Spinal anaesthesia with clonidine: pain relief and earlier mobilisation after open nephrectomy - a randomised clinical trial

Abstract

Objectives: Early mobilisation and effective pain management after open nephrectomy for renal cell carcinoma often include epidural analgesia (EDA), requiring an infusion pump and a urinary catheter, thus impeding mobilisation. Spinal anaesthesia (SpA) may be an alternative. This randomised clinical trial evaluated whether SpA improves analgesia and facilitates mobilisation over EDA and which factors influence mobilisation and length of stay (LOS).

Methods: Between 2012 and 2015, 135 patients were randomised and stratified by surgical method to either SpA with clonidine or EDA. Mobility index score (MobIs), pain scale, patient satisfaction questionnaire, and LOS were the main outcome measures.

Results: SpA patients exhibited an increase in MobIs significantly earlier than EDA patients. Among SpA patients >50% reached MobIs ≥13 by postoperative day 3, while 29% of EDA patients never reached MobIs ≥13 before discharge. SpA patients had higher maximum pain scores on postoperative days 1 and 2, but both groups had similar patient satisfaction. One day before discharge, 36/64 SpA versus 22/67 EDA patients (56% and 33%, respectively) were opioid-free. SpA patients were discharged significantly earlier than EDA patients.

Conclusions: SpA facilitates postoperative pain management and is associated with faster mobilisation and shorter LOS.The trial was registered at ClinicalTrials.org (ID-NCT02030717).

Keywords: Spinal anaesthesia; epidural analgesia; length of stay; mobilisation; mobility index; pain score; partial nephrectomy; radical nephrectomy; randomised clinical trial.

Conflict of interest statement

Declaration of conflicting interests: The authors declare that there is no conflict of interest.

Figures

Figure 1.

Flow chart of patient enrolment. SpA, spinal anaesthesia group; EDA, epidural group; ASA, American Society of Anesthesiologists classification.

Figure 2.

Mobility index on POD 1–6 and on the day of discharge. SpA, spinal anaesthesia group (blue line/solid rhombus); EDA, epidural analgesia group (red line/open square); POD, postoperative day. Data are presented as means and 95% confidence intervals. *Denotes a significant difference with p 

Figure 3.

Number of patients with mobility index ≥13 on the respective postoperative day (POD). SpA, spinal anaesthesia group (solid blue bars); EDA, epidural analgesia group (open red bars). Discharged patients are omitted. The two bars to the right show the number of patients within each respective group who did not reach a mobility index ≥13 before discharge.

Figure 4.

Numeric rating score on POD 1–6 and on the day of discharge. SpA, spinal anaesthesia group (solid blue rhombus); EDA, epidural analgesia group (open red squares); NRS, numeric rating scale; POD, postoperative day. Data are presented as the mean ± 95% confidence interval. *Denotes a significant difference with p 

Figure 5.

Multivariate logistic regression with LOS as the dependent variable, final model. Predictive value of this model, 74.6% and Nagelkerke R-squared, 0.325. MobIs, mobility index score; POD, postoperative day; LOS, length of stay.