Neuraxial Anesthesia and Analgesia During Cardiothoracic Surgery: A Narrative Review

PURPOSE OF REVIEW

The purpose of this review is to synthesize and examine the literature on the use of neuraxial anesthesia and analgesia during cardiothoracic surgery. As cardiothoracic procedures often require systemic anticoagulation, neuraxial techniques are quite often underutilized due to the theoretical risk of epidural hematoma. In this review, we seek to examine the literature to review the indications and contraindications and to explore if neuraxial anesthesia and analgesia has a role in cardiothoracic surgery.

RECENT FINDINGS

Neuraxial techniques have multiple advantages during cardiothoracic surgery including coronary vasodilation, decreased sympathetic surge, and a decreased cortisol level leading to overall reduction in stress response. Multiple studies have shown an improvement in pain scores, reduction in pulmonary complications, faster extubation times, with minimal complications when neuraxial techniques are utilized in cardiothoracic surgeries. Given the numerous advantages and minimal complications of neuraxial techniques in cardiothoracic surgeries, we hope its utilization continues to increase. Moving forward, we hope additional studies continue to reaffirm the benefits of neuraxial anesthesia and analgesia for cardiothoracic surgeries to improve its utilization.

Immunocyte profiling changes in patients received epidural versus intravenous analgesia after pancreatectomy: A randomized controlled trial

BACKGROUND

Perioperative immunosuppressants, such as surgical stress and opioid use may downregulate anti-cancer immunocytes for patients undergoing pancreatectomy. Thoracic epidural analgesia (TEA) may attenuate these negative effects and provide better anti-cancer immunocyte profile change than intravenous analgesia using opioid.

METHODS

We randomly assigned 108 adult patients undergoing pancreatectomy to receive one of two 72-h postoperative analgesia protocols: one was TEA, and the other was intravenous patient-controlled analgesia (IV-PCA). The perioperative proportional changes of immunocytes relevant to anticancer immunity-namely natural killer (NK) cells, cytotoxic T cells, helper T cells, mature dendritic cells, and regulatory T (Treg) cells were determined at 1 day before surgery, at the end of surgery and on postoperative day 1,4 and 7 using flow cytometry. In addition, the progression-free survival and overall survival between the two groups were compared.

RESULTS

After surgery, the proportions of NK cells and cytotoxic T cells were significantly decreased; the proportion of B cells and mature dendritic cells and Treg cells were significantly increased. However, the proportions of helper T cells exhibited no significant change. These results were comparable between the two groups. Furthermore, there were no significant differences in progression-free survival (52.75 [39.96] and 57.48 [43.66] months for patients in the TEA and IV-PCA groups, respectively; p = 0.5600) and overall survival (62.71 [35.48] and 75.11 [33.10] months for patients in the TEA and IV-PCA groups, respectively; p = 0.0644).

CONCLUSIONS

TEA was neither associated with favorable anticancer immunity nor favorable oncological outcomes for patients undergoing pancreatectomy.

To evaluate the analgesic effectiveness of bilateral erector spinae plane block versus thoracic epidural analgesia in open cardiac surgeries approached through midline sternotomy

BACKGROUND

The efficacy of the erector spinae plane (ESP) block in mitigating postoperative pain has been shown for a range of thoracic and abdominal procedures. However, there is a paucity of literature investigating its impact on postoperative analgesia as well as its influence on weaning and subsequent recovery in comparison to thoracic epidural analgesia (TEA) in median sternotomy-based approach for open-cardiac surgeries and hence the study.

METHODS

Irrespective of gender or age, 74 adult patients scheduled to undergo open cardiac surgery were enrolled and randomly allocated into two groups: the Group TEA (thoracic epidural block) and the Group ESP (bilateral Erector Spinae Plane block). The following variables were analysed prospectively and compared among the groups with regard to pain control, as determined by the VAS Scale both at rest (VASR) and during spirometry (VASS), time to extubation, quantity and frequency of rescue analgesia delivered, day of first ambulation, length of stay in the intensive care unit (ICU), and any adverse cardiac events (ACE), respiratory events (ARE), or other events, if pertinent.

RESULTS

Clinical and demographic variables were similar in both groups. Both groups had overall good pain control, as determined by the VAS scale both at rest (VASR) and with spirometry (VASS) with Group ESP demonstrating superior pain regulation compared to Group TEA during the post-extubation period at 6, 9, and 12 h, respectively (P > 0.05). Although statistically insignificant, the postoperative mean rescue analgesic doses utilised in both groups were comparable, but there was a higher frequency requirement in Group TEA. The hemodynamic and respiratory profiles were comparable, except for a few arrhythmias in Group TEA. With comparable results, early recovery, fast-track extubation, and intensive care unit (ICU) stay were achieved.

CONCLUSIONS

The ESP block has been found to have optimal analgesic effects during open cardiac surgery, resulting in a decreased need for additional analgesic doses and eliminating the possibility of a coagulation emergency. Consequently, it presents itself as a safer alternative to the potentially invasive thoracic epidural analgesia (TEA).

Characterization of Epidural Analgesia Interruption and Associated Outcomes After Esophagectomy

INTRODUCTION

Interruption of thoracic epidural analgesia may impact the postoperative course following esophagectomy. This study investigates the incidence and causes of epidural interruption in esophagectomy patients along with associated postoperative outcomes.

METHODS

This single-institution retrospective analysis examined patients undergoing esophagectomy who received a thoracic epidural catheter from 2016 to 2020. Patients were stratified according to whether epidural catheter infusion was interrupted or not postoperatively. Outcomes were compared between the two groups, and predictors of epidural interruption and postoperative complications were estimated using multivariable logistic regression.

RESULTS

Of the 168 patients who received a thoracic epidural before esophagectomy, 60 (35.7%) required epidural interruption and 108 (64.3%) did not. Interruption commonly occurred on postoperative day 1 and was due to hypotension 80% of the time. Heart failure (10.0% versus 0.9%, P = 0.009), atrial fibrillation (20.0% versus 3.7%, P = 0.002), preoperative opioid use (30.0% versus 16.7%, P = 0.043), and higher American Society of Anesthesiology classification (88.4% versus 70.4%, P = 0.008) were more prevalent in the epidural interruption cohort. The female gender was associated with epidural interruption on multivariable logistic regression (adjusted odds ratio [AOR] 2.45, P = 0.039). Patients in the epidural interruption cohort had a higher incidence of delirium (30.5% versus 13.9%, P = 0.010), sepsis (13.6% versus 3.7%, P = 0.028), and severe anastomotic leak (18.3% versus 7.4%, P = 0.032). On adjusted analysis, heart disease (AOR 4.26, P = 0.027), BMI <18.5 (AOR 9.83, P = 0.031), and epidural interruption due to hypotension (AOR 3.51, P = 0.037) were associated with severe anastomotic leak.

CONCLUSIONS

Early epidural interruption secondary to hypotension in esophagectomy patients may be a harbinger of postoperative complications such as sepsis and severe anastomotic leak. Patients requiring epidural interruption due to hypotension should have a low threshold for additional workup and early intervention.

Continuous nerve block versus thoracic epidural analgesia for post-operative pain of pectus excavatum repair: a systematic review and meta-analysis

Surgery to repair pectus excavatum (PE) is often associated with severe postoperative pain, which can impact the length of hospital stay (LOS). While thoracic epidural analgesia (TEA) has traditionally been used for pain management in PE, its placement can sometimes result in severe neurological complications. Recently, paravertebral block (PVB) and erector spinae plane block (ESPB) have been recommended for many other chest and abdominal surgeries. However, due to the more severe and prolonged pain associated with PE repair, it is still unclear whether continuous administration of these blocks is as effective as TEA. Therefore, we conducted this systematic review and meta-analysis to demonstrate the equivalence of continuous PVB and ESPB to TEA.

Postoperative analgesia for upper gastrointestinal surgery: a retrospective cohort analysis

BACKGROUND

Thoracic epidural analgesia is commonly used for upper gastrointestinal surgery. Intrathecal morphine is an appealing opioid-sparing non-epidural analgesic option, especially for laparoscopic gastrointestinal surgery.

METHODS

Following ethics committee approval, we extracted data from the electronic medical records of patients at Royal North Shore Hospital (Sydney, Australia) that had upper gastrointestinal surgery between November 2015 and October 2020. Postoperative morphine consumption and pain scores were modelled with a Bayesian mixed effect model.

RESULTS

A total of 427 patients were identified who underwent open (n = 300), laparoscopic (n = 120) or laparoscopic converted to open (n = 7) upper gastrointestinal surgery. The majority of patients undergoing open surgery received a neuraxial technique (thoracic epidural [58%, n = 174]; intrathecal morphine [21%, n = 63]) compared to a minority in laparoscopic approaches (thoracic epidural [3%, n = 4]; intrathecal morphine [12%, n = 14]). Intrathecal morphine was superior over non-neuraxial analgesia in terms of lower median oral morphine equivalent consumption and higher probability of adequate pain control; however, this effect was not sustained beyond postoperative day 2. Thoracic epidural analgesia was superior to both intrathecal and non-neuraxial analgesia options for both primary outcomes, but at the expense of higher rates of postoperative hypotension (60%, n = 113) and substantial technique failure rates (32%).

CONCLUSIONS

We found that thoracic epidural analgesia was superior to intrathecal morphine, and intrathecal morphine was superior to non-neuraxial analgesia, in terms of reduced postoperative morphine requirements and the probability of adequate pain control in patients who underwent upper gastrointestinal surgery. However, the benefits of thoracic epidural analgesia and intrathecal morphine were not sustained across all time periods regarding control of pain. The study is limited by its retrospective design, heterogenous group of upper gastrointestinal surgeries and confounding by indication.

Intercostal Nerve Cryoanalgesia Versus Thoracic Epidural Analgesia in Lung Transplantation: A Retrospective Single-Center Study

INTRODUCTION

The optimal pain management strategy after lung transplantation is unknown. This study compared analgesic outcomes of intercostal nerve blockade by cryoanalgesia (Cryo) versus thoracic epidural analgesia (TEA).

METHODS

Seventy-two patients who underwent bilateral lung transplantation via clamshell incision at our center from 2016 to 2018 were managed with TEA (N = 43) or Cryo (N = 29). We evaluated analgesic-specific complications, opioid use in oral morphine equivalents (OME), and pain scores (0-10) through postoperative day 7. Adjusted linear regression was used to assess for non-inferiority of Cryo to TEA.

RESULTS

The overall mean pain scores (Cryo 3.2 vs TEA 3.8, P = 0.21), maximum mean pain scores (Cryo 4.7 vs TEA 5.5, P = 0.16), and the total opioid use (Cryo 484 vs TEA 705 OME, P = 0.12) were similar in both groups, while the utilization of postoperative opioid-sparing analgesia, measured as use of lidocaine patches, was lower in the Cryo group (Cryo 21% vs TEA 84%, P < 0.001). Analgesic outcomes remained similar between the cohorts after adjustment for pertinent patient and analgesic characteristics (P = 0.26), as well as after exclusion of Cryo patients requiring rescue TEA (P = 0.32). There were no Cryo complications, with four patients requiring subsequent TEA for pain control. Two TEA patients experienced hemodynamic instability following a test TEA bolus requiring code measures. Additionally, TEA placement was delayed beyond postoperative day 1 in 33% owing to need for anticoagulation or clinical instability.

CONCLUSIONS

In lung transplantation, Cryo was found to be safe with analgesic effectiveness similar to TEA. Cryo may be advantageous in this complex patient population, as it can be used in all clinical scenarios and eliminates risks and delays associated with TEA.

Acute pain management after thoracoscopic lung resection: a systematic review and explorative meta-analysis

OBJECTIVES

Pain after thoracoscopic surgery may increase the incidence of postoperative complications and impair recovery. Guidelines lack consensus regarding postoperative analgesia. We performed a systematic review and meta-analysis to determine the mean pain scores of different analgesic techniques (thoracic epidural analgesia, continuous or single-shot unilateral regional analgesia and only systemic analgesia) after thoracoscopic anatomical lung resection.

METHODS

Medline, Embase and Cochrane databases were searched until 1 October 2022. Patients undergoing at least >70% anatomical resections through thoracoscopy reporting postoperative pain scores were included. Due to a high inter-study variability an explorative meta-analysis next to an analytic meta-analysis was performed. The quality of evidence has been evaluated using the Grading of Recommendations Assessment, Development and Evaluation system.

RESULTS

A total of 51 studies comprising 5573 patients were included. Mean 24, 48 and 72 h pain scores with 95% confidence interval on a 0-10 scale were calculated. Length of hospital stay, postoperative nausea and vomiting, additional opioids and the use of rescue analgesia were analysed as secondary outcomes. A common-effect size was estimated with an extreme high heterogeneity for which pooling of the studies was not appropriate. An exploratory meta-analysis demonstrated acceptable mean pain scores of Numeric Rating Scale <4 for all analgesic techniques.

CONCLUSIONS

This extensive literature review and attempt to pool mean pain scores for meta-analysis demonstrates that unilateral regional analgesia is gaining popularity over thoracic epidural analgesia in thoracoscopic anatomical lung resection, despite great heterogeneity and limitations of current studies precluding such recommendations.

PROSPERO REGISTRATION

ID number 205311.

Fast-tracking with continuous thoracic epidural analgesia in paediatric congenital heart surgeries: an institutional experience

Objective

To assess the success of fast-tracking in infants and small children undergoing paediatric cardiac surgery under general anaesthesia with continuous thoracic epidural analgesia (TEA).

Methodology

It is a retrospective study at a tertiary care hospital. A total of 461 children, aged 12 years or younger, were operated for congenital heart disease over a 2-year period from January 2018 to December 2019. After the exclusion of 71 patients, data from the remaining 390 patients were analysed.

Measurements and main results

The median time for extubation after intensive care unit admission was 2 h and 25 min (0-20 h). Extubation within 6 h was achieved in 215 patients (~ 55%). Patients in the early extubation group had significantly shorter hospital stay (4.1 ± 2.3 vs 6.9 ± 3.9 days, p = 0.004) than patients in the ventilated group. Reintubation was required in 27 (6.9%) patients. Thirteen patients died postoperatively on ventilator. Patients with low nadir temperature intraoperatively and cardiopulmonary bypass time > 90 min significantly predicted failure in fast-tracking with an odds ratio (OR) = 1.27; CI: 1.18-1.38 and OR = 2.3; CI: 1.8-2.96 respectively. The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Congenital Heart Surgery mortality score, younger age, Down syndrome and high vasopressor inotropic score did not adversely affect early extubation, contrary to contemporary concerns.

Conclusions

A multimodal approach for perioperative pain relief and sedation consisting of propofol and dexmedetomidine infusion along with TEA ensures early extubation in 59% of the cases undergoing paediatric cardiac surgery. Our data suggests that fast-tracking is feasible with safe and superior outcomes in a subset of appropriate patients undergoing paediatric cardiac surgery.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12055-022-01373-8.

Purely ropivacaine-based TEA vs single TAP block in pain management after elective laparoscopic colon surgery within an upgraded institutional ERAS program

Background

The aim of this study was to compare thoracic epidural analgesia (TEA) with transversus abdominis plane (TAP) block in post-operative pain management after laparoscopic colon surgery.

Methods

One hundred thirty-six patients undergoing laparoscopic colon resection randomly received either TEA or TAP with ropivacaine only. The primary endpoint was opioid requirement up to 48 h postoperatively. Intensity of pain, time to onset of bowel function, time to mobilization, postoperative complications, length of hospital stay, and patients’ satisfaction with pain management were also assessed.

Results

We observed a significant decrease in opioid consumption on the day of surgery with TEA compared with TAP block (30 mg vs 14 mg, p < 0.001). On the first two postoperative days (POD), the balance shifted to opioid consumption being smaller in the TAP group: on POD 1 (15.2 mg vs 10.6 mg; p = 0.086) and on POD 2 (9.2 mg vs 4.6 mg; p = 0.021). There were no differences in postoperative nausea/vomiting or time to first postoperative bowel movement between the groups. No direct blockade-related complications were observed and the length of stay was similar between TEA and TAP groups.

Conclusion

TEA is more efficient for acute postoperative pain than TAP block on day of surgery, but not on the first two PODs. No differences in pain management-related complications were detected.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-021-08647-z.

The Anesthetic Management of Patients Undergoing Nonintubated Video-Assisted Thoracic Surgery

Purpose of Review

This review focuses on describing the procedural and anesthetic management of patients undergoing nonintubated video-assisted thoracoscopy surgery.

Recent Findings

Most thoracic surgery is performed under general endotracheal anesthesia with either a double lumen endotracheal tube or a bronchial blocker. In an attempt to lessen the incidence and severity of postoperative complications, the nonintubated video-assisted thoracoscopic technique was developed, where the surgical procedure is performed under regional anesthesia with sedation. Currently, this technique is recommended for the elderly and in patients with severe cardiopulmonary disease who are at increased risk of complications after general anesthesia. It is the role of the anesthesia team to assist in the decisions whether the patient is a candidate and which block should be performed and to carefully monitor these patients in the operating room.

Summary

Nonintubated video-assisted thoracic surgery is an emerging technique with the goal of reducing postoperative complications. The anesthetic technique is highly variable and ranges from general anesthesia with a laryngeal mask airway with a truncal block to thoracic epidural anesthesia with minimal to no block. It is important to have excellent communication with the surgical team and the patient to ensure a safe, successful procedure.

Continuous erector spinae plane block versus thoracic epidural analgesia in video-assisted thoracic surgery: a study protocol for a prospective randomized open label non-inferiority trial

BACKGROUND

Thoracic epidural analgesia is considered the gold standard for pain relief in video-assisted thoracoscopic surgery. This neuraxial technique blocks pain sensation by injecting a local anesthetic agent in the epidural space near the spinal cord to block spinal nerve roots. Recently, the erector spinae plane block has been introduced as a practical alternative to the thoracic epidural. This interfascial regional anesthesia technique interrupts pain sensation by injecting a local anesthetic agent in between the muscular layers of the thoracic wall. Several case series and three RCTs described it as an effective pain management technique in video-assisted thoracoscopic surgery (Scimia et al., Reg Anesth Pain Med 42:537, 2017; Adhikary et al., Indian J Anaesth 62:75-8, 2018; Kim, A randomized controlled trial comparing continuous erector spinae plane block with thoracic epidural analgesia for postoperative pain management in video-assisted thoracic surgery, n.d.; Yao et al., J Clin Anesth 63:109783, 2020; Ciftci et al., J Cardiothorac Vasc Anesth 34:444-9, 2020). The objective of this study is to test the hypothesis that a continuous erector spinae plane block incorporated into an opioid-based systemic multimodal analgesia regimen is non-inferior in terms of the quality of postoperative recovery compared to continuous thoracic epidural local anesthetic-opioid analgesia in patients undergoing elective unilateral video-assisted thoracoscopic surgery.

METHODS

This is a prospective randomized open label non-inferiority trial. A total of 90 adult patients undergoing video-assisted thoracoscopic surgery will be randomized 1:1 to receive pain treatment with either (1) continuous erector spinae plane block plus intravenous patient-controlled analgesia with piritramide (study group) or (2) continuous thoracic epidural analgesia with a local anesthetic-opioid infusate (control group). All patients will receive additional systemic multimodal analgesia with paracetamol and non-steroidal anti-inflammatory drugs. The primary endpoint is the quality of recovery as measured by the Quality of Recovery-15 score. Secondary endpoints are postoperative pain as Numerical Rating Score scores, length of hospital stay, failure of analgesic technique, postoperative morphine-equivalent consumption, itching, nausea and vomiting, total operative time, complications related to surgery, perioperative hypotension, complications related to pain treatment, duration of bladder catheterization, and time of first assisted mobilization > 20 m and of mobilization to sitting in a chair.

DISCUSSION

This randomized controlled trial aims to confirm whether continuous erector spinae plane block plus patient-controlled opioid analgesia can equal the analgesic effect of a thoracic epidural local anesthetic-opioid infusion in patients undergoing video-assisted thoracoscopic surgery.

TRIAL REGISTRATION

Netherlands Trial Register NL6433 . Registered on 1 March 2018. This trial was prospectively registered.

Evaluation of early postoperative intravenous opioid rescue as a novel quality measure in patients who receive thoracic epidural analgesia: a retrospective cohort analysis and prospective performance improvement intervention

BACKGROUND

In this study, we explored the utility of intravenous opioid rescue analgesia in the post anesthesia care unit (PACU-OpResc) as a single marker of thoracic epidural analgesia (TEA) failure and evaluated the resource implications and quality improvement applications of this measure.

METHODS

We performed a retrospective analysis of all TEA placements over a three-year period at a single academic medical center in Boston, Massachusetts. The study exposure was PACU-OpResc. Primary outcome was PACU length of stay (LOS). Secondary outcomes included reasons for delayed PACU discharge and intraoperative hypotension. The analyses were adjusted for confounding variables including patient comorbidities, surgical complexity, intraoperative intravenous opioids, chronic opioid use and local anesthetic bolus through TEA catheter. Post analysis chart review was conducted to determine the positive predictive value (PPV) of PACU-OpResc for inadequate TEA. As a first Plan-Do-Study-Act cycle, we then introduced a checkbox for documentation of a sensory level check after TEA placement. Post implementation data was collected for 7 months.

RESULTS

PACU-OpResc was required by 211 (22.1%) patients who received preoperative TEA, was associated with longer PACU LOS (incidence rate ratio 1.20, 95% CI:1.07-1.34, p = 0.001) and delayed discharge due to inadequate pain control (odds ratio 5.15, 95% CI 3.51-7.57, p <  0.001). PACU-OpResc had a PPV of 76.3 and 60.4% for re-evaluation and manipulation of the TEA catheter in PACU, respectively. Following implementation of a checkbox, average monthly compliance with documented sensory level check after TEA placement was noted to be 39.7%. During this time, a reduction of 8.2% in the rate of PACU-OpResc was observed.

CONCLUSIONS

This study demonstrates that PACU-OpResc can be used as a quality assurance measure or surrogate for TEA efficacy, to track performance and monitor innovation efforts aimed at improving analgesia, such as our intervention to facilitate sensory level checks and reduced PACU-OpResc.

TRIAL REGISTRATION

not applicable.

Intercostal nerve cryoablation versus thoracic epidural for postoperative analgesia following pectus excavatum repair: a systematic review and meta-analysis

OBJECTIVES

Minimally invasive pectus excavatum repair via the Nuss procedure is associated with significant postoperative pain that is considered as the dominant factor affecting the duration of hospitalization. Postoperative pain after the Nuss procedures is commonly controlled by thoracic epidural analgesia. Recently, intercostal nerve cryoablation has been proposed as an alternative method with long-acting pain control and shortened hospitalization. The subsequent objective was to systematically review the outcomes of intercostal nerve cryoablation in comparison to thoracic epidural after the Nuss procedure.

METHODS

Six scientific databases were searched. Data concerning the length of hospital stay, operative time and postoperative opioid usage were extracted. If possible, data were submitted to meta-analysis using the mean of differences, random-effects model with inverse variance method and I2 test for heterogeneity.

RESULTS

Four observational and 1 randomized study were included, enrolling a total of 196 patients. Meta-analyses demonstrated a significantly shortened length of hospital stay [mean difference -2.91 days; 95% confidence interval (CI) -3.68 to -2.15; P < 0.001] and increased operative time (mean difference 40.91 min; 95% CI 14.42-67.40; P < 0.001) for cryoablation. Both analyses demonstrated significant heterogeneity (both I2 = 91%; P < 0.001). Qualitative analysis demonstrated the amount of postoperative opioid usage to be significantly lower for cryoablation in 3 out of 4 reporting studies.

CONCLUSIONS

Intercostal nerve cryoablation during the Nuss procedure may be an attractive alternative to thoracic epidural analgesia, resulting in shortened hospitalization. However, given the low quality and heterogeneity of studies, more randomized controlled trials are needed.

Intercostal misplacement of a thoracic epidural catheter discovered during lung cancer surgery: a case report

BACKGROUND

Blind epidural catheter placement can lead to inadvertent misplacement. We present a case of intercostal misplacement of a thoracic epidural catheter.

CASE PRESENTATION

A 67-year-old male underwent left lung cancer surgery via thoracotomy with epidural analgesia via the Th 5-6 intervertebral space, although with some difficulty. We detected dermatomal cold sensory loss around Th five min after initial administration of local anesthetics through the catheter before general anesthesia induction. However, the epidural catheter was intraoperatively found below the fifth rib, running along the course of the intercostal nerve. The catheter was successfully withdrawn via his back, and we postoperatively performed paravertebral block under ultrasound guidance. He did not complain of complications at discharge.

CONCLUSIONS

Detailed bilateral assessment of sensory loss after initial local anesthetic administration might have facilitated preoperative detection of the misplacement. In cases requiring multiple catheter insertion attempts, switching to another analgesic method should be considered.

A randomised controlled trial

Backgrounds

Impairment of gastrointestinal (GI) motility is an undesirable but inevitable consequence of surgery. This prospective randomised controlled study tested the hypothesis that postoperative thoracic epidural analgesia (TEA) with ropivacaine or a combination of ropivacaine and morphine accelerates postoperative GI function and shortens the duration of postoperative ileus following major thoracic surgery compared to intravenous (IV) morphine.

Methods

Thirty patients scheduled for major thoracic surgery were randomised to three groups. All patients had bowel motility assessments 1 week preoperatively. All patients received general anaesthesia. Group Ep-R received TEA with ropivacaine; group Ep-RM received TEA with ropivacaine and morphine and group IV-M received IV morphine via patient controlled analgesia pump (PCA). Bowel motility was assessed by clinical examination in addition to oro-ceacal transit time (OCTT) on the first and third postoperative days and colonic transit time (CTT).

Results

Overall the OCTT demonstrated a 2.5-fold decrease in bowel motility on the first postoperative day. The OCTT test revealed statistically significant differences between all groups (Ep-R vs Ep-RM, p = 0.43/Ep-R vs IV-M, p = 0.039 / Ep-RM vs IV-M, p < 0.001). Also, very significant differences were found in the OCCT test between days (Ep-R vs Ep-RM, p < 0.001/Ep-R vs IV-M, p < 0.001 / Ep-RM vs IV-M, p = 0.014). There were no significant differences in the CTT test or the clinical signs between groups. However, 70% of the patients in the Ep-R group and 80% in the Ep-RM group defecated by the third day compared to only 10% in the IV-M group, (p = 0.004).

Conclusions

Objective tests demonstrated the delayed motility of the whole GI system postoperatively following thoracic surgery. They also demonstrated that continuous epidural analgesia with or without morphine improved GI motility in comparison to intravenous morphine. These differences were more pronounced on the third postoperative day.

Trial registration

ISRCTN number: 11953159, retrospectively registered on 20/03/2017.

Thoracic epidural analgesia reduces gastric microcirculation in the pig

Background

Thoracic epidural analgesia (TEA) is used for pain relief during and after abdominal surgery, but the effect of TEA on the splanchnic microcirculation remains debated. We evaluated whether TEA affects splanchnic microcirculation in the pig.

Methods

Splanchnic microcirculation was assessed in nine pigs prior to and 15 and 30 min after induction of TEA. Regional blood flow was assessed by neutron activated microspheres and changes in microcirculation by laser speckle contrast imaging (LSCI).

Results

As assessed by LSCI 15 min following TEA, gastric arteriolar flow decreased by 22 % at the antrum (p = 0.020) and by 19 % at the corpus (p = 0.029) of the stomach. In parallel, the microcirculation decreased by 19 % at the antrum (p = 0.015) and by 20 % at the corpus (p = 0.028). Reduced arteriolar flow and microcirculation at the antrum was confirmed by a reduction in microsphere assessed regional blood flow 30 min following induction of TEA (p = 0.048). These manifestations took place along with a drop in systolic blood pressure (p = 0.030), but with no significant change in mean arterial pressure, cardiac output, or heart rate.

Conclusion

The results indicate that TEA may have an adverse effect on gastric arteriolar blood flow and microcirculation. LSCI is a non-touch technique and displays changes in blood flow in real-time and may be important for further evaluation of the concern regarding the effect of thoracic epidural anesthesia on gastric microcirculation in humans.

Trial registrations

Not applicable, non-human study.

Distance from Dura mater to spinal cord at the thoracic vertebral level: An introductory study on local subdural geometry for thoracic epidural block

OBJECTIVE

To evaluate the anatomical safety margins in relation to thoracic epidural block by analysing magnetic resonance (MR) images.

METHODS

This retrospective study identified consecutive patients who underwent MR imaging of the thoracic vertebral spine. The distance from the dura mater to the spinal cord (DTC) was measured at different thoracic intervertebral levels using three different pathways as references: the 'U', 'L' and 'M' lines.

RESULTS

A total of 346 patients provided MR images for analysis. The vertical DTC was the longest at the T5/6 intervertebral level (mean ± SD: 4.22 ± 1.43 mm) and the shortest at the T11/12 intervertebral level (mean ± SD: 2.51 ± 0.87 mm). The DTC was the longest on the 'L' line at the T1/2 and T5/6 intervertebral levels and on the 'U' line at the T10/11 intervertebral level. The difference in DTC between the 'U' and 'L' lines was the greatest at the T5/6 intervertebral level.

CONCLUSION

Differences in the DTC were observed among the thoracic intervertebral levels. The variability of the safety margin according to the angle of needle insertion was the largest at the T5/6 intervertebral level.

Effect of thoracic epidural analgesia on recovery of bowel function after major upper abdominal surgery

STUDY OBJECTIVE

We investigated whether thoracic epidural analgesia (TEA) shortens the first gas-out time compared to intravenous patient-controlled analgesia (iv-PCA) and promotes earlier discharge after major upper abdominal surgery.

DESIGN

Prospective observational study.

SETTING

A tertiary care university hospital.

PATIENTS

Fifty-six patients undergoing major upper abdominal surgery.

INTERVENTIONS

TEA (n=28) was performed using a paramedian approach at T6-7 or T7-8. Hydromorphone (8 μg/mL) was added to 0.15% ropivacaine (bolus/lockout time/basal: 3 mL/15 minutes/5 mL). The iv-PCA regimen (n=28) included 20 μg/mL fentanyl (bolus/lockout time/basal: 0.5 mL/15 minutes/0.5 mL). The 2 analgesic methods were maintained for 3 days.

MEASUREMENT

The primary end point was first gas-out time, and the secondary end points were hospital discharge, pain scores, and first voiding time.

MAIN RESULTS

No differences in first gas-out time (TEA, 4.1±1.2 days; iv-PCA, 3.4±1.9 days; P=.15) or hospital stay (TEA, 9.8±2.2 days; iv-PCA, 11.4±5.2 days; P=.19) were observed between the 2 groups. A visual analog pain scale scores during rest and coughing were lower in the TEA than those for iv-PCA even with 40% to 46% less rescue analgesic. However, TEA delayed first voiding time (3.6±0.9 vs 2.8±1.6 days; P=.02) and required more frequent bladder catheterization (46% vs 11%; P=.008) than those of iv-PCA.

CONCLUSION

TEA with a regimen of hydromorphone (8 μg/mL) added to 0.15% ropivacaine did not provide earlier gas-out compared to that of iv-PCA in patients who underwent major upper abdominal surgery.

Intra-operative hypotensive episodes may be associated with post-operative esophageal anastomotic leak. Updates Surg. 2016;68:185-190. [PMID: 27146868 DOI: 10.1007/s13304-016-0369-9]

This study aims to report the hypotensive episodes (HEs) during esophagectomy and their influence on the occurrence of anastomotic leak. Eighty-four patients underwent esophagectomy with gastric pull-up. Pre-, intra-, and post-operative data were prospectively collected. HEs were defined by systolic pressure decreasing more than 30 % of the basal value for more than 5 min. Nineteen patients had intra-operative HEs (22.6 %). HEs were significantly more frequent in patients undergoing prone esophagectomy (P = 0.001) and those with an epidural catheter (EC) (P = 0.04) used during surgery. Among them, 15 were treated with vasopressors. There were six severe post-operative anastomotic leaks, which required surgery; leaks were significantly more common in patients with intra-operative HEs (21 vs 3.1 %; P = 0.02), especially those treated with vasopressive agents (20 vs 0 %; P = 0.008). Intra-operative use of EC can, in certain conditions, significantly influence gastric blood flow due to HEs. A higher incidence of severe leak occurred in patients experiencing intra-operative HEs. Several factors can lead to intra-operative HEs, and the perioperative use of an EC should be carefully evaluated.

A comparison of parecoxib and thoracic epidural analgesia for postoperative analgesia following Nuss procedure

BACKGROUND

The purpose of this study was to compare the results of thoracic epidural analgesia (TEA) and parecoxib in controlling postoperative pain after the Nuss procedure.

METHODS

Between August 2005 and July 2014, 120 adolescents and adults underwent Nuss procedures and received either TEA or parecoxib for postoperative pain control. Demographic data, preoperative preparation times, visual analog scale (VAS) pain scores from postoperative day 1 to day 5, medical costs of pain control, days to Foley catheter removal, days to being able to sit up, days to being able to walk, days of hospital stay, nausea/vomiting scores, and complications related to pain control were compared.

RESULTS

A total of 106 patients received TEA, and 14 received parecoxib. No between-group differences in demographics were observed. Patients in the parecoxib group had shorter preparation times (p<0.001), lower VAS pain scores from postoperative day 2 to day 5 (day 2, p=0.006; day 3, p=0.006; day 4, p<0.001; day 5, p<0.001), shorter hospital stays (p<0.001), lower pain control costs (p<0.001), and lower nausea/vomiting scores (p=0.046).

CONCLUSIONS

For adolescents and adults undergoing the Nuss procedure, parecoxib affords better pain control efficacy, a shorter hospital stay, lower medical pain control costs, and fewer side effects compared with TEA.

Techniques and results of lobar lung transplantations

OBJECTIVES

We report our experience of lobar lung transplantations (LLTs) in patients with small thoracic volume.

METHODS

Since 1988, 50 LLTs were done for cystic fibrosis (n=35), fibrosis (n=7), bronchiectasis (n=3), emphysema (n=3) and lymphangiomyomatosis (n=2). There were 44 females and 6 males (mean age 31±13 years, mean size 155±5.5 cm and mean predicted total lung capacity (TLC) 4463±598 ml). Mean ratio between donor and recipient-predicted TLC was 1.65±0.26. Six patients were listed in high emergency, 2 of them on ECMO as a bridge to transplantation. Forty middle/lower right lobe with left lower LLT, four bilateral lower LLT and six split left lung LLT were performed through a clamshell incision (n=12) or a bilateral antero-lateral thoracotomy (n=38), with epidural analgesia in 17 cases. Thirty-two patients were transplanted under circulatory support (CPB n=16, veno-arterial ECMO n=16). In 11 cases, the right venous anastomosis was enlarged by a pericardial cuff. Ischaemic time was 4.4±1.2 h for the first lobe and 6.1±1.3 h for the second.

RESULTS

Median mechanical ventilation weaning time was 10.5 (1-136) days. Four patients were extubated in the operating room. Ten patients needed ECMO for primary graft dysfunction. In-hospital mortality was 28% related to sepsis (n=6), PGD (n=3), haemorrhage (n=2), broncho-vascular fistula (n=1), and multiorgan failure (n=2). Eight patients required endoscopic treatments for airway complications. Mean best FEV1 was 72±16% of the theoretical value. The actuarial 3-year and 5-year survival rates were 60 and 46%, respectively.

CONCLUSIONS

LLTs are a reliable solution and can be performed with satisfactory functional results and survival rates.