PREEMPTIVE EPIDURAL ANALGESIA AND RECOVERY FROM RADICAL PROSTATECTOMY- A RANDOMIZED CONTROLLED TRIAL

Context.-Preemptive analgesia can decrease the sensitization of the ce ntral nervous system that would ordinarily amplify subsequent nocicept ive input, but a clear demonstration of its clinical efficacy is neces sary for it to become a routine component of acute pain therapy. Objec tive.-To determine the impact of preemptive epidural analgesia on post operative pain and other clinically important outcome variables after radical retropubic prostatectomy. Design and Setting.-A block randomiz ed double-blind clinical trial lasting 20 months at a single academic medical center. Patients.-A total of 100 generally healthy and neurolo gically intact patients scheduled for radical retropubic prostatectomy for the treatment of prostate cancer in whom an epidural catheter for treating postoperative pain was to be placed prior to the induction o f general anesthesia. Interventions.-Epidural bupivacaine, epidural fe ntanyl, or no epidural drug was administered prior to induction of ane sthesia and throughout the entire operation, followed by aggressive po stoperative epidural analgesia for all patients. Main Outcome Measures .-Daily pain scores during hospitalization and pain scores obtained 3. 5, 5.5, and 9.5 weeks after hospital discharge. Results.-The patients who received epidural fentanyl or bupivacaine prior to surgical incisi on (preemptive analgesia) experienced 33% less pain while hospitalized (P=.007). Pain scores in those receiving preemptive analgesia were si gnificantly lower at 9.5 weeks (P=.02), but were not significantly dif ferent at 3.5 or 5.5 weeks. At 9.5 weeks, 32 (86%) of 37 patients rece iving preemptive analgesia were pain-free compared with 9 (47%) of 19 control patients (P=.004), Patients receiving preemptive analgesia wer e more active 3.5 weeks after surgery (P=.01), but not at 5.5 or 9.5 w eeks. Conclusions.-Even in the presence of aggressive postoperative pa in management, preemptive epidural analgesia significantly decreases p ostoperative pain during hospitalization and long after discharge, and is associated with increased activity levels after discharge.