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Chen K, Gashler K, Li T, Nguyen A. Neuraxial Anesthesia and Analgesia During Cardiothoracic Surgery: A Narrative Review. Curr Pain Headache Rep 2024; 28:315-319. [PMID: 38507134 DOI: 10.1007/s11916-024-01235-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2024] [Indexed: 03/22/2024]
Abstract
PURPOSE OF REVIEW The purpose of this review is to synthesize and examine the literature on the use of neuraxial anesthesia and analgesia during cardiothoracic surgery. As cardiothoracic procedures often require systemic anticoagulation, neuraxial techniques are quite often underutilized due to the theoretical risk of epidural hematoma. In this review, we seek to examine the literature to review the indications and contraindications and to explore if neuraxial anesthesia and analgesia has a role in cardiothoracic surgery. RECENT FINDINGS Neuraxial techniques have multiple advantages during cardiothoracic surgery including coronary vasodilation, decreased sympathetic surge, and a decreased cortisol level leading to overall reduction in stress response. Multiple studies have shown an improvement in pain scores, reduction in pulmonary complications, faster extubation times, with minimal complications when neuraxial techniques are utilized in cardiothoracic surgeries. Given the numerous advantages and minimal complications of neuraxial techniques in cardiothoracic surgeries, we hope its utilization continues to increase. Moving forward, we hope additional studies continue to reaffirm the benefits of neuraxial anesthesia and analgesia for cardiothoracic surgeries to improve its utilization.
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Affiliation(s)
- Kevin Chen
- Baylor College of Medicine, Houston, TX, 77030, USA
| | - Kyle Gashler
- Baylor College of Medicine, Houston, TX, 77030, USA
| | - Tommy Li
- Baylor College of Medicine, Houston, TX, 77030, USA
| | - Anvinh Nguyen
- Baylor College of Medicine, Houston, TX, 77030, USA.
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Moore A, Straube S, Fisher E, Eccleston C. Cannabidiol (CBD) Products for Pain: Ineffective, Expensive, and With Potential Harms. THE JOURNAL OF PAIN 2024; 25:833-842. [PMID: 37863344 DOI: 10.1016/j.jpain.2023.10.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 09/29/2023] [Accepted: 10/12/2023] [Indexed: 10/22/2023]
Abstract
Cannabidiol (CBD) attracts considerable attention for promoting good health and treating various conditions, predominantly pain, often in breach of advertising rules. Examination of available CBD products in North America and Europe demonstrates that CBD content can vary from none to much more than advertised and that potentially harmful other chemicals are often included. Serious harm is associated with chemicals found in CBD products and reported in children, adults, and the elderly. A 2021 International Association for the Study of Pain task force examined the evidence for cannabinoids and pain but found no trials of CBD. Sixteen CBD randomized trials using pharmaceutical-supplied CBD or making preparations from such a source and with pain as an outcome have been published subsequently. The trials were conducted in 12 different pain states, using 3 oral, topical, and buccal/sublingual administration, with CBD doses between 6 and 1,600 mg, and durations of treatment between a single dose and 12 weeks. Fifteen of the 16 showed no benefit of CBD over placebo. Small clinical trials using verified CBD suggest the drug to be largely benign; while large-scale evidence of safety is lacking, there is growing evidence linking CBD to increased rates of serious adverse events and hepatotoxicity. In January 2023, the Food and Drug Administration (FDA) announced that a new regulatory pathway for CBD was needed. Consumers and health care providers should rely on evidence-based sources of information on CBD, not just advertisements. Current evidence is that CBD for pain is expensive, ineffective, and possibly harmful. PERSPECTIVE: There is no good reason for thinking that CBD relieves pain, but there are good reasons for doubting the contents of CBD products in terms of CBD content and purity.
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Affiliation(s)
| | - Sebastian Straube
- Division of Preventive Medicine, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Emma Fisher
- Centre for Pain Research, University of Bath, Claverton Down, Bath, UK
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Tong SX, Li RS, Wang D, Xie XM, Ruan Y, Huang L. Artificial intelligence technology and ultrasound-guided nerve block for analgesia in total knee arthroplasty. World J Clin Cases 2023; 11:7026-7033. [PMID: 37946775 PMCID: PMC10631398 DOI: 10.12998/wjcc.v11.i29.7026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 09/14/2023] [Accepted: 09/22/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Knee diseases are more common in middle-aged and elderly people, so artificial knee replacement is also more used in middle-aged and elderly people. Although the patient's pain can be reduced through surgery, often accompanied by moderate pain after surgery and neutralization, which not only increases the psychological burden of the patient, but also greatly reduces the postoperative recovery effect, and may also lead to the occurrence of postoperative adverse events in severe cases. AIM To investigate the analgesic effect of artificial intelligence (AI) and ultrasound-guided nerve block in total knee arthroplasty (TKA). METHODS A total of 92 patients with TKA admitted to our hospital from January 2021 to January 2022 were opted and divided into two groups according to the treatment regimen. The control group received combined spinal-epidural anesthesia. The research group received AI technique combined with ultrasound-guided nerve block anesthesia. The sensory block time, motor block time, visual analogue scale (VAS) at different time points and complications were contrasted between the two groups. RESULTS The time of sensory block onset and sensory block perfection in the research group was shorter than those in the control group, but the results had no significant difference (P > 0.05). Duration of sensory block in the research group was significantly longer than those in the control group (P < 0.05). The time of motor block onset and motor block perfection in the research group was shorter than those in the control group, but the results had no significant difference (P > 0.05). Duration of motor block in the research group was significantly longer than those in the control group. The VAS scales of the research group were significantly lower than that of the control group at different time points (P < 0.05). The postoperative hip flexion and abduction range of motion in the research group were significantly better than those in the control group at different time points (P < 0.05). The incidence of complications was significantly lower in the research group than in the control group (P = 0.049). CONCLUSION In TKA, the combination of AI technology and ultrasound-guided nerve block has a significantly effect, with fewer postoperative complications and significantly analgesic effect, which is worthy of application.
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Affiliation(s)
- Sheng-Xiong Tong
- Department of Pain Management, Wuhan First Hospital, Wuhan 430033, Hubei Province, China
| | - Ren-Song Li
- Department of Orthopaedics, Wuhan Wuchang Hospital, Wuhan 430063, Hubei Province, China
| | - Dan Wang
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Xiao-Meng Xie
- Department of Nursing, Huanggang Central Hospital, Huanggang 438000, Hubei Province, China
| | - Yuan Ruan
- Department of Orthopaedics, Huanggang Central Hospital, Huanggang 438000, Hubei Province, China
| | - Lin Huang
- Department of Orthopaedics, Huanggang Central Hospital, Huanggang 438000, Hubei Province, China
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Chen LJ, Chen SH, Hsieh YL, Yu PC. Continuous nerve block versus thoracic epidural analgesia for post-operative pain of pectus excavatum repair: a systematic review and meta-analysis. BMC Anesthesiol 2023; 23:266. [PMID: 37559029 PMCID: PMC10410789 DOI: 10.1186/s12871-023-02221-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 07/26/2023] [Indexed: 08/11/2023] Open
Abstract
Surgery to repair pectus excavatum (PE) is often associated with severe postoperative pain, which can impact the length of hospital stay (LOS). While thoracic epidural analgesia (TEA) has traditionally been used for pain management in PE, its placement can sometimes result in severe neurological complications. Recently, paravertebral block (PVB) and erector spinae plane block (ESPB) have been recommended for many other chest and abdominal surgeries. However, due to the more severe and prolonged pain associated with PE repair, it is still unclear whether continuous administration of these blocks is as effective as TEA. Therefore, we conducted this systematic review and meta-analysis to demonstrate the equivalence of continuous PVB and ESPB to TEA.
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Affiliation(s)
- Li-Jung Chen
- Department of Anesthesiology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No.289, Jianguo Rd., Xindian Dist, 231405, New Taipei City, Taiwan
| | - Shih-Hong Chen
- Department of Anesthesiology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No.289, Jianguo Rd., Xindian Dist, 231405, New Taipei City, Taiwan
| | - Yung-Lin Hsieh
- Department of Anesthesiology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No.289, Jianguo Rd., Xindian Dist, 231405, New Taipei City, Taiwan
| | - Po-Chuan Yu
- Department of Anesthesiology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No.289, Jianguo Rd., Xindian Dist, 231405, New Taipei City, Taiwan.
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Makkad B, Heinke TL, Sheriffdeen R, Khatib D, Brodt JL, Meng ML, Grant MC, Kachulis B, Popescu WM, Wu CL, Bollen BA. Practice Advisory for Preoperative and Intraoperative Pain Management of Cardiac Surgical Patients: Part 2. Anesth Analg 2023; 137:26-47. [PMID: 37326862 DOI: 10.1213/ane.0000000000006506] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Pain after cardiac surgery is of moderate to severe intensity, which increases postoperative distress and health care costs, and affects functional recovery. Opioids have been central agents in treating pain after cardiac surgery for decades. The use of multimodal analgesic strategies can promote effective postoperative pain control and help mitigate opioid exposure. This Practice Advisory is part of a series developed by the Society of Cardiovascular Anesthesiologists (SCA) Quality, Safety, and Leadership (QSL) Committee's Opioid Working Group. It is a systematic review of existing literature for various interventions related to the preoperative and intraoperative pain management of cardiac surgical patients. This Practice Advisory provides recommendations for providers caring for patients undergoing cardiac surgery. This entails developing customized pain management strategies for patients, including preoperative patient evaluation, pain management, and opioid use-focused education as well as perioperative use of multimodal analgesics and regional techniques for various cardiac surgical procedures. The literature related to this field is emerging, and future studies will provide additional guidance on ways to improve clinically meaningful patient outcomes.
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Affiliation(s)
- Benu Makkad
- From the Department of Anesthesiology, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Timothy Lee Heinke
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Raiyah Sheriffdeen
- Department of Anesthesiology, Medstar Washington Hospital Center, Washington, DC
| | - Diana Khatib
- Department of Anesthesiology, Weil Cornell Medical College, New York, New York
| | - Jessica Louise Brodt
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California
| | - Marie-Louise Meng
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Michael Conrad Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bessie Kachulis
- Department of Anesthesiology, Columbia University, New York, New York
| | - Wanda Maria Popescu
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - Christopher L Wu
- Department of Anesthesiology, Hospital of Special Surgery, Weill Cornell Medical College, New York, New York
| | - Bruce Allen Bollen
- Missoula Anesthesiology, Missoula, Montana
- The International Heart Institute of Montana, Missoula, Montana
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Abstract
PURPOSE OF REVIEW Regional anesthesia is gaining attention as a valuable component of multimodal, opioid-sparing analgesia in cardiac surgery, where improving the patient's quality of recovery while minimizing the harms of opioid administration are key points of emphasis in perioperative care. This review serves as an outline of recent advancements in a variety of applications of regional analgesia for cardiac surgery. RECENT FINDINGS Growing interest in regional analgesia, particularly the use of newer "chest wall blocks", has led to accumulating evidence for the efficacy of multiple regional techniques in cardiac surgery. These include a variety of technical approaches, with results consistently demonstrating optimized pain control and reduced opioid requirements. Regional and pain management experts have worked to derive consensus around nerve block nomenclature, which will be foundational to establish best practice, design and report future research consistently, improve medical education, and generally advance our knowledge in this vital area of perioperative patient care. SUMMARY The field of regional analgesia for cardiac surgery has matured over the last several years. A variety of regional techniques have been described and shown to be efficacious as part of the multimodal, opioid-sparing approach to pain management in the cardiac surgical setting.
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Alalade E, Bilinovic J, Walch AG, Burrier C, Mckee C, Tobias J. Perioperative Pain Management for Median Sternotomy in a Patient on Chronic Buprenorphine/Naloxone Maintenance Therapy: Avoiding Opioids in Patients at Risk for Relapse. J Pain Res 2020; 13:295-299. [PMID: 32104051 PMCID: PMC7008173 DOI: 10.2147/jpr.s222885] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 01/17/2020] [Indexed: 12/14/2022] Open
Abstract
The opioid crisis in the United States has been pandemic. As such, anesthesia providers are frequently faced with patients who have a history of opioid abuse or are currently receiving chronic therapy for such disorders. The chronic administration of medications such as buprenorphine-naloxone can impact the choice of perioperative anesthesia and pain control. Furthermore, the postoperative administration of opioids may lead to relapse in patients with a history of opioid abuse. We present a 26-year-old male with a history of opioid abuse on maintenance therapy with buprenorphine-naloxone, who presented for median sternotomy, cardiopulmonary bypass, and pulmonary valve replacement. The perioperative implications of buprenorphine-naloxone and implementation of multimodal analgesia are discussed, along with options to decrease or eliminate the perioperative use of opioids.
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Affiliation(s)
- Emmanuel Alalade
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Jena Bilinovic
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Ana Gabriela Walch
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Candice Burrier
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Christopher Mckee
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Joseph Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
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NeMoyer RE, Pantin E, Aisner J, Jongco R, Mellender S, Chiricolo A, Moore DF, Langenfeld J. Paravertebral Nerve Block With Liposomal Bupivacaine for Pain Control Following Video-Assisted Thoracoscopic Surgery and Thoracotomy. J Surg Res 2020; 246:19-25. [DOI: 10.1016/j.jss.2019.07.093] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 07/18/2019] [Accepted: 07/23/2019] [Indexed: 11/16/2022]
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Monaco F, Pieri M, Barucco G, Karpatri V, Redaelli MB, De Luca M, Mattioli C, Bove T, Melissano G, Chiesa R, Landoni G, Zangrillo A. Epidural Analgesia in Open Thoraco-abdominal Aortic Aneurysm Repair. Eur J Vasc Endovasc Surg 2019; 57:360-367. [DOI: 10.1016/j.ejvs.2018.09.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 09/25/2018] [Indexed: 01/03/2023]
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Royse CF, Soeding PF, Royse AG. High Thoracic Epidural Analgesia for Cardiac Surgery: An Audit of 874 Cases. Anaesth Intensive Care 2019; 35:374-7. [PMID: 17591131 DOI: 10.1177/0310057x0703500309] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Despite clinical use for over 10 years, high thoracic epidural analgesia for cardiac surgery remains controversial, due to a perceived increased risk of epidural haematoma resulting from anticoagulation for cardiac pulmonary bypass. There are no sufficiently large randomised studies to address this question and few large case series reported. For this reason, we conducted an audit of neurological complications related to high thoracic epidural analgesia during cardiac surgery in our institution between 1998 and end 2005. During this period 874 patients received epidural analgesia. There were no neurological complications attributable to epidural use. Our findings suggest that major neurological complications related to high thoracic epidural use during cardiac surgery are rare.
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Affiliation(s)
- C F Royse
- Department of Anaesthesia and Pain Medicine, Royal Melbourne Hospital, Carlton, Victoria, Australia
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Brasileiro B, Imbelloni LE. Regional Anesthesia in Patients of Aged 99 Years in Clopidogrel Use. Anesth Essays Res 2017; 11:257-259. [PMID: 28298798 PMCID: PMC5341683 DOI: 10.4103/0259-1162.186869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The risk of neuraxial block in patients treated with antiplatelet drugs are uncertain. Elderly patients often have low physiological reserve, delaying surgery can lead to a high rate of morbidity and mortality. The aim of this paper is to present a case of a patient with 99 years using clopidogrel undergoing regional anesthesia for surgical treatment of hip fracture without complications.
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Affiliation(s)
| | - Luiz Eduardo Imbelloni
- School of Medicine Nova Esperança, Anesthesiologist Complexo Hospitalar Mangabeira, João Pessoa, PB, Brazil
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Bryskin RB, Robie DK, Mansfield FM, Freid EB, Sukumvanich S. Introduction of a novel ultrasound-guided extrathoracic sub-paraspinal block for control of perioperative pain in Nuss procedure patients. J Pediatr Surg 2017; 52:484-491. [PMID: 27810148 DOI: 10.1016/j.jpedsurg.2016.09.065] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 07/23/2016] [Accepted: 09/20/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND A safe and effective method of multilevel thoracic pain control remains an elusive goal in patients undergoing the Nuss procedure. The aim of our study was to develop a nonopioid centered approach using a novel regional technique as part of a quality improvement initiative. METHODS The proposed ultrasound-guided technique positions multi-perforated soaker catheter deep to the paraspinal muscles from T2 to T11. The project was conducted in two phases. First, a cadaveric dissection was performed to establish the pathway of spread of local anesthetic in vivo. Second, a pilot double blind randomized control project was conducted to evaluate effectiveness of the technique in ten patients and to derive parameters necessary for the definitive future study. Outcomes were evaluated based on the narcotic requirement, pain scores and functional measures. RESULTS Placement of the catheters in two cadavers demonstrated reliable positioning in the subparaspinal tissue plane, and multilevel dye spread along the intercostal nerve path. In addition, a potential route of spread toward the paravertebral space along the canal accommodating dorsal ramus of the thoracic nerve was demonstrated. The pilot trial demonstrated a trend in decreased cumulative hydromorphone requirement in comparison to the control group at both 24h (0.19±0.09mg/kg vs. 0.13±0.08mg/kg p=0.72) and 48h (0.37±0.2mg/kg vs. 0.3±0.12mg/kg p=0.37). Functional performance ability was higher in the treatment group on both POD#1 (6.7±1.8 vs. 4.8±1 p=0.0495) and POD#2 (8.9±0.8 vs. 6.5±1.2 p=0.04). Pain scores were similar among the two groups (p=0.96). CONCLUSIONS We describe a new technique to treat multilevel thoracic pain following the Nuss procedure that is reproducible, safe, allows diminished opioid use and enhances functional recovery.
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Affiliation(s)
- Robert B Bryskin
- Department of Anesthesiology, Nemours Children's Clinic, Jacksonville, FL, USA,.
| | - Daniel K Robie
- Department of Surgery, Nemours Children's Clinic, Jacksonville, FL, USA.
| | | | - Eugene B Freid
- Department of Anesthesiology, Nemours Children's Clinic, Jacksonville, FL, USA,.
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Rosero EB, Joshi GP. Nationwide incidence of serious complications of epidural analgesia in the United States. Acta Anaesthesiol Scand 2016; 60:810-20. [PMID: 26876878 DOI: 10.1111/aas.12702] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 12/01/2015] [Accepted: 01/15/2016] [Indexed: 01/05/2023]
Abstract
BACKGROUND This study aimed to describe the incidence and risk factors of in-hospital spinal hematoma and abscess associated with epidural analgesia in adult obstetric and non-obstetric populations in the United States. METHODS The Nationwide Inpatient Sample was analyzed to identify patients receiving epidural analgesia from 1998 to 2010. Primary outcomes were incidence of spinal hematoma and epidural abscess. Use of decompressive laminectomy was also investigated. Regression analyses were conducted to assess predictors of epidural analgesia complications. Differences in mortality and disposition of patients at discharge were compared in patients with and without neuraxial complications. Obstetric and non-obstetric patients were studied separately. RESULTS A total of 3,703,755 epidural analgesia procedures (2,320,950 obstetric and 1,382,805 non-obstetric) were identified. In obstetric patients, the incidence of spinal hematoma was 0.6 per 100,000 epidural catheterizations (95% CI, 0.3 to 1.0 × 10(-5) ). The incidence of epidural abscess was zero. In non-obstetric patients, the incidence of spinal hematoma and epidural abscess were, respectively, 18.5 per 100,000 (95% CI, 16.3 to 20.9 × 10(-5) ) and 7.2 per 100,000 (95% CI, 5.8 to 8.7 × 10(-5) ) catheterizations. Predictors of spinal hematoma included type of surgical procedure (higher in vascular surgery), teaching status of hospital, and comorbidity score. Patients with spinal complications had higher in-hospital mortality (12.2% vs. 1.1%, P < 0.0001) and were significantly less likely to be discharged to home. CONCLUSIONS This large nationwide data analysis reveals that the incidence of epidural analgesia-related complications is very low in obstetric population epidural analgesia and much higher in patients having vascular surgery.
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Affiliation(s)
- E B Rosero
- Department of Anesthesiology & Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - G P Joshi
- Department of Anesthesiology & Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Chakraborty A, Goswami J, Patro V. Ultrasound-guided continuous quadratus lumborum block for postoperative analgesia in a pediatric patient. ACTA ACUST UNITED AC 2015; 4:34-6. [PMID: 25642956 DOI: 10.1213/xaa.0000000000000090] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Quadratus lumborum block is a recently introduced variation of transversus abdominis plane block. In this report, we describe the use of ultrasound-guided continuous quadratus lumborum block for postoperative analgesia in a 7-year-old child scheduled to undergo radical nephrectomy (left-sided) for Wilms tumor. The result was excellent postoperative analgesia and minimal requirement for rescue analgesics. The modification described may allow easier placement of a catheter for continuous infusion of local anesthetic.
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Affiliation(s)
- Arunangshu Chakraborty
- From the Department of Anaesthesiology and Critical Care, Tata Medical Center, Kolkata, India
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The Second ASRA Practice Advisory on Neurologic Complications Associated With Regional Anesthesia and Pain Medicine. Reg Anesth Pain Med 2015; 40:401-30. [DOI: 10.1097/aap.0000000000000286] [Citation(s) in RCA: 243] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Abstract
High thoracic epidural analgesia (HTEA) offers a distinctive opportunity to enhance postoperative recovery for the thoracic surgery patient. In the modern hospital setting with day of admission surgery, the logistics of insertion of the epidural catheter has become increasingly difficult. The greatest limitation to its use might be the believed increased risk of epidural hematoma associated with anticoagulation during cardiopulmonary bypass. The aim of this review is to give an overview of complications and effect on outcomes with focus on cardiac performance and postoperative glycemic control and kidney function. Patients with epidurals may have improved postoperative pulmonary function and shorter ventilation time, while impact on length of stay in the intensive care unit and hospital is not as evident. HTEA is effective in pain management, attenuates perioperative stress and seems to improve postoperative blood glucose control. Whether HTEA improves recovery and facilitates fast-track is still to be confirmed. With regard to serious postoperative complications, there is evidence of reduction in supraventricular arrhythmias and lower frequency of postoperative acute kidney injury and dialysis. There are some indications of lower short term mortality and frequency of postoperative myocardial infarctions, but only as a combined outcome. The present short-term mortality of 1% to 2% should be compared with the most pessimistic frequency of epidural hematoma being 1 in 4600 patients.
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Mehta Y, Arora D. Benefits and Risks of Epidural Analgesia in Cardiac Surgery. J Cardiothorac Vasc Anesth 2014; 28:1057-63. [DOI: 10.1053/j.jvca.2013.07.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Indexed: 11/11/2022]
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McLintock C. Thromboembolism in pregnancy: challenges and controversies in the prevention of pregnancy-associated venous thromboembolism and management of anticoagulation in women with mechanical prosthetic heart valves. Best Pract Res Clin Obstet Gynaecol 2014; 28:519-36. [PMID: 24814194 DOI: 10.1016/j.bpobgyn.2014.03.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Accepted: 03/03/2014] [Indexed: 12/19/2022]
Abstract
Thromboembolism in pregnancy is an important clinical issue. Despite identification of maternal and pregnancy-specific risk factors for development of pregnancy-associated venous thromboembolism, limited data are available to inform on optimal approaches for prevention. The relatively low overall prevalence of pregnancy-associated venous thromboembolism has prompted debate about the validity of recommendations, which are mainly based on expert opinion, and have resulted in an increased use of pharmacological thromboprophylaxis in pregnancy and postpartum. A pragmatic approach is required in the absence of more robust data. Anticoagulation management of pregnant women with mechanical prosthetic heart valves is particularly challenging. Continuation of therapeutic anticoagulation during pregnancy is essential to prevent valve thrombosis. Warfarin, the most effective anticoagulant, is associated with adverse fetal outcomes, including embryopathy and stillbirth. Fetal outcome is improved with therapeutic-dose low-molecular-weight heparin, but there may be more thromboembolic complications. More intensive anticoagulation, targeting higher trough anti-Xa levels, may reduce the risk of valve thrombosis.
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Affiliation(s)
- Claire McLintock
- National Women's Health, Auckland City Hospital, Auckland, New Zealand.
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PITKÄNEN MT, AROMAA U, COZANITIS DA, FÖRSTER JG. Serious complications associated with spinal and epidural anaesthesia in Finland from 2000 to 2009. Acta Anaesthesiol Scand 2013; 57:553-64. [PMID: 23305109 DOI: 10.1111/aas.12064] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND Analyses of closed claims provide insight into the characteristics of rare complications. Serious complications related to spinal and epidural blocks are relatively rare. In Finland, all malpractice cases are primarily handled by the Patient Insurance Centre (PIC) within a 'no-fault scheme'. METHODS All claims attributed to central neuraxial blocks and settled by the PIC during the period, 2000-2009 were analysed. The number of spinal and epidural procedures performed during this time was estimated based on a questionnaire sent to all surgical hospitals in Finland in 2009, surveying the numbers and types of neuraxial blocks carried out in 2008. RESULTS During the study period, 216 closed claims were flagged with spinal or epidural blocks. In 41 of 216 instances, the neuraxial block was apparently responsible for a serious (fatal or critical or lasting >1 year) complication. These included six fatalities and 13 epidural haematomata (two in conjunction with fondaparinux, three with excessive doses of low molecular weight heparins, six where present guidelines were not observed). Fatalities occurred in 1 : 775,000 spinals for surgery, 1 : 62,000 in epidurals for surgery or acute pain relief, 1 : 12,000 epidurals for chronic pain relief, 1 : 89,000 in combined spinal and epidural for surgery, and 1 : 144,000 epidurals for labour. The incidence of neuraxial haematoma after spinal block was 1 : 775,000, that for epidural block 1 : 26,400, and in the case of combined spinal and epidural, 1 : 17,800. Irrespective of the method of neuraxial technique, the majority of patients suffering serious complications were the elderly having comorbidities. CONCLUSIONS In this closed claims analysis, major problems related to neuraxial blocks were rare. Epidural or a combined spinal and epidural technique resulted in more complications than did spinal procedure.
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Affiliation(s)
- M. T. PITKÄNEN
- Department of Anaesthesia; Orthopaedic Hospital Orton; Invalid Foundation; Helsinki; Finland
| | - U. AROMAA
- Helsinki University; Helsinki; Finland
| | | | - J. G. FÖRSTER
- Department of Anaesthesia; Orthopaedic Hospital Orton; Invalid Foundation; Helsinki; Finland
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GREISEN J, NIELSEN DV, SLOTH E, JAKOBSEN CJ. High thoracic epidural analgesia decreases stress hyperglycemia and insulin need in cardiac surgery patients. Acta Anaesthesiol Scand 2013; 57:171-7. [PMID: 22762307 DOI: 10.1111/j.1399-6576.2012.02731.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2012] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Assuming that high thoracic epidural analgesia (HTEA) with the sympathetic block might decrease postoperative blood glucose (BG) level and reduce the need of insulin, the aim was to evaluate the effect of HTEA on the BG level and insulin requirement in patients undergoing cardiac surgery. MATERIALS AND METHODS Forty-two low-risk patients age 65-79 years scheduled for elective coronary artery bypass grafting with or without aortic valve replacement were randomised to receive HTEA as supplement for general anaesthesia. BG and lactate were measured before and after cardiopulmonary bypass and postoperatively at least every 3 h together with administration of insulin. Postoperative pain was evaluated 30 min, 2, 4 and 6 h after extubation, and before discharge from the intensive care unit. RESULTS Overall BG levels showed great variation over time (P < 0.001). No statistically significant difference was found in perioperative BG, but postoperative lower BG levels were found in HTEA patients (P = 0.042). The number of patients not receiving insulin in postoperative period was significantly higher in HTEA group (9 vs. 2, P = 0.032). No differences were seen in lactate levels. Patients in the HTEA group had significant lower pain scores (P < 0.001). CONCLUSION HTEA preserves glucose metabolism better and leads to a lesser degree of 'stress hyperglycaemia' in cardiac surgery patients.
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Affiliation(s)
- J. GREISEN
- Department of Anaesthesiology & Intensive Care; Aarhus University Hospital; Aarhus; Denmark
| | - D. V. NIELSEN
- Department of Anaesthesiology & Intensive Care; Aarhus University Hospital; Aarhus; Denmark
| | - E. SLOTH
- Department of Anaesthesiology & Intensive Care; Aarhus University Hospital; Aarhus; Denmark
| | - C.-J. JAKOBSEN
- Department of Anaesthesiology & Intensive Care; Aarhus University Hospital; Aarhus; Denmark
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Meyer-Bender A, Kern A, Pollwein B, Crispin A, Lang PM. Incidence and predictors of immediate complications following perioperative non-obstetric epidural punctures. BMC Anesthesiol 2012; 12:31. [PMID: 23227938 PMCID: PMC3566923 DOI: 10.1186/1471-2253-12-31] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Accepted: 11/29/2012] [Indexed: 12/04/2022] Open
Abstract
Background Epidural Anesthesia (EA) is a well-established procedure. The aim of the present study was to evaluate the incidence of immediate complications following epidural puncture, such as sanguineous puncture, accidental dural perforation, unsuccessful catheter placement or insufficient analgesia and to identify patient and maneuver related risk factors. Methods A total of 7958 non-obstetrical EA were analyzed. The risk of each complication was calculated according to the preconditions and the level of puncture. For probabilistic evaluation we used a logistic regression model with forward selection. Results The risk of sanguineous puncture (n = 247, 3.1%) increases with both the patient’s age (P = 0.013) and the more caudal the approach (P < 0.01). Dural perforation (n = 123, 1.6%) was found to be influenced only by advanced age (P = 0.019). Unsuccessful catheter placement (n = 68, 0.94%) occurred more often in smaller individuals (P < 0.001) and at lower lumbar sites (P < 0.01). Amongst all cases with successful catheter placement a (partial) insufficient analgesia was found in 692 cases (8.8%). This risk of insufficient analgesia decreased with patient’s age (P <0 .01), being least likely for punctures of the lower thoracic spine (P < 0.001). Conclusions Compared to more cranial levels, EA of the lower spine is associated with an increased risk of sanguineous and unsuccessful puncture. Insufficient analgesia more often accompanies high thoracic and low lumbar approaches. The risk of a sanguineous puncture increases in elderly patients. Gender, weight and body mass index seem to have no influence on the investigated complications.
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Affiliation(s)
- Andreas Meyer-Bender
- Department of Anaesthesiology, University Hospital of Munich, Marchioninistr, 15, 81377, Munich, Germany.
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25
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Nielsen DV, Bhavsar R, Greisen J, Ryhammer PK, Sloth E, Jakobsen CJ. High Thoracic Epidural Analgesia in Cardiac Surgery: Part 2—High Thoracic Epidural Analgesia Does Not Reduce Time in or Improve Quality of Recovery in the Intensive Care Unit. J Cardiothorac Vasc Anesth 2012; 26:1048-54. [DOI: 10.1053/j.jvca.2012.05.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Indexed: 11/11/2022]
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26
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Pompeo E. Awake Thoracic Surgery— Is it Worth the Trouble? Semin Thorac Cardiovasc Surg 2012; 24:106-14. [DOI: 10.1053/j.semtcvs.2012.06.010] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2012] [Indexed: 11/11/2022]
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Warschkow R, Steffen T, Lüthi A, Filipovic M, Beutner U, Schmied BM, Müller SA, Tarantino I. Epidural analgesia in open resection of colorectal cancer: is there a clinical benefit? a retrospective study on 1,470 patients. J Gastrointest Surg 2011; 15:1386-93. [PMID: 21647766 DOI: 10.1007/s11605-011-1582-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Accepted: 05/25/2011] [Indexed: 01/31/2023]
Abstract
BACKGROUND Epidural analgesia (EA) is effective for postoperative pain relief and results in an earlier recovery from postoperative paralytic ileus. This study evaluated the influence of epidural analgesia on the postoperative 30-day mortality and morbidity after open colorectal cancer resection. METHODS A retrospective observational study was performed at a single, tertiary hospital. All patients with an open colorectal cancer surgery between 1991 and 2008 were identified from the hospital database. RESULTS Of the 1,470 patients included in the study, 838 (57.0%) received an EA. Mortality was lower after EA (1.5% vs. 5.7%, p < 0.001). Risk of pneumonia was reduced after EA (odds ratio (OR), 0.45; 95% confidence interval (CI), 0.28-0.74; p = 0.001), but not the risk of anastomotic leakage (OR, 1.18; 95% CI, 0.76-1.81; p = 0.465) or surgical site infections (OR, 1.09; 95% CI, 0.74-1.60; p = 0.663). A subgroup analysis of 427 patients operated on after 2002 (reflecting improved perioperative management) yielded similar results. However, no significant reduction in mortality was observed in the subgroup analysis. CONCLUSION For patients with open colorectal cancer surgery, the application of EA leads to a reduction in pneumonia. Although this is only a retrospective study, it strongly supports the use of EA.
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Affiliation(s)
- Rene Warschkow
- Department of Surgery, Kantonsspital St. Gallen, 9007, St. Gallen, Switzerland
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Goswami D, Das J, Deuri A, Deka AK. Epidural haematoma: Rare complication after spinal while intending epidural anaesthesia with long-term follow-up after conservative treatment. Indian J Anaesth 2011; 55:71-3. [PMID: 21431059 PMCID: PMC3057252 DOI: 10.4103/0019-5049.76596] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Epidural anaesthesia (EA) is an extensively used procedure for many surgeries. Increase incidence of bleeding in the epidural space [epidural haematoma (EH)] is reportedly more common in patients with altered coagulation and patients on anticoagulation treatment. EH secondary to spinal while intending EA for caesarean section (C-section) in a healthy individual leading to transient or persistent neurological problems is very rare. We report a case of EH after spinal while intending EA for C-section in a healthy young female along with 5-yrs follow-up after conservative treatment.
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Affiliation(s)
- Devalina Goswami
- Departments of Anaesthesiology and Critical Care, Gauhati Medical College, Guwahati, Assam, India
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29
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Schlack WS, De Hert SG, Hollmann MW. Epidurals and outcome after cardiac surgery: an example of wishful thinking? J Cardiothorac Vasc Anesth 2011; 25:e17-9; author reply e19-20. [PMID: 21376633 DOI: 10.1053/j.jvca.2010.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Indexed: 11/11/2022]
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30
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Kowalewski R, Seal D, Tang T, Prusinkiewicz C, Ha D. Neuraxial anesthesia for cardiac surgery: thoracic epidural and high spinal anesthesia - why is it different? HSR PROCEEDINGS IN INTENSIVE CARE & CARDIOVASCULAR ANESTHESIA 2011; 3:25-8. [PMID: 23440039 PMCID: PMC3484610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Anesthesiologists can offer much more then stable blood pressure and heart rate in the intraoperative period. By choosing appropriate anesthetic techniques they can tremendously influence perioperative stress. This may positively impact on the overall surgical outcome. One of the most intriguing aspects of neuraxial anesthesia is its ability to attenuate the stress response to surgery. At present there is no agreement on the clinical importance of such a response but there is substantial indirect evidence that it may play an important role in a patient's outcome. Neuraxial anesthesia supplemented by general anesthesia is justified and can be safely used in cardiac surgery. The authors of this expert opinion prefer spinal anesthesia to thoracic epidural anesthesia and have been using it routinely for the last 20 years without any neurological complications. The risk of spinal hematoma from a 27G spinal needle prior to full heparinization is unknown but in our opinion is remote. Both epidural and spinal techniques can and should have a place in modern cardiac anesthesia practice and should be further investigated.
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Abstract
As the life expectancy of our Western population progressively increases, so does the prevalence of cardiovascular disease and thus the use of antithrombotic drugs. The use of central neuraxial anaesthesia techniques in patients treated with these drugs is a major clinical problem as the presence of an impaired coagulation has been found to be the most important risk factor contributing to the formation of a spinal haematoma. The growing number of case reports of spinal haematoma has led many national societies of anaesthetists to come up with guidelines. This article presents an overview of current guidelines on the use of regional anaesthetic techniques in patients treated with various anticoagulants and also describes a possible strategy to deal with new antithrombotic drugs that have recently been introduced in some countries or will be shortly in others.
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Affiliation(s)
- Erik Vandermeulen
- Department of Anaesthesiology, University Hospitals Leuven, Katholieke Universiteit Leuven, Herestraat 49, B-3000 Leuven, Belgium.
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32
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Bignami E, Landoni G, Biondi-Zoccai GGL, Boroli F, Messina M, Dedola E, Nobile L, Buratti L, Sheiban I, Zangrillo A. Epidural analgesia improves outcome in cardiac surgery: a meta-analysis of randomized controlled trials. J Cardiothorac Vasc Anesth 2009; 24:586-97. [PMID: 20005129 DOI: 10.1053/j.jvca.2009.09.015] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2009] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The authors conducted a review of randomized studies to determine whether there were any advantages for clinically relevant outcomes by adding epidural analgesia in patients undergoing cardiac surgery under general anesthesia. DESIGN Meta-analysis. SETTING Hospitals. PARTICIPANTS A total of 2366 patients from 33 randomized trials. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS DATA SOURCES AND STUDY SELECTION PubMed, BioMedCentral, CENTRAL, EMBASE, Cochrane Central Register of Controlled Trials, and conference proceedings were searched (updated January 2008) for randomized trials that compared general anesthesia with an anesthetic plan including general anesthesia and epidural analgesia in cardiac surgery. Two independent reviewers appraised study quality, with divergences resolved by consensus. Overall analysis showed that epidural analgesia reduced the risk of the composite endpoint mortality and myocardial infarction (30/1125 [2.7%] in the epidural group v 64/1241 [5.2%] in the control arm, odds ratio [OR] = 0.61 [0.40-0.95], p = 0.03 number needed to treat [NNT] = 40), the risk of acute renal failure (35/590 [5.9%] in the epidural group v 54/618 [8.7%] in the control arm, OR = 0.56 [0.34-0.93], p = 0.02, NNT = 36), and the time of mechanical ventilation (weighted mean differences = -2.48 hours [-2.64, -2.32], p < 0.001). CONCLUSIONS This analysis suggested that epidural analgesia on top of general anesthesia reduced the incidence of perioperative acute renal failure, the time on mechanical ventilation, and the composite endpoint of mortality and myocardial infarction in patients undergoing cardiac surgery.
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Affiliation(s)
- Elena Bignami
- Department of Anesthesia and Intensive Care, Università Vita-Salute San Raffaele, Milano, Italy
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33
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Zangrillo A, Bignami E, Biondi-Zoccai GG, Covello RD, Monti G, D'Arpa MC, Messina M, Turi S, Landoni G. Spinal Analgesia in Cardiac Surgery: A Meta-analysis of Randomized Controlled Trials. J Cardiothorac Vasc Anesth 2009; 23:813-21. [PMID: 19800820 DOI: 10.1053/j.jvca.2009.07.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2009] [Indexed: 02/08/2023]
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34
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Mhuircheartaigh RJN, Moore RA, McQuay HJ. Analysis of individual patient data from clinical trials: epidural morphine for postoperative pain. Br J Anaesth 2009; 103:874-81. [PMID: 19889750 DOI: 10.1093/bja/aep300] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Individual patient information from clinical trials is infrequently available, but can provide insights for clinical trials and practice. METHODS We analysed individual patient information from five randomized trials (913 patients) of i.v. patient-controlled analgesia (IVPCA) plus epidural placebo, morphine sulphate (MS) 5 mg, or extended-release epidural morphine (EREM; DepoDur) at doses of 5-30 mg, to explore effects of a range of epidural morphine doses. Pain and opioid requirement on first and second postoperative days, dose-response, clinically relevant comparisons of IVPCA without epidural morphine, 5 mg MS, and 10 mg EREM, and relationship between patient rating and other measures were described. RESULTS There were three strong findings. Epidural morphine resulted in greater patient satisfaction, despite higher rates of adverse events. Those describing their analgesic medication as 'very good' or 'excellent' used IVPCA opioid less and had pain scores significantly below the global mean, whereas those describing their medication as 'poor' or 'fair' had pain scores significantly above the mean. Epidural morphine meant less need for postoperative IVPCA opioid than epidural placebo. The therapeutic gain with EREM was lower pain scores with less IVPCA opioid. Moderate or severe pruritus was more common with IVPCA plus epidural morphine, whatever the formulation, compared with IVPCA plus placebo. CONCLUSIONS Analysis of individual patient data from high-quality clinical trials provides important insights into characteristics of new agents not immediately apparent from original trials, and also informing clinical practice. Prophylactic epidural morphine provides a better patient experience than IVPCA alone.
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Affiliation(s)
- R J Ni Mhuircheartaigh
- Pain Research and Nuffield Department of Anaesthetics, University of Oxford, John Radcliffe Hospital, Level 6 West Wing, Oxford, UK
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35
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Massullo D, Di Benedetto P, Pinto G. Intraoperative strategy in patients with extended involvement of mediastinal structures. Thorac Surg Clin 2009; 19:113-120, vii-viii. [PMID: 19288826 DOI: 10.1016/j.thorsurg.2008.09.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The mediastinum is a virtual space containing several vital organs and structures. Biopsy and resection of lesions located within this region often require several considerations that bear on intraoperative strategy. To optimize outcome, clinicians must be able to predict which patients are at highest risk of anesthetic complications. Superior vena cava involvement, extensive compression of the airway, and pericardial effusion have a clear impact on the decision-making of the anesthetist and surgeon, who should plan together when forming the surgical strategy.
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Affiliation(s)
- Domenico Massullo
- Department of Anesthesiology, University of Rome La Sapienza, Ospedale S. Andrea, Via di Grottarossa 1035, 00189 Rome, Italy.
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36
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Kunstyr J, Klein A, Lindner J, Rubes D, Blaha J, Jansa P, Lips M, Ambroz D, Stritesky M. Use of High-Thoracic Epidural Analgesia in Pulmonary Endarterectomy: A Randomized Feasibility Study. Heart Surg Forum 2008; 11:E202-8. [DOI: 10.1532/hsf98.20081036] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Feltracco P, Brezzi ML, Barbieri S, Serra E, Milevoj M, Ori C. Epidural anesthesia and analgesia in liver resection and living donor hepatectomy. Transplant Proc 2008; 40:1165-8. [PMID: 18555139 DOI: 10.1016/j.transproceed.2008.03.108] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Parenteral analgesics are still diffusely administered for postoperative pain after major liver resection, while epidural analgesia is widely criticized because of possible changes in the postoperative coagulation profile. The safety of regional anesthesia in liver resections is based on appropriate timing of needle placement and catheter removal and on the individual's skill in performing both the puncture and the catheterization. In the absence of liver failure or in cases of only moderate hepatic dysfunction, the risk of neurologic complications and spinal hematomas does not appear greater than when an epidural is performed for routine abdominal or thoracic surgery. Various anesthetic strategies have been adopted to prevent bleeding during liver resection, such as fluid restriction, diuretic administration, and vasodilator drugs. Lowering central venous pressure (CVP) seems to play a prominent role in prevention of bleeding since an elevated CVP may be associated with increased blood loss at various phases of liver resection. However, a low CVP may not be tolerated by all patients: intraoperative hemodynamic instability may, in fact, easily ensue because of the cardiovascular depressant effects of anesthetics, surgical blood losses, and manipulation of the inferior vena cava. We suggest combining intraoperative epidural anesthesia with general (light) anesthesia as a useful strategy to keep the CVP low during liver resection without vasodilators or diuretics. Epidural anesthesia does not lead to changes in intravascular volume, but only promotes redistribution of blood, decreasing both venous return and portal vein pressure, thus contributing to reduced hepatic congestion and surgical blood loss.
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Affiliation(s)
- P Feltracco
- Department of Pharmacology and Anesthesiology, University Hospital of Padova, Padova, Italy.
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Olivier JF, Bracco D, Nguyen P, Le N, Noiseux N, Hemmerling T. A novel approach for pain management in cardiac surgery via median sternotomy: bilateral single-shot paravertebral blocks. Heart Surg Forum 2007; 10:E357-62. [PMID: 17855198 DOI: 10.1532/hsf98.20071082] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Regional analgesia has entered cardiac anesthesia in the form of spinal or epidural analgesia. However, the risk of spinal or epidural hematoma is a constant worry. Alternative regional techniques might be applicable in cardiac surgery. The purpose of this study is to present a novel technique of bilateral single-shot paravertebral blocks (BSS-PVB) for cardiac surgery via median sternotomy and compare its efficacy versus high thoracic epidural analgesia (TEA). Fifty-two patients were compared in this prospective cohort audit. In 26 patients, cardiac surgery was performed using low-dose fentanyl/BSS-PVB (bilateral blocks of 3 mL bupivacaine 0.5% each, T1-7) and general anesthesia; in another 26 patients, TEA (bupivacaine 0.125% at 10 mL/hour) and general anesthesia were used. Patients were assigned to cohorts according to their preoperative data and types of surgery. All patient data are shown as mean +/- SD; pain scores were compared between groups using the t test immediately, 6 hours, and 24 hours after surgery (P < .05). In the BSS-PVB-group (19 men, 7 women), mean age was 65 +/- 11 years, weight 74 +/- 16 kg, ejection fraction 59% +/- 12%, and duration of surgery 130 +/- 27 minutes; in the TEA-group (17 men, 9 women), mean age was 63 +/- 10 years, weight 75 +/- 16 kg, ejection fraction 58% +/- 12%, and duration of surgery 113 +/- 27 minutes. These data and preoperative comorbidity variables were not significantly different between the two groups. In each group, 18 patients underwent off-pump coronary artery bypass grafting, 3 on-pump and 5 mitral valve replacements. All patients were successfully immediately extubated. Postoperative pain scores were at any point significantly lower with TEA, immediately at 2.4 +/- 2.2 versus 3.7 +/- 2.6, at 6 hours at 1.1 +/- 1.5 versus 2.4 +/- 1.8, and at 24 hours at 1.0 +/- 1.4 versus 2.3 +/- 1.6 (0 = no pain, 10 = maximum pain). There was no complications related to epidural catheter placement or BSS-PVB. Using both techniques, immediate extubation after cardiac surgery is feasible; TEA provides better pain relief after cardiac surgery than BSS-PVB.
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Affiliation(s)
- Jean-François Olivier
- Department of Anesthesiology, McGill University Health Center, Montréal, Québec, Canada
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Abstract
INTRODUCTION The use of epidural anesthesia carries risks that have been known for 50 years. The debate about the use of locoregional technique in cardiac anesthesia continues. The objective of this report is to estimate the risks and their variability of a catheter-related epidural hematoma in cardiac surgery patients and to compare it with other anesthetic and medical procedures. METHODS Case series reporting the use of epidural anesthesia in cardiac surgery were researched through Medline. Additional references were retrieved from the bibliography of published articles and from the internet. Risks of complications in other anesthetic and medical activity were retrieved from recent reviews. RESULTS Based on the present evidence, the risk of epidural hematoma in cardiac surgery is 1:12,000 (95% CI of 1:2100 to 1:68,000), which is comparable to the risk in the nonobstetrical population of 1:10,000 (95% CI 1:6700 to 1:14,900). The risk of epidural hematoma is comparable to the risk of receiving a wrong blood product or the yearly risk of having a fatal road accident in Western countries. CONCLUSIONS The risk of a hematoma after epidural in cardiac surgery is comparable to other nonobstetrical surgical procedures. Its routine application in a controlled setting should be encouraged.
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Ruppen W, Derry S, McQuay HJ, Moore RA. Infection rates associated with epidural indwelling catheters for seven days or longer: systematic review and meta-analysis. BMC Palliat Care 2007; 6:3. [PMID: 17408476 PMCID: PMC1858684 DOI: 10.1186/1472-684x-6-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2006] [Accepted: 04/04/2007] [Indexed: 11/10/2022] Open
Abstract
Background To determine infection rate with use of epidural catheters in place for seven days or more. Methods Systematic review and pooled analysis of observational studies. Results Twelve studies with 4,628 patients (median 197 patients) provided information, of which nine (4,334 patients) were published after 1990. Eight studies (3,893 patients) were retrospective, and four studies (735 patients) prospective. Electronic searches identified three studies and searching reference lists nine. There were 257 catheter-related infections in total, of which 211 were superficial and 57 deep, giving rates of 6.1%, 4.6% and 1.2% respectively. Ten of the 12 studies had deep infection rates of 2% or less. The incidence of deep infection was 1 per 2391 days of treatment, or 0.4 per 1000 catheter treatment days. In nine studies (1503 patients), predominantly in cancer, and with average catheter duration of 74 days, the deep infection rate was 2.8%. The proportion of patients with infection of any type was higher in cancer patients with longer catheter duration. Limited numbers of events meant that no reliable estimate of the impact of prospective and retrospective design could be made. There appeared to be a relationship between catheter duration and infection rate from this and other recent estimates. Four of 57 (7%) patients with deep infection died. Conclusion The best estimate is that one person in 35 with an epidural catheter in place for 74 days for relief of cancer pain can be expected to have a deep epidural infection, and that about 1 in 500 may die of infection-related causes. This is a most uncertain estimate given the limited nature of the evidence.
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Affiliation(s)
- Wilhelm Ruppen
- Department of Anaesthetics, University Hospital of Basel, Hebelstrasse 32, CH-4031, Basel, Switzerland
- Pain Research and Nuffield Department of Anaesthetics, University of Oxford, Oxford Radcliffe NHS Trust, The Churchill, Headington, Oxford, OX3 7LJ, UK
| | - Sheena Derry
- Pain Research and Nuffield Department of Anaesthetics, University of Oxford, Oxford Radcliffe NHS Trust, The Churchill, Headington, Oxford, OX3 7LJ, UK
| | - Henry J McQuay
- Pain Research and Nuffield Department of Anaesthetics, University of Oxford, Oxford Radcliffe NHS Trust, The Churchill, Headington, Oxford, OX3 7LJ, UK
| | - R Andrew Moore
- Pain Research and Nuffield Department of Anaesthetics, University of Oxford, Oxford Radcliffe NHS Trust, The Churchill, Headington, Oxford, OX3 7LJ, UK
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