FastTrack approach to major colorectal surgery

Intensive rehabilitation programs after major abdominal, thoracic and vascular surgery have been published over the last few years, showing early recovery, fewer complications and a quicker discharge. The aim of the study was to evaluate the feasibility and efficacy of a multimodal intensive rehabilitation program (FastTrack) after major colorectal surgery, according to the experience of Dr. H. Kehlet of Hvidovre University Hospital, Copenhagen. The study design was of the prospective, randomized, controlled type. Forty patients undergoing elective colonic surgery were randomly selected and assigned to two groups well matched for age, weight, ASA and type of resection. The FastTrack group underwent a multimodal rehabilitation program with epidural analgesia, short laparotomy, early feeding and mobilisation. The control group had the usual postoperative treatment with a pain control program. The FastTrack group exhibited a shorter need for assisted ventilation, a lower sedation level and lower opioid consumption over the first 24 hours. We also observed a statistically significant earlier onset of peristalsis (0.5 vs 2.7 days), gastrointestinal function (defecation) (2.8 vs 5.8 days), regular feeding (3.1 vs 7.2 days) and autonomous ambulation (3.3 vs 6.9). The multimodal rehabilitation approach to colon surgery permits an earlier postoperative recovery, better postoperative performance and quicker functional autonomy. These results may have important implications for the management of patients after major colorectal surgery.     

Effect of epidural anesthesia and analgesia on perioperative outcome: a randomized, controlled Veterans Affairs cooperative study

OBJECTIVE: To test the hypothesis that epidural anesthesia and postoperative epidural analgesia decrease the incidence of death and major complications during and after four types of intraabdominal surgical procedures. SUMMARY BACKGROUND DATA: Even though many beneficial aspects of epidural anesthesia have been reported, clinical trials of epidural anesthesia for outcome of surgical patients have shown conflicting results. METHODS: The authors studied 1,021 patients who required anesthesia for one of the intraabdominal aortic, gastric, biliary, or colon operations. They were assigned randomly to receive either general anesthesia and postoperative analgesia with parenteral opioids (group 1) or epidural plus light general anesthesia and postoperative epidural morphine (group 2). The patients were monitored for death and major complications during and for 30 days after surgery, as well as for postoperative pain, time of ambulation, and length of hospital stay. RESULTS: Overall, there was no significant difference in the incidence of death and major complications between the two groups. For abdominal aortic surgical patients, unlike the other three types of surgical patients, the overall incidence of death and major complications was significantly lower in group 2 patients (22%) than in group 1 patients (37%), stemming from differences in the incidence of new myocardial infarction, stroke, and respiratory failure between the two groups. Overall, group 2 patients received significantly less analgesic medication but had better pain relief than group 1 patients. In group 2 aortic patients, endotracheal intubation time was 13 hours shorter and surgical intensive care stay was 3.5 hours shorter. CONCLUSIONS: The effect of anesthetic and postoperative analgesic techniques on perioperative outcome varies with the type of operation performed. Overall, epidural analgesia provides better postoperative pain relief. Epidural anesthesia and epidural analgesia improve the overall outcome and shorten the intubation time and intensive care stay in patients undergoing abdominal aortic operations.     

Fast track in abdominal aortic surgery

BACKGROUND: The aim of this work is to evaluate the efficacy of a new perioperative approach to improve the outcome and to reduce hospitalisation after abdominal aortic surgery. METHODS: EXPERIMENTAL DESIGN: observational study on patients operated from October 1996 to October 1997 (Group 1996), and from November 1997 to November 1998 (group 1998). CENTRE: Anaesthesiology Department of Regional Hospital. PATIENTS: historical group: 56 patients surgically treated with abdominal aortic bypass in 1996. CASE CONTROL GROUP: 58 patients surgically treated with abdominal aortic bypass in 1998. INTERVENTION: group 1996: maintenance of anaesthesia with forane and fentanyl; postoperative infusion of mepivacaine 1% through lumbar epidural catheter. GROUP 1998: preoperative anaesthesia through thoracic (T 4) epidural catheter with infusion of bupivacaine 0.5%; maintenance of anaesthesia with propofol, fentanyl and infusion of bupivacaine 0.125%; postoperative infusion of bupivacaine 0.125%, early rehabilitation care (early removal of nasogastric tube and urinary catheter, early deambulation, feeding and physiotherapy). Evaluation: analgesia efficacy, day of deambulation, day of removal of the urinary catheter and the nasogastric tube, day of bowel canalization, day of discharge, major complications. RESULTS: In group 1998 analgesia was better. Furthermore a significant improvement consisted in the earlier removal of the nasogastric tube and the urinary catheter, earlier return of the gastrointestinal function and earlier deambulation. The length of stay is significantly reduced. In group 1998 we have less complications. CONCLUSIONS: Total intra-venous anaesthesia associated with a thoracic epidural anaesthesia, connected with early rehabilitation may improve the outcome and reduce the length of stay in patients submitted to abdominal aortic surgery.     

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.     

Transabdominal versus retroperitoneal incision for abdominal aortic surgery: Report of a prospective randomized trial

Purpose: The purpose of this study was to perform a randomized, prospective trial that compares the transabdominal with the retroperitoneal approach to the aorta for routine infrarenal aortic reconstruction.Methods: From August 1990 through November 1993, patients undergoing surgery for abdominal aortic aneurysm (AAA) disease or aortoiliac occlusive disease (AIOD) were asked to participate in a randomized trial comparing the transabdominal incision (TAI) to the retroperitoneal incision (RPI) for aortic surgery. One hundred forty-five patients were randomized, with 75 (41 with AAA and 34 with AIOD) in the TAI group and 70 (40 with AAA and 30 with AIOD) in the RPI group. There were no significant differences between the groups in terms of age, sex, postoperative pain control (epidural vs patient-controlled analgesia), or comorbid conditions, except for a higher incidence of chronic obstructive pulmonary disease in the TAI group (21 vs 8 patients).Results: The incidence of intraoperative complications was similar for both groups. After surgery, the incidence of prolonged ileus (p = 0.013) and small bowel obstruction (p = 0.05) was higher in the TAI group. Overall, the RPI group had significantly fewer complications (p < 0.0001). The overall postoperative mortality rate (two deaths) was 1.4%, with both occurring in the TAI group (p = 0.507). The RPI group also had significantly shorter stays in the intensive care unit (p = 0.006), a trend toward shorter hospitalization (p = 0.10), lower total hospital charges (p = 0.019), and lower total hospital costs (p = 0.017). There was no difference in pulmonary complications (p = 0.71). In long-term follow-up (mean 23 months), the RPI group reported more incisional pain (p = 0.056), but no difference was found in incisional hernias or bulges (p = 0.297).Conclusions: We conclude that the RPI approach for abdominal aortic surgery is associated with fewer postoperative complications, shorter stays in the hospital and intensive care unit, and lower cost. There is, however, an increase in long-term incisional pain. Current methods of postoperative pain control seem to decrease the incidence of pulmonary complications. (J VASC SURG 1995;21:174-83.)     

Comparison of intravenous or epidural patient-controlled analgesia in the elderly after major abdominal surgery

BACKGROUND: Patient-controlled analgesia (PCA) with intravenous morphine and patient-controlled epidural analgesia (PCEA), using an opioid either alone or in combination with a local anesthetic, are two major advances in the management of pain after major surgery. However, these techniques have been evaluated poorly in elderly people. This prospective, randomized study compared the effectiveness on postoperative pain and safety of PCEA and PCA after major abdominal surgery in the elderly patient. METHODS: Seventy patients older than 70 yr of age and undergoing major abdominal surgery were assigned randomly to receive either combined epidural analgesia and general anesthesia followed by postoperative PCEA, using a mixture of 0.125% bupivacaine and sufentanil (PCEA group), or general anesthesia followed by PCA with intravenous morphine (PCA group). Pain intensity was tested three times daily using a visual analog scale. Postoperative evaluation included mental status, cardiorespiratory and gastrointestinal functions, and patient satisfaction scores. RESULTS: Pain relief was better at rest (P = 0.001) and after coughing (P = 0.002) in the PCEA group during the 5 postoperative days. Satisfaction scores were better in the PCEA group. Although incidence of delirium was comparable in the PCA and PCEA groups (24% vs. 26%, respectively), mental status was improved on the fourth and fifth postoperative days in the PCEA group. The PCEA group recovered bowel function more quickly than did the PCA group. Cardiopulmonary complications were similar in the two groups. CONCLUSION: After major abdominal surgery in the elderly patient, patient-controlled analgesia, regardless of the route (epidural or parenteral), is effective. The epidural route using local anesthetics and an opioid provides better pain relief and improves mental status and bowel activity.     

Anesthetic management of a patient with severe combined pulmonary disease under epidural anesthesia with spontaneous respiration

A 74-year-old man with gastric cancer was complicated with abdominal aortic aneurysm. A two-stage operation was scheduled (repair of abdominal aortic aneurysm and subsequent gastrectomy). He also had severe chronic obstructive pulmonary disease (COPD). We planned to maintain spontaneous breathing during operations under epidural anesthesia and light general anesthesia. For the first surgery, two epidural catheters were placed at T1-2 and T7-8 on the day before surgery. After establishing epidural anesthesia, general anesthesia was induced and maintained with midazolam, fentanyl and sevoflurane, but without muscle relaxants under BIS monitoring. Ropivacaine solution 0.375% was infused through an epidural catheter to provide analgesia, and spontaneous breathing was kept throughout the procedure. Surgery lasted 4 hours and 50 minutes, and patient recovered without complications. Forty days after the first surgery, the second operation was scheduled. Anesthetic management was almost the same as in the first one, except for the use of dexmedetomizine rather than sevoflurane. In both operations, sufficient analgesia was provided with epidural anesthesia, and the surgeons rated muscle relaxation as satisfactory. No respiratory complications developed postoperatively. Maintaining spontaneous breathing during abdominal surgery using epidural anesthesia and light general anesthesia is a good option for COPD patients.     

Continuous epidural chloroprocaine after abdominal surgery is associated with lower postoperative opioid exposure in NICU infants

Background: Epidural anesthesia in infants undergoing open abdominal surgery has the potential to reduce opioid consumption, lower pain scores, and expedite tracheal extubation. We evaluated associations between use of continuous epidural chloroprocaine and improved intra- and post-operative outcomes.Methods: This matched retrospective cohort study first identified 24 patients who between April 2018 through December 2019 were treated with a caudal catheter and epidural chloroprocaine infusion for a laparotomy at postnatal age of 6 months or less. A matched comparator group of 24 patients was derived based on age and type of surgery. Exclusion criteria were the presence of a preoperative opioid infusion, comorbidities that would preclude appropriate pain assessment, or a recent surgical procedure. Primary outcomes included opioid consumption and pain scores; we secondarily analyzed intraoperative anesthetic requirements, other systemic analgesic use, vital signs, tracheal extubation time, and procedural times.Results: Treatment with epidural anesthesia was associated with lower 5-day total postoperative opioid consumption (3.2 mg/kg vs. 19.7 mg/kg in the respective epidural vs. systemic groups, p = 0.001) and time to tracheal extubation (1.3 days vs. 3.2 days, p = 0.005). Any statistically significant differences in pain scores were not clinically meaningful. There were no differences in mean arterial pressure or intraoperative inhaled anesthetic doses.Conclusion: Continuous infusion of epidural chloroprocaine in infants following open abdominal surgery may limit exposure to systemic opioid medications while providing adequate postoperative analgesia and shortening time to tracheal extubation.     

Postoperative wound oxygen tension with epidural or intravenous analgesia: a prospective,randomized, single-blind clinical trial

BACKGROUND: Adequate tissue oxygen tension is an essential requirement for surgical-wound healing. The authors tested the hypothesis that epidural anesthesia and analgesia increases wound tissue oxygen tension compared with intravenous morphine analgesia. METHODS: In a prospective, randomized, blind clinical study, the authors allocated patients having major abdominal surgery (n = 32) to receive combined general and epidural anesthesia with postoperative patient-controlled epidural analgesia (epidural group, n = 16), or general anesthesia alone with postoperative patient-controlled intravenous analgesia (intravenous group, n = 16). An oxygen sensor and a temperature sensor were placed subcutaneously in the wound before closure. Wound oxygen tension (P(w)O(2)) and temperature were measured continuously for 24 h. Other variables affecting wound tissue oxygenation and visual analogue scale (VAS) pain scores were also documented. RESULTS: Despite epidural patients having lower body temperatures at the end of surgery (35.7 +/- 0.3) versus 36.3 +/- 0.5 degrees C, = 0.004), they had significantly higher mean P(w)O(2) over the 24 h period, compared with the intravenous group (64.4 +/- 14 vs. 50.7 +/- 15) mmHg, mean (SD), 95% CI difference, -22 to -5, = 0.002). Area under the P(w)O(2) -24 h time curve was also significantly higher in the epidural group (930 +/- 278 vs. 749 +/- 257) mmHg x h, 95% CI difference -344 to -18, = 0.03). VAS pain scores at rest and moving were significantly lower in the epidural group at all times. CONCLUSION: Epidural anesthesia and postoperative analgesia for major abdominal surgery increases wound tissue oxygen tension compared with general anesthesia and intravenous morphine analgesia.     

加速康复外科策略与常规策略在腹腔镜前列腺癌根治术中的效价比较

目的探讨基于多模式镇痛的加速康复外科（ERAS）理念应用于腹腔镜前列腺癌根治术中的优势。 方法回顾性分析2017年1月至12月我院同一组手术医师行腹腔镜下前列腺癌根治术患者围术期的相关资料,ERAS组患者11例,常规策略组患者24例。 结果两组患者年龄,ASA分级及心功能分级差异无统计学意义。ERAS组患者较常规治疗组术中补液量降低[（7.2±2.2）ml vs（10.7±3.8）ml/kg/h,P=0.009],术后住院时间明显减少[（7.5±2.8）d vs（10.3±2.8）d,P=0.008],术后首次排气时间缩短[（1.4±0.9）d vs（2.4±0.9）d,P=0.018]。ERAS组住院总费用及麻醉费用均较对照组增加[（75 129±21 217）元vs（55 201±19 109）元,P=0.009;（5 537±4 430） 元vs（3 121±726）元,P=0.01],而在总住院时间、麻醉费用所占住院总费用比例方面,两组差异无统计学意义。 结论在腹腔镜前列腺癌根治术中应用ERAS理念下多模式镇痛,可以加速患者胃肠道功能恢复,缩短术后住院时间,不增加围术期并发症的发生率。     

一项前瞻性随机双盲研究：胸段硬膜外给予新斯的明对腹主动脉手术后肠梗阻的影响

背景手术后肠梗阻是腹主动脉手术主要的胃肠并发症，可增加患者发病率和死亡率，延长住院时间，增加医疗费用。本项研究中，我们评价了硬膜外给予新斯的明对腹主动脉手术术后肠梗阻的影响。方法选择我院45例行择期腹主动脉手术的患者。所有患者均接受相同的全麻联合硬膜外麻醉。全麻诱导前，于T7～T8间隙放置硬膜外导管，给予布比卡因20ml（Q5％）（推注时间〉15分钟）。将患者随机分成两组，术毕和术后8小时分别通过硬膜外导管给予生理盐水稀释的1μg／kg新斯的明5ml（Ⅰ组），或给予生理盐水5ml（Ⅱ组）。在重症监护病房记录手术后出现肠鸣音的时间，同时记录每天肛门排气与排便的时间。结果Ⅰ组患者第1次出现肠鸣音时间和肛门排气时间均明显短于Ⅱ组（分别为11．6±11．2小时vs 22．6±12．8小时；21．8±15．6小时vs 36．6±19．1小时，P〈0．05）。两组第1次排便时间相近（P〉0．05）。Ⅱ组手术后恶心的发生明显高于Ⅰ组（P〈0.05）。两组手术后并发症发生率相近（P〉0.05）。结论胸段硬膜外给予新斯的明能够使腹主动脉手术后肠鸣音恢复更快，手术后肠梗阻时间缩短。     

Postoperative Wound Oxygen Tension with Epidural or Intravenous Analgesia: A Prospective, Randomized, Single-blind Clinical Trial

Background: Adequate tissue oxygen tension is an essential requirement for surgical-wound healing. The authors tested the hypothesis that epidural anesthesia and analgesia increases wound tissue oxygen tension compared with intravenous morphine analgesia.

Methods: In a prospective, randomized, blind clinical study, the authors allocated patients having major abdominal surgery (n = 32) to receive combined general and epidural anesthesia with postoperative patient-controlled epidural analgesia (epidural group, n = 16), or general anesthesia alone with postoperative patient-controlled intravenous analgesia (intravenous group, n = 16). An oxygen sensor and a temperature sensor were placed subcutaneously in the wound before closure. Wound oxygen tension (Pwo2) and temperature were measured continuously for 24 h. Other variables affecting wound tissue oxygenation and visual analogue scale (VAS) pain scores were also documented.

Results: Despite epidural patients having lower body temperatures at the end of surgery (35.7 +/- 0.3) versus 36.3 +/- 0.5 [degrees]C, P = 0.004), they had significantly higher mean Pwo2 over the 24 h period, compared with the intravenous group (64.4 +/- 14 vs. 50.7 +/- 15) mmHg, mean (SD), 95% CI difference, -22 to -5, P = 0.002). Area under the Pwo2 -24 h time curve was also significantly higher in the epidural group (930 +/- 278 vs. 749 +/- 257) mmHg x h, 95% CI difference -344 to -18, P = 0.03). VAS pain scores at rest and moving were significantly lower in the epidural group at all times.     

Epidural analgesia in patients with chronic obstructive pulmonary disease undergoing transperitoneal abdominal aortic aneurysmorraphy--a multi-institutional analysis

INTRODUCTION: Patients with chronic obstructive pulmonary disease (COPD) are more likely to develop pulmonary morbidity following major abdominal surgery. The purpose of this study was to examine the utility of epidural analgesia in patients with COPD who underwent elective transperitoneal abdominal aortic aneurysm (AAA) repair. METHODS: During a 7-year period, all patients diagnosed with COPD undergoing elective AAA repair (n=425) from three hospitals were reviewed. Inclusion criteria were an FEV(1)/FVC ratio <75% and/or a PaCO(2)>45 mmHg. Clinical outcomes were compared between those who received epidural analgesia (epidural group) and those who did not (control group). Primary endpoints measured were duration of intubation, ICU stay, hospital days, and pulmonary complications. RESULTS: Strict inclusion criteria were met by 131 patients, which included 86 patients in the epidural group and 45 patients in the control group. When comparing the epidural vs. control group, the mean AAA size was 6.3+/-0.9 cm vs. 6.0+/-1.5 cm (NS), FEV(1) was 57.2+/-24.7% vs. 49.0+/-10.3% (NS), and the mean FEV(1)/FVC ratio was 52.0+/-11.4% vs. 50.6+/-6.7% (NS), respectively. The epidural group had a significantly lower incidence of post-operative ventilator dependency and ICU stay (p<0.05), as well as a decreased trend in pulmonary complications when compared to the control group. The overall hospital stay remained similar between the two groups. The relative risk of developing a pulmonary complication in the absence of epidural analgesia was 2.3. CONCLUSIONS: Perioperative epidural analgesia is beneficial in patients with COPD undergoing AAA repair by reducing both the post-operative ventilator duration and ICU stay. Epidural analgesia should be considered in all COPD patients undergoing elective transperitoneal AAA repair.     

The use of intraoperative epidural or spinal analgesia modulates postoperative hyperalgesia and reduces residual pain after major abdominal surgery

INTRODUCTION: The use of intraoperative multimodal analgesia has clearly improved postoperative pain control, mortality and morbidity after major surgical procedures. However, very few clinical trials have studied the longterm impact of intraoperative epidural or spinal analgesia on chronic postsurgical pain (CPSP) development. Even less studies have evaluated the modulatory effect of intraoperative neuraxial analgesia on objective changes (i.e. mechanical hyperalgesia) reflecting central sensitization. METHODS: The present work compares general anesthesia alone (GA group) versus general anesthesia combined to either intraoperative epidural analgesia (EPID group: combination of bupicavaine, sufentanil and clonidine 1 microg/kg) or spinal analgesia (IT group: either bupivacaine or clonidine 300 microg) on the development of secondary mechanical hyperalgesia and the incidence of CPSP after major abdominal surgery. Data analyzed in the present work involve adult patients undergoing surgical resection of rectal adenocarcinoma who participated in three previously published randomized trials. RESULTS: Intraoperative epidural and particularly spinal analgesia reduced both incidence (p < 0.05 between GA alone and spinal analgesia) and extent (area) of secondary mechanical hyperalgesia surrounding the wound at 48h and 72 h after surgery. The use of intraoperative epidural and spinal analgesia also reduced CPSP incidence. Postoperative area of mechanical hyperalgesia seems positively correlated with the incidence CPSP. CONCLUSION: An effective intraoperative neuraxial block of nociceptive inputs from the wound using multimodal analgesia--specifically when involving spinal analgesics and antihyperalgesic drugs--contributes to prevent central sensitization and hence reduces CPSP after major abdominal procedures.     

Prophylacticiv ondansetron reduces nausea, vomiting and pruritus following epidural morphine for postoperative pain control

PURPOSE: To evaluate the prophylactic effect of ondansetron on nausea and vomiting following epidural morphine for postoperative pain control. METHODS: Seventy women (n = 35 in each group) undergoing abdominal total hysterectomy under epidural anesthesia were enrolled in this randomized, double-blinded, and placebo-controlled study. At the end of surgery, all patients received epidural morphine 3 mg for postoperative pain relief. Before morphine injection, the ondansetron group received iv ondansetron 4 mg, whereas the placebo group received iv saline. RESULTS: Patients in the ondansetron group reported a lower frequency of total postoperative nausea and vomiting (22%) and lower frequency of rescue antiemetic request (12%) than those in the placebo group (52% and 39%, respectively; P < 0.05). In addition, ondansetron was associated with a reduced incidence of pruritus following epidural morphine (28% vs 58%; P < 0.05). CONCLUSION: We conclude that iv ondansetron 4 mg is effective in the prevention of nausea, vomiting, and pruritus following epidural morphine for postoperative pain control.     

Endovascular repair for abdominal aortic aneurysms: initial experience of an endograft programme

OBJECTIVE: To evaluate early clinical results of elective endovascular repair of abdominal aortic aneurysms during the initial phase of an aortic endograft programme and to compare them with conventional open surgery. METHODS: Between July 1999 and September 2001, all patients with infrarenal abdominal aortic aneurysms undergoing elective repair were studied. The results of endovascular repair were compared with those of conventional repair. RESULTS: Twenty-seven endovascular repairs (24 men and three women; mean age, 74 yr) and 25 conventional repairs (19 men and six women; mean age, 73 yr) for infrarenal abdominal aortic aneurysms were evaluated. The aneurysm diameters in the two groups were similar (mean, 6.1 cm in the endovascular repair group and 6.6 cm in the conventional repair group). The comorbidities of the two groups were also comparable. The duration of operation was longer in the endograft group (249 +/- 86 min vs. 206 +/- 56 min), while the blood loss was significantly less (600 +/- 486 mL vs. 1074 +/- 1220 mL). The length of stay in the Intensive Care Unit (ICU) and the overall duration of hospitalization was also significantly less in the endograft group (1 +/- 1 d vs. 3 +/- 2 d in ICU; 9 +/- 5 d vs. 13 +/- 6 d of hospitalization). There was one hospital death in each group (4%), and the complications were similar between the two groups. During a mean follow-up period of 11.6 +/- 7.5 months, there was no rupture or open conversion in the endograft group. CONCLUSIONS: In the initial phase of the aortic endograft programme, the mortality and morbidity were acceptable and comparable to that of open surgery.     

Postoperative pain management: epidural analgesia

BACKGROUND: Epidural analgesia is one of the most effective regimens for postoperative pain relief after abdominal surgery. The use of epidural analgesia in high risk patients has been associated with significant decrease in surgical stress response, in cardiac and pulmonary morbidity, in recovery of gastrointestinal function and in thromboembolic events. The aim of this paper is to describe pain relief, side effects and recovery of gastrointestinal function during epidural analgesia. METHODS: During the period January 1999 to September 2001, 590 patients undergoing elective major abdominal surgery received epidural analgesia. Epidural catheters were inserted at T8-T9 (upper abdominal surgery) or T9-T11 (lower abdominal surgery) and ropivacaine 0.5% ml 7-12 combined with sufentanil 30 microg or with morphine 2 mg was injected. General anesthesia was induced and a continuous epidural infusion of ropivacaine 0.5% 5-10 ml/h was begun. Postoperatively, continuous epidural administration of ropivacaine 0.2% plus sufentanil 0.5 microg/ml or ropivacaine 0.2% plus morphine 0.02 mg/ml was continued. Data on the quality of analgesia, recovery of gastrointestinal function and all side effects were recorded for 4 days. RESULTS: Resting and incident pain scores were <4 and <5; 20% of patients received a rescue dose; the incidence of nausea was 6%, pruritus 5%; all patients also recovered from postoperative ileus. CONCLUSIONS: Continuous epidural analgesia resulted in good pain relief, provided the best balance of analgesia and side effects and improved postoperative outcome.     

Nitrogen accumulation during closed circuit anesthesia depends on the type of surgery

STUDY OBJECTIVE: The aim of this study is to test the hypothesis that the amount of nitrogen that accumulates within the closed breathing system would be greater during open abdominal surgery than during superficial surgery with small wounds. DESIGN: Prospective, comparative study. SETTING: Operating rooms of a university hospital. PATIENTS: Fourteen American Society of Anesthesiologists physical status I and II adult patients scheduled for abdominal surgery (n = 7) or tympanoplasty (n = 7). INTERVENTIONS: After induction of anesthesia and endotracheal intubation, the patients were denitrogenated for 30 minutes using 100% oxygen at a fresh gas flow of 10 L/min. The breathing system was then closed and patients were anesthetized using 60% xenon in oxygen, supplemented with epidural anesthesia in the abdominal surgery group and sevoflurane in the tympanoplasty group. MEASUREMENTS: Nitrogen concentration in the breathing system was determined by gas chromatography immediately before and 2 hours after the breathing system was closed. MAIN RESULTS: The median (range) increase in nitrogen concentration during the 2-hour period of closed circuit anesthesia was greater in the abdominal surgery patients than in the tympanoplasty patients (6.5% [4.0%-10.2%] vs 2.5% [1.4%-8.4%], P = 0.035, Mann-Whitney U test). CONCLUSIONS: The amount of nitrogen accumulation during closed circuit anesthesia is greater during open abdominal surgery than in superficial surgery such as tympanoplasty. We postulate that during open abdominal surgery, nitrogen in the ambient air enters the body across the peritoneum and then diffuses into the alveoli to be exhaled.     

Neuroleptanesthesia versus thoracic epidural anesthesia for abdominal aortic surgery

The hemodynamic consequences of abdominal aortic surgery with infrarenal cross-clamping were studied in 21 patients randomized in two groups. In Group I (11 patients), neuroleptanesthesia was utilized, while Group II (10 patients) received thoracic epidural anesthesia at the T8-9 level. Hemodynamic measurements were performed using Swan-Ganz catheters during the surgical procedures in all patients, with special attention to the periods of clamping and unclamping of the abdominal aorta. The thoracic epidural anesthesia group was characterized by greater hemodynamic stability during surgery, while patients in the neuroleptanesthesia group had significant lability of blood pressure, heart rate, and cardiac index. Nevertheless, in the two groups of patients, it is suggested that cardiac function was unfitted to the tissue oxygen demand after unclamping of the aortic prosthesis because the saturation in oxygen of the mixed venous blood and an increase in arteriovenous difference in oxygen were documented. These results point out that, whatever the anesthesia technique, the critical period in abdominal surgery could be aortic unclamping.     

Efficacy of low-dose intrathecal morphine for postoperative analgesia after abdominal aortic surgery: a double-blind randomized study

BACKGROUND AND OBJECTIVES: Several studies suggest that intrathecal morphine (ITM) improves analgesia after aortic surgery. We tested the hypothesis that in combination with multimodal postoperative pain management, low-dose ITM associated with general anesthesia would decrease postoperative analgesic requirements in patients undergoing abdominal aortic surgery. METHODS: Thirty patients were randomized to receive either general anesthesia alone or preceded by low-dose ITM (0.2 mg) administration. Patients and providers were blinded to treatment. Postsurgical multimodal pain management was similar in both groups, including parenteral paracetamol, followed by intravenous nefopam and then morphine if not sufficient. Intravenous analgesic requirements, visual analog scale (VAS) scores, and the incidence and severity of side effects were recorded for 48 hours after surgery. RESULTS: Intraoperative data were comparable between the 2 groups, except sufentanil consumption, which was significantly lower in the ITM group when compared with the control group (P = .023). ITM decreased postoperative total-morphine requirements with respect to both the number of patients who received morphine (4 v 12 patients, P = .003) and the cumulative dose of morphine administered (0 [0-12.4] v 23 [13.9-45.6] mg, P = .006). VAS scores at rest were higher in the control group than in the ITM group at awakening (P < .01), at 4 hours (P < .01) after surgery, and at 8 hours (P < .05) after surgery but did not differ between groups after this period. Whereas VAS scores on coughing were higher in the control group at awakening (P < .01) and 4 hours after surgery (P < .05), no differences were found between groups from 8 hours after surgery. CONCLUSION: In patients undergoing abdominal aortic surgery, intrathecal morphine (0.2 mg) improves postoperative analgesia and decreases the need in intraoperative and postoperative analgesics. Further studies are indicated to evaluate the role of ITM in postoperative recovery.