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Lu Y, Liu T, Wang P, Chen Y, Ji F, Hernanz F, Zucca-Matthes G, Youssif S, Peng S, Xu D. Can anesthetic effects and pain treatment influence the long-term prognosis of early-stage lymph node-negative breast cancer after breast-conserving surgery? ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1467. [PMID: 34734019 PMCID: PMC8506746 DOI: 10.21037/atm-21-4392] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 09/10/2021] [Indexed: 01/13/2023]
Abstract
Background Breast cancer is currently the leading cause of women’s death. It is crucial to further improve the approach to treatment and the long-term survival rate of breast cancer patients, and to reduce the rates of recurrence and metastasis. It has been reported that the possibility of tumor metastasis depends on the metastatic potential of the tumor and the host defense against tumor metastasis, in which cellular immunity and the function of natural killer (NK) cells are critical to maintaining this balance. Surgical stress response and postoperative pain inhibit perioperative immune function in patients and increase the likelihood of dissemination and metastasis of cancer cells after cancer surgery. The study aims to investigate the effect of anesthetic factors and pain treatment on the long-term prognosis of patients with early stage lymph node negative breast preservation surgery. Methods A total of 337 patients with early-stage lymph node negative breast cancer (ASA I-II) who had undergone successful breast-conserving surgery in our hospital were included in this retrospective analysis. Cases were divided into general anesthesia with postoperative analgesia group (GA + PCA), general anesthesia without postoperative analgesia group (GA), epidural anesthesia with postoperative analgesia group (EA + PCA), and epidural anesthesia without postoperative analgesia group (EA). The 5-year survival rate and 5-year disease-free survival were recorded in the 4 groups. Results The general condition and length of hospital stay of the patients were not statistically different between the 4 groups. However, the 5-year survival rate and 5-year disease-free survival rate of the 4 groups were statistically different. The 5-year survival rate and 5-year disease-free survival rate were the lowest in the GA group, while the EA + PCA group had the highest 5-year disease-free survival rate. The 5-year survival rate and 5-year disease-free survival rate in the GA + PCA group were significantly higher than those in the GA group. The 5-year disease-free survival rate in EA group was significantly higher than GA group. Conclusions Epidural anesthesia and postoperative pain treatment maybe beneficial to the long-term prognosis of patients with early-stage lymph node-negative breast cancer.
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Affiliation(s)
- Yanan Lu
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ting Liu
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Peizong Wang
- Department of Anesthesiology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Yi Chen
- Su Fengxi Clinic, Guangzhou, China
| | - Fengtao Ji
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Fernando Hernanz
- Oncoplastic Breast Unit, Hospital Universitario Valdecilla, University of Cantabria, Santander, Spain
| | - Gustavo Zucca-Matthes
- Department of Gynaecology, Obstetrics and Mastology, School of Medicine of Botucatu, UNESP, Botucatu-SP, Brazil
| | - Sherif Youssif
- Plastic and Reconstructive Surgery Division, Good Hope Hospital, University Hospitals Birmingham NHS Trust, Birmingham, UK.,Plastic surgery department, Assiut University, Assiut, Egypt
| | - Shuling Peng
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Dongni Xu
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
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Perioperative Care of Patients Undergoing Major Complex Spinal Instrumentation Surgery: Clinical Practice Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care. J Neurosurg Anesthesiol 2021; 34:257-276. [PMID: 34483301 DOI: 10.1097/ana.0000000000000799] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 07/14/2021] [Indexed: 11/25/2022]
Abstract
Evidence-based standardization of the perioperative management of patients undergoing complex spine surgery can improve outcomes such as enhanced patient satisfaction, reduced intensive care and hospital length of stay, and reduced costs. The Society for Neuroscience in Anesthesiology and Critical Care (SNACC) tasked an expert group to review existing evidence and generate recommendations for the perioperative management of patients undergoing complex spine surgery, defined as surgery on 2 or more thoracic and/or lumbar spine levels. Institutional clinical management protocols can be constructed based on the elements included in these clinical practice guidelines, and the evidence presented.
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Kawasaki Y, Park S, Miyamoto K, Ueki R, Kariya N, Tatara T, Hirose M. Modified model for predicting early C-reactive protein levels after gastrointestinal surgery: A prospective cohort study. PLoS One 2020; 15:e0239709. [PMID: 32970767 PMCID: PMC7514002 DOI: 10.1371/journal.pone.0239709] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 09/12/2020] [Indexed: 11/19/2022] Open
Abstract
Background Postoperative serum concentration of C-reactive protein (CRP) is one of the objective quantitative indices integrating the effects of preoperative and intraoperative variables. Higher levels of CRP after gastrointestinal surgery are associated with major postoperative complications. To develop a model for predicting CRP levels on postoperative day (POD) 1 in surgical patients both with and without serious conditions and comorbidities, we modified the previous formula for prediction of CRP levels on POD1, and assessed the accuracy of our modified predictive formula for CRP levels. Material and methods Consecutive patients of all ages undergoing gastrointestinal surgery under general anesthesia were enrolled in this single-institution prospective cohort study. We developed a modified predictive formula in a calculation cohort. Next, associations between measured CRP levels on POD1, predicted CRP levels on POD1 using the previous and modified models, and major complications after surgery were examined in a validation cohort. Results We obtained the following model in the calculation cohort (n = 222): Modified model for predicting CRP levels on POD1 (mg•dL-1) = -10.13 + 0.0025 Duration of surgery (min) + 15.9 Mean Nociceptive Response (NR) + 0.66 Preoperative CRP level (mg•dL-1). In the validation cohort (n = 440), there was a significant association between measured and predicted CRP levels on POD1 (P < 0.001) No significant difference between the measured and predicted CRP levels using the modified model was observed (P = 0.847). There were also significant associations between the predicted CRP levels and major complications after surgery. Conclusion CRP levels predicted using duration of surgery, mean NR, and preoperative CRP levels are likely identical to measured CRP levels on POD1, being associated with major complications after gastrointestinal surgery.
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Affiliation(s)
- Yui Kawasaki
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Soonhee Park
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Kazunori Miyamoto
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Ryusuke Ueki
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Nobutaka Kariya
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Tsuneo Tatara
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Munetaka Hirose
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
- * E-mail:
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Peng Y, Yang J, Guo D, Zheng C, Sun H, Zhang Q, Zou S, Zhang Y, Luo K, Candiotti KA. Sufentanil postoperative analgesia reduce the increase of T helper 17 (Th17) cells and FoxP3 + regulatory T (Treg) cells in rat hepatocellular carcinoma surgical model: A randomised animal study. BMC Anesthesiol 2020; 20:212. [PMID: 32847505 PMCID: PMC7448519 DOI: 10.1186/s12871-020-01129-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 08/16/2020] [Indexed: 11/17/2022] Open
Abstract
Background Surgery-related pain and opioids might exacerbate immune defenses in immunocompromised cancer patients which might affect postoperativd overall survival. Sufentanil is a good postoperative pain control drug,the present study aimed to figure out whether it effect T cell immunity in rat hepatocellular carcinoma surgical model. Methods A rat hepatocellular carcinoma (HCC) models was established by N-nitrosodiethylamine. Forty-eight of them were randomly divided into 3 equal groups: surgery without postoperative analgesia (Group C), surgery with morphine postoperative analgesia (Group M), surgery with sufentanil postoperative analgesia (Group S). Each animal underwent a standard left hepatolobectomy, and intraperitoneally implanted with osmotic minipumps filled with sufentanil, morphine or normal saline according to the different group. The food and water consumptions, body weight changes, locomotor activity and mechanical pain threshold (MPT) were observed. The ratio of CD4+/CD8+, proportions of Th1, Th2, Th17 and Treg cells in blood were detected using flow cytometry. The liver function and the rats’ survival situation of each group were observed. Results The food and water consumption, locomotor activity and MPT of group C declined than those of group S and M on d1, d2, d3 (P < 0.05). The CD4+/CD8+ ratio and the proportion of Th1 cells were significantly higher while the proportion of Th2, Th17 and Treg cells were significantly lower in group S and group M compared with group C. The rats of group S have higher CD4+/CD8+ ratio on d3, while lower proportion of Treg cells on d7 compared with group M. The plasma ALT and AST values in group C were significantly higher than that of group S and group M on both d3 and d7. There were not significant differences in mortality rate between 3 groups. Conclusions Sufentanil and morphine postoperative analgesia in HCC rats accepted hepatectomy could relieve postoperative pain, promote the recovery of liver function after surgery, alleviate the immunosuppressive effect of pain. Furthermore, Compared to morphine, sufentanil might have a slighter effect on CD4+/CD8+ ratio and Treg frequencies. Therefore, sufentanil postoperative analgesia is better than morphine in HCC hepatectomy rats.
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Affiliation(s)
- Yanhua Peng
- Department of Anesthesiology, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, 410013, Hunan, China
| | - Jinfeng Yang
- Department of Anesthesiology, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, 410013, Hunan, China.
| | - Duo Guo
- Department of Anesthesiology, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, 410013, Hunan, China
| | - Chumei Zheng
- Department of Anesthesiology, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, 410013, Hunan, China
| | - Huiping Sun
- Department of Anesthesiology, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, 410013, Hunan, China
| | - Qinya Zhang
- Department of Anesthesiology, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, 410013, Hunan, China
| | - Shuangfa Zou
- Department of Anesthesiology, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, 410013, Hunan, China
| | - Yanping Zhang
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami-Miller School of Medicine, Miami, FL, 33136, USA
| | - Ke Luo
- Department of Anesthesiology, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, 410013, Hunan, China
| | - Keith A Candiotti
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami-Miller School of Medicine, Miami, FL, 33136, USA
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Zhu R, Xiang J, Tan M. Effects of different anesthesia and analgesia on cellular immunity and cognitive function of patients after surgery for esophageal cancer. MINERVA CHIR 2020; 75:449-456. [PMID: 32773737 DOI: 10.23736/s0026-4733.20.08283-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The study intends to analyze influences of different anesthesia and analgesia on cellular immune and cognitive functions of patients undergoing thoracotomy for esophageal cancer (EsC). METHODS Patients undergoing thoracotomy for EsC were divided into four groups: Group A (received general anesthesia [GA]) and postoperative intravenous analgesia); B (received GA and postoperative epidural analgesia); C (received GA combined with thoracic epidural anesthesia [TEA]) and postoperative intravenous analgesia); D (received GA combined with TEA and postoperative epidural analgesia). The T-lymphocyte subsets were determined at 30 min before anesthesia induction (T<inf>0</inf>), 2 h after skin incision (T<inf>1</inf>), and at 4 h (T<inf>2</inf>), 24 h (T<inf>3</inf>), and 48 h (T<inf>4</inf>) after operation. Besides, visual analogue scale (VAS) and mini-mental state examination (MMSE) were assessed. RESULTS The percentage of CD3+ and CD4+ cells in groups B and C were higher than group A from T<inf>1</inf> to T<inf>3</inf>. The ratio of CD4+/CD8+ in group B and C were higher than in group A at T<inf>3</inf>. Compared with group A, group D had increased percentages of CD3+ and CD4+ from T<inf>1</inf> to T<inf>4</inf>, and elevated ratio of CD4+/CD8+ from T<inf>2</inf> to T<inf>4</inf> VAS scores were lower and MMSE scores were higher in groups B, C, and D than in group A, and group D had relatively lower VAS and higher MMSE scores as compared to group B. CONCLUSIONS The intraoperative general anesthesia combined with thoracic epidural anesthesia and postoperative epidural analgesia may reduce adverse effect on cellular immune and cognitive functions of patients undergoing thoracotomy for EsC.
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Affiliation(s)
- Rongyu Zhu
- Department of Anesthesiology, The Central Hospital of Enshi Autonomous Prefecture, Enshi, Hubei, China
| | - Jun Xiang
- Department of Anesthesiology, The Central Hospital of Enshi Autonomous Prefecture, Enshi, Hubei, China
| | - Ming Tan
- Department of Anesthesiology, The Central Hospital of Enshi Autonomous Prefecture, Enshi, Hubei, China -
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Ezhevskaya AA, Ovechkin AM, Prusakova ZB, Zagrekov VI, Mlyavykh SG, Anderson DG. Relationship among anesthesia technique, surgical stress, and cognitive dysfunction following spinal surgery: a randomized trial. J Neurosurg Spine 2019; 31:894-901. [PMID: 31491757 DOI: 10.3171/2019.4.spine184] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 04/19/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Surgical trauma is known to result in systemic inflammatory changes that can lead to postoperative cognitive dysfunction. In the present study, the authors compared the effects of an epidural anesthesia protocol to those of traditional anesthesia with regard to postoperative inflammatory changes, cellular immunity, and cognitive dysfunction. METHODS Forty-eight patients, ages 45-60 years, underwent multilevel thoracolumbar decompression and fusion and were randomly assigned to one of two groups: group 1 (27 patients) had combined epidural and general anesthesia, followed by epidural analgesia for 48 hours after surgery, and group 2 (21 patients) had general anesthesia, followed by traditional opioid pain management after surgery. At multiple time points, data on pain control, cognitive function, cellular immunity, and inflammatory markers were collected. RESULTS Group 1 patients demonstrated lower pain levels, less systemic inflammation, less cellular immune dysfunction, and less postoperative cognitive dysfunction than group 2 patients. CONCLUSIONS The use of combined epidural and general anesthesia followed by postoperative epidural analgesia during the first 48 hours after multilevel thoracolumbar decompression and fusion surgery had a significant positive effect on pain management, cellular immune function, systemic inflammation, and postoperative cognitive function.Clinical trial registration no.: 115080510080 (http://rosrid.ru).
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Affiliation(s)
- Anna A Ezhevskaya
- 1Federal State Budgetary Educational Institution of Higher Education Privolzhsky Research Medical University of the Ministry of Health of the Russian Federation, Nizhniy Novgorod, Russian Federation
| | - Alexei M Ovechkin
- 2I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation; and
| | - Zhanna B Prusakova
- 1Federal State Budgetary Educational Institution of Higher Education Privolzhsky Research Medical University of the Ministry of Health of the Russian Federation, Nizhniy Novgorod, Russian Federation
| | - Valery I Zagrekov
- 1Federal State Budgetary Educational Institution of Higher Education Privolzhsky Research Medical University of the Ministry of Health of the Russian Federation, Nizhniy Novgorod, Russian Federation
| | - Sergey G Mlyavykh
- 1Federal State Budgetary Educational Institution of Higher Education Privolzhsky Research Medical University of the Ministry of Health of the Russian Federation, Nizhniy Novgorod, Russian Federation
| | - D Greg Anderson
- 3Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
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Guner A, Kim HI. Biomarkers for Evaluating the Inflammation Status in Patients with Cancer. J Gastric Cancer 2019; 19:254-277. [PMID: 31598370 PMCID: PMC6769371 DOI: 10.5230/jgc.2019.19.e29] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 08/01/2019] [Accepted: 08/14/2019] [Indexed: 12/13/2022] Open
Abstract
Inflammation can be a causative factor for carcinogenesis or can result from a consequence of cancer progression. Moreover, cancer therapeutic interventions can also induce an inflammatory response. Various inflammatory parameters are used to assess the inflammatory status during cancer treatment. It is important to select the most optimal biomarker among these parameters. Additionally, suitable biomarkers must be examined if there are no known parameters. We briefly reviewed the published literature for the use of inflammatory parameters in the treatment of patients with cancer. Most studies on inflammation evaluated the correlation between host characteristics, effect of interventions, and clinical outcomes. Additionally, the levels of C-reactive protein, albumin, lymphocytes, and platelets were the most commonly used laboratory parameters, either independently or in combination with other laboratory parameters and clinical characteristics. Furthermore, the immune parameters are classically examined using flow cytometry, immunohistochemical staining, and enzyme-linked immunosorbent assay techniques. However, gene expression profiling can aid in assessing the overall peri-interventional immune status. The checklists of guidelines, such as STAndards for Reporting of Diagnostic accuracy and REporting recommendations for tumor MARKer prognostic studies should be considered when designing studies to investigate the inflammatory parameters. Finally, the data should be interpreted after adjusting for clinically important variables, such as age and cancer stage.
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Affiliation(s)
- Ali Guner
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea.,Department of General Surgery, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey.,Department of Biostatistics and Medical Informatics, Institute of Medical Science, Karadeniz Technical University, Trabzon, Turkey
| | - Hyoung-Il Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea.,Open NBI Convergence Technology Research Laboratory, Severance Hospital, Yonsei University Health System, Seoul, Korea.,Gastric Cancer Center, Yonsei Cancer Hospital; Seoul, Korea
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Wang J, Yin Y, Zhu Y, Xu P, Sun Z, Miao C, Zhong J. Thoracic epidural anaesthesia and analgesia ameliorates surgery-induced stress response and postoperative pain in patients undergoing radical oesophagectomy. J Int Med Res 2019; 47:6160-6170. [PMID: 31426685 PMCID: PMC7045687 DOI: 10.1177/0300060519866943] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Objective An acute severe stress response associated with major surgery can adversely affect the inflammatory and hormonal responses. We hypothesised that total intravenous anaesthesia (TIVA) combined with thoracic epidural anaesthesia and analgesia (TEA) attenuates the stress response and postoperative pain in patients undergoing radical oesophagectomy. Methods Forty patients scheduled for elective radical oesophagectomy were randomly assigned to one of two groups: TIVA or TIVA+TEA. The plasma levels of stress hormones and cytokines, consumption of fentanyl, postoperative visual analogue scale (VAS) scores within 48 hours, and extubation time were assessed. Results The plasma levels of interleukin-6, norepinephrine, cortisol, and adrenocorticotropic hormone at 3 hours after the beginning of surgery were significantly higher in the TIVA group than TIVA+TEA group. The plasma level of interleukin-10 at 3 hours after the beginning of surgery was significantly lower in the TIVA group than TIVA+TEA group. The consumption of fentanyl was significantly greater, VAS scores were significantly higher, and extubation time was significantly longer in the TIVA group than TIVA+TEA group. Conclusions The findings suggest that combination of TIVA and TEA may attenuate the intraoperative stress response and postoperative pain in patients undergoing radical oesophagectomy.
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Affiliation(s)
- Jing Wang
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yuehao Yin
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yun Zhu
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Pingbo Xu
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Zhirong Sun
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Changhong Miao
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jing Zhong
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
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Wang W, Xiao J, Shen S, Wang S, Chen M, Hu Y. Emerging effect of anesthesia on post-operative tumor recurrence and metastasis. J Int Med Res 2019; 47:3550-3558. [PMID: 31296069 PMCID: PMC6726782 DOI: 10.1177/0300060519861455] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Post-operative recurrence and metastasis of malignant tumors are difficult to control, which probably results from multiple factors that affect the prognosis and the undefined mechanism. Anesthesia may be an influential factor. Researchers have performed many meaningful studies on the relationship between anesthetic drugs/methods and tumor growth/immune function, which provide important references for the anesthetic selection and peri-operative management of tumor patients. Anesthetics, analgesics, and sedatives should be used with caution because their effects in post-operative patients remain controversial. This review summarizes the emerging progress on the effect of anesthesia on post-operative tumor recurrence and metastasis, particularly focusing on the effects of anesthetic drugs, anesthetic methods, and post-operative analgesia on tumor growth and metastasis. Future studies should provide strict criteria for the proper use of anesthetics in patients with malignant tumors and provide experimental evidence for the improvement and development of novel anesthetics and anesthetic methods that have the important clinical significance.
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Affiliation(s)
- Weilian Wang
- 1 Department of Anesthesia, Jingzhou Central Hospital, The Second Clinical Medical College, Yangtze University, Jingzhou, Hubei, P.R. China
| | - Jinliang Xiao
- 1 Department of Anesthesia, Jingzhou Central Hospital, The Second Clinical Medical College, Yangtze University, Jingzhou, Hubei, P.R. China
| | - Shuwei Shen
- 1 Department of Anesthesia, Jingzhou Central Hospital, The Second Clinical Medical College, Yangtze University, Jingzhou, Hubei, P.R. China
| | - Shu Wang
- 2 Department of Anesthesia, Benxi Central Hospital, Benxi, Liaoning, P.R. China
| | - Minghao Chen
- 3 Department of Anesthesia, Weihai Municipal Hospital, Weihai, Shandong, P.R. China
| | - Ya Hu
- 4 Department of Pharmacology, Health Science Center, Yangtze University, Jingzhou, Hubei, P.R. China
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Li Y, Dong H, Tan S, Qian Y, Jin W. Effects of thoracic epidural anesthesia/analgesia on the stress response, pain relief, hospital stay, and treatment costs of patients with esophageal carcinoma undergoing thoracic surgery: A single-center, randomized controlled trial. Medicine (Baltimore) 2019; 98:e14362. [PMID: 30762735 PMCID: PMC6408022 DOI: 10.1097/md.0000000000014362] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Appropriate postoperative pain management can improve outcomes in patients with esophageal cancer (EC). OBJECTIVE To compare different combinations of anesthesia and analgesia techniques in patients with EC undergoing open thoracotomy. METHODS This randomized, controlled, open-label trial enrolled 100 patients with EC (aged 40-65 years; American Society of Anesthesiologists [ASA] grade I/II) receiving elective surgery at Jiangsu Province Hospital (China) between July 2016 and December 2017. Patients were randomized to 4 groups (n = 25 per group): total intravenous general anesthesia plus patient-controlled intravenous analgesia (TIVA/PCIA); TIVA plus patient-controlled epidural analgesia (TIVA/PCEA); thoracic epidural anesthesia with intravenous general anesthesia plus PCIA (TEA-IVA/PCIA); and TEA-IVA/PCEA (TEA-IVA plus PCEA). Primary outcomes were plasma cortisol level (measured at baseline, 2 h after skin incision, surgery completion, and 24 and 48 h post-surgery) and pain (assessed at 24, 48, and 72 hours post-surgery using a visual analog scale). Secondary outcomes included time to first flatus, hospital stay and treatment costs. Postoperative adverse events (AEs) were analyzed. RESULTS Baseline and operative characteristics were similar between the 4 groups. Plasma cortisol level increased (P <.05 vs baseline) earlier in the TIVA groups (2 h after skin incision) than in the TEA-IVA groups (24 h after surgery). At 48 hours after surgery, plasma cortisol had returned to baseline levels in the PCEA groups but not in the PCIA groups. VAS pain scores at rest and during coughing were lower in the PCEA groups than in the PCIA groups (P <.05). Compared with the PCIA groups, the PCEA groups had shorter time to first flatus and shorter hospital stay, while use of TEA-IVA lowered the costs of intraoperative anesthesia (P <.05). However, the PCEA groups had a higher incidence of nausea, vomiting, and pruritus. CONCLUSION Thoracic epidural anesthesia/analgesia can reduce the stress response, improve postoperative recovery and reduce hospital stay and costs for patients with EC.
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Vicente D, Patino M, Marcus R, Lillmoe H, Limani P, Newhook T, Lee A, Tzeng CW, Segraves-Chun Y, Tweardy D, Gottumukkala V, Vauthey JN, Aloia T, Cata JP. Impact of epidural analgesia on the systemic biomarker response after hepatic resection. Oncotarget 2019; 10:584-594. [PMID: 30728909 PMCID: PMC6355178 DOI: 10.18632/oncotarget.26549] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 12/22/2018] [Indexed: 12/30/2022] Open
Abstract
Background Perioperative inflammation is associated with poor oncologic outcomes. Regional analgesia has been shown mitigate some of these inflammatory changes and be associated with better oncologic outcomes in patients with hepatic malignancies. The mechanism for this effect, however, remains unclear. The authors sought to compare systemic biomarker concentrations in a comprehensive and oncologically relevant panel in the perioperative setting between patients undergoing thoracic epidural analgesia (TEA) and intra-venous patient- controlled analgesia (IV-PCA) for resection of hepatic metastatic disease. Results Clinicopathologic variables and baseline biomarkers were similar between TEA (n = 46) and IV-PCA (n = 16) groups. Of the biomarkers which were significantly changed from baseline, there was a lower fold change from baseline in the TEA patients compared to IV-PCA including IL-6 (13.5vs19.1), MCP-1 (1.9vs3.0), IL-8 (2.4vs3.0), and Pentraxin-3 (10.8vs15.6). Overall decreased systemic concentrations of TGFb signaling were noted in TEA patients on POD1 TGFb3 (243.2 vs. 86.0, p = 0.005), POD3 TGFb1 (6558.0 vs. 2063.3, p = 0.004), POD3 TGFb2 (468.3 vs. 368.9, p = 0.036), POD3 TGFb3 (132.2 vs. 77.8, p = 0.028), and POD5 TGFb3 (306.5 vs. 92.2, p = 0.032). POD1 IL-12p70 concentrations were significantly higher in TEA patients (8.3 vs. 1.6, p = 0.024). Conclusion Epidural analgesia damped the postoperative inflammatory response and systemic immunosuppressive signaling, as well as promoted Th1 systemic signaling early in the post-operative period after hepatic resection for metastatic disease. These differences elaborate on known mechanisms for improved oncologic outcomes with regional anesthesia, and may be considered for biomarker monitoring of effective regional anesthesia in oncologic surgery. Materials and Methods Patient data, including clinicopathologic variables were collected for this study from the database of a randomized controlled trial comparing perioperative outcomes in patients undergoing hepatic resection with TEA vs. IV-PCA. Patients undergoing resection for metastatic disease were selected for this study. Plasma concentrations (pg/mL) of well-studied biomarkers (IL-1b/2/4/5/6/7/8/10/12p70/13/17, MCP-1 IFNγ, TNFα, MIP-1b, GM-CSF, G-CSF, VEGF, Resistin, TGFb1, TGFb2, and TGFb3), as well as novel perioperative markers (CXCL12, CXCL10, Omentin-1, sLeptin R, Vaspin, Pentraxin-3, Galactin-3, FGF-23, PON-1, FGF-21) were measured preoperatively, and on postoperative day (POD)1, POD3, and POD5 using multiplex bead assays. Clinicopathologic variables and perioperative variations in these biomarkers were compared between TEA vs IV-PCA groups.
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Affiliation(s)
- Diego Vicente
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA
| | - Miguel Patino
- Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA.,Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rebecca Marcus
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Heather Lillmoe
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Preparim Limani
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Timothy Newhook
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andy Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ching-Wei Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yun Segraves-Chun
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David Tweardy
- Department of Molecular and Cellular Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vijaya Gottumukkala
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Thomas Aloia
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Juan P Cata
- Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA.,Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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12
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Grandhi RK, Abd-Elsayed A. Post-operative Pain Management in Spine Surgery. TEXTBOOK OF NEUROANESTHESIA AND NEUROCRITICAL CARE 2019:447-455. [DOI: 10.1007/978-981-13-3387-3_32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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13
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Sayed JA, Abd Elshafy SK, Kamel EZ, Fathy Riad MA, Mahmoud AA, Khalaf GS. The impact of caudally administrated tramadol on immune response and analgesic efficacy for pediatric patients: a comparative randomized clinical trial. Korean J Pain 2018; 31:206-214. [PMID: 30013735 PMCID: PMC6037809 DOI: 10.3344/kjp.2018.31.3.206] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 06/05/2018] [Accepted: 06/07/2018] [Indexed: 11/05/2022] Open
Abstract
Background Immune responses appear to be affected by anesthetics and analgesics. We investigated the effects of caudal tramadol on the postoperative immune response and pain management in pediatric patients. Methods Sixty ASA-I pediatric patients aged 3–10 years undergoing lower abdominal surgery. Patients were randomly assigned either to a caudal bupivacaine (0.25%) group (group B), or a group that received caudal tramadol (1 mg/kg) added to the bupivacaine (0.25%) (group T). Both were diluted in a 0.9% NaCl solution to a total volume of 1ml/kg. The systemic immune response was measured by collecting blood samples preoperatively, at the end of anesthesia, and at 24 and 72 hours postoperatively, and studied for interleukin IL-6, C-reactive proteins (CRP) cortisol levels, and leucocytes with its differential count. Postoperative pain was assessed along with sedation scales. Results Postoperative production of IL-6 was significantly higher in group B at the end of anesthesia, than at the 24th hour, and at the 72nd hour in group B and group T, respectively. The immune response showed leukocytosis with increased percentages of neutrophil and monocytes, and a decreased lymphocyte response rate within both groups with no significant differences between the groups. Cortisol and CRP were significantly higher in group B. Conclusions Adding tramadol to a caudal bupivacaine block can attenuate the pro-inflammatory cytokine response, Cortisol, and CRP in children undergoing lower abdominal surgery.
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Affiliation(s)
- Jehan Ahmed Sayed
- Department of Anesthesia, College of Medicine, Assiut University, Assiut, Egypt
| | | | - Emad Zareif Kamel
- Department of Anesthesia, College of Medicine, Assiut University, Assiut, Egypt
| | | | - Amal Ahmed Mahmoud
- Department of Clinical Pathology, College of Medicine, Assiut University, Assiut, Egypt
| | - Ghada Shalaby Khalaf
- Department of Critical Care and Emergency Nursing, Faculty of Nursing, Assiut University, Assiut, Egypt
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14
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Karadeniz MS, Mammadov O, Çiftci HŞ, Usta SA, Pembeci K. Comparing the Effects of Combined General/Epidural Anaesthesia and General Anaesthesia on Serum Cytokine Levels in Radical Cystectomy. Turk J Anaesthesiol Reanim 2017; 45:203-209. [PMID: 28868167 DOI: 10.5152/tjar.2017.13285] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 04/25/2017] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE Surgical stress combined with general anaesthesia (GA) suppresses the immune system and leads to cancer cell growth and premature metastasis in major oncological interventions. Epidural analgesia decreases the need for inhalation agents and opioids during surgery by suppressing sympathetic and neuroendocrine responses in the postoperative period. This study aimed to compare the effects of combined general/epidural anaesthesia (GEA)+patient-controlled epidural analgesia (PCEA) and GA+IV patient-controlled analgesia (PCA) on serum tumour necrosis factor-alpha TNF-α), interleukin-1 beta (IL-1β) and interferon-gamma (IFN-γ) levels in patients undergoing radical cystectomy. METHODS Sixty-five patients were enrolled in this prospective study. Patients were randomly enrolled to the GEA group, i.e., combined GEA+ PCEA (0.1% bupivacaine+1 μg mL-1 fentanyl), and the GA group, namely combined GA+IV PCA (0.03 mg mL-1 morphine). To evaluate the cytokine response, blood samples were collected at preoperative, postoperative 1st and 24th hours. RESULTS There was no statistically significant difference in serum TNF-α, IL-1β and IFN-γ levels between groups GA and GEA at preoperative and postoperative 1st hour and 24th hour. Total remifentanil consumption was significantly lower and length of hospital stay was significantly shorter in the GEA group than in the GA group (p<0.05). CONCLUSION There is no difference between two anaesthesia methods in terms of serum cytokine levels; however, combined GEA+PCEA technique appeared to be superior to GA+IV PCA because of lower intraoperative narcotic analgesic consumption and shorter hospital stay.
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Affiliation(s)
- Meltem Savran Karadeniz
- Department of Anaesthesiology and Reanimation, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
| | - Orkhan Mammadov
- Department of Anaesthesiology and Reanimation, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
| | - Hayriye Şentürk Çiftci
- Department of Medical Biology, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
| | - Sebahat Akgül Usta
- Department of Medical Biology, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
| | - Kamil Pembeci
- Department of Anaesthesiology and Reanimation, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
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15
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Siekmann W, Eintrei C, Magnuson A, Sjölander A, Matthiessen P, Myrelid P, Gupta A. Surgical and not analgesic technique affects postoperative inflammation following colorectal cancer surgery: a prospective, randomized study. Colorectal Dis 2017; 19:O186-O195. [PMID: 28258664 DOI: 10.1111/codi.13643] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 01/04/2017] [Indexed: 12/12/2022]
Abstract
AIM Epidural analgesia reduces the surgical stress response. However, its effect on pro- and anti-inflammatory cytokines in the genesis of inflammation following major abdominal surgery remains unclear. Our main objective was to elucidate whether perioperative epidural analgesia prevents the inflammatory response following colorectal cancer surgery. METHODS Ninety-six patients scheduled for open or laparoscopic surgery were randomized to epidural analgesia (group E) or patient-controlled intravenous analgesia (group P). Surgery and anaesthesia were standardized in both groups. Plasma cortisol, insulin and serum cytokines [interleukin 1β (IL-1β), IL-4, IL-5, IL-6, IL-8, IL-10, IL-12p70, IL-13, tumour necrosis factor α, interferon γ, granulocyte-macrophage colony-stimulating factor, prostaglandin E2 and vascular endothelial growth factor] were measured preoperatively (T0), 1-6 h postoperatively (T1) and 3-5 days postoperatively (T2). Mixed model analysis was used, after logarithmic transformation when appropriate, for analyses of cytokines and stress markers. RESULTS >There were no significant differences in any serum cytokine concentration between groups P and E at any time point except for IL-10 which was 87% higher in group P [median and range 4.1 (2.3-9.2) pg/ml] compared to group E [2.6 (1.3-4.7) pg/ml] (P = 0.002) at T1. There was no difference in plasma cortisol and insulin between the groups at any time point after surgery. A significant difference in median serum cytokine concentration was found between open and laparoscopic surgery with higher levels of IL-6, IL-8 and IL-10 at T1 in patients undergoing open surgery compared to laparoscopic surgery. No difference in serum cytokine concentration was detected between the groups or between the surgical technique at T2. CONCLUSIONS Open surgery, compared to laparoscopic surgery, has greater impact on these inflammatory mediators than epidural analgesia vs intravenous analgesia.
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Affiliation(s)
- W Siekmann
- Department of Anaesthesiology and Intensive Care, Örebro University Hospital and School of Medical Sciences, Örebro University, Örebro, Sweden
| | - C Eintrei
- Department of Anesthesiology and Intensive Care, County Council of Östergötland, Linköping, Sweden
| | - A Magnuson
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - A Sjölander
- Cell and Experimental Pathology, Department of Translational Medicine, Lund University, Malmö, Sweden
| | - P Matthiessen
- Department of Surgery, Örebro University Hospital and School of Medical Sciences, Örebro University, Örebro, Sweden
| | - P Myrelid
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.,Department of Surgery, Linköping University Hospital, Linköping, Sweden
| | - A Gupta
- Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
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16
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Chen L, Sun L, Lang Y, Wu J, Yao L, Ning J, Zhang J, Xu S. Fast-track surgery improves postoperative clinical recovery and cellular and humoral immunity after esophagectomy for esophageal cancer. BMC Cancer 2016; 16:449. [PMID: 27401305 PMCID: PMC4940721 DOI: 10.1186/s12885-016-2506-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Accepted: 07/05/2016] [Indexed: 12/21/2022] Open
Abstract
Background Our aim was to investigate the influence of FTS on human cellular and humoral immunity using a randomized controlled clinical study in esophageal cancer patients. Methods Between October 2013 and December 2014, 276 patients with esophageal cancer in our department were enrolled in the study. The patients were randomized into two groups: FTS pathway group and conventional pathway group. The postoperative hospital stay, hospitalization expenditure, and postoperative complications were recorded. The markers of inflammatory and immune function were measured before operation as well as on the 1st, 3rd, and 7th postoperative days (POD), including serum level of interleukin-6 (IL-6), C-reactive protein (CRP), serum globulin, immunoglobulin G (IgG), immunoglobulin M (IgM), immunoglobulin A (IgA) and lymphocyte subpopulations (CD3 lymphocytes, CD4 lymphocytes, CD8 lymphocytes and the CD4/CD8 ratio) in the patients between the two groups. Results In all, 260 patients completed the study: 128 in the FTS group and 132 in the conventional group. We found implementation of FTS pathway decreases postoperative length of stay and hospital charges (P < 0.05). In addition, inflammatory reactions, based on IL-6 and CRP levels, were less intense following FTS pathway compared to conventional pathway on POD1 and POD3 (P < 0.05). On POD1 and POD3, the levels of IgG, IgA, CD3 lymphocytes, CD4 lymphocytes and the CD4/CD8 ratio in FTS group were significantly higher than those in control group (All P < 0.05). However, there were no differences in the level of IgM and CD8 lymphocytes between the two groups. Conclusions FTS improves postoperative clinical recovery and effectively inhibited release of inflammatory factors via the immune system after esophagectomy for esophageal cancer. Trial registration ChiCTR-TRC-13003562, the date of registration: August 29, 2013.
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Affiliation(s)
- Lantao Chen
- Department of Thoracic Surgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang Province, China
| | - Lixin Sun
- Department of Thoracic Surgery, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Yaoguo Lang
- Department of Thoracic Surgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang Province, China
| | - Jun Wu
- Department of Thoracic Surgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang Province, China.,Department of Thoracic Surgery, Hainan Cancer Hospital, Haikou, Hainan Province, China
| | - Lei Yao
- Department of Thoracic Surgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang Province, China
| | - Jinfeng Ning
- Department of Thoracic Surgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang Province, China
| | - Jinfeng Zhang
- Department of Thoracic Surgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang Province, China
| | - Shidong Xu
- Department of Thoracic Surgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang Province, China.
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17
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Clinical consequences of inadequate pain relief: barriers to optimal pain management. Plast Reconstr Surg 2016; 134:15S-21S. [PMID: 25254999 DOI: 10.1097/prs.0000000000000681] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
SUMMARY Uncontrolled postoperative pain may result in significant clinical, psychological, and socioeconomic consequences. Not only does inadequate pain management following surgery result in increased morbidity and mortality but it also may delay recovery, result in unanticipated readmissions, decrease patient satisfaction, and lead to chronic persistent postsurgical pain. Pain is multifactorial in nature, and understanding both the complexity of pain and its side effects is imperative to achieving a successful surgical outcome. In this section, we review the consequences of pain as they pertain to plastic surgery with a focus on the impact of pain on the surgical stress response and risk of wound infections and the effect of improved pain control on flap surgery. Uncontrolled acute postoperative pain may lead to chronic persistent postsurgical pain, which has a high incidence in patients undergoing breast cancer surgery. To achieve optimal postoperative analgesia, one must recognize the barriers to effective pain management, including both physician/nursing-related barriers and patient-related barriers, as well as the increasingly common appearance of opioid-tolerant patients.
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18
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Rasouli MR, Cavanaugh PK, Restrepo C, Celyan HH, Maltenfort MG, Viscusi ER, Parvizi J. Is neuraxial anesthesia safe in patients undergoing surgery for treatment of periprosthetic joint infection? Clin Orthop Relat Res 2015; 473:1472-7. [PMID: 25670655 PMCID: PMC4353555 DOI: 10.1007/s11999-015-4175-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 01/28/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND There is concern that neuraxial anesthesia in patients undergoing surgery for treatment of a periprosthetic joint infection (PJI) may increase the risk of having a central nervous system infection develop. However, the available data on this topic are limited and contradictory. QUESTIONS/PURPOSES We wished to determine whether neuraxial anesthesia (1) is associated with central nervous system infections in patients undergoing surgery for a PJI, and (2) increases the likelihood of systemic infection in these patients. METHODS All 539 patients who received neuraxial or general anesthesia during 1499 surgeries for PJI from October 2000 to May 2013 were included in this study; of these, 51% (n = 764) of the surgeries were performed in 134 patients receiving neuraxial anesthesia and 49% were performed in 143 patients receiving general anesthesia. Two hundred sixty-two patients received general and neuraxial anesthesia during different surgeries. We used the International Classification of Diseases, 9(th) Revision codes and the medical records to identify patients who had an intraspinal abscess or meningitis develop after surgery for a PJI. Multivariate analysis was used to assess the effect of type of anesthesia (neuraxial versus general) on postoperative complications. RESULTS There were no cases of meningitis, but one epidural abscess developed in a patient after neuraxial anesthesia. This patient underwent six revision surgeries during a 42-day period. Patients who received neuraxial anesthesia had lower odds of systemic infections (4% versus 12%; odds ratio, 0.35; 95% CI, 023-054; p < 0.001). CONCLUSIONS Central nervous system infections after neuraxial anesthesia in patients with a PJI appear to be exceedingly rare. Based on the findings of this study, it may be time for the anesthesiology community to reevaluate the risk of sepsis as a relative contraindication to the use of neuraxial anesthesia.
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Affiliation(s)
- Mohammad R. Rasouli
- />Rothman Institute of Orthopaedics, Thomas Jefferson Hospital, Philadelphia, PA USA
| | | | - Camilo Restrepo
- />Rothman Institute of Orthopaedics, Thomas Jefferson Hospital, Philadelphia, PA USA
| | - Hasan Huseyin Celyan
- />Rothman Institute of Orthopaedics, Thomas Jefferson Hospital, Philadelphia, PA USA
| | | | - Eugene R. Viscusi
- />Department of Anesthesiology, Thomas Jefferson University, Philadelphia, PA USA
| | - Javad Parvizi
- />Rothman Institute of Orthopaedics, Thomas Jefferson Hospital, Philadelphia, PA USA
- />Rothman Institute at Thomas Jefferson University, Sheridan Building, 10th Floor, 125 South 9th Street, Philadelphia, PA 19107 USA
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19
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Inagi T, Suzuki M, Osumi M, Bito H. Remifentanil-based anaesthesia increases the incidence of postoperative surgical site infection. J Hosp Infect 2015; 89:61-8. [DOI: 10.1016/j.jhin.2014.10.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Accepted: 10/06/2014] [Indexed: 11/26/2022]
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20
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Impact of epidural analgesia on mortality and morbidity after surgery: systematic review and meta-analysis of randomized controlled trials. Ann Surg 2014; 259:1056-67. [PMID: 24096762 DOI: 10.1097/sla.0000000000000237] [Citation(s) in RCA: 303] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To quantify benefit and harm of epidural analgesia, compared with systemic opioid analgesia, in adults having surgery under general anesthesia. BACKGROUND It remains controversial whether adding epidural analgesia to general anesthesia decreases postoperative morbidity and mortality. METHODS We searched CENTRAL, EMBASE, PubMed, CINAHL, and BIOSIS till July 2012. We included randomized controlled trials comparing epidural analgesia (with local anesthetics, lasting for ≥ 24 hours postoperatively) with systemic analgesia in adults having surgery under general anesthesia, and reporting on mortality or any morbidity endpoint. RESULTS A total of 125 trials (9044 patients, 4525 received epidural analgesia) were eligible. In 10 trials (2201 patients; 87 deaths), reporting on mortality as a primary or secondary endpoint, the risk of death was decreased with epidural analgesia (3.1% vs 4.9%; odds ratio, 0.60; 95% confidence interval, 0.39-0.93). Epidural analgesia significantly decreased the risk of atrial fibrillation, supraventricular tachycardia, deep vein thrombosis, respiratory depression, atelectasis, pneumonia, ileus, and postoperative nausea and vomiting, and also improved recovery of bowel function, but significantly increased the risk of arterial hypotension, pruritus, urinary retention, and motor blockade. Technical failures occurred in 6.1% of patients. CONCLUSIONS In adults having surgery under general anesthesia, concomitant epidural analgesia reduces postoperative mortality and improves a multitude of cardiovascular, respiratory, and gastrointestinal morbidity endpoints compared with patients receiving systemic analgesia. Because adverse effects and technical failures cannot be ruled out, individual risk-benefit analyses and professional care are recommended.
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21
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Honca M, Purtuloglu T, Akgul EO, Oztosun M, Honca T, Sizlan A, Agilli M, Aydin I, Yetim M, Aydin FN, Yaman H. Effects of general and spinal anesthetic techniques on endothelial adhesion molecules in cesarean section. Korean J Anesthesiol 2014; 66:364-70. [PMID: 24910728 PMCID: PMC4041955 DOI: 10.4097/kjae.2014.66.5.364] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 10/21/2013] [Accepted: 10/29/2013] [Indexed: 11/10/2022] Open
Abstract
Background The aim of this study was to investigate the effects of anesthetic techniques used during general anesthesia (GA) and spinal anesthesia (SA) on endothelial adhesion molecules in the fetal circulation of healthy parturients undergoing elective cesarean section. Methods Patients were randomly assigned to either the general anesthesia (n = 20) or spinal anesthesia (n = 20) group. Maternal and cord blood neopterin, sE-selectin, and sL-selectin levels were measured in both groups. Results Cord blood neopterin concentrations in the SA group were not different from those in the GA group, but maternal neopterin levels in the SA group were different from those in the GA group. Maternal blood levels of sE-selectin and sL-selectin were not different between the two groups. Similarly, the cord blood levels of sE-selectin and sL-selectin were not different between the two groups. We found an increased inflammatory process in the fetal circulation depending on the anesthetic method used. Conclusions These results indicate the effects of general and spinal anesthetic techniques on serum sL-selectin, sE-selectin, and neopterin levels in neonates and parturients undergoing elective cesarean section. sE-selectin and neopterin concentrations and leukocyte counts were higher in the fetal circulation than in the maternal circulation during both GA and SA.
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Affiliation(s)
- Mehtap Honca
- Department of Anesthesiology and Reanimation, Kecioren Training and Research Hospital, Ankara, Turkey
| | - Tarık Purtuloglu
- Department of Anesthesiology and Reanimation, Gulhane Military Medical Academy, Ankara, Turkey
| | - Emin Ozgur Akgul
- Department of Medical Biochemistry, Gulhane Military Medical Academy, Ankara, Turkey
| | - Muzaffer Oztosun
- Department of Biochemistry, Turkish Armed Forces, Health Services Command, Etimesgut, Ankara, Turkey
| | - Tevfik Honca
- Department of Medical Biochemistry, Gulhane Military Medical Academy, Ankara, Turkey
| | - Ali Sizlan
- Department of Anesthesiology and Reanimation, Gulhane Military Medical Academy, Ankara, Turkey
| | - Mehmet Agilli
- Department of Medical Biochemistry, Gulhane Military Medical Academy, Ankara, Turkey
| | - Ibrahim Aydin
- Department of Medical Biochemistry, Gulhane Military Medical Academy, Ankara, Turkey
| | - Memduh Yetim
- Department of Anesthesiology and Reanimation, Gulhane Military Medical Academy, Ankara, Turkey
| | - Fevzi Nuri Aydin
- Department of Medical Biochemistry, Gulhane Military Medical Academy, Ankara, Turkey
| | - Halil Yaman
- Department of Medical Biochemistry, Gulhane Military Medical Academy, Ankara, Turkey
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22
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Sultan SS. Paravertebral block can attenuate cytokine response when it replaces general anesthesia for cancer breast surgeries. Saudi J Anaesth 2013; 7:373-7. [PMID: 24348286 PMCID: PMC3858685 DOI: 10.4103/1658-354x.121043] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Context: Cytokine release is a well-known response to surgery especially when it is linked to cancer. Paravertebral block (PVB) is the suitable regional anesthesia for breast surgery. Aim: We tested the effect of replacing general anesthesia (GA) with PVB on cytokine response during and after surgeries for cancer breast. Settings and Design: Controlled randomized study. Methods: Forty cancer breast patients were divided in two groups; Group I received PVB and Group II received GA during performance of unilateral breast surgery without axillary clearance. Plasma concentrations of interleukin (IL)-6, IL-10, IL-12 and interferon-γ (IFN-γ) were measured and IL-10/IFN-γ were estimated in the following points; before starting PVB in Group I or induction of GA in Group II (Sample A), before skin incision (Sample B), at the end of procedure before shifting out of operating room (Sample C), 4-h post-operatively (Sample D) and 24-h post-operatively (Sample E). Statistical Analysis: unpaired Student t-test. Results: IL-6 increased progressively in both groups with statistically significant lower levels in samples C and D in Group I. IL-10 levels showed progressive increasing in both groups without differences between groups. IL-12 showed progressive decrease in both groups with statistically significant higher levels in samples C and D in Group I. IFN-levels showed significantly higher levels in samples C and D in Group I. IL-10/IFN-γ ratio was significantly lower in Group II in samples C and D. Conclusion: Replacing GA with PVB can attenuate cytokines response to cancer breast surgeries.
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Affiliation(s)
- Sherif S Sultan
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Effect of chronic morphine administration on circulating T cell population dynamics in rhesus macaques. J Neuroimmunol 2013; 265:43-50. [PMID: 24090653 DOI: 10.1016/j.jneuroim.2013.09.013] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Revised: 09/12/2013] [Accepted: 09/14/2013] [Indexed: 01/10/2023]
Abstract
Opioid receptor agonists modulate both innate and adaptive immune responses. In this study, we examined the impact of long-term chronic morphine administration on the circulating T cell population dynamics in rhesus macaques. We found that the numbers of circulating Treg cells, and the functional activity of Th17 cells, were significantly increased with chronic morphine exposure. Our results also show that T cell populations with surface markers characteristic of gut-homing (CD161 and CCR6) and HIV-1 susceptibility (CCR5 and β7 integrin) were increased. These results represent the first detailed report of the impact of chronic morphine administration on circulating T cell dynamics.
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Effects of continuous epidural anesthesia and postoperative epidural analgesia on pain management and stress response in patients undergoing major spinal surgery. Spine (Phila Pa 1976) 2013; 38:1324-30. [PMID: 23514874 DOI: 10.1097/brs.0b013e318290ff26] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective, randomized study was used to compare 2 anesthesia/analgesia methods for reconstructive spine surgery. OBJECTIVE To assess the efficacy and influence of 2 anesthetic methods on clinical outcome and stress response during reconstructive spine surgery. SUMMARY OF BACKGROUND DATA Pain control is an important goal of the postoperative care after spinal surgery. Some prior studies have suggested that epidural anesthesia with or without postoperative epidural analgesia may blunt the surgical stress response after major surgery. This treatment approach has not been fully investigated for patients undergoing major spinal surgery. We hypothesized that the stress response after major spine surgery would be attenuated by continuous epidural anesthesia/analgesia with ropivacaine, fentanyl, and epinephrine. METHODS Eighty-five patients were randomly allocated to 2 groups as follows: group E (n = 45) had epidural anesthesia and endotracheal anesthesia with sevoflurane during surgery and continuous epidural analgesia with ropivacaine, fentanyl, and epinephrine after surgery; group G (n = 40) had general anesthesia with sevoflurane and fentanyl and systemically administered opioids after surgery. Patient pain, nausea, mobility, and satisfaction were measured after surgery along with levels of cortisol, glucose, interleukin (IL)-1β, IL-6, and IL-10 during and after surgery. RESULTS In group E, there were significantly less pain, less nausea, earlier mobility, and higher satisfaction than those in group G. Group E also experienced significantly less introperative and postoperative blood loss. Group E demonstrated lower levels of glucose, cortisol, IL-1β, IL-6, and IL-10 during the postoperative period. CONCLUSION Combined epidural/general anesthesia and postoperative epidural analgesia produced better pain control, less bleeding, and a lower surgical stress response than general anesthesia with postoperative systemically administered narcotic analgesia. This technique deserves further study in the setting of major spinal surgery.
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Effects of surgery, general anesthesia, and perioperative epidural analgesia on the immune function of patients with non-small cell lung cancer. J Clin Anesth 2013; 25:255-62. [PMID: 23659826 DOI: 10.1016/j.jclinane.2012.12.007] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2012] [Revised: 12/04/2012] [Accepted: 12/07/2012] [Indexed: 02/03/2023]
Abstract
STUDY OBJECTIVE To assess preoperative and postoperative immune function in patients undergoing surgical resection of non-small cell lung cancer during general anesthesia and postoperative epidural analgesia. DESIGN Observational single-center study. SETTING University-affiliated academic center. PATIENTS 24 adult, ASA physical status 3 and 4 patients with stage 1, 2, or 3 non-small cell lung cancer. No study patient received preoperative chemotherapy or radiation. INTERVENTIONS Patients underwent thoracotomy with general anesthesia and postoperative epidural analgesia. MEASUREMENTS Bispectral index monitoring, sevoflurane requirements, and intraoperative transfusions were recorded. Total fentanyl consumption and pain (verbal numeric rating scale) were recorded 24 hours after surgery. Preoperative and 24-hour postoperative natural killer cell percentage and function and percentages of natural killer T cells, T helper cells (CD4+), and cytotoxic T lymphocytes (CD8+) were measured. Plasma concentrations of the TH1 cytokine interleukin-2 and interferon-gamma and the TH2 cytokines interleukin-4 were measured at the same time points. RESULTS The percentage (preoperative, 13.07 ± 9.81% vs postoperative, 9.6 ± 6.57%, P < 0.001) and function (preoperative, 31.61 ± 21.96%; postoperative, 13.61 ± 9.36%; P < 0.001) of natural killer cells was significantly decreased after surgery, but the percentage of natural killer T cells, T helper cells (CD4+), and cytotoxic T lymphocytes (CD8+) remained unchanged postoperatively; thus, the CD4/CD8 ratio remained unchanged. Postoperative plasma concentrations of the three cytokines were similar to preoperative levels; therefore, the TH1/TH2 ratio also remained unchanged. CONCLUSIONS Innate immunity is depressed in patients with non-small cell lung cancer after surgical resection, and immunity is not preserved by the use of postoperative epidural analgesia.
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Narahara H, Kadoi Y, Hinohara H, Kunimoto F, Saito S. Comparative effects of flurbiprofen and fentanyl on natural killer cell cytotoxicity, lymphocyte subsets and cytokine concentrations in post-surgical intensive care unit patients: prospective, randomized study. J Anesth 2013; 27:676-83. [PMID: 23543346 DOI: 10.1007/s00540-013-1597-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2012] [Accepted: 03/07/2013] [Indexed: 02/04/2023]
Abstract
PURPOSE The purpose of this study was to compare the effect of the long-term administration of flurbiprofen and fentanyl in the intensive care unit on natural killer cell cytotoxicity (NKCC), lymphocyte subsets and cytokine levels. METHODS In this prospective study, patients scheduled for at least 48 h sedation after neck surgery were randomly assigned to two groups called group N and group F. Group N patients were sedated with propofol and flurbiprofen after surgery (n = 12), while group F patients were sedated with propofol and fentanyl (n = 13). The NKCC, lymphocyte subsets, and plasma levels of tumor necrosis factor (TNF)-α, interleukin (IL)-1β, IL-6, and IL-10 were measured before and at the end of surgery, on postoperative day (POD) 1 and POD2. RESULTS The NKCC was significantly higher on POD1 in group N than in group F (14.5 ± 11.2 versus 6.3 ± 4.1%, p < 0.05), the difference between the groups disappearing on POD2. Lymphocyte subsets and plasma levels of cytokines were not significantly different between the two groups during the study period. CONCLUSIONS Transient suppressive effects on NKCC were observed in the fentanyl group as compared to the flurbiprofen group. This suggests that when choosing postoperative analgesics, physicians should bear in mind the potential immunosuppressive effects of these agents in patients requiring prolonged sedation in the intensive care unit.
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Affiliation(s)
- Hajime Narahara
- Intensive Care Unit, Gunma University Hospital, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan,
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Li G, Li S, An L, Wang B. Electroacupuncture alleviates intraoperative immunosuppression in patients undergoing supratentorial craniotomy. Acupunct Med 2013; 31:51-6. [PMID: 23315447 DOI: 10.1136/acupmed-2012-010254] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Clinical experience suggests that anaesthesia using a combination of acupuncture and drugs can reduce the dosage of anaesthetics required for craniotomy, decreasing both the disturbance in physiological functions during the operation and postoperative complications and improving the rate of recovery. The aim of the present study was to investigate the impact of electroacupuncture (EA) on the dynamic equilibrium of the immune system and immune cell populations during the pericraniotomy period. METHODS A total of 56 patients undergoing craniotomy were randomised into three groups: control (C, n=18), EA (A, n=19) and sham acupuncture (S, n=19) groups. Blood samples were collected before anaesthesia (T0) and 30 min, 2 h and 4 h after induction of anaesthesia (T1, T2 and T3, respectively,) to measure the levels of tumour necrosis factor α (TNFα), interleukin (IL)-8, IL-10, IgM, IgA, IgG and full blood count. RESULTS There was no significant difference between the measurements in groups A and S during craniotomy. The levels of IgM and IgA decreased significantly in group C compared with groups A and S at T2 and T3 time points. The levels of total T cells and suppressor T cells in group C decreased significantly compared with groups A and S at T1 and T2, and the level of natural killer cells in group C decreased significantly compared with groups A and S at T1. No significant differences between groups were found in the levels of TNFα, IgG, IL-10, IL-8, leucocytes, neutrophils, monocytes, Th cells or B cells. CONCLUSIONS EA appears to reduce immunosuppression of both the humoral and cellular components during surgery.
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Affiliation(s)
- Guoyan Li
- Department of Anesthesiology, Beijing Tiantan hospital, Capital Medical University, Beijing, China
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Viviano E, Renius M, Rückert JC, Bloch A, Meisel C, Harbeck-Seu A, Boemke W, Hensel M, Wernecke KD, Spies C. Selective Neurogenic Blockade and Perioperative Immune Reactivity in Patients Undergoing Lung Resection. J Int Med Res 2012; 40:141-56. [DOI: 10.1177/147323001204000115] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE: This double-blind, prospective, randomized, controlled trial examined the effects of thoracic epidural block and intravenous clonidine and opioid treatment on the postoperative Th1/Th2 cytokine ratio after lung surgery. The primary endpoint was the interferon γ (IFN-γ; Th1 cytokine)/interleukin 4 (IL-4; Th2 cytokine) ratio. Secondary endpoints were reductions in pain and incidence of pneumonia. METHODS: Sixty patients were randomized into three groups to receive remifentanil intravenously (remifentanil group, n = 20), remifentanil and clonidine intravenously (clonidine group, n = 20), or ropivacaine epidurally (ropivacaine group, n = 20). Pain was assessed using a numerical rating scale (NRS). Cytokines were measured using a cytometric bead array. RESULTS: Patients in the ropivacaine group (thoracic epidural block) had a significantly lower IFN-γ/IL-4 ratio at the end of surgery than those in the remifentanil group and clonidine group. There were no significant between-group differences in the IFN-γ/IL-4 ratio at other time-points. There were no differences in NRS scores at any time-point. No patient developed pneumonia. CONCLUSION: Intraoperative thoracic epidural block decreased the IFN-γ/IL-4 ratio immediately after lung surgery, indicating less inflammatory stimulation during surgery.
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Affiliation(s)
- E Viviano
- Department of Anaesthesiology and Intensive Care Medicine Unit
| | - M Renius
- Department of Anaesthesiology and Intensive Care Medicine Unit
| | - J-C Rückert
- Department of General, Visceral, Vascular and Thoracic Surgery
| | - A Bloch
- Department of Anaesthesiology and Intensive Care Medicine Unit
| | - C Meisel
- Institute of Immunology, Campus Virchow-Klinikum and Campus Charité Mitte, Charité—University Hospital Berlin, Berlin, Germany
| | - A Harbeck-Seu
- Department of Anaesthesiology and Intensive Care Medicine Unit
| | - W Boemke
- Department of Anaesthesiology and Intensive Care Medicine Unit
| | - M Hensel
- Department of Anaesthesiology and Intensive Care Medicine Unit
| | - K-D Wernecke
- Department of Medical Biometry, SOSTANA GmbH (CRO), Berlin, Germany
| | - C Spies
- Department of Anaesthesiology and Intensive Care Medicine Unit
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Conrick-Martin I, Kell MR, Buggy DJ. Meta-analysis of the effect of central neuraxial regional anesthesia compared with general anesthesia on postoperative natural killer T lymphocyte function. J Clin Anesth 2012; 24:3-7. [DOI: 10.1016/j.jclinane.2011.09.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2010] [Revised: 08/03/2011] [Accepted: 09/06/2011] [Indexed: 12/17/2022]
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Cata JP, Gottumukkala V, Sessler DI. How regional analgesia might reduce postoperative cancer recurrence. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.eujps.2011.08.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Abstract
Invasive surgery induces a combination of local response to tissue injury and generalized activation of systemic metabolic and hormonal pathways via afferent nerve pathways and the central nervous system. The local inflammatory responses and the parallel neurohumoral responses are not isolated but linked through complex signaling networks, some of which remain poorly understood. The magnitude of the response is broadly related to the site of injury (greater in regions with visceral pain afferents such as abdomen and thorax) and the extent of the trauma. The changes include alterations in metabolic, hormonal, inflammatory, and immune systems that can be collectively termed the stress response. Integral to the stress responses are the effects of nociceptive afferent stimuli on systemic and pulmonary vascular resistance, heart rate, and blood pressure, which are a combination of efferent autonomic response and catecholamine release via the adrenal medulla. Therefore, pain responses, cardiovascular responses, and stress responses need to be considered as different aspects of a combined bodily reaction to surgery and trauma. It is important at the outset to understand that not all components of the stress response are suppressed together and that this is important when discussing different analgesic modalities (i.e. opioids vs regional anesthesia). For example, in terms of the use of fentanyl in the infant, the dose required to provide analgesia (1-5 mcg·kg(-1)) is less than that required for hemodynamic stability in response to stimuli (5-10 mcg·kg(-1)) (1) and that this in turn is less than that required to suppress most aspects of the stress response (25-50 mcg·kg(-1)) (2). In contrast to this considerable dose dependency, central local anesthetic blocks allow blockade of the afferent and efferent sympathetic pathways at relatively low doses resulting in profound suppression of hemodynamic and stress responses to surgery.
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Affiliation(s)
- Andrew R Wolf
- Paediatric Anaesthesia and Intensive Care Unit, Bristol Royal Hospital for Children, Bristol, UK.
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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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Liu S, Wang B, Li S, Zhou Y, An L, Wang Y, Lv H, Zhang G, Fang F, Liu Z, Han R, Jiang T, Kang X. Immune cell populations decrease during craniotomy under general anesthesia. Anesth Analg 2011; 113:572-7. [PMID: 21813628 DOI: 10.1213/ane.0b013e3182278237] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Postoperative infections are common and potentially fatal complications in neurosurgical intensive care medicine. An impairment of immune function after central nervous system surgery is associated with higher risk of infection and postoperative complications. The aim of our study was to investigate how the immune cell population changes during the anesthesia process in patients undergoing craniotomy surgery. METHODS Patients undergoing craniotomy who had an inhaled general anesthetic were studied. Blood samples were collected before anesthesia and 30, 45, 60, 120, and 240 minutes after anesthesia began. Blood counts for neutrophils, monocytes, and lymphocytes were determined along with lymphocyte subpopulations (T cells, inducer and helper T cells, suppressor and cytotoxic T cells, natural killer cells, and B cells). Plasma concentrations of interleukin (IL)-2, IL-4, IL-6, and IL-10 were also measured along with tumor necrosis factor-α and interferon-γ. Data were analyzed by SPSS 13.0 software using repeated-measures analysis of variance followed by a Bonferroni correction. RESULTS Eighteen patients were enrolled in this study. In the comparison of the immune cell counts during neuroanesthesia, we found that at 30 minutes after anesthesia induction, neutrophils, monocytes, and lymphocytes decreased 18% (95% confidence interval [CI]: 11.0%-24.6%), 34% (95% CI: 16.2%-51.1%), and 39% (95% CI: 29.0%-48.9%) compared with their levels before anesthesia. At extubation the neutrophils returned to the base level. It also showed that natural killer cells decreased significantly during anesthesia. The concentration of cytokines in peripheral blood did not change significantly. CONCLUSION Our results showed that anesthesia and surgery upset the balance of the immune system during craniotomy, and a significant decrease in immune cell populations emerged after induction under general anesthesia.
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Affiliation(s)
- Shujing Liu
- Capital Medical University, Laboratory Diagnosis Center, Beijing Tiantan Hospital, No.6 Tiantan Xili, Chongwen Men District, Beijing, 100050, China
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Brack A, Rittner HL, Stein C. Immunosuppressive effects of opioids--clinical relevance. J Neuroimmune Pharmacol 2011; 6:490-502. [PMID: 21728033 DOI: 10.1007/s11481-011-9290-7] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Accepted: 06/26/2011] [Indexed: 02/06/2023]
Abstract
Opioid-induced immunosuppression has been demonstrated in cell culture experiments and in animal models. This is in striking contrast to the paucity of confirmatory studies in humans. This review describes the basic pharmacokinetics and -dynamics of opioid use in patients. It summarizes the major findings on opioid use and infectious complications in intensive care unit (ICU) patients, in patients with acute or chronic non-malignant pain, and in intravenous drug users (IDU). The limitations of studies in each area are discussed. For example, ethical concerns may complicate randomized placebo-controlled trials (RCT) in acute postoperative pain and for a large part of ICU patients. Importantly, most studies in patients with chronic (non-malignant) pain only inadequately report infectious complications in relation to opioid use since their incidence is usually not considered to be drug related. Infectious complications in IDUs are very frequent but cannot easily be distinguished from risk behavior or risk environment. In summary, convincing clinical evidence is lacking that opioids per se increase the rate of infectious complications in most patient categories. From a clinical standpoint, important unresolved issues are i) selection of relevant animal models, ii) opioid selection and discontinuation, and iii) the role of coexisting diseases and concomitant other medications.
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Affiliation(s)
- Alexander Brack
- Klinik und Poliklinik für Anästhesiologie, Zentrum Operative Medizin, Universitätsklinikum Würzburg, Oberdürrbacher Straße 6, 97080 Würzburg, Germany.
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Gupta A, Björnsson A, Fredriksson M, Hallböök O, Eintrei C. Reduction in mortality after epidural anaesthesia and analgesia in patients undergoing rectal but not colonic cancer surgery: a retrospective analysis of data from 655 patients in central Sweden. Br J Anaesth 2011; 107:164-70. [PMID: 21586443 DOI: 10.1093/bja/aer100] [Citation(s) in RCA: 125] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND There is some evidence that epidural analgesia (EDA) reduces tumour recurrence after breast and prostatic cancer surgery. We assessed whether EDA reduces long-term mortality after colorectal cancer surgery. METHODS All patients having colorectal cancer surgery between January 2004 and January 2008 at Linköping and Örebro were included. Exclusion criteria were: emergency operations, laparoscopic-assisted colorectal resection, and stage 4 cancer. Statistical information was obtained from the Swedish National Register for Deaths. Patients were analysed in two groups: EDA group or patient-controlled analgesia (PCA group) as the primary method of analgesia. RESULTS A total of 655 patients could be included. All-cause mortality for colorectal cancer (stages 1-3) was 22.7% (colon: 20%, rectal: 26%) after 1-5 yr of surgery. Multivariate regression analysis identified the following statistically significant factors for death after colon cancer (P<0.05): age (>72 yr) and cancer stage 3 (compared with stage 1). A similar model for rectal cancer found that age (>72 yr) and the use of PCA rather than EDA and cancer stages 2 and 3 (compared with stage 1) were associated with a higher risk for death. No significant risk of death was found for colon cancer when comparing EDA with PCA (P=0.23), but a significantly increased risk of death was seen after rectal cancer when PCA was used compared with EDA (P=0.049) [hazards ratio: 0.52 (0.27-1.00)]. CONCLUSIONS We found a reduction in all-cause mortality after rectal but not colon cancer in patients having EDA compared with PCA technique.
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Affiliation(s)
- A Gupta
- Department of Anaesthesiology and Intensive Care, University Hospital, Orebro, Sweden.
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Golubovic S, Golubovic V, Sotosek-Tokmadzic V, Sustic A, Petkovic M, Bacic D, Mrakovcic-Sutic I. The proposed mechanism of action during different pain management techniques on expression of cytolytic molecule perforin in patients after colorectal cancer surgery. Med Hypotheses 2011; 76:450-2. [PMID: 21195559 DOI: 10.1016/j.mehy.2010.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2010] [Accepted: 11/13/2010] [Indexed: 10/18/2022]
Abstract
The postoperative period is accompanied with neuroendocrine, metabolic and immune alteration which is caused by tissue damage, anesthesia, postoperative pain and psychological stress. Postoperative pain contributes to dysfunction of immune response as a result of interaction between central nervous and immune system. The postoperatively activated hypotalamo-pituitary-adrenocortical axis, sympathic and parasympathic nerve systems are important modulators of immune response. According to bidirectional communication of immune and nervous system, appropriate postoperative pain management could affect immune response in postoperative period. Although the postoperative suppression of immune response has been reported, a very little are known about the influences of different pain management techniques on cytotoxic function of immune cells in patients with colorectal cancer in early postoperative period. Perforin is a cytotoxic molecule expressed by activated lymphocytes which has a crucial role in elimination of tumor cells and virus-infected cells, mostly during the effector's phase of immune response. Immune compromise during the postoperative period could affect the healing processes, incidence of postoperative infections and rate and size of tumor metastases disseminated during operation. The pharmacological management of postoperative pain in patients with malignancies uses very different analgesic techniques whose possible influence on cytotoxic functions of immune cells are still understood poor. For decades the most common way of treating postoperative pain after colorectal cancer surgery was intravenous analgesia with opiods. In the last decade many investigations pointed out that opiods can also contribute to postoperative suppression of immune response. Epidural analgesia is a regional anesthesia technique that acts directly on the origin of pain impulses and pain relief can be achieved with small doses of opiods combined with local anesthetics. Local anesthetics potentate analgesic properties of opiods but per se are also acting as antiinflammatory drugs. Afferent neural blockade by epidural analgesia attenuates neuroendocrine stress response. We propose that epidural analgesia could be more convenient that intravenous analgesia in maintenance of immunological homeostasis that is altered by surgical stress, tumor growth and pain.
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Affiliation(s)
- S Golubovic
- Department of Anesthesiology, Reanimatology and Intensive Care, Medical Faculty, University of Rijeka, Brace Branchetta 20, Rijeka, Croatia
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Papadima A, Boutsikou M, Lagoudianakis EE, Kataki A, Konstadoulakis M, Georgiou L, Katergiannakis V, Manouras A. Lymphocyte apoptosis after major abdominal surgery is not influenced by anesthetic technique: a comparative study of general anesthesia versus combined general and epidural analgesia. J Clin Anesth 2009; 21:414-21. [DOI: 10.1016/j.jclinane.2008.10.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2007] [Revised: 10/26/2008] [Accepted: 10/30/2008] [Indexed: 10/20/2022]
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Volk T, Doering K, Granitza L, Perka C, Spies CD, Heymann CV. Washing of drained blood does not alter immediate immune effects of retransfusion. Transfusion 2008; 48:2612-7. [DOI: 10.1111/j.1537-2995.2008.01885.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ahlers O, Nachtigall I, Lenze J, Goldmann A, Schulte E, Höhne C, Fritz G, Keh D. Intraoperative thoracic epidural anaesthesia attenuates stress-induced immunosuppression in patients undergoing major abdominal surgery †. Br J Anaesth 2008; 101:781-7. [DOI: 10.1093/bja/aen287] [Citation(s) in RCA: 163] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Christopherson R, James KE, Tableman M, Marshall P, Johnson FE. Long-term survival after colon cancer surgery: a variation associated with choice of anesthesia. Anesth Analg 2008; 107:325-32. [PMID: 18635504 DOI: 10.1213/ane.0b013e3181770f55] [Citation(s) in RCA: 190] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND A previously published clinical trial of epidural-supplemented versus general anesthesia, Veterans Affairs Cooperative Study No. 345, showed no difference in 30-day mortality and morbidity rates between the two treatments. We hypothesized that long-term postoperative survival would be increased by epidural anesthesia/analgesia supplementation during colon cancer resection. METHODS We studied long-term survival after resection of colon cancer in a trial of general anesthesia with and without epidural anesthesia and analgesia supplementation for resection of colon cancer in Veterans Affairs Cooperative Study No. 345. Cox and log-normal survival models were used to test the effects of pathological stage, type of anesthesia and other covariates on survival in 177 patients. RESULTS The presence of distant metastases had the greatest effect on survival. Thus, analyses were performed separately for patients with and without metastases. For those without metastasis, the hazard ratio for the treatment effects changed at 1.46 years. Before 1.46 years, epidural supplementation was associated with improved survival (P = 0.012), while later, the type of anesthesia did not appear to affect survival (P = 0.27). Hypertension was associated with poorer survival (P = 0.029), as was alcoholism in patients who received epidural anesthesia (P = 0.014). Survival of patients with metastases was unaffected by type of anesthesia. There was a significant age by hypertension interaction (P = 0.002). Patients survived longer if they were hypertensive, but had reduced survival if they were older than 66 years and hypertensive. CONCLUSION Epidural supplementation was associated with enhanced survival among patients without metastases before 1.46 years. Epidural anesthesia had no effect on survival of patients with metastases. Additional studies to confirm or refute these findings are warranted.
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Affiliation(s)
- Rose Christopherson
- Anesthesiology Service, VA Medical Center and Department of Anesthesiology, OR Health and Science University, Portland, OR 97229, USA.
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Kurosawa S, Kato M. Anesthetics, immune cells, and immune responses. J Anesth 2008; 22:263-77. [PMID: 18685933 DOI: 10.1007/s00540-008-0626-2] [Citation(s) in RCA: 222] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2008] [Accepted: 03/13/2008] [Indexed: 12/13/2022]
Abstract
General anesthesia accompanied by surgical stress is considered to suppress immunity, presumably by directly affecting the immune system or activating the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system. Along with stress such as surgery, blood transfusion, hypothermia, hyperglycemia, and postoperative pain, anesthetics per se are associated with suppressed immunity during perioperative periods because every anesthetic has direct suppressive effects on cellular and neurohumoral immunity through influencing the functions of immunocompetent cells and inflammatory mediator gene expression and secretion. Particularly in cancer patients, immunosuppression attributable to anesthetics, such as the dysfunction of natural killer cells and lymphocytes, may accelerate the growth and metastases of residual malignant cells, thereby worsening prognoses. Alternatively, the anti-inflammatory effects of anesthetics may be beneficial in distinct situations involving ischemia and reperfusion injury or the systemic inflammatory response syndrome (SIRS). Clinical anesthesiologists should select anesthetics and choose anesthetic methods with careful consideration of the clinical situation and the immune status of critically ill patients, in regard to long-term mortality, morbidity, and the optimal prognosis.
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Affiliation(s)
- Shin Kurosawa
- Department of Anesthesiology and Intensive Care Medicine, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
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The evolution of pain management in the critically ill trauma patient: Emerging concepts from the global war on terrorism. Crit Care Med 2008; 36:S346-57. [DOI: 10.1097/ccm.0b013e31817e2fc9] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Intravenous flurbiprofen axetil accelerates restoration of bowel function after colorectal surgery. Can J Anaesth 2008; 55:414-22. [DOI: 10.1007/bf03016307] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Heijmans J, Fransen E, Buurman W, Maessen J, Roekaerts P. Comparison of the Modulatory Effects of Four Different Fast-Track Anesthetic Techniques on the Inflammatory Response to Cardiac Surgery With Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2007; 21:512-8. [PMID: 17678776 DOI: 10.1053/j.jvca.2007.02.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2006] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To test the hypothesis that the choice of anesthesia technique for coronary artery surgery influences the degree and magnitude of the subsequent inflammatory response and its consequences. DESIGN Prospective, randomized, comparative study. SETTING Major university teaching hospital. PARTICIPANTS Sixty patients undergoing elective surgery. INTERVENTIONS Patients were randomized into an alfentanil group, a high-dose remifentanil group, a low-dose remifentanil group, or a thoracic epidural group, in combination with a propofol target-controlled infusion. The study was blinded for the opioid, except in the epidural group. Tight control of perioperative hemodynamic parameters was maintained, and the postoperative management was strictly standardized. Bactericidal permeability-increasing protein as an indicator of the polymorphonuclear neutrophil response, interleukin-6 as an inducer of the acute-phase response, and lipopolysaccharide-binding protein and C-reactive protein as parameters of the acute phase response were determined at regular intervals. Ventilator dependency and analgesia were evaluated as clinical outcome measures. MEASUREMENTS AND MAIN RESULTS Interleukin-6 levels increased in all groups. Plasma levels in the epidural group were significantly higher at all time points than in the other groups. The increase in the plasma levels of bactericidal permeability-increasing protein, lipopolysaccharide-binding protein, and C-reactive protein showed the same pattern in all groups, and no significant differences among the 4 groups were observed. CONCLUSIONS Supplementation of a fast-track anesthetic technique with epidural analgesia preserves hemodynamic stability and is associated with faster extubation times (p = 0.003) and less postoperative pain (p = 0.045). Thoracic epidural analgesia was associated with significantly higher levels of IL-6 throughout the study period as compared with the total intravenous anesthesia groups. The exact clinical relevance of this finding remains unclear.
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Affiliation(s)
- John Heijmans
- Department of Anesthesiology, University Hospital Maastricht, Maastricht, the Netherlands
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Chen X, Geller EB, Rogers TJ, Adler MW. Rapid heterologous desensitization of antinociceptive activity between mu or delta opioid receptors and chemokine receptors in rats. Drug Alcohol Depend 2007; 88:36-41. [PMID: 17049756 PMCID: PMC1880888 DOI: 10.1016/j.drugalcdep.2006.09.010] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2006] [Revised: 09/06/2006] [Accepted: 09/15/2006] [Indexed: 11/19/2022]
Abstract
Previous studies have shown pretreatment with chemokines CCL5/RANTES (100 ng) or CXCL12/SDF-1alpha (100 ng) injected into the periaqueductal grey (PAG) region of the brain, 30 min before the mu opioid agonist DAMGO (400 ng), blocked the antinociception induced by DAMGO in the in vivo cold water tail-flick (CWT) antinociceptive test in rats. In the present experiments, we tested whether the action of other agonists at mu and delta opioid receptors is blocked when CCL5/RANTES or CXCL12/SDF-1alpha is administered into the PAG 30 min before, or co-administered with, opioid agonists in the CWT assay. The results showed that: (1) CXCL12/SDF-1alpha (100 ng, PAG) or CCL5/RANTES (100 ng, PAG), given 30 min before the opioid agonist morphine, or selective delta opioid receptor agonist DPDPE, blocked the antinociceptive effect of these drugs; (2) CXCL12/SDF-1alpha (100 ng, PAG) or CCL5/RANTES (100 ng, PAG), injected at the same time as DAMGO or DPDPE, significantly reduced the antinociceptive effect induced by these drugs. These results demonstrate that the heterologous desensitization is rapid between the mu or delta opioid receptors and either CCL5/RANTES receptor CCR5 or CXCL12/SDF-1alpha receptor CXCR4 in vivo, but the effect is greater if the chemokine is administered before the opioid.
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Affiliation(s)
- Xiaohong Chen
- Center for Substance Abuse Research, Temple University School of Medicine, 3400 N. Broad Street, Philadelphia, PA 19140, USA.
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Abstract
PURPOSE OF REVIEW To review the current anaesthetic management of patients undergoing transthoracic oesophagectomy. RECENT FINDINGS Oesophageal adenocarcinoma is increasing rapidly in the West. The perioperative mortality for oesophagectomy remains high. A relationship has been established between volume and outcome for oesophageal surgery. There is little evidence from randomized clinical studies to guide the management of patients undergoing oesophagectomy. The profile of patients presenting for oesophagectomy is changing. There is emerging evidence that anaesthetic management influences outcome. At present there are no clear advantages for minimal access surgery. SUMMARY Although nonsurgical treatments are being developed, at present surgery remains the mainstay of potentially curative treatment. Accurate risk stratification would greatly facilitate the assessment of strategies to reduce operative mortality. Anaesthetic research has the potential to further improve the safety of patients undergoing oesophageal surgery.
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Guay J. The benefits of adding epidural analgesia to general anesthesia: a metaanalysis. J Anesth 2006; 20:335-40. [PMID: 17072704 DOI: 10.1007/s00540-006-0423-8] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2006] [Accepted: 06/20/2006] [Indexed: 11/29/2022]
Abstract
The purpose of this metaanalysis was to determine the benefits of postoperative epidural analgesia in patients operated on under general anesthesia. By searching the American National Library of Medicine's Pubmed database from 1966 to July 10, 2004, 70 studies were identified. These included 5402 patients, of which 2660 had had epidural analgesia. Epidural analgesia reduces the incidence of arrhythmia, odds ratio (OR) = 0.59 (95%CI = 0.42, 0.81, P = 0.001); time to tracheal extubation, OR = -3.90 h (95%CI = -6.37, -1.42, P = 0.002); intensive care unit stay, OR = -2.94 h (95%CI = -5.66, -0.22, P = 0.03); visual analogical pain (VAS) scores at rest, OR = -0.78 (95%CI = -0.99, -0.57, P < 0.00001) and during movement, OR = -1.28 (95%CI = -1.81, -0.75, P < 0.00001); maximal blood epinephrine, OR = -165.70 pg.ml(-1) (95%CI = -252.18, -79.23, P = 0.0002); norepinephrine, OR = -134.24 pg.ml(-1) (95%CI = -247.92, -20.57, P = 0.02); cortisol, OR = -55.81 nmol.l(-1) (95%CI = -79.28, -32.34, P < 0.00001); and glucose concentrations achieved, OR = -0.87 nmol.l(-1) (95%CI = -1.37, -0.37, P = 0.0006). It also reduces the first 24-h morphine consumption, OR = -13.62 mg (95%CI = -22.70, -4.54, P = 0.003), and improves the forced vital capacity (FVC), OR = 0.23 l (95%CI = 0.09, 0.37, P = 0.001) at 24 h. A thoracic epidural containing a local anesthetic reduces the incidence of renal failure: OR = 0.34 (95%CI = 0.14, 0.81, P = 0.01). Epidural analgesia may thus offer many advantages over other modes of postoperative analgesia.
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Affiliation(s)
- Joanne Guay
- Department of Anesthesia, Maisonneuve-Rosemont Hospital, University of Montreal, 5415 L'Assomption Boulevard, Montreal, Quebec, H1T 2M4, Canada
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