Epidural Group Research Articles

Spinal analgesia for severe cancer pain: A retrospective analysis of 60 patients

Background and aimsPain is highly prevalent in advanced cancer, and in some patients refractory to conventional opioid treatment. For these patients, invasive methods of pain relief should be considered. Spinal administration of opioids has been shown to be an effective alternative in refractory cancer pain. The aim of this retrospective study was to collect information on the use of spinal analgesia for cancer pain in Helsinki University Hospital. MethodsA retrospective patient chart study of all cancer patients with spinal analgesia, either intrathecal or epidural, in a single academic center during a five year period (n=60). ResultsForty-four patients were treated with intrathecal (IT) and sixteen with epidural (EP) technique. The most common indication for spinal analgesia was pain refractory to systemic analgesics. Good analgesia was achieved in 50% and 70% of the patients in the EP and IT groups, respectively. The median daily systemic opioid doses prior to spinal analgesia were 874.5mg and 730.5mg as oral morphine equivalents in the IT and EP groups, respectively. The systemic opioid could be discontinued or significantly reduced in 83% of the patients. Morphine was used in all IT infusions and most EP infusions, mostly combined with bupivacaine 10mg (IT) or 66mg (EP). The median starting doses of morphine were 3mg/day (IT) and 19mg/day (EP) and were increased during titration 27% to 3.8mg/day (IT) and 91% to 36.2mg/day (EP). Clonidine (median 0.015mg/day IT and 0.15mg/day EP) and/or ketamine were used as adjuvants. The average titration time to stable analgesia was 7–9 days. Numbness in lower limbs was reported by 24% of the IT group. On average, catheters were placed 98 and 61 days before death in IT and EP groups, respectively. No serious complications occurred. Catheter dislocation occurred in 27% of all sixty patients during follow-up. Treatment was discontinued in 10 patients because of catheter dislocation (n=7) or local infection (n=3). Conclusions and implicationsSpinal administration of opioids is a safe and effective method of pain management in patients with severe cancer pain and can greatly reduce the need of systemic opioids. We are implementing closer collaboration with oncologists to provide spinal analgesia to more patients and earlier to reduce suffering. Catheter dislocation led to discontinuation of spinal analgesia in 17% of the patients and we are evaluating new ways to prevent catheter dislocation. The initial median spinal opioid dose was too low in both groups, and we are now using higher initial doses. A common adverse effect was numbness of the lower limbs, regardless of the relatively low doses of spinal bupivacaine. We now use lower doses and introduce the intrathecal catheter higher at L1–2 to reduce motor blockade at the level of conus.As an initial intrathecal infusions we suggest: morphine dose calculated using an oral to intrathecal ratio of 1:100 (unless the patient is elderly or already drowsy), clonidine dose 30μg/day and bupivacaine dose 7.5mg/day.

Patient-Controlled Analgesia (PCA) with Remifentanil Versus Intermittent Epidural Boluses for Labor Analgesia

Abstract Introduction. Remifentanil is becoming more and more popular for labor analgesia as an alternative for neuro-axial anesthesia. In this study we compared the severity of pain, patient satisfaction and side effects between two different types of labor analgesia. Methods. Eightyprimiparous patients ASA I or II, atterm pregnancy, were included in the study and divided in two groups. The first group (35 patients) received intravenous remifentanil on patient control pump in bolus doses. The second group (45 patients) received intermittent epidural boluses with highly diluted local anesthetic and opioid (Bupivacain and Fentanil). We analyzed oxygen saturation (SpO2), respiration rate, heart rate, blood pressure, sedation, nausea and vomiting as well as patient pain scores and satisfaction scores through 2 different VAS. Results. Mean SpO2 was significantly lower in the PCA remifentanil group 96.2%±1.6 versus 98.2±1.2 in the epidural group. Respiratory depression (RR<9 or SpO2 <90%) was not found in both groups. Sedation scores were significantly higher in the PCA remifentanil group, P<0.05. Incidence of nausea and vomiting was similar between the two groups, without significant difference. PCA remifentanil was inferior to epidural analgesia with respect to pain scores at all time points, but without significant difference in patient satisfaction between the two groups. Conclusion. Intravenous patient-controlled analgesia with remifentanil provides satisfactory level of labor analgesia, with lower SpO2 and more sedation. It could be an excellent alternative to epidural analgesia but continuous monitoring and oxygen supply is mandatory.

Spinal analgesia improves surgical outcome after open nephrectomy for renal cell carcinoma: a randomized controlled study

Objective: This study evaluated whether more effective perioperative analgesia can be part of a multimodal approach to minimizing morbidity and improving postoperative management after the open surgical approaches frequently used in the treatment of renal cell carcinoma (RCC). The aim of the study was to determine whether spinal anesthesia with clonidine can enhance postoperative analgesia, speed up mobilization and reduce the length of hospital stay (LOS).Materials and methods: Between 2012 and 2015, 135 patients with RCC were randomized, in addition to general anesthesia, to receive either spinal analgesia with clonidine or epidural analgesia, stratified to surgical technique. Inclusion criteria were American Society of Anesthesiologists (ASA) score of III or less, age over 18 years and no chronic pain medication or cognitive disorders.Results: The median LOS was 4 days for patients in the spinal group and 6 days in the epidural group (p = 0.001). There were no differences regarding duration of surgery, blood loss, RENAL score, tumor size or complications between the given analgesia methods. A limitation was that different anesthesiologists were responsible for administering spinal or epidural anesthesia, as in a real-world clinical situation.Conclusions: In this randomized controlled study, spinal analgesia with clonidine was superior to continuous epidural analgesia in patients operated on with open nephrectomy, based on shorter LOS. A shorter LOS in the study group indicates faster mobilization and improved analgesia. Spinal analgesia did not carry more complications than epidural analgesia.

Effect of wire-reinforced polyurethane epidural catheters on success rate of epidural catheterization in patients undergoing caesarean section

Objective To evaluate the effect of wire-reinforced polyurethane epidural catheters on the success rate of epidural catheterization in the patients undergoing caesarean section. Methods A total of 182 pregnant patients, aged 25-43 yr, with body height of 145-178 cm, weighing 51-100 kg, of American Society of Anesthesiologists physical status Ⅰor Ⅱ, scheduled for elective caesarean section under combined spinal-epidural anesthesia, were divided into 2 groups using a random number table: polyvinyl chloride epidural catheter group(group Ⅰ, n=94)and wire-reinforced polyurethane epidural catheter group(group Ⅱ, n=88). Spinal or epidural puncture was performed at L2, 3 or L3, 4 interspace, and the corresponding epidural catheter was inserted in each group after successful puncture.The development of difficult insertion, intravascular catheter insertion or paresthesia during puncture or insertion was defined as a failure of epidural catheterization.The occurrence of failed epidural catheterization was recorded. Results The failure rate of epidural catheterization was significantly lower in group Ⅱ than in group Ⅰ(P<0.05). Conclusion Wire-reinforced polyurethane epidural catheters can raise the success rate of epidural catheterization in the patients undergoing caesarean section. Key words: Catheterization; Epidural Space; Cesarean section

Comparative Analysis of Different Methods of Pain Management for Elderly Patients in the Surgical Intensive Care Unit

Summary Background With technological advancements, more elderly patients are undergoing surgery and require care from surgical intensive care units. We aimed to determine the pain management method that provides better acute pain control in all-cause elderly surgical intensive care unit patients. Methods This retrospective cohort study included a chart review of patients treated in a 26-bed surgical intensive care unit from April 2011 through September 2012. The patient exclusion criteria were as follows: unconscious, uncooperative, Results We evaluated 580 patients. The average age was 76 years, and 57% were male. At rest, the patient-controlled epidural analgesia group exhibited significantly lower pain scores (12.06 ± 9.53) compared with the other two groups. During movement, the patient-controlled epidural analgesia and pethidine/nonsteroidal anti-inflammatory drugs groups showed no difference; both exhibited lower pain scores than the patient-controlled analgesia group (41.38 ± 12.5). While coughing, the pethidine/nonsteroidal anti-inflammatory drugs group exhibited lower scores (39.67 ± 24.50) than the patient-controlled epidural analgesia and patient-controlled analgesia groups. The patient-controlled epidural analgesia group showed highest patient satisfaction (4.27 ± 0.51). Stepwise multiple linear regression analysis revealed that patient satisfaction was associated with patient-controlled epidural analgesia (positively) and T-piece trial (negatively). Conclusion Patient-controlled epidural analgesia appears to be a better choice for acute pain management for all-cause elderly surgical intensive care unit patients.

Early Post operative Pain Management and Early Extubation after Off-pump Coronary Artery Bypass Graft Surgery is better managed with Thoracic Epidural Analgesia

Background: Off-pump coronary artery bypass (OPCAB) graft surgery is the commonest operation worldwide. Sternotomy, pleurotomy with opening of the pleural space, harvesting of internal mammary artery may lead to severe post-operative pain. Thoracic epidural analgesia (TEA) may reduced significant post-operative pain &amp; allow the patient early extubation.Methods: A total of 60 patients with ischaemic heart disease (IHD) were included in the study who were admitted in the Department of Cardiac Surgery in NICVD, Dhaka from July 2006 to June 2008 &amp; underwent off-pump coronary artery bypass (OPCAB) graft surgery. Out of the total 60 patients, 30 were in the group-A receiving thoracic epidural analgesia along with general anaesthesia and the rest 30 were in the group-B receiving general anaesthesia alone.Results: Patients in the epidural group had significantly less pain on the operative day and for the next 2 days. Total ventilation time in hours in Group-A was 6.4 + 1.0 and in Group-B was 10.1 +1.8 hours respectively. Postoperative X-ray chest revealed significant pulmonary complication in Group- B than Group-A. There were no complications related to epidural haematoma and no permanent neurological squeal.Conclusion: Thoracic epidural analgesia reduced significant post-operative pain and improvement in pulmonary function and early extubation.Cardiovasc. j. 2017; 9(2): 142-146

Effects of domestic wire-reinforced epidural catheter on complications related to anesthesia during labor analgesia

Objective To evaluate the effects of the domestic wire-reinforced epidural catheter on complications related to anesthesia during labor analgesia. Methods A total of 2 407 parturients, aged 18-40 yr, weighing 50-100 kg, of American Society of Anesthesiologists physical status Ⅰor Ⅱ, scheduled for elective operations under combined spinal-epidural anesthesia for labor analgesia, were divided into 2 groups using a random number table: common epidural catheter group(group Ⅰ, n=1 203)and wire-reinforced epidural catheter group(group Ⅱ, n=1 204). After successful epidural puncture, the appropriate amount of local anesthetics was injected into the subarachnoid space, and the corresponding epidural catheter was then inserted, and the depth was 3 cm.Paresthesia during catheterization, unexpected catheter displacement, difficult extubation, catheter bending, epidural bleeding, successful insertion at first attempt, successful insertion time, the number of successfully delivered doses and consumption of patient-controlled analgesia solution were recorded.The patients were followed up after operation for nerve damage. Results Compared with group Ⅰ, the incidence of paresthesia during catheterization, unexpected catheter displacement and catheter bending was significantly decreased, the occurrence of epidural bleeding was reduced, the success rate of insertion at first attempt was increased, successful insertion time was shortened, the incidence of difficult extubation was increased(P 0.05). Conclusion Complications related to anesthesia are reduced when the domestic wire-reinforced epidural catheter is used for labor analgesia. Key words: Catheterization; Anesthesia, epidural; Intraoperative complications.

Patient-controlled analgesia with remifentanil versus alternative parenteral methods for pain management in labour.

Patient-controlled analgesia with remifentanil versus alternative parenteral methods for pain management in labour.

Application of general anesthesia combined with epidural anesthesia/analgesia in rehabilitation after gastric cancer resection

Objective: To investigate the efficacy of general anesthesia with epidural anesthesia and postoperative epidural analgesia in terms of pain relief and post-operative functional recovery. Methods: Ninety-six patients were randomly assigned to general anesthesia and intravenous analgesia group (GI) or general anesthesia combined with epidural anesthesia and epidural analgesia group (GE). Demographic and operative data, postoperative VAS pain scores, gastrointestinal function, postoperative hospital stays, general complications were assessed prospectively. Results: (1) The postoperative VAS scores of patients in the group GE at 2, 24, 48, and 72 hours were significantly lower than those in the group GI. (2) Compared with the group GI, the patients in group GE had earlier postoperative flatus and a shorter postoperative hospital stay (8.4 ± 2.5 vs 10.0 ± 3.2, P=0.012 8). Conclusion: General anesthesia combined with epidural anesthesia and postoperative epidural analgesia could provide better pain relief, enhance early rehabilitation and reduce the duration of hospital.

Comparison of the effects of patient-controlled epidural and intravenous analgesia on postoperative bowel function after laparoscopic gastrectomy: a prospective randomized study

Although laparoscopic surgery significantly reduces surgical trauma compared to open surgery, postoperative ileus is a frequent and significant complication after abdominal surgery. Unlike laparoscopic colorectal surgery, the effects of epidural analgesia on postoperative recovery after laparoscopic gastrectomy are not well established. We compared the effects of epidural analgesia to those of conventional intravenous (IV) analgesia on the recovery of bowel function after laparoscopic gastrectomy. Eighty-six patients undergoing laparoscopic gastrectomy randomly received either patient-controlled epidural analgesia with ropivacaine and fentanyl (Epi PCA group) or patient-controlled IV analgesia with fentanyl (IV PCA group), beginning immediately before incision and continuing for 48h thereafter. The primary endpoint was recovery of bowel function, evaluated by the time to first flatus. The balance of the autonomic nervous system, pain scores, duration of postoperative hospital stay, and complications were assessed. The time to first flatus was shorter in the epidural PCA group compared with the IV PCA group (61.3±11.1 vs. 70.0±12.3h, P=0.001). Low-frequency/high-frequency power ratios during surgery were significantly higher in the IV PCA group, compared with baseline and those in the epidural PCA group. The epidural PCA group had lower pain scores during the first 1h postoperatively and required less analgesics during the first 6h postoperatively. Compared with IV PCA, epidural PCA facilitated postoperative recovery of bowel function after laparoscopic gastrectomy without increasing the length of hospital stay or PCA-related complications. This beneficial effect of epidural analgesia might be attributed to attenuation of sympathetic hyperactivation, improved analgesia, and reduced opioid use.

Risk factors for anastomotic leakage following esophagectomy: Impact of thoracic epidural analgesia.

Anastomotic leakage (AL) is one of common complications after esophageal cancer surgery. Thoracic epidural analgesia (TEA) is often recommended in patients undergoing esophagectomy. However, the impact of TEA on AL is still controversial. Thus, we conducted this study to evaluate the effect of TEA on the occurrence of AL and identify risk factors for the development of AL following esophagectomy. Our retrospective study identified patients who underwent elective esophagectomy between July 2013 and July 2016. Univariate and multivariate logistics analyses and propensity score matching analysis were conducted to identify the risk factors for AL occurring within 30 days after operation. Overall 30-day AL was 7.9%. Multivariate analysis revealed that surgical procedure (Sweet: referent; Ivor-Lewis: OR 2.854; 95%CI 1.726-4.718; Three-incision: OR 4.837; 95%CI 3.457-6.768) and surgeon (high-volume: referent; low-volume: OR 1.740; 95%CI 1.269-2.384) were independent risk factors for AL after esophagectomy. No statistically significant difference was observed in the incidences of AL between the epidural analgesia group and the intravenous analgesia group either before or after propensity score matching (9.1% vs 7.7%, P = 0.359; 8.3% vs 9.2%, P = 0.683). TEA does not affect the AL risk after esophagectomy.

Pain management using acetaminophen throughout postoperative course of laparoscopic colorectal surgery: A case-matched control study.

BackgroudThe main advantage of laparoscopic surgery is that it is minimally invasive because of the use of small incisions. An approach using small incisions offers many benefits including attenuation of surgical wound pain. However, the presence of postoperative pain may undermine the advantages of laparoscopic surgery as a minimally invasive technique. In addition, perioperative pain management is an important factor affecting recovery after surgery. This study investigated the usefulness of a multimodal approach to postoperative pain management with acetaminophen as a baseline analgesic after minimally invasive laparoscopic colorectal surgery.Materials and methodsThe study included 40 patients who underwent laparoscopic colorectal surgery for colorectal cancer. 20 patients received acetaminophen as a baseline analgesic for postoperative pain management and 20 received epidural anesthesia.ResultsThe urethral catheter could be removed earlier in the acetaminophen group (2.1 ± 0.22 days postoperatively) compared with the epidural group (4.1 ± 0.45days postoperatively). The frequencies of vertigo were significantly lower in the acetaminophen than epidural group (10.0% and 45.0%, respectively). The frequencies of the use of analgesics on an as-needed basis for postoperative pain relief as well as the variabilities in these frequencies, although not significantly different between the acetaminophen and epidural groups, were lower in the acetaminophen group than the epidural group.ConclusionWe herein demonstrated that postoperative pain management with acetaminophen as a baseline analgesic, and without the use of epidural anesthesia, is a safe and useful analgesic modality.

Efficacy of Epidural Analgesia During Labour

Although labour is considered as a normal physiological process, it can produce significant pain, requiring appropriate pain management. A painful labour also had detrimental effects on the mother and fetus. Ideal labour analgesia technique should dramatically reduce the pain of labour, while allowing the parturient to actively participate in birthing experience and have minimal adverse effects on the fetus and progress of labour. Epidural analgesia and opioids are often used for management of labour pain. Epidural analgesia is an effective method for managing labour pain. Studies have indicated that the procedure has few contraindications and few side-effects. The study was done to see the efficacy and safety of epidural analgesia with conventional analgesia (Inj. Pethidine and phenergan) during labour. In this study, pregnant women with active labour (Cervical dilation 4cm) were grouped into two A &amp; B. Group A received epidural analgesia (0.125% Bupivacaine &amp; 50 microgram Fentanyl) &amp; group B received conventional analgesia (Inj. Pethidine &amp; phenergan). Then the subjects were followed up and outcomes were recorded in a preformed data collection sheet. All data were analyzed by computer based software SPSS version 15. The study demonstrated a significantly earlier onset of effective analgesia in epidural group than that in the conventional group. The pain score at onset of analgesia and at different time intervals following induction and at the time of delivery were appreciably lower in women receiving epidural analgesia than those receiving conventional analgesia (p&lt;0.001). There was no significant difference between epidural and conventional groups in terms of complications like nausea and/or vomiting (p=0.431), prolonged 2nd stage of labour (p=0.127), mode of delivery (Normal / Instrumental / Cesarean) (p=0.455). Neonatal outcome was evaluated in terms of APGAR score at 1&amp; 5 minutes of birth in both groups which showed no significant differences (p=0.401and p=0.536 respectively). So, epidural analgesia is an effective analgesia during labour.&#x0D; JCMCTA 2016 ; 27 (2) : 12 - 17

Effectiveness and safety of continuous ultrasound-guided femoral nerve block versus epidural analgesia after total knee arthroplasty

Abstract Objectives Total knee arthroplasty is associated with severe postoperative pain. The aim of this study was to compare continuous ultrasound-guided femoral nerve block with continuous epidural analgesia, both with low concentrations of local anaesthetic after total knee arthroplasty. Material and methods A prospective, randomised, unblinded study of 60 patients undergoing total knee replacement, randomised into two groups. A total of 30 patients received continuous epidural block, while the other 30 received continuous ultrasound-guided femoral nerve block, as well as using 0.125% levobupivacaine infusion in both groups. Differences in pain control, undesirable effects, and complications between the two techniques were assessed, as well as the need for opioid rescue and the level of satisfaction with the treatment received during the first 48 h after surgery. Results No differences were found in demographic and surgical variables. The quality of analgesia was similar in both groups, although in the first six hours after surgery, patients in the epidural group had less pain both at rest and with movement (p = 0.007 and p = 0.011). This difference was not observed at 24 h (p = 0.084 and p = 0.942). Pain control at rest in the femoral block group was better at 48 h after surgery than in the epidural group (p = 0.009). The mean consumption of morphine and level of satisfaction were similar. Epidural analgesia showed the highest rate of side effects (p = 0.003). Conclusions Continuous ultrasound-guided femoral nerve block provides analgesia and morphine consumption similar to epidural analgesia, with the same level of satisfaction, but with a lower rate of side effects after total knee arthroplasty.

Dural Puncture Epidural Technique Improves Labor Analgesia Quality With Fewer Side Effects Compared With Epidural and Combined Spinal Epidural Techniques: A Randomized Clinical Trial

The dural puncture epidural (DPE) technique is a modification of the combined spinal epidural (CSE) technique, where a dural perforation is created from a spinal needle but intrathecal medication administration is withheld. The DPE technique has been shown to improve caudal spread of analgesia compared with epidural (EPL) technique without the side effects observed with the CSE technique. We hypothesized that the onset of labor analgesia would follow this order: CSE > DPE > EPL techniques. A total of 120 parturients in early labor were randomly assigned to EPL, DPE, or CSE groups. Initial dosing for EPL and DPE consisted of epidural 20 mL of 0.125% bupivacaine plus fentanyl 2 μg/mL over 5 minutes, and for CSE, intrathecal 0.25% bupivacaine 1.7 mg and fentanyl 17 μg. Upon block completion, a blinded coinvestigator assessed the outcomes. Two blinded obstetricians retrospectively interpreted uterine contractions and fetal heart rate tracings 1 hour before and after the neuraxial technique. The primary outcome was time to numeric pain rating scale (NPRS) ≤ 1 analyzed by using Kaplan-Meier curves and Cox proportional hazard model. Secondary outcomes included block quality, maternal adverse effects, uterine contraction patterns, and fetal outcomes analyzed by using the χ test with Yates continuity correction. There was no significant difference in the time to NPRS ≤ 1 between DPE and EPL (hazard ratio 1.4; 95% confidence interval [CI] 0.83-2.4, P = .21). DPE achieved NPRS ≤ 1 significantly slower than CSE (hazard ratio 0.36; 95% CI 0.22-0.59, P = .0001). The median times (interquartile range) to NPRS ≤ 1 were 2 (0.5-6) minutes for CSE, 11 (4-120) minutes for DPE, and 18 (10-120) minutes for EPL. Compared with EPL, DPE had significantly greater incidence of bilateral S2 blockade at 10 minutes (risk ratio [RR] 2.13; 95% CI 1.39-3.28; P < .001), 20 minutes (RR 1.60; 95% CI 1.26-2.03; P < .001), and 30 minutes (RR 1.18; 95% CI 1.01-1.30; P < .034), a lower incidence of asymmetric block after 30 minutes (RR 0.19; 95% CI 0.07-0.51; P < .001) and physician top-up intervention (RR 0.45; 95% CI 0.23-0.86; P = .011). Compared with CSE, DPE had a significantly lower incidence of pruritus (RR 0.15; 95% CI 0.06-0.38; P < .001), hypotension (RR 0.38; 95% CI 0.15-0.98; P = .032), combined uterine tachysystole and hypertonus (RR 0.22; 95% CI 0.08-0.60; P < .001), and physician top-up intervention (RR 0.45; 95% CI 0.23-0.86; p = .011). Analgesia onset was most rapid with CSE with no difference between DPE and EPL techniques. The DPE technique has improved block quality over the EPL technique with fewer maternal and fetal side effects than the CSE technique for parturients requesting early labor analgesia.

Comparison of development of intraoperative atrial fibrillation in elderly patients undergoing thoracic surgery using different anesthetic methods: a large sample clinical trial

Objective To compare the development of intraoperative atrial fibrillation in elderly patients undergoing thoracic surgery using different anesthetic methods in a large sample clinical trial. Methods A total of 1 380 patients of both sexes, aged 60-80 yr, with body mass index of 16-33 kg/m2, of American Society of Anesthesiologists physical status Ⅰ or Ⅱ, scheduled for elective radical operations for lung or esophageal cancer, were divided into 3 groups(n=460 each)using a random number table: general anesthesia group(group G), general anesthesia combined with paravertebral block group(group GP), and general anesthesia combined with epidural block group(group GE). After induction of anesthesia, an epidural catheter was placed at T4-7 interspace on the operated side, and 0.375% ropivacaine 8 ml was administrated via the catheter in group GP.After induction of anesthesia, the patients were tracheally intubated and mechanically ventilated, and the end-tidal pressure of carbon dioxide was maintained at 35-45 mmHg in the 3 groups.Maintenance of anesthesia was as follows: propofol was given by target-controlled infusion with the target plasma concentration of 2.5-4.0 μg/ml in the 3 groups; intermittent iv boluses of sufentanil 10 μg were given, and the total dosage was not expected to exceed 1.0 μg/kg in group G; sufentanil 10 μg was injected intravenously when necessary in group GP; 0.25% ropivacaine 5 ml was injected epidurally every 1.5 h in group GE; bispectral index value was maintained at 40-60; rocuronium was injected intravenously according to the condition in the 3 groups.The development of intraoperative atrial fibrillation was recorded. Results The incidence of intraoperative atrial fibrillation was 6.1%, 3.7% and 2.2% in G, GP and GE groups, respectively.Compared with group G, the incidence of intraoperative atrial fibrillation was significantly decreased in group GE(P 0.05). Conclusion Compared with general anesthesia, general anesthesia combined with epidural block can decrease the development of intraoperative atrial fibrillation, it is more suitable for this type of patients, however, general anesthesia combined with paravertebral block produces no improvement in the development of intraoperative atrial fibrillation in elderly patients undergoing thoracic surgery. Key words: Atrial fibrillation; Anesthesia, general; Nerve block; Thoracic vertebrae; Anesthesia, epidural; Thoracic surgical procedures; Aged

Epidural Anesthesia vs General Anesthesia in Uterine Artery Embolization

Background: Uterine Artery Embolization (UAE) has been used worldwide for the treatment of uterine fibroids. The aim of the current study is to evaluate the effects of epidural analgesia (EDA) given only intraoperatively to those of general anesthesia (does it still affect in recovery) in women undergoing uterine artery embolization (UAE) for the treatment of systematic uterine fibroids. Patients and methods: A total of 40 ASA1-III patients (ages 35-55) selected for uterine artery embolization were divided into 2 groups i.e. an epidural anesthesia group (A) and a general anesthesia group (B). Each group comprised of 20 individuals. The parameters i.e. pain scoring, incidence of nausea and vomiting, need for opioids, overall patient satisfaction score and discharge from hospital were measured. Pain intensity was measured using VAS (1–10) at 0, 1, 2, 4, 8, 12 and 24 h. Nausea lasting more than 10 min or vomiting was treated with ondansetron 4 mg. Patient satisfaction for postoperative analgesia was recorded according to a satisfaction score (poor=0, fair=1, good=2, excellent=3). All data were recorded with residents of anesthesia. Primary outcome was morphine and or pethidine, consumption in the first 24 h. Secondary outcome measures were; pain intensity, postoperative analgesic consumption, postoperative nausea and vomiting (PONV) and patient satisfaction. Results: Differences in the heart rate between the 2 groups were statistically significant at all readings where group (B) patients developed less significant tachycardia compared to group (A) patients. Differences in systolic blood pressure values between the 2 groups were statistically significant lower in group (B) compared to group (A) at 2 points: after 5 min & after 10 min from induction of anesthesia. Differences in diastolic blood pressure values between the 2 groups were statistically significant lower in group (A) compared to group (B) at all times except preoperative reading. Thus the epidural anesthesia provided more hemodynamic stability than general anesthesia, Postoperative pain severity of the patients significantly decreased in each group at recovery room (time 0) and postoperative 1st, 2nd, 4th, 12th and 24th h (repeated measured variance analysis, p<0.001. However, the reduction of postoperative VAS scores was more in epidural anesthesia group than general anesthesia (repeated measured variance analysis, test, p=0.466. Conclusion: Uterine artery embolization for fibroids is an effective and safe therapeutic modality for symptomatic fibroids especially for those patients who like to preserve their uterus. Recovery and time to return to normal activities is shorter than hysterectomy and open myomectomy. With the results of the present study it can be concluded that epidural anaesthesia was much better in pain relief, less sedating effect and overall patient satisfaction. Thus, epidural anaesthesia technique can be helpful for women undergoing UAE to recover faster providing good symptom relief for most patients.

Comparison of Hemodynamic Changes in Unilateral Spinal Anesthesia Versus Epidural Anesthesia Below the T10 Sensory Level in Unilateral Surgeries: a Double-Blind Randomized Clinical Trial

Background:Unilateral spinal anesthesia is used to limit the spread of block. The aim of the present study was to compare hemodynamic changes and complications in unilateral spinal anesthesia and epidural anesthesia below the T10 sensory level in unilateral surgeries.Materials and Methods:In this double-blind randomized clinical trial in total 120 patients were randomly divided into a unilateral spinal anesthesia group (Group S) and an epidural anesthesia group (Group E). Systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), and heart rates were measured before and immediately after the administration of spinal or epidural anesthesia and then at 5-, 10-, 15-, 20-, 25-, and 30-min intervals. The rates of prescribed ephedrine and intraoperative respiratory arrest were recorded, in addition to postoperative nausea and vomiting, puncture headaches, and back pain during the first 24 h after the surgery.Results:SBP, DBP, and MAP values initially showed a statistically significant downward trend in both groups (p = 0.001). The prevalence of hypotension in Group S was lower than in Group E, and the observed difference was statistically significant (p < 0.0001). The mean heart rate change in Group E was greater than in Group S, although the difference was not statistically significant (p = 0.68). The incidence of prescribed ephedrine in response to a critical hemodynamic situation was 5.1% (n = 3) and 75% (n = 42) in Group S and Group E, respectively (p = 0.0001). The incidence of headaches, back pain, and nausea/vomiting was 15.3%, 15.3%, and 10.2% in Group S and 1.8%, 30.4%, and 5.4% in Group E (p = 0.017, 0.07, and 0.49, respectively).Conclusion:Hemodynamic stability, reduced administration of ephedrine, a simple, low-cost technique, and adequate sensory and motor block are major advantages of unilateral spinal anesthesia.

Comparison of transforaminal and interlaminar epidural steroid injections for the treatment of chronic lumbar pain

A cross-sectional study. We compared the 12 month outcomes of fluoroscopically guided transforaminal epidural steroid injections with interlaminar epidural steroid injections for the treatment of chronic lumbar spinal pain. Chronic lower back pain is a multifactorial disorder with many possible etiologies. The lifetime prevalence of spinal pain is reportedly 65-80% in the neck and lower back. Epidural injection of corticosteroids is a commonly used intervention for managing chronic spinal pain. Patients who did not benefit from previous treatments were included in this study. Injections were performed according to magnetic resonance imaging findings at the nearest level of lumbar pathology; 173 patients received interlaminar epidural steroid injections and 126 patients received transforaminal epidural steroid injections. All of the patients were regularly followed up for 12 months using a verbal numeric rating scale. Magnetic resonance imaging findings, complications, verbal numeric rating scale, and satisfaction scores were recorded. Lumbar disk pathology was the most frequently encountered problem. The interlaminar epidural steroid injections were preferred at the L4-L5 intervertebral level. Verbal numeric rating scale scores significantly decreased during the 12-month period compared to basal scores (p<0.001). Significant differences between the two groups according to verbal numeric rating scale and satisfaction scores were not observed (p>0.05). There were no major complications; however, the interlaminar epidural steroid injections group had 22 (12.7%) minor complications, and the transforaminal epidural steroid injections group had 12 (9.5%) minor complications. This study showed that interlaminar epidural steroid injections can be as effective as transforaminal epidural steroid injections when performed at the nearest level of lumbar pathology using fluoroscopy in 12-month intervals.

Comparison of the Intravenous and Epidural Administration of Tumor Necrosis Factor-alpha Antagonists in an Experimental Rat Pain Model.

Introduction:Inflammatory cytokines secreted from the nucleus pulposus are thought to lead to lumbar nerve root compression-like symptoms. Tumor necrosis factor-alpha (TNF-α), an inflammatory cytokine, likely plays an important role in lumbar disc hernia-related leg pain. In this experimental study, we compared the effectiveness of TNF-α antagonists administered through the intravenous or epidural route in lumbar spine pathologies.Materials and Methods:After ethics committee approval had been obtained, 24 Sprague Dawley male rats aged 70–90 days and weighing 250–300 g each were allocated to four groups. In Group I, only the surgical procedure was performed; in Group II, 1 ml of saline solution was administered into the epidural field; in Group III, 10 mg/kg of infliximab was administered into the coccygeal vein; and in Group IV (epidural group), 25 mg of etanercept was administered into the epidural region.Results:When the left leg pull values were analyzed on day 14, whereas there was not a significant difference among the three groups, a decreasing difference was observed in Group IV (P < 0.05). When the 21st and 28th day left leg pull values were compared between groups, the values from Groups II, III, and IV were significantly lower than those of Group I (P < 0.05).Conclusion:The absence of a difference between the baseline values and left leg pull values on days 14, 21, and 28 in Group IV indicates that recovery began on day 21 with the epidural administration of etanercept. There was no difference between intravenous saline administration and intravenous infliximab administration with regard to the start of the recovery. In the present study of rats with discopathy, TNF-α antagonists administered epidurally led to earlier recovery from radiculopathy-related allodynia compared to intravenous administration.