Must we press on until a young mother dies? Remifentanil patient controlled analgesia in labour may not be suited as a “poor man’s epidural”

BMC Pregnancy and Childbirth

Arnd Hönig¹  Johannes Wirbelauer⁵  Ralf M Muellenbach⁴  Johanna Jokinen⁴  Andrea Melber³  Patricia Lavand’homme⁶  Thierry Girard²  Peter Kranke⁴ 

[1] Department of Obstetrics and Gynecology, University Hospitals of Würzburg, Josef-Schneider-Strasse 4, Würzburg 97080, Germany;Department of Anaesthesia, University Hospital Basel, Spitalstrasse 21, Basel, CH 4031, Switzerland;Department of Anaesthesia, Salem-Spital, Schänzlistrasse 39, 3000, Bern 25, Switzerland;Department of Anaesthesia and Critical Care, University Hospitals of Würzburg, Oberdürrbacher Str. 6, Würzburg 97080, Germany;University Children’s Hospital, Josef-Schneider-Strasse 2, Würzburg 97080, Germany;Department of Anesthesiology, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium

关键词: Healthcare Economics;    Healthcare Cost;    Patient Satisfaction;    Patient Controlled Analgesia;    Labour Analgesia;    Labour Pain;    Epidural Analgesia;    Remifentanil;   

Others  :  1137971
DOI  :  10.1186/1471-2393-13-139

 received in 2012-11-22, accepted in 2013-06-28,  发布年份 2013

【 摘 要 】

Background

The epidural route is still considered the gold standard for labour analgesia, although it is not without serious consequences when incorrect placement goes unrecognized, e.g. in case of intravascular, intrathecal and subdural placements. Until now there has not been a viable alternative to epidural analgesia especially in view of the neonatal outcome and the need for respiratory support when long-acting opioids are used via the parenteral route. Pethidine and meptazinol are far from ideal having been described as providing rather sedation than analgesia, affecting the cardiotocograph (CTG), causing fetal acidosis and having active metabolites with prolonged half-lives especially in the neonate. Despite these obvious shortcomings, intramuscular and intravenously administered pethidine and comparable substances are still frequently used in delivery units.

Since the end of the 90ths remifentanil administered in a patient-controlled mode (PCA) had been reported as a useful alternative for labour analgesia in those women who either don’t want, can’t have or don’t need epidural analgesia.

Discussion

In view of the need for conversion to central neuraxial blocks and the analgesic effect remifentanil has been demonstrated to be superior to pethidine. Despite being less effective in terms of the resulting pain scores, clinical studies suggest that the satisfaction with analgesia may be comparable to that obtained with epidural analgesia. Owing to this fact, remifentanil has gained a place in modern labour analgesia in many institutions.

However, the fact that remifentanil may cause harm should not be forgotten when the use of this potent mu-agonist is considered for the use in labouring women. In the setting of one-to-one midwifery care, appropriate monitoring and providing that enough experience exists with this potent opioid and the treatment of potential complications, remifentanil PCA is a useful option in addition to epidural analgesia and other central neuraxial blocks. Already described serious consequences should remind us not refer to remifentanil PCA as a “poor man’s epidural” and to safely administer remifentanil with an appropriate indication.

Summary

Therefore, the authors conclude that economic considerations and potential cost-savings in conjunction with remifentanil PCA may not be appropriate main endpoints when studying this valuable method for labour analgesia.

【 授权许可】

   
2013 Kranke et al.; licensee BioMed Central Ltd.

【 参考文献 】

• [1]Hodnett ED: Pain and women’s satisfaction with the experience of childbirth: a systematic review. Am J Obstet Gynecol 2002, 186:S160-S172.
• [2]ACOG: Pain Relief During Labor. ACOG Committee on Obstetric Practice 2004, Number 295. 2012. [Last access: 20 November]
• [3]Gogarten W, Van Aken H, Kessler P, et al.: Durchführung von Analgesie- und Anästhesieverfahren in der Geburtshilfe. Anästh Intensivmed 2009, 50:S502-S507.
• [4]Goetzl LM: ACOG Practice Bulletin. Clinical Management Guidelines for Obstetrician-Gynecologists Number 36, July 2002. Obstetric analgesia and anesthesia. Obstet Gynecol 2002, 100:177-191.
• [5]IASP: Declaration of Montreal: Declaration that Access to Pain Management Is a Fundamental Human Right. last access: 20 November; 2012. http://www.iasp-pain.org/PainSummit/DeclarationOfMontreal.pdf webcite
• [6]Freeman LM, Bloemenkamp KW, Franssen MT, et al.: Remifentanil patient controlled analgesia versus epidural analgesia in labour. A multicentre randomized controlled trial. BMC Pregnancy Childbirth 2012, 12:63. BioMed Central Full Text
• [7]AWMF: S3-Leitlinie Behandlung akuter perioperativer und posttraumatischer Schmerzen. last access: 20 November; 2012. http://www.awmf.org/uploads/tx_szleitlinien/041-001_S3_Behandlung_akuter_perioperativer_und_posttraumatischer_Schmerzen_aktualisierte_Fassung_04-2009_05-2011.pdf webcite 2009
• [8]Olofsson C, Ekblom A, Ekman-Ordeberg G, Hjelm A, Irestedt L: Lack of analgesic effect of systemically administered morphine or pethidine on labour pain. Br J Obstet Gynaecol 1996, 103:968-972.
• [9]Tsui MH, Ngan Kee WD, Ng FF, Lau TK: A double blinded randomised placebo-controlled study of intramuscular pethidine for pain relief in the first stage of labour. Br J Obstet Gynaecol 2004, 111:648-655.
• [10]Ullman R, Smith LA, Burns E, Mori R, Dowswell T: Parenteral opioids for maternal pain relief in labour. Cochrane Database Syst Rev 2010., (9) CD007396
• [11]Tveit TO, Halvorsen A, Rosland JH: Analgesia for labour: a survey of Norwegian practice - with a focus on parenteral opioids. Acta Anaesthesiol Scand 2009, 53:794-799.
• [12]Schnabel A, Hahn N, Muellenbach R: Obstetric analgesia in German clinics: Remifentanil as alternative to regional analgesia. Anaesthesist 2011, 60:995-1001.
• [13]Jankovic K, IASP: Guide to Pain Management in Low-Resource Settings. Chapter 17: Pharmacological Management of Pain in Obstetrics. Last access: 21 November; 2012. http://www.iasp-pain.org/AM/Template.cfm?Section=Home&Template=/CM/ContentDisplay.cfm&ContentID=12180 webcite 2012
• [14]Sheikh A, Tunstall ME: Comparative study of meptazinol and pethidine for the relief of pain in labour. Br J Obstet Gynaecol 1986, 93:264-269.
• [15]Nel CP, Bloch B, Rush JM: A comparison of meptazinol and pethidine for pain relief during the first stage of labour. S Afr Med J 1981, 59:908-910.
• [16]Irestedt L: Current status of nitrous oxide for obstetric pain relief. Acta Anaesthesiol Scand 1994, 38:771-772.
• [17]Klomp T, Van Poppel M, Jones L, Lazet J, Di Nisio M, Lagro-Janssen AL: Inhaled analgesia for pain management in labour. Cochrane Database Syst Rev 2012, 9:CD009351.
• [18]Rosen MA: Nitrous oxide for relief of labor pain: a systematic review. Am J Obstet Gynecol 2002, 186:S110-S126.
• [19]Shu Y, Patel SM, Pac-Soo C, et al.: Xenon pretreatment attenuates anesthetic-induced apoptosis in the developing brain in comparison with nitrous oxide and hypoxia. Anesthesiology 2010, 113:360-368.
• [20]Volmanen P, Akural E, Raudaskoski T, Ohtonen P, Alahuhta S: Comparison of remifentanil and nitrous oxide in labour analgesia. Acta Anaesthesiol Scand 2005, 49:453-458.
• [21]Jones R, Pegrum A, Stacey RG: Patient-controlled analgesia using remifentanil in the parturient with thrombocytopaenia. Anaesthesia 1999, 54:461-465.
• [22]Thurlow JA, Waterhouse P: Patient-controlled analgesia in labour using remifentanil in two parturients with platelet abnormalities. Br J Anaesth 2000, 84:411-413.
• [23]Roelants F, De Franceschi E, Veyckemans F, Lavand’homme P: Patient-controlled intravenous analgesia using remifentanil in the parturient. Can J Anaesth 2001, 48:175-178.
• [24]D’Onofrio P, Novelli AM, Mecacci F, Scarselli G: The efficacy and safety of continuous intravenous administration of remifentanil for birth pain relief: an open study of 205 parturients. Anesth Analg 2009, 109:1922-1924.
• [25]Manullang TR, Chun K, Egan TD: The use of remifentanil for Cesarean section in a parturient with recurrent aortic coarctation. Can J Anaesth 2000, 47:454-459.
• [26]McCarroll CP, Paxton LD, Elliott P, Wilson DB: Use of remifentanil in a patient with peripartum cardiomyopathy requiring Caesarean section. Br J Anaesth 2001, 86:135-138.
• [27]Heesen M, Klohr S, Hofmann T, et al.: Maternal and foetal effects of remifentanil for general anaesthesia in parturients undergoing caesarean section: a systematic review and meta-analysis. Acta Anaesthesiol Scand 2013, 57:29-36.
• [28]Hill D: Remifentanil patient-controlled analgesia should be routinely available for use in labour. Int J Obstet Anesth 2008, 17:336-339.
• [29]Lavand’homme P, Roelants F: Patient-controlled intravenous analgesia as an alternative to epidural analgesia during labor: questioning the use of the short-acting opioid remifentanil. Survey in the French part of Belgium (Wallonia and Brussels). Acta Anaesthesiol Belg 2009, 60:75-82.
• [30]Schnabel A, Hahn N, Broscheit J, et al.: Remifentanil for labour analgesia: a meta-analysis of randomised controlled trials. Eur J Anaesthesiol 2012, 29:177-185.
• [31]Tveit TO, Seiler S, Halvorsen A, Rosland JH: Labour analgesia: a randomised, controlled trial comparing intravenous remifentanil and epidural analgesia with ropivacaine and fentanyl. Eur J Anaesthesiol 2012, 29:129-136.
• [32]Douma MR, Middeldorp JM, Verwey RA, Dahan A, Stienstra R: A randomised comparison of intravenous remifentanil patient-controlled analgesia with epidural ropivacaine/sufentanil during labour. Int J Obstet Anesth 2011, 20:118-123.
• [33]Bonner JC, McClymont W: Respiratory arrest in an obstetric patient using remifentanil patient-controlled analgesia. Anaesthesia 2012, 67:538-540.
• [34]Pruefer C, Bewlay A: Respiratory arrest with remifentanil patient-controlled analgesia–another case. Anaesthesia 2012, 67:1044-1045.
• [35]Sneyd R: Remifentanil on the labour ward. Anaesthesia 2012, 67:1045-1046.
• [36]Sneyd JR: Off-label use of medicines is bad medicine flying the flag of clinical freedom. Int J Obstet Anesth 2009, 18:249-250.
• [37]Bogod DG: Off-licence use of medicines is bad medicine flying the flag of clinical freedom. Int J Obstet Anesth 2009, 18:250-252.
• [38]Frambach T, Wirbelauer J, Schelling P, et al.: Patient-controlled intravenous analgesia with remifentanil as an alternative to epidural analgesia during labor: case series and discussion of medicolegal aspects. Z Geburtshilfe Neonatol 2010, 214:145-150.
• [39]Kranke P, Schelling P, Frambach T, Wirbelauer J: Remifentanil-PCA to alleviate labor-pain - a true and safe alternative to epidural labor analgesia? Anasthesiol Intensivmed Notfallmed Schmerzther 2009, 44:660-663.
• [40]Kranke P, Lavand’homme P: The relief of pain in labour and the role of remifentanil. Eur J Anaesthesiol 2012, 29:116-120.
• [41]Ismail MT, Hassanin MZ: Neuraxial analgesia versus intravenous remifentanil for pain relief in early labor in nulliparous women. Arch Gynecol Obstet 2012, 286:1375-1381.
• [42]Douma MR, Verwey RA, Kam-Endtz CE, van der Linden PD, Stienstra R: Obstetric analgesia: a comparison of patient-controlled meperidine, remifentanil, and fentanyl in labour. Br J Anaesth 2010, 104:209-215.
• [43]Eisenach JC, Pan PH, Smiley R, Lavand’homme P, Landau R, Houle TT: Severity of acute pain after childbirth, but not type of delivery, predicts persistent pain and postpartum depression. Pain 2008, 140:87-94.
• [44]Konopka KH, Van Wijhe M: Opioid-induced hyperalgesia: pain hurts? Br J Anaesth 2010, 105:555-557.
• [45]Lee L, Weinger M: Anesthesia Patient Safety Foundation Consensus Conference Report. Anesth Analg 2012, 114:918-919.
• [46]Greene MF: Two hundred years of progress in the practice of midwifery. N Engl J Med 2012, 367:1732-1740.
• [47]Tveit TO, Halvorsen A, Seiler S, Rosland JH: Efficacy and side effects of intravenous remifentanil patient-controlled analgesia used in a stepwise approach for labour: an observational study. Int J Obstet Anesth 2013, 22:19-25.
• [48]Anonymous: The Lancet. London: Saturday, May 14, 1853. Lancet 1953, 61:453.
• [49]Saunders TA, Glass PS: A trial of labor for remifentanil. Anesth Analg 2002, 94:771-773.
• [50]Hollmann MW, Strumper D, Durieux ME: The poor man’s epidural: systemic local anesthetics for improving postoperative outcomes. Med Hypotheses 2004, 63:386-9.
• [51]Volmanen P, Palomaki O, Ahonen J: Alternatives to neuraxial analgesia for labor. Curr Opin Anaesthesiol 2011, 24:235-41.