Epidural General Anesthesia Research Articles

A baseline audit of the efficacy and safety of an acute pain service (APS) for cesarean section patients

Abstract This study was conducted as a baseline audit to evaluate the efficacy and safety of an acute pain service (APS) using recent new postoperative analgesic techniques for Chinese patients undergoing cesarean delivery, against which to assess future practice. This was a prospective study conducted in a 12-month period on ASA one to two women presenting at term for elective or emergency cesarean section in our hospital. All patients received a standard general anaesthesia, spinal or epidural anaesthesia for surgery deemed suitable by the attending anaesthetist. The patients were allocated to either receive intrathecal morphine or intravenous patient-controlled analgesia (PCA) morphine for postoperative analgesia. Intrathecal morphine was given to patients that received spinal anaesthesia and patient approval. The rest of the patients received a PCA. In addition, all patients were given non-opioid analgesics, for postoperative analgesia. Postoperative pain, patient satisfaction, adverse effects and complications were assessed. Four hundred and sixty-five patients were treated with patient-controlled analgesia (244 patients) or intrathecal morphine (221 patients). The mean age was 31 (17–44) years and body weight 67 (46–101) kg. Method of anaesthesia included general anaesthesia (45 patients), spinal anaesthesia (305 patients) and epidural anaesthesia (115 patients). Pain control was good: less than 1.3% of patients complained of severe postoperative pain. Complete patient satisfaction with the method of analgesia was 92.2%; partial satisfaction 7.3% and less than 0.5% was dissatisfied. Adverse effects and complications included nausea and vomiting (11%), pruritus (29%), sedation (0.2%), dizziness (10%), urinary retention (51%), postdural puncture headache (0.4%) and wound infection (2%). Our experience provides a useful baseline audit data in the Chinese population against which to assess and improve future practice.

Frequency of hypotension and bradycardia during general anesthesia, epidural anesthesia, or integrated epidural-general anesthesia for total hip replacement

Study Objective: To evaluate the frequency of hypotension and bradycardia during integrated epidural-general anesthesia as compared with general anesthesia or epidural anesthesia alone. Design: Prospective, randomized, open, multicenter study Setting: Inpatient anesthesia at 7 University or Hospital Departments of anesthesia. Patients: 210 ASA physical status I, II, and III patients undergoing elective total hip replacement. Interventions: Using a balanced randomization method, each hospital enrolled 30 consecutive patients who received integrated epidural-general anesthesia, epidural anesthesia, or general anesthesia. Measurements and Main Results: Occurrence of clinically relevant hypotension (systolic arterial blood pressure (BP) decrease >30% from baseline), or bradycardia (heart rate (HR) <45 bpm) requiring pharmacologic treatment were recorded, as well as routine cardiovascular parameters. Clinically relevant hypotension during induction of nerve block was reported in 13 patients receiving epidural block (18%) and 16 patients receiving epidural-general anesthesia (22%) (p = 0.67). Subsequently, 22 of the remaining 54 patients in the epidural-general anesthesia group (41%) developed hypotension after the induction of general anesthesia, as compared with 16 patients of the general anesthesia group (23%) (p = 0.049). No differences in HR or in frequency of bradycardia were observed in the three groups. Conclusions: The induction of general anesthesia in patients with an epidural block up to T 10 increased the odds of developing clinically relevant hypotension as compared with those patients who received no epidural block, and was associated with a twofold increase of the odds of hypotension as compared with the use of epidural anesthesia alone.

The role of cervical sympathetic nervous system in secretions of stress or pineal hormone: a hypothesis

Cervical sympathetic nerves may affect blood adrenocorticotropic hormone (ACTH), cortisol (CS), melatonin or serotonin levels. We examined whether stellate ganglion block (SGB), which inhibits this nerve conduction, affects these substances. Five types of studies were performed: ACTH and CS were measured before and after SGB. Gastrectomy patients received general anesthesia (GA), general–epidural anesthesia (EPI), GA with SGB or EPI with SGB, and ACTH and CS were measured during surgery. Melatonin and serotonin were measured before and after SGB. In rats, melatonin and serotonin were measured at midnight during dark, light, light with right or bilateral cervical sympathectomy. Melatonin and serotonin were measured during the perioperative period in gastrectomy patients. As a result, SGB did not affect ACTH and CS levels. EPI with SGB showed lower values of ACTH or CS. SGB or cervical sympathectomy did not affect melatonin circadian rhythm and serotonin levels. During surgery, melatonin circadian rhythm and serotonin levels did not change, but melatonin increased only at night and serotonin decreased after surgery. These findings suggested that some stress stimuli are conducted via cervical sympathetic nerves to the hypothalamus, which is reduced by SGB, and to the pineal gland at night, which causes increased melatonin and decreased serotonin levels.

Comparison between Combined Epidural-General Anesthesia and General Anesthesia for Total Hip Replacement

Comparison between Combined Epidural-General Anesthesia and General Anesthesia for Total Hip Replacement

The Effect of Epidural Anesthesia on Coagulation Following Vascular Surgery in Patients with Arteriosclerosis Obliterance

Background : The purpose of this study was to examine the relationship of epidural anesthesia with coagulation status and surgery outcome following lower extremity revascularization. Methods : Twenty patients with arteriosclerosis obliterance (ASO) scheduled for lower extremity vas- cular reconstruction were randomized to receive either general anesthesia or combined general-epidural anesthesia. An additional 20 randomly selected patients without atherosclerotic vascular disease under- going lower abdominal or lower extrernity surgery served as controls for coagulation status. In the group with general anesthesia, anesthesia was induced by administration of pentothal sodium and succiny- Icholine and maintained with NzO-Oz, isoflurane and vecuronium. In the group with combined anesthesia, epidural anesthesia was performed at the level of Lz. or L3-4 epidural space using 2% lidocaine, followed by general anesthesia same as general group. Postoperative pain control was followed by on-demand oral or intravenous narcotics in the general group and followed by epidural 0.125% bupivacaine and morphine in the combined group. The coagulation status was monitored using thrombelastography (TEG) and standard coagulation tests. Results : The ASO patients were hypercoagulable compared to the control patients before operation and on the first postoperative day. The hypercoagulability was attenuated postoperatively in the combined group. In the ASO-general group, postoperative MA, a and TEG index were 69.5 ± 6.1 mm, 53.3 ± 7.5。and 1.18 ± 1.29 respectively, but in the ASO-combined anesthesia group, they were 58.0 ± 6.2 mm, 38.0 ± 4.0 ' and -0.38 ± 1.20 respectively (P < 0.05). The rates of postoperative compli- cations did not significantly differ between the two groups. Conchusions : In patients with arteriosclerosis oblitetance undergoing arterial reconstructive surgery, thrombelastographic evidence of increased platelet-fibrinogen interaction is associated with early postoperative thrombotic events, and epiduvl anesthesia is associated with beneficial effects on coagulation status. (Korean J Anesthesiol 2000; 38: 409 ~ 419)

Influence of thiopental and propofol on postoperative cognitive recovery in the elderly patient undergoing general anesthesia

Study Objective: To assess mental and psychomotor recovery following induction of anesthesia with thiopental or propofol in elderly patients undergoing general anesthesia. Design: Randomized, prospective, double-blind study. Setting: Large referral hospital. Patients: 40 elderly patients ASA physical status I-III (>65 years) undergoing abdomino-pelvic surgery with an estimated surgical time of at least 90 minutes. Interventions: All patients received combined epidural-general anesthesia. After establishing a T 6 sensory blockade, patients were randomized to receive either thiopental or propofol for induction of general anesthesia. The induction drug was slowly titrated until loss of eyelash reflex was noted. Thereafter, all patients received desflurane (2% to 3% end-tidal) and 70% nitrous oxide (N 2O) in oxygen for maintenance of general anesthesia. To facilitate tracheal intubation, intravenous alfentanil 10 μg/kg and atracurium 0.4 mg/kg were administered. Perioperative analgesia was maintained with epidural bupivacaine. Measurements and Main Results: A digit substitution test (DSST) and shape-sorter test, as well as patient-generated 100-mm visual analog score (VAS; 0 = minimal and 100 = maximal) for anxiety, sleepiness, and coordination, were performed during the preanesthetic interview, on postanesthesia care unit admission, and at 15, 45, 90, and 120 minutes thereafter. To induce loss of consciousness, either thiopental 2.5 ± 1.0 mg/kg or propofol 1.6 ± 0.6 mg/kg was administered. The mean anesthetic time was 109 ± 30 minutes and 114 ± 38 minutes for the thiopental and propofol groups, respectively. Emergence, extubation, and orientation times, as well as time to follow commands, were unaffected by patient randomization. Similarly, the DSST and shape-sorter tests, in addition to the patient-generated VAS for pain, anxiety, and coordination, were similar among groups. However, irrespective of treatment modality, return to baseline digit substitution and shape-sorter scores were significantly delayed (p < 0.01). Conclusion: When compared to thiopental, propofol does not facilitate improved cognitive recovery in geriatric patients undergoing prolonged surgery.

Combined general and thoracic epidural anaesthesia: When is it indicated?

Abstract There has been a large volume of recent literature which supports the use of combined general/thoracic epidural anaesthesia and postoperative epidural analgesia in high risk patients. Much of this literature has focused on patients undergoing surgery to treat cancer, patients undergoing vascular surgery, and patients at high risk for cardiovascular disease. In these groups of patients, combined thoracic epidural and general anaesthesia, with continuation of epidural analgesia into the postoperative period, has been shown to have certain advantages over general endotracheal anaesthesia followed by postoperative intravenous opioid analgesia. However, how the anaesthetic is conducted may be more important than merely placing an epidural catheter prior to induction of general anaesthesia. In this review, the authors will examine the physiological and clinical data underlying the advantages of combined thoracic epidural/general anaesthesia, examine how the conduct of the anaesthetic may be an important influence on clinical outcome, and discuss the indications for this technique of anaesthesia and postoperative analgesia.

The age-related effects of epidural lidocaine, with and without epinephrine, on spinal cord blood flow in anesthetized rabbits.

The effect of epidural or spinal epinephrine when added to local anesthetics on spinal cord blood flow (SCBF)are controversial. We evaluated the effects of epidural lidocaine, with or without epinephrine, on spinal cord blood flow in young and adult rabbits receiving 2% plain lidocaine, 2% lidocaine with epinephrine (1:200,000), or saline epidurally. Colored microspheres were injected through the left ventricle 10 min before and 7.5 and 30 min after epidural injection. The organs (brain, heart, kidneys, and the L6-7 segment of the spinal cord) were analyzed for regional blood flow determination. A significant decrease in mean arterial pressure was observed after the administration of lidocaine, with or without epinephrine, in both adult and young animals compared with saline. SCBF did not change over time in adult rabbits. Conversely, a significant decrease in SCBF was observed in the two groups of young rabbits receiving lidocaine. This decrease correlated with the decrease in mean arterial pressure but did not correlate with the use of epinephrine. We conclude that any reduction in blood pressure occurring in pediatric patients receiving a combined epidural-general anesthetic may result in decreased SCBF. In young rabbits, any decrease in blood pressure was followed by a decrease in spinal cord blood flow, a decrease that did not correlate to the use of epinephrine and was not observed in adult animals. These data suggest that blood pressure should be monitored closely to promptly treat any decrease in blood pressure when combined epidural-general anesthesia is used in children.

Subdural cannulation and local anesthetic injection as a complication of an intended epidural anesthetic

We report a 52-year-old woman scheduled for laparotomy with combined epidural-general anesthesia who experienced abnormal responses to local anesthetic injections administered via the epidural catheter. The catheter subsequently was found to be in the subdural space. A review of the literature is provided.

The Effects of Combined Epidural-General Anesthesia and Postoperative Epidural Analgesia on Recovery of Bowel Function and Complications in Colon Surgery

The Effects of Combined Epidural-General Anesthesia and Postoperative Epidural Analgesia on Recovery of Bowel Function and Complications in Colon Surgery

Delirium after Combined Epidural-General Anesthesia in a Elderly Patient: A case report

Delirium after Combined Epidural-General Anesthesia in a Elderly Patient: A case report

Interleukin-10 Production During and After Upper Abdominal Surgery

Study Objective: To evaluate the influence of major abdominal surgery on the plasma levels of interleukin-10 (IL-10). Design: Prospective study. Setting: University hospital. Patients: 10 ASA physical status I and II patients undergoing upper abdominal surgery. Interventions: All patients received combined general-epidural anesthesia with isoflurane and nitrous oxide, after insertion of an epidural catheter at T 8–T 9 dosed with 1.5% lidocaine. Measurements and Main Results: Plasma interleukin-6 (IL-6), interleukin-8 (IL-8), and IL-10 levels were determined with an enzyme-linked immunosorbent assay at preanesthesia, 0, 2, and 4 hours during surgery, and at the end of surgery, followed by sampling on the morning of postoperative days 1 (POD1) and 3 (POD3). Before anesthesia and at 0 hours of surgery, IL-10 was not detected. In all ten patients, the plasma levels of IL-10 showed significant elevations and achieved their maximal value 4 hours after the skin incision (p <0.05 vs. baseline). The plasma IL-10 levels returned to preanesthesia levels on POD3. The plasma levels of IL-6 and IL-8 also increased in the perioperative period. The peak cytokine levels correlated (r = 0.915, p = 0.0001 for IL-6 vs. IL-8; r = 0.82, p = 0.025 for IL-6 vs. IL-10; and r = 0.641, p = 0.06 for IL-8 vs. IL-10). The peak plasma IL-10 levels significantly correlated with the amount of intraoperative blood loss (r = 0.69, p <0.05). Conclusions: In patients undergoing major abdominal surgery, plasma IL-10 levels were elevated during and after operation. IL-10 may modulate the inflammatory responses in the perioperative period.

Total-body oxygen consumption after isoflurane anesthesia: Effects of mild hypothermia and combined epidural-general anesthesia

Study Objectives: To determine the effects of epidural anesthesia and avoidance of intraoperative heat loss on the increase in total-body oxygen consumption in the immediate postoperative period after major intraabdominal surgery. Design: Prospective, randomized (with regard to temperature management) study. Setting: University medical center. Patients: 24 ASA physical status I, II, and III adults. Interventions: All patients received either isoflurane-nitrous oxide (N 2O)-opioid general anesthesia or combined epidural-general anesthesia; patients were randomly assigned to active intraoperative warming or routine thermal care. Measurements and Main Results: VO 2 was measured by indirect calorimetry preoperatively (T 0), immediately postoperatively (T 1), and 60 to 90 minutes later (T 2). For all patients, VO 2 was 57 ± 45% (mean ± SD) greater at T 1 than at T 0 ( p < 0.05). After isoflurane-N 2O-opioid general anesthesia, VO 2 increased 15 ± 20% in normothermic patients (core temperature, 36.4 ± 0.2 °C) compared with 69 ± 52% in hypothermic patients (35.0 ± 0.5 °C). After combined epidural-general anesthesia, VO 2 increased 86 ± 39% on emergence in normothermic (36.4 ± 0.2 °C) and 58 ± 11% in hypothermic (35.1 ± 0.4 °C) patients. Conclusions: Total-body VO 2 was increased in the immediate postoperative period. After general anesthesia, the magnitude of the increase in VO 2 was significantly less in normothermic patients than in hypothermic patients. After combined epidural-general anesthesia, VO 2 was increased in normothermic and in hypothermic patients.

Active warming, not passive heat retention, maintains normothermia during combined epidural-general anesthesia for hip and knee arthroplasty

Study Objective: To compare passive heat retention by low-flow anesthesia, alone and with additional thermal insulation by reflective blankets, with forced-air warming preventing intraoperative hypothermia during combined epidural-general anesthesia. Design: Randomized, controlled study. Setting: Inpatient anesthesia at a university department of orthopedic surgery. Patients: 30 ASA physical status I and II patients, who were scheduled for elective hip or knee arthroplasty and were free from systemic disease. Interventions: Patients received epidural block up to T 10 by alkalinized lidocaine 2 %, and then were administered standard general anesthesia by means of low-flow rebreathing system (fresh gas flow = 1 L/min). All procedures started between 8 and 10 am, and operating room (OR) temperature was maintained between 21 ° and 23 °C, with relative humidity ranging between 40% and 45%. For heat retention or warming therapy, patients received either low-flow anesthesia only (control, n = 10), low-flow anesthesia with additional reflective blankets (blanket, n = 10), or low-flow anesthesia with active forced-air warming (forced-air, n = 10). Tympanic temperature was measured at OR arrival (baseline); immediately following general anesthesia induction; 30, 60, 90, and 120 minutes from general anesthesia induction; and at the end of surgery. Measurements and Main Results: Duration of anesthesia, invasiveness of surgery, and baseline core temperature were similar in the three groups. Core temperature decreased in all the three groups 30 minutes after general anesthesia induction compared with baseline ( p < 0.01); afterwards, it progressively decreased in the control and blankets groups ( p = 0.004), with a reduction from baseline values measured at the end of surgery of 2.0 °C and 1.6 °C, respectively. In the forced-air group, after the initial significant decrease ( p = 0.01 vs. baseline), core temperature progressively increased to 35.8 ± 0.6 °C, which was similar to preoperative values and significantly higher than either the control or blankets groups ( p = 0.004). Conclusions: During combined epidural-general anesthesia for elective hip and knee arthroplasty, passive heat retention by means of low-flow anesthesia alone and in combination with reflective blankets is ineffective in maintaining intraoperative normothermia and definitely inferior to active forced-air warming.

Hemodynamic Responses to an Epinephrine Test Dose in Adults During Epidural or Combined Epidural-General Anesthesia

Hemodynamic Responses to an Epinephrine Test Dose in Adults During Epidural or Combined Epidural-General Anesthesia

Elevated plasma levels of interleukin-6, interleukin-8, and granulocyte colony-stimulating factor during and after major abdominal surgery

Study Objective: To evaluate the influence of major abdominal surgery on the plasma levels of inflammatory cytokines interleukin-6 (IL-6), interleukin-8 (IL-8) and granulocyte colony-stimulating factor (G-CSF). Design: Prospective study. Setting: University hospital. Patients: 10 ASA physical status I and II patients undergoing upper abdominal surgery. Interventions: All patients received combined general-epidural anesthesia with isoflurane and nitrous oxide, after insertion of an epidural catheter at T 7-T 9 dosed with 1.5% lidocaine. Measurements and Main Results: Plasma cytokine (IL-6, IL-8, G-CSF) levels were determined with an enzyme-linked immunosorbent assay (ELISA) at pre-anesthesia, 0, 2, and 4 hours during surgery, and at the end of surgery, followed by sampling on the morning of postoperative days 1 (POD1) and 3 (POD3). Plasma cortisol levels were also determined. The plasma levels of IL-6 increased gradually after skin incision and reached the maximal value at the end of surgery ( p < 0.001). IL-8 levels also increased from the baseline value to their maximum at the end of surgery ( p < 0.05). G-CSF levels were elevated from the pre-anesthesia value to their maximum by the end of operation ( p < 0.005). Plasma cortisol levels were increased after skin incision ( p < 0.001). Postoperative cytokine levels correlated significantly with each other (r = 0.68, p < 0.05 for IL-6 vs. IL-8; r = 0.81, p < 0.005 for IL-6 vs. G-CSF; and r = 0.84, p < 0.005 for IL-8 vs. G-CSF). Postoperative IL-6 levels and intraoperative blood loss correlated significantly (r = 0.64, p < 0.05). Conclusions: These results suggest that major upper abdominal surgery stimulates the release of inflammatory cytokines presumably from the operation site. Further study is warranted to evaluate the modulation of inflammatory responses in the perioperative period.

Comparison of general anesthesia with and without lumbar epidural for total hip arthroplasty: Effects of epidural block on hip arthroplasty

Study Objectives: To determine whether lumbar epidural anesthesia, when combined with general anesthesia, decreases perioperative blood loss, the incidence of postoperative deep vein thrombosis (DVT), cardiac dysrhythmias, and ischemia in patients undergoing total hip arthroplasty (THA). Design: Randomized, controlled study. Setting: A university hospital. Patients: 37 ASA physical status I, II, and III patients, undergoing elective THA. Intervention: Patients were divided into two statistically comparable groups: Group GA = general anesthesia; Group CEGA = general anesthesia plus lumbar epidural anesthesia. All patients had 48-hour perioperative Holter monitoring, applied on admission, the day prior to surgery. In both groups, general anesthesia was induced with thiopental sodium and muscle relaxant, and maintained with oxygen, nitrous oxide, isoflurane, opioid, and muscle relaxant. Group B received lumbar epidural anesthesia with 10 ml 0.5% bupivacaine with 1:200,000 epinephrine prior to anesthesia induction. Blood loss was measured by suction bottle contents, sponge weights, and collection drainage. DVT was assessed with postoperative leg scanning, plethysmography, and venogram. Measurements and Main Results: Intraoperative blood loss was less after combined epidural-general anesthesia (663.8 ml ± 299.0 ml) than after general anesthesia alone (1,259.2 ml ± 366.0 ml). The difference was found to be statistically significant ( p < 0.00005). No difference was found between the two groups in postoperative blood loss, incidence of DVT, cardiac dysrhythmias, or ischemia. Conclusion: Combined regional-general anesthesia decreases intraoperative blood loss in THA, and thereby offers an advantage over general anesthesia alone.

Hemodynamic Responses to an Epinephrine Test Dose in Adults During Epidural or Combined Epidural-General Anesthesia

The efficacy of an epinephrine test dose during epidural and combined epidural-general anesthesia is unknown. Thirty-two patients were randomized to receive 2% lidocaine at either a high (25 mL) or low (12 mL) thoracic level of epidural anesthesia followed by general anesthesia with 1 minimum alveolar anesthetic concentration nitrous oxide and isoflurane. A 15-micro gram epinephrine test dose was intravenously administered prior to placement of the lumbar epidural catheter, 20 min after initiation of epidural anesthesia, and after 10 min of stable end-tidal concentrations of general anesthesia. Only high thoracic levels (T-5) of epidural anesthesia reduced the peak systolic blood pressure response to epinephrine (34 +/- 17 vs 18 +/- 11 mm Hg, control versus epidural stage; P < 0.05) and reduced the peak heart rate response when combined with general anesthesia (31 +/- 11 vs 15 +/- 8 bpm; P < 0.05). Incidences of identification of intravascular injection from hemodynamic responses were similarly reduced for systolic blood pressure (100% vs 44%) and heart rate (100% vs 38%). The standard 15-micro gram epinephrine test dose is unaffected by low thoracic levels of epidural anesthesia, but may have decreased sensitivity for detection of intravascular injection during high thoracic levels of epidural anesthesia, especially during general anesthesia. (Anesth Analg 1996;83:97-101)

Epidural Analgesia versus Intravenous Patient-Controlled Analgesia

Background and objectives This study evaluated 462 consecutive surgical cancer patients who underwent uncomplicated surgeries of the thorax or abdomen, or both, of more than 3 hours duration between 1989 and 1991. Methods Patients received either epidural analgesia (EA group) with 0.1% bupivacaine, 0.01% morphine sulfate after combined general-epidural anesthesia, or parenteral morphine therapy via intravenous patient-controlled analgesia (IV-PCA) after balanced general anesthesia after the operation. Patients in both the EA (n = 352) and IV-PCA (n = 100) groups were compared for demographics, length of surgical intensive care unit (SICU), and hospital stays. Moreover, the same comparisons were performed when patients were allocated into surgical subgroups: thoracic (TH), upper abdominal (UA), lower abdominal (LA), radical hysterectomies (RH), and RH with colon resection (RHCR). Results No differences existed with respect to age or sex between the EA and IV-PCA groups. All patients reported adequate dynamic pain control as evaluated with visual analog pain scores (VAS Conclusions The use of both analgesic techniques was associated with satisfactory postoperative pain control. However, patients receiving epidural anesthesia and analgesia experienced faster recovery as judged by shorter mechanical ventilation time, and decreased SICU and hospital stays, resulting in significantly lower hospitalization costs. The use of perioperative epidural techniques should be considered to expedite recovery of surgical patients, and has the added benefit of being cost effective by reducing hospital stays.

A Double-blind Comparison of Droperidol and Ondansetron with Placebo for Prevention of Emesis after General and Opioid Epidural Anesthesia

A Double-blind Comparison of Droperidol and Ondansetron with Placebo for Prevention of Emesis after General and Opioid Epidural Anesthesia