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Sabogal JC, Conde Monroy D, Rey Chaves CE, Ayala D, González J. Delayed gastric emptying after pancreatoduodenectomy: an analysis of risk factors. Updates Surg 2024; 76:1247-1255. [PMID: 38598061 PMCID: PMC11341576 DOI: 10.1007/s13304-024-01795-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 02/25/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is a frequent complication after pancreatoduodenectomy. Preoperative factors are limited and controversial. This study aims to identify associated factors related to this complication in the Colombian population. METHODS A retrospective review of a prospectively collected database was conducted. All patients over 18 years of age who underwent pancreaticoduodenectomy were included. Associations with DGE syndrome were evaluated with logistic regression analysis, Odds ratio, and b-coefficient were provided when appropriate. RESULTS 205 patients were included. Male patients constituted 54.15% (n = 111). 53 patients (25.85%) were diagnosed with DGE syndrome. Smoking habit (OR 17.58 p 0.00 95% CI 7.62-40.51), hydromorphone use > 0.6 mg/daily (OR 11.04 p 0.03 95% CI 1.26-96.66), bilirubin levels > 6 mg/dL (OR 2.51 p 0.02 95% CI 1.12-5.61), and pancreatic fistula type B (OR 2.72 p 0.02 CI 1.74-10.00). DISCUSSION Smoking history, opioid use (hydromorphone > 0.6 mg/Daily), type B pancreatic fistula, and bilirubin levels > 6 mg/dL should be considered as risk factors for DGE.
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Affiliation(s)
- Juan Carlos Sabogal
- Hepatobiliary and Pancreatic Surgery Department, Hospital Universitario Mayor, Méderi, Bogotá, Colombia
- School of Medicine, Universidad del Rosario, Bogotá, Colombia
| | - Danny Conde Monroy
- Hepatobiliary and Pancreatic Surgery Department, Hospital Universitario Mayor, Méderi, Bogotá, Colombia
- School of Medicine, Universidad del Rosario, Bogotá, Colombia
| | - Carlos Eduardo Rey Chaves
- Estudiante de Posgrado Cirugía General, Facultad de Medicina, Pontificia Universidad Javeriana, Carrera 6A #51A-48, 111711, Bogotá D.C, Colombia.
| | - Daniela Ayala
- Hepatobiliary and Pancreatic Surgery Department, Hospital Universitario Mayor, Méderi, Bogotá, Colombia
| | - Juliana González
- Hepatobiliary and Pancreatic Surgery Department, Hospital Universitario Mayor, Méderi, Bogotá, Colombia
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2
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Hartup S, Briggs M. Managing chronic pain after breast cancer treatments: are web-based interventions the future? Curr Opin Support Palliat Care 2024; 18:47-54. [PMID: 38170201 DOI: 10.1097/spc.0000000000000691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
PURPOSE OF THE REVIEW Chronic post-treatment pain in breast cancer affects a high proportion of patients. Symptom burden and financial costs are increasingly impacting patients and healthcare systems because of improved treatments and survival rates. Supporting long-term breast cancer symptoms using novel methodology has been examined, yet few have explored the opportunity to utilise these interventions for prevention. This review aims to explore the need for, range of, and effectiveness of such interventions. RECENT FINDINGS Three papers describe risk factors for chronic pain, with six recent papers describing the use of interventions for acute pain in the surgical setting. The evidence for the effectiveness of these interventions to improve pain management in this setting is limited but tentatively positive. The results have to take into account the variation between systems and limited testing. SUMMARY Multiple types of intervention emerged and appear well accepted by patients. Most assessed short-term impact and did not evaluate for reduction in chronic pain. Such interventions require rigorous effectiveness testing to meet the growing needs of post-treatment pain in breast cancer. A detailed understanding of components of web-based interventions and their individual impact on acute pain and chronic pain is needed within future optimisation trials. Their effectiveness as preventative tools are yet to be decided.
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Affiliation(s)
- Sue Hartup
- St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds
| | - Michelle Briggs
- Pain Research Institute, School of Health Sciences, Faculty of Health and Life Science University of Liverpool
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
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3
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Crettenand F, Assayed-Leonardi N, Rohrer F, Martinez Carrique S, Roth B. Is Continuous Wound Infiltration a Better Option for Postoperative Pain Management after Open Nephrectomy Compared to Thoracic Epidural Analgesia? J Clin Med 2023; 12:2974. [PMID: 37109313 PMCID: PMC10143069 DOI: 10.3390/jcm12082974] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/10/2023] [Accepted: 04/14/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Despite increasingly advanced minimally invasive percutaneous ablation techniques, surgery remains the only evidence-based therapy in curative intent for larger (>3-4 cm) renal tumors. Although minimally invasive surgery using (robotic-assisted) laparoscopic or retroperitoneoscopic approaches has gained popularity, open nephrectomy (ON) is still performed in 25% of cases, especially in tumors with central localization (partial ON) or large tumors with/without cava thrombus (total ON). As postoperative pain is one of the drawbacks of ON, our study aims to assess recovery and post-operative pain management using continuous wound infiltration (CWI) compared to thoracic epidural analgesia (TEA). METHODS Since 2012, all patients undergoing ON at our tertiary cancer center at CHUV have been included in our prospective ERAS® (enhanced recovery after surgery) registry that is centrally stored in ERAS® Interactive Audit System (EIAS) secured server. This study represents an analysis of all patients operated on with partial or total ON at our center between 2012 and 2022. An additional analysis was performed for the estimations of the total cost of CWI and TEA, based on the diagnosis-related group method. RESULTS 92 patients were included and analyzed in this analysis (n = 64 (70%) with CWI; n = 28 (30%) with TEA). Adequate oral pain control was earlier achieved in the CWI group compared to the TEA group (median 3 vs. 4 days; p = 0.001), whereas immediate postoperative pain relief was better in the TEA group (p = 0.002). Consequently, opioid use was higher in the CWI group (p = 0.004). Still, reported nausea was lower in the CWI group (p = 0.002). Median time to bowel recovery was similar in both groups (p = 0.03). A shorter LOS (0.5 days) was observed in patients managed with CWI, although this was not statistically significant (p = 0.06). The use of CWI has reduced total hospital costs by nearly 40%. CONCLUSIONS TEA has better results in terms of postoperative pain management compared to CWI following ON. However, CWI is better tolerated, and causes less nausea and earlier recovery, which leads to a shorter length of stay. Given its simplicity and cost-effectiveness, CWI should be encouraged for ON.
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Affiliation(s)
- François Crettenand
- Department of Urology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Nady Assayed-Leonardi
- Department of Urology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Felix Rohrer
- Department of Anesthesiology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Silvia Martinez Carrique
- Department of Urology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Beat Roth
- Department of Urology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
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4
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Ruby JM, Illescas A, Zhong H, DelPizzo KR, Poeran J, Liu J, Cozowicz C, Memtsoudis SG. Pediatric anesthesia practices during the COVID-19 pandemic: A retrospective cohort study. Health Sci Rep 2023; 6:e979. [PMID: 36519079 PMCID: PMC9742494 DOI: 10.1002/hsr2.979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 11/22/2022] [Accepted: 11/23/2022] [Indexed: 12/14/2022] Open
Abstract
Background and Aims The onset of the coronavirus 2019 (COVID-19) pandemic brought together the American Society of Regional Anesthesia and Pain Medicine (ASRA) and the European Society of Regional Anaesthesia and Pain Therapy (ESRA) to release a joint statement on anesthesia use. Their statement included a recommendation to use regional anesthesia whenever possible to mitigate the risk associated with aerosolizing procedures. We sought to examine the utilization of anesthesia in pediatric patients undergoing a surgical procedure for fractures or ligament repairs before and during COVID-19. Methods Using the Premier Health Database, we retrospectively analyzed pediatric patients undergoing a surgical intervention for fractures or ligament repair before and during COVID-19. We sought to determine if there were differences in anesthesia use among this cohort during the two time periods. Fracture groups included shoulder and clavicle, humerus and elbow, forearm and wrist, hand and finger, pelvis and hip, femur and knee, leg and ankles, and foot and toes. Ligament procedures included surgical intervention for the anterior cruciate ligament and ulnar collateral ligament repair. Results We identified a total of 5935 patients undergoing a surgical procedure for fractures or ligament repairs before and during COVID-19. After exclusion for unknown anesthesia use, 2,807 patients were included in our cohort with 81.5% (n = 2288) of patients undergoing a procedure under general anesthesia, 6.4% (n = 181) under regional anesthesia, and 12.0% (n = 338) under combined general-regional anesthesia. There did not appear to be a significant difference in the type of anesthesia used before and during COVID-19 (p = 0.052). Conclusions Our study did not identify a difference in anesthesia use before and during COVID-19 among pediatric patients undergoing a surgical procedure. Further studies should estimate the change in anesthesia used during the time period when elective procedures were resumed.
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Affiliation(s)
- Jordan M. Ruby
- Department of Anesthesiology, Critical Care & Pain ManagementHospital for Special SurgeryNew YorkNew YorkUSA
- Department of AnesthesiologyWeill Cornell MedicineNew YorkNew YorkUSA
| | - Alex Illescas
- Department of Anesthesiology, Critical Care & Pain ManagementHospital for Special SurgeryNew YorkNew YorkUSA
| | - Haoyan Zhong
- Department of Anesthesiology, Critical Care & Pain ManagementHospital for Special SurgeryNew YorkNew YorkUSA
| | - Kathryn R. DelPizzo
- Department of Anesthesiology, Critical Care & Pain ManagementHospital for Special SurgeryNew YorkNew YorkUSA
- Department of AnesthesiologyWeill Cornell MedicineNew YorkNew YorkUSA
| | - Jashvant Poeran
- Department of Population Health Science & Policy/Orthopedics, Icahn School of Medicine at Mount SinaiInstitute for Healthcare Delivery ScienceNew YorkNew YorkUSA
| | - Jiabin Liu
- Department of Anesthesiology, Critical Care & Pain ManagementHospital for Special SurgeryNew YorkNew YorkUSA
- Department of AnesthesiologyWeill Cornell MedicineNew YorkNew YorkUSA
| | - Crispiana Cozowicz
- Department of Anesthesiology, Perioperative Medicine and Intensive Care MedicineParacelsus Medical UniversitySalzburgAustria
| | - Stavros G. Memtsoudis
- Department of Anesthesiology, Critical Care & Pain ManagementHospital for Special SurgeryNew YorkNew YorkUSA
- Department of AnesthesiologyWeill Cornell MedicineNew YorkNew YorkUSA
- Department of Health Policy and ResearchWeill Cornell Medical CollegeNew YorkNew YorkUSA
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5
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Negrini D, Ihsan M, Freitas K, Pollazzon C, Graaf J, Andre J, Linhares T, Brandao V, Silva G, Fiorelli R, Barone P. The clinical impact of the perioperative epidural anesthesia on surgical outcomes after pancreaticoduodenectomy: A retrospective cohort study. Surg Open Sci 2022; 10:91-96. [PMID: 36062076 PMCID: PMC9436794 DOI: 10.1016/j.sopen.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 06/30/2022] [Accepted: 07/18/2022] [Indexed: 11/05/2022] Open
Abstract
Background Pancreaticoduodenectomy is a highly invasive procedure associated with high morbidity. Several preoperative variables are associated with postoperative complications. The role of perioperative factors is uncertain. The use of perioperative epidural analgesia is potentially associated with fewer postoperative surgical complications. We hypothesize that perioperative epidural analgesia might be associated with fewer surgical complications. Methods We reviewed data from 288 cases performed at our institution between 2012 and 2019, classifying patients into 2 groups: perioperative use of epidural analgesia and non-perioperative use of epidural analgesia. The decision to use epidural as an adjunct to general anesthesia was based on the judgment of the attending anesthesiologist. Uni- and multivariate analyses were then performed to determine factors associated with postoperative surgical complications, ie, postoperative pancreatic fistula, delayed gastric emptying, among others, after adjusting for confounders. Results Baseline and intraoperative factors were similar between the groups, except for sex and postoperative surgical complications. In the univariate analyses, factors associated with fewer postoperative surgical complications were the diameter of the pancreatic duct ≥ 6 mm, hard pancreatic gland parenchyma texture, younger age (< 65 years), and perioperative use of epidural analgesia. In the multivariate analyses, perioperative use of epidural analgesia was significantly associated with fewer postoperative surgical complications (odds ratio = 0.31; 95% confidence interval: 0.13–0.75; P = .009), even after adjusting for significant covariates. Conclusion Perioperative use of epidural analgesia might be associated with fewer postoperative surgical complications after pancreaticoduodenectomy even after adjusting for pancreatic gland parenchyma texture, pancreatic duct size, and age.
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6
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Yeung J, Small C. Impact of regional analgesia in surgery. Br J Surg 2021; 108:1009-1010. [PMID: 34131701 PMCID: PMC10364902 DOI: 10.1093/bjs/znab214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 05/16/2021] [Indexed: 11/14/2022]
Affiliation(s)
- J Yeung
- Warwick Medical School, Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - C Small
- Hereford County Hospital, Wye Valley NHS Trust, Hereford, UK
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7
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Feenstra ML, Ten Hoope W, Hermanides J, Gisbertz SS, Hollmann MW, van Berge Henegouwen MI, Eshuis WJ. Optimal Perioperative Pain Management in Esophageal Surgery: An Evaluation of Paravertebral Analgesia. Ann Surg Oncol 2021; 28:6321-6328. [PMID: 34050429 PMCID: PMC8460583 DOI: 10.1245/s10434-021-10172-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 04/01/2021] [Indexed: 11/18/2022]
Abstract
Background For esophagectomy, thoracic epidural analgesia (TEA) is the standard of care for perioperative pain management. Although effective, TEA is associated with moderate to serious adverse events such as hypotension and neurologic complications. Paravertebral analgesia (PVA) may be a safe alternative. The authors hypothesized that TEA and PVA are similar in efficacy for pain treatment in thoracolaparoscopic Ivor Lewis esophagectomy. Methods This retrospective cohort study compared TEA with PVA in two consecutive series of 25 thoracolaparoscopic Ivor Lewis esophagectomies. In this study, TEA consisted of continuous epidural bupivacaine and sufentanil infusion with a patient-controlled bolus function. In PVA, the catheter was inserted by the surgeon under thoracoscopic vision during surgery. Administration of PVA consisted of continuous paravertebral bupivacaine infusion after a bolus combined with patient-controlled analgesia using intravenous morphine. The primary outcome was the median highest recorded Numeric Pain Rating Scale (NRS) during the 3 days after surgery. The secondary outcomes were vasopressor consumption, fluid administration, and length of hospital stay. Results In both groups, the median highest recorded NRS was 4 or lower during the first three postoperative days. The patients with PVA had a higher overall NRS (mean difference, 0.75; 95% confidence interval 0.49–1.44). No differences were observed in any of the other secondary outcomes. Conclusion For the patients undergoing thoracolaparoscopic Ivor Lewis esophagectomy, TEA was superior to PVA, as measured by NRS during the first three postoperative days. However, both modes provided adequate analgesia, with a median highest recorded NRS of 4 or lower. These results could form the basis for a randomized controlled trial. Supplementary Information The online version contains supplementary material available at 10.1245/s10434-021-10172-1.
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Affiliation(s)
- Minke L Feenstra
- Department of Surgery, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands.,Department of Anesthesiology, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Werner Ten Hoope
- Department of Anesthesiology, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Anesthesiology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Jeroen Hermanides
- Department of Anesthesiology, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - Suzanne S Gisbertz
- Department of Surgery, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Markus W Hollmann
- Department of Anesthesiology, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Wietse J Eshuis
- Department of Surgery, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
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8
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Falk W, Gupta A, Forssten MP, Hjelmqvist H, Bass GA, Matthiessen P, Mohseni S. Epidural analgesia and mortality after colorectal cancer surgery: A retrospective cohort study. Ann Med Surg (Lond) 2021; 66:102414. [PMID: 34113442 PMCID: PMC8170121 DOI: 10.1016/j.amsu.2021.102414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/16/2021] [Accepted: 05/16/2021] [Indexed: 12/01/2022] Open
Abstract
Background Epidural analgesia (EA) has been the standard of care after major abdominal surgery for many years. This study aimed to correlate EA with postoperative complications, short- and long-term mortality in patients with and without EA after open surgery (OS) and minimally invasive surgery (MIS) for colorectal cancer. Methods Patient, clinical and outcome data were obtained from the Swedish Colorectal Cancer Registry and the Swedish Perioperative Registry. All adult patients diagnosed with colorectal cancer without metastases who underwent elective curative MIS or OS for colorectal cancer between January 2016 and December 2018 and who had data recorded in both registries, were included in the study. Data were analyzed for OS and MIS procedures separately. A Poisson regression model was used to investigate the association between EA and the outcomes of interest. Results Five thousand seven hundred sixty-two patients were included in the study, 2712 in the MIS and 3050 patients in the OS group. After adjusting for patient specific and clinically relevant variables in the regression model, no statistically significant difference in risk for complications; 30-day, 90-day, and up to 3-year mortality following either MIS or OS could be detected between the EA+ and EA-cohorts. Conclusions In this large study cohort, EA as part of the comprehensive care provided was not associated with a reduction in postoperative complications risk or improved 30-day, 90-day, or 3-year survival after MIS or OS for colorectal cancer. No reduction in postoperative complications with epidural analgesia. No reduction in short-term mortality with epidural analgesia after colorectal surgery. No reduction in long-term mortality with epidural analgesia in colorectal cancer.
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Affiliation(s)
- Wiebke Falk
- Department of Anesthesiology and Intensive Care, Orebro University Hospital, 701 85, Orebro, Sweden.,School of Medical Sciences, Orebro University, 702 81, Orebro, Sweden
| | - Anil Gupta
- Department of Physiology and Pharmacology, Karolinska Institutet and Karolinska University Hospital, 171 77, Stockholm, Sweden
| | - Maximilian Peter Forssten
- School of Medical Sciences, Orebro University, 702 81, Orebro, Sweden.,Department of Orthopedic Surgery, Orebro University Hospital, 701 85, Orebro, Sweden
| | - Hans Hjelmqvist
- School of Medical Sciences, Orebro University, 702 81, Orebro, Sweden.,Department of Anesthesiology and Intensive Care, Orebro University Hospital, 701 85, Orebro, Sweden
| | - Gary Alan Bass
- School of Medical Sciences, Orebro University, 702 81, Orebro, Sweden.,Division of Traumatology, Surgical Critical Care & Emergency Surgery, Penn Medicine, Penn Presbyterian Medical Center, Philadelphia, USA
| | - Peter Matthiessen
- School of Medical Sciences, Orebro University, 702 81, Orebro, Sweden.,Department of Surgery, Orebro University Hospital, 701 85, Orebro, Sweden
| | - Shahin Mohseni
- School of Medical Sciences, Orebro University, 702 81, Orebro, Sweden.,Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, 701 85, Orebro, Sweden
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9
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Thoracic Epidural Analgesia for Postoperative Pain Management in Liver Transplantation: A 10-year Study on 685 Liver Transplant Recipients. Transplant Direct 2021; 7:e648. [PMID: 33437863 PMCID: PMC7793348 DOI: 10.1097/txd.0000000000001101] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 10/11/2020] [Accepted: 11/01/2020] [Indexed: 12/16/2022] Open
Abstract
Thoracic epidural analgesia (TEA) is not widely used for postoperative pain management in liver transplantation due to hepatic coagulopathy-related increased risk of inducing an epidural hematoma. However, an increasing number of patients are transplanted for other indications than the end-stage liver disease and without coagulopathy allowing insertion of an epidural catheter.
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10
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Epidural analgesia for postoperative pain: Improving outcomes or adding risks? Best Pract Res Clin Anaesthesiol 2020; 35:53-65. [PMID: 33742578 DOI: 10.1016/j.bpa.2020.12.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 12/01/2020] [Indexed: 02/02/2023]
Abstract
Current evidence shows that the benefits of epidural analgesia (EA) are not as impressive as believed in the past, while the risks of adverse effects and serious complications are greater than previously estimated. There are many reasons for the decreasing role of epidural technique in clinical practice (table). Indeed, EA can cause harm and hinder early mobilization in enhanced recovery after surgery (ERAS) programmes. Some ERAS interventions are complex, confusing, sometimes contradictory and apparently unimplementable. In spite of much hype and after almost 25 years, the originator of the concept has described the current status of ERAS as 'far from good'. Outpatient surgery setup has been a remarkable success for many major surgical procedures, and it predates ERAS and appears to be a simpler and better model for reducing postoperative morbidity and hospitalization times. Systematic reviews of comparative studies have shown that less invasive and safer but equally effective alternatives to EA are available for almost all major surgical procedures. These include: paravertebral block, peripheral nerve blocks, catheter wound infusion, periarticular local infiltration analgesia, preperitoneal catheters and transversus abdominis plane block. Increasingly, these non-EA methods are being used as surgeon-delivered regional analgesia (RA) techniques. This encouraging trend of active surgeon participation, with anaesthesiologist collaboration, will undoubtedly improve the decades-old twin problems of underused RA techniques and undertreated postoperative pain. The continued use of EA at any institution can only be justified by results from its own audits; however, regrettably only very few institutions perform such regular audits.
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11
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Wagemans MF, Scholten WK, Hollmann MW, Kuipers AH. Epidural anesthesia is no longer the standard of care in abdominal surgery with ERAS. What are the alternatives? Minerva Anestesiol 2020; 86:1079-1088. [DOI: 10.23736/s0375-9393.20.14324-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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12
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Klotz R, Larmann J, Klose C, Bruckner T, Benner L, Doerr-Harim C, Tenckhoff S, Lock JF, Brede EM, Salvia R, Polati E, Köninger J, Schiff JH, Wittel UA, Hötzel A, Keck T, Nau C, Amati AL, Koch C, Eberl T, Zink M, Tomazic A, Novak-Jankovic V, Hofer S, Diener MK, Weigand MA, Büchler MW, Knebel P. Gastrointestinal Complications After Pancreatoduodenectomy With Epidural vs Patient-Controlled Intravenous Analgesia: A Randomized Clinical Trial. JAMA Surg 2020; 155:e200794. [PMID: 32459322 DOI: 10.1001/jamasurg.2020.0794] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Morbidity is still high in pancreatic surgery, driven mainly by gastrointestinal complications such as pancreatic fistula. Perioperative thoracic epidural analgesia (EDA) and patient-controlled intravenous analgesia (PCIA) are frequently used for pain control after pancreatic surgery. Evidence from a post hoc analysis suggests that PCIA is associated with fewer gastrointestinal complications. Objective To determine whether postoperative PCIA decreases the occurrence of gastrointestinal complications after pancreatic surgery compared with EDA. Design, Setting, and Participants In this adaptive, pragmatic, international, multicenter, superiority randomized clinical trial conducted from June 30, 2015, to October 1, 2017, 371 patients at 9 European pancreatic surgery centers who were scheduled for elective pancreatoduodenectomy were randomized to receive PCIA (n = 185) or EDA (n = 186); 248 patients (124 in each group) were analyzed. Data were analyzed from February 22 to April 25, 2019, using modified intention to treat and per protocol. Interventions Patients in the PCIA group received general anesthesia and postoperative PCIA with intravenous opioids with the help of a patient-controlled analgesia device. In the EDA group, patients received general anesthesia and intraoperative and postoperative EDA. Main Outcomes and Measures The primary end point was a composite of pancreatic fistula, bile leakage, delayed gastric emptying, gastrointestinal bleeding, or postoperative ileus within 30 days after surgery. Secondary end points included 30-day mortality, other complications, postoperative pain levels, intraoperative or postoperative use of vasopressor therapy, and fluid substitution. Results Among the 248 patients analyzed (147 men; mean [SD] age, 64.9 [10.7] years), the primary composite end point did not differ between the PCIA group (61 [49.2%]) and EDA group (57 [46.0%]) (odds ratio, 1.17; 95% CI, 0.71-1.95 P = .54). Neither individual components of the primary end point nor 30-day mortality, postoperative pain levels, or intraoperative and postoperative substitution of fluids differed significantly between groups. Patients receiving EDA gained more weight by postoperative day 4 than patients receiving PCIA (mean [SD], 4.6 [3.8] vs 3.4 [3.6] kg; P = .03) and received more vasopressors (46 [37.1%] vs 31 [25.0%]; P = .04). Failure of EDA occurred in 23 patients (18.5%). Conclusions and Relevance This study found that the choice between PCIA and EDA for pain control after pancreatic surgery should not be based on concerns regarding gastrointestinal complications because the 2 procedures are comparable with regard to effectiveness and safety. However, EDA was associated with several shortcomings. Trial Registration German Clinical Trials Register: DRKS00007784.
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Affiliation(s)
- Rosa Klotz
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany.,The Study Centre of the German Surgical Society, Heidelberg University Hospital, Heidelberg, Germany
| | - Jan Larmann
- Department of Anaesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christina Klose
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Thomas Bruckner
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Laura Benner
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Colette Doerr-Harim
- The Study Centre of the German Surgical Society, Heidelberg University Hospital, Heidelberg, Germany
| | - Solveig Tenckhoff
- The Study Centre of the German Surgical Society, Heidelberg University Hospital, Heidelberg, Germany
| | - Johan F Lock
- Department of General, Visceral, Transplant, Vascular and Paediatric Surgery, University Hospital of Würzburg, Würzburg, Germany
| | - Elmar-Marc Brede
- Department of Anaesthesiology and Critical Care, University Hospital of Würzburg, Würzburg, Germany
| | - Roberto Salvia
- Surgical and Oncological Department, Pancreas Institute, University Hospital Trust, Verona, Italy
| | - Enrico Polati
- Department of Anaesthesiology and Intensive Care, Verona University Hospital, Verona, Italy
| | - Jörg Köninger
- Department of General, Visceral, Thorax and Transplantation Surgery, Klinikum Stuttgart, Katharinenhospital, Stuttgart, Germany
| | - Jan-Henrik Schiff
- Department of Anaesthesiology and Operative Intensive Care, Klinikum Stuttgart, Katharinenhospital, Stuttgart, Germany.,Department of Anesthesiology and Intensive Care, Philipps-University Marburg, Marburg, Germany
| | - Uwe A Wittel
- Department of General and Visceral Surgery, Medical Centre, University of Freiburg, Freiburg, Germany
| | - Alexander Hötzel
- Department of Anaesthesiology and Critical Care, Medical Centre, University of Freiburg, Freiburg, Germany
| | - Tobias Keck
- Department of Surgery, University Medical Centre Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Carla Nau
- Department of Anaesthesiology and Intensive Care, University Medical Centre Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Anca-Laura Amati
- Department of Visceral, Thoracic, Transplant and Paediatric Surgery, Justus Liebig University of Giessen, Giessen, Germany
| | - Christian Koch
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Justus Liebig University of Giessen, Giessen, Germany
| | - Thomas Eberl
- Department of Surgery, General Public Hospital of the Brothers of St John of God, St Veit/Glan, Austria
| | - Michael Zink
- Department of Anaesthesiology and Intensive Care Medicine, General Public Hospital of the Brothers of St John of God, St Veit/Glan, Austria
| | - Ales Tomazic
- Department of Abdominal Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Vesna Novak-Jankovic
- Clinical Department of Anaesthesiology and Intensive Therapy, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Stefan Hofer
- Department of Anaesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus K Diener
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany.,The Study Centre of the German Surgical Society, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus A Weigand
- Department of Anaesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Phillip Knebel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany.,The Study Centre of the German Surgical Society, Heidelberg University Hospital, Heidelberg, Germany
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13
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[Optimization of perioperative care of high-risk patients-a permanent challenge]. Anaesthesist 2020; 68:651-652. [PMID: 31637497 DOI: 10.1007/s00101-019-0627-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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14
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Klotz R, Seide SE, Knebel P, Probst P, Bruckner T, Motsch J, Hyhlik-Dürr A, Böckler D, Larmann J, Diener MK, Weigand MA, Büchler MW, Mihaljevic AL. Continuous wound infiltration versus epidural analgesia for midline abdominal incisions - a randomized-controlled pilot trial (Painless-Pilot trial; DRKS Number: DRKS00008023). PLoS One 2020; 15:e0229898. [PMID: 32142529 PMCID: PMC7059935 DOI: 10.1371/journal.pone.0229898] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 02/14/2020] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVES To test the feasibility of a randomized controlled study design comparing epidural analgesia (EDA) with continuous wound infiltration (CWI) in respect to postoperative complications and mobility to design a future multicentre randomized controlled trial. DESIGN, SETTING, PARTICIPANTS CWI has been developed to address drawbacks of EDA. Previous studies have established the equivalent analgesic potential of CWI compared to EDA. This is a single centre, non-blinded pilot randomized controlled trial at a tertiary surgical centre. Patients undergoing elective non-colorectal surgery via a midline laparotomy were randomized to EDA or CWI. Endpoints included recruitment, feasibility of assessing postoperative mobility with a pedometer and morbidity. No primary endpoint was defined and all analyses were explorative. INTERVENTIONS CWI with local anaesthetics (experimental group) vs. thoracic EDA (control). RESULTS Of 846 patients screened within 14 months, 71 were randomized and 62 (31 per group) included in the intention-to-treat analysis. Mobility was assessed in 44 of 62 patients and revealed no differences within the first 3 postoperative days. Overall morbidity did not differ between the two groups (measured via the comprehensive complication index). Median pain scores at rest were comparable between the two groups, while EDA was superior in pain treatment during movement on the first, but not on the second and third postoperative day. Duration of preoperative induction of anaesthesia was shorter with CWI than with EDA. Of 17 serious adverse events, 3 were potentially related to EDA, while none was related to CWI. CONCLUSION This trial confirmed the feasibility of a randomized trial design to compare CWI and EDA regarding morbidity. Improvements in the education and training of team members are necessary to improve recruitment. TRIAL REGISTRATION DRKS00008023.
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Affiliation(s)
- Rosa Klotz
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Svenja E. Seide
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Phillip Knebel
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Pascal Probst
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Thomas Bruckner
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Johann Motsch
- Department of Anaesthesiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Alexander Hyhlik-Dürr
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Dittmar Böckler
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Jan Larmann
- Department of Anaesthesiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Markus K. Diener
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Markus A. Weigand
- Department of Anaesthesiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Markus W. Büchler
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Andre L. Mihaljevic
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
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15
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Kingma BF, Eshuis WJ, de Groot EM, Feenstra ML, Ruurda JP, Gisbertz SS, Ten Hoope W, Marsman M, Hermanides J, Hollmann MW, Kalkman CJ, Luyer MDP, Nieuwenhuijzen GAP, Scholten HJ, Buise M, van Det MJ, Kouwenhoven EA, van der Meer F, Frederix GWJ, Cheong E, Al Naimi K, van Berge Henegouwen MI, van Hillegersberg R. Paravertebral catheter versus EPidural analgesia in Minimally invasive Esophageal resectioN: a randomized controlled multicenter trial (PEPMEN trial). BMC Cancer 2020; 20:142. [PMID: 32087686 PMCID: PMC7036230 DOI: 10.1186/s12885-020-6585-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 01/29/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Thoracic epidural analgesia is the standard postoperative pain management strategy in esophageal cancer surgery. However, paravertebral block analgesia may achieve comparable pain control while inducing less side effects, which may be beneficial for postoperative recovery. This study primarily aims to compare the postoperative quality of recovery between paravertebral catheter versus thoracic epidural analgesia in patients undergoing minimally invasive esophagectomy. METHODS This study represents a randomized controlled superiority trial. A total of 192 patients will be randomized in 4 Dutch high-volume centers for esophageal cancer surgery. Patients are eligible for inclusion if they are at least 18 years old, able to provide written informed consent and complete questionnaires in Dutch, scheduled to undergo minimally invasive esophagectomy with two-field lymphadenectomy and an intrathoracic anastomosis, and have no contra-indications to either epidural or paravertebral analgesia. The primary outcome is the quality of postoperative recovery, as measured by the Quality of Recovery-40 (QoR-40) questionnaire on the morning of postoperative day 3. Secondary outcomes include the QoR-40 questionnaire score Area Under the Curve on postoperative days 1-3, the integrated pain and systemic opioid score and patient satisfaction and pain experience according to the International Pain Outcomes (IPO) questionnaire, and cost-effectiveness. Furthermore, the groups will be compared regarding the need for additional rescue medication on postoperative days 0-3, technical failure of the pain treatment, duration of anesthesia, duration of surgery, total postoperative fluid administration day 0-3, postoperative vasopressor and inotrope use, length of urinary catheter use, length of hospital stay, postoperative complications, chronic pain at six months after surgery, and other adverse effects. DISCUSSION In this study, it is hypothesized that paravertebral analgesia achieves comparable pain control while causing less side-effects such as hypotension when compared to epidural analgesia, leading to shorter postoperative length of stay on a monitored ward and superior quality of recovery. If this hypothesis is confirmed, the results of this study can be used to update the relevant guidelines on postoperative pain management for patients undergoing minimally invasive esophagectomy. TRIAL REGISTRATION Netherlands Trial Registry, NL8037. Registered 19 September 2019.
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Affiliation(s)
- B F Kingma
- Department of Surgery, University Medical Center Utrecht, POBOX 85500, 3508 GA, Utrecht, The Netherlands.
| | - W J Eshuis
- Department of Surgery, Amsterdam UMC, Amsterdam, The Netherlands
| | - E M de Groot
- Department of Surgery, University Medical Center Utrecht, POBOX 85500, 3508 GA, Utrecht, The Netherlands
| | - M L Feenstra
- Department of Surgery, Amsterdam UMC, Amsterdam, The Netherlands
| | - J P Ruurda
- Department of Surgery, University Medical Center Utrecht, POBOX 85500, 3508 GA, Utrecht, The Netherlands
| | - S S Gisbertz
- Department of Surgery, Amsterdam UMC, Amsterdam, The Netherlands
| | - W Ten Hoope
- Department of Anesthesiology, Amsterdam UMC, Amsterdam, The Netherlands
| | - M Marsman
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J Hermanides
- Department of Anesthesiology, Amsterdam UMC, Amsterdam, The Netherlands
| | - M W Hollmann
- Department of Anesthesiology, Amsterdam UMC, Amsterdam, The Netherlands
| | - C J Kalkman
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M D P Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | | | - H J Scholten
- Department of Anesthesiology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - M Buise
- Department of Anesthesiology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - M J van Det
- Department of Surgery, Hospital Group Twente, Almelo, The Netherlands
| | - E A Kouwenhoven
- Department of Surgery, Hospital Group Twente, Almelo, The Netherlands
| | - F van der Meer
- Department of Anesthesiology, Hospital Group Twente Almelo, Almelo, The Netherlands
| | - G W J Frederix
- Department of Public Health, Healthcare Innovation & Evaluation and Medical Humanities, University Medical Center Utrecht, Utrecht, the Netherlands
| | - E Cheong
- Department of Surgery, Norfolk and Norwich University Hospital, Norwich, UK
| | - K Al Naimi
- Department of Anesthesiology, Norfolk and Norwich University Hospital, Norwich, UK
| | | | - R van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, POBOX 85500, 3508 GA, Utrecht, The Netherlands.
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16
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Brown L, Danda L, Fahey TJ. A Quality Improvement Project to Determine the Effect of Aromatherapy on Postoperative Nausea and Vomiting in a Short-Stay Surgical Population. AORN J 2019; 108:361-369. [PMID: 30265393 DOI: 10.1002/aorn.12366] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Postoperative nausea and vomiting (PONV) is a major concern for short-stay surgical patients because it can delay discharge and cause preventable postoperative complications, which in turn can increase hospital costs. Evidence suggests that aromatherapy effectively reduces PONV, either as a monotherapy or in conjunction with pharmacologic antiemetics. This quality improvement project investigated the effectiveness of aromatherapy in reducing PONV in a short-stay surgical population. The outcome of this project supported the hypothesis that the administration of blended aromatherapy would result in a significant decrease in patients' self-reported ratings of nausea. This finding suggests that aromatherapy is an appropriate adjunct therapy for decreasing patient nausea and vomiting in this short-stay surgical unit and may help prevent discharge delays in this population.
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17
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Simpson RE, Fennerty ML, Colgate CL, Kilbane EM, Ceppa EP, House MG, Zyromski NJ, Nakeeb A, Schmidt CM. Post-Pancreaticoduodenectomy Outcomes and Epidural Analgesia: A 5-year Single-Institution Experience. J Am Coll Surg 2019; 228:453-462. [PMID: 30677524 DOI: 10.1016/j.jamcollsurg.2018.12.038] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 12/19/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Optimal pain control post pancreaticoduodenectomy is a challenge. Epidural analgesia (EDA) is used increasingly, despite inherent risks and unclear effects on outcomes. METHODS All pancreaticoduodenectomies (PDs) performed from January 2013 through December 2017 were included. Clinical parameters were obtained from a retrospective review of a prospective clinical database, the American College of Surgeons NSQIP prospective institutional database, and medical record review. Chi-square, Fisher's exact test, and independent-samples t-tests were used for univariable analyses. Multivariable regression was performed. RESULTS Six hundred and seventy-one consecutive PDs from a single institution were included (429 EDA, 242 non-EDA). On univariable analysis, EDA patients experienced significantly less wound disruption (0.2% vs 2.1%), unplanned intubation (3.0% vs 7.9%), pulmonary embolism (0.5% vs 2.5%), mechanical ventilation longer than 48 hours (2.1% vs 7.9%), septic shock (2.6% vs 5.8%), and lower pain scores. On multivariable regression (accounting for baseline group differences (ie sex, hypertension, preoperative transfusion, laboratory results, approach, and pancreatic duct size), EDA was associated with less superficial wound infections (odds ratio [OR] 0.34; 95% CI 0.14 to 0.83; p = 0.017), unplanned intubations (OR 0.36; 95% CI 0.14 to 0.88; p = 0.024), mechanical ventilation longer than 48 hours (OR 0.22; 95% CI 0.08 to 0.62; p = 0.004), and septic shock (OR 0.39; 95% CI 0.15 to 1.00; p = 0.050). Epidural analgesia improved pain scores post-PD days 1 to 3 (p < 0.001). No differences were seen in cardiac or renal complications; pancreatic fistula (B+C) or delayed gastric emptying, 30-/90-day mortality, length of stay, readmission, discharge destination, or unplanned reoperation. CONCLUSIONS Based on the largest single-institution series published to date, our data support the use of EDA for optimization of pain control. More importantly, our data document that EDA improved infectious and pulmonary complications significantly.
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Affiliation(s)
- Rachel E Simpson
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN; Pancreatic Cyst and Cancer Early Detection Center, Indiana University Health, Indianapolis, IN
| | - Mitchell L Fennerty
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | | | - E Molly Kilbane
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Eugene P Ceppa
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN; Pancreatic Cyst and Cancer Early Detection Center, Indiana University Health, Indianapolis, IN
| | - Michael G House
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Attila Nakeeb
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - C Max Schmidt
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN; Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, IN; Walther Oncology Center, Indianapolis, IN; Simon Cancer Center, Indianapolis, IN; Pancreatic Cyst and Cancer Early Detection Center, Indiana University Health, Indianapolis, IN.
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18
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Goal-directed therapy in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: a prospective observational study. Clin Transl Oncol 2018; 21:451-458. [PMID: 30218305 DOI: 10.1007/s12094-018-1944-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Accepted: 09/02/2018] [Indexed: 10/28/2022]
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19
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Epidural Against Systemic Analgesia: An International Registry Analysis on Postoperative Pain and Related Perceptions After Abdominal Surgery. Clin J Pain 2017; 33:189-197. [PMID: 27258998 DOI: 10.1097/ajp.0000000000000393] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND The PAIN OUT registry collected data from >30,000 patients on pain on the first postoperative day in hospitals worldwide. Utilizing the database, we compared systemic and epidural analgesia (EA) on postoperative pain and related side-effects in patients after abdominal surgeries (ASs). METHODS ASs were identified through the ICD9-Code and subgrouped into laparoscopic surgery and open surgery. After identifying patients in this subset with and without EA, propensity-score matching was performed on the basis of demographics and comorbidities. Primary outcomes were different qualities of pain, and secondary outcomes were pain-related sensations and treatment-related side effects measured with the numeric rating scale. They were calculated as the risk ratio (RR) using the median as the divisor. RESULTS The database contained 29,108 cases, with 5365 AS, and 646 cases remained after matching. A risk analysis revealed that for the AS group, EA posed a significantly lower risk for the perception of worst pain (RR, 0.75; confidence interval [CI], 0.64-0.87), least pain (RR, 0.61; CI, 0.5-0.75), time in severe pain (RR, 0.61; CI, 0.5-0.75), in-bed activity interference of pain (RR, 0.71; CI, 0.59-0.85), pain interference with coughing (RR, 0.68; CI, 0.57-0.82) or sleeping (RR, 0.73; CI, 0.61-0.87), and a higher chance of pain relief (RR, 1.5; CI, 1.23-1.83). The risk for itchiness (RR, 2.23; CI, 1.62-3.07) appeared to be higher, as did the probability of satisfaction (RR, 1.25; CI, 1.03-1.51). The risk for feeling helpless (RR, 0.83; CI, 0.7-0.99) and drowsiness (RR, 0.74; CI, 0.63-0.88) was reduced. Both subgroups showed similar tendencies. DISCUSSION Regarding the pain intensity, satisfaction, and relatable side-effects, EA seems to be superior compared with systemic analgesia after AS.
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Comparison of Epidural or Regional Analgesia and Patient-controlled Analgesia: A Critical Analysis of Patient Data by the Acute Pain Service in a University Hospital. Clin J Pain 2017; 32:681-8. [PMID: 26528866 DOI: 10.1097/ajp.0000000000000315] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVES A large number of patients still experience pain after surgery. This study investigates if epidural or regional analgesia (continuous infusion peripheral nerve blocks [CPNB]) provide superior pain relief compared with patient-controlled analgesia (PCIA) and identifies the incidence of minor and major adverse effects or complications of these techniques. MATERIALS AND METHODS Prospectively collected data of postoperative patients from an online data registration system of a special dedicated nurse-based acute pain service were analyzed. The acute pain service consultations were documented from January 2008 to August 2013 in a university hospital in The Netherlands. RESULTS An analysis was applied on data of 12,399 consecutive patients. Results showed that patients who received epidural analgesia and CPNB reported lower pain scores than those who received PCIA, after undergoing the same procedures. In addition, pain scores at rest were significantly lower than movement-evoked pain scores, in abdominal surgery. Severe nausea was mostly observed in patients with PCIA and itching was most common in patients with epidural analgesia. Opioid-induced respiratory depression was found in 5 patients with PCIA. DISCUSSION Epidural analgesia and CPNB provide better pain relief to patients than PCIA, especially in dynamic pain scores of patients. Evaluating real patient data on every patient visit is important for further improvement of the quality of postoperative pain management. Pain scores may vary widely between patients with similar surgical procedures. Therefore, we recommend that future research focuses on personalized pain measurement and pain management, to improve clinical practice more intensely.
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21
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Kim YK, Lee JH, Kang SH, Choi Y, Lee JY, Lee SY, Lee SN, Lee EJ, Lee C. The effects of epidural versus intravenous patient-controlled analgesia on postoperative outcomes in elderly patients who have undergone gastrectomy: a retrospective trial. Anesth Pain Med (Seoul) 2017. [DOI: 10.17085/apm.2017.12.4.363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Yun-kwang Kim
- Department of Anesthesiology and Pain Medicine, Korea Cancer Center Hospital, Seoul, Korea
| | - Ji Heui Lee
- Department of Anesthesiology and Pain Medicine, Korea Cancer Center Hospital, Seoul, Korea
| | - Seok Hee Kang
- Department of Anesthesiology and Pain Medicine, Korea Cancer Center Hospital, Seoul, Korea
| | - Yongjoon Choi
- Department of Anesthesiology and Pain Medicine, Korea Cancer Center Hospital, Seoul, Korea
| | - Ji-yeon Lee
- Department of Anesthesiology and Pain Medicine, Korea Cancer Center Hospital, Seoul, Korea
| | - So Young Lee
- Department of Anesthesiology and Pain Medicine, Korea Cancer Center Hospital, Seoul, Korea
| | - Su-Nam Lee
- Department of Anesthesiology and Pain Medicine, Korea Cancer Center Hospital, Seoul, Korea
| | - Eun-Ju Lee
- Department of Anesthesiology and Pain Medicine, Korea Cancer Center Hospital, Seoul, Korea
| | - Cheong Lee
- Department of Anesthesiology and Pain Medicine, Korea Cancer Center Hospital, Seoul, Korea
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Rashid A, Gorissen KJ, Ris F, Gosselink MP, Shorthouse JR, Smith AD, Pandit JJ, Lindsey I, Crabtree NA. No benefit of ultrasound-guided transversus abdominis plane blocks over wound infiltration with local anaesthetic in elective laparoscopic colonic surgery: results of a double-blind randomized controlled trial. Colorectal Dis 2017; 19:681-689. [PMID: 27943522 DOI: 10.1111/codi.13578] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Accepted: 09/12/2016] [Indexed: 02/08/2023]
Abstract
AIM Advances in laparoscopic techniques combined with enhanced recovery pathways have led to faster recuperation and discharge after colorectal surgery. Peripheral nerve blockade using transversus abdominis plane (TAP) blocks reduce opioid requirements and provide better analgesia for laparoscopic colectomies than do inactive controls. This double-blind randomized study was performed to compare TAP blocks using bupivacaine with standardized wound infiltration with local anaesthetic (LA). METHOD Seventy-one patients were randomized to receive either TAP block or wound infiltration. The TAP blocks were performed by experienced anaesthetists who used ultrasound guidance to deliver 40 ml of 0.25% bupivacaine post-induction into the transverse abdominis plane. In the control group, 40 ml of 0.25% bupivacaine was injected around the trocar and the extraction site by the surgeon. Both groups received patient-controlled analgesia (PCA) with intravenous morphine. Patients and nursing staff assessed pain scores 6, 12, 24 and 48 h after surgery. The primary outcome was overall morphine use in the first 48 h. RESULTS Of the 71 patients, 20 underwent a right hemicolectomy and 51 a high anterior resection. The modified intention-to-treat analysis showed no significant differences in overall morphine use [47.3 (36.2-58.5) mg vs 46.7 (36.2-57.3) mg; mean (95% CI), P = 0.8663] in the first 48 h. Pain scores were similar at 6, 12, 24 and 48 h. No differences were found regarding time to mobilization, resumption of diet and length of hospital stay. CONCLUSION In elective laparoscopic colectomies, standardized wound infiltration with LA has the same analgesic effect as TAP blocks post-induction using bupivacaine at 48 h.
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Affiliation(s)
- A Rashid
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - K J Gorissen
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - F Ris
- Service of Visceral Surgery, Geneva University Hospitals, Geneva, Switzerland
| | - M P Gosselink
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - J R Shorthouse
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - A D Smith
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - J J Pandit
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - I Lindsey
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - N A Crabtree
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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23
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Sussman M, Goodier E, Fabri I, Borrowman J, Thomas S, Guest C, Bantel C. Clinical benefits, referral practice and cost implications of an in-hospital pain service: results of a service evaluation in a London teaching hospital. Br J Pain 2016; 11:36-45. [PMID: 28386403 DOI: 10.1177/2049463716673667] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In-hospital pain services (IPS) are commonplace, but evidence of efficacy is inadequate, and patients' pain management in any hospital ward remains problematic. This service evaluation aimed to measure the effect of a contemporary IPS, its appropriate use and cost-efficacy. METHODS Records of 249 adults reviewed by the IPS in an inner London Teaching Hospital over an 8-month period were analysed for demographic data, interventions, workload and change in pain intensity measured by numerical rating scale (NRS). Non-parametric tests were used to evaluate differences between initial and final NRS. Spearman's rank correlation analysis was used to create a correlation matrix to evaluate associations between all identified independent variables with the change in NRS. All strongly correlated variables (ρ > 0.5) were subsequently included in a binary logistic regression analysis to identify predictors of pain resolution greater than 50% NRS and improvement rather than deterioration or no change in NRS. Finally, referral practice and cost of inappropriate referrals were estimated. Referrals were thought to be inappropriate when pain was not optimised by the referring team; they were identified using a set algorithm. RESULTS Initial median NRS and final median NRS were significantly different when a Wilcoxon signed-rank test was applied to the whole cohort; Z = -5.5 (p = 0.000). Subgroup analysis demonstrated no significant difference in the 'mild' pain group; z = -1.1 (p = 0.253). Regression analysis showed that for every unit increase in initial NRS, there was a 62% chance of general and a 33% chance of >50% improvement in final NRS. An estimated annual cost-saving potential of £1546 to £4558 was found in inappropriate referrals and patients experiencing no benefit from the service. DISCUSSION Results suggest that patients with moderate to severe pain benefit most from IPS input. Also pain management resources are often distributed inefficiently. Future research is required to develop algorithms for easy identification of potential treatment responders.
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Affiliation(s)
- Maya Sussman
- Acute Medicine, Heartlands Hospital NHS Foundation Trust, Birmingham, UK
| | - Elizabeth Goodier
- Department of Obstetrics and Gynaecology, Jersey General Hospital, Jersey, UK
| | - Izabella Fabri
- Clinic for Pediatric Surgery, Institute for the Healthcare of Youth and Children of Vojvodina, University of Novi Sad, Novi Sad, Serbia; Department for Surgery and Anesthesia, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Jessica Borrowman
- Medicine & Cardiovascular Division, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Sarah Thomas
- Pain Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Charlotte Guest
- Pain Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Carsten Bantel
- Anaesthetics Section, Department of Surgery and Cancer, Imperial College London, London, UK; Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, European Medical School Oldenburg-Groningen, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
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24
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Jakobsson J, Johnson MZ. Perioperative regional anaesthesia and postoperative longer-term outcomes. F1000Res 2016; 5:F1000 Faculty Rev-2501. [PMID: 27785357 PMCID: PMC5063036 DOI: 10.12688/f1000research.9100.1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/10/2016] [Indexed: 12/14/2022] Open
Abstract
Regional anaesthesia provides effective anaesthesia and analgesia in the perioperative setting. Central neuraxial blocks-that is, spinal and epidural blocks-are well established as an alternative or adjunct to general anaesthesia. Peripheral blocks may be used as part of multimodal anaesthesia/analgesia in perioperative practice, reducing the need for opioid analgesics and enhancing early recovery. Furthermore, regional anaesthesia has increased in popularity and may be done with improved ease and safety with the introduction of ultrasound-guided techniques. The effects of local anaesthetics and regional anaesthesia on long-term outcomes such as morbidity, mortality, the quality of recovery beyond the duration of analgesia, and whether it can expedite the resumption of activities of daily living are less clear. It has also been suggested that regional anaesthesia may impact the risk of metastasis after cancer surgery. This article provides an overview of current evidence around quality of recovery, risk for delirium, long-term effects, and possible impact on cancer disease progression associated with the clinical use of local and regional anaesthetic techniques. In summary, there is still a lack of robust data that regional anaesthesia has a clinical impact beyond its well-acknowledged beneficial effects of reducing pain, reduced opioid consumption, and improved quality of early recovery. Further high-quality prospective studies on long-term outcomes are warranted.
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Affiliation(s)
- Jan Jakobsson
- Department of Anaesthesia & Intensive Care, Institution for Clinical Science, Karolinska Institutet, Danderyds University Hospital, Stockholm, Sweden
| | - Mark Z. Johnson
- Department of Anaesthesia & Critical Care, Mater Misercordiae University Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
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A Clinical Comparison of Intravenous and Epidural Local Anesthetic for Major Abdominal Surgery. Reg Anesth Pain Med 2016; 41:28-36. [PMID: 26650426 DOI: 10.1097/aap.0000000000000332] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Epidural analgesia provides good pain control after many postoperative procedures, but it can lead to complications, has some contraindications, and occasionally fails. Intravenous lidocaine infusion has been suggested as an alternative. We assessed, in our clinical practice, the effects of perioperative intravenous lidocaine infusion compared with epidural analgesia for major abdominal surgery. METHODS We conducted a retrospective review of patients who had received intravenous lidocaine (1 mg/kg per hour) perioperatively after a major abdominal surgery. We matched them with patients who had received epidural analgesia. We tested a joint hypothesis of noninferiority of lidocaine infusion to epidural analgesia in postoperative pain scores and opioid consumption. We assigned a noninferiority margin of 1 point (on an 11-point numerical rating scale) difference in pain and a ratio [mean (lidocaine) / mean (epidural)] of 1.2 in opioid consumption, respectively. RESULTS Two hundred sixteen patients (108 in each group) were analyzed. Intravenous lidocaine was not inferior to epidural analgesia with respect to pain scores. Lidocaine infusion was inferior to epidural analgesia with respect to opioid consumption. Patients in the lidocaine group had fewer episodes of hypotension and less postoperative nausea and vomiting, pruritus, and urinary retention. Patients receiving lidocaine also had earlier urinary catheter removal and earlier first gastrointestinal function. Daily mental status assessment was similar between the 2 groups. CONCLUSIONS Patients who received systemic lidocaine infusions with the addition of PRN (as needed) opioids administered for breakthrough pain did not have clinically significant differences in pain scores on postoperative day 2 and beyond. Intravenous lidocaine infusion in major abdominal surgery was inferior to epidural analgesia with respect to opioid consumption. However, lidocaine was associated with improvements in several important aspects of recovery.
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Postoperative complications in cardiac patients undergoing noncardiac surgery. Curr Opin Crit Care 2016; 22:357-64. [DOI: 10.1097/mcc.0000000000000315] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Rosero EB, Joshi GP. Nationwide incidence of serious complications of epidural analgesia in the United States. Acta Anaesthesiol Scand 2016; 60:810-20. [PMID: 26876878 DOI: 10.1111/aas.12702] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 12/01/2015] [Accepted: 01/15/2016] [Indexed: 01/05/2023]
Abstract
BACKGROUND This study aimed to describe the incidence and risk factors of in-hospital spinal hematoma and abscess associated with epidural analgesia in adult obstetric and non-obstetric populations in the United States. METHODS The Nationwide Inpatient Sample was analyzed to identify patients receiving epidural analgesia from 1998 to 2010. Primary outcomes were incidence of spinal hematoma and epidural abscess. Use of decompressive laminectomy was also investigated. Regression analyses were conducted to assess predictors of epidural analgesia complications. Differences in mortality and disposition of patients at discharge were compared in patients with and without neuraxial complications. Obstetric and non-obstetric patients were studied separately. RESULTS A total of 3,703,755 epidural analgesia procedures (2,320,950 obstetric and 1,382,805 non-obstetric) were identified. In obstetric patients, the incidence of spinal hematoma was 0.6 per 100,000 epidural catheterizations (95% CI, 0.3 to 1.0 × 10(-5) ). The incidence of epidural abscess was zero. In non-obstetric patients, the incidence of spinal hematoma and epidural abscess were, respectively, 18.5 per 100,000 (95% CI, 16.3 to 20.9 × 10(-5) ) and 7.2 per 100,000 (95% CI, 5.8 to 8.7 × 10(-5) ) catheterizations. Predictors of spinal hematoma included type of surgical procedure (higher in vascular surgery), teaching status of hospital, and comorbidity score. Patients with spinal complications had higher in-hospital mortality (12.2% vs. 1.1%, P < 0.0001) and were significantly less likely to be discharged to home. CONCLUSIONS This large nationwide data analysis reveals that the incidence of epidural analgesia-related complications is very low in obstetric population epidural analgesia and much higher in patients having vascular surgery.
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Affiliation(s)
- E B Rosero
- Department of Anesthesiology & Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - G P Joshi
- Department of Anesthesiology & Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Klotz R, Hofer S, Schellhaaß A, Dörr-Harim C, Tenckhoff S, Bruckner T, Klose C, Diener MK, Weigand MA, Büchler MW, Knebel P. Intravenous versus epidural analgesia to reduce the incidence of gastrointestinal complications after elective pancreatoduodenectomy (the PAKMAN trial, DRKS 00007784): study protocol for a randomized controlled trial. Trials 2016; 17:194. [PMID: 27068582 PMCID: PMC4827246 DOI: 10.1186/s13063-016-1306-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Accepted: 03/19/2016] [Indexed: 12/11/2022] Open
Abstract
Background Despite substantial improvements in surgical and anesthesiological practices leading to decreased mortality of less than 5 % at high-volume centers, pancreatic surgery is still associated with high morbidity rates of up to 50 %. Attention is increasingly directed toward the optimization of perioperative management to reduce complications and enhance postoperative recovery. Currently, two different strategies for postoperative pain management after pancreatoduodenectomy are being routinely used: patient-controlled intravenous analgesia and thoracic epidural analgesia. Evidence is lacking to assess which strategy entails fewer postoperative complications. Methods/design The PAKMAN trial is designed as an adaptive, pragmatic, randomized, controlled, multicenter, open-label, superiority trial with two parallel study groups. A total of 370 patients scheduled for elective pancreatoduodenectomy will be randomized after giving written informed consent, and 278 patients are needed for analysis. Patients with chronic pancreatitis, severe chronic obstructive pulmonary disease (COPD), American Society of Anesthesiologists (ASA) physical status classification ≥ IV, or chronic pain syndrome will be excluded. The group A intervention includes intraoperative general anesthesia and postoperative patient-controlled intravenous analgesia; the group B intervention comprises combined intraoperative general anesthesia and epidural analgesia with postoperative epidural analgesia. The primary endpoint of this trial is a composite of the gastrointestinal complications (delayed gastric emptying, pancreatic fistula, biliary leak, gastrointestinal bleeding, and postoperative ileus) up to postoperative day 30. The aim is to investigate whether the frequency of gastrointestinal complications following pancreatoduodenectomy can be reduced by 15 % using postoperative, patient-controlled intravenous analgesia compared with epidural analgesia. Discussion Several previous studies investigating the two different strategies for postoperative pain management have mainly focused on their effectiveness in pain control. However, the PAKMAN trial is the first to compare them with regard to their impact on the surgical endpoint “postoperative gastrointestinal complications” after pancreatoduodenectomy. Trial registration German Clinical Trials Register, DRKS00007784 Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1306-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rosa Klotz
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.,The Study Center of the German Surgical Society (SDGC), Heidelberg University Hospital, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Stefan Hofer
- Department of Anesthesia, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Alexander Schellhaaß
- Department of Anesthesia, Intensive Care and Emergency Medicine, Red Cross Hospital Kassel, Hansteinstrasse 29, 34121, Kassel, Germany
| | - Colette Dörr-Harim
- The Study Center of the German Surgical Society (SDGC), Heidelberg University Hospital, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Solveig Tenckhoff
- The Study Center of the German Surgical Society (SDGC), Heidelberg University Hospital, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Thomas Bruckner
- Institute of Medical Biometry and Informatics, University of Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Christina Klose
- Institute of Medical Biometry and Informatics, University of Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Markus K Diener
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.,The Study Center of the German Surgical Society (SDGC), Heidelberg University Hospital, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Markus A Weigand
- Department of Anesthesia, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Phillip Knebel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany. .,The Study Center of the German Surgical Society (SDGC), Heidelberg University Hospital, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany.
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Verlinde M, Hollmann MW, Stevens MF, Hermanns H, Werdehausen R, Lirk P. Local Anesthetic-Induced Neurotoxicity. Int J Mol Sci 2016; 17:339. [PMID: 26959012 PMCID: PMC4813201 DOI: 10.3390/ijms17030339] [Citation(s) in RCA: 127] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 02/08/2016] [Accepted: 02/23/2016] [Indexed: 12/22/2022] Open
Abstract
This review summarizes current knowledge concerning incidence, risk factors, and mechanisms of perioperative nerve injury, with focus on local anesthetic-induced neurotoxicity. Perioperative nerve injury is a complex phenomenon and can be caused by a number of clinical factors. Anesthetic risk factors for perioperative nerve injury include regional block technique, patient risk factors, and local anesthetic-induced neurotoxicity. Surgery can lead to nerve damage by use of tourniquets or by direct mechanical stress on nerves, such as traction, transection, compression, contusion, ischemia, and stretching. Current literature suggests that the majority of perioperative nerve injuries are unrelated to regional anesthesia. Besides the blockade of sodium channels which is responsible for the anesthetic effect, systemic local anesthetics can have a positive influence on the inflammatory response and the hemostatic system in the perioperative period. However, next to these beneficial effects, local anesthetics exhibit time and dose-dependent toxicity to a variety of tissues, including nerves. There is equivocal experimental evidence that the toxicity varies among local anesthetics. Even though the precise order of events during local anesthetic-induced neurotoxicity is not clear, possible cellular mechanisms have been identified. These include the intrinsic caspase-pathway, PI3K-pathway, and MAPK-pathways. Further research will need to determine whether these pathways are non-specifically activated by local anesthetics, or whether there is a single common precipitating factor.
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Affiliation(s)
- Mark Verlinde
- Department of Anesthesiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, Amsterdam 1105AZ, The Netherlands.
| | - Markus W Hollmann
- Department of Anesthesiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, Amsterdam 1105AZ, The Netherlands.
| | - Markus F Stevens
- Department of Anesthesiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, Amsterdam 1105AZ, The Netherlands.
| | - Henning Hermanns
- Department of Anesthesiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, Amsterdam 1105AZ, The Netherlands.
| | - Robert Werdehausen
- Department of Anesthesiology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstrasse 5, Düsseldorf 40225, Germany.
| | - Philipp Lirk
- Department of Anesthesiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, Amsterdam 1105AZ, The Netherlands.
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Leslie K, McIlroy D, Kasza J, Forbes A, Kurz A, Khan J, Meyhoff CS, Allard R, Landoni G, Jara X, Lurati Buse G, Candiotti K, Lee HS, Gupta R, VanHelder T, Purayil W, De Hert S, Treschan T, Devereaux PJ. Neuraxial block and postoperative epidural analgesia: effects on outcomes in the POISE-2 trial†. Br J Anaesth 2015. [PMID: 26209855 DOI: 10.1093/bja/aev255] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND We assessed associations between intraoperative neuraxial block and postoperative epidural analgesia, and a composite primary outcome of death or non-fatal myocardial infarction, at 30 days post-randomization in POISE-2 Trial subjects. METHODS 10 010 high-risk noncardiac surgical patients were randomized aspirin or placebo and clonidine or placebo. Neuraxial block was defined as intraoperative spinal anaesthesia, or thoracic or lumbar epidural anaesthesia. Postoperative epidural analgesia was defined as postoperative epidural local anaesthetic and/or opioid administration. We used logistic regression with weighting using estimated propensity scores. RESULTS Neuraxial block was not associated with the primary outcome [7.5% vs 6.5%; odds ratio (OR), 0.89; 95% CI (confidence interval), 0.73-1.08; P=0.24], death (1.0% vs 1.4%; OR, 0.84; 95% CI, 0.53-1.35; P=0.48), myocardial infarction (6.9% vs 5.5%; OR, 0.91; 95% CI, 0.74-1.12; P=0.36) or stroke (0.3% vs 0.4%; OR, 1.05; 95% CI, 0.44-2.49; P=0.91). Neuraxial block was associated with less clinically important hypotension (39% vs 46%; OR, 0.90; 95% CI, 0.81-1.00; P=0.04). Postoperative epidural analgesia was not associated with the primary outcome (11.8% vs 6.2%; OR, 1.48; 95% CI, 0.89-2.48; P=0.13), death (1.3% vs 0.8%; OR, 0.84; 95% CI, 0.35-1.99; P=0.68], myocardial infarction (11.0% vs 5.7%; OR, 1.53; 95% CI, 0.90-2.61; P=0.11], stroke (0.4% vs 0.4%; OR, 0.65; 95% CI, 0.18-2.32; P=0.50] or clinically important hypotension (63% vs 36%; OR, 1.40; 95% CI, 0.95-2.09; P=0.09). CONCLUSIONS Neuraxial block and postoperative epidural analgesia were not associated with adverse cardiovascular outcomes among POISE-2 subjects.
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Affiliation(s)
- K Leslie
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Australia Anaesthesia, Perioperative and Pain Medicine Unit Department of Pharmacology, University of Melbourne, Melbourne, Australia Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - D McIlroy
- Department of Anaesthesia and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, Australia
| | - J Kasza
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - A Forbes
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - A Kurz
- Department of Outcomes Research, Cleveland Clinic, Cleveland, USA
| | - J Khan
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada Departments of Clinical Epidemiology Biostatistics, McMaster University, Hamilton, Canada Department of Anesthesiology, University of Toronto, Toronto, Canada
| | - C S Meyhoff
- Department of Anaesthesiology, Herlev Hospital and University of Copenhagen, Herlev, Denmark
| | - R Allard
- Department of Anesthesiology and Perioperative Medicine, Kingston General Hospital and Queen's University, Kingston, Canada
| | - G Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute and Vita-Salute University, Milan, Italy
| | - X Jara
- Department of Anesthesiology, Clinica Santa Maria and Universidad de Los Andes, Santiago, Chile
| | - G Lurati Buse
- Department of Anaesthesiology, Juravinski Hospital, Hamilton, Canada
| | - K Candiotti
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami, Miami, USA
| | - H-S Lee
- Department of Anesthesiology, Sultanah Aminah Hospital, Johor Bahru, Malaysia
| | - R Gupta
- Department of Medicine, Fortis Escorts Hospital, Jaipur, India
| | - T VanHelder
- Department of Anesthesia, Hamilton General Hospital, Hamilton, Canada
| | - W Purayil
- Department of Anaesthesia, Westfort Hi-tech Hospital, Thrissur, India
| | - S De Hert
- Department of Anaesthesiology, Ghent University Hospital, Ghent, Belgium
| | - T Treschan
- Department of Anaesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - P J Devereaux
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada Departments of Clinical Epidemiology Biostatistics, McMaster University, Hamilton, Canada Department of Medicine, McMaster University, Hamilton, Canada
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Do Neuraxial Techniques Affect Perioperative Outcomes? The Story of Vantage Points and Number Games. Anesth Analg 2014; 119:501-502. [DOI: 10.1213/ane.0000000000000276] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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