Evaluation of vital signs-controlled, patient-assisted intravenous analgesia (VPIA) using remifentanil for labor pain

Background Controversy concerning increased cesarean births as a result of epidural analgesia for relief of labor pain has been attributed, in large part, to difficulties interpreting published studies because of design flaws. In this study, the authors compared epidural analgesia to intravenous meperidine analgesia using patient-controlled devices during labor to evaluate the effects of labor epidural analgesia, primarily on the rate of cesarean deliveries while minimizing limitations attributable to study design. Methods Four hundred fifty-nine nulliparous women in spontaneous labor at term were randomly assigned to receive either epidural analgesia or intravenous meperidine analgesia. Epidural analgesia was initiated with 0.25% bupivacaine and was maintained with 0.0625% bupivacaine and fentanyl 2 microg/ml at 6 ml/h with 5-ml bolus doses every 15 min as needed using a patient-controlled pump. Women in the intravenous analgesia group received 50 mg meperidine with 25 mg promethazine hydrochloride as an initial bolus, followed by 15 mg meperidine every 10 min as needed, using a patient-controlled pump. A written procedural manual that prescribed the intrapartum obstetric management was followed for each woman randomized in the study. Results A total of 226 women were randomized to receive epidural analgesia, and 233 women were randomized to receive intravenous meperidine analgesia. Protocol violations occurred in 8% (38 of 459) of women. There was no difference in the rate of cesarean deliveries between the two analgesia groups (epidural analgesia, 7% [16 of 226; 95% confidence interval, 4-11%] vs. intravenous meperidine analgesia, 9% [20 of 233; 95% confidence interval, 5-13%]; P = 0.61). Significantly more women randomized to epidural analgesia had forceps deliveries compared with those randomized to meperidine analgesia (12% [26 of 226] vs. 3% [7 of 233]; P < 0.001). Women who received epidural analgesia reported lower pain scores during labor and delivery compared with women who received intravenous meperidine analgesia. Conclusions Epidural analgesia compared with intravenous meperidine analgesia during labor does not increase cesarean deliveries in nulliparous women.

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Novel vital signs-controlled, patient-assisted intravenous analgesia using remifentanil for labour and delivery

International Journal of Obstetric Anesthesia ◽

10.1016/j.ijoa.2013.11.007 ◽

2014 ◽

Vol 23 (2) ◽

pp. 196-198 ◽

Cited By ~ 8

Author(s):

A.T. Sia ◽

B.L. Sng ◽

S. Leo

Keyword(s):

Vital Signs ◽

Intravenous Analgesia

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Analgesia for Labor Pain

Anesthesiology ◽

10.1097/00000542-200003000-00028 ◽

2000 ◽

Vol 92 (3) ◽

pp. 841-850 ◽

Cited By ~ 19

Author(s):

Alex Macario ◽

W. Craig Scibetta ◽

John Navarro ◽

Ed Riley

Keyword(s):

Epidural Analgesia ◽

Cost Model ◽

Secondary Analysis ◽

Labor Pain ◽

Nursing Interventions ◽

Accounting System ◽

Expected Cost ◽

Intravenous Analgesia ◽

Nursing Costs ◽

The Cost

Background Epidural analgesia and intravenous analgesia with opioids are two techniques for the relief of labor pain. The goal of this study was to develop a cost-identification model to quantify the costs (from society's perspective) of epidural analgesia compared with intravenous analgesia for labor pain. Because there is no valid method to assign a dollar value to differing levels of analgesia, the cost of each technique can be compared with the analgesic benefit (patient pain scores) of each technique. Methods The authors created a cost model for epidural and intravenous analgesia by reviewing the literature to determine the rates of associated clinical outcomes (benefit of each technique to produce analgesia) and complications (e.g., postdural puncture headache). The authors then analyzed data from their institution's cost-accounting system to determine the hospital cost for parturients admitted for delivery, estimated the cost of each complication, and performed a sensitivity analysis to evaluate the cost impact of changing key variables. A secondary analysis was performed assuming that the cost of nursing was fixed (did not change depending on the number of nursing interventions). Results If the cesarean section rate equals 20% for both intravenous and epidural analgesia, the additional expected cost per patient to society of epidural analgesia of labor pain ranges from $259 (assuming nursing costs in the labor and delivery suite do not vary with the number of nursing interventions) to $338 (assuming nursing costs do increase as the number of interventions increases) relative to the expected cost of intravenous analgesia for labor pain. This cost difference results from increased professional costs and complication costs associated with epidural analgesia. Conclusions Epidural analgesia is more costly than intravenous analgesia. How the cost of the anesthesiologist and nursing care is calculated affects how much more costly epidural analgesia is relative to intravenous analgesia. Published studies have determined that epidural analgesia provides relief of labor pain superior to intravenous analgesia, quantified in one study as 40 mm better on a 100-mm scale during the first stage of labor and 29 mm better during the second stage of labor. Patients, physicians, and society need to weigh the value of improved pain relief from epidural analgesia versus the increased cost of epidural analgesia.

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Case Series of Vital Signs-controlled, Patient-assisted Intravenous Analgesia (VPIA) Using Remifentanil for Labor and Delivery

Obstetric Anesthesia Digest ◽

10.1097/01.aoa.0000530013.06592.65 ◽

2018 ◽

Vol 38 (1) ◽

pp. 47

Author(s):

W.L. Leong ◽

B.L. Sng ◽

Q. Zhang ◽

N.L.R. Han ◽

R. Sultana ◽

...

Keyword(s):

Vital Signs ◽

Case Series ◽

Labor And Delivery ◽

Intravenous Analgesia

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A Randomized Sequential Allocation Study to Determine the Minimum Effective Analgesic Concentration of Levobupivacaine and Ropivacaine in Patients Receiving Epidural Analgesia for Labor

Anesthesiology ◽

10.1097/00000542-200312000-00022 ◽

2003 ◽

Vol 99 (6) ◽

pp. 1383-1386 ◽

Cited By ~ 60

Author(s):

Dan Benhamou ◽

Caroline Ghosh ◽

Frédéric J. Mercier

Keyword(s):

Adverse Events ◽

Epidural Analgesia ◽

Vital Signs ◽

Sensory Block ◽

Labor Pain ◽

Double Blind Study ◽

Double Blind ◽

Treatment Groups ◽

Pain Scores ◽

Sequential Allocation

Background This study was designed to determine and compare the minimum local analgesic concentrations of levobupivacaine and ropivacaine when used in epidural obstetric analgesia. Methods In a double-blind study, healthy women requiring epidural analgesia for labor pain were randomized to receive either ropivacaine or levobupivacaine. Drugs were administered as a 20-ml epidural bolus. The concentration of each started at 0.11% and increased or decreased at intervals of 0.01%, depending on the response of the previous patient, using the technique of up-down sequential allocation. Minimum local analgesic concentrations were calculated using the formula of Dixon and Massey. Efficacy was assessed using visual analog pain scores and motor and sensory block assessments, and safety was assessed by recording maternal and fetal/neonate vital signs and adverse events. Results Forty-seven patients received levobupivacaine, and 47 received ropivacaine. Minimum local analgesic concentrations for levobupivacaine (0.077%; 95% CI, 0.058-0.096%) were lower than those for ropivacaine (0.092%; 95% CI, 0.082-0.102%). The 0.015% difference was not statistically significant. There was no notable difference between treatment groups in the proportion of patients reporting drug-related adverse events. Conclusions Levobupivacaine was 19% more potent than ropivacaine and provided similar safety results.

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