title: Postoperative pain control using continuous i.m. bupivacaine infusion plus patient-controlled analgesia compared with epidural analgesia after major hepatectomy.
abstract: OBJECTIVE
  There is debate concerning the best mode of delivery of analgesia following liver resection, with continuous i.m. infusion of bupivacaine (CIB) plus patient-controlled i.v. analgesia (PCA) suggested as an alternative to continuous epidural analgesia (CEA). This study compares these two modalities.
  
  
  METHODS
  A total of 498 patients undergoing major hepatectomy between July 2004 and July 2011 were included. Group 1 received CIB + PCA (n = 429) and Group 2 received CEA (n = 69). Groups were analysed on baseline patient and surgical characteristics. Primary endpoints were pain severity scores and total opioid consumption. Secondary endpoints were pain management failures, need for rescue medication, postoperative (opioid-related) morbidity and hospital length of stay (LoS).
  
  
  RESULTS
  In both groups pain was well controlled and >70% of patients had no or minimal pain on PoDs 1 and 2. The numbers of patients experiencing severe pain were similar in both groups: PoD 1 at rest: 0.3% in Group 1 and 0% in Group 2 (P = 1.000); PoD 1 on movement: 8% in Group 1 and 2% in Group 2 (P = 0.338); PoD 2 at rest: 0% in Group 1 and 2% in Group 2 (P = 0.126), and PoD 2 on movement: 5% in Group 1 and 5% in Group 2 (P = 1.000). Although the CIB + PCA group required more opioid rescue medication on PoD 0 (53% versus 22%; P < 0.001), they used less opioids on PoDs 0-3 (P ≤ 0.001), had lower morbidity (26% versus 39%; P = 0.018), and a shorter LoS (7 days versus 8 days; P = 0.005).
  
  
  CONCLUSIONS
  The combination of CIB + PCA provides pain control similar to that provided by CEA, but facilitates lower opioid consumption after major hepatectomy. It has the potential to replace epidural analgesia, thereby avoiding the occurrence of rare but serious complications.
authors.affiliation: Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands.
authors.forename: Edgar M
authors.initials: EM
authors.lastname: Wong-Lun-Hing
authors.forename: Ronald M
authors.initials: RM
authors.lastname: van Dam
authors.forename: Fenella K S
authors.initials: FK
authors.lastname: Welsh
authors.forename: John K G
authors.initials: JK
authors.lastname: Wells
authors.forename: Timothy G
authors.initials: TG
authors.lastname: John
authors.forename: Adrian B
authors.initials: AB
authors.lastname: Cresswell
authors.forename: Cornelis H C
authors.initials: CH
authors.lastname: Dejong
authors.forename: Myrddin
authors.initials: M
authors.lastname: Rees
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015360:Analgesia, Epidural / Q000009:adverse effects; D016058:Analgesia, Patient-Controlled / Q000009:adverse effects; D000701:Analgesics, Opioid / Q000008:administration & dosage* / Q000009:adverse effects; D000779:Anesthetics, Local / Q000008:administration & dosage* / Q000009:adverse effects; D002045:Bupivacaine / Q000008:administration & dosage* / Q000009:adverse effects; D005260:Female; D006498:Hepatectomy / Q000009:adverse effects*; D006801:Humans; D007263:Infusions, Parenteral; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D059408:Pain Management / Q000009:adverse effects / Q000379:methods*; D010147:Pain Measurement; D010149:Postoperative Pain / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control*; D012189:Retrospective Studies; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D000701:Analgesics, Opioid; D000779:Anesthetics, Local; D002045:Bupivacaine