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

Impact of spinal or epidural anaesthesia on perioperative outcomes in adult noncardiac surgery: a narrative review of recent evidence

Spinal and epidural anaesthesia and analgesia are important anaesthetic techniques, familiar to all anaesthetists and applied to patients undergoing a range of surgical procedures. Although the immediate effects of a well-conducted neuraxial technique on nociceptive and sympathetic pathways are readily observable in clinical practice, the impact of such techniques on patient-centred perioperative outcomes remains an area of uncertainty and active research. The aim of this review is to present a narrative synthesis of contemporary clinical science on this topic from the most recent 5-year period and summarise the foundational scholarship upon which this research was based. We searched electronic databases for primary research, secondary research, opinion pieces, and guidelines reporting the relationship between neuraxial procedures and standardised perioperative outcomes over the period 2018-2023. Returned citation lists were examined seeking additional studies to contextualise our narrative synthesis of results. Articles were retrieved encompassing the following outcome domains: patient comfort, renal, sepsis and infection, postoperative cancer, cardiovascular, and pulmonary and mortality outcomes. Convincing evidence of the beneficial effect of epidural analgesia on patient comfort after major open thoracoabdominal surgery outcomes was identified. Recent evidence of benefit in the prevention of pulmonary complications and mortality was identified. Despite mechanistic plausibility and supportive observational evidence, there is less certain experimental evidence to support a role for neuraxial techniques impacting on other outcome domains. Evidence of positive impact of neuraxial techniques is best established for the domains of patient comfort, pulmonary complications, and mortality, particularly in the setting of major open thoracoabdominal surgery. Recent evidence does not strongly support a significant impact of neuraxial techniques on cancer, renal, infection, or cardiovascular outcomes after noncardiac surgery in most patient groups.

Classic incisional hernia repair under awake thoracic combined spinal -epidural anesthesia in a geriatric patient with multiple co-morbidities

INTRODUCTION AND IMPORTANCE

Routine general anesthesia with tracheal intubation is an undesirable and risky technique in individuals with pre-existing chronic respiratory diseases undergoing abdominal surgery. Instead, other modalities of regional anesthesia, such as combined thoracic spinal -epidural anesthesia, could be used as the only anesthetic technique with more excellent health care outcomes.

CASE PRESENTATION

We introduce a 72-year-old morbidly obese female with multiple comorbidities who underwent successful open surgical repair for incarcerated abdominal hernia under awake combined thoracic spinal -epidural anesthesia. The procedure proceeded smoothly without any cardio-pulmonary complications. The patient was then admitted to the Surgical Intensive Care Unit for close monitoring. Six days later, she was discharged home with good general status without any complications.

CLINICAL DISCUSSION

Superior results are reported for combined thoracic spinal -epidural anesthesia over GA in reducing postoperative respiratory events and enhancing outcomes by blunting the stress response. In particular, in challenging airways, combined thoracic spinal -epidural anesthesia offers various benefits, one of which is reducing airway handling. Hemodynamic stability is another frequently mentioned feature.

CONCLUSION

Patients with high-risk conditions are a big challenge for anesthesiologists. The standard practice of general anesthesia should be avoided in this group of patients, as it exposes them to many threats. In this report, we highly advocate using regional anesthesia in this group of patients. This type of anesthesia significantly decreases intra and post-operative anesthetic complications.

Effects of midline laparotomy on cough strength: a prospective study measuring cough pressure

BACKGROUND

Laparotomy is assumed to decrease cough strength due to three factors: abdominal muscle trauma, postoperative pain, and diaphragmatic dysfunction. However, the effect of trauma from laparotomy itself on strength (net of the other two factors) has not been measured to our knowledge. The aim of this study was to measure the effect of laparotomy on cough strength after first measuring the effect of epidural analgesia.

METHODS

In 11 patients scheduled for open midline laparotomy, cough pressure (PCOUGH), a proxy for strength, was measured with a rectal balloon at three moments: before the procedure, at baseline; before surgery, under epidural bupivacaine to T6; and postoperatively, under epidural bupivacaine to the same analgesic level (T6). Continuous variables were compared using the Wilcoxon signed-rank test. The repeatability of PCOUGH measurements was confirmed with the intraclass correlation coefficient (ICC). Pain on coughing, hand grip strength, and the Ramsay and modified Bromage scores were also recorded.

RESULTS

Median (interquartile range) PCOUGH decreased from a baseline of 103 (89-137) to 71 (56-116) cmH2O under presurgical epidural bupivacaine (P=0.003). Postoperative PCOUGH remained unchanged at 76 (46-85) cmH2O under epidural analgesia (P=0.131). The ICCs indicated excellent repeatability of the PCOUGH measurements (P<0.001). Pain on coughing was 0 to 1 in all subjects. Hand grip strength and the Ramsay and Bromage scores were unchanged.

CONCLUSIONS

Although thoracic epidural bupivacaine reduces cough strength as measured by PCOUGH, midline laparotomy does not further reduce strength in the presence of adequate epidural analgesia.

Enhanced perioperative care in emergency general surgery: the WSES position paper

Enhanced perioperative care protocols become the standard of care in elective surgery with a significant improvement in patients' outcome. The key element of the enhanced perioperative care protocol is the multimodal and interdisciplinary approach targeted to the patient, focused on a holistic approach to reduce surgical stress and improve perioperative recovery. Enhanced perioperative care in emergency general surgery is still a debated topic with little evidence available. The present position paper illustrates the existing evidence about perioperative care in emergency surgery patients with a focus on each perioperative intervention in the preoperative, intraoperative and postoperative phase. For each item was proposed and approved a statement by the WSES collaborative group.

Enhanced recovery after surgery protocols and emergency surgery: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

This systematic review and meta-analysis seeks to assess the modified protocols used and patient outcomes when enhanced recovery after surgery (ERAS) protocols are utilized in an emergency setting.

METHODS

PubMed, MEDLINE, EMBASE and Cochrane Central Registry of Controlled Trials were comprehensively searched until 13 March 2023. The Cochrane Risk of Bias Assessment Tool was used to assess for bias, along with funnel plot asymmetry. We present log risk ratios for dichotomous variables and raw mean differences for continuous variables.

RESULTS

Seven randomized trials were included, comprising 573 patients. Results of the primary outcomes when comparing ERAS to standard care are as follows; withdrawal of nasogastric tube (raw mean difference -1.87 CI: -2.386 to -1.359), time to first liquid diet (raw mean difference -2.56 CI: -3.435 to -1.669), time to first solid diet (raw mean difference -2.35 CI: -2.933 to -1.76), time to first flatus (raw mean difference -2.73 CI: -5.726 to 0.257), time to first stool passed (raw mean difference -1.83 CI: -2.307 to -1.349), time to removal of drains (raw mean difference -3.23 CI: -3.609 to -2.852), time to removal of urinary catheter (raw mean difference -1.57 CI: -3.472 to 0.334), mean pain score (raw mean difference -1.79 CI: -2.222 to -1.351) and length of hospital stay (raw mean difference -3.16 CI: -3.688 to -2.63).

CONCLUSIONS

The adoption of ERAS protocols in an emergency surgery setting was observed to enhance patient recovery, while not indicating any statistically significant increase in adverse outcomes.

Emergency Awake Abdominal Surgery Under Thoracic Epidural Anaesthesia in a High-Risk Patient Within a Resource-Limited Setting

Awake abdominal surgery is performed daily around the world for caesarean section surgery under lumbar subarachnoid anaesthesia and/or graded lumbar epidural anaesthesia. Reports of awake abdominal surgery under thoracic epidural anaesthesia (TEA) for patients with bowel obstruction are scarce, as this patient population is at high risk for pulmonary aspiration. In this report, we describe a case in which a graded TEA was successfully used as the sole anaesthetic technique in a patient with severe pulmonary disease undergoing an awake emergency laparotomy for bowel ischaemia for whom no postoperative intensive care monitoring was available. No anaesthetic or surgical complications occurred, and the patient was discharged home seven days after the surgical procedure. A 30-day follow-up revealed no residual anaesthetic or surgical complications, with a return to baseline function.

Emergency Laparotomy

Emergency laparotomy is a high-risk surgical procedure with mortality and morbidity up to 10 times higher than for a similar procedure performed electively. An enhanced recovery approach has been shown to improve outcomes. A focus on rapid correction of underlying deranged acute physiology and proactive management of conditions associated with aging such as frailty and delirium are key. Patients are at high risk of complications and prevention and avoidance of failure to rescue are essential to improve outcomes. Other enhanced recovery components such as opioid-sparing analgesia and early postoperative mobilization are beneficial.

Inflammatory response, fluid balance and outcome in emergency high-risk abdominal surgery

BACKGROUND

The main disease etiologies requiring emergency high-risk abdominal surgery are intestinal obstruction and perforated viscus and the differences in immune response to these pathologies are largely unexplored. In search of improvement of patient assessment in the perioperative phase, we examined the inflammatory response in this setting, focusing on potential difference in pathophysiology.

METHODS

The electronic medical records of 487 patients who underwent emergency abdominal surgery from year 2013-2015 for intestinal obstruction and perforated viscus were reviewed. We evaluated the relationship between pre- and postoperative C-reactive protein (CRP) trajectory, fluid balance, and perioperative morbidity and mortality according to type of surgery, intervention, and surgical pathology.

RESULTS

A total of 418 patients were included. Pre- and postoperative absolute CRP values were significantly higher in patients with perforated viscus (n = 203) than in intestinal obstruction (n = 215) (P < .0001). Relative changes at hour 6 and POD 1 were non-significant (P = .716 and P = .816 respectively). There was significant association between both pre- (quartile 1 vs 4, OR 5.11; P < .01) and postoperative (quartile 1 vs 4, OR 4.10; P < .001) CRP and adverse outcome, along with fluid balance and adverse outcome in patients with obstruction but not in those with perforation. Fluid balance and CRP had statistically significant positive correlation in patients with obstruction.

CONCLUSIONS

In this explorative study, a high pre- and postoperative CRP and a high positive fluid balance were associated with worse outcome in patients with intestinal obstruction, but not in patients with perforated viscus. Future studies should address the different inflammatory and fluid trajectories in these specific pathologies.

The impact of ultrasound-guided bilateral rectus sheath block in patients undergoing cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy - a retrospective study

Background

Rectus sheath block (RSB) is known to attenuate postoperative pain and reduce perioperative opioid consumption. Thus, a retrospective study was performed to examine the effects of bilateral rectus sheath block (BRSB) in cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC).

Methods

A total of 178 patients undergoing CRS/HIPEC at our hospital were included. Patient information and anaesthesia-related indicators were collected from the electronic medical record (EMR) system. All subjects were divided into the following two groups: the G group (general anaesthesia) and the GR group (RSB combined with general anaesthesia). Patients in the GR group received 0.375% ropivacaine for BRSB before surgery. The primary outcomes included the total amount of remifentanil and rocuronium, the total consumption of dezocine after surgery, the visual analogue scale (VAS) score and the patient-controlled intravenous analgesia (PCIA) input dose at 1 h (T6), 6 h (T7), 12 h (T8), 24 h (T9) and 48 h (T10) after surgery. Other outcomes were also recorded, such as patient demographic data, the intraoperative heart rate (HR) and mean arterial pressure (MAP), and postoperative complications.

Results

Compared with the G group, the GR group showed a shorter time to tracheal extubation (P < 0.05), a decreased total amount of remifentanil and rocuronium (P < 0.05), and a reduced VAS score, PCIA input dose and number of PCIA boluses at 1 h, 6 h and 12 h after surgery (P < 0.05). However, at 24 h and 48 h after surgery, there were no differences in the VAS score of pain at rest or during motion between the two groups (P > 0.05). Moreover, the incidence of hypertension, emergence agitation, delayed recovery, hypercapnia, and nausea and vomiting was lower in the GR group than in the G group (P < 0.05). There were no differences in the changes in MAP and HR during the surgery between the two groups (P > 0.05). No complications associated with nerve block occurred.

Conclusion

BRSB could provide short-term postoperative analgesia, reduce perioperative opioid consumption and reduce the incidence of postoperative complications. It is an effective and safe procedure in CRS/HIPEC.