Epidural versus intravenous fentanyl for postoperative analgesia following orthopedic surgery: randomized controlled trial

Abstract

CONTEXT AND OBJECTIVE: Controversy exists regarding the site of action of fentanyl after epidural injection. The objective of this investigation was to compare the efficacy of epidural and intravenous fentanyl for orthopedic surgery. DESIGN AND SETTING:A randomized double-blind study was performed in Hospital São Paulo. METHODS:During the postoperative period, in the presence of pain, 29 patients were divided into two groups: group 1 (n = 14) received 100 µg of fentanyl epidurally and 2 ml of saline intravenously; group 2 (n = 15) received 5 ml of saline epidurally and 100 µg of fentanyl intravenously. The analgesic supplementation consisted of 40 mg of tenoxicam intravenously and, if necessary, 5 ml of 0.25% bupivacaine epidurally. Pain intensity was evaluated on a numerical scale and plasma concentrations of fentanyl were measured simultaneously. RESULTS:The percentage of patients who required supplementary analgesia with tenoxicam was lower in group 1 (71.4%) than in group 2 (100%): 95% confidence interval (CI) = 0.001-0.4360 (P = 0.001, Fisher's exact test; relative risk, RR = 0.07). Epidural bupivacaine supplementation was also lower in group 1 (14.3%) than in group 2 (53.3%): 95% CI = 0.06-1.05 (P = 0.03, Fisher's exact test; RR = 0.26). There was no difference in pain intensity on the numerical scale. Mean fentanyl plasma concentrations were similar in the two groups.CONCLUSION: Intravenous and epidural fentanyl appear to have similar efficacy for reducing pain according to the numerical scale, but supplementary analgesia was needed less frequently when epidural fentanyl was used. CLINICAL TRIAL REGISTRATION NUMBER: NCT00635986RESUMO CONTEXTO E OBJETIVO: Existem controvérsias sobre o local de ação do fentanil injetado por via peridural. O objetivo foi comparar a eficácia do fentanil peridural e do venoso em cirurgias ortopédicas. TIPO DE ESTUDO E LOCAL:Estudo aleatório, duplo-cego, realizado no Hospital São Paulo. MÉTODO:No pós-operatório, na presença de dor, 29 pacientes foram divididos em dois grupos: grupo 1 (n = 14) recebeu solução de 100 mcg de fentanil por via peridural e 2 ml de solução salina venosa; grupo 2 (n = 15), 5 ml de solução salina peridural e 100 µg de fentanil venoso. A complementação analgésica foi com 40 mg de tenoxicam venoso e, se necessário, 5 ml de bupivacaína 0.25%. A intensidade da dor foi avaliada pela escala numérica e a concentração plasmática do fentanil foi medida simultaneamente.RESULTADOS: A percentagem de pacientes que necessitaram de complementação analgésica com tenoxicam foi menor no grupo 1 (71.4% versus 100.0% grupo 2): intervalo de confiança, IC 95% = 0.001-0.4360 (P = 0.001, teste exato de Fisher; risco relativo, RR = 0.07). A complementação com bupivacaína peridural também foi menor no grupo 1 (14.3% versus 53.3% grupo 2): IC 95% = 0.06-1.05 (P = 0.03, teste exato de Fisher; RR = 0.26).Não houve diferença na intensidade da dor avaliada pela escala numérica. As concentrações plasmáticas do fentanil foram semelhantes nos dois grupos.CONCLUSÃO: A eficácia do...

Continuous Perioperative Thoracic Epidural Fentanyl-Bupivacaine Infusion vs. Continuous Perioperative Fentanyl Intravenous Infusion in Patients Undergoing Major Upper Abdominal Cancer Surgeries

“…Very similar to our results a study done by Privado et al, comparing epidural versus intravenous fentanyl for postoperative analgesia following orthopedic surgery, they found that epidural fentanyl is more efficient than intravenous fentanyl administration during first day postoperative and no significant difference between both groups after 24 h [19]. But against us, Welchew and Breen who found that both routes of fentanyl administration resulted in equally satisfactory analgesia but the total dose of fentanyl in intravenous group was twice the total dose of fentanyl in epidural group during the first 24 h postoperatively [20]. TEA by its sympathetic inhibition may cause hypotension.…”

Postoperative analgesia after major abdominal surgery: Fentanyl–bupivacaine patient controlled epidural analgesia versus fentanyl patient controlled intravenous analgesia

“…local anesthetic works on nerve routs and the plasma concentration of fentanyl was attained the threshold level to control pain. Other investigators also observed that, after the first postoperative hour, the pain was less intense after epidural fentanyl than after intravenous fentanyl administration, despite the similar or even lower plasma fentanyl concentrations in epidural fentanyl group [13]. At the end of the 24 h postoperatively there was no significant difference in NPRS between both groups as the plasma level of fentanyl was constant in controlling pain in both groups.…”

“…Epidural analgesia has been shown to provide superior analgesia compared with systemic opioids in systematic reviews [14,15]. In a study comparing epidural versus intravenous fentanyl for postoperative analgesia following orthopedic surgery Privado et al [13] found that epidural fentanyl is more efficient than intravenous fentanyl administration and the same result also reported in another study [16]. Welchew and Breen [17] found that both routes of fentanyl administration resulted in equally satisfactory analgesia but the total dose of fentanyl in intravenous group was twice the total dose of fentanyl in epidural group during the first 24 h postoperatively.…”

The effects of epidural versus intravenous patient-controlled analgesia on postoperative outcomes in elderly patients who have undergone gastrectomy: a retrospective trial

“…There are also contradictory results regarding the effectiveness of epidural vs. intravenous fentanyl [28,29]. Epidural fentanyl has been suggested to have both systemic and spinal actions.…”

“…Epidural fentanyl has been suggested to have both systemic and spinal actions. It may therefore be more effective than intravenous fentanyl [29]. In our study, we used similar doses of fentanyl in the regimens for epidural and intravenous PCA.…”