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GUEST EDITORIAL
Year : 2008  |  Volume : 54  |  Issue : 2  |  Page : 80-81

PCEA vs. PCA for post-thoracotomy pain: Is this any longer the question?


Department of Anaesthesia, Intensive Care and Pain Medicine, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland

Correspondence Address:
C L Burlacu
Department of Anaesthesia, Intensive Care and Pain Medicine, St. Vincent's University Hospital, Elm Park, Dublin 4
Ireland
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0022-3859.40767

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How to cite this article:
Burlacu C L. PCEA vs. PCA for post-thoracotomy pain: Is this any longer the question?. J Postgrad Med 2008;54:80-1

How to cite this URL:
Burlacu C L. PCEA vs. PCA for post-thoracotomy pain: Is this any longer the question?. J Postgrad Med [serial online] 2008 [cited 2018 Nov 18];54:80-1. Available from: http://www.jpgmonline.com/text.asp?2008/54/2/80/40767


As the currently published research illustrates, the topic of epidural analgesia for major surgery continues to fascinate the anaesthetic and surgical community despite being one of the most extensively studied matters in numerous systematic reviews. Epidural analgesia regardless of analgesic agent (i.e. local anaesthetic only, combination of local anaesthetic and lypophilic/hydrophilic opioid, and lypophilic opioid only), epidural delivery technique (continuous epidural infusion (CEI) or patient-controlled epidural analgesia (PCEA)), type of surgery determining ultimately the location of catheter (thoracic or lumbar) and type of pain (at rest or during movement) provides better analgesia than any type of parenteral opioid including that delivered via intravenous patient-controlled devices (PCA) for up to four days postoperatively. [1] Epidural analgesia is also associated with less nausea, vomiting and sedation than parenteral opioids, although a higher incidence of hypotension, urinary retention and motor block is common, especially with the CEI variant. [1] The need for prolonged mechanical ventilation and time to tracheal extubation after major surgery is reduced, and other complications such as cardiovascular events, [2],[3] pulmonary complications, [2],[4] gastric and renal complications [2] are also reduced, especially with thoracic epidural. The effect on postoperative mortality is still unclear. [2] Hence, excellent pain control and decreased perioperative morbidity propelled epidural analgesia to the status of gold standard for managing pain after major surgery.

Thoracic surgery is one of the clinical areas where there is universal agreement between surgeons and anaesthetists as to the value of aggressive pain management in decreasing postoperative immediate and long-term morbidity. A multimodal multidisciplinary approach to postoperative pain control to include scrupulous surgical technique and appropriate perioperative analgesia permitting adequate patient mobilization and physiotherapy is mandatory for reduced complications. There is recent Level 1 evidence available that continuous epidural analgesia decreases pain scores and maintains pulmonary function better than intravenous patient-controlled analgesia in thoracic surgery. [5] In the same way intravenous opioid PCA provides better analgesia and increased patient satisfaction compared to more conventional parenteral methods of opioid administration, [6] PCEA increasingly becomes the standard method of epidural administration in many institution. In a recent meta-analysis, Wu and colleagues [1] acknowledge the need to systematically compare the two analgesic alternatives for major inpatient surgery (epidural analgesia vs. systemic opioids) when both are delivered via patient-demand devices (PCEA vs. PCA). These authors demonstrate that PCEA (n= 353 patients) provides better analgesia compared to intravenous opioid PCA (n=1,583 patients) for overall pain, pain at rest and with activity ( p0 <0.001). [1] Although analgesia via CEI (n=1,272 patients) is statistically better than analgesia via PCEA for all types of pain ( p < 0.001), the latter offers the benefit of less motor block, nausea and vomiting. The results of the currently published study are, therefore, neither new, nor surprising. It emphasises yet again that PCEA is a meaningful epidural analgesia delivery mode that should be more often utilized in thoracotomy patients.

The authors of the present study choose to deprive their patients of intraoperative epidural analgesia disregarding the concept of pre-emptive analgesia. This theory is based on the assumption that a pharmacological analgesic agent or regional anaesthesia technique, administered prior to a nociceptive stimulus such as surgery, produces a painless post-injury state by preventing central sensitization of the nervous system. A recent meta-analysis indicated that epidural analgesia initiated before the thoracotomy incision was associated with a statistically significant reduction in the severity of acute dynamic pain in the first 48 hr postoperatively compared to thoracic epidural analgesia initiated after surgery completion. [7] Therefore, it is sensible to always use epidural analgesia intraoperatively, and decrease in the same time the need for opioids and their unwanted systemic side effects.

Despite unambiguous evidence, acute pain after thoracotomy continues to represent a challenge for the anaesthetic and surgical community. Although thoracic epidural is perceived as the gold standard analgesia technique, the incidence of failed thoracic epidural is still high even in experienced hands. Alternative regional anaesthesia techniques such as paravertebral analgesia, confirmed to be equally analgesic-effective with thoracic epidural with fewer side effects, and superior to parenteral opioids, [8] may be used in selective cases. Other authors suggest that intravenous opioid PCA should be concomitantly offered to thoracic surgery patients in addition to epidural or paravertebral analgesia [9] although there is little evidence for this approach. It is my belief that an individual evidence-based perioperative analgesia regime, highly effective, with minimal side effects, and user-friendly should be discussed and agreed in partnership with the patient, aiming to decrease the potentially harmful consequences of thoracic surgery on the immediate and long-term patient well being.

 
 :: References Top

1.Wu CL, Cohen SR, Richman JM, Rowlingson AJ, Courpas GE, CheungK, et al. Efficacy of postoperative patient-controlled and continuous infusion epidural analgesia versus intravenous patient-controlled analgesia with opioids. Anesthesiology 2005;103:1079-88.  Back to cited text no. 1    
2.Nishimori M, Ballantyne JC, Low JH. Epidural pain relief versus systemic opioid-based pain relief for abdominal aortic surgery. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD005059. DOI: 10.1002/ 14651858.CD005059.pub2  Back to cited text no. 2    
3.Beattie WS, Badner NH, Choi P. Epidural analgesia reduces postoperative myorcadial infarction: A meta-analysis. Anesth Analg 2001;93:853-8.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Ballantyne JC, Carr DB, deFerranti S, Suarez T, Lau J, Chalmers TC, et al. The comparative effects of postoperative analgesic therapies on pulmonary outcome: Cumulative meta-analyses of randomized, controlled trials. Anesth Analg 1998;86:598-612.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Bauer C, Hentz JG, Ducrocq X, Meyer N, Oswald-Mammosser M, Steib A, et al. Lung function after lobectomy: A randomised, double-blinded trial comparing thoracic epidural ropivacaine/sufentanil and intravenous morphine for patient-controlled analgesia. Anesth Analg 2007;105:238-44.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Hudcova J, McNichol, Quah C, Lau J, Carr DB. Patient-controlled opioid analgesia versus conventional opioid analgesia for postoperative pain Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD003348. DOI: 10.1002/14651858.CD003348.pub2  Back to cited text no. 6    
7.Bong CL, Samuel M, Ng JM, Ip-Yam C. Effects of preemptive epidural analgesia on post-thoracotomy pain. J Cardiothorac Vasc Anesth 2005;19:786-93.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]
8.Detterbeck FC. Efficacy of methods of intercostal nerve blockade for pain relief after thoracotomy. Ann Thorac Surg 2005;80:1550-9.  Back to cited text no. 8  [PUBMED]  
9.Koehler RP, Keenan RJ. Management of post-thoracotomy pain: Acute and chronic. Thorac Surg Clin 2006;16:287-97.  Back to cited text no. 9    



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1 Managing post-thoracotomy pain: Epidural or systemic analgesia and extended care – A randomized study with an “as usual” control group
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2 Analgesic techniques following thoracic surgery: a survey of United Kingdom practice :
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