PCEA Efficacy Versus Parenteral Opioids

Based on the results of several studies and meta-analyses, epidural analgesia is better than PCA with opioids in a number of ways. Pain control is improved for general surgery, orthopedic, and gynecologic patients. All epidural regimens (except hydrophilic opioids alone) when compared to PCA provide improved analgesia. There is statistically better analgesia at rest and during activity for all types of surgery (through postoperative day four), as well as clinically appreciable differences in pain with activity through postoperative day one. Greater improvements in analgesia are seen when epidurals contain a local anesthetic and when the insertion level is matched to the surgery (i.e., epidural insertion site around the mid-dermatome of the incision).

There is a reduction in pulmonary and cardiac complications (including postoperative myocardial infarction) in major vascular surgery and high-risk patient populations with the use of thoracic epidurals. In addition there is a reduction in the time of postoperative ileus (by 1-1.5 days) following abdominal surgery with the use of local anesthetic containing epidural regimens. There has also been the suggestion that epidurals decrease the time to mobilization, duration of intensive care unit stay, and time to discharge. In lower extremity revascular-ization, epidurals have been shown to improve the incidence of graft survival. Historically, epidurals have been shown to reduce the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE); however, no studies have been done with comparison to newer pharmacologic thromboprophylaxis. One negative is that epidural therapy is more expensive than PCA therapy. In terms of side effects, PCA therapy has a higher incidence of nausea and sedation whereas epidurals have a higher incidence of pruritus, urinary retention, and motor block (though this will vary with the agents and concentrations chosen).

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