Peridural Catheter Research Articles

The "Big Five" of Invasiveness - the Usefulness of Drains, Probes and Catheters in Colorectal Surgery

The perioperative management of colorectal resections is often dominated by traditional procedures and a strong focus on safety. Evidence-based measures such as those established in Fast Track or ERAS programs, are rarely applied in a standardised manner. As part of elective colorectal surgery, many patients therefore continue to routinely receive central venous access, peridural catheters, urinary catheters, drains and/or gastric tubes ("Big Five" of invasiveness). This article presents the currently available evidence on these measures in colorectal surgery. In addition, results relating to the "Big Five" from the author's own centre are presented. This review shows that the "Big Five" of invasiveness are clinically unnecessary or supported by evidence. In addition, they often impair the patient's function.

Anesthetic considerations and postoperative pain management in radical penectomy: Case report

Radical penectomy (RP) is infrequently performed as it is reserved for specific cases of penile cancer, hence the paucity of reports regarding surgical and anesthetic considerations. Acute postoperative pain, chronic post-surgical pain, concomitant mood disorders as well as a profound impact on the patient’s quality of life have been documented. This case is of a patient with diabetes and coronary heart disease, who presented with advanced, overinfected penile cancer, depressive disorder and a history of pain of neuropathic characteristics. The patient underwent radical penectomy using a combined spinal-epidural technique for anesthesia. Preoperatively, the patient was treated with pregabalin and magnesium sulphate, and later received a blood transfusion due to intraoperative blood loss. Adequate intra and postoperative analgesia was achieved with L-bupivacaine given through a peridural catheter during one week. Recovery was good, pain was stabilized to preoperative levels and the patient received pharmacological support and follow-up by psychiatry and the pain team.

Treatment Strategies and Outcome of the Exstrophy-Epispadias Complex in Germany: Data From the German CURE-Net.

Introduction: To evaluate the impact of reconstructive strategies and post-operative management on short- and long-term surgical outcome and complications of classical bladder exstrophy (CBE) patients' comprehensive data of the multicenter German-wide Network for Congenital Uro-Rectal malformations (CURE-Net) were analyzed.Methods: Descriptive analyses were performed between 34 prospectively collected CBE patients born since 2009, median 3 months old [interquartile range (IQR), 2–4 months], and 113 cross-sectional patients, median 12 years old (IQR, 6–21 years).Results: The majority of included individuals were males (67%). Sixty-eight percent of the prospectively observed and 53% of the cross-sectional patients were reconstructed using a staged approach (p = 0.17). Although prospectively observed patients were operated on at a younger age, the post-operative management did not significantly change in the years before and after 2009. Solely, in prospectively observed patients, peridural catheters were used significantly more often (p = 0.017). Blood transfusions were significantly more frequent in males (p = 0.002). Only half of all CBE individuals underwent inguinal hernia repair. Cross-sectional patients after single-stage reconstructions showed more direct post-operative complications such as upper urinary tract dilatations (p = 0.0021) or urinary tract infections (p = 0.023), but not more frequent renal function impairment compared to patients after the staged approach (p = 0.42). Continence outcomes were not significantly different between the concepts (p = 0.51). Self-reported continence data showed that the majority of the included CBE patients was intermittent or continuous incontinent. Furthermore, subsequent consecutive augmentations and catheterizable stomata did not significantly differ between the two operative approaches. Urinary diversions were only reported after the staged concept.Conclusions: In this German multicenter study, a trend toward the staged concept was observed. While single-stage approaches tended to have initially more complications such as renal dilatation or urinary tract infections, additional surgery such as augmentations and stomata appeared to be similar after staged and single-stage reconstructions in the long term.

Schmerztherapie nach thoraxchirurgischen Eingriffen

The treatment of pain after thoracic surgery is a challenge and takes place in the individual clinics mostly according to clinic internal standards. It exists no currently valid S3 guideline for the treatment of acute perioperative and posttraumatic pain. For an effective pain treatment as well individual pain experience as the pain intensity of the various thoracic surgical procedures must be considered. Regular pain assessment with appropriate methods and their documentation form the basis for adequate and adapted pain therapy.There are a number of different pain therapy methods, non-medicamentous and drug-based methods, whose effectiveness is described in the literature partially different. For the treatment of acute postoperative pain after thoracic surgery, mainly drug-related procedures are used, except for physiotherapy as a non-medicamentous method. Increasingly, alternative procedures for the peridural catheter as a therapeutic gold standard in the treatment of pain after thoracic surgery are used. Their application can be integrated into a therapeutic algorithm.

The use of peridural catheter in the treatment of chronic malignant pain in the abdomen: Case report (peridural catheter in the treatment chronic pain)

Introduction: Chronic pain in the abdomen occurs as a consequence of malignancy in these parts of the body, surgical, of radiological and chemotherapy treatments. It may also be as a result of relapse of the basic process. Non-invasive therapy of oral and transdermal analgesic was successful for some time, where necessary applies and epidural catheter. Case Report: The patient had a diagnosis of chronic postoperative pain malignant etiology. He is already used transdermal fentanyl and Nonsteroidal Anti-Inflammatory Drugs, but without success (VAS score 8-10). We increased doses of analgesics, but without success. In order of pain therapy, peridural catheter placed in the level L3 - L4. 5 ml of a solution of 8 ml of 0.25% bupivacaine, 2 ml (100 micrograms) of fentanyl and 10 ml of saline was administered every 6 hours through epidural catheter. The former chronic non-invasive treatment of pain did not stop. The first three to five days of pain relief was quite satisfactory in this way. Then the pain intensified but the peridural catheter had to be removed due to local infection. New peridural catheter was placed in the level L2 -L3. Then, 5 ml of the solution: of 8 ml 0,25% bupivacaine, 2 ml (100 micrograms) of fentanyl and 10 ml of saline is administered through peridural catheter. Peridural catheter was total used for 45 days. We had a need for more and more frequently administering analgesics through a catheter during use. The patient was using transdermal fentanyl and Nonsteroidal Anti-Inflammatory Drugs, all the time. The patient soon died due to progression of the underlying disease. Conclusion: After long-term administration of opioids, it is necessary to change the type and route of administration of the drug to achieve the success of the therapy. In this case it was the use of analgesics and local anesthetics through the peridural catheter.

DETECTION AND MONITORING OF TISSUE ISCHEMIA DUE TO ACUTE ARTERIAL OBSTRUCTION IN THE LIMBS OF PATIENTS WITH QUANTITATIVE VIOLATIONS IN CONSCIOUSNESS, PERIDURAL ANESTHESIA

Traced and interpreted is the dynamic and correlative relations between the values of certain biochemical parameters of the homeostasis connected with cell metabolism in skeletal muscles so a verification of tissue ischemia (TI) and ischemic tissue lesion (ITL) can be performed. The target group is patients with quantitative violations in consciousness and peridural catheters placed for anesthesia, with the suspicion that an acute arterial obstruction in the limbs (AAOL) has occurred, or one has already been verified. Test of the serum levels of CK; CK (MB); ASAT; ALAT and Myoglobin were initially performed and were monitored in dynamic. A valuation of the ASAT/ALAT index in close correlation with the other parameters and clinical course of the disease was also performed. A particular dynamic and correlation, before the operation, after the timely revascularization, during the development of ischemic gangrene and after the amputation on an optimal level, was observed. We found an acute elevation of the enzyme activity of CK; CK (MB) and ASAT in the case of AAOL which generated TI. ALAT and Myoglobin remained in the reference ranges. In cases with unsuccessful, late or impossible revascularization and transition to TI and ITL (ischemic rhabdomyolysis) we found progressive elevation in the levels of the parameters being monitored, including ALAT and Myoglobin. The registered values, in the patients who were not operated, before death, were 900 times above for CK, and CK (MB) did not exceed 5% of CK. Over 100 times the standard value for ASAT and ALAT without and hepatic pathology and acute coronary incident. The ASAT/ALAT index is extremely positive in the group with ITL. The registered values of serum Myoglobin reached up to 70 times above the reference range. Upon, revascularization, amputation on an optimal level or an experienced gangrene, a rapid decrease in the values to the reference range for a period 24-48 hours, was observed, except for ALAT, it normalized after 2-3 days. In cases with ischemic gangrene the ASAT/ALAT index from extremely positive in the beginning (>3.0-5.0) progressively decreased due to the rapid elevation of the values of ALAT with permanently high ASAT. The significant changes and correlative relations of the monitored parameters have distinct differences in cases with reversible TI and irreversible ITL, forming typical laboratory constellations in all of the controlled cases. This gives sufficient reason to believe that the implemented approach can form the basis of an objective method for early detection and monitoring of TI and ischemic tissue damage in AAOL in the target patient population for good clinical practice.

Anesthesia in obstetrics: Tried and trusted methods, current standards and new challenges

Obstetric analgesia and anesthesia have some specific aspects, which in particular are directly related to pathophysiological alterations during pregnancy and also to the circumstance that two or even more individuals are always affected by complications or therapeutic measures. This review article deals with some evergreens and hot topics of obstetric anesthesia and essential new knowledge on these aspects is described. The article summarizes the talks given at the 16th symposium on obstetric anesthesia organized by the Scientific Committee for Regional Anaesthesia and Obstetric Anaesthesia within the German Society of Anaesthesiology. The topics are in particular, special features and pitfalls of informed consent in the delivery room, challenges in education and training in obstetric anesthesia, expedient inclusion of simulation-assisted training and further education on risk minimization, knowledge and recommendations on fasting for the delivery room and cesarean sections, monitoring in obstetric anesthesia by neuraxial and alternative procedures, the possibilities and limitations of using ultrasound for lumbal epidural catheter positioning in the delivery room, recommended approaches in preparing peridural catheters for cesarean section, basic principles of cardiotocography, postoperative analgesia after cesarean section, the practice of early bonding in the delivery room during cesarean section births and the management of postpartum hemorrhage.

Síndrome neurológico transitorio y anestesia espinal-epidural combinada: ¿expresión de toxicidad por anestésico local?

Se reporta el caso de una paciente de 39 años de edad quien es llevada a histerectomía abdominal total, cistouretropexia retropúbica mas colporrafia posterior bajo anestesia espinal, realizada con bupivacaína hiperbárica al 0,5 % y uso de analgesia peridural; al momento del retiro de catéter peridural presenta sintomatología neurológica en miembros inferiores. Se diagnostica síndrome neurológico transitorio (TNS) y se realiza seguimiento hasta la desaparición de su sintomatología. Es importante entender que a pesar de la evolución benigna de esta entidad, este cuadro es de interés, ya que su verdadero impacto clínico aún está por definirse debido a que los primeros reportes en la literatura datan del año 1993 y que su incidencia presenta gran variabilidad. En este artículo se hace una revisión de la literatura actual sobre TNS, además se describen las características principales de dicha patología.

Acetazolamide in the resolution of cerebrospinal fluid cutaneous fistula after peridural analgesia: Case report1

Abstract Background Cerebrospinal fluid cutaneous fistula following spinal anaesthesia is a serious and rare complication which requires a prompt diagnosis. However, the treatment management is not well defined. Clinical case Female aged 50 with a stage IIB cervical carcinoma, who had a peridural catheter inserted at lumbar level. Three days after surgery she refers severe headache, which was corroborated by leakage of cerebrospinal fluid through the puncture. She was prescribed antibiotics and acetazolamide 250 mg every 8 hours for five days with a favourable outcome. Conclusion In this case, management with acetazolamide and suture of the fistula inhibits cerebrospinal fluid leakage, without the need for a blood patch.

Neonatal limb ischemia: caudal blockade and NIRS monitoring

The treatment of neonatal limb ischemia (LI) is challenging for neonatologists. Peripheral nerve blockade (PNB), alone or in association with other therapies, represents a valid therapy in case of vascular spasm or thromboembolic events responsible for LI. In the present case report, we describe the clinical history of a preterm neonate with catheter-related thrombosis of the left leg. PNB was not performed according to the traditional technique but rather by a peridural catheter left in situ for 9days with a continuous infusion of ropivacaine. In conclusion, the effectiveness of this approach was confirmed by the contemporary near-infrared spectroscopy monitoring, documenting gradual improvement of leg perfusion.

Open vs totally laparoscopic right colectomy: technique and results

BackgroundRight colectomy is the surgical treatment for malignantpathologies involving the intestinal tract between theileocecal Bahuino valve and the colic hepatic flexure.Laparoscopic resection must respect the same oncologi-cal criteria as the open approach including:‘’no-touchisolation technique’’, isolation and ligation of the vascularpedicles at the origin, oncological lymphadenectomy and‘’distal and radial clearance’’ of the neoplasm from resec-tion margins.Two major procedures have been described for thetreatment of right colon tumors: Open right colectomy(ORC) and Totally Laparoscopic resection (TL) in whichvascular ligations, intestinal resection and anastomosis areperformed by laparoscopy (Figure 1).In ORC technique, there is an abdominal right sidelaparotomy; in TL there is a minilaparotomy used only forendobag colon extraction and it is located in parapubicregion.MethodsFrom May 2004 to march 2013, we performed in HighSpecialistic Surgical Centers (Aosta “Parini” Hospital andNaples “Federico II” University) 132 laparoscopic rightcolectomies and 127 open right colectomies of which wehave selected 75 laparoscopic cases of these 11 for benignpathologies and 64 for neoplastic diseases and 75 OpenCases. The M/F rate was 1/1. The mean age was 64.7 ± 7.2.Colonic preoperative washout was performed to allpatients with 2 L for a day of polyethylene glycol (PEG) inthe two days before the operation, associated with a fiber-free diet. The day before operation, we positioned in allpatient antalgic peridural catheter with 0.5% levobupiva-caine (4 ml/h); on the following day, in the operatingroom, after anesthetic induction, we also positioned naso-gastric tube (NG tube) and urinary catheter (UC) and nodrain according to Kehlet protocols (in the last 23 cases).In the TL colectomy, the sovrapubic minilaparotomy of6 ± 2 cm is necessary only for the specimen extractionfrom the parapubic minilaparotomy performed by a 15-mm Endocatch, preventing the peritoneal spreading ofneoplastic cells.The procedures were considered curative only whenthere was no intraoperative evidence of secondarylocations.NG tube was removed after the operation and UC in themorning after surgery. The patients were allowed to drinkliquids with oral assumption of medicines the evening ofthe operation (Table 1) [1]. All the patients underwent acycle of postoperative physiokinesis therapy. Patients weredischarged when they became autonomous in movementsand walking with a restored bowel function without feverand pain.They were followed-up at least 1 year, starting on the30

Benefits and Risks of Preventing Thromboembolism With Enoxaparin in Patients With General Surgery in Real World—The CLEVER Study

We aimed to document enoxaparin use in real world and identify the risk factors for bleeding complications. Postauthorization study in 448 surgical patients receiving enoxaparin prophylaxis. Complete compression ultrasound (CCUS) was performed at day 10 ± 3. During treatment, 11 of 448 patients had suspected deep venous thrombosis (DVT) but none confirmed. One patient had symptoms of pulmonary embolism ([PE] 0.22%; 95% confidence interval [CI] -0.21-0.66). There were no asymptomatic cases detected upon CCUS. At the 90-day follow-up, 4 (0.9%) of the 440 patients had DVT symptoms (95% CI 0.02-1.80) and none had PE; 5.4% had major and 11.6% any type of bleeding complications. Major bleeding was more frequent in those with kidney disease (odds ratio [OR] 5.53), those who are bedridden (OR 5.49), those with peridural indwelling catheters (OR 4.01), and those on nonsteroidal anti-inflammatory drugs (OR 3.33). Enoxaparin is effective and safe in surgical patients to prevent venous thromboembolism.

Reply to Rychlik et al.

We would like to thank Rychlik et al. [1] for their interest regarding our comparative study about postoperative ipsilateral shoulder pain treatment and prevention [2]. The idea of injecting the periphrenic fat pad prior to resection and handling of the hilium seems to be very interesting to us, and probably will lead to a better control of postthoracotomy ipsilateral shoulder pain as has been well documented with the use preemptive analgesia through peridural catheter in thoracic (and others) surgeries [3, 4]. In contrast, even though we agree with Rychlik et al. [1] that levobupivacaine is a theoretically better agent for phrenic nerve block (longer half-time live and more powerful effect) than lidocaine, we would like to reflect our concerns about its clinical use because of its potential cardiotoxicity in case of systemic absorption that is something that could occur with its use in a wellvascularized area as the periphrenic fat pad. Regarding this matter, we believe that ropivacaine would be a better option than lidocaine or levobupivacaine because it’s a long-lasting, powerful anaesthetic with less cardiac toxicity [5], and it has proved safety in a clinical setting for phrenic nerve block [6]; unfortunately, we have no experience with this anaesthetic. Finally, we concur that further research is necessary to refine the technique of phrenic nerve infiltration for ipsilateral shoulder pain, but we strongly believe that actually there is enough evidence to recommend the widespread of the technique all over the thoracic surgery units.

Laparoscopic ultralow anterior rectal resection in APPEAR technique for deep rectal cancer

IndicationsThe key of modern rectal surgery has been the advent oftotal mesorectal excision (TME) [1]. Laparoscopic colorec-tal surgery is proven to be equivalent [2]. The AnteriorPerineal Plane for Ultralow Anterior Resection of theRectum (APPEAR) technique [3] allows a coloanalanastomosis by safe mobilization of the distal rectum andthe pelvic floor musculature under direct vision, especiallyfor the puborectal muscle and the external anal sphincter(EAS). As the APPEAR technique has only been combinedwith the abdominal part performed in the conventional“open” manner, we report the first case with previouslaparoscopic mobilization of the rectum with TME plusmobilization of the left colon and the splenic flexure.A 69-year-old male without further medical historypresented with a circular rectal adenocarcinoma (G2, M0),5 cm from the anal verge. Digital rectal examinationrevealed an almost circular ulceroinfiltrative lesion withrestricted mobility (Mason 3) about 5 to 6 cm from the analverge centered on the anterior rectal wall. There was noclinical evidence for sphincter involvement neither underresting pressure nor under squeeze. The endoscopicultrasound (EUS) staged the tumor as uT3 uN+. Thehigh-resolution MRI report of the pelvis concluded thatthe lesion was stranding the perirectal fat tissue but not themesorectal fascia; the anterior aspect of the circumferentialmargin was not at risk. Further there were obvious signs oflymphadenopathy (T3 N2) without pelvic wall infiltrationor inguinal lymph nodes, verifying the results of the EUS.For restaging after neoadjuvant treatment, the patientpresented without side effects in excellent condition. Thehigh-resolution MRI showed good tumor response (yT3yN0) with considerably regressive mesorectal infiltration.The tumor was mobile in the pelvis (Mason 2) and duringEUS the aboral tumor margin presented 5 cm oral of theanal verge and 2 cm oral of the puborectal muscle, showingsufficient resection margin for this tumor grading (G2). Thepatient was then referred to our department and scheduledfor laparoscopically assisted low anterior resection. Perinealapproach was considered as a valuable alternative tointersphincteric resection. The patient gave surgical consentto undergo any surgical procedure necessary to treat hisrectal cancer, preferably preserving anal continuity.MethodAfter preoperative insertion of a peridural catheter accord-ing to our standard “fast-track” scheme, the patient wasplaced under general anesthesia in the lithotomy positionand received prophylactic antibiotics on induction. Thelaparoscopic anterior resection was performed by a four-trocar approach (Fig. 1). TME was performed preservingthe autonomous nerves. In the prerectal space, the seminalvesicles were separated while the filmy Denonvillers’ fasciawas preserved. In this manner the spatium between theprostate and rectum was entered and dissected towards thepelvic floor. As the tumor was filling almost all pelvicspace, neither a linear nor an angular stapler could bepositioned below the tumor. Thus avoiding APR theAPPEAR technique was chosen as an intraoperativedecision. The mesocolon was divided and the colon

High-Flexion versus Conventional Total Knee Arthroplasty: A 5-Year Study

To compare mid-term outcomes of a high-flexion prosthesis with a conventional prosthesis. Records of 107 consecutive patients who underwent total knee arthroplasty (TKA) for primary osteoarthritis by a single surgeon were reviewed. 21 men and 36 women (mean age, 65 years) used a high-flexion prosthesis (NexGen CR-Flex Mobile, Zimmer), whereas 38 men and 12 women (mean age, 67 years) used a conventional prosthesis (Genesis II, Smith & Nephew) that preserves the posterior cruciate ligament, with mobile-bearing polyethylene inlay. The Knee Society knee and functional scores and the range of motion (especially maximum passive flexion) were assessed. Radiographs were evaluated to identify radiolucent lines at the bone cement interface, patella tracking, tibiofemoral alignment, and implant positioning. The mean follow-up period was 68 (range, 51- 70) months. In terms of the mean Knee Society scores and range of motion, the difference between groups was not significant (p>0.05), but the improvement in both groups after TKA was significant (p<0.005). Respectively in the high-flexion and conventional TKA groups, 2 and one of the patients developed deep vein thrombosis and were treated with anticoagulants for 3 months. One and 5 of the patients had an unsatisfactory range of motion (<60º) in week 1, which was resolved with mobilisation under general anaesthesia in combination with a peridural catheter for analgesia. No patient developed implant-specific complications such as aseptic loosening (osteolysis, progressive radiolucent lines, implant deviation) or dislocation of the polyethylene insert. The high-flexion prosthesis revealed no significant advantages over the conventional prosthesis in terms of the Knee Society scores and range of motion. Long-term studies are needed to determine whether the high-flexion implant is superior to the conventional implant in terms of polyethylene wear and aseptic loosening.

Readaptation of the Peritoneum Following Extended Pelvic Lymphadenectomy and Cystectomy Has a Significant Beneficial Impact on Early Postoperative Recovery and Complications: Results of a Prospective Randomized Trial

BackgroundProlonged postoperative pain and delayed intestinal transit are frequent problems following extended pelvic lymph-node dissection (PLND) and cystectomy. ObjectiveTo evaluate the impact of bilateral readaptation of the dorsolateral peritoneal layer on postoperative pain, gastrointestinal recovery, and complications following extended PLND and cystectomy. Design, setting, and participantsRandomized, single-blinded, single-center study of 200 consecutive cystectomy patients. InterventionIn group A (n=100), lateral peritoneal flaps ventral to the external iliac vessels were bilaterally rotated over the iliac vessels down to the distal obturator fossa and medially fixed to the pararectal peritoneal layer following extended PLND and cystectomy. In group B (n=100), the peritoneal layer was not readapted. MeasurementsPain according to the visual analog scale (VAS), amount of peridural anesthetics needed, and gastrointestinal activity were assessed on postoperative days 1, 3, and 7. Complications occurring within 30 d following surgery were documented. Results and limitationsReadaptation of the dorsolateral peritoneal layer resulted in a significant decrease in pain (p<0.01) with concurrent significantly reduced need for peridural anesthetics (p<0.01). Flatulence and first passage of stool as signs of intestinal transit were noted earlier in group A than in group B. Gastrostomy tube and peridural catheter could be removed 1 d earlier in group A than in group B (postoperative days 7 vs 8 and 6 vs 7, respectively). Group A (30%) had fewer complications than group B (56%; p<0.001). ConclusionsReadaptation of the dorsolateral peritoneal layer after extended PLND and cystectomy resulted in significantly less postoperative pain, earlier recovery of bowel function, and fewer complications in the early postoperative period.

1756 PERIDURAL ANESTHESIA IN RADICAL RETROPUBIC PROSTATECTOMY–A PROSPECTIVE RANDOMIZED TRIAL EVALUATING THE INFLUENCE ON INTRAOPERATIVE BLOOD LOSS

You have accessJournal of UrologyProstate Cancer: Localized VII1 Apr 20101756 PERIDURAL ANESTHESIA IN RADICAL RETROPUBIC PROSTATECTOMY–A PROSPECTIVE RANDOMIZED TRIAL EVALUATING THE INFLUENCE ON INTRAOPERATIVE BLOOD LOSS Daniel Baumunk, Kurt Miller, Mark Schrader, Steffen Weikert, Florian Jentzmik, Jan Ebbing, Frank Friedersdorff, Hannes Cash, Jan Breckwoldt, and Martin Schostak Daniel BaumunkDaniel Baumunk More articles by this author , Kurt MillerKurt Miller More articles by this author , Mark SchraderMark Schrader More articles by this author , Steffen WeikertSteffen Weikert More articles by this author , Florian JentzmikFlorian Jentzmik More articles by this author , Jan EbbingJan Ebbing More articles by this author , Frank FriedersdorffFrank Friedersdorff More articles by this author , Hannes CashHannes Cash More articles by this author , Jan BreckwoldtJan Breckwoldt More articles by this author , and Martin SchostakMartin Schostak More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1605AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES As previously described, restriction of intraoperative infusions, general anesthesia in combination with peridural anesthesia and maintainance of a 25-30° Trendelenburg position reduces bleeding in radical retropubic prostatectomy (RRP). This study was initialized to prospectively evaluate the influence of peridural anesthesia alone on blood loss in RRP. METHODS Of 350 consecutive patients for RRP at the Charité-Urology (CBF) between May 2006 and Dec 2007, 265 were prospectively randomized into 2 groups: group 1 (gr.1) with peridural anesthesia in combination with general anesthesia, group 2 (gr.2) with deep general anesthesia alone. There were no significant differences between the two groups concerning preoperative parameters such as patients age, BMI, hemoglobin levels, Charlson comorbidity score, PSA levels, Gleason score of biopsy, prostate size or clinical stage. All patients were operated by 3 highly experienced surgeons in relative volume restriction and 25-30° Trendelenburg position. Nerve sparing was achieved in 94% of all patients. RESULTS Assessment was possible in 235 out of 265 patients (gr.1: n=116; gr.2: n=119). Overall transfusion rate was 0.84%. There was no significant difference (p=0.63) in blood loss between the two groups neither regarding the hemoglobin difference between preoperative day and first postoperative day (3.7g/dl in gr.1 vs. 3.65g/dl in gr.2) nor counting volume of the surgical aspirator and weight of used lap sponges (gr.1: 665 gr; gr.2: 705 gr; p=0.948). The reduction of the mean arterial pressure as a sign of sympaticolysis was more intensive in gr.1 (p=0.001) which led to slightly more infusions (p=0.004), in particular more kolloids (p=0.007) for these patients. Postoperative pain relief and patients satisfaction were higher in gr.1. No differences were found between the two groups concerning oncological outcome, complications, operation time, hospitalization or duration of the transurethral catheterization. There were no additional complications with the peridural catheter but 2 patients in gr.2 were re-intubated for prolonged narcosis but extubated on the same day. CONCLUSIONS Perioperative use of peridural anesthesia leads to a very effective intraoperative sympathicolysis and painfree postoperative care but does not significantly reduce blood loss compared to deep general anesthesia alone. Berlin, Germany© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e678-e679 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daniel Baumunk More articles by this author Kurt Miller More articles by this author Mark Schrader More articles by this author Steffen Weikert More articles by this author Florian Jentzmik More articles by this author Jan Ebbing More articles by this author Frank Friedersdorff More articles by this author Hannes Cash More articles by this author Jan Breckwoldt More articles by this author Martin Schostak More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

UP-2.138: Pain after Radical Prostatectomy (RP) in Patients with Peridural Catheter (PDC) and Patient-Controlled Analgesia Pumps (PCA)

An optimal analgesia by PDC or PCA-pumps after RP enables a faster mobilisation of patients. This reduces the risk of pneumonia and thrombembolic complications. Aim of this study was to analyse the subjective pain score in patients after RP with PDC and PCA-pumps.

Wound Levobupivacaine Continuous Infusion for Postoperative Analgesia in Living Kidney Donors: Case-Control Study

Introduction The objective of this study was to evaluate the efficacy of an analgesic regimen based on levobupivacaine continuous infusion into the surgical wound of living kidney donors (LKDs). Patients and Methods Fifty adult LKDs (mean age, 53.1 ± 5.3 years; age range, 52–68 years) were retrospectively assigned to a no wound infusion (NWI) group (n = 25) or a wound infusion (WI) group (n = 25). At the end of surgery, patients in the WI group received 10 mg intramuscular morphine; a peridural catheter was placed 10 cm between the intercostal muscles fibers close to the lower rib extremity, and a solution of levobupivacaine, 150 mg/100 mL, was started at 5 ml/h −1. Patients in the NWI group received intramuscular morphine, 10 mg, every 8 hours; intravenous tramadole, 100 mg, was planned as a rescue drug for incidental pain. Pain was measured using a visual analog scale (VAS) ranging from 1 (no pain) to 10 (maximum pain) in both the basal condition (VASb) and during coughing (VASc) at 1 hour after leaving the operating room and 6, 12, and 24 hours thereafter. Results At 1, 6, 12, and 24 hours, VASb values in the NWI vs the WI group were 5.2 vs 3.1, 6.8 vs 4.1, 5.8 vs 4.9 (all p < .01), and 5.4 vs 5.1, respectively, and VASc values were 8.2 vs 6.3, 8.8 vs 5.9, 7.1 vs 5.3, and 6.8 vs 5.1 (all p < .01). Mean VAS score was significantly higher between 1 and 6 hours in the NWI group for all VASb measurements vs VASc values. Tramadole consumption was higher in the NWI group than in the WI group. Conclusions Continuous wound infusion with 5 mL/h −1 levobupivacaine, 1.5 mg/mL −1, resulted in a safe and effective analgesic protocol in LKDs both in the immediate postoperative period and in the first day after surgery, a result that was more effective than a morphine-tramadole regimen. No adverse effects were recorded, which confirmed the safety of the technique. It is probable that better results could be achieved with dedicated administration devices.

Entwicklung eines Weichteilulkus nach periduraler Langzeitinfusion

Local anaesthetic agents (LA) in clinical concentrations have the potential for tissue toxicity, although this is rarely observed in clinical practice. The case of a 74-year-old female patient (BMI 16.8 kg/m(2)) with a metastasising bronchial carcinoma is reported, who suffered from severe back pain due to tumour infiltration. For pain management a tunnelled continuous thoracic peridural catheter (PC) was placed and a mixture of bupivacaine 0.49%, morphine 0.0036% and clonidine 0.0001% was infused at 3 ml/h. After 8 weeks of continuous infusion an ulcer developed in the soft tissue close to the thoracic spine containing whitish crystalline material (CM). A computed tomography examination revealed a subcutaneously displaced PC with extensive fluid collection reaching down to the sacrospinalis muscle. Histologically an unreactive necrosis with enclosed CM of unknown etiology was found. The result of the chemical analysis of the deposits demonstrated bupivacaine, morphine and sodium chloride. It is concluded that the soft tissue ulcer was probably caused by precipitation of the LA mixture.