Does analgesia cause surgical complications

Posted 12 years ago

Can postoperative pain control cause surgical complications?

Can epidural analgesia cause postoperative surgical complications? I wasn’t aware of any evidence...until recently.

We are currently in the process of analysing data from the LACE trial. This is a trial comparing open with laparoscopic hysterectomy for early endometrial cancer. We used data only from patients who had a vertical midline incision and compared outcomes of patients who had an epidural versus who did not have an epidural. While the data set is not randomised it was very well balanced.

In summary, we found that patients who had an epidural had a significantly higher rate of postoperative surgical complications, blood loss, and longer hospital stay.

When I discussed these issues with my colleagues, some were concerned about the use of epidural anaesthesia without inotropes (which requires transfer to an ICU or at least intermediate care facility). They certainly shared my concerns about epidural and surgical wound healing, especially in case of bowel and other anastomoses.

Recently, I looked after a patient with advanced ovarian cancer recently. She had neoadjuvant chemotherapy and a great response. I took her to theatre for interval surgical cytoreduction. Her macroscopic residual tumour was zero. I was very happy with our decision making so far. My anaesthetist put up an epidural for her postoperative pain control.

A few hours postoperatively, I was called by nursing staff because her systolic blood pressure was reaching a maximum of 80 mmHg. I saw her and she looked great. Heart rate and full blood count fine. No pain, fully breathing, tolerating a diet already. Could not be better, I thought. After I got called a number of times, we turned down the epidural (after discussing with my anaesthetist) but pain set in and finally we decided to remove the epidural after 2 days and gave her a PCA instead. She dropped her PO2 sats, developed atelectasis, had chest physio at least twice daily (even on weekend), etc.

On day 7 after her procedure she burst her abdomen. I took her back to the operating theatre late Friday night, fixed it. Avoided a mesh due to concerns about infection, which she developed (subcutaneous) on day 3; I gave her a negative wound pressure dressing. After 2 weeks in hospital on the VAC dressing she got transferred closer to home where her gynaecologists very kindly babysat her until she could be discharged from hospital after another 4 weeks. The VAC dressing is still on. Chemotherapy had to be delayed because of wound concerns.

We live in times when quality control in surgery is becoming critical. We attend clinical case reviews, take part in morbidity and mortality meetings; we focus on learning through reflection (surgicalperformance.com). We do all this because we realise that we already provide great care but may cause significant collateral damage when we treat patients with the best of intentions.

The findings about epidural analgesia are novel, preliminary and will need to be validated by other surgical groups before we can consider it definitive. While the study was not randomised, it is based on a large number of patients, prospective data collection and a systematic capture of surgical adverse events.

At one of the hospitals I work, the pain team manages postoperative analgesia. Essentially, it works totally independent of the surgical team. They do their own rounds, draw up pain plans and chart analgesia. It may have developed that way because surgeons are apparently hopeless in charting medication.

The implication of that finding is that anaesthetists and surgeons will need to collaborate very closely, need to communicate like equal partners to minimise harm when looking after patients. Epidural might be useful in some patients but not in the best interest of all patients.

In the light of the recent findings, we surgeons should probably upskill, and request that the type of postoperative analgesia will be discussed with us. Until the above data are proven wrong, there is a possibility that the way anaesthetists control analgesia could impact on the incidence of "surgeons" complication rate.

Next week, we will hear about the anaesthetic point of view on epidurals. I look forward to it. If you don’t want to miss it, please register here.