Anaesthesia, 1992, Volume 47, pages 1037- 104 1
Patient-controlled epidura1 analgesia following post-traumatic pelvic reconstruction A comparison with continuous epidural analgesia
J. P. NOLAN, A. A . C. DOW, M . J. A. PARR, K. DAUPHINEE
AND
M . KALISH
Summary A randomised. single-blinded study was conducted to compare patient-controlled epidural analgesia with continuous infusion epidural analgesia for the treatment of pain following post-traumatic pelvic reconstruction. The patient-controlled group (n = 11) received a background infusion of 4 m1.h-I of bupivacaine 0.125% with fentanyl I p g m - ' , and 3-6 ml bolus doses, selfadministered, as required (with a 1.5 min lockout interval). The continuous infusion group (n = 12) received a continuous infusion of the same solution through an identical apparatus, but with the demand button deactivated. This was started at I0 m1.h-I and adjusted by the anaesthetist. as required, up to a maximum of 2.5 m1.h-'. Pain scores, side effects, and the volumes of drug infused were recorded over the first 3 postoperative days. One patient from each group was withdrawn because of catheter-related problems. Pain scores were similar and the incidence of nausea and pruritus was low in both groups. There was no recorded instance of respiratory depression or hypotension and there was no significant diflerence between the groups in the volumes of drug solution received. Patient satisfaction was equally very good in both groups. Patient-controlled epidural analgesia is an effective means of providing pain relief after post-traumatic pelvic reconstruction. but did not significantly reduce analgesic requirements in comparison with continuous infusion epidural analgesia.
Key words Anaesthetic techniques, regional; epidural. Anaesthetics, local; bupivacaine. Analgesics; fentanyl. Equipment; patient-controlled analgesia.
Intravenous patient-controlled analgesia (PCA) has been used for over 20 years and its popularity is rapidly increasing. In the light of the recent report from the Royal College of Surgeons of England and College of Anaesthetists [l], this trend is likely to continue. The technique is associated with greater patient satisfaction [2], and often, reduced requirements for postoperative analgesia in comparison with conventional methods of pain relief. Epidural administration of local anaesthetics and/or opioids has also been shown to be highly efficacious in the relief of postoperative pain [3, 41. Recently, a group from Sweden combined the concept of PCA with that of extradural opioids and studied postoperative patients who selfadministered epidural morphine or pethidine [S]. Subsequently, a number of studies have evaluated the efficacy of patient-controlled epidural analgesia (PCEA) during labour, and have found it to be a safe and effective technique [6-lo].
There have been a few preliminary reports describing the use of PCEA in nonlabouring patients [ 1 1-1 51, but only two have compared PCEA with continuous infusion epidural analgesia (CIEA) [16, 171. The first of these compared the analgesic dosage requirement and side effect profile of hydromorphone, given by CIEA or PCEA, in patients undergoing a wide range of operations [16]. The other study compared the two methods to deliver fentanyl to patients who had undergone laparotomy [17]. In both studies, the PCEA group required considerably less drug to achieve a comparable level of analgesia. Open reduction and internal fixation of major pelvic fractures requires extensive surgical exposure [ 181 and commonly results in severe postoperative pain. Our standard approach to the management of this pain is to use CIEA with a combination of fentanyl and bupivacaine. We wished to determine whether PCEA, with the same combination of drugs, would offer any advantages over CIEA
J.P. Nolan,* FRCAnaes, A.A.C. Dew,? MRCP, FRCAnaes, M.J.A. Parr, MRCP, FRCAnaes, K. Dauphinee, MD, FRCP(C), M. Kalish, MD, FACA, Attending Anesthesiologists, Department of Anaesthesia, Maryland Institute for Emergency Medical Services Systems (MIEMSS) Shock Trauma Center, 22 S. Greene St, Baltimore, Maryland 21201, USA. Current address: *Senior Registrar, Department of Anaesthesia, Royal United Hospital, Bath BA I 3NG. tLecturer/Senior Registrar, University Department of Anaesthesia, Southmead Hospital, Bristol. Accepted 28 March 1992. 0003-2409/92/121037 +05 $08.00/0
@ 1992 The Association of Anaesthetists of Gt Britain and Ireland
1037
1038
J.P. Nolan, A.A.C. Dow, M.J.A. Parr, K . Dauphinee and M . Kalish
in this group of patients. To address this issue we designed a randomised, single-blinded study to compare side effects, pain control, and drug requirements, between PCEA and CIEA in patients who had undergone post-traumatic pelvic reconstruction.
Methods The study was approved by the institution’s Committee on Human Volunteers Research and informed written consent was obtained from each patient. Twenty-three ASA 1 or 2 patients scheduled for post-traumatic pelvic reconstruction were entered into the study. Exclusion criteria included a GIasgow Coma Score of < 15, known hypersensitivity t o any of the medications being used, coagulopathy, systemic infection, and pregnancy. Patients who were less than 18 or greater than 75 years old, or were due to have additional surgery, other than to the lower limbs, were also not studied. O n the evening before their operation, patients were shown how to use the PCA pump (Provider 5500, Pancreatec Inc., San Diego, USA), and how to score their pain on a visual analogue scale. Patients were not premedicated. General anaesthesia was induced using thiopentone and fentanyl, and tracheal intubation was facilitated using suxamethonium or vecuronium. Anaesthesia was maintained, throughout the operation, by intermittent positive pressure ventilation with isoflurane (0.5-1.5%) in nitrous oxide and oxygen. Prior to surgery, the patient was turned into the lateral position and an epidural catheter was inserted at the L2-3or L34interspace. Following a test dose of 3 ml of 0.5% bupivacaine with 1 : 200000 adrenaline, a further dose of 12 ml of 0.5% bupivacaine was given before surgery commenced. Additional epidural boluses of 5 ml 0.5% bupivacaine were given, depending on the haemodynamic response to surgery. Upon arrival in the recovery room the patient was randomly assigned (sealed envelopes) to one of two groups. Patients in both groups received a loading dose of fentanyl 50 pg in 10 ml of bupivacaine 0.125% via the epidural catheter, which was then attached to the PCA pump. All patients subsequently received a solution of bupivacaine 0.125% containing fentanyl 1 pgml-‘, which had been prepared in bags of 500 ml by the hospital pharmacy. For patients in the PCEA group, the PCA pump was programmed to deliver a continuous infusion of 4 m1.h-’ and a bolus dose of 3 ml on activation of the patientdemand button, with a lockout interval of 15 min. For patients in the CIEA group, the PCA pump was programmed to deliver a continuous infusion of 10 m1.h-l and the patient-demand button was deactivated (it still made a beeping noise when pushed). All patients were unaware to which group they had been assigned and received the same instructions to push the demand button whenever they required additional analgesia. Before each patient left the recovery area (usually about 2-3 h postoperatively), the quality of analgesia was scored on a 10 cm visual analogue pain scale and any side effects were recorded. Patients were transferred to the high dependency ward. Nursing staff recorded the patient’s heart rate, respiratory rate, blood pressure and level of consciousness every 2 h, and recorded the pain score on a visual analogue scale
every 4 h. At any time, if analgesia was deemed inadequate a member of the acute pain team reprogrammed the PCA pump; for the PCEA group, the bolus dose could be increased up to a maximum of 6 ml but the continuous infusion and lockout interval were kept constant; for the CIEA group, the infusion rate could be increased up to a maximum of 25 m1.h-I. If patients in either group were pain-free for 4 consecutive hours, the dosage rates were reduced. A member of the study group interviewed each patient at 24, 48 and 72 h postoperatively. The patient’s assessment of their average level of pain over the previous 24 h was recorded on a 10 cm visual analogue scale. Additionally, patients were directly questioned regarding the incidence of pruritus, nausea and vomiting. At the 72 h assessment, patients were asked to record an overall impression of their pain control: very satisfactory, satisfactory, unsatisfactory, or very unsatisfactory. Demographic data were analysed using Student’s 1-test, the volumes of drug solution used by t-test with the Bonferroni correction, and pain scores using the Wilcoxon rank sum test. Results Of the 23 patients studied, two (one from each group) had to be withdrawn. The patient withdrawn from the PCEA group initially had very good analgesia, but after 24 h he complained of severe pain from one side and demanded that the epidural catheter be removed. The other patient’s epidural catheter became blocked after 36 h and despite having had excellent pain relief, he did not want another catheter inserted. The patients’ mean age, weight and blood loss are listed in Table 1. The higher mean weight in the CIEA group results from a greater proportion of men. The patients’ age and average blood loss was not significantly different between the two groups. At all assessment times, the median pain scores were Table 1. Demographic data. Results are expressed as mean (SD).
Age; years Weight; kg Blood loss; rnl Number female
PCEA ( n = 11)
CIEA (n = 12)
33 (14) 67 (7) 1472(1117) 4
35 (8) 81 (14) 1875(1354) 2
p*
NS
Patient-controlled epidura1 analgesia following post-traumatic pelvic reconstruction A comparison with continuous epidural analgesia
J. P. NOLAN, A. A . C. DOW, M . J. A. PARR, K. DAUPHINEE
AND
M . KALISH
Summary A randomised. single-blinded study was conducted to compare patient-controlled epidural analgesia with continuous infusion epidural analgesia for the treatment of pain following post-traumatic pelvic reconstruction. The patient-controlled group (n = 11) received a background infusion of 4 m1.h-I of bupivacaine 0.125% with fentanyl I p g m - ' , and 3-6 ml bolus doses, selfadministered, as required (with a 1.5 min lockout interval). The continuous infusion group (n = 12) received a continuous infusion of the same solution through an identical apparatus, but with the demand button deactivated. This was started at I0 m1.h-I and adjusted by the anaesthetist. as required, up to a maximum of 2.5 m1.h-'. Pain scores, side effects, and the volumes of drug infused were recorded over the first 3 postoperative days. One patient from each group was withdrawn because of catheter-related problems. Pain scores were similar and the incidence of nausea and pruritus was low in both groups. There was no recorded instance of respiratory depression or hypotension and there was no significant diflerence between the groups in the volumes of drug solution received. Patient satisfaction was equally very good in both groups. Patient-controlled epidural analgesia is an effective means of providing pain relief after post-traumatic pelvic reconstruction. but did not significantly reduce analgesic requirements in comparison with continuous infusion epidural analgesia.
Key words Anaesthetic techniques, regional; epidural. Anaesthetics, local; bupivacaine. Analgesics; fentanyl. Equipment; patient-controlled analgesia.
Intravenous patient-controlled analgesia (PCA) has been used for over 20 years and its popularity is rapidly increasing. In the light of the recent report from the Royal College of Surgeons of England and College of Anaesthetists [l], this trend is likely to continue. The technique is associated with greater patient satisfaction [2], and often, reduced requirements for postoperative analgesia in comparison with conventional methods of pain relief. Epidural administration of local anaesthetics and/or opioids has also been shown to be highly efficacious in the relief of postoperative pain [3, 41. Recently, a group from Sweden combined the concept of PCA with that of extradural opioids and studied postoperative patients who selfadministered epidural morphine or pethidine [S]. Subsequently, a number of studies have evaluated the efficacy of patient-controlled epidural analgesia (PCEA) during labour, and have found it to be a safe and effective technique [6-lo].
There have been a few preliminary reports describing the use of PCEA in nonlabouring patients [ 1 1-1 51, but only two have compared PCEA with continuous infusion epidural analgesia (CIEA) [16, 171. The first of these compared the analgesic dosage requirement and side effect profile of hydromorphone, given by CIEA or PCEA, in patients undergoing a wide range of operations [16]. The other study compared the two methods to deliver fentanyl to patients who had undergone laparotomy [17]. In both studies, the PCEA group required considerably less drug to achieve a comparable level of analgesia. Open reduction and internal fixation of major pelvic fractures requires extensive surgical exposure [ 181 and commonly results in severe postoperative pain. Our standard approach to the management of this pain is to use CIEA with a combination of fentanyl and bupivacaine. We wished to determine whether PCEA, with the same combination of drugs, would offer any advantages over CIEA
J.P. Nolan,* FRCAnaes, A.A.C. Dew,? MRCP, FRCAnaes, M.J.A. Parr, MRCP, FRCAnaes, K. Dauphinee, MD, FRCP(C), M. Kalish, MD, FACA, Attending Anesthesiologists, Department of Anaesthesia, Maryland Institute for Emergency Medical Services Systems (MIEMSS) Shock Trauma Center, 22 S. Greene St, Baltimore, Maryland 21201, USA. Current address: *Senior Registrar, Department of Anaesthesia, Royal United Hospital, Bath BA I 3NG. tLecturer/Senior Registrar, University Department of Anaesthesia, Southmead Hospital, Bristol. Accepted 28 March 1992. 0003-2409/92/121037 +05 $08.00/0
@ 1992 The Association of Anaesthetists of Gt Britain and Ireland
1037
1038
J.P. Nolan, A.A.C. Dow, M.J.A. Parr, K . Dauphinee and M . Kalish
in this group of patients. To address this issue we designed a randomised, single-blinded study to compare side effects, pain control, and drug requirements, between PCEA and CIEA in patients who had undergone post-traumatic pelvic reconstruction.
Methods The study was approved by the institution’s Committee on Human Volunteers Research and informed written consent was obtained from each patient. Twenty-three ASA 1 or 2 patients scheduled for post-traumatic pelvic reconstruction were entered into the study. Exclusion criteria included a GIasgow Coma Score of < 15, known hypersensitivity t o any of the medications being used, coagulopathy, systemic infection, and pregnancy. Patients who were less than 18 or greater than 75 years old, or were due to have additional surgery, other than to the lower limbs, were also not studied. O n the evening before their operation, patients were shown how to use the PCA pump (Provider 5500, Pancreatec Inc., San Diego, USA), and how to score their pain on a visual analogue scale. Patients were not premedicated. General anaesthesia was induced using thiopentone and fentanyl, and tracheal intubation was facilitated using suxamethonium or vecuronium. Anaesthesia was maintained, throughout the operation, by intermittent positive pressure ventilation with isoflurane (0.5-1.5%) in nitrous oxide and oxygen. Prior to surgery, the patient was turned into the lateral position and an epidural catheter was inserted at the L2-3or L34interspace. Following a test dose of 3 ml of 0.5% bupivacaine with 1 : 200000 adrenaline, a further dose of 12 ml of 0.5% bupivacaine was given before surgery commenced. Additional epidural boluses of 5 ml 0.5% bupivacaine were given, depending on the haemodynamic response to surgery. Upon arrival in the recovery room the patient was randomly assigned (sealed envelopes) to one of two groups. Patients in both groups received a loading dose of fentanyl 50 pg in 10 ml of bupivacaine 0.125% via the epidural catheter, which was then attached to the PCA pump. All patients subsequently received a solution of bupivacaine 0.125% containing fentanyl 1 pgml-‘, which had been prepared in bags of 500 ml by the hospital pharmacy. For patients in the PCEA group, the PCA pump was programmed to deliver a continuous infusion of 4 m1.h-’ and a bolus dose of 3 ml on activation of the patientdemand button, with a lockout interval of 15 min. For patients in the CIEA group, the PCA pump was programmed to deliver a continuous infusion of 10 m1.h-l and the patient-demand button was deactivated (it still made a beeping noise when pushed). All patients were unaware to which group they had been assigned and received the same instructions to push the demand button whenever they required additional analgesia. Before each patient left the recovery area (usually about 2-3 h postoperatively), the quality of analgesia was scored on a 10 cm visual analogue pain scale and any side effects were recorded. Patients were transferred to the high dependency ward. Nursing staff recorded the patient’s heart rate, respiratory rate, blood pressure and level of consciousness every 2 h, and recorded the pain score on a visual analogue scale
every 4 h. At any time, if analgesia was deemed inadequate a member of the acute pain team reprogrammed the PCA pump; for the PCEA group, the bolus dose could be increased up to a maximum of 6 ml but the continuous infusion and lockout interval were kept constant; for the CIEA group, the infusion rate could be increased up to a maximum of 25 m1.h-I. If patients in either group were pain-free for 4 consecutive hours, the dosage rates were reduced. A member of the study group interviewed each patient at 24, 48 and 72 h postoperatively. The patient’s assessment of their average level of pain over the previous 24 h was recorded on a 10 cm visual analogue scale. Additionally, patients were directly questioned regarding the incidence of pruritus, nausea and vomiting. At the 72 h assessment, patients were asked to record an overall impression of their pain control: very satisfactory, satisfactory, unsatisfactory, or very unsatisfactory. Demographic data were analysed using Student’s 1-test, the volumes of drug solution used by t-test with the Bonferroni correction, and pain scores using the Wilcoxon rank sum test. Results Of the 23 patients studied, two (one from each group) had to be withdrawn. The patient withdrawn from the PCEA group initially had very good analgesia, but after 24 h he complained of severe pain from one side and demanded that the epidural catheter be removed. The other patient’s epidural catheter became blocked after 36 h and despite having had excellent pain relief, he did not want another catheter inserted. The patients’ mean age, weight and blood loss are listed in Table 1. The higher mean weight in the CIEA group results from a greater proportion of men. The patients’ age and average blood loss was not significantly different between the two groups. At all assessment times, the median pain scores were Table 1. Demographic data. Results are expressed as mean (SD).
Age; years Weight; kg Blood loss; rnl Number female
PCEA ( n = 11)
CIEA (n = 12)
33 (14) 67 (7) 1472(1117) 4
35 (8) 81 (14) 1875(1354) 2
p*
NS
