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Blackshaw WJ, Bhawnani A, Pennefather SH, Al-Rawi O, Agarwal S, Shaw M. Propensity score-matched outcomes after thoracic epidural or paravertebral analgesia for thoracotomy. Anaesthesia 2018; 73:444-449. [DOI: 10.1111/anae.14205] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2017] [Indexed: 11/27/2022]
Affiliation(s)
- W. J. Blackshaw
- Anaesthetic Department; Liverpool Heart and Chest Hospital NHS Trust; Liverpool UK
| | - A. Bhawnani
- Anaesthetic Department; Liverpool Heart and Chest Hospital NHS Trust; Liverpool UK
| | - S. H. Pennefather
- Anaesthetic Department; Liverpool Heart and Chest Hospital NHS Trust; Liverpool UK
| | - O. Al-Rawi
- Anaesthetic Department; Liverpool Heart and Chest Hospital NHS Trust; Liverpool UK
| | - S. Agarwal
- Anaesthetic Department; Liverpool Heart and Chest Hospital NHS Trust; Liverpool UK
| | - M. Shaw
- Anaesthetic Department; Liverpool Heart and Chest Hospital NHS Trust; Liverpool UK
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Abstract
Thoracic epidural analgesia (TEA) offers a unique oppor tunity for the anesthesiologist to enhance postopera tive recovery for the thoracic surgery patient. By deliver ing analgesics to a limited dermatomal distribution, TEA can provide profound segmental analgesia and also serves to modulate neural outflow to improve cardiac and pulmonary parameters. The notable side-effects of hypotension and respiratory depression can be mini mized by using synergistic combinations of local anes thetic and opioids, and by adopting a continuous infu sion strategy. With thoughtful patient selection, careful technique, and a proactive approach to the recognition of the known hemodynamic and respiratory effects of epidural drugs, TEA can be administered safely. The significant benefits of TEA include better pain relief, increased FEV1, earlier extubation, and, perhaps, de creased morbidity and mortality.
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Abstract
Analgesia for critically ill patients can be provided most effectively by the use of modern techniques. Under standing of the anatomical pathways for nociceptive sig nal transmission allows the use of techniques that mod ulate or block nociceptive information at several levels (periphery, spinal cord, and systemic). A comprehen sive discussion of analgesic techniques at each level is presented. Formulation of a treatment plan is discussed. Several examples are presented to show the decision- making process for the use of modern analgesic tech niques in critically ill patients.
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Affiliation(s)
- Donald S. Stevens
- Department of Anesthesiology, University of Massachusetts Medical Center, Worcester, MA
| | - W. Thomas Edwards
- Department of Anesthesiology, University of Massachusetts Medical Center, Worcester, MA
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Engen DJ, Carns PE, Allen MS, Bauer BA, Loehrer LL, Cha SS, Chartrand CM, Eggler EJ, Cutshall SM, Wahner-Roedler DL. Evaluating efficacy and feasibility of transcutaneous electrical nerve stimulation for postoperative pain after video-assisted thoracoscopic surgery: A randomized pilot trial. Complement Ther Clin Pract 2016; 23:141-8. [DOI: 10.1016/j.ctcp.2015.04.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 03/09/2015] [Accepted: 04/08/2015] [Indexed: 12/21/2022]
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Veneziano G, Iliev P, Tripi J, Martin D, Aldrink J, Bhalla T, Tobias J. Continuous chloroprocaine infusion for thoracic and caudal epidurals as a postoperative analgesia modality in neonates, infants, and children. Paediatr Anaesth 2016; 26:84-91. [PMID: 26530835 DOI: 10.1111/pan.12807] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/25/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Neonates and infants have decreased metabolic capacity for amide local anesthetics and increased risk of local anesthetic toxicity compared to the general population. Chloroprocaine is an ester local anesthetic that has an extremely short plasma half-life in infants as well as adults. Existing reports support the safety and efficacy of continuous chloroprocaine epidural infusions in neonates and young infants during the intraoperative period. Despite this, continuous chloroprocaine epidural infusion may be an under-utilized method of postoperative analgesia for this patient population. In particular, it may improve pain control in neonates and infants with incisions stretching many dermatomes or those with hepatic impairment. METHODS We retrospectively reviewed our experience over 4 years with continuous chloroprocaine epidural infusions in neonates, infants, and children with a focus on the postoperative management of pain. RESULTS Twenty-one pediatric patients received continuous 2-chloroprocaine epidural infusions for postoperative pain management from January 2010 to April 2014 for thoracic, abdominal, and limb procedures. The epidural infusion consisted of 1.5% chloroprocaine or 1.5% chloroprocaine with fentanyl. Tabulating the morphine and hydromorphone used for rescue analgesia, the median (interquartile range) opioid consumption (mg·kg(-1) ·day(-1) of intravenous morphine equivalents) for the first, second, and third 24-h postoperative periods were 0.02 (0-0.48), 0.30 (0-0.44), and 0.14 (0-0.29), respectively. Examining the total fentanyl usage, the median (interquartile range) fentanyl consumption (μg·kg(-1) ·day(-1)) for first, second, and third 24-h postoperative periods were 3.89 (0.41-7.24), 0 (0.00-4.06), and 0 (0.00-0.51), respectively. The median N-PASS score assessed every 6 h from 0 to 72 h postoperatively was 0, 1, 2, 0, 0, 1, 0, 0, 0, 0, 1, 0, and 0, respectively. The median FLACC score assessed every 6 h from 0 to 72 h postoperatively was 0, 0, 2, 0, 0, 0, 0, 0, 0, 0, 0, 0, and 0, respectively. CONCLUSION The results suggest that chloroprocaine offers an efficacious alternative to the amide local anesthetics for postoperative epidural analgesia in the pediatric population.
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Affiliation(s)
- Giorgio Veneziano
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Peter Iliev
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Jennifer Tripi
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - David Martin
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Jennifer Aldrink
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Tarun Bhalla
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Joseph Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
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Son WG, Jang M, Jo SM, Yoon J, Lee I. The volume effect of lidocaine on thoracic epidural anesthesia in conscious Beagle dogs. Vet Anaesth Analg 2014; 42:414-24. [PMID: 25327756 DOI: 10.1111/vaa.12232] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Accepted: 08/19/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the volume effect of local anesthetic solution on thoracic epidural analgesia in dogs. STUDY DESIGN Prospective, experimental trial. ANIMALS Five healthy adult Beagle dogs weighing 9.7 ± 1.3 kg. METHODS A catheter was inserted into the seventh thoracic epidural space using a lumbosacral approach, and secured with suture under total intravenous (IV) anesthesia with propofol. Each dog was administered four volume treatments (0.05, 0.10, 0.15 and 0.20 mL kg(-1)) of 2% lidocaine via the catheter at 12 hour intervals. In every treatment, dogs were re-anesthetized with propofol (6 mg kg(-1), IV) and isoflurane, and received iohexol at each volume to visualize the epidural distribution (ED) through computed tomography. Three hours after epidurography, when dogs had recovered from anesthesia, the appropriate volume of lidocaine was injected through the catheter, and sensory blockade (SB) in dermatomes was evaluated by pinching with a mosquito forceps. Results were presented as median (range), and the volume effect on ED and SB was analyzed with one-way Kruskal-Wallis anova. RESULTS In proportion to volumes (0.05, 0.10, 0.15 and 0.20 mL kg(-1)), there were significant increases in the extent of ED from 7.4 (5.5-9.0) to 10.4 (8.0-12.0), 13.2 (12.5-13.0), and 15.2 (13.0-18.0) vertebrae, respectively, p < 0.001, and in SB from 2.7 (1.0-5.0) to 6.8 (4.5-10.5), 9.9 (6.5-13.0), and 13.1 (11.0-15.0) dermatomes, respectively, p < 0.001. Unilateral ED and SB were observed in all treatments with various grades, and this distribution was more frequent in the low volume treatments. In the high volume treatments, temporary complications including Horner's syndrome, ataxia, paraplegia, depression, stupor, and intermittent cough occurred often. CONCLUSIONS AND CLINICAL RELEVANCE The increase in volume of local anesthetic solution improved SB by resulting in more consistent bilateral dermatome blockade as well as an extended blockade. However, caution should be exerted, as higher volume injections of lidocaine caused side effects in all dogs.
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Affiliation(s)
- Won-gyun Son
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Seoul National University, Seoul, South Korea
| | - Min Jang
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Seoul National University, Seoul, South Korea
| | - Sang-min Jo
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Seoul National University, Seoul, South Korea
| | - Junghee Yoon
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Seoul National University, Seoul, South Korea
| | - Inhyung Lee
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Seoul National University, Seoul, South Korea
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Sullivan EA. The Role of the Anesthesiologist in Thoracic Surgery: We Can Make A Difference! J Cardiothorac Vasc Anesth 2009; 23:761-5. [DOI: 10.1053/j.jvca.2009.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2009] [Indexed: 11/11/2022]
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Cohen E. Postthoracotomy Pain Management. Semin Cardiothorac Vasc Anesth 1999. [DOI: 10.1177/108925329900300303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In modern medicine, postoperative analgesia is consid ered an integral part of the anesthetic management. Thoracotomy has been reported to be among the most intense clinical postoperative pain experiences. If pain is poorly controlled in the postoperative period, respira tory excursions, movements, and coughing may result in muscle splinting, atelectasis and postoperative pulmo nary dysfunction. This article focuses on the various analgesic modalities that are available for altering the flow of nociceptive information from the periphery to cortex: (1) the transduction of nociceptive information at the peripheral receptor (local anesthetics, nonsteroi dal anti-inflammatory drugs); (2) the transmission of nociceptive information along the afferent sensory neu ral pathways (intercostal, intrapleural, or epidural local anesthetics); and finally, (3) the modulation of nocicep tive input at the level of the dorsal horn of the spinal cord (lumbar or thoracic epidural and intrathecal opi oids) or the brain (systemic opioids). Finally, the role of preemptive analgesia in thoracic surgery is discussed.
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Affiliation(s)
- Edmond Cohen
- Department of Thoracic Anesthesia, Mount Sinai Medical Center, New York, NY
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Affiliation(s)
- P D Slinger
- Department of Anaesthesia, University of Toronto and The Toronto Hospital, Ontario, Canada
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Tobias JD, Rasmussen GE, Holcomb GW, Brock JW, Morgan WM. Continuous caudal anaesthesia with chloroprocaine as an adjunct to general anaesthesia in neonates. Can J Anaesth 1996; 43:69-72. [PMID: 8665639 DOI: 10.1007/bf03015961] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
PURPOSE The authors prospectively evaluated the use of a continuous caudal epidural infusion of chloroprocaine as an adjunct to general anaesthesia during intra-abdominal surgery in neonates. CLINICAL FEATURES The technique was used in 25 neonates ranging in age from 1 to 28 days and in weight from 2.2 to 4.9 kg. Following anaesthetic induction and tracheal intubation, an initial bolus dose of chloroprocaine 3% (1 or 1.5 ml.kg-1) was followed by a continuous infusion of 1 or 1.5 ml.kg-1.hr-1 administered through a caudal epidural catheter. No parenteral opioids were administered. The duration of the surgical procedures varied from one hour five minutes to three hours 15 min. The first three neonates received a bolus dose of 1.0 ml.kg-1 followed by an infusion of 1.0 ml.kg-1.hr-1 chloroprocaine 3%. These three neonates required an additional bolus dose followed by an increase in the infusion to 1.5 ml.kg-1.hr-1 to provide surgical anaesthesia. Adequate intraoperative anaesthesia was achieved in all 25 neonates with an infusion of 1.5 ml.kg-1.hr-1 of chloroprocaine 3%. This was evidenced by a lack of haemodynamic response to surgical manipulation. No neonate required more than 0.2% isoflurane or 70% nitrous oxide in oxygen. No episodes of haemodynamic instability (decreased blood pressure/bradycardia) related to the caudal epidural anaesthesia were noted. Twenty-three of 25 of the neonates' tracheas were extubated immediately (within 10 minutes) following the surgical procedure. CONCLUSIONS Caudal anaesthesia with a continuous infusion of chloroprocaine can be used as an adjunct to general anaesthesia during abdominal surgery in neonates. Our initial experience suggests that the combined technique may eliminate the need for parenteral opioids and limit the intraoperative requirements for inhalational anaesthetic agents.
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Affiliation(s)
- J D Tobias
- Department of Anesthesiology, University of Missouri, Columbia 65212, USA
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Hurford WE, Dutton RP, Alfille PH, Clement D, Wilson RS. Comparison of thoracic and lumbar epidural infusions of bupivacaine and fentanyl for post-thoracotomy analgesia. J Cardiothorac Vasc Anesth 1993; 7:521-5. [PMID: 8268429 DOI: 10.1016/1053-0770(93)90306-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Epidural analgesia, via either a thoracic or lumbar route, is commonly used to provide postoperative analgesia following thoracotomy for pulmonary resection, but little data indicate which location is better in terms of postoperative analgesia, side effects, or associated complications. In this study, 45 patients, who were scheduled to have epidural analgesia and undergo a lateral thoracotomy, were randomized to receive either a thoracic or a lumbar catheter. Pain assessments and routine clinical data were recorded to determine if either thoracic or lumbar epidural catheters provided superior analgesia, fewer side effects, or fewer complications. This study found no statistical difference in pain relief or side effects between lumbar and thoracic epidural analgesia for post-thoracotomy pain. An increased infusion rate (6.4 +/- 1.9 v 5.1 +/- 1.4 mL/h, P = 0.02) was required in the lumbar group to achieve equivalent analgesic levels.
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Affiliation(s)
- W E Hurford
- Department of Anesthesia, Massachusetts General Hospital, and Harvard Medical School, Boston 02114
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Tobias JD. Indications and application of epidural anesthesia in a pediatric population outside the perioperative period. Clin Pediatr (Phila) 1993; 32:81-5. [PMID: 8432084 DOI: 10.1177/000992289303200204] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
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.
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Affiliation(s)
- J D Tobias
- Department of Anesthesiology and Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
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Melendez JA, Cirella VN, Delphin ES. Lumbar epidural fentanyl analgesia after thoracic surgery. JOURNAL OF CARDIOTHORACIC ANESTHESIA 1989; 3:150-3. [PMID: 2519938 DOI: 10.1016/s0888-6296(89)92354-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Thoracic epidural fentanyl has been used successfully for postoperative analgesia in patients undergoing thoracic surgery. Prior investigators have suggested that increasing the administered dosage and volume of lumbar epidural fentanyl may increase the spread of analgesia. The feasibility of injecting a high volume (20 mL) of fentanyl into the lumbar epidural space for post-thoracic surgery analgesia was studied in 17 patients undergoing elective thoracotomy or sternotomy. All patients had a lumbar epidural catheter placed before induction of general anesthesia. No narcotic was administered during surgery. Thirty minutes before the conclusion of anesthesia, 200 micrograms of fentanyl in 16 mL of 0.9% saline was administered via the epidural route. In the intensive care unit (ICU), additional fentanyl in the same dosage and volume was injected when the patient complained of pain. Pain was scored on a linear analog scale pre-injection and 30 minutes post-injection. Arterial blood gases were obtained simultaneously. All patients experienced pain relief within 15 minutes of injection. No significant respiratory depression or hypercarbia was noted. Lumbar epidural fentanyl is a safe and practical alternative to thoracic epidural analgesia in the post-thoracic surgical patient.
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Affiliation(s)
- J A Melendez
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY 10021
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Brynitz S, Schrøder M. Intraoperative cryolysis of intercostal nerves in thoracic surgery. SCANDINAVIAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 1986; 20:85-7. [PMID: 3704603 DOI: 10.3109/14017438609105920] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Pain is a major problem associated with thoracotomy. Intraoperative cryolysis of the intercostal nerves around the incision can essentially reduce the postoperative analgesic requirement and diminish the impairment of ventilatory capacity. To obtain maximum effect, it is recommended that the sites of drainage should also be treated with cryolysis.
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Conacher ID, Paes ML, Jacobson L, Phillips PD, Heaviside DW. Epidural analgesia following thoracic surgery. A review of two years' experience. Anaesthesia 1983; 38:546-51. [PMID: 6869713 DOI: 10.1111/j.1365-2044.1983.tb14065.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The use of thoracic epidurals for postoperative pain relief in 58 patients following thoracic surgery is reviewed. Epidural catheters were inserted at the end of the operative procedure and it was planned that analgesia was to be maintained with a continuous infusion of bupivacaine. In those patients with evidence of successful neurological blockade there was a high incidence of adverse effects. Hypotension occurred in nearly 80% of patients and inadequate analgesia necessitating intramuscular opiates in 30%. The results suggest that the method adopted is unsuitable for some patients who have undergone major pulmonary surgery, although it has proved a useful adjuvant for pain relief in patients who have had other intrathoracic operations.
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Langenstein H, Wolff G. [Catheter epidural analgesia for treatment of postoperative and post-traumatic pain]. LANGENBECKS ARCHIV FUR CHIRURGIE 1982; 358:349-54. [PMID: 7169885 DOI: 10.1007/bf01271816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Postoperative epidural local anesthetics or opiates provide excellent analgesia but do not reduce the incidence of respiratory complications compared with systemic analgesics. Additional and sometimes lethal side effects reserve the routine use of epidural analgesia for highly selected patients. Thoracic epidural analgesia (TEA) may prevent ventilation in patients with serial rib fractures (SRF) without gross pulmonary parenchymal lesion. TEA results in fewer pulmonary complications, shorter hospital stay, and lower mortality than artificial respiration. Late global pulmonary tests after TEA for treatment of SRF show normal results within comparable groups without rib fractures.
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James EC, Kolberg HL, Iwen GW, Gellatly TA, Forks G. Epidural analgesia for post-thoracotomy patients. J Thorac Cardiovasc Surg 1981. [DOI: 10.1016/s0022-5223(19)39241-4] [Citation(s) in RCA: 51] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Peters RM, Clausen JL, Tisi GM. Extending resectability for carcinoma of the lung in patients with impaired pulmonary function. Ann Thorac Surg 1978; 26:250-60. [PMID: 752292 DOI: 10.1016/s0003-4975(10)63679-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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