Comparison of different delivery modalities of epidural analgesia and intravenous analgesia in labour: a systematic review and network meta-analysis
Authors' conclusion
Opioid PCA did not provide the same level of analgesia as epidural methods with a higher incidence of side effects.
Study context
- Population
- Nulliparous and/or multiparous parturients in spontaneous or induced labour; maintenance epidural solution with low-concentration local anesthetic and an opioid; specific subgroups (e.g. preeclampsia) excluded73 trials
- Comparison
- Continuous epidural infusion (CEI), programmed intermittent epidural bolus (PIEB), computer-integrated CEI, computer-integrated PIEB, PCEA, fentanyl patient-controlled analgesia (PCA) and remifentanil PCA, alone or in combination
- Outcome
- Coprimary: need for rescue analgesia; maternal satisfaction
Methodological detailsfrequentist network meta-analysis, coprimary outcomes
- Frequentist network meta-analysis
- Coprimary outcomes
Pooled result
As reported in the abstract
Need for rescue analgesia; maternal satisfaction (coprimary)
- Rescue analgesia: CEI inferior to PIEB; PIEB + PCEA superior to PCEA alone (low certainty of evidence)
- Maternal satisfaction improved by PIEB + PCEA vs CEI + PCEA and PCEA alone (low quality of evidence)
- Fentanyl PCA increased rescue analgesia requirement and decreased maternal satisfaction vs many epidural delivery methods
- Low certainty of evidence (serious limitations and imprecision)
Further pooled results
Analgesic efficacy and local anesthetic consumption
- PIEB increased analgesic efficacy vs CEI
- PCEA reduced local anesthetic consumption but inferior analgesia vs CEI and PIEB
PIEB + PCEA vs CEI + PCEA
- PIEB + PCEA superior for pain score at 2 h and 4 h, local anesthetic consumption, lower limb motor blockade and spontaneous vaginal delivery rate
Analgesia with opioid PCA
- Fentanyl and remifentanil PCA did not provide the same analgesia as all epidural methods; ineffectiveness increased with time in labour
- Remifentanil PCA superior to fentanyl PCA for analgesia at an early time point
Safety
Side effects of opioid PCA
- Fentanyl and remifentanil PCA: higher incidence of nausea and/or vomiting and sedation
- Remifentanil PCA increased oxygen desaturation vs other epidural delivery strategies
Original publication
Comparison of different delivery modalities of epidural analgesia and intravenous analgesia in labour: a systematic review and network meta-analysis. Can J Anaesth. Published 31 January 2023. doi:10.
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