Comparison of perioperative outcomes for epidural versus intravenous patient-controlled analgesia after radical cystectomy

Abstract

Background and objectives: The use of patient-controlled epidural analgesia after various operations has been associated with an early return of bowel function, thus decreasing patients' length of stay (LOS). The primary aim of this study was to compare LOS after radical cystectomy between patients who received epidural analgesia versus those who received intravenous patient-controlled analgesia. Our secondary analysis included the assessment of other metrics such as total opioid requirements, pain scores, return of bowel function, and complication rates between the 2 groups.

Methods: We conducted a retrospective review using the electronic medical records of 308 patients who underwent radical cystectomies at Memorial Sloan Kettering between 2006 and 2011. We aimed to understand if epidural analgesia was associated with a reduced LOS compared with patient-controlled intravenous opioid analgesia. We also aimed to identify performance improvements as a function of epidural analgesia status using various metrics such as pain management, bowel function return, and complication rates. We used both univariate and multivariate analyses to identify if epidural analgesia was associated with meaningful differences in the aforementioned metrics.

Results: Median age at radical cystectomy, body mass index, sex, American Society of Anesthesiologists score, and T stage were similar for both groups. For our primary objective of LOS, we found no significant difference between the 2 cohorts (8 vs 7 days, P = 0.2). Analysis of our secondary outcome measures revealed that epidural analgesia use was associated with less total opioid requirement for the first 3 postoperative days (PODs) (P = 0.0001). In addition, epidural analgesia was found to be associated with improved postoperative pain scores compared with intravenous patient-controlled analgesia on PODs 1 (P = 0.0001) and 2 (P = 0.004), and there was a slight improvement on POD 3, but this was not significant (P = 0.77). In contrast, we found no difference between pain management types with regard to proportion of patients who experienced a delay in gastrointestinal recovery, fluid bolus requirements within the first 3 perioperative days, rates of infection, pulmonary complications, and grade 3 or greater complications.

Conclusions: We have demonstrated that, despite significant improvements in initial pain control and less opioid requirement with patient-controlled epidural analgesia, there was no association between analgesic approach and LOS, return of bowel function, or complications.

Figure 1. Mean pain scores compared between patients who received PCEA and IV PCA on POD#1-3

* Statistically significant unpaired t-test, p-value <0.05 for mean pain scores

Figure 2. Statistical process control charts assessing temporal trends based on specific variables

A. XmR chart for hospital length of stay - Light grey lines represent upper and lower control limits based on 3-sigmas; vertical dashed line represents time point at which PCEA use was routinely initiated; each year was subdivided into quarters represented by individual dots (Q1-4). B. P-chart for proportion of patients experiencing grade 3 or higher complications (%) - Light grey lines represent upper and lower control limits based on 3-sigmas; vertical dashed line represents time point at which PCEA use was routinely initiated; each year was subdivided into quarters represented by individual dots (Q1-4).

Figure 2. Statistical process control charts assessing temporal trends based on specific variables

A. XmR chart for hospital length of stay - Light grey lines represent upper and lower control limits based on 3-sigmas; vertical dashed line represents time point at which PCEA use was routinely initiated; each year was subdivided into quarters represented by individual dots (Q1-4). B. P-chart for proportion of patients experiencing grade 3 or higher complications (%) - Light grey lines represent upper and lower control limits based on 3-sigmas; vertical dashed line represents time point at which PCEA use was routinely initiated; each year was subdivided into quarters represented by individual dots (Q1-4).