A comparison of thoracic or lumbar patient-controlled epidural analgesia methods after thoracic surgery

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

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

Post-Operative Thoracic Epidural Analgesia and Incidence of Major Complications according to Specific Safety Standardized Documentation: A Large Retrospective Dual Center Experience

(1) Background: Thoracic epidural analgesia is considered the gold standard in post-operative pain management following thoracic surgery. This study was designed to explore the safety of thoracic epidural analgesia and to quantify the incidence of its post-operative complications and side effects in patients undergoing thoracotomy for major surgery, such as resection of lung malignancies and lung transplantation. (2) Methods: This is a retrospective, dual-center observational study including patients that underwent major thoracic surgery including lung transplantation and received concurrent placement of thoracic epidural catheters for post-operative analgesia. An electronic system of referral and documentation of complications was used, and information was retrieved from our electronic critical care charting system. (3) Results: In total, 1145 patients were included in the study. None of the patients suffered any major complication, including hematoma, abscess, or permanent nerve damage. (4) Conclusions: the present study showed that in experienced centers, post-operative epidural analgesia in patients with thoracotomy is a safe technique, manifesting minimal, none-serious complications.

Ultrasound guided erector spinae plane block versus thoracic epidural analgesia in traumatic flail chest, a prospective randomized trial

Background and Aims

Pain contributes to flail chest morbidities. The aim of this study was to compare the analgesic effects of ultrasound-guided erector spinae plane block (ESPB) with thoracic epidural analgesia (TEA) in patients with traumatic flail chest.

Material and Methods

Sixty patients aged 18 - 60 years, ASA I-II, with unilateral flail chest were allocated into TEA group with a loading dose of 6 ml bupivacaine 0.25% and 2 μg/ml fentanyl and ESPB group with a loading dose of 20 ml bupivacaine 0.25% and 2 μg/ml fentanyl. This was followed by continuous infusion of 6 ml/hour bupivacaine 0.125% and 2 μg/ml fentanyl in both groups for 4 days. Pain scores at rest and on coughing, rescue analgesic consumption, PaO2/FIO2 ratio, PaCO2, pulmonary functions and adverse events were recorded.

Results

In both groups, Visual Analog Scale (VAS) scores at rest and on coughing were significantly decreased after block initiation as compared to pre-block value. At all-time points, VAS scores at rest and on coughing were insignificantly different between both groups. PaO2/FIO2 ratio, forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) were significantly increased and respiratory rate, PaCO2, were significantly decreased as compared to pre-block values of the same group without significant difference between both groups. The incidence of hypotension was significantly higher in TEA group than ESPB group.

Conclusions

ESPB can achieve adequate analgesia in traumatic flail chest equivalent to that of TEA with significant improvement of arterial oxygenation and pulmonary functions and without serious adverse effects.

Effect of opioid-free anaesthesia on postoperative epidural ropivacaine requirement after thoracic surgery: A retrospective unmatched case-control study

INTRODUCTION

Patients undergoing thoracic surgery are at risk of severe postoperative pain. Post-thoracotomy pain relief is usually provided with thoracic epidural analgesia (TEA). Intraoperative use of opioids may result in hyperalgesia and increase analgesics consumption. We investigated the effect of opioid-free anaesthesia (OFA) on epidural ropivacaine requirement after thoracotomy.

METHODS

This retrospective study compared postoperative epidural ropivacaine requirement of patients undergoing open thoracotomy and receiving either opioid-based anaesthesia (OBA group) or a non-opioid regimen including clonidine, ketamine and lidocaine (OFA group). All patients received postoperative multimodal analgesia including both epidural analgesia and intravenous analgesics. The primary outcome was the cumulative first 48 postoperative hours epidural ropivacaine consumption. Secondary outcomes included postoperative pain scores, requirement for postoperative morphine titration, total opioid analgesics consumption within the first 48 postoperative hours, incidence of nausea and vomiting, intraoperative haemodynamic.

RESULTS

From January 2015 to February 2018, 50 patients received an OBA and 25 received an OFA. The cumulative first 48 postoperative hours epidural ropivacaine consumption was significantly higher in the OBA-group (919 ± 311 mg versus 693 ± 270 mg, P = 0.002). Numerical Rating Scale at 6 and 24 h were significantly lower in the OFA-group (1[0-2] versus 3 [1-5], P = 0.0005 and 1[0-2] versus 3.5 [1-5], P = 0.001). In post-anaesthesia care unit, the proportion of patients requiring morphine was significantly higher in the OBA-group (42% versus 4%, P < 0.001). During anaesthesia, the OBA-group required more vasopressor support, while there were more hypertensive events in the OFA-group.

CONCLUSION

OFA might reduce ropivacaine consumption, early postoperative pain scores and requirement for morphine titration after thoracotomy.