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Caudal epidural anesthesia administered intraoperatively provides for effective postoperative analgesia after total hip arthroplasty
Journal of Clinical Anesthesia (2007) 19, 204 – 208
Original contribution
Caudal epidural anesthesia administered intraoperatively provides for effective postoperative analgesia after total hip arthroplastyB Takashi Kita MD, PhD (Staff Anesthesiologist)a,*, Naritoshi Maki MD (Staff Anesthesiologist)a, Yong Su Song MD (Staff Anesthesiologist)a, Fumio Arai MD (Staff Anesthesiologist)a, Tsuyoshi Nakai MD, PhD (Staff Surgeon)b a
Department of Anesthesiology, Osaka Police Hospital, Tennoji, Osaka 543-8502, Japan Department of Orthopedic Surgery, Osaka Police Hospital, Tennoji, Osaka 543-8502, Japan
b
Received 10 March 2006; revised 9 October 2006; accepted 9 October 2006
Keywords: Adult patients; Anesthesia, caudal epidural; Total hip arthroplasty
Abstract Study Objective: To investigate the use of caudal epidural anesthesia for postoperative pain after total hip arthroplasty. Design: Prospective study. Setting: University-affiliated hospital. Patients: 32 (4 men and 28 women) patients, aged 49 to 89 years, scheduled for total hip arthroplasty for osteoarthritis of the hip. Interventions and Measurements: Patients were allocated to three groups: lumbar epidural anesthesia (EA group; n = 16) or caudal epidural anesthesia (CA group; n = 16) groups, which were case-matched according to patient demographics. Nine patients received general anesthesia only (GA group). We evaluated the level of postoperative pain using a 100-mm Visual Analog Scale (VAS) recorded at 3, 6, 9, 12, and 24 hours after surgery. Main Results: Total requirement of diclofenac sodium suppositories was significantly larger in the GA group than in the EA or CA groups (444 F 302 vs 188 F 124 and 145 F 130 mg). The number of days requiring analgesics was significantly prolonged in the GA group compared with the EA or CA groups (14 F 9 vs 4 F 3 and 4 F 4 days). These items were similar between the EA group and the CA group. All VAS values for pain, rest, and movement in the postsurgical period over 24 hours were significantly higher in the GA group than in either the EA or CA groups. Conclusions: Caudal epidural anesthesia provides effective postoperative analgesia similar to lumbar epidural anesthesia. D 2007 Elsevier Inc. All rights reserved.
B Support for this work was obtained from institutional and/or departmental sources. * Corresponding author. Tel.: +81 6 6771 6051; fax: +81 6 6775 2875. E-mail address: [email protected] (T. Kita).
0952-8180/$ – see front matter D 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.jclinane.2006.10.011
1. Introduction Total hip arthroplasty (THA) causes severe postoperative pain in half of all patients who require the surgery [1].
Caudal epidural anesthesia and THA Table 1
205
2. Materials and methods
Patients demographics
Number Gender (M/F) Age (y) Body mass index (kg/m2) Complications Cerebral infarction Hypertension Diabetes mellitus Cardiac dysfunction Respiratory dysfunction Liver dysfunction Renal dysfunction
EA group
CA group
GA group
16 2/14 66 F 8 (53-77) 23.0 F 2.7 (18.4-27.6)
16 1/15 67 F 12 (49-89) 23.4 F 3.9 (17.7-31.6)
9 1/8 68 F 9 (47-79) 23.2 F 3.3 (19.6-29.0)
1 5 1 2 3
3 9 1 1 5
0 3 0 3 2
1 0
1 0
1 0
Data are N or means F SD values.
Inadequate postoperative pain control causes various complications such as inhibition of rehabilitation, prolonged hospital stay, and increased hospital costs. Although several treatment options for postoperative pain management have been reported in these patients (eg, various combinations of systemic analgesics with or without opioids and epidural, plexus, or peripheral block) a well-accepted management has not been established. In our hospital, we have been using lumbar epidural analgesia for postoperative pain control. In these patients, the problems of obesity or compression fracture of lumbar spine frequently exist, and thus epidural catheter placement is often difficult to perform and requires a significant amount of time to place. Caudal epidural anesthesia has been used effectively for a variety of surgical procedure, especially in children. Adults have variable sacral anatomy, thick presacral fat, and calcified ligaments that make it difficult to perform this procedure [2]. Usefulness of caudal epidural anesthesia for THA has not been well evaluated. Thus, the study was designed to evaluate the efficacy of caudal epidural anesthesia for postoperative analgesia after THA.
Table 2
The study was approved by the institutional review board of the Osaka Police Hospital, and informed consent was obtained from all patients involved in the study. Subjects consist of 41 patients (5 men and 36 women, 47-89 years old) who underwent elective THA for osteoarthritis of the hip. Patients with a history of previous surgery on the hip were excluded from the study. Administration of anti-inflammatory drugs was suspended at least one week before the surgery. We allocated patients to three groups: the lumbar epidural anesthesia group (EA group; n = 16), the caudal epidural anesthesia group without an epidural catheter (CA group; n = 16), or the GA group (9 patients who underwent surgery with general anesthesia only). In the EA and CA groups, none of the patients had coagulation abnormalities or had been taking anticoagulant drugs before surgery. In the EA group, an epidural catheter was placed with an 18-gauge Tuohy needle (B. Braun Aesculap, Perifix, B. Braun, Melsungen, Germany) inserted into the L1-L2 or L2-L3 interspace. The epidural space was located by a loss–of–resistance to saline technique. Before surgery, an epidural catheter was inserted to a depth of 5 cm in a cephalad direction of the epidural space. After the induction of general anesthesia, two mg of morphine with 1% lidocaine 60 mg was administered through the epidural catheter, before skin incision, and followed by continuous epidural infusion with 0.2% ropivacaine started at the rate of three mL/hr during the operation. The epidural catheter was removed one day after surgery. In the CA group, the sacral hiatus was identified once the patient was turned to the lateral decubitus position for surgery. After skin cleansing with povidone iodine, a short, beveled, 22-gauge needle (Terumo needle, 0.7 32 mm; Terumo, Tokyo, Japan) was inserted using loss-ofresistance to saline technique. After negative aspiration to exclude accidental intrathecal or intravascular insertion, caudal epidural anesthesia was performed with 1% lidocaine 200 mg containing 4 mg of morphine without placement of a catheter. In the operating room, these patients received routine monitoring (three-lead electrocardiogram, pulse oximetry, capnography, anesthetic blood gas
Intraoperative data EA group
Time from entering operating room to start of surgery (min) Time from end of surgery to leaving operating room (min) Duration of surgery (min) Bleeding volume (mL) Infusion volume (mL) Urine output (mL) Data are means F SD values. * P b 0.05.
CA group
GA group
47 F 10 (30-71)
34 F 6 (25-45)*
41 F 11 (30-60)
16 F 5 (7-30)
18 F 15 (6-65)
17 F 2 (15-20)
71 F 34 (35-132) 335 F 381 (50-1350) 1044 F 437 (600-2250) 235 F 174 (100-720)
52 F 9 (40-66) 325 F 216 (100-766) 678 F 258 (250-1100)* 209 F 162 (50-630)
84 485 1083 199
F F F F
34 (20-155) 383 (60-1130) 647 (200-2500) 126 (0-390)
206 Table 3
T. Kita et al. Postoperative data
Total requirement of analgesics (mg) Administration period of analgesics (d) Duration until first administration of analgesics after surgery (h) Duration until first administration until ambulation after surgery (h) Duration until first administration of hospital stay after surgery (d)
EA group
CA group
GA group
188 F 124 (0-400) 4 F 3 (0-11) 6 F 8 (0-27)
145 F 130 (50-500) 4 F 4 (1-13) 13 F 16 (0-58)
444 F 302 (150-950)* 14 F 9 (5-32)* 1 F 1 (0-4)
24 F 4 (21-27)
22 F 3 (19-29)
23 F 11 (23-50)
28 F 8 (21-47)
25 F 3 (19-29)
34 F 12 (22-58)
Data are N or means F SD values. * P b 0.05.
analyzer, and rectal temperature). Anesthesia was induced with fentanyl (1-2 lg/kg) and thiopental sodium (4-5 mg/kg), supplemented with 5% sevoflurane, and vecuronium bromide (0.1 mg/kg). Additional doses of fentanyl were administered at the discretion of the anesthesiologist. We also administered 2.5 mg of droperidol intravenously to prevent postoperative nausea and vomiting (PONV). After tracheal intubation, all patients were positioned in the lateral decubitus position for the operation. Anesthesia was maintained with sevoflurane with nitrous oxide. Surgery was performed via the posterolateral approach without trochanteric osteotomy. No patients from the EA or the CA group presented with hemodynamic instability at the time of incision. Bone reconstruction was not performed in all cases. After surgery, all patients were transferred to their ward, and pain was controlled with diclofenac sodium suppositories, as required by the attendant orthopedist.
According to our THA protocol, physical rehabilitation was started on the day after surgery. There was no significant difference in postoperative rehabilitation among the groups. Postoperative anticoagulant therapy was scheduled to start in the postoperative period. Intraoperative data included duration of anesthesia and surgery, blood losses, transfusion and infusion volume, and urine output. Postoperative data included total requirement and time of analgesic administration (diclofenac sodium suppositories), time of the first need for analgesics, time of ambulation after surgery, and duration of hospital stay. We also measured postoperative pain by using a 100-mm Visual Analog Scale (VAS). The VAS for pain ranged from 0 (bno painQ) to 100 (bstrongest pain experienced by the patientQ). The VAS score was recorded at three, 6, 9, 12 and 24 hours after surgery. All data from the three groups were analyzed by KruskalWallis test followed by the Dunn procedure or v 2 test, as
Fig. 1 Visual Analog Scale (VAS) for pain at rest until 24 hours after surgery in each group. In every point after surgery, GA group presented high VAS scores compared with the EA and CA groups. 5, EA group; , CA group; , GA group.
Fig. 2 Visual Analog Scale (VAS) for pain on movement until 24 hours after surgery in each group. In every point after surgery, the GA group presented high VAS scores compared with the EA and CA groups. 5, EA group; , CA group; GA group.
Caudal epidural anesthesia and THA needed. Correlation was analyzed by Spearman rank correlation, and statistical significance was defined as P b 0.05. Statistical analysis was performed with SPSS software (11.0; SPSS, Chicago, IL).
3. Results No statistical differences were seen in demographic data among the three groups (Table 1). In our study, no patients were given additional doses of antiemetics during the postoperative period, and there was no significant postoperative respiratory complication noted in any patient. The time for setting up for the operation was significantly shorter in the CA group than the EA group (47 F 10 vs 34 F 6 min; Table 2). Volume was significantly lower in the CA group compared with either the EA or the GA group (678 F 258, 1044 F 437, and 1083 F 647 mL, respectively; Table 2). Although there was no statistical differences among the three groups in fentanyl administration during surgery, a considerably greater amount of fentanyl was necessary in the GA group. The period for first request for analgesia postoperatively, time to ambulation, and duration of hospital stay were similar among the three groups. However, total requirement of analgesics was significantly greatest in the GA group than the EA or CA groups (444 F 302, 188 F 124, and 145 F 130 mg, respectively; Table 3). All VAS for pain in the 24-hour postsurgical period were significantly higher in the GA group than the EA or CA groups (Figs. 1 and 2). The time to first request for analgesia was longer in the GA group than the EA or CA group (14 F 9, 4 F 3, and 4 F 4 days, respectively; Table 3). In this study, only one patient from the EA group presented with postoperative delirium on the day after surgery. There were no statistical differences among the three groups in the rate of delirium.
207 (eg, lumber epidual anesthesia, caudal epidural anesthesia with local anesthetics) may be associated with lower incidence of DVT. Caudal epidural anesthesia is a simple procedure that provides good quality of analgesia for both the perioperative and postoperative periods. In a previous study, we reported that caudal injection of 0.25% bupivacaine (20 mL) and 0.1 mg buprenorphine reduced postoperative pain after spinal surgery [7]. However, skill and experience are necessary for success with this technique. In our hospital, experienced staff anesthesiologists have performed caudal epidural anesthesia for more than 15 years, and the success rate of the maneuver is 94.1%. Epidural catheter placement is sometimes difficult in the patient scheduled for THA because of positioning difficulty, patient obesity, or compression fracture of the lumbar spine. We were easily able to identify the site of injection in the CA group and, interestingly, the time of this procedure for CA was significantly shorter than in the EA group. In addition, there were no neurologic, respiratory, or hemodynamic complications in the CA group patients. Caudal injection provides good postoperative analgesia without requiring a catheter [8], thereby reducing the risk of epidural hematoma, which may be caused by postoperative anticoagulation for prophylaxis and treatment of DVT. Patients requiring general anesthesia needed a greater amount of analgesics for a longer period than did either the EA or the CA group (all values of VAS for pain at rest and at movement were significantly higher). We speculate that the efficacy of caudal epidural anesthesia may be attenuated in longer surgeries, for which continuous infusion of opioid with local anesthetics would be preferable in such cases. In conclusion, our study shows that caudal epidural anesthesia provided excellent postoperative pain control in THA.
Acknowledgments 4. Discussion In this study, caudal epidural anesthesia provided postoperative analgesia as effective as lumbar epidural anesthesia. Postoperative analgesia is very important because it hastens the time to ambulation and improves the quality of rehabilitation, both aspects of which can reduce the risk for deep vein thrombosis (DVT) [3]. Deep vein thrombosis is thought to be formed in the proximal veins during surgery as a result of the local stasis of blood flow in the femoral vein. Manipulating the femoral canal with a screw also releases intramedullary procoagulants into the circulation and aggravates thrombosis formation [4]. Epidural administration of local anesthetics significantly increases venous velocity and volume flow of the lower extremities [5]. In addition, epidural local anesthetics inhibit platelet function and enhance fibrinolysis [6]. These beneficial effects of epidural injection of local anesthetics
The authors are indebted to Drs Mammoto, Kakiuchi, and Sasaki for their helpful assistance throughout this investigation.
References [1] Bonica JJ. Postoperative pain. In: Bonica JJ, editor. The management of pain. Malvern (PA)7 Lea & Febiger; 1990. p. 461 - 80. [2] Crighton IM, Barry BP, Hobbs GJ. A study of the caudal space using magnetic resonance imaging. Br J Anaesth 1997;78:391 - 5. [3] Farag E, Dilger J, Brooks P, Tetzlaff JE. Epidural analgesia improves early rehabilitation after total knee replacement. J Clin Anesth 2005;17: 281 - 5. [4] Westrich GH, Salvati EA, Sharrock N, Potter HG, Sanchez PM, Sculco TP. The effect of intraoperative heparin administered during total hip arthroplasty on the incidence of proximal deep vein thrombosis assessed by magnetic resonance venography. J Arthroplasty 2005;20: 42 - 50.
208 [5] Delis KT, Knaggs AL, Mason P, Macleod KG. Effects of epidural-andgeneral anesthesia combined versus general anesthesia alone on the venous hemodynamics of the lower limb. A randomized study. Thromb Haemost 2004;92:1003 - 11. [6] Porter J, Crowe B, Cahill M, Shorten G. The effects of ropivacaine hydrochloride on platelet function: an assessment using the platelet function analyser (PFA-100). Anaesthesia 2001;56:15 - 8.
T. Kita et al. [7] Kakiuchi M, Abe K. Pre-incisional caudal epidural blockade and the relief of pain after lumbar spine operations. Int Orthop 1997;21: 62 - 6. [8] McCrirrick A, Ramage DT. Caudal blockade for postoperative analgesia: a useful adjunct to intramuscular opiates following emergency lower leg orthopaedic surgery. Anaesth Intensive Care 1991;19:551 - 4.
Original contribution
Caudal epidural anesthesia administered intraoperatively provides for effective postoperative analgesia after total hip arthroplastyB Takashi Kita MD, PhD (Staff Anesthesiologist)a,*, Naritoshi Maki MD (Staff Anesthesiologist)a, Yong Su Song MD (Staff Anesthesiologist)a, Fumio Arai MD (Staff Anesthesiologist)a, Tsuyoshi Nakai MD, PhD (Staff Surgeon)b a
Department of Anesthesiology, Osaka Police Hospital, Tennoji, Osaka 543-8502, Japan Department of Orthopedic Surgery, Osaka Police Hospital, Tennoji, Osaka 543-8502, Japan
b
Received 10 March 2006; revised 9 October 2006; accepted 9 October 2006
Keywords: Adult patients; Anesthesia, caudal epidural; Total hip arthroplasty
Abstract Study Objective: To investigate the use of caudal epidural anesthesia for postoperative pain after total hip arthroplasty. Design: Prospective study. Setting: University-affiliated hospital. Patients: 32 (4 men and 28 women) patients, aged 49 to 89 years, scheduled for total hip arthroplasty for osteoarthritis of the hip. Interventions and Measurements: Patients were allocated to three groups: lumbar epidural anesthesia (EA group; n = 16) or caudal epidural anesthesia (CA group; n = 16) groups, which were case-matched according to patient demographics. Nine patients received general anesthesia only (GA group). We evaluated the level of postoperative pain using a 100-mm Visual Analog Scale (VAS) recorded at 3, 6, 9, 12, and 24 hours after surgery. Main Results: Total requirement of diclofenac sodium suppositories was significantly larger in the GA group than in the EA or CA groups (444 F 302 vs 188 F 124 and 145 F 130 mg). The number of days requiring analgesics was significantly prolonged in the GA group compared with the EA or CA groups (14 F 9 vs 4 F 3 and 4 F 4 days). These items were similar between the EA group and the CA group. All VAS values for pain, rest, and movement in the postsurgical period over 24 hours were significantly higher in the GA group than in either the EA or CA groups. Conclusions: Caudal epidural anesthesia provides effective postoperative analgesia similar to lumbar epidural anesthesia. D 2007 Elsevier Inc. All rights reserved.
B Support for this work was obtained from institutional and/or departmental sources. * Corresponding author. Tel.: +81 6 6771 6051; fax: +81 6 6775 2875. E-mail address: [email protected] (T. Kita).
0952-8180/$ – see front matter D 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.jclinane.2006.10.011
1. Introduction Total hip arthroplasty (THA) causes severe postoperative pain in half of all patients who require the surgery [1].
Caudal epidural anesthesia and THA Table 1
205
2. Materials and methods
Patients demographics
Number Gender (M/F) Age (y) Body mass index (kg/m2) Complications Cerebral infarction Hypertension Diabetes mellitus Cardiac dysfunction Respiratory dysfunction Liver dysfunction Renal dysfunction
EA group
CA group
GA group
16 2/14 66 F 8 (53-77) 23.0 F 2.7 (18.4-27.6)
16 1/15 67 F 12 (49-89) 23.4 F 3.9 (17.7-31.6)
9 1/8 68 F 9 (47-79) 23.2 F 3.3 (19.6-29.0)
1 5 1 2 3
3 9 1 1 5
0 3 0 3 2
1 0
1 0
1 0
Data are N or means F SD values.
Inadequate postoperative pain control causes various complications such as inhibition of rehabilitation, prolonged hospital stay, and increased hospital costs. Although several treatment options for postoperative pain management have been reported in these patients (eg, various combinations of systemic analgesics with or without opioids and epidural, plexus, or peripheral block) a well-accepted management has not been established. In our hospital, we have been using lumbar epidural analgesia for postoperative pain control. In these patients, the problems of obesity or compression fracture of lumbar spine frequently exist, and thus epidural catheter placement is often difficult to perform and requires a significant amount of time to place. Caudal epidural anesthesia has been used effectively for a variety of surgical procedure, especially in children. Adults have variable sacral anatomy, thick presacral fat, and calcified ligaments that make it difficult to perform this procedure [2]. Usefulness of caudal epidural anesthesia for THA has not been well evaluated. Thus, the study was designed to evaluate the efficacy of caudal epidural anesthesia for postoperative analgesia after THA.
Table 2
The study was approved by the institutional review board of the Osaka Police Hospital, and informed consent was obtained from all patients involved in the study. Subjects consist of 41 patients (5 men and 36 women, 47-89 years old) who underwent elective THA for osteoarthritis of the hip. Patients with a history of previous surgery on the hip were excluded from the study. Administration of anti-inflammatory drugs was suspended at least one week before the surgery. We allocated patients to three groups: the lumbar epidural anesthesia group (EA group; n = 16), the caudal epidural anesthesia group without an epidural catheter (CA group; n = 16), or the GA group (9 patients who underwent surgery with general anesthesia only). In the EA and CA groups, none of the patients had coagulation abnormalities or had been taking anticoagulant drugs before surgery. In the EA group, an epidural catheter was placed with an 18-gauge Tuohy needle (B. Braun Aesculap, Perifix, B. Braun, Melsungen, Germany) inserted into the L1-L2 or L2-L3 interspace. The epidural space was located by a loss–of–resistance to saline technique. Before surgery, an epidural catheter was inserted to a depth of 5 cm in a cephalad direction of the epidural space. After the induction of general anesthesia, two mg of morphine with 1% lidocaine 60 mg was administered through the epidural catheter, before skin incision, and followed by continuous epidural infusion with 0.2% ropivacaine started at the rate of three mL/hr during the operation. The epidural catheter was removed one day after surgery. In the CA group, the sacral hiatus was identified once the patient was turned to the lateral decubitus position for surgery. After skin cleansing with povidone iodine, a short, beveled, 22-gauge needle (Terumo needle, 0.7 32 mm; Terumo, Tokyo, Japan) was inserted using loss-ofresistance to saline technique. After negative aspiration to exclude accidental intrathecal or intravascular insertion, caudal epidural anesthesia was performed with 1% lidocaine 200 mg containing 4 mg of morphine without placement of a catheter. In the operating room, these patients received routine monitoring (three-lead electrocardiogram, pulse oximetry, capnography, anesthetic blood gas
Intraoperative data EA group
Time from entering operating room to start of surgery (min) Time from end of surgery to leaving operating room (min) Duration of surgery (min) Bleeding volume (mL) Infusion volume (mL) Urine output (mL) Data are means F SD values. * P b 0.05.
CA group
GA group
47 F 10 (30-71)
34 F 6 (25-45)*
41 F 11 (30-60)
16 F 5 (7-30)
18 F 15 (6-65)
17 F 2 (15-20)
71 F 34 (35-132) 335 F 381 (50-1350) 1044 F 437 (600-2250) 235 F 174 (100-720)
52 F 9 (40-66) 325 F 216 (100-766) 678 F 258 (250-1100)* 209 F 162 (50-630)
84 485 1083 199
F F F F
34 (20-155) 383 (60-1130) 647 (200-2500) 126 (0-390)
206 Table 3
T. Kita et al. Postoperative data
Total requirement of analgesics (mg) Administration period of analgesics (d) Duration until first administration of analgesics after surgery (h) Duration until first administration until ambulation after surgery (h) Duration until first administration of hospital stay after surgery (d)
EA group
CA group
GA group
188 F 124 (0-400) 4 F 3 (0-11) 6 F 8 (0-27)
145 F 130 (50-500) 4 F 4 (1-13) 13 F 16 (0-58)
444 F 302 (150-950)* 14 F 9 (5-32)* 1 F 1 (0-4)
24 F 4 (21-27)
22 F 3 (19-29)
23 F 11 (23-50)
28 F 8 (21-47)
25 F 3 (19-29)
34 F 12 (22-58)
Data are N or means F SD values. * P b 0.05.
analyzer, and rectal temperature). Anesthesia was induced with fentanyl (1-2 lg/kg) and thiopental sodium (4-5 mg/kg), supplemented with 5% sevoflurane, and vecuronium bromide (0.1 mg/kg). Additional doses of fentanyl were administered at the discretion of the anesthesiologist. We also administered 2.5 mg of droperidol intravenously to prevent postoperative nausea and vomiting (PONV). After tracheal intubation, all patients were positioned in the lateral decubitus position for the operation. Anesthesia was maintained with sevoflurane with nitrous oxide. Surgery was performed via the posterolateral approach without trochanteric osteotomy. No patients from the EA or the CA group presented with hemodynamic instability at the time of incision. Bone reconstruction was not performed in all cases. After surgery, all patients were transferred to their ward, and pain was controlled with diclofenac sodium suppositories, as required by the attendant orthopedist.
According to our THA protocol, physical rehabilitation was started on the day after surgery. There was no significant difference in postoperative rehabilitation among the groups. Postoperative anticoagulant therapy was scheduled to start in the postoperative period. Intraoperative data included duration of anesthesia and surgery, blood losses, transfusion and infusion volume, and urine output. Postoperative data included total requirement and time of analgesic administration (diclofenac sodium suppositories), time of the first need for analgesics, time of ambulation after surgery, and duration of hospital stay. We also measured postoperative pain by using a 100-mm Visual Analog Scale (VAS). The VAS for pain ranged from 0 (bno painQ) to 100 (bstrongest pain experienced by the patientQ). The VAS score was recorded at three, 6, 9, 12 and 24 hours after surgery. All data from the three groups were analyzed by KruskalWallis test followed by the Dunn procedure or v 2 test, as
Fig. 1 Visual Analog Scale (VAS) for pain at rest until 24 hours after surgery in each group. In every point after surgery, GA group presented high VAS scores compared with the EA and CA groups. 5, EA group; , CA group; , GA group.
Fig. 2 Visual Analog Scale (VAS) for pain on movement until 24 hours after surgery in each group. In every point after surgery, the GA group presented high VAS scores compared with the EA and CA groups. 5, EA group; , CA group; GA group.
Caudal epidural anesthesia and THA needed. Correlation was analyzed by Spearman rank correlation, and statistical significance was defined as P b 0.05. Statistical analysis was performed with SPSS software (11.0; SPSS, Chicago, IL).
3. Results No statistical differences were seen in demographic data among the three groups (Table 1). In our study, no patients were given additional doses of antiemetics during the postoperative period, and there was no significant postoperative respiratory complication noted in any patient. The time for setting up for the operation was significantly shorter in the CA group than the EA group (47 F 10 vs 34 F 6 min; Table 2). Volume was significantly lower in the CA group compared with either the EA or the GA group (678 F 258, 1044 F 437, and 1083 F 647 mL, respectively; Table 2). Although there was no statistical differences among the three groups in fentanyl administration during surgery, a considerably greater amount of fentanyl was necessary in the GA group. The period for first request for analgesia postoperatively, time to ambulation, and duration of hospital stay were similar among the three groups. However, total requirement of analgesics was significantly greatest in the GA group than the EA or CA groups (444 F 302, 188 F 124, and 145 F 130 mg, respectively; Table 3). All VAS for pain in the 24-hour postsurgical period were significantly higher in the GA group than the EA or CA groups (Figs. 1 and 2). The time to first request for analgesia was longer in the GA group than the EA or CA group (14 F 9, 4 F 3, and 4 F 4 days, respectively; Table 3). In this study, only one patient from the EA group presented with postoperative delirium on the day after surgery. There were no statistical differences among the three groups in the rate of delirium.
207 (eg, lumber epidual anesthesia, caudal epidural anesthesia with local anesthetics) may be associated with lower incidence of DVT. Caudal epidural anesthesia is a simple procedure that provides good quality of analgesia for both the perioperative and postoperative periods. In a previous study, we reported that caudal injection of 0.25% bupivacaine (20 mL) and 0.1 mg buprenorphine reduced postoperative pain after spinal surgery [7]. However, skill and experience are necessary for success with this technique. In our hospital, experienced staff anesthesiologists have performed caudal epidural anesthesia for more than 15 years, and the success rate of the maneuver is 94.1%. Epidural catheter placement is sometimes difficult in the patient scheduled for THA because of positioning difficulty, patient obesity, or compression fracture of the lumbar spine. We were easily able to identify the site of injection in the CA group and, interestingly, the time of this procedure for CA was significantly shorter than in the EA group. In addition, there were no neurologic, respiratory, or hemodynamic complications in the CA group patients. Caudal injection provides good postoperative analgesia without requiring a catheter [8], thereby reducing the risk of epidural hematoma, which may be caused by postoperative anticoagulation for prophylaxis and treatment of DVT. Patients requiring general anesthesia needed a greater amount of analgesics for a longer period than did either the EA or the CA group (all values of VAS for pain at rest and at movement were significantly higher). We speculate that the efficacy of caudal epidural anesthesia may be attenuated in longer surgeries, for which continuous infusion of opioid with local anesthetics would be preferable in such cases. In conclusion, our study shows that caudal epidural anesthesia provided excellent postoperative pain control in THA.
Acknowledgments 4. Discussion In this study, caudal epidural anesthesia provided postoperative analgesia as effective as lumbar epidural anesthesia. Postoperative analgesia is very important because it hastens the time to ambulation and improves the quality of rehabilitation, both aspects of which can reduce the risk for deep vein thrombosis (DVT) [3]. Deep vein thrombosis is thought to be formed in the proximal veins during surgery as a result of the local stasis of blood flow in the femoral vein. Manipulating the femoral canal with a screw also releases intramedullary procoagulants into the circulation and aggravates thrombosis formation [4]. Epidural administration of local anesthetics significantly increases venous velocity and volume flow of the lower extremities [5]. In addition, epidural local anesthetics inhibit platelet function and enhance fibrinolysis [6]. These beneficial effects of epidural injection of local anesthetics
The authors are indebted to Drs Mammoto, Kakiuchi, and Sasaki for their helpful assistance throughout this investigation.
References [1] Bonica JJ. Postoperative pain. In: Bonica JJ, editor. The management of pain. Malvern (PA)7 Lea & Febiger; 1990. p. 461 - 80. [2] Crighton IM, Barry BP, Hobbs GJ. A study of the caudal space using magnetic resonance imaging. Br J Anaesth 1997;78:391 - 5. [3] Farag E, Dilger J, Brooks P, Tetzlaff JE. Epidural analgesia improves early rehabilitation after total knee replacement. J Clin Anesth 2005;17: 281 - 5. [4] Westrich GH, Salvati EA, Sharrock N, Potter HG, Sanchez PM, Sculco TP. The effect of intraoperative heparin administered during total hip arthroplasty on the incidence of proximal deep vein thrombosis assessed by magnetic resonance venography. J Arthroplasty 2005;20: 42 - 50.
208 [5] Delis KT, Knaggs AL, Mason P, Macleod KG. Effects of epidural-andgeneral anesthesia combined versus general anesthesia alone on the venous hemodynamics of the lower limb. A randomized study. Thromb Haemost 2004;92:1003 - 11. [6] Porter J, Crowe B, Cahill M, Shorten G. The effects of ropivacaine hydrochloride on platelet function: an assessment using the platelet function analyser (PFA-100). Anaesthesia 2001;56:15 - 8.
T. Kita et al. [7] Kakiuchi M, Abe K. Pre-incisional caudal epidural blockade and the relief of pain after lumbar spine operations. Int Orthop 1997;21: 62 - 6. [8] McCrirrick A, Ramage DT. Caudal blockade for postoperative analgesia: a useful adjunct to intramuscular opiates following emergency lower leg orthopaedic surgery. Anaesth Intensive Care 1991;19:551 - 4.