

@Ron_George
PIEB Volume - 10ml
PIEB Interval - 60min
0
4
8
12
2.5/15 5/30 10/60
8.8
10.010.4 Bupiv mg/h
(C) Ronald George

@Ron_George
Kanczuk et al. Anesth Analg 2017;124
(C) Ronald George

@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)
(C) Ronald George

@Ron_George
SOAP 2017 Abstract # O-01
10 ml
5 ml
0.0625%
0.125%
40 minutes
35 minutes
(C) Ronald George

@Ron_George
EV90 = 10.7 (95%CI 10.3–11.0) ml
Zakus et al. Anaesthesia 2017
(C) Ronald George

@Ron_George
Klumpner et al. J Clin Anesth 2016;34
(C) Ronald George

@Ron_George
Anesthesia & Analgesia 2018; PMID 30028347
(C) Ronald George

@Ron_George
Anesthesia & Analgesia 2018;
PMID 30028347
(C) Ronald George

@Ron_George
Anesthesiology 2018; 128(4): 745-753
(C) Ronald George

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

@Ron_George
A&A 2016; 123: 965-71
(C) Ronald George

@Ron_George
A&A 2016; 123: 965-71
Labor Epidural
PIEB + PCEA
PIEB Bolus
PIEB Interval
PCEA Bolus
PCEA Lockout
NEXT Bolus
8 ml
45 min
6 ml
10 min
15 min
(C) Ronald George

@Ron_George
© Smiths Medical
© Smiths Medical
(C) Ronald George

@Ron_George
PCEA
Lockout
P
C
E
A
P
C
E
A
Denied
PCEA
Request
P
I
E
B
P
I
E
B
Dosage
PIEB
Interval
30 min 15 min
Clinician Bolus
(CSE or Epi)
30 60 90 120
(C) Ronald George

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

@Ron_George
P
I
E
B
P
I
E
B
Dosage Clinician Bolus
(CSE or Epi)
30 60 90 120
P
C
E
A
(C) Ronald George

@Ron_George
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
(C) Ronald George

@Ron_George
P
I
E
B
P
I
E
B
Dosage
30 60 90 120
“Bolus interval type”
(C) Ronald George

@Ron_George
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
(C) Ronald George

@Ron_George
P
I
E
B
P
I
E
B
P
I
E
B
Dosage
30 60 90 120
P
C
E
A
bolus
(C) Ronald George

@Ron_George
P
I
E
B
P
I
E
B
P
I
E
B
Dosage
30 60 90 120
P
C
E
A
PIEB
Interval
bolus
P
C
E
A
(C) Ronald George

@Ron_George
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
(C) Ronald George

@Ron_George
Lockout Interval
Labor Epidural
PIEB + PCEA
PIEB Bolus
PIEB Interval
PCEA Bolus
PCEA Lockout
NEXT Bolus
? ml
? min
? ml
? min
? min
(C) Ronald George

@Ron_George
Lockout Interval
(C) Ronald George

@Ron_George
Lockout Interval
Gabriel et al. BJA 2019; ePub doi:10.1016/j.bja.2019.02.016
(C) Ronald George

@Ron_George
P
I
E
B
PI
E
B
PI
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
PIEB & PCEA
(C) Ronald George

@Ron_George
PIEB & PCEA
PIEB
5 ml q60min
PCEA
5 ml
20 min
lockout
P
I
E
B
P
I
E
B
P
I
E
B
Dosage
PCEA Lockout
30 60 90 120
P
C
E
A
P
C
E
A
P
C
E
A
PIEB
Interval
Gabriel et al. BJA 2019; ePub doi:10.1016/j.bja.2019.02.016
Wong & Mercier. BJA 2019 doi:10.1016/j.bja.2019.02.008
(C) Ronald George

@Ron_George
Rodriguez-Campoo et al. J Clin Monit Comp 2018 PMID 30506299
(C) Ronald George

@Ron_George
Rodriguez-Campoo et al. J Clin Monit Comp 2018 PMID 30506299
PIEB group — 2ml/h + 7ml q30min + PCEA
CEI — 5ml/h + PCEA
Outcome — Total dose
(C) Ronald George

@Ron_George
P
I
E
B
P
I
E
B
P
I
E
B
P
C
E
A
P
I
E
B
P
C
E
A
STAT C/S
Safety Concerns
(C) Ronald George

@Ron_George
P
I
E
B
30 60 90 120
Clinician Bolus
(CSE or Epi)
Dosage
(C) Ronald George

@Ron_George
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

@Ron_George
P
I
E
B
30 60 90 120
Clinician Bolus
(CSE or Epi)
P
I
E
B
P
I
E
B
P
I
E
B
Dosage
Next Bolus
Interval
‘NEXT’ Bolus Study - Munro & George
(C) Ronald George

#EA19 @Ron_George
PIEB Volume
PIEB
Interval
NEXTInterval
(C) Ronald George

#EA19 @Ron_George
(C) Ronald George

@Ron_George Sia et al. Anaesthesia (2013)
(C) Ronald George

@Ron_George
Data / Quality
Improvement
(C) Ronald George

@Ron_George
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
Dinges et al. IJOA 2018; 33: 100-101
(C) Ronald George

@Ron_George
P
I
E
B
P
I
E
B
P
I
E
B
P
I
E
B
P
I
E
B
P
C
E
A
(C) Ronald George

@Ron_George
PIEB Interval – 45-60 minutes

PIEB volume – 6-10 ml

First Bolus – TBD

PIEB + PCEA ✅

PCEA Lockout – 10 minutes

PIEB/PCEA Interaction ✅
An Evolution of Labour Analgesia
(C) Ronald George

@Ron_George
Improved satisfaction

Less local anesthetic

Less anesthesia interventions

??? Less IVD

??? Safety concerns

Opportunity - Patient Engagement

Opportunity - Personalized analgesia
An Evolution of Labour Analgesia
(C) Ronald George

EuroAnaesthesia 2019 - PIEB Labour Analgesia

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