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Hewson DW, Tedore TR, Hardman JG. Impact of spinal or epidural anaesthesia on perioperative outcomes in adult noncardiac surgery: a narrative review of recent evidence. Br J Anaesth 2024; 133:380-399. [PMID: 38811298 PMCID: PMC11282476 DOI: 10.1016/j.bja.2024.04.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/23/2024] [Accepted: 04/30/2024] [Indexed: 05/31/2024] Open
Abstract
Spinal and epidural anaesthesia and analgesia are important anaesthetic techniques, familiar to all anaesthetists and applied to patients undergoing a range of surgical procedures. Although the immediate effects of a well-conducted neuraxial technique on nociceptive and sympathetic pathways are readily observable in clinical practice, the impact of such techniques on patient-centred perioperative outcomes remains an area of uncertainty and active research. The aim of this review is to present a narrative synthesis of contemporary clinical science on this topic from the most recent 5-year period and summarise the foundational scholarship upon which this research was based. We searched electronic databases for primary research, secondary research, opinion pieces, and guidelines reporting the relationship between neuraxial procedures and standardised perioperative outcomes over the period 2018-2023. Returned citation lists were examined seeking additional studies to contextualise our narrative synthesis of results. Articles were retrieved encompassing the following outcome domains: patient comfort, renal, sepsis and infection, postoperative cancer, cardiovascular, and pulmonary and mortality outcomes. Convincing evidence of the beneficial effect of epidural analgesia on patient comfort after major open thoracoabdominal surgery outcomes was identified. Recent evidence of benefit in the prevention of pulmonary complications and mortality was identified. Despite mechanistic plausibility and supportive observational evidence, there is less certain experimental evidence to support a role for neuraxial techniques impacting on other outcome domains. Evidence of positive impact of neuraxial techniques is best established for the domains of patient comfort, pulmonary complications, and mortality, particularly in the setting of major open thoracoabdominal surgery. Recent evidence does not strongly support a significant impact of neuraxial techniques on cancer, renal, infection, or cardiovascular outcomes after noncardiac surgery in most patient groups.
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Affiliation(s)
- David W Hewson
- Department of Anaesthesia and Critical Care, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK; Academic Unit of Injury, Recovery and Inflammation Sciences, School of Medicine, University of Nottingham, Nottingham, UK.
| | - Tiffany R Tedore
- Department of Anesthesiology, Weill Cornell Medicine, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
| | - Jonathan G Hardman
- Department of Anaesthesia and Critical Care, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK; Academic Unit of Injury, Recovery and Inflammation Sciences, School of Medicine, University of Nottingham, Nottingham, UK
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Gonon A, Richter A, Cederholm I, Khan J, Novak J, Milovanovic M, Janerot-Sjoberg B. Effects of thoracic epidural analgesia on exercise-induced myocardial ischaemia in refractory angina pectoris. Acta Anaesthesiol Scand 2019; 63:515-522. [PMID: 30374950 DOI: 10.1111/aas.13291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Revised: 10/05/2018] [Accepted: 10/11/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND Thoracic epidural analgesia (TEDA) was offered to patients with refractory angina pectoris. Our primary objectives were to evaluate TEDAs´ influence on quality of life (QoL, base for power analysis), and hypothesising that TEDA with bupivacaine during 1 month counteracts exercise-induced myocardial hypoperfusion and increase physical performance. METHODS Patients with refractory angina and exercise inducible hypoperfusion, as demonstrated by myocardial perfusion imaging (MPI), were randomised to 1-month treatment with TEDA with bupivacaine (B-group, n = 9) or saline (P-group, n = 10) in a double-blind fashion. MPI and bicycle ergometry were performed before TEDA and after 1 month while subjective QoL on a visual analogue scale (VAS) reported by the patients was checked weekly. RESULTS During this month VAS (mean [95%CI]) increased similarly in both groups (B-group from 33 [18-50] to 54 [30-78] P < 0.05; P-group from 40 [19-61] to 48 [25-70] P < 0.05). The B-group reduced their exertional-induced myocardial hypoperfusion (from 32% [12-52] to 21% [3-39]; n = 9; P < 0.05), while the P-group showed no significant change (before 21% [6-35]; at 1 month 23% [6-40]; n = 10). MPI at rest did not change and no improvement in physical performance was detected in neither of the groups. CONCLUSIONS In refractory angina, TEDA with bupivacaine inhibits myocardial ischaemia in contrast to TEDA with saline. Regardless of whether bupivacaine or saline is applied intermittently every day, TEDA during 1 month improves the quality of life and reduces angina, even when physical performance remains low. A significant placebo effect has to be considered.
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Affiliation(s)
- Adrian Gonon
- Department of Clinical Science, Intervention & Technology; Karolinska Institutet; Stockholm Sweden
- Department of Clinical Physiology; Karolinska University Hospital; Stockholm Sweden
| | - Arina Richter
- Department of Medicine & Health; Linköping University; Linköping Sweden
- Linköping University Hospital (Heart Centre); Linköping Sweden
| | - Ingemar Cederholm
- Department of Medicine & Health; Linköping University; Linköping Sweden
- Linköping University Hospital (Heart Centre); Linköping Sweden
| | - Jehangir Khan
- Department of Medical Physics; Karolinska University Hospital; Stockholm Sweden
| | - Jacek Novak
- Department of Laboratory Medicine; Karolinska Institutet; Stockholm Sweden
- Department of Clinical Physiology; Karolinska University Hospital; Stockholm Sweden
| | - Micha Milovanovic
- Department of Welfare and Care; Linköping University; Linköping Sweden
| | - Birgitta Janerot-Sjoberg
- Department of Clinical Science, Intervention & Technology; Karolinska Institutet; Stockholm Sweden
- Department of Clinical Physiology; Karolinska University Hospital; Stockholm Sweden
- Department of Medical Technology; Karolinska University Hospital; Stockholm Sweden
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Effects of Thoracic Epidural Anesthesia on Neuronal Cardiac Regulation and Cardiac Function. Anesthesiology 2019; 130:472-491. [DOI: 10.1097/aln.0000000000002558] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Abstract
Cardiac sympathetic blockade with high-thoracic epidural anesthesia is considered beneficial in patients undergoing major surgery because it offers protection in ischemic heart disease. Major outcome studies have failed to confirm such a benefit, however. In fact, there is growing concern about potential harm associated with the use of thoracic epidural anesthesia in high-risk patients, although underlying mechanisms have not been identified. Since the latest review on this subject, a number of clinical and experimental studies have provided new information on the complex interaction between thoracic epidural anesthesia–induced sympatholysis and cardiovascular control mechanisms. Perhaps these new insights may help identify conditions in which benefits of thoracic epidural anesthesia may not outweigh potential risks. For example, cardiac sympathectomy with high-thoracic epidural anesthesia decreases right ventricular function and attenuates its capacity to cope with increased right ventricular afterload. Although the clinical significance of this pathophysiologic interaction is unknown at present, it identifies a subgroup of patients with established or pending pulmonary hypertension for whom outcome studies are needed. Other new areas of interest include the impact of thoracic epidural anesthesia–induced sympatholysis on cardiovascular control in conditions associated with increased sympathetic tone, surgical stress, and hemodynamic disruption. It was considered appropriate to collect and analyze all recent scientific information on this subject to provide a comprehensive update on the cardiovascular effects of high-thoracic epidural anesthesia and cardiac sympathectomy in healthy and diseased patients.
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Slikkerveer J, de Boer K, Robbers LFHJ, van Rossum AC, Kamp O. Evaluation of extracorporeal shock wave therapy for refractory angina pectoris with quantitative analysis using cardiac magnetic resonance imaging: a short communication. Neth Heart J 2016; 24:319-25. [PMID: 27059621 PMCID: PMC4840110 DOI: 10.1007/s12471-016-0825-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Aims There is a continuing search for new treatment options in patients who suffer from refractory angina pectoris to improve quality of life. Several studies have recently demonstrated promising results by stimulating angiogenesis using extracorporeal shockwave therapy in these patients. The purpose of this study is to quantitatively analyse the effect of extracorporeal shockwave therapy on myocardial perfusion in patients with refractory angina pectoris. Methods We included 15 patients with NYHA class 3–4 of whom 8 patients underwent baseline and follow-up cardiac magnetic resonance imaging (CMR). All patients received 9 shockwave treatments of their ischaemic zone over a period of 3 months. Results Quantitative analysis of myocardial perfusion using CMR revealed no significant improvement of myocardial perfusion after treatment (0.80 ± 0.22 vs 0.76 ± 0.31; p = 0.42). However, the total group of 15 patients did experience a significant improvement in NYHA class (p = 0.034) and reduction of nitroglycerin use (p = 0.012). Conclusion Although treatment with extracorporeal shockwave was associated with an improvement in NYHA class, we could not observe an improvement in myocardial ischaemic zone and perfusion with CMR. To unravel the exact mechanisms of shockwave treatment, more in vitro and animal studies as well as larger (placebo-controlled) studies are required.
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Affiliation(s)
- J Slikkerveer
- Department of Cardiology and Institute of Cardiovascular Research, VU University Medical Center, De Boelelaan 1117, 1081, HV Amsterdam, the Netherlands.
- Interuniversity Cardiology Institute of the Netherlands, Utrecht, the Netherlands.
| | - K de Boer
- Department of Cardiology and Institute of Cardiovascular Research, VU University Medical Center, De Boelelaan 1117, 1081, HV Amsterdam, the Netherlands
| | - L F H J Robbers
- Department of Cardiology and Institute of Cardiovascular Research, VU University Medical Center, De Boelelaan 1117, 1081, HV Amsterdam, the Netherlands
- Interuniversity Cardiology Institute of the Netherlands, Utrecht, the Netherlands
| | - A C van Rossum
- Department of Cardiology and Institute of Cardiovascular Research, VU University Medical Center, De Boelelaan 1117, 1081, HV Amsterdam, the Netherlands
| | - O Kamp
- Department of Cardiology and Institute of Cardiovascular Research, VU University Medical Center, De Boelelaan 1117, 1081, HV Amsterdam, the Netherlands
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Landoni G, Isella F, Greco M, Zangrillo A, Royse CF. Benefits and risks of epidural analgesia in cardiac surgery. Br J Anaesth 2015; 115:25-32. [PMID: 26089444 DOI: 10.1093/bja/aev201] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Epidurals provide excellent analgesia for cardiac surgery and may reduce complications. However, their use has been tempered because of concern of the rare, but serious complication of epidural haematoma. The aim of this meta-analysis was to assess the effect of epidural on survival and the risk estimate of epidural haematoma. METHODS A systematic review of the literature (Pubmed, Embase, Scopus and the Cochrane Register) and a meta-analysis of the available randomized and case-matched studies were performed to estimate the effect on survival. An international, directed and viral anonymous survey was performed to identify the incidence of haematomas with a corresponding estimate of the number of epidurals performed. RESULTS Of 66 randomized and case-matched studies, 57 trials including 6383 patients reported the incidence of all-cause mortality at the longest follow up available, with a significant reduction with epidurals (59/3123 [1.9%] vs 108/3260 [3.3%] in the control arm, RR 0.65 [95% CI 0.48-0.86], P=0.003, NNT=70). No epidural haematoma was reported in these 66 trials (3320 epidurals). All other literature revealed nine haematomas in 13,100 patients. Through the anonymous, web-based, viral, international survey, we identified 16 further, non-published, epidural haematomas from 72,400 positioned epidurals. Therefore, a total of 25 haematomas have been identified from an estimate of 88,820 positioned epidurals, producing an estimated risk of 1:3552 (95% CI 1:2552-1:5841). CONCLUSIONS The use of epidural analgesia in cardiac surgery is associated with a reduction in mortality (NNT=70), and with an estimated risk of epidural haematoma of 1:3552.
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Affiliation(s)
- G Landoni
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute Vita-Salute San Raffaele University, Via Olgettina 60, Milan 20132, Italy
| | - F Isella
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute
| | - M Greco
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute
| | - A Zangrillo
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute Vita-Salute San Raffaele University, Via Olgettina 60, Milan 20132, Italy
| | - C F Royse
- Anaesthesia and Pain Management Unit, The Royal Melbourne Hospital Department of Surgery, The University of Melbourne, The Royal Melbourne Hospital, Level 6 Clinical Medical Research Building, Melbourne, VIC 3050, Australia
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GE TONG, QIN HAO, WANG XU, YANG SHUSEN, GUO LI, HAN WEI, CHANG HUIYING. Effects of Thoracic Epidural Anesthesia on Cardiac Function and Myocardial Cell Apoptosis in Isoproterenol-Induced Chronic Heart Failure Rats. J Interv Cardiol 2014; 27:446-55. [PMID: 25267251 DOI: 10.1111/joic.12147] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- TONG GE
- Department of Respiratory Medicine; the Second Hospital of Harbin; Harbin 150000 P.R. China
| | - HAO QIN
- Department of Respiratory Medicine; the Second Hospital of Harbin; Harbin 150000 P.R. China
| | - XU WANG
- Department of Cardiology; The First Affiliated Hospital of Harbin Medical University; Harbin P.R. China
| | - SHU-SEN YANG
- Department of Cardiology; The First Affiliated Hospital of Harbin Medical University; Harbin P.R. China
| | - LI GUO
- Department of Respiratory Medicine; the Second Hospital of Harbin; Harbin 150000 P.R. China
| | - WEI HAN
- Department of Cardiology; The First Affiliated Hospital of Harbin Medical University; Harbin P.R. China
| | - HUI-YING CHANG
- Department of Cardiology; The First Affiliated Hospital of Harbin Medical University; Harbin P.R. China
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Dobias M, Michalek P, Neuzil P, Stritesky M, Johnston P. Interventional treatment of pain in refractory angina. A review. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2014; 158:518-27. [PMID: 24993738 DOI: 10.5507/bp.2014.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Accepted: 05/22/2014] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Refractory angina is characterized by repeated attacks of chest pain in patients on maximal anti-anginal pharmacotherapy, with a professional conscensus that further surgical or radiological revascularization would be futile. Refractory angina is a serious but relatively uncommon health problem, with a reported incidence of approximately 30 patients per million people/year. In this condition simply treating the associated pain alone is important as this can improve exercise tolerance and quality of life. METHODS An extensive literature search using five different medical databases was performed and from this, eighty-three papers were considered appropriate to include within this review. RESULTS AND CONCLUSION Available literature highlights several methods of interventional pain treatment, including spinal cord stimulation and video-assisted upper thoracic sympathectomy which can provide good analgesia whilst improving physical activities and quality of life. The positive effect of spinal cord stimulation on the intensity of pain and quality of life has been confirmed in nine randomized controlled trials. Other potential treatment methods include stellate ganglion blocks, insertion of thoracic epidural or spinal catheters and transcutaneous electrical nerve stimulation. These approaches however appear more useful for diagnostic purposes and perhaps as short-term treatment measures.
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Affiliation(s)
- Milos Dobias
- Department of Anaesthesia and Intensive Medicine, 1st Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
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Zhao YJ, Liu FQ, Xiu CH, Jiang J, Wang JH, Xu YS, Fu SY, Huang Q. The Effects of High Thoracic Epidural Anesthesia on Sympathetic Activity and Apoptosis in Experimentally Induced Congestive Heart Failure. J Cardiothorac Vasc Anesth 2014; 28:317-22. [DOI: 10.1053/j.jvca.2013.05.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Indexed: 01/17/2023]
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The challenges of understanding and managing pain in the heart failure patient. Curr Opin Support Palliat Care 2013; 7:14-20. [PMID: 23254859 DOI: 10.1097/spc.0b013e32835c1f2f] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE OF REVIEW Heart failure is a leading cause of significant disability and death throughout the world. The assessment and management of pain syndromes in heart failure require specialized knowledge of the pathophysiology of pain and of heart failure. Effective treatment entails an understanding of the physical, psychological, spiritual and social aspects of the pain experience and how pharmacological interventions need to be carefully tailored in this patient population. As we intensify technology to manage the challenges of heart failure it is critical that we review as a profession this critical issue. RECENT FINDINGS We will review the various aspects of the pain experience for the heart failure patient, disease-specific treatment modalities and ways to incorporate existing expertise in pain management in to the care of these complex patients. Most recently the Pain Assessment, Incidence & Nature in Heart Failure trial has been completed and is currently in publication. This study was the first attempt at trying to understand the complexity of pain in the heart failure patients and will be the foundation for future work. SUMMARY In closing, as palliative care and hospice move further in to the care of patients with complex, chronic illnesses, it is essential that we take this foundational work and expand upon it. Recognizing that pain and suffering in the heart failure patient is multidimensional and that the physical experience of pain is multifactorial is the beginning of developing expertise and improving the quality of care delivered to these patients.
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