IV PCA vs EPIDURAL

IV PCA v/s EPIDURAL : 

IV PCA v/s EPIDURAL Dr. Rajesh P Varghese

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2/11/2012 IV PCA V/S EPIDURAL ANESTHESIA 2 EARLY 1990S, THE ASA ADOPTED EVIDENCE-BASED MODEL FOR THE EVALUATION OF SCIENTIFIC LITERATURE EVIDENCE-BASED MODEL

Outline : 

Basics of pain ACUTE AND CHRONIC Physiological sequelae of pain Comparison of EA and PCA on management of pain as evidenced by various studies Areas of uncertainty Guidelines 2/11/2012 IV PCA V/S EPIDURAL ANESTHESIA 3 Outline

BASICS OF PAIN : 

BASICS OF PAIN

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INFLAMMATORY MEDIATORS SURGERY TISSUE INJURY HISTAMINE PEPTIDES LIPIDS NEURO TRANSMITTERS NEURO TROPHINS 2/11/2012 IV PCA V/S EPIDURAL ANESTHESIA 5

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Activation Of Peripheral Nociceptors TRANSDUCTION AND TRANSMISSION OF NOCICEPTIVE INFORMATIONS 2/11/2012 IV PCA V/S EPIDURAL ANESTHESIA 6 INFLAMMATORY MEDIATORS

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TRANSDUCTION AND TRANSMISSION OF NOCICEPTIVE INFORMATIONS 2/11/2012 IV PCA V/S EPIDURAL ANESTHESIA 7 DORSAL HORN OF SPINAL CORD

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VENTRAL AND VENTROLATERAL HORNS (SPINAL REFLEX) ENKEPHALIN, γ- AMINOBUTYRIC ACID Integration Of Nociceptive Sensations With Modulatory Input From CNS DORSAL HORN OF SPINAL CORD 2/11/2012 IV PCA V/S EPIDURAL ANESTHESIA 8 SPINOTHALAMIC AND SPINORETICULAR TRACTS

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SPINOTHALAMIC AND SPINORETICULAR TRACTS INCREASED SKELETAL MUSCLE TONE INHIBITION OF PHRENIC NERVE FUNCTION DECREASED GIT MOTILITY VENTRAL AND VENTROLATERAL HORNS (SPINAL REFLEX) 2/11/2012 IV PCA V/S EPIDURAL ANESTHESIA 9

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SUPRA SEGMENTAL AND CORTICAL RESPONSES 2/11/2012 IV PCA V/S EPIDURAL ANESTHESIA 10 SPINOTHALAMIC AND SPINORETICULAR TRACTS AFFECTIVE COMPONENT OF PAIN

ACUTE AND CHRONIC EFFECTS OF POSTOPERATIVE PAIN : 

ACUTE AND CHRONIC EFFECTS OF POSTOPERATIVE PAIN

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NEURO ENDOCRINE STRESS RESPONSES Invoves hypothalamic, pitutary , adrenocortical and sympathoadrenal interactions 2/11/2012 IV PCA V/S EPIDURAL ANESTHESIA 12 CONTINUOUS RELEASE OF INFLAMMATORY MEDIATORS Sensitizes the functional receptors Activate the dormant ones Decrease the threshold of activation Increase basal discharge HYPER EXCITABILITY PAIN SYNDROMES Functional changes in dorsal horn of spinal cord Central sensitization

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key for improving short term and long term goal for HRQL Transition from acute to chronic pain is very quick ( within 1 hour ) . Largely unrecognized problem (10-65 %) 2-10% severe CPSP Limb amputation Thoracotomy Sternotomy Breast surgery Chronic post surgical pain 2/11/2012 IV PCA V/S EPIDURAL ANESTHESIA 13 PAIN SYNDROMES CPSP Poorly controlled acute post operative pain site of surgery type of analgesia Predictive factors Preventing the establishment of altered central processing ANALGESIC TREATMENT

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Cortisol Adreno Corticotropic Hormones ADH Glucagone Aldosterone Renin – angiotensin 2/11/2012 IV PCA V/S EPIDURAL ANESTHESIA 14 NEURO ENDOCRINE STRESS RESPONSES SYMPATHETIC TONE CATECHOLAMINES CATABOLIC HORMONES ANABOLIC HORMONES GIT FUNCTIONS RESPIRATORY FUNCTIONS Supra segmental reflex - responses

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Myocardial ischemia & infarction Pulmonary embolism DVT Graft failure Myocardial ischemia & infarction Decreased natural anti – coagulants Increased pro – coagulants Increased platelet reactivity Inhibition of fibrinolysis 2/11/2012 IV PCA V/S EPIDURAL ANESTHESIA 15 NEURO ENDOCRINE STRESS RESPONSES HYPER COAGULABILITY Na and water retention Increased blood glucose , ketone bodies etc… Depression of immune functions Poor wound healing Increased myocardial oxygen consumption HYPERGLYCEMIA SYMPATHETIC ACTIVATION Increased metabolism Increased O2 consumption HYPERMETABOLIC CATABOLIC STATE

COMPARISON : 

COMPARISON 2/11/2012 IV PCA V/S EPIDURAL ANESTHESIA 16

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2/11/2012 17 Drugs Mechanisms of action Indications EA PCA Local anesthetics eg: lidocaine, bupivacaine, ropivacaine etc… Opiods Opioid agonists eg: morphine , pethidine, fentanyl, remifentanyl, sufentanyl etc… Conduction blockade by inhibition of ion selective sodium channels at nerve roots Act as agonists at stereospesific opioid receptors at perisynaptic sites in CNS Major orthopedic procedures (e.g., total knee and hip replacement) Can be used in almost all surgeries if not medically contra indicated Thoracotomy Gastrointestinal surgery (e.g., esophagus, stomach, bowel) Lower genitourinary and gynecological oncology procedures Obstetric procedures (i.e. labor and delivery) Major plastic reconstructive procedures COMPARISON

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2/11/2012 IV PCA V/S EPIDURAL ANESTHESIA 18 Contra –Indications EA PCA Patient refusal COMPARISON too young / too old to use PCA Psychiatric disorder Local sepsis Coagulopathy Haemo - dynamic unstability Severe AS or MS Respiratory depression PONV Disadvantages Technically difficult Dural puncture Total spinal Catheter migration Itching Increased intracranial pressure Urinary retention

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2/11/2012 IV PCA V/S EPIDURAL ANESTHESIA 19 STUDIES Major Proposed Advantage EA v/s PCA Neuro - endocrine stress response Pain relief IMPROVE ATTENUATE Velickovic I, Yan J, Grass JA: Modifying the neuroendocrine stress response.  Semin Anesth Perioperative Med Pain  2002; 21:16-25. Evidenced by the decreased level of stress hormones (ACTH, cortisol, catecholamines) EA alter the physiologic sequelae inhibit or decrease THE EFFERENT SYMPATHETIC PATHWAYS THE NEURAL REFLEX ARCS. IV - PCA lessens the amount of PAIN associated with a SURGICAL PROCEDURE does not significantly alter the NEUROENDOCRINE STRESS RESPONSE Quality of analgesia

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Fentanyl Sufentanil Superior analgesia Stable sensory block Improved quality of dynamic pain relief Early short term goals 2/11/2012 IV PCA V/S EPIDURAL ANESTHESIA 20 IV PCA & EPIDURAL Traditional IM Opiods EPIDURAL OPIODS LOCAL ANESTHETICS LOCAL ANESTHETICS AND OPIODS PCA Opiods Opiods PCA Opiods Grass JA: The role of epidural anesthesia and analgesia in postoperative outcome.  Anesthesiol Clin North America  2000; 18:407-428.

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2/11/2012 IV PCA V/S EPIDURAL ANESTHESIA 21 MEAN PAIN SEVERITY Total hip replacement 8.1 Total knee replacement 7.6 Strassels SA, Chen C, Carr DB: Postoperative analgesia: Economics, resource use, and patient satisfaction in an urban teaching hospital.  Anesth Anal  2002; 94:130-137.

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2/11/2012 IV PCA V/S EPIDURAL ANESTHESIA 22 VISUAL ANALOG SCALE Behavior observation pain rating scale

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2/11/2012 IV PCA V/S EPIDURAL ANESTHESIA 23 RCTs Comparing Postoperative Analgesia via Combination Epidurals or IV-PCA Routes Following Major Knee Surgery Singelyn FJ, Deyaert M, Joris D, Pendeville E, Gouverneur JM: Effects of intravenous patient-controlled analgesia with morphine, continuous epidural analgesia, and continuous three-in-one block on postoperative pain and knee rehabilitation after unilateral total knee arthroplasty.  Anesth Analg  1998; 87:88-92. Capdevila X, Barthelet Y, Biboulet P, Ryckwaert Y, Rubenovitch J, d'Athis F: Effects of perioperative analgesic technique on the surgical outcome and duration of rehabilitation after major knee surgery.  Anesthesiology  1999; 91:8-15.

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2/11/2012 IV PCA V/S EPIDURAL ANESTHESIA 24 CARDIOVASCULAR SYSTEM SURGICAL STIMULI Activity Of The Sympathetic Nervous System Myocardial Oxygen Demand Supply Generation Of Dysrrhythmias Majority Of “Silent Ischemia” CONTRIBUTES Scott NB, Turfrey DJ, Ray DAA, Nzewi O, Scutcliffe NP, Lal AB, Norrie J, Nagels WJB, Ramayya GP: A prospective randomized study of the potential benefits of thoracic epidural anesthesia and analgesia in patients undergoing coronary artery bypass grafting.  Anesth Analg  2001; 93:528-535.

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BLOCKS 2/11/2012 IV PCA V/S EPIDURAL ANESTHESIA 25 CARDIOVASCULAR SYSTEM THORACIC EPIDURAL ANESTHESIA AND ANALGESIA (TEA) spinal levels T1-T5 sympathetic innervation to the heart VASODIALATION Endocardial to Epicardial Blood Flow Ratio to ischemic regions of myocardium in the luminal diameter of stenotic vessels blood flow IMPROVES CORONARY BLOOD FLOW ABLATES Beattie WS, Badner NH, Choi P: Epidural analgesia reduces postoperative myocardial infarction: A meta-analysis.  Anesth Analg  2001; 93:853-858.

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2/11/2012 IV PCA V/S EPIDURAL ANESTHESIA 26 HYPERCOAGULABLE STATE SURGICAL TRAUMA Begins POST – OPERATIVE PERIOD Persists into TKR THR DVT PE 70% 80% 1% 2% Frequency GA with PCA Sorenson RM, Pace NL: Anesthetic techniques during surgical repair of femoral neck fractures: A meta-analysis.  Anesthesiology  1992; 77:1095-1104. EA Popliteal and femoral veins DVT of the calf and thigh veins PE detected by a perfusion lung scan 13% 67% 40% 77% 10% 33% Five fold reduction in reoperation rate with EA compared to PCA (4% vs 22%) ARTERIAL GRAFT PATENCY Urwin SC, Parker MJ, Griffiths R: General versus regional anaesthesia for hip fracture surgery: A meta-analysis of randomized trials.  Br J Anaesth  2000; 84:450-455.

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2/11/2012 IV PCA V/S EPIDURAL ANESTHESIA 27 Ballantyne JC, Carr DB, deFerranti , Suarez T, Lau J, Chalmers TC, Angelillo IF, Mosteller F: The comparative effects of postoperative analgesic therapies on pulmonary outcome: Cumulative meta-analyses of randomized, controlled trials.   Anesth Analg  1998; 86:598-612. PULMONARY SYSTEM EA Incidence Of Atelectasis Incidence Of Pulmonary Infections Arterial O₂ Pressure PROPOSED MECHANISM EA attenuates SPINAL REFLEX ARC Improve Diaphragmatic Motility And Accessory Muscle Contractilty

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THORACIC EPIDURAL ANESTHESIA AND ANALGESIA TEA 2/11/2012 IV PCA V/S EPIDURAL ANESTHESIA 28 GIT GASTRO -INTESTINAL MOTILITY CRANIOSACRAL PARASYMPATHETIC OUTPUT augments THORACOLUMBAR SYMPATHETIC EFFERENTS delays THORACOLUMBAR SYMPATHETIC EFFERENTS CRANIOSACRAL PARASYMPATHETIC OUTPUT Without DISTURBING MODULATES

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2/11/2012 IV PCA V/S EPIDURAL ANESTHESIA 29 GIT LIU ET AL Effects of 4 PERIOPERATIVE ANALGESIC TECHNIQUES On the rate of GASTROINTESTINAL RECOVERY after colon surgery Liu SS, Carpenter RL, Mackey DC, Thirlby RC, Rupp SM, Shine TS, Feinglass NG, Metzger PP, Fulmer JT, Smith SL: Effects of perioperative analgesia technique on rate of recovery after colon surgery.  Anesthesiology  1995; 83:757-765.

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1.5 days earlier return GIT recovery & discharge criteria 2/11/2012 IV PCA V/S EPIDURAL ANESTHESIA 30 PERIOPERATIVE ANALGESIC TECHNIQUES Thoracic Epidural Infusion Of Morphine And Bupivacaine Thoracic Epidural Infusion Of Morphine IV-PCA Analgesia With Morphine. Thoracic Epidural Infusion Of Bupivacaine 4 2 3 1 Liu SS, Carpenter RL, Mackey DC, Thirlby RC, Rupp SM, Shine TS, Feinglass NG, Metzger PP, Fulmer JT, Smith SL: Effects of perioperative analgesia technique on rate of recovery after colon surgery.  Anesthesiology  1995; 83:757-765.

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Preservation Of Baseline Immune Function 2/11/2012 IV PCA V/S EPIDURAL ANESTHESIA 31 Yeager MP, Colacchio TA, Yu CT, Hildebrandt L, Howell AL, Weiss J, Guyre PM: Morphine inhibits spontaneous and cytokine-enhanced natural killer cell cytotoxicity in volunteers.  Anesthesiology  1995; 83:500-508. Buggy DJ, Doherty WL, Hart EM, Pallett EJ: Postoperative wound oxygen tension with epidural or intravenous analgesia.  Anesthesiology  2002; 97:952-958. IMMUNE SYSTEM YEAGER ET AL Standard dose POSTOPERATIVE MORPHINE ADMINISTRATION suppress 24 HRS The Human Immune System POSSIBLE MECHANISMS EA Prevention Of : Neuroendocrine Stress Response The Direct Cytoprotective Antiinflammatory Effects Of Local Anesthetics Increase Mean Oxygen Wound Tension

AREAS OF UNCERTAINTY : 

AREAS OF UNCERTAINTY 2/11/2012 IV PCA V/S EPIDURAL ANESTHESIA

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ability to consistently affect final patient outcomes 2/11/2012 IV PCA V/S EPIDURAL ANESTHESIA 33 BALLANTYNE ET AL META ANALYSIS & the lack of scientific rationale IV-PCA does not improve outcome CONCLUDES improves dynamic pain relief improves intermediate outcomes EA WITH LOCAL ANESTHETIC AND OPIOIDS NO STUDIES Morbidity, Mortality, Time To Discharge, Return To Work Prevention Of Chronic Pain The Ability To Provide Preemptive Analgesia Timing Of EA Both Initiation (Before Incision Versus After Incision) And Postoperative Duration, Cost Benefit Analysis For Each Form Of Analgesia Treatment. CURRENTLY UNCERTAIN OTHER CLINICAL AREAS

GUIDELINES : 

GUIDELINES 2/11/2012 IV PCA V/S EPIDURAL ANESTHESIA

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2/11/2012 IV PCA V/S EPIDURAL ANESTHESIA 35 no formal guidelines type of analgesia that should be employed for a particular surgical operation SURGERIES MOST LIKELY TO BENEFIT FROM EAA

SUMMARY : 

SUMMARY 2/11/2012 IV PCA V/S EPIDURAL ANESTHESIA 36

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2/11/2012 IV PCA V/S EPIDURAL ANESTHESIA 37 POTENTIAL BENEFITS OF EAA

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2/11/2012 IV PCA V/S EPIDURAL ANESTHESIA 38 POTENTIAL BENEFITS OF EAA Contd…

TAKE AWAY …… : 

TAKE AWAY …… In terms of pain relief, respiratory functions and mental state, epidural is more superior than IV PCA. Epidural is also unique in prevention thromboemolism and myocardial ischaemia. Though it is conceivable that epidural will have a positive impact on N&V,early ambulation and early discharge, they are not convincingly demonstrated in all studies. However, epidural is no worse than IV PCA in terms of these parameter. Therefore patients with cardiovascular, respiratory diseases, patients undergo major operations for lower limbs operations, epidural analgesia should be considered first 2/11/2012 IV PCA V/S EPIDURAL ANESTHESIA 39

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2/11/2012 IV PCA V/S EPIDURAL ANESTHESIA 40 thank you… Show is over YOU MAY NOW RELAX