A Retrospective Cohort Assessment of Labor Epidural Catheter Replacement With Programmed Intermittent Epidural Bolus and Continuous Epidural Infusion

BACKGROUND: Labor epidural analgesia (LEA) catheter failure and replacement is a common problem in obstetrical anesthesia. The relationship between LEA catheter replacement and labor analgesia maintenance regimen is not well defined. The primary study objective was to investigate whether maintenance with programmed intermittent epidural boluses (PIEB) is associated with fewer epidural catheter replacements than continuous epidural infusions (CEI). A secondary study objective was to investigate whether initiation of LEA by the combined spinal epidural (CSE) technique was associated with fewer catheter replacements than the common epidural (EPID) technique. METHODS: A combined pre-post and historical cohort study was conducted with data retrieved between July 1, 2013, and December 31, 2019, to compare patients who received labor LEA initiated by either EPID or CSE (cohort study) and maintained with either PIEB or CEI (pre-post comparison), each in combination with patient-controlled epidural analgesia. The a priori primary outcome was catheter replacement. Secondary outcomes consisted of time until catheter replacement, incidence of catheter top-ups, incidence of catheter withdrawal, a collapsed composite index of catheter intervention, and time until catheter top-up. Data were analyzed using confounder-adjusted logistic regression and Cox proportional hazards regression, and primary factors were assessed for 2-way interactions. RESULTS: A total of 11,277 EPIDs and 4082 CSEs were included. A total of 13,177 were maintained with PIEB and 2182 with CEI. When considering the primary outcome, EPID was associated with a 1.28× increase in the odds of replacement of the LEA catheter compared to CSE (95% confidence interval [CI], 1.01-1.65; P = .049). However, CEI was not significantly related to the primary outcome of LEA catheter replacement (odds ratio [OR] = 1.19; 95% CI, 0.90-1.56; P = .21). Among secondary outcomes, CEI was associated with a 1.34× increase in the odds of at least 1 catheter top-up (95% CI, 1.17-1.55; P < .001), a 1.34× increase in the odds of catheter intervention (95% CI, 1.10-1.64; P = .004), and had a greater hazard ratio (HR) for shorter time until catheter top-up (HR = 1.29; 95% CI, 1.14-1.46; P < .001) compared to PIEB. CONCLUSIONS: LEA catheter replacement was more common with EPID than CSE, but not markedly different between CEI and PIEB. Clinician interventions to optimize analgesia were more common with CEI than with PIEB.