PIEB ASRA Meeting Spring 2019
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The document discusses programmed intermittent bolus (PIEB) versus continuous infusion for obstetric epidurals. It summarizes current evidence showing PIEB requires less local anesthetic, improves maternal satisfaction, and may reduce the need for anesthesia interventions compared to continuous infusion. The document outlines strategies for implementing PIEB to optimize effective and safe utilization, including selecting optimal PIEB volumes, intervals, and settings to interface with patient-controlled epidural analgesia.
PIEB ASRA Meeting Spring 2019
- 1. (c) Ronald B. George, MD FRCPC
- 2. An Evolution of Labour Analgesia Programmed Intermittent Bolus versus Continuous Infusion for Obstetric Epidurals (c) Ronald B. George, MD FRCPC
- 3. 犢 Describe the current knowledge regarding PIEB impact on analgesia & obstetrical outcomes 犢 Demonstrate the limitations in evidence for PIEB for labour analgesia 犢 Describe implementation strategies for PIEB to optimize effective and safe utilization on your labour units Learning Objectives (c) Ronald B. George, MD FRCPC
- 4. #ASRASpring19@Ron_George No Financial Disclosures(c) Ronald B. George, MD FRCPC
- 5. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
- 6. #ASRASpring19@Ron_George Clinician Bolus (CSE or Epi) Dosage (c) Ronald B. George, MD FRCPC
- 7. #ASRASpring19@Ron_George P C E A P C E A P C E A PCEA Lockout Clinician Bolus (CSE or Epi) Dosage (c) Ronald B. George, MD FRCPC
- 8. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
- 9. #ASRASpring19@Ron_George Patients who receive PCEA bolus analgesia were less likely to require anesthetic interventions (c) Ronald B. George, MD FRCPC
- 10. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
- 11. #ASRASpring19@Ron_George LC was associated with a reduction in the incidence of IVD (OR = 0.70; 95%CI 0.56 to 0.86) (c) Ronald B. George, MD FRCPC
- 12. #ASRASpring19@Ron_George Kaynar et al, Anesth Analg 1999;89 10.5 ml/hour 3.5 ml bolus (c) Ronald B. George, MD FRCPC
- 13. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
- 14. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
- 15. #ASRASpring19@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 B. George, MD FRCPC
- 16. #ASRASpring19@Ron_George Capogna, Fernando, and van de Velde. Eur School of OB Anesthesia 2016 (c) Ronald B. George, MD FRCPC
- 17. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
- 18. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
- 19. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
- 20. #ASRASpring19@Ron_George A&A 2011;113:826-31 (c) Ronald B. George, MD FRCPC
- 21. #ASRASpring19@Ron_George A&A 2011;113:826-31 (c) Ronald B. George, MD FRCPC
- 22. #ASRASpring19@Ron_George A&A 2011;113:826-31 IVD: 20% CEI vs 7% PIEB (p=0.03) RR 2.9 (95% CI: 1.17.9) (c) Ronald B. George, MD FRCPC
- 23. #ASRASpring19@Ron_George A&A 2011;113:826-31 (c) Ronald B. George, MD FRCPC
- 24. #ASRASpring19@Ron_George Capogna et al. Curr Opin Anesthesiol 2013, 26:261267 Capogna, Fernando, and van de Velde. Eur School of OB Anesthesia 2016 (c) Ronald B. George, MD FRCPC
- 25. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
- 26. #ASRASpring19@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 B. George, MD FRCPC
- 27. #ASRASpring19@Ron_George Local Anesthesia consumption (mg/hr) (c) Ronald B. George, MD FRCPC
- 28. #ASRASpring19@Ron_George Local Anesthesia consumption (mg/hr) Maternal Satisfaction (c) Ronald B. George, MD FRCPC
- 29. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
- 30. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
- 31. #ASRASpring19@Ron_George ??? NEXT dose PCEA dose PCEA lock-out PIEB dose PIEB interval (c) Ronald B. George, MD FRCPC
- 32. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
- 33. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
- 34. #ASRASpring19@Ron_George PIEB Volume - 10ml PIEB Interval - 60min (c) Ronald B. George, MD FRCPC
- 35. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
- 36. #ASRASpring19@Ron_George The optimal time interval between PIEB of 10 mL of bupivacaine 0.0625% with fentanyl 2 亮g/mL is approximately 40 minutes 42.6 minutes (95% CI 38.946.4) Kanczuk et al. Anesthesia & Analgesia 2017;124:537-41 (c) Ronald B. George, MD FRCPC
- 37. #ASRASpring19@Ron_George SOAP 2017 Abstract # O-01 10 ml 5 ml 0.0625% 0.125% 40 minutes 35 minutes (c) Ronald B. George, MD FRCPC
- 38. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
- 39. #ASRASpring19@Ron_George EV90 = 10.7 (95%CI 10.311.0) ml (c) Ronald B. George, MD FRCPC
- 40. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
- 41. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
- 42. #ASRASpring19@Ron_George Capogna, Fernando, and van de Velde. Eur School of OB Anesthesia 2016 (c) Ronald B. George, MD FRCPC
- 43. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
- 44. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
- 45. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
- 46. #ASRASpring19@Ron_George Anesthesia & Analgesia 2018; PMID 30028347 (c) Ronald B. George, MD FRCPC
- 47. #ASRASpring19@Ron_George Anesthesia & Analgesia 2018; PMID 30028347 (c) Ronald B. George, MD FRCPC
- 48. #ASRASpring19@Ron_George Anesthesiology 2018; 128(4): 745-753 (c) Ronald B. George, MD FRCPC
- 49. #ASRASpring19@Ron_George Anesthesiology 2018; 128(4): 745-753 (c) Ronald B. George, MD FRCPC
- 50. #ASRASpring19@Ron_George A&A 2016; 123: 965-71 (c) Ronald B. George, MD FRCPC
- 51. #ASRASpring19@Ron_George A&A 2016; 123: 965-71 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 (c) Ronald B. George, MD FRCPC
- 52. #ASRASpring19@Ron_George 息 Smiths Medical 息 Smiths Medical (c) Ronald B. George, MD FRCPC
- 53. (c) Ronald B. George, MD FRCPC
- 54. #ASRASpring19@Ron_George P I E B Dosage PIEB Interval 30 min Clinician Bolus (CSE or Epi) 30 60 90 120 (c) Ronald B. George, MD FRCPC
- 55. #ASRASpring19@Ron_George P C E A P C E A Denied PCEA Request P I E B P I E B Dosage PCEA Lockout 15 min Clinician Bolus (CSE or Epi) 30 60 90 120 (c) Ronald B. George, MD FRCPC
- 56. (c) Ronald B. George, MD FRCPC
- 57. (c) Ronald B. George, MD FRCPC
- 58. #ASRASpring19@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 B. George, MD FRCPC
- 59. #ASRASpring19@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 PCEA lockout type (c) Ronald B. George, MD FRCPC
- 60. (c) Ronald B. George, MD FRCPC
- 61. (c) Ronald B. George, MD FRCPC
- 62. #ASRASpring19@Ron_George P I E B P I E B Dosage 30 60 90 120 Bolus interval type (c) Ronald B. George, MD FRCPC
- 63. #ASRASpring19@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 Bolus interval type (c) Ronald B. George, MD FRCPC
- 64. #ASRASpring19@Ron_George 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 (c) Ronald B. George, MD FRCPC
- 65. #ASRASpring19@Ron_George 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 (c) Ronald B. George, MD FRCPC
- 66. #ASRASpring19@Ron_George Shrink the change Tweak the environment Build habits Script critical points (c) Ronald B. George, MD FRCPC
- 67. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
- 68. #ASRASpring19@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 Restroom Bromage 4 Safety Concerns(c) Ronald B. George, MD FRCPC
- 69. #ASRASpring19@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 B. George, MD FRCPC
- 70. #ASRASpring19@Ron_George P I E B 30 60 90 120 Clinician Bolus (CSE or Epi) Dosage (c) Ronald B. George, MD FRCPC
- 71. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
- 72. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
- 73. #ASRASpring19@Ron_George OPTIMAL (c) Ronald B. George, MD FRCPC
- 74. #ASRASpring19@Ron_George PIEB Volume PIEB Interval NEXTInterval (c) Ronald B. George, MD FRCPC
- 75. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
- 76. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
- 77. #ASRASpring19@Ron_George Sia et al. Anaesthesia (2013) (c) Ronald B. George, MD FRCPC
- 78. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
- 79. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
- 80. #ASRASpring19@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 B. George, MD FRCPC
- 81. #ASRASpring19@Ron_George (c) Ronald B. George, MD FRCPC
- 82. #ASRASpring19@Ron_George Improved satisfaction Less local anesthetic ? Less anesthesia interventions ??? Less IVD ??? Safety concerns ??? Patient Engagement ??? Personalized labour analgesia (c) Ronald B. George, MD FRCPC
- 83. (c) Ronald B. George, MD FRCPC