Comparison of Patient-controlled Intravenous and Epidural Analgesia on Postoperative Complications after Abdominal and Thoracic Surgery: A Meta-Analysis_Chinese Journal of Evidence-Based Medicine

Authors：

 WANG He , SUN Xijia , MA Hong

Department of Anesthesiology, the First Affiliated Hospital, China Medical University, Shenyang 110001, China;

Corresponding author：

WANG He, Email: wanghe1977@126.com

Keywords：

Epidural analgesia; Intravenous analgesia; Postoperative complications; Abdominal and thoracic surgery; Systematic review; Randomized controlled trial; Meta-analysis

DOI：

10.7507/1672-2531.20100585

Video：

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Objective 　To compare the effect of intravenous and epidural analgesia on postoperative complications after abdominal and thoracic surgery.
Methods 　A literature search was conducted by using computerized database on PubMed, EBSCO, Springer, Ovid, and CNKI from 1985 to Jan 2009. Further searches for articles were conducted by checking all references describing postoperative complications with intravenous and epidural anesthesia after abdominal and thoracic surgery. All included randomized controlled trials (RCTs) were assessed and data were extracted by the standard of Cochrane systematic review. The homogeneous studies were pooled using RevMan 4.2.10 software.
Results 　Thirteen RCTs involving 3 055 patients met the inclusion criteria. The results of meta-analyses showed that, a) pulmonary complications and lung function: patient-controlled epidural analgesia can significantly decrease the incidence of pneumonia (RR=0.66, 95%CI 0.53 to 0.83) and improve the FEV1 (WMD=0.17, 95%CI 0.05 to 0.29) and FVC (WMD=0.21, 95%CI 0.1 to 0.32) of lung function after abdominal and thoracic surgery, but no differences in decreasing postoperative respiratory failure (RR=0.77, 95%CI 0.58 to 1.02) and prolonged ventilation (RR=0.75, 95%CI 0.51 to 1.13) compared with intravenous analgesia; b) cardiovascular event: epidural analgesia could significantly decrease the incidence of myocardial infarction (RR=0.58, 95%CI 0.35 to 0.95) and arrhythmia (RR=0.64, 95%CI 0.47 to 0.88) than the control group, but could not better reduce the risk of heart failure (RR=0.79, 95%CI 0.47 to 1.34) and hypotension (RR=1.21, 95%CI 0.63 to 2.29); and c) Other complications: epidural and intravenous analgesia had no difference in decreasing the risk of postoperative renal insufficient (RR=0.78, 95%CI 0.53 to 1.14), gastrointestinal hemorrhage (RR=0.78, 95%CI 0.49 to 1.23), infection (RR=0.89, 95%CI 0.70 to 1.12) and nausea (RR=1.03, 95%CI 0.38 to 2.81).
Conclusions 　Epidural analgesia can obviously decrease the risk of pneumonia, myocardial infarction and severe arrhythmia, and can improve the lung function after abdominal or thoracic surgery.

Citation： WANG He,SUN Xijia,MA Hong. Comparison of Patient-controlled Intravenous and Epidural Analgesia on Postoperative Complications after Abdominal and Thoracic Surgery: A Meta-Analysis. Chinese Journal of Evidence-Based Medicine, 2010, 10(11): 1285-1292. doi: 10.7507/1672-2531.20100585 Copy

1.	盛卓人, 王俊科. 实用临床麻醉学. 北京: 科学出版社, 2009.
2.	Block BM, Liu SS, Rowlingson AJ, et al. Efficacy of postoperative epidural analgesia: a meta-analysis. JAMA, 2003, 290(18): 2455-2463.
3.	Chen LM, Weinberg VK, Chen C, et al. Perioperative outcomes comparing patient controlled epidural versus intravenous analgesia in gynecologic oncology surgery. Gynecol Oncol, 2009, 115(3): 357-361.
4.	Hansdottir V, Philip J, Olsen MF, et al. Thoracic epidural versus intravenous patient-controlled analgesia after cardiac surgery: a randomized controlled trial on length of hospital stay and patient-perceived quality of recovery. Anesthesiology, 2006, 104(1): 142-151.
5.	Peyton PJ, Myles PS, Silbert BS, et al. Perioperative epidural analgesia and outcome after major abdominal surgery in high-risk patients. Anesth Analg, 2003, 96(2): 548.
6.	Park WY, Thompson JS, Lee KK. Effect of epidural anesthesia and analgesia on perioperative outcome: a randomized, controlled Veterans Affairs cooperative study. Ann Surg, 2001, 234(4): 560-569.
7.	Boisseau N, Rabary O, Padovani B, et al. Improvement of ‘dynamic analgesia’ does not decrease atelectasis after thoracotomy. Br J Anaesth, 2001, 87(4): 564-569.
8.	Scott NB, Turfrey DJ, Ray DA, 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, 2001, 93(3): 528-535.
9.	Mann C, Pouzeratte Y, Boccara G, et al. Comparison of intravenous or epidural patient-controlled analgesia in the elderly after major abdominal surgery. Anesthesiology, 2000, 92(2): 433-441.
10.	Boylan JF, Katz J, Kavanagh BP, et al. Epidural bupivacaine-morphine analgesia versus patient-controlled analgesia following abdominal aortic surgery: analgesic, respiratory, and myocardial effects. Anesthesiology, 1998, 89(3): 585-593.
11.	Garnett RL, MacIntyre A, Lindsay P, et al. Perioperative ischaemia in aortic surgery: combined epidural/general anaesthesia and epidural analgesia vs general anaesthesia and i.v. analgesia. Can J Anaesth, 1996, 43(8): 769-777.
12.	Baxter AD, Laganière S, Samson B, et al. A comparison of lumbar epidural and intravenous fentanyl infusions for post-thoracotomy analgesia. Can J Anaesth, 1994, 41(3): 184-191.
13.	Davies MJ, Silbert BS, Mooney PJ, et al. Combined epidural and general anaesthesia versus general anaesthesia for abdominal aortic surgery: a prospective randomised trial. Anaesth Intensive Care, 1993, 21(6): 790-794.
14.	Grant RP, Dolman Jf, Harper JA, et al. Patient-controlled Lumbar epidural fentanyl compares with patient-controller intravenous fentanyl for post-thoracotomy pain. Can J Anaesth, 1992, 39(3): 214-219.
15.	Tuman KJ, Mc Carthy RJ, March RJ, et al. Effects of epidural anesthesia and analgesia on coagulation and outcome after major vascular surgery. Anesth Analg, 1991, 73(6): 696-704.
16.	Ferguson SE, Malhotra T, Seshan VE, et al. A prosepective randomized trial comparing patient-controlled epidural analgesia to patient-controlled intravenous analgesia on postoperative pain control and recovery after major open gynecologic cancer surgery. Gynecol Oncol, 2009, 114(1): 111-116.
17.	Werawatganon T, Charuluxanun S. Patient controlled intravenous opioid analgesiaversus continuous epidural analgesia for pain after intra-abdominal surgery. Cochrane Database Syst Rev, 2005, CD004088.
18.	Paulsen EK, Porter MG, Helmer SD, et al. Thoracic epidural versus patient-controlled analgesia in elective bowel resections. Am J Surg, 2001, 182(6): 570–577.
19.	Liu S, Carpenter RL, Neal JM. Epidural anesthesia and analgesia: their role in postoperative outcome. Anesthesiology, 1995, 82(6): 1474-1506.
20.	Beattie WS, Badner NH, Choi p, et al. Epidural Analgesia Reduces Postoperative Myocardial Infarction: A Meta-Analysis. AnesthAnalg, 2001, 93: 853–858.
21.	Ballantyne JC, Carr DB, et al. The Comparative Effects of Postoperative Analgesic Therapies on Pulmonary Outcome: Cumulative Meta-Analyses of Randomized, Controlled Trials. AnesthAnalg, 1998, 86: 598-612.
22.	Ben-Eliyahu S. The promotion of tumor metastasis by surgery and stress: immunological basis and implications for psychoneuroimmunology. Brain Behav Immun, 2003, 17(Suppl 1): S27-36.
23.	Dolin SJ, Cashman JN, Bland JM. Effectiveness of acute postoperative pain management: I. evidence from published data. Br J Anaesth, 2002, 89(3): 409-423.

1. 盛卓人, 王俊科. 实用临床麻醉学. 北京: 科学出版社, 2009.
2. Block BM, Liu SS, Rowlingson AJ, et al. Efficacy of postoperative epidural analgesia: a meta-analysis. JAMA, 2003, 290(18): 2455-2463.
3. Chen LM, Weinberg VK, Chen C, et al. Perioperative outcomes comparing patient controlled epidural versus intravenous analgesia in gynecologic oncology surgery. Gynecol Oncol, 2009, 115(3): 357-361.
4. Hansdottir V, Philip J, Olsen MF, et al. Thoracic epidural versus intravenous patient-controlled analgesia after cardiac surgery: a randomized controlled trial on length of hospital stay and patient-perceived quality of recovery. Anesthesiology, 2006, 104(1): 142-151.
5. Peyton PJ, Myles PS, Silbert BS, et al. Perioperative epidural analgesia and outcome after major abdominal surgery in high-risk patients. Anesth Analg, 2003, 96(2): 548.
6. Park WY, Thompson JS, Lee KK. Effect of epidural anesthesia and analgesia on perioperative outcome: a randomized, controlled Veterans Affairs cooperative study. Ann Surg, 2001, 234(4): 560-569.
7. Boisseau N, Rabary O, Padovani B, et al. Improvement of ‘dynamic analgesia’ does not decrease atelectasis after thoracotomy. Br J Anaesth, 2001, 87(4): 564-569.
8. Scott NB, Turfrey DJ, Ray DA, 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, 2001, 93(3): 528-535.
9. Mann C, Pouzeratte Y, Boccara G, et al. Comparison of intravenous or epidural patient-controlled analgesia in the elderly after major abdominal surgery. Anesthesiology, 2000, 92(2): 433-441.
10. Boylan JF, Katz J, Kavanagh BP, et al. Epidural bupivacaine-morphine analgesia versus patient-controlled analgesia following abdominal aortic surgery: analgesic, respiratory, and myocardial effects. Anesthesiology, 1998, 89(3): 585-593.
11. Garnett RL, MacIntyre A, Lindsay P, et al. Perioperative ischaemia in aortic surgery: combined epidural/general anaesthesia and epidural analgesia vs general anaesthesia and i.v. analgesia. Can J Anaesth, 1996, 43(8): 769-777.
12. Baxter AD, Laganière S, Samson B, et al. A comparison of lumbar epidural and intravenous fentanyl infusions for post-thoracotomy analgesia. Can J Anaesth, 1994, 41(3): 184-191.
13. Davies MJ, Silbert BS, Mooney PJ, et al. Combined epidural and general anaesthesia versus general anaesthesia for abdominal aortic surgery: a prospective randomised trial. Anaesth Intensive Care, 1993, 21(6): 790-794.
14. Grant RP, Dolman Jf, Harper JA, et al. Patient-controlled Lumbar epidural fentanyl compares with patient-controller intravenous fentanyl for post-thoracotomy pain. Can J Anaesth, 1992, 39(3): 214-219.
15. Tuman KJ, Mc Carthy RJ, March RJ, et al. Effects of epidural anesthesia and analgesia on coagulation and outcome after major vascular surgery. Anesth Analg, 1991, 73(6): 696-704.
16. Ferguson SE, Malhotra T, Seshan VE, et al. A prosepective randomized trial comparing patient-controlled epidural analgesia to patient-controlled intravenous analgesia on postoperative pain control and recovery after major open gynecologic cancer surgery. Gynecol Oncol, 2009, 114(1): 111-116.
17. Werawatganon T, Charuluxanun S. Patient controlled intravenous opioid analgesiaversus continuous epidural analgesia for pain after intra-abdominal surgery. Cochrane Database Syst Rev, 2005, CD004088.
18. Paulsen EK, Porter MG, Helmer SD, et al. Thoracic epidural versus patient-controlled analgesia in elective bowel resections. Am J Surg, 2001, 182(6): 570–577.
19. Liu S, Carpenter RL, Neal JM. Epidural anesthesia and analgesia: their role in postoperative outcome. Anesthesiology, 1995, 82(6): 1474-1506.
20. Beattie WS, Badner NH, Choi p, et al. Epidural Analgesia Reduces Postoperative Myocardial Infarction: A Meta-Analysis. AnesthAnalg, 2001, 93: 853–858.
21. Ballantyne JC, Carr DB, et al. The Comparative Effects of Postoperative Analgesic Therapies on Pulmonary Outcome: Cumulative Meta-Analyses of Randomized, Controlled Trials. AnesthAnalg, 1998, 86: 598-612.
22. Ben-Eliyahu S. The promotion of tumor metastasis by surgery and stress: immunological basis and implications for psychoneuroimmunology. Brain Behav Immun, 2003, 17(Suppl 1): S27-36.
23. Dolin SJ, Cashman JN, Bland JM. Effectiveness of acute postoperative pain management: I. evidence from published data. Br J Anaesth, 2002, 89(3): 409-423.

Chinese Journal of Evidence-Based Medicine

Comparison of Patient-controlled Intravenous and Epidural Analgesia on Postoperative Complications after Abdominal and Thoracic Surgery: A Meta-Analysis

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