Bertoglio, S., Fabiani, F., Negri, P.D., Corcione, A., Merlo, D.F., Cafiero, F., . . . Zappi, L. (2012). The postoperative analgesic efficacy of preperitoneal continuous wound infusion compared to epidural continuous infusion with local anesthetics after colorectal cancer surgery: A randomized controlled multicenter study. Anesthesia and Analgesia, 115, 1442–1450.

To evaluate the effectiveness of preperitoneal continuous wound infusion (CWI) with ropivacaine, compared to continuous epidural infusion (CEI) with ropivacaine, on pain control after open colorectal surgery and on the quality of patient recovery

The intervention group had preperitoneal CWI analgesia. The control group had preperitoneal CEI analgesia. Participants were randomly assigned and received either CWI or CEI during first 48 hours postop. Infusion consisted of 0.2% ropivacaine at 10 ml/hour. All patients received morphine patient-controlled analgesia during the first 72 hours postop. All received standardized postoperative care not adhering to fast-track surgery programs. Investigators used the 100 mm visual analog scale (VAS) to measure pain.

A 4.5-point difference in VAS pain score showed that preperitoneal CWI was not inferior to CEI analgesia.

• The sample was composed of 106 patients. 
• The range of patient age was 57.9–73.5 years.
• Of all patients, 52% were male and 48% were female.
• All patients had colorectal cancer and underwent open nonemergency colorectal surgery for cancer.
• Types of surgery represented in the sample were hemicolectomy, rectal resection, segmentary colonic resection, and total colectomy. Authors noted differences regarding duration of surgery (in minutes), length of wound catheter in intervention group, and vertebral level of epidural catheter insertion in control group.

• Multisite 
• Inpatient
• Italy

• Phase of care: transition phase after active treatment
• Clinical application: eldercare

Multicenter randomized controlled trial (noninferiority design)

The primary outcome measure was a VAS whose scale ranged from 0 (no pain) to 100 (worst pain imaginable). 

Other outcome measures included

• Morphine titration and usage
• Morphine patient-controlled analgesia at varying intervals during the first 72 hours postop
• Time of first flatus
• Time of first bowel movement
• Duration of hospital stay, from surgery to discharge
• Quality of sleep (0–10 scale)
• Patient satisfaction with pain control (rated poor, good, or excellent) at 72 hours postop
• Side effects noted during the first 30 days postop (Side effects included hypotension requiring treatment, central nervous system toxicity, nausea and vomiting requiring medication, and presence of motor block [epidural complications in control group and abdominal complications in intervention group].)

• At 2, 6, 12, and 24 hours postop, the CEI and CWI groups demonstrated similar responses, indicating achievement of sufficient pain control. 
• At 48 and 72 hours postop, the CWI group—in contrast to the CEI group—demonstrated a statistically significant reduction in reported pain score.
• In terms of the secondary end-point measures, the results the CWI group achieved were similar to those the CEI group achieved in regard to duration of hospital stay, quality of night sleep, and requirement for rescue analgesia.
• In the CWI group, 45.3%  reported excellent pain control at 72 hours postop. In the CEI group, 7.6% reported excellent postop pain control.
• Compared to the CEI group, the CWI group demonstrated a significantly shorter time to first flatus (p = 0.002) and first bowel movement (p = 0.001). 
• Compared to the CEI group, the CWI group had a statistically significant lower incidence of postop nausea and vomiting at 24 hours (p = 0.02), 48 hours (p = 0.01), and 72 hours (p = 0.007).

CWI provides an acceptable alternative to CEI for the management of patients' pain after colorectal surgery for the treatment of cancer.

The study had a risk of bias due to no blinding.

This study shows that oncology nurses, as advocates for patients, can support CWI as an alternative to CEI as a means of postoperative pain management. Because CWI was associated with significant benefits regarding postoperative sleep disturbance, bowel function, and nausea and vomiting—as well as pain management—nurses can advocate for the use of CWI to address several symptoms of concern to oncology patients and direct-care nurses.