Yonsei Med J.  2014 Jul;55(4):1106-1114. 10.3349/ymj.2014.55.4.1106.

Efficacy of Intrathecal Morphine Combined with Intravenous Analgesia versus Thoracic Epidural Analgesia after Gastrectomy

• Lee JH
• Park JH
• Kil HK
• Choi SH
• Noh SH
• Koo BN

• KMID: 2130840
• DOI: http://doi.org/10.3349/ymj.2014.55.4.1106

Abstract

PURPOSE
Epidural analgesia has been the preferred analgesic technique after major abdominal surgery. On the other hand, the combined use of intrathecal morphine (ITM) and intravenous patient controlled analgesia (IVPCA) has been shown to be a viable alternative approach for analgesia. We hypothesized that ITM combined with IVPCA is as effective as patient controlled thoracic epidural analgesia (PCTEA) with respect to postoperative pain control after conventional open gastrectomy.
MATERIALS AND METHODS
Sixty-four patients undergoing conventional open gastrectomy due to gastric cancer were randomly allocated into the intrathecal morphine combined with intravenous patient-controlled analgesia (IT) group or patient-controlled thoracic epidural analgesia (EP) group. The IT group received preoperative 0.3 mg of ITM, followed by postoperative IVPCA. The EP group preoperatively underwent epidural catheterization, followed by postoperative PCTEA. Visual analog scale (VAS) scores were assessed until 48 hrs after surgery. Adverse effects related to analgesia, profiles associated with recovery from surgery, and postoperative complications within 30 days after surgery were also evaluated.
RESULTS
This study failed to demonstrate the non-inferiority of ITM-IVPCA (n=29) to PCTEA (n=30) with respect to VAS 24 hrs after surgery. Furthermore, the IT group consumed more fentanyl than the EP group did (1247.2+/-263.7 microg vs. 1048.9+/-71.7 microg, p<0.001). The IT group took a longer time to ambulate than the EP group (p=0.021) and had higher incidences of postoperative ileus (p=0.012) and pulmonary complications (p=0.05) compared with the EP group.
CONCLUSION
ITM-IVPCA is not as effective as PCTEA in patients undergoing gastrectomy, with respect to pain control, ambulation, postoperative ileus and pulmonary complications.

Keyword

Analgesia; epidural; gastrectomy; intrathecal; opioid; postoperative pain

MeSH Terms

Adult
Analgesia, Epidural/*methods
Analgesia, Patient-Controlled/methods
Analgesics, Opioid/administration & dosage/therapeutic use
Female
Gastrectomy/*methods
Humans
Male
Middle Aged
Morphine/*administration & dosage/*therapeutic use
Pain Management/methods
Pain, Postoperative/*drug therapy
Analgesics, Opioid
Morphine

Figure

• 

  Fig. 1 CONSORT diagram showing the flow of participants through each stage of our randomized trial. EP, patient-controlled thoracic epidural analgesia; IT, intrathecal morphine combined with intravenous patient-controlled analgesia; CONSORT, consolidated standards of reporting trials.

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  Fig. 2 VAS scores of maximum pain experienced since last questioning (or recovery from anesthesia) (A) at rest and (B) on coughing. The VAS scores were compared using unpaired Student's t-tests. VAS, visual analogue scale; EP, patient-controlled thoracic epidural analgesia; IT, intrathecal morphine combined with intravenous patient-controlled analgesia.

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  Fig. 3 Mean differences in VAS scores of maximum pain experienced at 24 hours after surgery. Error bars indicate two-sided 95% confidence intervals (CIs). As the CIs include Δ and zero, the difference was non-significant, and the results regarding non-inferiority were inconclusive. Δ, margin of non-inferiority. Non-tinged area indicates zone of inferiority. ITM-IVPCA, intrathecal morphine combined with intravenous patient-controlled analgesia; VAS, visual analogue scale; PCTEA, patient-controlled thoracic epidural analgesia.

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