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Journal of Postgraduate Medicine, Vol. 54, No. 2, April-June, 2008, pp. 80-81 Guest Editorial PCEA vs. PCA for post-thoracotomy pain: Is this any longer the question? Burlacu CL Department of Anaesthesia, Intensive Care and Pain Medicine, St. Vincent's University Hospital, Elm Park, Dublin 4 Code Number: jp08032 As the currently published research illustrates, the topic of epidural analgesia for major surgery continues to fascinate the anaesthetic and surgical community despite being one of the most extensively studied matters in numerous systematic reviews. Epidural analgesia regardless of analgesic agent (i.e. local anaesthetic only, combination of local anaesthetic and lypophilic/hydrophilic opioid, and lypophilic opioid only), epidural delivery technique (continuous epidural infusion (CEI) or patient-controlled epidural analgesia (PCEA)), type of surgery determining ultimately the location of catheter (thoracic or lumbar) and type of pain (at rest or during movement) provides better analgesia than any type of parenteral opioid including that delivered via intravenous patient-controlled devices (PCA) for up to four days postoperatively. [1] Epidural analgesia is also associated with less nausea, vomiting and sedation than parenteral opioids, although a higher incidence of hypotension, urinary retention and motor block is common, especially with the CEI variant. [1] The need for prolonged mechanical ventilation and time to tracheal extubation after major surgery is reduced, and other complications such as cardiovascular events, [2],[3] pulmonary complications, [2],[4] gastric and renal complications [2] are also reduced, especially with thoracic epidural. The effect on postoperative mortality is still unclear. [2] Hence, excellent pain control and decreased perioperative morbidity propelled epidural analgesia to the status of gold standard for managing pain after major surgery. Thoracic surgery is one of the clinical areas where there is universal agreement between surgeons and anaesthetists as to the value of aggressive pain management in decreasing postoperative immediate and long-term morbidity. A multimodal multidisciplinary approach to postoperative pain control to include scrupulous surgical technique and appropriate perioperative analgesia permitting adequate patient mobilization and physiotherapy is mandatory for reduced complications. There is recent Level 1 evidence available that continuous epidural analgesia decreases pain scores and maintains pulmonary function better than intravenous patient-controlled analgesia in thoracic surgery. [5] In the same way intravenous opioid PCA provides better analgesia and increased patient satisfaction compared to more conventional parenteral methods of opioid administration, [6] PCEA increasingly becomes the standard method of epidural administration in many institution. In a recent meta-analysis, Wu and colleagues [1] acknowledge the need to systematically compare the two analgesic alternatives for major inpatient surgery (epidural analgesia vs. systemic opioids) when both are delivered via patient-demand devices (PCEA vs. PCA). These authors demonstrate that PCEA (n= 353 patients) provides better analgesia compared to intravenous opioid PCA (n=1,583 patients) for overall pain, pain at rest and with activity ( p0 < 0.001). [1] Although analgesia via CEI (n=1,272 patients) is statistically better than analgesia via PCEA for all types of pain ( p < 0.001), the latter offers the benefit of less motor block, nausea and vomiting. The results of the currently published study are, therefore, neither new, nor surprising. It emphasises yet again that PCEA is a meaningful epidural analgesia delivery mode that should be more often utilized in thoracotomy patients. The authors of the present study choose to deprive their patients of intraoperative epidural analgesia disregarding the concept of pre-emptive analgesia. This theory is based on the assumption that a pharmacological analgesic agent or regional anaesthesia technique, administered prior to a nociceptive stimulus such as surgery, produces a painless post-injury state by preventing central sensitization of the nervous system. A recent meta-analysis indicated that epidural analgesia initiated before the thoracotomy incision was associated with a statistically significant reduction in the severity of acute dynamic pain in the first 48 hr postoperatively compared to thoracic epidural analgesia initiated after surgery completion. [7] Therefore, it is sensible to always use epidural analgesia intraoperatively, and decrease in the same time the need for opioids and their unwanted systemic side effects. Despite unambiguous evidence, acute pain after thoracotomy continues to represent a challenge for the anaesthetic and surgical community. Although thoracic epidural is perceived as the gold standard analgesia technique, the incidence of failed thoracic epidural is still high even in experienced hands. Alternative regional anaesthesia techniques such as paravertebral analgesia, confirmed to be equally analgesic-effective with thoracic epidural with fewer side effects, and superior to parenteral opioids, [8] may be used in selective cases. Other authors suggest that intravenous opioid PCA should be concomitantly offered to thoracic surgery patients in addition to epidural or paravertebral analgesia [9] although there is little evidence for this approach. It is my belief that an individual evidence-based perioperative analgesia regime, highly effective, with minimal side effects, and user-friendly should be discussed and agreed in partnership with the patient, aiming to decrease the potentially harmful consequences of thoracic surgery on the immediate and long-term patient well being. References
Copyright 2008 - Journal of Postgraduate Medicine |
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