Brazilian Journal of Anesthesiology
https://app.periodikos.com.br/journal/rba/article/doi/10.1016/j.bjane.2026.844766
Brazilian Journal of Anesthesiology
Review Article

Programmed intermittent epidural bolus versus continuous epidural infusion combined with patient-controlled epidural analgesia for postoperative analgesia: a meta-analysis of randomized controlled trials

Bolus epidural intermitente programado versus infusão epidural contínua combinados com analgesia epidural controlada pelo paciente para analgesia pós-operatória: uma metanálise de ensaios clínicos randomizados

Gabriel Lemos González, Vinícius Fernandes Sarmento, Bruno Francisco Minetto Wegner, Gustavo Roberto Minetto Wegner, Alesson Marinho Miranda, Iaci Luisa Lopes de Mattos, Tatiana Souza do Nascimento

http://dx.doi.org/10.1016/j.bjane.2026.844766 Braz J Anesthesiol, vol.76, n4, 844766, 2026
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Abstract

Background

Programmed Intermittent Epidural Bolus (PIEB) and Continuous Epidural Infusion (CEI) are widely used strategies for maintaining postoperative analgesia, typically combined with Patient-Controlled Epidural Analgesia (PCEA). Although PIEB is theorized to enhance epidural drug distribution and analgesic effectiveness through intermittent high-pressure boluses, evidence supporting its superiority over CEI in the postoperative setting remains inconsistent.

Methods

We conducted a systematic review and meta-analysis of Randomized Controlled Trials (RCTs) comparing PIEB and CEI, both with PCEA, in adult postoperative patients (PROSPERO CRD420251046001). PubMed, Embase, and Cochrane were searched until May 1, 2025. Primary outcome: pain at 24 hours. Secondary outcomes: pain at other intervals, anesthetic consumption, and adverse events. Data were synthesized using a random-effects model; Risk of Bias (RoB-2) and small-study effects were assessed.

Results

Ten RCTs comprising 692 patients were included. No significant difference was found in 24-hour pain scores at rest (MD = -0.45; 95% CI -0.99 to 0.10) or movement (MD = -0.88; 95% CI -2.07 to 0.32). PIEB showed mildly lower pain at other time points and reduced total epidural volume (MD = -7.31 mL; 95% CI -13.7 to -0.92 mL). However, PIEB was associated with higher hypotension risk (RR = 1.71; 95% CI 1.05 to 2.78). No differences were found in opioid consumption, PCEA demands, or other adverse events.

Conclusion

PIEB offers no significant analgesic advantage and increases hypotension risk compared to CEI in postoperative settings, when both are combined with PCEA. These findings should be interpreted with caution due to the limited number of studies and substantial heterogeneity.

Keywords

Continuous epidural infusion; Epidural analgesia; Patient-controlled epidural analgesia; Postoperative pain; Programmed intermittent epidural bolus

Resumo

Introdução

O bolus epidural intermitente programado (BEIP) e a infusão epidural contínua (IEC) são estratégias amplamente utilizadas para a manutenção da analgesia pós-operatória, tipicamente combinadas com a analgesia epidural controlada pelo paciente (AECP). Embora se teorize que o BEIP melhore a distribuição de fármacos no espaço epidural e a eficácia analgésica por meio de bolus intermitentes de alta pressão, as evidências que sustentam sua superioridade sobre a IEC no cenário pós-operatório permanecem inconsistentes.

Métodos

Realizamos uma revisão sistemática e metanálise de ensaios clínicos randomizados (ECRs) comparando o BEIP e a IEC, ambos com AECP, em pacientes adultos no pós-operatório (PROSPERO CRD420251046001). As bases de dados PubMed, Embase e Cochrane foram consultadas até 1º de maio de 2025. O desfecho primário foi a dor em 24 horas. Os desfechos secundários incluíram dor em outros intervalos, consumo de anestésicos e eventos adversos. Os dados foram sintetizados por meio de um modelo de efeitos aleatórios; o risco de viés (RoB-2) e os efeitos de pequenos estudos foram avaliados.

Resultados

Foram incluídos dez ECRs totalizando 692 pacientes. Nenhuma diferença significativa foi encontrada nos escores de dor em 24 horas em repouso (DM = -0,45; IC 95% -0,99 a 0,10) ou em movimento (DM = -0,88; IC 95% -2,07 a 0,32). O BEIP apresentou dor levemente menor em outros momentos e redução no volume epidural total (DM = -7,31 mL; IC 95% -13,7 a -0,92 mL). No entanto, o BEIP foi associado a um maior risco de hipotensão (RR = 1,71; IC 95% 1,05 a 2,78). Não foram encontradas diferenças no consumo de opioides, nas demandas de AECP ou em outros eventos adversos.

Conclusão

O BEIP não oferece vantagem analgésica significativa e aumenta o risco de hipotensão em comparação à IEC em contextos pós-operatórios, quando ambos são combinados com AECP. Esses achados devem ser interpretados com cautela devido ao número limitado de estudos e à heterogeneidade substancial.

Palavras-chave

Infusão epidural contínua; Analgesia epidural; Analgesia epidural controlada pelo paciente; Dor pós-operatória; Bolus epidural intermitente programado

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Submitted date:
12/12/2025

Accepted date:
16/05/2026

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