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    Does patient-controlled analgesia have benefits over an epidural? Plus CKD research

    COG-SpecialDelivery-Issue_2641.jpg

    A large multicenter randomized controlled trial has tested the hypothesis that a potent, ultra-short-acting synthetic opioid might provide pain relief equivalent to that for an epidural. But the results—the first from a well-powered study in this area—suggest caution in use of a patient-controlled form of analgesia perceived to be safe but with significant side effects.

    More: What's behind the wide variation of US cesarean delivery rates?

    Researchers performed the trial at 15 hospitals in the Netherlands, enrolling 1414 women with intermediate to high obstetric risk who had the intention of delivering vaginally. The participants were randomized to either patient-controlled remifentanil (n = 709) or epidural analgesia (n = 705) if they requested pain relief during labor. Baseline characteristics were comparable across both groups. Satisfaction with pain relief was expressed as area under the curve (AUC), with higher AUC equaling more satisfaction with pain relief.

    Pain relief was requested by 65% of the remifentanil group and 52% of the epidural analgesia group (relative risk 1.32, 95% confidence interval 1.18 to 1.48) with cross over in 7% and 8%, respectively. In the remifentanil group, 13% were converted to epidural analgesia, while 1% in the epidural anesthesia group converted to remifentanil. The AUC for total satisfaction with pain relief in the remifentanil group was 30.9 versus 33.7 in the epidural analgesia group. The rate of cesarean delivery was 15% in both groups.

    Oxygen saturation was lower in the remifentanil group (relative risk 1.5, 1.4 to 1.7), at <92% in 18% and <95% in 38% versus 5% and 12% of the epidural group. Four women in the remifentanil group also had respiratory depressions <8 breaths a minute, versus none who received epidurals. Duration of the second stage of labor was significantly shorter with remifentanil versus epidural (median duration 25, interquartile range 11-51 versus 34, 15-60; P=0.01)

    Researchers considered the main weakness of the study to be the number of missing values for satisfaction with pain relief and pain intensity. The AUC for pain relief satisfaction during active labor was 57% in the remifentanil group and 43% in the epidural group. Among those who did receive pain relief, the AUCs were 71% and 57% respectively. The researchers also performed a similar study on women who were considered low-risk and the data for that population are currently being analyzed.

    NEXT: Does kidney disease increase the risk of adverse pregnancy outcomes?

    Miranda Hester
    Ms. Hester is Content Specialist with Contemporary OB/GYN and Contemporary Pediatrics.

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