Thoracic epidural analgesia: What about the urinary bladder?

Effect of Early Removal of Urinary Catheter in Patients Undergoing Abdominal and Thoracic Surgeries with Continuous Thoracic Epidural Analgesia on Postoperative Urinary Retention

Background

Postoperative continuous thoracic epidural analgesia (TEA) is an integral aspect of pain management after major abdominal and thoracic surgery. Under TEA, postoperative urinary retention (POUR) is frequently noted, prompting a common practice of maintaining the transurethral catheter (UC) until the cessation of TEA to avoid the necessity for reinsertion of the UC. This study analyzes the effect of an early bladder catheter removal during TEA on POUR incidence.

Methods

The retrospective study was conducted on 71 patients undergoing elective abdominal and thoracic operations with TEA for postoperative pain control. Patients were divided into two groups based on the UC removal time in relation to the epidural catheter removal. In the early removal group (ERG), the UC was removed within 3 days of surgery, while in the standard group (SG), it was removed after completion of TEA. All patients in the ERG were still receiving TEA at the time of the UC removal. The primary outcome assessed was the incidence of POUR, while secondary outcomes included urinary tract infections (UTI), hospital length of stay (LOS), and patient's comfort.

Results

The overall prevalence of POUR was 7%, with five POUR cases - two (4.9%) of 41 patients in SG and three (10%) of 30 in ERG (p = 0.644). No significant difference was found in POUR occurrence between ERG and SG (p = 0.644). Additionally, no UTIs were observed in the study. The postoperative pain scores (visual analog scale [VAS]) 72 h and 96 h and the LOS (SG: 16.74 [±8.39] days; ERG: 14.53 [±6.99] days; p = 0.3) were similar between both study groups.

Conclusion

Based on our results, it can be concluded that the removal of UC in the early postoperative period, even during TEA, can be performed safely without significantly increasing the risk of recatheterization.

Pain management after thoracotomy with dexamethasone and bupivacaine through a peripleural cather: a randomized controlled trial

INTRODUCTION

Thoracotomy procedures can result in significant pain and cause nausea/vomiting. Glucocorticoids have anti-emetic and analgesic effects due to their anti-inflammatory and nerve-blocking properties. This study investigates the additive effect of local dexamethasone with bupivacaine as sole analgesic medication through a peripleural catheter after thoracotomy.

METHOD

The study was conducted as a randomized control trial on 82 patients. Participants were allocated to receive either 2.5 mg/kg of bupivacaine plus 0.2 mg/kg of dexamethasone or 2.5 mg/kg of bupivacaine plus the same amount of normal saline as placebo through a 6 French peripleural catheter implemented above the parietal pleura and beneath the musculoskeletal structure of the chest wall. The primary outcome was the severity of pain 24 h after the operation in the visual analogue scale (VAS) score. Secondary outcomes were the incidence of nausea/vomiting, opioid consumption for pain control, and incidence of any adverse effects.

RESULTS

A total of 50 participants were randomized to each group, and the baseline characteristics were similar between the groups. Median of VAS score (6 (3-8) vs. 8 (6-9), p < 0.001), postoperative opioid consumption (9 (36%) vs. 17 (68%) patients, p=0.024), and median length of hospital stay (4 (3-8) vs. 6 (3-12) days, p < 0.001) were significantly lower in the dexamethasone group. However, postoperative nausea/vomiting (p=0.26 for nausea and p=0.71 for vomiting) and surgical site infection (p = 0.55) were similar between the two groups.

CONCLUSION

In thoracotomy patients, administering local dexamethasone + bupivacaine through a peripleural catheter can reduce postoperative pain, analgesic consumption, and length of hospital stay.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials (IRCT20220309054226N1, registration date: 3/21/2022.

Occurrence and Severity of Catheter-Related Bladder Discomfort of General Anesthesia Plus Epidural Anesthesia vs. General Anesthesia in Abdominal Operation With Urinary Catheterization: A Randomized, Controlled Study

Background: This randomized, controlled study aimed to investigate the effect of general anesthesia plus epidural anesthesia on catheter-related bladder discomfort (CRBD) in patients who underwent abdominal operation with urinary catheterization.

Methods: A total of 150 patients scheduled for abdominal operation under anesthesia with urinary catheterization were randomized to receive general anesthesia plus epidural anesthesia (N = 74, GA + EA group) or general anesthesia (N = 76, GA group). The occurrence and severity of CRBD, systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) were recorded at 0 hour (h), 0.5, 1, and 3 h after tracheal extubation. Besides, postoperative adverse events were assessed.

Results: The occurrence and severity of CRBD at 0, 0.5, 1, and 3 h were all reduced in GA + EA group compared to GA group (all P < 0.05). Meanwhile, subgroup analyses showed that the reduction of occurrence and severity of CRBD in GA + EA group compared to GA group was more obvious in male patients and patients ≥50 years. Besides, SBP at 0, 0.5, 1, and 3 h, as well as DBP at 0, 0.5, and 3 h were all decreased in GA + EA group compared to GA group (all P < 0.05), while HR was increased at 0 h in GA + EA group compared to GA group (P = 0.034). Moreover, the occurrence of pain, severity of pain and occurrence of vomiting were similar between GA + EA group and GA group (all P > 0.05).

Conclusion: General anesthesia plus epidural anesthesia decreases CRBD occurrence and severity with tolerable safety compared with general anesthesia in patients who undergo abdominal operation with urinary catheterization.

Subpleural multilevel intercostal continuous analgesia after thoracoscopic pulmonary resection: a pilot study

BACKGROUND

Sufficient pain control and rapid mobilisation after VATS are important to enhance recovery and prevent complications. Thoracic epidural analgesia (TEA) is the gold standard, but failure rates of 9-30% have been described. In addition, TEA reduces patient mobilisation and bladder function. Subpleural continuous analgesia (SCA) is a regional analgesic technique that is placed under direct thoracoscopic vision and is not associated with the mentioned disadvantages of TEA. The objective of this study was to assess surgical feasibility, pain control and patient satisfaction of SCA.

METHODS

Observational pilot study in patients who underwent VATS pulmonary resection and received SCA (n = 23). Pain scores (numeric rating scale 0-10) and patient satisfaction (5-point Likert scale) were collected on postoperative day (POD) 0-3. Secondary outcomes were the period of urinary catheter use and period to full mobilisation.

RESULTS

Placement of the subpleural catheter took an average of 11 min (SD 5) and was successful in all patients. Pain scores on POD 0-3 were 1.2 (SD 1.2), 2.0 (SD 1.9), 1.7 (SD 1.5) and 1.2 (SD 1.1) respectively. On POD 0-3 at least 79% of patients were satisfied or very satisfied on pain relief and mobilisation. The duration of subpleural continuous analgesia was 4 days (IQR 3-5, range 2-11). Urinary catheters were used zero days (IQR 0-1, range 0-6) and full mobilisation was achieved on POD 2 (IQR 1-2, range 1-6).

CONCLUSION

Subpleural continuous analgesia in VATS pulmonary resection is feasible and provides adequate pain control and good patient satisfaction.

TRIAL REGISTRATION

This pilot study was not registered in a trial register.