Intervention Review

Epidural local anaesthetics versus opioid-based analgesic regimens for postoperative gastrointestinal paralysis, PONV and pain after abdominal surgery

  1. Henrik Jørgensen1,*,
  2. Jørn Wetterslev2,
  3. Steen Møiniche3,
  4. Jørgen B Dahl4

Editorial Group: Cochrane Colorectal Cancer Group

Published Online: 22 JAN 2001

Assessed as up-to-date: 31 AUG 2000

DOI: 10.1002/14651858.CD001893


How to Cite

Jørgensen H, Wetterslev J, Møiniche S, Dahl JB. Epidural local anaesthetics versus opioid-based analgesic regimens for postoperative gastrointestinal paralysis, PONV and pain after abdominal surgery. Cochrane Database of Systematic Reviews 2001, Issue 1. Art. No.: CD001893. DOI: 10.1002/14651858.CD001893.

Author Information

  1. 1

    Herlev University Hospital, Copenhagen, Department of Anaesthesiology and Intensive Care, Herlev, Copenhagen County, Denmark

  2. 2

    Centre for Clinical Intervention Research, Copenhagen Trial Unit, Copenhagen, Denmark

  3. 3

    Amtssygehuset i Glostrup, Department of Surgery and Anaeshtesiology, Y, Glostrup, Denmark

  4. 4

    Glostrup University Hospital, Department of Anaesthesia and Intensive Care, Glostrup, Denmark

*Henrik Jørgensen, Department of Anaesthesiology and Intensive Care, Herlev University Hospital, Copenhagen, Herlev Ringvej, Herlev, Copenhagen County, 2730, Denmark. hjorgensen@dadlnet.dk.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 22 JAN 2001

SEARCH

 

Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Background

Gastrointestinal paralysis, nausea and vomiting, and pain, are major clinical problems following abdominal surgery. Anaesthetic and analgesic techniques that reduce pain and postoperative nausea and vomiting (PONV), and prevent or reduce postoperative ileus, may reduce postoperative morbidity, duration of hospitalisation and hospital costs.

Objectives

To compare effects of postoperative epidural local anaesthetic with regimens based on systemic or epidural opioids, on postoperative gastrointestinal function, postoperative pain, PONV and surgical/anaesthetic complications.

Search methods

Trials were identified by computerised searches of the Cochrane Controlled Trials Register, MEDLINE, EMBASE and by checking the reference lists of trials and review articles.

Selection criteria

Randomised controlled trials comparing the effects of postoperative epidural local anaesthetic with systemic or epidural opioids.

Data collection and analysis

Collected data included treatment in active (local anaesthetic) and control (opioid based) groups, time to first postoperative stool, time to first postoperative flatus, gastric emptying measured by the paracetamol absorption test, duration of the passage of barium sulphate, pain assessments, use of supplementary analgesics, nausea, vomiting and surgical/anaesthetic complications.

Main results

Most studies in this review involved a small number of patients. Furthermore half of the studies indicated a poor level of methodology in particular regarding blinding and report of withdrawals. Heterogeneity of included studies was substantial.
Results consistently showed reduced time to return of gastrointestinal function in the epidural local anaesthetic group compared with groups receiving systemic or epidural opioid (37 hours and 24 hours, respectively). Postoperative pain was comparable.
Two studies compared the effect of epidural local anaesthetic with a combination of epidural local anaesthetic and opioid on gastrointestinal function. One study favoured epidural local anaesthetic and one study was indifferent.
A meta analysis of five of eight studies comparing the effect of epidural local anaesthetic with a combination of epidural local anaesthetic and opioid on postoperative pain, yielded a reduction in VAS pain scores (0-100 mm) on the first postoperative day of 15 mm, in favour of the combination.
No significant differences in PONV were observed between epidural local anaesthetic and opioid based regimens.

Authors' conclusions

Administration of epidural local anaesthetics to patients undergoing laparotomy reduce gastrointestinal paralysis compared with systemic or epidural opioids, with comparable postoperative pain relief. Addition of opioid to epidural local anaesthetic may provide superior postoperative analgesia compared with epidural local anaesthetics alone. The effect of additional epidural opioid on gastrointestinal function is so far unsettled. Randomized, controlled trials comparing the effect of combinations of epidural local anaesthetic and opioid with epidural local anaesthetic alone on postoperative gastrointestinal function and pain are warranted.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Epidural local anaesthetics versus opioid-based regimens used for reduction of postoperative pain on nausea and vomiting (PONV) and gastrointestinal paralysis after abdominal surgery

Following abdominal surgery, pain, gastrointestinal paralysis and nausea and vomiting can cause major problems. Anaesthetic and analgesic techniques that reduce the pain, nausea and vomiting and lack of gastrointestinal function (ileus) may reduce further postoperative complications and the length of hospital stay. Opioids themselves can cause nausea and vomiting so that using opioid-sparing anaesthetic and pain-relieving (analgesic) techniques may reduce PONV and improve bowel movement (motility).
Administration of epidural local anaesthetics to patients after undergoing abdominal surgery involving a laparotomy reduced gastrointestinal paralysis compared with using systemic or epidural opioids. Pain relief was comparable. These conclusions are based on 22 randomised controlled trials involving a total of 1023 patients undergoing abdominal surgery. Publication dates were from 1984 to 2000. Results consistently showed a reduction in time to return of gastrointestinal function in patients receiving epidural local anaesthetic compared with opioids delivered systemically (by 19 to 56 hours, mean 37 hours) or epidurally (by 10 to 39 hours, mean 24 hours). No clear differences in PONV were apparent. The epidural local anaesthetic used was bupivacaine (0.1 to 0.5%), continuous or with intermittent injections, in all trials but one where ropivacaine was used. Addition of opioid to epidural local anaesthetic may provide better postoperative pain relief compared with epidural local anaesthetics alone. Only two studies compared epidural local anaesthetic with a combination of epidural local anaesthetic and opioid on gastrointestinal function, with no clear findings. Most studies involved a small number of patients and some studies appeared to have poor methodology. The surgical procedures included colon or rectal surgery, hysterectomy, caesarean section, removal of the gall bladder (cholecystectomy), abdominal aortic surgery and major abdominal gynaecological surgery.

 

摘要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

背景

硬膜外局部麻醉劑(Epidural local anaesthetics)和鴉片類止痛劑治療法對於進行腹部手術後產生的術後腸胃道麻痺、術後噁心嘔吐和疼痛現象的影響

進行腹腔手術後常出現腸胃道麻痺、嘔吐噁心和疼痛等臨床問題。利用麻醉和止痛技術降低疼痛、術後嘔吐噁心(PONV)和預防或降低術後腸閉塞,可能有助降低死亡率、減少住院時間和住院花費。

目標

本研究的主要目的在比較進行術後硬膜外局部麻醉和使用全身性或硬膜外鴉片的藥劑對於術後腸胃道功能、術後疼痛和手術性/麻醉性併發症的影響。

搜尋策略

經由電子化的搜尋Cochrane Controlled Trials Register、MEDLINE和EMBASE等資料庫,以及確認試驗的相關參考文獻清單和回顧性質的文獻可以挑選出適於納入本研究的試驗。

選擇標準

比較術後硬膜外局部麻醉與全身性或硬膜外鴉片藥劑的效果的隨機對照試驗。

資料收集與分析

蒐集到的數據包括主動治療(局部麻醉)和對照治療(使用鴉片類藥物)兩組,並記錄術後首次排便時間、術後首次排氣時間、利用paracetamol 吸收試驗來測試胃排空現象、硫酸鋇通過時間、疼痛評估、使用補充性的止痛藥、嘔吐、噁心和手術性/麻醉性併發症。

主要結論

本研究中納入的試驗大多針對少數患者進行試驗,此外,有一半的試驗研究方法不佳,特別是盲法及退出治療的報告方面。被納入研究的試驗之間存在著異質性。結果一致的顯示相較於接受全身性或硬膜外鴉片藥物的組別來說,使用硬膜外局部麻醉的組別可以降低縮短恢復腸胃道功能的時間(分別為37小時和24小時)。術後疼痛也是可以比較的因子,研究中有2個試驗比較施行硬膜外局部麻醉和同時結合硬膜外局部麻醉以及鴨片用來治療術後疼痛的效果,有1個試驗傾向於支持硬膜外麻醉的效果,但是另一個試驗則持反對意見,對於8個試驗中的5個試驗進行統合分析以比較施行硬膜外局部麻醉和同時結合硬膜外局部麻醉以及鴨片對於術後疼痛的影響,結果顯示,在術後的第一天,使用混合治療的組別在視覺類比(visual analog scale,VAS)疼痛量表(0至100毫米)的評分結果便降低了15毫米,硬膜外局部麻醉的組別和以鴉片藥物為基礎的治療組別在PONV上並沒有出現明顯的差異。

作者結論

本研究在有可比較的疼痛緩解為前提下,將使用硬膜外局部麻醉降低腹部手術的患者術後腸胃道麻痺症狀,與使用全身性或硬膜外鴉片麻醉進行比較。將鴉片類藥物添加至硬膜外局部麻醉劑中可能比單獨使用硬膜外局部麻醉劑更能夠使患者達到術後止痛的效果。添加硬膜外鴉片藥物對於腸胃道功能的影響仍尚未被建立。尚需比較將硬膜外局部麻醉劑與鴉片藥物併用的混合藥劑和單獨使用硬膜外局部麻醉劑對於術受腸胃道功能和疼痛的隨機對照試驗。

翻譯人

此翻譯計畫由臺灣國家衛生研究院 (National Health Research Institutes, Taiwan) 統籌。

總結

硬膜外局部麻醉和類鴉片藥物都可以用來降低腹部手術患者的術後疼痛、PONV和腸胃道麻痺的現象。 在進行腹部手術後,產生疼痛、腸胃道麻痺和噁心嘔吐現象會成回患者要面對的首要問題,用來降低疼痛、噁心嘔吐和腸胃道失去功能(腸阻塞)的麻醉和止痛技術可能可以降低術後併發症的發生,以及減少住院時間,鴉片類藥物本身便會造成噁心嘔吐的感受,所以使用降低鴉片用量的麻醉或是疼痛舒緩(止痛)技術可能可以降低PONV現象的發生,並且達到促進腸胃運動(能動性)的目的。與使用全身性或硬膜外鴉片藥物的方法相比,對於經歷與剖腹有關的腹部手術患者使用硬膜外局部麻醉較能降低腸胃道麻痺症狀。疼痛的舒緩也是可以進行比較的,這些結論是依據22個隨機對照試驗,針對1023位腹部受術的患者進行試驗所歸納出來的,文獻的發表時間自1984年至2000年,結果一致顯示,與使用全身性鴉片藥物(19至56小時,平均為37小時)或硬膜外鴉片藥物(10至39小時,平均為24小時),進行硬膜外局部麻醉的患者可以縮短腸胃道功能恢復的時間,各組之間在PONV的數據上並沒有出現清楚的差異,經常使用的硬膜外局部麻醉劑為bupivacaine(濃度為0.1至0.5%),使用方式為連續是或間歇性的進行注射,本研究中的試驗都使用bupivacaine,只有一個試驗是使用ropivacaine。與單獨使用硬膜外局部麻醉劑的要果相比較,將鴉片類藥物添加至硬膜外局部麻醉劑中可能可以提供較佳的疼痛舒緩效果。研究中只有2個試驗是針對硬膜外局部麻醉劑和硬膜外局部麻醉劑與鴉片類藥物的混合劑對於腸胃道功能影響進行比較,但是也沒有明確的發現。大多數試驗的受試族群較小,且有些試驗顯然研究方法不佳。這些試驗的手術包含大腸和直腸手術、子宮切除術(hysterectomy)、剖腹生產(caesarean section)、切除膽囊(膽囊切除術,cholecystectomy)、腹主動脈手術(abdominal aortic surgery)和主要的腹部婦科手術(abdominal gynaecological surgery)。