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EFFICACY OF PCEA vs PCEA + CIEA FOR AMBULATORY LABOUR ANALGESIA

Department of Anesthesia, Royal University Hospital, College of Medicine, University of Saskatchewan, 103 Hospital Drive, Saskatoon, SK, S7N 0W8

INTRODUCTION: The utilization of patient controlled epidural analgesia (PCEA) delivery systems for labour reduces the amount of epidural medication (1,2) and need for anesthesiologist-delivered supplemental analgesia (1,3) compared to continuous infusion epidural analgesia (CIEA). To date, no studies have evaluated the efficacy of ambulatory labour analgesia (4) nor need for Anesthesiologist-administered "top ups" when PCEA alone is compared to PCEA + CIEA. Therefore, the purpose of this prospective, randomized, double-blinded study was to compare the impact of PCEA vs PCEA + CIEA on labour analgesic efficacy and need for Anesthesiologist-administered "top ups".

METHODS: This study was conducted between Jan 2000 and Dec 2003. Following IRB approval and written informed consent, 300 nulliparous women undergoing induced labour, determined to be in established labour, <6 cm dilated and requesting labour epidural analgesia (LEA) were randomized. LEA was established with 20 ml of 0.8% Ropiv + 2 µg/ml Fent (4), with each woman then randomized to receive this same analgesic solution either via PCEA alone (5 ml bolus; 10 min lockout, No 4 hour limit) alone or PCEA (5 ml bolus; 10 min lockout, No 4 hour limit) plus CIEA (10 ml/hr) in a double-blind manner to maintain LEA. LEA and obstetric management were predetermined using strict protocols. An "a priori" decision was made to analyze only the data for a vaginal delivery to eliminate the potential impact of "dystocia" which has a higher analgesic requirement. Data analysis included 2-tailed unpaired T-test and Chi square with P<0.05 considered significant.

RESULTS: 211 women of the 300 randomized, 104 (73.8%) PCEA alone and 107 (73.6%) PCEA + CIEA delivered vaginally and were included in the analysis. There were no statistical differences in demographics, method of labour induction, cervical dilation at time of LEA initiation, gestational age, VAS pain scores prior to LEA and 30 min post LEA initiation and neonatal weight. 3 PCEA (2.8%) withdrew due to inadequate analgesia and 1 PCEA + CIEA (0.9%) withdrew. VAS Pain scores were significantly higher (P<0.02) at each cervical dilation between 3–10 cm in PCEA vs PCEA + CIEA (Figure 1). Significantly more women required Anesthesiologist-administered supplemental "top ups" with 43 PCEA (41.3%) requiring a total of 64 "top ups" and 29 PCEA + CIEA (27.1%) requiring a total of 45 "top ups" (P<0.03). Mean postpartum analgesic satisfaction was significantly greater at 2 hrs with PCEA + CIEA (90.3 ± 12.6) vs PCEA (84.2 ± 20.9) and 24 hrs with PCEA + CIEA (90.6 + 10.9) vs PCEA (84.7 + 21.1), both P<0.02.

View larger version (12K): [in this window] [in a new window]   Figure 1: Labour VAS Pain Scores at Cervical Dilatation

REFERENCES:

1 CJA 40:211–7, 1993

2 CJA 35:249–54, 1988

3 IJOA 2:73–7, 1993

4 Anesth Analg 90: 1384–9, 2000[Abstract/Free Full Text]

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