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

Patel, Amit; Stasiowska, Maria; Waheed, Umeer; Brett, Stephen; Patel, Parind

doi:10.1097/mpa.0000000000000031

Cited by 10 publications

(17 citation statements)

References 26 publications

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“…The study cohorts were largely comparable regarding sex, age and ASA grade, except one study 7 in which patients in the N-EA group had a higher ASA grade. The types of EA infusion were: patient-controlled (1) 23 , continuous infusion (5) 4,5,7,20,25 , patient-controlled and continuous infusion (1) 21 , and no information regarding infusion (4) 3,14,22,24 . The EA protocols warranted termination between POD 3 and 6 (4 studies did not provide information on duration of EA).…”

Section: Resultsmentioning

confidence: 99%

“…Four studies 3,5,7,23 reported on treatment failure of EA, which occurred in 121 (28⋅5 per cent) of 425 patients (range between studies 14⋅8-55⋅6 per cent). The reason for EA treatment failure was specified in 111 patients in three studies 5,7,23 : 49 (44⋅1 per cent) due to haemodynamic compromise, 47 (42⋅3 per cent) to inadequate pain control and 15 (13⋅5 per cent) to catheter migration or malfunction. In the study 20 that looked at EA and paravertebral catheters, two patients (8⋅7 per cent) receiving EA but none who had paravertebral catheter treatment required intervention for hypotension, although it was unclear whether this led to treatment failure.…”

Section: Treatment Failure Of Initial Analgesiamentioning

confidence: 99%

“…There EA versus i.v. morphine Choi and Schoeniger 3 Patel et al 7 Axelrod et al 23 Sakowska et al 24 EA versus CWI Mungroop et al 21 Pratt et al 5 Shah et al 25 Amini et al 3,5,7,14,23 -25 . Neither the study 21 comparing EA with continuous wound infiltration nor the study 24 comparing EA and intrathecal morphine found any difference in mortality.…”

Section: Mortalitymentioning

confidence: 99%

“…Epidural analgesia (EA) is the perioperative analgesic technique of choice for most open abdominal surgical procedures and has been associated with better pain control after pancreatoduodenectomy 2 -5 . Patients receiving EA appear to have fewer pulmonary complications and a lower incidence of postoperative ileus 6 . However, some studies 3,5,7,8 have noted adverse effects related to EA, including increased postoperative complication rates, ICU admissions and duration of hospital stay in these patients. EA has been associated with haemodynamic instability, sometimes requiring vasoactive medication or excessive fluid administration, thought to be associated with impaired anastomotic healing and other complications 3,5,9,10 .…”

Section: Introductionmentioning

confidence: 99%

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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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Section: Resultsmentioning

confidence: 99%

Section: Treatment Failure Of Initial Analgesiamentioning

confidence: 99%

Section: Mortalitymentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Meta‐analysis of epidural analgesia in patients undergoing pancreatoduodenectomy

et al. 2019

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“…3–6 The most used alternative for EA is the patient-controlled analgesia with intravenous morphine (ivPCAM). 3,5,7…”

Section: Introductionmentioning

confidence: 99%

Epidural and Non-epidural Analgesia in Patients Undergoing Open Pancreatectomy: a Retrospective Cohort Study

Groen

Slotboom

Vuyk

et al. 2019

Journal of Gastrointestinal Surgery

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BackgroundThe use of epidural analgesia (EA) in pancreatic surgery remains under debate. This study compares patients treated with EA versus non-EA after open pancreatectomy in a tertiary referral center.MethodsAll patients undergoing open pancreatectomy from 2013 to 2017 were retrospectively reviewed. (Non-)EA was terminated on postoperative day (POD) 3 or earlier if required.ResultsIn total, 190 (72.5%) patients received EA and 72 (27.5%) patients received non-EA (mostly intravenous morphine). EA was terminated prematurely in 32.6% of patients and non-EA in 10.5% of patients. Compared with non-EA patients, EA patients had significantly lower pain scores on POD 0 (1.10 (0–3.00) versus 3.00 (1.67–5.00), P < 0.001) and POD 1 (2.00 (0.50–3.41) versus 3.00 (2.00–3.80), P = 0.001), though significantly higher pain scores on POD 3 (3.00 (2.00–4.00) versus 2.33 (1.50–4.00), P < 0.001) and POD 4 (2.50 (1.50–3.67) versus 2.00 (0.50–3.00), P = 0.007). EA patients required more vasoactive medication perioperatively and had higher cumulative fluid balances on POD 1–3. Postoperative complications were similar between groups.ConclusionsIn our cohort, patients with EA experienced significantly lower pain scores in the first PODs compared with non-EA, yet higher pain scores after EA had been terminated. Although EA patients required more vasoactive medication and fluid therapy, the complication rate was similar.Electronic supplementary materialThe online version of this article (10.1007/s11605-019-04136-w) contains supplementary material, which is available to authorized users.

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Postoperative Pain Relief after Pancreatic Resection: Systematic Review and Meta‐Analysis of Analgesic Modalities

et al. 2021

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Background This systematic review explored the efficacy of different pain relief modalities used in the management of postoperative pain following pancreatoduodenectomy (PD) and distal pancreatectomy (DP) and impact on perioperative outcomes. Methods MEDLINE (OVID), Embase, Pubmed, Web of Science and CENTRAL databases were searched using PRISMA framework. Primary outcomes included pain on postoperative day 2 and 4 and respiratory morbidity. Secondary outcomes included operation time, bile leak, delayed gastric emptying, postoperative pancreatic fistula, length of stay, and opioid use. Results Five randomized controlled trials and seven retrospective cohort studies (1313 patients) were included in the systematic review. Studies compared epidural analgesia (EDA) (n = 845), patient controlled analgesia (PCA) (n = 425) and transabdominal wound catheters (TAWC) (n = 43). EDA versus PCA following PD was compared in eight studies (1004 patients) in the quantitative meta-analysis. Pain scores on day 2 (p = 0.19) and 4 (p = 0.18) and respiratory morbidity (p = 0.42) were comparable between EDA and PCA. Operative times, bile leak, delayed gastric emptying, pancreatic fistula, opioid use, and length of stay also were comparable between EDA and PCA. Pain scores and perioperative outcomes were comparable between EDA and PCA following DP and EDA and TAWC following PD. Conclusions EDA, PCA and TAWC are the most frequently used analgesic modalities in pancreatic surgery. Pain relief and other perioperative outcomes are comparable between them. Further larger randomized controlled trials are warranted to explore the relative merits of each analgesic modality on postoperative outcomes with emphasis on postoperative complications.

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

Abstract: Premature epidural abortion rate was high and associated with analgesic morbidity. Pain score was predictive of epidural abortion. Thus, preference toward epidural analgesia cannot be supported.

Cited by 10 publications

References 26 publications

Meta‐analysis of epidural analgesia in patients undergoing pancreatoduodenectomy

Meta‐analysis of epidural analgesia in patients undergoing pancreatoduodenectomy

Epidural and Non-epidural Analgesia in Patients Undergoing Open Pancreatectomy: a Retrospective Cohort Study

Postoperative Pain Relief after Pancreatic Resection: Systematic Review and Meta‐Analysis of Analgesic Modalities

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