Postoperative Epidural Analgesia Research Articles

The Effect of Epidural Analgesia on Quality of Recovery (QoR) after Open Radical Nephrectomy: Randomized, Prospective, and Controlled Trial.

No studies are currently evaluating the quality of recovery (QoR) after open radical nephrectomy (ORN) and epidural morphine analgesia. This was a randomized, prospective, and controlled study that explored the QoR on the first postoperative day after ORN. Eighty subjects were randomized into two groups. The first group received general anesthesia combined with epidural anesthesia and postoperative epidural analgesia with morphine and ropivacaine. The second group received general anesthesia and continuous postoperative intravenous analgesia with tramadol. Both groups received multimodal analgesia with metamizole. The primary outcome measure was the total QoR-40 score. The secondary outcome measures were QoR-15, QoR-VAS, and the visual analog scale (VAS) for pain, anxiety, and nausea. The median difference in the QoR-40 score after 24 postoperative hours between the two groups of patients was 10 (95% CI: 15 to 5), p < 0.0001. The median score and IQR of QoR-40 during the first 24 postoperative hours in the epidural group was 180 (9.5), and in the control group, it was 170 (13). The general independence test for secondary outcomes between groups was significant (p < 0.01). QoR-VAS was correlated with QoR-40 (r = 0.63, p ≤ 0.001) and with QoR-15 (r = 0.54, p ≤ 0.001). The total QoR-40 and QoR-15 alpha coefficients with a 95% CI were 0.88 (0.85-0.92) and 0.73 (0.64-0.81), respectively. There was a significant difference in the QoR between the epidural and the control groups after ORN. The QoR-40 and QoR-15 showed good convergent validity and reliability.

Ultrasound estimates of the epidural depth in the paramedian sagittal oblique and transverse median planes: the correlation between estimated and actual depth to the epidural space in children with scoliosis

IntroductionThe present study aimed to compare the correlation and agreement of epidural depth estimation using ultrasound in the paramedian sagittal oblique (PSO) versus the transverse median (TM) plane relative to...

Post-Operative Thoracic Epidural Analgesia and Incidence of Major Complications according to Specific Safety Standardized Documentation: A Large Retrospective Dual Center Experience.

(1) Background: Thoracic epidural analgesia is considered the gold standard in post-operative pain management following thoracic surgery. This study was designed to explore the safety of thoracic epidural analgesia and to quantify the incidence of its post-operative complications and side effects in patients undergoing thoracotomy for major surgery, such as resection of lung malignancies and lung transplantation. (2) Methods: This is a retrospective, dual-center observational study including patients that underwent major thoracic surgery including lung transplantation and received concurrent placement of thoracic epidural catheters for post-operative analgesia. An electronic system of referral and documentation of complications was used, and information was retrieved from our electronic critical care charting system. (3) Results: In total, 1145 patients were included in the study. None of the patients suffered any major complication, including hematoma, abscess, or permanent nerve damage. (4) Conclusions: the present study showed that in experienced centers, post-operative epidural analgesia in patients with thoracotomy is a safe technique, manifesting minimal, none-serious complications.

Effects of epidural anesthesia on the prognosis of ovarian cancer—a systematic review and meta-analysis

IntroductionThe global low survival rate among ovarian cancer patients has resulted in significant social and economic burdens. Nevertheless, previous studies have produced mixed results when exploring the link between anesthetic techniques and the prognosis of ovarian cancer. The study aims to compare the effect of epidural anesthesia with general anesthesia on survival time after cytoreductive surgery in patients with ovarian cancer.MethodsThe PubMed (National Library of Medicine), Cochrane library, Web of science, Embase, CNKI (China National Knowledge Internet), Wanfang Med Online (China database), were systematically searched from inception to May, 2023, using the Medical Subject Headings [MeSH] of “Ovarian Neoplasm” and “Anesthesia, Epidural” and free words to identify systematic reviews or meta-analyses.The research methodology involved analyzing randomized controlled trials (RCTs), as well as prospective or retrospective cohort studies, which compared the long-term prognosis of patients with ovarian cancer under general anesthesia combined with epidural anesthesia (GEA) versus general anesthesia alone (GA).The Newcastle Ottawa Scale (NOS) was used to assess methodological quality and bias. Data extraction and assessment of study quality were conducted by two independent reviewers. A meta-analysis was then performed to calculate hazard ratios (HRs) and corresponding 95% confidence intervals (CIs). Overall survival (OS) was defined as the primary outcome, time to tumor recurrence (TTR) was the secondary outcome. Epidural anesthesia could be used intraoperatively and immediately postoperatively (EIP), or postoperatively only (EP). GEA includes EIP and EP.ResultsIn total, 8 retrospective cohort studies with 2036 participants met the inclusion criteria. The pooled results demonstrated that GEA could extend OS (HR 0.75, 95% CI 0.67–0.84, I2 = 0%, P < 0.05, fixed-effect model) when compared with GA in ovarian cancer patients undergoing cytoreductive surgery, but not TTR (sensitivity analysis revealed substantial heterogeneity among the included studies). The result of analyzing a total of 1490 patients in 4 studies was that EIP had a better prognosis on OS than GA (HR 0.68, 95%CI 0.55–0.85, I2 = 61%, P < 0.05, random-effect model). However, EP had no advantage in TTR (sensitivity analysis revealed it was unstable outcome). Ovarian cancer FIGO(International Federation of Gynecology and Obstetrics) stage III, stage IV compared to stage I on OS was statistically significant, HRs respectively are 3.67 (95%CI 2.25–5.98), I2 = 0%, fixed-effect model, P < 0.05, and 7.43 (95%CI 3.67–15.03), I2 = 31%, fixed-effect model, P < 0.05, but there was no statistically significant difference between stage II and stage I, HR 2.00, 95%CI0.98–4.09, I2 = 0%, fixed-effect model, P > 0.05. 1-10 mm tumor residuals shorten TTR compared with 0 residuals, HR 1.75, 95% CI1.50–2.04, I2 = 0%, fixed-effect model, P < 0.05.ConclusionsIt is hard to conclude that postoperative epidural analgesia offers greater benefits than GA. However, general anesthesia combined with epidural anesthesia (EIP) can improve overall survival in ovarian cancer patients, allowing the anesthesiologist to use anesthesia techniques to provide a favorable prognosis for the ovarian cancer patient. Tumor staging and the extent of cell reduction are also critical factors that significantly influence the long-prognosis of ovarian cancer patients.

Perioperative interventions to improve early mobilisation and physical function after hip fracture: a systematic review and meta-analysis.

Perioperative interventions could enhance early mobilisation and physical function after hip fracture surgery. Determine the effectiveness of perioperative interventions on early mobilisation and physical function after hip fracture. Ovid MEDLINE, CINAHL, Embase, Scopus and Web of Science were searched from January 2000 to March 2022. English language experimental and quasi-experimental studies were included if patients were hospitalised for a fractured proximal femur with a mean age 65years or older and reported measures of early mobilisation and physical function during the acute hospital admission. Data were pooled using a random effect meta-analysis. Twenty-eight studies were included from 1,327 citations. Studies were conducted in 26 countries on 8,192 participants with a mean age of 80years. Pathways and models of care may provide a small increase in early mobilisation (standardised mean difference [SMD]: 0.20, 95% confidence interval [CI]: 0.01-0.39, I2= 73%) and physical function (SMD: 0.07, 95% CI 0.00 to 0.15, I2= 0%) and transcutaneous electrical nerve stimulation analgesia may provide a moderate improvement in function (SMD: 0.65, 95% CI: 0.24-1.05, I2= 96%). The benefit of pre-operative mobilisation, multidisciplinary rehabilitation, recumbent cycling and clinical supervision on mobilisation and function remains uncertain. Evidence of no effect on mobilisation or function was identified for pre-emptive analgesia, intraoperative periarticular injections, continuous postoperative epidural infusion analgesia, occupational therapy training or nutritional supplements. Perioperative interventions may improve early mobilisation and physical function after hip fracture surgery. Future studies are needed to model the causal mechanisms of perioperative interventions on mobilisation and function after hip fracture.

Comparative study between dexmedetomidine and fentanyl as adjuvants to bupivacaine for postoperative epidural analgesia in abdominal surgeries: A randomized controlled trial

ABSTRACT Background Epidural analgesia is an efficient strategy to relieve postoperative pain after abdominal surgeries. This study aimed to evaluate dexmedetomidine or fentanyl when added to bupivacaine, providing postoperative epidural analgesia after abdominal procedures. Patients and methods Epidural catheter was placed on 75 patients scheduled for lower abdominal procedures under general anesthesia, and they were randomly assigned into three equal groups. Epidural analgesia was activated before the procedure was completed by injection of bupivacaine (0.125%) plus dexmedetomidine or fentanyl or normal saline mixture, according to the study groups. After complete recovery from general anesthesia, the epidural block was evaluated. Then, the infusion started through an elastomeric pump with an infusion rate of 5 ml/hr and continued for 24 hr postoperatively. Group D Dexmedetomidine 1 ml (100 μg) plus normal saline 1 ml were added to bupivacaine (0.125%) 48 ml (a total volume of 50 ml). Group F: 2 ml (100 μg) fentanyl was added to bupivacaine (0.125%) 48 ml (a total volume of 50 ml). Group C: Normal saline 2 ml was added to bupivacaine (0.125%) 48 ml (a total volume of 50 ml). Measured outcomes Primary outcomes The onset of sensory analgesia (from the beginning of epidural infusion until scoring 1 on a 3-point scale) and the duration of analgesia (from the start of epidural infusion till the first demand for further pain medication) were observed and recorded. Secondary outcomes Postoperative pain was evaluated using a visual analogue scale (VAS), and the number of patients requesting additional analgesia with pethidine over paracetamol as well as the pethidine consumption during postoperative 24 hr were recorded. The hemodynamic parameters, including heart rate (HR) and mean arterial blood pressure (MAP), were monitored and recorded at baseline, 2, 6, 12, and 24 hr, and any adverse events were properly recorded and managed during the study period. Results The dexmedetomidine group showed an earlier onset and longer duration of analgesia, with a highly significant difference (P-value <0.001) than other groups. The study groups differed significantly concerning pethidine needs and consumption (P-value <0.05). The VAS revealed a considerable decrease in the dexmedetomidine group compared to other groups, with a significant difference (P-value <0.05) at the intervals of (baseline, 12 hr, and 24 hr) and a highly significant difference (P-value <0.001) at the intervals of (2 and 6 hr). Postoperative blood pressure and heart rate measurements in the dexmedetomidine group were lower than in other groups. MAP showed a statistically highly significant difference at 6 and 24 hr (P-value <0.001) and a significant difference after 12 hr (P-value <0.05), while HR showed a statistically significant difference after 6 hr (P-value <0.05) and a highly significant difference at 12 and 24 hr (P-value <0.001). Regarding postoperative adverse events, no statistical difference was detected between groups except in pruritis and dry mouth. Conclusion Dexmedetomidine is preferred to fentanyl when added to epidural bupivacaine to relieve pain after abdominal procedures.

Training programmes for healthcare professionals in managing postoperative epidural analgesia: A scoping review protocol.

Epidural analgesia is an effective technique advocated worldwide for postoperative analgesia after a wide range of surgical procedures. Despite the benefits of epidural analgesia for pain management, systematic education of ward nurses in managing epidural analgesia appears to be lacking. The aim of the proposed scoping review is to map the body of evidence and identify training programmes for healthcare professionals in the safe management of postoperative epidural analgesia. The methodology will follow the Preferred Reporting Items for Systematic and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). In addition, the five main steps set forth by Arksey and O'Malley and refined by Levac for guidance of the process will be used. The scoping review will include any study design of any date, design, setting and duration. We will present results descriptively, accompanied with visual presentations as tables and graphs. The outlined scoping review will provide an overview of existing training programmes for healthcare professionals in the safe management of postoperative epidural analgesia and map the body of available evidence on the topic. The study may support the development of a training programme for ward nurses caring for patients receiving postoperative epidural analgesia.

Effect of epidural blockade on immune parameters in the perioperative period: randomized controlled study

BACKGROUND: The potential benefits of anaesthesia techniques in the parameters of cellular immunity and prevention of metastasis in various types of cancer are attracting increasing attention.&#x0D; OBJECTIVE: Our aim was to estimate the influence of the epidural blockade as a component of the anesthesia support on the immunity indexes in the patients operated for gastric cancer.&#x0D; MATERIALS AND METHODS: 89 patients operated on for gastric cancer, divided into two groups were investigated: in the 1st group (n=27) there was general anesthesia (GA) in combination with extended epidural blockade; in the 2nd group (n=24) GA with postoperative intravenous administration of analgesics. T-cell counts (CD3+, CD4+ CD8+, CD4+/CD8+) and cytokines (IL-4, IL-6, IL-10, INF-y and TNF-a) were determined.&#x0D; RESULTS: The CD3+ T-cell levels in both groups were significantly (р 0.05) reduced immediately after surgery. On the 2nd and 3rd day the decrease in CD3+ T-cells was more pronounced (р 0.05) in the 2nd group compared to the 1st group. The content of CD4+ T-cells decreased by the 1st day of the postoperative period (р 0,05) but then gradually increased, the CD4+ level in the 1st group was significantly (р 0.05) higher than in the 2nd group. The changes of CD8+ content between the studied groups were not statistically significant. The immunoregulatory index in both groups decreased by1st day (р 0.05). On the 9th day the index in the 1st group returned to the basic values, while in the 2nd group it remained significantly lower. On the 1st and 3rd day, the levels of IL-4 and IL-6 significantly (р 0.05) increased, while in the 2nd group the levels were higher than in the 1st group (р 0.05). On the 9th day IL-4 and IL-6 indices returned to their initial values. The changes of IL-10 level had a similar pattern, while in the 1st group the rate was significantly higher (р 0.05). At all stages of investigation, the level of IFN- was significantly (р 0.05) higher in the 2nd group, the level of TNF- was higher in the 1st group (р 0.05).&#x0D; CONCLUSION: The use of postoperative epidural analgesia during gastric resection for malignant neoplasm is associated with a less suppressive effect on the content of subpopulations of T-lymphocytes and cytokines in comparison with intravenous administration of analgesics and may contribute to the activation of antitumor immune response. Prospective long-term studies are needed to evaluate physician epidural analgesia for oncological outcomes after surgery for gastric cancer.

Multimodal approach to pain management in thoracic surgery

The American Cancer Society estimated that 68,820,000 men and 61,360,000 women in the United States of America would die from lung and bronchial cancer in 2022, which is equal to 21% of all cancer deaths. Patients who undergo thoracotomy have a higher risk of postoperative complications due to the severe pain syndrome that typically develops after surgery. Even though there has been extensive research on the advantages and disadvantages of various perioperative analgesia techniques, the search for the best and safest still continues.&#x0D; Objective — to improve the results of perioperative anesthesia in patients undergoing thoracotomy by choosing the optimal method of analgesia.&#x0D; Materials and methods. A total of 59 patients with lung cancer who underwent thoracotomy at the communal non‑profit enterprise «Kyiv City Clinical Hospital No 17» from 2018 to 2020 were included in an open‑label noncommercial randomized controlled clinical trial. Patients were divided into 2 groups: the multimodal analgesia (MA) group (32 patients) and the epidural analgesia (EA) group (27 patients). According to the concept of preemptive analgesia, patients in the MA group received 1000 mg of paracetamol and 50 mg of dexketoprofen intravenously 1 hour before surgery. In the postoperative period, dexketoprofen and paracetamol were administered every 8 hours in combination with epidural analgesia. During postoperative epidural analgesia, patients received 40 mg of a 2% lidocaine solution through a catheter inserted into the epidural space (Th5—Th6) and a ropivacaine 2 mg/mL (3—14 mL/h) infusion. Patients in the EA group received only epidural analgesia in the postoperative period. After placement of an epidural catheter in the epidural space (Th5—Th6), they had an injection of 40 mg of a 2% lidocaine solution and an epidural infusion of ropivacaine 2 mg/ml (3—14 mL/h).&#x0D; Results. The study groups did not demonstrate a statistically significant difference in terms of age, hight, weight, a grade of anesthesiological risk (ASA), blood loss, surgery duration, and surgical volume (р &gt;0,05). The level of analgesia was assessed using the numerological rating scale (NRS) after 3, 6, 24, and 32 hours after surgery. Every research stage revealed a significant difference in the level of pain syndrome between the study groups (p&lt;0.05). Patients in the EA group experienced more severe pain syndrome than those in the MA group. Consequently, 7 patients (26%) in the EA group were anesthetized with morphine 10 mg intramuscularly compared to 3 patients (9%) in the MA group.&#x0D; Conclusions. In patients undergoing thoracic surgery, a multimodal analgesic approach, which includes the use of COX‑2 and COX‑3 inhibitors in combination with epidural analgesia, has been shown to produce better analgesia compared to epidural anesthesia alone. The beneficial effect of multimodal analgesia was seen in a significant difference (p&lt;0.05) in the intensity of pain syndrome between the study groups in the early postoperative period after thoracotomy.

Comparison of Epidural Bupivacaine and Buprenorphine to Bupivacaine and Butorphanol for Postoperative Analgesia in Lower Limb Orthopedic Surgery.

Postoperative analgesia is of utmost importance in the treatment of patients undergoing surgery. Good postoperative pain management reduces hospital stay and improves early ambulation. This study compared the efficacy of epidural bupivacaine with buprenorphine to butorphanol in lower limb orthopedic surgery. This study was carried out to investigate the onset of analgesia, the extent of analgesia, sedation score, and side effects of butorphanol with bupivacaine versus buprenorphine with bupivacaine. In a clinical trial study, 100 patients who underwent elective orthopedic lower limb surgery were randomly allocated to two groups. A total of 100 patients with American Society of anesthesiologists grades I and II posted for lower limb orthopedic surgery were enrolled in this randomized, double-blind study. The patients were divided into groups A and B. Subarachnoid block was achieved with 3.4 mL of 0.5% bupivacaine. The pain was monitored by the visual analog scale postoperatively. The patients in group A received bupivacaine with buprenorphine, and group B received bupivacaine with butorphanol when they complained of pain in the postoperative period. The onset of analgesia, duration of analgesia, sedation score, and side effects were compared between the two groups. The onset of analgesia was observed earlier in group A than in group B (7.7 ± 1.6 vs. 12.6 ± 1.7 minutes, P < 0.001). The duration of analgesia was longer in group A than in group B (590 ± 40 vs. 480 ± 54 minutes, P < 0.001). Pulse rates and mean arterial pressures were significantly different (P < 0.001). Side effects were common in both groups. Buprenorphine added to bupivacaine provides earlier onset and longer postoperative epidural analgesia than epidural butorphanol with bupivacaine.

COMPARISON BETWEEN PRE-EMPTIVE THORACIC EPIDURALANALGESIA VS CONVENTIONAL THORACIC EPIDURALANALGESIA IN PATIENTS UNDERGOING THORACOTOMY IN A TERTIARY CARE CENTRE

Background: Relative effects of timing of providing analgesia, type of surgery of local anaesthetics used for postoperative thoracic epidural analgesia and the possibility of establishment of pre-emptive analgesia as a superior mode for thoracic epidural analgesia are still in grey zone. In this observational study, we evaluated the idea of Pre-emptive thoracic epidural analgesia which can counter the post thoracotomy pain through pain scoring. Objective: To nd out whether pre-emptive thoracic epidural analgesia is superior to conventional postoperative epidural analgesia for post-thoracotomy pain. Study Design: Observational study. Place and Duration of Study: Department of Anesthesiology and Critical Care, Assam Medical College and Hospital, from Januray 2022 to January 2023. Methodology:After ethical committee approval and informed consent from patients, 22 patients undergoing thoracotomy were included in study. Preoperatively thoracic epidural catheter was inserted at T8-9 intervertebral space level. Group P was given 0.5ml/kg of 0.125% bupivacaine before induction of anesthesia; whereas group C was administered 0.5 ml 0.125% bupivacaine after closure of wound in supine position. All patients received thoracic epidural analgesia with a bolus dose of 0.1 ml/kg of 0.125% bupivacaine every 6 hourly post operatively .Visual analog scale (VAS) was used to assess pain severity at 1 and 24 hours postoperatively, both at rest and after cough (R1, R24, C1 and C24 respectively). Data were analyzed with SPSS and Microsoft Excel 2010. Results: There was no statistical difference in demographic prole of both groups in terms of age, gender, American Society of Anaesthesiologists (ASA) status or type of surgery, complications. Pain was signicantly less in group P at 1hour postoperatively (p=0.0001). However, there was no difference in pain severity at rest at 24 hours and with cough at 01 hour or 24 hours postoperatively. Conclusion: Pre-emptive thoracic epidural analgesia provides better pain control in immediate post operative period at rest. However, no such differences were observed in pain scores in immediate post operative period on coughing. No differences were observed at 24 hours at rest or coughing in both the groups

Effectiveness of Postoperative Pain Management and Postoperative Emergency Pain Management at Prof.Dr. I.G.N.G. Ngoerah General Hospital

Background: Early postoperative recovery has undergone many developments. Early mobilization, early nutritional intake, and adequate postoperative pain management are the scope of early postoperative recovery. The principle of postoperative pain management starts from preoperative evaluation which includes medical and psychological conditions, medication history, history of chronic pain, drug abuse, and previous postoperative treatment regiments to guide postoperative pain management plans. Method: This research is an analytical observational study, carried out at Sanglah Hospital Denpasar from June 2021 to December 2021. The accessible population of this study was all postoperative patients at the Central Surgical Installation and the Emergency Room at Sanglah Hospital Denpasar who were consulted by the Acute Pain Service (APS) team. Inclusion criteria were all patients who underwent surgical procedures under general and regional anesthesia, ASA physical status 1-3, and age above 18 years. Results: There were 166 patients managed by continuous intravenous postoperative analgesia (73.1%), 43 patients by epidural postoperative analgesia (18.9%), and 18 patient-controlled analgesia/PCA (7.9%). The most widely used intravenous regiment was fentanyl by 85 (37.4%).Conclusion: This study shows incidences number of acute postoperative pain in the elective and emergency department at Sanglah Hospital Denpasar gave good results with a much lower incidence of pain compared to the existing literature.

Assessment on Perioperative Outcome of Epidural Anesthesia &amp; Analgesia

Introduction: Epidural anesthesia and analgesia have the potential to reduce or eliminate the perioperative physiologic stress responses to surgery and thereby decrease surgical complications and improve outcomes. This study aimed to integrate experimental and clinical data addressing the physiologic effects of epidural anesthesia and postoperative epidural analgesia on surgical patients and to review the real and potential benefits of this technology concerning patient outcomes. Methods: This prospective observational study was conducted at the Department of Anesthesia, Upazilla Health Complex, Daganbhuiya, Feni, Bangladesh. The study was carried out from June 2020 to July 2021. A total of 110 patients were selected as study subjects as per inclusion criteria. Result: Out of 110 study subjects 20 (18.19%) subjects were in the 25-30 years age group, 30 (27.27%) were in the 31-35 years age group and the rest 60 (54.54%) were in &gt;35 years, age group. Regarding the region of surgery done, 50% of subjects underwent lower abdominal surgery, 20% underwent surgery of lower extremities, 15% underwent labor pain, and the rest 15% underwent cardiothoracic surgery. Concerning intraoperative complication, hypotension was predominant which constituted 9% of total study subjects followed by nausea &amp; vomiting seen in 3% of patients. 2.5% of patients had bradycardia, 2% experienced hypertension, only 1% of patients had tachycardia, and none experienced poor anesthesia. In terms of postoperative complications, post-dural puncture headache was predominant which was seen in 4% of patients, 2% had prolonged ICU stay, 2% had cardiopulmonary complications, 1% had postoperative pain, and 1% experienced occlusion of catheter and catheter fragment retention. It was seen that 95.5% of total patients did not need ephedrine or atropine, only 2% of patients needed ephedrine during the operation due to hypotension and 2.5% needed atropine during the operation due to bradycardia. Regarding the advantages of epidural anesthesia, reduced ileus was seen in 105 (95.45%) patients, reduced length of hospital stay in 108 (98.18%) patients, and reduced 30-day morbidity and mortality in 110 (100%) patients. The overall surgical outcome was excellent as well. In 98% of cases, the surgical outcome was satisfactory and only 2% showed poor surgical outcome. Conclusion: The effect of anesthetic and postoperative analgesic techniques on perioperative outcomes varies with the type of operation performed. Overall, epidural analgesia provides better postoperative pain relief and surgical outcomes.

ASSESSING DEGREE OF EXTERNAL DISLOCATION OF EPIDURAL CATHETER IN CLINICAL PRACTICE IN TRAUMA PATIENTS

For the purpose of the study, we selected 73 patients who underwent combined two-level spinal-epidural anesthesia with a catheter in the subcutaneous tunnel during operations for lower limbs fractures. All patients underwent postoperative epidural analgesia. We applied a method for assessing the degree of external dislocation of the epidural catheter and an algorithm of actions when a dislocation of the epidural catheter is detected. When changing the fixing aseptic sticker, the degree of epidural catheter dislocation was assessed, and if a pronounced dislocation was detected, additional measures were taken to enhance the fixation of epidural catheter. In 14 cases, we used additional fixation devices “Epi-Fix”, which was associated with the threat of falling out of the epidural catheter with a pronounced degree of dislocation. Additional fixation in this case helped to avoid prolapse and ensure continuation of anesthesia. However, in two cases, the epidural catheter was removed because the dislocation corresponded to the 6th degree of the proposed scale, and its continued use was useless. Thus, the use of the scale we developed enables to monitor and assess the risk of worsening anesthesia and catheter migration or prolapse. Further tactics in relation to prolonged anesthesia depend on an objective assessment of the position of the catheter.

Comparative Evaluation of Levobupivacaine with Fentanyl Versus Bupivacaine with Fentanyl for Postoperative Epidural Analgesia in Patients Undergoing Gynae-Oncological Surgeries: A Randomised Clinical Study

Introduction: Epidural analgesia is one of the preferred mode of perioperative management. Neuraxial opioids like fentanyl when used in epidural offer advantage of augmenting local anaesthetic effect and reducing the anaesthetic and analgesic requirement. Aim: To compare the adequacy of analgesia, requirement of rescue analgesics between 0.125% bupivacaine with 2 mcg/cc fentanyl and 0.125% levobupivacaine with 2 mcg/cc fentanyl. Materials And Methods: The randomised clinical study was carried out from September 2016 to May 2017 in 70 patients (35 in each group) of American Society of Anaesthesiologists (ASA) 1 and 2 scheduled for elective gynae-oncological surgeries. The epidural analgesia in group Bupivacaine with Fentanyl (BF) was 0.125% Bupivacaine with 2 mcg/cc Fentanyl and group Levobupivacaine with Fentanyl (LF) was 0.125% Levobupivacaine with 2 mcg/cc fentanyl. All data was statistically analysed and compared using Student t-test, Chisquare/Fisher-Exact test. Results: Total of 70 patients were analysed, 35 each in Group BF (mean age: 50.06±7.19 years) and Group LF (mean age: 46.43±8.41 years). Both the groups were compatible with regard to demographic data and haemodynamic variables. The mean Visual Analogue Scale (VAS) score was higher in group BF compared to group LF at 0,1,4,6,1,2 and 18 hours but the observed difference in both the groups was not statistically significant except at 2nd (p-value: 0.016) and 24th hour (p-value 0.017). Number of rescue analgesics as epidural boluses (p-value=0.001) and paracetamol (p-value=0.044) requirement were more in group BF compared to group LF respectively. Conclusion: On account of adequate postoperative analgesia, haemodynamic stability, levobupivacaine with fentanyl is a better option than bupivacaine with fentanyl for epidural infusion.

A Comparative Study of Epidural Butorphanol and Epidural Fentanyl for Postoperative pain relief in Lower Limb Orthopaedic Surgeries.

Background: Epidural narcotic agonists like fentanyl, and morphine has been studied as an adjunct to Bupivacaine for intraoperative and to provide epidural postoperative analgesia. Side effects like pruritus, nausea, vomiting, respiratory depression, and urinary retention occur with their use. The search for an effective analgesic with no or low incidence of side effects is continuing. Aims and objective: To evaluate the onset of anaesthesia, duration of analgesia with epidural administration of Butorphanol and fentanyl in 2 groups. Observe and compare side effects between these groups during post-operative period. Material and Methods: We had done this study on 60 patients with Orthopaedic fractures (lowerlimb), which are treated with IM IL nailing femur and tibia distributed to two groups of 30 each. Surgery was done under CSE technique, with Group A receiving butorphanol and Group B Fentanyl as adjuvant. The onset, duration of analgesia and side effects were recorded in each group. Results: The onset of analgesia was rapid in Fentanyl group (3.26+/- 0.95) than Butorphanol group (6.54 +/-1.10). Duration of analgesia was longer in Butorphanol group (330 +/- 62 minutes) in comparison to Fentanyl group (210 +/- 32 minutes). Quality of analgesia is better in Butorphanol group (80%) than Fentanyl group (43 %). Side effects were more in Group B than Group A. Conclusion: Epidural Fentanyl has faster onset of analgesia. Epidural Butorphanol has longer duration of analgesia with better quality of analgesia. Epidural butorphanol has fewer side effects when compared to Fentanyl.

The Effect of Epidural Analgesia on Quality of Recovery (QoR) after Radical Prostatectomy.

No studies are currently regarding the quality of recovery (QoR) after open radical prostatectomy (ORP) and epidural morphine analgesia. This was a randomized, prospective, and controlled study that explored QoR on the first postoperative day after ORP. Sixty-one men were randomized into two groups. The first (epidural) group received general anesthesia combined with epidural anesthesia and postoperative epidural analgesia with morphine and ropivacaine. The second (control) group received general anesthesia and continuous postoperative intravenous analgesia with tramadol. Both groups received multimodal analgesia with metamizole. The primary outcome measure was the total QoR-40 score. Secondary outcome measures were: QoR-15, QoR-VAS and the visual analogue scale (VAS) for pain, anxiety and nausea. The median difference in the total QoR-40 score after 24 postoperative hours between the two groups of patients was 2 (95% CI: -3 to 8), p = 0.35. The global multivariate inference test for secondary outcomes between groups was not significant p &gt; 0.05). QoR-VAS was correlated with QoR-40 (r = 0.69, p ≤ 0.001) and with QoR-15 (r = 0.65, p ≤ 0.001). The total QoR-40 and QoR-15 alpha coefficient with 95% CI was 0.88 (0.83-0.92) and 0.83 (0.77-0.89), respectively. There was no difference in the QoR between the epidural and the control group after ORP. The QoR-40 and QoR-15 showed good convergent validity and adequate reliability.

Fluoroscopy-assisted epidural catheter placement: the effect of dye distribution in preoperative epidurograms on postoperative analgesia

BackgroundPostoperative epidural analgesia provides superior postoperative analgesia at rest and with activity, compared with systemic opioids. However, the impact of postoperative epidural analgesia on postoperative morbidity and/or mortality remains controversial, because of the sub-optimal reliability of epidural catheters that are placed preoperatively and used for postoperative pain control. The present study used the technique of lumbar epidurography. The study aims to better understand the possible correlation between the fluoroscopic characteristics of epidural catheters following injection of contrast medium and the postoperative functional characteristics regarding analgesia. In this single-arm clinical trial, 70 patients, aged 50 to 75 years old, underwent surgical urological procedures, involving incisions up to T8 dermatome, under combined general and epidural anesthesia. At the L2-L3 level, the epidural space was reached using the loss of resistance technique before general anesthesia was induced. The catheters were threaded upwards for 4–6 cm. Preoperative epidurograms were then done by injecting a 3-ml contrast medium OmnipaqueTM (240 mg I/ml) in the epidural catheters. The epidurograms were investigated for the location of the catheter tip in relation to the vertebral body, the extent of dye spread, laterality of dye spread (midline, right, or left), and the presence or absence of dye spread anterior to the spinal cord on the lateral image. The patients were followed postoperatively while epidural analgesia was infused.ResultsBoth the postoperative epidural infusion and postoperative visual analog scale (VAS) scores were lower when catheter tips ended at L1 than when they ended at L2. As the contrast’s vertical spread increases in preoperative epidurograms, the analgesic infusion rate and VAS score decrease, and the number of dermatomes insensitive to cold increases. Epidurographically right-sided catheters showed more dermatomes deficient to cold sensations on the right side, compared with mid-line and left-sided catheters. Restriction of contrast to the posterior epidural space was associated with lower VAS scores and wider anesthesia to cold.ConclusionsThe use of epidurography to study epidural catheters may have the potential advantage of predicting the functionality of catheters and improving the reliability of postoperative epidural analgesia.

Inflammatory Response in Patients With Crohn's Disease Compared With Ulcerative Colitis: Secondary Results of a Prospective Pilot Study.

The aim of this study was to compare the inflammatory response (IR) to surgery between patients with Crohn's disease (CD) and patients with ulcerative colitis (UC). This study is a secondary analysis of data collected in a previous study by the authors. We included all adult patients who underwent elective surgery for CD and UC. The primary outcome variable was the difference in postoperative IR as measured by interleukin 6 (IL-6), interleukin 10 (IL-10), C-reactive protein (CRP), and the count of white blood cells (WBCs) in peripheral blood. Two-way repeated-measures analysis of variance with a mixed effect (disease type as the between-patient factor, and time as the within patient factor). We included 46 patients in this pilot study. Median age was 42.5 years (IQR 30.5-42.2), 25/46 were females (54.3%). Patients with CD had a more marked IR to surgery compared with those with UC as shown by significant differences in levels of IL-6, IL-10, and CRP. Patients with CD were more often treated with postoperative epidural analgesia 17 (53.1%) versus 1 (7.1%), P = .009. Patients with colonic CD had a more intense IR to surgery than patients with UC after the same surgical resection. This significant trend continued when patients who underwent small bowel resection compared with those with colectomy. The changes in inflammatory markers and WBC counts from baseline to peak value were also higher in patients with CD indicating a more severe IR. However, there was a similar response in patients undergoing laparoscopic compared with open approaches. The postoperative IR was greater in patients with CD than those with UC. This is important to tackle in preoperative optimization as well as postoperative recovery protocols.

Combined Double-Segment Spinal-Epidural Anesthesia With Fixation of the Epidural Catheter in the Subcutaneous Canal Using a Modified Spinal Needle

Aim of study To develop a new safe and reliable method of fixing an epidural catheter (EC), to study and compare the results of this method of fixing EC in the subcutaneous canal using a modified spinal needle (MSN) and an adhesive tape with a standard method of fixing an EC using only an adhesive tape when performing the combined double-segment spinal-epidural anesthesia (CDSEA) in the surgical treatment of fractures of the bones of the lower limb.Material and methods A comparative study of two methods of EC fixation was carried out in patients undergoing CDSEA during the surgical treatment of fractures of the bones of the lower limb. The patients were divided into two groups. The Group 1 (comparison, n=65), where EC was fixed at the site of epidural access with adhesive tape and the Group 2 (study, n=65), where EC was fixed in the subcutaneous canal using MSN and adhesive tape at the site of EC exit on the skin.Results In the study group, where EC was fixed in the subcutaneous canal using MSN and adhesive tape at the site of EC exit to the skin, there were 32.3% fewer cases with clinically significant dislocation (more than 15 to 30 mm) than in the comparison group, where EC was fixed at the site of epidural access only with adhesive tape.Conclusions A used spinal needle in a modified version can be used to perform EC in the subcutaneous canal. The dimensions of the MSN allow tunneling of the EC less traumatic and at a great distance from the site of the epidural access, which provides more reliable fixation of the EC, the number of cases with clinically significant + dislocation decreases, this allows for a longer and better postoperative epidural analgesia. This method does not solve all the problems of EC fixation; it is required to develop new methods of EC fixation, including fixation in the subcutaneous canal.