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Howle R, Ng SC, Wong HY, Onwochei D, Desai N. Comparison of analgesic modalities for patients undergoing midline laparotomy: a systematic review and network meta-analysis. Can J Anaesth 2021; 69:140-176. [PMID: 34739706 DOI: 10.1007/s12630-021-02128-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 09/08/2021] [Accepted: 09/08/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Midline laparotomy is associated with severe pain. Epidural analgesia has been the established standard, but multiple alternative regional anesthesia modalities are now available. We aimed to compare continuous and single-shot regional anesthesia techniques in this systematic review and network meta-analysis. METHODS We included randomized controlled trials on adults who were scheduled for laparotomy with solely a midline incision under general anesthesia and received neuraxial or regional anesthesia for pain. Network meta-analysis was performed with a frequentist method, and continuous and dichotomous outcomes were presented as mean differences and odds ratios, respectively, with 95% confidence intervals. The quality of evidence was rated with the grading of recommendations, assessment, development, and evaluation system. RESULTS Overall, 36 trials with 2,056 patients were included. None of the trials assessed erector spinae plane or quadratus lumborum block, and rectus sheath blocks and transversus abdominis plane blocks were combined into abdominal wall blocks (AWB). For the co-primary outcome of pain score at rest at 24 hr, with a minimal clinically important difference (MCID) of 1, epidural was clinically superior to control and single-shot AWB; epidural was statistically but not clinically superior to continuous wound infiltration (WI); and no statistical or clinical difference was found between control and single-shot AWB. For the co-primary outcome of cumulative morphine consumption at 24 hr, with a MCID of 10 mg, epidural and continuous AWB were clinically superior to control; epidural was clinically superior to continuous WI, single-shot AWB, single-shot WI, and spinal; and continuous AWB was clinically superior to single-shot AWB. The quality of evidence was low in view of serious limitations and imprecision. Other results of importance included: single-shot AWB did not provide clinically relevant analgesic benefit beyond two hr; continuous WI was clinically superior to single-shot WI by 8-12 hr; and clinical equivalence was found between epidural, continuous AWB, and continuous WI for the pain score at rest, and epidural and continuous WI for the cumulative morphine consumption at 48 hr. CONCLUSIONS Single-shot AWB were only clinically effective for analgesia in the early postoperative period. Continuous regional anesthesia modalities increased the duration of analgesia relative to their single-shot counterparts. Epidural analgesia remained clinically superior to alternative continuous regional anesthesia techniques for the first 24 hr, but reached equivalence, at least with respect to static pain, with continuous AWB and WI by 48 hr. TRIAL REGISTRATION PROSPERO (CRD42021238916); registered 25 February 2021.
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Affiliation(s)
- Ryan Howle
- Department of Anaesthesia, Mater Misericordiae University Hospital, Dublin, Ireland.
| | - Su-Cheen Ng
- Department of Anaesthesia, Beacon Hospital, Dublin, Ireland
| | - Heung-Yan Wong
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Desire Onwochei
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK.,King's College London, London, UK
| | - Neel Desai
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK.,King's College London, London, UK
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Vester‐Andersen M, Lundstrøm LH, Møller MH. The association between epidural analgesia and mortality in emergency abdominal surgery: A population-based cohort study. Acta Anaesthesiol Scand 2020; 64:104-111. [PMID: 31437307 DOI: 10.1111/aas.13461] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 07/08/2019] [Accepted: 07/27/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Emergency abdominal surgery carries a considerable risk of mortality and post-operative complications, including pulmonary complications. In major elective surgery, epidural analgesia reduces mortality and pulmonary complications. We aimed to evaluate the association between epidural analgesia and mortality in emergency abdominal surgery. METHODS In this population-based cohort study with prospective data collection, we included adults undergoing emergency abdominal laparotomy or laparoscopy between 1 January 2009 and 31 December 2010 at 13 Danish hospitals. Appendectomies were excluded. The primary outcome was 90-day mortality. Secondary outcomes included 30-day mortality and serious adverse events. We used binary logistic regression analyses (odds ratios (ORs) with 95% confidence intervals (CIs)). RESULTS We included 4920 patients, of whom 1134 (23.0%) died within 90 days. Overall, 27.9% of the patients were treated with epidural analgesia perioperatively. This increased to 34.0% among patients undergoing major laparotomy. The crude and adjusted association between epidural analgesia and 90-day mortality was OR 0.99 (95%CI: 0.86-1.15, P = .94) and OR 0.80 (95%CI: 0.67-0.94; P = .01), respectively. For 30-day mortality the corresponding estimates were OR 0.90 (95% CI: 0.76-1.06, P = .21) and OR 0.75 (95% CI: 0.62-0.90, P < .01), respectively. No serious adverse events were reported. CONCLUSION In this population-based cohort study of adult patients undergoing emergency abdominal surgery, we found that the use of epidural analgesia perioperatively was associated with a decreased risk of mortality in the adjusted analysis.
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Affiliation(s)
- Morten Vester‐Andersen
- Herlev Anaesthesia Critical and Emergency Care Science Unit (ACES) Department of Anaesthesiology Copenhagen University Hospital Herlev‐Gentofte Herlev Denmark
| | - Lars Hyldborg Lundstrøm
- Department of Anaesthesiology and Intensive Care Medicine Copenhagen University Hospital Nordsjælland Hillerød Denmark
| | - Morten Hylander Møller
- Department of Intensive Care 4131 Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
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Gimeno AM, Errando CL. Neuraxial Regional Anaesthesia in Patients with Active Infection and Sepsis: A Clinical Narrative Review. Turk J Anaesthesiol Reanim 2018; 46:8-14. [PMID: 30140495 DOI: 10.5152/tjar.2018.12979] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 11/23/2017] [Indexed: 12/31/2022] Open
Abstract
Infection is considered to be a relative contraindication for regional anaesthesia. However, there is a paucity of articles addressing the topic of regional anaesthesia in patients with an active infectious process. Recent publications show a low incidence of infection (0.007% to 0.6%) of the central nervous system after neuraxial punctures in patients at risk of, or with ongoing bacteraemia, and a low incidence of infection after performing regional anaesthesia techniques in immunosuppressed patients, or patients with an actual infection. Therefore, some authors conclude that it seems that there is little justification to set strict contraindications regarding this indication and that the risk-benefit ratio should prevail. In addition, a low incidence of meningitis or abscesses after the lumbar puncture has been observed in patients with unsuspected and ongoing bacteraemia, or who were at risk of bacteraemia, when antibiotic therapy has been previously started. For viral infections, regional techniques seem to be safe, being applied in patients with HIV infection. The only established absolute contraindication for any type of regional anaesthesia technique is the infection at the puncture site. Debate persists if a neuraxial anaesthesia technique is to be performed in the course of sepsis with the origin away from the puncture site. In case of thoracic epidural anaesthesia and analgesia, experimental and clinical studies highlight their potential benefits in the systemic inflammatory response syndromes and founded sepsis, both in surgical and non-surgical patients. Finally, the anti-inflammatory and anti-infective effects of local anaesthetics and the basis of excessive inflammatory response are described, as the latter might be involved, in part, in the clinical outcomes.
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Smith LM, Cozowicz C, Uda Y, Memtsoudis SG, Barrington MJ. Neuraxial and Combined Neuraxial/General Anesthesia Compared to General Anesthesia for Major Truncal and Lower Limb Surgery. Anesth Analg 2017; 125:1931-1945. [DOI: 10.1213/ane.0000000000002069] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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5
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Guay J, Nishimori M, Kopp SL. Epidural Local Anesthetics Versus Opioid-Based Analgesic Regimens for Postoperative Gastrointestinal Paralysis, Vomiting, and Pain After Abdominal Surgery: A Cochrane Review. Anesth Analg 2017; 123:1591-1602. [PMID: 27870743 DOI: 10.1213/ane.0000000000001628] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The aim of this review was to compare the effects of postoperative epidural analgesia with local anesthetics to postoperative systemic or epidural opioids in terms of return of gastrointestinal transit, postoperative pain control, postoperative vomiting, incidence of gastrointestinal anastomotic leak, hospital length of stay, and cost after abdominal surgery. METHODS Trials were identified by computerized searches of the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 12), Medical Literature Analysis and Retrieval System Online (MEDLINE) (from 1950 to December, 2014) and Excerpta Medica dataBASE (EMBASE) (from 1974 to December 2014) and by checking the reference lists of trials retained. We included parallel randomized controlled trials comparing the effects of postoperative epidural local anesthetic with regimens based on systemic or epidural opioids. The quality of the studies was rated according to the Cochrane tool. Two authors independently extracted data. We judged the quality of evidence according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) working group scale. RESULTS Based on 22 trials including 1138 participants, an epidural containing a local anesthetic will decrease the time required for return of gastrointestinal transit as measured by time required to observe the first flatus after an abdominal surgery standardized mean difference (SMD) -1.28 (95% confidence interval [CI], -1.71 to -0.86; high quality of evidence; equivalent to 17.5 hours). The effect is proportional to the concentration of local anesthetic used. Based on 28 trials including 1559 participants, we also found a decrease in time to first feces (stool): SMD -0.67 (95% CI, -0.86 to -0.47; low quality of evidence; equivalent to 22 hours). Based on 35 trials including 2731 participants, pain on movement at 24 hours after surgery is also reduced: SMD -0.89 (95% CI, -1.08 to -0.70; moderate quality of evidence; equivalent to 2.5 on a scale from 0 to 10). Based on 22 trials including 1154 participants, we did not find a difference in the incidence of vomiting within 24 hours: risk ratio 0.84 (95% CI, 0.57-1.23); low quality of evidence. Based on 17 trials including 848 participants we did not find a difference in the incidence of gastrointestinal anastomotic leak: risk ratio 0.74 (95% CI, 0.41-1.32; low quality of evidence). Based on 30 trials including 2598 participants, epidural analgesia reduces length of hospital stay for an open surgery: SMD -0.20 (95% CI, -0.35 to -0.04; very low quality of evidence; equivalent to 1 day). Data on cost were very limited. CONCLUSIONS An epidural containing a local anesthetic, with or without the addition of an opioid, accelerates the return of the gastrointestinal transit (high quality of evidence). An epidural containing a local anesthetic with an opioid decreases pain after an abdominal surgery (moderate quality of evidence). An epidural containing a local anesthetic does not affect the incidence of vomiting or anastomotic leak (low quality of evidence). For an open surgery, an epidural containing a local anesthetic would reduce the length of hospital stay (very low quality of evidence).
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Affiliation(s)
- Joanne Guay
- From the *University of Sherbrooke, Sherbrooke, Quebec, Canada; †Teaching and Research Unit, Health Sciences, University of Quebec in Abitibi-Temiscamingue, Rouyn-Noranda, Quebec, Canada; ‡Department of Anesthesiology, Seibo International Catholic Hospital, Tokyo, Japan; and §Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, Minnesota
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Tyagi A, Bansal A, Das S, Sethi AK, Kakkar A. Effect of thoracic epidural block on infection-induced inflammatory response: A randomized controlled trial. J Crit Care 2017; 38:6-12. [DOI: 10.1016/j.jcrc.2016.10.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 09/09/2016] [Accepted: 10/10/2016] [Indexed: 10/20/2022]
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Ehieli E, Yalamuri S, Brudney CS, Pyati S. Analgesia in the surgical intensive care unit. Postgrad Med J 2016; 93:38-45. [PMID: 27777355 DOI: 10.1136/postgradmedj-2016-134047] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 07/10/2016] [Accepted: 08/27/2016] [Indexed: 01/30/2023]
Abstract
Critically ill patients are a heterogeneous group with diverse comorbidities and physiological derangements. The management of pain in the critically ill population is emerging as a standard of care in the intensive care unit (ICU). Pain control of critically ill patients in the ICU presents numerous challenges to intensivists. Inconsistencies in pain assessment, analgesic prescription and variation in monitoring sedation and analgesia result in suboptimal pain management. Inadequate pain control can have deleterious effects on several organ systems in critically ill patients. Therefore, it becomes incumbent on physicians and nurses caring for these patients to carefully evaluate their practice on pain management and adopt an optimal pain management strategy that includes a reduction in noxious stimuli, adequate analgesia and promoting education regarding sedation and analgesia to the ICU staff. Mechanistic approaches and multimodal analgesic techniques have been clearly demonstrated to be the most effective pain management strategy to improve outcomes. For example, recent evidence suggests that the use of short acting analgesics and analgesic adjuncts for sedation is superior to hypnotic based sedation in intubated patients. This review will address analgesia in the ICU, including opioid therapy, adjuncts, regional anaesthesia and non-pharmacological options that can provide a multimodal approach to treating pain.
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Affiliation(s)
- Eric Ehieli
- Department of Anesthesiology, Duke University Medical Center, Surgical Intensive Care Unit, Veterans Affairs Medical Center, Durham, North Carolina, USA
| | - Suraj Yalamuri
- Department of Anesthesiology, Duke University Medical Center, Surgical Intensive Care Unit, Veterans Affairs Medical Center, Durham, North Carolina, USA
| | - Charles S Brudney
- Department of Anesthesiology, Duke University Medical Center, Surgical Intensive Care Unit, Veterans Affairs Medical Center, Durham, North Carolina, USA
| | - Srinivas Pyati
- Department of Anesthesiology, Duke University Medical Center, Surgical Intensive Care Unit, Veterans Affairs Medical Center, Durham, North Carolina, USA
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Werntz M, Chun C, Togioka BM. Anesthetic Considerations for Neuraxial Anesthesia in Pregnant Patients With Pityriasis Rosea With Skin Lesions Covering the Lumbar Spine. ACTA ACUST UNITED AC 2016; 7:165-168. [PMID: 27513966 DOI: 10.1213/xaa.0000000000000371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Pityriasis rosea (PR) is an acute exanthematous skin disease that is likely due to reactivation of human herpesviruses (HHVs) 6b and 7. In contrast to herpes simplex and zoster (alphaherpesviruses), HHV-6b and -7 (betaherpesviruses) are not found predominantly in skin lesions. This difference in virion location may decrease the possibility of causing central nervous system infection through skin contamination, but the risk for hematogenous spread likely remains the same. This article uses the first-known epidural placement through active PR to illustrate risk-benefit considerations when deciding between neuraxial and general anesthesia for obstetric patients with PR.
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Affiliation(s)
- Megan Werntz
- From Oregon Health & Science University, Portland, Oregon
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Guay J, Nishimori M, Kopp S. Epidural local anaesthetics versus opioid-based analgesic regimens for postoperative gastrointestinal paralysis, vomiting and pain after abdominal surgery. Cochrane Database Syst Rev 2016; 7:CD001893. [PMID: 27419911 PMCID: PMC6457860 DOI: 10.1002/14651858.cd001893.pub2] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Gastrointestinal paralysis, nausea and vomiting and pain are major clinical problems following abdominal surgery. Anaesthetic and analgesic techniques that reduce pain and postoperative nausea and vomiting (PONV), while preventing or reducing postoperative ileus, may reduce postoperative morbidity, duration of hospitalization and hospital costs. This review was first published in 2001 and was updated by new review authors in 2016. OBJECTIVES To compare effects of postoperative epidural analgesia with local anaesthetics versus postoperative systemic or epidural opioids in terms of return of gastrointestinal transit, postoperative pain control, postoperative vomiting, incidence of anastomotic leak, length of hospital stay and costs after abdominal surgery. SEARCH METHODS We identified trials by conducting computerized searches of the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 12), MEDLINE (from 1950 to December 2014) and EMBASE (from 1974 to December 2014) and by checking the reference lists of trials retained. When we reran the search in February 2016, we added 16 potential new studies of interest to the list of 'Studies awaiting classification' and will incorporate these studies into formal review findings during the next review update. SELECTION CRITERIA We included parallel randomized controlled trials comparing effects of postoperative epidural local anaesthetic versus regimens based on systemic or epidural opioids. DATA COLLECTION AND ANALYSIS We rated the quality of studies by using the Cochrane 'Risk of bias' tool. Two review authors independently extracted data and judged the quality of evidence according to the GRADE (Grades of Recommendation, Assessment, Development and Evaluation Working Group) scale. MAIN RESULTS We included 128 trials with 8754 participants in the review, and 94 trials with 5846 participants in the analysis. Trials included in the review were funded as follows: charity (n = 19), departmental resources (n = 8), governmental sources (n = 15) and industry (in part or in total) (n = 15). The source of funding was not specified for the other studies.Results of 22 trials including 1138 participants show that an epidural containing a local anaesthetic will decrease the time required for return of gastrointestinal transit as measured by time to first flatus after an abdominal surgery (standardized mean difference (SMD) -1.28, 95% confidence interval (CI) -1.71 to -0.86; high quality of evidence; equivalent to 17.5 hours). The effect is proportionate to the concentration of local anaesthetic used. A total of 28 trials including 1559 participants reported a decrease in time to first faeces (stool) (SMD -0.67, 95% CI -0.86 to -0.47; low quality of evidence; equivalent to 22 hours). Thirty-five trials including 2731 participants found that pain on movement at 24 hours after surgery was also reduced (SMD -0.89, 95% CI -1.08 to -0.70; moderate quality of evidence; equivalent to 2.5 on scale from 0 to 10). From findings of 22 trials including 1154 participants we did not find a difference in the incidence of vomiting within 24 hours (risk ratio (RR) 0.84, 95% CI 0.57 to 1.23; low quality of evidence). From investigators in 17 trials including 848 participants we did not find a difference in the incidence of gastrointestinal anastomotic leak (RR 0.74, 95% CI 0.41 to 1.32; low quality of evidence). Researchers in 30 trials including 2598 participants noted that epidural analgesia reduced length of hospital stay for an open surgery (SMD -0.20, 95% CI -0.35 to -0.04; very low quality of evidence; equivalent to one day). Data on costs were very limited. AUTHORS' CONCLUSIONS An epidural containing a local anaesthetic, with or without the addition of an opioid, accelerates the return of gastrointestinal transit (high quality of evidence). An epidural containing a local anaesthetic with an opioid decreases pain after abdominal surgery (moderate quality of evidence). We did not find a difference in the incidence of vomiting or anastomotic leak (low quality of evidence). For open surgery, an epidural containing a local anaesthetic would reduce the length of hospital stay (very low quality of evidence).
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Affiliation(s)
- Joanne Guay
- University of SherbrookeDepartment of Anesthesiology, Faculty of MedicineSherbrookeQuebecCanada
| | - Mina Nishimori
- Seibo International Catholic HospitalDepartment of Anesthesiology2‐5‐1, Naka‐OchiaiShinjyukuTokyoJapan161‐8521
| | - Sandra Kopp
- Mayo Clinic College of MedicineDepartment of Anesthesiology and Perioperative Medicine200 1st St SWRochesterMNUSA55901
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10
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Kako H, Hakim M, Kundu A, Tobias TD. Caudal anesthesia in a patient with peritonitis: Is it safe?? Saudi J Anaesth 2016; 10:228-32. [PMID: 27051378 PMCID: PMC4799619 DOI: 10.4103/1658-354x.168826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Neuraxial anesthesia combined with general anesthesia has become a widely accepted method of providing effective postoperative analgesia and decreasing intraoperative anesthetic needs in the pediatric population. In clinical practice, there still appears to be hesitancy for the use of a neuraxial technique (spinal or epidural) in patients at risk for bacteremia or with an on-going systemic infection. However, evidence-based medicine lacks any data to support an increase in the risk of infectious complications following neuraxial anesthesia. We present two pediatric patients with intra-abdominal infectious processes who received caudal epidural blockade for postoperative operative analgesia. The use of neuraxial techniques in patients at risk for bacteremia is reviewed, evidence-based medicine regarding the risks of infection discussed, and the potential favorable effects of neuraxial blockade on the neurohumoral response to sepsis and the systemic inflammatory responses presented.
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Affiliation(s)
- H Kako
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA; Department of Anesthesiology and Pain Medicine, The Ohio State University, Columbus, Ohio, USA
| | - M Hakim
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - A Kundu
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA; Department of Anesthesiology and Pain Medicine, The Ohio State University, Columbus, Ohio, USA
| | - T D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA; Department of Anesthesiology and Pain Medicine, The Ohio State University, Columbus, Ohio, USA
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Sugimoto M, Nesbit L, Barton JG, William Traverso L. Epidural anesthesia dysfunction is associated with postoperative complications after pancreatectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 23:102-9. [DOI: 10.1002/jhbp.307] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 12/08/2015] [Indexed: 12/18/2022]
Affiliation(s)
- Motokazu Sugimoto
- Center for Pancreatic and Liver Disease; St. Luke's Health System; 100 East Idaho Street, Suite 301 Boise Idaho 83712 USA
| | - Lauren Nesbit
- Center for Pancreatic and Liver Disease; St. Luke's Health System; 100 East Idaho Street, Suite 301 Boise Idaho 83712 USA
| | - Joshua G. Barton
- Center for Pancreatic and Liver Disease; St. Luke's Health System; 100 East Idaho Street, Suite 301 Boise Idaho 83712 USA
| | - L. William Traverso
- Center for Pancreatic and Liver Disease; St. Luke's Health System; 100 East Idaho Street, Suite 301 Boise Idaho 83712 USA
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Khanna AK, Laudanski K. Septic shock and anesthesia: Much ado about nothing? J Anaesthesiol Clin Pharmacol 2014; 30:481-3. [PMID: 25425770 PMCID: PMC4234781 DOI: 10.4103/0970-9185.142804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Affiliation(s)
- Ashish K Khanna
- Anesthesiology Institute & Outcomes Research, Cleveland Clinic Foundation, Surgical ICU, Cleveland, OH 44195, USA
| | - Krzysztof Laudanski
- Department of Anesthesiology and Critical Care, University of Pennsylvania, PA 19104, USA
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Sharma K, Kumar M, Batra UB. Anesthetic management for patients with perforation peritonitis. J Anaesthesiol Clin Pharmacol 2014; 29:445-53. [PMID: 24249978 PMCID: PMC3819835 DOI: 10.4103/0970-9185.119128] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Perforation peritonitis is a common surgical emergency. Anesthesia in patients with perforation peritonitis can be challenging. Delayed presentations, old age, hemodynamic instability, presence of sepsis and organ dysfunction are some of the predictors of poor outcome in such patients. Pre-operative optimization can reduce intraoperative and post-operative morbidity and mortality, but surgery should not be unnecessarily delayed. Intensive care in critical care settings may be essential.
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Affiliation(s)
- Kiran Sharma
- Department of Anaesthesiology and Critical Care, Kalpana Chawla Medical College Karnal, New Delhi, India
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Enigk F, Wagner A, Samapati R, Rittner H, Brack A, Mousa SA, Schäfer M, Habazettl H, Schäper J. Thoracic epidural anesthesia decreases endotoxin-induced endothelial injury. BMC Anesthesiol 2014; 14:23. [PMID: 24708631 PMCID: PMC4001105 DOI: 10.1186/1471-2253-14-23] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 03/31/2014] [Indexed: 11/29/2022] Open
Abstract
Background The sympathetic nervous system is considered to modulate the endotoxin-induced activation of immune cells. Here we investigate whether thoracic epidural anesthesia with its regional symapathetic blocking effect alters endotoxin-induced leukocyte-endothelium activation and interaction with subsequent endothelial injury. Methods Sprague Dawley rats were anesthetized, cannulated and hemodynamically monitored. E. coli lipopolysaccharide (Serotype 0127:B8, 1.5 mg x kg-1 x h-1) or isotonic saline (controls) was infused for 300 minutes. An epidural catheter was inserted for continuous application of lidocaine or normal saline in endotoxemic animals and saline in controls. After 300 minutes we measured catecholamine and cytokine plasma concentrations, adhesion molecule expression, leukocyte adhesion, and intestinal tissue edema. Results In endotoxemic animals with epidural saline, LPS significantly increased the interleukin-1β plasma concentration (48%), the expression of endothelial adhesion molecules E-selectin (34%) and ICAM-1 (42%), and the number of adherent leukocytes (40%) with an increase in intestinal myeloperoxidase activity (26%) and tissue edema (75%) when compared to healthy controls. In endotoxemic animals with epidural infusion of lidocaine the values were similar to those in control animals, while epinephrine plasma concentration was 32% lower compared to endotoxemic animals with epidural saline. Conclusions Thoracic epidural anesthesia attenuated the endotoxin-induced increase of IL-1β concentration, adhesion molecule expression and leukocyte-adhesion with subsequent endothelial injury. A potential mechanism is the reduction in the plasma concentration of epinephrine.
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Affiliation(s)
- Fabian Enigk
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, Berlin 12203, Germany
| | - Antje Wagner
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, Berlin 12203, Germany
| | - Rudi Samapati
- Institute of Physiology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, Berlin 10117, Germany
| | - Heike Rittner
- Department of Anesthesia and Critical Care, Josef-Schneider-Straße 2, 97080 Würzburg, Germany
| | - Alexander Brack
- Department of Anesthesia and Critical Care, Josef-Schneider-Straße 2, 97080 Würzburg, Germany
| | - Shaaban A Mousa
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, Berlin 13353, Germany
| | - Michael Schäfer
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, Berlin 13353, Germany
| | - Helmut Habazettl
- Institute of Physiology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, Berlin 10117, Germany ; Department of Anesthesiology and Operative Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, Berlin 13353, Germany
| | - Jörn Schäper
- Department of Anesthesiology, Emergency Medicine and Critical Care Medicine, Universitätsmedizin Göttingen, Robert-Koch-Straße 40, Göttingen 37099, Germany
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Freise H, Van Aken HK. Risks and benefits of thoracic epidural anaesthesia. Br J Anaesth 2011; 107:859-68. [PMID: 22058144 DOI: 10.1093/bja/aer339] [Citation(s) in RCA: 195] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Thoracic epidural anaesthesia (TEA) reduces cardiac and splanchnic sympathetic activity and thereby influences perioperative function of vital organ systems. A recent meta-analysis suggested that TEA decreased postoperative cardiac morbidity and mortality. TEA appears to ameliorate gut injury in major surgery as long as the systemic haemodynamic effects of TEA are adequately controlled. The functional benefit in fast-track and laparoscopic surgery needs to be clarified. Better pain control with TEA is established in a wide range of surgical procedures. In a setting of advanced surgical techniques, fast-track regimens and a low overall event rate, the number needed to treat to prevent one death by TEA is high. The risk of harm by TEA is even lower, and other methods used to control perioperative pain and stress response also carry specific risks. To optimize the risk-benefit balance of TEA, safe time intervals regarding the use of concomitant anticoagulants and consideration of reduced renal function impairing their elimination must be observed. Infection is a rare complication and is associated with better prognosis. Close monitoring and a predefined algorithm for the diagnosis and treatment of spinal compression or infection are crucial to ensure patient safety with TEA. The risk-benefit balance of analgesia by TEA is favourable and should foster clinical use.
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Affiliation(s)
- H Freise
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Münster, Albert Schweitzer Strasse 33, 48149 Muenster, Germany
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