- Email: [email protected]
Con: Every postthoracotomy patient does not deserve thoracic epidural analgesia
Con: Every Postthoracotomy Patient Does Not Deserve Thoracic Epidural Analgesia R a y m e r P. Grant, MD, FRCPC
HE PATIENT WITH end-stage emphysema presenting for lung volume reduction surgery, severe chronic obstructive pulmonary disease (COPD) presenting for lobectomy, moderate COPD presenting for pneumonectomy, and the patient presenting for thoracoabdominal esophagectomy are cases in which the author believes thoracic epidural analgesia (TEA) results in an improved outcome. The author believes that without TEA, many such patients would require prolonged ventilation after thoracotomy and might have a significantly increased risk for hospital mortality. Yet this is only a strongly held clinical impression, perhaps shared by many readers, that is remarkable in that it is not supported by compelling evidence from well-designed clinical studies. In contrast, the otherwise healthy young adult needing a lobectomy to remove a carcinoid tumor, or even the smoker (all too often these days a woman aged in her 40s or 50s) with bronchogenic carcinoma scheduled for an upper lobectomy through a third interspace axillary incision, does not need or "deserve" TEA, because there is virtually no evidence that invasive analgesic management has any effect on outcome in such patients. It is obvious that no medical treatment, especially an invasive one with the potential for serious complications, should be routine for every patient. Dr Slinger agreed to take the difficult, perhaps untenable, position that every thoracotomy patient should receive TEA to ensure a lively debate at the recent Canadian Anesthesiologists' Society meeting. The author's position, more easily supported by the evidence available to date, is that TEA should be practiced on a selective basis, considering the potential risks and benefits for each individual patient. When the clinician sees a postthoracotomy patient receiving TEA in the postanesthesia care unit (PACU) after an expertly managed anesthetic, he or she is struck by "how good the patient looks." They appear alert, comfortable, and able to breathe deeply and cough effectively. It is disappointing, therefore, to realize that the evidence available at present documents only modest improvement in outcome in the majority of patients who receive TEA. The author reviews the evidence concerning the actual benefits of TEA, the documented risks, and makes some recommendations as to which patients should receive TEA. The potential beneficial effects of epidural anesthesia and analgesia on postoperative outcome have been thoroughly reviewed by Liu et al, 1 who cite evidence that suggests in selected patients TEA may reduce the incidence of pulmonary complications, reduce the risk for myocardial ischemia or arrythmias, lead to an earlier return of bowel function, and reduce the risk for thromboembolic complications. 1 A comprehensive review of several techniques used to manage pain after thoracotomy has been published by Kavanagh et al.2 The limited benefits of TEA on pulmonary function and the incidence of postoperative pulmonary complications after upper abdominal surgery were reported by Jayr et al. 3 In a study of 153 patients comparing TEA (bupivicaine plus morphine) to subcutaneous morphine, the TEA group had better pain control and
T
pulmonary function (vital capacity) for the first 24 to 48 hours. There was, however, no difference in the incidence of either clinical or radiologic pulmonary complications between the two groups. The relatively short-term difference in improved pain control reported by Jayr et al 3 in TEA patients will be familiar to those whose clinical duties include acute pain management. In the author's experience, after 48 hours the majority of surgical patients report their pain is well controlled regardless of the primary modality of analgesia. Many investigators have studied analgesic efficacy and pulmonary outcome. The results of 65 randomized, controlled studies were recently subjected to a meta-analysis by Ballantyne et al,4 who assessed the effects of seven analgesic therapies on postoperative pulmonary function after a variety of surgical procedures. Compared with systemic opioids, either epidural opioids or epidural local anesthetics alone resulted in a modest but significant reduction in the incidence of pulmonary complications. Similar results, however, were noted in studies comparing intercostal local anesthetics with systemic opioids. Included in the analysis of Ballantyne et al4 were seven controlled studies comparing epidural local anesthetic plus opioid to systemic opioid. Epidural analgesia resulted in better pain control in all studies. There was a trend toward a reduced incidence of pulmonary complications, but the results did not reach statisticai significance. Also of note, Ballantyne et al4 reviewed several studies in which lumbar epidural opioid alone was compared with thoracic epidural opioid and found no difference, regardless of the opioid being studied. Therefore, if the clinician plans to manage postthoracotomy pain with an epidural opioid alone, particularly when morphine is the agent chosen, it would seem prudent to administer the drug by the most familiar route, which would be at the lumbar level for most anesthesiologists. TEA has also been reported to reduce the incidence of intraoperative and postoperative myocardial ischemia and cardiac complications in high-risk patients. ~ TEA has even been used successfully to treat patients with unstable angina who were refractory to maximal medical therapy and who were not candidates for coronary artery bypass grafting or angioplasty,s Other studies, including a recent report by Bois et al, 6 failed to identify a beneficial effect for TEA (fentanyl plus bupivacaine) compared with patient-controlled analgesia (PCA) intravenous morphine in a large prospective study of patients undergoing abdominal aortic surgery. The incidences of myocardial ischeemia and adverse cardiac outcomes were the same in both groups. As suggested by Liu et al,1 postoperative myocardial ischemia is more frequent, more severe, and more prolonged than ischemia occurring preoperatively and intraoperatively.
From the Department of Anaesthesia, Faculty of Medicine, University of British Columbia; and the Division of Thoracic Anaesthesia, Vancouver General Hospital, Vancouve~ BC, Canada. Reprints not available. Copyright © 1999 by W.B. Saunders Company 1053-0770/99/1303-0021510.00/0 Key words: analgesia, epidural, thoracic surgery, thoracic
Journal of Cardiothoracic and Vascular Anesthesia, Vo113, No 3 (June), 1999: pp 355-357
355
356
The beneficial effects of TEA on intraoperative hemodynamics and the reported decrease in intraoperative myocardial ischemia are therefore not necessarily followed by a reduced incidence of myocardial ischemia in the more critical and stressful postoperative period. TEA with local anesthetics with or without opioids has been reported to result in an earlier return of bowel function after colon surgery.7 A recent report by Groudine et al,8 however, raises questions about the mechanism by which TEA might shorten the duration of postoperative ileus. In that study, intravenous lidocaine administered throughout a retropubic prostatectomy was compared with placebo and resulted in significantly better analgesia in the PACU, earlier return of bowel function, and earlier discharge from the hospital. Prolonged ileus is rare after thoracotomy for lung resection, but very common after esophagectomy, a procedure that merits separate comment. Esophagectomy, either by a transhiatal or thoracoabdominal approach, is a major operation and is frequently performed in patients debilitated by their disease and preoperative radiation therapy. Brodner et al9 recently reported that patient-controlled TEA combined with aggressive postoperative physiotherapy and patient mobilization resulted in earlier tracheal extubafion, shorter intensive care unit stays, earlier return of bowel function, and less negative nitrogen balance postoperatively in patients undergoing thoracoabdominal esophagectomy. The importance of a mulfmodal or balanced approach to postoperative analgesia, combining epidural local anesthetics and opioids with systemic nonsteroidal and/or glucocorticoid agents, has been reviewed by Kehlet and Jorgen.10 TEA has been suggested to reduce the incidence of arrhythmias and to improve pulmonary function after cardiac surgery performed through a median sternotomy. 11,12Careful review of these studies shows that the pulmonary benefits were modest at best. A reduction in the rate of postoperative atrial fibrillation can be achieved pharmacologically using prophylactic amiodarone 13 or metoprolo114 without resorting to TEA, the safety of which has yet to be proven in a large series of patients who require full systemic anticoagulation for cardiopulmonary bypass. Similarly, whereas TEA has been suggested to reduce the incidence of postoperative tachyarrhythmias after thoracotomy for lung resection, the same benefits have been documented in patients receiving intraoperative and postoperative verapamil or metoprolol. 15J6 The simple continuation of supplemental oxygen for at least 72 hours postthoracotomy and the resulting reduction of pulmonary artery and right atrial pressures is probably equally as important as the reduction of sympathetic tone resulting from TEA in the reduction of postoperative tachyarrhythmias. Only one recent report deals specifically with the risks of TEA, and although the investigators reported no permanent neurologic sequelae, their study was too small to draw conclusions about the incidence of complications, which are undoubtedly rate. 17 Conversely, the risks of epidural catheterization (lumbar or thoracic levels) have been reported in three larger series, the results of which are listed in Table 1.18-2°In the largest series, that of Auroy et al,2o the risks of epidural catheterization were very low. Dahlgren and Tornebrandt, 19 however, reported a much greater incidence of neurologic
RAYMER P. GRANT
Table 1. Epidural Complications Reference Giebler et aP 17
No. of Failure DP Neurologic Patients (%) (%) I n j u r y Paraplegia 4,185
1.1
0.7
20t
Tanaka et al TM 15,020 Dahlgren and Tornebrandt ~9 9,232
4.1
0.6
2.6t 10.8
-3,25
3.6t
0.3
Auroy et al 2°
30,413
--
NOTE. Neurologic injury and paraplegia are frequency per 10,000. Abbreviation: DP, dural puncture. *TEA only. tFull recovery.
injury in patients receiving lumbar epidural analgesia. Differences in methodology may explain the differences in the reported incidence of complications; the data of Auroy et a120 were based on information volunteered by almost 5,000 anesthesiologists in a nationwide survey in France, whereas the data of Dahlgren and Tornebrandt19 were from a single institution. In another report, Hetland et a121 described three cases of spinal hematoma associated with TEA in just 1 year, and in a report comparing TEA with interpleural analgesia, Brockmeier et a122 described 1 of 32 patients who had permanent T5 paraplegia. Very large case series are required to determine the true safety of procedures associated with rare complications, otherwise, clustering of adverse outcomes, as described by Renck23 in the editorial accompanying the report by Dahlgren and Tornebrandt19may occur. Special mention must be made of the risks of epidural catheterization in the patient receiving anticoagulant prophylaxis, in particular those patients treated with low-molecularweight heparin. This subject has recently been reviewed by Horlocker et al.24,2s A recent notice from the Food and Drug Administration alerted anesthesiologists that there have been more than 30 reports describing patients who developed spinal hematoma in association with concurrent use of enoxaparin. 26 Many of the reported cases occurred in the setting of continuous epidural analgesia; one half were associated with removal of the epidural catheter. In deciding whether to recommend TEA to a patient, the clinician must therefore consider both the frequency and magnitude of complications. In the elderly patient with COPD scheduled for right pneumonectomy who faces a 3% to 10% hospital mortality rate, TEA is appropriate in an attempt to provide the benefits previously described. As stated by Liu et al,1 "the importance of studying high-risk patient populations cannot be overemphasized." What is needed is a randomized controlled trial of TEA compared with systemic analgesics in medically high-risk patients undergoing procedures with the highest risk for severe complications, such as pneumonectomy or esophagectomy. Such a study may never be undertaken; who would be willing to randomize the highest risk patients to intravenous opioids alone after major thoracic surgery? In the absence of evidence that TEA improves outcome in patients with reasonably good cardiopulmonary reserve, the author believes this therapy should be recommended on a selective basis. TEA should be considered in patients scheduled for full posterolateral thoracotomy who meet any of the following criteria: (1) significant pulmonary disease (FEV1 < 60%, carbon monoxide diffusing capacity < 60%,
PRO AND CON
357
unable to climb three flights of stairs; (2) symptomatic arteriosclerotic heart disease or a history of congestive heart failure; (3) undergoing pneumonectomy, chest wall resection, or esophagectomy; or (4) demand optimal pain control.
For other patients, intercostal blocks before incision combined with PCA opioids and regular doses of acetaminophen and a nonsteroidal anti-inflammatory agent provide satisfactory analgesia with minimal risk.
REFERENCES 1. Liu S, Carpenter RL, Neal JM: Epidural anesthesia and analgesia: Their role in postoperative outcome. Anesthesiology 82:1474-1506, 1995 2. Kavanagh BE Katz J, Sandler AN: Pain control after thoracic surgery: A review of current techniques. Anesthesiology 81:737-759, 1994 3. Jayr C, Thomas H, Rey A, et al: Postoperative pulmonary complications: Epidural analgesia using bupivcaine and opioids versus parenteral opioids. Anesthesiology 78:666-676, 1993 4. Ballantyne JC, Cart DB, deFerranti S, et al: The comparative effects of postoperative analgesia therapies on pulmonary outcome: Cumulative meta-analysis of randomized, controlled trials. Anesth Analg 86:598-612, 1998 5. Olausson K, Magnusdottir H, Lurje L, et al: Anti-ischemic and anti-anginal effects of thoracic epidural anesthesia versus those of conventional medical therapy in the treatment of severe refractory unstable angina pectoris. Circulation 98:2178-2182, 1997 6. Bois S, Couture P, Boucreanlt D, et al: Epidural analgesia and intravenous patient-controlled analgesia result in similar rates of postoperative myocardial ischemia after aortic surgery. Anesth Aualg 85:1233-1239, 1997 7. Liu SS, Carpenter RL, Mackey DC, et al: Effects of perioperative analgesic technique on rate of recovery after colon surgery. Anesthesiology 83:757-765, 1995 8. Groudine SB, Fisher HAG, Kaufman RP, et al: Intravenous lidocaine speeds the return of bowel function, decreases postoperative pain, and shortens hospital stay in patients undergoing radical retropubic prostatectomy. Anesth Analg 86:235-239, 1998 9. Brodner G, Pogatski E, Van Aken H, et al: A multimodal approach to control of postoperative pathophysiology and rehabilitation in patients undergoing abdominothoracic esophagectomy. Anesth Analg 86:228-234, 1998 10. Kehlet H, Jorgen BD: The value of "multimodal" or "balanced analgesia" in postoperative pain treatment. Anesth Analg 77:10481056, 1993 11. Stenseth R, Bjella L, Berg EM, et al: Effects of thoracic epidural analgesia on pulmonary function after coronary artery bypass surgery. Eur J Cardiothorac Surg 10:859-865, 1996 12. Turfrey DJ, Ray DA, Sutcliffe NR et ai: Thoracic epidural anaesthesia for coronary artery bypass graft surgery. Effects on postoperative complications. Anaesthesia 52:1090-1095, 1997
13. Daoud EG, Strickberger SA, Man KC, et al: Preoperative amiodarone as prophylaxis against atrial fibrillation after heart surgery. N Engl J Med 337:1785-1791, 1997 14. All IM, Sanalla AA, Clark V: Beta-blocker effects on postoperative atrial fibrillation. Eur J Cardiothorac Surg 11:1154-1157, 1997 15. Lindgren L, Lepantalo M, von Knorring J, et al: Effect of verapamil on fight ventricular pressure and atrial tachyarrhythmias after thoracotomy. Br J Anaesth 66:205-311,1991 16. Jakobsen CJ, Bille S, Ahlburg P, et al: Perioperative metoprolol reduces the frequency of atrial fibrillation after thoracotomy for lung resection. J Cardiothorac Vasc Anesth 11:746-751, 1997 17. Giebler RM, Scherer RY, Peters J: Incidence of neurological complications related to thoracic epidural catheterization. Anesthesiology 86:55-63, 1997 18. Tanaka K, Watanabe R, Harada T, Dan K: Extensive application of epidural anesthesia and analgesia in a university hospital: Incidence of complications related to technique. Reg Anesth 18:34-38, 1993 19. Dahlgren N, Tomebrandt K: Neurological complications after anaesthesia. A follow-up of 18,000 spinal and epidural anaesthetics performed over three years. Acta Anaesth Scaud 39:872-880, 1995 20. Auroy Y, Narchi P, Messiah A, et al: Serious complications related to regional anesthesia: Results of a prospective survey in France. Anesthesiology 87:479-486, 1997 21. Hetland S, Berg-Jobnsen J, Heier T, Nakstad PH: Intraspinal hematoma after thoracic epidural analgesia. Tidsskr Nor Laegeforen 20:241-244, 1998 22. Brockmeier V, Moen H, Karlsson BR, et al: Interpleural or thoracic epidural analgesia for pain after thoracotomy: A double-blind study. Acta Anaesth Scand 38:317-321, 1994 23. Renck H: Neurological complications of central nerve blocks. Acta Anaesth Scand 39:859-863, 1995 24. Hortocker TT, Heit JA: Low-molecular-weight heparin: Biochemistry, pharmacology, perioperative prophylaxis regimens, and guidelines for regional anesthetic management. Anesth Analg 85:874-885, 1997 25. Horlocker TT, Wedel D J: Regional anesthesia in the anticoagulated patient: Yes or no? Semin Anesthes Periop Med Pain 17:73-82, 1998 26. Food and Drug Administration Public Health Advisory. Anesthesiology 88:27A-28A, 1998
HE PATIENT WITH end-stage emphysema presenting for lung volume reduction surgery, severe chronic obstructive pulmonary disease (COPD) presenting for lobectomy, moderate COPD presenting for pneumonectomy, and the patient presenting for thoracoabdominal esophagectomy are cases in which the author believes thoracic epidural analgesia (TEA) results in an improved outcome. The author believes that without TEA, many such patients would require prolonged ventilation after thoracotomy and might have a significantly increased risk for hospital mortality. Yet this is only a strongly held clinical impression, perhaps shared by many readers, that is remarkable in that it is not supported by compelling evidence from well-designed clinical studies. In contrast, the otherwise healthy young adult needing a lobectomy to remove a carcinoid tumor, or even the smoker (all too often these days a woman aged in her 40s or 50s) with bronchogenic carcinoma scheduled for an upper lobectomy through a third interspace axillary incision, does not need or "deserve" TEA, because there is virtually no evidence that invasive analgesic management has any effect on outcome in such patients. It is obvious that no medical treatment, especially an invasive one with the potential for serious complications, should be routine for every patient. Dr Slinger agreed to take the difficult, perhaps untenable, position that every thoracotomy patient should receive TEA to ensure a lively debate at the recent Canadian Anesthesiologists' Society meeting. The author's position, more easily supported by the evidence available to date, is that TEA should be practiced on a selective basis, considering the potential risks and benefits for each individual patient. When the clinician sees a postthoracotomy patient receiving TEA in the postanesthesia care unit (PACU) after an expertly managed anesthetic, he or she is struck by "how good the patient looks." They appear alert, comfortable, and able to breathe deeply and cough effectively. It is disappointing, therefore, to realize that the evidence available at present documents only modest improvement in outcome in the majority of patients who receive TEA. The author reviews the evidence concerning the actual benefits of TEA, the documented risks, and makes some recommendations as to which patients should receive TEA. The potential beneficial effects of epidural anesthesia and analgesia on postoperative outcome have been thoroughly reviewed by Liu et al, 1 who cite evidence that suggests in selected patients TEA may reduce the incidence of pulmonary complications, reduce the risk for myocardial ischemia or arrythmias, lead to an earlier return of bowel function, and reduce the risk for thromboembolic complications. 1 A comprehensive review of several techniques used to manage pain after thoracotomy has been published by Kavanagh et al.2 The limited benefits of TEA on pulmonary function and the incidence of postoperative pulmonary complications after upper abdominal surgery were reported by Jayr et al. 3 In a study of 153 patients comparing TEA (bupivicaine plus morphine) to subcutaneous morphine, the TEA group had better pain control and
T
pulmonary function (vital capacity) for the first 24 to 48 hours. There was, however, no difference in the incidence of either clinical or radiologic pulmonary complications between the two groups. The relatively short-term difference in improved pain control reported by Jayr et al 3 in TEA patients will be familiar to those whose clinical duties include acute pain management. In the author's experience, after 48 hours the majority of surgical patients report their pain is well controlled regardless of the primary modality of analgesia. Many investigators have studied analgesic efficacy and pulmonary outcome. The results of 65 randomized, controlled studies were recently subjected to a meta-analysis by Ballantyne et al,4 who assessed the effects of seven analgesic therapies on postoperative pulmonary function after a variety of surgical procedures. Compared with systemic opioids, either epidural opioids or epidural local anesthetics alone resulted in a modest but significant reduction in the incidence of pulmonary complications. Similar results, however, were noted in studies comparing intercostal local anesthetics with systemic opioids. Included in the analysis of Ballantyne et al4 were seven controlled studies comparing epidural local anesthetic plus opioid to systemic opioid. Epidural analgesia resulted in better pain control in all studies. There was a trend toward a reduced incidence of pulmonary complications, but the results did not reach statisticai significance. Also of note, Ballantyne et al4 reviewed several studies in which lumbar epidural opioid alone was compared with thoracic epidural opioid and found no difference, regardless of the opioid being studied. Therefore, if the clinician plans to manage postthoracotomy pain with an epidural opioid alone, particularly when morphine is the agent chosen, it would seem prudent to administer the drug by the most familiar route, which would be at the lumbar level for most anesthesiologists. TEA has also been reported to reduce the incidence of intraoperative and postoperative myocardial ischemia and cardiac complications in high-risk patients. ~ TEA has even been used successfully to treat patients with unstable angina who were refractory to maximal medical therapy and who were not candidates for coronary artery bypass grafting or angioplasty,s Other studies, including a recent report by Bois et al, 6 failed to identify a beneficial effect for TEA (fentanyl plus bupivacaine) compared with patient-controlled analgesia (PCA) intravenous morphine in a large prospective study of patients undergoing abdominal aortic surgery. The incidences of myocardial ischeemia and adverse cardiac outcomes were the same in both groups. As suggested by Liu et al,1 postoperative myocardial ischemia is more frequent, more severe, and more prolonged than ischemia occurring preoperatively and intraoperatively.
From the Department of Anaesthesia, Faculty of Medicine, University of British Columbia; and the Division of Thoracic Anaesthesia, Vancouver General Hospital, Vancouve~ BC, Canada. Reprints not available. Copyright © 1999 by W.B. Saunders Company 1053-0770/99/1303-0021510.00/0 Key words: analgesia, epidural, thoracic surgery, thoracic
Journal of Cardiothoracic and Vascular Anesthesia, Vo113, No 3 (June), 1999: pp 355-357
355
356
The beneficial effects of TEA on intraoperative hemodynamics and the reported decrease in intraoperative myocardial ischemia are therefore not necessarily followed by a reduced incidence of myocardial ischemia in the more critical and stressful postoperative period. TEA with local anesthetics with or without opioids has been reported to result in an earlier return of bowel function after colon surgery.7 A recent report by Groudine et al,8 however, raises questions about the mechanism by which TEA might shorten the duration of postoperative ileus. In that study, intravenous lidocaine administered throughout a retropubic prostatectomy was compared with placebo and resulted in significantly better analgesia in the PACU, earlier return of bowel function, and earlier discharge from the hospital. Prolonged ileus is rare after thoracotomy for lung resection, but very common after esophagectomy, a procedure that merits separate comment. Esophagectomy, either by a transhiatal or thoracoabdominal approach, is a major operation and is frequently performed in patients debilitated by their disease and preoperative radiation therapy. Brodner et al9 recently reported that patient-controlled TEA combined with aggressive postoperative physiotherapy and patient mobilization resulted in earlier tracheal extubafion, shorter intensive care unit stays, earlier return of bowel function, and less negative nitrogen balance postoperatively in patients undergoing thoracoabdominal esophagectomy. The importance of a mulfmodal or balanced approach to postoperative analgesia, combining epidural local anesthetics and opioids with systemic nonsteroidal and/or glucocorticoid agents, has been reviewed by Kehlet and Jorgen.10 TEA has been suggested to reduce the incidence of arrhythmias and to improve pulmonary function after cardiac surgery performed through a median sternotomy. 11,12Careful review of these studies shows that the pulmonary benefits were modest at best. A reduction in the rate of postoperative atrial fibrillation can be achieved pharmacologically using prophylactic amiodarone 13 or metoprolo114 without resorting to TEA, the safety of which has yet to be proven in a large series of patients who require full systemic anticoagulation for cardiopulmonary bypass. Similarly, whereas TEA has been suggested to reduce the incidence of postoperative tachyarrhythmias after thoracotomy for lung resection, the same benefits have been documented in patients receiving intraoperative and postoperative verapamil or metoprolol. 15J6 The simple continuation of supplemental oxygen for at least 72 hours postthoracotomy and the resulting reduction of pulmonary artery and right atrial pressures is probably equally as important as the reduction of sympathetic tone resulting from TEA in the reduction of postoperative tachyarrhythmias. Only one recent report deals specifically with the risks of TEA, and although the investigators reported no permanent neurologic sequelae, their study was too small to draw conclusions about the incidence of complications, which are undoubtedly rate. 17 Conversely, the risks of epidural catheterization (lumbar or thoracic levels) have been reported in three larger series, the results of which are listed in Table 1.18-2°In the largest series, that of Auroy et al,2o the risks of epidural catheterization were very low. Dahlgren and Tornebrandt, 19 however, reported a much greater incidence of neurologic
RAYMER P. GRANT
Table 1. Epidural Complications Reference Giebler et aP 17
No. of Failure DP Neurologic Patients (%) (%) I n j u r y Paraplegia 4,185
1.1
0.7
20t
Tanaka et al TM 15,020 Dahlgren and Tornebrandt ~9 9,232
4.1
0.6
2.6t 10.8
-3,25
3.6t
0.3
Auroy et al 2°
30,413
--
NOTE. Neurologic injury and paraplegia are frequency per 10,000. Abbreviation: DP, dural puncture. *TEA only. tFull recovery.
injury in patients receiving lumbar epidural analgesia. Differences in methodology may explain the differences in the reported incidence of complications; the data of Auroy et a120 were based on information volunteered by almost 5,000 anesthesiologists in a nationwide survey in France, whereas the data of Dahlgren and Tornebrandt19 were from a single institution. In another report, Hetland et a121 described three cases of spinal hematoma associated with TEA in just 1 year, and in a report comparing TEA with interpleural analgesia, Brockmeier et a122 described 1 of 32 patients who had permanent T5 paraplegia. Very large case series are required to determine the true safety of procedures associated with rare complications, otherwise, clustering of adverse outcomes, as described by Renck23 in the editorial accompanying the report by Dahlgren and Tornebrandt19may occur. Special mention must be made of the risks of epidural catheterization in the patient receiving anticoagulant prophylaxis, in particular those patients treated with low-molecularweight heparin. This subject has recently been reviewed by Horlocker et al.24,2s A recent notice from the Food and Drug Administration alerted anesthesiologists that there have been more than 30 reports describing patients who developed spinal hematoma in association with concurrent use of enoxaparin. 26 Many of the reported cases occurred in the setting of continuous epidural analgesia; one half were associated with removal of the epidural catheter. In deciding whether to recommend TEA to a patient, the clinician must therefore consider both the frequency and magnitude of complications. In the elderly patient with COPD scheduled for right pneumonectomy who faces a 3% to 10% hospital mortality rate, TEA is appropriate in an attempt to provide the benefits previously described. As stated by Liu et al,1 "the importance of studying high-risk patient populations cannot be overemphasized." What is needed is a randomized controlled trial of TEA compared with systemic analgesics in medically high-risk patients undergoing procedures with the highest risk for severe complications, such as pneumonectomy or esophagectomy. Such a study may never be undertaken; who would be willing to randomize the highest risk patients to intravenous opioids alone after major thoracic surgery? In the absence of evidence that TEA improves outcome in patients with reasonably good cardiopulmonary reserve, the author believes this therapy should be recommended on a selective basis. TEA should be considered in patients scheduled for full posterolateral thoracotomy who meet any of the following criteria: (1) significant pulmonary disease (FEV1 < 60%, carbon monoxide diffusing capacity < 60%,
PRO AND CON
357
unable to climb three flights of stairs; (2) symptomatic arteriosclerotic heart disease or a history of congestive heart failure; (3) undergoing pneumonectomy, chest wall resection, or esophagectomy; or (4) demand optimal pain control.
For other patients, intercostal blocks before incision combined with PCA opioids and regular doses of acetaminophen and a nonsteroidal anti-inflammatory agent provide satisfactory analgesia with minimal risk.
REFERENCES 1. Liu S, Carpenter RL, Neal JM: Epidural anesthesia and analgesia: Their role in postoperative outcome. Anesthesiology 82:1474-1506, 1995 2. Kavanagh BE Katz J, Sandler AN: Pain control after thoracic surgery: A review of current techniques. Anesthesiology 81:737-759, 1994 3. Jayr C, Thomas H, Rey A, et al: Postoperative pulmonary complications: Epidural analgesia using bupivcaine and opioids versus parenteral opioids. Anesthesiology 78:666-676, 1993 4. Ballantyne JC, Cart DB, deFerranti S, et al: The comparative effects of postoperative analgesia therapies on pulmonary outcome: Cumulative meta-analysis of randomized, controlled trials. Anesth Analg 86:598-612, 1998 5. Olausson K, Magnusdottir H, Lurje L, et al: Anti-ischemic and anti-anginal effects of thoracic epidural anesthesia versus those of conventional medical therapy in the treatment of severe refractory unstable angina pectoris. Circulation 98:2178-2182, 1997 6. Bois S, Couture P, Boucreanlt D, et al: Epidural analgesia and intravenous patient-controlled analgesia result in similar rates of postoperative myocardial ischemia after aortic surgery. Anesth Aualg 85:1233-1239, 1997 7. Liu SS, Carpenter RL, Mackey DC, et al: Effects of perioperative analgesic technique on rate of recovery after colon surgery. Anesthesiology 83:757-765, 1995 8. Groudine SB, Fisher HAG, Kaufman RP, et al: Intravenous lidocaine speeds the return of bowel function, decreases postoperative pain, and shortens hospital stay in patients undergoing radical retropubic prostatectomy. Anesth Analg 86:235-239, 1998 9. Brodner G, Pogatski E, Van Aken H, et al: A multimodal approach to control of postoperative pathophysiology and rehabilitation in patients undergoing abdominothoracic esophagectomy. Anesth Analg 86:228-234, 1998 10. Kehlet H, Jorgen BD: The value of "multimodal" or "balanced analgesia" in postoperative pain treatment. Anesth Analg 77:10481056, 1993 11. Stenseth R, Bjella L, Berg EM, et al: Effects of thoracic epidural analgesia on pulmonary function after coronary artery bypass surgery. Eur J Cardiothorac Surg 10:859-865, 1996 12. Turfrey DJ, Ray DA, Sutcliffe NR et ai: Thoracic epidural anaesthesia for coronary artery bypass graft surgery. Effects on postoperative complications. Anaesthesia 52:1090-1095, 1997
13. Daoud EG, Strickberger SA, Man KC, et al: Preoperative amiodarone as prophylaxis against atrial fibrillation after heart surgery. N Engl J Med 337:1785-1791, 1997 14. All IM, Sanalla AA, Clark V: Beta-blocker effects on postoperative atrial fibrillation. Eur J Cardiothorac Surg 11:1154-1157, 1997 15. Lindgren L, Lepantalo M, von Knorring J, et al: Effect of verapamil on fight ventricular pressure and atrial tachyarrhythmias after thoracotomy. Br J Anaesth 66:205-311,1991 16. Jakobsen CJ, Bille S, Ahlburg P, et al: Perioperative metoprolol reduces the frequency of atrial fibrillation after thoracotomy for lung resection. J Cardiothorac Vasc Anesth 11:746-751, 1997 17. Giebler RM, Scherer RY, Peters J: Incidence of neurological complications related to thoracic epidural catheterization. Anesthesiology 86:55-63, 1997 18. Tanaka K, Watanabe R, Harada T, Dan K: Extensive application of epidural anesthesia and analgesia in a university hospital: Incidence of complications related to technique. Reg Anesth 18:34-38, 1993 19. Dahlgren N, Tomebrandt K: Neurological complications after anaesthesia. A follow-up of 18,000 spinal and epidural anaesthetics performed over three years. Acta Anaesth Scaud 39:872-880, 1995 20. Auroy Y, Narchi P, Messiah A, et al: Serious complications related to regional anesthesia: Results of a prospective survey in France. Anesthesiology 87:479-486, 1997 21. Hetland S, Berg-Jobnsen J, Heier T, Nakstad PH: Intraspinal hematoma after thoracic epidural analgesia. Tidsskr Nor Laegeforen 20:241-244, 1998 22. Brockmeier V, Moen H, Karlsson BR, et al: Interpleural or thoracic epidural analgesia for pain after thoracotomy: A double-blind study. Acta Anaesth Scand 38:317-321, 1994 23. Renck H: Neurological complications of central nerve blocks. Acta Anaesth Scand 39:859-863, 1995 24. Hortocker TT, Heit JA: Low-molecular-weight heparin: Biochemistry, pharmacology, perioperative prophylaxis regimens, and guidelines for regional anesthetic management. Anesth Analg 85:874-885, 1997 25. Horlocker TT, Wedel D J: Regional anesthesia in the anticoagulated patient: Yes or no? Semin Anesthes Periop Med Pain 17:73-82, 1998 26. Food and Drug Administration Public Health Advisory. Anesthesiology 88:27A-28A, 1998