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Epidural vs IV PCA. C CHU SMO Dept of Anesthesia, AHNH. IV PCA. Programmable mechanical pump Self-administered Press button to give a set dose of morphine iv Lock-out period to minimize overdose. Continuous Infusion via a catheter. In epidural space:

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Epidural vs IV PCA

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    1. Epidural vs IV PCA C CHU SMO Dept of Anesthesia, AHNH

    2. IV PCA • Programmable mechanical pump • Self-administered • Press button to give a set dose of morphine iv • Lock-out period to minimize overdose

    3. Continuous Infusion via a catheter In epidural space: Local anaesthestics - block motor/ sensory/ sympathetic nerve; Opioids block opioid receptors in spinal cord

    4. New drugs for epidural • LA • Levobupivacaine • Ropivacaine • Both less toxic than bupivacaine and less motor block • Other additional drugs • Clonidine • Ketamine • Neostigmine • midazolam • Tramadol • Prolonged analgesic effect but potential neurotoxicity for midazolam/ketamine

    5. Indications for PCA / Epidural • Postoperative Pain relief after operation that cause severe pain

    6. Advantages over Traditional IM/ SC Opioids • More reliable absorption of drugs (epidural and iv > IM/SC) • No screening/waiting • Maintain a more stable analgesic level than prn analgesic regime

    7. How do we decide between IV PCA or epidural? • Age: • too young / too old to use PCA • Mental state: • able to comprehend and understand the instructions to use PCA • Psychiatric disorder • Effort • Press the PCA Button

    8. How do we decide between IV PCA or epidural? • Site of the operations • Can epidural reach?- head and neck surgery • Patient’s acceptance • Co-operation in inserting epidural • Risks of epidural • Insertion risk: dural puncture, post-spinal headache, infection, haematoma, paralysis • Medical conditions: • Any particular benefits with epidural • Any contraindications to epidural • Local sepsis. Coagulopathy, unstable BP, on-going bleeding

    9. Example 1 • 55 yrs • Diet control DM; Good control HT • TKR • IV PCA or epidural? • Probably not much difference

    10. Example 2 • 80 yrs • Chronic smoker, chronic bronchitis, MI 2 yrs ago, HT, DM • Ca Colon; A-P Resection • IV PCA vs Epidural? • Prob. epidural

    11. Proposed Advantages of Epidural • Better pain relief • LA blocking spinal nerve roots • May mobilize earlier • Opioid sparing • Dosage of opioid is much less: avoiding its complications; e.g N&V, over-sedation • Block sympathetic/ spare vagal innervation: better peristalsis of bowels. • Opioid can cause constipation

    12. Proposed Advantages of Epidural • Better respiratory performance • Block pain signal- able to breathe deeper; better cough effort • PCA -larger dose of opioid to relief pain and may become more sedated;Deep breathing/ coughing may still elicit pain in upper abdominal/ thoracic operations. • Earlier Mobilization and Discharge • Less pain, faster mobilization • Earlier bowel recovery • Less respiratory, cardiovascular complications

    13. Are there any evidences that epidural is better than PCA ? • 38 papers on IV PCA vs epidural • Abdominal, thoracic, orthopaedic, gynaecological surgery. • Pain relief • Opioid sparing effects: less N&V, less sedative • Mobilization • Respiratory function • Cardiovascular complications • Hospital Stay

    14. 1.        Steinberg RB, Liu SS, Wu CL, Mackey DC, Grass JA, Ahlen K, Jeppsson L. Comparison of ropivacaine-fentanyl patient-controlled epidural analgesia with morphine intravenous patient-controlled analgesia for perioperative analgesia and recovery after open colon surgery. J Clin Anesth. 2002 Dec;14(8):571-7. • 2.        Mann C, Pouzeratte Y, Boccara G, Peccoux C, Vergne C, Brunat G, Domergue J, Millat B, Colson P. Comparison of intravenous or epidural patient-controlled analgesia in the elderly after major abdominal surgery. Anesthesiology. 2000 Feb;92(2):433-41. • 3.        Wulf H, Biscoping J, Beland B, Bachmann-Mennenga B, Motsch J. Ropivacaine epidural anesthesia and analgesia versus general anesthesia and intravenous patient-controlled analgesia with morphine in the perioperative management of hip replacement. Ropivacaine Hip Replacement Multicenter Study Group. Anesth Analg. 1999 Jul;89(1):111-6. • 4.        Jayr C, Beaussier M, Gustafsson U, Leteurnier Y, Nathan N, Plaud B, Tran G, Varlet C, Marty J. Continuous epidural infusion of ropivacaine for postoperative analgesia after major abdominal surgery: comparative study with i.v. PCA morphine. Br J Anaesth. 1998 Dec;81(6):887-92. • 5.        Tsui SL, Lee DK, Ng KF, Chan TY, Chan WS, Lo JW. Epidural infusion of bupivacaine 0.0625% plus fentanyl 3.3 micrograms/ml provides better postoperative analgesia than patient-controlled analgesia with intravenous morphine after gynaecological laparotomy. Anaesth Intensive Care. 1997 Oct;25(5):476-81.

    15. 6. Kampe S, Randebrock G, Kiencke P, Hunseler U, Cranfield K, Konig DP, Diefenbach C. Comparison of continuous epidural infusion of ropivacaine and sufentanil with intravenous patient-controlled analgesia after total hip replacement. Anaesthesia. 2001 Dec;56(12):1189-93. • 7.        Ngan Kee WD, Lam KK, Chen PP, Gin T. Comparison of patient-controlled epidural analgesia with patient-controlled intravenous analgesia using pethidine or fentanyl. Anaesth Intensive Care. 1997 Apr;25(2):126-32. • 8.        Bois S, Couture P, Boudreault D, Lacombe P, Fugere F, Girard D, Nadeau N. Epidural analgesia and intravenous patient-controlled analgesia result in similar rates of postoperative myocardial ischemia after aortic surgery. Anesth Analg. 1997 Dec;85(6):1233-9. • 9.        Silvasti M, Pitkanen M. Continuous epidural analgesia with bupivacaine-fentanyl versus patient-controlled analgesia with i.v. morphine for postoperative pain relief after knee ligament surgery. Acta Anaesthesiol Scand. 2000 Jan;44(1):37-42 • 10.        Benzon HT, Wong HY, Belavic AM Jr, Goodman I, Mitchell D, Lefheit T, Locicero J A randomized double-blind comparison of epidural fentanyl infusion versus patient-controlled analgesia with morphine for postthoracotomy pain. Anesth Analg. 1993 Feb;76(2):316-22

    16. 11.        de Leon-Casasola OA, Karabella D, Lema MJ. Bowel function recovery after radical hysterectomies: thoracic epidural bupivacaine-morphine versus intravenous patient-controlled analgesia with morphine: a pilot study. J Clin Anesth. 1996 Mar;8(2):87-92 • 12.        Joshi GP, McCarroll SM, O'Rourke K. Postoperative analgesia after lumbar laminectomy: epidural fentanyl infusion versus patient-controlled intravenous morphine. Anesth Analg. 1995 Mar;80(3):511-4. • 13.Correll DJ, Viscusi ER, Grunwald Z, Moore JH Jr. Epidural analgesia compared with intravenous morphine patient-controlled analgesia: postoperative outcome measures after mastectomy with immediate TRAM flap breast reconstruction. Reg Anesth Pain Med. 2001 Sep-Oct;26(5):444-9. • 14.        Liu SS, Carpenter RL, Mackey DC, Thirlby RC, Rupp SM, Shine TS, Feinglass NG, Metzger PP, Fulmer JT, Smith SL. Effects of perioperative analgesic technique on rate of recovery after colon surgery. Anesthesiology. 1995 Oct;83(4):757-65. • 15.        Bowdle TA, Ready LB, Kharasch ED, Nichols WW, Cox K. Transition to post-operative epidural or patient-controlled intravenous analgesia following total intravenous anaesthesia with remifentanil and propofol for abdominal surgery. Eur J Anaesthesiol. 1997 Jul;14(4):374-9.

    17. 16.        George KA, Wright PM, Chisakuta AM, Rao NV. Thoracic epidural analgesia compared with patient controlled intravenous morphine after upper abdominal surgery. Acta Anaesthesiol Scand. 1994 Nov;38(8):808-12. • 17.        Carli F, Trudel JL, Belliveau P. The effect of intraoperative thoracic epidural anesthesia and postoperative analgesia on bowel function after colorectal surgery: a prospective, randomized trial. Dis Colon Rectum. 2001 Aug;44(8):1083-9. • 18.        Flisberg P, Rudin A, Linner R, Lundberg CJ. Pain relief and safety after major surgery. A prospective study of epidural and intravenous analgesia in 2696 patients. Acta Anaesthesiol Scand. 2003 Apr;47(4):457-65. • 19.        Bertini L, Tagariello V, Molino FM, Posteraro CM, Mancini S, Rossignoli L. [Patient-controlled postoperative analgesia in orthopedic surgery: epidural PCA versus intravenous PCA] Minerva Anestesiol. 1995 Jul-Aug;61(7-8):319-28. • 20.         Cooper DW, Saleh U, Taylor M, Whyte S, Ryall D, Kokri MS, Desira WR, Day H, McArthur E. Patient-controlled analgesia: epidural fentanyl and i.v. morphine compared after caesarean section. Br J Anaesth. 1999 Mar;82(3):366-70.

    18. 21.   Wu CL, Jani ND, Perkins FM, Barquist E. Thoracic epidural analgesia versus intravenous patient-controlled analgesia for the treatment of rib fracture pain after motor vehicle crash. J Trauma. 1999 Sep;47(3):564-7. • 22.        Stehr-Zirngibl S, Doblinger L, Neumeier S, Zirngibl H, Taeger K. [Intravenous versus thoracic-epidural patient-controlled analgesia following extended abdominal or thoracic surgery] Anaesthesist. 1997 Sep;46 Suppl 3:S172-8. • 23.        Fisher CG, Belanger L, Gofton EG, Umedaly HS, Noonan VK, Abramson C, Wing PC, Brown J, Dvorak MF. Prospective randomized clinical trial comparing patient-controlled intravenous analgesia with patient-controlled epidural analgesia after lumbar spinal fusion. Spine. 2003 Apr 15;28(8):739-43. • 24.        Cassady JF Jr, Lederhaas G, Cancel DD, Cummings RJ, Loveless EA. A randomized comparison of the effects of continuous thoracic epidural analgesia and intravenous patient-controlled analgesia after posterior spinal fusion in adolescents. Reg Anesth Pain Med. 2000 May-Jun;25(3):246-53. • 25. Egan KJ, Ready LB. Patient satisfaction with intravenous PCA or epidural morphine. Can J Anaesth. 1994 Jan;41(1):6-11.

    19. 26.         de Leon-Casasola OA, Parker BM, Lema MJ, Groth RI, Orsini-Fuentes J. Epidural analgesia versus intravenous patient-controlled analgesia. Differences in the postoperative course of cancer patients. Reg Anesth. 1994 Sep-Oct;19(5):307-15. • 27.        Seeling W, Bothner U, Eifert B, Rockemann M, Schreiber M, Schurmann W, Steffen P, Zeininger A. [Patient-controlled analgesia versus epidural analgesia using bupivacaine or morphine following major abdominal surgery. No difference in postoperative morbidity] Anaesthesist. 1991 Nov;40(11):614-23. • 28.        Qiao L, Lu Q, Zhang S. [Clinical assessment of the effect of intravenous patient controlled intravenous analgesia and epidural patient controlled epidural analgesia in postoperative analgesia] Zhonghua Fu Chan Ke Za Zhi. 2001 May;36(5):285-6. • 29.        Weller R, Rosenblum M, Conard P, Gross JB. Comparison of epidural and patient-controlled intravenous morphine following joint replacement surgery. Can J Anaesth. 1991 Jul;38(5):582-6. • 30.        Klasen JA, Opitz SA, Melzer C, Thiel A, Hempelmann G. Intraarticular, epidural, and intravenous analgesia after total knee arthroplasty. Acta Anaesthesiol Scand. 1999 Nov;43(10):1021-6.

    20. 31.        Della Rocca G, Coccia C, Pompei L, Costa MG, Pierconti F, Di Marco P, Tommaselli E, Pietropaoli P. Post-thoracotomy analgesia: epidural vs intravenous morphine continuous infusion. Minerva Anestesiol. 2002 Sep;68(9):681-93. • 32.        Goodarzi M, Shier NH, Ogden JA. Epidural versus patient-controlled analgesia with morphine for postoperative pain after orthopaedic procedures in children. J Pediatr Orthop. 1993 Sep-Oct;13(5):663-7. . • 33.        Cohen BE, Hartman MB, Wade JT, Miller JS, Gilbert R, Chapman TM. Postoperative pain control after lumbar spine fusion. Patient-controlled analgesia versus continuous epidural analgesia. Spine. 1997 Aug 15;22(16):1892-6 • 34.        Paulsen EK, Porter MG, Helmer SD, Linhardt PW, Kliewer ML. Thoracic epidural versus patient-controlled analgesia in elective bowel resections. Am J Surg. 2001 Dec;182(6):570-7   • 35.        Chen PP, Cheam EW, Ma M, Lam KK, Ngan Kee WD, Gin T. Patient-controlled pethidine after major upper abdominal surgery: comparison of the epidural and intravenous routes. Anaesthesia. 2001 Nov;56(11):1106-12.

    21. 36..        de Leon-Casasola OA, Lema MJ, Karabella D, Harrison P. Postoperative myocardial ischemia: epidural versus intravenous patient-controlled analgesia. A pilot project. Reg Anesth. 1995 Mar-Apr;20(2):105-12. • 37.        Singelyn FJ, Deyaert M, Joris D, Pendeville E, Gouverneur JM. Effects of intravenous patient-controlled analgesia with morphine, continuous epidural analgesia, and continuous three-in-one block on postoperative pain and knee rehabilitation after unilateral total knee arthroplasty. Anesth Analg. 1998 Jul;87(1):88-92. Anesth Analg. 1998 Jul;87(1):88-92. • 38.        Welchew EA, Breen DP. Patient-controlled on-demand epidural fentanyl. A comparison of patient-controlled on-demand fentanyl delivered epidurally or intravenously. Anaesthesia. 1991 Jun;46(6):438-41.

    22. Epidural vs IV PCA

    23. Cardiovascular complications: Epidural vs IV PCA • Unique for Epidural • Thoracic epidural: block cardiac sympathetic fibres- slower heart rate • Better pain control: less stress to the heart

    24. Cardiovascular complications: Epidural vs IV PCA • Better with Epidural • de Leon-Casasola OA, Lema MJ, Karabella D, Harrison P. Postoperative myocardial ischemia: epidural versus intravenous patient-controlled analgesia. A pilot project. Reg Anesth. 1995 Mar-Apr;20(2):105-12. • Garnett RL, MacIntyre A, Lindsay P, Barber GG, Cole CW, Hajjar G, McPhail NV, Ruddy TD, Stark R, Boisvert D. Perioperative ischaemia in aortic surgery: combined epidural/general anaesthesia and epidural analgesia vs general anaesthesia and i.v. analgesia. Can J Anaesth. 1996 Aug;43(8):769-77. • No difference • Bois S, Couture P, Boudreault D, Lacombe P, Fugere F, Girard D, Nadeau N. Epidural analgesia and intravenous patient-controlled analgesia result in similar rates of postoperative myocardial ischemia after aortic surgery. Anesth Analg. 1997 Dec;85(6):1233-9. • A meta- analysis showed that epidural is effective in reducing myocardial ischaemia and MI (though IV PCA is not directing compared) • Beattie WS, Badner NH, Choi P Epidural analgesia reduces postoperative myocardial infarction: a meta-analysis. Anesth Analg. 2001 Oct;93(4):853-8.

    25. Thromboembolism • Unique for epidural • Sympathetic block vasodilatation • Better blood flow in the major vessels of the lower limbs, lessened tendency to coagulation of the blood and better preservation of fibrinolysis function. • Other characteristics include an inhibitory action on platelet aggregation and stabilizing effect on leukocytes and endothelial cells--effects exerted by the local anaesthetics per se.

    26. Vascular Graft Patency: Epidural vs IV PCA • Better with epidural • Perler BA, Christopherson R, Rosenfeld BA, Norris EJ, Frank S, Beattie C, Williams GM. The influence of anesthetic method on infrainguinal bypass graft patency: a closer look. Am Surg. 1995 Sep;61(9):784-9. • Tuman KJ, McCarthy RJ, March RJ, DeLaria GA, Patel RV, Ivankovich AD.Effects of epidural anesthesia and analgesia on coagulation and outcome after major vascular surgery.Anesth Analg. 1991 Dec;73(6):696-704. • Though some found that anesthetic techniques (GA vs EA) were not a factor • Pierce ET, Pomposelli FB Jr, Stanley GD, Lewis KP, Cass JL, LoGerfo FW, Gibbons GW, Campbell DR, Freeman DV, Halpern EF, Bode RH Jr. Anesthesia type does not influence early graft patency or limb salvage rates of lower extremity arterial bypass. J Vasc Surg. 1997 Feb;25(2):226-32 • Schunn CD, Hertzer NR, O'Hara PJ, Krajewski LP, Sullivan TM, Beven EG.Epidural versus general anesthesia: does anesthetic management influence early infrainguinal graft thrombosis? Ann Vasc Surg. 1998 Jan;12(1):65-9.

    27. Venous Thromboembolism • Epidural analgesia decreased venous thromoembolism (not compared against iv PCA) • Jorgensen LN, Rasmussen LS, Nielsen PT, Leffers A, Albrecht-Beste E. Antithrombotic efficacy of continuous extradural analgesia after knee replacement. Br J Anaesth. 1991 Jan;66(1):8-12 • Nielsen PT, Jorgensen LN, Albrecht-Beste E, Leffers AM, Rasmussen LS. Lower thrombosis risk with epidural blockade in knee arthroplasty. Acta Orthop Scand. 1990 Feb;61(1):29-31. • Modig J, Borg T, Karlstrom G, Maripuu E, Sahlstedt B. Thromboembolism after total hip replacement: role of epidural and general anesthesia. Anesth Analg. 1983 Feb;62(2):174-80. • Modig J, Hjelmstedt A, Sahlstedt B, Maripuu E. Comparative influences of epidural and general anaesthesia on deep venous thrombosis and pulmonary embolism after total hip replacement. Acta Chir Scand. 1981;147(2):125-30. • Dalldorf PG, Perkins FM, Totterman S, Pellegrini VD Jr. Deep venous thrombosis following total hip arthroplasty. Effects of prolonged postoperative epidural anesthesia.J Arthroplasty. 1994 Dec;9(6):611-6. • Hendolin H, Mattila MA, Poikolainen E. The effect of lumbar epidural analgesia on the development of deep vein thrombosis of the legs after open prostatectomy. Acta Chir Scand. 1981;147(6):425-9.

    28. Disadvantages of Epidural • Insertion risks • Dural puncture with post spinal headache • Nerve root / cord damage • Haematoma • Infection • Hypotension- sympathetic block • Dehydration, on-going blood loss • Overdose • Catheter problems • Dislodgement; infection; haematoma; coagulopathy • Migration to blood vessel/ subarachnoid space • May not work • More labour-intensive • More monitoring: Inappropriate increase level of block, lower limb weakness

    29. Summary • In terms of pain relief, respiratory functions and mental state, epidural is more superior than IV PCA. Epidural is also unique in prevention thromboemolism and myocardial ischaemia. • Though it is conceivable that epidural will have a positive impact on N&V,early ambulation and early discharge, they are not convincingly demonstrated in all studies. • However, epidural is no worse than IV PCA in terms of these parameter. • Therefore patients with cardiovascular, respiratory diseases, patients undergo major operations for lower limbs operations, epidural analgesia should be considered first.