A prospective cohort study of intrathecal versus epidural analgesia for patients undergoing hepatic resection

Abstract

Background: The aim of this prospective observational study was to compare peri/post-operative outcomes of thoracic epidural analgesia (TEA) versus intrathecal morphine and fentanyl patient-controlled analgesia (ITM+fPCA) for patients undergoing a hepatic resection (HR).

Method: Patients undergoing elective, one-stage, open HR for benign and malignant liver lesions, receiving central neuraxial block as part of the anaesthetic, in a high-volume hepato-pancreato-biliary unit, were included in the study. The primary outcome measure was post-operative length of stay (LoS).

Results: A total of 73 patients (36 TEA and 37 ITM+fPCA) were included in the study. The median (IQR) post-operative LoS was 13 (11-15) and 11 (9-13) days in the TEA and ITM+fPCA groups, respectively (P = 0.011). There was significantly lower median intra-operative central venous pressure (P < 0.001) and blood loss (P = 0.017) in the TEA group, and a significant reduction in the time until mobilization (P < 0.001), post-operative intra-venous fluid/vasopressor requirement (P < 0.001/P = 0.004) in the ITM+fPCA group. Pain scores were lower at a clinically significant level 12 h post-operatively in the TEA group (P < 0.001); otherwise there were no differences out to day five. There were no differences in quality of recovery or postoperative morbidity/mortality between the two groups.

Conclusion: ITM+fPCA provides acceptable post-operative outcomes for HR, but may also increase the incidence of intra-operative blood loss in comparison to TEA.

© 2014 International Hepato-Pancreato-Biliary Association.

Figures

Figure 1

Flow of patients throughout the study. *Including three patients who had initial failed attempts at placement of TEA. ALLPS; associating liver partition with portal vein ligation for staged hepatectomy; CNB, central neuraxial block; TEA, thoracic epidural analgesia; ITM+fPCA, intra-thecal morphine and fentanyl patient controlled analgesia; fPCA, fentanyl patient controlled analgesia

Figure 2

Comparison of intra-operative central venous pressure (CVP) measurements between thoracic epidural analgesia (TEA) and intrathecal morphine and fentanyl patient-controlled analgesia (ITM+fPCA). CVP measurements compared between types of central neuraxial block (CNB) at different time points using the Mann–Whitney U-test, *P < 0.001. Error bars indicate 95% confidence intervals

Figure 3

Visual analogue scale scores (VAS) of post-operative pain on coughing, comparing thoracic epidural analgesia (TEA) and intrathecal morphine and fentanyl patient-controlled analgesia (ITM+fPCA) for hepatic resection surgery. VAS scores compared between type of central neuraxial block (CNB) at different time points post-operatively, with the Mann–Whitney U-test *P < 0.001, **P = 0.010. Error bars indicate 95% confidence intervals