remifentanil in labor - sfai.se€¦ · remifentanil in labour analgesia – where are we in 2017...
TRANSCRIPT
Remifentanil in labour analgesia ndashwhere are we in 2017 ndash an update
Vegard Dahl Head of Dept ofAnaesthesia and Intensive Care
Professor Akershus University Hospital Norway
SSAI Malmoslash 2017
Disclosures
bull Nonehellip
SSAI Malmoslash 2017
Agenda
bull Pharmacology
bull Does it work
bull Whys use it at all
bull Conclusion
SSAI Malmoslash 2017
Remifentanil - Pharma
SSAI Malmoslash 2017
Pharmacology
bull Highly lipid soluble micro-receptor agonist opioid
bull 70 proteinbound
bull Esther linkage - undergoes rapid hydrolysis to remifentanil acid by tissue and plasma estherase T12 1-5min
bull Context sensitive half-life 3-4 minutes
bull Potency = 2x fentanyl 100-200x morphine
bull Lower plasma concentration in pregnants versus non-pregnants ndash large variability
SSAI Malmoslash 2017
Fetal exposure
bull Uterine veinMaternal artery ratio 088
bull Umbilical arteryumbilical vein ratio 029
ndash Redistribution rapid fetal metabolism
SSAI Malmoslash 2017
Is it in use
SSAI Malmoslash 2017
SSAI Malmoslash 2017
RemiPCA SAFE NetworkcopyRegimenConcentration of Remifentanil 20mcgml (2mg Remifentanil in 100ml NaCl 09)Bolus 10-30 μgLockout interval 2 minNo additional infusion of remifentanil No application of any other opioid or analgesicdrug
httpswwwgooglecommapsdviewermid=1BrSGgixaIx0JjdvPPBPbHjzlkUAampusp=sharing
2017 7800 deliveries
266 Hypoxia26 Sedation17 Nausea
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Labor or Delivery Opioids cross the placenta and may produce respiratory depression and psycho-physiologic effects in neonates An opioid antagonist such as naloxone must be available for reversal of opioid-induced respiratory depression in the neonate ULTIVA is not recommended for use in pregnant women during or immediately prior to labor when other analgesic techniques are more appropriate Opioid analgesics including ULTIVA can prolong labor through actions which temporarily reduce the strength duration and frequency of uterine contractions However this effect is not consistent and may be offset by an increased rate of cervical dilation which tends to shorten labor Monitor neonates exposed to opioid analgesics during labor for signs of excess sedation and respiratory depression
USA2015 36 occasionally
Bhatia K Unknowns in the use of remifentanil PCA for labour analgesia Anaesthesia 201368(6)641-2
Birnbach DJ Ranasinghe JS Is remifentanil a safe and effective alternative to neuraxial labor analgesia It all depends Anesth Analg 2014118(3)491-3
Bonner JC McClymont W Respiratory arrest in an obstetric patient using remifentanil patient-controlled analgesia Anaesthesia 201267(5)538-40
Daly O Kelly KP McCormack JG Heidemann BH Remifentanil PCA in labour Anaesthesia 201368(7)780-1
Devabhakthuni S Efficacy and safety of remifentanil as an alternative labor analgesic Clin Med Insights Womens Health 2013637-49
Freeman LM Bloemenkamp KW Franssen MT et al Patient controlled analgesia with remifentanil versus epidural analgesia in labour randomised multicentreequivalence trial BMJ 2015350(7997)11
Kranke P Girard T Lavandhomme P Melber A Jokinen J Muellenbach RM et al Must we press on until a young mother dies Remifentanil patient controlled analgesia in labourmay not be suited as a poor mans epidural BMC Pregnancy Childbirth 201313139
Muchatuta NA Kinsella SM Remifentanil for labour analgesia time to draw breath Anaesthesia 201368(3)231-5
SSAI Malmoslash 2017
The ideal opioid delivery
SSAI Malmoslash 2017
Time
Pain
intensity
and effect
Contraction pain
Pain relief
Does not exist
Opioids and labour analgeisahellip
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Tramadol meptazinol pethidine diamorphine pentazocine nalbuphinefentanylIMIV Pca vs bolus
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Van De Velde and Carvalho IJOA 2016 15 66-74
SSAI Malmoslash 2017
Remi 40microg2minsFenta 20microg + loadingPet 5 mg + loading
SSAI Malmoslash 2017
Other opioids better
bull CONCLUSIONS Intravenous patient-controlled analgesia with either remifentanil or fentanyl provides a moderate degree of labour analgesia whereas transient maternal oxygen desaturation is observed more commonly with remifentanil Fentanyl is associated with a higher need for neonatal resuscitation Marwah R
Hassan S Carvalho JC Balki M Remifentanil versus fentanyl for intravenous patient-controlled labour analgesia an observational study Canadian Journal of Anaesthesia 201259(3)246-54
SSAI Malmoslash 2017
Remifentanil provides betterpain relief than other opioids but only during the first twohours
SSAI Malmoslash 2017
Does it work
SSAI Malmoslash 2017
From M Van De Velde B Carvalho IJOA 2016 25 66-74
SSAI Malmoslash 2017
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 TRIAL REGISTRATION Netherlands Trial Register NTR2551
CONCLUSION In terms of labor duration average VAS pain scores and maternal overall satisfaction score with analgesia CSE analgesia is superior to that provided by epidural analgesia or PCIA with remifentanil for pain relief in early labor in nulliparous women However there were no differences in the mode of delivery side effects or neonatal outcomes between the three techniques
Efficacy of Remifentanil PCA as compared to CSEEpidural
SSAI Malmoslash 2017
Oxygen saturation was significantly lower (SpO2 lt92) in women who used remifentanil (relative risk 15 14 to 17)
Remifentanil IVPCA provides poorer efficacy on labor analgesia than epidural analgesia with more sedation on parturients and a trend of newborn acidosis
Lin R Tao Y Yu Y Xu Z Su J Liu Z Intravenous remifentanil versus epidural ropivacaine with sufentanil for labour analgesia a retrospective study PLoS ONE [Electronic Resource] 20149(11)e112283
SSAI Malmoslash 2017
Meta Analyses
bull This meta-analysis suggests that remifentanil PCIA is not superior to epidural analgesia in analgesic efficacy during labor Given the wide CIs of the pooled results for secondary maternal and neonatal outcomes definite conclusions cannot be drawn for those outcomes Further studies are still warranted to validate these conclusions Liu ZQ Chen XB Li HB Qiu MT Duan T A comparison of remifentanil parturient-controlled intravenous analgesia with
epidural analgesia a meta-analysis of randomized controlled trials Anesth Analg 2014118(3)598-603
bull CONCLUSION During labour remifentanil-PCA provided superior analgesia and higher patient satisfactioncompared with pethidine with a comparable degree of adverse events Epidural analgesia providedsuperior pain relief in comparison with remifentanil Due to a low number of reported adverse events thesafety issue of remifentanil use in labour remains an open question that needs to be addressed in futuretrials Schnabel A Hahn N Broscheit J Muellenbach RM Rieger L Roewer N et al Remifentanil for labour analgesia a meta-analysis of
randomised controlled trials European Journal of Anaesthesiology 201229(4)177-85
bull Conclusions Pooled assessment of remifentanil intervention seems an attractive strategy for controlling labor pain in health term parturients but it is not supported by strong evidence Current evidencesuggests that it may produce effective analgesia by only a modest level HealthMED 20126(7)2407-18
Effect size difference 3 cm
SSAI Malmoslash 2017
SSAI Malmoslash 2017
APRIL 2017
20 RCTrsquos 3569 women
Results Weibel et al
bull Based on the current systematic review there is mostly low-quality evidence to inform practiceand future research may significantly alter thecurrent 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 safetyoutcomes (maternal apnoe and respiratorydepression Apgar score) and on the optimal mode and regimen of remifentanil administrationto provide highets efficacy with reasonableadverse effects for mother and their newborns
SSAI Malmoslash 2017
Always satisfied
Off course they are Who wouldnrsquot
SSAI Malmoslash 2017
Optimal administration of remi
SSAI Malmoslash 2017
Optimal administration of remi
bull Protocols varies (bolus dose lock-out background infusion TCI etc)
bull Fixed bolus 20-50 microg without backgroundinfusion lock-out 2-3 minutes
bull If background ndash small dose lt 005microgkgxmin
bull TCI 05-15 ngml
bull New systems VPIA (Vital signs patientcontrolled intravenous analgesia)
SSAI Malmoslash 2017
SIA et al IJOA correspondence 2014 23 196-8
SSAI Malmoslash 2017
Cont infusion or PCA
bull Shen MK Wu ZF Zhu AB et al Remifentanil for labour analgesia a double-blinded randomised controlled trial of maternal and neonatal effects ofpatient-controlled analgesia versus continuous infusion (0005-02 microgkgxmin) Anaesthesia 201368(3)236-44 The results suggest thatremifentanil PCA (01-04 microgkg) provides better pain relief and similarplacental transfer compared with continuous infusion (Author)
bull Per protocol TCI Norwegian National Hospital (Oslo University Hospital)
ndash 05 ndash 2 ngml + nurse controlled boluses) ndash easier for anaesthesia personell
SSAI Malmoslash 2017
Remifentanil TCI
bull Why notbull Acta Anaesthesiol Scand 2013 Jul57(6)802-8 doi 101111aas12096 Epub 2013 Mar 15
bull Remifentanil target-controlled infusion during second stage labour in high-risk parturients a case series Schwarz GL1 Volmanen P Albrechtsen S Bjoernestad E
bull 1ngml start incremental doses of 05 ngml titrated untill satisfied mother or side-effects(1-6 ngml)
SSAI Malmoslash 2017
Why use remifentanil
The boss
SSAI Malmoslash 2017
In conclusionhellip
SSAI Malmoslash 2017
When to use it
bull For parturients with contraindications to regional analgesia
ndash Bleeding disorders
ndash Infections
ndash Mother does not want regional
bull In places with reduced anaesthesia service
SSAI Malmoslash 2017
Then remifentanil is the best choice
bull Continuous monitoring
bull Including capnography or RR counting
bull Well educated staff
SSAI Malmoslash 2017
Remifentanil PCA
bull Is cheap
bull Easy to administer
bull Gives (some) pain relief
SSAI Malmoslash 2017
BUT
bull Has a poor analgesic effect compared to thegolden standard of regional analgesia
bull May cause a lot of harm
bull Andhellip
SSAI Malmoslash 2017
AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS
Is too dangerous to be used as routineanalgesia in the labour ward
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
Disclosures
bull Nonehellip
SSAI Malmoslash 2017
Agenda
bull Pharmacology
bull Does it work
bull Whys use it at all
bull Conclusion
SSAI Malmoslash 2017
Remifentanil - Pharma
SSAI Malmoslash 2017
Pharmacology
bull Highly lipid soluble micro-receptor agonist opioid
bull 70 proteinbound
bull Esther linkage - undergoes rapid hydrolysis to remifentanil acid by tissue and plasma estherase T12 1-5min
bull Context sensitive half-life 3-4 minutes
bull Potency = 2x fentanyl 100-200x morphine
bull Lower plasma concentration in pregnants versus non-pregnants ndash large variability
SSAI Malmoslash 2017
Fetal exposure
bull Uterine veinMaternal artery ratio 088
bull Umbilical arteryumbilical vein ratio 029
ndash Redistribution rapid fetal metabolism
SSAI Malmoslash 2017
Is it in use
SSAI Malmoslash 2017
SSAI Malmoslash 2017
RemiPCA SAFE NetworkcopyRegimenConcentration of Remifentanil 20mcgml (2mg Remifentanil in 100ml NaCl 09)Bolus 10-30 μgLockout interval 2 minNo additional infusion of remifentanil No application of any other opioid or analgesicdrug
httpswwwgooglecommapsdviewermid=1BrSGgixaIx0JjdvPPBPbHjzlkUAampusp=sharing
2017 7800 deliveries
266 Hypoxia26 Sedation17 Nausea
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Labor or Delivery Opioids cross the placenta and may produce respiratory depression and psycho-physiologic effects in neonates An opioid antagonist such as naloxone must be available for reversal of opioid-induced respiratory depression in the neonate ULTIVA is not recommended for use in pregnant women during or immediately prior to labor when other analgesic techniques are more appropriate Opioid analgesics including ULTIVA can prolong labor through actions which temporarily reduce the strength duration and frequency of uterine contractions However this effect is not consistent and may be offset by an increased rate of cervical dilation which tends to shorten labor Monitor neonates exposed to opioid analgesics during labor for signs of excess sedation and respiratory depression
USA2015 36 occasionally
Bhatia K Unknowns in the use of remifentanil PCA for labour analgesia Anaesthesia 201368(6)641-2
Birnbach DJ Ranasinghe JS Is remifentanil a safe and effective alternative to neuraxial labor analgesia It all depends Anesth Analg 2014118(3)491-3
Bonner JC McClymont W Respiratory arrest in an obstetric patient using remifentanil patient-controlled analgesia Anaesthesia 201267(5)538-40
Daly O Kelly KP McCormack JG Heidemann BH Remifentanil PCA in labour Anaesthesia 201368(7)780-1
Devabhakthuni S Efficacy and safety of remifentanil as an alternative labor analgesic Clin Med Insights Womens Health 2013637-49
Freeman LM Bloemenkamp KW Franssen MT et al Patient controlled analgesia with remifentanil versus epidural analgesia in labour randomised multicentreequivalence trial BMJ 2015350(7997)11
Kranke P Girard T Lavandhomme P Melber A Jokinen J Muellenbach RM et al Must we press on until a young mother dies Remifentanil patient controlled analgesia in labourmay not be suited as a poor mans epidural BMC Pregnancy Childbirth 201313139
Muchatuta NA Kinsella SM Remifentanil for labour analgesia time to draw breath Anaesthesia 201368(3)231-5
SSAI Malmoslash 2017
The ideal opioid delivery
SSAI Malmoslash 2017
Time
Pain
intensity
and effect
Contraction pain
Pain relief
Does not exist
Opioids and labour analgeisahellip
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Tramadol meptazinol pethidine diamorphine pentazocine nalbuphinefentanylIMIV Pca vs bolus
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Van De Velde and Carvalho IJOA 2016 15 66-74
SSAI Malmoslash 2017
Remi 40microg2minsFenta 20microg + loadingPet 5 mg + loading
SSAI Malmoslash 2017
Other opioids better
bull CONCLUSIONS Intravenous patient-controlled analgesia with either remifentanil or fentanyl provides a moderate degree of labour analgesia whereas transient maternal oxygen desaturation is observed more commonly with remifentanil Fentanyl is associated with a higher need for neonatal resuscitation Marwah R
Hassan S Carvalho JC Balki M Remifentanil versus fentanyl for intravenous patient-controlled labour analgesia an observational study Canadian Journal of Anaesthesia 201259(3)246-54
SSAI Malmoslash 2017
Remifentanil provides betterpain relief than other opioids but only during the first twohours
SSAI Malmoslash 2017
Does it work
SSAI Malmoslash 2017
From M Van De Velde B Carvalho IJOA 2016 25 66-74
SSAI Malmoslash 2017
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 TRIAL REGISTRATION Netherlands Trial Register NTR2551
CONCLUSION In terms of labor duration average VAS pain scores and maternal overall satisfaction score with analgesia CSE analgesia is superior to that provided by epidural analgesia or PCIA with remifentanil for pain relief in early labor in nulliparous women However there were no differences in the mode of delivery side effects or neonatal outcomes between the three techniques
Efficacy of Remifentanil PCA as compared to CSEEpidural
SSAI Malmoslash 2017
Oxygen saturation was significantly lower (SpO2 lt92) in women who used remifentanil (relative risk 15 14 to 17)
Remifentanil IVPCA provides poorer efficacy on labor analgesia than epidural analgesia with more sedation on parturients and a trend of newborn acidosis
Lin R Tao Y Yu Y Xu Z Su J Liu Z Intravenous remifentanil versus epidural ropivacaine with sufentanil for labour analgesia a retrospective study PLoS ONE [Electronic Resource] 20149(11)e112283
SSAI Malmoslash 2017
Meta Analyses
bull This meta-analysis suggests that remifentanil PCIA is not superior to epidural analgesia in analgesic efficacy during labor Given the wide CIs of the pooled results for secondary maternal and neonatal outcomes definite conclusions cannot be drawn for those outcomes Further studies are still warranted to validate these conclusions Liu ZQ Chen XB Li HB Qiu MT Duan T A comparison of remifentanil parturient-controlled intravenous analgesia with
epidural analgesia a meta-analysis of randomized controlled trials Anesth Analg 2014118(3)598-603
bull CONCLUSION During labour remifentanil-PCA provided superior analgesia and higher patient satisfactioncompared with pethidine with a comparable degree of adverse events Epidural analgesia providedsuperior pain relief in comparison with remifentanil Due to a low number of reported adverse events thesafety issue of remifentanil use in labour remains an open question that needs to be addressed in futuretrials Schnabel A Hahn N Broscheit J Muellenbach RM Rieger L Roewer N et al Remifentanil for labour analgesia a meta-analysis of
randomised controlled trials European Journal of Anaesthesiology 201229(4)177-85
bull Conclusions Pooled assessment of remifentanil intervention seems an attractive strategy for controlling labor pain in health term parturients but it is not supported by strong evidence Current evidencesuggests that it may produce effective analgesia by only a modest level HealthMED 20126(7)2407-18
Effect size difference 3 cm
SSAI Malmoslash 2017
SSAI Malmoslash 2017
APRIL 2017
20 RCTrsquos 3569 women
Results Weibel et al
bull Based on the current systematic review there is mostly low-quality evidence to inform practiceand future research may significantly alter thecurrent 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 safetyoutcomes (maternal apnoe and respiratorydepression Apgar score) and on the optimal mode and regimen of remifentanil administrationto provide highets efficacy with reasonableadverse effects for mother and their newborns
SSAI Malmoslash 2017
Always satisfied
Off course they are Who wouldnrsquot
SSAI Malmoslash 2017
Optimal administration of remi
SSAI Malmoslash 2017
Optimal administration of remi
bull Protocols varies (bolus dose lock-out background infusion TCI etc)
bull Fixed bolus 20-50 microg without backgroundinfusion lock-out 2-3 minutes
bull If background ndash small dose lt 005microgkgxmin
bull TCI 05-15 ngml
bull New systems VPIA (Vital signs patientcontrolled intravenous analgesia)
SSAI Malmoslash 2017
SIA et al IJOA correspondence 2014 23 196-8
SSAI Malmoslash 2017
Cont infusion or PCA
bull Shen MK Wu ZF Zhu AB et al Remifentanil for labour analgesia a double-blinded randomised controlled trial of maternal and neonatal effects ofpatient-controlled analgesia versus continuous infusion (0005-02 microgkgxmin) Anaesthesia 201368(3)236-44 The results suggest thatremifentanil PCA (01-04 microgkg) provides better pain relief and similarplacental transfer compared with continuous infusion (Author)
bull Per protocol TCI Norwegian National Hospital (Oslo University Hospital)
ndash 05 ndash 2 ngml + nurse controlled boluses) ndash easier for anaesthesia personell
SSAI Malmoslash 2017
Remifentanil TCI
bull Why notbull Acta Anaesthesiol Scand 2013 Jul57(6)802-8 doi 101111aas12096 Epub 2013 Mar 15
bull Remifentanil target-controlled infusion during second stage labour in high-risk parturients a case series Schwarz GL1 Volmanen P Albrechtsen S Bjoernestad E
bull 1ngml start incremental doses of 05 ngml titrated untill satisfied mother or side-effects(1-6 ngml)
SSAI Malmoslash 2017
Why use remifentanil
The boss
SSAI Malmoslash 2017
In conclusionhellip
SSAI Malmoslash 2017
When to use it
bull For parturients with contraindications to regional analgesia
ndash Bleeding disorders
ndash Infections
ndash Mother does not want regional
bull In places with reduced anaesthesia service
SSAI Malmoslash 2017
Then remifentanil is the best choice
bull Continuous monitoring
bull Including capnography or RR counting
bull Well educated staff
SSAI Malmoslash 2017
Remifentanil PCA
bull Is cheap
bull Easy to administer
bull Gives (some) pain relief
SSAI Malmoslash 2017
BUT
bull Has a poor analgesic effect compared to thegolden standard of regional analgesia
bull May cause a lot of harm
bull Andhellip
SSAI Malmoslash 2017
AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS
Is too dangerous to be used as routineanalgesia in the labour ward
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
Agenda
bull Pharmacology
bull Does it work
bull Whys use it at all
bull Conclusion
SSAI Malmoslash 2017
Remifentanil - Pharma
SSAI Malmoslash 2017
Pharmacology
bull Highly lipid soluble micro-receptor agonist opioid
bull 70 proteinbound
bull Esther linkage - undergoes rapid hydrolysis to remifentanil acid by tissue and plasma estherase T12 1-5min
bull Context sensitive half-life 3-4 minutes
bull Potency = 2x fentanyl 100-200x morphine
bull Lower plasma concentration in pregnants versus non-pregnants ndash large variability
SSAI Malmoslash 2017
Fetal exposure
bull Uterine veinMaternal artery ratio 088
bull Umbilical arteryumbilical vein ratio 029
ndash Redistribution rapid fetal metabolism
SSAI Malmoslash 2017
Is it in use
SSAI Malmoslash 2017
SSAI Malmoslash 2017
RemiPCA SAFE NetworkcopyRegimenConcentration of Remifentanil 20mcgml (2mg Remifentanil in 100ml NaCl 09)Bolus 10-30 μgLockout interval 2 minNo additional infusion of remifentanil No application of any other opioid or analgesicdrug
httpswwwgooglecommapsdviewermid=1BrSGgixaIx0JjdvPPBPbHjzlkUAampusp=sharing
2017 7800 deliveries
266 Hypoxia26 Sedation17 Nausea
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Labor or Delivery Opioids cross the placenta and may produce respiratory depression and psycho-physiologic effects in neonates An opioid antagonist such as naloxone must be available for reversal of opioid-induced respiratory depression in the neonate ULTIVA is not recommended for use in pregnant women during or immediately prior to labor when other analgesic techniques are more appropriate Opioid analgesics including ULTIVA can prolong labor through actions which temporarily reduce the strength duration and frequency of uterine contractions However this effect is not consistent and may be offset by an increased rate of cervical dilation which tends to shorten labor Monitor neonates exposed to opioid analgesics during labor for signs of excess sedation and respiratory depression
USA2015 36 occasionally
Bhatia K Unknowns in the use of remifentanil PCA for labour analgesia Anaesthesia 201368(6)641-2
Birnbach DJ Ranasinghe JS Is remifentanil a safe and effective alternative to neuraxial labor analgesia It all depends Anesth Analg 2014118(3)491-3
Bonner JC McClymont W Respiratory arrest in an obstetric patient using remifentanil patient-controlled analgesia Anaesthesia 201267(5)538-40
Daly O Kelly KP McCormack JG Heidemann BH Remifentanil PCA in labour Anaesthesia 201368(7)780-1
Devabhakthuni S Efficacy and safety of remifentanil as an alternative labor analgesic Clin Med Insights Womens Health 2013637-49
Freeman LM Bloemenkamp KW Franssen MT et al Patient controlled analgesia with remifentanil versus epidural analgesia in labour randomised multicentreequivalence trial BMJ 2015350(7997)11
Kranke P Girard T Lavandhomme P Melber A Jokinen J Muellenbach RM et al Must we press on until a young mother dies Remifentanil patient controlled analgesia in labourmay not be suited as a poor mans epidural BMC Pregnancy Childbirth 201313139
Muchatuta NA Kinsella SM Remifentanil for labour analgesia time to draw breath Anaesthesia 201368(3)231-5
SSAI Malmoslash 2017
The ideal opioid delivery
SSAI Malmoslash 2017
Time
Pain
intensity
and effect
Contraction pain
Pain relief
Does not exist
Opioids and labour analgeisahellip
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Tramadol meptazinol pethidine diamorphine pentazocine nalbuphinefentanylIMIV Pca vs bolus
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Van De Velde and Carvalho IJOA 2016 15 66-74
SSAI Malmoslash 2017
Remi 40microg2minsFenta 20microg + loadingPet 5 mg + loading
SSAI Malmoslash 2017
Other opioids better
bull CONCLUSIONS Intravenous patient-controlled analgesia with either remifentanil or fentanyl provides a moderate degree of labour analgesia whereas transient maternal oxygen desaturation is observed more commonly with remifentanil Fentanyl is associated with a higher need for neonatal resuscitation Marwah R
Hassan S Carvalho JC Balki M Remifentanil versus fentanyl for intravenous patient-controlled labour analgesia an observational study Canadian Journal of Anaesthesia 201259(3)246-54
SSAI Malmoslash 2017
Remifentanil provides betterpain relief than other opioids but only during the first twohours
SSAI Malmoslash 2017
Does it work
SSAI Malmoslash 2017
From M Van De Velde B Carvalho IJOA 2016 25 66-74
SSAI Malmoslash 2017
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 TRIAL REGISTRATION Netherlands Trial Register NTR2551
CONCLUSION In terms of labor duration average VAS pain scores and maternal overall satisfaction score with analgesia CSE analgesia is superior to that provided by epidural analgesia or PCIA with remifentanil for pain relief in early labor in nulliparous women However there were no differences in the mode of delivery side effects or neonatal outcomes between the three techniques
Efficacy of Remifentanil PCA as compared to CSEEpidural
SSAI Malmoslash 2017
Oxygen saturation was significantly lower (SpO2 lt92) in women who used remifentanil (relative risk 15 14 to 17)
Remifentanil IVPCA provides poorer efficacy on labor analgesia than epidural analgesia with more sedation on parturients and a trend of newborn acidosis
Lin R Tao Y Yu Y Xu Z Su J Liu Z Intravenous remifentanil versus epidural ropivacaine with sufentanil for labour analgesia a retrospective study PLoS ONE [Electronic Resource] 20149(11)e112283
SSAI Malmoslash 2017
Meta Analyses
bull This meta-analysis suggests that remifentanil PCIA is not superior to epidural analgesia in analgesic efficacy during labor Given the wide CIs of the pooled results for secondary maternal and neonatal outcomes definite conclusions cannot be drawn for those outcomes Further studies are still warranted to validate these conclusions Liu ZQ Chen XB Li HB Qiu MT Duan T A comparison of remifentanil parturient-controlled intravenous analgesia with
epidural analgesia a meta-analysis of randomized controlled trials Anesth Analg 2014118(3)598-603
bull CONCLUSION During labour remifentanil-PCA provided superior analgesia and higher patient satisfactioncompared with pethidine with a comparable degree of adverse events Epidural analgesia providedsuperior pain relief in comparison with remifentanil Due to a low number of reported adverse events thesafety issue of remifentanil use in labour remains an open question that needs to be addressed in futuretrials Schnabel A Hahn N Broscheit J Muellenbach RM Rieger L Roewer N et al Remifentanil for labour analgesia a meta-analysis of
randomised controlled trials European Journal of Anaesthesiology 201229(4)177-85
bull Conclusions Pooled assessment of remifentanil intervention seems an attractive strategy for controlling labor pain in health term parturients but it is not supported by strong evidence Current evidencesuggests that it may produce effective analgesia by only a modest level HealthMED 20126(7)2407-18
Effect size difference 3 cm
SSAI Malmoslash 2017
SSAI Malmoslash 2017
APRIL 2017
20 RCTrsquos 3569 women
Results Weibel et al
bull Based on the current systematic review there is mostly low-quality evidence to inform practiceand future research may significantly alter thecurrent 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 safetyoutcomes (maternal apnoe and respiratorydepression Apgar score) and on the optimal mode and regimen of remifentanil administrationto provide highets efficacy with reasonableadverse effects for mother and their newborns
SSAI Malmoslash 2017
Always satisfied
Off course they are Who wouldnrsquot
SSAI Malmoslash 2017
Optimal administration of remi
SSAI Malmoslash 2017
Optimal administration of remi
bull Protocols varies (bolus dose lock-out background infusion TCI etc)
bull Fixed bolus 20-50 microg without backgroundinfusion lock-out 2-3 minutes
bull If background ndash small dose lt 005microgkgxmin
bull TCI 05-15 ngml
bull New systems VPIA (Vital signs patientcontrolled intravenous analgesia)
SSAI Malmoslash 2017
SIA et al IJOA correspondence 2014 23 196-8
SSAI Malmoslash 2017
Cont infusion or PCA
bull Shen MK Wu ZF Zhu AB et al Remifentanil for labour analgesia a double-blinded randomised controlled trial of maternal and neonatal effects ofpatient-controlled analgesia versus continuous infusion (0005-02 microgkgxmin) Anaesthesia 201368(3)236-44 The results suggest thatremifentanil PCA (01-04 microgkg) provides better pain relief and similarplacental transfer compared with continuous infusion (Author)
bull Per protocol TCI Norwegian National Hospital (Oslo University Hospital)
ndash 05 ndash 2 ngml + nurse controlled boluses) ndash easier for anaesthesia personell
SSAI Malmoslash 2017
Remifentanil TCI
bull Why notbull Acta Anaesthesiol Scand 2013 Jul57(6)802-8 doi 101111aas12096 Epub 2013 Mar 15
bull Remifentanil target-controlled infusion during second stage labour in high-risk parturients a case series Schwarz GL1 Volmanen P Albrechtsen S Bjoernestad E
bull 1ngml start incremental doses of 05 ngml titrated untill satisfied mother or side-effects(1-6 ngml)
SSAI Malmoslash 2017
Why use remifentanil
The boss
SSAI Malmoslash 2017
In conclusionhellip
SSAI Malmoslash 2017
When to use it
bull For parturients with contraindications to regional analgesia
ndash Bleeding disorders
ndash Infections
ndash Mother does not want regional
bull In places with reduced anaesthesia service
SSAI Malmoslash 2017
Then remifentanil is the best choice
bull Continuous monitoring
bull Including capnography or RR counting
bull Well educated staff
SSAI Malmoslash 2017
Remifentanil PCA
bull Is cheap
bull Easy to administer
bull Gives (some) pain relief
SSAI Malmoslash 2017
BUT
bull Has a poor analgesic effect compared to thegolden standard of regional analgesia
bull May cause a lot of harm
bull Andhellip
SSAI Malmoslash 2017
AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS
Is too dangerous to be used as routineanalgesia in the labour ward
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
Remifentanil - Pharma
SSAI Malmoslash 2017
Pharmacology
bull Highly lipid soluble micro-receptor agonist opioid
bull 70 proteinbound
bull Esther linkage - undergoes rapid hydrolysis to remifentanil acid by tissue and plasma estherase T12 1-5min
bull Context sensitive half-life 3-4 minutes
bull Potency = 2x fentanyl 100-200x morphine
bull Lower plasma concentration in pregnants versus non-pregnants ndash large variability
SSAI Malmoslash 2017
Fetal exposure
bull Uterine veinMaternal artery ratio 088
bull Umbilical arteryumbilical vein ratio 029
ndash Redistribution rapid fetal metabolism
SSAI Malmoslash 2017
Is it in use
SSAI Malmoslash 2017
SSAI Malmoslash 2017
RemiPCA SAFE NetworkcopyRegimenConcentration of Remifentanil 20mcgml (2mg Remifentanil in 100ml NaCl 09)Bolus 10-30 μgLockout interval 2 minNo additional infusion of remifentanil No application of any other opioid or analgesicdrug
httpswwwgooglecommapsdviewermid=1BrSGgixaIx0JjdvPPBPbHjzlkUAampusp=sharing
2017 7800 deliveries
266 Hypoxia26 Sedation17 Nausea
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Labor or Delivery Opioids cross the placenta and may produce respiratory depression and psycho-physiologic effects in neonates An opioid antagonist such as naloxone must be available for reversal of opioid-induced respiratory depression in the neonate ULTIVA is not recommended for use in pregnant women during or immediately prior to labor when other analgesic techniques are more appropriate Opioid analgesics including ULTIVA can prolong labor through actions which temporarily reduce the strength duration and frequency of uterine contractions However this effect is not consistent and may be offset by an increased rate of cervical dilation which tends to shorten labor Monitor neonates exposed to opioid analgesics during labor for signs of excess sedation and respiratory depression
USA2015 36 occasionally
Bhatia K Unknowns in the use of remifentanil PCA for labour analgesia Anaesthesia 201368(6)641-2
Birnbach DJ Ranasinghe JS Is remifentanil a safe and effective alternative to neuraxial labor analgesia It all depends Anesth Analg 2014118(3)491-3
Bonner JC McClymont W Respiratory arrest in an obstetric patient using remifentanil patient-controlled analgesia Anaesthesia 201267(5)538-40
Daly O Kelly KP McCormack JG Heidemann BH Remifentanil PCA in labour Anaesthesia 201368(7)780-1
Devabhakthuni S Efficacy and safety of remifentanil as an alternative labor analgesic Clin Med Insights Womens Health 2013637-49
Freeman LM Bloemenkamp KW Franssen MT et al Patient controlled analgesia with remifentanil versus epidural analgesia in labour randomised multicentreequivalence trial BMJ 2015350(7997)11
Kranke P Girard T Lavandhomme P Melber A Jokinen J Muellenbach RM et al Must we press on until a young mother dies Remifentanil patient controlled analgesia in labourmay not be suited as a poor mans epidural BMC Pregnancy Childbirth 201313139
Muchatuta NA Kinsella SM Remifentanil for labour analgesia time to draw breath Anaesthesia 201368(3)231-5
SSAI Malmoslash 2017
The ideal opioid delivery
SSAI Malmoslash 2017
Time
Pain
intensity
and effect
Contraction pain
Pain relief
Does not exist
Opioids and labour analgeisahellip
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Tramadol meptazinol pethidine diamorphine pentazocine nalbuphinefentanylIMIV Pca vs bolus
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Van De Velde and Carvalho IJOA 2016 15 66-74
SSAI Malmoslash 2017
Remi 40microg2minsFenta 20microg + loadingPet 5 mg + loading
SSAI Malmoslash 2017
Other opioids better
bull CONCLUSIONS Intravenous patient-controlled analgesia with either remifentanil or fentanyl provides a moderate degree of labour analgesia whereas transient maternal oxygen desaturation is observed more commonly with remifentanil Fentanyl is associated with a higher need for neonatal resuscitation Marwah R
Hassan S Carvalho JC Balki M Remifentanil versus fentanyl for intravenous patient-controlled labour analgesia an observational study Canadian Journal of Anaesthesia 201259(3)246-54
SSAI Malmoslash 2017
Remifentanil provides betterpain relief than other opioids but only during the first twohours
SSAI Malmoslash 2017
Does it work
SSAI Malmoslash 2017
From M Van De Velde B Carvalho IJOA 2016 25 66-74
SSAI Malmoslash 2017
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 TRIAL REGISTRATION Netherlands Trial Register NTR2551
CONCLUSION In terms of labor duration average VAS pain scores and maternal overall satisfaction score with analgesia CSE analgesia is superior to that provided by epidural analgesia or PCIA with remifentanil for pain relief in early labor in nulliparous women However there were no differences in the mode of delivery side effects or neonatal outcomes between the three techniques
Efficacy of Remifentanil PCA as compared to CSEEpidural
SSAI Malmoslash 2017
Oxygen saturation was significantly lower (SpO2 lt92) in women who used remifentanil (relative risk 15 14 to 17)
Remifentanil IVPCA provides poorer efficacy on labor analgesia than epidural analgesia with more sedation on parturients and a trend of newborn acidosis
Lin R Tao Y Yu Y Xu Z Su J Liu Z Intravenous remifentanil versus epidural ropivacaine with sufentanil for labour analgesia a retrospective study PLoS ONE [Electronic Resource] 20149(11)e112283
SSAI Malmoslash 2017
Meta Analyses
bull This meta-analysis suggests that remifentanil PCIA is not superior to epidural analgesia in analgesic efficacy during labor Given the wide CIs of the pooled results for secondary maternal and neonatal outcomes definite conclusions cannot be drawn for those outcomes Further studies are still warranted to validate these conclusions Liu ZQ Chen XB Li HB Qiu MT Duan T A comparison of remifentanil parturient-controlled intravenous analgesia with
epidural analgesia a meta-analysis of randomized controlled trials Anesth Analg 2014118(3)598-603
bull CONCLUSION During labour remifentanil-PCA provided superior analgesia and higher patient satisfactioncompared with pethidine with a comparable degree of adverse events Epidural analgesia providedsuperior pain relief in comparison with remifentanil Due to a low number of reported adverse events thesafety issue of remifentanil use in labour remains an open question that needs to be addressed in futuretrials Schnabel A Hahn N Broscheit J Muellenbach RM Rieger L Roewer N et al Remifentanil for labour analgesia a meta-analysis of
randomised controlled trials European Journal of Anaesthesiology 201229(4)177-85
bull Conclusions Pooled assessment of remifentanil intervention seems an attractive strategy for controlling labor pain in health term parturients but it is not supported by strong evidence Current evidencesuggests that it may produce effective analgesia by only a modest level HealthMED 20126(7)2407-18
Effect size difference 3 cm
SSAI Malmoslash 2017
SSAI Malmoslash 2017
APRIL 2017
20 RCTrsquos 3569 women
Results Weibel et al
bull Based on the current systematic review there is mostly low-quality evidence to inform practiceand future research may significantly alter thecurrent 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 safetyoutcomes (maternal apnoe and respiratorydepression Apgar score) and on the optimal mode and regimen of remifentanil administrationto provide highets efficacy with reasonableadverse effects for mother and their newborns
SSAI Malmoslash 2017
Always satisfied
Off course they are Who wouldnrsquot
SSAI Malmoslash 2017
Optimal administration of remi
SSAI Malmoslash 2017
Optimal administration of remi
bull Protocols varies (bolus dose lock-out background infusion TCI etc)
bull Fixed bolus 20-50 microg without backgroundinfusion lock-out 2-3 minutes
bull If background ndash small dose lt 005microgkgxmin
bull TCI 05-15 ngml
bull New systems VPIA (Vital signs patientcontrolled intravenous analgesia)
SSAI Malmoslash 2017
SIA et al IJOA correspondence 2014 23 196-8
SSAI Malmoslash 2017
Cont infusion or PCA
bull Shen MK Wu ZF Zhu AB et al Remifentanil for labour analgesia a double-blinded randomised controlled trial of maternal and neonatal effects ofpatient-controlled analgesia versus continuous infusion (0005-02 microgkgxmin) Anaesthesia 201368(3)236-44 The results suggest thatremifentanil PCA (01-04 microgkg) provides better pain relief and similarplacental transfer compared with continuous infusion (Author)
bull Per protocol TCI Norwegian National Hospital (Oslo University Hospital)
ndash 05 ndash 2 ngml + nurse controlled boluses) ndash easier for anaesthesia personell
SSAI Malmoslash 2017
Remifentanil TCI
bull Why notbull Acta Anaesthesiol Scand 2013 Jul57(6)802-8 doi 101111aas12096 Epub 2013 Mar 15
bull Remifentanil target-controlled infusion during second stage labour in high-risk parturients a case series Schwarz GL1 Volmanen P Albrechtsen S Bjoernestad E
bull 1ngml start incremental doses of 05 ngml titrated untill satisfied mother or side-effects(1-6 ngml)
SSAI Malmoslash 2017
Why use remifentanil
The boss
SSAI Malmoslash 2017
In conclusionhellip
SSAI Malmoslash 2017
When to use it
bull For parturients with contraindications to regional analgesia
ndash Bleeding disorders
ndash Infections
ndash Mother does not want regional
bull In places with reduced anaesthesia service
SSAI Malmoslash 2017
Then remifentanil is the best choice
bull Continuous monitoring
bull Including capnography or RR counting
bull Well educated staff
SSAI Malmoslash 2017
Remifentanil PCA
bull Is cheap
bull Easy to administer
bull Gives (some) pain relief
SSAI Malmoslash 2017
BUT
bull Has a poor analgesic effect compared to thegolden standard of regional analgesia
bull May cause a lot of harm
bull Andhellip
SSAI Malmoslash 2017
AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS
Is too dangerous to be used as routineanalgesia in the labour ward
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
Pharmacology
bull Highly lipid soluble micro-receptor agonist opioid
bull 70 proteinbound
bull Esther linkage - undergoes rapid hydrolysis to remifentanil acid by tissue and plasma estherase T12 1-5min
bull Context sensitive half-life 3-4 minutes
bull Potency = 2x fentanyl 100-200x morphine
bull Lower plasma concentration in pregnants versus non-pregnants ndash large variability
SSAI Malmoslash 2017
Fetal exposure
bull Uterine veinMaternal artery ratio 088
bull Umbilical arteryumbilical vein ratio 029
ndash Redistribution rapid fetal metabolism
SSAI Malmoslash 2017
Is it in use
SSAI Malmoslash 2017
SSAI Malmoslash 2017
RemiPCA SAFE NetworkcopyRegimenConcentration of Remifentanil 20mcgml (2mg Remifentanil in 100ml NaCl 09)Bolus 10-30 μgLockout interval 2 minNo additional infusion of remifentanil No application of any other opioid or analgesicdrug
httpswwwgooglecommapsdviewermid=1BrSGgixaIx0JjdvPPBPbHjzlkUAampusp=sharing
2017 7800 deliveries
266 Hypoxia26 Sedation17 Nausea
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Labor or Delivery Opioids cross the placenta and may produce respiratory depression and psycho-physiologic effects in neonates An opioid antagonist such as naloxone must be available for reversal of opioid-induced respiratory depression in the neonate ULTIVA is not recommended for use in pregnant women during or immediately prior to labor when other analgesic techniques are more appropriate Opioid analgesics including ULTIVA can prolong labor through actions which temporarily reduce the strength duration and frequency of uterine contractions However this effect is not consistent and may be offset by an increased rate of cervical dilation which tends to shorten labor Monitor neonates exposed to opioid analgesics during labor for signs of excess sedation and respiratory depression
USA2015 36 occasionally
Bhatia K Unknowns in the use of remifentanil PCA for labour analgesia Anaesthesia 201368(6)641-2
Birnbach DJ Ranasinghe JS Is remifentanil a safe and effective alternative to neuraxial labor analgesia It all depends Anesth Analg 2014118(3)491-3
Bonner JC McClymont W Respiratory arrest in an obstetric patient using remifentanil patient-controlled analgesia Anaesthesia 201267(5)538-40
Daly O Kelly KP McCormack JG Heidemann BH Remifentanil PCA in labour Anaesthesia 201368(7)780-1
Devabhakthuni S Efficacy and safety of remifentanil as an alternative labor analgesic Clin Med Insights Womens Health 2013637-49
Freeman LM Bloemenkamp KW Franssen MT et al Patient controlled analgesia with remifentanil versus epidural analgesia in labour randomised multicentreequivalence trial BMJ 2015350(7997)11
Kranke P Girard T Lavandhomme P Melber A Jokinen J Muellenbach RM et al Must we press on until a young mother dies Remifentanil patient controlled analgesia in labourmay not be suited as a poor mans epidural BMC Pregnancy Childbirth 201313139
Muchatuta NA Kinsella SM Remifentanil for labour analgesia time to draw breath Anaesthesia 201368(3)231-5
SSAI Malmoslash 2017
The ideal opioid delivery
SSAI Malmoslash 2017
Time
Pain
intensity
and effect
Contraction pain
Pain relief
Does not exist
Opioids and labour analgeisahellip
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Tramadol meptazinol pethidine diamorphine pentazocine nalbuphinefentanylIMIV Pca vs bolus
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Van De Velde and Carvalho IJOA 2016 15 66-74
SSAI Malmoslash 2017
Remi 40microg2minsFenta 20microg + loadingPet 5 mg + loading
SSAI Malmoslash 2017
Other opioids better
bull CONCLUSIONS Intravenous patient-controlled analgesia with either remifentanil or fentanyl provides a moderate degree of labour analgesia whereas transient maternal oxygen desaturation is observed more commonly with remifentanil Fentanyl is associated with a higher need for neonatal resuscitation Marwah R
Hassan S Carvalho JC Balki M Remifentanil versus fentanyl for intravenous patient-controlled labour analgesia an observational study Canadian Journal of Anaesthesia 201259(3)246-54
SSAI Malmoslash 2017
Remifentanil provides betterpain relief than other opioids but only during the first twohours
SSAI Malmoslash 2017
Does it work
SSAI Malmoslash 2017
From M Van De Velde B Carvalho IJOA 2016 25 66-74
SSAI Malmoslash 2017
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 TRIAL REGISTRATION Netherlands Trial Register NTR2551
CONCLUSION In terms of labor duration average VAS pain scores and maternal overall satisfaction score with analgesia CSE analgesia is superior to that provided by epidural analgesia or PCIA with remifentanil for pain relief in early labor in nulliparous women However there were no differences in the mode of delivery side effects or neonatal outcomes between the three techniques
Efficacy of Remifentanil PCA as compared to CSEEpidural
SSAI Malmoslash 2017
Oxygen saturation was significantly lower (SpO2 lt92) in women who used remifentanil (relative risk 15 14 to 17)
Remifentanil IVPCA provides poorer efficacy on labor analgesia than epidural analgesia with more sedation on parturients and a trend of newborn acidosis
Lin R Tao Y Yu Y Xu Z Su J Liu Z Intravenous remifentanil versus epidural ropivacaine with sufentanil for labour analgesia a retrospective study PLoS ONE [Electronic Resource] 20149(11)e112283
SSAI Malmoslash 2017
Meta Analyses
bull This meta-analysis suggests that remifentanil PCIA is not superior to epidural analgesia in analgesic efficacy during labor Given the wide CIs of the pooled results for secondary maternal and neonatal outcomes definite conclusions cannot be drawn for those outcomes Further studies are still warranted to validate these conclusions Liu ZQ Chen XB Li HB Qiu MT Duan T A comparison of remifentanil parturient-controlled intravenous analgesia with
epidural analgesia a meta-analysis of randomized controlled trials Anesth Analg 2014118(3)598-603
bull CONCLUSION During labour remifentanil-PCA provided superior analgesia and higher patient satisfactioncompared with pethidine with a comparable degree of adverse events Epidural analgesia providedsuperior pain relief in comparison with remifentanil Due to a low number of reported adverse events thesafety issue of remifentanil use in labour remains an open question that needs to be addressed in futuretrials Schnabel A Hahn N Broscheit J Muellenbach RM Rieger L Roewer N et al Remifentanil for labour analgesia a meta-analysis of
randomised controlled trials European Journal of Anaesthesiology 201229(4)177-85
bull Conclusions Pooled assessment of remifentanil intervention seems an attractive strategy for controlling labor pain in health term parturients but it is not supported by strong evidence Current evidencesuggests that it may produce effective analgesia by only a modest level HealthMED 20126(7)2407-18
Effect size difference 3 cm
SSAI Malmoslash 2017
SSAI Malmoslash 2017
APRIL 2017
20 RCTrsquos 3569 women
Results Weibel et al
bull Based on the current systematic review there is mostly low-quality evidence to inform practiceand future research may significantly alter thecurrent 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 safetyoutcomes (maternal apnoe and respiratorydepression Apgar score) and on the optimal mode and regimen of remifentanil administrationto provide highets efficacy with reasonableadverse effects for mother and their newborns
SSAI Malmoslash 2017
Always satisfied
Off course they are Who wouldnrsquot
SSAI Malmoslash 2017
Optimal administration of remi
SSAI Malmoslash 2017
Optimal administration of remi
bull Protocols varies (bolus dose lock-out background infusion TCI etc)
bull Fixed bolus 20-50 microg without backgroundinfusion lock-out 2-3 minutes
bull If background ndash small dose lt 005microgkgxmin
bull TCI 05-15 ngml
bull New systems VPIA (Vital signs patientcontrolled intravenous analgesia)
SSAI Malmoslash 2017
SIA et al IJOA correspondence 2014 23 196-8
SSAI Malmoslash 2017
Cont infusion or PCA
bull Shen MK Wu ZF Zhu AB et al Remifentanil for labour analgesia a double-blinded randomised controlled trial of maternal and neonatal effects ofpatient-controlled analgesia versus continuous infusion (0005-02 microgkgxmin) Anaesthesia 201368(3)236-44 The results suggest thatremifentanil PCA (01-04 microgkg) provides better pain relief and similarplacental transfer compared with continuous infusion (Author)
bull Per protocol TCI Norwegian National Hospital (Oslo University Hospital)
ndash 05 ndash 2 ngml + nurse controlled boluses) ndash easier for anaesthesia personell
SSAI Malmoslash 2017
Remifentanil TCI
bull Why notbull Acta Anaesthesiol Scand 2013 Jul57(6)802-8 doi 101111aas12096 Epub 2013 Mar 15
bull Remifentanil target-controlled infusion during second stage labour in high-risk parturients a case series Schwarz GL1 Volmanen P Albrechtsen S Bjoernestad E
bull 1ngml start incremental doses of 05 ngml titrated untill satisfied mother or side-effects(1-6 ngml)
SSAI Malmoslash 2017
Why use remifentanil
The boss
SSAI Malmoslash 2017
In conclusionhellip
SSAI Malmoslash 2017
When to use it
bull For parturients with contraindications to regional analgesia
ndash Bleeding disorders
ndash Infections
ndash Mother does not want regional
bull In places with reduced anaesthesia service
SSAI Malmoslash 2017
Then remifentanil is the best choice
bull Continuous monitoring
bull Including capnography or RR counting
bull Well educated staff
SSAI Malmoslash 2017
Remifentanil PCA
bull Is cheap
bull Easy to administer
bull Gives (some) pain relief
SSAI Malmoslash 2017
BUT
bull Has a poor analgesic effect compared to thegolden standard of regional analgesia
bull May cause a lot of harm
bull Andhellip
SSAI Malmoslash 2017
AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS
Is too dangerous to be used as routineanalgesia in the labour ward
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
Fetal exposure
bull Uterine veinMaternal artery ratio 088
bull Umbilical arteryumbilical vein ratio 029
ndash Redistribution rapid fetal metabolism
SSAI Malmoslash 2017
Is it in use
SSAI Malmoslash 2017
SSAI Malmoslash 2017
RemiPCA SAFE NetworkcopyRegimenConcentration of Remifentanil 20mcgml (2mg Remifentanil in 100ml NaCl 09)Bolus 10-30 μgLockout interval 2 minNo additional infusion of remifentanil No application of any other opioid or analgesicdrug
httpswwwgooglecommapsdviewermid=1BrSGgixaIx0JjdvPPBPbHjzlkUAampusp=sharing
2017 7800 deliveries
266 Hypoxia26 Sedation17 Nausea
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Labor or Delivery Opioids cross the placenta and may produce respiratory depression and psycho-physiologic effects in neonates An opioid antagonist such as naloxone must be available for reversal of opioid-induced respiratory depression in the neonate ULTIVA is not recommended for use in pregnant women during or immediately prior to labor when other analgesic techniques are more appropriate Opioid analgesics including ULTIVA can prolong labor through actions which temporarily reduce the strength duration and frequency of uterine contractions However this effect is not consistent and may be offset by an increased rate of cervical dilation which tends to shorten labor Monitor neonates exposed to opioid analgesics during labor for signs of excess sedation and respiratory depression
USA2015 36 occasionally
Bhatia K Unknowns in the use of remifentanil PCA for labour analgesia Anaesthesia 201368(6)641-2
Birnbach DJ Ranasinghe JS Is remifentanil a safe and effective alternative to neuraxial labor analgesia It all depends Anesth Analg 2014118(3)491-3
Bonner JC McClymont W Respiratory arrest in an obstetric patient using remifentanil patient-controlled analgesia Anaesthesia 201267(5)538-40
Daly O Kelly KP McCormack JG Heidemann BH Remifentanil PCA in labour Anaesthesia 201368(7)780-1
Devabhakthuni S Efficacy and safety of remifentanil as an alternative labor analgesic Clin Med Insights Womens Health 2013637-49
Freeman LM Bloemenkamp KW Franssen MT et al Patient controlled analgesia with remifentanil versus epidural analgesia in labour randomised multicentreequivalence trial BMJ 2015350(7997)11
Kranke P Girard T Lavandhomme P Melber A Jokinen J Muellenbach RM et al Must we press on until a young mother dies Remifentanil patient controlled analgesia in labourmay not be suited as a poor mans epidural BMC Pregnancy Childbirth 201313139
Muchatuta NA Kinsella SM Remifentanil for labour analgesia time to draw breath Anaesthesia 201368(3)231-5
SSAI Malmoslash 2017
The ideal opioid delivery
SSAI Malmoslash 2017
Time
Pain
intensity
and effect
Contraction pain
Pain relief
Does not exist
Opioids and labour analgeisahellip
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Tramadol meptazinol pethidine diamorphine pentazocine nalbuphinefentanylIMIV Pca vs bolus
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Van De Velde and Carvalho IJOA 2016 15 66-74
SSAI Malmoslash 2017
Remi 40microg2minsFenta 20microg + loadingPet 5 mg + loading
SSAI Malmoslash 2017
Other opioids better
bull CONCLUSIONS Intravenous patient-controlled analgesia with either remifentanil or fentanyl provides a moderate degree of labour analgesia whereas transient maternal oxygen desaturation is observed more commonly with remifentanil Fentanyl is associated with a higher need for neonatal resuscitation Marwah R
Hassan S Carvalho JC Balki M Remifentanil versus fentanyl for intravenous patient-controlled labour analgesia an observational study Canadian Journal of Anaesthesia 201259(3)246-54
SSAI Malmoslash 2017
Remifentanil provides betterpain relief than other opioids but only during the first twohours
SSAI Malmoslash 2017
Does it work
SSAI Malmoslash 2017
From M Van De Velde B Carvalho IJOA 2016 25 66-74
SSAI Malmoslash 2017
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 TRIAL REGISTRATION Netherlands Trial Register NTR2551
CONCLUSION In terms of labor duration average VAS pain scores and maternal overall satisfaction score with analgesia CSE analgesia is superior to that provided by epidural analgesia or PCIA with remifentanil for pain relief in early labor in nulliparous women However there were no differences in the mode of delivery side effects or neonatal outcomes between the three techniques
Efficacy of Remifentanil PCA as compared to CSEEpidural
SSAI Malmoslash 2017
Oxygen saturation was significantly lower (SpO2 lt92) in women who used remifentanil (relative risk 15 14 to 17)
Remifentanil IVPCA provides poorer efficacy on labor analgesia than epidural analgesia with more sedation on parturients and a trend of newborn acidosis
Lin R Tao Y Yu Y Xu Z Su J Liu Z Intravenous remifentanil versus epidural ropivacaine with sufentanil for labour analgesia a retrospective study PLoS ONE [Electronic Resource] 20149(11)e112283
SSAI Malmoslash 2017
Meta Analyses
bull This meta-analysis suggests that remifentanil PCIA is not superior to epidural analgesia in analgesic efficacy during labor Given the wide CIs of the pooled results for secondary maternal and neonatal outcomes definite conclusions cannot be drawn for those outcomes Further studies are still warranted to validate these conclusions Liu ZQ Chen XB Li HB Qiu MT Duan T A comparison of remifentanil parturient-controlled intravenous analgesia with
epidural analgesia a meta-analysis of randomized controlled trials Anesth Analg 2014118(3)598-603
bull CONCLUSION During labour remifentanil-PCA provided superior analgesia and higher patient satisfactioncompared with pethidine with a comparable degree of adverse events Epidural analgesia providedsuperior pain relief in comparison with remifentanil Due to a low number of reported adverse events thesafety issue of remifentanil use in labour remains an open question that needs to be addressed in futuretrials Schnabel A Hahn N Broscheit J Muellenbach RM Rieger L Roewer N et al Remifentanil for labour analgesia a meta-analysis of
randomised controlled trials European Journal of Anaesthesiology 201229(4)177-85
bull Conclusions Pooled assessment of remifentanil intervention seems an attractive strategy for controlling labor pain in health term parturients but it is not supported by strong evidence Current evidencesuggests that it may produce effective analgesia by only a modest level HealthMED 20126(7)2407-18
Effect size difference 3 cm
SSAI Malmoslash 2017
SSAI Malmoslash 2017
APRIL 2017
20 RCTrsquos 3569 women
Results Weibel et al
bull Based on the current systematic review there is mostly low-quality evidence to inform practiceand future research may significantly alter thecurrent 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 safetyoutcomes (maternal apnoe and respiratorydepression Apgar score) and on the optimal mode and regimen of remifentanil administrationto provide highets efficacy with reasonableadverse effects for mother and their newborns
SSAI Malmoslash 2017
Always satisfied
Off course they are Who wouldnrsquot
SSAI Malmoslash 2017
Optimal administration of remi
SSAI Malmoslash 2017
Optimal administration of remi
bull Protocols varies (bolus dose lock-out background infusion TCI etc)
bull Fixed bolus 20-50 microg without backgroundinfusion lock-out 2-3 minutes
bull If background ndash small dose lt 005microgkgxmin
bull TCI 05-15 ngml
bull New systems VPIA (Vital signs patientcontrolled intravenous analgesia)
SSAI Malmoslash 2017
SIA et al IJOA correspondence 2014 23 196-8
SSAI Malmoslash 2017
Cont infusion or PCA
bull Shen MK Wu ZF Zhu AB et al Remifentanil for labour analgesia a double-blinded randomised controlled trial of maternal and neonatal effects ofpatient-controlled analgesia versus continuous infusion (0005-02 microgkgxmin) Anaesthesia 201368(3)236-44 The results suggest thatremifentanil PCA (01-04 microgkg) provides better pain relief and similarplacental transfer compared with continuous infusion (Author)
bull Per protocol TCI Norwegian National Hospital (Oslo University Hospital)
ndash 05 ndash 2 ngml + nurse controlled boluses) ndash easier for anaesthesia personell
SSAI Malmoslash 2017
Remifentanil TCI
bull Why notbull Acta Anaesthesiol Scand 2013 Jul57(6)802-8 doi 101111aas12096 Epub 2013 Mar 15
bull Remifentanil target-controlled infusion during second stage labour in high-risk parturients a case series Schwarz GL1 Volmanen P Albrechtsen S Bjoernestad E
bull 1ngml start incremental doses of 05 ngml titrated untill satisfied mother or side-effects(1-6 ngml)
SSAI Malmoslash 2017
Why use remifentanil
The boss
SSAI Malmoslash 2017
In conclusionhellip
SSAI Malmoslash 2017
When to use it
bull For parturients with contraindications to regional analgesia
ndash Bleeding disorders
ndash Infections
ndash Mother does not want regional
bull In places with reduced anaesthesia service
SSAI Malmoslash 2017
Then remifentanil is the best choice
bull Continuous monitoring
bull Including capnography or RR counting
bull Well educated staff
SSAI Malmoslash 2017
Remifentanil PCA
bull Is cheap
bull Easy to administer
bull Gives (some) pain relief
SSAI Malmoslash 2017
BUT
bull Has a poor analgesic effect compared to thegolden standard of regional analgesia
bull May cause a lot of harm
bull Andhellip
SSAI Malmoslash 2017
AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS
Is too dangerous to be used as routineanalgesia in the labour ward
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
Is it in use
SSAI Malmoslash 2017
SSAI Malmoslash 2017
RemiPCA SAFE NetworkcopyRegimenConcentration of Remifentanil 20mcgml (2mg Remifentanil in 100ml NaCl 09)Bolus 10-30 μgLockout interval 2 minNo additional infusion of remifentanil No application of any other opioid or analgesicdrug
httpswwwgooglecommapsdviewermid=1BrSGgixaIx0JjdvPPBPbHjzlkUAampusp=sharing
2017 7800 deliveries
266 Hypoxia26 Sedation17 Nausea
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Labor or Delivery Opioids cross the placenta and may produce respiratory depression and psycho-physiologic effects in neonates An opioid antagonist such as naloxone must be available for reversal of opioid-induced respiratory depression in the neonate ULTIVA is not recommended for use in pregnant women during or immediately prior to labor when other analgesic techniques are more appropriate Opioid analgesics including ULTIVA can prolong labor through actions which temporarily reduce the strength duration and frequency of uterine contractions However this effect is not consistent and may be offset by an increased rate of cervical dilation which tends to shorten labor Monitor neonates exposed to opioid analgesics during labor for signs of excess sedation and respiratory depression
USA2015 36 occasionally
Bhatia K Unknowns in the use of remifentanil PCA for labour analgesia Anaesthesia 201368(6)641-2
Birnbach DJ Ranasinghe JS Is remifentanil a safe and effective alternative to neuraxial labor analgesia It all depends Anesth Analg 2014118(3)491-3
Bonner JC McClymont W Respiratory arrest in an obstetric patient using remifentanil patient-controlled analgesia Anaesthesia 201267(5)538-40
Daly O Kelly KP McCormack JG Heidemann BH Remifentanil PCA in labour Anaesthesia 201368(7)780-1
Devabhakthuni S Efficacy and safety of remifentanil as an alternative labor analgesic Clin Med Insights Womens Health 2013637-49
Freeman LM Bloemenkamp KW Franssen MT et al Patient controlled analgesia with remifentanil versus epidural analgesia in labour randomised multicentreequivalence trial BMJ 2015350(7997)11
Kranke P Girard T Lavandhomme P Melber A Jokinen J Muellenbach RM et al Must we press on until a young mother dies Remifentanil patient controlled analgesia in labourmay not be suited as a poor mans epidural BMC Pregnancy Childbirth 201313139
Muchatuta NA Kinsella SM Remifentanil for labour analgesia time to draw breath Anaesthesia 201368(3)231-5
SSAI Malmoslash 2017
The ideal opioid delivery
SSAI Malmoslash 2017
Time
Pain
intensity
and effect
Contraction pain
Pain relief
Does not exist
Opioids and labour analgeisahellip
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Tramadol meptazinol pethidine diamorphine pentazocine nalbuphinefentanylIMIV Pca vs bolus
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Van De Velde and Carvalho IJOA 2016 15 66-74
SSAI Malmoslash 2017
Remi 40microg2minsFenta 20microg + loadingPet 5 mg + loading
SSAI Malmoslash 2017
Other opioids better
bull CONCLUSIONS Intravenous patient-controlled analgesia with either remifentanil or fentanyl provides a moderate degree of labour analgesia whereas transient maternal oxygen desaturation is observed more commonly with remifentanil Fentanyl is associated with a higher need for neonatal resuscitation Marwah R
Hassan S Carvalho JC Balki M Remifentanil versus fentanyl for intravenous patient-controlled labour analgesia an observational study Canadian Journal of Anaesthesia 201259(3)246-54
SSAI Malmoslash 2017
Remifentanil provides betterpain relief than other opioids but only during the first twohours
SSAI Malmoslash 2017
Does it work
SSAI Malmoslash 2017
From M Van De Velde B Carvalho IJOA 2016 25 66-74
SSAI Malmoslash 2017
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 TRIAL REGISTRATION Netherlands Trial Register NTR2551
CONCLUSION In terms of labor duration average VAS pain scores and maternal overall satisfaction score with analgesia CSE analgesia is superior to that provided by epidural analgesia or PCIA with remifentanil for pain relief in early labor in nulliparous women However there were no differences in the mode of delivery side effects or neonatal outcomes between the three techniques
Efficacy of Remifentanil PCA as compared to CSEEpidural
SSAI Malmoslash 2017
Oxygen saturation was significantly lower (SpO2 lt92) in women who used remifentanil (relative risk 15 14 to 17)
Remifentanil IVPCA provides poorer efficacy on labor analgesia than epidural analgesia with more sedation on parturients and a trend of newborn acidosis
Lin R Tao Y Yu Y Xu Z Su J Liu Z Intravenous remifentanil versus epidural ropivacaine with sufentanil for labour analgesia a retrospective study PLoS ONE [Electronic Resource] 20149(11)e112283
SSAI Malmoslash 2017
Meta Analyses
bull This meta-analysis suggests that remifentanil PCIA is not superior to epidural analgesia in analgesic efficacy during labor Given the wide CIs of the pooled results for secondary maternal and neonatal outcomes definite conclusions cannot be drawn for those outcomes Further studies are still warranted to validate these conclusions Liu ZQ Chen XB Li HB Qiu MT Duan T A comparison of remifentanil parturient-controlled intravenous analgesia with
epidural analgesia a meta-analysis of randomized controlled trials Anesth Analg 2014118(3)598-603
bull CONCLUSION During labour remifentanil-PCA provided superior analgesia and higher patient satisfactioncompared with pethidine with a comparable degree of adverse events Epidural analgesia providedsuperior pain relief in comparison with remifentanil Due to a low number of reported adverse events thesafety issue of remifentanil use in labour remains an open question that needs to be addressed in futuretrials Schnabel A Hahn N Broscheit J Muellenbach RM Rieger L Roewer N et al Remifentanil for labour analgesia a meta-analysis of
randomised controlled trials European Journal of Anaesthesiology 201229(4)177-85
bull Conclusions Pooled assessment of remifentanil intervention seems an attractive strategy for controlling labor pain in health term parturients but it is not supported by strong evidence Current evidencesuggests that it may produce effective analgesia by only a modest level HealthMED 20126(7)2407-18
Effect size difference 3 cm
SSAI Malmoslash 2017
SSAI Malmoslash 2017
APRIL 2017
20 RCTrsquos 3569 women
Results Weibel et al
bull Based on the current systematic review there is mostly low-quality evidence to inform practiceand future research may significantly alter thecurrent 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 safetyoutcomes (maternal apnoe and respiratorydepression Apgar score) and on the optimal mode and regimen of remifentanil administrationto provide highets efficacy with reasonableadverse effects for mother and their newborns
SSAI Malmoslash 2017
Always satisfied
Off course they are Who wouldnrsquot
SSAI Malmoslash 2017
Optimal administration of remi
SSAI Malmoslash 2017
Optimal administration of remi
bull Protocols varies (bolus dose lock-out background infusion TCI etc)
bull Fixed bolus 20-50 microg without backgroundinfusion lock-out 2-3 minutes
bull If background ndash small dose lt 005microgkgxmin
bull TCI 05-15 ngml
bull New systems VPIA (Vital signs patientcontrolled intravenous analgesia)
SSAI Malmoslash 2017
SIA et al IJOA correspondence 2014 23 196-8
SSAI Malmoslash 2017
Cont infusion or PCA
bull Shen MK Wu ZF Zhu AB et al Remifentanil for labour analgesia a double-blinded randomised controlled trial of maternal and neonatal effects ofpatient-controlled analgesia versus continuous infusion (0005-02 microgkgxmin) Anaesthesia 201368(3)236-44 The results suggest thatremifentanil PCA (01-04 microgkg) provides better pain relief and similarplacental transfer compared with continuous infusion (Author)
bull Per protocol TCI Norwegian National Hospital (Oslo University Hospital)
ndash 05 ndash 2 ngml + nurse controlled boluses) ndash easier for anaesthesia personell
SSAI Malmoslash 2017
Remifentanil TCI
bull Why notbull Acta Anaesthesiol Scand 2013 Jul57(6)802-8 doi 101111aas12096 Epub 2013 Mar 15
bull Remifentanil target-controlled infusion during second stage labour in high-risk parturients a case series Schwarz GL1 Volmanen P Albrechtsen S Bjoernestad E
bull 1ngml start incremental doses of 05 ngml titrated untill satisfied mother or side-effects(1-6 ngml)
SSAI Malmoslash 2017
Why use remifentanil
The boss
SSAI Malmoslash 2017
In conclusionhellip
SSAI Malmoslash 2017
When to use it
bull For parturients with contraindications to regional analgesia
ndash Bleeding disorders
ndash Infections
ndash Mother does not want regional
bull In places with reduced anaesthesia service
SSAI Malmoslash 2017
Then remifentanil is the best choice
bull Continuous monitoring
bull Including capnography or RR counting
bull Well educated staff
SSAI Malmoslash 2017
Remifentanil PCA
bull Is cheap
bull Easy to administer
bull Gives (some) pain relief
SSAI Malmoslash 2017
BUT
bull Has a poor analgesic effect compared to thegolden standard of regional analgesia
bull May cause a lot of harm
bull Andhellip
SSAI Malmoslash 2017
AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS
Is too dangerous to be used as routineanalgesia in the labour ward
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
SSAI Malmoslash 2017
RemiPCA SAFE NetworkcopyRegimenConcentration of Remifentanil 20mcgml (2mg Remifentanil in 100ml NaCl 09)Bolus 10-30 μgLockout interval 2 minNo additional infusion of remifentanil No application of any other opioid or analgesicdrug
httpswwwgooglecommapsdviewermid=1BrSGgixaIx0JjdvPPBPbHjzlkUAampusp=sharing
2017 7800 deliveries
266 Hypoxia26 Sedation17 Nausea
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Labor or Delivery Opioids cross the placenta and may produce respiratory depression and psycho-physiologic effects in neonates An opioid antagonist such as naloxone must be available for reversal of opioid-induced respiratory depression in the neonate ULTIVA is not recommended for use in pregnant women during or immediately prior to labor when other analgesic techniques are more appropriate Opioid analgesics including ULTIVA can prolong labor through actions which temporarily reduce the strength duration and frequency of uterine contractions However this effect is not consistent and may be offset by an increased rate of cervical dilation which tends to shorten labor Monitor neonates exposed to opioid analgesics during labor for signs of excess sedation and respiratory depression
USA2015 36 occasionally
Bhatia K Unknowns in the use of remifentanil PCA for labour analgesia Anaesthesia 201368(6)641-2
Birnbach DJ Ranasinghe JS Is remifentanil a safe and effective alternative to neuraxial labor analgesia It all depends Anesth Analg 2014118(3)491-3
Bonner JC McClymont W Respiratory arrest in an obstetric patient using remifentanil patient-controlled analgesia Anaesthesia 201267(5)538-40
Daly O Kelly KP McCormack JG Heidemann BH Remifentanil PCA in labour Anaesthesia 201368(7)780-1
Devabhakthuni S Efficacy and safety of remifentanil as an alternative labor analgesic Clin Med Insights Womens Health 2013637-49
Freeman LM Bloemenkamp KW Franssen MT et al Patient controlled analgesia with remifentanil versus epidural analgesia in labour randomised multicentreequivalence trial BMJ 2015350(7997)11
Kranke P Girard T Lavandhomme P Melber A Jokinen J Muellenbach RM et al Must we press on until a young mother dies Remifentanil patient controlled analgesia in labourmay not be suited as a poor mans epidural BMC Pregnancy Childbirth 201313139
Muchatuta NA Kinsella SM Remifentanil for labour analgesia time to draw breath Anaesthesia 201368(3)231-5
SSAI Malmoslash 2017
The ideal opioid delivery
SSAI Malmoslash 2017
Time
Pain
intensity
and effect
Contraction pain
Pain relief
Does not exist
Opioids and labour analgeisahellip
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Tramadol meptazinol pethidine diamorphine pentazocine nalbuphinefentanylIMIV Pca vs bolus
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Van De Velde and Carvalho IJOA 2016 15 66-74
SSAI Malmoslash 2017
Remi 40microg2minsFenta 20microg + loadingPet 5 mg + loading
SSAI Malmoslash 2017
Other opioids better
bull CONCLUSIONS Intravenous patient-controlled analgesia with either remifentanil or fentanyl provides a moderate degree of labour analgesia whereas transient maternal oxygen desaturation is observed more commonly with remifentanil Fentanyl is associated with a higher need for neonatal resuscitation Marwah R
Hassan S Carvalho JC Balki M Remifentanil versus fentanyl for intravenous patient-controlled labour analgesia an observational study Canadian Journal of Anaesthesia 201259(3)246-54
SSAI Malmoslash 2017
Remifentanil provides betterpain relief than other opioids but only during the first twohours
SSAI Malmoslash 2017
Does it work
SSAI Malmoslash 2017
From M Van De Velde B Carvalho IJOA 2016 25 66-74
SSAI Malmoslash 2017
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 TRIAL REGISTRATION Netherlands Trial Register NTR2551
CONCLUSION In terms of labor duration average VAS pain scores and maternal overall satisfaction score with analgesia CSE analgesia is superior to that provided by epidural analgesia or PCIA with remifentanil for pain relief in early labor in nulliparous women However there were no differences in the mode of delivery side effects or neonatal outcomes between the three techniques
Efficacy of Remifentanil PCA as compared to CSEEpidural
SSAI Malmoslash 2017
Oxygen saturation was significantly lower (SpO2 lt92) in women who used remifentanil (relative risk 15 14 to 17)
Remifentanil IVPCA provides poorer efficacy on labor analgesia than epidural analgesia with more sedation on parturients and a trend of newborn acidosis
Lin R Tao Y Yu Y Xu Z Su J Liu Z Intravenous remifentanil versus epidural ropivacaine with sufentanil for labour analgesia a retrospective study PLoS ONE [Electronic Resource] 20149(11)e112283
SSAI Malmoslash 2017
Meta Analyses
bull This meta-analysis suggests that remifentanil PCIA is not superior to epidural analgesia in analgesic efficacy during labor Given the wide CIs of the pooled results for secondary maternal and neonatal outcomes definite conclusions cannot be drawn for those outcomes Further studies are still warranted to validate these conclusions Liu ZQ Chen XB Li HB Qiu MT Duan T A comparison of remifentanil parturient-controlled intravenous analgesia with
epidural analgesia a meta-analysis of randomized controlled trials Anesth Analg 2014118(3)598-603
bull CONCLUSION During labour remifentanil-PCA provided superior analgesia and higher patient satisfactioncompared with pethidine with a comparable degree of adverse events Epidural analgesia providedsuperior pain relief in comparison with remifentanil Due to a low number of reported adverse events thesafety issue of remifentanil use in labour remains an open question that needs to be addressed in futuretrials Schnabel A Hahn N Broscheit J Muellenbach RM Rieger L Roewer N et al Remifentanil for labour analgesia a meta-analysis of
randomised controlled trials European Journal of Anaesthesiology 201229(4)177-85
bull Conclusions Pooled assessment of remifentanil intervention seems an attractive strategy for controlling labor pain in health term parturients but it is not supported by strong evidence Current evidencesuggests that it may produce effective analgesia by only a modest level HealthMED 20126(7)2407-18
Effect size difference 3 cm
SSAI Malmoslash 2017
SSAI Malmoslash 2017
APRIL 2017
20 RCTrsquos 3569 women
Results Weibel et al
bull Based on the current systematic review there is mostly low-quality evidence to inform practiceand future research may significantly alter thecurrent 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 safetyoutcomes (maternal apnoe and respiratorydepression Apgar score) and on the optimal mode and regimen of remifentanil administrationto provide highets efficacy with reasonableadverse effects for mother and their newborns
SSAI Malmoslash 2017
Always satisfied
Off course they are Who wouldnrsquot
SSAI Malmoslash 2017
Optimal administration of remi
SSAI Malmoslash 2017
Optimal administration of remi
bull Protocols varies (bolus dose lock-out background infusion TCI etc)
bull Fixed bolus 20-50 microg without backgroundinfusion lock-out 2-3 minutes
bull If background ndash small dose lt 005microgkgxmin
bull TCI 05-15 ngml
bull New systems VPIA (Vital signs patientcontrolled intravenous analgesia)
SSAI Malmoslash 2017
SIA et al IJOA correspondence 2014 23 196-8
SSAI Malmoslash 2017
Cont infusion or PCA
bull Shen MK Wu ZF Zhu AB et al Remifentanil for labour analgesia a double-blinded randomised controlled trial of maternal and neonatal effects ofpatient-controlled analgesia versus continuous infusion (0005-02 microgkgxmin) Anaesthesia 201368(3)236-44 The results suggest thatremifentanil PCA (01-04 microgkg) provides better pain relief and similarplacental transfer compared with continuous infusion (Author)
bull Per protocol TCI Norwegian National Hospital (Oslo University Hospital)
ndash 05 ndash 2 ngml + nurse controlled boluses) ndash easier for anaesthesia personell
SSAI Malmoslash 2017
Remifentanil TCI
bull Why notbull Acta Anaesthesiol Scand 2013 Jul57(6)802-8 doi 101111aas12096 Epub 2013 Mar 15
bull Remifentanil target-controlled infusion during second stage labour in high-risk parturients a case series Schwarz GL1 Volmanen P Albrechtsen S Bjoernestad E
bull 1ngml start incremental doses of 05 ngml titrated untill satisfied mother or side-effects(1-6 ngml)
SSAI Malmoslash 2017
Why use remifentanil
The boss
SSAI Malmoslash 2017
In conclusionhellip
SSAI Malmoslash 2017
When to use it
bull For parturients with contraindications to regional analgesia
ndash Bleeding disorders
ndash Infections
ndash Mother does not want regional
bull In places with reduced anaesthesia service
SSAI Malmoslash 2017
Then remifentanil is the best choice
bull Continuous monitoring
bull Including capnography or RR counting
bull Well educated staff
SSAI Malmoslash 2017
Remifentanil PCA
bull Is cheap
bull Easy to administer
bull Gives (some) pain relief
SSAI Malmoslash 2017
BUT
bull Has a poor analgesic effect compared to thegolden standard of regional analgesia
bull May cause a lot of harm
bull Andhellip
SSAI Malmoslash 2017
AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS
Is too dangerous to be used as routineanalgesia in the labour ward
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
RemiPCA SAFE NetworkcopyRegimenConcentration of Remifentanil 20mcgml (2mg Remifentanil in 100ml NaCl 09)Bolus 10-30 μgLockout interval 2 minNo additional infusion of remifentanil No application of any other opioid or analgesicdrug
httpswwwgooglecommapsdviewermid=1BrSGgixaIx0JjdvPPBPbHjzlkUAampusp=sharing
2017 7800 deliveries
266 Hypoxia26 Sedation17 Nausea
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Labor or Delivery Opioids cross the placenta and may produce respiratory depression and psycho-physiologic effects in neonates An opioid antagonist such as naloxone must be available for reversal of opioid-induced respiratory depression in the neonate ULTIVA is not recommended for use in pregnant women during or immediately prior to labor when other analgesic techniques are more appropriate Opioid analgesics including ULTIVA can prolong labor through actions which temporarily reduce the strength duration and frequency of uterine contractions However this effect is not consistent and may be offset by an increased rate of cervical dilation which tends to shorten labor Monitor neonates exposed to opioid analgesics during labor for signs of excess sedation and respiratory depression
USA2015 36 occasionally
Bhatia K Unknowns in the use of remifentanil PCA for labour analgesia Anaesthesia 201368(6)641-2
Birnbach DJ Ranasinghe JS Is remifentanil a safe and effective alternative to neuraxial labor analgesia It all depends Anesth Analg 2014118(3)491-3
Bonner JC McClymont W Respiratory arrest in an obstetric patient using remifentanil patient-controlled analgesia Anaesthesia 201267(5)538-40
Daly O Kelly KP McCormack JG Heidemann BH Remifentanil PCA in labour Anaesthesia 201368(7)780-1
Devabhakthuni S Efficacy and safety of remifentanil as an alternative labor analgesic Clin Med Insights Womens Health 2013637-49
Freeman LM Bloemenkamp KW Franssen MT et al Patient controlled analgesia with remifentanil versus epidural analgesia in labour randomised multicentreequivalence trial BMJ 2015350(7997)11
Kranke P Girard T Lavandhomme P Melber A Jokinen J Muellenbach RM et al Must we press on until a young mother dies Remifentanil patient controlled analgesia in labourmay not be suited as a poor mans epidural BMC Pregnancy Childbirth 201313139
Muchatuta NA Kinsella SM Remifentanil for labour analgesia time to draw breath Anaesthesia 201368(3)231-5
SSAI Malmoslash 2017
The ideal opioid delivery
SSAI Malmoslash 2017
Time
Pain
intensity
and effect
Contraction pain
Pain relief
Does not exist
Opioids and labour analgeisahellip
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Tramadol meptazinol pethidine diamorphine pentazocine nalbuphinefentanylIMIV Pca vs bolus
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Van De Velde and Carvalho IJOA 2016 15 66-74
SSAI Malmoslash 2017
Remi 40microg2minsFenta 20microg + loadingPet 5 mg + loading
SSAI Malmoslash 2017
Other opioids better
bull CONCLUSIONS Intravenous patient-controlled analgesia with either remifentanil or fentanyl provides a moderate degree of labour analgesia whereas transient maternal oxygen desaturation is observed more commonly with remifentanil Fentanyl is associated with a higher need for neonatal resuscitation Marwah R
Hassan S Carvalho JC Balki M Remifentanil versus fentanyl for intravenous patient-controlled labour analgesia an observational study Canadian Journal of Anaesthesia 201259(3)246-54
SSAI Malmoslash 2017
Remifentanil provides betterpain relief than other opioids but only during the first twohours
SSAI Malmoslash 2017
Does it work
SSAI Malmoslash 2017
From M Van De Velde B Carvalho IJOA 2016 25 66-74
SSAI Malmoslash 2017
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 TRIAL REGISTRATION Netherlands Trial Register NTR2551
CONCLUSION In terms of labor duration average VAS pain scores and maternal overall satisfaction score with analgesia CSE analgesia is superior to that provided by epidural analgesia or PCIA with remifentanil for pain relief in early labor in nulliparous women However there were no differences in the mode of delivery side effects or neonatal outcomes between the three techniques
Efficacy of Remifentanil PCA as compared to CSEEpidural
SSAI Malmoslash 2017
Oxygen saturation was significantly lower (SpO2 lt92) in women who used remifentanil (relative risk 15 14 to 17)
Remifentanil IVPCA provides poorer efficacy on labor analgesia than epidural analgesia with more sedation on parturients and a trend of newborn acidosis
Lin R Tao Y Yu Y Xu Z Su J Liu Z Intravenous remifentanil versus epidural ropivacaine with sufentanil for labour analgesia a retrospective study PLoS ONE [Electronic Resource] 20149(11)e112283
SSAI Malmoslash 2017
Meta Analyses
bull This meta-analysis suggests that remifentanil PCIA is not superior to epidural analgesia in analgesic efficacy during labor Given the wide CIs of the pooled results for secondary maternal and neonatal outcomes definite conclusions cannot be drawn for those outcomes Further studies are still warranted to validate these conclusions Liu ZQ Chen XB Li HB Qiu MT Duan T A comparison of remifentanil parturient-controlled intravenous analgesia with
epidural analgesia a meta-analysis of randomized controlled trials Anesth Analg 2014118(3)598-603
bull CONCLUSION During labour remifentanil-PCA provided superior analgesia and higher patient satisfactioncompared with pethidine with a comparable degree of adverse events Epidural analgesia providedsuperior pain relief in comparison with remifentanil Due to a low number of reported adverse events thesafety issue of remifentanil use in labour remains an open question that needs to be addressed in futuretrials Schnabel A Hahn N Broscheit J Muellenbach RM Rieger L Roewer N et al Remifentanil for labour analgesia a meta-analysis of
randomised controlled trials European Journal of Anaesthesiology 201229(4)177-85
bull Conclusions Pooled assessment of remifentanil intervention seems an attractive strategy for controlling labor pain in health term parturients but it is not supported by strong evidence Current evidencesuggests that it may produce effective analgesia by only a modest level HealthMED 20126(7)2407-18
Effect size difference 3 cm
SSAI Malmoslash 2017
SSAI Malmoslash 2017
APRIL 2017
20 RCTrsquos 3569 women
Results Weibel et al
bull Based on the current systematic review there is mostly low-quality evidence to inform practiceand future research may significantly alter thecurrent 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 safetyoutcomes (maternal apnoe and respiratorydepression Apgar score) and on the optimal mode and regimen of remifentanil administrationto provide highets efficacy with reasonableadverse effects for mother and their newborns
SSAI Malmoslash 2017
Always satisfied
Off course they are Who wouldnrsquot
SSAI Malmoslash 2017
Optimal administration of remi
SSAI Malmoslash 2017
Optimal administration of remi
bull Protocols varies (bolus dose lock-out background infusion TCI etc)
bull Fixed bolus 20-50 microg without backgroundinfusion lock-out 2-3 minutes
bull If background ndash small dose lt 005microgkgxmin
bull TCI 05-15 ngml
bull New systems VPIA (Vital signs patientcontrolled intravenous analgesia)
SSAI Malmoslash 2017
SIA et al IJOA correspondence 2014 23 196-8
SSAI Malmoslash 2017
Cont infusion or PCA
bull Shen MK Wu ZF Zhu AB et al Remifentanil for labour analgesia a double-blinded randomised controlled trial of maternal and neonatal effects ofpatient-controlled analgesia versus continuous infusion (0005-02 microgkgxmin) Anaesthesia 201368(3)236-44 The results suggest thatremifentanil PCA (01-04 microgkg) provides better pain relief and similarplacental transfer compared with continuous infusion (Author)
bull Per protocol TCI Norwegian National Hospital (Oslo University Hospital)
ndash 05 ndash 2 ngml + nurse controlled boluses) ndash easier for anaesthesia personell
SSAI Malmoslash 2017
Remifentanil TCI
bull Why notbull Acta Anaesthesiol Scand 2013 Jul57(6)802-8 doi 101111aas12096 Epub 2013 Mar 15
bull Remifentanil target-controlled infusion during second stage labour in high-risk parturients a case series Schwarz GL1 Volmanen P Albrechtsen S Bjoernestad E
bull 1ngml start incremental doses of 05 ngml titrated untill satisfied mother or side-effects(1-6 ngml)
SSAI Malmoslash 2017
Why use remifentanil
The boss
SSAI Malmoslash 2017
In conclusionhellip
SSAI Malmoslash 2017
When to use it
bull For parturients with contraindications to regional analgesia
ndash Bleeding disorders
ndash Infections
ndash Mother does not want regional
bull In places with reduced anaesthesia service
SSAI Malmoslash 2017
Then remifentanil is the best choice
bull Continuous monitoring
bull Including capnography or RR counting
bull Well educated staff
SSAI Malmoslash 2017
Remifentanil PCA
bull Is cheap
bull Easy to administer
bull Gives (some) pain relief
SSAI Malmoslash 2017
BUT
bull Has a poor analgesic effect compared to thegolden standard of regional analgesia
bull May cause a lot of harm
bull Andhellip
SSAI Malmoslash 2017
AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS
Is too dangerous to be used as routineanalgesia in the labour ward
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Labor or Delivery Opioids cross the placenta and may produce respiratory depression and psycho-physiologic effects in neonates An opioid antagonist such as naloxone must be available for reversal of opioid-induced respiratory depression in the neonate ULTIVA is not recommended for use in pregnant women during or immediately prior to labor when other analgesic techniques are more appropriate Opioid analgesics including ULTIVA can prolong labor through actions which temporarily reduce the strength duration and frequency of uterine contractions However this effect is not consistent and may be offset by an increased rate of cervical dilation which tends to shorten labor Monitor neonates exposed to opioid analgesics during labor for signs of excess sedation and respiratory depression
USA2015 36 occasionally
Bhatia K Unknowns in the use of remifentanil PCA for labour analgesia Anaesthesia 201368(6)641-2
Birnbach DJ Ranasinghe JS Is remifentanil a safe and effective alternative to neuraxial labor analgesia It all depends Anesth Analg 2014118(3)491-3
Bonner JC McClymont W Respiratory arrest in an obstetric patient using remifentanil patient-controlled analgesia Anaesthesia 201267(5)538-40
Daly O Kelly KP McCormack JG Heidemann BH Remifentanil PCA in labour Anaesthesia 201368(7)780-1
Devabhakthuni S Efficacy and safety of remifentanil as an alternative labor analgesic Clin Med Insights Womens Health 2013637-49
Freeman LM Bloemenkamp KW Franssen MT et al Patient controlled analgesia with remifentanil versus epidural analgesia in labour randomised multicentreequivalence trial BMJ 2015350(7997)11
Kranke P Girard T Lavandhomme P Melber A Jokinen J Muellenbach RM et al Must we press on until a young mother dies Remifentanil patient controlled analgesia in labourmay not be suited as a poor mans epidural BMC Pregnancy Childbirth 201313139
Muchatuta NA Kinsella SM Remifentanil for labour analgesia time to draw breath Anaesthesia 201368(3)231-5
SSAI Malmoslash 2017
The ideal opioid delivery
SSAI Malmoslash 2017
Time
Pain
intensity
and effect
Contraction pain
Pain relief
Does not exist
Opioids and labour analgeisahellip
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Tramadol meptazinol pethidine diamorphine pentazocine nalbuphinefentanylIMIV Pca vs bolus
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Van De Velde and Carvalho IJOA 2016 15 66-74
SSAI Malmoslash 2017
Remi 40microg2minsFenta 20microg + loadingPet 5 mg + loading
SSAI Malmoslash 2017
Other opioids better
bull CONCLUSIONS Intravenous patient-controlled analgesia with either remifentanil or fentanyl provides a moderate degree of labour analgesia whereas transient maternal oxygen desaturation is observed more commonly with remifentanil Fentanyl is associated with a higher need for neonatal resuscitation Marwah R
Hassan S Carvalho JC Balki M Remifentanil versus fentanyl for intravenous patient-controlled labour analgesia an observational study Canadian Journal of Anaesthesia 201259(3)246-54
SSAI Malmoslash 2017
Remifentanil provides betterpain relief than other opioids but only during the first twohours
SSAI Malmoslash 2017
Does it work
SSAI Malmoslash 2017
From M Van De Velde B Carvalho IJOA 2016 25 66-74
SSAI Malmoslash 2017
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 TRIAL REGISTRATION Netherlands Trial Register NTR2551
CONCLUSION In terms of labor duration average VAS pain scores and maternal overall satisfaction score with analgesia CSE analgesia is superior to that provided by epidural analgesia or PCIA with remifentanil for pain relief in early labor in nulliparous women However there were no differences in the mode of delivery side effects or neonatal outcomes between the three techniques
Efficacy of Remifentanil PCA as compared to CSEEpidural
SSAI Malmoslash 2017
Oxygen saturation was significantly lower (SpO2 lt92) in women who used remifentanil (relative risk 15 14 to 17)
Remifentanil IVPCA provides poorer efficacy on labor analgesia than epidural analgesia with more sedation on parturients and a trend of newborn acidosis
Lin R Tao Y Yu Y Xu Z Su J Liu Z Intravenous remifentanil versus epidural ropivacaine with sufentanil for labour analgesia a retrospective study PLoS ONE [Electronic Resource] 20149(11)e112283
SSAI Malmoslash 2017
Meta Analyses
bull This meta-analysis suggests that remifentanil PCIA is not superior to epidural analgesia in analgesic efficacy during labor Given the wide CIs of the pooled results for secondary maternal and neonatal outcomes definite conclusions cannot be drawn for those outcomes Further studies are still warranted to validate these conclusions Liu ZQ Chen XB Li HB Qiu MT Duan T A comparison of remifentanil parturient-controlled intravenous analgesia with
epidural analgesia a meta-analysis of randomized controlled trials Anesth Analg 2014118(3)598-603
bull CONCLUSION During labour remifentanil-PCA provided superior analgesia and higher patient satisfactioncompared with pethidine with a comparable degree of adverse events Epidural analgesia providedsuperior pain relief in comparison with remifentanil Due to a low number of reported adverse events thesafety issue of remifentanil use in labour remains an open question that needs to be addressed in futuretrials Schnabel A Hahn N Broscheit J Muellenbach RM Rieger L Roewer N et al Remifentanil for labour analgesia a meta-analysis of
randomised controlled trials European Journal of Anaesthesiology 201229(4)177-85
bull Conclusions Pooled assessment of remifentanil intervention seems an attractive strategy for controlling labor pain in health term parturients but it is not supported by strong evidence Current evidencesuggests that it may produce effective analgesia by only a modest level HealthMED 20126(7)2407-18
Effect size difference 3 cm
SSAI Malmoslash 2017
SSAI Malmoslash 2017
APRIL 2017
20 RCTrsquos 3569 women
Results Weibel et al
bull Based on the current systematic review there is mostly low-quality evidence to inform practiceand future research may significantly alter thecurrent 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 safetyoutcomes (maternal apnoe and respiratorydepression Apgar score) and on the optimal mode and regimen of remifentanil administrationto provide highets efficacy with reasonableadverse effects for mother and their newborns
SSAI Malmoslash 2017
Always satisfied
Off course they are Who wouldnrsquot
SSAI Malmoslash 2017
Optimal administration of remi
SSAI Malmoslash 2017
Optimal administration of remi
bull Protocols varies (bolus dose lock-out background infusion TCI etc)
bull Fixed bolus 20-50 microg without backgroundinfusion lock-out 2-3 minutes
bull If background ndash small dose lt 005microgkgxmin
bull TCI 05-15 ngml
bull New systems VPIA (Vital signs patientcontrolled intravenous analgesia)
SSAI Malmoslash 2017
SIA et al IJOA correspondence 2014 23 196-8
SSAI Malmoslash 2017
Cont infusion or PCA
bull Shen MK Wu ZF Zhu AB et al Remifentanil for labour analgesia a double-blinded randomised controlled trial of maternal and neonatal effects ofpatient-controlled analgesia versus continuous infusion (0005-02 microgkgxmin) Anaesthesia 201368(3)236-44 The results suggest thatremifentanil PCA (01-04 microgkg) provides better pain relief and similarplacental transfer compared with continuous infusion (Author)
bull Per protocol TCI Norwegian National Hospital (Oslo University Hospital)
ndash 05 ndash 2 ngml + nurse controlled boluses) ndash easier for anaesthesia personell
SSAI Malmoslash 2017
Remifentanil TCI
bull Why notbull Acta Anaesthesiol Scand 2013 Jul57(6)802-8 doi 101111aas12096 Epub 2013 Mar 15
bull Remifentanil target-controlled infusion during second stage labour in high-risk parturients a case series Schwarz GL1 Volmanen P Albrechtsen S Bjoernestad E
bull 1ngml start incremental doses of 05 ngml titrated untill satisfied mother or side-effects(1-6 ngml)
SSAI Malmoslash 2017
Why use remifentanil
The boss
SSAI Malmoslash 2017
In conclusionhellip
SSAI Malmoslash 2017
When to use it
bull For parturients with contraindications to regional analgesia
ndash Bleeding disorders
ndash Infections
ndash Mother does not want regional
bull In places with reduced anaesthesia service
SSAI Malmoslash 2017
Then remifentanil is the best choice
bull Continuous monitoring
bull Including capnography or RR counting
bull Well educated staff
SSAI Malmoslash 2017
Remifentanil PCA
bull Is cheap
bull Easy to administer
bull Gives (some) pain relief
SSAI Malmoslash 2017
BUT
bull Has a poor analgesic effect compared to thegolden standard of regional analgesia
bull May cause a lot of harm
bull Andhellip
SSAI Malmoslash 2017
AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS
Is too dangerous to be used as routineanalgesia in the labour ward
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
Bhatia K Unknowns in the use of remifentanil PCA for labour analgesia Anaesthesia 201368(6)641-2
Birnbach DJ Ranasinghe JS Is remifentanil a safe and effective alternative to neuraxial labor analgesia It all depends Anesth Analg 2014118(3)491-3
Bonner JC McClymont W Respiratory arrest in an obstetric patient using remifentanil patient-controlled analgesia Anaesthesia 201267(5)538-40
Daly O Kelly KP McCormack JG Heidemann BH Remifentanil PCA in labour Anaesthesia 201368(7)780-1
Devabhakthuni S Efficacy and safety of remifentanil as an alternative labor analgesic Clin Med Insights Womens Health 2013637-49
Freeman LM Bloemenkamp KW Franssen MT et al Patient controlled analgesia with remifentanil versus epidural analgesia in labour randomised multicentreequivalence trial BMJ 2015350(7997)11
Kranke P Girard T Lavandhomme P Melber A Jokinen J Muellenbach RM et al Must we press on until a young mother dies Remifentanil patient controlled analgesia in labourmay not be suited as a poor mans epidural BMC Pregnancy Childbirth 201313139
Muchatuta NA Kinsella SM Remifentanil for labour analgesia time to draw breath Anaesthesia 201368(3)231-5
SSAI Malmoslash 2017
The ideal opioid delivery
SSAI Malmoslash 2017
Time
Pain
intensity
and effect
Contraction pain
Pain relief
Does not exist
Opioids and labour analgeisahellip
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Tramadol meptazinol pethidine diamorphine pentazocine nalbuphinefentanylIMIV Pca vs bolus
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Van De Velde and Carvalho IJOA 2016 15 66-74
SSAI Malmoslash 2017
Remi 40microg2minsFenta 20microg + loadingPet 5 mg + loading
SSAI Malmoslash 2017
Other opioids better
bull CONCLUSIONS Intravenous patient-controlled analgesia with either remifentanil or fentanyl provides a moderate degree of labour analgesia whereas transient maternal oxygen desaturation is observed more commonly with remifentanil Fentanyl is associated with a higher need for neonatal resuscitation Marwah R
Hassan S Carvalho JC Balki M Remifentanil versus fentanyl for intravenous patient-controlled labour analgesia an observational study Canadian Journal of Anaesthesia 201259(3)246-54
SSAI Malmoslash 2017
Remifentanil provides betterpain relief than other opioids but only during the first twohours
SSAI Malmoslash 2017
Does it work
SSAI Malmoslash 2017
From M Van De Velde B Carvalho IJOA 2016 25 66-74
SSAI Malmoslash 2017
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 TRIAL REGISTRATION Netherlands Trial Register NTR2551
CONCLUSION In terms of labor duration average VAS pain scores and maternal overall satisfaction score with analgesia CSE analgesia is superior to that provided by epidural analgesia or PCIA with remifentanil for pain relief in early labor in nulliparous women However there were no differences in the mode of delivery side effects or neonatal outcomes between the three techniques
Efficacy of Remifentanil PCA as compared to CSEEpidural
SSAI Malmoslash 2017
Oxygen saturation was significantly lower (SpO2 lt92) in women who used remifentanil (relative risk 15 14 to 17)
Remifentanil IVPCA provides poorer efficacy on labor analgesia than epidural analgesia with more sedation on parturients and a trend of newborn acidosis
Lin R Tao Y Yu Y Xu Z Su J Liu Z Intravenous remifentanil versus epidural ropivacaine with sufentanil for labour analgesia a retrospective study PLoS ONE [Electronic Resource] 20149(11)e112283
SSAI Malmoslash 2017
Meta Analyses
bull This meta-analysis suggests that remifentanil PCIA is not superior to epidural analgesia in analgesic efficacy during labor Given the wide CIs of the pooled results for secondary maternal and neonatal outcomes definite conclusions cannot be drawn for those outcomes Further studies are still warranted to validate these conclusions Liu ZQ Chen XB Li HB Qiu MT Duan T A comparison of remifentanil parturient-controlled intravenous analgesia with
epidural analgesia a meta-analysis of randomized controlled trials Anesth Analg 2014118(3)598-603
bull CONCLUSION During labour remifentanil-PCA provided superior analgesia and higher patient satisfactioncompared with pethidine with a comparable degree of adverse events Epidural analgesia providedsuperior pain relief in comparison with remifentanil Due to a low number of reported adverse events thesafety issue of remifentanil use in labour remains an open question that needs to be addressed in futuretrials Schnabel A Hahn N Broscheit J Muellenbach RM Rieger L Roewer N et al Remifentanil for labour analgesia a meta-analysis of
randomised controlled trials European Journal of Anaesthesiology 201229(4)177-85
bull Conclusions Pooled assessment of remifentanil intervention seems an attractive strategy for controlling labor pain in health term parturients but it is not supported by strong evidence Current evidencesuggests that it may produce effective analgesia by only a modest level HealthMED 20126(7)2407-18
Effect size difference 3 cm
SSAI Malmoslash 2017
SSAI Malmoslash 2017
APRIL 2017
20 RCTrsquos 3569 women
Results Weibel et al
bull Based on the current systematic review there is mostly low-quality evidence to inform practiceand future research may significantly alter thecurrent 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 safetyoutcomes (maternal apnoe and respiratorydepression Apgar score) and on the optimal mode and regimen of remifentanil administrationto provide highets efficacy with reasonableadverse effects for mother and their newborns
SSAI Malmoslash 2017
Always satisfied
Off course they are Who wouldnrsquot
SSAI Malmoslash 2017
Optimal administration of remi
SSAI Malmoslash 2017
Optimal administration of remi
bull Protocols varies (bolus dose lock-out background infusion TCI etc)
bull Fixed bolus 20-50 microg without backgroundinfusion lock-out 2-3 minutes
bull If background ndash small dose lt 005microgkgxmin
bull TCI 05-15 ngml
bull New systems VPIA (Vital signs patientcontrolled intravenous analgesia)
SSAI Malmoslash 2017
SIA et al IJOA correspondence 2014 23 196-8
SSAI Malmoslash 2017
Cont infusion or PCA
bull Shen MK Wu ZF Zhu AB et al Remifentanil for labour analgesia a double-blinded randomised controlled trial of maternal and neonatal effects ofpatient-controlled analgesia versus continuous infusion (0005-02 microgkgxmin) Anaesthesia 201368(3)236-44 The results suggest thatremifentanil PCA (01-04 microgkg) provides better pain relief and similarplacental transfer compared with continuous infusion (Author)
bull Per protocol TCI Norwegian National Hospital (Oslo University Hospital)
ndash 05 ndash 2 ngml + nurse controlled boluses) ndash easier for anaesthesia personell
SSAI Malmoslash 2017
Remifentanil TCI
bull Why notbull Acta Anaesthesiol Scand 2013 Jul57(6)802-8 doi 101111aas12096 Epub 2013 Mar 15
bull Remifentanil target-controlled infusion during second stage labour in high-risk parturients a case series Schwarz GL1 Volmanen P Albrechtsen S Bjoernestad E
bull 1ngml start incremental doses of 05 ngml titrated untill satisfied mother or side-effects(1-6 ngml)
SSAI Malmoslash 2017
Why use remifentanil
The boss
SSAI Malmoslash 2017
In conclusionhellip
SSAI Malmoslash 2017
When to use it
bull For parturients with contraindications to regional analgesia
ndash Bleeding disorders
ndash Infections
ndash Mother does not want regional
bull In places with reduced anaesthesia service
SSAI Malmoslash 2017
Then remifentanil is the best choice
bull Continuous monitoring
bull Including capnography or RR counting
bull Well educated staff
SSAI Malmoslash 2017
Remifentanil PCA
bull Is cheap
bull Easy to administer
bull Gives (some) pain relief
SSAI Malmoslash 2017
BUT
bull Has a poor analgesic effect compared to thegolden standard of regional analgesia
bull May cause a lot of harm
bull Andhellip
SSAI Malmoslash 2017
AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS
Is too dangerous to be used as routineanalgesia in the labour ward
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
The ideal opioid delivery
SSAI Malmoslash 2017
Time
Pain
intensity
and effect
Contraction pain
Pain relief
Does not exist
Opioids and labour analgeisahellip
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Tramadol meptazinol pethidine diamorphine pentazocine nalbuphinefentanylIMIV Pca vs bolus
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Van De Velde and Carvalho IJOA 2016 15 66-74
SSAI Malmoslash 2017
Remi 40microg2minsFenta 20microg + loadingPet 5 mg + loading
SSAI Malmoslash 2017
Other opioids better
bull CONCLUSIONS Intravenous patient-controlled analgesia with either remifentanil or fentanyl provides a moderate degree of labour analgesia whereas transient maternal oxygen desaturation is observed more commonly with remifentanil Fentanyl is associated with a higher need for neonatal resuscitation Marwah R
Hassan S Carvalho JC Balki M Remifentanil versus fentanyl for intravenous patient-controlled labour analgesia an observational study Canadian Journal of Anaesthesia 201259(3)246-54
SSAI Malmoslash 2017
Remifentanil provides betterpain relief than other opioids but only during the first twohours
SSAI Malmoslash 2017
Does it work
SSAI Malmoslash 2017
From M Van De Velde B Carvalho IJOA 2016 25 66-74
SSAI Malmoslash 2017
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 TRIAL REGISTRATION Netherlands Trial Register NTR2551
CONCLUSION In terms of labor duration average VAS pain scores and maternal overall satisfaction score with analgesia CSE analgesia is superior to that provided by epidural analgesia or PCIA with remifentanil for pain relief in early labor in nulliparous women However there were no differences in the mode of delivery side effects or neonatal outcomes between the three techniques
Efficacy of Remifentanil PCA as compared to CSEEpidural
SSAI Malmoslash 2017
Oxygen saturation was significantly lower (SpO2 lt92) in women who used remifentanil (relative risk 15 14 to 17)
Remifentanil IVPCA provides poorer efficacy on labor analgesia than epidural analgesia with more sedation on parturients and a trend of newborn acidosis
Lin R Tao Y Yu Y Xu Z Su J Liu Z Intravenous remifentanil versus epidural ropivacaine with sufentanil for labour analgesia a retrospective study PLoS ONE [Electronic Resource] 20149(11)e112283
SSAI Malmoslash 2017
Meta Analyses
bull This meta-analysis suggests that remifentanil PCIA is not superior to epidural analgesia in analgesic efficacy during labor Given the wide CIs of the pooled results for secondary maternal and neonatal outcomes definite conclusions cannot be drawn for those outcomes Further studies are still warranted to validate these conclusions Liu ZQ Chen XB Li HB Qiu MT Duan T A comparison of remifentanil parturient-controlled intravenous analgesia with
epidural analgesia a meta-analysis of randomized controlled trials Anesth Analg 2014118(3)598-603
bull CONCLUSION During labour remifentanil-PCA provided superior analgesia and higher patient satisfactioncompared with pethidine with a comparable degree of adverse events Epidural analgesia providedsuperior pain relief in comparison with remifentanil Due to a low number of reported adverse events thesafety issue of remifentanil use in labour remains an open question that needs to be addressed in futuretrials Schnabel A Hahn N Broscheit J Muellenbach RM Rieger L Roewer N et al Remifentanil for labour analgesia a meta-analysis of
randomised controlled trials European Journal of Anaesthesiology 201229(4)177-85
bull Conclusions Pooled assessment of remifentanil intervention seems an attractive strategy for controlling labor pain in health term parturients but it is not supported by strong evidence Current evidencesuggests that it may produce effective analgesia by only a modest level HealthMED 20126(7)2407-18
Effect size difference 3 cm
SSAI Malmoslash 2017
SSAI Malmoslash 2017
APRIL 2017
20 RCTrsquos 3569 women
Results Weibel et al
bull Based on the current systematic review there is mostly low-quality evidence to inform practiceand future research may significantly alter thecurrent 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 safetyoutcomes (maternal apnoe and respiratorydepression Apgar score) and on the optimal mode and regimen of remifentanil administrationto provide highets efficacy with reasonableadverse effects for mother and their newborns
SSAI Malmoslash 2017
Always satisfied
Off course they are Who wouldnrsquot
SSAI Malmoslash 2017
Optimal administration of remi
SSAI Malmoslash 2017
Optimal administration of remi
bull Protocols varies (bolus dose lock-out background infusion TCI etc)
bull Fixed bolus 20-50 microg without backgroundinfusion lock-out 2-3 minutes
bull If background ndash small dose lt 005microgkgxmin
bull TCI 05-15 ngml
bull New systems VPIA (Vital signs patientcontrolled intravenous analgesia)
SSAI Malmoslash 2017
SIA et al IJOA correspondence 2014 23 196-8
SSAI Malmoslash 2017
Cont infusion or PCA
bull Shen MK Wu ZF Zhu AB et al Remifentanil for labour analgesia a double-blinded randomised controlled trial of maternal and neonatal effects ofpatient-controlled analgesia versus continuous infusion (0005-02 microgkgxmin) Anaesthesia 201368(3)236-44 The results suggest thatremifentanil PCA (01-04 microgkg) provides better pain relief and similarplacental transfer compared with continuous infusion (Author)
bull Per protocol TCI Norwegian National Hospital (Oslo University Hospital)
ndash 05 ndash 2 ngml + nurse controlled boluses) ndash easier for anaesthesia personell
SSAI Malmoslash 2017
Remifentanil TCI
bull Why notbull Acta Anaesthesiol Scand 2013 Jul57(6)802-8 doi 101111aas12096 Epub 2013 Mar 15
bull Remifentanil target-controlled infusion during second stage labour in high-risk parturients a case series Schwarz GL1 Volmanen P Albrechtsen S Bjoernestad E
bull 1ngml start incremental doses of 05 ngml titrated untill satisfied mother or side-effects(1-6 ngml)
SSAI Malmoslash 2017
Why use remifentanil
The boss
SSAI Malmoslash 2017
In conclusionhellip
SSAI Malmoslash 2017
When to use it
bull For parturients with contraindications to regional analgesia
ndash Bleeding disorders
ndash Infections
ndash Mother does not want regional
bull In places with reduced anaesthesia service
SSAI Malmoslash 2017
Then remifentanil is the best choice
bull Continuous monitoring
bull Including capnography or RR counting
bull Well educated staff
SSAI Malmoslash 2017
Remifentanil PCA
bull Is cheap
bull Easy to administer
bull Gives (some) pain relief
SSAI Malmoslash 2017
BUT
bull Has a poor analgesic effect compared to thegolden standard of regional analgesia
bull May cause a lot of harm
bull Andhellip
SSAI Malmoslash 2017
AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS
Is too dangerous to be used as routineanalgesia in the labour ward
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
Opioids and labour analgeisahellip
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Tramadol meptazinol pethidine diamorphine pentazocine nalbuphinefentanylIMIV Pca vs bolus
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Van De Velde and Carvalho IJOA 2016 15 66-74
SSAI Malmoslash 2017
Remi 40microg2minsFenta 20microg + loadingPet 5 mg + loading
SSAI Malmoslash 2017
Other opioids better
bull CONCLUSIONS Intravenous patient-controlled analgesia with either remifentanil or fentanyl provides a moderate degree of labour analgesia whereas transient maternal oxygen desaturation is observed more commonly with remifentanil Fentanyl is associated with a higher need for neonatal resuscitation Marwah R
Hassan S Carvalho JC Balki M Remifentanil versus fentanyl for intravenous patient-controlled labour analgesia an observational study Canadian Journal of Anaesthesia 201259(3)246-54
SSAI Malmoslash 2017
Remifentanil provides betterpain relief than other opioids but only during the first twohours
SSAI Malmoslash 2017
Does it work
SSAI Malmoslash 2017
From M Van De Velde B Carvalho IJOA 2016 25 66-74
SSAI Malmoslash 2017
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 TRIAL REGISTRATION Netherlands Trial Register NTR2551
CONCLUSION In terms of labor duration average VAS pain scores and maternal overall satisfaction score with analgesia CSE analgesia is superior to that provided by epidural analgesia or PCIA with remifentanil for pain relief in early labor in nulliparous women However there were no differences in the mode of delivery side effects or neonatal outcomes between the three techniques
Efficacy of Remifentanil PCA as compared to CSEEpidural
SSAI Malmoslash 2017
Oxygen saturation was significantly lower (SpO2 lt92) in women who used remifentanil (relative risk 15 14 to 17)
Remifentanil IVPCA provides poorer efficacy on labor analgesia than epidural analgesia with more sedation on parturients and a trend of newborn acidosis
Lin R Tao Y Yu Y Xu Z Su J Liu Z Intravenous remifentanil versus epidural ropivacaine with sufentanil for labour analgesia a retrospective study PLoS ONE [Electronic Resource] 20149(11)e112283
SSAI Malmoslash 2017
Meta Analyses
bull This meta-analysis suggests that remifentanil PCIA is not superior to epidural analgesia in analgesic efficacy during labor Given the wide CIs of the pooled results for secondary maternal and neonatal outcomes definite conclusions cannot be drawn for those outcomes Further studies are still warranted to validate these conclusions Liu ZQ Chen XB Li HB Qiu MT Duan T A comparison of remifentanil parturient-controlled intravenous analgesia with
epidural analgesia a meta-analysis of randomized controlled trials Anesth Analg 2014118(3)598-603
bull CONCLUSION During labour remifentanil-PCA provided superior analgesia and higher patient satisfactioncompared with pethidine with a comparable degree of adverse events Epidural analgesia providedsuperior pain relief in comparison with remifentanil Due to a low number of reported adverse events thesafety issue of remifentanil use in labour remains an open question that needs to be addressed in futuretrials Schnabel A Hahn N Broscheit J Muellenbach RM Rieger L Roewer N et al Remifentanil for labour analgesia a meta-analysis of
randomised controlled trials European Journal of Anaesthesiology 201229(4)177-85
bull Conclusions Pooled assessment of remifentanil intervention seems an attractive strategy for controlling labor pain in health term parturients but it is not supported by strong evidence Current evidencesuggests that it may produce effective analgesia by only a modest level HealthMED 20126(7)2407-18
Effect size difference 3 cm
SSAI Malmoslash 2017
SSAI Malmoslash 2017
APRIL 2017
20 RCTrsquos 3569 women
Results Weibel et al
bull Based on the current systematic review there is mostly low-quality evidence to inform practiceand future research may significantly alter thecurrent 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 safetyoutcomes (maternal apnoe and respiratorydepression Apgar score) and on the optimal mode and regimen of remifentanil administrationto provide highets efficacy with reasonableadverse effects for mother and their newborns
SSAI Malmoslash 2017
Always satisfied
Off course they are Who wouldnrsquot
SSAI Malmoslash 2017
Optimal administration of remi
SSAI Malmoslash 2017
Optimal administration of remi
bull Protocols varies (bolus dose lock-out background infusion TCI etc)
bull Fixed bolus 20-50 microg without backgroundinfusion lock-out 2-3 minutes
bull If background ndash small dose lt 005microgkgxmin
bull TCI 05-15 ngml
bull New systems VPIA (Vital signs patientcontrolled intravenous analgesia)
SSAI Malmoslash 2017
SIA et al IJOA correspondence 2014 23 196-8
SSAI Malmoslash 2017
Cont infusion or PCA
bull Shen MK Wu ZF Zhu AB et al Remifentanil for labour analgesia a double-blinded randomised controlled trial of maternal and neonatal effects ofpatient-controlled analgesia versus continuous infusion (0005-02 microgkgxmin) Anaesthesia 201368(3)236-44 The results suggest thatremifentanil PCA (01-04 microgkg) provides better pain relief and similarplacental transfer compared with continuous infusion (Author)
bull Per protocol TCI Norwegian National Hospital (Oslo University Hospital)
ndash 05 ndash 2 ngml + nurse controlled boluses) ndash easier for anaesthesia personell
SSAI Malmoslash 2017
Remifentanil TCI
bull Why notbull Acta Anaesthesiol Scand 2013 Jul57(6)802-8 doi 101111aas12096 Epub 2013 Mar 15
bull Remifentanil target-controlled infusion during second stage labour in high-risk parturients a case series Schwarz GL1 Volmanen P Albrechtsen S Bjoernestad E
bull 1ngml start incremental doses of 05 ngml titrated untill satisfied mother or side-effects(1-6 ngml)
SSAI Malmoslash 2017
Why use remifentanil
The boss
SSAI Malmoslash 2017
In conclusionhellip
SSAI Malmoslash 2017
When to use it
bull For parturients with contraindications to regional analgesia
ndash Bleeding disorders
ndash Infections
ndash Mother does not want regional
bull In places with reduced anaesthesia service
SSAI Malmoslash 2017
Then remifentanil is the best choice
bull Continuous monitoring
bull Including capnography or RR counting
bull Well educated staff
SSAI Malmoslash 2017
Remifentanil PCA
bull Is cheap
bull Easy to administer
bull Gives (some) pain relief
SSAI Malmoslash 2017
BUT
bull Has a poor analgesic effect compared to thegolden standard of regional analgesia
bull May cause a lot of harm
bull Andhellip
SSAI Malmoslash 2017
AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS
Is too dangerous to be used as routineanalgesia in the labour ward
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Tramadol meptazinol pethidine diamorphine pentazocine nalbuphinefentanylIMIV Pca vs bolus
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Van De Velde and Carvalho IJOA 2016 15 66-74
SSAI Malmoslash 2017
Remi 40microg2minsFenta 20microg + loadingPet 5 mg + loading
SSAI Malmoslash 2017
Other opioids better
bull CONCLUSIONS Intravenous patient-controlled analgesia with either remifentanil or fentanyl provides a moderate degree of labour analgesia whereas transient maternal oxygen desaturation is observed more commonly with remifentanil Fentanyl is associated with a higher need for neonatal resuscitation Marwah R
Hassan S Carvalho JC Balki M Remifentanil versus fentanyl for intravenous patient-controlled labour analgesia an observational study Canadian Journal of Anaesthesia 201259(3)246-54
SSAI Malmoslash 2017
Remifentanil provides betterpain relief than other opioids but only during the first twohours
SSAI Malmoslash 2017
Does it work
SSAI Malmoslash 2017
From M Van De Velde B Carvalho IJOA 2016 25 66-74
SSAI Malmoslash 2017
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 TRIAL REGISTRATION Netherlands Trial Register NTR2551
CONCLUSION In terms of labor duration average VAS pain scores and maternal overall satisfaction score with analgesia CSE analgesia is superior to that provided by epidural analgesia or PCIA with remifentanil for pain relief in early labor in nulliparous women However there were no differences in the mode of delivery side effects or neonatal outcomes between the three techniques
Efficacy of Remifentanil PCA as compared to CSEEpidural
SSAI Malmoslash 2017
Oxygen saturation was significantly lower (SpO2 lt92) in women who used remifentanil (relative risk 15 14 to 17)
Remifentanil IVPCA provides poorer efficacy on labor analgesia than epidural analgesia with more sedation on parturients and a trend of newborn acidosis
Lin R Tao Y Yu Y Xu Z Su J Liu Z Intravenous remifentanil versus epidural ropivacaine with sufentanil for labour analgesia a retrospective study PLoS ONE [Electronic Resource] 20149(11)e112283
SSAI Malmoslash 2017
Meta Analyses
bull This meta-analysis suggests that remifentanil PCIA is not superior to epidural analgesia in analgesic efficacy during labor Given the wide CIs of the pooled results for secondary maternal and neonatal outcomes definite conclusions cannot be drawn for those outcomes Further studies are still warranted to validate these conclusions Liu ZQ Chen XB Li HB Qiu MT Duan T A comparison of remifentanil parturient-controlled intravenous analgesia with
epidural analgesia a meta-analysis of randomized controlled trials Anesth Analg 2014118(3)598-603
bull CONCLUSION During labour remifentanil-PCA provided superior analgesia and higher patient satisfactioncompared with pethidine with a comparable degree of adverse events Epidural analgesia providedsuperior pain relief in comparison with remifentanil Due to a low number of reported adverse events thesafety issue of remifentanil use in labour remains an open question that needs to be addressed in futuretrials Schnabel A Hahn N Broscheit J Muellenbach RM Rieger L Roewer N et al Remifentanil for labour analgesia a meta-analysis of
randomised controlled trials European Journal of Anaesthesiology 201229(4)177-85
bull Conclusions Pooled assessment of remifentanil intervention seems an attractive strategy for controlling labor pain in health term parturients but it is not supported by strong evidence Current evidencesuggests that it may produce effective analgesia by only a modest level HealthMED 20126(7)2407-18
Effect size difference 3 cm
SSAI Malmoslash 2017
SSAI Malmoslash 2017
APRIL 2017
20 RCTrsquos 3569 women
Results Weibel et al
bull Based on the current systematic review there is mostly low-quality evidence to inform practiceand future research may significantly alter thecurrent 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 safetyoutcomes (maternal apnoe and respiratorydepression Apgar score) and on the optimal mode and regimen of remifentanil administrationto provide highets efficacy with reasonableadverse effects for mother and their newborns
SSAI Malmoslash 2017
Always satisfied
Off course they are Who wouldnrsquot
SSAI Malmoslash 2017
Optimal administration of remi
SSAI Malmoslash 2017
Optimal administration of remi
bull Protocols varies (bolus dose lock-out background infusion TCI etc)
bull Fixed bolus 20-50 microg without backgroundinfusion lock-out 2-3 minutes
bull If background ndash small dose lt 005microgkgxmin
bull TCI 05-15 ngml
bull New systems VPIA (Vital signs patientcontrolled intravenous analgesia)
SSAI Malmoslash 2017
SIA et al IJOA correspondence 2014 23 196-8
SSAI Malmoslash 2017
Cont infusion or PCA
bull Shen MK Wu ZF Zhu AB et al Remifentanil for labour analgesia a double-blinded randomised controlled trial of maternal and neonatal effects ofpatient-controlled analgesia versus continuous infusion (0005-02 microgkgxmin) Anaesthesia 201368(3)236-44 The results suggest thatremifentanil PCA (01-04 microgkg) provides better pain relief and similarplacental transfer compared with continuous infusion (Author)
bull Per protocol TCI Norwegian National Hospital (Oslo University Hospital)
ndash 05 ndash 2 ngml + nurse controlled boluses) ndash easier for anaesthesia personell
SSAI Malmoslash 2017
Remifentanil TCI
bull Why notbull Acta Anaesthesiol Scand 2013 Jul57(6)802-8 doi 101111aas12096 Epub 2013 Mar 15
bull Remifentanil target-controlled infusion during second stage labour in high-risk parturients a case series Schwarz GL1 Volmanen P Albrechtsen S Bjoernestad E
bull 1ngml start incremental doses of 05 ngml titrated untill satisfied mother or side-effects(1-6 ngml)
SSAI Malmoslash 2017
Why use remifentanil
The boss
SSAI Malmoslash 2017
In conclusionhellip
SSAI Malmoslash 2017
When to use it
bull For parturients with contraindications to regional analgesia
ndash Bleeding disorders
ndash Infections
ndash Mother does not want regional
bull In places with reduced anaesthesia service
SSAI Malmoslash 2017
Then remifentanil is the best choice
bull Continuous monitoring
bull Including capnography or RR counting
bull Well educated staff
SSAI Malmoslash 2017
Remifentanil PCA
bull Is cheap
bull Easy to administer
bull Gives (some) pain relief
SSAI Malmoslash 2017
BUT
bull Has a poor analgesic effect compared to thegolden standard of regional analgesia
bull May cause a lot of harm
bull Andhellip
SSAI Malmoslash 2017
AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS
Is too dangerous to be used as routineanalgesia in the labour ward
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
Tramadol meptazinol pethidine diamorphine pentazocine nalbuphinefentanylIMIV Pca vs bolus
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Van De Velde and Carvalho IJOA 2016 15 66-74
SSAI Malmoslash 2017
Remi 40microg2minsFenta 20microg + loadingPet 5 mg + loading
SSAI Malmoslash 2017
Other opioids better
bull CONCLUSIONS Intravenous patient-controlled analgesia with either remifentanil or fentanyl provides a moderate degree of labour analgesia whereas transient maternal oxygen desaturation is observed more commonly with remifentanil Fentanyl is associated with a higher need for neonatal resuscitation Marwah R
Hassan S Carvalho JC Balki M Remifentanil versus fentanyl for intravenous patient-controlled labour analgesia an observational study Canadian Journal of Anaesthesia 201259(3)246-54
SSAI Malmoslash 2017
Remifentanil provides betterpain relief than other opioids but only during the first twohours
SSAI Malmoslash 2017
Does it work
SSAI Malmoslash 2017
From M Van De Velde B Carvalho IJOA 2016 25 66-74
SSAI Malmoslash 2017
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 TRIAL REGISTRATION Netherlands Trial Register NTR2551
CONCLUSION In terms of labor duration average VAS pain scores and maternal overall satisfaction score with analgesia CSE analgesia is superior to that provided by epidural analgesia or PCIA with remifentanil for pain relief in early labor in nulliparous women However there were no differences in the mode of delivery side effects or neonatal outcomes between the three techniques
Efficacy of Remifentanil PCA as compared to CSEEpidural
SSAI Malmoslash 2017
Oxygen saturation was significantly lower (SpO2 lt92) in women who used remifentanil (relative risk 15 14 to 17)
Remifentanil IVPCA provides poorer efficacy on labor analgesia than epidural analgesia with more sedation on parturients and a trend of newborn acidosis
Lin R Tao Y Yu Y Xu Z Su J Liu Z Intravenous remifentanil versus epidural ropivacaine with sufentanil for labour analgesia a retrospective study PLoS ONE [Electronic Resource] 20149(11)e112283
SSAI Malmoslash 2017
Meta Analyses
bull This meta-analysis suggests that remifentanil PCIA is not superior to epidural analgesia in analgesic efficacy during labor Given the wide CIs of the pooled results for secondary maternal and neonatal outcomes definite conclusions cannot be drawn for those outcomes Further studies are still warranted to validate these conclusions Liu ZQ Chen XB Li HB Qiu MT Duan T A comparison of remifentanil parturient-controlled intravenous analgesia with
epidural analgesia a meta-analysis of randomized controlled trials Anesth Analg 2014118(3)598-603
bull CONCLUSION During labour remifentanil-PCA provided superior analgesia and higher patient satisfactioncompared with pethidine with a comparable degree of adverse events Epidural analgesia providedsuperior pain relief in comparison with remifentanil Due to a low number of reported adverse events thesafety issue of remifentanil use in labour remains an open question that needs to be addressed in futuretrials Schnabel A Hahn N Broscheit J Muellenbach RM Rieger L Roewer N et al Remifentanil for labour analgesia a meta-analysis of
randomised controlled trials European Journal of Anaesthesiology 201229(4)177-85
bull Conclusions Pooled assessment of remifentanil intervention seems an attractive strategy for controlling labor pain in health term parturients but it is not supported by strong evidence Current evidencesuggests that it may produce effective analgesia by only a modest level HealthMED 20126(7)2407-18
Effect size difference 3 cm
SSAI Malmoslash 2017
SSAI Malmoslash 2017
APRIL 2017
20 RCTrsquos 3569 women
Results Weibel et al
bull Based on the current systematic review there is mostly low-quality evidence to inform practiceand future research may significantly alter thecurrent 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 safetyoutcomes (maternal apnoe and respiratorydepression Apgar score) and on the optimal mode and regimen of remifentanil administrationto provide highets efficacy with reasonableadverse effects for mother and their newborns
SSAI Malmoslash 2017
Always satisfied
Off course they are Who wouldnrsquot
SSAI Malmoslash 2017
Optimal administration of remi
SSAI Malmoslash 2017
Optimal administration of remi
bull Protocols varies (bolus dose lock-out background infusion TCI etc)
bull Fixed bolus 20-50 microg without backgroundinfusion lock-out 2-3 minutes
bull If background ndash small dose lt 005microgkgxmin
bull TCI 05-15 ngml
bull New systems VPIA (Vital signs patientcontrolled intravenous analgesia)
SSAI Malmoslash 2017
SIA et al IJOA correspondence 2014 23 196-8
SSAI Malmoslash 2017
Cont infusion or PCA
bull Shen MK Wu ZF Zhu AB et al Remifentanil for labour analgesia a double-blinded randomised controlled trial of maternal and neonatal effects ofpatient-controlled analgesia versus continuous infusion (0005-02 microgkgxmin) Anaesthesia 201368(3)236-44 The results suggest thatremifentanil PCA (01-04 microgkg) provides better pain relief and similarplacental transfer compared with continuous infusion (Author)
bull Per protocol TCI Norwegian National Hospital (Oslo University Hospital)
ndash 05 ndash 2 ngml + nurse controlled boluses) ndash easier for anaesthesia personell
SSAI Malmoslash 2017
Remifentanil TCI
bull Why notbull Acta Anaesthesiol Scand 2013 Jul57(6)802-8 doi 101111aas12096 Epub 2013 Mar 15
bull Remifentanil target-controlled infusion during second stage labour in high-risk parturients a case series Schwarz GL1 Volmanen P Albrechtsen S Bjoernestad E
bull 1ngml start incremental doses of 05 ngml titrated untill satisfied mother or side-effects(1-6 ngml)
SSAI Malmoslash 2017
Why use remifentanil
The boss
SSAI Malmoslash 2017
In conclusionhellip
SSAI Malmoslash 2017
When to use it
bull For parturients with contraindications to regional analgesia
ndash Bleeding disorders
ndash Infections
ndash Mother does not want regional
bull In places with reduced anaesthesia service
SSAI Malmoslash 2017
Then remifentanil is the best choice
bull Continuous monitoring
bull Including capnography or RR counting
bull Well educated staff
SSAI Malmoslash 2017
Remifentanil PCA
bull Is cheap
bull Easy to administer
bull Gives (some) pain relief
SSAI Malmoslash 2017
BUT
bull Has a poor analgesic effect compared to thegolden standard of regional analgesia
bull May cause a lot of harm
bull Andhellip
SSAI Malmoslash 2017
AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS
Is too dangerous to be used as routineanalgesia in the labour ward
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Van De Velde and Carvalho IJOA 2016 15 66-74
SSAI Malmoslash 2017
Remi 40microg2minsFenta 20microg + loadingPet 5 mg + loading
SSAI Malmoslash 2017
Other opioids better
bull CONCLUSIONS Intravenous patient-controlled analgesia with either remifentanil or fentanyl provides a moderate degree of labour analgesia whereas transient maternal oxygen desaturation is observed more commonly with remifentanil Fentanyl is associated with a higher need for neonatal resuscitation Marwah R
Hassan S Carvalho JC Balki M Remifentanil versus fentanyl for intravenous patient-controlled labour analgesia an observational study Canadian Journal of Anaesthesia 201259(3)246-54
SSAI Malmoslash 2017
Remifentanil provides betterpain relief than other opioids but only during the first twohours
SSAI Malmoslash 2017
Does it work
SSAI Malmoslash 2017
From M Van De Velde B Carvalho IJOA 2016 25 66-74
SSAI Malmoslash 2017
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 TRIAL REGISTRATION Netherlands Trial Register NTR2551
CONCLUSION In terms of labor duration average VAS pain scores and maternal overall satisfaction score with analgesia CSE analgesia is superior to that provided by epidural analgesia or PCIA with remifentanil for pain relief in early labor in nulliparous women However there were no differences in the mode of delivery side effects or neonatal outcomes between the three techniques
Efficacy of Remifentanil PCA as compared to CSEEpidural
SSAI Malmoslash 2017
Oxygen saturation was significantly lower (SpO2 lt92) in women who used remifentanil (relative risk 15 14 to 17)
Remifentanil IVPCA provides poorer efficacy on labor analgesia than epidural analgesia with more sedation on parturients and a trend of newborn acidosis
Lin R Tao Y Yu Y Xu Z Su J Liu Z Intravenous remifentanil versus epidural ropivacaine with sufentanil for labour analgesia a retrospective study PLoS ONE [Electronic Resource] 20149(11)e112283
SSAI Malmoslash 2017
Meta Analyses
bull This meta-analysis suggests that remifentanil PCIA is not superior to epidural analgesia in analgesic efficacy during labor Given the wide CIs of the pooled results for secondary maternal and neonatal outcomes definite conclusions cannot be drawn for those outcomes Further studies are still warranted to validate these conclusions Liu ZQ Chen XB Li HB Qiu MT Duan T A comparison of remifentanil parturient-controlled intravenous analgesia with
epidural analgesia a meta-analysis of randomized controlled trials Anesth Analg 2014118(3)598-603
bull CONCLUSION During labour remifentanil-PCA provided superior analgesia and higher patient satisfactioncompared with pethidine with a comparable degree of adverse events Epidural analgesia providedsuperior pain relief in comparison with remifentanil Due to a low number of reported adverse events thesafety issue of remifentanil use in labour remains an open question that needs to be addressed in futuretrials Schnabel A Hahn N Broscheit J Muellenbach RM Rieger L Roewer N et al Remifentanil for labour analgesia a meta-analysis of
randomised controlled trials European Journal of Anaesthesiology 201229(4)177-85
bull Conclusions Pooled assessment of remifentanil intervention seems an attractive strategy for controlling labor pain in health term parturients but it is not supported by strong evidence Current evidencesuggests that it may produce effective analgesia by only a modest level HealthMED 20126(7)2407-18
Effect size difference 3 cm
SSAI Malmoslash 2017
SSAI Malmoslash 2017
APRIL 2017
20 RCTrsquos 3569 women
Results Weibel et al
bull Based on the current systematic review there is mostly low-quality evidence to inform practiceand future research may significantly alter thecurrent 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 safetyoutcomes (maternal apnoe and respiratorydepression Apgar score) and on the optimal mode and regimen of remifentanil administrationto provide highets efficacy with reasonableadverse effects for mother and their newborns
SSAI Malmoslash 2017
Always satisfied
Off course they are Who wouldnrsquot
SSAI Malmoslash 2017
Optimal administration of remi
SSAI Malmoslash 2017
Optimal administration of remi
bull Protocols varies (bolus dose lock-out background infusion TCI etc)
bull Fixed bolus 20-50 microg without backgroundinfusion lock-out 2-3 minutes
bull If background ndash small dose lt 005microgkgxmin
bull TCI 05-15 ngml
bull New systems VPIA (Vital signs patientcontrolled intravenous analgesia)
SSAI Malmoslash 2017
SIA et al IJOA correspondence 2014 23 196-8
SSAI Malmoslash 2017
Cont infusion or PCA
bull Shen MK Wu ZF Zhu AB et al Remifentanil for labour analgesia a double-blinded randomised controlled trial of maternal and neonatal effects ofpatient-controlled analgesia versus continuous infusion (0005-02 microgkgxmin) Anaesthesia 201368(3)236-44 The results suggest thatremifentanil PCA (01-04 microgkg) provides better pain relief and similarplacental transfer compared with continuous infusion (Author)
bull Per protocol TCI Norwegian National Hospital (Oslo University Hospital)
ndash 05 ndash 2 ngml + nurse controlled boluses) ndash easier for anaesthesia personell
SSAI Malmoslash 2017
Remifentanil TCI
bull Why notbull Acta Anaesthesiol Scand 2013 Jul57(6)802-8 doi 101111aas12096 Epub 2013 Mar 15
bull Remifentanil target-controlled infusion during second stage labour in high-risk parturients a case series Schwarz GL1 Volmanen P Albrechtsen S Bjoernestad E
bull 1ngml start incremental doses of 05 ngml titrated untill satisfied mother or side-effects(1-6 ngml)
SSAI Malmoslash 2017
Why use remifentanil
The boss
SSAI Malmoslash 2017
In conclusionhellip
SSAI Malmoslash 2017
When to use it
bull For parturients with contraindications to regional analgesia
ndash Bleeding disorders
ndash Infections
ndash Mother does not want regional
bull In places with reduced anaesthesia service
SSAI Malmoslash 2017
Then remifentanil is the best choice
bull Continuous monitoring
bull Including capnography or RR counting
bull Well educated staff
SSAI Malmoslash 2017
Remifentanil PCA
bull Is cheap
bull Easy to administer
bull Gives (some) pain relief
SSAI Malmoslash 2017
BUT
bull Has a poor analgesic effect compared to thegolden standard of regional analgesia
bull May cause a lot of harm
bull Andhellip
SSAI Malmoslash 2017
AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS
Is too dangerous to be used as routineanalgesia in the labour ward
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
Van De Velde and Carvalho IJOA 2016 15 66-74
SSAI Malmoslash 2017
Remi 40microg2minsFenta 20microg + loadingPet 5 mg + loading
SSAI Malmoslash 2017
Other opioids better
bull CONCLUSIONS Intravenous patient-controlled analgesia with either remifentanil or fentanyl provides a moderate degree of labour analgesia whereas transient maternal oxygen desaturation is observed more commonly with remifentanil Fentanyl is associated with a higher need for neonatal resuscitation Marwah R
Hassan S Carvalho JC Balki M Remifentanil versus fentanyl for intravenous patient-controlled labour analgesia an observational study Canadian Journal of Anaesthesia 201259(3)246-54
SSAI Malmoslash 2017
Remifentanil provides betterpain relief than other opioids but only during the first twohours
SSAI Malmoslash 2017
Does it work
SSAI Malmoslash 2017
From M Van De Velde B Carvalho IJOA 2016 25 66-74
SSAI Malmoslash 2017
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 TRIAL REGISTRATION Netherlands Trial Register NTR2551
CONCLUSION In terms of labor duration average VAS pain scores and maternal overall satisfaction score with analgesia CSE analgesia is superior to that provided by epidural analgesia or PCIA with remifentanil for pain relief in early labor in nulliparous women However there were no differences in the mode of delivery side effects or neonatal outcomes between the three techniques
Efficacy of Remifentanil PCA as compared to CSEEpidural
SSAI Malmoslash 2017
Oxygen saturation was significantly lower (SpO2 lt92) in women who used remifentanil (relative risk 15 14 to 17)
Remifentanil IVPCA provides poorer efficacy on labor analgesia than epidural analgesia with more sedation on parturients and a trend of newborn acidosis
Lin R Tao Y Yu Y Xu Z Su J Liu Z Intravenous remifentanil versus epidural ropivacaine with sufentanil for labour analgesia a retrospective study PLoS ONE [Electronic Resource] 20149(11)e112283
SSAI Malmoslash 2017
Meta Analyses
bull This meta-analysis suggests that remifentanil PCIA is not superior to epidural analgesia in analgesic efficacy during labor Given the wide CIs of the pooled results for secondary maternal and neonatal outcomes definite conclusions cannot be drawn for those outcomes Further studies are still warranted to validate these conclusions Liu ZQ Chen XB Li HB Qiu MT Duan T A comparison of remifentanil parturient-controlled intravenous analgesia with
epidural analgesia a meta-analysis of randomized controlled trials Anesth Analg 2014118(3)598-603
bull CONCLUSION During labour remifentanil-PCA provided superior analgesia and higher patient satisfactioncompared with pethidine with a comparable degree of adverse events Epidural analgesia providedsuperior pain relief in comparison with remifentanil Due to a low number of reported adverse events thesafety issue of remifentanil use in labour remains an open question that needs to be addressed in futuretrials Schnabel A Hahn N Broscheit J Muellenbach RM Rieger L Roewer N et al Remifentanil for labour analgesia a meta-analysis of
randomised controlled trials European Journal of Anaesthesiology 201229(4)177-85
bull Conclusions Pooled assessment of remifentanil intervention seems an attractive strategy for controlling labor pain in health term parturients but it is not supported by strong evidence Current evidencesuggests that it may produce effective analgesia by only a modest level HealthMED 20126(7)2407-18
Effect size difference 3 cm
SSAI Malmoslash 2017
SSAI Malmoslash 2017
APRIL 2017
20 RCTrsquos 3569 women
Results Weibel et al
bull Based on the current systematic review there is mostly low-quality evidence to inform practiceand future research may significantly alter thecurrent 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 safetyoutcomes (maternal apnoe and respiratorydepression Apgar score) and on the optimal mode and regimen of remifentanil administrationto provide highets efficacy with reasonableadverse effects for mother and their newborns
SSAI Malmoslash 2017
Always satisfied
Off course they are Who wouldnrsquot
SSAI Malmoslash 2017
Optimal administration of remi
SSAI Malmoslash 2017
Optimal administration of remi
bull Protocols varies (bolus dose lock-out background infusion TCI etc)
bull Fixed bolus 20-50 microg without backgroundinfusion lock-out 2-3 minutes
bull If background ndash small dose lt 005microgkgxmin
bull TCI 05-15 ngml
bull New systems VPIA (Vital signs patientcontrolled intravenous analgesia)
SSAI Malmoslash 2017
SIA et al IJOA correspondence 2014 23 196-8
SSAI Malmoslash 2017
Cont infusion or PCA
bull Shen MK Wu ZF Zhu AB et al Remifentanil for labour analgesia a double-blinded randomised controlled trial of maternal and neonatal effects ofpatient-controlled analgesia versus continuous infusion (0005-02 microgkgxmin) Anaesthesia 201368(3)236-44 The results suggest thatremifentanil PCA (01-04 microgkg) provides better pain relief and similarplacental transfer compared with continuous infusion (Author)
bull Per protocol TCI Norwegian National Hospital (Oslo University Hospital)
ndash 05 ndash 2 ngml + nurse controlled boluses) ndash easier for anaesthesia personell
SSAI Malmoslash 2017
Remifentanil TCI
bull Why notbull Acta Anaesthesiol Scand 2013 Jul57(6)802-8 doi 101111aas12096 Epub 2013 Mar 15
bull Remifentanil target-controlled infusion during second stage labour in high-risk parturients a case series Schwarz GL1 Volmanen P Albrechtsen S Bjoernestad E
bull 1ngml start incremental doses of 05 ngml titrated untill satisfied mother or side-effects(1-6 ngml)
SSAI Malmoslash 2017
Why use remifentanil
The boss
SSAI Malmoslash 2017
In conclusionhellip
SSAI Malmoslash 2017
When to use it
bull For parturients with contraindications to regional analgesia
ndash Bleeding disorders
ndash Infections
ndash Mother does not want regional
bull In places with reduced anaesthesia service
SSAI Malmoslash 2017
Then remifentanil is the best choice
bull Continuous monitoring
bull Including capnography or RR counting
bull Well educated staff
SSAI Malmoslash 2017
Remifentanil PCA
bull Is cheap
bull Easy to administer
bull Gives (some) pain relief
SSAI Malmoslash 2017
BUT
bull Has a poor analgesic effect compared to thegolden standard of regional analgesia
bull May cause a lot of harm
bull Andhellip
SSAI Malmoslash 2017
AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS
Is too dangerous to be used as routineanalgesia in the labour ward
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
Remi 40microg2minsFenta 20microg + loadingPet 5 mg + loading
SSAI Malmoslash 2017
Other opioids better
bull CONCLUSIONS Intravenous patient-controlled analgesia with either remifentanil or fentanyl provides a moderate degree of labour analgesia whereas transient maternal oxygen desaturation is observed more commonly with remifentanil Fentanyl is associated with a higher need for neonatal resuscitation Marwah R
Hassan S Carvalho JC Balki M Remifentanil versus fentanyl for intravenous patient-controlled labour analgesia an observational study Canadian Journal of Anaesthesia 201259(3)246-54
SSAI Malmoslash 2017
Remifentanil provides betterpain relief than other opioids but only during the first twohours
SSAI Malmoslash 2017
Does it work
SSAI Malmoslash 2017
From M Van De Velde B Carvalho IJOA 2016 25 66-74
SSAI Malmoslash 2017
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 TRIAL REGISTRATION Netherlands Trial Register NTR2551
CONCLUSION In terms of labor duration average VAS pain scores and maternal overall satisfaction score with analgesia CSE analgesia is superior to that provided by epidural analgesia or PCIA with remifentanil for pain relief in early labor in nulliparous women However there were no differences in the mode of delivery side effects or neonatal outcomes between the three techniques
Efficacy of Remifentanil PCA as compared to CSEEpidural
SSAI Malmoslash 2017
Oxygen saturation was significantly lower (SpO2 lt92) in women who used remifentanil (relative risk 15 14 to 17)
Remifentanil IVPCA provides poorer efficacy on labor analgesia than epidural analgesia with more sedation on parturients and a trend of newborn acidosis
Lin R Tao Y Yu Y Xu Z Su J Liu Z Intravenous remifentanil versus epidural ropivacaine with sufentanil for labour analgesia a retrospective study PLoS ONE [Electronic Resource] 20149(11)e112283
SSAI Malmoslash 2017
Meta Analyses
bull This meta-analysis suggests that remifentanil PCIA is not superior to epidural analgesia in analgesic efficacy during labor Given the wide CIs of the pooled results for secondary maternal and neonatal outcomes definite conclusions cannot be drawn for those outcomes Further studies are still warranted to validate these conclusions Liu ZQ Chen XB Li HB Qiu MT Duan T A comparison of remifentanil parturient-controlled intravenous analgesia with
epidural analgesia a meta-analysis of randomized controlled trials Anesth Analg 2014118(3)598-603
bull CONCLUSION During labour remifentanil-PCA provided superior analgesia and higher patient satisfactioncompared with pethidine with a comparable degree of adverse events Epidural analgesia providedsuperior pain relief in comparison with remifentanil Due to a low number of reported adverse events thesafety issue of remifentanil use in labour remains an open question that needs to be addressed in futuretrials Schnabel A Hahn N Broscheit J Muellenbach RM Rieger L Roewer N et al Remifentanil for labour analgesia a meta-analysis of
randomised controlled trials European Journal of Anaesthesiology 201229(4)177-85
bull Conclusions Pooled assessment of remifentanil intervention seems an attractive strategy for controlling labor pain in health term parturients but it is not supported by strong evidence Current evidencesuggests that it may produce effective analgesia by only a modest level HealthMED 20126(7)2407-18
Effect size difference 3 cm
SSAI Malmoslash 2017
SSAI Malmoslash 2017
APRIL 2017
20 RCTrsquos 3569 women
Results Weibel et al
bull Based on the current systematic review there is mostly low-quality evidence to inform practiceand future research may significantly alter thecurrent 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 safetyoutcomes (maternal apnoe and respiratorydepression Apgar score) and on the optimal mode and regimen of remifentanil administrationto provide highets efficacy with reasonableadverse effects for mother and their newborns
SSAI Malmoslash 2017
Always satisfied
Off course they are Who wouldnrsquot
SSAI Malmoslash 2017
Optimal administration of remi
SSAI Malmoslash 2017
Optimal administration of remi
bull Protocols varies (bolus dose lock-out background infusion TCI etc)
bull Fixed bolus 20-50 microg without backgroundinfusion lock-out 2-3 minutes
bull If background ndash small dose lt 005microgkgxmin
bull TCI 05-15 ngml
bull New systems VPIA (Vital signs patientcontrolled intravenous analgesia)
SSAI Malmoslash 2017
SIA et al IJOA correspondence 2014 23 196-8
SSAI Malmoslash 2017
Cont infusion or PCA
bull Shen MK Wu ZF Zhu AB et al Remifentanil for labour analgesia a double-blinded randomised controlled trial of maternal and neonatal effects ofpatient-controlled analgesia versus continuous infusion (0005-02 microgkgxmin) Anaesthesia 201368(3)236-44 The results suggest thatremifentanil PCA (01-04 microgkg) provides better pain relief and similarplacental transfer compared with continuous infusion (Author)
bull Per protocol TCI Norwegian National Hospital (Oslo University Hospital)
ndash 05 ndash 2 ngml + nurse controlled boluses) ndash easier for anaesthesia personell
SSAI Malmoslash 2017
Remifentanil TCI
bull Why notbull Acta Anaesthesiol Scand 2013 Jul57(6)802-8 doi 101111aas12096 Epub 2013 Mar 15
bull Remifentanil target-controlled infusion during second stage labour in high-risk parturients a case series Schwarz GL1 Volmanen P Albrechtsen S Bjoernestad E
bull 1ngml start incremental doses of 05 ngml titrated untill satisfied mother or side-effects(1-6 ngml)
SSAI Malmoslash 2017
Why use remifentanil
The boss
SSAI Malmoslash 2017
In conclusionhellip
SSAI Malmoslash 2017
When to use it
bull For parturients with contraindications to regional analgesia
ndash Bleeding disorders
ndash Infections
ndash Mother does not want regional
bull In places with reduced anaesthesia service
SSAI Malmoslash 2017
Then remifentanil is the best choice
bull Continuous monitoring
bull Including capnography or RR counting
bull Well educated staff
SSAI Malmoslash 2017
Remifentanil PCA
bull Is cheap
bull Easy to administer
bull Gives (some) pain relief
SSAI Malmoslash 2017
BUT
bull Has a poor analgesic effect compared to thegolden standard of regional analgesia
bull May cause a lot of harm
bull Andhellip
SSAI Malmoslash 2017
AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS
Is too dangerous to be used as routineanalgesia in the labour ward
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
Other opioids better
bull CONCLUSIONS Intravenous patient-controlled analgesia with either remifentanil or fentanyl provides a moderate degree of labour analgesia whereas transient maternal oxygen desaturation is observed more commonly with remifentanil Fentanyl is associated with a higher need for neonatal resuscitation Marwah R
Hassan S Carvalho JC Balki M Remifentanil versus fentanyl for intravenous patient-controlled labour analgesia an observational study Canadian Journal of Anaesthesia 201259(3)246-54
SSAI Malmoslash 2017
Remifentanil provides betterpain relief than other opioids but only during the first twohours
SSAI Malmoslash 2017
Does it work
SSAI Malmoslash 2017
From M Van De Velde B Carvalho IJOA 2016 25 66-74
SSAI Malmoslash 2017
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 TRIAL REGISTRATION Netherlands Trial Register NTR2551
CONCLUSION In terms of labor duration average VAS pain scores and maternal overall satisfaction score with analgesia CSE analgesia is superior to that provided by epidural analgesia or PCIA with remifentanil for pain relief in early labor in nulliparous women However there were no differences in the mode of delivery side effects or neonatal outcomes between the three techniques
Efficacy of Remifentanil PCA as compared to CSEEpidural
SSAI Malmoslash 2017
Oxygen saturation was significantly lower (SpO2 lt92) in women who used remifentanil (relative risk 15 14 to 17)
Remifentanil IVPCA provides poorer efficacy on labor analgesia than epidural analgesia with more sedation on parturients and a trend of newborn acidosis
Lin R Tao Y Yu Y Xu Z Su J Liu Z Intravenous remifentanil versus epidural ropivacaine with sufentanil for labour analgesia a retrospective study PLoS ONE [Electronic Resource] 20149(11)e112283
SSAI Malmoslash 2017
Meta Analyses
bull This meta-analysis suggests that remifentanil PCIA is not superior to epidural analgesia in analgesic efficacy during labor Given the wide CIs of the pooled results for secondary maternal and neonatal outcomes definite conclusions cannot be drawn for those outcomes Further studies are still warranted to validate these conclusions Liu ZQ Chen XB Li HB Qiu MT Duan T A comparison of remifentanil parturient-controlled intravenous analgesia with
epidural analgesia a meta-analysis of randomized controlled trials Anesth Analg 2014118(3)598-603
bull CONCLUSION During labour remifentanil-PCA provided superior analgesia and higher patient satisfactioncompared with pethidine with a comparable degree of adverse events Epidural analgesia providedsuperior pain relief in comparison with remifentanil Due to a low number of reported adverse events thesafety issue of remifentanil use in labour remains an open question that needs to be addressed in futuretrials Schnabel A Hahn N Broscheit J Muellenbach RM Rieger L Roewer N et al Remifentanil for labour analgesia a meta-analysis of
randomised controlled trials European Journal of Anaesthesiology 201229(4)177-85
bull Conclusions Pooled assessment of remifentanil intervention seems an attractive strategy for controlling labor pain in health term parturients but it is not supported by strong evidence Current evidencesuggests that it may produce effective analgesia by only a modest level HealthMED 20126(7)2407-18
Effect size difference 3 cm
SSAI Malmoslash 2017
SSAI Malmoslash 2017
APRIL 2017
20 RCTrsquos 3569 women
Results Weibel et al
bull Based on the current systematic review there is mostly low-quality evidence to inform practiceand future research may significantly alter thecurrent 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 safetyoutcomes (maternal apnoe and respiratorydepression Apgar score) and on the optimal mode and regimen of remifentanil administrationto provide highets efficacy with reasonableadverse effects for mother and their newborns
SSAI Malmoslash 2017
Always satisfied
Off course they are Who wouldnrsquot
SSAI Malmoslash 2017
Optimal administration of remi
SSAI Malmoslash 2017
Optimal administration of remi
bull Protocols varies (bolus dose lock-out background infusion TCI etc)
bull Fixed bolus 20-50 microg without backgroundinfusion lock-out 2-3 minutes
bull If background ndash small dose lt 005microgkgxmin
bull TCI 05-15 ngml
bull New systems VPIA (Vital signs patientcontrolled intravenous analgesia)
SSAI Malmoslash 2017
SIA et al IJOA correspondence 2014 23 196-8
SSAI Malmoslash 2017
Cont infusion or PCA
bull Shen MK Wu ZF Zhu AB et al Remifentanil for labour analgesia a double-blinded randomised controlled trial of maternal and neonatal effects ofpatient-controlled analgesia versus continuous infusion (0005-02 microgkgxmin) Anaesthesia 201368(3)236-44 The results suggest thatremifentanil PCA (01-04 microgkg) provides better pain relief and similarplacental transfer compared with continuous infusion (Author)
bull Per protocol TCI Norwegian National Hospital (Oslo University Hospital)
ndash 05 ndash 2 ngml + nurse controlled boluses) ndash easier for anaesthesia personell
SSAI Malmoslash 2017
Remifentanil TCI
bull Why notbull Acta Anaesthesiol Scand 2013 Jul57(6)802-8 doi 101111aas12096 Epub 2013 Mar 15
bull Remifentanil target-controlled infusion during second stage labour in high-risk parturients a case series Schwarz GL1 Volmanen P Albrechtsen S Bjoernestad E
bull 1ngml start incremental doses of 05 ngml titrated untill satisfied mother or side-effects(1-6 ngml)
SSAI Malmoslash 2017
Why use remifentanil
The boss
SSAI Malmoslash 2017
In conclusionhellip
SSAI Malmoslash 2017
When to use it
bull For parturients with contraindications to regional analgesia
ndash Bleeding disorders
ndash Infections
ndash Mother does not want regional
bull In places with reduced anaesthesia service
SSAI Malmoslash 2017
Then remifentanil is the best choice
bull Continuous monitoring
bull Including capnography or RR counting
bull Well educated staff
SSAI Malmoslash 2017
Remifentanil PCA
bull Is cheap
bull Easy to administer
bull Gives (some) pain relief
SSAI Malmoslash 2017
BUT
bull Has a poor analgesic effect compared to thegolden standard of regional analgesia
bull May cause a lot of harm
bull Andhellip
SSAI Malmoslash 2017
AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS
Is too dangerous to be used as routineanalgesia in the labour ward
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
Remifentanil provides betterpain relief than other opioids but only during the first twohours
SSAI Malmoslash 2017
Does it work
SSAI Malmoslash 2017
From M Van De Velde B Carvalho IJOA 2016 25 66-74
SSAI Malmoslash 2017
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 TRIAL REGISTRATION Netherlands Trial Register NTR2551
CONCLUSION In terms of labor duration average VAS pain scores and maternal overall satisfaction score with analgesia CSE analgesia is superior to that provided by epidural analgesia or PCIA with remifentanil for pain relief in early labor in nulliparous women However there were no differences in the mode of delivery side effects or neonatal outcomes between the three techniques
Efficacy of Remifentanil PCA as compared to CSEEpidural
SSAI Malmoslash 2017
Oxygen saturation was significantly lower (SpO2 lt92) in women who used remifentanil (relative risk 15 14 to 17)
Remifentanil IVPCA provides poorer efficacy on labor analgesia than epidural analgesia with more sedation on parturients and a trend of newborn acidosis
Lin R Tao Y Yu Y Xu Z Su J Liu Z Intravenous remifentanil versus epidural ropivacaine with sufentanil for labour analgesia a retrospective study PLoS ONE [Electronic Resource] 20149(11)e112283
SSAI Malmoslash 2017
Meta Analyses
bull This meta-analysis suggests that remifentanil PCIA is not superior to epidural analgesia in analgesic efficacy during labor Given the wide CIs of the pooled results for secondary maternal and neonatal outcomes definite conclusions cannot be drawn for those outcomes Further studies are still warranted to validate these conclusions Liu ZQ Chen XB Li HB Qiu MT Duan T A comparison of remifentanil parturient-controlled intravenous analgesia with
epidural analgesia a meta-analysis of randomized controlled trials Anesth Analg 2014118(3)598-603
bull CONCLUSION During labour remifentanil-PCA provided superior analgesia and higher patient satisfactioncompared with pethidine with a comparable degree of adverse events Epidural analgesia providedsuperior pain relief in comparison with remifentanil Due to a low number of reported adverse events thesafety issue of remifentanil use in labour remains an open question that needs to be addressed in futuretrials Schnabel A Hahn N Broscheit J Muellenbach RM Rieger L Roewer N et al Remifentanil for labour analgesia a meta-analysis of
randomised controlled trials European Journal of Anaesthesiology 201229(4)177-85
bull Conclusions Pooled assessment of remifentanil intervention seems an attractive strategy for controlling labor pain in health term parturients but it is not supported by strong evidence Current evidencesuggests that it may produce effective analgesia by only a modest level HealthMED 20126(7)2407-18
Effect size difference 3 cm
SSAI Malmoslash 2017
SSAI Malmoslash 2017
APRIL 2017
20 RCTrsquos 3569 women
Results Weibel et al
bull Based on the current systematic review there is mostly low-quality evidence to inform practiceand future research may significantly alter thecurrent 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 safetyoutcomes (maternal apnoe and respiratorydepression Apgar score) and on the optimal mode and regimen of remifentanil administrationto provide highets efficacy with reasonableadverse effects for mother and their newborns
SSAI Malmoslash 2017
Always satisfied
Off course they are Who wouldnrsquot
SSAI Malmoslash 2017
Optimal administration of remi
SSAI Malmoslash 2017
Optimal administration of remi
bull Protocols varies (bolus dose lock-out background infusion TCI etc)
bull Fixed bolus 20-50 microg without backgroundinfusion lock-out 2-3 minutes
bull If background ndash small dose lt 005microgkgxmin
bull TCI 05-15 ngml
bull New systems VPIA (Vital signs patientcontrolled intravenous analgesia)
SSAI Malmoslash 2017
SIA et al IJOA correspondence 2014 23 196-8
SSAI Malmoslash 2017
Cont infusion or PCA
bull Shen MK Wu ZF Zhu AB et al Remifentanil for labour analgesia a double-blinded randomised controlled trial of maternal and neonatal effects ofpatient-controlled analgesia versus continuous infusion (0005-02 microgkgxmin) Anaesthesia 201368(3)236-44 The results suggest thatremifentanil PCA (01-04 microgkg) provides better pain relief and similarplacental transfer compared with continuous infusion (Author)
bull Per protocol TCI Norwegian National Hospital (Oslo University Hospital)
ndash 05 ndash 2 ngml + nurse controlled boluses) ndash easier for anaesthesia personell
SSAI Malmoslash 2017
Remifentanil TCI
bull Why notbull Acta Anaesthesiol Scand 2013 Jul57(6)802-8 doi 101111aas12096 Epub 2013 Mar 15
bull Remifentanil target-controlled infusion during second stage labour in high-risk parturients a case series Schwarz GL1 Volmanen P Albrechtsen S Bjoernestad E
bull 1ngml start incremental doses of 05 ngml titrated untill satisfied mother or side-effects(1-6 ngml)
SSAI Malmoslash 2017
Why use remifentanil
The boss
SSAI Malmoslash 2017
In conclusionhellip
SSAI Malmoslash 2017
When to use it
bull For parturients with contraindications to regional analgesia
ndash Bleeding disorders
ndash Infections
ndash Mother does not want regional
bull In places with reduced anaesthesia service
SSAI Malmoslash 2017
Then remifentanil is the best choice
bull Continuous monitoring
bull Including capnography or RR counting
bull Well educated staff
SSAI Malmoslash 2017
Remifentanil PCA
bull Is cheap
bull Easy to administer
bull Gives (some) pain relief
SSAI Malmoslash 2017
BUT
bull Has a poor analgesic effect compared to thegolden standard of regional analgesia
bull May cause a lot of harm
bull Andhellip
SSAI Malmoslash 2017
AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS
Is too dangerous to be used as routineanalgesia in the labour ward
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
Does it work
SSAI Malmoslash 2017
From M Van De Velde B Carvalho IJOA 2016 25 66-74
SSAI Malmoslash 2017
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 TRIAL REGISTRATION Netherlands Trial Register NTR2551
CONCLUSION In terms of labor duration average VAS pain scores and maternal overall satisfaction score with analgesia CSE analgesia is superior to that provided by epidural analgesia or PCIA with remifentanil for pain relief in early labor in nulliparous women However there were no differences in the mode of delivery side effects or neonatal outcomes between the three techniques
Efficacy of Remifentanil PCA as compared to CSEEpidural
SSAI Malmoslash 2017
Oxygen saturation was significantly lower (SpO2 lt92) in women who used remifentanil (relative risk 15 14 to 17)
Remifentanil IVPCA provides poorer efficacy on labor analgesia than epidural analgesia with more sedation on parturients and a trend of newborn acidosis
Lin R Tao Y Yu Y Xu Z Su J Liu Z Intravenous remifentanil versus epidural ropivacaine with sufentanil for labour analgesia a retrospective study PLoS ONE [Electronic Resource] 20149(11)e112283
SSAI Malmoslash 2017
Meta Analyses
bull This meta-analysis suggests that remifentanil PCIA is not superior to epidural analgesia in analgesic efficacy during labor Given the wide CIs of the pooled results for secondary maternal and neonatal outcomes definite conclusions cannot be drawn for those outcomes Further studies are still warranted to validate these conclusions Liu ZQ Chen XB Li HB Qiu MT Duan T A comparison of remifentanil parturient-controlled intravenous analgesia with
epidural analgesia a meta-analysis of randomized controlled trials Anesth Analg 2014118(3)598-603
bull CONCLUSION During labour remifentanil-PCA provided superior analgesia and higher patient satisfactioncompared with pethidine with a comparable degree of adverse events Epidural analgesia providedsuperior pain relief in comparison with remifentanil Due to a low number of reported adverse events thesafety issue of remifentanil use in labour remains an open question that needs to be addressed in futuretrials Schnabel A Hahn N Broscheit J Muellenbach RM Rieger L Roewer N et al Remifentanil for labour analgesia a meta-analysis of
randomised controlled trials European Journal of Anaesthesiology 201229(4)177-85
bull Conclusions Pooled assessment of remifentanil intervention seems an attractive strategy for controlling labor pain in health term parturients but it is not supported by strong evidence Current evidencesuggests that it may produce effective analgesia by only a modest level HealthMED 20126(7)2407-18
Effect size difference 3 cm
SSAI Malmoslash 2017
SSAI Malmoslash 2017
APRIL 2017
20 RCTrsquos 3569 women
Results Weibel et al
bull Based on the current systematic review there is mostly low-quality evidence to inform practiceand future research may significantly alter thecurrent 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 safetyoutcomes (maternal apnoe and respiratorydepression Apgar score) and on the optimal mode and regimen of remifentanil administrationto provide highets efficacy with reasonableadverse effects for mother and their newborns
SSAI Malmoslash 2017
Always satisfied
Off course they are Who wouldnrsquot
SSAI Malmoslash 2017
Optimal administration of remi
SSAI Malmoslash 2017
Optimal administration of remi
bull Protocols varies (bolus dose lock-out background infusion TCI etc)
bull Fixed bolus 20-50 microg without backgroundinfusion lock-out 2-3 minutes
bull If background ndash small dose lt 005microgkgxmin
bull TCI 05-15 ngml
bull New systems VPIA (Vital signs patientcontrolled intravenous analgesia)
SSAI Malmoslash 2017
SIA et al IJOA correspondence 2014 23 196-8
SSAI Malmoslash 2017
Cont infusion or PCA
bull Shen MK Wu ZF Zhu AB et al Remifentanil for labour analgesia a double-blinded randomised controlled trial of maternal and neonatal effects ofpatient-controlled analgesia versus continuous infusion (0005-02 microgkgxmin) Anaesthesia 201368(3)236-44 The results suggest thatremifentanil PCA (01-04 microgkg) provides better pain relief and similarplacental transfer compared with continuous infusion (Author)
bull Per protocol TCI Norwegian National Hospital (Oslo University Hospital)
ndash 05 ndash 2 ngml + nurse controlled boluses) ndash easier for anaesthesia personell
SSAI Malmoslash 2017
Remifentanil TCI
bull Why notbull Acta Anaesthesiol Scand 2013 Jul57(6)802-8 doi 101111aas12096 Epub 2013 Mar 15
bull Remifentanil target-controlled infusion during second stage labour in high-risk parturients a case series Schwarz GL1 Volmanen P Albrechtsen S Bjoernestad E
bull 1ngml start incremental doses of 05 ngml titrated untill satisfied mother or side-effects(1-6 ngml)
SSAI Malmoslash 2017
Why use remifentanil
The boss
SSAI Malmoslash 2017
In conclusionhellip
SSAI Malmoslash 2017
When to use it
bull For parturients with contraindications to regional analgesia
ndash Bleeding disorders
ndash Infections
ndash Mother does not want regional
bull In places with reduced anaesthesia service
SSAI Malmoslash 2017
Then remifentanil is the best choice
bull Continuous monitoring
bull Including capnography or RR counting
bull Well educated staff
SSAI Malmoslash 2017
Remifentanil PCA
bull Is cheap
bull Easy to administer
bull Gives (some) pain relief
SSAI Malmoslash 2017
BUT
bull Has a poor analgesic effect compared to thegolden standard of regional analgesia
bull May cause a lot of harm
bull Andhellip
SSAI Malmoslash 2017
AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS
Is too dangerous to be used as routineanalgesia in the labour ward
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
From M Van De Velde B Carvalho IJOA 2016 25 66-74
SSAI Malmoslash 2017
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 TRIAL REGISTRATION Netherlands Trial Register NTR2551
CONCLUSION In terms of labor duration average VAS pain scores and maternal overall satisfaction score with analgesia CSE analgesia is superior to that provided by epidural analgesia or PCIA with remifentanil for pain relief in early labor in nulliparous women However there were no differences in the mode of delivery side effects or neonatal outcomes between the three techniques
Efficacy of Remifentanil PCA as compared to CSEEpidural
SSAI Malmoslash 2017
Oxygen saturation was significantly lower (SpO2 lt92) in women who used remifentanil (relative risk 15 14 to 17)
Remifentanil IVPCA provides poorer efficacy on labor analgesia than epidural analgesia with more sedation on parturients and a trend of newborn acidosis
Lin R Tao Y Yu Y Xu Z Su J Liu Z Intravenous remifentanil versus epidural ropivacaine with sufentanil for labour analgesia a retrospective study PLoS ONE [Electronic Resource] 20149(11)e112283
SSAI Malmoslash 2017
Meta Analyses
bull This meta-analysis suggests that remifentanil PCIA is not superior to epidural analgesia in analgesic efficacy during labor Given the wide CIs of the pooled results for secondary maternal and neonatal outcomes definite conclusions cannot be drawn for those outcomes Further studies are still warranted to validate these conclusions Liu ZQ Chen XB Li HB Qiu MT Duan T A comparison of remifentanil parturient-controlled intravenous analgesia with
epidural analgesia a meta-analysis of randomized controlled trials Anesth Analg 2014118(3)598-603
bull CONCLUSION During labour remifentanil-PCA provided superior analgesia and higher patient satisfactioncompared with pethidine with a comparable degree of adverse events Epidural analgesia providedsuperior pain relief in comparison with remifentanil Due to a low number of reported adverse events thesafety issue of remifentanil use in labour remains an open question that needs to be addressed in futuretrials Schnabel A Hahn N Broscheit J Muellenbach RM Rieger L Roewer N et al Remifentanil for labour analgesia a meta-analysis of
randomised controlled trials European Journal of Anaesthesiology 201229(4)177-85
bull Conclusions Pooled assessment of remifentanil intervention seems an attractive strategy for controlling labor pain in health term parturients but it is not supported by strong evidence Current evidencesuggests that it may produce effective analgesia by only a modest level HealthMED 20126(7)2407-18
Effect size difference 3 cm
SSAI Malmoslash 2017
SSAI Malmoslash 2017
APRIL 2017
20 RCTrsquos 3569 women
Results Weibel et al
bull Based on the current systematic review there is mostly low-quality evidence to inform practiceand future research may significantly alter thecurrent 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 safetyoutcomes (maternal apnoe and respiratorydepression Apgar score) and on the optimal mode and regimen of remifentanil administrationto provide highets efficacy with reasonableadverse effects for mother and their newborns
SSAI Malmoslash 2017
Always satisfied
Off course they are Who wouldnrsquot
SSAI Malmoslash 2017
Optimal administration of remi
SSAI Malmoslash 2017
Optimal administration of remi
bull Protocols varies (bolus dose lock-out background infusion TCI etc)
bull Fixed bolus 20-50 microg without backgroundinfusion lock-out 2-3 minutes
bull If background ndash small dose lt 005microgkgxmin
bull TCI 05-15 ngml
bull New systems VPIA (Vital signs patientcontrolled intravenous analgesia)
SSAI Malmoslash 2017
SIA et al IJOA correspondence 2014 23 196-8
SSAI Malmoslash 2017
Cont infusion or PCA
bull Shen MK Wu ZF Zhu AB et al Remifentanil for labour analgesia a double-blinded randomised controlled trial of maternal and neonatal effects ofpatient-controlled analgesia versus continuous infusion (0005-02 microgkgxmin) Anaesthesia 201368(3)236-44 The results suggest thatremifentanil PCA (01-04 microgkg) provides better pain relief and similarplacental transfer compared with continuous infusion (Author)
bull Per protocol TCI Norwegian National Hospital (Oslo University Hospital)
ndash 05 ndash 2 ngml + nurse controlled boluses) ndash easier for anaesthesia personell
SSAI Malmoslash 2017
Remifentanil TCI
bull Why notbull Acta Anaesthesiol Scand 2013 Jul57(6)802-8 doi 101111aas12096 Epub 2013 Mar 15
bull Remifentanil target-controlled infusion during second stage labour in high-risk parturients a case series Schwarz GL1 Volmanen P Albrechtsen S Bjoernestad E
bull 1ngml start incremental doses of 05 ngml titrated untill satisfied mother or side-effects(1-6 ngml)
SSAI Malmoslash 2017
Why use remifentanil
The boss
SSAI Malmoslash 2017
In conclusionhellip
SSAI Malmoslash 2017
When to use it
bull For parturients with contraindications to regional analgesia
ndash Bleeding disorders
ndash Infections
ndash Mother does not want regional
bull In places with reduced anaesthesia service
SSAI Malmoslash 2017
Then remifentanil is the best choice
bull Continuous monitoring
bull Including capnography or RR counting
bull Well educated staff
SSAI Malmoslash 2017
Remifentanil PCA
bull Is cheap
bull Easy to administer
bull Gives (some) pain relief
SSAI Malmoslash 2017
BUT
bull Has a poor analgesic effect compared to thegolden standard of regional analgesia
bull May cause a lot of harm
bull Andhellip
SSAI Malmoslash 2017
AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS
Is too dangerous to be used as routineanalgesia in the labour ward
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
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 TRIAL REGISTRATION Netherlands Trial Register NTR2551
CONCLUSION In terms of labor duration average VAS pain scores and maternal overall satisfaction score with analgesia CSE analgesia is superior to that provided by epidural analgesia or PCIA with remifentanil for pain relief in early labor in nulliparous women However there were no differences in the mode of delivery side effects or neonatal outcomes between the three techniques
Efficacy of Remifentanil PCA as compared to CSEEpidural
SSAI Malmoslash 2017
Oxygen saturation was significantly lower (SpO2 lt92) in women who used remifentanil (relative risk 15 14 to 17)
Remifentanil IVPCA provides poorer efficacy on labor analgesia than epidural analgesia with more sedation on parturients and a trend of newborn acidosis
Lin R Tao Y Yu Y Xu Z Su J Liu Z Intravenous remifentanil versus epidural ropivacaine with sufentanil for labour analgesia a retrospective study PLoS ONE [Electronic Resource] 20149(11)e112283
SSAI Malmoslash 2017
Meta Analyses
bull This meta-analysis suggests that remifentanil PCIA is not superior to epidural analgesia in analgesic efficacy during labor Given the wide CIs of the pooled results for secondary maternal and neonatal outcomes definite conclusions cannot be drawn for those outcomes Further studies are still warranted to validate these conclusions Liu ZQ Chen XB Li HB Qiu MT Duan T A comparison of remifentanil parturient-controlled intravenous analgesia with
epidural analgesia a meta-analysis of randomized controlled trials Anesth Analg 2014118(3)598-603
bull CONCLUSION During labour remifentanil-PCA provided superior analgesia and higher patient satisfactioncompared with pethidine with a comparable degree of adverse events Epidural analgesia providedsuperior pain relief in comparison with remifentanil Due to a low number of reported adverse events thesafety issue of remifentanil use in labour remains an open question that needs to be addressed in futuretrials Schnabel A Hahn N Broscheit J Muellenbach RM Rieger L Roewer N et al Remifentanil for labour analgesia a meta-analysis of
randomised controlled trials European Journal of Anaesthesiology 201229(4)177-85
bull Conclusions Pooled assessment of remifentanil intervention seems an attractive strategy for controlling labor pain in health term parturients but it is not supported by strong evidence Current evidencesuggests that it may produce effective analgesia by only a modest level HealthMED 20126(7)2407-18
Effect size difference 3 cm
SSAI Malmoslash 2017
SSAI Malmoslash 2017
APRIL 2017
20 RCTrsquos 3569 women
Results Weibel et al
bull Based on the current systematic review there is mostly low-quality evidence to inform practiceand future research may significantly alter thecurrent 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 safetyoutcomes (maternal apnoe and respiratorydepression Apgar score) and on the optimal mode and regimen of remifentanil administrationto provide highets efficacy with reasonableadverse effects for mother and their newborns
SSAI Malmoslash 2017
Always satisfied
Off course they are Who wouldnrsquot
SSAI Malmoslash 2017
Optimal administration of remi
SSAI Malmoslash 2017
Optimal administration of remi
bull Protocols varies (bolus dose lock-out background infusion TCI etc)
bull Fixed bolus 20-50 microg without backgroundinfusion lock-out 2-3 minutes
bull If background ndash small dose lt 005microgkgxmin
bull TCI 05-15 ngml
bull New systems VPIA (Vital signs patientcontrolled intravenous analgesia)
SSAI Malmoslash 2017
SIA et al IJOA correspondence 2014 23 196-8
SSAI Malmoslash 2017
Cont infusion or PCA
bull Shen MK Wu ZF Zhu AB et al Remifentanil for labour analgesia a double-blinded randomised controlled trial of maternal and neonatal effects ofpatient-controlled analgesia versus continuous infusion (0005-02 microgkgxmin) Anaesthesia 201368(3)236-44 The results suggest thatremifentanil PCA (01-04 microgkg) provides better pain relief and similarplacental transfer compared with continuous infusion (Author)
bull Per protocol TCI Norwegian National Hospital (Oslo University Hospital)
ndash 05 ndash 2 ngml + nurse controlled boluses) ndash easier for anaesthesia personell
SSAI Malmoslash 2017
Remifentanil TCI
bull Why notbull Acta Anaesthesiol Scand 2013 Jul57(6)802-8 doi 101111aas12096 Epub 2013 Mar 15
bull Remifentanil target-controlled infusion during second stage labour in high-risk parturients a case series Schwarz GL1 Volmanen P Albrechtsen S Bjoernestad E
bull 1ngml start incremental doses of 05 ngml titrated untill satisfied mother or side-effects(1-6 ngml)
SSAI Malmoslash 2017
Why use remifentanil
The boss
SSAI Malmoslash 2017
In conclusionhellip
SSAI Malmoslash 2017
When to use it
bull For parturients with contraindications to regional analgesia
ndash Bleeding disorders
ndash Infections
ndash Mother does not want regional
bull In places with reduced anaesthesia service
SSAI Malmoslash 2017
Then remifentanil is the best choice
bull Continuous monitoring
bull Including capnography or RR counting
bull Well educated staff
SSAI Malmoslash 2017
Remifentanil PCA
bull Is cheap
bull Easy to administer
bull Gives (some) pain relief
SSAI Malmoslash 2017
BUT
bull Has a poor analgesic effect compared to thegolden standard of regional analgesia
bull May cause a lot of harm
bull Andhellip
SSAI Malmoslash 2017
AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS
Is too dangerous to be used as routineanalgesia in the labour ward
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
Oxygen saturation was significantly lower (SpO2 lt92) in women who used remifentanil (relative risk 15 14 to 17)
Remifentanil IVPCA provides poorer efficacy on labor analgesia than epidural analgesia with more sedation on parturients and a trend of newborn acidosis
Lin R Tao Y Yu Y Xu Z Su J Liu Z Intravenous remifentanil versus epidural ropivacaine with sufentanil for labour analgesia a retrospective study PLoS ONE [Electronic Resource] 20149(11)e112283
SSAI Malmoslash 2017
Meta Analyses
bull This meta-analysis suggests that remifentanil PCIA is not superior to epidural analgesia in analgesic efficacy during labor Given the wide CIs of the pooled results for secondary maternal and neonatal outcomes definite conclusions cannot be drawn for those outcomes Further studies are still warranted to validate these conclusions Liu ZQ Chen XB Li HB Qiu MT Duan T A comparison of remifentanil parturient-controlled intravenous analgesia with
epidural analgesia a meta-analysis of randomized controlled trials Anesth Analg 2014118(3)598-603
bull CONCLUSION During labour remifentanil-PCA provided superior analgesia and higher patient satisfactioncompared with pethidine with a comparable degree of adverse events Epidural analgesia providedsuperior pain relief in comparison with remifentanil Due to a low number of reported adverse events thesafety issue of remifentanil use in labour remains an open question that needs to be addressed in futuretrials Schnabel A Hahn N Broscheit J Muellenbach RM Rieger L Roewer N et al Remifentanil for labour analgesia a meta-analysis of
randomised controlled trials European Journal of Anaesthesiology 201229(4)177-85
bull Conclusions Pooled assessment of remifentanil intervention seems an attractive strategy for controlling labor pain in health term parturients but it is not supported by strong evidence Current evidencesuggests that it may produce effective analgesia by only a modest level HealthMED 20126(7)2407-18
Effect size difference 3 cm
SSAI Malmoslash 2017
SSAI Malmoslash 2017
APRIL 2017
20 RCTrsquos 3569 women
Results Weibel et al
bull Based on the current systematic review there is mostly low-quality evidence to inform practiceand future research may significantly alter thecurrent 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 safetyoutcomes (maternal apnoe and respiratorydepression Apgar score) and on the optimal mode and regimen of remifentanil administrationto provide highets efficacy with reasonableadverse effects for mother and their newborns
SSAI Malmoslash 2017
Always satisfied
Off course they are Who wouldnrsquot
SSAI Malmoslash 2017
Optimal administration of remi
SSAI Malmoslash 2017
Optimal administration of remi
bull Protocols varies (bolus dose lock-out background infusion TCI etc)
bull Fixed bolus 20-50 microg without backgroundinfusion lock-out 2-3 minutes
bull If background ndash small dose lt 005microgkgxmin
bull TCI 05-15 ngml
bull New systems VPIA (Vital signs patientcontrolled intravenous analgesia)
SSAI Malmoslash 2017
SIA et al IJOA correspondence 2014 23 196-8
SSAI Malmoslash 2017
Cont infusion or PCA
bull Shen MK Wu ZF Zhu AB et al Remifentanil for labour analgesia a double-blinded randomised controlled trial of maternal and neonatal effects ofpatient-controlled analgesia versus continuous infusion (0005-02 microgkgxmin) Anaesthesia 201368(3)236-44 The results suggest thatremifentanil PCA (01-04 microgkg) provides better pain relief and similarplacental transfer compared with continuous infusion (Author)
bull Per protocol TCI Norwegian National Hospital (Oslo University Hospital)
ndash 05 ndash 2 ngml + nurse controlled boluses) ndash easier for anaesthesia personell
SSAI Malmoslash 2017
Remifentanil TCI
bull Why notbull Acta Anaesthesiol Scand 2013 Jul57(6)802-8 doi 101111aas12096 Epub 2013 Mar 15
bull Remifentanil target-controlled infusion during second stage labour in high-risk parturients a case series Schwarz GL1 Volmanen P Albrechtsen S Bjoernestad E
bull 1ngml start incremental doses of 05 ngml titrated untill satisfied mother or side-effects(1-6 ngml)
SSAI Malmoslash 2017
Why use remifentanil
The boss
SSAI Malmoslash 2017
In conclusionhellip
SSAI Malmoslash 2017
When to use it
bull For parturients with contraindications to regional analgesia
ndash Bleeding disorders
ndash Infections
ndash Mother does not want regional
bull In places with reduced anaesthesia service
SSAI Malmoslash 2017
Then remifentanil is the best choice
bull Continuous monitoring
bull Including capnography or RR counting
bull Well educated staff
SSAI Malmoslash 2017
Remifentanil PCA
bull Is cheap
bull Easy to administer
bull Gives (some) pain relief
SSAI Malmoslash 2017
BUT
bull Has a poor analgesic effect compared to thegolden standard of regional analgesia
bull May cause a lot of harm
bull Andhellip
SSAI Malmoslash 2017
AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS
Is too dangerous to be used as routineanalgesia in the labour ward
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
Meta Analyses
bull This meta-analysis suggests that remifentanil PCIA is not superior to epidural analgesia in analgesic efficacy during labor Given the wide CIs of the pooled results for secondary maternal and neonatal outcomes definite conclusions cannot be drawn for those outcomes Further studies are still warranted to validate these conclusions Liu ZQ Chen XB Li HB Qiu MT Duan T A comparison of remifentanil parturient-controlled intravenous analgesia with
epidural analgesia a meta-analysis of randomized controlled trials Anesth Analg 2014118(3)598-603
bull CONCLUSION During labour remifentanil-PCA provided superior analgesia and higher patient satisfactioncompared with pethidine with a comparable degree of adverse events Epidural analgesia providedsuperior pain relief in comparison with remifentanil Due to a low number of reported adverse events thesafety issue of remifentanil use in labour remains an open question that needs to be addressed in futuretrials Schnabel A Hahn N Broscheit J Muellenbach RM Rieger L Roewer N et al Remifentanil for labour analgesia a meta-analysis of
randomised controlled trials European Journal of Anaesthesiology 201229(4)177-85
bull Conclusions Pooled assessment of remifentanil intervention seems an attractive strategy for controlling labor pain in health term parturients but it is not supported by strong evidence Current evidencesuggests that it may produce effective analgesia by only a modest level HealthMED 20126(7)2407-18
Effect size difference 3 cm
SSAI Malmoslash 2017
SSAI Malmoslash 2017
APRIL 2017
20 RCTrsquos 3569 women
Results Weibel et al
bull Based on the current systematic review there is mostly low-quality evidence to inform practiceand future research may significantly alter thecurrent 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 safetyoutcomes (maternal apnoe and respiratorydepression Apgar score) and on the optimal mode and regimen of remifentanil administrationto provide highets efficacy with reasonableadverse effects for mother and their newborns
SSAI Malmoslash 2017
Always satisfied
Off course they are Who wouldnrsquot
SSAI Malmoslash 2017
Optimal administration of remi
SSAI Malmoslash 2017
Optimal administration of remi
bull Protocols varies (bolus dose lock-out background infusion TCI etc)
bull Fixed bolus 20-50 microg without backgroundinfusion lock-out 2-3 minutes
bull If background ndash small dose lt 005microgkgxmin
bull TCI 05-15 ngml
bull New systems VPIA (Vital signs patientcontrolled intravenous analgesia)
SSAI Malmoslash 2017
SIA et al IJOA correspondence 2014 23 196-8
SSAI Malmoslash 2017
Cont infusion or PCA
bull Shen MK Wu ZF Zhu AB et al Remifentanil for labour analgesia a double-blinded randomised controlled trial of maternal and neonatal effects ofpatient-controlled analgesia versus continuous infusion (0005-02 microgkgxmin) Anaesthesia 201368(3)236-44 The results suggest thatremifentanil PCA (01-04 microgkg) provides better pain relief and similarplacental transfer compared with continuous infusion (Author)
bull Per protocol TCI Norwegian National Hospital (Oslo University Hospital)
ndash 05 ndash 2 ngml + nurse controlled boluses) ndash easier for anaesthesia personell
SSAI Malmoslash 2017
Remifentanil TCI
bull Why notbull Acta Anaesthesiol Scand 2013 Jul57(6)802-8 doi 101111aas12096 Epub 2013 Mar 15
bull Remifentanil target-controlled infusion during second stage labour in high-risk parturients a case series Schwarz GL1 Volmanen P Albrechtsen S Bjoernestad E
bull 1ngml start incremental doses of 05 ngml titrated untill satisfied mother or side-effects(1-6 ngml)
SSAI Malmoslash 2017
Why use remifentanil
The boss
SSAI Malmoslash 2017
In conclusionhellip
SSAI Malmoslash 2017
When to use it
bull For parturients with contraindications to regional analgesia
ndash Bleeding disorders
ndash Infections
ndash Mother does not want regional
bull In places with reduced anaesthesia service
SSAI Malmoslash 2017
Then remifentanil is the best choice
bull Continuous monitoring
bull Including capnography or RR counting
bull Well educated staff
SSAI Malmoslash 2017
Remifentanil PCA
bull Is cheap
bull Easy to administer
bull Gives (some) pain relief
SSAI Malmoslash 2017
BUT
bull Has a poor analgesic effect compared to thegolden standard of regional analgesia
bull May cause a lot of harm
bull Andhellip
SSAI Malmoslash 2017
AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS
Is too dangerous to be used as routineanalgesia in the labour ward
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
SSAI Malmoslash 2017
APRIL 2017
20 RCTrsquos 3569 women
Results Weibel et al
bull Based on the current systematic review there is mostly low-quality evidence to inform practiceand future research may significantly alter thecurrent 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 safetyoutcomes (maternal apnoe and respiratorydepression Apgar score) and on the optimal mode and regimen of remifentanil administrationto provide highets efficacy with reasonableadverse effects for mother and their newborns
SSAI Malmoslash 2017
Always satisfied
Off course they are Who wouldnrsquot
SSAI Malmoslash 2017
Optimal administration of remi
SSAI Malmoslash 2017
Optimal administration of remi
bull Protocols varies (bolus dose lock-out background infusion TCI etc)
bull Fixed bolus 20-50 microg without backgroundinfusion lock-out 2-3 minutes
bull If background ndash small dose lt 005microgkgxmin
bull TCI 05-15 ngml
bull New systems VPIA (Vital signs patientcontrolled intravenous analgesia)
SSAI Malmoslash 2017
SIA et al IJOA correspondence 2014 23 196-8
SSAI Malmoslash 2017
Cont infusion or PCA
bull Shen MK Wu ZF Zhu AB et al Remifentanil for labour analgesia a double-blinded randomised controlled trial of maternal and neonatal effects ofpatient-controlled analgesia versus continuous infusion (0005-02 microgkgxmin) Anaesthesia 201368(3)236-44 The results suggest thatremifentanil PCA (01-04 microgkg) provides better pain relief and similarplacental transfer compared with continuous infusion (Author)
bull Per protocol TCI Norwegian National Hospital (Oslo University Hospital)
ndash 05 ndash 2 ngml + nurse controlled boluses) ndash easier for anaesthesia personell
SSAI Malmoslash 2017
Remifentanil TCI
bull Why notbull Acta Anaesthesiol Scand 2013 Jul57(6)802-8 doi 101111aas12096 Epub 2013 Mar 15
bull Remifentanil target-controlled infusion during second stage labour in high-risk parturients a case series Schwarz GL1 Volmanen P Albrechtsen S Bjoernestad E
bull 1ngml start incremental doses of 05 ngml titrated untill satisfied mother or side-effects(1-6 ngml)
SSAI Malmoslash 2017
Why use remifentanil
The boss
SSAI Malmoslash 2017
In conclusionhellip
SSAI Malmoslash 2017
When to use it
bull For parturients with contraindications to regional analgesia
ndash Bleeding disorders
ndash Infections
ndash Mother does not want regional
bull In places with reduced anaesthesia service
SSAI Malmoslash 2017
Then remifentanil is the best choice
bull Continuous monitoring
bull Including capnography or RR counting
bull Well educated staff
SSAI Malmoslash 2017
Remifentanil PCA
bull Is cheap
bull Easy to administer
bull Gives (some) pain relief
SSAI Malmoslash 2017
BUT
bull Has a poor analgesic effect compared to thegolden standard of regional analgesia
bull May cause a lot of harm
bull Andhellip
SSAI Malmoslash 2017
AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS
Is too dangerous to be used as routineanalgesia in the labour ward
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
Results Weibel et al
bull Based on the current systematic review there is mostly low-quality evidence to inform practiceand future research may significantly alter thecurrent 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 safetyoutcomes (maternal apnoe and respiratorydepression Apgar score) and on the optimal mode and regimen of remifentanil administrationto provide highets efficacy with reasonableadverse effects for mother and their newborns
SSAI Malmoslash 2017
Always satisfied
Off course they are Who wouldnrsquot
SSAI Malmoslash 2017
Optimal administration of remi
SSAI Malmoslash 2017
Optimal administration of remi
bull Protocols varies (bolus dose lock-out background infusion TCI etc)
bull Fixed bolus 20-50 microg without backgroundinfusion lock-out 2-3 minutes
bull If background ndash small dose lt 005microgkgxmin
bull TCI 05-15 ngml
bull New systems VPIA (Vital signs patientcontrolled intravenous analgesia)
SSAI Malmoslash 2017
SIA et al IJOA correspondence 2014 23 196-8
SSAI Malmoslash 2017
Cont infusion or PCA
bull Shen MK Wu ZF Zhu AB et al Remifentanil for labour analgesia a double-blinded randomised controlled trial of maternal and neonatal effects ofpatient-controlled analgesia versus continuous infusion (0005-02 microgkgxmin) Anaesthesia 201368(3)236-44 The results suggest thatremifentanil PCA (01-04 microgkg) provides better pain relief and similarplacental transfer compared with continuous infusion (Author)
bull Per protocol TCI Norwegian National Hospital (Oslo University Hospital)
ndash 05 ndash 2 ngml + nurse controlled boluses) ndash easier for anaesthesia personell
SSAI Malmoslash 2017
Remifentanil TCI
bull Why notbull Acta Anaesthesiol Scand 2013 Jul57(6)802-8 doi 101111aas12096 Epub 2013 Mar 15
bull Remifentanil target-controlled infusion during second stage labour in high-risk parturients a case series Schwarz GL1 Volmanen P Albrechtsen S Bjoernestad E
bull 1ngml start incremental doses of 05 ngml titrated untill satisfied mother or side-effects(1-6 ngml)
SSAI Malmoslash 2017
Why use remifentanil
The boss
SSAI Malmoslash 2017
In conclusionhellip
SSAI Malmoslash 2017
When to use it
bull For parturients with contraindications to regional analgesia
ndash Bleeding disorders
ndash Infections
ndash Mother does not want regional
bull In places with reduced anaesthesia service
SSAI Malmoslash 2017
Then remifentanil is the best choice
bull Continuous monitoring
bull Including capnography or RR counting
bull Well educated staff
SSAI Malmoslash 2017
Remifentanil PCA
bull Is cheap
bull Easy to administer
bull Gives (some) pain relief
SSAI Malmoslash 2017
BUT
bull Has a poor analgesic effect compared to thegolden standard of regional analgesia
bull May cause a lot of harm
bull Andhellip
SSAI Malmoslash 2017
AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS
Is too dangerous to be used as routineanalgesia in the labour ward
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
Always satisfied
Off course they are Who wouldnrsquot
SSAI Malmoslash 2017
Optimal administration of remi
SSAI Malmoslash 2017
Optimal administration of remi
bull Protocols varies (bolus dose lock-out background infusion TCI etc)
bull Fixed bolus 20-50 microg without backgroundinfusion lock-out 2-3 minutes
bull If background ndash small dose lt 005microgkgxmin
bull TCI 05-15 ngml
bull New systems VPIA (Vital signs patientcontrolled intravenous analgesia)
SSAI Malmoslash 2017
SIA et al IJOA correspondence 2014 23 196-8
SSAI Malmoslash 2017
Cont infusion or PCA
bull Shen MK Wu ZF Zhu AB et al Remifentanil for labour analgesia a double-blinded randomised controlled trial of maternal and neonatal effects ofpatient-controlled analgesia versus continuous infusion (0005-02 microgkgxmin) Anaesthesia 201368(3)236-44 The results suggest thatremifentanil PCA (01-04 microgkg) provides better pain relief and similarplacental transfer compared with continuous infusion (Author)
bull Per protocol TCI Norwegian National Hospital (Oslo University Hospital)
ndash 05 ndash 2 ngml + nurse controlled boluses) ndash easier for anaesthesia personell
SSAI Malmoslash 2017
Remifentanil TCI
bull Why notbull Acta Anaesthesiol Scand 2013 Jul57(6)802-8 doi 101111aas12096 Epub 2013 Mar 15
bull Remifentanil target-controlled infusion during second stage labour in high-risk parturients a case series Schwarz GL1 Volmanen P Albrechtsen S Bjoernestad E
bull 1ngml start incremental doses of 05 ngml titrated untill satisfied mother or side-effects(1-6 ngml)
SSAI Malmoslash 2017
Why use remifentanil
The boss
SSAI Malmoslash 2017
In conclusionhellip
SSAI Malmoslash 2017
When to use it
bull For parturients with contraindications to regional analgesia
ndash Bleeding disorders
ndash Infections
ndash Mother does not want regional
bull In places with reduced anaesthesia service
SSAI Malmoslash 2017
Then remifentanil is the best choice
bull Continuous monitoring
bull Including capnography or RR counting
bull Well educated staff
SSAI Malmoslash 2017
Remifentanil PCA
bull Is cheap
bull Easy to administer
bull Gives (some) pain relief
SSAI Malmoslash 2017
BUT
bull Has a poor analgesic effect compared to thegolden standard of regional analgesia
bull May cause a lot of harm
bull Andhellip
SSAI Malmoslash 2017
AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS
Is too dangerous to be used as routineanalgesia in the labour ward
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
Optimal administration of remi
SSAI Malmoslash 2017
Optimal administration of remi
bull Protocols varies (bolus dose lock-out background infusion TCI etc)
bull Fixed bolus 20-50 microg without backgroundinfusion lock-out 2-3 minutes
bull If background ndash small dose lt 005microgkgxmin
bull TCI 05-15 ngml
bull New systems VPIA (Vital signs patientcontrolled intravenous analgesia)
SSAI Malmoslash 2017
SIA et al IJOA correspondence 2014 23 196-8
SSAI Malmoslash 2017
Cont infusion or PCA
bull Shen MK Wu ZF Zhu AB et al Remifentanil for labour analgesia a double-blinded randomised controlled trial of maternal and neonatal effects ofpatient-controlled analgesia versus continuous infusion (0005-02 microgkgxmin) Anaesthesia 201368(3)236-44 The results suggest thatremifentanil PCA (01-04 microgkg) provides better pain relief and similarplacental transfer compared with continuous infusion (Author)
bull Per protocol TCI Norwegian National Hospital (Oslo University Hospital)
ndash 05 ndash 2 ngml + nurse controlled boluses) ndash easier for anaesthesia personell
SSAI Malmoslash 2017
Remifentanil TCI
bull Why notbull Acta Anaesthesiol Scand 2013 Jul57(6)802-8 doi 101111aas12096 Epub 2013 Mar 15
bull Remifentanil target-controlled infusion during second stage labour in high-risk parturients a case series Schwarz GL1 Volmanen P Albrechtsen S Bjoernestad E
bull 1ngml start incremental doses of 05 ngml titrated untill satisfied mother or side-effects(1-6 ngml)
SSAI Malmoslash 2017
Why use remifentanil
The boss
SSAI Malmoslash 2017
In conclusionhellip
SSAI Malmoslash 2017
When to use it
bull For parturients with contraindications to regional analgesia
ndash Bleeding disorders
ndash Infections
ndash Mother does not want regional
bull In places with reduced anaesthesia service
SSAI Malmoslash 2017
Then remifentanil is the best choice
bull Continuous monitoring
bull Including capnography or RR counting
bull Well educated staff
SSAI Malmoslash 2017
Remifentanil PCA
bull Is cheap
bull Easy to administer
bull Gives (some) pain relief
SSAI Malmoslash 2017
BUT
bull Has a poor analgesic effect compared to thegolden standard of regional analgesia
bull May cause a lot of harm
bull Andhellip
SSAI Malmoslash 2017
AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS
Is too dangerous to be used as routineanalgesia in the labour ward
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
Optimal administration of remi
bull Protocols varies (bolus dose lock-out background infusion TCI etc)
bull Fixed bolus 20-50 microg without backgroundinfusion lock-out 2-3 minutes
bull If background ndash small dose lt 005microgkgxmin
bull TCI 05-15 ngml
bull New systems VPIA (Vital signs patientcontrolled intravenous analgesia)
SSAI Malmoslash 2017
SIA et al IJOA correspondence 2014 23 196-8
SSAI Malmoslash 2017
Cont infusion or PCA
bull Shen MK Wu ZF Zhu AB et al Remifentanil for labour analgesia a double-blinded randomised controlled trial of maternal and neonatal effects ofpatient-controlled analgesia versus continuous infusion (0005-02 microgkgxmin) Anaesthesia 201368(3)236-44 The results suggest thatremifentanil PCA (01-04 microgkg) provides better pain relief and similarplacental transfer compared with continuous infusion (Author)
bull Per protocol TCI Norwegian National Hospital (Oslo University Hospital)
ndash 05 ndash 2 ngml + nurse controlled boluses) ndash easier for anaesthesia personell
SSAI Malmoslash 2017
Remifentanil TCI
bull Why notbull Acta Anaesthesiol Scand 2013 Jul57(6)802-8 doi 101111aas12096 Epub 2013 Mar 15
bull Remifentanil target-controlled infusion during second stage labour in high-risk parturients a case series Schwarz GL1 Volmanen P Albrechtsen S Bjoernestad E
bull 1ngml start incremental doses of 05 ngml titrated untill satisfied mother or side-effects(1-6 ngml)
SSAI Malmoslash 2017
Why use remifentanil
The boss
SSAI Malmoslash 2017
In conclusionhellip
SSAI Malmoslash 2017
When to use it
bull For parturients with contraindications to regional analgesia
ndash Bleeding disorders
ndash Infections
ndash Mother does not want regional
bull In places with reduced anaesthesia service
SSAI Malmoslash 2017
Then remifentanil is the best choice
bull Continuous monitoring
bull Including capnography or RR counting
bull Well educated staff
SSAI Malmoslash 2017
Remifentanil PCA
bull Is cheap
bull Easy to administer
bull Gives (some) pain relief
SSAI Malmoslash 2017
BUT
bull Has a poor analgesic effect compared to thegolden standard of regional analgesia
bull May cause a lot of harm
bull Andhellip
SSAI Malmoslash 2017
AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS
Is too dangerous to be used as routineanalgesia in the labour ward
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
SIA et al IJOA correspondence 2014 23 196-8
SSAI Malmoslash 2017
Cont infusion or PCA
bull Shen MK Wu ZF Zhu AB et al Remifentanil for labour analgesia a double-blinded randomised controlled trial of maternal and neonatal effects ofpatient-controlled analgesia versus continuous infusion (0005-02 microgkgxmin) Anaesthesia 201368(3)236-44 The results suggest thatremifentanil PCA (01-04 microgkg) provides better pain relief and similarplacental transfer compared with continuous infusion (Author)
bull Per protocol TCI Norwegian National Hospital (Oslo University Hospital)
ndash 05 ndash 2 ngml + nurse controlled boluses) ndash easier for anaesthesia personell
SSAI Malmoslash 2017
Remifentanil TCI
bull Why notbull Acta Anaesthesiol Scand 2013 Jul57(6)802-8 doi 101111aas12096 Epub 2013 Mar 15
bull Remifentanil target-controlled infusion during second stage labour in high-risk parturients a case series Schwarz GL1 Volmanen P Albrechtsen S Bjoernestad E
bull 1ngml start incremental doses of 05 ngml titrated untill satisfied mother or side-effects(1-6 ngml)
SSAI Malmoslash 2017
Why use remifentanil
The boss
SSAI Malmoslash 2017
In conclusionhellip
SSAI Malmoslash 2017
When to use it
bull For parturients with contraindications to regional analgesia
ndash Bleeding disorders
ndash Infections
ndash Mother does not want regional
bull In places with reduced anaesthesia service
SSAI Malmoslash 2017
Then remifentanil is the best choice
bull Continuous monitoring
bull Including capnography or RR counting
bull Well educated staff
SSAI Malmoslash 2017
Remifentanil PCA
bull Is cheap
bull Easy to administer
bull Gives (some) pain relief
SSAI Malmoslash 2017
BUT
bull Has a poor analgesic effect compared to thegolden standard of regional analgesia
bull May cause a lot of harm
bull Andhellip
SSAI Malmoslash 2017
AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS
Is too dangerous to be used as routineanalgesia in the labour ward
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
Cont infusion or PCA
bull Shen MK Wu ZF Zhu AB et al Remifentanil for labour analgesia a double-blinded randomised controlled trial of maternal and neonatal effects ofpatient-controlled analgesia versus continuous infusion (0005-02 microgkgxmin) Anaesthesia 201368(3)236-44 The results suggest thatremifentanil PCA (01-04 microgkg) provides better pain relief and similarplacental transfer compared with continuous infusion (Author)
bull Per protocol TCI Norwegian National Hospital (Oslo University Hospital)
ndash 05 ndash 2 ngml + nurse controlled boluses) ndash easier for anaesthesia personell
SSAI Malmoslash 2017
Remifentanil TCI
bull Why notbull Acta Anaesthesiol Scand 2013 Jul57(6)802-8 doi 101111aas12096 Epub 2013 Mar 15
bull Remifentanil target-controlled infusion during second stage labour in high-risk parturients a case series Schwarz GL1 Volmanen P Albrechtsen S Bjoernestad E
bull 1ngml start incremental doses of 05 ngml titrated untill satisfied mother or side-effects(1-6 ngml)
SSAI Malmoslash 2017
Why use remifentanil
The boss
SSAI Malmoslash 2017
In conclusionhellip
SSAI Malmoslash 2017
When to use it
bull For parturients with contraindications to regional analgesia
ndash Bleeding disorders
ndash Infections
ndash Mother does not want regional
bull In places with reduced anaesthesia service
SSAI Malmoslash 2017
Then remifentanil is the best choice
bull Continuous monitoring
bull Including capnography or RR counting
bull Well educated staff
SSAI Malmoslash 2017
Remifentanil PCA
bull Is cheap
bull Easy to administer
bull Gives (some) pain relief
SSAI Malmoslash 2017
BUT
bull Has a poor analgesic effect compared to thegolden standard of regional analgesia
bull May cause a lot of harm
bull Andhellip
SSAI Malmoslash 2017
AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS
Is too dangerous to be used as routineanalgesia in the labour ward
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
Remifentanil TCI
bull Why notbull Acta Anaesthesiol Scand 2013 Jul57(6)802-8 doi 101111aas12096 Epub 2013 Mar 15
bull Remifentanil target-controlled infusion during second stage labour in high-risk parturients a case series Schwarz GL1 Volmanen P Albrechtsen S Bjoernestad E
bull 1ngml start incremental doses of 05 ngml titrated untill satisfied mother or side-effects(1-6 ngml)
SSAI Malmoslash 2017
Why use remifentanil
The boss
SSAI Malmoslash 2017
In conclusionhellip
SSAI Malmoslash 2017
When to use it
bull For parturients with contraindications to regional analgesia
ndash Bleeding disorders
ndash Infections
ndash Mother does not want regional
bull In places with reduced anaesthesia service
SSAI Malmoslash 2017
Then remifentanil is the best choice
bull Continuous monitoring
bull Including capnography or RR counting
bull Well educated staff
SSAI Malmoslash 2017
Remifentanil PCA
bull Is cheap
bull Easy to administer
bull Gives (some) pain relief
SSAI Malmoslash 2017
BUT
bull Has a poor analgesic effect compared to thegolden standard of regional analgesia
bull May cause a lot of harm
bull Andhellip
SSAI Malmoslash 2017
AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS
Is too dangerous to be used as routineanalgesia in the labour ward
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
Why use remifentanil
The boss
SSAI Malmoslash 2017
In conclusionhellip
SSAI Malmoslash 2017
When to use it
bull For parturients with contraindications to regional analgesia
ndash Bleeding disorders
ndash Infections
ndash Mother does not want regional
bull In places with reduced anaesthesia service
SSAI Malmoslash 2017
Then remifentanil is the best choice
bull Continuous monitoring
bull Including capnography or RR counting
bull Well educated staff
SSAI Malmoslash 2017
Remifentanil PCA
bull Is cheap
bull Easy to administer
bull Gives (some) pain relief
SSAI Malmoslash 2017
BUT
bull Has a poor analgesic effect compared to thegolden standard of regional analgesia
bull May cause a lot of harm
bull Andhellip
SSAI Malmoslash 2017
AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS
Is too dangerous to be used as routineanalgesia in the labour ward
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
In conclusionhellip
SSAI Malmoslash 2017
When to use it
bull For parturients with contraindications to regional analgesia
ndash Bleeding disorders
ndash Infections
ndash Mother does not want regional
bull In places with reduced anaesthesia service
SSAI Malmoslash 2017
Then remifentanil is the best choice
bull Continuous monitoring
bull Including capnography or RR counting
bull Well educated staff
SSAI Malmoslash 2017
Remifentanil PCA
bull Is cheap
bull Easy to administer
bull Gives (some) pain relief
SSAI Malmoslash 2017
BUT
bull Has a poor analgesic effect compared to thegolden standard of regional analgesia
bull May cause a lot of harm
bull Andhellip
SSAI Malmoslash 2017
AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS
Is too dangerous to be used as routineanalgesia in the labour ward
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
When to use it
bull For parturients with contraindications to regional analgesia
ndash Bleeding disorders
ndash Infections
ndash Mother does not want regional
bull In places with reduced anaesthesia service
SSAI Malmoslash 2017
Then remifentanil is the best choice
bull Continuous monitoring
bull Including capnography or RR counting
bull Well educated staff
SSAI Malmoslash 2017
Remifentanil PCA
bull Is cheap
bull Easy to administer
bull Gives (some) pain relief
SSAI Malmoslash 2017
BUT
bull Has a poor analgesic effect compared to thegolden standard of regional analgesia
bull May cause a lot of harm
bull Andhellip
SSAI Malmoslash 2017
AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS
Is too dangerous to be used as routineanalgesia in the labour ward
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
Then remifentanil is the best choice
bull Continuous monitoring
bull Including capnography or RR counting
bull Well educated staff
SSAI Malmoslash 2017
Remifentanil PCA
bull Is cheap
bull Easy to administer
bull Gives (some) pain relief
SSAI Malmoslash 2017
BUT
bull Has a poor analgesic effect compared to thegolden standard of regional analgesia
bull May cause a lot of harm
bull Andhellip
SSAI Malmoslash 2017
AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS
Is too dangerous to be used as routineanalgesia in the labour ward
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
Remifentanil PCA
bull Is cheap
bull Easy to administer
bull Gives (some) pain relief
SSAI Malmoslash 2017
BUT
bull Has a poor analgesic effect compared to thegolden standard of regional analgesia
bull May cause a lot of harm
bull Andhellip
SSAI Malmoslash 2017
AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS
Is too dangerous to be used as routineanalgesia in the labour ward
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
BUT
bull Has a poor analgesic effect compared to thegolden standard of regional analgesia
bull May cause a lot of harm
bull Andhellip
SSAI Malmoslash 2017
AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS
Is too dangerous to be used as routineanalgesia in the labour ward
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
AND SHOULD BE RESERVED FOR THE SPECIAL OCCATIONS
Is too dangerous to be used as routineanalgesia in the labour ward
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
Thank you
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017
Large randomized prospective trials are required before it may be recommended for routine use in labouring women copy 2013 Elsevier Ltd
Lim LFM Leo S Role of remifentanil in labour analgesia Trends in Anaesthesia and Critical Care 20133(3)152-6
SSAI Malmoslash 2017