Impact of general anaesthesia on breast cancer survival: a 5-year follow up of a pragmatic, randomised, controlled trial, the CAN-study, comparing propofol and sevoflurane

Background

Anaesthesia may impact long-term cancer survival. In the Cancer and Anaesthesia study, we hypothesised that the hypnotic drug propofol will have an advantage of at least five percentage points in five-year survival over the inhalational anaesthetic sevoflurane for breast cancer surgery.

Methods

From 2118 eligible breast cancer patients scheduled for primary curable, invasive breast cancer surgery, 1764 were recruited after ethical approval and individual informed consent to this open label, single-blind, randomised trial at four county- and three university hospitals in Sweden and one Chinese university hospital. Of surveyed patients, 354 were excluded, mainly due to refusal to participate. Patients were randomised by computer at the monitoring organisation to general anaesthesia maintenance with either intravenous propofol or inhaled sevoflurane in a 1:1 ratio in permuted blocks. Data related to anaesthesia, surgery, oncology, and demographics were registered. The primary endpoint was five-year overall survival. Data are presented as Kaplan-Meier survival curves and Hazard Ratios based on Cox univariable regression analyses by both intention-to-treat and per-protocol. EudraCT, 2013-002380-25 and ClinicalTrials.gov, NCT01975064.

Findings

Of 1764 patients, included from December 3, 2013, to September 29, 2017, 1670 remained for analysis. The numbers who survived at least five years were 773/841 (91.9% (95% CI 90.1-93.8)) in the propofol group and 764/829 (92.2% (90.3-94.0)) in the sevoflurane group, (HR 1.03 (0.73-1.44); P = 0.875); the corresponding results in the per-protocol-analysis were: 733/798 (91.9% (90.0-93.8)) and 653/710 (92.0% (90.0-94.0)) (HR = 1.01 (0.71-1.44); P = 0.955). Survival after a median follow-up of 76.7 months did not indicate any difference between the groups (HR 0.97, 0.72-1.29; P = 0.829, log rank test).

Interpretation

No difference in overall survival was found between general anaesthesia with propofol or sevoflurane for breast cancer surgery.

Funding

Swedish Research Council; Uppsala-Örebro Regional Research Council; Västmanland Regional Research Fund; Västmanland Cancer Foundation; Stig and Ragna Gohrton Foundation; Birgit and Henry Knutsson Foundation.

Pre- to postoperative coagulation profile of 307 patients undergoing oesophageal resection with epidural blockade over a 10-year period in a single hospital: implications for the risk of spinal haematoma

Background

Epidural anaesthesia and analgesia are indicated for oesophageal surgery. A rare but serious complication is spinal haematoma, which can occur on insertion, manipulation or withdrawal of catheters. Evidence and guidelines are vague regarding which tests are appropriate and how to interpret their results. We aimed to describe how routine coagulation test results change during oesophagectomy’s perioperative course.

Methods

Following ethical approval, we retrospectively identified patients who had undergone oesophagectomy between 2002 and 2012. Blood test results and details of operations, haemorrhage and complications were recorded and analysed with Excel and R. A literature search was conducted using the PubMed terms ‘epidural’ AND ‘coagulation’ AND English language. Relevant articles published in 2000 and after were included.

Results

Three hundred and seven patients received a thoracic epidural infusion with bupivacaine and morphine while 51 received an intravenous morphine infusion. Tests taken preoperatively and before the planned withdrawal of the epidural catheter demonstrated increases in all three measures: aPTT (activated partial thromboplastin time), PT-INR (prothrombin international normalised ratio) and platelet count (Plc). Postoperative thrombocytopenia was almost non-existent while aPTT or PT-INR was elevated above the reference range in 129/307 patients: aPTT was elevated in 116/307 while PT-INR was elevated in 32/307. This is too small a sample to allow meaningful estimation of risk of spinal haematoma: it may be as high as 2.3%. The literature search returned 275 articles, of which 57 were relevant. Twenty-one concerned the natural history of postoperative coagulation; 16, the incidence of and risk factors for spinal haematoma; and 5, evaluation of specific blood tests. Postoperative coagulation is characterised by thrombocytosis and transient moderately abnormal routine coagulation test results. Viscoelastic tests are not validated in the stable postoperative setting.

Conclusions

Screening for coagulopathy before removal of epidural catheters is of unclear benefit since elevated aPTT and PT-INR are usual and may not indicate hypocoagulation. A thorough clinical assessment is important. We nevertheless recommend caution when being presented with elevated routine tests of coagulation before withdrawing an epidural catheter: viscoelastic haemostatic tests may have a role in testing before withdrawal of epidural catheters but they are so far not validated. Future research should include advanced coagulation analysis as soon as a patient is unfortunate enough to have a spinal haematoma.

Electronic supplementary material

The online version of this article (10.1186/s13741-017-0070-7) contains supplementary material, which is available to authorized users.

Sleep and recovery in physicians on night call: a longitudinal field study

BACKGROUND

It is well known that physicians' night-call duty may cause impaired performance and adverse effects on subjective health, but there is limited knowledge about effects on sleep duration and recovery time. In recent years occupational stress and impaired well-being among anaesthesiologists have been frequently reported for in the scientific literature. Given their main focus on handling patients with life-threatening conditions, when on call, one might expect sleep and recovery to be negatively affected by work, especially in this specialist group. The aim of the present study was to examine whether a 16-hour night-call schedule allowed for sufficient recovery in anaesthesiologists compared with other physician specialists handling less life-threatening conditions, when on call.

METHODS

Sleep, monitored by actigraphy and Karolinska Sleep Diary/Sleepiness Scale on one night after daytime work, one night call, the following first and second nights post-call, and a Saturday night, was compared between 15 anaesthesiologists and 17 paediatricians and ear, nose, and throat surgeons.

RESULTS

Recovery patterns over the days after night call did not differ between groups, but between days. Mean night sleep for all physicians was 3 hours when on call, 7 h both nights post-call and Saturday, and 6 h after daytime work (p < 0.001). Scores for mental fatigue and feeling well rested were poorer post-call, but returned to Sunday morning levels after two nights' sleep.

CONCLUSIONS

Despite considerable sleep loss during work on night call, and unexpectedly short sleep after ordinary day work, the physicians' self-reports indicate full recovery after two nights' sleep. We conclude that these 16-hour night duties were compatible with a short-term recovery in both physician groups, but the limited sleep duration in general still implies a long-term health concern. These results may contribute to the establishment of safe working hours for night-call duty in physicians and other health-care workers.

Epidural lipomatosis and congenital small spinal canal in spinal anaesthesia: a case report and review of the literature

Introduction

Complications after lumbar anaesthesia and epidural blood patch have been described in patients with congenital small spinal canal and increased epidural fat or epidural lipomatosis. These conditions, whether occurring separately or in combination, require magnetic resonance imaging for diagnosis and grading, but their clinical significance is still unclear.

Case presentation

A 35-year-old Caucasian woman who was undergoing a Caesarean section developed a longstanding L4-L5 unilateral neuropathy after the administration of spinal anaesthesia. There were several attempts to correctly position the needle, one of which resulted in paraesthesia. A magnetic resonance image revealed that the patient's bony spinal canal was congenitally small and had excess epidural fat. The cross-sectional area of the dural sac was then reduced, which left practically no free cerebrospinal fluid space.

Conclusion

The combination of epidural lipomatosis of varying degrees and congenital small spinal canal has not been previously discussed with spinal anaesthesia. Due to the low cerebrospinal fluid content of the small dural sac, the cauda equina becomes a firm system with a very limited possibility for the nerve roots to move away from the puncture needle when it is inserted into the dural sac. This constitutes risks of technical difficulties and neuropathies with spinal anaesthesia.

The effects of platelet transfusions evaluated using rotational thromboelastometry

BACKGROUND

In this study, we assessed the immediate effects of platelet transfusion on whole blood coagulation.

METHODS

Ten thrombocytopenic patients given a single unit platelet transfusion of 200-300 x 10(9) platelets had their coagulation status assessed before and immediately after transfusion using rotational thromboelastometry.

RESULTS

Transfusion increased the median platelet count from 31.5 to 43.5 x 10(9)/L. Clot formation time decreased by 32% (P = 0.005), whereas maximum clot strength increased by 47% (P = 0.005).

CONCLUSION

Statistically significant improvements in rotational thromboelastometry-measured parameters were observed in association with a mean increase of 12 x 109/L in platelet count after platelet transfusion in these patients.

Could benefits of epidural analgesia following oesophagectomy be measured by perceived perioperative patient workload?

BACKGROUND

A controversy exists whether beneficial analgesic effects of epidural analgesia over intravenous analgesia influence the rate of post-operative complications and the length of hospital stay. There is some evidence that favours epidural analgesia following major surgery in high-risk patients. However, there is a controversy as to whether epidural analgesia reduces the intensive care resources following major surgery. In this study, we aimed at comparing the post-operative costs of intensive care in patients receiving epidural or intravenous analgesia.

METHODS

Clinical data and rates of post-operative complications were extracted from a previously reported trial following thoraco-abdominal oesophagectomy. Cost data for individual patients included in that trial were retrospectively obtained from administrative records. Two separate phases were defined: costs of pain treatment and the direct cost of intensive care.

RESULTS

Higher calculated costs of epidural vs. intravenous pain treatment, 1,037 vs. 410 Euros / patient, were outweighed by lower post-operative costs of intensive care 5,571 vs. 7,921 Euros / patient (NS).

CONCLUSION

Higher costs and better analgesic effects of epidural analgesia compared with intravenous analgesia do not reduce total costs for post-operative care following major surgery.

Physiological restitution after night-call duty in anaesthesiologists: impact on metabolic factors

BACKGROUND

Several studies have shown impaired mental well-being and performance in physicians work on call, but knowledge of the physiological effects is scarce. The aims of the present study were to investigate if there was a metabolic stress response in the restitutional phase after night-call duty, indicating potential negative health effects, and determine whether there were differences between physician specialities.

METHODS

Anaesthesiologists (n = 19) were compared with paediatricians/ear, nose and throat (ENT) surgeons (n = 18). On an ordinary workday, 1 and 3 days after work on night call, blood samples were taken for analysis of glucose, thyroid-stimulating hormone (TSH), free thyroxine, testosterone, insulin growth factor-1 (IGF-1), high- and low-density lipoprotein cholesterol (HDL and LDL), triglycerids (TG) and insulin. Saliva cortisol was sampled on an ordinary working day, a day including 16-h night call, the third day following, and for anaesthesiologists also on a day off work.

RESULTS

TSH differed significantly between days in both groups, with a 26% lower level 1 day after on-call duty (P < 0.001). A 48% cortisol rise in the morning preceding night duty was found for paediatricians/ENT surgeons (P < 0.01).

CONCLUSION

The significant dip in TSH level 24 h after night-call duty indicates a metabolic effect of working on night call and should be studied further. However, the levels were within the normal range and the overall results do not imply any serious metabolic changes and only minor differences were seen between specialist groups.

Morphine metabolism after major liver surgery

BACKGROUND

Impaired metabolism of morphine may lead to an increase in sedation and respiratory depression.

METHODS

In the present study we investigated morphine pharmacokinetics in patients who had undergone liver resection (n = 15) compared to a control group undergoing colon resection (n = 15). Morphine was administered IV by patient-controlled analgesia. Plasma concentrations of morphine, morphine-6-glucuronide, and morphine-3-glucuronide were measured 2-3 times daily for the first two postoperative days. Pain intensity scores were assessed three times daily and respiratory rate and sedation scores every third hour.

RESULTS

There were no differences in morphine requirements 1.1 (0.8-2.5 [median, interquartile range]) mg/h (liver resection) and 1.5 (1.1-1.7) mg/h (colon resection) [P = 0.84]) or in pain intensity scores (P > 0.3) between the groups. Plasma morphine concentrations were higher in patients undergoing liver resection than in the control group (P < 0.01) reflecting a lower rate of morphine metabolism. Plasma morphine concentrations were correlated with the volume of liver resection (P < 0.02). However, plasma concentrations of morphine-6-glucuronide and morphine-3-glucuronide did not differ between the groups (P = 0.62 and P = 0.48, respectively). There was a higher incidence of sedation (P = 0.02), but not respiratory depression (P = 0.48), after liver resection.

CONCLUSION

The study demonstrates that plasma concentrations of morphine are higher in patients undergoing liver resection compared with patients undergoing colon resection. Sedation scores were higher in patients undergoing liver resection. Caution is therefore recommended when administering morphine to this patient group.

Thoracic Epidural Analgesia or Intravenous Morphine Analgesia After Thoracoabdominal Esophagectomy: A Prospective Follow-up of 201 Patients

OBJECTIVE

Thoracoabdominal esophagectomy is a major surgical procedure that carries significant postoperative morbidity and mortality. Because the choice of analgesic technique may influence outcome, the impact of thoracic epidural or intravenous analgesia was investigated after esophagectomy.

DESIGN

Prospective observational study during January 1996 until January 2002.

SETTING

University hospital.

PARTICIPANTS

All patients undergoing thoracoabdominal esophagectomy during the 6-year period.

INTERVENTIONS

Patients were prospectively monitored during a 6-year period. Duration of surgery, intraoperative blood loss, fluid administration, postoperative intubation time, intensive care unit (ICU) stay, pain relief and related side effects, postoperative complications, hospital stay, and in-hospital and long-term mortality were compared in relation with the analgesic technique.

MEASUREMENTS AND MAIN RESULT

Thoracic epidural analgesia with bupivacaine/morphine was used in 166 patients, and intravenous morphine analgesia was used in 35 patients. Postoperative intubation time and ICU stay were similar in both groups. Patients with epidural analgesia experienced less pain. Sedation, respiratory depression, hallucinations, and confusion were more common in the intravenous morphine group. Postoperative weight did not differ between the groups, despite fluid replacement that was higher in the epidural group during the first 24 hours. The in-hospital mortality rate was 0.5%.

CONCLUSIONS

No differences in morbidity/mortality rates depending on analgesic treatment were observed in patients undergoing thoracoabdominal esophagectomy. Thoracic epidural analgesia provided better pain relief with fewer opioid-related side effects than intravenous morphine analgesia. However, postoperative epidural analgesia was associated with more technical difficulties.

Pain relief and safety after major surgery. A prospective study of epidural and intravenous analgesia in 2696 patients

BACKGROUND

Adverse effects may still limit the use of continuous epidural and intravenous analgesia in surgical wards. This study postulated that postoperative epidural analgesia was more efficient, and had fewer side-effects than intravenous morphine. The aim was to investigate efficacy, adverse effects and safety of the treatments in a large patient population.

METHODS

During a five-year period 2696 patients undergoing major surgery, received either epidural or intravenous analgesia for postoperative pain relief. The patients were prospectively monitored in surgical wards. Pain was evaluated with a numeric rating scale (0-10) at rest/mobilization. Treatment duration, respiratory depression, sedation/hallucinations/nightmares/confusion, nausea/vomiting, pruritus, orthostatism/leg weakness, and insufficient pain relief were registered. Pain relief for all patients aimed at a pain scoring of less than 4 at rest.

RESULTS

Epidural analgesia was used in 1670 patients, and intravenous morphine in 1026 patients. Patients with epidural analgesia experienced less pain both at rest and during mobilization. Insufficient treatment effects such as dose adjustments, orthostatism/leg weakness, and pruritus were more common in the epidural group. Respiratory depression and sedation/hallucinations/nightmares/confusion occurred more often in the intravenous group. Thoracic epidural catheters caused a lower incidence of motor blockade compared to lumbar catheter placements.

CONCLUSION

In a large patient population the use of epidural and intravenous postoperative analgesia was considered safe in surgical wards, and the incidence of adverse effects was low. Patients with epidural analgesia experienced overall less pain, while opioid related side-effects were more common with intravenous morphine analgesia.

Thoracic epidural anesthesia and epidural hematoma

This report involves a 74-year-old-male who developed a thoracic epidural hematoma with paraparesis on the second postoperative day in conjunction with thoracic epidural anesthesia established before surgery for acute abdominal aortic dissection. The finding indicates that laminectomy can be performed successfully as late as three days after diagnosis of the hematoma, with a complete restitution of neurological function. High-dose steroid treatment may have been a contributing factor for the positive outcome.

Local metabolic changes in subcutaneous adipose tissue during intravenous and epidural analgesia

BACKGROUND

This clinical study aimed at investigating the impact of postoperative thoracic epidural analgesia on extracellular glycerol concentration and glucose metabolism in subcutaneous adipose tissue, using the microdialysis technique. The sympathetic nervous activity, which can be attenuated by epidural anesthesia, influences lipolysis and the release of glycerol.

METHODS

Fourteen patients who underwent major abdominal or thoraco-abdominal surgery were studied postoperatively over 3 days. For postoperative analgesia the patients were prospectively randomized to receive either thoracic epidural analgesia with a bupivacaine/morphine infusion (EPI-group, n=6) or a continuous i.v. infusion of morphine (MO-group, n=8). The concentration of glycerol, glucose and lactate in the abdominal and deltoid subcutaneous adipose tissue were measured using a microdialysis technique.

RESULTS

The abdominal glycerol levels were equal in both groups. In the deltoid region of the EPI-group, glycerol concentrations started to increase on Day 2, and reached significantly higher levels on Day 3 compared with the MO-group. The glucose and lactate levels showed no differences between groups in the two regions.

CONCLUSION

The uniform glycerol levels in abdominal subcutaneous adipose tissue in conjunction with the difference in glycerol levels in the deltoid area indicate that the local lipolysis is different in the two study groups. This might be explained by a regional metabolic influence of thoracic epidural analgesia, possibly via the sympathetic nervous system.

Apnea and bradypnea in patients receiving epidural bupivacaine-morphine for postoperative pain relief as assessed by a new monitoring method

STUDY OBJECTIVE

To evaluate postoperative breathing patterns with a new monitoring device in patients given bupivacaine-morphine epidural analgesia.

DESIGN

Open explorative study.

SETTING

Inpatient anesthesia in a university hospital setting.

PATIENTS

15 ASA physical status I and II patients aged 28 to 87 years and scheduled for major abdominal surgery.

INTERVENTIONS

All patients underwent abdominal surgery with epidural anesthesia combined with general anesthesia. Postoperatively, they continued with epidural analgesia consisting of bupivacaine and morphine. On the first postoperative night, the breathing pattern was studied with a new noninvasive monitoring device measuring respiratory frequency and apnea. Arterial blood gas analysis was performed in case of apnea or low respiratory frequency.

MEASUREMENTS AND MAIN RESULTS

A total of 84 alarm events were registered in 11 patients. Twenty-one percent (18/84) of the alarms were associated with arterial carbon dioxide tension (PaCO2) levels greater than 48.8 mmHg. Three of the four patients with PaCO2 levels greater than 48.8 mmHg were older than 80 years of age.

CONCLUSION

The tested noninvasive monitoring device may detect abnormal respiratory breathing patterns in patients at risk for respiratory depression during epidural analgesia with bupivacaine-morphine.

Pain relief after esophagectomy: Thoracic epidural analgesia is better than parenteral opioids

OBJECTIVE

To compare postoperative pain relief and pulmonary function in patients after thoracoabdominal esophagectomy treated by continuing perioperative thoracic epidural anesthesia or changing to parenteral opioids.

DESIGN

Prospective, randomized study.

SETTING

University teaching hospital.

PARTICIPANTS

Thirty-three patients undergoing thoracoabdominal esophagectomy.

INTERVENTIONS

General anesthesia was combined with thoracic epidural anesthesia during surgery. The patients either continued with thoracic epidural analgesia (n = 18) or were switched to patient-controlled analgesia with intravenous morphine (n = 15) for 5 postoperative days. Pain scores were estimated twice daily, at rest and after mobilization. Peak expiratory flow, forced expiratory volume, and vital capacity were measured the day before surgery, postoperative day 2, and postoperative day 6. Adverse events and complications were recorded.

MEASUREMENTS AND MAIN RESULTS

At rest, there were no differences in pain relief between the groups. Pain scores at mobilization showed a significantly lower value in the epidural group (p < 0.027). No intergroup differences were found regarding pulmonary function, which decreased on postoperative day 2, but was improved on postoperative day 6.

CONCLUSION

Continuation of intraoperative thoracic epidural anesthesia for 5 postoperative days provides better pain relief at mobilization compared with a switch to patient-controlled analgesia with intravenous morphine. There was no intergroup difference in the impact on measures of pulmonary function.

A comparison of the effects on postoperative pain relief of epidural analgesia started before or after surgery

In a randomized, prospective clinical study pain relief and pulmonary function were compared after upper abdominal surgery when thoracic epidural analgesia was instituted either before or after surgery. Twenty-six patients admitted for surgery to treat gastro-oesophageal reflux received thoracic epidural analgesia as an adjunct to general anaesthesia either before or after surgery. Twelve patients received epidural mepivacaine 20 mg mL(-1) and morphine perioperatively. Another 14 patients received an epidural bolus of bupivacaine 2.5 mg mL(-1) and morphine after skin closure. Bupivacaine 2.5 mg mL(-1) with morphine was adminstered to all patients for three postoperative days. No intergroup differences were found regarding pain at rest and mobilization. The requirement for additional analgesics was similar in both groups as well as peak expiratory flow. Thoracic epidural analgesia that had already been induced before surgery, and was continued into the postoperative period, does not seem to add any advantage regarding pain relief and lung function compared with thoracic epidural analgesia instituted in the immediate postoperative period.