Efficacy of Postoperative Epidural Analgesia

Abstract

AWARENESS OF THE UNDERtreatment of acute pain, introduction of new pain management standards by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and recognition of the untoward consequences of uncontrolled postoperative pain have led to a greater appreciation for the importance of acute postoperative pain control. Inadequate control of postoperative pain may result in a higher incidence of chronic postsurgical pain, increased postoperative morbidities, and worsened patient-oriented outcomes such as quality of life. More than 40 million inpatient surgical procedures were performed in the United States in 2000, with systemic opioids (frequently administered parenterally) and epidural analgesia used probably as the 2 most common forms of postoperative analgesia. However, delivery of medications, especially local anesthetic drugs, directly into the epidural space (epidural analgesia) may provide better pain control and improve perioperative pathophysiology, resulting in decreased postoperative morbidity. The question of whether epidural analgesia provides better pain control than parenteral opioid analgesia has not been examined in a systematic fashion, despite the analgesic benefits demonstrated in some individual randomized controlled trials (RCTs). Most studies have focused on whether epidural therapy improves traditional anesthetic outcomes, such as myocardial ischemia, myocardial infarction, or death, and not on analgesia. It is not clearly establishedwhetherpostoperativeepidural analgesia is better than systemic opioids or if the adverse effect profiles differ. In addition, epidural analgesia should not be considered as a single generic entity because many factors (eg, the congruency of catheter insertion location to site of surgical incision [catheter-incision congruency], type of analgesic regimen [local anesthetic vs opioid], and type of pain