Epidural Local Anesthetics Research Articles

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

(Obstet Gynecol. 2017;130(5):1097–1103) Although epidural analgesia provides effective labor pain relief, studies have found an association with a prolonged duration of second stage labor, and thus, increased risk of adverse outcomes. Subsequently, many obstetric care providers request termination of epidural infusions for the second stage of labor. In the present study, the authors evaluated the use of low-concentration epidural local anesthetics and hypothesized that this management technique would have minimal effect on second stage labor.

Epidural haloperidol enhances epidural morphine analgesia: Three case reports

Epidural opioids provide significant postoperative analgesia; however, their use is often limited by side effects such as nausea and pruritus, or they require the addition of epidural local anesthetics with possible side effects of motor block and hypotension. Adjuncts to epidural opioid analgesia would benefit pain management. There is evidence that epidural butyrophenones may enhance opioid analgesics and reduce side effects. The authors present the first reported use of epidural haloperidol to enhance epidural morphine analgesia in three individuals. Pharmacodynamic interactions of haloperidol, which may explain its analgesic efficacy, are summarized.

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.

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

The Role Of Epidural Fentanyl In Painless Labour

Background: Epidural analgesia for providing Painless normal vaginal deliveries has been developed over the last 20 years,epidural local anaesthetics was the only available option. However, cetain drugs were added with the local anaesthetics to improves the quality of analgesia.Aims : to ascertain the efficiency of fentanyl added to the epidural local anaesthetics in comparison with the use of an epidural local anaesthetics alone.Patient and methods : This study was carried out on 30 parturients prepared for painless normal vaginal delivery under epidural analgesia in Al-khuder general hospital.
 Anaesthesiologist (ASA) classification were grade 1 between 20-40 of age with length taller than 160 cm.Subjects were allocated into two groups (15 patients in each group): Group A (n=15) received through an epidural catheter 8 ml lidocaine 0.75%+ 2ml normal saline for the first main dose and subsequent top up doses. Group B (n=15) received through an epidural catheter 8ml lidocaine o.75% + 20 microgram fentanyl diluted with normal saline to a total 2 ml volume for the first main dose and subsequent top up doses. Onset of action of local anaesthetic , the interval from initial bolus dose to the maternal request for additional analgesia , the number of top up doses and the neonatal condition in both groups were recorded.Results : the group B is associated with shorter onset of action , longer interval from initial bolus dose to the maternal request for additional dose and a lesser number of top up doses than group A. The effect on neonatal condition manifested by APGAR score at 5 minute after delivery is similar in both groups.conclusions : 20 microgram of fentanyl added to the usual dose of local anaesthetic epidurally is safe , effective and much better than the use of epidural local anaesthetic alone.

Treatment of acute sciatica with transforaminal epidural corticosteroids and local anesthetic: design of a randomized controlled trial

BackgroundTransforaminal epidural injections with steroids (TESI) are used increasingly for patients with sciatica. However there is much debate about their safety and effectiveness. It is important to identify patients that benefit most from TESI and only few trials have yet evaluated the effects in patients with acute sciatica.MethodsWe describe a prospective, randomized controlled trial (RCT), with the aim to evaluate the hypothesis that TESI plus Levobupivacaine (TESI-plus) added to oral pain medication is more effective compared to pain medication alone or compared to transforaminal injection with a local anesthetic of short duration among patients with acute sciatica. We will recruit a total of 264 patients with sciatica (<8 weeks) caused by a herniated disc, from two clinical sites. Participants are randomly assigned one of three study groups: 1) oral pain medication (control group), 2) oral pain medication and TESI-plus (intervention group one), 3) oral pain medication and transforaminal epidural injection (TEI) with Levobupivaine and saline solution (intervention group two). Primary outcomes are functional status (Roland-Morris Disability Questionnaire), pain intensity for both leg and back, (100 mm visual analogous scale (VAS)), and global perceived recovery (GPR, reported on a 7-point Likert scale, dichotomized into ‘recovered’ and ‘not recovered’). The secondary outcomes are health-related quality of life (EQ5D-5 L) and patient satisfaction (7-point Likert scale). We will also collect information on healthcare utilization and costs, to perform an economic evaluation. All outcomes are measured at three and six weeks, three and six months after randomization. We defined a minimal clinically relevant difference between groups as a difference between both intervention groups and the control group of 20 points for pain (100-point VAS), four points for functional status (24-point RDQ) and a 20% difference on dichotomized GPR (recovered versus not recovered).DiscussionA clinically relevant outcome in favor of TESI-plus implies that future patients with acute sciatica should be recommended TESI-plus within the first few weeks rather than being treated with pain medication alone in order to relieve pain and improve their functioning. In case of a negative result (no relevant differences in outcome between the three study arms), pain medication will remain the mainstay of treatment in the acute stages of sciatica.Trial registrationDutch National trial register: NTR4457 (March, 6th, 2014)

A comparative study of dexmedetomidine and fentanyl as an adjuvant to epidural bupivacaine in lower limb surgeries

Background: Epidural anesthesia is the most commonly used technique for inducing surgical anesthesia and postoperative analgesia in patients undergoing lower limb surgeries. Fentanyl as an adjuvant to epidural local anesthetic has been used for a long time. Dexmedetomidine is a potent and highly selective α-2-adrenoceptor agonist with analgesic potency. Aim: The aim of the present study was to compare the effect of dexmedetomidine and fentanyl as an adjuvant to epidural bupivacaine in lower limb surgeries. Materials and Methods: Sixty patients belonging to the American Society of Anesthesiologists' Grade I or II who were undergoing lower limb surgery were randomly divided into two groups. Group BD: received epidural study solution of 38 ml of 0.25% bupivacaine hydrochloride + 1 ml of 100 μg dexmedetomidine + 1 ml of normal saline. Group BF: received epidural study solution of 38 ml of 0.25% bupivacaine hydrochloride + 2 ml of 100 μg fentanyl. Onset and maximum level of sensory blockade, time to attain maximum sensory level, time to complete motor blockade, time for two-segment regression, duration of analgesia and motor block, heart rate, and blood pressure were observed. Pain and sedation were assessed by numerical rating scale and Ramsay Sedation Scale, respectively. Data were recorded and statistically analyzed. Results: The onset of sensory blockade and time to attain maximum sensory level in Group BD were earlier than that of Group BF (P < 0.001). Duration of analgesia and motor blockade in Group BD were significantly more than that of Group BF (P < 0.001). Postoperative visual analog scale was reduced statistically significantly in Group BD (P < 0.001). Conclusion: Dexmedetomidine as an adjuvant to epidural bupivacaine is a better alternative to fentanyl with higher analgesic property.

Epidural Local Anesthetics Versus Opioid-Based Analgesic Regimens for Postoperative Gastrointestinal Paralysis, Vomiting, and Pain After Abdominal Surgery: A Cochrane Review.

The aim of this review was to compare the effects of postoperative epidural analgesia with local anesthetics to postoperative systemic or epidural opioids in terms of return of gastrointestinal transit, postoperative pain control, postoperative vomiting, incidence of gastrointestinal anastomotic leak, hospital length of stay, and cost after abdominal surgery. Trials were identified by computerized searches of the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 12), Medical Literature Analysis and Retrieval System Online (MEDLINE) (from 1950 to December, 2014) and Excerpta Medica dataBASE (EMBASE) (from 1974 to December 2014) and by checking the reference lists of trials retained. We included parallel randomized controlled trials comparing the effects of postoperative epidural local anesthetic with regimens based on systemic or epidural opioids. The quality of the studies was rated according to the Cochrane tool. Two authors independently extracted data. We judged the quality of evidence according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) working group scale. Based on 22 trials including 1138 participants, an epidural containing a local anesthetic will decrease the time required for return of gastrointestinal transit as measured by time required to observe the first flatus after an abdominal surgery standardized mean difference (SMD) -1.28 (95% confidence interval [CI], -1.71 to -0.86; high quality of evidence; equivalent to 17.5 hours). The effect is proportional to the concentration of local anesthetic used. Based on 28 trials including 1559 participants, we also found a decrease in time to first feces (stool): SMD -0.67 (95% CI, -0.86 to -0.47; low quality of evidence; equivalent to 22 hours). Based on 35 trials including 2731 participants, pain on movement at 24 hours after surgery is also reduced: SMD -0.89 (95% CI, -1.08 to -0.70; moderate quality of evidence; equivalent to 2.5 on a scale from 0 to 10). Based on 22 trials including 1154 participants, we did not find a difference in the incidence of vomiting within 24 hours: risk ratio 0.84 (95% CI, 0.57-1.23); low quality of evidence. Based on 17 trials including 848 participants we did not find a difference in the incidence of gastrointestinal anastomotic leak: risk ratio 0.74 (95% CI, 0.41-1.32; low quality of evidence). Based on 30 trials including 2598 participants, epidural analgesia reduces length of hospital stay for an open surgery: SMD -0.20 (95% CI, -0.35 to -0.04; very low quality of evidence; equivalent to 1 day). Data on cost were very limited. An epidural containing a local anesthetic, with or without the addition of an opioid, accelerates the return of the gastrointestinal transit (high quality of evidence). An epidural containing a local anesthetic with an opioid decreases pain after an abdominal surgery (moderate quality of evidence). An epidural containing a local anesthetic does not affect the incidence of vomiting or anastomotic leak (low quality of evidence). For an open surgery, an epidural containing a local anesthetic would reduce the length of hospital stay (very low quality of evidence).

Fluoroscopically Guided Thoracic Interlaminar Epidural Injection: A Comparative Epidurography Study Using 2.5 mL and 5 mL of Contrast Dye

Background: Thoracic epidural anesthesia (TEA) is frequently used to maintain intraoperative analgesia. After injecting the initial bolus dose of epidural local anesthetics (LA), intermittent injection of LA through an epidural catheter is required to maintain the intraoperative analgesia. For intermittent epidural administration, usually 2 – 5 mL of LA has been used. However, no studies have suggested an optimal volume of LA of TEA for intermittent epidural administration of TEA. Objective: We focused on identifying an optimal volume of LA of TEA using epidurography of the thoracic level with 2 different volumes of contrast dye. Study Design: Prospective, randomized study. Setting: An interventional pain management practice in South Korea. Methods: After Institutional Review Board approval, 70 patients undergoing thoracic epidural catheterization for upper abdominal and thoracic surgery were randomly assigned to one of the 2 contrast dye volume groups of 35 patients each (A, 2.5 mL and B, 5.0 mL). Epidurography was evaluated to confirm how many spinal segments were covered by contrast dye. The spreads in the cephalad and caudad directions were also evaluated. Results: The total number of vertebral segments evaluated by contrast dye were 7.5 ± 2.0, and 8.4 ± 2.6, respectively in groups A and B. The number of patients who showed contrast dye spread of more than 5 vertebral segments was 34/35 (97%) in both groups. Group B resulted in higher contrast dye distribution in the cephalad direction compared to group A (T2.6 vs. T3.6 ). Limitations: We used a test dose of contrast dye to confirm the contrast was in epidural space, not intrathecal or vascular, before injection of the main dose of contrast dye. The present study did not include the volume of test dose. Conclusion: The volume of 2.5 mL for intermittent epidural administration would be enough for the analgesic effect of upper abdominal and thoracic surgery while avoiding excessive upper thoracic and cervical spread. Key words: Thoracic epidural anesthesia, intermittent epidural administration, optimal volume, epidurography, cephalad, caudad, analgesic effect

Controlled release ibuprofen-poloxamer gel for epidural use – A pharmacokinetic study using microdialysis in pigs

In order to avoid the risks of sideeffects of epidural local anesthetics and opioids, the use of nonsteroidal anti-inflammatory drugs (NSAIDs) epidurally would be an interesting option of analgesic therapy. The fairly short duration of action of spinally administered NSAIDs, e.g., ibuprofen, may be prolonged by using controlled release poloxamer gel formulation. Using a microdialysis technique we studied the epidural and intrathecal pharmacokinetics of ibuprofen after its epidural administration as a poloxamer 407 formulation or a solution formulation. In addition, plasma ibuprofen concentrations were analyzed from central venous blood samples. Ibuprofen concentrations in the epidural space were significantly higher and longer lasting after the epidural gel injection compared with the epidural solution injection. The epidural AUC of ibuprofen was over threefold greater after epidural ibuprofen gel injection compared with the ibuprofen solution injection (p<0.001). The systemic absorption of ibuprofen from 25% poloxamer 407 gel was very low. The in situ forming poloxamer gel acted as a reservoir allowing targeted ibuprofen release at the epidural injection site and restricted ibuprofen molecules to a smaller spinal area. Ibuprofen diffusion from the epidural space to the intrathecal space was steady and prolonged. These results demonstrate that the use of epidurally injectable poloxamer gel can increase and prolong ibuprofen delivery from epidural space to the CSF enhancing thus ibuprofen entry into the central neuroaxis for spinal analgesia. Further toxicological and dose-finding studies are justified.

Epidural local anaesthetics versus opioid-based analgesic regimens for postoperative gastrointestinal paralysis, vomiting and pain after abdominal surgery.

Gastrointestinal paralysis, nausea and vomiting and pain are major clinical problems following abdominal surgery. Anaesthetic and analgesic techniques that reduce pain and postoperative nausea and vomiting (PONV), while preventing or reducing postoperative ileus, may reduce postoperative morbidity, duration of hospitalization and hospital costs. This review was first published in 2001 and was updated by new review authors in 2016. To compare effects of postoperative epidural analgesia with local anaesthetics versus postoperative systemic or epidural opioids in terms of return of gastrointestinal transit, postoperative pain control, postoperative vomiting, incidence of anastomotic leak, length of hospital stay and costs after abdominal surgery. We identified trials by conducting computerized searches of the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 12), MEDLINE (from 1950 to December 2014) and EMBASE (from 1974 to December 2014) and by checking the reference lists of trials retained. When we reran the search in February 2016, we added 16 potential new studies of interest to the list of 'Studies awaiting classification' and will incorporate these studies into formal review findings during the next review update. We included parallel randomized controlled trials comparing effects of postoperative epidural local anaesthetic versus regimens based on systemic or epidural opioids. We rated the quality of studies by using the Cochrane 'Risk of bias' tool. Two review authors independently extracted data and judged the quality of evidence according to the GRADE (Grades of Recommendation, Assessment, Development and Evaluation Working Group) scale. We included 128 trials with 8754 participants in the review, and 94 trials with 5846 participants in the analysis. Trials included in the review were funded as follows: charity (n = 19), departmental resources (n = 8), governmental sources (n = 15) and industry (in part or in total) (n = 15). The source of funding was not specified for the other studies.Results of 22 trials including 1138 participants show that an epidural containing a local anaesthetic will decrease the time required for return of gastrointestinal transit as measured by time to first flatus after an abdominal surgery (standardized mean difference (SMD) -1.28, 95% confidence interval (CI) -1.71 to -0.86; high quality of evidence; equivalent to 17.5 hours). The effect is proportionate to the concentration of local anaesthetic used. A total of 28 trials including 1559 participants reported a decrease in time to first faeces (stool) (SMD -0.67, 95% CI -0.86 to -0.47; low quality of evidence; equivalent to 22 hours). Thirty-five trials including 2731 participants found that pain on movement at 24 hours after surgery was also reduced (SMD -0.89, 95% CI -1.08 to -0.70; moderate quality of evidence; equivalent to 2.5 on scale from 0 to 10). From findings of 22 trials including 1154 participants we did not find a difference in the incidence of vomiting within 24 hours (risk ratio (RR) 0.84, 95% CI 0.57 to 1.23; low quality of evidence). From investigators in 17 trials including 848 participants we did not find a difference in the incidence of gastrointestinal anastomotic leak (RR 0.74, 95% CI 0.41 to 1.32; low quality of evidence). Researchers in 30 trials including 2598 participants noted that epidural analgesia reduced length of hospital stay for an open surgery (SMD -0.20, 95% CI -0.35 to -0.04; very low quality of evidence; equivalent to one day). Data on costs were very limited. An epidural containing a local anaesthetic, with or without the addition of an opioid, accelerates the return of gastrointestinal transit (high quality of evidence). An epidural containing a local anaesthetic with an opioid decreases pain after abdominal surgery (moderate quality of evidence). We did not find a difference in the incidence of vomiting or anastomotic leak (low quality of evidence). For open surgery, an epidural containing a local anaesthetic would reduce the length of hospital stay (very low quality of evidence).

A dose reduction study of local anesthetic with addition of dexmedetomidine on postoperative epidural analgesia after total knee arthroplasty

BackgroundEpidural analgesia is still the preferred method of postoperative analgesia for total knee arthroplasty in many countries. Dexmedetomidine is a new alpha-2 agonist which had many beneficial effects when administered epidurally. The aim of study was to provide effective postoperative analgesia with hemodynamic stability through reduction of the amount of epidural local anesthetic by adding dexmedetomidine.Methods75 patients, 50–70 years old, ASA physical status I–III undergoing total knee arthroplasty were randomly divided into three equal groups, group I received 0.125% bupivacaine 5 ml/h for postoperative analgesia, group II received 4 ml of a mixture of bupivacaine 0.125% and dexmedetomidine 0.2 μg/kg/h and group III received 3 ml of a mixture of bupivacaine 0.125% and dexmedetomidine 0.2 μg/kg/h. Postoperative pain were scored by visual analog scale (VAS), sedation score, postoperative nalbuphine consumption and hemodynamic parameters were recorded every 4 h for 48 h postoperatively.ResultsThe demographic data were comparable in all groups. VAS (visual analog scale) of pain showed a significant reduction between the two groups II, III and group I with insignificant difference between groups II and III at both rest and movement. The mean of nalbuphine consumption during the study period was significantly reduced in group II, III than in group I with insignificant difference between groups II and III. Sedation scores were significantly higher in groups II and III compared to group I. Heart rate was more reduced in groups II and III than in group I with insignificant difference between the groups. The mean arterial blood pressure was significantly reduced in group I than groups II and III from hour 8 till the end of the study.ConclusionDexmedetomidine is an effective adjuvant to epidural bupivacaine for postoperative analgesia after total knee arthroplasty through reducing the amount of local anesthetic.

Effect of Adding Calcitonin to Translaminar Epidural Steroid in Degenerative Lumbar Spinal Canal Stenosis

Background: Spinal canal stenosis is one of the most common causes of low back pain and disability. Its management varies from surgical to conservative, and the indications for ideal management are not clearly defined. Objectives: This study was conducted to evaluate the effect of adding calcitonin to local anesthetic and corticosteroid in epidural injection for patients suffering from degenerative lumbar spinal canal stenosis. Study Design: Randomized double-blind clinical trial. Setting: Hospital outpatient setting. Methods: One hundred thirty-two patients with degenerative spinal canal stenosis were randomly allocated into 2 groups. Group I received C-arm guided epidural injection of local anesthetic and corticosteroid and Group II received 50 international unit calcitonin added to the mixture of local anesthetic and corticosteroid. Both groups received 2 sets of injections, one week apart. Visual analogue scale for pain during movement and walking distance until incidence of neurogenic claudication have been used for pain assessment, and Oswestry Low Back Pain Disability Questionnaire and analgesic consumption were evaluated for one year. Results: Both groups showed comparable benefits regarding improvement in pain intensity, walking distance, Oswestry scale, and analgesic consumption during the first month follow-up period. These beneficial effects continued in calcitonin group for one year. Limitations: The present study patients would be graded as having mild or at worst moderate stenosis. So, the present study did not examine the efficacy of epidural calcitonin in severe spinal canal stenosis and did not stratify the results according to degree of stenosis which would also have been useful in determining the validity of calcitonin in different degrees of stenosis. Conclusion: Adding calcitonin to epidural steroid and local anesthetic injection seems to be more effective than epidural steroid and local anesthesia alone in management of spinal canal stenosis regarding increased walking distance, better Oswestry scale, diminished pain intensity and perception of paresthesia, and less analgesic consumption, all the above mentioned benefits continued up to one year. So, epidural calcitonin may be considered as a new therapeutic modality in the management of pain in spinal canal stenosis. Key words: Calcitonin, epidural steroid, lumbar, spinal canal stenosis

Transforaminal Epidural Steroid Injections for Treating Lumbosacral Radicular Pain from Herniated Intervertebral Discs: A Systematic Review and Meta-Analysis.

Steroids often are administered into the epidural space through the transforaminal epidural (TFE) route to treat lumbosacral radicular pain secondary to herniated intervertebral discs. However, their efficacy and safety compared with transforaminal epidural local anesthetics (LAs) or saline injections is unclear. We reviewed randomized controlled trials that compared TFE injections of steroids (with or without LA) with LA or saline in adult outpatients with lumbosacral radicular pain secondary to herniated intervertebral disks. Databases searched included MEDLINE, EMBASE, Cochrane central register of controlled trials, Cochrane database of systematic reviews, and Google Scholar up to February 2015. Data on scores of numerical rating scale for pain, validated scores for measuring physical disability and quality of life, and incidence of surgery measured at 1 month to 2 years after the interventions were meta-analyzed. Strength of evidence was classified with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Eight randomized controlled trials including 771 patients (366 in steroid and 405 in comparator groups) were included. There was variability in the studies in the dose of TFE steroids, frequency, and number of procedures. Patients who received TFE steroids reported a significant, but clinically modest, reduction in mean pain scores (0-10 scale) compared with LA/saline (-0.97 points; 95% confidence interval, -1.42 to -0.51 points; P < 0.0001, I² = 90%; GRADE weak recommendation; moderate-quality evidence) at 3 months after the interventions. TFE steroids did not decrease physical disability at 1 to 3 months after the intervention (GRADE strong recommendation ↓; high-quality evidence) or incidence of surgery at 12 months after the intervention (GRADE strong recommendation ↓; moderate-quality evidence) compared with LA/saline. TFE steroids provide modest analgesic benefit at 3 months in patients with lumbosacral radicular pain secondary to herniated intervertebral disks, but they have no impact on physical disability or incidence of surgery. There was a high degree of heterogeneity among the publications included in this meta-analysis. Well-designed, large, randomized studies are required to evaluate appropriate dosages, adverse effects, number of procedures, and the effect of this intervention on psychological disability and quality of life.

Neuraxial block and postoperative epidural analgesia: effects on outcomes in the POISE-2 trial

BackgroundWe assessed associations between intraoperative neuraxial block and postoperative epidural analgesia, and a composite primary outcome of death or non-fatal myocardial infarction, at 30 days post-randomization in POISE-2 Trial subjects. Methods10 010 high-risk noncardiac surgical patients were randomized aspirin or placebo and clonidine or placebo. Neuraxial block was defined as intraoperative spinal anaesthesia, or thoracic or lumbar epidural anaesthesia. Postoperative epidural analgesia was defined as postoperative epidural local anaesthetic and/or opioid administration. We used logistic regression with weighting using estimated propensity scores. ResultsNeuraxial block was not associated with the primary outcome [7.5% vs 6.5%; odds ratio (OR), 0.89; 95% CI (confidence interval), 0.73–1.08; P+0.24], death (1.0% vs 1.4%; OR, 0.84; 95% CI, 0.53–1.35; P+0.48), myocardial infarction (6.9% vs 5.5%; OR, 0.91; 95% CI, 0.74–1.12; P+0.36) or stroke (0.3% vs 0.4%; OR, 1.05; 95% CI, 0.44–2.49; P+0.91). Neuraxial block was associated with less clinically important hypotension (39% vs 46%; OR, 0.90; 95% CI, 0.81–1.00; P+0.04). Postoperative epidural analgesia was not associated with the primary outcome (11.8% vs 6.2%; OR, 1.48; 95% CI, 0.89–2.48; P+0.13), death (1.3% vs 0.8%; OR, 0.84; 95% CI, 0.35–1.99; P+0.68], myocardial infarction (11.0% vs 5.7%; OR, 1.53; 95% CI, 0.90–2.61; P+0.11], stroke (0.4% vs 0.4%; OR, 0.65; 95% CI, 0.18–2.32; P+0.50] or clinically important hypotension (63% vs 36%; OR, 1.40; 95% CI, 0.95–2.09; P+0.09). ConclusionsNeuraxial block and postoperative epidural analgesia were not associated with adverse cardiovascular outcomes among POISE-2 subjects.

Efficacy of epidural local anesthetic and dexamethasone in providing postoperative analgesia: A meta-analysis.

Background:Dexamethasone is a potent anti-inflammatory, analgesic, and antiemetic drug. Individual randomized controlled trials found a possible benefit of epidural dexamethasone. The purpose of this meta-analysis is to estimate the benefit of epidural dexamethasone on postoperative pain and opioid consumption and to formulate a recommendation for evidence-based practice.Materials and Methods:Prospective, randomized controlled trials comparing the analgesic efficacy of epidural local anesthetic and dexamethasone combination, with local anesthetic alone for postoperative pain management after abdominal surgery, were planned to be included in this meta-analysis. PubMed, PubMed Central, Scopus, and Central Register of Clinical Trials of the Cochrane Collaboration (CENTRAL) databases were searched for eligible controlled trials using the following search words: “Epidural”, “dexamethasone”, and “postoperative pain”, until February 20, 2015.Results:Data from five randomized control trials have been included in this meta-analysis. Epidural dexamethasone significantly decreased postoperative morphine consumption (mean difference −7.89 mg; 95% confidence interval [CI]: −11.66 to −3.71) and number of patients required postoperative rescue analgesic boluses (risk ratio: 0.51; 95% CI: 0.41-0.63).Conclusion:The present data shows that the addition of dexamethasone to local anesthetic in epidural is beneficial for postoperative pain management.

Caudal extradural catheterization in pediatric renal transplant and its effect on perioperative hemodynamics and pain scoring: a prospective randomized study

'Hockey stick incision' used in renal transplant is large enough to cause severe postoperative morbidity especially in pediatric recipients. Although epidural analgesia is known to be effective in pain control, the resulting sympathectomy might affect hemodynamics interfering with the transplant process. In our study, we evaluated the feasibility and safety of inserting an epidural catheter to the thoracic level via the caudal route, and the effect of using epidural local anesthetics at low concentrations on hemodynamics. After approval from the ethical committee at Kasr Al Ainy University Hospital and consent from parents/legal guardians, sixty patients aged 3-12years who were scheduled for renal transplant were randomly divided into two equal groups. Group I (epidural group) received continuous caudal epidural bupivacaine 0.125% with fentanyl together with intravenous (IV) fentanyl and paracetamol. Group II (control group) received only IV fentanyl and paracetamol. Intraoperative data included heart rate (HR), mean arterial blood pressure (MAP) and central venous pressure (CVP). Postoperative variables included HR, MAP, CVP, pain score and complications. Threading failure via the caudal route occurred in 6.67% of cases. Intraoperative differences in hemodynamics and CVP were not clinically significant between groups. Postoperative HR, MAP, and CVP were generally higher in the control group. Pain control was more satisfactory and postoperative complications were less in the epidural group. Caudal epidural anesthesia in pediatric renal transplant is a valuable addition to general anesthesia as it provides stable perioperative hemodynamics, excellent postoperative analgesia and is associated with fewer complications than narcotic-dependent analgesia. NCT02037802.

Epidural administration of anesthetics and corticosteroids in treatment of acute radicular pain syndrome of lumbar spine in neurosurgical department

Мета. Оцінка ефективності епідурального введення кортикостероїдів та місцевих анестетиків (МА) при корінцевих синдромах, пов’язаних з дискорадикулярним конфліктом у поперековому відділі хребта. Матеріали і методи. Епідуральні ін’єкції (ЕІ) кортикостероїдів та МА з приводу корінцевих больових синдромів поперекового відділу хребта здійснені у 348 пацієнтів, яких лікували у нейрохірургічному відділенні Вінницької обласної психоневрологічної лікарні. Процедуру проводили в умовах операційної під місцевим знеболенням. Ми не використовували рентгеноскопічний контроль під час виконання блокади. Вводили суміш розчину бетаметазону 2 мл з 0,5% розчином бупівакаїну 5 мл. Результати. Позитивний результат епідуральної блокади (ЕБ) досягнутий у 86,8% спостережень. Як правило, пацієнти відчували зменшення вираженості больового синдрому відразу після процедури, ефект збільшувався до 2–3-ї доби. У 54 (15,5%) пацієнтів вираженість больового синдрому зменшилася на 30–50% (інтенсивність болю оцінювали за ВАШ) після першої блокади, тому ЕБ проводили повторно. У 46 (13,2%) пацієнтів після ЕБ полегшення не було, з приводу інтенсивного больового синдрому здійснено операцію. Висновки. Епідуральне введення кортикостероїдів та МА у практиці нейрохірургічного відділення є ефективним методом лікування больових синдромів в поперековому відділі хребта та корінцевого больового синдрому, зумовлених запальним процесом, має низький рівень ризику, є критерієм для визначення необхідності виконання хірургічного втручання.

Non-intubated video-assisted thoracic surgery management of secondary spontaneous pneumothorax.

Secondary spontaneous pneumothorax (SSP) is serious entity, usually due to underlying disease, mainly chronic obstructive pulmonary disease (COPD). Its morbidity and mortality is high due to the pulmonary compromised status of these patients, and the recurrence rate is almost 50%, increasing mortality with each episode. For persistent or recurrent SSP, surgery under general anesthesia (GA) and mechanical ventilation (MV) with lung isolation is the gold standard, but ventilator-induced damages and dependency, and postoperative pulmonary complications are frequent. In the last two decades, several groups have reported successful results with non-intubated video-assisted thoracic surgery (NI-VATS) with thoracic epidural anesthesia (TEA) and/or local anesthesia under spontaneous breathing. Main benefits reported are operative time, operation room time and hospital stay reduction, and postoperative respiratory complications decrease when comparing to GA, thus encouraging for further research in these moderate to high risk patients many times rejected for the standard regimen. There are also reports of special situations with satisfactory results, as in contralateral pneumonectomy and lung transplantation. The aim of this review is to collect, analyze and discuss all the available evidence, and seek for future lines of investigation.