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Koster ITS, den Os MM, Rutten MVH, van den Dungen TRI, de Jong T, Winters HAH, Driessen C. The Effect of Regional Anaesthesia on Free Flap Survival in Lower Extremity Reconstructions. Strategies Trauma Limb Reconstr 2024; 19:15-20. [PMID: 38752188 PMCID: PMC11091895 DOI: 10.5005/jp-journals-10080-1612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 04/07/2024] [Indexed: 05/18/2024] Open
Abstract
Background The effect of different modalities of anaesthesia in microvascular free flap surgery has been a topic of ongoing debate. Comparative data to study the effect of general anaesthesia and regional anaesthesia in the form of peripheral nerve blocks (PNBs) on lower extremity free flap survival is lacking to date. This study aims to elucidate the effect of regional anaesthesia on flap survival in lower extremity free flap reconstructions. Methods A retrospective cohort study of all patients who underwent free vascularised flap reconstruction of the lower extremities between 2012 and 2021 at the Amsterdam University Medical Centre (UMC), The Netherlands, and between 2019 and 2021 at the Radboud UMC, Nijmegen, The Netherlands. In this cohort, we analysed partial and total flap failures. Results In this cohort, 87 patients received a total of 102 microvascular free flap reconstructions of the lower extremity. In 20.5% of these operations, patients received a supplemental PNB. Total flap failure was 23.8% in the regional anaesthesia group compared to 21% in the group with general anaesthesia only (p = 0.779). Operation time was longer for patients with regional anaesthesia (p = 0.057). Length of stay was on average 2 days shorter for patients with supplemental regional anaesthesia (p = 0.716). Discussion This is the largest cohort comparing flap survival in patients receiving general anaesthesia to general anaesthesia with a PNB in lower extremity reconstructions to date. We cannot attribute a significant beneficial or detrimental effect of regional anaesthesia to flap survival. High failure rates stress the need for future studies. How to cite this article Koster ITS, den Os MM, Rutten MVH, et al. The Effect of Regional Anaesthesia on Free Flap Survival in Lower Extremity Reconstructions. Strategies Trauma Limb Reconstr 2024;19(1):15-20.
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Affiliation(s)
- Isabelle TS Koster
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Matthijs M den Os
- Department of Anesthesiology, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Martin VH Rutten
- Department of Anesthesiology, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Thibault RI van den Dungen
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Tim de Jong
- Department of Plastic Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Hay AH Winters
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Caroline Driessen
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Centre, Amsterdam, The Netherlands
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Zhang Q, Ling M, Wang X, Cui D. A Comparison of Two Peripheral Nerve Blocks Combined With General Anesthesia in Elderly Patients Undergoing Arthroplasty for Hip Fractures: A Pilot Randomized Controlled Trial. Front Surg 2022; 9:715422. [PMID: 35252320 PMCID: PMC8891216 DOI: 10.3389/fsurg.2022.715422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 01/14/2022] [Indexed: 11/23/2022] Open
Abstract
Background Combined anesthesia can be a promising option for hip surgery when neuraxial anesthesia is contraindicated. Lumbar and sacral plexus blocks, and femoral nerve and lateral femoral cutaneous (LFC) nerve blocks in combination with general anesthesia (GA) are commonly used in elderly patients undergoing arthroplasty for hip fracture surgery. However, no study has compared these two anesthetic strategies in the perioperative period. Methods A total of 41 elderly patients scheduled for arthroplasty for hip fracture surgery were randomized into group A (n = 20) and group B (n = 21). Group A received femoral nerve block, LFC nerve blocks, and GA, and group B received lumbar plexus block, sacral plexus block, and GA. Primary outcomes were incidences of hemodynamic events and changes in blood pressure (BP) and heart rate (HR). Secondary outcomes included time and drug consumption, infusion and bleeding volume, eyes opening time after surgery, and postoperative quality recovery rate. Results Compared with group B, group A showed a lower incidence of intraoperative hypotension (p < 0.001), higher BP [including mean arterial pressure (MAP), systolic BP (SBP), and diastolic BP (DBP)] following induction (IN), and higher HR from mid-surgery. Time required for nerve blockade (p < 0.001) and ephedrine consumption was significantly shorter in group A (p < 0.001), while sufentanil consumption was higher as compared to group B (p = 0.002). No significant differences in other intraoperative parameters and postoperative quality recovery rate were reported during the observation. Conclusion Our pilot data indicate that compared with lumbar and sacral plexus blocks, femoral nerve and LFC nerve blocks may provide more stable intraoperative hemodynamics and a comparable postoperative recovery for elderly patients undergoing arthroplasty for hip fracture under GA. Further studies with a larger sample size are needed to derive stronger evidence.
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Affiliation(s)
- Qingfu Zhang
- Department of Anesthesiology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Ming Ling
- Department of Orthopedics, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Xintao Wang
- Department of Anesthesiology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Derong Cui
- Department of Anesthesiology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China
- *Correspondence: Derong Cui
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Continuous Incisional Lidocaine in Pediatric Patients following Open Heart Surgery. BIOMED RESEARCH INTERNATIONAL 2022; 2022:1403539. [PMID: 35028312 PMCID: PMC8752221 DOI: 10.1155/2022/1403539] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 11/24/2021] [Accepted: 12/03/2021] [Indexed: 11/17/2022]
Abstract
Continuous incisional lidocaine infusion has been proposed as an adjunctive therapy in the management of postoperative pain in adult patients. The aim of this study was to determine the efficacy and safety of a continuous subcutaneous lidocaine infusion in pediatric patients following open heart surgery. All patients receiving a subcutaneous lidocaine infusion in median sternotomy incisions after open heart surgery during 2 consecutive years were included in the study. A historical cohort of patients was used as a control group. Demographic variables (age, size, and surgical procedure), variables related to sedation and analgesia (COMFORT and analgesia scales, drug doses, and duration), and complications were registered. 106 patients in the lidocaine infusion group and 79 patients in the control group were included. Incisional analgesia was effective for the treatment of pain as it reduced the dose and duration of intravenous fentanyl (odds ratio (OR) 6.26, confidence interval (CI) 95%: 2.48-15.97, p = 0.001; OR 4.30, CI 95%: 2.09-8.84, p = 0.001, respectively). The reduction in fentanyl use was more important in children over two years of age. Adverse effects were seen in three children (2.8%): they all had decreased level of consciousness, and one of them presented seizures as well. Two of these three patients had lidocaine levels over 2 mcg/ml. A continuous lidocaine incisional infusion is effective for the treatment of pain after open heart surgery. This procedure reduced intravenous analgesic drug requirements in pediatric patients undergoing a median sternotomy incision. Although the incidence of secondary effects is low, monitoring of neurologic status and lidocaine blood levels are recommended in all patients.
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Ashouri M, Karvandian K, Ataie-Ashtiani Z, Mohammadzadeh N. Continuous epidural catheter for anaesthesia management and post-op pain relief in colorectal surgery, complicated by epidural haematoma and bilateral paraplegia: A case report. Int J Surg Case Rep 2021; 83:106039. [PMID: 34090200 PMCID: PMC8188378 DOI: 10.1016/j.ijscr.2021.106039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 05/23/2021] [Accepted: 05/23/2021] [Indexed: 12/05/2022] Open
Abstract
Introduction Utilising epidural analgesia (EA) during major abdominal surgery in combination with general anaesthetic, is a proven approach to decrease anaesthetic requirement in patients with severe comorbidities, enhance recovery and improve pain management. Case presentation Herein we report a case of an 81-years-old female with bilateral lower limb sensory loss, saddle paraesthesia, paraplegia, and incontinence following a thoracic epidural catheterisation required for low anterior resection of rectal adenocarcinoma. The complication was reported by the patient on the third day of post-op. Clinical discussion The magnetic resonance imaging results revealed an extradural extramedullary hyperintense haematoma in the spinal cord at T12-L2 vertebral level. The neurological deficit was addressed urgently with laminectomy; and following implementation of intensive inpatient physiotherapy and rehabilitation regiment the patient restored mild motor function. Conclusion We believe the culprit of the acute focal neurology deficits in this patient could be due to the epidural catheterisation and the post-op local anaesthetic injections. From this case, we anecdotally recommend performing thoracolumbar MRI as part of pre-op workup in patients with long standing back issues or claudication, considering x-ray guided catheterisation in higher risk patients for epidural hematoma, and early and repeated neurological examination and rapid investigation for any mild neurological deficits. Epidural anaesthesia is a common practice in colorectal surgery for pain management. Epidural haematoma formation due to epidural anaesthesia in a colorectal surgical case Delayed presentation of neurological deficits: bilateral paraesthesia, paraplegia, and incontinence Identifying at risk patients, proactive thoracolumbar MRI imaging Recommend X-ray guided epidural catheter insertion and close neurological monitoring
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Affiliation(s)
| | - Kasra Karvandian
- Department of Anesthesiology, Imam Khomeini Hospital Complex, Iran
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Zanjani AP, Ghorbani A, Eslami B, Mirzashahi B. Epidural Anesthesia Combined with Light General Anesthesia for a Juvenile with Charcot-Marie-Tooth Disease Undergoing Corrective Spine Surgery: A Case Report. Anesth Pain Med 2017; 7:e14189. [PMID: 29696112 PMCID: PMC5903216 DOI: 10.5812/aapm.14189] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 05/28/2017] [Accepted: 10/10/2017] [Indexed: 11/16/2022] Open
Abstract
General anesthesia (GA) is associated with serious concerns in advanced cases of Charcot-Marie-Tooth (CMT). Despite several benefits of applying regional anesthesia (RA), recommendation for RA is controversial in CMT due to insufficient supporting documents and trials. We report combined epidural/general anesthesia for a 12-year-old boy with CMT disease undergoing major spine corrective surgery. This manuscript is presented not only to evaluate the costs and benefits of RA, but also to highlight the safety of neuraxial anesthesia and emphasis on the broad potential role of RA to reduce risks of GA in CMT patients.
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Affiliation(s)
- Amir Poya Zanjani
- Departement of Anesthesiology and Critical Care, Tehran University of Medical Sciences, Tehran, Iran
- Corresponding author: Amir Poya Zanjani, Assistant Professor of Anesthesiology, Departement of Anesthesiology and Critical Care, Tehran University of Medical Sciences, Tehran, Iran. Tel: +98-21-66581632, E-mail:
| | - Azam Ghorbani
- Departement of Anesthesiology and Critical Care, Tehran University of Medical Sciences, Tehran, Iran
| | - Babak Eslami
- Departement of Anesthesiology and Critical Care, Tehran University of Medical Sciences, Tehran, Iran
| | - Babak Mirzashahi
- Departement of Orthopedics, Tehran University of Medical Sciences, Tehran, Iran
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Ozturk L, Kesimci E, Albayrak T, Kanbak O. Bispectral index-guided general anaesthesia in combination with interscalene block reduces desflurane consumption in arthroscopic shoulder surgery: a clinical comparison of bupivacaine versus levobupivacaine. BMC Anesthesiol 2015; 15:104. [PMID: 26194656 PMCID: PMC4508821 DOI: 10.1186/s12871-015-0087-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Accepted: 07/13/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The goal of this study was to compare the influence of an interscalene brachial plexus block (ISB) performed with either bupivacaine or levobupivacaine in conjunction with general anaesthesia (GA) on desflurane consumption, which was titrated to maintain the recovery profiles and postoperative analgesia while also keeping the bispectral index score (BIS) between 40 and 60 in patients undergoing arthroscopic shoulder surgery. METHODS Sixty patients undergoing arthroscopic shoulder surgery were prospectively randomized to receive GA with desflurane alone (group C) or in combination with a preoperative ISB by either bupivacaine 0.25 % (group B) 40 ml or levobupivacaine 0.25 % (group L) 40 ml. BIS scores or respiratory and hemodynamic parameters during the operation, recovery characteristics, consumed doses of desflurane and pain intensities were evaluated. RESULTS The eye opening time was 4.0 ± 2.5 minutes for group B, 4.6 ± 2.4 minutes for group L, and 6.2 ± 2.1 minutes for group C (p < 0.05). Group B and group L saved 36 % and 25 % desflurane per unit time respectively when compared with group C (p < 0.001and p < 0.05) while the mean pain scores and analgesic requirements the first day after surgery were higher in group C (p < 0.05). CONCLUSIONS Because of lower desflurane consumption, a superior recovery profile, and a high degree of patient acceptance, general anaesthesia in combination with interscalene block may be preferred in arthroscopic shoulder surgery. TRIAL REGISTRATION The trial registration number is ACTRN12613000381785.
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Affiliation(s)
- Levent Ozturk
- Department of Anaesthesiology and Reanimation, Yıldırım Beyazıt University Ataturk Training and Research Hospital, Bilkent, Ankara, 06800, Turkey.
| | - Elvin Kesimci
- Anaesthesiology and Intensive Care Department, Ankara Ataturk Training and Research Hospital, Ankara, Turkey
| | - Tuna Albayrak
- Anaesthesiology and Intensive Care Department, Ankara Ataturk Training and Research Hospital, Ankara, Turkey
| | - Orhan Kanbak
- Anaesthesiology and Intensive Care Department, Ankara Ataturk Training and Research Hospital, Ankara, Turkey
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Pleth variability index-directed fluid management in abdominal surgery under combined general and epidural anesthesia. J Clin Monit Comput 2014; 29:47-52. [PMID: 24557584 DOI: 10.1007/s10877-014-9567-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Accepted: 02/13/2014] [Indexed: 01/13/2023]
Abstract
Pleth variability index (PVI), a noninvasive dynamic indicator of fluid responsiveness has been demonstrated to be useful in the management of the patients with goal directed fluid therapy under general anesthesia, but whether PVI can be used to optimize fluid management under combined general and epidural anesthesia (GEN-EPI) remains to be elucidated. The aim of our study was to explore the impact of PVI as a goal-directed fluid therapy parameter on the tissue perfusion for patients with GEN-EPI. Thirty ASA I-II patients scheduled for major abdominal surgeries under GEN-EPI were randomized into PVI-directed fluid management group (PVI group) and non PVI-directed fluid management group (control group). 2 mL/kg/h crystalloid fluid infusion was maintained in PVI group, once PVI>13%, a 250 mL colloid or crystalloid was rapidly infused. 4-8 mL/kg/h crystalloid fluid infusion was maintained in control group, and quick fluid infusion was initiated if mean arterial blood pressure (BP)<65 mmHg. Small doses of norepinephrine were given to keep mean arterial BP above 65 mmHg as needed in both groups. Perioperative lactate levels, hemodynamic changes were recorded individually. The total amount of intraoperative fluids, the amount of crystalloid fluid and the first hour blood lactate levels during surgery were significantly lower in PVI than control group, P<0.05. PVI-based goal-directed fluid management can reduce the intraoperative fluid amount and blood lactate levels in patients under GEN-EPI, especially the crystalloid. Furthermore, the first hour following GEN-EPI might be the critical period for anesthesiologist to optimize the fluid management.
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Sundarathiti P, Pasutharnchat K, Jommaroeng P. Thoracic epidural-general analgesia in scoliosis surgery. J Clin Anesth 2011; 22:410-4. [PMID: 20868960 DOI: 10.1016/j.jclinane.2009.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2007] [Revised: 09/28/2009] [Accepted: 10/01/2009] [Indexed: 10/19/2022]
Abstract
STUDY OBJECTIVE To evaluate the efficacy of thoracic epidural analgesia (TEA) in scoliosis surgery. DESIGN Descriptive clinical study. SETTING University hospital. PATIENTS 15 ASA physical status I, II, and III patients undergoing thoracolumbar scoliosis correction. INTERVENTIONS TEA was performed at three to 5 cm cephalad to the incision, and 5 to 10 mL of 0.125% - 0.2% levobupivacaine was given initially. Then, 5 to 10 mL of levobupivacaine was infused hourly throughout the operation. General anesthesia (GA) was induced with thiopental sodium (5 mg/kg) and fentanyl (one μg/kg) and was maintained with 0.2% sevoflurane and 50% nitrous oxide in oxygen. Intraoperative epidural morphine (two to three mg) was administered, and 0.1% levobupivacaine with morphine (0.04 to 0.08 mg/mL) was infused at two to 4 mL/hr for postoperative analgesia. MEASUREMENTS Adequacy of anesthesia, postanesthetic recovery and analgesia, adverse effects, and patient satisfaction were recorded. MAIN RESULTS 20% of patients underwent more than 10 levels of correction, and 53% had coexisting morbid diseases. All had adequate anesthesia. Immediately in the Postanesthesia Care Unit (PACU), 67% of patients reached an Aldrete score of 10, and 40% were fully awake and oriented. All patients were arousable to command and able to flex their hips and knees. None had intraoperative recall. 73% reported no pain in the PACU or 6 hours postoperatively. No serious adverse effects occurred. 80% of patients rated their satisfaction as "good". CONCLUSIONS Preincisional application of TEA with light GA may be used effectively in thoracolumbar scoliosis surgery.
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Affiliation(s)
- Petchara Sundarathiti
- Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand.
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Stamenković DM, Ranković VI, Slavković ZV, Ostojić M. [Current opinion in epidural analgesia influence on incidence of complications after major abdominal surgery]. ACTA CHIRURGICA IUGOSLAVICA 2007; 54:105-108. [PMID: 18044326 DOI: 10.2298/aci0702105s] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Review article summarizes current knowledge of general and epidural anaesthesia combination for major abdominal surgery and incidence of postoperative complications. Continuous epidural local anaesthetics especially through thoracic placed epidural catheter decrease opioids use and as part of "acute rehabilitation" plays important role in postoperative recovery. Most of the studies showed tion is not dependent on kind of anaesthesia and analgesia. Successfully treated postoperative pain prevents chronic postoperative pain, which is best achieved in abdominal surgery with thoracic epidural use.
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Affiliation(s)
- D M Stamenković
- Washington University, School of Medicine, Anesthesiology Department, St Louis, Missouri, USA
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