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class="bkr_bib"><h1 id="_NBK596254_"><span itemprop="name">Evidence reviews for remifentanil patient-controlled analgesia</span></h1><div class="subtitle">Intrapartum care</div><p><b>Evidence review D</b></p><p><i>NICE Guideline, No. 235</i></p><div class="half_rhythm">London: <a href="https://www.nice.org.uk" ref="pagearea=meta&targetsite=external&targetcat=link&targettype=publisher"><span itemprop="publisher">National Institute for Health and Care Excellence (NICE)</span></a>; <span itemprop="datePublished">2023 Sep</span>.<div class="small">ISBN-13: <span itemprop="isbn">978-1-4731-5389-9</span></div></div><div><a href="/books/about/copyright/">Copyright</a> © NICE 2023.</div></div><div class="bkr_clear"></div></div><div id="niceng235er4.s1"><h2 id="_niceng235er4_s1_">Remifentanil patient-controlled analgesia</h2><div id="niceng235er4.s1.1"><h3>Review question</h3><p>What is the effectiveness of remifentanil administered by intravenous patient-controlled analgesia (PCA) compared to other intramuscular opioids?</p><div id="niceng235er4.s1.1.1"><h4>Introduction</h4><p>Safe and effective methods of analgesia for use during labour are important for mother and baby outcomes. A commonly used method in the UK is intramuscular (IM) administration of opioids, such as pethidine, diamorphine and meptazinol. However, their use is associated with maternal side effects including nausea, possible effects on the baby such as drowsiness and delay in breastfeeding, and intermittent administration can lead to break-through pain. An alternative is epidural analgesia and while this is an effective method of pain relief, it is associated with an extended second stage of labour and an increased incidence of instrumental births. Furthermore, there may be some women who do not wish to receive an epidural. Patient-controlled infusions of intravenous analgesia may offer a compromise – providing continuous analgesia, avoiding the restrictions and possible complications of an epidural, and being acceptable to women. Remifentanil is an opioid analgesic for IV administration with a short duration of action which is known to be metabolised by neonates and which offers the potential for use in obstetric PCA.</p><p>This review aims to identify the evidence for the safety and effectiveness of IV remifentanil PCA compared to other IM opioids.</p></div><div id="niceng235er4.s1.1.2"><h4>Summary of the protocol</h4><p>See <a class="figpopup" href="/books/NBK596254/table/niceng235er4.tab1/?report=objectonly" target="object" rid-figpopup="figniceng235er4tab1" rid-ob="figobniceng235er4tab1">Table 1</a> for a summary of the Population, Intervention, Comparison and Outcome (PICO) characteristics of this review.</p><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng235er4tab1"><a href="/books/NBK596254/table/niceng235er4.tab1/?report=objectonly" target="object" title="Table 1" class="img_link icnblk_img figpopup" rid-figpopup="figniceng235er4tab1" rid-ob="figobniceng235er4tab1"><img class="small-thumb" src="/books/NBK596254/table/niceng235er4.tab1/?report=thumb" src-large="/books/NBK596254/table/niceng235er4.tab1/?report=previmg" alt="Table 1. Summary of the protocol (PICO table)." /></a><div class="icnblk_cntnt"><h4 id="niceng235er4.tab1"><a href="/books/NBK596254/table/niceng235er4.tab1/?report=objectonly" target="object" rid-ob="figobniceng235er4tab1">Table 1</a></h4><p class="float-caption no_bottom_margin">Summary of the protocol (PICO table). </p></div></div><p>For further details see the review protocol in <a href="#niceng235er4.appa">appendix A</a>.</p></div><div id="niceng235er4.s1.1.3"><h4>Methods and process</h4><p>This evidence review was developed using the methods and process described in <a href="https://www.nice.org.uk/process/pmg20/chapter/introduction" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Developing NICE guidelines: the manual</a>. Methods specific to this review question are described in the review protocol in <a href="#niceng235er4.appa">appendix A</a> and the <a href="/books/NBK596254/bin/NG235_Supplement_1_Methods.pdf">methods document</a> (supplement 1).</p><p>During guideline development, the BNF notation for oxytocin dose changed to ‘units’, so this has been reflected in the evidence report. The evidence tables in <a href="#niceng235er4.appd">appendix D</a> reflect the dose notations as defined by the original study.</p><p>Declarations of interest were recorded according to <a href="https://www.nice.org.uk/about/who-we-are/policies-and-procedures" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">NICE’s conflicts of interest policy</a>.</p></div><div id="niceng235er4.s1.1.4"><h4>Effectiveness</h4><div id="niceng235er4.s1.1.4.1"><h5>Included studies</h5><p>Five studies were included in this review: 4 randomised controlled trials (RCTs) (<a class="bibr" href="#niceng235er4.s1.ref1" rid="niceng235er4.s1.ref1">Gunes 2014</a>, <a class="bibr" href="#niceng235er4.s1.ref3" rid="niceng235er4.s1.ref3">Ng 2011</a>, <a class="bibr" href="#niceng235er4.s1.ref4" rid="niceng235er4.s1.ref4">Thurlow 2002</a> and <a class="bibr" href="#niceng235er4.s1.ref5" rid="niceng235er4.s1.ref5">Wilson 2018</a>) and 1 retrospective cohort study (<a class="bibr" href="#niceng235er4.s1.ref2" rid="niceng235er4.s1.ref2">Murray 2019</a>).</p><p>Four RCTs compared IV remifentanil PCA to IM pethidine (<a class="bibr" href="#niceng235er4.s1.ref1" rid="niceng235er4.s1.ref1">Gunes 2014</a>, <a class="bibr" href="#niceng235er4.s1.ref3" rid="niceng235er4.s1.ref3">Ng 2011</a>, <a class="bibr" href="#niceng235er4.s1.ref4" rid="niceng235er4.s1.ref4">Thurlow 2002</a> and <a class="bibr" href="#niceng235er4.s1.ref5" rid="niceng235er4.s1.ref5">Wilson 2018</a>). One of these studies included a third arm which compared IV remifentanil PCA with a background infusion of remifentanil to IM pethidine (<a class="bibr" href="#niceng235er4.s1.ref1" rid="niceng235er4.s1.ref1">Gunes 2014</a>). The retrospective cohort study compared IV remifentanil PCA to IM diamorphine (<a class="bibr" href="#niceng235er4.s1.ref2" rid="niceng235er4.s1.ref2">Murray 2019</a>).</p><p>The bolus dose of remifentanil administered by the PCA device varied between studies: 2 studies used a 40 microgram bolus of remifentanil (<a class="bibr" href="#niceng235er4.s1.ref2" rid="niceng235er4.s1.ref2">Murray 2019</a> and Wilson 2002); 1 study used a 20 microgram bolus (<a class="bibr" href="#niceng235er4.s1.ref4" rid="niceng235er4.s1.ref4">Thurlow 2002</a>); and 2 studies used a bolus dose which accounted for the weight of the woman (<a class="bibr" href="#niceng235er4.s1.ref1" rid="niceng235er4.s1.ref1">Gunes 2014</a> and <a class="bibr" href="#niceng235er4.s1.ref3" rid="niceng235er4.s1.ref3">Ng 2011</a>). The <a class="bibr" href="#niceng235er4.s1.ref4" rid="niceng235er4.s1.ref4">Thurlow 2002</a> study was a very small pilot study with a low (20 micrograms) dose of remifentanil, and for this reason the results from this study were not meta-analysed with other studies with higher dose of remifentanil. The rate of delivery and lockout period for each bolus varied between studies.</p><p>The included studies were conducted in Ireland, Hong Kong, Turkey and the UK</p><p>The included studies are summarised in <a class="figpopup" href="/books/NBK596254/table/niceng235er4.tab2/?report=objectonly" target="object" rid-figpopup="figniceng235er4tab2" rid-ob="figobniceng235er4tab2">Table 2</a>.</p><p>See the literature search strategy in <a href="#niceng235er4.appb">appendix B</a> and study selection flow chart in <a href="#niceng235er4.appc">appendix C</a>.</p></div><div id="niceng235er4.s1.1.4.2"><h5>Excluded studies</h5><p>Studies not included in this review are listed, and reasons for their exclusion are provided in <a href="#niceng235er4.appj">appendix J</a>.</p></div><div id="niceng235er4.s1.1.4.3"><h5>Summary of included studies</h5><p>Summaries of the studies that were included in this review are presented in <a class="figpopup" href="/books/NBK596254/table/niceng235er4.tab2/?report=objectonly" target="object" rid-figpopup="figniceng235er4tab2" rid-ob="figobniceng235er4tab2">Table 2</a>.</p><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng235er4tab2"><a href="/books/NBK596254/table/niceng235er4.tab2/?report=objectonly" target="object" title="Table 2" class="img_link icnblk_img figpopup" rid-figpopup="figniceng235er4tab2" rid-ob="figobniceng235er4tab2"><img class="small-thumb" src="/books/NBK596254/table/niceng235er4.tab2/?report=thumb" src-large="/books/NBK596254/table/niceng235er4.tab2/?report=previmg" alt="Table 2. Summary of included studies." /></a><div class="icnblk_cntnt"><h4 id="niceng235er4.tab2"><a href="/books/NBK596254/table/niceng235er4.tab2/?report=objectonly" target="object" rid-ob="figobniceng235er4tab2">Table 2</a></h4><p class="float-caption no_bottom_margin">Summary of included studies. </p></div></div><p>See the full evidence tables in <a href="#niceng235er4.appd">appendix D</a> and the forest plots in <a href="#niceng235er4.appe">appendix E</a>.</p></div></div><div id="niceng235er4.s1.1.5"><h4>Summary of the evidence</h4><p>Overall, across comparisons, IV remifentanil administered by PCA pump (particularly at a dose of 25-40 mcg) had some important benefits compared to pethidine and diamorphine administered intramuscularly and some important harms compared to pethidine administered intramuscularly.</p><div id="niceng235er4.s1.1.5.1"><h5>Remifentanil PCA (20 to 40 microgram) versus IM pethidine</h5><p>Evidence from one RCT suggested that there was an important benefit for the use of rescue analgesia with remifentanil PCA at a dose of 40 micrograms but no evidence of an important difference at a dose of 20 micrograms. For spontaneous vaginal birth there was an important benefit for remifentanil PCA at a dose of 25 to 40 micrograms (2 RCTs) but evidence of an important harm at a dose of 20 micrograms (1 RCT). For instrumental vaginal birth there was an important benefit for remifentanil PCA at 25-40 micrograms (2 RCTs) but no evidence of an important difference at a dose of 20 micrograms (1 RCT). For caesarean birth there was no evidence of an important difference for remifentanil PCA at 25-40 micrograms (2 RCTs) or 20 micrograms (1 RCT). This evidence was graded as low to very low quality.</p><p>Evidence from one large RCT suggested that there was an important harm for remifentanil PCA (40 micrograms) when compared to IM pethidine for the outcome of respiratory depression, measured by the requirement for supplemental oxygen for the mother. There was possible important harm for remifentanil PCA (40 micrograms) when compared to IM pethidine for the outcome respiratory depression measured by oxygen saturation <94%. There was no evidence of important difference in terms of respiratory depression in the mother measured by respiratory rate < 8 breaths per minute, maternal satisfaction, neonatal admission, pain in labour and breastfeeding within first hour of birth for remifentanil PCA (40 micrograms) versus IM pethidine. This evidence was graded as moderate to low quality.</p><p>Evidence from one RCT comparing remifentanil PCA (0.25 micrograms/kg) versus IM pethidine, suggested that remifentanil PCA had an important benefit on pain in labour (measured by a verbal rating scale). There was no important difference for remifentanil PCA (0.25 microgram/kg) when compared to IM pethidine for respiratory depression in mother measured by oxygen saturation (threshold undefined) and neonatal respiratory depression. The overall quality of the evidence for these outcomes was considered to be moderate to low quality.</p><p>No important benefits of remifentanil PCA (remifentanil 25 microgram bolus if <60kg, 30 micrograms if >60kg) versus IM pethidine were found for the outcome maternal satisfaction. The quality of the evidence contributing to this outcome was considered to be moderate quality.</p></div><div id="niceng235er4.s1.1.5.2"><h5>Remifentanil PCA (0.25 micrograms/kg) plus background infusion versus IM pethidine</h5><p>For the comparison of remifentanil PCA (0.25 micrograms/kg) with a background infusion versus IM pethidine, one RCT found that remifentanil PCA had an important benefit on pain (measured by a verbal rating scale). The study also reported respiratory depression in the mother and neonatal respiratory depression, however, no important differences were found. Evidence for these outcomes was from a single study with a small sample size and the outcomes were considered moderate to low quality. No other critical or important outcomes were reported for this comparison.</p></div><div id="niceng235er4.s1.1.5.3"><h5>Remifentanil PCA (40 microgram) versus IM diamorphine</h5><p>For the comparison of remifentanil PCA (40 microgram) versus intramuscular diamorphine, remifentanil PCA had an important benefit on neonatal admission. The quality of the evidence from this observational study was low. No other critical or important outcomes were reported for this comparison.</p><p>See <a href="#niceng235er4.appf">appendix F</a> for full GRADE tables.</p></div></div><div id="niceng235er4.s1.1.6"><h4>Economic evidence</h4><div id="niceng235er4.s1.1.6.1"><h5>Included studies</h5><p>A systematic review of the economic literature was conducted but no economic studies were identified which were applicable to this review question.</p></div><div id="niceng235er4.s1.1.6.2"><h5>Excluded studies</h5><p>Economic studies not included in this review are listed and reasons for their exclusion are provided in <a href="#niceng235er4.appk">appendix K</a>.</p></div></div><div id="niceng235er4.s1.1.7"><h4>Summary of included economic evidence</h4><p>See <a class="figpopup" href="/books/NBK596254/table/niceng235er4.tab3/?report=objectonly" target="object" rid-figpopup="figniceng235er4tab3" rid-ob="figobniceng235er4tab3">Table 3</a> for the economic evidence profile of the economic model developed for this guideline.</p><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng235er4tab3"><a href="/books/NBK596254/table/niceng235er4.tab3/?report=objectonly" target="object" title="Table 3" class="img_link icnblk_img figpopup" rid-figpopup="figniceng235er4tab3" rid-ob="figobniceng235er4tab3"><img class="small-thumb" src="/books/NBK596254/table/niceng235er4.tab3/?report=thumb" src-large="/books/NBK596254/table/niceng235er4.tab3/?report=previmg" alt="Table 3. Economic evidence profile of a systematic review of economic evaluations of the effectiveness of remifentanil administered by intravenous patient-controlled analgesia (PCA) compared to other intramuscular opioids?" /></a><div class="icnblk_cntnt"><h4 id="niceng235er4.tab3"><a href="/books/NBK596254/table/niceng235er4.tab3/?report=objectonly" target="object" rid-ob="figobniceng235er4tab3">Table 3</a></h4><p class="float-caption no_bottom_margin">Economic evidence profile of a systematic review of economic evaluations of the effectiveness of remifentanil administered by intravenous patient-controlled analgesia (PCA) compared to other intramuscular opioids? </p></div></div></div><div id="niceng235er4.s1.1.8"><h4>Economic model</h4><p>An original economic model was developed to compare remifentanil administered by intravenous PCA with intramuscular pethidine for pain relief in labour. The model is summarised below with full details provided in <a href="#niceng235er4.appi">appendix I</a>.</p><p>The model took the form of a cost-utility analysis and focused on a population of women with a single baby who go into labour at term and are giving birth in an obstetric unit in an NHS setting. The decision analytic structure of the model is shown in <a class="figpopup" href="/books/NBK596254/figure/niceng235er4.fig1/?report=objectonly" target="object" rid-figpopup="figniceng235er4fig1" rid-ob="figobniceng235er4fig1">Figure 1</a>. The model was based on a time horizon of 12 weeks reflecting published data on health-related quality of life according to mode of birth.</p><p>Clinical outcomes included in the model were the need for rescue analgesia, maternal respiratory depression, mode of birth, use of an antiemetic and pain in labour. Baseline values and relative treatment effects were based on included studies in the systematic review of the evidence. The model included both the costs of the respective treatments along with any costs arising from the clinical outcomes.</p><p>A QALY dyad was estimated for each treatment alternative to incorporate any impact on health-related quality of life (HRQoL) on both mother and baby. Health state utilities, estimated from published sources, were assigned to the model’s clinical outcomes or “health states”. A duration in these “states” was also estimated using published sources in order to calculate the QALYs over the time horizon of the model for PCA remifentanil and IM pethidine.</p><div class="iconblock whole_rhythm clearfix ten_col fig" id="figniceng235er4fig1" co-legend-rid="figlgndniceng235er4fig1"><a href="/books/NBK596254/figure/niceng235er4.fig1/?report=objectonly" target="object" title="Figure 1" class="img_link icnblk_img figpopup" rid-figpopup="figniceng235er4fig1" rid-ob="figobniceng235er4fig1"><img class="small-thumb" src="/books/NBK596254/bin/niceng235er4f1.gif" src-large="/books/NBK596254/bin/niceng235er4f1.jpg" alt="Figure 1. Decision model structure." /></a><div class="icnblk_cntnt" id="figlgndniceng235er4fig1"><h4 id="niceng235er4.fig1"><a href="/books/NBK596254/figure/niceng235er4.fig1/?report=objectonly" target="object" rid-ob="figobniceng235er4fig1">Figure 1</a></h4><p class="float-caption no_bottom_margin">Decision model structure. ‘+’ denotes that the tree is truncated at that point </p></div></div><p>Both deterministic and probabilistic results were calculated. Probabilistic sensitivity analysis involved 10000 repeated Monte Carlo simulations in which model parameters were sampled from a pre-specified probability distribution. In addition to the base case analysis, a number of additional analyses were undertaken to address alternative assumptions with respect to the estimation of health state utilities. Tornado analysis was undertaken to assess the impact of varying different model parameters on the cost-effectiveness of remifentanil and provide insights into the key drivers of model results. It additionally highlighted variables where uncertainty was likely to be more important. This was complemented by several one-way and two-way sensitivity analyses.</p><p>The results presented in this analysis provide evidence for the cost-effectiveness of IV remifentanil PCA for pain relief compared to IM pethidine. Deterministic analyses suggested that remifentanil dominated pethidine (cheaper and more effective) and probabilistic sensitivity analyses suggested that, when factoring in parameter uncertainty across those input parameters with a well-defined probability distribution, there was an approximately 57% probability that remifentanil was cost-effective.</p><p>Deterministic sensitivity analysis indicated that cost or resource parameters were key drivers of the cost-effectiveness of remifentanil. In the base case analysis reductions in the costs of “downstream” effects just offset the higher cost of remifentanil administration. An “ingredients” based or micro costing approach was used to estimate the costs of PCA remifentanil and IM pethidine. Staffing costs were the most important component of the treatment cost and hence reliable treatment cost estimates depend on accurately estimating the staff grade, tasks and time taken to undertake tasks. Nevertheless, a threshold analysis suggested that remifentanil would remain cost-effective providing its treatment cost was not more than £191 greater than pethidine, compared with the £146 differential estimated for the base case analysis.</p><p>This analysis suggests with that IV remifentanil PCA may be cost-effective relative to an alternative of IM pethidine for pain relief in labour. This finding is driven by the fact that reductions in the costs of rescue analgesia, antiemetic use, and instrumental vaginal births with remifentanil just offset the higher intervention costs associated with remifentanil although it should be recognised that the strength of this finding does depend on accurate estimates of staff time and grade.</p></div><div id="niceng235er4.s1.1.9"><h4>Unit costs</h4><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng235er4tab4"><a href="/books/NBK596254/table/niceng235er4.tab4/?report=objectonly" target="object" title="Table" class="img_link icnblk_img figpopup" rid-figpopup="figniceng235er4tab4" rid-ob="figobniceng235er4tab4"><img class="small-thumb" src="/books/NBK596254/table/niceng235er4.tab4/?report=thumb" src-large="/books/NBK596254/table/niceng235er4.tab4/?report=previmg" alt="Image " /></a><div class="icnblk_cntnt"><h4 id="niceng235er4.tab4"><a href="/books/NBK596254/table/niceng235er4.tab4/?report=objectonly" target="object" rid-ob="figobniceng235er4tab4">Table</a></h4></div></div></div><div id="niceng235er4.s1.1.10"><h4>The committee’s discussion and interpretation of the evidence</h4><div id="niceng235er4.s1.1.10.1"><h5>The outcomes that matter most</h5><p>As the aim of this review was to determine the effectiveness of remifentanil patient-controlled analgesia for pain relief in labour, the committee agreed that use of epidural analgesia was a critical outcome as the need for escalation to regional analgesia is a good measure of the direct effectiveness of the intervention. The committee agreed that respiratory depression in the mother and the baby were critical outcomes for this review as opioids can lead to respiratory depression and so this captures the safety of the intervention. Evidence was available for all of the above 3 critical protocol outcomes.</p><p>The committee agreed that mode of birth and women’s experience of labour and birth were important outcomes as they wanted to find out whether remifentanil patient-controlled analgesia would reduce the need for interventions during labour and whether this method could improve subjective scores of pain and satisfaction during labour. The committee recognised the great importance of women’s experience of labour and birth, including pain, for this review, but they were aware that data on this outcome was likely to be sparse and unlikely to inform decision-making in a meaningful way, so they prioritised other outcomes as critical. The majority of women and babies would have been healthy prior to birth and the committee agreed that neonatal admission should be included as an important outcome to capture any adverse effects on the baby associated with the intervention. The committee agreed that breastfeeding was an important outcome for this review as it may be impacted by the method of pain relief used in labour and it has important consequences for the long-term health of the mother and baby.</p></div><div id="niceng235er4.s1.1.10.2"><h5>The quality of the evidence</h5><p>The quality of the evidence ranged from low to moderate with most of the evidence being of low quality. The main issues were around the indirectness of the evidence. Most of the studies did not report the risk status of the women or whether the labour was induced. Some of the studies included women who had been induced, and some did not report the proportion of those out of the whole sample who had been induced. There were some concerns with risk of bias in the evidence. This was mainly due to missing data, for example excluding women who were escalated to rescue epidural analgesia. With the exception of one study which included a saline IM injection or saline PCA bolus, there was a risk of bias across studies due to participants not being blinded to the intervention. Whilst there is no clear evidence of the effectiveness of IV remifentanil PCA over intramuscular opioid on pain relief in labour, it is possible that participants in the PCA arms may have had better perceived control over pain as they could self-administer their analgesic. There were concerns over imprecision of the evidence for several outcomes due to the size of the confidence intervals around the estimate of effect and due to the low number of participants in each arm.</p><p>It was not possible to carry out the pre-planned stratification by BMI at booking as no data were available to inform this subgrouping.</p></div><div id="niceng235er4.s1.1.10.3"><h5>Benefits and harms</h5><p>The committee discussed the evidence around remifentanil PCA and used this alongside their expert opinion and clinical knowledge to make recommendations. The committee noted that the studies used included different doses of remifentanil and that this may impact on the results seen so considered the evidence in terms of doses. They also noted that one study, (<a class="bibr" href="#niceng235er4.s1.ref4" rid="niceng235er4.s1.ref4">Thurlow 2002</a>) was a very small pilot study with a low (20 micrograms) dose of remifentanil and that the results from this study were very different to those seen in other larger studies. The committee therefore considered it was not appropriate to meta-analyse these results (using a random effects model due to the heterogeneity) with the results from the larger studies, and instead considered the results from this study separately.</p><p>For the comparison of remifentanil PCA (25 to 40 micrograms) with IM pethidine, there was evidence to suggest that remifentanil reduced the need for rescue epidural analgesia, increased the rate of spontaneous vaginal birth and reduced instrumental vaginal birth. However, there was no important difference in terms of caesarean birth, respiratory depression in the mother measured by respiratory rate < 8 breaths per minute, maternal satisfaction, neonatal unit admission, pain in labour and breastfeeding within first hour of birth for remifentanil compared to IM pethidine. However, remifentanil 25 to 40 micrograms increased the requirement for supplemental oxygen compared to IM pethidine. There was a possible increased respiratory depression measured by oxygen saturation <94% saturation with remifentanil 40 micrograms compared to IM pethidine. Remifentanil PCA (0.25 microgram/kg) was associated with reduction in pain in labour (measured by a verbal rating scale) compared to IM pethidine, but there was no important difference in maternal or neonatal respiratory depression.</p><p>Low dose remifentanil PCA (20 micrograms) when compared to IM pethidine was found to be associated with a reduction in the rate of spontaneous vaginal birth but there was no important difference for instrumental vaginal birth. There was no clinically important difference between remifentanil PCA 20 micrograms and IM pethidine for use of rescue epidural analgesia and caesarean birth.</p><p>The committee noted that the evidence for remifentanil 40 micrograms compared to diamorphine showed a reduction in neonatal admission, but the committee noted this was based on low quality evidence from the cohort study. Looking at the raw data reported by the study in detail (<a class="bibr" href="#niceng235er4.s1.ref2" rid="niceng235er4.s1.ref2">Murray 2019</a>, data not reported as part of the evidence review), the committee noted that the rate of neonatal admission for women receiving IM diamorphine was higher than PCA remifentanil in 2011 (3.5% vs 1.1%) but by 2013 and 2014 was very similar (1.7% and 1.8% respectively in 2013 and 2.3% and 1.9% respectively in 2014). Furthermore, there was no important difference in terms of neonatal unit admission for the comparison of remifentanil PCA versus IM pethidine. They therefore agreed that it was difficult to conclude that remifentanil reduced neonatal unit admission, and so did not include this in their summary of the risks and benefits for women.</p><p>The committee discussed the inconclusive evidence in terms of women’s experience of labour and birth for remifentanil PCA versus IM pethidine: there was evidence of an important benefit of remifentanil PCA on pain in labour (when measured by verbal rating scale) from one small RCT using remifentanil 0.25 micrograms/kg (with and without a background infusion), and no important difference on pain in labour (when measured by a visual analogue scale) from a larger RCT using remifentanil 40 micrograms.</p><p>Due to concerns over the quality of the evidence and the heterogeneity of the evidence, the committee agreed that they could not make a strong recommendation. However, based on the evidence that higher doses of remifentanil PCA had benefits for use of rescue epidural analgesia and spontaneous vaginal birth when compared to other IM opioids and there was no evidence of inferiority on pain outcomes, they agreed that remifentanil PCA should be considered instead of intramuscular opioids for women who want ongoing pain relief during labour but who do not want an epidural.</p><p>The committee discussed the dose of remifentanil that should be used. They were aware that remifentanil is currently used at a dose of 40 micrograms in a number of obstetric units, and this was in line with the doses used in the two largest and most recent studies (Murray 2018, <a class="bibr" href="#niceng235er4.s1.ref5" rid="niceng235er4.s1.ref5">Wilson 2018</a>). However, the committee noted that it was at this dose that an increase in maternal respiratory depression had been seen. Hence the committee agreed that it was important the recommendations highlighted the need for all units to have clear guidelines in place in responding to respiratory depression if using remifentanil PCA. The committee discussed appropriate settings for using remifentanil PCA and based on their experience and expertise, they agreed that it should only be offered on obstetric units where the risk of respiratory depression could be appropriately managed. Based on this rationale, the committee agreed that intramuscular opioids remain the most appropriate opioid-based pain analgesia in midwifery-led units or for home births.</p><p>The committee discussed the benefits and harms of remifentanil PCA using both the evidence and their own experience, and agreed that it was important for healthcare professionals to explain these to women to inform decision making about pain relief in labour. Based on the evidence, the committee agreed that women should be informed which outcomes are more and less likely for remifentanil PCA compared to IM pethidine.</p><p>There was evidence showing no increase in neonatal respiratory depression compared to IM opioids, and the committee agreed that this was expected based on the fact that remifentanil is metabolised by ubiquitous pseudocholinesterase enzymes in the neonate to an inactive compound and so can be given throughout labour and birth. The comparison with diamorphine also showed that remifentanil reduced neonatal unit admission, but the committee noted this was based on low quality evidence from the cohort study. Looking at the raw data reported by the study in detail (<a class="bibr" href="#niceng235er4.s1.ref2" rid="niceng235er4.s1.ref2">Murray 2019</a>, data not reported as part of the evidence review), the committee noted that the rate of neonatal admission for women receiving IM diamorphine was higher than PCA remifentanil in 2011 (3.5% vs 1.1%) but by 2013 and 2014 was very similar (1.7% and 1.8% respectively in 2013 and 2.3% and 1.9% respectively in 2014). Furthermore, there was no important difference in terms of neonatal unit admission for the comparison of remifentanil PCA versus IM pethidine. They therefore agreed that it was difficult to conclude that remifentanil reduced neonatal unit admission, and so did not include this in their summary of the risks and benefits for women.</p><p>The committee agreed that the recommendations should be explicit in outlining additional monitoring needed to ensure the woman’s safety if using remifentanil PCA. Based on the evidence and their own experience and knowledge, the committee agreed it was important that women using remifentanil PCA had continuous one-to-one midwifery care from a midwife who was trained in the care of women receiving a remifentanil PCA and their respiratory function was monitored, both via observation of breathing and continuous pulse oximetry. In addition, the committee discussed the importance of having supplemental oxygen readily accessible so women would not have to discontinue their pain relief in response to a drop in oxygen saturation. The committee agreed that units should also ensure access to an anaesthetist for all women using remifentanil PCA in order to manage cases of respiratory depression. Based on the evidence and their experience, the committee also agreed that continuous cardiotocography (CTG) monitoring would be required for women using remifentanil PCA. The committee were aware of a large observational study (<a class="bibr" href="#niceng235er4.s1.ref13" rid="niceng235er4.s1.ref13">Melber 2019</a>) in the public domain which was designed to monitor maternal and neonatal outcomes when using remifentanil PCA and inform standards of care. Although this study was not included in this review because it did not include a comparator arm, the committee highlighted that this was an important source of information relevant to guide decisions on standard procedures.</p></div><div id="niceng235er4.s1.1.10.4"><h5>Cost effectiveness and resource use</h5><p>Remifentanil PCA is more expensive than IM opioids because of higher drug costs and the more intensive staffing requirements for drug administration and monitoring. However, a health economic model developed for this guideline, which compared remifentanil PCA with IM pethidine, suggested that these additional treatment costs for remifentanil could be more than offset by downstream savings resulting from a reduced need for rescue analgesia and antiemetics, lower costs of birth and lower neonatal admission costs. The committee recognised that this cost saving finding was small and sensitive to assumptions about staff tasks, timings, and grade in the administration of the respective drugs as well as the risk of neonatal admission.</p><p>The model also suggested that remifentanil PCA would generate small QALY gains when compared to IM pethidine meaning that remifentanil dominated IM pethidine in the deterministic analysis, albeit the net incremental monetary benefit was small in absolute terms. Probabilistic sensitivity analysis suggested that there was a 55% probability that remifentanil PCA was more cost-effective than IM pethidine.</p><p>Therefore, the committee considered there was cost-effectiveness evidence to support a consider recommendation for intravenous remifentanil patient-controlled analgesia (PCA) instead of intramuscular opioids as an option for women who want ongoing pain relief during labour, but who do not want an epidural.</p></div></div><div id="niceng235er4.s1.1.11"><h4>Recommendations supported by this evidence review</h4><p>This evidence review supports recommendations 1.6.20 to 1.6.23.</p></div></div><div id="niceng235er4.s1.rl.r1"><h3>References</h3><ul class="simple-list"><div id="niceng235er4.s1.rl.r1.1"><h4>Effectiveness included studies</h4><ul class="simple-list"><li class="half_rhythm"><p><div class="bk_ref" id="niceng235er4.s1.ref1"><p id="p-154">
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<strong>Gunes 2014</strong>
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</p>Gunes, Suleyman, Turktan, Mediha, Gulec, Umran Kucukgoz
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et al. (2014) The Comparison of Patient-Controlled Remifentanil Administered by Two Different Protocols (Bolus and Bolus+Infusion) and Intramuscular Meperidine for Labor Analgesia. Turkish journal of anaesthesiology and reanimation
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42(5): 264–9 [<a href="/pmc/articles/PMC4894172/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC4894172</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/27366433" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 27366433</span></a>]</div></p></li><li class="half_rhythm"><p><div class="bk_ref" id="niceng235er4.s1.ref2"><p id="p-155">
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<strong>Murray 2019</strong>
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</p>Murray, H.; Hodgkinson, P.; Hughes, D. (2019) Remifentanil patient-controlled intravenous analgesia during labour: a retrospective observational study of 10years’ experience. International Journal of Obstetric Anesthesia
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39: 29–34 [<a href="https://pubmed.ncbi.nlm.nih.gov/31230993" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 31230993</span></a>]</div></p></li><li class="half_rhythm"><p><div class="bk_ref" id="niceng235er4.s1.ref3"><p id="p-156">
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<strong>Ng 2011</strong>
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</p>Ng, T. K., Cheng, B. C., Chan, W. S.
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et al. (2011) A double-blind randomised comparison of intravenous patient-controlled remifentanil with intramuscular pethidine for labour analgesia. Anaesthesia
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66(9): 796–801 [<a href="https://pubmed.ncbi.nlm.nih.gov/21707564" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 21707564</span></a>]</div></p></li><li class="half_rhythm"><p><div class="bk_ref" id="niceng235er4.s1.ref4"><p id="p-157">
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<strong>Thurlow 2002</strong>
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</p>Thurlow, J. A., Laxton, C. H., Dick, A.
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et al. (2002) Remifentanil by patient-controlled analgesia compared with intramuscular meperidine for pain relief in labour. British journal of anaesthesia
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88(3): 374–378 [<a href="https://pubmed.ncbi.nlm.nih.gov/11990269" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 11990269</span></a>]</div></p></li><li class="half_rhythm"><p><div class="bk_ref" id="niceng235er4.s1.ref5"><p id="p-158">
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<strong>Wilson 2018</strong>
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</p>Wilson, M. J. A., MacArthur, C., Hewitt, C. A.
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et al. (2018) Intravenous remifentanil patient-controlled analgesia versus intramuscular pethidine for pain relief in labour (RESPITE): an open-label, multicentre, randomised controlled trial. Lancet (london, england)
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392(10148): 662–672 [<a href="https://pubmed.ncbi.nlm.nih.gov/30115484" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 30115484</span></a>]</div></p></li></ul></div><div id="niceng235er4.s1.rl.r1.2"><h4>Economic used in HE modelling (see also <a href="#niceng235er4.appi">appendix I</a>)</h4><ul class="simple-list"><li class="half_rhythm"><p><div class="bk_ref" id="niceng235er4.s1.ref6"><p id="p-159">
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<strong>Albers 1999</strong>
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</p>Albers, L.L. (1999) The duration of labour in healthy women. Journal of Perinatology
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19(2):114–9 [<a href="https://pubmed.ncbi.nlm.nih.gov/10642971" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 10642971</span></a>]</div></p></li><li class="half_rhythm"><p><div class="bk_ref" id="niceng235er4.s1.ref7"><p id="p-160">
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<strong>Bergendahl 2019</strong>
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</p>Bergendahl, S., Ankarcrona, V., Leijonhufvud, Å., et al. (2019) Lateral episiotomy versus no episiotomy to reduce obstetric anal sphincter injury in vacuum-assisted delivery in nulliparous women: study protocol on a randomised controlled trial. BMJ Open
|
|
9(3) [<a href="/pmc/articles/PMC6429882/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC6429882</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/30872546" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 30872546</span></a>]</div></p></li><li class="half_rhythm"><p><div class="bk_ref" id="niceng235er4.s1.ref8"><p id="p-161">
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<strong>Fairlie 1999</strong>
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</p>Fairlie, F.M., Marshall, L., Walker, J.J., Elbourne, D. (1999) Intramuscular opioids for maternal pain relief in labour: A randomised controlled trial comparing pethidine with diamorphine. British Journal of Obstetrics and Gynaecology
|
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106: 1181–7 [<a href="https://pubmed.ncbi.nlm.nih.gov/10549964" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 10549964</span></a>]</div></p></li><li class="half_rhythm"><p><div class="bk_ref" id="niceng235er4.s1.ref9"><p id="p-162">
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<strong>Jones 2021</strong>
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</p>Jones, K., Burns, A. (2021) Unit Costs of Health and Social Care 2021, Personal Social Services Research Unit, University of Kent, Canterbury.</div></p></li><li class="half_rhythm"><p><div class="bk_ref" id="niceng235er4.s1.ref10"><p id="p-163">
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<strong>Tan 2010</strong>
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</p>Tan, J.M., Macario, A., Carvalho, B., Druzin, M.L., El-Sayed, Y.Y. (2010) Cost-effectiveness of external cephalic version for term breech presentation. BMC Pregnancy and Childbirth
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10(3) [<a href="/pmc/articles/PMC2826287/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC2826287</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/20092630" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 20092630</span></a>]</div></p></li><li class="half_rhythm"><p><div class="bk_ref" id="niceng235er4.s1.ref11"><p id="p-164">
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<strong>Turner 2008</strong>
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</p>Turner, C.E., Young, J.M., Solomon, M.J., Ludlow, J., Benness, C., Phipps, H. (2008) Vaginal delivery compared with elective caesarean section: the views of pregnant women and clinicians. British Journal of Obstetrics and Gynaecology
|
|
115:1494–1502 [<a href="https://pubmed.ncbi.nlm.nih.gov/18752584" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 18752584</span></a>]</div></p></li><li class="half_rhythm"><p><div class="bk_ref" id="niceng235er4.s1.ref12"><p id="p-165">
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<strong>Wetherington 2014</strong>
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</p>Wetherington, S., Delong, D., Kini, S., Veledar, E., Schaufele, M.K., Mckenzie-Brown, A.M., Chen, S.C. (2014) Pain quality of life as measured by utilities. Pain Medicine
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15(5):865–870 [<a href="https://pubmed.ncbi.nlm.nih.gov/24716656" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 24716656</span></a>]</div></p></li></ul></div><div id="niceng235er4.s1.rl.r1.3"><h4>Other</h4><ul class="simple-list"><li class="half_rhythm"><p><div class="bk_ref" id="niceng235er4.s1.ref13"><p id="p-166">
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<strong>Melber 2019</strong>
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</p>Melber, A. A., Jelting, Y., Huber, M., et al. (2019) Remifentanil patient-controlled analgesia in labour: six-year audit of outcome data of the RemiPCA SAFE Network (2010-2015). International journal of obstetric anesthesia, 39, 12–21. [<a href="https://pubmed.ncbi.nlm.nih.gov/30685299" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 30685299</span></a>]</div></p></li></ul></div></ul></div></div><div id="appendixesappgroup1"><h2 id="_appendixesappgroup1_">Appendices</h2><div id="niceng235er4.appa"><h3>Appendix A. Review protocols</h3><p id="niceng235er4.appa.et1"><a href="/books/NBK596254/bin/niceng235er4-appa-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Review protocol for review question: What is the effectiveness of remifentanil administered by intravenous patient-controlled analgesia (PCA) compared to other intramuscular opioids?</a><span class="small"> (PDF, 215K)</span></p></div><div id="niceng235er4.appb"><h3>Appendix B. Literature search strategies</h3><p id="niceng235er4.appb.et1"><a href="/books/NBK596254/bin/niceng235er4-appb-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Literature search strategies for review question: What is the effectiveness of remifentanil administered by intravenous patient-controlled analgesia (PCA) compared to other intramuscular opioids?</a><span class="small"> (PDF, 139K)</span></p><p id="niceng235er4.appb.et2"><a href="/books/NBK596254/bin/niceng235er4-appb-et2.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Health economics search strategies</a><span class="small"> (PDF, 124K)</span></p></div><div id="niceng235er4.appc"><h3>Appendix C. Effectiveness evidence study selection</h3><p id="niceng235er4.appc.et1"><a href="/books/NBK596254/bin/niceng235er4-appc-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Study selection for: What is the effectiveness of remifentanil administered by intravenous patient-controlled analgesia (PCA) compared to other intramuscular opioids?</a><span class="small"> (PDF, 201K)</span></p></div><div id="niceng235er4.appd"><h3>Appendix D. Evidence tables</h3><p id="niceng235er4.appd.et1"><a href="/books/NBK596254/bin/niceng235er4-appd-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Evidence tables for review question: What is the effectiveness of remifentanil administered by intravenous patient-controlled analgesia (PCA) compared to other intramuscular opioids?</a><span class="small"> (PDF, 301K)</span></p></div><div id="niceng235er4.appe"><h3>Appendix E. Forest plots</h3><p id="niceng235er4.appe.et1"><a href="/books/NBK596254/bin/niceng235er4-appe-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Forest plots for review question: What is the effectiveness of remifentanil administered by intravenous patient-controlled analgesia (PCA) compared to other intramuscular opioids?</a><span class="small"> (PDF, 149K)</span></p></div><div id="niceng235er4.appf"><h3>Appendix F. GRADE tables</h3><p id="niceng235er4.appf.et1"><a href="/books/NBK596254/bin/niceng235er4-appf-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">GRADE tables for review question: What is the effectiveness of remifentanil administered by intravenous patient-controlled analgesia (PCA) compared to other intramuscular opioids?</a><span class="small"> (PDF, 214K)</span></p></div><div id="niceng235er4.appg"><h3>Appendix G. Economic evidence study selection</h3><p id="niceng235er4.appg.et1"><a href="/books/NBK596254/bin/niceng235er4-appg-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Study selection for: What is the effectiveness of remifentanil administered by intravenous patient-controlled analgesia (PCA) compared to other intramuscular opioids?</a><span class="small"> (PDF, 210K)</span></p></div><div id="niceng235er4.apph"><h3>Appendix H. Economic evidence tables</h3><div id="niceng235er4.apph.s1"><h4>Economic evidence tables for review question: What is the effectiveness of remifentanil administered by intravenous patient-controlled analgesia (PCA) compared to other intramuscular opioids?</h4><p>No evidence was identified which was applicable to this review question.</p></div></div><div id="niceng235er4.appi"><h3>Appendix I. Economic model</h3><p id="niceng235er4.appi.et1"><a href="/books/NBK596254/bin/niceng235er4-appi-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Economic model for review question: What is the effectiveness of remifentanil administered by intravenous patient-controlled analgesia (PCA) compared to other intramuscular opioids?</a><span class="small"> (PDF, 1.2M)</span></p><ul class="simple-list"><li class="half_rhythm"><p><div class="bk_ref" id="niceng235er4.appi.ref1"><p id="p-174">
|
|
<strong>Albers 1999</strong>
|
|
</p>Albers, L.L. (1999) The duration of labour in healthy women. Journal of Perinatology
|
|
19(2):114–9 [<a href="https://pubmed.ncbi.nlm.nih.gov/10642971" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 10642971</span></a>]</div></p></li><li class="half_rhythm"><p><div class="bk_ref" id="niceng235er4.appi.ref2"><p id="p-175">
|
|
<strong>Bergendahl 2019</strong>
|
|
</p>Bergendahl, S., Ankarcrona, V., Leijonhufvud, Å., et al. (2019) Lateral episiotomy versus no episiotomy to reduce obstetric anal sphincter injury in vacuum-assisted delivery in nulliparous women: study protocol on a randomised controlled trial. BMJ Open
|
|
9(3) [<a href="/pmc/articles/PMC6429882/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC6429882</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/30872546" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 30872546</span></a>]</div></p></li><li class="half_rhythm"><p><div class="bk_ref" id="niceng235er4.appi.ref3"><p id="p-176">
|
|
<strong>Fairlie 1999</strong>
|
|
</p>Fairlie, F.M., Marshall, L., Walker, J.J., Elbourne, D. (1999) Intramuscular opioids for maternal pain relief in labour: A randomised controlled trial comparing pethidine with diamorphine. British Journal of Obstetrics and Gynaecology
|
|
106: 1181–7 [<a href="https://pubmed.ncbi.nlm.nih.gov/10549964" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 10549964</span></a>]</div></p></li><li class="half_rhythm"><p><div class="bk_ref" id="niceng235er4.appi.ref4"><p id="p-177">
|
|
<strong>Jones 2021</strong>
|
|
</p>Jones, K., Burns, A. (2021) Unit Costs of Health and Social Care 2021, Personal Social Services Research Unit, University of Kent, Canterbury.</div></p></li><li class="half_rhythm"><p><div class="bk_ref" id="niceng235er4.appi.ref5"><p id="p-178">
|
|
<strong>Tan 2010</strong>
|
|
</p>Tan, J.M., Macario, A., Carvalho, B., Druzin, M.L., El-Sayed, Y.Y. (2010) Cost-effectiveness of external cephalic version for term breech presentation. BMC Pregnancy and Childbirth
|
|
10(3) [<a href="/pmc/articles/PMC2826287/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC2826287</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/20092630" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 20092630</span></a>]</div></p></li><li class="half_rhythm"><p><div class="bk_ref" id="niceng235er4.appi.ref6"><p id="p-179">
|
|
<strong>Turner 2008</strong>
|
|
</p>Turner, C.E., Young, J.M., Solomon, M.J., Ludlow, J., Benness, C., Phipps, H. (2008) Vaginal delivery compared with elective caesarean section: the views of pregnant women and clinicians. British Journal of Obstetrics and Gynaecology
|
|
115:1494–1502 [<a href="https://pubmed.ncbi.nlm.nih.gov/18752584" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 18752584</span></a>]</div></p></li><li class="half_rhythm"><p><div class="bk_ref" id="niceng235er4.appi.ref7"><p id="p-180">
|
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<strong>Wetherington 2014</strong>
|
|
</p>Wetherington, S., Delong, D., Kini, S., Veledar, E., Schaufele, M.K., Mckenzie-Brown, A.M., Chen, S.C. (2014) Pain quality of life as measured by utilities. Pain Medicine
|
|
15(5):865–870 [<a href="https://pubmed.ncbi.nlm.nih.gov/24716656" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 24716656</span></a>]</div></p></li></ul></div><div id="niceng235er4.appj"><h3>Appendix J. Excluded studies</h3><div id="niceng235er4.appj.s1"><h4>Excluded studies for review question: What is the effectiveness of remifentanil administered by intravenous patient-controlled analgesia (PCA) compared to other intramuscular opioids?</h4></div><div id="niceng235er4.appj.s2"><h4>Excluded effectiveness studies</h4><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng235er4appjtab1"><a href="/books/NBK596254/table/niceng235er4.appj.tab1/?report=objectonly" target="object" title="Table 40" class="img_link icnblk_img figpopup" rid-figpopup="figniceng235er4appjtab1" rid-ob="figobniceng235er4appjtab1"><img class="small-thumb" src="/books/NBK596254/table/niceng235er4.appj.tab1/?report=thumb" src-large="/books/NBK596254/table/niceng235er4.appj.tab1/?report=previmg" alt="Table 40. Excluded studies and reasons for their exclusion." /></a><div class="icnblk_cntnt"><h4 id="niceng235er4.appj.tab1"><a href="/books/NBK596254/table/niceng235er4.appj.tab1/?report=objectonly" target="object" rid-ob="figobniceng235er4appjtab1">Table 40</a></h4><p class="float-caption no_bottom_margin">Excluded studies and reasons for their exclusion. </p></div></div></div><div id="niceng235er4.appj.s3"><h4>Excluded economic studies</h4><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng235er4appjtab2"><a href="/books/NBK596254/table/niceng235er4.appj.tab2/?report=objectonly" target="object" title="Table" class="img_link icnblk_img figpopup" rid-figpopup="figniceng235er4appjtab2" rid-ob="figobniceng235er4appjtab2"><img class="small-thumb" src="/books/NBK596254/table/niceng235er4.appj.tab2/?report=thumb" src-large="/books/NBK596254/table/niceng235er4.appj.tab2/?report=previmg" alt="Image " /></a><div class="icnblk_cntnt"><h4 id="niceng235er4.appj.tab2"><a href="/books/NBK596254/table/niceng235er4.appj.tab2/?report=objectonly" target="object" rid-ob="figobniceng235er4appjtab2">Table</a></h4></div></div></div></div><div id="niceng235er4.appk"><h3>Appendix K. Research recommendations – full details</h3><div id="niceng235er4.appk.s1"><h4>Research recommendations for review question: What is the effectiveness of remifentanil administered by intravenous patient-controlled analgesia (PCA) compared to other intramuscular opioids?</h4><p>No research recommendations were made for this review question.</p></div></div></div></div><div class="fm-sec"><div><p>Final</p></div><div><p>Evidence reviews underpinning recommendations 1.6.20 to 1.6.23 in the NICE guideline</p><p>These evidence reviews were developed by NICE</p></div><div><p><b>Disclaimer</b>: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.</p><p>Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.</p><p>NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the <a href="https://www.gov.wales/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Welsh Government</a>, <a href="http://www.scotland.gov.uk/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Scottish Government</a>, and <a href="http://www.northernireland.gov.uk/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Northern Ireland Executive</a>. All NICE guidance is subject to regular review and may be updated or withdrawn.</p></div><div class="half_rhythm"><a href="/books/about/copyright/">Copyright</a> © NICE 2023.</div><div class="small"><span class="label">Bookshelf ID: NBK596254</span><span class="label">PMID: <a href="https://pubmed.ncbi.nlm.nih.gov/37856639" title="PubMed record of this title" ref="pagearea=meta&targetsite=entrez&targetcat=link&targettype=pubmed">37856639</a></span></div></div><div class="small-screen-prev"></div><div class="small-screen-next"></div></article><article data-type="table-wrap" id="figobniceng235er4tab1"><div id="niceng235er4.tab1" class="table"><h3><span class="label">Table 1</span><span class="title">Summary of the protocol (PICO table)</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK596254/table/niceng235er4.tab1/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng235er4.tab1_lrgtbl__"><table><tbody><tr><th id="hd_b_niceng235er4.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Population</th><td headers="hd_b_niceng235er4.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
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<ul><li class="half_rhythm"><div>Women in labour who are pregnant with a single baby, who go into labour at term (37 to 42 weeks of pregnancy) and who do not have any pre-existing medical conditions or antenatal conditions that predispose to a higher risk birth</div></li><li class="half_rhythm"><div>Women in labour whose baby has not been identified before labour to be at high risk of adverse outcomes</div></li><li class="half_rhythm"><div>Singleton babies born at term (37 to 42 weeks of pregnancy) with no previously identified problems (for example, congenital malformations, genetic anomalies, intrauterine growth restriction, placental problems)</div></li></ul>
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</td></tr><tr><th id="hd_b_niceng235er4.tab1_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Intervention</th><td headers="hd_b_niceng235er4.tab1_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<ul><li class="half_rhythm"><div>Remifentanil administered by intravenous patient controlled analgesia</div></li></ul>
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</td></tr><tr><th id="hd_b_niceng235er4.tab1_1_1_3_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Comparison</th><td headers="hd_b_niceng235er4.tab1_1_1_3_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<ul><li class="half_rhythm"><div>Opioids administered intramuscularly:
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<ul class="circle"><li class="half_rhythm"><div>Pethidine</div></li><li class="half_rhythm"><div>Diamorphine</div></li><li class="half_rhythm"><div>Meptazinol</div></li></ul></div></li></ul>
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</td></tr><tr><th id="hd_b_niceng235er4.tab1_1_1_4_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Outcome</th><td headers="hd_b_niceng235er4.tab1_1_1_4_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><b>Critical</b>
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<ul><li class="half_rhythm"><div>Use of rescue epidural analgesia</div></li><li class="half_rhythm"><div>Respiratory depression in the mother</div></li><li class="half_rhythm"><div>Neonatal respiratory depression</div></li></ul>
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<b>Important</b>
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<ul><li class="half_rhythm"><div>Mode of birth (for example spontaneous vaginal, forceps, caesarean birth)</div></li><li class="half_rhythm"><div>Women’s experience of labour and birth, including experience of pain</div></li><li class="half_rhythm"><div>Neonatal unit admission</div></li><li class="half_rhythm"><div>Breastfeeding</div></li></ul></td></tr></tbody></table></div></div></article><article data-type="table-wrap" id="figobniceng235er4tab2"><div id="niceng235er4.tab2" class="table"><h3><span class="label">Table 2</span><span class="title">Summary of included studies</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK596254/table/niceng235er4.tab2/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng235er4.tab2_lrgtbl__"><table class="no_bottom_margin"><thead><tr><th id="hd_h_niceng235er4.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Study</th><th id="hd_h_niceng235er4.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Population</th><th id="hd_h_niceng235er4.tab2_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Intervention</th><th id="hd_h_niceng235er4.tab2_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Comparison</th><th id="hd_h_niceng235er4.tab2_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Outcomes</th></tr></thead><tbody><tr><td headers="hd_h_niceng235er4.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>
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<a class="bibr" href="#niceng235er4.s1.ref1" rid="niceng235er4.s1.ref1">Gunes 2014</a>
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</p>
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<p>Randomised controlled trial</p>
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<p>Turkey</p>
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</td><td headers="hd_h_niceng235er4.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>N= 90</p>
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<p>Gestational age, mean (SD): 39.4 (0.6)</p>
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</td><td headers="hd_h_niceng235er4.tab2_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><u>IV remifentanil PCA</u>
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<ul><li class="half_rhythm"><div>0.25 microgram kg<sup>-1</sup> bolus of remifentanil (2 mg remifentanil in 100 mL of sodium chloride 0.9%, 20 μg mL<sup>-1</sup>) via canula and PCA pump</div></li></ul>
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<u>IV remifentanil PCA + infusion</u>
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<ul><li class="half_rhythm"><div>0.25 microgram kg<sup>-1</sup> bolus of remifentanil (2 mg remifentanil in 100 mL of sodium chloride 0.9%, 20 μg mL<sup>-1</sup>) via canula and PCA pump and continuous infusion remifentanil (0.025 microgram kg<sup>-1</sup> hr<sup>-1</sup>)</div></li></ul>
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<u>For both groups:</u>
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<ul><li class="half_rhythm"><div>2 minute lockout interval (for bolus dose)</div></li><li class="half_rhythm"><div>Ringer Lactate infusion (started at rate 1-3 mL kg<sup>-1</sup> h<sup>-1</sup>) before administration of analgesia</div></li></ul></td><td headers="hd_h_niceng235er4.tab2_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><u>IM pethidine</u>
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<ul><li class="half_rhythm"><div>Intramuscular injection of 1 mg kg<sup>-1</sup> meperidine</div></li><li class="half_rhythm"><div>Ringer Lactate infusion (started at rate 1-3 mL kg<sup>-1</sup> h<sup>-1</sup>) before administration of analgesia</div></li></ul>
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Note: meperidine is an alternative name for pethidine</td><td headers="hd_h_niceng235er4.tab2_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<ul><li class="half_rhythm"><div>Respiratory depression in the mother</div></li><li class="half_rhythm"><div>Neonatal respiratory depression</div></li><li class="half_rhythm"><div>Pain in labour</div></li></ul>
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</td></tr><tr><td headers="hd_h_niceng235er4.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>
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<a class="bibr" href="#niceng235er4.s1.ref2" rid="niceng235er4.s1.ref2">Murray 2019</a>
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</p>
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<p>Retrospective cohort study</p>
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<p>Ireland</p>
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</td><td headers="hd_h_niceng235er4.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>N= 6345</p>
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<p>Gestational age: ≥37 weeks</p>
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</td><td headers="hd_h_niceng235er4.tab2_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><u>IV remifentanil PCA</u>
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<ul><li class="half_rhythm"><div>40 microgram remifentanil (1 mL bolus) via dedicated canula and PCA pump</div></li><li class="half_rhythm"><div>Delivered over 6 seconds, 2 minute lockout interval</div></li><li class="half_rhythm"><div>No background infusion</div></li></ul></td><td headers="hd_h_niceng235er4.tab2_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><u>IM diamorphine</u>
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<ul><li class="half_rhythm"><div>Intramuscular administration of 5 mg diamorphine by midwives</div></li><li class="half_rhythm"><div>Up to 2 doses every 4 hours</div></li></ul></td><td headers="hd_h_niceng235er4.tab2_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<ul><li class="half_rhythm"><div>Neonatal admission</div></li></ul>
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</td></tr><tr><td headers="hd_h_niceng235er4.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>
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<a class="bibr" href="#niceng235er4.s1.ref3" rid="niceng235er4.s1.ref3">Ng 2011</a>
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</p>
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<p>Randomised controlled trial</p>
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<p>Hong Kong</p>
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</td><td headers="hd_h_niceng235er4.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>N= 68</p>
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<p>Gestational age: 36-40 weeks</p>
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</td><td headers="hd_h_niceng235er4.tab2_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><u>IV remifentanil PCA</u>
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<ul><li class="half_rhythm"><div>25-30 microgram bolus remifentanil via canula and PCA pump (participants weighing < 60 kg received 25 microgram bolus in 1.25 ml; participants weighing ≥60 kg received 30 microgram in 1.5 ml)</div></li><li class="half_rhythm"><div>3.75-4.50 minute lockout interval (hourly limit of 25 ml)</div></li><li class="half_rhythm"><div>Intramuscular injection of 1.5 ml sodium chloride 0.9%</div></li><li class="half_rhythm"><div>No background infusion</div></li></ul></td><td headers="hd_h_niceng235er4.tab2_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><u>IM pethidine</u>
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<ul><li class="half_rhythm"><div>Intramuscular injection of 50 - 75 mg pethidine (participants weighing < 60 kg received 50 mg pethidine in 1.5 ml sodium chloride; participants weighing ≥60 kg received 75 mg pethidine in 1.5 ml sodium chloride)</div></li><li class="half_rhythm"><div>Sodium chloride 0.9% administered intravenously by PCA device, on demand</div></li></ul></td><td headers="hd_h_niceng235er4.tab2_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<ul><li class="half_rhythm"><div>Mode of birth</div></li><li class="half_rhythm"><div>Women’s experience of labour and birth (satisfaction)</div></li></ul>
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</td></tr><tr><td headers="hd_h_niceng235er4.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>
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<a class="bibr" href="#niceng235er4.s1.ref4" rid="niceng235er4.s1.ref4">Thurlow 2002</a>
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</p>
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<p>Randomised controlled trial</p>
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<p>UK</p>
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</td><td headers="hd_h_niceng235er4.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>N= 36</p>
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<p>Gestational age: 38-42 weeks</p>
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</td><td headers="hd_h_niceng235er4.tab2_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><u>IV remifentanil PCA</u>
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<ul><li class="half_rhythm"><div>20 microgram bolus remifentanil via dedicated cannula and PCA pump</div></li><li class="half_rhythm"><div>Delivered over 20 seconds, 3 minute lockout interval</div></li><li class="half_rhythm"><div>No background infusion</div></li></ul></td><td headers="hd_h_niceng235er4.tab2_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><u>IM pethidine</u>
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<ul><li class="half_rhythm"><div>Intramuscular injection of 100 mg meperidine</div></li><li class="half_rhythm"><div>Antiemetic</div></li></ul></td><td headers="hd_h_niceng235er4.tab2_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<ul><li class="half_rhythm"><div>Use of rescue epidural analgesia</div></li><li class="half_rhythm"><div>Mode of birth</div></li><li class="half_rhythm"><div>Pain 1 hour after analgesia commenced</div></li></ul>
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</td></tr><tr><td headers="hd_h_niceng235er4.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>
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<a class="bibr" href="#niceng235er4.s1.ref5" rid="niceng235er4.s1.ref5">Wilson 2018</a>
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</p>
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<p>Randomised controlled trial</p>
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<p>UK</p>
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</td><td headers="hd_h_niceng235er4.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>N= 401</p>
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<p>Gestational age: 37 weeks</p>
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</td><td headers="hd_h_niceng235er4.tab2_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><u>IV remifentanil PCA</u>
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<ul><li class="half_rhythm"><div>40 microgram bolus remifentanil via dedicated cannula and PCA pump</div></li><li class="half_rhythm"><div>2 minute lockout interval</div></li><li class="half_rhythm"><div>One-to-one midwifery care</div></li><li class="half_rhythm"><div>No background infusion</div></li></ul></td><td headers="hd_h_niceng235er4.tab2_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><u>IM pethidine</u>
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<ul><li class="half_rhythm"><div>100 mg dose pethidine administered by intramuscular injection, up to 4 h in frequency, to a maximum dose of 400 mg in 24 h</div></li><li class="half_rhythm"><div>Delivered by attending midwife</div></li><li class="half_rhythm"><div>One-to-one midwifery care</div></li></ul></td><td headers="hd_h_niceng235er4.tab2_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<ul><li class="half_rhythm"><div>Use of rescue epidural analgesia</div></li><li class="half_rhythm"><div>Respiratory depression in the mother</div></li><li class="half_rhythm"><div>Mode of birth</div></li><li class="half_rhythm"><div>Women’s experience of labour and birth (satisfaction)</div></li><li class="half_rhythm"><div>Pain in labour</div></li><li class="half_rhythm"><div>Neonatal admission</div></li><li class="half_rhythm"><div>Breastfeeding</div></li></ul>
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</td></tr></tbody></table></div><div class="tblwrap-foot"><div><dl class="temp-labeled-list small"><dl class="bkr_refwrap"><dt></dt><dd><div><p class="no_margin">IM: intramuscular; IV: intravenous; PCA: patient-controlled analgesia; SD: standard deviation</p></div></dd></dl></dl></div></div></div></article><article data-type="table-wrap" id="figobniceng235er4tab3"><div id="niceng235er4.tab3" class="table"><h3><span class="label">Table 3</span><span class="title">Economic evidence profile of a systematic review of economic evaluations of the effectiveness of remifentanil administered by intravenous patient-controlled analgesia (PCA) compared to other intramuscular opioids?</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK596254/table/niceng235er4.tab3/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng235er4.tab3_lrgtbl__"><table class="no_bottom_margin"><thead><tr><th id="hd_h_niceng235er4.tab3_1_1_1_1" rowspan="2" colspan="1" headers="hd_h_niceng235er4.tab3_1_1_1_1" style="text-align:left;vertical-align:bottom;">Study</th><th id="hd_h_niceng235er4.tab3_1_1_1_2" rowspan="2" colspan="1" headers="hd_h_niceng235er4.tab3_1_1_1_2" style="text-align:left;vertical-align:bottom;">Limitations</th><th id="hd_h_niceng235er4.tab3_1_1_1_3" rowspan="2" colspan="1" headers="hd_h_niceng235er4.tab3_1_1_1_3" style="text-align:left;vertical-align:bottom;">Applicability</th><th id="hd_h_niceng235er4.tab3_1_1_1_4" rowspan="2" colspan="1" headers="hd_h_niceng235er4.tab3_1_1_1_4" style="text-align:left;vertical-align:bottom;">Other comments</th><th id="hd_h_niceng235er4.tab3_1_1_1_5" colspan="3" rowspan="1" style="text-align:left;vertical-align:bottom;">Incremental</th><th id="hd_h_niceng235er4.tab3_1_1_1_6" rowspan="2" colspan="1" headers="hd_h_niceng235er4.tab3_1_1_1_6" style="text-align:left;vertical-align:bottom;">Uncertainty</th></tr><tr><th headers="hd_h_niceng235er4.tab3_1_1_1_5" id="hd_h_niceng235er4.tab3_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Costs</th><th headers="hd_h_niceng235er4.tab3_1_1_1_5" id="hd_h_niceng235er4.tab3_1_1_2_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Effect</th><th headers="hd_h_niceng235er4.tab3_1_1_1_5" id="hd_h_niceng235er4.tab3_1_1_2_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Cost effectiveness</th></tr></thead><tbody><tr><td headers="hd_h_niceng235er4.tab3_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">NICE guideline model 2022</td><td headers="hd_h_niceng235er4.tab3_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Minor limitations<sup>1</sup></td><td headers="hd_h_niceng235er4.tab3_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Directly applicable</td><td headers="hd_h_niceng235er4.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Cost-utility analysis</td><td headers="hd_h_niceng235er4.tab3_1_1_1_5 hd_h_niceng235er4.tab3_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">−£20</td><td headers="hd_h_niceng235er4.tab3_1_1_1_5 hd_h_niceng235er4.tab3_1_1_2_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">0.00051 QALYs</td><td headers="hd_h_niceng235er4.tab3_1_1_1_5 hd_h_niceng235er4.tab3_1_1_2_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Remifentanil dominates pethidine</p>
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<p>Incremental NMB = £31</p>
|
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</td><td headers="hd_h_niceng235er4.tab3_1_1_1_6" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Probabilistic sensitivity analysis suggested there was a 55% probability that remifentanil was cost-effective</p>
|
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<p>Mean incremental NMB = £14 (95% CrInt: −£329 to £328)</p>
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</td></tr></tbody></table></div><div class="tblwrap-foot"><div><dl class="temp-labeled-list small"><dl class="bkr_refwrap"><dt></dt><dd><div><p class="no_margin">CrInt = Credible Intervals; NMB = Net monetary benefit; QALY = Quality adjusted life-year</p></div></dd></dl><dl class="bkr_refwrap"><dt>1</dt><dd><div id="niceng235er4.tab3_1"><p class="no_margin">Health state utilities were obtained from published literature, but they were not derived using NICE’s preferred method</p></div></dd></dl></dl></div></div></div></article><article data-type="fig" id="figobniceng235er4fig1"><div id="niceng235er4.fig1" class="figure bk_fig"><div class="graphic"><a href="/core/lw/2.0/html/tileshop_pmc/tileshop_pmc_inline.html?title=Figure%201.%20Decision%20model%20structure.&p=BOOKS&id=596254_niceng235er4f1.jpg" target="tileshopwindow" class="inline_block pmc_inline_block ts_canvas img_link" title="Click on image to zoom"><div class="ts_bar small" title="Click on image to zoom"></div><img data-src="/books/NBK596254/bin/niceng235er4f1.jpg" alt="Figure 1. Decision model structure." class="tileshop" title="Click on image to zoom" /></a></div><h3><span class="label">Figure 1</span><span class="title">Decision model structure</span></h3><div class="caption"><p>‘+’ denotes that the tree is truncated at that point</p></div></div></article><article data-type="table-wrap" id="figobniceng235er4tab4"><div id="niceng235er4.tab4" class="table"><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK596254/table/niceng235er4.tab4/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng235er4.tab4_lrgtbl__"><table><thead><tr><th id="hd_h_niceng235er4.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Resource</th><th id="hd_h_niceng235er4.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Unit costs</th><th id="hd_h_niceng235er4.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Source</th></tr></thead><tbody><tr><td headers="hd_h_niceng235er4.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Remifentanil (as Remifentanil hydrochloride) 2 mg</td><td headers="hd_h_niceng235er4.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£10.23 per vial</td><td headers="hd_h_niceng235er4.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">BNF 2021</td></tr><tr><td headers="hd_h_niceng235er4.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Pethidine hydrochloride 50 mg per 1 ml</td><td headers="hd_h_niceng235er4.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£0.47 per ampoule</td><td headers="hd_h_niceng235er4.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">BNF 2021</td></tr><tr><td headers="hd_h_niceng235er4.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Diamorphine hydrochloride 5 mg</td><td headers="hd_h_niceng235er4.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£2.56 per ampoule</td><td headers="hd_h_niceng235er4.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">BNF 2021</td></tr><tr><td headers="hd_h_niceng235er4.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Meptazinol (as Meptazinol hydrochloride) 100 mg per 1 ml</td><td headers="hd_h_niceng235er4.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£1.92 per ampoule</td><td headers="hd_h_niceng235er4.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">BNF 2021</td></tr></tbody></table></div></div></article><article data-type="table-wrap" id="figobniceng235er4appjtab1"><div id="niceng235er4.appj.tab1" class="table"><h3><span class="label">Table 40</span><span class="title">Excluded studies and reasons for their exclusion</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK596254/table/niceng235er4.appj.tab1/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng235er4.appj.tab1_lrgtbl__"><table><thead><tr><th id="hd_h_niceng235er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Study</th><th id="hd_h_niceng235er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Reason</th></tr></thead><tbody><tr><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Bhagvandas, J., Foon, R., Fong, K.
|
|
et al. (2022) The effect of remifentanil patient-controlled analgesia versus epidural in labour: maternal and neonatal outcomes. Anaesthesia
|
|
77(suppl2): 9
|
|
</td><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">- Conference abstract.</td></tr><tr><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Blair, J. M., Dobson, G. T., Hill, D. A.
|
|
et al. (2001) Patient-controlled analgesia for labor: a comparison of remifentanil and pethidine. Anesthesiology
|
|
95: abstractnoa1063 [<a href="https://pubmed.ncbi.nlm.nih.gov/15601268" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 15601268</span></a>]
|
|
</td><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">- Conference abstract.</td></tr><tr><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Blair, J. M., Dobson, G. T., Hill, D. A.
|
|
et al. (2005) Patient controlled analgesia for labour: a comparison of remifentanil with pethidine. Anaesthesia
|
|
60(1): 22–27 [<a href="https://pubmed.ncbi.nlm.nih.gov/15601268" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 15601268</span></a>]
|
|
</td><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Comparator not in PICO</p>
|
|
<p>Pethidine administered intravenously via PCA</p>
|
|
</td></tr><tr><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Bricker, Leanne and Lavender, Tina (2002) Parenteral opioids for labor pain relief: a systematic review. American journal of obstetrics and gynecology
|
|
186(5supplnature): 94–109 [<a href="https://pubmed.ncbi.nlm.nih.gov/12011876" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 12011876</span></a>]
|
|
</td><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Intervention not in PICO</p>
|
|
<p>Systematic review does not include remifentanil PCA</p>
|
|
</td></tr><tr><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Calderon, E., Martinez, E., Roman, M. D.
|
|
et al. (2006) Intravenous remifentanil delivered through an elastomeric device versus intramuscular meperidine comparative study for obstetric analgesia. Revista de la sociedad espanola del dolor
|
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13(7): 462–467
|
|
</td><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">- Article not in English</td></tr><tr><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Douma, M. R., Verwey, R. A., Kam-Endtz, C. E.
|
|
et al. (2010) Obstetric analgesia: a comparison of patient-controlled meperidine, remifentanil, and fentanyl in labour. British journal of anaesthesia
|
|
104(2): 209–215 [<a href="https://pubmed.ncbi.nlm.nih.gov/20008859" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 20008859</span></a>]
|
|
</td><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Comparator not in PICO</p>
|
|
<p>Comparator opioids (meperidine and fentanyl) administered intravenously via PCA</p>
|
|
</td></tr><tr><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Elbourne
|
|
D and Wiseman
|
|
RA (2000) Types of intra-muscular opioids for maternal pain relief in labour. The Cochrane database of systematic reviews: CD001237 [<a href="https://pubmed.ncbi.nlm.nih.gov/10796255" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 10796255</span></a>]
|
|
</td><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Intervention not in PICO</p>
|
|
<p>Systematic review does not include remifentanil PCA</p>
|
|
</td></tr><tr><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Fairlie, F M, Marshall, L, Walker, J J
|
|
et al. (1999) Intramuscular opioids for maternal pain relief in labour: a randomised controlled trial comparing pethidine with diamorphine. British journal of obstetrics and gynaecology
|
|
106(11): 1181–7 [<a href="https://pubmed.ncbi.nlm.nih.gov/10549964" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 10549964</span></a>]
|
|
</td><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Intervention not in PICO</p>
|
|
<p>Study does not include remifentanil PCA</p>
|
|
</td></tr><tr><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Haslam, D., Donaldson, H., Davies, S.
|
|
et al. (2021) Low-dose remifentanil patient-controlled analgesia: Efficacy and safety in two North West obstetric units. Anaesthesia
|
|
76(suppl6): 40
|
|
</td><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">- Conference abstract.</td></tr><tr><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Isenor, L and Penny-MacGillivray, T (1993) Intravenous meperidine infusion for obstetric analgesia. Journal of obstetric, gynecologic, and neonatal nursing : JOGNN
|
|
22(4): 349–56 [<a href="https://pubmed.ncbi.nlm.nih.gov/8410434" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 8410434</span></a>]
|
|
</td><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Intervention not in PICO</p>
|
|
<p>Study does not include remifentanil PCA</p>
|
|
</td></tr><tr><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Jelting, Y., Weibel, S., Jokinen, J.
|
|
et al. (2017) Patient-controlled analgesia with remifentanil vs. alternative parenteral methods for pain management in labour: a Cochrane systematic review. Anaesthesia
|
|
72(8): 1016–1028 [<a href="https://pubmed.ncbi.nlm.nih.gov/28695584" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 28695584</span></a>]
|
|
</td><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Systematic review- comparator not in PICO</p>
|
|
<p>Includes studies with comparators delivered intravenously</p>
|
|
</td></tr><tr><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Keskin, H L, Keskin, E Aktepe, Avsar, A F
|
|
et al. (2003) Pethidine versus tramadol for pain relief during labor. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics
|
|
82(1): 11–6 [<a href="https://pubmed.ncbi.nlm.nih.gov/12834936" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 12834936</span></a>]
|
|
</td><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Intervention not in PICO</p>
|
|
<p>Study does not include remifentanil PCA</p>
|
|
</td></tr><tr><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Leong, Wan Ling; Sng, Ban Leong; Sia, Alex Tiong Heng (2011) A comparison between remifentanil and meperidine for labor analgesia: A systematic review. Anesthesia and Analgesia
|
|
113(4): 818–825 [<a href="https://pubmed.ncbi.nlm.nih.gov/21890889" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 21890889</span></a>]
|
|
</td><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Systematic review- comparator not in PICO</p>
|
|
<p>Includes studies with comparators delivered intravenously</p>
|
|
</td></tr><tr><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
MacArthur, C., Hewitt, C., Handley, K.
|
|
et al. (2019) Remifentanil patient-controlled analgesia versus intramuscular pethidine for pain relief in labour: The RESPITE randomised controlled trial. BJOG: An International Journal of Obstetrics and Gynaecology
|
|
126(supplement2): 128
|
|
</td><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">- Conference abstract.</td></tr><tr><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
McInnes, Rhona J, Hillan, Edith, Clark, Diana
|
|
et al. (2004) Diamorphine for pain relief in labour : a randomised controlled trial comparing intramuscular injection and patient-controlled analgesia. BJOG : an international journal of obstetrics and gynaecology
|
|
111(10): 1081–9 [<a href="https://pubmed.ncbi.nlm.nih.gov/15383110" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 15383110</span></a>]
|
|
</td><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Intervention not in PICO</p>
|
|
<p>Study does not include remifentanil PCA</p>
|
|
</td></tr><tr><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Moran, V. H., Thomson, G., Cook, J.
|
|
et al. (2019) Qualitative exploration of women’s experiences of intramuscular pethidine or remifentanil patient-controlled analgesia for labour pain. BMJ open
|
|
9(12): e032203 [<a href="/pmc/articles/PMC7008414/" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC7008414</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/31874879" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 31874879</span></a>]
|
|
</td><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Qualitative study</p>
|
|
<p>Relevant quantitative outcomes reported in main trial data (included article)</p>
|
|
</td></tr><tr><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Morley-Forster, P K; Reid, D W; Vandeberghe, H (2000) A comparison of patient-controlled analgesia fentanyl and alfentanil for labour analgesia. Canadian journal of anaesthesia = Journal canadien d’anesthesie
|
|
47(2): 113–9 [<a href="https://pubmed.ncbi.nlm.nih.gov/10674503" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 10674503</span></a>]
|
|
</td><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Intervention not in PICO</p>
|
|
<p>Study does not include remifentanil PCA</p>
|
|
</td></tr><tr><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Nelson, Kenneth E and Eisenach, James C (2005) Intravenous butorphanol, meperidine, and their combination relieve pain and distress in women in labor. Anesthesiology
|
|
102(5): 1008–13 [<a href="https://pubmed.ncbi.nlm.nih.gov/15851889" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 15851889</span></a>]
|
|
</td><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Intervention not in PICO</p>
|
|
<p>Study does not include remifentanil PCA</p>
|
|
</td></tr><tr><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Schnabel, Alexander, Hahn, Niklas, Broscheit, Jens
|
|
et al. (2012) Remifentanil for labour analgesia: a meta-analysis of randomised controlled trials. European journal of anaesthesiology
|
|
29(4): 177–85 [<a href="https://pubmed.ncbi.nlm.nih.gov/22273829" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 22273829</span></a>]
|
|
</td><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Systematic review- comparator not in PICO</p>
|
|
<p>Includes studies with comparators not administered intramuscularly</p>
|
|
</td></tr><tr><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Smith, Lesley A.; Burns, Ethel; Cuthbert, Anna (2018) Parenteral opioids for maternal pain management in labour. Cochrane Database of Systematic Reviews
|
|
2018(6): cd007396 [<a href="/pmc/articles/PMC6513033/" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC6513033</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/29870574" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 29870574</span></a>]
|
|
</td><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Systematic review- comparator not in PICO</p>
|
|
<p>Comparator administered intravenously via PCA</p>
|
|
</td></tr><tr><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Soontrapa, Sukree, Somboonporn, Woraluk, Komwilaisak, Ratana
|
|
et al. (2002) Effectiveness of intravenous meperidine for pain relief in the first stage of labour. Journal of the Medical Association of Thailand = Chotmaihet thangphaet
|
|
85(11): 1169–75 [<a href="https://pubmed.ncbi.nlm.nih.gov/12546313" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 12546313</span></a>]
|
|
</td><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Intervention not in PICO</p>
|
|
<p>Study does not include remifentanil PCA</p>
|
|
</td></tr><tr><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Sosa, Claudio G, Balaguer, Erica, Alonso, Justo G
|
|
et al. (2004) Meperidine for dystocia during the first stage of labor: A randomized controlled trial. American journal of obstetrics and gynecology
|
|
191(4): 1212–8 [<a href="https://pubmed.ncbi.nlm.nih.gov/15507943" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 15507943</span></a>]
|
|
</td><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Intervention not in PICO</p>
|
|
<p>Study does not include remifentanil PCA</p>
|
|
</td></tr><tr><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Stourac, Petr, Kosinova, Martina, Harazim, Hana
|
|
et al. (2016) The analgesic efficacy of remifentanil for labour. Systematic review of the recent literature. Biomedical papers of the Medical Faculty of the University Palacky, Olomouc, Czechoslovakia
|
|
160(1): 30–38 [<a href="https://pubmed.ncbi.nlm.nih.gov/26460593" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 26460593</span></a>]
|
|
</td><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Systematic review- comparator not in PICO</p>
|
|
<p>Includes studies with comparators delivered intravenously or epidural</p>
|
|
</td></tr><tr><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Tan, A., Wilson, A.N., Eghrari, D.
|
|
et al. (2022) Outcomes to measure the effects of pharmacological interventions for pain management for women during labour and birth: a review of systematic reviews and randomised trials. BJOG: An International Journal of Obstetrics and Gynaecology
|
|
129(6): 845–854 [<a href="https://pubmed.ncbi.nlm.nih.gov/34839565" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 34839565</span></a>]
|
|
</td><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Systematic review - intervention not in PICO</p>
|
|
<p>Does not include Remifentanil</p>
|
|
</td></tr><tr><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Thurlow, J. A., Laxton, C. H., Dick, A.
|
|
et al. (2000) Comparison of patient controlled analgesia (PCA) using remifentanil with intramuscular pethidine for pain relief in labour. International journal of obstetric anesthesia
|
|
9: 200
|
|
</td><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">- Conference abstract.</td></tr><tr><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Tsui, Michelle H Y, Ngan Kee, Warwick D, Ng, Floria F
|
|
et al. (2004) A double blinded randomised placebo-controlled study of intramuscular pethidine for pain relief in the first stage of labour. BJOG : an international journal of obstetrics and gynaecology
|
|
111(7): 648–55 [<a href="https://pubmed.ncbi.nlm.nih.gov/15198753" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 15198753</span></a>]
|
|
</td><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Intervention not in PICO</p>
|
|
<p>Study does not include remifentanil PCA</p>
|
|
</td></tr><tr><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Tveit, T. O., Seiler, S., Halvorsen, A.
|
|
et al. (2012) Labour analgesia: a randomised, controlled trial comparing intravenous remifentanil and epidural analgesia with ropivacaine and fentanyl. European journal of anaesthesiology
|
|
29(3): 129–136 [<a href="https://pubmed.ncbi.nlm.nih.gov/22249153" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 22249153</span></a>]
|
|
</td><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Comparator not in PICO</p>
|
|
<p>Comparator is epidural</p>
|
|
</td></tr><tr><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Volikas, I. and Male, D. (2001) A comparison of pethidine and remifentanil patient-controlled analgesia in labour. International journal of obstetric anesthesia
|
|
10(2): 86–90 [<a href="https://pubmed.ncbi.nlm.nih.gov/15321621" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 15321621</span></a>]
|
|
</td><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Comparator not in PICO</p>
|
|
<p>Comparator is administered intravenously</p>
|
|
</td></tr><tr><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Weibel, S., Jelting, Y., Afshari, A.
|
|
et al. (2017) Patient-controlled analgesia with remifentanil versus alternative parenteral methods for pain management in labour. Cochrane Database of Systematic Reviews [<a href="/pmc/articles/PMC6478102/" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC6478102</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/28407220" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 28407220</span></a>]
|
|
</td><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Systematic review- comparator not in PICO</p>
|
|
<p>Includes studies with comparators administered intravenously</p>
|
|
</td></tr><tr><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Wilson, M. J., MacArthur, C., Smith, F. G.
|
|
et al. (2017) A randomised controlled trial of remifentanil intravenous patient controlled analgesia (PCA) versus intramuscular pethidine for pain relief in labour (RESPITE trial). International journal of obstetric anesthesia
|
|
31: S8
|
|
</td><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">- Conference abstract.</td></tr><tr><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Xu, Shiqin, Shen, Xiaofeng, Wang, Fuzhou
|
|
et al. (2012) Effectiveness of remifentanil for labor pain control: A systematic review and meta-analysis. HealthMED
|
|
6(7): 2407–2418
|
|
</td><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Systematic review- comparator not in PICO</p>
|
|
<p>Includes studies with comparators not delivered intramuscularly</p>
|
|
</td></tr><tr><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Zhang, Peijun, Yu, Zhiqiang, Zhai, Meili
|
|
et al. (2021) Effect and Safety of Remifentanil Patient-Controlled Analgesia Compared with Epidural Analgesia in Labor: An Updated Meta-Analysis of Randomized Controlled Trials. Gynecologic and obstetric investigation
|
|
86(3): 231–238 [<a href="https://pubmed.ncbi.nlm.nih.gov/34192701" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 34192701</span></a>]
|
|
</td><td headers="hd_h_niceng235er4.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Systematic review- comparator not in PICO</p>
|
|
<p>Comparator is epidural analgesia</p>
|
|
</td></tr></tbody></table></div></div></article><article data-type="table-wrap" id="figobniceng235er4appjtab2"><div id="niceng235er4.appj.tab2" class="table"><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK596254/table/niceng235er4.appj.tab2/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng235er4.appj.tab2_lrgtbl__"><table><thead><tr><th id="hd_h_niceng235er4.appj.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Study</th><th id="hd_h_niceng235er4.appj.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Reason</th></tr></thead><tbody><tr><td headers="hd_h_niceng235er4.appj.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
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Freeman, Liv, Middeldorp, Johanna, van den Akker, Eline
|
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et al. (2018) An economic analysis of patient controlled remifentanil and epidural analgesia as pain relief in labour (RAVEL trial); a randomised controlled trial. PloS one
|
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13(10): e0205220 [<a href="/pmc/articles/PMC6181333/" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC6181333</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/30307986" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 30307986</span></a>]
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</td><td headers="hd_h_niceng235er4.appj.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">- Cost analysis only</td></tr></tbody></table></div></div></article></div><div id="jr-scripts"><script src="/corehtml/pmc/jatsreader/ptpmc_3.22/js/libs.min.js"> </script><script src="/corehtml/pmc/jatsreader/ptpmc_3.22/js/jr.min.js"> </script></div></div>
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