| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
Correspondence |
Calgary, Alberta
To the Editor:
In their recent article, Charghi et al.1 conclude that in grossly obese patients undergoing gastric bypass surgery patient-controlled analgesia (PCA) with iv morphine is an acceptable strategy for pain management and may confer some advantages when compared to epidural analgesia. This article raises several interesting points that merit further discussion.
We would first like to comment on some of the methodological limitations outlined briefly by the authors. As this was a retrospective review, selection bias was inevitable. Informed consent is difficult to obtain under normal circumstances but when consent is delegated to individual anesthesiologists the content and manner of presentation will vary enormously.
Placing epidural catheters at T11–12, L1 levels for upper abdominal surgery is a formula for failure. This one flaw seriously limits any conclusions that can be drawn.
Placing epidural catheters in bariatric patients may present a challenge. However, this possibility should not discourage prospective studies - failure to place an epidural catheter should simply be considered a failure of epidural analgesia.
The lack of adequate surveillance data (incident pain, extent of block, etc.) further prevents any firm conclusions from being drawn about comparative analgesia. In summary, we feel that the conclusions drawn may be relevant, but only to patients managed in exactly the manner described.
Our practice is to place a thoracic epidural catheter (T7–9 for upper abdominal surgery), confirm its placement and function with a Tsui test,2 and manage the catheter with a PCA system using a combination of either fentanyl or hydromorphone and 0.1% bupivacaine. We believe that the analgesia conferred by this method is superior to that provided by iv PCA narcotic but we have no comparative trial in this patient population to substantiate our opinion.
References
1 Charghi R, Backman S, Christou N, Rouah F, Schricker T. Patient controlled iv analgesia is an acceptable pain management strategy in morbidly obese patients undergoing gastric bypass surgery. A retrospective comparison with epidural analgesia. Can J Anesth 2003; 50: 672–8.
2 Tsui BC, Gupta S, Finucane B. Confirmation of epidural catheter placement using nerve stimulation. Can J Anaesth 1998; 45: 640–4.
Related articles in CJA:
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
