A prospective, randomized, double-blind comparison of epidural and intravenous sufentanil after radical retropubic prostatectomy

Introduction. The site of action (spinal vs. central) and clinical benefits of epidural administration of lipid-soluble opioids has been a subject of controversy. We compared the analgesic efficacy, plasma concentration, side effects, and impact on speed of recovery and stress catecholamine and cortisol responses of epidural (Son) and intravenously (Sw) administered sufentanil after radical rctropubic prostatectomy (RRP). Methods. After 1RB approval and written informed consent, 16 patients undergoing RRP under lumbar epidural anesthesia were randomized to receive SEPI or Sjv (n=8/group) utilizing a dual activated, double-blind PCA pump set-up. On first complaint of postoperative pain, Sw patients were given an 8 jig bolus and then a 6 fig/h infusion intravenously. SEW patients were given the same bolus and infusion epidurally. All patients received bolus injections and an infusion of coded saline via the alternate route. Analgesic requirements were tailored continuously to individual needs by patientcontrolled supplementary boluses of 4 g (10 min lockout) via the designated route of delivery, or by 2 ng/h reduction in infusion rate at predetermined intervals. Patients were assessed for pain (0-100 mm visual analogue scale, VAS) at rest and with getting out of bed (OOB), sedation, nausea, vomiting, pruritus, satisfaction, sufentanil use and plasma levels, plasma epinephrine and norepinephrine levels, and urine cortisol excretion for 72 h after the initial bolus. Recovery parameters were recorded. Results. Similar VAS pain scores were found between the two groups: pain at rest <, 30 mm was established by 30 nun and maintained throughout; pain with getting OOB was £ 45 mm on POD1 and decreased to <> 26 mm on POD3. There were no differences in sedation, nausea, vomiting, pruritus, satisfaction, recovery parameters, sufentanil use or plasma levels. Mean sufentanil requirements (±SD) were at 24h: 289±75 Jig (Siv), 292 ± 72 fig (SEPI); at 48h: 499±174 ng (Snr), 504±129 Hg (SEPI); and at 72h: 687±261 fig (Sw), 669±270 fig (SEPI)- Epinephrine and norepinephrine levels were mildly elevated equally in both groups at complaint of pain and 15 min later compared to preoperative baselines (P<0.05), but returned to baseline ranges in both groups thereafter. Urine cortisol excretion was similar between the two groups. Discussion. This study corroborates two previous studies which found that little clinical difference exists between epidural and intravenous administration of sufentanil (1,2). Furthermore, the stress response after RRP under epidural anesthesia is mild and equally suppressed by either epidural or intravenous administration of sufentanil.