Pain trajectories after bilateral orthotopic lung transplantation surgery performed via a clamshell incision

INTRODUCTION

The nature, intensity, and progression of acute pain after bilateral orthotopic lung transplantation (BOLT) performed via a clamshell incision has not been well investigated. We aimed to describe acute pain after clamshell incisions using pain trajectories for the study cohort, in addition to stratifying patients into separate pain trajectory groups and investigating their association with donor and recipient perioperative variables.

METHODS

After obtaining IRB approval, we retrospectively included all patients ≥18 years old who underwent primary BOLT via clamshell incision at a single center between January 1, 2017, and June 30, 2022. We modeled the overall pain trajectory using pain scores collected over the first seven postoperative days and identified separate pain trajectory classes via latent class analysis.

RESULTS

Three hundred one adult patients were included in the final analysis. Three separate pain trajectory groups were identified, with most patients (72.8%) belonging to a well-controlled, stable pain trajectory. Uncontrolled pain was either observed in the early postoperative period (10%), or in the late postoperative period (17.3%). Late postoperative peaking trajectory patients were younger (p = .008), and sicker with a higher lung allocation score (p = .005), receiving preoperative mechanical ventilation (p < .001), or VV-ECMO support (p < .001).

CONCLUSION

Despite the extensive nature of a clamshell incision, most pain trajectories in BOLT patients had a well-controlled stable pain profile. The benign nature of pain profiles in our patient population may be attributed to the routine institutional practice of early thoracic epidural analgesia for BOLT patients unless contraindicated.

Comparative Analysis of Intravenous Opioids Versus Thoracic Epidural Anesthesia in Fractured Rib Pain Management: A Systematic Review and Meta-Analysis

Rib fractures, common among trauma victims, lead to significant morbidity and mortality. Managing the associated pain is challenging, with IV opioids and thoracic epidural analgesia (TEA) being utilized. While epidural analgesia is often preferred for fractured rib pain, existing data encompasses both lumbar and thoracic approaches. This review aimed to compare TEA and IV opioids for persistent rib fracture pain. A comprehensive search across five databases yielded 987 articles, of which seven met the eligibility criteria. Outcomes were categorized into primary (pain reduction) and secondary (mortality, hospital/ICU stays, analgesia-related complications) endpoints. Analyzed with Review Manager (RevMan) Version 5.4.1 (2020; The Cochrane Collaboration, London, United Kingdom), the pooled data from two sources showed TEA significantly more effective in reducing pain than IV opioids (standardized mean difference (SMD): 2.23; 95%CI: 1.65-2.82; p < 0.00001). Similarly, TEA was associated with shorter ICU stays (SMD: 0.73; 95%CI: 0.33-1.13; p = 0.0004), while hospitalization duration showed no substantial difference (SMD: 0.82; 95%CI: -0.34-1.98). Mortality rates also did not significantly differ between TEA and IV opioids (risk ratio (RR): 1.20; 95%CI: 0.36-4.01; p = 0.77). Subgroup analysis revealed fewer pneumonia cases with TEA (RR: 2.06; 95%CI: 1.07-3.96; P = 0.03), with no notable disparities in other complications. While TEA's superiority in pain relief for rib fractures suggests it is the preferred analgesic, the recommendation's strength is tempered by the low methodological quality of supporting articles.

A Randomized Clinical Study to Compare the Perioperative Analgesic Efficacy of Ultrasound-Guided Erector Spinae Plane Block Over Thoracic Epidural in Modified Radical Mastectomy

Aim This study aims to compare the effectiveness of ultrasound-guided erector spinae block (ESB) with thoracic epidural (TE) in managing postoperative pain among breast cancer (BC) surgery patients. Methods A total of 42 patients were enrolled and randomly divided into two groups, each comprising 21 participants. Primary endpoints assessed included intraoperative fentanyl consumption, postoperative pain scores, and the need for rescue analgesia. Secondary endpoints encompassed intraoperative hemodynamic changes and the incidence of postoperative nausea and vomiting (PONV). Results The study found no significant difference in intraoperative fentanyl requirement (p=0.62) or postoperative pain scores measured using numerical rating scores (NRS) throughout the 48-hour postoperative period. None of the patients in either group required rescue analgesia. Notably, there was a statistically significant difference in postoperative nausea and vomiting at the two-hour mark, favoring the erector spinae block. Both groups exhibited comparable hemodynamic changes during intraoperative monitoring. Conclusions Our investigation concludes that the ESF offers equivalent analgesic efficacy to the thoracic epidural during both surgery and the postoperative period without inducing any significant hemodynamic instability. Considering the lower complication rate associated with paraspinal blocks compared to neuraxial blocks, the ESB presents itself as a promising alternative method for effective pain relief in mastectomy procedures.

Comparing Thoracic Epidural Anaesthesia to Rectus Sheath Catheter Analgesia for Postoperative Pain After Major Abdominal Surgeries: A Systematic Review

Controlling postoperative pain is essential for the greatest recovery following major abdominal surgery. Thoracic epidural analgesia (TEA) has traditionally been considered the preferred method of providing pain relief after major abdominal surgeries. Thoracic epidural analgesia has a wide range of complications, including residual motor blockade, hypotension, urine retention with the need for urinary catheterisation, tethering to infusion pumps, and occasional failure rates. In recent years, rectus sheath catheter (RSC) analgesia has been gaining popularity. The purpose of this review is to compare the effectiveness of TEA and RSC in reducing pain following major abdominal surgeries. Four randomised controlled trials (RCTs) reporting outcomes of the visual analogue scale (VAS) pain score were included according to the set criteria. A total of 351 patients undergoing major abdominal surgery were included in this meta-analysis. There were 176 patients in the TEA group and 175 patients in the RSC group. In the random effect model analysis, there was no significant difference in VAS pain score in 24 hours at rest (standardised mean difference (SMD) -0.46; 95% CI -1.21 to 0.29; z=1.20, P=0.23) and movement (SMD -0.64; 95% CI -1.69 to -0.14; z=1.19, P=0.23) between TEA and RSC. Similarly, there was no significant difference in pain score after 48 hours at rest (SMD -0.14; 95% CI -0.36 to 0.08; z=1.29, P=0.20) or movement (SMD -0.69; 95% CI -2.03 to 0.64; z=1.02, P=0.31). In conclusion, our findings show that there was no significant difference in pain score between TEA and RSC following major abdominal surgery, and we suggest that both approaches can be used effectively according to the choice and expertise available.

Comparison of safety and efficacy of thoracic epidural block and erector spinae plane block for analgesia in patients with multiple rib fractures: A pilot single-blinded, randomised controlled trial

Background and Aims

Pain associated with rib fractures is challenging to manage. This pilot trial aimed to assess the efficacy of erector spinae plane block (ESPB) compared with thoracic epidural analgesia (TEA) for controlling pain associated with multiple rib fractures.

Methods

This randomised, single-blinded, controlled pilot study was conducted on trauma patients who had three or more rib fractures and had been admitted at a tertiary care centre. The study was conducted after receiving ethical approval and trial registration. Patients were randomised into two groups: TEA and ESPB, from February 2019 to February 2020. In the ESPB group, a unilateral or bilateral catheter was inserted in the erector spinae space, and an infusion of 0.125% bupivacaine was started. In the TEA group, the thoracic epidural catheter was inserted, and 0.125% bupivacaine infusion was started. Rescue analgesia using intravenous morphine (0.1 mg/kg) was administered if the Visual Analogue Scale (VAS) score was >3 for 48 hours postoperatively. The primary endpoint was total morphine consumption after administration of ESPB and TEA in patients with a rib fracture.

Results

Forty patients completed the study, with 20 in each group. Total morphine consumption by patients in the ESPB group was 5.38 ± 2.6 mg per 48 hours, and by those in the TEA group was 5.22 ± 2.11 mg per 48 hours (P = 0.883). Thirty minutes after starting the infusion, mean arterial pressure (MAP) was 64.8 ± 2.1 mmHg in the ESPB group and 57.2 ± 1.3 mmHg in the TEA group (P = 0.00001).

Conclusion

Total morphine consumption was not statistically different in this pilot trial among the two groups. ESP block may provide similar analgesia with better haemodynamic stability compared to TEA in patients with multiple traumatic rib fractures.

Comparison of postoperative analgesic effects of thoracic epidural analgesia and rectus sheath block in laparoscopic abdominal surgery: A randomized controlled noninferiority trial

INTRODUCTION

In the Enhanced Recovery After Surgery program, abdominal wall blocks are strongly recommended as postoperative multimodal analgesia for laparoscopic abdominal surgery. The purpose of this study was to compare the efficacy of single-shot rectus sheath block (RSB) with that of thoracic epidural analgesia (TEA) as a method of multimodal analgesia in patients receiving conventional laparoscopic abdominal surgery.

METHODS

A noninferiority comparison was performed. Patients scheduled for laparoscopic gastric or colorectal surgery were enrolled in this study. Patients were divided randomly into two groups: TEA and RSB. The primary endpoint was the numerical rating scale (NRS) score upon coughing as of 24 hours after surgery.

RESULTS

In total, 80 patients were randomly assigned to receive TEA (n = 42) or RSB (n = 38). Three patients were excluded from the TEA group after randomization. The NRS score on coughing as of 24 hours after surgery was significantly lower in the TEA group than in the RSB group (least square mean: 3.59 vs 6.39; 95% confidence interval for the difference: 1.87 to 3.74, P < .001). The NRS scores upon coughing and at rest were significantly lower in the TEA group than in the RSB group as of 4, 24 and 48 hours after surgery. Patient satisfaction with postoperative analgesia was significantly higher in the TEA group. Postoperative adverse events were not significantly different between groups.

CONCLUSION

This is the first report of comparing RSB with TEA in laparoscopic surgery. TEA may be recommended as a multimodal analgesia protocol for laparoscopic gastric and colorectal surgery.

Benefit of epidural analgesia for postoperative pain control after a Kasai Portoenterostomy: A ten-year retrospective cohort study

INTRODUCTION

Biliary atresia is a rare obstructive cholangiopathy that presents in infants. The Kasai portoenterostomy procedure, which reestablishes biliary drainage into the intestine, is a surgical procedure that has been found to improve survival with the native liver. The options for postoperative analgesia include systemic opioids and epidural analgesia. The primary objective of this study was to compare the postoperative systemic opioids used in morphine equivalents (mg/kg) on postoperative days 0 through 3 between patients who underwent a Kasai portoenterostomy and received a thoracic epidural infusion to those without thoracic epidural analgesia.

METHODS

We conducted a retrospective cohort study of 91 infants with biliary atresia undergoing a Kasai portoenterostomy between January 1, 2009, and September 1, 2019, at the Children's Hospital of Philadelphia.

RESULTS

Sixty-three of the 91 patients (69%) had a continuous epidural catheter placed intraoperatively for postoperative analgesia. The total opioid requirement (morphine equivalents) for the first 72 h in the epidural group of (Mean (95% confidence interval): 0.52 mg/kg (0.38, 0.67 mg/kg) was lower than the non-epidural group (Mean (95% confidence interval): 1.15 mg/kg (0.8, 1.48 mg//kg) for a difference in mean opioid requirement (95% confidence interval) of 0.63 mg/kg (0.32, 0.94 mg/kg). Patients in the non-epidural group had higher rates of unplanned ICU admissions (36% non-epidural group vs. 3.3% epidural group, difference in proportion (95% confidence interval) 32.7% (13, 52%), p < .01). A higher percentage of patients in the non-epidural group had a postoperative oxygen requirement (32.1% vs. 11.3%, difference in proportion (95% confidence interval) 21% (2, 40%), p = .02).

CONCLUSION

In our cohort study, continuous thoracic epidural analgesia in patients undergoing a Kasai portoenterostomy was associated with lower postoperative opioid use. We also observed that the epidural group had a lower ICU admission rate and a lower rate of postoperative supplemental oxygen requirement over the first three postoperative days.

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.

Impact of early thoracic epidural analgesia in patients with severe acute pancreatitis

OBJECTIVE

This study was designed to assess the impact of thoracic epidural analgesia (TEA) in patients with severe acute pancreatitis (SAP).

METHODS

This is a single-centre retrospective study. In this study, the outcomes of SAP patients were compared between patients received TEA (TEA group) and without TEA (NTEA group). Early TEA was defined as TEA performed within 48 hours after onset. The main outcome was the mortality at 30 days after ICU admission, and secondary outcomes included the incidence of acute respiratory distress syndrome (ARDS), the acute renal injury (AKI) and sepsis, the hospital stay and hospitalization expenses.

RESULTS

The mortality of SAP patients in TEA versus NTEA was 8.0% and 13.3% (p = .1520). Multivariate regression analysis showed significant difference in mortality between the TEA and NTEA groups (OR, 0.387; 95% CI, 0.168-0.892; p = .026). The incidence of ARDS in TEA versus NTEA was 46.0% and 62.4% (p = .0044); the proportion of patients requiring invasive ventilator assisted ventilation in TEA, and NTEA was 22.6% and 39.2% (p = .0016). The incidence of AKI in TEA versus NTEA was 27.7% and 45.3% (p = .0044); the proportion of patients needing for continuous renal replacement therapy (CRRT) in TEA and NTEA was 48.2% and 74.0% (p < .0001). The mortality of SAP patients in early TEA versus NTEA was 4.8% and 15.3% (p = .0263).

CONCLUSIONS

TEA was associated with low incidence of ARDS and AKI in patients with SAP. Early TEA may benefit mortality in SAP patients and is a possible protective factor for the mortality of SAP patients.

The effect of thoracic epidural analgesia on short-term outcome and mortality in geriatric patients undergoing open heart surgery

BACKGROUND

In open-heart surgeries, many organ functions, particularly the respiratory system, are affected by post-operative pain, and so is mortality. Following open-heart surgery, geriatric patients have a higher risk of organ dysfunction and mortality. We aimed to compare the short-term outcomes and mortality of thoracic epidural analgesia (TEA) and intravenous (IV) analgesia in geri-atric patients undergoing open heart surgery.

METHODS

This study included patients over the age of 65 who had open-heart surgery between 2010 and 2020. The patients were divided into two groups: Those who received TEA (Group E) and those who received IV paracetamol or tramadol or dexmedetomi-dine (Group I). The patients' post-operative sedation and analgesia requirements, mechanical ventilation (MV) duration, blood glucose levels, liver and kidney function tests, complications, intensive care and hospital stay lengths, and mortality rates were all compared.

RESULTS

The study included a total of 548 patients, with 408 in Group E and 140 in Group I. As a result of the comparisons be-tween the groups, sedation requirement, analgesia requirement, MV duration, post-extubation facial mask oxygen requirement, non-invasive MV need, re-intubation requirement, and blood glucose level were found to be lower in Group E than in Group I. Moreover, periods spent in intensive care and lengths of hospital stay were found to be lower in Group E than Group I. There was no difference found between the two groups in terms of hospital mortality.

CONCLUSION

In elderly patients undergoing open-heart surgery, TEA reduced the length of time in intensive care and hospital stays by improving the respiratory status and blood glucose regulation by supplying analgesia and sedation.

Thoracic Epidural Analgesia Use in Large Recurrent Desmoid Fibromatosis Resection: A Case Report

We present a case report of the successful use of thoracic epidural analgesia for the surgical resection of a large recurrent desmoid tumor and forequarter amputation in an adolescent male. Spinal anesthesia has been reported for intra-operative management of desmoid tumor resection, however, there are no reported cases of thoracic epidural analgesia for this tumor. Thoracic epidural should be used with caution in this patient population due to risk of de novo tumor creation but can be useful adjuvant to multi-modal analgesia to decrease post-operative opioid requirement.

Is there a relationship between body mass index and postoperative pain scores in thoracotomy patients with thoracic epidural analgesia?

Postoperative efficacy of thoracic epidural analgesia (TEA) following thoracic surgery may vary in patients with different body mass index (BMI) values, regardless of the success of the method. This study aimed to investigate the effects of BMI on postoperative pain scores in patients who underwent thoracotomy with TEA.After obtaining the ethical committee approval (Date: May 11, 2021, Number: 2012-KEAK-15/2305) the data of 1326 patients, who underwent elective thoracic surgery in high volume tertiary thoracic surgery center between January 2017 and January 2021, were analyzed retrospectively. Patients between the age of 18 and 80 years, who underwent thoracotomy and thoracic epidural catheterization (TEC), and who were assigned American Society of Anesthesiologists I to III physical status were included to the study. Of the 406 patients, who underwent a successful TEC, 378 received postoperative analgesia for 72 hours. Visual analog scale (VAS) scores of these patients were evaluated statistically. Based on BMI, patients were categorized into the following 5 groups: Group I: BMI < 20 kg/m2, Group II: BMI = 20 to 24.9 kg/m2, Group III: BMI = 25 to 29.9 kg/m2, Group IV: BMI = 30 to 34.9 kg/m2, and Group V: BMI ≥ 35 kg/m2.There were no statistically significant differences in TEC success across different BMI groups (P > .05). Catheter problems and VAS scores significantly increased with higher BMI values in the postoperative 72-hours period (P < .05). Rates of rescue analgesic use were higher in BMI groups of 30 toto 34.9 kg/m2 and ≥35 kg/m2 compared to the other BMI groups.This study revealed that higher BMI in patients may increase VAS scores, who administered TEA for pain management following thoracotomy. This correlation was supported by the increased need for additional analgesics in patients with high BMI. Therefore, patients with high BMI values would require close monitoring and follow-up.

Comparison of Thoracic Epidural Analgesia and Thoracic Paravertebral Block Applications in the Treatment of Acute Pain After Thoracotomy in Geriatric Patients

Background

Thoracic epidural analgesia (TEA) and thoracic paravertebral block (TPVB) are commonly used in geriatric patients for pain management after thoracotomy. In this study, we aimed to investigate the effect of TEA and TPVB on postoperative analgesia in geriatric patients who underwent thoracotomy.

Methodology

Postoperative analgesia follow-up files of patients over 65 years of age who underwent thoracotomy were analyzed retrospectively. Patient’s demographic data, diagnosis, type of surgery, postoperative 24-hour mean arterial pressure (MAP), heart rate, respiratory rate, peripheral oxygen saturation, static/dynamic visual analog scale (VAS) scores, need for additional analgesics, global pain assessment, and side effects such as nausea, vomiting, hypotension, bradycardia, and respiratory depression were examined. The patients were divided into two groups: those treated with TEA (Group 1) and those treated with TPVB (Group 2).

Results

There was no statistically significant difference between the groups in terms of demographic data (p > 0.05). MAP in the TEA group was statistically significantly lower than in the second and sixth-hour TPVB group (p = 0.008, p < 0.001). VAS static scores in the TEA group were statistically significantly lower at 30 minutes (p = 0.001), and at one, two, six, twelve, and twenty-four hours compared to the TPVB group (p < 0.001, except at 30 minutes). VAS dynamic scores were statistically significantly lower in the TEA group at 30 minutes, and at one, two, six, twelve, and twenty-four hours compared to the TPVB group (p < 0.001). There was no statistically significant difference between the groups in terms of nausea, vomiting, hypotension, and bradycardia (p > 0.05). The use of additional analgesics in the TEA group was statistically significantly lower than in the TPVB group (p < 0.001).

Conclusions

More effective postoperative analgesia results with stable hemodynamic conditions were observed in geriatric patients who underwent TEA for thoracotomy compared to TPVB. Regarding side effects, although there was a lower incidence in TPVB, this was not statistically significant when compared to TEA. TEA, as a component of the multimodal analgesia approach, can be accepted as a safe and effective method in the elderly patient group who underwent thoracotomy.

Thoracic Epidural Analgesia for Lumbosacral Spine Surgery: A Randomized, Case-Control Study

Background:

Traditional analgesics such as diclofenac and celecoxib have long been used in lumbosacral spine surgeries. Recently, preemptive single-shot caudal analgesia has been investigated by some workers with favorable results. We hypothesized that the thoracic route would not only allow preemptive but also postoperative analgesia through catheter insertion.

Aim:

We aimed at studying the feasibility and efficacy of thoracic epidural analgesia (TEA) in lumbosacral spine surgeries.

Settings and Design:

This was a prospective, randomized, controlled study that comprised 60 American Society of Anesthesiologist (ASA) Physical Status I and II patients posted for lumbosacral spine surgeries.

Materials and Methods:

Sixty ASA I and II patients were randomly divided into two groups: Group T – TEA was given using 0.2% ropivacaine 10 mL preemptive and postoperatively. Group C patients were given analgesia with intramuscular diclofenac 75 mg. Hemodynamic parameters, postoperative Visual Analog Scale scores, and neurological complications were noted.

Statistical Analysis:

Student's independent t-test for comparing the continuous variables and Chi-square test for the categorical variables. Kruskal–Wallis test was used for postoperative pain data.

Results:

Duration and quality of analgesia were superior in Group T. There were more hemodynamic alterations in Group C but no neurological complication in any patient.

Conclusion:

TEA proves to be an effective analgesic technique for lumbosacral spine surgeries.

Comparison between epidural and intravenous analgesia effects on disease-free survival after colorectal cancer surgery: a randomised multicentre controlled trial

Background

Thoracic epidural analgesia (TEA) has been suggested to improve survival after curative surgery for colorectal cancer compared with systemic opioid analgesia. The evidence, exclusively based on retrospective studies, is contradictory.

Methods

In this prospective, multicentre study, patients scheduled for elective colorectal cancer surgery between June 2011 and May 2017 were randomised to TEA or patient-controlled i.v. analgesia (PCA) with morphine. The primary endpoint was disease-free survival at 5 yr after surgery. Secondary outcomes were postoperative pain, complications, length of stay (LOS) at the hospital, and first return to intended oncologic therapy (RIOT).

Results

We enrolled 221 (110 TEA and 111 PCA) patients in the study, and 180 (89 TEA and 91 PCA) were included in the primary outcome. Disease-free survival at 5 yr was 76% in the TEA group and 69% in the PCA group; unadjusted hazard ratio (HR): 1.31 (95% confidence interval [CI]: 0.74–2.32), P=0.35; adjusted HR: 1.19 (95% CI: 0.61–2.31), P=0.61. Patients in the TEA group had significantly better pain relief during the first 24 h, but not thereafter, in open and minimally invasive procedures. There were no differences in postoperative complications, LOS, or RIOT between the groups.

Conclusions

There was no significant difference between the TEA and PCA groups in disease-free survival at 5 yr in patients undergoing surgery for colorectal cancer. Other than a reduction in postoperative pain during the first 24 h after surgery, no other differences were found between TEA compared with i.v. PCA with morphine.

Effectiveness of ESPITO analgesia in enhancing recovery in patients undergoing open radical cystectomy when compared to a contemporaneous cohort receiving standard analgesia: an observational study

OBJECTIVES

Bowel dysfunction is a major complication following open surgery for invasive cancer of the bladder that results in significant discomfort; complications and can prolong the length of stay. The incidence of postoperative ileus following open radical cystectomy has been reported as 23-40%. The median length of hospital stay after this surgery in the United Kingdom is 11 days. Standard analgesic techniques include wound infusion analgesia combined with systemic morphine or thoracic epidural analgsia. Combined erector spinae plane and intrathecal opioid analgesia is a novel technique that has been reported to be an effective method of providing perioperative analgesia thereby enhancing recovery after open radical cystectomy.

METHODS

We performed a prospective study on the effectiveness of the novel analgesic technique (combined erector spinae plane and intrathecal opioid analgesia) in reducing the incidence of postoperative ileus, thereby facilitating early discharge following open radical cystectomy when compared to a contemporaneous control group receiving standard analgesia. Twenty-five patients received the novel analgesia while 31 patients received standard analgesia as a part of enhanced recovery programme. Standard analgesia arm included 14 patients who recived thoracic epidural analgesia (14/31, 45%) and 17 patients who received combined wound infusion analgesia and patient controlled analgesia with morphine (17/31, 55%). Primary outcome was the incidence of postoperative ileus. Secondary outcomes included length of hospital stay, tramadol consumption and time to bowel opening.

RESULTS

Combined erector spinae plane and intrathecal opioid analgesia was associated with a reduced incidence of postoperative ileus (16 [4/25] vs. 65% [20/31], p<0.001), reduced time to first open bowel (4.4 ± 2.3 vs. 6.6 ± 2.3, p<0.001) and reduced median (IQR) length of hospital stay (7[6, 12] vs. 10[8, 15], p=0.007). There was no significant difference in rescue analgesia (intravenous tramadol) consumption. Complete avoidance of systemic morphine played a key role in improved outcomes.

CONCLUSIONS

ESPITO was successful in reducing postoperative ileus and length of hospital stay after open radical cystectomy when compared to standard analgesia within an enhanced recovery programme.

Comparison of Thoracic Epidural Analgesia and Traditional Intravenous Analgesia With Respect to Postoperative Respiratory Effects in Cardiac Surgery

OBJECTIVES

Surgical stress and pain affect the respiratory condition of patients and can cause complications that affect morbidity and mortality in cardiac surgeries. The authors studied the effect of thoracic epidural analgesia (TEA) versus traditional intravenous analgesia on postoperative respiratory mechanics in cardiac surgery.

DESIGN

Retrospective, observational study.

SETTING

Single, university hospital.

PARTICIPANTS

Patients undergoing cardiac surgery.

INTERVENTIONS

Comparing the postoperative respiratory effects of TEA with bupivacaine or intravenous analgesia with tramadol or paracetamol or dexmedetomidine.

MEASUREMENTS AND MAIN RESULTS

A total of 1,369 patients were screened, and 1,280 patients were enrolled in the study. Postoperative sedation and analgesia level, extubation times, respiratory complications, lengths of intensive care and hospital stay, morbidity, and mortality were compared. Additional sedative and analgesic drug requirement in the TEA group (25.3% and 60.1% respectively) were significantly lower than the intravenous group (41.4% and 71.8%, respectively; p < 0.001 and p < 0.05, respectively). Extubation time in the TEA group also was significantly lower than the intravenous group (p < 0.01). Respiratory complication and hospital stay in the TEA group were lower than intravenous group (p < 0.05).

CONCLUSIONS

TEA provided better postoperative respiratory condition via better sedative analgesia in cardiac surgery.

Effect of Regional Analgesia Techniques on Opioid Consumption and Length of Stay After Thoracic Surgery

BACKGROUND

We examined how intercostal nerve block (ICNB) with standard bupivacaine and ICNB with extended-release liposomal bupivacaine, compared with thoracic epidural analgesia (TEA), were associated with postoperative opioid pain medication consumption and hospital length of stay (LOS) after thoracic surgery.

METHODS

We studied 1935 patients who underwent thoracic surgery between January 1, 2010, and November 30, 2017, at a tertiary academic center. Primary and secondary outcomes were postoperative opioid consumption expressed as morphine milligram equivalents (MMEs) at 24, 48, and 72 hours after surgery, the LOS, and total MME consumption from surgery to discharge.

RESULTS

Of these patients, 888 (45.9%) received TEA, 730 (37.7%) ICNB with standard bupivacaine, 127 (6.6%) ICNB with liposomal bupivacaine, and 190 (9.8%) no regional analgesia. Compared with epidural analgesia, in 2017, ICNB liposomal bupivacaine provided similar pain control in terms of MME consumption at 24 and 72 hours, but decreased MME consumption at 48 hours (odds ratio [OR] = 0.33; confidence interval [CI] = 0.14-0.81) and at discharge (OR = 0.28; CI = 0.12-0.68) and was associated with a higher likelihood for a shorter LOS (hazard ratio = 3.46; CI = 2.42-4.96). Compared with TEA, ICNB with standard bupivacaine and no regional analgesia use showed varying impact on MME consumption between 24 and 72 hours after surgery, and their use was not associated with a significantly reduced MME consumption at discharge but with a shorter hospital LOS.

CONCLUSIONS

Multimodal analgesia involving regional anesthetic alternatives to TEA could help manage postoperative pain in thoracic surgery patients.

Post-thoracotomy ipsilateral shoulder pain: What should be preferred to optimize it - phrenic nerve infiltration or paracetamol infusion?

Background

Post thoracotomy ipsilateral shoulder pain (PTISP) is a distressing and highly prevalent problem after thoracic surgery and has not received much attention despite the incidence as high as 85%.

Objectives

To study the effect of phrenic nerve infiltration with Ropivacaine compared to paracetamol infusion on PTISP in thoracotomy patients with epidural analgesia as standard mode of incisional analgesia in both the groups.

Study Design

Prospective Randomised and Double Blind Study.

Methods

126 adult patients were divided randomly into 2 groups, "Group A (Phrenic Nerve Infiltration Group) received 10 mL of 0.2% Ropivacaine close to the diaphragm into the periphrenic fat pad" and "Group B (Paracetamol Infusion Group) received 20mg/kg paracetamol infusion" 30 minutes prior to chest closure respectively. A blinded observer assessed the patients PTISP using the VAS score at 1, 4, 8, 12 and 24 hours (h) postoperatively. The time and number of any rescue analgesic medication were recorded.

Results

PTISP was relieved significantly in Group A (25.4℅) as compared to Group B (61.9℅), with significantly higher mean duration of analgesia in Group A. The mean time for first rescue analgesia was significantly higher in Group A (11.1 ± 7.47 hours) than in Group B (7.40 ± 5.30 hours). The number of rescue analgesic required was less in Group A 1.6 ± 1.16 as compared to Group B 2.9 ± 1.37 (P value <0.5).

Conclusions

Phrenic Nerve Infiltration significantly reduced the incidence and delayed the onset of PTISP as compared to paracetamol infusion and was not associated with any adverse effects.

Safety and Efficacy of Oral Melatonin When Combined with Thoracic Epidural Analgesia in Patients with Bilateral Multiple Fracture Ribs

BACKGROUND

The purpose of this study is to evaluate the safety and efficacy of oral melatonin administered with thoracic epidural analgesia in patients with multiple bilateral fractured ribs.

PATIENTS AND METHODS

A prospective, double-blind randomized control study was carried out on 80 patients of either sex, American Society of Anesthesiologists (ASA) Grade I and II, aged above 18 years, presenting with multiple bilateral fractured ribs. They were randomly divided into two groups, 40 patients each. Placebo group patients received oral placebo tablets and melatonin group (TEA and melatonin) patients received oral melatonin tablets (5 mg), about 1 hour before epidural infusion of local anesthetics and then every 12 hours till the cessation of bupivacaine infusion.

RESULTS

Melatonin administration was associated with a significant decrease in total morphine analgesia consumption, from 31.8 ± 1.41 mg in the TE group to 13.03 ± 0.85 mg in the melatonin group (P < 0.001), with a significant decrease (P < 0.001) in the mean infusion rate of bupivacaine required for controlling the pain, from 0.17 ± 0.014 mL/kg/hour in the TE group to 0.12 ± 0.001 mL/kg/hour in the melatonin group. The duration of bupivacaine infusion in the melatonin group was also significantly shorter than in the TE group (96.48 ± 1.87 and 100.05 ± 3.39 hours, resp., P < 0.001).

CONCLUSION

We conclude that premedication of patients with 5 mg melatonin is associated with significant prolongation of thoracic epidural analgesic effects compared to placebo.

REGISTRATION

This clinical study was registered at Pan African Clinical Trial Registry with no. "PACTR 201711002741378" on 02-11-2017.

A randomized control trial to compare thoracic epidural with intercostal block plus intravenous morphine infusion for postoperative analgesia in patients undergoing elective thoracotomy

Objective

The objective of the study is to compare the efficacy of Thoracic epidural with Intercostal block plus intravenous morphine infusion for postoperative analgesia in patients undergoing elective thoracotomy.

Methodology and Design

This study is designed as a prospective randomized clinical trial. Setting: Christian Medical College Hospital, Vellore, India.

Participants

Patients undergoing elective thoracic surgery through posterolateral thoracotomy.

Intervention

In Group A (TEA) patients epidural catheter was inserted at T5-6 level before induction of GA and analgesia was activated using 0.25% of bupivacaine towards the end of the surgery, before chest closure and infusion of 0.1% bupivacaine with 2 mcg/ml of fentanyl was started. In Group B (ICN) patients, an intercostal blockade of the 5 intercostal spaces was performed by the surgeon just before chest closure using 0.25% bupivacaine and a continuous intravenous morphine infusion of 0.015-0.02 mg/kg/hr was started.

Measurements

Assessment of resting and dynamic pain intensity using Numerical rating scale and sedation using Ramsay sedation scale was done and recorded at 1, 6,12,18,24 hours during the first postoperative day. The other parameters that were measured include side effects and the requirement of rescue analgesia. Results: Resting and Dynamic (NRS) pain scores were less in Group A (TEA) than Group B (ICN). In the first 12 hours, the differences in both the resting (P = 0.0505) and dynamic (P = 0.0307) pain scores were statistically significant. By the end of the first postoperative day, sedation scores were more or less similar in both groups. The incidence of side effects and requirement of rescue analgesia were found to be similar in both the groups.

Conclusion

To summarize, though the results show a slightly better quality of analgesia with the thoracic epidural, the difference being clinically insignificant intercostal blockade could be considered as a valid alternative.

Fentanyl-based intravenous patient-controlled analgesia with low dose of ketamine is not inferior to thoracic epidural analgesia for acute post-thoracotomy pain following video-assisted thoracic surgery: A randomized controlled study

BACKGROUND

Thoracic epidural analgesia is the preferred method for postoperative analgesia following thoracic surgery. However, intravenous patient-controlled analgesia (IVPCA) may be an effective alternative. This study was conducted because few scientific reports exist comparing fentanyl-based IVPCA including a low dose of ketamine (fk-IVPCA) with thoracic patient-controlled epidural analgesia (t-PCEA) for the treatment of postoperative pain after video-assisted thoracic surgery (VATS).

METHODS

This prospective, and randomized study included 70 patients randomized into fk-IVPCA and t-PCEA groups. Pain at rest and during movement, successful and unsuccessful triggers after pressing the PCA device button, the need for rescue analgesia, drug-related adverse events, and patient satisfaction were recorded for 48 hours postoperatively.

RESULTS

No significant differences in the intensity of pain at rest or during movement were observed between the 2 groups within 48 hours postoperatively. The number of unsuccessful PCA triggers in the t-PCEA group 0 to 4 hours after surgery was significantly higher than that in the fk-IVPCA group. However, the numbers of successful PCA triggers in the fk-IVPCA group at 4 to 12 and 0 to 24 hours after surgery were significantly higher than those in the t-PCEA group. The incidence of analgesic-related side effects and patient satisfaction were similar in both groups.

CONCLUSIONS

Compared with t-PCEA, the addition of a subanesthetic dose of ketamine to fentanyl-based IVPCA resulted in similar pain control after VATS with no increase in the incidence of drug-related adverse effects. The results confirm that both multimodal intravenous analgesia and epidural analgesia can provide sufficient pain control and are safe strategies for treating acute post-thoracotomy pain.

Auriculotherapy in the prevention of postoperative urinary retention in patients with thoracotomy and thoracic epidural analgesia: A randomized, double-blinded trial

BACKGROUND

Thoracic epidural analgesia is associated with a high rate of postoperative urine retention (POUR). Auriculotherapy can reduce visceral dysfunction and can be helpful in anesthesiology and pain control. The aim of this study was to test the efficacy of preoperative auriculotherapy to decrease the occurrence of POUR.

METHODS

This single-center, double-blinded, 2-arm randomized study was performed between January 2015 and May 2016 in a tertiary care university hospital. Male patients scheduled for an elective lung surgical procedure under combined general anesthesia and thoracic epidural analgesia were included. Auriculotherapy (A group) was performed once the patient was under general anesthesia with 5 semi-permanent needles inserted in both ears at the "Shen Men" "bladder", "pelvic parasympathetic", "anterior hypothalamus", and "frontal lobe" points. Five small round patches of adhesive pads were positioned bilaterally at the same points in the control group (C group). The main outcome measure was the requirement for bladder catheterization during the day and the first night following surgery.

RESULTS

Fifty-three patients were randomized and 25 analyzed in each group. Requirement for bladder catheterization was different between groups: 24 C group patients (96%) and 18 A group patients (72%) (P = .049, Fisher exact test; Odds Ratio = 0.11 [0.01-0.95]. The number of patients needed to treat with auriculotherapy to avoid 1 case of bladder catheterization was 4. No adverse effect was observed due to auriculotherapy.

CONCLUSION

This study demonstrates that auriculotherapy is a safe and useful technique reducing POUR in thoracotomy patients benefiting from thoracic epidural analgesia.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT02290054 (November 13, 2014).

Comparison of continuous thoracic epidural analgesia with bilateral erector spinae plane block for perioperative pain management in cardiac surgery

Objective:

Continuous thoracic epidural analgesia (TEA) is compared with erector spinae plane (ESP) block for the perioperative pain management in patients undergoing cardiac surgery for the quality of analgesia, incentive spirometry, ventilator duration, and intensive care unit (ICU) duration.

Methodology:

A prospective, randomized comparative clinical study was conducted. A total of 50 patients were enrolled, who were randomized to either Group A: TEA (n = 25) or Group B: ESP block (n = 25). Visual analog scale (VAS) was recorded in both the groups during rest and cough at the various time intervals postextubation. Both the groups were also compared for incentive spirometry, ventilator, and ICU duration. Statistical analysis was performed using the independent Student's t-test. A value of P < 0.05 was considered statistically significant.

Results:

Comparable VAS scores were revealed at 0 h, 3 h, 6 h, and 12 h (P > 0.05) at rest and during cough in both the groups. Group A had a statistically significant VAS score than Group B (P ≤ 0.05) at 24 h, 36 h, and 48 h but mean VAS in either of the Group was ≤4 both at rest and during cough. Incentive spirometry, ventilator, and ICU duration were comparable between the groups.

Conclusion:

ESP block is easy to perform and can serve as a promising alternative to TEA in optimal perioperative pain management in cardiac surgery.

Effects of thoracic epidural analgesia on exercise-induced myocardial ischaemia in refractory angina pectoris

BACKGROUND

Thoracic epidural analgesia (TEDA) was offered to patients with refractory angina pectoris. Our primary objectives were to evaluate TEDAs´ influence on quality of life (QoL, base for power analysis), and hypothesising that TEDA with bupivacaine during 1 month counteracts exercise-induced myocardial hypoperfusion and increase physical performance.

METHODS

Patients with refractory angina and exercise inducible hypoperfusion, as demonstrated by myocardial perfusion imaging (MPI), were randomised to 1-month treatment with TEDA with bupivacaine (B-group, n = 9) or saline (P-group, n = 10) in a double-blind fashion. MPI and bicycle ergometry were performed before TEDA and after 1 month while subjective QoL on a visual analogue scale (VAS) reported by the patients was checked weekly.

RESULTS

During this month VAS (mean [95%CI]) increased similarly in both groups (B-group from 33 [18-50] to 54 [30-78] P < 0.05; P-group from 40 [19-61] to 48 [25-70] P < 0.05). The B-group reduced their exertional-induced myocardial hypoperfusion (from 32% [12-52] to 21% [3-39]; n = 9; P < 0.05), while the P-group showed no significant change (before 21% [6-35]; at 1 month 23% [6-40]; n = 10). MPI at rest did not change and no improvement in physical performance was detected in neither of the groups.

CONCLUSIONS

In refractory angina, TEDA with bupivacaine inhibits myocardial ischaemia in contrast to TEDA with saline. Regardless of whether bupivacaine or saline is applied intermittently every day, TEDA during 1 month improves the quality of life and reduces angina, even when physical performance remains low. A significant placebo effect has to be considered.

Postoperative analgesia after combined thoracoscopic-laparoscopic esophagectomy: a randomized comparison of continuous infusion and intermittent bolus thoracic epidural regimens

Purpose

Judicious postoperative pain management after thoracoscopic–laparoscopic esophagectomy (TLE) facilitates enhanced rehabilitation. Thoracic epidural analgesia (TEA) offers many benefits in esophagectomy, while several complications are associated with the delivery mode by continuous epidural infusion. This study compared the efficiency and safety of intermittent epidural bolus to continuous epidural infusion for pain management after TLE.

Patients and methods

Sixty patients, aged 18–80 years, with American Society of Anesthesiologists classes I–III and scheduled for TLE with combined general anesthesia and TEA were randomly allocated to two groups. Patients received either a continuous epidural infusion with 0.3% ropivacaine and 1.5 µg/mL fentanyl at 6 mL/h plus a patient-controlled bolus of 3 mL (continuous group) or an intermittent bolus of 6 mL of the same solution on demand with lockout time of 30 minutes (intermittent group). If the patient complained of pain and the visual analog scale score was >4, an intravenous injection of tramadol or dezocine was administered as rescue treatment. The primary outcome variable was the consumption of epidural opioids and local anesthetics for TEA.

Results

TEA for pain management following TLE by intermittent epidural bolus was associated with significantly lower consumption of fentanyl and ropivacaine and lower incidences of breakthrough pain and hypotension than continuous epidural infusion. No significant differences were observed between the two groups in terms of pain score at rest or while coughing, patient satisfaction, or incidence of postoperative complications.

Conclusion

Compared with continuous epidural infusion, TEA by on-demand intermittent bolus greatly reduced the consumption of local anesthetics and opioids with comparable pain relief and little impairment in hemodynamics when used for pain management after TLE.

Pain management and safety profiles after preoperative vs postoperative thoracic epidural insertion for bilateral lung transplantation

OBJECTIVE

Thoracic epidural analgesia provides effective pain control after lung transplantation; however, the optimal timing of placement is controversial. We sought to compare pain control and pulmonary and epidural morbidity between patients receiving preoperative vs postoperative epidurals.

METHODS

Institutional records were reviewed for patients undergoing a bilateral lung transplant via a bilateral anterior thoracotomy with transverse sternotomy incision between January 2014 and January 2017. Pain control was measured using visual analog scale pain scores (0-10). Pulmonary complications included a composite of pneumonia, prolonged intubation, and reintubation/tracheostomy.

RESULTS

Among 103 patients, 72 (70%) had an epidural placed preoperatively and 31 (30%) had an epidural placed within 72 hours posttransplant. There were no differences in the rates of cardiopulmonary bypass (3% vs 0%, P = 0.59); however, patients with a preoperative epidural were less likely to be placed on extracorporeal membrane oxygenation intraoperatively (25% vs 52%, P = 0.01). Pain control was similar at 24 hours (1.2 vs 1.7, P = 0.05); however, patients with a preoperative epidural reported lower pain scores at 48 (1.2 vs 2.1, P = 0.02) and 72 hours posttransplant (0.8 vs 1.7, P = 0.02). There were no differences in primary graft dysfunction (42% vs 56%, P = 0.28), length of mechanical ventilation (19.5 vs 24 hours, P = 0.18), or adverse pulmonary events (33% vs 52%, P = 0.12). No adverse events including epidural hematoma, paralysis, or infection resulted from epidural placement.

CONCLUSION

Preoperative thoracic epidural placement provides improved analgesia without increased morbidity following lung transplantation.

Calming the Electrical Storm: Use of Stellate Ganglion Block and Thoracic Epidural in Intractable Ventricular Tachycardia

Imbalances in the autonomic nervous system contribute to ventricular tachyarrhythmias. Sympatholysis with thoracic epidural analgesia or a stellate ganglion block attenuates myocardial excitability and the proarrhythmic effects of sympathetic hyperactivity.

Epidural Analgesia With Surgical Stabilization of Flail Chest Following Blunt Thoracic Trauma in Patients With Multiple Trauma

Flail chest, often defined as the fracture of three or more ribs in two or more places, represents the most severe form of rib fractures. Conservative treatment, consisting of respiratory assistance with endotracheal intubation and mechanical ventilation (internal pneumatic stabilization) and pain control, are the current treatments of choice in the majority of patients with multiple rib fractures. However, the use of mechanical ventilation may create complications. In selected patients, operative fixation of fractured ribs within 72 h post injury may lead to better outcomes. We conducted a retrospective analysis of a series of nine cases of patients who developed flail chest after blunt trauma, and were treated with surgical osteofixation of the chest wall and postoperative epidural analgesia at the University Clinical Center of the Republic of Srpska during the period from January 2015. to December 2016. Two patients had trauma to the chest only, and the other patients had associated injuries to the head, abdomen, spine, and fractures of the pelvis and long bones. In the majority of patients (77.7%), surgical stabilization of the chest was performed on the second day following the injury, (mean, 2.33 days) and no later than 5 days after the injury. All patients received epidural analgesia with 0, 25% bupivacaine and 0, 01% morphine and intravenous multimodal analgesia, beginning 6 h after thoracotomy. The average length of ICU stay was 14.7 days (range 2–36), while the average number of days of mechanical ventilation was 8.1. The average duration of hospitalization was 25.4 days. Tracheotomy was performed in 33.3% of study patients. Mortality in the observed group was 44.4%. This study shows that surgical stabilization and epidural analgesia reduced ventilator support, shortened trauma intensive care unit stay, and reduced medical costs vs internal pneumatic stabilization.

The impact of fluoroscopic confirmation of thoracic imaging on accuracy of thoracic epidural catheter placement on postoperative pain control

Background

Thoracic epidural analgesia (TEA) provides superior postoperative pain control compared to parenteral opioids after major thoracic and abdominal surgeries. However, some studies with respect to benefits of continuous TEA have shown mixed results. The purpose of this study was to determine the rate of successful TEA catheter insertion into the epidural space using contrast fluoroscopy and the impact of placement location on postoperative analgesia and opioid use.

Patients and methods

After Advocate health care institutional review board approval, we conducted a prospective, open-label, single intervention study on patients undergoing thoracic or upper abdominal surgery. A thoracic paramedian epidural approach and a loss of resistance to saline technique were used to place an epidural catheter above the T11 level and fluoroscopic images with injected contrast were taken to locate the catheter tip in the epidural space.

Results

Twenty-five subjects were included in the study, of which 3 catheters (12%) were not identified as being in the epidural space. We found an average difference of 1.5 vertebral levels between clinical and radiological assessments of catheter tips. Thirteen catheters (52%) were more than 1 vertebral level away from the clinically assessed level. No significant difference was found in the pain scores at 1, 24, and 48 hours after surgery between patients with correct versus incorrect catheter placement. Less opioids were used in the correct catheter placement group at 24 hours (256 morphine milligram equivalent [MME] vs 201 MME) and at 48 hours after surgery (250 MME vs 173 MME), but it was not statistically significant (p=0.149 and p=0.068, respectively).

Conclusion

Improvement in assuring success in the technique for TEA catheter placement following major thoracic or upper abdominal surgery exists, for which contrast-enhanced fluoroscopy might be a promising solution.

CONSORT-epidural dexmedetomidine improves gastrointestinal motility after laparoscopic colonic resection compared with morphine

BACKGROUND

We have previously shown that epidural dexmedetomidine, when used as an adjunct to levobupivacaine for control of postoperative pain after open colonic resection, improves recovery of gastrointestinal motility compared with morphine.

METHODS

Sixty patients undergoing laparoscopic colonic resection were enrolled and allocated randomly to treatment with dexmedetomidine (group D) or morphine (group M). Group D received an epidural loading dose of dexmedetomidine (5 mL, 0.5 μg/kg), followed by continuous epidural administration of dexmedetomidine (80 μg) in 0.125% levobupivacaine (240 mL) at a rate of 5 mL/h for 2 days. Group M received an epidural loading dose of morphine (5 mL, 0.03 mg/kg) followed by continuous epidural administration of morphine (4.5 mg) in 0.125% levobupivacaine (240 mL) at a rate of 5 mL/h for 2 days. Verbal rating score (VRS) of pain, postoperative analgesic requirements, side effects related to analgesia, and time to postoperative first flatus (FFL) and first feces (FFE) were recorded.

RESULTS

VRS and postoperative analgesic requirements were not significantly different between the treatment groups. In contrast, FFL and FFE were significant delayed in group M compared with group D (P < .05). Patients in group M also had a significantly higher incidence of nausea, vomiting, and pruritus (P < .05). No neurological deficits were observed in either group.

CONCLUSIONS

Compared with morphine, epidural dexmedetomidine is a better adjunct to levobupivacaine for control of postoperative pain after laparoscopic colonic resection.

Thoracic epidural analgesia reduces myocardial injury in ischemic patients undergoing major abdominal cancer surgery

Background and objectives

Major abdominal cancer surgeries are associated with significant perioperative mortality and morbidity due to myocardial ischemia and infarction. This study examined the effect of perioperative patient controlled epidural analgesia (PCEA) on occurrence of ischemic cardiac injury in ischemic patients undergoing major abdominal cancer surgery.

Patients and methods

One hundred and twenty patients (American Society of Anesthesiologists grade II and III) of either sex were scheduled for elective upper gastrointestinal cancer surgeries. Patients were allocated randomly into two groups (60 patients each) to receive, besides general anesthesia: continuous intra and postoperative intravenous (IV) infusion with fentanyl for 72 h postoperatively (patient controlled intravenous analgesia [PCIA] group) or continuous intra and postoperative epidural infusion with bupivacaine 0.125% and fentanyl (PCEA group) for 72 h postoperatively. Perioperative hemodynamics were recorded. Postoperative pain was assessed over 72 h using visual analog scale (VAS). All patients were screened for occurrence of myocardial injury (MI) by electrocardiography, echocardiography, and cardiac troponin I serum level. Other postoperative complications as arrhythmia, deep venous thrombosis (DVT), pulmonary embolism, pneumonia, and death were recorded.

Results

There was a significant reduction in overall adverse cardiac events (myocardial injury, arrhythmias, angina, heart failure and nonfatal cardiac arrest) in PCEA group in comparison to PCIA group. Also, there was a significant reduction in dynamic VAS pain score in group PCEA in comparison to PCIA at all measured time points. Regarding perioperative hemodynamics, there was a significant reduction in intra-operative mean arterial pressure (MAP); and heart rate in PCEA group in comparison to PCIA group at most of measured time points while there was not a significant reduction in postoperative MAP and heart rate in the second and third postoperative days. The incidence of other postoperative complications such as DVT, pneumonia and in hospital mortality were decreased in PCEA group.

Conclusion

Perioperative thoracic epidural analgesia in patients suffering from coronary artery disease subjected to major abdominal cancer surgery reduced significantly postoperative major adverse cardiac events with better pain control in comparison with perioperative IV analgesia.

Postoperative pain management in patients undergoing thoracoscopic repair of pectus excavatum: A retrospective analysis of opioid consumption and adverse effects in adolescents

Introduction:

Although the Nuss procedure provides excellent cosmetic results for the correction of pectus excavatum, the provision of analgesia following such procedures can be challenging.

Methods:

The current study retrospectively reviews our experience over a 2.5 year period with thoracic epidural analgesia (TE), paravertebral blockade (PVB), and intravenous opioids delivered via patient-controlled analgesia (PCA) to provide postoperative analgesia.

Results:

The study cohort included 30 patients (mean age = 15.6 ± 1.5 years), 15 of whom were treated with PCA, 8 with TE, and 7 with PVB. There were no significant differences in pain scores between the 3 groups at any time point during the first 3 postoperative days. Compared to PCA, the PVB group had lower opioid consumption over the first 24 hours of hospitalization by 1.7 mg/kg morphine equivalents (95% CI of difference: 0.1, 3.3; p=0.035); but had higher opioid consumption by 2.0 mg/kg morphine equivalents than the TE group (95% CI of difference: 0.3, 3.7; p=0.024). There were no differences in opioid consumption between PVB and PCA or between PVB and TE at 48 or 72 hours. The number of intraoperative hypotension episodes was significantly lower in the PCA group when compared to the PVB group (p=0.001), with no difference between the PVB and TE groups.

Conclusions:

The use of regional anesthesia should be considered a viable option for the relief of postoperative pain in pediatric patients following the Nuss procedure albeit with a higher incidence of intraoperative hemodynamic effects. A randomized, prospective, study powered to compare all 3 techniques against one another would be necessary to confirm the significance of these findings.

Pain relief following thoracic surgical procedures: A literature review of the uncommon techniques

Thoracic surgical procedures can be either thoracotomy or thoracoscopy. In thoracotomy, the incision could be either muscle-cutting or muscle-sparing incision. The posterolateral thoracotomy incision is used for most general thoracic surgical procedures. This incision, which involves division of the latissimus dorsi and serratus anterior muscles, affords excellent exposure of the thoracic cavity. However, it is associated with significant morbidity, including impaired pulmonary function, postoperative chest pain, and restricted arm and shoulder movement. Various muscle-sparing incisions have been proposed to decrease the morbidity. Postthoracotomy pain originates from pleural and muscular damage, costovertebral joint disruption, and intercostal nerve damage during surgery. Inadequate pain relief after surgery affects the quality of patient's recovery and exposes the patients to postoperative morbidities. There is a tendency nowadays among thoracic surgeons and anesthesiologists toward the area of enhanced recovery after thoracic surgery which requires careful titration of the anesthetic drugs in awake patients undergoing thoracoscopic procedures. There is a common feeling among thoracic anesthesiologists that potthoracoscopy procedures produce less pain intensity versus thoracotomy which is partially true. However, effective management of acute pain following either thoracotomy/thoracoscopy is needed and may prevent these complications and reduce the likelihood of developing chronic pain. In this report, we are going to review the newly introduced postthoracotomy/thoracoscopy pain relief modalities with special reference to the new tendency of awake thoracic surgical procedures and its impact on enhanced recovery after surgery.

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.

Prospective, comparative study of the On-Q® PainBuster® postoperative pain relief system and thoracic epidural analgesia after thoracic surgery

OBJECTIVE

Pain after thoracotomy is associated with intense discomfort leading to impaired pulmonary function.

DESIGN

Prospective, non-randomized trial from April 2009 to September 2011.

SETTING

Department of Thoracic Surgery, single-center.

PARTICIPANTS

Thoracic surgical patients.

INTERVENTIONS

Comparison of thoracic epidural analgesia (TEA) with the On-Q® PainBuster® system after thoracotomy.

MEASUREMENTS AND MAIN RESULTS

The TEA group (n=30) received TEA with continuous 0.2% ropivacaine at 4 mL-to-8 mL/h, whereas Painbuster® patients (n=32) received 0.75% ropivacaine at 5 mL/h until postoperative day 4 (POD4). Basic and on-demand analgesia were identical in both groups. Pain was measured daily on a numeric analog scale from 0 (no pain) to 10 (worst pain) at rest and at exercise. There were no significant differences regarding demographic and preoperative data between the groups, but PainBuster® patients had a slightly lower relative forced expiratory volume in 1 second (FEV1) (71±20% versus 86±21%; p=0.01). Most common surgical procedures were lobectomies (38.8%) and atypical resections (28.3%) via anterolateral thoracotomy. Most common primary diagnoses were lung cancer (48.3%) and tumor of unknown origin (30%). At POD1, median postoperative pain at rest was 2.1 (1; 2.8) in the TEA group and 2 (1.5; 3.8; p=0.62) in the PainBuster® group. At exercise, median pain was 4.3 (3.5; 3.8) in the TEA group compared to 5.0 (4.0; 6.5; p=0.07). Until POD 5 there were decreases in pain at rest and exercise but without significant differences between the groups.

CONCLUSIONS

Sufficient analgesia after thoracotomy can be achieved with the intercostal PainBuster® system in patients, who cannot receive TEA.

Anaesthetic management of cytoreductive surgery followed by hyperthermic intrathoracic chemotherapy perfusion

BACKGROUND

Macroscopic cytoreductive surgery and hyperthermic intrathoracic chemotherapy perfusion (HITHOC) is a new multimodal approach for selected patients with primary and secondary pleural tumors, which may provide the patient with better local tumor control and increased overall survival rate.

METHODS

We present a single-center study including 20 patients undergoing cytoreductive surgery and HITHOC between September 2008 and April 2013 at the University Medical Center Regensburg, Germany. Objective of the study was to describe the perioperative, anaesthetic management with special respect to pain and complication management.

RESULTS

Anaesthesia during this procedure is characterized by increased intrathoracic airway and central venous pressure, hemodynamic alterations and the risk of systemic hypo- and hyperthermia. Securing an adequate intravascular volume is one of the primary goals to prevent decreased cardiac output as well as pulmonary edema. Transfusion of packed red blood cells (PRBC) was necessary in seven of 20 (35%) patients. Only two patients (10%) showed an impairment of coagulation in postoperative laboratory analysis. Perioperative forced diuresis is recommended to prevent postoperative renal insufficiency. Supplementary thoracic epidural analgesia in 13 patients (65%) showed a significant reduction of post-operative pain compared with peroral administration of opioid and non-opioid analgesics.

CONCLUSION

This article summarizes important experiences of the anaesthesiological and intensive care management in patients undergoing HITHOC.

Duration of one-lung ventilation stage, POSSUM value and the quality of post-operative analgesia significantly affect survival and length of stay on intensive care unit of patients undergoing two-stage esophagectomy

Purpose:

To analyze different factors affecting the outcome of patients undergoing Two Stage Esophagectomy (TSE) for the treatment of esophageal carcinoma (EC) while relating these factors to the length of stay on Intensive Care Unit (ILOS), mortality, and morbidity.

Methods:

Retrospective study of case-notes of 45 patients who underwent a TSE for resection of EC at a general district hospital in the United Kingdom (UK). These procedures were performed by the same surgical team and followed same approach, known as the Ivor-Lewis procedure.

Results:

The duration of One Lung Ventilation (OLV) during TSE was found to be critical for patient's outcome. Statistical analysis suggested a potentially strong effect of the duration of OLV (range: 90-320 minutes) on the ILOS (P=0.001). The ratio OLV: Total duration of surgery (TOT) was significantly different in early post-operative (PO) deaths (within 3 months) and late deaths after the third month (P=0.032). The POSSUM value (Physiological and Operative Severity Score for Enumeration of Mortality) correlated well with ILOS (P=0.05). Regression analysis showed a strong relationship between the two variables (P=0.03). An excellent to good quality of PO analgesia allowed for shorter ILOS (P=0.023).

Conclusions:

Duration of the OLV appears as an important factor in the outcome of patients. POSSUM value could help in planning the post-operative critical care need of patients undergoing TSE. A well managed post-operative pain allowed to reduce the ILOS.

Use of transcutaneous electrical nerve stimulation as an adjunctive to epidural analgesia in the management of acute thoracotomy pain

The present randomized study was conducted in our institute of pulmonary medicine and tuberculosis over a period of 1 year. This study aimed to evaluate the effectiveness of transcutaneous electrical nerve stimulation (TENS) as an adjunctive to thoracic epidural analgesia for the treatment of postoperative pain in patients who underwent posterolateral thoracotomy for decortication of lung. Sixty patients in the age group 15–40 years scheduled to undergo elective posterolateral thoracotomy were divided into two groups of 30 each. Patients were alternatively assigned to one of the groups. In group I, only thoracic epidural analgesia with local anaesthetics was given at regular intervals; however, an identical apparatus which did not deliver an electric current was applied to the control (i.e. group I) patients. While in group II, TENS was started immediately in the recovery period in addition to the epidural analgesia. A 0–10 visual analog scale (VAS) was used to assess pain at regular intervals. The haemodynamics were also studied at regular intervals of 2 h for the first 10 h after the surgery. When the VAS score was more than three, intramuscular analgesia with diclofenac sodium was given. The VAS score and the systolic blood pressure were comparable in the immediate postoperative period (P = NS) but the VAS score was significantly less in group II at 2, 4, 6, 8 h (P < 0.01, P < 0.05, P < 0.05, P < 0.05, respectively), and at 10 h the P value was not significant. Similarly, the systolic blood pressure was significantly less in group II at 2, 4, 6 h after surgery, that is P < 0.02, P < 0.01, P < 0.01, respectively, but at 8 and 10 h the pressures were comparable in both the groups. Adding TENS to epidural analgesia led to a significant reduction in pain with no sequelae. The haemodynamics were significantly stable in group II compared to group I. TENS is a valuable strategy to alleviate postoperative pain following thoracic surgery with no side effects and with a good haemodynamic stability; however, the effects are short lasting.