Prospective Survey of Patient-Controlled Epidural Analgesia With Bupivacaine and Hydromorphone in 3736 Postoperative Orthopedic Patients

Background and Objectives: Patient-controlled epidural analgesia (PCEA) has been shown to be superior to intravenous patient-controlled analgesics (PCA) for postoperative analgesia after thoracic, abdominal, pelvic, and lower extremity surgery. However, it is unclear which opioid is optimal for PCEA. Hydromorphone has potential advantages, yet there are no data to establish its efficacy and safety. Thus, we prospectively monitored our patients receiving PCEA with bupivacaine combined with hydromorphone after orthopedic surgery. Methods: All postoperative patients who received PCEA from March 1 to September 21, 2009, were included. Lumbar PCEA was initiated after central neuraxial anesthesia with 0.06% bupivacaine combined with hydromorphone 10 mu g/mL. Initial settings were a bolus dose of 4 mL, lockout interval of 10 mins, and background infusion of 4 mL/hr. Patients were allowed oral analgesics, and meloxicam was routinely administered as an adjunct analgesic. Patients were evaluated twice a day at our Acute Pain Service department. Pain scores, adverse effects, and medications were entered prospectively into the electronic patient record. Results: Verbal pain scores (0-10) at rest were 3, 3, 3, and 2 on postoperative days 0 to 3. Verbal pain scores with activity were 4, 3, 3, and 3. Most adverse effects were modest to rare (15% pruritus, 10% hypotension, 0.08% sedation, and 0% respiratory depression) with the exception of nausea (30%). There were no epidural hematomas or abscesses. Median duration of PCEA was 27 hrs. Conclusions: Patient-controlled epidural analgesia with bupivacaine and hydromorphone provides effective and safe postoperative analgesia for orthopedic surgery.