W. Jaksch, J. Cup-Grundtner, S. Resch, R. Reichhalter , B. Gustorff

W. Jaksch, J. Cup-Grundtner, S. Resch, R. Reichhalter , B. Gustorff

PF 16
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
We checked retrospectively 15 908 records in our database and
analyzed 3 347 patients.
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:
Perfusor group
1729
7569
62a
42
58
patients (n)
visits (ASD n)
age (∅)
female (%)
male (%)
Standard group
1618
8339
64a
50
50
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.
Results
Complications:
100%
90%
80%
patients with no complications
Fig 4
perfusor
12
10,2
60%
50%
57,1%
40%
10
9
postoperative day
Fig 2a
perfusor
standard
8
500ml ropivacaine 2mg/ml
+ sufentanil 0,5µg/ml
The aim of our study was to show differences in efficacy and side
effects between the perfusor group and the standard group.
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:
2,8%
p<0.05
11,6%
8,3%
6
p<0.001
5
5
4
4
3
3
1
0
2,86
1,39
31,2%
at rest
at movement
30%
25%
32,8%
15%
10%
urological
gynecological
p<0.01
30%
0
Fig 3
p<0.001
standard
plastic
5%
0%
19,5%
12,5%
7,3
p<0.05
4
20%
2
10%
0
0%
local infections
2,0%
perfusor
Fig 6
standard
1,5%
0,50%
Fig 6: A lower rate of local infections (cutis
and subcutis) in the standard group
Additional visits:
p<0.001
2,5
neurological
0,5
technical
disconnection
accidental loss
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.
need for additional visits
1600
1400
p<0.001
perfusor
Fig 7
standard
1200
1000
2,4
2
1,06
perfusor
traumatological
2,67
1
20%
vascular
standard
0,96
2,15
Fig 7:Significantly less additional visits
were necessary in the standard group
0,7
at rest
1017
800
600
13,4%
400
at movement
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.
0
Conclusions:
668
8,0%
200
inadequate analgesia
13,3%
visceral
9
Fig 2b
perfusor
7
2
Fig 1
10
10,3
6
0,0%
postoperative day
8
7
6
58,8%
0,10%
3rd
13,1
8
pain scores: NRS (0 – 10)
1st
standard
p<0.05
10
70%
0,5%
Fig 5
perfusor
standard
1,0%
Efficacy:
complications
14
%
Aim of Investigation
all visits
7569
8339
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.
wolfgang.jaksch@wienkav.at