High vs mid thoracic epidural analgesia – A comparative study on the ease of insertion and effects on pain, hemodynamics, and oxygenation in patients undergoing thoracotomies

Background: Thoracic epidural analgesia offers effective perioperative pain relief in patients undergoing thoracotomies apart from attenuating stress responses. It helps in fast tracking by facilitating early mobilization and improving respiratory function. Literature on high (T1–T2 level) thoracic segmental analgesia for thoracotomy is less. Aim: The aim of present study was to compare the ease of insertion, effect on pain relief in high (T1–T2 level) vs mid (T5–T6) approach of thoracic epidural. Setting and Design: The present study was a randomized control trial conducted at our institute. Materials and Methods: About 52 patients aged between 18–65 years scheduled for elective thoracotomies under general and thoracic epidural anesthesia were randomized into two groups. Intraoperatively ease of epidural insertion, extent of blockade, and postoperatively pain relief were assessed. Ropivacaine with fentanyl was used for epidural analgesia. Statistical Analysis: Data were presented as mean ± standard deviation and analyzed by the Student's t test, Chi-square test, and non-parametric test whereever applicable. A P value <0.05 was considered statistically significant. Results: We observed that high thoracic epidural anesthesia was easier to place (time taken 123.42 vs 303.08 s) P < 0.05, with less number of attempts (1.27 vs 1.92) P < 0.05. Extent of blockade, postoperative pain scores, rescue analgesia requirement, hemodynamics, and oxygenation were comparable. Conclusion: We conclude that high thoracic epidural is easier to insert, provides adequate pain relief, and stable hemodynamics with the advantage of patient comfort and safety.

Effects of High Thoracic Epidural Anesthesia on Cerebral Blood Flow and Hippocampal Apoptosis during Global Cerebral Ischemia and Reperfusion in Rats / 现代生物医学进展

Objective:To investigate the effects of high thoracic epidural anesthesia (HTEA) on the cerebral blood flow (CBF) and hippocampal apoptosis-related proteins Bcl-2 and Bax during global cerebral ischemia and reperfusion (GCI) in rats.Methods:Fifteen-minute global ischemia was established by 4-vessel occlusion and epidural catheterization was performed through T4-5 intervertebral spaces in adult male Wistar rats.According to the different drugs infused into the epidural space,the rats were randomly divided into four groups:Sham group (0.9 ％ NaC1),Sham-HTEA group (0.25 ％ bupivacaine),GCI group (global cerebral ischemia,0.9 ％ NaC1) and HTEA group (global cerebral ischemia,0.25 ％ bupivacaine).And 0.25 ％bupivacaine or 0.9 ％ saline (20 μL·h-1) was infused continuously to the thoracic epidural space from 15 minutes before ischemia to 24 hours after reperfusion.Mean arterial pressure (MAP),heart rate (HR) and cerebral blood flow (CBF) were determined until 2 hours after reperfusion,and the hippocampal Bcl-2 and Bax proteins at 24 hours after reperfusion were examined by Western-blot.Results:Compared with the GCI group,HTEA group has no significant difference on MAP and HR during ischemia and 2 hours after reperfusion,andcompared with the Sham group,MAP in GCI group increased in ischemia 0 min and decreased in reperfusion 0 min.The CBF in HTEA group was significantly lower than that in GCI group (123.1％± 35.2％ vs 177.5％± 32.4％,P＜0.01) in reperfusion 10 min,and higher than that in GCI group during the hypoperfusion of 60 to 120 minutes after reperfusion (P＜0.05),and the ratio of Bax/Bcl-2 in hippocampus was significantly decreased in HTEA group 24 hours after reperfusion (P＜0.01).Conclusions:Continuous HTEA infusion of 0.25 ％ bupivacaine 20 μL ·h-1 could maintain the hemodynamic stability,and improve the CBF of hypoperfusion period in rats,as well as reduce the ratio of Bax/Bcl-2 at 24 hours after reperfusion.

Epidural catheterization in cardiac surgery: The 2012 risk assessment.

Aims and Objectives: The risk assessment of epidural hematoma due to catheter placement in patients undergoing cardiac surgery is essential since its benefits have to be weighed against risks, such as the risk of paraplegia. We determined the risk of the catheter-related epidural hematoma in cardiac surgery based on the cases reported in the literature up to September 2012. Materials and Methods: We included all reported cases of epidural catheter placement for cardiac surgery in web and in literature from 1966 to September 2012. Risks of other medical and non-medical activities were retrieved from recent reviews or national statistical reports. Results: Based on our analysis the risk of catheter-related epidural hematoma is 1 in 5493 with a 95% confidence interval (CI) of 1/970-1/31114. The risk of catheter-related epidural hematoma in cardiac surgery is similar to the risk in the general surgery population at 1 in 6,628 (95% CI 1/1,170-1/37,552). Conclusions: The present risk calculation does not justify not offering epidural analgesia as part of a multimodal analgesia protocol in cardiac surgery.

Anesthesia for off-pump coronary artery bypass surgery.

The evolution of techniques and knowledge of beating heart surgery has led anesthesia toward the development of new procedures and innovations to promote patient safety and ensure high standards of care. Off-pump coronary artery bypass (OPCAB) surgery has shown to have some advantages compared to on-pump cardiac surgery, particularly the reduction of postoperative complications including systemic inflammation, myocardial injury, and cerebral injury. Minimally invasive surgery for single vessel OPCAB through a limited thoracotomy incision can offer the advantage of further reduction of complications. The anesthesiologist has to deal with different issues, including hemodynamic instability and myocardial ischemia during aorto-coronary bypass grafting. The anesthesiologist and surgeon should collaborate and plan the best perioperative strategy to provide optimal care and ensure a rapid and complete recovery. The use of high thoracic epidural analgesia and fast-track anesthesia offers particular benefits in beating heart surgery. The excellent analgesia, the ability to reduce myocardial oxygen consumption, and the good hemodynamic stability make high thoracic epidural analgesia an interesting technique. New scenarios are entering in cardiac anesthesia: ultra-fast-track anesthesia with extubation in the operating room and awake surgery tend to be less invasive, but can only be performed on selected patients.

CT-Guided Percutaneous Vertebroplasty in the Treatment of an Upper Thoracic Compression Fracture

Percutaneous vertebroplasty (PVP) has been used to relieve pain and to prevent further collapse of the vertebral body in patients with an osteoporotic compression fracture. The most commonly affected site for the use of PVP is the thoracolumbar junction. There are few reports that have described on the usefulness of PVP in the treatment of a high thoracic compression fracture. We report a case of an upper thoracic compression fracture that was treated with computed tomography (CT)-guided PVP. It was possible to obtain easy access to the narrow thoracic pedicle and it was also possible to monitor continuously the proper volume of polymethylmethacrylate employed, under CT guidance.

Application of high thoracic washing in treating leakage of thoracic esophageal anastomosis / 中国综合临床

Objective To evaluate the clinical value of high thoracic washing in leakage of thoracic esophageal anastomosis.Methods 16 cases of anastomosis leakage after esophageaoctomy were treated with high thoracic washing.Results 13 of 16 patients were cured,with a cure rate of 81.25% and the average hospital time of 46 days.One patient died of bleeding and one died of lung infection and respiratory failure.The other one gave up therapy and discharged selfishly.Conclusion High thoracic washing in treating leakage of thoracic esophageal anastomosis is a reliable way with effect,simple procedure and less complication