Programmed Intermittent Epidural Boluses (PIEB) for Maintenance of Labor Analgesia: An Incremental Step Before the Next Paradigm Shift?

e agree with the evidence comparing programmed intermittent epidural boluses (PIEB) to conventional continuous epidural infusions (CEI) for maintaining epidural labor analgesia presented by Munro and George, (1) showing advantages with PIEB for both the patient (with less local anesthetic consumption, improved maternal satisfaction, potentially shorter duration of labor) and the anesthesia team (with decreased workload requirements) (2). However we disagree with their interpretation of the data, specifically the effect size of the demonstrated improvements (3). As we previously stated, the observed differences are modest and of limited clinical impact (4). The epidural analgesic technique of PIEB therefore needs to be considered only an incremental improvement over CEI for the maintenance of epidural labor analgesia. As such rather than focusing on the limited improvement of PIEB, perhaps we need to shift our overall perspective.