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Obersztyn M, Trejnowska E, Nadziakiewicz P, Knapik P. Evaluation of thoracic epidural analgesia in patients undergoing coronary artery bypass surgery - a prospective randomized trial. KARDIOCHIRURGIA I TORAKOCHIRURGIA POLSKA = POLISH JOURNAL OF CARDIO-THORACIC SURGERY 2018; 15:72-78. [PMID: 30069186 PMCID: PMC6066681 DOI: 10.5114/kitp.2018.76471] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 02/12/2018] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Most recent studies tend to confirm the beneficial effect of thoracic epidural analgesia (TEA) in cardiac surgery. AIM To assess whether intensive care unit TEA has an influence on the perioperative course following low-risk coronary artery surgery. MATERIAL AND METHODS This prospective, randomized trial was performed in patients scheduled for low-risk coronary artery surgery. Eighty patients undergoing off-pump or on-pump coronary artery bypass surgery were prospectively randomized to receive either combined general and epidural anesthesia or general anesthesia only. Time of postoperative ventilations and intensive care unit stay was compared between the groups. For all comparisons (p < 0.05) was considered statistically significant. RESULTS The addition of TEA to general anesthesia significantly attenuated the stress response expressed by intraoperative heart rate, systolic blood pressure and cumulative doses of opioids. Time to the return of spontaneous respiration, time to extubation and time of stay in the postoperative care unit were all shorter in the study group, with no difference in hospital stay. Patients with TEA required midazolam less frequently (12.8% vs. 53.8%, p < 0.001). The percentage of patients given morphine in the study group was lower (46.2% vs. 89.7%, p < 0.001) and the mean dose given in patients receiving morphine was also lower (9.3 ±5.3 mg vs. 18.2 ±9.1 mg, p < 0.001). CONCLUSIONS Addition of TEA to general anesthesia shortens the return of respiratory function, duration of mechanical ventilation and ICU stay in the postoperative period after coronary artery surgery, providing comparable hemodynamic stability to general anesthesia alone.
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Affiliation(s)
- Maciej Obersztyn
- Department of Anesthesia, University Clinical Centre, Medical University of Silesia, Katowice, Poland
| | - Ewa Trejnowska
- Department of Cardiac Anesthesia and Intensive Therapy, Silesian Centre for Heart Diseases in Zabrze, Medical University of Silesia in Katowice, Poland
| | - Paweł Nadziakiewicz
- Department of Cardiac Anesthesia and Intensive Therapy, Silesian Centre for Heart Diseases in Zabrze, Medical University of Silesia in Katowice, Poland
| | - Piotr Knapik
- Department of Cardiac Anesthesia and Intensive Therapy, Silesian Centre for Heart Diseases in Zabrze, Medical University of Silesia in Katowice, Poland
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Pedroviejo Sáez V. [Nonanalgesic effects of thoracic epidural anesthesia]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2011; 58:499-507. [PMID: 22141218 DOI: 10.1016/s0034-9356(11)70125-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Thoracic epidural anesthesia, which has been performed since the 1950s, has progressed from being one analgesic technique among others to its present status as the technique of choice for managing pain after major abdominal and thoracic surgery. In addition to providing effective analgesia, the epidural infusion of local anesthetic agents produces a sympathetic block that offers advantages over other types of pain control, particularly with respect to the cardiovascular, respiratory, and gastrointestinal systems. Thoracic epidural anesthesia provides dynamic pain relief, allowing the patient to resume activity early. It also permits early extubation and is associated with fewer postoperative pulmonary complications, shorter duration of paralytic ileus, and a better response to the stress of anesthesia and surgery. However, meta-analyses have not yet demonstrated that postoperative outcomes are improved. This review describes the nonanalgesic effects of thoracic epidural anesthesia.
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Affiliation(s)
- V Pedroviejo Sáez
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid.
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Licker M, Tschopp JM, Robert J, Frey JG, Diaper J, Ellenberger C. Aerosolized Salbutamol Accelerates the Resolution of Pulmonary Edema After Lung Resection. Chest 2008; 133:845-52. [DOI: 10.1378/chest.07-1710] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
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Bauer C, Hentz JG, Ducrocq X, Meyer N, Nicolas M, Oswald-Mammosser M, Steib A, Dupeyron JP. Lung function after lobectomy: a randomized, double-blinded trial comparing thoracic epidural ropivacaine/sufentanil and intravenous morphine for patient-controlled analgesia. Anesth Analg 2007; 105:238-44. [PMID: 17578981 DOI: 10.1213/01.ane.0000266441.58308.42] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Although thoracic epidural analgesia (TEA) is considered superior to IV opioids for postoperative analgesia after thoracic surgery, a few studies clearly demonstrate an improvement in pulmonary function attributable to TEA using a local anesthetic in combination with an opioid. METHODS In this prospective, randomized, double-blind study, we compared the effects of TEA with ropivacaine and sufentanil (TEA group) to IV morphine (IV group), as they affected pain and pulmonary function after lobectomy in 68 patients. Pain intensity, forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), FEV1/FVC ratio, forced expiratory flows, and sniff nasal inspiratory pressure as a marker of inspiratory muscle strength were measured from the first to the fourth postoperative day. RESULTS Pain relief was better in the TEA group at rest and on coughing (P < 0.001). The impairment of FVC and FEV1 was less in the TEA group when compared with that in the IV group (P < 0.001 and P = 0.003, respectively). Sniff nasal inspiratory pressure, FEV1/FVC ratio, and expiratory flow values decreased similarly in both groups. In-hospital mortality, as well as postoperative pulmonary complications, was not different between groups. CONCLUSION After lobectomy, TEA enables a significant increase in pulmonary function concomitant with better pain relief than systemic morphine, although a modest intercostal motor block may occur.
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Affiliation(s)
- Christian Bauer
- Department of Anesthesia and Intensive Care, Hopital Cardio-Vasculaire et Pneumologique Louis Pradel, Hospices Civils de Lyon, Lyon-Bron, France.
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Michelet P, Hélaine A, Avaro JP, Guervilly C, Gaillat F, Kerbaul F, Thomas P, Auffray JP. Influence de la stratégie analgésique sur la fonction respiratoire après chirurgie thoracique pour lobectomie. ACTA ACUST UNITED AC 2007; 26:405-11. [PMID: 17336489 DOI: 10.1016/j.annfar.2007.01.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2006] [Accepted: 01/24/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To compare the influence of thoracic epidural analgesia (TEA) with intravenous patient-controlled analgesia with morphine (PCA) on the early postoperative respiratory function after lobectomy. STUDY DESIGN Prospective and comparative observational study. PATIENTS AND METHODS Fourty-four patients scheduled for lobectomy (n=22 per group) were studied on the evolution of the postoperative respiratory function assessed by the forced vital capacity (FVC) and the forced expired volume (FEV(1)) during the first two postoperative days and the analysis of noctural arterial desaturation during the three first postoperative nights. RESULTS The use of TEA resulted in fewer decrease both in FEV(1) (1.01+/-0.34 versus 1.31+/-0.51 l/s for Day 1, P=0.03; 1.13+/-0.37 versus 1.53+/-0.59 l/s for Day 2, P=0.01) and in FVC (1.23 [1.05-1.51] versus 1.57 [1.38-2.53] l for day 1, P=0.008; 1.33+/-0.43 versus 2.24+/-0.87 l for day 2, P<0.001). Moreover, the duration of arterial desaturation<90% were longer in the PCA group during the first (8.6 [0.8-28.2] versus 1.3 [0-2.6] min, P=0.02) and the second postoperative night (13.5 [3.5-54] versus 0.4 [0-2.6] min, P=0.025). CONCLUSION The results of this study suggest that the use of TEA is associated with a better preservation of respiratory function assessed by spirometric data and noctural arterial desaturation recording after thoracic surgery for lobectomy.
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Affiliation(s)
- P Michelet
- Département d'anesthésie-réanimation, hôpital Sainte-Marguerite, boulevard Sainte-Marguerite, 13009 Marseille, France.
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Abstract
Autonomic nerves in most mammalian species mediate both contractions and relaxations of airway smooth muscle. Cholinergic-parasympathetic nerves mediate contractions, whereas adrenergic-sympathetic and/or noncholinergic parasympathetic nerves mediate relaxations. Sympathetic-adrenergic innervation of human airway smooth muscle is sparse or nonexistent based on histological analyses and plays little or no role in regulating airway caliber. Rather, in humans and in many other species, postganglionic noncholinergic parasympathetic nerves provide the only relaxant innervation of airway smooth muscle. These noncholinergic nerves are anatomically and physiologically distinct from the postganglionic cholinergic parasympathetic nerves and differentially regulated by reflexes. Although bronchopulmonary vagal afferent nerves provide the primary afferent input regulating airway autonomic nerve activity, extrapulmonary afferent nerves, both vagal and nonvagal, can also reflexively regulate autonomic tone in airway smooth muscle. Reflexes result in either an enhanced activity in one or more of the autonomic efferent pathways, or a withdrawal of baseline cholinergic tone. These parallel excitatory and inhibitory afferent and efferent pathways add complexity to autonomic control of airway caliber. Dysfunction or dysregulation of these afferent and efferent nerves likely contributes to the pathogenesis of obstructive airways diseases and may account for the pulmonary symptoms associated with extrapulmonary disorders, including gastroesophageal reflux disease, cardiovascular disease, and rhinosinusitis.
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Oh EJ, Mazzone SB, Canning BJ, Weinreich D. Reflex regulation of airway sympathetic nerves in guinea-pigs. J Physiol 2006; 573:549-64. [PMID: 16581869 PMCID: PMC1779716 DOI: 10.1113/jphysiol.2005.104661] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Sympathetic nerves innervate the airways of most species but their reflex regulation has been essentially unstudied. Here we demonstrate sympathetic nerve-mediated reflex relaxation of airway smooth muscle measured in situ in the guinea-pig trachea. Retrograde tracing, immunohistochemistry and electrophysiological analysis identified a population of substance P-containing capsaicin-sensitive spinal afferent neurones in the upper thoracic (T1-T4) dorsal root ganglia (DRG) that innervate the airways and lung. After bilateral vagotomy, atropine pretreatment and pre-contraction of the trachealis with histamine, nebulized capsaicin (10-60 microm) evoked a 63+/-7% reversal of the histamine-induced contraction of the trachealis. Either the beta-adrenoceptor antagonist propranolol (2 microm, administered directly to the trachea) or bilateral sympathetic nerve denervation of the trachea essentially abolished these reflexes (10+/-9% and 6+/-4% relaxations, respectively), suggesting that they were mediated primarily, if not exclusively, by sympathetic adrenergic nerve activation. Cutting the upper thoracic dorsal roots carrying the central processes of airway spinal afferents also markedly blocked the relaxations (9+/-5% relaxation). Comparable inhibitory effects were observed following intravenous pretreatment with neurokinin receptor antagonists (3+/-7% relaxations). These reflexes were not accompanied by consistent changes in heart rate or blood pressure. By contrast, stimulating the rostral cut ends of the cervical vagus nerves also evoked a sympathetic adrenergic nerve-mediated relaxation that were accompanied by marked alterations in blood pressure. The results indicate that the capsaicin-induced reflex-mediated relaxation of airway smooth muscle following vagotomy is mediated by sequential activation of tachykinin-containing spinal afferent and sympathetic efferent nerves innervating airways. This sympathetic nerve-mediated response may serve to oppose airway contraction induced by parasympathetic nerve activation in the airways.
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Affiliation(s)
- Eun Joo Oh
- Department of Pharmacology and Experimental Therapeutics, University of Maryland School Of Medicine, Baltimore, MD 21201, USA
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Bir LS, Ozkurt S, Daloğlu G, Kurt T. Impaired sympathetic skin response in chronic obstructive pulmonary disease. TOHOKU J EXP MED 2005; 207:243-8. [PMID: 16272793 DOI: 10.1620/tjem.207.243] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The sympathetic skin response (SSR) is considered as one of the indexes of autonomic nervous system functions, especially related with the sudomotor function of unmyelinated sympathetic fibers. SSRs are recorded as the potentials with biphasic or multiphasic waveforms by conventional electromyography. SSRs are evaluated by measuring latency (time from the stimulus to the onset), amplitude, and area (the space under the curve of the waveform). Although dysautonomia is a feature of chronic obstructive pulmonary disease (COPD), as demonstrated by acetylcholine sweat-spot test, there are no data concerning SSR in COPD patients. In this study, we electrophysiologically investigated the sudomotor function of the sympathetic nervous system in patients with COPD. SSRs were recorded in 30 patients with COPD and 21 healthy volunteers. Normal responses were obtained from all subjects in the control group. No response was observed in three patients with COPD. The mean latency, amplitude and area values of the potentials recorded of the remaining 27 patients were compared to the control. The mean latency was longer (p<0.01) and the mean amplitude and area values were lower (p=0.012, p=0.021, respectively) in the patients compared to the control. We also demonstrated significant correlations between the latency, amplitude, or area values of the SSR and two parameters of pulmonary function tests forced expiratory volume one second/forced vital capacity (FEV1/FVC) and FEV1/FVC %. In conclusion, SSR is impaired in patients with COPD, which indicates the dysfunction of the sympathetic nervous system. Furthermore, the degree of impairment in SSR may reflect the severity of airway obstruction in patients with COPD.
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Affiliation(s)
- Levent Sinan Bir
- Department of Neurology, Pamukkale University Faculty of Medicine, Denzli, and Department of Neurology, Atatürk Education and Research Hospital Izmir, Turkey.
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Groeben H. Effects of high thoracic epidural anesthesia and local anesthetics on bronchial hyperreactivity. J Clin Monit Comput 2003; 16:457-63. [PMID: 12580229 DOI: 10.1023/a:1011448927817] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Bronchial hyperreactivity can cause life threatening bronchospasm after airway irritation. Therefore, endotracheal intubation is avoided in asthmatics when feasible. High thoracic epidural anesthesia can be used to avoid endotracheal intubation and offers less postoperative pulmonary complications when compared to systemic postoperative analgesia. However, there are concerns that it might also cause impaired ventilation by extended motor blockade, increased airway resistance, and increased bronchial reactivity because of pulmonary sympathicolysis. Nevertheless, high thoracic epidural anesthesia causes only a slight decrease in vital capacity and neither an increase in airway resistance nor increased bronchial reactivity. In fact, it causes a decrease in bronchial reactivity in patients with bronchial hyperreactivity mostly due to the systemic effect of the local anesthetic. The attenuation of bronchial hyperreactivity can be shown as a dose dependent effect of lidocaine and bupivacaine. The intravenous effect of lidocaine is comparable to the effect of a moderate dose of salbutamol and leads to an additive effect when both drugs are used in combination. Overall, high thoracic epidural anesthesia can be used safely in patients with bronchial hyperreactivity and intravenous administration of lidocaine (1.5-2.0 mg x kg(-1)) can be used as a prophylactic treatment prior to airway instrumentation.
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Affiliation(s)
- H Groeben
- Abteilung für Anaesthesiologie & Intensivmedizin, Universität Essen, Germany.
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Gruber EM, Tschernko EM, Kritzinger M, Deviatko E, Wisser W, Zurakowski D, Haider W. The effects of thoracic epidural analgesia with bupivacaine 0.25% on ventilatory mechanics in patients with severe chronic obstructive pulmonary disease. Anesth Analg 2001; 92:1015-9. [PMID: 11273942 DOI: 10.1097/00000539-200104000-00039] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED Optimal analgesia is important after thoracotomy in pulmonary-limited patients to avoid pain-related pulmonary complications. Thoracic epidural anesthesia (TEA) can provide excellent pain relief. However, potential paralysis of respiratory muscles and changes in bronchial tone might be unfavorable in patients with end-stage chronic obstructive pulmonary disease (COPD). Therefore, we evaluated the effect of TEA on maximal inspiratory pressure, pattern of breathing, ventilatory mechanics, and gas exchange in 12 end-stage COPD patients. Pulmonary resistance, work of breathing, dynamic intrinsic positive end-expiratory pressure, and peak inspiratory and expiratory flow rates were evaluated by assessing esophageal pressure and airflow. An increase in minute ventilation (7.50 +/- 2.60 vs 8.70 +/- 2.10 L/min; P = 0.04) by means of increased tidal volume (0.46 +/- 0.16 vs 0.53 +/- 0.14 L/breath; P = 0.003) was detected after TEA. These changes were accompanied by an increase in peak inspiratory flow rate (0.48 +/- 0.17 vs 0.55 +/- 0.14 L/s; P = 0.02) and a decrease in pulmonary resistance (20.7 +/- 9.9 vs 16.6 +/- 8.1 cm H(2)O. L(-1). s(-1); P = 0.02). Peak expiratory flow rate, dynamic intrinsic positive end-expiratory pressure, work of breathing, PaO(2), and maximal inspiratory pressure were unchanged (all P > 0.50). We conclude that TEA with bupivacaine 0.25% can be used safely in end-stage COPD patients. IMPLICATIONS Thoracic epidural anesthesia with bupivacaine 0.25% does not impair ventilatory mechanics and inspiratory respiratory muscle strength in severely limited chronic obstructive pulmonary disease patients. Thus, thoracic epidural anesthesia can be used safely in patients with end-stage chronic obstructive pulmonary disease.
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Affiliation(s)
- E M Gruber
- Department of Cardiothoracic and Vascular Anesthesia & Intensive Care Medicine, University of Vienna, Austria
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Yuan HB, Tang GJ, Kou YR, Lee TY. Effects of high thoracic epidural anaesthesia on the peripheral airway reactivity in dogs. Acta Anaesthesiol Scand 1998; 42:85-90. [PMID: 9527750 DOI: 10.1111/j.1399-6576.1998.tb05085.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND It has been speculated that epidural anaesthesia may induce bronchoconstriction via the mechanism of a sympathetic blockade. However, this hypothesis has not been confirmed by any experimental evidence. Therefore, we investigated the effects of high thoracic epidural anaesthesia with neural sympathetic blockade on basal airway resistance and airway reactivity in response to bronchoconstrictive stimuli in a canine periphery lung model. METHODS Acetylcholine (Ach, 8 microg kg[-1] i.v.) or histamine (His, 3 microg kg[-1] i.v.) was administered to 7 anaesthetized mongrel dogs before and after thoracic epidural anaesthesia. Successful neuronal sympathectomy was confirmed by nitroglycerin test. The changes of peripheral airway resistance (Rp), haemodynamics, cardiac output (CO), and the recovery time for Rp from peak returning to baseline in each challenge were studied. RESULTS Thoracic epidural anaesthesia altered neither the baseline Rp nor the peak Rp evoked by Ach or His. However, the recovery time of the Rp was prolonged significantly after epidural anaesthesia (P<0.01) and correlated inversely with the CO in response to Ach or His challenge (Ach, r=0.542; His, r=0.651). CONCLUSIONS Our results suggest that epidural anaesthesia with neural sympathetic blockade has no influence on the basal peripheral airway resistance; however, it prolongs the airway reactivity to Ach or His challenge, probably by the mechanism of reducing CO.
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Affiliation(s)
- H B Yuan
- Department of Anesthesiology, Veterans General Hospital-Taipei and National Yang-Ming University, Taiwan, ROC
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Sharrock NE, Salvati EA. Hypotensive epidural anesthesia for total hip arthroplasty: a review. ACTA ORTHOPAEDICA SCANDINAVICA 1996; 67:91-107. [PMID: 8615115 DOI: 10.3109/17453679608995620] [Citation(s) in RCA: 121] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Hypotensive epidural anesthesia provides arterial hypotension to maintain a mean arterial pressure of 50 mmHg and it can be used to reduce blood loss during total hip replacement. The technique combines an extensive epidural blockade with an intravenous infusion of low-dose epinephrine. This results in arterial hypotension, but with preservation of central venous pressure, heart rate, stroke volume, cardiac output, and an augmentation of blood flow to the lower extremity. The technique does not appear to adversely affect cardiac, renal, or cerebral function and is used safely in patients with hypertension, ischemic heart disease, and in the elderly. Intraoperative blood losses during primary total hip replacement are between 100 and 300 mL. Perioperative transfusions have declined with the introduction of the technique. Radiological evidence of improved fixation of cemented acetabular components has been observed. Rates of deep-vein thrombosis are low: 2-3% proximal deep-vein thrombosis with an overall rate of 10%. In-hospital mortality is 0.1%; lower than previously published rates. In conclusion, hypotensive epidural anesthesia is safe and provides a number of advantages over conventional anesthetic techniques for total hip replacement.
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Affiliation(s)
- N E Sharrock
- Department of Anesthesiology, The Hospital for Special Surgery, New York, NY 10021, USA
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