title: Programmed intermittent epidural boluses for maintenance of labor analgesia: an impact study.
abstract: BACKGROUND
  The aim of this impact study was to compare the analgesic efficacy and side effect profile of programmed intermittent epidural boluses (PIEB)+patient-controlled epidural analgesia (PCEA) to continuous epidural infusion (CEI)+PCEA for maintenance labor analgesia after the introduction of PIEB at our institution.
  
  
  METHODS
  We conducted a retrospective analysis after replacing the background CEI with PIEB for our labor PCEA. Pre-change pump settings were CEI 12mL/h with PCEA (12mL bolus, lockout 15min); PIEB settings were a 9mL bolus every 45min with PCEA (10mL bolus, lockout 10min). We compared medical records of all women receiving epidural or combined spinal-epidural labor analgesia for vaginal delivery for two months before PIEB implementation to a two-month period of PIEB utilization following a five-month introductory familiarization period. The primary outcome was the proportion of women requiring rescue clinician boluses.
  
  
  RESULTS
  Fewer patients in the PIEB group required rescue clinician boluses compared to the CEI group (12% vs. 19%, P=0.012). Time to first rescue bolus request and total bolus dose were not different. Peak (median [IQR]) pain scores were 2[0-5] with CEI and 0[0-4] with PIEB. There was no difference in instrumental delivery rates.
  
  
  CONCLUSIONS
  Using PIEB compared to CEI as the background maintenance epidural analgesia method in conjunction with PCEA reduced the number of women requiring clinician rescue boluses while providing comparable labor analgesia. The findings of this clinical care impact study confirm the results of randomized controlled studies and suggest PIEB may be a preferable technique to CEI for the maintenance of labor analgesia.
authors.affiliation: Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: C P
authors.initials: CP
authors.lastname: McKenzie
authors.affiliation: Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: B
authors.initials: B
authors.lastname: Cobb
authors.affiliation: Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: E T
authors.initials: ET
authors.lastname: Riley
authors.affiliation: Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA. Electronic address: bcarvalho@stanford.edu.
authors.forename: B
authors.initials: B
authors.lastname: Carvalho
mesh_terms: D000328:Adult; D015360:Analgesia, Epidural / Q000379:methods*; D016362:Analgesia, Obstetrical / Q000379:methods*; D016058:Analgesia, Patient-Controlled; D005260:Female; D006801:Humans; D011247:Pregnancy; D016032:Randomized Controlled Trials as Topic; D012189:Retrospective Studies
keywords: Automated epidural boluses; Epidural; Labor analgesia; Programmed intermittent epidural bolus