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PERIOPERATIVE EPIDURAL ANALGESIA:Still Applicable ?
Muhammad Ramli AhmadDepartment of Anesthesiology Faculty of MedicineHasanuddin UniversityMakassar
INTRODUCTION
Pre- operative Intraoperative Post operative
Surgery
Peemptive Analgesia Preventive Analgesia
Epidural Analgesia
Perioperative Analgesia
Kissin I. Anesthesiology 2000;93:1138-43
Surgery
Pain
Incidence of Cardiac Infarction
Deranged Pulmonary Mechanics
Surgical Stress Response
Tissue Injury Physical Danger
Activation of neural, metabolic, endocrine, immune & coagulation system
Thromboembolic Complications
Impaired GIT Function
Blood Loss & Related Effect
?
PERIOPERATIVE EPIDURAL ANALGESIA:Still Applicable ?
BASIC CONSEP EPIDURAL ANALGESIA" pain free " and "stress
free ".
EPIDURAL ANALGESIA
Postoperative pain
Surgical stress response
Theoretical benefits for Cardiovascular, Respiratory, Gastrointestinal, and Metabolic function.
" pain free " and “ not stress free ".
Not completely block
1995 - 2000
2010
The Dynamics of TNF-alpha levels, on both Groups During Observation Time
Observation Time
TNF-alpha Level (pg/ml)
SignificanceEpidural Group (n=24) Control Group (n=24)
Min - Max Median Min - Max Median
Pre Operative 1,08 – 11,87 2,26 1,17 – 12,34 2,50 p=0,773
Early Post Operative 0,35 – 22,11 1,67 1,24 – 32,00 2,32 p=0,635
4 Hrs Post Operative 0,62 – 29,37 2,00 0,57 – 32,00 2,02 p=0,381
8 Hrs Post Operative 0,71 – 29,37 1,77 1,28 – 20,40 1,98 p=0,359
24 Hrs Post Operative 1,37 – 32,00 3,24 1,17 – 20,40 4,18 p=0,091
Data presented in the form of minimum, maximum and median values, and p values were tested with Mann Whitney-U Test. P Value of <0.05 were signiificant.
The Dynamics of Interleukin-1β level, on Both Groups During Observation Time
Observation Time
Interleukin-1β Level (pg/ml)
SignificanceEpidural Group
(n=24)Control Group (n=24)
Min - Max Median Min - Max Median
Pre Operative 0,08 – 9,5 0,95 0,05 – 8,00 1,30 p=0,695
Early Post Operative 0,05 – 8,0 0,63 0,05 – 8,00 0,84 p=0,244
4 Hrs Post Operative 0,04 – 8,0 0,89 0,05 – 8,00 1,15 p=0,749
8 Hrs Post Operative 0,04 – 8,0 0,60 0,16 – 8,16 0,68 p=0,845
24 Hrs Post Operative 0,05 – 8,0 0,69 0,20 – 8,00 1,04 p=0,421
Data presented in the form of minimum, maximum and median values, and p values were tested with Mann Whitney-U Test. P Value of <0.05 were signiificant.
The Dynamics of Interleukin-6 level, on Both Groups During Observation Time
Data presented in the form of minimum, maximum and median values, and p values were tested with Mann Whitney-U Test. P Value of <0.05 were signiificant.
Obervation Time
Inter leukin-6 level (pg/ml)
SignificanceEpidural Group (n=24) Control Group(n=24)
Min - Max Median Min - Max Median
Preoperatif 0,66 – 8,69 2,84 0,81 – 8,46 2,52 p=0,976
Early Post Operative 3,93 – 29,94 17,93 4,69 – 25.55 20,11 p=0,437
4 hrs Post Operative 7,36 – 27,16 21,38 15,01 – 25,94 21,25 p=0,907
8 hrs Post Operative 4,51 – 27,16 21,63 16,01 – 25,55 21,50 p=0,456
24 hrs Post Operative 5,39 – 26,25 21,81 15,11 – 25,99 22,65 p=0,065
BASIC CONSEP EPIDURAL ANALGESIA
Epidural BlockLocal Anesthetic
NeuroendocrineStress Response
ACTHADHGHTSH
Central COX-2
inhibition
CytokinesIL-1βIL-2IL-6TNF
NorepinephrineEpinephrineCortisolAldosteroneRenin
Sympathetic efferent
Humoral stress response
COX-2
Inflammatory mediators
Cytokines, Histamine, Leukotrienes, Norepinephrine,, Bradykinin, Prostaglandins, Neuropeptides, 5-HT,
Purines, H+/K+ions
The Stress Response, Neuroendocrine Hormon and Cytokines
Stress Response
Stress Response to Surgery
PAIN, NEUROHUMORAL RESPONSE NEUROENDOKRIN, AND IMMUNE RESPONSE
PAIN
Nociception
Neurohumoral Response
Immune Response
Sommer, C and Kress, M. 2004. Recent findings on how proinflammatory cytokines cause pain : peripheral mechanisms in inflammatory and neuropatic hyperalgesia. Neurosci. Lett. 361:184–7.
Cytokines
Sommer,2004
Tunentul,1999
Surgery
• ↓ DVT 44%/↓ PE 55%• ↓ Transfusion requirements 50%• ↓ Pneumonia 39%/↓ Respiratory depression 59%• Reduced incidence of postoperative ileus• Reduced time to extubation and ICU stay• Decreased perioperative coagulability
• Systematic review of 141 trials, 9559 patients• Overall mortality after 30 days was 1/3 less in
neuraxial group• Decreased pulmonary embolisms, cardiac
events, strokes, deaths from infection, and deaths from other causes
BMJ VOLUME 321 16 DECEMBER 2000 bmj.com
• Neuraxial blockade reduced risk of PE/DVT by almost half
• 1/3 fewer cardiac events• Decreased bleeding with decreased transfusions in NB
BMJ VOLUME 321 16 DECEMBER 2000 bmj.com
• 420 patients undergoing routine CABG• TEA 0.125% bupivacaine/0.6 µg/mL clonidine vs.
alfentanil infusion/morphine PCA• Postop complications data collected for 5 days• Pulmonary complications, arrhythmias, MI, renal
failure, CVA, acute confusion, bleeding
• 50% reduction in lower respiratory tract infections
• 30% increase in lung volumes• Faster extubation within first 4 hours• Quicker transfer from ICU to step down unit
• Analyzed data from 9 systemic reviews• Decreased 30 day mortality in intermediate-to-high risk
surgery• Decreased risk of pneumonia• No difference in risk of MI• No difference when neuraxial anesthesia was combined
with GAAnesth Analg 2014; 119: 716-25
• Effects on cardiac complications are minimal and limited to a subpopulation of high risk patients and procedures
• Benefits of epidural anesthesia for reduction in pulmonary complications is seen in high-risk intra-thoracic procedures and patients
• Statistical but not clinical significance decrease in pain scores with epidural analgesia
Department of Anesthesiology, Academic Medical Center, Amsterdam, the Netherlands.
Block et al Efficacy of postoperative epidural analgesia: a meta-analysis.JAMA. 2003 Nov 12;290(18):2455-63. Review
Muh. Ramli Ahmad, Husni Tanra, Irawan Yusuf FK Unhas 2012
Graph. Median Score of Numerical Rating Scale with Resting in Two Groups . *A Probability Value is Significant (p<0,05) after being tested with Mann Whitney-U Test.
Graph. Median Score of Numerical Rating Scale with Movement in Two Groups . *A Probability Value is Significant (p<0,05) after being tested with Mann Whitney-U Test.
Muh. Ramli Ahmad, Husni Tanra, Irawan Yusuf FK Unhas 2012
• Hysterectomy patients receiving lumbar epidurals
• Preemptive analgesia (PA) epidural doses with continuation of PCEA vs. postop PCEA alone
• Decreased pain scores in PA + PCEA group• Decreased postop cytokine production in PA +
PCEA group
• Intraoperative use of thoracic epidural (TEA-I) vs. postop thoracic epidural (TEA-P) alone
• Stress response and immune response• Decreased epinephrine and cortisol in TEA-I• Decreased cytokine production, circulating NK
cells
Incidence of Complications of Epidural AnalgesiaComplications Reported Incidence (%)
Related to catheter Insetion
Dural Puncture 0.32-1.23
Neurological damage (usually transient) 0.016-0.56
Related to catheter in situ
Epidural haematoma 0.0004-0.03
Epidural abscess 0.01-0.05
Catheter migration 0.15-0.18
Related to epidural drugs
Drug errors Not known
Respiratory depression 0.13-0.4
Hypotension 3-30
CNS toxicity 0.01-0.12
Motor block 3
SUMMARY
1. Epidural Analgesia is effective in the management of perioperative pain
neural transmission process can be inhibited by epidural analgesia
2. Epidural Analgesia decreases risk of Venous thromboembolisms, Pulmonary,
complications, Arrhythmias, Postoperative ileus, Transfusion requirements,
Pain, Stress/immune response
3. Epidural analgesia can not inhibit the surgical stress response perfectly,
because this technique we can not block the circulation pathway / humoral
pathway.
4. Surgical stress response affect the cardiovascular system, respiratory system,
gastroinstestinal system, immune system, and metabolic function.
Thank you! FOR YOUR ATTENTION