W. Jaksch, J. Cup-Grundtner, S. Resch, R. Reichhalter , B. Gustorff
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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. [email protected]
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