Compared with analgesics administered intramuscularly or intravenously, epidural analgesia is associated with improved pulmonary function postoperatively, a lower incidence of pulmonary complications, a decrease in postoperative venous thromboembolic complications (most likely secondary to earlier ambulation), fewer gastrointestinal side effects, a lower incidence of central nervous system depression, and shorter convalescence (47). A systematic review concluded that continuous epidural anesthesia is more effective than intravenous opioid PCA in reducing postoperative pain for up to 72 hours after abdominal surgery (48). Severe respiratory depression, which occurs in less than 1% of patients, is the most serious potential complication. A lower incidence of respiratory depression occurs with the more lipophilic drugs such as fentanyl, which is quickly absorbed within the spinal cord and is less likely to diffuse to the central nervous system respiratory control centers. Pruritus, nausea, and urinary retention are common but can be managed easily and usually are of little clinical significance. Cost is perhaps the main and most limiting drawback of epidural analgesia.
Close monitoring by nursing staff is required for safe administration of epidural analgesia.
An intensive care setting is not necessary. Epidural analgesics can be administered safely in a hospital ward setting under close nursing supervision, using respiratory monitoring with hourly ventilatory checks during the first 8 hours of epidural analgesia.
Current therapeutic strategies for perioperative pain control are largely dependent on multimodal therapy with opioid analgesics and nonsteroidal anti-inﬂammatory drugs (NSAIDs). The nonselective NSAID ketorolac is a potent drug that can be given orally or parenterally. Ketorolac has a slightly slower onset of activity than fentanyl but has an analgesic potency comparable to morphine. The theoretical advantages of NSAIDs over opioids include absence of respiratory depression, lack of abuse potential, decreased sedative effects, decreased nausea, early return of bowel function, and faster recovery. In clinical studies, ketorolac is found to have analgesic effects similar to those of morphine in postoperative orthopedic patients and, when used in conjunction with PCA, significantly reduced opioid requirements (49,50). Depending on the type of surgery, ketorolac has an opioid dose-sparing effect of a mean of 36% and improves analgesic control of moderate to severe pain 24 hours postoperatively (51). In the obstetric population, intravenous ketorolac is effective in reducing postoperative narcotic use after cesarean delivery (52). Although the U.S. Food and Drug Administration has not approved ketorolac for use during lactation, it was quantified in breast milk and has lower levels than ibuprofen (53).