[Combination of intravenous patient-controlled analgesia with epidural anesthesia for postoperative pain therapy].

The aim of this study was to prove the hypothesis that a combination of epidural anaesthesia with intravenous patient-controlled analgesia (PCA) could improve perioperative pain management. Patients of the urological department undergoing lower abdominal surgery were randomized for two different pain managements. Patients of group 1 (n = 37) were narcotized, intubated and ventilated for the operation; arriving at the recovery room, they were given a PCA-pump, the drug used was piritramide and the parameters were bolus 2.5 mg, blocking time 20 minutes and no basal infusion rate. In group 2 (n = 37) an epidural catheter was inserted preoperatively followed by narcosis with intubation and ventilation. Additionally, epidural anaesthesia was performed intraoperatively using bupivacaine 0.5%. For postoperative pain management, patients of group 2 were also given a PCA-pump (same parameters as mentioned above) and a continuous epidural infusion was started additionally (bupivacaine 0.1875%, infusion rate 8 ml/h). Patients were monitored at the urological ICU for 36 hours. Assessment of pain (6-degree scale), grade of sedation (4-degree scale), cumulative doses of piritramide, heart rate, blood pressure, respiratory rate, in group 2 additional motoric function (Bromage) and degree of epidural anaesthesia were recorded at fixed time intervals: 0, 1, 2, 3, 5, 8, 11, 15, 19, 24, 28, 32, 36 hours. There was no difference regarding age of patients or type of operation. Assessment of pain showed a significant pain reduction in group 2 compared to group 1 during the first 8 hours. This result was underlined by a significantly smaller dose of piritramide. All other parameters showed no differences except lower blood pressure and heart rate in group 2 for the first three hours. The benefits of better pain management contrast with the risks resulting from combining the two techniques. In our patients we found an improvement of pain management in the early postoperative period. The combination of epidural anaesthesia with intravenous patient-controlled analgesia can be regarded as a further possibility for treating postoperative pain in the sense of "balanced pain management".