A comparison of thoracic and lumbar epidural techniques for post-thoracoabdominal esophagectomy analgesia

Evaluating analgesia strategies in patients who have undergone oesophagectomy-a systematic review and network meta-analysis of randomised clinical trials

Optimal pain control following esophagectomy remains a topic of contention. The aim was to perform a systematic review and network meta-analysis (NMA) of randomized clinical trials (RCTs) evaluating the analgesia strategies post-esophagectomy. A NMA was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-NMA guidelines. Statistical analysis was performed using Shiny and R. Fourteen RCTs which included 565 patients and assessed nine analgesia techniques were included. Relative to systemic opioids, thoracic epidural analgesia (TEA) significantly reduced static pain scores at 24 hours post-operatively (mean difference (MD): -13.73, 95% Confidence Interval (CI): -27.01-0.45) (n = 424, 12 RCTs). Intrapleural analgesia (IPA) demonstrated the best efficacy for static (MD: -36.2, 95% CI: -61.44-10.96) (n = 569, 15 RCTs) and dynamic (MD: -42.90, 95% CI: -68.42-17.38) (n = 444, 11 RCTs) pain scores at 48 hours. TEA also significantly reduced static (MD: -13.05, 95% CI: -22.74-3.36) and dynamic (MD: -18.08, 95% CI: -31.70-4.40) pain scores at 48 hours post-operatively, as well as reducing opioid consumption at 24 hours (MD: -33.20, 95% CI: -60.57-5.83) and 48 hours (MD: -42.66, 95% CI: -59.45-25.88). Moreover, TEA significantly shortened intensive care unit (ICU) stays (MD: -5.00, 95% CI: -6.82-3.18) and time to extubation (MD: -4.40, 95% CI: -5.91-2.89) while increased post-operative forced vital capacity (MD: 9.89, 95% CI: 0.91-18.87) and forced expiratory volume (MD: 13.87, 95% CI: 0.87-26.87). TEA provides optimal pain control and improved post-operative respiratory function in patients post-esophagectomy, reducing ICU stays, one of the benchmarks of improved post-operative recovery. IPA demonstrates promising results for potential implementation in the future following esophagectomy.

Segmental thoracic epidural anaesthesia in a dog undergoing intercostal thoracotomy and lung lobectomy

A seven-year-old, 25-kg female crossbreed dog received segmental thoracic epidural anaesthesia for left lateral thoracotomy and lung lobectomy. At presentation mild exercise intolerance and weight loss were reported. A chest CT scan revealed a solitary soft tissue mass in the left caudal lobe. Lung lobectomy surgery was scheduled. Under isoflurane anaesthesia, an epidural catheter was threaded through T13–L1 and advanced 50 mm cranially. Bupivacaine and morphine were administered 30 minutes before incision and at 12-hour intervals thereafter. To minimise side effects, the postoperative dose was titrated to guarantee segmental analgesia. Purposeful movements and signs of sympathetic stimulation in response to surgery were not observed. Intraoperatively, a transient 13% increase in arterial blood pressure occurred, while heart rate remained stable compared with baseline. Although the intended postoperative dose was decreased to prevent side effects, pain scores were below the analgesic intervention score. The catheter was removed on the fourth postoperative day. Complications and neurological sequelae were not noticed.

Postoperative pain management after esophagectomy: a systematic review and meta-analysis

Effective pain management after esophagectomy is essential for patient comfort, early recovery, low surgical morbidity, and short hospitalization. This systematic review and meta-analysis aims to determine the best pain management modality focusing on the balance between benefits and risks. Medline, Embase, and the Cochrane library were systematically searched to identify all studies investigating different pain management modalities after esophagectomy in relation to primary outcomes (postoperative pain scores at 24 and 48 hours, technical failure, and opioid consumption), and secondary outcomes (pulmonary complications, nausea and vomiting, hypotension, urinary retention, and length of hospital stay). Ten studies investigating systemic, epidural, intrathecal, intrapleural and paravertebral analgesia involving 891 patients following esophagectomy were included. No significant differences were found in postoperative pain scores between systemic and epidural analgesia at 24 (mean difference (MD) 0.89; 95% confidence interval (CI) -0.47-2.24) and 48 hours (MD 0.15; 95%CI -0.60-0.91), nor described for systemic and other regional analgesia. Also, no significant differences in pulmonary complication rates were identified between systemic and epidural analgesia (relative risk (RR) 1.69; 95%CI 0.86-3.29), or between systemic and paravertebral analgesia (RR 1.49; 95%CI 0.31-7.12). Technical failure ranged from 17% to 22% for epidural analgesia. Sample sizes were too small to draw inferences on opioid consumption, the risk of nausea and vomiting, hypotension, urinary retention, and length of hospital stay when comparing the different pain management modalities including systemic, epidural, intrathecal, intrapleural, and paravertebral analgesia. This systematic review and meta-analysis shows no differences in postoperative pain scores or pulmonary complications after esophagectomy between systemic and epidural analgesia, and between systemic and paravertebral analgesia. Further randomized controlled trails are warranted to determine the optimal pain management modality after esophagectomy.

Thoracic Epidural Analgesia

Thoracic epidural analgesia (TEA) offers a unique oppor tunity for the anesthesiologist to enhance postopera tive recovery for the thoracic surgery patient. By deliver ing analgesics to a limited dermatomal distribution, TEA can provide profound segmental analgesia and also serves to modulate neural outflow to improve cardiac and pulmonary parameters. The notable side-effects of hypotension and respiratory depression can be mini mized by using synergistic combinations of local anes thetic and opioids, and by adopting a continuous infu sion strategy. With thoughtful patient selection, careful technique, and a proactive approach to the recognition of the known hemodynamic and respiratory effects of epidural drugs, TEA can be administered safely. The significant benefits of TEA include better pain relief, increased FEV1, earlier extubation, and, perhaps, de creased morbidity and mortality.

Perioperative multimodal anesthesia using regional techniques in the aging surgical patient

Background. Elderly patients have unique age-related comorbidities that may lead to an increase in postoperative complications involving neurological, pulmonary, cardiac, and endocrine systems. There has been an increase in the number of elderly patients undergoing surgery as this portion of the population is increasing in numbers. Despite advances in perioperative anesthesia and analgesia along with improved delivery systems, monotherapy with opioids continues to be the mainstay for treatment of postop pain. Reliance on only opioids can oftentimes lead to inadequate pain control or increase in the incidence of adverse events. Multimodal analgesia incorporating regional anesthesia is a promising alternative that may reduce needs for high doses and dependence on opioids along with any potential associated adverse effects. Methods. The following databases were searched for relevant published trials: Cochrane Central Register of Controlled Trials and PubMed. Textbooks and meeting supplements were also utilized. The authors assessed trial quality and extracted data. Conclusions. Multimodal drug therapy and perioperative regional techniques can be very effective to perioperative pain management in the elderly. Regional anesthesia as part of multimodal perioperative treatment can often reduce postoperative neurological, pulmonary, cardiac, and endocrine complications. Regional anesthesia/analgesia has not been proven to improve long-term morbidity but does benefit immediate postoperative pain control. In addition, multimodal drug therapy utilizes a variety of nonopioid analgesic medications in order to minimize dosages and adverse effects from opioids while maximizing analgesic effect and benefit.

A survey of postoperative epidural and intravenous analgesia in Greece

BACKGROUND AND OBJECTIVE

Epidural and intravenous analgesia are widely used for postoperative pain management. Efficacy and safety is enhanced with the establishment of acute pain services. We studied the terms of application of these techniques in Greek hospitals and compared practices between anaesthetic departments with or without acute pain services.

METHODS

We performed a postal survey regarding departmental policy on the application of epidural and intravenous analgesia, patient monitoring, audit and educational activities, acute pain service teams and proposals for improvement. Pain services were classified according to predetermined quality criteria. Hospitals with or without acute pain services were compared.

RESULTS

Response rate was 46.3% (51 of 110 departments). Epidural analgesia was used in 49 departments, equally applied as intermittent boluses or continuous infusion. Twenty-two of the 39 departments that were using continuous infusion, used exclusively a lumbar approach. Intravenous analgesia was used by 42 (82%) departments; 13 used exclusively continuous infusion. All eight departments that had an established acute pain service fulfilled the predefined quality criteria compared with only ten of the remaining 43 (P < 0.001).

CONCLUSION

Our study discloses important issues regarding the use of intravenous and epidural analgesia and postoperative patient monitoring in Greek hospitals. Implementation of acute pain services that are satisfying the quality criteria may help to improve patient care.

Prise en charge anesthésique de l'œsophagectomie: avancées et perspectives

Oesophagectomy is still characterized by a high postoperative mortality and respiratory morbidity. Nevertheless, epidemiological, medical and surgical advances have improved the management of this surgical procedure. The anaesthesiologist influence is present at each level, from the preoperative evaluation to the management of postoperative complications. The preoperative period is improved by the use of assessment scores, the better knowing of respiratory risk factors and of the neoadjuvant therapy adverse effects. The main objective of the operative period is to ensure a rapid weaning procedure and stability of the respiratory and haemodynamic functions, warranting the anastomotic healing. The interest of the association between respiratory rehabilitation and thoracic epidural analgesia is highlighted in the postoperative period. The management of postoperative complications, mainly represented by respiratory failure and anastomotic leakages, requires a multidisciplinary analysis. The potential interest of non-invasive ventilation and of the modulation of postoperative inflammatory response needs further investigation.

Advantages and disadvantages of adrenaline in regional anaesthesia

Adrenaline has been added to local anaesthetic solutions for more than a century. The aim has been to delay the absorption of the local anaesthetic drug and to prolong and enhance its anaesthetic effect, both in peripheral and central neuraxial blockades. The intention in this chapter has been to give up-to-date knowledge about adrenaline as an adjuvant to local anaesthetics and/or opioids in clinical peripheral and central blockades. My own research has focused on optimizing postoperative epidural analgesia by adding adrenaline and/or fentanyl to an epidural mixture with dilute bupivacaine or ropivacaine. The main part of this chapter will therefore focus on the advantages and disadvantages of adrenaline in epidural analgesia. However, recent knowledge about adrenaline in peripheral blockade will also be covered, together with some pharmaceutical comments on the shelf-life of local anaesthetic mixtures containing adrenaline.

Epidural Analgesia for Postoperative Pain

Epidural analgesia provides superior analgesia compared with other postoperative analgesic techniques. Additionally, perioperative epidural analgesia confers physiologic benefits, which may potentially decrease perioperative complications and improve postoperative outcome. However, there are many variables (eg, choice of analgesics, catheter-incision congruency, and duration of analgesia) that may influence the efficacy of epidural analgesia. In addition, the use of epidural analgesia should be evaluated on an individual basis because there are risks associated with this technique.

Impact of Acute Pain and Its Management for Thoracic Surgical Patients

Perioperative analgesia for thoracotomy has evolved in concert with increasing knowledge of the impact of pain on recovery, the origin of this pain, and new methods for treating it. Thoracic surgery is one of the few areas where there is more general agreement between surgeons and anesthesiologists as to the importance of aggressive pain management, often with an indwelling epidural catheter left in place until after thoracostomy tube removal. The reasons for this agreement is that it has become increasingly clear to both specialties that pain puts patients with decreased pulmonary reserve who undergo thoracotomy at greater risk for morbidity. Future studies need to examine drugs or drug combinations that can lead to further reductions in the often intense pain that patients receiving aggressive epidural analgesia still experience. Studies directed at finding interventions capable of reducing the rate of long-term postthoracotomy pain still need to be performed.

Strategies for postoperative pain management

Despite advances in our understanding of the neurobiology of nociception, postoperative pain continues to be undertreated. There are many modalities that may provide effective postoperative analgesia, including systemic (e.g. opioids, non-steroidal anti-inflammatory agents) and regional analgesic options. The particular modality or modalities utilized for a particular patient will depend on the risk-benefit profile and patient preferences. Ideally, analgesic options should be incorporated into a multimodal approach to facilitate patient recovery after surgery.

Patient-controlled epidural analgesia reduces analgesic requirements compared to continuous epidural infusion after major abdominal surgery

PURPOSE

To compare the quality of pain relief and incidence of side effects between 24-hr postoperative continuous epidural infusion (CEI) and subsequent patient-controlled epidural analgesia (PCEA) with different analgesics after major abdominal surgery.

METHODS

Twenty-eight women undergoing extended gynecological tumour surgery received postoperative CEI with 0.15 mL x kg(-1) x hr(-1) 0.2% ropivacaine (R: n = 14) or 0.125% bupivacaine plus 0.5 micro g x mL(-1) sufentanil (BS: n = 14) during 24 postoperative hours. Twenty-four hours later, postoperative pain management was switched to PCEA without background infusion and 5 mL single bolus application of R or BS every 20 min at most. Visual analogue scales (VAS; 1-100 mm) were assessed by patients at rest and on coughing after 24 hr of CEI and PCEA. Side effects, doses of local anesthetics and opioids were recorded and plasma concentrations of total and unbound ropivacaine and bupivacaine were measured.

RESULTS

Patients required lower doses of each respective analgesic medication with PCEA (R: 108 +/- 30 mL; BS: 110 +/- 28 mL) than with CEI (R: 234 +/- 40; BS: 260 +/- 45; P < 0.01). Ropivacaine plasma concentrations were lower 24 hr after PCEA when compared with CEI (P < 0.01). No patient after PCEA but two after CEI (n = 4; NS) presented motor block. PCEA with R provided better postoperative pain relief than CEI (37 +/- 32 vs 59+/-27, P < 0.05). No difference in parenteral opioid rescue medication between CEI and PCEA was seen.

CONCLUSION

PCEA in comparison to preceding CEI provides equivalent analgesia with lower local anesthetic doses and plasma levels, and without motor blocking side effects, irrespective of the applied drug regimen.