Changing from epidural to multimodal analgesia for colorectal laparotomy: an audit

In April 2002 our practice ceased routine use of epidural analgesia for colorectal laparotomy in favour of a six-drug multimodal regimen comprising ketamine, clonidine, morphine, tramadol, paracetamol and a non-steroidal anti-inflammatory drug. The records of 54 patients who received this multimodal analgesia regimen (MM) after April 2002 were compared to the 59 patients who had previously received epidural analgesia (EPI). Patients had the same surgeon and anaesthetist. Daily pain score (verbal rated 0-10) at rest (mean) over the first three postoperative days was satisfactorily low with both MM (1.2 +/- 1.2) and EPI (0.4 +/- 0.4). Over this period there was little difference between the maximum pain score at rest (MM 2.3 +/- 1.9 vs. EPI 2.2 +/- 1.7, P = 0.58). Major complications and side-effects occurred solely in EPI patients: epidural abscess (1), respiratory depression (2), pneumonia (3), venous thromboembolism (3), delirium (7), high block (7) and motor block (3). Hypotension requiring intervention was 4.8 times more frequent in the EPI group (95% CI 2.1-11). Antiemetic use was similar between groups; on average 13 patients in the MM groups (24%) and 15 patients in the EPI groups (26%) received antiemetics each day. MM patients had shorter anaesthetic preparation time (20 +/- 8 min vs. 32 +/- 8 min, P < 0.001), shorter high-dependency unit stay (0.4 +/- 1.2 days vs. 4.5 +/- 0.9 days, P < 0.001), and shorter hospital stay (10 +/- 4 days vs. 13 +/- 8 days, P = 0.003). In our practice, changing from epidural to multimodal analgesia produced comparable pain relief with reduction in anaesthesia preparation time, high-dependency unit stay and hospital stay and the requirement for staff interventions. There was also a reduction in the incidence of major complications and side-effects.