Brazilian Journal of Anesthesiology
https://app.periodikos.com.br/journal/rba/article/doi/10.1590/S0034-70942004000300010
Brazilian Journal of Anesthesiology
Clinical Information

Analgesia peridural contínua: análise da eficácia, efeitos adversos e fatores de risco para ocorrência de complicações

Continuous epidural analgesia: analysis of efficacy, side effects and risk factors

Leonardo Teixeira Domingues Duarte; Maria do Carmo C. Barreto Fernandes; Marcelino Jäger Fernandes; Renato Ângelo Saraiva

Downloads: 2
Views: 1099

Resumo

JUSTIFICATIVA E OBJETIVOS: A analgesia promovida pela infusão peridural de anestésico local com analgésicos opióides é reconhecidamente de boa qualidade e com poucos efeitos adversos. O objetivo deste estudo foi determinar o número, formas e gravidade das complicações pós-operatórias relacionadas à analgesia peridural e à inserção do cateter peridural. MÉTODO: Foram avaliados, retrospectivamente, 469 pacientes submetidos à analgesia peridural pós-operatória entre 18/10/1999 e 18/10/2001. A analgesia peridural foi conduzida usando-se solução de bupivacaína a 0,1% com fentanil (1 a 5 µg.ml-1), iniciando-se a infusão de 3 ml.h-1. A velocidade de infusão era ajustada de acordo com a queixa álgica do paciente. Foram analisadas as seguintes variáveis: a duração da infusão peridural; a ocorrência de efeitos adversos e complicações, relacionando-os aos dados demográficos, tipo de cirurgia e posição do cateter peridural; e a qualidade da analgesia obtida com a técnica (escala analógico-visual de dor e índice de satisfação do paciente). RESULTADOS: Os cateteres peridurais permaneceram implantados uma média de 2,2 dias, variando de 6 horas a 10 dias, e o índice global de complicações relacionadas à técnica foi de 46,3%, sendo que a maioria foi de pequena magnitude, sem repercussão clínica. Destas, 13,9% estavam relacionadas diretamente ao cateter peridural (desconexão, exteriorização, dor lombar, inflamação e infecção local). Outras complicações mais comumente encontradas foram vômitos e retenção urinária. A analgesia pós-operatória foi efetiva com 97,2% dos pacientes referindo satisfação com a técnica. Pacientes sem dor ou com dor leve, no primeiro, segundo e terceiro dias de pós-operatório, constituíram, respectivamente, 80,1%, 92,8% e 93,3% da população estudada. CONCLUSÕES: A analgesia peridural contínua é efetiva e segura. As complicações ocorridas não foram consideradas graves. Todavia, não se pode dispensar rigorosa vigilância a fim de se obter analgesia satisfatória e diminuir as complicações.

Palavras-chave

ANALGESIA, TÉCNICAS ANESTÉSICAS, TÉCNICAS ANESTÉSICAS

Abstract

BACKGROUND AND OBJECTIVES: Epidural analgesia with local anesthetics and opioids has a reputation of high efficacy with low incidence of side effects. This study aimed at determining incidence, type and severity of postoperative complications related to epidural analgesia and catheter insertion. METHODS: Participated in this retrospective study 469 patients submitted to postoperative epidural analgesia in the period 10/18/99 to 10/18/01. Epidural analgesia was induced with 0.1% bupivacaine and fentanyl (1 to 5 µg.mL-1), at a 3 mL.h-1 rate. Infusion rate was adjusted according to patients' pain complaint. The following variables were evaluated: epidural infusion duration; incidence of side-effects and complications related to demographics, type of surgery and epidural catheter position; and quality of analgesia by means of a pain visual analog scale and a patients' satisfaction index. RESULTS: Epidural catheters remained in place 2.2 days in average, varying from 6 to 10 days. Global rate of technique-related complications was 46.3%, most of them minor complications without clinical repercussion. From these, 13.9% were directly related to the epidural catheter (disconnection, externalization, low back pain, inflammation and local infection). Other common complications were vomiting and urinary retention. Postoperative analgesia was effective in 97.2% of the patients which referred satisfaction with the technique. Patients without pain or slight pain during the first, second and third postoperative day represented 80.1%, 92.8% and 93.3%, respectively, of the studied population. CONCLUSIONS: Continuous epidural analgesia is effective and safe. Complications were not severe. However, strict vigilance is mandatory to achieve satisfactory analgesia and a low incidence of complications.

Keywords

ANALGESIA, ANESTHETIC TECHNIQUES, ANESTHETIC TECHNIQUES

References

Yeager MP, Glass DD, Neff RK. Epidural anesthesia and analgesia in high-risk surgical patients. Anesthesiology. 1987;66:729-736.

Shulman M, Sandler AN, Bradley JW. Postthoracotomy pain and pulmonary function following epidural and systemic morphine. Anesthesiology. 1984;61:569-575.

Guinard JP, Mavrocordatos P, Chiolero R. A randomized comparison of intravenous versus lumbar and thoracic epidural fentanyl for analgesia after thoracotomy. Anesthesiology. 1992;77:1108-1115.

Ballantyne JC, Carr DB, deFerranti S. The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analysis of randomised, controlled trials. Anesth Analg. 1998;86:598-612.

Beattie WS, Buckley DN, Forrest JB. Epidural morphine reduces the risk of postoperative myocardial ischaemia in patients with cardiac risk factors. Can J Anaesth. 1993;40:532-541.

Liu SS, Carpenter RL, Mackey DC. Effects of perioperative analgesic technique on rate of recovery after colon surgery. Anesthesiology. 1995;83:757-765.

Carli F, Mayo N, Klubien K. Epidural analgesia enhances functional exercise capacity and health-related quality of life after colonic surgery: results of a randomized trial. Anesthesiology. 2002;97:540-549.

Capdevila X, Barthelet Y, Biboulet P. Effects of perioperative analgesic technique on the surgical outcome and duration of rehabilitation after major knee surgery. Anesthesiology. 1999;91:8-15.

Carvalho WA, Lemônica L. Mecanismos centrais de transmissão e de modulação da dor: Atualização terapêutica. Rev Bras Anestesiol. 1998;48:221-241.

Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth. 1997;78:606-617.

Brodner G, Van Aken H, Hertle L. Multimodal perioperative management - combining thoracic epidural analgesia, forced mobilization, and oral nutrition - reduces hormonal and metabolic stress and improves convalescence after major urologic surgery. Anesth Analg. 2001;92:1594-1600.

Lutti MN, Simoni RF, Cangiani LM. Analgesia controlada pelo paciente com morfina ou fentanil no pós-operatório de reconstrução de ligamentos do joelho: Estudo comparativo. Rev Bras Anestesiol. 2000;50:8-13.

Liu S, Carpenter RL, Neal JM. Epidural anesthesia and analgesia: Their role in postoperative outcome. Anesthesiology. 1995;82:1474-1506.

Rodgers A, Walker N, Schug S. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomized trials. BMJ. 2000;321:1493.

Buggy DJ, Smith G. Epidural anaesthesia and analgesia: better outcome after major surgery? Growing evidence suggestes so.. BMJ. 1999;319:530-531.

Etches RC, Sandler AN, Daley MD. Respiratory depression and spinal opioids. Can J Anaesth. 1989;36:165-185.

Weightman WM. Respiratory arrest during epidural infusion of bupivacaine and fentanyl. Anaesth Intensive Care. 1991;19:282-284.

Wheatley RG, Schug SA, Watson D. Safety and efficacy of postoperative epidural analgesia. Br J Anaesth. 2001;87:47-61.

Tripathi M, Pandey M. Epidural catheter fixation: subcutaneous tunneling with a loop to prevent displacement. Anaesthesia. 2000;55:1113-1116.

Kehlet H, Holte K. Effect of postoperative analgesia on surgical outcome. Br J Anaesth. 2001;87:62-72.

Lutti Mn, Vieira JL, Eickhoff DR. Analgesia controlada pelo paciente com fentanil e sufentanil no pós-operatório de reconstrução de ligamentos do joelho: Estudo comparativo. Rev Bras Anestesiol. 2002;52:166-174.

Dahl JB, Rosenberg J, Hansen BL. Differential analgesic effects of low-dose epidural morphine and morphine-bupivacaine at rest and during mobilization after major abdominal surgery. Anesth Analg. 1992;74:362-365.

Rygnestad T, Borchgrevink PC, 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;41:868-876.

Rigg JR, Jamrozik K, Myles PS. Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial. The Lancet. 2002;359:1276-1282.

Sorenson RM, Pace NL. Anesthetic techniques during surgical repair of femoral neck fractures: A meta-analysis. Anesthesiology. 1992;77:1095-1104.

Boylan JF, Katz J, Kavanagh BP. Epidural bupivacaine-morphine analgesia versus patient-controlled analgesia following abdominal aortic surgery: analgesic, respiratory, and myocardial effects. Anesthesiology. 1998;89:585-593.

Mann C, Pouzeratte Y, Boccara G. Comparison of intravenous or epidural patient-controlled analgesia in the elderly after major abdominal surgery. Anesthesiology. 2000;92:433-441.

Correll DJ, Viscusi ER, Grunwald Z. Epidural analgesia compared with intravenous morphine patient-controlled analgesia: postoperative outcome measures after mastectomy with immediate TRAM flap breast reconstruction. Reg Anesth Pain Med. 2001;26:444-449.

Flisberg P, Tornebrandt K, Walther B. Pain relief after esophagectomy: Thoracic epidural analgesia is better than parenteral opioids. J Cardiothorac Vasc Anesth. 2001;15:282-287.

Crews JC, Hord AH, Denson DD. A comparison of the analgesic efficacy of 0.25% levobupivacaine combined with 0.005% morphine, 0.25% levobupivacaine alone, or 0. 005% morphine alone for the management of postoperative pain in patients undergoing major abdominal surgery. Anesth Analg. 1999;89:1504-1509.

Kampe S, Weigand C, Kaufmann J. Postoperative analgesia with no motor block by continuous epidural infusion of ropivacaine 0. 1% and sufentanil after total hip replacement. Anesth Analg. 1999;89:395-398.

Kopacz DJ, Sharrock NE, Allen HW. A comparison of levobupivacaine 0. 125%, fentanyl 4 µg/ml, or their combination for patient-controlled epidural analgesia after major orthopedic surgery. Anesth Analg. 1999;89:1497-1503.

Paech MJ, Westmore MD. Postoperative epidural fentanyl infusion: is the addition of 0. 1% bupivacaine of benefit?. Anaesth Intensive Care. 1994;22:9-14.

Scott DA, Blake D, Buckland M. A comparison of epidural ropivacaine infusion alone and in combination with 1, 2, and 4 µg/ml fentanyl for seventy-two hours of postoperative analgesia after major abdominal surgery. Anesth Analg. 1999;88:857-864.

Wiebalck A, Brodner G, Van Aken H. The effects of adding sufentanil to bupivacaine for postoperative patient-controlled epidural analgesia. Anesth Analg. 1997;85:124-129.

George KA, Chisakuta AM, Gamble JÁ. Thoracic peridural infusion for postoperative relief following abdominal aortic surgery: bupivacaine, fentanyl or a mixture of both?. Anaesthesia. 1992;47:388-394.

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;70:503-507.

Breivik H, Niemi G, Haugtomt H. Optimal epidural analgesia: importance of drug combinations and correct segmental site of injection. Baillière¢s Clin Anaesthesiol. 1995;9:493-512.

Cooper DW, Ryall DM, Mattardy FE. Patient-controlled extradural analgesia with bupivacaine, fentanyl, or a mixture of both after, Caesarean section. Br J Anaesth. 1996;76:611-615.

Cousins MJ, Mather LE. Intrathecal and epidural administration of opioids. Anesthesiology. 1984;61:276-310.

White MJ, Berghausen EJ, Dumont SW. Side effects during continuous epidural infusion of morphine and fentanyl. Can J Anaesth. 1992;39:576-582.

Lejus C, Roussière G, Testa S. Postoperative extradural analgesia in children: comparison of morphine with fentanyl. Br J Anaesth. 1994;72:156-159.

Polley LS, Columb MO, Naughton NU. Effect of intravenous versus epidural fentanyl on the minimun local analgesic concentration of epidural bupivacaine in labor. Anesthesiology. 2000;93:122-128.

D'Angelo R, Gerancher JC, Eisenach JC. Epidural fentanyl produces labor analgesia by a spinal mechanism. Anesthesiology. 1998;88:1519-1523.

Niemi G, Breivic H. Epidural fentanyl markedly improves thoracic epidural analgesia in a low-dose infusion of bupivacaine, adrenaline and fentanyl: A randomized, double-blind crossover study with and without fentanyl. Acta Anaesthesiol Scand. 2001;45:221-232.

Cohen S, Pantuck CB, Amar D. The primary action of epidural fentanyl after cesarean delivery is via a spinal mechanism. Anesth Analg. 2002;94:674-679.

Cohen S, Lowerwirt I, Pantuck CB. Bupivacaine 0. 01% and/or epinephrine 0.5 µg/ml improve epidural fentanyl analgesia after caesarean section. Anesthesiology. 1998;89:1354-1361.

Welchew EA. The optimum concentration for epidural fentanyl: A randomised, double-blind comparison with and without 1: 200,000 adrenaline. Anaesthesia. 1983;38:1037-1041.

Curatolo M, Schnider TW, Petersen-Felix S et al. A direct search procedure to optimize combinations of epidural bupivacaine, fentanyl, and clonidine for postoperative analgesia. Anesthesiology. 2000;92:325-337.

Baron CM, Kowalski SE, Greengrass R. Epinephrine decreases postoperative requirements for continuous thoracic epidural fentanyl infusions. Anesth Analg. 1996;82:760-765.

Niemi G, Breivik H. Epinephrine markedly improves thoracic epidural analgesia produced by a small-dose infusion of ropivacaine, fentanyl, and epinephrine after major thoracic and abdominal surgery: a randomized, double-blinded crossover study with and without epinephrine. Anesth Analg. 2002;94:1598-1605.

Sawchuk CW, Ong B, Unruh HW. Thoracic versus lumbar epidural fentanyl for postothoracotomy pain. Ann Thorac Surg. 1993;55:1472-1476.

Scott DA, Beilby DS, McClymont C. Postoperative analgesia using epidural infusions of fentanyl with bupivacaine: A prospective analysis of 1, 014 patients. Anesthesiology. 1995;83:727-737.

Liu SS, Allen HW, Olsson GL. Patient-controlled epidural analgesia with bupivacaine and fentanyl on hospital wards: prospective experience with 1,030 surgical patients. Anesthesiology. 1998;88:688-695.

Gedney JA, Liu HC. Side effects of epidural infusions of opioid bupivacaine mixtures. Anaesthesia. 1998;53:1148-1155.

Burstal R, Wegener F, Hayes C. Epidural Analgesia: Prospective audit of 1062 patients. Anaesth Intensive Care. 1998;26:165-172.

Dolin SJ, Cashman JN, Bland JM. Effectiveness of acute postoperative pain management: I. Evidence from published data. Br J Anaesth. 2002;89:409-423.

Zimmermann DL, Stewart J. Postoperative pain management and acute pain service activity in Canada. Can J Anaesth. 1993;40:568-575.

Gustafsson LL, Schildt B, Jacobsen K. Adverse effects of extradural and intrathecal opiates: report of a nationwide survey in Sweden. Br J Anaesth. 1982;54:479-486.

Ready LB, Loper KA, Nessly M. Postoperative epidural morphine is safe on surgical wards. Anesthesiology. 1991;75:452-456.

Fuller JG, McMorland GH, Douglas MJ. Epidural morphine for analgesia after caesarean section: a report of 4880 patients. Can J Anaesth. 1990;37:636-640.

Leith S, Wheatley RG, Jackson IJ. Extradural infusion analgesia for postoperative pain relief. Br J Anaesth. 1994;73:552-558.

McLeod G, Davies H, Munnoch N. Postoperative pain relief using thoracic epidural analgesia: outstanding success and disappointing failures. Anaesthesia. 2001;56:75-81.

de Leon-Casasola OA, Parker B, Lema MJ. Postoperative epidural bupivacaine-morphine therapy: Experience with 4227 surgical cancer patients. Anesthesiology. 1994;81:368-375.

Schug SA, Fry RA. Continuous regional analgesia in comparison with intravenous opioid administration for routine postoperative pain control. Anaesthesia. 1994;49:528-532.

Hamilton CL, Riley ET, Cohen SE. Changes in position of epidural catheters associated with patient movement. Anesthesiology. 1997;86:778-784.

Hamza J, Smida M, Benhamou D. Parturient's posture during epidural puncture affects the distance from skin to epidural space. J Clin Anaesth. 1995;7:1-4.

Darchy B, Forceville X, Bavoux E. Clinical and bacteriologic survey of epidural analgesia in patients in the intensive care unit. Anesthesiology. 1996;85:988-998.

Holt HM, Andersen SS, Andersen O. Infections following epidural catheterization. J Hosp Infect. 1995;30:253-260.

Brooks K, Pasero C, Hubbard L. The risk of infection associated with epidural analgesia. Infect Control Hosp Epidemiol. 1995;16:725-728.

Kindler CH, Seeberger MD, Staender SE. Epidural abscess complicating epidural anesthesia and analgesia: An analysis of the literature. Acta Anaesthesiol Scand. 1998;42:614-620.

Dawson SJ. Epidural catheters infections. J Hosp Infect. 2001;47:3-8.

Bengtsson M, Nettelblad H, Sjoberg F. Extradural catheter-related infections in patients with infected cutaneous wounds. Br J Anaesth. 1997;79:668-670.

Simpson RS, Macintyre PE, Shaw D. Epidural catheter tip cultures: Results of a 4-year audit and implications for clinical practice. Reg Anesth Pain Med. 2000;25:360-367.

Kinirons B, Mimoz O, Lafendi L. Chlorhexidine versus povidone iodine in preventing colonization of continuous epidural catheters in children: a randomized, controlled trial. Anesthesiology. 2001;94:239-244.

Bevacqua BK, Slucky AV, Cleary WF. Is postoperative intrathecal catheter use associated with central nervous system infection?. Anesthesiology. 1994;80:1234-1240.

Kee WD, Jones MR, Thomas P. Extradural abscess complicating extradural anaesthesia for caesarean section. Br J Anaesth. 1992;69:647-652.

Hunt JR, Rigor BM, Collins JR. The potential for contamination of continuous epidural catheters. Anesth Analg. 1977;56:222-225.

Du Pen SL, Peterson DG, Williams A. Infection during chronic epidural catheterization: diagnosis and treatment. Anesthesiology. 1990;73:905-909.

De Cicco M, Matovic M, Castellani GT. Time-dependent efficacy of bacterial filters and infection risk in long-term epidural catheterization. Anesthesiology. 1995;82:765-771.

Shapiro JM, Bond EL, Garman JK. Use of a chlorhexidine dressing to reduce microbial colonization of epidural catheters. Anesthesiology. 1990;73:625-631.

Mather CM, Anaes FC, Ready LB. Inflammatory cutaneous reactions to epidural catheters. Anesthesiology. 1993;78:200-203.

Wigfull J, Welchew E. Survey of 1057 patients receiving postoperative patient-controlled epidural analgesia. Anaesthesia. 2001;56:70-75.

Andersen G, Rasmussen H, Rosenstock C. Postoperative pain control by epidural analgesia after transabdominal surgery: Efficacy and problems encountered in daily routine. Acta Anaesthesiol Scand. 2000;44:296-301.

Silvasti M, Pitkänen M. Patient-controlled epidural analgesia versus continuous epidural analgesia after total knee arthroplasty. Acta Anaesthesiol Scand. 2001;45:471-476.

Jylli L, Lundeberg S, Olsson GL. Retrospective evaluation of continuous epidural infusion for postoperative pain in children. Acta Anaesthesiol Scand. 2002;46:654-659.

Lejus C, Surbled M, Schwoerer D. Postoperative epidural analgesia with bupivacaine and fentanyl: hourly pain assessment in 348 paediatric cases. Paed Anaesth. 2001;11:327-332.

Quality improvement guidelines for the treatment of acute pain and cancer pain: American Pain Society of Care Committee. JAMA. 1995;274:1874-1880.

Bardiau FM, Taviaux NF, Albert A. An intervention study to enhance postoperative pain management. Anesth Analg. 2003;96:179-185.

Valverde Filho J, Ruiz-Neto PP, Freire RCMC. Análise descritiva de serviço de dor aguda pós-operatória em hospital terciário. Rev Bras Anestesiol. 2000;50:386-90.

Smitt PS, Tsafka A, Teng van de Zande F. Outcome and complications of epidural analgesia in patients with chronic cancer pain. Cancer. 1998;83:2015-2022.

Stenseth R, Sellevold O, Breivik H. Epidural morphine for postoperative pain: experience with 1085 patients. Acta Anaesthesiol Scand. 1985;29:148-156.

5dd7e7970e8825536c13f286 rba Articles
Links & Downloads

Braz J Anesthesiol

Share this page
Page Sections