Patient controlled intravenous opioid analgesia versus

continuous epidural analgesia for pain after intraabdominal

surgery (Protocol)

Werawatganon T, Charuluxanun S

This is a reprint of a Cochrane protocol, prepared and maintained by The Cochrane Collaboration and published in The Cochrane
Library 2003, Issue 1
http://www.thecochranelibrary.com

Patient controlled intravenous opioid analgesia versus continuous epidural analgesia for pain after intraabdominal surgery (Protocol)
Copyright © 2004 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 TABLE OF CONTENTS
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW . . . . . . . . . . . . . . . . . . 2
SEARCH STRATEGY FOR IDENTIFICATION OF STUDIES . . . . . . . . . . . . . . . . . . . . 2
METHODS OF THE REVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
POTENTIAL CONFLICT OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
COVER SHEET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Patient controlled intravenous opioid analgesia versus continuous epidural analgesia for pain after intraabdominal surgery (Protocol) i
Copyright © 2004 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Patient controlled intravenous opioid analgesia versus
continuous epidural analgesia for pain after intraabdominal
surgery (Protocol)

Werawatganon T, Charuluxanun S

This record should be cited as:

Werawatganon T, Charuluxanun S. Patient controlled intravenous opioid analgesia versus continuous epidural analgesia for pain
after intraabdominal surgery. (Protocol) The Cochrane Database of Systematic Reviews , Issue . Art. No.: CD004088. DOI:
10.1002/14651858.CD004088.

This version first published online: 20 January 2003 in Issue , .

Date of most recent substantive amendment: 25 October 2002

ABSTRACT
This is the protocol for a review and there is no abstract. The objectives are as follows:
To compare PCA opioid therapy with CEA for pain control after intra abdominal surgery in terms of analgesic efficacy, side effects,
patient satisfaction and surgical outcome.

BACKGROUND provide some evidence that in postoperative period, PCA with

Postoperative pain is one of the most significant problems that
confronts surgical patients. It disturbs the cardiovascular, respira-
tory, and endocrine systems (Rademaker 1992; Kouraklis 2000).
Pain is distressing for the patient. Good perioperative analgesia
management reduces the occurrence of serious postoperative com-
plications (Cuschieri 1985; Gust 1999; Major 1996).
opioids, compared with conventional opioid treatment, improves
analgesia and decreases the risk of pulmonary complications. In
addition, it was found that patients prefer PCA. Presently PCA
devices are widely used in clinical practice and are amongst the
recommended techniques for the control of pain in the postoper-
ative period (ASA 1995). Nevertheless PCA devices are expensive
and material costs are high.(Choiniere 1998)

In the development of methods for postoperative pain control, For more than two decades, neuraxial opioids, by epidural or in-
two techniques are currently popular: patient controlled analgesia trathecal administration, have been a standard for treating acute
(PCA) with intravenous opioids and continuous epidural analgesia and chronic pain (Behar 1979; Wang 1979). Opioids exert a
(CEA). prominent analgesic action at the level of the spinal dorsal horn.
Common side effects associated with the use of neuraxial opioids
Patient controlled analgesia (PCA) with intravenous opioids was are pruritus, nausea, respiratory depression and sedation. More-
introduced around 1971(Keeri-Szanto 1971; Evans 1976). The over, the procedure to set up the administration is more invasive
principles of PCA brought in a new concept of pain relief. When- than the intravenous route.
ever the patient requires pain relief, he pushes a button of an elec-
tronic device which then delivers a small amount of opioids into There is still doubt as to which technique is better: PCA with
the venous line. The delivered opioids act on all parts of the body intravenous opioids or continuous epidural analgesia, in terms of
that have opiate receptors, especially the brain. The patients can analgesia and adverse effects (Benzon 1993; Parker 1992).
titrate the delivery of the opioids to their individual pain level.
Some physicians consider that this is an important step towards an
optimized postoperative pain treatment. There were two system- OBJECTIVES
atic reviews comparing PCA with conventional opioid analgesia
in surgical patients (Ballantyne 1993; Walder 2001). Both reviews To compare PCA opioid therapy with CEA for pain control after
Patient controlled intravenous opioid analgesia versus continuous epidural analgesia for pain after intraabdominal surgery (Protocol) 1
Copyright © 2004 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
intra abdominal surgery in terms of analgesic efficacy, side effects, We shall use the electronic databases, MEDLINE (January 1966
patient satisfaction and surgical outcome. - October 2002), EMBASE (January 1988 - October 2002),
and the Cochrane Library (Issue 4, 2002) without language
restrictions.
CRITERIA FOR CONSIDERING The search strategy is
STUDIES FOR THIS REVIEW 1 PATIENT-CONTROLLED OR PCA
2 ANALGESIA[TI] OR ANALGESIC[TI] OR PAIN[TI]
Types of studies 3 #1 AND #2
4 EPIDURAL[TI] OR PERIDURAL[TI]
All prospective randomized comparisons. Trials had to be original 5 #3 AND #4
(not another duplicated report of the same study). 6 ABDOM* OR LAPAROTOMY OR GATR* OR INTESTIN*
Types of participants OR BOWEL OR HEPAT* OR BILIARY
7 #5 AND #6
Adult patients after intra-abdominal surgery who are eligible for 8 LABOR OR LABOUR
either PCA or for continuous epidural analgesia administration 9 #7 NOT #8
(CEA). Age above 14 years old. ASA physical status I to IV. Preg- We will use the bibliography of retrieved articles in order to
nant women will be included, if eligible. Other analgesic sup- identify further relevant trials.
plements such as, non-steriodal anti-inflammation, are allowed,
except intravenous opioids via a PCA device in the continuous
epidural analgesia group. The medication for continuous epidural METHODS OF THE REVIEW
analgesia may be any opioids and/or local anaesthetic agents.
Two independent reviewers will evaluate the title and abstract
Types of intervention
of all identified studies for eligibility. They will not be blind to
Patient-controlled analgesia (PCA) with opioids by intravenous the authors and source paper of the studies. Blinding is difficult
route compared with continuous epidural analgesia without a PCA to achieve, time consuming and may not substantially alter the
device. results of a review (Berlin 1997). Disagreement will be resolved by
Types of outcome measures discussion.

Effectiveness
- pain score by visual analogue scale during 6-hour period (early POTENTIAL CONFLICT OF
phase), 24-hour period, and 24-hour to 72-hour period (late INTEREST
phase).
- total 24-hour opioids consumption None known
- number of failures defined as: change of regimen of pain man-
agement.
- length of hospital stay ACKNOWLEDGEMENTS
- time to ambulation
- patient satisfaction We would like to thank Dr Tom Pedersen, Dr Jane Ballantyne, Dr
Adverse effects Vlad Frenk, Phil Wiffen (Co-ordinating Editor PaPaS Cochrane
- nausea Group), and Jane Cracknell, for their help and editorial advice
- vomiting during the preparation of this protocol.
- respiratory depression (respiratory rate below 10/min)
- respiratory complication: hypoxaemia (SaO2 less than 90% by
pulse oximetry) SOURCES OF SUPPORT
- pruritus
External sources of support

• No sources of support supplied

SEARCH STRATEGY FOR
IDENTIFICATION OF STUDIES Internal sources of support
• Department of Anaesthesiology, Faculty of Medicine, Chula-
See: search strategy longkorn University THAILAND

Patient controlled intravenous opioid analgesia versus continuous epidural analgesia for pain after intraabdominal surgery (Protocol) 2
Copyright © 2004 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
 REFERENCES
Additional references
ASA 1995
(No authors listed). Practice guidelines for acute pain management in
the perioperative setting. A report by the American Society of Anes-
thesiologists Task Force on Pain Management, Acute Pain Section.
Anesthesiology 1995;82(4):1071-81.
Ballantyne 1993
Ballantyne JC, Carr DB, Chalmers TC, Dear KB, Angelillo
IF, Mosteller F. Postoperative patient-controlled analgesia: Meta-
analyses of initial randomized control trials. Journal of Clinical Anes-
thesia 1993;5(3):182-193.
Frenette 1991
Frenette L, Boudreault D, Guay J. Interpleural analgesia improves
pulmonary function after cholecystectomy. Can J Anaesth 1991;38
(1):71-4.
Gust 1999
Gust R, Pecher S, Gust A, Hoffmann V, Bohrer H, Martin E. Effect of
patient-controlled analgesia on pulmonary complications after coro-
nary artery bypass grafting. Crit Care Med 1999;27(10):2218-23.
Keeri-Szanto 1971
Keeri-Szanto M. Apparatus for demand analgesia. Can Anaesth Soc J
1971;18(5):581-2.

Behar 1979 Kouraklis 2000

Behar M, Olshwang D, Magora F, Davidson JT. Epidural morphine
in the treatment of pain. Lancet 1979;1(8115):527-9.
Benzon 1993
Benzon HT, Wong HY, Belavic AM Jr, Goodman I, Mitchell D,
Lefheit T, Locicero J. A randomized double-blind comparison of
epidural fentanyl infusion versus patient-controlled analgesia with
morphine for postthoracotomy pain. Anesth Analg 1993;76(2):316-
22.
Berlin 1997
Berlin JA. Does blinding of readers affect the results of meta-analyses?
University of Pennsylvania Meta-analysis Blinding Study Group.
Lancet 1997;350(9072):185-6.
Choiniere 1998
Choiniere M, Rittenhouse BE, Perreault S, Chartrand D, Rousseau P,
Smith B, Pepler C. Efficacy and costs of patient-controlled analgesia
versus regularly administered intramuscular opioid therapy. Anesthe-
siology 1998;89(6):1377-88.
Cuschieri 1985
Cuschieri RJ, Morran CG, Howie JC, McArdle CS. Postoperative
pain and pulmonary complications: comparison of three analgesic
regimens. Br J Surg 1985;72(6):495-8.
Evans 1976
Evans JM, Rosen M, MacCarthy J, Hogg MI. Apparatus for patient-
controlled administration of intravenous narcotics during labour.
Lancet 1976;1(7949):17-8.
Kouraklis G, Glinavou A, Raftopoulos L, Alevisou V, Lagos G,
Karatzas G. Epidural analgesia attenuates the systemic stress response
to upper abdominal surgery: a randomized trial. Int Surg 2000;85
(4):353-7.
Major 1996
Major CP, Jr, Greer MS, Russell WL, Roe SM. Postoperative pul-
monary complications and morbidity after abdominal aneurysmec-
tomy: a comparison of postoperative epidural versus parenteral opi-
oid analgesia. Am Surg 1996;62(1):45-51.
Parker 1992
Parker RK, White PF. Epidural patient-controlled analgesia: an alter-
native to intravenous patient-controlled analgesia for pain relief after
cesarean delivery. Anesth Analg 1992;75(2):245-51.
Rademaker 1992
Rademaker BM, Ringers J, Odoom JA, de Wit LT, Kalkman CJ,
Oosting J. Pulmonary function and stress response after laparoscopic
cholecystectomy: comparison with subcostal incision and influence
of thoracic epidural analgesia. Anesth Analg 1992;75(3):381-5.
Walder 2001
Walder B, Schafer M, Henzi I, Tramer MR. Efficacy and safety of
patient-controlled opioid analgesia for acute postoperative pain. A
quantitative systematic review. Acta Anaesthesiol Scand 2001;45(7):
795-804.
Wang 1979
Wang JK, Nauss LA, Thomas JE. Pain relief by intrathecally applied
morphine in man. Anesthesiology 1979;50:149-51.

COVER SHEET

Title Patient controlled intravenous opioid analgesia versus continuous epidural analgesia for
pain after intraabdominal surgery

Authors Werawatganon T, Charuluxanun S

Contribution of author(s) THWE: wrote the protocol, searched the electronic library and evaluated the eligibility of
the studies
SCHA :reviewed the protocol and evaluated the eligibility ot the studies

Issue protocol first published 2003/1

Date of most recent amendment 26 November 2003

Patient controlled intravenous opioid analgesia versus continuous epidural analgesia for pain after intraabdominal surgery (Protocol) 3
Copyright © 2004 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Date of most recent 25 October 2002
SUBSTANTIVE amendment
Review expected to be published in Issue 1, 2005
What’s New Information not supplied by author
DOI 10.1002/14651858.CD004088
Cochrane Library number CD004088
Editorial group Cochrane Anaesthesia Group
Editorial group code HM-ANAESTH

Patient controlled intravenous opioid analgesia versus continuous epidural analgesia for pain after intraabdominal surgery (Protocol) 4
Copyright © 2004 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd