For Patients Undergoing Pancreatoduodenectomy, Epidural Anesthesia and Analgesia Improves Pain But Increases Rates of Intensive Care Unit Admissions and Alterations in Analgesics

Choi, Daniel X.; Schoeniger, Luke O.

doi:10.1097/mpa.0b013e3181bdfc76

Cited by 25 publications

(56 citation statements)

References 21 publications

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“…All epidural and IV PCA patients received concurrent IV paracetamol (acetaminophen) 1 g 6-hourly unless contraindicated and standard postoperative care as described in other cohorts. 17 Analysis groups were similar to those reported by Pratt et al 14 : epidural analgesia, IV PCA, functional epidurals, aborted epidurals. Analgesic efficacy was assessed between functional (working) and aborted epidurals at 24 hours, 48 hours, and overall for the duration of pain assessment, which was 2 days.…”

Section: Methodssupporting

confidence: 68%

“…14, 16,17 Inadequate block was the commonest reason for epidural abortion; 70.9% is higher than the 43.1% 14 previously quoted, but definitions vary between studies for epidural blockade, breakthrough pain, and epidural adjustment. 17 Hypotension was the reason for premature abortion in our cohort in only 6.5%, which is lower than the 33% to 41% previously reported, although heterogeneous definitions and practice are caveats that might explain this apparent disparity. 14,16 Our baseline patient demographics were similar to most other cohorts, with slightly more male patients aged 60 to 70 years.…”

Section: Discussionmentioning

confidence: 67%

“…14,16 Our baseline patient demographics were similar to most other cohorts, with slightly more male patients aged 60 to 70 years. 14Y17 However, other studies included patients with chronic pancreatitis 14,17 or those who did not receive a pancreaticoduodenectomy, for example, hepatectomy, 16 so the reported studies are each slightly different with respect to case mix.…”

Section: Discussionmentioning

confidence: 97%

“…14, 16 Aborted epidurals comprise 14%, 25%, and 38% in cohorts. 14,16,17 The main reasons are inadequate block and hypotension leading to hemodynamic compromise. The largest cohort is from a high-volume single US center and compared 58 aborted epidurals to 127 functioning epidurals and included 48 patients managed with IV PCA only.…”

mentioning

confidence: 99%

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Poor Analgesic Efficacy of Epidural Analgesia in Critical Care Patients After Pancreaticoduodenectomy

Patel¹,

Stasiowska²,

Waheed³

et al. 2014

Pancreas

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Section: Methodssupporting

confidence: 68%

Section: Discussionmentioning

confidence: 67%

Section: Discussionmentioning

confidence: 97%

mentioning

confidence: 99%

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Poor Analgesic Efficacy of Epidural Analgesia in Critical Care Patients After Pancreaticoduodenectomy

Patel¹,

Stasiowska²,

Waheed³

et al. 2014

Pancreas

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“…Interestingly, this observation reflects the general opinion throughout the surgical literature. Epidural analgesia provides superior pain relief after PD than IV PCA; 44 however, the impact of epidural analgesia on postoperative morbidity and mortality is not completely understood. Recent studies have suggested that epidural use results in fewer postoperative complications; 45 in contrast, epidural analgesia has been found to promote hemodynamic instability following PD and possibly contributes to an increased incidence of various gastrointestinal and respiratory complications.…”

mentioning

confidence: 99%

Canadian practice patterns for pancreaticoduodenectomy

Cyr

Truong

Lam-McCulloch

et al. 2015

cjs

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Background: Discordant practice patterns may be a consequence of evidence-practice gaps or deficiencies in knowledge translation. We examined the current strategies used by hepato-pancreatico-biliary (HPB) surgeons in Canada for the perioperative management of pancreaticoduodenectomy (PD). Methods:We generated a web-based survey that focused on the perioperative measures surrounding PD. The survey was distributed to all members of the Canadian Hepato-Pancreatico-Biliary Association. Results:The survey was distributed to 74 surgeons and received a response rate of 50%. Many similarities in surgical techniques were reported; for example, most surgeons (86.5%) reconstruct the pancreas with pancreaticojejunostomy rather than pancreaticogastrostomy. In contrast, variable techniques regarding the use of peritoneal drainage tubes, anastomotic stents, octreotide and other intraoperative modalities were reported. Most surgeons (75.7%) reported that their patients frequently required preoperative biliary drainage, yet there was minimal agreement with the designated criteria. There was variability in postoperative care, including the use of epidural analgesia and timing of postoperative oral nutrition. Conclusion:We identified heterogeneity among Canadian HPB surgeons, suggesting a number of evidence-practice gaps within specific domains of pancreatic resections. Focused research in these areas may facilitate technical agreement and improve patient outcomes following PD.Contexte : La discordance entre les modes de pratique pourrait être due à des lacunes au plan des pratiques fondées sur des preuves ou à une déficience du transfert des connaissances. Nous avons étudié les stratégies actuellement utilisées par les chirurgiens hépato-pancréato-biliaires (HPB) au Canada pour la prise en charge périopératoire de la pancréatoduodénectomie (PD). Méthodes :Nous avons préparé un questionnaire électronique sur les mesures péri-opératoires entourant la PD. Le questionnaire a été distribué à tous les membres de l'Association hépato-pancréato-biliaire canadienne.Résultats : Le questionnaire a été distribué à 74 chirurgiens et a généré un taux de réponse de 50 %. De nombreuses similitudes dans les techniques chirurgicales ont été signalées : par exemple, la majorité des chirurgiens (86,5 %) reconstruisent le pancréas par pancréatojéjunostomie plutôt que par pancréatogastrostomie. En revanche, on a observé une variabilité dans les techniques d'utilisation des drains péritonéaux, des endoprothèses anastomotiques, des octréotides et autres modalités peropératoires. La majorité des chirurgiens (75,7 %) ont signalé que leurs patients avaient souvent besoin de drains biliaires préopératoires et pourtant, les critères désignés ne semblaient pas faire l'unanimité. On a aussi noté des différences dans les soins postopératoires, y compris en ce qui concerne le recours à l'analgésie péridurale et le moment de la reprise de l'alimentation orale après la chirurgie. Conclusion :Nous avons observé une hétérogénéité dans la pratique des chirurgiens HP...

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Meta‐analysis of epidural analgesia in patients undergoing pancreatoduodenectomy

et al. 2019

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BackgroundThe optimal analgesic technique after pancreatoduodenectomy remains under debate. This study aimed to see whether epidural analgesia (EA) has superior clinical outcomes compared with non‐epidural alternatives (N‐EA) in patients undergoing pancreatoduodenectomy.MethodsA systematic review with meta‐analysis was performed according to PRISMA guidelines. On 28 August 2018, relevant literature databases were searched. Primary outcomes were pain scores. Secondary outcomes were treatment failure of initial analgesia, complications, duration of hospital stay and mortality.ResultsThree RCTs and eight cohort studies (25 089 patients) were included. N‐EA treatments studied were: intravenous morphine, continuous wound infiltration, bilateral paravertebral thoracic catheters and intrathecal morphine. Patients receiving EA had a marginally lower pain score on days 0–3 after surgery than those receiving intravenous morphine (mean difference (MD) −0·50, 95 per cent c.i. −0·80 to −0·21; P < 0·001) and similar pain scores to patients who had continuous wound infiltration. Treatment failure occurred in 28·5 per cent of patients receiving EA, mainly for haemodynamic instability or inadequate pain control. EA was associated with fewer complications (odds ratio (OR) 0·69, 95 per cent c.i. 0·06 to 0·79; P < 0·001), shorter duration of hospital stay (MD −2·69 (95 per cent c.i. −2·76 to −2·62) days; P < 0·001) and lower mortality (OR 0·69, 0·51 to 0 93; P = 0·02) compared with intravenous morphine.ConclusionEA provides marginally lower pain scores in the first postoperative days than intravenous morphine, and appears to be associated with fewer complications, shorter duration of hospital stay and less mortality.

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For Patients Undergoing Pancreatoduodenectomy, Epidural Anesthesia and Analgesia Improves Pain But Increases Rates of Intensive Care Unit Admissions and Alterations in Analgesics

Abstract: For patients undergoing PD, EAA was not associated with clinical benefits except for a modest reduction in postoperative pain, which was limited to a single day. Therefore, in this study, the clinical benefits of EAA seem underwhelming.

Cited by 25 publications

References 21 publications

Poor Analgesic Efficacy of Epidural Analgesia in Critical Care Patients After Pancreaticoduodenectomy

Poor Analgesic Efficacy of Epidural Analgesia in Critical Care Patients After Pancreaticoduodenectomy

Canadian practice patterns for pancreaticoduodenectomy

Meta‐analysis of epidural analgesia in patients undergoing pancreatoduodenectomy

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