HawaKEITA-MEYER

SERVICED’ANESTHÉSIE.HÔPITALLOUISMOURIER,COLOMBES.

NEWMODESOFOBSTETRICANALGESIA:DOESPIEBMODEBRINGAREALBENEFIT?

LABORPAINMelzackR.Pain1984;19(4):321-337

LABORSTAGES

• Intenseorintolerable• Variablefromonewomantoanother

• Increasesduringlabor• Isincreasedbyoxytocin/prostaglandins

LABORPAIN«PARTICULARITIES»

LABORPAIN

EPIDURALANALGESIA(EA)

• EffecUvethroughoutthework• Flexible• LiYleornore-injecUonbycaregivers• Nomotorblockade• Noimpactonlaboranddelivery• Nosideeffects:hypotension,pruritus,nausea-vomiUng…

« IDEAL» EA

J J J

« IDEAL» EA = MATERNAL SATISFACTION !!

EPIDURALANALGESIA(EA)

HOWTOOBTAIN«IDEAL»EA?

WHICHAGENTS/WHICHCONCENTRATIONS?

• Alocalanesthesia(LA)• Anopioid• ±Clonidine

AGENTS

• Ropivacaïne:0.08–0.15%•  LEvobupivacaïne:0.0625–0.125%•  Bupivacaïne:0.0625–0.125%•  Sufentanil:0.25–0.50µg/mL•  Clonidine:1-2µg/mL

CONCENTRATIONS

WongCA.IntJWomHealth2009AvelinLandauRetal.AnesthAnalg2002;95:728-34BazinMetal.Anaesthesia2010;66:769-79

WHICHMODESOFADMINISTRATION?

ConUnuousepiduralInfusion(CEI)

PCEA

PCEA+PIEB

INTERACTIVEPCEA

Evolution of modes of administration

VanderVyverM,HalpernS.BJA2002;89:459-65

Number of patients without supplemental intervention

Less intervention (top up) with PCEA

PCEAvsCONTINUOUSEPIDURALINFUSION(CEI)

Dose of LA (mg. h-1)

Reduction of LA doses by 25% - 30% with PCEA

VanderVyverM,HalpernS.BJA2002;89:459-65

PCEAvsCONTINUOUSEPIDURALINFUSION(CEI)

NODIFFERENCEFOR:

ü  DuraUonoflabor

ü  Instrumentaldeliveries

ü  CaesareansecUons

ü  Neonataloutcomes

VanderVyverM,HalpernS.BJA2002;89:459-65

PCEAvsCONTINUOUSEPIDURALINFUSION(CEI)

«IDEAL»PCEA?

Bolus5ml Bolus10ml

Bolus5ml Bolus10ml

YokoyamaMetal.Anesthesiology2004;100:1504-10

PCEA:BOLUSVOLUME?

10mlvs5mlèDiffusiononmoremetamersèMorehomogeneousdistribuQon

MLAV=9.2ml(95%CI6.9-11.5)MLAD=23mg(95%CI17.2-28.9)

MLAV=13.6ml(95%CI12.4–14.8)*MLAD=17mg(95%CI15.5-18.5)***P=0.002**P=0.045

ReducQoninLAconcentraQonsforlargerboluseswithlessriskoftoxicity(LyonsGRetal.AnesthAnalg2007;104:412-5)

PCEA:BOLUSVOLUME?

• LargesvolumesofdilutedsoluUon(8-10ml)withlonglockoutperiodstoimprove:

è Analgesiaè MaternalsaUsfacUon

• MaximaldosestopreventtheriskifthereisanunrecognizedintrathecalKTèbupivacaïne≤5-6mgropivacaïne≤7-8mg

PCEABOLUSVOLUME

HalpernSH,AnesthAnalg2009;108:921-8RCPSFAR2006«Blocspérimédullaireschezl’adulte»

PCEA:BOLUSVOLUME?

HalpernSH,AnesthAnalg2009;108:921-8

B = Bupivacaine; F = Fentanyl; S = Sufentanil; E = Epinephrine; R = Ropivacaine

PCEA:INTERESTINCEI?

• ReducUonofcareproviderrescuebolus• ImprovematernalsaUsfacUon• Especiallyiflowbolusvolumes(≤5ml)

YES

HalpernSH,AnesthAnalg2009;108:921-8

PCEA:INTERESTINCEI?

MODEPIEB«ProgrammedIntermiientEpiduralBolus»

MODEPIEB

ü  AdiministraUonatregularintervalsofaprogrammedbolus±associatedwithPCEAmode

ü  Currentlypossiblewithsomepumps(CADD®-Solisv3.0Smithsmedical)

ü  PIEB:bolusvolume,lockoutinterval,infusionrate(250–500mL/h)ü  NoCEI!

PIEB:Whythisconcept?

ü MulUorificeepiduralKT

ü  ConUnuous(10.5ml/h)vsbolus(3,5mlsur1min/20min)

ü  KTplacedontoapieceofwhitesemiabsorbentpaperover1h

Area of diffusion è bolus (1.2 in2) > continuous infusion (0.3in2)

KaynarAMetal.AnesthAnalg1999;89:531-8

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

PIEB:Whythisconcept?

PIEB+PCEAvsPCEA+CEI

CapognaGetal.AnesthAnalg2011;113:826-31

PCEABupi0.125%5ml/10min15mlmax/h

PIEB

-Levobupi0.0625%+suf0.5μg/ml-10mlboluseveryh-N=75nulliparous

CEI

-Levobupi0.0625%+suf0.5μg/ml-10ml/h-N=70nulliparous

ü  Primaryoutcome:incidenceofmotorblockthroughoutlabor

ü  Secondaryoutcome:incidenceinstrumentaldeliveries

+

+

1.Completeblock(unabletomovefeetorknees)2.Almostcompleteblock(abletomovefeetonly)3.ParUalblock(justabletomoveknees)4.Detectableweaknessofhipflexionwhilesupine(betweenscores3and5)5.Nodetectableweaknessofhipflexionwhilesupine(fullflexionofknees)6.AbletostandandtoperformparUalkneebend

BRENNMODIFIEDBROMAGESCORE

Motor block if score < 6 !!

CapognaGetal.AnesthAnalg2011;113:826-31

PIEB+PCEAvsPCEA+CEI

Motor block more frequent throughout labor in CEI group

37%

2,7%

CapognaGetal.AnesthAnalg2011;113:826-31

PIEB+PCEAvsPCEA+CEI

ü  MotorblockatfullcervicaldilataQon(p<0.001)-  CEI=25/55(33%)-  PIEB=5/61(8%)

ü  Incidenceofinstrumentaldelivery(p=0.03etRR=2.9)-  CEI=20%-  PIEB=7%

ü  StrongassociaQonbetweenmotorblockatfullcervicaldilataQonandinstrumentaldelivery!

CapognaGetal.AnesthAnalg2011;113:826-31

PIEB+PCEAvsPCEA+CEI

PIEB:bolusvolumeandlockoutperiod?

Primaryoutcome=totaldoseofLAuse

Solution = bupivacaine 0,625 ml/ml + fentanyl 11,95 µg/ml Débit continu = 10 ml/h

Programmedintervalbolus+PCEA

Wong CA et al. Anesth Analg 2011; 112: 904-11

PIEBat10ml/hèRéduReducQonoftotaldoseofLA≈2mg/hClinicallysignificant??

Wong CA et al. Anesth Analg 2011; 112: 904-11

PIEB:bolusvolumeandlockoutperiod?

Nodifferenceforanalgesicefficacy,motorblock,modeofdelivery

Wong CA et al. Anesth Analg 2011; 112: 904-11

PIEB:bolusvolumeandlockoutperiod?

VariousPIEBprogrammaQonsproposed

PIEB:opQmalprogrammaQon?

Current trend = 8 – 10 mL / 60 min

u  Randomized controlled studies, 2004 – 2011 u  9 studies:

-  PIEB, n = 350 -  Nulli et multiparous

ü  Meta-analyse PIEB vs EA (CEI or PCEA)

Georges RB et al. Anesth Analg 2013; 116: 133-44

Georges RB et al. Anesth Analg 2013; 116: 133-44

ü  Principaux résultats

ü  PCEA=referencetechniqueactually

ü  EAisthemosteffecQvemethodforlaboranalgesia

ü  PIEB=greaterspreadofLAsoluQonintheepiduralspace è beiersensoryblockadecomparedwithCEI

CONCLUSION

ü  PIEB=improvementinmaternalsaQsfacQon

ü  PIEB=LAsparingeffect  è fewerinstrumentalvaginaldeliveries,lessmotorblockade,   shorterduraQonoflabor

ü  PIEB=opQmalregimenandpumpsetngsremainunknown

Thank you for your attention