Is epidural analgesia still a viable option for enhanced recovery after abdominal surgery

Quadratus lumborum block is feasible alternative to epidural block for postoperative analgesia after open radical cystectomy: surgical and oncological outcomes of a randomised clinical trial

OBJECTIVE

The current lack of standardised perioperative pain management protocols for open radical cystectomy (ORC) underscores the need for alternative approaches to the longstanding tradition of epidural block. The aim of this study was to assess the impact of bilateral single injection quadratum lumborum block (QLB) on patients' recovery and complication rates compared with epidural analgesia after ORC in a single-centre, randomised, parallel-group trial including adult patients with bladder cancer.

MATERIAL AND METHODS

Consecutive ORC patients were randomly allocated into QLB and the epidural group. The primary endpoint of this study was related to opioid consumption, and the results have been published earlier. This report focuses on secondary outcomes.

RESULTS

This study included a total of 41 patients, with 20 patients in the QLB group and 21 patients in the epidural group. Finally, 39 patients were included in the analysis.  There was a trend for more frequent need for postoperative norepinephrine and fluid support in the epidural group but without statistical significance. Postoperative complication rate was similar. Two patients in the epidural group compared to none in the QLB group were rehospitalised within 30 and 90 days. Mortality rate within 90 days was higher in the epidural group (4 vs. 0 patients, P = 0.064).

CONCLUSIONS

In this trial, there were no significant differences in surgical and oncological outcomes after ORC when QLB is compared with epidural block for postoperative analgesia.  Trial registration: ClinicalTrials.gov Identifier: NCT03328988.

Ultrasound-assisted middle thoracic epidural catheter placement utilizing the most dorsal sites of bilateral transverse process roots as anatomical landmarks: A cadaveric observational study and a clinical randomized controlled trial

STUDY OBJECTIVE

We developed an innovative method for ultrasound-assisted thoracic epidural catheter placement and assessed its potential to reduce procedural duration for trainees.

DESIGN

A cadaveric observational study and a clinical randomized controlled trial.

SETTING

Sapporo Medical University Hospital.

PATIENTS

A total of 52 adult patients scheduled for thoracic or abdominal surgery and four cadavers.

INTERVENTIONS

Patients were randomly assigned to either group receiving conventional palpation (conventional group) or combination of the ultrasound examination and conventional palpation (ultrasound group).

MEASUREMENTS

The primary outcome was total procedure time (sum of skin marking time and needling time) by trainees. The secondary outcomes were (1) skin marking time, (2) needling time, (3) multiple skin punctures, (4) needle redirection, (5) complications, and (6) failed cases.

MAIN RESULTS

Through dissection of four cadavers, the most dorsal site of the transverse process root was identifiable by ultrasound and the reliable indicator of the interlaminar space. We devised ultrasound-assisted middle thoracic epidural catheter placement utilizing the most dorsal sites of bilateral transverse process roots as anatomical landmarks. Trainees in the ultrasound group had significantly longer skin marking time and significantly shorter needling time than those in the conventional group (107 [87-158] vs 46 s [34-54] s, p < 0.001 and 197 [156-328] vs 341 [303-488] s, p = 0.003). Consequently, there was no significant difference between the two groups in total procedure time (326 [263-467] s vs 391 [354-533] s, p = 0.167). Moreover, the probability of trainee failure in epidural anesthesia was significantly lower in the ultrasound group (2/26 [17.7 %] vs 10/26 [38.5 %], p = 0.019).

CONCLUSIONS

Our novel technique for thoracic epidural catheter placement resulted in expedited needling and enhanced success rates among trainees, although there was no significant difference between total procedure time when using ultrasound guidance and that when using conventional palpation.

Readability and quality assessment of online patient education materials for spinal and epidural anesthesia

PURPOSE

Guidelines recommend that health-related information for patients should be written at or below the sixth-grade level. We sought to evaluate the readability level and quality of online patient education materials regarding epidural and spinal anesthesia.

METHODS

We evaluated webpages with content written specifically regarding either spinal or epidural anesthesia, identified using 11 relevant search terms, with seven commonly used readability formulas: Flesh-Kincaid Grade Level (FKGL), Gunning Fox Index (GFI), Coleman-Liau Index (CLI), Automated Readability Index (ARI), Simple Measure of Gobbledygook (SMOG), Flesch Reading Ease (FRE), and New Dale-Chall (NDC). Two evaluators assessed the quality of the reading materials using the Brief DISCERN tool.

RESULTS

We analyzed 261 webpages. The mean (standard deviation) readability scores were: FKGL = 8.8 (1.9), GFI = 11.2 (2.2), CLI = 10.3 (1.9), ARI = 8.1 (2.2), SMOG = 11.6 (1.6), FRE = 55.7 (10.8), and NDC = 5.4 (1.0). The mean grade level was higher than the recommended sixth-grade level when calculated with six of the seven readability formulas. The average Brief DISCERN score was 16.0.

CONCLUSION

Readability levels of online patient education materials pertaining to epidural and spinal anesthesia are higher than recommended. When we evaluated the quality of the information using a validated tool, the materials were found to be just below the threshold of what is considered good quality. Authors of educational materials should provide not only readable but also good-quality information to enhance patient understanding.

Could epidural analgesia be safely used for acute postoperative pain in older adults to enhance recovery?

Epidural analgesia is often considered cornerstone in multimodal analgesia when used in major surgeries. However, its role in managing acute postoperative pain in elderly patients is debatable because of its known potential complications. Furthermore, postoperative pain in elderly patients is under-treated because of complex comorbidities, and they are more prone to adverse events related to pain therapies. All systemic analgesic drugs have pharmacological limitations and precautions in elderly people. Recent meta-analyses showed that epidural analgesia provided better postoperative pain control compared to intravenous opioids. Interestingly, peripheral nerve blocks had no superior control of pain over epidural analgesia. In addition, epidural analgesia has shown to positively affect perioperative morbidities and mortalities, and reduce opioid-related side effects because of its non-analgesic effects on each organ system. When tailored in a specific multimodal approach, it shortens the intensive care and hospital stays. In conclusion, if complications are identified and treated early, and contraindications are ruled out, epidural analgesia can achieve sufficient postoperative pain management with insignificant adverse events in this population.

Comparative efficacy and safety of non-neuraxial analgesic techniques for midline laparotomy: a systematic review and frequentist network meta-analysis of randomised controlled trials

BACKGROUND

Fascial plane blocks provide effective analgesia after midline laparotomy; however, the most efficacious technique has not been determined. We conducted a systematic review and network meta-analysis of randomised controlled trials to synthesise the evidence with respect to pain, opioid consumption, and adverse events.

METHODS

We searched Ovid MEDLINE, Embase, Cochrane Central, and Scopus databases for studies comparing commonly used non-neuraxial analgesic techniques for midline laparotomy in adult patients. The co-primary outcomes of the study were 24-h cumulative opioid consumption and 24-h resting pain score, reported as i.v. morphine equivalents and 11-point numerical rating scale, respectively. We performed a frequentist meta-analysis using a random-effects model and a cluster-rank analysis of the co-primary outcomes.

RESULTS

Of 6115 studies screened, 67 eligible studies were included (n=4410). Interventions with the greatest reduction in 24-h cumulative opioid consumption compared with placebo/no intervention were single-injection quadratus lumborum block (sQLB; mean difference [MD] -16.1 mg, 95% confidence interval [CI] -29.9 to -2.3, very low certainty), continuous transversus abdominis plane block (cTAP; MD -14.0 mg, 95% CI -21.6 to -6.4, low certainty), single-injection transversus abdominis plane block (sTAP; MD -13.7 mg, 95% CI -17.4 to -10.0, low certainty), and continuous rectus sheath block (cRSB; MD -13.2 mg, 95% CI -20.3 to -6.1, low certainty). Interventions with the greatest reduction in 24-h resting pain score were cRSB (MD -1.2, 95% CI -1.8 to -0.6, low certainty), cTAP (MD -1.0, 95% CI -1.7 to -0.2, low certainty), and continuous wound infusion (cWI; MD -0.7, 95% CI -1.1 to -0.4, low certainty). Clustered-rank analysis including the co-primary outcomes showed cRSB and cTAP blocks to be the most efficacious interventions.

CONCLUSIONS

Based on current evidence, continuous rectus sheath block and continuous transversus abdominis plane block were the most efficacious non-neuraxial techniques at reducing 24-h cumulative opioid consumption and 24-h resting pain scores after midline laparotomy (low certainty). Future studies should compare techniques for upper vs lower midline laparotomy and other non-midline abdominal incisions.

CLINICAL TRIAL REGISTRATION

PROSPERO Registration Number: CRD42021269044.

Accuracy Evaluation Trial of Mixed Reality-Guided Spinal Puncture Technology

Purpose

To evaluate the accuracy of mixed reality (MR)-guided visualization technology for spinal puncture (MRsp).

Methods

MRsp involved the following three steps: 1. Lumbar spine computed tomography (CT) data were obtained to reconstruct virtual 3D images, which were imported into a HoloLens (2nd gen). 2. The patented MR system quickly recognized the spatial orientation and superimposed the virtual image over the real spine in the HoloLens. 3. The operator performed the spinal puncture with structural information provided by the virtual image. A posture fixation cushion was used to keep the subjects' lateral decubitus position consistent. 12 subjects were recruited to verify the setup error and the registration error. The setup error was calculated using the first two CT scans and measuring the displacement of two location markers. The projection points of the upper edge of the L3 spinous process (L3↑), the lower edge of the L3 spinous process (L3↓), and the lower edge of the L4 spinous process (L4↓) in the virtual image were positioned and marked on the skin as the registration markers. A third CT scan was performed to determine the registration error by measuring the displacement between the three registration markers and the corresponding real spinous process edges.

Results

The setup errors in the position of the cranial location marker between CT scans along the left-right (LR), anterior-posterior (AP), and superior-inferior (SI) axes of the CT bed measured 0.09 ± 0.06 cm, 0.30 ± 0.28 cm, and 0.22 ± 0.12 cm, respectively, while those of the position of the caudal location marker measured 0.08 ± 0.06 cm, 0.29 ± 0.18 cm, and 0.18 ± 0.10 cm, respectively. The registration errors between the three registration markers and the subject's real L3↑, L3↓, and L4↓ were 0.11 ± 0.09 cm, 0.15 ± 0.13 cm, and 0.13 ± 0.10 cm, respectively, in the SI direction.

Conclusion

This MR-guided visualization technology for spinal puncture can accurately and quickly superimpose the reconstructed 3D CT images over a real human spine.

Analgesic effects of combined transversus abdominis plane block and intramuscular electrical stimulation in patients undergoing cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy: a randomized controlled trial

BACKGROUND

To evaluate the analgesic efficacy of a four-quadrant transversus abdominis plane (4QTAP) block and a combination of 4QTAP block with needle electrical twitch and intramuscular electrical stimulation (NETOIMS) in patients undergoing cytoreductive surgery (CRS) followed by hyperthermic intraperitoneal chemotherapy (HIPEC).

MATERIALS AND METHODS

Eighty-one patients who underwent CRS followed by HIPEC were included in this study. Patients were randomly assigned to one of three groups: group 1 (intravenous patient-controlled analgesia, control group), group 2 (preoperative 4QTAP block), and group 3 (preoperative 4QTAP block and postoperative NETOIMS). The primary study endpoint was the pain score assessed by the visual analog scale (VAS: 0, no pain; 10, worst imaginable pain) on postoperative day (POD) 1.

RESULTS

The VAS pain score on POD 1 was significantly lower in group 2 than in group 1 (6.0±1.7 and 7.6±1.9, P =0.004), whereas that in group 3 was significantly lower than that in groups 1 and 2 ( P <0.001 and P =0.004, respectively). Opioid consumption and nausea and vomiting incidence during POD 7 were significantly lower in group 3 than in groups 1 and 2. Gait speed and peak cough flow on POD 4 and 7, as well as the quality of recovery (QoR)-40 score on POD 4, were significantly higher in group 3 than in groups 1 and 2.

CONCLUSIONS

The combination of a 4QTAP block with NETOIMS provided more effective analgesia than a 4QTAP block alone after CRS, followed by HIPEC, and enhanced functional restoration and quality of recovery.

Real-time ultrasound-guided versus anatomic landmark-based thoracic epidural placement: a prospective, randomized, superiority trial

Background

Thoracic epidural placement (TEP) using the conventional anatomic landmark-based technique is technically challenging, may require multiple attempts, and is associated with a high failure rate (12–40%). We hypothesized that real-time ultrasound guidance would be superior in the “first-pass” success rate of TEP, when compared with the conventional technique.

Methods

This prospective, randomized, superiority trial was conducted in a University hospital, and recruited 96 patients undergoing elective major abdominal or thoracic surgery and scheduled to receive a TEP for postoperative analgesia. Patients were randomly allocated to receive TEP using either the conventional technique (Gp-Conv, n = 48) or real-time ultrasound guidance (Gp-Usg, n = 48). The success of TEP was defined as eliciting loss of resistance technique and being able to insert the epidural catheter. The primary outcome variable was the “first-pass success rate” meaning the successful TEP at the first needle insertion without redirection or readvancement of the Tuohy needle. The secondary outcomes included the number of skin punctures, number of attempts, the overall success rate, TEP time, and total procedure time.

Results

The first-pass success rate of TEP was significantly higher (p = 0.002) in Gp-Usg (33/48 (68.8%); 95%CI 55.6 to 81.9) than in Gp-Conv (17/48 (35.4%); 95%CI 21.9 to 49.0). There was no statistically significant difference (p = 0.12) in the overall success rate of TEP between the 2 study groups (Gp-Usg; 48/48 (100%) vs. Gp-Conv; 44/48 (91.7%); 95%CI 83.9 to 99.5). Ultrasound guidance reduced the median number of skin punctures (Gp-Usg; 1 [1, 1] vs Gp-Conv; 2 [1, 2.2], p < 0.001) and attempts at TEP (Gp-Usg; 1 [1, 2] vs Gp-Conv; 3 [1, 7.2], p < 0.001) but the procedure took longer to perform (Gp-Usg; 15.5 [14, 20] min vs Gp-Conv; 10 [7, 14] min, p < 0.001).

Conclusions

This study indicates that real-time ultrasound guidance is superior to a conventional anatomic landmark-based technique for first-pass success during TEP although it is achieved at the expense of a marginally longer total procedure time. Future research is warranted to evaluate the role of real-time ultrasound guidance for TEP in other groups of patients.

Trial registration

Thai Clinical Trials Registry; http://www.thaiclinicaltrials.org/; Trial ID: TCTR20200522002, Registration date: 22/05/2020.

Efficacy and Safety of Thoracic Epidural Analgesia in Patients With Acute Pancreatitis: A Narrative Review

Patients admitted to the intensive care unit with moderate to severe acute pancreatitis carry significant morbidity and mortality. A few unfortunate patients in whom the initial line of treatment fails to show clinical improvement develop multiorgan dysfunction involving lungs (adult respiratory distress syndrome), renal failure, intra-abdominal infections, sepsis, and septic shock, which ultimately leads to prolonged hospitalization and a substantial cost of treatment. The acute abdominal pain experienced by these patients is excruciating and requires multimodal analgesia. Continuous epidural analgesia has been found to provide good quality, opioid-sparing analgesia in these patients. A few studies have also demonstrated that segmental sympathectomy resulting from epidural blockade could lead to lowering of serum amylase and lipase levels improve paralytic ileus, and thus hastens the process of recovery. The present paper aims to discuss the advantages of continuous epidural analgesia in patients with acute pancreatitis of varying severity and to review the existing literature using specific keywords.

Accidental epidural catheter infusion of potassium chloride for postoperative analgesia: A case report

An infusion of 100 cc of 0,2% potassium chloride was accidental performed through a thoracic epidural catheter, inserted to perioperative analgesia, to a 66 years old man who was scheduled for right hemicolectomy, 48 h after surgery. Paresis of upper limbs, flaccid paralysis of lower limbs and a sensitive level at T8 was observed. An epidural lavage with an initial dose of 20 cc of saline was slowly injected, followed for a saline infusion of 20 cc per hour. Neurologic signs were totally reverted some hours later and 24 h after the incident the physical exam was normal. We reviewed the clinical presentation of the complication and its mechanisms, the more frequent clinical evolution, as well as treatment measures and strategies to prevent the incident.

Serious Complications After Epidural Catheter Placement: Two Case Reports

Thoracic epidural analgesia (TEA) is a standard procedure in multimodal analgesia applied in major thoracic and abdominal surgeries. Two cases are presented with serious complications related to TEA. In both cases, earlier reaction of the treating physicians to patient-reported sensory symptoms could have prevented the complicated course. The first case was a 73-year-old patient with bronchial carcinoma who underwent right lower lobe resection. In this case, dabigatran 150 mg/d (indication: permanent atrial fibrillation) had been discontinued 72 hours before surgery, and enoxaparin 80 mg (every 12 hours) had been started 11 hours after surgery. An epidural hematoma developed postoperatively. Magnetic resonance imaging (MRI) was performed only after paraplegia had developed the next day. Unfortunately, delayed hematoma evacuation could not prevent persistent paraplegia in this case, which was complicated by hospital-acquired pneumonia with sepsis and acute renal failure. The second case was a 39-year-old patient with ulcerative colitis and an initially undetected malposition of the epidural catheter. Immediately after test bolus injection, the patient reported paresthesia and overall discomfort, which however could not be safely attributed to either the test dose or the already started general anesthesia. The patient could only be extubated after stopping the epidural infusion. Accidental re-start of epidural infusion led to coma, conjugate eye deviation, and respiratory arrest, necessitating re-intubation. Computed tomography (CT) ruled out intracerebral pathology and showed a catheter position centrally in the spinal canal. Fortunately, no neurological deficits were detected after catheter removal.

Epidural Analgesia Is Associated with Prolonged Length of Stay After Open HPB Surgery in Over 27,000 Patients

BACKGROUND

The impact of epidural analgesia (EA) on postoperative morbidity and length of stay (LOS) after HPB surgery remains to be determined. These specific outcomes have been highlighted by the implementation of multiple enhanced recovery pathways (ERAS). The authors hypothesized that EA in the current environment may be associated with LOS and other outcomes.

METHODS

The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) databases from 2014 to 2017 for patients undergoing open hepatopancreaticobiliary (HPB) surgery were included in a retrospective cohort analysis with propensity score matching (PSM) comparing EA with control.

RESULTS

Twenty-seven thousand two hundred eighteen patients underwent open HPB surgery, of which 6048 (22%) received EA. There was an increase use of EA over time (from 19.3 to 25.5%, p = 0.001). On PSM, EA was associated with more than half of a day increase in LOS for both pancreatic (p < 0.001) and hepatic surgery (p < 0.001). Furthermore, for pancreatic surgery, there was an increase in urinary tract infection (2.5% vs. 3.3%, p = 0.018), time to drain removal (7.8 vs. 8.7 days, p < 0.001), and discharge to rehabilitation (2.9% vs. 4.3%, p = 0.029). For hepatic surgery, there was an increase in blood transfusion requirements (17% vs. 20%, p = 0.019). There were no differences in overall morbidity and mortality.

CONCLUSION

In this cohort of over 27,000 patients with granular surgical details, there was a significant increase in LOS associated with EA after HPB surgery, along with increased procedure-specific UTI and blood transfusion. With the ever-increasing need for standardized and efficient patient care pathways that reduce LOS, alternative analgesic adjuncts may be considered to optimize patient outcomes.

Accidental epidural catheter infusion of potassium chloride for postoperative analgesia: A case report

An infusion of 100cc of 0,2% potassium chloride was accidental performed through a thoracic epidural catheter, inserted to perioperative analgesia, to a 66years old man who was scheduled for right hemicolectomy, 48hours after surgery. Paresis of upper limbs, flaccid paralysis of lower limbs and a sensitive level at T8 was observed. An epidural lavage with an initial dose of 20cc of saline was slowly injected, followed for a saline infusion of 20cc per hour. Neurologic signs were totally reverted some hours later and 24hours after the incident the physical exam was normal. We reviewed the clinical presentation of the complication and its mechanisms, the more frequent clinical evolution, as well as treatment measures and strategies to prevent the incident.

Avoid suboptimal perioperative analgesia during major surgery by enhancing thoracic epidural catheter placement and hemodynamic performance

Thoracic epidural analgesia (TEA) is an established gold standard for postoperative pain control especially following laparotomy and thoracotomy. The safety and efficacy of TEA is well known when the attention to patient selection is upheld. Recently, the use of fascial plane blocks (FPBs) has evolved as an alternative to TEA most likely because these blocks avoid problems such as neurological comorbidity, coagulation disorders, epidural catheter failure and hypotension due to sympathetic denervation. However, if an FPB is performed, postoperative monitoring and adjuvant treatments are still necessary. Also, the true efficacy of FPBs is questioned. Thus, should we prioritize less efficient analgesic regimens with FPBs when preventive treatment strategies for epidural catheter failure and hypotension exist for TEA? It is time to promote and underscore the benefits of TEA provided to patients undergoing major open surgical procedures. In our mind, FPBs and landmark-guided techniques should be limited to less extensive surgery and when either neuraxial blockade is contraindicated or resources for optimal epidural catheter placement and maintenance are not available.

Combined use of transversus abdominis plane block and laryngeal mask airway during implementing ERAS programs for patients with primary liver cancer: a randomized controlled trial

The incidence and mortality of primary liver cancer are very high and resection of tumor is the most crucial treatment for it. We aimed to assess the efficacy and safety of combined use of transversus abdominis plane (TAP) block and laryngeal mask airway (LMA) during implementing Enhanced Recovery After Surgery (ERAS) programs for patients with primary liver cancer. This was a prospective, evaluator-blinded, randomized, controlled parallel-arm trial. A total of 96 patients were enrolled (48 in each group). Patients in the control group received general anesthesia with endotracheal intubation, while patients in the TAP + LMA group received general anesthesia with LMA and an ultrasound-guided subcostal TAP block. The primary end-point was postoperative time of readiness for discharge. The secondary end-points were postoperative pain intensity, time to first flatus, quality of recovery (QoR), complications and overall medical cost. Postoperative time of readiness for discharge in the TAP + LMA group [7 (5–11) days] was shorter than that of the control group [8 (5–13) days, P = 0.004]. The postoperative apioid requirement and time to first flatus was lower in the TAP + LMA group [(102.8 ± 12.4) µg, (32.7 ± 5.8) h, respectively] than the control group [(135.7 ± 20.1) µg, P = 0.000; (47.2 ± 7.6) h, P = 0.000; respectively]. The QoR scores were significantly higher in the TAP + LMA group than the control group. The total cost for treatment in the TAP + LMA group [(66,608.4 ± 6,268.4) CNY] was lower than that of the control group [(84,434.0 ± 9,436.2) CNY, P = 0.000]. There was no difference in complications between these two groups. The combined usage of a TAP block and LMA is a simple, safe anesthesia method during implementing ERAS programs for patients with primary liver cancer. It can alleviate surgical stress, accelerate recovery and reduce medical cost.

Erector spinae plane and intra thecal opioid (ESPITO) analgesia in radical nephrectomy utilising a rooftop incision: novel alternative to thoracic epidural analgesia and systemic morphine: a case series

Background

Open radical nephrectomy and inferior vena cava exploration through a roof top incision involves significant peri-operative morbidity including severe postoperative pain. Although thoracic epidural analgesia provides excellent pain relief, recent trends suggest search for effective alternatives. Systemic morphine is often used as an alternative analgesic technique. However, it does not provide dynamic analgesia and can often impede recovery in patients undergoing major surgery on the abdomen. The authors present the first report of a novel analgesic regimen in this cohort with good outcomes.

Methods

Five patients undergoing open radical nephrectomy and inferior vena cava exploration received erector spinae plane infusion and intra thecal opioid analgesia at a tertiary care university teaching hospital. Outcomes included dynamic analgesia, length of hospital stay and complications

Results

Five adult patients undergoing major upper abdominal surgery, who refused thoracic epidural analgesia, received erector spinae plane infusion and intrathecal opioid analgesia. Patients reported effective dynamic analgesia, minimal use of rescue analgesia, early ambulation and enhanced recovery.

Conclusion

The novel regimen that avoids both epidural analgesia and systemic morphine can be an option in enabling enhanced recovery in this cohort.

Continuous wound infiltration versus epidural analgesia for midline abdominal incisions - a randomized-controlled pilot trial (Painless-Pilot trial; DRKS Number: DRKS00008023)

OBJECTIVES

To test the feasibility of a randomized controlled study design comparing epidural analgesia (EDA) with continuous wound infiltration (CWI) in respect to postoperative complications and mobility to design a future multicentre randomized controlled trial.

DESIGN, SETTING, PARTICIPANTS

CWI has been developed to address drawbacks of EDA. Previous studies have established the equivalent analgesic potential of CWI compared to EDA. This is a single centre, non-blinded pilot randomized controlled trial at a tertiary surgical centre. Patients undergoing elective non-colorectal surgery via a midline laparotomy were randomized to EDA or CWI. Endpoints included recruitment, feasibility of assessing postoperative mobility with a pedometer and morbidity. No primary endpoint was defined and all analyses were explorative.

INTERVENTIONS

CWI with local anaesthetics (experimental group) vs. thoracic EDA (control).

RESULTS

Of 846 patients screened within 14 months, 71 were randomized and 62 (31 per group) included in the intention-to-treat analysis. Mobility was assessed in 44 of 62 patients and revealed no differences within the first 3 postoperative days. Overall morbidity did not differ between the two groups (measured via the comprehensive complication index). Median pain scores at rest were comparable between the two groups, while EDA was superior in pain treatment during movement on the first, but not on the second and third postoperative day. Duration of preoperative induction of anaesthesia was shorter with CWI than with EDA. Of 17 serious adverse events, 3 were potentially related to EDA, while none was related to CWI.

CONCLUSION

This trial confirmed the feasibility of a randomized trial design to compare CWI and EDA regarding morbidity. Improvements in the education and training of team members are necessary to improve recruitment.

TRIAL REGISTRATION

DRKS00008023.

Regional Catheters for Postoperative Pain Control: Review and Observational Data

Context

Perioperative analgesia is an essential but frequently underrated component of medical care. The purpose of this work is to describe the actual situation of surgical patients focusing on effective pain control by discarding prejudice against ‘aggressive’ measures.

Evidence Acquisition

This is a narrative review about continuous regional pain therapy with catheters in the postoperative period. Included are the most-relevant literature as well as own experiences.

Results

As evidenced by an abundance of studies, continuous regional/neuraxial blocks are the most effective approach for relief of severe postoperative pain. Catheters have to be placed in adequate anatomical positions and meticulously maintained as long as they remain in situ. Peripheral catheters in interscalene, femoral, and sciatic positions are effective in patients with surgery of upper and lower limbs. Epidural catheters are effective in abdominal and thoracic surgery, birth pain, and artery occlusive disease, whereas paravertebral analgesia may be beneficial in patients with unilateral approach of the truncus. However, failure rates are high, especially for epidural catheter analgesia. Unfortunately, many reports lack a comprehensive description of catheter application, management, failure rates and complications and thus cannot be compared with each other.

Conclusions

Effective control of postoperative pain is possible by the application of regional/neuraxial catheters, measures requiring dedication, skill, effort, and funds. Standard operating procedures contribute to minimizing complications and adverse side effects. Nevertheless, these methods are still not widely accepted by therapists, although more than 50% of postoperative patients suffer from ‘moderate, severe or worst’ pain.

Randomized clinical trial of continuous transversus abdominis plane block, epidural or patient-controlled analgesia for patients undergoing laparoscopic colorectal cancer surgery

Background

The optimal analgesia regimen after laparoscopic colorectal cancer surgery is unclear. The aim of the study was to characterize the beneficial effects of continuous transversus abdominis plane (TAP) blocks initiated before operation on outcomes following laparoscopic colorectal cancer surgery.

Methods

Patients undergoing surgery for colorectal cancer were divided randomly into three groups: combined general–TAP anaesthesia (TAP group), combined general–thoracic epidural anaesthesia (TEA group) and standard general anaesthesia (GA group). The primary endpoint was duration of hospital stay. Secondary endpoints included gastrointestinal motility, pain scores and plasma levels of cytokines.

Results

In total, 180 patients were randomized and 165 completed the trial. The intention-to-treat analysis showed that duration of hospital stay was significantly longer in the TEA group than in the TAP and GA groups (median 4·1 (95 per cent c.i. 3·8 to 4·3) versus 3·1 (3·0 to 3·3) and versus 3·3 (3·2 to 3·6) days respectively; both P &lt; 0·001). Time to first flatus was earlier in the TAP group (P &lt; 0·001). Visual analogue scale (VAS) scores during coughing were lower in the TAP and TEA groups than the GA group (P &lt; 0·001). Raised plasma levels of vascular endothelial growth factor C, interleukin 6, adrenaline and cortisol were attenuated significantly by continuous TAP block.

Conclusion

Continuous TAP analgesia not only improved gastrointestinal motility but also shortened duration of hospital stay. A decreased opioid requirement and attenuating surgical stress response may be potential mechanisms. Registration number: ChiCTR-TRC-1800015535 (http://www.chictr.org.cn).

Surgical safety in radical cystectomy: the anesthetist's point of view-how to make a safe procedure safer

PURPOSE

The aim of this review is to present an anesthesiological overview on surgical safety for radical cystectomy implementing the cornerstones of today's rapidly evolving field of perioperative medicine.

METHODS

This is a narrative review of current perioperative medicine and surgical safety concepts for major surgery in general with special focus on radical cystectomy.

RESULTS

The tendency for perioperative care and surgical safety is to consider it a continuous proactive pathway rather than a single surgical intervention. It starts at indication for surgery and lasts until full functional recovery. Preoperative optimization leads to superior outcome by mobilizing and/or increasing physiological reserve. Multidisciplinary teamwork involving all the relevant parties from the beginning of the pathway is crucial for outcome rather than an isolated specialist approach. This fact has gained importance in times of an ageing frail population and rising health care cost. We also present our 2019 Cystectomy Enhanced Recovery Approach for optimization of perioperative care for open radical cystectomy in a high caseload center.

CONCLUSIONS

With the implementation of in itself simple but crucial steps in perioperative medicine such as multimodal prehabilitation, safety checks, better perioperative monitoring and enhanced recovery concepts, even complex surgical procedures such as radical cystectomy can be performed safer. Emphasis has to be laid on a more global view of the patients' path through the perioperative process than on the surgical procedure alone.

Decreased opioid prescribing in children using an enhanced recovery protocol

BACKGROUND

A previously implemented Enhanced Recovery Protocol (ERP) for children undergoing elective gastrointestinal operations demonstrated decreased length of stay (LOS) and in-hospital opioid use. We hypothesized that the ERP would be associated with decreased postdischarge opioid prescribing.

METHODS

Demographic, operative, and opioid prescription data were retrospectively compared between elective gastrointestinal surgical patients in the pre-ERP (1/2012-12/2014) and the post-ERP periods (1/2015-12/2017).

RESULTS

Of the 99 patients reviewed, 56 (56.7%) were treated in the post-ERP era. Overall, 48 (48.5%) were male, and the most common operation was partial or total colectomy (n = 39, 39.4%) followed by ileocecectomy (n = 26, 26.3%). Most patients were 15-16 years of age and had inflammatory bowel disease (n = 88, 88.9%). LOS decreased from a median 4 days pre-ERP to 3 days post-ERP (p = 0.02). Patients receiving intraoperative opioids decreased from 100% to 46% (p < 0.01) and postoperative opioids from 95% to 59% (p < 0.01). Patients receiving an opioid prescription at discharge decreased from 69.8% pre-ERP to 30.9% post-ERP (p < 0.01). Among patients prescribed opioids at discharge, the number of doses (median 23 to 17, p = 0.44) and the median morphine equivalents/kg remained stable (median 2.3 to 1.7, p = 0.10).

CONCLUSIONS

A pediatric gastrointestinal surgery ERP resulted in decreased postdischarge prescribing of opioids.

TYPE OF STUDY

Retrospective cohort study.

LEVEL OF EVIDENCE

Level II.

Epidural electrical stimulation test versus local anesthetic test dose for thoracic epidural catheter placement: a prospective observational study

PURPOSE

This study examined the concordance between epidural electrical stimulation test (EEST) and local anesthetic (LA) test dose to indicate correct thoracic epidural catheter position. The relationship between the test results and epidural postoperative analgesia was also assessed.

METHODS

This prospective observational cohort study was done in patients receiving thoracic epidural analgesia for abdominal surgery. After insertion, the epidural catheter was tested using a nerve stimulator to elicit a motor response. The LA test dose was then administered, and sensory block to ice and pinprick was assessed. The primary outcome was the presence/absence of motor response to EEST and sensory block to test dose. Concordance of responses was assessed using kappa statistics, and their predictive power of postoperative epidural analgesia was evaluated.

RESULTS

Sixty-eight thoracic epidural catheters were inserted, of which 62 were used perioperatively. The kappa agreement between EEST and LA test dose responses was moderate at 0.42 (95% confidence interval [CI], 0.18 to 0.67). Positive responses to EEST and LA test dose were observed in 62 (100%) and 50 (81%) patients, respectively, while 52 patients (84%) showed adequate analgesia postoperatively. The sensitivity (95% CI) of EEST and LA test dose to predict adequate postoperative epidural analgesia was 1 (0.93 to 1) and 0.79 (0.65 to 0.89), respectively, and the positive predictive values (95% CI) of EEST and LA test dose were 0.84 (0.75 to 0.93) and 0.82 (0.71 to 0.92), respectively.

CONCLUSION

Following thoracic epidural catheter insertion, the responses to the EEST and LA test dose showed "moderate" agreement. The EEST has a higher sensitivity than the LA test dose to predict adequate epidural analgesia following abdominal surgery, however, both tests have a comparable positive predictive value.

Postoperative analgesia after combined thoracoscopic-laparoscopic esophagectomy: a randomized comparison of continuous infusion and intermittent bolus thoracic epidural regimens

Purpose

Judicious postoperative pain management after thoracoscopic–laparoscopic esophagectomy (TLE) facilitates enhanced rehabilitation. Thoracic epidural analgesia (TEA) offers many benefits in esophagectomy, while several complications are associated with the delivery mode by continuous epidural infusion. This study compared the efficiency and safety of intermittent epidural bolus to continuous epidural infusion for pain management after TLE.

Patients and methods

Sixty patients, aged 18–80 years, with American Society of Anesthesiologists classes I–III and scheduled for TLE with combined general anesthesia and TEA were randomly allocated to two groups. Patients received either a continuous epidural infusion with 0.3% ropivacaine and 1.5 µg/mL fentanyl at 6 mL/h plus a patient-controlled bolus of 3 mL (continuous group) or an intermittent bolus of 6 mL of the same solution on demand with lockout time of 30 minutes (intermittent group). If the patient complained of pain and the visual analog scale score was >4, an intravenous injection of tramadol or dezocine was administered as rescue treatment. The primary outcome variable was the consumption of epidural opioids and local anesthetics for TEA.

Results

TEA for pain management following TLE by intermittent epidural bolus was associated with significantly lower consumption of fentanyl and ropivacaine and lower incidences of breakthrough pain and hypotension than continuous epidural infusion. No significant differences were observed between the two groups in terms of pain score at rest or while coughing, patient satisfaction, or incidence of postoperative complications.

Conclusion

Compared with continuous epidural infusion, TEA by on-demand intermittent bolus greatly reduced the consumption of local anesthetics and opioids with comparable pain relief and little impairment in hemodynamics when used for pain management after TLE.