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Created May 21, 2015, last updated almost 4 years ago.
Collection: 21, Score: 2199, Trend score: 0, Read count: 2630, Articles count: 11, Created: 2015-05-21 04:33:17 UTC. Updated: 2021-02-08 23:44:39 UTC.Notes
The remifentanil PCA for labour analgesia controversy continues...
Those advocating its first-line use point to reassuring evidence of maternal satisfaction and acceptability, reduced epidural rates, and some suggestion of reduced instrumental delivery rates.
For the negative, the ongoing safety concerns created by routine use of remifentanil PCAs are foremost, particularly given how uneven hospitals can be at implementing best safety practices. Observed rates of significant desaturation range from 25-70%, in addition to potential neonatal effects.
The greatest challenge facing the remiPCA advocates, is that the labour epidural is still the most effective form of labour analgesia, and has only improved over the decades as safety has been both maintained and increased.
Daniel Jolley
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Collected Articles
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Randomized Controlled Trial Comparative Study
Remifentanil for labour analgesia: a double-blinded, randomised controlled trial of maternal and neonatal effects of patient-controlled analgesia versus continuous infusion.
Remifentanil patient controlled analgesia during labour is more effective and results in less remifentanil consumed than does continuous infusion.
pearl -
Randomized Controlled Trial Multicenter Study Comparative Study
Intravenous remifentanil patient-controlled analgesia versus intramuscular pethidine for pain relief in labour (RESPITE): an open-label, multicentre, randomised controlled trial.
What did they do?
Wilson et al randomized 401 laboring women across multiple centers to either remifentanil PCA or pethidine/meperidine IM, then compared the progression of these women to labour epidural.
On the surface... this might appear disingenuous, as it compares remifentanil PCA to widely-shown-to-be-ineffective parenteral pethidine – rather than to the gold standard labour epidural. But it's also a study of how the technique might practically be used in the real world.
What they found
Women with remifentanil PCA progressed half as often to require epidural analgesia than those receiving pethidine (19% vs 41%).
Though it's one of the secondary findings that is most interesting: the remifentanil group were less likely to need instrumental delivery (15% vs 26%).
But don't get carried away
Despite the demonstrated superiority of remi PCA to pethidine, the technique is not without it's issues:
- Safety concerns regarding respiratory depression cannot be ignored, and because managing this relies upon staff vigilance, increased PCA use may conversely lead to a normalisation of risk and institutional complacency, rather than safety improvement.
- Analgesia is still inferior to epidural, even if maternal satisfaction is comparable.
- Technique acceptability might not be as good in communities with high pre-existing epidural use.
And finally... why are we so eager to do away with the labour epidural? Serious complications are very uncommon to rare, the technique is widely acceptable to women, and it is more effective than any other modality.
Is this change driven by the needs of pregnant women, or the health system's limited resources?
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Cochrane Db Syst Rev · Apr 2017
Review Meta AnalysisPatient-controlled analgesia with remifentanil versus alternative parenteral methods for pain management in labour.
Multiple analgesic strategies for pain relief during labour are available. Recently remifentanil, a short-acting opioid, has recently been used as an alternative analgesic due to its unique pharmacological properties. ⋯ Based on the current systematic review, there is mostly low-quality evidence to inform practice and future research may significantly alter the current situation. The quality of evidence is mainly limited by poor quality of the studies, inconsistency, and imprecision. More research is needed on maternal and neonatal safety outcomes (maternal apnoea and respiratory depression, Apgar score) and on the optimal mode and regimen of remifentanil administration to provide highest efficacy with reasonable adverse effects for mothers and their newborns.
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Randomized Controlled Trial Multicenter Study Comparative Study
Patient controlled analgesia with remifentanil versus epidural analgesia in labour: randomised multicentre equivalence trial.
To determine women's satisfaction with pain relief using patient controlled analgesia with remifentanil compared with epidural analgesia during labour. ⋯ In women in labour, patient controlled analgesia with remifentanil is not equivalent to epidural analgesia with respect to scores on satisfaction with pain relief. Satisfaction with pain relief was significantly higher in women who were allocated to and received epidural analgesia.
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Int J Obstet Anesth · Aug 2019
Serious adverse events attributed to remifentanil patient-controlled analgesia during labour in The Netherlands.
During labour, remifentanil patient-controlled analgesia is used as an alternative to neuraxial analgesia. Remifentanil is associated with hypoventilation and respiratory depression but the frequency of serious maternal and neonatal adverse events is unknown. The aim of this study was to estimate the number of serious adverse events attributed to the use of remifentanil patient-controlled analgesia during labour in The Netherlands and to investigate the circumstances (e.g. monitoring, practice deviations) of these events and the subsequent management. ⋯ The risk of a potentially life-threatening serious adverse event attributed to remifentanil patient-controlled analgesia seems to be low. All patients recovered without deficit. Adherence to strict monitoring and the attendance of trained healthcare providers is required to safely use remifentanil for labour analgesia.
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Cochrane Db Syst Rev · May 2018
Review Meta AnalysisEpidural versus non-epidural or no analgesia for pain management in labour.
Epidural analgesia is a central nerve block technique achieved by injection of a local anaesthetic close to the nerves that transmit pain, and is widely used as a form of pain relief in labour. However, there are concerns about unintended adverse effects on the mother and infant. This is an update of an existing Cochrane Review (Epidural versus non-epidural or no analgesia in labour), last published in 2011. ⋯ Low-quality evidence shows that epidural analgesia may be more effective in reducing pain during labour and increasing maternal satisfaction with pain relief than non-epidural methods. Although overall there appears to be an increase in assisted vaginal birth when women have epidural analgesia, a post hoc subgroup analysis showed this effect is not seen in recent studies (after 2005), suggesting that modern approaches to epidural analgesia in labour do not affect this outcome. Epidural analgesia had no impact on the risk of caesarean section or long-term backache, and did not appear to have an immediate effect on neonatal status as determined by Apgar scores or in admissions to neonatal intensive care. Further research may be helpful to evaluate rare but potentially severe adverse effects of epidural analgesia and non-epidural analgesia on women in labour and long-term neonatal outcomes.
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Review Comparative Study
Patient-controlled analgesia with remifentanil vs. alternative parenteral methods for pain management in labour: a Cochrane systematic review.
We aimed to assess the effectiveness of remifentanil used as intravenous patient-controlled analgesia for the pain of labour. We performed a systematic literature search in December 2015 (updated in December 2016). We included randomised, controlled and cluster-randomised trials of women in labour with planned vaginal delivery receiving patient-controlled remifentanil compared principally with other parenteral and patient-controlled opioids, epidural analgesia and continuous remifentanil infusion or placebo. ⋯ However, the relative risk (95%CI) for maternal respiratory depression for patient-controlled remifentanil compared with epidural analgesia (three trials, 687 patients, low-quality evidence) was 0.91 (0.51-1.62). Compared with continuous intravenous infusion of remifentanil (two trials, 135 patients, low-quality evidence) no conclusion could be reached as all study arms showed zero events. The relative risk (95%CI) of Apgar scores less than 7 at 5 min after birth compared with epidural analgesia (five trials, 1322 participants, low-quality evidence) was 1.26 (0.62-2.57).
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Observational Study
A prospective observational study of maternal oxygenation during remifentanil patient-controlled analgesia use in labour.
Maternal desaturation is common during remifentanil PCA analgesia for labour.
pearl -
Randomized Controlled Trial
Labour pain with remifentanil patient-controlled analgesia versus epidural analgesia: a randomised equivalence trial.
Women are more satisfied with pain relief with labour epidural analgesia than with remifentanil PCA.
pearl
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