Special Topics in Pain: Opioids

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Epidural Local Anesthetics Versus Opioid-Based Analgesic Regimens for Postoperative Gastrointestinal Paralysis, Vomiting, and Pain After Abdominal Surgery: A Cochrane Review.

Author(s): Guay, et al
Journal: Anesth Analg. 2016; 123: 1591-1602. 104 references.
Reprint: Joanne Guay, MD, Clinical Assistant Professor, University of Sherbrooke, Sherbrooke, QC, Canada. Email: joanneguay@bell.net
Faculty Disclosure: Abstracted by N Walea, who has nothing to disclose.
Objective: Review and evaluate the latest advances and newest information in the area of Opioids; Review and evaluate the latest advances and newest information in the area of Local Anesthetics


Editor’s Note: Cochrane reviews are usually most helpful in deciding clinical issues.

Gastrointestinal paralysis and postoperative pain are 2 major issues needing to be addressed after abdominal surgery. Gastrointestinal paralysis may result in prolonged hospital stay and costs. Epidural analgesia may promote a faster return in intestinal transit.

An epidural with a local anesthetic will accelerate the return of gastrointestinal transit by approximately 17 hours. The effect is proportional to the local anesthetic concentration. This effect will translate in shorter hospital length of stay for open surgeries only. An epidural with a local anesthetic also improves pain scores (open or laparoscopic surgeries). Adding an opioid to the solution of local anesthetic will improve pain scores without affecting its effect on gastrointestinal transit. An epidural containing a local anesthetic does not affect the incidence of vomiting or anastomotic leak.

Class: Pharmacology comparison: Epidural Local Anesthetics Versus Opioid-Based Analgesic Regimens for Postoperative Gastrointestinal Paralysis, Vomiting, and Pain After Abdominal Surgery

Gastrointestinal paralysis and postoperative pain are 2 major issues needing to be addressed after abdominal surgery. Gastrointestinal paralysis may result in prolonged hospital stay and costs. Epidural analgesia may promote a faster return in intestinal transit.

For this review, an electronic database search to identify potential studies was performed and the methodological quality of the studies selected was evaluated with the Cochrane tool.

Based on 22 trials that included 1138 participants, an epidural containing a local anesthetic reduced the time required for return of gastrointestinal transit after abdominal surgery as measured by the time required before observing the first flatus (high quality of evidence; equivalent to 17.5 hours). The effect was seen for almost every type of abdominal surgery and is proportional to the concentration of local anesthetic administered after the surgery. Adding an opioid to the mixture does not reduce the benefit. Return of gastrointestinal transit is generally considered required before hospital discharge and postoperative ileus will increase hospital costs.

 Based on 28 trials including 1559 participants, there was found a decrease in time to first stool equivalent to 22 hours (low quality of evidence).

 Based on 35 trials including 2731 patients, an epidural infusion with a local anesthetic after an abdominal surgery decreased VAS pain scores on movement at 24 hours the equivalent of 2.5 (on a 0 to 10 scale). The level of evidence was rated as moderate.

This review did not find a difference in the number of participants who experienced vomiting during the first 24 hours after abdominal surgery performed under general anesthesia based on 22 trials with 1154 participants. For gynecologic surgery, a reduced incidence of vomiting was seen only at relatively high local anesthetic concentrations. The quality of evidence was rated as low.

There were 17 trials with 848 participants and they failed to find a difference in the incidence of anastomotic leak. The level of evidence was rated as low.

The positive effects on gastrointestinal transit translated in an interesting shortening of hospital length of stay of 1 day for participants undergoing open surgeries only (low quality of evidence).

Many factors will either increase or decrease beneficial effects. For patients themselves, the older the patient, the higher the difference in pain scores between an epidural with local anesthetic and an opioid based regimen (pain scores at rest and on movement at 48 hours [results not show here]).

Important Points:
An epidural with a local anesthetic will accelerate the return of gastrointestinal transit by approximately 17 hours. The effect is proportional to the local anesthetic concentration. This effect will translate in shorter hospital length of stay for open surgeries only. An epidural with a local anesthetic also improves pain scores (open or laparoscopic surgeries). Adding an opioid to the solution of local anesthetic will improve pain scores without affecting its effect on gastrointestinal transit. An epidural containing a local anesthetic does not affect the incidence of vomiting or anastomotic leak.

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