Epidural Analgesia In Patients Research Articles

Positive effect on survival of epidural analgesia in patients undergoing cytoreductive surgery for peritoneal metastasis.

e15064 Background: Potential benefits of regional analgesia in reduction of cancer recurrence have been reported for colon and ovarian cancer. The aim of this study was to evaluate the influence of regional analgesia with patient controlled epidural analgesia (PCEA) on disease-free survival (DFS) and overall survival (OS) in patients with peritoneal metastasis (PM) of various origins operated to achieve cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Methods: From 2006 to 2015, 734 patients were operate on curative purpose to undergone CRS and HIPEC for PM. Three hundred patients for which details on PCEA were available were included in the present study. Aiming to obtain two well-balanced cohorts for available variables influencing early outcome and survival, the PCEA group was matched 1:1 with the non PCEA group by using a propensity score-based method. Results: Matching criteria included demographic characteristics, ASA score, origin of PM, presence of liver metastasis, Peritoneal Carcinomatosis Index (PCI) and complete resection. The median duration of follow-up was 18 months. In the matched cohort (PCEA: 68, non-PCEA: 68), early outcomes were comparable between the two group in terms of blood lost (200 vs 200 ml), transfusion (15 vs 18%), length of surgery (440 vs 450 min) and of hospitalization (12 vs 13 days) and major morbidity (25 vs 22%). After PS-matching, the PCEA group had better OS comparing non-PCEA (Hazard ratio and 95% confidence interval at 0.41 [0.21 – 0.86]). Improvement of DFS rate in PCEA group was observed only in the original sample but not after PS-matching (HR 95%CI: 0.70 [0.45 – 1.07]). Conclusions: In our study, regional analgesia is associated with improved overall survival and transient effect on disease-free survival in patients with peritoneal metastasis of various origins.

Benefits of Thoracic Epidural Analgesia in Patients Undergoing an Open Posterior Component Separation for Abdominal Herniorrhaphy

ABSTRACTAn open posterior component separation (PCS) is a commonly utilized surgical approach for repair of complex abdominal wall defects and hernias. Although this approach may improve surgical outcomes, significant postoperative pain can be expected given the required laparotomy and extensive abdominal wall manipulation. Both systemic opioids and thoracic epidural analgesia (TEA) are viable postoperative analgesic options, and both are commonly utilized. Although the benefits of TEA have been investigated following a variety of surgeries, there is a paucity of literature related to its efficacy for this particular surgery. The aim of this study was to evaluate the benefits of TEA following open PCS under the hypothesis that the incorporation of TEA into the postoperative analgesic regimen would hasten bowel recovery. Patients who previously underwent an open PCS were identified through an electronic medical record query. A retrospective chart review was then performed, and patients who had TEA, either alone or combined with systemic opioids, were compared with patients who had only systemic opioids. The primary end point was a comparison of the postoperative day (POD) on which a full diet was started. Secondarily, time to liquid diet, postsurgical length of stay (LOS), intensive care unit (ICU) admission rate, ICU LOS, and the rates of several postoperative adverse events were compared. A post hoc analysis was also performed, using the same end points, to compare the subgroup of TEA patients who avoided systemic opioids with all patients who received systemic opioids, whether alone or combined with TEA. One hundred and one patients were ultimately included for analysis. Time to full diet was not significantly different between patients who had TEA, either with or without systemic opioids, and those who received only systemic opioids (TEA 2.6 ± 1.7 vs. systemic opioids 3.1 ± 2.1 [mean POD ± SD], P = .21). Additionally, no statistically significant differences were found for any secondary outcome. In the post hoc analysis, the subgroup of TEA patients who avoided systemic opioids had a significantly faster time to bowel recovery when compared with all patients who received systemic opioids (2.2 ± 1.0 vs. 3.2 ± 2.2, P = .0033). This subgroup also had a significantly shorter time to liquid diet and a decreased postoperative LOS. In conclusion, for patients undergoing an open PCS, the inclusion of TEA in the postoperative analgesic regimen did not by itself hasten the return of bowel function. However, when TEA was utilized and systemic opioids were avoided, bowel recovery occurred significantly sooner and resulted in a shortened hospital LOS.

Thoracic epidural analgesia reduces myocardial injury in ischemic patients undergoing major abdominal cancer surgery.

Background and objectivesMajor abdominal cancer surgeries are associated with significant perioperative mortality and morbidity due to myocardial ischemia and infarction. This study examined the effect of perioperative patient controlled epidural analgesia (PCEA) on occurrence of ischemic cardiac injury in ischemic patients undergoing major abdominal cancer surgery.Patients and methodsOne hundred and twenty patients (American Society of Anesthesiologists grade II and III) of either sex were scheduled for elective upper gastrointestinal cancer surgeries. Patients were allocated randomly into two groups (60 patients each) to receive, besides general anesthesia: continuous intra and postoperative intravenous (IV) infusion with fentanyl for 72 h postoperatively (patient controlled intravenous analgesia [PCIA] group) or continuous intra and postoperative epidural infusion with bupivacaine 0.125% and fentanyl (PCEA group) for 72 h postoperatively. Perioperative hemodynamics were recorded. Postoperative pain was assessed over 72 h using visual analog scale (VAS). All patients were screened for occurrence of myocardial injury (MI) by electrocardiography, echocardiography, and cardiac troponin I serum level. Other postoperative complications as arrhythmia, deep venous thrombosis (DVT), pulmonary embolism, pneumonia, and death were recorded.ResultsThere was a significant reduction in overall adverse cardiac events (myocardial injury, arrhythmias, angina, heart failure and nonfatal cardiac arrest) in PCEA group in comparison to PCIA group. Also, there was a significant reduction in dynamic VAS pain score in group PCEA in comparison to PCIA at all measured time points. Regarding perioperative hemodynamics, there was a significant reduction in intra-operative mean arterial pressure (MAP); and heart rate in PCEA group in comparison to PCIA group at most of measured time points while there was not a significant reduction in postoperative MAP and heart rate in the second and third postoperative days. The incidence of other postoperative complications such as DVT, pneumonia and in hospital mortality were decreased in PCEA group.ConclusionPerioperative thoracic epidural analgesia in patients suffering from coronary artery disease subjected to major abdominal cancer surgery reduced significantly postoperative major adverse cardiac events with better pain control in comparison with perioperative IV analgesia.

Comparison of Three Different Concentrations 0.2%, 0.5%, and 0.75% Epidural Ropivacaine for Postoperative Analgesia in Lower Limb Orthopedic Surgery.

Introduction:Ropivacaine has been studied previously and holds promise as an agent that offers a safe, efficacious, and better recovery profile than other conventional agents such as bupivacaine. The aim of the present study was to compare the safety and efficacy of equal volume of different concentration of ropivacaine for epidural analgesia in patients undergoing major lower limb orthopedic surgery.Subjects and Methods:One hundred and fifty adult patients were randomized into three groups to receive single dose of equal volume of ropivacaine through epidural route in concentrations of 0.2%, 0.5%, and 0.75%, respectively. All the groups received equal dose of ropivacaine of same concentration for subarachnoid block using combined spinal-epidural technique.Results:Modified Bromage Scale and Numeric rating scale was used to assess motor block and analgesia. Data analysis was done using WINDOW SPSS Student Version 17 ANOVA test. Student's t-test was performed for comparison between two groups, and qualitative data were analyzed by applying Chi-square test.Conclusion:0.5% and 0.75% ropivacaine were sufficient and effective for intrathecal subarachnoid block as well as for postoperative analgesia with epidural use. Shorter duration of motor blockade and analgesia was seen with ropivacaine 0.2%.

Improved Outcomes Associated with the Liberal Use of Thoracic Epidural Analgesia in Patients with Rib Fractures.

Each year, more than 150,000 patients with rib fractures are admitted to US trauma centers; as many as 10% die. Effective pain control is critical to survival. One way to manage pain is thoracic epidural analgesia. If this treatment reduces mortality, more frequent use may be indicated. We analyzed the patient registry of a level II trauma center. All patients admitted with one or more rib fractures (N = 1,347) were considered. Patients who were not candidates for epidural analgesia (N = 382) were eliminated. Mortality was assessed with binary logistic regressions. Across the total population, mortality was 6.7%; incidence of pneumonia was 11.1%; mechanical ventilation was required in 23.8% of patients, for an average duration of 10.0 days; average stay in the hospital was 7.7 nights; and 49.7% of patients were admitted to the ICU for an average of 7.2 nights. Epidural analgesia was administered to 18.4% of patients. After matching samples for candidacy, patients who received epidurals were 3.7 years older, fractured 2.6 more ribs, had higher injury severity scores, and were more likely to present with bilateral fractures, flail segments, pulmonary contusions, hemothoraces, and pneumothoraces. Despite greater injury severity, mortality among these patients was lower (0.5%) than those who received alternative care (1.9%). Controlling for age, injury severity, and use of mechanical ventilation, epidural analgesia predicted a 97% reduction in mortality. Thoracic epidural analgesia associates with reduced mortality in rib fracture patients. Better care of this population is likely to be facilitated by more frequent reliance on this treatment.

Epidural Hematoma and Abscess Related to Thoracic Epidural Analgesia: A Single-Center Study of 2,907 Patients Who Underwent Lung Surgery

To report the major complications (epidural hematoma and abscess) of postoperative thoracic epidural analgesia in patients who underwent lung surgery. Prospective, monocentric study. A university hospital. All lung surgical patients who received postoperative thoracic epidural analgesia between November 2007 and November 2015. Thoracic epidural analgesia for patients who underwent lung surgery. During the study period, data for 2,907 patients were recorded. The following 3 major complications were encountered: 1 case of epidural hematoma (0.34 case/1,000; 95% confidence interval 0.061-1.946), for which surgery was performed, and 2 cases of epidural abscesses (0.68 case/1,000; 95% confidence interval 0.189-2.505), which were treated medically. The risk range of serious complications was moderate; only the patient who experienced an epidural hematoma also experienced permanent sequelae.

Warming before and after epidural block before general anaesthesia for major abdominal surgery prevents perioperative hypothermia: A randomised controlled trial.

Epidural analgesia (EDA) is known to be an independent risk factor for perioperative hypothermia and its many known adverse effects. Combined general and epidural anaesthesia decreases intraoperative core temperature more rapidly than general anaesthesia alone. Hence, adequate warming procedures are needed for these patients. We evaluated the effects of active skin-surface warming before and/or after initiation of EDA during general anaesthesia as a procedure to prevent perioperative hypothermia. A randomised controlled trial. Department of Anaesthesiology in a general hospital in Germany from January 2013 until August 2014. After obtaining written informed consent, we included 99 adult patients undergoing elective major abdominal surgery under combined general anaesthesia and EDA with an expected duration of surgery of at least 120 min. Patients were excluded if they were under 18 years of age, classified as American Society of Anesthesiologists' physical status 4 or higher or if patients refused EDA. Patients were randomly assigned to one of three groups and received either only passive insulation, 15 min of active air-forced warming after EDA and before induction of general anaesthesia, or two periods, each of 15 min, of active air-forced warming before and after EDA. Core and skin temperatures were measured at several time points throughout the study. The primary outcome measure was the incidence of hypothermia on arrival in the ICU. The secondary outcome measure was the incidence of postoperative shivering. In addition, the perioperative change in body core temperature was recorded. Without prewarming (n = 32), 72% of patients became hypothermic (<36°C) at the end of anaesthesia. Fifteen minutes of warming after insertion of the epidural catheter and before initiation of general anaesthesia reduced the incidence of postoperative hypothermia to 6% (n = 33). After two periods of 15 min of warming before and after insertion of the epidural catheter, no patient became hypothermic (n = 34). Prewarming in either 'warming' group prevents the initial temperature drop which was observed in the control group. Warming for 15 min before and after initiation of EDA in patients receiving combined anaesthesia is effective in preventing postoperative hypothermia. This trial was registered with ClinicalTrials.gov (identifier: NCT01795482).

Randomized controlled trial of peri-operative nerve block and continuous local anesthetic infiltration via wound catheter versus epidural analgesia in patients undergoing open liver resection

Randomized controlled trial of peri-operative nerve block and continuous local anesthetic infiltration via wound catheter versus epidural analgesia in patients undergoing open liver resection

Intraoperative haemodynamic stability and stress response to surgery in patients undergoing thoracotomy: comparison between ultrasound-assisted thoracic paravertebral and epidural block

Objectives and aim Thoracotomy is a procedure usually associated with severe postoperative pain. This study aimed to evaluate intraoperative haemodynamics and stress response to thoracotomy in patients receiving thoracic epidural or thoracic paravertebral block. Patients and methods Sixty patients undergoing elective thoracotomy were randomly allocated into two equal groups: the thoracic paravertebral analgesia (TPVA) group, which received ultrasound-assisted thoracic paravertebral catheter, and the thoracic epidural analgesia (TEA) group, which received ultrasound-assisted thoracic epidural catheter. The primary outcome was the measuring of stress response to surgery using plasma cortisol level. The secondary outcomes included intraoperative haemodynamic parameters, visual analogue pain score and postoperative complications. Results Heart rate showed significantly lower values in the TEA group compared with the TPVA group. The mean arterial blood pressure showed significantly lower values in the TEA group compared with the TPVA group. In both groups, there was a significant increase in plasma cortisol level after surgical stress compared with basal values. Moreover, there were significantly lower values in the TPVA group compared with the TEA group at 2 h after surgical incision, 2 h postoperatively and 24 h postoperatively. Visual analogue pain score was noncomparable in both groups at all measurement timepoints. As regards complications, group TPVA had less complications compared with group TEA. Conclusion Thoracic paravertebral block is an effective analgesic technique showing greater haemodynamic stability and less stress response to surgery compared with epidural analgesia in patients undergoing thoracotomy.

A comparative study on adding Dexmedetomidine versus Clonidine to epidural 0.125% Bupivacaine for postoperative analgesia in patients undergoing upper abdominal surgeries

Background: The pain experienced after upper abdominal surgery leads to a reduction in 70-75% of vital capacity which leads to postoperative pulmonary complications. The ideal adjuvant for epidural analgesia in patients undergoing upper abdominal surgery seems to be every effective for better outcome and early immobilization in the immediate postoperative period. With this background we planned to conduct a study on epidural analgesia by comparing two alpha 2 agonists. Methods: 50 patients who have planned for elective upper abdominal surgery under general anaesthesia were enrolled in our study. Before induction of general anaesthesia, epidural catheterization was done. The surgical procedure was carried out under routine general anaesthesia with endotracheal controlled ventilation. The patients were given either Dexmedetomidine or Clonidine in the dosage of 2mcg/Kg with 0.125% Bupivacaine via epidural catheter after extubation. Patients were shifted to Post Anaesthesia Care Unit for observation. Sedation and pain were assessed with monitoring of vital parameters. The side effects were also noted. Results: Statistical analysis showed that the duration of analgesia was prolonged in the patients who received Dexmedetomidine as an adjuvant with local anaesthetic agent (417.32±67.36 minutes, p value < 0.05). The time to first rescue analgesia was comparatively delayed in Dexmedetomidine group while comparing with Clonidine group (425.6±64.27 minutes, p value < 0.05). The incidence of hypotension and bradycardia was greater in Clonidine group. There was no significant statistical difference with respect to side effects in both groups. Conclusion: From our study we concluded that Dexmedetomidine provides both analgesia and sedation with better hemodynamic status while compared to Clonidine used as adjuvants in epidural analgesia. But needs further study to optimize the dosage of these two adjuvants while giving via epidural route along with local an

Pre-incisional epidural magnesium provides pre-emptive and postoperative analgesia in lower abdominal surgeries: a comparative study

Background: Magnesium sulphate has been used successfully as a non opioid analgesic adjuvant for postoperative pain management. This prospective controlled study was designed to evaluate the pre-emptive analgesic efficacy of adding magnesium to epidural analgesia in patients undergoing lower abdominal surgeries.Methodology: In a randomized, double- blind study sixty patients undergoing lower abdominal surgery under general anesthesia were assigned to three groups. Pre-magnesium (Group PI), post-magnesium (Group PO) and control (Group C) group. Anesthetic technique was standardized. Patients in pre-magnesium group received bolus of magnesium 50 mg via epidural before induction of anaesthesia followed by boluses of 10 mg h-1 until end of surgery. Post-magnesium group patients received epidural saline during the same time periods plus bolus epidural magnesium 50 mg at the end of surgery. Patients in control group received epidural saline during all three periods. Patients in the magnesium groups received bolus epidural analgesia with Fentanyl 8mcg, Bupivacaine 0.1%, and Magnesium 8mg in a volume of 8 ml after operation, when patient complained of pain and VAS score was more than 4. Patients in the control group received epidural analgesia with Fentanyl 8 mcg and Bupivacaine 0.1% in a volume of 8ml. Blood Pressure, pulse rate, respiratory rate, time to the first request for analgesic, visual analogue scale at rest, 24 hour, opioids consumption and side effect profiles were studied for 24 hours postoperatively.Results: The demographic parameters were comparable. Group PI had significantly lower VAS scores at all times 0,2,4,6,10,14,18 and 24 hours than those in the Group PO or Group C(P&lt;0.05). The groups were similar with respect to haemodynamic, respiratory variables and side effects.Conclusion: Epidural Magnesium sulphate provided preemptive analgesia, and an a analgesic-sparing effect that improved postoperative analgesia without increasing the incidence of side-effects.Journal of Society of Anesthesiologists 2014 1(1): 22-28

A nationwide analysis of the use and outcomes of perioperative epidural analgesia in patients undergoing hepatic and pancreatic surgery

BackgroundWe sought to define trends in the use of epidural analgesia (EA) for hepatopancreatic procedures, as well as to characterize inpatient outcomes relative to the use of EA. MethodsThe Nationwide Inpatient Sample database was queried to identify all elective hepatopancreatic surgeries between 2000 and 2012. In-hospital outcomes were compared among patients receiving EA vs conventional analgesia using propensity matching. ResultsEA utilization was 7.4% (n = 3,961). The use of EA among minimally invasive procedures increased from 3.8% in 2000 to 9.1% in 2012. The odds of sepsis (odds ratio [OR] .72, 95% confidence interval [CI] .56 to .93), respiratory failure (OR .79, 95% CI .69 to .91), and postoperative pneumonia (OR .77, 95% CI .61 to .98), as well as overall in-hospital mortality (OR .72, 95% CI .56 to .93) were lower in the EA cohort (all P < .05). In contrast, no association was noted between EA and postoperative hemorrhage (OR .81, 95% CI .65 to 1.01, P = .06). ConclusionsEA use among patients undergoing hepatopancreatic procedures remains low. After controlling for confounding factors, EA remained associated with a reduction in specific pulmonary-related complications, as well as in-hospital mortality.

Improved peri-operative outcomes with epidural analgesia in patients undergoing a pancreatectomy: a nationwide analysis

BackgroundIn spite of limited evidence demonstrating a benefit, epidural analgesia (EA) is often used for patients undergoing a pancreatectomy. In the present study, the impact of epidural analgesia on post-operative outcomes after a pancreatectomy is examined. MethodsUtilizing the Nationwide Inpatient Sample, the effect of EA on peri-operative outcomes after a pancreatectomy was examined. Multivariable logistic and linear regression with propensity score matching were utilized for risk adjustment. ResultsFrom 2008–2011, 12 440 patients underwent a pancreatectomy. Of these, 1130 (9.1%) patients received epidural analgesia. Using univariate comparison, patients receiving EA had a significantly decreased length of stay (LOS), hospital charges and post-operative inpatient mortality. In multivariate analyses, EA was independently associated with a decreased post-operative LOS (adjusted mean difference = −1.19 days, P < 0.001), decreased hospital charges (adjusted mean difference = −$16 814, P = 0.002) and decreased post-operative inpatient mortality [adjusted odds ratio (OR) = 0.42, P < 0.001]. Using 1:1 propensity score matching, patients who received an EA (n = 1070) had significantly decreased post-operative LOS (11.0 versus 12.1 days, P = 0.011), lower hospital charges ($112 086 versus $128 939, P = 0.001) and decreased post-operative inpatient mortality (1.5% versus 3.6%, P = 0.002) compared with matched controls without EA (n = 1070). ConclusionAnalysis of a large hospital database reveals that EA is associated with improved peri-operative outcomes after a pancreatectomy. Additional studies are required to understand fully if this relationship is causal.

Epidural analgesia in patients with traumatic rib fractures: a systematic review of randomised controlled trials.

Traumatic rib fractures are a common condition associated with considerable morbidity and mortality. Observational studies have suggested improved outcome in patients receiving continuous epidural analgesia (CEA). The aim of the present systematic review of randomised controlled trials (RCTs) was to assess the benefit and harm of CEA compared with other analgesic interventions in patients with traumatic rib fractures. We performed a systematic review with meta-analysis and trial sequential analysis (TSA). Eligible trials were RCTs comparing CEA with other analgesic interventions in patients with traumatic rib fractures. Cumulative relative risks (RRs) and mean differences (MDs) with 95% confidence intervals (CIs) were estimated, and risk of systematic and random errors was assessed. The predefined primary outcome measures were mortality, pneumonia and duration of mechanical ventilation. A total of six trials (n = 223) were included; all were judged as having a high risk of bias. In the conventional meta-analyses, there was no statistically significant difference in mortality (RR 2.18, 95% CI 0.21-22.42; P = 0.51; I(2) = 0%), duration of mechanical ventilation (MD -7.53, 95% CI -16.32 to 1.26; P = 0.09; I(2) = 91%) or pneumonia (RR 0.49, 95% CI 0.19-1.25; P = 0.13; I(2) = 0%) between CEA and other analgesic interventions. Subgroup analyses and sensitivity analyses, including TSA confirmed the results. The quality and quantity of evidence for the use of CEA in patients with traumatic rib fractures is low, and there is no firm evidence for benefit or harm of CEA compared with other analgesic interventions. Well-powered RCTs with low risk of bias reporting clinically relevant patient-centred outcome measures are needed.

Оценка эффективности эпидуральной анальгезии у больных после геморроидэктомии в зависимости от направления эпидурального катетера

Оценка эффективности эпидуральной анальгезии у больных после геморроидэктомии в зависимости от направления эпидурального катетера

Оценка эффективности эпидуральной анальгезии у больных после геморроидэктомии в зависимости от направления эпидурального катетера

Оценка эффективности эпидуральной анальгезии у больных после геморроидэктомии в зависимости от направления эпидурального катетера

Coagulation profile changes and safety of epidural analgesia after hepatectomy: a retrospective study.

We aimed to review post-hepatectomy coagulation profile changes, to assess outcomes of epidural catheter placement in post-hepatectomy patients, and to make justifications regarding use of epidural analgesia in patients undergoing hepatectomy. We performed a retrospective study of 141 patients undergoing liver resection at Brigham and Women's Hospital between January 1, 2007 and December 31, 2011. All patients were between 21 and 85 years old, with ASA physical status classification of II or III, and Child-Pugh scores ≤6. Patients undergoing laparoscopy or resection of less than three hepatic segments were excluded. We examined pre-operative hematocrit, platelet count, coagulation studies, and liver function tests, and trended values for 7 post-operative days. We examined frequency of epidural placement, use of peri-operative anticoagulation, and incidence of epidural-related complications. We demonstrated statistically significant decreases in hematocrit and platelet counts, as well as statistically significant increases in prothrombin time and international normalized ratio (INR) values. Thirty-two percent of patients required vitamin K or fresh frozen plasma to achieve an INR ≤1.3. No patient required platelet transfusion to achieve platelets ≥100,000 prior to catheter removal. Changes in post-operative partial thromboplastin time were not significant. Epidural catheters were placed in 90% of liver resections performed at our institution. We noted no epidural hematomas, even in the 7% of patients in whom the epidural catheter was inadvertently removed before coagulation criteria were met. The latter group was monitored with hourly neurologic exams for 24 h. Epidural analgesia may be safely used in patients undergoing major hepatic resection, providing that they have normal pre-operative coagulation and catheters are removed only when resection-induced perioperative coagulopathy has resolved or has been corrected.

Epidurals in patients receiving thromboprophylaxis with unfractionated heparin three times a day: the value of activated partial thromboplastin time testing.

Dosing subcutaneous (SC) unfractionated heparin (UFH) 3 times a day (TID) for deep venous thrombosis prophylaxis is used for patients in the United States undergoing nonorthopedic surgery. There is a lack of data on the risks of neuraxial techniques in patients receiving TID SC UFH; however, concerns have been raised about higher bleeding risks. In this prospective study, we evaluated the value of activated partial thromboplastin time (aPTT) testing at the time of removal of epidural catheters as a risk-reduction strategy for this population. We collected data from our electronic hospital databases for all patients receiving epidural analgesia in conjunction with 5000 units TID or twice daily dosing (BID) SC UFH from December 2011 to December 2013. Our cohort received aPTT testing before removal of the catheter in all patients receiving TID SC UFH. An aPTT was ordered for patients receiving BID SC UFH only if risk factors for abnormal coagulation variables were identified. Chart reviews were performed on all patients with abnormal aPTT values to evaluate contributing risk factors. Over a 2-year period, 3523 epidurals were placed at our institution, including 714 (20.3%) for patients receiving TID SC UFH, and 1594 (45.2%) for patients receiving BID SC UFH. Of those patients receiving BID SC UFH, 186 (11.7%) had aPTT values drawn on the basis of risk factors. Ten (5.4 %, 95% CI: 2.6%-9.7%) of those patients had an aPTT value of greater than 35 seconds on the date of epidural removal. Of those patients receiving TID SC UFH, 20 (2.8%, 95% CI: 1.7%-4.3%) had an initial aPTT value of more than 35 seconds on the date of epidural removal. All patients who had abnormal aPTT values on TID heparin dosing were identified as having obvious concomitant risk factors for coagulation parameter abnormalities. There were no epidural hematomas in patients receiving either BID or TID dosing (95% CI: 0%-0.001%). The routine use of aPTT testing on patients receiving TID SC UFH at the time of removal of epidural catheters as a risk-reduction strategy is not supported by our results, where only 2.8% (95% CI: 1.7%-4.3%) of these patients had abnormal aPTT values. Our study adds to the limited data currently available on the safety of epidural analgesia in patients receiving TID SC UFH. Given the rare incidence of neuraxial hematoma (95% CI: 0%-0.001%), definitive conclusions on the risks of TID SC UFH administration in patients receiving epidural analgesia cannot be drawn based on our sample size.

Perioperative Cardiac Morbidity in Elderly Patients with Epidural versus Systemic Analgesia for Hip Fracture Surgery

Abstract Introduction. Patients with hip fracture are usually older patients. Uncontrolled acute pain and surgical stress in elderly patients may cause increased cardiac morbidity and mortality. Epidural analgesia blocks sympathetic nervous system and reduces the incidence of myocardial ischemia and dysrhythmias as well as the response to stress. Methods. Sixty patients with hip fracture older than 65 years with previously defined high peroperative cardiac risk according to ACC/AHA guidelines were included and were randomly assigned to two groups of 30 patients: SA group-patients with systemic analgesia. niflam 2 × 100 mg/iv and tramadol 1 mg/kg/iv every 8 hours; and EDC group-patients with a continuous epidural analgesia with bupivacaine 0.125%-5 ml/h and fentanyl 3 µg/ml. As end points of the study the incidence of cardiac events in both groups were registered: cardiac death, myocardial infarction, congestive heart failure, unstable angina and new-onset atrial fibrillation. Laboratory parameters and pain intensity were determined in all patients by using Verbal Descriptive Scale. Side effects were also monitored. Results. The epidural analgesia decreased the incidence of peroperative cardiac events in patients with high per-operative cardiac risk for hip fracture surgery (46.6% in SA group vs. 15% in EDC group) and at the same time decreased cardiac mortality (10% in SA group vs. 0% in EDC group). The values of VDS were significantly lower in patients with EDC block versus patients with systemic analgesia in all experimental times and there was a smaller number of side effects. Conclusion. Early administration of continuous epidural analgesia in patients with high peroperative risk with hip fracture decreases the incidence of cardiac morbidity and mortality and provides superior pre- and post-operative analgesia compared to systemic analgesia with minimal side effects.

Comparison of analgesic efficacy of four‐quadrant transversus abdominis plane (TAP) block and continuous posterior TAP analgesia with epidural analgesia in patients undergoing laparoscopic colorectal surgery: an open‐label, randomised, non‐inferiority trial

Posterior transversus abdominis plane blocks have been reported to be an effective method of providing analgesia after lower abdominal surgery. We compared the efficacy of a novel technique of providing continuous transversus abdominis plane analgesia with epidural analgesia in patients on an enhanced recovery programme following laparoscopic colorectal surgery. A non-inferiority comparison was used. Adult patients undergoing elective laparoscopic colorectal surgery were randomly assigned to receive continuous transversus abdominis plane analgesia (n = 35) vs epidural analgesia (n = 35), in addition to a postoperative analgesic regimen comprising regular paracetamol, regular diclofenac and tramadol as required. Sixty-one patients completed the study. The transversus group received four-quadrant transversus abdominis plane blocks and bilateral posterior transversus abdominis plane catheters that were infused with levobupivacaine 0.25% for 48 h. The epidural group received an infusion of bupivacaine and fentanyl. The primary outcome measure was visual analogue scale pain score on coughing at 24 h after surgery. We found no significant difference in median (IQR [range]) visual analogue scores during coughing at 24 h between the transversus group 2.5 (1.0-3.0 [0-5.5]) and the epidural group 2.5 (1.0-5.0 [0-6.0]). The one-sided 97.5% CI was a 0.0 (∞-1.0) difference in means, establishing non-inferiority. There were no significant differences between the groups for tramadol consumption. Success rate was 28/30 (93%) in the transversus group vs 27/31 (87%) in the epidural group. Continuous transversus abdominis plane infusion was non-inferior to epidural infusion in providing analgesia after laparoscopic colorectal surgery.