Anaesthesia 2013, 68, 267275

doi:10.1111/anae.12093

Original Article
A randomised comparison of variable-frequency
automated mandatory boluses with a basal infusion for
patient-controlled epidural analgesia during labour and
delivery
A. T. Sia,1 S. Leo2 and C. E. Ocampo3
1 Chairman Medical Board and Senior Consultant, 2 Consultant, 3 Senior Resident Physician, Department of Womens
Anaesthesia, KK Womens and Childrens Hospital, Singapore

Summary
This trialwas conductedtocompare the analgesic effcacyof administeringvariable-frequencyautomatedboluses ata rate
proportional to the patients needs with fxed continuous basal infusion in patient-controlled epidural analgesia (PCEA)
during labour and delivery. We recruited a total of 102 parturients in labour who were randomly assigned to receive
either anovelPCEAwithautomatedmandatorybolusesof5 mladministeredonce,twice,threeorfourtimesperhourdepending
on the history of the parturients analgesic demands over the past hour (Automated bolus group), or a conventional
PCEA with a basal infusion of 5 ml.h 1 (Infusion group). The incidence of breakthrough pain requiring supplementation
by an anaesthetist was signifcantly lower in the Automated bolus group, three out of 51 (5.9%) compared with the
Infusion group, 12 out of 51 (23.5%, p = 0.023). The time-weighted mean (SD) hourly consumption of ropivacaine was
similar in both groups, 10.0 (3.0) mg in the Automated bolus group vs 11.1 (3.2) mg in the Infusion group (p = 0.06).
Parturients from the Automated bolus group reported higher satisfaction scores compared with those in the Infusion
group, 96.5 (5.0) vs 89.2 (9.4), respectively (p < 0.001). There was no difference in the incidence of maternal sideeffects and obstetric and neonataloutcomes.
.................................................................................................................................................................

Correspondence to: S. Leo

Email: danxer159@yahoo.com.sg
Accepted: 24 October 2012

extensive research over the last decade, the optimal

PCEA program settings have not been elucidated. In
particular, there have been conficting results in the

Patient-controlled epidural analgesia (PCEA) is a mode

of labour epidural drug delivery that confers greater
autonomy and fexibility by enabling the parturient to
self-administer boluses of epidural solution as
necessary. Several studies have affrmed the advantages
of PCEA over a conventional epidural infusion and it
has become established as a safe and effcacious mode
of labour epidural drug delivery [13]. However, despite

literature with regard to the merit of administering a

basal infusion as well as an optimal infusion rate [48].
At our institution we postulated that, although a basal
infusion may not be benefcial in early labour, its role
may become increasingly important as pain intensifes
with the progress of labour. This led to the creation of a
computer-integrated PCEA program, which could
analyse the parturients demand boluses over the last
hour and adjust its infusion rate proportionally,

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2013, 68, 267275

essentially operating on an auto regulatory feedback

loop. Results from initial trials utilising the computerintegrated PCEA program were encouraging,
demonstrating a reduced incidence of breakthrough pain
and greater maternal satisfaction with no increase in
total local anaesthetic consumption [911].
Studies in the past have suggested that maintaining
labour analgesia using regular intermittent epidural
boluses instead of a slow continuous infusion can be
more effcacious [1214]. This may be attributed to a
more extensive spread of epidural solution when
delivered as a bolus rather than as a steady infusion [15,
16]. When incorporated into a PCEA regimen and used
in place of a continuous basal infusion, automated
intermittent boluses have been shown to reduce overall
local anaesthetic consumption without compromising
analgesic effcacy [17, 18].
The purpose of our current trial was to combine the
above concepts by administering variable-frequency
automated boluses at a rate proportional to the patients
needs, in place of a fxed continuous basal infusion in a
PCEA regimen. We designed a complex software
program that enables an ordinary syringe pump to
function as a PCEA pump with the ability to deliver
variable-frequency automated mandatory boluses in
addition to patient-driven PCEA boluses. This was
compared with a conventional PCEA using a basal
infusion, which is the standard regimen used at our
institution. Our primary outcome measure was the
incidence
of
breakthrough
pain
requiring
supplementation by an anaesthetist.

Methods
This study was conducted with the approval of the
Hospital Ethics Committee and written informed
consent was obtained from every parturient who
participated in the study. We recruited 102 healthy (ASA
physical status 1) nulliparous parturients at term (> 36
weeks, gestation) with a singleton fetus, who were in
early labour (cervical dilation < 5 cm) and who had
requested labour epidural analgesia.
Parturients with multiple pregnancies, non-cephalic
fetal presentation and obstetric complications (e.g. preeclampsia and premature rupture of amniotic
membranes) were not studied. Parturients who had

contraindications to neuraxial blockade or who had

received parenteral opioids within the last 2 h were also
not studied.
After establishing intravenous access, the cuff of a
non-invasive blood pressure monitor (Dinamap,
Critikon, FL, USA) was applied over the parturients
right brachial artery. Baseline systolic blood pressure
and heart rate were measured in the supine position with
left uterine displacement. Each parturient was preloaded
with 500 ml intravenous Ringers lactate solution. A
baseline visual analogue pain score (VAS) on a 010 cm
scale was obtained from the parturient during a uterine
contraction, and only those who had a VAS > 3 cm
were entered into the study. Pre-block data such as the
cervical dilation before neuraxial blockade, use of
cervical prostaglandin E2 for induction of labour,
artifcial rupture of membranes and administration of
oxytocin infusion for labour augmentation were
recorded.
Combined spinalepidural (CSE) analgesia was
explained to each parturient and informed consent
obtained as per the institution protocol. All neuraxial
blocks were performed by a single operator at the L34
interspace using the needle-through-needle technique
with the patient sitting. The epidural space was located
with an 18-G Tuohy needle (Espocan; B. Braun,
Melsungen, Germany) using loss of resistance to < 2
ml saline. A 27-G pencil-point needle was then used to
puncture the dura mater and free fow of cerebrospinal
fuid (CSF) was confrmed before a standard intrathecal
dose of ropivacaine 2 mg (Naropin; Astra Zeneca,
Sodertalje, Sweden) and fentanyl 15 lg (David Bull
Laboratories, Melbourne, Australia) was injected over
15 s with the needle orifce facing cephalad. A multiorifce catheter (Perifx; B. Braun) was inserted into
the epidural space to a distance of 4 cm. A test dose of 3
ml lidocaine 1.5% (Xylocaine; Astra Zeneca) was
administered through the catheter following negative
aspiration for blood and CSF. The patient was then
placed supine with left uterine displacement and the
post-block profle was recorded. If a profound motor
block (defned as inability to fex either knee) or
signifcant hypotension (reduction in systolic blood
pressure > 30%) developed within the next 15 min, the
patient was withdrawn from the study in case this was
due to intrathecal catheter misplacement. Patients with a
recognised accidental dural puncture, intravascular

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2013, 68, 267275

catheter placement and those in whom there was a failed

spinal (defned as failure to obtain CSF backfow
following two dural punctures with the spinal needle)
were also not studied and were managed according to
departmental protocols.
The parturients were randomly allocated into two
groups using sealed opaque envelopes and
computergenerated random number tables by a different
investigator, who then programmed the epidural drug
delivery system according to the group assignment. The
parturients were subsequently monitored by a second
anaesthetist who was not involved in performing the
block. Neither the parturient nor the anaesthetist who
recorded the post-block data was aware of the group
assignment.
The parturients received 0.1% ropivacaine +
fentanyl 2 lg.ml1 via one of two regimens for
maintenance of labour epidural analgesia:
1

Automated bolus group: a PCEA algorithm as

illustrated in Fig. 1 was used, initiated immediately

after the completion of CSE. The pump was

designed to administer automated boluses of 5 ml in
addition to the patient-controlled boluses. The
frequency of such automated boluses was dependent
on the history of the patients analgesic requirement
over the past hour. The frst automated bolus was
programmed to be delivered 60 min from time 0 and
every hour thereafter if no PCEA patient-bolus was
made (one automated bolus of 5 ml every hour). At
the frst activation of a PCEA patient-bolus, the
timer would be reset with the subsequent automated
bolus delivered 30 min following the PCEA patientbolus, and every hour thereafter if no further PCEA
patientbolus was made (one automated bolus of 5 ml
every hour). If there was a second PCEA
patientbolus in that same hour after the initial bolus,
the time interval between two automated boluses
would be shortened to 30 min (two automated
boluses of 5 ml every hour). If there was a third
PCEA patient-bolus within that hour, the automated
bolus
Figure 1 Schematic representation of the algorithm for
dose adjustment in the variable-frequency automated
mandatory bolus regimen.
would be delivered at 20-min intervals (three
automated boluses of 5 ml every hour). A fourth
PCEA patient-bolus within the same hour would
further shorten the time interval between two
automated boluses to 15 min (four automated
boluses of 5 ml every hour). On the other hand, if
there were no patient-bolus for 60 min, the
frequency of automated boluses would step down in
the reverse fashion. The lockout period for both
PCEA and automated boluses was 10 min. If a
PCEA demand was made within 10 min of an
automated bolus, no patient-bolus would be given
and this would be recorded as an unsuccessful PCEA
attempt. The PCEA demand bolus was set at 5 ml
with a maximum hourly limit of 20 ml.h1 (inclusive
of automated boluses).
2

Infusion group: PCEA with basal infusion 5 ml.h1

initiated immediately following intrathecal drug
administration (noted as time 0). The PCEA demand
bolus was set at 5 ml, lockout interval at 10 min and

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Anaesthesia 2013, 68, 267275 Sia et al. | Comparison of variable-frequency mandatory boluses with
basal infusion for PCEA

maximum dose at 20 ml.h1 (inclusive of

background infusion).
Our institution collaborated with computer
engineers to create a software program that allowed
an ordinary syringe driver to function as a PCEA
with the ability to deliver background mandatory
boluses in addition to patient-demand boluses. We
developed an epidural drug delivery system utilising
a Hewlett Packard Compaq 2710p Tablet PC
operating on Microsoft Windows XP Tablet PC
Edition 2005 (Microsoft, Redmond, WA, USA)
connected to a modifed Perfusor Compact S
infusion pump (B. Braun) (Fig. 2). Program source
codes for both the automated bolus and basal
infusion PCEA regimens were loaded into the Tablet
PC. The two-way communication between the pump
and the HP Tablet PC was accomplished by
connecting the pump serial ports to the USB port on
the Tablet PC. The 5-ml automated boluses as well
as PCEA demand boluses were time-cycled, based
on an infusion rate of 100 ml.h1 and required 3 min
to complete. Both programs underwent rigorous in
vitro testing at our institutions Biomedical
Engineering Unit and by all investigators
independently before being applied to patients in a
clinical setting.
Once the parturient reported a VAS < 3 cm 15
min after CSE, she was given the hand set and
instructed to self-administer a PCEA bolus by
pressing the button on the device when she
experienced a recurrence of pain. She was instructed

Figure 2 The patient-controlled epidural analgesia

system utilising a Hewlett Packard Compaq Tablet PC
connected to a modifed B. Braun Perfusor Compact S
infusion pump. The program source codes for both the
270

to activate the PCEA bolus if the pain was mild and

before it increased in severity. She was informed about
the purpose of a lockout period and maximum hourly
dose limit. Parturients who did not obtain satisfactory
pain relief (defned as VAS < 3 cm) 15 min after CSE
were deemed to have an ineffective spinal. The epidural
catheter would then be used to administer rescue
analgesia and the patient removed from the study.
Post-block parameters were monitored by a separate
blinded anaesthetist after the procedure. Maternal
systolic blood pressure and heart rate were monitored
every 5 min for the frst 30 min and subsequently at 2-h
intervals until delivery. Maternal VAS was monitored at
15 and 30 min from time 0 and subsequently at 2-h
intervals until delivery. Maternal sensory block height
(loss of cold sensation to ice tested at the midclavicular
line bilaterally) was monitored at 15 and 30 min from
time 0 and subsequently at 2-h intervals until delivery.
The degree of maternal lower limb motor block was
monitored at 15 and 30 min from time 0 and
subsequently at 2-h intervals until delivery, based on the
modifed Bromage scale (0 = no motor block, 1 =
unable to fex either hip, but able to move knee and
ankle joints, 2 = unable to fex hip and knee joint of
either limb, but able to move ankle joints, 3 = unable to
move hip, knee or ankle joint of either limb). The
occurrence of post-block maternal sideeffects such as
shivering, nausea, vomiting, pruritus, maternal pyrexia,
signifcant maternal hypotension (systolic BP < 90
mmHg or > 20% decrease from baseline) and fetal
bradycardia requiring review by an
variable-frequency automated mandatory bolus and the
background infusion regimens are loaded into the Tablet
PC.
obstetrician were documented. Treatment for maternal
hypotension and fetal bradycardia was administered as
per institution protocol, i.e. intravenous adrenaline in 5mg aliquots if maternal hypotension was present, and
intravenous terbutaline 0.25 mg if uterine
hyperstimulation was diagnosed. Continuous fetal heart
rate monitoring was maintained throughout the labour.
The parturient was instructed to inform the
attending anaesthetist if she experienced inadequate
pain relief (VAS 3 cm) during PCEA. In this case,
additional pain relief was administered by the

Anaesthesia 2012 The Association of Anaesthetists of Great Britain and Ireland

Sia et al. | Comparison of variable-frequency mandatory boluses with basal infusion for PCEA Anaesthesia
2013, 68, 267275

anaesthetist via the epidural catheter and an episode of

breakthrough pain was recorded. According to
departmental guidelines, the attending anaesthetist
would administer epidural 0.2% ropivacaine in 5-ml
aliquots every 10 min (up to a maximum of 20 ml) until
VAS decreased to < 3 cm. Fentanyl 50 lg was added if
the VAS remained 3 cm after 10 ml epidural 0.2%
ropivacaine had been given. The pumps were paused for
the duration of time taken to administer each clinician
bolus, and resumed immediately afterwards. Such
anaesthetist-administered manual boluses did not affect
the PCEA pump settings in any way. The episode of
breakthrough pain was concluded once the parturient
reported a VAS < 3 cm. The following data were
recorded at each episode of breakthrough pain: time of
occurrence; pain score; cervical dilation; use of
oxytocin; and total dose of epidural medication needed
to abolish the pain. If the epidural top-up failed to
achieve adequate analgesia (defned as VAS < 3 cm),
the catheter was deemed ineffective and the parturient
would be removed from the study.
Obstetric and neonatal outcomes such as the mode
of delivery, indication for instrumental or caesarean
delivery, duration of second stage of labour and neonatal
Apgar scores at 1 and 5 min were noted. The parturient
was interviewed within 24 h of delivery by a separate
anaesthetist not involved in the study for an overall
assessment of her satisfaction with labour analgesia
(graded on a verbal scale from 0 = very dissatisfed to
100 = extremely satisfed).
A sample size of 49 patients in each group was
required to detect an 80% reduction in the incidence of
breakthrough pain requiring physician top-up for
patients in the Automated bolus group compared with
those in the Infusion group (a = 0.05, b = 0.2). A
reduction in the incidence of breakthrough pain from a
baseline of 25% at our institution to 5% was deemed
clinically signifcant as this could potentially improve
patient satisfaction and reduce clinician workload. All
data and statistical analyses were managed with SPSS
version 15 (SPSS Inc., Chicago, IL, USA). Students ttest was used for the analysis of continuous data, which
was normally distributed and the MannWhitney test
employed for non-continuous data. For categorical data
and proportions, the chi-squared test with Yates

correction (where appropriate) was applied. For analysis

of serial measurements such as pain scores and sensory
levels, the mixed model repeated measurement analysis
technique with a compound symmetry covariance
structure for the data points was employed to adjust for
missing data at time intervals after the parturients had
delivered and the epidural infusion had been stopped.

Results
All 102 recruited parturients completed the study (Fig.
3). Baseline demographic and pre-block obstetric data
were similar for parturients in both groups (Table 1).
None of the patients had a failed spinal or an ineffective
epidural catheter. No parturients had intravascular
misplacement of the epidural catheter or accidental
dural puncture.
The incidence of the primary study outcome,
breakthrough pain requiring epidural top-up by an
attending anaesthetist, was signifcantly lower in the
Automated bolus group with three patients (5.9%)
compared with the Infusion group with 12 patients
(23.5%, p = 0.023). There were two patients in the
Infusion group who experienced two episodes of
breakthrough pain, of whom one delivered vaginally
and the other underwent caesarean delivery for poor
progress of labour. The patient profles at the time of
breakthrough pain are shown in Table 2.
The improved analgesic effcacy in the Automated
bolus group was achieved without any signifcant
difference in the amount of local anaesthetic consumed.
The time-weighted mean hourly consumption of
ropivacaine, inclusive of clinician-administered
supplemental boluses, was similar in both groups, 10.0
(3.0) mg in the Automated bolus group vs 11.1 (3.2) mg
in the Infusion group (p = 0.06). There was no
difference in the total amount of ropivacaine used, 62.0
(32.6) mg in the Automated bolus group vs 74.2 (34.0)
mg in the Infusion group (p = 0.07). The time to frst
patientdemand bolus following CSE was similar, 115.8
(65.2) min in the Automated bolus group vs 112.1 (70.4)
min in the Infusion group (p = 0.78).
Mixed model repeated measurement analysis did
not detect any difference in post-block serial pain scores
(p = 0.146 for the interactive term of group and VAS
score) or sensory levels (p = 0.619 for the interactive

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Anaesthesia 2013, 68, 267275 Sia et al. | Comparison of variable-frequency mandatory boluses with
basal infusion for PCEA

term of group and hourly block height), although this

could be due to the studys not being adequately
powered for these comparisons. Maternal side-effects
experienced were also similar in both groups (Table 3).
One parturient from the Infusion group had hypotension
that resolved following administration of intravenous
ephedrine 5 mg. Two patients in the Automated bolus
group had fetal bradycardia,

one resolving spontaneously and the other requiring

intravenous terbutaline 0.5 mg. Two patients in the
Infusion group had fetal bradycardia requiring
administration of intravenous terbutaline 0.25 mg. None
of these four parturients required an emergency
caesarean section.
Parturients in both groups had a similar mean
duration of labour. There was no difference in the

Figure 3 Enrolment fow diagram.

Table 1 Baseline characteristics and obstetric data of 102 parturients before combined spinalepidural insertion and
random assignment to PCEA with an automated bolus or basal infusion. Values are mean (SD) or number (proportion).
Automated bolus
(n = 51)
BMI; kg.m2
Cervical dilation pre-block; cm
Maternal systolic BP; mmHg
Maternal diastolic BP; mmHg
Maternal heart rate; beats.min1
Fetal heart rate; beats; min1
Pain VAS; cm
Using Entonox
Previous use of pethidine; > 2 h
Oxytocin infusion
Previous use of prostaglandin E2
Artifcial rupture of membranes

BP, blood pressure; VAS, visual analogue score.

272

27.3 (3.9)
3.2 (0.7)
113.8 (10.6)
67.8 (9.5)
76.0 (10.1)
139.4 (10.1)
8.0 (1.7)
28 (55.0%)
4 (7.8%)
18 (35.3%)
23 (45.1%)
33 (64.7%)

Infusion
(n = 51)
28.2 (4.9)
3.2 (0.9)
115.9 (11.9)
68.4 (9.3)
79.2 (13.2)
141.2 (11.1)
7.8 (1.5)
24 (47.1%)
6 (11.8%)
14 (27.5%)
20 (39.2%)
28 (54.9%)

duration of the second stage of labour amongst

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Sia et al. | Comparison of variable-frequency mandatory boluses with basal infusion for PCEA Anaesthesia
2013, 68, 267275

parturients who delivered vaginally, either with or

without instrumental assistance. This was in spite of the
signifcantly higher mean rate of machine-delivered
epidural

When asked to rate their overall labour analgesia

experience, parturients in the Automated bolus group
reported higher satisfaction scores compared with those
in the Infusion group, 96.5 (5.0) vs 89.2 (9.4)

Table 2 Analgesic and obstetric profle of parturients assigned to PCEA with an automated bolus or basal infusion, at
the time that breakthrough pain was experienced. Values are median (IQR [range]).
Automated
bolus (n = 3)
Time to 1st breakthrough pain; min

Infusion
(n = 12)

205 (139555 [139555])

Volume of epidural solution infused

at 1st breakthrough pain; ml
Cervical dilation at 1st breakthough pain; cm
VAS at 1st breakthrough pain; cm
Oytocin infusion at 1st breakthrough pain; ml.h 1
Sensory level at 1st breakthrough pain
Bromage score at 1st breakthrough pain

25 (1565 [1565])
6 (37 [37])
6 (66 [66])
18 (1242 [1242])
T8 (T6T10 [T6T10])
0 [00]

p
value*
286.5 (164391 [145630]) 0.99
47.5 (3465 [20100])
6.5 (58 [310])
7.5 (69 [510])
12 (027 [072])
T8 (T7T10 [T6T10])
0 [00]

0.25
0.42
0.12
0.30
0.89
1.0

*Non-parametric tests were applied owing to the small number of patients with breakthrough pain.

Table 3 Side-effects of combined spinalepidural in

102 parturients assigned to PCEA with an automated
bolus or basal infusion. Values are number (proportion).

respectively (p < 0.001).

Discussion

In this study, we demonstrated that using

variablefrequency automated intermittent boluses in
Shivering
23 (45.1%)
26 (51.0%)
place of a continuous basal infusion in PCEA for labour
Pruritus
29 (56.9%)
27 (52.9%) 0.84
analgesia resulted in a reduced incidence of
Nausea
1 (2.0%)
1 (2.0%)
1.0
breakthrough
Vomiting
1 (2.0%)
2 (3.9%)
1.0
Maternal pyrexia
3 (5.9%)
4 (7.8%)
1.0
pain requiring supplementation by the anaesthetist and
Maternal
0
1 (2.0%)
1.0
greater overall maternal satisfaction, without any
hypotension
increase in local anaesthetic consumption.
Fetal bradycardia
2 (3.9%)
2 (3.9%)
1.0
The role of a basal infusion in PCEA has long been
medication in the Automated bolus group, 10.9 (4.5)
a topic of debate. On one hand, studies have shown that
ml.h1 compared with the mean background infusion rate
PCEA with a basal infusion can reduce the incidence of
of 4.8 (1.0) ml.h1 in the Infusion group at full cervical
breakthrough pain and reduce pain scores with no
dilation (p < 0.001). Two parturients in the Infusion
increase in local anaesthetic consumption compared
group had their epidural infusion stopped by the
with a demand-only PCEA [46]. On the other hand,
obstetrician during the second stage of labour and their
some investigators found that using a basal infusion in a
data were analysed up to the point of cessation of
PCEA regimen may increase local anaesthetic
analgesia. Neonatal outcomes such as birth weight and
consumption without improving analgesic effcacy [7,
Apgar scores were similar (Table 4).
8]. However, a constant background infusion may not be
Table 4 Obstetric and neonatal outcomes in 102 parturients. Values are mean (SD), number (proportion) or median
(IQR [range]).
Automated
Infusion
bolus (n = 51) (n = 51)

p
value
0.69

Automated
bolus (n = 51)
Duration of labour; min
Duration of 2nd stage; min
Rate of machine-delivered
epidural medication during
2nd stage of labour; ml.h1
Mode of delivery
Normal
Instrumental

389.4 (202.9)

414.2 (181.3)

69.8 (48.9)
10.9 (4.5)

84.9 (57.9)
4.8 (1.0)

33 (64.7%)
5 (9.8%)

Caesarean
13 (25.5%)
Anaesthesia
2012 The Association of Anaesthetists of Great
Britain and Ireland
Neonatal birthweight; g
Neonatal Apgar score at 5 min
Satisfaction score

Infusion
(n = 51)

3244.4 (392.5)
9 (99 [79])
96.5 (5.0)

p value
0.52
0.22
<
0.001

32 (62.7%)
8 (15.7%)

0.65

11 (21.6%)

273
0.08
1.00
<
0.001

3083.5 (502.9)
9 (99 [99])
89.2 (9.4)

Anaesthesia 2013, 68, 267275 Sia et al. | Comparison of variable-frequency mandatory boluses with
basal infusion for PCEA

ideal as it cannot be responsive to the dynamic and

progressive nature of labour pain. This spurred us to
create a novel computer-integrated PCEA program that
analyses the number of patientdemand boluses over the
past hour and adjusts its basal infusion rate according to
the mothers analgesic requirements [9]. The basal
infusion is initiated by the parturient after her frst
demand bolus. Earlier studies that compared this
interactive computer-integrated PCEA program to
conventional PCEA regimens demonstrated similar
analgesic effcacy and greater maternal satisfaction with
the computer-integrated PCEA, without increasing the
total amount of local anaesthetic consumed [10, 11].
However, these studies were not powered to detect a
difference in the incidence of breakthrough pain
requiring supplementation by an anaesthetist.
Previous experiments have also suggested that
administering epidural drugs in the form of regular
intermittent boluses instead of a slow continuous
infusion may be more effcacious. In a study on human
cadavers, Hogan [15] found that intermittent boluses
that were delivered at higher infusion pressures could
result in a more uniform spread of medication within the
epidural space compared with a continuous infusion
delivered at lower pressures. In a laboratory experiment
using multi-orifce epidural catheters, Kaynar et al. [16]
demonstrated that administering a slow continuous
infusion at low injection pressures resulted in fow of
solution primarily through the proximal hole with none
fowing through the distal hole. In contrast, when the
solution was delivered by a bolus at higher injection
pressures, there was fow through all the catheter ports.
This could translate into improved quality of block in a
clinical setting where multi-orifce catheters are used.
Experimental evidence has been applied successfully in
clinical practice through several studies that have
demonstrated that intermittent epidural boluses given in
place of a continuous infusion can decrease the
incidence of breakthrough pain and increase maternal
satisfaction [1214]. The automated mandatory bolus
concept has also been incorporated successfully into
PCEA regimens, conferring similar analgesic effcacy
with lower local anaesthetic consumption and greater
maternal satisfaction when used in place of a continuous
basal infusion [17, 18].
274

In this study, we have successfully incorporated

variable-frequency automated boluses in place of a
conventional basal infusion into our PCEA regimen.
Varying the frequency of automated mandatory boluses
in tandem with the frequency of patientdemand boluses
improves the analgesic effcacy of a PCEA regimen, as
shown by the fourfold reduction in incidence of
breakthrough pain when the Automated bolus regimen
is used instead of a conventional PCEA with basal
infusion. The lack of difference in local anaesthetic
consumption between the two groups is likely to be due
to the auto regulatory nature of the Automated bolus
regimen, which minimises drug usage in early labour
when pain is less intense and allows greater drug
consumption to match the escalating pain of advanced
labour. Indeed, we found a signifcantly higher rate of
machine-delivered background epidural boluses in the
Automated bolus group compared with the mean basal
infusion rate in the Infusion group at full cervical
dilatation. We postulate that this may have alleviated
perineal pain more effectively and thus contributed to
the observed increase in maternal satisfaction in the
Automated bolus group. We did not detect any adverse
effects resulting from the higher consumption of local
anaesthetic during advanced labour, as shown by the
similar duration of second stage, mode of delivery and
neonatal outcomes in both groups, although this could
be due to the studys not being adequately powered for
such comparisons. Also, despite patient profles at the
frst episode of breakthrough pain being largely similar
in both groups, the number of patients was too small to
draw any meaningful conclusion.
In conclusion, variable-frequency automated
mandatory boluses are superior to a constant
background infusion in PCEA for the maintenance of
labour epidural analgesia. A reduction in the need for
anaesthetist-administered supplementation of the
epidural block not only increases maternal satisfaction
but may also be important in reducing workload at a
busy tertiary obstetric unit like ours. Harnessing the
power of technological advancement to create newer
and more interactive PCEA algorithms may bring us a
step closer to achieving seamless labour analgesia for
every parturient in the future.

Anaesthesia 2012 The Association of Anaesthetists of Great Britain and Ireland

Sia et al. | Comparison of variable-frequency mandatory boluses with basal infusion for PCEA Anaesthesia
2013, 68, 267275

Acknowledgements

8.

We would like to acknowledge our research assistant

Miss Agnes Teo and our systems analyst Mr Philip
Cheong for their contributions to this project.

9.

Competing interests
No
external funding and
interests declared.

no

competing

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