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Improving postoperative outcomes with epidural analgesia
PAIN CARE
Improving Postoperative Outcomes With Epidural Analgesia Chris Pasero, MS, RN, FAAN THE ADVERSE EFFECTS of poorly managed postoperative pain are numerous. Unrelieved pain can interfere with recovery and contribute to a higher incidence of postoperative complications, such as wound infection and respiratory dysfunction.1-3 A proliferation of research over the past 20 years has shown superior pain relief and improved functional outcomes following major surgery in patients who receive epidural analgesia with local anesthetics compared with traditional methods of postoperative pain management, such as intramuscular (IM) opioids and intravenous (IV) patient-controlled analgesia (PCA).2,4-6 Perianesthesia nurses have led the way in managing this excellent method of postoperative pain control by assisting with epidural catheter placement and titrating, maintaining, and discontinuing the therapy. The epidural route of administration is now accepted as an appropriate first-line route for the management of moderate-to-severe postoperative pain that is expected to last for at least 24 hours.3,6
Adverse Effects of Postoperative Pain The surgical stress response has been described as the common feature shared by all patients who undergo surgery and the key pathogenic factor in postoperative morbidity and mortality.1 The stress response is mediated by endocrine-metabolic changes and causes alterations in organ function postoperatively.1,4 An increase in insulin resistance plays a major role in this process.7 Failure to control the stress response can throw the postoperative patient into a catabolic state, resulting in breakdown of body tissues and physiologic reserve. Consequently, these changes contribute to increased Journal of PeriAnesthesia Nursing, Vol 20, No 1 (February), 2005: pp 51-55
pain, fatigue, gastrointestinal (GI) distress, ileus, hypoxemia, confusion, and cardiopulmonary, infectious, and thromboembolic complications.1,2,4 It seems logical that there would be a direct relationship between postoperative pain and both short- and long-term functional outcomes. Indeed, research conducted in older adults elucidates such a link. Daily interviews and assessments of 411 older adults were conducted to evaluate the effect of postoperative pain on outcomes following hip fracture.8 Patients who had higher pain scores at rest were less likely to be ambulating by the third postoperative day, took longer to ambulate, were more likely to miss or shorten their physical therapy sessions, and had significantly longer hospital stays than those with well-controlled pain. A long-term outcome was impacted as well; locomotion scores at 6 months were significantly lower in patients with high postoperative pain intensity scores. Another study of elders (N ⫽ 85) who had undergone surgical repair of hip fracture revealed similar findings.9 The intent of this prospective study was to determine if pain report or pain treatment in the hospital was a predic-
Chris Pasero is a Pain Management Educator and Clinical Consultant in El Dorado Hills, CA. Address correspondence to Chris Pasero, MS, RN, FAAN, 1252 Clearview Drive, El Dorado Hills, CA 95762; e-mail address: [email protected]. © 2005 by American Society of PeriAnesthesia Nurses. 1089-9472/05/2001-0011$30.00/0 doi:10.1016/j.jopan.2004.11.007 51
52
tor of functional outcomes (eg, walking, climbing stairs, and getting in and out of the bathtub) 2 months after the surgery. Age, mental status, illness severity, and pain reported as moderate with movement during hospitalization were found to influence long-term functional outcomes, accounting for 51% of the variance noted. A disturbing finding was that the nurses caring for these patients administered less than 25% of the mean amount of analgesics prescribed during the first and second 48 hours postoperatively. The researchers pointed out that although nurses may be limited in their ability to influence factors such as age, mental status, and illness severity, they certainly can influence pain severity. There can be lifelong adverse effects as well. Tissue trauma and injury to nerves during surgery can result in chronic postsurgical pain. Chronic postsurgical pain has been defined as pain that has developed after a surgical procedure, is of at least 2 months’ duration, and is not the result of other factors (eg, continued malignancy or chronic infection) or the exacerbation of a preexisting condition.10 Chronic pain has been associated with a variety of surgical procedures, including thoracotomy, cholecystectomy, amputation, and cardiac surgery.2,10 Persistent scar pain, paresthesias, and phantom breast pain are alarmingly common after breast surgery.10 Research shows that a number of factors can reduce the likelihood of chronic postsurgical pain, including the use of less-invasive surgical techniques, early physical rehabilitation, and control of postoperative pain.2 For instance, the only factor found to predict long-term postthoracotomy pain in one study was early postoperative pain.11 Pain intensity 24 hours after thoracotomy was significantly greater in the patients who developed chronic postthoracotomy pain than those who were pain free. Similarly, in another study, women who developed chronic breast pain following modified radical breast mastectomy or breast resection for cancer were
CHRIS PASERO
more likely to recall more severe postoperative pain than those who did not develop chronic breast pain.12
Improved Outcomes With Epidural Analgesia Decades of research have shown epidural analgesia to be superior to traditional pain management techniques in patients undergoing certain major surgical procedures. Following is a review of some of the more recent literature. Researchers compared outcomes in 90 patients after hip replacement who had received either general anesthesia and postoperative IV PCA morphine or epidural anesthesia followed by a continuous epidural infusion of ropivacaine postoperatively.13 The PACU time was comparable for the 2 groups of patients; however, median time until patients were deemed ready for discharge from the PACU was considerably shorter in the epidural group (the lack of actual difference may have been due to surgeon-controlled rather than researcher-controlled discharge). Pain control during the first 24 hours, which is the time postoperative pain is likely to be the most severe, were better in the patients who received epidural analgesia. Nausea and vomiting was less common, and postoperative bowel function were significantly improved (26 hours versus 47 hours until first passage of flatus) in the epidural group. In another study, postoperative IV PCA morphine was compared with patient-controlled epidural analgesia (PCEA) sufentanil and bupivacaine in 70 older patients (mean age was 76 years) undergoing major abdominal surgery.14 Patients who received PCEA experienced better pain relief at rest and after coughing, higher satisfaction scores, and better bowel function and mental status than those who received IV PCA. Three methods of perioperative pain management were compared in 114 patients undergoing gastric bypass surgery.15 The patients were
IMPROVING OUTCOMES WITH EPIDURAL ANALGESIA
randomized to receive (1) incisional local anesthetic infiltration plus postoperative IV PCA, (2) epidural anesthesia and postoperative epidural analgesia, or (3) postoperative IV PCA. All of the patients received general anesthesia during surgery and nonsteroidal antiinflammatory drugs (NSAIDs) postoperatively in conjunction with their therapies. Length of stay and patient satisfaction were similar among the groups; however, lower pain scores and less analgesic use were noted in those who received epidural analgesia. Use of intraoperative fentanyl was lowest in the epidural group, and morphine consumption was equivalent in the 2 IV PCA groups. Nausea was significantly less common in the epidural group. The relationship between pain management technique (thoracic epidural fentanyl and bupivacaine or IV PCA morphine) and the outcomes of 64 patients undergoing colon resection was the focus of an extensive study.16 Both short- and long-term data were collected. Patients in both groups received similar perioperative care and were offered the same postoperative oral nutrition and assistance with ambulation. Those who received epidural analgesia experienced significantly lower postoperative fatigue and pain scores at rest and on coughing and moving. In addition, pulmonary and GI functions were significantly better in the epidural group than in the IV PCA group. Although length of hospital stay was the same in both groups, the researchers thought the patients who received epidural analgesia were ready for discharge earlier than those who received IV PCA (as in other studies, the lack of actual difference may have been due to surgeon-controlled discharge). The long-term findings of this study were equally impressive. Compared with the patients who received epidural analgesia, those who received IV PCA experienced nearly twice the deterioration in mobility (measured by 6-minute walking
53
tests) at 3 weeks and greater than 4 times at 6 weeks after surgery. Providing optimal pain relief with thoracic epidural bupivacaine and sufentanil was found to be key in a multimodal recovery program that focused on early endotracheal extubation, parenteral nutrition, and goal-oriented mobilization in 42 patients undergoing abdominothoracic esophagectomy.17 A retrospective review of 49 patients who had received traditional management that included postoperative IV PCA was conducted for comparison. Patients who received epidural analgesia and multimodal treatment experienced significantly better pain relief and were extubated and mobilized significantly sooner than were those who received traditional treatment. They also experienced earlier return of bowel function and better nutritional status (less protein breakdown). Finally, the patients who received epidural analgesia and multimodal treatment were discharged from the ICU at 1.7 days, compared with 4.0 days for patients who received traditional treatment. In a small study (N ⫽ 18), epidural analgesia with morphine and ropivacaine was compared with IV PCA morphine following unilateral mastectomy with immediate transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction.18 All of the patients received general anesthesia. The patients in the epidural group had significantly lower pain scores and were discharged from the hospital 25 hours earlier than patients in the IV PCA group. A prospective, randomized study was conducted to evaluate major organ complications in 408 patients undergoing routine coronary artery bypass graft surgery.19 Approximately half of the patients (n ⫽ 206) received thoracic epidural analgesia, and the others (n ⫽ 202) received conventional opioid analgesia (IV PCA morphine after a 24-hour target-controlled infusion of alfentanil). All of the patients were given general anesthesia and could receive supplemental oral analgesia postoperatively. The pa-
CHRIS PASERO
54
Table 1. Guidelines for Use of Epidural Analgesia Patient selection ● Absence of contraindications to epidural needle or catheter placement (eg, coagulopathies, abnormal clotting studies, sepsis). ● The systemic routes (ie, oral, IV) have been considered and are not an option because they would produce unmanageable and intolerable adverse effects at the anticipated doses required for adequate analgesia. ● Patient is having a surgical procedure for which reduced morbidity and mortality is important and impractical or unattainable with other routes of administration. Such conditions include major thoracic, abdominal, and orthopedic surgery. ● Epidural preemptive analgesia could prevent or reduce the severity of a chronic pain syndrome (eg, elective amputation). Other considerations ● Appropriate equipment and supplies are available for epidural analgesia therapy. ● Staff are trained to assess and manage epidural analgesia. ● Clinical support systems are available around-the-clock, 7 days a week. Adapted from Pasero et al.3
tients who received epidural analgesia were extubated earlier, had better pulmonary function, experienced less confusion, and had fewer respiratory infections, new supraventricular dysrhythmias, and strokes than those who received conventional postoperative analgesia. All surgical patients are at risk for cardiac morbidity and mortality.5,20 Epidural analgesia may afford some protection for patients, especially those who are at high risk for cardiac morbidity and undergo major surgical procedures. A metaanalysis was conducted to determine if postoperative epidural analgesia reduced the incidence of postoperative myocardial infarction or in-hospital death in surgical patients.20 Although there was no difference in the frequency of in-hospital deaths, the rate of postoperative myocardial infarction was significantly lower among patients who received epidural analgesia compared with those who did not.
Guidelines for Use of Epidural Analgesia The findings of the studies described above and others like them have implications for nurses who care for surgical patients at all phases, particularly perianesthesia nurses. Perianesthesia nurses are ideally positioned to identify the factors that place patients at high risk for poor short- and long-term functional outcomes and to ensure aggressive perioperative pain management plans are initiated. This includes encouraging the use of epidural analgesia when it is indicated and appropriate. Epidural analgesia should be considered whenever outcome research and clinical experience support its use. Risk and benefit must always be weighed. Table 1 lists patient selection guidelines and other considerations when using the epidural route of administration for postoperative pain management.
References 1. Kehlet H: Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 78:606-617, 1997 2. Pasero C, Paice JA, McCaffery M: Basic mechanisms underlying the causes and effects of pain, in McCaffery M, Pasero C: Pain: Clinical Manual (ed 2). St. Louis, MO: Mosby, 1999,15-34
3. Pasero C, Portenoy RK, McCaffery M: Opioid analgesics, in McCaffery M, Pasero C. Pain: Clinical Manual (ed 2). St. Louis, MO: Mosby, 1999:161-299 4. Kehlet H: Modification of stress responses to surgery by neural blockade: Clinical implications, in Cousins MJ, Bridenbaugh PO (eds): Neural Blockade in Clinical Anesthesia and
IMPROVING OUTCOMES WITH EPIDURAL ANALGESIA Management of Pain. Philadelphia, PA: Lippincott-Raven, 1998:129-175 5. Kehlet H, Holte K: Effect of postoperative analgesia on surgical outcome. Br J Anaesth 87:62-72, 2001 6. Pasero C: Epidural analgesia for postoperative pain management. Am J Nurs 103:43-45, 2003 7. Carli F, Bennett GJ: Pain and postoperative recovery (editorial). Anesthesiology 95:573-574, 2001 8. Morrison RS, Magaziner J, McLaughlin MA, et al: The impact of post-operative pain on outcomes following hip fracture. Pain 103:303-311, 2003 9. Feldt KS, Oh, HL: Pain and hip fracture outcomes in older adults. Orthop Nurs 19:35-44, 2000 10. Macrae WA: Chronic pain after surgery. Br J Anaesth 87:88-98, 2001 11. Katz J, Jackson M, Kavanaugh B, et al: Acute pain after thoracic surgery predicts long-term post-thoracotomy pain. Clin J Pain 12:50-55, 1996 12. Tasmuth T, Estlanderb A, Kalso E: Effect of present pain and mood on the memory of past postoperative pain in women treated surgically for breast cancer. Pain 68:343-347, 1996 13. Wulf H, Biscoping J, Beland B, et al: Ropivacaine epidural anesthesia and analgesia versus general anesthesia and intravenous patient-controlled analgesia with morphine in the perioperative management of hip replacement. Anesth Analg 89:111-116, 1999
55
14. Mann C, Pouzeratte Y, Boccara G, et al: Comparison of intravenous or epidural patient controlled analgesia in the elderly after major abdominal surgery. Anesthesiology 92:433441, 2000 15. Schumann R, Shikora S, Weiss JM, et al: A comparison of multimodal perioperative analgesia to epidural pain management after gastric bypass surgery. Anesth Analg 96:468-474, 2003 16. Carli F, May N, Klubien K, et al: Epidural analgesia enhances functional exercise capacity and health-related quality of life after colonic surgery. Anesthesiology 97:540-549, 2002 17. Brodner G, Pogatzki E, Van Aken H, et al: A multimodal approach to control postoperative pathophysiology and rehabilitation in patients undergoing abdominothoracic esophagectomy. Anesth Analg 86:228-234, 1998 18. Correll DJ, Viscusi ER, Grunwald Z, et al: Epidural analgesia compared with intravenous morphine patient-controlled analgesia: Postoperative outcome measures after mastectomy with immediate TRAM flap breast reconstruction. Reg Anesth Pain Med 26:444-449, 2001 19. Scott NB, Turfrey DJ, Ray DAA, et al: A prospective randomized study of the potential benefits of thoracic epidural anesthesia and analgesia in patients undergoing coronary artery bypass grafting. Anesth Analg 93:528-535, 2001 20. Beattie WS, Badner NH, Choi P: Epidural analgesia reduces postoperative myocardial infarction: A meta-analysis. Anesth Analg 93:853-858, 2001
Improving Postoperative Outcomes With Epidural Analgesia Chris Pasero, MS, RN, FAAN THE ADVERSE EFFECTS of poorly managed postoperative pain are numerous. Unrelieved pain can interfere with recovery and contribute to a higher incidence of postoperative complications, such as wound infection and respiratory dysfunction.1-3 A proliferation of research over the past 20 years has shown superior pain relief and improved functional outcomes following major surgery in patients who receive epidural analgesia with local anesthetics compared with traditional methods of postoperative pain management, such as intramuscular (IM) opioids and intravenous (IV) patient-controlled analgesia (PCA).2,4-6 Perianesthesia nurses have led the way in managing this excellent method of postoperative pain control by assisting with epidural catheter placement and titrating, maintaining, and discontinuing the therapy. The epidural route of administration is now accepted as an appropriate first-line route for the management of moderate-to-severe postoperative pain that is expected to last for at least 24 hours.3,6
Adverse Effects of Postoperative Pain The surgical stress response has been described as the common feature shared by all patients who undergo surgery and the key pathogenic factor in postoperative morbidity and mortality.1 The stress response is mediated by endocrine-metabolic changes and causes alterations in organ function postoperatively.1,4 An increase in insulin resistance plays a major role in this process.7 Failure to control the stress response can throw the postoperative patient into a catabolic state, resulting in breakdown of body tissues and physiologic reserve. Consequently, these changes contribute to increased Journal of PeriAnesthesia Nursing, Vol 20, No 1 (February), 2005: pp 51-55
pain, fatigue, gastrointestinal (GI) distress, ileus, hypoxemia, confusion, and cardiopulmonary, infectious, and thromboembolic complications.1,2,4 It seems logical that there would be a direct relationship between postoperative pain and both short- and long-term functional outcomes. Indeed, research conducted in older adults elucidates such a link. Daily interviews and assessments of 411 older adults were conducted to evaluate the effect of postoperative pain on outcomes following hip fracture.8 Patients who had higher pain scores at rest were less likely to be ambulating by the third postoperative day, took longer to ambulate, were more likely to miss or shorten their physical therapy sessions, and had significantly longer hospital stays than those with well-controlled pain. A long-term outcome was impacted as well; locomotion scores at 6 months were significantly lower in patients with high postoperative pain intensity scores. Another study of elders (N ⫽ 85) who had undergone surgical repair of hip fracture revealed similar findings.9 The intent of this prospective study was to determine if pain report or pain treatment in the hospital was a predic-
Chris Pasero is a Pain Management Educator and Clinical Consultant in El Dorado Hills, CA. Address correspondence to Chris Pasero, MS, RN, FAAN, 1252 Clearview Drive, El Dorado Hills, CA 95762; e-mail address: [email protected]. © 2005 by American Society of PeriAnesthesia Nurses. 1089-9472/05/2001-0011$30.00/0 doi:10.1016/j.jopan.2004.11.007 51
52
tor of functional outcomes (eg, walking, climbing stairs, and getting in and out of the bathtub) 2 months after the surgery. Age, mental status, illness severity, and pain reported as moderate with movement during hospitalization were found to influence long-term functional outcomes, accounting for 51% of the variance noted. A disturbing finding was that the nurses caring for these patients administered less than 25% of the mean amount of analgesics prescribed during the first and second 48 hours postoperatively. The researchers pointed out that although nurses may be limited in their ability to influence factors such as age, mental status, and illness severity, they certainly can influence pain severity. There can be lifelong adverse effects as well. Tissue trauma and injury to nerves during surgery can result in chronic postsurgical pain. Chronic postsurgical pain has been defined as pain that has developed after a surgical procedure, is of at least 2 months’ duration, and is not the result of other factors (eg, continued malignancy or chronic infection) or the exacerbation of a preexisting condition.10 Chronic pain has been associated with a variety of surgical procedures, including thoracotomy, cholecystectomy, amputation, and cardiac surgery.2,10 Persistent scar pain, paresthesias, and phantom breast pain are alarmingly common after breast surgery.10 Research shows that a number of factors can reduce the likelihood of chronic postsurgical pain, including the use of less-invasive surgical techniques, early physical rehabilitation, and control of postoperative pain.2 For instance, the only factor found to predict long-term postthoracotomy pain in one study was early postoperative pain.11 Pain intensity 24 hours after thoracotomy was significantly greater in the patients who developed chronic postthoracotomy pain than those who were pain free. Similarly, in another study, women who developed chronic breast pain following modified radical breast mastectomy or breast resection for cancer were
CHRIS PASERO
more likely to recall more severe postoperative pain than those who did not develop chronic breast pain.12
Improved Outcomes With Epidural Analgesia Decades of research have shown epidural analgesia to be superior to traditional pain management techniques in patients undergoing certain major surgical procedures. Following is a review of some of the more recent literature. Researchers compared outcomes in 90 patients after hip replacement who had received either general anesthesia and postoperative IV PCA morphine or epidural anesthesia followed by a continuous epidural infusion of ropivacaine postoperatively.13 The PACU time was comparable for the 2 groups of patients; however, median time until patients were deemed ready for discharge from the PACU was considerably shorter in the epidural group (the lack of actual difference may have been due to surgeon-controlled rather than researcher-controlled discharge). Pain control during the first 24 hours, which is the time postoperative pain is likely to be the most severe, were better in the patients who received epidural analgesia. Nausea and vomiting was less common, and postoperative bowel function were significantly improved (26 hours versus 47 hours until first passage of flatus) in the epidural group. In another study, postoperative IV PCA morphine was compared with patient-controlled epidural analgesia (PCEA) sufentanil and bupivacaine in 70 older patients (mean age was 76 years) undergoing major abdominal surgery.14 Patients who received PCEA experienced better pain relief at rest and after coughing, higher satisfaction scores, and better bowel function and mental status than those who received IV PCA. Three methods of perioperative pain management were compared in 114 patients undergoing gastric bypass surgery.15 The patients were
IMPROVING OUTCOMES WITH EPIDURAL ANALGESIA
randomized to receive (1) incisional local anesthetic infiltration plus postoperative IV PCA, (2) epidural anesthesia and postoperative epidural analgesia, or (3) postoperative IV PCA. All of the patients received general anesthesia during surgery and nonsteroidal antiinflammatory drugs (NSAIDs) postoperatively in conjunction with their therapies. Length of stay and patient satisfaction were similar among the groups; however, lower pain scores and less analgesic use were noted in those who received epidural analgesia. Use of intraoperative fentanyl was lowest in the epidural group, and morphine consumption was equivalent in the 2 IV PCA groups. Nausea was significantly less common in the epidural group. The relationship between pain management technique (thoracic epidural fentanyl and bupivacaine or IV PCA morphine) and the outcomes of 64 patients undergoing colon resection was the focus of an extensive study.16 Both short- and long-term data were collected. Patients in both groups received similar perioperative care and were offered the same postoperative oral nutrition and assistance with ambulation. Those who received epidural analgesia experienced significantly lower postoperative fatigue and pain scores at rest and on coughing and moving. In addition, pulmonary and GI functions were significantly better in the epidural group than in the IV PCA group. Although length of hospital stay was the same in both groups, the researchers thought the patients who received epidural analgesia were ready for discharge earlier than those who received IV PCA (as in other studies, the lack of actual difference may have been due to surgeon-controlled discharge). The long-term findings of this study were equally impressive. Compared with the patients who received epidural analgesia, those who received IV PCA experienced nearly twice the deterioration in mobility (measured by 6-minute walking
53
tests) at 3 weeks and greater than 4 times at 6 weeks after surgery. Providing optimal pain relief with thoracic epidural bupivacaine and sufentanil was found to be key in a multimodal recovery program that focused on early endotracheal extubation, parenteral nutrition, and goal-oriented mobilization in 42 patients undergoing abdominothoracic esophagectomy.17 A retrospective review of 49 patients who had received traditional management that included postoperative IV PCA was conducted for comparison. Patients who received epidural analgesia and multimodal treatment experienced significantly better pain relief and were extubated and mobilized significantly sooner than were those who received traditional treatment. They also experienced earlier return of bowel function and better nutritional status (less protein breakdown). Finally, the patients who received epidural analgesia and multimodal treatment were discharged from the ICU at 1.7 days, compared with 4.0 days for patients who received traditional treatment. In a small study (N ⫽ 18), epidural analgesia with morphine and ropivacaine was compared with IV PCA morphine following unilateral mastectomy with immediate transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction.18 All of the patients received general anesthesia. The patients in the epidural group had significantly lower pain scores and were discharged from the hospital 25 hours earlier than patients in the IV PCA group. A prospective, randomized study was conducted to evaluate major organ complications in 408 patients undergoing routine coronary artery bypass graft surgery.19 Approximately half of the patients (n ⫽ 206) received thoracic epidural analgesia, and the others (n ⫽ 202) received conventional opioid analgesia (IV PCA morphine after a 24-hour target-controlled infusion of alfentanil). All of the patients were given general anesthesia and could receive supplemental oral analgesia postoperatively. The pa-
CHRIS PASERO
54
Table 1. Guidelines for Use of Epidural Analgesia Patient selection ● Absence of contraindications to epidural needle or catheter placement (eg, coagulopathies, abnormal clotting studies, sepsis). ● The systemic routes (ie, oral, IV) have been considered and are not an option because they would produce unmanageable and intolerable adverse effects at the anticipated doses required for adequate analgesia. ● Patient is having a surgical procedure for which reduced morbidity and mortality is important and impractical or unattainable with other routes of administration. Such conditions include major thoracic, abdominal, and orthopedic surgery. ● Epidural preemptive analgesia could prevent or reduce the severity of a chronic pain syndrome (eg, elective amputation). Other considerations ● Appropriate equipment and supplies are available for epidural analgesia therapy. ● Staff are trained to assess and manage epidural analgesia. ● Clinical support systems are available around-the-clock, 7 days a week. Adapted from Pasero et al.3
tients who received epidural analgesia were extubated earlier, had better pulmonary function, experienced less confusion, and had fewer respiratory infections, new supraventricular dysrhythmias, and strokes than those who received conventional postoperative analgesia. All surgical patients are at risk for cardiac morbidity and mortality.5,20 Epidural analgesia may afford some protection for patients, especially those who are at high risk for cardiac morbidity and undergo major surgical procedures. A metaanalysis was conducted to determine if postoperative epidural analgesia reduced the incidence of postoperative myocardial infarction or in-hospital death in surgical patients.20 Although there was no difference in the frequency of in-hospital deaths, the rate of postoperative myocardial infarction was significantly lower among patients who received epidural analgesia compared with those who did not.
Guidelines for Use of Epidural Analgesia The findings of the studies described above and others like them have implications for nurses who care for surgical patients at all phases, particularly perianesthesia nurses. Perianesthesia nurses are ideally positioned to identify the factors that place patients at high risk for poor short- and long-term functional outcomes and to ensure aggressive perioperative pain management plans are initiated. This includes encouraging the use of epidural analgesia when it is indicated and appropriate. Epidural analgesia should be considered whenever outcome research and clinical experience support its use. Risk and benefit must always be weighed. Table 1 lists patient selection guidelines and other considerations when using the epidural route of administration for postoperative pain management.
References 1. Kehlet H: Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 78:606-617, 1997 2. Pasero C, Paice JA, McCaffery M: Basic mechanisms underlying the causes and effects of pain, in McCaffery M, Pasero C: Pain: Clinical Manual (ed 2). St. Louis, MO: Mosby, 1999,15-34
3. Pasero C, Portenoy RK, McCaffery M: Opioid analgesics, in McCaffery M, Pasero C. Pain: Clinical Manual (ed 2). St. Louis, MO: Mosby, 1999:161-299 4. Kehlet H: Modification of stress responses to surgery by neural blockade: Clinical implications, in Cousins MJ, Bridenbaugh PO (eds): Neural Blockade in Clinical Anesthesia and
IMPROVING OUTCOMES WITH EPIDURAL ANALGESIA Management of Pain. Philadelphia, PA: Lippincott-Raven, 1998:129-175 5. Kehlet H, Holte K: Effect of postoperative analgesia on surgical outcome. Br J Anaesth 87:62-72, 2001 6. Pasero C: Epidural analgesia for postoperative pain management. Am J Nurs 103:43-45, 2003 7. Carli F, Bennett GJ: Pain and postoperative recovery (editorial). Anesthesiology 95:573-574, 2001 8. Morrison RS, Magaziner J, McLaughlin MA, et al: The impact of post-operative pain on outcomes following hip fracture. Pain 103:303-311, 2003 9. Feldt KS, Oh, HL: Pain and hip fracture outcomes in older adults. Orthop Nurs 19:35-44, 2000 10. Macrae WA: Chronic pain after surgery. Br J Anaesth 87:88-98, 2001 11. Katz J, Jackson M, Kavanaugh B, et al: Acute pain after thoracic surgery predicts long-term post-thoracotomy pain. Clin J Pain 12:50-55, 1996 12. Tasmuth T, Estlanderb A, Kalso E: Effect of present pain and mood on the memory of past postoperative pain in women treated surgically for breast cancer. Pain 68:343-347, 1996 13. Wulf H, Biscoping J, Beland B, et al: Ropivacaine epidural anesthesia and analgesia versus general anesthesia and intravenous patient-controlled analgesia with morphine in the perioperative management of hip replacement. Anesth Analg 89:111-116, 1999
55
14. Mann C, Pouzeratte Y, Boccara G, et al: Comparison of intravenous or epidural patient controlled analgesia in the elderly after major abdominal surgery. Anesthesiology 92:433441, 2000 15. Schumann R, Shikora S, Weiss JM, et al: A comparison of multimodal perioperative analgesia to epidural pain management after gastric bypass surgery. Anesth Analg 96:468-474, 2003 16. Carli F, May N, Klubien K, et al: Epidural analgesia enhances functional exercise capacity and health-related quality of life after colonic surgery. Anesthesiology 97:540-549, 2002 17. Brodner G, Pogatzki E, Van Aken H, et al: A multimodal approach to control postoperative pathophysiology and rehabilitation in patients undergoing abdominothoracic esophagectomy. Anesth Analg 86:228-234, 1998 18. Correll DJ, Viscusi ER, Grunwald Z, et al: Epidural analgesia compared with intravenous morphine patient-controlled analgesia: Postoperative outcome measures after mastectomy with immediate TRAM flap breast reconstruction. Reg Anesth Pain Med 26:444-449, 2001 19. Scott NB, Turfrey DJ, Ray DAA, et al: A prospective randomized study of the potential benefits of thoracic epidural anesthesia and analgesia in patients undergoing coronary artery bypass grafting. Anesth Analg 93:528-535, 2001 20. Beattie WS, Badner NH, Choi P: Epidural analgesia reduces postoperative myocardial infarction: A meta-analysis. Anesth Analg 93:853-858, 2001