Efficacy and Safety of Patient-controlled Analgesia Compared With Epidural Analgesia After Open Hepatic Resection

Abstract

Objective: To compare the efficacy and safety of patient-controlled analgesia (PCA) to epidural analgesia in adults undergoing open hepatic resection. Background: Effective pain management in patients undergoing open hepatic resection is often achieved with epidural analgesia. However, associated risks have prompted investigation of alternative analgesic methods in this patient population. Methods: A comprehensive systematic literature review via Medline, Embase, and the Cochrane databases from inception until December 2, 2017 was conducted, followed by meta-analysis. Abstract and full-text screening, data extraction, and quality assessment were conducted by 2 investigators. Odds ratios (OR), mean differences (MD), and 95% confidence intervals were calculated using RevMan 5.3. Results: Four randomized controlled trials with 278 patients were identified. All studies compared the use of PCA to epidural, with differing regimens. Pooled MD and 95% confidence interval for pain score were higher for PCA at rest 24 hours postoperatively (0.59 [0.30, 0.88]), and with movement at 48 hours postoperatively (0.95 [0.31, 1.60]. Pooled MD for hospital length of stay was 1.23 days (−2.72, 5.19). Pooled OR was 0.68 (0.36, 1.3) and 0.24 (0.04, 1.36) for overall and analgesia-related complications, respectively. Need for blood transfusion had a pooled OR of 1.14 (0.31, 4.18). Conclusions: Epidural analgesia was observed to be superior to PCA for pain control in patients undergoing open hepatic resection, with no significant difference in hospital length of stay, complications, or transfusion requirements. Thus, epidural analgesia should be the preferred method for the management of postoperative pain in this patient population.

Pain management after open liver resection: Procedure-Specific Postoperative Pain Management (PROSPECT) recommendations

“…Five RCTs [35][36][37][38][39] and one meta-analysis 40 compared the analgesic effect of TEA with opioid intravenous PCA. The meta-analysis that included four RCTs (n=278 patients) demonstrated that, compared with opioid intravenous PCA, TEA provided superior pain relief at rest and with movement at 12 and 24 hours after surgery, with no significant difference in hospital length of stay (LOS).…”

“…The meta-analysis that included four RCTs (n=278 patients) demonstrated that, compared with opioid intravenous PCA, TEA provided superior pain relief at rest and with movement at 12 and 24 hours after surgery, with no significant difference in hospital length of stay (LOS). 40 Of the four RCTs included in the meta-analysis, two RCTs 32 35 are also included in our review. Of note, the meta-analysis did not consider the use of basic analgesics in the included RCTs.…”

“…Li et al40 Systematic review and meta-analysis.Intravenous PCA versus EA after open hepatic resection. Pain scores at rest at 12 hours no difference, at 24 hours higher pain scores in intravenous PCA group (significant), at 48 hours no statistical significance.…”

Postoperative Analgesia after Open Liver Surgery: Systematic Review of Clinical Evidence

“…Systemic intravenous administration of analgesics (as opioids and non-steroidal anti-inflammatory drugs) is effective but associated with potentially harmful side effects, such as respiratory depression, nausea and vomiting, pruritus, gastrointestinal bleeding, and renal failure [13,14]. Epidural analgesia might provide improved pain control, but in the specific setting of open liver surgery, may potentially challenge and have harmful drawbacks as a sympathetic blockade (with hypotension, bradycardia) and intraoperative fluid overload arises and its use might be limited because of the possible perioperative coagulopathy [13,[15][16][17][18]. A peripheral nerve block, such as the paravertebral nerve block (PVB), transversus abdominis plane block (TAP), or quadratus lumborum block (QLB), performed under ultrasound guidance is an emerging alternative that could provide effective analgesia with a potentially low-risk profile after open liver surgery.…”

Perioperative Management of Complex Hepatectomy for Colorectal Liver Metastases: The Alliance between the Surgeon and the Anesthetist

“…Several randomized controlled trials have been carried out to compare the effectiveness and safety of PCA to epidural analgesia in patients undergoing open hepatic resection and have reported conflicting results [ 82 , 83 ]. In a systematic review and meta-analysis, Li et al reported that EA was more effective than PCA in controlling postoperative pain in patients undergoing open hepatic resection, with no significant differences in length of hospital stay, complications or transfusion requirements [ 84 ].…”