Efficacy of postoperative epidural analgesia: a meta-analysis.

CONTEXT Whether epidural analgesia is a better method than parenteral opioids for postoperative pain control remains controversial. OBJECTIVE To systematically review the efficacy of postoperative epidural analgesia vs parenteral opioids, the primary alternative technique. DATA SOURCES Studies were identified primarily by searching the National Library of Medicine's PubMed database (1966 to April 25, 2002) and other sources for studies related to postoperative epidural analgesia. STUDY SELECTION Inclusion criteria were a comparison of epidural therapy vs parenteral opioids for postoperative analgesia, measurement of pain using a visual analog scale (VAS) or numeric rating scale, randomization of patients to either therapy, and adult patients (> or =18 years). A total of 1404 abstracts were identified, 100 of which met all inclusion criteria. DATA EXTRACTION Each article was reviewed and data extracted from tables, text, or extrapolated from figures as needed. Weighted mean pain scores, weighted mean differences in pain score, and weighted incidences of complications were determined by using a fixed-effect model. DATA SYNTHESIS Epidural analgesia provided better postoperative analgesia compared with parenteral opioids (mean [SE], 19.40 mm [0.17] vs 29.40 mm [0.20] on the VAS; P<.001). When analyzed by postoperative day, epidural analgesia was better than parenteral opioids on each postoperative day (P<.001 for each day after surgery). For all types of surgery and pain assessments, all forms of epidural analgesia provided significantly better postoperative analgesia compared with parenteral opioid analgesia (P<.001 for all), with the exception of thoracic epidural analgesia vs opioids for rest pain after thoracic surgery (weighted mean difference, 0.6 mm; 95% confidence interval, -0.3 to 1.5 mm; P =.12). The complication rates were lower than expected for nausea or vomiting and pruritus but comparable with existing data for lower extremity motor block. CONCLUSION Epidural analgesia, regardless of analgesic agent, location of catheter placement, and type and time of pain assessment, provided better postoperative analgesia compared with parenteral opioids.

[1]  B. Walder,et al.  Efficacy and safety of patient‐controlled opioid analgesia for acute postoperative pain , 2001, Acta anaesthesiologica Scandinavica.

[2]  R. Thirlby,et al.  Effects of Perioperative Analgesic Technique on Rate of Recovery after Colon Surgery , 1995, Anesthesiology.

[3]  J. Bland,et al.  Effectiveness of acute postoperative pain management: I. Evidence from published data. , 2002, British journal of anaesthesia.

[4]  L. Ready,et al.  Acute Pain: Lessons Learned From 25,000 Patients , 1999, Regional Anesthesia & Pain Medicine.

[5]  D. Scott,et al.  Postoperative Analgesia Using Epidural Infusions of Fentanyl with Bupivacaine: A Prospective Analysis of 1,014 Patients , 1995, Anesthesiology.

[6]  L. Mather,et al.  Multimodal Analgesia and Intravenous Nutrition Preserves Total Body Protein Following Major Upper Gastrointestinal Surgery , 2001, Regional Anesthesia & Pain Medicine.

[7]  Jesse A. Berlin,et al.  Defining the clinically important difference in pain outcome measures , 2000, PAIN.

[8]  A R Jadad,et al.  Assessing the quality of reports of randomized clinical trials: is blinding necessary? , 1996, Controlled clinical trials.

[9]  W. S. Beattie,et al.  Epidural Analgesia Reduces Postoperative Myocardial Infarction: A Meta-Analysis , 2001, Anesthesia and analgesia.

[10]  D. König,et al.  Comparison of continuous epidural infusion of ropivacaine and sufentanil with intravenous patient‐controlled analgesia after total hip replacement , 2001, Anaesthesia.

[11]  A. Gottschalk,et al.  Preemptive Epidural Analgesia and Recovery from Radical Prostatectomy: A Randomized Controlled Trial , 1999 .

[12]  D. Carr.  The development of national guidelines for pain control: synopsis and commentary , 2001, European journal of pain.

[13]  D. Cook,et al.  Does quality of reports of randomised trials affect estimates of intervention efficacy reported in meta-analyses? , 1998, The Lancet.

[14]  R. Rosenquist,et al.  Regional Anesthesia in the Anticoagulated Patient: Defining the Risks (The Second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation) , 2003, Regional Anesthesia & Pain Medicine.

[15]  P. Couture,et al.  Epidural Analgesia and Intravenous Patient-Controlled Analgesia Result in Similar Rates of Postoperative Myocardial Ischemia After Aortic Surgery , 1997, Anesthesia and analgesia.

[16]  H. Kehlet,et al.  Multimodal Perioperative Management—Combining Thoracic Epidural Analgesia, Forced Mobilization, and Oral Nutrition—Reduces Hormonal and Metabolic Stress and Improves Convalescence After Major Urologic Surgery , 2001, Anesthesia and analgesia.

[17]  J. Farrar,et al.  Clinically important changes in acute pain outcome measures: a validation study. , 2003, Journal of pain and symptom management.

[18]  F. Mosteller,et al.  The Comparative Effects of Postoperative Analgesic Therapies on Pulmonary Outcome , 1998 .

[19]  E. Viscusi,et al.  Epidural Analgesia Compared With Intravenous Morphine Patient-Controlled Analgesia: Postoperative Outcome Measures After Mastectomy With Immediate TRAM Flap Breast Reconstruction , 2001, Regional Anesthesia & Pain Medicine.

[20]  P. Myles,et al.  Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial , 2002, The Lancet.

[21]  T. Mammoto,et al.  Continuous epidural, not intravenous, droperidol inhibits pruritus, nausea, and vomiting during epidural morphine analgesia. , 2002, Journal of clinical anesthesia.

[22]  D. Chestnut,et al.  Intrathecal Opioids Versus Epidural Local Anesthetics for Labor Analgesia: A Meta-Analysis , 2001, Regional Anesthesia & Pain Medicine.

[23]  Spencer S. Liu,et al.  Patient‐controlled Epidural Analgesia with Bupivacaine and Fentanyl on Hospital Wards: Prospective Experience with 1,030 Surgical Patients , 1998, Anesthesiology.

[24]  Peter Jüni,et al.  Direction and impact of language bias in meta-analyses of controlled trials: empirical study. , 2002, International journal of epidemiology.

[25]  D. Kopacz,et al.  A comparison of levobupivacaine 0.125%, fentanyl 4 microg/mL, or their combination for patient-controlled epidural analgesia after major orthopedic surgery. , 1999, Anesthesia and analgesia.

[26]  M. Tramèr,et al.  Pharmacological control of opioid-induced pruritus: a quantitative systematic review of randomized trials , 2001, European journal of anaesthesiology.

[27]  M. White,et al.  Side effects during continuous epidural infusion of morphine and fentanyl , 1992, Canadian journal of anaesthesia = Journal canadien d'anesthesie.

[28]  P. Couture,et al.  Epidural analgesia and intravenous patient-controlled analgesia result in similar rates of myocardial ischemia after aortic surgery. , 1998 .

[29]  T. Horlocker,et al.  Anticoagulation and neuraxial block: historical perspective, anesthetic implications, and risk management. , 1998, Regional anesthesia and pain medicine.

[30]  R. Wheatley,et al.  Safety and efficacy of postoperative epidural analgesia. , 2001, British journal of anaesthesia.

[31]  M. Kaneko,et al.  Synergistic Antinociceptive Interaction after Epidural Coadministration of Morphine and Lidocaine in Rats , 1994, Anesthesiology.

[32]  D. M. Phillips.  JCAHO Pain Management Standards Are Unveiled , 2000 .

[33]  G. Lederhaas,et al.  A Randomized Comparison of the Effects of Continuous Thoracic Epidural Analgesia and Intravenous Patient‐Controlled Analgesia After Posterior Spinal Fusion in Adolescents , 2000, Regional anesthesia and pain medicine.

[34]  Christopher L. Wu,et al.  Outcomes research in regional anesthesia and analgesia. , 2000, Anesthesia and analgesia.

[35]  B. Parker,et al.  Postoperative Epidural Bupivacaine‐Morphine Therapy Experience with 4,227 Surgical Cancer Patients , 1994, Anesthesiology.

[36]  H. Kehlet,et al.  Effect of postoperative analgesia on surgical outcome. , 2001, British journal of anaesthesia.

[37]  H. Buerkle,et al.  Acute pain management: analysis, implications and consequences after prospective experience with 6349 surgical patients. , 2000, European journal of anaesthesiology.

[38]  Ethan M Balk,et al.  Correlation of quality measures with estimates of treatment effect in meta-analyses of randomized controlled trials. , 2002, JAMA.

[39]  Christopher L. Wu,et al.  Measurement of Patient Satisfaction as an Outcome of Regional Anesthesia and Analgesia: A Systematic Review , 2000, Regional Anesthesia & Pain Medicine.

[40]  H. Kehlet,et al.  Chronic Pain as an Outcome of Surgery: A Review of Predictive Factors , 2000, Anesthesiology.

[41]  E. Liu,et al.  Side‐effects of epidural infusions of opioid bupivacaine mixtures , 1998, Anaesthesia.

[42]  J. Wigfull,et al.  Survey of 1057 patients receiving postoperative patient‐controlled epidural analgesia , 2001, Anaesthesia.

[43]  A. Hrõbjartsson,et al.  Is the placebo powerless? An analysis of clinical trials comparing placebo with no treatment. , 2001, The New England journal of medicine.

[44]  D. Kopacz,et al.  A Comparison of Levobupivacaine 0.125%, Fentanyl 4 μg/mL, or Their Combination for Patient-Controlled Epidural Analgesia After Major Orthopedic Surgery , 1999 .

[45]  J. Ashley,et al.  Towards optimal analgesia after caesarean section: comparison of epidural and intravenous patient-controlled opioid analgesia. , 1993, Anaesthesia and intensive care.

[46]  N. Mayo,et al.  Epidural analgesia enhances functional exercise capacity and health-related quality of life after colonic surgery: results of a randomized trial. , 2002, Anesthesiology.

[47]  J. Ioannidis,et al.  Comparison of evidence of treatment effects in randomized and nonrandomized studies. , 2001, JAMA.

[48]  Anthony Rodgers,et al.  Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials , 2000, BMJ : British Medical Journal.

[49]  John D. Miller,et al.  A comparison of thoracic and lumbar epidural techniques for post-thoracoabdominal esophagectomy analgesia , 1999, Canadian journal of anaesthesia = Journal canadien d'anesthesie.

[50]  B. Kavanagh,et al.  Epidural Bupivacaine-Morphine Analgesia versus Patient-controlled Analgesia following Abdominal Aortic Surgery: Analgesic, Respiratory, and Myocardial Effects , 1998, Anesthesiology.

[51]  H. Kehlet,et al.  Accelerated postoperative recovery programme after colonic resection improves physical performance, pulmonary function and body composition , 2002, The British journal of surgery.

[52]  J. Neal,et al.  Epidural Anesthesia and Analgesia: Their Role in Postoperative Outcome , 1995, Anesthesiology.

[53]  R Rosenthal,et al.  Meta‐analysis: a review. , 1991, Psychosomatic medicine.