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1 1. TITLE PAGE LITHUANIAN UNIVERSITY OF HEALTH SCIENCE DEPARTMENT OF GENERAL SURGERY MONIKA BLAZEWICZ FACULTY OF MEDICINE VI GROUP 32 PATIENT STATUS AFTER RADICAL PROSTATECTOMIA ASSESSING VARIOUS METHODS OF ANASTHESIA.

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DEPARTMENT OF GENERAL SURGERY
VARIOUS METHODS OF ANASTHESIA.
3. SUMMARY ................................................................................................................................. 3
4. SANTRAUKA .............................................................................................................................. 4
5. ACKNOWLEDGMENTS ................................................................................................................ 5
7. ABBREVIATIONS AND TERMS ..................................................................................................... 7
8. INRODUCTION ........................................................................................................................... 7
10. LITERATURE REVIEW .............................................................................................................. 10
13. CONCLUSSIONS ...................................................................................................................... 22
14. REFERENCES .......................................................................................................................... 23
Key words: radical prostatectomy; epidural analgesia; parenteral analgesia.
Radical prostatectomy is presently most often chosen option for prostate cancer treatment. Study of
complications after the surgery is important to evaluate morbidity. As well as anesthetic choice
evaluation to improve patient status after major procedure.
Purpose of this study was to establish patient status after radical prostatectomy assessing different
methods of anesthesia. Aiming analysis of validity of PEA after radical prostatectomy we compared EA
with pain status after surgery with other anesthesia methods during the procedure. To obtain significant
results we analyzed differences in patient status after radical prostatectomy with EA, GA, SA, assessed
analgesia requirements after surgery in each of the anesthetic groups, assessed PEA course,
postoperative pain level and additional analgesia requirements. Data for assessment collected from
archives that included: age, operation risk, hours in ICU, hours in operating room, anesthesia duration
after operation, analgetics, additional analgetics, pain level, hospitalization duration, first analgetic
injection time. Examination of values from inpatients was done by retrospective study in number of
patients was 33 placed into 3 groups: EA group (n=10), SA group (n=12) and GA group (n=11).
Analyzing patient’s status after radical prostatectomy we compared operating room stay of each group
which revealed longest time in operation room stay in GA group (3.47) and shortest in SA group (2.06).
Relationship between hours spent in ICU and time of operating room stay showed that highest rates in
ICU time along with OR time was found in GA group (ICU time-7.70) and lowest value were in SA
group (ICU time-5.21). There was no significance found on ICU hours and hospitalization time. Pain
level in EA group of patients after injection of epidural analgesia was significantly lower although still
almost all the patients needed parenteral analgetic injections. EA group requirements for parenteral
analgesia are the lowest of all groups and shows expressive difference to GA. There is significant decline
in ketaprofen requirement. The greatest amount of average number of parenteral injection in EA was on
second day after operation (0.8). GA needed biggest amount of analgetic injections straight after
operation (1.7) and epidural additional analgesia had the least requirements of extra analgesia (0.6 after
operation). In SA group amount of injections requirements are the largest in the second day (1.4). Pain
level was established before (4.30) and after (1.60) epidural analgesia injection.
Results lead to conclussions that epidural analgesia not shortens time of hospitalization and might
increase hospital costs due to prolonged stay in ICU. Analgetics requierements are the smallest in EA
4
but there is need of taking additional analgesia. Postoperative pain level is significantly improved after
analgesia injection but results achieved are summed with help of parenteral analgesia. Overall SA may
be best way for radical prostatectomy, because requires less medication (no PEA) and efforts for pain
relief after surgery.
Radikali prostektomija šiuo metu yra daniausiai pasirenkamas prostatos vio gydymo metodas.
Operacija yra sunki ir traumatiška, todl perioperacnio laikotarpio analiz gali padti pasirenkant
optimali gydymo taktika.
panašus pagal ami ir gretutin patologij, su tokios pai diagnoz, chirurgij, bet skirtingomis
anestezijos ir pooperacines analgezijos metodikomis. Pacientus suskirstme 3 grupes: epidurins
anestezijos (EA grup n = 10), spinalins (SA, n = 12) ir bendrins (GA, n = 11).
Liginome anestezijos ir pooperacines analgezijos eig, skausm ir nuskausminimo eig po operacijos,
vaist panaudojim, ankstyv pooperacin laikotarp intensyvios terapijos palatoje(ICU), komplikacijas
ir hospitalizacijos trukm.
Analiz paruod, kad ilgiausiai operuoti GA grupes pacientai daugiau laiko išbuvo ICU, taiau
ligoninje praleido maiau laiko. SA grupes pacientams stebtas priešingas vaizdas. Statistiškai
reikšmingo ryšio tarp intensyvios terapijos skyriuje praleisto laiko ir hospitalizacijos trukms neaptikta.
EA grups pacientams stebtas maiausias skausmo lygis, beveik visiems pacientams reikjo
papildom analgetiko injekcij. Didiausias skausmingumas ir parenterini analgetiku doz SA ir EA
grupse buvo antra para po operacijos. GA grupje skausmingumas ir parenterini analgetiku doz
buvo pirm para.
Epidurin analgezija sumaindavo skausm vidutiniškai 2,5 karto (4.30 ir 1.60 balo pagal VAS), taiau
papildom analgetik poreikis vis tiek išlieka. Stacionarizavimo laikas buvo maiausias GA grupeje.
5
5. ACKNOWLEDGMENTS
I would like to state my sencere gratitude to my supervison Dr. Edvardas Daugela for patience and
support as well as motivation and knowledge. He helped me throughout the process of writing my thesis
and gave guidance when needed.
6
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PSA (prostate specific antigen), ICU (intensive care unit), EA (epidural anesthesia), PEA (postoperative
epidural analgesia), GA (general anesthesia), SA (spinal anesthesia), RRP (radical retropubic
prostatectomy), RPP (radical perineal prostatectomy), GA-EA (combined general and epidural
anesthesia), CSE (combined spinal and epidural anesthesia), IV-PCA (intravenous patient controlled
anesthesia), ASA (physical status classification system), COX-2 (cyclo-oxygenase -2 inhibitors),
NSAIDs (non-steroidal anti-inflammatory drugs), PCEA (patient controlled epidural anesthesia), OR
(operating room).
anesthesia, spinal anesthesia postoperative analgesia.
8. INRODUCTION
Radical prostatectomy increased in effectiveness and decreased in morbidity over the years as a result
of progressing surgical techniques and advancing knowledge of surgical anatomy. For localized prostate
cancer patients this procedure is best way of treatment. For patients younger than 65 years old with
localized disease results after radical prostatectomy are better than any other treatment for prostate
cancer (1). Men that age is above 65 years old and chose surgery as a course of treatment had the same
results as men that chose other treatments. As a second most common cancer among men detecting in
early stage of disease is crucial for a positive outcome. Most common prostate cancer that is diagnosed
is adenocarcinoma. Due to PSA testing (prostate-specific antigen) detection of malignancy is possible
in earlier age and stage of disease therefore radical prostatectomy gives advantage for these possibly
curable lesions. Patient status after radical prostatectomy we can estimate observing patients: any
postoperative complication, temperature persistence, pain level, main and additional analgesia and
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length of hospital stay. Beside all complication possibilities and other comorbidities that patient may
have, data obtained during hospitalization allows to reveal some specific information and its validity of
each anesthesia method that have been used during radical prosthatectomy.
Selecting one from various anesthesia methods depends on patient’s condition, operation risk, type of
surgery, and real clinical experience in hospital. Anesthesia methods influence patients comfort after
surgery, recovery time and general treatment price. But looking at one procedure, similar in case of
patient’s age group, disease and type of surgery can bring results leading to estimation of validity of
specific anesthesia methods.
Epidural anesthesia for major surgery is used because of variety of reasons. Primarily for surgical
anesthesia as a sole technique, in addition to general anesthesia and as strong postoperative pain relief.
EA and PEA aiming in pain control and patient overall satisfaction, but also improve patients condition
in case of perioperative stress responces which could influence outcome and possibility of
complications. As epidural anesthesia influence outcome of surgery in postoperative morbidity and
neccesity of hostpital stay duration, our goal is to establish validity of EA with PEA after radical
prostatectomy in comparison to patients with other anesthetic methods.
We evaluated patients from general surgery department throughout their hospitalization by
retrospective study. Research included n=33 patients with a similar age, ASA status and cancer stage to
get better understanding of analgetics requirements after radical prostatectomy, focusing on
postoperative epidural anesthesia effectiveness.
9. AIMS AND OBJECTIVES
Direction of the study and problems analyzed:
Throughout the years anesthetic methods were studied and compared according to importnace for
patient outcome. Postoperative analgesia in comparison of anasthetic methods focusing on
epidural analgesia validity after radical prosthatectomy was not so often examined. Number of
studies show advantage of epidural analgesia after main surgeries, which reveal decreased
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demands for aditional analgesia and improved management of postoperative pain which influence
patients recovery and hospital stay therefore costs of care (2).
Research process and research instruments:
Process of the study and instruments were established upon patient’s case histories and their
medical requirements during and after operation: anesthesia method and duration, EA course,
analgetic demands and use after surgery, complication and other medication after radical
prostatectomy. From patients history we gathered information involved age, ASA, postoperative
complication, pain level and medication after surgery, medication and additional analgesia in EA
group, hospitalization time.
Systematic review based on collected data found in case histories we gathered was made analysis
of postoperative EA data compared with other postoperative anesthetic methods for functional
outcome for patients undergoing radical prostatectomy in urology department.
Aim of the thesis:
Aim of this research is to analyze validity of PEA after radical prostatectomy with EA compared
with EA compared with pain status after radical prostatectomy with other anesthesia methods
during surgery, if all patient have similar age, ASA and surgery. This may help to establish best
possible analgesia way after surgery.
Objectives of the thesis:
1. To analyze differences in patients status after radical prostatectomy with EA, GA and SA.
2. To assess analgesia requirements after surgery in each of the anesthetic groups.
3. To assess PEA course, postoperative pain level and additional analgesia requirements.
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10. LITERATURE REVIEW
Radical prostatectomy is aimed to remove localized prostate cancer. During the operation prostate
gland and surrounding tissues which includes seminal vesicles and some nearby lymph nodes are
removed. We can distinguish two ways of open radical prostatectomy: radical retropubic prostatectomy
(RRP) and radical perineal prostatectomy (RPP). Retropubic aproach starts with lower midline incision
and with perineal inverted – U incision is made in perineum. RRP allows to perform pelvic lymph nodes
examination and dissection which is impossible because of site of incision in RPP. Less blood loss and
trauma to the patient as well as shorter recovery time ar results in perineal approach but it’s harder with
nerve preservation around the prostate.
Several of anesthetic procedures can be used in radical prostatectomy surgery: general anasthesia,
regional anesthesia or combined anesthesia of two techniques. To determine what kind of anesthesia is
going to be performed numbers of factors have to be taken into consideration. General anesthesia (GA)
allows for good control of airway breathing and circulation, is convinient for patient and used in long
lasting procedures. Combined anesthesia can help to decrease GA depth, useful for analgesia after
surgery, reduce of general analgetics dose. Spinal anesthesia brings immediate anesthesia and effective
anesthesia, amount of drug needed is very small (3). SA opioids have strong analgetic effect till 24
hours after surgery. Epidural anesthesia allows for continues postoperative analgesia.
Numerous studies were initiated about prostatectomy surgery and anasthetic influence on outcome of
the procedure and analgesia after surgery (4–11). In Vilnius University, Institute of Oncology in
Lithuania Renata Tikuisis studied differences between epidural and general anestesia versus general
anesthesia influence on blood loss during radical prostatectomy (4). In each of two groups were chosen
27 patients, study group got epidural/general anesthesia with 0.5% solution of bupivacaine and
maintained by suvoflurane. Control group got general anesthesia with endotracheal ventilation from
sevoflurane and intravenous fentanyl. Results revealed changes in intraoperative blood pressure, which
was higher in control group, time in surgery slightly shorter in study group and significant changes in
intraoperative blood loss much lower in study group with results more need for transfusion in control
group. This study definitely showed positive outcome of epidural anesthesia in addition to general in
case of reduction in mean arterial pressure that has an influence on intraoperative blood loss.
11
Question of influence on surgical outcome of epidural anesthesia and anlgesia studied Department of
Anasthesia and Surgery in Kaunas Medcial University Hospital (12). Doctor Rimaitis was checking
surgical complications and outcome together with postoperative course after colorectal cancer surgery.
During one year prospective, randomised clinical study 100 patients were divided into two groups:
general anesthesia followed with opioid analgesia after operation (GA group), epidural-general
anesthesia, continues with epidural anesthesia (GA-EA group). Beneficial results of this research once
again were showed for GA-EA group for major surgery like small reduce in throbotic events and
pulmonary complications but was unsignificant on patient’s outcome.
Following statement about effectiveness of epidural anesthesia for colorectal cancer surgery Vilnius
University Oncology Clinic decided to check correlation of administrating epidural anesthesia prior and
at the end of the surgery (13). Group that got epidural anesthesia before operation needed less anesthetics
during the operation and experienced less pain in first 6 hours after operation, they also needed smaller
amount of aditional analgesic infusions after operation. Therefore conclusion shows that if epidural
anesthesia is used for major surgery it’s much more effective to use it preoperatively.
Interesting study of Continous Postoperative Epidural analgesia for all patients was made in 2007 in
Lithuania, Kaunas University of Medicine in Anesthesiology Clinic (14). Study revealed pain intensity
at rest and motion (80% of patients didnt experience any pain after surgery), epidural block intensity,
additional alagetics requirements (only 30% of patient’s reqired additional analgesics), treatment
duration and side effects (hypotension and bradycardia in 6%). Results of this very general study are
positive for effectiveness and safety on postoperative analgesia.
Another comparison of epidural and general anesthesia in patients that went through radical
prostatectomy were publications both from Johns Hopkins University School of Medicine, Baltimore,
Maryland (5,6). Checking intraoperative anasthetic approach and postoperative complication in a first
research schowed no specific findings. In the second one postoperative demands on analgesia was
observed and in epidural anasthesia these demands were decreased.
Pain management after radical prostatectomy is investigated in several other studies (7–10) brought
mostly advantages of epidural analgesia after radical prostatectomy, one study brought interesting and
totally different view (10). University of Melbourne, Department of Surgery concluded that epidural
analgesia prolonged lenght of hospitalization and revealed technical problems connected with epidural.
In addition to that results men receiving an epidural anasthesia showed an increased recurrence of
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prostate specific antigen therefore for this procedure epidural anasthesia and analgesia wasnt
recommended.
Large patient population investigation was done to compare combined general and epidural anasthesia
with combined spinal and epidural anasthesia to estimate patient safety (11). Analyzed group of 1207
patients who underwent radical retropubic prostatectomy in period of 2008-2011 was didvided to
combined spinal epidural anasthesia (CSE) of total 698 patients and 509 patients with combined general
and epidural anesthesia (INT/PDA). CSE caused respectively to anesthesia time, shorter surgical length
and length of hospitalization and recovery. This retrospective study revealed positive outcome for
combined spinal and epidural anasthesia considering patients quality of care and safety.
Another combined anasthesia study was made by doctor Stamencovic (15) that compared effectiveness
of CSE analgesia to epidural analgesia (EA). Group of 160 patients undergoing major abdominal surgery
were divided into four groups. Subarachnoid morphine, bupivacaine and fentanyl (MBF group), fentanyl
and epidural bupivacaine (MB group), morphine (M group), and normal saline (i/v) (EA group).
Research was recording pain at rest, movement, with cough, additional analgesia requests, and
postoperative side effects. This study also showed positive outcome for combination of spinal- epidural
analgesia as improvement of intra-operative analgesia but as well decreased pain with movement and
cough posteoperatively.
Pain management after major surgery is the matter of patient’s satisfaction, fast recovery, surgery
outcome and hospitalization costs. Numer of researchers tried to find answers for the best possible
postoperative care. (16–18)
Publication of population based study was made by Kenneth C. Cummings compared survival and
recurence after gastric cancer resection (18). Possible decrease of exposure to immunosuppressive factor
by choosing epidural anesthesia havent shown distinctive outcome. There were no differnce found in
researched groups therefore recurrence of gastric cancer was found not to be associated with anasthesia
choice.
Postoperative pain control was studied Rosewell Park Center Institute where surgical cancer patients
were studied after uncomplicated surgeries (17). Patients divided into two groups of epidural analgesia
(EA group) and intravenous patient- controlled analgesia (IV-PCA) which they received
postoperatively. Intensive care untis stay and hospitalization was studied and results showed decreased
time in epidural analgesia. Both analgesia came out to be satisfactory for postoperative pain management
but faster recovery was seen in epidural analgesia group.
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Patient satisfaction and hospital stay, that helps with proper and profitable use of hospital resources is
very important and should be considered when choosing type of anesthesia (2). Reserach that compared
epidural anesthesia with general anesthesia in patients that underwent minimally invasie direct coronary
artery bypass (MIDCAB) surgery studied these data in prospective and randomised study. Group of 42
patients were given general anasthesia (GA group) and 34 patients received epidural anasthesia (EA
group). Less ICU time and hospital stay was discovered in EA group as well as less postoperative pain
and blood loss. Long term results as well as patients satisfaction was insignificant. Therefore study
shows that efficient use of hospital resources may would be choice of epidural anesthesia.
Efficacy and safety of postoperative pain management is still not well established as 30-80% of patients
after surgery suffers from moderate to severe pain (19). Which approach would be the most efficient
and satisfactory for the patient have been researched in numer o publications (19–26).
Multimodal analgesia after major surgery is the approach that contain combination of non-opioid
analgesic drugs and opioid that has a purpose of reducing nee of opioid use therefore minimizing opioid
side effects. In systematic review of paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs) and
cyclo-oxygenase 2 inhibitors (COX-2) were studied to establish effectiveness of decreasing opioid use
related side effects after surgery (20). NSAIDs use showed decrease in nause and vomiting but revealed
bleeding related with surgery cases. There were no significant difference between paracetamol, NSAIDs
and COX-2 in reduction of morphine consumption which was observed in 24 hours in all groups.
Paracetamol was found to be slightly less effective in decreasing morphine consumption.
Further analysis of pain relief effectiveness proves that patient-controlled epidural analgesia (PCEA)
and iv patient-controlled analgesia (IV-PCA) is more sufficient than opioid treatment given on demand
(19). Database analysis of prospective collected data shows 18925 patients examined posteoperatively
from 1998 till 2006. There were four groups of patients: PCEA, continous brachial plexus block,
continous femoral/sciatic nerve block and IV-PCA. All proceedings turned out to be effective and
considered safe for the patient. The least effective pain relief turned out to be IVPCA.
Interesting study was made in Mexican social Security institute where management of pain after major
surgery was analyzed in sphere of costs of a drug and its effectiveness (21). Ketarolac, Parecoxib and
Morphine was introduced after gynecologic laparotomy surgery. Costs of parecoxib and ketarolac were
smaller than morphine and parecoxib compared to ketarolac was reasonably higher. Research then
shows that parecoxib is effective in postoperative pain and is good alternative for ketarolac when
contraindicated.
14
Considering major surgery and its postoperative analgesia systemic review of randomised trials was
done by Marieke Nauta to compare opioid – codeine with acetaminophen (A+C) versus NSAIDs
effectiveness after laparotomy and precisely cesarean delivery. From all nine studies that was examined
revealed no difference in pain relief after treamtement with A+C comparing to NSAIDs. Less side
effects of drugs were observed in NSAIDs group in some studies.
Even though there are many studies about radical prostatectomy anesthesia choice and postoperative
analgesia, there are still a lot of inconclussives. There are less intraoperative complications and with
general anesthesia combined with epidural anesthesia when compared with general anesthesia (4,12).
Examining postoperative epidural analgesia itself there are decrease in pain in rest and motion, as well
as decreased additional analgetics requirements (14). As one study shows prolonged stay in hospital due
to technical problems with epidural (10) others state that epidural analgesia actually shortens
hospitalization days (11) and faster recovery and patients satisfaction and safety (2). In Lithuania there
were several researches made about epidural anesthesia during and epidural analgesia after radical
prostatectomy but there was no study that would include three different anesthesia methods in similar
age and operation risk with estimating validity of epidural analgesia.
Research that would reveal more information about postoperative pain and clarify weather epidural
analgesia is needed and beneficial after radical prostatectomy operation would be interesting.
Large number of researchers were showing different evaluation of results from studying postoperative
analgesia and methods of anesthesia in major surgeries. Aiming to find more specific results of which
analgetics should be given after operation to minimize adverse effects and maximize good postoperative
status of the patient. EA has impact on postoperative complications such as decreasing in throbotic
events number and pulmonary complications (12), also reduce intraoperative blood loss and mean
arterial pressure (4). Moreover EA is significant in duration of intensive care unit stay and
hospitalization (17). Main need for PEA is due to strongest analgesic effect. Comparable in pain level
after the same surgery to EA is SA and both feel significantly better than patients for whom GA was
used (27).
11. METHODOLOGY AND METHODS
Research planning: We collect data from patient history from archives of General Surgery department
with information’s including: age, ASA, surgery anesthesia type, analgesia demand and duration after
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hospitalization duration.
Object of study: In the study we tried to establish analgesia course and validity after radical
prostatectomy for patients with same pathology, surgery, GA, SA and EA during surgery in Kaunas
Clinical Hospital urology department. The study was done to find out if PEA is a beneficial choice of
treatment of postoperative pain and assessment whether outcome is better than nonepidural analgesia.
Research methods and methods of data analysis:
Examination of values from inpatients of Kaunas Clinical Hospital urology department was done by
retrospective study in which of whole patients number 33. Patients were placed into 3 groups depending
on anasthesia method during uncomplicated radical prostatectomy. First group was epidural anesthesia
(EA group) in (n=10), second contained patients after spinal anesthesia (SA group) in (n=12), last
evaluated group was general anesthesia (GA group) having (n=11) patients. We evaluated anasthesia
duration and focused on analgesia after operation, its first analgetic injection, overall pain relief duration
and its requirements. Also in EA group we focused on pain level changes and its change during PEA.
12. RESULTS AND DISCUSSION
Information collected from 33 patients. Youngest patient was 41 years old and the oldest was 78 years
old, average age was 63 years.
To analyze differences in patient’s status after radical prostatecomy we focused on collecting data of
patient status after surgery like pain level after surgery, various postoperative complication and analgetic
and other medication use. Also we check surgery duration of operating room, anesthesia kind during
surgery, hospitalization length and time spent in ICU.
Surgery duration certainly can affect patient’s status after surgery.
Surgery duration analysis depend on anesthesia type.
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Figure 1 Duration of OR stay (in hours)
Although, the anesthesia type selection criteria are not known, surgery time in SA and EA is group
significantly lower than in GA, it could affect patient’s condition after surgery (Fig.1.)
Table 1 Relationship between age, ICU hours and hours in OR (average)
Even though patients in SA group have the biggest average age recovery after surgery, which indicate
ICU stay, is shortest of all groups. Recovery in GA group after surgery takes the longest time. Shorter
treatment in ICU is logically consistent with a shorter surgery time, and opposite (Fig.2). Mean ASA is
very similar in all groups and possibly had no effect on post-operative patien’s condition (Tab.1).
Description above is shown clearer in a graph.
17
Figure 2 Relationship between OR stay and hours in ICU
Another graph shows information about duration in average of ICU hours and days spent in hospital.
Figure 3: Average duration of ICU hours and hospitalization days
Hospitalization days in GA are slightly lower but shows no significance (Fig.3.)
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Pain and analgetic relief requirements after surgery:
Main motivation to choose EA for surgery is possibility to make PEA. It always has stronger analgetic
effect than parenteral opioid. All patients in EA group for PEA received epidurally 2mg of morphine
with 10ml 0,125 percent local anesthetic- bupivacaine twice a day. PEA theoretically should be enough
for all pain relief after surgery and no additional analgesia would be needed. Although in our study we
discovered that not only GA and SA group need analgesia but EA as well.
SA features during and after surgery: is always fast, effective, and has low cost. For spinal injection in
all cases was used 0,5 percent bipivacaine 12,5-17,5mg (depend of patients anthropometric), fentanil
50mkg and morphine 300mkg. Main advantage of SA with morphine is that it provides strong analgetic
effect for long time- from 16 up to 24 hours. Therefore, in SA group patient doesn’t need additional
analgesia in first day after surgery.
Without EA or SA patients needs another method of postoperative analgesia - paraenteral (i/v or i/m)
analgetics. GA effect stops after surgery therefore patient require parenteral analgesia.
Analgesia requirements in all groups is compared with total number of paraenteral analgetic injections.
For making general analgesia ketaprofen is used usually 100mg/3x/day. We analyze analgetics first
admission time, use and dosage in GA, EA and SA groups.
19
In this graph we analize how many parenteral analgetic injections need patient after surgery in various
groups.
Figure 4: Real Ketaprofen use in SA, GA and EA groups' average
EA group (all patient with PEA) requirements for parenteral analgesia are the lowest of all groups and
shows expressive difference to GA. There is significant decline in ketaprofen requirement (Fig.4.).
Parenteral analgetic requirement on second day after surgery in SA group slightly increased, but remains
less than in GA group.
Less parenteral analgetic’s demand means less pain after surgery.
In EA group for PEA all patient received two doses of morphine 2 mg with 10ml of 0.125% Bupivacaine.
Epidural analgesia duration after operation in all patients has average of 3 days. Parenteral analgesia
was given from two to four days as ketonal injections. Most of first injections of ketonal were
administered during the day of operation usually at noon.
This table shows epidural analgesia effectiveness in EA group.
20
Table 2: Pain level in average before and after first PEA injection
VAS pain level in EA group before and 15-20min. after epidural injection on average 4.3 and after 1.6
score’s. This effect is reachable only due to additional analgetics (Tab.2.)
Graph below shows average number of analgetic injections in EA group.
Figure 5 : Average number of injections in EA
Pain level (VAS score) in EA group after injection of epidural analgesia was significantly lower, but
data show that almost all patients during PEA needed additional parenteral analgetic injections.
Researched data shows that epidural analgesia is not insufficient alone for pain management. The
greatest amount of average number of parenteral injection was on second day after operation (Fig.5.).
21
Patient’s without PEA perenteral analgetic requiremen is compared in the graph below.
Figure 6 Average number of injections per day in SA and GA
As expected SA group patients’ required almost twice lower dose of ketaprofen compared with GA
group. In SA group amount of injections requirements are the largest in the second day due to the fact
that after operation for 16 to 24 hours injection of morphine injection of SA is still working. In GA
requirements for parenteral analgesia was the biggest in the first day after surgery, and decreases very
slowly (Fig.6.).
In all groups from 6th day after surgery patients’ does not require analgetics.
Comparison to results obtained by researchers in the field:
1. Similar retrospective study was done in Kaunas University of Medicine in Anesthesiology Clinic
of all surgery patients that had epidural analgesia postoperatively administered in year 2007 (14).
Research established effectiveness and safety of postoperative epidural analgesia. To achieve
that study provided information about pain intensity (80% of patient’s didnt experience pain after
surgery), treatment duration and additional analgesia requirements (only 30% of patients
22
required additional analgesics) while in our research additional analgesia need was much bigger
(60% of patients required additional analgetics) and pain after surgery was present in all patients.
2. Comparison similar to our study was done in John Hopkins University School of Medicine in
Baltimore where epidural anesthesia versus general anesthesia were studied (5). Postoperative
pain and analgetic needs were assessed but due to similar analgetic regimen and not distinctive
prevalence of complications data were inconclusive. Difference in our approach was patients
division into three groups: EA, GA, and SA and aside postoperative pain and analgetics
requirements we researched OR stay, ICU hours and hospitalization period and its correlation to
review influence on patients recovery, postoperative status and possible economic benefits.
13. CONCLUSSIONS
The purpose of this study was to evaluate validity of epidural analgesia after radical prostatectomy
compared with other anesthesia methods.
1. Studies showed that Spinal anesthesia group had the least hours spent in OR. Prostatectomy with
SA may be associated with facilitating surgery process. Better correlation with SA illustrates
ICU time cause less complicated procedure shows better outcome. Additionally it influences
hospital costs, because less time in surgery and in intensive care department lowers significantly
health care, hospital and ICU costs.
2. Requirements for additional analgetics during PEA revealed management of pain to certain
extend, but not enough for patients comfort and achieve pain relief alone. Second day
always require biggset amount of parenteral injections. 60% of patients needed additional
analgesia.
3. Patients’ from SA group on the second day after surgery had biggest analgetics requirement.
Overall SA may be best way for radical prostatectomy, because requires less medication (no
PEA) and efforts for pain relief after surgery.
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14. REFERENCES
1. Bill-Axelson A, Holmberg L, Ruutu M, Garmo H, Stark JR, Busch C, et al. Radical prostatectomy
versus watchful waiting in early prostate cancer. N Engl J Med. 2011;364(18):1708–17.
2. Kurtoglu M, Ates S, Bakkaloglu B, Besbas S, Duvan I, Akdas H, et al. Epidural anesthesia versus
general anesthesia in patients undergoing minimally invasive direct coronary artery bypass
surgery. Anadolu Kardiyol Derg [Internet]. 2009;9(1):54–8. Available from:
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