Comparison of Epidural Analgesia with Ultrasound?Guided Bilateral Erector Spinae Plane Block in Aorto?Femoral Arterial Bypass Surgery

Objective:Thoracic Epidural Analgesia (TEA) was compared with ultrasound?guided bilateral erector spinae plane (ESP) block in aorto?femoral arterial bypass surgery for analgesic efficacy, hemodynamic effects, and pulmonary rehabilitation. Design: Prospective randomized. Setting: Tertiary care centre. Participants: Adult patients, who were scheduled for elective aorto?femoral arterial bypass surgery. Interventions: It was a prospective pilot study enrolling 20 adult patients who were randomized to group A (ESP block = 10) and group B (TEA = 10). Monitoring of heart rate (HR) and mean arterial pressure (MAP) and pain assessment at rest and deep breathing using visual analog scale (VAS) were done till 48?h post?extubation. Rescue analgesic requirement, Incentive spirometry, oxygenation, duration of ventilation and stay in Intensive Care Unit (ICU) were reported as outcome measures. Statistical analysis was performed using unpaired Student T?test or Mann?Whitney U test. A value of P < 0.05 was considered significant. Results: HR was lower in group B than group A at 1 and 2 h post? surgery and at 0.5, 16, 20, and 32 h post?extubation (P < 0.05). MAP were lower in group B than A at 60, 90, 120, 150, 180, 210, 240, 270 minutes and at 0 hour post?surgery and at 4 hours, every 4 hours till 32 hours post?extubation (P < 0.05). Intraoperative midazolam and fentanyl consumption, ventilatory hours, VAS at rest, incentive spirometry, oxygenation, and ICU stay were comparable between the two groups. VAS during deep breathing was more in group A than B at 0.5, 4 hours and every 4 hours till 44 hours post?extubation. The time to receive the first rescue analgesia was shorter in group A than B (P < 0.05). Conclusion: Both ESP block and TEA provided comparable analgesia at rest. Further studies with larger sample size are required to evaluate whether ESP block could be an alternative to TEA in aorto?femoral arterial bypass surgery

Effectiveness of pre-emptive thoracic epidural analgesia for acute post thoracotomy pain relief: a randomised blinded study

Background: Thoracotomy is one of the most damaging surgical insults on respiratory mechanics and management of post-thoracotomy pain is a challenge. This study was conducted to compare intensity of postoperative pain, measured by VAS, in patients receiving Pre-emptive TEA compared to patients receiving epidural analgesia during surgical closure.Method: Group A comprised of patients receiving Pre-emptive TEA with 0.1%Ropivacaine and 2 μg/ml fentanyl, 20 minutes before incision. Group B comprised of patients receiving the same drug, during surgical closure.Results: Demographic profile was comparable between both groups. Both groups offered good analgesia, but pre-emptive group took an upper hand upto4th postoperative hour (p<0.05), both at rest and coughing. Beyond 4thhour, analgesic efficacy of both groups was comparable.Conclusion: Pre-emptive technique offered better analgesia over the postoperative technique up to 4th postoperative hour, both at rest and coughing.

Post-thoracotomy ipsilateral shoulder pain: What should be preferred to optimize it - phrenic nerve infiltration or paracetamol infusion?

Background: Post thoracotomy ipsilateral shoulder pain (PTISP) is a distressing and highly prevalent problem after thoracic surgery and has not received much attention despite the incidence as high as 85%. Objectives: To study the effect of phrenic nerve infiltration with Ropivacaine compared to paracetamol infusion on PTISP in thoracotomy patients with epidural analgesia as standard mode of incisional analgesia in both the groups. Study Design: Prospective Randomised and Double Blind Study. Methods: 126 adult patients were divided randomly into 2 groups, “Group A (Phrenic Nerve Infiltration Group) received 10 mL of 0.2% Ropivacaine close to the diaphragm into the periphrenic fat pad” and “Group B (Paracetamol Infusion Group) received 20mg/kg paracetamol infusion” 30 minutes prior to chest closure respectively. A blinded observer assessed the patients PTISP using the VAS score at 1, 4, 8, 12 and 24 hours (h) postoperatively. The time and number of any rescue analgesic medication were recorded. Results: PTISP was relieved significantly in Group A (25.4℅) as compared to Group B (61.9℅), with significantly higher mean duration of analgesia in Group A. The mean time for first rescue analgesia was significantly higher in Group A (11.1 ± 7.47 hours) than in Group B (7.40 ± 5.30 hours). The number of rescue analgesic required was less in Group A 1.6 ± 1.16 as compared to Group B 2.9 ± 1.37 (P value <0.5). Conclusions: Phrenic Nerve Infiltration significantly reduced the incidence and delayed the onset of PTISP as compared to paracetamol infusion and was not associated with any adverse effects.

Evaluation the Anesthesia Techniques for Reduction of Intraoperative and Postoperative Complications and Post-Operative Morbidity and Mortality Of Stroke Patients in ICU

Objective: In this study our main objective is to evaluateanesthesia techniques for reductions in intraoperative andpostoperative complications and post-operative morbidity andmortality of stroke patients in ICU.Method: This Retrospective study was carried out at theDepartment of Surgery, tertiary care hospital, Dhaka from June2017 to June 2018 where 120 patients who underwent differenttypes of surgery were randomized to receive thoracic epiduralanalgesia along with general anaesthesia in Group-A (60patients) and only GA in Group-B (60 patients) were includedthe study.Results: During the study, most of the patients belong to 41-50years age group for both Group A (47.78%) and group B(43.34%). Most of the patients in group A faced cardiac surgeryand in group most of the patients faced neurologic surgerybefore stroke. Also, 89% of Group-A patients stay in ICU for39-4 hours whereas Group B it was 11%.Conclusion: From our results; we can say that, TEA incombination with general anesthesia for surgery iscomparatively safe rather than general anesthesia whichreduces stroke development in patients. Further study isneeded for better outcome.

Comparison of continuous thoracic epidural analgesia with bilateral erector spinae plane block for perioperative pain management in cardiac surgery

Objective: Continuous thoracic epidural analgesia (TEA) is compared with erector spinae plane (ESP) block for the perioperative pain management in patients undergoing cardiac surgery for the quality of analgesia, incentive spirometry, ventilator duration, and intensive care unit (ICU) duration. Methodology: A prospective, randomized comparative clinical study was conducted. A total of 50 patients were enrolled, who were randomized to either Group A: TEA (n = 25) or Group B: ESP block (n = 25). Visual analog scale (VAS) was recorded in both the groups during rest and cough at the various time intervals postextubation. Both the groups were also compared for incentive spirometry, ventilator, and ICU duration. Statistical analysis was performed using the independent Student's t-test. A value of P < 0.05 was considered statistically significant. Results: C omparable VAS scores were revealed at 0 h, 3 h, 6 h, and 12 h (P > 0.05) at rest and during cough in both the groups. Group A had a statistically significant VAS score than Group B (P ≤ 0.05) at 24 h, 36 h, and 48 h but mean VAS in either of the Group was ≤4 both at rest and during cough. Incentive spirometry, ventilator, and ICU duration were comparable between the groups. Conclusion: ESP block is easy to perform and can serve as a promising alternative to TEA in optimal perioperative pain management in cardiac surgery.

Evaluation of Pulmonary Function after Off- Pump Coronary Artery Bypass Graft Surgery with Thoracic Epidural Analgesia.

Background: A substantial reduction of lung volumes and pulmonary function follows cardiac surgery. Pain may prevent effective breathing and coughing, as thoracic epidural analgesia may reduce post operative pain and improve early post operative pulmonary function. We tested the effect of thoracic epidural analgesia (TEA) on pulmonary function after off- pump coronary artery bypass (OPCAB) graft surgery. Methods: 60 patients undergoing off- pump coronary artery bypass (OPCAB) graft surgery were nonrandomized in to two groups. Group-I (30 patients) receiving thoracic epidural analgesia along with general anaesthesia (G/A) but Group-II (30 patients) receiving general anaesthesia alone. Total ventilation time, intensive care unit (ICU) stay, spirometric data, arterial blood gas (ABG) and X-ray chest (CXR) were recorded in postoperative follow-up period. Results: Thirty patients were enrolled in each group. The demographics of the groups were similar. Patients in the epidural group had significantly less pain on the operative day and for the next 2 days. Total ventilation time in hours in Group-I was 6.4±1.0 and in group-II was 10.1±1.8 hours respectively. FVC and FEV1 were significantly different in group-I than group-II. On the postoperative period, ABG was done pre and postoperative period in both groups of patients. Significant differences was found in pao2 and paco2, half an hour after extubation, 1st postoperative day, 2nd postoperative day (p<0.05). Postoperative CXR revealed significant pulmonary complication in group-II than group-I, higher in the epidural group on the first and second postoperative days. There were no complications related to epidural hematoma and no permanent neurologic squeal. Conclusion: Thoracic epidural analgesia yields a slight, but significant improvement in pulmonary function most likely due to a more profound postoperative analgesia.

Thoracic epidural analgesia for off-pump coronary artery bypass surgery in patients with chronic obstructive pulmonary disease.

The benefits of thoracic epidural analgesia in patients undergoing coronary artery bypass grafting are well documented. However, the literature available on the role of high thoracic epidural analgesia (HTEA) in patients with chronic obstructive pulmonary disease undergoing off-pump coronary artery bypass graft (OPCAB) surgery is scarce. We conducted a randomized clinical trial to establish whether HTEA is beneficial in patients with chronic obstructive pulmonary disease undergoing elective OPCAB surgery. After institutional ethics board approval and informed consent, 62 chronic obstructive pulmonary disease patients undergoing elective OPCAB were randomly grouped into two (n = 31 each). Both groups received general anesthesia (GA), but in the HTEA group patients, TEA was also administered. Standardized surgical and anesthetic techniques were used for both the groups. Pulmonary function tests were performed pre-operatively, 6 h and 24 h post-extubation and on days 2, 3, 4 and 5 along with arterial blood gas analysis (ABG) analysis. Time for extubation (h) and time for oxygen withdrawal (h) were recorded. Pain score was assessed by the 10-cm visual analogue scale. All hemodynamic/oxygenation parameters were noted. Any complications related to the TEA were also recorded. Patients in the HTEA group were extubated earlier (10.8 h vs. 13.5 h, P < 0.01) and their oxygen withdrawal time was also significantly lower (26.26 h vs. 29.87 h, P < 0.01). The VAS score, both at rest and on coughing, was significantly lower in the HTEA group at all times, post-operatively (P < 0.01). The forced vital capacity improved significantly at 6 h post-operatively in the HTEA group (P = 0.026) and remained significantly higher thereafter. A similar trend was observed in forced expiratory volume in the first second on day 2 in the HTEA group (P = 0.024). We did not observe any significant side-effects/mortality in either group. In chronic obstructive pulmonary disease patients undergoing elective OPCAB surgery, HTEA is a good adjunct to GA for early extubation, faster recovery of pulmonary function and better analgesia.

Thoracic epidural analgesia in obese patients with body mass index of more than 30 kg/m 2 for off pump coronary artery bypass surgery.

Perioperative Thoracic epidural analgesia (TEA) is an important part of a multimodal approach to improve analgesia and patient outcome after cardiac and thoracic surgery. This is particularly important for obese patients undergoing off pump coronary artery bypass surgery (OPCAB). We conducted a randomized clinical trial at tertiary care cardiac institute to compare the effect of TEA and conventional opioid based analgesia on perioperative lung functions and pain scores in obese patients undergoing OPCAB. Sixty obese patients with body mass index >30 kg/m 2 for elective OPCAB were randomized into two groups (n=30 each). Patients in both the groups received general anesthesia but in group 1, TEA was also administered. We performed spirometry as preoperative assessment and at six hours, 24 hours, second, third, fourth and fifth day after extubation, along with arterial blood gases analysis. Visual analogue scale at rest and on coughing was recorded to assess the degree of analgesia. The other parameters observed were: time to endotracheal extubation, oxygen withdrawal time and intensive care unit length of stay. On statistical analysis there was a significant difference in Vital Capacity at six hours, 24 hours, second and third day postextubation. Forced vital capacity and forced expiratory volume in one second followed the same pattern for first four postoperative days and peak expiratory flow rate remained statistically high till second postoperative day. ABG values and PaO 2 /FiO 2 ratio were statistically higher in the study group up to five days. Visual analogue scale at rest and on coughing was significantly lower till fourth and third postoperative day respectively. Tracheal extubation time, oxygen withdrawal time and ICU stay were significantly less in group 1. The use of TEA resulted in better analgesia, early tracheal extubation and shorter ICU stay and should be considered for obese patients undergoing OPCAB.

High Thoracic Epidural Analgesia for the Control of Pain in Unstable Angina Pectoris: A case report / 대한통증학회지

Unstable angina is a critical phase of coronary heart disease, with widely variable symptoms and prognoses. Recently, despite the advances in surgical revascularization, catheter-based revascularization and medical treatment, an increasing number of patients with angina pectoris are refractory to medical therapy and; therefore, can not be considered as candidates for coronary artery bypass grafting or interventional angioplasty. These patients are often treated with narcotics for pain relief, and forced to severely reduce their levels of activity and productivity. It has become clear that alleviating the pain caused by myocardial ischemia may be possible by altering the sympathetic afferent nerve fibers. Sympathetic blockade can be produced using high thoracic epidural analgesia. Herein, the case of a patient with intractable angina and poor ventricular function, who received high thoracic epidural analgesia to relieve ischemic chest pain, is reported.

Thoracic Epidural Analgesia with 0.2% or 0.5% Bupivacaine during Upper Abdominal Operations / 대한마취과학회지

BACKGROUND: Thoracic epidural block has been widely used to control postoperative pain. The relative effects of the mass, volume, and concentration of local anesthetic solutions used are still subjects of debate, and the relationship between general anesthesia and thoracic epidural block is unclear. METHODS: In study I, 20 conscious patients scheduled for elective upper abdominal surgery received 0.2% bupivacaine with morphine 3 mg (group CL: n = 10) or 0.5% bupivacaine with morphine 3 mg (group CH: n = 10) via an epidural catheter inserted at the T8-T9 epidural space. The width of sensory block, blood pressure and heart rate were assessed for 30 minutes and then general anesthesia was administered. In study II, under general anesthesia, 72 patients scheduled for elective upper abdominal surgery were injected with the same formula as used in study I (group UL: n = 36, group UH: n = 36). Blood pressure, heart rate, vol% of end-tidal inhalation agent were measured for an hour. Postoperatevely, the VAS scores of both study groups were assessed in the recovery room, after 24 hours and 48 hours. RESULTS: In study I, the mean arterial pressures were significantly lower in the CH group than the CL group (P = 0.0419 and P = 0.0328 at 20 and 25 minutes after local anesthetic infusion), but heart rate and VAS score were not significantly different. In study II, no difference was observed between the groups in terms of blood pressure, heart rate, enflurane requirement, or VAS score. But hypotension requiring treatment was more frequent in the UH group than in the UL group (group UL: n = 3, group UH: n = 6). CONCLUSIONS: Epidural administration of the same volume of 0.2% bupivacaine or 0.5% bupivacaine provided similar pain relief and hemodynamic change, but profound hypotension was more frequent in the 0.5% bupivacaine group during general anesthesia. This study shows no benefit of using 0.5% bupivacaine to improve postoperative analgesia in upper abdominal surgery.

The Effect of the Thoracic Epidural Analgesia on Postoperative Pain and Pulmonary Function Recovery after Thoracoscopic Surgery / 대한마취과학회지

BACKGROUND: The study was performed to evaluate the effect of the thoracic epidural analgesia on the postoperative pain and pulmonary function after thoracoscopic surgery. METHODS: Postoperative pain control consisted of continuous thoracic epidural infusion of normal saline in group 1 (Control group) and 0.125% bupivacaine mixed with fentanyl 5microgram/ml in group 2 (TEA group) added in single intercostal nerve block patient in sixty patients who had undergone elective thoracoscopic surgery. The visual analogue scale (VAS), Prince-Henry score (PHS) and pulmonary function (FVC and FEV1) were measured preoperatively and postoperatively at 4, 8, 12, 24, 48 hours. RESULTS: There were significant improvement of the degree of pain in both groups but TEA group was lower than control group during 48 hours except at postoperative 4 hours. Pulmonary function was decreased less and recovered faster in TEA group than control group during 48 hours (P < 0.05). CONCLUSIONS: Thoracic epidural analgesia added in single intercostal nerve block has a benefit on the recovery of the postoperative pulmonary function and also provide superior analgesia after thoracoscopic surgery when compared to single intercostal nerve block alone. The authors recommend thoracic epidural analgesia for patient undergoing thoracoscopic surgery who receive single intercostal nerve block.

Influence of Thoracic Epidural Analgesia on Postoperative Respiratory Complications in Esophageal Cancer Patients / 대한마취과학회지

BACKGROUND: Respiratory complications have been the main cause of death after a resection of esophageal cancer. This retrospective study was conducted to investigate the effect of thoracic epidural analgesia on respiratory complications after a resection of esophageal cancer. METHODS: This study enrolled two groups of patients undergoing an esophageal resection during a 7-year period. The first group (control group) was comprised of 105 patients in whom thoracic epidural analgesia was not used. The second group (epidural group) was comprised of 121 patients in whom thoracic epidural analgesia was done routinely. The latter group received an initial bolus of 0.1% bupivacaine 10 ml with 2 mg of morphine at the end of surgery and an infusion of 2 ml/hr of the solution comprised of 0.1% bupivacaine with 0.2 mg/ml morphine for 3 days. The incidence of respiratory complications and the duration of ventilator care and ICU stay were investigated by reviewing of charts. RESULTS: There were no significant differences in the incidence of respiratory complications and the duration of ventilator care and ICU stay in both groups. CONCLUSIONS: The results of this study suggest that the routine use of thoracic epidural analgesia did not reduce the incidence of respiratory complications after resection of esophageal cancer.