Continuous Thoracic Epidural Anesthesia Research Articles

Continuous spinal versus continuous thoracic epidural anesthesia for major abdominal surgery in patients with chronic obstructive pulmonary disease

Background Most anesthetists preferred general anesthesia for major abdominal surgery which was not devoid of complications in cases with chronic obstructive pulmonary disease (COPD). Recently, the use of neuraxial anesthesia is supported to avoid or decrease these complications. This study aimed at the description, evaluation, and comparison between the use of continuous spinal anesthesia (CSA) and continuous thoracic epidural anesthesia (CTEA) as a sole anesthesia for major abdominal surgeries in cases with COPD. Patients and methods Sixty patients of both sexes aged 40–75 years with American Society of Anesthesiologists physical status classes II and III complaining of COPD scheduled for various elective major abdominal operations were included. According to the neuraxial block type, the patients were randomly assigned into two equal groups with 30 patients in each. The first group (CSA group) received continuous lumbar spinal anesthesia and the second group (CTEA group) received continuous thoracic epidural anesthesia. The data recorded included patients’ demographic data, characteristics of the used neuraxial blockade, hemodynamic changes, changes in pulmonary functions, incidence of the various side effects, and postoperative pain severity. Results The final statistical analysis included 55 patients where five patients were excluded from the study. Although there were no statistically significant differences between both groups regarding demographics, hemodynamics, changes in pulmonary functions, side effects, surgeon, and patients’ satisfactions, and postoperative visual analog scale. The CSA group has faster block onset with less local anesthetic dose compared with the CTEA group (P<0.001). Also, there were statistically significant decrease in peak expiratory flow rate, forced expiratory volume in 1 s, and forced expiratory volume in 1 s/forced vital capacity at 1, 2, and 6 h postoperatively compared with the preoperative baseline values in both groups (P<0.05). Hypotension was significantly more frequent in the CTEA group than in the CSA group (P=0.047). Conclusion Although both CSA and CTEA can be used for anesthesia and for postoperative analgesia in major abdominal surgery in COPD patients, the CSA was easier, safer, had faster onset, gave more predictable block, with less hemodynamic instability, and less technical failure compared with CTEA. The preoperative optimization of the lung functions, intraoperative close observation, and postoperative neuraxial analgesia with chest physiotherapy improved the outcome.

Comparative Study between Continuous Thoracic Epidural vs. Thoracic Spinal Anaesthesia in Breast Surgery

Objective: The aim of this work is to compare between thoracic epidural anesthesia (TEA) and segmental thoracic spinal anesthesia (TSA) conducted for breast surgeries as regard to hemodynamic changes (blood pressure, heart rate, oxygen saturation, ETCO2), postoperative pain control, postoperative analgesic requirements, surgeon satisfaction, postoperative ambulation time and perioperative complication. Setting: Al-Hussein and Sayed Galal hospitals. Patients and Methods: This work was done upon 40 female patient undergoing breast surgeries. Patients were divided randomly into 2 equal groups according to the type of anesthetic technique had been chosen. Group I were anaesthetized by thoracic epidural anesthesia and group II by segmental thoracic spinal anesthesia. Results: Recovery and ambulation time was more or less equal in the both groups. This is important since the patient can readily return to her family and social environment and can decrease the cost of the procedure, although this was not specifically assessed in this study. Post-operative pain was compared at the time 0, 1, 2, 4 and 8 hour by using VAS. Conclusion: We found that epidural blockade a preferred choice of anesthetic management for breast surgery.

Retrospective analysis of quality improvement when using liposome bupivacaine for postoperative pain control.

Background/objectiveLiposome bupivacaine, a prolonged-release bupivacaine formulation, recently became available at the Naval Medical Center San Diego (NMCSD); before availability, postsurgical pain for large thoracic/abdominal procedures was primarily managed with opioids with/without continuous thoracic epidural (CTE) anesthesia. This retrospective chart review was part of a clinical quality initiative to determine whether postsurgical outcomes improved after liposome bupivacaine became available.MethodsData from patients who underwent laparotomy, sternotomy, or thoracotomy at NMCSD from May 2013 to May 2014 (after liposome bupivacaine treatment became available) were compared with data from patients who underwent these same procedures from December 2011 to May 2012 (before liposome bupivacaine treatment became available). Collected data included demographics, postoperative pain control methods, opioid consumption, perioperative pain scores, and lengths of intensive care unit and overall hospital stays.ResultsData from 182 patients were collected: 88 pre-liposome bupivacaine (laparotomy, n=52; sternotomy, n=26; and thoracotomy, n=10) and 94 post-liposome bupivacaine (laparotomy, n=49; sternotomy, n=31; and thoracotomy, n=14) records. Mean hospital stay was 7.0 vs 5.8 days (P=0.009) in the pre- and post-liposome bupivacaine groups, respectively, and mean highest reported postoperative pain score was 7.1 vs 6.2 (P=0.007), respectively. No other significant between-group differences were observed for the overall population. In the laparotomy subgroup, there was a reduction in the proportion of patients who received CTE anesthesia post-liposome bupivacaine (22% [11/49] vs 35% [18/52] pre-liposome bupivacaine).ConclusionSurgeons and anesthesiologists have changed the way they manage postoperative pain since the time point that liposome bupivacaine was introduced at NMCSD. Our findings suggest that utilization of liposome bupivacaine may be a useful alternative to epidural anesthesia.

Continuous Thoracic Epidural Anesthesia for Mammoplasty Reduction

Female 45 years old patient with bilateral breast hyperplasia. A functional reduction mammoplasty is done under continuous high thoracic epidural regional anesthesia (0.5% bupivacaine) through an epidural catheter inserted in T3-T4 for 7 hours. The patient presented a permanent hemodynamic stability without deterioration in ventilatory parameters. She did not have neurological injuries. Excellent continuous epidural analgesia (0.125% Bupivacaine) in immediate post-operative reaction and within the next 24 hours. The continuous high thoracic epidural anesthesia is an alternative anesthetic technique in breast surgery.

Continuous transverse abdominis plane block vs thoracic epidural anesthesia in radical cystectomy under a enhanced recovery after surgery (ERAS) program: preliminar results

Continuous transverse abdominis plane block vs thoracic epidural anesthesia in radical cystectomy under a enhanced recovery after surgery (ERAS) program: preliminar results

A Comparative Study between Thoracic Epidural Anesthesia and General Anesthesia for Patients Who Underwent Modified Radical Mastectomy with Axillary Lymph Node Dissection in De La Salle University Medical Center

BACKGROUND: To compare the recovery time and other related clinical outcomes among patients who underwent Modified Radical Mastectomy (MRM) with axillary lymph node dissection under Continuous Thoracic Epidural Anesthesia (CTEA) and General Endotracheal Tube Anesthesia (GETA).METHODS: A retrospective cross-sectional study with 70 patients who underwent MRM in De La Salle University Medical Centre (DLSUMC), categorized into GETA and CTEA group consisted of 35 patients each. Per oral premedications 15 mg midazolam, 40 mg omeprazole and 10 mg metoclopramide were given 1 hour prior to surgery. Intra-operative hypotension/hypertension, tachycardia/bradycardia status, length of Post-Anesthesia Care Unit (PACU) and hospital stay, and Post Operative Nausa and Vomiting (PONV) incidence were compared between 2 groups.RESULTS: Preoperatively, there were no significant differences between the groups in terms of subject characteristic. Intra-operatively, hypertension was more frequent in GETA group (28.6% vs. 0%), while hypotension was more frequent in the CTEA (80% vs. 57.1%). Tachycardia was more frequent in GETA group (46.6% vs. 0%), meanwhile bradycardia was more frequent in CTEA (40% vs. 17.1%). Postoperatively, the GETA group had shorter PACU stay than CTEA (230 mins vs. 267 mins), but CTEA group had a shorter time of hospital stay compared to GETA (58.1 hours vs. 67.7 hours). The incidence of PONV were comparable among the two groups (GETA 46.7% vs. CTEA 50%). Statistically there were no significant differences between the two groups in all of the above characteristics.CONCLUSION: CTEA technique has no effect on inducing hypertension and tachycardia, but hypotension and bradycardia may occur. Although GETA gives shorter PACU duration, CTEA gives shorter hospital stay. This gave impression that CTEA is an effective alternative technique to GETA in patients who underwent MRM with axillary dissection.KEYWORDS: modified radical mastectomy, general anesthesia, epidural anesthesia

Priapism following continuous thoracic epidural anaesthesia: emergency or a benign condition?

Priapism is a rare complication of epidural anaesthesia, and the pathophysiology is poorly understood. In general, 95% of all priapism episodes are ischemic because of decreased penile blood flow, and therefore requires immediate treatment. A case is reported of a 45-year-old male patient in which a clear relation is demonstrated between continuous thoracic epidural analgesia and priapism after transabdominal nephrectomy. The level of epidural anaesthesia supports the theory that the erection is a consequence of increased penile blood flow, thus a relatively harmless condition. However, confirmation by serial cavernous blood gas analysis or colour duplex ultrasonography is mandatory. Until this hypothesis is confirmed, termination of epidural infusion is advised as a primary treatment.

Role of Continuous High Thoracic Epidural Anesthesia in Hippocampal Apoptosis after Global Cerebral Ischemia in Rats

Background: Cervical sympathetic blockade has been found to reduce cerebral vascular resistance and improve focal cerebral ischemia/reperfusion injury. In this study, we tested the hypothesis that the sympathetic blockade of high thoracic epidural anesthesia (HTEA) would reduce hippocampal apoptosis after global cerebral ischemia (GCI) injury. Methods: Fifteen-minute global ischemia was established by 4-vessel occlusion in adult male Wistar rats. And 0.5% bupivacaine or 0.9% saline (20 μl//h) was infused continuously to the thoracic epidural space through the T4-5 intervertebral space from 15 minutes before ischemia to 24 hours or 72 hours after ischemia. Cerebral blood flow (CBF), Mortality, neurodeficit scores (NDS), Nissl and TUNEL staining, hippocampal superoxide dismutase (SOD) activity, malondialdehyde (MDA) concentrations, western blot of poly (ADP-ribose) polymerase (PARP) and immunohistochemical staining (PARP, Bax and Bcl-2) were determined. Results: Both the hyperpefusion and hypoperfusion after reperfusion were improved by HTEA. HTEA decreased the number of apoptotic neurons in cornu ammonis area 1 (CA1), reduced PARP and Bax expressions with a decrease of Bax/Bcl-2 ratio induced by ischemic injury. The upregulation of SOD activity and the downregulation of MDA were obvious in the HTEA group compared with the GCI group. HTEA also improved NDS but not the mortality rate. Conclusion: Our study demonstrated that continuous HTEA attenuates hippocampal apoptosis and a behavioral deficit after global cerebral ischemia, and that these protective effects are associated with the improved microcirculation, reduced oxidative stress and the less activation of PARP.

Thoracic epidural anesthesia for modified radical mastectomy in carcinoma of breast patient with chronic obstructive pulmonary disease: A case report

Introduction: Modified radical mastectomy, the standard surgical procedure in the management of carcinoma of breast is routinely performed under general anesthesia. But the patients of chronic obstructive pulmonary disease with other comorbidites are at increased risk of perioperative morbidity and mortality especially because of pulmonary complications. We report successful perioperative management of modified radical mastectomy only with thoracic epidural anesthesia in a diagnosed case of carcinoma of breast with hypertension, type 2 diabetes mellitus and severely compromised pulmonary function. Case Report: A 66-year-old female, a known case of chronic obstructive pulmonary disease since seven years with comorbidites (ASA grade III), presented with carcinoma of breast was scheduled for modified radical resection. Continuous thoracic epidural anesthesia was administered at T4-5 level. Local anesthetic titrated as per the demands of surgery and postoperative analgesia. Chromic obstructive pulmonary disease has been considered as independent risk factor for postoperative morbidity and mortality because of cardiopulmonary complications. But Thoracic epidural anesthesia, one of the regional anesthesia techniques, with use of low dose of local anesthetic helps preserving respiratory function. The procedure was well tolerated without cardiopulmonary complications which lead to prompt recovery with additional effect of prolonged postoperative analgesia. Conclusion: Thoracic epidural anesthesia provided not only hemodynamic, cardiopulmonary stability but also adequate anesthesia, analgesia and satisfaction to patient in postoperative phase. It proved to be an excellent anesthesia technique for modified radical mastectomy in patient with chronic obstructive pulmonary disease.

Total radical gastrectomy under continuous thoracic epidural anaesthesia

Total radical gastrectomy under continuous thoracic epidural anaesthesia

321 POSTER Continuous high thoracic epidural anesthesia with 0.125% bupivacaine and fentanyl versus general anesthesia for management of oncologic mastectomy

321 POSTER Continuous high thoracic epidural anesthesia with 0.125% bupivacaine and fentanyl versus general anesthesia for management of oncologic mastectomy

Effects of continuous high thoracic epidural anesthesia with different local anesthetic in breast augmentation

目的 观察隆乳手术中不同局部麻醉药混合液行硬膜外阻滞的麻醉效果及并发症.方法 120例行乳房假体置入术患者分为4组,以T4～T5棘突间隙为硬膜外穿刺点,分别注入含1 %利多卡因及0.375 %罗哌卡因、0.25 %罗哌卡因、0.25 %布比卡因的混合液及单纯1.3 %利多卡因溶液,初量13 ml,观察麻醉效果及对血流动力学的影响和并发症.结果切皮均无疼痛,脉搏氧饱和度无明显变化,血压及心率轻度降低.1 %利多卡因加0.375 %罗哌卡因、0.25 %罗哌卡因或0.25 %布比卡因混合液组的阻滞麻醉效果较好,单纯1.3 %利多卡因组效果较差.65例(54 %)患者出现鼻塞,39例(33 %)麻醉后发生心动过缓,无组间差异.结论高位硬膜外阻滞麻醉可安全、有效地应用于隆乳房手术麻醉,1 %利多卡因与0.25 %罗哌卡因或布比卡因混合液不仅阻滞麻醉效果较好,对生理功能影响也较小。

Continuous Thoracic Epidural Anesthesia Induces Segmental Sympathetic Block in the Awake Rat

Thoracic epidural anesthesia (TEA) is used increasingly in critical care, especially for cardiac and intestinal sympathetic block. In this study we evaluated cardiorespiratory function and sympathetic activity in a new model of continuous TEA in awake rats. Thirteen rats received epidural saline control (CON) or bupivacaine 0.5% epidural infusion (EPI) at 15 microl/h for 2 h on day 1 and day 3. Mean arterial blood pressure, heart rate, respiration rate, arterial PCO2, and motor score were recorded at baseline and after 30, 60, 90, and 120 min. Skin temperature was measured at front paws, high-thoracic, mid-thoracic, and low-thoracic, hind paws, and the proximal and distal tail. Changes in sympathetic activity were assessed by skin temperature changes from baseline (DeltaT). In the EPI group, hemodynamics and respiration remained unchanged and only mild motor deficits occurred. DeltaT in thoracic segments was higher in the EPI than in the CON group (P <0.001 at all times at high-thoracic, mid-thoracic, and low-thoracic segments). Skin temperature decreased in the distal tail in the EPI group, e.g., after 90 min DeltaT=-0.86 +/- 0.25 degrees C (EPI) versus 0.4 +/- 0.12 degrees C (CON) (P <0.05 at 60, 90, and 120 min). DeltaT on day 3 was comparable to day 1. TEA induced stable segmental sympathetic block without cardiorespiratory and motor side effects in awake rats. This new technique may be applied in prolonged models of critical illness.

Continuous thoracic epidural anesthesia induces segmental sympathetic block in the awake rat

Freise, H.; Anthonsen, S.; Fischer, L.; Lauer, S.; Daudel, F.; Van Aken, H.; Sielenkaemper, A. Author Information

Free lidocaine concentrations during continuous epidural anesthesia in geriatric patients

Background and Objectives: To evaluate the effects of aging on lidocaine pharmacokinetics, the plasma concentrations of total and free lidocaine and its metabolites were measured during continuous thoracic epidural anesthesia in middle-aged (age 41 ± 9 years, n = 7) and elderly (age 72 ± 2 years, n = 7) male patients. Methods: After establishment of general anesthesia, 7 mL 1.5% lidocaine with epinephrine 1:200,000 was injected into the epidural space and subsequently infused at a rate of 5 mL/h for 5 hours. Plasma concentrations of total and free lidocaine, monoethylglycinexylidide (MEGX), and glycinexylidide (GX) were measured at 10, 15, 20, 30, 45, 60, 90, 120, 150, 180, 240, and 300 minutes after initial lidocaine injection using high-performance liquid chromatography (HPLC) with ultraviolet (UV) detection. Results: The elderly group showed a stronger upward trend in the corrected free lidocaine concentrations and lower corrected total MEGX concentrations than the middle-aged group. Conclusions: Lidocaine metabolite activity in the elderly male patients was lower than that in the middle-aged male patients. Free lidocaine concentration is prone to increase in elderly patients. Caution must be exercised during continuous thoracic epidural anesthesia combined with general anesthesia in geriatric patients. Reg Anesth Pain Med 2003;28:215-220.

Continuous Thoracic Epidural Anesthesia with 0.2% Ropivacaine Versus General Anesthesia for Perioperative Management of Modified Radical Mastectomy

We evaluated in this prospective study the effectiveness of continuous thoracic epidural anesthesia (TEA) and postoperative analgesia with ropivacaine and compared it with general anesthesia (GA) and opioids for pain relief, side effects, postanesthesia recovery, and hospital discharge after modified radical mastectomy. Sixty ASA physical status II and III patients undergoing mastectomy were randomly assigned to two study groups of 30 patients each. In the TEA group, an epidural catheter was inserted at T6-7, and 5--10 mL of 0.2% ropivacaine was injected to maintain anesthesia and to continuously administer adequate analgesia for 48 h. GA was induced with IV 1--2 mg of midazolam or 50--100 microg/mL of fentanyl followed by 50--150 mg of propofol and was maintained with sevoflurane and 50% N(2)O in oxygen. The Aldrete score system was used to evaluate postanesthesia recovery, a verbal rating scale was used for assessment of pain intensity, and a postanesthesia discharge scoring system was used for discharge home. The demographic data and side effects (except for nausea and vomiting) (GA 43%, TEA 10%, P = 0.0074) and discharge home were similar in both groups. However, the number of patients ready for discharge from the recovery room during the first postanesthesia hour (Aldrete score of 10) was significantly larger after TEA (80%) than after GA (33%) (P = 0.0006). GA patients experienced significantly more (P < 0.001) substantial pain than TEA patients on Day 0 (70%), Day 1 (53%), and Day 2 (27%) after the surgery. Patient satisfaction was greater with TEA (70%) than with GA (30%) (P < 0.001). We conclude that TEA with ropivacaine provides better postoperative pain relief and less nausea and vomiting, facilitates postanesthesia recovery, and gives greater patient satisfaction than GA.

Continuous Thoracic Epidural Anesthesia for Breast Augmentation

Thirty consecutive cases were scheduled for submuscular breast augmentation under continuous thoracic epidural anesthesia. The epidural tube was placed into the intervertebral space between the third and fourth thoracic vertebrae. An average of 15 ml of 2% lidocaine with 1:80,000 epinephrine was used as a primary anesthetic agent. There were no significant changes in respiratory function; only a transient elevation of blood pressure and increased heart rate were noted. All cases were successfully anesthetized, except one case (3%) who had a partial analgesic effect and needed to combine general anesthesia. One patient needed a single dose of ephedrine, 20 mg, to treat hypotension. Perioperative complications included transient shivering (33%), stuffy nose (20%), nausea (7%), and shortness of breath (13%). These symptoms were alleviated after reassurance or light sedation and oxygen inhalation. Immediate postoperative pain of the operative site was effectively controlled by injection of local anesthetics through the epidural tube. This study revealed that thoracic epidural anesthesia was feasible, effective, and even better than conventional alternative anesthetic techniques for breast augmentation.

Continuous Thoracic Epidural Anesthesia for Biliary Tract Surgery and for Postoperative Pain Relief in a Patient with Cystic Fibrosis

*Chairman, Department of Anesthesia, Gundersen Clinic, Ltd., La Crosse, Wisconsin, and Assistant Clinical Professor of Anesthesiology, University of Wisconsin Medical School, Madison, Wisconsin. The Department of Anesthesiology, Gundersen Clinic, Ltd., La Crosse, Wisconsin. Reprint requests to Dr. Kang, Gundersen Clinic, Ltd., 1836 South Ave, La Crosse, WI 54601. Accepted for publication May 5, 1982.