Combined Epidural-general Anesthesia Research Articles

Efficacy of Combined Epidural-General Anaesthesia [CEGA] in Attenuating Hemodynamic Responses to Pneumoperitoneum in Laparoscopic Cholecystectomies: A Prospective Randomised Study

Background: Pnuemoperitonium in laparoscopy is associated with cardiorespiratory changes. Combination of epidural with General anaesthesia (GA) will offer benefit of hemodynamic control and perioperative analgesia. We aimed to study the efficacy of Combined Epidural- General Anaesthesia (CEGA) with pre-emptive activation over general anaesthesia in laparoscopic cholecystectomies.
 Methods: In this prospective double blind –randomised study, 90 surgical inpatients were studied in two study groups. Group GE-(n=45) received Lumbar Epidural analgesia with ropivacaine 0.2% along with GA and Group G (n=45) received only GA. Heart rate (HR), Mean arterial Pressure (MAP), systolic blood pressure (SBP), diastolic blood pressure (DBP), Capnogram (ETCO2), saturation (spo2), VAS score, Ramsay sedation score, requirement of propofol, muscle relaxants and analgesics were studied.
 Results: Statistical analysis was carried out with SPSS version 20. Statistical value of p<0.05 was considered significant. We noted significant difference in MAP, SBP, DBP, muscle relaxants, Propofol, Fentanyl and lesser pain scores in Group GE than Group G i.e (p<0.001).
 Conclusion: Combination of epidural and general anaesthesia technique with pre emptive activation has the benefit of better control of hemodynamics .It reduced requirements of analgesics and anaesthetic drugs and had faster recovery with less post operative pain in laparoscopic cholecystectomies.

Propofol EC50 for inducing loss of consciousness in patients under combined epidural-general anesthesia or general anesthesia alone: a randomized double-blind study.

Combined epidural-general anesthesia (GA + EA) has been recommended as a preferred technique for both thoracic and abdominal surgery. The epidural anesthesia on the general anesthetic (GA) requirements has not been well investigated. Therefore, we conducted the present study to explore the predicted effect-site concentration of propofol (Ceprop) required for achieving the loss of consciousness (LOC) in 50% of patients (EC50) with or without epidural anesthesia. Sixty patients scheduled for gastrectomy were randomized into the GA + EA group or GA alone group to receive general anesthesia alone. Ropivacaine 0.375% was used for epidural anesthesia to achieve a sensory level of T4 or above prior to the induction of general anesthesia. The EC50 of predicted Ceprop for LOC was determined by the up-down sequential method. The consumption of anesthetics, emergence time from anesthesia, and postoperative outcomes were also recorded and compared. The EC50 of predicted Ceprop for LOC was lower in the GA + EA group than in the GA alone group [2.97 (95% CI: 2.63-3.31) vs. 3.36 (95% CI: 3.19-3.53) μg mL-1, (p = 0.036)]. The consumption of anesthetics was lower in the GA + EA group than in the GA alone group (propofol: 0.11 ± 0.02 vs. 0.13 ± 0.02 mg kg-1 min-1, p = 0.014; remifentanil: 0.08 ± 0.03 vs. 0.14 ± 0.04 μg kg-1 min-1, p < 0.001). The emergence time was shorter in the GA + EA group than in the GA alone group (16.0 vs. 20.5 min, p = 0.013). Concomitant epidural anesthesia reduced by 15% the EC50 of predicted Ceprop for LOC, decreased the consumptions of propofol and remifentanil during maintenance of anesthesia, and fastened recovery from anesthesia. ClinicalTrials.gov, identifier: NCT05124704.

Effectiveness of Low-Dose Intermittent Epidural Bolus of 1 mg Morphine as Postoperative Analgesia

&lt;strong&gt;Background:&lt;/strong&gt; Patients who have undergone major surgery typically experience postoperative pain that persists for seven days following surgery. The challenge for the anesthesiologist is to provide adequate postoperative pain control which is not always achievable. In contrast to systemic administration, epidural administration of opioids places the medications close to the site of action, allowing for relatively small doses to be effective with a low incidence of side effects. Morphine is a long-established analgesia drug that characteristically slows diffusion and long duration in epidural analgesia, making it widely used in postoperative pain management. However, giving morphine is not without any complications.&lt;strong&gt;&lt;/strong&gt;&lt;p&gt;&lt;strong&gt;Case Illustration:&lt;/strong&gt; Nine patients who underwent major surgeries either under combined epidural-general anesthesia or epidural anesthesia received a low-dose intermittent epidural bolus of 1 mg morphine in 10 mL normal saline every 12 hours after surgery. Postoperative pain scores were recorded at the 1&lt;sup&gt;st&lt;/sup&gt;,12&lt;sup&gt;th&lt;/sup&gt;,24&lt;sup&gt;th&lt;/sup&gt;, 36&lt;sup&gt;th&lt;/sup&gt;, and 48&lt;sup&gt;th&lt;/sup&gt; hours after surgery, data of additional rescue analgesia, and the incidence of nausea, vomiting, pruritus, sedation, and respiratory depression were also collected. Only one patient needed rescue analgesia with 30 mg Ketorolac IV, and one patient needed anti-emetic with 4 mg ondansetron IV an hour after the completion of surgery. The rest of the patients have mild pain (NRS≤3/10) within 48 hours after surgery. Furthermore, there is no other adverse effects of morphine were found&lt;/p&gt;&lt;strong&gt;Conclusion:&lt;/strong&gt; low dose intermittent epidural bolus of 1 mg morphine can be used as effective postoperative analgesia and has fewer adverse effects.

Effect-site concentrations of remifentanil for smooth emergence from combined epidural–general anesthesia or general anesthesia in patients using video double-lumen tube: A randomized trial

ObjectiveThe present study aimed to determine the effect-site concentration of remifentanil of 90% (EC90) for smooth emergence in patients with a video DLT (VDLT) under sevoflurane-maintained general anesthesia and to investigate whether the EC90 was affected by epidural anesthesia. MethodsOne hundred and twenty patients who underwent video-assisted thoracic surgery (VATS) were enrolled. Patients received either general anesthesia combined with epidural anesthesia (PEA group, n = 60) or general anesthesia (GA group, n = 60). The primary outcome was the EC90 for smooth emergence in both groups. The secondary outcomes were intraoperative emergence, smooth emergence, recovery, and hemodynamic profiles in both groups. ResultThe EC90 values for smooth emergence in patients using VDLT were 3.5 ng/ml (95% confidence interval [CI], 3.3–4.4 ng/ml) in the PEA group and 2.7 ng/ml (95% CI, 2.5–3.2 ng/ml) in the GA group. The total amount of remifentanil infusion during emergency was significantly higher in the PEA group (164.6 ± 47.9 μg) than in the GA group (127.1 ± 30.4 μg) (P < 0.001). The number of patients who experienced hypotension during emergency in the PEA group was higher than that in the GA group (46.7% versus 13.3%, P < 0.001). ConclusionThe EC90 of remifentanil for smooth emergence in patients with VDLT under general anesthesia combined with epidural anesthesia (3.5 ng/ml) was higher than that under general anesthesia (2.7 ng/ml). Trial registrationChinese Clinical Trial Registry, ChiCTR2100054230.

Is there a relationship between two different anesthetic methods and postoperative length of stay during radical resection of malignant esophageal tumors in China?: a retrospective cohort study

BackgroundData providing a relationship between the anesthetic method and postoperative length of stay (PLOS) is limited. We aimed to investigate whether general anesthesia alone or combined with epidural anesthesia might affect perioperative risk factors and PLOS for patients undergoing radical resection of malignant esophageal tumors.MethodsThe study retrospectively analyzed the clinical data of 680 patients who underwent a radical esophageal malignant tumor resection in a Chinese hospital from January 01, 2010, to December 31, 2020. The primary outcome measure was PLOS, and the secondary outcome was perioperative risk-related parameters that affect PLOS. The independent variable was the type of anesthesia: general anesthesia (GA) or combined epidural-general anesthesia (E-GA). The dependent variable was PLOS. We conducted univariate and multivariate logistic regression and propensity score matching to compare the relationships of GA and E-GA with PLOS and identify the perioperative risk factors for PLOS. In this cohort study, the confounders included sociodemographic data, preoperative chemotherapy, coexisting diseases, laboratory parameters, intraoperative variables, and postoperative complications.ResultsIn all patients, the average PLOS was 19.85 ± 12.60 days. There was no significant difference in PLOS between the GA group and the E-GA group either before or after propensity score matching (20.01 days ± 14.90 days vs. 19.79 days ± 11.57 days, P = 0.094, 18.09 ± 9.71 days vs. 19.39 ± 10.75 days, P = 0.145). The significant risk factors for increased PLOS were lung infection (β = 3.35, 95% confidence interval (CI): 1.54–5.52), anastomotic leakage (β = 25.73, 95% CI: 22.11–29.34), and surgical site infection (β = 9.39, 95% CI: 4.10-14.68) by multivariate regression analysis. Subgroup analysis revealed a stronger association between PLOS and vasoactive drug use, blood transfusions, and open esophagectomy. The results remained essentially the same (stable and reliable) after subgroup analysis.ConclusionsAlthough there is no significant association between the type of anesthesia(GA or E-GA) and PLOS for patients undergoing radical esophageal malignant tumor resection, an association between PLOS and lung infection, anastomotic leakage, and surgical site infection was determined by multivariate regression analysis. A larger sample future study design may verify our results.

Comparison of two different anesthesia methods on the quality of surgical condition in transvaginal natural-orifice transluminal endoscopic surgery (vNOTES): A prospective single-blind randomized clinical trial

BackgroundThe purpose of the current study is to compare the quality of surgical condition of combined epidural-general anesthesia (EGA) versus general anesthesia (GA) in patients undergoing transvaginal natural orifice transluminal endoscopic surgery (vNOTES). MethodsPatients undergoing vNOTES were randomly allocated to receive GA or EGA. The primary outcome was evaluate the quality of surgical condition. We further assessed patients’ medical data regarding the need and consumption of intraoperative analgesics and vasoactive drugs. The visual analogue scale (VAS) and postoperative nausea and vomiting (PONV) scores were assessed at 2 h and 24 h postoperatively. We have registered the number of patients who needed rescue analgesics and antiemetics within 24 h after surgery. ResultsThe scores of the quality of surgical condition was 1.9 ± 0.8 in the GA group and 1.4 ± 0.7 (P = 0.001) in the EGA group. The PONV scores were not significantly different in the first two 2 h following surgery between the groups. The obviously differences in the PONV scores between the EGA group and GA group were detected at the 24th postoperatively. Moreover, there were no significant differences in the consumption of atropine, sufentanil, cisatracurium, propofol, sevoflurane and neostigmine between the two groups. Regarding the duration of extubated time, operative time, duration of anesthesia time and postoperative length of hospital stay (PLOS), our findings did not showcase significant differences between the two groups. Similarly, we did not detect significant changes in the postoperative pain at the two time points between the groups. ConclusionOur results showed that compared with GA, EGA improved the quality of surgical condition in patients undergoing vNOTES. As epidural block is an additional invasive procedure with its attendant risks, we should weigh the pros and cons when combined epidural-general anesthesia is used for vNOTES in the future. Trial registrationThis study was registered at Chinese Clinical Trial Registry chictr.org.cn (http://www.chictr.org.cn/) with No. 2000032406 on April 27, 2020.

Abstract No. : ABS0646: Efficacy of combined epidural general anaesthesia in laparoscopic cholecystectomies - a prospective randomised study

Background &Aims:Pnuemoperitonium in laparoscopy is associated with cardiorespiratory changes. Combination of epidural with general anaesthesia might offer benefits of haemodynamic control and peri-operative analgesia. We aimed to study the efficacy of combinedepidural-general anaesthesia(CEGA) over general anaesthesia in laparoscopic cholecystectomies.Methods:A prospective, randomised, double blind study was conducted on 90 surgical in-patients after obtaining ethical and informed consent from the institution and participants respectively.In Group GE-(n=45), Lumbar epidural analgesia with ropivacaine with GA ;In Group G, only GA was administered. Propofol ,vecuronium, fentanyl, paracetamol, isofluranewereused in both the groups. Along with minimum mandatory monitoringfor study purpose, heart rate(HR), mean arterial Pressure(MAP), end-tidal carbon-dioxide (ETCO2), peripheral oxygen saturation ( SpO2) ,visualanaloguescale score, Ramsay sedation score , requirement of propofol, muscle relaxants and analgesics were studied with recovery and pain in 12 hours post operatively.Statistical analysis was carried out with SPSS version 20. Student’s t test, Chi-square test were used for comparison.Results:Statistical value of p<0.05 was considered significant. We noted significantly lesser readingsin group GE than inGroup G i.e (p<0.001) in MAP, SBP, DBP muscle relaxants, propofol and Fentanyl (p<0.001) . Early recovery and lesser pain scores were noted in group GE than Group G.Conclusion:CEGAtechnique has the benefit of better control of haemodynamics .It reduces requirements of analgesics and anaesthetic drugs and has faster recovery with less post-operative pain in laparoscopic cholecystectomies.

Effect of combined epidural-general anesthesia on long-term survival of patients with colorectal cancer: a meta-analysis of cohort studies.

This study aimed to analyze the long-term survival of patients with colorectal cancer after receiving combined epidural-general anesthesia (EGA) or general anesthesia (GA) alone. The PubMed, MEDLINE, Web of Science, Cochrane Library, and Embase databases were used to search for cohort studies that explored the differences between the effects of EGA and GA on overall survival (OS) and recurrence-free survival (RFS) of patients with colorectal cancer. The hazard ratios (HRs) and their 95% confidence intervals (95%CIs) were used as indicators to evaluate the strength of the effects and were pooled. Nine studies were included in the meta-analysis. EGA improved the OS of patients with colorectal cancer compared with GA (HR = 0.904, 95%CI 0.871-0.938, P < 0.05). In the subgroup analysis, EGA was more protective for OS of patients with colon cancer than GA (HR = 0.840, 95%CI 0.732-0.963, P < 0.05), but not for OS of patients with rectal cancer (HR = 0.764, 95%CI 0.398-1.469, P > 0.05). Additionally, EGA could not further prolong RFS in patients with colorectal cancer (HR = 1.015, 95%CI 0.942-1.093, P > 0.05), which was the same in the subgroup analysis of patients with colon cancer (HR = 0.908, 95%CI 0.760-1.085, P > 0.05). EGA could improve the OS of patients with colorectal cancer, especially those with colon cancer, but it could not improve the OS in the subgroup of patients with rectal cancer. This difference may be due to the immune protective function of the parasympathetic nerve innervating the intestinal tubes above the splenic flexure retained by EGA. Additionally, although EGA has a protective effect on RFS in patients with colorectal cancer, the difference was not significant. The design of this analysis is registered and displayed in the PROSPERO database (CRD42021274864).

Regional Analgesia Does Not Reduce Cancer Recurrence. Case closed

Regional Analgesia Does Not Reduce Cancer Recurrence. Case closed

Epidural Anesthesia and Arterial Maximal Flow Velocity of Free Flap in Patients Having Microvascular Lower Extremity Reconstruction: A Randomized Controlled Trial.

One of the critical factors for free flap survival is to maintain adequate perfusion. The authors evaluated the effect of epidural anesthesia on arterial maximal flow velocity of the free flap in microvascular lower extremity reconstruction. This is a prospective randomized study where patients were allocated to receive either combined general-epidural anesthesia (epidural group, n = 26) or general anesthesia alone (control group, n = 26). After injecting epidural ropivacaine 10 ml in the epidural group, the effect on arterial maximal flow velocity of the free flap was analyzed using ultrasonography. The primary outcome measurement was the arterial maximal flow velocity 30 minutes after establishing the baseline. Intraoperative hemodynamics and postoperative outcomes such as postoperative pain, opioid requirements, surgical complications, intensive care unit admission, and hospital length of stay were also assessed. The arterial maximal flow velocity 30 minutes after the baseline measurement was significantly higher in the epidural group (35.3 ± 13.9 cm/second versus 23.5 ± 8.4 cm/second; p = 0.001). The pain score at 1 hour postoperatively and opioid requirements at 1 and 6 hours postoperatively were significantly lower in the epidural group [3.0 (interquartile range, 2.0 to 5.0) versus 5.0 (interquartile range, 3.0 to 6.0), p = 0.019; 0.0 μg (interquartile range, 0.0 to 50.0 μg) versus 50.0 μg (interquartile range, 0.0 to 100.0 μg), p = 0.005; and 46.9 μg (interquartile range, 0.0 to 66.5 μg) versus 96.9 μg (interquartile range, 41.7 to 100.0 μg), p = 0.014, respectively]. There were no significant differences in intraoperative hemodynamics or other postoperative outcomes between the two groups. Epidural anesthesia increased the arterial maximal flow velocity of the free flap and decreased postoperative pain and opioid requirements in microvascular lower extremity reconstruction. Therapeutic, I.

Epidural Anesthesia and Postoperative Delirium: Reply

We appreciate the comments from Zhang et al.1 on our recent article “Delirium in Older Patients after Combined Epidural–General Anesthesia or General Anesthesia for Major Surgery: A Randomized Trial.”2Consistent with many others,3 our study also found that intraoperative hypotension occurred more frequently in patients given combined epidural–general anesthesia. Increasing evidence suggests that intraoperative hypotension is associated with an increased risk of postoperative delirium.4,5 According to the suggestion of Zhang et al.,1 we included intraoperative hypotension in a post hoc treatment-by-covariate interaction analysis for the primary outcome. Our results did not find significant interaction between treatment intervention and intraoperative hypotension. The effect of combined epidural–general anesthesia on delirium was similar in the subgroups with or without intraoperative hypotension (with intraoperative hypotension [systolic blood pressure &lt; 80 mmHg]: relative risk 0.68; 95% CI, 0.20 to 2.37; without intraoperative hypotension: 0.33, 0.16 to 0.67; interaction P = 0.243).In our study, delirium was assessed twice daily with the Confusion Assessment Method for the Intensive Care Unit during the first 7 postoperative days. Immediately before assessing delirium, sedation or agitation was assessed with the Richmond Agitation-Sedation Scale. Patients who developed delirium were classified into three subtypes according to the Richmond Agitation-Sedation Scale assessment results. Hyperactive delirium was defined when the Richmond Agitation-Sedation Scale score was consistently positive (from +1 to +4). Hypoactive delirium was defined when the Richmond Agitation-Sedation Scale score was consistently negative or neutral (from –3 to 0). Mixed-type delirium was defined when both hyperactive and hypoactive episodes existed.6 In accord with the results of others, hypoactive delirium was the most common subtype in our patients of the two groups.2Among our patients, 58 (3.4%) developed delirium within the first 7 postoperative days; of those who developed delirium, 21 (36%) had two episodes or more. The duration of delirium (number of days with at least one episode of delirium) was shorter in patients given combined epidural–general anesthesia (median 0 days [interquartile range, 0 to 0] with combined epidural-general anesthesia vs. 0 days [0 to 0] with general anesthesia alone; mean difference –0.04, 95% CI, –0.08 to –0.01; P &lt; 0.001). Among 58 patients who developed delirium, the duration of delirium did not differ between the two groups (median 1 day [interquartile range, 1 to 2] vs. 1 day [1 to 2]; mean difference 0.42, 95% CI, –0.26 to 1.10; P = 0.546).This work was funded by the Peking University (Beijing, China) Clinical Research Program [PUCRP201101]. The funder had no role in the study design, data collection, data analysis, data interpretation, or writing of the report.The authors declare no competing interests.

Long-term Survival after Combined Epidural-General Anesthesia or General Anesthesia Alone: Follow-up of a Randomized Trial

Long-term Survival after Combined Epidural-General Anesthesia or General Anesthesia Alone: Follow-up of a Randomized Trial

The Cognitive Neuraxis: Epidurals and Postoperative Delirium

Editorial| August 2021 The Cognitive Neuraxis: Epidurals and Postoperative Delirium Phillip E. Vlisides, M.D.; Phillip E. Vlisides, M.D. Search for other works by this author on: This Site PubMed Google Scholar George A. Mashour, M.D., Ph.D. George A. Mashour, M.D., Ph.D. Search for other works by this author on: This Site PubMed Google Scholar Author and Article Information From the Department of Anesthesiology (P.E.V., G.A.M.), the Center for Consciousness Science (P.E.V., G.A.M.), and the Neuroscience Graduate Program (G.A.M.), University of Michigan Medical School, Ann Arbor, Michigan. This editorial accompanies the article on p. 218. This article has a related Infographic on p. A19. Accepted for publication April 16, 2021. Address correspondence to Dr. Mashour: gmashour@med.umich.edu Anesthesiology August 2021, Vol. 135, 197–199. https://doi.org/10.1097/ALN.0000000000003824 Connected Content Commentary: Delirium in Older Patients after Combined Epidural–General Anesthesia or General Anesthesia for Major Surgery: A Randomized Trial Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Cite Icon Cite Get Permissions Search Site Citation Phillip E. Vlisides, George A. Mashour; The Cognitive Neuraxis: Epidurals and Postoperative Delirium. Anesthesiology 2021; 135:197–199 doi: https://doi.org/10.1097/ALN.0000000000003824 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search nav search search input Search input auto suggest search filter All ContentAll PublicationsAnesthesiology Search Advanced Search Topics: axon, postoperative delirium, delirium Delirium is a distressing syndrome that affects many surgical patients. Postoperative delirium is associated with falls, cognitive and functional decline, and prolonged hospitalization.1 Indeed, delirium is a major public health issue, and postoperative delirium serves as a target for surgical quality improvement.2 A promising strategy for reducing risk involves sustained interventions that simultaneously target multiple risk factors.3 Epidural analgesia is one such candidate intervention that has been demonstrated to reduce key delirium risk factors: pain, opioid consumption, and inflammation.4–6 Furthermore, epidural therapy can be continued over multiple days, particularly during time windows of peak delirium risk. Taken together, it seems plausible that such a sustained intervention, which simultaneously targets multiple risk factors, could reduce risk of postoperative delirium. As reported in this issue of Anesthesiology, Li et al. sought to determine whether combined general-epidural anesthesia, with continued postoperative epidural analgesia, would reduce the risk of... You do not currently have access to this content.

Epidural Anesthesia-Analgesia and Recurrence-free Survival after Lung Cancer Surgery: A Randomized Trial.

Regional anesthesia and analgesia reduce the stress response to surgery and decrease the need for volatile anesthesia and opioids, thereby preserving cancer-specific immune defenses. This study therefore tested the primary hypothesis that combining epidural anesthesia-analgesia with general anesthesia improves recurrence-free survival after lung cancer surgery. Adults scheduled for video-assisted thoracoscopic lung cancer resections were randomized 1:1 to general anesthesia and intravenous opioid analgesia or combined epidural-general anesthesia and epidural analgesia. The primary outcome was recurrence-free survival (time from surgery to the earliest date of recurrence/metastasis or all-cause death). Secondary outcomes included overall survival (time from surgery to all-cause death) and cancer-specific survival (time from surgery to cancer-specific death). Long-term outcome assessors were blinded to treatment. Between May 2015 and November 2017, 400 patients were enrolled and randomized to general anesthesia alone (n = 200) or combined epidural-general anesthesia (n = 200). All were included in the analysis. The median follow-up duration was 32 months (interquartile range, 24 to 48). Recurrence-free survival was similar in each group, with 54 events (27%) with general anesthesia alone versus 48 events (24%) with combined epidural-general anesthesia (adjusted hazard ratio, 0.90; 95% CI, 0.60 to 1.35; P = 0.608). Overall survival was also similar with 25 events (13%) versus 31 (16%; adjusted hazard ratio, 1.12; 95% CI, 0.64 to 1.96; P = 0.697). There was also no significant difference in cancer-specific survival with 24 events (12%) versus 29 (15%; adjusted hazard ratio, 1.08; 95% CI, 0.61 to 1.91; P = 0.802). Patients assigned to combined epidural-general had more intraoperative hypotension: 94 patients (47%) versus 121 (61%; relative risk, 1.29; 95% CI, 1.07 to 1.55; P = 0.007). Epidural anesthesia-analgesia for major lung cancer surgery did not improve recurrence-free, overall, or cancer-specific survival compared with general anesthesia alone, although the CI included both substantial benefit and harm.

A Randomized Comparative Trial to Study the effect of Preoperative single shot Epidural with Ropivacaine in Lumbar Laminectomy

Background: laminectomy surgeries are usually performed in cases of spinal canal stenosis, disc prolapse etc. It has been reported that the use of regional anesthesia techniques in combination to general anaesthesia has shown better heamodynamic stability intraoperatively, better pain scores and reduced intraoperative blood loss. The present study was conducted to evaluate the efficacy of fusion technique of combining epidural and general anaesthesia in patients undergoing lumbar laminectomies. Aim: To evaluate the efficacy of combined epidural general anesthesia for lumbar laminectomy surgeries with epidural ropivacaine. Materials and Methods: A prospective randomised study was conducted in 100 patients who are scheduled for lumbar laminectomy surgeries belonging to ASA Class I and II age between 40-60 years were randomly allocated into two groups (Group E and Group F) of 50 each. Group E: 12ml of 0.5% Ropivacaine and 50µg fentanyl epidurally. Group F:12ml of Normal Saline and 50µg fentanyl epidurally. The parameters recorded were intraoperative analgesia by heart rate and blood pressure, Rescue analgesia, Blood loss. Results: Intraoperatively requirement of general anesthetics, Heart rate, MBP, Blood loss, is lesser in Group E when compared with Group F. It was observed that longer time to rescue analgesia in group E than in group F. Conclusion: combined epidural general anesthesia with local anesthetic (ropivacaine) with narcotic (fentanyl) is a better technique for anesthetic management of patients posted for lumbar laminectomy. Thus from our study we conclude that combined epidural general anesthesia technique with epidural ropivacaine is a better alternative to general anesthesia providing stable hemodynamics, reducing dose of general anesthetics, less blood loss.

Long-term Survival after Combined Epidural-General Anesthesia or General Anesthesia Alone: Follow-up of a Randomized Trial.

Experimental and observational research suggests that combined epidural-general anesthesia may improve long-term survival after cancer surgery by reducing anesthetic and opioid consumption and by blunting surgery-related inflammation. This study therefore tested the primary hypothesis that combined epidural-general anesthesia improves long-term survival in elderly patients. This article presents a long-term follow-up of patients enrolled in a previous trial conducted at five hospitals. Patients aged 60 to 90 yr and scheduled for major noncardiac thoracic and abdominal surgeries were randomly assigned to either combined epidural-general anesthesia with postoperative epidural analgesia or general anesthesia alone with postoperative intravenous analgesia. The primary outcome was overall postoperative survival. Secondary outcomes included cancer-specific, recurrence-free, and event-free survival. Among 1,802 patients who were enrolled and randomized in the underlying trial, 1,712 were included in the long-term analysis; 92% had surgery for cancer. The median follow-up duration was 66 months (interquartile range, 61 to 80). Among patients assigned to combined epidural-general anesthesia, 355 of 853 (42%) died compared with 326 of 859 (38%) deaths in patients assigned to general anesthesia alone: adjusted hazard ratio, 1.07; 95% CI, 0.92 to 1.24; P = 0.408. Cancer-specific survival was similar with combined epidural-general anesthesia (327 of 853 [38%]) and general anesthesia alone (292 of 859 [34%]): adjusted hazard ratio, 1.09; 95% CI, 0.93 to 1.28; P = 0.290. Recurrence-free survival was 401 of 853 [47%] for patients who had combined epidural-general anesthesia versus 389 of 859 [45%] with general anesthesia alone: adjusted hazard ratio, 0.97; 95% CI, 0.84 to 1.12; P = 0.692. Event-free survival was 466 of 853 [55%] in patients who had combined epidural-general anesthesia versus 450 of 859 [52%] for general anesthesia alone: adjusted hazard ratio, 0.99; 95% CI, 0.86 to 1.12; P = 0.815. In elderly patients having major thoracic and abdominal surgery, combined epidural-general anesthesia with epidural analgesia did not improve overall or cancer-specific long-term mortality. Nor did epidural analgesia improve recurrence-free survival. Either approach can therefore reasonably be selected based on patient and clinician preference.

Delirium in Older Patients after Combined Epidural-General Anesthesia or General Anesthesia for Major Surgery: A Randomized Trial.

Delirium is a common and serious postoperative complication, especially in the elderly. Epidural anesthesia may reduce delirium by improving analgesia, reducing opioid consumption, and blunting stress response to surgery. This trial therefore tested the hypothesis that combined epidural-general anesthesia reduces the incidence of postoperative delirium in elderly patients recovering from major noncardiac surgery. Patients aged 60 to 90 yr scheduled for major noncardiac thoracic or abdominal surgeries expected to last 2 h or more were enrolled. Participants were randomized 1:1 to either combined epidural-general anesthesia with postoperative epidural analgesia or general anesthesia with postoperative intravenous analgesia. The primary outcome was the incidence of delirium, which was assessed with the Confusion Assessment Method for the Intensive Care Unit twice daily during the initial 7 postoperative days. Between November 2011 and May 2015, 1,802 patients were randomized to combined epidural-general anesthesia (n = 901) or general anesthesia alone (n = 901). Among these, 1,720 patients (mean age, 70 yr; 35% women) completed the study and were included in the intention-to-treat analysis. Delirium was significantly less common in the combined epidural-general anesthesia group (15 [1.8%] of 857 patients) than in the general anesthesia group (43 [5.0%] of 863 patients; relative risk, 0.351; 95% CI, 0.197 to 0.627; P < 0.001; number needed to treat 31). Intraoperative hypotension (systolic blood pressure less than 80 mmHg) was more common in patients assigned to epidural anesthesia (421 [49%] vs. 288 [33%]; relative risk, 1.47, 95% CI, 1.31 to 1.65; P < 0.001), and more epidural patients were given vasopressors (495 [58%] vs. 387 [45%]; relative risk, 1.29; 95% CI, 1.17 to 1.41; P < 0.001). Older patients randomized to combined epidural-general anesthesia for major thoracic and abdominal surgeries had one third as much delirium but 50% more hypotension. Clinicians should consider combining epidural and general anesthesia in patients at risk of postoperative delirium, and avoiding the combination in patients at risk of hypotension.

Effect of perioperative use of parecoxib on chronic post-surgical pain in elderly patients after hepatectomy: a prospective randomized controlled study

BackgroundChronic post-surgical pain (CPSP) has a negative impact on the recovery, quality of life, and physical functioning of elderly patients. This study aimed to test the superiority of parecoxib vs. placebo in preventing chronic post-hepatectomy pain in elderly patients under combined general-epidural anesthesia.MethodsA total of 105 elderly patients undergoing hepatectomy under combined general-epidural anesthesia were randomized into the parecoxib or placebo group. The primary outcome was the proportion of patients with CPSP 3 months postoperatively. The secondary outcomes included the Short-Form McGill Pain Questionnaire score in CPSP-positive responders, acute pain intensity, postoperative analgesic demand, inflammatory markers change, and postoperative complications within 28 days.ResultsThe parecoxib group provided a non-significant absolute 9.1% reduction in the rate of CPSP compared to the placebo group (P = 0.34). The average chronic pain visual analog scale in the parecoxib group was lower than that in the placebo group (P = 0.04). Significantly less moderate-to-severe acute pain at rest (P = 0.04) and with coughing (P < 0.001), less patient-controlled epidural analgesia (PCEA) consumption (P = 0.01), and less rescue analgesia (P < 0.001) were observed in the parecoxib group compared to the placebo group. Furthermore, no between-group difference was observed in inflammatory markers (P > 0.05) and postoperative complications (P = 0.65).ConclusionsParecoxib reduced the prevalence of CPSP in elderly patients after hepatectomy under combined general-epidural anesthesia from 44.4 to 35.3% with no statistical significance. Moreover, significantly alleviated CPSP intensity and improved acute pain management were observed.Trial registrationThis study was retrospectively registered in the Chinese Clinical Trial Registry (URL: http://www.chictr.org.cn/edit.aspx?pid=56961&htm=4) on August 3, 2020 (ChiCTR-2,000,035,198).

The effect of combined Epidural-general Anesthesia on Hemodynamic Instability during Pheochromocytoma and Paraganglioma Surgery: A multicenter retrospective cohort study.

Objectives: The purpose of this study was to compare the effects of combined epidural-general anesthesia with those of general anesthesia alone on hemodynamic instability (intraoperative hypotension and hypertensive crisis) during pheochromocytoma and sympathetic paraganglioma surgery.Methods: A total of 119 patients' medical records were reviewed who were diagnosed as having pheochromocytoma and sympathetic paraganglioma on the basis of histological findings. Intraoperative hypotension was defined as a mean blood pressure < 60 mmHg or a decrease > 30% in baseline systolic blood pressure after adrenal vein ligation. Hypertensive crisis was defined as a systolic blood pressure > 200 mmHg or an increase > 30% in baseline systolic blood pressure during the operation. The predictor variables for intraoperative hypotension and hypertensive crisis were analyzed with logistic regression models. Data were presented as adjusted odds ratio with 95% confidence interval.Results: The independent predictors of intraoperative hypotension were an increased attenuation number on unenhanced computed tomography (1.112 [1.009-1.226], p = 0.033), a high baseline mean blood pressure (1.063 [1.012-1.117], p = 0.015), and the combined epidural-general anesthesia (5.439 [1.410-20.977], p = 0.014). In contrast, an increased attenuation number on unenhanced computed tomography was the only independent predictor of hypertensive crisis (1.087 [1.021-1.158], p = 0.009).Conclusions: The combined epidural-general anesthesia was not effective in attenuating hypertensive responses, but could have exacerbated intraoperative hypotension. These findings should be taken into account before selecting the anesthetic technique in pheochromocytoma and sympathetic paraganglioma surgery.

Remifentanil for abdominal surgery is associated with unexpectedly unfavorable outcomes.

Insufficient perioperative pain treatment is known as a highly predictive risk factor for the development of chronic postoperative pain. Remifentanil is an ultrashort-acting opioid that provides quick and efficient analgesia but is associated with the induction of opioid-induced hyperalgesia. Despite these well-known characteristics, this substance is being increasingly used in anesthesia and in a variety of medical fields, such as intensive-care medicine and obstetrics. The aim of our study was to reveal whether remifentanil influences postoperative pain, the requirement for postoperative analgesics, and requirement of antiemetics (as indirect indicator of postoperative nausea and vomiting), as well as the effects on time to extubation and length of stay in the postanesthesia care unit in daily clinical routine. From an electronic medical records database of 55,693 anesthesias, we analyzed data from all patients receiving intraabdominal surgery (visceral, gynecological, and urological) under general anesthesia or combined general-epidural anesthesia by propensity score matching. The administration of remifentanil was associated with higher postoperative pain scores despite a higher requirement of postoperative analgesics. Additional epidural analgesia was not able to avoid this finding. The intraoperative use of remifentanil is associated with a deterioration of pain levels and postoperative analgesic requirement, wherefore the potential benefit of this substance seems to be outweighed by its potential disadvantages. Especially in operative procedures in which high postoperative pain scores are expected, the unreflective use should be critically questioned.