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A service evaluation to assess epidural bolus requirements

Thursday, 22 May, 2014 - 11:05
Board 5

Poster Presenter: Hannah Wrigleyhannahwrigley@hotmail.com
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Epidural & equipment

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Service Evaluation

A Service Evaluation to Assess Epidural Bolus Requirements
HK Wrigley, P Yoxall. Department of Anaesthesia, St Helens and Knowsley NHS Trust
In our department, we have been using both continuous infusion and programmed intermittent bolus techniques for labour epidural management. As a service evaluation project we decided to assess the number of additional boluses which were being required with each of these techniques.  This would help assess the additional workload for both the midwifery and anaesthetic staff associated with the use of our labour epidurals.
We retrospectively  examined the clinical records of 97 women who had received labour epidurals. After placement of the epidural all women received a test dose of 2.5 – 3 ml 0.5% Bupivacaine then a loading dose of 10ml 0.1% Lbupivacaine + 2mcg/ml fentanyl. They then all had epidural infusions of 0.1% Lbupivacaine + 2mcg/ml either as a continuous infusion, between 10 – 15 ml/hr, or a programmed intermittent bolus regime (PIB) giving 8ml/hr plus a 5ml bolus every hour. Midwives could give further boluses of 10 ml from the pump every 30 minutes.  If these were not adequate the anaesthetist could give ‘rescue boluses’ of whatever local anaesthetic/ opiate combination they felt appropriate. We recorded the number of the two different types of boluses which were being administrated as well as the highest level of sensory block documented.
49 women had a continuous infusion epidural and 48 a PIB epidural. The requirements for midwife led boluses (MLB) and anaesthetist led boluses (ALB) are shown below. There was no statistically significant difference in required boluses between the two regimes  (MLB p=0.133, ALB p=0.72)  The highest recorded sensory block in the continuous infusion group had a range from T12-T3 (median T6), and in the PIB group T11-T5 (median T8).  The sensory block was significantly higher in the continuous infusion group (p=0.002)
Studies suggest the use of PIB epidurals can reduce manual bolus requirements1. In addition there may be reduced local anaesthetic usage and improved maternal satisfaction2.  This evaluation has given us information about our current requirement for manual boluses and therefore the workload impact on both midwifery and anaesthetic staff.. The requirement for anaesthetic led  ‘rescue boluses’ was reassuringly low at < 15%. 
Our finding that the highest  recorded level of sensory block  is significantly higher in the continuous infusion group is interesting as locally concerns have been raised to us by midwifery staff that the PIB epidural regime could cause complications due to an excessive high block and this finding should offer reassurance.
We did not show a significantly lower requirement for boluses in our PIB group to support recent studies1. However further work with greater patient numbers may show more difference between the groups.
1.Wong CA, Ratliff JT, Sullivan JT et al. A randomized comparisonof programmed intermittent epidural bolus with continuous epidural infusion for labor analgesia. Anaes Analg. 2006 Mar;102(3):904-9
2. George RB, Allen TK, Habib AS. Intermittent epidural bolus compared with continuous epidural infusions for labor analgesia: a systematic review and meta-analysis. Anaes Analg 2 013 Jan;116(1):133-44