Postoperative analgesia with epidural catheter - improved clinical outcome after standardizing the procedures

W. Jaksch, J. Cup-Grundtner, S. Resch, R. Reichhalter , B. Gustorff Department of Anesthesia, Intensive Care and Pain Medicine, Wilhelminenhospital, Vienna, Austria

PF 16

Aim of Investigation After introducing an acute pain service (APS) in 1996 all patients with epidural catheters for postoperative analgesia were visited at least once a day. Only in cases of complications we carried out more than one visit a day. Pain at rest and at movement using an 11-point numeric rating scale (NRS) as well as all side effects were documented electronically at each visit. Until 2006 different drug combinations (local anaesthetics ± opioids ± clonidine) were administered by perfusor pumps (50ml syringe). The procedure changed significantly in 2006. In terms of hygienical aspects and for earlier mobilization we introduced a standard regimen with a 500ml bag of ropivacaine 0.2% + sufentanil 0.5µg/ml using a small portable electronically controlled pump: The aim of our study was to show differences in efficacy and side effects between the perfusor group and the standard group.

500ml ropivacaine 2mg/ml + sufentanil 0,5µg/ml

Methods Between 1996 and 2013 the APS visited and documented 3195 patients. The indications for lumbar or thoracic epidural analgesia were major operations of different surgical departments:

31,2%

32,8%

13,3%

11,6% 8,3%

2,8%

visceral vascular traumatological urological gynecological plastic

We checked retrospectively 15 908 records in our database and analyzed 3 347 patients. We looked at the NRS scores on the first and third postoperative days and the incidence of complications, which were divided in technical defects, accidental loss of catheter or disconnection, insufficient analgesia, neurological symptoms and signs of infections and the need for additional visits. For statistical significance we used the t-test.

0,96

2,4

0,7

2,15

0

1

2

3

4

5

6

7

8

9

10perfusor

standard

Perfusor group Standard group patients (n) 1729 1618 visits (ASD n) 7569 8339 age (∅) 62a 64a female (%) 42 50 male (%) 58 50

Results Efficacy:

pain scores: NRS (0 – 10) 1st postoperative day 3rd postoperative day

at rest at rest at movement at movement

19,5%

12,5%

0%

5%

10%

15%

20%

25%

30%perfusorstandard

Fig 2a+b: The NRS scores were significantly lower in the standard group at rest as well as at movement at the first (1.1 ± 1.6 vs 1.4 ± 1.7 at rest and 2.7 ± 2.2 vs 2.9 ± 2.3 at movement) and third postoperative day (0.7 ± 1.3 vs. 1.0 ± 1.5 at rest and 2.1 ± 1.9 vs 2.4 ± 2.1 at movement).

Fig 3: Significantly more patients of the perfusor group had inadequate analgesia and needed additional analgesics.

inadequate analgesia Fig 1

Fig 2b

Fig 3

1,39

2,86

1,06

2,67

0

1

2

3

4

5

6

7

8

9

10perfusorstandard

p<0.001

Fig 2a

Complications:

57,1% 58,8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%perfusorstandard

10,2

2,5

7,3

10,3

0,5

13,1

0

2

4

6

8

10

12

14

%

perfusorstandard

0,50%

0,10%

0,0%

0,5%

1,0%

1,5%

2,0%perfusorstandard

Fig 4 patients with no complications

Fig 5 complications

neurological technical disconnection accidental loss

Fig 6 local infections

Fig 4: The number of patients with no complications was comparable in both groups Fig 5: In both groups 10% had neurological deficiencies (paraesthesia or motoric weakness in the lower extremities). In the standard group there was more often an accidental loss of catheter or disconnection whereas technical problems (alarm of the devices) were more frequent in the perfusor group.

Fig 6: A lower rate of local infections (cutis and subcutis) in the standard group

1017

668

0

200

400

600

800

1000

1200

1400

1600perfusorstandard

13,4%

8,0%

need for additional visits Fig 7

all visits 7569 8339

Fig 7:Significantly less additional visits were necessary in the standard group

Conclusions: Postoperative analgesia performed with epidural catheters is a very efficient and safe method for perioperative pain management. The analgesic efficacy could be significantly improved and the rate of insufficient analgesia could be evidently reduced by using a standard procedure. The increased incidence of disconnections or accidental loss of catheter in the standard group may be attributed to the earlier mobilization. Overall additional visits could be nearly halved with the implementation of a standard drug group.

Additional visits: p<0.001

p<0.05 p<0.01

p<0.001

p<0.001

p<0.05

p<0.05

wolfgang.jaksch@wienkav.at