Correlation of postoperative epidural analgesia on morbidity and mortality after colectomy in Medicare patients

STUDY OBJECTIVE: To examine, with a large database, the effect of postoperative epidural analgesia (vs systemic analgesia) on mortality after colectomy is unclear. DESIGN: Retrospective cohort (database) design. SETTING: Medicare beneficiaries undergoing elective colectomy. PATIENTS: We examined a cohort of 12817 patients obtained from a 5% nationally random sample of Medicare beneficiaries from 1997 to 2001 who underwent elective partial excision of the large intestine. INTERVENTIONS: Patients were divided into two groups depending on the presence or absence of billing for postoperative epidural analgesia (Current Procedural Terminology code 01996). MEASUREMENTS: The primary outcomes assessed were death at 7 and 30 days after the procedure. The rates of major morbidity were also compared. Multivariate regression analysis incorporating race, gender, age, comorbidities, hospital size, hospital teaching status, and hospital technology status was performed to determine whether the presence of postoperative epidural analgesia had an independent effect on mortality or major morbidity. MAIN RESULTS: Multivariate regression analysis revealed that there was no difference between the groups with regard to overall major morbidity; however, the presence of epidural analgesia was associated with a significantly lower odds of death at 7 days (odds ratio, 0.35; 95% confidence interval, 0.21-0.59; P < 0.0001) and 30 days (odds ratio, 0.54; 95% confidence interval, 0.42-0.70; P < 0.0001) after surgery. CONCLUSIONS: The presence of postoperative epidural analgesia may decrease the odds of death after elective colectomy; however, the mechanism of such a benefit is not clear from our analysis.     

Usefulness of epidural anesthesia in gynecologic laparoscopic surgery for infertility in comparison to general anesthesia

Background Although the advantages of epidural anesthesia in open surgery have been established, its usefulness in the setting of laparoscopic surgery remains to be studied.Methods Patients undergoing laparoscopic surgery for infertility were randomly administered epidural anesthesia (group A, n = 11) or general anesthesia (group B, n = 9). The operation was performed under 4 mmHg pneumoperitoneum and in the 20° Trendelenburg position. Respiratory function tests using a spirometer and blood gas analysis were performed during the intra- or perioperative period. Pain status was evaluated with visual analog scale scoring. The number of postoperative recovery days needed to resume daily activities was obtained by a questionnaire.Results Respiratory rate, minute volume, P_aCO₂, % vital capacity (VC), and forced expiratory volume in 1 s (FEV1) % were virtually constant throughout the study period in group A, whereas %VC was decreased immediately after operation in group B (p < 0.05). Minute volume immediately after operation was significantly increased in group B compared with group A (p < 0.01), suggesting shallow respiration in women undergoing general anesthesia. Observed pain scores on abdominal pain, shoulder pain, and dyspnea were very low during operation in group A. Pain scores immediately and 3 h after operation were also minimal in group A, whereas abdominal pain scores at these points were significantly higher in group B than those in group A (both p < 0.01). The number of days required for a half reduction in wound pain, trotting, and full recuperation for group A were less than those for group B (p < 0.05).Conclusions Epidural anesthesia, when used in laparoscppic surgery for infertility treatment, has advantages over general anesthesia in terms of analgesic effects, postoperative respiratory function, and a return to preoperative daily activities.     

Sedation guidelines for midazolam infusion during combined spinal and epidural anesthesia

STUDY OBJECTIVE: To investigate the adequate infusion dose regimen of midazolam to induce sedation with the Ramsay score 4 with rapid onset during combined spinal and epidural anesthesia DESIGN: Prospective, randomized study. SETTING: Operating room of a university hospital. PATIENTS: 80 ASA physical status I and II patients aged 30 to 70 years, undergoing combined spinal and epidural anesthesia. INTERVENTIONS: Patients were randomized to four groups of 20 patients each at random. After starting surgery, an infusion of midazolam 0.3, 0.6, 0.9, or 1.2 mg/kg/hr was started. When patients closed their eyes spontaneously, the infusion dose was decreased to one half of the initial dose. At 2.5 and 5 minutes after decrease the dose and at 5-minute intervals for the first 30 minutes then at 15-minute intervals thereafter until the end of surgery, infusion dose was adjusted by decreasing to one half or increasing to twice to keep the Ramsay score 4. MEASUREMENTS AND MAIN RESULTS: The number of patients who required oxygen was significantly larger in the groups received 0.9 and 1.2 mg/kg/hr. Eleven patients with 0.9 mg/kg/hr and 17 patients with 1.2 mg/kg/hr at 5 minutes, but no patients with 0.3 or 0.6 mg/kg/hr showed Ramsay score 6 (heavy sedation). Amnesia was observed in all patients. Time to eye closure was dose dependently faster with the larger doses. CONCLUSIONS: During combined spinal and epidural anesthesia, midazolam 0.6 mg/kg/hr given until closing of the eyes (for 1.6 min) followed by midazolam 0.15 mg/kg/hr provides rapidly induced sedation, with a Ramsay score of 4 and amnesia with stable hemodynamics and respiration.     

Incidence and characteristics of failures in obstetric neuraxial analgesia and anesthesia: a retrospective analysis of 19,259 deliveries

A retrospective analysis was performed on 19,259 deliveries that occurred in our institution from January 2000 to December 2002. Anesthesia records and quality assurance data sheets were reviewed for the characteristics and failure rates of neuraxial blocks performed for labor analgesia and anesthesia. The neuraxial labor analgesia rate was 75% and the overall failure rate was 12%. After adequate analgesia from initial placement, 6.8% of patients had subsequent inadequate analgesia during labor that required epidural catheter replacement. Ultimately 98.8% of all patients received adequate analgesia even though 1.5% of patients had multiple replacements. Six percent of epidural catheters had initial intravenous placement but 46% were made functional by simple manipulations without higher subsequent failure. Unintended dural puncture occurred in 1.2% of labor neuraxial analgesia. The incidences of overall failure, intravenous epidural catheter, wet tap, inadequate epidural analgesia and catheter replacement were lower in patients receiving combined spinal-epidural versus epidural analgesia. For cesarean section, 7.1% of pre-existing labor epidural catheters failed and 4.3% of patients required conversion to general anesthesia. Spinal anesthesia for cesarean section had a lower failure rate of 2.7%, with 1.2% of the patients requiring general anesthesia. The overall use of general anesthesia decreased from 8% to 4.3% over the three-year period. Furthermore, regional anesthesia was used in 93.5% of cesarean deliveries with no anesthetic-related mortalities. Future investigations should identify acceptable international standards, risk factors associated with failure and methods to reduce failure before cesarean section.     

Dispersion of cerebral temperature, cerebral perfusion and intracranial pressure in rabbits placed with epidural balloons

This study examines the intracranial pressure and temperature dispersion in a rabbit model after epidural balloon compression. Right and left supratentorial, intraventricular and infratentorial pressures and temperatures of the rabbits have been measured before epidural balloon was placed. Afterwards, the epidural balloon was placed in right parietal epidural area. The intracranial pressure and temperature dispersion values were recorded after inflation with 0.3 and 0.6 ml, respectively. The control values of intracranial pressure measurements of four different brain regions were found to be similar. When the balloon was inflated to 0.3 ml, the intracranial pressure distribution was found to be equal in all the fields. After the balloon was inflated up to 0.6 ml, right and left supratentorial intracranial pressure values were found to be equal. However, infratentorial pressure values were lower and intraventricular pressure values were higher when compared with the right hemisphere. Before the inflation and at two different inflation volumes, perfusion pressure and temperature dispersion were found to be similar between right hemisphere and other compartments. We conclude that, the effective mechanism in cerebral temperature regulation may be related to preserved cerebral perfusion pressure and cerebral blood flow.     

Acute traumatic spinal epidural hematoma: imaging and neurologic outcome

The purpose of this study was to present MRI characteristics of traumatic spinal epidural hematomas (TSEHs) and to evaluate their effect on neurologic outcome. A retrospective analysis was performed of all 74 cases in which patients underwent emergent spinal MRI in the setting of acute trauma at our institutions Emergency Department between June 2002 and January 2003. MRI studies were evaluated for the presence of a TSEH. CT studies were evaluated for the presence of osseous trauma. Patient data were collected from medical records on the initial neurologic status at admission and at 6 months after injury. Twenty-seven of 74 patients had a spinal fracture and a TSEH. Twenty-five of 74 patients had a spinal fracture with no TSEH. Twenty-two of 74 patients had normal imaging studies. Six-month follow-up of neurologic status demonstrated no statistically significant difference in neurologic outcome between patients with spinal fractures and TSEH and those with spinal fractures but no TSEH. If a spinal fracture and abnormal neurologic exam are present, the neurologic outcome at 6 months is not worsened by the presence of a TSEH.     

The effects of cryoanalgesia combined with thoracic epidural analgesia in patients undergoing thoracotomy

This study was performed to evaluate the effects of cryoanalgesia combined with thoracic epidural analgesia on pain and respiratory complications in patients undergoing thoracotomy. Ninety patients were prospectively randomised to epidural analgesia alone (n = 45) or epidural analgesia and cryoanalgesia combined (n = 45). We monitored the use of rescue pain medication and changes in forced vital capacity and forced expired volume in 1 s, and recorded pain and opioid-related side-effects during the immediate postoperative period. The incidence of post-thoracotomy pain and numbness were also assessed up to the sixth month after surgery. Cryoanalgesia combined with thoracic epidural analgesia was associated with earlier recovery in pulmonary function, less pain during movement and a lower daily requirement for rescue analgesia one week after surgery. However, the combination of cryoanalgesia and epidural analgesia failed to decrease the incidence of long-term pain and numbness. In view of its associated long-term morbidity, cryoanalgesia combined with thoracic epidural analgesia is not recommended for patients undergoing thoracotomy.     

Management of perioperative pain in patients chronically consuming opioids

BACKGROUND: The prevalence of licit and illicit opioid use is growing, and a greater percentage of chronically opioid-consuming patients are presenting for surgery. These patients can be expected to experience increased postoperative pain, greater postoperative opioid consumption, and prolonged use of healthcare resources for managing their pain. METHODS: Achieving adequate pain control in these patients can be challenging because commonly used strategies for alleviating postoperative pain may have diminished effectiveness. We explore the prevalence and characteristics of opioid use in the United States and discuss its impact on the perioperative management of pain. We examine mechanistically why adequate perioperative pain control in chronically opioid-consuming patients may be difficult. CONCLUSIONS: We present strategies for providing adequate analgesia to these patients that include the optimal use of opioids, adjuvant medications, and regional anesthetic techniques.     

曲安奈德复合液治疗腰椎间盘突出症

目的探讨曲安奈德不同剂量复合液硬膜外腔前外侧间隙注射治疗腰椎间盘突出症疗效及不良反应。方法32例腰椎间盘突出症患者随机分为A、B两组。A组16例,取侧外位,患侧在下;选腰3-4间隙行硬膜外腔穿刺,向尾向下朝腰4-5硬外腔前外侧间隙方向插入硬外导管4cm,注入1.5%利多卡因3ml试验剂;接着注入曲安奈德20mg加布比卡因20mg加维生素B121000μg加生理盐水至8ml,保持原体位10min朝腹侧方向转成俯卧位10min。3d一次、共3次;卧床休息3周。B组16例。曲安奈德40mg,其他同A组。结果(1)总有效率:A组100%。B组100%。(2)总不良反应率:A组31%。B组75%。两组比较差异显著(P<0.05)。结论曲安奈德20mg复合液治疗腰椎间盘突出症总有效率100%,总不良反应率较少。     

Acute spontaneous spinal epidural haematoma in a child

Spontaneous spinal epidural haematomas rarely occur. Patients tend to be in their sixties or seventies. Acute spontaneous spinal epidural haematomas in children without a predisposition for bleeding disorders, trauma, vascular malformations or anticoagulant therapy have seldom been described. We present a case of a 4-year-old girl with a spontaneous cervical epidural haematoma diagnosed with MR. Received: 20 January 2000; Revised: 18 April 2000; Accepted: 19 April 2000