Labour analgesia - epidural or alternatives ? Thierry Girard Basel, Switzerland CONFLICT OF INTEREST Smiths-medical Cochrane Database Syst Rev. 2011;(12):CD000331. Epidural versus non-epidural or no analgesia in labour (Review) Anim-Somuah M, Smyth RMD, Jones L This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2011, Issue 12 http://www.thecochranelibrary.com Epidural versus non-epidural or no analgesia in labour (Review) Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Inhaled analgesia for pain management in labour (Review) Authors’ conclusions Klomp T, van Poppel M, Jones L, Lazet J, Di Nisio M, Lagro-Janssen ALM Inhaled analgesia appears to be effective in reducing pain intensity and in giving pain relief in labour. ... nitrous oxide appears to result in even more side effects such as nausea, vomiting, dizziness and drowsiness... This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2012, Issue 9 http://www.thecochranelibrary.com Inhaled analgesia for pain management in labour (Review) Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. http://tinycheese.blogspot.com/2010_06_01_archive.html INCREDIBLE PAIN continued all night - I eventually got on Remifentanil - the new morphine based drug which you self-administer, dosing yourself when you need it. It was absolutely WONDERFUL. Didn't actually stop you feeling pain but does stop you caring about it. I got absolutely sky high, thoroughly amused the midwife by talking utter rubbish, …., I even started seeing things - including Nelson Mandela on a bicycle... blooming weird but there you go. CE: Madhur; EJA/200723; Total nos of Pages: 9; EJA 200723 ORIGINAL ARTICLE Remifentanil for labour analgesia: a meta-analysis of randomised controlled trials Alexander Schnabel, Niklas Hahn, Jens Broscheit, Ralf M. Muellenbach, Lorenz Rieger, Norbert Roewer and Peter Kranke CE: Madhur; EJA/200723; Total nos of Pages: 9; EJA 200723 Context Remifentanil is a potent short-acting m-opioid receptor had higher satisfaction scores (P < 0.05) in comparison with agonist which is rapidly metabolised in the mother and fetus and women receiving pethidine. Epidural analgesia decreased pain may be ideal for labour analgesia. scores compared with remifentanil (P 0.003). There was only ¼ Objectives To assess efficacy and safety of remifentanil a limited amount of data comparing remifentanil with nitrous compared with other analgesic techniques for labour pain. oxide or fentanyl. Serious maternal or fetal adverse outcomes ORIGINALData sources We ARTICLE systematically searched the central register were not reported in these trials. of controlled trials of the Cochrane Library (till August 2011) and Conclusion During labour, remifentanil-PCA provided superior MEDLINE (till August 2011). analgesia and higher patient satisfaction compared with RemifentanilEligibility criteria Randomised for controlled labour trials analgesia: investigating pethidine a meta-analysis with a comparable degree of adverse of events. Epidural randomisedefficacy and safety of remifentanil controlled administered trials via a patient- analgesia provided superior pain relief in comparison with Alexandercontrolled Schnabel, analgesia (PCA) Niklas device Hahn, compared Jens Broscheit, with any other Ralf M.remifentanil. Muellenbach, Due toLorenz a low number Rieger, of reported adverse events, analgesic technique for labour pain were included. the safety issue of remifentanil use in labour remains an open Norbert Roewer and Peter Kranke Results We finally included 12 randomised controlled trials question that needs to be addressed in future trials. (published from 2001 to 2011). Women treated with Eur J Anaesthesiol 2012; 29:000–000 Context Remifentanil is a potent short-acting m-opioid receptor had higher satisfaction scores (P < 0.05) in comparison with remifentanil had a lower risk of conversion to epidural analgesia Keywords: analgesia, epidural analgesia, labour, patient-controlled agonist(P < which0.001), is rapidly a lower metabolised mean pain score in the motherafter 1 h and (P < fetus0.001) and and womenanalgesia, receiving pethidine, pethidine. remifentanil Epidural analgesia decreased pain may be ideal for labour analgesia. scores compared with remifentanil (P 0.003). There was only ¼ Objectives To assess efficacy and safety of remifentanil a limited amount of data comparing remifentanil with nitrous compared with other analgesic techniques for labour pain. oxide or fentanyl. Serious maternal or fetal adverse outcomes DataIntroduction sources We systematically searched the central register wereRemifentanil not reported in is these an ultra-short-acting trials. m-1 opioid receptor of controlledSome of trials the of most the Cochrane common Library anaesthetic(till August procedures 2011) and per- ConclusionagonistDuring with an labour, onset remifentanil-PCA time of 30–60 provided s, and peak superior effect MEDLINEformed(till are August interventions 2011). to relieve labour pain. Several analgesiaafter and2.5 min. higher5 Due patient to satisfaction fast metabolism compared through with plasma Eligibilitysurveys criteria haveRandomised shown that thecontrolled right timing trials investigating and availability pethidineand tissue with a esterases, comparable remifentanil degree of adverse offers events. the advantage Epidural of efficacyof analgesia and safety – of independent remifentanil administered of the mode via a of patient- analgesia analgesiaa short provided half-life. superior6 Furthermore, pain relief in it comparison has a short with context- controlleditself –analgesia are very (PCA) important device factors compared for with maternal any other satisfac- remifentanil.sensitive Due half-life to a low (3.5 number min) ofand reported can be adverse used over events, a long analgesiction.1 techniqueAccording for labour to the pain guidelines were included. of the American the safetyperiod issue without of remifentanil fear of use accumulation. in labour remains7 Remifentanil an open ResultsSocietyWe finally of Anesthesiologists included 12 randomised (ASA) controlled and the trials American questionrapidly that crosses needs to the be placenta, addressed but in future it is trials. metabolised and (publishedCollege from of 2001 Obstetricians to 2011). Women and Gynecologists treated with (ACOG), Eurredistributed J Anaesthesiol very2012; quickly 29:000–000 by the fetus.8 Due to its remifentanilepidural had analgesia a lower risk is of recommended conversion to epidural in labour analgesia as the Keywords:unique analgesia, pharmacodynamic epidural analgesia, and labour, pharmacokinetic patient-controlled profile, (P <‘most0.001), flexible, a lower mean effective pain score and after least 1 h depressing (P < 0.001) and to the analgesia,remifentanil pethidine, remifentanil may be the best opioid for labour analgesia. central nervous system’ of the choices available.2 How- Its use during labour is gaining in popularity,9 although ever, obstetric anaesthesiologists are occasionally faced pethidine, despite its poor efficacy and known adverse with absolute or relative contraindications: women with effects on the newborn, remains the most popular Introductiona higher risk for thrombosis or thromboembolism (e.g. Remifentanilsystemic analgesic is an ultra-short-acting for labour pain.m-110,11 opioidThe receptor aim of this Somefactor of the V mutation) most common receiving anaesthetic prophylactic procedures anticoagulants per- agonistmeta-analysis with an onset was time to assess of 30–60 the efficacy s, and peak and effect safety of formedduring are interventions pregnancy or to with relieve former labour congenital pain. Several heart afterremifentanil 2.5 min.5 Due patient-controlled to fast metabolism infusion through compared plasma with surveyscorrection have shown surgery that who the rightneed timing lifelong and anticoagulation availability 3 andother tissue analgesic esterases, techniques remifentanil for offers labour the pain. advantage of of analgesiaor with obesity – independent and diabetes. of the4 Women mode may of analgesia also ask for a short half-life.6 Furthermore, it has a short context- itselfalternatives – are very to important central neuraxial factors for analgesia maternal because satisfac- they sensitiveMethods half-life (3.5 min) and can be used over a long tion.do1 notAccording (yet) want to this the type guidelines of pain relief. of the Therefore, American there periodThis without meta-analysis fear of was accumulation. in accord with7 Remifentanil the Preferred Societyis a need of Anesthesiologists for effective and well (ASA) tolerated and the systemic American analge- rapidlyReporting crosses Items the placenta, for Systematic but it is reviewsmetabolised and and Meta- Collegesics for of labour Obstetricians pain to andprovide Gynecologists an alternative (ACOG), to central redistributedAnalyses (PRISMA) very quickly statement. by the12 fetus.8 Due to its epiduralneuraxial analgesia analgesia. is recommended in labour as the unique pharmacodynamic and pharmacokinetic profile, ‘most flexible, effective and least depressing to the remifentanilSearch strategy may be the best opioid for labour analgesia. 2 9 centralFrom thenervous Department system’ of Anaesthesiology of the choices and Intensive available. Care, UniversityHow- Hospital of Its useThe during systematic labour