Comparing epidural surgical anesthesia and spinal anesthesia following epidural labor analgesia for intrapartum cesarean section: a prospective randomized controlled trial.
ABSTRACT: The conversion of epidural labor analgesia (ELA) to epidural surgical anesthesia (ESA) for intrapartum cesarean section (CS) often fails, resulting in intraoperative pain. Spinal anesthesia (SA) can provide a denser sensory block than ESA. The purpose of this prospective, non-blinded, parallel-arm, randomized trial was to compare the rate of pain-free surgery between ESA and SA following ELA for intrapartum CS.Both groups received continuous epidural infusions for labor pain at a rate of 10 ml/h. In the ESA group (n = 163), ESA was performed with 17 ml of 2% lidocaine mixed with 100 µg fentanyl, 1 : 200,000 epinephrine, and 2 mEq bicarbonate. In the SA group (n = 160), SA was induced with 10 mg of 0.5% hyperbaric bupivacaine and 15 µg fentanyl. We investigated the failure rate of achieving pain-free surgery and the incidence of complications between the two groups.The failure rate of achieving pain-free surgery was higher in the ESA group than the SA group (15.3% vs. 2.5%, P < 0.001). There was no statistical difference between the two groups in the rate of conversion to general anesthesia; however, the rate of analgesic requirement was higher in the ESA group than in the SA group (12.9% vs. 1.3%, P < 0.001). The incidence of high block, nausea, vomiting, hypotension, and shivering and Apgar scores were comparable between the two groups.SA after ELA can lower the failure rate of pain-free surgery during intrapartum CS compared to ESA after ELA.
Project description:The analgesic and sedative effect of clonidine explain its common use as adjuvant in regional anesthesia, however the hemodynamic instability associated with its neuroaxial administration is the major drawback. Our study hypothesis is to compare the hemodynamic and analgesic effect of epidural fentanyl in comparison to meperidine when added to clonidine in patients undergoing lower limbs orthopedic surgery using combined spinal-epidural anesthesia.One hundred thirty five ASA physical status I or II patients were recruited for lower limb orthopedic surgery. All received 2 mL intrathecal 0.5 % hyperbaric bupivacaine, 10 mL epidural 0.25 % plain bupivacaine, and 1 mL epidural clonidine 2 ?g/kg (Clonidine group) and then either 1 ml fentanyl 25 ?g (Fentanyl Group) or 1 ml meperidine 25 mg (Meperidine Group). The quality of surgical anesthesia, incidence of hypotension and bradycardia, intra-operative pain assessment, and onset of postoperative pain, sedation scores and side effects in the postoperative period were recorded.The 1(st) analgesic requirement in the postoperative period was significantly prolonged in the meperidine group (p = 0.001). Significant decrease in the mean arterial blood pressure in fentanyl group was at 15, 30, 45, 60 and 90 min (p = 0.035, 0.019, 0.027, 0.032 and 0.039) respectively, significant decrease in meperdine group was at 15 and 30 min (p = 0.038 and 0.043), while in clonidine group a significant decrease was at 15, 30, 45, and 60 min (p = 0.025, 0.028, 0.036 and 0.042) respectively. Among group changes, the mean arterial blood pressure was significantly higher in meperdine group at 30, 45, 60 and 90 min (p = 0.007, 0.015, 0.029 and 0.033) respectively. A significant decrease in the heart rate in fentanyl group at 15, 30 and 45 min (p = 0.035, 0.018 and 0.029), in meperdine group a significant decrease in the heart rate was at 15 min (p = 0.038), while in clonidine group a significant decrease was at 15, and 30 min (p = 0.016 and 0.003) . Among group changes, the heart rate was significantly higher in meperdine group at 30, 45 and 60 min (p = 0.021, 0.017 and 0.011). VAS were significantly lower in meperdine group in comparison to fentanyl and clonidine groups at 2 h, 3 h and 4 h post-operative period (p = 0.024, 0.001 and 0.039).The combined administration of epidural clonidine and meperidine provided better intraoperative hemodynamics and prolonged postoperative analgesia than epidural clonidine fentanyl combination in patients undergoing lower limb orthopedic surgery.Clinical Trail Registry (Clinicaltrail.gov) NCT 02128451 .
Project description:Study Design Case report. Objectives To describe a case of delayed-onset spinal hematoma following the breakage of a spinal epidural catheter. Methods The authors describe the clinical case review. Results A 64-year-old woman had undergone epidural anesthesia 18 years before she was referred to our hospital because of lower-back pain and lower neurologic deficit with leg pain. The clinical examination showed the presence of a fragment of an epidural catheter in the thoracolumbar canal, as assessed by computed tomography, and a spinal hematoma that compressed the spinal cord at the same spinal level, as assessed by magnetic resonance imaging. Surgical removal of the epidural catheter and decompression surgery were performed. The patient exhibited substantial clinical improvement 1 month after surgery; she achieved a steady gait without the need for a cane and had no leg pain. Conclusion This is the first report of delayed onset of spinal hematoma following the breakage of an epidural catheter. Generally, when the breakage of an epidural catheter occurs without symptoms, follow-up alone is recommended. However, because spinal hematoma might exhibit a late onset, the possibility of this complication should be considered when deciding whether to remove the catheter fragment. We believe that in our patient, there could be a relationship between the catheter fragment and subdural hematoma, and catheter breakage could have been a risk factor for the spinal hematoma.
Project description:PURPOSE:Continuous intraoperative epidural analgesia may improve post-operative pain control and decrease opioid requirements. We investigate the effect of epidural infusion initiation before or after arrival in the post-anesthesia care unit on recovery room duration and post-operative opioid use. METHODS:We performed a retrospective chart review of abdominal, thoracic and orthopedic surgeries where an epidural catheter was placed prior to surgery at the University of Washington Medical Center during a 24 month period. RESULTS:Patients whose epidural infusions were started prior to PACU arrival (Group 2: n = 540) exhibited a shorter PACU length of stay (p = .004) and were less likely to receive intravenous opioids in the recovery room (34 vs. 48%; p < .001) compared to patients whose infusions were started after surgery (Group 1: n = 374). Although the highest patient-reported pain scores were lower in Group 2 (5.3 vs. 6.0; p = .030), no differences in the pain scores prior to PACU discharge were observed. CONCLUSION:Intraoperative continuous epidural infusions decrease PACU LOS as discharge criteria for patient-reported NRS pain scores are met earlier.
Project description:BACKGROUND:Patients after total knee arthroplasty (TKA) often develop moderate to severe pain. This study compared the analgesic effect of low-dose epidural morphine vs. a comparable saline injection in patients following TKA surgery. METHODS:This randomized, double-blinded, and placebo-controlled trial was conducted in a tertiary hospital in Beijing between July 1, 2017 and May 30, 2018. One hundred and ten patients following TKA under combined spinal-epidural anesthesia were randomized to receive either epidural morphine (2 mg diluted to 5 ml normal saline, the epidural morphine group) or placebo (5 ml normal saline, the placebo group). For all patients, single-injection femoral nerve block was performed, and a supplementary patient-controlled intravenous analgesia pump was provided. The severity of pain was assessed with the numerical rating scale (NRS, an 11-point scale where 0 = no pain and 10 = the worst pain) at 6, 12, 24, 36, and 48 hours after surgery. The primary endpoint was moderate to severe pain (NRS pain score ?4) within 48 hours after surgery. RESULTS:The percentage with moderate to severe pain within 48 hours was lower in the epidural morphine group than in the placebo group (58.2% [32/55] with epidural morphine vs. 76.4% [42/55] with placebo; OR 0.43, 95% CI 0.19-0.98; p = 0.042). Furthermore, the cumulative morphine consumption within 48 hours was lower (18.4±6.1 mg vs. 22.4±7.3 mg; p = 0.002) whereas the mental component summary score of 30-day quality of life was higher (63.8±2.9 vs. 61.9±4.2; p = 0.008) in the epidural morphine group than in the placebo group. CONCLUSIONS:For patients following TKA, the addition of epidural morphine to single-injection femoral nerve block improves the quality of analgesia within 48 hours, without increasing adverse events. TRIAL REGISTRATION:ClinicalTrials.gov NCT03203967.
Project description:INTRODUCTION:Although controversial, pre-emptive analgesia has shown some promise in preventing altered pain perception and reducing pain amplification after surgery. Hence, it has the potential to be more effective than a similar analgesic regimen started after surgery with an appropriate combination of patient category and analgesic modality. Hence, the present study was undertaken to evaluate the effect of preventive epidural analgesia in reducing pain severity and duration after bilateral single-stage knee arthroplasty. METHODS:Fifty patients, 18-70 years, with American Society of Anesthesiologists physical status class I & II posted for bilateral single-stage knee replacement under regional anesthesia were randomly allocated into preventive versus postoperative epidural analgesia group to compare severity of post-operative pain, analgesic consumption, day of mobilization, C-reactive protein (CRP) levels, and hospital stay. RESULTS:The pain score after surgery [2.0 (1.5, 2.0); 3.0 (1.5, 3.0), p?=?0.005] and day of mobilization [(2. 92 ± 0. 28; 3. 31 ± 0. 48; p value 0.02)] were significantly lesser in the preventive epidural group. However, there was no difference in the hospital stay (9.92 ± 3.71 and 9.00 ± 2.12, p?=?0.95) and analgesic consumption (65.38 ± 37.55 and 73.08 ± 43.85, p?=?0.30). The preventive group had a larger drop in CRP and experienced a lesser number of days with pain after surgery as compared to the controls [(64.29 ± 21.29); (142.37 ± 80.04), p?=?0.0001]. Six patients in the preemptive group (24%) and 13 of the control group (24 vs. 56.5%; p?=?0.02) had chronic postsurgical pain. CONCLUSIONS:Preventive epidural analgesia reduces the severity and number of chronic pain days after bilateral single-stage knee replacement. TRIAL REGISTRATION:The study was registered in the Indian national registry (CTRI/2017/03/008240 on 28/03/2017).
Project description:BACKGROUND:Continuous epidural infusion (CEI) is the standard application setting for epidural infusion. A new mode, the programmed intermittent epidural bolus (PIEB) technique, showed reduced local anesthetic (LA) consumption and improved analgesia in obstetric analgesia. Goal of this trial was to evaluate the effects of PIEB versus CEI [combined with patient-controlled bolus (PCEA)] on LA consumption and pain scorings in major abdominal cancer surgery. METHODS:Following ethical approval, patients scheduled for major abdominal cancer surgery under general anesthesia in combination with epidural analgesia were randomized to receive either a PIEB mode of 6 mL/h or a CEI mode set at 6 mL/h of ropivacaine 0.2%, both combined with a PCEA mode set at a 4 mL bolus. LA consumptions and pain scorings were documented until the second postoperative evening. RESULTS:Eighty-four datasets were analyzed (CEI: n =?40, PIEB: n =?44). Regarding the primary endpoint, cumulative LA PCEA bolus volumes until day 2 differed significantly between the groups [PIEB 10 mL (2-28 mL) versus CEI, 28 mL (12-64 mL), median (25th-75th percentiles), p =?0.002]. Overall, LA consumption volumes were significantly lower in the PIEB group versus in the CEI group [PIEB: 329 mL (291-341 mL) vs. CEI: 350 mL (327-381 mL), p =?0.003]. Pain scores were comparable at each time point. CONCLUSIONS:This trial demonstrates reduced needs for PCEA bolus in the PIEB group. There were no clinically relevant benefits regarding morphine consumption, pain scorings, or other secondary outcome parameters. TRIAL REGISTRATION:This study has been registered retrospectively in the ClinicalTrials.gov registry ( NCT03378804 ), date of registration: December, 20th 2017.
Project description:BACKGROUND:Loss of resistance (LOR) technique is a widely used method to identify the epidural space. However, cases of inadequate epidural anesthesia in cesarean section were frequently reported. Also, the success rate of epidural anesthesia with LOR technique varied depending on the proficiency of the practitioner. The purpose of this study was to assess the efficacy and safety of electrical stimulation to identify epidural spaces in cesarean section for novices or clinicians with recent gap in experience. METHODS:Pregnant women scheduled for elective cesarean section were randomly allocated to two groups. Groups were classified based on the methods used for identifying the epidural space: the LOR group (group L) and the LOR with epidural electrical stimulation group (group E). Clinicians with less than 10 epidural cesarean section experiences in the recent year performed epidural anesthesia for cesarean section. In the group E, a RegionalStim® conductive catheter was inserted through the Tuohy needle, and the guidewire passing through the catheter was connected to a peripheral nerve stimulator. The intensity of the stimulation was gradually increased from 0.25?mA to 1.5?mA until paresthesia was elicited and radiated. We assessed the success of epidural anesthesia (complete success, partial success or failure). Other clinical parameters including maternal satisfaction, time required for epidural anesthesia, neonatal Apgar scores, pain scores and adverse events were compared between the two groups. RESULTS:Except for 6 patients who withdrew consent, 54 patients were enrolled in this study (28 for the group L and 26 for the group E). The demographic data showed no difference between the two groups. There was no adverse event resulted from electrical stimulation. The group E showed higher rate of complete success, sensitivity in finding epidural space and maternal satisfaction compared to the group L (21/26 vs. 15/28, p?=?0.034, 0.96 vs. 0.68, p?=?0.012 and 4.04 vs. 3.39, p?=?0.02, respectively). The other clinical parameters showed no differences between the two groups. CONCLUSION:In addition to the conventional LOR technique, identifying epidural spaces using electrical stimulation led to better outcomes without additional risks for novices as well as clinicians with recent gap in experience. TRIAL REGISTRATION:This study was retrospectively registered in the ClinicalTrials.gov Registry (NCT03443466) on February 23, 2018.
Project description:BACKGROUND Whether regional anesthesia is associated with tumor-free and long-term survival is controversial. Here, we focused on whether epidural anesthesia affects the long-term survival of gastric cancer patients after surgery. MATERIAL AND METHODS We obtained the records of 273 patients undergoing gastric cancer surgery between August 2006 and December 2010. All patients received elective surgery, and the end-point was death. The general anesthesia group comprised 116 patients and the epidural-supplemented group comprised 157 patients. The results were analyzed using a multivariable model to determine the relationship between epidural use and long-term survival. RESULTS No obvious association was detected between epidural use and long-term survival according to the Cox model (P=0.522); the adjusted estimated hazard ratio was 0.919 (95% CI 0.71-1.19). However, according to Kaplan-Meier analysis, epidural anesthesia was associated with long-term survival among younger patients (age up to 64) (p=0.042, log-rank) (but not among older patients (p=0.203, log-rank). A lower American Society of Anesthesiologists (ASA) class and less chemoradiotherapy exposure were also associated with a longer survival. However, advanced tumor stage still has a significant negative impact on survival. CONCLUSIONS No obvious difference was detected between the 2 anesthesia groups, but younger patients may benefit from epidural anesthesia.
Project description:Background:The present study aimed to describe the evolution of hemodynamic parameters over time of patients with invasive placentation during their third trimester who were delivered via cesarean section and subsequently underwent obstetric hysterectomy under epidural anesthesia. Methods:A prospective, descriptive, longitudinal, 11-month cohort study of 43 patients aged between 18 and 37 years who presented with invasive placentation. Minimal invasive monitoring was placed before the administration of epidural anesthesia for hemodynamic parameter tracking during the cesarean section. After delivery, the patients underwent an obstetric hysterectomy. Blood loss, hemodynamic parameters, and coagulation were managed via goal-directed therapy. Parameters were compared via repeated measures ANOVA and effect size estimation (Cohen's d). Results:The mean age of the patients was 29.2?±?3.4 years and was moderately overweight. They had minor cardiac index variance (P=NS, no significance), vascular systemic resistance index (NS), heart rate (P=NS), and median arterial pressure (P=NS). Differences were observed in the stroke volume index (P=0.015) due to moderately higher values (d?=?0.3, P=0.016) in the middle of the surgery. Patients had lower cardiac index (d?=?-0.36, NS) and cardiac workload requirements (d?=?-0.29, P=0.034) toward the completion of surgery. Conclusion:Patients who are in their third trimester and who subsequently underwent obstetric hysterectomy under epidural anesthesia had modest surgical hemodynamic variance and reduced cardiac workload requirements toward the end of the surgery.
Project description:Current evidences show that regional anesthesia is associated with decreased risk of complications after major surgery. However, the effects of combined regional-general anesthesia remain controversial. The purpose of our study was to analyze the impact of anesthesia (combined epidural-general anesthesia vs. general anesthesia) on the risk of postoperative complications in patients undergoing open surgery for pheochromocytoma.This was a retrospective cohort study. 146 patients who underwent open surgery for pheochromocytoma (100 received combined epidural-general anesthesia and 46 received general anesthesia) in Peking University First Hospital from January 1, 2002 to December 31, 2015 were enrolled. The primary outcome was the occurrence of postoperative complications during hospital stay after surgery. Multivariate Logistic regression models were used to analyze the association between the choice of anesthetic method and the risk of postoperative complications.17 (11.6%) patients developed complications during postoperative hospital stay. The incidence of postoperative complications was lower in patients with combined epidural-general anesthesia than in those with general anesthesia (6% [6/100] vs. 23.9% [11/46], P = 0.006). Multivariate Logistic regression analysis showed that use of combined epidural-general anesthesia (OR 0.219, 95% CI 0.065-0.741; P = 0.015) was associated with lower risk, whereas male gender (OR 5.213, 95% CI 1.283-21.177; P = 0.021) and perioperative blood transfusion (OR 25.879; 95% CI 3.130-213.961; P = 0.003) were associated with higher risk of postoperative complications.For patients undergoing open surgery for pheochromocytoma, use of combined epidural-general anesthesia may decrease the occurrence of postoperative complications.