perioperative epidural analgesia . still applicable - prof. ramli

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