1 Department of Anaesthesia, St George's Hospital, London SW17 0QT, UK. 2 Pain Clinic, St Richard's Hospital, Chichester PO19 4E, UK
* Corresponding author. E-mail: jeremy.cashman{at}stgeorges.nhs.uk
Accepted for publication March 4, 2004.
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Abstract |
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Methods. A MEDLINE search of the literature was conducted for publications concerned with the management of postoperative pain. Information relating to variables indicative of respiratory depression and of hypotension was extracted from these studies. Over 800 original papers and reviews were identified. Of these papers, 212 fulfilled the inclusion criteria but only 165 provided usable data on adverse effects. Pooled data obtained from these studies, which represent the experience of a total of nearly 20 000 patients, form the basis of this study.
Results. There was considerable variability between studies in the criteria used for defining respiratory depression and hypotension. The overall mean (95% CI) incidence of respiratory depression of the three analgesic techniques was: 0.3 (0.11.3)% using requirement for naloxone as an indicator; 1.1 (0.71.7)% using hypoventilation as an indicator; 3.3 (1.47.6)% using hypercarbia as an indicator; and 17.0 (10.226.9)% using oxygen desaturation as an indicator. For i.m. analgesia, the mean (95% CI) reported incidence of respiratory depression varied between 0.8 (0.22.5) and 37.0 (22.645.9)% using hypoventilation and oxygen desaturation, respectively, as indicators. For PCA, the mean (95% CI) reported incidence of respiratory depression varied between 1.2 (0.71.9) and 11.5 (5.622.0)%, using hypoventilation and oxygen desaturation, respectively, as indicators. For epidural analgesia, the mean (95% CI) reported incidence of respiratory depression varied between 1.1 (0.61.9) and 15.1 (5.634.8)%, using hypoventilation and oxygen desaturation, respectively, as indicators. The mean (95% CI) reported incidence of hypotension for i.m. analgesia was 3.8 (1.97.5)%, for PCA 0.4 (0.11.9)%, and for epidural analgesia 5.6 (3.010.2)%. Whereas the incidence of respiratory depression decreased over the period 198099, the incidence of hypotension did not.
Conclusions. Assuming a mixture of analgesic techniques, Acute Pain Services should expect an incidence of respiratory depression, as defined by a low ventilatory frequency, of less than 1%, and an incidence of hypotension related to analgesic technique of less than 5%.
Keywords: anaesthetic techniques, epidural ; analgesia, patient-controlled ; analgesic techniques, intramuscular ; complications, hypotension ; complications, respiratory depression ; pain, postoperative
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Introduction |
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In this, the second of three studies, we have examined the evidence from published data with regard to adverse respiratory and haemodynamic effects of i.m., patient controlled and epidural analgesic techniques. In particular, we have examined the three analgesic techniques with respect to the incidence of respiratory depression and hypotension after major surgery.
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Methods |
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Definitions
We examined measures of safety after major surgery for each of the three analgesic techniques in common practice: patient-controlled analgesia (PCA), epidural analgesia, and i.m. injections as outlined previously. Information was extracted from published studies, which reported variables indicative of respiratory depression and of hypotension. The different measurements have been recorded and where studies involved comparison between drugs (e.g. opioids), the results have been pooled. Where the study compared analgesic techniques, results have been entered separately under each form of analgesia.
Statistical methodology
The mean percentage reporting a given level of pain was found by the method of weighted mean, with weighting by the number of subjects in the group.2 When patients were grouped by the method of analgesia, some studies contributed subjects to more than one group. This was ignored in the analysis, possibly resulting in a small loss of power.
Analysis was by estimation of the confidence interval (CI) of the log odds ratio and its CI. The standard error from which the confidence interval was estimated was adjusted for the clustering of the individual clusters within the study and treatment groups, thus allowing for the extra variation, which exists between studies. The log odds was then converted to a percentage by:
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The effects of analgesic technique and year were tested using logistic regression adjusted for clustering. Analgesic technique was represented by two dummy variables, representing i.v.-PCA and epidural. Both were zero for i.m. analgesia. The significance of the modality effect was tested using the overall 2 statistic. To test for analgesic technique adjusted for year, we took the difference between the
2 statistics and associated degrees of freedom for the model with modality and year, and for that with year only. All analysis was done using Stata 5.0 (Stata Corporation, College Station, TX).
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Results |
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Ventilatory frequency
104 studies reported ventilatory frequency. For studies that reported more than one ventilatory frequency, we used the higher reported ventilatory frequency in our analysis of respiratory depression. We identified 70 study groups that defined respiratory depression as a ventilatory frequency of less than 10 bpm, and 46 study groups that defined it as a ventilatory frequency of less than 8 bpm. This represents a total of 29 607 patients in 116 study groups (1590 patients i.m. analgesia; 6922 patients PCA; and 21 035 patients epidural analgesia). Another 35 studies reported respiratory depression but did not define it; these have not been included in the analysis. The overall mean (95% CI) rate of respiratory depression as defined by a specific ventilatory frequency, whatever the ventilatory frequency the authors of the various studies chose (less than 10 or less than 8 bpm), was 1.1 (0.71.7)%. There was no difference in respiratory depression between the three analgesic techniques (P=0.7; Table 1).
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Cardiovascular depression
We report on 81 studies relating to haemodynamic indices. There were a total of 24 955 patients included in papers published between 1956 and 1999, which provided suitable data for analysis.
Hypotension
Studies varied in their definition of hypotension, commonly tending to present the number of patients with arterial pressure below a threshold level recorded at a particular time. A total of 54 studies presented data on the number of patients with arterial pressure below a pre-defined level, or alternatively data on the number of patients with a decrease of arterial pressure greater than a pre-defined amount. For all of these studies, which reported more than one haemodynamic parameter, we used the first reported arterial pressure in our analysis of hypotension. Thus, there were 27 study groups in which hypotension was defined as a systolic arterial pressure of less than 100 mm Hg and/or a greater than 20% decrease in arterial pressure; 24 study groups in which hypotension was defined as a systolic arterial pressure of less than 90 mm Hg; and a further 23 study groups in which hypotension was defined as a systolic arterial pressure of less than 80 mm Hg and/or a greater than 30% decrease in arterial pressure. Another 27 studies reported haemodynamic depression but did not strictly define hypotension. This represents a total of 22 573 patients (631 patients i.m. analgesia; 3954 patients PCA; and 20 370 patients epidural analgesia). If all definitions of hypotension from the 81 papers are included, the overall rate of hypotension (mean (95% CI)) was 4.7 (2.87.7)%. The results were remarkably similar when a definition based on a predetermined level of arterial pressure was used 4.9 (2.78.8)%. The effect of analgesic technique was significant, being lowest with PCA and highest with epidural analgesia (P=0.01, P=0.007; all and strict definitions, respectively). The effect of analgesic technique persisted after controlling for year of publication (P=0.027, P=0.018; all and strict definitions, respectively). The rates of hypotension are shown in Tables 5 and 6.
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Discussion |
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There is a relative lack of studies assessing the incidence of respiratory depression after intermittent, as required, opioid analgesia. This may be due partly to the fact that oxygen saturation monitoring did not become routine until the mid 1980s, yet most studies of i.m. analgesia were conducted before this date. In one of the few studies that reported oxygen saturations following i.m. opioid analgesia, Jayr and colleagues reported a 13% incidence of desaturation,5 which is very similar to the figure of 12.5% reported by Tsui and colleagues,6 whilst a 20% incidence of prolonged desaturation was reported in another much smaller study.7 Using strict criteria for drug administration, Rawal and colleagues suggested that intermittent opioid analgesia was a safe technique on the basis that no patients required ventilatory support.8 These studies, although less comprehensive than comparable studies of epidural or PCA, suggest a somewhat higher incidence of respiratory depression using intermittent i.m. opioid analgesia, an observation borne out by our analysis.
When PCA is used postoperatively, our analysis suggests that low ventilatory frequencies occur in 1.2% of patients, although at least one large study suggests a slightly higher figure.9 Arterial desaturation occurred in 11.5% of patients, yet paradoxically, larger studies seem to indicate a lower rate. In one large series of 3016 patients, Schug and Torrie reported an overall respiratory depression rate of 0.56% for i.v. opioids, but many of these were administered by a continuous infusion.10 Furthermore, respiratory depression in this study was defined by the decision to give naloxone. As has been pointed out previously, there are no clear protocols to dictate when to give naloxone, which at present is by clinician preference. In comparison, our analysis suggests a higher respiratory depression rate of 1.9% based on naloxone administration.
When epidurals are used for postoperative analgesia, the incidence of respiratory depression depends to some extent on whether or not an opiate has been used in addition to the local anaesthetic. Several large prospective studies indicate that the incidence of respiratory depression varies between 0.2 and 1.2% of patients.1113 This may be lower than the incidence with PCA, although the two have not been formally compared in the same study. One large retrospective survey of epidural analgesia reported an incidence of respiratory depression requiring naloxone administration of 0.4%, but did not define any criteria for the administration of naloxone.14 In a multi-hospital follow-up survey, Rawal and colleagues found the incidence of delayed respiratory depression to be 0.09%.15 However, because the survey was conducted over a number of hospitals, it is unclear if they were all using the same criteria to define respiratory depression.
Hypotension has been defined in a number of ways: a decrease in systolic arterial pressure of greater than 20% of a stable preoperative value has been used;16 as has a greater than 30% decrease,17 18 absolute values of systolic arterial pressure of less than 100 mm Hg,16 or less than 80 mm Hg;5 17 and systolic/diastolic arterial pressure of less than 90/60 mm Hg.18 In a number of studies, hypotension was not defined other than by the need for an intervention. Morphine administration can result in a reduction in arterial pressure, and thus hypotension may be a problem with both PCA and i.m. analgesia as well as with epidural analgesia. However, hypotension may be the result of factors other than the analgesic technique. In a large survey, Tsui and colleagues recorded a 1.9% incidence of hypotension, of which the majority were a result of surgical factors resulting in haemorrhage.4 These authors were able to implicate the analgesic technique as the cause of hypotension in only six out of 2509 cases, giving an incidence of 0.2%.4 In one of the few reasonably sized reviews of i.m. opioid analgesia that also provided details of arterial pressures, Slack and colleagues recorded a 4% incidence of hypotension.19 The results of our analysis produced a very similar figure. A slightly higher incidence of 8% has been reported with s.c. morphine.5 In contrast, the incidence of hypotension associated with PCA was 0% in two other large studies.20 21 There is much more published data on the hypotensive effect of epidural analgesia, with a number of large retrospective surveys suggesting that the incidence of hypotension lies between 2 and 4%.18 2224
This analysis differs from a formal systematic review with meta-analysis in a number of respects. We did not confine ourselves to randomized controlled trials and no attempt was made to grade individual papers according to quality. All of the studies used in the analysis were given equal value as we were not concerned with the conclusion of the individual study, merely the incidences of respiratory depression and hypotension. We feel that this approach is justified as we were not considering the results of published studies but were concerned with extracting the data from them. It is inevitable in a study of this type that there will be a degree of variability in the analgesic regimens, surgical procedures, and indeed in the data presented. Therefore, a degree of heterogeneity is unavoidable in this analysis. However, we feel that the large numbers of studies included and the small number of differences sought will reduce the likelihood of statistical heterogeneity. Also, we were mindful of the dangers of over interpretation inherent in searching for causes of heterogeneity. With respect to clinical heterogeneity, we found that the surgical case mix of the studies used was very similar between the three analgesic techniques and we feel confident that the groups mirror clinical practice. Furthermore, at least one subsequent large study has reported incidences of respiratory depression and hypotension with epidural and i.v. opiate analgesia not dissimilar to our own findings.25 The rapid evolution of Acute Pain Services is another source of variability of the data. Many of the studies analysed were reports of the initial experiences of individual centres' Pain Service. It is likely that these services have evolved, and this may well explain the decrease in the odds ratio for respiratory depression over the time period of the analysis. However, this fails to explain why the incidence of hypotension has not changed.
In summary, we present an analysis of published data on the adverse respiratory and haemodynamic effects of acute postoperative pain management. Most Acute Pain Services will use a mixture of techniques, and even when PCA and epidural analgesia are freely available, intermittent administration of opioids will still be used in up to 30% of cases after major surgery.26 Allowing for the variety of definitions, as well as the heterogeneity of the data, the following suggestions for clinical practice can be made. Acute Pain Services should expect respiratory depression related to analgesic technique to occur no more frequently than in 1% of cases as defined by a low ventilatory frequency. If oxygen desaturation is used to indicate respiratory depression, a much higher figure should be expected. I.M. opioid analgesia is associated with a similar incidence of respiratory depression to PCA or epidural analgesia, although naloxone use is greatest in association with PCA. There has been a significant decrease in the incidence of respiratory depression over the course of the last two decades. Acute Pain Services should expect an incidence of hypotension related to analgesic technique of less than 5%. Hypotension occurs most frequently with epidural analgesia and least often in association with PCA. These figures may be helpful to Acute Pain Services in setting standards of care.
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Appendix 1 |
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Watts RW, Fletcher IA, Kiroff GK, Weber C, Owen H, Plummer JL. The introduction of patient-controlled analgesia into isolated rural hospital. Aust NZ J Surg 1995; 65: 58891
Weller R, Rosenblum M, Conard P, Gross JB. Comparison of epidural and patient controlled intravenous morphine following joint replacement surgery. Can J Anaesth 1991; 38: 5826
Wheatley RG, Madej TH, Jackson IJ, Hunter D. The first year's experience of an acute pain service. Br J Anaesth 1991; 67: 3539
White MJ, Berghausen EJ, Dumont SW, et al. Side effects during continuous epidural infusion of morphine and fentanyl. Can J Anaesth 1992; 39: 57682
Whiting WC, Sandler AN, Lau LC, et al. Analgesia and respiratory effects of epidural sufentanil in patients following thoracotomy. Anesthesiology 1988; 69: 3643
Wiebalck A, Brodner G, Van Aken H. The effects of adding sufentanil to bupivacaine for postoperative patient-controlled analgesia. Anesth Analg 1997; 8: 1249
Wong LT, Koh LH, Kaur K, Boey SK. A two-year experience of an acute pain service in Singapore. Singapore Med J 1997; 38: 20913
Writer WD, Hurtig JB, Evans D, Needs RE, Hope CE, Forrest JB. Epidural morphine prophylaxis of postoperative pain: report of a double blind multicentre study. Can Anaesth Soc J 1985; 32: 3308
Yamaguchi H, Watanabe S, Harukuni I, Hamaya Y. Effective doses of epidural morphine for relief of postcholecystectomy pain. Anesth Analg 1991; 72: 803
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Appendix 2 |
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Blackburn A, Stevens JD, Wheatley RG, Madej TH, Hunter D. Balanced analgesia with intravenous kerorolac and patient-controlled analgesia morphine following abdominal surgery. J Clin Anesth 1995; 7: 1038
Boudreault D, Brasseur L, Samii K, Lemoing JP. Comparison of continuous epidural bupivacaine infusion plus either continuous epidural infusion or patient-controlled epidural injection of fentanyl for postoperative analgesia. Anesth Analg 1991; 73: 1327
Brose WG, Cohen SE. Oxyhemoglobin saturation following cesarean section in patients receiving epidural morphine, patient-controlled analgesia, or intramuscular meperidine analgesia. Anesthesiology 1989; 70: 94853
Catley DM, Thornton C, Jordan C, Lehane J, Royston D, Jones JG. Pronounced episodic oxygen dresaturation in the postoperative period; its association with ventilatory pattern and analgesic regimen. Anesthesiology 1985; 63: 208
Chauvin M, Hongnat JM, Mourgeon E, Lebrault C, Bellenfait F, Alfonsi P. Equivalence of postoperative analgesia with patient controlled intravenous or epidural alfentanil. Anesth Analg 1993; 76: 12518
Egbert AM, Parks LH, Short LM, Burnett ML. Randomized trial of postoperative patient controlled analgesia vs intramuscular narcotics in frail elderly men. Arch Int Med 1990; 150: 1897903
Entwistle MD, Roe PG, Sapsford DJ, Berrisford RG, Jones JG. Patterns of oxygenation after thoracotomy. Br J Anaesth 1991; 67: 70411
Etches RS, Warriner CB, Badner N, et al. Continuous intravenous administration of ketorolac reduces pain and morphine consumption after total hip and knee arthroplasty. Anesth Analg 1995; 81: 117580
Grant GJ, Zakowski M, Pamanthan S, Boyd A, Turndorf H. Thoracic versus lumbar administration of epidural morphine for postoperative analgesia after thoracotomy. Reg Anesth 1993; 18: 3515
Guinard JP, Mavrocordatos P, Chiolero R, Carpenter RL. A randomized comparison of intravenous versus lumbar and thoracic epidural fentanyl for analgesia after thoracotomy. Anesthesiology 1992; 77: 110815
Jayr C, Thomas H, Rey A, Farhat F, Lasser P, Bourgain J. Postoperative pulmonary complications: epidural analgesia using bupivacaine and opioids versus parenteral opioids. Anesthesiology 1993; 78: 66676
Jayr C, Beaussier M, Gustafsson U, et al. Continuous epidural infusion of ropivacaine for postoperative analgesia after abdominal surgery. Br J Anaesth 1998; 81: 88792
Johnson RG, Miller M, Murphy M. Intraspinal narcotic analgesia: a comparison of two methods of postoperative pain relief. Spine 1989; 14: 3636
Langford R, Bakhshi K, Moylan S, Foster JM. Hypoxaemia after lower abdominal surgery: comparison of tramadol and morphine. Acute Pain 1998; 1: 712
Lehmann KA, Gerhard A, Horrichs-Haermeyer G, Grond S, Zech D. Postoperative patient-controlled analgesia with sufentanil: analgesic efficacy and minimum effective concentrations. Acta Anaesthesiol Scand 1991; 35; 2216
Madej TH, Wheatley RG, Jackson IT, Hunter D. Hypoxaemia and pain relief after lower abdominal surgery: comparison of extradural and patient controlled analgesia. Br J Anaesth 1992; 69: 5547
Nozaki-Taguchi N, Oka T, Kochi T, Taguchi N, Mizaguchi T. Apnoea and oximetric desaturation in patients receiving epidural morphine after gastrectomy. Anaesth Intens Care 1993; 21: 2927
Parker RK, Holtmann B, White PF. Effects of a nighttime opioid infusion with patient-controlled analgesia therapy on patient comfort and analgesic requirements after abdominal hysterectomy. Anesthesiology 1992; 76: 3627
Patrick J, Meyer-Witting M, Reynolds F. Lumbar epidural diamorphine following thoracic surgery. Anaesthesia 1991; 46: 859
Rosenberg J, Dirkes WE, Kehlet H. Episodic arterial oxygen desaturation and heart rate variations following major abdominal surgery. Br J Anaesth 1989; 63: 6514
Rosenberg J, Rasmussen V, von Jessen F, Ullstad T, Kehlet H. Late postoperative episodic and constant hypoxaemia and associated ECG abnormalities. Br J Anaesth 1990; 65: 68491
Saito Y, Uchita H, Kaneko M, Nakatani T, Kosaka Y. Comparison of continuous epidural infusion of morphine/bupivacaine with fentanyl/bupivacaine for postoperative pain. Acta Anaesthesiol Scand 1994; 38: 398401
Salomaki TE, Laitinen JO, Vainionpaa V, Nuutinen LS. 0.1% bupivacaine does not reduce the requirement for epidural fentanyl infusion after major abdominal surgery. Reg Anesth 1995; 20: 43543
Schug S, Fry R. Continuous regional analgesia in comparison with intravenous opioid administration for routine postoperative pain control. Anaesthesia 1994; 49: 52832
Sidebotham D, Dijkhuizen MR, Schug SA. The safety and utilization of patient controlled analgesia. J Pain Symptom Manage 1997; 14: 2029
Sidebotham DA, Russell K, Dijkhuizen M, Tester P, Schug SA. Low dose fentanyl improves continuous bupivacaine epidural analgesia following orthopaedic, urological or general surgery. Acute Pain 1997; 1: 2732
Tsui SL, Chan CS, Chan AS, Wong SJ, Lam CS, Jones RD. Postoperative analgesia for oesophageal surgery: a comparison of three analgesic regimens. Anaesth Intens Care 1991; 19: 32937
Tsui SL, Lo RJ, Tong WN, et al. A clinical audit for postoperative pain control on 1443 surgical patients. Acta Anaesthesiol Sin 1995; 33: 13748
Tsui SL, Tong WN, Irwin M, et al. The efficacy, applicability and side effects of postoperative intravenous patient controlled morphine analgesia: an audit of 1233 Chinese patients. Anaesth Intens Care 1996; 24: 65864
Vercauteren M, Lauwers E, Meert T, DeHert S, Adriaensen H. Comparison of epidural sufentanil plus clonidine with sufentanil alone for postoperative pain relief. Anaesthesia 1990; 45: 5314
Wheatley RG, Shepherd D, Jackson IJ, Madej TH, Hunter D. Hypoxaemia and pain relief after upper abdominal surgery: comparison of intramuscular and patient controlled analgesia. Br J Anaesth 1992; 69: 55861
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Appendix 3 |
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Guinard JP, Mavrocordatos P, Chiolero R, Carpenter RL. A randomized comparison of intravenous versus lumbar and thoracic epidural fentanyl for analgesia after thoracotomy. Anesthesiology 1992; 77: 110815
Hansdottir V, Bake B, Nordberg G. The analgesic efficacy and adverse effects of continuous epidural sufentanil and bupivacaine infusion after thoracotomy. Anesth Analg 1996; 83: 394400
Laveaux MM, Hasenbos MA, Harbers JB, Liem T. Thoracic epidural bupivacaine plus sufentanil: high concentration/low volume versus low concentration/high volume. Reg Anesth 1993; 18: 3943
Nimmo WS, Todd JG. Fentanyl by constant rate intravenous infusion for postoperative analgesia. Br J Anaesth 1985; 57: 2504
Pelton JJ, Fish DJ, Keller SM. Epidural narcotic analgesia after thoracotomy. South Med J 1993; 86: 11069
Rapp S, Ready L, Greer B. Postoperative pain management in gynecologic oncology patients utilizing epidural opiate analgesia and patient-controlled analgesia. Gynecol Oncol 1989; 35: 3414
Ready LB, Oden R, Chadwick HS, et al. Development of an anesthesiology-based postoperative pain management service. Anesthesiology 1988; 68: 1006
Rosenberg PH, Heino A, Scheinin B. Comparison of intramuscular analgesia, intercostal block, epidural morphine and on-demand intravenous fentanyl in the control of pain after upper abdominal surgery. Acta Anaesthesiol Scand 1984; 28: 6037
Salomaki TE, Laitinen JO, Nuutinen LS. A randomized double blind comparison of epidural versus intravenous fentanyl infusion for analgesia after thoracotomy. Anesthesiology 1991; 75: 7905
Salomaki TE, Laitinen JO, Vainionpaa V, Nuutinen LS. 0.1% bupivacaine does not reduce the requirement for epidural fentanyl infusion after major abdominal surgery. Reg Anesth 1995; 20: 43543
Scheinin B, Asantila R, Orko R. The effect of bupivacaine and morphine on pain and bowel function after colonic surgery. Acta Anaesthesiol Scand 1987; 31: 1614
Shulman M, Sandler AN, Bradley JW, Young PS, Brebner J. Post-thoracotomy pain and pulmonary function following epidural and systemic morphine. Anesthesiology 1984; 61: 56975
Snijdelaar DG, Hasenbos MA, van Egmond J, Wolff AP, Liem TH. High thoracic epidural sufentanil with bupivacaine: continuous infusion of high volume versus low volume. Anesth Analg 1994; 78: 4904
Tamsen A, Hartvig P, Faherlund G, Dahlstrom B, Bondessen U. Patient controlled analgesic therapy: clinical experience. Acta Anaesthesiol Scand 1982; 74 (Suppl.): 15760
Tsui SL, Chan CS, Chan AS, Wong SJ, Lam CS, Jones RD. Postoperative analgesia for oesophageal surgery: a comparison of three analgesic regimens. Anaesth Intens Care 1991; 19: 32937
Tsui SL, Lo RJ, Tong WN, et al. A clinical audit for postoperative pain control on 1443 surgical patients. Acta Anaesthesiol Sin 1995; 33: 13748
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Appendix 4 |
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Hurford WE, Dutton RP, Alfille PH, Clement D, Wilson RS. Comparison of thoracic and lumbar epidural infusions of bupivacaine and fentanyl for postthoracotomy analgesia. J Cardiothorac Vasc Anaesth 1993; 7: 5215
Kilbride MJ, Senagore AJ, Mazier WP, Ferguson C, Ufkes T. Epidural analgesia. Surg Gynecol Obstet 1992; 174: 13740
Liu SS, Allen HW, Olsson GL. Patient controlled epidural analgesia with bupivacaine and fentanyl on hospital wards. Anesthesiology 1998; 88: 68895
Logas WG, el-Baz N, el-Ganzouri A et al. Continuous thoracic epidural analgesia for postoperative pain relief following thoracotomy. Anesthesiology 1987; 67: 78791
Mahoney OM, Noble PC, Davidson J, Tullos HS. The effect of continuous epidural analgesia on postoperative pain, rehabilitation and duration of hospitalisation in total knee arthroplasty. Clin Orthop 1990; 260: 307
Mehnert J, Dupont T, Rose D. Intermittent epidural morphine instillation for control of postoperative pain. Am J Surg 1983; 146: 14551
Rawal N, Allvin R. Epidural and intrathecal opioids for postoperative pain management in Europea 17-nation questionnaire study of selected hospitals. Euro Pain Study Group on Acute Pain. Acta Anaesthesiol Scand 1996; 40: 111926
Welch D, Hrynaszkiewicz. Post-operative analgesia using epidural methadone: administration by the lumbar route for thoracic pain relief. Anaesthesia 1981; 36: 10514
Whipple JK, Quebbeman EJ, Lewis KS, Gaughan LM, Gallup EL, Ausman RK. Identification of patient-controlled analgesia overdoses in hospitalized patients: a computerized method of monitoring adverse events. Ann Pharmacother 1994; 28: 6558
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Appendix 5 |
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el-Baz N, Goldin M. Continuous epidural infusion of morphine for pain relief after cardiac operations. J Thorac Cardiovasc Surg 1987; 93: 87883
Broekema AA, Gielein MJ, Hennis PJ. Postoperative analgesia with continuous epidural sufentanil and bupivacaine. Anesth Analg 1996; 82: 7549
Burgess FW, Anderson DM, Colonna D, Cavanaugh DG. Thoracic epidural analgesia with bupivacaine and fentanyl for postoperative thoracotomy pain. J Cardiothorac Vasc Anesth 1994; 8: 4204
Burstal R, Wegener F, Hayes C, Lantry G. Epidural analgesia: prospective audit of 1062 patients. Anaesth Intens Care 1998; 26: 16572
Capdevila X, Barthelet Y, Biboulet P, Ryckwaert Y, Rubenovitch J, d'Athis F. Effects of perioperative analgesic technique on the surgical outcome and duration of rehabilitation after major knee surgery. Anesthesiology 1999; 91: 815
Chisakuta AM, George KA, Hawthorne CT. Postoperative epidural infusion of a mixture of bupivacaine with fentanyl for upper abdominal surgery. Anaesthesia 1995; 50: 725
Coleman S, Brooker-Milburn J. Audit of postoperative pain control. Anaesthesia 1996; 51: 10936
Conacher ID, Paes ML, Jacobsen L, Phillips PH, Heaviside DW. Epidural analgesia following thoracic surgery. Anaesthesia 1983; 38: 54651
Cooper DW, Turner G. Patient-controlled extradural analgesia to compare bupivacaine, fentanyl and bupivacaine with fentanyl in the treatment of postoperative pain. Br J Anaesth 1993; 70: 5037
Cox CR, Serpell MG, Bannister J, Coventry DM, Williams DR. A comparison of epidural infusions of fentanyl or pethidine with bupivacaine in the management of postoperative pain. Anaesthesia 1996; 51: 6958
Crawford ME, Moniche S, Orbaek J, Bjerrum H, Kehlet H. Orthostatic hypotension during postoperative continuous thoracic epidural bupivacaine-morphine in patients undergoing abdominal surgery. Anesth Analg 1996; 83: 102832
Dahl JB, Hjortso NC, Stage JG, et al. Effects of combined perioperative epidural bupivacaine and morphine, ibuprofen, and incisional bupivacaine on postoperative pain, pulmonary and endocrine-metabolic function after minilaparotomy cholecystectomy. Reg Anesth 1994; 19: 199205
Etches R, Gammer T-L, Cornish R. Patient controlled epidural analgesia after thoracotomy: a comparison of meperidine with and wihout bupivacaine. Anesth Analg 1996; 83: 816
George KA, Chisakuta AM, Gamble JA, Browne GA. Thoracic epidural infusion for postoperative pain relief following abdominal aortic surgery. Anaesthesia 1992; 47: 38894
George KA, Wright PM, Chisakuta AM, Rao NV. Thoracic epidural analgesia compared with patient controlled intravenous morphine after upper abdominal surgery. Acta Anaesthesiol Scand 1994; 38: 80812
Hansdottir V, Bake B, Nordberg G. The analgesic efficacy and adverse effects of continuous epidural sufentanil and bupivacaine infusion after thoracotomy. Anesth Analg 1996; 83: 394400
Hasenbos M, van Egmond J, Gielen M, Crul JF. Postoperative analgesia by epidural versus intramuscular nicomorphine after thoracotomy. Part II. Acta Anaesthesiol Scand 1985; 29: 57782
Hasenbos M, van Egmond J, Gielen M, Crul JR. Postoperative analgesia by high thoracic epidural versus intramuscular nicomorphine after thoracotomy. Acta Anaesthesiol Scand 1987; 31: 60815
Hobbs GJ, Roberts FL. Epidural infusion of bupivacaine and diamorphine for postoperative analgesia: use on general surgical wards. Anaesthesia 1992; 47: 5862
Jayr C, Thomas H, Rey A, Farhat F, Lasser P, Bourgain J. Postoperative pulmonary complications: epidural analgesia using bupivacaine and opioids versus parenteral opioids. Anesthesiology 1993; 78: 66676
Knapp M, Beecher H. Postanaesthetic nausea, vomiting and retching. JAMA 1956; 160: 37685
van Lancker P, Mortier E, Pieters A, Rolly G. Evaluation of morphine for patient controlled analgesia with the infusor system after opiate free locoregional anaesthesia for osteotomy of the foot. Acta Anaesthesiol Belgica 1995; 46:1139
Laveaux MM, Hasenbos MA, Harbers JB, Liem T. Thoracic epidural bupivacaine plus sufentanil: high concentration/low volume versus low concentration/high volume. Reg Anesth 1993; 18: 3943
Leith S, Wheatley RG, Jackson IJ, Madej TH, Hunter D. Extradural infusion analgesia for postoperative pain relief. Br J Anaesth 1994; 73: 5528
de Leon-Casasola OA, Parker B, Lema MJ, Harrison P, Masey J. Postoperative epidural bupivacaine-morphine therapy. Anesthesiology 1994; 81: 36875
de Leon-Casasola OA, Lema MJ, Karabella D, Harrison P. Postoperative myocardial ischaemia: epidural versus intravenous patient-controlled analgesia. Reg Anesth 1995; 20: 10512
Liu S, Angel JM, Owens BD, Carpenter RL, Isabel L. Effects of epidural bupivacaine after thoracotomy. Reg Anesth 1995; 20: 30310
Liu SS, Carpenter RL, Mackey DC, et al. Effects of perioperative analgesic technique on rate of recovery after colon surgery. Anesthesiology 1995; 83:75765
Liu SS, Allen HW, Olsson GL. Patient controlled epidural analgesia with bupivacaine and fentanyl on hospital wards. Anesthesiology 1998; 88: 68895
Liu SS, Moore JM, Luo AM, Trautman WJ, Carpenter RL. Comparison of three solutions of ropivacaine/fentanyl for postoperative patient-controlled epidural analgesia. Anesthesiology 1999; 90: 72733
MacIntyre PE. An acute pain service in an Australian teaching hospital: the first year. Med J Aust 1990; 153: 41721
Matthews PJ, Govenden V. Comparison of continuous paravertebral and extradural infusions of bupivacaine for pain relief after thoracotomy. Br J Anaesth 1989; 62: 2045
Naji P, Farschtschian M, Wilder-Smith OH, Wilder-Smith CH. Epidural droperidol and morphine for postoperative pain. Anesth Analg 1990; 70: 5838
van den Nieuwenhuyzen MC, Engbers FH, Burm AG, Vletter AA, van Kleef JW, Bovill JG. Computer controlled infusion of alfentanil versus patient controlled administration of morphine for postoperative analgesia: a double blind randomised trial. Anesth Analg 1995; 81: 6719
Olson B, Ustanko L, Melland H, Langemo D. Variables associated with hypotension in postoperative total knee arthroplasty patients receiving epidural analgesia. Orthop Nurs 1992; 11: 317
Paech MJ, Pavy TJ, Orlikowski CE, Lim W, Evans SF. Postoperative epidural infusion: a randomised double blind dose finding trial of clonidine in combination with bupivacaine and fentanyl. Anesth Analg 1997; 84: 13238
Reiz S, Westberg M. Side-effects of epidural morphine. Lancet 1980; 2: 2034
Reiz S, Ahlin J, Ahrenfeldt B, Andersson M, Andersson S. Epidural morphine for postoperative pain relief. Acta Anaesthesiol Scand 1981; 25: 1114
Richardson J, Sabanathan S, Jones J, Shah RD, Cheama S, Mearns AJ. A prospective randomised comparison of preoperative and continuous balanced epidural or paravertebral bupivacaine post-thoracotomy pain, pulmonary function and stress response. Br J Anaesth 1999; 83: 38792
Ross R, Clarke J, Armitage E. Postoperative pain prevention by continuous epidural infusion. Anaesthesia 1980; 35: 6638
Rygnestad T, Borchgrevink P, Eide E. Postoperative epidural infusion of morphine and bupivacaine is safe on surgical wards. Organisation of the treatment, effects and side effects in 2000 consecutive patients. Acta Anaesthesiol Scand 1997; 41: 86879
Rygnestad T, Zahlsen K, Bergslien O, Dale O. Focus on mobilisation after lower abdominal surgery. A double blind randomised comparison of epidural bupivacaine with morphine versus lidocaine with morphine postoperative analgesia. Acta Anaesthesiol Scand 1999; 43: 3807
Saito Y, Uchita H, Kaneko M, Nakatani T, Kosaka Y. Comparison of continuous epidural infusion of morphine/bupivacaine with fentanyl/bupivacaine for postoperative pain. Acta Anaesthesiol Scand 1994; 38: 398401
Salomaki TE, Laitinen JO, Vainionpaa V, Nuutinen LS. 0.1% bupivacaine does not reduce the requirement for epidural fentanyl infusion after major abdominal surgery. Reg Anesth 1995; 20: 43543
Salomaki TE, Kokki H, Turunen M, Havukainen U, Nuutinen LS. Introducing epidural fentanyl for on-ward pain relief after major surgery. Acta Anaesthesiol Scand 1996; 40: 7049
Scheinin B, Asantila R, Orko R. The effect of bupivacaine and morphine on pain and bowel function after colonic surgery. Acta Anaesthesiol Scand 1987; 31: 1614
Scott DA, Chamley DM, Mooney PH, Deam R, Mark AH, Hagglof B. Epidural ropivacaine infusion for postoperative analgesia after major lower abdominal surgerya dose finding study. Anesth Analg 1995; 81: 9826
Scott DA, Beilby DS, McClymont C. Postoperative analgesia using epidural infusions of fentanyl with bupivacaine. Anesthesiology 1995; 82: 72737
Sidebotham DA, Russell K, Dijkhuizen M, Tester P, Schug SA. Low dose fentanyl improves continuous bupivacaine epidural analgesia following orthopaedic, urological or general surgery. Acute Pain 1997; 1: 2732
Snijdelaar DG, Hasenbos MA, van Egmond J, Wolff AP, Liem TH. High thoracic epidural sufentanil with bupivacaine: continuous infusion of high volume versus low volume. Anesth Analg 1994; 78: 4904
Torda T, Pybus D. Comparison of four narcotic analgesics for extradural analgesia. Br J Anaesth 1982; 54: 2914
Tsui SL, Lee DK, Ng KF, Chan TY, Chan WS, Lo JW. Epidural infusion of bupivacaine plus fentanyl provides better postoperative analgesia than patient controlled analgesia with intravenous morphine after gynaecological laparotomy. Anaesth Intens Care 1997; 25: 47681
Vercauteren M, Lauwers E, Meert T, DeHert S, Adriaensen H. Comparison of epidural sufentanil plus clonidine with sufentanil alone for postoperative pain relief. Anaesthesia 1990; 45: 5314
Watts RW, Fletcher IA, Kiroff GK, Weber C, Owen H, Plummer JL. The introduction of patient-controlled analgesia into isolated rural hospital. Aust NZ J Surg 1995; 65: 58891
Welchew EA, Hosking J. Patient-controlled postoperative analgesia with alfentanil. Adaptive, on-demand intravenous alfentanil or pethidine compared double-blind for postoperative pain. Anaesthesia 1985; 40: 11727
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Acknowledgments |
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