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Preemptive Epidural Analgesia and Recovery From Radical Prostatectomy
A Randomized Controlled Trial
Allan Gottschalk, MD, PhD;
David S. Smith, MD, PhD;
David R. Jobes, MD;
Sean K. Kennedy, MD;
Sara E. Lally, BA;
Vicki E. Noble, BA;
Kathy F. Grugan, RN, MSN;
Harry A. Seifert, MD;
Albert Cheung, MD;
S. Bruce Malkowicz, MD;
Brett B. Gutsche, MD;
Alan J. Wein, MD
JAMA. 1998;279:1076-1082.
Context.— Preemptive analgesia can decrease the sensitization of the central nervous system that would ordinarily amplify subsequent nociceptive input, but a clear demonstration of its clinical efficacy is necessary for it to become a routine component of acute pain therapy.
Objective.— To determine the impact of preemptive epidural analgesia on postoperative pain and other clinically important outcome variables after radical retropubic prostatectomy.
Design and Setting.— A block randomized double-blind clinical trial lasting 20 months at a single academic medical center.
Patients.— A total of 100 generally healthy and neurologically intact patients scheduled for radical retropubic prostatectomy for the treatment of prostate cancer in whom an epidural catheter for treating postoperative pain was to be placed prior to the induction of general anesthesia.
Interventions.— Epidural bupivacaine, epidural fentanyl, or no epidural drug was administered prior to induction of anesthesia and throughout the entire operation, followed by aggressive postoperative epidural analgesia for all patients.
Main Outcome Measures.— Daily pain scores during hospitalization and pain scores obtained 3.5, 5.5, and 9.5 weeks after hospital discharge.
Results.— The patients who received epidural fentanyl or bupivacaine prior to surgical incision (preemptive analgesia) experienced 33% less pain while hospitalized (P=.007). Pain scores in those receiving preemptive analgesia were significantly lower at 9.5 weeks (P=.02), but were not significantly different at 3.5 or 5.5 weeks. At 9.5 weeks, 32 (86%) of 37 patients receiving preemptive analgesia were pain-free compared with 9 (47%) of 19 control patients (P=.004). Patients receiving preemptive analgesia were more active 3.5 weeks after surgery (P=.01), but not at 5.5 or 9.5 weeks.
Conclusions.— Even in the presence of aggressive postoperative pain management, preemptive epidural analgesia significantly decreases postoperative pain during hospitalization and long after discharge, and is associated with increased activity levels after discharge.
From the Department of Anesthesia (Drs Gottschalk, Smith, Jobes, Kennedy, Seifert, Cheung, and Gutsche and Mss Lally, Noble, and Grugan) and the Department of Surgery, Division of Urology (Drs Malkowicz and Wein), School of Medicine, University of Pennsylvania, Philadelphia.
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