Complications related to thoracic epidural analgesia: a prospective study in 1071 surgical patients

Infectious complications following regional anesthesia: a narrative review and contemporary estimates of risk

INTRODUCTION

Infectious complications following regional anesthesia (RA) while rare, can be devastating. The objective of this review was to estimate the risk of infectious complications following central neuraxial blocks (CNB) such as epidural anesthesia (EA), spinal anesthesia (SA) and combined spinal epidural (CSE), and peripheral nerve blocks (PNB).

MATERIALS AND METHODS

A literature search was conducted in PubMed, Embase and Cochrane databases to identify reference studies reporting infectious complications in the context of RA subtypes. Both prospective and retrospective studies providing incidence of infectious complications were included for review to provide pooled estimates (with 95% CI). Additionally, we explored incidences specifically associated with spinal anesthesia, incidences of central nervous system (CNS) infections and, the incidences of overall and CNS infections following CNB in obstetric population.

RESULTS

The pooled estimate of overall infectious complications following all CNB was 9/100 000 (95% CI: 5, 13/100 000). CNS infections following all CNB was estimated to be 2/100 000 (95% CI: 1, 3/100 000) and even rarer following SA (1/100 000 (95% CI: 1, 2/100 000)). Obstetric population had a lower rate of overall (1/100 000 (95% CI: 1, 3/100 000)) and CNS infections (4 per million (95% CI: 0.3, 1/100 000)) following all CNB. For PNB catheters, the reported rate of infectious complications was 1.8% (95% CI: 1.2, 2.5/100).

DISCUSSION

Our review suggests that the risk of overall infectious complications following neuraxial anesthesia is very rare and the rate of CNS infections is even rarer. The infectious complications following PNB catheters seems significantly higher compared with CNB. Standardizing nomenclature and better reporting methodologies are needed for the better estimation of the infectious complications.

Pain trajectories after bilateral orthotopic lung transplantation surgery performed via a clamshell incision

INTRODUCTION

The nature, intensity, and progression of acute pain after bilateral orthotopic lung transplantation (BOLT) performed via a clamshell incision has not been well investigated. We aimed to describe acute pain after clamshell incisions using pain trajectories for the study cohort, in addition to stratifying patients into separate pain trajectory groups and investigating their association with donor and recipient perioperative variables.

METHODS

After obtaining IRB approval, we retrospectively included all patients ≥18 years old who underwent primary BOLT via clamshell incision at a single center between January 1, 2017, and June 30, 2022. We modeled the overall pain trajectory using pain scores collected over the first seven postoperative days and identified separate pain trajectory classes via latent class analysis.

RESULTS

Three hundred one adult patients were included in the final analysis. Three separate pain trajectory groups were identified, with most patients (72.8%) belonging to a well-controlled, stable pain trajectory. Uncontrolled pain was either observed in the early postoperative period (10%), or in the late postoperative period (17.3%). Late postoperative peaking trajectory patients were younger (p = .008), and sicker with a higher lung allocation score (p = .005), receiving preoperative mechanical ventilation (p < .001), or VV-ECMO support (p < .001).

CONCLUSION

Despite the extensive nature of a clamshell incision, most pain trajectories in BOLT patients had a well-controlled stable pain profile. The benign nature of pain profiles in our patient population may be attributed to the routine institutional practice of early thoracic epidural analgesia for BOLT patients unless contraindicated.

Necessity of routine perioperative epidural catheter placement in laparoscopic colorectal resections: a retrospective data analysis

PURPOSE

Whether epidural anesthesia leads to further improvement in the postoperative course of colorectal procedures is under discussion. The aim of this study was to evaluate the effects of minimally invasive colorectal oncological interventions without epidural anesthesia (EDA).

METHODS

This retrospective data analysis included the clinical data of all patients who underwent minimally invasive oncological colorectal resection at our clinic between January 2013 and April 2019. Of 385 patients who met the inclusion criteria, 183 (group I; 47.5% of 385) received EDA, and 202 (group II; 52.5% of 385) received transversus abdominis plane block instead. The relevant target parameters were evaluated and compared between the groups. The postoperative complications were graded according to the Clavien-Dindo classification.

RESULTS

The patients in group I (n=183; women, 77; men, 106; age 66.8 years) were younger (p=0.0035), received a urinary catheter more often (99.5% versus [vs.] 28.2% p<0.001), required longer, more frequent arterenol treatment (1.1 vs. 0.6 days; p<0.001), and had a longer intermediate care unit stay than those in group II (2.8 vs. 1.1 days; p<0.001). Postoperative pain levels were not significantly different between the groups (p=0.078). The patients in group I were able to ambulate later than those in group II (4 vs. 2 days; p<0.001). The difference in the postoperative day of the first defecation was not significant between the groups (p=0.236). The incidence of postoperative complications such as bleeding (p=0.396), anastomotic leaks (p=0.113), and wound infections (p=0.641) did not differ between the groups. The patients in group I had significantly longer hospital stays than those in group II (12.2 vs. 9.4 days; p<0.001).

CONCLUSION

EDA can be safely omitted from elective minimally invasive colorectal resections, and its omission is not accompanied by any relevant disadvantages to the patient.

Laparoscopic rectal resection without epidural catheters-does it work?

PURPOSE

Placement of an epidural catheter (EC) in colorectal resections is still recommended as a valid measure to achieve a low level of pain. However, EC is associated with increased invasiveness and with an increased risk of bladder emptying disorders and a decrease in blood pressure, which all relate to delayed mobilization. Preliminary data shows that EC placement may not be necessary for laparoscopic colon resections. The aim of this prospective study was to investigate how the omission of EC placement influences short-term postoperative outcomes in laparoscopic rectal resections.

METHODS

All laparoscopic rectal resections occurring between 2013 and 2020 were prospectively examined. Resections from January 2013 to February 2018 (group A) were compared with resections from March 2018 to December 2020 (group B; after the internal change of the perioperative pain regime). In addition to EC placement, the other target parameters of our study were urinary catheter placement during the inpatient stay, postoperative pain > 3 days on a numerical rating scale (NRS), mobilization in the first 5 postoperative days, time until the first postoperative bowel movement, postoperative complications according to Clavien-Dindo, intermediate care unit stay (IMC stay) in days, and hospital length of stay in days.

RESULTS

In the entire study period, 221 laparoscopic rectal resections were performed: 122 in group A and 99 resections in group B. The frequency of EC placement and urinary catheter placement, postoperative IMC stay, and hospital length of stay was significantly lower in group B (p < 0.05). The postoperative mobilization of patients in group B was possible more quickly. There were no differences in the level of pain, time until the first postoperative bowel movement, and postoperative complications according to Clavien-Dindo.

CONCLUSION

Omission of EC placement in laparoscopic rectal resections led to faster mobilization, a shorter IMC stay, and a shorter hospital stay without increasing the pain level. Postoperative complications did not change when an EC was not placed. Therefore, routine EC placement in laparoscopic rectal resections is unnecessary.

Impact on Postoperative Pain and Recovery of a Regional Analgesia Strategy Based on the Surgical Approach for Lung Resection: A Prospective Observational Study

Various regional anesthesia (RA) techniques were shown to reduce pain after lung surgery, but controversies remain regarding the best technique to use to improve recovery. In this observational prospective study, the aim was to assess the efficacy of an RA strategy depending on the surgical approach. Patients who underwent lung surgery were included if an RA was planned following our unit procedure (erector spinae plane block (ESP) for video-assisted thoracic surgery (VATS) and thoracic epidural analgesia (TEA) or intrathecal analgesia (IA) for thoracotomy). Patients were compared according to the RA used. In total, 116 patients were included, 70 (60%), 32 (28%), 14 (12%) in the ESP, TEA and IA groups, respectively. Between Day 1 and Day 3, median NRS values were ≤4 at rest, and <50% patients experienced moderate-to-severe pain in each group. There were no significant differences in opioid consumption and in pain at rest or during chest physiotherapy on Days 1 and 2 between groups. However, patients who received an IA had lower NRS than other groups on Day 0 and 3 and a shorter length of hospital stay in comparison with those who received a TEA. Thus, in our institution, a strategy combining ESP for VATS and TEA, or IA for thoracotomy, allowed for effective analgesia after a lung resection. Interestingly, IA appeared to be more effective than TEA in reducing the length of hospital stay and pain on Day 0 and 3.

Inadvertent neuraxial block placement at or above the L1-L2 interspace in the super-obese parturient: a retrospective study

BACKGROUND

Increasing body mass index (BMI) increases the difficulty of neuraxial procedures. We hypothesized that it may put patients at risk for inappropriately high dural puncture. The accuracy of anesthesiologists' estimates of the interspinous level in super-obese parturients has not been studied. We evaluated the frequency of inadvertently high epidural and/or intrathecal catheter placement (at or above the L1/L2 interspace) in parturients of BMI ≥50 kg/m².

METHODS

Inclusion criteria for this retrospective study were women with a BMI ≥50 kg/m² who delivered by cesarean with an epidural or intrathecal catheter. The primary outcome was the percentage of catheters placed at or above L1/L2, determined by reviewing the retained foreign object radiograph. Secondary outcomes were agreement between the estimated and actual catheter location and subgroup analysis of catheters placed under ultrasound guidance.

RESULTS

After excluding 15 cases for which the catheter location could not be determined and 10 cases for which the estimated level of insertion was not recorded, 125 cases were included. Inadvertent high placement occurred in 26/125 (21%, 95% confidence interval (CI) 15% to 29%) patients. There was poor agreement between the estimated and actual catheter location (27% accurate, unweighted κ-statistic 0.02). Eleven of 39 catheters placed with ultrasound (28%, 95% CI 17% to 44%) were at or above L1/L2 compared with 15/86 catheters placed without ultrasound (17%, 95% CI 11% to 27%, P=0.17). There were no neurological complications.

CONCLUSIONS

A high rate of inadvertently high epidural or intrathecal catheter placement occurs in super-obese parturients. Ultrasound did not prevent this.

Myelopathy with Syringomyelia following Thoracic Epidural Anaesthesia

Under general anaesthesia and muscle relaxation, a thoracic epidural catheter was inserted at the T8-T9 level in a 7-year-old boy scheduled to have a Nissen fundoplication to provide postoperative analgesia. After 4 ml of lignocaine 1.5% was injected through the catheter, hypotension resulted. Fifty-five minutes later 5 ml of bupivacaine 0.25% produced the same effect. In the recovery room a similar injection resulted in lower blood pressure and temporary apnoea. Sensory and motor deficits were noted the next day and four days later magnetic resonance imaging demonstrated spinal cord syringomyelia extending from T5 to T10. Four years later, dysaesthesia from T6 to T10 weakness of the left lower extremity and bladder and bowel dysfunction persist. The risks of inserting thoracic epidural catheters in patients under general anaesthesia and muscle relaxation are discussed, emphasising the possibility of spinal cord injury with disastrous consequences.

Neurologic Complications in the Intensive Care Unit

Complications involving the central and peripheral nervous system are frequently encountered in critically ill patients. All components of the neuraxis can be involved including the brain, spinal cord, peripheral nerves, neuromuscular junction, and muscles. Neurologic complications adversely impact outcome and length of stay. These complications can be related to underlying critical illness, pre-existing comorbid conditions, and commonly used and life-saving procedures and medications. Familiarity with the myriad neurologic complications that occur in the intensive care unit can facilitate their timely recognition and treatment. Additionally, awareness of treatment-related neurologic complications may inform decision-making, mitigate risk, and improve outcomes.

Epidural Hematoma and Abscess Related to Thoracic Epidural Analgesia: A Single-Center Study of 2,907 Patients Who Underwent Lung Surgery

OBJECTIVE

To report the major complications (epidural hematoma and abscess) of postoperative thoracic epidural analgesia in patients who underwent lung surgery.

DESIGN

Prospective, monocentric study.

SETTING

A university hospital.

PARTICIPANTS

All lung surgical patients who received postoperative thoracic epidural analgesia between November 2007 and November 2015.

INTERVENTIONS

Thoracic epidural analgesia for patients who underwent lung surgery.

MEASUREMENTS AND MAIN RESULTS

During the study period, data for 2,907 patients were recorded. The following 3 major complications were encountered: 1 case of epidural hematoma (0.34 case/1,000; 95% confidence interval 0.061-1.946), for which surgery was performed, and 2 cases of epidural abscesses (0.68 case/1,000; 95% confidence interval 0.189-2.505), which were treated medically.

CONCLUSIONS

The risk range of serious complications was moderate; only the patient who experienced an epidural hematoma also experienced permanent sequelae.

Pain management using patient controlled anaesthesia in adults post Nuss procedure: an analysis with respect to patient satisfaction

BACKGROUND

The Nuss procedure for correction of pectus excavatum is commonly associated with severe postoperative pain. The belief that thoracic epidural offers the best pain control has recently come under scrutiny after several studies have shown patient controlled anaesthesia (PCA) to be just as effective. Nevertheless, centres who have shifted to an exclusively PCA regime exist in the minority. We have conducted a retrospective survey of all patients who underwent the Nuss procedure at the Heart Hospital, London, where all patients are managed exclusively using PCA. The study aims to assess the efficacy and validity of our practice.

METHODS

A retrospective survey was carried out on 149 patients (139 males and 10 females), with an average age of 28, after undergoing a Nuss bar insertion. The study was conducted between August and October, 2014. The PCA technique used a 1 mg bolus dose of morphine sulphate, administered through a 5-minute lockout. There was no background infusion and no maximum dose limit in a 4-hour period. The outcome of the study measured patient satisfaction with postoperative analgesia and medication prescribed for home usage. The pre-operative provision of information with regard to patient expectations of pain was also assessed. The study is approved by the institutional ethical committee and has obtained the informed consent from every patient.

RESULTS

The majority of patients were either satisfied or extremely satisfied with the pain management received in hospital immediately following surgery. Additionally, a substantial number of patients strongly agreed that they were adequately warned about postoperative pain prior to the operation. None of the cohort specified that they experienced more pain than expected or thought that the medication prescribed for home usage was inadequate. Moreover, a small minority of patients reported postoperative long-term or chronic pain, with only one reporting that it lasted for longer than 6 months.

CONCLUSIONS

Results obtained from retrospective patient satisfaction surveys indicate high efficacy for PCA as a pain management strategy. The large majority of patients did not seek more medication for pain alleviation and found in-hospital treatment sufficient. Further, all patients agreed that they were adequately informed of pain-risk prior to surgery.

Segmental thoracic spinal has advantages over general anesthesia for breast cancer surgery

BACKGROUND

Thoracic spinal anesthesia has been used for laparoscopic cholecystectomy and abdominal surgeries, but not in breast surgery. The present study compared this technique with general anesthesia in breast cancer surgeries.

MATERIALS AND METHODS

Forty patients were enrolled in this comparative study with inclusion criteria of ASA physical status I-III, primary breast cancer without known extension beyond the breast and axillary nodes, scheduled for unilateral mastectomy with axillary dissection. They were randomly divided into two groups. The thoracic spinal group (S) (n = 20) underwent segmental thoracic spinal anesthesia with bupivacaine and fentanyl at T5-T6 interspace, while the other group (n = 20) underwent general anesthesia (G). Intraoperative hemodynamic parameters, intraoperative complications, postoperative discharge time from post-anesthesia care unit (PACU), postoperative pain and analgesic consumption, postoperative adverse effects, and patient satisfaction with the anesthetic techniques were recorded.

RESULTS

Intraoperative hypertension (20%) was more frequent in group (G), while hypotension and bradycardia (15%) were more frequent in the segmental thoracic spinal (S) group. Postoperative nausea (30%) and vomiting (40%) during PACU stay were more frequent in the (G) group. Postoperative discharge time from PACU was shorter in the (S) group (124 ± 38 min) than in the (G) group (212 ± 46 min). The quality of postoperative analgesia and analgesic consumption was better in the (S) group. Patient satisfaction was similar in both groups.

CONCLUSIONS

Segmental thoracic spinal anesthesia has some advantages when compared with general anesthesia and can be considered as a sole anesthetic in breast cancer surgery with axillary lymph node clearance.

The volume effect of lidocaine on thoracic epidural anesthesia in conscious Beagle dogs

OBJECTIVE

To evaluate the volume effect of local anesthetic solution on thoracic epidural analgesia in dogs.

STUDY DESIGN

Prospective, experimental trial.

ANIMALS

Five healthy adult Beagle dogs weighing 9.7 ± 1.3 kg.

METHODS

A catheter was inserted into the seventh thoracic epidural space using a lumbosacral approach, and secured with suture under total intravenous (IV) anesthesia with propofol. Each dog was administered four volume treatments (0.05, 0.10, 0.15 and 0.20 mL kg(-1)) of 2% lidocaine via the catheter at 12 hour intervals. In every treatment, dogs were re-anesthetized with propofol (6 mg kg(-1), IV) and isoflurane, and received iohexol at each volume to visualize the epidural distribution (ED) through computed tomography. Three hours after epidurography, when dogs had recovered from anesthesia, the appropriate volume of lidocaine was injected through the catheter, and sensory blockade (SB) in dermatomes was evaluated by pinching with a mosquito forceps. Results were presented as median (range), and the volume effect on ED and SB was analyzed with one-way Kruskal-Wallis anova.

RESULTS

In proportion to volumes (0.05, 0.10, 0.15 and 0.20 mL kg(-1)), there were significant increases in the extent of ED from 7.4 (5.5-9.0) to 10.4 (8.0-12.0), 13.2 (12.5-13.0), and 15.2 (13.0-18.0) vertebrae, respectively, p < 0.001, and in SB from 2.7 (1.0-5.0) to 6.8 (4.5-10.5), 9.9 (6.5-13.0), and 13.1 (11.0-15.0) dermatomes, respectively, p < 0.001. Unilateral ED and SB were observed in all treatments with various grades, and this distribution was more frequent in the low volume treatments. In the high volume treatments, temporary complications including Horner's syndrome, ataxia, paraplegia, depression, stupor, and intermittent cough occurred often.

CONCLUSIONS AND CLINICAL RELEVANCE

The increase in volume of local anesthetic solution improved SB by resulting in more consistent bilateral dermatome blockade as well as an extended blockade. However, caution should be exerted, as higher volume injections of lidocaine caused side effects in all dogs.

Thoracic epidural catheter placement using a paramedian approach with cephalad angulation in three dogs

OBJECTIVE

To describe a technique for insertion of a thoracic epidural catheter.

STUDY DESIGN

Clinical report.

ANIMALS

Dogs (n = 3) undergoing thoracic wall resection and thoracotomy.

METHODS

A paramedian approach with cephalic angulation was used to place a 24-g epidural catheter in 3 dogs. Dogs 1 and 2 had left caudal thoracic wall resection and dog 3 had left thoracotomy. In dog 1, the epidural catheter was inserted at L2-L3 intervertebral space and the tip of the catheter advanced to the level of T13 vertebral body. In dog 2, the epidural catheter was inserted at T12-T13 intervertebral space and the tip of the catheter was advanced to the level of T8 vertebral body. In dog 3, the epidural catheter was inserted at T13-L1 intervertebral space and its tip advanced until reaching the vertebral body of T10. All dogs were administered a combination of bupivacaine and morphine through the epidural catheter to provide intra- and postoperative analgesia.

RESULTS

The peridural space was identified and the tip of the catheter was positioned where intended in all dogs. Dog 1 developed transient Horner's syndrome and dog 3 required intraoperative fentanyl during the first part of the procedure.

CONCLUSION

Paramedian approach with cephalad angulation is a suitable technique to place thoracic epidural catheters in dogs.

Buprenorphine in postoperative pain management

Several decades ago, the analgesic properties of buprenorphine were discovered. Its approval for the use as an agent for the treatment of opioid abuse has led to increasing numbers of patients presenting for surgery on buprenorphine. This article describes the challenges, advantages, and disadvantages of the use of buprenorphine as an analgesic for postoperative pain in patients with and without preoperative maintenance therapy.

A new method for release of severe mentosternal contractures under central neuraxial blockade

A new method for release of severe mentosternal contractures has been described in this paper under central neuraxial blockade. The contracture release was performed under thoracic epidural analgesia. This technique can benefit patients with mentosternal contractures to avoid the problems of entubation and it can also assist in postoperative recovery and analgesia. The epidural catheter can be used to extend the height or duration of intraoperative block and is also useful to provide postoperative epidural analgesia.

Neurological impairment following myocardial ischemia associated with postoperative epidural analgesia

Although epidural analgesia reduces the postoperative stress response and provides good pain relief for patients, potential complications associated with the technique may decrease its acceptability for some patients. We describe a 76-year-old female who underwent surgery for carcinoma of the urinary tract. Postoperative epidural analgesia was performed at the postanesthesia care unit. Neither a repeat attempt nor accidental dural puncture was encountered during the procedure. Unfortunately, she sustained neurological impairment of the bilateral lower limbs following an episode of myocardial ischemia during the early postoperative period. When the neurological deficit was recognized following epidural anesthesia, poor puncture technique was the first to be blamed. In fact, a high level of sensory blockade could markedly decrease blood pressure and heart rate, particularly in the presence of hypovolemia, which might lead to impairment of coronary perfusion and result in myocardial ischemia. Severe systemic hypotension might further lead to hypoperfusion of the spinal cord, most possibly in the mid-thoracic region (T4 to T8) due largely to its relative hypovascularity. Therefore, we recommend that maintaining sufficient circulatory volume of the patient, evaluating and recording the neurological function of the patient and determining the possible risk factors associated with coronary arterial disease are imperative prior to performing an epidural procedure.

Incidence of epidural haematoma and neurological injury in cardiovascular patients with epidural analgesia/anaesthesia: systematic review and meta-analysis

Background

Epidural anaesthesia is used extensively for cardiothoracic and vascular surgery in some centres, but not in others, with argument over the safety of the technique in patients who are usually extensively anticoagulated before, during, and after surgery. The principle concern is bleeding in the epidural space, leading to transient or persistent neurological problems.

Methods

We performed an extensive systematic review to find published cohorts of use of epidural catheters during vascular, cardiac, and thoracic surgery, using electronic searching, hand searching, and reference lists of retrieved articles.

Results

Twelve studies included 14,105 patients, of whom 5,026 (36%) had vascular surgery, 4,971 (35%) cardiac surgery, and 4,108 (29%) thoracic surgery. There were no cases of epidural haematoma, giving maximum risks following epidural anaesthesia in cardiac, thoracic, and vascular surgery of 1 in 1,700, 1 in 1,400 and 1 in 1,700 respectively. In all these surgery types combined the maximum expected rate would be 1 in 4,700. In all these patients combined there were eight cases of transient neurological injury, a rate of 1 in 1,700 (95% confidence interval 1 in 3,300 to 1 in 850). There were no cases of persistent neurological injury (maximum expected rate 1 in 4,600).

Conclusion

These estimates for cardiothoracic epidural anaesthesia should be the worst case. Limitations are inadequate denominators for different types of surgery in anticoagulated cardiothoracic or vascular patients more at risk of bleeding.

Adverse Effects of Fluoroscopically Guided Interlaminar Thoracic Epidural Steroid Injections

OBJECTIVES

To assess the prevalence of adverse effects or complications from fluoroscopically guided thoracic interlaminar epidural steroid injections.

DESIGN

A retrospective study with independent observer review. Patients presenting with thoracic radicular pain, caused by either herniated nucleus pulposus or thoracic spondylosis as confirmed by magnetic resonance imaging, received an interlaminar thoracic epidural steroid injection as part of a conservative-care treatment plan. The study was performed in a multidisciplinary spine care center. All injections were performed over a 5-yr period. An independent observer reviewed medical charts, which included a 24-hr postprocedure standardized questionnaire completed by telephone by an ambulatory surgical center nurse. Ambulatory surgical center operative reports and physician follow up office notes up to 3 mos after the procedures, along with epidurograms, were also reviewed.

RESULTS

A total of 21 patients who received 39 injections were reviewed. Adverse effects or complications per injection observed included three with increased pain at injection site (7.7%), two with facial flushing (5.1%), one transient nonpositional headache (2.6%), one episode of insomnia the night of the injection (2.6%), and one episode of fever the night of the procedure (2.6%). Statistical analysis revealed no significant difference based on diagnosis (herniated nucleus pulposus vs. spondylosis, P = 0.9156), and age was not linked to higher prevalence of adverse/effects complications (P = 0.3137).

CONCLUSIONS

No major complication arose. Adverse effects did occur with a rate of 20.5%. All adverse effects resolved without morbidity. No statistical difference was observed in the rate of adverse effects in patients with herniated nucleus pulposus or spondylosis.

Thoracic epidural anesthesia in cardiac surgical patients: A prospective audit of 2,113 cases

OBJECTIVE

The purpose of this study was to present an audit report of thoracic epidural anesthesia without permanent neurologic deficits in more than 2,000 patients undergoing cardiac surgery.

DESIGN

A prospective audit of cases conducted over a 13-year period.

SETTING

Tertiary referral heart hospital.

PARTICIPANTS

Two thousand one hundred thirteen patients over a period of 13 years.

INTERVENTIONS

Epidural catheters were inserted at the C7 to T3 intervertebral space on the day before the operation in all patients; cardiac surgery was performed with or without cardiopulmonary bypass.

MEASUREMENTS AND RESULTS

The authors did not encounter any permanent neurologic deficits in their series. The authors encountered 18 (0.85%) primary dural punctures and 4 cases (0.18%) of temporary neurologic deficits.

CONCLUSION

This series adds to the worldwide experience of the use of epidural analgesia concomitantly with anticoagulation in cardiac surgery without serious complications.

An Epidural Hematoma in an Adolescent Patient After Cardiac Surgery

An 18-yr-old patient had a thoracic epidural placed under general anesthesia preceding an uneventful aortic valve replacement with a bioprosthetic valve. On the second postoperative day, he was anticoagulated and also received an antithrombotic medication. While ambulating, he experienced pain in his back, and there was blood in his epidural catheter. The catheter was removed, and he developed motor and sensory loss. Rapid surgical decompression resulted in recovery of his lost neurological function. Management and strategies for preventing this problem are discussed.

IMPLICATIONS

Epidural hematoma is a rare complication of epidural anesthesia and has not been reported in pediatric patients undergoing cardiac surgery. The successful treatment of this complication requires swift recognition, diagnosis, and surgical intervention.

Current trends in perioperative pain management

Wider use of optimized multimodal accelerated postoperative recovery programs require that anesthesiologists step out of traditional operating room anesthesia roles and even beyond current pain management consultant roles. Development of optimal postoperative recovery services requires close collaboration between anesthesiologists, surgeons, nurses, physical therapists, administrators, and others involved in the management of patients after surgery. Optimization of perioperative care is an ongoing process enhanced by clinical investigation; however, making significant improvements to clinical practice does not have to wait for additional research data, but should proceed now, with broader application of techniques known to enhance rehabilitation and recovery. Based on existing data, the challenges of developing perioperative recovery services seem likely to be rewarded with improved patient outcomes and reduced cost.

Transient Horner's Syndrome in a Trauma Patient with Thoracic Epidural Analgesia: A Case Report

Horner's syndrome, which classically presents as ipsilateral ptosis, meiosis, and facial anhydrosis, may present as a consequence of thoracic epidural analgesia. Pain that limits the patient's ability to maintain adequate pulmonary mechanics may optimally be treated with a thoracic epidural. The importance of recognition of a Horner's syndrome in such a patient is critical in preventing unnecessary anxiety for the patient and potentially embarking on an unnecessary diagnostic workup. The following is a case presentation of a patient who sustained multiple rib fractures in an automobile accident. The patient presented with a Horner's syndrome after a thoracic epidural infusion had begun. This article highlights the importance of early recognition of this benign, transient syndrome and discusses the pathways and potential mechanism of this process.

Acute Horner syndrome due to thoracic epidural analgesia in a paediatric patient

A 4-year-old boy with coarctation of the aorta underwent surgical aortic arch repair with general anaesthesia and thoracic epidural analgesia. In the immediate postoperative period, the child developed a unilateral Horner syndrome which appeared to be related to the epidural infusion rate. Management of this patient as well as alternate aetiologies of Horner syndrome are described. Horner syndrome is a rare complication of epidural catheters and is often unrecognized, especially in children.

Postoperative pain control by epidural analgesia after transabdominal surgery. Efficacy and problems encountered in daily routine

BACKGROUND

The efficacy of postoperative epidural pain treatment has been well documented in controlled studies. However, the literature concerning results of daily routine use of this method often only emphasises certain aspects of it.

METHODS

A prospective study of 168 patients scheduled for major surgery with transabdominal access was performed in order to evaluate efficacy, side effects, complications and rate of acceptance of postoperative epidural pain treatment. The epidural catheter was placed before surgery and the patients received epidural analgesia by a bupivacaine/morphine mixture for 3 days postoperatively, continued by another 3 days with bolus injections of morphine only.

RESULTS

Only few complications followed the insertion of the epidural catheter, but in about 16% of the patients the epidural catheter or the drugs administered by it made reinsertion or change in the type of analgesia necessary during the first 3 post-operative days. Despite the possibility for individualising the treatment and p.r.n. analgesics, pain relief when coughing and moving during day 1-3 was insufficient in 30-50% of the patients. Serious side effects were rare, but pruritus was frequent, as were the symptoms of nausea and vomiting. The patients were generally satisfied with the treatment; however, a small group had unacceptable pain when the epidural catheter was inserted.

CONCLUSION

Analgesia was insufficient when coughing and moving in an unacceptably large number of the patients. Also the number of epidural catheter related problems was high. In order to make early intervention possible, the patients and epidural catheters should be observed daily and systematically by members of the staff competent to detect possible problems.

An epidural scoring scale for arm movements (ESSAM) in patients receiving high thoracic epidural analgesia for coronary artery bypass grafting

Thoracic epidural analgesia appears to improve the outcome of patients undergoing coronary artery bypass graft surgery. Cranial extension of nerve blockade involving the third, fourth and fifth cervical nerve roots can cause apnoea. However, progressive paraesthesia and weakness due to cephalad spread of thoracic epidural analgesia will affect the arms before the diaphragm. A scale was designed to test three active movements of the arms bilaterally: hand grip (T1/C8), wrist flexion (C8/7) and elbow flexion (C6/5). This epidural scoring scale for arm movements (ESSAM) consists of four grades (0-3) based on the number of absent movements, and suggests appropriate action. The reliability of this scale was tested in 40 patients undergoing coronary artery bypass surgery. Twelve of the 40 patients had their epidural infusion reduced on the basis of the scale. Of these 12 patients, eight had a worst ESSAM score of 1, three had a worst score of 2 and one had a worst score of 3. In each patient, motor power returned following the reduction in infusion rate, taking between 30 min and 3 h. This scale appears to be a simple and reliable method for the early detection of the cephalad spread of thoracic epidural analgesia.

Neurologic complications in the intensive care unit

Neurologic complications resulting from critical illness and intensive care unit therapies are common, but frequently unrecognized because these patients are often intubated, sedated, and, occasionally, receiving neuromuscular blocking agents. Neurologic complications are associated with an increased intensive care unit mortality. This article discusses central nervous system complications that are secondary to critical illness or to therapeutic interventions in the critically ill patient.

A comparison of thoracic and lumbar epidural techniques for post-thoracoabdominal esophagectomy analgesia

PURPOSE

To compare thoracic epidural analgesia (TEA) using a bupivacaine/fentanyl mixture and lumbar epidural analgesia (LEA) with morphine, in respect to the time to extubation and the quality of post-operative analgesia, in patients having thoracoabdominal esophagectomy.

METHODS

Twenty two patients scheduled for elective thoracoabdominal esophagectomy were randomized to TEA or LEA. Postoperatively, the TEA group received Patient Controlled Epidural Analgesia (PCEA) with bupivacaine 0.125% and 5 microg x ml(BI) fentanyl, and the LEA group received PCEA with 0.2 microg x ml(BI) morphine. A blinded observer assessed criteria for tracheal extubation and the time of tracheal extubation was recorded. Early extubation was defined as tracheal extubation within four hours postoperatively. Visual analogue pain scores at rest (Static Visual Analogue Pain Scores, SVAPS) and with movement (Dynamic Visual Analogue Pain Scores, DVAPS) were recorded at 1, 6, 12, 18 and 24 hr post-extubation. Failure of the epidural protocol (FEP) was defined as a request for additional analgesia.

RESULTS

Tracheal extubation was achieved in 70% of the LEA and 100% of the TEA at four hours postoperatively (P=NS). However, the TEA group achieved earlier extubation times when assessed with log rank testing (P = 0.01). By six hours post-extubation FEP had occurred in 50% of the LEA group but in none of the TEA group (P = 0.01). Mean SVAPS and DVAPS were lower in the TEA than in the LEA group at all measured times (P < 0.01).

CONCLUSION

This study has demonstrated superior pain control in patients undergoing thoraco-abdominal esophagectomy treated with TEA than with LEA, particularly for pain with movement. Tracheal extubation occurred earlier in the TEA group, but this difference was not significant at four hours postoperatively.

Assessment of operative risk for patients with advanced lung disease

Increasingly, patients with advanced lung disease are being offered operative procedures. The assessment of the perioperative risk of these patients must include not only the assessment of their lung disease, but the assessment of the patient's cardiovascular disease, their age, and their other medical problems. Knowledge of the stress of particular surgical procedures is also of importance in risk assessment, and is addressed in this article.