Why do thoracic epidurals fail? A literature review on thoracic epidural failure and catheter confirmation

Ultrasound image-based paravertebral nerve block combined with general anesthesia in laparoscopic radical resection of esophageal cancer : Paravertebral nerve block versus general anesthesia in the treatment of esophageal cancer: a randomized controlled trial

BACKGROUND

Thoracic epidural analgesia (TEA) is the gold standard for analgesia after thoracotomy, but it has limitations. There are few studies on the analgesic effect of ultrasound-guided paravertebral nerve block (PVB) combined with general anesthesia in esophageal cancer surgery.

METHODS

52 TLE patients from November 2020 - November 2021 were randomly divided into Group G (general anesthesia, n = 26) and Group G + P (ultrasound - guided PVB + general anesthesia, n = 26). General data, intraoperative/postoperative indicators, VAS scores, HR, MAP, NTI, and patient satisfaction were recorded.

RESULTS

There were no significant differences in general data such as age, gender, BMI, and ASA grade between the two groups (P > 0.05). The intraoperative dosages of propofol, remifentanil, and sufentanil in Group G + P were significantly lower than those in Group G, while the dosage of phenylephrine was higher. The extubation time, PACU stay time, and postoperative hospital stay in Group G + P were shorter, the dosage of sufentanil in PACU was less, and the incidence of agitation was lower. The VAS scores of Group G + P in the resting and coughing states at multiple time points such as waking up, leaving the PACU, and after surgery were significantly lower than those of Group G. There was no significant difference in HR between the two groups at most time points during the operation. The MAP of Group G was higher than that of Group G + P at time points t8 and t9, and there were significant differences in NTI between the two groups from t2 to t7. The satisfaction rate of patients in Group G + P (96.14%) was significantly higher than that in Group G (80.76%).

CONCLUSION

Ultrasound - guided PVB combined with general anesthesia reduces opioid use, eases pain, lowers agitation, shortens hospital stay, and boosts satisfaction in esophageal cancer surgery patients.

Adequacy of Anesthesia Guidance for Combined General/Epidural Anesthesia in Patients Undergoing Open Abdominal Infrarenal Aortic Aneurysm Repair; Preliminary Report on Hemodynamic Stability and Pain Perception

Background/Objectives: Hemodynamic instability and inappropriate postoperative pain perception (IPPP) with their consequences constitute an anesthesiological challenge in patients undergoing primary elective open lumbar infrarenal aortic aneurysm repair (OLIAAR) under general anesthesia (GA), as suboptimal administration of intravenous rescue opioid analgesics (IROAs), whose titration is optimized by Adequacy of Anaesthesia (AoA) guidance, constitutes a risk of adverse events. Intravenous or thoracic epidural anesthesia (TEA) techniques of preventive analgesia have been added to GA to minimize these adverse events. Methods: Seventy-five patients undergoing OLIAAR were randomly assigned to receive TEA with 0.2% ropivacaine (RPV) with fentanyl (FNT) 2.5 μg/mL (RPV group) or 0.2% bupivacaine (BPV) with FNT 2.5 μg/mL (BPV group) or intravenous metamizole/tramadol (MT group). IROA using FNT during GA was administered under AoA guidance. Systemic morphine was administered as a rescue agent in all groups postoperatively in the case of IPPP, assessed using the Numeric Pain Rating Score > 3. The maximum score at admission and the minimum at discharge from the postoperative care unit to the Department of Vascular Surgery, perioperative hemodynamic stability, and demand for rescue opioid analgesia were analyzed. Results: Ultimately, 57 patients were analyzed. In 49% of patients undergoing OLIAAR, preventive analgesia did not prevent the incidence of IPPP, which was not statistically significant between groups. No case of acute postoperative pain perception was noted in the RPV group, but at the cost of statistically significant minimum mean arterial pressure values, reflecting hemodynamic instability, with clinical significance < 65mmHg. Demand for postoperative morphine was not statistically significantly different between groups, contrary to significantly lower doses of IROA using FNT in patients receiving TEA. Conclusions: AoA guidance for IROA administration with FNT blunted the preventive analgesia effect of TEA compared with intravenous MT that ensured proper perioperative hemodynamic stability along with adequate postoperative pain control with acceptable demand for postoperative morphine.