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

4. #AnesGR@Ron_George

13. #AnesGR@Ron_George

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

18. #AnesGR@Ron_George
Dosage
Clinician Bolus
(CSE or Epi)

19. #PIEB#ANES17 @Ron_George@Ron_George #AnesGR
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

22. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR

23. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR
LC was associated with a
reduction in the incidence of IVD
(OR = 0.70; 95%CI 0.56 to 0.86)

24. #AnesGR@Ron_George
Kaynar et al, Anesth Analg 1999;89
10.5 ml/hour
3.5 ml bolus

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26. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR

27. #PIEB#ANES17 @Ron_George@Ron_George #AnesGR
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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36. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR
Capogna et al. Curr Opin Anesthesiol 2013, 26:261–267

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38. #AnesGR@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

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Local Anesthesia consumption (mg/hr)

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Local Anesthesia consumption (mg/hr)
Maternal Satisfaction

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45. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR
PIEB Volume - 10ml
PIEB Interval - 60min

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47. #AnesGR@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)

48. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR
SOAP 2017 Abstract # O-01
10 ml
5 ml
0.0625%
0.125%
40 minutes
35 minutes

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50. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR
A&A 2016; 123: 965-71

51. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR
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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56. #PIEB#ANES17 @Ron_George@Ron_George #AnesGR
P
I
E
B
P
I
E
B
Dosage
Clinician Bolus
(CSE or Epi)
30 60 90 120
“PCEA lockout type”

57. #PIEB#ANES17 @Ron_George@Ron_George #AnesGR
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”

58. #PIEB#ANES17 @Ron_George@Ron_George #AnesGR
P
I
E
B
P
I
E
B
Dosage
30 60 90 120
“Bolus interval type”

59. #PIEB#ANES17 @Ron_George@Ron_George #AnesGR
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”

60. #PIEB#ANES17 @Ron_George@Ron_George #AnesGR
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”

61. #PIEB#ANES17 @Ron_George@Ron_George #AnesGR
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”

62. #PIEB#ANES17 @Ron_George@Ron_George #AnesGR

63. #PIEB#ANES17 @Ron_George@Ron_George #AnesGR
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

64. #PIEB#ANES17 @Ron_George@Ron_George #AnesGR
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

65. #PIEB#ANES17 @Ron_George@Ron_George #AnesGR
30 60 90 120
Clinician Bolus
(CSE or Epi)
Dosage

66. #PIEB#ANES17 @Ron_George@Ron_George #AnesGR
P
I
E
B
30 60 90 120
Clinician Bolus
(CSE or Epi)
Dosage

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71. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR
• Shrink the change
• Tweak the environment
• Build habits
• Script critical points

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74. #AnesGR@Ron_George
PIEB Volume
PIEB
Interval
PCEAVolume

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78. #AnesGR@Ron_George Sia et al. Anaesthesia (2013)

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81. #PIEBepidural@Ron_George CAS 2017@Ron_George #AnesGR
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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