NEW MODES OF OBSTETRIC ANALGESIA: DOES PIEB MODE BRING A REAL BENEFIT?

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1 NEW MODES OF OBSTETRIC ANALGESIA: DOES PIEB MODE BRING A REAL BENEFIT? Hawa KEITA-MEYER SERVICE D ANESTHÉSIE. HÔPITAL LOUIS MOURIER, COLOMBES.

2 LABOR PAIN Melzack R. Pain 1984; 19(4):

3 LABOR STAGES

4 LABOR PAIN LABOR PAIN «PARTICULARITIES» Intense or intolerable Variable from one woman to another Increases during labor Is increased by oxytocin/prostaglandins

5 EPIDURAL ANALGESIA (EA) EffecUve throughout the work Flexible LiYle or no re-injecuon by caregivers No motor blockade «IDEAL» EA No impact on labor and delivery No side effects: hypotension, pruritus, nauseavomiung

6 EPIDURAL ANALGESIA (EA) «IDEAL» EA = MATERNAL SATISFACTION!! J J J

7 HOW TO OBTAIN «IDEAL» EA?

8 WHICH AGENTS / WHICH CONCENTRATIONS? Wong CA. Int J Wom Health 2009 AvelinLandau R et al. Anesth Analg 2002; 95: Bazin M et al. Anaesthesia 2010; 66: AGENTS A local anesthesia (LA) An opioid ± Clonidine CONCENTRATIONS Ropivacaïne : % LEvobupivacaïne : % Bupivacaïne : % Sufentanil : µg / ml Clonidine : 1-2 µg/ml

9 WHICH MODES OF ADMINISTRATION? Evolution of modes of administration ConUnuous epidural Infusion (CEI) PCEA PCEA + PIEB INTERACTIVE PCEA

10 PCEA vs CONTINUOUS EPIDURAL INFUSION (CEI) Van der Vyver M, Halpern S. BJA 2002; 89: Number of patients without supplemental intervention Less intervention (top up) with PCEA

11 PCEA vs CONTINUOUS EPIDURAL INFUSION (CEI) Van der Vyver M, Halpern S. BJA 2002; 89: Dose of LA (mg. h -1 ) Reduction of LA doses by 25% - 30% with PCEA

12 PCEA vs CONTINUOUS EPIDURAL INFUSION (CEI) Van der Vyver M, Halpern S. BJA 2002; 89: NO DIFFERENCE FOR: ü DuraUon of labor ü Instrumental deliveries ü Caesarean secuons ü Neonatal outcomes

13 «IDEAL» PCEA?

14 PCEA: BOLUS VOLUME? Yokoyama M et al. Anesthesiology 2004; 100: Bolus 5 ml Bolus 10 ml Bolus 5 ml Bolus 10 ml 10 ml vs 5 ml è Diffusion on more metamers è More homogeneous distribuqon

15 PCEA: BOLUS VOLUME? ReducQon in LA concentraqons for larger boluses with less risk of toxicity (Lyons GR et al. Anesth Analg 2007; 104: 412-5) MLAV = 9.2 ml (95% CI ) MLAD = 23 mg (95% CI ) MLAV = 13.6 ml (95% CI ) * MLAD = 17 mg (95%CI )** *P = ** P = 0.045

16 PCEA: BOLUS VOLUME? Halpern SH, Anesth Analg 2009; 108: RCP SFAR 2006 «Blocs périmédullaires chez l adulte» PCEA BOLUS VOLUME Larges volumes of diluted soluuon (8-10 ml) with long lockout periods to improve: è Analgesia è Maternal sausfacuon Maximal doses to prevent the risk if there is an unrecognized intrathecal KT è bupivacaïne 5-6 mg ropivacaïne 7-8 mg

17 PCEA: INTEREST IN CEI? Halpern SH, Anesth Analg 2009; 108: B = Bupivacaine; F = Fentanyl; S = Sufentanil; E = Epinephrine; R = Ropivacaine

18 PCEA: INTEREST IN CEI? Halpern SH, Anesth Analg 2009; 108: YES ReducUon of care provider rescue bolus Improve maternal sausfacuon Especially if low bolus volumes ( 5ml)

19 MODE PIEB «Programmed Intermiient Epidural Bolus»

20 ü PIEB: bolus volume, lockout interval, infusion rate ( ml/h) ü No CEI! MODE PIEB ü AdiministraUon at regular intervals of a programmed bolus ± associated with PCEA mode ü Currently possible with some pumps (CADD -Solis v3.0 Smiths medical)

21 PIEB: Why this concept? Kaynar AM et al. Anesth Analg 1999; 89: ü MulUorifice epidural KT ü ConUnuous (10.5 ml/h) vs bolus (3,5 ml sur 1 min / 20 min) ü KT placed onto a piece of white semiabsorbent paper over 1h Area of diffusion è bolus (1.2 in 2 ) > continuous infusion (0.3in 2 )

22 PIEB: Why this concept? Perfusion continue Accumulation dans le nerf avec le temps car persistance d A locaux à l extérieur du fait débit du continu Bolus Répartition harmonieuse Pénétration et équilibration, Chute régulière de la concentration des A Locaux du fait des bolus: Pas de surdosage

23 PIEB + PCEA vs PCEA + CEI Capogna G et al. Anesth Analg 2011; 113: PCEA Bupi 0.125% 5 ml / 10 min 15 ml max / h + + PIEB - Levobupi % + suf 0.5 μg/ml - 10 ml bolus every h - N = 75 nulliparous CEI - Levobupi % + suf 0.5 μg/ml - 10 ml / h - N = 70 nulliparous ü Primary outcome: incidence of motor block throughout labor ü Secondary outcome: incidence instrumental deliveries

24 PIEB + PCEA vs PCEA + CEI Capogna G et al. Anesth Analg 2011; 113: BRENN MODIFIED BROMAGE SCORE 1. Complete block (unable to move feet or knees) 2. Almost complete block (able to move feet only) 3. ParUal block (just able to move knees) 4. Detectable weakness of hip flexion while supine (between scores 3 and 5) 5. No detectable weakness of hip flexion while supine (full flexion of knees) 6. Able to stand and to perform parual knee bend Motor block if score < 6!!

25 PIEB + PCEA vs PCEA + CEI Capogna G et al. Anesth Analg 2011; 113: Motor block more frequent throughout labor in CEI group 37% 2,7%

26 PIEB + PCEA vs PCEA + CEI Capogna G et al. Anesth Analg 2011; 113: ü Motor block at full cervical dilataqon (p < 0.001) - CEI = 25 / 55 (33%) - PIEB = 5 / 61 (8%) ü Incidence of instrumental delivery (p = 0.03 et RR = 2.9) - CEI = 20 % - PIEB = 7% ü Strong associaqon between motor block at full cervical dilataqon and instrumental delivery!

27 PIEB: bolus volume and lockout period? Wong CA et al. Anesth Analg 2011; 112: Programmed interval bolus + PCEA Solution = bupivacaine 0,625 ml/ml + fentanyl 11,95 µg/ml Débit continu = 10 ml/h Primary outcome = total dose of LA use

28 PIEB: bolus volume and lockout period? Wong CA et al. Anesth Analg 2011; 112: PIEB at 10ml / h è RéduReducQon of total dose of LA 2mg/h Clinically significant??

29 PIEB: bolus volume and lockout period? Wong CA et al. Anesth Analg 2011; 112: No difference for analgesic efficacy, motor block, mode of delivery

30 PIEB: opqmal programmaqon? Various PIEB programmaqons proposed Current trend = 8 10 ml / 60 min

31 Georges RB et al. Anesth Analg 2013; 116: ü Meta-analyse PIEB vs EA (CEI or PCEA) u Randomized controlled studies, u 9 studies: - PIEB, n = Nulli et multiparous

32 ü Principaux résultats Georges RB et al. Anesth Analg 2013; 116:

33 CONCLUSION ü EA is the most effecqve method for labor analgesia ü PCEA = reference technique actually ü PIEB = greater spread of LA soluqon in the epidural space è beier sensory blockade compared with CEI ü PIEB = LA sparing effect è fewer instrumental vaginal deliveries, less motor blockade, shorter duraqon of labor ü PIEB = improvement in maternal saqsfacqon ü PIEB = opqmal regimen and pump setngs remain unknown

34 Thank you for your attention

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