Epidural Infusion Research Articles

Comparison of analgesic efficacy and safety of continuous epidural infusion versus local infiltration and systemic opioids in video-assisted thoracoscopic surgery decortication in pediatric empyema patients.

Introduction:The stripping of the densely innervated and inflamed parietal pleura in empyema during video-assisted thoracoscopic surgery (VATS) decortication can lead to significant pain and major postoperative respiratory compromise. Hence, we compared the analgesic efficacy of continuous epidural infusion versus local infiltration and systemic opioids in children undergoing VATS decortications.Methodology:Following ethics approval and informed consent, forty patients from 1 to 12 years of age were randomized into two groups, Group E (epidural) and Group L (local infiltration) after induction of anesthesia. In Group E, a thoracic epidural catheter was inserted between T4 and T8. A bolus dose of 0.5 ml/kg of 0.25% injection bupivacaine was given epidurally before incision. Postoperatively, the patients received epidural infusion with bupivacaine and fentanyl up to 48 h using an elastomeric balloon pump. In Group L, patients received local infiltration of bupivacaine (2 mg/kg) and lignocaine (5 mg/kg) at the port sites before incision and at the end of surgery. They also received injection tramadol 1 mg/kg intravenously TDS with thrice daily postoperatively. The pain scores (Face, Legs, Activity, Cry, Consolability/ Wong-Baker FACES scale) were assessed every 4 h on the 1st day and 6 h on the 2nd day. Injection diclofenac 1 mg/kg intravenous was used as a rescue analgesic for pain scores more than 4. Side effects such as nausea, vomiting, constipation, and motor blockade were noted. Quantitative and categorical data were assessed using t-test and Chi-square test, respectively.Results:The pain scores were lower in the epidural group than in the local infiltration group at 0, 4, and 20 h postoperatively (P = 0.001, 0.01, and 0.038, respectively). Seventeen out of nineteen patients required rescue analgesia in the local infiltration group in the postoperative period as compared to five patients in the epidural group with a P value of 0.000081.Conclusion:Epidural analgesia can be considered as an effective modality of reducing pain in patients undergoing VATS decortication for empyema in pediatric patients.

Magnesium Sulfate as a Preemptive Adjuvant to Levobupivacaine for Postoperative Analgesia in Lower Abdominal and Pelvic Surgeries under Epidural Anesthesia(Randomized Controlled Trial).

Background:Magnesium (Mg) has been evaluated as an adjuvant to local anesthetics for prolongation of postoperative epidural and intrathecal analgesia but not with epidural levobupivacaine in lower abdominal surgeries.Aim of the Study:The aim of the study was to evaluate the preemptive analgesic effect of Mg added to epidural levobupivacaine anesthesia in infraumbilical abdominal surgeries.Settings and Design:This study design was a prospective randomized controlled trial.Patients and Methods:Two groups, each with fifty patients undergoing lower abdominal and pelvic surgeries with epidural anesthesia. Group M received 15 ml of a mixture of 14 ml levobupivacaine 0.5%, 0.5 ml magnesium sulfate 10% (50 mg), and 0.5 ml 0.9 NaCl at induction. Group L received 15 ml of 14 ml levobupivacaine 0.5% and 1 ml 0.9 NaCl at induction. Then, continuous infusion was used as 5 ml/h of the specific mixture of each group till the end of the surgery.Statistical Analysis:Chi-square test, unpaired t-test or Mann–Whitney, and Wilcoxon sign rank test were used.Results:No statistically significant difference between the two groups regarding intraoperative hemodynamics (P > 0.05). Sensory and motor block onset was significantly shorter in Group M (14.5 [±1.51] and 12.42 [±1.69]) compared to Group L (19.86 [±1.39] and 19.34 [±1.62]) (P = 0.001). Group M showed lower visual analog scale (VAS) pain score compared to Group L from the 2nd to the 5th h postoperatively. Time for first analgesic dose was longer in Group M (294.98 [±21.67]) compared to Group L (153.96 [±10.04]) (P = 0.001).Conclusions:Preoperative and intraoperative epidural Mg infusion with levobupivacaine resulted in prolonged postoperative analgesia and lower VAS.

An observational study to evaluate the effect of different epidural analgesia regimens on dynamic pain scores in patients receiving epidural analgesia for postoperative pain relief after elective gynecological surgery.

Background and Aims:The primary measure of efficacy of any analgesic regimen is pain relief, but it is important to measure dynamic pain relief rather than pain relief at rest. Epidural analgesia is an effective technique for postoperative analgesia. The drug combinations given therein (local anesthetics with adjuvants such as opioids/alpha-2 agonists), however, remain a personal choice. The aim of this study was to evaluate dynamic pain scores in patients receiving different epidural analgesia regimens for postoperative pain relief after elective gynecological surgery used in our institution.Material and Methods:One hundred eighty-seven patients enrolled in this study received postoperatively either bupivacaine 0.125% + morphine 0.1 mg/mL (group BM) or bupivacaine 0.125% + fentanyl 2 μg/mL (group BF) or bupivacaine 0.125% + clonidine 1 μg/mL (group C1) or bupivacaine 0.125% + clonidine 2 μg/mL (group C2) by continuous epidural infusion @ 5 mL/h. Differences in dynamic pain scores (on coughing and mobilization), pain scores at rest, sensory and motor blockade, sedation scores, dry mouth, pruritus, nausea, and vomiting were recorded. Also duration of postoperative analgesia, epidural top-ups, requirement of rescue analgesic, and patient satisfaction were determined. All observations were carried out at 1, 2, 4, 8, and 12 h after surgery and then at 8 am, 12 noon, 4 pm, 8 pm on subsequent postoperative day till removal of epidural catheter (after 96 h).Results:There was no difference in demographic or hemodynamic profile among the four groups (P > 0.05). There was no statistically significant difference in pain scores at rest among the four groups but dynamic pain scores were found to be better in group C2 as compared to group BM, BF, and C1 at most of the time intervals although not statistically significant (P > 0.05). Requirement of rescue analgesics was lower in group BM and group C2 as compared to group BF and C1 (P < 0.01). Incidence of pruritus was 43.5% in group BM and 19% in group BF, while no patients in group C1 or C2 had pruritus. Mean postoperative nausea and vomiting (PONV) scores were higher in group BM and group BF as compared to group C1 and C2 (P < 0.001). Mean sedation scores were comparable in all four groups. Incidence of dry mouth was 22% in group C2 as compared to 11% in group C1, while no patients in group BM or BF had dry mouth. Patients in group C2 were more satisfied as compared to other three groups.Conclusions:Combination of clonidine 2 μg/mL to 0.125% bupivacaine @ 5 mL/h in combined spinal epidural provides better postoperative analgesia as compared to combination of bupivacaine with opioids with greater patient satisfaction and significantly reduced side effects.

Comparison of continuous epidural infusion of 0.125% ropivacaine with 1 μg/ml fentanyl versus 0.125% bupivacaine with 1 μg/ml fentanyl for postoperative analgesia in major abdominal surgery.

Background and Aim:The present study was carried out to compare the efficacy of continuous epidural infusion of two amide local anesthetics, ropivacaine and bupivacaine with fentanyl for postoperative analgesia in major abdominal surgeries.Material and Methods:A total of 60 patients scheduled for major abdominal surgery were randomized into two study Groups B and R with thirty patients in each group. All patients were administered general anesthesia after placing epidural catheter. Patients received continuous epidural infusion of either 0.25% bupivacaine with 1 ug/ml fentanyl (Group B) or of 0.25% ropivacaine with 1 ug/ml fentanyl (Group R) at the rate 6 ml/h intraoperatively. Postoperatively, they received 0.125% bupivacaine with 1 ug/ml fentanyl (Group B) or 0.125% ropivacaine with 1 ug/ml fentanyl (Group R) at the rate 6 ml/h. Hemodynamic parameters, visual analog scale (VAS), level of sensory block, and degree of motor block (based on Bromage scale) were monitored for 24 h postoperatively.Results:Hemodynamic parameters and VAS scores were comparable in the two groups. The level of sensory block was higher in bupivacaine group. There were more patients with higher Bromage score in the (23.3%) bupivacaine group than in (6.7%) ropivacaine group though the difference was not statistically significant.Conclusion:Both ropivacaine and bupivacaine in the concentration of 0.125% with fentanyl 1 ug/ml are equally safe, with minimal motor block and are effective in providing postoperative analgesia.

Assessment of complications of epidural infusion analgesia in pediatric patients- A clinical study

Background: Epidural analgesia is now firmly established in pediatric anaesthetic practice and its popularity continues to grow. The present study was conducted to determine complications due to epidural infusion analgesia in children. Materials & Methods: The present study was conducted on 52 patients of both genders. All children undergoing elective or emergency surgeries under general anaesthesia and given concomitant epidural analgesia for post-operative pain management. In all patients, complications such as at the time of insertion, during maintenance nerve injuries, and during removal catheter breakage was recorded. Results: Out of 52 cases, males were 32 and females were 20. Complications in patients were at the time of insertion such as blood trap in 2, failure to identify space in 1, wet tap in 4, epidural hematoma in 1 and nerve injuries in 1. The difference was significant (P< 0.05). During maintenance of epidural such as peri catheter leaks in 2, catheter migration in 3, during removal such as infections in 5 and other causes were seen in 1 cases. The difference was significant (P< 0.05). Conclusion: Authors stated that epidural infusion analgesia is an effective and safe method of providing analgesia.

Labor analgesia in parturients of fetal growth restriction having raised umbilical Doppler vascular indices.

Background and Aims:Fetuses with abnormal umbilical blood flow are at a higher risk of adverse perinatal outcome than those with normal flow. Epidural analgesia (EA) has shown to decrease villous vascular resistance in preeclamptic women during labor. The present study evaluates the effects of epidural ropivacaine and intramuscular (IM) tramadol on Doppler blood flow in parturients with fetal growth restriction and raised umbilical artery (UmA) blood flow.Material and Methods:In this prospective nonrandomized comparative study, 36 term parturients with sonographic evidence of UmA systolic-diastolic (S-D) ratio ≥3 were enrolled. Parturients received either continuous epidural ropivacaine 0.2% or 1 mg/kg IM tramadol 4–6 hourly. Doppler flow parameters of UmA and bilateral uterine arteries (UtAs) were measured at 0, 1, and 6 h of labor analgesia. Doppler indices change with time during labor analgesia was assessed as the primary outcome. Change of Doppler indices of UtAs, Apgar score, and cord blood gases was considered as secondary measures.Results:Data from thirty laboring women who completed the study were analyzed. The pulsatility index, resistance index, and S-D ratio in UmA and right UtA reduced significantly with continuous epidural infusion during first 6 h of labor. However, these values increased or unchanged with tramadol administration. Better neonatal pH and base deficit (P = 0.039) were observed with EA.Conclusions:Continuous epidural ropivacaine causes improved fetoplacental circulation in parturients with growth-restricted fetuses having raised Doppler indices during labor analgesia. We also found better neonatal outcome with continuous infusion of epidural ropivacaine as compared to IM tramadol.

Comparison of Postoperative Analgesic Efficacy between Continuous Transversus Abdominis Plane Block, Lumbar Paravertebral and Epidural Blocks after Abdominal Surgeries

Background: The study was done to assess the postoperative analgesic efficacy of ultrasound-guided continuous transverses abdominis plane block, continuous lumbar paravertebral block and a continuous lumbar epidural block in patients undergoing lower abdominal surgeries (unilateral inguinal hernia repair). We compared their analgesic efficacy over the first 48 hour postoperative, in a randomized, single-blind study in 120 patients divided into four equal groups, 30 patients in each group. Methods: 120 patients randomly assigned into four equal groups, with 30 patients in each group. Group T received ultrasound-guided transverses abdominis plane block with 20 ml of bupivacaine 0.25% followed by continuous infusion of bupivacaine 0.125% (0.1 ml/kg/hr) and group P received ultrasound-guided continuous lumbar paravertebral block with bupivacaine 0.25% bolus dose 20 ml, followed by continuous infusion of bupivacaine 0.125% (0.1 ml/kg/hr). Group E received continuous lumbar epidural infusion of bupivacaine 0.25% bolus dose 20 ml, followed by continuous infusion of bupivacaine 0.125% (0.1 ml/kg/hr) and group C received normal saline bolus dose 20 ml, followed by continuous infusion of normal saline (0.1 ml/kg/hr). General anesthesia induced with fentanyl 1 - 2 μg/kg and propofol 1 - 3 mg/kg followed by atracurium 0.5 mg/kg. At the end of the surgical procedure, we activated the regional block with recording of parameters in the postoperative period each patient was assessed for visual analog scale (VAS) at rest and on movement, analgesic consumption, vital signs and presence of complications (nausea, vomiting, sedation), and postoperative patient satisfaction all data collected postoperatively by a blinded investigator at one, two, 6, 12, 24 and 48 hours postoperatively. Results: Postoperative analgesic efficacy is more in group E than group P and group T, the latter is least effective in pain control. Also in group E the postoperative analgesic consumption is lower than in group P and group T, re-garding complications as nausea and vomiting more recorded in epidural than the other two groups. Conclusion: Regarding postoperative analgesic efficacy, the continuous lumbar epidural block is more effective than continuous paravertebral and continuous transverses abdominis plane block, but regarding complications, there was a higher incidence in epidural group than other two groups.

Comparing epidural and wound infiltration analgesia for total abdominal hysterectomy: A randomised controlled study.

Background and Aims:Continuous wound infiltration (CWI) is emerging as an alternative to continuous epidural infusion (CEI). This study compared postoperative pain scores of CEI with CWI in patients undergoing total abdominal hysterectomy (TAH).Methods:This prospective randomised controlled trial included 102 patients planned for TAH who were randomised into either Group E (CEI) or Group L (CWI). The catheter (epidural/wound infiltration) was inserted in Group E before induction) and Group L at the end of surgery. General anaesthesia was administered according to standard protocol. At the end of surgery, both groups received 10 mL bolus of 0.2% ropivacaine followed by infusion at 6 mL/h through the respective catheters. They also received intravenous patient-controlled analgesia with morphine. The primary outcome was the visual analogue score at rest (VASR) and at deep breathing (VASDB) post-operatively. Secondary outcomes were post-operative morphine consumption, side effects and patient satisfaction.Results:The mean VASR between two groups were comparable up to 8 h. Group E showed significantly reduced VASR compared to Group L at 12 h (2.32 ± 0.59 vs 2.62 ± 0.67, P = 0.019) and 24 h (2.30 ± 0.58 vs 2.62 ± 0.57, P = 0.006). Group E showed significantly reduced VASDB compared to Group L at 5 min and from 4 to 24 h. Total morphine consumption, side effects and patient satisfaction were comparable.Conclusion:We conclude that CEI is a superior analgesic technique compared to CWI in total abdominal hysterectomy in terms of reduced pain scores.

The Efficacy of Programmed Intermittent Epidural Bolus for Postoperative Analgesia after Open Gynecological Surgery: A Randomized Double-Blinded Study.

Background It is well known that the programmed intermittent epidural bolus (PIEB) technique effectively provides epidural anesthesia in labor. This randomized double-blind trial compared the postoperative analgesic efficacy of PIEB with that of continuous epidural infusion (CEI) in patients undergoing gynecological surgery under combined general-epidural anesthesia. Methods Patients undergoing open gynecological surgery under combined general-epidural anesthesia were randomized at a 1 : 1 ratio to receive PIEB or CEI. In the PIEB group, the pump delivered 4 mL ropivacaine 0.2% plus fentanyl 2 μg/mL every hour. In the CEI group, the pump delivered the same solution at a rate of 4 mL/h. In both groups, additional 4 mL boluses of ropivacaine 0.2% plus fentanyl 2 μg/mL were provided, when necessary, by patient-controlled epidural analgesia after surgery. The primary outcome was the total ropivacaine dose 40 hours after surgery. The secondary outcomes were the number of PCEA boluses and postoperative pain (evaluated on an 11-point numerical rating scale) 3, 24, and 48 hours after surgery. Results In total, 57 patients were randomized (n = 28 and 29 in the PIEB and CEI groups, resp.). The two groups differ significantly in terms of the total ropivacaine dose 40 hours after surgery (mean (standard deviation): 155.38 (4.55) versus 159.73 (7.87) mL, P = 0.016). Compared to the CEI group, the PIEB group had significantly lower numerical rating scale scores 3 hours (median [lower–upper quartiles]: 0 [0–0.5] versus 3 [0–5.5], P = 0.002), 24 hours (1 [0–2] versus 3 [1–4], P = 0.003), and 48 hours (1 [0–2] versus 2 [2–3.5], P = 0.002) after surgery. Conclusion PIEB was better than CEI in terms of providing postoperative analgesia after open gynecological surgery under combined general-epidural anesthesia.

The effects of lower thoracic epidural blockade on intestinal epithelial barrier and activation of enteric glial cells in rats with hemorrhagic shock and resuscitation

Objective To investigate the effects of lower thoracic epidural blockade on integrity of intestinal epithelial barrier(IEB) and activation of enteric glial cell(EGC) in rats with hemorrhagic shock and resuscitation. Methods Seventy-two SD rats with epidural catheterization according to a modified method described by Bahar et al. were randomly divided into four groups with 18 in each group: sham group(group S), control group(group C), normal saline group(group N) and thoracic epidural blockade group(group T). In group S, rats were just received vascular cannulation, whereas the rats in other groups were subjected to hemorrhagic shock and resuscitation with normal saline according to the modified method described by Wiggers. Thirty minutes before bleeding, either 0.075% ropivacaine(group T) or normal saline(group N) 100 μl/kg was infused through thoracic epidural catheters. The survival rates of rats in 72 h after resuscitation were evaluated. The MAP and HR were monitored after vascular cannulation(T0), 30 min after epidural infusion(T1), 30 min of shock(T2), 60 min of shock(T3), 30 min and 60 min after resuscitation(T4 and T5 respectively). Arterial blood samples were collected for blood gas analysis at T0, T3 and T5. At 3 h following resuscitation, the severity of intestinal edema, the pathological changes of intestinal mucosa, and the function of IEB were evaluated by wet/dry ratio(W/D), Chiu's score, and lipopolysaccharide(LPS) concentrations in the portal vein, respectively. The expression of Occludin and glial fibrillary acidic protein(GFAP), a marker of EGCs, were determined by western blot. Results Compared with group C and group N, the survival rates and median survival time of group T were significantly promoted (P<0.05), While MAP and HR decreased at T4 and T5, the levels of pH and lactic acid at T3 and T5 were alleviated (P<0.05). Besides these, in group T, the levels of W/D, Chiu's score and LPS were decreased while the expression of Occludin and GFAP were increased significantly in comparison with group C and group N(P<0.05). Conclusions Lower thoracic epidural blockade attenuates IEB impairment induced by hemorrhagic shock and resuscitation in rats, alleviating internal environment disturbance and thus promoting survival rates after resuscitation, whose mechanism is related to activation of EGC. Key words: Thoracic epidural blockade; Hemorrhagic shock; Resuscitation; Intestinal epithelial barrier; Enteric glial cell

Epidural therapy for the treatment of severe pre-eclampsia in non labouring women.

Epidural therapy for the treatment of severe pre-eclampsia in non labouring women.

A Novel Technique of Paravertebral Thoracic and Preperitoneal Analgesia Enhances Early Recovery After Oesophagectomy.

Excellent analgesia following oesophagectomy facilitates patient comfort, early extubation, physiotherapy and mobilisation, reduces post-operative complications and should enhance recovery. Thoracic epidural analgesia (TEA), the gold standard analgesic regimen for this procedure, is often associated with systemic hypotension treated with inotropes or fluid. This may compromise enhanced recovery and be complicated by anastomotic ischaemia or tissue oedema. We report a novel analgesic regimen to reduce post-operative inotrope usage. Infusion of ropivicaine via bilateral preperitoneal and right paravertebral catheters was used. Patient-controlled epidural pethidine provided rescue analgesia (WC) (n=21). A retrospective audit of inotrope requirement, mean pain scores, episodes of respiratory depression and excessive sedation, need for reintubation, reoperation in the first 5 post-operative days, time to mobilisation, time in intensive care, time in hospital and 30-day mortality were measured. These results were compared with those of an earlier patient group who received a thoracic epidural infusion of low-dose local anaesthetic and fentanyl (TEA) (n=21). Inotrope use was reduced by 29% in the WC group (p=0.03) and the mean intensive care stay reduced by 2.4days (p=0.03), as was reintubation rate (p=0.01) and early mobilisation (p=0.03). The pain score was comparable in both groups, and there was no difference in the other outcomes examined. The data demonstrated that it was possible to provide excellent post-oesophagectomy analgesia equivalent to thoracic epidural infusions of local anaesthetic with reduction in inotrope requirements, intensive care stay, more rapid mobilisation, facilitating enhanced recovery.

Can early oral prolonged-release oxycodone with or without naloxone reduce the duration of epidural analgesia after cystectomy? A 3-arm, randomized, double-blind, placebo-controlled trial.

Thoracic epidural analgesia (TEA) enhances recovery after bowel surgery. Early postoperative prolonged-release oral formulation of oxycodone or oxycodone/naloxone is potentially useful as a second analgesic step to reduce the duration of TEA. We hypothesized that oxycodone would decrease the duration of TEA and combined with naloxone preserve gastrointestinal function. Ninety patients undergoing open cystectomy and urinary diversion were enrolled in this randomized double-blind, three-arm, parallel-group, placebo-controlled single-center trial between September 2015 and February 2017. Exclusion criteria were known allergy to oxycodone/naloxone, pulmonary diseases, hepatopathy, and analgesics nonnaïve patients. From postoperative day 3, patients received batches with oxycodone, oxycodone/naloxone, or placebo every 12 hours (n = 30 in each arm). Reduction of the epidural drug infusion rate was attempted with the goal to maintain a pain intensity <3 at rest and <5 (numeric rating score) at mobilization during 6 hours. Primary endpoint was duration of TEA and secondary endpoint return of gastrointestinal function. The median duration of TEA did not differ between patients treated with oxycodone/naloxone (6.7 [range 3.1-10.3] days), oxycodone (7.0 [3.0-9.1]), or placebo (6.4 [3.1-8.4]); P = 0.88. Time to the first defecation was prolonged in the oxycodone group compared to the placebo group (difference 22.48 hours ±8.95; P = 0.037). In the oxycodone group, we found 8/30 patients with ileus (27%) compared to 2/28 (7%) in the oxycodone/naloxone group and to 2/30 (7%) in the placebo group; (P = 0.031). Oxycodone, with or without naloxone, did not reduce the duration of TEA. Oxycodone alone led to a delayed return of bowel function, whereas the combination was not different from placebo.

Epidural Analgesia During the Second Stage of Labor: A Randomized Controlled Trial.

To evaluate whether maintaining a motor-sparing epidural analgesia infusion affects the duration of the second stage of labor in nulliparous parturients compared with a placebo control. We conducted a double-blind, randomized, placebo-controlled trial involving nulliparous women with term cephalic singleton pregnancies who requested epidural analgesia. All women received epidural analgesia for the first stage of labor using 0.08% ropivacaine with 0.4 micrograms/mL sufentanil with patient-controlled epidural analgesia. At the onset of the second stage of labor, women were randomized to receive a blinded infusion of the same solution or placebo saline infusion. The primary outcome was the duration of the second stage of labor. A sample size of 200 per group (400 total) was planned to identify at least a 15% difference in duration. Between March 2015 and September 2015, 560 patients were screened and 400 patients (200 in each group) completed the study. Using an intention-to-treat analysis, the duration of the second stage was similar between groups (epidural 52±27 minutes compared with saline 51±25 minutes, P=.52). The spontaneous vaginal delivery rate was also similar (epidural 193 [96.5%] compared with saline 198 [99%], P=.17). Pain scores were similar between groups at each measurement during the second stage. More women who received placebo reported satisfaction scores of 8 or less (epidural 32 [16%] compared with saline 61 [30.5%], P=.001). Maintaining the infusion of epidural medication had no effect on the duration of the second stage of labor compared with a placebo infusion. Maternal and neonatal outcomes were similar. A low concentration of epidural local anesthetic does not affect the duration of the second stage of labor. Chinese Clinical Trial Register, http://www.chictr.org.cn/enindex.aspx, ChiCTR-IOR-15005875.

Epidural analgesia in a paediatric teaching hospital: Trends, developments, and a brief review of literature

Introduction: Continuous epidural analgesia has proven to be a good tool in the anaesthetist’s quest to provide excellent pain relief for an extended perioperative period. Pharmaceutical advances provide us with a larger array of both local anaesthetic (LA) drugs and additives that can prolong the duration or enhance the quality of analgesia, or both. The avoidance of LA toxicity is of paramount importance for safe prescription, especially in the high-risk neonatal and infant cohort, and all patients stand to benefit from ‘safer’ LA agents and adjuvants that promote the use of a lowered concentration of epidural LA infusions. We present a descriptive review of trends in epidural prescription and technique in our hospital. Methods: Our observational study was conducted over a period of 19 years in a tertiary paediatric teaching hospital. Prospectively collected data that included patient demographics, level of epidural catheter insertion, LA drugs and adjuvants used, as well as postoperative infusion rates, were then analysed retrospectively. Results: There was a decline in the use of paediatric epidural analgesia. Over the study period, we also observed a shift in preference of LAs and adjuvant drugs toward safer alternatives. Conclusion: Paediatric epidural analgesia is gradually being superseded by other analgesic modalities with superior safety profiles (e.g. peripheral neural blockade). However, indications remain for its continued use, and anaesthetists should be familiar with its technical aspects and pitfalls.

Acute transient spinal paralysis and cardiac symptoms following an accidental epidural potassium infusion \u2013 a case report

BackgroundTo describe a case of an accidental epidural potassium infusion leading to an acute transient spinal paralysis and cardiac symptoms and review the literature on that topic.Case presentationWe report the case of an accidental infusion of 900 mg potassium chloride 7.45% (KCl) into the epidural space, which occurred during epidural analgesia in a 74-year-old patient suffering from immobilization due to lumbar back pain as well as from a paralytic Ileus. The event was resulting in vegetative symptoms, such as tachycardia and hypertension accompanied by a motor complete tetraplegia (AIS B) sub C2 with respiratory depression. The endotracheal intubation was necessary.The patient was treated with 40 mg dexamethasone intravenously, as well an epidural lavage with sodium chloride solution 0.9% (NaCl) through the epidural catheter. The neurologic symptoms completely resolved within five days. An elevation of troponin-T values and a reduced left ventricular ejection fraction (LVEF) of 40% accompanied by transient pectanginous pain were documented. An exertional dyspnea remained.ConclusionsA symptom complex with elevated sympathetic nervous system activity up to a stress cardiomyopathy is possible following epidural potassium infusion. Additionally, generalized pain and muscle spasticity evolve and a progressive acute spinal cord injury syndrome can occur within minutes, accompanied by respiratory depression. Treatment consists of early intensive care and the symptomatic therapy of the associated symptoms, leading in most of the reported cases to a good clinical outcome.

Continuous epidural infusion versus programmed intermittent epidural bolus for labor analgesia: optimal configuration of parameters to reduce physician-administered top-ups

Background and objectives: Programmed intermittent epidural bolus (PIEB) is a delivery mode associated with decreased local analgesia dosing, motor block, and physician-administered top-ups (PATUs) during labor analgesia. We hypothesized that PIEB delivery at different settings will result in fewer PATUs for labor analgesia than the same hourly volume of a continuous epidural infusion (CEI).Methods: “Before and after” study design of combined spinal–epidural (CSE) for labor, with bupivacaine 0.0625%–fentanyl 2 mcg/ml and patient-controlled epidural analgesia (PCEA; 5 ml bolus with 10 min lock-out). The “before” group (N = 120) received a CEI at 10 ml/hour. PIEB groups received a programmed bolus of 10 ml: every 60 min (PIEB60, N = 120), every 45 min (PIEB45, N = 140), or every 45 min with high flow (500 ml/hour) (PIEB45HF, N = 25).Main outcome measures: Number of women requesting a PATU, time intervals from CSE to PATU and to delivery, and obstetric outcomes.Results: There was no difference in the proportion of women requesting PATUs between the CEI and PIEB60 groups (45/120 versus 52/120, respectively; p > .05). The PATU rate was lower in the PIEB45 group compared with the PIEB60 and CEI groups (23/140 versus 52/120 and 45/120, p < .005 and p < .05, respectively), and in the PIEB45HF versus PIEB60 groups (5/25 versus 52/120, p < .05). No difference in other outcomes was observed.Conclusions: The number of women requesting a PATU was lowest with the PIEB45 and PIEB45HF settings. There were no differences in any other outcomes between groups. This study emphasizes the many variations in programming that need to be further tested to establish the benefits of PIEB delivery compared with traditional CEI with PCEA.

Pre- to postoperative coagulation profile of 307 patients undergoing oesophageal resection with epidural blockade over a 10-year period in a single hospital: implications for the risk of spinal haematoma

BackgroundEpidural anaesthesia and analgesia are indicated for oesophageal surgery. A rare but serious complication is spinal haematoma, which can occur on insertion, manipulation or withdrawal of catheters. Evidence and guidelines are vague regarding which tests are appropriate and how to interpret their results. We aimed to describe how routine coagulation test results change during oesophagectomy’s perioperative course.MethodsFollowing ethical approval, we retrospectively identified patients who had undergone oesophagectomy between 2002 and 2012. Blood test results and details of operations, haemorrhage and complications were recorded and analysed with Excel and R. A literature search was conducted using the PubMed terms ‘epidural’ AND ‘coagulation’ AND English language. Relevant articles published in 2000 and after were included.ResultsThree hundred and seven patients received a thoracic epidural infusion with bupivacaine and morphine while 51 received an intravenous morphine infusion. Tests taken preoperatively and before the planned withdrawal of the epidural catheter demonstrated increases in all three measures: aPTT (activated partial thromboplastin time), PT-INR (prothrombin international normalised ratio) and platelet count (Plc). Postoperative thrombocytopenia was almost non-existent while aPTT or PT-INR was elevated above the reference range in 129/307 patients: aPTT was elevated in 116/307 while PT-INR was elevated in 32/307. This is too small a sample to allow meaningful estimation of risk of spinal haematoma: it may be as high as 2.3%. The literature search returned 275 articles, of which 57 were relevant. Twenty-one concerned the natural history of postoperative coagulation; 16, the incidence of and risk factors for spinal haematoma; and 5, evaluation of specific blood tests. Postoperative coagulation is characterised by thrombocytosis and transient moderately abnormal routine coagulation test results. Viscoelastic tests are not validated in the stable postoperative setting.ConclusionsScreening for coagulopathy before removal of epidural catheters is of unclear benefit since elevated aPTT and PT-INR are usual and may not indicate hypocoagulation. A thorough clinical assessment is important. We nevertheless recommend caution when being presented with elevated routine tests of coagulation before withdrawing an epidural catheter: viscoelastic haemostatic tests may have a role in testing before withdrawal of epidural catheters but they are so far not validated. Future research should include advanced coagulation analysis as soon as a patient is unfortunate enough to have a spinal haematoma.

A Novel Use of Epidural Continuous Infusion in the Outpatient Setting

Complex regional pain syndrome (CRPS, type 1 and type 2) describes a variety of disorders characterized by spontaneous or stimulus-induced pain that is disproportional to the inciting event and is accompanied by a myriad of autonomic and motor disturbances in highly variable combinations. Physical therapy, started as early as possible, is the mainstay of treatment, and pharmacological management and interventional techniques can be used to facilitate the participation in rehabilitation programs. Epidural local anesthetic (LA) use has been reported in the inpatient setting for the treatment of CRPS, but outpatient options are limited. Elastomeric pumps are commonly used for peripheral nerve blocks, postoperative pain, and palliative care in outpatient settings, but not described with epidural infusions. We describe a case of a cervical epidural catheter placed under fluoroscopy, utilizing an elastomeric pump in an outpatient setting. The system consists of a 270 mL elastomeric pump which is filled with 0.05% bupivicaine, delivering a constant 10 mL/hour. The system has a clamp that can be used by the patient to start and stop the infusion. A 23–year-old man presented with right hand/ thumb pain of approximately 2 months duration after an injury while cutting meat at work, resulting in an incomplete fracture of the proximal phalanx and injury to the extensor tendons of his thumb, which were repaired by orthopedics, and a thumb spica splint was placed. The patient described the pain as constant and stabbing, scored as a 5 – 6/10 on a numerical rating scale (NRS), and increased with any activities. The pain was associated with intermittent temperature changes, hypersensitivity to cold water, and occasional color changes. Physical examination was remarkable for a well-healed right thumb, mottling skin discoloration over the right thumb and hand, and hypersensitivity and allodynia to light touch and pinprick over the right hand and radial aspect of the wrist. Previous treatments consisted of physical therapy and oxycodone-acetaminophen as needed. A 3-week trial of pregabalin was tried, without improvement. After discussing alternative treatments (stellate ganglion block), the patient elected to try a local anesthetic (LA) infusion through a cervical epidural catheter. The epidural space was accessed at the C7-T1 level via left paramedian approach under fluoroscopy; the catheter was threaded 5 cm, and a 0.05% bupivacaine infusion was started via an elastomeric pump. On post-procedural day 4 the bupivacaine concentration was increased to 0.1% due to insufficient pain relief. The patient had good pain relief on day 8 and discontinued the infusion on day 16. The catheter was removed on day 18. We report a case of successful treatment of CRPS with an outpatient cervical epidural infusion. This modality has been used successfully for years at Geisinger Medical Center. Our goal is to bring attention to the outpatient use of elastomeric pumps for epidural infusion in the treatment of CRPS. The successful resolution of debilitating symptoms in this patient is encouraging, and the use of elastomeric pumps should be considered for further investigation into its efficacy in patients with CRPS. Key words: Complex regional pain syndrome (CRPS), cervical epidural, outpatient epidural infusion, tunneled epidural catheter

Effect of programmed intermittent epidural boluses and continuous epidural infusion on labor analgesia and obstetric outcomes: a randomized controlled trial.

Continuous epidural infusion and programmed intermittent epidural boluses are analgesic techniques routinely used for pain relief in laboring women. We aimed to assess both techniques and compare them with respect to labor analgesia and obstetric outcomes. After Institutional Review Board approval, 132 laboring women aged between 18 and 45years were randomized to epidural analgesia of 10mL of a mixture of 0.1% bupivacaine plus 2µg/mL of fentanyl either by programmed intermittent boluses or continuous infusion (66 per group). Primary outcome was quality of analgesia. Secondary outcomes were duration of labor, total drug dose used, maternal satisfaction, sensory level, motor block level, presence of unilateral motor block, hemodynamics, side effects, mode of delivery, and newborn outcome. Patients in the programmed intermittent epidural boluses group received statistically less drug dose than those with continuous epidural infusion (24.9 vs 34.4mL bupivacaine; P=0.01). There was no difference between groups regarding pain control, characteristics of block, hemodynamics, side effects, and Apgar scores. Our study evidenced a lower anesthetic consumption in the programmed intermittent boluses group with similar labor analgesic control, and obstetric and newborn outcomes in both groups.