| Popis: |
Objectives: We investigated the time to achieve postoperative milestones in patients who underwent exploratory laparotomy for suspected gynecologic malignancy and received either patient-controlled analgesia alone (PCA), PCA with transversus abdominus plane block (TAP), or PCA with continuous epidural infusion (CEI). Methods: A retrospective cohort study of patients who underwent open gynecologic oncology surgery in a university was conducted over 18 months. Our primary outcomes included time to achieve the following postoperative milestones: pain control (mean pain score ≤ 5), foley catheter removal, ambulation, flatus, tolerating a regular diet, and control of nausea and emesis. All milestones, except for foley catheter removal, were measured using postoperative day (POD). Foley catheter removal was measured in hours after insertion and analyzed as a categorical variable using quartiles. All postoperative milestones were compared using Fisher's Exact Test. Results: Of 214 eligible patients, 127 received PCA alone, 76 received additional TAP block, and 11 received additional CEI. 19 patients without PCA or regional, and 13 patients without PCA, were excluded. Pain control took longer in the CEI group as over half of those who received PCA alone (54%) or TAP (57%) achieved pain control on POD 0 compared to 30% in CEI (p=0.02). Similarly, by POD 3, only 80% of the CEI group had pain controlled compared to 96% in PCA and 85% in TAP (p=0.02). CEI also lagged in time to foley removal as none (0%) of the CEI group had foley removal within the first quartile, 0-15 hours, whereas 23% of the PCA group and 27% of the TAP group had achieved successful removal by that time (p=0.02). This trend continued with 73%, 28%, and 20% of the CEI, PCA, and TAP groups, respectively had foley removal within the last quartile, 41-503 hours (p=0.02). The CEI group also took longer to ambulate with 18% ambulating by POD 1 compared to 59% in PCA and 64% in TAP (p=0.01). Similarly, by POD 2, only 54% of the CEI patients were ambulating compared to 89% in PCA and 90% in TAP (p=0.01). The CEI group lagged in time to regular diet, as only 9% were eating by POD 1 vs 35% in PCA and 29% in TAP, although this finding was not statistically significant (p=0.07). The CEI group also experienced increased time to flatus with 9% on POD 1 compared to 17% in PCA and 7% in TAP (p=0.02). Only 9% of the CEI patients had nausea controlled by POD 1, whereas 48% in PCA and 49% in TAP groups met that milestone by then (p=0.02). It took 3 or more postoperative days for 82% of the CEI group to have controlled nausea. When reviewing these results in the combined regional group (TAP and CEI) vs PCA alone, there were no statistically significant differences except in time to flatus, with 17% of the PCA group passing flatus by POD 1 compared to 7% in the regional group (p=0.03). Download : Download high-res image (205KB) Download : Download full-size image Conclusions: Our study showed that regional anesthesia increased time to flatus in patients who underwent open gynecologic surgery. Although limited by small sample size, CEI was an outlier in time to postoperative milestones, including pain control, ambulation, control of nausea and emesis, and foley removal. Benefits and drawbacks of CEI anesthesia should be considered using full assessment of the effect on postoperative milestones. Further study of costs of CEI vs TAP anesthesia, while not in the scope of this study, can provide further context for decision making. Our results merit future investigation into the effects of regional anesthesia, especially epidural, on time to postoperative milestones. |
Full Text from ScienceDirect