A COMPARISON OF INTRATHECAL DIAMORPHINE AND THORACIC EPIDURAL ANALGESIA FOR POSTOPERATIVE PAIN RELIEF AFTER HEPATECTOMY SURGERY

Background: For postoperative pain relief after hepatectomy, the safety of thoracic epidural analgesia relies on timing of epidural needle placement and catheter removal Coagulopathy after hepatic surgery increases the risk of epidural haematoma. The present prospective randomized study compared the efficacy and safety of preoperative intrathecal diamorphine with continuous thoracic epidural analgesia for patients undergoing major hepatectomy surgery. Methods: Eighty patients scheduled for major hepatectomy were enrolled in this study. Patients were randomly allocated into two groups. Group A: Patients received a preoperative single injection of intrathecal diamorphine (10ug/kg). Group B: Patients received thoracic epidural analgesia, inserted in the preoperative period and used for analgesia in postoperative period. The primary outcome measures were: visual analogue score at rest and during movement in first 6 hours, time to first analgesic request, total morphine consumption in first 6 hours post-surgery, and haemodynamic variables. Secondary outcomes were: postoperative international normalized ratio changes, total intravenous fluid and vasopressors use, incidence of nausea, vomiting, pruritus, and respiratory depression, and patient s sedation and satisfaction. Results: Intrathecal diamorphine was associated with statistically significant reduction in total morphine consumption up to 48 hrs. (34±11mg in diamorphine group versus 66 ±11mg in epidural group). Patients in diamorphine group had shown lower pain score at rest and with movement, superior haemodynamic stability, less total intravenous fluid requirements and high percent of patient satisfaction with pain therapy. Patients in epidural group had tendency to have significantly lower blood pressure and bradycardia and required more intravenous fluid and vasopressors boluses than patients in diamorphine group. Postoperatively, all patients in both groups had coagulation derangement. Epidural catheters were not taken out until fifth postoperative day after normalization of INR. Conclusion: Preoperative intrathecal diamorphine is effective in the intraoperative and postoperative pain relief and is safe alternative to epidural analgesia after major hepatectomy surgery.