Mininvasive abdominal aortic surgery. Early recovery and reduced hospitalization after multidisciplinary approach

AIM: Clinical experience in gastrointestinal surgery demonstrated that a multimodal approach can improve the outcome and reduce the length of hospital stay. In this paper we investigate the impact of a multimodal clinical program, based on mininvasive surgery, epidural anesthesia and early feeding and mobilization, on postoperative morbidity and hospitalization after abdominal aortic surgery. METHODS: A 2-armed study was designed. All patients undergoing abdominal aortic surgery between May 2000 and April 2001 were enrolled in a multidisciplinary clinical program including thoracic epidural anesthesia and analgesia, left sub-costal minilaparotomy without evisceration, encouragement to feed and mobilize soon after surgery (Multidisciplinary group: n=82). For comparison purposes, a retrospective analysis was conducted using the data of all patients operated on between January and December 1997, receiving standard anesthesia care and a standard surgical and nursing program (Standard group: n=64). RESULTS: In the Multidisciplinary group we observed significantly better pain relief (p<0.01), earlier restoration of ambulation (p<0.01), earlier feeding (p<0.01) and passage of stools (p<0.01). The incidence of complications was significantly lower in the Multidisciplinary group: pulmonary (0% vs 14.1%), cardiac (2.4% vs 9.4% ) and gastrointestinal (0% vs 10.9%). None of the patients in the Multidisciplinary group required admission to Intensive Care. Median postoperative hospitalization was 3 days in the Multidisciplinary group compared to 9 days in the Standard group (p<0.01). CONCLUSION: These results suggest that a multidisciplinary intervention with review of the traditional surgical care program would enhance recovery, decrease morbidity and hospitalization after abdominal aortic surgery.     

The use of epidural anesthesia and analgesia in aortic surgery.

During a 3-year period, sixty-four consecutive patients, who had elective aortic reconstruction were investigated to determine whether epidural anesthesia and analgesia, combined with light general anesthesia, would lower the rate of perioperative complications in this high-risk group of patients. The epidural group comprised 32 consecutive patients who had surgery during the 20-month period from July 1986 to December 1987. These patients were compared with the previous 32 patients who had aortic reconstruction at Huntington Memorial Hospital (Pasadena, CA) using conventional general anesthetic techniques. Cardiovascular and respiratory morbidity, length of hospital stay, length of intensive care unit stay, and duration of endotracheal intubation were compared. There was no statistically significant difference in cardiovascular morbidity, length of hospital stay, or intensive care unit stay between the two groups. There was however, a striking decrease in respiratory complications and length of intubation in the epidural anesthesia group (P less than 0.005). The authors conclude that epidural anesthesia and analgesia, combined with a light general anesthetic may confer benefits over conventional general anesthesia in patients undergoing aortic surgery.     

Effects of epidural anesthesia and analgesia on coagulation and outcome after major vascular surgery

To examine the interaction of epidural anesthesia, coagulation status, and outcome after lower extremity revascularization, 80 patients with atherosclerotic vascular disease were prospectively randomized to receive general anesthesia combined with postoperative epidural analgesia (GEN-EPI) or general anesthesia with on-demand narcotic analgesia (GEN). Demographics did not differ between groups except that the GEN-EPI group had a higher incidence of diabetes mellitus and of previous myocardial infarction. Coagulation status was monitored using thromboelastography. An additional 40 randomly selected patients without atherosclerotic vascular disease undergoing noncardiovascular procedures served as controls for coagulation status. Vascular surgical patients were hypercoagulable compared with control patients before operation and on the first postoperative day. Postoperatively, this hypercoagulability was attenuated in the GEN-EPI group and was associated with a lower incidence of thrombotic events (peripheral arterial graft coronary artery or deep vein thromboses). The rates of cardiovascular, infectious, and overall postoperative complications, as well as duration of intensive care unit stay, were significantly reduced in the GEN-EPI group. Stepwise logistic regression demonstrated that the only significant predictors of postoperative cardiovascular complications were preoperative congestive heart failure and general anesthesia without epidural analgesia. We conclude that in patients with atherosclerotic vascular disease undergoing arterial reconstructive surgery (a) thromboelastographic evidence of increased platelet-fibrinogen interaction is associated with early postoperative thrombotic events, and (b) epidural anesthesia and analgesia is associated with beneficial effects on coagulation status and postoperative outcome compared with intermittent on-demand opioid analgesia.     

Epidural analgesia enhances functional exercise capacity and health-related quality of life after colonic surgery: results of a randomized trial

BACKGROUND: Multimodal analgesia programs have been shown to decrease hospital stay, but it not clear which functions are restored after surgery. The objective of this study is to evaluate the impact of epidural anesthesia and analgesia on functional exercise capacity and health-related quality of life. METHODS: Sixty-four patients undergoing elective colonic resection were randomized to either patient-controlled analgesia with morphine or thoracic epidural analgesia with bupivacaine and fentanyl (epidural group). All patients in both groups received similar perioperative care and were offered the same amount of postoperative oral nutrition and assistance with mobilization. Primary outcome was functional exercise capacity as measured by the 6-min walking test, and secondary outcome was health-related quality of life, as measured by the SF-36 health survey. These were assessed before surgery and at 3 and 6 weeks after hospital discharge. Other variables measured in hospital included pain and fatigue visual analogue scale, bowel function, time out of bed, nutritional intake, complication rate, readiness for discharge, and length of hospital stay. RESULTS: Although the 6-min walking test and the SF-36 physical health component decreased in both groups at 3 and 6 weeks after surgery, the patient-controlled analgesia group experienced a significantly greater decrease at both times (P < 0.01). Patients in the epidural group had lower postoperative pain and fatigue scores, which allowed them to mobilize to a greater extent (P < 0.05) and eat more (P < 0.05). Length of hospital stay and incidence of complications were similar in both groups, although patients in the epidural group were ready to be discharged earlier. CONCLUSIONS: The superior quality of pain relief provided by epidural analgesia had a positive impact on out-of-bed mobilization, bowel function, and intake of food, with long-lasting effects on exercise capacity and health-related quality of life.     

Thoracic epidural versus intravenous patient-controlled analgesia after cardiac surgery: a randomized controlled trial on length of hospital stay and patient-perceived quality of recovery

BACKGROUND: Perioperative thoracic epidural analgesia reduces stress response and pain scores and may improve outcome after cardiac surgery. This prospective, randomized trial was designed to compare the effectiveness of patient-controlled thoracic epidural analgesia with patient-controlled analgesia with intravenous morphine on postoperative hospital length of stay and patients' perception of their quality of recovery after cardiac surgery. METHODS: One hundred thirteen patients undergoing elective cardiac surgery were randomly assigned to receive either combined thoracic epidural analgesia and general anesthesia followed by patient-controlled thoracic epidural analgesia or general anesthesia followed by to patient-controlled analgesia with intravenous morphine. Postoperative length of stay, time to eligibility for hospital discharge, pain and sedation scores, degree of ambulation, lung volumes, and organ morbidities were evaluated. A validated quality of recovery score was used to measure postoperative health status. RESULTS: Length of stay and time to eligibility for hospital discharge were similar between the groups. Study groups differed neither in postoperative global quality of recovery score nor in five dimensions of quality of recovery score. Time to extubation was shorter (P < 0.001) and consumption of anesthetics was lower in the patient-controlled thoracic epidural analgesia group. Pain relief, degree of sedation, ambulation, and lung volumes were similar between the study groups. There was a trend for lower incidences of pneumonia (P = 0.085) and confusion (P = 0.10) in the patient-controlled thoracic epidural analgesia group, whereas cardiac, renal, and neurologic outcomes were similar between the groups. CONCLUSIONS: In elective cardiac surgery, thoracic epidural analgesia combined with general anesthesia followed by patient-controlled thoracic epidural analgesia offers no major advantage with respect to hospital length of stay, quality of recovery, or morbidity when compared with general anesthesia alone followed by to patient-controlled analgesia with intravenous morphine.     

Effects of intravenous patient-controlled analgesia with morphine, continuous epidural analgesia, and continuous femoral nerve sheath block on rehabilitation after unilateral total-hip arthroplasty

BACKGROUND AND OBJECTIVES: Regional analgesic techniques allow better postoperative rehabilitation and shorter hospital stay after major knee surgery. The authors tested the hypothesis that similar results could be obtained after total-hip arthroplasty. METHODS: Forty-five patients scheduled for THA under general anesthesia were randomly divided into 3 groups. Postoperative analgesia was provided during the first 48 hours, with intravenous patient-controlled analgesia (IV PCA) induced by morphine (dose, 1.5 mg; lockout interval, 8 min) in group IV, continuous femoral nerve sheath block in group FNB, and continuous epidural analgesia in group EPI. The day after surgery, the 3 groups started identical physical therapy regimens. Pain scores at rest and on movement, supplemental analgesia, side effects, daily degree of maximal hip flexion and abduction, day of first walk, and duration of hospital stay were recorded. RESULTS: Population data, quality of pain relief, postoperative hip rehabilitation, and duration of hospital stay were comparable in the 3 groups. When compared with the two other techniques, continuous FNB was associated with a lower incidence of side effects (no nausea/vomiting, urinary retention, arterial hypotension, or catheter problem during the first 48 hours in 20%, 60%, and 13% of patients in groups IV, FNB, and EPI, respectively). CONCLUSIONS: This study suggests that IV PCA with morphine, continuous FNB, and continuous epidural analgesia provide similar pain relief and allow comparable hip rehabilitation and duration of hospital stay after total-hip arthroplasty (THA). As continuous FNB is associated with less side effects, it appears to offer the best option of the three.     

Postoperative pulmonary complications: general anesthesia with postoperative parenteral morphine compared with epidural analgesia

In a prospective study, patients undergoing abdominal cancer surgery were randomly allocated to receive either general anesthesia with fentanyl intravenously and postoperative analgesia with parenteral morphine (GA group) or general anesthesia combined with epidural bupivacaine and epidural morphine for postoperative pain relief (EP group). Analgesia was tested on a visual pain scale. Pulmonary complications were evaluated by clinical complications, blood gas analysis, x-ray film changes, and pulmonary volumes (vital capacity, forced expiratory volume in 1 second). Measurements were performed on the day before the operation and on the first 5 postoperative days. In the EP group the pain relief was significantly better on the first day (p less than 0.03). Whatever the criteria used, the rates of pulmonary complications were similar in the two groups: clinical complications 21% versus 26%, radiologic complications 50% versus 64% for GA and EP groups, respectively. Postoperative PaO2 and spirometric values were similar in the two groups. Postoperative epidural analgesia may improve the patient's comfort but does not decrease the incidence of pulmonary complications.     

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.     

Kontinuierliche Periduralanalgesie versus patientenkontrollierte intravenöse Analgesie

Objectives: Continuous epidural analgesia (EA) and patient-controlled intravenous analgesia (PCA) are widely used for postoperative pain control. Studies indicate that both analgesic regimens provide good analgesia after major surgery. However, because of the following reasons it is still unclear whether one of the two modes of application is superior. First, there are conflicting data regarding the differences in pain relief and drug use between epidural and intravenous administration of opioids. Second, in many studies epidural analgesia is performed by a combination of local anaesthetics and opioids. Third, reduced morbidity was observed only in some of the studies, in which epidural analgesia provided better pain relief than systemic opioid supply. Despite these conflicting results, EA with local anaesthetics and fentanyl as well as PCA with piritramid, a highly potent μ-agonist, are routinely used in Germany. The purpose of this study was to compare these two treatments for analgesic efficacy, pulmonary function, incidence of side effects and complications in patients undergoing thoracotomy. Methods: In this prospective randomized trial 50 patients were included. For postoperative pain control 25 patients (EA group) received thoracic epidural infusion of local anaesthetics (bupivacaine 0.125% or ropivacaine 0,2%) and fentanyl 4,5µg/ml with a flow rate of 4-10 ml/h. 25 patients received intravenous PCA with piritramid (bolus 2,5 mg, lock out 15 minutes, maximum of 25 mg/4 h, no background infusion). Results: Analgesia at rest and while coughing, as evaluated by visual analogue scale, was significantly better in the EA group. EA also resulted in superior values of pulmonary function tests, general condition and a lower incidence of sedation and nausea. In contrast, patients with EA reported distinctly more pruritus than patients with PCA. Duration of hospital stay was shorter in the EA group, but this difference did not reach statistical significance. There was one atelectasis in the EA group. No major complications related to EA or PCA were observed. Conclusion: In this study EA with local anaesthetics and fentanyl provided superior postoperative pain control and a lower incidence of sedation and nausea compared to intravenous PCA with piritramid, but there was no superiority as to pulmonary complications and duration of hospital stay.     

Perioperative management in patients undergoing pancreatic surgery: the anesthesiologist's point of view

BACKGROUND: A high rate of mortality and morbidity has been associated with pancreaticoduodenectomy; the 5-year survival rate is 15% to 25% compared with 1% to 5% among those who did not have any cancer-directed treatment. Systemic rather than surgical complications cause the majority of perioperative deaths, so the anesthesiologist has a crucial role in the management of these patients. This work sought to evaluate an improved approach to perioperative pain management, postsurgical complications as well as outcomes. PATIENTS: From 2002 to 2007, 40 patients underwent pancreaticoduodenectomy for pancreatic or periampullary cancer. The anesthesia protocol was standardized for postoperative pain control. Patients were randomly divided into two groups: 16 patients received an epidural analgesia with local anesthetics combined with opioids (T(9)-T(10); group A) and 24 had IV analgesia with morphine (group B). RESULTS: Postoperative mortality was 2.5%. With regard to complications we observed 4 biliary fistulas, 2 pancreatic fistulas with spontaneous healing in one patient and death in the other as well as wound infections. Patients treated with epidural analgesia experienced better pain relief, compared with subjects receiving IV analgesia, which demonstrated a higher incidence of opioid-related adverse effects such as sedation and respiratory depression. CONCLUSION: Adequate perioperative treatment included suitable nutritional support and pain management using loco-regional techniques, which seem to improve the surgical outcomes among pancreatic cancer patients.     

Pain relief and safety after major surgery. A prospective study of epidural and intravenous analgesia in 2696 patients

BACKGROUND: Adverse effects may still limit the use of continuous epidural and intravenous analgesia in surgical wards. This study postulated that postoperative epidural analgesia was more efficient, and had fewer side-effects than intravenous morphine. The aim was to investigate efficacy, adverse effects and safety of the treatments in a large patient population. METHODS: During a five-year period 2696 patients undergoing major surgery, received either epidural or intravenous analgesia for postoperative pain relief. The patients were prospectively monitored in surgical wards. Pain was evaluated with a numeric rating scale (0-10) at rest/mobilization. Treatment duration, respiratory depression, sedation/hallucinations/nightmares/confusion, nausea/vomiting, pruritus, orthostatism/leg weakness, and insufficient pain relief were registered. Pain relief for all patients aimed at a pain scoring of less than 4 at rest. RESULTS: Epidural analgesia was used in 1670 patients, and intravenous morphine in 1026 patients. Patients with epidural analgesia experienced less pain both at rest and during mobilization. Insufficient treatment effects such as dose adjustments, orthostatism/leg weakness, and pruritus were more common in the epidural group. Respiratory depression and sedation/hallucinations/nightmares/confusion occurred more often in the intravenous group. Thoracic epidural catheters caused a lower incidence of motor blockade compared to lumbar catheter placements. CONCLUSION: In a large patient population the use of epidural and intravenous postoperative analgesia was considered safe in surgical wards, and the incidence of adverse effects was low. Patients with epidural analgesia experienced overall less pain, while opioid related side-effects were more common with intravenous morphine analgesia.     

A comparison of the analgesic efficacy of 0.25% levobupivacaine combined with 0.005% morphine, 0.25% levobupivacaine alone, or 0.005% morphine alone for the management of postoperative pain in patients undergoing major abdominal surgery

We compared the relative efficacy of the combination of the single-isomer local anesthetic levobupivacaine and the opioid analgesic morphine versus both drugs alone for postoperative epidural analgesia after major abdominal surgical procedures. Thoracic epidural anesthesia was produced and maintained with levobupivacaine 0.75% in combination with general inhaled anesthesia without opioids. Patients were randomized to one of three postoperative treatment groups: 1) a combination of levobupivacaine 0.25% and morphine 0.005%; 2) levobupivacaine 0.25%; or 3) morphine 0.005%. Postoperatively, all epidural infusions were commenced at a rate of 4 mL/h. Patients could receive a 4 mL-bolus dose and an increase in the epidural infusion rate by 2 mL/h on request for supplemental analgesia. Patients were also allowed ketorolac as a supplemental analgesic at any time after the first analgesic request. Patients in the combination group had longer times to request for supplemental analgesia as compared with the levobupivacaine only group (P < 0.05) and a trend toward longer time to request as compared with the morphine only group (P = 0.066). Patients in the combination group had lower visual analog scale pain scores at rest and activity at 4 and 8 h and fewer requests for supplemental ketorolac (P < 0.05). In conclusion, this study demonstrates a significant improvement in postoperative analgesic efficacy with the combination of levobupivacaine and morphine for continuous epidural analgesia after major abdominal surgical procedures. IMPLICATIONS: A significant improvement in postoperative analgesic efficacy is demonstrated with the thoracic epidural administration of the combination of the single-isomer local anesthetic levobupivacaine 0.25% and morphine 0.005% in patients after major abdominal surgical procedures as compared with either drug used alone.     

No reduction in postoperative complications by the use of catheterized epidural analgesia following major abdominal surgery

This study was designed to assess whether intra- and postoperative epidural analgesia would diminish the overall rate of postoperative complications after major abdominal operations when compared to a standard anesthetic and postoperative analgesic regimen. A total of 214 patients undergoing infrarenal aortic bypass operations, gastric resection, gastrectomy, Whipple's operation, or duodenum-preserving pancreatic resection were randomly divided into two groups. Patients in the epidural group (n = 98) were operated on under light general anesthesia (midazolam, low-dose fentanyl, N2O/O2, pancuronium bromide). In addition, a mixture of bupivacaine (0.25%) and fentanyl (2 micrograms/ml) was infused (6-10 ml/h) via a thoracic epidural catheter intra- and postoperatively for 76:1.45 h (logarithmic normal distribution). Patients in the control group (n = 116) were operated on under a standard general anesthesia (midazolam, fentanyl, N2O/O2, isoflurane, pancuronium-bromide). Piritramid was injected for postoperative pain relief, either i.v. (recovery room, intensive care unit) or i.m. (surgical ward). In the epidural group the quality of analgesia and ability to cough were significantly better (2 P less than 0.0071) than in the control group (four observations each on the 1st and 2nd postoperative days). Heart rate and mean arterial pressure were lower in the epidural group at the same points of observation (2 P less than 0.01), as was the plasma glucose on the 1st postoperative day. The time up to the first postoperative defecation was shorter in the epidural group (79:1.51 h) as compared to the control group (93:1.38 h; 2 P less than 0.0167). The time to hospital discharge was equal in both groups (epidural group 19:1.6 days, control group 18:1.6 days).(ABSTRACT TRUNCATED AT 250 WORDS)     

Double-masked randomized trial comparing alternate combinations of intraoperative anesthesia and postoperative analgesia in abdominal aortic surgery.

BACKGROUND: Improvement in patient outcome and reduced use of medical resources may result from using epidural anesthesia and analgesia as compared with general anesthesia and intravenous opioids, although the relative importance of intraoperative versus postoperative technique has not been studied. This prospective, double-masked, randomized clinical trial was designed to compare alternate combinations of intraoperative anesthesia and postoperative analgesia with respect to postoperative outcomes in patients undergoing surgery of the abdominal aorta. METHODS: One hundred sixty-eight patients undergoing surgery of the abdominal aorta were randomly assigned to receive either thoracic epidural anesthesia combined with a light general anesthesia or general anesthesia alone intraoperatively and either intravenous or epidural patient-controlled analgesia postoperatively (four treatment groups). Patient-controlled analgesia was continued for at least 72 h. Protocols were used to standardize perioperative medical management and to preserve masking intraoperatively and postoperatively. A uniform surveillance strategy was used for the identification of prospectively defined postoperative complications. Outcome evaluation included postoperative hospital length of stay, direct medical costs, selected postoperative morbidities, and postoperative recovery milestones. RESULTS: Length of stay and direct medical costs for patients surviving to discharge were similar among the four treatment groups. Postoperative outcomes were similar among the four treatment groups with respect to death, myocardial infarction, myocardial ischemia, reoperation, pneumonia, and renal failure. Epidural patient-controlled analgesia was associated with a significantly shorter time to extubation (P = 0.002). Times to intensive care unit discharge, ward admission, first bowel sounds, first flatus, tolerating clear liquids, tolerating regular diet, and independent ambulation were similar among the four treatment groups. Postoperative pain scores were also similar among the four treatment groups. CONCLUSIONS: In patients undergoing surgery of the abdominal aorta, thoracic epidural anesthesia combined with a light general anesthesia and followed by either intravenous or epidural patient-controlled analgesia, offers no major advantage or disadvantage when compared with general anesthesia alone followed by either intravenous or epidural patient-controlled analgesia.     

Perioperative Schmerztherapie

Scientific studies have proven without doubt that an optimized perioperative pain therapy will improve patient comfort, reduce postoperative complications, enhance postoperative recovery and shorten the length of postoperative hospital stay. It is necessary to incorporate the acute pain therapy into a perioperative multimodal and interdisciplinary therapeutic concept. Local or regional anesthesia will provide the best analgesic effect after surgery and should be considered in all patients. Optimal treatment of patients with peripheral nerve blocks, spinal or epidural analgesia should be treated by a specialized acute pain service. However, only 15?C20% of all surgical cases will be taken care of by such a pain service. Therefore, most surgical patients will only receive adequate analgesia if surgeons are familiar with the principles of postoperative pain therapy. Regular assessment of pain perception is the cornerstone of optimized pain therapy. Furthermore, pain assessment will allow the administration and to some extent dosage of analgesic therapy to be delegated to nursing personnel.     

Epidural Analgesia Enhances Functional Exercise Capacity and Health-related Quality of Life after Colonic Surgery: Results of a Randomized Trial

Background: Multimodal analgesia programs have been shown to decrease hospital stay, but it not clear which functions are restored after surgery. The objective of this study is to evaluate the impact of epidural anesthesia and analgesia on functional exercise capacity and health-related quality of life.

Methods: Sixty-four patients undergoing elective colonic resection were randomized to either patient-controlled analgesia with morphine or thoracic epidural analgesia with bupivacaine and fentanyl (epidural group). All patients in both groups received similar perioperative care and were offered the same amount of postoperative oral nutrition and assistance with mobilization. Primary outcome was functional exercise capacity as measured by the 6-min walking test, and secondary outcome was health-related quality of life, as measured by the SF-36 health survey. These were assessed before surgery and at 3 and 6 weeks after hospital discharge. Other variables measured in hospital included pain and fatigue visual analogue scale, bowel function, time out of bed, nutritional intake, complication rate, readiness for discharge, and length of hospital stay.

Results: Although the 6-min walking test and the SF-36 physical health component decreased in both groups at 3 and 6 weeks after surgery, the patient-controlled analgesia group experienced a significantly greater decrease at both times (P < 0.01). Patients in the epidural group had lower postoperative pain and fatigue scores, which allowed them to mobilize to a greater extent (P < 0.05) and eat more (P < 0.05). Length of hospital stay and incidence of complications were similar in both groups, although patients in the epidural group were ready to be discharged earlier.     

Patient-controlled analgesia versus epidural analgesia using bupivacaine or morphine following major abdominal surgery. No difference in postoperative morbidity]

In 1987, Yeager et al. reported that intraoperative epidural anesthesia with local anesthetics and postoperative epidural analgesia with opiates diminished postoperative morbidity. In our first clinical trial on this topic, the better postoperative analgesia with epidural bupivacaine-fentanyl failed to improve the outcome after major abdominal operations over that obtained with parenteral piritramide. This randomized controlled investigation was designed to assess whether intraoperative epidural anesthesia with bupivacaine plus light general anesthesia and postoperative epidural analgesia with morphine would diminish the overall rate of postoperative complications after major abdominal operations compared with general anesthesia (without epidural) followed by patient controlled analgesia with morphine, and with intraoperative epidural anesthesia with bupivacaine and light general anesthesia followed by postoperative bupivacaine-morphine analgesia. METHODS. A total of 292 patients undergoing infrarenal aortic bypass operation, gastric resection, gastrectomy, duodenum-preserving pancreatic resection, Whipple's operation or cystectomy and neobladder formation were randomly divided into three groups: 1. PCA group (patient controlled analgesia, n = 107): patients were operated on under general anesthesia (midazolam, fentanyl, N2O/O2, if necessary with addition of halothane, enflurane or isoflurane; muscle relaxation with pancuronium bromide). Postoperative management consisted in patient-controlled analgesia with morphine (Prominject), bolus 2 mg, lock-out 5 min (recovery room, intensive care unit) or 15 min (surgical ward). 2. EBM group (epidural bupivacaine+morphine, n = 95): operation under light general anesthesia (midazolam, low-dose fentanyl, N2O/O2, pancuronium bromide). In addition, a mixture of bupivacaine (0.25%) and morphine (60 micrograms/ml) was infused (approximately 0.1 ml/kg.h) via an epidural catheter during and after the operation (approximately 72 h). 3. EM group (epidural morphine, n = 90): operation under the same kind of general-epidural anesthesia as in the EBM group. Postoperatively, epidural injection of morphine (0.05 mg/kg in 10 ml of saline) on request up to the 3rd postoperative day. Quality of analgesia (at rest and when patients coughed vigorously), strength of cough, and rate-pressure product were recorded at 8:00 h, 12:00 noon, 16:00 h and 20:00 h on the 1st, 2nd and 3rd postoperative days. Incidence and intensity of all postoperative complications (cardiovascular, pulmonary, renal and other organ failure, reoperations, major infection, sepsis, thromboembolism, metabolic and mental disturbances) were assessed from the day of operation until discharge or death (n = 10), respectively. RESULTS AND DISCUSSION. In the PCA and EM groups analgesia was equal but of slightly inferior quality compared with the EBM group. The ability to cough was best in the EBM group and significantly worse in the PCA and EM groups, with no difference between the last two. (ABSTRACT TRUNCATED AT 400 WORDS)     

Epidural analgesia compared with intravenous morphine patient-controlled analgesia: postoperative outcome measures after mastectomy with immediate TRAM flap breast reconstruction

BACKGROUND AND OBJECTIVES: Epidural analgesia has been shown to provide superior pain control compared with intravenous (IV) opioids after major surgical procedures. In this study, we compared the effect of epidural analgesia and IV morphine patient-controlled analgesia (PCA) on pain relief, duration of hospitalization, oral nutrition, ambulation, and side effects in patients undergoing a major surgical procedure (i.e., unilateral mastectomy with immediate transverse rectus abdominis musculocutaneous flap reconstruction). METHODS: Eighteen patients were prospectively randomized to receive either epidural analgesia or PCA during the postoperative period. The intensity of pain was assessed daily by a 100-mm visual analog scale. The total length of hospital stay, time to ambulation, and time to oral nutrition were recorded. RESULTS: The epidural group had significantly lower pain scores at 3 evaluation times through postoperative day number 4 (P < .05). The total length of hospitalization for the epidural group (median, 101 hours) was significantly less than the PCA group (median, 126 hours; P = .0498). The time to first ambulation, time to first bowel sounds, time to tolerating oral nutrition, incidence of nausea/vomiting or pruritus, and time to first flatus were not statistically different between the groups. CONCLUSIONS: These results show that epidural analgesia compared with PCA offered improved pain control after breast reconstruction with immediate transverse rectus abdominis musculocutaneous flap reconstruction. It also resulted in a 25-hour reduction in time of hospitalization.     

Retentissements de la douleur postopératoire,bénéfices attendus des traitements

Physiological responses to postoperative acute pain may impede organ functions (cardiovascular, pulmonary, coagulation, endocrine, gastrointestinal, central nervous system, etc). Pain alleviation improves patient's comfort, but also may minimise perioperative stress response, physiological responses and postoperative organ dysfunction, assist postoperative nursing and physiotherapy, enhance clinical outcome, and potentially shorten the hospital stay. Potent postoperative analgesia, especially by epidural route, may be associated with reduction in incidence and severity of many perioperative dysfunctions. Peridural analgesia using local anaesthetics is the best technique for decreasing postoperative stress after lower abdominal or lower limb surgery. Analgesia using either epidural or high doses of morphine may improve some cardiac variables such as tachycardia and ischaemia, but does not change the incidence of severe cardiac complications. For patients undergoing vascular or orthopaedic surgery, epidural analgesia can improve clinical outcome by preventing the development of arterial or venous thromboembolic complications. However, in comparative studies, the control groups did not receive adequate prophylactic treatment for thromboembolic complications. Epidural analgesia can hasten the return of gastrointestinal motility and shorten the hospital stay. Postoperative mental dysfunction is decreased using intravenous PCA morphine in the elderly. Epidural analgesia with local anaesthetics improves postoperative respiratory function but, for unknown reasons, these benefits are not associated with a decrease in respiratory complications. On balance, the mode of acute pain relief decreases adverse physiological responses and many intermediate outcome variables; however, there is inconclusive evidence that it affects clinical outcome. Major advances in postoperative recovery can be achieved by early aggressive perioperative care, including potent analgesia, early mobilisation and oral nutrition. As a result, the hospital stay may be shortened.     

Complications related to thoracic epidural analgesia: a prospective study in 1071 surgical patients

In a prospective study, the complications of 1071 patients scheduled for thoracic epidural catheterization for postoperative analgesia (TEA) were studied. All catheters were inserted preoperatively between segment Th 2/3 and Th 11/12 under local anesthesia. Balanced anesthesia with endotracheal intubation and TEA were combined. Postoperatively 389 patients (36.9%) were monitored on a normal surgical ward. Buprenorphine, 0.15 to 0.3 mg, and if needed bupivacaine 0.375% 3–5 ml h^-1 were given epidurally. Primary perforation of the dura occurred in 13 patients (1.23%). Radicular pain syndromes were observed in six patients (0.56%). In one patient (0.09%) respiratory depression was seen in close connection with the epidural administration of 0.3 mg buprenorphine. Although 116 patients (10.83%) showed one abnormal clotting parameter but no clinical signs of hemorrhage, there was no complication related to this group. No persisting neurological sequelae caused by the thoracic epidural catheters were found. In conclusion, continuous TEA with buprenorphine for postoperative pain relief after major abdominal surgery is a safe method without too high a risk of catheter-related or drug-induced complications, even on a normal surgical ward and when one clotting parameter is abnormal.