Is breakthrough pain better managed by adding programmed intermittent epidural bolus to a background infusion during labor epidural analgesia? A randomized controlled trial

BACKGROUND Breakthrough pain (BTP) is a common problem during labor analgesia. Programmed intermittent epidural bolus (PIEB) has demonstrated superior to background epidural infusion (BEI) concerning BTP, but the effect of combining both modes remains unknown. We hypothesized that this combination could reduce BTP incidence. METHODS Nulliparous parturients with early cervical dilation were randomized to receive 5 mL/h BEI of levobupivacaine 0.125% plus fentanyl 1.45 µg/mL (standard group) or 5 mL/h BEI + 10 mL/h PIEB (PIEB group). In case of BTP, patient-controlled epidural analgesia (PCEA) boluses of 10 mL (20-min lockout interval) were administered. If PCEA was insufficient, a 10-mL clinician bolus was delivered. The primary endpoint was the percentage of parturients who required supplementary epidural boluses. RESULTS One hundred and twenty women were recruited. Eighty-nine percent of parturients required supplementary boluses in standard group versus 30% in PIEB group (RR=3.07; 95% CI: 1.99-4.76; P