Epidural local anaesthetics versus opioid-based analgesic regimens for postoperative gastrointestinal paralysis, vomiting and pain after abdominal surgery

Postoperative epidural analgesia versus systemic analgesia for thoraco-lumbar spine surgery in children

BACKGROUND

Spine surgery may be associated with severe acute postoperative pain. Compared with systemic analgesia alone, epidural analgesia may offer better pain control. However, epidural analgesia has sometimes been associated with rare but serious complications. Therefore, it is critical to quantify the real benefits of epidural analgesia over other modes of pain treatment.

OBJECTIVES

To assess the effectiveness and safety of epidural analgesia compared with systemic analgesia for acute postoperative pain control after thoraco-lumbar spine surgery in children.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and Cumulative Index to Nursing and Allied Health Literature on 14 November 2018, together with the references lists of related reviews and retained trials, and two trials registers.

SELECTION CRITERIA

We included all randomized controlled trials performed in children undergoing any type of thoraco-lumbar spine surgery comparing epidural analgesia with systemic analgesia for postoperative pain. We applied no language or publication status restriction.

DATA COLLECTION AND ANALYSIS

We assessed risk of bias of included trials using the Cochrane tool. We analysed data using random-effects models. We rated the quality of the evidence according to the GRADE scale.

MAIN RESULTS

We included 11 trials (559 participants) in the review, and seven trials (249 participants) in the analysis: 140 participants received epidural analgesia and 109 received systemic analgesia.Most studies included adolescents. Three trials included in the analysis contained some participants older than 18 years. The types of surgery were posterior spinal fusion for idiopathic scoliosis (nine trials), anterior correction for idiopathic scoliosis (one trial), or selective dorsal rhizotomy in children with cerebral palsy (one trial). The mean numbers of vertebrae operated on were between nine and 14.5 and the mean numbers of spinal levels were between three and four and a half. The length of surgery varied between three and six and a half hours.Compared with systemic analgesia, epidural analgesia reduced pain at rest at all time points. At six to eight hours, the mean pain score on a 0 to 10 scale with systemic analgesia was 3.1 (standard deviation 0.7) and with epidural analgesia was -1.32 points (95% confidence interval (CI) -1.83 to -0.82; 4 studies, 116 participants; moderate-quality evidence). At 72 hours, the mean pain score with epidural analgesia was equivalent to a -0.8 point reduction on a 0 to 10 scale (standardized mean difference (SMD) -0.65, 95% CI -1.19 to -0.10; 5 studies, 157 participants; moderate-quality evidence).Return of gastrointestinal functionThere was no difference for nausea and vomiting between groups (risk ratio (RR) 0.87, 95% CI 0.58 to 1.30; 6 studies, 215 participants; low-quality evidence). One study found epidural analgesia with local anaesthetics may have increased the number of participants who had their first flatus within 48 hours (RR 1.63, 95% CI 1.08 to 2.47; 30 participants; very low-quality evidence). Two studies found epidural analgesia with local anaesthetics may have increased the number of participants in whom first bowel movement occurred within 48 hours (RR 11.52, 95% CI 2.36 to 56.26; 60 participants; low-quality evidence). It was uncertain whether epidural analgesia reduced the time to first bowel movement (MD 0.09 days, 95% CI -0.32 to 0.50; 1 study, 60 participants; very low-quality evidence) and time to first liquid ingestion following epidural infusion of an opioid alone or a local anaesthetic plus an opioid (mean difference (MD) -5.02 hours, 95% CI -13.15 to 3.10; 2 studies, 56 participants; very low-quality evidence). Epidural analgesia with local anaesthetics may have increased the risk of having first solid food ingestion within 48 hours (RR 7.00, 95% CI 1.91 to 25.62; 1 study, 30 participants; very low-quality evidence).Secondary outcomesIt was uncertain whether there was a difference in time to ambulate (MD 0.08 days, 95% CI -0.24 to 0.39; 1 study, 60 participants; very low-quality evidence) and hospital length of stay (MD -0.29 days, 95% CI -0.69 to 0.10; 2 studies, 89 participants; very low-quality evidence). Two studies found participants were more satisfied when treated with epidural analgesia (MD 1.62 on a scale from 0 to 10, 95% CI 1.26 to 1.97; 60 participants; very low-quality evidence). It was unclear whether there was a difference in parent satisfaction for epidural analgesia with an opioid alone (MD 0.60, 95% CI -0.81 to 2.01; 1 trial, 27 participants; very low-quality evidence).ComplicationsIt was uncertain whether there was a difference in the risk of complications such as: respiratory depression (risk difference (RD) -0.05, 95% CI -0.16 to 0.05; 4 studies, 126 participants; very low-quality evidence); wound infection (RD 0.01, 95% CI -0.05 to 0.08; 2 trials, 93 participants; very low-quality evidence); epidural abscess (RD 0, 95% CI -0.05 to 0.05; 3 trials, 120 participants; very low-quality evidence); and neurological complications (RD 0.01, 95% CI -0.04 to 0.06; 4 studies, 151 participants; very low-quality evidence).

AUTHORS' CONCLUSIONS

There is moderate- and low-quality evidence that there may be a small additional reduction in pain up to 72 hours after surgery with epidural analgesia compared with systemic analgesia. Two very small studies showed epidural analgesia with local anaesthetic alone may accelerate the return of gastrointestinal function. The safety of this technique in children undergoing thoraco-lumbar surgery is uncertain due to the very low-quality of the evidence. The study in 'Studies awaiting classification' may alter the conclusions of the review once assessed.

Effects of Thoracic Epidural Anaesthesia on the Serosal Microcirculation of the Human Small Intestine

BACKGROUND

The effect of thoracic epidural analgesia (TEA) on splanchnic blood flow during abdominal surgery remains unclear. The purpose of this study was to examine whether the hemodynamic effects of TEA resulted in microcirculatory alterations to the intestinal serosa, which was visualized using incident dark-field (IDF) videomicroscopy.

METHODS

An observational cohort study was performed. In 18 patients, the microcirculation of the intestinal serosa was visualized with IDF. Microcirculatory and hemodynamic measurements were performed prior to (T1) and after administering a bolus of levobupivacaine (T2). If correction of blood pressure was indicated, a third measurement was performed (T3). The following microcirculatory parameters were calculated: microvascular flow index, proportion of perfused vessels, perfused vessel density and total vessel density. Data are presented as median [IQR].

RESULTS

Mean arterial pressure decreased from 73 mmHg (68-83) at T1 to 63 mmHg (±11) at T2 (p = 0.001) with a systolic blood pressure of 114 mmHg (98-128) and 87 (81-97), respectively (p = 0.001). The microcirculatory parameters of the bowel serosa, however, were unaltered. In seven patients, blood pressure was corrected to baseline values from a MAP of 56 mmHg (55-57), while microcirculatory parameters remained constant.

CONCLUSION

We examined the effects of TEA on the intestinal serosal microcirculation during abdominal surgery using IDF imaging for the first time in patients. Regardless of a marked decrease in hemodynamics, microcirculatory parameters of the bowel serosa were not significantly affected.

TRIAL REGISTRY NUMBER

ClinicalTrials.gov identifier NCT02688946.

Non-Hepatic Abdominal Surgery in Patients with Cirrhotic Liver Disease

Cirrhotic liver disease is an important cause of peri-operative morbidity and mortality in general surgical patients. Early recognition and optimization of liver dysfunction is imperative before any elective surgery. Patients with MELD <12 or classified as Child A have a higher morbidity and mortality than matched controls without liver dysfunction, but are generally safe for elective procedures with appropriate patient education. Patients with MELD >20 or classified as Child C should undergo transplantation before any elective procedure given mortality exceeds 40%. Laparoscopic procedures are feasible and safe in cirrhotic patients.

Thoracic Epidural Analgesia: Does It Enhance Recovery?

BACKGROUND

Thoracic epidural analgesia has been shown to be an effective method of pain control. The utility of epidural analgesia as part of an enhanced recovery after surgery protocol is debatable.

OBJECTIVE

This study aimed to determine if the use of thoracic epidural analgesia in an enhanced recovery after surgery protocol decreases hospital length of stay or inpatient opioid consumption after elective colorectal resection.

DESIGN

This is a single-institution retrospective cohort study.

SETTINGS

The study was performed at a high-volume, tertiary care center in the Midwest. An institutional database was used to identify patients.

PATIENTS

All patients undergoing elective transabdominal colon or rectal resection by board-certified colon and rectal surgeons from 2013 to 2017 were included.

MAIN OUTCOME MEASURES

The main outcome was length of stay. The secondary outcome was oral morphine milligram equivalents consumed during the first 48 hours.

RESULTS

There were 1006 patients (n = 815 epidural, 191 no epidural) included. All patients received multimodal analgesia with opioid-sparing agents. Univariate analysis demonstrated no difference in length of stay between those who received thoracic epidural analgesia and those who did not (median, 4 vs 5 days; p = 0.16), which was substantiated by multivariable linear regression. Subgroup analysis showed that the addition of epidural analgesia resulted in no difference in length of stay regardless of an open (n = 362; p = 0.66) or minimally invasive (n = 644; p = 0.46) approach. Opioid consumption data were available after 2015 (n = 497 patients). Univariate analysis demonstrated no difference in morphine milligram equivalents consumed in the first 48 hours between patients who received epidural analgesia and those who did not (median, 135 vs 110 oral morphine milligram equivalents; p = 0.35). This was also confirmed by multivariable linear regression.

LIMITATIONS

The retrospective observational design was a limitation of this study.

CONCLUSION

The use of thoracic epidural analgesia within an enhanced recovery after surgery protocol was not found to be associated with a reduction in length of stay or morphine milligram equivalents consumed within the first 48 hours. We cannot recommend routine use of thoracic epidural analgesia within enhanced recovery after surgery protocols. See Video Abstract at http://links.lww.com/DCR/A765.

Protective loop ileostomy increases the risk for prolonged postoperative paralytic ileus after open oncologic rectal resection

PURPOSE

Postoperative gut dysmotility is a physiologic and frequent temporary reaction after major abdominal surgery. If paralysis merges into a prolonged ileus state, it causes significant morbidity and subsequently worse outcome and discomfort for the patients. Pathophysiology of pathologic prolonged postoperative paralytic ileus remains multifactorial.

METHODS

We present a retrospective single-center analysis of patients, who underwent a primary open oncologic anterior rectal resection with primary anastomosis with or without defunctioning loop ileostomy during a 43-month period of observation. Primary endpoint was the rate of prolonged postoperative paralytic ileus, defined by the intravenous administration of neostigmine. Confounders for regression analysis were assessed by univariate analysis and correlations between confounders were examined. Odds ratio for prolonged postoperative paralytic ileus in patients with defunctioning loop ileostomy was estimated by a logistic regression model.

RESULTS

Of 101 patients (62 male), 62 (61.39%) received defunctioning loop ileostomy. In univariate analysis, male gender and patients with ileostomy showed more frequently prolonged paralysis by tendency (both p = 0.07). Logistic regression analysis proves the influence of a defunctioning ileostomy on the development of prolonged postoperative paralytic ileus after oncologic rectal resection (p = 0.047). Odds ratio for prolonged postoperative paralytic ileus in patients with ileostomy was 4.96 [95% CI 1.02-24.03].

CONCLUSIONS

Although the construction of defunctioning loop ileostomies during rectal resection is a safe, uncomplicated surgical procedure, they can cause significant postoperative morbidity for the patients. High fluid and electrolyte loss are well-known complications, but herewith we raise the evidence for prolonged gut paralysis in patients with defunctioning loop ileostomy.

Frailty and anesthesia - risks during and post-surgery

Frailty is a state of decreased physiologic reserve and resistance to stressors. Its prevalence increases with age and is estimated to be 26% in those aged above 85 years. As the population ages, frailty will be increasingly seen in surgical patients receiving anesthesia. Here, we evaluate the instruments which have been developed and validated for measuring frailty in surgical patients and summarize frailty tools used in 110 studies linking frailty status with adverse outcomes post-surgery. Frail older people are vulnerable to geriatric syndromes, and complications such as postoperative cognitive dysfunction and delirium are explored. This review also considers how frailty, with its decline of organ function, affects the metabolism of anesthetic agents and may influence the choice of anesthetic technique in an older person. Optimal perioperative care includes the identification of frailty, a multisystem and multidisciplinary evaluation preoperatively, and discussion of treatment goals and expectations. We conclude with an overview of the emerging evidence that Comprehensive Geriatric Assessment can improve postoperative outcomes and a discussion of the models of care that have been developed to improve preoperative assessment and enhance the postoperative recovery of older surgical patients.

Nerve blocks or no nerve blocks for pain control after elective hip replacement (arthroplasty) surgery in adults

BACKGROUND

It is estimated that over 300,000 total hip replacements are performed each year in the USA. For European countries, the number of hip replacement procedures per 100,000 people performed in 2007 varied from less than 50 to over 250. To facilitate postoperative rehabilitation, pain must be adequately treated. Peripheral nerve blocks and neuraxial blocks have been proposed to replace or supplement systemic analgesia.

OBJECTIVES

We aimed to compare the relative effects (benefits and harms) of the different nerve blocks that may be used to relieve pain after elective hip replacement in adults.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 12, 2016), MEDLINE (Ovid SP) (1946 to December Week 49, 2016), Embase (Ovid SP) (1980 to December week 49, 2016), CINAHL (EBSCO host) (1982 to 6 December 2016), ISI Web of Science (1973 to 6 December 2016), Scopus (from inception to December 2016), trials registers, and relevant web sites.

SELECTION CRITERIA

We included all randomized controlled trials (RCTs) performed in adults undergoing elective primary hip replacement and comparing peripheral nerve blocks to any other pain treatment modality. We applied no language or publication status restrictions.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two review authors. We contacted study authors.

MAIN RESULTS

We included 51 RCTs with 2793 participants; of these 45 RCTs (2491 participants: peripheral nerve block = 1288; comparators = 1203) were included in meta-analyses. There are 11 ongoing studies and three awaiting classification.Compared to systemic analgesia alone, peripheral nerve blocks reduced: pain at rest on arrival in the postoperative care unit (SMD -1.12, 95% CI -1.67 to -0.56; 9 trials, 429 participants; equivalent to 3.2 on 0 to 10 scale; moderate-quality evidence); risk of acute confusional status: risk ratio (RR) 0.10 95% CI 0.02 to 0.54; 1 trial, 225 participants; number needed to treat for additional benefit (NNTB) 12, 95% CI 11 to 22; very low-quality evidence); pruritus (RR 0.16, 95% CI 0.04 to 0.70; 2 trials, 259 participants for continuous peripheral nerve blocks; NNTB 4 (95% CI 4 to 8); very low-quality evidence); hospital length of stay (SMD -0.75, 95% CI -1.02 to -0.48; very low-quality evidence; 2 trials, 249 participants; equivalent to 0.75 day). Participant satisfaction increased (SMD 0.67, 95% CI 0.45 to 0.89; low-quality evidence; 5 trials, 363 participants; equivalent to 2.4 on 0 to 10 scale). We did not find a difference for the number of participants walking on postoperative day one (very low-quality evidence). Two nerve block-related complications were reported: one local haematoma and one delayed persistent paresis.Compared to neuraxial blocks, peripheral nerve blocks reduced the risk of pruritus (RR 0.33, 95% CI 0.19 to 0.58; 6 trials, 299 participants; moderate-quality evidence; NNTB 6 (95% CI 5 to 9). We did not find a difference for pain at rest on arrival in the postoperative care unit (moderate-quality evidence); number of nerve block-related complications (low-quality evidence); acute confusional status (very low-quality evidence); hospital length of stay (low quality-evidence); time to first walk (low-quality evidence); or participant satisfaction (high-quality evidence).We found that peripheral nerve blocks provide better pain control compared to systemic analgesia with no major differences between peripheral nerve blocks and neuraxial blocks. We also found that peripheral nerve blocks may be associated with reduced risk of postoperative acute confusional state and a modest reduction in hospital length of stay that could be meaningful in terms of cost reduction considering the increasing numbers of procedures performed annually.

AUTHORS' CONCLUSIONS

Compared to systemic analgesia alone, there is moderate-quality evidence that peripheral nerve blocks reduce postoperative pain, low-quality evidence that patient satisfaction is increased and very low-quality evidence for reductions in acute confusional status, pruritus and hospital length of stay .We found moderate-quality evidence that peripheral nerve blocks reduce pruritus compared with neuraxial blocks.The 11 ongoing studies, once completed, and the three studies awaiting classification may alter the conclusions of the review once assessed.

Effects of epidural analgesia on recovery after open colorectal surgery

The use of epidural analgesia (EA) has been suggested as an integral part of an enhanced recovery program for colorectal surgery. However, the effects of EA on postoperative outcomes and hospital length of stay remain controversial. Data from the American College of Surgeons National Surgical Quality Improvement Program database for 2014 and 2015 were queried for adult patients who underwent elective open colorectal surgery. We included only cases with general anesthesia as the main anesthetic. Cases with other types of anesthesia were excluded. A 1:3 matched sample of EA versus non-EA cases was created based on propensity scores. The primary outcome of interest was the occurrence of major cardiopulmonary complications within 7 days of the surgery. Secondary outcome measures were hospital length of stay and 30-day mortality. A total of 24,927 patients were included in the analysis. EA was utilized in 15.02% (n = 3745). The cumulative risk over the study period for major cardiopulmonary complications was 2.52% (n = 627). There were no statistically significant differences in the rate of postoperative complications (relative risk 0.91, 95% CI 0.66-1.27, P = 0.59), length of stay (median [interquartile range], EA 6 [5-9] versus non-EA 6 [4-9] days, P = 0.36), and 30-day mortality rate (relative risk 0.71, 95% CI 0.42-1.20, P = 0.20) between the two propensity-matched cohorts. In conclusion, our study revealed that the benefits of EA in patients undergoing open colorectal surgery are limited, as it does not influence immediate postoperative cardiopulmonary complications or hospital length of stay.

Pain Management in Abdominal Wall Reconstruction

Background:

In abdominal wall reconstruction, adequate pain control and minimization of narcotic consumption are essential to improving patient outcomes and satisfaction. Previous studies have examined the role of individual strategies, such as neuraxial analgesia and multimodal analgesia. However, there has not been a study that examined all potential determinants of postoperative narcotic requirements, including intraoperative strategies.

Methods:

Consecutive patients who underwent abdominal wall reconstruction were reviewed. Preoperative factors (chronic preoperative narcotic usage, indication for abdominal wall reconstruction, administration of neuraxial analgesia), intraoperative factors (intraoperative narcotics administered, method of mesh fixation), and postoperative factors (multimodal analgesia, complications) were collected. The main outcomes were daily amount of opioids used and length of hospital stay.

Results:

Ninety-three patients were included in the study. Patients who had an epidural required lower doses of opioids postoperatively, while those on chronic preoperative opioids, those whose mesh was fixated using transfascial sutures, and those who received large doses of opioids intraoperatively required higher doses of postoperative opioids. Hospital length of stay was longer in patients who received transfascially sutured mesh and those on chronic opioids preoperatively.

Conclusions:

This study provides potential strategies to improve pain control and minimize narcotic consumption postoperatively in patients undergoing abdominal wall reconstruction. Intraoperative administration of opioids should be minimized to avoid the development of tolerance. Epidural analgesia reduces postoperative narcotic requirement and may be especially beneficial in patients at highest risk for postoperative pain, including those on chronic opioids, and those in whom transfascial sutures are used for mesh fixation.

The effects of intra- and post-operative anaesthesia and analgesia choice on outcome after gastric cancer resection: a retrospective study

Background

Epidural use can provide a better short-term outcome and protect patients from the postoperative development of tumour recurrence and metastases. In this study, we sought to assess the effects of intra- and postoperative anaesthesia and analgesia choice on outcome after gastric cancer resection, searched for evidence of interaction between intra-and postoperative epidural use and outcomes of gastric cancer patients.

Methods

Four thousand two hundred and eighteen cases of gastric cancer were identified from the Records of Hospital Patients. Patients who received only general anesthesia (GA group) or epidural anesthesia combined with general anesthesia (EGA group), were administered patient-controlled intravenous or epidural analgesia for 72-120 hours postoperatively. Flatus time, length of stay in hospital, incidence of nausea and vomiting, and visual analogue scale (VAS ) scores were collected for evaluating the short-outcome of the patients. A Kaplan-Meier log-rank test was used for a univariable analysis, and Cox proportional hazards regressions were used for a multivariable analysis of the survival time in both groups.

Results

The VAS scores and incidence of nausea and vomiting in the EGA group were lower than the GA group. There was a significant association between intra-and postoperative epidural use and improved survival.

Conclusions

These results indicated that epidural anaesthesia combined with general anaesthesia and patient-controlled epidural analgesia may be associated with the improved overall survival in gastric cancer patients who underwent resection.

Perioperative regional anaesthesia and postoperative longer-term outcomes

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.