1 1. TITLE PAGE
LITHUANIAN UNIVERSITY OF HEALTH SCIENCE DEPARTMENT OF GENERAL SURGERY
MONIKA BLAZEWICZ FACULTY OF MEDICINE VI
GROUP 32
PATIENT STATUS AFTER RADICAL PROSTATECTOMIA ASSESSING VARIOUS METHODS OF ANASTHESIA.
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2. TABLE OF CONTENTS
1. TITLE PAGE ... 1 2. TABLE OF CONTENTS ... 2 3. SUMMARY ... 3 4. SANTRAUKA ... 4 5. ACKNOWLEDGMENTS ... 56. CLEARANCE ISSUED BY THE ETHICS COMMITTEE ... 6
7. ABBREVIATIONS AND TERMS ... 7
8. INRODUCTION ... 7
9. AIMS AND OBJECTIVES ... 8
10. LITERATURE REVIEW ... 10
11. METHODOLOGY AND METHODS ... 14
12. RESULTS AND DISCUSSION ... 15
13. CONCLUSSIONS ... 22
14. REFERENCES ... 23
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3. SUMMARY
Key words: radical prostatectomy; epidural analgesia; parenteral analgesia.
Radical prostatectomy is presently most often chosen option for prostate cancer treatment. Study of complications after the surgery is important to evaluate morbidity. As well as anesthetic choice evaluation to improve patient status after major procedure.
Purpose of this study was to establish patient status after radical prostatectomy assessing different methods of anesthesia. Aiming analysis of validity of PEA after radical prostatectomy we compared EA with pain status after surgery with other anesthesia methods during the procedure. To obtain significant results we analyzed differences in patient status after radical prostatectomy with EA, GA, SA, assessed analgesia requirements after surgery in each of the anesthetic groups, assessed PEA course, postoperative pain level and additional analgesia requirements. Data for assessment collected from archives that included: age, operation risk, hours in ICU, hours in operating room, anesthesia duration after operation, analgetics, additional analgetics, pain level, hospitalization duration, first analgetic injection time. Examination of values from inpatients was done by retrospective study in number of patients was 33 placed into 3 groups: EA group (n=10), SA group (n=12) and GA group (n=11). Analyzing patient’s status after radical prostatectomy we compared operating room stay of each group which revealed longest time in operation room stay in GA group (3.47) and shortest in SA group (2.06). Relationship between hours spent in ICU and time of operating room stay showed that highest rates in ICU time along with OR time was found in GA group (ICU time-7.70) and lowest value were in SA group (ICU time-5.21). There was no significance found on ICU hours and hospitalization time. Pain level in EA group of patients after injection of epidural analgesia was significantly lower although still almost all the patients needed parenteral analgetic injections. EA group requirements for parenteral analgesia are the lowest of all groups and shows expressive difference to GA. There is significant decline in ketaprofen requirement. The greatest amount of average number of parenteral injection in EA was on second day after operation (0.8). GA needed biggest amount of analgetic injections straight after operation (1.7) and epidural additional analgesia had the least requirements of extra analgesia (0.6 after operation). In SA group amount of injections requirements are the largest in the second day (1.4). Pain level was established before (4.30) and after (1.60) epidural analgesia injection.
Results lead to conclussions that epidural analgesia not shortens time of hospitalization and might increase hospital costs due to prolonged stay in ICU. Analgetics requierements are the smallest in EA
4 but there is need of taking additional analgesia. Postoperative pain level is significantly improved after analgesia injection but results achieved are summed with help of parenteral analgesia. Overall SA may be best way for radical prostatectomy, because requires less medication (no PEA) and efforts for pain relief after surgery.
4. SANTRAUKA
Raktažodžiai: radikali prostektomija; parenteraliniu analgetikai; epidurinė analgetikai.
Radikali prostektomija šiuo metu yra dažniausiai pasirenkamas prostatos vėžio gydymo metodas. Operacija yra sunki ir traumatiška, todėl perioperacnio laikotarpio analizė gali padėti pasirenkant optimalią gydymo taktika.
Šiuo tyrimo tikslas- įvertinti ar skirtingi intraoperacines anestezijos ir pooperacinės analgezijos metodai gali įtakoti paciento būklę po operacijos. Retrospektiviam vertinimui buvo pasirinkti 33 pacientai, panašus pagal amžių ir gretutinę patologiją, su tokios pačią diagnozę, chirurgiją, bet skirtingomis anestezijos ir pooperacines analgezijos metodikomis. Pacientus suskirstėme į 3 grupes: epidurinės anestezijos (EA grupė n = 10), spinalinės (SA, n = 12) ir bendrinės (GA, n = 11).
Liginome anestezijos ir pooperacines analgezijos eigą, skausmą ir nuskausminimo eigą po operacijos, vaistų panaudojimą, ankstyvą pooperacinį laikotarpį intensyvios terapijos palatoje(ICU), komplikacijas ir hospitalizacijos trukmę.
Analizė paruodė, kad ilgiausiai operuoti GA grupes pacientai daugiau laiko išbuvo ICU, tačiau ligoninėje praleido mažiau laiko. SA grupes pacientams stebėtas priešingas vaizdas. Statistiškai reikšmingo ryšio tarp intensyvios terapijos skyriuje praleisto laiko ir hospitalizacijos trukmės neaptikta. EA grupės pacientams stebėtas mažiausias skausmo lygis, beveik visiems pacientams reikėjo papildomų analgetiko injekcijų. Didžiausias skausmingumas ir parenterinių analgetiku dozė SA ir EA grupėse buvo antra para po operacijos. GA grupėje skausmingumas ir parenterinių analgetiku dozė buvo pirmą para.
Epidurinė analgezija sumažindavo skausmą vidutiniškai 2,5 karto (4.30 ir 1.60 balo pagal VAS), tačiau papildomų analgetikų poreikis vis tiek išlieka. Stacionarizavimo laikas buvo mažiausias GA grupeje.
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5. ACKNOWLEDGMENTS
I would like to state my sencere gratitude to my supervison Dr. Edvardas Daugela for patience and support as well as motivation and knowledge. He helped me throughout the process of writing my thesis and gave guidance when needed.
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6. CLEARANCE ISSUED BY THE ETHICS COMMITTEE
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7. ABBREVIATIONS AND TERMS
Abbreviations:
PSA (prostate specific antigen), ICU (intensive care unit), EA (epidural anesthesia), PEA (postoperative epidural analgesia), GA (general anesthesia), SA (spinal anesthesia), RRP (radical retropubic prostatectomy), RPP (radical perineal prostatectomy), GA-EA (combined general and epidural anesthesia), CSE (combined spinal and epidural anesthesia), IV-PCA (intravenous patient controlled anesthesia), ASA (physical status classification system), COX-2 (cyclo-oxygenase -2 inhibitors), NSAIDs (non-steroidal anti-inflammatory drugs), PCEA (patient controlled epidural anesthesia), OR (operating room).
Terms:
Prostate cancer, PSA (prostatę specific antigen), epidural anesthesia, general anesthesia, regional anesthesia, spinal anesthesia postoperative analgesia.
8. INRODUCTION
Radical prostatectomy increased in effectiveness and decreased in morbidity over the years as a result of progressing surgical techniques and advancing knowledge of surgical anatomy. For localized prostate cancer patients this procedure is best way of treatment. For patients younger than 65 years old with localized disease results after radical prostatectomy are better than any other treatment for prostate cancer (1). Men that age is above 65 years old and chose surgery as a course of treatment had the same results as men that chose other treatments. As a second most common cancer among men detecting in early stage of disease is crucial for a positive outcome. Most common prostate cancer that is diagnosed is adenocarcinoma. Due to PSA testing (prostate-specific antigen) detection of malignancy is possible in earlier age and stage of disease therefore radical prostatectomy gives advantage for these possibly curable lesions. Patient status after radical prostatectomy we can estimate observing patients: any postoperative complication, temperature persistence, pain level, main and additional analgesia and
8 length of hospital stay. Beside all complication possibilities and other comorbidities that patient may have, data obtained during hospitalization allows to reveal some specific information and its validity of each anesthesia method that have been used during radical prosthatectomy.
Selecting one from various anesthesia methods depends on patient’s condition, operation risk, type of surgery, and real clinical experience in hospital. Anesthesia methods influence patients comfort after surgery, recovery time and general treatment price. But looking at one procedure, similar in case of patient’s age group, disease and type of surgery can bring results leading to estimation of validity of specific anesthesia methods.
Epidural anesthesia for major surgery is used because of variety of reasons. Primarily for surgical anesthesia as a sole technique, in addition to general anesthesia and as strong postoperative pain relief. EA and PEA aiming in pain control and patient overall satisfaction, but also improve patients condition in case of perioperative stress responces which could influence outcome and possibility of complications. As epidural anesthesia influence outcome of surgery in postoperative morbidity and neccesity of hostpital stay duration, our goal is to establish validity of EA with PEA after radical prostatectomy in comparison to patients with other anesthetic methods.
We evaluated patients from general surgery department throughout their hospitalization by retrospective study. Research included n=33 patients with a similar age, ASA status and cancer stage to get better understanding of analgetics requirements after radical prostatectomy, focusing on postoperative epidural anesthesia effectiveness.
9. AIMS AND OBJECTIVES
Direction of the study and problems analyzed:
Throughout the years anesthetic methods were studied and compared according to importnace for patient outcome. Postoperative analgesia in comparison of anasthetic methods focusing on epidural analgesia validity after radical prosthatectomy was not so often examined. Number of studies show advantage of epidural analgesia after main surgeries, which reveal decreased
9 demands for aditional analgesia and improved management of postoperative pain which influence patients recovery and hospital stay therefore costs of care (2).
Research process and research instruments:
Process of the study and instruments were established upon patient’s case histories and their medical requirements during and after operation: anesthesia method and duration, EA course, analgetic demands and use after surgery, complication and other medication after radical prostatectomy. From patients history we gathered information involved age, ASA, postoperative complication, pain level and medication after surgery, medication and additional analgesia in EA group, hospitalization time.
Systematic review based on collected data found in case histories we gathered was made analysis of postoperative EA data compared with other postoperative anesthetic methods for functional outcome for patients undergoing radical prostatectomy in urology department.
Aim of the thesis:
Aim of this research is to analyze validity of PEA after radical prostatectomy with EA compared with EA compared with pain status after radical prostatectomy with other anesthesia methods during surgery, if all patient have similar age, ASA and surgery. This may help to establish best possible analgesia way after surgery.
Objectives of the thesis:
1. To analyze differences in patients status after radical prostatectomy with EA, GA and SA. 2. To assess analgesia requirements after surgery in each of the anesthetic groups.
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10. LITERATURE REVIEW
Radical prostatectomy is aimed to remove localized prostate cancer. During the operation prostate gland and surrounding tissues which includes seminal vesicles and some nearby lymph nodes are removed. We can distinguish two ways of open radical prostatectomy: radical retropubic prostatectomy (RRP) and radical perineal prostatectomy (RPP). Retropubic aproach starts with lower midline incision and with perineal inverted – U incision is made in perineum. RRP allows to perform pelvic lymph nodes examination and dissection which is impossible because of site of incision in RPP. Less blood loss and trauma to the patient as well as shorter recovery time ar results in perineal approach but it’s harder with nerve preservation around the prostate.
Several of anesthetic procedures can be used in radical prostatectomy surgery: general anasthesia, regional anesthesia or combined anesthesia of two techniques. To determine what kind of anesthesia is going to be performed numbers of factors have to be taken into consideration. General anesthesia (GA) allows for good control of airway breathing and circulation, is convinient for patient and used in long lasting procedures. Combined anesthesia can help to decrease GA depth, useful for analgesia after surgery, reduce of general analgetics dose. Spinal anesthesia brings immediate anesthesia and effective anesthesia, amount of drug needed is very small (3). SA opioids have strong analgetic effect till 24 hours after surgery. Epidural anesthesia allows for continues postoperative analgesia.
Numerous studies were initiated about prostatectomy surgery and anasthetic influence on outcome of the procedure and analgesia after surgery (4–11). In Vilnius University, Institute of Oncology in Lithuania Renata Tikuisis studied differences between epidural and general anestesia versus general anesthesia influence on blood loss during radical prostatectomy (4). In each of two groups were chosen 27 patients, study group got epidural/general anesthesia with 0.5% solution of bupivacaine and maintained by suvoflurane. Control group got general anesthesia with endotracheal ventilation from sevoflurane and intravenous fentanyl. Results revealed changes in intraoperative blood pressure, which was higher in control group, time in surgery slightly shorter in study group and significant changes in intraoperative blood loss much lower in study group with results more need for transfusion in control group. This study definitely showed positive outcome of epidural anesthesia in addition to general in case of reduction in mean arterial pressure that has an influence on intraoperative blood loss.
11 Question of influence on surgical outcome of epidural anesthesia and anlgesia studied Department of Anasthesia and Surgery in Kaunas Medcial University Hospital (12). Doctor Rimaitis was checking surgical complications and outcome together with postoperative course after colorectal cancer surgery. During one year prospective, randomised clinical study 100 patients were divided into two groups: general anesthesia followed with opioid analgesia after operation (GA group), epidural-general anesthesia, continues with epidural anesthesia (GA-EA group). Beneficial results of this research once again were showed for GA-EA group for major surgery like small reduce in throbotic events and pulmonary complications but was unsignificant on patient’s outcome.
Following statement about effectiveness of epidural anesthesia for colorectal cancer surgery Vilnius University Oncology Clinic decided to check correlation of administrating epidural anesthesia prior and at the end of the surgery (13). Group that got epidural anesthesia before operation needed less anesthetics during the operation and experienced less pain in first 6 hours after operation, they also needed smaller amount of aditional analgesic infusions after operation. Therefore conclusion shows that if epidural anesthesia is used for major surgery it’s much more effective to use it preoperatively.
Interesting study of Continous Postoperative Epidural analgesia for all patients was made in 2007 in Lithuania, Kaunas University of Medicine in Anesthesiology Clinic (14). Study revealed pain intensity at rest and motion (80% of patients didnt experience any pain after surgery), epidural block intensity, additional alagetics requirements (only 30% of patient’s reqired additional analgesics), treatment duration and side effects (hypotension and bradycardia in 6%). Results of this very general study are positive for effectiveness and safety on postoperative analgesia.
Another comparison of epidural and general anesthesia in patients that went through radical prostatectomy were publications both from Johns Hopkins University School of Medicine, Baltimore, Maryland (5,6). Checking intraoperative anasthetic approach and postoperative complication in a first research schowed no specific findings. In the second one postoperative demands on analgesia was observed and in epidural anasthesia these demands were decreased.
Pain management after radical prostatectomy is investigated in several other studies (7–10) brought mostly advantages of epidural analgesia after radical prostatectomy, one study brought interesting and totally different view (10). University of Melbourne, Department of Surgery concluded that epidural analgesia prolonged lenght of hospitalization and revealed technical problems connected with epidural. In addition to that results men receiving an epidural anasthesia showed an increased recurrence of
12 prostate specific antigen therefore for this procedure epidural anasthesia and analgesia wasnt recommended.
Large patient population investigation was done to compare combined general and epidural anasthesia with combined spinal and epidural anasthesia to estimate patient safety (11). Analyzed group of 1207 patients who underwent radical retropubic prostatectomy in period of 2008-2011 was didvided to combined spinal epidural anasthesia (CSE) of total 698 patients and 509 patients with combined general and epidural anesthesia (INT/PDA). CSE caused respectively to anesthesia time, shorter surgical length and length of hospitalization and recovery. This retrospective study revealed positive outcome for combined spinal and epidural anasthesia considering patients quality of care and safety.
Another combined anasthesia study was made by doctor Stamencovic (15) that compared effectiveness of CSE analgesia to epidural analgesia (EA). Group of 160 patients undergoing major abdominal surgery were divided into four groups. Subarachnoid morphine, bupivacaine and fentanyl (MBF group), fentanyl and epidural bupivacaine (MB group), morphine (M group), and normal saline (i/v) (EA group). Research was recording pain at rest, movement, with cough, additional analgesia requests, and postoperative side effects. This study also showed positive outcome for combination of spinal- epidural analgesia as improvement of intra-operative analgesia but as well decreased pain with movement and cough posteoperatively.
Pain management after major surgery is the matter of patient’s satisfaction, fast recovery, surgery outcome and hospitalization costs. Numer of researchers tried to find answers for the best possible postoperative care. (16–18)
Publication of population based study was made by Kenneth C. Cummings compared survival and recurence after gastric cancer resection (18). Possible decrease of exposure to immunosuppressive factor by choosing epidural anesthesia havent shown distinctive outcome. There were no differnce found in researched groups therefore recurrence of gastric cancer was found not to be associated with anasthesia choice.
Postoperative pain control was studied Rosewell Park Center Institute where surgical cancer patients were studied after uncomplicated surgeries (17). Patients divided into two groups of epidural analgesia (EA group) and intravenous patient- controlled analgesia (IV-PCA) which they received postoperatively. Intensive care untis stay and hospitalization was studied and results showed decreased time in epidural analgesia. Both analgesia came out to be satisfactory for postoperative pain management but faster recovery was seen in epidural analgesia group.
13 Patient satisfaction and hospital stay, that helps with proper and profitable use of hospital resources is very important and should be considered when choosing type of anesthesia (2). Reserach that compared epidural anesthesia with general anesthesia in patients that underwent minimally invasie direct coronary artery bypass (MIDCAB) surgery studied these data in prospective and randomised study. Group of 42 patients were given general anasthesia (GA group) and 34 patients received epidural anasthesia (EA group). Less ICU time and hospital stay was discovered in EA group as well as less postoperative pain and blood loss. Long term results as well as patients satisfaction was insignificant. Therefore study shows that efficient use of hospital resources may would be choice of epidural anesthesia.
Efficacy and safety of postoperative pain management is still not well established as 30-80% of patients after surgery suffers from moderate to severe pain (19). Which approach would be the most efficient and satisfactory for the patient have been researched in numer o publications (19–26).
Multimodal analgesia after major surgery is the approach that contain combination of non-opioid analgesic drugs and opioid that has a purpose of reducing nee of opioid use therefore minimizing opioid side effects. In systematic review of paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs) and cyclo-oxygenase 2 inhibitors (COX-2) were studied to establish effectiveness of decreasing opioid use related side effects after surgery (20). NSAIDs use showed decrease in nause and vomiting but revealed bleeding related with surgery cases. There were no significant difference between paracetamol, NSAIDs and COX-2 in reduction of morphine consumption which was observed in 24 hours in all groups. Paracetamol was found to be slightly less effective in decreasing morphine consumption.
Further analysis of pain relief effectiveness proves that patient-controlled epidural analgesia (PCEA) and iv patient-controlled analgesia (IV-PCA) is more sufficient than opioid treatment given on demand (19). Database analysis of prospective collected data shows 18925 patients examined posteoperatively from 1998 till 2006. There were four groups of patients: PCEA, continous brachial plexus block, continous femoral/sciatic nerve block and IV-PCA. All proceedings turned out to be effective and considered safe for the patient. The least effective pain relief turned out to be IVPCA.
Interesting study was made in Mexican social Security institute where management of pain after major surgery was analyzed in sphere of costs of a drug and its effectiveness (21). Ketarolac, Parecoxib and Morphine was introduced after gynecologic laparotomy surgery. Costs of parecoxib and ketarolac were smaller than morphine and parecoxib compared to ketarolac was reasonably higher. Research then shows that parecoxib is effective in postoperative pain and is good alternative for ketarolac when contraindicated.
14 Considering major surgery and its postoperative analgesia systemic review of randomised trials was done by Marieke Nauta to compare opioid – codeine with acetaminophen (A+C) versus NSAIDs effectiveness after laparotomy and precisely cesarean delivery. From all nine studies that was examined revealed no difference in pain relief after treamtement with A+C comparing to NSAIDs. Less side effects of drugs were observed in NSAIDs group in some studies.
Even though there are many studies about radical prostatectomy anesthesia choice and postoperative analgesia, there are still a lot of inconclussives. There are less intraoperative complications and with general anesthesia combined with epidural anesthesia when compared with general anesthesia (4,12). Examining postoperative epidural analgesia itself there are decrease in pain in rest and motion, as well as decreased additional analgetics requirements (14). As one study shows prolonged stay in hospital due to technical problems with epidural (10) others state that epidural analgesia actually shortens hospitalization days (11) and faster recovery and patients satisfaction and safety (2). In Lithuania there were several researches made about epidural anesthesia during and epidural analgesia after radical prostatectomy but there was no study that would include three different anesthesia methods in similar age and operation risk with estimating validity of epidural analgesia.
Research that would reveal more information about postoperative pain and clarify weather epidural analgesia is needed and beneficial after radical prostatectomy operation would be interesting.
Large number of researchers were showing different evaluation of results from studying postoperative analgesia and methods of anesthesia in major surgeries. Aiming to find more specific results of which analgetics should be given after operation to minimize adverse effects and maximize good postoperative status of the patient. EA has impact on postoperative complications such as decreasing in throbotic events number and pulmonary complications (12), also reduce intraoperative blood loss and mean arterial pressure (4). Moreover EA is significant in duration of intensive care unit stay and hospitalization (17). Main need for PEA is due to strongest analgesic effect. Comparable in pain level after the same surgery to EA is SA and both feel significantly better than patients for whom GA was used (27).
11. METHODOLOGY AND METHODS
Research planning: We collect data from patient history from archives of General Surgery department with information’s including: age, ASA, surgery anesthesia type, analgesia demand and duration after
15 operation, analgetics use, analgetics types, additional analgetics use, pain level, ICU and general hospitalization duration.
Object of study: In the study we tried to establish analgesia course and validity after radical prostatectomy for patients with same pathology, surgery, GA, SA and EA during surgery in Kaunas Clinical Hospital urology department. The study was done to find out if PEA is a beneficial choice of treatment of postoperative pain and assessment whether outcome is better than nonepidural analgesia. Research methods and methods of data analysis:
Examination of values from inpatients of Kaunas Clinical Hospital urology department was done by retrospective study in which of whole patients number 33. Patients were placed into 3 groups depending on anasthesia method during uncomplicated radical prostatectomy. First group was epidural anesthesia (EA group) in (n=10), second contained patients after spinal anesthesia (SA group) in (n=12), last evaluated group was general anesthesia (GA group) having (n=11) patients. We evaluated anasthesia duration and focused on analgesia after operation, its first analgetic injection, overall pain relief duration and its requirements. Also in EA group we focused on pain level changes and its change during PEA.
12. RESULTS AND DISCUSSION
Information collected from 33 patients. Youngest patient was 41 years old and the oldest was 78 years old, average age was 63 years.
To analyze differences in patient’s status after radical prostatecomy we focused on collecting data of patient status after surgery like pain level after surgery, various postoperative complication and analgetic and other medication use. Also we check surgery duration of operating room, anesthesia kind during surgery, hospitalization length and time spent in ICU.
Surgery duration certainly can affect patient’s status after surgery.
16 Figure 1 Duration of OR stay (in hours)
Although, the anesthesia type selection criteria are not known, surgery time in SA and EA is group significantly lower than in GA, it could affect patient’s condition after surgery (Fig.1.)
Table 1 Relationship between age, ICU hours and hours in OR (average)
Even though patients in SA group have the biggest average age recovery after surgery, which indicate ICU stay, is shortest of all groups. Recovery in GA group after surgery takes the longest time. Shorter treatment in ICU is logically consistent with a shorter surgery time, and opposite (Fig.2). Mean ASA is very similar in all groups and possibly had no effect on post-operative patien’s condition (Tab.1).
17 Figure 2 Relationship between OR stay and hours in ICU
Another graph shows information about duration in average of ICU hours and days spent in hospital.
Figure 3: Average duration of ICU hours and hospitalization days
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Pain and analgetic relief requirements after surgery:
Main motivation to choose EA for surgery is possibility to make PEA. It always has stronger analgetic effect than parenteral opioid. All patients in EA group for PEA received epidurally 2mg of morphine with 10ml 0,125 percent local anesthetic- bupivacaine twice a day. PEA theoretically should be enough for all pain relief after surgery and no additional analgesia would be needed. Although in our study we discovered that not only GA and SA group need analgesia but EA as well.
SA features during and after surgery: is always fast, effective, and has low cost. For spinal injection in all cases was used 0,5 percent bipivacaine 12,5-17,5mg (depend of patients anthropometric), fentanil 50mkg and morphine 300mkg. Main advantage of SA with morphine is that it provides strong analgetic effect for long time- from 16 up to 24 hours. Therefore, in SA group patient doesn’t need additional analgesia in first day after surgery.
Without EA or SA patients needs another method of postoperative analgesia - paraenteral (i/v or i/m) analgetics. GA effect stops after surgery therefore patient require parenteral analgesia.
Analgesia requirements in all groups is compared with total number of paraenteral analgetic injections. For making general analgesia ketaprofen is used usually 100mg/3x/day. We analyze analgetics first admission time, use and dosage in GA, EA and SA groups.
19 In this graph we analize how many parenteral analgetic injections need patient after surgery in various groups.
Figure 4: Real Ketaprofen use in SA, GA and EA groups' average
EA group (all patient with PEA) requirements for parenteral analgesia are the lowest of all groups and shows expressive difference to GA. There is significant decline in ketaprofen requirement (Fig.4.). Parenteral analgetic requirement on second day after surgery in SA group slightly increased, but remains less than in GA group.
Less parenteral analgetic’s demand means less pain after surgery.
In EA group for PEA all patient received two doses of morphine 2 mg with 10ml of 0.125% Bupivacaine. Epidural analgesia duration after operation in all patients has average of 3 days. Parenteral analgesia was given from two to four days as ketonal injections. Most of first injections of ketonal were administered during the day of operation usually at noon.
20 Table 2: Pain level in average before and after first PEA injection
VAS pain level in EA group before and 15-20min. after epidural injection on average 4.3 and after 1.6
score’s. This effect is reachable only due to additional analgetics (Tab.2.)
Graph below shows average number of analgetic injections in EA group.
Figure 5 : Average number of injections in EA
Pain level (VAS score) in EA group after injection of epidural analgesia was significantly lower, but data show that almost all patients during PEA needed additional parenteral analgetic injections. Researched data shows that epidural analgesia is not insufficient alone for pain management. The greatest amount of average number of parenteral injection was on second day after operation (Fig.5.).
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Patient’s without PEA perenteral analgetic requiremen is compared in the graph below.
Figure 6 Average number of injections per day in SA and GA
As expected SA group patients’ required almost twice lower dose of ketaprofen compared with GA group. In SA group amount of injections requirements are the largest in the second day due to the fact that after operation for 16 to 24 hours injection of morphine injection of SA is still working. In GA requirements for parenteral analgesia was the biggest in the first day after surgery, and decreases very slowly (Fig.6.).
In all groups from 6th day after surgery patients’ does not require analgetics.
Comparison to results obtained by researchers in the field:
1. Similar retrospective study was done in Kaunas University of Medicine in Anesthesiology Clinic of all surgery patients that had epidural analgesia postoperatively administered in year 2007 (14). Research established effectiveness and safety of postoperative epidural analgesia. To achieve that study provided information about pain intensity (80% of patient’s didnt experience pain after surgery), treatment duration and additional analgesia requirements (only 30% of patients
22 required additional analgesics) while in our research additional analgesia need was much bigger (60% of patients required additional analgetics) and pain after surgery was present in all patients. 2. Comparison similar to our study was done in John Hopkins University School of Medicine in Baltimore where epidural anesthesia versus general anesthesia were studied (5). Postoperative pain and analgetic needs were assessed but due to similar analgetic regimen and not distinctive prevalence of complications data were inconclusive. Difference in our approach was patients division into three groups: EA, GA, and SA and aside postoperative pain and analgetics requirements we researched OR stay, ICU hours and hospitalization period and its correlation to review influence on patients recovery, postoperative status and possible economic benefits.
13. CONCLUSSIONS
The purpose of this study was to evaluate validity of epidural analgesia after radical prostatectomy compared with other anesthesia methods.
1. Studies showed that Spinal anesthesia group had the least hours spent in OR. Prostatectomy with SA may be associated with facilitating surgery process. Better correlation with SA illustrates ICU time cause less complicated procedure shows better outcome. Additionally it influences hospital costs, because less time in surgery and in intensive care department lowers significantly health care, hospital and ICU costs.
2. Requirements for additional analgetics during PEA revealed management of pain to certain extend, but not enough for patients comfort and achieve pain relief alone. Second day always require biggset amount of parenteral injections. 60% of patients needed additional analgesia.
3. Patients’ from SA group on the second day after surgery had biggest analgetics requirement. Overall SA may be best way for radical prostatectomy, because requires less medication (no PEA) and efforts for pain relief after surgery.
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