For adults with pain following intra‐abdominal surgery, how does epidural analgesia compare with intravenous patient‐controlled analgesia (IV PCA)?

Abstract

Although pain control after intra‐abdominal surgery may be better with epidural analgesia than with IV PCA, the need for a second analgesic technique and adverse events may be greater.RCTs compared epidural analgesia (most often, bupivacaine or ropivacaine plus an opioid at the thoracic level via a programmable pump) with IV PCA (most often morphine) for adults who had undergone intra‐abdominal surgery (most with American Society of Anesthesiologists physical status I to II). Pain scores at rest (moderate‐certainty evidence) and pain on movement (low‐certainty evidence) were better with epidural anesthesia within the first 24 hours and beyond (5.1 to 26 points lower on a 100‐point scale with epidural; all values on average). Duration of hospital stay may be slightly shorter with epidural anesthesia, but low‐certainty evidence suggests that time to ambulation may be similar for the two analgesic regimens. However, moderate‐certainty evidence shows that more people could experience failure of analgesia (defined as a clinical decision for any reason to use a second analgesic technique; 87 vs 35 per 1000 people), pruritus (219 vs 93 per 1000 people), and hypotension (121 vs 17 per 1000 people) with epidural analgesia than with IV PCA. The impact of analgesic regimen on mortality, development of venous thromboembolism, nausea/vomiting, hypoxemia (low‐ to moderate‐certainty evidence), and sedation remains unclear, as results are too imprecise to draw conclusions.