Pain treatment in open liver resection, systemic multimodal analgesia vs epidural analgesia: a randomized controlled trial(data from Oslo-Comet study)

Abstract

Background: Epidural analgesia (EA) is commonly provided to treat pain following major abdominal surgery. There is a discussion on the efficacy and safety of EA compared with other kinds of patient controlled analgesia. The aim of our study was to evaluate systemic multimodal analgesia including Intravenous Patient Controlled Analgesia (IV-PCA) vs EA in patients undergoing liver resection by open laparotomy. Our hypothesis is that IV-PCA is non-inferior to EA. Methods: Patients were randomized to ketobemidon based IV-PCA in combination with fixed doses of ketorolac, or EA. Both groups received a single dose of dexamethasone and paracetamol 1 g 4 qid. Primary outcome measure was overall pain intensity during the days 1-5 and scores on day 0 and 1 using numeric rating scale (NRS). Secondary endpoints included hospital length of stay, complications and side-effects. Results: A total of 143 patients were included. Overall pain intensity was similar between the groups and with mean NRS < 2,(p=0.31). On postoperative day 0 and 1 the EA group showed somewhat better pain relief, but thereafter IV-PCA was superior. Total opioid reduction and removal of the infusion pumps were achieved earlier in the IV-PCA group while opioid side-effects were more frequent in the EA group. Hospital stay was shorter in the IV-PCA group (median 74 vs 104h,p<0.001) Conclusion: Overall,IV-PCA demonstrated effective postoperative analgesia non-inferior to EA with a trend towards less side-effects and significantly shorter hospital length of stay.