Seven years of patient-controlled epidural analgesia in a Swedish hospital: A prospective survey

ASRA Pain Medicine consensus practice infection control guidelines for regional anesthesia and pain medicine

BACKGROUND

To provide recommendations on risk mitigation, diagnosis and treatment of infectious complications associated with the practice of regional anesthesia, acute and chronic pain management.

METHODS

Following board approval, in 2020 the American Society of Regional Anesthesia and Pain Medicine (ASRA Pain Medicine) commissioned evidence-based guidelines for best practices for infection control. More than 80 research questions were developed and literature searches undertaken by assigned working groups comprising four to five members. Modified US Preventive Services Task Force criteria were used to determine levels of evidence and certainty. Using a modified Delphi method, >50% agreement was needed to accept a recommendation for author review, and >75% agreement for a recommendation to be accepted. The ASRA Pain Medicine Board of Directors reviewed and approved the final guidelines.

RESULTS

After documenting the incidence and infectious complications associated with regional anesthesia and interventional pain procedures including implanted devices, we made recommendations regarding the role of the anesthesiologist and pain physician in infection control, preoperative patient risk factors and management, sterile technique, equipment use and maintenance, healthcare setting (office, hospital, operating room), surgical technique, postoperative risk reduction, and infection symptoms, diagnosis, and treatment. Consensus recommendations were based on risks associated with different settings and procedures, and keeping in mind each patient's unique characteristics.

CONCLUSIONS

The recommendations are intended to be multidisciplinary guidelines for clinical care and clinical decision-making in the regional anesthesia and chronic interventional pain practice. The issues addressed are constantly evolving, therefore, consistent updating will be required.

The Role of Patient-Controlled Epidural Analgesia in the Short-Term Outcomes of Laparoscopic-Assisted Gastrectomy in Elderly Gastric Cancer Patients

INTRODUCTION

Patient-controlled intravenous analgesia (PCIA) and patient-controlled epidural analgesia (PCEA) constitute two major advances in pain management after major abdominal surgery. However, the role of PCIA or PCEA has not been particularly studied in elderly patients with gastric cancer. The aim of this study is to make a comparison between PCIA and PCEA in terms of their performance on short-term outcomes in elderly patients undergoing laparoscopic-assisted gastrectomy.

METHODS

This single-center, retrospective study included 254 elderly patients (≥70 y) who underwent laparoscopic radical gastrectomy for gastric cancer. Patients received either general anesthesia combined with epidural anesthesia followed by PCEA (PCEA group, n = 123) or general anesthesia alone followed by PCIA (PCIA group, n = 131). The primary endpoint was pain intensity-tested using a 100-mm visual analog scale on postoperative days 1, 2, and 3. Demographics, comorbidities, perioperative data, postoperative short-term outcomes, and analgesia-related side effects were also assessed.

RESULTS

The visual analog scale scores at rest were lower in the PCEA group compared to the PCIA group on postoperative day 1, 2, and 3 (27.8 ± 13.9 versus 33.1 ± 15.0, P = 0.004; 25.2 ± 11.3 versus 30.1 ± 14.3, P = 0.002; 16.9 ± 7.1 versus 20.9 ± 9.5, P < 0.001, respectively). The postoperative hospital stay was shorter in the PCEA group than in the PCIA group (11 versus 12 d, P = 0.018). The times to postoperative first flatus, semifluid diet, independent ambulation, and tracheal extubation after surgery in the PCEA group were significantly shorter than in the PCIA group. Overall morbidity, mortality, hospital readmission rate, and reoperation rate were not significantly different between the two groups. Regarding side-effects related to analgesia, there were no significant differences in terms of the rates of postoperative nausea and vomiting, urinary retention, or oxygen saturation <90% between the two groups. However, PCEA was associated with a higher incidence of postoperative hypotension compared to PCIA (10.6% versus 3.8%, P = 0.036).

CONCLUSIONS

In elderly patients undergoing laparoscopic radical gastrectomy, epidural anesthesia and analgesia may convey superior pain relief, faster restoration of gastrointestinal motility, and shorter hospitalization.

Infectious complications following regional anesthesia: a narrative review and contemporary estimates of risk

INTRODUCTION

Infectious complications following regional anesthesia (RA) while rare, can be devastating. The objective of this review was to estimate the risk of infectious complications following central neuraxial blocks (CNB) such as epidural anesthesia (EA), spinal anesthesia (SA) and combined spinal epidural (CSE), and peripheral nerve blocks (PNB).

MATERIALS AND METHODS

A literature search was conducted in PubMed, Embase and Cochrane databases to identify reference studies reporting infectious complications in the context of RA subtypes. Both prospective and retrospective studies providing incidence of infectious complications were included for review to provide pooled estimates (with 95% CI). Additionally, we explored incidences specifically associated with spinal anesthesia, incidences of central nervous system (CNS) infections and, the incidences of overall and CNS infections following CNB in obstetric population.

RESULTS

The pooled estimate of overall infectious complications following all CNB was 9/100 000 (95% CI: 5, 13/100 000). CNS infections following all CNB was estimated to be 2/100 000 (95% CI: 1, 3/100 000) and even rarer following SA (1/100 000 (95% CI: 1, 2/100 000)). Obstetric population had a lower rate of overall (1/100 000 (95% CI: 1, 3/100 000)) and CNS infections (4 per million (95% CI: 0.3, 1/100 000)) following all CNB. For PNB catheters, the reported rate of infectious complications was 1.8% (95% CI: 1.2, 2.5/100).

DISCUSSION

Our review suggests that the risk of overall infectious complications following neuraxial anesthesia is very rare and the rate of CNS infections is even rarer. The infectious complications following PNB catheters seems significantly higher compared with CNB. Standardizing nomenclature and better reporting methodologies are needed for the better estimation of the infectious complications.

Perioperative Comfort and Discomfort: Transitioning From Epidural to Oral Pain Treatment After Pancreas Surgery: A Qualitative Study

PURPOSE

To explore patients' experiences of pain treatment in the perioperative period after surgery for pancreatic cancer.

DESIGN

A qualitative descriptive design using semi-structured interviews.

METHODS

This study was a qualitative study based on 12 interviews. Participants were patients that had undergone surgery for pancreatic cancer. The interviews were conducted 1 to 2 days after the epidural was turned off, in a surgical department in Sweden. The interviews were analysed with qualitative content analysis. The Standard for Reporting Qualitative Research checklist was used for reporting the qualitative research study.

FINDINGS

The analysis of the transcribed interviews, generated one theme: Maintaining a sense of control in the perioperative phase, and two subthemes: (i) Sense of vulnerability and safety, and (ii) Sense of comfort and discomfort, were found.

CONCLUSIONS

The participants experienced comfort after pancreas surgery if they maintained a sense of control in the perioperative phase and when the epidural pain treatment provided pain relief without any side effects. The transition from epidural pain treatment to oral pain treatment with opioid tablets was experienced individually, from an almost unnoticed transition to the experience of severe pain, nausea, and fatigue. The sense of vulnerability and safety among the participants were affected by nursing care relationship and the environment on the ward.

Complications of Postoperative Epidural Analgesia For Oncologic Surgery: A Review of 18,895 Cases

OBJECTIVE

The risks of epidural analgesia (EA) differ depending on the population studied. We describe our experience with postoperative EA for oncologic surgery.

MATERIALS AND METHODS

We searched our Acute Pain Medicine database for cases in which postoperative EA was used between 2003 and 2012. We used word search to identify and catalog cases of neurological changes, magnetic resonance imaging or computed tomography of the spine, electromyography studies, and neurologist or neurosurgeon consultations. Medical records of patients with documented persistent neurological deficits and patients who had spine imaging or neurology consultations were reviewed further. In addition, we cross-checked medical records with billing diagnosis codes for spinal epidural abscess or hematoma.

RESULTS

We reviewed 18,895 cases in which postoperative EA was used. Complications included neurological symptoms in 2436 cases (12.9%), epidural insertion site abnormalities in 1062 cases (5.6%), complete epidural catheter migration in 829 cases (4.4%), epidural replacement in 619 cases (3.3%), and inadvertent dura puncture in 322 cases (1.7%). There were 6 cases of persistent deficits of uncertain etiology, 4 deep spinal infections (1:4724), and 2 cases of catheter tip shearing. No spinal epidural hematomas were identified (95% confidence interval, 0-0.0002).

DISCUSSION

Our findings provide a contemporary review of some risks associated with the use of postoperative EA for patients undergoing oncologic surgery. Despite a not-uncommon incidence of neurological changes, serious complications resulting in prolonged sequelae were rare.

Patient satisfaction with continuous epidural analgesia after major surgical procedures at a Swedish University hospital

Objective

The use of epidural analgesia after major surgery is a well-established analgesia method. Epidural analgesia for postoperative pain relief needs to be monitored regularly in order to evaluate patient satisfaction and avoid side effects. However, due to the new available regional techniques, the role of epidural analgesia is being questioned and data about patient satisfaction is lacking. The current study was designed to evaluate patient satisfaction with epidural analgesia, its efficacy and reasons for premature termination of epidural analgesia.

Materials and methods

We conducted a retrospective survey of all patients who undergone surgery at Uppsala University hospital between October 2012 and January 2014 requiring continuous epidural analgesia for postoperative pain relief. Patients’ satisfaction with epidural analgesia and its effectiveness were evaluated by using paper questionnaire.

Results

During the study period 579 epidurals were inserted in patients scheduled for vascular, hepatobiliary, esophageal and other major abdominal surgery. The average treatment time was 3.8±1.8 days. Epidural analgesia consisted either of bupivacaine 0.1%+sufentanil 1 μg/ml solution or ropivacaine 0.2% solution. If patient needed opiates during treatment with epidural analgesia, only ropivacaine 0,2% solution was used. 494 (87.9%) patients were satisfied with their analgesia with no difference in satisfaction between sexes being observed. In 62 cases (11.2%) patient controlled analgesia was used on top of epidural analgesia with ropivacaine 0.2% solution, and 50.8% of patients were satisfied in this group. 514 (91.4%) patients were reported as having a good effect, 24 (4.3%) patients reported or were tested to show some effect, and 24 (4.3%) had no effect. No major neurological complications (epidural hematoma or abscess) were observed.

Conclusions

Our retrospective survey indicates that patients are satisfied with continuous epidural analgesia used in major surgery.

The association between epidural analgesia and mortality in emergency abdominal surgery: A population-based cohort study

BACKGROUND

Emergency abdominal surgery carries a considerable risk of mortality and post-operative complications, including pulmonary complications. In major elective surgery, epidural analgesia reduces mortality and pulmonary complications. We aimed to evaluate the association between epidural analgesia and mortality in emergency abdominal surgery.

METHODS

In this population-based cohort study with prospective data collection, we included adults undergoing emergency abdominal laparotomy or laparoscopy between 1 January 2009 and 31 December 2010 at 13 Danish hospitals. Appendectomies were excluded. The primary outcome was 90-day mortality. Secondary outcomes included 30-day mortality and serious adverse events. We used binary logistic regression analyses (odds ratios (ORs) with 95% confidence intervals (CIs)).

RESULTS

We included 4920 patients, of whom 1134 (23.0%) died within 90 days. Overall, 27.9% of the patients were treated with epidural analgesia perioperatively. This increased to 34.0% among patients undergoing major laparotomy. The crude and adjusted association between epidural analgesia and 90-day mortality was OR 0.99 (95%CI: 0.86-1.15, P = .94) and OR 0.80 (95%CI: 0.67-0.94; P = .01), respectively. For 30-day mortality the corresponding estimates were OR 0.90 (95% CI: 0.76-1.06, P = .21) and OR 0.75 (95% CI: 0.62-0.90, P < .01), respectively. No serious adverse events were reported.

CONCLUSION

In this population-based cohort study of adult patients undergoing emergency abdominal surgery, we found that the use of epidural analgesia perioperatively was associated with a decreased risk of mortality in the adjusted analysis.

Influence on number of top-ups after implementing patient controlled epidural analgesia: A cohort study

Postoperative epidural analgesia often needs rate readjustment using top-ups. Patient-controlled epidural analgesia (PCEA) is said to reduce the requirement of epidural top-ups when compared to continuous epidural analgesia (CEA). We compared CEA and PCEA in major thoracic and abdominal surgery, in a cohort study. The primary endpoint was the required number of epidural top-ups. Secondary endpoints were pain scores, side effects and workload differences. We analysed 199 patients with CEA and 187 with PCEA. Both groups had similar pain scores. The total number of top-ups was 75 in 57 patients (CEA) versus 20 top-ups in 18 patients (PCEA). (p = 0.0001) Sedation tended to occur more frequently in patients with CEA versus PCEA, 5.5% vs 1.6% (p = 0.05). Implementation of PCEA led to a decreased number of top-ups, fewer side-effects and decreased use of the postoperative care unit.

Endogenous Opiates and Behavior: 2015

This paper is the thirty-eighth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2015 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia, stress and social status, tolerance and dependence, learning and memory, eating and drinking, drug abuse and alcohol, sexual activity and hormones, pregnancy, development and endocrinology, mental illness and mood, seizures and neurologic disorders, electrical-related activity and neurophysiology, general activity and locomotion, gastrointestinal, renal and hepatic functions, cardiovascular responses, respiration and thermoregulation, and immunological responses.

Epidural Hematoma and Abscess Related to Thoracic Epidural Analgesia: A Single-Center Study of 2,907 Patients Who Underwent Lung Surgery

OBJECTIVE

To report the major complications (epidural hematoma and abscess) of postoperative thoracic epidural analgesia in patients who underwent lung surgery.

DESIGN

Prospective, monocentric study.

SETTING

A university hospital.

PARTICIPANTS

All lung surgical patients who received postoperative thoracic epidural analgesia between November 2007 and November 2015.

INTERVENTIONS

Thoracic epidural analgesia for patients who underwent lung surgery.

MEASUREMENTS AND MAIN RESULTS

During the study period, data for 2,907 patients were recorded. The following 3 major complications were encountered: 1 case of epidural hematoma (0.34 case/1,000; 95% confidence interval 0.061-1.946), for which surgery was performed, and 2 cases of epidural abscesses (0.68 case/1,000; 95% confidence interval 0.189-2.505), which were treated medically.

CONCLUSIONS

The risk range of serious complications was moderate; only the patient who experienced an epidural hematoma also experienced permanent sequelae.