Continuous epidural anesthesia and postoperative epidural narcotics in vascular surgery

Epidural anesthesia and analgesia: effects on recovery from cardiac surgery

OBJECTIVE

To measure predefined clinical effects resulting from the use of epidural anesthesia and analgesia during and after cardiac surgery.

DESIGN

Prospective, randomized, nonblinded clinical trial.

SETTING

Single academic medical center.

PARTICIPANTS

Sixty patients scheduled for elective cardiac surgery with cardiopulmonary bypass.

INTERVENTIONS

Sixty participants were randomly assigned to 1 of 2 study groups: (1) A control group received general anesthesia during surgery and intravenous opiate analgesia after surgery. (2) A treatment group received thoracic epidural anesthesia combined with general anesthesia during surgery and epidural analgesia for the first 24 postoperative hours.

MEASUREMENTS AND MAIN RESULTS

Primary study measurements were planned to evaluate recovery from surgery and included time to tracheal extubation, duration of postoperative intensive care unit stay, duration of postoperative hospitalization, pain control, urinary free cortisol, cardiopulmonary complication rate, and total hospital charges. No statistically significant differences between the 2 study groups were found in these main measurements.

CONCLUSIONS

The clinical course of elective cardiac surgical patients who receive epidural anesthesia during surgery and epidural analgesia after surgery is comparable to that of patients managed with general anesthesia alone during surgery followed by parenteral opiate analgesia after surgery.

Current trends in perioperative pain management

Wider use of optimized multimodal accelerated postoperative recovery programs require that anesthesiologists step out of traditional operating room anesthesia roles and even beyond current pain management consultant roles. Development of optimal postoperative recovery services requires close collaboration between anesthesiologists, surgeons, nurses, physical therapists, administrators, and others involved in the management of patients after surgery. Optimization of perioperative care is an ongoing process enhanced by clinical investigation; however, making significant improvements to clinical practice does not have to wait for additional research data, but should proceed now, with broader application of techniques known to enhance rehabilitation and recovery. Based on existing data, the challenges of developing perioperative recovery services seem likely to be rewarded with improved patient outcomes and reduced cost.

Awake aortic aneurysm repair in patients with severe pulmonary disease

BACKGROUND

We report the use of retroperitoneal aortic aneurysm repair utilizing exclusive regional anesthesia (no intubation or inhalation anesthetic) in high pulmonary risk patients.

METHODS

Six patients were retrospectively reviewed. Pulmonary disease was diagnosed by clinical history and pulmonary function tests. Patients received intravenous sedation and regional anesthesia. Retroperitoneal aortoiliac aneurysm repair was performed.

RESULTS

All patients used inhaled steroids and albuterol. Three required theophylline and home oxygen. FEV1 = 23% +/- 5% predicted, FVC = 34% +/- 5% predicted, and PO2 = 62 +/- 2 mm Hg. Operative time was 247 +/- 25 minutes. Blood loss was 840 +/- 479 mL. Five of six patients (83%) tolerated awake aneurysm repair and had intensive care unit stays of 2.4 +/- 0.6 days, and postoperative hospital stays of 8.2 +/- 1.8 days. One patient was converted to general anesthesia and had a prolonged hospital stay.

CONCLUSIONS

With thorough patient communication, awake retroperitoneal aortic aneurysm repair can be safely performed in select patients with severe pulmonary disease.

Retroperitoneal approach used exclusively with epidural anesthesia for infrarenal aortic disease

BACKGROUND

The retroperitoneal approach for elective infrarenal aortic procedures is an attractive alternative to the standard transperitoneal approach. In an effort to limit the number of extraneous influences on patient outcome, this approach was performed using epidural anesthesia without the use of endotracheal intubation or general anesthesia.

METHODS

From June 1991 through July 1993, 62 consecutive patients with aorto-occlusive or aorto-iliac disease underwent infrarenal aortic repair using the retroperitoneal approach. Epidural anesthesia was used exclusively in all cases. Patients were evaluated for age, sex, comorbid conditions, morbidity, operating time, blood loss, ileus, and length of hospital stay.

RESULTS

There were 29 aortobiiliac bypasses, 18 aortobifemoral bypasses, and 15 aortic tube grafts. Three patients had an associated renal artery procedure performed. There were 48 men and 14 women. The average age was 74.2 years (range 30 to 88). Comorbid conditions including smoking (69%), coronary artery disease (61%), hypertension (61%), prior myocardial infarction (43%), chronic obstructive pulmonary disease (35%), prior surgery (27%), diabetes mellitus (24%), and a history of cancer (8%) were identified. The average length of surgery was 2 hours and 10 minutes (range 1 hour 20 minutes to 3 hours 15 minutes). The average blood loss was 510 mL (range 200 to 4,000). A nasogastric tube was not used in any patient perioperatively, and oral feeding was started on average by postoperative day 2. The average intensive care unit stay was 1.3 days (range 1 to 7). A mortality rate of 1.6%, and major complication rate of 11% were found. None were of pulmonary nature, which may be ascribed to the absence of endotracheal intubation or general anesthesia. A minor complication rate of 19% was achieved under the presented method. The average hospital stay was 7.7 days (range 5 to 15).

CONCLUSION

No large series using the retroperitoneal approach exclusively under epidural anesthesia has been reported. Recent literature on the retroperitoneal approach makes use of general anesthesia with/without epidural anesthesia. This review supports our contention that the procedure of choice for elective infrarenal aortic surgery is the retroperitoneal approach utilizing epidural anesthesia in the absence of endotracheal intubation and general anesthesia. There is a decrease in the physiologic disturbances associated with general anesthesia, notably pulmonary and gastrointestinal, when only epidural anesthesia is used. This translated into a low complication rate, improved patient comfort, early hospital discharge, and subsequent lower costs.

Indications and application of epidural anesthesia in a pediatric population outside the perioperative period

The techniques of spinal and epidural anesthesia have been key components of anesthetic care for the past 100 years. Although commonly used in the operating room, their use in children outside the perioperative period has been limited. The author presents his experience with the use of epidural anesthesia to provide analgesia in five children when parenteral narcotics were ineffective in treating pain associated with burns, sickle cell crisis, trauma, and malignancies. Additionally, the principles and adverse effects of epidural anesthesia are discussed.

Epidural versus general anesthesia for infrainguinal arterial reconstruction

A prospective evaluation of 213 consecutive infrainguinal bypass procedures was performed to determine the effect of anesthesia technique on the postoperative complication rate. Limb salvage was the indication for surgery in 92% of cases. No significant differences were observed in age, sex, indication for surgery, presence of cardiovascular and pulmonary risk factors, American Society of Anesthesiologists classification, or Goldman scores between patients receiving epidural anesthesia and those receiving general endotracheal anesthesia. Epidural anesthesia was used for 96 procedures and general endotracheal anesthesia was used in 117 cases. Cardiac complications for the epidural anesthesia and general endotracheal anesthesia groups, respectively, included a mortality rate of 5% versus 3%, nonfatal infarctions in 6% versus 7%, and reversible cardiac events in 14% versus 16%. A high-risk subgroup of 69 patients (American Surgical Association classes IV and V or Goldman score greater than 10 points) also had no significant difference in outcome between epidural anesthesia and general endotracheal anesthesia. Major noncardiac complications occurred in an additional 8% of each group. Regional and general anesthesia therefore produce equivalent cardiovascular risk for infrainguinal arterial reconstruction. These results suggest that indicated operations should not be postponed or avoided for patients either requiring or requesting general anesthesia. Furthermore, other investigations of cardiac risk in vascular surgery do not require a uniform anesthetic technique for valid interpretation of results.

Epidural anesthesia as an adjunct to retroperitoneal aortic surgery

Recent developments in vascular surgery suggest that the retroperitoneal approach to the aorta and the use of epidural anesthesia for lower limb revascularization are associated with decreased morbidity and shorter hospital stays. By combining these principles, we sought to determine if retroperitoneal aortic surgery could be performed under epidural anesthesia and if this might be advantageous. Over a 16-month period, 57 patients underwent aortic surgery via the retroperitoneal (n = 33) or transperitoneal (n = 24) approach. In the former, epidural anesthesia was employed in 10 patients, general anesthesia in 3, and combined epidural anesthesia and general anesthesia in the remaining 20. In the transperitoneal group, general anesthesia was employed in 21 patients and combined epidural anesthesia and general anesthesia in 3. Both groups were similar in age and gender, but risk factors were predominant in the retroperitoneal group. With the exception of one death due to aspiration, there were no significant differences between the transperitoneal and retroperitoneal groups with respect to overall morbidity, pulmonary complications, and length of stay in the intensive care unit and hospital. Despite these findings, we favor the combination of epidural and general anesthesia for retroperitoneal aortic surgery. Morbidity was significantly decreased (p less than 0.05) in low-risk retroperitoneal patients when combined epidural anesthesia and general anesthesia were employed.

Use of single-dose epidural morphine in a patient undergoing an abdominal aortic aneurysm resection

To avoid possible trauma to the epidural venous plexus in a 56-year-old male who presented for abdominal aortic aneurysm resection, the authors preoperatively injected a single dose of epidural morphine rather than inserting an indwelling epidural catheter. The patient's intraoperative anesthetic requirements appeared to have been decreased, he was extubated shortly after the end of the procedure, and he experienced good postoperative analgesia. No untoward neurologic sequelae occurred. The authors feel that a single dose of epidural morphine, compared to epidural catheter placement when systemic heparinization is planned, decreases intraoperative anesthetic requirements, provides good postoperative analgesia, and may have the benefit of decreasing the possibility of epidural hematoma formation.