Intravenous Patient-controlled Analgesia Versus Thoracic Epidural Analgesia After Open Liver Surgery

Abstract

Objective: We conducted a randomized, controlled, noninferiority trial to investigate if intravenous, multimodal, patient-controlled analgesia (IV-PCA) could be noninferior to multimodal thoracic epidural analgesia (TEA) in patients undergoing open liver surgery. Summary Background Data: The increasing use of minimally invasive techniques and fast track protocols have questioned the position of epidural analgesia as the optimal method of pain management after abdominal surgery. Methods: Patients operated with open liver resection between February 2012 and February 2016 were randomly assigned to receive either IV-PCA enhanced with ketorolac/diclofenac (IV-PCA, n = 66) or TEA (n = 77) within an enhanced recovery after surgery protocol. Noninferiority would be declared if the mean pain score on the numeric rating scale (NRS) for postoperative days (PODs) 0 to 5 in the IV-PCA group was no worse than the mean pain score in the TEA group by a margin of <1 point on an 11-point scale (0–10). Results: The primary endpoint, mean NRS pain score was 1.7 in the IV-PCA group and 1.6 in the TEA group, establishing noninferiority. Pain scores were lower in the TEA group on PODs 0 and 1, but higher or equal on PODs 2 and 5. Postoperative hospital stay was significantly shorter for patients in the IV-PCA group (74 vs 104 h, P < 0.001). The total opioid consumption during the first 3 days was significantly lower in the IV-PCA group. Conclusions: IV-PCA was noninferior to TEA for the treatment of postoperative pain in patients undergoing open liver resection.

Pain management after open liver resection: Procedure-Specific Postoperative Pain Management (PROSPECT) recommendations

“…Five RCTs [35][36][37][38][39] and one meta-analysis 40 compared the analgesic effect of TEA with opioid intravenous PCA. The meta-analysis that included four RCTs (n=278 patients) demonstrated that, compared with opioid intravenous PCA, TEA provided superior pain relief at rest and with movement at 12 and 24 hours after surgery, with no significant difference in hospital length of stay (LOS).…”

“…One RCT compared TEA with ketobemidone (opioid) intravenous PCA combined with intravenous NSAIDs, while both groups received acetaminophen on a scheduled basis. 38 Another placebo-controlled RCT compared intraoperative TEA with sham epidural analgesia and intrathecal morphine (500 µg) and fentanyl (15 µg). Patients in the TEA group suffered less pain at rest and with movements, and demonstrated significantly lower opioid use.…”

Adjunctive dexmedetomidine infusion in open living donor hepatectomy: A way to enhance postoperative analgesia and recovery

“…16 However, epidural analgesia is a more invasive method for postoperative pain control and may cause serious complications. 16,17 Furthermore, compared with IV-PCA, additional pain reduction using epidural analgesia seemed modest in these procedures. 16 Hence, the optimal form of analgesia after abdominal surgery remains debated.…”

“…In our previous study, opioid-based IV-PCA with an adjunct could provide sufficient pain relief, similar to thoracic epidural analgesia, after video-assisted thoracic surgery, leading to moderate-to-severe postoperative pain. 11 Hausken et al 17 20 demonstrated that intraoperative DEX infusion could decrease bleeding and provide a better surgical field, because of more stable hemodynamics. In addition, a meta-analysis showed that systemic administration of DEX could significantly decrease intraoperative blood loss in nasal surgery.…”

Ultrasound-Guided Bilateral Superficial Cervical Plexus Block Enhance the Quality of Recovery in Patients following Parathyroidectomy with Secondary Hyperparathyroidism

“…Patients experience mild to moderate postoperative incision site pain after thyroidectomy or parathyroidectomy, and opioid analgesics are prescribed to relieve the pain [5]. But inappropriate opioid usage patterns can increase drugrelated adverse effects,risk for dependence and abuse, and perioperative complications,morbidity [17].Several studies have demonstrated that multimodal analgesia (MMA) can effectively relieve postoperative pain and reduce the consumption of opioid analgesics following orthopedic, thoracic, and gastric surgery [18][19][20].A previous study showed that MMA protocol including use of nonopioid multimodal agents, incorporating NSAIDs, is safe,and declined in prescription of postoperative opioid analgesics for patients undergoing thyroid and parathyroid surgery [21].Additionally,administration of local anesthesia before incision can prevent central sensitization and relieve postoperative acute pain. In view of the its ability to block the branches of super cial cervical plexus including lesser occipital, greater auricular, transverse cervical,and supraclavicularnerves,BSCPB has been performed in neck surgery.…”