Combined Epidural-general Anesthesia Research Articles

The Effect of Epidural Bupivacaine on BIS Levels in the Awake Phase and on the Maintenance Doses of Propofol and Fentanyl During General Anesthesia

BackgroundSimultaneous administration of epidural local anesthetic agents (LA) and general anesthetics (intravenous or inhaled) is a common procedure in patients undergoing major operations. The effects of epidural anesthesia during combined general-epidural anesthesia on the alertness level (CGEA) in the awake phase and the doses of anesthetics have been reported.ObjectivesThe present study was designed to determine the effects of epidural bupivacaine on the alertness level measured by bispectral index (BIS) in the awake phase and the maintenance doses of propofol and fentanyl during general anesthesia for vascular operation on the lower limb.Patients and MethodsA double-blinded randomized clinical trial was conducted on patients awaiting vascular surgery on lower extremities in a teaching hospital from October 2007 to October 2008. During the epidural anesthesia, the control group received 0.9% NS while 0.125% bupivacaine was injected in the case group via the epidural route. No sedative drug was utilized for epidural catheter placement. The BIS measurement was performed in both groups during the awake phase, before performing epidural anesthesia, and 10 minutes after epidural injection at 1-min intervals for 15 min. After induction of general anesthesia in both groups, anesthesia maintenance was established using the infusion of propofol with the aim of keeping the BIS level between 40 and 50 throughout the anesthesia. At the end of the study period, maintenance dose requirements of propofol and fentanyl were measured.ResultsThirty-two patients were enrolled in the study. There was no difference in BIS levels of the two groups in the awake phase. There was a significant difference between the propofol and fentanyl requirements of the two groups.ConclusionsPerforming CGEA using bupivacaine was reported to reduce propofol and fentanyl doses required to maintain BIS levels between 40 and 50 considerably.

The effects of combined epidural and general anesthesia on the autonomic nervous system and bioavailability of nitric oxide in patients undergoing laparoscopic pelvic surgery

Pneumoperitoneum during laparoscopic surgery is known to affect visceral blood flow and result in oxidative stress. Whether epidural anesthesia will effectively reduce visceral ischemia and oxidative stress by blocking the sympathetic nervous system (SNS) during laparoscopic surgery has not been proven. Forty-five patients who were to undergo robot-assisted laparoscopic prostatectomy were randomly assigned to the combined general-epidural anesthesia group (group GE, n = 22) or to the general anesthesia group (group G, n = 23). Blood pressure, heart rate, and the balance between sympathetic and parasympathetic nervous system activity as measured by heart rate variability were recorded at 10 min after induction of anesthesia (T1), 60 (T2) and 120 (T3) min after intra-abdominal CO(2) insufflation, and 10 min after returning the patient to the supine position following CO(2) exsufflation (T4). Arterial blood gas analysis and blood sampling for measurements of nitrite (NO(2-)) and malondialdehyde (MDA) were performed at all time points. Intraoperative mean blood pressure was significantly lower in group GE compared with group G. The low-frequency to high-frequency ratio was significantly increased after induction of pneumoperitoneum in group G but was unchanged in group GE. Plasma levels of nitrite decreased after pneumoperitoneum induction in group G while there was no change in group GE. A significant increase in MDA levels was seen in group G after pneumoperitoneum induction and were higher than group GE at T3 and T4. The 24-h urine output was higher in group GE than in group G on POD 1. The 24-h CrCl was higher in group GE on POD 1 but was not different between groups on POD 2. Combined epidural and general anesthesia effectively blocks SNS stimulation during laparoscopic surgery and reduces NO inactivation and oxidative stress.

Comparison of degree of pain in patients after radical gastrectomy under different anesthetic regimens

Objective To compare the degree of pain in patients after radical gastrectomy under different anesthetic regimens.Methods One hundred and two ASA Ⅰ or Ⅱ patients of both sexes,aged 50-75 yr,weighing 45-70 kg,undergoing elective radical gastrectomy,were randomly divided into 3 groups ( n =34 each):general anesthesia (GA) group,combined general-subcostal transversus abdominis plane block (CGTA) group and combined general-epidural anesthesia (CGEA) group.The patients were sent to the postanesthesia care unit (PACU) after tracheal extubation,and the VAS score on arrival in the PACU was recorded.The degree of pain was evaluated by VAS score,and when VAS scores ＞ 3,the patients received intravenous morphine titration.When VAS scores ≤ 3,morphine titration was stopped and all the patients were connected to patient-controlled intravenous analgesia and/or epidural analgesia pump.The total amount of morphine consumed was recorded at the end of titration,and the occurrence of adverse reactions was also observed.Results Compared with groups GA and CGTA,the incidence of moderate to severe postoperative pain was significantly decreased in group CGEA (P ＜0.01).The incidence of severe postoperative pain,the VAS score on arrival in the PACU and the total amount of morphine consumed were decreased gradually in groups GA,CGTA and CGEA ( P ＜ 0.01 ).The incidence of sedation was significantly lower in group CGEA than in group GA (P ＜ 0.01 ).There were no significant differences in the other adverse reactions among the three groups ( P ＞ 0.05 ).Conclusion The degree of pain is reduced gradually in patients after radical gastrectomy under GA,CGTA and CGEA. Key words: Anesthesia; Stomach neoplasms; Pain,postoperative

Postsurgical Inflammatory Neuropathy

Perioperative nerve injuries are devastating complications that are commonly attributed to a variety of patient, surgical, or anesthetic factors. Well-documented causes of postsurgical neuropathy include nerve compression, stretch, contusion, or transection, which can occur following surgical trauma or patient positioning. Potential anesthetic causes of perioperative nerve injury include mechanical trauma, local anesthetic toxicity, and ischemic injury. We present a case of a diffuse, bilateral neurologic deficit of unclear etiology in a patient who underwent a combined neuraxial-general anesthetic for bilateral total hip arthroplasty. A 17-year old boy with end-stage Legg-Perthes disease presented with severe lower-extremity neuropathy of both legs following bilateral total hip arthroplasty under combined epidural-general anesthesia. A thorough workup excluded potentially devastating and treatable causes, including epidural hematoma or abscess and surgical bleeding or trauma. A neurology consultation and further testing (electromyography, nerve biopsy) resulted in a diagnosis of postsurgical inflammatory neuropathy. Treatment with prolonged, high-dose corticosteroids was undertaken, and although the patient's symptoms improved, he continues to have significant neurologic deficits 8 months after surgery. Perioperative nerve deficits not readily explained by direct surgical or anesthesia-related causes should prompt early neurologic consultation to seek alternative etiologies such as postsurgical inflammatory neuropathy. Although this condition is poorly understood, it is believed to be an idiopathic immune-mediated response to a physiologic stress (eg, surgery, regional block) and is treated with prolonged, high-dose corticosteroids. Because suppression of the immune system with high-dose steroids may result in improved neurologic outcome, it is essential that surgeons and anesthesiologists are aware of this condition so that treatment is not delayed.

Pulmonary Postoperative Complications: Is There a Place for Anesthesia?

We thank Dr. Lebard and colleagues and Drs. Marret and Jaber for their interest in our study of postoperative pulmonary complications (PPC).1In reply, we are glad to have the opportunity to provide information that was not included in the article itself.Lebard et al. compare and contrast our study with the excellent work of McAlister et al. ,2finding discrepancies attributable to differences of aim and design. The previous study was accomplished in a single hospital and included a more narrowly defined surgical population. Our principal aim was to calculate the incidence of PPC and predict risk in a larger sample that would be more representative of a broad general surgical population. To that end, we selected patients from 59 hospitals (which together account for 63% of the anesthesia case load in our geographic area of Catalonia, Spain) using a random sampling procedure to reflect case loads over the course of a calendar year. As Lebard et al. point out, the two studies defined PPC according to different criteria. Our list included more minor clinical events, yet we also found that PPC had a significant impact on postoperative outcome (see our table 4) and are therefore worthy of the clinician's serious consideration. Lebard et al. also express surprise at the 19.5% mortality we observed in patients with PPC, finding it high; they suggest that overlapping postoperative cardiovascular complications (CVC) might have played a role. In fact, however, high mortality is not unusual in patients with PPC: mortality was 27% and 21% in two studies by Arozullah et al. 3,4Nonetheless, we did record postoperative CVC in detail in our study, finding them in 36.6% of the patients with a PPC. Thirty-day mortality in this subgroup was 33.3%, which was similar to mortality in the study of Lawrence et al. 5and in sharp contrast with the rate of 11.5% we saw in patients with a PPC but no added CVC. Meanwhile, mortality in patients with a CVC but no PPC was low in our study (3.4%). We therefore think that although the cooccurrence of a PPC and a CVC is an ominous event, the PPC still play a large role in increasing risk of death. We emphasize that, although we analyzed factors associated with PPC, it was not our aim to examine how they might have arisen. Generally speaking, if a patient first develops a PPC, the clinical course that culminates in death may also include the development of cardiovascular or other complication that will influence the outcome. Conversely, if a PPC is not the first complication to appear, its later development nonetheless will play a role.Marret and Jaber suggest that anesthetic technique may play role in the development of PPC, and they specifically ask about the effect of combining general anesthesia with an epidural block. This subgroup accounted for 8.4% of our study population undergoing general anesthesia (n = 1,336) and comprised patients who on average were older, in a poorer state of health, and undergoing more aggressive and longer-lasting surgical procedures. In a post hoc analysis of our data, we compared a group of 112 patients who underwent general anesthesia with another group of 112 who received combined general-epidural anesthesia, finding no significant differences in the incidence of PPC (18.8% vs. 20.5%, P = 0.867) or pain intensity at 24 h (score of 3 or less on a visual analog pain scale, 56.3% vs. 67%, P = 0.131) (statistical results from the ARISCAT database run on March 1, 2011). Thus, there seems to be no suggestion of a beneficial effect of combined anesthesia, although we must emphasize that our study was not designed to compare anesthetic strategies. We agree with Drs. Marret and Jaber that there is a possible influence of ventilatory settings on the development of PPC. The anesthesiologists in charge of care chose the settings in all cases in our study, and although our database includes recordings of positive end-expiratory pressures, alveolar recruitment maneuvers, and hyperoxygenation, we have no reliable information on tidal volume. Finally, with regard to fluid therapy and postoperative pain, we included both in the list of potential risk factors for PPC, but neither achieved statistical significance in the bivariable analysis. We agree with Drs. Marret and Jaber that different perioperative strategies might reduce risk; nonetheless, so far, systematic analysis has found that only a few have been shown to clearly or possibly do so,6whereas others remain to be tried. We think controlled studies should now be designed to analyze the possible benefit of promising strategies given the impact of PPC on postoperative mortality. Our study has provided evidence of the magnitude of the problem in general surgical populations and the possibility of easily and reliably identifying patients at greater risk of PPC.*Hospital Universitari Germans Trias i Pujol, Barcelona, Spain. jcanet.germanstrias@gencat.cat

Transdermal nitroglycerine potentiates the analgesic effect of patient controlled epidural analgesia after lower abdominal surgery

BackgroundThis study was designed to evaluate the effect of pre-emptive use of transdermal nitroglycerine (NTG) patch as an adjuvant to combined general epidural anesthesia (CGEA) in patients undergoing lower abdominal surgery.MethodForty patients (ASA I or II) were randomly allocated to two equal groups; control group (group C) and nitroglycerine group (group NG). Nitroderm patch, 5 mg, was applied to patients in group NG, 2 h before surgery. All patients received epidural bolus of 18 ml of 0.25% bupivacaine with fentanyl 2 μg/ml followed by continuous infusion at the rate of 5 ml/h combined with general anesthesia. Patients used patient controlled analgesia (PCA) device to receive bolus dose of 5 ml of patient controlled epidural analgesia (PCEA) solution containing bupivacaine 0.125% and fentanyl 2 μg/ml after surgery. Perioperative mean arterial blood pressure (MAP) and heart rate (HR), time to first rescue analgesic, postoperative bupivacaine and fentanyl consumption, and VAS pain scores were measured for 24 h postoperatively. Patient satisfaction score was also recorded.ResultsPostoperative MAP and HR increased significantly to both baseline and the other group at 2 h in group C and at 4 h in group NG (p < 0.05). The time to first rescue analgesic was significantly longer in group NG (238.62 ± 54.3 min) than in group C (126.75 ± 35.1 min) (p < 0.05). Pain scores were significantly higher compared to the other group at 2 h in group C and at 4 h in group NG (p < 0.05). Postoperative bupivacaine and fentanyl consumption were significantly lower in group NG (74.91 ± 26.34 mg and 121.83 ± 32.5 μg, respectively) than in group C (118.68 ± 29.4 mg and 194.21 ± 45.31 μg, respectively). Patient satisfaction was significantly better in group NG than in group C (p < 0.05).ConclusionPre-emptive application of 5 mg transdermal nitroglycerine patch as adjuvant to CGEA provided significant prolongation of the postoperative analgesia and reduction of the postoperative bupivacaine and fentanyl consumption.

Clinical observation of remifentanil anaesthesia combined with epidural anesthesia in thoracic surgery

Objective To investigate the effect and safety of remifentanil anaesthesia combined with epidural anesthesia in thoracic surgery. Methods Two hundred patients, ASA Ⅰ - Ⅱ grade, undergoing thoracotmy were randomly allocated to two groups:Remifentanil group (group R) and Fentanyl group (group F). Two groups were given combined general-epidural anesthesia. Patients in group R received remifentanil. Group F received fentanyl. The blood pressure, heart rate, blood oxygen saturation and plasma cortisol were measured before the operation (T0), 1 min (T1) and 5 min (T2) after tracheal intubation, skin incision(T3) and 5 min after the operation (T4). The endotracheal extubation time and conscious recovery were recorded. Results Compared with group R, the incidence of endotracheal intubation reaction in group F is significantly higher (group F-14/26,53.8% ;group R-4/26,15.4% ;P<0.05 ).All the patients in group R were extubated and recovered conscious completely at 7 min after operation. 6 patients in group F were extubated at 25 min after operation and 3 of them recovered recognition completely one hour later. Conclusion Remifentanil have a faster recovery after surgery than fentanyl, and it can effectively inhibit tracheal intubation stress response. Remifentanil anaesthesia combined with epidural anesthesia can provide perfect acesodyne and maintain steady circulation. Key words: Remifentanil; Epidural analgesia; Thoracotomy

Application of combined general-epidural anesthesia on gynecologic oncology radical operation

Objective To discuss the effect of combined general-epidural anesthesia on gynecologic oncology radical operation.Methods Sixty patients of ASA Ⅰ～Ⅲ-class who had selected gynecologic oncology radical operation were randomly divided into epidural anesthesia combined anesthesia group(GE group)and general anesthesia alone group(G group).GE Group prior to general anesthesia induced by L3-4 epidural catheterization and injection of 2% lidocaine 5 ml,and anesthetic incubates was performed when the plane narcotic anesthesia emerged.Every 60 minutes,mixture of local anesthetics 5ml were injected by the epidural catheter.Group G received general anesthesia alone.Two groups were of the same induction of anesthesia,and maintenance of anesthesia by microinfusion pump with propofol and vecuronium and inhaled with isoflurane.The doses to maintain anesthesia,the degree of muscle relaxation,postoperative awake time,extubation time,conscious quality,circulation condition and so on between two groups were compared.Results There were significant differences between two groups in doses to maintain anesthesia,the degree of muscle relaxation,postoperative awake time,extubation time,conscious quality and circulation changes(P＜0.05).Conclusion Combined general-epidural anesthesia with the exact results,less narcotic drugs,soon postoperative awake,clear-headed quality,the advantages of hemodynamic stability,could better meet the needs of the gynecologic oncology radical operation. Key words: Combined general-epidural anesthesia; Gynecologic oncology radical operation

Anestesia combinada general-epidural versus anestesia general, morbimortalidad y eficacia analgésica en cirugía toracoabdominal. Revisión sistemática-metaanálisis

We performed a systematic review of randomized controlled trials to compare combined general-epidural anesthesia, followed by postoperative epidural analgesia, and general anesthesia followed by postoperative parenteral analgesia without epidural analgesia in patients undergoing thoracoabdominal surgery. Outcome measures considered were mortality, length of stay in hospital and in the intensive care unit, analgesia, and morbidity. We performed a systematic search of online databases (MEDLINE, EMBASE, the Cochrane Controlled Trials Registry and the metaRegister of clinical trials at http://www.controlled-trials.com/mrct/ mrct info es.asp). We also hand-searched the literature. Authors were contacted when deemed necessary. A total of 30 trials (4294 patients) were analyzed. Combined anesthesia showed significant advantages in relation to 2 variables: respiratory failure (odds ratio, 0.71; 95% confidence interval [CI], 0.58 to 0.87) and analgesia on the first day after surgery (weighted mean difference, -6.91 95% CI, -9.46 to -4.36). No significant differences were found in the other variables. Combined anesthesia provides better analgesia and is associated with fewer cases of postoperative respiratory failure. No significant differences were found in mortality, length of stay in hospital, or other morbidity variables.

Laparoscopy-assisted subtotal gastrectomy under thoracic epidural-general anesthesia leading to the effects on postoperative micturition

Recently, the laparoscopic surgical technique has been widely applied to major surgery as it can minimize surgical incision, reduce blood loss, and shorten hospital stay. In this study, we evaluated the effectiveness of the laparoscopic surgery on postoperative micturitional function in comparison to open surgery. Sixty patients undergoing subtotal gastrectomy were assigned to either laparoscopic (L group, n = 30) or open surgery (O group, n = 30) groups. The combined thoracic epidural-general anesthesia was performed on all patients, and epidural patient-controlled analgesia (PCA) using ropivacaine and sufentanil was maintained for two days following surgery. After surgery, visual analog pain score (VAS), levels of sensory and motor block, observer's assessment of alertness/sedation score (OAA/S), time to first flatus, ambulation and oral intake, and micturition function were assessed. The L group showed much earlier ambulation, flatus and oral intake than the O group. Although the scores of VAS and OAA/S were not significantly different between the two groups, the micturition problem scores of the L group were lower than that of the O group (P < 0.05). All patients of the L group had no difficulty in self-voiding, whereas four patients in the O group required urinary catheterization on the first postoperative day (POD1). Patients who underwent laparoscopic subtotal gastrectomy had a low incidence of micturitional problem and showed early recovery. Therefore, urinary catheterization on POD1 may not be a routine procedure for those who undergo laparoscopic subtotal gastrectomy under combined thoracic epidural-general anesthesia.

Intraoperative low doses of ketamine increase BIS-guided sevoflurane requirements during combined general and thoracic epidural anesthesia for major abdominal surgery

Intraoperative low doses of ketamine increase BIS-guided sevoflurane requirements during combined general and thoracic epidural anesthesia for major abdominal surgery

The Effect of Epidural Anesthesia with Different Concentrations of Ropivacaine on Sevoflurane Requirements

We evaluated sevoflurane requirements during combined general-epidural anesthesia with different concentration of ropivacaine. Fifty-six patients were randomly divided into three groups to epidurally receive saline, 0.2% ropivacaine or 1% ropivacaine. Sevoflurane concentration was adjusted to maintain certain anesthesia depth. BIS values and end-tidal sevoflurane concentrations were recorded at time points of pre-intubation and 5 min, 10 min, 15 min, 20 min, 25 min, 30 min after intubation. End-tidal sevoflurane was significantly lower in the group receiving higher concentration of sevoflurane. Epidural anesthesia can decrease sevoflurane requirements to a larger extent when a higher concentration of ropivacaine was applied.

Comparison of Blood Loss according to Different Anesthetic Technique for Total Hip Replacement

The mean blood loss is about 500−1,700 ml by general anesthesia technique in total hip replacement (THR) and the amount of blood loss is dependent on the degree of induced hypotension. We performed this study to evaluate the differences on the amount of blood loss and the number of transfused patients according to different anesthetic technique under the similar hypotension level. Methods: Forty-seven patients of ASA physical status class 1, 2 and 3, scheduled for THR, were randomly assigned into epidural anesthesia group (E group), combined general epidural anesthesia group (GE group) and general anesthesia group (G group). G group was maintained with sevoflurane anesthesia and the monitoring of central and arterial blood pressure was performed. The remifentanil (0.1μg/kg/min) was infused continuously for the target mean arterial pressure of 60 ± 5 mmHg. GE group received general anesthesia with the same technique of G group and epidural anestheia was combined after general anesthesia. The remifentanil (0.1μg/kg/min) was infused continuously for the target mean arterial blood pressure of 60 ± 5 mmHg. E group received epidural anesthesia with 0.75% ropivacaine and additional bolus dose of local anesthetics was injected if the mean arterial blood pressure did not reach 60 ± 5 mmHg. Results: The mean volume of blood loss and the number of transfused patients was significantly less in E or GE group at 24 hour after surgery (P ＜ 0.05), however we could not find any significant differences during intraoperative period. Conclusions: Epidural or combined general epidural anesthesia technique is a good method to reduce bleeding and the number of transfused patients.

Risk of Hematoma After Epidural Anesthesia and Analgesia for Cardiac Surgery

To the Editor: We read Dr. Chaney’s excellent review on neuraxial block for cardiac surgery (1). As he points out, the risk of neuraxial hematoma remains a great concern (1). Unfortunately, the true risk is difficult to precisely quantify (2). To help clinicians decide whether neuraxial block is worthwhile, we should report all successful cases and series, as well as occurrences of neuraxial hematoma and other major complications. To this end, we bring to your attention the following two cases: one reported in a newsletter (3) and the second in a surgical journal (4). In the first case, a 60-yr-old man underwent coronary artery bypass grafting (3). His preoperative platelet count and coagulation were normal (antiplatelet medication status not stated). Prior to surgery, an 18-G epidural catheter was inserted at T12/L1. No bleeding was noted. The patient was heparinized 1 h after induction of anesthesia. Surgery was uneventful, with normal blood loss. Protamine, 4 U of fresh-frozen plasma, and 6 U of platelets were given. An epidural infusion of fentanyl and bupivacaine was given postoperatively. The next morning, the patient’s trachea was extubated. At that time, he was able to move his upper limbs, but his legs had no movement or sensation, a condition that persisted despite discontinuation of the epidural infusion. A magnetic resonance imaging (MRI) scan that afternoon revealed a hematoma from T5 to T10 with cord displacement. Four hours later, he underwent laminectomy. The patient remained paraplegic. In the second case a 65-yr-old patient with diabetes underwent minimally invasive direct coronary artery bypass grafting under combined general-epidural anesthesia (4). Postoperative paraplegia developed after the patient presented with anterior spinal artery syndrome. The risk of catastrophic neurologic complication after neuraxial block is increased by the fact that assessing lower limb functions may be difficult and delayed. Further delay could occur if a patient needs to be kept sedated and tracheally intubated after cardiac surgery because of hemodynamic instability, bleeding, and/or surgical re-exploration. One can also imagine that it would be hazardous to place a patient in the prone position for emergency laminectomy after recent cardiac surgery. In addition, there are two reports of spontaneous epidural hematoma after cardiac surgery without epidural instrumentation (5,6). Thus, there is the possibility that hematoma can spontaneously occur at sites of epidural placement. Two other patients suffered from this complication after epidural catheters were placed before cardiac surgery scheduled for the following day (7,8). Conceivably, if surgery had immediately followed, the consequence could have been worse. There are other considerations. First, inserting an epidural catheter the night before surgery theoretically reduces the risk of hematoma, but it necessitates early admission. Second, if epidural catheterization occurs just before induction of anesthesia, theoretically the risk of hematoma increases for the rare patient who has to be put on cardiopulmonary bypass urgently due to hemodynamic instability. Furthermore, the risks to patients from postponing a case after a bloody tap are significant. Finally, 3% of catheterizations were unsuccessful in one series (9). Multiple attempts put the patient at risk of neuraxial complications, even if no catheter is inserted, and thus the patient is afforded no benefits of neuraxial block. Anthony M.-H. Ho, MS, MD, FRCPC, FCCP Peggy T. Y. Li, MB, ChB Manoj K. Karmakar, MD, FRCA Department of Anaesthesia and Intensive Care The Chinese University of Hong Kong Prince of Wales Hospital, Shatin, NT Hong Kong Special Administrative Region of the People’s Republic of China [email protected]

Peritoneal cytokines are associated with reports of fatigue following major abdominal surgery

Study Objective: To evaluate the influence of major abdominal surgery on the plasma levels of inflammatory cytokines interleukin-6 (IL-6), interleukin-8 (IL-8) and granulocyte colony-stimulating factor (G-CSF).Design: Prospective study.Setting: University hospital.Patients: 10 ASA physical status I and II patients undergoing upper abdominal surgery.Interventions: All patients received combined general-epidural anesthesia with isoflurane and nitrous oxide, after insertion of an epidural catheter at T7-T9 dosed with 1.5% lidocaine.Measurements and Main Results: Plasma cytokine (IL-6, IL-8, G-CSF) levels were determined with an enzyme-linked immunosorbent assay (ELISA) at pre-anesthesia, 0, 2, and 4 hours during surgery, and at the end of surgery, followed by sampling on the morning of postoperative days 1 (POD1) and 3 (POD3). Plasma cortisol levels were also determined. The plasma levels of IL-6 increased gradually after skin incision and reached the maximal value at the end of surgery (p < 0.001). IL-8 levels also increased from the baseline value to their maximum at the end of surgery (p < 0.05). G-CSF levels were elevated from the pre-anesthesia value to their maximum by the end of operation (p < 0.005). Plasma cortisol levels were increased after skin incision (p < 0.001). Postoperative cytokine levels correlated significantly with each other (r = 0.68, p < 0.05 for IL-6 vs. IL-8; r = 0.81, p < 0.005 for IL-6 vs. G-CSF; and r = 0.84, p < 0.005 for IL-8 vs. G-CSF). Postoperative IL-6 levels and intraoperative blood loss correlated significantly (r = 0.64, p < 0.05).Conclusions: These results suggest that major upper abdominal surgery stimulates the release of inflammatory cytokines presumably from the operation site. Further study is warranted to evaluate the modulation of inflammatory responses in the perioperative period.

Clinical study of combined general-epidural anesthesia with controlled hypotension in orthopedic surgery

目的 研究全麻复合硬膜外麻醉辅助控制性降压在骨科手术中应用的效应及可行性.方法 40例骨科手术患者随机分为对照组(A组,n＝20)和治疗组(B组,n＝20),均采用全麻复合硬膜外麻醉,B组在手术开始后使用尼卡地平控制性降压.观察术中出血量、输异体血量、停药后患者清醒及拔管时间、术后第2天肝功能和血常规.结果 (1)术中出血量、输异体血量分别为A组(1 160±382)、(420±233)ml,B组(307±143)、(20±61)ml,组间对比差异有显著意义(P＜0.01).(2)停药后患者清醒及拔管时间,组间对比差异均无显著意义(P＞0.05).(3)术后第2天肝功能,组内与术前、组间相比差异均无显著意义(P＞0.05);红细胞压积(Hct)、血红蛋白(Hb)与术前相比,两组差异均有显著意义(P＜0.01),组间差异无显著意义.结论全麻复合硬膜外麻醉辅助控制性降压在骨科手术中应用安全可靠,是一种可行的麻醉方法。

Sparing Effects of Sevoflurane Requirement during Combined Epidural-General Anesthesia Comparing to General Anesthesia for Laparoscopic Distal Gastrectomy

Background: Combined thoracic epidural-general anesthesia have many advantages, which are including early recovery, postoperative analgesia and less requirement of inhalation anesthetic. The aim of this study was to compare the requirements of sevoflurane during combined epidural-general anesthesia with those during only general anesthesia for laparoscopic distal gastrectomy. Methods: Forty patients undergoing laparoscopic distal gastectomy under general anesthesia were allocated randomly to two groups receiving infusion of epidural 0.375% ropivacaine mixed with 2g/ml sufentanil at 5 ml/hr following 8 ml bolus (group R), or epidural normal saline (group C) as the same method. All the patients were permitted to be infused to epidural 0.2% ropivacaine mixed with 1g/ml sufentanil at 5 ml/hr 30 minutes before end of surgery for postoperative analgesia. Anesthetic depth was maintained within 15% mean arterial blood pressure (MAP) of basal values. We recorded the end-tidal sevoflurane concentration (ETsev), mean arterial pressure (MAP) and heart rate (HR) at the critical time during the surgery (intubation, 3 minuets after intubation, skin incision, pneumoperitoneum, 3 minuets after pneumoperitoneum, end point of pneumoperitoneum, abdominal wall suture, extubation) and hourly consumptional volume of sevoflurane. Results: Both groups were similar in demographic data, surgery anesthetic time and postoperative pain score. But the stay time in post anesthetic care unit was significantly shorter in R group. ETsev were lower in group R than in group C during the study period. Actually approximately half volume of sevoflurane was consumed in group R comparing to group C. Conclusions: For laparoscopic distal gastrectomy, smaller amount of sevoflurane was used during combined thoracic epidural-general anesthesia than during general anesthesia.

Combined general‐epidural anesthesia decreases the desflurane requirement for equivalent A‐line ARX index in colorectal surgery

The present study used the A-line ARX index, derived from auditory evoked potential measurements, to examine the effect of epidural lidocaine on the end-tidal concentration of desflurane during general anesthesia. Thirty ASA I-II patients scheduled for elective colorectal surgery were included and randomized, in a double-blinded fashion, to receive general anesthesia, and 15 ml of either 2% lidocaine (group GE, n=15) or normal saline (group GS, n=15) was administered epidurally with a maintenance infusion rate of 6 ml h-1. After a 10-min high-flow oxygen wash-in period, desflurane was titrated to a target A-line ARX index (AAI) of 20+/-5. Epidural lidocaine reduced the end-tidal concentration of desflurane required to maintain an adequate clinical effect by 42% compared to general anesthesia alone (2.6% vs. 4.5%, respectively; P<0.001). The initial mean value of AAI was 87.8 (range 78-99) in group GE and 88.13 (79-99) in group GS before general anesthesia induction, the AAI values were approximately 19.7 (15-25) in group GE and 20.2 (16-25) in group GS during anesthesia maintenance, and returned to 84.53 (77-98) in group GE and 86.87 (79-98) in group GS when the patients regained consciousness in the recovery room. No statistical difference in the AAI values was observed either before, during, or after emergence of anesthesia. No patient reported intraoperative awareness. Lower-than-expected concentrations of volatile anesthetics are sufficient to maintain appropriate a clinical anesthesia effect during combined general-epidural anesthesia under auditory-evoked potential monitoring.

Total spinal anesthesia during combined general-epidural anesthesia in a 7-year-old child

Total spinal anesthesia (TSA) is a rare complication of lumbar epidural anesthesia through inadvertent spinal injection of local anesthetics following an undiagnosed dural breach or spinal placement of the catheter. TSA has rarely been reported in children. TSA occurred during epidural anesthesia in a 7-year-old child undergoing abdominal surgery. Recent previous lumbar punctures and intrathecal chemotherapy for Burkitt's lymphoma at the same level may have facilitated dural breach. Epidural anesthesia should not be attempted at the same intervertebral level as prior recent lumbar punctures.

Comparison of Continuous Epidural and Intravenous Analgesia for Postoperative Pain Control in Pediatric Lower Extremity Surgery

In recent years epidural anesthesia and analgesia techniques were used in pediatric surgery owing to the development of pediatric epidural catheter needles. And the need of postoperative pain control in pediatric patients is also increasing. We compared combined general-epidural anesthesia and analgesia technique with intravenous fentanyl analgesia after general anesthesia for postoperative analgesic effect and complications in these pediatric patients. We randomly allocated 91 pediatric patients undergoing lower extremities surgery into epidural lidocaine group (n=61) and IV fentanyl group (n=30). During the operation, end-tidal sevoflurane concentration (ET(sev)) was controlled to maintain the blood pressure and heart rate within 10% of preoperative value. At the postoperative period, Parent Visual Analog Scale (PVAS), Objective Pain Score (OPS) and the incidence of nausea/ vomiting were checked immediately, 6 hours and 24 hours after the patient's arrival at general ward. ET(sev) was significantly low in epidural lidocaine group (p < 0.05). Compare to IV fentanyl group, epidural lidocaine group had significantly lower OPSs at 6 hours after arrival. Epidural lidocaine group had significantly lower PVASs immediately, 6 hrs and 24 hours after arrival. There was no significant difference in the incidence of postoperative nausea and vomiting. A combined general-epidural anesthesia technique significantly reduces intraoperative end-tidal sevoflurane concentration compared to general anesthesia alone. And continuous patient-controlled epidural analgesia reduces postoperative pain scores significantly more than continuous patient-controlled IV fentanyl analgesia without any serious complications in pediatric lower extremity surgery.