A Comparison of Continuous Wound Infiltration Plus Patient Controlled Analgesia Versus Epidural Analgesia after Open Renal Surgery
DOI:
https://doi.org/10.17140/UAOJ-4-127Keywords:
nephrectomy, post-operative pain, continuous wound infusion (CWI), renal surgeryAbstract
Aim
Open nephrectomy is associated with significant post-operative pain. Epidurals have been a core method for provision of analgesia,
however, there is increased use of novel analgesic strategies with comparative analgesia but potentially fewer side effects. This pilot
study aims to assess the feasibility of a randomised control trial comparing continuous wound infusion (CWI) to epidural analgesia
for open renal surgery. Objectives included estimation of recruitment rates, failure rates and complications and refining design of
a randomised control trial.
Methods
Participants were randomised using randomisation software. Patients received standardised anaesthesia as per the study protocol.
Patients randomised to the CWI group had a wound infiltration catheter inserted at the end of surgery. In the epidural group,
patients had an epidural sited prior to surgery. Primary outcomes evaluated were visual analogue pain scores. Secondary outcomes
included intravenous fluid use, hypotensive episodes, patient mobilisation, evidence of post-operative ileus, respiratory morbidity,
demands on medical and nursing care, length of hospital stay and patient acceptability as assessed by the Quality of Recovery
(QoR-15) questionnaire.
Results
Pain scores were similar for both groups with marginally higher mean scores in the wound infiltration group on post-operative day
1 and 3. Supplementary analgesia rates were comparable for both groups with tramadol use being higher in the wound infiltration
group.
Conclusion
Collecting outcome data for an appropriately powered randomised controlled trial is feasible. Recruitment was challenging due to
the increased minimally invasive laparoscopic or robotic nephrectomies and consideration of a multicentre study is warranted. The
two analgesic techniques appear broadly comparable in efficacy and time to discharge. CWI potentially presents safety advantages
compared to epidural analgesia.
References
Wick EC, Grant MC, Wu CL. Post-operative multimodal analgesia pain management with nonopioid analgesics and techniques. JAMA Surg. 2017; 152(7): 691-697. doi: 10.1001/ jamasurg.2017.0898
Rigg JRA, Jamrozik K, Myles PS, Silbert BS, Peyton PJ, Parsons RW, et al. Epidural anaesthesia and analgesia and outcome of major surgery: A randomised trial. Lancet. 2002; 359(9314): 1276- 1282. doi: 10.1016/S0140-6736(02)08266-1
Cook TM, Counsell D, Wildsmith JA, Royal College of Anaesthetists. Major complications of central neuraxial block : Report on the third National Audit Project of the Royal College of Anaesthetists. Br J Anaesth. 2009; 102(2): 179-190. doi: 10.1093/ bja/aen360
Chaney MA. Side effects of intrathecal and epidural opioids. Can J Anaesth. 1995; 42(10): 891-903. doi: 10.1007/BF03011037
Araújo R, PAMA Trial. Pain management, local infection, satisfaction, adverse effects and residual pain after major open abdominal surgery: Epidural versus continuous wound infusion (PAMA Trial). Acta Med Port. 2017; 30(10): 683-690. doi: 10.20344/ amp.8600
Capdevila X, Moulard S, Plasse C, Peshaud J-L, Molinari N, Dadure C, et al. Effectiveness of epidural analgesia, continuous surgical site analgesia, and patient-controlled analgesic morphine for post-operative pain management and hyperalgesia, rehabilitation, and health-related quality of life after open nephrectomy: A prospective. Anesth Analg. 2017; 124(1): 336-345. doi: 10.1213/ ANE.0000000000001688
Ventham NT, Hughes M, O’Neill S, Johns N, Brady RR, Wigmore SJ. Systematic review and meta-analysis of continuous local anaesthetic wound infiltration versus epidural analgesia for post-operative pain following abdominal surgery. Br J Surg. 2013; 100(10): 1280-1289. doi: 10.1002/bjs.9204
Chaykovska L, Blohmé L, Mayer D, Gloekler S, Rancic Z, Schmidt CAP, et al. Paraincisional subcutaneous infusion of ropivacaine after open abdominal vascular surgery shows significant advantages. Ann Vasc Surg. 2014; 28(4): 837-844. doi: 10.1016/j.avsg.2013.11.019
Chan SK, Lai PB, Li PT, Wong J, Karmakar MK, Lee KF, et al. The analgesic efficacy of continuous wound instillation with ropivacaine after open hepatic surgery. Anaesthesia. 2010; 65(12): 1180-1186. doi: 10.1111/j.1365-2044.2010.06530.x
Forastiere E, Sofra M, Giannarelli D, Fabrizi L, Simone G. Effectiveness of continuous wound infusion of 0.5% ropivacaine by On-Q pain relief system for post-operative pain management 25 Thompson E et al after open nephrectomy. Br J Anaesth. 2008; 101(6): 841-847. doi: 10.1093/bja/aen309
Stark PA, Myles PS, Burke JA. Devlopment and pyschometric evaluation of a post-operative quality of recovery score: The QoR-15. Anaesthesiology. 2013; 118(6): 1332-1340.
Downloads
Published
How to Cite
Issue
Section
License
This work is licensed under a Creative Commons Attribution 4.0 International License.
All content published in Urology and Andrology (UA) is licensed under the Creative Commons Attribution 4.0 International License (CC BY 4.0). This license allows anyone to copy, distribute, transmit, and adapt the work — including for commercial purposes — provided appropriate credit is given to the original author(s) and source.
